Gastrointestinal Flashcards
A 52-year-old man presents with a 6-month history of heartburn and atypical chest pain, both unrelated to food. He also described ‘gurgling’ sounds in his chest. A month before presentation he developed intermittent dysphagia to both solids and liquids, regurgitation, and weight loss of 3 kg.
Achalasia
A 65-year-old woman presents to the emergency department with a 2-day history of progressive RUQ pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have started to become loose but with no diarrhoea, bright red blood, or black tarry stools. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs (NSAIDs) or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. She has elevated WCC, ALT, ALP and bilirubin.
Cholangitis
A 45-year-old alcoholic man presents to the emergency department with restlessness and tremors. He is anxious, pacing in the hallway. Initial vital signs show a heart rate of 121 beats per minute and blood pressure of 169/104 mmHg; other vital signs are normal. On further questioning by the nurse he states that he is nauseous and wants something to help with the shakes.
Alcohol withdrawal
A 50-year-old man presents to his general practitioner with complaints of fatigue for 2 months. The patient also notes distension of his abdomen and shortness of breath beginning 2 weeks ago. His wife reports that the patient has been having episodes of confusion lately. The patient has a significant medical history of chronic heavy alcohol consumption of about half a pint of vodka daily for around 20 years. On physical exam the patient is noted to have scleral icterus, tremors of both hands, and spider angiomata on the chest. There is abdominal distension with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low haemoglobin, low platelets, low sodium, AST elevation > ALT elevation, and high PT and INR. Ultrasound of the abdomen shows liver hyperechogenicity, portal hypertension, splenomegaly, and ascites.
Alcoholic liver disease
A 38-year-old man presents to the emergency department for severe alcohol abuse with nausea and vomiting. He has a significant medical history of chronic heavy alcohol consumption of half a pint of vodka daily for about 5 years until 1 year ago; since then he has had severe intermittent binge alcohol intake. He reports no other significant medical problems. The patient is confused and slightly obtunded, and hepatomegaly is discovered on physical exam. His BMI is 22. Pertinent positive laboratory values show low haemoglobin, AST elevation > ALT elevation, normal PT and INR, and very high serum alcohol level. Ultrasound of the abdomen shows fatty infiltration in the liver.
Alcoholic liver disease
A 79-year-old man presents with dyspnoea on exertion for 1 year and lower extremity oedema. As part of a cardiac work-up, the echo shows concentric left ventricular hypertrophy. Cardiac catheterisation shows normal coronary arteries and he is referred for further evaluation of non-cardiac dyspnoea.
Amyloidosis
A 62-year-old man is referred for management of atypical multiple myeloma. He has a mild anaemia of 120 g/L (12 g/dL), a urinary protein loss of 2.2 g/day with a urinary immunofixation showing free lambda light chains. However, the bone marrow shows only 5% plasma cells and does not fulfil criteria for multiple myeloma.
Amyloidosis
A 28-year-old woman presents with a history of severe pain on defecation for the last 3 months. She has noticed a small amount of blood on the stool. The pain is severe and she is worried about the pain she will experience with the next bowel action.
Anal fissure
A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C; 100.5°F), pain on palpation at right lower quadrant (McBurney’s sign), and leukocytosis (12 x 10^9/L or 12,000/microlitre) with 85% neutrophils.
Appendicitis
A 12-year-old girl presents with sudden-onset severe generalised abdominal pain associated with nausea, vomiting, and diarrhoea. On examination she appears unwell and has a temperature of 40°C (104°F). Her abdomen is tense with generalised tenderness and guarding. No bowel sounds are present.
Appendicitis
A 45-year-old woman presents with insidious onset of fatigue, malaise, lethargy, anorexia, nausea, abdominal discomfort, mild pruritus, and arthralgia involving the small joints. Her past medical history includes coeliac disease. Physical examination reveals hepatomegaly and spider angiomata.
Autoimmune hepatitis
A 55-year-old obese man presents with frequent heartburn. He describes a post-prandial, retrosternal burning sensation following fatty and spicy meals. This symptom also frequently wakes him from sleep, with occasional coughing and a sour taste in his throat. He has tried many OTC antacids, which only relieve symptoms in the short term. He has suffered from this symptom for over 10 years. He denies dysphagia, odynophagia, or weight loss, but reports frequent hoarseness in the mornings. His past medical history is significant only for HTN. His family history is unremarkable. He did smoke cigarettes, but stopped 5 years ago.
Barrett’s oesophagus
A 65-year-old woman presents to her primary care physician with a 4-month history of intermittent abdominal pain localised to the RUQ with radiation to the epigastrium; the pain increases with the ingestion of fatty food and decreases with fasting. In the last 2 weeks the pain has been more frequent and steady. The patient complains of nausea, pruritus, anorexia, and weight loss, which she relates to the lack of appetite. At physical examination, there is RUQ tenderness and jaundice of the conjunctival sclera. No lymphadenopathy or palpable masses are found.
