GI 1

Question 1

Pt presents with sexual dysfunction, weightloss, gynocomastia, small testes and low T3 and T4. Dx? Why is there a low T3 and T4?

Answer 1

This is chronic liver dz in a man (cirrhosis). Low thyroxine binding (made from liver) globulin means a decrease T3 and T4. Pts liver can’t make protein or enzymes.

Question 2

Management when a pt Alocholic who has been binge drinking presents with midepigastric pain that radiates to back? Dx? 2. What to do if the pts does not improve within the next 24-48hrs 3. What is the complication of this? Management? 4. Management when this is really severe. 5. Complication of pancreatitis that occurs 2-4 weeks later. Management?

Answer 2

Acute Pancreatitis. Check Amylase and Lipase. IVF, NPO, Morphine. 2. Do CT scan to check for necrosis.3. >30% Necrosis can lead to infection or hemorrahgic pancreatitis. Start Ertapenem. 4. Percutaneous biopsy if infection is present then surgical debriedment. 5. Pseudocyst. Drain only if expanding, rupture, fistula or painful.

Question 3

1. Test for lactose intolerance ? 2. Test for Celiac Dz or other malabsroptive syndromes?

Answer 3

1. Positive hydrogen breath test. 2. D-Xylose Test

Question 4

Test for Ascites. Name 4 rx for Ascites. Prophylaxis for SBP? Rx for SBP?

Answer 4

SAAG (Serum Albumin - Ascitic Albumin) > 1.1 means Ascitic fluid coming from portal HTN, CHF and hepatic vein thrombosis. < 1.1 means it coming from cancer or nephrotic syndrome (low serum albumin). 1. Salt and water restriction 2. Lasix 3. Spironolactone 4. Paracentesis 2-4 L/daily SBP Prohylaxis is Bactrim. Rx is Ceftriaxone. E.Coli most likely organism ANC>250 on Tap.

Question 5

Pt old person has anemia, painless GI bleeding, murmur systolic ejection murmur of AS. Dx?

Answer 5

Angiodysplasia. (DDx includes Cancer, Polyps, Diverticuolosis, Hemorrhoids)

Question 6

Abdominal pain, fever, skin hyperpigmenation, and polyathropathy, dementia, valvular regurgitation, seizures. Dx? Best initial/most accurate test?

Answer 6

Whipples dz Biopsy: PAS positive villi after doing and ruling out everything else. Diganosis of exclusion.

Question 7

Transmurual inflammation, Fistula formation, Skip lesions, cobblestone appearance, mouth to anus, noncaseating granulomas that can form palpale masses which can be palpated, diarrhea may or may not be bloody. Joint pain, erythema nodosum/pyoderma, Uveitis/episcleritis/Iristis. Xray shows “string sign” appearance of bowel. Dx? Most accurate test? Acute Flare up? Chronic Rx?

Answer 7

Crohns Dz. +ASCA. Endoscopy Confirms Diagnosis. Budesonide for Acute Symptoms. Mesalamine (Pentasa) for chronic management. Azathioprine/ 6-Mecaptopurine (Pancreatitis) is given to ween pts off steroids after acute symptoms. Infliximb (Anti-TNF, TB, NonHodgkins) for refractory disease or especially if fistulas are present.

Question 8

Mucosal and submucousal inflammation only, crypt abscesses, lost of haustra “lead pipe appearence of bowel” only colon, high association with colerectal cancer. Erythema/nodusom/pyoderma, athralgias. Xray shows “lead pipe” appearance of bowel. Dx? Rx? Extraintestinal manisfestaions?

Answer 8

Ulcerative Colitis. +ANCA. Sigmoidoscopy/ Colonoscopy. Ascol (Mesalamine). Azathioprine and 6-MP to ween pts off steroids (Bidesonide) during flare ups. 1. Pyoderma gangrenosum. 2. primary PSC 3. Ankylosing spondylitis.

Question 9

Name 2 common medications associated with pill esophagitis. Management?

Answer 9

Alendronate and Doxycycline. If they havent contracted it tell them to take pill with water and sit up right. If they have already contracted it then STOP pill.

