IM EOR - GI conditions Part 4: IBD, Diverticular Dz, Gastritis, Hemorroids

The antibody test for Crohn disease is ______________________.

Anti-Saccharomyces cerevisiae antibodies (ASCA)

The antibody test for Ulcerative colitis is _______________________.

Antineutrophil cytoplasmic antibodies (pANCA)

____________________ is a feature of chronic gastritis that occurs in response to reduced acid production in parallel to mucosal atrophy.

Antral G-cell hyperplasia

__________________ is an oral extraintestinal manifestation of Crohn disease and ulcerative colitis.

Aphthous stomatitis

________________ and steroids, such as budesonide, are immunosuppressants that are used to treat Crohn disease.

Azathioprine

A 63-year-old male who is being evaluated in the emergency department for an episode of painless bright red blood per rectum for two hours. What is the most likely diagnosis? A. Colonic diverticulitis B. Colonic diverticulosis C. Colonic polyps D. Crohn disease E. Ulcerative colitis

B (Colonic diverticulosis)

A 65-year-old man comes to the emergency department because of blood in his stools for the last few days. He denies fever, chills, nausea, or vomiting, and also says that his bleeding is painless. His last colonoscopy was five years ago and only showed several colonic diverticula, but no colonic polyps or cancer. His temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 15/min, and blood pressure is 120/80 mm Hg. Rectal examination does not show any abnormalities. Leukocyte count is 5,000/mm3. Barium swallow multiple outpouchings of sigmoid colon. Which of the following is the most likely diagnosis? A. Colonic diverticulitis B. Colonic diverticulosis C. Colonic polyps D. Crohn disease E. Ulcerative colitis

B (Colonic diverticulosis) (Colonic diverticulosis is an outpouching of the colonic mucosa and submucosa that arises from an unclear etiology. Patients are often asymptomatic; however, a small fraction of patients with diverticulosis develop symptoms. Bleeding alone can sometimes be the only sign of diverticulosis) (Colonic diverticulosis is an outpouching of the colonic mucosa and submucosa that arises from an unclear etiology. This condition is common in older patients and more common in the sigmoid colon. Interestingly, there is more right sided diverticulosis in Asian populations. Patients are often asymptomatic; however, a small fraction of patients with diverticulosis develop symptoms. Common symptoms include abdominal pain, bloating, altered bowel habits, or flatulence. Bleeding alone can sometimes be the only sign of diverticulosis) (Diverticulosis is often found incidentally during a routine colonoscopy, but they can be found through various imaging modalities including abdominal X-rays, CT, barium enema, and colonoscopy. Plain abdominal X-ray may show signs of bowel wall thickening. Barium enema will show out-pouching of the colonic wall, but it is important to rule out colonic diverticulitis before performing a barium swallow or colonoscopy because the chances of barium leakage or colonic perforation is increased with diverticulitis)

A 66-year-old man is brought to the emergency department because of worsening left lower quadrant pain and diarrhea over the past 2 days. His temperature is 38.7°C (101.6°F), pulse is 115/min, respirations are 20/min, and blood pressure is 145/85 mm Hg. Physical examination shows left lower quadrant tenderness. Laboratory studies show leukocytosis. Which of the following is the most appropriate next step in diagnosis? A. Colonoscopy B. Computed tomography scan C. Esophagogastroduodenoscopy D. Magnetic resonance imaging E. Ultrasonography

B (Computed tomography scan) (Patients with acute diverticulitis will complain of left lower quadrant tenderness. A computed tomography scan is the preferred imaging test for diagnosis and staging of the disease) (Diverticulitis is the inflammation of the diverticulum or a false diverticulum of the colon. It is a disease which occurs predominantly among the elderly population. Symptoms and findings include fever, leukocytosis, and left lower quadrant tenderness) (For diagnosis, the preferred imaging test is a computed tomography scan of the abdomen and pelvis. Computed tomography findings can help in confirming the clinical suspicion of diverticulitis and in excluding other abdominal or pelvic disease. Computed tomography can also stage the extent and severity of the inflammation as well as evaluate for abscess formation and fistulas. From a computed tomography scan, diverticulitis can be staged depending on surrounding involvement and severity. The modified Neff criteria is as follows: Stage 0 shows only minor local colonic wall involvement. Stages I and II show the contiguous spread of inflammation outside of the colon. Stages III and IV show peritoneal involvement with distant abscesses, ascites, and frank peritonitis. Stage 0 may be treated conservatively with oral antibiotics with outpatient follow-up with a primary care provider. The other stages usually necessitate surgical intervention)

______________ fistula, a fistula between the colon and bladder, can develop as a complication of diverticulitis, presents with air or stool in the urine, and may progress to pneumaturia without treatment.

Colovesical

The first line treatment of ulcerative colitis is 5-aminosalicylic preparations such as _____________________.

Mesalamine

__________________ is the antibiotic used if there is no response to 5-ASA in a patient with inflammatory bowel disease.

Metronidazole

Chronic ulcerative colitis is a potential risk factor for ____________________.

Colorectal cancer

Bleeding internal hemorrhoids can be treated by __________________ with 5% phenol in vegetable oil. Bleeding should cease at least temporarily.

Injection sclerotherapy

_______________ is an inflammatory bowel disease with histological findings of crypt abscesses with neutrophils, ulcers, and no granulomas.

Ulcerative colitis

________________ is an inflammatory bowel disease associated with primary sclerosing cholangitis and p-ANCA positivity.

Ulcerative colitis

_________________ is an inflammatory bowel disease that involves only mucosal and submucosal inflammation.

Ulcerative colitis

__________________ is an inflammatory bowel disease associated with pseudopolyps, loss of haustra, and a resultant "lead pipe" appearance on imaging.

Ulcerative colitis

In gastritis a _____________(test), fecal antigen testing or serology can be used to detect H.pylori.

Urea breath test

Low-residue diet and _____________________ are appropriate treatments for patients with mild diverticulitis.

broad-spectrum antibiotics

Crohn disease is an inflammatory bowel disease that causes a ___________________ appearance in the mucosa.

cobblestone

Diverticulosis is defined as large outpouchings of the mucosa in the __________.

colon

Ulcerative colitis is an inflammatory bowel disease that is limited to the (sections of the GI tract) ___________, including the rectum.

colon

Rectal bleeding should be attributed to hemorrhoids only after more serious conditions are excluded (ie, by ___________________ or colonoscopy).

sigmoidoscopy

Symptomatic treatment is usually all that is needed for internal hemorrhoids including stool softeners (eg, docusate, psyllium), __________________ after each bowel movement and as needed, anesthetic ointments containing lidocaine, or witch hazel (Hamamelis) compresses.

sitz baths

The surgical treatment for spasms of the anal sphincter leading to anal fissures is __________________.

sphincterotomy

Fistula must be treated _________________.

surgically

The most common site affected by Crohn disease is the _____________________.

terminal ileum

The distribution of Crohn disease is from mouth to anus and will commonly present with __________________, cobblestoning and "skip" lesions

thickened bowel wall

Internal hemorrhoids may be uncomfortable but are not as painful as ________________ external hemorrhoids.

thrombosed

________________ is essential in evaluating painless or bleeding hemorrhoids.

Anoscopy

____________________ is used to diagnosis Fistula in Ano (Perianal Fistula).

Anoscopy

Dyspepsia and abdominal pain are common indicators of ________________.

Gastritis

___________________ is defined as inflammation of the stomach lining.

Gastritis

Ulcerative colitis has a bimodal distribution of peak onset:

15-25 and 55-65

The first line treatment of ulcerative colitis is ____________________ preparations such as mesalamine.

5-aminosalicylic

A 38-year-old man comes to the office because of recent onset of abdominal pain around his umbilicus. He has a history of Crohn disease that was diagnosed a few years ago. He says that his pants have been feeling a little loose, and he is worried he might have lost some weight unintentionally. His temperature is 38°C (100.4°F). Physical examination shows a palpable abdominal mass in the right lower quadrant. Which of the following is the most appropriate next step in the management of this patient? A. Abdominal CT B. Abdominal plain film X-ray C. Administration of corticosteroids D. Administration of methotrexate or azathioprine E. Surgical consultation

A (Abdominal CT) (Abscesses are a clinical manifestation of Crohn disease. In these cases, a CT with intravenous and oral contrast is the diagnostic test of choice) (Crohn disease is characterized by focal, asymmetric, transmural skip lesions of the gastrointestinal tract. Abdominal pain, weight loss, and fever suggest chronicity. Given the patient's history of Crohn disease, a palpable mass and fever indicate the possibility of an abdominal abscess. 10-30% of patients with Crohn disease will develop an abdominal or pelvic abscess. Abscesses develop due to the transmural inflammation and micro-perforation of the bowel. Sinus tracts may lead to phlegmon or abscess formation, with an acute presentation of localized peritonitis with fever, abdominal pain, and tenderness. They occur most commonly in the terminal ileum or ileocecum. A CT scan with intravenous and oral contrast is the diagnostic test of choice. A diagnosis of infection or abscess requires appropriate antibiotic therapy and percutaneous or open surgical drainage)

A 35-year-old woman comes to the emergency department because of worsening symptoms of diverticulitis over the past 2 days. She was in the emergency department 5 days ago for similar symptoms for which she was discharged home with moxifloxacin with a follow-up appointment with a primary care provider follow-up. She now has decreased oral intake with nausea and vomiting. Her temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 130/80 mm Hg. The patient rates the pain as a 10 on a 10-point scale. Physical examination shows left lower quadrant tenderness. Which of the following is the most appropriate next step in the management of this patient? A. Abdominal X-ray B. Admit and switch antibiotic coverage to piperacillin-tazobactam C. Barium enema D. Continue moxifloxacin

A (Abdominal X-ray) (Patients on antibiotic therapy for diverticulitis who have worsened are at risk for nosocomial infections and complications. Consider expanding their antibiotic regimen to cover these resistant organisms (like Pseudomonas aeruginosa), while searching for sources of occult infection (like abscesses).) (In this clinical vignette, the next best step in management is to admit the patient and switch her antibiotic. Outpatient therapy should resolve symptoms within 48-72 hours. A persistent fever beyond this time period should increase suspicions for a nosocomial infection and/or complications such as an abscess or peritonitis. Piperacillin-tazobactam is one of many appropriate choices after failure with outpatient therapy; it is delivered intravenously, which is particularly necessary in this patient who has a decreased ability to tolerate oral preparations. Piperacillin-tazobactam covers both anaerobes and resistant gram negative organisms such as Pseudomonas aeruginosa. A computed tomography scan of the abdomen and pelvis is also appropriate to evaluate for abscess, fistulas, and obstruction.) (Once the patient improves on antibiotics, percutaneous drainage of the abscess can be done if shown on computed tomography scan. Additionally, surgical intervention in this patient is a possibility as this is her second flare of diverticulitis. As always, risks and benefits of the surgery should be discussed prior to any invasive procedures)

Which of the statements is false about diverticular disease: A. Acute diverticulitis most commonly affects the ascending colon. B. Patients with Ehlers-Danlos syndrome are disposed to development of diverticulosis. C. Diverticular disease is asymptomatic in 95% of cases. D. Mild attacks can be treated on an outpatient basis using oral antibiotics such as ciprofloxacin and metronidazole.

