Gastroenterology Q
Tx of autoimmune pancreatitis
->
high dose prednisone
Dx of 45 yo female with Elevated ALP and pruritus
->
primary biliary cholangitis (formerly primary biliary cirrhosis)
-> intrahepatic small bile ducts
vs primary sclerosing cholangitis affects both intrahpatic and extra hepatic bile ducts
Diagnostic test of primary biliary cholangitis
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antimitochondrial Ab
BP med to avoid for liver failure with ascites
->
ACEI/ARB (decrease renal perfusion)
What is Immune control phase of HBV infection
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inactive chronic infection (carrier): normal ALT (no inflammation), HBV-DNA - (no replication), HBsAg +, HBsAb -, HBeAg - / HBeAb + (no replication), HB core Ab + (previous infection)
Signs of acute alcoholic hepatitis
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fever, leukocytosis, (jaundice, tender hepatomegaly)
Tx of acute alcoholic hepatitis
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prednisone, N-acetylcysteine
Surveillance interval of colonoscopy for sessile polyp
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5-10y for 1-2 polyps (all<10mm), 3-5y for 3-4 polyps (all<10mm), 3y for 5-10 polyps or >10mm
Diagnostic test of celiac disease in the setting of selective IgA deficiency
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anti-deamidated gliadin peptid IgG Ab measurement (in general, Tissue transglutaminase IgA Ab is serologit test for Celiac disease)
Post-exposure prophylaxis to HAV in 22 yo male (5 days after the exposure)
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hepatitis A virus vaccine (consider HAV vaccine + immune globulin for age > 40)
What is MEN1
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parathyroid, anterior pituitary, pancreatic islet (insulinoma or gastrinoma)
What is MEN2
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Thyroid (medually carcinoma), parathyroid (adenoma), adrenal gland (pheochromocytoma)
What condition is Primary sclerosing cholangitis associated with
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inflammatory bowel disease (Pt who is diagnosed with PSC requires colonoscopy)
Diagnostic test of PSC
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MRCP (ERCP required when jaundice, cholangitis, bile duct mass)
Tx duration of autoimmune hepatitis
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at least 2-3 years with prednsione +/- azathioprine (high rate relapse)
Tx for ulcerative proctitis
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5-aminosalicylate suppository (within 18cm of the anal verge)
5-ASA enema for left-sided UC (extending from sigomid to splenic flexure)
Combined 5-ASA (oral and topical) for mild-mod left-sided or extensive UC (beyond splenic flexure)
Oral glucocorticoid for mod to severe UC
Test for young patients with chronic diarrhea
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Giardia, fecal calprotectin (for inflammatory bowel disease), tissue transglutaminase IgA (for celiac disease)
What does patient with maroon stools showing Bilious return by gastric lavage indicate
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no active upper GI bleed proximal to the ligament of Treitz
Test for Hemodynamically unstable lower GI bleed
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CTA abdomen
Next step for patient found to have large gastric varices to gastric fundus, along the greater curvature of stomach by upper endoscopy
->
abd CT with contrast to assess vasculature for optimal Tx
(depend on the anatomy of abdominal vasculature (splenectomy, balloon-occluded retrograde transvenous obliteration, TIPS))
Tx of Familial adenomatous polyposis
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colectomy
Tx for hepatocellular cancer in Pt with well-compensated cirrhosis
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surgical resection (transarterial chemoembolization as second-line Tx, not candidate for surgery)
Diagnostic test for primary sclerosing cholangitis with normal MRCP
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liver biopsy
Cancer screening for women with IBD receiving immunosuppressive Tx
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annual pap smear and skin cancer (IBD increase risk for cervical and skin cancer in addition to colon cancer)
Timing of initial colonoscopy for IBD
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8-10 years after Dx
HELLP syndrome stands for
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hemolysis, elevated liver enzymes, low platelets
Tx of HELLP Sx
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prompt delivery
Type of Chronic diarrhea that improve with fasting
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osmotic diarrhea (lactose deficiency, fructose malabsorption)
