IM EOR - GI Conditions Part 1 (Celiac Dz/IBD/GERD/PUD/Hernias)

Extraintestinal Manifestations of active IBD disease

Reactive Arthropathy -Usually HLA-B27 (+) Episcleritis Erythema Nodosum Pyoderma Gangrenosum

_____________________ is mechanical or functional abnormality of the LES.

Reflux esophagitis

Peptic Disorders Evaluation

U/S EGD pH probe

Imaging studies for GERD

UGI pH probe Manometry Impedance monitoring Endoscopy

What study for peptic disorders allows you to evaluate anatomic abnormality as well as PUD?

UGI study/series

In which type of IBD are you more likely to encounter primary sclerosing cholangitis?

Ulcerative colitis

Surgery is curative in (Ulcerative colitis/ Crohn's disease).

Ulcerative colitis

What disease? Affects Colon only Usually involves rectum Skip lesions are not common Diffuse mucosal Inflammation Pseudopolyp formation Distal to proximal spread

Ulcerative colitis

What disease? Bloody Diarrhea Lower abdominal cramps Fecal urgency Tenesmus Severity graded

Ulcerative colitis

Which medications most commonly cause "pill ulcers" if they are not taking with enough water?

Tetracycline NSAIDs Bisphosphanates

What disease? Chronic, recurrent exacerbations & remissions Diffuse mucosal erythema, edema Always begins distal and spreads proximal in continuous fashion Loss of haustral folds in chronic disease Characteristic histologic lesion is Crypt abscess

Ulcerative colitis

Which IBD response better to aminosalicylates?

Ulcerative colitis

What characteristics of the bowel would you expect in Crohn's disease?

Thickened, edematous bowel Bowel loops adhered together Abscess and fistula formation Stricture formation

Diagnosis of a hernia is based upon history and physical exam, including attempt to reduce the mass, however an _____________ may be performed, especially in a male child where other scrotal masses (hydrocele, varicocele) are considered.

Ultrasound

What type of hernia: Very common, generally is congenital and appears at birth. Many resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life.

Umbilical hernia

What are the manifestations of PUD?

Upper abdominal pain -Gnawing, burning Fullness, bloating Nausea May see vomiting

What type of hernia: Often from previous abdominal surgery, obesity. Abdominal mass noted at site of previous incision

Ventral hernia

What is seen on small bowel biopsy that is diagnostic of Celiac disease?

Villous atrophy

What warning signs with PUD manifestations should concern you?

Weight loss Hematemesis Melena Heme positive stool Microcytic anemia Nocturnal awakenings

The treatment for candidal esophagitis is with ___________________100 mg PO daily

Fluconazole

What is the most common type of constipation?

Functional

What are the types of constipation?

Functional Organic

What condition? Voluntary withholding of stool with posturing and infrequent passage of large, painful BM Can be associated with encopresis (fecal soiling resulting from pasty stool oozing around large stool ball) - this is secondary

Functional fecal retention (habit constipation)

Effortless retrograde movement of gastric contents into esophagus and/or nasopharynx

GERD

Patients with a Schatzki ring are also at risk for ___________.

GERD

CMV esophagitis is treated with _______________.

Ganciclovir

Common causes of acute diarrhea

Gastroenteritis Infection Overfeeding (volume; quantity) Antibiotics

A Schatzki ring will cause dysphagia to: A. solids B. liquids C. both solids and liquids

A (solids) (A Schatzki ring is a stricture of the mucosa causing a lower esophageal constriction at the squamocolumnar junction. MC associated with a hiatal hernia.)

Common causes of chronic diarrhea

Allergic Celiac Malabsorption IBD Toddler's Diarrhea

What is the treatment of Carbohydrate intolerance?

Avoid lactose or give lactase

_________________ is caused by ingestion of alkali or acid from attempted suicide - treat with steroid.

Corrosive

_________________ is a disorder of the pyloric sphincter that is not present at birth but develops in the first month of infancy.

Congenital pyloric stenosis

In Crohn's disease what is the mesenteric adipose tissue that spreads over the serosal surface known as?

Creeping fat

In which type IBD would you be more likely to see Episcleritis?

Crohn's disease

What are the forms or pancreatic insufficiency?

Cystic fibrosis Acute Pancreatitis Chronic Pancreatitis

Esophageal strictures are often due to scarring from the healing process of ulcerative ___________________.

Esophagitis

What condition? Retrosternal, epigastric pain or burning Sensation of regurgitation Odynophagia, dysphagia GERD induced - causes acidic injury

Esophagitis

What kind of hernia: A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.

Incarcerated hernia

What type of hernia: Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.

Indirect Inguinal Hernia

Odynophagia is the hallmark sign of _______________________

Infectious esophagitis

_____________________ occurs mainly in patients with impaired host defenses.

Infectious esophagitis

What are the biologic (TNF blockers) that are used to treat IBD?

Infliximab (Remicaid) Humira Cimzia Tysabri

What type of diarrhea will usually stop if the pt does not eat?

Osmotic

What type of diarrhea? Malabsorption of ingested substance, which leaves and/or pulls H2O intralumenally

Osmotic

What is triple therapy for h. pylori infection?

PPI + clarithromycin + metronidazole or PPI + clarithromycin + amoxicillin

What is the treatment of Esophagitis?

PPI for 4-5 months

What is the treatment of PUD without H.pylori?

PPI for 4-8 weeks

What condition do you suspect? Upper abdominal pain -Gnawing, burning Fullness, bloating Nausea May see vomiting

Peptic Ulcer Disease

What condition? Esophageal webs + dysphagia + iron deficiency anemia

Plummer-Vinson syndrome

____________________ is characterized by a triad of dysphagia, iron deficiency anemia, and esophageal webs.

Plummer-Vinson syndrome

What PPI medications are used for GERD?

Prevacid Solutab Nexium

The second step of the stepwise drug therapy of GERD switch to a _____________________ if symptoms persist.

Proton Pump Inhibitor

What are the manifestations of GERD?

Pyrosis Cough Dysphagia Wheezing Aspiration pneumonia Recurrent Otitis media or sinusitis

Dysphagia and dynophagia lasting weeks-months after therapy

Radiation esophagitis

____________________ is caused by radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin

Radiation esophagitis

The most common cause of large bowel obstructions is __________________.

tumors/masses

A thin protrusion of the esophageal (mucosa/muscularis) is called an esophageal web.

mucosa

Endoscopic biopsy is the only test that consistently detects the columnar mucosal changes of Barrett esophagus. Patients with unremarkable endoscopy findings who have typical symptoms despite treatment with proton pump inhibitors should undergo 24-h ___________

pH testing

First line treatment of gastroesophageal reflux disease is lifestyle changes, antacids, and (medication class) ___________________.

proton pump inhibitors

Most common location of a large bowel obstruction is in the ___________ colon due to neoplasms, fecal impaction, and diverticulitis.

sigmoid

Celiac disease is characterized by inflammation of the ___________ secondary to the ingestion of gluten-containing foods such as wheat, rye, and barley leading to malabsorption.

small bowel

A hernia whose blood supply has been cut off is called A. Obstructed hernia B. Strangulated hernia C. Incarcerated hernia D. None of the above

B (Strangulated hernia) (A hernia becomes strangulated when the blood supply of its contents is seriously impaired)

__________________ to confirm and establish location of the large bowel obstruction

Barium enema

What are the signs and symptoms of pill ulcers?

Chest pain Odynophagia Dysphagia

Two or fewer stools per week or Passage of hard pellet-like stools for two weeks

Constipation

In which type IBD would you more likely see erythema nodosum?

Crohn's disease

Surgery is of limited use in (Ulcerative colitis/ Crohn's disease).

Crohn's disease

What disease? Rectal sparing Skip lesions common Transmural Inflammation Cobblestone appearance -intersecting longitudinal & transverse linear ulcers

Crohn's disease

Which IBD may affect any part of the GI tract?

Crohn's disease

Which IBD response better to steroids?

Crohn's disease

What is the characteristic histologic lesion in ulcerative colitis?

Crypt abscess

What study for peptic disorders is mandatory is alarms symptoms are present?

EGD

What is the treatment of Celiac disease?

Eliminate gluten from diet

Oral effects of systemic disease: GERD and bulemia

Enamel erosion and dental carries

*What is indicated with suspected caustic ingestion regardless of oral mucosal damage?*

Endoscopy

Pt with Asthma symptoms and GERD not responsive to antacids

Eosinophilic esophagitis

What can you do with NG tube placement in the treatment of pill ulcers/caustic burns?

Feeding Provide "stent" effect

__________________ can be caused by NSAIDS or bisphosphonates.

Medication-induced esophagitis

What is the treatment of pill ulcers/ caustic burns?

NG tube placement Steroid, antibiotics if infection suspected Surgical reconstruction if severe damage

What type of diarrhea is lactose intolerance?

Osmotic

What condition: Chest pain Odynophagia Dysphagia

Pill ulcer

What corticosteroids are used to help treat IBD?

Prednisone Entocort

A barium swallow of Eosinophilic esophagitis will show a:

Ribbed esophagus and multiple corrugated rings

Extraintestinal Manifestations of IBD at Anytime

Sacroiliitis Ankylosing Spondylitis Scleritis, Uveitis Primary Sclerosing Cholangitis Cholelithiasis

What type of diarrhea is cholera?

Secretory

IBD: Extra-Intestinal Manifestations can involve which other organs and systems?

Skin Joints Eyes Hepatobiliary system

How do you diagnose celiac disease?

Small bowel biopsy (while ON gluten)

KUB shows dilated loops of bowel with air fluid levels with little or no gas in the colon

Small bowel obstruction

___________________ presents with abdominal pain, distention, vomiting of partially digested food, and obstipation

Small bowel obstruction

What is the treatment of chronic pancreatitis?

Supportive Pancreatic enzymes Octreotide Low-fat diet ERCP

What causes pill ulcers?