A (Acute diverticulitis most commonly affects the ascending colon) (Acute diverticulitis most commonly affects the sigmoid (descending) colon. This may be a result of the relative high-pressure zone within the sigmoid colon.)

A 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid-abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC. What is the most likely diagnosis? A. Colonic diverticulitis B. Colonic diverticulosis C. Colonic polyps D. Crohn disease E. Ulcerative colitis

A (Colonic diverticulitis)

________________ is an open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses.

Anorectal fistula

A 42-year-old man comes to the emergency department because of 3-day abdominal pain. The pain occurs intermittently throughout the day, but is not associated with meals or sleep. He has a history of rheumatoid arthritis, for which he takes multiple non-opioid pain relief medications per day. He otherwise appears well in spite of his acute pain. His vitals show no abnormalities and he has epigastric tenderness without distention. Which of the following diagnostic tests is the most appropriate next step in the management of this patient? A. Complete blood count B. Endoscopic evaluation C. Fecal H. pylori antigen testing D. Serum electrolytes E. Serum gastrin concentration

A (Complete blood count) (Patients taking large amounts of nonsteroidal anti-inflammatory drug (NSAID) medications are at risk for developing gastritis or even frank peptic ulcer disease. The most feared complications of peptic ulcer disease are hemorrhage (upper GI bleeding) and perforation) (A complete blood count (CBC) is the most appropriate next step for this patient. This patient has a presentation concerning for a nonsteroidal anti-inflammatory drug- (NSAID) induced peptic ulcer (all those 'non-opioid pain medications': they are probably NSAIDs -- ibuprofen and/or naproxen). The potential for previous and ongoing GI bleeding is worth investigating in this patient, and a CBC showing anemia will alert the physician to this) (Another valuable test to obtain would be a serum lipase concentration. Epigastric pain radiating to the back with associated abdominal pain is also potentially consistent with acute pancreatitis. As such, a lipase level should be tested to help rule out (or confirm) this diagnosis)

A 29-year-old man comes to the office because of pain during urination. He was treated for a urinary tract infection last month. He also says he has progressively worsening diarrhea over the past two years. These episodes of diarrhea typically last 1-2 weeks, then subside for several weeks to months. Physical examination shows joint pain in many locations, especially in his sacroiliac joint. A urine sample is collected and shows pneumaturia. Which of the following best explains the patient's recurrent urinary tract symptoms? A. Enterovesical fistulization B. Nephrocalcinosis C. Nephrolitiasis D. Polycystic kidney disease E. Pseudomembranous colitis

A (Enterovesical fistulization) (Enterovesical fistulization may occur as a presenting symptom or complication of Crohn disease. It leads to recurrent, polymicrobial urinary tract infections and pneumaturia) (The patient's signs and symptoms should raise suspicion for inflammatory bowel disease, due to its chronic and relapsing character. Physical examination shows extraintestinal manifestations of Crohn disease.) (Fistulization between abdominal structures is common in Crohn disease since the inflammation is transmural. Up to 45% of patients with fistulas present before the diagnosis of Crohn disease is made. Enterovesical fistulization is an abnormal connection between the intestine and urinary bladder. It leads to recurrent urinary tract infection (UTI) and gas bubbles in the urine.) (In general, pneumaturia is indicative of a colovesical fistula or an emphysematous UTI. Aside from Crohn disease, diverticulosis is another cause of enterovesicular fistula formation)

Which of the following is the most common cause of gastritis? A. H. pylori B. NSAIDS C. Autoimmune D. Severe physiological stress

A (H. pylori) (H. pylori is a Gram-negative, spiral shaped bacillus. It is the most common cause of gastritis and is implicated in almost all non-NSAID-induced GI mucosal inflammation. It is associated with peptic ulcer, gastric adenocarcinoma, and gastric lymphoma)

A 56-year old woman came to the clinic complaining of a lump protruding from her anal opening. It was initially reducible, but it now irreducible. There is associated pain and itching. She also noticed bright-red blood on her stool when she defecates. There is an associated history of chronic constipation. Examination of the perianal area revealed skin tags and a tender perianal mass with covered with mucosa. Inspection of the anal mucosa showed no fissure. What is the most likely diagnosis? A. Internal hemorrhoid B. External hemorrhoid C. Perianal hematoma D. Proctitis

A (Internal hemorrhoid) (Hemorrhoids are symptomatic anal venous cushions. Symptoms of internal hemorrhoids include bright-red, painless bleeding, mucus discharge, prolapse, and pain only on prolapse.)

A 60-year-old woman comes to the colorectal clinic for a screening colonoscopy. A rectal mass was found. Biopsy of the lesion reveals squamous cell carcinoma with invasion through the muscularis propria. The lesion is located 1 cm proximal to the pectinate line. Which of the following is true concerning lesions above the pectinate line? A. They are usually not painful B. They are composed of stratified squamous epithelium C. They receive blood from the inferior rectal artery D. They are innervated by the inferior rectal nerve E. They generally do not bleed

A (They are usually not painful) (Hemorrhoids occurring above the pectinate line are classified as internal hemorrhoids. These hemorrhoids are generally non-painful, but they are more prone to bleeding.) (The pectinate, or dentate, line marks the transition from the rectum to the anus. Several distinctions can be made depending on anatomical location in relation to the pectinate line. Above the pectinate line, the mucosa is composed of intestinal simple columnar epithelium. The superior and middle rectal arteries supply blood to the tissues above this line and venous drainage occurs through the corresponding veins. Hemorrhoids occurring above the pectinate line are classified as internal hemorrhoids. These hemorrhoids are generally non-painful, but they are more prone to bleeding.) (Of note, internal hemorrhoids are associated with portal hypertension, as the superior rectal vein is part of the portal system. Below the pectinate line, the mucosa is composed of stratified squamous epithelium. Blood is supplied by the inferior rectal artery and vein. Hemorrhoids occurring below the pectinate line are external hemorrhoids. These are generally painful due to somatic innervation by the inferior rectal nerve,which is a branch of the pudendal nerve, and they do not generally bleed)

Anorectal abscess is a result of infection, whereas ________________ is a chronic complication of an abscess.

Anorectal fistula

__________________ and infliximab are two monoclonal antibodies that can be used to treat Crohn disease by binding to tumor necrosis factor-alpha.

Adalimumab

The malignancy _______________ of the colon can be a complication of ulcerative colitis that is usually not a concern until after ten years of disease.

Adenocarcinoma

___________ on CT scan for a patient with known diverticulitis raises suspicion for microperforation of the bowel.

Air bubbles

The cause of ____________________ may be a hard bowel movement, which is associated with diets low in fiber.

Anal fissure

_______________ is a tear in the anal mucosa below the pectinate line.

Anal fissure

Examination reveals localized tenderness, erythema, swelling, and fluctuance; fever is uncommon.

Anorectal abscess

_________________ is a result of infection, whereas fistula is a chronic complication of an abscess.

Anorectal abscess

_________________ produce painful swelling at the anus as well as painful defecation.

Anorectal abscess

a 47-year-old man with severe rectal pain when he defecates. He has a fever of 102.2 F (39 C). On exam there is perianal swelling, redness and tenderness. A palpable mass is felt at the anal verge. What is the most likely diagnosis?

Anorectal abscess

An ___________________ may present with recurrent malodorous drainage, recurrent abscesses, and pain with sitting and moving.

Anorectal fistula

A 19-year-old woman student comes to the office because of multiple bouts of abdominal pain and diarrhea for the past three months. On many occasions, she has seen blood in her stool. She has a sister who suffers similar symptoms. The patient is referred to a gastroenterologist for a colonoscopy and she's found to have pathology affecting her distal colon. Which of the following histologic features is most likely to be observed? A. Cobblestone mucosa B. Crypt abscesses C. Noncaseating granulomas D. Skip lesions E. Transmural involvement

B (Crypt abscesses) (Ulcerative colitis (UC) is characterized by inflammation that spreads proximally and continuously from the rectum. Damage is usually limited to the mucosa) (Ulcerative colitis (UC) is a subtype of inflammatory bowel disease (IBD) that primarily affects the distal colon. The other subtype of IBD is Crohn disease (CD) which usually affects the ileum, though all areas of the gastrointestinal tract may be involved. UC and CD are both suspected to have a genetic component; UC has been associated with the major histocompatibility complex, class II DR beta 1 (HLA-DRB1) gene, while CD has been associated with the HLA-DR7 and DQ4 alleles. Both UC and CD are characterized by intermittent episodes of diarrhea and abdominal pain. Bloody stool can be seen in both conditions but is more consistent with UC. The inflammation, seen in UC, generally begins in the rectum and spreads proximally and continuously. Histologic features include a friable muscosa with pseudopolyp formation and a diffuse mononuclear inflammatory infiltrate in the lamina propria. Crypt abscesses are seen in UC but are not very specific as they may be present in other types of inflammatory colitis, including CD)

