GI Uworld

Primary scloersing cholangitis is associated with which IBD?

- ulcerative colitis, crypts, PSC is often asymptomatic but may present with fatigue and pruritus - continued bile duct destruction leads to cholestatic complication, end stage liver disease and portal hypertension

52M abnormal liver chemistry. fatigued and pedal edema after prolonged standing. IV drugs past. palmart erythema and multiple spider angiomas. Hep C virus antibody positive. Hep C RNA 1 million copies. abdominal ultrasonography reveals coarse, nodular appearing liver with no masses mild ascites and splenomegaly. uper GI endoscopy demonstrates medium sized but non bleeding esophageal varices. best management for this pt?

- treat with nonselective beta blockers which decrease progression to large varices.

64M diarrhea and intermittent abdminal cramps for last 6 weeks. 4,5 bowel movements everyday and stool contains blood and mucus. poor appetite fatigue lost weight. right knee swelling tenderness responsed to ibuprofen.

- ulcerative colitis

44F 2 months of low grade fever abdominal pain and bloody diarrhea. 2 days her symptoms have increased. lost weight over 4 weeks. 102F. pale and dry mucous membranes. abd exam shows diffuse tenderness and distension. HIV is negative. Xray of abdmen is shown.

- toxic megacolon

what is Transjugular intrahepatic portosystemic shunting?

- transjugular- intrahepatic portosystemic shunt gets the blood straight from the portal system into the IVC - protein restriction

69M 3 days of pain in lower left abdomen. constant over the past day. nausea fever past two days and frequent urination. chronic constipation. 101.3. tender palpation in LLQ. bowel sounds are present. What's the next test?

- ABdominal CT scan with contrast ACUTE DIVERTICULITIS - to check out acute diverticulitis. chronic constipation and low fiber, high fat are risk factors. leukocytosis.

65F GI melana in last two weeks. normal bowel movements. systolic ejection murmur in right second intercostal space. BUN/Cr is over 20/1. unremarkable colonscopy in asecnding colon due to suboptimal bowel prep. What's the cause?

- Angiodysplasia NOT diverticulosis - painless GI bleeding, dilated submucosal veins and AV malformations. frequently diagnosed in pts w/ advanced renal disease and willebrand disease possibly due to bleeding tendency. aortic stenosis, possibly due to acquired vW factor deficiency

23M frequent foul smelling bulky stools and weight loss over last 6 months. 10 lb lost over past 3 months. poor energy and occasional joint pains. mild pallor.A Anti tissue transglutaminase antibody is negative.

- Anti tissue transglutaminase (first test) - atiendomysial antibody. IGA antigliadin antibody. - most accurate diagnostic test for celiac disease is a small bowel biopsy, flattening of the villi

62M anorexia, fatigue, and 20lb weight loss over past 6 months. diverticulosis external hemorrhoids. atenolol and aspirin. icteric and skin is jaundiced. total bili is HIGH. alk phos is HIGH. AMA negative. ultrasound demonstrates mild dilation of common bile duct.

- CT scan for abdominal

54F worsening epigastric pain last two months. worse at night. intermittent to constant and radiates to back. 15 lb weight losss. improvement with pancreative enzymes. BMI 21. What test to perform?

- CT scan is best - worsening epigastric pan and wieght loss suggests pancreatic cancer - gnawing abdominal pain radiating to back.

45M for evaluation of chronic diarrhea. lost 15lbs in past year. no blood in stool. fecal fat content. 25g oral D xylose solution and urinary excretion at 5 hours is 1.2 g. 4 weeks of treatment with rifaximin, the D xylose test is repeated and urinary excretion at 5 hours is 1.3 what's the diagnosis?

- Celiac's disease problem with malabsorption and is characterized by atrophy of intestinal villi in proximal small bowel due to exposure to guten containing wheat products. - the D xylose should normally be absorbed in prox small bowel into kidneys and peed out. low levels in urine means malabsorption

34M foul smelling anal discharge and perianal discomfort for weeks. recurrent anal fissues. takes fiber stool softer and topical analgesic. ocassional canker sores and recurent abdominal pain and diarhea. attributes to use laxataives. 100.4 RLQ pain. large posterior tage on perianus. fistula anterolateral to anus is draining whitis material. what next?

