IntDis E2 Quiz Review

Mutation of the adenomatous polyposis coli gene (APC gene), without mutations of any other tumor suppressor genes, is the cause of what very common neoplastic disorder? a. Adenomatous polyps b. Peutz-Jeghers syndrome c. Hyperplastic polyps d. Inflammatory polyps

a. Adenomatous polyps

55-year-old woman comes to the emergency department because of a 24-hour history of severe lower abdominal pain. She has had two episodes of non-bloody vomiting today and has been unable to keep down food or fluids. She has not had a bowel movement since the day before. PMH: She has hyperlipidemia and rheumatoid arthritis treated with NSAIDS and periodically with glucocorticoids. Cholecystectomy 5 years ago due to acute cholecystitis. Drugs: 20 pack-years of cigarettes (i.e., patient has been smoking one pack of cigarettes/day for the past 20 years). Currently smoking. Current medications include atorvastatin (for high cholesterol), and naproxen (NSAID) & sporadically high-dose glucocorticoids (Prednisone) RA. Vital statistics: temp 38.8°C (101.8°F); HR 102/min, regular rhythm; RR 20/min; BP 118/78 mm Hg. BMI is 33.4 kg/m2. Abdominal examination reveals soft abdomen with hypoactive bowel sounds. There is moderate left lower quadrant tenderness (TTP). A tender mass is palpable on digital rectal examination. No involuntary muscle guarding or rebound tenderness. Diagnosis? a. Diverticulitis b. Peritonitis c. Constipation d. Appendicitis

a. Diverticulitis

18 year old caucasian male came in for colonoscopy. Grandfather and uncle were diagnosed with colon cancer in early thirties. >100 polyps found on colonoscopy. a. Familial Adenomatous Polyposis b. CRC of right colon c. CRC of left colon

a. Familial Adenomatous Polyposis

The most common type of groin hernia in males and females is... a. Indirect inguinal hernia b. Direct inguinal hernia c. Femoral hernia

a. Indirect inguinal hernia

What condition is described below? Presents with signs and symptoms classically associated with appendicitis (e.g., RLQ pain, muscle guarding, fever, vomiting, leukocytosis). It often is associated with a recent or coexisting viral infection of the upper respiratory tract or GI tract. The condition mimics appendicitis, except the pain is more diffuse, signs of peritonitis often are absent, and generalized lymphadenopathy may be present. a. Mesenteric adenitis b. Necrotizing enterocolitis c. Meckel diverticulitis d. Midgut volulus

a. Mesenteric adenitis

A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1-2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Given the clinical data, what is the most likely differential diagnosis? a. Ulcerative colitis b. Crohn's disease c. Diverticulitis d. Small bowel obstruction

a. Ulcerative colitis

Paneth cells are located in... a. crypts of Lieberkühn in small intestine b. hepatic flexure of large intestine c. ileocecal junction d. vermiform appendix

a. crypts of Lieberkühn in small intestine d. vermiform appendix

Ulcerative colitis often presents with... (select all that apply) a. frequent diarrhea b. watery diarrhea c. voluminous diarrhea d. bloody diarrhea e. tenesmus

a. frequent diarrhea b. watery diarrhea d. bloody diarrhea e. tenesmus

A 19-year-old woman comes to the physician because of a 1-year history of severe abdominal pain, bloating, and episodic diarrhea. She has also had a 10-kg (22-lb) weight loss over the past 10 months. Physical examination shows a mildly distended abdomen, diffuse abdominal tenderness, and multiple erythematous, tender nodules on the anterior aspect of both legs. There is a small draining lesion in the perianal region. Further evaluation of this patient's gastrointestinal tract is most likely to show which of the following findings? a. transmural inflammation b. neuroendocrine tumor cells c. villous atrophy d. crypt abscesses e. no structural abnormalities

a. transmural inflammation

Crohn disease often presents with... (select all that apply) a. voluminous diarrhea b. watery diarrhea c. non-bloody diarrhea d. steatorrhea e. tenesmus