A 55-year old woman come to the emergency department because of light headedness, fatigue, and a racing heart for 6 hours. She tells you that she has also had very dark stools in the last day. Her medical history includes hyperlipidemia, and daily cigarette smoking. Her temperature is 36.8°C (98°F), pulse is 110/min, respirations are 23/min, and blood pressure is 90/65 mm Hg. Abdominal examination is noncontributory. A biopsy from upper gastrointestinal endoscopy shows partial replacement of the gastric mucosal epithelium by intestinal metaplasia in the antrum. Which of the following most likely explains this patient's problem? A. Autoimmune disease B. H. pylori C. Dysplasia D. Inflammation due to neutrophilic infiltration E. Reactive gastropathy

B (H. pylori) (Helicobacter pylori is a curvilinear (or corkscrew) gram-negative rod that causes chronic gastritis. Histologically, partial replacement of the gastric mucosal epithelium by intestinal metaplasia will be seen in the antrum or throughout the entire stomach) (This patient has chronic gastritis secondary to Helicobacter pylori infection, which is a curvilinear (or corkscrew) gram-negative rod. The patients symptoms of fatigue, light-headedness, tachycardia, hypotension, and melena suggest an upper gastrointestinal bleed, most likely due to chronic gastritis. This organism is able to move through gastric mucous with its flagella. Urease within the organism produces ammonia and carbon dioxide, which allows provides the organism a buffer from gastric acid. H. pylori has the most significant association with chronic gastritis. Non-invasive diagnostic methods include antibody serology, fecal bacterial detection, and urea breath tests. Specifically, the breath test determines if there is a production of ammonia by bacterial urease.) (Once exposed to H.pylori, gastritis can occur in two patterns; either antral predominant with increased risk for duodenal ulcer or pangastritis that leads to multifocal atrophy with higher risk for adenocarcinoma. Histologically, chronic gastritis shows partial replacement ofthe gastric mucosa by intestinal metaplasia. Inflammation occurs in the lamina propria due to lymphocytes and plasma cells)

A 56-year old woman came to the clinic complaining of a lump protruding from her anal opening. It was initially reducible, but it now irreducible. There is associated pain and itching. She also noticed bright-red blood on her stool when she defecates. There is an associated history of chronic constipation. Examination of the perianal area revealed skin tags and a tender perianal mass with covered with mucosa. Inspection of the anal mucosa showed no fissure. Which of the following is the most appropriate treatment? A. Sclerotherapy B. Hemorrhoidectomy C. Rubber band ligation D. Conservative measures

B (Hemorrhoidectomy) (Hemorrhoidectomy is the treatment of choice for grade IV hemorrhoids)

A 40-year-old woman comes to the emergency department because of sudden onset hemoptysis. She has started a new treatment for her Crohn disease and says that she has had a low-grade fever and night sweats for the past five days. Which of the following agents added to her treatment regimen is most likely responsible for her new symptoms? A. Azathioprine B. Infliximab C. Methotrexate D. Prednisone E. Sulfasalazine

B (Infliximab) (TNFα inhibitors increase the risk of reactivation of latent tuberculosis. Infliximab is a monoclonal antibody against TNFα that is used in the treatment of Crohn disease) (It has been widely accepted that the chronic inflammation seen in Crohn disease is due to the increased production of cytokines, notably TNFα. These conclusions led to the development of the human-murine chimeric monoclonal antibody against TNFα infliximab, which has shown to be effective in treating Crohn. Adalimumab and certolizumab are other TNFα antagonists developed for this purpose) (Patients being treated with infliximab are predisposed to reactivation of latent tuberculosis, which is the most likely explanation of the patient's symptoms of weight loss, hemoptysis, and night sweats. This is because TNFα is required for the orderly recruitment of the macrophages and lymphocytes maintaining the granuloma structure that sequesters Mycobacteria spp. Hence, it is recommended that patients are screened for tuberculosis before beginning treatment with infliximab)

A 35-year-old pregnant woman comes to the emergency department because of rectal bleeding. She denies any trauma to the area. She also denies having any pain. Vaginal examination is normal, however, there is bright red blood per rectum noted during digital rectal examination. Which of the following is the most likely diagnosis in this patient? A. colorectal carcinoma B. Internal hemorrhoids above the pectinate line C. External hemorrhoids below the pectinate line D. Internal hemorrhoids below the pectinate line E. External hemorrhoids above the pectinate line

B (Internal hemorrhoids above the pectinate line) (Hemorrhoids are the most common cause of rectal bleeding. The painless nature of the bleeding in this patient, however, eliminates external hemorrhoids as a possibility because of the tendency of external hemorrhoids to be painful) (Hemorrhoids are the most common cause of rectal bleeding. The painless nature of the bleeding in this patient, however, eliminates external hemorrhoids as a possibility because of the tendency of external hemorrhoids to be painful) (Hemorrhoids are vascular structures in the anal canal. Normally, they are cushions that help with stool control. They become a disease when swollen or inflamed. Signs and symptoms of hemorrhoids depend on the type. Internal hemorrhoids usually present with painless, bright red rectal bleeding when defecating. External hemorrhoids are often painful and swollen. If the bleeding does occur with extern hemorrhoids, the blood is typically darker. A skin tag may remain after the healing of an external hemorrhoid.)

A 62-year-old man comes to the office because of painless rectal bleeding for the past 3 months. He describes the intermittent occurrence of streaks of "bright red blood" on the toilet paper after wiping, and blood on but not mixed within the stool. Occasionally he has noted a small volume of blood within the toilet bowl, and associates this with straining. For the past two weeks he has noticed an "uncomfortable lump" in his anus when defecating, which goes away by itself immediately afterwards. He says he has no abdominal pain, weight loss, or fevers. He is a well-appearing man with obesity. Digital rectal examination shows bright red blood on the examination glove following the procedure. Anoscopy shows enlarged blood vessels above the pectinate line. Which of the following is the most appropriate next-step in management? A. Hemorrhoid arterial ligation B. Rubber band ligation C. Sclerotherapy D. Surgical hemorrhoidectomy E. Topical corticosteroids (hydrocortisone)

B (Rubber band ligation) (Internal hemorrhoids are graded according to their degree of protrusion into the anal canal. This grading determines the first line treatment. Rubber band ligation is the most effective treatment for grade 2 and 3 internal hemorrhoids) (This patient has presented with grade 2 internal hemorrhoids. Risk factors for the development of hemorrhoids include, being between the ages of 45 and 65 years, history of constipation, and pregnancy. The most common symptom is bright red per rectal bleeding associated with straining or defecation. Discomfort, pain, and pruritus may also be present. The most specific diagnostic test is anoscopic examination. Internal hemorrhoids occur above the pectinate line and are classified according to the degree in which they protrude into the anal canal. Grade 1 hemorrhoids do not protrude, grade 2 protrude with straining but spontaneously resolve, grade 3 require manual reduction, and grade 4 cannot be reduced manually. This patient therefore is suffering from grade 2 hemorrhoids, for which the first line treatment is rubber band ligation, with lifestyle and dietary modification. Rubber band ligation is performed using an anoscope and involves placing a rubber band around the hemorrhoidal tissue above the pectinate line. This tissue will necrose and slough after approximately a week. Rubber band ligation is considered the most effective treatment)

Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease? A. Prednisone B. Sulfasalazine C. Metronidazole D. Azathioprine (Imuran)

B (Sulfasalazine) (Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties)

A 23-year-old American Jewish woman comes to the emergency department due to a 4-day history of fever, left lower quadrant pain, and abdominal distention. Her medical history is relevant for Hashimoto's hypothyroidism, situational anxiety, and positive family history of inflammatory bowel disease. The patient currently takes levothyroxine, vitamin C/zinc supplement, and alprazolam. Upon further questioning, the patient mentions that she has increasing bowel movements (every hour) and has small amounts of watery-mucousy red stools. Physical exam shows distended abdomen and tympanitic, drum-like sounds over her right upper and left upper quadrant. Her temperature is 38.6°C (101.48°F), pulse is 121/min, respirations are 18/min, blood pressure is 80/70 mmHg. Upon hospital admission, the patient's clinical condition deteriorates despite antibiotic therapy and steroids. An abdominal radiograph shows marked dilatation of the colon and loss of haustral marking. Which of the following is the most likely cause of this patient's condition? A. Pseudomembranous colitis B. Ulcerative colitis C. Ischemic colitis D. Crohn's disease E. Fulminant colitis

B (Ulcerative colitis) (Toxic megacolon is a life-threatening and severe complication seen in patients with ulcerative colitis. In this case, this condition is characterized by a marked dilatation of the colon (at least 6 cm or greater), loss of haustral markings, abdominal distension (i.e., tympanitic percussion), fever, and tachycardia) (This patient who developed signs and symptoms of toxic megacolon such as dilated transverse colon (at least 6 cm), loss of haustral markings, bloody diarrhea, left sided abdominal cramping, fever, and tachycardia, likely has ulcerative colitis. Toxic megacolon (TM) is a severe complication seen in patients with inflammatory bowel diseases. However, the presence of toxic megacolon is more common among patients with ulcerative colitis. Although the pathogenesis of toxic megacolon is not fully understood. The use of certain medications (i.e. antidepressants, anticholinergics) may interfere with bowel motility, and thus may be implicated in the development of toxic megacolon) (In the general population, Jewish people, specifically Ashkenazi Jews are more prone to ulcerative colitis than other ethnic groups. This condition is also more common among young adults between 20 to 40 years. Approximately 10% of patients with ulcerative colitis develop toxic megacolon.) (The mainstay therapy for toxic megacolon is (1) fluid and electrolyte replacement (2) broad-spectrum antibiotics, (3) corticosteroids. Other treatments may include, colectomy (severe cases), anti-TNF-alpha monoclonal antibody, or cyclosporin. Common complications may include bowel perforation, sepsis, and shock. The prognosis of toxic megacolon is generally regarded as unfavorable, with an estimated mortality of 50%.)

