GI

Question 1

Which one of the following has been shown to be LEAST effective in the treatment of irritable bowel syndrome? (check one)
-Fiber
- Probiotics
-Antispasmodics
-Antidepressants

Answer 1

Fiber

Fiber is ineffective in the treatment of adult irritable bowel syndrome (IBS) (SOR A). Symptoms do improve, however, with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.

Question 2

A 44-year-old female presents with a 2-week history of postprandial right upper abdominal pain. Since yesterday her pain has worsened in intensity and she has been vomiting. The patient does not use tobacco or drink alcohol, and takes no medications. Laboratory findings include a serum lipase level of 105 IU/L (N 14–51), a serum amylase level of 155 U/L (N 36–128), a serum total bilirubin level of 1.5 mg/dL (N 0.0–1.0) and an alkaline phosphatase level of 200 IU/L (N 33–96).

The recommended initial imaging in this situation is (check one)
- no routine imaging unless the clinical course becomes complicated
- transabdominal ultrasonography
- contrast-enhanced CT
- magnetic resonance cholangiopancreatography (MRCP)
- MRI

Answer 2

transabdominal ultrasonography

The American College of Gastroenterology recommends transabdominal ultrasonography for all patients with acute pancreatitis (strong recommendation, low quality evidence). Contrast-enhanced CT and MRI should be reserved for patients who have an unclear diagnosis, are not clinically improving after 48–72 hours, or develop complications.

Question 3

A 35-year-old otherwise healthy male who is not on any medications presents to your office complaining of 3–4 episodes of watery diarrhea beginning 2 days earlier. The diarrhea is accompanied by some nausea and abdominal cramping. He denies fever, dehydration, and bloody stool.

Which one of the following is indicated at this time? (check one)
Testing for fecal leukocytes
A stool culture
A stool examination for ova and parasites
A stool test for Clostridium difficile toxin
No testing

Answer 3

No testing

Most watery diarrhea is self-limited and testing is not indicated. A diagnostic workup is usually reserved for patients with severe dehydration or illness, diarrhea persisting for more than 3–7 days, fever, bloody stool, immunosuppression, or a history suggesting nosocomial infection or an outbreak. Indiscriminate use of laboratory testing is inefficient and not cost-effective.

Question 4

A 22-year-old male college student presents with 1–2 weeks of worsening tenesmus associated with frequent stools that are mixed with blood and mucus. He is afebrile and has no other signs of systemic illness. Initial blood and stool testing is normal.

Which one of the following would be most appropriate at this point to evaluate this patient for the presence of inflammatory bowel disease? (check one)
Serum markers
Ultrasonography
CT of the abdomen and pelvis
Colonoscopy with biopsies
A barium enema

Answer 4

Colonoscopy with biopsies

Inflammatory bowel disease is an autoimmune disorder that affects the gastrointestinal tract, usually beginning in early adulthood. Ulcerative colitis and Crohn’s disease are the most common of these conditions. Ulcerative colitis involves just the mucosa of the colon, starting at the anus and extending proximally to a variable distance. Crohn’s disease, on the other hand, may involve all layers of gastrointestinal tissue and can occur anywhere between the mouth and the anus. The diagnosis of either of these conditions is made by endoscopy with biopsies in order to best assess the extent and depth of inflammation.

Question 5

A 62-year-old male presents with a 3-day history of left lower quadrant pain and a low-grade fever. Findings on CT are consistent with acute diverticulitis. The patient has a history of intolerance to metronidazole (Flagyl).

If antibiotics are given, the preferred agent for this patient would be

(check one)
amoxicillin/clavulanate (Augmentin)
azithromycin (Zithromax)
cephalexin (Keflex)
ciprofloxacin (Cipro)
doxycycline

Answer 5

amoxicillin/clavulanate (Augmentin)

The traditional approach to outpatient management of acute diverticulitis consists of clinical diagnosis (with or without imaging), antibiotics, and bowel rest. Two cohort studies found no difference in the effectiveness of outpatient treatment of diverticulitis with amoxicillin/clavulanate or with metronidazole plus a fluoroquinolone. Azithromycin is more appropriate for Campylobacter or Escherichia coli infections that cause lower gastrointestinal bleeding. Cephalexin is not an appropriate treatment, and ciprofloxacin monotherapy will not provide adequate coverage. Doxycycline is a treatment for watery diarrhea caused by Vibrio cholerae and Yersinia infections.

Question 6

A 72-year-old white female presents to your office with a 6-week history of “tanned skin.” She initially attributed it to having gone on a cruise 2 months ago, but noticed her skin continued to darken as time passed. She is slender and has lost 5 kg (11 lb) since her last checkup 6 months ago. She denies fever, malaise, or abdominal pain. Her only medications are hydrochlorothiazide and a baby aspirin daily.

On examination your suspicion of jaundice is confirmed by the presence of scleral icterus. You also note a single enlarged left supraclavicular lymph node which is nontender. The abdomen is soft and nontender; on deep palpation of the right upper quadrant you feel a smooth, nontender mass.

Which one of the following is the most likely diagnosis? (check one)
Biliary cirrhosis
Ascending cholangitis
Obstructing pancreatic pseudocyst
Carcinoma of the head of the pancreas
Hepatocellular carcinoma

Answer 6

Carcinoma of the head of the pancreas

The presence of a solitary enlarged left supraclavicular lymph node (Virchow’s node) is associated with a gastrointestinal system malignancy. When combined with painless jaundice and a palpable nontender gallbladder (Courvoisier’s sign), pancreatic cancer is the most likely diagnosis.

A pancreatic pseudocyst develops after repeated bouts of pancreatitis and is not directly associated with jaundice. Biliary cirrhosis and hepatocellular carcinoma typically present with pain, fatigue, malaise, hepatomegaly, jaundice, and eventually ascites. The jaundice of biliary cirrhosis is generally accompanied by severe pruritus. In neither condition is a palpably enlarged gallbladder present. Ascending cholangitis presents with a high fever, right upper quadrant pain, and an overall toxic, septic picture, often accompanied by delirium and rigors.

Question 7

An 85-year-old male smoker presents with a 6-day history of subacute abdominal pain. He reports nausea without vomiting, and no change in stool. His past medical history includes coronary artery disease, peripheral vascular disease, and a cholecystectomy. The physical examination reveals moderate periumbilical tenderness without guarding or rebound.

Laboratory Findings
WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20,000/mm3 (N 4500–10,800) Segmented neutrophils.. . . . . . . . . . . . . . . . 82% Bands. ……………………….. 7%
Chemistry panel.. . . . . . . . . . . . . . . . . . . . . . . normal
Urinalysis.. . . . . . . . . . . . . . . . . . . . . . . . . . . . normal
Amylase………………………… 180 U/L (N <140)
Lipase.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . normal
Lactic acid………………………. 3.8 mmol/L (N 0.5–2.2)

Abdominal CT reveals air within the wall of dilated loops of small bowel.

Which one of the following is the most likely diagnosis? (check one)
Acute cholangitis secondary to a common duct stone
Acute diverticulitis
Acute mesenteric ischemia
Acute pancreatitis
Acute appendicitis

Answer 7

Acute mesenteric ischemia

Mesenteric ischemia presents with pain disproportionate to the findings on examination, often with nausea, vomiting, or diarrhea. Air within the wall of dilated loops of small bowel (pneumatosis intestinalis) and evidence of acidosis also suggest bowel ischemia. Cholangitis most likely would be associated with a more substantial elevation of the amylase and/or lipase levels, as well as elevated bilirubin and/or alkaline phosphatase levels. Pancreatitis would also be associated with higher amylase and/or lipase levels.

