Gastroenterology Flashcards
What are the types of hiatal hernias?
What is the most common type?
- Type I (sliding)
- Type II (paraesophageal)
- Type III (mixed)
- Type IV (complex with other organs involved)
Type 1 Sliding
What is the anatomical defect in a sliding hiatal hernia?
The gastroesophageal junction and part of the stomach slide upward through the esophageal hiatus into the thorax
What is the primary risk factor for developing a hiatal hernia?
Increased intra-abdominal pressure, often caused by obesity, heavy lifting, or pregnancy.
What are the potential complications of a paraesophageal hernia?
- Strangulation
- Ischemia
- Obstruction of the stomach
What is the gold standard diagnostic tool for hiatal hernia?
Esophagogastroduodenoscopy (EGD) or barium swallow study
What are the typical symptoms of a sliding hiatal hernia?
GERD symptoms such as heartburn, regurgitation, or dysphagia
What are the key anatomical landmarks to identify during a hiatal hernia repair?
- Esophageal hiatus
- Gastroesophageal junction
- Crura of the diaphragm
- Vagus nerve
A 45-year-old female presents with a 6-month history of heartburn, regurgitation, and a sensation of food getting stuck in her chest after eating. She denies any weight loss or hematemesis. An upper endoscopy reveals the gastroesophageal junction above the diaphragm with no evidence of esophagitis. What is the most likely diagnosis?
A) Esophageal cancer
B) Barrett’s esophagus
C) Achalasia
D) Sliding hiatal hernia
Sliding hiatal hernia
The most common hiatal hernia is a sliding type, which can present with GERD-like symptoms. The absence of other alarming features (e.g., weight loss or bleeding) suggests a benign cause like a sliding hiatal hernia.
A 60-year-old male presents with chest pain, postprandial fullness, and vomiting. Physical exam reveals mild epigastric tenderness. A barium swallow study shows part of the stomach located above the diaphragm, while the gastroesophageal junction remains in its normal position. What is the most appropriate next step in management?
A) Proton pump inhibitor therapy
B) Observation with lifestyle modifications
C) Elective surgical repair
D) Urgent endoscopy
Elective Surgical Repair
This is a paraesophageal hernia, which can cause serious complications like strangulation. Elective surgical repair is recommended in paraesophageal hernia’s to prevent these outcomes.
A 67-year-old female with a paraesophageal hernia presents to the emergency room with acute onset of severe chest pain, nausea, and vomiting. Her vitals show tachycardia and hypotension. Abdominal imaging reveals gastric volvulus and signs of ischemia. What is the most appropriate next step in management?
A) Emergency surgical repair
B) Intravenous proton pump inhibitors
C) Barium swallow study
D) Nasogastric decompression
Emergency Surgical Repair
Gastric volvulus is a surgical emergency, and prompt intervention is necessary to prevent further ischemia and necrosis of the stomach.
Approximately 85% of hiatal hernias can be treated effectively with diet modifications and PPI’s, if these treatments are not effective what surgical procedure should be considered?
Laparoscopic Nissen fundopication
What is the most common cause of appendicitis?
Obstruction of the appendiceal lumen, often by a fecalith (hardened stool), lymphoid hyperplasia, or less commonly by tumors or foreign bodies.
What is the classic initial symptom of appendicitis?
Periumbilical pain that later migrates to the right lower quadrant (RLQ) as the inflammation progresses.
What is McBurney’s point?
It is a point located two-thirds of the distance from the umbilicus to the anterior superior iliac spine (ASIS). Tenderness at this point is a classic sign of appendicitis.
What is the most common complication of untreated appendicitis?
Perforation, which can lead to peritonitis or an intra-abdominal abscess.
Which physical exam sign suggests appendicitis if the patient experiences pain upon passive extension of the right hip?
Psoas Sign
What is the typical sequence of symptoms in acute appendicitis?
Periumbilical pain → anorexia → nausea/vomiting → RLQ pain
What imaging modality is most commonly used to diagnose appendicitis in adults?
CT scan of the abdomen and pelvis with contrast
What is the treatment for uncomplicated appendicitis?
Appendectomy
What are the typical laboratory findings in acute appendicitis?
Leukocytosis with a left shift (increased neutrophils), but normal labs do not rule out appendicitis
What is the most common cause of emergent abdominal surgery in the United States?
Acute appendicitis
Can you have an abnormal urinanalysis with appendicitis?
Yes, mild hematuria and pyuria are common in appendicitis w/ pelvic inflammation, resulting in inflammation of the ureter
What are the preoperative medications and preperation for an appendectomy?
- Rehydration with IV fluids (LR)
- Preoperative antibiotics with anaerobic coverage
How long after removal of a NONRUPTURED appendix should antibiotics continue post-op?
24 hours
Which antibiotic is used for NONPERFERORATED appendicitis?
What about a perforated appendicitis?
Anaerobic coverage: Cefoxitin, Fefotetan, Unasyn, Cipro, or Flagyl
Broad-Spectrum abx (amp/cipro or zyosyn)
A 32-year-old pregnant female presents with right lower quadrant pain, nausea, and vomiting. On physical exam, she has tenderness in the RLQ, and a positive psoas sign. Ultrasound is non-diagnostic. What is the most appropriate next step in management?
A) MRI of the abdomen
B) CT scan of the abdomen with contrast
C) Immediate laparoscopic appendectomy
D) Exploratory laparotomy
MRI of the abdomen
In pregnant patients, MRI is preferred for diagnosis of appendicitis if ultrasound is non-diagnostic, as CT should be avoided due to radiation risks. Surgery is indicated if imaging confirms appendicitis.
A 15-year-old boy presents with diffuse abdominal pain and fever for 2 days. He now has sharp pain in the right lower quadrant, along with nausea and vomiting. On exam, he has rebound tenderness and guarding in the RLQ. His WBC count is 18,000/mm³. What is the most likely complication if his condition is left untreated?
A) Bowel obstruction
B) Appendiceal perforation
C) Pancreatitis
D) Intussusception
Appendiceal perforation
Untreated appendicitis commonly leads to perforation, which may cause peritonitis or an abscess.
What is the first step in treating cholysistitis?
Fluid resuscitation
Patients with acute cholecystitis should be given fluids and IV antibiotics. What are the three most common bugs to cause cholecystitis?
What antibiotics are typically used?
