GI - EXAM I Case Studies

Presentation of pyloric stenosis? How do you workup and tx?

• Presentation: projectile non-bilious vomiting, palpable olive in upper abdomen • Workup ◦ Labs: hypochloremic metabolic alkalosis with hypokalemia ◦ US: hypertrophic muscle around pylorus ◦ Barium swallow: narrow pyloric channel • Tx: pyloromyotomy

Does SSRI and NSAID increase risk of GI bleed?

yaaasss

What are symptoms of dyspepsia? When/how should you work up red flag symptoms?

• Presentation: epigastric pain, burning, postprandial fullness, early satiety • Red Flags: weight loss, GI bleed, progressive, odynophagia, persistent vomiting, fhx cancer • Workup ◦ EGD: >60yo and new onset ◦ H pylori test: no alarm findings

Candida Esophagitis Presentation, Workup, Tx?

• Presentation: painful swallowing (odynophagia), dysphagia, heartburn, chest pain, globus sensation • Workup: EGD, look for immunocompromised state • Tx: PO fluconazole 400mg qd x14-21d

A 23-year-old man presents with the complaint of rectal pain and bleeding. The pain is described as "tearing and intense" and occurs only during bowel movements. He notices bright red blood on the toilet paper after defecation but at no other time. Rectal exam is very painful but otherwise negative. His vital signs are within normal limits. Which of the following is the most likely diagnosis? (A) anal fissure (B) colon cancer (C) proctalgia fugax (D) internal hemorrhoids (E) anorectal abscess

(A) Anal fissure is thought to be due to trauma to the anal canal during defecation. Patients will complain of severe pain during defecation with occasional blood noted on the surface of the stool or on the toilet paper. Proctalgia fugax presents with acute, severe rectal pain but without bleeding. Internal hemorrhoids may have bleeding but are typically painless. Colorectal cancer more typically presents with a change in bowel habits or obstructive symptoms. Anorectal abscess typically manifests as continuous, throbbing perianal pain. (McQuaid, 2009, pp. 580- 581; Rugo, 2009, p. 1450)

A patient has had problems with prolonged diarrhea. Stool cultures grow out Cryptosporidium. It is important to (A) test the patient for HIV (B) check family members for the organism (C) perform a colonoscopy (D) perform blood cultures (E) isolate the patient

(A) Chronic diarrhea from cryptosporidiosis may be indicative of underlying immunodeficiency. Patients with a positive culture should be checked for HIV. Rarely do patients with intact immune systems have problems with this organism, so checking family members would not be useful. Isolation also is not indicated. Blood cultures and colonoscopy study would not offer increased information with this diagnosis. (Rosenthal, 2009, pp. 1336-1337)

The majority of cases of thiamine deficiency in the United States are due to which of the following underlying conditions? (A) alcoholism (B) pernicious anemia (C) celiac disease (D) bulimia (E) cholestatic liver disease

(A) Most cases of thiamine deficiency in the United States are due to chronic alcoholism. Patients with chronic alcoholism have poor dietary intake as well as impaired thiamine absorption and metabolism. (Baron, 2009, p. 1113)

In most cases, the best approach to treatment for acute, mild to moderate, nonbloody diarrhea in an otherwise healthy adult may include all of the following except (A) antibiotics (B) bland diet (C) electrolyte replacement by mouth (D) acetaminophen for fever (E) bismuth subsalicylate

(A) Most mild diarrhea will not lead to dehydration if the patient takes adequate oral fluids containing carbohydrates and electrolytes. "Resting" the bowel by avoiding high-fiber foods, fats, and caffeine may be helpful. Loperamide and bismuth subsalicylate may also be safely used to reduce symptoms and acetaminophen to reduce a low-grade fever. Empiric antibiotic treatment of all patients with diarrhea is not indicated. Antibiotic treatment is typically considered only if the patient presents with moderate to severe fever, tenesmus, and bloody diarrhea. (McQuaid, 2009, pp. 497-499)

The Dietary Guidelines for Americans 2005 recommends 2 to 3 servings of protein per day. A 3- oz serving of lean meat is about the size of a (A) checkbook (B) deck of cards (C) paperback book (D) matchbook (E) legal envelope

(B) A deck of cards or a bar of soap is a good way to help a person visualize a 3-oz portion size of lean meat. A matchboxbook would be about the size of a 1-oz serving and a thin paperback book would represent an 8-oz serving of lean meat. (Blackburn, 2005, p. 612)

Which of the following is the most common cause of traveler's diarrhea in adults? (A) rotavirus (B) E coli (C) Giardia lamblia (D) Vibrio cholera (E) S typhi

(B) Bacteria cause 80% of cases of traveler's diarrhea, with enterotoxigenic E. coli, Shigella species, and C jejuni being the most common pathogens. Viruses such as rotavirus are the most common cause of acute gastroenteritis in children. (Sondheimer, 2007, pp. 621-622; Trier, 2009, pp. 50-56)

In Western society, diverticulosis most often occurs in which portion of the colon? (A) transverse (B) sigmoid (C) descending (D) ascending (E) equally common in all parts of the colon

(B) Diverticulosis may arise anywhere in the large intestine, from the cecum to the end of the sigmoid colon. In Western societies, diverticula most often occur in the sigmoid colon where there is greatest intraluminal pressure. (McQuaid, 2009, p. 572)