Diagnostic test of lactose deficiency
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trial of lactose-free diet
Diagnostic criteria of spontaneous bacterial peritonitis
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neutrophil > 250/uL
Tx of SBP
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3rd generation cephalosporin +/- albumin (if bilirubin > 4)
Calculation of Fecal osmotic gap
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290 - (2 x (stool Na + stool K)), gap > 100 indicates osmotic diarrhea (lactose, fructose, sorbitol (artificial sweetener))
Tx of hepatic adenoma in men
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surgical resection if > 5cm (risk of malignant transformation)
Tx of hepatic adenoma in women
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stop exogenous hormones (oral contraceptives)
Most common cause of recurrent celiac disease symptoms after symptoms once resolved with gluten-free diet
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inadvertent gluten exposure (tissue transglutaminase IgA level normalize after starting gluten-free diet)
Tx of left-sided ulcerative colitis
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5-aminosalicylate enema (sigmoid to splenic flexure), (proctitis: rectum -> 5-ASA suppository)
Tx of esophageal hypomotility disorder in the setting of systemic sclerosis
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lifestyle changes and PPI (eating upright, consume a liquid diet (poor peristalsis -> dysphagia, hypotensive lower esophageal sphincter -> reflux))
Management of hepatic sarcoidosis
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upper endoscopy (portal hypertension is common)
Differentiation of cirrhotic ascites and cardiac ascites
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TP in ascites low in cirrhosis (<2.5) and high in cardiac (>2.5) (SAAG (serum-ascites albumin gradient: > 1.1-> portal hypertensive ascites, cirrhosis/HF both cause SAAG > 1.1))
Onset of Drug-induced liver disease
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up to 6 months after the exposure
Common medication causing Drug-induced cholestasis
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(T-bil/ALP high) amoxicillin-clavulanate, phenytoin, valproate
Typical Sx of hepatitis A infection
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Fever, RUQ discomfort
Management of hepatic decompensation from cirrhosis / HCV infection not receiving antiviral Tx
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referral to liver transplantation (not all patients experience benefit from anti-viral Tx)
Tx for recurrent Sx of UC on tapering of steroid
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azathioprine (slow onset of action / alone Tx inappropriate) and infliximab (anti-TNF)
Management of ASA in the setting of lower GI bleed in established cardiovascular disease
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continue ASA (discontinuation a/w threefold increased risk of CV events)
What is Andexanet
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recombinant modified factor Xa protein, to reverse apixaban/rivaroxaban, but associated with MI, stroke, cardiac arrest, sudden death, ASH recommends four-factor prothrombin complex concentrates, instead
Source of Maroon stool
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lower GI source
Tx for severe ileocolonic Crohn disease
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azathioprine and infliximab
(Sulfasalazine (two component: 5–amiosalicylate and sulfapyridine) effective for mild-mod colonic Crohn disease, not effective for small-bowel Crohn disease)
Cause of Diarrhea including oil droplets in the setting of jejunal diverticulum
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small intestinal bacterial overgrowth (one of the causes of fat malabsorption)
Diagnostic test of small intestinal bacterial overgrowth
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glucose breath test (byproducts of bacterial metabolism of ingested glucose)
Management of pancreatic serous cystadenoma
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no further evaluation or intervention (multicystic, lobulated structure (“bunch of grapes”))
Type of Malignant potential pancreatic cyst
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mucin-producing cyst (intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm)
First Evaluation of young patients with dyspepsia for 6 months
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stool antigen testing for H.pylori (PPI trial if Ag negative, or fail to improve after eradication Tx)
Dx of melanotic macules in lips
->
Peutz-Jeghers syndrome
プーチイエガー
Management of multiple fundic gland polyps without dysplasia
