GI Board Review 2008

1
GI Board Review2008

• Louis Chaptini, MD

2
Esophagus

• GERD
• Heartburn
• Regurgitation
• Retrosternal burning
• Atypical manifestations
• Chest pain
• Asthma
• Aspiration
• Chronic cough
• Hoarseness
• Chronic laryngitis
• Dental erosions

3
Esophagus

• 53 y/o with 10 y hx of heartburn presents to your
  OP clinic. The next step in the evaluation
• Endosocpy
• Nexium 40 mg qd
• CBC
• Order esophageal manometry
• 24 hr pHmetry

4
Esophagus

• 53 y/o with 10 y hx of heartburn presents to your
  OP clinic. The next step in the evaluation
• Endoscopy
• Nexium 40 mg qd
• CBC
• Order esophageal manometry
• 24 hr pHmetry

5
Esophagus

• Lifestyle modification
• Weight loss
• Stop smoking
• Elevate head of bed
• Allow enough time between dinner and sleeping

6
Esophagus

• H2Receptor blocker
• PPI
• Most rapid and complete symptom relief
• Faster mucosal healing
• Endoscopy
• Screen for Barretts in long standing symptoms
• If alarm symptoms
• Dysphagia
• Anemia/Bleeding
• Weight loss

7
Esophagus

• Antireflux surgery
• Same efficacy as PPI
• Before surgery esophageal manometry is necessary
• pHmetry
• To confirm the diagnosis in non erosive GERD
• Evaluate patients not responding to therapy
• Evaluate extraesophageal manifestations of GERD

8
Esophagus

• What is the most common cause of non cardiac
  chest pain?
• Esophageal spasm
• Nutcracker esophagus
• Achalasia
• GERD
• Biliary disease

9
Esophagus

• GERD is the most common cause of non cardiac
  chest pain
• The diagnosis is confirmed by 24h pHmetry or
  successful trial of PPI (usually high dose and
  for long term)

10
Esophagus

• The patient in the first case had an EGD with
  biopsy of an irregular GE junction that showed
  intestinal metaplasia/goblet cells.
• What is your diagnosis?
• What is the associated risk?
• How do you treat/manage this patient?

11
Esophagus

• Barretts occurs in patients with early age at
  onset and long standing heartburn
• Adenocarcinoma is now as frequent as squamous
  cell carcinoma
• Barretts is present in up to 10 of patients
  with GERD
• Screening for Barretts is appropriate in
• Older patients (gt50)
• Long-standing GERD symptoms (gt5 years, MKSAP 13
  gt1 year)
• Especially white men

12
Esophagus

• Periodic mucosal biopsy to look for dysplasia
• Esophagectomy should be considered with high
  grade dysplasia
• Smoking and drinking are risk factors for
  squamous cell cancer

13
Esophagus
14
Esophagus

• Dysphagia
• Weight loss think Cancer
• Intermittent web, ring
• Solid and liquid neuromuscular, diffuse
  esophageal spasm, scleroderma, achalasia
• Chronic GERD peptic stricture

15
Esophagus

• Achalasia
• Lack of peristalsis
• Incomplete relaxation of LES
• Dg on esophageal manometry
• Pneumatic dilation or surgical myotomy
• Diffuse Esoph Spasms
• Simultaneous contractions with intermittent
  normal peristalsis
• Nitrate, calcium channel blocker

• Nutcracker Esophagus
• High amplitude peristaltic contractions
• Hypertensive LES
• High LES pressure
• Normal LES relaxation
• Ineffective motility
• With scleroderma
• Weak peristalsis
• Low LES

16
Esophagus

• 33 y/o men with HIV, unknown CD4 count, presents
  for odynophagia for the past couple of days. He
  was taking doxycycline for one week.
• What is your differential diagnosis?
• How do you confirm it?

