Gastrointestinal and Nutritional Flashcards
Where does referred pain for Cholecystitis go
Right Subscapular pain (also epigastric)
Where does referred pain for appendicitis go?
Early: periumbilical
Rarely: testicular pain
Where does referred pain for Diaphragmatic irritation go
Shoulder pain (+ Kehrs sign on the left)
Where does referred pain for Pancreatitis/cancer
back pain
Where does referred pain for Rectal disease go
pain in the small of the back
Where does referred pain for Nephrolithiasis
testicular/flank pain
Where does referred pain for rectal pain go
midline small of the back pain
Where does referred pain for small bowel pain go?
periumbilical pain
Where does referred pain for uterine pain go?
midline small of back pain
what needs to be ruled out with “abdominal pain out of proportion to exam”?
Mesenteric ischemia
what presents with fever, LLQ pain and change in bowel habits
Diverticulitis
What is an “acute abdomen”?
acute abdominal pain so severe that the pt seeks medical attention (not the same as a “surgical abdomen”)
what are peritoneal signs?
extreme tenderness
percussion tenderness
rebound tenderness
voluntary guarding
motion pain
involuntary guarding/rigidity (late)
What conditions can mask abdominal pain?
Steroids
Diabetes
Paraplegia
what are potential diagnoisis/conditions associated with epigastric pain
PUD
gastritis
MI
pancreatitis
biliary colic
gastric volvulus
mallory-weiss
What is the most common cause of acute abdominal surgery in the US?
Acute Appendicitis
what are potential diagnoisis/conditions associated with RUQ pain
cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis. cholangitis, pyelonephritis, nephrolithiasis, appendicitis
thoracic causes: PE, pericarditis, MI
what are potential diagnoisis/conditions associated with LUQ pain
PUD, perforated ulcer, gastritis, splenic injury, abscess, reflux, dissecting aortic aneurysm, thoracic causes, pyelonephritis, hiatal hernia, boerhaaves syndrome, mallory weiss tear, splenic artery aneurysm, colon disease
what are potential diagnoisis/conditions associated with LLQ pain
Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, UTI, SBO, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic cuases, appendicitis (rare)
what are potential diagnoisis/conditions associated with RLQ pain
Appendicitis
same as LLQ
mesenteric lymphadenitis, cecal diverticulitis, meckels diverticulum, intussusception
what is the population for presentation of acute/chronic cholecystitis
5 F’s: Female, Fat, Forty, Fertile, Fair
What is the preferred initial imaging for acute/chonic cholecystitis
Ultrasound
what is the gold standard test for acute/chornic cholecystitis
HIDA scan
what is a porcelain gallbladder
chronic cholecystitis
what is the treatment of acute/chronic cholecystitis
cholecystectomy
how is acute pancreatitis described
epigastric abdominal pain with radiation to the back and elevated lipase
what are the common etiologies of acute/chronic pancreatitis
cholelithiasis
alcohol abuse
what is Grey Turner sign
flank bruising seen with acute/chronic pancreattisis
what is cullens sign
brusing near the umbilicus with acute/chronic pancreatitis
what is the treatment of acute pancreatitis
IV fluids (best), analgesics, bowel rest
what are complications of acute pancreatitis
pancreatic pseudocysts
what is a pancreatic pseudocyst
circumscribed collection of fluid rich in pancreatic enzymes, blood and necrotic tissue
what is the classic triad of chronic pancreatitis
pancreatic calcification (plain abd XR), steatorrhea (high fecal fat) and diabetes mellitus
what is the treatment of chronic pancreatitis
no alcohol, low-fat diet
what is the difference from anorectal abscess and anorectal fistula
anorectal abscess is a result of infection
fistula is a chornic complication of an abscess
what is an anorectal fistula
open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses
what is the treatment of anorectal fistula
surgical treatment
what is an anal fissure
tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper
what is the treatment of anal fissures
sitza baths, increased dietary fiber and water intake, stool softeners or laxatives
what are symptoms of gastric ulcers
epigastric pain
vomiting
anorexia
nausea
what are symptoms of duodenal ulcers
epigastric pain - burning or aching usually several hours after meals
bleeding
back pain
nausea
vomiting
and decreased appetite
what are symptoms of gastric cancer
what is the acronym
WEAPON
Weight loss, Emesis, Anorexia, Pain/epigastric discomfort, Obstruction, Nausea
what are symptoms of lower GI bleed
hematochezia with or w/o abdominal pain
melena
anorexia
fatigue
syncope
SOB
shock
what are symptoms of carcinoma of the GB
biliary colic
weight loss
anorexia
many pts are asymptomatic until late
what are symptoms of pancreatic carcinoma
painless jaundice from obstruction of the common bile duct
weight loss
abdominal pain
back pain
weakness
pruruitis from bile salt on skin
anorexia
courvoisiers sign
acholic stools
dark urine
diabetes
what medications commonly cause anorexia
sedatives
digoxin
laxatives
thiazide diuretics
narcotics
antibiotics
what is the first symptom of appendicitis
crampy or “colicky” pain around the navel (periumbilical)
what are the three signs/special tests of appendicitis
Rovsing
Obturator
Psoas
what is the most common cause of small bowel obstruction in adults
post operative adhesions
hernias, cancer, IBD, volvulus
what is the most common cause of small bowel obstruction in children
intussusception
where are SBO ususally located
ileium or jejunum
how are SBO diagnosed
plain XR (KUB) or CT of the abdomen and pelvis
with is the treatment of SBO
Decompression with an NGT, surgery if a mechanical obstruction is suspected
what are the most common causes of LBO
Cancer
strictures
hernias
voluvulus
fecal impaction
where are LBO usually found
colon or rectum
how are SBO and LBO differentiated on physical exam
SBO: more vomiting and periumilical pain that is internmittent
LBO: vomiting less common, pain is lower in abdomen and longer and less frequent bouts of pain
what is seen on xray with LBO
Haustra that do not transverse bowel
what is Haustra
small pouches cuased by sacculation, which give the colon its segmented appearance
What is the presentation of cholangitis
RUQ pain, jaundice and fever
(aka charcots triad)
what is cholangitis
complication of gallstones with symtpoms secondary to an infected obstruction of the common bile duct
what is the most common cause of cholangitis (pathogen)
E. coli (#1 cause)
what is Charcots triad
RUQ tenderness, jaundice, fever (for cholangitis)
what is Reynolds Pentad
charcots triad (RUQ pain, jaundice, fever) + AMS and Hypotension
what is the treatment for Cholangitis
ERCP is optimal procedure for both diagnosis and treatment
what is seen on enema with colorectal cancer
apple core lesion
what is the most common type of colorectal cancer
adenoma
what is the tumor marker for colorectal cancer
CEA
what are colon cancer screening tests and when should they begin?