Acute appendicitis often has a vague presentation in older patients, presenting without fever and not localizing to the right lower quadrant as it does in younger patients. However, the leukocytosis is usually not as dramatic as in this case, there is usually no elevation of the amylase or lipase levels, and imaging does not show air within the small bowel.

Question 8

. A 62-year-old male has a 1-month history of intermittent vomiting, early satiety, and a weight loss of 4 kg (9 lb). Initially he had diarrhea but it has resolved. He does not have abdominal pain or bloody stools. He says that over-the-counter famotidine (Pepcid) has relieved the symptoms somewhat.

Which one of the following would be most appropriate at this point? (check one)
Abdominal radiographs
Abdominal ultrasonography
Esophagogastroduodenoscopy
Famotidine at a higher dosage
A proton pump inhibitor

Answer 8

Esophagogastroduodenoscopy

This patient has red flag findings of older age and weight loss with chronic vomiting and is at risk for a gastrointestinal malignancy. He should be referred for esophagogastroduodenoscopy (EGD). Abdominal ultrasonography or radiographs would not be necessary at this time. A proton pump inhibitor or H2-blocker can be prescribed but should not delay referral for EGD.

Question 9

A 45-year-old female has been admitted to the hospital for an episode of acute diverticulitis. Which one of the following features would most strongly suggest a need for surgical intervention? (check one)
A previous admission for diverticulitis in the last 12 months
Pain uncontrolled by oral analgesics
A microperforation seen on CT at the site of the diverticulitis
A 4-cm simple abscess at the site of the diverticulitis
The presence of generalized peritonitis

Answer 9

The presence of generalized peritonitis

Acute diverticulitis can be treated using oral antibiotics on an outpatient basis in 90% of cases. In fact, there is good evidence that those with uncomplicated diverticulitis (no signs of abscess, fistula, phlegmon, obstruction, bleeding, or perforation) can be treated without the use of antibiotics, using only bowel rest and close follow-up. Among patients who require hospitalization, it is estimated that <10% of cases will require surgical intervention. Thus, the majority of patients hospitalized with this condition, even those with complicated diverticulitis, will respond well to bowel rest and intravenous antibiotics.

Indications for surgery include generalized peritonitis, unconfined perforation, uncontrolled sepsis, an undrainable abscess, and failure of conservative management. CT-guided percutaneous drainage of an accessible abscess is a well-proven treatment to avoid the use of open surgery. Prevention of future episodes of diverticulitis increasingly revolves around the use of daily oral medications. Some experts recommend considering surgery to remove a section of bowel after a patient’s third admission for diverticulitis.

Question 10

An 80-year-old male presents with a 10-day history of intermittent colicky abdominal pain. The pain is low and central and seems to be worse after eating. He has no associated fever or vomiting but does feel nauseated when the pain is present. He says that prior to this episode he had hard stools once or twice a week that were difficult to pass. For the past several days he has had only watery stools, several times a day.

On examination there is fullness in his left lower quadrant with nonspecific tenderness diffusely and no guarding or rebound. A urine dipstick is normal.

Which one of the following is the most likely diagnosis? (check one)
Viral gastroenteritis
Acute colitis
Constipation
Urinary tract infection
Nephrolithiasis

Answer 10

Constipation

The Rome criteria define constipation as the presence of two or more of the following: straining on defecation, hard stools, incomplete evacuation, or less than three bowel movements per week. This patient has multiple symptoms on this list. The presence of watery bowel movements does not rule out the diagnosis of constipation, as it is common for liquid stool to pass an obstructive source.

Question 11

A 66-year-old male sees you for follow-up after a recent hospitalization for his second episode
of diverticulitis in the past 3 years. He is currently in excellent health and takes no daily
medications except for occasional acetaminophen for arthritis pain. His physical examination is
unremarkable except for a BMI of 19.0 kg/m2. He asks you about preventing further recurrences
of his diverticulitis.

You suggest that he do which one of the following?
(check one)
Lose weight
Increase his dietary fiber intake
Stop acetaminophen use
Avoid eating nuts, corn, or popcorn
Avoid high-impact aerobic exercise

Answer 11

Increase his dietary fiber intake

Increased intake of dietary fiber and increased exercise have been shown to prevent recurrences of
diverticulitis (SOR B). Weight loss has been shown to be effective in persons with a body mass index of
30 kg/m2 or higher but this patient is underweight and should not be counseled to lose weight (SOR B).
There is no evidence that avoiding nuts, corn, or popcorn decreases the risk of diverticulitis (SOR B). Risk
factors for diverticulitis include the use of NSAIDs, but not acetaminophen.

Question 12

A 37-year-old male sees you for a routine health maintenance examination. He is morbidly obese with a BMI of 42 kg/m2. In addition to his obesity diagnosis, his past medical history is significant for diabetes mellitus, hypertension, hyperlipidemia, GERD, and bilateral knee osteoarthritis, which are all adequately controlled with oral medications. His father died of a myocardial infarction (MI), and the patient is worried about his risk of dying of an MI like his father, since they share a similar body habitus and comorbidities. He is concerned about his weight and has researched metabolic surgical interventions on the internet. He is overwhelmed with the options and is seeking your guidance.

Given his medical conditions, which one of the following surgical options is the recommended intervention? (check one)
Adjustable gastric band
Sleeve gastrectomy
Roux-en-Y gastric bypass
Biliopancreatic diversion with a duodenal switch

Answer 12

Roux-en-Y gastric bypass

In obese patients with a medical history of GERD, a Roux-en-Y gastric bypass is preferred over sleeve gastrectomy (SOR A). Adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion all function by limiting the physical size of the stomach. This has a potential for exacerbating GERD symptoms, despite anticipated significant weight loss. This patient meets criteria for metabolic surgery due to a diagnosis of morbid obesity, in addition to comorbidities such as diabetes mellitus and hypertension.

Question 13

A 2½-year-old male is brought to the emergency department with the acute onset of diffuse abdominal pain that began approximately 6 hours ago. He has also had 3 episodes of bilious emesis in the last 2 hours. A review of systems is positive for anorexia today but negative for fever, weight loss, diarrhea, and bloody stools.

On examination the patient’s height and weight are in the 50th percentile for age, his blood pressure is normal, his heart rate is 110 beats/min, and his temperature is 36.9°C (98.4°F). Cardiovascular and pulmonary examinations are unremarkable. The abdominal examination is significant for slightly hypoactive bowel sounds and diffuse tenderness to palpation without rebound, guarding, or rigidity. A genitourinary examination is normal.

Which one of the following studies is the most appropriate next step to diagnose the cause of abdominal pain in this patient? (check one)
Scrotal ultrasonography
Abdominal ultrasonography
Abdominal and pelvic CT
An upper gastrointestinal series

Answer 13

An upper gastrointestinal series

In young children with bilious emesis, anorexia, and lack of fever, the most likely diagnosis is intestinal malrotation with volvulus. Abdominal ultrasonography is less sensitive and specific for malrotation than an upper gastrointestinal series, so an upper GI series should be ordered initially if volvulus is suspected. If appendicitis were suspected, ultrasonography would be preferred. CT is not a good choice because of the amount of radiation it delivers, especially given efforts to decrease the use of CT in children unless absolutely necessary. This patient’s presentation is not typical for testicular torsion, therefore scrotal ultrasonography should not be the initial test of choice.

Question 14

A 66-year-old female sees you for the first time. She has a history of iron deficiency anemia and
chronic diarrhea associated with a diagnosis of celiac disease.

