Gastrointestinal

Question 1

Enteric fistula

Answer 1

Abnormal connection between two parts of the intestines. Hallmark sign seen in chrons disease/

Question 2

Achalasia
- What is the causing mechanism?
- What are the signs and symptoms?
- Workup?
- Treatment?

Answer 2

Esophageal motility disorder that decreases the esophagus ability to move food into the stomach. Impaired relaxation of the lower esophageal sphincter and loss of esophageal peristalsis leads to food not adequately moving forward into the stomach.

S&S - heartburn (unrelieved by PPI), regurgitation of food, progressive dysphagia of solids and liquids

Workup:
- barium swallow study - reveals the stricture around the LES
- Upper endoscopy - visualization and biopsy to test for malignancy

Treatment:
- Pneumatic dilation
- Surgery
- Botox
- Medications to relax the LES muscle (nitroglycerin or nifedipine)

Question 3

Severely painful knot at the anus, acute onset. In exam bluish painful perianal node. Best treatment?

Answer 3

Describes thrombosed hemorrhoid. Blood clot obstructing blood flow in the hemorrhoid vein. Triggered by coughing, heavy lifting, straining.

Best treatment is excision within 24-48 hours. Under local anesthesia.

Question 4

Functional abdominal pain

Answer 4

Genuine experience of pain with no specific organic cause.

Most common complaint of pain in preschoolers.
No evidence of inflammation, anatomical, metabolic, or neoplasticism processes

Question 5

CYP2C19

Answer 5

Cytochrome P450 is a family of enzymes that are found in the liver and help metabolize certain medications.
- Clopidogrel (Plavix)
- PPIs
- Citlopram

Question 6

CYP2C9

Answer 6

Cytochrome that is a family of enzymes that are found in the liver and help metabolize certain medications.
- Warfarin (Coumadin)
- Celecoxib
- NSAIDs

Question 7

CYP1A2

Answer 7

Cytochrome that is a family of enzymes that are found in the liver and help metabolize certain medications.
- Antidepressants
- Antipsychotics
- Acetaminophen
- Caffeine

Question 8

CYP2D6

Answer 8

Cytochrome that is a family of enzymes that are found in the liver and help metabolize certain medications.
- Depressants (SSRIs, TCAs)
- Dextromethorphan
- Codeine

Question 9

CYP3A4

Answer 9

• Statins
• CCBs
• Benzos
• macrolides
• HIV meds

Question 10

STICKFACES.COM Group

Answer 10

S - sodium valproate
T - Ticlodipine (antiplatelet)
I - Isoniazid
C - Cimetidine
K - ketoconazole
F - fluconazole
A - alcohol
C - ciprofloxacin, chloramphenicol
E - erythromycin
S - sulfonamides
.
C - cranberry juice
O - omeprazole
M - metronidazole

Group - Grape fruit juice

These medications and foods inhibit CYP450 leading to decreased clearance of these medications leading to a great effect of the medications.

Question 11

BS CRAP GPS

Answer 11

B - barbiturate’s
S - St. Johns Wort

C - Carbamazepine
R - rifampin
A - alcohol (chronic)
P - Phenytoin

G - Griseofulvin
P - phenobarbital
S - Sulfonylureas

These medications activate CYP450 enzymes leading to increased metabolism and decreased drug action.

Question 12

How does certain PPIs affect absorption and metabolism of other medications?
What PPIs and what other medications?

Answer 12

Omperazole (Prilosec) and Esomeprazole (Nexium)

These medications are strong CYP450 enzyme inhibitors, this leads to decreased activity of the enzyme needed to breakdown and then absorb the medications.

Clopidogrel

Question 13

How is lactose intolerance diagnosed?

Answer 13

Hydrogen breath test - measures amount of hydrogen in a person’s breath after consuming a lactose solution.

A solution containing lactose is consumed and breath samples are collected 2-3 hours later. This hydrogen is created by bacteria fermentation of the lactose in the colon.

Question 14

What does corticosteroid use increase the risk for, especially when paired with NSAIDs?

Answer 14

GI bleed - NSAIDs inhibit protective prostaglandins in the stomach lining which leads to mucosal damage and ulcer formation. Steroids impair mucosal defenses, delay ulcer healing, and amplify the effects of other ulcerogenic agents.

