CR - Abdominal and Gastrointestinal Disorders

Question 1

What is the clinical presentation of a patient with Boerhaave’s syndrome and which diagnostic study is likely to be most beneficial?

Answer 1

Severe retching or vomiting followed by lower thorax or epigastric pain is the most common presentation; the most common tear site is the left posterolateral wall 2-3cm before the stomach. Occasionally pain is also reported in the retrosternal, left shoulder, or upper chest areas.

A standard chest radiograph is almost always abnormal and may show left pleural effusion (most common) mediastinal or free peritoneal air, widened mediastinum, or left pneumothorax. Diagnosis may be confirmed by either CT scan or an esophogram using water soluble contrast (gastrografin) since barium may cause additional pleura-mediastinal inflammation if a tear is present

Question 2

What are the differentiating clinical features that distinguish crohn’s disease from ulcerative colitis?

Answer 2

Both develop in teenagers and young adults. Patients have abdominal pain and diarrhea.

Ulcerative colitis - affects only colon
Crohns disease - affects anywhere from mouth to anus. 30% perianal fissure or fistulas, perirectal abscess

Question 3

What is the general management of ingested foreign bodies that are sharp or pointed?

Answer 3

Sharp or pointed objects, as well as objects longer than 5cm and wider than 2cm or oddly shaped foreign bodies such as opened safety pins, must be removed endoscopically. They should be removed before passing through the pylorus because 15-35% will cause perforation, usually in the region of the ileocecal valve

Question 4

What is the management of ingested foreign bodies that are sharp or pointed in children?

Answer 4

• initial phyiscal exam and xray in all children, labs are usually not necessary
• if symptoms are present, obtain surgical consult. If the ingested item is a sewing needle, needles in the stomach need endoscopic removal. Needles that have passed into the intestines require early surgical consult
• If no symptoms are present, follow with serial xrays
• no progression past the stomach necessitates contrast xray to exclude perforation
• signs of perforation or failure to pass through the GI tract require surgical consultation

Question 5

A small child swallows a quarter. Where is it most likely to become impacted?

Answer 5

The esophagus

The three most common sites for impaction are:
1 - the cricopharyngeous muscle (C6) = 7-%
2 - adjacent to the aortic arch and carina (T4) = 15%
3 - lower esophageal sphincter/diaphragmatic hiatus (T10-11) = 15%

Question 6

Which types of hepatitis produce neither a chronic infection nor a carrier state?

Answer 6

Hepatitis A and hepatitis E

Rarely a chronic hepatitis E infection may occur in immunosuppressed patients

Question 7

The clinical presentation of an esophageal foreign body in children may be “dysphagia” what else is possible?

Answer 7

Respiratory distress due to compression of the pliable trachea, including cough or stridor. Food refusal, weight loss, drooling, gagging, emesis / hematemesis, chest pain, or sore throat may also occur

Question 8

What is the appropriate therapy for a patient with a cecal volvulus? is the treatment the same for a sigmoid volvulus?

Answer 8

Cecal volvulus requires surgery as soon as possible

No, acute management of sigmoid volvulus in stable patients is detorsion and decompression with a rectal tube via either a sigmoidoscopy or colonoscopy (90% success rate). Unstable patients with signs of peritonitis, ischemic bowel, or failure of endoscopic decompression require emergent surgery

Question 9

Name the most common causes of:
1. all types of intestinal obstruction
2. small bowel obstruction
3. large bowel obstruction

Answer 9

1. Adynamic ileus
2. adhesions, external hernias, neoplasm
3. carcinoma, sigmoid diverticulitis, and volvulus

Adhesions are the most common cause of mechanical small bowel obstruction, whereas carcinoma is the most common cause of mechanical colon obstruction

Question 10

Clinical presentation: a 45 year old presents with substernal chest pain following forceful vomiting.

What is the most likely diagnosis and which side is most frequently involved?

Answer 10

Boerfaave’s syndrome (spontaneous esophageal rupture) occurs mainly in males between the ages of 40-60 and usually involves the left posterior lateral aspect of the esophagus

Question 11

Both mallory-weiss syndrome and boerhaave’s syndrome involve tears of the esophagus. How do these tears differ anatomically?

Answer 11

Mallory-Weiss syndrome involves a vertical tear of the inner mucosa and sometimes submucosa. Bleeding is generally from submucoasl vessels. Often from powerful wretching, tears usually occur in the distal esophagus and proximal stomach. Typically, upper GI bleeding is the presentation.

Boerhaave’s syndrome involves a complete rupture of all layers of the esophagus, both mucosal and muscular. It typically presents as left-sided chest pain. One may hear subcutaneous emphysema or a “crunching” sound when auscultating the heart.

Question 12

A patient has recently returned from a back-packing trip in colorado and presents with abdominal pain, bloating and gas. He also complains of postprandial abdominal cramping, an urgency to defecate and has diarrhea that is frothy and foul-smelling. A stool specimen sent to the lab is negative for ova and parasites. What is the most likely etiology?

Answer 12

Giardia lamblia - with passage of stool giardia cysts and trophozoites are not always present, making a positive diagnosis difficult. Stool antigen tests or PCR may be used instead of ova and parasite tests but detection can be difficult with these as well

Question 13

Clinical presentation: a 43 year old woman presents with epigastric discomfort after eating dinner. She is tender in both the epigastrium and RUQ.

What radiographic study is used in establishing the diagnosis?

Answer 13

Ultrasound is the preferred imaging modality. It is 99% sensitive for cholecystitis and 84% specific.

Hepatobiliary scintigraphy or HIDA scan, can be used if ultrasound reveals equivocal results

Question 14

What are poor prognostic signs in patients with pancreatitis?

Answer 14

Persistence of SIRS vital signs, elevated BUN, hematocrit, or creatinine, evidence of organ failure, age > 55, obesity (BMI >30), established comorbid disease, altered mental status.

On imaging presence of extra-pancreatic fluid collections, pleural effusions, pulmonary infiltrate.

Note: scoring modalities for pancreatitis include Ranson’s criteria, Apache-II, and CT severity index

Question 15

Name the most common causes of bright red rectal bleeding

Answer 15

Anal lesions particularly fissures and hemorrhoids

Question 16

Name the most common bacterial cause of bloody diarrhea

Answer 16

E. coli

Most common cause of bloody diarrhea worldwide and in the US

Question 17

Name the most common cause of upper GI bleeding

Answer 17

Peptic ulcer disease (duodenal ulcer most common)

Question 18

A patient with diagnosed ulcerative colitis demonstrates a transverse colon measuring >6cm on an abdominal film. What is the significance of this finding?

Answer 18

Toxic megacolon

Question 19

What is the first line treatment for patients with severe pseudomembranous colitis?

Answer 19

Oral fidaxomicin or vancomycin. If critically ill, intravenous metronidazole or oral vancomycin

Question 20

What is the most common complication of upper GI endoscopy

Answer 20

Esophageal trauma

Question 21

Why should all femoral hernias be referred for surgical evaluation and repair on an urgent basis?

Answer 21

Femoral hernias are particularly prone to complications if not repaired. This type of hernia is at high risk of strangulation

Question 22

Clinical presentation: a patient with recent history of CAD, MI or peripheral vascular disease develops sudden onset of abdominal pain. There is also diarrhea that is positive for occult blood.

What is the suspected diagnosis?

Answer 22

Mesenteric vascular occlusion

Question 23

A young woman presents with recurrent episodes of altered bowel function (diarrhea or constipation). The episodes are usually precipitated by stress and the pain is described as crampy or achy and is confined to the lower abdomen. In association with constipation, it is relieved by defecation or gas passage. Extracolonic symptoms (bloating, belching, reflux) are common. The patient denies anorexia, fever, and weight loss. Nonspecific exam findings may include vague lower abdominal tenderness and a palpable stool-filled sigmoid colon. Labs are unremarkable. What is the likely diagnosis?

Answer 23

Irritable bowel syndrome (IBS)

Question 24

Which abnormal electrolyte finding should be considered in patients with acute pancreatitis?

Answer 24

Hypocalcemia

Question 25

Hemorrhagic shock is a potential complication of which inflammatory GI disorder

Answer 25

Pancreatitis

Question 26

What are the historical findings consistent with the diagnosis of irritable bowel syndrome?

Answer 26

Rome IV criteria
Recurrent abdominal pain on average at least 1 day/week during the previous 3 months associated with two or more of the following:
-related to defecation (increased or unchanged)
-associated with a change in stool frequency
- associated with a change in stool form or stool appearance

Question 27

What are the most likely causes of lower GI bleeding in children?

Answer 27

Meckel’s diverticulum is the most common cause of significant lower GI bleeding in children

Anal fissure is the most likely cause of minor lower GI bleeding in a healthy infant beyond the neonatal period without previous GI history. It is commonly associated with recent introduction of cow’s milk or solid foods

Question 28

What is the most common cause of upper GI bleeding in pregnancy?

Answer 28

Esophagitis
(secondary to reflux and repeated vomiting)

Question 29

A patient presents with sudden onset LUQ pain associated with violent retching (but no vomiting). Upright films of the chest and abdomen reveal a distended stomach with one or two air-fluid levels. What is the diagnosis?

Answer 29

Gastric volvulus presents with sudden onset of severe abdominal pain with retching or vomiting.

Upright films of the chest and abdomen may reveal stomach distension with one or two air fluid levels, or a retrocardiac stomach air-filled gastric shadow, or a large, gas filled loop of bowel in the abdomen or chest

Question 30

What is the most common cancer of the small intestine

Answer 30

Adenocarcinoma

Usually occurs in the proximal small bowel
Higher incidence in patients with long-standing crohns disease

Question 31

What is the most frequent site for aortoenteric fistula?

Answer 31

Distal duodenum

(consider this diagnosis in patients with GI bleeding and a history of aneurysms)

Question 32

What is carcinoid syndrome?

Answer 32

Carcinoid tumor cells (usually in the distal small bowel) secrete 5-hydroxytryptophan causing wheezing, shortness of breath, intermittent flushing, abdominal pain, diarrhea, signs and symptoms of right sided valvular heart disease.

Diagnosis is confirmed by obtaining a urine level of 5-hydroxyindoleacetic acid (5HIAA)

Question 33

What is the most common presenting symptom related to cholelithiasis?

Answer 33

Biliary colic
RUQ pain without fever

Question 34

What is the most commonly isolated organism from a hepatic abscess? (pyogenic and amebic)

Answer 34

Pyogenic (usually e.coli) -> 90%
Amebic (entamoeba histolytica) -> 10%

Question 35

What are the most common causes of portal hypertension worldwide? (pre-hepatic, intra-hepatic, and post-hepatic)

Answer 35

Pre-hepatic - portal vein thrombosis

Intra-hepatic - alcoholic cirrhosis (USA), schistosomiasis (wordlwide)

Post-hepatic - restrictive pericarditis vs hepatic vein thrombosis

Question 36

What is the most common blood-borne viral infection in the united states

Answer 36

hepatitis c virus (HCV)

Question 37

What are the two most common causes of esophageal bleeding

Answer 37

Varices
Mallory weiss tear

Question 38

UGI bleeding due to ruptured esophageal varices can be controlled in 90-95% of cases with what type of treatment?

Answer 38

Endoscopic sclerotherapy
Pharmacologic agents (octreotide)

Question 39

Clinical presentation: a middle aged male with cirrhosis who is confused and unable to hold an assumed position (asterixis).

What is the diagnosis and appropriate management?

Answer 39

Hepatic encephalopahy is the diagnosis

Management includes:
Lactulose
Decreased protein intake (especially animal protein)
Avoidance of all sedatives and tranquelizers
Avoid bicarbonate (alkalosis may precipitate or worsen encephalopahy)
Correction of hypokalemia
Rifaximin

Question 40

When is the insertion of a sengstaken-blakemore tube for esophageal varix hemorrhage contraindicated.

What procedure should be done prior to the insertion of the tube?

Answer 40

Contraindications include:
-hiatal hernia (precludes proper tube placement)
- peptic ulcer disease with stricture of the esophagus
-bleeding from esophageal lacerations
-inability of the patient to protect the airway

Endoscopy should precede insertion (if at all possible) so that the diagnosis may be confirmed

Question 41

Bloody diarrhea should warrant testing for which bacteria?

Answer 41

Shigella
Salmonella
Campylobacter
Hemorrhagic e. coli
Yersinia enterocolitica

Question 42

Protozoal pathogens most frequently associated with diarrhea that persists for more than 7-10 days are ____ and ____

Answer 42

Giardia
Cryptosporidiuim

Question 43

Patients with refratory cryptosporidiosis, cyclosporiasis, or isosporiasis should be tested for ____ ____

Answer 43

HIV infection

Question 44

What is the most common cause of esophageal perforation?

Answer 44

Iatrogenic perofration

Iatrogenic perforation may be the result of intraluminal procedures, endoscopy, dilation, gastric intubation, or intraoperative injury. Boerhaave’s syndrome is responsible for 10-15% of perforations

Question 45

What is the orientation of a swallowed coin in the esophagus when view on AP chest X-ray

Answer 45

The coin generally presents in the coronal orientation (with the face of the coin seen on AP view) as opposed to tracheal aspiration which shows the face on the lateral prjection

Question 46

What is likely your best imaging modality for a non-radiopaque esophageal foreign body

Answer 46

CT scanning is the best high-yield test for evaluation of non-radiopaque esophageal foreign bodies. CT scan will also provide more information regarding complications from the foreign body such as perforation or infection

Question 47

Why is a button battery lodged in the esophagus considered a true emergency?

Answer 47

Button batteries lodged in the esophagus can perforate in as little as six hours. Lithium cells tend to have the worst outcomes. If the button battery has already reached the stomach it can be managed expectantly

Question 48

What type of patient frequently develops cecal volvulus?

Answer 48

Marathon runners and pregnant patients

Question 49

What are charcots triad and reynolds pentad used to diagnose

Answer 49

Ascending cholangitis

Charcots triad is abdominal pain (particularly RUQ), jaundice, fever

Reynold’s pentad adds the additional findings of shock and altered mental status

Question 50

What is the difference between reducible, incarcerated and strangulated hernias

Answer 50

Reducible - hernia sac able to be replaced back through te defect

Incarcerated - hernia sac cannot be replaced back through the defect

Strangulated - impairment of blood flow