Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PSBIM: PGH REVIEW > GASTRO > Flashcards

GASTRO Flashcards

1
Q

What is purpose of high-dose proton pump inhibitor infusion in patients with upper gastrointestinal bleeding secondary to peptic ulcer disease? (HPIM 20th ed. C44 P272)

a. Enhance clot stability
b. Prevent H. pylori proliferation
c. Maintain intragastric pH at 5
d. Decrease splanchnic circulation

A

The correct answer is: Enhance clot stability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A 45/F came in due to melena. She has been having episodes of epigastric pain for 1 year. She noted that her stools became tarry in the last 3 days which prompted her consult. On endoscopy, a flat pigmented spot was noted. Which of the following management strategies is NOT appropriate for this patient? (HPIM 20th ed. C44 P274 F44-1)

a. No endoscopic therapy is required
b. Once daily PPI therapy
c. Regular diet post-endoscopy
d. Hospitalization for 1-2 days for observation

A

The correct answer is: Regular diet post-endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

A 35/M was brought to the emergency room due to hematochezia. He had an episode of bleeding of approximately 2 tbsp of bright red blood admixed with stools 3 hours prior to consult. Personal and family medical history were unremarkable. Initial vital signs showed BP 120/80, HR 110, RR 20 and afeb. PE revealed bright red blood per examining finger, no masses palpated. What is the next step for this patient? (HPIM 20th ed. C44 P275)

a. Observe.
b. Flexible sigmoidoscopy
c. Colonoscopy
d. CT angiography

A

The correct answer is: Flexible sigmoidoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the initial test used to evaluate massive bleeding suspected to be from the small intestine? (HPIM 20th ed. C44 P275)

a. Angiography
b. Video capsule endoscopy
c. Push enteroscopy
d. Small bowel barium radiography

A

The correct answer is: Angiography

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Which of the following is true regarding fecal occult blood test? (HPIM 20th ed. C44 P275)

a. Recommended as part of initial work up for anemia
b. A positive test warrants colonoscopy
c. Can be substituted for colonoscopy as screening for colon CA in high-risk individuals
d. Used for screening for colon CA starting at age 45

A

The correct answer is: A positive test warrants colonoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How long should prasugrel be discontinued in a patient undergoing colonoscopy with polypectomy? (HPIM 20th ed. C315 P2195 T315-2)

a. 5 days
b. 7 days
c. 10 days
d. 14 days

A

The correct answer is: 7 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

A young man presented in the OPD with substernal heartburn. He already self-medicated with a proton pump inhibitor for a month and had temporary relief of symptoms. However, upon discontinuing the drug, the heartburn returned. What is the next appropriate step for this patient? (HPIM 20th ed. C315 P2202)

a. Upper abdominal UTZ
b. FOBT
c. H. pylori testing
d. Endoscopy

A

The correct answer is: Endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

A 50/M presented to the OPD with a protruding rectal mass which he is able to reduce manually. Which of the following treatment modalities is particularly indicated for this stage of the disease? (HPIM 20th ed. C321 P2289 T321-6)

a. Fiber supplementation
b. Cortisone suppository
c. Sclerotherapy
d. Rubber band ligation

A

The correct answer is: Rubber band ligation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

A 25/F post-valve replacement RHD patient came in due to a two-day history of severe abdominal pain. She was previously maintained on warfarin, but was recently discontinued due to financial constraints. She reports diffuse abdominal pain with associated nausea, vomiting and bloody diarrhea. On arrival, her vital signs were 120/90, 110, 24, Afeb. Her abdomen was soft, slightly distended and had hypoactive bowel sounds. Palpation revealed minimal tenderness only. Given the patient’s presentation, what is the gold standard to diagnose her disease? (HPIM 20th ed. C322 P2293)

a. Angiography
b. Spiral CT
c. Duplex ultrasonography
d. Exploratory laparotomy

A

The correct answer is: Angiography

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Which of the following disease conditions will cause a falsely normal amylase level in a patient with acute pancreatitis? (HPIM 20th ed. C340 P2433)

a. Hypertriglyceridemia
b. Esophageal cancer
c. Renal insufficiency
d. Sepsis

A

The correct answer is: Hypertriglyceridemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the most common cause of acute pancreatitis? (HPIM 20th ed. C341 P2484)

a. Gallstone
b. Hypertriglyceridemia
c. Alcoholism
d. Post-ERCP

A

The correct answer is: Gallstone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

A 40/F came to the ER due to severe abdominal pain described as boring and dull, located in the epigastric area. Initial vital signs were BP 90/60, HR 120, RR 24 and afeb. She was awake and coherent. PE revealed decreased breath sounds on the right lower lung field. Labs showed BUN 28 mg/dL, Crea 0.8mg/dL. STAT CXR showed a hazy opacity blunting the right costophrenic angle. What is the BISAP score of this patient? (HPIM 20th ed. C341 P2441 T341-3)

a. 1
b. 2
c. 3
d. 4

A

The correct answer is: 3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which of the following characteristics is a risk factor for pigment stone formation and nor cholesterol stones? (HPIM 20th ed. C339 P2425 T339-1)

a. Weight loss
b. Alcoholic liver cirrhosis
c. Increasing age
d. Pregnancy

A

The correct answer is: Alcoholic liver cirrhosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Which of the following conditions predisposes one to develop emphysematous cholecystitis? (HPIM 20th ed. C339 P2428)

a. Salmonella carrier state
b. Gallstones
c. Diabetes mellitus
d. Prolonged parenteral nutrition

A

The correct answer is: Diabetes mellitus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What autoimmune marker is important in diagnosing primary biliary cholangitis? (HPIM 20th ed. C329 P2335 T329-3)

a. Mitochondrial antibody
b. P-ANCA
c. Anti-LKM
d. Anti-smooth muscle

A

The correct answer is: Mitochondrial antibody

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Which of the following conditions will NOT exhibit extreme elevations in aminotransferase levels (i.e. > 1000 IU/L)? (HPIM 20th ed. C330 P2339)

a. Acute alcoholic hepatitis
b. Toxin-induced liver injury
c. Ischemic liver injury
d. Passage of a gallstone in the bile duct

A

The correct answer is: Acute alcoholic hepatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Which of the following proteins will NOT be decreased in the setting of liver disease? (HPIM 20th ed. C330 P2340)

a. Factor V
b. Serum globulin
c. Serum albumin
d. Prothrombin

A

The correct answer is: Serum globulin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which hepatitis virus is exclusively transmitted via the feco-oral route? (HPIM 20th ed. C332 P2356 T332-2)

a. Hepatitis A
b. Hepatitis B
c. Hepatitis D
d. Hepatitis E

A

The correct answer is: Hepatitis E

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Which of the following hepatitis profiles correspond to infection with a pre-core mutant? (HPIM 20th ed. C332 P2360 T332-5)

a. HBsAg+ AntiHBs- AntiHBc:IgG HBeAg- AntiHBe+
b. HBsAg+ AntiHBs- AntiHBc:IgM HBeAg+ AntiHBe-
c. HBsAg- AntiHBs- AntiHBc:IgM HBeAg- AntiHBe-
d. HBsAg- AntiHBs+ AntiHBc:IgG HBeAg- AntiHBe+

A

The correct answer is: HBsAg+ AntiHBs- AntiHBc:IgG HBeAg- AntiHBe+

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

A 25/F was admitted to the ER due ingestion of 20 tablets of paracetamol 12 hours prior to consult. She had mild nausea and vomiting, but was otherwise asymptomatic. PE was also unremarkable. Initial measurement of serum paracetamol showed 150 ug/ml. Serum AST and ALT and bilirubins were slightly elevated. Which of the following is part of the management of the patient? (HPIM 20th ed. C333 P2371)

a. Activated charcoal for gastric lavage
b. IV N-acetylcysteine therapy
c. Liver transplantation
d. Hemodialysis to facilitate removal of paracetamol in the bloodstream

A

The correct answer is: IV N-acetylcysteine therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

. Which of the following characteristics would exclude the use of glucocorticoids in patients with alcoholic hepatitis with discriminant function of >32? (HPIM 20th ed. C335 P 2400)

a. Hepatic encephalopathy
b. Active infection
c. Renal failure
d. Concomitant viral hepatitis

A

The correct answer is: Renal failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Among patients with alcoholic liver disease, liver biopsy is usually done after how many months of abstinence to demonstrate residual, nonreversible disease? (HPIM 20th ed. C337 P2406)

a. 2 months
b. 4 months
c. 6 months
d. 8 months

A

The correct answer is: 6 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

A known cirrhotic patient presented in the ER with hematemesis. What is the first line of treatment to control bleeding acutely? (HPIM 20th ed. C337 P2411)

a. Endoscopic therapy
b. Proton pump inhibitors
c. Blood transfusion
d. Epinephrine

A

The correct answer is: Endoscopic therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

A 70/F with CLD initially presented with constipation, then developed confusion and irritability over several days. PE revealed normal vital signs, was drowsy but arousable, with increased abdominal girth but no abdominal tenderness. What is the most likely diagnosis? (HPIM 20th ed. C337 P2413)

a. Electrolyte imbalance
b. Hepatic encephalopathy
c. Spontaneous bacterial peritonitis
d. Variceal bleed

A

The correct answer is: Hepatic encephalopathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Which of the following pathologic features characterizes Crohn’s disease as opposed to ulcerative colitis? (HPIM 20th ed. C319 P2262-3)

a. Limited to mucosa and superficial submucosa
b. Rectum is always involved
c. Granulomas are characteristic features
d. Can present with megacolon or toxic colitis in fulminant disease

A

The correct answer is: Granulomas are characteristic features

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Which of the following is NOT an indication for surgery in ulcerative colitis? (HPIM 20th ed. C319 P2274 T319-8)

a. Toxic megacolon
b. Colon cancer prophylaxis
c. Disease limited to the colon
d. Colonic obstruction

A

The correct answer is: Disease limited to the colon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Which of the following is NOT part of the ROME IV criteria to diagnose irritable bowel syndrome? (HPIM 20th ed. C320 P2276)

a. Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months
b. Related to defecation
c. Associated with a change in frequency of stool
d. Associated with a change in form/appearance of stool

A

The correct answer is: Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Which of the following interventions is appropriate for gas and bloating in patients with IBS? (HPIM 20th ed. C320 P2282 T320-4)

a. High FODMAP diet
b. Probiotics
c. Loperamide
d. Lactulose

A

The correct answer is: Probiotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is the most common complication of diverticulitis? (HPIM 20th ed. C321 P2284 T321-1)

a. Abscess
b. Fistula
c. Perforation
d. Stricture

A

The correct answer is: Abscess

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What laboratory test is used to indicate degree of catabolism and adequacy of protein replacement? (HPIM 20th ed. C327 P2323 T327-2)

a. Serum albumin
b. Urine urea nitrogen
c. C-reactive protein
d. Carotene

A

The correct answer is: Urine urea nitrogen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Which of the following antibiotics pose the LEAST risk of C. difficile infection?

a. Ampicillin
b. Ceftriaxone
c. Ciprofloxacin
d. Piperacillin-tazobactam

A

The correct answer is: Piperacillin-tazobactam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is the recommended colonoscopy monitoring for patients with long-standing (>8 years) ulcerative pancolitis or Crohn’s colitis?

a. Colonoscopy on diagnosis then subsequent colonoscopy based on initial findings
b. Colonoscopy every 10 years
c. Colonoscopy every 5 years
d. Colonoscopy with biopsies every 1-2 years

A

The correct answer is: Colonoscopy with biopsies every 1-2 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Who of the following patients require periprocedural antibiotic prophylaxis?

a. 34/M with mitral regurgitation from rheumatic heart disease undergoing flexible sigmoidoscopy
b. 55/M undergoing endoscopic ultrasound and fine-needle aspiration of a solid lesion in the esophagus
c. 68/F with prosthetic left knee undergoing routine colonoscopy
d. 75/M undergoing percutaneous endoscopic feeding tube placement

A

The correct answer is: 75/M undergoing percutaneous endoscopic feeding tube placement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Which of the following is LEAST helpful for constipation-predominant irritable bowel syndrome?

a. Cholestyramine resin
b. Magnesium hydroxide
c. Lactulose
d. Psyllium husk

A

The correct answer is: Cholestyramine resin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

A 38/F consults for abdominal discomfort on most days of the week with variable location and intensity for the past 6 months. She admits to being stressed from work and notes the symptoms are more intense then. She experiences both constipation and diarrhea but diarrhea predominates. Defecation relieves her abdominal discomfort. PE was unremarkable. Labs showed normal WBC, ESR of 44 mm/hr. FOBT was negative. Which of the following interventions is MOST appropriate for this patient?