A 35-year-old man comes to your office with rectal bleeding, mucoid discharge from the rectum, and protrusion of certain structures through the anal canal. On proctoscopic examination, large internal hemorrhoids are seen. What is the best next step in the management of this patient? A. proceed with definitive treatment B. proceed with further investigations C. prescribe a hemorrhoidal cream D. do nothing; ask the patient to return in 6 months for review

B (proceed with further investigations)

A 57-year-old man comes to the emergency department because of worsening left lower quadrant pain and diarrhea over the past three days. He says that he has developed a fever over the past 24 hours and denies nausea and vomiting. His temperature is 38.7°C (101.6°F), pulse is 115/min, respirations are 20/min, and blood pressure is 145/85 mm Hg. Examination of the left lower quadrant shows tenderness. Laboratory studies show leukocytosis. A computed tomography scan is ordered and shows the following image. Which of the following is the most appropriate next step in management? A. Exploratory laparotomy B. Oral antibiotics with primary care provider followup C. Colonoscopy D. Upper gastrointestinal endoscopy

B. Oral antibiotics with primary care provider followup) (Symptoms of diverticulitis include fever, leukocytosis, and left lower quadrant pain. Patients with an uncomplicated first episode of diverticulitis should be treated with oral antibiotics as an outpatient) (A diverticulum is a herniation through the muscular layer of the colonic wall (known as diverticulosis or diverticular disease). Usually, the diverticulum are asymptomatic until they become blocked by fecal matter or undigested food particles. Once impacted, the diverticulum can become inflamed and undergo microperforations. This leads to diverticulitis. Patients with diverticulitis will often complain of left lower quadrant pain with a fever and leukocytosis) (The diagnosis can be made clinically but a computed tomography scan is used to confirm the suspicion of acute diverticulitis or to rule out complications such as a perforation, fistula, or an abscess. Uncomplicated diverticulitis appears on CT scan as localized colonic wall thickening with inflammation extending into the fat surrounding the colon. A barium enema is not recommended in the acute phase due to concerns about intraperitoneal leakage of barium. Patients with an uncomplicated first episode of diverticulitis should be treated with oral antibiotics as an outpatient. If patients are initially unable to maintain oral hydration or if symptoms persist beyond 72 hours, they should be admitted to the hospital for IV antibiotics and IV fluids. Perforated diverticulitis with peritonitis is treated with surgical exploration and resection)

Crohn disease is an inflammatory bowel disease that is most commonly associated with vitamin _____ deficiency.

B12

A colonoscopy (should / should not) be performed in acute diverticular disease.

should not

_____________________ are used for patients with terminal ileal disease in IBD who cannot absorb bile acids.

Bile acid sequestrants (cholestyramine or colestipol)

Which of the following imaging modalities is the best during an acute episode of diverticulitis? A. Barium enema B. Endoscopy C. CT scan D. Ultrasound

C (CT scan) (CT scan is the best imaging modality during acute episode of diverticulitis. It can help in assessing disease severity, presence of complications, and clinical staging. Specificity and sensitivity, especially with helical CT and colonic contrast can be as high as 97%. Barium enema and endoscopy are contraindicated during the initial stages of an acute attack because of the risk of free perforation)

A 66-year-old man comes to the emergency department because of diarrhea and abdominal cramps. He reports unintentional weight loss of 4.5-kg (10-lb) over the past month. He has had lower abdominal pain for years. Recently, his diarrhea has become disruptive to his career, since he often has more than 10 watery bowel movements a day and is awakened at night by the need to defecate. He denies blood in his stool. Which of the following tests is the most appropriate first step in the management of this patient? A. Abdominal CT B. Abdominal X-ray C. Colonoscopy D. Endoscopy

C (Colonoscopy) (Colonoscopy is the preferred study for evaluation of the lower bowel and is necessary for the initial workup of inflammatory bowel disease) (Crohns disease is a type of inflammatory bowel disease (the other main type of IBD is ulcerative colitis). Crohns affects both the large and small intestine, while ulcerative colitis affects the large intestine (although in some situations, one may see changes in the terminal ileum due to "backwash ileitis").) (The patient's clinical picture is suggestive of Crohns disease or possibly ulcerative colitis, and he requires a colonoscopy plus biopsies for diagnosis. However, even colonoscopy is not always sufficient in diagnosing Crohn disease. Crohn affecting the small intestine is difficult to see with colonoscopy (as the colonoscope can only reach the terminal ileum), and thus further testing may be required (such as capsule endoscopy).)

A 25-year-old woman comes to the office because of painful new lesions on both of her legs. The lesions are purple, firm nodules, and her legs are mildly swollen. She has had loose stools, intermittent fevers, and weight loss for the past three weeks. Which of the following is the most likely diagnosis? A. Campylobacter enterocolitis B. Celiac disease C. Crohn disease D. Primary biliary cholangitis E. Rheumatic fever

C (Crohn disease) (Erythema nodosum is an inflammation of subcutaneous fat that is characterized by raised, painful erythematous nodules. It is associated with a variety of disorders, including Crohn's disease.) (This patient has erythema nodosum. Erythema nodosum (EN) is a skin condition where red lumps form on the shins, and, less commonly, on the thighs and forearms. It is the most frequent form of panniculitis, an inflammatory disorder affecting subcutaneous fat. It may be triggered by a wide variety of stimuli and is thought to be a delayed hypersensitivity reaction. Up to 55% of cases are idiopathic, but the most common causes include infections, drugs, systemic illnesses such as sarcoidosis and inflammatory bowel disease, pregnancy, and malignancy. The nodules of EN are slightly raised above the surrounding skin; they are hot and painful, bright red when they first appear, and later become purple like a bruise) (The patient has intermittent fevers, loose stools, and weight loss suggestive of inflammatory bowel disease. EN has been reported in as many as 15% of patients with Crohn disease and 10% with ulcerative colitis)

A 76-year-old woman comes to the emergency department because of worsening left lower quadrant abdominal pain for the past two days with nausea and vomiting. She has had episodes of diarrhea and constipation over the past two weeks. Her temperature is 38°C (100.4°F), pulse is 72/min, respirations are 18/min, and blood pressure is 145/80 mm Hg. Physical examination shows generalized tenderness with localized rebound within the left lower quadrant. Heme occult examination is positive for occult blood in the stool. Laboratory studies are ordered and venous lactate levels were within normal limits. An abdominal CT is obtained, the results of which are shown below. Which of the following is the most likely diagnosis? A. Acute mesenteric ischemia B. Appendicits C. Diverticulitis D. Diverticulosis E. Meckel diverticulum

C (Diverticulitis) (Diverticulitis is the inflammation of the diverticulum and occurs predominantly among the elderly population. Diagnosis and severity of the disease are made by an abdominal computed tomography (CT) scan.) (Diverticulitis is the inflammation of the diverticulum or a false diverticulum of the colon. It is a disease which occurs predominantly among the elderly population (60% of the population will develop diverticulosis at the age of 60). Diverticulosis most commonly affects the sigmoid colon as opposed to the cecum in the United States. Risk factors for diverticulosis formation include a low fiber diet, red meats, obesity, and smoking. Diverticulitis can either be acute or chronic. Patients with acute diverticulitis will come to the emergency department with left lower quadrant pain, nausea and vomiting, and a low-grade fever. Physical examination may reveal localized peritoneal signs. A heme-occult test may be positive for blood in the stool. If severe enough, diverticulitis can lead to an abscess, bowel obstruction, fistula or perforation. Diagnosis and severity of the disease are determined by an abdominal computed tomography (CT) scan)

A 62-year-old man comes to the primary care clinic because of pain in his lower left abdominal quadrant, painless hematochezia, and constipation for the past few weeks. Medical history shows that he has suffered a myocardial infarction two years ago and has been taking aspirin daily since. His doctor orders a colonoscopy and notices small sacs bulging out around the large intestine. Which of the following is the most likely explanation for this patient's physical findings? A. Anal fissures B. Angiodysplasia of the colon C. Diverticulosis D. Drug-induced gastrointestinal bleeding E. Ulcerative colitis

C (Diverticulosis) (Gastrointestinal bleeding is bleeding of the gastrointestinal tract and is often categorized into upper and lower gastrointestinal bleeding depending on the affected area. Symptoms depend on the etiology and typically include rectal bleeding, melena, and bloody stools. The condition has many different etiologies with diverticulosis being the most common cause.) (Gastrointestinal bleeding has many different etiologies. All of the answer choices above can lead to gastrointestinal bleeding, but it is important to differentiate these conditions and understand their characteristic clinical manifestations. Diverticulosis, which most likely fits in with this patient's vignette, is the most common cause of gastrointestinal bleeding. This patient has a few risk factors of diverticulosis, including his age and the use of NSAIDs. Diverticulosis is a condition in which out-pouchings, called diverticula, are produced within the colon lining, and if these pouches become inflamed, the condition is referred to as diverticulitis. The diverticula may present throughout the colon but are commonly found in the left lower quadrant around the sigmoid colon. Diverticula can be divided into "true" and "pseudo" diverticula, depending on whether all layers (mucosa, submucosa, and muscle) of the colon wall are involved or if only the mucosa and submucosa layers are involved, respectively. When complicated, this condition is characterized by pain in the lower left quadrant that is relieved by passing flatus or bowel movements, and constipation. A notable complication is gastrointestinal bleeding, often manifested as painless hematochezia. Diverticular bleeding is one of the most common causes of gastrointestinal bleeding)

A 29-year-old man comes to the emergency department because of right lower abdominal pain, bloody diarrhea, and fever for the past week. He says that he has been having these episodes of right lower abdominal pain and loose stools over the course of the past year. However, this is the first time he has noticed blood in his diarrhea. Physical examination shows tenderness along the sacroiliac joint. There are raised erythematous lesions along his back that are painful to touch. A barium swallow is obtained and the results of which are shown below: A colonoscopy is performed and shows diffuse granulomatous inflammation of ileocecal junction with transmural ulcerations. Biopsies show non-caseating granulomas and skip lesions, with ulcers that are transmural. Which of the following is most likely to result as a complication of this patient's disease? A. Diverticulosis B. Exocrine pancreatic insufficiency C. Fat and vitamin malabsorption D. Pseudomembranous colitis E. Toxic megacolon

