Gastrointestinal Flashcards
1
Q
Epigastric pain that radiates to R shoulder is most suggestive of …
A
Cholelithiasis … (pancreatitis won’t radiate to shoulder)
2
Q
Typical duration of abdominal pain in setting of cholelithiasis?
A
< 6 hours
3
Q
Best initial test for diagnosing cholelithiasis?
A
Abdominal US
4
Q
Best treatment for patients with typical biliary colic symptoms and confirmed gallstones on US?
A
Pain management + Elective laparoscopic cholecystectomy
5
Q
US finding that suggests pancreatitis due to gallstones?
A
Dilation of CBD
6
Q
Patient presents with abdominal pain, jaundice, LFT abnormalities; CBD appears dilated on US – diagnosis?
A
Choledocholithiasis
7
Q
Best treatment for Choledocholithiasis?
A
ERCP
8
Q
Best treatment for Cholangitis?
A
ERCP
9
Q
2 most common sites of metastasis for choriocarcinoma?
A
Lungs, Vagina
10
Q
41 yo female presents 4 months post-partum with abnormal vaginal bleeding; Exam shows enlarged uterus, vascular vaginal lesion; Labs show (+) pregnancy test – diagnosis?
A
Choriocarcinoma
11
Q
Post-cholecystectomy diarrhea is a type of ___ diarrhea
A
Bile-salt induced
12
Q
What accounts for colonic stimulation in the setting of post-cholecystectomy diarrhea?
A
Bile acids are secreted from the liver directly into the intestinal lumen
13
Q
In which 2 settings is bile-salt induced diarrhea present?
A
Ileal resection, Short bowel syndrome
14
Q
Best treatment for bile-salt induced post-cholecystectomy diarrhea?
A
Cholestyramine
15
Q
MOA of cholestyramine in treatment of bile-salt induced post-cholecystectomy diarrhea?
A
Resin that binds and sequesters bile-salts
16
Q
Epidemiology of hepatic adenoma?
A
Young women on OCPs
17
Q
Appearance of hepatic adenoma on CT?
A
Well-demarcated lesion, Shows peripheral enhancement with IV contrast
18
Q
Best treatment for hepatic adenomas <5 cm in size?
A
Discontinuation of OCPs … (usually results in tumor regression)
19
Q
Best treatment for hepatic adenomas that are symptomatic, or >5 cm in size?
A
Surgical resection
20
Q
4 protect factors against colon CA?
A
High-fiber diet, NSAID use, Hormone replacement therapy, Regular exercise
21
Q
3 most common symptoms associated with Primary Biliary Cholangitis (PBC)?
A
Fatigue, Pruritis, Xanthelasma
22
Q
Lab value associated with PBC?
A
Elevated alkaline phosphatase
23
Q
Highly-specific antibody associated with PBC?
A
Anti-mitochondrial antibody
24
Q
Diagnostic test for PBC?
A
Liver biopsy
25
Appearance of liver biopsy in setting of PBC?
Fibrosis + obliteration of intrahepatic bile ducts
26
Which treatment may slow the progression of PBC?
Ursodeoxycholic acid
27
Only curative treatment for PBC?
Liver transplant
28
Common complication of PBC?
Osteopenia/Osteoporosis … from Vitamin D deficiency
29
Best treatment for prevention of Osteopenia/Osteoporosis in setting of PBC?
Ca2+, Vitamin D, Bisphosphonates
30
Alternate name for Vitamin B2?
Riboflavin
31
Clinical presentation of Riboflavin deficiency?
Angular cheilosis, stomatitis
32
Alternate name for Vitamin B1?
Thiamine
33
Clinical presentation of Thiamine deficiency?
Wet Beriberi, Wernicke-Korsakoff Syndrome
34
Alternate name for Vitamin B3?
Niacin
35
Clinical presentation of Niacin deficiency (aka Pellagra)?
3 D’s … Diarrhea, Dermatitis, Dementia
36
Metabolic + electrolyte disturbance associated with pyloric stenosis?
Hypokalemic, hypochloremic metabolic alkalosis
37
Renal lab results associated with pyloric stenosis?
Elevated creatinine + BUN
38
Why might BUN and creatinine be elevated in setting of pyloric stenosis?
Pre-Renal AKI
39
Diagnostic test for pyloric stenosis?
Abdominal US
40
Initial step of treatment for pyloric stenosis?
Rehydration + correction of electrolyte abnormalities … Before surgery
41
Which 2 ABX are associated with increased risk of pyloric stenosis?
Azithromycin + Erythromycin
42
Azithromycin + Erythromycin belong to class of …
Macrolides
43
Why might Azithromycin + Erythromycin be prescribed to an infant?
Post-exposure prophylaxis against pertussis
44
Feeding behavior that might increase an infant’s risk for pyloric stenosis?
Bottle-feeding, rather than breast-feeding
45
Clinical presentation of anal abscess?
Severe, constant pain accompanied by fever; Erythematous, indurated mass with fluctuance
46
Typical location of anal abscesses?
Midway between anus + ischial tuberosity
47
Best management of anal abscesses?
Prompt I&D
48
Which patients with anal abscesses should also be treated with ABX?
DM, immunosuppression, cellulitis, valvular heart disease
49
Most common complication of anal abscesses?
Fistula formation
50
Clinical presentation of anal abscess, complicated by fistula formation?
Abscess that undergoes I&D, but continues to drain
51
Most common location of abdominal pain in setting of lactose intolerance?
Periumbilical
52
2 foods that contain high lactose content?