17
Esophagus
18
Esophagus

• Pill esophagitis always on the board
• HIV patient with odynophagia
• Candida
• HSV
• CMV
• Idiopathic ulcer
• Severe esophagitis secondary to GERD can cause
  odynophagia

19
PUD

• What are the 2 most common causes of PUD?
• NSAID
• H.Pylori
• Steroids
• Idiopathic

20
PUD

• H.Pylori is responsible of
• 50 to 80 of duodenal ulcers
• 40 to 60 of gastric ulcers
• 80 of gastric cancers
• 90 of gastric lymphomas
• The lifelong incidence of ulcer disease in those
  infected with H.Pylori is only 20

21
PUD

• You find an ulcer in the antrum of a 43y/o female
  who presented for dyspepsia. Whats the next
  step?
• Biopsy
• Check H.Pylori serology
• Start PPI

22
PUD

• You find an ulcer in the antrum of a 43y/o female
  who presented for dyspepsia. Whats the next
  step?
• Biopsy
• Check H.Pylori serology
• Start PPI

23
PUD

• Gastric ulcers should be biopsied to R/O
  malignancy, as opposed to duodenal ulcers.
• H.Pylori should be checked, usually on biopsy, if
  not possible serology is appropriate
• Detection of H.Pylori
• Endoscopic
• Culture
• Histology
• Urease testing

• Non Endoscopic
• Antibody tests
• Urea breath test
• Fecal antigen test

24
PUD

• Treatment regimens
• PPI/Amox/Clarithromycin
• PPI/Flagyl/Clarithromycin
• PPI/Peptobismol/Flagyl/Tetracycline
• 14 days better than 10 days

25
PUD

• Risk factors for NSAID induced GI complications
• Advanced age (gt75)
• Pre-existing ulcer disease
• Multiple NSAIDs or high dose NSAIDs
• Concomitant steroid therapy or anticoagulant
  therapy
• Comorbid diseases

26
PUD

• Eradicating H.Pylori in NSAID users is still
  controversial
• But if NSAID induced gastropathy with H.Pylori,
  eradication is indicated
• NSAID gastropathy is a dose related phenomenon
• COX-2 selective NSAID result in fewer GI ulcers

27
Dyspepsia

• Endoscopy is indicated if
• Age greater than 50
• Alarm symptoms (weight loss, anemia)
• Patient concerned about serious disease
• Otherwise, test for H.Pylori
• If (), treat
• If (-) , trial of H2Blocker or PPI

28
Case

• 65 y/o presents with N/V, found to have thickened
  gastric folds. Differential includes
• Zollinger Ellison
• MALT
• H.Pylori infection
• Menetriers disease
• All of the above

29
Case

• 65 y/o presents with N/V, found to have thickened
  gastric folds. Differential includes
• Zollinger Ellison
• MALT
• H.Pylori infection
• Menetriers disease
• All of the above

30
Case

• Biopsy was consistent with MALT lymphoma
• Treat H.Pylori if present
• Send for gastrectomy
• Chemotherapy
• Observation since its a benign condition

31
Case

• Biopsy was consistent with MALT lymphoma
• Treat H.Pylori if present
• Send for gastrectomy
• Chemotherapy
• Observation since its a benign condition

32
MALT/ZE

• 70 to 80 of MALT will regress when H.Pylori is
  eradicated
• Think about ZE when
• Recurrent ulcers on treatment
• Chronic diarrhea
• Other endocrine disorders (MEN)

33
Case

• 46 y/o with type I diabetes presents for N/V,
  early satiety, vague epigastric pain for the past
  4 months. His condition will improve with
• PPI
• Low fat diet, small meals, control of DM, and
  Reglan
• Eradication of H.Pylori if present

34
Case

• 46 y/o with type I diabetes presents for N/V,
  early satiety, vague epigastric pain for the past
  4 months. His condition will improve with
• PPI
• Low fat diet, small meals, control of DM, and
  Reglan
• Eradication of H.Pylori if present

35
Gastroparesis

• Causes
• Drugs
• Systemic disease (DM, Scleroderma..)
• Idiopathic, post viral
• Diagnosis
• Gastric Emptying Scan
• Treatment
• Prokinetics
• Surgery
• Nutritional support

36
Case

• 37 y/o female with epigastric pain is found to
  have lipase level of 1050. Her management
  includes the following except
• IV fluids
• Pain meds
• RUQ US
• ERCP
• NPO

37
Case

• 37 y/o female with epigastric pain is found to
  have lipase level of 1050. Her management
  includes the following except
• IV fluids
• Pain meds
• RUQ US
• ERCP
• NPO

38
Acute Pancreatitis

• The most common cause is
• Gallstones
• P. Divisum
• Alcohol
• Medication
• Trauma
• Hypercalcemia
• High triglycerides