C (Fat and vitamin malabsorption) (Crohn disease is characterized by chronic and relapsing episodes of abdominal pain and diarrhea. The chronic inflammation of the small bowel and colon lead to a high risk of nutrient malabsorption.) (Crohn disease is an inflammatory bowel disease. Whereas ulcerative colitis starts at the rectum and only involves the colon, Crohn disease can occur anywhere along the gastrointestinal tract from the mouth to the anus. The most common location for active Crohn disease inflammation is at the ileocolic junction. Patients tend to have on and off episodes of abdominal pain with diarrhea. Crohn disease has many extraintestinal manifestations such as calcium oxalate renal stones, seronegative spondyloarthropathy, and erythema nodosum. A biopsy and pathological examination are required for a definitive diagnosis between Crohn disease and ulcerative colitis. Crohn disease is characterized by deep skip lesions while ulcerative colitis has superficial and broad ulcerations. Additionally, the presence of non-caseating granulomas is highly specific for Crohn disease, although approximately only 35% of patients have these. Crohn disease will show a "string sign" on small bowel follow through studies with intestinal strictures. Gross pathology of affected bowel will show a prominent cobblestone appearance in Crohn patients) (Since parts of the small bowel and the colon are chronically inflamed, there is a high risk of nutrient malabsorption. Deficiencies in iron, protein, vitamin B12, and bile salts can result from the disease)

Which of the following best describes H. pylori? A. Gram-negative diplococci B. Gram-positive cocci C. Gram-negative spiral-shaped bacillus D. Gram-negative rod

C (Gram-negative spiral-shaped bacillus)

A 29-year-old man comes to the emergency department because of right lower quadrant abdominal pain, diarrhea, and fever. He says that these episodes have progressively worsened over the past two years. They typically last 1-2 weeks, then subside for many weeks to months. During the episodes, he sometimes has bloody diarrhea. Physical examination shows joint pain in many locations, especially in his sacroiliac joint. There are multiple erythema nosodum lesions on his back. A biopsy from colonoscopy shows noncaseating granulomas and skip lesions of transmural ulcers. A barium swallow is done and the results are shown below. Which of the following is the most appropriate medication to be administered? A. Alvimopan B. Bismuth subsalicylate C. Mesalamine (5-ASA) D. Octreotide E. Polyethylene glycol

C (Mesalamine (5-ASA)) (Mesalamine is a mainstay of treatment in inflammatory bowel disease. Crohn disease is characterized by stricture on barium study and granulomatous skip lesions) (Due to their chronic and relapsing character, the patient's signs and symptoms should raise suspicion for an inflammatory bowel disease (IBD). Physical examination shows extraintestinal manifestations of Crohn disease) (The biopsy findings are also indicative of Crohn disease rather than of ulcerative colitis. Crohn disease is characterized by deep skip lesions, while ulcerative colitis is characterized by superficial and broad ulcerations extending from the rectum. The barium study shows evidence of strictures, which supports the diagnosis of Crohn. The presence of noncaseating granulomas is highly specific for Crohn disease, although only ~35% of patients have these) (Since parts of the small bowel and the colon are chronically inflamed in this condition, mesalamine (5-aminosalicylic acid) would be an appropriate therapy as it works to decrease inflammation. It is a derivative of salicylic acid (aspirin). Along with local corticosteroids, 5-ASA is used in the therapy of mild IBD)

A 22-year-old Jewish woman comes to the emergency department because of severe right lower quadrant abdominal pain for the past two hours. She has had diarrhea and weight loss for several weeks. A colonoscopy is performed, and an image from the procedure is shown below. Which of the following is the most likely complication of this patient's diagnosis? A. Dehydration B. Perforation of the appendix C. Perianal fistulas D. Right ovarian necrosis E. Toxic megacolon

C (Perianal fistulas) (Crohn disease leads to fistulas as a common clinical manifestation and complication. Since the bowel inflammation is transmural, sinus tracts penetrate the intestinal wall and give rise to these fistulas.) (Based on her symptoms of intermittent diarrhea, weight loss, and abdominal pain, as well as the results of endoscopy, the patient likely has Crohn disease. Notably in the clinical description, this patient's right lower quadrant pain is typical, since the terminal ileum is often affected. Malabsorption of nutrients is common in Crohn, hence her weight loss. Granulomatous skip lesions may be seen on endoscopy. Histologically, Crohn disease is characterized by transmural intestinal inflammation and cobblestone mucosa. Crohn disease can affect anywhere in the GI tract ("mouth to anus"), so aphthous ulcers can be seen in the mouth, and even the esophagus can be affected, though rarely) (Complications of Crohn disease include fistulas. Sinus tracts that penetrate the serosa give rise to fistulas, which are usually indolent rather than presenting as an acute abdomen. Up to 45% of patients develop a fistula before a diagnosis of Crohn disease. The fistulas mostly occur in the perianal region, but they can also form between the intestine and bladder/uterus.)

_______________ is the definitive surgical treatment of ulcerative colitis.

Colectomy

Diverticula most commonly occur in the _______________ colon.

sigmoid

A 27-year-old woman comes to the office because of intermittent episodes of bloody diarrhea and abdominal pain. She also reports that she noticed a lesion on her left shin. She initially believed that she must have bruised it, but she then noticed that a painful ulcer began to form quite rapidly. Which of the following is the most appropriate step in management? A. Perform a biopsy B. Perform wide surgical debridement C. Prescribe a corticosteroid D. Prescribe antibiotic therapy

C (Prescribe a corticosteroid) (Pyoderma gangrenosum is a neurophilic dermatosis that causes painful skin ulceration, usually of the lower legs, and may be triggered by an underlying disease. The best management of pyoderma gangrenosum is treatment of the underlying disease or anti-inflammatory agents) (Pyoderma gangrenosum is an uncommon cause of very painful skin ulceration. It may affect any part of the skin, but the lower legs are the most common site. Pyoderma gangrenosum is classified as a neutrophilic dermatosis and may be a reaction to a systemic disease or condition such as inflammatory bowel disease, rheumatoid arthritis, myeloproliferative disorders, or others. The best management is the treatment of the underlying disease, which in this case is ulcerative colitis. Treatment with oral corticosteroids as well as sulfasalazine will address the underlying bowel inflammation in this patient. Topical and systemic corticosteroids may be helpful in treating pyoderma gangrenosum regardless of underlying disease)

Complications of hemorrhoids include all of the following except: A. Ulceration B. Portal pyemia C. Rectal cancer D. Anemia

C (Rectal cancer)

A 40-year-old man comes to the office for a follow-up evaluation of his inflammatory bowel disease. He asks what the risk factors are, and would like to know what modifications he can make to his lifestyle that will decrease the risk of exacerbation. Which of the following is the most appropriate physician response to his question? A. His previous appendectomy increases his risk of exacerbations B. NSAIDs may provide symptomatic relief C. Smoking may aggravate Crohn disease and relieve ulcerative colitis D. Smoking may relieve both Crohn disease and ulcerative colitis E. Strenuous physical activity can lead to flare-ups

C (Smoking may aggravate Crohn disease and relieve ulcerative colitis) (Smoking is known to have different effects on inflammatory bowel disease, with a protective effect on ulcerative colitis and an exacerbating effect on Crohn disease) (Inflammatory bowel disease can be divided into ulcerative colitis (UC) and Crohn disease (CD). While UC causes superficial inflammation of the GI mucosa at the descending colon and extends proximally, CD tends to cause transmural inflammation in skip lesions along all locations of the GI tract.) (Smoking is known to have different effects on the two diseases, with a protective effect on UC and exacerbating effect on CD. The mechanism is poorly understood; however, the effect of nicotine and smoking byproducts on the mucosal immune response and vascular supply are thought to play a role. In either case, patients are always recommended to quit smoking since the overall negative impact of smoking outweigh the benefit)

What is the treatment of choice for this patient? A. hemorrhoidal cream B. hemorrhoidal ointment C. rubber band ligation of the internal hemorrhoids D. injection of phenol into the hemorrhoidal tissue

C (rubber band ligation of the internal hemorrhoids) (This patient has internal hemorrhoids. The treatment of choice for the protruding internal hemorrhoids that this patient has is rubber band ligation. Rubber band ligation is especially useful in situations in which the hemorrhoids are enlarged or prolapsing)

___________________ are used for acute exacerbations of inflammatory bowel disease and if no response to metronidazole.

Corticosteroids (prednisone)

(Crohn disease / Ulcerative colitis) is more likely to have linear fissures.

Crohn disease

A 25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having "nervous stomach," irritable bowel syndrome, and "depression." Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area. What is the most likely diagnosis?

Crohn disease

A colonoscopy that shows cobblestone or skip lesions should make you think of what diagnosis?

Crohn disease

Obstruction, abscess, fistula, and sinus tracts are more common in (Crohn disease / Ulcerative colitis).

Crohn disease

Presents with abdominal pain, weight loss, diarrhea and oral mucosal aphthous ulcers. Longer standing disease may have severe anemia, polyarthralgia, and fatigue.

Crohn disease

The most common etiological agent of short bowel syndrome is (disorder) ____________________.

Crohn disease

What disease should be considered with fistula in ano?

Crohn disease

_____________ is an inflammatory bowel disease that can affect any portion of the gastrointestinal tract, though often spares the rectum.

Crohn disease

_________________ is an inflammatory bowel disease that is associated with cholelithiasis.

Crohn disease

Which of the following drugs has no role in the management of inflammatory bowel disease (IBD)? A. Infliximab B. Budesonide C. Mercaptopurine D. Cisapride

D (Cisapride) ( Cisapride is a prokinetic agent. It has no role in the management of IBD.)

Which of the following is not a known complication of diverticulitis? A. Fistula B. Colonic stricture C. Abscess D. Colon cancer

D (Colon cancer) (Colon cancer is not a complication of diverticulitis. All other options are.)