Milk, ice cream
53
2 foods that contain low lactose content?
Cheese, yogurt
54
How can you distinguish lactose intolerance from gluten intolerance?
Gluten intolerance = patients undergo weight loss + growth failure
55
Chronic watery diarrhea, bloating, flatulence in adults is suspicious for …
Lactose intolerance
56
Cause of Lactose intolerance?
Reduced activity of lactase enzyme
57
Additional evaluation + management for patients with new-onset Lactose intolerance?
Ca2+ and Vitamin D
58
Classic triad of clinical presentation for intussusception?
Episodic abdominal pain, Red currant jelly stool, Sausage-shaped mass
59
Imaging study of choice for intussusception?
US
60
Classic US finding seen in cases of intussusception?
Target sign
61
Best initial management for intussusception?
Air enema, Water-soluble enema
62
What accounts for telescoping of bowel in setting of intussusception?
Lymphoid hyperplasia (Peyer’s patches), Pathologic lead point (Meckel diverticulum)
63
Most common age of presentation for intussusception?
6 months – 3 years
64
Complication of intussusception?
Intestinal perforation
65
Clinical presentation of Intestinal perforation in cases of intussusception?
Severe abdominal pain, rebound, guarding
66
Best initial management of suspected Intestinal perforation in intussusception?
Abdominal XR … looking for free air
67
If free air is noted on abdominal XR, what is next step of management for suspected Intestinal perforation in intussusception?
Surgical repair (immediate)
68
Best test to evaluate pancreatic cysts for malignancy?
Endoscopic US with aspiration
69
Triad of symptoms seen in acute appendicitis?
Fever, R-sided abdominal pain, Leukocytosis
70
What accounts for lack of peritoneal signs (+ McBurney’s TTP) in setting o appendicitis during pregnancy?
Upward displacement of appendix … decreased contact with peritoneum
71
Best initial evaluation of suspected appendicitis during pregnancy?
Compression US
72
Complication of untreated appendicitis?
Pylephlebitis
73
Pylephlebitis refers to …
Infective portal vein thrombosis
74
Clinical presentation of Pylephlebitis?
Fever, RUQ pain, jaundice, hepatomegaly
75
Pylephlebitis commonly results from …
Untreated appendicitis or diverticulitis
76
Why does Pylephlebitis result from infection of abdominal cavity?
Portal vein drains that majority of the GI tract
77
Best treatment of Pylephlebitis?
Prolonged ABX therapy
78
Definition of acute diarrhea?
Lasting <14 days
79
Definition of dysentery?
Acute diarrhea with visible blood + mucus
80
4 most common pathogens responsible for dysentery?
Salmonella, Shigella, EHEC, Campylobacter
81
Non-infectious causes of dysentery?
Inflammatory bowel disease, Ischemic colitis
82
3 aspects of initial evaluation of dysentery?
Stool culture, immunoassay for Shiga toxin, Fecal leukocyte count
83
Low fecal leukocyte count in the setting of dysentery suggests …
Invasive amebiasis
84
G6PD deficiency results in ___ hyperbilirubinemia
Unconjugated (indirect)
85
Additional lab feature of G6PD deficiency?
Hemolytic anemia
86
Appearance of G6PD deficiency on blood smear?
Bite cells with Heinz bodies
87
Inheritance pattern of G6PD deficiency?
X-linked
88
Best treatment for cases of mild G6PD deficiency?
Supportive care (hydration)
89
Best treatment for cases of moderate/severe G6PD deficiency?
Phototherapy, exchange transfusion
90
Biliary atresia results in ___ hyperbilirubinemia
Conjugated (direct)
91
Etiology of biliary atresia?
Destruction of extrahepatic biliary tree
92
Breastmilk jaundice results in ___ hyperbilirubinemia
Unconjugated (indirect)
93
At what age does colon CA screening begin for general population?
50 yo
94
3 options for colon CA screening in general population?
Colonoscopy q10y, Flexible sigmoidoscopy q5y, High sensitivity fecal occult blood testing q1y
95
Recommended age of screening for patient with colon CA in 1st-degree relative?
40 yo … OR 10 years prior to age of diagnosis (whichever comes first)
96
3 features of adenomatous polyp associated with increased risk of colon CA?
Size > 1 cm, Villous morphology, High-grade dysplasia
97
Recommendation for patients with high-risk adenomatous polyp?
Repeat colonoscopy in 3 years
98
Patient with high-risk adenomatous polyp completes colonoscopy 3 years after initial discovery of high-risk adenomatous polyp; No new polyps are found - what is recommended follow-up?
Repeat colonoscopy in 5 years
99
1st step of workup for patient with suspected gastroparesis?
Upper GI endoscopy, Barium swallow
100
Value of upper GI endoscopy or barium swallow in the initial evaluation of suspected gastroparesis?
Rule out mechanical obstruction
101
Diagnostic test for suspected gastroparesis?
Nuclear gastric emptying study
102
Metabolic abnormality associated with gastroparesis?
Unstable diabetic control, frequent hypoglycemia
103
Clinical presentation of gastroparesis?
Delayed emptying, sweating, constipation
104
What accounts for sweating in the setting of gastroparesis?
Autonomic neuropathy
105
Best management of gastroparesis?
Dietary modification
106
2 medications that may be used in cases of gastroparesis, unresponsive to dietary changes?
Erythromycin, Metoclopramide
107
Clinical presentation for oropharyngeal dysphagia?
Difficulty initiating swallow
108
Clinical presentation for esophageal dysphagia?
Delayed sensation of food sticking in chest
109
Typical etiology of dysphagia that involves both solids and liquids?