39
Acute pancreatitis

• True or False
• Idiopathic pancreatitis 10 of cases
• Cholecystectomy is indicated after the second
  bout of IP pancreatitis
• The management of necrotizing pancreatitis should
  be in ICU setting, may include CT guided
  aspiration and Abx therapy and sometimes surgical
  debridement
• Ransons score is calculated at presentation and
  is the best prognostic factor

40
Acute pancreatitis

• True or False
• Idiopathic pancreatitis 10 of cases
• Cholecystectomy is indicated after the second
  bout of IP pancreatitis
• The management of necrotizing pancreatitis should
  be in ICU setting, may include CT guided
  aspiration and Abx therapy and sometimes surgical
  debridement
• Ransons score is calculated at presentation and
  is the best prognostic factor

FALSE
TRUE
TRUE
FALSE
41
Case

• 55 y/o male with a history of chronic alcohol
  abuse presents with early satiety, nausea and
  vomiting. On exam he has a non tentder epigastric
  mass. The most likely dg
• Pancreatic abscess
• Pseudocyst
• Gastric cancer
• Pancreatic cancer

42
Case

• 55 y/o male with a history of chronic alcohol
  abuse presents with early satiety, nausea and
  vomiting. On exam he has a non tentder epigastric
  mass. The most likely dg
• Pancreatic abscess
• Pseudocyst
• Gastric cancer
• Pancreatic cancer

43
Chronic pancreatitis

• True or False
• Gallstones are the most common cause of chronic
  pancreatitis
• The characteristics of chr panc are pain,
  steatorrhea, diabetes and pancreatic
  calcification
• The presence of a pseudocyst is an indication for
  drainage to prevent infection
• Endoscopic drainage is only indicated if the panc
  duct is dilated

44
Chronic pancreatitis

• True or False
• Gallstones are the most common cause of chronic
  pancreatitis FALSE
• The characteristics of chr panc are pain,
  steatorrhea, diabetes and pancreatic
  calcification TRUE
• The presence of a pseudocyst is an indication for
  drainage to prevent infection FALSE
• Endoscopic drainage is only indicated if the panc
  duct is dilated TRUE

45
Chronic pancreatitis

• Complications of chr panc
• Infection
• Pseudocyst
• Hemorrhage
• Fistulas
• Pancreatic enzymes have little or no effect on
  pain but help with steatorrhea

46
Autoimmune pancreatitis

• Chronic pancreatitis with hypergammaglobulinemia
  (IgG4)
• Diffuse enlargement of the pancreas
• Irregular main pancreatic duct and strictured CBD
• Association with other autoimmune dz

47
Case

• 67 y/o male presents with weight loss, fatigue,
  anorexia and painless jaundice. What is your
  diagnosis?
• Lymphoma
• Pancreatic adenocarcinoma
• Cystic neoplasm of the pancreas
• Biliary stricture
• choledocholithiasis

48
Pancreatic adenocarcinoma

• The management of pancreatic cancer includes
• Tissue diagnosis
• Surgery if
• No metastsases
• No local invasion
• No vascular encasement
• Whipple procedure (pancreaticoduodenectomy)
• Palliative treatment

49
Diarrhea

• 32 y/o female presents with 2 day hx of crampy
  abdominal pain and bloody diarrhea
• What is your differential?
• What if she is 75 y/o and has CAD and PVD?
• How do you manage this patient? Would you start
  abx?

50
Diarrhea

• The most common causes of acute bloody diarrhea
• Infectious dysentery
• IBD
• Ischemic colitis

51
Diarrhea

• Common causes of infectious dysentery
• Campylobacter, Salmonella
• Shigella, E.Coli
• Yersinia, Entameba, Aeromonas, Plesiomonas
• Seafood induced dysentery
• Vibrio parahemolyticus (mainly watery but can be
  bloody)
• Plesiomonas shigelloides
• Campylobacter

52
Diarrhea

• Parasites that cause bloody diarrhea
• Entamoeba Histolytica
• Balantidium Coli
• Dientamoeba fragilis
• Schistosomas
• Parasites that non-bloody diarrhea
• Giardia
• Cryptosporidiosis
• Cyclospora

53
Diarrhea

• 45 y/o male with HIV presents with bloody
  diarrhea. The differential includes all of the
  following except
• Gono, chlamydia, syphilis, Herpes
• CMV
• TB, Histoplasmosis
• Cyclospora