Which of the following is not an extraintestinal manifestation of inflammatory bowel disease? A. Uveitis B. Erythema nodosum C. Arthritis D. Dermatitis herpetiformis

D (Dermatitis herpetiformis) (Dermatitis herpetiformis - A chronic, very itchy skin rash made up of bumps and blisters) is an extraintestinal manifestation of celiac disease. All other options are correct.)

A 79-year old woman presents with left lower quadrant abdominal pain with a history of changes in her elimination pattern. Physical examination reveals abdominal distention, tenderness and a palpable mass in the left lower quadrant. Barium enema shows segmental spasm and muscular thickening with a narrowed lumen. What is the most likely diagnosis? A. Celiac disease B. Crohn disease C. Ulcerative colitis D. Diverticulitis

D (Diverticulitis) (Diverticulitis presents commonly as left lower quadrant pain, tenderness, palpable mass, and abdominal distention)

A 20-year-old woman comes to the office because of a new rash that appeared two days ago on her legs as shown below. The lesions are non-pruritic and tender to touch. She was recently diagnosed with an inflammatory bowel disease that is still being worked-up. Which of the following is the most likely diagnosis for her dermatological condition? A. Dermatitis herpetiformis B. Erythema chronicum migrans C. Erythema marginatum D. Erythema nodosum

D (Erythema nodosum)

A 58-year-old alcoholic man comes to the office because of diarrhea for the past 4 days. He has been taking heartburn medication for the past week for worsening epigastric pain. His pulse is 95/min and blood pressure is 100/60 mm Hg. Laboratory studies show a serum potassium of 3.3 mEq/L. Which of the following medications did the patient most likely overuse? A. Aluminum hydroxide B. Calcium carbonate C. Cimetidine D. Magnesium hydroxide E. Ondansetron

D (Magnesium hydroxide) (Magnesium hydroxide is an antacid used in the treatment of gastritis and gastroesophageal reflux disease. It can produce diarrhea and hypotension in an overdose) (Alcoholism, over time, can produce many adverse effects. Its effects on the gastrointestinal tract are particularly salient, notably on the liver and the stomach. Gastritis can occur in the setting of alcoholism, and implies an inflammatory process is happening. Patients can be characterized by symptoms of gastric inflammation and pain due to its effects on the lining of the stomach. Antacids, among others, can provide some relief.) (While antacids are generally well-tolerated, there does exist a risk for overdose. This can happen in cases of gastritis that turn chronic, such as in alcoholism, for which patients continually take antacids to provide symptomatic relief. Magnesium-based antacids such as magnesium hydroxide, in particular, carries the risk of diarrhea and hypotension.)

A 33-year-old man comes to the clinic because of abdominal cramps for the past five months. His older brother has had similar episodes in the past. He has recently lost 10 lbs (unintentionally) and has occasional diarrhea, sometimes with blood. He denies nausea, vomiting, constipation, and food allergies. A colonoscopy shows lesions that extend proximally beyond the ileocecal valve. Which of the following is most closely associated with the likely diagnosis? A. Ankylosing spondylitis B. Inflammation of mucosa and submucosa only C. Markedly increased risk of colon cancer D. Non-caseating granulomas E. Pancolitis involving the rectum

D (Non-caseating granulomas) (Crohn disease, unlike ulcerative colitis, is associated with non-caseating granulomas. A number of other factors distinguish the two conditions including the site of origin, a pattern of progression, the thickness of inflammation, any predominant symptoms, complications, radiographic findings, and risk of colon cancer.) (Crohn disease and ulcerative colitis are two types of chronic inflammatory bowel disease. Crohn disease is about 30 times more likely if a sibling has it. It may involve any part of the GI tract from the mouth to the anus and may present with fever, rectal bleeding, weight loss, anorexia, nausea, vomiting, malnutrition, and vitamin deficiencies. While ulcerative colitis does not move proximally into the ileum, Crohn disease does. Crohn disease, unlike ulcerative colitis, affects the entire thickness of the colon and may cause fistulae, abscesses, and fibrotic strictures. Non-caseating granulomas may be visible in 15-30% of biopsy specimens and 40-60% of resected bowel. Management of Crohn disease includes lifestyle changes, medication, and often in cases of intestinal blockage, surgery.)

A 23-year-old man comes to the emergency department because of an episode of bloody diarrhea. He has been experiencing intermittent abdominal pain for the past two months that is sometimes relieved with defecation. He has lost 4.5-kg (9.9-lb) of weight during that time period. He currently rates his pain a 7 on a 10-point scale. A complete blood count shows a hemoglobin concentration of 9.7 g/dL, hematocrit of 39%, and a leukocyte count of 14,700/mm3. The patient is admitted and scheduled for a colonoscopy with biopsy. Which of the following cell types, if found in the descending colon, is the most closely associated with the patient's condition? A. Absorptive cells B. Goblet cells C. Neuroendocrine cells D. Paneth cells E. Parietal cells

D (Paneth cells) (Ulcerative colitis (UC) is an inflammatory bowel disease affecting the distal colon. Paneth cells are involved in innate immunity and indicate an inflammatory process when found in the descending colon) (Ulcerative colitis (UC) is an inflammatory bowel disease that most commonly affects the distal colon. It is characterized by recurring episodes of inflammation that begin at the rectum and spread proximally. Inflammation is usually limited to the mucosa and submucosa. Bloody diarrhea, colicky abdominal pain, urgency, fever, fatigue, and weight loss are common clinical features of UC. Biopsies of affected segments show mucosal inflammation, ulceration, and chronic mucosal damage. Pseudopolyps and crypt abscesses can be seen as well. Paneth cells can be present in the small bowel or ascending colon, but are pathologic when in the descending colon. They are exocrine cells with large eosinophilic secretory granules. They release contents such as lysozyme, phospholipase A2, and defensins which all function to break down membranes of microorganisms. They are involved in innate immunity and regulation of the intestinal crypt microenvironment. Paneth cell metaplasia is an epithelial cell abnormality that is associated with UC.)

A 24-year-old woman comes to the emergency department because of severe diffuse abdominal pain. She has a six-month history of crampy abdominal pain accompanied by intermittent bloody diarrhea. Her temperature is 38.5°C (101.3°F), pulse is 126/min, respirations are 25/min, and blood pressure is 80/40 mm Hg. Physical examination shows marked abdominal distention. A complete blood count shows a leukocyte count of 12,500/mm3, a hemoglobin of 8.5 g/dL, and a hematocrit of 30%. An abdominal radiograph shows marked distention of the distal colon. A surgical consult is called for an immediate colectomy. Which of the following is most likely shown upon pathological examination of the patient's colon? A. Cobblestone mucosa B. Fistulae C. Granulomas D. Pseudomembranes E. Pseudopolyps

D (Pseudomembranes) (Ulcerative colitis (UC) is an inflammatory bowel disease that affects the distal colon. It is characterized by inflammatory, ulcerative damage to the mucosa and submucosa and by the formation of pseudopolyps) (Ulcerative colitis (UC) is an inflammatory bowel disease that affects the distal colon. The peak incidence of UC is between age 20-25, and 20% of affected individuals have family members also with the disease. The inflammation of UC generally begins in the rectum and spreads proximally and continuously to other parts of the colon. Pathologic features of UC include mucosal inflammation, ulceration, and chronic mucosal damage. Pseudopolyps can be seen as regenerating areas of mucosa bulge outward. A diffuse mononuclear inflammatory infiltrate can be seen in the lamina propria. Crypt abscesses, submucosal fibrosis, and disruption of mucosal architecture are other common features. Inflammation is generally limited to the mucosa and submucosa except in severe cases, such as in the development of toxic megacolon, a potentially lethal complication)

Which of the following is the correct combination for triple therapy ? A. One PPI + One H2 receptor antagonist + One antibiotic B. Two PPIs + One antibiotic C. Two H2 receptor antagonists + one antibiotic D. Two antibiotics + one PPI

D (Two antibiotics + one PPI) (The 14-day combinations of omeprazole or lansoprazole plus amoxicillin and clarithromycin have an approximately 85% to 90% eradication rate)

Which of the following statements concerning inflammatory bowel disease is not true? A. Ulcerative colitis is more common in non-smokers and ex-smokers. B. Appendectomy protects against ulcerative colitis. C. Crohn disease causes segmental transmural inflammation of the bowel. D. Ulcerative colitis affects the colon in a descending fashion.

D (Ulcerative colitis affects the colon in a descending fashion) (Ulcerative colitis is isolated to colon and confined to mucosa and submucosa. Most common site is the rectum. Ulcerative colitis affects the colon in an ascending fashion starting from the rectum up to the ascending colon.)

Which of the following organisms is (are) most likely to be involved in the diverticulitis? A. Escherichia coli B. Bacteroides fragilis C. Streptococcus pneumoniae D. a and b

D (a and b) (The most common organisms involved in the development of diverticulitis are E. coli and B. fragilis)

When diverticulosis develops inflamed microperforations, the condition is called __________________.

Diverticulitis

_______________ is defined as inflammation of the diverticula caused by obstructing matter.

Diverticulitis

__________________ presents with constipation, left lower quadrant pain, fever, ↑ WBC, and may bleed.

Diverticulitis

What is the most common cause of lower GI bleed?