- E. coli
- Klebselia
- Entercococus faecialis
IV ceftriaxone or cipro plus mitronidazole or zosyn
What artery supplies the gallbladder?
Cystic Artery
The cystic artery is a branch of the right hepatic artery that is given off behind the CBD; it lies in Calot triangle, where it divides into an anterior and a posterior branch and supplies the gallbladder
What is Calot’s Triangle?
Calot’s triangle is formed by the inferior surface of the liver (superior border), the cystic duct (inferior border), and the common hepatic duct (medial border); it is a surgical landmark containing the cystic artery and the cystic lymph node (of Lund) within its boundaries.
A 55-year-old male presents with recurrent right upper quadrant abdominal pain and bloating, especially after fatty meals. He has a history of gallstones but no fever or jaundice. Which imaging modality is most appropriate to diagnose chronic cholecystitis in this patient?
Ultrasound
What is the mechanism of action of lactulose?
Reduces absorption of ammonium from the gastrointestinal tract
What is the 3-6-9 rule?
Bowel is considered dilated when dilation is > 3 cm, 6 cm, and 9 cm for the small bowel, large bowel, and cecum, respectively
A previously healthy 8-year-old boy presents to your office with his parents for his annual well-child exam. The parents are wondering about the need for cancer screening, given the patient’s father having a recent diagnosis of colorectal cancer at age 35 years due to familial adenomatous polyposis. Which of the following is the most appropriate guidance?
A) Screening starting at age 10 years
B) Screening starting at age 25 years
C) Screening starting at age 35 years
D) Screening starting at age 50 years
Screening starting at age 10
individuals with a known family history of familial adenomatous polyposis should begin screening with either colonoscopy or flexible sigmoidoscopy at age 10 years. Repeat screening is recommended annually until the patient undergoes colectomy, which is the recommended treatment for patients with familial adenomatous polyposis.
What surgery is used to treat GERD refractory to medical treatment?
What are the indications for surgery?
Fundoplication
Indications for surgery:
- Intractability (failure of medical treatment)
- Respiratory problems as a result of reflux and aspiration of gastric contents (e.g., pneumonia)
- Severe esophageal injury (e.g., ulcers, hemorrhage, stricture, +/- Barrett’s esophagus)
What is the most specific diagnostic test for acute cholecystitis?
What is the first line imaging modality for cholecystitis?
HIDA Scan
GOLD STANDARD: Perform a radionuclide scanning (HIDA) when clinical suspicion is high with an equivocal ultrasound or when acalculous cholecystitis is suspected. A HIDA scan may be useful if performed during an attack since the scan assesses the patency of the cystic duct
Ultrasound
What is cholecystitis?
Inflammation of the gallbladder, usually as a result of a complication of cholelithiasis (gallstones) and obstruction of the biliary duct by gallstones
What is Murphy’s sign?
Acute RUQ pain/tenderness with palpation with inspiration associated with cholecystitis
What is Boas Sign?
Referred pain to the right subscapular area due to phrenic nerve irritation in cholecystitis
What is the procedure of choice for uncomplicated acute and chronic cholecystitis?
What is the most common composition of stones?
Laparoscopic cholecystectomy
cholesterol
Describe Grey-Turner’s Sign?
Flank ecchymosis often related to pancreatitis
Which of the radiologic imaging techniques is the most sensitive in diagnosis of acute pancreatitis and pancreatic pseudocyst?
A) transabdominal ultrasonography
B) contrast-enhanced CT of the abdomen
C) magnetic resonance cholangiopancreatography
D) plain radiograph (abdominal series)
Contrast-enhanced CT of the abdomen
A 67-year-old man presents with abdominal pain and fever for the past 2 hours. Physical exam reveals tenderness below the navel and heme-positive stool. Duplex ultrasound is ordered and demonstrates a complete lack of arterial blood flow to the superior mesenteric artery. Which of the following risk factors would you expect to find in this patient’s history?
A) Alcohol use disorder
B) Atrial fibrillation
C) Cholelithiasis
D) Diverticulosis
Atrial fibrillation, this patient has mesenteric ischemia
Risk factors for developing acute mesenteric ischemia include any factors that would place the patient at risk for a thromboembolic event, including a history of atrial fibrillation, recent cardiac catheterization, and valvular heart disease. Patients only occasionally present with the classic triad of abdominal pain, fever, and heme-positive stool.
Which of the following interventions is recommended to decrease the risk of diverticulosis?
A) Avoiding nuts
B) Decreased physical activity
C) High-fiber diet
D) Increased fat intak
High-fiber diet
What is Hesselbach’s triangle?
- Inguinal ligament
- Epigastric vessels
- Lateral border of the rectus sheath
What is Calot’s Triangle?
- Cystic duct
- Common hepatic duct
- Cystic artery
Which parts of the GI tract do not have serosa?
- Esophagus
- Middle and distal rectum
Which dermatone is at the umbilicus?
T10
What are the major layers of an atery?
- Adventitia
- Media
- Intima
What are the actions of cholecystokinin (CCK)?
What inhibits the release of CCK?
- Opens ampulla of Vater
- Empties gallbladder
- Slows gastric emptying
- Stimulates pancreatic acinar cell growth and release of exocrine products
Trypsin and chymotrypsin
What stimulates the release of CCK?
Fat, protein, amino acids, and HCl
What are the actions of secretin?
Where is secretin produced?
- Releases pancreatic bicarbonate/enzymes/H20
- Releases bile/bicarbonate
- Decreases lower esophageal sphincter (LES) tone
- Decreases release of gastric acid
Duodenal cells
What GI hormone globally inhibits GI function when food stimulates its release?
Somatostatin
Where is calcium absorbed?
Doudenum actively, jejunum passively
Where is iron absorbed?
Duodenum
Where is vitamin B12 absorbed?
Terminal ileum
Which hormone primarily controls gallbladder contraction?
CCK
What supplement does a patient need after removal of the terminal ilium or stomach?
Vitamin B12
What is the blood supply of the liver?
75% from the portal vein, rich in products of digestion
25% from the hepatic artery, rich in oxygen
What conditions can mask abdominal pain?
- Steroids
- Diabetes
- Paraplegia
- Opioids
What is the most common cause of acute abdominal surgery in the United States?
Acute appendicitis (7% of the population will develop it sometime during their lives)
During the GI exam, what should go first, auscultation or palpation?
Auscultation
What is the classic position of a patient with peritonitis?