Taking meds without enough water or in patients with poor esophageal motility

Anti-endomysial, anti-tissue transglutaminase, _____________ are three IgA antibodies that are associated with celiac disease.

anti-gliadin

Drugs that lower LES pressure include ________________, antihistamines, tricyclic antidepressants, Ca channel blockers, progesterone, and nitrates.

anticholinergics

Villous ______________, crypt hyperplasia, and intraepithelial lymphocytosis are histological findings in celiac disease.

atrophy

Celiac disease is an ____________ disorder

autoimmune

What presents with more severe symptoms, viral or bacterial diarrhea?

bacterial

Medication-induced esophagitis can be caused by NSAIDS or ______________________.

bisphosphonates

Achalasia is characterized by dysphagia which is severe when swallowing (solids / liquids/ both). A barium swallow study will show a "bird's beak" pattern on barium swallow caused by an overactive lower oesophageal sphincter.

both

Tympanic bowel sounds or decreased bowel sounds can be signs of ___________________.

bowel obstruction

A chronic _________ can be an easily overlooked symptom of GERD

cough

The treatment for a small bowel obstruction is _______________.

decompression with an NGT

Celiac disease is associated with the dermatological condition _________________.

dermatitis herpetiformis

___________________ on abdominal x-ray is highly suggestive of a bowel obstruction.

dilated bowel loops with air/fluid levels

Endoscopic ______________ is the procedure of choice for the treatment of an esophageal web.

dilation

The only effective treatment for celiac disease is a strict lifelong ___________-free diet.

gluten

The demographic most associated with celiac disease is _______________.

northern European

Tissue __________ is an intestinal enzyme targeted by autoantibodies in celiac disease.

transglutaminase

What antibiotics are used to help treat IBD?

Flagyl Quinilones

What is the main risk factor for esophagitis?

Immunocompromised patient

If symptoms of an esophageal stricture is sufficiently troublesome, the treatment of choice is rupture of the ring by ______________.

dilation

Ulcerative colitis spreads: (distal to proximal / proximal to distal)

distal to proximal

Diarrhea is defined as excessive, daily, liquid stood with a volume greater than __________________.

10mL stool/kg/day

How long is the triple therapy give for h.pylori infection?

2 weeks

Once Barrett's esophagus has been identified, screening every __________ by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in a patient with Barrett's esophagus."

3 to 5 years

What are the treatments for IBD

5-Aminosalicylic Acid (5-ASA's) Corticosteroids Immunosuppressive drugs Antibiotics Biologics - TNF blockers Nutritional Support Education & psychological therapy Surgery

What immunosuppressive drugs are used to help treat IBD?

6MP Azothioprine Methotrexate

Which of the following is a complication of GERD? A. Barrett's esophagus B. Zenker's diverticulum C. Gastritis D. Diffuse esophageal spasm

A (Barrett's esophagus) (GERD may predispose to Barrett's esophagus and cancer. All other options are independent disease entities. They are not complications of GERD.)

A 38-year-old man presents to the clinic for complaints of abdominal pain and diarrhea. He reports a long-standing history of the symptoms except for the time when he attempted a carbohydrate-free diet 5 years ago. The pain is described as stabbing, diffuse, 8/10, and is especially worse following food intake. Recently, he noticed some numbness and tingling of his feet but denies any bloody stool, nausea, vomiting, fevers, weight loss, or focal neurological deficits. What histopathological findings would you expect to find in this patient? A. Blunting of the intestinal villi at the ileum B. Crypt abscesses at the descending colon C. Noncaseating granulomas at the ileum D. Normal gastric mucosa at the jejunum E. PAS-positive foamy macrophages at the jejunum

A (Blunting of the intestinal villi at the ileum) (This patient is presenting with signs of celiac disease, which include diarrhea, abdominal pain, and peripheral neuropathy secondary to vitamin B12 deficiency. The pathognomonic histopathology finding of celiac disease is blunting of the intestinal villi)

A 45-year old HIV + patient presented to you with one week history of dysphagia, odynophagia, retrosternal pain, nausea and vomiting. Esophagoscopy done showed small, yellow-white raised plaques with surrounding erythema. Brushings obtained were smeared and stained with periodic acid-Schiff revealed mycelia forms and masses of budding yeast. What is the diagnosis? A. Candidal esophagitis B. Herpes esophagitis C. CMV esophagitis D. Tuberculosis esophagitis

A (Candidal esophagitis) (Diagnosis of Candida esophagitis is made by demonstration of yeast or hyphal forms in plaque smears and exudate stained with periodic acid- Schiff or Gomori silver stains. Characteristic endoscopic finding is diffuse, linear, yellow-white plaques adherent to the mucosa.)

A patient presents with reflux. When further questioned, he reports the regurgitation of small amounts of food back into his mouth. You notice he has very foul-smelling breath. What do you suspect? A. Zenker's diverticulum B. Peptic Ulcer Disease C. Achalasia D. Gastric Cancer E. Pyloric stenosis

A (Zenker's diverticulum) (Zenker Diverticulum is an outpouching of the hypopharynx which causes foul smelling breath and regurgitation of solid foods.

A 32-year-old woman comes to the clinic complaining of diarrhea which started three weeks ago. She also says she has lost four kg (8.8 lb) of weight, experiences fatigue, and has recently developed extremely itchy blisters on her skin. She has recently returned from a trip to Haiti and had received all of her travel vaccinations as recommended by her doctor. Her medical history includes hypothyroidism and vitiligo. Examination shows conjunctival pallor, but is otherwise unremarkable. An antibody screen shows anti-endomysial antibodies, and a duodenal biopsy is requested to confirm the diagnosis, as shown below. Which of the following is the most likely diagnosis? A. Celiac disease B. Lactose intolerance C. Short bowel syndrome D. Tropical sprue E. Whipple's disease

A (Celiac disease) (Celiac disease is an autoimmune T-cell mediated gluten intolerance, and classically causes symptoms of malabsorption such as diarrhoea and weight loss. It is characterized by the presence of IgA antibodies to endomysium, TTG, or gliadin, and is commonly associated with dermatitis herpetiformis) (Celiac disease is an autoimmune T-cell mediated gluten sensitivity and is a common cause of malabsorption in children and adults. In celiac disease, alpha-gliadin, a protein found in gluten, interacts with an enzyme in the lamina propria called tissue transglutaminase (TTG). The interaction leads to a modification of alpha-gliadin, causing T cells to recognize it as foreign and attacking it, leading to inflammation of the small intestine. The T-cell activation leads to generation of autoimmune antibodies - IgA antibodies to endomysium, TTG, or gliadin are highly sensitive and specific for celiac and should always be tested if celiac is suspected. The diagnosis is confirmed by duodenal biopsy (as seen in image above), which would show evidence of villous atrophy, crypt hyperplasia, and increased intra-epithelial lymphocytes. This case illustrates the classical presentation of celiac disease, in which the patient describes symptoms of malabsorption such as diarrhea and weight loss. The fatigue is suggestive of iron-deficiency anaemia, a common nutrient deficiency in celiac disease. The itchy rash described is that of dermatitis herpetiformis, a condition frequently associated with celiac disease in which herpes-like vesicles arise on the skin. This is caused by IgA deposition at the tips of dermal papillae, and resolves with a gluten-free diet which is the mainstay of treatment for celiac disease)

The gold standard test to confirm the diagnosis of celiac disease is A. Endoscopic mucosal biopsy of the small intestine. B. Antigliadin antibodies C. IgA tissue transglutaminase antibodies D. IgA antiendomysial antibodies

A (Endoscopic mucosal biopsy of the small intestine)

A 45 year old Caucasian female presents with dysphagia to solid foods with a CBC indicative of iron deficiency anemia. What finding on endoscopy would lead you to a diagnosis of Plummer-Vinson Syndrome? A. Esophageal webs B. Mallory-Weiss tear C. Barrett's Esophagus D. Varices E. A solid tumor

A (Esophageal webs) (Plummer-Vinson syndrome (PVS), also called Paterson-Brown-Kelly syndrome or sideropenic dysphagia, is a rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs. Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome. Plummer-Vinson Syndrome has 3 main findings: 1. dysphagia 2. esophageal webs 3. iron deficiency anemia)

A 55-year-old Caucasian man comes to the office because of progressively worsening gastroesophageal reflux for the past nine months. His medical history includes severe gastroesophageal reflux disease that was unresponsive to proton pump inhibitors. Nissan fundoplication was performed a year ago and, initially controlled his symptoms adequately. His current symptoms are worse than they were before the operation. Upper gastrointestinal endoscopy shows high grade dysplasia of the distal esophagus. Which of the following is the most appropriate next step in management? A. Esophagectomy B. Pancreaticoduodenectomy C. Revision of the Nissen fundoplication or an alternate anti-reflux surgery D. Stenting E. Takedown of Nissen fundoplication

A (Esophagectomy) (Esophagectomy is a large surgery and is associated with many risks. However, it is the only treatment option for patient's with high-grade dysplasia that removes the neoplastic epithelium of the distal esophagus) (Treatment options for patients with high-grade dysplasia of the distal esophagus due to severe, chronic gastroesophgeal reflux disease include: esophagectomy, endoscopic therapies to ablate neoplastic tissue, endoscopic resection of the mucosa, and aggressive endoscopic surveillance with biopsy until adenocarcinoma, followed by surgical resection) (Since Barrett's esophagus demonstrates dysplasia that can frequently progress to adenocarcinoma of the esophagus, it must be taken seriously and treated fairly aggressively. Esophageal cancer is one of the most aggressive cancers and often does not produce symptoms (such as difficulty swallowing) until relatively late stages. Esophageal cancer often metastasizes early, so the prognosis for esophageal cancer patients is poor, even with aggressive surgical and neoadjuvant therapy. As a result, patient's with high-grade dysplasia are often advised to undergo surgical resection of the esophagus in order to prevent further progression of the disease)

Which of the following is the drug treatment for Cytomegalovirus (CMV) esophagitis? A. Ganciclovir B. Fluconazole C. Tenofovir DF D. Acyclovir

A (Ganciclovir) (Ganciclovir is the drug of choice for the treatment CMV esophagitis.)