An adult patient presents with acute onset of watery, nonbloody, voluminous diarrhea accompanied by nausea and vomiting. Which of the following organisms is the most likely cause? (A) Clostridium difficile (B) enterotoxigenic Escherichia coli (C) Salmonella typhi (D) Shigella flexneri (E) Campylobacter jejuni

(B) Large volume, watery, nonbloody diarrhea accompanied by nausea and vomiting characterizes small bowel diarrhea caused by a toxin-producing bacteria such as E coli or a virus. Infection with Salmonella, Shigella, C difficile, and Campylobacter results in an inflammatory diarrhea characterized by small volume, often bloody diarrhea without prominent nausea. (McQuaid, 2009, pp. 496-497)

A 30-year-old woman presents for evaluation of chronic diarrhea. You also note the presence of a papulovesicular rash on her extensor surfaces of the arms and legs, trunk, and neck, which is noted to be pruritic. A diagnosis of dermatitis herpetiformis is made. Which of the following disorders is the most likely cause of her diarrhea? (A) irritable bowel syndrome (B) celiac disease (C) pancreatitis (D) diverticulosis (E) chronic hepatitis

(B) Nearly all patients presenting with dermatitis herpetiformis have histological evidence of celiac disease even if it is not clinically apparent. Less than 10% of patients with celiac disease will also have this dermatologic disorder. Dermatitis herpetiformis is not associated with the other disorders. (McQuaid, 2009, p. 544)

An ICU patient with sepsis who is being mechanically ventilated due to respiratory failure is at significantly increased risk for which of the following? (A) esophageal varices (B) stress ulcer (C) gastroparesis (D) Mallory-Weiss tear (E) volvulus

(B) Stress-related ulcers develop in a majority of critically ill patients within 72 hours of admission. Additional factors that place the patient at risk for significant bleeding are mechanical ventilation for greater than 72 hours and coagulopathy. Additional risk factors for development of stress ulcers are severe burns, trauma, and sepsis. Mallory-Weiss tears usually with hematemesis usually follow a prolonged period of retching/vomiting. Volvulus or a twisting of the bowel is most frequently due to adhesions or redundant colon in adults. Gastroparesis is a chronic condition with multiple etiologies including endocrine and neurologic conditions such as diabetes and multiple sclerosis. (McQuaid, 2009, pp. 529, 551)

The most common malignant tumor of the esophagus in the African American male population is (A) adenocarcinoma (B) leiomyoma (C) small cell carcinoma (D) squamous cell carcinoma (E) granular cell tumor

(D) Men are more likely than women to get esophageal cancer. The most common esophageal malignancy in the African American population is squamous cell carcinoma. Risk factors include excessive alcohol and tobacco use. Adenocarcinoma is more common in whites and is thought to be a complication of chronic gastroesophageal reflux. Benign tumors such as leiomyomas are rare. (McQuaid and Rugo, 2009, p. 1441)

A middle-aged man presents with the acute onset of left upper quadrant (LUQ) and midepigastric pain. He describes the severe pain as constant and gradually worsening over the past couple of hours. In the ED, he has an episode of vomiting. His LUQ and midepigastrium is tender to palpation, and no rebound or masses are noted. The patient appears anxious; his vitals are as follows: temp 100°F, BP 90/40 mm Hg, pulse 120 bpm, respirations 26 per minute. Which of the following is the most likely diagnosis? (A) cholecystitis (B) pancreatitis (C) diverticulitis (D) appendicitis (E) gastroenteritis

(B) The classic presentation of acute pancreatitis is the typically sudden onset of severe, deep epigastric or LUQ pain, which often radiates to the back or left shoulder. Fever, nausea, vomiting, and signs of hypovolemic shock may be present. Cholecystitis, diverticulitis, appendicitis would typically present with pain in different quadrants; low-grade fever and hypovolemic signs would be uncommon. Gastroenteritis would present with nausea, vomiting, and possibly low-grade fever but without abdominal pain or hypovolemia. (Friedman, 2009, pp. 617-618, 623-624; Seidel et al., 2006, p. 552)

Which of the following is a complication of Barrett esophagus? (A) achalasia (B) adenocarcinoma (C) diffuse spasm (D) varices (E) stricture

(B) The most serious complication of Barrett esophagus is esophageal adenocarcinoma, which arises from dysplastic epithelium. Patients with Barrett esophagus have a significantly increased risk compared to those patients who do not. (Poneros, 2009, pp. 148-150)

Which one the following symptoms is a "red flag" symptom that suggests a diagnosis other than irritable bowel syndrome? (A) passage of mucus in the stool (B) hematochezia (C) constipation (D) abdominal cramping (E) watery stools

(B) Typical symptoms of irritable bowel syndrome include abdominal pain relieved by defecation, constipation, loose or watery stools, mucus in the stools, and a feeling of abdominal bloating. The presence of blood in the stools, hematochezia, is not a feature of irritable bowel syndrome and warrants further investigation. (McQuaid, 2009, pp. 554-555)

The best initial diagnostic modality to diagnose cholelithiasis is which one of the following? (A) CT scan of the abdomen (B) ultrasound of the abdomen (C) oral cholecystogram (D) abdominal plain film (E) MRI of the abdomen

