PD - GI

A 5-week-old, full-term male infant presents with progressive post-feeding emesis for the past 2 weeks. Initially he was diagnosed as having formula intolerance; formula type was changed several times without relief. Subsequently, he was thought to have gastroesophageal reflux. The parents continue to report non-bilious post-feeding emesis, which has become progressively forceful and projectile.

pyloric stenosis

A 27-year-old man presents with crampy abdominal pain of sudden onset, emesis, and failure to pass any gas or stool for 24 hours. The patient has no history of prior surgery. Physical exam reveals peritonitis. Computed tomography reveals the level of the obstruction.

small bowel obstruction

A 53-year-old man with a history of hepatitis C presents with a complaint of abdominal distention, fever, vomiting, and blood in his stool. Paracentesis has improved symptoms on the numerous occasions that he has previously presented with abdominal distension.

spontaneous bacterial peritonitis

A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4-6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. She has no dysphagia, vomiting, abdominal pain, exertional symptoms, melena, or weight loss. Past medical history and family history are noncontributory. The patient drinks alcohol occasionally and does not smoke. On physical exam, height is 5 feet 4 inches, weight 170 pounds, and blood pressure 140/88 mmHg. The remainder of the exam is unremarkable.

GERD

A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by famotidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole. Physical examination reveals a fit, apparently healthy man in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen.

PUD

A 34-year-old woman who is otherwise healthy has had a fever, nausea, and right-sided back pain for 2 days. The physical exam shows a temperature of 102.2ºF (39.0ºC), blood pressure of 120/60, pulse of 110, respiratory rate of 18, and right-sided costovertebral angle tenderness to percussion. Dipstick urinalysis is positive for leukocytes, nitrites, and blood.

acute pyelonephritis

A 22-year-old male presents to the emergency room with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain is steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (100.5°F [38°C]), pain on palpation at right lower quadrant (McBurney sign), and leukocytosis (12,000/microliter) with 85% neutrophils.

acute appendicitis

A 26-year-old female newlywed presents complaining of painful urination, feeling of urgent need to urinate, and more frequent urination for 2 days. She denies any fever, chills, nausea, vomiting, back pain, vaginal discharge, or vaginal pruritus.

acute cystitis

A 76-year-old male with diabetes with known incomplete bladder emptying due to benign prostatic obstruction presents with hematuria, suprapubic pain, frequency, and urgency with associated fever.

acute cystitis

A 53-year-old man presents to the emergency room complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain evolved over 1 hour. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcohol intake over many years, including this past week. He is tachycardic, tachypneic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic and tender in the epigastric region with guarding and rebound tenderness.

acute pancreatitis

A 39-year-old woman presents with a 2-year history of gradually worsening constipation. She complains of bloating, gas, and lower abdominal discomfort with irregular bowel habits. She describes her stool as mostly sausage-shaped, hard, and lumpy. She takes metoprolol for hypertension and lansoprazole for heartburn. She has previously used sennosides and bisacodyl without improvement of her symptoms. She also increased her daily fiber and fluid intake without relief. Physical exam is unremarkable except for mild abdominal distention and palpable stool in the right and left lower quadrants. Perianal inspection is normal, and the anocutaneous reflex is present in all 4 quadrants. Digital rectal exam reveals a large amount of stool in the rectum. When asked to push and bear down, she shows adequate pelvic descent with normal anal relaxation.

adult constipation

A 12-year-old girl presents with sudden-onset severe generalized abdominal pain associated with nausea, vomiting, and diarrhea. On exam she appears ill and has a temperature of 104°F (40°C). Her abdomen is tense with generalized tenderness and guarding. No bowel sounds are present.

appendicitis

A 55-year-old man presents with a long history of uncontrolled hypertension, increased urinary albumin excretion, and benign prostatic hypertrophy. He reports a past history of bladder infections and surgery on the bladder as an infant. For the past 1 to 2 weeks he has been feeling ill, and he noted some blood in his urine last night. On physical exam the physician notes the patient is obese, in mild distress, with blood pressure 150/90 mmHg, regular pulse 84 beats per minute, and temperature 98.6°F (37°C). The patient has no costovertebral angle tenderness.A 64-year-old man presents with painless hematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical exam shows only moderate enlargement of the prostate. Urinalysis

bladder cancer

A 48-year-old woman presents with intermittent diffuse abdominal pain, worse after eating meals. The pain has been present for the previous 6 months, but has worsened recently. She has had significant weight loss since the onset of symptoms. Her past medical history includes systemic lupus erythematosus, which has been difficult to manage medically.

ischemic bowel disease

A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down toward his groin. The patient is writhing in pain, which is unrelieved by position. He also complains of nausea and vomiting.

kidney stone

A 46-year-old woman presents with fatigue and is found to have iron deficiency with anemia. She has experienced intermittent episodes of mild diarrhea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms such as diarrhea, bloating, or abdominal pain. Examination reveals two oral aphthous ulcers and pallor. Abdominal examination is normal and results of fecal testing for occult blood are negative.

