GI exammaster

When is surgery necessary for gastric polyps? Answer Choices 1 For all polyps larger than 2 cm 2 When the question of cancer cannot be completely answered by endoscopic biopsy 3 When the polyp is pedunculated and greater than 2 cm in size 4 When there are multiple polyps 5 For ulcerated bleeding polyps only

2 When the question of cancer cannot be completely answered by endoscopic biopsy Explanation Gastric polyps are often found by barium x-ray studies or at the time of upper endoscopy. Polyps which are small can be easily biopsied, and pedunculated polyps, even those larger than 2 cm in diameter can be excised by use of a snare. Lesions which are sessile do not lend themselves to snare excision endoscopically, and large sessile polyps may harbor cancer not found in the forceps biopsy specimen. When patients have multiple large polyps or have polyposis, it is difficult to excise all the polyps to ensure that none of them are harboring cancer. Bleeding polyps are not an absolute indication for surgical excision. When there is a question as to the presence of cancer, surgery is indicated for resection and possible cure of early gastric carcinoma.

A 15-year-old female adolescent is brought into the emergency department by her mother with a history of ingesting an unknown number of acetaminophen tablets within the past hour. Neither the mother nor the daughter had any idea how many pills had previously been used or were ingested. The daughter stated she took a lot of pills. The mother stated her daughter had no other medical problems. Both the mother and daughter said that no other medications were being taken. What is the most appropriate time to evaluate an acetaminophen level after the reported ingestion in this patient to determine if therapy is indicated? Answer Choices 1 8 hours 2 4 hours 3 12 hours 4 24 hours 5 2 hours

4 hrs In an acute ingestion, the peak concentration may not be achieved until 4 hoursafter ingestion. Absorption may be affected by coingestants that affect gastric motility. Concretions of multiple tablets ingested at the same time may form bezoars in the stomach and alter absorption, or provide a continuing source of supply. A single acetaminophen level drawn at least 4 hours after ingestion is sufficient to determine patient management. If time of ingestion is unknown, an immediate level and at least 2 additional levels drawn 4 hours apart may be useful. Clinical toxicity may not be evident soon after overdose, and the risk of morbidity increases when the initiation of therapy is delayed. At therapeutic doses, peak concentration is generally achieved after 1 hour, with half-life of 2 to 4 hours. The toxic dose of acetaminophen is approximately 150 mg/kg or 7 grams in adults. Children may tolerate doses up to 200 mg/kg. Acetaminophen is rapidly absorbed from the stomach and small intestine and metabolized by conjugation in the liver to nontoxic agents. These water-soluble conjugates are then eliminated in the urine. Ninety percent are metabolized to either metabolites of sulfate (primarily in children) or glucuronide (primarily in adults). Approximately 4% is metabolized by the cytochrome p450 system to an active metabolite, NAPQI (n-acetyl-p-benzoquinoneimine). Normally, NAPQI is conjugated with glutathione resulting in detoxification and excreted as mercapturic acid and cysteine conjugates. In acute ingestion, glutathione is depleted, so NAPQI covalently binds to vital proteins and the lipid bilayer of hepatocyte membranes. The result is hepatocellular death and centrilobular liver necrosis. Other organs may be affected. The acetaminophen level should be plotted on the Rumack-Matthew nomogram, a semi-logarithmic plot of the acetaminophen level over time (4-24 hours post ingestion) based on adult data. Approximately 60% of patients with levels above the line will develop serum transaminases >1000 IU/L. A second line 25% below the first line was added. Levels between the first and second line are considered possibly toxic and take into account such factors as lab error and error in time of ingestion. There is no clinical evidence suggesting that patients in this range need to be treated. Levels below the second line are low risk. The nomogram is not valid for ingestions less than 4 hours, chronic ingestions, or for patients who have ingested toxic doses of extended release preparations. Because the absorption of extended release preparations is delayed, a measurement at 4 hours will not accurately reflect absorption. The nomogram is also not valid for patients with chronic alcohol consumption.

A 63-year-old woman presents with acute onset of abdominal pain. She describes it as a steady deep discomfort in the left lower quadrant. Initially she was constipated, but is now experiencing diarrhea. On physical examination, she has a temperature of 38°C. The abdomen is tender in the LLQ with guarding and rebound tenderness. She has positive fecal occult blood. What is the best test to determine her most likely diagnosis? Answer Choices 1 Abdominal ultrasound 2 Abdominal CT 3 Barium enema 4 Upper GI series 5 Colonoscopy

Abdominal CT Explanation Diverticulitis is a common cause of left lower quadrant abdominal pain that is associated with fecal occult blood. It is best diagnosed with abdominal CT. Findings of sigmoid diverticula, a thickened colonic wall and inflammation within the pericolonic fat suggest the diagnosis. While an ultrasound is less expensive and non-invasive, it is less specific and operator dependent. Barium enema and colonoscopy will both demonstrate diverticula, but there is risk of perforation with these modalities. An upper GI is not indicated in this patient with lower abdominal pain.

A 52-year-old male presents to the office with a complaint of intermittent dysphagia. His symptoms occur mostly when he eats steak, and have been ongoing for about six months. The symptoms have not worsened and he denies weight loss. You are concerned that he may have an esophageal web or ring. The diagnostic test that best visualizes an esophageal web or ring is which of the following? A Endoscopy B Esophageal manometry C Barium esophagram D Esophageal pH monitoring E CT scan of the abdomen

Barium Esophagram

Ulcerative Colitis appearance on colonoscopy

Crypt abscesses and if toxic megacolon present loss of haustra and blood vessels

A 16-year-old boy is gripped with sudden abdominal pain at school and starts throwing up. The pain is initially central around the umbilicus without any radiation then becomes more vaguely centered in the right lower abdomen. He is brought to the ER where his vitals are: temperature 101.1 F, BP 110/72 mm Hg, pulse 106/min, and SPO2 92%. Chest is clear and abdominal exam reveals tenderness in the right lower quadrant with rebound and hypoactive bowel sounds. Labs show HB of 14g/dl, WBC 15500, and platelets 420,000/uL. Obstructive series shows non specific bowel dilatation. CT scan of the abdomen is ordered. What is the likely diagnosis? Answer Choices 1 Acute gastroenteritis 2 Acute cholecystitis 3 Acute appendicitis 4 Acute diverticulitis 5 Incarcerated hernia

Explanation Acute appendicitis is a common cause of acute abdominal pain. It can occur at any age and is caused by the obstruction of the lumen of the appendix by foreign body, inflammation, fecolith, or tumor. Increased intraluminal pressure causes necrosis and perforation with signs of localized peritonitis. Pain starting in the umbilical area and later migrating to the right lower quadrant at McBurney's point is classic. Fever, vomiting, diarrhea, and leukocytosis support the diagnosis. CT scan in adults and abdominal ultrasound in children are diagnostic, and treatment is immediate surgical removal. In a female patient, endometriosis, ovarian cyst, and ovarian torsion are the other differential diagnoses. Acute gastroenteritis can mimic appendicitis but watery diarrhea is usually the predominant symptom with vomiting in some infections. Abdominal pain is diffuse and crampy and is not localized to McBurney's point. Fever and leukocytosis may be present. CT scan rules out localized pathology and is necessary only in limited cases. Treatment is supportive, since it is a self-limiting condition. Acute cholecystitis is typically characterized by right upper quadrant pain with radiation to the back, nausea and vomiting, fever, and right upper quadrant tenderness, also known as Murphy's sign. Jaundice may be present occasionally, with elevated liver enzymes and leukocytosis. It is caused by inflammation of the gall bladder wall, usually with one or multiple gallstones. Infection within the biliary system also plays a role in acute cholecystitis. Ultrasound reveals gallstones in most cases. Gall bladder wall thickening more than 4-5 mm, edema (causing double wall sign), and sonographic Murphy's sign (tenderness in the right upper quadrant while palpation with the ultrasound transducer) are also seen in the ultrasound. Patients need hospitalization for proper management. Treatment is conservative with hydration, pain control, bowel rest, and correction of any electrolyte disturbances. Antibiotics are not recommended as a rule but are generally given. Cholecystectomy is recommended for empyema, gangrene, rupture of the gall bladder, recurrent disease, or gallstones. Asymptomatic gallstones, however, are not treated surgically. Acute diverticulitis is usually left-sided and rarely right-sided. It presents with left lower quadrant pain, constipation or diarrhea, and left lower tenderness. Fever and mild leukocytosis are common but liver enzymes are normal. If right sided it is frequently mistaken for appendicitis. Diverticulitis can occur anywhere in the GI tract and may be mistaken for other common conditions. For example, diverticulitis of the transverse colon may be confused with cholecystitis, pancreatitis, and peptic ulcer disease. A tender mass may be present in a few cases. But it is very rare in less than 30 years of age and CT scan differentiates it from other conditions. Treatment is usually conservative in the first episode, with bowel rest and antibiotics. Colonic resection is advised in recurrent episode, complications like perforation, fistula or abscess, intractable symptoms, or suspicion of carcinoma. Incarcerated hernia presents with severe pain in the groin area, with a mass that may be purplish in color due to ischemia and gangrene. It should be suspected when a reducible hernia becomes painful and non-reducible. Treatment is surgical.

A 2-year-old boy presents with acute abdominal pain. The boy has not passed a stool for 2 days. On examination, the abdomen is distended and tender. Bowel sounds are absent. The boy is taken to surgery. Refer to the image for the gross appearance of the surgical specimen. What is the most likely diagnosis in this case? Answer Choices 1 Acute appendicitis 2 Meckel's diverticulitis 3 Intussusception 4 Volvulus 5 Ischemic bowel disease

Intussusception Intussusception is the telescoping of a segment of intestine into the segment below due to peristalsis. The telescoped segment is called the intussusceptum and lower receiving segment is called the intussuscipiens. The condition commonly occurs in infants and young children, more often in the ileocecal region. Less commonly, ileoileal and coli-colic intussusception occurs. In children, the cause is not known, though enlargement of the lymphoid tissue in terminal ileum has been suggested. In adults, the usual causes are foreign bodies and tumors. The main complications include intestinal obstruction, infarction, gangrene, perforation, and peritonitis. The picture shows cecum, which has been cut open to show the ileum that has intussuscepted inside. Acute appendicitis, the acute inflammation of the appendix, is the most common acute abdominal condition confronting the surgeon. The most common etiological factor is the obstruction of the lumen that leads to increased intraluminal pressure. This presses upon the blood vessels to produce ischemic injury, which in turn favors the bacterial proliferation and acute appendicitis. Grossly, the appendix is swollen and hyperemic during early stages. The serosa then is covered with fibrinopurulent exudate, called acute suppurative appendicitis. As the disease advances, there is necrosis and ulceration of the mucosa, which extends through the wall so that the appendix becomes soft and friable and the surface shows greenish black gangrenous necrosis (known as acute gangrenous appendicitis). Microscopically, the diagnostic criterion is the neutrophilic infiltration of the muscularis. Clinically, the patient presents with acute abdominal pain. If not adequately managed, complications like peritonitis, appendicular abscess, adhesions, mucocele, and portal pylephlebitis occur. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. It occurs in 2% of population, and it is more common in men. It is commonly situated on the antimesenteric border of the ileum, about 1 meter above the ileocecal valve. Meckel's diverticulum is an out pouching containing all the layers of the intestinal wall in their normal orientation. It is usually lined by small intestinal type of epithelium. At times, it may contain gastric mucosa or pancreatic tissue. Meckel's diverticulitis is the common complication of the diverticulum. If not treated, it may lead to perforation and hemorrhage. Volvulus is the twisting of loop of intestine upon itself through 180 degrees or more. This leads to obstruction of the intestine as well as cutting of vascular supply to the affected region. It is usually due to bands, adhesions, and long mesenteric attachment. The condition affects mainly the sigmoid colon. Ischemic bowel disease applies to the structural changes in the colon that occur due to deprivation of blood supply. The causes for deprivation of blood could be arterial occlusion, venous occlusion, and non-occlusive ischemia. The causes of non-occlusive ischemia include cardiac failure, shock, dehydration, and vasoconstrictive drugs. Depending on the severity and the presentation, it is classified into transmural, mural and mucosal infarction, and chronic ischemic colitis. In transmural infarction, there is hemorrhagic infarction of the bowel with gangrenous changes, and a risk of perforation. In the mucosal and mural type, the mucosa is hemorrhagic and oedematous but the remaining layers will remain intact. In chronic ischemia, mucosal ulceration and inflammation develops, and sub-mucosal chronic inflammation and fibrosis may lead to stricture formation. In the setting of transmural infarction, patients generally present with acute abdominal pain, vomiting, fever, and bloody diarrhea. The patient may progress to shock and vascular collapse within hours.

A 44-year-old man with a history of ulcerative colitis presents with bloody diarrhea. The patient has had a long history of poorly controlled ulcerative colitis despite being on optimal medical management. The patient subsequently is surgically managed with a proctocolectomy with permanent ileostomy. However, complications in his procedure call for a long hospital stay. After a few months, the patient is found to have ascites, pitting edema, and a fatty liver. Question What is the most likely diagnosis? Answer Choices 1 Hypovitaminosis B1 2 Kwashiorkor 3 Total parenteral nutrition-induced steatosis 4 Marasmus 5 Primary sclerosing cholangitis

Kwashiorkor This patient is having protein deficiency, and therefore the most likely answer is kwashiorkor. Kwashiorkor is secondary to total protein deficiency. This finding is typically found in patients who are severely malnourished. The typical findings in these patients are ascites and pitting edema due to hypoalbuminemia. In this patient, his long hospital stay with a complicated proctocolectomy, has led to protein deficiency. Marasmus is a total caloric and protein deficiency. These patients typically present with broomstick extremities (muscle wasting). These patients do not present with ascites and pitting edema. Total parenteral nutrition (TPN) related microvesicular steatosis is a common finding in patients who are on TPN. However, there is no mention in the question stem that this patient was on TPN. Primary sclerosing cholangitis (PSC) is commonly associated with patients who have ulcerative colitis. PSC is a chronic liver disease, which presents as inflammation, destruction, and fibrosis of both the intrahepatic and extrahepatic bile ducts, with the resultant destruction leading to cirrhosis of liver. Hypovitaminosis B1 (thiamine) is not the correct answer choice. This deficiency is known as wet beri beri. Though it may cause edema, there will be dilated cardiomyopathy, which is not found in this case.

A 52-year-old man presents with heartburn, sometimes associated with reflux of sour-tasting material into the mouth. Some of these episodes are accompanied by increased salivation and coughing. He denies any bleeding or abnormalities in his stools. He is slightly overweight and has mild hypertension, which is well controlled with enalapril. Vital signs are within normal ranges and the physical examination is unremarkable. An upper endoscopy reveals coalescing linear erosions throughout the esophageal circumference and a 5.5-cm-long, circumferential cherry-red patch above the gastroesophageal junction. Biopsy of the patch reveals columnar metaplasia, but no dysplasia. What can improve the patient's symptoms most effiiciently? Answer Choices 1 Laparoscopic fundoplication 2 Start omeprazole 3 Esophagectomy 4 Radiofrequency thermal coagulation of the lower esophageal wall 5 Laser ablation of the Barrett's mucosa

Laparoscopic fundoplication Laparoscopic fundoplication leads to long-term relief for about 90% patients with gastroesophageal reflux disease (GERD). The most common technique is the Nissen procedure (i.e., suturing the gastric fundus to the lower esophagus throughout the full esophageal circumference). Side effects are uncommon and mostly minor: abdominal bloating, inability to belch, paraesophageal herniation, dysphagia, and diarrhea. Barrett's esophagus sometimes disappears after fundoplication, but this procedure does not eliminate the risk of dysplasia and carcinoma in all patients. Therefore, endoscopic screening after the procedure is mandatory. The other major therapeutic option for patients with GERD is long-term proton pump inhibitors (PPIs). Patients treated with these drugs have esophageal healing and symptom relief rates comparable to those of operated patients. However, about 30-40% of patients only improve after dose escalation. Therefore, PPI users take longer on average to achieve symptom control. Esophagectomy would be an option if there were an esophageal carcinoma or high-grade dysplasia, particularly in younger patients without significant comorbidities. The decision to operate must take into account the patient's general health and comorbidities, which are common given that Barrett's esophagus often occurs in elderly patients. However, advanced age by itself does not contraindicate esophagectomy. Several endoscopic techniques (e.g. mucosectomy, laser ablation, and photodynamic therapy) have had some success in the treatment of Barrett's esophagus. However, complication such as bleeding after extensive mucosectomies, laser perforations, and skin burns from photoporphyrin-induced photosensibility are common. Incomplete mucosectomies, after which small areas of high-grade dysplasia or even cancers remained in the esophageal wall, have also been documented. Radiofrequency thermal coagulation of the esophageal wall (Stretta procedure) consists of using a special catheter to induce controlled heating of the esophageal wall at the level of the gastroesophageal junction. This induces fibrosis and contraction of the gastroesophageal junction, which increases sphincter pressure and improves reflux. However, recurrence is high after this procedure (about 50%), and it cannot be performed when there is a hiatal hernia, as in this case.

A 92-year-old woman with Alzheimer's disease is brought in from her long term care facility. She was found holding her abdomen and screaming in pain. She is unable to provide any history, but her aide states that the patient was incontinent of liquid stool shortly before being brought to the hospital. On examination, her abdomen is distended; there are no palpable masses. On rectal examination, there are firm feces in the rectal vault. Question What is the best initial treatment? Answer Choices 1 Fiber supplementation 2 Decompressive colonoscopy 3 Magnesium citrate 4 Mineral oil enema 5 Colectomy

Mineral oil enema Mineral oil enema is the correct response. The patient is suffering from fecal impaction. Initial treatment requires resolving the impaction by the use of enemas, digital removal, or a combination of the 2. This is necessary to avoid the development of large bowel obstruction. Fiber supplementation is incorrect. Once the patient's obstruction has resolved, fiber may be used to help prevent the development of constipation and further episodes of fecal impaction. Unless the impaction has resolved, fiber supplementation could actually harm the patient Decompressive colonoscopy is incorrect. A colonoscope would not be able to make it pass the stool involved in the fecal impaction. Magnesium citrate is incorrect. The patient should have therapy aimed at disrupting the fecal impaction. Colectomy is incorrect. Surgery would not be warranted in this patient unless she showed signs of perforation.

A 37-year-old man presents with diarrhea, nausea, vomiting, and a rash. He also complains of memory problems and depression. He states that he and his family live on a farm that produces corn. Due to recent financial problems, his diet has become more limited. He eats mainly corn products and only small amounts of fish and vegetables. He takes no vitamin supplementation, and he states that his symptoms began about 1 month ago. He began having trouble with his memory about 1 week ago. He has no significant past medical history, but he does admit to daily alcohol consumption. His physical examination is significant for stomatitis, glossitis, and a rash over his arms and legs. His mini mental status exam score is 24. Question What deficiency does this patient most likely have? Answer Choices 1 Niacin 2 Zinc 3 Folate 4 Vitamin B12 5 Vitamin B1

Niacin This patient probably has niacin deficiency. Niacin (nicotinamide, nicotinic acid) deficiency is uncommon in the United States. It is often found in people who live on a diet that consists mainly of corn (maize). This is due to the fact that the niacin in corn cannot be absorbed unless it is chemically treated with alkali first. If a person consumes a diet rich in tryptophan, but low in niacin, they are able to compensate since tryptophan can be converted into niacin. Deficiency may also result from alcoholism, cirrhosis, or diarrhea. Men and women are affected equally. Symptoms of niacin deficiency include nausea, vomiting, diarrhea, rash, glossitis, stomatitis, depression, and psychosis. Niacin deficiency, also known as pellagra, manifests as the '3 Ds': diarrhea, dermatitis, and dementia. Treatment consists of niacin supplementation. The causes of zinc deficiency include malnutrition, chronic debilitating diseases, chronic renal disease, alcoholism, drugs such as penicillamine and diuretic, and genetic disorders, such as sickle cell disease. Clinical manifestations in severe cases include alopecia, diarrhea, weight loss, infections, dermatitis, hypogonadism in men, and intercurrent infections. Supplementation with zinc is the treatment of choice. Folate deficiency causes megaloblastic macrocytic anemia, as folate plays a key role in nucleic acid synthesis. The early manifestation of folate deficiency, especially in its suboptimal state, predisposes to occlusive vascular disease and thrombosis. These manifestations are linked to increased homocysteine levels found in folate deficiency. Neurological disturbances, such as mood disturbance and spinal cord syndromes, are also seen. It is also associated with predisposition to neoplasia and interferes with immunologic status. Folate replacement is the option to prevent and to treat the deficiency. Vitamin B1 (or thiamine deficiency) causes beri beri, occurring mostly in the malnourished and alcoholics. The deficiency manifests with acute heart failure, neurologic deficits, and epilepsy. Empiric use of thiamine and prophylactic use in high-risk population is strongly recommended even before blood reports are obtained, as the treatment is inexpensive and prevents major catastrophes. Vitamin B12 (or cobalamin deficiency) manifests as megaloblastic macrocytic anemia, pancytopenia, and a spectrum of neuropsychiatric disorders such as peripheral neuropathy, parasthesias, and demyelination of corticospinal tract. Nutritional deficiency, alcoholism, and malabsorption syndromes are some causes of B12 deficiency. It is also associated with homocysteinemia and atherosclerosis. Diagnosis is by serum estimation of B12, and oral supplementation is safe and effective. Intramuscular injections may also be used.

A 56-year-old man presents with a 10-day history of epigastric pain and vomiting. He states that similar symptoms have appeared frequently throughout the past year and that he was diagnosed with a duodenal ulcer 8 months ago. He was given eradication therapy for a Helicobacter pylori infection and urea breath test confirmed successful eradication. With the discontinuation of protein pump inhibitors, his symptoms reappeared. He has a surgical history of an incomplete vagotomy at age 22 for the treatment of duodenal ulcer. He denies intake of salicylates or any other drugs that could damage duodenal mucosa or be a causative agent for recurrent ulcers. General physical findings are unremarkable, except for the presence of epigastric and periumbilical pain on palpation. Neither routine laboratory analyses nor an abdominal echo-sonogram reveal abnormalities. Endoscopy reveals the presence of an ulcer in the first portion of the duodenum. His BAO is 15.3 mEq/hr, and his BAO/MAO (basal/maximal acid output) ratio is 0.75. His serum gastrin level is 268 pg/mL (non-fasting normal is 200 pg/mL). What test should be used first to confirm the suspected diagnosis of Zollinger-Ellison syndrome? Answer Choices 1 Repeated gastrin determination 2 Secretin stimulation test 3 Calcium infusion test 4 Endoscopic echo-sonography 5 CT scan of pancreas

Secretin Stimulation test Hypergastrinemia is always present in patients with Zollinger-Ellison syndrome but may also be present in other diseases and conditions. In order to discriminate patients with Zollinger-Ellison syndrome from patients with hypergastrinemia caused by other factors, a stimulatory test with secretin is performed. The test, which is highly sensitive and specific, is based on the fact that secretin administration causes a striking elevation of serum gastrin level in patients with Zollinger-Ellison syndrome that cannot be noted in persons with hypergastrinemia caused by other factors. The repeated determination of serum gastrin level is of no diagnostic value, particularly if vagotomy (which influences serum gastrin level) was formerly performed. Calcium infusion test may also be utilized for the diagnosis of Zollinger-Ellison syndrome. However, this test is less sensitive and less specific than secretin test, and its performance is associated with more side effects and potential false negatives. Endoscopic echo-sonography may be of valuein detection of tumor site once diagnosis of Zollinger-Ellison syndrome is firmly established. Also, CT scan of the pancreas may be helpful in detecting tumor lesiona, but it is of no value in detection of hormonal potential of the tumor.