- Crohn's disease will show transmural damage -

52F intermittent RUQ pain and N. elective cholecystemctomy year ago. 30-60 min pain. high conjugated bili. high alkphos. ultra sound reveals mild dilated of common bile duct. pancreas normal. Next best step?

- ERCP is the next best thing - post cholecystectomy syndrome

Lynch Syndrome (HNPCC)

- Familial Adenomatous Polyposis Syndrome (FAP) 100% will develop colon cancer without resection - Hereditary Nonpolyposis Colorectal Cancer (HNPCC) where a person has a single polyp that can turn to cancer Lynch Syndrome I (HNPCC I) - autosomal dominant predisposition to colorectal CA right sided predominance (70% proximal to splenic flexure) Lynch Syndrome II (HNPCC II) - same features of Lynch I plus extra-colonic cancers especially endometrial carcinoma carcinoma of ovary, small bowel, stomach, pancreas transitional cell CA of the ureter and renal pelvis

51M difficulty swallowing solids but not liquids. barret's esophagus 6 months. GERD. heart burn resolved 3 months after diagnosis. BMI 38. symmetric circumferential narrowing affecting the distal esophagus.

- GERD and symmetric esophageal narrowing suggests esophageal peptic stricture - starts with just solid foods without anorexia

How can you confirm for hep B?

- HbsAg and IgM anti-HBc - HBsAg 4-8 weeks, IgM anti-HBc appear shortly after, which develop elevations in hepatic aminotransferases levels. disappearance of HBsAg and appearance of anti-HBc is called the window period. IgM anti-HBc is likely the only thing that will be detectable.

54M 6 months of fatigue anorexia and weight loss. pants getting tigether and socks leave imprints. bilateral gynecomastia and spider angiomas on upper trunk, cardiac examination reveals normal heart sounds w/o murmurs. decreased at bases.

- IV drug use causes cirrhosis with infection of viral hepatitis. -

35F f/u genetic testing Lynch Syndrome. Pap normal. mother has colon cancer. uncle cancer. 49. first cousin colon cancer at 36. which type of cancer is she at highest risk for?

- Lynch Syndrome, highest risk for colorectal cancer, ENDOMETRIAL CANCER, ovarian cancer - endometrial biopsy cancer screening with annual endometrial biopsy should begin age 30-35.

68M coffee ground emesis followed by lightheadedness. black tarry stools for past few days. ibuprofen. 2 hyperplastic colon polyps. BUN/Cr elevated. what to give him in addition to fluid?

- RBC transfusion threshold - RBC transfusion is recommended in acute GI bleed for Hg under 7. higher threshold if they are unstable.

in addition to antibiotic use, what else predisposes to C diff?

- common risk factors are advanced age, and gastric acid suppression (PPI)

20 2 month history of d. 4-6 movements per day. fecal urgency and abdominal cramps. bright red blood per rectum last two weeks. sigmoidoscopy demonstrates mild erythema involving rectum and idstal sigmoid.

- Ulcerative colitis which should screen for cancer, crypts, continuous - crohn's screen for sclerosing angitis

76M multifarct dementia, cough and low grade fever. pneumonia twice last year. difficulty swallowing and occasionally regurgitating undigest food.long histroy of HTN chronic AF. 101.3. 150/93foul smelling breath and fluctant mass in left neck. CXR infiltrate without cavitation in right lower lung field. admitted sputum and blood cultures are sent and antibiotics are startd. most appropriate next step?

- Zenker's diverticulum, most common in elderly patients, particularly men - contrast esophagram, diverticulum is diagnostic test of choice.

From what anatomical point does melena typically begin?

- above the ligament of treitz

56M fever on third postop. 102F. RUQ tenderness to mild palpation. bowel sounds decreased. increasd Alk phos and amylase cause?

- acalculous cholecystits - severe trauma, extensive burns, recent surgery, prolonged fasting or critical illness.

What are characteristic signs of acute bacterial cholangitis, drug induced hepatotoxicity, metastatic colon cancer, polyarteritis nodosa, primary biliary cholangitis, primary sclerosing cholangitis?