Question 10

Failure of the Criocopharyngeal muscle (Constrictor muscle of the pharynx) to relax during swallowing causes increase intraluminal pressure and outpouching of the mucosa. Pt presents with halotosis, regurgitation and dysphagia. Dx? Test? Rx? Complication(1)?

Answer 10

Zenker diverticulum - true diverticulum that involves all layers. (Motor dysfunction problem - incoordination btw UES contraction and pharyngeal contraction). Test: Barium Swallow. Rx: Cricopharygneal myomotomy.- Surigical disease. No medical therapy. Chronic aspiration pt may have continuous episodes of aspiration pneumonia.

Question 11

Pt has Transmural/Full Penetration Tear. There is creptius when you palpate the thorax and neck. (Hamman’s Sign when the heart beats against air filled tissues) Dx? Test? Rx?

Answer 11

Boerhaavens Syndrome. Test: Gastrografffin swallow. CXR shows air in the mediastinum (pleural effusion, Amylase and lipase present in plueral fluid,pneumothorax) are complications. Rx: If patient is stable IV fluids, NPO, Abx if needed. If not stable pt needs surgery.

Question 12

Transmurual inflammation, Fistula formation, Skip lesions, cobblestone appearance, mouth to anus, noncaseating granulomas that can form palpale masses which can be palpated, diarrhea may or may not be bloody. Joint pain, erythema nodosum/pyoderma, Uveitis/episcleritis/Iristis. Xray shows “string sign” appearance of bowel. Dx? Most accurate test? Acute Flare up? Chronic Rx?

Answer 12

Crohns Dz. +ASCA. Endoscopy Confirms Diagnosis. Budesonide for Acute Symptoms. Mesalamine (Pentasa) for chronic management. Azathioprine/ 6-Mecaptopurine (Pancreatitis) is given to ween pts off steroids after acute symptoms. Infliximab (Anti-TNF, TB, NonHodgkins) for refractory disease or especially if fistulas are present.

Question 13

Pt presents with INTERMITTENT dysphagia and anemia. Dx? Best initial/most accurate test? Rx? Complication (2)?

Answer 13

Plummer Vinson Syndrome (Web). Can transform in squamous cell carcinoma. Iron deficiency anemia is another complication. Barium Swallow. Iron sulfate 325 mg may help reduce web.

Question 14

Young patient with no smoking or tobacco use presents with Weight loss, difficulty Swallowing LIQUIDS AND SOLIDS @ the SAME TIME. Can be progressive WITH BOTH. Dx? Next best step? Most accurate Test? Rx?

Answer 14

Achalasia (Loss of LES relaxtaion and loss of peristalsis caused by degeneration of inhibitory neurons from myenteric (Auerbech’s plexus.) Barium Swallow “dilated esophagus with smooth tapering of the distal esophagus.” MANOMETRY CONFRIMS (Absent peristalsis and Higher resting pressure of the LES). Endoscopy is done for Alarm Symptoms (> 60 years, Blood, Anemia, Excessive Weightloss, >6 month duration.) Rx: 1. Pneumatic dilation 3. Surgical Myotomy. Botox for those who fail or refuse dilation (Temporary.)

Question 15

Colicky abdominal pain and protracted vomiting for several days. Abdominal distention, has not had bowel movement in 5 days. High pitched bowel sounds on physical exam. 5 years ago pt had ex lap. 6 hrs after NG and IV fluids pts develops fever, leukocytosis and abdominal tenderness with rebound tenderness. Dx? Rx?

Answer 15

Strangulated Obstruction. (Obtructed bowel impinges on artery and causes ischemia) Emergent Surgery.

Question 16

Mucousal tear of the esophagus after binge drinking and vomiting causing a lot of bleeding BUT NO AIR WHEN PALPATING THORAX AND NECK (Negative Hamman’s sign.) There is Bright red blood in the emesis and black tarry stools. Pt presents with streaks of blood. Dx? Test? Rx?

Answer 16

Mallory-Weis Syndrome (Submucosal tear of the arteries as oppose to dilated esophgeal veins/varices - cirrhosis). Test: Upper Endoscopy for direct visualization. Rx: 1. Self limiting resolves on own can do embolization with the endsocopy if it doesnt heal.