Neuromuscular disorder
110
Typical etiology of dysphagia that involves solids?
Mechanical obstruction
111
2 best initial tests for patient with suspected Mechanical obstruction causing dysphagia?
Nasopharyngeal laryngoscopy, Barium swallow
112
Typical location of esophageal adenocarcinoma?
Mid-distal esophagus
113
Typical location of esophageal squamous cell carcinoma?
Upper esophagus
114
Strongest risk factor for development of esophageal adenocarcinoma?
GERD
115
Strongest risk factor for development of esophageal squamous cell carcinoma?
Smoking, ETOH
116
Pathology of Barrett’s esophagus?
Metaplastic columnar epithelium replacing normal stratified squamous epithelium
117
Risk of Barrett’s esophagus?
Development into esophageal adenocarcinoma
118
Gross appearance of Barrett’s esophagus?
Columnar epithelium that appears as red velvet
119
EGD shows intestinal metaplasia (Barrett’s) without dysplasia – best management?
Repeat EGD in 3-5 years
120
EGD shows intestinal metaplasia (Barrett’s) with low-grade dysplasia – best management?
Repeat EGD in 0.5-1 year
121
EGD shows intestinal metaplasia (Barrett’s) with high-grade dysplasia – best management?
Endoscopic eradication therapy
122
Patient with HX of ulcerative colitis presents with diarrhea, abdominal pain; Vitals show fever, tachycardia, abdominal tympany to percussion – diagnosis?
Toxic megacolon
123
DOC for management for toxic megacolon?
Glucocorticoids
124
MOA of Glucocorticoids in management for toxic megacolon?
Decrease severity of underlying inflammatory bowel disease (IBD)
125
Which patients with toxic megacolon should NOT receive Glucocorticoids?
Patients with toxic megacolon secondary to C. diff infection
126
Which medications should be held in the setting of toxic megacolon?
Meds that decrease peristalsis … opioids, anticholinergics
127
Non-pharmacologic management for toxic megacolon?
NG tube placement
128
22 yo male presents with R shoulder pain, dry cough; Reports open laparotomy 2 weeks ago for appendectomy; Exam shows fever, abdominal TTP; Labs show leukocytosis - diagnosis?
Subphrenic abscess
129
2 hallmark aspects of clinical presentation for Subphrenic abscess?
Cough, R shoulder pain
130
Diagnostic test for Subphrenic abscess?
Abdominal US
131
65 yo male presents with severe upper abdominal pain; Reports HX of GERD; PE shows extreme TTP of abdomen, but exam is limited by patient discomfort – diagnosis?
Peritonitis … caused by ruptured peptic ulcer
132
Best management of ruptured peptic ulcer?
Emergency surgery
133
Additional treatments for ruptured peptic ulcer, before patient goes to OR?
IV fluids, IV ABX, IV PPI
134
IV ABX in setting of ruptured peptic ulcer should cover …
Gram (-) bacteria
135
Most common cause of small bowel obstruction in patients with HX of abdominal surgery?
Adhesions
136
65 yo female presents with epigastric pain, worse after eating, radiating to back; States that she has no desire to eat, lost 20 lbs; HX of T2DM, HTN, smoking, HLD, CABG; CT abdomen demonstrates diffuse aortic atherosclerosis – diagnosis?
Acute mesenteric ischemia
137
What accounts for severe abdominal pain after eating in setting of Acute mesenteric ischemia?
Increased O2 demand
138
3 diagnostic tests for Acute mesenteric ischemia?
CT angiogram, MR angiogram, US duplex
139
Gold-standard test for diagnosis of Acute mesenteric ischemia?
Angiogram
140
33 yo female presents with elevated alkaline phosphatase levels – which additional lab value suggests liver abnormality vs. bone abnormality?
Elevated g glutamyl transpeptidase (GGT = liver)
141
Initial management of symptomatic hepatic sarcoidosis?
Systemic glucocorticoids
142
CXR finding seen in sarcoidosis?
Bilateral hilar adenopathy
143
48 yo male presents with AMS; Reports HX of ETOH cirrhosis; PE shows asterixis; Labs show elevated ammonia – diagnosis?
Hepatic encephalopathy
144
Circumstance that may increase patient’s likelihood of developing hepatic encephalopathy?
Volume loss (hypovolemia) … due to use of furosemide for treatment of volume overload
145
In addition to hypovolemia, what are 2 other changes that can precipitate hepatic encephalopathy in a cirrhotic patient?
Hypokalemia, Metabolic acidosis
146
1st step in treatment of hepatic encephalopathy that was likely precipitated by hypovolemia?
Electrolyte + fluid repletion
147
3 drugs in Analgesic class that may cause pancreatitis?
Acetaminophen, NSAIDs, Mesalamine, Sulfasalazine
148
4 drugs in ABX class that may cause pancreatitis?
TMP-SMX, Metronidazole, Tetracyclines, Isoniazid
149
2 drugs in Antiepileptic class that may cause pancreatitis?
Valproate, Carbamazepine
150
3 drugs in Anti-HTN class that may cause pancreatitis?
HCTZ, Chlorthalidone, Furosemide
151
2 drugs in Anti-viral class that may cause pancreatitis?
Lamivudine, Didanosine
152
1 drug in Anti-inflammatory class that may cause pancreatitis?
Azathioprine
153
What is the best test for confirming diagnosis of acute pancreatitis in patient with high clinical suspicion?
Lab analysis … better than CT abdomen with contrast!