a. Antidepressants
b. Endoscopy
c. Reassurance
d. Stool bulking agents

A

The correct answer is: Endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

A 50/F was recently started on atorvastatin for dyslipidemia and fatty liver by her primary physician. One month after initiation, she was noted to have asymptomatic elevations of ALT and AST 3x from upper limit and normal bilirubins. Which of the following is TRUE regarding her condition?

a. Atorvastatin needs to be discontinued pending a repeat measurement of transaminases
b. Her hepatic steatosis increased her risk of having drug-induced hepatotoxicity
c. Statin dose needs to be decreased
d. Statin therapy need not be discontinued for this patient

A

The correct answer is: Statin therapy need not be discontinued for this patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Which of the following causes most cases of upper gastrointestinal bleeding? (C44, P272-273)

a. Esophageal varices
b. Peptic ulcers
c. Mallory-Weiss tears
d. Vascular ectasias

A

UPPER GI BLEEDING: ETIOLOGIES
Peptic ulcers: account for ~50% of cases

Esophageal varies: varies widely but accounts for ~2-40% of cases

Mallory-Weiss tears: account for ~2-10% of cases

Erosive disease
• Erosive gastritis and duodenitis: ~10-15%
• Erosive esophagitis (probably from GERD): ~1-10%
Less common causes
• Neoplasms
• Vascular ectasias: hereditary hemorrhagic telangiectasis (Osler-Weber-Rendu)
• Dieulafoy’s lesions
• Prolapse gastropathy
• Fistulas

The correct answer is: Peptic ulcers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Which of the following is NOT a common cause of small-intestinal gastrointestinal bleeding among patients above the age of 40 years?

a. Meckel’s diverticulum
b. Neoplasms
c. NSAID-induced erosions and ulcers
d. Vascular ectasias

A

SMALL-INTESTINAL GI BLEEDING

May account for ~5-10% of GIB cases

Accounts for ~75% of cases previously-labelled as obscure GIB

The correct answer is: Meckel’s diverticulum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Which among the following patients with peptic ulcer disease DO NOT require endoscopic therapy and may receive only standard doses of proton pump inhibitors? (C44, P272)

a. 45/F with actively spurting blood vessel on upper endoscopy
b. 34/M with adherent clot on upper endoscopy
c. 32/F with a nonbleeding visible vessel on upper endoscopy
d. 48/M with a flat pigmented spot on upper endoscopy

A

PEPTIC ULCER DISEASE

The correct answer is: 48/M with a flat pigmented spot on upper endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Which of the following is NOT a benefit of high-dose constant-infusion proton pump inhibitors among patients with GI bleeding from peptic ulcer disease? (C44, P272)

a. Decreases rebleeding rates
b. Enhancement of clot stability
c. Improves mortality among those with high-risk ulcers
d. Sustains intragastric pH to less than 6

A

PEPTIC ULCER DISEASE: PROTON PUMP INHIBITORS
High-dose constant-infusion IV proton pump inhibitors (PPIs)
• 80 mg bolus and 8 mg/hr infusion
• Benefits
o Sustains intragastric pH >6
o Enhances clot stability
o Decreases further rebleeding
o Decreases mortality in patients with high-risk ulcers: recent studies showed that high-dose intermitted PPIs are non-inferior to constant-infusion PPI in this population

The correct answer is: Sustains intragastric pH to less than 6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

A 30/M presented with burning epigastric pain usually relieved by food intake and sometimes with antacids. He has no pallor, dysphagia, vomiting, or weight loss. PE showed epigastric tenderness but no masses. What is the most appropriate next step in the management of this patient? (C317, P2236)

a. Empiric treatment with H2 blockers; if no improvement, step up to proton pump inhibitors
b. Non-invasive testing for H. pylori
c. Whole abdominal ultrasound
d. Upper endoscopy (EGD) with rapid urease test for H. pylori

A

DYSPEPSIA: ALARM FEATURES

  • Age >40 y/o with new-onset dyspepsia
  • Family history of upper GI
  • GI bleeding
  • Jaundice
  • Left supraclavicular lymphadenopathy
  • Palpable abdominal mass
  • Persistent vomiting
  • Progressive dysphagia
  • Unexplained weight loss

NON-INVASIVE DETECTION OF HELICOBACTER PYLORI

The correct answer is: Non-invasive testing for H. pylori

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

A 36/M with presents with burning epigastric pain unrelated to meals and occasional episodes of black tarry stools. He is an 8-pack year smoker and drinks alcohol daily. He denies weight loss, vomiting or dysphagia. PE showed mild epigastric tenderness. CBC showed mild anemia with mild leukocytosis. What is the next best step in the management of this patient? (C317, P2236)

a. Ambulatory pH study
b. Non-invasive H. pylori testing
c. Trial of proton pump inhibitors
d. Upper gastrointestinal endoscopy

A 
DYSPEPSIA: ALARM FEATURES
•	Age >40 y/o with new-onset dyspepsia
•	Family history of upper GI
•	GI bleeding
•	Jaundice
•	Left supraclavicular lymphadenopathy
•	Palpable abdominal mass
•	Persistent vomiting
•	Progressive dysphagia
•	Unexplained weight loss

The correct answer is: Upper gastrointestinal endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

A 42/M presented at the ER for hematemesis of about 1-2 teaspoons with mild nausea and epigastric pain. He reports incessant retching a few hours prior. He is a 5 pack-year smoker and drinks alcohol into intoxication about 2-3x/week. Which of the following findings do you expect to see on upper GI endoscopy? (C44, P272)

a. Aberrant vessel in the gastric mucosa with pinpoint mucosal defect
b. Grape-like structures emanating from the gastroesophageal junction
c. Mucosal tear on the gastric side of the gastroesophageal junction
d. Regular, flat, smooth ulcer with a base filled with exudate in the duodenum

A

UPPER GIB: ENDOSCOPIC FINDINGS
• Peptic ulcer disease: varies from clean-based ulcers to ulcers with active oozing/squirting of blood
• Mallory-Weiss tears: tears, usually on the gastric side of the GEJ
• Esophageal/gastric varices: large, swollen vessels which are fragile and may rupture easily
• Erosive disease: visualized breaks in mucosa with no major bleeding due to absence of arteries and veins in the mucosa
• Gastric vascular antral ectasia: watermelon stomach
• Dieulafoy’s lesion: aberrant bleeding vessel in mucosa from a pinpoint mucosal defect

The correct answer is: Mucosal tear on the gastric side of the gastroesophageal junction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

A 54/M presented burning epigastric pain with episodes of black tarry stools. He is a 10-pack-year smoker and drinks alcohol 3-4x/week. He also has osteoarthritis for which he takes naproxen liberally. PE shows mild epigastric pain and intact rectal vault with black tarry stools per examining finger on rectal examination. EGD was done which showed mucosal breaks in his gastric mucosa with no visible vessels. Which of the following risk factors present in the patient is the most important cause for his condition? (C44, P273)

a. Alcohol intake
b. H. pylori infection
c. NSAID use
d. Smoking history

A

EROSIVE DISEASE
• Common cause of mild UGIB
• Endoscopically visualized breaks confined to the mucosa which do not cause major bleeding due to absence of arteries and veins in the mucosa
• Most important cause of gastric and duodenal erosions: NSAID use
• Other potential causes of gastric erosions
o Alcohol intake
o H. pylori infection
o Stress-related mucosal injury

The correct answer is: NSAID use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Which of the following best describes lower gastrointestinal bleeding caused by diverticular disease? (C44, P273)

a. Abrupt, usually painless, and sometimes massive
b. Chronic and usually occult
c. Chronic, only occasionally hemodynamically significant but may be overt or occult
d. Intermittent and causes only minor bleeding and pain

A

DIVERTICULAR BLEEDING

• Abrupt in onset, usually painless, sometimes massive
• Often from right colon
• Chronic or occult bleeding is not characteristic!
• 80-90% may stop bleeding spontaneously while 15-40% may rebleed
• Treatment
o Transcatheter arterial embolization by superselective technique stops bleeding in majority of patients (for those with bleeding seen during angiography)
o Persistent/refractory bleeding: segmental surgical resection

The correct answer is: Abrupt, usually painless, and sometimes massive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Which of the following is the best way to initially assess a patient with gastrointestinal bleeding? (C44, P273)

a. Angiography
b. Emergency upper GI endoscopy
c. Measurement of heart rate and blood pressure
d. STAT hemoglobin and hematocrit measurements

A

GASTROINTESTINAL BLEEDING: INITIAL ASSESSMENT
Measurement of HR and BP: best way to initially assess a patient with gastrointestinal bleeding
• Clinically significant bleeding –> postural changes in HR/BP, tachycardia, and finally, recumbent hypotension
Hemoglobin does not fall immediately (patients bleed whole blood!)
• There is proportional reduction in plasma and red cell volumes
• Fall may be seen within 72 hours when extravascular fluid enters vascular space to restore volume

The correct answer is: Measurement of heart rate and blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Among patients with gastrointestinal bleeding, blood transfusion is recommended when hemoglobin drops below what value? (C44, P273)

a. 7 g/dL
b. 8 g/dL
c. 9 g/dL
d. 10 g/dL

A

GI BLEEDING: BLOOD TRANSFUSION
Transfusion threshold: <7 g/dL
• Restrictive transfusion strategy decreases rebleeding and death in acute UGIB compared to a transfusion threshold of 9 g/dL

The correct answer is: 7 g/dL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Which of the following clinical findings is more indicative of an upper gastrointestinal cause of bleeding? (C44, P273)

a. Abdominal pain
b. Hematochezia
c. Hematemesis
d. Melena

A

UPPER GI BLEEDING

UGIB more common than LGIB

Clinical findings
• Hematemesis: usually indicates upper GI source
• Melena: indicates blood has been present in the GI tract for >14 hours and as long as 3-5 days [more proximal bleeding site, more likely melena will present]
• Hematochezia: usually indicates lower GI source (but may also be from brisk UGIB!)
• Hyperactive bowel sounds: blood is cathartic
• Elevated BUN: indicates volume depletion and also reflects absorption of blood proteins in the small intestine

The correct answer is: Hematemesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

A 43/M presented at the ER with melena and a few weeks history of epigastric pain. He is a chronic smoker and alcoholic drinker. PE showed epigastric tenderness but no palpable abdominal masses. Endoscopy was done which showed a 5-mm ulcer at the antral area with an adherent clot. Endoscopic therapy was performed. Which of the following is the most appropriate management for this patient? (C44, P274)

a. Start intensive IV PPI; advise clear liquids for ~2 days and ICU stay for at least 3 days
b. Start intensive IV PPI; advise clear liquids for ~2 days and ward admission for at least 3 days
c. Start once-daily oral PPI; advise clear liquids for ~1 day and ward admission for ~1-2 days
d. Start once-daily oral PPI; advise regular diet and discharge after endoscopy

A

The correct answer is: Start intensive IV PPI; advise clear liquids for ~2 days and ward admission for at least 3 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

A 48/M was brought to the ER for lightheadedness and hematochezia. He reports also having episodes of burning epigastric pain and occasional nausea. PE showed tachycardia, postural hypotension, epigastric tenderness and bright-red blood per examining finger on rectal examination. Which of the following initial diagnostic modalities is most appropriate for this patient? (C44 P275)

a. Angiography
b. Colonoscopy
c. Flexible sigmoidoscopy
d. Upper GI endoscopy

A

LOWER GI BLEEDING: INITIAL ASSESSMENT
Patients with LGIB and hemodynamic instability should have upper endoscopy to rule out an upper GI source before evaluation of the lower GI tract

The correct answer is: Upper GI endoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Which of the following is the most appropriate initial test for a patient presenting with massive bleeding suspected to be from the small intestine? (C44 P275)

a. Angiography
b. Colonoscopy
c. Flexible sigmoidoscopy
d. Upper GI endoscopy

A

SMALL INTESTINAL GI BLEEDING

Massive bleeding suspected to be from small intestines: angiography
• CT angiography or 99mTc-labeled red cell scan prior to angiography if patient’s clinical status permits
Repeat upper and lower endoscopy may also be considered as initial evaluation
• Second-look procedures often identify a source in ~25% of cases
• Push enteroscopy may substitute for standard upper endoscopy
Capsule endoscopy: unable to provide full visualization, biopsy or therapeutic interventions, however

CT enterography: may be used in patients with possible small bowel narrowing and may follow negative video capsule (higher sensitivity for small-intestinal masses)

“Deep” enteroscopy (double-balloon, single-balloon, or spiral endoscopy)
• Next test undertaken for clinically important GIB documented or suspected to be from small intestines
• Allows biopsy and provision of therapy
OBSCURE GI BLEEDING
Other tests used in evaluation of obscure GI bleeding
• 99mTc-labeled red blood cell scintigraphy
• CT angiography
• 99mTc-pertechnate scintigraphy (for Meckel’s diverticulum, especially in young patients)
If previous and above are non-revealing, intraoperative endoscopy is indicated in patients with severe recurrent or persistent bleeding requiring repeated blood transfusions.