(B) Ultrasound has replaced oral cholecystograms as the test of choice for diagnosing cholelithiasis. CT is useful in the evaluation of the acute abdomen but the sensitivity for viewing the gallstones is poor. KUB is also not a sensitive study for cholelithiasis. MRI is expensive and not recommended as an initial screening exam for gallstones but can be used if ultrasound is equivocal. (Paumgartner, 2009, pp. 541-542)

Which of the following is considered the first-line medical therapy for mild to moderate ulcerative pancolitis? (A) cimetidine (B) metronidazole (C) sulfasalazine (D) infliximab (E) dexamethasone

(C) 5-ASA products such as sulfasalazine or mesalamine are generally considered initial treatment agents for patients with mild to moderate colitis. Topical therapy with 5-ASA products or hydrocortisone may be effective for patients with distal colitis. Immunomodulating agents such as infliximab are generally reserved for patients with severe or unresponsive disease. Oral antibiotics such as metronidazole and ciprofloxacin are used in the treatment of active Crohn with little evidence for effectiveness. (McQuaid, 2009, pp. 564-569)

Which of the following is required for adequate absorption of vitamin B12 from the stomach? (A) homocysteine (B) cholecystokinin (C) intrinsic factor (D) prostaglandin (E) folate

(C) After ingestion, vitamin B12 binds to intrinsic factor, which is secreted by gastric parietal cells. Vitamin B12 is involved in the conversion of homocysteine to methionine. Cholecystokinin is secreted by cells of the small intestine and stimulates contraction of the gallbladder. Absorption of iron occurs in the stomach, duodenum, and upper jejunum. Folate absorption occurs along the entire GI tract. (Linker, 2009, pp. 427, 433-434)

Which one of the following is a characteristic finding on computed tomography (CT) of the abdomen in a patient with acute diverticulitis? (A) toxic megacolon (B) air-fluid levels (C) soft tissue inflammation of the pericolic fat (D) thinning of the colon wall (E) paucity of bowel gas in the colon

(C) CT findings consistent with diverticulitis include soft tissue thickening of the pericolic fat (98%), diverticula, and thickening of the bowel wall. In immunosuppressed patients, findings may include intraperitoneal and extraperitoneal gases without fluid or abscess formation. (Travis, 2009, p. 249)

Which of the following is a risk factor for non-healing of a duodenal ulcer? (A) age greater than 50 (B) high-fat diet (C) cigarette smoking (D) chronic stress (E) alcohol use

(C) Cigarette smoking is known to retard ulcer healing. Alcohol, dietary factors, and stress do not appear to cause or exacerbate ulcer disease. Ulcers occur more frequently in the age range of 30 to 55 years, but age is not implicated in nonhealing. (McQuaid, 2009, pp. 532, 538)

Which of the following is more likely to be associated with Crohn disease versus ulcerative colitis? (A) anemia (B) large bowel involvement (C) anal fissure (D) bloody diarrhea (E) arthritis

(C) Crohn disease and ulcerative colitis are inflammatory conditions affecting the GI tract. Crohn disease primarily involves the small bowel (terminal ileum) and the proximal ascending colon. One-third of cases may have perioral or perianal involvement (fissure, fistula, abscess). Ulcerative colitis affects only the colon, most commonly the distal portion and does not have perianal involvement. Extraintestinal manifestations such as arthritis, arthralgias, and skin rash may occur with both conditions. Both conditions may have bloody diarrhea although it is more common in ulcerative colitis. (McQuaid, 2009, pp. 562-563, 567-568)

A 14-year-old boy presents for evaluation of diarrhea, bloating, and anorexia for the past 3 weeks. He describes four to five episodes of loosely formed stools per day. No one else in his family is sick; he thinks that his symptoms may have started after returning from a camping trip about a month ago. He denies fever, weight loss, or blood in his stools. Which of the following tests would you order next to confirm your diagnosis? (A) stool assay for rotavirus (B) stool assay for C difficile (C) stool for ova and parasites (D) stool for fecal leukocytes (E) stool cultures

(C) Giardiasis, caused by Giardia lamblia, typically presents with chronic diarrhea, anorexia, malabsorption, and weight loss. Giardiasis is the most common intestinal protozoal infection in children in the United States and is diagnosed by finding the parasite in the stool or detecting Giardia antigen in feces. (Weinberg, 2007, p. 1228)

A diet high in nitrates is a significant risk factor for cancer of which of the following? (A) oropharynx (B) esophagus (C) stomach (D) pancreas (E) liver

(C) In addition to chronic H pylori infections, dietary nitrates are a significant risk factor for gastric cancer. (Rugo, 2009, pp. 1443-1444)

Which of the following is indicated to confirm the diagnosis of celiac sprue in a patient with positive serologic testing? (A) stool for fecal fat (B) barium enema (C) intestinal biopsy (D) antimitochondrial antibodies (E) food challenge

(C) Intestinal biopsy is the most specific test in establishing the diagnosis of celiac sprue in a patient who has a positive test for IgA endomysial antibody. Classic symptoms of malabsorption are more common in infants but less common in adults. Stool for fecal fat would be a nonspecific finding. Antimitochondrial antibodies are seen in patients with primary biliary cirrhosis. (McQuaid, 2009, pp. 543-544)

Having patients stand straight kneed, 3 then rise from the flat foot, up on to their toes and drop down on to their heels, is a test used to evaluate patients with abdominal pain. It is known as (A) Grey Turner sign (B) Blumberg sign (C) Markle sign (D) Psoas sign (E) Kernig sign