stool tests:
* Guaiac-based fecal occult blood -1/y
* Fecal immunochemical test -1/y
* FIT-DNA test - 1/1-3y
flexible sigmoidosocopy- 1/5-10y
colonoscopy - 1/10y
CT colonography - 1/5y
Average risk pts should begin screenings at 45yo and end at 75
how is constipation defined?
less than 2 BM / week
How does SBO present
colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention, obstipation, hyperactive bowel sounds
how is LBO present
gradually increasing abdominal pain with longer intervals btwn episodes of pain, abdominal distention, obstipation, less vomiting, more common in elderly.
what is the primary sign of illeus
absent bowel sounds
what is an ileus
a painful obstruction of the ileum or other part of the intestine.
what is the imagine of choice for an ileus
CT with Gastrografin - must exclude mechanical obstruction
what is gastroparesis
condition that affects the stomach mucscles and prevents proper stomach emptying
what is the most common cause of gastroparesis
Diabetes
what is pseudomembranous colitis
inflammation of colon caused by c.diff
what is the cause of pseudomambranous colitis
c.diff occurs secondary to treatment with braod-spectrum abx
what are signs of pseudomembranous colitis
mild watery, foul smelling diarrhea (>3 but <20 stools/day)
what is the treatment of pseudomembranous colitis
IV metronidazole
OR
PO vanco (only use for oral vanco)
what is inflammation of an abnormal puch in intestinal wall
diverticular disease (diverticulitis)
where is the most common location of diverticulitis
sigmoid colon
how is diverticulitis diagnosed
abdominal and pelvic CT with oral, rectal and IV contrast
how long after acute flare of diverticulitis can colonoscopy be done
1-3 months to assess for cancer
what does CT of diverticulitis show
fat stranding and bowel wall thickening
what is the treatment of divericulitis
depends on severity - conservative management (Pain control and liquid diet x 2-3 days), sometimes abx, and sometiems percutaneous/endoscopic US guided drainage
what is the most common type of esophageal cancer
squamous cell (m/c world wide)
adenocarcinoma (m/c in US)
what type of esophageal cancer is a complication of Barretts esophagus
adenocarcinoma
what type of esphageal cancer is associated with smoking and alcohol use
squamous cell carcinoma
what are symptoms of esphageal strictures
difficulty and painful swallowing, weight loss and regurgitation of food
what is esophageal achalasia
primary esophageal motility d/o characterized by the absence of lower esophageal peristalsis
how are esophageal strictures diagnosed
barium swallow - “birds beak” or “rats tail” appearance
what is the treatment for esophageal strictures
EDG dilation of esophagus or myotomy
what is an esophageal web
thin membranes in the mid-upper esophagus. may be acquired or congenital
what is Plummer-Vinson
esophageal webs + dysphagia + iron deficiency anemia
what is a schatzki ring
diaphragm like mucosal ring that forms at the esophagogastric juntion (B ring).
what are risk factors for gastic cancer
family history of gastric cancer
gastric ulcers
H. pylori
pernicious anemia
what are signs of gastric cancer
loss of appetite
difficulty swallowing (increasing over time)
vague abdominal fullness
N/V/weight loss
what are three causes of heartburn and dyspepsia
- autoimmune or hypersensitivity reaction
- infection - H.pylori (m/c)
- inflam of stomach lining (NSAIDs and Alcohol)
what is the treatment of H.pylori
PPI (omeprazole) + clarithromycin + amoxicillin +/- metronidazole
what are the common etiologies of PUD
H.pylori (M/c), NSAID use, Zollinger-Ellison syndrome
What is Zollinger-Ellison syndrome
refractory PUD - rare digestive condition that cuases the stomach to produce too much acid
what are signs of PUD
hematemesis, abdominal discomfort, dull pain
what is the gold standard for diagnosis of PUD
endoscopy with bx
what are signs of esophageal varicies
hematemesis
bleeding
difficulty swallowing
what is a Mallory-Weiss syndrome
tearing in lining of the stomach just above the esophagus cuased by violent retching and vomiting
45yo woman with hemorrhoids that bulges into the anal canal during BM..what type and degree of hemorrhoid is this?
1st degree internal hemorrhoids
56yo woman with hemorrhoids that prolapse with defecation but then retract by themselves..what type of hemorrhoids is this?
2nd degree internal hemorrhoids
34yo woman with hemorrhoids that prolapse after defecation and that she has to “push it back in”..what type and degree of hemorrhoids is this?