- acute bacterial cholangitis - charcot triad (fever, RUQ pain, jaundice) - metastatic colon cancer - weight loss and hepatomegaly - polyarteritis nodosa - necrotizing vasculitis that affects medium sized arteries and presents with systemic symptoms (fever, malaise weight loss) neuropathy, arthralgias and renal disease - primary biliary cholangitis - middle aged women and no association with ulcerative colitis - primary sclerosing cholangitis - fatigue, pruritis

33M abd discomfort, N and 2V small amount of blood past hours. drank alcohol and used coke last night. terrible headache, improved after aspirin tablets.reveals mild epigastric tendernes, no masses rebound or guarding. most likely cause of pts hematemesis?

- acute mucosal gastropathy - hemorrhagic lesions after exposure of gastric mucosa to various injurous agents after substantial reduction in blood flow. aspirin screws that up, coke causes vasoconstriction and alcohol damages mucosal injury

34M hospital w suddent onset of severe epigasric pain and vomiting. marked epigastric tenderness. bowel sounds decreased. crops of yellowred papules seen on extensor surfaces of arms and shoulders. alk phos high. lipase HIGH. what's the cause?

- acute pancreatitis due to high lipid profile

45M poor appetite and N for 3-4 weeks. heavy drinker. admitted for seizures but no medical follow up. icteric. liver enlarged. gall bladder not palpable. no signs of liver cirrhosis or H encephalopathy. no fever. normal BP. what's the cause and how would LFTs look?

- alcoholic hepatitis with jaundice, anorexia and tender hepatomegaly - most likely has alcoholic hepatitis - AST/ALT would be high with AST being double ALT but only in hundreds, not thousands. GGT would show drinking, and ferritin is high because acute phase reactant. AST/ALT increase because the alcohol causes deficienecy of pyridoxal 5' phosphate, and ALT enzyme factor. - in the thousands is when you have toxin induced damage

52F intense itching and fatigue. current med levothyroxine. hepatomegaly. no icterus or jaundice. bilateral xanthelasma and skin excoriations. HIGH cholesterol. high alk phos. RUQ normal commob bile duct. What test should you perform>

- antimitochondrial antibody is checking for PBC

83F 1 year history of progressive severe crampy abdominal pain that occurs immediately after she eats. pain is diffuse but more pronounced in the epigastric, frequent bloating and nausea and occasional diarrhea. 30lb weight loss. lost appetite. she suffered an inferior wall MI. treated with drug eluting stent. cause?

- atherosclerosis of mesenteric arteries.

Cholecystitis vs biliary colic

- biliary colic resolves within 4-6 hours and absence of abdominal tenderness fever and leukocytosis

36F severe epigastric and right shoulder pain 2 hours. emesis. unintentionally fasted all day and had cheeseburger 2 hours ago. prev episode but resolved in few hours. this one resolves after 4 hrs. best explanation?

- biliary colic secondary to gallstones - pain comes for gallbladder contraction, once fatty food passes rock comes down pain goes away

When to do a bronchoscopy, GI feeding tub placement, neck mass biopsy, upper GI endoscopy?

- bronchoscopy - obstructing mass that may be causing recurrent pneumonias - GI feeding tube placement - premature - neck mass biopsy - could cause - upper GI endoscopy - not the test of choice when attempting to diagnose ZD as it can be confusing or even risky if diverticulum itself is inadvertently cannulated during procedure

45M epigastric pain and D. endoscopy shows prominent gastric olds, 3 duodenal ulcers and upper jejunal ulceraiton. most approprite next step?

- check for serum gastrin concentration - over 1000pg/mL is diagnostic for gastrinoma - secretin stimulates the release of gastrin by gastrinoma cells, normal gastric G cells are inhibited by secretin,

42F 4 weeks of episodic upper abd pain. burning that waxes and wanes and associated with nausea. awakened her. bloating after meals. stool guiaic is postiive. cause?

- chronic discomfort intermittent and posprandial caused by dyspepsia. can also be caused by NSAID GERD and symptomaticinfection with H pylori. low income country with high prevalence

65F 2 m ho fatigue and dyspnea on exertion. microcytic anemia. stool guiaic test negative. what do you check for next?

- colonoscopy and endoscopy - not isotope labeled erythrocytes scintigraphy because first you have to look at age groups and specific predispositions. single negative FOBT should not exclude GI bleed. elderly should be scoped despite.

27F malaise anorexia and N few weeks. urine dark yellow. more moody. yellow sclera, spinder nevi uper torso, rigidty and remor at rest. slit lamp exam greenish brown deposits around corneas. hepatomegaly.

- compensated cirrhosis, not hemachromatosis - cirrhosis, neurospychiatric symptoms and kayser fleischer rings highly suggestive of wilson's disease (hepatolenticular degeneration) - liver function abnormalities, tremors, associated with fanconi syndrome,

Melanosis Coli

- dark brown discoloration of colon with pale patches of lymph follicles that can give appearance of alligator skin. may demonstrate the pigment in macrophages of lamina propria

Hepatorenal Syndrome

- decreased GFR, absence f shock proteinuria and other clear cause fo renal dysfunctiona nd failure to respond to 1.5 L saline bolus - results from renal vasoconstriction in response to decrased total renal blood flow and vasodilatory substance

what to do when you have esophageal dysphagia?

- determine if solids progressing to liquids = mechanical obstruction. determine if history of radiation, caustic injury complex stricture or surgery for esophageal laryngeal cnacer. If yes then barium swallow following possible endoscopy. If not, then upper endoscopy - if solids and liquids, then motility disorder

Difficulty initiating swallow vs difficulty swallowing?

- difficulty initiating = oropharyngeal dysphagia - difficulty swallowing = esophageal dysphagia

56M new onset lethargy and confusion. cirrhosis secondary to alcoholism. 100.4 asterixis. labored breathing. abd shifting dullness and diffuse tenderness. abd x ray reveals gas in small and large bowels w/o air fluid levels. most appropriate next step?

- do diagnostic paracentesis to check for spontaneous bacterial peritonitis and hepatic encephalopathy. fever and suble changes in mental status are most common symptoms. - if fluid is ascites fluid culture and neutrophil count >250

what anti seizure medication is most likely associated with acute pancreatitis.

- drug induced acute pancreatitis likely due to drugs, most likely valproic acid is commonly used antiseizure medication associated with acute pancreatitis. - drug induced pancreatitis is usually mild. CT should reveal swellin of the pancreas with prominent peripancreatic fluid and fat stranding, resolves with supportive care

H Pylroi diagnosis, what do you do next?

- endoscopy is or definitive diagnosis. only do if >55 with alarm symptoms. kinda overkill otherwise. - without alarm symptoms, urea breath testing, stool antigen testing is good enough. - failure of antibiotics and PPI should undergo endosopy

44M vague fatigue past 6 monhs. depression, dental abscess, onychomycosis. spider angioms on chest and dullness in flanks abd ultrasound reveals splenomegaly mild ascitic flid and echogenic shrunken liver. what test is bext next step?

- esophageal endoscopy not liver biopsy because

50F severeal month intermitttent substernal chest pain. difficuly swallowing both liuids and solids. no associated wieight loss or change in appeitite. sudden worsening of pain. normal MI exam. What is it/

- esophageal spasm which are uncoordinated simultaneous contractions of esophageal body. - esophagram corkscrew pattern. treat with ccb nitrates TCA

57M intermittent arthralgias for past 8 years. transiently elevated hepatic transaminase levels. episode of mild jaundice 2 years ago after having mitral valve replaced. daily takes warfarin. vesicles and erosion on dorsum of both hands. what's the disease?