(C) Markle sign is also known as the jar sign and it may prove superior to rebound tenderness as a localizing sign of peritoneal irritation, especially in the pelvis. It is performed by having the patients go from standing on their toes to dropping quickly down to their heels. When they hit the floor, the location of their abdominal pain should be noted. Blumberg sign is another name for rebound tenderness. It is elicited by pressing the fingers gently into the abdomen and then suddenly withdrawing them. The pain will worsen in a certain area when the fingers are taken away. Succession splash refers to air and fluid in the stomach and the bowel moving and making audible splashing noise. Kernig sign is a test for spinal cord irritation. (Seidel, 2006, p. 557; LeBlond, 2009, p. 481)

Patients with chronic gastroesophageal reflux disease (GERD) are at risk for (A) candidal esophagitis (B) Zenker diverticulum (C) Barrett esophagus (D) esophageal varices (E) achalasia

(C) Patients with chronic GERD are at risk for Barrett esophagus, which is a metaplasia linked to chronic reflux-induced injury to the squamous epithelium. It may lead to esophageal adenocarcinoma. Therefore, screening endoscopy may be recommended. Candidal esophagitis is likely to be found in immunosuppressed patients, uncontrolled diabetic patients, and those being treated with systemic steroids or antibiotics. A Zenker diverticulum is a protrusion of the pharyngeal mucosa that develops at the pharyngoesophageal junction. Symptoms include dysphagia and regurgitation. It is not a complication of GERD. Esophageal varices develop in patients secondary to portal hypertension. They are associated with cirrhosis and may result in serious upper gastrointestinal bleeding. (McQuaid, 2009, pp. 516-517)

Which of the following conditions is associated with perifollicular hemorrhages, ecchymoses of legs, bleeding gums, loose teeth, and gastrointestinal (GI) bleeding? (A) Peutz-Jeghers syndrome (B) Osler-Weber-Rendu Syndrome (C) scurvy (D) neurofibromatosis (E) Blue Rubber-Bleb Nevus

(C) Scurvy is caused by the lack of dietary vitamin C. It will cause perifollicular hemorrhages, ecchymoses of the legs, bleeding gums, loose teeth, and GI bleeding. Melanin spots on the lips, buccal mucosa, and tongue with bleeding polypoid lesions in the small intestines are referred to as Peutz-Jeghers syndrome. Rendu-Osler-Weber is associated with telangiectasias on the face and buccal mucosa and similar lesions in the GI tract. Neurofibromatosis is associated with café au late pigmentation, pedunculated fibromas, and fibromas in the GI tract that may bleed. Rubber- bleb nevus syndrome is associated with cavernous hemangiomas of the skin and similar lesion in the small intestines. (LeBlond et al., 2009, pp. 607-608)

Which of the following agents is a significant cause of pill-induced esophagitis? (A) fluoxetine (B) omeprazole (C) ibuprofen (D) Vitamin D (E) ciprofloxacin

(C) The most common causes of pill-induced esophagitis are nonsteroidal medications. Other commonly prescribed medications causing esophageal injury include slow release of potassium chloride, iron sulfate, quinine sulfate, and alendronate sodium. (McQuaid, 2009, pp. 520-521)

Which of the following clinical profiles is consistent with a diagnosis of Whipple disease? (A) 40-year-old woman, right upper quadrant (RUQ) severe pain related to fatty food ingestion and vomiting (B) 70-year-old woman, left lower quadrant (LLQ) pain and mass, and fever (C) 50-year-old man, fever, arthritis, and malabsorption (D) 20-year-old man, abdominal cramps, frequent bloody diarrhea, and anemia

(C) Whipple disease typically occurs in white men in their fourth to sixth decades. It is characterized by seronegative arthritis, fever, lymphadenopathy, weight loss, malabsorption, and diarrhea. Whipple disease is caused by the Tropheryma whippelii organism and is diagnosed by polymerase chain reaction (PCR) or endoscopic biopsy of the duodenum. (McQuaid, 2009, pp. 545-546)

A nonpenetrating tear of the gastroesophageal junction in association with a history of vomiting is known as (A) Boerhaave syndrome (B) Plummer-Vinson syndrome (C) Peutz-Jeghers syndrome (D) Mallory-Weiss syndrome (E) Zollinger-Ellison syndrome

(D) A mucosal tear of the gastroesophageal junction with a history of prolonged vomiting is known as Mallory-Weiss tear syndrome. Plummer-Vinson is a congenital syndrome associated with anemia and webbing of the esophagus. Boerhaave syndrome is a rare life-threatening problem characterized by a full-thickness tear of the esophageal wall. Zollinger-Ellison syndrome is caused by gastrinsecreting neuroendocrine tumors resulting in acid hypersecretion. (McQuaid, 2009, pp. 489, 521-522, 541, 576)

What is the most common drug to cause acute liver failure? (A) estradiol (B) ketoconazole (C) lisinopril (D) acetaminophen (E) methotrexate

(D) A number of drugs may cause acute liver failure but acetaminophen toxicity is the most common of acute hepatic failure. Suicide attempts account for a significant portion of acetaminophen-induced hepatic failure. All of the drugs listed can cause acute liver failure. (Friedman, 2009, p. 591)