3rd degree internal hemorrhoids
56yo woman with hemorrhoids that are “stuck out” after BM
4th degree internal hemorrhoid
what are hemorroids
varicose veins of the anus and rectum
what are risk facotrs for hemorrhoids
constipation/straining
pregnancy
portal HTN
obesity
prolonged sitting/standing
anal intercourse
what are the etiologies of Hepatic carcinoma
Cirrhosis
hep B, C, D
aflatoxin from aspergillus
what is the most common inguinal hernias
indirect: through internal inguinal ring with inguinal canal
what is a direct inguinal hernia
passage of intestine through external inguinal ring at Hesselbachs triangle
what makes up hesselbachs triangle
aka inguinal triangle
medial- lateral border of rectus abdominis muscle
lateral - inferior epigastric vessels
inferior - inguinal ligament
what is a ventral hernia
often from previous abdominal surgery, obesity.
abdominal mass noted at the site of previous incision
what is an obstructed hernia
irreducible hernia containing intestine that is obstructed from without or within, but no interference of blood supply to the bowel.
what is a hiatal hernia
diaphragmatic - protrustion of stomach through the diaphragm via esophageal hiatus
what portion of the bowel is affected with Ulcerative colitis
isolated tothe colon - starts at the rectum and moves proximally.
what portion of the bowels are affected by Crohns disease
from mouth to anus, transmural, skip lesions and cobblestoning.
m/c in terminal ileum
what is the treatment for Crohns flares
prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin
what is the maintenance medication for crohns
mesalamine
what is melena
black, tarry stools
(usually indicating Upper GI bleed)
what is hematochezia
bright red blood per rectum (BRBPR) - lower GI bleed
what is pathognomonic of pancreatic carcinoma
painless jaundice
what type and where is pancreatic carcinoma usually located
ductal adenocarcinoma located at the pancreatic head
what is the presentation of pancreatic carcinoma
weight loss/epigastric pain, clay-colored stools
Courvoisiers sign
Virchows node
what is courvoisiers sign
jaundice + palpable non-tender gallbladder
what is Virchows node
lymph node in the left supraclavicular fossa
what is a pancreatic pseudocyst
cystic collection of tissue, fluid, and necrotic debris surrounding the pancreas
when does pancreatic pseudocyst occur
typically occurs 2-3 weeks after acute pancreatitis
what is the presentation of pancreatic pseudocyst
abdominal pain and a palpable epigastric mass
what is the treatment for pancreatic pseudocyst
if pseudocysts persists for 4-6 weeks or continues to enlarge.. surgical decompression, percutaneous drainage and can become infected and lead to peritonitis
what is pyloric stenosis
congenital condition where newborns pylorus undergoes hyperplasia and hypertrophy, leading to obstruction of pyloric valve which causes vomiting as well as dehydration and metabolic alkalosis
when does pyloric stenosis present
<3 months of age
how is pyloric stenosis diagnosed
Ultrasound - double track
barium studies - “string sign” or “shoulder sign”
what is toxic megacolon
a complication of UC (m/c), Crohns, hirschprungs etc that is a life-threatening form of colon distention
how is toxic megacolon diagnosed
clinical signs of systemic toxicity in combo with xray evidence
what is the treatment of toxic megacolon
decompression of colon is required
- in some cases colostomy or even complete colonic resection may be required
Which of the following is most commonly associated with acute cholecystitis?
A. grey-turner sign
B. Murphy’s sign
C. Psoas sign
D. Rovsings sign
E. Cullen’s sign
B. Murphy’s sign
elicited by asking the pt to take a deep breath while the examiners fingers are placed just below the right costal margin causing pain due to inflamed peritoneum
A 55yo male persents wtih recurrent RUQ abdominal pain and bloating, especially after fatty meals. He has a hx of gallstones but no fever or jaundice. Which imaging modality is most appropriate to diagnose chronic cholecystitis in the patient?
A. Abdominal XR
B. CT scan of the abdomen
C. US of the abdomen
D. MRCP
E. ERCP
C. US of the abdomen
imaging modality of choice for dx of chronic cholecystitis.
60 yo female is dx with acute cholecystitis, confirmed by imagine. she has mild symptoms and no signs of complications. what is the most appropriate initial treatment for this patient?
A. immediate cholecystectomy
B. conservative management with analgesics and abx
C. ERCP
D. Percutaneous cholecystosomy
E. oral cholecystography
B. Conservative management with analgesics and abx
a 62 yo male with CHF and emphysema has sympotms of substernal chest pain and regurgitation after meals and at bedtime. He obtains incomplete relief of symptoms with famotidine. an endoscopy confirms mild esophagitis. which of the following is the most appropriate next step?
a. reassure him that continued occurance of symtpms while receiving therapy is normal
b. prescribe omeprazole 20mg/day
c. schedule him for 24 hour pH monitoring, manometry and barium esophagogram for further eval
d. schedule him for a laparoscopic nissen fundoplication
e. recommend dietary changes
b. prescribe him omeprazole 20mg/day
given the pts comorbidities (CHF and emphysema) he isnt a good surgical candidate. important part of hx is partial relief with H2 blocker as oppposed to no respoonse at all, therefore the hx suggests dx of GERD is a correct one and pts may simply have an ascalation of GERD tx. this pt should be switched to PPI b/c the relapse rate associated with H2 blockers is much higher than that associated with PPIs.
A 51-year-old woman has a 6-month history of substernal chest pain and vague upper abdominal discomfort. She has been taking antacid therapy with minimal relief and has had a negative upper endoscopy. Which of the following is the best next step in her workup?
A. barium esophagogram to evaluate for a hiatal hernia
B. performing manometry to r/o motility disorder such as diffuse esophageal spasm or achalasia
C. referring the patient to cardiac workup as a potential cause of her chest pain
D. referring to psychiatrist for possible conversion disorder
E. performing a CT of chest and abdomen
C. referring pt for cardiac workup as potential cause of her chest pain
When chest or epigastric pain does not respond to antacid therapy, and especially with a negative upper endoscopy, etiologies other than GERD (such as cardiac pain) should be considered. This patient’s history qualifies as atypical chest pain and may benefit from an exercise stress test. Documentation of a hiatal hernia does not necessarily correlate causally to her symptoms. Cardiac disease would be the most concerning disease, and that is why this disorder should be ruled out first. CT of the abdomen and chest may be helpful to identify other potential anatomic causes of her chest and abdominal pain but should only be done after appropriate cardiac evaluations
a 45yo male has been dx with GERD for 3 years with tx with H2-blocking agents. recently he has complained of epigastric pain. an Upper endoscopy was performed showing barrett esophagus at the distal esophagus. which of the following is the best next step in the treatment of teh individual?