This history increases her risk for which one of the following? (check one)
Diverticulitis
Ulcerative colitis
Crohn’s disease
Colon cancer
Osteoporosis

Answer 14

Osteoporosis

Patients who are diagnosed with celiac disease are at increased risk of osteoporosis due to bone loss from
decreased calcium and vitamin D absorption. These patients are at higher risk for fractures. Patients with
celiac disease are not at increased risk for inflammatory bowel disease, diverticulitis, or colon cancer.

Question 15

A 42-year-old female sees you for follow-up 6 weeks after starting treatment for Helicobacter pylori. She was diagnosed with the urea breath test. She completed her antibiotic regimen as prescribed and stopped her proton pump inhibitor (PPI) 2 weeks ago. She is symptom free.

Which one of the following is the recommended next step? (check one)
Repeating the H. pylori urea breath test
Ordering H. pylori serology
Resuming PPI therapy
Screening for colon cancer
Screening for a peptic ulcer

Answer 15

Repeating the H. pylori urea breath test

According to current American College of Gastroenterology guidelines, whenever Helicobacter pylori is identified and treated, testing to prove eradication should be performed at least 4 weeks after completing antibiotic therapy and 2 weeks after discontinuing the proton pump inhibitor (PPI). With increasing resistance and thus declining success in treatment, many patients will be persistently infected after treatment and remain at risk for complications, including gastric malignancy. There is no role for H. pylori serology in testing for treatment success. This patient does not need further PPI therapy since she is symptom free. She is not at the age threshold to begin colon cancer screening, and without further familial risk information there is no indication to begin screening earlier. There is no evidence that she needs to be screened for a peptic ulcer.

Question 16

A 20-year-old male presents with complaints of abdominal pain and diarrhea. He says he often has abdominal cramping that is relieved with defecation. The pain is accompanied by frequent loose, mucous stools, and his symptoms tend to get worse with stress. He says he has tried antidiarrheal medications and antispasmodics, but did not get satisfactory results.
Your evaluation leads to a diagnosis of diarrhea-predominant irritable bowel syndrome. Which one of the following would be the most appropriate treatment?
(check one)
Fiber supplements
Neomycin
Citalopram (Celexa)
Alosetron (Lotronex)
Lubiprostone (Amitiza)

Answer 16

Citalopram (Celexa)

A Cochrane review of 15 studies involving 922 patients showed that antidepressants had a beneficial effect on the symptoms of irritable bowel syndrome (IBS). Both SSRIs and tricyclic antidepressants have shown benefit. Another Cochrane review of 12 randomized, controlled trials did not show any benefit from the use of fiber in any type of IBS. Antibiotics have been shown to have some beneficial effects, but neomycin is used only in constipation-predominant IBS. Lubiprostone is a selective C-2 chloride channel activator and can be used for patients with chronic constipation. Alosetron is a 5-hydroxytryptamine 3 antagonist and is FDA approved to treat severe diarrhea-predominant IBS only in women who have not improved with conventional therapy. Alosetron is associated with uncommon but serious adverse events (ischemic colitis, constipation, death) and its use is restricted in the United States. Other potentially beneficial therapies for IBS include peppermint oil, psychological treatments, exercise, and probiotics.

Question 17

A 30-year-old male presents to your office with a 3-week history of nausea, weight loss, diarrhea, and hematochezia. He states that he has had similar episodes twice in the past and was treated at the local urgent care clinic for infectious diarrhea, with resolution of his symptoms. Your initial laboratory workup is negative for enteric pathogens and you refer the patient for colonoscopy and esophagogastroduodenoscopy with small bowel follow-through. The patient is found to have multiple noncontiguous transmural ulcerations throughout both the small and large intestines.

Which one of the following initial management strategies is most likely to induce remission in this patient?
(check one)
Laparotomy with colectomy
Metronidazole (Flagyl)
Prednisone
Infliximab (Remicade)

Answer 17

Prednisone

Inflammatory bowel disease is divided into two categories: Crohn’s disease and ulcerative colitis. Noncontiguous or “skip” lesions that are transmural in nature and are found throughout the gastrointestinal tract make a diagnosis of Crohn’s disease likely in this patient. Corticosteroids are more effective in inducing remission than placebo and 5-ASA products (SOR A). A Cochrane review revealed no difference between elemental and nonelemental diets with regard to symptom remission (SOR A). Anti-TNF agents such as infliximab should be considered in patients with moderate to severe Crohn’s disease who do not respond to initial corticosteroid or immunosuppressive therapy, but these are not recommended for initial treatment. While antibiotics such as metronidazole are widely used for both their anti-inflammatory and anti-infectious properties, controlled trials have not demonstrated their effectiveness. Surgical intervention should be considered in patients with ulcerative colitis, but surgery is not indicated for Crohn’s disease.

Question 18

A 19-year-old white male with a history of fever, fatigue, weight loss, and mild diarrhea of 2 months’ duration is found to have a palpable mass in the right lower quadrant of the abdomen. The most likely diagnosis is: (check one)
Crohn’s disease (regional enteritis)
Ulcerative colitis
Amebic colitis
Diverticulitis
Lymphoma

Answer 18

Crohn’s disease (regional enteritis)

When Crohn’s disease affects primarily the distal small intestine (regional enteritis), a most characteristic clinical pattern emerges. A young person, usually in the second or third decade, will present with a period of episodic abdominal pain, largely postprandial and often periumbilical, occasionally with low-grade fever and mild diarrhea. Anorexia, nausea, and vomiting may also be present. Weight loss is frequent. Some patients may be aware of tenderness in the right lower quadrant and even of a palpable mass in that region

Question 19

Which one of the following statements is true about celiac disease (gluten-sensitive enteropathy) in adults? (check one)
It is more common among African-Americans
Symptoms are limited to gastrointestinal complaints
Type 2 diabetics are at increased risk for the disease
Serum antibody tests are sensitive and specific
Colonoscopy with mucosal biopsy is required to make the diagnosis

Answer 19

Serum antibody tests are sensitive and specific

Celiac disease is thought to be greatly underdiagnosed in the United States. Antibody tests indicate that the prevalence is approximately 1:250 among adult Americans of European ancestry. Approximately 7% of type 1 diabetics have celiac disease. A number of other autoimmune syndromes have been associated with celiac disease, including thyroid disease and rheumatoid arthritis. There is no reported association with type 2 diabetes. Gastrointestinal involvement may manifest as diarrhea, constipation, or other symptoms of malabsorption, such as bloating, flatus, or belching. Fatigue, depression, fibromyalgia-like symptoms, aphthous stomatitis, bone pain, dyspepsia, gastroesophageal reflux, and other nonspecific symptoms may be present and can make the diagnosis quite challenging. Dermatitis herpetiformis is seen in 10% of patients with celiac disease. Serum antibody testing, especially IgA antiendomysial antibody, is highly sensitive and specific and readily available at a cost of about $100 to $200. Definitive diagnosis generally requires esophagogastroduodenoscopy with a biopsy of the distal duodenum to detect characteristic villous flattening.

Question 20

A 72-year-old Asian female is found to have asymptomatic gallstones on abdominal ultrasonography performed to evaluate an abdominal aortic aneurysm. Which one of the following would be the most appropriate management for the gallstones? (check one)
Laparoscopic cholecystectomy
Open cholecystectomy
Lithotripsy
Treatment with ursodeoxycholic acid (Actigall)
Observation

Answer 20

Observation

Gallstones are frequently discovered on a diagnostic workup for an unrelated problem. Only 1%–2% of persons with asymptomatic gallstones will require cholecystectomy in a given year, and two-thirds of patients with asymptomatic gallstones will remain symptom free over a 20-year period. The longer the patient remains asymptomatic, the more likely that no symptoms will develop in the future. This patient may have had gallstones for several years, and the best management would be to do nothing unless symptoms develop.