In a patient who presents with hematemesis, which of the following is the most likely etiology? (A) Meckel diverticulum (B) diverticulitis (C) mesenteric ischemia (D) peptic ulcer (E) hiatal hernia

(D) Approximately 50% of episodes of upper GI bleeding are due to peptic ulcers. Meckel diverticulum, diverticular disease, and mesenteric ischemia may present with lower GI bleeding. Hiatal hernias usually cause no symptoms. (McQuaid, 2009, pp. 502, 515, 532)

Which of the following statements concerning gastroesophageal reflux disease (GERD) is not true? (A) may exacerbate asthma symptoms (B) behavioral interventions include weight loss and eating smaller meals (C) mild to moderate symptoms are treated with H2-receptor agonists (eg, ranitidine or cimetidine) or proton pump inhibitors (D) barium esophagography is recommended for most patients

(D) Barium esophagography has a limited role in the diagnostic management of patients with GERD. It may be used in patients with severe dysphagia to evaluate the degree of stricture. Asthma, chronic cough, chronic laryngitis, sore throat, and atypical chest pain are increasingly being recognized as atypical manifestations of GERD and reflux may be a causative or exacerbating factor. Behavioral interventions such as those mentioned above (B) as well as avoiding bending after meals have a role in the management of GERD as do the H2-receptor agonists and proton pump inhibitors. (McQuaid, 2009, p. 525)

A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child was playing normally and then "doubled over" with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis? (A) pyloric stenosis (B) mesenteric ischemia (C) Crohn disease (D) intussusception (E) Hirschsprung disease

(D) Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements. Pyloric stenosis typically presents prior to the age of 6 months with vomiting but not with diarrhea. Hirschsprung disease results from an absence of ganglion cells in the colon and typically presents early in life with failure to pass meconium, followed by vomiting and abdominal distension. The typical age of onset is later in adolescence in Crohn disease and in the elderly in mesenteric ischemia. (Sondheimer, 2007, pp. 607-608, 612, 617, 634)

The triad of "dermatitis, diarrhea, and dementia" (pellagra) results from a severe deficiency of which of the following vitamins? (A) thiamine (B) vitamin K (C) riboflavin (D) niacin (E) pyridoxine

(D) Niacin deficiency is known as pellagra. It is rare in the United States and is most often a complication of alcoholism or malabsorption syndrome. Clinical signs of pellagra are known as the 3 Ds—dermatitis, diarrhea, and dementia. (Baron, 2009, pp. 1114-1115)

Regular use of which of the following medications is a significant risk factor for the development of erosive gastropathy? (A) acetaminophen (B) fluoxetine (C) isoniazid (D) ibuprofen (E) trazodone

(D) One of the most common causes of erosive gastropathy are NSAID medications. Other common causes are alcohol, mechanical ventilation, and stress related to critical illness. (McQuaid, 2009, p. 529)

A 5-week-old male infant presents with a 1-week history of vomiting which occurs shortly after feeding. The mother describes the vomiting as forceful and the vomitus is occasionally blood streaked; the infant has not had diarrhea. You note that the infant appears slightly dehydrated and has lost weight since a routine check at 2 weeks. Which of the following is the most likely diagnosis? (A) peptic ulcer disease (B) viral gastroenteritis (C) Hirschsprung disease (D) pyloric stenosis (E) intussusception

(D) Pyloric stenosis usually presents with forceful/projectile vomiting between 2 and 4 weeks of age. There is a 4:1 male predominance; dehydration and failure to thrive may develop. Peptic ulcer disease can occur at any age and commonly affects more men but is more common from 12 to 18 years of age. Intussusception is more common in men but presents with colicky abdominal pain with subsequent development of vomiting and bloody diarrhea. (Sondheimer, 2007, pp. 607- 610, 616)

The presence of which of the following risk factors is an important clue in the diagnosis of colitis due to C difficile? (A) advanced age (B) non-insulin-dependent diabetes mellitus (C) travel to an underdeveloped country (D) recent hospital stay (E) attending a daycare or preschool center

(D) Risk factors for the development of C difficile include concurrent or recent use of antibiotics as well as a hospital or nursing home stay. C difficile colonization is found in approximately 3% of healthy adults. Increasing rates of infection are being noted in hospitalized patients secondary to transmission by hospital personnel. (McQuaid, 2009, p. 558)

The best initial diagnostic study for a suspected perforated peptic ulcer is which of the following? (A) abdominal ultrasound (B) upper GI barium swallow (C)esophagogastroduodenoscopy (EGD) (D) upright/decubitus abdominal plain film (E) colonoscopy

(D) The presence of free intraperitoneal air on an upright or decubitus film in the majority of patients with peptic ulcer perforation. This finding along with a classic history of sudden onset of severe abdominal pain and a rigid, quiet abdomen should establish the diagnosis in most cases without the need for further studies. Barium studies are contraindicated in patients with a possible perforation. (McQuaid, 2009, p. 540)

The treatment of choice for diarrhea caused by Giardia lamblia is (A) erythromycin (B) tetracycline (C) quinolones (D) metronidazole (E) ampicillin

(D) The treatment of choice for diarrhea caused by Giardia is metronidazole 250 to 750 mg po three times per day. Erythromycin can be used to treat Campylobacter. Doxycycline or tetracycline can be used to treat cholera. Quinolones can also be used to treat cholera and shigellosis. (Dipiro, 2008, p. 1888)