54
Diarrhea

• 45 y/o male with HIV presents with bloody
  diarrhea. The differential includes all of the
  following except
• Gono, chlamydia, syphilis, Herpes
• CMV
• TB, Histoplasmosis
• Cyclospora

55
Diarrhea

• HIV with non bloody diarrhea
• Cryptosporidium
• Isospora Belli
• Cyclospora
• Microsporidia
• Giardia
• MAI

56
Diarrhea

• 4 hours after eating in a restaurant, a healthy
  men presents to the ER with several episodes of
  watery diarrhea. All of the following are
  possible except
• Bacillus cereus
• Staph aureus
• E.coli

57
Diarrhea

• 4 hours after eating in a restaurant, a healthy
  men presents to the ER with several episodes of
  watery diarrhea. All of the following are
  possible except
• Bacillus cereus
• Staph aureus
• E.coli

58
Diarrhea

• True or False
• Rotavirus, Calciviruses (Norwalk), Adenovirus are
  all causes of acute diarrhea
• E.coli O157H7 should be treated with quinolones
• Entertotoxigenic E.Coli is associated with HUS in
  10 of the cases
• Yersinia Enterolytica can mimic appendicitis
• C.diff recurs in 20 of cases after successful
  treatment

59
Diarrhea

• True or False
• Rotavirus, Calciviruses (Norwalk), Adenovirus are
  all causes of acute diarrhea TRUE
• E.coli O157H7 should be treated with Quinolones
  FALSE
• Entertotoxigenic E.Coli is associated with HUS in
  10 of the cases FALSE
• Yersinia Enterolytica can mimic appendicitis TRUE
• C.diff recurs in 20 of cases after successful
  treatment TRUE

60
Diarrhea

• 45 y/o obese female presents for chronic diarrhea
  for the past 4 months. Stool studies and
  colonoscopy were normal. Stool Na 30, K 40.
• What is the fecal osmotic gap in her?
• Would a stool pH be helpful in this case?
• What is your differential?

61
Diarrhea

• Fecal osmotic gap
• 280 2 x (NaK)
• If gt50? osmotic diarrhea
• Iflt50? secretory diarrhea
• With laxative abuse, the stools are acid (low
  pH), they will turn red with alkalinization

62
Diarrhea

• Causes of osmotic diarrhea (gapgt50)
• Lactose intolerance
• Laxative abuse
• Intestinal malabsorption (celiac disease)
• With fasting ? less than 500g of stools

63
Diarrhea

• Causes of secretory diarrhea (gaplt50)
• Enterotoxin mediated infectious diarrhea
• Hormone mediated (gastrin, VIP, serotonin,
  calcitonin)
• Secreting villous adenoma
• Microscopic colitis
• With fasting ? more than 500g of stools

64
Diarrhea

• Inflammatory diarrhea
• Neutrophils in the stools, colonic ulcerations
• Causes
• IBD
• Radiation colitis
• Enteroinvasive infections

65
Diarrhea

• Large volume
• Think about a proximal origin (small bowel..)
• Small volume
• Distal source (colonic..)
• Always look at the medications
• Endocrine causes DM, Hyperthyroidism
• C.diff and Giardia can give chronic diarrhea

66
Diarrhea

• 42 y/o male with iron deficiency anemia and
  chronic diarrhea. GI work-up including EGD,
  colonoscopy, capsule endoscopy is negative.
• Whats your diagnosis?
• Whats the next step?
• Whats the gold standard for the diagnosis?
• What is the skin manifestation associated with
  this condition?

67
Diarrhea

• Celiac sprue is caused by sensitivity to gluten
  and is characterized by malabsorption and
  diarrhea
• Antibodies to Gliadin, Endomysium and tissue
  transglutaminase are used for the diagnosis
• Small bowel biopsy is the gold standard for the
  diagnosis
• Complications include lymphoma, ulcerative
  jejunoileitis
• Dermatitis herpetiformis is the associated skin
  condition
• Tropical sprue is infectious in source and is
  identical to celiac sprue, Klebsiella and E.coli
  are incriminated.

