GI

Question 1

What diagnoses require manometry for most accurate test?

Answer 1

Achalasia

Diffuse esophageal spasm

Nutcracker esophagus

Scleroderma (immobile esophagus- presents like reflux)

Question 2

When should you suspect esophageal cancer and what do you do?

Answer 2

PROGRESSIVE dysphasia (solids then liquids)

Can only officially dx w/ biopsy (may do initial barium swallow)

Question 3

AIDS pt w/ odynophagia

Answer 3

Suspect esophageal candida and treat empirically with oral fluconazole

If no improvement then endoscopy w/ biopsy

Question 4

How do you diagnose Zenker diverticulum?

Answer 4

Barium study

No endoscopy or NG tube - PERFORATION RISK

Question 5

Barrett Esophagus Mgt

Answer 5

Endoscopy after 5-10 yrs GERD sx

If just metaplasia … PPI + re-scope 2-3 yrs

If low grade dysplasia … PPI + re-scope 6-12 mo

If high grade dysplasia … ablation, resection w/ scope

Question 6

4 times to use stress ulcer ppx

Answer 6

1- mechanical ventilation

2- burns

3- head trauma

4- coagulopathy

Question 7

H pylori Tx

Answer 7

PPI + clarithromycin + amoxicillin

If do not respond …add metro or tetracycline

If PCN allergy … clarithromycin + metro

Can add bismuth to aid in resolution

**test 30-60 days for eradication confirmation (stool antigen or breath test)

Question 8

Gastrinoma

Answer 8

1-2 cm mass normally in distal duodenum

High gastrin levels (esp despite secretin injection)

Sx = persistent ulcers despite h pylori eradication, diarrhea

Look for high Ca++ (MEN)

Question 9

1st steps in upper GI bleed?

Answer 9

ABCs - bolus of normal saline (BEFORE DIAGNOSIS)

1- normal saline

2- packed RBCs if HCT low

3- FFP if high PT/INR

4- Platelets if < 50,000 while bleeding

5- Octreotide if vatical

6- scopes, PPI, surgery ?

Question 10

1 Cause Upper GI Bleed & Lower GI Bleed

Answer 10

Upper = PUD

Lower = diverticulosis

Question 11

Tx of Varices

Answer 11

ABCs - fluid resuscitation

Octreotide

Propranolol for long-term mgt to prevent later episodes of bleeding

Abx for SBP ppx (ceftriaxone because E coli)

Question 12

Tx of C diff

Answer 12

ORAL VANCO (not metro)

If no response –> fidaxomicin

If multiple recurrences –> fecal transplant

Question 13

Sx Dx and Tx of Whipple’s Disease

Answer 13

Diarrhea

Arthralgia

Dementia

Sz

Fever

lymphadenopathy

ocular findings

Dx = must get biopsy with scope

Tx = ceftriaxone then bactrim

Question 14

Carcinoid Syndrome

Answer 14

Flushing, wheezing, intermittent diarrhea, R side cardiac problems

5-IHAA in urine

Tx = octreotide

Question 15

Tx of SIBO

Answer 15

Rifaximin

Question 16

Colon Cx Screening (Normal and special populations)

Answer 16

Normal = 50 yo then q 10 yrs (if have polyp then q 3-5 yrs)

Family hx? Then 10 yrs before that relative diagnosed OR 40 yo

HNPCC - 25 yo q 1-2 yrs

FAP = every yr from age 12

Juvenile polyposis = start at age 12

Gardner = sigmoidoscopy at age 12 (teeth, osteomas, soft tissue tumors)

Peutz-Jegher = at age 8 q 3 yrs (melanotic spots on lips and skin)

Question 17

SAAG

Answer 17

SAAG < 1.1 - infection, nephrotic, cx

SAAG > 1.1 - portal HTN, hepatic vein thrombosis, constrictive pericarditis, CHF (high protein)

Question 18

Hep B Tx (which one for pregnancy?)

Answer 18

MONOTHERAPY

• adefovir
• entecavir
• tenofovir (PREG)
• Interferon alpha
• lamivudine
• telbivudine

Question 19

Hep C Tx

What predicts response to tx?

How do you measure response to tx?

Answer 19

Combo agents dep on genotype (Sofosbuvir, etc)

• genotype predicts
• Meas viral PCR for response

Question 20

What tells you the extent of liver damage in Hep C?

Answer 20

Liver biopsy

Question 21

Wilson Disease - how does it present? What is the most accurate diagnostic test? Tx?

Answer 21

Sx - psychosis, tremor, sz, ataxia, dysarthria, coombs neg hemolytic anemia, RTA or stones

Kayser-Fleischer rings (brown) - slit lamp

Most accurate = inc copper excretion in urine after administration of penicillamine

Tx = penicillamine, zinc, trientine

Question 22

4 Components of MELD Score

Answer 22

Age

Cr

INR

Bilirubin

Question 23

Focal Nodular Hyperplasia in Liver

Answer 23

Benign

Stellate star scarring in center (vessel)

No tx

Question 24

Hepatic Adenoma

Answer 24

Grows w/ estrogen (preg)

May rupture

Small malignant potential

Question 25

Hepatic Hemangioma

Answer 25

US, CT, MRI Rarely cause RUQ pain If < 5 cm - no tx

Question 26

How does diffuse esophageal spasm present?

Answer 26

Chest or epigastric pain NOT with exertion that improves w/ Ca channel blockers or nitrates (CONFUSED W/ ATYPICAL CP) Can be precipitated by drinking cold liquids Think of it as similar to Prinzmantel angina Normal ECG, stress, esophagram, endoscopy

Question 27

Acute Hep B Serology

Answer 27

Order HB surface antigen (HBsAg) Order HB core IgM (HBC IgM) First thing to appear in serum is HB surface antigen --> HB surface antibody (there is a window period in between this transition when only core IgM is present)

Question 28

Microscopic Colitis

Answer 28

Watery, non-bloody diarrhea Triggers - smoking, PPIs, SSRIs, NSAIDs, ranitidine Biopsy - lymphocytic invasion in lamina propria Tx - stop trigger, +/- budenoside and loperamide for symptomatic relief Esp in women > 60 yo