Which of the following vitamins helps increase the absorption of calcium in the GI tract? (A) A (B) B (C) C (D) D (E) E

(D) Vitamin D increases the absorption of calcium and phosphorus in the GI tract and induces osteoclast activity, which causes an overall increase in serum calcium levels. (Hutton, 2005, p. 32)

Cullen sign is associated with (A) diastasis recti (B) ventral hernia (C) musculoskeletal injury (D) umbilical hernia (E) retroperitoneal bleeding

(E) A faint blue coloration may occur as a result of retroperitoneal bleeding. This is known as Cullen sign. Diastasis recti occurs when the rectus muscles lack a normal fibrous band that attaches them at the midline. An umbilical calculus is usually the result of poor hygiene. An umbilical hernia will occur when a weakness occurs in the abdominal wall in the area of the umbilicus, and a fistula in that area can tract from various organs causing discharge from the umbilicus. (LeBlond, 2009, p. 478)

A 50-year-old woman presents with constipation and crampy abdominal pain for the past 3 months. She is also undergoing a divorce and has had a 15-lb weight loss in the past 3 months. You note mild tenderness to palpation in the left lower quadrant; no masses are noted. Rectal exam result is negative, but her stool tests positive for fecal occult blood. Which of the following is the most appropriate next step to evaluate her symptoms? (A) keep a food diary for the next 2 weeks (B) flexible sigmoidoscopy (C) increase dietary fiber and increase daily water intake (D) refer for psychologic evaluation to help with stress of her divorce (E) colonoscopy

(E) Any symptomatic adult with a positive fecal occult blood test should undergo colonoscopy to rule out colorectal cancer. A flexible sigmoidoscopy will allow for only partial visualization of the colon. (McQuaid, 2009, p. 507)

Mrs. Jones was referred for screening colonoscopy at the age of 50. She has no personal or family history of colorectal cancer. No polyps or lesions were found during the exam. She should be advised that colonoscopy should be repeated in how many years? (A) 1 year (B) 2 years (C) 3 years (D) 5 years (E) 10 years

(E) In average-risk individuals aged 50 or greater than 50, screening colonoscopy should be repeated every 10 years following an initial normal exam. If the individual has a first-degree relative with a history of adenomas or colorectal cancer, screening should begin earlier, generally at age 40 or 10 years younger than the age at diagnosis of the youngest affected relative. (Rugo, 2009, pp. 1452-1453)

An elderly patient is brought in to the emergency department (ED) complaining of incontinence of liquid "like tea water" stool. He is complaining of rectal pressure and lower abdominal pain. The pain is cramping in quality and the patient's abdomen is "bloated." Digital rectal exam reveals hard stool in the rectum. Which of the following should be selected as the initial treatment for this patient? (A) passing a nasogastric tube (B) milk of magnesia (C) opiate analgesics for pain (D) oral sodium phosphate (E) manual disimpaction

(E) Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives. A nasogastric tube would not be used for an obstruction in the distal colon/rectum. One would avoid opiates in fecal impactions and other constipation problems because they tend to be more constipating. This patient needs to be disimpacted. Oral agents are unlikely to be effective against the fecal impaction and may cause complications. (McQuaid, 2008, p. 481)

Which of the following antibiotics is the most appropriate treatment for antibiotic-associated colitis? (A) oral ciprofloxacin (B) intravenous vancomycin (C) oral sulfasalazine (D) intravenous penicillin (E) oral metronidazole

(E) Oral metronidazole is the drug of choice. Both vancomycin and metronidazole are effective; however, metronidazole is less expensive and there is less of a concern for vancomycin resistance. (Dipiro, 2008, p. 1863)

Which of the following hernias is most common in men and will typically be palpated below the inguinal ligament? (A) obturator (B) indirect inguinal (C) direct inguinal (D) femoral E) ventral

B

Abdominal Examination and Disorder Match? Carnett sign: Cough Test: Closed eye test: Murphy sign: Psoas sign: Rovsing: Taxi test: RLQ inflammation, cholecystitis, peritoneal irritation, peritoneal inflammation, abdominal wall tenderness, retroperitoneal inflammation, non-organic pain

Carnett sign: abdominal wall tenderness Cough Test: peritoneal irritation Closed eye test: non-organic pain Murphy sign: cholecystitis Psoas sign: retroperitoneal inflammation Rovsing: RLQ inflammation Taxi test: peritoneal inflammation

Difference between gastritis and gastropathy?

Gastritis • Inflammation of gastric area • Etiology: infectious, autoimmune Gastropathy • Disorder of stomach but no inflammation or breakdown • Etiology: alcohol, NSAID, increased acid secretion

• What are recommendations prior to getting an EGD?

NPO for 4h, no blood thinners

What esophageal condition involves dysphagia with solid foods only, and workup/tx is EGD with balloon dilatation?

Stricture

• Cranial nerves involved in swallowing?