A 3-year old girl is brought to the office because of a protuberant abdomen and wasted extremities. Her mother says that her daughter has had recurrent watery diarrhea, poor appetite, and multiple episodes of emesis. She also reports new-onset bedwetting and increased drinking behaviors. At her 1-year evaluation, it was noted that she was failing to thrive. The patient was diagnosed with celiac disease following a duodenal biopsy. There are no other significant physical findings on the exam. Which of the following tests should be conducted? A. Glucose concentrations B. Hepatitis panel C. Skin biopsy D. Stool toxin test E. Vitamin C concentration

A (Glucose concentrations) (In a patient with newly diagnosed celiac disease, it is important to screen for other related autoimmunities as well, e.g. type 1 diabetes mellitus and autoimmune thyroiditis) (This patient has new-onset symptoms concerning for diabetes mellitus type 1, including bedwetting and increased thirst. Given the patients existing diagnosis with celiac disease, it is important to be vigilant for other autoimmune diseases. Celiac disease is an autoimmune disorder that primarily affects the small intestine. Typically, it is triggered by gluten-containing foods such as rye, wheat, and barley. It most commonly occurs between the ages of 6 months to 2 years, with the introduction of gluten-containing foods to the diet. Classic symptoms are diarrhea, steatorrhea, weight loss, and vitamin deficiency. Celiac disease is closely associated with autoimmune diseases such as type 1 diabetes mellitus and autoimmune thyroiditis. 10-20% of patients with Celiac will develop autoimmune thyroiditis. Upon diagnosis with Celiac disease, children should get have their TSH and glucose concentrations evaluated for other autoimmune disorders)

Which of the following drug class is most effective in relieving symptoms of GERD? A. Proton pump inhibitors (PPI) B. The dopamine antagonist prokinetic agents C. H2-receptor antagonists D. Alginate-containing antacids

A (Proton pump inhibitors (PPI)) (Proton pump inhibitors (e.g. Omeprazole) are the most effective in symptom relief and more commonly used)

True or False: PH Monitoring with intra-esophageal electrode is the GOLD STANDARD for diagnosing GERD. A. True B. False

A (True) (Although we rarely order it, this is the GOLD standard for diagnosing GERD)

What pancreatic disease? Nausea Vomiting Epigastric pain radiates to back, continuous

Acute Pancreatitis

Esophagitis due to HSV is treated with _____________.

Acyclovir

What will the bowel sounds be later on in a small bowel obstruction?

Absent

__________ is characterized by dysphagia which is equal in severity for both food and liquids. A barium swallow study will show a "bird's beak" pattern on barium swallow caused by an overactive lower oesophageal sphincter.

Achalasia

What are the organic or structural causes of constipation?

Anorectal, colonic malformation Chronic disease - CF, DM, MR Spinal cord abnormalities Medication side effects

What treatment should be avoided in a vomiting pt with a surgical abdomen or when a specific cause can be found that can be treated.

Anti-emetics

A 15-year-old boy presents to his pediatrician concerned that he is not growing as well as his peers. He had previously grown 2 inches in the past year but is concerned that many of his friends are now taller than him. He reports eating a healthy diet and plays soccer recreationally. He admits to having increasingly frequent episodes of abdominal pain over the past 6 months and occasional loose stools. He also recently developed a rash, but he dismissed this as being acne. The boy's height is 65 inches (166 cm) and weighs 107 pounds (48.5 kg), unchanged from previous measurements last year. His current height is significantly lower than his mean parental height. Physical exam demonstrates a non-tender, non-distended abdomen with mildly increased bowel sounds. The boy's rash is pictured in Figure A. Which of the following is the next best step in management? A. Anti-ASCA antibody testing B. Anti-endomysial antibody testing C. Anti-smooth muscle antibody testing D. Colonoscopy with tissue biopsy E. HLA-DQ2 and -DQ8 testing

B (Anti-endomysial antibody testing) (The patient's symptoms of abdominal pain with occasional loose stools, poor growth velocity, and dermatitis herpetiformis is consistent with a diagnosis of celiac disease, making testing for anti-endomysial antibodies the next best step.)

A 37-year-old woman comes to the office because of multiple episodes of diarrhea and bloating for several years. She also reports some itchy vesicles on her skin around her arms and legs. Physical examination shows abdominal distention, but the rest of the exam is normal except for mucosal and conjunctival pallor. Which of the following is the most appropriate first-line treatment for her condition? A. Barium swallow B. Dietary changes C. Imodium D. Iron pills E. Sulfasalazine

B (Dietary changes) (Celiac disease is an autoimmune disease in which affected individuals have an immunologically mediated response to gluten leading to mucosal damage in the small intestine. This subsequently leads to maldigestion and malabsorption. Thus, first-line treatment is a gluten-free diet) (This patient likely has celiac disease. The physical examination shows pruritic vesicles and bullae that are due to autoimmune deposition of IgA at dermal papillae tips; this is called dermatitis herpetiformis, a condition often associated with celiac disease) (IgA antibodies to gliadin, endomysium, and tissue transglutaminase malabsorption lead steatorrhea, diarrhea, weight loss, and failure to thrive in children. There is malabsorption of vitamins A, D, E, K, as well as inadequate calcium and vitamin D absorption. Calcium malabsorption causes osteopenia and iron malabsorption causes iron deficiency anemia. Diagnosis can be made with serology testing for IgA endomysial, gliadin, and tissue transglutaminase antibodies. The diagnosis can also be confirmed with a biopsy of the small intestine which would show blunting of the villi, called villous atrophy) (First-line treatment of celiac disease is a gluten-free diet. This requires major lifestyle changes since gluten is commonly consumed in a Western diet. Thus, dietary counseling is recommended to improve compliance)

What type of hernia involves passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum. A. Indirect inguinal hernia B. Direct inguinal hernia C. Ventral hernia D. Hiatal hernia

B (Direct inguinal hernia) (Direct Inguinal Hernias involve passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum)

A 58-year-old woman comes to the office because of heartburn for two weeks. The pain most often appears as she lies down to sleep. She also frequently wakes up with burning in her throat and epigastric area. She sometimes has an unpleasant bile taste in her mouth. She states that she has recently been having difficulty swallowing in addition to her usual symptoms. She has hypertension and hypothyroidism. Her current medications include Lopressor 50 mg daily, and Synthroid daily. Her temperature is 36.8°C (98°F), pulse is 87/min, respirations are 15/min, and blood pressure is 134/86 mm Hg. Which of the following is the most appropriate next step? A. Advise lifestyle changes B. Endoscopy C. H2 receptor antagonist D. Nissen fundoplication E. Proton pump inhibitor

B (Endoscopy) (Gastroesophageal reflux disease (GERD) may lead to Barrett's esophagus, a type of intestinal metaplasia and precursor condition for carcinoma. Patients with GERD should have an upper endoscopy if they present with any alarm symptoms such as the presence of dysphagia, odynophagia, weight loss, anemia, GI bleeding, or recurrent vomiting) (Gastroesophageal reflux disease (GERD) is a condition in which stomach contents leak back into the esophagus from the stomach. GERD is usually associated with changes in the barrier between the esophagus and stomach, this includes: abnormal relaxation of the lower esophageal sphincter (which normally holds the top of the stomach closed); impaired expulsion of gastric reflux from the esophagus; or a hiatal hernia) (Chronic GERD may lead to Barrett's esophagus, a type of intestinal metaplasia and precursor condition for carcinoma. Patients with GERD should have an upper endoscopy if they are characterized by any alarming symptoms which include the presence of dysphagia, odynophagia, weight loss, anemia, GI bleeding, and recurrent vomiting. Men >50 years old with chronic symptoms and cancer risk factors (i.e. tobacco) also require evaluation. The endoscopy is for evaluation of possible Barrett's esophagus or adenocarcinoma)

Which of the following is the most common cause of esophageal stricture? A. Corrosive ingestion B. Gastroesophageal reflux disease (GERD) C. Postoperative scarring D. Esophageal cancer

B (Gastroesophageal reflux disease (GERD))

Which of the following concerning femoral hernias is not true? A. They are more common in women. B. Has a low incidence of strangulation. C. Cannot be controlled with a TRUSS. D. accounts for about of 5% hernias in men.

B (Has a low incidence of strangulation) (Femoral hernias have a high incidence of strangulation mainly because of the narrowness of the neck of the sac and the rigidity of the femoral ring)

A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process? A. Femoral hernia B. Hydrocele C. Varicocele D. Diaphragmatic hernia E. Testicular torsion

B (Hydrocele) (This patient has an indirect hernia. Failure of the processus vaginalis to close can result in a hydrocele or an indirect hernia)

What type of hernia involves passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one? A. Direct inguinal hernia B. Indirect inguinal hernia C. Umbilical hernia D. Ventral hernia

B (Indirect inguinal hernia) (Indirect Inguinal Hernia (Most Common) is described as passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one. Remember: Indirect goes through the Internal Inguinal Ring (an "I" for an "I"))

A 40-year-old man comes to the office because of diarrhea and abdominal cramps. He says that he was diagnosed with celiac disease 15 years ago, but is beginning to eat gluten-containing food again because he thought that he would be able to tolerate it now. Which of the following cellular patterns would most likely be found on a biopsy of this patient's small intestine? A. Crypt abscesses with inflammatory neutrophils B. Intraepithelial lymphocytes C. Neutrophilic infiltration of lumen and tissue D. Non-necrotizing crypt granulomas E. Transmural lymphocytic inflammation

B (Intraepithelial lymphocytes) (The histologic features of celiac disease include increased intraepithelial lymphocytes (IEL), mucosal atrophy, loss of villi, and crypt hyperplasia) (Patients with a positive serology and a high probability of celiac disease should undergo an upper endoscopy with small bowel biopsy to confirm the diagnosis of celiac disease. Intraepithelial lymphocytes (IEL) are NK type cells that are present in the epithelial layer of the GI tract. They recognize the gluten antigens and are central to gluten-induced enteropathy, i.e. celiac disease. Because of the inflammatory destruction in celiac disease, the villi are absent or blunted in the mucosa, leading to reduced surface area and malabsorption. Increased IEL (40+ IEL per 100 epithelial cells) are a characteristic finding. IEL may undergo mutation, leading to the development of T-cell lymphoma)

Which of the following is not a radiographic feature of intestinal obstruction? A. Multiple air-fluid levels on erect film. B. Thumbprinting sign. C. The jejunum is characterized by its valvulae conniventes. D. Large bowel, except for the caecum, shows haustral folds.