Diverticulosis

________________ is defined as large outpouchings of the mucosa in the colon.

Diverticulosis

___________________ presents with painless rectal bleeding, particularly in an elderly patient.

Diverticulosis

Crohn's disease is associated with which of the following? A. Inflammation limited to the superficial layer of the bowel wall B. The affinity to involve the rectosigmoid junction C. Decreased risk of colon cancer D. Continuous mucosal areas of ulceration that affect the anus E. Fistula formation

E (Fistula formation) (Crohn's disease is characterized by a transmural inflammation of the GI tract. It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal thickening give the bowel a cobblestone appearance, with some skipped areas of normal bowel. In addition to the transmural inflammation, there are granulomas, abscesses, fissures, and fistula formation. Symptoms include fever, weight loss, abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated blood), and growth retardation in children. In children, Crohn's disease is more common than ulcerative colitis. Complications include intestinal obstruction; toxic megacolon, which is usually more common in ulcerative colitis; malabsorption, particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal perforation; fistula formation; and development of gall and kidney stones)

A 29-year-old man comes to the emergency department because of right lower abdominal pain and distension, diarrhea, and fever. He says that he has been experiencing these episodes for two years due to his inflammatory bowel disease. The episodes typically last 1-2 weeks and then subside. His condition is currently being managed by a gastroenterologist. Despite medical management with 2 medications, his symptoms have worsened. A biopsy from colonoscopy at the time of diagnosis showed the presence of noncaseating granulomas and skip lesions with transmural ulcers. A barium swallow is obtained and shown multiple string signs. Which of the following treatments is the most appropriate next step for management of this patient's condition? A. Anti-TNFα therapy B. Glucocorticoids C. Mesalamine D. Metronidazole E. Surgical resection

E (Surgical resection) (Operative management of Crohn disease is reserved primarily for patients who develop complications or have disease refractory to medical management) (The next step in management of this patient is surgical resection of the obstructed segment of the bowel) (His noncaseating granulomas and skip lesions with transmural ulcers indicate that his underlying condition is Crohn disease. Physical examination shows many of the extraintestinal manifestations of Crohn disease. The presence of noncaseating granulomas is highly specific for Crohn disease, although only ~35% of patients have these. The barium study shows an obstruction, which is a common complication of Crohn disease) (Crohn disease is most often located at the terminal ileum, but it is diffuse and expansive throughout the gastrointestinal tract. Thus, surgery is used for management, but it is not curative. As many as 50% patients require at least one surgical procedure during the course of their disease) (Operative management is reserved for patients who develop complications or have disease refractory to medical management. Indications for surgery include: Persistent symptoms despite high-dose corticosteroid therapy Treatment-related complications including intra-abdominal abscesses Medically intractable fistulae Fibrotic strictures with obstructive symptoms Toxic megacolon Intractable hemorrhage Perforation Cancer)

A 52-year-old homeless man comes to the emergency department because of several episodes of severe bloody diarrhea. He is responsive only to painful stimuli and is unable to answer questions. His temperature is 39.2°C (102.6°F), pulse is 125/min, respirations are 8/min, and blood pressure is 86/54 mm Hg. Physical examination shows marked lower abdominal distension. A complete blood count shows a hemoglobin concentration of 6.5 g/dL, hematocrit of 25%, and a leukocyte count of 14,000/mm3. Despite aggressive antibiotic treatment and multiple blood transfusions, he passes away. An autopsy shows extensive, continuous inflammation and necrosis of the distal colon from the sigmoid colon to the rectum. Which of the following is the most appropriate diagnosis? A. Crohn disease B. Hirschsprung megacolon C. Intussusception D. Irritable bowel syndrome E. Ulcerative colitis

E (Ulcerative colitis) (Ulcerative colitis (UC) is characterized by inflammation that develops in the rectum and spreads proximally. Toxic megacolon is a potentially lethal complication of UC) (Ulcerative colitis (UC) is a subtype of inflammatory bowel disease, a chronic relapsing inflammatory disorder that affects the gastrointestinal tract. UC is characterized by inflammatory ulceration and destruction of the mucosa that begins in the rectum and spreads proximally. The spread of inflammation is continuous, and skip lesions are not observed. Affected individuals experience attacks of bloody diarrhea that may persist for days to months, colicky lower abdominal pain, and cramps. In rare cases, the muscularis propria and neural plexuses can be exposed to fecal material. The subsequent inflammatory response can cause toxic megacolon, a potentially lethal complication consisting of colonic distension, gangrene, and perforation)

A 21-year-old woman comes to the office because of abdominal pain and bloody stools with intermittent diarrhea and constipation. Additionally, she complains of fatigue and unintentional weight loss over the past six months. A blood test shows an erythrocyte sedimentation rate (ESR) of 30 mm/hour and a platelet count of 510,000/mm3. A computed tomography scan of the abdomen shows a large lesion that is restricted to the distal colon. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn disease C. Irritable bowel syndrome D. Radiation colitis E. Ulcerative colitis

E (Ulcerative colitis) (Ulcerative colitis is characterized by mucosal inflammation and is limited to the colon. Crohn disease will be characterized by transmural inflammation on biopsy and may be found throughout the GI tract) (Ulcerative colitis (UC) is a subtype of inflammatory bowel disease (IBD), a chronic relapsing-remitting inflammatory disorder of the gastrointestinal tract. IBD is caused by autoimmune responses against the normal gut flora and/or self-antigens. IBD appears to have a genetic basis, with the major histocompatibility complex, class II, DR beta 1 (HLA-DRB1) gene linked to UC and the HLA-DR7 and DQ4 alleles associated with Crohn disease (CD). UC generally involves at least the rectum and sigmoid colon. Colonic involvement is continuous, without skip lesions. The major clinical feature of UC is blood diarrhea that can persist for days to months. Cramps, tenesmus, and colicky lower abdominal pain relieved by defecation may also be present. Inflammation and damage in UC most often affect the mucosa. A mononuclear infiltrate in the lamina propria and crypt abscesses may also be observed)

A 37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day. What is the most likely diagnosis?

Gastritis

A 30-year-old woman comes to the office because of increasing fatigue over the past several months. She was diagnosed with Crohn disease as a teenager, for which she had an ileocolic resection 3 years ago. She has not had any recent diarrhea or abdominal pain and says that she has not seen any blood in her stool. She eats a well-balanced diet and takes a multivitamin regularly. Her fecal occult blood test is negative. Which of the following best explains this patient's fatigue? A. Calorie deficiency B. Folate deficiency C. Iron deficiency D. Protein deficiency E. Vitamin B12 deficiency

E (Vitamin B12 deficiency) (Deficiency in vitamin B12 is a complication of Ileal resection, which is necessary for some patients with Crohn disease. Because the ileum is the site of vitamin B12 absorption, stores will be depleted in several years without adequate supplementation) (This patient is suffering from Crohn disease, which commonly affects the terminal ileum, and had her ileum surgically resected three years ago. Therefore, the most likely cause of her fatigue is anemia caused by a vitamin B12 deficiency. B12 is absorbed in the ileum, so this patient can no longer absorb B12 from her diet. The human body usually stores enough B12 to last for a couple of years, which is why she is presenting three years after surgery. The treatment for this condition would be B12 injections. Those without an ileum can also suffer from diarrhea and steatorrhea (fatty stools) since the ileum is where most of the bile acids are reabsorbed. Bile acids are necessary for fat absorption)

Which of the following is most sensitive and specific for detection of Helicobacter infections? A. serology for IgG against H. pylori B. urea breath test C. H. pylori stool antigen D. none of the above is particularly sensitive E. endoscopic biopsy with histologic examination

E (endoscopic biopsy with histologic examination) (Endoscopy with biopsy and histologic examination has a sensitivity of more than 95% and 100% specificity. Not everyone can or needs to have endoscopy, however, and other noninvasive tests have excellent sensitivity and specificity. In the office setting, stool examination for H. pylori antigen has a sensitivity of 93% and a specificity of 98%, and it is a good tool for the identification of infection in symptomatic outpatients. The urea breath test has a sensitivity of 95% and a specificity of 98%, but it requires special equipment not often found in family medicine offices. The serum IgG antibody test is 85% sensitive and 78% specific, but it is not useful to assess eradication because it remains positive for some time after treatment.)

_____________________ is the gold standard for diagnosis of gastritis with 4 biopsies along stomach lining will reveal the location and extent of the gastritis as well as the presence of H.pylori

Endoscopy

________________ are painful when thrombosed, as they receive somatic innervation from the inferior rectal branch of the pudendal nerve.

External hemorrhoids

___________________ may become thrombosed, resulting in a painful, purplish swelling. Rarely, they ulcerate and cause minor bleeding. Cleansing the anal region may be difficult.

External hemorrhoids

A patient on sulfasalazine for an inflammatory bowel disease should be supplemented with what vitamin?

Folate

In gastritis a urea breath test can be used to detect the presence of ____________.

H.pylori

Chronic autoimmune gastritis is an example of a type _____ hypersensitivity reaction.

IV

_______________________ are used in conjunction with steroids if the patient with IBD does not respond to metronidazole or 5-ASA's.

Immunosuppressants (azathioprine, 6-mercaptopurine)

Diverticulitis is defined as inflammation of the diverticula caused by obstructing matter, which leads to ______________________.

Infection and macroperforation

Adalimumab and __________________ are two monoclonal antibodies that can be used to treat Crohn disease by binding to tumor necrosis factor-alpha.

Infliximab

A 43-year-old has recently noticed bright red blood on the toilet paper when he wipes. He denies any fatigue, decreased exercise tolerance, abdominal pain, or maroon-colored or black, tarry stools. He has no family history of colon cancer. He has never had a colonoscopy. On physical exam, his temperature is 98.6 F, heart rate 70/min, and blood pressure 120/75 mmHg. He does not have conjunctival pallor. There are no abnormalities on cardiac, pulmonary, and abdominal exams. What is the most likely diagnosis?

Internal hemorrhoids

What type of hemorrhoids No pain, but bright red blood per rectum

Internal hemorrhoids

_________________ typically manifest with bleeding after defecation; blood is noted on toilet tissue and sometimes in the toilet bowl.

Internal hemorrhoids

__________________ receive visceral innervation and therefore are not painful.

Internal hemorrhoids

_____________________ and broad-spectrum antibiotics are appropriate treatments for patients with mild diverticulitis.

Low-residue diet

Causes acute gastritis include:

NSAID overuse EtOH abuse Pathophysiologic stress (i.e. burns, CNS injury) H. pylori infection Herpes CMV

Pain caused by a thrombosed external hemorrhoid can be treated with _____________.

NSAIDs

___________________ is a morphological feature of autoimmune type chronic gastritis.

Neuroendocrine hyperplasia

Diverticular disease is diagnosed with ___________________.

Non-contrast CT scan

_______________ in the stool and mild to moderate leukocytosis may occur with diverticulitis.

Occult blood

_____________________ is a triple therapy regime against H.pylori infection in gastritis.

Omeprazole + Amoxicillin + Clarithromycin

____________________ is a red cell complication of chronic autoimmune gastritis that manifests due to the lack of intrinsic factor.