Question 21

Which one of the following complications occurs most frequently after Roux-en-Y gastric bypass surgery for obesity? (check one)
Early dumping syndrome
Late dumping syndrome
Pulmonary embolism
Iron and vitamin B12 deficiency

Answer 21

Iron and vitamin B12 deficiency

Iron and vitamin B12 deficiencies develop in more than 30% of patients after Roux-en-Y gastric bypass. The incidence of pulmonary embolus is 1%–2%. The incidence of dumping syndrome is very low.

Question 22

You are considering recommending surgical treatment for obesity in selected patients. All other attempts to control weight have failed in these patients, including diet education, medication, exercise, and behavior modification. Each of these individuals is a well-informed and motivated patient with acceptable operative risks and is able to participate in treatment and long-term follow-up. They strongly desire substantial weight loss because their obesity impairs the quality of their lives, and they have asked about surgical options. Which one of these patients would meet the criteria for surgical treatment of obesity? (check one)
A 44-year-old with a BMI of 34 and degenerative joint disease of the knees that significantly limits his ability to walk
A 45-year-old with a BMI of 36 and controlled diabetes mellitus
A 48-year-old with a BMI of 42 and no other health problems
A 52-year-old with a BMI of 29 and sleep apnea
A 55-year-old with a BMI of 29 and uncontrolled diabetes mellitus

Answer 22

A 48-year-old with a BMI of 42 and no other health problems

The 1991 National Institutes of Health Consensus Development Panel recommended that surgical treatment of severe obesity be considered for any patient with a BMI >40 or those with a BMI >35 who have serious coexisting medical problems. Examples of such coexisting medical problems include severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, and severe diabetes mellitus.

Question 23

A 42-year-old male presents with a 2-day history of right lower quadrant pain, fever, nausea, and anorexia. His medical history is remarkable for hypertension treated with lisinopril (Zestril), type 2 diabetes managed without medication, microalbuminuria, and stage 3 chronic kidney disease with an estimated glomerular filtration rate of 48 mL/min/1.73 m2. He has not had any previous surgeries. An examination is remarkable for tenderness in the right lower quadrant. You order a CBC, urinalysis, and metabolic panel.

To complete the initial workup, which one of the following would be the most appropriate imaging modality in this situation? (check one)
Ultrasonography
CT without contrast
CT with oral contrast
CT with intravenous contrast
MRI with intravenous contrast

Answer 23

CT with intravenous contrast

The preferred imaging for suspected appendicitis in an adult is CT with intravenous (IV) contrast (SOR C). While there is concern about the use of IV contrast in patients with chronic kidney disease, studies have shown that there is no significant increase in the risk for acute kidney injury with the use of IV contrast in patients with or without pre-existing renal dysfunction (SOR B). IV contrast is considered safe in patients with an estimated glomerular filtration rate (eGFR) ³30 mL/min/1.73 m2. Pretreating patients with an eGFR <30 mL/min/1.73 m2 with isotonic crystalloid volume expansion is recommended.

Oral contrast has not been shown to increase the sensitivity or specificity of CT in the evaluation of appendicitis. Ultrasonography is the preferred imaging modality for children with suspected appendicitis, but not adults. MRI is not recommended for the evaluation of appendicitis.

Question 24

A 48-year-old male presents to the emergency department for an initial episode of acute gallstone pancreatitis with a lipase level of 700 U/L (N 10–140). A right upper quadrant ultrasound shows gallstones within the gallbladder but is otherwise normal. He is treated with intravenous fluids and medications to control pain and nausea, and is admitted to a regular medical floor bed. The next morning he reports that his symptoms are improving with oral medications. A physical examination is notable for normal vital signs and mild epigastric tenderness. A comprehensive metabolic panel shows improving leukocytosis and stable parameters including a normal bilirubin level.

Which one of the following management options is most appropriate in this situation? (check one)
Rechecking a serum lipase level and starting oral feeding if the result is normal
Initiating enteral feeding through a nasojejunal tube
Initiating parenteral feeding through an intravenous line
Consulting a gastroenterologist for endoscopic retrograde cholangiopancreatography (ERCP)
Consulting a general surgeon for cholecystectomy during this admission

Answer 24

Consulting a general surgeon for cholecystectomy during this admission

When compared to delayed cholecystectomy, early cholecystectomy has been shown to decrease complications, hospital readmission rates, and length of hospital stay without increasing surgical complication rates. Therefore, patients with mild acute gallstone pancreatitis should be considered for cholecystectomy during the index admission (SOR B). Evidence also supports early enteral feeding as tolerated, as opposed to restricted oral intake (SOR A). In this case, the patient should be offered oral feeding without a repeat serum lipase level factoring into this decision. Both placement of an enteral feeding tube and initiation of parenteral nutrition would be inappropriate, given the evidence to support early oral feeding. The risks of parenteral feeding include longer hospitalization and increased rates of infection, multiorgan failure, and mortality when compared to enteral feeding (SOR A). Endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours is indicated when acute pancreatitis is complicated by cholangitis or persistent biliary tract obstruction, but otherwise it is not indicated.

Question 25

A 26-year-old female presents with a 1-year history of recurring abdominal pain associated with intermittent diarrhea, 5-7 days per month. Her pain improves with defecation. There has been no blood in her stool and no weight loss. Laboratory findings are normal, including a CBC, chemistry profile, TSH level, and antibodies for celiac disease. Which one of the following would be most appropriate at this point? (check one)
Colonoscopy
An upper GI series with small-bowel follow-through
Abdominal CT with contrast
A gluten-free diet
Loperamide (Imodium)

Answer 25

Loperamide (Imodium)

This patient has classic symptoms of irritable bowel syndrome (IBS) and meets the Rome criteria by having 3 days per month of abdominal pain for the past 3 months, a change in the frequency of stool, and improvement with defecation. According to current clinical guidelines IBS can be diagnosed by history, physical examination, and routine laboratory testing, as long as there are no warning signs. Warning signs include rectal bleeding, anemia, weight loss, fever, a family history of colon cancer, onset of symptoms after age 50, and a major change in symptoms. Colonoscopy, CT, and GI contrast studies are not indicated. A gluten-free diet would not be indicated since the antibody tests for celiac disease are negative. Antidiarrheal agents such as loperamide are generally safe and effective in the management of diarrheal symptoms in IBS.

Question 26

A 42-year-old previously healthy white female presents to your office with her third episode of abdominal pain. This episode began 2 hours ago, and the pain is improving. She describes colicky right upper quadrant and epigastric pain. On examination you note mild right upper quadrant tenderness, with otherwise unremarkable findings. Renal function tests are normal.

Which one of the following would be most appropriate at this point? (check one)
KUB films
Ultrasonography of the right upper quadrant
Abdominal CT with intravenous contrast
Abdominal CT with intravenous and oral contrast
MRI of the abdomen

Answer 26

Ultrasonography of the right upper quadrant

Ultrasonography of the right upper quadrant is recommended as the initial imaging study for right upper quadrant pain (SOR C). KUB films can detect kidney stones but may miss gallstones. CT also may miss gallstones, and is more invasive than ultrasonography. Abdominal CT with intravenous contrast is the preferred test for right lower quadrant pain, and abdominal CT with intravenous and oral contrast is preferred for left lower quadrant pain. MRI is preferred for detecting tumors, and is inappropriate as the initial imaging study for right upper quadrant pain.

