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Question 1

Ulcerative colitis differs from Crohn’s disease in that it:

A.Can involve any portion of the gastrointestinal tract
B.Is characterized by transmural inflammation
C.Affects only the colon and rectum
D.Presents with diarrhea and abdominal pain

Answer 1

Answer: C. Affects only the colon and rectum

Ulcerative colitis and Crohn’s disease are subtypes of inflammatory bowel disease. Ulcerative colitis is an inflammatory condition characterized by diffuse mucosal inflammation of the colon. Crohn’s disease is characterized by transmural inflammation and may involve any portion of the gastrointestinal tract (oral cavity to perianal area). Both Crohn’s disease and ulcerative colitis can cause crampy abdominal pain and diarrhea.

Question 2

Which of the following is the serologic hallmark of hepatitis B virus infection?

A.Anti-HBs
B. HBcAg
C.Anti-HBc
D. HBsAg

Answer 2

Answer: D. HBsAg

Hepatitis B surface antigen (HBsAg) is the serologic hallmark of hepatitis B virus infection; it can be detected in high levels during acute or chronic infection. Hepatitis B core antibody (anti-HBc) appears at onset and can be detected through the course of hepatitis B virus infection. Hepatitis B core antigen (HBcAg) is an intracellular antigen expressed in infected hepatocytes and is usually not detectable. Hepatitis V surface antibody (Anti-HBs) persists for life in most patients, conferring lifelong immunity from reinfection. Immunity after vaccination is indicated by the presence of anti-HBs.

Question 3

Risk factors for C. Diff

Answer 3

Antibiotic use especially clindamycin, cephalosporin, fluoroquinolone

Use of PPI (increases risk of C. Diff)

Antiseptics are not effective against C.diff. Needs soap and water

Question 4

First line for c.diff

Answer 4

Vancomycin PO 125 mg orally QID x 10-14 days

Metronidazole PO 500mg TID x 10-14 days

Question 5

First line treatment for GERD

Answer 5

Lifestyle changes
Avoid high fat meals
Weight reduction
Cease smoking

Question 6

Pharm first like for mild GERD

Answer 6

H2RA

If poor relief step up to PPI

Question 7

Diagnosis of H. Pylori

Answer 7

Urea breath test

Gold standard is upper endoscopy and biopsy

Question 8

H. Pylori alarm features ?

Answer 8

Bleeding
Anemia
Early satiety
Unexplained weight loss
Progressive dysphagia
Recurrent vomiting
Family history’s of GI cancer
Previous esophogastric malignancy

Question 9

First line pharm for H. Pylori

Answer 9

PPI Pantoloc 40mg BID x 14 days
+
Amoxicillin 1g BID x 14 days
+
Metronidazole 500mg BID x 14 days
+
Clarithromycin 500mg BID x 14 days

Or

PPI panto 40mg BID x 14 days
+
Bismuth salicylates 525 mg QID x 14 days
+
Metronidazole 500mg QID x 14 days
+
Tetracycline 500mg QID x 14 days

Question 10

A patient presents with dyspepsia and upper abdominal discomfort that radiates to the epigastric area. The patient reports that the pain improves after meals but worsens 2 to 5 hours after a meal. The patient also reports bloating and weight gain. This presentation suggests the presence of which of the following?

A.Gastric ulcer
B.Gastroesophageal reflux disease
C.Duodenal ulcer
D.Pancreatitis

Answer 10

Answer: C. Duodenal ulcer

The patient is presenting with symptoms consistent with peptic ulcer disease and, more specifically, a duodenal ulcer. Upper abdominal pain or discomfort is the most common symptom seen with peptic ulcers; about 80% report epigastric pain. The pain of duodenal ulcers is often improved with eating but worsens 2 to 5 hours after a meal, when acid is secreted in the absence of a food buffer, and at night (11 p.m. to 2 a.m.) when the circadian pattern of acid secretion is highest. The pain associated with gastric ulcers generally worsens while eating. Epigastric pain can also be caused by pancreatic etiologies; however, the patient’s other symptoms are more specific for peptic ulcer disease. The patient does not report feelings of heartburn or regurgitation, so gastroesophageal reflux disease is less likely.

Question 11

Which of the following best describes Cullen’s sign?