The correct answer is: Angiography

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Which of the following endoscopic findings require a biopsy due to increased risk of being malignant? (C317 P2223)

a. A 0.5 mm ulcer in the duodenum located within 2 cm from the pylorus
b. A 1 cm ulcer in the gastric fundus
c. A 3 cm ulcer in the second part of the duodenum
d. A 6 cm ulcer in the first portion of the duodenum

A

GASTRIC ULCERS
In contrast to duodenal ulcers (DU), gastric ulcers (GU) can represent a malignancy and should be biopsied upon discovery
• Benign GUs usually seen distal to the junction between the antrum and the acid secretory mucosa
• Benign Gus are rare in the gastric fundus

The correct answer is: A 1 cm ulcer in the gastric fundus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Which of the following is NOT an identified risk factor for H. pylori colonization and possibly infection? (C317 P2224)

a. Exposure to gastric contents of an infected individual
b. Less education
c. Poor socioeconomic status
d. Race

A

H. PYLORI INFECTION: RISK FACTORS

Two factors that predispose to higher colonization rates
• Poor socioeconomic status
• Less education

Other risk factors
• Birth or residence in a developing country
• Domestic crowding
• Unsanitary living conditions
• Unclean food or water
• Exposure to gastric contents of an infected individual

The correct answer is: Race

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Which of the following infectious agents may also cause ulcer disease? (C317 P227)

a. Campylobacter jejuni
b. Cytomegalovirus
c. Mycoplasma pneumoniae
d. Varicella zoster virus

A

INFECTIONS CAUSING NON-HP AND NON-NSAID ULCER DISEASE
• Cytomegalovirus
• Herpes simplex virus
• Helicobacter heilmanii
OTHER CAUSES OF NON-HP AND NON-NSAID ULCER DISEASE

Drug/Toxin
•	Bisphosphonates
•	Chemotherapy
•	Clopidogrel
•	Crack cocaine
•	Glucocorticoids (when combined with NSAIDs)
•	Mycophenolate mofetil
•	Potassium chloride
Miscellaneous
Basophilia in myeloproliferative disease
Duodenal obstruction
Infiltrating disease
Ischemia
Radiation therapy
Eosinophilic infiltration
Sarcoidosis
Crohn’s disease
Idiopathic hypersecretory state

The correct answer is: Cytomegalovirus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

A 45/M previously diagnosed with a duodenal ulcer in the first part of the duodenum but failed to complete prescribed H. pylori treatment regimen presented with few weeks history of early satiety, nausea, vomiting and post-prandial abdominal pain. PE revealed epigastric fullness and tenderness. No masses were palpated. Which of the following will MOST LIKELY account for his current complaints?

a. Gastric outlet obstruction
b. Malignant transformation
c. Penetration of duodenal ulcer to pancreatic bed
d. Perforation of duodenal ulcer

A

PUD-RELATED COMPLICATIONS
GI bleeding: most common complication

Perforation
• Penetration: form of perforation in which ulcer bed tunnels into an adjacent organ
Gastric outlet obstruction: less common complication
• Mechanisms
o Relative obstruction from ulcer-related inflammation and edema in the peripyloric region (resolves with ulcer healing)
o Fixed mechanical obstruction from scar formation in the peripyloric areas

The correct answer is: Gastric outlet obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

A 29/M presented at the clinic with a 2-month history of burning epigastric pain partly relieved by food intake. He did no have any other symptoms. PE was unremarkable. Stool antigen testing was positive for H. pylori. Which of the following is an appropriate treatment regimen for the patient’s condition? (C317 P2232)

a. Pantoprazole and clarithromycin for 7 days
b. Omeprazole, clarithromycin, and metronidazole for 7 days
c. Esomeprazole, clarithromycin, and amoxicillin for 14 days
d. Omeprazole, bismuth subcitrate, tetracycline, and metronidazole for 14 days

A

H. PYLORI TREATMENT
Combination of antibiotics and acid suppression

No single agent is effective in eradicating the organism

Combination therapy for 14 days provides the greatest efficacy
• Shorter courses least successful
Triple therapy is recommended
• Dual therapy has unacceptable eradication rates (<80-85%)
• Quadruple therapy usually reserved for treatment failure

The correct answer is: Esomeprazole, clarithromycin, and amoxicillin for 14 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Which of the following accounts for most cases of dyspepsia among the general population? (C41 P257)

a. Functional dyspepsia
b. Gastroesophageal reflux disease
c. Malignancy
d. Peptic ulcer disease

A

FUNCTIONAL DYSPEPSIA
Cause of symptoms of >70% of patients with dyspepsia

Bothersome postprandial fullness, early satiety, or epigastric pain or burning with symptom onset at least 6 months before diagnosis in the absence of an organic cause

Subclassifications
• Postprandial distress syndrome: meal-induced fullness and early satiety
• Epigastric pain syndrome: epigastric pain or burning which may or may not be meal-related

Most patients follow a benign course but some who also have H. pylori infection or concurrent NSAID use develop ulcers

The correct answer is: Functional dyspepsia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

A 31/F presents at the clinic for heartburn that worsens after intake of food for more than 6 months duration and occasional epigastric discomfort. She reports that she has been having increasing frequency of symptoms recently which sometimes also wakes her up from sleep. She, however, denies dysphagia, weight loss, recurrent vomiting, jaundice or changes in bowel movement. PE was unremarkable save for poor dentition. What is the next best step in the management of this patient? (C41 P257)

a. Ambulatory esophageal pH testing
b. High-resolution esophageal manometry
c. Upper endoscopy
d. Non-invasive H. pylori testing

A

GERD: TESTING AND TREATMENT
Once these alarm features are excluded, patients with typical GERD do not need further evaluation and are treated empirically
• Patients <55 y/o without alarm factors should be managed based on H. pylori prevalence
o If low (<10%), 4-week trial of acid suppressants
o If high <>10%), test and treat for H. pylori and acid-suppression if failed
Alarm features
• Odynophagia or dysphagia
• Unexplained weight loss
• Recurrent vomiting
• Occult or gross GI bleeding
• Jaundice
• Palpable mass or adenopathy
• Family history of gastroesophageal malignancy
Upper endoscopy: indicated to exclude mucosal injury in patients with atypical symptoms or alarm factors

Ambulatory esophageal pH testing: for drug-refractory symptoms and atypical symptoms

High-resolution esophageal manometry: when surgical management of GERD is contemplated

The correct answer is: Non-invasive H. pylori testing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Which of the following statements is TRUE regarding non-invasive testing for H. pylori? (C41 P257)

a. Exposure to low-dose radiation is a limitation of the urea breath test
b. Recent use of NSAIDs may lead to false-negative results in the urea breath test
c. Plasma antibodies against H. pylori has the highest sensitivity for diagnosis of infection
d. Stool antigen testing is appropriate for diagnosis and assessment of treatment response to H. pylori eradication

A

TESTS TO DETECT H. PYLORI
Urea breath test relies on presence of urease secreted by H. pylori to digest the swallowed radioactive urea and liberates 14C or 13C as part of ammonia

Urea breath test may be false negative with recent use PPIs, antibiotics, or bismuth compounds

Stool antigen testing not useful to establish proof of eradication

The correct answer is: Exposure to low-dose radiation is a limitation of the urea breath test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Which of the following conditions is closely associated with gastroesophageal reflux disease? (P316 P2216)

a. Chronic sinusitis
b. Dental erosions
c. Recurrent aspiration pneumonia
d. Sleep apnea

A 
GERD: EXTRAESOPHAGEAL SYNDROMES
Well-established association with GERD
•	Chronic cough
•	Laryngitis
•	Asthma
•	Dental erosions
GERD as potentially contributory
•	Pharyngitis
•	Pulmonary fibrosis
•	Chronic sinusitis
•	Cardiac arrhythmias
•	Sleep apnea
•	Recurrent aspiration pneumonia
Potential mechanisms
•	Regurgitation  with direct contact between refluxate and supraesophageal structures
•	Vagovagal reflex wherein reflux activation of esophageal afferent nerves triggers efferent vagal reflexes such as bronchospasm, cough, or arrythmias

The correct answer is: Dental erosions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Which of the following approaches to primary prevention of NSAID-related mucosal injury is NOT recommended? (P317 P2234)

a. Using the lowest possible dose of NSAIDs
b. Using the NSAIDs for the shortest period of time possible
c. Using NSAIDs that are theoretically less injurious
d. Using oral over topical NSAIDs preparations

A

APPROACH TO PRIMARY PREVENTION OF NSAID-INDUCED MUCOSAL INJURY

Using lowest possible dose of agent for shortest period of time possible

Using NSAIDs that are theoretically less injurious
• Lower likelihood of GI and CV toxicity: naproxen and ibuprofen
Using newer topical NSAID preparations

Using concomitant medical therapy to prevent NSAID-induced injury

The correct answer is: Using oral over topical NSAIDs preparations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

A 65/M was admitted to the ICU for respiratory failure from high-risk pneumonia and decompensated heart failure. Which of the following is the best option for stress-related mucosal injury prevention (P317 P2241)?

a. H2 receptor antagonists
b. Misoprostol
c. Proton pump inhibitors
d. Vasopressin

A

STRESS-RELATED MUCOSAL INJURY
Injury most commonly observed in the acid-producing (fundus and body) portions of the stomach

Most common presentation: GI bleeding (usually minimal but may be life-threatening)

Best choice for prophylaxis: PPIs

Treatment of bleeding
•	Endoscopy
•	Intraarterial vasopressin
•	Embolization
•	Surgery

The correct answer is: Proton pump inhibitors

63
Q

Which of the following is the most common cause of acute gastritis (P317 P2241)?

a. Alcohol
b. Autoimmune disease
c. Infections
d. Infiltrative disease

A

GASTRITIS
Should be reserved for histologically documented inflammation of the gastric mucosa

NOT the mucosal erythema seen during endoscopy

NOT interchangeable with dyspepsia

Can be classified based on
•	Time course (acute vs chronic)
•	Histologic features
•	Anatomic distribution
•	Proposed pathogenic mechanism
Acute gastritis
•	Most common cause: infectious
Chronic gastritis
•	Inflammatory cell infiltrate: lymphocytes and plasma cells with scanty neutrophils
•	Early phase: superficial gastritis
•	Next phase: atrophic gastritis
•	Final phase: gastric atrophy

The correct answer is: Infections

64
Q

A 54/M was recently diagnosed with chronic gastritis. Which of the following histologic findings is an important predisposing factor for gastric cancer in this patient? (P317 P2241)

a. Conversion of gastric glands into a small intestinal phenotype
b. Inflammatory changes limited to the lamina propria of surface mucosa with surrounding edema
c. Progressive distortion and destruction of gastric glands
d. Thinned out mucosa with loss of glandular structures and paucity of inflammatory infiltrates

A

CHRONIC GASTRITIS

Spectrum: from infiltration of mucosa with lymphocytes and plasma cells to progressive glandular destruction, with atrophy and metaplasia
• Intestinal metaplasia: conversion of gastric glands into a small intestinal phenotype with small-bowel mucosal glands containing goblet cells [this is an important predisposing factor for gastric cancer]
Type A: body-predominant (autoimmune)
Type B: antral-predominant (H. pylori-related)
Type AB: mixed antral/body picture

The correct answer is: Conversion of gastric glands into a small intestinal phenotype

65
Q

A 48/F presented with a 2-year history of dyspepsia, intermittent vague epigastric pain and mild pallor. Upper endoscopy was done which showed atrophic mucosa involving primarily the fundus and body with antral sparing. Biopsy confirmed gastric atrophy. Which of the following antibodies are more specific for the patients condition? (P317 P2242)

a. Anti-intrinsic factor antibodies
b. Gliadin antibodies
c. Parietal cell antibodies
d. Transglutaminase antibodies

A

TYPE A GASTRITIS
• Traditionally associated with pernicious anemia –> autoimmune gastritis
• Anti-IF antibodies are more specific than parietal cell antibodies for this type of gastritis
• Higher incidence of specific familial histocompatibility haplotypes such as HLA-B8 and HLA-DR3

The correct answer is: Anti-intrinsic factor antibodies

66
Q

Which of the following is TRUE regarding gastric MALT lymphoma? (P317 P2242)

a. It is a high-grade lymphoma associated with H. pylori infection
b. Chronic T cell stimulation caused by the infection leads to production of cytokines that promote the T cell tumor
c. Tumor growth is dependent on presence of H. pylori
d. Treatment involves combination of H. pylori eradication and limited gastric surgery