Question 27

A 55-year-old male presents with intermittent epigastric pain, early satiety, and bloating. His symptoms have been present for years with minimal change. You suspect a diagnosis of functional dyspepsia.

Which one of the following additional findings would constitute an alarm symptom and warrant further workup? (check one)
Epigastric tenderness
Increased abdominal pain when the abdominal wall muscles are tensed
Lymphadenopathy
Nausea
Weight gain

Answer 27

Lymphadenopathy

In patients with epigastric pain, alarm symptoms include age 60, persistent vomiting, unintended weight loss, dysphagia or odynophagia, gastrointestinal bleeding, a palpable mass, lymphadenopathy, night waking, symptoms that have a sudden/recent onset or are progressive in character, a family history of gastrointestinal cancer, and a poor response to empiric therapy. Epigastric tenderness is common in patients with functional dyspepsia and is not concerning unless accompanied by other alarm findings. Abdominal pain that increases when the abdominal wall muscles are tensed is called the Carnett sign. It is indicative of abdominal wall pain (musculoskeletal) and is not an alarm symptom for patients with dyspepsia. Chronic nausea is common and, unless accompanied by chronic vomiting, it is not an alarm symptom. Weight loss, not weight gain, is an alarm symptom.

Question 28

Which one of the following nutritional management strategies is associated with better outcomes
in patients with mild acute pancreatitis whose pain and nausea have resolved?
(check one)
Waiting until lipase has normalized before beginning oral intake
Early initiation of a clear liquid diet
Early initiation of a low-fat diet
Early initiation of tube feeding
Early initiation of total parenteral nutrition 70

Answer 28

Early initiation of a low-fat diet

Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that
bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of
bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral
feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious
complications, decreased morbidity, and decreased mortality. Starting with a low-fat solid diet has been
shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.
Total parenteral nutrition should be avoided in patients with mild or severe acute pancreatitis. There have
been multiple randomized trials showing that total parenteral nutrition is associated with infectious and
other line-related complications.

Question 29

A 35-year-old white male presents with dyspepsia. He has had no symptoms that suggest gastroesophageal reflux or bleeding, but a test for Helicobacter pylori is positive. After 2 weeks of treatment with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin), he is asymptomatic.
Which one of the following is recommended to test for the eradication of H. pylori in this patient?
(check one)
Immunoglobulin G serology
A urea breath test
Upper endoscopy with a biopsy
An upper gastrointestinal series

Answer 29

A urea breath test

There is strong evidence that eradication of H. pylori improves healing and reduces the risk of recurrence or rebleeding in patients with duodenal or gastric ulcer. A test-and-treat approach is recommended for most patients with undifferentiated dyspepsia. This strategy reduces the need for antisecretory medications, as well as the number of endoscopies. The currently recommended test for eradication of H. pylori in this clinical setting is either the urea breath test or H. pylori stool antigen.

Serology remains positive for months after eradication and may give misleading information. Although upper endoscopy, with a biopsy for histology, urease activity, or culture, can be used to test for eradication, it is an invasive procedure with a higher cost and the potential for more morbidity compared to the urea breath test or the H. pylori stool antigen test. Rather than recommending endoscopy for all patients, most national guidelines suggest a test-and-treat strategy unless the patient is over 45 years old or has red flags for malignancy or a complicated ulcer. Although an upper gastrointestinal series might provide information about gross pathology, it will not provide information about the eradication of H. pylori following treatment.

Question 30

A 55-year-old male sees you because of heartburn and dysphagia. Esophagogastroduodenoscopy shows moderately severe esophagitis.

Which one of the following is the most appropriate long-term pharmacologic management for this condition? (check one)
Famotidine (Pepcid), 10 mg daily
Metoclopramide (Reglan), 10 mg before meals
Omeprazole, 40 mg daily
Sucralfate (Carafate), 1 g twice daily

Answer 30

Omeprazole, 40 mg daily

PPIs) to manage symptoms. There is a nearly 100% recurrence of symptoms at 6 months if a PPI is stopped. Lifelong omeprazole use would be the best choice for this patient. PPIs are recommended over H2-blockers such as famotidine for maintenance and healing of erosive esophagitis. Prokinetic agents such as metoclopramide are not recommended for GERD unless gastroparesis is also present. Sucralfate is not recommended for GERD except in the case of pregnancy.

Question 31

A 60-year-old male presents with left lower quadrant abdominal pain. His medical and surgical histories are remarkable only for a history of hypertension controlled with hydrochlorothiazide and lisinopril (Zestril), and a screening colonoscopy 5 years ago that showed diverticulosis without polyps. He is afebrile, and a physical examination is notable only for mild abdominal tenderness in the left lower quadrant without peritoneal signs. A urinalysis is normal. You diagnose mild diverticulitis.

Which one of the following would be indicated at this time? (check one)
Rest and clear liquids
Avoidance of seeds, nuts, and popcorn
Abdominal CT
Referral for colonoscopy
Hospital admission for intravenous fluids and intravenous antibiotics

Answer 31

Rest and clear liquids

In patients with mild diverticulitis, outpatient management with rest and oral clear liquids is preferred. Avoidance of seeds, nuts, and popcorn does not reduce recurrence rates. CT of the abdomen may be indicated if the diagnosis is uncertain or if complications are suspected. Colonoscopy is contraindicated acutely and is only necessary for follow-up when age-appropriate cancer screening is indicated, or in cases of complicated disease. Antibiotics may not be necessary in all cases, and hospital admission is unnecessary for mild cases.

Question 32

Which one of the following tests has the highest negative predictive value to rule out celiac disease? (check one)
An antigliadin antibody test
A C-reactive protein level
A fecal calprotectin level
Genetic testing for HLA-DQ2 and HLA-DQ8
An IgA tissue transglutaminase (tTG) antibody test

Answer 32

Genetic testing for HLA-DQ2 and HLA-DQ8

Celiac disease occurs almost exclusively in people with HLA-DQ2 or HLA-DQ8 genotypes. Though not routinely performed, a negative result has more than a 99% negative predictive value for the disease. A positive IgA tissue transglutaminase (tTG) antibody test is helpful in making a diagnosis if symptoms are present and has 95% sensitivity and specificity for active disease, but a negative IgA tTG test does not rule out future risk. A negative antigliadin antibody test has lower sensitivity and specificity than IgA tTG, and is used to diagnose the disease in the presence of symptoms rather than to rule out future risk. Negative C-reactive protein and fecal calprotectin levels make active inflammatory bowel disease less likely.

Question 33

A 63-year-old female is concerned about her long-term use of medication. She has been taking omeprazole (Prilosec), 20 mg daily for the past 4 months, and tells you that it works well to relieve her symptoms of heartburn and regurgitation. She notes, however, that if she misses a dose her symptoms return.

You tell her that long-term proton pump inhibitor use is associated with which one of the following complications? (check one)
Gastrointestinal malignancy
Hip fracture
Myocardial infarction
Nephrotic syndrome
Vitamin D deficiency

Answer 33

Hip fracture

Proton pump inhibitors (PPIs) are safe and well tolerated for short-term use. It is recommended that the lowest dosage and shortest duration of therapy be used to control symptoms of GERD. Long-term PPI use is associated with fractures, hypomagnesemia, vitamin B12 deficiency, iron deficiency, and acute interstitial nephritis with progression to chronic kidney disease. Use of PPIs has also been associated with community-acquired pneumonia and Clostridium difficile infection, although studies have been conflicting. Vitamin D deficiency, nephrotic syndrome, gastrointestinal malignancy, and myocardial infarction are not proven complications of long-term PPI use.