Motion (often with knees flexed)
What is the classic position of a patient with a kidney stone?
Cannot stay still, restless, writhing in pain
What lab tests are used to evaluate the patient with an acute abdomen?
CBC with differential, chem-10, lipase, type and screen, urinalysis, LFT’s
What is a “left shift” on CBC differential?
Sign of inflammatory response: Immature neutrophils (bands)
Note: many call > 80% of WBC’s as neutrophils a “left shift”
What diagnosis must be considered in every patient with an acute abdomen?
Appendicitis
What is a hernia?
Protrusion of a peritoneal sac through a musculoaponeurotic barrier (abdominal wall), a fascial defect
What are the risk factors for hernias?
- Increased intra-abdominal pressure
- Straining at defecation or urination
- Obesity
- Pregnancy
- Ascitis
- COPD
- Congenital sources
What is more dangerous: a small or large hernia defect?
Small defect is more dangerous because a tight defect is more likely to strangulate if incarcerated
What type of hernia is most commonly seen after gastric bipass surgery?
Petersen’s hernia: internal herniation of small bowel through the mesenteric defect from the Roux limb
What is a parastomal hernia?
Hernia adjacent to an ostomy (e.g. colostomy)
What are the boundaries of Hesselbach’s triangle?
- Lateral:Inferior epigastric vessels
- Inferior:Inguinal ligament (Poupart’s)
- Medial: Lateral border of the rectus abdominis
What nerve runs with the spermatic cord in the inguinal canal?
Ilioinguinal nerve
What is the first identifiable subcutaneous named layer?
Scarpa’s fascia
What is the name of the subcutaneous vein that is ligated during an inguinal hernia repair?
Superficial epigastric vein
From what abdominal muscle layer is the cremaster muscle delivered?
Internal oblique
What is the spermatic cord (6)?
- Cremasteric muscle fibers
- Vas deferens
- Testicular artery
- Testicular pampiniform venous plexus
- +/- hernia sac
- Genital branch of the genitofemoral nerve
What is the herna sac made of?
Peritoneum (direct) or a patent prcessus vaginalis (indirect)
What lies in the inguinal canal in females instead of the VAS?
Round ligament
What is the main difference between a direct and an indirect inguinal hernia?
An indirect inguinal hernia passes through the deep inguinal ring and may descend into the scrotum, while a direct inguinal hernia protrudes through the Hesselbach’s triangle and is medial to the inferior epigastric vessels.
Which type of inguinal hernia is more common in infants and young adults?
Indirect inguinal hernia
What structure passes through the inguinal canal in males?
Spermadic cord (containing the vas deferens, testicular artery, and pampiniform plexus)
A 58-year-old male presents with a bulge in his right groin that has been gradually increasing in size over the past 6 months. He reports mild discomfort when lifting heavy objects but denies nausea, vomiting, or changes in bowel habits. On physical exam, you note a bulge that increases in size when he is standing and reduces when he lies down. The bulge is palpable in the inguinal canal and is found to be lateral to the inferior epigastric vessels. What is the most likely diagnosis?
A) Direct inguinal hernia
B) Indirect inguinal hernia
C) Femoral hernia
D) Ventral hernia
Indirect inguinal hernia
The hernia is located lateral to the inferior epigastric vessels, indicating an indirect inguinal hernia, which follows the pathway of the spermatic cord through the inguinal canal. This is more common than direct inguinal hernias, especially in younger patients.
A 72-year-old male presents with a bulge in his left groin. He reports that the bulge becomes more pronounced when he coughs or strains. He denies any pain or discomfort. On exam, you identify a reducible mass in the left groin. The mass is located medial to the inferior epigastric vessels and within Hesselbach’s triangle. What type of hernia is most likely?
A) Direct inguinal hernia
B) Indirect inguinal hernia
C) Femoral hernia
D) Umbilical hernia
Direct inguinal hernia
A direct inguinal hernia is characterized by a protrusion through Hesselbach’s triangle and is medial to the inferior epigastric vessels. It is more common in older adults due to weakened abdominal muscles.
A 36-year-old woman presents with a painful bulge in her right groin. She reports that the pain worsened over the past 24 hours and is now constant. On physical exam, a tender mass is palpated below the inguinal ligament. The mass is not reducible, and there is tenderness to palpation. What is the most appropriate next step in management?
A) Observation with close follow-up
B) Emergent hernia repair
C) CT scan of the abdomen and pelvis
D) Manual reduction and discharge home
Emergent hernia repair
This patient likely has a femoral hernia, which occurs below the inguinal ligament. Femoral hernias have a high risk of incarceration and strangulation, requiring emergent surgery to prevent bowel ischemia and necrosis.
A 42-year-old male presents with a bulge in his groin that appeared suddenly after lifting a heavy object. He reports sharp pain in the area but denies nausea, vomiting, or fever. On physical exam, there is a tender, irreducible mass in the right inguinal region. The bulge is located lateral to the inferior epigastric vessels. The patient’s white blood cell count is elevated. What is the most likely complication of this condition if left untreated?
A) Peritonitis
B) Bowel obstruction
C) Intestinal perforation
D) Volvulus
Bowel Obstruction
An incarcerated indirect inguinal hernia can lead to bowel obstruction if the herniated bowel becomes trapped and its blood supply compromised. This patient’s irreducible mass, pain, and elevated WBC count suggest incarceration and possible progression to strangulation.
A 65-year-old female presents with chronic discomfort in her lower abdomen and groin. She notes a bulge that becomes more noticeable when standing or after heavy meals. On exam, a reducible mass is noted in the area just above the umbilicus. What is the most appropriate treatment option for this patient?
A) Watchful waiting
B) Laparoscopic hernia repair
C) Antibiotics and observation
D) Weight loss and observation
Laparoscopic hernia repair
The patient likely has a ventral hernia, possibly an umbilical hernia based on the location. In symptomatic patients, surgical repair (laparoscopic or open) is the treatment of choice, especially if the hernia is increasing in size or causing discomfort.
A 54-year-old man undergoes elective laparoscopic inguinal hernia repair for a reducible hernia. During the surgery, the surgeon identifies a hernia sac that is lateral to the inferior epigastric vessels. The repair is completed without complications. One month later, the patient presents with persistent groin pain and numbness along the upper thigh and scrotum. Which nerve is most likely injured?