A

GASTRIC MALT LYMPHOMA
Low-grade B cell lymphoma associated with H. pylori

Chronic T cell stimulation caused by the infection leads to production of cytokines that promote tumor growth

Tumor is staged with CT of the abdomen and endoscopic US

Tumor growth remains dependent on presence of H. pylori and its eradication is often associated with complete regression of the tumor
• Patients are followed by EUS every 2-3 months
• If tumor is stable or decreases in size –> no other therapy needed
• If tumor grows –> re-biopsy to check for evolution to high-grade lymphoma

The correct answer is: Tumor growth is dependent on presence of H. pylori

67
Q

This is a rare gastropathy characterized by large, tortuous mucosal folds most prominent in the body and fundus, sparing the antrum. (P317 P2243)

a. Familial polyposis syndrome
b. Gastritis polyposa profunda
c. Menetrier’s disease
d. Zollinger-Ellison syndrome

A

MENETRIER’S DISEASE
Very rare gastropathy characterized by large, tortous mucosal folds most prominent in the body and fundus, sparing the antrum

Histology: massive foveolar hyperplasia and marked reduction in oxyntic glands, parietal cells, and chief cells

In children, usually related to CMV (etiology in adults unknown)

Associated with overstimulation of EGFR pathway
• Cetuximab is now considered as the first-line therapy for this disease
• Total gastrectomy for severe disease with persistent and substantial protein loss despite use of cetuximab

The correct answer is: Menetrier’s disease

68
Q

Which of the following conditions is associated with hypercoagulable states such as inherited thrombophilias, polycythemia vera, and carcinoma (P322 P2292)

a. Arterial embolic mesenteric ischemia
b. Arterial thrombotic mesenteric ischemia
c. Non-occlusive mesenteric ischemia
d. Mesenteric venous thrombosis

A

INTESTINAL ISCHEMIA
Occurs when splanchnic perfusion fails to meet the demands of the intestines –> ischemic tissue injury

Risk factors

The correct answer is: Mesenteric venous thrombosis

69
Q

Which of the following is one of the most common locations for colonic ischemia and is situated where collateral vessels within the colon meet at the splenic flexure? (P322 P2292)

a. Arc of Riolan
b. Douglas’ point
c. Griffith’s point
d. Sudeck’s point

A

INTESTINAL ISCHEMIA: ANATOMY
Areas which are inherently at risk for decreased blood flow
• Griffith’s point: splenic flexure
• Sudeck’s point: descending/sigmoid colon

The correct answer is: Griffith’s point

70
Q

A 72/M was brought to the ER for progressive abdominal pain for a few day’s duration which was described as sharp and stabbing with anorexia and vomiting. He was previously diagnosed with atrial fibrillation, heart failure and dyslipidemia. PE showed normal BP, tachycardia, mildly distended abdomen with hypoactive bowel sounds. No abdominal tenderness was noted. FOBT was positive. Which of the following MOST likely explains the patient’s presentation? (C322 P2292)

a. Acute diverticulitis
b. Arterioocclusive mesenteric ischemia
c. Non-occlusive mesenteric ischemia
d. Mesenteric venous thrombosis

A

ARTERIOOCCLUSIVE MESENTERIC ISCHEMIA
Severe acute, nonremitting abdominal pain strikingly out of proportion to PE findings
• With exception of minimal abdominal distention and hypoactive bowel sounds, early abdominal PE is unimpressive
• Later findings: peritonitis, cardiovascular collapse
Associated symptoms
• Nausea and vomiting
• Transient diarrhea
• Anorexia
• Bloody stools

The correct answer is: Arterioocclusive mesenteric ischemia

71
Q

A 72/M was brought to the ER for progressive abdominal pain for a few day’s duration which was described as sharp and stabbing with anorexia and vomiting. He was previously diagnosed with atrial fibrillation, heart failure and dyslipidemia. PE showed normal BP, tachycardia, mildly distended abdomen with hypoactive bowel sounds. No abdominal tenderness was noted. FOBT was positive. Few hours into the admission, patient was noted to be hypotensive with rigid abdomen. Which of the following modalities is MOST USEFUL in the management of this patient?(C322 P2292)

a. Colonoscopy
b. Early laparotomy
c. Mesenteric duplex scan
d. Plain abdominal film

A

ARTERIOOCCLUSIVE MESENTERIC ISCHEMIA: EMBOLIC DISEASE

Diagnosis: CT angiography; early laparotomy

Treatment of underlying cause: anticoagulation, cardioversion, proximal thrombectomy

Treatment of specific lesion: laparotomy, embolectomy, vascular bypass, assessment of viability and possible resection of dead bowel

Other essential components of treatment
•	Hydration
•	Antibiotics
•	Reversal of acidosis
•	Oxygenation
•	Avoidance of vasoconstrictors

The correct answer is: Early laparotomy

72
Q

A 61/F was admitted to the ICU for septic shock from pneumonia and bacteremia. She is a diabetic and also had prior MI. She was started on antibiotics and vasopressors. Few hours into ICU admission, she complained of worsening abdominal pain, abdominal distension and bloody stools. BP was borderline at 90/60 mmHg, HR of 106 and RR of 26. PE showed a diffusely tender abdomen with no audible bowel sounds. Which of the following is the MOST LIKELY diagnosis? (C322 P2293)

a. Arterial embolus
b. C. difficile colitis
c. Nonocclusive mesenteric ischemia
d. Venous thrombosis

A

NON-OCCLUSIVE/VASOSPASTIC MESENTERIC ISCHEMIA
Presents with generalized abdominal pain, anorexia, bloody stools and abdominal distention

Patients usually obtunded; PE findings not always useful

Advanced disease: metabolic acidosis, leukocytosis, elevated amylase or creatinine phosphokinase, and/or lactic acidosis

Diagnosis
• Vasospasm: angiography
• Hypoperfusion: spiral CT or colonoscopy

Treatment of underlying cause: hydration, support cardiac output, avoid vasoconstrictors

Treatment of specific lesion
• Vasospasm: intraarterial vasodilators
• Hypoperfusion: delayed laparotomy; assess viability and resect dead bowel
Other supportive treatment
• Hydration, antibiotics, acidosis reversal, oxygenation, support cardiac output, avoid vasoconstrictors

The correct answer is: Nonocclusive mesenteric ischemia

73
Q

A 72/F presented with sudden vague abdominal pain, nausea and vomiting. She is a diagnosed case of high-risk polycythemia vera maintained on aspirin, hydroxyurea and periodic phlebotomy with poor compliance. PE showed abdominal distention with moderate diffuse tenderness. Which of the following is the MOST APPROPRIATE management for this patient? (C322 P2293)

a. Anticoagulation
b. Arterial stenting
c. Early laparotomy
d. Vascular bypass

A

MESENTERIC VENOUS THROMBOSIS
Diagnosis: spiral CT; angiography with venous phase

Treatment of underlying cause: anticoagulation; massive hydration

Treatment of specific lesion:
•	Anticoagulation +/- laparotomy
•	Thrombectomy/catheter-directed thrombolysis
•	Assess viability and resect dead bowel
Other supportive therapies
•	Antibiotics
•	Reverse acidosis
•	Optimize oxygenation
•	Support cardiac output
•	Avoid vasoconstrictors

The correct answer is: Anticoagulation

74
Q

A 29/F presented in the ER for abdominal pain. She reports loss of appetite for a few days followed by progressive severe crampy abdominal pain initially noted around the umbilicus but now is localized to her right lower quadrant. She also reports an episode of emesis the morning before the ER consult. Vitals were normal. PE showed right lower quadrant tenderness and unremarkable pelvic exam. Pregnancy test was negative. Which of the following imaging modalities will MOST LIKELY confirm her diagnosis? (C324 P2300)

a. CT of the abdomen without contrast
b. Colonoscopy
c. Plain abdominal film
d. Whole abdominal ultrasound

A

ACUTE APPENDICITIS: IMAGING
Plain abdominal films: rarely helpful; not usually obtained unless other conditions such as intestinal obstruction, perforated viscus or ureterolithiasis need to be ruled out

Presence of fecalith is NOT diagnostic

Ultrasound: highly operator-dependent; more useful to identify pelvic pathology in women
• Suggestive findings: wall thickening, increased appendiceal diameter, presence of free liquid
CT scan: high negative predictive value
• Superior method for assessing severity of disease
• Suggestive findings: dilation >6 mm with wall thickening, lumen that does not fill with enteric contrast, fatty tissue stranding or air surrounding the appendix

The correct answer is: CT of the abdomen without contrast

75
Q

A 29/F presented in the ER for abdominal pain. She reports loss of appetite for a few days followed by progressive severe crampy abdominal pain initially noted around the umbilicus but now is localized to her right lower quadrant. She also reports an episode of emesis and fever the morning before the ER consult. Vitals were normal. PE showed right lower quadrant tenderness and unremarkable pelvic exam. Pregnancy test was negative. CT scan showed a ~5 cm RLQ mass suspicious for abscess. Which of the following DOES NOT constitute appropriate management for this patient? (C324 P2302)

a. Broad-spectrum antibiotics
b. Bowel rest
c. Emergent laparoscopic appendectomy
d. Imaging-guided drainage of abscess

A

ACUTE APPENDICITIS: TREATMENT
Either laparoscopic or open appendectomy is satisfactory for patients with uncomplicated appendicitis

Management of patients with phlegmon or abscess
• Broad-spectrum antibiotics
• Drainage if there is an abscess >3 cm in diameter
• Parenteral fluids
• Bowel rest
• Appendix can be safely removed 6-12 weeks later when inflammation has diminished

The correct answer is: Emergent laparoscopic appendectomy

76
Q

Which of the following is NOT a cardinal sign/symptom of peritonitis? (P324 P2302)

a. Abdominal pain, usually severe
b. Abdominal tenderness
c. Hyperactive bowel sounds
d. Fever

A

ACUTE PERITONITIS
Most often (but not always) infectious in origin
Cardinal signs and symptoms
• Abdominal pain, typically severe
• Abdominal tenderness: often diffuse with local guarding, rigidity and with other signs of parietal peritoneal irritation
• Fever
Bowel sounds usually absent to hypoactive

Most present with tachycardia and signs of volume depletion

Labs: leukocytosis; severe acidosis

The correct answer is: Hyperactive bowel sounds

77
Q

A 40/M presented at the ER for acute severe abdominal pain. He however, reports that he has been having epigastric pain for about a year already accompanied by weight loss. He occasionally takes antacids which seem to offer some relief of his epigastric pain. PE shows fever, tachycardia, tachypnea, but normal BP. Abdomen was noted to be rigid with involuntary guarding. Bowel sounds were absent. Scout abdominal film should free air under the diaphragm. Which of the following will be MOST LIKELY seen in the peritoneum during surgical exploration? (C324 P2302)

a. Bile
b. Blood
c. Foreign body
d. Gastric contents

A 
ACUTE PERITONITIS
Most commonly associated with bacterial infection but can be caused by abnormal presence of the following:
•	Gastric contents
•	Bile
•	Pancreatic enzymes
•	Blood
•	Urine
•	Foreign bodies

The correct answer is: Gastric contents

78
Q

Which of the following is TRUE regarding the occurrence of liver injury in idiosyncratic drug reactions? (P333 P2367)

a. Dose-dependent
b. Frequent
c. May occur at any time
d. Predictable

A

DRUG-INDUCED LIVER INJURY: IDIOSYNCRATIC DRUG REACTIONS
Occurrence of hepatitis
• Usually infrequent (1 in 103-105 patients)
• Unpredictable
• Response not clearly dose-dependent
• May occur any time during or shortly after drug exposure

The correct answer is: May occur at any time

79
Q

Which of the following drugs produces predictable and dose-related hepatic injury? (P333 P2369)

a. Amoxicillin-clavulanate
b. Androgenic steroids
c. Ciprofloxacin
d. Isoniazid

A

The correct answer is: Androgenic steroids

80
Q

Treatment of drug/toxin-induced liver disease is largely supportive save for which of the following in which a specific agent may be effective? (P333 P2369)

a. Androgenic steroids
b. Fluconazole
c. Paracetamol
d. Valproic acid

A

TOXIC/DRUG-INDUCED HEPATIC DISEASE: TREATMENT
Treatment largely supportive
• Except in paracetamol hepatotoxicity: N-acetylcysteine is effective
Fulminant hepatitis: liver transplantation may be life-saving