154
Limitation of CT abdomen in diagnosis of acute pancreatitis?
CT has low SN during first 72 hours of presentation
155
Diagnostic lab result for acute pancreatitis?
Serum lipase + amylase > 3x ULL
156
When should CT abdomen be used in diagnosis of pancreatitis?
CT abdomen should be reserved for cases of diagnostic uncertainty (non-confirmatory lipase/amylase values)
157
2 most common causes of acute pancreatitis?
Gallstones, ETOH
158
If patient with acute pancreatitis has no evidence of gallstones or ETOH use – what should next step of workup be?
Lipid panel to evaluate triglyceride level
159
Level of triglycerides typically associated with acute pancreatitis?
TG > 1,000
160
Clinical presentation of infected pancreatic necrosis?
Patient with acute pancreatitis is treated with supportive care … persistent abdominal pain condition deteriorates (fever, leukocytosis, hypotension)
161
Best management of infected pancreatic necrosis?
IV ABX
162
Most common pathogen responsible for infected pancreatic necrosis?
Gram (-) bacteria
163
ABX of choice for infected pancreatic necrosis?
Meropenem; Fluoroquinolone + metronidazole
164
Diagnostic test for infected pancreatic necrosis?
CT abdomen
165
CT scan result that suggests infected pancreatic necrosis?
Gas within pancreatic necrosis
166
Clinical presentation of Spontaneous Bacterial Peritonitis (SBP)?
Fever, Abdominal pain, AMS
167
Diagnostic test for Spontaneous Bacterial Peritonitis (SBP)?
Ascitic fluid showing > 250 PMNs
168
Best management of Spontaneous Bacterial Peritonitis (SBP)?
Empiric ABX
169
Empiric ABX of choice for Spontaneous Bacterial Peritonitis (SBP)?
3rd generation cephalosporins
170
ABX of choice for SBP prophylaxis?
Fluoroquinolones
171
Additional aspect of management for patient with Spontaneous Bacterial Peritonitis (SBP) … in addition to IV ABX?
IV albumin
172
What is the most commonly used calculation to predict mortality in patient with liver disease?
MELD score
173
4 aspects of MELD score used to predict mortality in patient with liver disease?
Bilirubin, INR, creatinine, Na+
174
45 yo male presents to ED 8 weeks after pancreatitis; Reports persistent abdominal pain; Labs show slightly elevated serum lipase - diagnosis?
Pancreatic pseudocyst
175
Best management for asymptomatic Pancreatic pseudocyst?
Supportive
176
Best management for symptomatic Pancreatic pseudocyst?
Surgical + endoscopic drainage
177
Which structure separates the upper and lower GI tract?
Ligament of Trietz
178
Bright red blood per rectum is nearly always due to ..
Lower GI bleed
179
Hematemesis and melanoma are most commonly caused by ..
Upper GI bleed
180
BUN:creatinine ratio of ___ is suggestive of upper GI bleed
> 20
181
NG lavage with aspiration of bile and absence of blood increases likelihood of …
Lower GI bleed
182
Best initial step of work up for suspected lower GI bleed?
Colonoscopy
183
If no bleeding source is found during colonoscopy for suspected lower GI bleed what is next best step of work up?
EGD
184
Best first step of work up for suspected upper GI bleed?
EGD
185
Definition of chronic diarrhea?
Lasting 4+ weeks
186
First step of workup for chronic diarrhea?
Comprehensive HX
187
Next step of workup for chronic diarrhea?
Stool analysis (pH, microscopy, WBCs, parasites, fat content)
188
In additional to chronic diarrhea, what is another aspect of clinical presentation commonly seen in Celiac disease?
Microcytic anemia
189
Celiac disease causes a type of ___ diarrhea
Osmotic
190
Histology associated with Celiac disease?
Villous atrophy, infiltration of lymphocytes
191
What kind of anemia is associated with Small Intestinal Bacterial Growth (SIBO)?
B12 deficiency … macrocytic anemia
192
In addition to dietary modification, what are other steps of treatment for Celiac disease?
ADEK, iron, Ca2+, Folate supplementation … DEXA scan for Vitamin D deficiency
193
Which vaccine should be administered to patients with Celiac disease?
Pneumococcal vaccine … due to hyposplenism
194
Alternate name for Boerhaave Syndrome?
Esophageal perforation
195
Diagnostic test for Boerhaave Syndrome?
Esophagraphy, CT scan with water-soluble contrast
196
Hallmark PE finding for Boerhaave Syndrome?
Crepitus
197
Example of water-soluble contrast used in CT scan used to diagnose Boerhaave Syndrome?
Diatrizoate
198
Best management of Boerhaave Syndrome?
Emergency surgical consult
199
Clinical presentation of Mallory Weiss tear?
Hematemesis
200
Diagnostic test for Mallory Weiss tear?
EGD
201
Best management of Mallory Weiss tear?
Most heal spontaneously; Acid suppression
202
CXR findings associated with Boerhaave Syndrome?
L-sided pleural effusion, Pneumomediastinum
203
Complication of Boerhaave Syndrome?
Acute mediastinitis
204
Clinical presentation of Boerhaave Syndrome complicated by Acute mediastinitis?
Fever, retrosternal CP
205
Most common cause of recurrent symptoms in patient with Celiac disease?
Continued gluten intake
206
3 risk factors for development of rectal prolapse?
Constipation, BPH, Pelvic surgery
207
Clinical presentation of rectal prolapse?
Rectal bleeding, Protruding rectal mass
208
Appearance of protruding rectal mass in rectal prolapse?