V, VII, IX, X, XII

What is the difference between paralytic ileus and mechanical SBO? How do you workup>

• Etiology ◦ Mechanical: intrinsic or extrinsic obstacle that impedes flow ◦ Paralytic ileus: neurogenic failure of peristalsis that impedes flow • Risk: previous abdominopelvic surgeries, hernia, adhesions (extrinsic) • Presentation: nausea, vomiting, colicky abdominal pain, obstipation, tympanic abdomen ◦ Partial: no stool but some liquid and gas ◦ Complete: no stool, liquid or gas ◦ Simple/strangulated: bowel edema compresses vasculature causing necrosis (med emergency) • Workup ◦ Imaging: KUB > CT scan (dilated loops of bowel) ◦ Labs: CBC, CMP • Tx: consult surgery (may lyse adhesions) > supportive care

Esophageal Cancer What risk factors are associated with squamous cell vs adenocarcinoma?

• Etiology ◦ Squamous cell: smoking, alcohol ◦ Adenocarcinoma: barrets, gerd, obesity, smoking • Presentation: weight loss, fatigue, smoking, gerd, dysphagia • Workup ◦ Labs: CBC, CMP ◦ EGD with biopsy • Tx: refer to oncology

Barretts Esophagus Etiology, Workup, Tx, Surveillance?

• Etiology: change in mucosa from squamous cell to metaplastic columnar epithelium • Risk: chronic GERD, smoking • Presentation: chronic sx of GERD • Workup ◦ Gold standard: EGD and biopsy of distal esophagus • Tx ◦ Indefinite PPI therapy, refer to gastroenterology • Surveillance ◦ No dysplasia: PPI + EGD 1y, then 5y ◦ Low grade: PPI + yearly EGD ◦ High grade: PPI + EGD q3mo

Toxic Megacolon Etiology, Pathophys, Presentation, Workup, Tx?

• Etiology: complication of IBD or infectious colitis • Pathophys: severe colonic inflammation > nitrous oxide produced > dilated smooth muscle > paralysis of colonic smooth muscle • Presentation: diarrhea, abdominal pain, distension • Workup ◦ Labs: c diff, leukocytosis, hypokalemia ◦ Imaging: KUB initial (colonic distension >6cm), abdominal CT to assess for complications • Tx: bowel rest, NPO, NG tube, daily KUB, consider abx if infectious, steroids if IBD, surgical consult

Etiologies of fistulas?

• Etiology: complication of infection, IBD, or friends (foreign body, radiation, infection, epithelization, neoplasm, distal obstruction)

Achalasia etiology, presentation, workup, tx?

• Etiology: degeneration of nitrergic inhibitory neurons in myenteric plexus causing non-peristalsis contractions at esophagus • Presentation: dysphagia with liquids and solids, regurgitating food, not relieved with antacids • Workup ◦ Barium esophogram: bird beak ◦ Esophageal manometry is diagnostic: assess motility of sphincters and esophageal body • Tx ◦ Meds: CCB, sublingual NTG ◦ Surgery: heller myotomy

Esophageal Spasm Etiology, Presentation, Workup, Tx?

• Etiology: diffuse non-peristaltic contractions, spares LES • Presentation: dysphagia with solids and liquids, chest pain, exacerbating factor • Workup ◦ Barium esophogram: cork screw esophagus ◦ Esophageal manometry: may be normal because sx are episodic • Tx ◦ GERD sx: PPI, H2 blocker ◦ May improve over time and resolve

Varices Etiology, Presentation, Workup, Tx?

• Etiology: dilation/enlargement of veins within the esophagus and gastric area • Risk: cirrhosis, portal HTN • Presentation: hematemesis, melena • Workup ◦ Endoscopy ◦ Labs: CBC, CMP, LFTs • Tx ◦ Urgent treatment of bleed ◦ Prevention: beta blockers

Celiac Etiology, Presentation, Workup, Diagnostic criteria, tx?

• Etiology: immune mediated gluten intolerance • Presentation: diarrhea, weight loss, abdominal pain/cramping/bloating, steatorrhea, weakness, anemia • Associated: dermatitis herpetiforms = blistering, pruritic rash • Workup ◦ Labs: CBC (anemia), CMP, lipids, stool analysis (steatorrhea) ◦ Serology: DGP-IgA, tTG IgA ◦ Endoscopy with biopsy shows villus atrophy • Diagnostic criteria met ◦ +serology and + biopsy ◦ +serology and dermatitis herpetiforms ◦ - serology and +biopsy -> +HLA • Tx: refer to GI, gluten free diet

GERD Etiology, Risk, Presentation, Red flags, Workup, Tx?

• Etiology: mucosal damage produced by abnormal reflux of gastric contents into the esophagus • Risk: old, smoking, obesity (increased gastric pressure), dietary habits, medications (inhalers, anticholinergics, CCB, estrogen) • Presentation: heartburn, dysphagia, globus sensation, chronic dry cough, nausea 2x/wk for 4-8wks • Red Flags: new onset >50yo, dysphagia, weight loss, GI bleed, fhx, anemia • Workup ◦ Red flags/fail PPI: EGD • Tx ◦ Mild/Intermittent: lifestyle + H2 blocker or antacids ◦ Severe/frequent: lifestyle + PPI ◦ Resolution of sx: step down therapy: PPI > H2 > antacids ◦ Surgical: nissen fundoplication, hill gastropexy, gastric bypass, prothesis

What typically causes a Mallory Weiss Tear?

• Etiology: tear of esophageal mucosa from severe vomiting

ZES Etiology, Presentation, Workup, Tx?