a. voluminous b. watery c. non-bloody diarrhea d. steatorrhea

63 year old caucasian male. Progressive fatigue, weight loss in past 6 months. Lab findings: positive occult blood test & iron-deficiency anemia. Top DDx? a. Familial Adenomatous Polyposis b. CRC of right colon c. CRC of left colon

b. CRC of right colon

55-year-old woman comes to the emergency department because of a 24-hour history of severe lower abdominal pain. She has had two episodes of non-bloody vomiting today and has been unable to keep down food or fluids. She has not had a bowel movement since the day before. PMH: She has hyperlipidemia and rheumatoid arthritis treated with NSAIDS and periodically with glucocorticoids. Cholecystectomy 5 years ago due to acute cholecystitis. Drugs: 20 pack-years of cigarettes (i.e., patient has been smoking one pack of cigarettes/day for the past 20 years). Currently smoking. Current medications include atorvastatin (for high cholesterol), and naproxen (NSAID) & sporadically high dose glucocorticoids (Prednisone) RA. Vital statistics: temp 38.8°C (101.8°F); HR 102/min, regular rhythm; RR 20/min; BP 118/78 mm Hg. BMI is 33.4 kg/m2. Abdominal examination reveals soft abdomen with hypoactive bowel sounds. There is moderate left lower quadrant tenderness (TTP). A tender mass is palpable on digital rectal examination. No involuntary muscle guarding or rebound tenderness. Which of the following is most appropriate to confirm the diagnosis, its extent, and detecting potential complications? a. abdominal ultrasound b. CT scan of abdomen with contrast c. colonscopy d. abdominal x-ray e. exploratory laparotomy

b. CT scan of abdomen with contrast

A patient with IBD has the following extra-intestinal disorders: Erythema Nodusum Pyoderma Gangrenosum Acrodermatitis enteropathica What is the best clinical assessment? a. Crohn disease, but not Ulcerative Colitis b. Either Ulcerative Colitis or Crohn disease c. Ulcerative Colitis, not Crohn disease

b. Either Ulcerative Colitis or Crohn disease

A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1-2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Which of the following is the most appropriate next step in management? a. Wireless capsule endoscopy b. colonoscopy c. flexible sigmoidoscopy d. assessment of anti-gliadin antibodies e. CT scan of abdomen and pelvis with contrast f. assessment of auto-antibodies of parietal cells and intrinsic factor

b. colonoscopy

A 37-year-old woman comes to the physician because of right-sided inguinal pain for the past 8 weeks. During this period, the patient has had increased pain during activities such as walking and standing. She has no nausea, vomiting, or fever. Her temperature is 36.8°C (98.2°F), pulse is 73/min, and blood pressure is 132/80 mm Hg. The abdomen is soft and non-tender. There is a visible and palpable groin protrusion above the inguinal ligament on the right side. Bulging is felt during Valsalva maneuver. Which of the following is the most likely diagnosis? a. strangulated hernia b. indirect inguinal hernia c. direct inguinal hernia d. femoral hernia e. subcutaneous abdominal lipoma f. inguinal lymphadenopathy

b. indirect inguinal hernia Auscultation of the area over the groin protrusion might provide another clue.

63-year-old man comes to the emergency department because of pain in his left groin for the past hour. The pain began soon after he returned from a walk. He describes it as 8 out of 10 in intensity and vomited once on the way to the hospital. He has had a swelling of the left groin for the past 2 months. He has chronic obstructive pulmonary disease and hypertension. Current medications include amlodipine, albuterol inhaler, and a salmeterol-fluticasone inhaler. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 101/min, and blood pressure is 126/84 mm Hg. Examination shows a tender bulge on the left side above the inguinal ligament that extends into the left scrotum; lying down or applying external force does not reduce the swelling. Coughing does not make the swelling bulge further. There is no erythema. The abdomen is distended. Bowel sounds are hyperactive. Scattered rhonchi are heard throughout both lung fields. Which of the following is the most appropriate next step in management? What is the correct clinical assessment? a. direct inguinal hernia b. indirect inguinal hernia c. inguinal lymphadenopathy d. incarcerated inguinal hernia e. femoral hernia