Concentric rings of rectal mucosa
209
Best management of partial thickness rectal prolapse?
Medical management
210
Best management of full thickness rectal prolapse?
Urgent surgical intervention
211
Complication of untreated full thickness rectal prolapse?
Strangulation, gangrene of rectal mucosa
212
31 yo male presents with RUQ pain; Labs show elevated bilirubin, very elevated ALT/AST levels – diagnosis?
Acute hepatitis
213
When can anti-HCV Ig be detected?
2-6 months after Hep C exposure
214
When can HCV RNA be detected?
Days after Hep C exposure
215
Which patients are candidates for delayed cholecystectomy in gallstone pancreatitis?
Severe gallstone pancreatitis with organ failure (hypotension not responsive to fluid resuscitation)
216
Mainstay of treatment for Hepatitis C infection?
Direct-acting anti-virals
217
Additional management of Hepatitis C infection?
Prevent Hep A + Hep B infection (can precipitate liver failure) … vaccinate against Hep A + Hep B
218
Most common complication of diverticulitis?
Colonic abscess
219
Clinical presentation of diverticulitis complicated by Colonic abscess?
Diverticulitis that does not improve after 2-3 days of ABX treatment
220
First step of workup for a patient with suspected colonic abscess as complication of diverticulitis?
Repeat CT
221
2 aspects of diagnosis of C. diff infection, requiring ABX treatment?
(+) stool antigen testing; watery diarrhea (3+ stools in 24 hours)
222
2 risk factors for development of C. diff infection?
ABX use; PPI use (gastric acid suppression)
223
Classic manometry findings in patient with diffuse esophageal spasm?
Multiple simultaneous contractions
224
3 DOCs for patients with diffuse esophageal spasm?
CCBs, nitrates, TCAs
225
Most common etiology of fecal impaction?
Constipation, reduction in anal sphincter tone
226
Best management of fecal impaction?
Manual disimpaction, followed by an enema
227
31 yo male presents for epigastric fullness, occasional nausea; Workup is otherwise negative - diagnosis?
Dyspepsia
228
What is best management of dyspepsia without alarm symptoms in patients < 60 yo?
H. pylori testing
229
What is best management of dyspepsia in patients > 60 yo, or with alarm symptoms?
EGD
230
63 yo male presents with SOB, fatigue; PE shows mucosal pallor; Stool testing for occult blood is (+); Labs show Hgb 8.6, MCV 70; Colonoscopy reveals several small, flat cherry red lesions in R colon - diagnosis?
Angiodysplasia
231
Angiodysplasia is most strongly associated with which 3 other condition?
ESRD, Von Willebrand Disease, Aortic stenosis
232
53 yo male presents for recurrent biliary colic, nausea; PE reveals mild TTP with guarding, diminished bowel sounds; Labs show WBC 16; T100.4; Abd XR shows generalized distention of small and large intestines, intraperitoneal free air - diagnosis?
Bowel injury
233
What is next best step in management for suspected bowel injury?
Abdominal CT with oral contrast
234
Acute management of hypertriglyceridema-associated pancreatitis includes …
Insulin, or plasmapheresis for rapid lowering of serum TG levels
235
Long term management of hypertriglyceridema-associated pancreatitis, to prevent recurrence?
Fenofibrate, gemfibrozil
236
40 yo male presents with (+) Anti-HBc levels in routine labs; What is next step in management?
Measure IgM anti-HBc, liver enzyme levels
237
What defines the “window period” in Hepatitis B infection?
Fall in HBsAg, before rise in anti-HBc
238
What is typically the only diagnostic marker found in acute HBV infection during “window period”?
IgM anti-HBc
239
2 yo female presents with bloody stool; Afebrile, VSS; Technicium-99 scan shows increased uptake in RLQ - diagnosis?
Meckel’s diverticulum
240
Pathogenesis of Meckel’s diverticulum?
Persistent vitelline duct
241
Alternate name for vitelline duct?
Omphalomesenteric duct
242
Typically location of Meckel’s diverticulum?
Within 2 feet of ileocecal valve
243
Clinical presentation of Meckel’s diverticulum?
Painless GI bleed
244
Etiology of Meckel’s diverticulum?
Ectopic gastric tissue
245
Best management of symptomatic Meckel’s diverticulum?
Surgical resection
246
Clinical presentation of intussusception?
Significant abdominal pain
247
Treatment consideration for clozapine?
Routine labwork to monitor ANC
248
What is the preferred initial therapy for insomnia?
CBT
249
DOC for decreasing cravings in patients with ETOH?
Naltrexone
250
Indication for buproprion in substance abuse?
Used to treat depression, smoking cessation … (not effective in ETOH use disorder)
251
Route of transmission for C. Diff?
Fecal-oral
252
Etiology of C. Diff infection?
Ingested spores germinate the colon to become fully-functional bacilli
253
When does spitting up typically resolve in children?
12-18 months
254
67 yo female presents with upper abdominal pain; Reports episgastric fullness, nausea that occurs after eating; No GERD, colonoscopy 3 years ago was NML - what is next best step of workup?
EGD
255
67 yo female presents with upper abdominal pain; Reports episgastric fullness, nausea that occurs after eating; No GERD, colonoscopy 3 years ago was NML - diagnosis?
Dyspepsia
256
What is best management of new-onset dyspepsia in adults > 60?
EGD
257
RBC transfusion threshold for patients with stable GI bleed?
HGB < 7
258
Which patients should qualify for transfusion threshold < 8?
Patients with CAD
259
First line treatment for viral gastroenteritis?