A) Genitofemoral nerve
B) Femoral nerve
C) Ilioinguinal nerve
D) Obturator nerve
Ilioinguinal nerve
The ilioinguinal nerve runs along the spermatic cord and can be injured during inguinal hernia repair, causing pain or numbness in the groin, upper thigh, and scrotum.
A 66-year-old man presents to his primary care provider with fatigue and decreased appetite for the past 3 months. He reports an unintentional 20-pound weight loss in the past 3 months. He has a history of chronic hepatitis C. Which of the following tumor markers is associated with the most likely diagnosis?
A) Elevated alpha-fetoprotein
B) Elevated cancer antigen 125
C) Elevated cancer antigen 19-9
D) Elevated carcinoembryonic antigen
Elevated alpha-fetoprotein
This patient most likely has hepatic carcinoma, which is associated with an elevated alpha-fetoprotein (AFP). Risk factors associated with hepatic carcinoma include chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, chronic alcohol-related cirrhosis, non-alcohol-related fatty liver disease, alpha-1 antitrypsin deficiency, autoimmune hepatitis, Wilson disease, and hemochromatosis.
What risk stratification tool is used to assess upper gastrointestinal bleeding?
The Glasgow-Blatchford score
A 75-year-old man with a history of diabetes, myocardial infarction, and heart failure presents with an acute onset of mild cramping abdominal pain and bloody diarrhea. On exam, you note localized abdominal tenderness with palpation. Laboratory studies are unremarkable, and fecal pathogen test is negative. Colonoscopy demonstrates friable, edematous mucosa, bluish hemorrhagic nodules, and interspersed pale areas in the affected segment of the bowel. Which of the following segments of the bowel is most likely affected, given the most likely diagnosis?
A) Ascending colon
B) Proximal transverse colon
C) Small bowel
D) Splenic flexure
Splenic flexure
The ascending colon (A), proximal transverse colon (B), and small bowel (C) are incorrect because they are not areas of the bowels that are most commonly affected by colonic ischemia. In the setting of mesenteric ischemia involving the superior mesenteric artery, these areas would be most likely affected. Colonic ischemia affects watershed areas of the colon where collateral blood supply is limited, such as the splenic flexure and rectosigmoid junction
Which physical exam finding is highly suggestive of mesenteric ischemia?
Abdominal pain that is out of proportion to the exam
A 68-year-old man with a history of chronic back pain presents with an acute onset of black, tarry stools and is vomiting blood. His chronic back pain is managed with diclofenac and ibuprofen. On exam, he is hypotensive, tachycardic, and dyspneic. A stool guaiac test is positive. Laboratory studies demonstrate an elevated blood urea nitrogen-creatinine ratio. Which of the following is the most common cause of the suspected diagnosis?
A) Diverticulosis
B) Esophageal varices
C) Mallory-Weiss tear
D) Peptic ulcer disease
Peptic Ulcer Disease
What two symptoms are highly suggestive of upper gestational tract bleeding?
What defines upper GI bleeds?
- Melana (black, tarry, liquid stools)
- Hematemesis
Bleeds occuring above the ligament of Trietz
What is the most common cause of melana?
Peptic Ulcer Disease
What is the most common cause of rectal bleeding in patients younger than 50 years of age?
Hemorrhoids
Which bariatric surgery is most effective at reducing the risk of diabetes mellitus?
Biliopancreatic diversion with duodenal switch
A biliopancreatic diversion with duodenal switch is a form of bariatric surgery where three-quarters of the stomach is removed and bile and pancreatic juices are introduced at a location farther along the small intestine by relocating the duodenum. This procedure results in a smaller gastrointestinal tract and less caloric absorption
Describe a lap-band procedure?
The lap band procedure is a type of bariatric surgery. It refers to the use of a small, inflatable device that is surgically placed around the stomach. The device constricts the stomach and limits the total gastric volume. Since the gastric space is smaller, the patient may experience feelings of early satiety and will not consume as much food.
What is the most common bariatric surgery preformed in the U.S.?
A sleeve gastrectomy is a bariatric surgical procedure where 80% of the stomach is removed. There is no anastomosis of the intestines. This procedure results in early satiety and smaller gastric volume giving it both restrictive and malabsorptive properties.
A 4-week-old male infant presents to the ED with his parent for a 4-day history of projectile vomiting. The parent says the infant is constantly fussy and hungry but vomits after every feeding. Physical exam reveals dry mucous membranes and a small, hard, mobile mass in the right upper quadrant. A pediatric surgeon is consulted and agrees with the initial ED assessment. Which of the following is the most likely diagnosis?
A) Intussusception
B) Pyloric stenosis
C) Rotavirus infection
D) Wilms tumor
Pyloric Stenosis
What is the most common cause of pyloric stenosis in adults?
Chronic Ulcer Disease
A 67-year-old woman presents with abdominal pain for three days. CT abdomen and pelvis with IV contrast showed appendiceal rupture and abscess. She was admitted to the surgical floor, where her daily treatment includes bowel rest, IV fluids, and piperacillin-tazobactam. A percutaneous tube was placed to drain the abscess. On hospital day two, her total drain output is 30 mL with no drainage in the last 10 hours. Her vitals are T 38.4°C, HR 98 bpm, BP 130/68 mm Hg, RR 14 breaths/min, and SpO2 95%. Serial abdominal exams show persistent right lower quadrant tenderness without rebound, guarding, or rigidity. Which of the following is the best next step?
A) CT abdomen and pelvis with IV contrast
B) Laparoscopic appendectomy
C) Open appendectomy
D) Switch to PO antibiotics
Laparoscopic appendectomy
Laparoscopic appendectomy is indicated in cases of complicated appendicitis that do not improve with nonoperative management.
What is Rovsing’s Sign?
RLQ pain with palpation of LLQ
What is Obturator Sign?
RLQ pain with internal rotation of the hip
What is Psoas Sign?
RLQ pain with hip extension
What is the typical initial symptom of appendicitis?
What is the treatment?
Crampy or “colicky” pain around the umbilicus
Surgical appendectomy
Which of the following is the most common symptom of appendicitis in children?
A. Constipation
B. Vomiting
C. Right lower quadrant pain
D. High fever
Right lower quadrant pain
A 10-year old child presents with periumbilical pain that later localizes to the right lower quadrant. What is the most likely diagnosis?
Appendicitis
What is the most common complication of appendicitis in pediatric patients?