Cholangiocarcinoma
A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant RUQ pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.
Cholecystitis
A 56-year-old man with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical examination reveals telangiectasias, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (AST: 90 U/L, ALT: 87 U/L), and the patient is positive for anti-hepatitis C antibody.
Cirrhosis
A 60-year-old woman with a past medical history of obesity, diabetes, and dyslipidaemia is noted to have abnormal liver enzymes with elevated aminotransferases (ALT: 68 U/L, AST: 82 U/L), and normal alkaline phosphatase and bilirubin. She denies significant alcohol consumption, and tests for viral hepatitis and autoimmune markers are negative. An abdominal ultrasound reveals evidence of fatty infiltration of the liver and slight enlargement of the spleen.
Cirrhosis
A 46-year-old woman presents with fatigue and is found to have iron deficiency with anaemia. She has experienced intermittent episodes of mild diarrhoea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms such as diarrhoea, bloating, or abdominal pain. Examination reveals two oral aphthous ulcers and pallor. Abdominal examination is normal and results of faecal testing for occult blood are negative.
Coeliac disease
A 9-year-old boy presents with vomiting for 5 days. His growth has been normal and he has not experienced any other possible symptoms of coeliac disease, except for intermittent constipation. Immunoglobulin A-tissue transglutaminase titre is 5 times the upper limit of normal.
Coeliac disease
A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool, which is associated with a change in his normal bowel habit such that he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well and there was no family history of GI disease. Examination of his abdomen and digital rectal examination are normal.
Colorectal carcinoma
A 25-year-old white man presents to his general practitioner with cramping abdominal pain for 2 days. He reports having loose stools and losing 6.8 kg over a 3-month duration. He also reports increased fatigue. On physical examination, his temperature is 37.6°C (99.6°F). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the right lower quadrant, without guarding or rigidity. Rectal examination is normal and the stool is guaiac positive. The rest of the examination is unremarkable.
Crohn’s disease
A 16-year-old girl presents to emergency care with perianal pain and discharge. She reports a 2-year history of intermittent bloody diarrhoea with nocturnal symptoms. On examination, she is apyrexial with normal vital signs. Her abdomen is soft and slightly tender on palpation in the left lower quadrant. Rectal examination is difficult to perform due to pain, but an area of erythematous swelling is visible close to the anal margin, discharging watery pus from its apex. Several anal tags are also present.
Crohn’s disease
A 57-year-old female with history of hypertension and hypercholesterolaemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for GI disorders.
Diverticular disease
A 32-year-old obese, but otherwise healthy, male presents to the emergency department with onset of acute lower abdominal pain of 2-hour duration. He has no fever and there is no history of any previous significant illness, except loud snoring, possible sleep apnoea, and being overweight.
Diverticular disease
A 34-year-old mother of three presents to her family physician with a 3-week history of abdominal cramping pain in both lower quadrants. She has been having frequent small, soft stools accompanied by some mucus but no blood. Her symptoms are improved with bowel movement or passage of flatus. She has had these symptoms almost monthly since she was in college, but they have been worse recently. Past history is negative except for three normal pregnancies. Family history is negative for colon cancer. A sister has similar symptoms but has not seen a physician. Personal/social history reveals that she is an accountant working long hours. Her firm is about to merge with another, and she fears her job situation is tenuous. Review of systems is otherwise negative. She has not lost any weight or had any other constitutional symptoms. On physical examination, the only finding is some mild tenderness in the right lower quadrant. No mass is felt.
irritable bowel syndrome
A 40-year-old housewife complains of recurrent constipation. She has had problems since her 20s, but they are worse now. The constipation is accompanied by abdominal bloating and abdominal pain, and the discomfort is only better when she has a bowel movement. On her gynaecologist’s advice, she has tried more fibre in her diet, including fresh fruits and leafy vegetables, but that has only made the bloating worse. Her past history includes a cholecystectomy and a hysterectomy. Physical examination is entirely normal. Rectal examination reveals normal consistency stool. Stool samples test negative for occult blood.
irritable bowel syndrome
A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the RUQ that began after eating dinner and radiates through to her back. This pain gradually increased and became constant over the last few hours. She has had previous episodes of similar pain for which she has not sought medical advice. Her vital signs are normal. The pertinent findings on physical examination are tenderness to palpation in the right upper quadrant without guarding or rebound.
Cholelithiasis (gallstones and biliary colic)
A 77-year-old man presents to his general practitioner with weight loss of 6.8 kg (15 lbs) and a 3-month history of dysphagia and abdominal pain. The only abnormal finding on physical examination is stools positive for occult blood. He is referred for an upper endoscopy, which shows an exophytic, ulcerated mass in the cardia of the stomach.