b. indirect inguinal hernia d. incarcerated inguinal hernia

79-year-old man is brought to the emergency department because of a 1-hour history of severe groin pain, nausea, and vomiting. He reports that he has had a groin swelling that worsens with standing, coughing, and straining for the past 3 months, but he has not sought medical attention for it. Examination shows a non-reducible bulging mass of the left groin that is severely tender to palpation; the overlying skin is erythematous. Abdominal ultrasound shows protrusion of abdominal contents through a defect medial to the inferior epigastric vessels. Which of the following is the most likely site of protrusion of the patient's groin mass? a. linea alba b. inguinal triangle (aka Hesselbach triangle) c. deep inguinal d. femoral ring e. rectus abdominis muscle f. inferior lumbar triangle

b. inguinal triangle (aka Hesselbach triangle)

The functions of Paneth cells include... (include all that apply) a. enzyme release to aid in digestion b. protection of enterocyte stem cells c. antimicrobial activity required for a healthy gut flora d. absorption of fat in large intestine

b. protection of enterocyte stem cells c. antimicrobial activity required for a healthy gut flora

Which IBD has the following unique clinical features? Watery, non-bloddy diarrhea +/- steatorrhea Smoking is a risk factor Appendectomy increases the risk for the disease a. Neither Crohn's or UC. Both diseases have the same clinical features b. Ulcerative colitis c. Crohn disease

c. Crohn disease

2-week-old infant is brought to the emergency room because of 4 episodes of bilious vomiting and inconsolable crying for the past 3 hours. Abdominal examination shows no abnormalities. An upper GI contrast series shows the duodenojejunal junction to the right of the vertebral midline; an air-filled cecum is noted in the right upper quadrant. Which of the following is the most likely cause of this patient's condition? a. Hypertrophy and hyperplasia of the pyloric sphincter b. Defective neural crest migration c. Incomplete rotation of the intestines d. Failure of duodenal recanalization e. Telescoping of ileum into cecum

c. Incomplete rotation of the intestines

Patient with peritonitis due to ruptured appendicitis. Develops fever, tachycardia, tachypnea, hypotension, and ↑ WBC. Treated with vasopressors => persistent hypotension and after adequate fluid resuscitation, there is persistent lactic acidosis. Best assessment? a. Obstructive ileus b. Paralytic ileus c. Septic shock and risk for Multiple organ dysfunction syndrome d. Acute diverticulitis

c. Septic shock and risk for Multiple organ dysfunction syndrome

Which IBD is most likely when the HPI includes the following clinical features? (Reminder HPI = history of present illness) Severe hematochezia Toxic megacolon with risk for perforation and peritonitis High risk for CRC The disease can potentially be cured surgically 90% of individuals with primary sclerosing cholangitis (PSC) has this IBD disease a. Crohn Disease b. IBS-M c. Ulcerative Colitis

c. Ulcerative Colitis

CASE 1 A 54-year-old man comes to the emergency department because of a 2-day history of increasingly severe, colicky abdominal pain, nausea, and bilious vomiting. His last bowel movement was yesterday and he has not passed flatus since then. No long-term change in bowel habits, until the acute onset of abdominal pain. Negates weight loss, history of anemia, or blood in stool. PMH: He underwent appendectomy at the age of 39. Vitals: BMI 35.4 kg/m2. Temp 36.8°C (98.4°F); RR 15/min; HR 90/min, regular rhythm; B/L BP 112/67 mmHg. Abdominal examination shows three well-healed laparoscopic scars. The abdomen is distended. Hyperresonant percussion note. Absence of bowel sounds, except for occational, metallic high-pitched bowel sounds on auscultation. Digital rectal examination shows an empty rectum. Laboratory studies show: Abdominal ultrasound shows nonpropulsive peristalsis of the small bowel. What is the top differential diagnosis and clinical features? Select two. a. intramural bowel obstruction b. obstructive ileus - mechanical bowel obstruction c. extrinsic bowel obstruction d. Gastric outlet obstruction (GOO) e. Intraluminal bowel obstruction f. Colorectal Cancer g. small bowel obstruction h. large bowel obstruction i. paralytic ileus - functional bowel obstruction