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no follow-up endoscopy (common benign epithelial gastric polyp, dysplasia rare)
Timing of resuming anticoaglant Tx for Afib in the setting of GI bleed after hemostasis is certain
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within 7 days
Management of asymptomatic gallstone
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observation (prophylactic surgery not recommended, except for stone > 3cm, porcelain gallbladder, gallbladder polyp > 1cm)
Dx of germline genetic testing positive for MSH2 mutation
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Lynch syndrome
Management of Lynch syndrome
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(Increased risk for colorectal and endometrial cancer) screening with upper endoscopy and colonoscopy (capsule endoscopy is not recommended)
Evaluation of Pt with cirrhosis ℅ dyspnea on exertion with normal CXR
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TTE / portopulmonary hypertension
Diagnosis and evaluation of Pt with cirrhosis worsening oxygen sat while upright
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hepatopulmonary syndrome (pulmonary vasculature dilated -> Right to left shunt) / diagnosed by TTE with agitated saline
Pulmonary vascular dilation allows blood to flow too quickly, reducing the time for oxygen to be absorbed
Dx and Tx of patient with epigastric pain with nausea for 6 mo, H.pylori negative, PPI ineffective, normal endoscopy
->
functional dyspepsia /TCAs (nortriptyline)
Tx of mild traveler’s diarrhea
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loperamide
Tx of moderate to severe traveler’s diarrhea
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azithromycin or fluoroquinolone
Timing of fecal antigen test after H.pylori eradication Tx
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4 weeks after
Tx for persistent H.pylory infection after the first eradication Tx
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salvage Tx, not including any ABXs from the first regimen
Dx of HIV patient with dysphagia and odynophagia
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candida esphagitis (viral esphagitis associated more with odynophagia, than dysphagia)
Definitive Diagnostic test of gastroparesis
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4 hour gastric scintigraphy (endoscopy to rule out obstruction, but not diagnostic)
Tx of dermatitis herpetiformis in patient with celiac disease
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dapsone (antibiotic for leprosy, but also for skin conditions)
Test before starting dapsone
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glucose-6-phospate dehydrogenase activity (glucose-6-phosphate dehydrogenase deficiency develops hemolytic anemia)
Life modification of chronic pancreatitis
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tobacco cessation with alcohol cessation
Management of ASA as primary prevention after GI bleed
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Discontinue indefinitely
HLA-DQ2 / HLA-DQ8
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most patients with celiac disease carry
Management of patient highly suspected of celiac disease, but negative tissue transglutaminase IgA
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Repeat tissue transglutaminase IgA after resumption of gluten-containing diet (gluten-free diet reduce the sensitivity of the test)
Diagnosis of patient with bloody stools, colonoscopy showing inflamed mucosa that starts at the anorectal verge and extends proximally in a continuous and symmetric fashion to the splenic flexure, normal terminal ileum
->
UC (Crohn disease: skip lesion, spare rectum, ileocecal area commonly affected)
When to restart warfarin for 75 yo M hospitalized for GI bleed, EGD showing a large duodenal ulcer with an actively bleeding visible vessels, hemostasis achieved, no bleeding 24 hours after EGD, h/o Afib on warfarin and TIA
->
Restart now (antithrombotic Tx should be reinitiated within 7 days of initial drug discontinuation to avoid an increased risk for a thromboembolic event)
Ab for primary biliary cholangitis
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Antimitochondrial Ab
Symptoms of primary sclerosing cholangitis
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Pruritus, cholestatic pattern of liver enzyme abnormalities
Condition with positive Anti-smooth muscle Ab
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Autoimmune hepatitis (high titer (1:20 is low))
Management of 35 yo M with h/o GERD, on PPI bid, ℅ persistent cough, normal EGD 1 year ago
->
Ambulatory pH testing (extraesophageal Sx of GERD resulting from laryngopharyngeal reflux, ambulatory pH testing to confirm Dx of laryngopharyngeal reflux)