B (Thumbprinting sign)

Chronic gastroesophageal reflux disease can cause metaplasia of the lower esophagus, which is the first stage of __________________.

Barrett esophagus

A 15-year-old girl comes to the office because of abdominal pain, diarrhea, flatulence, and borborygmi. The only known relieving factor is not eating, and as a consequence, she has lost 6.8-kg (15-lb) in 6 weeks. She is earning excellent grades in school and is involved in numerous extracurricular activities. She denies any new stress or unusual behavior. She has noticed numerous fluid-filled blisters along her arms and legs, as shown below. Her temperature is 37.6°C (99.7°F), pulse is 88/min, respirations 13/min, and blood pressure 118/80 mm Hg. Serologic evaluation is positive for anti-tissue transglutaminase IgA and anti-endomysial IgA. Which of the following is most likely seen on abdominal radiograph with barium contrast? A. Decreased duodenal folds, decreased ileal folds B. Decreased jejunal folds, decreased ileal folds C. Decreased jejunal folds, increased ileal folds D. Increased jejunal folds, decreased ileal folds E. Increased jejunal folds, increased ileal folds

C (Decreased jejunal folds, increased ileal folds) (In celiac disease, imaging and biopsy of the GI mucosa show a characteristic blunting of distal duodenal and jejunal villi. This is often associated with a compensatory "jejunization" of the ileum to enhance nutrient absorption.) (Celiac disease, also known as gluten-sensitive enteropathy, is an autoimmune disorder in which the body cannot tolerate the presence of gliadin, a digestive byproduct of gluten. Gluten is a protein mostly found in wheat, rye, and barley. When it is ingested, an inflammatory reaction damages gastrointestinal mucosa, leading to abdominal pain, maldigestion, and malabsorption) (The first diagnostic step when working up suspected celiac disease is to look for anti-tissue transglutaminase IgA and anti-endomysial IgA. Transglutaminase is an enzyme involved in protein metabolism and is found in various sites throughout the body and autoantibodies against transglutaminase are present in many diseases. This includes the characteristic rash associated with celiac disease, dermatitis herpetiformis. The endomysium is a layer of connective tissue that ensheaths a muscle fiber and contains a form of transglutaminase called tissue transglutaminase. IgA antibodies against this form of transglutaminase are called "anti-endomysial antibody.") (Imaging and biopsy of the GI mucosa in celiac disease show a characteristic blunting of distal duodenal and jejunal villi. This is often associated with a compensatory "jejunization" of the ileum to enhance nutrient absorption)

A 37-year-old woman comes to the office because of multiple episodes of diarrhea and bloating for several years. She thinks she has lost weight because of this indigestion. She also has some itchy vesicles on her arms and legs. Physical examination shows abdominal distention as well as mucosal and conjunctival pallor. Antibodies against which of the following are more likely associated with her condition? A. Epimysium B. Hemidesmosome C. Endomysium D. Perimysium E. Desmoglein

C (Endomysium) (Celiac disease is an autoimmune disease in which the 3 major IgA antibodies act against gliadin, endomysium, and tissue transglutaminase. They trigger an inflammatory response leading to mucosal damage and malabsorption. These patients commonly have anemia, weight loss, and steatorrhea) (Celiac disease is a chronic autoimmune disorder that results in an inability to tolerate gliadin, the alcohol-soluble fraction of gluten. Gluten is a protein commonly found in wheat, rye, and barley. When patients with celiac sprue ingest gliadin, an immunologically mediated inflammatory response occurs that damages the mucosa of their intestines, resulting in maldigestion and malabsorption of food nutrients) (Many children with celiac disease have steatorrhea, diarrhea, weight loss, or failure to thrive. These patients also have malabsorption of vitamins A, D, E, and K (fat-soluble vitamins), as well as inadequate calcium and vitamin D absorption. Calcium malabsorption causes osteopenia and iron malabsorption causes iron deficiency anemia. Furthermore, celiac disease is associated with dermatitis herpetiformis, which appears as a vesicular rash, commonly on the elbows or buttocks. This is likely the "itchy vesicles" described in this vignette) (Patients with celiac disease have IgA antibodies to gliadin, endomysium, and tissue transglutaminase. Therefore, serology testing should be performed for these antibodies. The diagnosis can also be confirmed with a biopsy of the small intestine, which would show blunting of the villi, called villous atrophy. The treatment of celiac disease is a gluten-free diet)

Which one of the following medications would you give to treat someone with Candidal esophagitis? A. Interferon alfa B. Ciprofloxacin C. Fluconazole D. Acyclovir

C (Fluconazole) ( Fluconazole is an antifungal agent used as initial therapy for Candidal esophagitis.)

A 20-year-old female presents to the college health clinic concerned about a rash that has recently developed along her back and flank. Aside from a history of chronic diarrhea and flatulence, she reports being otherwise healthy. She is concerned that this rash could be either from bed bugs or possible be sexually transmitted, as she has engaged in unprotected sex multiple times over the past two years. The physician orders several lab tests and finds that the patient does indeed have chlamydia and elevated tissue transglutaminase (tTG) levels. What is the most likely cause of her rash? A. Disseminiated chlamydial infection B. Streptococcal meningitis infection C. Immunologic response to gluten D. Immunologic response to dairy E. Bed bug infestation

C (Immunologic response to gluten) (This woman has celiac disease (CD). Her skin findings are consistent with dermatitis herpetiformis, which is an extraintestinal manifestation that is pathognomonic for celiac disease)

A 55-year-old man comes to the office because of severe diarrhea for the past three days. He says his diarrhea developed suddenly, and there have been no associated symptoms. Medical history includes an over-the-counter medication for heartburn, and regurgitation for the past five days. He says these have been present for the past six months, and occur daily but are not getting worse. Examination shows an afebrile man with a large body habitus. Abdominal examination is non-contributory. A barium study is obtained. Which of the following medications is the patient most likely taking for his heartburn? A. Aluminum hydroxide antacid B. Histamine 2 (H2) receptor antagonists C. Magnesium hydroxide antacid D. Prokinetic E. Proton-pump inhibitor

C (Magnesium hydroxide antacid) (Gastroesophageal reflux disease (GERD) can be treated with over-the-counter antacids which may include magnesium hydroxide. Magnesium hydroxide can act as an osmotic laxative, resulting in the adverse effect of diarrhea) (The patient most likely has gastroesophageal reflux disease (GERD) which is reflux of acid from the stomach due to reduced lower esophageal sphincter tone. It is defined as a condition which develops when the reflux of stomach contents causes troublesome symptoms (i.e. at least two heartburn episodes per week) and/or complications. Risk factors include alcohol, tobacco, obesity, fat-rich diet, caffeine, hiatal hernias, hypercalcemia, chocolate, etc. Clinical features include heartburn, dysphagia, regurgitation, new adult-onset of asthma, and cough. Ulceration with stricture and Barrett's esophagus are late complications. Treatment options include dietary and lifestyle changes, antacids, histamine 2 receptor antagonists, proton pump inhibitors, prokinetics, and surgery) (Magnesium hydroxide is sold for medical use as chewable tablets, capsules, and as liquids having various added flavors. It is primarily used to alleviate constipation, but also to relieve indigestion and heartburn. When taken orally as a laxative, the osmotic force of the magnesia suspension acts to draw fluids from the body and to retain those already within the lumen of the intestine. This distends the bowel, thus stimulating nerves within the colon wall, inducing peristalsis and resulting in evacuation of colonic contents)

Which of the following is the most common type of esophagitis? A. Infectious esophagitis B. Radiation esophagitis C. Reflux esophagitis D. Medication-induced esophagiti

C (Reflux esophagitis) (The most common cause of esophagitis is that associated with GERD (i.e Reflux esophagitis). Esophageal reflux symptoms occur monthly in 33-44% of the general population; up to 7-10% of people have daily symptoms.)

A 25-year-old woman comes to the emergency department because of a 2-day history of nausea, vomiting, subjective fever, profuse diarrhea, and abdominal cramping. She states that she had attended a large family picnic several days earlier where there were several cold salads. Following admission, which of the following is the most appropriate first step in management for this patient? A. Empiric therapy assuming multi-drug resistance B. IV antibiotic therapy to prevent disseminated disease C Replacement of fluids and electrolytes D. Short course of oral antibiotics to prevent asymptomatic carrier state E. Isolation in a negative pressure room

C (Replacement of fluids and electrolytes) (Nontyphoidal salmonella gastroenteritis is a self-limiting disease that requires no specific antibiotic therapy in otherwise healthy patients. Supportive management primarily involves fluid maintenance and electrolyte replacement) (Nontyphoidal salmonella gastroenteritis is characterized by nausea, vomiting, fever, abdominal cramping, and diarrhea, usually within 8-72 hours of ingestion of contaminated food. The quantity of bacteria ingested is correlated with the severity and duration of illness) (Salmonella gastroenteritis is typically self-limiting. While diarrhea may last from four to ten days, fever usually clears within 48 to 72 hours. If diarrhea persists more than 10 days, other diagnoses should be considered. Clinically, salmonella-induced gastroenteritis is indistinguishable from gastroenteritis from other pathogens but can be suspected with recent ingestion of meat, chicken or egg products that have not been stored or cooked properly. Stool cultures can provide a definitive diagnosis, but take 48-72 hours.) (For patients with symptoms and history consistent with Salmonella gastroenteritis, the standard therapy is supportive management with replacement of fluids and electrolytes. Antibiotics have not been shown to be effective in shortening the illness. Antimicrobials are not recommended for healthy individuals as they may not eliminate the bacteria and may select for resistant strains. Antibiotics may be appropriate when managing Salmonella gastroenteritis in immunocompromised adults and children, such as those on corticosteroid therapy, AIDS patients, or patients who have received an organ transplant)

