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USMLE2 Medicine 05


dysphagia diff swallowing
odynophagia pain on swallowing
best initial test for dysphagia or odynophagia barium swallow
best initial test if there is esophageal obstruction upper endoscopy
Achalasia idiopathic loss of the normal neural structure of the LES -- stays contracted.
progressive dysphagia to both solids and liquids simultaneously; regurgitation several hours after eating achalasia
how does EtOH and tob affect achalasia no relationship
dysphagia to solid foods that progresses to liquids, h/o EtOH and tob esophageal CA
what are alarm sx's of achalasia? what is the next step if a pt has this? Sound the WO BAD alarm 60+6 times! Wt loss, Odynophagia, Bleeding (FOBT+), Anemia, Dysphagia, onset >60yo, sx's >6mo. Next step is EGD (esophagogastroduodenoscopy)
Bird's beak on barium esophagography achalasia
what is the most accurate test for achalasia? esophageal manometry, which will show increased LES resting pressure
best initial therapy for achalasia pneumatic dilation
Therapy for achalasia (3) in order that they would be attempted 1. pneumatic dilation, 2. botulinum toxin injections, 3. surgical myotomy (reflux as complication in 20%)
describe the types of CA one sees in the esophagus and their location proximal 2/3: squamous cell CA (ass with EtOH and tob). distal 1/3: adenoCA (ass with GERD and Barrett esophagus).
How to dx esophageal CA? 1. endoscopy for bx, 2. CT to assess local spread, and 3. US to stage.
Tx of Esophageal CA resection is curative; also chemo with 5-FU and radiation.
LES in person with h/o scleroderma LES will neither contract nor relax - just like a constantly open tube
How to tx LES immobility in pt with scleroderma PPI (omeprazole) for reflux and metoclopramide for promotility of esophagus and bowels
34 yo man w no PMH complains of crushing chest discomfort and dysphagia. CP is not associated with exertion or eating, occ brought on my cold liquids. Nl EKG. Relieved with NTG. diffuse esophageal spasm/nutcracker esophagus
corkscrew pattern on barium swallow diffuse esophageal spasm/nutcracker esophagus
best test for diffuse esophageal spasm/nutcracker esophagus manometry -- will show high-intensity disorganized esophageal contractions (too disorganized to move food forward)
tx for diffuse esophageal spasm/nutcracker esophagus CCB (nifedipine) and nitrates
Schatzki's ring narrowing of the lower part of the esophagus by a ring of tissue that can cause difficulty swallowing.
episodic dysphagia with solid foods, or a sensation that the food "sticks" while swallowing, no pain Schatzki's ring
Plummer-Vinson Syndrome triad of WIG. Web --> dysphagia, Iron def anemia, Glossitis
burning sensation with the tongue and oral mucosa, and atrophy of lingual papillae produces a smooth, shiny red tongue dorsum Plummer-Vinson Syndrome
how are plummer-vinson, Schatzki's ring, and achalasia distinguished from each other? achalasia sx's are progressive, unlike PV and SchR. PV has Fe-def anemia.
location of Schatzki's ring vs. Plummer-Vinson web Sch - more distal, just proximal to the LES. PV - in the hypopharynx.
what CA is associated with PV syndrome? squamous cell CA of esophagus
who gets PVS most commonly? middle aged women
how to best dx an esophageal web? barium swallow
How to tx PVS? treat the Fe def anemia, then pneumatic dilation or surg
How to tx Schatzki's ring? pneumatic dilation or surg
What is the most common cause of esophagitis? Who gets it? Candida (1. HIV+, CD4<200; 2. DM pts)
pt with progressive odynophagia, HIV+. how to tx? Candida esophagitis. Tx empirically with fluconazole first, and then if no improvement, get upper endoscopy.
how to distinguish esophagitis pain from esophageal spasm? esophagitis pain only happens with swallowing - mechanical friction. Spastic pain occurs intermittently sometimes without swallowing
young pt taking meds for acne with acute onset of odynophagia pill esophagitis
Zenker diverticulum outpocketing of the posterior pharyngeal constrictor muscles at back of pharynx
older pt with bad breath, diff initiating swallowing, find regurgitated food from few days before on their pillow upon waking from sleeping Zenker diverticulum
how to dx Zenker diverticulum? barium swallow. CONTRAINDICATED: endoscopy or NG tube!!! (risk of perforation)
Tx of Zenker diverticulum surgical resection
Mallory Weiss Syndrome nontransmural tear of lower esophagus, ass with retching and vomiting
pt presents with painless hematemesis and black stool (melena), h/o bulemia Mallory Weiss tear
how to dx Mallory Weiss tear upper endoscopy
Tx for Mallory Weiss tear most spontaneously resolve. otherwise, can do sclerotherapy.
Ddx for epigastric pain (5) epigastric Pain Causes "UGG!" Pancreatitis, Cancer - gastric, Ulcers, Gastritis, GERD.
H.pylori associated with what (3) H.pylori DiGGs into the tummy. Duodenal and Gastric ulcers, Gastritis.