Fluid repletion
260
43 yo male presents with diarrhea, cramping abdominal pain, NV, dizziness, sweating, SOB; Partial gastrectomy performed 1 month ago - diagnosis?
Dumping syndrome
261
What is best intervention for Dumping syndrome?
High-protein, Low-CHO diet
262
Best treatment regimen for H. pylori infection?
PPI, amoxicillin, clarithromycin
263
Clinical presentation of radiation proctitis?
Bloody diarrhea, mucus drainage, tenesmus
264
62 yo male presents with periumbilical pain, sudden-onset; 2 weeks ago, was diagnosed with STEMI, requiring PCI; Labs show leukocytosis, AGMA - diagnosis?
Acute mesenteric ischemia
265
Best test to establish diagnosis of Acute mesenteric ischemia?
Abdominal CTA
266
55 yo male presents for blood-tinged vomit, beginning after he consumed a large amount of ETOH last night; Hgb 9.8, PL 90, K 3.2, AST 112, ALT 49; EGD shows erythematous ulcerations, varices in the gastric fundus - what is most likely cause of these varices?
Splenic vein thrombosis
267
Most patients with Splenic vein thrombosis have history of …
Pancreatic CA, pancreatitis
268
What is the hallmark of clinical presentation for Splenic vein thrombosis?
Isolated gastric varices
269
62 yo female presents with R groin heaviness and discomfort; Pain is worse with cough and standing; PE shows R femoral hernia - what is best management?
Refer for surgical repair
270
62 yo male presents for burning pain in epigastric region, occurring 30-40 min after meals; No V, melena, hematemesis; Smoking HX for 20 yrs; Upper EGD is used to evaluate ___ in this patient
Cellular metaplastic changes
271
2+ risk factors that warrant EGD in patients for evaluation of Barrett’s esophagus?
Age > 50, Male, Smoking (former or current), Caucasian, Hiatal hernia, OB, 1st degree relative with Barrett’s
272
36 yo female presents for hip pain, radiating into lower back; HX of BL OA, morbid OB, OSA; BMI is 41 - what is next best step of management?
Referral for bariatric surgery
273
3 indications for bariatric surgery?
BMI > 40; BMI > 35 with T2DM/HTN/OSA; BMI > 30 with resistant T2DM
274
When should all patients undergo screening colonoscopy?
40 yo
275
If patient has a NML initial screening colonoscopy or 1st-degree relative with colorectal cancer diagnosed at age >60, how often should patient undergo screening colonoscopy?
Every 10 years
276
If patient has an ABNML initial screening colonoscopy or 1st-degree relative with colorectal cancer diagnosed at age <60, how often should patient undergo screening colonoscopy?
Every 5 years
277
34 yo male presents to ICU 3 days after MVC with head trauma and blunt chest trauma; Patient is noted to have heme (+) liquid stool - what intervention could have prevented patient’s current condition?
PPI administration
278
62 yo male presents for follow-up after recent hospitalization; Treated for bacterial prostatitis with ciprofloxacin; Now has 4-5 watery bowel movements per day, stool testing is (+) for C. Diff – how should this patient’s ABX regimen be changed?
Switch ciprofloxacin to TMP-SMX
279
4 ABX with low risk for C. Diff?
TMP-SMX, Macrolides, Tetracycline, Aminoglycosides
280
3 ABX with high risk for C. Diff?
Fluoroquinolones, Cephalosporins, Clindamycin
281
In addition to oral vancomycin, what is another appropriate treatment for patients with C. Diff?
Oral fidaxomicin
282
Etiology of recurrent C. Diff infection?
Re-infection by same strain of C. Diff, likely due to persistent spores
283
Clinical presentation of acute cholangitis?
Charcot triad – fever, jaundice, RUQ pain
284
Additional clinical presentation for acute cholangitis?
Fever, jaundice, RUQ pain + hypotension, AMS (Raynaud pentad)
285
2 lab results seen in setting of acute cholangitis?
Elevated direct bilirubin, Elevated alkaline phosphatase
286
Appearance of acute cholangitis on abdominal imaging?
Biliary dilation
287
Best management of acute cholangitis?
ERCP
288
Best diagnostic test for acute mesenteric ischemia?
CT angiogram
289
Etiology of acute colonic ischemia?
Transient reduction in blood flow to colon due to hypovolemic state
290
Which portions of the bowel are most affected by acute colonic ischemia?
Watershed areas (splenic flexure, rectosigmoid junction)
291
Clinical presentation for acute colonic ischemia?
Bloody diarrhea
292
Appearance of acute colonic ischemia seen in abdominal XR?
Colonic distension, pneumatosis
293
What are the 2 best lab tests for evaluation of autoimmune hepatitis?
ANA, Anti-smooth muscle Ig
294
Change to AST and ALT in autoimmune hepatitis?
Normal AST and ALT
295
25 yo female with FHX of celiac disease presents for bone pain over both shins; Reports weight loss; Personal HX of vitiligo; Labs show absent Vitamin D, decreased Ca2+, increased alkaline phosphatase, decreased phosphorus, microcytic anemia – diagnosis?
Celiac disease
296
What is the best initial test of choice for a male > 50 yo with iron deficiency anemia and (+) fecal occult blood test?
Colonoscopy
297
Next step of workup for male > 50 yo with iron deficiency anemia, (+) fecal occult blood test, and NML colonoscopy?
EGD
298
60 yo male presents for wellness visit; Had a normal screening colonoscopy 10 years ago; Really didn’t like the colonoscopy prep, so recently has a sigmoidoscopy, which showed 2 villous adenomatous polyps – what is next best step of treatment?
