1
Q
Describe the presentation, diagnosis, and treatment of hiatal hernias.
A
- present with heartburn, chest pain, and dysphagia; very similar to GERD
- the diagnosis is made with a barium study or endoscopy
- best initial therapy is weight loss and a PPI followed by surgical correction
2
Q
What alarm systems are indications for endoscopy in those with esophageal dysfunction?
A
if weight loss, anemia, or heme-positive stool are present, endoscopy should be performed to exclude cancer
3
Q
Describe the presentation, diagnosis, and treatment of achalasia.
A
- presents in younger patients as progressive dysphagia for both solids and liquids
- barium esophagram is the best initial test and will show a “bird’s beak” but manometry is the most accurate
- treat with pneumatic dilation, myotomy, or repeated botox injection
4
Q
Describe the risk factors, presentation, diagnosis, and treatment of esophageal carcinoma.
A
- GERD and Barrett esophagus are risk factors for adenocarcinoma while irritation as from alcohol and tobacco are major risk factors for squamous cell
- both present with progressive dysphagia first for solids and later for liquids; squamous cell is more likely to be invasive and produce cough or hoarseness
- barium esophagram may be an appropriate first test, but diagnosis requires biopsy; CT and MRI are used for staging
- treat with surgical resection when possible and add chemotherapy or radiation; stent placement can be palliative in cases where resection isn’t possible
5
Q
What is the difference between squamous cell carcinoma and adenocarcinoma of the esophagus?
A
- adenocarcinoma refers to a proliferation of glands, and arises from pre-existing Barrett esophagus in the lower third of the esophagus
- squamous cell carcinoma arises in the upper and middle thirds of the esophagus in response to irritation; risk factors include alcohol, tobacco, very hot tea, achalasia, esophageal web, and esophageal injury
- furthermore, squamous cell is more invasive and more likely to involve the recurrent laryngeal nerve or trachea, producing hoarseness and cough
6
Q
Describe the presentation, diagnosis, and treatment of esophageal spasm.
A
- presents with sudden onset chest pain unrelated to exertion which may be confused with ACS but will be accompanied by a normal ECG and stress test
- the only abnormality and method for diagnosis is manometry
- first line treatment uses a CCB or nitrate alongside a PPI
- move to TCAs or sildenafil as second-line agents
7
Q
Describe the presentation, diagnosis, and treatment of eosinophilic esophagitis.
A
- presents with dysphagia, food impaction, and heartburn, typically in a patient with a history of atopy
- endoscopy will show multiple concentric rings but diagnosis requires biopsy finding eosinophils
- treat with PPIs and trigger avoidance; can swallow steroid inhalers if PPIs are ineffective
8
Q
How is dysphagia managed in those with AIDS?
A
- dysphagia in patients with CD4 less than 100 is usually caused by esophageal candidiasis
- so we start with empiric oral fluconazole
- if patients fail to improve, an endoscopy is performed
- if large ulcerations are found, indicative of CMV esophagitis, ganciclovir is started; if small ulcerations are found, indicative of herpes esophagitis, acyclovir is started
9
Q
Describe the pathophysiology, presentation, diagnosis, and treatment of a Schatzki ring.
A
- this is a distal esophageal stricture related to acid reflux
- presents with intermittent dysphagia for solid foods
- diagnosis is with barium esophagram
- treat with endoscopic pneumatic dilation
10
Q
Describe the pathophysiology, presentation, diagnosis, and treatment of esophageal webs.
A
- this is a thin protrusion of the esophageal mucosa into the lumen of the upper esophagus associated with iron deficiency
- presents with dysphagia for solid foods
- diagnosis is with barium esophagram
- treat with iron replacement first and then pneumatic dilation if the obstruction fails to resolve
11
Q
What are the features of Plummer-Vinson syndrome?
A
- iron deficiency anemia
- esophageal web
- beefy-red tongue due to atrophic glossitis
12
Q
Describe the pathogenesis, presentation, diagnosis, and treatment of Zenker diverticulum.
A
- a false diverticulum caused by dysmotility which results in herniation of the esophageal mucosa through posterior pharyngeal constrictor muscles
- presents with dysphagia, halitosis, a neck mass, and regurgitation of food particles
- it is diagnosed with barium esophagram
- treatment is surgical
13
Q
How is the esophageal dysfunction of scleroderma diagnosed and treated?
