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USMLE2 Medicine 06


how to best dx UC? how to best dx Crohn's? both with colonoscopy with bx
"string sign" on small bowel follow through Crohn's or colon CA. pt drinks contrast --> xrays of distal duodenum/duodenojejunal junction to the ileocecal valve.
how to tx acute exacerbations of UC? CD? high- dose steroids (budesonide)
CD or UC associated with palpable and painful abd masses? CD. Transmural granulomas in the bowel wall --> inflammed --> stick together --> form mass.
skip lesions CD (anywhere from mouth to anus)
large bowel involvement only - UC or CD? UC
fistula formation - UC or CD? CD
oral and perianal involvement CD
more likely to cause bloody diarrhea - UC or CD UC (with mucus)
What is UC/CD relationship with CA? IBD will lead to colon CA after 8 -10 years of colon involvement. If CD does not involve the colon, then it will not lead to CA.
Ca oxalate kidney stones and cholesterol gallstones associated with UC or CD? CD. Kidney stones 2/2 fat malabsorption --> low Ca + increased absorption of oxalate --> kidney stone formation
anti-Saccharomyces cerevisiae Ab's (ASCA) CD. AS-Crohn's
cANCA associated with what? UC and Wegener's
prothrombin time in Crohn's prolonged because of Vit K malabsorption
Mesalamine (3 drugs) anti-inflammatory (5-ASA) for IBD. PANtasa - released in upper and lower bowel - used in CD. AS(S)acol - released in colon - used in UC. Rowasa (Row around the Rectum) - used only for rectal disease.
side effects of sulfa drugs Sulfa is a HLR IN pts. Hemolysis, Leukopenia, Rash, Interstitial Nephritis (allergic)
IBD drugs 6-SAM. 6-mercaptopurine, Steroids for flares, Azathioprine, Mesalamine derivatives
what are azathioprine and 6-mercaptopurine associated with drug-induced pancreatitis
drugs to use in CD with perianal disease cipro and metronidazole
drug to use in CD if have fistulae or refractory disease infliximab
most common side effects of infliximab arthralgias
Surg in IBD - better for UC or CD? curative in UC. Not effective in CD and will recur at site of anastomosis.
which has more extra-intestinal manifestations? UC or CD? CD
which has more likely to have arthritis? UC or CD? CD
perianal disease - UC or CD? CD
mucosal cobblestoning Crohn's
fistulas, fissures, strictures Crohn's
lead pipe colon on barium enema UC
which form of IBD has risk for megacolon with perforation? UC
transmural lesions Crohn's
granulomas Crohn's
Crypt abscesses UC
what is the most important thing when assessing diarrhea is pt hypovolemic? (hypotension, orthostasis)
what to do if see bloody diarrhea abx (also, if fever)
w/u of diarrhea CBC, chem10, Stool (O&P, cx, WBC's)
most common causes of infectious diarrhea campylobacter and salmonella (esp in sickle cell and achlorhydria)
refried Chinese food b.cereus (spores, vomiting 1-6 h later, never blood)
infectious diarrhea in reactive arthritis or Guillian Barre campylobacter
diarrhea in HIV+ pt CD4<100 (2 organisms) Cryptosporidia or Isospora
pathogenesis of e. coli 0157:H7 hamburger meat --> Shiga toxin --> HUS once organism dies --> abx contraindicated (because don't want to kill them if they're in there!)