Withdrawal of suspected agent is indicated at first sign of an adverse reaction

Agents used occasionally but with questionable value
• Glucocorticoids: drug hepatotoxicity with allergic features
• Silibinin: hepatotoxic mushroom poisoning
• Ursodeoxycholic acid: cholestatic drug hepatotoxicity

The correct answer is: Paracetamol

81
Q

Which of the following biochemical signatures should almost always trigger further assessment for the possibility of paracetamol overdose? (P333 P2371)

a. Elevated gamma-glutamyl transferase levels with normal aminotransferase and bilirubin levels
b. Extremely elevated aminotransferase levels with low bilirubin levels
c. Predominantly elevated bilirubin levels with mild aminotransferase level elevations
d. Mixed hepatitis and cholestasis

A

PARACETAMOL HEPATOTOXICITY
Most prevalent cause of acute liver failure in the Western world
• Fatal fulminant disease usually associated with ingestion of >25 g
Blood levels of paracetamol correlated with severity of hepatic injury

Clinical manifestations
• Early manifestations (4-12 hours post-ingestion): nausea, vomiting, diarrhea, abdominal pain and shock
• 24-28 hrs after: early features abate and hepatic injury becomes apparent
• 3-5 days post-ingestion: maximal abnormalities and hepatic failure

Extremely high aminotransferase levels with low bilirubin levels: characteristic of this hyperacute injury

The correct answer is: Extremely elevated aminotransferase levels with low bilirubin levels

82
Q

Which of the following is FALSE regarding isoniazid hepatotoxicity? (P333 P2372)

a. May be both direct toxic and idiosyncratic drug reaction
b. Most cases are self-limited and mild
c. Resolution of aminotransferase elevations require discontinuation of the drug
d. Variable latency period of up to 6 months

A

ISONIAZID HEPATOTOXICITY
Toxic and idiosyncratic reaction

~10% of patients on INH may develop elevations in serum transaminases during first few weeks of therapy
• Most are self-limited, mild (ALT <200) and resolve despite continued use (adaptive response which allows continuation of the agent if symptoms and progressive enzyme elevations do not follow initial elevations)
Variable latency period up to 6 months
• More frequent in alcoholics and patients on other meds (barbiturates, rifampin, pyrazinamide)

The correct answer is: Resolution of aminotransferase elevations require discontinuation of the drug

83
Q

A 53/F was recently started on atorvastatin for dyslipidemia and fatty liver by her primary physician. One month after initiation, she was noted to have asymptomatic elevations of ALT and AST 3x from upper limit and normal bilirubins. Which of the following is TRUE regarding her condition (P333 P2374)?
a.
Atorvastatin needs to be discontinued pending a repeat measurement of transaminases
b. Her hepatic steatosis increased her risk of having drug-induced hepatotoxicity
c. This condition occurs in more than half of patients first exposed to statin therapy
d. Statin therapy need not be discontinued for this patient

A

STATIN HEPATOTOXICITY
Idiosyncratic mixed hepatocellular and cholestatic reaction
~1-2% of patients taking statins experience asymptomatic, reversible elevation (>3x) of aminotransferase activity

Clinically meaningful aminotransferase elevations are rare
• Liver test monitoring not necessary
• Statins need not be discontinued in patients found to have asymptomatic isolated aminotransferase elevations

Statin hepatotoxicity NOT increased in patients with chronic hepatitis C, hepatic steatosis, or other underlying liver diseases
• Statins can be used safely in these patients

The correct answer is: Statin therapy need not be discontinued for this patient

84
Q

Which of the following is NOT included in the Rome IV diagnostic criteria for irritable bowel syndrome? (P320 P2276)

a. Abdominal pain related to defecation
b. Abdominal pain associated with change in form and frequency of stool
c. Recurrent abdominal pain
d. Presence of malnutrition

A

IRRITABLE BOWEL SYNDROME (IBS)
Functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in absence of detectable structural abnormalities

Malnutrition due to inadequate caloric intake is rare in IBS

The correct answer is: Presence of malnutrition

85
Q

Which of the following is considered as the most consistent clinical feature in IBS? (P320 P2277)

a. Abdominal pain
b. Alteration in bowel habits
c. Gas and flatulence
d. Nausea and vomiting

A

IRRITABLE BOWEL SYNDROME (IBS)
Alteration in bowel habits is the most consistent clinical feature in IBS

Most common pattern: constipation alternating with diarrhea, usually with one of these symptoms predominating
• Bowel pattern subtypes, however, are highly unstable
Diarrhea in IBS usually consists of small volumes of loose stools (most have stool volumes <200 mL)
• Nocturnal diarrhea DOES NOT occur in IBS
• May be aggravated by emotional stress or eating
Most experience tenesmus (sense of incomplete evacuation)

Bleeding is NOT a feature

Malabsorption or weight loss DOES NOT occur

The correct answer is: Alteration in bowel habits

86
Q

The presence of which of the following argues against the diagnosis of IBS? (P320 P2279)

a. Absence of systemic symptoms such as fever and weight loss
b. Onset of symptoms during periods of stress or emotional upset
c. Persistent diarrhea after a 48-hour fast
d. Small-volume stool without evidence of blood

A

IRRITABLE BOWEL SYNDROME (IBS)

The correct answer is: Persistent diarrhea after a 48-hour fast

87
Q

Who among the following patients require no further testing before making the diagnosis of irritable bowel syndrome and initiating treatment? (P320 P2279)

a. 78/F with 6 months of intermittent crampy abdominal pain that is worse with stress and associated with bloating and diarrhea
b. 25/F with 6 months of abdominal pain, bloating, and diarrhea that has worsened steadily and now awakens from sleep at night to move her bowels
c. 30/M with 6 months of crampy lower abdominal pain relieved by bowel movements which are usually loose with symptoms worse during daytime at work
d. 19/F with 2 months of diarrhea and worsening abdominal pain with occasional blood in her stool

A 
IRRITABLE BOWEL SYNDROME (IBS)
Factors to consider when determining aggressiveness of diagnostic evaluation
•	Duration of symptoms
•	Change of symptoms over time
•	Age and sex of patient
•	Referral status of patient
•	Prior diagnostic studies
•	Family history of colorectal malignancy
•	Degree of psychosocial dysfunction

The correct answer is: 30/M with 6 months of crampy lower abdominal pain relieved by bowel movements which are usually loose with symptoms worse during daytime at work

88
Q

A 27/F presented at the clinic for abdominal discomfort which she notes on most days of the week with variable location and intensity for the past 6 months. She experiences both constipation and diarrhea but diarrhea predominates. She recently notes increasing frequency of bloating and flatulence than before. Identified aggravating factors are eating and stress. Defecation relieves her abdominal discomfort. PE was unremarkable. Labs showed normal WBC, ESR of 44 mm/hr. FOBT was negative. Which of the following interventions is MOST appropriate for this patient? (P320 P2279)

a. Antidepressants
b. Endoscopy
c. Reassurance
d. Stool bulking agents

A

IRRITABLE BOWEL SYNDROME (IBS)
Laboratory features that argue against IBS
• Anemia
• Elevated ESR
• Presence of leukocytes or blood in stool
• Stool volume >200-300 mL/day

Alarm symptoms and lab features warrant further investigation to rule out other GI disorders

The correct answer is: Endoscopy

89
Q

A 33/M presents with 2-year history of episodic abdominal pain relieved by bowel movements. He reports that he has frequent small stools soon after eating. He has tried taking supplements and eating bananas but these were not always effective for his symptoms. He was previously diagnosed with mild depression and was previously on fluoxetine. PE was unremarkable. CBC, metabolic panel and thyroid function tests were all normal. A diet low in the which of the following has been shown to beneficial in patients such as him? (P320 P2280)

a. Animal protein
b. Capsaicin
c. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols
d. Rice and rice products

A

IRRITABLE BOWEL SYNDROME (IBS)
Meticulous dietary history may reveal substances (e.g., coffee, disaccharides, legumes, and cabbage) that aggravate symptoms
• Excessive fructose and artificial sweeteners may cause diarrhea, bloating, cramping, or flatulence
Advice against nutritionally depleted diets

Diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been shown to be helpful in IBS patients

The correct answer is: Fermentable oligosaccharides, disaccharides, monosaccharides and polyols

90
Q

Which of the following is LEAST helpful for constipation-predominant irritable bowel syndrome? (P320 P2282)

a. Cholestyramine resin
b. Magnesium hydroxide
c. Lactulose
d. Psyllium husk

A

IRRITABLE BOWEL SYNDROME: TREATMENT
Treatment depends on severity of disorders and predominant symptoms

The correct answer is: Cholestyramine resin

91
Q

Who of the following patients require periprocedural antibiotic prophylaxis (P315 P2194)?

a. 34/M with mitral regurgitation from rheumatic heart disease undergoing flexible sigmoidoscopy
b. 55/M undergoing endoscopic ultrasound and fine-needle aspiration of a solid lesion in the esophagus
c. 68/F with prosthetic left knee undergoing routine colonoscopy
d. 75/M undergoing percutaneous endoscopic feeding tube placement

A

The correct answer is: 75/M undergoing percutaneous endoscopic feeding tube placement

92
Q

What is the recommended colorectal cancer prevention strategy for patients with long-standing (>8 years) ulcerative pancolitis or Crohn’s colitis(P315 P2194)?

a. Colonoscopy on diagnosis then subsequent colonoscopy based on initial findings
b. Colonoscopy every 10 years
c. Colonoscopy every 5 years
d. Colonoscopy with biopsies every 1-2 years

A

The correct answer is: Colonoscopy with biopsies every 1-2 years

93
Q

A 67/F presented with increasing abdominal discomfort and distension 3 days after a left total hip arthroplasty for a fracture secondary to a fall. PE shows normal BP with tachycardia at 110, mild tachypnea at 22, distended tympanitic abdomen with absent bowel sounds with no direct and rebound tenderness. Upright abdominal film showed massively dilated colon extending to the rectum with no small bowel air-fluid levels and no extraintestinal air. Which of the following is the most likely diagnosis? (P323 P2295)

a. Colonic pseudo-obstruction
b. Perforated duodenal ulcer
c. Small bowel ileus
d. Small bowel obstruction

A

COLONIC PSEUDO-OBSTRUCTION
Ogilvie’s syndrome

Relatively rare disease

May be seen among elderly patients after nonabdominal surgery or in patients with underlying autonomic dysfunction

Treatment: neostigmine
• Acetylcholinesterase inhibitor that increase parasympathetic activity and stimulate colonic motility
• Initiated once it is certain that there is no mechanical obstruction
• Surgery may be needed in bowel perforation or impending perforation

The correct answer is: Colonic pseudo-obstruction

94
Q

Which of the following metabolic abnormalities is NOT associated with ileus (P315 P2194)?

a. Hypokalemia
b. Hypomagnesemia
c. Hypernatremia
d. Hyperglycemia

A

FUNCTIONAL OBSTRUCTION
Also known as ileus and pseudo-obstruction

Present when dysmotility prevents intestinal contents from being propelled distally

No mechanical blockage exists

Most common form: ileus after intraabdominal surgery
• Most often transient but prolongs hospital stay
Treatment: supportive with IV fluids and NGT decompression
• Pharmacologic therapy is NOT yet proven to be efficacious or cost-effective
• Peripherally active mu-opioid receptor antagonists (e.g., alvimopan and methylnatrexone) may accelerate gastrointestinal recovery in some post-abdominal surgery patients

The correct answers are: Hypernatremia,
Hyperglycemia

95
Q

Which of the following sites is commonly spared by diverticular diseases (P321 P2293)?

a. Cecum
b. Esophagus
c. Rectum
d. Sigmoid colon

A

DIVERTICULAR DISEASE

Two types (intestinal)
• True: saclike herniation of entire bowel wall
• False (pseudo-diverticula): involves only a protrusion of the mucosa and submucosa through the muscularis propria of the colon (most commonly affects colon)
These occur at points where the nutrient artery, or vasa recti, penetrates through the muscularis propria, resulting in a break in the integrity of the colonic wall
• Vasa recti either compressed or eroded –> perforation or bleeding
Dysbiosis also an important aspect of this disease

Commonly affects left and sigmoid colon; rectum is always spared

Diverticulitis: inflammation of a diverticulum

The correct answer is: Rectum

96
Q

A 65/M presents at the ER with fever, anorexia, occasional constipation and left lower quadrant abdominal pain which started 4 days prior and progressively worsened. PE showed temperature of 38.9oC, normal BP, HR of 108, RR of 20, and direct tenderness over the left lower quadrant. CBC showed leukocytosis with left shift. Metabolic panel was unremarkable. Which of the following is TRUE regarding abdominal imaging in this patient? (P321 P2284)

a. Air-fluid levels are commonly seen on plain abdominal films
b. Collection of contrast or material or fluid may be seen in the pathologic lesion
c. Thickened colonic wall on CT scan is not required for the diagnosis
d. Whole abdominopelvic ultrasound is the best modality to visualize the pathologic process