A 30-year-old woman gravida 1, para 1, comes to the office because of colicky abdominal pain for 12 hours. She states that along with the pain she has felt nauseated and vomited twice. She has never experienced these symptoms before, but her medical history includes appendicectomy 2 years ago. Her temperature is 36.5ºC (97.7ºF), pulse is 87/min, respirations are 18/min, and blood pressure is 116/82 mm Hg. Examination shows abdominal distension. The abdomen is tender to palpation, especially in the right lower quadrant. Bowel sounds are present and high-pitched. There are no signs of peritonism. Which of the following is the most likely diagnosis? A. Ovarian cyst accident B. Ruptured peptic ulcer C. Small bowel obstruction D. Ectopic pregnancy E. Pyelonephritis

C (Small bowel obstruction) (Intestinal obstruction commonly occurs due to adhesion formation following abdominal and pelvic surgeries. Characteristic signs are abdominal distension, and high-pitched bowel sounds) (Intestinal obstruction characteristically causes nausea and vomiting, abdominal distention, constipation and colicky abdominal pain. Obstruction can be caused by many pathologies such as intussusception, volvulus, hernia, inflammatory bowel diseases, impaction of feces, and the formation of adhesions following surgery. The formation of adhesions is the cause in this case, and is also the most common cause. Bowel obstruction is diagnosed clinically, with the aid of radiology namely abdominal X-ray, and abdominal CT) (Strangulation refers to disruption of arterial or venous flow resulting in ischemia of intestinal tissues. This brings about chronic abdominal pain. Strangulation is a surgical emergency and upon diagnosis, has to be managed by performing immediate laparotomy and relieving surgery)

What initial labs should you order in the evaluation of Peptic Disorders?

CBC Serum, stool or breath H. Pylori Consider -Pancreatic enzymes -ESR =LFTs

What type of esophogitis? Large solitary ulcers or erosions on EGD

CMV

What pancreatic disease? Repeated acute attacks Milder phenotype of CF Familial Disease

Chronic pancreatitis

*How is GERD almost always diagnosed?*

Clinical

What nutritional support can be given to help treat IBD?

Calcium B12 Vitamin D

Type of infectious esophagitis that presents with linear yellow-white plaques and odynophagia or pain on swallowing.

Candida

What type of chronic diarrhea? Acquired enzyme deficiency Watery diarrhea, cramping, gas

Carbohydrate intolerance *Usually Lactose

What type of chronic diarrhea? Symptoms seen at 1-2 yrs. May be subtle but can see: -failure to thrive -bloating -distention Sensitivity to gluten

Celiac disease

What do you suspect? Immune mediated injury to small intestinal mucosa triggered by gluten ingestion (wheat, rye, barley, grains) Should be considered in children with chronic abdominal complaints Either diarrhea or constipation may be associated Serum markers

Celiac disease (celiac sprue)

What can you use for caustic burns/ pill ulcers to evaluate for mediastinal air and aspiration

Chest X-Ray

Diarrhea lasting more than 2 weeks

Chronic diarrhea

A 32 year old Caucasian woman comes to the office because of an "itchy rash." She has had it off and on for years, but it has been particularly bad in the last 6 months. She explains the rash usually occurs on her forearms and elbows, but she has also had it on her back and buttocks. She tries to not scratch, but "can't help sometimes because it's so itchy." She has tried lotions and moisturizers with no improvement. She had a thyroidectomy in her twenties due to Graves' disease and currently takes levothyroxine. She endorses occasional headaches, anxiety about her job, as well as frequent nausea and loose stools after meals. Examination shows multiple, grouped vesicles and papules distributed over her dorsal forearms, elbows, back and buttocks. Multiple excoriations are noted. Which of the following tests will likely confirm the diagnosis? A. Patch testing with multiple fabric types B. Antinuclear antibody testing C. Punch biopsy D. Anti-gliadin antibodies IgA and IgM testing E. Un-roof vesicle and send for viral analysis

D (Anti-gliadin antibodies IgA and IgM testing) (Dermatitis herpetiformis is a common dermatologic manifestation of Celiac disease. The presence of serum anti-gliadin antibodies would confirm the diagnosis of Celiac) (Dermatitis herpetiformis is a common dermatologic manifestation of Celiac disease. As the name implies, the clinical appearance of the lesion is not unlike herpes simplex (small vesicles grouped together). However, there is no underlying viral cause. Lesions are most often seen on the forearms, elbows, scalp, knees, and back. One theory connecting Celiac disease to dermatitis herpetiformis involves IgA reactive against epidermal transglutaminase that arises from epitope spreading initiated by the exposure to gliadin (found in wheat, barley, and rye) in the gut.) (The patient has a rash that is herpetic in appearance, but it appears in multiple locations not usually associated with herpes simplex. This is likely dermatitis herpetiformis, a skin condition most often associated with Celiac Disease. Additionally, she is Caucasian, has history of autoimmune disorders (Graves') and persistent GI symptoms. In this context, you should suspect Celiac disease. The initially screening test would be serum levels of anti-gliadin antibodies)

A 30-year-old man comes to the clinic because of a rash that appeared a week ago. He says that it is so itchy that it has kept him up at night. He first noticed it on his knees and since then, it has spread to both of his elbows, neck, and back. He denies recent illness or exposure to other new products or chemicals. He has no significant past medical history except for a cholecystectomy three years ago. Physical examination shows many erythematous vesicles and plaques located on his elbows, the extensor surface of his forearms, knees, neck, and back, as show below. His mucous membranes are not involved and nail changes are not visible. A biopsy of the affected skin and direct immunofluorescence reveals IgA deposits in the dermal papillae. Which of the following additional symptoms is this patient most likely to experience? A. Arthritis and dactylitis B. A painless ulcer on the genitals C. Desquamation of his palms and soles D. Bloating and diarrhea E. Periodic swelling of the lips and tongue

D (Bloating and diarrhea) (Celiac disease is associated with dermatitis herpetiformis, a pruritic, vesicular skin rash caused by IgA deposition in the papillary dermis) (Dermatitis herpetiformis (DH) is an autoimmune, pruritic skin rash of vesicles and plaques on the extensor surfaces that is caused by deposition of IgA formed in celiac disease. Patients with DH should be screened for gastrointestinal symptoms, but they may have an asymptomatic gastropathy on presentation. DH is associated with celiac disease (gluten sensitivity), in which the body forms IgA antibodies against gluten-tissue transglutaminase (t-TG)) (Patients with celiac disease are often characterized by nonspecific complaints of gas, bloating, diarrhea, and weight loss. DH manifests as a very itchy rash consisting of vesicles, papules, and plaques on the extensor surfaces of the knees, elbows, buttocks and back.) (Diagnosis is made by a skin biopsy with direct immunofluorescence showing IgA in the papillary dermis, which results in skin lesions by causing an immunologic cascade after deposition. Treatment is a gluten-free diet and dapsone for refractory or severe cases)

Which of the following is not an extraintestinal manifestation of celiac disease? A. Dermatitis herpetiformis B. Aphthous ulcers C. Iron-deficiency anemia D. Conjunctivitis

D (Conjunctivitis)

A 20-years-old man comes to the ward from the emergency department because of a sudden intense feeling of burning and itching followed, after some time, by the appearance of these strongly pruritic lesions. He is in great distress and rates the pain for the intense pruritus as a 9 on a 10-point scale. His vitals show no abnormalities. He also complains of weakness, general abdominal discomfort, and loose stools for the past few weeks. Physical examination shows a distended abdomen, with diffuse tympany on percussion. His has no relevant personal or family medical history. Laboratory studies show a hemoglobin concentration of 10 g/dL, ferritin concentration of 30 ng/mL. He is positive for transglutaminase and anti-endomysial antibodies. Which of the following is the most appropriate treatment for the prompt relief of the patient dermatologic symptoms? A. Aciclovir B. Aspirin C. Cholestyramine D. Dapsone E. Gluten-free diet

D (Dapsone) (Dermatitis herpetiformis is characterized by a very strong itchy symmetrical papulo-vesicular eruption. It is almost always associated with a gluten-sensitive enteropathy (e.g. Coeliac disease). Administration of dapsone with resolution of symptomatology within hours will prove diagnostic for DH) (The patient in this question has Dermatitis herpetiformis (DH). The disease presents most commonly during the 2nd, 3rd, 4th decades. It is characterized by intensely itchy, chronic papulo-vesicular eruption distributed symmetrically most frequently on extensor surfaces. Most patients usually can predict the eruption of a lesion as much as 8 - 12 hours before its appearance because of localized stinging, burning or itching. Most, if not all, dermatitis herpetiformis patients have an associated gluten-sensitive enteropathy. DH is associated with higher incidence of other autoimmune diseases such as thyroid disease, insulin-dependent diabetes, lupus erythematosus, Sjörgen syndrome and vitiligo. Granular immunoglobulin (Ig) A deposits in normal-appearing skin are diagnostic. The rash responds rapidly to dapsone and, in many patients, to a strict adherence to a gluten-free diet. Apart from the characteristic presentation, which could mimic anyhow other diseases, the gastrointestinal symptoms were there to help in the diagnosis, as DH is almost always associated with a gluten-sensitive enteropathy. There were hints suggesting that this young boy, with this subtle gastrointestinal symptom, the anemia and the positivity to transglutaminase and anti-endomysial antibodies, was also affected by a still not diagnosed Coeliac disease or another associated gluten-sensitive enteropathy. Once diagnosis was done, one should have not be confused by the name (herpetiformis), which is just a way to describe a clinical appearance and not its etiology, and thus go towards dapsone as the quickest way for patient recovery)

Which of the following is not a risk factor for abdominal hernias? A. Chronic cough B. Obesity C. Heavy lifting D. Diarrhea

D (Diarrhea) (Diarrhea is not a risk factor for abdominal hernias, but chronic constipation is. Any condition that increases intra-abdominal pressure may contribute to the formation of abdominal hernia. All other options are correct)

Which of the following is not a treatment modality for esophageal stricture? A. Proton Pump Inhibitor B. Endoscopic dilatation C. Endoscopic intralesional steroid D. Endoscopic sclerotherapy

D (Endoscopic sclerotherapy) (Endoscopic sclerotherapy is used in the treatment of bleeding esophageal varices)

Which of the following statements is false? A. Hiatal hernia contributes to the development of GERD. B. Excessive reflux is defined as a pH <4 for >4% of the time C. In most patients with GERD, baseline LES pressures are normal (10-35 mm Hg). D. Endoscopy is indicated in all cases of GERD.

