Study questions

Constipation/Diarrhea

The definition of constipation includes:

1. 2-3 or fewer bowel movements per week
2. Stool weight less than 35 g/d
3. Straining and /or having hard lumpy stools on more than 25% of occasions
4. Inability to have bowel movement daily

(A, B, C are true)

Typical symptoms of constipation include all of the following EXCEPT?

1. abdominal distention
2. bloody stool
3. hard stools
4. straining

(B) 

What are some diseases and disorders associated with constipation?

(Neurogenic:  MS, Parkinsonism;

Mech. Obstruction: CA, post-surgical;

Metabolic: DM with autonomic neuropathy, uremia, hypokalemia, hypercalcemia, hypothyroidism.)

Which medications can cause constipation?

(Opiates, NSAIDs, calcium and aluminum antacids, anticholinergics (H1 antihistamines, antiparkinsonian agents, antipsychotics, tricyclic antidepressants), barium sulfate, iron preparations, Ca channel blockers (esp. verapamil/diltiazem), bile acid binders, vinca alkaloids, ondansetron)

Which non-pharmacological interventions would you recommend to your patient with constipation (unless contraindicated)?

a.      Increase fiber and fluid intake

b.      Take prune juice daily if there is no daily bowel movement

c.      Increase physical activity

(A and C)

A possible side effect of mineral oil can be?

1. dark-stained stools
2. hypercalcemia
3. vitamin K deficiency
4. obstruction of the esophagus

(C)

Bisacodyl is a ….. laxative?

1. Stimulant
2. Hyperosmotic
3. Lubricant
4. Saline

(A)

Which of the following laxatives would you recommend short-term to a patient recovering from abdominal surgery to prevent straining ?

1. magnesium citrate
2. castor oil
3. glycerin
4. mineral oil

(D)

The following are therapies for chronic constipation, EXCEPT?

1. Lactulose
2. Lubricants
3. Loperamide
4. Enemas
5. Psyllium

(C)

Which of the following medications is incorrectly matched with its side effects ?

1. Laculose-bloating, cramps
2. Mg citrate-hypermagnesemia, hyperphosphatemia, hypocalcemia
3. Senna-melanosis coli, hepatitis
4. Methylcellulose: cramps, fecal impaction

(B)

The definition of diarrhea includes:

1. Passage of loose stools
2. More than three movements/day
3. Rectal urgency
4. A and B
5. A, B and C

(E)

List possible underlying causes of chronic diarrhea.

(excessive intake of caffeine and foods and medications containing sorbitol, diverticular disease, collagenous and microscopic colitis, infections, IBD, irritable bowel syndrome, lactose intolerance, malabsorption (bacterial overgrowth, bile-salt deficiency, pancreatic  insufficiency, small bowel diseases), fecal impaction, post surgical syndromes, Addison’s disease, diabetes, hyperthyroidism, tumors)

From the following medications, choose one agent that is least associated  with diarrhea

1. Morphine
2. Misoprostol
3. Colchicine
4. Oral Gold
5. Orlistat
6. Chenodeoxycholic Acid

(A)

T/F about the clinical assessment of degree of dehydration

1. In mild dehydration, the fluid deficit is between 5-9%
2. Thirst is always present in dehydration
3. Heart rate is always increased
4. Blood pressure is always increased
5. Urine output is always decreased

(B, C, E-true)

When should you refer a patient with diarrhea for physical evaluation?

(Symptoms of diarrhea do not improve or vomiting continues for  48 h (more than 24 hours in a child), severe abdominal pain or rectal pain, fever of 102 F in adults and 100.5 children <6mo, severe dehydration, blood or worms in the stool)

What is the most common pathogen associated with traveler’s diarrhea?

1. E. coli
2. Shigella
3. Salmonella
4. Cryptosporidium

(A)

T/F

The first line of therapy for viral gastroenteritis is OTC anti-diarrheal medications that prevent the dehydration from fluid loss.

(F)

Which of the following are true?

1. E. coli 0157 should be treated with TMP/SMX
2. I. belli, cyclospora, are treated with TMP/SMX
3. Salmonella/Shigella are treated with TMP/SMX , but not with quinolones or amoxicillin
4. Severe C. jejuni can be treated with erythromycin or flouroquinolones
5. G. lamblia can be prevented by boiling water for 10 min or adding I or Cl in the water
6. Metronidazole is the drug of choice for treating C. difficle and G. lamblia

(B, D and F are true)

What can be done to prevent prophylaxis of Traveler’s diarrhea?