A

DIVERTICULITIS: IMAGING
Diagnosis best made on CT with ff findings:
• Sigmoid diverticula
• Thickened colonic wall >4 mm
• Inflammation with the pericolic
• Collection of contrast material or fluid
Air-fluid levels in LLQ may rarely be seen: signifies giant diverticulum

Colonoscopy should be performed ~6 weeks after an attack of diverticular disease to exclude colorectal disease

The correct answer is: Collection of contrast or material or fluid may be seen in the pathologic lesion

97
Q

What is the Hinchey classification for a perforated diverticulitis that has closed spontaneously but with distant abscess formation (P321 P2284)?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

A

COMPLICATED DIVERTICULAR DISEASE
Diverticular disease associated with an abscess or perforation, or less common with a fistula

Perforated diverticular disease staged using the Hinchey classification system

The correct answer is: Stage II

98
Q

An asymptomatic 56/M underwent colonoscopy for colorectal cancer screening was noted to have multiple outpouchings in the sigmoid colon and left colon. He is smoker but does not drink alcohol. He does not have any other co-morbid conditions. What is the MOST appropriate intervention for this patient? (P321 P2284)?

a. Antibiotic therapy with third-generation cephalosporin or ciprofloxacin and metronidazole
b. Bowel rest
c. Initiation of a fiber-enriched diet and smoking cessation
d. Probiotic therapy

A

DIVERTICULAR DISEASE: MEDICAL MANAGEMENT

Asymptomatic diverticular disease (discovered during imaging/colonoscopy): lifestyle changes (high fiber diet and smoking cessation)

Symptomatic uncomplicated diverticular disease
• Bowel rest
• Hospitalization for those unable to take oral therapy
• Antimicrobial coverage: 3rd-generation cephalosporin or ciprofloxacin and metronidazole (addition of ampicillin for non-responders)
• Limited diet until pain resolves

The correct answer is: Initiation of a fiber-enriched diet and smoking cessation

99
Q

A 34/M presented at the clinic for painless bright-red bleeding noted during wiping after defecation and a palpable soft mass in the perianal area. Rectal examination reveals a protrusion with spontaneous reduction and absence of evidence of thrombosis or excoriation. Which of the following is LEAST useful for the patient (P321 P2289)?

a. Fiber supplementation
b. Sclerotherapy
c. Short course of cortisone suppository
d. Operative hemorrhoidectomy

A

HEMORRHOIDAL DISEASE
Treatment for bleeding hemorrhoids is based on the stage of disease

Young patients with no family history of colorectal CA: treat first and do colonoscopy if bleeding continues

Older patients who have not had colorectal cancer screening: colonoscopy or flexible sigmoidoscopy

The correct answer is: Operative hemorrhoidectomy

100
Q

A 45/F presented with constipation-predominant irritable bowel syndrome presents with severe anal pain on defecation with occasional bright-red bleeding per rectum on wiping. Which of the following finding is worrisome for a possible systemic disorder (P321 P2337)?

a. Fissure in the anterior position
b. Fissure in the lateral position
c. Fissure in the posterior position
d. Fissure with hypertrophied anal papilla at the proximal end of the fissure and a sentinel pile or skin tag at the distal end

A

ANAL FISSURE
Occurs in all ages but are more common in 3rd to 5th decades

Associated with constipation, diarrhea, infectious etiologies, perianal trauma and Crohn’s disease

A fissure that is not in the posterior or anterior position should raise suspicion for other causes (e.g., TB, syphilis, Crohn’s disease, and malignancy)

Chronic fissure: indicated by presence of hypertrophied anal papilla at the proximal end of the fissure and a sentinel pile or skin tag at the distal end

Anal manometry: elevated anal resting pressures; sawtooth deformity with paradoxical contractions of the sphincter muscles (pathognomonic)

The correct answer is: Fissure in the lateral position

101
Q

Which of the following is TRUE regarding the epidemiology of ulcerative colitis (P319 P2258)?

a. Appendectomy increases the risk of ulcerative colitis
b. Highest incidence among Hispanics and Asians
c. Peak incidence in 5th to 6th decades
d. Smoking may prevent disease

A

INFLAMMATORY BOWEL DISEASE: EPIDEMIOLOGY
Greatest incidence: white and Jewish people (incidence in Hispanic in Asian people is increasing, however)

Peak incidence in 2nd to 4th decades (with second modest rise between the 7th and 9th decades)

The correct answer is: Smoking may prevent disease

102
Q

A 22/F presented at the ER for 6-month history of severe crampy abdominal pain (usually in right lower quadrant) and chronic diarrhea with occasional episodes of hematochezia. She also reports significant weight loss, night sweats and low-grade intermittent fevers. She has no other illnesses. PE shows abdominal rebound tenderness and involuntary guarding. Scout film shows free air in the peritoneum. She underwent emergent exploration which showed perforated terminal ileum with multiple strictures. There was rectal sparing. Which of the following histologic findings confirms her diagnosis? (P319 P2263)?

a. Crypt abscesses
b. Flat villi
c. Non-caseating granuloma throughout the bowel wall
d. Process limited to mucosa and superficial submucosa

A

INFLAMMATORY BOWEL DISEASE: CROHN’S DISEASE
Discontinuous lesions with presence of strictures and fissures

Hallmark of Crohn’s Disease: granulomas throughout bowel wall and may involve lymph nodes, mesentery, peritoneum, liver and pancreas

The correct answer is: Non-caseating granuloma throughout the bowel wall

103
Q

Probiotics are increasingly being used for inflammatory bowel disease. Which of the following organisms has been used to treat IBD (P319 P2274)?

a. Bifidobacterium spp.
b. Campylobacter spp.
c. Escherichia spp.
d. Yersinia spp.

A 
IBD: PROBIOTICS
Probiotics may prevent recurrence of pouchitis in IBD
•	Lactobacillus
•	Bifidobacterium
•	Streptococcus salivarius

The correct answer is: Bifidobacterium spp.

104
Q

Which of the following is FALSE regarding cancer in inflammatory bowel disease (P319 P2274)?

a. Cancer risks in CD and UC are probably equivalent for similar extent and duration of disease
b. Patients with long-standing UC are at increased risk for developing colonic epithelial dysplasia and carcinoma
c. Patients with CD may have increased risk for NHL, leukemia and MDS
d. Small-bowel adenocarcinoma risk is significantly increased in CD

A

IBD AND CANCER

Cancer risks in CD and UC are probably equivalent for similar extent and duration of disease
• Same endoscopic surveillance strategy for both CD and UC
• Annual or biennial colonoscopy with multiple biopsies is recommended for patients with >8-10 years of extensive colitis (>1/3 of colon involved) or 12-15 years of proctosigmoiditis

Risk factors for cancer
• UC: long-duration disease, extensive disease, family hx of colon CA, PSC, colon stricture, presence of post-inflammatory pseudopolyps
• CD: long-duration disease, extensive disease, bypassed colon segments, colon strictures, PSC, family history of colon cancer
Other cancers
• CD: may have increased risk of NHL, leukemia, and MDS; CA in lower rectum and anal canal (SCCA)
• Low absolute risk of small-bowel adenoCA

The correct answer is: Small-bowel adenocarcinoma risk is significantly increased in CD

105
Q

Which of the following antibiotics pose the LEAST risk of C. difficile infection (P319 P2274)?

a. Ampicillin
b. Ceftriaxone
c. Ciprofloxacin
d. Piperacillin-tazobactam

A

CLOSTRIDIUM DIFFICILE INFECTION (CDI)
Acquired most commonly in association with antimicrobial use and consequent disruption of the normal colonic microbiota

Most commonly diagnosed diarrheal illness in the hospital

Results from ingestion of spores of C. difficile that vegetate, multiply, and secrete toxics causing diarrhea and pseudomembranous colitis is most severe cases

Antibiotic association
• Clindamycin, ampicillin, cephalosporins: first antibiotics associated with CDI
• Frequently responsible: 2nd- and 3rd-generation cephalosporins
• Most recent implicated drug class: fluoroquinolones
• Penicillin/beta-lactamase combinations pose significantly less risk
• However, all antibiotics, including vancomycin and metronidazole have been found to carry a risk of subsequent CDI

The correct answer is: Piperacillin-tazobactam

106
Q

Who among the following patients is C. difficile infection treatment NOT indicated (P319 P2274)?

a. 57/M living in a nursing home with diarrhea of 2 weeks and pseudomembranes found on colonoscopy with no evidence of toxin A or B in stool
b. 67/F presenting with fever, leukocytosis, adynamic ileus, and a positive PCR for C. difficile in stool
c. 68/M admitted to ICU for abdominal pain and diarrhea with severe abdominal tenderness with hypotension, absent bowel sounds, and colonic wall thickening on CT scan with recent history of antibiotic intake for UTI
d. 72/F with two LBM per day for the past 3 days with no fever and normal WBCs; took amoxicillin for throat itchiness 1 day prior to presentation

A

CDI: DIAGNOSIS

Diagnosis of CDI is based on a combination of clinical criteria

  • Diarrhea (>3 unformed stools per 24 hours for >2 days) with no other recognized cause plus
  • Detection of toxin A or B in the stool, detection of toxin-producing C. difficile in the stool by NAAT/PCR or by culture or
  • Visualization of pseudomembranes in the colon (advanced finding)

The correct answer is: 72/F with two LBM per day for the past 3 days with no fever and normal WBCs; took amoxicillin for throat itchiness 1 day prior to presentation

107
Q

Which of the following organisms is the most likely etiology for nausea, vomiting, crampy abdominal pain and diarrhea four hours after intake of food with mayonnaise (P319 P2274)?

a. Bacillus aureus
b. Clostridium perfringens
c. Salmonella spp.
d. Staphylococcus aureus

A

FOOD POISONING
History and stool examination indicating a non-inflammatory etiology of diarrhea and there is an evidence of a common-source outbreak –> ingestion of specific foods and time of onset of symptoms can provide clues to bacterial cause of illness

Not all food poisoning has a bacterial cause
• Capsaicin: short-incubation period
• Toxins from fish and shellfish

The correct answer is: Staphylococcus aureus

108
Q

Which of the following ancillary tests is appropriately indicated for the corresponding clinical condition? HPIM 20th ed p. 2336

a. ERCP is more valuable in evaluating bile duct obstruction and congenital biliary diseases
b. MRCP is useful in the diagnosis of ampullary lesions and primary sclerosing cholangitis
c. Elastography is accurate in assessing fibrosis and cirrhosis and disease activity
d. Ultrasound is used to to monitor surgically or radiologically placed vascular shunts

A

MRCP is superior to ultrasound and CT for detecting choledocholithiasis
MRCP is useful in the diagnosis of bile duct obstruction and congenital biliary abnormalities
ERCP is more valuable in evaluating ampullary lesions and primary sclerosis cholangitis
Ultrasound and MRI are used to assess hepatic vasculature and hemodynamics and to monitor surgically or radiologically placed vascular shunts including TIPS.
Multi-detector or spiral CT and MRI with contrast enhancement for evaluation of hepatic masses, staging of liver tumors, and pre-operative assessment
US and MR Elastography: hepatic stiffness - fibrosis and cirrhosis except when in activity
Liver biopsy: gold standard for chronic liver disease; more often useful for assessment of the severity (grade) and stage of liver dam- age, prediction of prognosis, and monitoring of the response to treatment. Liver biopsy is also the most accurate means of assessing stage of disease as early or advanced, precirrhotic, and cirrhotic.