Question 34

A 58-year-old male with a history of tobacco and alcohol abuse presents with the sudden onset of many well circumscribed brown, oval, rough papules with a “stuck-on” appearance on his trunk and proximal extremities. On examination you also note an unintentional 6-kg (13-lb) weight loss over the last 3 months and conjunctival pallor. A review of systems is positive for more frequent stomachaches, decreased appetite, and mild fatigue.

You order a laboratory workup. Which one of the following would be most appropriate at this point? (check one)
Reassurance that the skin lesions are benign
A skin biopsy
Referral to a dermatologist
CT of the abdomen and pelvis
Upper and lower endoscopy

Answer 34

Upper and lower endoscopy

This patient’s age, risk factors, red-flag symptoms, and other clinical findings indicate the need for endoscopy. The Leser-Trélat sign may be defined as the abrupt onset of multiple seborrheic keratoses, which is an unusual finding that often indicates an underlying malignancy, most commonly an adenocarcinoma of the stomach. CT is not an initial approach for diagnosing a suspected malignancy of the stomach or colon. Further skin evaluation and lifestyle changes, which are indicated, will not address the need for evaluation of weight loss and other abnormal symptoms and findings.

Question 35

A 48-year-old female smoker presents with solid, but not liquid, dysphagia that causes her to feel as if food is “getting stuck.” She sometimes regurgitates this food. When you ask her where it feels like the food is sticking she points to a location below the suprasternal notch.

The most appropriate next step is (check one)
a fluoroscopic swallowing study
barium radiography
CT of the chest
endoscopy
esophageal manometry

Answer 35

endoscopy

Solid but not liquid dysphagia suggests a structural lesion. A location in the chest indicates esophageal dysphagia. Endoscopy is the single most useful test for esophageal dysphagia and can visualize mucosal lesions better than barium radiography. Therapy can also be performed during the procedure. A fluoroscopic swallowing study would be indicated if the patient’s history pointed to oral or pharyngeal dysphagia. Even if it is thought that the dysphagia is caused by a motility disorder, endoscopy is still preferred, because neoplastic and inflammatory conditions can produce spasm and motility symptoms. Manometry can be performed if endoscopy does not adequately explain the symptoms.

Question 36

A 68-year-old male with a 40-pack-year history of smoking presents with a 2-month history of dyspepsia and difficulty swallowing. He also reports a 20-lb unintentional weight loss. He takes omeprazole (Prilosec), 20 mg daily.

Which one of the following would be most appropriate at this point? (check one)
Increasing omeprazole to 40 mg twice daily
Abdominal CT
Barium esophagography
Esophageal manometry
Upper endoscopy

Answer 36

Upper endoscopy

This patient has risk factors and symptoms that suggest esophageal cancer. According to the Society of Thoracic Surgeons and the National Comprehensive Cancer Network, upper endoscopy with a biopsy of suspicious lesions is the recommended initial evaluation for symptoms of esophageal cancer (SOR C). Esophagography would be appropriate in patients unable to undergo endoscopy but would not be the preferred test. CT of the abdomen is not indicated in the initial evaluation for esophageal cancer but can be integrated with a PET scan for staging. Esophageal manometry is reserved for patients with dysphagia if upper endoscopy does not establish a diagnosis and a motility disorder is suspected. Increasing the dosage of the proton pump inhibitor would not be an appropriate treatment for this patient’s condition and may delay the diagnosis and treatment of suspected cancer if the patient is not referred promptly for upper endoscopy.

Question 37

You suspect a 45-year-old female may have irritable bowel syndrome. She has a 6-month history of crampy, diffuse abdominal pain associated with defecation. Her symptoms occur several days per week.

According to the Rome IV criteria, an associated symptom that would help in making this diagnosis is (check one)
a change in stool frequency
increased gas and bloating
pain brought on by eating
waking up at night to defecate
weight loss of 5 lb (2 kg)

Answer 37

a change in stool frequency

The Rome IV criteria are widely used as guidelines to diagnose suspected irritable bowel syndrome. These criteria specify that there should be recurrent abdominal pain associated with two or more additional symptoms at least 1 day per week in the last 3 months. These symptoms include pain related to defecation, a change in stool frequency, or a change in stool form. Pain brought on by eating and increased gas and bloating are observed in irritable bowel syndrome but are not included in the Rome IV criteria. Weight loss and waking at night to defecate are not typically seen in this disorder.

Question 38

A 66-year-old female with a previous history of hypertension, stable angina, and carotid endarterectomy presents with acute upper abdominal pain, which has developed over the past 3 hours. A physical examination reveals epigastric tenderness without guarding or rebound, but does not reveal a cause for the level of pain reported by the patient. Initial laboratory findings are within normal limits, including a CBC, glucose, lactic acid, amylase, lipase, liver enzymes, and kidney function tests. You suspect acute mesenteric ischemia.

Which one of the following diagnostic imaging tests is the preferred initial evaluation for this problem? (check one)
Duplex ultrasonography
CT angiography
Catheter angiography
Magnetic resonance angiography (MRA)
Upper and lower GI endoscopy

Answer 38

CT angiography

CT angiography (CTA) is the recommended imaging procedure for the diagnosis of acute mesenteric vascular disease. The procedure can also identify other possible intra-abdominal causes of pain. Duplex ultrasonography is also accurate, especially for proximal lesions, but can be difficult to perform in patients with obesity, bowel gas, and marked calcification of the vessels, and may be problematic in patients presenting acutely, due to the length of the study and the abdominal pressure required. It is more useful in cases of suspected chronic mesenteric ischemia. Endoscopy is often normal in acute ischemia and may not reach the ischemic section of bowel. MR angiography may be useful, but it takes longer to perform than CTA and lacks the necessary resolution. Catheter angiography is required for endovascular therapies such as thrombolysis or angioplasty with or without stenting, but is usually not performed for making the initial diagnosis in the acute setting.

Question 39

A 68-year-old female presents with a history of episodic severe lower abdominal pain relieved by defecation. She has had a long history of constipation with normal to very firm stools. Her history and a physical examination are otherwise normal. A colonoscopy 3 years ago was normal. You diagnose constipation-predominant irritable bowel syndrome.

Which one of the following agents would be the most appropriate treatment for this patient?
What is the best initial management for this patient?
(check one)
Lactulose
Magnesium citrate
Milk of magnesia
Polyethylene glycol
Sodium phosphate

Answer 39

Polyethylene glycol

Hypertonic osmotic laxatives such as milk of magnesia, magnesium citrate, and sodium phosphate draw water into the bowel and should be used with caution in older adults and those with renal impairment because of the risk of electrolyte abnormalities and dehydration in patients with irritable bowel syndrome (IBS). Lactulose, also an osmotic laxative, should be avoided in patients with IBS because it is broken down by colonic flora and produces excessive gas. Polyethylene glycol, a long-chain polymer of ethylene oxide, is a large molecule that causes water to be retained in the colon, which softens the stool and increases the number of bowel movements. It is approved by the FDA for short-term treatment in adults and children with occasional constipation and is commonly prescribed for patients with IBS. It is considered safe and effective for moderate to severe constipation when used either daily or as needed.

Question 40

An 8-year-old male is brought to your office because of acute lower abdominal pain. He is not constipated and has never had abdominal surgery. You suspect acute appendicitis.

Which one of the following would be most appropriate at this point? (check one)
Plain radiography
Ultrasonography
CT without contrast
CT with contrast
MRI

Answer 40

Ultrasonography

Ultrasonography is recommended as the first imaging modality to evaluate acute abdominal pain in children. It avoids radiation exposure and is useful for detecting many causes of abdominal pain, including appendicitis. After ultrasonography, CT or MRI can be used if necessary to diagnose appendicitis. Abdominal radiography is helpful in patients with constipation, possible bowel obstruction, or a history of previous abdominal surgery.