(food and water precautions, Bi subsalicylate, do not use antimicrobials in most people)

What host factors can make the individual more susceptible to Traveler’s diarrhea?

(<6y.o., reduced gastric acidity, pre-existing GI dz, immunodeficiency)

Which are true about treatment of Traveler’s diarrhea?

1. Use antimicrobial if diarrhea is severe and accompanied by bloody stools, high fever and severe abdominal pain
2. Never use Loperamide in treatment of Traveler’s diarrhea
3. Most people who use antimicrobial prophylaxis should be advised to wear sun-screen because many of the agents may cause photosensitivity
4. A single or three day course of therapy may be sufficient for treatment of Traveler’s diarrhea
5. Ciprofloxacin and doxycycline are the drugs of choice in pregnancy

(A, C, D are true)

T/F

Probiotics have been shown effective in prevention of Traveler’s diarrhea, acute infantile diarrhea, and C. difficile abx associated diarrhea

(T)

IBD

Which are true about IBD?

1. IBD onset peaks in patients at 20-30 y.o.
2. Ashkenazi Jews are at a higher risk for IBD compared to the general population
3. Etiology of IBD is unknown, and therefore, symptomatic treatment is used
4. Smoking is an exacerbating factor for ulcerative colitis
5. History of symptoms, endoscopy and radiology are used in diagnosis of IBD

(D is false)

What are the signs and symptoms in a patient presenting with IBD?

(Incr. bowel frequency, blood in stool, fever, decr. Hgb, abdominal signs, tachycardia, extraintestinal signs/symptoms)

What are some of the extraintestinal manifestations of IBD?

(Liver: chronic active hepatitis, cirrhosis, sclerosing cholangitis, gallstones, cancer; musculoskeletal: arthritis, ankylosing spondylitis; eye: iritis, uveitis, conjunctivitis; skin/mouth: variety of lesions; kidney: oxalate stones)

Compare Crohn’s and UC

(Crohn’s commonly presents with malaise, fever, abdominal pain or mass.  Radiologic findings include fistulas, granulomas, strictures, ileal involvement, asymmetric, linear distribution of lesions, transmural

UC commonly presents with rectal bleeding and rectal dz that is diffuse, continuous and symmetric.  Crypt abscesses are commonly present.  Fistulas, strictures and transmural involvement are rare)

What are the main medications used to treat IBD?

(SASP, 5-ASA (topical and systemic), corticosteroids (topical and systemic), antimicrobials (Crohn’s only), Immunosuppressives, Infliximab)

All of the statements below about SASP are true except:

1. Mechanism of action includes antibacterial activity and anti-inflammatory activiry
2. Its dose-related SE are rash, hepatotoxicity, neuropathy, bloody diarrhea, serum sickness; therefore dose reduction or desensitization would be helpful in patients with these symptoms
3. It is generally well tolerated
4. Folate supplementation is required
5. Pregnancy and lactation are not absolute contraindications

(B, C)  

With regards to Corticosteroids in the treatment of IBD, all of the statemtents below are true, except

1. Corticosteroids are effective in acute treatment of UC and Crohn’s
2. Corticosteroids are effective in maintenance tx of UC, but not Crohn’s
3. Ca, vit D, and bisphosphonates are often used for prevention of osteoporosis associated with use of corticosteroids
4. Topical, IV and oral preps are available

(B is false)  

Which antibiotics can be used in treatment of IBD?

1. Metronidazole
2. Ciprofloxacin
3. Cephalexin
4. A and B can be used in Crohn’s
5. B and C can be used in UC

(D)  

From the following list, select the agents that can help to close fistulas

1. Metronidazole
2. 5-ASA, 4-ASA
3. SASP
4. Azathioprine
5. 6-Mercaptopurine

(A, D, E)

Which statements are true about the side effects of immunosuppressives used to treat IBD?

1. Bone marrow suppression, allergic rxn, rash, superinfections, pancreatitis are the possible side effects of 6-MP and Azathioprine
2. Birth control should be used during and for 3 mo following tx. If these agents are being used at time of conception, abortion is indicated
3. Both children and adults should receive the same mg/kg dose
4. When 6-MP is concomitantly given with allopurinol, the dose of 6-MP should be reduced by at least ½, and CBC must be monitored very closely

(A, C, D are true)

When should use of immunosuppressives be considered?