The correct answer is: Ultrasound is used to to monitor surgically or radiologically placed vascular shunts

109
Q

Which of the following aminotransferase pattern is interpreted correctly? HPIM 20th ed p. 2339

a. ALT of > 1000 IU may suggest acute phase of choledocholithiasis
b. ALT is twice elevated in alcoholic liver disease
c. AST:ALT ratio of > 1 may suggest non-alcoholic fatty liver disease
d. AST that is less than or equal to ALT suggest and acute hepatocellular disorder

A

AMINOTRANSFERASES
ALT
• found primarily in the liver
• liver cell necrosis is not required for the release of aminotransferases
• There is a poor correlation between the degree of liver cell damage and the level of aminotransferases
• Aminotransferases has no prognostic significance in acute hepatocellular disorders

Elevations in ALT:
•	>300 non-specific
•	>1000 IU/L
o	viral hepatitis
o	ischemic liver injury
o	toxin or drug induced liver injury
o	choledocholithiasis
ALT> AST: acute hepatocellular disorder
AST ALT ratio  < 1 chronic viral hepatitis and non-alcoholic fatty liver disease
AST: ALT 2-3:1 alcoholic liver disease
Normal ALT in alcoholic liver disease  deficiency of pyridoxal phosphate while AST in alcoholic liver disease is rarely > 300

The correct answer is: ALT of > 1000 IU may suggest acute phase of choledocholithiasis

110
Q

Which laboratory parameter increases the likelihood of a cholestasis?

a. two fold elevation of alkaline phosphatase
b. elevated gamma glutamyl transpeptidase is more specific
c. (+) 5’-nucleotidase in an isolated alkaline phosphatase elevation
d. ten fold increase of aspartate aminotransferase

A

ENZYMES THAT REFLECT CHOLESTASIS
The activities of three enzymes— alkaline phosphatase, 5’-nucleotidase, and g-glutamyl transpeptidase (GGT)—are usually elevated in cholestasis. Alkaline phosphatase and 5’-nucleotidase are found in or near the bile canalicular membrane of hepatocytes, whereas GGT is located in the endoplasmic reticulum and in bile duct epithelial cells. Reflecting its more diffuse localization in the liver, GGT elevation in serum is less specific for cholestasis than are elevations of alkaline phosphatase or 5’-nucleotidase. Some have advocated the use of GGT to identify patients with occult alcohol use. Its lack of specificity makes its use in this setting questionable.
The normal serum alkaline phosphatase consists of many distinct isoenzymes found in the liver, bone, placenta, and, less commonly, in the small intestine. Patients over age 60 can have a mildly elevated alkaline phosphatase (1–1.5 times normal), whereas individuals with blood types O and B can have an elevation of the serum alkaline phosphatase after eating a fatty meal due to the influx of intestinal alkaline phosphatase into the blood. It is also elevated in children and adolescents undergoing rapid bone growth because of bone alkaline phosphatase, and late in normal pregnancies due to the influx of placental alkaline phosphatase.
If an elevated serum alkaline phosphatase is the only abnormal finding in an apparently healthy person, or if the degree of elevation is higher than expected in the clinical setting, identification of the source of elevated isoenzymes is helpful. This problem can be approached in two ways. First, and most precise, is the fractionation of the alkaline phosphatase by electrophoresis. The second, best substantiated, and most available approach involves the measurement of serum 5¢-nucleotidase or GGT. These enzymes are rarely elevated in conditions other than liver disease.
In the absence of jaundice or elevated aminotransferases, an elevated alkaline phosphatase of liver origin often, but not always, suggests early cholestasis and, less often, hepatic infiltration by tumor or granulomata. Other conditions that cause isolated elevations of the alkaline phosphatase include Hodgkin’s disease, diabetes, hyperthyroidism, congestive heart failure, amyloidosis, and inflammatory bowel disease.
The level of serum alkaline phosphatase elevation is not helpful in distinguishing between intrahepatic and extrahepatic cholestasis. There is essentially no difference among the values found in obstructive jaundice due to cancer, common duct stone, sclerosing cholangitis, or bile duct stricture. Values are similarly increased in patients with intrahepatic cholestasis due to drug-induced hepatitis, primary biliary cirrhosis, rejection of transplanted livers, and, rarely, alcohol-induced steatohepatitis. Values are also greatly elevated in hepatobiliary disorders seen in patients with AIDS (e.g., AIDS cholangiopathy due to cytomegalovirus or cryptosporidial infection and tuberculosis with hepatic involvement).

The correct answer is: (+) 5’-nucleotidase in an isolated alkaline phosphatase elevation

111
Q

Which of the following ancillary results is likely in a 63 year old male complaining of jaundice with 2x elevated transaminases with a ratio of 0.8 and elevated bilirubin with 4x elevated alkaline phosphatase? (HPIM 20th ed pp. 271 and 2053)

a. Dilated biliary ducts in ultrasound to determine the presence of intrahepatic cholestasis
b. Viral Serologies for Hepatitis B or C will determine etiology of hepatocellular cholestasis
c. Peripheral Blood Smear to determine cases of indirect hyperbilirubinemia
d. ERCP for further determination of biliary duct dilatation

A

The correct answer is: ERCP for further determination of biliary duct dilatation

112
Q

A patient with acute hepatitis should undergo which serologic tests for initial screening ? HPIM 20th ed Ch 45 pp278-279

a. HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV
b. HBsAg, Anti-Hbs, IgM anti-HAV, HCV RNA, and anti-HDV
c. HBsAg, HBV-DNA, and HCV RNA
d. HBsAg and Anti-HCV

A

EVALUATING ACUTE HEPATITIS
HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV
IgM anti-HBc, IgG Anti-HAV, with or without IgM anti-HBc, represents HBV infection
If IgM anti-HBc is present, the HBV infection is considered acute;
IgM anti-HBc is absent, the HBV infection is considered chronic.
A diagnosis of acute hepatitis B can be made in the absence of HBsAg when IgM anti-HBc is detectable.
A diagnosis of acute hepatitis A is based on the presence of IgM anti-HAV. If IgM anti-HAV coexists with HBsAg, a diagnosis of simultaneous HAV and HBV infections can be made; if IgM anti-HBc (with or without HBsAg) is detectable, the patient has simultaneous acute hepatitis A and B,and if IgM anti-HBc is undetectable, the patient has acute hepatitis. A superimposed on chronic HBV infection.
The presence of anti-HCV supports a diagnosis of acute hepatitis C. Occasionally, testing for HCV RNA or repeat anti-HCV testing later during the illness is necessary to establish the diagnosis.
Absence of all serologic markers is consistent with a diagnosis of “non-A, non-B, non-C” hepatitis (no other proven human hepatitis viruses have been identified), if the epidemiologic setting is appropriate.

The correct answer is: HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV

113
Q

A patient with chronic hepatitis should undergo which serologic tests for initial screening ? HPIM 20th ed Ch 332 p 2350

a. HBsAg, anti-HDV, IgG anti-HBc, and anti-HCV
b. HBsAg, anti-Hbs, anti-HDV, HCV RNA
c. HBsAg, HBV-DNA, HCV RNA
d. HBsAg and Anti-HCV

A

EVALUATING CHRONIC HEPATITIS
In patients with chronic hepatitis, initial testing should consist of HBsAg and anti-HCV.
Anti-HCV supports and HCV RNA testing establishes the diagnosis of chronic hepatitis C.
If a serologic diagnosis of chronic hepatitis B is made, testing for HBeAg and anti-HBe is indicated to evaluate relative infectivity.
Testing for HBV DNA in such patients provides a more quantitative and sensitive measure of the level of virus replication, and therefore is very helpful during antiviral therapy.
In patients with chronic hepatitis B and normal aminotransferase activity in the absence of HBeAg, serial testing over time is often required to distinguish between inactive carriage and HBeAg-negative chronic hepatitis B with fluctuating virologic and necroinflammatory activity.
In persons with hepatitis B, testing for anti-HDV is useful in those with severe and fulminant disease, with severe chronic disease, with chronic hepatitis B and acute hepatitis-like exacerbations, with frequent percutaneous exposures, and from areas where HDV infection is endemic.

The correct answer is: HBsAg and Anti-HCV

114
Q

A 23 year old female was admitted for jaundice. On physical examination, she had multiple tattoos, icteric sclerae and skin.The liver size was normal. Her hepatitis profile was consistent with acute Hepatitis B infection. Which serologic profile is expected for the patient? HPIM 20th ed Ch 332 p 2350

a. Anti-HbsAg is detectable during the entire icteric phase of acute hepatitis B
b. HBcAg is readily demonstrable in serum after the appearance of the Anti-HBsAg
c. Anti-HBc of the IgG class predominates by the 12th week of jaundice
d. HBeAg appears concurrently with or shortly after HBsAg

A

The correct answer is: HBeAg appears concurrently with or shortly after HBsAg

115
Q

A 48 year old male seafarer came in the clinic for pre-employment clearance. Upon review, his hepatitis profile showed the following result: Anti-Hbs (+), IgG (+) AntiHbC, IgM (-) AntiHbC, HbsAg (-), HbeAg (-), Anti-Hbe (+). The patient __________________. (HPIM 20th ed Table 360-5)

a. Had hepatitis B in remote past
b. Has chronic HbeAg negative (pre-core mutant) Hepatitis B
c. Is a low-level hepatitis B carrier
d. Had recovered from Hepatitis B

A

The correct answer is: Had recovered from Hepatitis B

116
Q

A 40 year old male with jaundice overseas Filipino came back for follow-up in the clinic after his pre-employment evaluation. His hepatitis B profile was a late chronic hepatitis B with low infectivity. This condition is best described as ________________. (HPIM 20th ed Table 360-5)

a. (-)HBsAg, (+) Anti-HBsAg, (+) Anti-HBc, (-) HBeAg, (+) Anti-HBe
b. (+)HBsAg, (-) Anti-HBsAg, ( + ) Anti-HBc, (-) HBeAg, (+) Anti-HBe
c. (-)HBsAg, (+) Anti-HBsAg, (-) Anti-HBc, (-) HBeAg, (-) Anti-HBe
d. (+)HBsAg, (+) Anti-HBsAg, (-) Anti-HBc, (+) HBeAg, (-) Anti-HBe

A

The correct answer is: (+)HBsAg, (-) Anti-HBsAg, ( + ) Anti-HBc, (-) HBeAg, (+) Anti-HBe

117
Q

A 48 year old male with jaundice came back for follow-up in the clinic. His hepatitis B profile was a non-replicative Hbe-Ag reactive chronic hepatitis B. This condition is best described as ________________. (HPIM 20th ed Ch 334 pp 2376-2377)

a. HBV DNA levels well in excess of 103−104 IU/mL
b. the presence of HBcAg
c. the appearance of anti-HBe
d. fluctuating levels of aminotransferases

A

INFECTIVITY OF HEPATITIS B
Chronic HBV infection can occur in the presence or absence of serum hepatitis B e antigen (HBeAg), and generally, for both HBeAg-reactive and HBeAg-negative chronic hepatitis B, the level of HBV DNA correlates with the level of liver injury and risk of progression.
In HBeAg-reactive chronic hepatitis B, the relatively replicative phase is characterized by the presence in the serum of HBeAg and HBV DNA levels well in excess of 103−104 IU/mL, sometimes exceeding 109 IU/mL; by the presence in the liver of detectable intrahepatocyte nucleocapsid antigens (primarily hepa- titis B core antigen [HBcAg]); by high infectivity; and by accompanying liver injury. Patients in the replicative phase tend to have more severe chronic hepatitis.
In HBeAg-reactive chronic hepatitis B, the relatively nonreplicative phase is characterized by the absence of the conventional serum marker of HBV replication (HBeAg), the appearance of anti-HBe, levels of HBV DNA below a threshold of ~103 IU/mL, the absence of intrahepatocytic HBcAg, limited infectivity, and minimal liver injury. Those in the nonreplicative phase tend to have minimal or mild chronic hepatitis or to be inactive hepatitis B carriers.
The likelihood in a patient with HBeAg-reactive chronic hepatitis B of converting spontaneously from relatively replicative to nonreplicative infection is approximately 10% per year
HBeAg-negative chronic hepatitis B (i.e., chronic HBV infection with active virus replication, readily detectable HBV DNA but without HBeAg [anti-HBe-reactive]), have levels of HBV DNA that are several orders of magnitude lower (no more than 105−106 IU/mL) than those observed in the HBeAg-reactive subset, HBeAg- negative chronic hepatitis B can have progressive liver injury (complicated by cirrhosis and HCC) and experience episodic reactivation of liver disease reflected in fluctuating levels of aminotransferase activity (“flares”). The biochemical and histologic activity of HBeAg-negative disease tends to correlate closely with levels of HBV replication, unlike the case mentioned above of Asian patients with HBeAg-reactive chronic hepatitis B during the early decades of their HBV infection.