- essential mixed cryoglobulinemia - clinical features of chronic hepatitis C intermittent elevations of transaminases and skin findings suggest porphyria cutanea tarda (fragile skin and photosensitivity, vesicles and erosions on the dorsum of hands - arthralgias - HCV strong correlation with HCV. 1/2 of pts with HCV have cryoglobulinemia - waxing and waning elevations

*Colon Cancer screening guidelines

- family history of CRC 40 years or 10 years before age of diagnosis in the relative, repeat 3-5 years - inflammatory bowel disease, begin 8 years post diagnosis (12-15 years if disease only in left colon) - FAP begin at age 10 colonoscopy every year - HNPCC egin at 20-25 every 1-2 years

Spontaneous bacterial peritonitis

- fever and change in mental status. paracentesis is test of choice if positive ascites fluid culture and neutrophil count >250

60M progressive lethargy. history of alcoholic cirrhosis. increasing abd distension and leg swelling. furosemide and spirnolacton helped. last two days he's been irritable and confused. slpet lots not eaten. 96/50 lethargic but arousable. dry. asterixis. low potassium what's the first concern?

- fix the potassium first - hepatic encephalopathy, cirrhosis has lethargy confusion and asterixis suggestive of HE. impaired central nervous system function. - diuretics therapy, poor oral intake led to low volume despite volume overload (edema). metabolic alkalosis associated with hypokalemia

44M extensive small bowel resection for Crohn's disease. on parenteral nutrition for two years. epigastric and RUQ pain. US shows gallstones. most likely cause of stones?

- gall bladder stasis predisposes to stone formation and bile sludging both which may lead to cholecystitis

42M fatigue and dark urine. uses IV drugs. sclera and skin icteric. high direct bilirubin. foul smelling stools. abd cramps, bloating. 3 days of ciprofloxacin did not help.

- giardia is like stool antigen - transmitted via water in rural areas and developing countries

53M two day history of right cal pain and swelling. worse with knee flexion. IV drug abusebacterial endocarditis and embolic stroke. wheelchair bound. abd distended with shifting dullness and a fluid wave suggesting ascites. hepatosplenomegaly. righ cal swollen and tender to palp. most likley cause?

- guy has liver cirrhosis likely caused by the hepatitis C from IV drug use. -

33F dull aching pain in RUQ abd several weeks. takes OCP. Hyperechoic lesion 7CM. what is it?

- hepatic adenoma

56M worsening confusion. forgetful and irritable past days. lethargic and disoriented. heavy drinker previously hospitalized for acute alcoholic pancreatitis. somnolent but speech slurred. abd moderately distended. asterixis (flapping hand).

- hepatic encephalopathy, give lactulose

What causes the confusion in hepatic encephalopathy? Metabolic alkalosis and hyokalemia?

- the neurotoxicity from ammonia in setting of impaired liver function

53F right sided abd pain starting 2 days ago. constant burning and severe enough to interfere with sleep. had chemo for breast cancer a year ago. lightly brushing skin to the right of umbilicus elicits intense pain. what other symptom is associated?

- herpes zoster - post chemo shingles can develop. pain from shingles may precede the onset of classic vesicular rash by several days, during which the diagnosis may not be obvious. triggered by physical stress. - post herpetic neuralgia

58M skin discoloration anorexia weightloss 3 months, dark urine and pale stools. BMI 32, hypertension and hyperlipidemia. Scleral icterus. no ascites, abdmiinal imaging will reveal which?

- intra and extrahepatic biliary tract dilation pancreatic cancer -

How do you tell pancreatic cancer at head of pancreas?

- jaundice caused by common bile duct obstruction, steatorrhea due to duct blockage

45M known cirrhosis due to hep C. abdominal discomfort and confusion. 95/60 and pulse is 100. distended abd ,leg edema, deep yellow discoloration of skin and sclerae. Na is 127. K 2.9. kidney dysfunction can be best corrected by?

- liver transplantation - hepatorenal syndrome. decrased GFR absence of shock, proteinuria and other clear cause of renal dysfunctiona nd a fialure to respond to 1.5 L normal saline

46M episodes of V which contained blood. 5 hours ago, fatty meal and several alcoholic drinks. enlarged hyperechoic liver and gallstones in gallbladder and the endoscopy revealed enlarged hyperechoic liver and gall stones in bladder. nasogastric suction returns to normal stomach contents mixed with bright red blood.

- mallory weiss tear due t suden inrease in intrabdominal pressure

40M 2 day history of retrosternal chest pain, pain with swallowing and epigastric burning. afraid to swallow. takes furosemide carvedilol spironlactone. linsopril and potassium chloride. soft holosystolic murmur. endoscopy reveals circumferential deep ulceration normal surrounding mucosa at the middle third of esophagus. Wht's the cause.