A. initiate PPI
B. Advise the pt to continue to take the H2 blocker
C. Perform a laparoscopic Nissen fundoplicaiton
D. Advise surgical therapy involving gastrectomy and esophageal bypass
E. discontiue the Hblocker and initiate antacids
A. Initiate PPI
The next step in medical therapy for GERD is the addition of a PPI, which is a more effective medication for GERD. The patient has been symptomatic and developed Barrett esophagitis on an H2 blocker, and therefore additional therapy is needed for relief of symptoms and to decrease the progression of the Barrett esophagitis to adenocarcinoma. An antireflux surgery (such as the Nissen fundoplication) is an option but not gastrectomy and esophageal bypass. In general, most practitioners would elect to place the patient on the more appropriate medical treatment at this time rather than proceed with fundoplication. This patient also needs endoscopic surveillance of the Barrett esophagus.
A 24yo man with long standing GERD, currently taking PPis, is being evaluated for possible surgical threapy. which fo the following is an indication for surgery?
A. inability to tolerate PPIs
B. Inability to afford PPIs
C. incomplete relief of sympotms despite a maximum dosage of medical therapy
D. the pts desire to d/c medications
E. All of the above
E. all of the above
The indications for surgery are relative and determined in part by the patient; thus, inability to tolerate, inability to pay for, or a desire to discontinue medical therapy is a consideration for operative management.
What is GERD?
Excessive reflux of gastric contents into the esophagus, “heartburn”
What are the causes of GERD?
decreased lower esophageal sphincter (LES) tone
decreased esophageal motility to clear refluxed liquid
gastric outlet obstruction
Hiatal hernia
What disease must be ruled out when the symptoms of GERD are present?
Coronary Artery Disease
What is Barretts Esophagus
columnar metaplasia from the normla squamous epithelium as a result of chronic irritation from reflux
What is the major concern with Barretts esophagus?
developing cancer
what type of cancer develops in Barretts esophagus
Adenocarcinoma
What is the treatment of Barretts esophagus with dysplasia?
Non surgical: endoscopic mucosal resection and photo therapy. readio frequency ablation, cryoablation
a 36yo male presents with sudden onset severe epigastric pain following an alcohol binge. pain is referred to his back. pain is alleviated when he sits and leans forward. there is also N/V. PE revealed upper abdomnal tenderness, bluish discoloration around umbilicus and bowel sounds are absent. what is the most likely dx?
A. acute pancreatitis
B. acute appendicitis
C. acute cholecystitis
D. acute gastroenteritis
A. acute pancreatitis
Sudden severe epigastric pain (following alcohol binge) that is referred to the back and relieved by sitting and leaning forward with Cullen’s sign (periumbilical ecchymosis) strongly suggest acute pancreatitis.
a 36yo male presents with sudden onset severe epigastric pain following an alcohol binge. pain is referred to his back. pain is alleviated when he sits and leans forward. there is also N/V. PE revealed upper abdomnal tenderness, bluish discoloration around umbilicus and bowel sounds are absent. all of the following tests hsould be ordered next except
a. CBC with diff
B. serum amylase and lipase level
C. CT of abdomen with contrast
D. CMP
E. ABG
C. CT abdomen with contrast
The initial laboratory evaluation should include a complete blood count with differential, amylase and lipase levels, metabolic panel (blood urea nitrogen, creatinine, glucose, and calcium levels), liver function tests, and arterial blood gas analysis. Results from these tests should be used to guide further evaluation. CT scan of the abdomen would help in diagnosis of pancreatitis and pseudocyst formation but should be done after the initial laboratory investigations and stabilization of the patient
Which of the radiologic imaging techniques is the most sensitive in diagnosis of acute pancreatitis and pancreatic pseudocyst?
A. transabdominal US
B. contrast enhanced CT of abdomen
C. MRCP
D. Plain radiograph (adominal series)
B. Contrast enhanced CT of the abdomen
Question 3 Explanation: Contrast-enhanced CT has become the standard imaging technique for detection of acute pancreatitis and pseudocyst formation. Not only does it help in diagnosis, but some studies have shown that a CT severity index is helpful in predicting the severity of acute pancreatitis compared with the Ranson criteria and the APACHE II scale.
Fullness in the epigastric region and a palpable mass in this patient are most likely due to
A. Pancreatic psuedocyst formation
B. palpable gallbladder
C. enlarged spleen
D. enlarged liver
A. Pancreatic pseudocyst formation
The palpable mass in this patient is most likely due to pancreatic pseudocyst formation. These patients are jaundiced and do not present with such acute symptoms and pain.
What is acute pancreatitis
suddend inflammation that develops quickly and lasts a short time. usually settles in a few days but sometimes it becomes severe
what are the causes and risk factors of acute pancreatitis
caused by gallstones and alcohol consuption
RF: autoimmune disease, infxn, meds, surgery, trauma, metabolic d/o
What are symptoms of acute pancreatitis
pain in epigastrum that radiates to the back. typically lessens when pt leans forward or lies in fetal positon. eating may make it worse.
severe abd pain, N/V,abd distention
what are symptoms of chronic pancreatitis
epigastric pain, malabsorption
(diarrhea and weight loss), diabetes, upset stomach, vomiting
what are causes of chronic pancreatitis causes
90% caused by alcohol abuse
- cystic fibrosis, gallstones, high triglycerides and medications
what is the mnemonic for common causes of acute pancreatitis
GET SMASHHED
what is the mnemonic GET SMASHHED
most common causes of acute pancreatitis
- gallstones
- ethanol
- trauma
- steroids
- mumps
- autoimmune disease
- scorpion stine
- hypercalcemia
- hyperlipidemia
- ERCP
- Drugs
What is the treatment of acute pancreatitis
fluid resuscitation, pain control and nutrition
abx if pancreas is infected
ERCP to remove gallstones
what is the treatment of chronic pancreatitis
water
abstaining from alcohol
eating small low-fat meals
what is Ransons Criteria
form a clinical prediction rule for predicting the severity of acute pancreatitis.
which of the following surgical procedures is Not associated with increase risk of PONV and POV?