What is the definitive treatment for acute cholecystitis? Answer Choices 1 Antibiotics 2 Antibiotics and observation 3 Surgery 4 Cholecystostomy 5 Observation alone

Surgery The definitive treatment for acute cholecystitis is surgery. Antibiotics and cholecystostomy may be temporizing maneuvers to calm down an acute situation or to temporize a patient that is otherwise too ill to undergo surgery, but the only treatment that will cure the pathology causing the problem is surgery, be it an open cholecystectomy or a laparoscopic cholecystectomy.

A 52-year-old Caucasian man presents with easy fatigability, poor concentration, and "stronger than usual" effort-related palpitations. He denies any constipation or weight loss. His past medical history includes type II diabetes, which was diagnosed 10 years ago; it is well controlled with diet and metformin, and there are no complications. Both his parents are in good health; his sister had a malignant breast nodule removed 2 years ago, but she showed no signs of metastatic disease. His physical examination shows mild obesity (BMI 32 kg/m2), but it is otherwise normal. A laboratory workup shows glucose 91 mg/dL, Na+ 138 mEq/L, K+ 4.9 mEq/L, Cl- 100 mEq/L, hemoglobin 11 g/dL, hematocrit 32%, mean corpuscular volume(MCV) 82 fl, mean corpuscular hemoglobin concentration (MCHC) 24 pg/mL, leukocytes 7,400 /mm3 w/normal differential. Platelets 310,000 /mm3, ferritin 29 ng/L (25-300 ng/mL), and a total iron binding capacity of 450 ng/dL. Question What is the most appropriate next step in diagnosis? Answer Choices 1 Fecal occult blood testing (FOBT) 2 Full colonoscopy 3 Bone marrow biopsy 4 Double-contrast barium enema 5 Capsule endoscopy

The correct response is fecal occult blood testing. The pattern of low mean corpuscular volume and hemoglobin concentration, low ferritin, and elevated total iron-binding capacity (TIBC) is diagnostic of iron deficiency. Lack of iron inhibits hemoglobin synthesis, thereby reducing the volume and hemoglobin concentration of erythrocytes. Some patients have thrombocytosis. The mechanism is unclear, but hypotheses include stimulation by high circulating erythropoietin concentrations or circulating cytokines. Besides asthenia and pallor, other symptoms include pagophagia (craving ice or cold foods), pica (clay eating), and leg cramps; physical examination may reveal esophageal webbing, koilonychia (spoon-shaped nails), glossitis, angular stomatitis, and gastric atrophy. New-onset anemia with hypochromia and microcytosis in an adult should be considered secondary to gastrointestinal bleeding until proved otherwise. The most common etiologies are diverticular disease, angiodysplasia, colitis (including from NSAIDs), and colon cancer, particularly left-sided colon cancer. Testing for occult blood in a stool specimen is the initial diagnostic method of choice. If the fecal occult blood test is positive, the patient should undergo upper endoscopy and colonoscopy examinations. Colonoscopy is a useful exam for identifying sources of occult gastrointestinal bleeding. It is more sensitive than barium enema or CT scans for early lesions and permits biopsy when indicated (e.g., lesions suspicious for malignancy or colitis). However, none of these are cost-effective screening examinations. Bone marrow biopsy can evaluate bone marrow iron stores and reveal erythroid hyperplasia. However, it has been practically abandoned in the workup of iron-deficiency anemia, as there is considerable interobserver variability and assays for iron, ferritin, and TIBC permit evaluation of the body's iron stores less invasively. Capsule endoscopy is the most sensitive method for diagnosing small-bowel bleeding. However, small-bowel bleeding is much less common than upper (proximal to the angle of Treitz) or colonic bleeding. Therefore, it should only be undertaken after colonoscopy and upper endoscopy are negative.

A 50-year-old man with a past medical history of hyperlipidemia presents with a recurrent "bitterness and sour sensation in his mouth" and a nonproductive cough; both have been occurring over the last year. There is associated progressive dysphagia and odynophagia to solid foods, but not to liquids; as a result, he has lost 15 pounds over the past 5 months. He admits to drinking 1 to 2 beers per week, but he denies alcohol use beyond this. He also denies cigarette smoking and illicit drug use. He denies fever, chills, sputum production, chest pain, palpitations, dyspnea, shortness of breath, wheezing, peripheral edema, abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, and changes in bowel habits. The physical exam reveals normal vital signs. Oropharyngeal, neck, cardiopulmonary, and abdominal exams are normal. Question What is the most appropriate initial intervention for this patient at this time? Answer Choices 1 Perform a chest X-ray 2 Upper endoscopic evaluation 3 Prescribe a trial of esomeprazole 4 Barium esophagography 5 Ambulatory esophageal pH monitoring

This patient's most concerning diagnosis is a malignant esophageal lesion. However, nonmalignant etiologies may also be responsible for this presentation. A barium esophagography is obtained as the first study to evaluate dysphagia. In patients with progressive esophageal dysphagia, a radiographic barium study is used to differentiate between mechanical lesions (such as peptic stricture and esophageal cancer) and motility disorders (such as achalasia). The sensitivity of barium radiography for detecting esophageal strictures is greater than that of endoscopy. Barium studies also provide an assessment of esophageal function and morphology that may be undetected on endoscopy. Hypopharyngeal pathology and disorders of the cricopharyngeal muscle are better appreciated on radiographic examination, particularly with videofluoroscopic recording. Either a positive or a negative study is usually followed by an endoscopic evaluation; it is done in order to clarify findings in the case of a positive examination or to add a level of certainty in the case of a negative one. A chest X-ray may reveal adenopathy, a widened mediastinum, metastatic lesions to the lungs or bone, or signs of tracheoesophageal fistula, such as pneumonia. It will not, however, reliably identify esophageal lesions. Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with high reliability. It is the study of choice for evaluating persistent heartburn, odynophagia, and structural abnormalities detected on barium esophagography. Ambulatory esophageal pH monitoring is the preferred study for documenting acid reflux. It is indicated in the following clinical scenarios: for patients being considered for anti-reflux surgery with a normal endoscopy; in patients with a normal endoscopy but with continued reflux symptoms following therapy with a proton pump inhibitor; and in the evaluation of atypical reflux symptoms that continues despite anti-reflux therapy. Patients with alarm symptoms, such as unexplained weight loss, odynophagia, jaundice, recurrent vomiting, blood loss, a palpable mass or lymph node, or a family history of GI malignancy, should have diagnostic testing performed promptly.

A 19-year-old woman gives birth to an apparently healthy 8-pound female infant. During her first attempt at feeding, choking, coughing, and cyanosis occur. Historically, the mother had polyhydramnios during her pregnancy. What is the most likely explanation for the newborn's distress? Answer Choices 1 Choanal atresia 2 Respiratory distress syndrome 3 Polycystic kidney disease 4 Structural heart disease, cyanotic 5 Tracheoesophageal fistula

Transesophageal fistula The clinical picture is suggestive of tracheoesophageal fistula. Commonly, the infant presents with choking, cyanosis, copious secretions, and respiratory distress. Polyhydramnios is common. Symptoms worsen during feedings; stomach distention and pneumonia are possible complications. Continuous esophageal suctioning should persist until definitive repair. Diagnosis is made by placing a NG tube to where resistance is met. An X-ray is taken, and the tube should be visible in a blind pouch. Choanal atresia is a disorder where the back of the nasal passage is blocked. It is defined as bilateral or unilateral. Bilateral is a life-threatening condition that results in severe respiratory distress at birth; it requires immediate placement of an oral airway. Unilateral choanal atresia usually presents later and is confused with chronic sinusitis. Respiratory distress syndrome infants present with tachypnea (respiratory rate > 60 breaths/minute), cyanosis on room air, expiratory grunting, and intercostal/sternal retractions. Infants with polycystic kidney disease are usually diagnosed by prenatal ultrasound. It is most severe when the cystic kidneys are nonfunctional in utero. Hypertension is a common finding. Renal masses may be felt upon palpation of the abdomen. Structural heart disease with cyanotic presentation typically presents with cyanosis, without associated respiratory distress and failure to increase PaO2 with supplemental oxygen.

A 28-year-old woman presents with bloody diarrhea for 1 week. After further questioning, she reveals that she had similar attacks in the past that subsided on their own. Her stool specimen is negative for ova and parasites. Stool culture did not grow any pathogens. A sigmoidoscopy is performed. There is friable erythematous mucosa extending from the rectum to the mid-descending colon, with broad-based ulcers in the descending colon. A biopsy taken from the rectum shows diffuse mononuclear inflammatory infiltrates in the lamina propria with crypt abscesses. However, no granulomas are seen. What is the most likely diagnosis in her case? Answer Choices 1 Ulcerative colitis 2 Crohn's disease 3 Ischemic colitis 4 Shigellosis 5 Amebic colitis

Ulcerative Colitis Ulcerative colitis is an ulcera-inflammatory disease limited to the colon and affecting only the mucosa and submucosa, except in the most severe cases. Ulcerative colitis extends in a continuous fashion proximally from the rectum in contrast to the skip lesions in Crohn's disease. Histologically, there is mononuclear inflammatory cell infiltration of the lamina propria collection of neutrophils in the crypts, called crypt abscesses and epithelial cell necrosis. However, there are no well-formed granulomas. Ischemic bowel disease applies to the structural changes in the colon that occur due to deprivation of blood supply .The causes for deprivation of blood could be arterial occlusion, venous occlusion and non-occlusive ischemia. The causes of non-occlusive ischemia include cardiac failure, shock, dehydration, and vasoconstrictive drugs. Depending on the severity and the presentation, it is classified into transmural, mural and mucosal infarction, and chronic ischemic colitis. The diagnosis is based on the natural history of the disease and endoscopic findings with supportive biopsy. Crohn's disease is a chronic, relapsing inflammatory disorder of obscure origin. It is a granulomatous disease and most often involves the small intestine and colon. It is characterized by transmural inflammation affecting all layers, presence of non-caseating granulomas, fissuring with formation of fistulas, and skip lesions. Shigellosis is a bacterial enterocolitis caused by shigella. It primarily involves distal colon with acute mucosal inflammation and erosion with purulent exudates. Stool culture is diagnostic. Amebic colitis is caused by Entamoeba histolytica, a protozoan parasite that spreads by faeco-oral route. They form flask shaped ulcers with a narrow neck and broad base. A stool examination for ova and cyst shows trophozoites and cysts of ameba. These parasites penetrate portal vessels, embolize to the liver to produce solitary discrete hepatic abscess, some exceeding 10 cm.

A premature infant presents with jaundice and a hemoglobin level of 8 g/dL. The peripheral blood film reveals reticulocytosis; a vitamin deficiency is suspected. Question What is the most likely diagnosis? Answer Choices 1 Vitamin A deficiency 2 Pyridoxine deficiency 3 Vitamin C deficiency 4 Niacin deficiency 5 Vitamin E deficiency

Vit E deficiency is the correct answer. Vitamin E deficiency may cause a hemolytic anemia in premature infants. Laboratory investigations reveal low plasma tocopherol levels, a low hemoglobin level, reticulocytosis, hyperbilirubinemia, and creatinuria. Causes of vitamin E deficiency in premature infants include limited placental transfer of vitamin E and the resultant low levels at birth; this is combined with its relative deficiency in the infant diet. Dietary sources for older children and adults include wheat germ, vegetable oils, egg yolk, and leafy vegetables. In cases of vitamin A deficiency, patients can present with night blindness or an inability to see well in dim light. There may also be conjunctival and corneal xerosis, as well as pericorneal and corneal opacities and Bitot's spots. Bitot's spots are a collection of keratin appearing as triangular, foamy spots on the conjunctiva. The patient may also have xeroderma, hyperkeratotic skin lesions, and increased susceptibility to infections. Causes include inadequate dietary intake and malabsorption. Dietary sources of vitamin A include fish, liver, egg yolk, butter, cream, dark green leafy vegetables, and yellow fruits and vegetables. In cases of pyridoxine (vitamin B6 deficiency), patients can present with peripheral neuropathy, seborrheic dermatosis, glossitis, and cheilosis. Laboratory analysis reveals anemia with lymphopenia. Causes include malabsorption, as well as medications (e.g., isoniazid and penicillamine). Dietary sources of vitamin B6 include liver, legumes, whole grain cereals, and meats. In cases of vitamin C (ascorbic acid) deficiency, patients can present with bleeding tendencies (as a result of weakened capillaries) and impaired wound healing due to the impaired formation of connective tissue. On examination, the gums may be swollen and friable; the teeth may be loose. There may also be multiple splinter hemorrhages on the nails and ecchymoses, especially over the lower limbs. Causes include inadequate dietary intake and certain conditions (e.g., pregnancy and lactation) which increase vitamin C requirements. Dietary sources of vitamin C include citrus fruits, (e.g., oranges, lemons, and tangerines), as well as tomatoes and potatoes. Niacin deficiency causes pellagra, which is characterized by: A symmetrical dermatitis, usually on parts of the body exposed to sunlight Scarlet glossitis and stomatitis Diarrhea Mental aberrations (e.g., memory impairment, depression, and dementia) which may appear alone or in combination Causes of niacin deficiency include inadequate dietary intake (especially in patients with corn-based diets or alcoholism). Dietary sources include legumes, yeast, meat, and enriched cereal products.

What is the preferred treatment for infantile intestinal obstruction due to intussusception? Answer Choices 1 Colonoscopy 2 Emergent colon resection 3 Nasogastric decompression 4 Barium or air enema 5 Intravenous fluids only

barium or air enema In cases of childhood intussusception, the most common location is in the right colon. The treatment of choice is a low-pressure barium enema to reduce the intussusception. If this procedure is not successful, then laparotomy with manual reduction is indicated. Reduction of the intussusception is necessary in order to prevent ischemia and gangrene of that segment of intestine.

A 38-year-old man presents with upper abdominal pain. More recently, he has experienced nausea. A stool sample is tested for occult blood, and it is positive. An upper endoscopy reveals no esophageal lesions, but there is a solitary 2-cm diameter ulceration of the stomach. The ulceration is sharply demarcated. What is the most appropriate statement regarding this lesion? Answer Choices 1 It is probably located in the antrum 2 It is probably associated with increased gastric acid production 3 A gastrinoma of the pancreas is probably present 4 It is probably malignant 5 Because of its small size, a biopsy is not necessary

it is probably located in the antrum From the findings described in the above patient with a sharply demarcated area of ulceration suggests that it is a benign peptic ulcer. The gastric antrum is a typical location for benign peptic ulcer. There is usually decreased acid production in patients with peptic ulceration, but not a total absence of acid production. A gastrinoma of the pancreas (Zollinger-Ellison syndrome) will be accompanied by multiple gastric ulcerations. The small size with the sharp demarcation suggests that it is a benign ulcer; however, the size is not a reliable clue that it is benign. All gastric ulcers seen on endoscopys hould be biopsied.

A 47-year-old Hispanic woman presents with a 2-month history of persistent abdominal pains. She becomes uncomfortable after eating, especially after consuming fats, eggs, chocolate, fried foods, fatty foods, and rich desserts. Her pains are primarily located in her right upper abdominal quadrant and often radiate to her right shoulder blade. Physical examination is essentially unremarkable at this time. Her blood pressure is 122/82 mm Hg, she has a pulse of 72 per minute, and a temperature of 98.6°F with respirations 16 per minute. Her abdominal examination reveals no tenderness, no guard, no rebound, and normally active bowel sounds. Her liver and spleen are not palpable. She has no readily palpable abdominal masses. She is not jaundiced. She has no scleral icterus. Question What test should be given in order to confirm the probable diagnosis? Answer Choices 1 Oral cholecystogram 2 X-ray abdomen 3 Ultrasound abdomen 4 CT scan abdomen 5 Biliary scintigraphy 6 MRI abdomen

ultrasound of the abdomen Based on the patient's history, cholelithiasis is suspected. This condition is more common in females of Caucasian or Hispanic descent than in others. The incidence increases with age. Most (80%) of the stones in the US are the cholesterol type. Bilirubin, pigment, and calcium stones constitute the other 20%. Cholelithiasis may be asymptomatic (the presence of gallstones without symptoms), symptomatic (biliary colic), or complicated (e.g. cholecystitis, choledocholithiasis, cholangitis). Ultrasonography is a safe, reliable, and non-invasive test that can be performed at the bedside and is also safe in pregnant women. It is quite sensitive and specific for stones larger than 2 mm. Only about 10-30% gall stones are radio-opaque and hence abdominal X-ray may not be so useful. The oral cholecystogram is the X-ray taken after administering contrast medium to the patient. Although it can identify gall bladder pathology, it requires preparation and is not as convenient as the ultrasound. CT scan is not the first choice in suspected gallstones, although it may prove useful in intrahepatic stones. Biliary scintigraphy is of value in cystic duct obstruction. MRI is also an excellent choice but is expensive, requires sophisticated equipment, and is not used as the first choice investigation in most centers. Symptomatic stones are treated with cholecystectomy. Asymptomatic stones may also require surgery under special circumstances such as large (>2 cm) stones, those with spinal cord injuries affecting the abdomen, and in calcified gall bladder.

A 30-year-old man presents with a 1-year history of watery diarrhea. He has lost 5 kg. He has joint pains of 1-month duration. His stool examination for occult blood is negative. Stool culture is negative. No ova and cyst are seen in the stool. Laboratory tests fail to reveal rheumatoid factor or anti-nuclear antibodies. Serum calcium, phosphorous and alkaline phosphatase is 9.2 mg/dl, 4 mg/dl and 110 U/L respectively. A biopsy taken from the upper intestine shows distended macrophages in the lamina propria, which is found to be positive with PAS stain. What is the most likely diagnosis in this case? Answer Choices 1 Celiac sprue 2 Tropical sprue 3 Whipple disease 4 Disaccharidase deficiency 5 Amebic dysentery

whipple disease Whipple disease is a rare condition that can involve any organ of the body but principally affects the intestine, central nervous system, and joints. It is caused by gram-positive actinomycetes called Tropheryma whippelii. Histologically, the small intestinal mucosa is laden with distended macrophages in the lamina propria. These macrophages contain periodic acid-Schiff positive granules and rod-shaped bacilli by electron microscopy. These patients usually present with a form of malabsorption, including diarrhea and weight loss, and generally respond to antibiotic therapy. Celiac sprue is a rare chronic disease in which there is a characteristic mucosal lesion of the small intestine in the form of blunting of the villi and an overall increase in plasma cells, lymphocytes, macrophages, and eosinophils in the lamina propria. Also known as the gluten-sensitive enteropathy, non-tropical sprue, and celiac disease, it is due to sensitivity to gluten, which is an alcohol soluble, water insoluble protein component called gliadin of wheat and other closely related grains. Detection of circulating anti-gliadin or anti-endomysial antibodies strongly favors the diagnosis. Both the symptoms and the mucosal histology improve on withdrawal of gluten from the diet. Tropical sprue is a celiac-like disease occurring in people living or visiting the tropics. Bacterial overgrowth by an enterotoxigenic organism is said to be the cause for this disease. Intestinal changes are similar to celiac sprue, but injury is seen at all levels of the small intestine in contrast to celiac sprue, where it is concentrated in the proximal small intestine. It is mainly treated by broad-spectrum antibiotics. The disaccharidases, of which the most important is lactase, are located in the apical cell membrane of the villous absorptive epithelial cells, the deficiency of which leads to the incomplete breakdown of the disaccharide lactose into its monosaccharides, glucose, and galactose, leading to diarrhea from the unabsorbed lactose. Bacterial fermentation of the unabsorbed sugars leads to increased hydrogen production, which is readily measured in the exhaled air by gas chromatography. There are both hereditary and acquired forms. Histologically in both, there is no abnormality of the mucosal cells of the bowel. Malabsorption is promptly corrected when exposure to milk and milk products is terminated. Amebic dysentery is caused by Entamoeba histolytica, a protozoan, and generally causes diarrhea with blood and mucus. A stool examination will show the cysts and trophozoites of Entamoeba histolytica, which is diagnostic.

A 21-year-old man is brought to the emergency room by his friends. One hour earlier he started having excessive retching and he vomited violently several times. He has been drinking for the last 3 hours. The vomitus was mainly bright red blood (about 2 quarts) and dizziness followed. What is the likely causer of this clinical picture? Answer Choices 1 Acute gastritis 2 Carcinoma of stomach 3 Acute esophagitis 4 A gastroesophageal mucosal tear 5 Rupture of the lower esophagus

A gastroesophageal mucosal tear This is a classic presentation of Mallory-Weiss syndrome. Vomiting and retching may cause a tear that involves only the mucosa and is not transmural. The tear usually involves the gastric mucosa near the squamous to columnar mucosal junction, but it may also involve the esophageal mucosa. A wide variety of causes such as gastroenteritis, alcohol binging, ulcers, and hiatus hernia have been cited. In fact, any condition which causes retching and vomiting can cause the tear. Patients present with upper gastrointestinal bleeding that may be severe. Most patients recover with only conservative management, but those with severe arterial bleeding require surgery.

A 63 year-old woman complains of fatigue, loss of appetite, a sore-red tongue, paresthesias of her feet and hands, and unsteadiness of her gait. Which of the following tests is be used to confirm the patient's suspected diagnosis? A Anti-intrinsic factor antibodies B Antiparietal cell antibodies C Coomb's test D Schilling Test E Serum folate levels

Anti-intrinsic factor antibodies A diagnosis of pernicious anemia (PA) can be supported through the presence of anti-intrinsic factor antibodies. Antiparietal (B) cell antibodies aren't associated with the development of PA. The Coomb's test (C) is used in the evaluation of hemolytic anemias. Serum folate (D) levels are beneficial in evaluating macrocytic anemias, but will not establish a diagnosis of PA. The Schilling test (D) was once commonly used to diagnosis PA, but is no longer available due to lack of available radiolabeled human intrinsic factor.