68
Diarrhea

• 45 y/o male lost 150 cm of ileum after an MVA and
  extensive abdominal surgery. He presents with
  diarrhea. TRUE or FALSE
• Cholestyramine will help and should be tried
• Antidiarrheal agents should be used
• Cholestyramine will worsen the diarrhea

69
Diarrhea

• 45 y/o male lost 150 cm of ileum after an MVA and
  extensive abdominal surgery. He presents with
  diarrhea. TRUE or FALSE
• Cholestyramine will help and should be tried
  False
• Antidiarrheal agents should be used True
• Cholestyramine will worsen the diarrhea True

70
Diarrhea

• This is a guaranteed question
• If resection is lt 100 cm, cholestyramine helps
  because the diarrhea is caused by colonic
  irritation by bile salts (bile salt diarrhea)
• If resection is gt 100 cm, the bile salt pool is
  depleted and cholestyramine will NOT help.
• Memorize
• RESECTIONlt100cm?CHOLESTYRAMINE

71
IBD

• Can simulate appendicitis
• Skip areas on endoscopy
• Smoking is protective in
• Granulomas found on bx
• Crypt abscesses
• Enterocutaneous fistulas
• 75 positive for p-ANCA

Crohns disease UC
72
IBD

• Can simulate appendicitis
• Skip areas on endoscopy
• Smoking is protective in
• Granulomas found on bx
• Crypt abscesses
• Enterocutaneous fistulas
• 75 positive for p-ANCA

Crohns disease UC
73
IBD

• Transmural inflammation
• Abdominal mass
• Backwash ileitis
• Perianal disease
• Crypt abscesses
• Malnutrition
• Rectal bleeding

Crohns disease UC
74
IBD

• Transmural inflammation
• Abdominal mass
• Backwash ileitis
• Perianal disease
• Crypt abscesses
• Malnutrition
• Rectal bleeding

Crohns disease UC
75
IBD

• Extraintestinal manifestations of Crohns
• Polyarticular arthritis
• E.Nodosum
• Pyoderma Gangrenosum
• Uveitits
• Nephrolithiasis

76
IBD

• 35 y/o male with entercutaneous fistulas from
  Crohns disease should be treated with
• Surgery
• Infliximab
• Azathioprine
• Cyclosporine

77
IBD

• 35 y/o male with entercutaneous fistulas from
  Crohns disease should be treated with
• Surgery
• Infliximab
• Azathioprine
• Cyclosporine

78
IBD

• What kind of kidney stones are associated with
  Crohns?
• Oxalate
• Cystine stones
• Uric acid
• Why?

79
IBD

• 34 y/o female with history of UC presents for
  abnormal LFT. The differential includes
• Fatty liver
• Chronic hepatitis
• PSC
• Pericholangitis
• All of the above

80
IBD

• 34 y/o female with history of UC presents for
  abnormal LFT. The differential includes
• Fatty liver
• Chronic hepatitis
• PSC
• Pericholangitis
• All of the above

81
IBD

• Extraintestinal manifestations of UC
• Arthritis
• Ankylosing spondylitis
• PG
• E. Nodosum
• PSC
• Uveitis

82
IBD

• Ankylosing spondylitis does NOT follow colitis
  activity
• Polyarthritis, PG, E. Nodosum follow colitis
  activity
• Patients with extensive UC for at least 8 years
  should be screened for colorectal cancer every 1
  to 3 years

83
IBD

• Steroids can be used to induce remission in IBD,
  5-ASA to maintain remission
• 6-MP, Azathioprine (precursor of 6-MP),
  Methotrexate, Cyclosporine are steroid sparing
  agents
• Infliximab is used for fistulizing disease
• Surgery for stricturing disease

84
Colon Cancer

• Screening should begin at age ____
• The lifetime risk of developing CRC is ___
• Genetic syndromes associated with high risk CRC
  are _____
• ___ of adenomatous polyps will progress to
  cancer
• 5-year survival
• Localized ___
• Regional lymph nodes ___
• Distant mets ___

85
Colon Cancer

• Screening should begin at age 50
• The lifetime risk of developing CRC is 6
• Genetic syndromes associated with high risk CRC
  are FAP and HNPCC
• 5 of adenomatous polyps will progress to cancer
• 5-year survival
• Localized 90
• Regional lymph nodes 65
• Distant mets 7

86
Colon Cancer

• Screening
• For general population FOBT every year and
  sigmoidoscopy every 3 to 5 years
• HNPCC risk colonoscopy at age 25 or 10 years
  younger than youngest affected relative, q 2
  years until age 40 and then q year
• FAP sigmoidoscopy at age 12, every 1 to 2 years
• If adenoma gt 1cm, or multiple adenomas
  colonoscopy in 3 years