Question 17

Diabetic pt presents with Abdominal pain, CONSTIPATION, BLOATING and nausea. Dx? Rx? What study to conduct if diagnosis is equivocal?

Answer 17

Diabetic gastroparesis. Metoclopramide or Erythromycin. Gastric Emptying Study.

Question 18

1. These hemorroids bleed but do not hurt. Rx? 2. These hemorroids dont bleed but hurt? Rx?

Answer 18

Cancer must always be ruled out so do anoscopy, flexible sigmoidoscopy or protocsigmoidocopy. 1. Internal Hemorrhoids band ligation to stop bleeding. 2. External Hemorrhoids surgical removal so they dont cause any more pain.

Question 19

When to give the following during GI bleeding: 2. Pack red cells? 2. FFP or IV Vit K (Takes longer to work)? 3. Platelets? 4. Octerotide? 5. PPI? 6. Surgery?

Answer 19

1. HCT < 30/Hgb < 9 with comorbidities. HCT 20-25/Hgb < 7 in the young and healthy (May need to give FFP with packed red cells to protect dilution of clotting factors.) 2. When INR an PT are elevated + active bleeding. 3. When platelets are < 50,000 + active bleeding, < 20,000 + fever < 10,000 + No fever 4. Octerotide given when there is hx of cirrhosis to decrease portal HTN. 5. PPI can be given any time to help stop bleeding to anyone but especially gastritis and PUD pts. 6. Surgery is when all else fails (Angiogram + Embolization)

Question 20

Difference in cholecystitis and Ascending cholangitis?

What can we use to help infection before the surgery.

Answer 20

Cholangitis is an obstructive jaundice in the duct that raises CB. So pts will present with yellow skin. Unasyn or Zoysn.

Question 21

Common complication of Peritoneal Dialysis. What do you do when a pt presents with High fever and elevated leukocyte after having 2 hrs of peritoneal dialysis?

Answer 21

Peritonitis(Infection.) Peritoneal fluid amylase and lipase (helps differentiate secondary peritonitis (cholecystitis, pancreatitis (entric) from peritoneal- dialysis (PD) peritonitis. Obtain blood cultures if pts have systemic symptoms.

Question 22

Name 6 organisms that give bloody stool and leukocytes (Invasive Diarrhea)

Answer 22

1. Camplybactor 2. Salmonella 3. Shigella 4. E. Coli 5. Yersinia 6. Vibrio Parahemolyticus.

Question 23

Old person with Afib has acute abdomen. NO BOWEL SOUNDS. Bright red blood per rectum. Acidosis on ABG. Xrays show distended small loops of bowel and distended colon up to the middle of the transverse. Dx? Management?

Answer 23

Mesenteric Ischemia. Emergent Embolectomy and resect infarcted bowel.

Question 24

Pt has a upper endoscopy to r/o gastric cancer. 4 hrs later he develops SOB, tachypnea, dyspnea and CXR shows a new left pleural effusion. Dx?

Answer 24

Esophgeal Rupture from endoscope (iatrogenic.) Do Gastragraffin (water soluble contrast esophagram)

Question 25

Old person with Afib has acute abdomen. NO BOWEL SOUNDS. BRBPR!!!. Acidosis!!! on ABG. Xrays show distended small loops of bowel and distended colon up to the middle of the transverse. Dx? Management?

Answer 25

Mesenteric Ischemia. Emergent Embolectomy and resect infarcted bowel.

Question 26

Pt presents with colicky abdominal pain, protracted vomiting, abdominal distention, no bowel movement in last 5 days, high pitched bowel sounds. AXR shows small loops of dilated bowel. On physical exam groin mass is noted, he explains he was once able to push it back. Dx? Rx?

Answer 26

Mechanical intestinal obstruction 2/2 inguinal hernia. Surgery.

Question 27

Management of pts that fail triple therapy (PPI/Clarithromycin/Amoxicillin) for treatment of H pylori.

Answer 27

1. Urea breath test to check for eradication 2. Repeat endoscopy to check for resolved ulcer. 3. Try different combination of abx, check for sensitivity. 4 R/o Zollinger-Ellison Syndrome if fail 2nd drug regime.

Question 28

Once pt is Stabilized give the Steps of Diagnosis with GI bleeding?