Pernicious anemia

___________________ should be done in diverticular disease to rule out free air.

Plain-film radiography

____________________ is a local anesthetic used for analgesia and antipruritic effects for hemorrhoids, burns, minor cuts, scrapes and minor skin irritation.

Pramoxine

Ulcerative colitis is an inflammatory bowel disease associated with (hepatobiliary disorder) __________________ and p-ANCA positivity.

Primary sclerosing cholangitis

______________ is useful in inflammatory bowel disease if the colon is involved.

Sulfasalazine

___________________ is used for larger, prolapsing internal hemorrhoids or those that do not respond to conservative management.

Rubber band ligation

Symptomatic treatment is usually all that is needed for internal hemorrhoids including ___________________, warm sitz baths after each bowel movement and as needed, anesthetic ointments containing lidocaine, or witch hazel (Hamamelis) compresses.

Stool softeners (eg, docusate, psyllium)

_______________________ occur when protrusion and constriction occlude the blood supply. They cause pain that is occasionally followed by necrosis and ulceration.

Strangulated hemorrhoids

Crohn disease is associated with the ________________ or narrowing of the bowel lumen on X-ray.

String sign

________________ may be necessary in severe cases of diverticular disease, including peritonitis, large abscesses, fistulae, or obstruction.

Surgical management

What type of chronic gastritis? Slowly developing lesions Usually occurs in gastric fundus Caused by anti-parietal cell antibodies Associated with pernicious anemia Patients at increased risk of developing adenocarcinoma

Type A

What type of chronic gastritis? Slowly developing lesions Usually occurs in the gastric antrum Caused by NSAID use H. pylori infection Often asymptomatic Associated with increased risk of developing PUD

Type B

Is surgery curative for Crohn's or ulcerative colitis?

Ulcerative Colitis

A 32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had an intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points. What is the most likely diagnosis?

Ulcerative colitis

A complication of __________________ that may be a presenting symptom is toxic megacolon, which is severe dilation of the colon.

Ulcerative colitis

Non-contrast CT scan of diverticular disease will demonstrate fat stranding and __________________.

bowel wall thickening

Internal hemorrhoids are found (above/below) the pectinate line.

above

Colovesical fistula, a fistula between the colon and bladder, can develop as a complication of diverticulitis, presents with stool or ______________ in the urine.

air (pneumaturia)

Liver function tests should be done of pts with UC. Elevated _________________ and γ-glutamyl transpeptidase levels in patients with major colonic involvement suggest possible primary sclerosing cholangitis.

alkaline phosphatase

Acute gastritis is from rapidly developing lesions, usually located in the gastric __________.

antrum

The _______________ of the stomach is most commonly affected by Helicobacter pylori chronic gastritis.

antrum

Neuroendocrine hyperplasia is a morphological feature of _______________ type chronic gastritis.

autoimmune

The most common cause of vitamin B12 deficiency is chronic __________ gastritis.

autoimmune

Diagnosis of ulcerative colitis is by __________________ and colonoscopy with biopsy.

barium enema

External hemorrhoids are found (above/below) the pectinate line

below

Diverticulosis is caused by chronic, intermittent, increased intraluminal pressure at a point of weakness in the muscular layer of the colon wall where (location) _____________________.

blood vessels enter the tissue.

The (anatomical location) _________________ of the stomach are affected in autoimmune chronic gastritis.

body and fundus

(Crohn disease/Ulcerative colitis/both) is an/are inflammatory bowel disease(s) associated with migratory polyarthritis.

both

Aphthous stomatitis is an oral extraintestinal manifestation of (Crohn disease / ulcerative colitis / both).

both

Ulcerative colitis is an inflammatory bowel disease with histological findings of __________________with neutrophils, ulcers, and no granulomas.

crypt abscesses

A ________________ abscess may produce buttock or coccyx pain and rectal fullness; fever is more likely.

deeper

External hemorrhoids are located below the _______________line.

dentate

Fistulae will produce anal ______________ and pain when the tract becomes occluded.

discharge

Treatment of an anorectal abscess requires surgical _______________, followed by warm-water cleansing, analgesics, stool softeners and a high-fiber diet are prescribed for all patients.

drainage

Occasionally _______________ is used for thrombosed external hemorrhoids.

excision

Colonoscopy with biopsy for ulcerative colitis will show both show continuous inflammation starting from rectum and ______________ with loss of haustral markings and lumen narrowing.

extending proximally

Non-contrast CT scan of diverticular disease will demonstrate ______________ and bowel wall thickening.

fat stranding

Diverticulitis occurs when diverticula are blocked by ________________ in the bowel.

fecal material

A standard surgery for simple anal fistulas is _______________ with or without marsupialization.

fistulotomy

Plain-film radiography should be done in diverticular disease to rule out _____________.

free air

Patients with chronic gastritis are at increased risk of developing ______________.

gastric carcinoma

Anal fistulas are identified by _________________ tissue on exam.

granulation

Ulcerative colitis is an inflammatory bowel disease associated with a Th2 mediated response and hence NO ______________.

granulomas

Diverticulosis is present in roughly _________ of people over 60 years old.

half

Two complications of diverticulosis include diverticulitis and ________________.

hematochezia

The gastrin level in autoimmune chronic gastritis is (high/low).

high

Crohn disease most commonly affects the ________________.

ileum and colon

Internal hemorrhoids sometimes cause mucus discharge and a sensation of _________________________.

incomplete evacuation

5-ASA compounds block prostaglandin release and serve to reduce ___________________.

inflammation

Ulcerative colitis is an inflammatory bowel disease associated with pseudopolyps, loss of haustra, and a resultant "____________" appearance on imaging.

lead pipe

While most patients are asymptomatic, diverticulosis can cause bleeding in 5 to 15% of patients and is most likely from the (right/left) colon in Western countries.

left

Diverticulitis presents with constipation, _____________ pain, fever, ↑ WBC, and may bleed.

left lower quadrant

Ulcerative colitis is an inflammatory bowel disease associated with ________________ pain and bloody diarrhea.

left lower quadrant

Occult blood in the stool and mild to moderate _____________ may occur with diverticulitis.

leukocytosis

Colonoscopy with biopsy for ulcerative colitis will show both show continuous inflammation starting from rectum and extending proximally with __________________ and lumen narrowing.

loss of haustral markings

Diverticulosis is associated with a (high/low) fiber diet.

low

The gastric acid level in Helicobacter pylori-caused chronic gastritis with extensive gastritis is typically (high/low).

low

The gastric acid level in autoimmune chronic gastritis is (high/low).

low

Colonoscopy with biopsy for ulcerative colitis will show both show continuous inflammation starting from rectum and extending proximally with loss of haustral markings and ___________________.

lumen narrowing

Diverticulosis is defined as large outpouchings of the _________ in the colon.

mucosa

Ulcerative colitis is an inflammatory bowel disease that involves only (layers of the GI tract) ______________ inflammation.

mucosal and submucosal

Protective factors against gastritis include ________________. Any imbalance in protective factors can lead to inflammation

mucus, bicarbonate, prostaglandins, alkaline state, hydrophobic layer and epithelial renewal

Diverticula arise where the vasa recta traverses the ___________________, a common weak spot in the colonic wall.

muscularis propria

Crohn disease is an inflammatory bowel disease involving _________________ granulomas.

noncaseating

Diverticulitis is defined as inflammation of the diverticula caused by _____________________.

obstructing matter

Diverticulosis is defined as large ______________ of the mucosa in the colon.

outpouchings

The most common symptom of anal fissures is _________.

pain

External hemorrhoids are (painful / painless) with no bleeding.

painful

Diverticulosis resents with (painful / painless) rectal bleeding, particularly in an elderly patient.

painless

Internal hemorrhoids are (painful / painless) with bleeding.

painless

Ulcerative colitis that extends from the rectum to the entire rest of the colon is termed _____________.

pancolitis

Chronic gastritis presents with decreased levels of serum _____________________ as chief cells are lost with parietal cells.

pepsinogen I

Complications of diverticulitis include abscesses, fistula formation, intestinal obstruction, and perforation, which are treated with ________________ or surgery.

percutaneous drainage

DO NOT perform colonoscopy in the setting of acute diverticular disease as you can:

perforate the colon

Anal Abscess is a clinical diagnosis, it will show a __________________.

perirectal tender swollen mass

If left untreated, diverticulitis may lead to a perforated bowel, resulting in _______________.

peritonitis

Anal fissures most often occur in the (anterior/posterior) midline.

posterior

Liver function tests should be done of pts with UC. Elevated alkaline phosphatase and γ-glutamyl transpeptidase levels in patients with major colonic involvement suggest possible _______________________.

primary sclerosing cholangitis

5-ASA compounds block ____________ release and serve to reduce inflammation.

prostaglandin

External hemorrhoids are painful when thrombosed, as they receive somatic innervation from the inferior rectal branch of the ______________ nerve.

pudendal

Crohn disease is an inflammatory bowel disease that can affect any portion of the gastrointestinal tract, though often spares the ______________.

rectum

Most common site of inflammation in ulcerative colitis is the __________________.

rectum

Ulcerative colitis is an inflammatory bowel disease that is limited to the (sections of the GI tract) colon, including the _____________.

rectum

A complication of ulcerative colitis that may be a presenting symptom is __________________, which is severe dilation of the colon.

toxic megacolon

Crohn disease is an inflammatory bowel disease that is more commonly associated with (mucosal/transmural) inflammation and skip lesions.

transmural

Diverticula arise where the ______________ traverses the muscularis propria, a common weak spot in the colonic wall.

vasa recta

Most painful hemorrhoids, thrombosed, ulcerated or not, are seen on ___________________ of the anus and rectum.

visual inspection

Internal hemorrhoids are painless (with / without) bleeding.

with

External hemorrhoids are painful (with / without) bleeding.

without

Labs for ulcerative colitis will show:

↑ WBC ↑ ESR Anemia