A
- manometry is used for diagnosis and will show decreased LES tone
- treatment is with PPIs
14
Q
How is a Mallory-Weiss tear managed?
A
- in most cases it is managed expectantly
- however, for persistent bleeding, epinephrine or electrocautery can be used
15
Q
Describe the presentation and treatment of cannabinoid hyperemesis syndrome.
A
- presents with recurrent nausea, vomiting, and crampy abdominal pain which is relieved by a hot shower
- management involves cessation of cannabis use and antiemetics
16
Q
What is the most common cause of epigastric pain?
A
non-ulcer dyspepsia
17
Q
What is the most likely diagnosis for epigastric pain with the following associated features:
- worse with food
- better with food
- weight loss
- tenderness
- persistent cough
- history of diabetes and bloating
- no additional features
A
- worse with food: gastric ulcer
- better with food: duodenal ulcer
- weight loss: cancer or gastric ulcer
- tenderness: pancreatitis
- persistent cough: GERD
- history of diabetes and bloating: gastroparesis
- no additional features: non-ulcer dyspepsia
18
Q
Describe the presentation, diagnosis, and treatment of GERD.
A
- presents as a burning epigastric pain that radiates up into the chest is associated with cough, hoarseness, sore throat, or bad taste in the mouth
- it is usually a clinical diagnosis, but if unclear then 24-hour pH monitor is done to confirm
- perform an endoscopy in the case of weight loss, anemia, or heme-positive stool and after 5-10 years of symptoms to exclude Barrett esophagus
- treat with weight loss; avoidance of alcohol, tobacco, and caffeine; no eating within 3 hours of sleep; elevation of the head of the bed; and PPIs
19
Q
How do we screen for and manage Barrett esophagus?
A
- patients with GERD should be screened after 5-10 years with endoscopy and biopsy
- if Barrett is found alone, rescoped every 2-3 years
- if low-grade dysplasia is also found, rescope every 6-12 months
- if high-grade dysplasia is also found, perform endoscopic ablation
20
Q
Describe the pathogenesis, presentation, diagnosis, and treatment of gastritis.
A
- can be autoimmune or secondary to alcohol, NSAIDs, H. pylori, portal hypertension, and stress
- it typically presents as GI bleeding without pain
- diagnosis requires upper endoscopy and testing for H. pylori should be performed at that time
- treat with PPIs and eradication of H. pylori if present
21
Q
What are four ways of testing for H. pylori?
A
- endoscopic biopsy is most accurate
- serology lacks specificity for active disease
- urea breath testing is expensive
- stool antigen testing
22
Q
What are the key differences between duodenal and gastric ulcers?
A
- the two cannot be differentiated without upper endoscopy; however, there are key differences
- duodenal more often improve with eating while gastric worsening with eating and are thus associated with weight loss
- a great portion of duodenal ulcers are associated with H. pylori while a greater proportion of gastric ulcers are malignant
23
Q
Describe the most common etiologies, presentation, diagnosis, and treatment of gastric ulcers.
A
- the most common cause is H. pylori followed by NSAIDs
- presents with recurrent, dull, gnawing epigastric pain which is worse with eating and is sometimes accompanied by GI bleeding and weight loss
- the only way to definitively make the diagnosis is with upper endoscopy, at which time H. pylori testing should be performed
- treat with PPIs and H. pylori eradication
- rescope patients if they fail to confirm healing or if patients fail to improve with medical management due to the risk of malignancy
24
Q
Describe the most common etiologies, presentation, diagnosis, and treatment of duodenal ulcers.
A
- the most common cause is H. pylori followed by NSAIDs
- presents with recurrent, dull, gnawing epigastric pain which improves with eating and is sometimes accompanied by GI bleeding
- the only definitive method for diagnosis is with upper endoscopy, at which time H. pylori testing should be performed
- treat with PPIs and H. pylori eradication
- switch to quadruple therapy if patients fail to improve and then a repeat upper endoscopy for continued symptoms
25
How is H. pylori treated?