- medication induced esophagitis, direct effect of medication on esophageal mucosa. mucosal injury in pill esophagitis can be due to direct effect of certain medicaitons - antibiotics, antinflammatory agents, bisphosphnates

45M random high AST/ALT and BUN/Cr 20/1. but otherwise perfectly healthy. What to check for/

- meds or alcohol and other stuff intake

63M vague abdominal pain several weeks. fatigability. mildly istended belly and liver edge is hard. ankle edema. Hb low. MCV low. alk phos high. coagulation normal. small left sided pleural effusion. fecal occult blood positive. whats the cause?

- metastatic disease - abd pain, microcytic anemia, postive fecal hepatomegaly ard edge on liver typical features of GI malignancy. liver is most common site of metastasis in colon cancer. rando small pleural effusion should check for malig - CT abdomen with IV contrast to evaluate for malignancy -

63M anorexia and weight losss 2 months. HTN and tlatent tb 30yrs ago. mucosal pallor and mild hepatomegaly. fecal occult +. anemic/microcytic. Ultra sound solitary liver lesion 2X3. most likely diagnosis?

- metastatic disease is the most common cause of liver mass is much more than primary liver cancer. undiagnosed colorectal cancer.

What is the most important issue with zenker's diverticulum?

- motor dysmotility because it can cause tracheal compression, ulceration regurg. - upper sphincter dysfunction and esophagea dysmotility are beleived to cause ZD. image with barium esophagram and cricopharyngeal myotomy

Crohn's Disease

- mouth to anus, rectal sparing, skip lesions, non caseating granulomas, cobblestoning, transmural inflammation, creeping fat, perianal tags - treat with 5 aminosalicyclic acid drugs

Non alcohol fatty liver disease

- need to be fatty. BMI

46M sensation of RUQ fullness. obese since childhood. acanthosis nigricans over neck creases and hepatomegaly. negative hepatitis serology, AMA, ANA ceruloplasmin and transferrin saturation. what's the disease?

- non alcoholic fatty liver disease because hepatocellular disease in absence of viral hepatitis or autoimmune disease is most consistent. - features of metabolic syndrome, peripheral insulin resistance leading to increased peripheral lipolysis

25M 3 month history of abd pain and diarrhea. bowel movements occur 3 or 4 times a day. he has occasionally noticed blood in his stool. low energy. anterior uveitis 3 years ago. abdmen tender with active sounds. elevated ESR . He has crohn's, which supports this diagnosis?

- noncaseating granulomas -

65M 4 wk h/o weakness and vague postprandial epigastric pain, fecal occult blood test is +. GDE shows antral ulcer. consistent with adenocarcinoma. most appropriate next test?

- not H pylori but CT scan. - CT scan will help determine the stage at time of diagnosis

categories of watery diarrhea

- osmotic - non-absorbed and unmeasured osmotically active agents in GI tract. these ions result in elevated osmotic gaps. - secretory - - functional

Angiodysplasia

- painless GI bleeding, dilated submucosal veins is cmmon cause of recurrent. diagnosis made by colonscopy althought frequency missed. cauterize - venous bleeding, low volume

What as same pathogenesis as spider angiomas?

- palmar erythema

Zollinger Ellinson Syndrome symptoms? what should they be screeened for?

- pancreatic enzyme inactivation - lots of ulcers - gastrinoma is confirmed, MEN1 screening - CT MRI and somatostatin receptor scintigraphy can be used to identify pancreatic tumors and metastatic disease.

27M episodic abdominal pain. concentrated in epigastrium and gnawing quality. relived by eating. occasional dark stools. what's good for long term treatmnet?

- pantoprazole and antibiotics for h pylori

75M found unreponsive. CAD with stengin two years ago. hospitalized two months ago w/ pneumonia and upper GI bleeding. four blood transfusions. 70/40/120 resp 32 new right upper lobe infiltrate. BUN/Cr 51/2.1. AST/ALT 2720/2250. which is most likely accounts for abnormal liver function panel?