Initial Tx of chronic pancreatitis with worsening pain
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NSAIDs (use of simple analgesics, pancreatic enzyme replacement Tx less effective for persistent pain, but may improve fat absorption)
Next colonoscopy of 55 yo F with colonoscopy showing three polyps (3mm, 5mm, 6mm), excised, pathology showing hyperplastic
->
10 years (hyperplastic polyp is non-neoplastic, no clinical significance)
Tx of diarrhea-predominant IBS
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low-FODMAP diet (fermentable oligosaccharides, diasccharides, monosaccharides, and polyols), reducing abd pain and bloating
Management of functional dyspepsia not responding to omeprazole for 4 weeks
->
Tricyclic antidepressant
Management of 45 yo M with h/o bleeding gastric ulcer from NSAIDs having hip pain refractory to acetaminophen and tramadol
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Celecoxib + PPI (RCT showing ulcer bleeding 0% in pt with celecoxib + omeprazole vs 9% in pt with celecoxib alone)
Nutritional management of patient hospitalized 4 days ago for pancreatitis with necrosis, NPO for 4 days, with no appetite, T 100.4 BP 130/70, HR 90, abd tenderness in the epigastrium with no abd distention
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Initiate Enteral feeding (in mild case, oral feeding as soon as possible when N/V controlled, in mod-severe case, enteral feeding should begin within 72 hours)
Medication for refractory irritable bowel syndrome-constipation type
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Linaclotide (guanylate cyclase-C agonist)
Management of 26 yo F with 7 months h/o postprandial bloating, early satiety. No alarm features. Minimal epigastric tenderness without a succession splash. H.pylori negative
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Empiric PPI (then consider nortriptyline if no improvement)
Management of persistent rectal pain from anal fissure s/p sitz baths and topical hydrocortisone and improved constipation by medications
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Topical calcium channel blocker (rectal spasm is the major reason for anal fissure becoming chronic)
Management of 50 yo M with heartburn and regurgitation of gastric contents several times a week for 3 mo, on omeprazole bid, no other symptoms or signs
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Upper endoscopy (refractory GERD (failure to improve after 8 wks of BID PPI) requires EGD. To evaluate for complications, stricture, malignancy, or eosinophilic esophagitis)
Diagnosis of 58 yo F with 5 year history of slowly progressive dysphagia with both solid and liquid and regurgitation of undigested food without a/w heartburn, weight loss or chest pain
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Achalasia (Sx slowly progressive, waiting an average of 5 years before seeking medical attention)
What is bidirectional endoscopy
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EGD and colonoscopy
Tx for mild Crohn disease in the ileum and right colon
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Controlled ileal release budesonide (for induction of remission. Aminosalicylates (mesalamine) are effective in Tx of mild UC, but not Crohn disease)
Tx for patient with IBS-diarrhea predominant subtype refractory to diet low in FODMAPs, rifaximine, eluxadoline, alosetron, and loperamide
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Tricyclic antidepressant
Diagnostic test for 55 yo M with progressive halitosis, difficulty swallowing, intermittent regurgitation of undigested food for 4 months. H/o well controlled GERD. EGD unremarkable 1 year ago.
->
Barium esophagography (initial diagnostic test for Zenker diverticulum (pharyngoesophageal diverticulum). EDG more invasive)
Management of 45 yo M with h/o GERD, symptoms improved from daily to sporadic episodes of heartburn with omeprazole, which was discontinued 8 weeks after. Now daily symptoms have returned
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EGD (if Sx of GERD don’t respond to PPI or if Sx recur, EGD is indicated to evaluate for signs of GERD and to rule out other abnormalities)
How often compensated cirrhosis without varices need EGD surveillance
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Every 3 years
Management of 35 yo F, asymptomatic, two blood tests; AST 45-50 ALT 65-120 ALP 60-60 T-bil 1.1-1.1, US abdomen unremarkable, iron studies normal, hep B/C serologies negative
->
Antinuclear antibody (hepatocellular injury pattern -> check viral hepatitis, hemochromatosis, autoimmune hepatitis, wilson disease, If cholestatic injury pattern -> check antimitochondrial Ab)
Tx for IBS with predominant constipation refractory to first-line Tx
->
Linaclotide
Cholestyramine for what
->
Diarrhea related to bile acid malabsorption