A 25-year-old man presents due to heartburn. It only occurs 1 or 2 times a month, but it is extremely noticeable when these episodes do occur. He states that eating large meals, eating late at night right before going to sleep, and excessive alcohol consumption seem to exacerbate and even initiate episodes. He has noticed that limiting the aforementioned behaviors has decreased the severity of the symptoms in recent months, but it is still occurring despite this modification. He denies any difficulty swallowing, weight loss, night sweats, chest pain, use of tobacco, or coughing up blood. Physical examination is unremarkable for any abnormalities. Question Since this patient's symptoms would be classified as mild, intermittent symptoms and modifications have been attempted and failed, what would be the next best option for this patient? Answer Choices 1 Antacids 2 H2-receptor antagonists 3 Proton-pump inhibitor 4 Antibiotics 5 Prokinetic agents

Antacids Mild or intermittent symptoms of gastroesophageal reflux disease (GERD) are not typically seen as adversely affecting patients' quality of life. Initially, action is taken in terms of modification of behaviors, such as eating smaller meals as well as eliminating acidic foods and foods known to precipitate the reflux (fatty foods, alcohol, chocolate, or peppermint). Weight loss has also been shown to help decrease issues, and so has advising patients to avoid lying down at least 3 hours after eating meals. Elevation of the head of the bed is also suggested to initiate relief. From a pharmacological standpoint, antacids are considered the mainstay for rapid relief of occasional heartburn. Antacids work by neutralizing stomach acid only; alone, they will not heal any inflammation that may be caused by stomach acid. Patients should be told that the duration of action of these medications is typically less than 2 hours. Antacids are also contraindicated in any patients with renal failure. Many types of antacids are available over the counter. The next step up in terms of treatment would be considered to be H2-receptor antagonists. These medications work by reducing stomach acid production. Again, these agents are available over the counter as 50% the prescription dose. Examples include cimetidine 200 mg, ranitidine 75 mg, and famotidine 10 mg. When these agents are taken for active reflux symptoms, they have a delay of onset of at least 30 minutes; once they do take effect, relief is supplied for up to 8 hours per dose. Proton pump inhibitors are initial pharmacological treatment reserved for patients with moderate to severe symptoms of reflux as well as known complications from GERD. Proton pump inhibitors work by actually blocking the production of acid. Examples of these include omeprazole 20 mg or lansoprazole 30 mg. There are proton pump inhibitors available over the counter, but some are only available with a prescription. Proton pump inhibitors help patients achieve adequate control of their heartburn symptoms, and they can potentially offer resolution of these symptoms; they even aid in healing of erosive esophagitis if it is present. Antibiotics in relation to reflux or heartburn would not be indicated directly for the symptoms of this pathology; antibiotics could potentially be used as a component of the treatment of a H. pylori infection. Prokinetic agents are not indicated as treatment of mild, intermittent reflux symptoms.

A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What imaging study is the best initial test to obtain in this patient? A Abdominal plain film B Barium enema C Barium upper GI series D CT scan of the abdomen E Upper GI endoscopy

Barium Upper Gi series The suspected diagnosis is pyloric stenosis. An upper GI series with barium is the best test to obtain in this instance. A barium enema is a good choice in suspected intussusception cases. An upper GI endoscopy is best used when a gastric or duodenal ulcer is suspected. An abdominal plain film or CT could be ordered, but aren't the best initial tests to obtain in this patient's presentation.

A 52-year-old woman with a 5-year history of heartburn presents with difficulty in swallowing food. She is able to drink fluids without any problem, but solids go down with difficulty. She denies any weight loss or weight gain. She has had dyspepsia-like symptoms for a long time, with belching and abdominal fullness after meals. Her medications include the intermittent use of over-the-counter ranitidine and acetaminophen for mild aches and pains. Her vitals are stable, and the physical examination is unremarkable. What is the next step in the evaluation of this patient? Answer Choices 1 Empiric treatment with a course of proton pump inhibitor 2 Endoscopy 3 Barium swallow 4 Swallow evaluation and video fluoroscopy 5 Esophageal manometry

Barium Swallow This patient has had a long standing gastrointestinal reflux disease (GERD), which is obvious based on her symptoms. She has not used H2 blockers consistently as she should have. They would have likely reduced or eliminated her symptoms. Now, due to repeated acid-induced injury to the esophageal lining, she has developed an esophageal stricture; this caused dysphagia, which usually starts with solids and progresses to both solids and liquids. A barium swallow is indicated because it is the least invasive and will give information regarding the location, length, number of strictures, and size of the lumen. It is has a sensitivity of 100% for luminal diameter less than 9 mm and above 90% for luminal diameter greater than 10 mm. It will also impact the next step in the treatment, which includes endoscopic dilatation of the stricture, in the technique of dilatation and number of sessions needed; in addition, it impacts counseling the patient on the risks of the procedure. Dysphagia due to other pathologies, like esophageal diverticulum, extra-luminal pathology, malignancy, and perforation, can be ruled out too. Empiric treatment with proton pump inhibitors is indicated in simple GERD without symptoms of stricture. Once the patient has dysphagia, it is important to assess them for complications, like stricture, especially if they have had long standing GERD. In the majority of patients, endoscopy is the most useful test for the work-up of dysphagia. Endoscopy can help identify structural abnormalities such as esophageal webs and strictures, as well as identify tumors and esophagitis. During endoscopy, biopsies may be performed to help confirm diagnosis and direct treatment. Therapeutic interventions may also be undertaken, such as esophageal dilatations for the treatment of strictures. In certain patients, endoscopy is not the preferred first-line test in the management of dysphagia. These include patients with a history of esophageal or laryngeal cancer and those who have been exposed to a caustic ingestion or radiation therapy. In these patients, blind insertion of the endoscope may cause esophageal damage. Therefore, barium swallow is the preferred diagnostic exam. Swallow evaluation and video fluoroscopy permit evaluation of the cervical esophagus only. The rest of the esophagus cannot be evaluated; therefore, this option is inadequate. These tests are more important for pathology suspected in the pharynx, larynx, and upper esophageal sphincter. Esophageal manometry is indicated in motility disorders of the esophagus. Motility disorders present with dysphagia to both liquids and solids, as in achalasia, esophageal spasms, and scleroderma. Manometry is indicated when a barium swallow has ruled out the more common causes of dysphagia.

A 66-year-old man presents with tingling sensations in his hands and feet; his movements are clumsy, and he has difficulty with walking. He notes that he feels generally weak, and that he sometimes has 'the feeling that he can not locate his limbs'. He often feels depressed or irritable. His vitals are normal, but neurological examination reveals decreased reflexes. Question What test should be performed next? Answer Choices 1 Blood tests to measure level of cobalamin 2 Blood tests to measure level of thiamine 3 Blood tests to measure the level of glucose 4 Thyroid-stimulating hormone (TSH) test 5 Neuroimaging studies

Blood tests to measure level of cobalamin Blood tests should be performed to measure the level of cobalamin. Based on the symptoms, the patient likely suffers from subacute combined degeneration of spinal cord due to degeneration of the posterior and lateral columns of the spinal cord. This is a result of a vitamin B12 (cobalamin) deficiency; a blood test to determine the level of vitamin B12 should be performed to confirm the diagnosis. Performing blood tests to measure the level of thiamine is an incorrect response. A deficit in vitamin B1 (thiamine) causes symptoms that are characteristic of patients with Wernicke-Korsakoff syndrome. These include confusion and movement disability; however, the patients with Wernicke-Korsakoff syndrome do not generally have tingling or numbness sensations. Performing blood tests to measure the level of glucose is an incorrect response. Symptoms such as pain, tingling, and numbness in the hands and feet, as well as depression, can be signs of developing diabetic neuropathy. This patient lacks other symptoms associated with diabetes, making this diagnosis unlikely; therefore, testing for glucose levels is not a necessary next step. A thyroid-stimulating hormone (TSH) test is an incorrect response. Muscle weakness, numbness, pain, as well as depression, are associated with the late stages of chronic hypothyroidism; however, these symptoms are not sufficient to suspect hypothyroidism. Hypothyroidism is characterized by weight gain, loss of concentration, and hearing loss in the elderly, which are not conditions that affect this patient; therefore, a TSH test would not be useful in this case. Neuroimaging studies are performed to provide information about brain tumors, skull fractures, and other diseases of the brain and blood vessels in the brain. Based on the symptoms seen in this patient, neuroimaging would not help in establishing a diagnosis.

A 60-year-old man with a past medical history of COPD, hypertension, peptic ulcer disease, and hyperlipidemia is being evaluated for a 1-hour history of severe pain in the mid-abdominal region. His history includes abdominal surgery 6 months ago for a small intestinal obstruction, and his pain emanates from his incisional site. He also states that he has shaking chills, nausea, and vomiting, but denies chest pain, shortness of breath, wheezing, or abnormal bowel habits. Upon physical exam, he is found to be hypotensive, tachycardic, diaphoretic, and in acute painful distress. The abdomen is obese; bowel sounds are hypoactive; and rebound tenderness is noted. There is an exquisitely tender 2.0 cm ventral hernia located inferior to the umbilicus that is indurated, tender to palpation, and is not reducible. Auscultation of the mass reveals the presence of bowel sounds. Question What is the most appropriate therapeutic intervention for this patient at this time? Answer Choices 1 Broad spectrum antibiotics 2 Maintain a solid diet 3 Apply hot packs to the hernia 4 Oral motrin for pain 5 Attempt hernia reduction

Broad spectrum antibiotics This patient's presentation is significant of a strangulated hernia. Manifestations of hernia strangulation, a medical emergency, include an exquisitely tender mass associated with systemic signs and symptoms, such as intestinal obstruction, toxic appearance, peritonitis, or meeting sepsis criteria. General surgery should be consulted immediately.Additional interventions include the administering broad-spectrum IV antibiotics, such as cefoxitin, providing fluid resuscitation and adequate narcotic analgesia, and obtaining preoperative laboratory studies. If there is any concern for strangulation, do not attempt hernia reduction. The reintroduction of ischemic, necrotic bowel back into the peritoneal cavity can result in subsequent perforation and sepsis. Bedside ED US, using a linear high frequency probe with color or power Doppler of the hernia sac can be useful in these borderline cases to establish the presence or absence of blood flow.

A 35-year-old man has a routine physical examination with no abnormal findings. His family history, however, is positive for familial adenomatous polyposis. What screening test would be best for him to obtain? Answer Choices 1 No screening necessary before the age of 50 2 Colonoscopy 3 Fecal occult blood test 4 Fecal immunochemical test 5 Stool DNA test (sDNA) 6 AFP tumor marker

Colonoscopy The best test to recommend is a colonoscopy since it detects both polyps and cancer. Colorectal cancer is the 4th most common form of cancer in the United States; it arises from adenomatous polyps in the colon. Familial adenomatous polyposis (FAP) has different inheritance patterns and different genetic causes. In this patient, the pattern is probably autosomal dominant which puts him at a risk of nearly 100% for developing colorectal cancer by the age of 40. That means that screening tests for colorectal cancer must be performed earlier than suggested for the rest of the population (i.e., before the age of 50). A fecal occult blood test, fecal immunochemical test, and stool DNA test (sDNA) find cancer, not polyps. The AFP (alpha-fetoprotein) tumor marker is a useful marker for hepatocellular carcinoma and germ cell tumors, but not for colorectal cancer.

A 15-year-old girl presents with a 1-year history of intermittent abdominal pain with nausea and occasional bloody diarrhea. She denies fever or weight loss, as well as any travel history. Past medical history is significant only for migraines. She takes a multivitamin. Her vital signs are within normal limits. She has mild diffuse abdominal tenderness to palpation and guaiac-positive stool. Her exam is otherwise normal. Her hemoglobin is 9.7, hematocrit is 28%, and her WBC is 12,000/uL. Question What finding would indicate a possible cure if a colectomy is performed? Answer Choices 1 Skip lesions, transmural involvement on colonoscopy 2 Crypt abscesses, superficial mucosal involvement on colonoscopy 3 Ileal disease 4 Fistulas, fissures 5 Mouth ulcers

Crypt abscesses, superficial mucosal involvement on colonoscopy Crypt abscesses and superficial mucosal involvement are colonoscopy findings associated with ulcerative colitis. A colectomy is performed for severe and intractable disease. A colectomy can be a relative cure since the disease is limited to the colon. Skip lesions, transmural involvement, fistulas, and fissures are all associated with colonoscopy findings in Crohn's disease. Crohn's disease can also affect any structure of the alimentary tract from the mouth to anus, causing ileal disease and mouth ulcers.

A 15-year-old boy presents with bloody diarrhea and abdominal cramping. A double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. A biopsy finds an extensive inflammatory process in the mucosa and submucosa. The glands are filled with eosinophilic secretions; there is also mild involvement of the terminal ileum. Sulfasalazine treatment is attempted, but fails to bring about improvement. What is the most appropriate next step in the management? Answer Choices 1 Corticosteroids 2 Metronidazole 3 6-mercaptopurine 4 Diphenoxylate 5 Loperamide

Corticosteroids Fine serrations (ulcers) and pseudopolyps suggest colitis ulcerosa (ulcerative colitis). It is usually limited to the colon but occasionally, as in this case, the terminal ileum is also affected (backwash ileitis). In addition to sulfasalazine or 5-amino-salicylacid, more severe ulcerative colitis cases require corticosteroids. Corticosteroids are also helpful in Crohn's disease involving the small bowel. Metronidazole is helpful in treating the characteristic fistulas of Crohn's disease. Immunosuppressive agents (e.g., 6-mercaptopurine) are used in severe Crohn's disease cases. Diphenoxylate and loperamide provide only symptomatic relief. While surgical removal of the colon can give relief in ulcerative colitis, Crohn's disease tends to recur in approximately 1/2 of the cases involving removal of the diseased bowel.

A 57-year-old man presents with a sudden onset of left lower quadrant pain, fever, and guarding. The patient appears septic and ill. His hemoglobin is 12.2 g/dL, and hematocrit is 37%; white blood cell count (WBC) is 15 x109/L, and platelets are 150 x109/L. You suspect diverticulitis, with a probable perforation. What study would best confirm the diagnosis? Answer Choices 1 Barium enema 2 Colonoscopy 3 CT scan of the abdomen 4 Flexible sigmoidoscopy 5 Sonogram

Ct scan of the abdomen The correct response is a CT scan of the abdomen. Patients with acute diverticulitis can be diagnosed based on the clinical presentation. Since other acute surgical conditions can present in a similar clinical pattern, confirmation of the diagnosis is important. Contrast radiography (barium enema) or colonoscopy should be undertaken with caution in patients with suspected acute diverticulitis. The increased luminal pressure from the injected contrast material, or from insufflation of air, may lead to free rupture of a previously well-localized peridiverticular abscess or phlegmon. Although studies have suggested that both contrast enemas and colonoscopies (when performed by experienced personnel) can be done safely with a high diagnostic yield, the introduction of computerized tomography has substantially reduced their use. CT scanning has the advantages of being non-invasive, avoiding increased luminal pressure, and being able to detect extraluminal disease; therefore, it is the test of choice to confirm the diagnosis of diverticulitis. Fiber-optic endoscopy offers little information in the evaluation of suspected diverticulitis and carries a significant risk of increasing the pericolic contamination. A sonogram is not as sensitive in picking up diverticulitis as a CT scan, and it would probably end up requiring a CT scan to confirm.

A 45-year-old chronic alcoholic presents with history of massive hematemesis. This hematemesis followed a bout of prolonged vomiting. Patient has been a known alcoholic for 20 years. On examination, he has a pulse rate of 100/min and a BP of 90/70 mm Hg with cold extremities. These findings are typical for what condition? Answer Choices 1 Hiatus hernia 2 Esophageal pulsion diverticulum 3 Barrett's esophagus 4 Esophageal squamous cell carcinoma 5 Esophageal laceration

Esophageal Laceration Esophageal laceration extends to the submucosal veins that bleed profusely, also known as Mallory-Weiss syndrome. Hiatus hernia may cause a reflux along with inflammation and possible ulceration, but bleeding is not typically massive. Diverticula of the esophagus usually do not bleed. Barrett's esophagus (metaplasia with gastric mucosa) is associated with reflux and inflammation and possible ulceration, but bleeding is not usually massive. Esophageal squamous cell carcinoma will cause ulceration, but massive bleeding is not common.

A 45-year-old chronic alcoholic presents with history of massive hematemesis. This hematemesis followed a bout of prolonged vomiting. Patient has been a known alcoholic for 20 years. On examination, he has a pulse rate of 100/min and a BP of 90/70 mm Hg with cold extremities. These findings are typical for what condition? Answer Choices 1 Hiatus hernia 2 Esophageal pulsion diverticulum 3 Barrett's esophagus 4 Esophageal squamous cell carcinoma 5 Esophageal laceration

Esophageal laceration Esophageal laceration extends to the submucosal veins that bleed profusely, also known as Mallory-Weiss syndrome. Hiatus hernia may cause a reflux along with inflammation and possible ulceration, but bleeding is not typically massive. Diverticula of the esophagus usually do not bleed. Barrett's esophagus (metaplasia with gastric mucosa) is associated with reflux and inflammation and possible ulceration, but bleeding is not usually massive. Esophageal squamous cell carcinoma will cause ulceration, but massive bleeding is not common.

A 23-year-old woman presents with 'heartburn'; she mentions the reflux of her gastric juice. What pathology is most likely to be seen in this patient's esophagus? Answer Choices 1 Esophageal diverticula 2 Esophageal web 3 Esophageal laceration 4 Esophagitis 5 Mallory-Weiss tear

Esophagitis

A 43-year-old man presents with fever, productive cough, and wheezing, leading to an intial diagnosis of bilateral patchy pneumonia and admission to the hospital. The patient's history is positive for increasing dysphagia for both solids and liquids over the past 2-3 years, and an approximate weight loss of 12 lbs recently. He occasionally gets severe chest pain for which he uses OTC meds but he has not consulted a physician. At night he experiences bouts of coughing. 8 months ago he had bronchitis and 4 months ago he had pneumonia. Both were treated on an outpatient basis. A barium swallow shows a dilated flaccid esophagus filled partly with fluid. Endoscopy reveals erythematous esophageal mucosa with resistance to passage of the endoscope at the lower esophageal sphincter. No structural lesions are found. What is the next step in the definitive diagnosis of this condition? Answer Choices 1 Biopsy of the mucosa of the esophagus 2 Swallow evaluation and video fluoroscopy 3 CT scan of the chest 4 24 hour pH monitoring 5 Esophageal manometry

Esophageal manometry Explanation This patient is suffering from achalasia of the cardia. This is a motility disorder of the esophagus that occurs due to a neurological deficit from fibrosis, scarring in the Auerbach's plexus, and degeneration of vagal fibers in the esophagus. This causes decreased peristalsis in the body of the esophagus and incomplete relaxation of the lower esophageal sphincter. Dysphagia to solids and liquids, weight loss, chest pain, nocturnal cough due aspiration of esophageal contents, and recurrent bronchitis and pneumonia are classic symptoms. Radiography and endoscopy are performed to rule out anatomic pathology. Manometry is needed for the definitive diagnosis, which shows elevated lower esophageal sphincter pressure, absence of normal peristalsis in the entire esophagus, and incomplete relaxation of the lower sphincter. Treatment is with pneumatic dilatation, endoscopic injection of botulinum toxin, or Heller myotomy. Biopsy of the mucosa may rule out malignancy at the esophagogastric junction (which can cause secondary achalasia or pseudoachalasia) will not assist in the definitive diagnosis of achalasia. Swallow evaluation and video fluoroscopy permit evaluation of the cervical esophagus only, and therefore are inadequate. CT scan of the chest is indicated in malignancy related and obstructive esophageal conditions. 24 hour pH monitoring is a tool used for diagnosis of reflux esophagitis.

What is the most common cause of hemodynamically significant bleeding from the lower gastrointestinal tract? Answer Choices 1 Colonic diverticula 2 Colonic cancer 3 Colonic polyps 4 Vascular ectasia of the colon 5 Inflammatory bowel disease

The most common cause of hemodynamically significant hemorrhage from the lower gastrointestinal tract is colonic diverticula, which accounts for about 25% of the cases. The bleeding is typically painless and associated with voluminous hematochezia. Colonic cancer and polyps together make up about 20% of the cases of hemodynamically significant bleeding from the lower gastrointestinal tract; inflammatory bowel disease and vascular ectasia are considerably less frequent causes.

A 35-year-old Hispanic man is too embarrassed to explain his chief symptom. You enter the room and coerce him to give you the reason he has come for medical treatment. He admits to having a sore that will not heal around his rectum and anal area. This lesion has been draining pus consistently for the last week. The patient further explains that he has only had intermittent pain with this lesion (4/10 on a 0 - 10 pain scale) that is made slightly worse when he has a bowel movement (ranking it a 6/10). More recently, especially in the last few days, he has noted that simply sitting increases the pain. The patient also admits to intermittent periods of itching. He denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease. Physical examination of the anorectal area reveals excoriated and inflamed perianal skin with a palpated induration. Question What is this patient's most likely diagnosis? Answer Choices 1 Anal fistula 2 Crohn's disease 3 Anal fissure 4 Anal cancer 5 Internal hemorrhoid

The patient in this scenario is experiencing signs and symptoms from an anorectal fistula. Anorectal fistulas are commonly a chronic manifestation of an acute perirectal process that eventually comes from an anorectal abscess. Many fistulas originate from an infected anal crypt gland. Patients with anorectal fistulas usually will present with a "non-healing" area (an anorectal abscess that is draining) or may describe chronic purulent drainage and a pustule-like lesion on the perianal or buttock area. They will only have intermittent pruritus or rectal pain; pain is increased during defecation, sitting, or standing. Physical examination reveals excoriated and inflamed perianal skin. An external opening of the fistula may be visualized. If no opening is seen, palpation will reveal induration just below the skin. Anal fissure is not the most likely diagnosis in this case scenario. Anal fissures most often affect infants as well as middle-aged individuals. The majority of fissures are considered primary and caused by local trauma such as passage of hard stool, prolonged diarrhea, vaginal delivery, or anal sex. Presentation of anal fissures is a tearing pain accompanying bowel movements as well as bright red rectal bleeding that is limited to a small amount noted on the toilet paper or surface of the stool. The patient described all of these components. Patients will also complain of perianal pruritus or irritation, which he also admits to experiencing. Patients with Crohn's disease often have extremely variable signs and symptoms and possibly will have these for many years prior to diagnosis. Fatigue, prolonged diarrhea and abdominal pain, weight loss, and fever with or without gross bleeding are considered hallmarks of Crohn's disease. Signs and symptoms of anal carcinoma include rectal bleeding (occurring in 45% of patients), anorectal pain or sensation of a rectal mass (30%), or even no issues (20%). Very often issues are confused with hemorrhoids and therefore patients may delay evaluation. Over 80% of patients developing anal cancer have detected human papilloma virus. Internal hemorrhoids create principle issues of bleeding, prolapse, and mucoid discharge.Bleeding may range from bright red blood that is seen as streaks on the toilet paper to actual dripping of it into the toilet bowl after a bowel movement. Over time, hemorrhoids potentially will develop into a prolapsed state achieve a point in time when patients will note a sense of fullness or discomfort along with mucoid drainage that results in further irritation and soiling of underclothes.