Colonoscopy ASAP
299
Best management for any patient who has a suspicious finding on flexible sigmoidoscopy?
Urgent colonoscopy
300
How often should flexible sigmoidoscopy be repeated for patients with normal findings?
Every 5 years
301
45 yo male with extensive Celiac history presents with mid-abdominal pain; PE shows black stools, abdominal distension; Labs show (+) occult blood – diagnosis?
Enteropathy-associated T-cell lymphoma (EATL)
302
Which portion of the bowel is typically affected by Enteropathy-associated T-cell lymphoma (EATL)?
Proximal jejunum
303
3 complications of Enteropathy-associated T-cell lymphoma (EATL)?
Bowel perforation, SBO, GI bleeding
304
Major risk factor for Enteropathy-associated T-cell lymphoma (EATL)?
Untreated celiac disease
305
Clinical presentation of Enteropathy-associated T-cell lymphoma (EATL)?
B symptoms, Abdominal pain, GI bleeding
306
39 yo male presents with burning epigastric pain, worse after meals during past 3 months; Patient has tried ranitidine for past 2 weeks, minimal relief – what is next best step?
H. pylori stool or breath test
307
Best initial treatment of GERD?
Lifestyle modification, 8 weeks of PPI therapy
308
3 common aspects of clinical presentation for GERD?
Hoarseness, throat irritation, chest pain
309
Symptoms of GERD are typically exacerbated by …
ETOH
310
54 yo male with HX of ETOH abuse presents with cough, SOB; Lung exam shows decreased breath sounds on R, dullness to percussion; Abdomen is distended with (+) fluid wave; Labs suggest transudative pleural effusion – diagnosis?
Hepatic hydrothorax
311
Etiology of Hepatic hydrothorax?
Effusion of peritoneal ascites through the diaphragm
312
On which side do Hepatic hydrothorax typically occur?
R … R hemidiaphragm is thinner, with more porous defects
313
What is best management for a Hepatic hydrothorax (transudative pleural effusion)?
Furosemide, spironolactone, dietary Na restriction
314
3 yo male presents for constipation; Family has adjusted diet to include more fiber/water; PE shows had stool retention, with small anal fissure present; What is best long-term therapy to benefit patient?
Oral osmotic laxative therapy
315
3 complications of pediatric constipation?
Anal fissure, UTI, hemorrhoids
316
Example of Oral osmotic laxative therapy used for pediatric constipation?
Lactulose
317
52 yo female presents with SOB, massive ascites, 25-lb weight loss; HX of COPD, CAD, Hepatitis C; Extensive smoking and ETOH HX, family HX of breast CA; Labs show AST 78, ALT 55, Total protein 5.6, serum albumin 2.8; Ascitic fluid shows WBC 150, albumin 2.2, Amylase 48, Glucose 32 – what is etiology of this patient’s ascites?
Ovarian cancer
318
SAAG level that suggests portal HTN?
SAAG > 1.1
319
3 diagnosis with SAAG > 1.1?
Portal HTN, CHF, Alcoholic hepatitis
320
SAAG level that suggests nonportal HTN?
SAAG < 1.1
321
5 conditions associated with SAAG < 1.1?
Pancreatitis, peritoneal carcinoma, peritoneal TB, nephrotic syndrome, serositis
322
54 yo female presents with RUQ pain; PE shows fever, tachycardia, RUQ tenderness with guarding; Labs shows leukocytosis; US shows several small gallstones without CBD dilation or gallbladder wall edema; Murphy’s sign is negative – diagnosis?
Acute cholecystitis
323
3 aspects of Clinical presentation for Acute cholecystitis?
Fever, RUQ pain, Leukocystosis
324
54 yo female presents with RUQ pain; PE shows fever, tachycardia, RUQ tenderness with guarding; Labs shows leukocytosis; US shows several small gallstones without CBD dilation or gallbladder wall edema; Murphy’s sign is negative – Best management?
HIDA scan … performed when RUQ US is inconclusive, but still high clinical suspicion for acute cholecystitis
325
46 yo male with HX of ETOH use presents with AMS; During workup, he experiences large-volume hematemesis with BRB; Vitals are now BP 100/50 and HR 110 – what is next best step of management?
Endotracheal intubation
326
46 yo male with HX of ETOH use presents with AMS; During workup, he experiences large-volume hematemesis with BRB; Vitals are now BP 100/50 and HR 110; After intubation, patient undergoes upper GI endoscopy – what additional treatment is also indicated now?
IV octreotide
327
MOA of IV octreotide in treatment of acute variceal bleeding?
Decreases elevated pressure through varices by decreasing splanchnic flow
328
46 yo male with HX of ETOH use presents with AMS; During workup, he experiences large-volume hematemesis with BRB; Vitals are now BP 100/50 and HR 110; After intubation, patient undergoes upper GI endoscopy – at time of discharge, which medication should patient receive to decrease future risk of recurrent variceal bleeding?
Non-selective b blocker
329
Most common etiology of Porcelain gallbladder?
Chronic cholelithiasis
330
Best management of Porcelain gallbladder?
Prophylactic cholecystectomy
331
Etiology of physiologic gynecomastia in obese men?
Imbalance of testosterone vs. estrogen … Decreased testosterone production, and increased conversion of testosterone to estrogen by aromatase in adipose tissue
332
62 yo male presents with nausea, vomiting, crampy lower abdominal pain + distention; Last BM was 4 days ago; PSHX of appendectomy, surgical repair of perforated ulcer; PE shows abdominal distension, increased bowel sounds, tympany; Initial labs show many electrolyte abnormalities; Imaging in ED shows multiple air-fluid levels in small intestine, consistent with SBO; Some air is seen in the colon – diagnosis?