what is contraindicated in diarrhea caused by e. coli 0157:H7 abx and plt transfusions
unfiltered water in mountains Giardia (never blood, +fullness, bloating, gas)
chicken eggs, dairy products salmonella
vomiting, diarrhea, flushing, wheezing minutes after eating tuna, mahi mahi, mackerel Scombroid. Org invade fish --> histamine released into fish --> eating dish give you huge dose of histamine
raw shellfish, mussels, oysters, clams vibrio parahaemolyticus
raw shellfish in pts with liver disease or d/o iron metabolism vibrio vulnificans
associated with development of skin bullae vibrio vulnificans
child in day care, no WBCs or blood on stool studies viral
dairy products, eggs, salads --> mostly n/v 1-6 h after eating S. aureus
grouper, red snapper, barracuda --> 2-6 hours get diarrhea and neuro sx's (paresthesia, weakness, reversal of heat/cold Ciguiatera-toxin
when are fecal leukocytes positive? invasion of the intestinal mucosa --> bloody diarrhea (dysentery)
name all the organisms that can cause invasive bloody diarrhea S Sh C VP VV Y E. VV is the VP of Camp ShEY (chez) Surrender. Vibrio vulnificans, Vibrio parahaemolyticus, Campylobacter, Shigella, E.coli, Yersina, Salmonella
how to dx Cryptosporidiosis modified acid-fast stool
how to dx Giardia ELISA stool antigen
best empiric tx for infectious diarrhea cipro +/- metronidazole
how to tx scromboid poisoning? anti-histamine diphenhydramine
how to tx giardia metronidazole/tinidazole
how to tx Cryptosporidiosis paromomycin, raise CD4 >100 with antiretrovirals
abx most likely to cause C. diff diarrhea clindamycin, but really, any abx
how to dx C.diff stool c diff toxin
how to tx c.diff colitis oral metronidazole. oral vanc if refractory (can't use this IV because doesn't get through bowel wall). IV metronidazole if NPO.
how to dx lactose intolerance usu tx empirically but -- inc stool osmolality and inc osmolar gap (measured stool osmolality is greater than would be expected just by the Na and K --> extra osmoles from lactose. DDx (also panc insuff, celiac, bacterial overgrowth)
IBS irritable bowel syndrome, inc peristaltic contractions
abd pain, diarrhea/constipation, woman, h/o childhood abuse IBS
Dx IBS Rome criteria (at least 3 months). 1. Pain relieved by BM or change in bowel habit (developing diarrhea makes pain go away), 2. fewer sx's at night, 3. diarrhea alternating with constipation
What sx's DON'T you have in IBS? fever, wt loss, anorexia, anemia
Tx for IBS high fiber diet, anti-diarrheal agents (loperamide, alosetron), antispasmodics (hyoscyamine, belladonna), TCAs (anti-depressant, analgesic for neuropathic pain), tegaserod (for constipation)
Carcinoid syndrome tumor of the neuroendocrine system that releases serotonin. in GI (appendix, ileum, rectum) and lung (rare in bronchus). metastatic.
when does a pt get sx's of carcinoid syndrome? 1. when tumor is in bronchi --> serotonin directly into systemic circulation. 2. when liver is overwhelmed and can't metabolize all the serotonin anymore (late in dz)
Sx's of carcinoid syndrome Carcinoid has a FHx of DTR's. Flushing, HypoTN, Diarrhea, Tachy, Rash (niacin def)
what deficiency in Carcinoid and why? Serotonin and niacin both from tryptophan. Serotonin overproduction uses up tryptophan --> niacin deficiency.
endocardial fibrosis carcinoid (constant exposure of R heart to serotonin)
cardiac effects of carcinoid syndrome RH endocardial fibrosis, tricuspid insuff, pulmonic stenosis
Dx of carcinoid syndrome Urinary 5-HIAA level
Tx of carcinoid octreotide (somatostain analog, control diarrhea). if localized tumor --> resection (most often possible with bronchial)
Causes of fat malabsorption: all have steatorrhea and wt loss: celiac, pancreatitis, tropical sprue, Whipple disease, giardia
why do pts with malabsorption also have bleeding abnormalities and hypocalcemia? ADEK malabsorption, esp vit D (Ca) and vit K.