A 55-year-old man presents with a 12-hour history of severe epigastric abdominal pain that radiates into his back, nausea, vomiting, and chills. His pertinent physical examination findings include oral temperature of 102°F and epigastric tenderness upon palpation. He is admitted to the hospital for management of his condition. Question What criteria would increase the likelihood of a severe attack associated with a high incidence of short and long term morbidity and mortality? Answer Choices 1 White blood cell (WBC) count of 10,000cells/mm3 upon admission 2 A 14% decrease of his hematocrit at 48 hours after admission 3 Serum glucose of 130 mg/dL upon admission 4 Aspartate transaminase of 240 U/dL upon admission 5 Serum calcium of 10 mg/dL 48 hours after admission

2 A 14% decrease of his hematocrit at 48 hours after admissionA patient who is admitted to the hospital for treatment of acute pancreatitis is assessed using the Ranson criteria to determine the severity of their disease, which in turn helps determine prognosis. About 70 - 80% of cases of acute pancreatitis are considered mild and result in virtually no morbidity or mortality. The remainder are severe attacks and have a 10 - 30% mortality rate. Fast identification of the severe cases is helpful to reduce the morbidity and mortality for each patient. There are 11 Ranson criteria, 5 of which are determined upon admission, and 6 at 48 hours after admission. Patients who have 2 or fewer of the criteria have minimal mortality. Patients with 3 - 5 of the criteria have about a 10 - 20% chance of mortality. Patients with 5 or more of the criteria have at least a 50% mortality rate. A patient with at least a 10% decrease in their hematocrit at 48 hours after admission meets one of the Ranson criteria, so the correct answer is a 14% decrease in hematocrit 48 hours after admission. WBC count of 10,000 cells/mm3 is not one of the Ranson criteria. A WBC count of >16,000 cells/mm3 would meet one of the Ranson criteria. Serum glucose of 130 mg/dL upon admission is also not one of the Ranson criteria. The patient's serum glucose would have to be at least 200 mg/dL to count as one of the Ranson criteria and increase the severity of their disease. Aspartate transaminase of 240 U/dL upon admission is not one of the Ranson criteria either. The patient's aspartate transaminase would have to be at least 250 U/dL to count as a Ranson criteria and increase the severity of their disease. A serum calcium of 10 mg/dL 48 hours after admission is not one of the Ranson criteria. If the patient's serum calcium is under 8 mg/dL 58 hours after admission, this would count as one of the Ranson criteria.

A 52-year-old Caucasian woman presents with a 2-week history of rectal bleeding. Over the last 3 months, she has become progressively more tired, and could no longer play tennis on weekends. She denies diarrhea, abdominal pain or tenesmus. Her past medical history includes peptic ulcer disease 5 years ago, treated with an anti-H.pylori scheme and which has not recurred. Her vital signs are stable, and the physical examination shows no abnormalities. A CBC shows the following: Ht: 28% Hb: 8.8 mg/dl MCV: 82 fl Leukocytes: 8.100/mm3 w/ normal differential An upper endoscopy is normal except for a duodenal ulcer scar without signs of active ulceration, and a repeat colonoscopy is normal. Question What is most likely to identify the source of bleeding? Answer Choices 1 Celiac angiography 2 Computed tomography of the abdomen 3 Wireless capsule endoscopy 4 Push enteroscopy 5 Biopsy of the healed ulcer bed

3. Wireless capsule endoscopy Wireless capsule endoscopy is performed by ingestion of a battery-powered capsule containing a camera and a transmitter. The capsule transmits images to sensors outside the patient during its transit in the gastrointestinal tract. Indications for capsule endoscopy are still evolving, but several series have shown that capsule endoscopy is more sensitive than small bowel radiography or push enteroscopy for locating the source of small-bowel bleeding. The most common etiologies of bleeding in this region are angioectasia and Crohn's disease. Several other small bowel lesions, such as tumors (leiomyoma, lymphomas, carcinoids, or carcinomas), varices, and polyps, have also been described. An important concern is the possibility of capsule impaction and small bowel obstruction. Some centers are reluctant to perform capsule endoscopy in patients with partial or intermittent obstruction of the small bowel. However, capsule impaction may reveal the site of a lesion and allow its surgical removal, obviating the need for intraoperative enteroscopy. Other relative contraindications are incapacity of cooperating with the examination (e.g. dementia), swallowing disorders, esophageal stricture, gastroparesis, and poor surgical risk. In patients with obstruction or gastroparesis, the examiner may place the capsule endoscopically. This patient has no signs of ulcer activity. Therefore, biopsy of the duodenal scar is not indicated. A 99mTc scan is the test of choice for Meckel's diverticulum, a remnant of the embryonic omphalomesenteric duct found in 1.5% of the general population. Its most common location is the antimesenteric border of the mid-to-distal small bowel. Some diverticula contain ectopic, acid-producing gastric mucosa. Therefore, they can ulcerate and bleed. Rectal bleeding caused by Meckel's diverticulum is often maroon or brick-red in color, and its incidence decreases with age. Therefore, this diagnosis is unlikely in this case. Angiography can be used if other less invasive procedures (i.e. small bowel radiography, push enteroscopy, or small bowel radiography) are non-diagnostic. Computed tomography is not indicated in the absence of other symptoms indicating a specific etiology (e.g. a palpable mass or suspicion of pancreatic disease). Of note, colonoscopy after rapid oral purging has emerged as the procedure of choice for the evaluation of acute lower GI bleeding, and it also provides a means for therapy. Scintigraphy and/or angiography also play important roles in diagnosis and embolization when colonoscopy reveals negative findings or when it is not feasible.

A 60-year-old man presents with severe abdominal pain that started 10 hours ago. It is increasing in severity and is colicky in nature. The patient has not had a bowel movement for 3 days. In the last 2 days, he vomited up what he ate 4 times. He looks tired and dehydrated. On examination, increased bowel sounds were noticed. There is also a mass in the right inguinal area. The patient said he the mass has been present for 10 years but disappears when he lies on his back. Question What is the investigation of choice to confirm the diagnosis? Answer Choices 1 Abdominal X-Ray Erect film 2 Abdominal Ultrasound 3 CBC 4 Colonoscopy 5 Upper GIT endoscopy

Abdominal X-ray Erect film. Intestinal obstruction occurs when bowel movement is encountering an obstacle in the passage through the bowel. Actually this can be caused by any mass, adhesion, or any other means of mechanical obstruction. The symptoms of obstruction vary according to the site of obstruction, but generally there is increased bowel movement proximal to obstruction with the reflected increase in bowel sounds. There may be vomiting. There may be no bowel movement, from absolute constipation to feces and flatus. Here the patient has inguinal hernia which is recently irreducible and obstructed. The best diagnostic procedure is erect X-ray film which shows multiple fluid levels and gives confirmation of the diagnosis. The treatment is exploratory surgery, and there is no place for any conservative treatment without surgery. Paralytic ileus is a type of intestinal obstruction that usually follows general anesthesia and is characterized by silent abdomen with no bowel sounds, usually treated by bowel rest and proper hydration. Colonoscopy here is contraindicated. Upper GIT endoscopy is generally used to detect pathology in upper GIT, not in the case of intestinal obstruction. Abdominal ultrasound is of value in diagnosis of gall bladder disease and also urinary bladder pathology. CBC is generally used to detect leukocytosis in acute appendicitis or inflammatory reactions.

A 31-year-old man presents with gastric pain and heartburn. A gastroscopy was performed and a gastric ulcer diagnosed. What medication should he take for the pain? Answer Choices 1 Aspirin 2 Diclofenac 3 Ibuprofen 4 Naproxen 5 Acetaminophen

Acetaminophen Acetaminophen is a mild analgesic and antipyretic without anti-inflammatory properties. The mechanism of action is unknown; it is believed to block generation of pain impulses by inhibiting the synthesis or action of substances that sensitize pain receptors. The antipyretic effect is thought to be by central action in the hypothalamic heat-regulating center. Long-term use can result in liver damage, especially in combination of alcohol abuse. It can lead to neutropenia, leukopenia, pancytopenia, and hemolytic anemia. The drug may cause false positive test results for urinary 5-hydroxyindoleacetic acid and interfere with home glucose testing. Aspirin, acetylsalicylic acid, is an analgesic, antipyretic and anti-inflammatory drug, which inhibits the prostaglandin synthesis. Since prostaglandin also stimulates mucus production and decreases acid production in the stomach blockage, it is reversing those processes. Therefore, aspirin is contraindicated in patients with gastrointestinal ulcers. Emanated from acetylsalicylic acid, many other anti-inflammatories, analgesic, and antipyretic drugs have been developed and comprehended as acid-antiphlogistics. They have the same mode of action and similar side effects. diclofenac, ibuprofen, and naproxen are in this group and therefore contraindicated in patients with gastrointestinal ulcers.

A 35-year-old man presents with a 4-week history of difficulty swallowing food. He has developed chest pain over the last few days, and he has also noticed regurgitation of food. On detailed history, he says that the regurgitation contains undigested fragmented food material; it is unassociated with a foul smell. He has lost 3 kg over the past month. On examination, his pulse is 94 bpm and blood pressure is 130/86 mm Hg. Mild pallor is noted, but there is no icterus. Epigastric tenderness is present. CBC shows a hemoglobin of 9.5 g/dL (total count 7400 cells/mm3 and ESR 12 mm/hr). An X-ray of the abdomen shows an absence of a fundic air shadow. The patient undergoes barium studies which show a dilated esophagus; the lower end appears beak-shaped. Question What is the most likely diagnosis? Answer Choices 1 Achalasia cardia 2 Barrett's esophagus 3 Hiatal hernia 4 Plummer-Vinson syndrome 5 Zenker's diverticulum

Achalasia Cardia Gradual onset of difficulty in swallowing food, the regurgitation of undigested food, the absence of fundic air on a plain X-ray of the abdomen, and a dilated esophagus with a beak-shaped lower end are diagnostic of achalasia cardia. It occurs due to the degeneration of inhibitory neurons in the lower end of esophagus. The most common cause of achalasia is primary/idiopathic. There is a deficiency of inhibitory neurons containing vasoactive intestinal peptide and nitric oxide synthase in this condition. Barrett's esophagus is the metaplasia of the lower esophageal junction; it is usually a consequence of gastroesophageal reflux disorder. Hiatal hernia is usually a sliding type and is not associated with the esophageal narrowing. Plummer-Vinson syndrome is associated with web formation in the upper esophagus; it is associated with iron deficiency anemia in menopausal women. Zenker's diverticulum is a posterior pharyngeal wall abnormality due to dehiscence between the 2 layers of inferior constrictors. Undigested food usually comes back with a foul smell a long time after the ingestion.

A 38-year-old woman is going through a divorce and simultaneously filing bankruptcy. She is very stressed about her financial situation and failed marriage. One day, after a particularly long crying spell, she notices a sudden onset of extreme difficulty swallowing at dinnertime. She has difficulty swallowing both solids and liquids. She feels that the food is sticking in her throat. She ignores it. She has numerous bouts of these episodes of difficulty with swallowing. She notices that when she lies down, undigested food comes up. Finally, she sees her doctor. On questioning by her doctor, she insists she has no heartburn. She has not seen any blood when she regurgitates nor has she vomited blood. Manometry is performed which shows an absence of normal peristalsis and an elevated LES pressure. What is the most likely diagnosis? Answer Choices 1 Achalasia 2 Scleroderma 3 Esophageal varices 4 Gastroesophageal reflux disease 5 Mallory-Weiss syndrome

Achalasia is the right answer it is characterized by dysphagia. There is poor peristalsis in achalasia. This patient has a characteristic history for achalasia. The onset is during a period of stress. The symptoms consist of dysphagia, complaints of food sticking in the throat, and regurgitation. Scleroderma can present with dysphagia. However, manometry would show a decreased LES pressure, not an elevated LES pressure as the case here. In addition, scleroderma can be associated with heartburn. Esophageal varices usually present with hematemesis. Gastroesophageal reflux disease would present with heartburn. If anything, the LES pressure would be lower than normal, rather than elevated. Mallory-Weiss syndrome is an esophageal tear. This would present with hematemesis.

A 57-year-old woman with a 40 pack-year history of smoking and a long history of Type 2 Diabetes presents with fatigue, middle abdominal pain, and loss of appetite. She indicates that these bouts have been coming and going for the last few months and she finally decided to get checked out. She indicates that she has also lost considerable weight. On physical examination, she appears mildly jaundiced. You perform a CT scan that reveals a mass in the pancreas. Question What is the most likely diagnosis? Answer Choices 1 Gastrinoma 2 Adenocarcinoma 3 Teratoma 4 Insulinoma 5 Pancreatic sarcoma

Adenocarcinoma The clinical picture is suggestive of a chronic pancreatitis that has developed into pancreatic cancer. 90% of all pancreatic cancers are adenocarcinomas. The rest are adenosquamous, anaplastic, and acinar cell carcinomas. Virtually all pancreatic carcinomas (99%) originate in duct cells. A gastrinoma is a tumor that secretes the hormone gastrin. It is commonly found in the duodenum and is associated with Zollinger-Ellison syndrome. Symptoms include diarrhea, epigastric pain, hematemesis, and difficulty eating. Teratoma is a neoplasm consisting of all 3 germ layers. Insulinoma is a tumor of the pancreas associated with the beta-cells. Sarcomas are neoplasms of connective tissue. Pancreatic cancers are of epithelial cell origin.

A 50-year-old man is sent for a screening colonoscopy for colon cancer by his primary care physician. The test shows no evidence of cancer but reveals 1 polyp in the right colon. It is removed and sent for tissue biopsy by the gastroenterologist, who asks him to return to his office in 2 weeks for the result and further advice. What biopsy result indicates an increased risk for cancer? Answer Choices 1 Hyperplastic polyp 1 cm in size 2 Adenomatous polyp 2 cm in size 3 Pedunculated mucosal polyp 4 Inflammatory pseudopolyp 5 Tubular polyp 0.5 mm in size

Adenomatous polyp 2 cm in size Adenomatous polyps are precursors of adenocarcinoma, and the risk is more if the size is more than 1 cm, if it is sessile rather than pedunculated, and if it is villous rather than tubular. Adenomatous polyps with high-grade dysplasia and invasive cancer are at a high risk of developing colon cancer and should be treated aggressively. Removal by colonoscopy is advocated. The relative risk decreases to 2.3 after removal, as compared to those who do not get it removed, for whom the risk is 8. Hyperplastic polyp is the most common type of colon polyp in the general population and rarely premalignant. Mucosal polyps are benign, small, and of unknown significance. Whether pedunculated or sessile, they are not premalignant. Inflammatory pseudopolyps occur in inflammatory bowel disease (IBD) and are themselves not premalignant. They are caused by boggy mucosa between ulcerations and are not dysplastic. IBD, however, is a premalignant condition by itself. Small tubular adenomatous polyps do not increase colon cancer risk significantly.

A 65-year-old man presents because this morning a morsel of meat he had eaten 3 days ago reappeared on his pillow. About a year ago, he noticed difficulty swallowing, particularly solid foods, which seems to be worsening. His wife complains about his bad breath, and he noticed that people are avoiding being close to him. He does not drink, does not smoke, and was in a good health before. His physical examination is within normal range for his age, except that you notice that he is repeatedly clearing his throat, as if he is embarrassed. Question What is the next best step in the management of this patient? Answer Choices 1 Barium study 2 Upper endoscopy and tissue biopsy 3 Endoscopic ultrasound 4 24 hours pH monitor 5 Manometry

Barium study The recollection of slow progressing difficulties in initiating swallowing and regurgitation in an older patient makes you suspect Zenker diverticulum. Your clinical diagnosis is supported by bad breath and throat clearing. Definitive diagnosis is made by barium studies. Endoscopy is actually contraindicated in this patient because the lesion is proximal and there is a risk of perforation of the pharynx. Endoscopic ultrasound is performed in patients with esophageal carcinoma for staging. Your patient has no typical signs of esophageal carcinoma (progressive dysphagia for solid foods first, followed by liquids, with weight loss in a smoker and/or alcoholic). That diagnosis is not excluded; however, the probability of Zenker diverticulum will prevent you from choosing endoscopy as the first step in management. 24 hours pH monitoring should be considered in a patient with symptoms of gastroesophageal reflux (GERD) when the diagnosis is not clear. GERD will present with epigastric or substernal pain, sore throat, metallic taste in mouth, hoarseness, cough, and wheezing. It is not likely that your patient has GERD. Manometry should be considered if you suspect a disorder of esophageal peristalsis, as is the case in achalasia, esophageal spasm, nutcracker esophagus, or lower esophageal sphincter diseases. These disorders can present with dysphagia for both solid foods and liquids, sometimes accompanied by pain and weight loss. Manometry includes the placement of a nasogastric tube, and the procedure will increase the risk of pharyngeal perforation. Manometry should be performed only after barium studies exclude Zenker diverticulum.

A 60-year-old man presents with a 6-month history of dysphagia to solids, regurgitation of undigested food, and halitosis. He denies a decrease in appetite, abdominal pain, weight loss, or change in bowel habits. His past medical history is significant for a total hip replacement. His lab work is as follows: Hemoglobin 14.0 g/dL Hematocrit 43% White cell count 6.0 x 109/L Platelets 300 x 109/L Sodium 135 mEq/L Potassium 4.0 mEq/L Urea 6 mg/dL Creatinine 0.6 mg/dL Glucose 98 mg/dL Chloride 100 mEq/L HCO3- 25 mEq/L His liver panel is normal. Question The diagnosis can be determined initially by what technique? Answer Choices 1 Barium swallow 2 Esophageal manometry 3 MRI of the head and neck 4 Radionuclide scanning 5 Upper endoscopy

Barium swallow The patient may have a Zenker's diverticulum, which could predispose the patient to an aspiration pneumonia. Zenker's diverticulum is an outpouching of the posterior pharyngeal wall immediately above the upper esophageal sphincter. Collection of food particles in the pouch results in halitosis and the symptom of regurgitation of undigested food particles. The diagnosis is likely to be Zenker's diverticulum because the patient has dysphagia to solids, regurgitation of undigested food particles, and halitosis. Barium swallow is the diagnostic procedure of choice because it is the least invasive. Esophageal manometry would not be useful in this case; it is normally used in evaluating patients with noncardiac chest pain, motor disorders of the esophagus, achalasia, or gastroesophageal reflux disease. MRI of the head and neck is not routinely used for the diagnosis of Zenker's diverticulum. Radionuclide scanning would be used in evaluating the patient for a thyroid tumor, which is low on the differential list for this patient based on his symptoms (e.g., lack of weight loss or appetite loss). As part of the work up before surgery (to reduce the size of the diverticulum), an upper endoscopy is used to rule out an esophageal cancer.

Which of the following is true regarding Mallory-Weiss syndrome? Answer Choices 1 Operative repair usually is necessary 2 Is the most common cause of gastrointestinal bleeding during pregnancy 3 Endoscopy is contraindicated 4 Bleeding stops spontaneously in the majority of cases 5 Accounts for 1/3 of deaths from upper gastrointestinal bleeding

Bleeding stops spontaneously in the majority of cases Explanation Mallory-Weiss syndrome involves a tear of the mucosa and submucosa of the lower esophagus or gastric cardia and accounts for up to 9% of cases of significant upper gastrointestinal bleeding. This syndrome results from forceful events that increase intra-abdominal pressure, including trauma, seizures, coughing, and, most commonly, vomiting, with retching preceding hematemesis in approximately 50% of patients. Mallory-Weiss syndrome is associated with alcoholism, hiatal hernias, esophagitis, or gastritis. The majority of episodes involve only mild to moderate bleeding that stops spontaneously, and surgery is rarely required. Only 3% of deaths from upper GI bleeding are due to Mallory-Weiss tears. Endoscopy is the diagnostic procedure of choice if performed within the first 12 to 24 hours. Esophagitis secondary to reflux and repeated vomiting is the most common cause of upper GI bleeding during the pregnancy.

An 8-year-old boy complained of abdominal pain in the afternoon and vomited twice. No fever is noted, and he has not had any diarrhea. On examination the next morning, he has diffuse lower abdominal pain with rebound tenderness on the lower right side. On rectal examination, there is no localization. Question What is your next recommendation? Answer Choices 1 Complete blood count (CBC) and urine analysis (UA) only 2 Immediate surgery for appendicitis 3 Observation without further treatment 4 CBC, UA, and abdominal ultrasound 5 Barium enema to diagnose and treat a presumed intussusception

CBC, UA, and abdominal U/S This child's history and physical examination are not specific enough to go directly to surgery for presumed appendicitis; however, the child needs more of a work-up than just observation. While not all children with appendicitis have an elevated white count and a left shift, other findings on the CBC such as a hemolytic anemia with thrombocytopenia may lead one to consider Henoch-Schönlein purpura. The same is true if there is marked hematuria and proteinuria. A periappendiceal abscess against the bladder can produce some hematuria and pyuria. A barium enema is sometimes used to assist in the diagnosis of appendicitis. If the appendix fills with barium, it is not swollen from inflammation. However, in the situation outlined, a CBC, UA, and ultrasound to look for a swollen appendix or evidence of a periappendiceal abscess would be the least invasive evaluative protocol with the lowest risk of side effects.

A 41-year-old man presents with acute hematemesis. Abdominal exam reveals distension, no rebound or guarding, hepatosplenomegaly, and dull fluid wave. What is the most likely source of the upper gastrointestinal bleeding (UGI)? Answer Choices 1 Mallory-Weiss tear 2 Perforated duodenal ulcer 3 Chronic gastritis 4 Arteriovenous malformation (AVM) 5 Esophageal varices

Esophageal varices Bleeding from esophageal varices secondary to portal hypertension and obstruction of splenic blood flow is a common source of UGI bleeding presented to emergency departments. Mallory-Weiss tears and perforated duodenal ulcers may result in hematemesis, but they are associated with significant abdominal pain. Chronic gastritis is a common source of abdominal pain and may result in occult fecal blood. AVMs in the small intestine should be suspected in cases of hematochezia.