What is the most common reason for epigastric tenderness on palpation? pancreatitis
how to test for H.pylori (3) 1. serology (good negative predictive value, but can't tell if recent disease), 2. breath test, 3. stool antigen, 4. bx
What must you ensure if testing for H.pylori? off PPI's and abx for 1-2 wks prior (can give false negative)
If testing for eradication of H.pylori after treatment, which test to use? breath test or stool antigen (not serology)
Indications for endoscopy in pt with epigastric pain 1. > 45 yo (r/o CA), or 2. alarm sx's (bleeding, wt loss, dysphagia), or 3. pt who failed trial of PPI's
alarm sx's in epigastric pain sound the WO BAD alarm 60+6 times! Wt loss, Odynophagia, Bleeding (FOBT+), Anemia, Dysphagia, onset >60yo, sx's >6mo
what agents can cause decreased LES tone? nicotine, EtOH, caffeine, peppermint, chocolate, anti-cholinergics
pt with sore throat, metallic taste in mouth, substernal CP, recurs with lying down, hoarseness, cough and wheeze GERD
two types of surg to tighten LES 1. Nissen fundoplication, 2. circular purse string suture in LES
indication for surg for GERD need GERD surg if can't wear RL clothing. 1. Refractory to PPIs 2/2 side effects such as HA and diarrhea, 2. don't want to take Lifelong PPI's
Barrett esophagus complication of chronic GERD, squamous epithelium in lower esophagus --> columnar epithelium
how to manage pt with Barrett's repeat endoscopy q2-3y to check for dysplasia/CA
if low-grade dysplasia is found in Barrett's endoscopy, what to do? repeat endoscopy in 3-6 mo --> lesion progressed or resolved
if high-grade dysplasia is found in Barrett's endoscopy, what to do? distal esophagectomy to prophylax against invasive esophageal CA
when to do endoscopy in GERD pt? if pt has GERD > 5y or if they develop alarm sx's
Tx for Barrett's PPI's
What causes ulcers? what causes ulcers: CHaos IZ IN VT (Vermont) 1. gastric CA, 2. H.pylori, 3. IBD - Crohn's, 4. Zollinger-Ellison, 4. prolonged Intubation 5. NSAIDs, 6. mechanical Ventilation, 7. Trauma/burns
how to distinguish between duodenal and gastric ulcers? endoscopy
ulcer associated with pain on eating gastric
ulcer associated with relief of pain on eating duodenal
ulcer associated with tenderness to palpation consider perforation
Tx of H.pylori-related ulcer H.Pylori is cured in CA or Tennessee (TM). PPI + clarithromycin + amoxicillin OR PPI + tetracycline + metronidazole; 10-14d
Best way to dx ulcer dz endoscopy
If pt fails one course of treatment to eradicate H.Pylori, what do you do next? Tx with different abx and add bismuth subsalicylate
Indications for surg in PUD Need PUD surg if pt BRPs Goo. 1. Bleeding continues, UGIB not fixable by endoscopy, 2. refractory ulcers, 3. perforation, 4. gastric outlet obstruction
Causes of gastritis Type B (increased acid production) Gassy B subscribes to HEN TV. H.pylori, EtOH, NSAIDs, trauma/burns, mechanical ventilation
Causes of gastritis Type A (autoimmume/atrophy of gastric mucosa/decreased HCL production) Vit B12 deficiency - pernicious anemia
pt with super high gastrin levels consider achlrohydria (no HCl production). HCl usu inhibits gastrin release from G cells
What is MALT and what is its associated with cancer? mucosal-associated lymphoid tissue. MALT --> metaplasia --> dysplasia --> gastric CA
asymptomatic GI bleed (hematemesis or melena) consider gastritis
epigastric pain if not pancreatitis consider erosive severe gastritis
how to dx pernicous anemia? anti-parietal cell Abs and anti-IF Abs
how to tx pernicious anemia? B12 replacement. oral --> SL --> injection
Zollinger-Ellison excessive production of gastrin by gastrinoma (G cells in the stomach). G cells --> gastrin --> parietal cells --> HCl
gastrinoma associated with what other disease? MEN I (pan pit pth). Gastrinoma is a type of gastro-pancreatic tumor!
ulcer that is recurrent after therapy, multiple in number, and occur in the distal duodenum or resistant to routine therapy consider Zollinger Ellison Syndrome
diarrhea x6mo, h/o ulcer disease resistant to tx, hypercalcemia MEN I. pancreatic tumor (gastrinoma --> ulcer), pit, PTH (hyperCa)
how to diagnose Zollinger Eliison Syndrome? gastrin levels (pt must stop PPIs/H2 blockers several days before since suppression of HCl --> increased gastrin, which will give false positive)
secretin stiumlation test tests for gastrinoma. secretin usually suppresses gastrin release from G cells. If administrer secretin and gastrin levels still high--> abnormal, positive test.
causes of increased gastrin levels GAZTRin 1. chronic gastritis, 2. pernicious anemia, 3. Zollinger Ellison (gastrinoma), 4. hyper thyroidism, 5. renal failure
how to tx gastrinoma? if localized, surgically remove (curative), if metastatic, suppress with PPI's.
how to figure out if gastrinoma is metastatic? most sensitive test: endoscopic U/S. (can also use less effective nuclear test, U/S, CT, and MRI; good positive predictive value, but not good negative predictive value because not as sensitive)
most common cause of gastroparesis DM
pt with early satiety, post-prandial nausea, increased abdominal fullness, h/o DM, poor glycemic control, and peripheral neuropathy consider gastroparesis
If suspect gastroparesis in DM, what should you do? endoscopy to exclude other etiologies, then use erythromycin or metoclopramide (rarely need gastric emptying scan to dx)
pt with sweating, shaking, palpitations, and lightheadedness shortly after a meal dumping syndrome
what causes dumping syndrome? 1. chyme (hypertonic) --> duodenum --> osmotic pull into the duodenum --> decreased intravascular volume --> sx's. 2. glucose peak after eating --> insulin --> hypoglycemia.
how to tx dumping syndrome? no cure. eat multiple small meals
Created by: christinapham



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