87
Colon Cancer

• Treatment
• No nodes or mets surgery
• Nodes surgery 5 FU
• Distant mets surgery 5 FU resection of
  solitary met (lung, liver)

88
Hepatitis

• Alcoholic Hepatitis
• Hemochromatosis
• Auto-immune hepatitis
• Wilsons disease
• NASH
• Hepatitis C

• 50 y/o F obese, DM, ALT 112, AST 107
• 35 y/o, drugs, alcohol, ALT 77, AST 89
• 22 y/o, neuropsych sympt., AST 165, ALT 40
• 34 y/o, DM, arthralgia, skin pigm., AST 100, ALT
  122
• 28 y/o F, rash, arthritis, increased globulins,
  AST 97, ALT 80
• 44 y/o, alcoholic, T Bil 5, D Bil 3.3, Ast 180,
  ALT 100

89
Hepatitis

• Alcoholic Hepatitis
• Hemochromatosis
• Auto-immune hepatitis
• Wilsons disease
• NASH
• Hepatitis C

• 50 y/o F obese, DM, ALT 112, AST 107
• 35 y/o, drugs, alcohol, ALT 77, AST 89
• 22 y/o, neuropsych sympt., AST 165, ALT 40
• 34 y/o, DM, arthralgia, skin pigm., AST 100, ALT
  122
• 28 y/o F, rash, arthritis, increased globulins,
  AST 97, ALT 80
• 44 y/o, alcoholic, T Bil 5, D Bil 3.3, AST 180,
  ALT 100

90
Abnormal LFT

• Alcoholic Hepatitis
• Hemochromatosis
• Auto-immune hepatitis
• Wilsons disease
• NASH
• Hepatitis C

• Discontinuation, observation
• ANA, ASMA, Anti LKM
• Ceruloplasmin, 24 hr urine copper
• Hep C Ab
• Ferritin, iron saturation
• Response to weight loss

91
Abnormal LFT

• Alcoholic Hepatitis
• Hemochromatosis
• Auto-immune hepatitis
• Wilsons disease
• NASH
• Hepatitis C

• Discontinuation, obervation
• ANA, ASMA, Anti LKM
• Ceruloplasmin, 24 hr urine copper
• Hep C Ab
• Ferritin, iron saturtion
• Response to weight loss

92
NASH

• Risk factors
• Obesity
• DM
• Hyperlipidemia
• Gastric bypass
• TPN
• Meds (amiodarone)

93
Alcoholic Hepatitis

• Role of steroids
• DF 4.6 x (PT PT control) T bil
• If gt 32, steroids are indicated

94
Acute hepatitis

• 19 y/o men, AST and ALT in the 2000 range,
  jaundiced, PMH depression, recent travel to
  Cancun. Next step
• Tylenol Level
• Urine drug screen
• Hepatitis serologies (acute panel)
• Steroids
• Empiric treatment with Mucomyst (17 doses)

95
Acute hepatitis

• In the previous case, Ig M anti HAV, PT 25,
  confused. Next step
• Observation in ICU
• Liver transplantation evaluation
• Interferon/Ribavarin
• Interferon/Lamivudine

96
Acute hepatitis

• In the previous case, Ig M anti HAV, PT 25,
  confused. Next step
• Observation in ICU
• Liver transplantation evaluation
• Interferon/Ribavarin
• Interferon/Lamivudine

97
Acute hepatitis

• What about the household contacts?
• Hep A vaccine
• Hep A immunoglobulin
• Hep A vaccine immunoglobulin
• LFT
• Wait and see

98
Acute hepatitis

• What about the household contacts?
• Hep A vaccine
• Hep A immunoglobulin
• Hep A vaccin immunoglobulin
• LFT
• Wait and see
• Hep A vaccine should be given to travelers to
  endemic area 0, 6m, 12m (boosters)

99
Acute hepatitis

• 33 y/o nurse presents after a needle stick with
  blood from patient with history of hepatitis B.
  the patient is HBS Ag (-) and Ab (). The nurse
  should have
• Hep B immunoglobulins (HBIG)
• Hep B vaccine
• Check Hep B S Ab
• HBIG vaccine