Gastric cancer
A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4 to 6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. The patient has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m (5 feet 4 inches), weight 77.1 kg, and BP 140/88 mmHg. The remainder of the examination is unremarkable.
GORD
A 42-year-old man presents with a 48-hour history of bloody diarrhoea. He has been opening his bowels 6 to 8 times per day, and has associated nausea, lethargy, and generalised abdominal discomfort. There is no recent travel history. He lives with his wife and 2 children, who are all well. They had a meal in a restaurant 5 days ago, when he ate a beef burger and French fries. A friend who was with them ate the same meal and has developed similar symptoms. Exam shows a low-grade pyrexia (37.5°C) but is otherwise unremarkable. FBC reveals a raised white cell count (15,000/mm^3). Stool culture results are available 3 days later and are positive for Escherichia coli
Gastroenteritis
A 21-year-old woman presents with profuse watery diarrhoea 15 to 20 times per day. There is associated nausea, anorexia, and lethargy. She returned 4 days ago from Kenya, where she had tried many local delicacies, often from street vendors. On exam she has dry mucous membranes and reduced skin turgor. She is hypotensive (blood pressure 95/50 mmHg) and tachycardic (pulse 110 bpm). Abdominal exam is unremarkable. She responds well to intravenous fluid replacement, with resolution of her symptoms within 48 hours. Stool cultures are subsequently positive for enterotoxigenic E coli (ETEC).
Gastroenteritis
A 30-year-old man with a history of ulcerative colitis presents with severe abdominal pain and distention. He is currently being treated for an acute colitis flare characterised by 20 bloody bowel movements daily, fevers to 38.9°C (102°F), and left upper quadrant pain. Physical examination reveals tachycardia and hypotension. Abdominal examination shows distention with signs of focal peritonitis in the left lower quadrant.
Toxic colitis
A 60-year-old woman presents to the accident and emergency department with a 4-day history of watery diarrhoea, fevers, and worsening abdominal pain. Her significant past medical history includes sinusitis, for which she has been taking antibiotics for the past 3 weeks. On physical examination, she is tachycardic and febrile, and her abdominal examination reveals diffuse abdominal tenderness and distention.
Toxic colitis
A 68-year-old male presents to A&E with acute onset of severe upper abdominal pain which is worse on breathing, which radiates to the back and shoulders. On examination, he has board like rigidity in his abdomen, with marked guarding and tenderness. His CXR revelas air under the diaphragm. He recently underwent abdominal surgery to repair a left inguinal hernia.
GI perforation
A 57-year-old man is evaluated for progressive arthralgias. There is swelling and tenderness over the first, second, and third metacarpophalangeal joints of both hands. Findings on hand radiographs are suggestive of calcium pyrophosphate deposition. Iron studies are obtained, showing a transferrin saturation of 88% and serum ferritin of nearly 2700 picomols/L (1200 nanograms/mL).
Haemochromatosis
A 50-year-old man with a history of obesity and heavy alcohol use presents with a 2-month history of weakness, jaundice, and ascites. Laboratory testing shows a transferrin saturation of 76% and ferritin of 11,000 picomols/L (5000 nanograms/mL). Imaging studies demonstrate a cirrhotic-appearing liver with an ill-defined mass in the right lobe and multiple pulmonary nodules suspicious for metastases. Hepatic iron overload with metastatic hepatocellular carcinoma is confirmed at autopsy.
Haemochromatosis
A 42-year-old man presents to his primary care physician complaining of a 3-month history of lower intestinal bleeding. He describes the bleeding as painless, bright blood appearing on the tissue following a bowel movement. He has had 2 episodes recently where blood was visible in the toilet bowl following defecation. He denies any abdominal pain and any family history of GI malignancy. Physical examination reveals a healthy man with the only finding being bright blood on the examining finger following a digital rectal examination.
Haemorrhoids
A 28-year-old woman presents complaining of rectal pain of 3 days’ duration. She states that on the day before the onset of symptoms she had been moving boxes at her home. She describes the pain as sharp and present constantly, but worse with bowel movements or sitting. She denies any fevers or chills or perianal discharge. Physical examination reveals a 2-cm, painful, bluish lesion adjacent to the anal canal.
Haemorrhoids
A 60-year-old Asian man with a long-standing history of chronic hepatitis B virus complicated by cirrhosis presents to his primary care physician with abdominal distension, yellow eyes, right upper quadrant (RUQ) abdominal pain, decreased appetite, weight loss, and change in his sleep pattern for several weeks. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, a palpable mass in RUQ, and asterixis.
Hepatocellular carcinoma