- start with amoxicillin/metronidazole, clarithromycin, and a PPI
- if this fails to improve symptoms switch to quadruple therapy with metronidazole, tetracycline, a PPI, and bismuth
26
How are refractory ulcers managed?
- retest for H. pylori and switch to quadruple therapy if the organism hasn't been eradicated
- repeat upper endoscopy for those with a gastric ulcer to exclude cancer as a reason for not improving
27
What does the differential diagnosis for dyspepsia include and how is it managed?
- could be caused by gastric or duodenal ulcers, non-ulcer dyspepsia, or gastritis
- for those under 45 without alarm symptoms, start empiric treatment with a PPI
- for those over 55 or who have alarm symptoms, perform an upper endoscopy
28
Describe the management of non-ulcer dyspepsia.
- for those under 45 without alarm symptoms, start empiric treatment; otherwise, first perform an upper endoscopy to rule out other causes
- for empiric treatment or after diagnosis is confirmed, start a PPI
- if symptoms fail to resolve and patients are positive for H. pylori, treat with triple therapy
29
Describe the presentation, diagnosis, and treatment of a gastrinoma.
- presents with ulcers that are large, recurrent, multiple, or distal to the duodenum
- upper endoscopy diagnoses the ulcers; then a gastrin level with high gastric acidity or persistent high gastrin levels following secretin injection confirms the gastrinoma
- CT or MRI are done to look for metastatic disease but are insensitive; follow negative results with a somatostatin receptor scintigraphy
- treat with surgical resection of location disease or PPIs for metastatic disease
30
Describe the pathogenesis, presentation, diagnosis, and treatment of diabetic gastroparesis.
- autonomic neuropathy prevents the sense of stretch in the GI tract which causes dysmotility
- presents with chronic abdominal discomfort, bloating, and constipation in a long-term diabetic
- it is largely a clinical diagnosis, but if needed the best initial test is upper endoscopy or abdominal CT to rule out cancer and the most accurate is a nuclear gastric emptying study
- treat with a blenderized diet and either metoclopramide or erythromycin before trying gastric electrical stimulation
31
What is the most common cause of upper and lower GI bleeding?
- upper: ulcer disease
| - lower: diverticulosis
32
How is orthostasis defined?
a more than 10 point rise in pulse or 20 point drop in systolic blood pressure
33
How is GI bleeding treated?
1. fluid replacement
2. pRBCs as needed
3. FFP if INR is elevated
4. platelets if count is less than 50K
5. octreotide for variceal bleeding
6. endoscopic intervention with banding, cautery, or epi
7. IV PPI for upper bleeds
8. surgical resection if all else fails
34
What is used for the acute management and for prophylaxis of variceal bleeding?
- octreotide is used acutely
| - propanolol is used prophylactically
35
How is C. diff treated?
- oral vancomycin is the preferred therapy
- switch to fidaxomicin if unresponsive
- use a vancomycin or fidaxomicin taper for recurrence
- use a fecal transplantation for multiple recurrences
36
How is fulminant C. diff defined and treated?
- defined by a high WBC, metabolic acidosis, high lactate, or high creatinine
- treat with both oral vancomycin and metronidazole
37
What group of malabsorbative conditions cause B12 deficiency?
most because it requires an intact bowel wall as well as pancreatic enzymes for absorption
38
Describe the presentation, diagnosis, treatment and complications of Celiac disease.
- presents with abdominal distention, diarrhea, malabsorption, weight loss, and dermatitis herpetiformis
- the best initial test is for anti-tissue transglutaminase antibodies; others are enti-endomysial and anti-gliadin
- the most accurate test is small bowel biopsy showing flattened villi
- treat with avoidance of wheat, oats, rye, and barley
- small bowel carcinoma and T-cell lymphoma are late complications that often presents as refractory disease despite good dietary control
39
Describe the presentation, diagnosis, and treatment of Whipple disease.
- presents with abdominal distention, diarrhea, and weight loss characteristic of malabsorption
- also presents with arthralgia, ocular disturbance, neurologic abnormalities, fever, and lymphadenopathy
- the most accurate test is small bowel biopsy showing intracellular gram positive organisms and PAS-positive foamy macrophages
- treat with ceftriaxone followed by bactrim
40
What is the main distinction in malabsorbative pattern between Celiac disease and pancreatic insufficiency?