malabsorption where causes Fe deficiency? duodenum
Fe def anemia is what kind of anemia? Microcytic
malabsorption where causes B12 deficiency? terminal ileum
most common presentation of celiac disease Fe deficiency anemia
dermatitis herpetiformis celiac (skin rash on extensor surfaces)
severe UC attack Ulcerative colitis: definition of a severe attack A STATE: 1. Anemia less than 10g/dl, 2. Stool frequency greater than 6 stools/day with blood, 3. T >37.5, 4. Alb < 30g/L 4. Tachycardia greater than 90bpm, 5. ESR greater than 30mm/hr
Causes of pancreatitis GET SMASHED. Gallstones, EtOH, Trauma, Steroids, Mumps (paramyxovirus, other viruses - EBV/CMV, Autoimmune (PAN, SLE), Scorpion/Snake, HLP/HyperCa/Hypotherm, ERCP, Drugs (SAND - 6-mercaptopurine/sulfonamide, Azathioprine, NSAIDs, diuretics - furosemide)
Indications for surg in IBD IBD: surgery indications "I CHOP": Infection Carcinoma Haemorrhage Obstruction Perforation
extra-intestinal manifestations of IBD IBD: extraintestinal manifestations A PIE SAC: Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing of fingertips
Complications of UC Ulcerative colitis: complications "PAST Colitis": Pyoderma gangrenosum, Ankylosing spondylitis, Sclerosing pericholangitis, Toxic megacolon, Colon carcinoma
Crohn's sx's CHRISTMAS: Cobblestones, High temperature, Reduced lumen, Intestinal fistulae, Skip lesions, Transmural (all layers, may ulcerate), Malabsorption, Abdominal pain, Submucosal fibrosis
Whipple Disease infectious dz caused by Tropheryma whipplei. David DHALMO has Whipple's. Dementia/Diarrhea, Hyperpigmentation, Arthritis, LAD/fatty deposits in lymph nodes of the intestine, Malabsorption, Oculomasticatory myorhythmia. Also Fever.
Tropical sprue malabsorption disease commonly found in the tropical regions, marked with abnormal flattening of the villi and inflammation of the lining of the small intestine; not autoimmune like celiac is.
oculomasticatory myorhythmia pendular vergence oscillations of the eyes and synchronous contractions of the masticatory but not palatal muscles) is pathognomonic of Whipple disease
anti-gliadin Celiac's
anti-endomysial Celiac's
anti-transglutaminase Celiac's
how to diagnose Celiac's and what do you find? small bowel bx, find flattening of villi
Why does chronic pancreatitis cause VitB12 deficiency? B12 requires proteases from the pancreas to be cleaved from its carrier in the duodenum so that it can attach to IF. only when B12 is attached to IF can it be absorbed in the terminal ileum.
Why are Vit K and Ca malabsorbed in Celiac's Vit K is a fat-soluble vitamin that is absorbed in the terminal ileum, which is damaged in Celiac's. Ca requires Vit D, which is also a fat-soluble vitamin. Also, when fat is not absorbed, it binds to Ca.
how is tropical sprue diagnosed? bowel wall bx showing the organism that caused it
Most sensitive test for Whipple Disease PCR of bowel bx showing Tropheryma whippelli
bx that shows foamy macrophages that are PAS + Whipple Disease
Tx of chronic pancreatitis oral enzyme replacement
tx for tropical sprue bactrim (SMZ/TMP) or doxy x 6mo
tx for Whipple disease bactrim (SMZ/TMP) or doxy or CTX x 1yr
Diverticulosis outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. more common in sigmoid colon - a common place for increased pressure.
Who gets diverticulosis >40 yo, increasing with age
What causes diverticulosis? lack of fiber --> decreased bulk in stool --> increased intracolonic P --> outpocketing of colon
colicky LLQ pain, 60yo man, painless bloody stool diverticulosis
Dx of diverticulosis colonoscopy
diverticula more common where in the bowel? Bleeding more commonly from where? L -- diverticula more common, R -- bleeding more common because of thinner mucosa
diverticulitis infection in one of the diverticula (entrance to diverticula blocked by something like corn or nut)
fever, LLQ tenderness, increased WBC, h/o diverticulosis consider diverticulitis
how to dx diverticulitis CT
what studies are contraindicated in diverticulitis? endoscopy and barium since danger of perforation
tx for diverticulitis abx (cipro and metronidazole)
tx for diverticulosis more fiber in diet
how do TCA's and CCB's affect bowel movements cause constipation
risk factors for colon CA fam hx (most are sporadic), smoking, high fat and high red meat diet
which side of colon is affected if pt comes in with heme-positive brown stool and chronic anemia R
which side of the colon is affected if pt comes in with narrowing of stool caliber or obstruction? L or sigmoid
what bacteria is associated with colon CA S bovis, clostridium septicum
pt comes in with endocarditis from Strep bovis. what should be considered? w/u for colon CA (also for clostridium septicum)
dx colon ca colonoscopy with bx
resectable vs non-resectable colon CA resectable if localized and not touching outermost layer (serosa) or nodes
Tx for colon CA resect if not spread beyond muscularis layers (before the serosa); chemo if spread (use 5FU); if only 1 liver met then resect.