D (Endoscopy is indicated in all cases of GERD)

Which of the following types of esophagitis is associated with atopy? A. Corrosive esophagitis B. Radiation esophagitis C. Infectious esophagitis D. Eosinophilic esophagitis

D (Eosinophilic esophagitis) (Eosinophilic esophagitis is a disorder in which food or environmental antigens are thought to stimulate an inflammatory response. A history of allergies or atopic conditions (asthma, eczema, hay fever) is present in over half of patients)

A 60-year old man has had GERD for years. For about 13 months now he has noticed an increasing difficulty in swallowing his food. Which of the following is the most likely diagnosis? A. Achalasia B. Diffuse esophageal spasm (DES) C. Pyloric stenosis D. Esophageal stricture

D (Esophageal stricture)

Which of the following is correct concerning large bowel obstruction: A. Vomiting occurs early and is profuse with rapid dehydration B. Pain is predominant with central distension. C. Distension is minimal. D. Vomiting and dehydration are late.

D (Vomiting and dehydration are late) (In large bowel obstruction, distension is early and pronounced. Pain is mild and vomiting and dehydration are late)

A 49-year-old man comes to the office because of difficulty swallowing for three months. He says food has been getting "stuck" when he tries to swallow it. This sensation only happens with food, especially bread, and not with liquids. He has tried many over-the-counter remedies, including a medication which decreases stomach acid secretion. These treatments have had little effect. His medical history includes persistent "heartburn" for the past five years. A barium swallow is obtained. Which of the following is the most likely diagnosis? A. Achalasia B. Eosinophilic esophagitis C. Esophageal candidiasis D. Esophageal stricture E. Gastric carcinoma

D (Esophageal stricture) (Esophageal strictures occur in about 10% of those who are treated for gastroesophageal reflux disease (GERD) but can also occur secondary to neck surgery, radiation, ingestion of caustic chemicals, or any other mechanism causing damage to the esophageal mucosa) (An esophageal stricture is a narrowing or tightening of the esophagus that causes swallowing difficulties) (It can be caused by or associated with gastroesophageal reflux disease (GERD), esophagitis, a dysfunctional lower esophageal sphincter, disordered motility, lye ingestion, or a hiatal hernia. Strictures can form after esophageal surgery and other treatments such as laser therapy or photodynamic therapy. While the area heals, a scar forms, causing the tissue to pull and tighten, leading to difficulty in swallowing) (Strictures, and other mechanical causes of dysphagia (e.g. esophageal cancer) are characterized by progressive symptoms. Patients often first notice difficulty swallowing solid foods (especially breads and meats), and this then progresses to softer foods, and then fluids. This occurs as the lumen becomes narrower and the mechanical obstruction becomes larger)

An 18-year-old man comes to the emergency department because of sub-sternal chest pain for an hour. He has experienced this pain before, typically after heavy meals, during times of stress, and when he goes running in the park. He also feels the pain at night when he is lying in bed and has previously been woken from sleep by discomfort. He has not noticed any dyspnea, diaphoresis, or palpitations but is currently experiencing some nausea and a sour taste in his mouth. Medical history is non-contributory. ECG shows normal sinus rhythm. Which of the following is the most likely diagnosis? A. Achalasia B. Diffuse esophageal spasm C. Esophageal stricture D. Gastroesophageal reflux E. Stable angina

D (Gastroesophageal reflux) (Gastroesophageal reflux disease (GERD) is the most common non-cardiac cause of chest pain. It is characterized by chest pain that may occur in a supine position, after meals, and along with a sour, acidic taste in the mouth.) (Gastroesophageal reflux is the most common cause of non-cardiac chest pain and the most likely cause of this patient's chest pain. Typical symptoms include burning substernal pain associated with food, as well as increased discomfort in the supine position, nausea and vomiting, and a sour taste in the mouth due to acid regurgitation ("water brash").) (Less common causes of non-cardiac, gastrointestinal related chest pain include esophageal motility disorders, esophageal rupture, or tears and esophagitis)

A 30-year-old Caucasian female presents with weight loss, pallor, and periodic abdominal discomfort. Physical exam reveals pruritic, red lesions on the patient's shoulders, elbows, and knees. An endoscopic duodenal biopsy is taken and shown in Figure A. Which of the following diseases is associated with the patient's condition? A. Zollinger-Ellison syndrome B. Hirschsprung's disease C. Peutz-Jehger's polyposis D. Hashimoto's thyroiditis E. Helicobacter pylori infection

D (Hashimoto's thyroiditis) (Celiac disease is a chronic, hereditary, autoimmune intestinal malabsorption disorder caused by intolerance to gluten. It is associated with other autoimmune diseases such as Hashimoto's thyroiditis and diabetes mellitus type I)

Which of the following is not a cause of paralytic ileus A. Gastrointestinal surgery B. Hypokalemia C. Intra-abdominal sepsis D. Hyperkalemia

D (Hyperkalemia) (Hyperkalemia does not cause paralytic ileus. It can cause cardiac arrhythmia. All other options are correct)

Which of the following is not a cause of distal esophageal stricture? A. GERD B. Adenocarcinoma C. Scleroderma D. Infectious esophagitis

D (Infectious esophagitis) (Infectious esophagitis causes stricture mostly at the proximal and mid esophagus)

A 26 year old mildly obese woman presents with 2-month history of heartburn, 2 weeks history of regurgitation. She drinks alcohol and smokes occasionally. Which of the following would you not advise her to do? A. Eating smaller meals at a time B. Elimination of acidic foods C. Weight loss; stop smoking and alcohol ingestion D. Lying down within 3 hours after meal

D (Lying down within 3 hours after meal) (Lying down within 3 hours after meal is not advisable for patient with GERD as it worsen reflux. Patient should wait 3 hours after a meal before lying down)

A 65-year-old man comes to the office because of dull chest pain, dyspnea, and heart palpitations. He occasionally feels his food "balling up" in his throat, causing significant discomfort in his chest. He denies exacerbation of his chest discomfort during exercise. He has tried taking calcium carbonate tablets to ease his symptoms with some success. His chest X-ray shows a mass in the posterior mediastinum containing air or an air-fluid level.. Which of the following is the most appropriate surgical management of the patient's underlying condition? A. Gastropexy B. Heller myotomy C. Ivor-Lewis transthoracic esophagectomy D. Nissen fundoplication E. Ometoplasty

D (Nissen fundoplication) (Nissen fundoplication is a surgical procedure to repair hiatus hernia. Hiatus hernias are characterized on chest radiographs by a mass in the posterior mediastinum containing air or an air-fluid level) (Nissen fundoplication is a common surgical treatment of hiatus hernia, a condition in which the proximal stomach protrudes superiorly through the diaphragm into the thoracic cavity. Clinical features of hiatus hernia include gastroesophageal reflux (GERD), epigastric or substernal pain, postprandial fullness, nausea, and retching. Chest radiographs show a mass in the posterior mediastinum that can be either filled with air or display a fluid-air level. In fundoplication, the gastric fundus is wrapped, or plicated, around the distal esophagus to strengthen the juncture between the esophagus and the diaphragm, thereby reducing the likely that abdominal viscera can pass through the diaphragm into the thoracic cavity. Often done laparoscopically, fundoplication is a relatively safe procedure with a quick recovery)

Your patient has positive serology testing for celiac sprue. To confirm the diagnosis, you need to perform what test?

Endoscopic intestinal mucosal biopsy

A 22-year-old man comes to the family medical clinic because of foul-smelling and bulky stools for the past 6 months. The patient also lost 4.5-kg (10-lb) over this time period as well. A D-xylose test and small bowel series are ordered and results are normal. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn disease C. Duodenal ulcer D. Pancreatic insufficiency E. Small intestinal bacterial overgrowth

D (Pancreatic insufficiency) (D-xylose is a monosaccharide which is absorbed through the small intestines and excreted through the kidneys. A D-xylose test is helpful in differentiating between structural and functional causes of malabsorption) (Steatorrhea, or fatty stools, can be assessed using a 72-hour fecal fat collection and Sudan staining. Once apparent that a patient has fat malabsorption, the next step is to determine if the fat malabsorption is secondary to structural pathology (e.g. villous blunting in as with Celiac disease, non-caseating granulomas in Crohn disease) or functional (e.g. decreased lipase secretion secondary to exocrine pancreatic insufficiency). To differentiate between structural and functional steatorrhea, a D-xylose test can be utilized. D-xylose is a monosaccharide which can be absorbed through the small intestines and excreted through the kidneys into the urine. An abnormally low excretion of D-xylose is indicative of a structural pathology. Note that patients with chronic kidney disease or reduced glomerular filtration rate can lead to false negative results. An abdominal x-ray, also known as a kidney, ureter, and urinary bladder X-ray, can be ordered to rule out any obstruction) (In this clinical vignette, the patient displays classic symptoms of steatorrhea (bulky and foul smelling stools). D-xylose test was within normal limits. Hence, exocrine pancreatic insufficiency is the most likely answer)

Which of the following statements is false concerning celiac disease? A. IgA tissue transglutaminase antibody is a serologic screening test for celiac disease. B. Intestinal symptoms in children include diarrhea, weight loss, abdominal distension, failure to thrive. C. Gluten-free diet is essential in the treatment of patients with celiac disease. D. Prednisolone has no role in the management of celiac disease.