100
Acute hepatitis

• 33 y/o nurse presents after a needle stick with
  blood from patient with history of hepatitis B.
  the patient is HBS Ag (-) and Ab (). The nurse
  should have
• Hep B immunoglobulins (HBIG)
• Hep B vaccine
• Check Hep B S Ab
• HBIG vaccine

101
Acute hepatitis

• What if the patient is Hep B S Ag () and the
  nurse is Ag (-) and Ab (-)?
• HBIG
• Hep B vaccine
• Both
• None

102
Acute hepatitis

• What if the patient is Hep B S Ag () and the
  nurse is Ag (-) and Ab (-)?
• HBIG
• Hep B vaccine
• Both
• None
• Other circumstances where HBIG should be
  administered
• Sexual exposure
• Parenteral exposure
• Vertical transmission

103
Hepatitis

• Chronic Hep B
• The risk of developing chronic hep B is inversely
  related to ___________
• The FDA approved trt for chr hep B is ___________
• In patients with chr hep B, hepatocellular
  carcinoma can occur w/o________
• _________is a sign of replication

104
Hepatitis

• Chronic Hep B
• The risk of developing chronic hep B is inversely
  related to age at acquisition of infection
• The FDA approved trt for chr hep B is interferon
  and Lamivudine , adefovir, entacavir
• In patients with chr hep B, hepatocellular
  carcinoma can occur w/o cirrhosis
• Hep Be Ag is a sign of replication

105
Hepatitis

• 45 y/o, IVDA, presents for evaluation and
  treatment of Hep C
• Acute hep C progress to chronic in _____ of cases
• Progression from chronic hep C to cirrhosis
  occurs in ______ of cases
• HCC in cirrhotic develops in the range of _____
  per year

106
Hepatitis

• 45 y/o, IVDA, presents for evaluation and
  treatment of Hep C
• Acute hep C progress to chronic in 85 of cases
• Progression from chronic hep C to cirrhosis
  occurs in 5 to 20 of cases
• HCC in cirrhotic develops in the range of 1-4
  per year

107
Hepatitis

• On exam, he has mild ascites, spider angiomas and
  splenomegaly. His ALT is 95, AST 93, T Bil 1.5, D
  Bil 0.9, AP 211, Plt 54. Hes asking about
  treatment for hep C
• Hes not a candidate because he has cirrhosis
• Because he has low platelets
• He can be treated with interferon only
• He can be started immediately on IFN and Ribavarin

108
Hepatitis

• On exam, he has mild ascites, spider angiomas and
  splenomegaly. His ALT is 95, AST 93, T Bil 1.5, D
  Bil 0.9, AP 211, Plt 54. Hes asking about
  treatment for hep C
• Hes not a candidate because he has cirrhosis
• Because he has low platelets
• He can be treated with interferon only
• He can be started immediately on IFN and Ribavarin

109
Hepatitis

• Contraindication for trt of hep C with IFN and
  Ribavarin
• Hb lt 12, WBC lt 1500, Plt lt 100000
• Decompensated cirrhosis
• Poorly controlled DM
• Severe psychiatric illness

110
Hepatitis

• Extra intestinal manif of Hep C
• Hematologic (cryo, lymphoma)
• Autoimmune (thyroiditis, sjogrens, ITP)
• Renal (GN, Membranous GN)
• Dermatologic (vasculitis, lichen planus, PCT)
• Rheumatologic (inflammatory arthritis)

111
Autoimmune Hepatitis

• Type I
• Female
• ANA , ASMA , Hypergammaglobulinemia (IgG)
• Type II
• Anti LKM
• Childhood or early adolescence
• Type III
• No positive markers

112
Wilsons disease

• Autosomal recessive
• lt 35 y/o
• Hemolytic anemia, neuropathy, neuropsch symptoms
• Decreased ceruloplasmin level, increased urinary
  copper, increased hepatic copper content
• Kayser Fleisher rings
• Trt D-Penicillamine

113
Alpha 1 antitrypsin

• Normal phenotype MM
• Disease ZZ
• Prevalence highest in white northern European

114
PSC v/s PBC

• Men Women
• Women gt Men (91)
• Inc AP, AMA
• Associated with IBD
• Urso decr rate of progression
• Urso can cure
• Liver transplant is curative
• Segmental intrahepatic and extrahepatic duct
  strictures