Celiac disease presents with iron deficiency while pancreatic insufficiency does not
41
What is a D-xylose test?
a test of bowel wall functioning, which will be normal in those with malabsorption secondary to pancreatic insufficiency
42
What is the best initial test and what is the most accurate test for chronic pancreatitis?
- the best initial is abdominal radiograph or CT showing calcifications
- the most accurate is a secretin stimulation test, which will show diminished release of bicarbonate-rich fluids
43
Describe the presentation, diagnosis, and treatment of carcinoid syndrome.
- presents with intermittent, watery diarrhea, flushing, wheezing, bronchospasm, and right-heart valve lesions
- the best initial test is urinary 5-HIAA
- treat with octreotide
44
What happens to the stool osmolality in those with lactose intolerance?
it increases
45
Describe the presentation and treatment of IBS.
- presents with pain that is less at night and relieved by bowel movements, often with diarrhea or constipation
- all patients should be started on a high fiber diet, an antispasmodic agent (hyoscyamine, dicyclomine, or peppermint oil), and an SSRI or TCA
- diarrhea-predominant should be started on rifaximin or the mu-opioid receptor agonists eluxadoline or diphenoxylate
- constipation-predominant should be started on PEG
46
Describe the pathology, presentation, diagnosis, and treatment of ulcerative colitis.
- the pathology involves mucosal ulcers beginning in the rectum and extending proximally in a continuous manner
- there are pseudopolyps, loss of haustra, and crypt abscesses with neutrophils
- presents with left lower quadrant pain, bloody diarrhea, and weight loss; extra intestinal manifestations include arthralgia, uveitis, and erythema nodosum
- may be complicated by PSC, toxic megacolon, or CRC
- endoscopy is the most accurate test and p-ANCA may be found in serum
- treat acute exacerbations with steroids and use a taper of azathioprine or 6-MP if necessary
- use sulfasalazine and 5-ASA derivatives like mesalamine for maintenance therapy
47
Describe the pathology, presentation, diagnosis, and treatment of Crohn disease.
- the pathology involves transmural, skip lesions
- may see transmural granulomas, cobblestoning, creeping fat, and strictures
- presents with right lower quadrant pain, diarrhea, and weight loss; often complicated by obstruction and fistula formation
- endoscopy is the most accurate test
- treat acute exacerbations with steroids and use a taper of azathioprine or 6-MP if necessary
- treat fistulas with TNFa inhibitors and surgery if there is no response
- use sulfasalazine and 5-ASA derivatives like mesalamine for maintenance therapy
48
What is vedolizumab?
an alpha-integrin inhibitor used to treat refractory inflammatory bowel disease
49
What is budesonide?
a steroid specifically used for IBD because of it's high first pass effect
50
Describe the presentation and treatment of short bowel syndrome.
- presents with diarrhea, dehydration, malnutrition, steatorrhea, and weight loss
- avoid high fats, supplement vitamins and IV nutrients, and slow the gut with loperamide
51
Describe the pathogenesis, presentation, diagnosis, and treatment of small intestine bacterial overgrowth.
- the normally sterile small bowel dilates in response to resection leading to a loss of the ileocecal valve, which allows bacteria into the small bowel
- presents with flatulence, bloating, diarrhea, and steatorrhea
- diagnosis is with small bowel aspirate and culture
- treat with rifaximin
52
What is microscopic colitis?
a syndrome of chronic, non-bloody, watery diarrhea with a normal colonoscopy but microscopic inflammation present on biopsy which responds to steroids
53
What is the most accurate test for diverticulosis? How do we diagnose diverticulitis?
- the most accurate for diverticulosis is colonscopy
| - the best test for diverticulitis is CT
54
What is the treatment for diverticulitis?
- ciprofloxacin and metronidazole while NPO
- use surgery for refractory disease, frequent recurrences, and complications such as perforation, fistulae formation, or stricture
55
Is it better for younger or older patients to undergo surgical treatment of diverticulitis?
younger because they are more likely to be affected by a higher number of recurrences
56
Wilson Disease
- presentation
- initial test
- most accurate test
- treatment
- presents with hepatic insufficiency and cirrhosis, neurologic symptoms including psychosis and delusions, coombs negative hemolytic anemia, and nephrolithiasis
- best initial test is slit lamp looking for Keyser-Fleischer rings but will also find low ceruplasmin
- most accurate test is looking for abnormally elevated amounts of copper in urine following pencillamine
- treat with pencillamine; use zinc if allergic to penicillin
57
Describe the presentation, diagnosis, and treatment of autoimmune hepatitis.