- this is caused septic shock and developed AST/ALT one day later. ischemic hepatic injury

42M recen emigration. N africa due to 1 month history of abd pain and watery diarrhea. skin rash last two months worsening with sun exposure. depressed recently and lost weight. latent tb taking isoniazid and pyridoxine. vvegetarian, mostly corn and cereal grains. pigmented scaly skin rash in malar distribution on face neck and back of hands. abdominal tenderness. What does he have?

- pellagra due to niacin deficiency and is characterized by 3 Ds. Dermatitis, diarrhea, dementia, death - dermatitis on sun exposed areas of body. rough hyperpigemented scaly skin - niacin comes from tryptophan, not absorbable in corn diet. - pellagra can also be seen in carcinoid syndrome (depltion of tryptophan) or hartnup disease (congenital disorder of tryptophan absorption). prolonged isoniazid therapy can interfere with metabolism of tryptophan.

45F asian bloating, farting abd cramp and explosive watery diarhea. ingesting dairy products. test results most likely be obsereved?

- positive hydrogen breath test

26F near syncope. had chronic diarrhea 10-12 per day. wakens her at night. hypokalemia and metabolic alkalosis. IV fluids and electrolyte supplements are started. scoping reveals dark brown mucosal pigmentation in pox colon. suspected?

- positive stool laxative - facticious diarhea, laxative abuse. watery, frequent and voluminous. nocturnal bowel movements and abdominal cramps are common accompanying sympoms. hypokalemia from increased loss of potassium in stool. this impairs chloride reabsorption and results in decreased chloride bicarbonate exchange, increasing serum bicarb causing metabolic alkalosis - melanosis coli

20M jaundice and dark urine. asymptomatic. recent immigrant. scleral icterus and jaundiced skin. positive for bilirubin and negative for urobilinogen. Normal AST/ALT and alk phos.

- positive urine bilirubin asssay reflects buildup of conjugated bilirubin. unconjugated form which undergoes hepatic conjugation. - unconjugated bilirubin is high insoluble so can not be excreted in urine. - urobilinogen excess is primarily recycled however higher then normal smounts excreted in feces or urine

62M 6-8 wks fatigue and jaundice. weight loss. mild N. alk phos HIGH. bilirubin HIGH conjugated.

- predominantly conjugated hyperbilirubinemia can be caused by many different things. increased bilirubin, production, decreased bilirubin uptake, abnormal bilirubin conjugation.

43F intense pruritus past 4 months. tried emollients and antihistamines, did not get any relief. felt extremely fatigued and frequently takes naps during daytime. refreshed after waking up and has no dyspnea or night time sleep problems. has the lipid eye thing (xanthelasma), mild hepatomegaly. positive antimitochondrial antibody assay.

- primary biliary cholangitis - malabsorption causing malabosrption with associated nutrient deficiencies and hepatocellular carcinoma. metabolic

42M progressive fatigue. recurrent episodes of abdominal pain and diarrhea associated with bloody stools. contigous proctocolitis with pseudopolyps mucosal ulcerations and crypt abscesses. 5 aminosalicylic acid and corticosteroid enemas helped. had extreme fatigue for past several months feeling drained. what's causing this

- primary sclerosing cholangitis, chronic progressive disorder of unknown etiology characterized by inflammation, fibrosis and stricturing of intra-hepatic and extra-hepatic bile ducts. - ulcerative colitis, - increased alk phos with increased LFTs

70M ER complaining of weakness dizzines and back pain. warfrarin for coagulation. irregular irregular. WBC high. hgb high. CT imaging, what is it?

- retroperitoneal hematoma due to the warfarin that he's on

28M chronic diarrhea. 5-6 nonbloody liquid bowel movements daily that awaken him at night. weight loss. occasional bloating. abd shot. bowel sounds active in all 4 quadrants. rectal exam. brown stool present and occult blood negative. gap between measured calculated stool osmolarity low.

- secretory diarrhea. after multiple abdominal surgeries - larger daily stool vlumes and diarrhea that occurs even during fasting or sleep. reduced stool osmotic gap <50 mOsm

42M s onset severe abd pain and 2vomit, 9/10 pain radiating to back. binge drink last night. 112/70 102. what's the next best step in management test wise?