screening for colon CA FOBT qyr; sigmoidoscopy q5yr; colonoscopy q10yr. starting at age 50.
what causes false + FOBT? false -? Fe, red meat, poultry, ASA, NSAIDs. False - caused by Vit C.
What happens if a polyp is found on colonoscopy? repeat colonoscopy q3-5yr
when should screening begin for someone with fam h/o colon CA? at 40, or 10 years earlier than the youngest age of diagnosis in family member, whichever comes first
Lynch Syndrome Hereditary Non-polyposis - HN. 3 family members in at least 2 generations with colon CA, at least 1 dx <50.
Cancers associated with Lynch Sydrome Hereditary Non-polyposis. Colon CA by definition, but also Ovarian and Endometrial. Lynch Amy COE!
CA screening for people with family h/o Lynch syndrome colonoscopy q yr starting at age 25
Familial Adenomatous Polyposis gene APC - adenomatous polyposis coli
what is the chance that a pt will develop colon CA if they have the APC gene? 100% chance of adenoma by age 35 (usu polyps by age 25), and colon CA by age 50.
CA screening for people with family h/o Familial Adenomatous Polyposis (FAP) flex sig q1-2yr starting at age 12!!!
Prophylaxis for Familial Adenomatous Polyposis as soon as polyp found, perform COLECTOMY and make NEW RECTUM from terminal ileum!
Juvenile Polyposis Syndrome (JPS) - how much risk for colon CA? 10%
Difference in polyps found in Familial Adenomatous Polyposis vs. Juvenile Polyposis Syndrome Familial Adenomatous Polyposis polyps are adenomas. Juvenile Polyposis Syndrome polyps are hamartomas (much less risk of developing into CA)
rectal bleeding in childhood Juvenile Polyposis Syndrome or Cowden Syndrome
Cowden Syndrome genetic polyposis syndrome with harmartoma polyps, only slightly inc risk of colon CA compared to general population
Gardner Syndrome Colon CA + soft tissue tumors (osteomas, lipomas, cysts, fibrosarcomas)
mandible osteoma Gardner Syndrome - do colonoscopy looking for colon CA!
how to dx Gardner Syndrome colonoscopy
Peutz Jehgers Syndrome harmatomatous polyps in bowels with hyperpigmented melanotic spots on lips, buccal mucosa, and skin.
Harmartomatous polyps Peutz Jehgers, Cowden Syndrome, Juvenile Polyposis Syndrome. PJ had to use GPS (JPS) to get to her C/S to deliver her baby Hamma (Hannah).
Peutz Jehgers Syndrome and risk of colon CA only slightly more than general population
abd pain due to obstruction or intussusception, plus hyperpigmentation on lips and skin Peutz Jehgers Syndrome
xray finds osteoma. what would you do? Gardner Syndrome - do colonoscopy looking for colon CA!
Turcot Syndrome Colon CA with CNS malignancy. Turban made of colon wrapped about the head (CNS).
what is the most important step when pt presents with significant GIB? fluid resuscitation
pt has active GIB + elevated PT. what should pt get? fluid resuscitation PLUS FFP
Pt has active GIB and plt <50K. what should you do? fluid resuscitation PLUS plt transfusion
pt with active GIB and h/o cirrhosis. what should you do? fluid resuscitation PLUS octreotide (decreases portal htn)
pt with GIB and gastritis or h/o ulcer. What should to start? fluid resuscitation PLUS PPI (not H2 blocker)
T or F: 80% of GIB will spontaneously resolve with supportive therapy, regardless of etiology true
dx GIB colonoscopy
pt with GIB and esophageal varices. What should to start? IVF and octreotide to lower portal htn
if supportive therapy does not work for bleeding esophageal varices, then what? banding via emergency endoscopy or sclerotherapy or TIPS (transjugular intrahepatic portosystemic shunting - connects portal vein to hepatic veins so that blood bypasses liver and decrease PHTN)
complication of TIPS procedure worsening of hepatic encephalopathy
pt has portal HTN and esophageal varices. what drug should they be on? propranolol - decreases frequency of bleeding
most common causes of UGIB bleeding proximal to the ligament of Treitz. Ddx: ulcer, gastritis, Mallory Weiss, esophagitis and gastric CA. UGMEC. Upper GastroEnterology Can Make the diagnosis.