D (Prednisolone has no role in the management of celiac disease) (Prednisolone may be required in refractory cases. All other statements are true)

A 14-year old female presented at the outpatient clinic on account of chronic diarrhea. Signs of delayed sexual maturity was seen. A diagnosis of celiac disease was made after physical examination and laboratory findings. The malabsorption syndrome is due to A. Lactase deficiency B. Impaired absorption of fat C. Impaired absorption of Vitamin B12 D. Sensitivity to gliadin

D (Sensitivity to gliadin) (Celiac disease is caused by genetic susceptibility to sensitivity to gliadins, which is an alcohol-water soluble fraction of GLUTEN.)

A 15-year-old boy comes to the office because of an intensely itchy rash on his elbows and knees. He states that the rash began as small vesicles a week ago. Family history is significant for Graves disease in his mother. Physical examination shows excoriated papules and erosions that are crusted over on his elbows, knees, and buttocks, as shown below. Which of the following is most likely to confirm thediagnosis? A. Anti-nuclear antibody testing B. Mite detection with skin scraping with microscopy C. Potassium hydroxide preparation of skin scraping with microscopy D. Skin biopsy E. Tzanck smear

D (Skin biopsy) (Celiac disease is associated with dermatitis herpetiformis and autoimmune diseases. When clinical suspicion for dermatitis herpetiformis is high, a skin biopsy can confirm the diagnosis) (While the diagnosis based on clinical appearance may be difficult and easily confused with other causes of rash, this patient has dermatitis herpetiformis, which is associated with celiac disease. Celiac disease is associated with other autoimmune disorders such as type 1 diabetes mellitus and thyroid disease) (Dermatitis herpetiformis characteristically presents as an intensely itchy rash with multiple excoriations on the extensor surfaces. This rash is not common in children, but it may occur and further workup is warranted. A family history of Grave disease gives some clue that an autoimmune process may be involved) (The diagnosis of dermatitis herpetiformis is made from a tissue biopsy. Immunofluorescence will demonstrate the deposition of IgA in the papillary dermis. In addition, serologic testing may be performed to look for anti-gliadin, anti-tissue transglutaminase, or anti-endomysial antibodies)

A 63-year-old man comes to the office because of heartburn for the past four months. He experiences a burning feeling in his chest whenever he eats. He has also had difficulty swallowing his food. The patient has lost 6.8-kg (15-lb) over the past four months. A chest radiograph is obtained and shown below. Which of the following is the most likely diagnosis? A. Achalasia B. Gastroparesis C. Paraesophageal hernia D. Sliding hiatal hernia E. Zenker diverticulum

D (Sliding hiatal hernia) (Sliding hiatus hernias (type I) are protrusions of the gastroesophageal junction and proximal stomach into the thoracic cavity. Type I hernias are associated with the development of gastroesophageal reflux. (Sliding hernias are the most common types of hiatal hernias, making up 90% of cases. A sliding hernia refers to a protrusion of the gastroesophageal junction (GEJ) and the cardia of the stomach through the crura of the diaphragm and into the thoracic cavity. Sliding hernias are also referred to as type I hiatal hernias. Small sliding hernias can remain asymptomatic, while larger ones are characterized by symptoms related to gastroesophageal reflux disease (GERD), which include heartburn, regurgitation, and dysphagia. Loss of diaphragmatic support of the lower esophageal sphincter (LES) facilitates entry of stomach hydrochloric acid into the esophagus, predisposing individuals with sliding hernias to develop GERD. A chest X-ray can show large sliding hernias as retrocardiac masses that may or may not have an air-fluid level)

The initial management of a patient with strangulated inguinal hernia includes all of the following except: A. Placing of intravenous line for rehydration and electrolyte correction. B. Passage of nasogastric tube for decompression. C. Administration of oxygen D. Surgery

D (Surgery) (Surgery, when indicated for acute intestinal obstruction is done after the patient has been adequately resuscitated. All other options are resuscitative measures)

The initial management of intestinal obstruction includes all of the following except A. Passage of nasogastric tube for decompression. B. Placing of intravenous line for rehydration and electrolyte correction. C. Administering intravenous antibiotics. D. Surgery

D (Surgery) (Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete obstruction, surgery. If bowel ischemia or infarction is suspected, antibiotics should be given (eg, a 3rd-generation cephalosporin, such as cefotetan 2 g IV) before operative exploration. Surgery, when indicated for acute intestinal obstruction is done after the patient has been adequately resuscitated. All other options are resuscitative measures)

The human leukocyte antigen subtype associated with celiac disease is ____________.

DQ2/DQ8

What are the causes of functional constipation?

Dietary Hirschsprung's (Sensory ganglia)

What type of hernia: Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum

Direct Inguinal Hernia

Watery discharge, infection, pain, and photophobia that is often an extraintestinal manifestation of IBD

Episcleritis

What extraintestinal manifestation of IBD can mimic Reiter's syndrome?

Erythema Nodosum

Patient will present with solid food dysphagia in a patient with a history of GERD

Esophageal stricture

A 2-month-old infant is brought to the office because of vomiting and cough for a month. The vomiting is worse following meals, and the infant is exclusively formula fed. The mother states these symptoms have been worsening. She says there has been no projectile or bilious vomiting, fever, sputum production, or lethargy. She says she keeps the child upright while feeding and has tried to switching formulas without improvement. Physical examination shows the infant is in the 5th percentile for height and weight. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate diagnostic investigation? A. Abdominal ultrasound B. Barium swallow C. Endoscopy D. Esophageal manometry E. Esophageal pH monitoring

E (Esophageal pH monitoring) (Infantile gastroesophageal reflux disease (GERD) is confirmed with 24-hour esophageal pH monitoring. Advantages in using pH monitoring include the quantification of reflux and the ability to establish a temporal relationship with atypical symptoms (e.g. obstructive apnea) and reflux events) (The most likely diagnosis is gastroesophageal reflux (GERD). The gold standard for confirming reflux is 24-hour esophageal pH monitoring. Infant reflux is typically characterized by emesis following meals, irritability, and cough. Infants may be in the lower percentile for height and weight due to decreased formula intake. An infectious etiology should be ruled out if it is an acute presentation. Advantages in using pH monitoring include the quantification of reflux and the ability to establish a temporal relationship with atypical symptoms (eg, obstructive apnea) and reflux events) (The diagnosis is usually made clinically and conservative recommendations are made before further diagnostic workup. These recommendations include; smaller and more frequent meals, thickening the formula with rice cereal, elevating the head to 20-30 degrees after feeds)

A 42-year-old woman comes to the office because of hematemesis and melena for the past week. She has been experiencing abdominal pain, which she currently rates a 4 on a 10-point scale. She says that the pain worsens when she eats and that she often develops nausea after eating. The pain is worse, particularly when eating fried foods. Physical examination shows tenderness to palpation in the epigastric area, but no other abnormalities. Which of the following is the most likely cause of her symptoms? A. Achalasia B. Eosinophilic esophagitis C. Esophageal rupture D. Esophageal varices E. Hiatal hernia

E (Hiatal hernia) (Hiatus hernias occur when part of the stomach protrudes through and above the diaphragm. Gastric ulcers can develop in individuals with hiatus hernias) (Hiatus hernias refer to protrusions of the stomach through the crura of the diaphragm and into the thoracic cavity. Hiatus hernias are subdivided into sliding (type I) and paraesophageal (type II, III, and IV) hernias. Sliding hernias consist of a protrusion of the gastroesophageal junction (GEJ) and cardia of the stomach above the diaphragm, while in paraesophageal hernias only the fundus of the stomach generally protrudes above the diaphragm. Hiatus hernias may be asymptomatic, but common clinical features include gastroesophageal reflux disease (GERD), epigastric or substernal pain, postprandial fullness, and nausea. Radiographic imaging of paraesophageal hernias shows a posterior mediastinum mass that often has an air-fluid level in the thoracic cavity. Individuals with hiatus hernias may develop gastric ulcers, which are characterized by hematemesis, melena, nausea, and epigastric pain that is worsened after eating, especially after eating fatty foods)

A 16-year-old man comes to the clinic because of 7 days of flatulence and greasy, foul-smelling diarrhea. He states he recently went camping and reports that his friend collected water from a stream, but did not boil or chemically treat the water before they consumed it. The patient also reports symptoms of nausea, weight loss, and abdominal cramps followed by sudden diarrhea. Which of the following is the most appropriate treatment option? A. Trimethoprim B. Cephalexin C. Erythromycin D. Ciprofloxacin E. Metronidazole

E (Metronidazole) (Patients with acute giardiasis present with a sudden onset of diarrhea, malaise, foul-smelling fatty stools, abdominal cramps, flatulence, nausea and weight loss. First line treatment is via oral metronidazole) (Giardiasis is an infection of Giardia lamblia, a protozoan parasite that can cause epidemic or sporadic diarrhea. Water is an important source of giardiasis transmission. Giardia cysts survive in streams due to their tolerance of cold temperatures. Some water-dwelling animals may serve as ongoing environmental sources of contamination. As with this patient, Giardia lamblia is a significant cause of diarrhea in hikers and campers in wilderness areas, who ingest water that has not been adequately boiled or filtered, or eat food rinsed in such water) (The most common symptoms of acute giardiasis are the sudden onset of diarrhea, malaise, foul-smelling fatty stools, abdominal cramps, flatulence, nausea and weight loss. Symptoms usually present after a 7-14 day incubation period and may last from two to four weeks) Supportive measures to correct fluid and electrolyte imbalances are recommended. In addition, symptomatic patients should also be treated with antibiotics. Metronidazole is an antimicrobial typically prescribed for Giardia infections. Metronidazole can be used in children and adults. Typically, a 5-day course is prescribed. Side effects include nausea, gastrointestinal discomfort, a metallic taste in the mouth, and headache. Patients should avoid alcohol consumption while taking Metronidazole.