A.Cessation of inspiration upon deep palpation of the right upper quadrant of the abdomen
B.Bruising around the periumbilical area of the abdomen
C.Deep palpation of the left lower quadrant of the abdomen that causes pain to radiate to the right lower quadrant
D.Blue–black discoloration that is located on the right flank of the trunk

Answer 11

Answer: B. Bruising around the periumbilical area of the abdomen

Cullen’s sign is bruising around the periumbilical area of the abdomen that is associated with pancreatitis. The color can range from blue–black to purple, and then the color changes as the bruise resolves. It is caused by retroperitoneal bleeding, when the blood migrates to the subcutaneous tissue in the periumbilical area (Cullen’s sign) or flank (Grey-Turner sign). It may also be present in other conditions such as splenic rupture, ruptured aortic aneurysm, rectus sheath hematoma, perforated duodenal ulcer, ruptured ectopic pregnancy, and hepatocellular cancer. It occurs in only 3% of patients with acute pancreatitis but suggests the presence of retroperitoneal bleeding in the setting of pancreatic necrosis.

Question 12

A patient undergoes an upper endoscopy for peptic ulcer disease; the gastric mucosal biopsy is positive for Helicobacter pylori. The patient has recently been treated with azithromycin for a sinus infection. Which of the following antibiotic regimens is appropriate for this patient?

A.Bismuth, metronidazole, tetracycline, and a proton pump inhibitor (PPI)
B.Clarithromycin, amoxicillin, and a PPI
C.Clarithromycin, metronidazole, and a PPI
D.Clarithromycin, metronidazole, amoxicillin, and a PPI

Answer 12

Answer: A. Bismuth, metronidazole, tetracycline, and a proton pump inhibitor (PPI)

Treatment regimens for H. pylori are based on the presence of risk factors for macrolide resistance and the presence of a penicillin allergy. Bismuth quadruple therapy is recommended for patients with any prior exposure to macrolides for any reason and in areas of local clarithromycin resistance rates >15% or eradication rates with clarithromycin triple therapy <85%. Clarithromycin-based triple therapy is used in patients without risk factors. Metronidazole can be used instead of amoxicillin in patients who are allergic to penicillin.

Question 13

Which of the following best describes McBurney’s point?

A.Mild tenderness at 2.5 to 4 inches from the anterior superior iliac spine
B.Maximal tenderness at 2.5 to 4 inches from the anterior superior iliac spine
C.Maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine
D.Area free from tenderness at 1.5 to 2 inches from the anterior superior iliac spine

Answer 13

Answer: C. Maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine

McBurney’s point is characterized as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine on a straight line to the umbilicus (in the right lower quadrant). Tenderness or pain suggests acute appendicitis.

Question 14

Which of the following best describes McBurney’s point?

A.Mild tenderness at 2.5 to 4 inches from the anterior superior iliac spine
B.Maximal tenderness at 2.5 to 4 inches from the anterior superior iliac spine
C.Maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine
D.Area free from tenderness at 1.5 to 2 inches from the anterior superior iliac spine

Answer 14

Answer: C. Maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine

McBurney’s point is characterized as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine on a straight line to the umbilicus (in the right lower quadrant). Tenderness or pain suggests acute appendicitis.

Question 15

A 30-year-old patient presents with mild-to-moderate lower left quadrant (LLQ) abdominal pain, constipation, and mild abdominal tenderness. Routine laboratory work is significant for elevated C-reactive protein and leukocytosis. Abdominal CT scan is pending to confirm diagnosis. The patient’s vital signs are stable, and they are able to tolerate oral intake. Based on this presentation, first-line treatment for most patients includes:

A.Intravenous antibiotics
B.Nothing by mouth for complete bowel rest
C.Oral antibiotics
D.Pain control with oral analgesics and a liquid diet

Answer 15

Answer: D. Pain control with oral analgesics and a liquid diet

Acute diverticulitis should be suspected in patients with LLQ abdominal pain, abdominal tenderness, and leukocytosis. The diagnosis is confirmed based on an abdominal CT scan with contrast. Most uncomplicated cases can be treated outpatient; inpatient treatment is indicated for those with complications (e.g., sepsis, perforation, older age, significant comorbidities). Initial outpatient treatment consists of pain control with oral analgesics and a liquid diet. Patients should be reassessed until resolution of symptoms. Oral antibiotics are often not indicated initially. Inpatient treatment often requires intravenous antibiotics and further management of complications.

Question 16

A 45-year-old female patient complains of intermittent, burning epigastric pain over the past few months. It is worse at night, especially after a heavy or spicy meal. She goes to sleep about 2 hours after eating. The pain is not, or is only partially, relieved by antacids. The patient is not a smoker and denies radiation of pain to neck, arms, or jaw; diaphoresis; and dyspnea. What is the best next step?