Peritonitis
Which imaging study is preferred initially for diagnosing appendicitis in children?
Abdominal Ultrasound
True or False: Appendicitis can sometimes present with diarrhea in pediatric patients
True
A high fever is typically a primary symptom of appendicitis in children?
False
A 9-year-old female presents with a 24-hour history of abdominal pain that initially started around the navel but has now localized to the right lower quadrant. She has vomited twice and reports a decrease in appetite. On examination, she has a fever of 37.8°C (100°F) and tenderness in the right lower quadrant with guarding. What is the next best step in management?
A. Administer IV fluids and observe
B. Order an ultrasound of the abdomen
C. Schedule for immediate surgery
D. Start broad-spectrum antibiotics
Order an ultrasound of the abdomen
What congenital disorder is classified by the absence or complete closure of a portion of the lumen of the duodenum?
What is seen in utero in this diagnosis?
Duodenal Atresia
Increased levels of amniotic fluid (polyhydramnios)
Which of the following is the most common presenting symptom of duodenal atresia in a newborn?
A. Bilious vomiting
B. Watery diarrhea
C. Intermittent abdominal pain
D. Jaundice
Bilious vomiting
A newborn presents with bilious vomiting within the first 24 hours of life. An abdominal x-ray shows a “double bubble” sign. What is the most likely diagnosis?
A. Pyloric stenosis
B. Intussusception
C. Duodenal atresia
D. Necrotizing enterocolitis
Duodenal atresia
What is the most appropriate initial management for a newborn diagnosed with duodenal atresia?
A. Immediate surgical correction
B. Pharmacological closure of the patent ductus arteriosus
C. Placement of a nasogastric tube and fluid resuscitation
D. Initiation of enteral feeding
Placement of a nasogastric tube and fluid resuscitation
Duodenal atresia is commonly associated with which of the following chromosomal abnormalities?
A. Trisomy 21 (Down syndrome)
B. Turner syndrome
C. Klinefelter syndrome
D. Trisomy 18
Trisomy 21
What is the hallmark presentation of Hirschsprungs Disease?
Delayed passage of meconium
A newborn fails to pass meconium within the first 48 hours of life and has abdominal distension. Which diagnostic test is most likely to confirm a diagnosis of Hirschsprung’s disease?
A. Abdominal ultrasound
B. Barium enema
C. Rectal biopsy
D. Complete blood count (CBC)
What is the definitive treatment for Hirschsprung’s disease?
Rectal biopsy
Surgical resection
Which part of the intestine is most commonly affected by Hirschsprung’s disease?
A. The entire colon
B. The rectosigmoid region
C. The ileum
D. The jejunum
The rectosigmoid region
A 3-year-old boy is brought to the pediatric clinic by his parents who noticed a bulge in his groin that becomes more apparent when he cries. The bulge is reducible and the child does not appear to be in discomfort while you examine him. Based on this presentation, what is the most likely diagnosis and the recommended management?
A. Inguinal hernia; refer for surgical evaluation.
B. Umbilical hernia; reassure and observe.
C. Hydrocele; schedule a follow-up in six months.
D. Testicular torsion; immediate surgical intervention.
Inguinal hernia; refer for surgical evaluation.
A 6-week-old male infant presents to the pediatrician with a 2-week history of progressive non-bilious vomiting after feeding. The mother reports that the vomiting is forceful and the infant seems hungry again soon after vomiting. On examination, the infant appears mildly dehydrated and a small olive-sized mass can be palpated in the right upper quadrant of the abdomen. What is the most likely diagnosis and the appropriate diagnostic test?
A. Pyloric stenosis; order an abdominal ultrasound.
B. Gastroesophageal reflux disease; perform a barium swallow.
C. Intussusception; conduct an abdominal CT scan.
D. Food allergy; recommend an elimination diet and allergy testing.
Pyloric stenosis; order an abdominal ultrasound
An 8-week-old boy is evaluated for projectile vomiting that has progressively worsened over the last 3 weeks. His parents report that he vomits forcefully shortly after each feeding, but he remains eager to eat. Upon examination, the child is noted to be somewhat lethargic and has a palpable olive-like mass in the right upper quadrant. What is the most definitive treatment for this condition?
A. Surgical pyloromyotomy
B. Administration of prokinetic agents
C. Initiation of thickened feedings
D. A course of oral antibiotics
Surgical pyloromyotomy
A 7-week-old infant with a history of projectile vomiting is diagnosed with pyloric stenosis based on clinical findings and confirmed by ultrasound. Prior to any surgical intervention, which complication must be corrected?
A. Hypernatremia
B. Hypoglycemia
C. Metabolic alkalosis
D. Respiratory acidosis
How should it be corrected?
Metabolic alkalosis
Pyloric stenosis leads to projectile vomiting, which is typically non-bilious. This condition often results in significant loss of gastric acid (hydrochloric acid). The stomach’s continual production and subsequent loss of hydrochloric acid through vomiting leads to a state where there is an abnormal increase in blood pH, known as metabolic alkalosis.
IV fluids
What is the most common cause of toxic megacolon?
A) Ulcerative colitis
B) Crohn’s disease
C) Ischemic colitis
D) Infectious colitis
Ulcerative colitis
Toxic megacolon most commonly arises as a complication of inflammatory bowel disease, particularly ulcerative colitis.
Which imaging modality is preferred for diagnosing toxic megacolon?
A) CT scan
B) Abdominal X-ray
C) MRI
D) Ultrasound
Abdominal x-ray
Abdominal X-ray typically shows colonic dilation greater than 6 cm, which is characteristic of toxic megacolon
A 35-year-old male with a 10-year history of ulcerative colitis presents to the emergency department with severe abdominal pain, distension, and fever. His vital signs show a heart rate of 120 bpm, BP of 90/60 mmHg, and a temperature of 102°F. Physical exam reveals marked abdominal tenderness with decreased bowel sounds. An abdominal X-ray shows a dilated colon greater than 7 cm. What is the next best step in management?
A) Start broad-spectrum antibiotics and IV fluids
B) Perform an immediate total colectomy
C) Administer corticosteroids and monitor
D) Place a nasogastric tube and start bowel rest
Start broad-spectrum antibiotics and IV fluids
Initial management of toxic megacolon includes aggressive fluid resuscitation and broad-spectrum antibiotics. Surgery may be needed if there is no improvement with medical management.