A 61-year-old man comes to the clinic because of dysphagia and "heartburn," which he states have become more troublesome over the past 5 months. Examination shows mild tenderness to palpation over his epigastrium. Upper gastrointestinal barium swallow fluoroscopy demonstrates a subdiaphragmatic gastroesophageal junction, but apparent herniation of the gastric fundus superiorly and into the left hemithorax. Which of the following is the most appropriate management of this patient's underlying condition? A. Calcium carbonate B. Cimetidine C. Lifestyle modification D. Omeprazole E. Surgical gastropexy

E (Surgical gastropexy) (Axial subtype hiatal hernias can be treated conservatively, with either lifestyle modification or medical therapy. The less common paraesophageal hiatal hernia is associated with a risk of gastric volvulus and requires definitive surgical treatment) (This patient is presenting with gastroesophageal reflux disease secondary to a paraesophageal hiatal hernia. The paraesophageal subtype is a relatively rare variety of hiatal hernias, occurring in less than 5% of all documented cases, and is due to herniation of the gastric fundus itself into the thoracic cavity. Unlike the much more common axial sliding subtype of hiatal hernia, paraesophageal hiatal hernias require surgical gastropexy (attachment of the stomach to the rectus sheath) to prevent gastric volvulus. If left untreated, gastric volvulus can lead to gastric wall ischemia, infarction, and perforation with resultant pneumoperitoneum and bacterial peritonitis)

______________________ are thin membranes in the mid-upper esophagus. May be congenital or acquired

Esophageal web

______________________ is an outpouching of the esophageal mucosa that confers an increased risk for esophageal squamous cell carcinoma.

Esophageal web

A 54-year-old female presents with odynophagia (painful swallowing), dysphagia and retrosternal chest pain. What is the most likely diagnosis?

Esophagitis

A 3-year-old girl comes to the office because her parents say that she frequently has foul-smelling diarrhea, particularly after eating pasta or bread. Physical examination shows excoriated papules and vesicles on her elbows, knees, back, and buttocks. She is in the 10th percentile on the growth curve for height and weight. An endoscopic small bowel biopsy is obtained and is shown below. Which of the following gastrointestinal neoplasm is she at the greatest risk of developing if her disease becomes refractory to treatment? A. Adenocarcinoma B. Carcinoid C. Gastrointestinal stromal tumor D. Hamartoma E. T-cell lymphoma

E (T-cell lymphoma) (Patients with refractory celiac disease have an elevated risk of developing small bowel T-cell lymphoma, which is a non-Hodgkin lymphoma that affects T cells) (This patient has the signs and symptoms of celiac sprue, which is an autoimmune-mediated intolerance of gliadin, leading to malabsorption and steatorrhea. Celiac sprue is more common in people of northern European descent. The patient's skin findings are typical of dermatitis herpetiformis, which is often associated with Celiac. Her biopsy shows blunting of the villi, crypt hyperplasia, and lymphocytic infiltration. Patients with refractory celiac disease have an elevated risk of developing small bowel T-cell lymphoma, which is a non-Hodgkin lymphoma that affects T cells. The other answer choices are GI neoplasms that are not associated with celiac disease)

A 22-year-old Caucasian woman comes to clinic because of "greasy" diarrhea, abdominal distention, pruritus, and 10 pound weight loss over the past week. She is originally from England, but moved to the United States 5 years ago. She says her symptoms are exacerbated after consuming bread and pasta. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 80/50 mm Hg. Physical examination shows diffuse rash on her scalp and buttocks, diffuse tenderness to palpation of the abdomen, and spooned fingernails. Upper endoscopy and duodenal biopsy are ordered. Which of the following histological features are likely to be seen of the duodenum? A. Caseating granulomas with central necrosis containing Langerhans giant cells B. Crypt abscesses and noncaseating granulomas C. Foamy macrophages in the lamina propria D. Mucin-filled signet-ring cells with nuclei displaced to the periphery of the cell E. Villous atrophy, crypt hyperplasia, and intraepithelial CD8+ lymphocytes

E (Villous atrophy, crypt hyperplasia, and intraepithelial CD8+ lymphocytes) (Celiac disease classically has histological features of villous atrophy, crypt hyperplasia, and intraepithelial CD8+ lymphocytes predominantly in the duodenum. These features occur due to an interaction between gliadin in carbohydrates and IgA antibodies in the gut) (The patient shows signs and symptoms consistent with celiac disease. Celiac disease is most common in caucasian patients of European ancestry. Steatorrhea, abdominal distention, and weight loss are common presentations of celiac disease. The patient's rash on her scalp and buttocks is consistent with dermatitis herpetiformis, an associated condition of celiac disease due to the the accumulation of neutrophils and IgA antibodies in the dermis of the skin. She has tachycardia, low-blood pressure, and spooned fingernails most likely because of iron-deficiency anemia, also common in celiac disease. Villous atrophy, crypt hyperplasia, and intraepithelial CD8+ lymphocytes are common histological features of celiac disease, most notably to the second portion of the duodenum and proximal jejunum, where most of the absorption occurs)

What are the risk factors for developing peptic ulcer disease?

H. pylori Drugs Tobacco use Family history Sepsis Head trauma Burn injuries Hypotension

What is the treatment for pathologic GERD?

H2Blockers PPI therapy

What type of infectious esophagitis? Shallow punched out lesions on EGD

HSV

An endoscopy for presumed esophagitis shows multiple shallow ulcers. What is the most likely diagnosis?

Herpes simplex virus

What type of hernia: Involves protrusion of the stomach through the diaphragm via the esophageal hiatus. Can cause symptoms of GERD; acid reduction may suffice, although surgical repair can be used for more serious cases.

Hiatal (diaphragmatic) hernia

In the stepwise drug therapy of GERD start with a _______________________ QD then increasing BID if needed.

Histamin 2 receptor antagonist

How is a diagnosis of Carbohydrate intolerance made?

Hydrogen breath test

What will the bowel sounds be early on in a small bowel obstruction?

Hyperactive

What kind of chronic abdominal pain? May not occur as often Usually associated with *bowel habit disturbance* but definitely related to gut motility Food, BM may relieve or exacerbate

Irritable Bowel Syndrome

Classic example of osmotic diarrhea

Lactose intolerance

KUB shows dilated large intestine

Large bowel obstruction

Presents with distention and pain. Patients may be febrile and tachycardic. Shock may ensue.

Large bowel obstruction

What 5-Aminosalicylic Acid (5-ASA's) are used to help treat IBD?

Mesalamine Sulfasalazine

Which agent for GERD is less effective?

Metoclopramide

The use of which medications increase a persons risk for Peptic Ulcer Disease?

NSAIDS Bisphosphonates Potassium

What disease? Similar symptoms of PUD But NO evidence of mucosal irregularity H. pylori plays no role

Non-ulcer Dyspepsia (NUD)

What kind of hernia: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel.

Obstructed hernia

Oral effects of systemic disease: DM, immunodeficiency

Oral candidiasis

A _________________ is a diaphragm-like mucosal ring that forms at the esophagogastric junction (the B ring). If the lumen of this ring becomes too small, symptoms occur.

Schatzki ring

When is the peak incidence of IBD?

Second decade of life

What type of diarrhea? Intestinal mucosa directly secretes fluid and electrolytes into the stool Inflammatory or chemical

Secretory

How is a diagnosis of celiac disease made?

Serology with biopsy confirmation

Celiac disease moderately increases the risk of ____________________ (malignancy).

T-cell lymphoma

What kind of hernia: A hernia becomes strangulated when the blood supply of its contents is seriously impaired.

Strangulated hernia

What are the complications of caustic burns/ pill ulcer?

Stricture formation

What treatment is used for severe cases of GERD?

Surgery or J-Tube placement

Chronic gastroesophageal reflux disease causes _______________ of the lower esophagus.

adenocarcinoma

The most common cause of small bowel obstruction is ____________ from previous surgery.

adhesions

Esophageal webs almost always arise from the (anterior/posterior) wall of the esophagus.

anterior

A diagnosis of esophageal stricture is confirmed by radiographic __________________ or endoscopy.

barium swallow

A/an ____________________ is the best initial test for the diagnosis of a suspected esophageal web.

barium swallow

What is a classic example of secretory diarrhea?

cholera

Most patients with esophageal strictures have intermittent, nonprogressive _______________ for solid food that occurs while consuming a heavy meal with meat that was "wolfed down," hence the pseudonym the "steakhouse syndrome."

dysphagia

Plummer-Vinson syndrome is characterized by a triad of ________________, iron deficiency anemia, and esophageal webs.

dysphagia

Acid reflux in chronic gastroesophageal reflux disease can lead to damage of the _______ layer of teeth.

enamel

A diagnosis of esophageal stricture is confirmed by radiographic barium swallow or _________________.

endoscopy

Prolonged reflux may lead to ___________, stricture, and rarely metaplasia or cancer.

esophagitis

People with a ____________ with celiac disease (parent, child, sibling) have a 1 in 10 risk of developing celiac disease.

first-degree relative

Chronic __________________ can present with chronic cough, hoarseness, regurgitation, and dysphagia.

gastroesophageal reflux disease

What is the treatment for celiac disease?

gluten free diet

In Crohn's disease "creeping fat" is a (hyperplasia / hypertrophy) that starts as an attempt to control.

hyperplasia

Medication-induced esophagitis is treated by drinking pills with water, avoid ______________ for at least 30-60 minutes after ingestion

laying down

Chronic gastroesophageal reflux disease results from decreased tone of the (upper / lower) esophageal sphincter.

lower

Chronic gastroesophageal reflux disease often presents with feelings of heartburn and regurgitation when (sitting up / lying down)

lying down

Esophageal webs confer an increased risk of ________________ (type of) carcinoma of the esophagus.

squamous cell

Bowel obstructions typically require (medical/surgical) intervention, though some will resolve spontaneously.

surgical

If the patient with a hernia is otherwise well, refer non-urgently to surgery for definitive ____________.

surgical repair

Esophageal webs are typically found in the (upper/lower) esophagus.

upper

In North America, most diarrhea is (viral / bacterial) and self-limited.

viral