Partial SBO … (due to some air in colon)
333
Best management of Partial SBO?
Observation and supportive care
334
What is initial aspect of workup for patients with delayed gastric emptying?
Exclude mechanical obstruction … via EGD, or CT/MRI
335
After mechanical obstruction has been excluded in a patient with delayed gastric emptying – what is next step of workup?
Confirm impaired motility with gastric emptying study
336
Study used to confirm the diagnosis of gastroparesis?
Scintigraphic gastric emptying study
337
In a patient with confirmed gastroparesis (due to DM) – what is best initial therapy?
Advise small frequent meals … in addition to glycemic control
338
Recommended meal content in patients with gastroparesis (due to DM)?
Low fat, only soluble fiber
339
Firstline DOC for gastroparesis (due to DM)?
Metoclopramide
340
2 additional drug options for gastroparesis (due to DM)?
Domperidone, erythromycin
341
51 yo male presents with abdominal cramping, nausea, bloody diarrhea; Diarrhea described as large-volume red/maroon liquid; Reports sprained ankle 2 weeks ago, treating with ibuprofen; HX of diverticulosis; Vitals show HR 112, BP 90/60; Exam shows diaphoresis; Rectal exam (+) for maroon stool; HBG 12 – diagnosis?
Hematochezia
342
Patients with hematochezia and HD instability should be assumed to have …
Upper GI source of bleeding
343
Best management of suspected upper GI bleed?
Volume resuscitation, then EGD
344
What is most appropriate recommendation for pregnancy after bariatric surgery?
Pregnancy should be delayed for at least 1 year after bariatric surgery … to stabilize nutritional status
345
Indication for bariatric surgery?
BMI 35 + 1 comorbidity (DM, HTN, OSA) … OR … BMI 40
346
What are 2 obstetric benefits of bariatric surgery in females of child-bearing age?
Decreased risk of preeclampsia, gestational DM
347
55 yo male presents after 1 episode of hematemesis; HX of cirrhosis, ascites; EGD shows esophageal varices – what is most likely complication that this patient will develop in hospital?
SBP
348
Best prophylactic ABX for prevention of SBP in patients with recent variceal bleeding?
Ceftriaxone x7 days
349
Which ABX should be started in patients with SBP who cannot complete 7-day trial of ceftriaxone?
Transition to TMP-SMX or fluoroquinolone
350
53 yo male presents for intermittent abdominal pain, steatorrhea; Long history of alcohol abuse - which of the following tests is most likely to provide a diagnosis?
MRCP
351
Diagnostic alternative to MRCP in the diagnosis of chronic pancreatitis?
Abdominal CT
352
What is the hallmark finding on MRCP and abdominal CT for chronic pancreatitis?
Pancreatic calcifications
353
Best management of chronic pancreatitis?
Lifestyle, dietary modification
354
What is the best approach to pain management in the setting of chronic pancreatitis?
Reassess in 1-2 months for pain improvement
355
42 yo female with chronic ETOH use presents with severe mid abdominal pain; Labs show MCV 102, Na 133, K 3.1, Cl 94, BUN 24, Lipase 652, TC 220; Which lab value is strongest indication of poor prognosis?
BUN > 20
356
5 lab findings that indicate poor prognosis in setting of acute pancreatitis?
BUN, hematocrit, CRP, advanced age, obesity
357
33 yo male presents for solid-food dysphagia; Reports previous episode that resolved after ‘following a diet’; Reports periodic CP behind sternum; Currently smokes 1PPD - diagnosis?
Esophageal stricture
358
Esophageal stricture is a complication of …
GERD
359
Etiology of Esophageal stricture as a complication of GERD?
Results from the healing process of ulcerative esophagitis
360
What causes rectal bleeding in the setting of diverticulosis?
Eroded small colonic artery
361
Etiology of diverticulosis?
Outpouching of colon wall at points of weakness where vasa recta penetrate the circular muscle of colon
362
What is the appropriate duration of PPI trial for treatment of GERD?
8 weeks + lifestyle modifications
363
Recommendation for patient whose brother was recently diagnosed with colon cancer at age 52?
Begin colon cancer screenings at 10 years prior to diagnosis, or at age 40 (whichever comes first)
364
50-hour old male presents with bilious emesis; has not yet passed meconium, birth by C-section; PE shows distended abdomen, no stool is palpable in rectal vault; abdominal x-ray shows multiple dilated loops of large bowel, no air in rectum; contrast enema shows normal caliber rectosigmoid colon, dilated descending colon -- diagnosis?
Hirschsprung disease
365
What is the gold standard diagnostic test for Hirschsprung disease?
Rectal suction biopsy
366
Appearance of meconium ileus on contrast enema?
Microcolon
367
Appearance of Hirschsprung disease on contrast enema?
Dilated descending colon, narrow sigmoid colon
368
30-year-old male presents with nausea, vomiting, diarrhea, abdominal cramping, fever; symptoms began 12 hours ago after consuming smoothie that contained 3 raw eggs; stool culture positive for Salmonella - what is best management?
Supportive care
369
32-year-old Hispanic man presents after an episode of choking on fishbone; patient drank 4 glasses of water, still reports difficulty swallowing saliva, can still feel fishbone lodged in posterior throat -- next step of work-up?
Perform urgent endoscopy to remove fishbone