Answer 28

2. Steps to diagnosis: 1. Upper, Lower Endoscopy or Colonoscopy 2. When these are equivocal do Nuclear RBC scan (Tech-99) 3. When that is equivocal do Capsule Endoscopy (Swallow camera and it takes pictures of small bowel btw ligament of treitz and colon- where other imaging studies cant reach)

Question 29

1. Management of Cirrhosis and bleeding? 2. Management of Renal failure (UREMIA) and bleeding.

Answer 29

1.IVF, Octerotide and Emergent Endoscopy with banding or ligation of the varices. Can place blackmore tube to control surgery before TIPS procedure if ligation/banding fails. Chronic treatment with propanolol. 2. DDVAP (Increase factor 8 and vWF from the vascular endothelial cells.)

Question 30

Juandice, hepatomegaly, leukocytosis AST/ALT > 2 with AST< 500 and ALT < 150. Dx? What would it be if the AST > 1000? Rx? What is the discriminant function?

Answer 30

Acute Alcoholic Liver Hepatitis (fatty vacuolization of liver.) AST > 1000 is acetaminophen toxicity. Glucose, Thiamine and IVF. Discriminant function tells us the risk of mortality (>32 is bad risk.)

Question 31

Name 3 main causes of esophgeal perforation. Management?

Answer 31

1. Boorehaven Syndrome 2. Endoscopy!!!!!!!!!!!!! 3. Neoplasm/Severe Esophagitis. CT Scan to r/o Aortic Dissection (tearing CP radiating to back) Water soluble Contrast/Gastrograffin.

Question 32

Management when you suspect C. Diff?

Answer 32

1. C. diff stool toxin screen, Do C. Diff PCR if equivocal. 2. Give Metronidazole. Recurrence? One more course of Metro, then switch to oral Vanc if it recurs again. Treatment failure? Oral Vanc or Fidoximicin.

Question 33

Next step in management when a patient with hx of IBD presents with fever, anemia, hypotension and WBCs > 10,000? Dx? What is the most common complication of this disease? What is the reccomended prevention?

Answer 33

AXR to check for toxic megacolon 2/2 UC. Colon Cancer is common so pts should get yearly colonoscopsies! YEARLY!

Question 34

Name the extra hepatic manifestations of HEP C in each organ 1. Hematologic 2. Dermatological 3. Ocular 4. Renal 5. Vascular

Answer 34

1. Mixed cryoglobulinemia, thrombocytopenia, aplastic anemia 2. Porphyria cutaneous tarda 3. Corneal Ulcer 4. Glomerulonephritis 5. Necrotizing vasculitis.

Question 35

What is the management of an old person that presents with crushing chest pain or dull epigastric pain though you suspect diffuse esophageal spams?

Answer 35

1. EKG, CIPs, Stress test to r/o MI, MUST R/o MI!!! 2. Barium Studies.

Question 36

Pt presents with heart burn 30-90 minutes after a meal. Complains of sour waterbash taste in mouth. Alcohol, smoking, coffee, orange juice make it worse. Test? Rx?

Answer 36

Its a Obvious clinical diagnosis. Test with response to PPIs. 24Hr Ph monitoring ONLY if symptoms are unclear. OR EGD if Alarm Symptoms are present.
Rx: 1. All patients get Food restriction and Elevate the head at night. PPIs for moderate and constant symptoms. H2 for mild and intermittent symptoms. Nissen Fundolipocation if they fail PPIs.

Question 38

Acute work up when you suspect active bleeding?

Answer 38

1. Take vitals (BP, HR) 2. CBC (do this twice to confrim accurate drops in Hgb and Hematocrit) PT/INR,3. Orthostatics (greater then 20mmgh drop when pt stand and > 10 bpm increase in HR + 20% blood loss)

Question 38

Management of pts that fail triple therapy (PPI/Clarithromycin/Amoxicillin) for treatment of H pylori.

Answer 38

1. Urea breath test or stool antigen to check for eradication 2. Repeat endoscopy to check for resolved ulcer. 3. Try different combination of abx, check for sensitivity. 4 R/o Zollinger-Ellison Syndrome if fail 2nd drug regime.