A 28-year-old female with a history of Crohn’s disease presents with fever, tachycardia, and severe abdominal pain. She reports passing fewer bowel movements than usual over the last 24 hours. Abdominal X-ray reveals dilation of the colon consistent with toxic megacolon. What complication is this patient at greatest risk for if her condition is not promptly treated?
A) Perforation
B) Stricture formation
C) Fistula development
D) Malabsorption
Perforation
The major complication of toxic megacolon is perforation, which can lead to peritonitis and septic shock
A 40-year-old male with a known history of ulcerative colitis is admitted for suspected toxic megacolon. His abdominal X-ray shows colonic dilation, and his WBC count is elevated. He has been on corticosteroids for his ulcerative colitis flares in the past. What medication should be added to his regimen to reduce the inflammatory response?
A) Methotrexate
B) Infliximab
C) Cyclosporine
D) Azathioprine
Infliximab
Infliximab, a TNF-alpha inhibitor, is often used in severe ulcerative colitis or Crohn’s disease that is refractory to corticosteroids, and it can be helpful in managing toxic megacolon due to underlying IBD
Which of the following is the most common complication associated with colonoscopy?
A) Perforation
B) Hemorrhage
C) Anesthesia reaction
D) Infection
Perforation
Colonic perforation is a rare but serious complication of colonoscopy, particularly in patients with diverticulosis or those undergoing polypectomy
What is the recommended screening interval for colonoscopy in a patient with no personal or family history of colorectal cancer and normal findings on the previous colonoscopy?
Every 10 years
A 55-year-old male with no significant medical history presents to your office for a routine health checkup. He reports no family history of colorectal cancer and has never had a colonoscopy. What is the best next step in this patient’s care?
A) Order a fecal occult blood test (FOBT)
B) Schedule a screening colonoscopy
C) Recommend a sigmoidoscopy
D) No screening is required at this time
Schedule a screening colonoscopy
Screening begins at age 50 for average risk adults
A 60-year-old woman undergoes a routine screening colonoscopy. During the procedure, several polyps are identified and removed. The pathology report shows tubular adenomas. When should this patient have her next colonoscopy?
A) In 1 year
B) In 3 years
C) In 5 years
D) In 10 years
In 3 years
Patients with adenomatous polyps, especially tubular adenomas, are at increased risk for colorectal cancer and should undergo repeat colonoscopy in 3 years
What are the risk factors for developing an incisional hernia?
What is the definitive treatment?
- Advanced age
- Immunosuppression
- Connective tissue disorders
- Malnutrition
Surgical repair
Which incision site has the highest incidence of developing an incisional hernia?
Midline incisions
A 47-year-old woman presents with complaints of bleeding with bowel movements for the past 2 days and a sensation of fullness in the anal area. The symptoms began after straining with a bowel movement. Physical exam reveals a purple, nodular protrusion from the anus. From what anatomical location did this issue likely arise?
A) Internal hemorrhoidal plexus
B) Internal pudendal vein
C) Perianal dermis
D) Superior hemorrhoidal cushion
Superior hemorrhoidal cushion
Internal hemorrhoids are a normal anatomical part of the anal canal. These hemorrhoids consist of connective tissue, smooth muscle fibers, and terminal branches of the rectal arteries and veins providing normal closure and pressures in the anal canal. They are located in the right anterior, right posterior, and left lateral areas of the canal and arise from the superior hemorrhoidal cushion.
What position should a patient be in to perform an examination for hemorrhoids?
Prone or Left Lateral Position
A 27-year-old woman presents with vomiting and 10/10 right lower extremity pain. The symptoms started suddenly 1 hour ago when she was lifting weights. The pain is constant and worsening. She has no significant medical or surgical history, but she noticed a painless mass below her right inguinal crease 1 month ago. Her vital signs are T 37.1°C, HR 107 bpm, BP 141/92 mm Hg, RR 23/min, and SpO2 99%. Her BMI is 22 kg/m2. On examination, she is diaphoretic and pale, and there is a right-sided erythemic mass protruding inferior and lateral to the pubic tubercle. The mass is hot, firm, pulseless, and exquisitely tender to palpation. What is the best way to diagnose this condition?
A) Clinical exam
B) CT of the abdomen and pelvis with IV contrast
C) Hernia sac laparoscopy
D) Ultrasound of the abdomen and pelvis
What is the treatment?
Clinical Exam
Strangulated hernias are surgical emergencies
What medications should be prescribed to the patient after incision and drainage of a perianal abscess?
- Antibiotics
- Stool Softeners
- NSAIDs
What is the most common gastric carcinoma?
What is Virchow’s Node?
Adenocarcinoma
Supraclavicular lymph node on exam associated with gastric cancer
Which part of the gastrointestinal tract is most commonly affected by Crohn’s disease?
A) Esophagus
B) Stomach
C) Ileum
D) Rectum
Illeum
Crohn’s disease most commonly affects the terminal ileum and the beginning of the colon, though it can involve any part of the GI tract
What is the hallmark microscopic feature of Crohn’s disease?
A) Non-caseating granulomas
B) Crypt abscesses
C) Goblet cell hyperplasia
D) Villous atrophy
Non-caseating granulomas
The presence of non-caseating granulomas on biopsy is a characteristic finding of Crohn’s disease, although it is not present in all cases.
What is the preferred diagnostic test for identifying the extent and severity of Crohn’s disease?
Colonoscopy with biopsy
Colonoscopy with biopsy is the preferred diagnostic test for evaluating Crohn’s disease and determining the extent of inflammation
A 30-year-old female presents with a 6-month history of intermittent abdominal pain, diarrhea, and weight loss. She reports having had several episodes of rectal bleeding. Physical examination reveals tenderness in the right lower quadrant. Lab tests show an elevated C-reactive protein and anemia. Colonoscopy reveals patchy areas of inflammation with ulcerations and skip lesions. What is the most likely diagnosis?
A) Ulcerative colitis
B) Irritable bowel syndrome
C) Crohn’s disease
D) Ischemic colitis
Crohn’s Disease
The patchy areas of inflammation, skip lesions, and right lower quadrant pain are characteristic of Crohn’s disease
A 45-year-old male with a long-standing history of Crohn’s disease presents with fever, severe abdominal pain, and distension. Physical examination reveals diffuse tenderness and guarding. A CT scan of the abdomen shows a thickened bowel wall and free air in the abdomen. What is the next best step in management?