A 23-year-old woman presents with 'heartburn'; she mentions the reflux of her gastric juice. What pathology is most likely to be seen in this patient's esophagus? Answer Choices 1 Esophageal diverticula 2 Esophageal web 3 Esophageal laceration 4 Esophagitis 5 Mallory-Weiss tear

Esophagitis Esophagitis is an inflammation of the esophagus. A variety of conditions, such as gastric reflux, are associated with esophagitis. Esophageal diverticula are pockets in the esophagus. Esophageal diverticula may not present with any symptoms, but a patient with esophageal diverticula may complain of dysphagia or regurgitation. Esophageal webs are mucosal folds; they can be single or multiple. Esophageal webs are typically observed in Plummer-Vinson syndrome and are located in the upper esophagus; however, they can be found anywhere in the esophagus. They often present with dysphagia. An esophageal laceration is also referred to as a Mallory-Weiss tear. An esophageal laceration would present with hematemesis. Esophageal lacerations are usually associated with vomiting. Alcoholics are more prone to esophageal lacerations.

A 27-year-old man has been experiencing heartburn on and off for approximately 6 years. At this current visit, the patient is also describing symptoms of chest pain, dysphagia, and even early satiety. Because of the persistence of his symptoms despite pharmacologic therapy with both proton pump inhibitors and various histamine blockers, you decide to consult with a local gastroenterologist group. The patient undergoes an endoscopy, with biopsies of tissue. Results of the biopsy show no ulcers and are H. pylori negative; the tissue samples themselves are prominently infused with an abundant amount of eosinophils. Question Based on the history and physical exam findings above, what is the most effective pharmaceutical intervention at this time? Answer Choices 1 Oral omeprazole 2 Oral ampicillin 3 Oral cetirizine 4 Fluticasone metered dose inhaler 5 Topical fluconazole

Fluticasone metered dose inhaler The patient described in the above scenario has the diagnosis of eosinophilic esophagitis (EE). Because this is a relatively new diagnosis, the prevalence of EE is unknown, although the incidence is increasing in both children as well as adults. These patients will have symptoms typically 4 - 5 years before they have a confirmed diagnosis. EE is more commonly seen in male patients who are Caucasian, and up to 70% of patients with EE have personal history of atopy to environmental or foods. The most common symptoms found in adults with EE are dysphasia, refractory heartburn, chest pain, and food impaction. Usually, no physical exam abnormalities will be detected. An endoscopy with esophageal biopsy is the only definitive method to diagnose EE. The presence of eosinophils of 15 or more per high power field is required for a diagnosis. Other physical findings that may be visualized during an endoscopy that are highly suggestive of EE include stacked circular rings ('feline esophagus'), proximal strictures, linear furrowing, as well as white exudates or even papules that signify eosinophilic purulent material. Currently there are no FDA approved medications for the treatment of EE. The most efficient treatment for symptoms is topical corticosteroids, either via fluticasone metered dose inhaler or viscous budesonide. These medications are swallowed and therefore coat the esophagus; the symptoms as well as the overall eosinophilia improve fairly quickly. Patient response is usually in the first few days of treatment; however, symptoms will reoccur once the medication regimen is discontinued. Topical fluconazole is not the correct option; EE is not a fungal infection. Oral ampicillin is not correct because EE's underlying pathology is not a bacterial infection. Oral omeprazole is not specifically recommended for treatment of EE; however, it may treat the co-existent GERD. Oral cetirizine is also not an appropriate choice; if there is evidence of severe atopy, therapy should be initiated, but no evidence presents in the case scenario showing that the treatment of airborne allergic disorders improves EE.

A 60-year-old Caucasian man comes to your office to establish care. He has no known medical problems and his only medication is daily ibuprofen for 5 years for musculoskeletal aches associated with his work as a handyman. He is at most risk for which following due to chronic NSAID use? Answer Choices 1 Chronic kidney disease not requiring dialysis 2 Chronic kidney disease requiring dialysis 3 Gastrointestinal bleed 4 Accidental job injury 5 Chronic joint pain

GI bleed The patient described in this question is at most risk for a gastrointestinal bleed secondary to his chronic non-steroidal use. Patients in their 60s are at an approximate 3-fold increased risk for a gastrointestinal bleed when they take non-steroidal anti-inflammatory medications compared to not taking them. The non-steroidals inhibit the prostaglandins responsible for homeostasis, and thus can lead to gastrointestinal mucosal injury. Chronic analgesic consumption is associated with chronic kidney disease. Analgesic nephropathy is still a relatively uncommon cause of chronic kidney disease; its prevalence is higher in Europe and Australia than in the United States, where it accounts for only 2-4% of the cases of end stage kidney disease. End stage kidney disease is the most advanced stage of kidney disease, for which patients typically require dialysis. Some studies have debated causality, however a recent New England Journal of Medicine article addressed the risk in patients with chronic consumption and found a 2.5-5 fold increase risk of chronic renal failure in patients who chronically used acetaminophen vs. those who did not. Cumulative lifetime use increased the odds of renal failure, and results were similar for patients who took aspirin. The highest risk was noted among patients who took >500g/yr acetaminophen (>1.4g/day). Other studies have found increased risk among users of >3-5 gram per lifetime and >6 tablets/day for 3 years. The National Kidney Foundation currently classifies 5 stages of chronic kidney disease in patients who have structural or functional damage of the kidneys for greater than or equal to 3 months, as evidenced by abnormal pathology or laboratory markers of kidney damage (blood, urine, imaging studies). Patients who have a GFR less than 60ml/min/1.73m3 for at least 3 months, with or without such markers, are also considered to have chronic kidney disease. This patient presumably already has chronic aches (for which he takes the ibuprofen) and should not be at any additional risk for accidental injury secondary to the ibuprofen.

A 65-year-old Caucasian man presents due to losing 15 lbs over the past 6 months; he is also experiencing abdominal pain and bloody stools. He also has a 35-year history of daily alcohol intake and smoking. On examination, the patient is found to have pallor and several hyperpigmented velvety papillomatous plaques on the back of his neck and axilla, as shown in the image. Question What condition is suspected based on patient's signs and symptoms? Answer Choices 1 Chronic liver disease 2 Gastric carcinoma 3 Inflammatory bowel disease 4 Pancreatitis 5 Colon cancer

Gastric carcinoma Gastric carcinoma is the correct answer. The sudden appearance of extensive skin lesions suggestive of seborrheic keratosis or acanthosis nigricans must include workup for intra-abdominal malignancy; in particular, gastric cancer should be considered. It is a para-neoplastic syndrome; it has been given the eponym 'Leser-Trelat sign'. Chronic liver disease is incorrect. Skin manifestations of cirrhosis include spider naevi and caput medusae. Inflammatory bowel disease is incorrect. The skin manifestations most commonly seen with the condition are erythema nodosum and pyoderma gangrenosum. Pancreatitis is incorrect. Severe acute pancreatitis is sometimes associated with ecchymoses of the abdominal wall; they are known as Grey-Turner's sign and Cullen's sign. Colon cancer is incorrect. It is rarely associated with dermatomyositis.

A 72-year-old woman presents because she "threw up fresh blood" 1 hour ago. She denies any heartburn or gastric symptoms. Her past medical history includes type II diabetes controlled with diet and glyburide and ibuprofen use for severe, chronic osteoarthritis. On initial examination, she appears anxious, but she is ambulatory and has no noticeable pallor. Family history is unremarkable. Vital signs are as follows: BP 140 x 80 mmHg without postural hypotension, HR 104 bpm, and RR 18 bpm. The rest of the physical examination shows no abnormalities. The patient is admitted and undergoes upper endoscopy. What finding is most probable? Answer Choices 1 An actively bleeding duodenal ulcer 2 A malignant gastric ulcer 3 Brisk arterial bleeding originating from a point in the gastric wall 4 Gastritis 5 A positive test for Helicobacter pylori

Gastritis Non-steroidal anti-inflammatory agents (NSAIDs) cause ulcer diathesis because they inhibit prostaglandin synthesis. Virtually all NSAID users develop some degree of gastritis, and hemorrhagic gastritis is a common cause of upper gastrointestinal bleeding in these patients. Erosions and ulceration, sometimes with multiple ulcers, are also common. Endoscopic studies have shown that 15-20% of chronic NSAID users develop ulcers; however, most of these lesions are not associated with serious complications (e.g. bleeding, perforation, etc), and screening is not indicated. Chronic NSAID users have a 2 - 4% per year risk of upper gastrointestinal bleeding. It is estimated that NSAID-associated bleeding causes 2,600 deaths annually in the United States. Its incidence is rising because of population aging, which has led to an increased number of people with chronic rheumatic conditions.

A 13-year-old boy presents with a long history of intermittent jaundice without other signs and symptoms. Yesterday he took several paracetamol tablets, and the headache and jaundice appeared again. His parents have a consanguineous marriage, and nobody in the family has similar symptoms. His physical examination today is within normal limits, except for mild scleral icterus. The initial laboratory examinations show: RBC 4.5mill/mm3; WBC 6000/mm3; total bilirubin 2.2 mg/dl; indirect bilirubin 2.0 mg/dl; direct bili 0.2 mg/dl; liver enzymes, serum copper, and all other parameters are normal; hepatitis B (-); and the full set of his autoimmune markers (-) and Coombs test (-). Blood smear is normal. Ultrasonography of liver, gallbladder, pancreas, spleen, and for both kidneys are normal. His urine appears very yellow. Question What is the most likely the diagnosis? Answer Choices 1 Gilbert's syndrome 2 Intravascular hemolysis 3 Chronic viral hepatitis 4 Crigler-Najjar syndrome 5 Budd-Chiari syndrome

Gilbert's disease Your patient most probably has Gilbert's syndrome (GS), also known as Gilbert-Meulengracht syndrome. It is a relatively common genetic disease found in up to 5% - 10% of the population and generally does not need special treatment. Inherited non-haemolytic hyperbilirubinemic conditions include Dubin-Johnson, Rotor, and GB syndromes, and all are important differential diagnoses indicating benign disease that requires no immediate treatment. GB can be diagnosed by clinical presentation, biochemistry, and genotyping, and is significant because of the presence of the disposition towards drug-associated toxicity. A major characteristic is jaundice, caused by elevated levels of unconjugated bilirubin in the bloodstream. The cause of this hyperbilirubinemia is the reduced activity of the enzyme glucuronyltransferase, which conjugates both bilirubin and some lipophilic molecules, including drugs. Intravascular hemolysis, with resulting hemoglobinemia, hemoglobinuria, and bilirubinemia, will show fragments of the red blood cells ("schistocytes") and sometimes spherocytes in peripheral blood smear, reticulocytosis, elevated unconjugated bilirubin that may lead to jaundice, elevated lactate dehydrogenase (LDH) in the blood, and decreased haptoglobin levels. If the direct Coombs test is positive, hemolysis is caused by an immune process. Hemosiderin in the urine indicates chronic intravascular hemolysis. There is also urobilinogen in the urine. Viral hepatitis with jaundice will have elevated liver function tests (AST and ALT elevated out of proportion to alkaline phosphatase, usually with hyperbilirubinemia), and viral serologic testing will be positive. Crigler-Najjar syndrome is a rare inherited form of non-hemolytic jaundice, which results in high levels of unconjugated bilirubin and often leads to brain damage in infancy. Budd-Chiari syndrome is caused by occlusion of the hepatic veins. It presents with the classical triad of abdominal pain, ascites, and hepatomegaly. The syndrome can be fulminant, acute, chronic, or asymptomatic.

A 68-year-old man presents for a routine physical exam. A soft venous hum over the epigastric and umbilical area is noted on auscultation. The venous hum is due to increased collateral circulation resulting from what type of condition? Answer Choices 1 Hepatic cirrhosis 2 Chlamydial perihepatitis 3 Gonococcal perihepatitis 4 Liver tumor 5 Recent liver biopsy

Hepatic cirrhosis A venous hum is due to an increased collateral circulation between the systemic and portal venous system resulting from hepatic cirrhosis. Chlamydial and gonococcal perihepatitis, liver tumor, and a recent liver biopsy cause grating sounds called "friction rubs" along the hepatic and splenic borders of the abdomen.

A 36-year-old Jewish man presents with abdominal pain and diarrhea, as well as a 2-day history of a low-grade fever. He is initially treated with fluids and antibiotics, but his symptoms worsen. On evaluation, he is diagnosed with Crohn's disease. He is a nonsmoker, but has alcoholic drinks on alternate days; he underwent an appendectomy 2 years ago. His mother was diagnosed with irritable bowel syndrome (IBS) 10 years ago. Question What in his history is a risk factor for Crohn's disease? Answer Choices 1 His age 2 Alcohol consumption 3 His Jewish ancestry 4 Family history of IBS 5 Appendectomy

His jewish ancestry Crohn's disease (CD) is more common in the Jewish population; it is more common in whites than African-Americans. Environmental factors may play a role in its etiopathogenesis because African-Americans seem to have the same risk as whites, but African blacks have a lower risk. The age of onset is between 15 to 30 years with a second peak between 60 to 80 years. CD is an inflammatory bowel disease affecting any part of the GIT from mouth to anus; the most commonly affected region is the ileocecal region. Symptoms include abdominal pain, diarrhea (which may be bloody), vomiting, fever, and weight loss. Extraintestinal symptoms (e.g., arthritis, uveitis) may also develop. Smoking, not alcohol, is a risk factor for CD. A family history of IBS is unrelated to CD; however, a family history of CD itself is a risk factor. An appendectomy neither increases the risk nor is protective in CD.

A 56-year-old woman presents with heartburn and dyspepsia. She was diagnosed with osteoarthritis 4 years prior to presentation, and for the past 18 months, she has been managing pain with naproxen. An upper gastrointestinal endoscopy shows several areas of gastric irritation and a single ulcer about 3 mm in diameter. The gastroenterologist suggests that the patient be tested for Helicobacter pylori infection. What is the gold standard for diagnosis of this infection? Answer Choices 1 Culture 2 Histology 3 Antigen test 4 Western blot serology 5 Urease breath test

Histology The long term use of non-steroidal antiinflammatory drugs (NSAIDS) in treatment of arthropathies carries about a 4-fold increase in the relative risk of duodenal or gastric ulcers. This risk is multifactorial; 1 risk factor for development of gastric ulcers in patients taking NSAIDS is infection with Helicobacter pylori. Histologic examination of gastric biopsies obtained during endoscopy is the gold standard for diagnosis of this infection based on sensitivity and specificity (refer to the table). This approach has the added benefit of allowing simultaneous assessment of the pathology of the lesion, which can rule out neoplasms. Culture of H. pylori is difficult and requires considerable microbiologic expertise. However, indicators in the cultivation medium can detect urease. Invasive procedures can be preceded by the urease breath test as a screening for the presence of the organism. Helicobacter serology by ELISA is limited to screening and detection of a past or present infection. An antigen test is also available that detects H. pylori protein in the stool.

A 34-year-old male presents to the primary care office with a complaint of heartburn that has been present for three months. He has symptoms two to three times a week, which occurs about 30 minutes after eating. He has tried over-the-counter antacids and they were helping to relieve his symptoms for a few months, but they are not working well now. He denies dysphagia, odynophagia, or weight loss. You decide to treat him with a proton pump inhibitor at this visit, and he achieves good symptomatic relief with this therapy. What length of therapy is appropriate in this patient? A Two to four weeks B Eight to twelve weeks C Four to six months D One year E Continue indefinitely

If a patient achieves good symptomatic relief with a course of an empiric, once-daily proton pump inhibitor, therapy may be discontinued after eight to twelve weeks.

A 55-year-old African-American man presents as febrile with massive swelling of the abdomen and diarrhea. He has a 20-year history of heavy alcohol use. A fluid wave is elicited on physical examination of the abdomen by striking one flank and feeling the transmitted wave on the opposite flank. Question In what case would ascitic fluid analysis suggest cirrhosis as a cause of ascites in this patient? Answer Choices 1 If the acidic fluid and leukocyte count is more than 500/mm3 2 If the fluid has a protein concentration below 3 g/dL 3 If there is a large number of red blood cells in the fluid 4 If fluid is designated as a exudate 5 If the Serum Ascites Albumin Gradient is lower than 1.1 g/dL

If the fluid has a protein concentration below 3 g/dL The correct response is if the fluid protein concentration below 3/dL. After the diagnosis of ascites is made by physical examination, all patients with new-onset ascites should undergo abdominal paracentesis and ascitic fluid analysis. The most important tests to order for fluid analysis include protein concentrationand cell count. Fluids with protein concentration above 3 g/dL are designated as exudates. Those with values below 3 g/dL are designated as transudates. Diseases usually associated with transudates include congestive heart failure, cirrhosis, constrictive pericarditis, inferior vena cava obstruction, hypoalbuminemia, Meigs syndrome, and some cases of nephrotic syndrome. The amount of albumin in the ascitic fluid compared to the serum albumin (the Serum Ascites Albumin Gradient, SAAG) can be indicative of the cause of ascites. Ascites related to hypertension, cirrhosis, or congestive heart failure generally shows a SAAG greater than 1.1 g/dL. Exudates are more commonly seen with peritoneal neoplasm, pancreatic ascites, myxedema, and tuberculous peritonitis. A large number of red blood cells in the fluid or grossly bloody ascites suggests a diagnosis of neoplasm. An acidic fluid and leukocyte count of more than 500/mm3 strongly suggests a peritoneal infection or inflammatory process. Other tests that should be ordered in the appropriate clinical setting include cytologic examination, lactic dehydrogenase (LDH), specific tumor markers, glucose, and cultures for bacteria, mycobacteria, and fungi.

A 58-year-old man presents with a 1-day history of severe abdominal pain, nausea, and vomiting. He initially thought he had some indigestion, with pain located in the epigastric region, and tried some calcium carbonate (Tums) with no relief. The pain and vomiting progressed through the night and kept him from sleeping and going to work. He feels the pain boring through to his back. He denies hematemesis, fever, diarrhea, out-of-the-country travel, and contact with sick people. Prior to onset of pain, he reports good health. He has no known medical conditions and takes no medications. He has had no surgeries. He smokes cigarettes (1ppd x 40 years), admits "moderate" alcohol use, and denies drug use. He is married and works as a welder. Vitals are: BP: 102/56 mmHg; HR: 116bpm; RR: 15; Temp: 98.9F; O2Sat: 95% on room air. On physical exam, the patient appears uncomfortable on the exam table and grimaces when changing position for exam. He is cooperative, alert, and oriented. Abnormal physical exam findings include: abdomen distended, decreased bowel sounds, and tender epigastric region, with guarding. He is tachycardic. No jaundice is noted. The remainder of the exam is normal. This patient's test results are shown in the table. Alk Phosphatase150 (50-136) Amylase 272 (20-110) Lipase 290 (0-160) Question What pharmacologic treatment is the most important intervention for this patient's likely condition? Answer Choices 1 Ertapenem 2 Hyoscyamine 3 Lactated Ringer's 4 Pancrelipase 5 Promethazine

LR This patient is presenting with an episode of acute pancreatitis. Pancreatitis is characterized by epigastric pain, nausea, and vomiting. Many other acute abdomen conditions may present similarly. Significant elevations of lipase and amylase, as well as CT evidence of pancreatic inflammation, fluid collections, and/or necrosis, will establish the diagnosis. Pancreatitis can be acute or chronic, and those with chronic disease may have periodic acute flares. In acute pancreatitis, early fluid resuscitation is one of the "few medical interventions that appears to affect outcome," so (of the choices listed) administering lactated Ringer's (or saline) would be the best answer for this patient. Also, ensuring the patient has "nothing by mouth" (NPO) until symptoms decrease is standard treatment. Ertapenem is a carbapenem antibiotic, indicated for complicated intra-abdominal, skin, and urinary tract infections. Although this patient's white blood cell count (WBC) is elevated, the primary process is not infectious. The WBC increases in inflammatory states. Rarely are antibiotics needed in acute pancreatitis. Hyoscyamine is an anticholinergic medication, with a wide range of uses, including many gastrointestinal conditions. It may be used for reducing spasm in irritable bowel syndrome and for biliary colic. Before the test results pointed to pancreatitis, as in this patient's diagnosis, biliary colic and obstruction would be on the differential. However, hyoscyamine would not be a primary treatment for pancreatitis. Pancrelipase is a digestive enzyme, taken with meals, and indicated for pancreatic insufficiency, a common complication of many years of chronic pancreatitis. This patient may be at risk for future pancreatitic disease, but the pancrelipase would not benefit him at this time. Promethazine is a common antiemetic with antihistamine and anticholinergic properties. Although it may be reasonable to consider antiemetic treatment for a patient with acute pancreatitis, it is an adjunct treatment and does not have a vital impact on the course of the disorder.

A 25-year-old man presents with a 3-hour history of retrosternal chest pain. He reports that he has been vomiting since the previous evening and his last vomitus had fresh blood in it. He denies any trauma to the chest. On examination his BP is 90/60 mm Hg and PR 110/min. Question What is the most likely cause of this patient's chest pain? Answer Choices 1 Tietze's syndrome 2 Myocardial infarction 3 Panic disorder 4 Mallory-Weiss Syndrome 5 Tuberculous pleuritis

Mallory weiss Syndrome In cases of Mallory-Weiss Syndrome, patients present with hematemesis, especially after repeated severe retching and vomiting, which results in a mucosal tear at the gastroesophageal junction. They may also have retrosternal chest pain. Tuberculous pleuritis chest pain ispleuritic and aggravated by coughing. It is described as sharp. Other symptoms (e.g., fever, dyspnea, and weight loss) may also be present. On examination, there may be dullness on percussion as well as absent breath sounds on the affected side. In Tietze's syndrome, patients present with anterior chest pain that is aggravated by taking a deep breath, sneezing, and turning motions. On examination, the affected costochondral junctions are erythematous, warm, and tender on palpation. The most commonly affected are the 2nd or 3rd costochondral joints. Patients with myocardial infarction usually present with a left-sided or retrosternal pain that may radiate to the jaw, neck, and shoulder. They describe it as heaviness or a squeezing sensation. It is of variable duration and often lasts for more than 30 minutes. There is a gradual intensification of the pain. The onset of the pain may be during physical exertion or at rest. It is not relieved by nitroglycerine. On examination, they may be dyspneic and diaphoretic. Chest pain due to a panic disorder has a variable presentation. It can be retrosternal or localized, brief or over 30 minutes in duration. Numerous terms, such as aching and sharp, can be used to describe it. Other symptoms of a panic disorder include lightheadedness, shortness of breath, nausea, paresthesias, palpitations, derealization, and the fear of losing control. The history helps elicit precipitating factors and prior panic attacks.