c. extrinsic bowel obstruction g. small bowel obstruction

CASE 1 A 54-year-old man comes to the emergency department because of a 2-day history of increasingly severe, colicky abdominal pain, nausea, and bilious vomiting. His last bowel movement was yesterday and he has not passed flatus since then. PMH: He underwent appendectomy at the age of 39. Vitals: BMI 35.4 kg/m2. Temp 36.8°C (98.4°F); RR 15/min; HR 90/min, regular rhythm; B/L BP 112/67 mmHg. Abdominal examination shows three well-healed laparoscopic scars. The abdomen is distended. Hyperresonant percussion note. Absence of bowel sounds, except for occational, metallic high-pitched bowel sounds on auscultation. Digital rectal examination shows an empty rectum. Laboratory studies show: Abdominal ultrasound shows nonpropulsive peristalsis of the small bowel. What is the most probable cause of the patient's current acute abdominal disorder? a. inflamed colonic diverticula b. obesity c. history of abdominal surgery d. inflammatory bowel disease

c. history of abdominal surgery

15-year-old girl is brought to the physician by her mother for a 2-day history of abdominal pain, nausea, vomiting, diarrhea, and decreased appetite. Her last menstrual period was 3 weeks ago. Her temperature is 37.6°C (99.7°F). Abdominal examination shows tenderness to palpation with guarding in the right lower quadrant. Laboratory studies show a leukocyte count of 12,600/mm3. What is the most likely underlying cause of this patient's condition? a. Colonic diverticular inflammation b. Gestation in the fallopian tube (extra-uterine pregnancy) c. intraluminal obstruction, infection, and ischemia d. mesenteric adenitis

c. intraluminal obstruction, infection, and ischemia

54-year-old woman comes to the emergency department because of a 5-hour history of diffuse, severe abdominal pain, nausea, and vomiting. She reports that there is no blood or bile in the vomitus. Two weeks ago, she started having mild aching epigastric pain, which improved with eating. Since then, she has gained 1.4 kg (3 lb). PMH: She has a 2-year history of osteoarthritis of both knees, for which she takes ibuprofen (NSAID). She drinks 1-2 glasses of wine daily. Physical exam: patient is lying supine with her knees drawn up and avoids any movement. Her temperature is 38.5°C (101.3°F), pulse is 112/min, respirations are 20/min, and blood pressure is 115/70 mm Hg. Abdominal examination reveals RUQ and epigastric abdominal tenderness (TTP), involuntary muscle guarding and rebound tenderness in the epigastric region and the RUQ; absent bowel sounds. Diagnosis? a. acute appendicitis with perforation b. gastroesophageal reflux disease (GERD) c. perforated peptic ulcer d. gastric cancer

c. perforated peptic ulcer Viscus rupture (perforation): Perforation of a peptic ulcer can manifest with acute, diffuse abdominal pain, nausea, vomiting, fever, and tachycardia, all of which are seen in this patient. The chest x-ray finding of pneumoperitoneum further supports this diagnosis. Examination findings are typical for peritonitis (abdominal involuntary muscle guarding and rebound tenderness) and developing paralytic ileus (decreased bowel sounds). This patient's recent history of epigastric pain relieved by food intake in combination with regular alcohol consumption and NSAID (ibuprofen) use indicates an underlying duodenal ulcer. Comment: H. pylori infection needs to be ruled out or treated if detected. H. pylori is the most common cause of gastric and duodenal PUD and gastritis (except for AMAG). Perforation is the second most common complication of peptic ulcer disease (after gastrointestinal bleeding).

A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1-2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Which of the following is the most appropriate next step in management? a. Assessment of anti-gliadin antibodies b. Flexible sigmoidoscopy c. CT scan of the abdomen and pelvis with contrast d. Colonoscopy e. assessment of auto-antibodies for parietal cells and intrinsic factor f. wireless capsule endoscopy