UGIB with h/o AAA repair in last year think: aortic-enteric fistula
DDx for LGIB diverticulosis, AVM, hemorroids, CA, IBD. CHADI has LGIB
red blood in stool vs. black stool or melena red blood- LGIB vs. black stool or melena - UGIB
melena indicates how much blood has been lost? at least 100mL
orthostasis - in terms of HR >10 rise in HR when pt lying to standing/sitting
orthostasis in terms of BP >20 pt drop in SBP from lying to standing/sitting
what does orthostasis indicate in terms of volume 15-20% blood loss or decrease in intravascular volume
HR > 100/min or SBP <100 indicates what? >30% blood loss
how to detect low volume GIB? nuclear bleeding scan
two most common causes of endoscopy EtOH and gallstones
what causes the pathology in pancreatitis? premature activation of trypsinogen into trypsin while still in the pancreas --> autodigestion of pancreas
midepigastric pain that radiates through to the back, tenderness, n/v pancreatitis
Cullen sign blue discoloration around the umbilicus --> hemoperitoneum
Turner's sign Must "turn" to flanks to see Turner's. Blue-ish purple discoloration around the flanks --> tissue catabolism of Hb --> bleed
which is better in pancreatitis? amylase or lipase? lipase more specific to the pancreas
Best test for pancreatitis CT
Ranson criteria for pancreatitis: at admission "GA LAW": Glucose >200, AST >250, LDH >350, Age >55 y.o., WBC >16000
Ranson criteria for pancreatitis: initial 48 hours "C & HOBBS" (Calvin and Hobbes): Calcium < 8, Hct drop > 10%, Oxygen < 60 mm, BUN > 5, Base deficit > 4, Sequestration of fluid > 6L
best test to see biliary and pancreatic ductal pathology ERCP
test to predict severity of pancreatitis Urinary trypsinogen activation peptide
tx for pancreatitis. what if there's pancreatic necrosis? necrosis and fever? necrosis and infection? bowel rest, pain meds, IVF. If necrosis on CT scan: abx (imipenum). If necrosis and persistent fever: percutaneous needle bx. If infection + necrosis, then surgical debridement.
when do pancreatic pseudocysts occur? 2-4 weeks after episode of pancreatitis.
When do you need to drain a pancreatic pseudocyst? pain, fistula, rupture, expanding (when cyst is >5cm)
most common cause of cirrhosis in US EtOH
most common reason to need a liver transplant HepC
Causes of cirrhosis Cirrhosis is caused by a HEPatitis WASH. HepC, EtPH, Primary biliary cirrhosis, Wilson’s disease, A-1-anti-trypsin deficiency, Sclerosing cholangitis, Hemochromatosis.
physical manifestations of cirrhosis ascited, peripheral edema, spider angiomata, palmar erythema, asterixis, encephalopathy, jaundice & pruritis
where are clotting factors made? all clotting factors are made in the liver except F8 and vWF (these are made in EC's)
how to diagnose SBP? spontaneous bacterial peritonitis if WBC>500/mm3, neutrophils >250/mm3 on paracentesis
tx SBP cefotaxime or CTX PLUS albumin (decreases risk of hepato-renal syndrome)
SAAG and its interpretation of ascites fluid serum ascites albumin gradient. the diff btwn the two is usually >>1 because serum albumin is way greater than albumin in ascetic fluid. if SAAG > 1.1, PHTN or cirrhosis is usu cause of ascites. If SAAG <1.1, albumin in ascites is high --> CA or infxn
what is a complication of cirrhosis? hepatocellular CA
what is the diuretic most effective in cirrhosis? why? spironolactone. cirrhotic pts have intravascular volume depletion --> high aldosterone (keeps Na, H2O, excretes K H). Spironolactone blocks aldosterone.