The American Academy of Pediatrics Choosing Wisely recommendation on the evaluation of abdominal pain states that CT is not always necessary. The American College of Surgeons Choosing Wisely recommendation on the evaluation of suspected appendicitis in children says that CT should be avoided until after ultrasonography has been considered as an option.

Question 41

A 60-year-old female sees you because she has recently lost 20 lb without trying and is having trouble swallowing. Her other medical problems include obesity, tobacco abuse, and GERD.

Which one of the following is the most appropriate diagnostic test in this situation? (check one)
A barium swallow
Endoscopic esophageal ultrasonography
Chest CT
Upper endoscopy

Answer 41

Upper endoscopy

Dysphagia alone or with unintentional weight loss is the most common presenting symptom of esophageal cancer. Adenocarcinoma is the most common esophageal cancer in developed nations, and risk factors include GERD, obesity, and tobacco abuse. Upper endoscopy is the recommended diagnostic tool (SOR B). If cancer is confirmed, CT and PET scanning are useful for staging.

Question 42

An 82-year-old male presents to the emergency department with severe generalized abdominal pain. He has a history of paroxysmal atrial fibrillation and stopped taking rivaroxaban (Xarelto) 2 months ago because of the cost. The physical examination reveals generalized abdominal tenderness and an epigastric bruit. You suspect mesenteric ischemia.

Which one of the following is the recommended imaging study? (check one)
Ultrasonography
Endoscopy
Catheter angiography
CT angiography
MR angiography

Answer 42

CT angiography

CT angiography (CTA) is the recommended imaging modality for the diagnosis of visceral ischemic syndromes because of its 95%–100% accuracy. Images of the origins and length of the vessels can be obtained rapidly, characterize the extent of stenosis or occlusion and the relationship to branch vessels, and aid in the assessment of options for revascularization. Endoscopy is most useful for diagnosing conditions other than mesenteric ischemia. The value of ultrasonography is extremely dependent on the skills of the technologist. In addition, adequate imaging can be difficult to obtain in patients with obesity, bowel gas, and heavy calcification in the vessels. Angiography with selective catheterization of mesenteric vessels is now used after a plan for revascularization has been chosen. MR angiography takes longer to perform than CTA, lacks the necessary resolution, and can overestimate the degree of stenosis.

Question 43

A 43-year-old female is very distressed about symptoms of postprandial fullness and early satiety. She has seen several physicians over the last 6 months but said she was always told “nothing’s wrong.” You review her most recent workup, including normal blood tests, normal gallbladder testing, and upper endoscopy that shows no abnormalities, including negative testing for Helicobacter pylori . She has tried multiple antacid medications, including omeprazole (Prilosec), lansoprazole (Prevacid), and ranitidine (Zantac), with no success.

Which one of the following medications has the best chance of providing this patient with symptom relief? (check one)
Clonazepam (Klonopin)
Escitalopram (Lexapro)
Metoclopramide (Reglan)
Ondansetron (Zofran)
Sucralfate (Carafate)

Answer 43

Metoclopramide (Reglan)

This patient’s history fits the diagnosis of functional dyspepsia. Two subtypes of this disorder have been described. The first, epigastric pain syndrome, is described as intermittent pain and burning in the epigastrium. The second, postprandial distress syndrome, is more typical of the symptoms this patient describes: postprandial fullness and early satiety. Although there is considerable benefit from reassurance and “naming” a patient’s condition, empiric treatment is also warranted. Patients with epigastric pain syndrome are more likely to respond to proton pump inhibitors or H2-blockers. Patients with predominantly postprandial distress symptoms are more likely to improve with a motility agent such as metoclopramide. Sucralfate, antacids, and selective antidepressants have not been shown to be more effective than placebo in functional dyspepsia, whereas tricyclic antidepressants and buspirone have shown some benefit and are reasonable next steps for this patient.

Question 44

A patient is admitted to the hospital with severe acute pancreatitis, based on diagnostic criteria for severity. After appropriate intravenous hydration, which one of the following is associated with shorter hospital stays and lower mortality? (check one)
Parenteral nutrition
Nothing by mouth until the pain has resolved
Clear liquids by mouth after 48 hours
Bolus nasogastric enteral nutrition
Continuous nasogastric enteral nutrition

Answer 44

Continuous nasogastric enteral nutrition

The American College of Gastroenterology recommends that patients with severe acute pancreatitis receive enteral nutrition. Enteral feedings help prevent infectious complications, such as infected necrosis, by maintaining the gut mucosal barrier and preventing translocation of bacteria that may seed pancreatic necrosis. Currently, continuous enteral feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay.

Total parenteral nutrition is not recommended because of infectious and line-related complications. It should be avoided unless the enteral route cannot be used.

Question 45

A previously healthy 44-year-old female presents to the emergency department (ED) with severe, sharp, right upper quadrant abdominal pain and nausea that began shortly after eating dinner. On examination she is noted to have a low-grade fever with a positive Murphy sign. A laboratory analysis is notable for leukocytosis with a left shift and a mildly elevated total bilirubin level. A lipase level and liver transaminases are normal. Ultrasonography reveals several small gallstones, gallbladder wall thickening, and pericholecystic fluid. After receiving intravenous fluids, pain management, and antiemetic treatment in the ED, her symptoms improve | In addition to intravenous antibiotics, the most appropriate next step in management would be to offer (check one)
expectant management
endoscopic retrograde cholangiopancreatography (ERCP)
laparoscopic cholecystectomy
outpatient general surgery consultation
Ticks

Answer 45

laparoscopic cholecystectomy

This patient presents with signs and symptoms of acute cholecystitis, and ultrasonography confirms the presence of gallstones and gallbladder inflammation. While most patients with acute cholecystitis will have symptoms that improve with supportive care over 2–7 days, the risk of recurrent symptoms and complications increases with delayed surgical intervention. The Choosing Wisely initiative recommends that surgical treatment be offered to the patient during the initial hospitalization. The Society of American Gastrointestinal and Endoscopic Surgeons has found that laparoscopic cholecystectomy is safe and cost-effective in the immediate hospital setting. This stable, uncomplicated patient should be offered laparoscopic cholecystectomy during the current visit. Offering outpatient options such as expectant management and surgical consultation at a later date may increase this patient’s risk of recurrent symptoms and complications as well as costs. Since she does not have signs of obstructive cholangitis such as elevated liver enzymes and jaundice, endoscopic retrograde cholangiopancreatography (ERCP) is not indicated.

Question 46

A 33-year-old female comes to your office for follow-up of irritable bowel syndrome. You ruled out other causes of her abdominal bloating, abdominal pain, and diarrhea at earlier visits. She has no change in symptoms, such as constipation or blood in her stool. She has resisted treatment in the past, but her symptoms are becoming more frequent and she would now like to consider treatment.

Evidence shows that which one of the following would most likely be beneficial for this patient? (check one)
Acupuncture
Increased insoluble fiber in her diet
Fluoxetine (Prozac), 20 mg daily
Neomycin, 1000 mg every 6 hours for 7 days
Polyethylene glycol (MiraLAX), 17 g daily

Answer 46

Fluoxetine (Prozac), 20 mg daily

This patient has diarrhea-predominant irritable bowel syndrome (IBS). There are many treatments available, with varying degrees of evidence. SSRIs, along with tricyclic antidepressants, have been shown to decrease abdominal pain and improve global assessment scores in those with IBS. Polyethylene glycol is a treatment for constipation and would not help this patient. Acupuncture has not been shown to be superior to sham acupuncture in improving IBS symptoms. Neomycin has been shown to improve symptoms in constipation-predominant IBS but would not be helpful in diarrhea-predominant IBS. Soluble fiber such as psyllium improves symptoms and decreases abdominal pain scores in patients with IBS. Insoluble fiber has not been shown to improve any IBS outcomes.