• PBC
• PSC
• Both
• None

115
PSC v/s PBC

• Men Women
• Women gt Men (91)
• Inc AP, AMA
• Associated with IBD
• Urso decr rate of progression
• Urso can cure
• Liver transplant is curative
• Segmental intrahepatic and extrahepatic duct
  strictures

• PBC
• PSC
• Both
• None

116
Cirrhosis

• Beta blockers and endoscopic variceal ligation
  reduce risk of variceal bleeding
• Cirrhotic patients with evidence of clinical or
  biochemical decompensation should be considered
  for transplant
• SBP PMN gt 250, SAAG gt 1.1
• TIPS is an option in refractory ascites but
  increase risk of encephalopathy

117
Cirrhosis

• Mean survival after onset of ascites or
  encephalopathy is 2 years
• Mean survival after SBP or refractory ascites is
  6 months
• Screening for hepatoma is advised although
  efficacy is unknown

118
Liver transplant

• CI for LT
• Active HIV (?)
• Severe underlying medical illness
• Unresolved sepsis
• Active drug or alcohol abuse
• Unresolved extrahepatic malignancy

119
Liver and pregnancy

• 32 y/o pregnant, 3rd trimester, referred for abnl
  LFT. AP 250, AST 22, ALT 23, T bil 0.4. Shes
  asymptomatic. Differential includes
• Acute Fatty Liver of Pregnancy (AFLP)
• HELLP
• Pre-eclampsia
• Hepatitis
• None of the above

120
Liver and pregnancy

• 32 y/o pregnant, 3rd trimester, referred for abnl
  LFT. AP 250, AST 22, ALT 23, T bil 0.4. Shes
  asymptomatic. Differntial includes
• Acute Fatty Liver of Pregnancy (AFLP)
• HELLP
• Pre-eclampsia
• Hepatitis
• None of the above

121
AFLP

• Presents in 3rd trimester with malaise, headache,
  nausea, poor appetite, abd pain
• Moderate elevations of transaminases
• Incr PT
• With early detection, mother survivalgt90,
  infantgt60

122
HELLP

• Hemolytic anemia
• Elevated Liver enz
• Low Platelets
• More severe variant of pre-eclampsia/eclampsia

123
Pre-eclampsia/Eclampsia

• Hypertension
• Edema
• Proteinuria
• With or without sz

124
Now Some Pictures
125
Barretts esophagus
126
Achalasia
127
Esophageal ulcer
128
PSC
129
Peutz-Jeghers syndrome
130
Acanthosis Nigricans
131
E. Nodosum
132
Pyoderma Gangrenosum
133
Anal Crohns
134
Crohns fistulas
135
Dupuytrens contractures
136
Porphyria Cutanea Tarda
137
UC
138
Crohns
139
Radiation colitis
140
Dermatitis Herpetiformis
141
Celiac Sprue
142
Finally some questions from the board
143

• Diarrhea with dairy products
• Lactose deficiency
• D-xylose test positive, diarrhea, steatorrhea
• Small bowel biopsy r/o celiac

144

• Diarrhea, malabsorption, s/p radiation
• Radiation enteritis
• Duke C
• Chemotherapy
• IBS associated
• Child abuse

145

• UC with abnormal LFT
• ERCP
• Cholangitis
• ERCP
• FAP
• Colectomy

146

• Colonoscopy 3 adenomatous polyps
• Repeat in 3 years
• Dysphagia after long term heart burn
• Stricture, PPI forever
• Meds working immediateky in Crohns
• Budesonide (?)

147

• AST, ALT in the thousands
• Acute hep, ischemic hep, drug toxicity
• Post exposure prophylaxis for hep B
• Immunoglobulin
• Hep B
• PAN

148

• PBC
• Send for liver transplant
• Cimetidine
• Interacts with theophylline
• Activity of hep B
• Hbe Ag

149

• Trt of diarrhea in carcinoid
• Octreotide
• Periumbilical pain after Afib
• Small bowel infarction
• Gastroparesis
• Control blood sugar

150

• Treatment for dermatitis herpetiformis gluten
  free diet
• Moderate ingestin of tylenol in chronic liver
  disease? hepatitis/tylenol toxicity

151

• Ascites with SAAGlt1.1 peritoneal carcinomatosis
• 58 yo with dyspepsia and heme stools do EGD
• HIDA scan detects cystic duct obstruction

152
GOOD LUCK FOR THE BOARDS