- serum amylase and lipase testing pancreatitis - because uncomplicated pancreatits, do not need comfirmatory, but if unsure, then do CT

35F 3 days of progressive nausea anorexia, malaise abdominal pain and lethargy. chronic hep B history of IV use. 100.2 106/64 and pulse 114. mild hepatomegaly. markdly elevated ALT> and positive hep D. what is required to diagnosi acute liver failure?

- signs of hepatic encephalopathy - acute liver failure is defined by pt without cirhosis or underlying liver diease. severely elevated aminotrasnferases, hepatic encephalotphy signs and INR>1.5

52Mheavy smoker, drinker and coffee addict. diabetic 190. what interventions would have greatest impact on decreasing patients risk of pancreatic cancer?

- smoking for pancreatic cancer.

what is the combo of cocaine and opiate?

- speedball, which predisposes you to seizures and muscle pain

32M midline chest pain and diaphoresis of 4 hours. n/v/HIV. medication noncompliance, alcohol abuse, alcoholic hepatitis. cocaine. 100F low BP high pulse. injeted conjunctivae ad dilated pupils. widened mediastinum and moderate left sided pleural effusion. yellow exudate with high amylase. diagnosis?

- spontaneous esophageal rupture (boerhaave syndrome) - shows subcutaneous emphysema. XCR may reveal pneumomediastinum or unilateral pleural effusion. - exudative with low pH and high amylase due to saliva and high esophageal content.

45F abnormal liver chem. hypercholesterolemia and medication statin. Alk phos is high high AMA. RUQ shows no abnormalities. best next step in management.

- start urosdeoxycholic acid

35F 5month history episodic retrosternal pain that radiates to interscap. last 15 min. emotional stress or hot/cold food. she regurgitates food intermittently. EKG during pain is normal. sublingual nitro alleviates pain. stress ekg is normal.CXR, upper gi endoscopy and echo show no abnormalities. most appropriate next step?

- suggestive of diffuse esophageal spasm. resolution of her chest pain after taking nitro supports esophageal motility disorder such as diffuse esophageal spasm

67M acute onset upper abd pain associated with nausea and vomiting. d/c 24 hrs earlier for elective coronary angio. Cholesterol emboli, how to treat?

- supportive care and IV fluids

82M 3 days fever, productive cough and SOB. 2 months ago RL lobe pneumonia. CGH symptoms. nasal regurgitation when swallowing liquids or solids. food gets stuck in throat when swallowing. 101.7. 142/90. neck midline trachea w/o palpable mass. crackles in right lower lung field. reveals right lower lobe pneumonia w/o additional mass. most appropriate next step?

- videofluoroscopic modified barium swallow

What to do when you have difficulty initiating swallowing?

- videofluroscopic modified barium swallow

52M w/ 1.5 cm polyp in left descending colon.

- villous adenoma worst. - tubulovillous is next worst. tubular adenoma and then hamatomatous polyp and hyperplastic polyp

three categories of diarrhea

- watery - osmotic secretory and functional. - fatty - - inflammatory

42M crohn disease. had partial ileal resection due to striture and multiple surgeries to treat an enterocutaneous fistula. paraenteral nutrition for past seeral weeks, recently starred oral feeding. food doesn't taste the same as before. patchy alopecia and vesciular, crusting skin rash with scaling and erythema around the mouth and on the extremities. What would improve situation?

- zinc supplement helps with perioral invovlement, hypogonadism, impaired taste impaired wound healing alpecia

What are the characteristics of different types of solid liver masses? Focal nodular hyperplasia, hepatic adenoma, regenerative nodules, hepatocellular carinoma, liver metastasis?

Focal nodular hyperplasia - anomalous arteries, arterial flow and central scar on imaging Hepatic adenoma - women on OCP, possible hemorrhage or malignant transformation Regenerative nodules - acute or chronic liver injury Hepatocellular carcinoma - systemic symptoms, chronic hepatitis or cirrhosis, elevated alpha-fetoprotein Liver metastasis - single/multiple lesions, known extrahepatic malignancy