Question 15

Bloomberg Sign
- What is this assessment testing for?

Answer 15

Pain with quick release of abdominal pressure to the right lower quadrant. This is used in evaluation of peritonitis.

Question 16

What are symptoms of peritonitis? Causes?

Answer 16

Abdominal pain, tenderness, rigidity, fever.

Causes:
- infection
- perforation of GI tract
- inflammation from other organs

Question 17

Bloomberg Vs McBurney

Answer 17

Bloomberg - rebound tenderness when gentle pressure is released from the RLQ in the assessment of peritonitis. REBOUND TENDERNESS.

McBurney - pain upon palpation in the RLQ (between umbilicus and right anterior superior iliac spine). Positive test if the patient reports maximal tenderness at the site. Indicative of acute appendicitis. Rebound tenderness can be assessed suggesting peritoneal involvement.

Question 18

Cullen Sign

Answer 18

Periumbilical ecchymosis that is used to evaluate retroperitoneal hemorrhage.

Question 19

Markle Sign (modified)

Answer 19

Assessment done looking for intraperitoneal inflammation. Patient is asked to stand on their toes and suddenly and forcefully drop to their heels. This sends a shockwave up the leg and can result in RLQ pain.

Modified form of this evaluation can be done with the patient laying down and striking their heel firmly with a fist. If this reproduces RLQ pain this could indicate intraperitoneal inflammation.

Question 20

Murphy Sign

Answer 20

Application of pressure at the costal margin of the RUQ while the patient takes a deep breath causes pain, and interruption of breath. Assesses for cholecystitis.

Question 21

Treatment options for anal fissures?

Answer 21

Anal fissures are small tears that occur on the lining of the anal canal. Caused by increased pressure from BMs.
1. Stool softners
2. Topical analgesics
3. Topical nitroglycerin - reduces anal sphincter spasms
4. Sitz baths
5. High-fiber diet

Question 22

How often should a colonoscopy be done for a patient of average risk? What about patients that are older than 75?

Answer 22

Starting at age 45 - a colonoscopy should be done every 10 years. This should continue through age 75.

Patients that are 75 and older should have annual fecal occult blood testing done and if positive should be further evaluated.

Question 23

Rovsing’s sign

Answer 23

Exam used to assess suspected appendicitis. The LLQ is palpated and if pain extends from the LLQ to the RLQ this suggests peritoneal involvement near the appendix.

Question 24

How would mild vs severe diverticulitis present? What is the treatment for each?

Answer 24

Mild - localized LLQ tenderness, low-grade fever, nausea, constipation or diarrhea. Treated with antibiotics, bowel rest, and close outpatient monitoring

Severe - diffuse abdominal pain, high fever, chills, peritoneal signs (rigidity, rebound, systemic toxicity). Marked leukocytosis, elevated CRP, abscess, perforation, fistula, obstruction on CT scan. Hospitalization, IV antibiotics, surgery.

Question 25

The Psoas muscle test is done how? What does it assess for? What other assessment technique can be done to assess for acute appendicitis?

Answer 25

The Psoas muscle test is performed by flexing the right leg at the hip and knee which would cause pain in the RLQ due to appendicitis. The appendix is in close proximity to the psoas muscle which can become irritated. Acute appendicitis can also be assessed for by performing the obturator test.

Question 26

Metoclopramide - Generic and Drug class - MOA - Indications - Side effects - Black box warning

Answer 26

Reglan - D2-receptor antagonist MOA - Decreases nausea (decreases dopamine release in the chemoreceptor trigger zone of the brain). Stimulates gastric emptying (increases acetylcholine release in the GI tract (increases gastric motility). Indications: - Nausea and Vomiting - Gastroparesis - Postop ileus Side effects: - Drowsy - Fatigue - Diarrhea + Extrapyramidal symptoms: - Tardive dyskinesia - neurological movement disorder caused by long-term use of dopamine blocking agents. Involuntary, repetitive movements of the face, limb, and trunk + Depression + Neuroleptic malignant syndrome BBW: Tardive dyskinesia

Question 27

What are the colon cancer screening guidelines for those at high risk? Who is at high risk?

Answer 27

High risk patients - personal history of colon cancer or advanced adenomas. First-degree relative with colorectal cancer or advanced adenoma. Two or more affected first or second-degree relatives, IBD. Start at age 40 (normally start at age 45) or 10 years younger than the youngest age of the first-degree relative (whichever comes first). And do a colonoscopy every 5 years.