d. Colonoscopy

A 33-year-old woman comes to the physician because of a 4-month history of intermittent lower abdominal cramps associated with diarrhea, bloating, and mild nausea. During this period, she has had a 5-kg (11-lb) weight loss. She feels like she cannot fully empty her bowels. She has no history of serious illness. She has a high-fiber diet. Her father is of Ashkenazi Jewish descent. She has smoked 2 packs of cigarettes daily for 15 years. She appears well. Her temperature is 36.9°C (98.5°F), pulse is 90/min, and blood pressure is 130/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Abdominal examination shows mild tenderness to palpation in the right lower quadrant without guarding or rebound. Bowel sounds are normal. Test of the stool for occult blood is negative. Her hemoglobin concentration is 10.5 g/dL, leukocyte count is 12,000/mm3, platelet count is 480,000/mm3, and erythrocyte sedimentation rate is 129 mm/h. A barium enema shows ulceration and narrowing of the right colon. Which of the following is the most likely diagnosis? a. Ulcerative colitis b. Celiac disease c. Diverticulitis d. Crohn's disease e. irritable bowel syndrome

d. Crohn's disease

A 19-year-old woman, gravida 1, para 0, at 21 weeks' gestation comes to the physician for a follow-up prenatal visit. At her previous appointment, her serum α-fetoprotein concentration was elevated. She had smoked 1 pack of cigarettes daily for 3 years but quit at 6 weeks' gestation. Examination shows a uterus consistent in size with a 21-week gestation. Ultrasonography shows fetal viscera suspended freely into the amniotic cavity. Which of the following is the most likely diagnosis? a. Femoral hernia b. Omphalocele c. Diastasis recti d. Gastroschisis

d. Gastroschisis

A 2-week-old infant is brought to the emergency room because of 4 episodes of bilious vomiting and inconsolable crying for the past 3 hours. Abdominal examination shows no abnormalities. An upper GI contrast series shows the duodenojejunal junction to the right of the vertebral midline; an air-filled cecum is noted in the right upper quadrant. Which of the following is the most likely cause of this patient's condition? a. Hypertrophy and hyperplasia of the pyloric sphincter b. Defective neural crest migration c. Telescoping of ileum into cecum d. Incomplete rotation of the intestines e. Failure of duodenal recanalization

d. Incomplete rotation of the intestines

A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1-2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Given the clinical data, what is the most likely differential diagnosis? a. Diverticulitis b. Small bowel obstruction c. Crohn's disease d. Ulcerative colitis

d. Ulcerative colitis

A 6-week-old male infant is brought to the physician by his mother because of a 2-day history of recurrent nonbilious vomiting. Vomiting occurs almost immediately after most feeds. Each time, he becomes irritable while feeding and refuses to finish the bottle. He was born at 37 weeks' gestation and weighed 3300 g (7 lb 4 oz); he currently weighs 4000 g (8 lb 13 oz). He has Down syndrome. His vaccinations are up-to-date. He appears agitated and cries during the examination. His temperature is 37.2°C (99°F), pulse is 156/min, respirations are 32/min, and blood pressure is 100/49 mm Hg. Examination shows upward slanting of the eyelids, a broad and flat nasal bridge, and a single transverse palmar crease on both hands. The abdomen is soft and nontender. A 2.5-cm (1-inch) epigastric mass is palpated. Cardiac examination shows no abnormalities. What is the top differential diagnosis? a. Mesenteric adenitis b. Acute appendicitis c. Midgut volvulus d. Meckel diverticulitis e. Congenital pyloric stenosis

e. Congenital pyloric stenosis

10-year-old girl is brought to the emergency department because of lower abdominal pain for the past 12 hours. The pain has progressively worsened and was accompanied by occasional episodes of diarrhea. She has vomited twice. Her mother has Crohn disease. Her temperature is 38.1°C (100.6°F), pulse is 95/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. The abdomen is soft, and there is mild tenderness to palpation in the right lower quadrant without rebound or guarding. Bowel sounds are normal. Her hemoglobin concentration is 13.0 g/dL, leukocyte count is 12,800/mm3, and platelet count is 345,000/mm3. Urine dipstick is negative for nitrites and leukocyte esterase. Urinalysis shows 3 WBC/hpf and no RBCs. Which of the following is the most appropriate next step in management? a. Emergency laparoscopy b. CT scan of the abdomen c. MRI of the abdomen d. Colonoscopy e. X-ray of the abdomen f. ultrasound of the abdomen

f. ultrasound of the abdomen