A. cholecystectomy
B. gynecologic procedures
C. Laparoscopy
D. Stabismus surgery
E. total hip replacement
E. total hip replacemement
Some surgical procedures are associated with an increased risk of PONV and POV, including the following:
Adults – Cholecystectomy, gynecologic procedures, laparoscopy
Children – Strabismus surgery, adenotonsillectomy
Which of the following dx studies is indicated in the evaluation of an upper GI bleed?
A. esophageal manometry
B. bleeding scan
C. upper endoscopy
D. barium swallow
C. upper endoscopy
define upper GI bleed
bleeding into lumen of proximal GI tract. proximal to ligament of treitz
what is the most comon cause of significant UGI bleeding?
PUD - duodenal and gastric ulcers
A 26-year old female presents with colicky abdominal pain which was initially at the periumbilical region, then after about 3 hours radiated to the right iliac fossa. She also has nausea and anorexia and has had two episodes of vomiting. On examination, she’s acutely ill looking, has low grade pyrexia (99.8oF), localized abdominal tenderness over McBurney’s point with muscle guarding and rebound tenderness. Blood test reveals Leucocytosis and a shift to left. Which of the following is the most likely diagnosis?
a. ruptured ectopic pregnancy
b. salpingitis
c. torsion of an ovarian cyst
d. acute appendicitis
D. acute appendicitis
The classic presentation of acute appendicitis is colicky abdominal pain frequently first noticed in the periumbilical region, then at the right iliac fossa. There is usually nausea, anorexia, fever and 1 or 2 episodes of vomiting. Examination findings usually show tenderness, muscle guarding and rebound tenderness over the McBurney’s point.
Which of the following signs is not associated with acute appendicitis?
A. murphys
B pointing
C Rovsings
D obturator
A. murphys
this is for acute cholecystitis
Deep palpation of left iliac fossa causing pain in right iliac fossa is
a. rovsings
b. psoas
c. obturator
d. dunphys
A. Rovsings
Rovsing’s sign, named after the Danish surgeon Niels Thorkild Rovsing (1862 -1927), is a sign of appendicitis. If palpation of the left lower quadrant of a person’s abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing’s sign and may have appendicitis.
Which lab marker is most helpful in supporting dx of acute appendicitis?
a. amylase
b. WBC count
C. CRP
D. UA
B. WBC count
A WBC count is often elevated. In acute appendicitis, the average leukocyte count is 15,000/mm3, and 80% of patients have a leukocyte count greater than 11,000/mm3. The differential count will often show a left shift. A leukocytosis can be helpful in supporting a diagnosis of appendicitis but does not differentiate it from other intra-abdominal processes.
the test with the highest sensitivty in dx of appendicitis is
a. US
b. barium enema
c. abdominal xr
d. CT with IV and oral contrast agents
D. CT with IV and oral contrast
The sensitivity of CT is 94%. The sensitivity of ultrasonography is 83% to 88% and is operator dependent. Barium enema is 80% to 90% sensitive but is no longer recommended because up to 40% of studies can be equivocal secondary to only partial filling of the appendix. Abdominal radiography is not routinely recommended because of very low sensitivity and specificity. Note that although imaging can be helpful, the diagnosis of appendicitis is primarily made by history and physical examination, and imaging study results can be equivocal!
what is the m/c cause of acute abdomen
appendicitis
Following bariatric surgery, a patient is at increased risk for which of the following nutritional deficiencies?
A. Vitamin C
B. Calcium and vitamin D
C. Potassium
D. Vitamin B12
E. Vitamin A
B. Calcium and Vitamin D
Patients who undergo bariatric surgery, especially malabsorptive procedures like Roux-en-Y gastric bypass, are at increased risk for calcium and vitamin D deficiencies due to altered gastrointestinal anatomy and reduced absorption. This can lead to bone demineralization and increased risk of fractures.
What is the formula for BMI?
Body weight (Kg) divided by height (meters squared)
What medical conditions are associated with morbid obesity?
sleep apnea
CAD
Pulmonary disease
DM
venous stasis ulcers
arthritis
infections
sex-hormone abnormalities
HTN
breast cancer
colon cancer
what is the most common sign of an astomotic leak after gastric bypass?
tachycardia
What is Ghrelin?
Hormone produced in stomach fundus that stimulates hunger.
which of the following is the most common cause of esophageal stricture?
A. corrosive ingestion
B. GERD
C. Post op scarring
D. esophageal cancer
B. GERD
GERD accounts for aprox 70-80% of all cases of esophageal stricutre
Which of the following is not a cause of distal esophageal stricture?
A. GERD
B. Adenocarcinoma
C. Scleroderma
D. Infectious esophagitis
D. infectious esophagitis
infectious esophagitis causes stricture mostly at the proximal and mid esophagus
60yo man has had GERD for 2 years. for about 13 months now, he has noticed an increaseing difficulty with swallowing his food. which of the following is the most likely diagnosis:?
A. Achalasia
B. diffuse esophageal spasm (DES)
C. Pyloric stenosis
D. esophageal stricture
D. esophageal stricture
which of the following is not a treatment modality for esophageal stricture?
A. PPI
B. endoscopic dilation
C. endoscopic intralesional steroid
D. endoscopic sclerotherapy
D. endoscopic sclerotherapy
this is the treatment of bleeding esophageal varices.
A Schatzki ring will cause dysphagia to:
A. solids
B. liquids
C. both solids and liquids
A. solids
a 45yo caucasian female presents with dysphagia to solids foods with a CBC indicative or iron deficiency anemia. What finding on endoscopy would lead to you a diagnosis of Plummer-Vinson Syndrome?
A. esophageal web
B. Mallory-Weiss Tear
C. Barrett’s esophagus
D. varicies
E. solid tumor
A. esophageal webs
Plummer–Vinson syndrome (PVS), also called Paterson–Brown–Kelly syndrome or sideropenic dysphagia, is a rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs. Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome.Plummer-Vinson Syndrome has 3 main findings: 1. dysphagia 2. esophageal webs 3. iron deficiency anemia
what is Plummer-Vinson syndrome
Aka Paterson-Brown-Kelly syndrome or Sideropenic dysphagia
rare disease characterized by difficulty swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs
what is the treatment of Plummer-Vinsons syndrome
iron supplementation and mechanical widening of esophagus
what is an esophageal stricture
abnormal tightening/narrowing of esophagus making it more difficult for food to travel down the tube
What are the types of esophageal strictures?