- presents with signs of liver inflammation and a positive ANA
- diagnosis is suggested by finding anti-smooth muscle and anti-microsomal antibodies but the most accurate test is liver biopsy
- treat with prednisone and azathioprine
58
What are the two types of nonalcoholic fatty liver disease?
- NAFL is a benign condition associated with no fibrosis or malignant potential
- NASH is considered premalignant and associated with inflammation and fibrosis which may progress to cirrhosis
59
What is non-alcoholic fatty liver disease? How is it diagnosed and treated?
- it is either NAFL or NASH with the later being more associated with fibrosis, cirrhosis, and malignant potential
- diagnosis is with liver biopsy
- treatment is of the underlying cause: obesity, hyperlipidemia, diabetes, and corticosteroid use
60
What is a MELD score based on?
age, creatinine, bilirubin, and INR
61
Describe the presentation, diagnosis, and treatment of hepatic focal nodular hyperplasia.
- this is a benign lesion consisting of hyper plastic growth around an abnormal blood vessel and carries no malignant potential
- diagnosis is based on imaging which shows a central stellate scar
- treatment isn't needed
62
Describe the presentation, diagnosis, and treatment of hepatic hemangiomas.
- this is a benign lesion most often found incidentally
- imaging is used for diagnosis
- treatment isn't needed for lesions less than 5cm
63
Describe the presentation and diagnosis of hepatic adenomas.
- these are hepatic lesions that respond to hormones and thus grow with cOCP use and pregnancy
- they cause RUQ and may rupture, causing extensive hemorrhage
- diagnosis requires biopsy
64
How can hepatic adenomas, focal nodular hyperplasia, and hemangiomas be differentiated?
- adenomas are hormonally responsive, have some malignant potential, and require biopsy for diagnosis
- focal nodular hyperplasia has no malignant potential and is diagnosed based on imaging which shows a central stellate scar
- hemangiomas have no malignant potential and are also diagnosed based on imaging
65
What is Peutz-Jeghers syndrome? What cancer screening guidelines are there?
- the primary feature is multiple hamartomatous polyps with the GI tract
- as well as melanotic spots on the lips and skin and increased frequency of breast, gonadal, and pancreatic cancer
- screen with colonoscopy every three years starting at age 8
66
What is Gardner syndrome? What cancer screening guidelines are there?
- it is a syndrome of colon cancer and osteomas
| - begin yearly screening with sigmoidoscopy at age 12
67
Wha tis juvenile polyposis and how does the condition impact cancer screening recommendations?
- it is a a syndrome of colon cancer and multiple hamartomatous polyps
- patients should have upper and lower GI tracts screened for cancer yearly beginning at age 12
68
How is anticoagulation managed for colonoscopy?
- skip NOACs the day before the procedure and restart the day after the procedure
- hold warfarin for 3-5 days prior to the procedure
69
The combination of acute epigastric pain, tenderness, and n/v should suggest what diagnosis?
pancreatitis
70
What lab value offers the worst prognosis for those with pancreatitis?
hypocalcemia
71
Describe the presentation, diagnosis, and treatment of pancreatitis.
- most cases are secondary to alcohol or cholelithiasis
- presents with epigastric pain and tenderness as well as nausea and vomiting
- the best initial test is amylase and lipase; the most specific is CT; MRCP plays a role in determining etiology
- needle biopsy should only be performed for greater than 30% necrosis seen on CT to look for infection
- treat with analgesics, NPO, fluids, and PPIs; drain pseudocysts if enlarging or painful; use ERCP to remove stones
- if greater than 30% necrosis is seen on CT start antibiotics, imipenem or meropenem, and perform a needle biopsy; necrotectomy is performed if needle biopsy identifies infection
72
What should you do in patients with pancreatitis if greater than 30% necrosis is seen on CT?
- start antibiotics: imipenem or meropenem
- perform a needle biopsy looking for infection
- if infected, perform a necrotectomy
73
Describe the management of pancreatitis.
1. get an amylase and lipase first
2. confirm diagnosis with CT, which also shows pseudocysts or necrosis
3. all patients should be treated with analgesics, fluids, NPO, and PPIs
> for those with pseudocysts that are enlarging or painful, drain percutaneously
> for those with obstructing stones, perform ERCP
> for those with 30% necrosis, start antibiotics, perform needle biopsy, then resect if infected
74
Describe the presentation, diagnosis, and treatment for autoimmune pancreatitis.
- presents as an enlarged "sausage-shaped" pancreas on CT with elevated serum IgG4, ANA, and RF
- importantly patients will have no history of alcohol intake or cholelithiasis
- biopsy is occasionally done to exclude cancer and shows lymphatic and plasma cell infiltrates
- treat with steroids
75
How is pancreatic cancer diagnosed?
- CT is the best initial test
- if positive, perform a surgical biopsy/resection
- if negative, perform an ERCP with biopsy of any lesion
76
How are pancreatic cysts treated?
pancreatic cystic neoplasms have some malignant potential and must be removed before becoming invasive
77
What screening recommendation is made for those with cirrhosis?
liver ultrasound every 6 months to monitor for cancer
78
What are the indications for paracentesis in patients with liver disease?
- new onset
- fever
- abdominal pain or tenderness
79
What is the importance of the serum-ascites albumin gradient?
- if greater than 1.1, it suggests an increase in hydrostatic pressure: portal hypertension in particular, but CHF, hepatic vein thrombosis, or constrictive pericarditis are also possible
- if less than 1.1, it is highly suggestive of infection, cancer, or nephrotic syndrome
80
What is the most common organism that causes spontaneous bacterial peritonitis?
E. coli
81
How is spontaneous bacterial peritonitis treated?
- use ceftriaxone or cefotaxime
- use a fluoroquinolone or bactrim as prophylaxis in those who have ever had SBP, have vatical bleeding with ascites, or have a very low ascites albumin level
82
What is orthodeoxia?
hypoxia on sitting upright, which is suggestive of hepatopulmonary syndrome
83
Describe the presentation, diagnosis, and treatment of primary biliary cholangitis.
- presents as fatigue and itching in women in their 40s or 50s; bilirubin is typically normal with an elevated alk phos
- the most accurate blood test is anti-mitochondrial antibodies; the most accurate test is biopsy
- treat with ursodeoxycholic acid for itching or obeticholic acid which decreases fibrosis
84
Describe the presentation, diagnosis, and treatment of primary sclerosing cholangitis.
- presents as pruritus with an elevated alk phos and bilirubin in patients with IBD
- the most accurate test is MRCP showing beading
- treat with cholestyramine or ursodeoxycholic acid
85
Describe the pathophysiology, presentation, diagnosis, and treatment of hemochromatosis.
- due to a C282y gene mutation that leads to over absorption of iron from the duodenum
- presents with bronze diabetes, cardiomyopathy, liver disease, ED or amenorrhea from pituitary involvement, and joint pain
- the best initial test are iron studies; the most accurate test is a liver biopsy; expected iron studies and an MRI showing deposition in the liver is enough to make the diagnosis and avoid a biopsy
- first line treatment is phlebotomy; second line is iron chelation
86
What is the treatment for hemochromatosis?
- treat most patients with phlebotomy
| - use iron chelation for those who are anemic and have the disease secondary to over transfusion such as thalassemia
STEP2
flashcards
Decks in class (27)
# Cards
-
UWorld Review 1161
-
UWorld Review 2162
-
UWorld Review 344
-
GI86
-
Endocrinology68
-
Cardiology87
-
Pulmonology53
-
Infectious Disease67
-
Allergy/Immunology11
-
Rheumatology60
-
Hematology30
-
Oncology31
-
Neurology61
-
Nephrology75
-
Preventative31
-
Dermatology28
-
Surgery90
-
Sports Medicine14
-
ENT17
-
Pediatrics134
-
OB119
-
GYN59
-
Radiology19
-
Ophthalmology12
-
Psychology63
-
Emergency Med60
-
Social Sciences42