Question 47

A previously healthy 45-year-old female presents with upper abdominal pain and dysphagia. An upper GI series reveals no significant reflux. On esophagogastroduodenoscopy the esophagus has a ringed appearance and a biopsy reveals >15 eosinophils/hpf. Helicobacter pylori testing is negative. She does not currently take any medications.

Which one of the following would be the best initial treatment? (check one)
Budesonide oral suspension, 1 mg twice daily
Fexofenadine, 180 mg daily
Pantoprazole (Protonix), 40 mg once daily
Prednisone, 40 mg daily for 7 days
Ranitidine (Zantac), 150 mg once daily

Answer 47

Budesonide oral suspension, 1 mg twice daily

The clinical presentation and esophagogastroduodenoscopy findings indicate eosinophilic esophagitis (EoE)
in this patient. In the absence of other causes of eosinophilia, the presence of >15 eosinophils/hpf is
considered diagnostic. Application of corticosteroids to the esophagus is generally the treatment of choice,
either in the form of an oral suspension of budesonide or an inhaled corticosteroid sprayed into the mouth
and swallowed. Although EoE can occur in patients with other atopic illnesses, this patient does not have
any symptoms of allergies or asthma, so an antihistamine such as fexofenadine is not needed. EoE does
not respond to proton pump inhibitor therapy or H2-blocker therapy and systemic corticosteroids are not
necessary.

Question 48

A 42-year-old male with a history of alcohol abuse was admitted to the hospital last night with mid-epigastric pain and tenderness. The hospital evaluation included an elevated lipase level and a normal ultrasound examination. He was diagnosed with acute pancreatitis, placed on NPO status, and started on intravenous fluids and pain control. This morning he still has moderate epigastric pain and tenderness, and mild nausea but no vomiting. He says he would like to try eating some food.

Which one of the following would you recommend at this time? (check one)
Remaining NPO until the pain and tenderness have improved
Allowing the patient an oral diet as tolerated
Initiating nasogastric feeding
Initiating nasojejunal tube feeding
Initiating total parenteral nutrition

Answer 48

Allowing the patient an oral diet as tolerated

The American Gastroenterological Association guidelines on acute pancreatitis recommend initiating oral
feedings early in the course in order to protect the gut-mucosal barrier, which may limit infectious
complications and does not increase hospital length of stay or other complications. Nasogastric or
nasojejunal tube feeding may be considered at 3–5 days if oral feedings are not tolerated. Total parenteral
nutrition is indicated only when enteral feedings cannot supply adequate caloric intake or are not possible
for other reasons. The incidence of single or multiple organ failure or infected necrosis is significantly
increased with the use of total parenteral nutrition.

Question 49

A 55-year-old patient with a history of alcoholism is admitted through the emergency department with acute pancreatitis. Which one of the following tests performed at the time of admission can best predict the severity of pancreatitis? (check one)
Hematocrit
C-reactive protein
Serum amylase
Serum lipase
CT of the abdomen

Answer 49

Hematocrit

Knowing the severity of pancreatitis helps predict how aggressive management should be. Hematocrit,
BUN, and creatinine levels are the most useful predictors of the severity of pancreatitis, reflecting the
degree of intravascular volume depletion. C-reactive protein is often elevated, but it is not as useful as
hematocrit for predicting severity. Serum amylase and lipase have no prognostic value. CT evidence of
severe pancreatitis lags behind clinical and laboratory evidence, and early CT underestimates the severity
of the acute process.

Question 50

A 40-year-old female sees you because of burning upper abdominal and chest pain and an acidic taste in her mouth after nearly every meal. She has pain at night that sometimes keeps her awake, but she does not have any nausea, vomiting, difficulty swallowing, bloating, bloody stools, or weight loss. She does not smoke.

Which one of the following would be the most appropriate next step? (check one)
Test for Helicobacter pylori and treat if present
Start a 4- to 8-week trial of a proton pump inhibitor
Order abdominal ultrasonography
Schedule esophagogastroduodenoscopy
Refer to a surgeon to consider fundoplication

Answer 50

Start a 4- to 8-week trial of a proton pump inhibitor

Patients with symptoms typical for GERD can be treated conservatively initially unless there are warning
signs such as anemia, weight loss, evidence of bleeding or obstruction, dysphagia, or persistent symptoms
despite maximal treatment, or the patient is age 50 or over. In the absence of any of these concerns,
medical therapy with a proton pump inhibitor can be initiated. While H2 histamine blockers can also treat
reflux symptoms they are somewhat less effective, and stepwise therapy may increase costs.
Routine testing for Helicobacter pylori in patients with GERD alone is not recommended because treating
H. pylori has been shown in some studies to increase esophagitis and GERD symptoms. However, in the
presence of dyspepsia (fullness, bloating, nausea), which can be associated with GERD, testing for and
treating H. pylori is expected to be beneficial. This patient has classic signs and symptoms of GERD and
abdominal ultrasonography would not be likely to reveal any helpful findings. In the presence of warning
signs, esophagogastroduodenoscopy would be indicated to evaluate for a more serious pathology. Surgical
intervention for GERD should be reserved for patients who fail maximal medical therapy or patients who
are unable to take proton pump inhibitors.

Question 51

Which one of the following is necessary to make the diagnosis of a functional gastrointestinal disorder? (check one)
Symptom-based clinical criteria
Noninvasive testing for Helicobacter pylori infection
Celiac serology
Gastric emptying studies
Esophagogastroduodenoscopy

Answer 51

Symptom-based clinical criteria

In the absence of red-flag symptoms such as nocturnal defecation, weight loss, or gastrointestinal bleeding, functional gastrointestinal disorders can be diagnosed using symptom-based clinical criteria. Symptoms such as recurrent abdominal pain related to defecation, pain related to a change in the frequency of defecation, abdominal bloating and distension, and loose and watery or lumpy and hard stools are used to diagnose functional bowel disorders. Noninvasive testing for Helicobacter pylori, celiac serology, gastric emptying studies, and esophagogastroduodenoscopy are not required in order to make a diagnosis.

Question 52

A 35-year-old female presents with very pruritic, recurrent, grouped papules, vesicles, and erosions on her knees and elbows. She does not have any known connective tissue diseases, gastrointestinal disturbances, sexually transmitted infections, or recurrent exposures. A skin biopsy is consistent with dermatitis herpetiformis.

A positive test for which one of the following is most consistent with this diagnosis? (check one)
Anti-thyroid antibodies
Herpes simplex virus antibody titers
Intrinsic factor antibodies
IgA tissue transglutaminase (tTG) antibodies
Varicella zoster virus antibody titers

Answer 52

IgA tissue transglutaminase (tTG) antibodies

Dermatitis herpetiformis is a very pruritic, papulovesicular reaction that is secondary to cutaneous IgA and immune complex deposition related to gluten sensitivity, as in celiac disease. The majority of patients do not have the gastrointestinal disturbances of celiac disease but do have the changes of gluten enteropathy on small bowel biopsies. The diagnosis is supported by elevated IgA tissue transglutaminase (tTG) antibodies, which is the serology of choice for diagnosing celiac disease. The rash frequently responds well to a gluten-free diet and is classically treated with dapsone. The disease is not related to thyroid disease, herpesviruses, or pernicious anemia.