Simple or complex strictures
what type of strictures are smaller and lead a wider opening in the esophagus.
simple sticture
what type of strictures are usually not straight or symmetrical andhave uneven surfaces/margins?
Complex strictures
what are risk factors for esophageal strictures
alcohol use
cancer in the neck area
GERD
hiatal hernia
PUD
hx of dysphagia
What is the most common cause of esophageal stricture
GERD
what is eosinophilic esophagitis
allergic reaction/immune system problem causing inflammation in the esophagus, possibly leading to strictures
Define esophageal web
thin membrane in the mid-upper exsophagus. Mya be congenital or acquired
Define Schatzki ring
diaphragm like mucosal ring that forms at the esophagogastic junction (B-ring).
A 65yo man presents to you with 3 month hx of dysphagia initially to solid food and then 4 weeks later to liquid. hx of tobacco use and higher level of alcohol ingestion over 20 years. He has lost 22lbs in the past 2 months. what is the most likely diagnosis?
A. Zenkers diverticulum
B. Achalasia
C. esophageal cancer
D/ diffuse escophageal spasm
C. Esophageal cancer
Esophageal cancer occurs in the elderly population. Presents as dysphagia initially to solids then weeks later to liquid. Prolonged histories of tobacco use and alcohol ingestion are strong risk factors for esophageal cancer.
what is the first line investigative modality in a pt with concerns for esophageal cancer?
A. CXR
B. esophagoscopy
C. barium swallow
D. edoscopic US
B. esophagoscopy
first line for an elderly pt presenting with dysphagia. used to diagnose esophageal cacner along with bx.
60yo man presents with a 4 week hx of dysphagia to only solid foods. he is a non-smoker but has hx of GERD for 20 years. what is the most liekly dx?
A. adenocarcinoma of esophagus
B. SCC of esophagus
C. Kaposi’s sarcoma of esophagus
D. Leiomyoma of esophagus
A. adenocarcinoma of esophagus
Adenocarcinoma of the esophagus is most likely to occur at what part of the esophagus?
A. upper third
B. Middle third
C. Lower third
D. all of the above
C. Lower third
what are the two main types of esophageal carcinoma
adenocarcinoma at GE junction
SCC (in most of esophagus)
what are the 5 common etiologies of esophageal carcinoma?
- tobacco
- alcohol
- GERD
- barrets esophagus
- radiation
Which of the following is not a risk facotr for the formation of cholestrol gallstones?
A. pregnancy
B. obesity
C. sickle cell anemia
D. estrogen
C. sickle cell anemia
this is a risk factor for the formation of black pigment gallstones
which of the statements is false about cholelithiasis?
a. gallstone disease is responsible for about 10,000 deaths per year in the US
b. consuption of caffeinated coffee appears to protect against gallstones in women.
c. acute pancreatitis is a possible complication of cholelithiasis
d. gallstones are more common in men then women
D. gallstones are more common in men then women
Women are more likely to develop cholesterol gallstones than men, especially during their reproductive years, when the incidence of gallstones in women is 2-3 times that in men.
Gallstones have been classified into all of the following except:
a. cholesterol stones
b. cystine stones
c. pigment stones
e. mixed stones
B. cystine stone
these are examples of kidney stones
which of the following is not a complication of cholelithiasis?
a. intestinal obstruction
b. acute cholangitis
c. gallbladder empyema
d. pyelonephritis
d. pyelonephritis
which antibiotic is a major cause of biliary sludge?
a. amoxicillin
b. ciprofloxacin
c. ceftriaxone
d. doxycycline
c. ceftriaxone
Ceftriaxone is a major cause of biliary sludge. The mechanism of biliary sludge formation during ceftriaxone therapy appears to be the propensity of ceftriaxone to bind calcium and form insoluble crystals in bile in the gallbladder, resulting in biliary sludge or frank stones.
define cholelithiasis
gallstones in the gallbladder
define choledocholithiasis
gallstones in common bile duct
define cholecystitis
inflammation of gallbladder
define cholangitis
infection of biliary tract
what are the “big 4” risk facotrs of chonelithiasis
Female, Fat, Forty, and fertile
what are the causes of black pigmented stones?
cirrhosis, hemolysis
What is Boas’ sign?
referred right subscapular pain of biliary colic
60yo male with hx of rectal bleeding and change in bowel habits undergoes colonoscopy, whihc reveals a mass in the ascending colon. which of the following is the most appropriate next step inthe management of this patinet?
A. repeat colonoscopy in one year
B. immediate initiation of chemo
C. biopsy of mass during colonoscopy
D. surgical resection of the mass without biopsy
E. prescription of high fiber diet
C. biopsy of mass during colonoscopy
which of the following is the standard treatment for localized stage 2 colon cancer?
a. palliative care only
b. chemo alone
c. radiation alone
d. surgical resection followed by adjuvant chemo based on risk factors
e. immunotherapy
d. surgical resection followed by adjuvant chemo based on risk factors
carcinoma of the colon most commonly originates in which of the following?
a. adenomatous polyp
b. inflammatory polyp
c. hyperplastic polyp
d. benign lymphoid polyp
e. hamartomatous poylp
a. adenomatous polyp
the majority of colon carcinomas originate from adenomatous polyps through the adenoma-carcinoma sequence, a well-documented pathway in colorectal cancer development. These polyps are considered precancerous, and their transformation into cancer is influenced by various genetic and environmental factors.
What is Lynch syndrome
Hereditary non-polyposis colon cancer (HNPCC)
autosomal-dominant inheritance of high risk for the development of colon cancer
what are the current recommendations for colorectal cancer screening if there is a hx of colorectal cancer in a first-degree relative less than 60 years old?
colonoscopy at age 40, or 10 years before the age at dx of the youngest first-degree relative, and every 5 years thereafter
what is the most common site of distant metastasis from colorectal cancer?
liver
what are the risk factors for gastric cancer?
diet: smoked meats, high nitrates, low fruits/veggies, alochol and tobacco
environment
what is sister mary joseph’s sign?
periumbilical lymph node - presents as periumbilical mass
what finding on barium swallow is associated with pyloric stenosis?
a. string sign
b. birds beak
c. corkscrew esophagus
a. string sign
which of the following is not a known complication of diverticulitis?
a. fistula
b. colonic stricture
c. abscess
d. colon cancer
d. colon cancer
which of the following is not a component of Charcots triad?
a. hepatomegaly
b. RUQ pain
c. fever
d. jaundice
a. hepatomegaly
Which of the following is not a part of Reynolds pentad?
a. metal confusion
b. hypotension
c. fever
d. anorexia
e. jaundice
d. anorexia
the most common cause of acute cholantitis is:
a. choledocholithiasis
b. ERCP
c. biliary tract tumors
d. parasitic infection
a. choledocholithasis
which of the following organisms is the most common cause of acute cholangitis?
a. streptococcus
b. e.coli
c. staphylococcus aureus
d. pseudomonas aeruginosa
e. klebsiella pneumonia
b. e.coli
ascending cholangitis is defined as bacterial infection of what?
bile duct
what is charcot triad
jaundice, fever and RUQ pain with cholangitis
what is the initial imaging study for ascending cholangitis?
US
A 45-year-old man with a history of chronic alcoholism presents with persistent abdominal pain and weight loss for the past two months. He had an episode of acute pancreatitis six months ago. On examination, he has epigastric tenderness. His serum amylase and lipase levels are mildly elevated. An abdominal CT scan reveals a 5 cm cystic lesion in the region of the pancreas without evidence of calcification or solid components. Which of the following is the most likely diagnosis?
a. pancreatic adenocarcinoma
b. pancreatic pseudocyst
c. acute pancreatitis
d. pancreatic serous cystadenoma
e. chronic pancreatitis
b pancreatic psuedocyst
what are three tx options for pancreatic pseudocysts?
- percutaneous aspiration/drain
- operative drainage
- transpapilary stent via ERCP
which of the following is a tumor marker elevated in liver cancer?
a. CEA
b. AFP
c. CA-125
d. CA27-29
b. alpha-fetoprotein (AFP)
The most abundant plasma protein found in the human fetus is alpha-fetoprotein (AFP). AFP is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP in both the bloodstream and in the amniotic fluid. In adults, high blood levels (over 500 nanograms/milliliter [or ng/ml]) of AFP are seen in hepatocellular carcinoma.
A 69-year old man presents with epigastric pain which radiates to his back, progressive weight loss, jaundice, and pruritus. On physical examination, patient looks cachectic, is icteric, has scratch marks, palpable gallbladder. His fasting blood sugar (FBS) is 13mg/dl. What is the most likely diagnosis?
a. pancreatic cancer
b. gastric cancer
c. gastric ulcer
d. hepatocellular carcinoma
a. pancreatic cancer
what are risk factors for pancreatic carcinomas?
smoking 3x risk
DM
heavy alcohol use
chronic pancreatitis
diet high in fried meats
previous gastrectomy
What is Courvoisiers sign?
palpable, nontender, distended gallbladder which may indicate pancreatic neoplasm
What tumor markers are associated with pancreatic cancer?
CA-19-9
which medicatiosn is considered the mainstay of therapy for mild to moderate IBD?
a. prednisone
b sulfasalazine
c. metronidazol
d. azathioprine (imuran)
b. sulfasalazine
Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.
Which of the following is not an extraintestinal manifestation of inflammatory bowel disease?
a. uveitis
b erythema nodosum
c. arthritis
d. dermatitits hepetiformis
d. dermatitis herpetiformis
Dermatitis herpetiformis (A chronic, very itchy skin rash made up of bumps and blisters) is an extraintestinal manifestation of celiac disease. All other options are correct.
A 60-year-old individual presents to your office with persistent abdominal pain, unexplained weight loss, and occasional gastrointestinal bleeding. The patient’s family history reveals a sibling with colorectal cancer. After a series of diagnostic tests, including a CT scan and endoscopy, a small bowel carcinoma is diagnosed. What is the most appropriate initial treatment approach for localized small bowel carcinoma?
a. chemotherapy alone
b. radiation therapy alone
c. surgical resection
d. palliative care only
e. high-dose vitamin therapy
c. surgical resection
A 58-year-old individual presents to your office with recurrent cramping abdominal pain, fatigue, and melena. Laboratory tests reveal iron-deficiency anemia. A capsule endoscopy is performed, revealing a mass in the jejunum. Biopsy confirms the diagnosis of small bowel adenocarcinoma. What is the most common risk factor associated with small bowel adenocarcinoma?
a. chronic alcohol consuption
b. celiac dissease
c. smoking
d. crohns disease
e. high-fat diet
d. Crohn’s disease
Crohn’s disease is the most common risk factor associated with small bowel adenocarcinoma. Chronic inflammation of the small intestine in Crohn’s disease can lead to dysplasia and eventually adenocarcinoma. While small bowel adenocarcinoma is relatively rare, individuals with Crohn’s disease have an increased risk compared to the general population.
what are risk factors associated with small bowel carcinoma?
age
family hx
celiac disease
crohns disease
FAP/Lynch syndrome
the first manifestation of conjugated hyperbilirubinemia is?
a. scleral icterus
b. jaundice
c. clay-colored stools
d. tea-colored urine
e. pruritis
d. tea-colored urine
name the causes of prehepatic postop jaundice
hemolysis (prosthetic valve)
resolving hematoma
transfusion rxn
post CP bypass
transfusions
name the cuases of postop hepatic jaundice
drugs
hypotension
hypoxia
sepsis
hepatitis
“sympathetic” hepatic inflammation
etc.
name the causes of postop posthepatic jaundice
choledocholithiaiss, stricture, cholangitis, cholecystitis, biliary-duct injury, pancreatitis, etc.
In colorectal cancer, from which site is melena more common?
right-sided colon cancer
what are causes of melena
gastric cancer
duodenal ulcers
right sided colon cancer
portal HTN with esophageal varicies
severe erosive esophagitis
mallory-weiss syndrome
what are causes of hematochezia
hemorrhoids
anal fissures
polyps
proctitis
rectal ulcers
colorectal cancer
An 83-year-old female patient presents to the ED with abdominal pain and distention. The abdominal radiograph demonstrates multiple air–fluid levels and dilated large-bowel loops consistent with a large-bowel obstruction. What is the most likely cause of the obstruction?
A Inguinal hernia
B Adhesions
C Carcinoma of the colon
D Diverticulitis
E Sigmoid volvulus
c. carcinoma of the colon
Colorectal cancer is the most common cause of large bowel obstruction in adults. Tumors can grow to a size that blocks the passage of feces through the colon, leading to obstruction. Diverticulitis can also cause LBOs, and patients often give a history of intermittent left lower quadrant pain. Sigmoid volvulus is a less common cause of LBO. It is seen most often in the elderly with poor bowel habits and chronic constipation.
A 72-year-old man presents with abdominal distension, constipation, and vomiting. Abdominal X-ray shows dilated loops of colon with air-fluid levels. Which of the following is the most appropriate next step in the diagnosis?
A Colonoscopy
B CT scan of the abdomen with contrast
C MRI of the abdomen
D Barium enema
E Ultrasound of the abdomen
b. CT of the abdomen with contrast
A CT scan of the abdomen with contrast is the most appropriate next step in diagnosing large bowel obstruction. It provides detailed images that can help identify the location and cause of the obstruction, such as a tumor, volvulus, or diverticular disease, and assess for complications like ischemia or perforation.
What is the most appropriate initial management for a patient diagnosed with acute large bowel obstruction due to suspected colorectal cancer?
A Immediate surgical resection of the obstructed segment
B Intravenous fluids and bowel rest
C Administration of oral laxatives
D Endoscopic stent placement
E Total parenteral nutrition (TPN)
b. IV fluids and bowel rest
The most appropriate initial management for a patient with acute large bowel obstruction, especially due to suspected colorectal cancer, includes stabilization with intravenous fluids and bowel rest. This approach addresses dehydration and electrolyte imbalances while further diagnostic and therapeutic plans are made, such as surgical intervention or endoscopic stent placement for palliation or as a bridge to surgery.
what is the most common site for anal fissures?
posterior midline (comparatively low blood flow)
A patient describes abdominal discomfort that improves with meals and gets worse an hour or so later after eating. What do you suspect?
A duodenal ulcer
B gastric ulcer
C acute cholecystitis
a. duodenal ulcer
A patient describes abdominal discomfort that is worse with meals and gets better an hour or so later after eating. What do you suspect?
A Duodenal ulcer
B Gastic Ulcer
C Acute pancreatitis
b. gastric ulcer
Which of the following is not a component of the TRIPLE THERAPY for H. pylori eradication
A Amoxicillin
B Clarithromycin
C A proton pump inhibitor
D Bismuth
d. bismuth
A 26-year old lady presents at the outpatient clinic with 11 month history of recurrent epigastric pain which is worse when she’s hungry. It is temporarily relieved by food and antacids. It is also worse at night. It sometimes awakens her. Pain occurs for a few weeks, then goes and occurs again after several weeks. There is history of chronic NSAID ingestion, nausea and anorexia. Which of the following is the most likely diagnosis?
A Esophagitis
B Acute pancreatitis
C Peptic ulcer disease
D Gastroesophageal reflux disease
C. peptic ulcer disease
the most common presentation of PUD is that of recurrent epigastric pain which has three notable characteristics: localization to the epigastrium, relationship to food and episodic occurrence (periodicity). Chronic NSAID ingestion can cause PUD.
Which of the following is the gold standard for definitive diagnosis of Peptic Ulcer Disease(PUD)
A Upper gastrointestinal endoscopy
B Double-contrast barium enema
C Chest radiograph
D None of the above
a. upper gastrointestinal endoscopy
What type of hernia involves passage of intestine through the external inguinal ring at Hesselbach triangle and rarely enters the scrotum
A Indirect inguinal hernia
B Direct inguinal hernia
C Ventral hernia
D Hiatal hernia
B. direct inguinal hernia
What type of hernia involves passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one?
A Direct inguinal hernia
B Indirect inguinal hernia
C Umbilical hernia
D Ventral hernia
b. indirect inguinal hernia
A 45-year old woman being managed for ulcerative colitis, developed abdominal pain, vomiting, diarrhea, passage of blood and mucus per rectum and fever. On examination, she was pale, febrile (temp: 102.20C), moderately dehydrated, heart rate: 124bpm. There was abdominal distention and tenderness, bowel sounds were hypoactive. Lab results showed Hb: 9g/dl, WBC: 14 x 109/L, elevated CRP. Stool was negative for C. difficile. HIV status was negative. Abdominal radiograph showed dilated transverse colon of about 11 cm. What is the most likely diagnosis of this patient?
A Hirschsprung’s disease
B Cytomegalovirus colitis
C Toxic megacolon
D Kaposi’s sarcoma
d. toxic megacolon
Diagnostic criteria for Toxic megacolon includes all of the following except
A Radiographic evidence of colonic dilatation (>6cm)
B Fever (>101.50F)
C Blood pressure > 150/90
D Heart rate > 120/min
C. blood pressure > 150/90
Which of the following is not an etiology for toxic megacolon?
A Ulcerative colitis
B Pancreatitis
C Crohn colitis
D Pseudomembranous colitis
b. pancreatitis
what is a rare yet life threatening complication of severe colon disease or infection that is characterized by non-obstructive segmantal or pancolonic dilation
toxic megacolon