A) IV corticosteroids
B) Immediate surgical consultation
C) Oral antibiotics
D) Colonoscopy
Immediate surgical consultation
The presence of free air suggests bowel perforation, a surgical emergency. Immediate surgical consultation is necessary
A 28-year-old female with a known history of Crohn’s disease presents with persistent diarrhea and abdominal cramping despite being on mesalamine for maintenance therapy. Which of the following is the best next step in her management?
A) Increase the dose of mesalamine
B) Add corticosteroids
C) Initiate infliximab therapy
D) Perform a colonoscopy
Initiate infliximab therapy
Infliximab, a TNF-alpha inhibitor, is often used in patients with moderate to severe Crohn’s disease who are not responsive to mesalamine
What is mesalamine?
Mesalamine (also known as 5-aminosalicylic acid or 5-ASA) is an anti-inflammatory medication used to treat inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis. It works by reducing inflammation in the lining of the colon and rectum, helping to control symptoms like abdominal pain, diarrhea, and rectal bleeding.
A 40-year-old male with Crohn’s disease presents with perianal pain and drainage. Physical examination reveals a perianal fistula. What is the best initial treatment option for this patient?
A) Oral antibiotics
B) Fistulotomy
C) Seton placement
D) Immunosuppressive therapy
Seton placement
A seton is often placed in patients with Crohn’s disease who have complex perianal fistulas to allow drainage and prevent abscess formation. Surgical intervention may be required if medical management is insufficient
A 36-year-old woman with Crohn’s disease is being evaluated for surgery due to recurrent bowel obstructions. What is the most common surgical procedure performed for this indication?
A) Total colectomy
B) Partial bowel resection
C) Ileostomy creation
D) Stricturoplasty
Stricturoplasty
Stricturoplasty is a bowel-sparing procedure that is often performed to manage recurrent obstructions caused by strictures in Crohn’s disease
What is the most common cause of acute pancreatitis in the U.S.?
Gallstones
Gallstones are the most common cause of acute pancreatitis in the U.S., followed by alcohol use. Smaller gallstones are more commonly associated than larger stones as they can travel down the duct more freely.
Which serum marker is most specific for the diagnosis of acute pancreatitis?
Lipase
What is the most appropriate initial imaging study for suspected acute pancreatitis?
A) Abdominal ultrasound
B) Abdominal CT scan
C) Abdominal X-ray
D) MRI
Abdominal ultrasound
Abdominal ultrasound is typically the first imaging study used to identify gallstones as a potential cause of acute pancreatitis
A 50-year-old male with a history of heavy alcohol use presents with epigastric pain radiating to the back, nausea, and vomiting. His lipase and amylase levels are elevated. What complication is he at greatest risk for during the first 48 hours of hospitalization?
A) Pancreatic abscess
B) Pseudocyst formation
C) Sepsis
D) Acute respiratory distress syndrome (ARDS)
Acute respiratory distress syndrome (ARDS)
Severe acute pancreatitis can lead to systemic complications such as ARDS, especially in the early stages
A 60-year-old man with a history of hyperlipidemia presents with severe abdominal pain, nausea, and vomiting. His lipase and amylase levels are elevated, and a CT scan confirms acute pancreatitis. Triglyceride levels are found to be 1200 mg/dL. What is the best initial treatment?
A) IV antibiotics
B) NPO (nothing by mouth) and IV fluids
C) Urgent cholecystectomy
D) Insulin and plasmapheresis
NPO and IV fluids
The mainstay of treatment for acute pancreatitis is supportive care, including bowel rest (NPO) and IV fluid resuscitation. Hypertriglyceridemia is a known cause, but initial management focuses on hydration and pain control.
A 48-year-old female presents with epigastric pain that started suddenly 24 hours ago and radiates to her back. Her lipase level is significantly elevated, and a CT scan shows diffuse pancreatic enlargement. Over the next few days, she develops a tender, palpable mass in the upper abdomen. What is the most likely complication?
A) Pancreatic abscess
B) Pancreatic pseudocyst
C) Pancreatic necrosis
D) Bowel perforation
Pancreatic pseudocyst
Pancreatic pseudocyst is a common complication of acute pancreatitis, often presenting weeks after the initial episode as a palpable mass
By what mechanism does a Roux-en-Y procedure promote weight loss?
A) By bypassing most of the stomach, duodenum, and proximal jejunum
B) By creating three small bowel limbs to induce malabsorption
C) By partitioning the stomach into a small proximal pouch
D) By removing a majority of the greater curvature of the stomach
What surgical method is commonly used for Roux-en-Y gastric bypass?
By bypassing most of the stomach, duodenum, and proximal jejunum
Laproscopic approach
A 40-year-old woman presents to the emergency department with right upper quadrant pain. On exam, she is afebrile but has right upper quadrant tenderness. Laboratory testing reveals an alkaline phosphatase of 640 U/L, AST of 204 U/L, and ALT of 220 U/L. The common bile duct measures 9 mm on transabdominal ultrasound, and the gallbladder is present. Which of the following is both diagnostic and therapeutic for the most likely diagnosis?
A) Endoscopic retrograde cholangiopancreatography
B) Endoscopic ultrasound
C) Magnetic resonance cholangiopancreatography
D) Right upper quadrant abdominal ultrasound
Endoscopic retrograde cholangiopancreatography
True or false: hypoalbuminemia is suggestive of acute liver disease
False, hypoalbuminia indicates chronic liver disease
What is the surgical repair of an anal fissure called?
Lateral internal sphincterotomy
What is the most common type and location of pancreatic cancer?
Adenocarcinoma in the head of the pancreas
A 48-year-old woman with a history of obesity, diabetes mellitus, and hypertension presents with worsening abdominal pain and nausea for the past 2 hours. She reports the pain began after eating a fast food meal. It initially began around the center of her abdomen, but it is now worse in the right upper quadrant of her abdomen and radiates to her right shoulder. She reports the pain has been constant despite taking two doses of omeprazole. On physical exam, she is ill appearing. Palpation of the abdomen reveals significant tenderness in the right upper quadrant. Bloodwork shows total bilirubin of 0.8 mg/dL, alkaline phosphatase of 50 IU/L, and white blood cell count of 14,000/mm3. Which diagnostic study is considered to be the gold standard for the suspected diagnosis?