The correct answer is: the appearance of anti-HBe

118
Q
  1. Which of the following is NOT a benefit of high-dose constant-infusion proton pump inhibitors among patients with GI bleeding from peptic ulcer disease?
    a. Decreases rebleeding rates
    b. Enhancement of clot stability
    c. Improves mortality among those with high-risk ulcers
    d. Sustains intragastric pH to less than 6
A

The correct answer is: Sustains intragastric pH to less than 6

119
Q

Free air under the diaphragm in a case 50/M with chronic epigastric pain relieved with antacids and self-prescribed PPI, consulting for fever and board-like rigidity of the abdomen, which of the following will be MOST LIKELY seen in the abdominal cavity during exploratory laparotomy?

a. Bile
b. Blood
c. Foreign body
d. Gastric contents

A

The correct answer is: Gastric contents

120
Q

Which of the following drugs produces predictable and dose-related hepatic injury?

a. Amoxicillin-clavulanate
b. Androgenic steroids
c. Ciprofloxacin
d. Isoniazid

A

The correct answer is: Androgenic steroids

121
Q

Which of the following biochemical signatures should almost always trigger further assessment for the possibility of paracetamol overdose?

a. Elevated gamma-glutamyl transferase levels with normal aminotransferase and bilirubin levels
b. Extremely elevated aminotransferase levels with low bilirubin levels
c. Predominantly elevated bilirubin levels with mild aminotransferase level elevations
d. Mixed hepatitis and cholestasis

A

The correct answer is: Extremely elevated aminotransferase levels with low bilirubin levels

122
Q

Which of the following is considered as the most consistent clinical feature in IBS?

a. Abdominal pain
b. Alteration in bowel habits
c. Gas and flatulence
d. Nausea and vomiting

A

The correct answer is: Alteration in bowel habits

123
Q

Who among the following patients require no further testing before making the diagnosis of irritable bowel syndrome and initiating treatment?

a. 78/F with 6 months of intermittent crampy abdominal pain that is worse with stress and associated with bloating and diarrhea
b. 25/F with 6 months of abdominal pain, bloating, and diarrhea that has worsened steadily and now awakens from sleep at night to move her bowels
c. 30/M with 6 months of crampy lower abdominal pain relieved by bowel movements which are usually loose with symptoms worse during daytime at work
d. 19/F with 2 months of diarrhea and worsening abdominal pain with occasional blood in her stool

A

The correct answer is: 30/M with 6 months of crampy lower abdominal pain relieved by bowel movements which are usually loose with symptoms worse during daytime at work

124
Q

Which of the following foods should be minimally taken or avoided by patients with IBS?

a. Red meat
b. fruit juices in cans or carton packs
c. Fish and chicken
d. Green leafy vegetables

A

The correct answer is: fruit juices in cans or carton packs

125
Q

A 38/Male is admitted for hematochezia for a 2nd time after a negative endoscopy and colonoscopy for a similar complaint 8 months ago. He has started working night shifts for the past 2 months. He is an occasional alcohol drinker, denies smoking but remembers an uncle who had a similar hospitalization when he was his age. Which of the following diseases would be the candidate cause?

a. Crohn’s disease
b. Adenocarcinoma
c. Vascular ectasia
d. Intestinal ischemia

A

The correct answer is: Crohn’s disease

126
Q

In new-onset dyspepsia, which of the following symptoms is a red flag?

a. Comes at night after a full meal
b. Associated with vomiting
c. Relief only with H2 antagonists and not with antacids
d. Age less than 30 years

A

The correct answer is: Associated with vomiting

127
Q

A 45 male lawyer had sudden onset of hematochezia and was brought to the ER with BP 90/60 mmHg, HR 110/min, alert but with confusion. Which of the following procedure is recommended to be first done in determining the source of bleeding?

a. Upper endoscopy
b. Bowel prep for emergency colonoscopy
c. Emergency CT angiogram
d. Emergency MRA

A

The correct answer is: Upper endoscopy

128
Q

Which of the following endoscopic findings require a biopsy due to increased risk of being malignant?

a. 0.5 mm ulcer in the duodenum located within 2 cm from the pylorus
b. 1.0 cm ulcer in the gastric fundus
c. 3.0 cm ulcer in the second part of the duodenum
d. 6.0 cm ulcer in the first portion of the duodenum

A

The correct answer is: 1.0 ulcer in the gastric fundus

129
Q

Which of the following infectious agents may also cause ulcer disease?

a. Campylobacter jejuni
b. Cytomegalovirus
c. Mycoplasma pneumoniae
d. Varicella zoster virus

A

The correct answer is: Cytomegalovirus

130
Q

Which of the following drugs by itself is known to cause ulcer disease?

a. Glucocorticoids
b. ACE inhibitors
c. Clopidogrel
d. Macrolides

A

The correct answer is: Clopidogrel

131
Q

A 29/M presented at the clinic with a 2-month history of burning epigastric pain partly relieved by food intake. He did no have any other symptoms. PE was unremarkable. Stool antigen testing was positive for H. pylori. Which of the following is an appropriate treatment regimen for the patient’s condition?

a. Pantoprazole and clarithromycin for 7 days
b. Omeprazole, clarithromycin, and metronidazole for 7 days
c. Esomeprazole, clarithromycin, and amoxicillin for 14 days
d. Omeprazole, bismuth subcitrate, tetracycline, and metronidazole for 14 days

A

The correct answer is: Omeprazole, bismuth subcitrate, tetracycline, and metronidazole for 14 days

132
Q

A 33 year old housewife received amoxicillin clavulanic acid for urinary tract infection. She noted that her long time GERD symptoms have worsened. Consulting her gastroenterologist after 2 weeks of treatment, she forgot to disclose the treatment she received for UTI. What would be the mostly likely result of the urea-breath test for H. pylori done?

a. Equivocal
b. False positive
c. True negative
d. False negative

A

The correct answer is: False negative

133
Q

Which of the following extraesophageal conditions has established causative association with GERD?

a. Laryngitis
b. Pharyngitis
c. Sleep apnea
d. Chronic sinusitis

A

The correct answer is: Laryngitis

134
Q

. A 70/M was admitted to the ICU for acute stroke and is comatose. Which of the following is the best option for stress-related mucosal injury prevention?

a. Sucralfate
b. Misoprostol
c. Proton pump inhibitors
d. H2 receptor antagonists

A

The correct answer is: Proton pump inhibitors

135
Q

Which of the following is the most common cause of acute gastritis?

a. Alcohol
b. Infections
c. Missing meals
d. Smoking

A

The correct answer is: Infections

136
Q

A 50/M was recently diagnosed with chronic gastritis. Which of the following histologic findings is an important predisposing factor for gastric cancer in this patient?

a. Conversion of gastric glands into a small intestinal phenotype
b. Inflammatory changes limited to the lamina propria of surface mucosa with surrounding edema
c. Progressive distortion and destruction of gastric glands
d. Thinned out mucosa with loss of glandular structures and paucity of inflammatory infiltrates

A

The correct answer is: Conversion of gastric glands into a small intestinal phenotype

137
Q

Which of the following clinical manifestations will negate peritonitis as a main diagnostic consideration?

a. Fever
b. severe abdominal pain
c. hyperactive bowel sounds
d. diffuse tenderness with local guarding

A

The correct answer is: diffuse tenderness with local guarding

138
Q

In suspected cases of acute intestinal ischemia, early diagnosis by CT angiography plus laparotomy is recommended in which form/cause of disease?

a. Arterial embolus
b. Arterial thrombosis
c. Venous thrombosis
d. Non-occlussive mesenteric ischemia

A

The correct answer is: Arterial embolus

139
Q

In deciding on which diagnostic procedure to use to rule out acute appendicitis, which of the following statements is true?

a. Plain abdominal film is useful especially in the presence of fecalith in the area of the appendix
b. Abdominal CT scan has high negative predictive value
c. Ultrasound is superior since it can identify pathology near the pelvis
d. Air around the appendix on plain xray is high in positive predictive value for appendicitis

A

The correct answer is: Abdominal CT scan has high negative predictive value

140
Q

Which of the following statements is true as regards diagnostic procedures in hepatobiliary diseases?

a. ERCP is more valuable in evaluating bile duct obstruction and congenital biliary
b. MRCP is useful in the diagnosis of ampullary lesions and primary sclerosis cholangitis
c. Elastography is accurate in assessing fibrosis and cirrhosis and disease activity
d. Ultrasound is used to to monitor surgically or radiologically placed vascular shunts

A

The correct answer is: Ultrasound is used to to monitor surgically or radiologically placed vascular shunts

141
Q

Which of the following statements is true regarding liver enzyme readings?

a. Increasing trend of ALT starting 3-5X elevation is suggestive of acute phase of choledocholithiasis
b. ALT is twice elevated with AST more than 3x elevated in alcoholic liver disease
c. AST: ALT ratio of > 1 may suggest non-alcoholic fatty liver disease
d. Acute hepatocellular disorder can have normal ALT and AST

A

The correct answer is: AST: ALT ratio of > 1 may suggest non-alcoholic fatty liver disease

142
Q

Which of the following ancillary results is likely in a 63 year old male complaining of jaundice with 2x elevated transaminases with a ratio of 0.8 and elevated bilirubin with 4x elevated alkaline phosphatase?

a. Dilated biliary ducts in ultrasound to determine the presence of intrahepatic cholestasis
b. Viral Serologies for Hepatitis B or C will determine etiology of hepatocellular cholestasis
c. Peripheral Blood Smear to determine cases of indirect hyperbilirubinemia
d. ERCP for further determination of biliary duct dilatation

A

The correct answer is: ERCP further determination of biliary duct dilatation

143
Q

A patient with acute hepatitis should undergo which serologic tests for initial screening?

a. HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV
b. HBsAg, Anti-Hbs, IgM anti-HAV, HCV RNA, and anti-HDV
c. HBsAg, HBV-DNA, and HCV RNA
d. HBsAg and Anti-HCV

A

The correct answer is: HBsAg, IgM anti-HAV, IgM anti-HBc, and anti-HCV

144
Q

Which of the following serologic profile is consistent with acute Hepatitis B infection?

a. Anti-HbsAg is detectable during the entire icteric phase of acute hepatitis B
b. HBcAg is readily demonstrable in serum after the appearance of the Anti-HBsAg
c. Anti-HBc of the IgG class predominates by the 12th week of jaundice
d. HBeAg appears concurrently with or shortly after HBsAg

A

The correct answer is: HBeAg appears concurrently with or shortly after HBsAg

145
Q

Which of the following statements is an acceptable strategy for Hepatitis B post exposure prophylaxis?

a. single IM dose of HBIG to HbsAg-positive mothers prior to labor
b. single IM dose of HBIG should be administered within 1 week to an accidental needle stick injury to HBsAg-positive body fluids
c. Sexual contact to a patient with acute hepatitis B should be given HBIG as soon as possible
d. Booster immunizations are recommended routinely for hemodialysis patients

A

The correct answer is: Booster immunizations are recommended routinely for hemodialysis patients

146
Q

Which of the following choices is a cause of pre-hepatic portal hypertension?

a. Splenic Vein Thrombosis
b. Hepatic Sinusoidal obstruction
c. Alcoholic hepatitis
d. Schistosomiasis

A

The correct answer is: Splenic Vein Thrombosis

147
Q

Which of the following complications of cirrhosis is correctly paired with its expected laboratory finding?

a. Spontaneous bacterial peritonitis: ascitic fluid absolute neutrophil count is 150/uL
b. Type 2 hepatorenal syndrome: rapid decline in estimated glomerular filtration rate
c. Portal hypertension: SAAG of 1.2 gm/dL
d. Hepatic encephalopathy: elevated serum ammonia level

A

The correct answer is: Portal hypertension: SAAG of 1.2 gm/dL

148
Q

Which of the following tests will help identify causes of ascites outside of cirrhosis?

a. Request for ascitic fluid neutrophil count
b. Obtain cultures of ascitic fluid
c. Await ascitic total protein concentration
d. Measure serum–ascites albumin gradient

A

The correct answer is: Measure serum–ascites albumin gradient

149
Q

Which of the following is an important contraindication for liver transplant?

a. Primary hepatocellular malignancy
b. Fulminant Hepatitis
c. Autoimmune hepatitis
d. Alcoholic abuse

A

The correct answer is: Alcoholic abuse

150
Q

What is the recommended management for a patient with EGD findings of esophageal varices, non-bleeding, known case of compensated cirrhosis?

a. No treatment
b. Propranolol
c. Pantoprazole
d. Spironolactone

A

The correct answer is: Propranolol

151
Q

What is the most common cause of acute pancreatitis?

a. alcohol abuse
b. oral contraceptives
c. diabetes mellitus
d. gallstones

A

The correct answer is: gallstones

152
Q 
What is the main enzyme that is seen to cause pancreatic acinar cell injury and inflammatory cascade in acute pancreatitis?
a. Pepsin
b. Gastrin
c. Secretin
d. Trypsin
F
A

The correct answer is: Trypsin

153
Q

Which of the following dietary approach is most appropriate for patients with moderately severe acute pancreatitis?

a. Pancreatic activation is attenuated using parenteral route
b. Reduction of infectious complications is reduced with enteral route
c. Nasojejunal administration is preferred than nasogastric feeding
d. Pancreatic rest by NPO is maintained for 4-5 days

A

The correct answer is: Reduction of infectious complications is reduced with enteral route

PSBIM: PGH REVIEW (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions