hard deets

Question 1

Maternal or environmental causes of CHD (1-2%) (are preventable!)

Answer 1

-Illness:
Pre-Gestational Diabetes: 50 % inc. risk (poorly controlled, not gestational DM): risk for VSD, Transposition (TGA), Coarctation (COA)

• Lupus: complete heart block (may do C-section, watch moms w. SLE)
• Infection (Viral): rubella in 1st 7 wks = Patent Ductus Arteriosus
• Substance Abuse: Severe FAS (EtOH) = 50 % have CHD

Question 2

ERCP provides ??

Answer 2

ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL

Sphincterotomy with stone extraction or stenting can be done as needed during this procedure

Question 3

more Primary Sclerosing Cholangitis tx

Answer 3

Ursodeoxycholic acid can improve LFTs and decrease itching
Possible balloon intervention of some of the sclerosed areas
Possible stenting as a short term solution to relieve symptoms
Long-term stenting may increase complications
Liver transplantation for those with cirrhosis and clinical decompensation

Question 4

Primary Sclerosing Cholangitis px

Answer 4

Average survival 9-17 years and up to 21 years in some studies
Survival may be less with a dominant bile duct stricture
Higher risk for colon cancer associated with longer survival
Survival rates with liver transplantation are as high as 85% at 3 years

Question 5

tx: Acute bacterial cholangitis component of Primary Sclerosing Cholangitis
tx: Cholangitis
tx: cholecystitis

Answer 5

-abx against G-s: ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems

-abx against G-s (acutely IV) and ~2 weeks of p.o. agents
Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate

-gut rest, pain medications, and abx: 
A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Piperacillin/tazobactam
Carbapenem (imipenem, meropenem, ertapenem)

Question 6

Ranson’s criteria

Answer 6

Blood glucose  > 200 mg/dL
Age in years > 55 years
Serum LDH > 350 IU/L
Serum AST > 250 IU/L
White blood cell count > 16000 cells/mm3
Within 48 hours:
Serum calcium less than 8.0 mg/dL
Hematocrit fall > 10%
Oxygen: PaO2 below 60mmHg
BUN rise more than 5 mg/dL
base deficit more than 4 mEq/L
Sequestration of fluids > 6 L

mnemonic GALAW AND CHOBBS: Glucose, Age, LDH, AST and Whites; Calcium, Hematocrit, Oxygen, BUN, Base, Sequestration.

Question 7

pancreatitis complications: Pancreatic necrosis and fluid collections (pseudocysts)

Answer 7

can be acute or chronic and can be sterile or infected
This complication occurs in 5-10% of cases and is a frequent predictor of mortality
An infected pseudocyst can form a pancreatic abscess
Often associated with splenic vein thrombosis and L sided pleural effusions as well

about 50% mortality, not good candidate for sx, can only effectively drain thru tubes

Question 8

tx of pancreatitis complications

Answer 8

Surgery should follow all severe cases especially with nercocosis/pseudocyst:
Some mild cases with stones may need a cholecystectomy or cholecystotomy
Necrosectomy may improve survival but patient must be good candidates: If possible delay until patient is stable and necrosis has organized
Internal or external drainage of pseudocysts a consideration as well:
Risk for infection, fistula formation

Mortality: 25% and if there is multiorgan failure present, 50%

Question 9

Barium esophagography

Answer 9

Dysphagia patients often evaluated via barium swallow first before EGD is performed
If a high suspicion exists for a mechanical lesion, EGD often is done first
(intervention can be done at same time)

Question 10

Esophageal Varices tx options

Answer 10

• Antibiotic prophylaxis: High risk of SBP (spont. bac. peritonitis) or pneumonia
• Vasoactive drugs: Somatostatin and octreotide – reduce splanchnic and hepatic blood flow
• Vitamin K
• Lactulose for encephalopathy which can complicate an acute variceal bleeding episode
• Emergent endoscopy: Banding or balloon tamponade

Question 11

Esophageal Achalasia

Answer 11

Gradual, progressive dysphagia for solids and liquids

• Loss of peristalsis in the distal 2/3rds (smooth muscle) of the esophagus
• 50% experience substernal chest pain
• Regurgitation of undigested food
• Patients may lift their chins or throw their shoulders back to get food to move through
• Barium esophagram with “bird’s beak” appearance to the distal esophagus (also looks like esophageal ca, but w. less systemic symps)
• Diagnosis confirmed with esophageal manometry

Question 12

PUD

Answer 12

A peptic ulcer is a break in the gastric mucosa that can occur when usual defense factors are impaired or there is a hypersecretion of acid/low pH environment
-Ulcers extend through the muscularis mucosa and are over 5mm in diameter.
-May be singular or multiple
Lifetime prevalence in adults is 10%
Gastric ulcers are located most commonly in the antrum of the stomach (60%)
More common in smokers, drinkers, and men aged 30-55yo.