• Etiology: tumor hypersecretes gatstrin • Risk: neuroendocrine tumor MEN1 • Presentation: abdominal pain, diarrhea, refractory PUD • Workup ◦ Fasting gastrin level ◦ EGD: asses for tumor or ulcers ◦ CT or MRI of abdomen to assess for tumor • Tx: referral to GI, continuous PPIs, surgery

Diverticulitis Presentation, Workup, Tx?

• Presentation: LLQ pain, fever • Workup ◦ Labs: CBC, CMP, ESR, CRP ◦ Imaging: CT abd/pelvis w/ contrast: bowel wall thickening, fat stranding, diverticula • Tx ◦ Outpatient: clear liquid diet + abx (cipro + flagyl) ◦ Inpatient: NPO, IV abx

Gastroparesis Presentation, Workup, Tx?

• Presentation: delayed emptying leading causing nausea, vomiting, epigastric pain post-prandial • Workup ◦ EGD to assess esophagus and stomach ◦ Gastric emptying study: diagnostic • Tx: refer to GI... ◦ Diet: smaller meals ◦ Prokinetic agents: erythromycin, metoclopramide

PUD Presentation, Workup, Tx?

• Presentation: dyspepsia, GERD, hunger pain better with eating (duodenal), pain worse with eating (gastric) • Workup ◦ Labs: CBC, CMP ◦ EGD and biopsy • Tx: PPI for 4-8w and repeat EGD in 12w

EoE Presentation, Workup, Tx?

• Presentation: dysphagia and chest pain, history of allergies • Workup ◦ Endoscopy with biopsy: >15 eosinophils/hpf • Tx ◦ Food elimination: dairy, nuts ◦ PPIs ◦ Swallowed fluticasone ◦ Severe sx: oral steroids for short term relief ◦ Refer to GI fo sho

How to screen for colon cancer? Age start and stop. Colonoscopy, FIT, flexible sigmoidoscopy +/- FIT, Multitargeted fecal DNA, CT colonography?

• Screening: at age 50, stop at 75yo ◦ Colonoscopy: q10yr ◦ FIT kit: q1yr ◦ Flexible sigmoidoscopy + FIT: q10yr + q1yr FIT ◦ Flexible sigmoidoscopy: q5yr ◦ Multitargeted fecal DNA: q3y ◦ Computed tomography colonography: q5yr

What is the difference between Crohns dx and Ulcerative Colitis?

• Ulcerative Colitis: mucosal layer inflammation, rectum involved ◦ Presentation: rectal bleeding and tenesmus (urgency), abdominal pain, fever ◦ Workup ‣ Labs: leukocytosis, anemia, elevated ESR/CRP, low albumin, elevated alk phos & bilirubin (cholangitis) ‣ Stool: fecal calprotectin or lactoferrin ‣ Antibody: +pANCA ‣ Imaging: abdominal XR, CT, MRI ‣ Colonoscopy: inflammation starting in rectum and ascending up the colon ◦ Tx: refer to GI, can consider J-pouch • Crohn Disease: transmural inflammation and skip lesions (mouth to anus) ◦ Presentation: chronic abdominal pain, diarrhea, weight loss, intermittent fever ◦ Workup ‣ Labs: anemia, low albumin, vitamin deficiencies, elevated ESR/CRP ‣ Antibodies: +pANCA & +ASCA ‣ Stool study: fecal calprotectin or lactoferrin ‣ Imaging: CT enterography or MR enterography ‣ Colonoscopy: cobble stoning, skip lesions, strictures, rectum spared ◦ Tx: refer to GI • Flare ups: rule out infection, use steroids, call GI

How to test and treat Hpylori? w/ and w/o PCN allergy

• Workup ◦ Urea breath test or stool antigen test ◦ Endoscopy if warning signs • Tx (10-14d) ◦ NML: clarithromycin, PPI, amoxicillin ◦ PCN allergy: clarithromycin, PPI, metronidazole

Hernia Matching? Femoral, Inguinal (direct and indirect), Umbilical, Ventral Hiatal *hernia medial to the inferior * usually from abdominal surgery with poor closure *in femoral canal and posterior inguinal ligament (women > men) *common in newborns *hernia through the inguinal ring, lateral to the inferior epigastric vessel *sliding of stomach superior above diaphragm, can cause GERD

◦ Femoral: in femoral canal and posterior inguinal ligament (women > men) ◦ Inguinal ‣ Indirect: hernia through the inguinal ring, lateral to the inferior epigastric vessel ‣ Direct: hernia medial to the inferior ◦ Umbilical: common in newborns ◦ Ventral: usually from abdominal surgery with poor closure ◦ Hiatal: sliding of stomach superior above diaphragm, can cause GERD

What is the imaging for appendicitis for adult and child?

◦ Imaging: CT abd/pelvis (adult), US (pediatric)

Match type of vomit with condition? Undigested food: Partially digested food: Bile: Feculent or odorous: Large volume: Hematemesis: *proximal SBO *achalasia/stricture/diverticulum *fistula/bacterial *mallory weis/varices *organic cause *gastric outlet obstruction/gastroparesis

◦ Undigested food: achalasia/stricture/diverticulum ◦ Partially digested food: gastric outlet obstruction/gastroparesis ◦ Bile: proximal SBO ◦ Feculent or odorous: fistula/bacterial ◦ Large volume: organic cause ◦ Hematemesis: mallory weis/varices