A 60-year-old man presents with a 6-month history of pain in his knee joints. It has been gradually increasing, and now limits his activities. X-ray reveals osteoarthritic changes in both knee joints. You consider treating him with a non-steroidal anti-inflammatory drug (NSAID); however, you note that he has a history of gastric ulcers. In the past, the patient has not tolerated proton pump inhibitors well; he has had several episodes of severe headache, diarrhea, and dizziness when treated with them. Question What is the best way to reduce the risk of NSAID-induced gastric mucosal injury in this patient? Answer Choices 1 Misoprostol 2 Milk of Magnesia 3 Octreotide 4 Ranitidine 5 Sucralfate

Misoprostol Misoprostol is a prostaglandin analogue that acts on the gastric parietal cells to reduce gastric acid secretions. Proton pump inhibitors (PPI) are better tolerated than misoprostol and may be preferred over misoprostol, even in NSAID-induced gastric injury. Ideally, this patient should be treated with a selective COX-2 inhibitor NSAID with a PPI; however, considering his poor tolerance to PPI (which is rare), misoprostol is the next best choice. Misoprostol causes nausea, diarrhea, abdominal pain, and dysmenorrhea. It should be avoided in pregnancy, as it may cause an abortion. Milk of magnesia is an antacid that acts by neutralizing the acid in the stomach; it is commonly used in dyspepsia. Octreotide is a somatostatin analogue that inhibits gastric and pancreatic secretion. It is used in Zollinger-Ellison syndrome. H2 receptor blockers (e.g., ranitidine) are used to treat gastroesophageal reflux disease, as well as gastric, duodenal, and stress ulcers; however, they are not the 1st choice in NSAID-induced injury because a double dose would be required. Sucralfate is an ulcer protective; it forms a coating on the ulcer crater and acts as a barrier to acid and pepsin.

A 62-year-old man passed a foul-smelling, tarry stool 1 week ago. 3 weeks ago, he began taking diclofenac because of worsening osteoarthritis. His past medical history includes primary hypertension, coronary heart disease, and 2 episodes of venous thrombosis in the calf. Besides diclofenac, his medications include warfarin, enalapril, low-dose aspirin, propranolol, and sublingual nitroglycerin. A screening colonoscopy performed 2 weeks ago was entirely normal. Vital signs are stable, and the physical examination is unremarkable. Upper endoscopy shows only pangastritis and erosions. What is the most effective way of reducing his risk of rebleeding? Answer Choices 1 Misoprostol 2 Omeprazole 3 Famotidine 4 Switch to valdecoxib 5 Take the diclofenac tablets with at least 250 ml of water

Misoprostol The correct response is misoprostol. Besides NSAID use, this patient has several risk factors for gastric bleeding (a previous episode, advanced age, use of anticoagulants and low-dose aspirin). Therefore, prophylaxis against bleeding must be seriously considered. Prostaglandin analogues are the most effective drugs for reducing the risk of rebleeding. One study described reductions of up to fivefold in the incidence of gastric ulcers on endoscopy. However, this drug requires 2 to 4 daily doses and has several side effects. The most common are diarrhea (up to 30% of patients) and abdominal discomfort. It is also a potent abortifacient. Starting the drug at a low dose and then progressively raising it might reduce the incidence of these side effects and improve tolerance. Proton-pump inhibitors such as omeprazole also reduce the incidence of gastrointestinal complications in chronic users of NSAIDs. They are slightly less effective than prostaglandin analogues, but their once-daily dosage is more convenient and the incidence of side effects is lower. The use of low-dose aspirin abrogates the protective effects of COX-2-selective anti-inflammatory drugs (i.e., celecoxib, rofecoxib, or valdecoxib). Therefore, switching to COX-2 inhibitors would not be advantageous for this patient. H2-blockers such as famotidine have only marginal efficacy in reducing the incidence of NSAID-associated gastric ulcers and should not be prescribed in this case. The medications that should be taken with at least 250 ml of water are the bisphosphonates. This precaution reduces the risk of pill esophagitis. This drug should also be taken on an empty stomach and with the patient in an upright position. If these precautions are not followed, bisphosphonates can cause severe esophagitis, which can even lead to strictures or bleeding.

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never experienced heartburn as bad as she does currently. She is treating this with over-the-counter histamine-2 receptor antagonist, famotidine, 1 tablet daily. The patient denies any other significant past medical history and is currently taking a daily multivitamin and an antihistamine for seasonal allergies. She recently admits to having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days; she hopes that after finals are finished, her headaches will subside. She also states that she was given amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stool, use of tobacco/alcohol, or coughing up blood. Physical examination is unremarkable for any abnormalities. Question Which of the following medications that the patient mentioned is most likely causing her increased gastrointestinal symptoms? Answer Choices 1 Antibiotic 2 H2-receptor antagonist 3 Multivitamin 4 H1-receptor antagonist 5 NSAID

NSAID Patients classified as having mild or intermittent symptoms of gastroesophageal reflux disease (GERD) typically are seen as not adversely affecting the patient's quality of life. Initial action includes modification of behaviors, such as eating smaller meals and eliminating acidic foods or known foods that precipitate the reflux (fatty foods, alcohol, chocolate, or peppermint). Weight loss has also been shown to help decrease issues, as well as advising patients to avoid lying down at least 3 hours after eating meals. Elevation of the head of the bed is also suggested to initiate relief. The next step in terms of treatment would be to discontinue any medications that may be increasing the symptoms of GERD. Medications that potentially irritate the esophagus and cause gastritis symptoms include: tetracycline, bisphosphonates, iron supplements, Non-Steroidal Anti-inflammatories (NSAIDs), and potassium supplements. Medications that increase acid reflux and worsen the condition of GERD include: anticholinergics, calcium channel blockers, narcotics, progesterone, quinidine, benzodiazepines, or even theophylline.

A 35-year-old woman presents with watery diarrhea. It began 1 day after eating at a party. Her 6-year-old daughter ate the same food and is vomiting, but she does not have diarrhea. On examination, the woman is not dehydrated or febrile. A stool examination is negative for leukocytes and trophozoites. Question What is the causative organism? Answer Choices 1 Entamoeba histolytica 2 Enterotoxigenic Escherichia coli 3 Shigella dysenteriae 4 Bacillus cereus 5 Norwalk virus

Norwalk virus Norwalk virus can cause water and food borne outbreaks. The incubation period is 1 to 3 days. Patients present with watery diarrhea and vomiting. They may also report abdominal and muscle pains. In adults, diarrhea is usually more prominent than vomiting. In children, the reverse is true. On examination, they may be febrile. The stool examination is negative for leukocytes, ova, and trophozoites. The mainstay of therapy is hydration, as symptoms usually resolve within 2 days. Entamoeba histolytica colitis develops 2 to 6 weeks after ingesting contaminated water or food. Patients usually present with bloody and mucoid diarrhea. Stool examination reveals hematophagous trophozoites and cysts. Patients with Enterotoxigenic Escherichia coli food poisoning present with watery diarrhea 12 to 72 hours after ingesting contaminated water or raw fruit salads. Examination of the stool reveals no fecal leukocytes or trophozoites. Patients with Shigella dysenteriae food poisoning present with bloody diarrhea; symptoms usually start 16 hours after ingesting contaminated foods like potato salad. A stool examination reveals polymorphonuclear leukocytes. In emetic Bacillus cereus food poisoning, patients develop vomiting 1 to 6 hours after ingesting contaminated food like reheated fried rice. In the diarrheal form, they develop watery diarrhea 8 to 16 hours after ingestion. There are no fecal leukocytesor trophozoites.

A 33-year-old woman presents seeking advice. She is concerned regarding the appearance of spider angiomas that are present on her trunk and face. She states that spider angiomas appeared during pregnancy and that they persist now, 9 months after delivery. Before pregnancy, she was treated with imipramine because of depression and she is currently still taking this drug. She denies alcohol intake, however she tells you that 3 years ago, she had acute infection with hepatitis C virus. She was also frequently treated with flucloxacillin during the past couple of years for recurrent respiratory tract infections. In addition, she started taking oral contraceptives after delivery. The remainder of her personal history is unremarkable. Physical examination reveals the presence of multiple spider angiomas on the patient's face, forearms, and back. The remainder of the patient's general physical findings are unremarkable. Routine laboratory analyses reveal normal AST (26 IU/l, reference values 8 to 27 IU/l) and ALT (22 IU/l, reference value 8 to 23 IU/l) levels. Alkaline phosphatase level is normal (43 IU/l, reference value 23-71 IU/l) and other routine laboratory analyses reveal no abnormalities. HbSAg, HbeAg, and antiHbc antibodies are not present in patient's serum. IgG antibodies to hepatitis C are present, but testing for hepatitis C virus (HCV) does not reveal the presence of HCV RNA in patient's serum. Question What is the most likely cause of the patient's spider angiomas? Answer Choices 1 Flucloxacillin-induced hepatitis 2 Imipramine-induced hepatitis 3 Oral contraceptives 4 Chronic hepatitis caused by hepatitis C virus 5 Pregnancy-related appearance

OCP The most likely cause of this patient's spider angiomas are Oral contraceptives. In conditions when estrogen hormones are present in excess such as during pregnancy, contraceptive intake, or liver disease (due to decreased degradation of estrogens), the surplus of estrogens cause the appearance of spider nevi. In pregnant women, spider angiomas appear from the second to fifth month of pregnancy and disappear in a short period of time (within 2 months) after the delivery. Since in the presented case, spider angiomas are present for a longer period of time, it is unlikely that they are pregnancy-related. In untreated patients with acute Hepatitis C, disease evolves towards chronicity in about 80% of patients, while only about 20% of patients recover completely. Patients who have chronic hepatitis C also have HCV RNA in their serum, but those who have recovered completely have no HCV RNA in serum and have IgG antibodies against hepatitis C virus as the marker of past hepatitis C infection. As the presented patient satisfies criteria for the patient who had hepatitis C in the past, her spider angiomas are not related to chronic hepatitis C infection. Imipramine seldom causes liver damage. In addition, hepatitis caused by imipramine administration is of a cholestatic type, i.e. it is associated with increased serum levels of transaminases and alkaline phosphatase. Since the alkaline phosphatase level in the presented patient is normal, imipramine-induced hepatitis is not likely. Similar to imipramine, hepatitis caused by flucloxacillin administration is also of a cholestatic type. For the reasons presented above, the possibility of flucloxacillin-induced hepatitis is also unlikely.

A 46-year-old woman presents with a 2-month history of heartburn, epigastric discomfort, nausea, and occasional vomiting. She has a history of hyperlipidemia, controlled with diet and exercise, as well as asthma, for which she takes inhalers as needed. She takes no other medications, including over-the-counter analgesics. Family history is noncontributory. On exam she is afebrile, BP120/70 mm Hg, pulse 74/min, and SPO2 92%. Lungs are clear, and she has minimal epigastric tenderness. Otherwise, physical examination is unremarkable. She is advised by her physician to take lansoprazole once daily, which provides only partial relief. Endoscopy is then recommended, which shows a duodenal ulcer. Biopsy reveals infection with Helicobacter pylori. What would be the recommended regimen at this time? Answer Choices 1 Lansoprazole, amoxicillin, and metronidazole twice daily for 2 weeks 2 PPI (proton pump inhibitor), amoxicillin, and clarithromycin twice daily for 2 weeks 3 Omeprazole, tetracycline, and clarithromycin twice daily for 2 weeks 4 Bismuth, metronidazole, and lansoprazole twice daily for 2 weeks 5 Bismuth, metronidazole, and tetracycline 4 times daily for 2 weeks

PPI (proton pump inhibitor), amoxicillin, and clarithromycin twice daily for 2 weeks There are several regimens recommended for H. pylori infection, which is an important cause of peptic ulcer disease and should be treated if found associated with symptoms. The choice of the regimen depends on considerations such as cost, side effects, and ease of administration. Allergy to one of the medications, as well as intolerance, should also be taken into account. Any proton pump inhibitor (PPI) with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily for 2 weeks or PPI with metronidazole 500mg twice daily and clarithromycin 500mg twice daily for 2 weeks are recommended. These are the triple drug therapies available. The other regimens suggested are bismuth, metronidazole, and tetracycline 4 times daily for 2 weeks along with PPI twice daily for 2 weeks or H2 receptor antagonist twice daily for 4 weeks (quadruple drug therapy). Dual therapy with a proton pump inhibitor and an antibiotic (amoxicillin or clarithromycin) is not recommended as primary therapy, since eradication rates are much lower than the above regimens. The most common side effect is a metallic taste in the mouth due to clarithromycin or metronidazole. Amoxicillin can cause diarrhea or a rash. Clarithromycin can also cause nausea, vomiting, abdominal pain, and (rarely) QT prolongation. Metronidazole can cause peripheral neuropathy, seizures, and a disulfiram-like reaction when taken with alcohol. Tetracycline is teratogenic and causes photosensitivity.

A 63-year-old woman presents with a 6-month history of worsening difficulty in swallowing. Shortly after swallowing, she feels like something is getting stuck in her upper chest, and the sensation lasts long enough to begin causing significant chest discomfort just behind her breastbone. The difficulty swallowing is often extremely variable and intermittent; it has not been progressive. It gets to the point that she feels like she is going to regurgitate her food, and she is also experiencing substantial episodes of acid reflux. The difficulty swallowing seems to be worsened by when the patient is extremely stressed and when she eats hot or cold food. She denies any weight loss, night sweats, or other significant issues. Physical examination of the patient is otherwise noncontributory. An extensive gastrointestinal evaluation, which included a comprehensive endoscopic evaluation, is negative. Question What is the first-line prescribed medication that would help alleviate this patient's signs and symptoms? Answer Choices 1 Injected Botulinum toxin 2 Intravenous nitroglycerin 3 Oral proton pump inhibitor (PPI) 4 Oral prednisone 5 Oral Metoclopramide

PPIs The correct response is oral proton pump inhibitor. The patient in this presented scenario is showing signs and symptoms that are most consistent with esophageal dysphagia. Difficulty swallowing is the main complaint and is typically caused by 1 of 2 entities: localized neuromuscular disorders or obstructive lesions. Our patient specifically is showing issues of diffuse esophageal spasm. This is a motility disorder that is defined by simultaneous uncoordinated contraction of several esophageal segments. This can lead to potentially retrosternal pain and is worsened or precipitated by acid reflex, rapid eating, stress/anxiety, and hot/cold food. The dysphagia found in these patients is intermittent, non-progressive and does not cause weight loss. These patients have no documented abnormality in the distribution of myenteric neurons, normal lower esophageal sphincter relaxation, and no evidence of obstruction. All of these components are consistent with the patient described. In terms of a first-line treatment, acid suppression with a proton pump inhibitor (PPI) is the first-line pharmaceutical intervention that should be initiated. Sublingual nitroglycerin and calcium channel blockers may also be considered as treatment, but they are not typically considered first-line options. Botulinum toxin is not considered first-line treatment for diffuse esophageal spasms; it may be considered to be administered/injected in the lower esophageal sphincter and lower esophagus to reduce chest pain caused by diffuse esophageal spasm but again is not the first line treatment. Also, the patient described above is experiencing other symptoms, not just the chest pain. Prokinetic agents, such as metoclopramide, are considered treatment options for reflux esophagitis and Barrett esophagus-related causes of dysphagia. Oral corticosteroids may be considered in patients with diagnosed eosinophilic esophagitis.

A 42-year-old morbidly obese woman is referred back to her primary care provider to supervise her weight loss program. A surgeon evaluated her for a 'gallbladder attack' 1 month ago, which then resolved; she currently denies abdominal pain. When examined via ultrasound, she still has visible stones in the gallbladder. She declined to have surgery until she achieves her initial weight loss goal of 50 pounds. She is on a supervised healthy diet of about 1200 kilocalories daily; she exercises 1 hour a day 6 days per week. She is losing about 15 - 16 pounds a month. Question What intervention would be most effective at preventing the recurrence of her gallbladder "attack" until she achieves her weight loss goal? Answer Choices 1 Prescribe orlistat 2 Prescribe ursodiol 3 Recommend over-the-counter omeprazole 4 Reduce patient's exercise 5 Restrict caloric consumption further

Prescribe Ursodiol Both morbid obesity and rapid weight loss are risk factors for development of cholecystitis. Gallstones may be present within the gallbladder and remain asymptomatic, or the gallbladder walls may become inflamed, resulting in cholecystitis. Ursodiol is approved for prevention of gallstones in obesity patients with rapid weight loss. It would be the best choice in health maintenance and delaying or preventing need for surgical cholecystectomy. Orlistat is a prescription medication approved for treatment of obesity. Its mechanism is to block fat absorption. It does not have a direct role in health maintenance or prevention of cholecystitis or cholelithiasis. In fact, it has pronounced gastrointestinal side effects. Over-the-counter omeprazole is a commonly used proton-pump-inhibitor (PPI); it is helpful in acid lowering in the stomach and treatment of gastroesophageal reflux disease. It has not been shown to help gallbladder disease, and there is some evidence that PPIs may worsen it. Reducing the patient's exercise may aggravate her condition and negatively impact her weight loss. Exercise has an inverse relationship with cholecystitis and rates of cholecystectomies, so this patient should be encouraged to continue frequent exercise. This patient should not be instructed to restrict caloric consumption further. She is already losing weight quite rapidly at around 4 pounds per week. Her daily caloric intake is low; recommending further restriction will likely discourage her, and there will not be any benefit in regard to her gallbladder disease.

A 45-year-old man is admitted to the medical floor of a hospital with increasing jaundice, swollen legs, and episodes of disorientation for the last several weeks. His abdomen is distended and he looks ill. According to the family, he is an alcoholic and has recently been diagnosed with cirrhosis of liver. On examination, he has a temperature of 99 F, BP 100/72 mm Hg, and his pulse is 86/minute. Sclerae are icteric, and he has 2+ pitting pedal edema. Lungs are clear, and heart sounds are normal. Abdomen is distended with moderate ascites, caput medusae, and no tenderness. Liver and spleen are not palpable. He is awake but drowsy and oriented to person and place but not to time. He does have a fine tremor in his hands. Labs show WBC 8000/uL, platelets 100,000/uL, Hb 12g%, AST 76 U/L, ALT 56 U/L, AP 62 U/L, and ammonia is 124 mg/dL. Question At this time which of the following is most important to avoid full decompensation into hepatic encephalopathy? Answer Choices 1 Increase dietary protein 2 Prevent constipation 3 Sedate the patient to avoid injury from disorientation 4 Start IV antibiotics empirically anticipating infection 5 Add thiamine and folic acid for nutritional support

Prevent Constipation Explanation This patient is already in the initial phases of hepatic encephalopathy due to alcoholic liver disease as evidenced by the disorientation and tremors, also known as asterixis. The primary cause of hepatic encephalopathy is unclear. Metabolic abnormalities due to liver dysfunction, resulting in a spectrum of neuropsychiatric signs and symptoms, are seen. High levels of ammonia are found in the blood. Constipation causes increased ammonia production and absorption due to prolonged intestinal contact and aggravates the condition. Lactulose should be administered frequently to eliminate the ammonia in the stool. It is an indigestible sugar that acts as an osmotic laxative by increasing the water content of the stool and promoting bowel movements. It is digested by the colonic bacteria, and the acidic remains convert ammonia into ammonium ions in the colon, which are then excreted in the stool. Oral antibiotics can lower blood ammonia levels by decreasing ammonia production and absorption. The commonly used ones are neomycin, metronidazole, vancomycin, and, lately, rifaximin. The last three are better tolerated than neomycin. However antibiotics have their side effects and can cause bacterial overgrowth syndromes. Their main use continues to be in patients who cannot tolerate disaccharides like lactulose. Acarbose and fermentable fiber can also cause decrease in intestinal ammonia production and absorption. Newer studies with sodium benzoate are ongoing. Benzoate and glycine react to form hippurate, and for every mole of benzoate utilized this way, one mole of nitrogen is excreted in the urine, thereby enhancing ammonia metabolism. This, however, still needs to be studied further to be used widely. Studies with ornithine-aspartate are also being done as a stimulator of ammonia metabolism. All the products mentioned are yet to replace lactulose as the first line of treatment but are potentially useful once more studies are done. Other precipitating factors for hepatic encephalopathy include azotemia, hypokalemia, gastrointestinal bleeding, high protein diet, alkalosis, infection, sedatives, and other hepatotoxic agents. High protein diet is a contraindication in this condition, as protein catabolism causes increase in ammonia levels. Daily protein should be restricted to 40 g/day. Sedation of the patient should also be avoided, since sedatives cause cerebral depression and worsening of encephalopathy. These drugs are also not metabolized adequately by the diseased liver. Though infection is an important precipitating factor for hepatic encephalopathy, empiric treatment is not recommended. However, early and adequate treatment of an infection should be done, especially for spontaneous bacterial peritonitis. In fact multiple randomized control trials have been done regarding antibiotic prophylaxis for SBP, and they have shown not only a decrease in bacterial infections but also a significant reduction in mortality. Prophylaxis is recommended in cirrhotic patients with risk factors for SBP like GI bleeding, prior history of SBP, and low ascitic fluid protein. Thiamine and folic acid should be added for nutritional support to all alcoholic patients, since they are malnourished and vitamin depleted. However, this will not change the outcome in hepatic encephalopathy as quickly or as much as avoiding constipation.

A 35-year-old man presents with a 4-week history of difficulty swallowing food. He has developed chest pain over the last few days, and he has also noticed regurgitation of food. On detailed history, he says that the regurgitation contains undigested fragmented food material; it is unassociated with a foul smell. He has lost 3 kg over the past month. On examination, his pulse is 94 bpm and blood pressure is 130/86 mm Hg. Mild pallor is noted, but there is no icterus. Epigastric tenderness is present. CBC shows a hemoglobin of 9.5 g/dL (total count 7400 cells/mm3 and ESR 12 mm/hr). An X-ray of the abdomen shows an absence of a fundic air shadow. The patient undergoes barium studies which show a dilated esophagus; the lower end appears beak-shaped. Question What is the most common cause for the above condition? Answer Choices 1 Diabetes mellitus 2 Chagas disease 3 Eosinophilic gastroenteritis 4 Neurodegenerative disorder 5 Primary idiopathic

Primary idiopathic Explanation Gradual onset of difficulty in swallowing food, regurgitation of undigested food, absence of fundic air on plain abdominal X-ray, and dilated esophagus with beak shaped lower end are diagnostically indicative of Achalasia cardia. It is due to degeneration of inhibitory neurons in the lower end of esophagus. The most common cause of Achalasia is primary idiopathic. There is a deficiency of inhibitory neurons, vasoactive intestinal peptide, and nitric oxide synthase in this condition. Other rarer causes of achalasia include Chagas' disease, lymphoma, neurodegenerative disorders, esophageal gastroenteritis, and certain viral infections.