A) Cholescintigraphy
B) Computed tomography with intravenous contrast
C) Endoscopic retrograde cholangiopancreatography
D) Ultrasonography
Cholescintigraphy (HIDA Scan)
While an ultrasound is typically the first diagnostic test performed, the gold standard for diagnosing cholecystitis is cholescintigraphy, also known as a HIDA scan.
In chronic pancreatitis, are amylase and lipase levels elevated?
What is the diagnostic test of choice for chronic pancreatitis?
No, they are within normal limits
Magnetic resonance cholangiopancreatography (MRCP)
This finding is in part due to the fibrosis that occurs in the pancreas with this process and the low levels of the enzymes that are secreted even in the setting of inflammation.
Which genetic variations have been associated with chronic pancreatitis?
- CFTR gene (Cystic Fibrosis)
- SPINK1 and PRSS1 (Hereditary pancreatitis)
What is the treatment for chronic pancreatitis?
What complications are associated with chronic pancreatitis?
- ERCP
- Pain control
- Nutrition
- Surgery
Glucose intolerance, malabsoprtion, and osteoporosis
A 40-year-old woman presents to the emergency department with an acute onset of epigastric pain, nausea, fever, and vomiting. On exam, an inspiratory arrest is noted during deep palpation of the right upper quadrant of the abdomen. Laboratory studies demonstrate leukocytosis with a left shift. Her ultrasound image is shown above. Which of the following is the initial intervention indicated for this patient?
A) Administration of intravenous fluids
B) Outpatient antibiotic therapy
C) Refer to surgery for cholecystectomy
D) Refer to surgery for cholecystostomy
Administration of intravenous fluids
Once the diagnosis of acute cholecystitis is made, administration of intravenous fluids is the next step in management, followed by broad-spectrum intravenous antibiotics, bowel rest, analgesics, and correction of electrolyte abnormalities. Definitive treatment is with laparoscopic cholecystectomy within the first 72 hours.
What autosomal dominant genetic disorder is associated with the formation of gastrinoma?
Multiple endocrine neoplasia type 1
When should surgical treatment for anal fissures be considered?
For refractory cases or if symptoms last longer than 8 weeks
What is the most common symptom of internal hemorroids?
Where do internal hemorroids originate?
Painless rectal bleeding
Above the dentate line
What is the best initial treatment for mild symptomatic hemorrhoids?
A) Hemorrhoidectomy
B) Topical corticosteroids
C) Rubber band ligation
D) High-fiber diet and increased fluid intake
High-fiber diet and increased fluid intake
A 60-year-old woman presents with severe anal pain that began suddenly after lifting a heavy object. On examination, a bluish, swollen mass is visible at the anal verge. What is the most appropriate management for this patient?
A) High-fiber diet and increased fluid intake
B) Rubber band ligation
C) Surgical excision of the thrombosed hemorrhoid
D) Oral analgesics and sitz baths
Surgical excision of the thrombosed hemorrhoid
A 55-year-old patient with a history of internal hemorrhoids reports ongoing rectal bleeding despite conservative management with fiber supplements and sitz baths. What is the next best step in management?
A) Continue conservative treatment
B) Rubber band ligation
C) Hemorrhoidectomy
D) Colonoscopy
Rubber band ligation
For internal hemorrhoids that do not respond to conservative management, rubber band ligation is an effective, minimally invasive procedure.
A 55-year-old man with alcoholic liver disease presents to the office with upper abdominal pain, weight loss, and anemia. An endoscopy reveals the presence of small- to medium-sized esophageal varices. Which of the following medications is used as primary prophylaxis for the prevention of variceal hemorrhage?
A) Isosorbide mononitrate
B) Nitroglycerin
C) Propranolol
D) Vasopressin
Proponolol
What is Charcot Triad?
What is the first line treatment for acute cholangitis?
Triad of symptoms for acute cholangitis
* Fever
* Jaundice
* Abdominal Pain
Biliary drainage via ERCP
What symptoms comprise the Reynolds pentad?
- Fever
- Jaundice
- Abdominal Pain
- Hypotension
- Mental status change
What is a femoral hernia?
What type of hernia is most likely to become incarcerated?
A protrusion of tissue inferior to the inguinal ligament through the femoral ring
Femoral hernia
What is the most common presentation of Meckel diverticulum?
Painless rectal bleeding in a child 2 years or younger, typically male
What type of ulcer is alleviated by ingesting food?
Doudenal Ulcer
What are the watershed areas of the colon?
The splenic flexure and rectosigmoid junction
Which of the following types of bile duct stones are most likely to be found in primary choledocholithiasis?
A) Calcium oxalate stone
B) Cholesterol stone
C) Mixed stone
D) Pigmented stone
What is the most common stone found in cholysistitis?
Pigmented stone
Cholesterol stone
In industrialized countries, the secondary form of choledocholithiasis from stones in the gallbladder is the most common. The primary form is less common. Pigmented stones are most commonly seen in the primary form of the disease and are brown in color, resulting from biliary stasis. Patients with biliary stasis, such as those with cystic fibrosis, or older patients with large bile ducts are at higher risk. Patients who have frequent infections of the bile tract are also at risk.
What are some complications of choledocholithiasis?
- Cholangitis
- Obstructive Jaundice
- Biliary cirrhosis
- Pancreatitis
What is the recommended surgical intervention for internal hemmoriods refractory to medical treatment?
For internal hemorrhoids that do not respond to conservative management, rubber band ligation is an effective, minimally invasive procedure.
A 35-year-old man presents to the clinic with a complaint of epigastric pain for about a month. He reports that he has been taking naproxen for the past month due to knee pain. How long after a meal would pain be expected to occur if the symptoms are due to a duodenal ulcer?
A) 1 hour
B) 3 hours
C) 30 minutes
D) 9 hours
3 Hours
Gastric ulcers cause food-provoked pain or postprandial belching and epigastric fullness, whereas duodenal ulcers often cause pain 2 to 5 hours following a meal or at night between 11 PM and 2 AM when the circadian pattern of acid secretion is maximal.
What GI condition typically presents with dysphagia to both liquids and solid foods?
Achalasia
What disease is associated with the classic triad of fever, right upper quadrant pain, and jaundice?
Acute cholangitis
What is a Schatzki ring?
A circumferential ring in the lower esophagus that can cause dysphagia and often accompanies a sliding hiatal hernia.
What is the first-line therapeutic option for achalasia?
Laparoscopic Heller myotomy