A.Order a 12-lead EKG
B.Prescribe a proton pump inhibitor
C.Instruct patient to stop eating at least 4 hours before bedtime and avoid spicy or heavy meals at night
D.Schedule a fasting lipid profile, including cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides

Answer 16

Answer: C. Instruct patient to stop eating at least 4 hours before bedtime and avoid spicy or heavy meals at night

Lifestyle changes are the first-line treatment for gastroesophageal reflux disease. Patients should stop eating (especially heavy or spicy meals) at least 4 hours before bedtime and avoid caffeine and mint. The patient does not need laboratory testing or a 12-lead EKG due to the negative symptoms of radiating pain, diaphoresis, and dyspnea. Prescribing a proton-pump inhibitor may be indicated, but nonpharmacologic modifications should be trialed first before initiating pharmacologic therapy.

Question 17

A patient with irritable bowel syndrome (IBS) reports increased flatulence and discomfort despite dietary modifications. When asked about their 24-hour diet recall, the patient reports eating eggs and sausage with herbal tea for breakfast, a turkey sandwich with coleslaw for lunch, and baked chicken with carrots and rice for dinner, with ice cream for dessert. The patient needs further education about the exclusion of which foods?

A.Coleslaw, ice cream
B.Eggs, chicken
C.Turkey, rice
D.Carrots, herbal tea

Answer 17

Answer: A. Coleslaw, ice cream

Patients with IBS should avoid foods that increase flatulence. These include wheat germ, pretzels, bagels, certain dairy products (e.g., milk, ice cream, cheese), some vegetables (e.g., cabbage, Brussels sprouts, cauliflower, broccoli, onions), certain fruits (e.g., prunes, apples, pears, raisins, cherries), legumes (e.g., beans, peas, baked beans, soybeans), fatty and fried foods, high-fructose corn syrup, carbonated beverages, alcohol, caffeine, and artificial sweeteners. This patient should be advised to avoid some of their recent food choices, including the ice cream and the coleslaw (which contains cabbage). Although regular tea, which contains caffeine, could be a concern, most herbal teas are free of caffeine.

Question 18

Which of the following suggests gallbladder inflammation?

A.Rovsing’s maneuver
B.Rebound tenderness
C.Murphy’s maneuver
D.McMurray’s maneuver

Answer 18

Answer: C. Murphy’s maneuver

Gallbladder inflammation is also known as cholecystitis. If Murphy’s maneuver is performed with the patient supine, the palpating hand is placed just below the right costal margin midclavicular area. The patient is instructed to exhale. Then the patient is instructed to inhale and the clinician presses down, palpating the hand over the liver. The result is positive if the patient stops midinhalation due to the pain.

Question 19

Which of the following physical exam findings suggests the presence of choledocholithiasis in a patient with acute pancreatitis?

A.Guarding and abdominal rigidity
B.Positive Cullen’s sign
C.Positive Grey Turner’s sign
D.Scleral icterus and jaundice

Answer 19

Answer: D. Scleral icterus and jaundice

Patients with acute pancreatitis may present with scleral icterus due to obstructive jaundice secondary to choledocholithiasis or edema of the head of the pancreas. Patients with concern for a perforation may present with sudden-onset abdominal pain with guarding, rigidity, and rebound tenderness concerning for peritonitis. Cullen’s sign (ecchymotic discoloration in the periumbilical region) and Grey Turner’s sign (ecchymosis along the flank) may be noted in some patients with acute pancreatitis, suggesting the presence of retroperitoneal bleeding in the setting of pancreatic necrosis.

Cholelithiasis involves the presence of gallstones (see the image below), which are concretions that form in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct (CBD).

Question 20

The best test of cure after treating a patient with Helicobacter pylori infection is:

A.Complete blood count with white blood cell differential
B.Stool guaiac test
C.H. pylori IgM and IgG serology
D.Urea breath test

Answer 20

Answer: D. Urea breath test

The urea breath test is a specific (>95%) and sensitive (>88%) test for detecting active H. pylori infection in patients with peptic ulcer disease. H. pylori serology is not as sensitive or specific as the urea breath test; it can remain positive even if there is no infection. Stool antigen assay can be used to establish the initial diagnosis of H. pylori and confirm eradication, but a stool guaiac test determines the presence of blood in the stool. A complete blood count may indicate leukocytosis in a patient with H. pylori infection but is not a specific test for identification of a specific infection.