A 30-year-old man presents with a 1-month history of severe indigestion. He has tried over-the-counter antacids for the last 2 weeks to help relieve the pain, but they provided only mild relief. He describes the pain as a dull, aching, "hunger-like pain". He also states that a few hours after eating the pain lessens, and then worsens a few hours later. His physical examination is unremarkable except for epigastric pain on deep palpation of the abdomen. His stool guaiac test is negative. Question What therapeutic regimen should be prescribed? Answer Choices 1 H2-blocker therapy and bismuth therapy 2 Dietary modifications 3 Continue antacids and modify diet 4 Stress reduction, bismuth therapy, and dietary modifications 5 Proton pump inhibitor therapy, dietary modifications, and stress reduction

Proton pump inhibitor therapy, dietary modifications, and stress reduction The clinical picture is suggestive of peptic ulcer disease (PUD). The treatment of choice is proton pump inhibitors due to their ease of use and efficacy. Dietary modifications and stress reduction will assist in the decrease of stomach acid production. The hallmark symptom of PUD is epigastric pain (dyspepsia). The pain can be described as aching, dull, or gnawing. About 50% of patients do get some relief with over-the-counter antacids or other treatments. Some patients may have gastric pain that awakens them at night. Duodenal ulcers are usually indicated when there is relief of pain for a few hours after eating. H2-blocker therapy is effective in treating PUD, but it has been replaced by proton pump inhibitors. Dietary modifications alone are not helpful in this situation due to the patient experiencing severe dyspepsia. Continuing antacids would not be helpful since they offer only mild relief; they are no longer used as first-line therapy for active ulcers. Bismuth therapy (Pepto-Bismol), which is another over-the-counter antacid, is no longer used as first-line therapy for active ulcers; however, it is included in quadruple first-line therapy.

A middle-aged woman presents with diarrhea and vomiting that started this afternoon. She does not remember eating any meat, chicken, pudding, or ice cream the day before. She lives alone and says she warmed up leftover rice for supper last night. She looks sick from vomiting, but she is not dehydrated. She has no fever, and her blood pressure and pulse are within normal limits. What would be the best next step? Answer Choices 1 Admit and observe 2 Start oral fluids and metronidazole 3 Reassure the patient and send home with oral rehydration 4 Send stool specimen to the lab and ask patient to come the next day for follow up 5 Admit for parenteral treatment

Reassure the patient and send home with oral rehydration This patient is suffering from acute food poisoning. The history gives us the clue that she acquired this food poisoning from reheated rice. The most common organism that might cause this condition in this case would be Bacillus cereus. Bacillus cereus is a Gram-positive, spore-forming rod. Spores on grains, such as rice, survive steaming and rapid frying. The spores germinate when rice is kept warm for many hours. B. cereus produces 2 enterotoxins. The mode of action of 1 of the enterotoxins is the same as that of cholera toxin ( i.e., ADP-ribosylates G protein, which stimulates adenylate cyclase and leads to an increased concentration of cyclic AMP within the enterocyte). The mode of the other enterotoxin is uncertain. Clinically, it is a self-limiting situation and requires supportive treatment only. The incubation period is about 18 hours. The best advice for this patient would be to reassure her that it will get better and give her some oral rehydration supplements.

A 46-year-old woman presents with nausea, vomiting, crampy abdominal pain, and loud bowel sounds for the past several hours. She denies weight loss. She has had 1 normal bowel movement since the symptoms began, but this did not help her symptoms. She has a past surgical history of an abdominal hysterectomy 7 years prior. On physical exam, she is afebrile, with hyperactive and high-pitched bowel sounds localized to the left upper quadrant. She also has mild, diffuse abdominal tenderness. Question What is the most likely diagnosis? Answer Choices 1 Small bowel obstruction 2 Whipple's disease 3 Diverticulitis 4 Acute paralytic ileus 5 Irritable bowel syndrome

SBO The correct answer is small bowel obstruction, as it typically presents with localized high pitched bowel sounds with crampy abdominal pain, nausea, and vomiting. The bowel sounds will diminish if complete obstruction occurs. Acute paralytic ileus typically presents with very diminished or no bowel sounds. Patients with diverticulitis often have more severe, localized abdominal tenderness on exam and typically present with fever and possibly peritoneal signs. Whipple's disease is an infectious disorder characterized by fever, lymphadenopathy, arthralgias, weight loss, and chronic diarrhea. Irritable bowel syndrome is not typically associated with nausea and vomiting, and the abdominal pain is relieved with defecation.

What statement is true concerning balloon tamponade of esophageal varices? Answer Choices 1 An excellent measure for long term control of esophageal varices 2 Need not be preceded by upper endoscopy in a patient with a prior history of bleeding 3 Should be preceded by endotracheal intubation to protect the airway from aspiration 4 Position confirmation can be made by auscultation of the abdomen 5 Is associated with minimal morbidity and mortality

Should be preceded by endotracheal intubation to protect the airway from aspiration The use of balloon tamponade, most commonly with the Sengstaken-Blakemore tube, for esophageal varices is temporarily effective in controlling bleeding in 80-90% of patients. However, rebleeding will occur in 60% of patients and therefore is not effective for long term control. This is not a benign procedure, there is a significant risk of aspiration and esophageal or gastric perforation. Therefore, elective endotracheal intubation prior to placement of the tube is preferential. Careful placement of the tube with meticulous monitoring of balloon pressures is essential to minimize the risks of perforation. Radiologic confirmation of the tube position should always precede inflation of the balloons and frequent radiologic studies should be performed to assure maintenance of this position. In a patient with a history of esophageal varices with a new upper gastrointestinal bleed, 25% of the time it will be from a source other than the varices. Therefore, if the patient is not having exsanguinating hemorrhage, it is useful to perform upper endoscopy to confirm the source of bleeding and possibly treat the varices with sclerotherapy, which can control the bleeding in 90-95% of cases.

A 15-year-old boy was healthy until 3 months ago. He has been having episodes of crampy abdominal pain and explosive liquid stools 2-3 times a day. He has had intermittent fevers and has noted blood in the stool. He has a documented 15-lb weight loss. Question What is the best way to start treatment? Answer Choices 1 Diphenoxylate hydrochloride with atropine sulfate 2 Eliminate lactose-containing foods 3 Loperamide HCL 4 Eliminate all high fiber foods 5 Sulfasalazine

Sulfasalazine This patient has ulcerative colitis. Therefore, it would be most appropriate to start treatment with sulfasalazine at 50-75 mg/kg/day in 2-4 divided doses. Sulfasalazine is a sulfa drug that has important anti-inflammatory properties because it inhibits the synthesis of mediators of the inflammatory response. In some patients, sulfasalazine is poorly tolerated, in which case mesalamine (50-100 mg/kg/day) and balsalazide (110-175 mg/kg/day) are preferable treatments. Diphenoxylate hydrochloride with atropine sulfate at 1-2 mL t.i.d. and loperamide HCl at 0.04-0.08 mg/kg/day in 2-4 divided doses are contraindicated because they would suppress the symptoms of ulcerative colitis without amelioration of the underlying cause of the condition. Elimination of lactose-containing food would have no effect because the patient is lactose-tolerant. In addition, elimination of dietary fiber would not have any effect.

A 60-year-old man presents with a 2-week history of nausea and several episodes of epigastric pain. The pain is characteristically dull and lasts for several hours. His symptoms are not worsened by any particular food or activity. What is the most appropriate initial test? Answer Choices 1 Upper endoscopy 2 Gastrointestinal series 3 CT Scan of the abdomen 4 Ultrasonography of the upper abdomen 5 MRI of the abdomen

Ultrasonography of the upper abdomen Ultrasonography (USG) of the upper abdomen is the 1st choice in the investigation of acute or subacute abdominal pain. A common cause of acute abdominal pain in the elderly is cholecystitis, which can be investigated through USG. Changes occurring in the biliary system because of aging make older patients susceptible to cholecystitis, the most common indication for surgery in this population. Differential diagnosis would include diverticulitis (the most common cause of severe abdominal pain in patients over the age of 50), as well as bowel obstruction, pancreatitis, and peptic ulcer disease. Catastrophic conditions (e.g., abdominal aortic aneurysm rupture and mesenteric ischemia) must also be considered. This patient's symptoms are not very intense (his symptoms have been present for 2 weeks) and, therefore, do not necessitate urgent invasive investigations. If ultrasonography of the upper abdomen shows no significant findings, then a number of other tests can be performed (e.g., an upper endoscopy to rule out peptic ulcer disease, a gastrointestinal series to rule out bowel obstruction, and a CT scan or MRI of the abdomen to rule out pancreatitis or diverticulitis); any other undetermined pathology may be undertaken to exclude other possibilities.

A 10-year-old boy presents with a 2-month history of intermittant burning pain in the epigastrium. Pain is felt more during the night and between meals and is partly relieved by eating food or by taking antacids. Pain usually lasts for about ½ to 1 hour and is accompanied by nausea and vomiting. The patient often has a feeling of bloating and burping. The child remains asymptomatic for several days in between. There is no history of taking analgesics or anti-inflammatory drugs. Physical examination shows epigastric tenderness. The rest of the examination is essentially normal. Stool examination for occult blood is positive. Question What is the investigation of choice for establishing the diagnosis? Answer Choices 1 Ultrasound abdomen 2 Upper GI barium studies 3 CT Scan abdomen 4 Upper GI endoscopy 5 Stool microscopy

Upper GI endoscopy The patient's history, clinical examination, and stool testing positive for occult blood are suggestive of peptic ulcer disease. Upper GI endoscopy is the investigation of choice in children with suspected peptic ulcer disease. Endoscopy allows direct visualization of the esophagus, stomach, and duodenum, identifies the specific lesions, and also screens for the presence of H. pylori in the biopsy specimens. H. pylori is a gram negative S-shaped rod. Biopsy should always be obtained from the antrum of the stomach regardless of endoscopic findings. Endoscopic findings may vary from grossly normal mucosa to nonspecific gastritis with prominent rugal folds to nodularity and ulcers. Stool microscopy has no role in the diagnosis of H. pylori infection. However, stool antigen testing identifies active H. pylori infection by detecting the presence of H. pylori antigen in the stool. Single contrast barium studies have overall sensitivity of 75%, but double contrast studies have sensitivity of 95% in detection of gastric ulcer. These results are comparable to endoscopy. However, barium studies have the disadvantage that the biopsy specimen cannot be obtained and ulcers smaller than 5mm may not be detected on barium studies. CT san has no primary role in the detection of gastric ulcers. It is helpful in the detection of subphrenic collection that may occur after perforation of gastric ulcer. Ultrasound abdomen has no role in the detection of gastric ulcer but is useful in the detection of other causes of upper abdominal pain like gallstones, pancreatitis, and subphrenic, as well as other collections due to perforated gastric ulcer.

A 48-year-old woman underwent gastric bypass surgery. She followed the prescribed diet and lost approximately 100 pounds in 18 months. She presents with numbness in her feet, and blood tests reveal a deficiency in 1 vitamin. Based on these observations, this woman is most likely deficient in what vitamin? Answer Choices 1 Biotin 2 Thiamine 3 Vitamin B12 4 Vitamin D 5 Vitamin K

Vitamin B12 The gastric bypass procedure bypasses the duodenum and much of the jejunum and can lead to malabsorption problems, particularly of vitamin B12, iron, folate, and calcium. The gastric bypass procedure done on morbidly obese patients is an operation that makes the stomach smaller and allows food to bypass part of the small intestine. This bypass of the intestine allows fewer calories to be absorbed, resulting in weight loss, but can also lead to insufficient absorption of some needed nutrients. The deficiency in vitamin B12 leads to problems associated with numbness and tingling of the hands and feet, weakness, fatigue, and anemia. Vitamin B12 is normally absorbed from the digestive system after it binds to a protein called intrinsic factor. An individual lacking intrinsic factor can also develop vitamin B12 deficiency. Vitamin B12 is required for 2 reactions in humans: the methylation of homocysteine to form methionine and the conversion of methylmalonyl CoA to succinyl CoA. The metabolism of vitamin B12 is tied to folic acid metabolism; therefore, a deficiency in vitamin B12 can lead to a metabolic deficiency of folic acid. This lack of usable folic acid leads to deficiencies in purine and dTMP synthesis. This in turn affects nucleotide synthesis needed for DNA synthesis. Rapidly dividing cells, such as blood cells, are affected, leading to pernicious anemia in the cases of vitamin B12 deficiency. The absorption of biotin, thiamine, and vitamins K are usually less affected by the gastric bypass procedure. A deficiency in vitamin D is also possible but would not cause the numbness in her feet. Deficiencies in vitamin D would manifest themselves in bone and calcium problems.

A 32-year-old woman presents with a 1-month history of bleeding gums when brushing her teeth. She also reports that her wounds are taking longer than usual to heal. She is a stay-at-home mother and is breastfeeding her 6-month old twins. On examination, you note multiple splinter hemorrhages on her nails and ecchymoses over her lower limbs. Question What is the most likely diagnosis? Answer Choices 1 Vitamin A deficiency 2 Pyridoxine deficiency 3 Vitamin C deficiency 4 Niacin deficiency 5 Vitamin E deficiency

Vitamin C In cases of vitamin C (or ascorbic acid) deficiency, patients can present with bleeding tendencies (as a result of weakened capillaries) and impaired wound healing due to impaired formation of connective tissue. On examination, the gums may be swollen and friable; the teeth may be loose. There may also be multiple splinter hemorrhages on the nails and ecchymoses, especially over the lower limbs. Causes include inadequate dietary intake and certain conditions, such as pregnancy and lactation, which increase vitamin C requirements. Dietary sources of vitamin C include citrus fruits, such as oranges, lemons, and tangerines, as well as tomatoes and potatoes. Vitamin E deficiency may cause a hemolytic anemia in premature infants. Laboratory investigations reveal low plasma tocopherol levels, a low hemoglobin level, reticulocytosis, hyperbilirubinemia, and creatinuria. Causes of vitamin E deficiency in premature infants include limited placental transfer of vitamin E and the resultant low levels at birth combined with its relative deficiency in the infant diet. Dietary sources for older children and adults include wheat germ, vegetable oils, egg yolk, and leafy vegetables. In cases of vitamin A deficiency, patients can present with inability to see well in dim light or night blindness. There may also be conjunctival and corneal xerosis, as well as pericorneal and corneal opacities, and Bitot's spots. Bitot's spots are a collection of keratin appearing as triangular foamy spots on the conjunctiva. Patients may also have xeroderma, hyperkeratotic skin lesions, and increased susceptibility to infections. Causes include inadequate dietary intake and malabsorption. Dietary sources of vitamin A include fish, liver, egg yolk, butter, cream, dark green leafy vegetables, as well as yellow fruits and vegetables. Niacin deficiency causes pellagra, which is characterized by: A symmetrical dermatitis, usually on parts of the body exposed to sunlight Scarlet glossitis and stomatitis Diarrhea Mental aberrations, such as memory impairment, depression, and dementia. These may appear alone or in combination. Causes include inadequate dietary intake, especially in patients with corn-based diets or alcoholism. Dietary sources include legumes, yeast, meat, and enriched cereal products. In cases of pyridoxine or (vitamin B6 deficiency), patients can present with peripheral neuropathy, seborrheic dermatosis, glossitis, and cheilosis. Laboratory investigations reveal anemia with lymphopenia. Causes include malabsorption as well as medications, such as isoniazid and penicillamine. Dietary sources of vitamin B6 include liver, legumes, whole grain cereals, and meats.

A 64-year-old man presents with a history of progressive dysphagia to solids; recently, he has been having trouble with liquids. He also experiences occasional regurgitation of undigested food. His physical exam is unremarkable. A barium esophagram reveals a distinctive bird's beak appearance of the distal esophagus. Question What is the most likely diagnosis? Answer Choices 1 Gastroparesis 2 Gastroesophageal reflux disease 3 Mallory-Weiss syndrome 4 Achalasia 5 Candidal esophagitis

achalasia The correct answer is achalasia; it often presents with progressive dysphagia to liquids and solids as well as complaints of regurgitation of undigested food. Classic radiographic findings include a bird's beak appearance in the distal esophagus, demonstrating the narrowing of lumen. Gastroparesis is delayed gastric emptying, not an esophageal disorder that would cause the progressive dysphagia noted by the patient. The vagus nerve is not functioning properly in these cases. Gastroesophageal reflux disease can cause dysphagia, but it is not typical; this condition causes regurgitation of undigested food and does not have the classic appearance on esophagram. Mallory-Weiss syndrome presents typically with hematemesis, typically due to forceful vomiting or retching, which causes tears in the esophagus. It is associated with alcoholism. Candidal esophagitis is a fungal infection of the esophagus often seen in immunocompromised patients, such as those who are HIV infected. It presents with progressive dysphagia, but oral thrush is often present in these patients, and an esophagram will not show the classic appearance of achalasia.

Early one afternoon, a male adolescent presents with abdominal pain, nausea, and vomiting. The pain has been worsening since the onset of symptoms in the morning. There is no known gastrointestinal disease in the history; no one in the immediate environment has one either. Physical examination finds no abdominal tenderness, but Psoas sign and tenderness on rectal examination are detected. Temperature and pulse are slightly elevated. Skin turgor is reduced, and there is a 10 mm Hg drop in postural blood pressure. Laboratory studies find 18,000 white blood cells per microliter. What is the most likely diagnosis? Answer Choices 1 Acute mesenteric lymphadenitis 2 Acute appendicitis 3 Salmonella gastroenteritis 4 Meckel's diverticulitis 5 Regional enteritis

acute appendicitis The course and signs of the disease indicate appendicitis. The lack of abdominal tenderness and positive rectal examination indicate inflammation of retrocecal or pelvic appendix. Salmonella gastroenteritis would likely affect other persons in the child's environment. Regional enteritis is associated with a prolonged history. Acute mesenteric lymphadenitis poses a differential diagnostic challenge more frequently among children than adults. The diagnosis is impossible clinically, although the temperature tends to be higher and the pain is more diffuse. Culture of mesenteric nodes and serologic titers confirms Yersinia infection in some patients. Meckel's diverticulitis is rare, but it is impossible to distinguish from appendicitis. Considering the risk of perforation and limited observation, if unavoidable, overdiagnosis is preferred in cases of suspected appendicitis.

A 48-year-old Caucasian woman with a chronic history of inability to tolerate oral intake is admitted to the hospital for J-tube placement. The patient also complains of a rash that she has developed on her upper extremities. Examination reveals a ring of hemorrhage around hair follicles in the upper extremities. What is the most likely etiology of the rash? Answer Choices 1 Niacin deficiency 2 Cobalamin deficiency 3 Biotin deficiency 4 Ascorbic acid deficiency 5 Riboflavin deficiency

ascorbic acid deficiency Explanation The correct answer choice is ascorbic acid deficiency. This patient has scurvy due to ascorbic acid or Vitamin C deficiency. Patients with scurvy typically report a history of a poor diet (tea and toast), or in this case, malnutrition secondary to a chronic inability to tolerate oral intake of foods. Patients with scurvy also present with skin ecchymosis and the characteristic perifollicular hemmorhage. Note that lysyl oxidase, an important enzyme involved in cross-linking collagen, utilizes Vitamin C. Niacin deficiency usually presents as the 3 D's: diarrhea, dermatitis, and dementia. Patients on corn diets or those with an inability to reabsorb tryptophan (Hartnup disease) present with this condition. Cobalamin deficiency presents with megaloblastic anemia. Patients may also present with neurologic disease (subacute combined degeneration). Biotin deficiency presents with dermatitis, alopecia, and lactic acidosis. Riboflavin deficiency presents with cheilosis, angular stomatitis, and glossitis.

An 18-month-old boy presents with a 1-day history of colicky abdominal pain and blood in the stools. He had been playing normally until the onset of his symptoms. According to his parents, he has vomited several times and has been febrile. The infant has been lethargic for 1 hour. No history of accidental ingestion of drugs or alcohol was elicited. Past medical history is unremarkable. He is on no medications and has no known drug allergies. Physical exam shows a blood pressure of 110/76 mm Hg, pulse of 126 BPM, and a respiratory rate of 20/min. HEENT is within normal limits and his chest is clear with no murmurs, rubs, or gallops in the heart. Rate and rhythm are regular. His abdomen is soft; there is tenderness in the right upper quadrant, diminished bowel sounds, and an ovular mass palpated in the right upper quadrant. Lab results show normal electrolytes and CBC; the drug screen is negative. The infant is given intravenous fluids and nasogastric decompression is done. Question What investigation will help confirm the diagnosis? Answer Choices 1 Barium enema 2 Plain radiograph of abdomen 3 Upper GI endoscopy 4 Colonoscopy 5 CT scan of the abdomen

barium enema Intussusception, in which a part of the bowel telescopes into an adjacent part of the bowel, is the most common cause of bowel obstruction in children between ages 6 months and 3 years of age. Typical presenting signs include intermittent colicky, abdominal pain, vomiting, and bloody, mucousy stools sometimes described as "currant-jelly" in appearance. Some children may present with only irritability and progressive or alternating lethargy. On abdominal examination, a slightly tender, sausage-shaped palpable mass is characteristic. Most cases are idiopathic; however, it is felt that hypertrophied Peyer's patches in the ileum stimulate peristalsis and cause the intussusception. Other causes, usually found in older children, include polyp, lymphoma, intestinal parasites, Meckel diverticulum, intramural hematoma, and hemangioma. Ileocolic intussusceptions are by far the most common, but cecocolic and ileoileal presentations may occur. The telescoping of the bowel causes diminished venous blood flow resulting in edema and hemorrhage, leading to decreased arterial blood flow, ischemia, and infarction. Left untreated, death occurs in most cases. The diagnostic test of choice is to perform a barium enema; it helps in confirming the diagnosis because the enema shows a typical "cervix-like mass" or a "coiled spring" appearance on the evacuation film. Treatment by hydrostatic reduction with the same barium enema is successful in 50 - 90% of cases. Air contrast enemas are being used widely now, but barium enemas are still standard as well. If the intussusception is not reducible by the enema, then surgical treatment is indicated. Imaging with CT scan is usually not indicated for establishing the diagnosis of intussusception, unless a lead point is suspected. A lead point is found in only 10% of children less than 2 years old. Plain radiographs may be normal or show a pattern of small bowel obstruction with no gas in the right colon, indicating intussusception; however, it needs to be followed up with barium enema for confirmation. An upper GI endoscopy would be unlikely to demonstrate any pathology at the ileocolic level, and a colonoscopy would not be as helpful in either identifying the intussusception or providing therapeutic relief.