Question 13

more perforated ulcer tx (after sx and abx)

Answer 13

PPI therapy should be initiated

• H2 blocker therapy is effective in the treatment of PUD, however PPIs have superior efficacy
• Caveat – H2 blockers remain the drugs of choice for patients taking other medications that require an acidic gastric environment (certain HIV medications, for example)
• Appropriate triple or quadruple H.pylori therapy if indicated

Question 14

ZES dx: Most sensitive test is ??
what should be withheld??
what may be concurrently elevated implying ??
Why do CT ??

Answer 14

demonstration of an increased serum gastrin concentration >150pg/mL

• H2 blockers should be held for 24 hours, PPIs should be held for 6 days
• Withdrawal of PPI may cause massive gastrin hypersecretion and miserable results for the patient
• Concurrent elevated serum calcium suggests hyperparathyroidism and a possible diagnosis of MEN-I
• CT scan should be performed in an attempt to determine the site of the primary tumor and possible metastasis

Question 15

Pre-Hepatic Etiology: Hemolysis can be investigated by examining ??

Answer 15

• Peripheral blood smear (and bone marrow smear)
• Measuring reticulocyte count, haptoglobin, lactate dehydrogenase (LDH), erythrocyte fragility and Coomb’s test (done by specialist, not PC)

Question 16

drugs that can induce cholestasis (impaired hepatic excretion, C bill)

Answer 16

• Nitrofurantoin, oral contraceptives, anabolic steroids
• Erythromycin, cimetidine, chlorpromazine
• Prochlorperazine, imipramine, sulindac, and Penicillins

ALSO Post-operative Jaundice:
Occurs 1-10 days after surgery, 15% incidence after heart surgery

Question 17

ascites flow chart: if refractory ascites despite max diuretic dose OR e-lyte abnormality/renal dysfunction at submax dose

Answer 17

• large-volume paracentesis w. colloid expansion (IV albumin)
• shunt placement: TIPS/sx shunt
• aquaretics?

if these fail, consider liver transplant

Question 18

Term infant. Born via c section for failure to progress. Mom’s blood type is A+. Infant is A+ coombs negative. Mom is breastfeeding.
At 24 hours, infant is jaundiced

Answer 18

consider dehydration, just a little bit of colostrum

• slow gut, reabsorbing bilirubin
• C-section, not as much trauma
• asian races more hyperbili, harder to see on darker skin
• also worry about infection, (chorio/congenital infection)
• physiologic jaundice assoc. w. breastfeeding; Uncon.hyperbili that occurs after the first postnatal day and can last up to 1 week.
• 3-5 pk for normal Hgb
• 5-7 for premies
• more than 15 not physiologic

Question 19

Rh and ABO incompatibility

Answer 19

• ABO and Rh (D) blood T/S for other isoimmune antibodies should be evaluated in all pregs
• if not done or mom is O or Rh-negative, the infant’s cord blood should be evaluated for a direct antibody (Coombs) test, blood type, and Rh determination.
• Mother-infant ABO incompatibility (more common than Rh- typically given Rhogam) occurs in approximately 15% of all pregnancies, but symptomatic hemolytic disease occurs in only 5% of these infants.

Question 20

Maternal Blood type is O+
Infant Blood type is B+, COOMBs +
Reticulocyte count is 14 (high)
Hemoglobin is 17 (normal?)
assessment?

Answer 20

hemorrhagic/hemolytic, due to ABO incompatability

Question 21

TEF and VACTERL (if have one congenital problem, need to look for others)

Answer 21

V: Vertebral Hemivertebrae (etiology: sacral element agenesis, caudal regression, Dx: Plain radiography, spine US, MRI (if U/S +)
A: Anorectum Imperforate anus: Dx: Exam
C: Cardiac Structural congenital heart dz: Dx: Echo
T: TE fistula: Suspect with esophageal atresia
E: Esophageal atresia: Dx: NG tube passage with plain radiography
R: Renal Horseshoe kidney, renal collecting system anomalies: Dx: Renal ultrasound
L: Limb Radial hypoplasia, atresia: Dx: Plain radiography

Question 22

diarrhea definitions

Answer 22

10L approximately entering duodenum, all but 1.5 L absorbed, colon absorbs rest less 200ml in stool lost
Definition: 200-300g in 24 hour period
Alternate Definition: more than 3 bowel movements per day or liquidity

Question 23

N/V: Brainstem mediated in medulla, stimulated by:

Answer 23

• Afferent vagal fibers from GI viscera 5-HT3 receptors due to biliary or GI distention, mucosal or peritoneal irritation, or infections.
• Vestibular system, H1 and muscarinic cholinergic receptors
• Amygdala, sights/smells/emotion
• Chemoreceptor trigger zone (outside blood brain barrier): Rich in opioid, serotonin 5-HT3, dopamine D2 receptors

Question 24

Early Goal Directed Therapy for Septic Shock

Answer 24

• 0.9 NS (saline) to achieve CVP 8-12 mmHg
• vasopressors to achieve MAP 65 or greater → given through central line (NOT iv → local necrosis)
• PRBCs to achieve Hgb 10 or greater