how to treat hepatic encephalopathy. how does the drug work? neomycin or lactulose. nonabsorbed disaccharide that bacteria metab in colon --> makes colon more acidic --> NH3 to NH4+ --> NH4+ isn't absorbed well --> excretion of ammonia
is it effective to give Vit K to cirrhotic pts with coag problems? no because the liver isn't able to synth clotting factors
what is primary biliary cirrhosis? idiopathic autoimmune d/o. damage of the small biliary ducts in the liver--> bile builds up --> damage to liver
who gets primary biliary cirrhosis? middle aged women
how often do we see high bili leves in pt with primary biliary cirrhosis? only if the disease is very very advanced
primary biliary cirrhosis is associated with what other autoimmune diseases? Sjogren, RA, and scleroderma
middle aged woman with fatigue, pruritis, with elevated alkPhos/GGTP, nl LFT's, and osteoporosis primary biliary cirrhosis
what is the most specific blood test for primary biliary cirrhosis? anti-mitochondrial Ab
tx for primary biliary cirrhosis no real tx. UV light for pruritis, liver txplt for late stage disease
primary sclerosing cholangitis progressive inflammation and scarring of the bile ducts of the liver (2/2 autoimmunity) --> impedes flow of bile to the gut --> cirrhosis/failure/CA. definitive treatment is liver transplantation.
anti-mitochondrial Ab primary biliary cirrhosis. Mity-mouse - PB and Chocolate
primary sclerosing cholangitis is associated with what disease IBD, most likely UC
most specific test for primary sclerosing cholangitis ERCP or transhepatic cholangiogram. this is the only chronic liver disease in which liver bx is not most accurate test
primary sclerosing cholangitis tx no cure. could try cholestyramine (bile-acid-binding resin), UV light for pruritis, liver txnsplnt for late stage.
hemochromatosis over-absorption of Fe in duodenum --> Fe buildup in other tissues --> chronic hepatic inflammation/fibrosis (cirrhosis)
hemochromatosis associated with what CA? hepatocellular CA
what cardiac condition associated with hemochromatosis? restrictive cardiomyopathy
what infections are associated with hemochromatosis Vibrio vulnificans and yersinia because of their affinity for Fe. VV and Yersinia love pumping iron!
Screening test for hemochromatosis. What is best test? Screen is Fe blood level. Dx is liver bx.
Tx of hemochromatosis phlebotomy to remove large amounts of Fe from body. deferoxamine in pts who can't undergo phlebotomy.
pt presenting with choreoathetoid movements and psychosis. what should you do next? do slit lamp exam --> kayser-fleischer rings --> Wilson's disease
Wilson disease genetics autosomal recessive
Wilson disease can't excrete Cu, inc absorption of Cu thru intestines; Cu buildup makes one feel BLE. Brain, Liver, Eye. in brain (basal ganglia - choreoathetosis), liver, cornea (Kayser Fleischer rings).
kidney problems in Wilson disease Cu deposition in kidney --> Fanconi Syndrome (fanCuKidni). Loss of HCO3 in Fanconi will lead to type 2 proximal renal tubular acidosis.
Fanconi Syndrome disease of the proximal renal tubules of the kidney in which glucose, amino acids, uric acid, phosphate and bicarbonate are passed into the urine, instead of being reabsorbed
Tx for Wilson disease penicillamine - chelator. liver txplnt is curative.
a-1-antitrypsin deficiency genetics autosomal recessive
cirrhosis and emphysema in a young person, never smoker a-1-antitrypsin deficiency
dx a-1-antitrypsin deficiency blood level of enzyme
tx for a-1-antitrypsin deficiency none. enzyme replacement and don't smoke
Dx Hep B and Hep C Hep B - HepB surface antigen (HBsAg) persists >6mo. HepC - Ab to Hep C + elevated viral load by PCR. Most accurate for both is liver bx.
Tx for HepB interferon, lamivudine, or adefovir
Tx for Hep C pegylated interferon AND ribavarin
Created by: christinapham



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