A 57-year-old African-American woman presents with retrosternal burning sensation. The symptoms started during the day several months ago, and lately they have been occurring at night. Heavy meals and sweets seem to trigger them. She also mentions that swallowing solid foods is uncomfortable and she needs to "wash" everything down with water. The burning starts in the epigastrium, which is sensitive to pressure; it radiates to the lower jaw, and it is accompanied by heartburn. The patient describes her job as very stressful, and she complains about never having enough time for herself. She is 165cm tall, weighs 95kg, her blood pressure reads 145/90, pulse is 75/min, and respiration rate is 23. A stool sample tested positive for hemoglobin. What step should be taken next in order to corroborate the suspected diagnosis? Answer Choices 1 ECG 2 Abdominal ultrasound 3 Test for Helicobacter pylori 4 Esophageal manometry 5 Gastric secretory testing and serum gastrin measuring 6 Barium swallow

barium swallow The symptoms described let you suspect GERD (gastroesophageal reflux disease). Diagnostic measurements depend upon symptoms. If symptoms are of short duration and there are no systemic manifestations, empiric treatment should be tried. With good response to that, chronic maintenance treatment should be considered. Poor response should lead to endoscopy of the upper gastrointestinal tract. With dysphagia, the 1st diagnostic step is barium swallow. If it is normal, treatment should be empiric; if it is abnormal, an endoscopy should be performed. If the endoscopy shows reflux, chronic treatment for GERD will be necessary. With an unclear diagnosis after history and endoscopy, if empiric treatment does not show any response or surgical treatment is considered, esophageal manometry with Bernstein test and 24-hour esophageal pH monitoring need to be performed. An ECG would be appropriate if you suspected angina pectoris as the cause of the symptoms. Angina pectoris, a common manifestation of coronary artery disease, can present as heartburn with radiating pain from the epigastrium to jaw, left shoulder, and/or left axilla. It can be triggered by physical and mental stress, cold temperatures, or heavy meals. One kind of angina, Prinzmetal's angina, typically occurs in bed at night; it is caused by coronary spasms, and it is not precipitated by cardiac work. Dysphagia, however, is not a symptom of angina. When there is no dysphagia, but there are chronic symptoms and/or signs of blood-loss (heme-positive stool, anemia, or hematemesis), an esophagogastroscopy would be proper. Helicobacter pylori (HP) plays a role in gastritis and peptic ulcers. There is no proof of any connection to GERD. Acute HP gastritis is characterized by epigastric pain, nausea, and vomiting. Ulcus duodeni classically presents with burning epigastric pain 1 - 3 hours after meals and at night. It tends to wax and wane over months. Additionally, ulcer patients may present with hemorrhages. Esophageal manometry, which measures intraesophageal pressure, is performed if a patient with symptoms of GERD has a normal upper endoscopy after barium swallow or empiric treatment for GERD. Gastric secretory testing and serum gastrin measuring is indicated in patients with refractory ulcer disease; it is also indicated if Zollinger-Ellison syndrome (caused by a gastrin producing endocrine tumor, which is usually located in pancreas or duodenum) is suspected, or in patients who will undergo elective surgery for duodenal ulcers. Treatment of GERD First line lifestyle modification (avoid spicy foods and foods that delay gastric emptying, smaller meal sizes, weight loss, avoid lying down after meals Second line H2-receptor antagonist for 8 - 12 weeks Third line Proton pump inhibitors Fourth line Surgical fundoplication

A 53-year-old man presents with increased difficulty swallowing and occasional regurgitation of his meals. His symptoms have been occurring with greater frequency and severity over the last 4 months. He also gets some shortness of breath, but attributes that to his weight and lack of physical activity. His past medical history is remarkable for chronic heartburn, which he treats intermittently with over the counter antacids. He takes no regular medications, and he has no allergies. He has not had any surgeries. He is smoker, but he denies use of alcohol and drugs. He works as a building inspector, and he lives with his wife and children. The patient is obese, but the rest of his physical exam is normal. Blood tests, electrocardiogram, and chest X-ray are done in the clinic; they are normal. He is referred for endoscopy, and esophageal biopsy shows specialized intestinal metaplastic cells (of columnar epithelium). Question What is the medication of choice for this patient's condition? Answer Choices 1 Alendronate 2 Dicyclomine 3 Esomeprazole 4 Famotidine 5 Simethicone

esomeprazole This patient is presenting with Barrett's esophagus, which is a type of chronic esophagitis in which the normal squamous epithelium is replaced with columnar epithelium. Barrett's esophagus is a complication of chronic gastroesophageal reflux disease (GERD) and can develop into esophageal adenocarcinoma. Use of proton pump inhibitors (PPIs), such as esomeprazole, reduces the risk of cancer. In order to monitor for the development of cancer, a routine endoscopy should be periodically performed in patients with known Barrett's esophagus. Alendronate is a bisphosphonate; it is used for both treatment and prevention of osteoporosis. Alendronate can cause multiple gastrointestinal adverse effects, including esophagitis and esophageal ulcerations and strictures. This medication could dramatically worsen this patient's current condition. Dicyclomine is an anticholinergic medication that relaxes smooth muscle. It is used for spasms associated with irritable bowel syndrome. It does not have a role in treating GERD or Barrett's esophagus. Famotidine antagonizes H2 histamine receptors (H2 blocker). It is used in treating duodenal and gastric ulcers as well as GERD. H2 blockers are usually considered less potent than PPIs. PPIs are the treatment of choice for Barrett's esophagus. Simethicone is sold in various over-the-counter products for flatulence. It has no role in treating GERD or Barrett's esophagus.

A 53-year-old man presents with increased difficulty swallowing and occasional regurgitation of his meals. His symptoms have been occurring with greater frequency and severity over the last 4 months. He also gets some shortness of breath, but attributes that to his weight and lack of physical activity. His past medical history is remarkable for chronic heartburn, which he treats intermittently with over the counter antacids. He takes no regular medications, and he has no allergies. He has not had any surgeries. He is smoker, but he denies use of alcohol and drugs. He works as a building inspector, and he lives with his wife and children. The patient is obese, but the rest of his physical exam is normal. Blood tests, electrocardiogram, and chest X-ray are done in the clinic; they are normal. He is referred for endoscopy, and esophageal biopsy shows specialized intestinal metaplastic cells (of columnar epithelium). Question What recommendation would best prevent complications from this patient's current condition? Answer Choices 1 Avoidance of antacids 2 Referral for fundoplication 3 Regular exercise 4 Use of proton pump inhibitors 5 Weight loss

use of ppi This patient is presenting with Barrett's esophagus, a type of chronic esophagitis in which the normal squamous epithelium is replaced with columnar epithelium. Barrett's esophagus is a complication of chronic gastroesophageal reflux disease (GERD) and can develop into esophageal adenocarcinoma. Use of proton pump inhibitors (PPIs) reduces the risk of cancer. In order to monitor for the development of cancer, a routine endoscopy should be periodically performed in patients with known Barrett's esophagus. While the antacids are not necessarily adequate to control the GERD and damage to this patient's esophagus, avoidance of antacids will have no role in prevent subsequent Barrett's esophagus complications, such as adenocarcinoma. While the acid reflux appears to be a major mechanism for damage to the esophageal tissue, anti-reflux surgeries do not appear to prevent complications from Barrett's esophagus and subsequent development of adenocarcinoma. This patient does not need referral for fundoplication (surgical 'wrapping' of the stomach around the esophagus). Regular exercise would be helpful for this patient in general terms for cardiovascular health and weight reduction. However, exercise does not play a significant role in reducing risks for Barrett's esophagus complications. Obesity is a risk factor for development of Barrett's esophagus. (Other risk factors include male gender, smoking, and especially chronic GERD.) Once Barrett's esophagus has developed, however, weight loss does not dramatically alter the risk of complications, such as adenocarcinoma. Weight loss should be recommended for any obese patient, but the PPIs are the best approach to reduce complications from his Barrett's esophagus.

A 22-year-old woman presents with a history of chronic diarrhea. She gives a history of large volumes of watery fecal output that is non-bloody and can be easily flushed; the diarrhea is painless and persists with fasting. The patient's mother complains that she eats less and has lost weight. She has no history of fever, flushing, wheezing, intolerance to heat/cold, or infection. Her family history and menstrual history are insignificant. On examination, her weight is 130lb; height is 5 feet 5 inches; pulse is 80/min; BP is 100/74mmHg; and temperature is 98.8°F. The tongue is dry, but the rest of her physical examination is within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Carcinoid tumor 2 Laxative abuse 3 Celiac disease 4 Hyperthyroidism 5 Inflammatory diarrhea

laxative abuse The most likely diagnosis is laxative abuse. Large volumes of watery fecal output that is non-bloody, painless, and persists with fasting suggests secretory diarrhea that can result from use of stimulant laxatives like senna, bisacodyl, or castor oil1. The patient is young, dehydrated, and based on her symptoms, is likely taking laxatives to lose weight and get rid of unwanted calories. There are no signs and symptoms of other causes of secretory diarrhea, such as carcinoid syndrome, and the rest of the options do not have conditions that cause secretory diarrhea. Many patients might not admit the use of laxatives to lose weight. Carcinoid tumor can cause secretory diarrhea1, but it is unlikely in this patient; she has no associated symptoms, such as episodic wheezing or flushing. Hyperthyroidism results in diarrhea due to dysmotility1. However, the patient does not have any symptoms of hyperthyroidism, such as unexplained weight loss or heat intolerance. Inflammatory diarrhea can be ruled out in this patient; there is no fever or signs of inflammation or bloody stools. Celiac disease causes diarrhea due to mucosal malabsorption. Patients present with multiple nutritional deficiencies and fatty diarrhea, which are not present in this patient, making this diagnosis unlikely1.

A 28-year-old man presents for a barium enema; he has a 6-month history of abdominal cramping, pain, tenesmus, bloody diarrhea, and painful urgency. He also reports arthralgias, but denies a history of traveling abroad or the use of antibiotics. On physical exam, he has indurated and painful erythematous plaques and nodules on both shins. An abdominal exam reveals a mild tenderness in the lower left quadrant (LLQ). Stool exam is positive for occult blood and negative for ova and parasites. Lab analysis reveals mild leukocytosis, microcytic anemia, positive p-ANCA antibodies, and elevated ESR. What would be the most likely result of a barium enema? Answer Choices 1 Apple core appearance 2 Cobblestone appearance 3 Lead pipe appearance 4 String sign 5 Thumb printing

lead pipe appearance on barium enema Lead pipe colon is the appearance on barium enema of a foreshortened, narrow colon with loss of redundancy and haustral markings. This sign is specific for ulcerative colitis (UC), an inflammatory disease of the rectum and colon. The peak incidence of UC is around 25 to 45 years. P-ANCA antibodies are associated with UC. Iron deficiency can lead to microcytic anemia. Common extra intestinal manifestations of UC are erythema nodosum (described as erythematous plaques and nodules on pretibial areas), arthritis, pyoderma gangrenosum, uveitis, episcleritis, and sclerosing cholangitis. Toxic megacolon is a complication of UC characterized by the dilation of the colon; there is a risk of perforation. There is an increased incidence of colon cancer (10%) after 10 years of this disease. The inflammation involves the mucosal tissues only, which are friable and show ulcerations on colonoscopy. There is also a characteristic continuous involvement and pseudopolyp appearance caused by mucosal regeneration. Sulfapyridine, mesalamine, corticosteroids, 6-mercaptopurine, and azathioprine are used for treatment. Colectomy is curative and is indicated for intractable disease, or in the case of dysplasia. An apple core appearance on barium enema is seen in patients with colon cancer. This sign refers to the shouldered margins of the stricture caused by the neoplasmic invasion. A cobblestone appearance and string sign are characteristic for Crohn's disease, another inflammatory disease of the digestive tract. The cobblestone appearance refers to the discontinuous areas of inflammation separated by healthy bowel. String sign, seen in the small bowel series, is the appearance caused by stricture areas. Thumb printing is a radiological sign seen in ischemic colitis, a disease most likely found in elderly patients with left lower abdominal pain and gross rectal bleeding.

A 66-year-old man with a history of obesity and hyperlipidemia presents with an 8-month history of progressing "burning in his chest". This sensation is noted in the midline of his chest, and it is provoked when he bends over, wears tight clothing, after he eats a large meal, and when lying supine. He denies any chest pressure, cough, shortness of breath, palpitations, dizziness, lightheadedness, and diaphoresis. His physical examination is unremarkable. An upper endoscopy is performed, which reveals the attached image. Question What is the preferred pharmacotherapeutic intervention for this patient? Answer Choices 1 Omeprazole 2 Nystatin 3 Cisapride 4 Cimetidine 5 Sucralfate

omeprazole The correct response is Omeprazole. This patient's presentation is most consistent with gastroesophageal reflux disease (GERD). Previously, histamine-2 receptor antagonist (H2RA) therapy was recommended as the initial treatment for esophagitis associated with GERD; however, newer evidence in cost-effectiveness analysis and symptomatic relief suggests proton pump inhibitors (PPIs) (such as omeprazole, pantoprazole or lansoprazole daily for 4 - 8 weeks) to be superior to ranitidine, cimetidine, and placebo. This patient is not experiencing fungal esophagitis (which is most commonly caused by Candida albicans). Medical therapy includes topically active agents, such as nystatin or clotrimazole. Oral amphotericin B, fluconazole, or itraconazole are also useful. Gastroprokinetic agents, such as metoclopramide or cisapride, and sucralfate, a coating agent, are less effective, but they may be useful in selected patients or as second-line agents. Cisapride is only available through an investigational limited-access program because of its potential for risk of serious cardiac arrhythmias and death.

A 47-year-old man presents with abdominal pain and difficulties breathing. He has a history of alcohol abuse and confirmed cirrhosis of the liver. On examination, you see a malnourished, jaundiced patient with a distended belly. Percussion of the abdomen reveals a huge amount of fluid and wave sign. What is the primary cause of the ascites? Answer Choices 1 Increased albumin production 2 Increased ammonia production 3 Portal hypertension 4 Decreased fluid intake 5 Blockage of the common bile duct

portal hypertension In cirrhosis the fibrotic changes in the liver tissue increase the resistance to blood flow through the organ and this results in increased portal pressure. The lesion is intrahepatic and sinusoidal. Hepatic synthetic failure causes hypoalbuminemia and decreased albumin production, which leads to reduced portal oncotic pressure in cirrhotic patients. Ammonia levels may be elevated, but elevated levels do not cause ascites. Ammonia is a highly toxic metabolic product of the urea cycle. The urea cycle is the only major pathway to remove waste nitrogen, and it usually gets converted to non-toxic urea in the liver. Increased portal pressure, reduced portal oncotic pressure, and elevated aldosterone level with sodium retention cause ascites. Decrease in fluid intake is actually one of the therapeutic strategies for ascites. Blockage of the common bile duct results in jaundice, but it has nothing to do with the development of ascites.

A 53-year old-man presents with a history of indolent, dull pain in his rectal area; it is associated with pruritus. The pain is increased upon movement, defecation, and prolonged sitting. He has experienced constipation and describes his stools are described as "hard", but they retain their normal brown color without evidence of blood. He denies ever having had these symptoms before. He denies any sexual contact, drug use, or fever, chills, or other gastrointestinal symptoms. Upon inspection, erythema is observed, and a digital rectal exam reveals a fluctuant, tender, and indurated mass, which is seen in the attached image. Question What is the most likely diagnosis? Answer Choices 1 External hemorrhoid 2 Rectal fistula 3 Acute proctitis 4 Rectal abscess 5 Necrotizing fasciitis

rectal abscess This patient's presentation is most consistent with an anorectal abscess. Perirectal abscesses are associated with indolent, dull perirectal pain that is exacerbated by movement and increased perineal pressure from sitting or defecation. There may be associated pruritis. Those with an ischiorectal abscess often present with systemic fevers, chills, and severe perirectal pain and fullness consistent with the more advanced nature of this process. External signs are minimal and may include erythema, induration, or fluctuance. Physical examination demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice. On digital rectal examination (DRE), a fluctuant, indurated mass may be encountered. The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse, with rectal bleeding being the most common presenting symptom. An anal fistula is an inflammatory tract between the anal canal and the skin. A patient with an anal fistula may complain of recurrent malodorous perianal drainage, pruritus, recurrent abscesses, fever, or perianal pain due to an occluded tract. Inflammation of the mucosal lining of the rectum is defined as proctitis. The presentation includes persistent bright red rectal bleeding, a decrease in stool volume and an increase in mucoid consistency, tenesmus, fecal urgency or constipation, and abdominal cramping. Necrotizing fasciitis is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. It may be caused by aerobic, anaerobic, or mixed flora bacteria. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area. The hallmark symptom of necrotizing fasciitis is intense pain and tenderness over the involved skin and underlying muscle. Pain usually develops prior to other symptoms, such as fever, malaise, and myalgias. Other findings include edema extending beyond the area of erythema, skin vesicles, and crepitus.

A 45-year-old man presents with hematemesis. He has had 2 episodes of vomiting 'coffee-ground'-appearing material; the vomiting began 45 minutes prior to presentation. Additionally, he reports passing black, sticky stools for the past 3 or 4 days. Past medical history is positive for occasional headaches; they have been coming more frequenly lately. Social history reveals alcohol use (1 case of beer each weekend) and tobacco (1 pack per day). Medications include ibuprofen as needed for headaches; he has been taking 800 mg 3 times a day for the past week. You place a nasogastric tube and find bright red blood that fails to clear with saline irrigation. Hemoglobin is 8.9 g/dL. Evaluation of his blood pressure and pulse reveals orthostatic changes that resolve with an intravenous fluid bolus of 500 cc of Lactated Ringer's solution. What should you do next? Answer Choices 1 Transfuse 2 units of packed red blood cells and recheck CBC in 8 hours 2 Check serum for Helicobacter pylori antibody 3 Order a double contrast barium swallow to evaluate for a gastric ulcer 4 Refer for emergency upper endoscopy 5 Discontinue his ibuprofen use and encourage cessation of alcohol and tobacco

refer for emergency endoscopy He should be referred for an emergency upper endoscopy. This patient is most likely bleeding from a gastric ulcer. His recent NSAID use, as well as his alcohol and tobacco habits, make him at risk for peptic ulcer disease. His symptoms of melena and hematemesis, along with his anemia, make the diagnosis quite straightforward. It appears that this patient is still actively bleeding based on the results of the nasogastric tube irrigation; therefore, the priority should be getting the ulcer to stop bleeding. Upper endoscopy should be performed so that the bleeding site can be identified and treated with electrocautery, coagulation, or injection of epinephrine or a sclerosing agent. If the bleeding cannot be stopped with endoscopic interventions, angiographic embolization should also be tried. If these interventions do not succeed, the patient has rapid deterioration, or if he requires more than 6 units of blood in a 24-hour period, then emergency surgery may be indicated. The other choices are not the best options for immediate management. This individual cannot be followed simply with transfusions and serial CBC's because he appears to still be actively bleeding. Helicobacter pylori infection may very well be playing a part in the etiology of this man's ulcer, but evaluation for H. pylori can be done with a biopsy at the time of his endoscopy; it will not help in his immediate management. A barium esophagram will not identify actively bleeding ulcers and cannot treat active bleeding. While NSAID, alcohol, and tobacco use may have precipitated this man's GI bleed, counseling about his use of these substances will not sufficiently treat his immediate bleed.

A 52-year-old Caucasian woman presents with a 2-week history of rectal bleeding. Over the last 3 months, she has become progressively more tired, and could no longer play tennis on weekends. She denies diarrhea, abdominal pain or tenesmus. Her past medical history includes peptic ulcer disease 5 years ago, treated with an anti-H.pylori scheme and which has not recurred. Her vital signs are stable, and the physical examination shows no abnormalities. A CBC shows the following: Ht: 28% Hb: 8.8 mg/dl MCV: 82 fl Leukocytes: 8.100/mm3 w/ normal differential An upper endoscopy is normal except for a duodenal ulcer scar without signs of active ulceration, and a repeat colonoscopy is normal. Question What is most likely to identify the source of bleeding? Answer Choices 1 Celiac angiography 2 Computed tomography of the abdomen 3 Wireless capsule endoscopy 4 Push enteroscopy 5 Biopsy of the healed ulcer bed 6 99mTc scan 7 Small bowel follow-through99mTc scan

wireless capsule endoscopy Wireless capsule endoscopy is performed by ingestion of a battery-powered capsule containing a camera and a transmitter. The capsule transmits images to sensors outside the patient during its transit in the gastrointestinal tract. Indications for capsule endoscopy are still evolving, but several series have shown that capsule endoscopy is more sensitive than small bowel radiography or push enteroscopy for locating the source of small-bowel bleeding. The most common etiologies of bleeding in this region are angioectasia and Crohn's disease. Several other small bowel lesions, such as tumors (leiomyoma, lymphomas, carcinoids, or carcinomas), varices, and polyps, have also been described. An important concern is the possibility of capsule impaction and small bowel obstruction. Some centers are reluctant to perform capsule endoscopy in patients with partial or intermittent obstruction of the small bowel. However, capsule impaction may reveal the site of a lesion and allow its surgical removal, obviating the need for intraoperative enteroscopy. Other relative contraindications are incapacity of cooperating with the examination (e.g. dementia), swallowing disorders, esophageal stricture, gastroparesis, and poor surgical risk. In patients with obstruction or gastroparesis, the examiner may place the capsule endoscopically. This patient has no signs of ulcer activity. Therefore, biopsy of the duodenal scar is not indicated. A 99mTc scan is the test of choice for Meckel's diverticulum, a remnant of the embryonic omphalomesenteric duct found in 1.5% of the general population. Its most common location is the antimesenteric border of the mid-to-distal small bowel. Some diverticula contain ectopic, acid-producing gastric mucosa. Therefore, they can ulcerate and bleed. Rectal bleeding caused by Meckel's diverticulum is often maroon or brick-red in color, and its incidence decreases with age. Therefore, this diagnosis is unlikely in this case. Angiography can be used if other less invasive procedures (i.e. small bowel radiography, push enteroscopy, or small bowel radiography) are non-diagnostic. Computed tomography is not indicated in the absence of other symptoms indicating a specific etiology (e.g. a palpable mass or suspicion of pancreatic disease). Of note, colonoscopy after rapid oral purging has emerged as the procedure of choice for the evaluation of acute lower GI bleeding, and it also provides a means for therapy. Scintigraphy and/or angiography also play important roles in diagnosis and embolization when colonoscopy reveals negative findings or when it is not feasible.