(When pt. prefers surgery and failed other med. modalities, has evidence of corticosteroid toxicity or continuous steroids are needed, when entire colon is affected in UC or fistula(s) is/are present in Crohn’s, maintenance of remission in both UC and Crohn’s)

T/F Both UC and Crohn’s can be cured with surgical intervention.

(F-it is possible to cure UC with surgery.  Patients might want to delay surgery, but after 10-15 years their risk of developing colon cancer begins to substantially increase, therefore, if surgery is not performed, yearly surveillance colonoscopy is required.  Crohn’s is not a continuous dz, therefore, even when one affected part of the bowel is removed, the dz appears again and again.  It is best for Crohn’s patients to delay surgery for as long as possible.)

T/F IV cyclosporin is used for severe, chronic, active IBD.  When  remission is achieved, it can be switched to p.o. for maintenance of remission.

(F)

T/F MTX works faster than 6-MP/AZA and may be effective in 6-MP/AZA nonresponders.   Its side effects include hepatic cirrhosis, bone marrow suppression and pulmonary fibrosis.

(T)

T/F Loperamide, diphenoxylate and iron should be avoided during acute attacks of IBD

(T)

Which is false about Inflixamab?

1. It is anti-TNF antibody
2. One dose of IV tx is suggested for pts with moderate to severe Crohn’s unresponsive to other txs, and three doses for enterocutaneous fistulizing Crohn’s
3. It has no role in managing UC
4. TB risk-screening is required before use (TB-skin test)
5. Live attenuated vaccines should be avoided w/n 3 months of therapy

(C )

Viral Hepatitis

Please, fill in the table

Who should consider HAV immunization?

(International travelers, military, Native Alaskans and Americans, others where endemicity rates are high (high-risk sexual activity, illicit drug user, handlers of primates; routine childhood immunization where background (endemic) annual rate of dz ≥ 2-fold the nat. mean and optional where rate > nat. mean but < 2-fold above it)

Which serologic marker of HBV indicates poor prognosis?

(HbeAg)

Which serologic marker of HBV indicates recovery and immunity?

(Anti-HBs)

Which serologic marker is the first one to appear and is associated with acute and chronic infection?

(HbsAg)

Which serologic marker of HBV is indicative of recent acute infection?

(IgM anti-HBc)

With regard to prevention of HBV, which of the following is/are false?

1. It is recommended to screen all pregnant women for HBV
2. ACIP recommendations include universal childhood vaccination
3. Everyone needs to be re-vaccinated because antibody titers will decrease over time
4. Risk of acquisition of HBV from needle-stick is up to 60%.  When this occurs, one must be treated with HBIG stat and with vaccine later, because both cannot be administered at the same time.

(C, D)

When should chronic HBV be treated?

(Seropositive for HBsAg > 6mo, HBV DNA positive in serum, increased AST/ALT, compensated liver dz)

Which medications are used for tx of chronic HBV?

(Alpha-interferon (not used in decompensated liver dz); lamivudine (well-tolerated, no alteration in vertical transmission (ie from mother to fetus), rebound viral replication upon withdrawal, not effective if co-infection with HDV); adefovir (similar to lamivudine except active vs. lamivudine-resistant virus, nephrotoxic); entecavir (similar to lamivudine except active vs. lamivudine-resistant virus, not active vs. HIV)

What are the effective ways to prevent HCV infection?

1. Vaccination
2. Immune serum globulin or interferon post-exposure
3. Screening of blood, organ, tissue and semen donors for HCV
4. Use latex condoms to avoid possible sex. transmission
5. Do not share toothbrushes and  razors with HCV+ individuals

(C, D, E)

Which medications are used for control of chronic HCV?

(IFN alfacon-1, IFN alpha-2b, 2a, pegylated IFN alpha 2a, 2b, IFN+ribavirin; PEG INF alpha 2a, 2b+ribavirin is the first choice for initial therapy today)

What are some side effects of IFN?

(Fever, HA, fatigue, arthralgias, myalgias common; depression, psychosis irritability; decr. blood counts; can induce autoimmune disease such as thyroiditis (hypothyroidism, hyperthyroidism) + aggravates other autoimmune disorders)

What are some side effects of ribavirin?

(anemia-monitor hemoglobin, fetotoxicity)

T/F Liver transplantation is an effective way to cure HCV

(F)

Which are true about HDV?

1. Requires HBV to express infection and , therefore, prevented by HBV vaccine
2. The increased risk of fulminant hepatic failure can be reduced with Lamivudine tx
3. IFN alpha tx can be used for 12 months
4. All of the above are true

(A, C)