celiac disease

A 9-year-old boy presents with vomiting for 5 days. His sister, who has celiac disease, has had similar symptoms. His growth has been normal and he has not experienced any other possible symptoms of celiac disease, except for intermittent constipation. Immunoglobulin A-tissue transglutaminase titer is 5 times the upper limit of normal.

celiac disease

A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhea. Three months ago she developed intermittent, sharp RUQ pains. On physical exam she has a temperature of 100.4°F (38ºC), moderate RUQ tenderness on palpation, but no evidence of jaundice.

cholecystitis

A 25-year-old white man presents to his primary care physician with cramping abdominal pain for 2 days. He reports having loose stools and losing 15 lb (6.8 kg) over a 3-month duration. He also reports increased fatigue. On physical exam, his temperature is 99.6°F (37.6°C). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the right lower quadrant, without guarding or rigidity. Rectal exam is normal and the stool is guaiac positive. The rest of the examination is unremarkable.

chrons disease

A 56-year-old man with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical exam reveals spider nevi, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (aspartate aminotransferase [AST]: 90 U/L, alanine aminotransferase [ALT]: 87 U/L), and the patient is positive for anti-hepatitis C antibody.

cirrhosis

A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool and a change from his normal bowel habit as he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well, and there is no family history of gastrointestinal disease. Examination of his abdomen and digital rectal examination are normal.

colorectal cancer

Many patients with nephrolithiasis are actually asymptomatic, as their stone may be in the kidney and nonobstructing. In these patients, diagnosis may be made following imaging (CT scan, abdominal x-ray, renal ultrasound, etc.) for other reasons. In contrast, other patients may present with gross hematuria, evidence of an obstructive uropathy or sepsis with fever, tachycardia, and hypotension.

kidney stone (alt presentation)

A 68-year-old man presents to the emergency room complaining of an inability to urinate during the previous 12 hours. He has severe lower abdominal pain. Prior to this, he noted a weaker force of urinary stream, difficulty in starting his urinary stream, and frequent episodes of waking at night to pass urine. On examination, he has lower abdominal distention, which is dull to percussion.

obstructive hydronephrosis

A 57-year-old woman with a history of hypertension and hypercholesterolemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant gastrointestinal problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for gastrointestinal disorders.

diverticulitis

A 34-year-old man presents 2 weeks after returning from a month-long trip to India. He denies attending pretravel vaccination clinic and did not take prophylaxis of any sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain, nausea with emesis, and dark urine. He consumed salad at a roadside vendor 3 weeks before onset of symptoms. On examination there is icterus. His alanine transaminase (ALT) is 5660 units/L, and total bilirubin 9 mg/dL. Serum IgM anti-hepatitis A virus antibodies are detected.

hep a

A 60-year-old man presents with several months of gradually worsening abdominal swelling, intermittent hematemesis, and dark stool. He denies chest pain or difficulty breathing. Past medical and family history are not contributory. Past surgical history is significant for back surgery requiring blood transfusion in 1990. Social history is significant for occasional alcohol use. Blood pressure is 110/80 mmHg. Physical examination is significant for spider angiomata on the upper chest, gynecomastia, caput medusae, and a fluid wave of the abdomen. The rest of the examination is normal.

hep c

A 52-year-old man undergoes an elective sigmoid resection with primary colorectal anastomosis for chronic diverticulitis. The operative course is routine. Postoperatively, he starts on a clear-liquid diet and receives morphine via patient-controlled analgesia pump. On the second postoperative day, he has a distended abdomen, is nauseated, and has not passed flatus. He vomits repeatedly and requires nasogastric decompression.

ileus

A 9-month-old boy presents to the emergency room with a 24-hour history of colicky abdominal pain, anorexia, fever, and progressive lethargy. Episodes of pain last 1 to 2 minutes marked by crying and drawing his knees to his chest, alternating with 20-minute pain-free periods where he behaves normally. The infant has vomited yellow material several times, which became green just prior to coming to the hospital. Also, just prior to presentation, he had a bowel movement that appeared red, similar to redcurrant jelly. An abdominal exam reveals a distended, tender abdomen with pain out of proportion to examination and a palpable right-sided abdominal mass. This could only be felt when he was settled between waves of pain, and was easiest to feel when he was lying on his side on his mother's lap.

intussusception

A 27-year-old man with a 3-month history of rectal bleeding and diarrhea is referred for evaluation. Laboratory tests show mild anemia, a slightly elevated erythrocyte sedimentation rate, and the presence of white blood cells in stool. Stool culture is negative. Colonoscopy shows continuous active inflammation with loss of vascular pattern and friability from the anal verge up to 35 cm, with a sharp cut-off. The colonic mucosa above 35 cm appears normal, as does the terminal ileum. Biopsy specimens show active chronic colitis.

ulcerative colitis

A previously healthy, 3-year-old female patient presents with progressive abdominal distension and left, upper quadrant prominence. On examination the mass is firm, smooth, nontender, and does not cross the midline. The patient is also found to have moderate hypertension. Urinalysis reveals microscopic hematuria.

wilms tumor