Question 28

What medication type increases the risk for cholelithiasis? What is an example of this medication? What does this medication class do?

Answer 28

Fibrates - fibrate medications are used to lower triglycerides and increase HDL levels. They do this by decreasing hepatic free fatty acids and inhibiting lipolysis in the peripheral tissue. It increases cholesterol excretion in the bile. This increased cholesterol excretion leads to increased risk for cholelithiasis. Fibrate medications end in fibrozil.

Question 29

What is atrophic gastritis? What about autoimmune atrophic gastritis? - What is it? - What causes it? - Risk factors? - Symptoms? - complications? - Treatment?

Answer 29

Atrophic gastritis is a condition where the parietal cells of the stomach, the ones that secrete gastric acid to help break down consumed food and drink and secrete intrinsic factor, is reduced. Atrophic gastritis can be caused by: - H. Pylori - Autoimmune Risk factors: - Smoking - Crowded living - High salt diet - Older age Symptoms: - Loss of intrinsic factor results in vitamin B12 deficiency; this presents with megaloblastic anemia, fatigue, pallor, glossitis, shortness of breath, and neurological symptoms such as paresthesias, gait instability, and cognitive changes, and if untreated can cause irreversible neurologic damage. - Loss of stomach acid results in indigestion, nausea, weight loss Treatment: - Treating H. Pylori - Treating VB12 deficiency - Nutrition supplementation

Question 30

What is pernicious anemia?

Answer 30

A type of megaloblastic anemia that is seen with VB12 deficiencies

Question 31

What is the FDA's take on using probiotics to treat GI disorders?

Answer 31

Probiotics are not consistently effective in treating and preventing GI disorders.

Question 32

What medications are used when treating H. Pylori with quad therapy?

Answer 32

Treat - Tetracycline My - metronidazole Belly - bismuth Pain - Prevacid

Question 33

What drugs are used for triple therapy treatment of H. Pylori ?

Answer 33

CAP CLARITHROMYCIN AMOXICILLIN PPI

Question 34

Campylobacter jejuni - Symptoms - How is it spread?

Answer 34

A common travel-related bacterial infection - transmitted through waterborne outbreaks or indirect contact with animals or animal products (undercooked meat or contaminated milk). Incubation period is 1-7 days Symptoms: - Cramping - abdominal pain - Diarrhea with 10 or more watery, bloody stools per day - Prodromal symptoms like high fever, generalized aches, fatigue, dizziness

Question 35

How to recognize bile acid sequestrants?

Answer 35

Medications end in chole/cole/coles

Question 36

What are common side effects of bile acid sequestrants?

Answer 36

Constipation, diarrhea, abdominal pain, gas, bloating, N/V, pancreatitis, malabsorption.

Question 37

What is the recommended antibiotic treatment for Travelers Diarrhea?

Answer 37

Azithromycin or fluoroquinolones - these have good coverage of the most common culprits, E.Coli and Campylobacter jejuni

Question 38

H. Pylori What is it? How is it assessed for? What are the treatments? How to assess for treatment success?

Answer 38

H-pylori is a bacteria that can infect the stomach and duodenum. Spread person-to-person and through contaminated water and food. Symptoms include bloating, abdominal pain, frequent gas, weight loss, peptic ulcers. Assessment is made through stool test or Urea breath test. There are a couple treatment options: Both are used for 14 days. First line treatment (Penicillin allergy?) - Amoxicillin (BID) - can be subbed for Metronidazole (Flagyl) - PPI (Omeprazole BID) - Clarithromycin (500mg BID) Second line treatment - PPI (Omeprazole) - Tetracycline - Metronidazole - Bismuth Subsalicylate Reassessment post treatment is typically performed via Urea breath test.

Question 39

Diverticulosis VS Diverticulitis

Answer 39

Diverticulosis - presence of sac-like protrusions from the intestinal wall. Can be symptomatic or asymptomatic. Diverticulitis - inflammation of one or more diverticulum.

Question 40

What are important indicators of diverticulitis? What test should be done to confirm?

Answer 40

- left lower abdominal pain - elevated CRP - indicates inflammation Confirmation should be obtained via CT scan with contrast. Usually both oral and intravenous.