GI 2

Question 1

44 yo woman presents with epigastric pain that has occured for the last several months. She denies N/V/D, weightloss, blood in stool or emesis. Dx? Test? Rx: age 45? Test age 55?

Answer 1

Non-ulcer dyspepsia. Endoscopy. < 45 rx with PPI. >55 do Endoscopy to rule out cancer then PPI.

Question 2

Condition that occurs from chronic GERD of at least 5 years that leads to intestinal metaplasia of the esophagus. What can this condition develop into? Best initial/Most accurate test? Rx (2)?

Answer 2

Barretts Esophagus. Can turn into adenocarcinoma especially if there is a lot of intestinal metaplasia. Takes many years to turn into cancer. Endoscopy + Biopsy. Rx: Mild: PPI and rescope 2-3 yrs. High grade dysplasia: Ablation with endoscopy.

Question 3

This type of Gastric Carcinoma is differentiated, originates from intestinal metaplasia of gastric mucousal cells. Risk factors included Nitrosamines, salt, low veggies diet (no antioxidants), H. Pylori infection, Chronic gastritis type B. Best initial Test? Most accurate test? Rx?

Answer 3

Intestinal type. Endoscopy + Biopsy. CT to check for extent of metastasis and to see how pt will respond to chemo/palliative surgery.

Question 4

This type of gastric carcinoma is undifferentiated not associated with H. Pylori or Chronic gastritis. Signet ring cells present. Dx? Best initial Test? Most accurate Test? Rx?

Answer 4

Diffuse type. (Worse) Endoscopy + Biopsy. CT to check for extent of metastasis and to see how pt will respond to chemo/palliative surgery.

Question 5

Pt presents with large recurrent ulcers after H. Pylori eradication. Pts can present with diarrhea. Its present distal in the duodenum. There are multiples. Dx? Best initial Test? Most accurate test? Association? What test to perform to look for metastatic dz? Rx?

Answer 5

Zollinger-Ellison Syndrome (Gastrin Producing Tumors in the duodenum and/or pancreas.) High gastrin levels present but make sure pt is off PPIs and have excluded Pernicious Anemia/B12. Confrim with High Gastrin Levels after Secretin Stimulation Test. Check for MEN type 1 ( Parathyroid, Pancrease and Pituitary,) Somatostatin-receptor scintigraphy and Endoscopic US are good for detection of metastasis. Localized can do surgery. Metastatic is life long PPIs.

Question 6

Pt presents with papulovesicular pruritic lesions located on Elbow and knew as well as scalp and buttocks. Dx? What GI condition is this associated with? Best initial test? Most accurate test? Rx?

Answer 6

Dermatitis Herpatitformis. Celiac disease. Anti-tissue transglutaminase. Anti-endomysial and IgA antigliadin antibody. Biopsy of tissue shows flat/atrophic villi. Avoid wheat, barley and rye. Dapsone for skin lesions. Associated with other autoimmune disorders, DM type 1, PA

Question 7

Pt presents with flushing, diarrhea, abdominal cramps, wheezing and right sided cardiac valvular lesions. Dx? Test? Rx?

Answer 7

Carcinoid syndrome (Metastatic) It passed 1st pass metabolism. Test: Urine 5-HIAA (serotonin.) Octerotide and surgical resection.

Question 8

Condition is common in women btw 20s to 30s. This condition presents with abdominal pain which is relieved with bowel movements. Pts can have constipation and/or diarrhea. Associated with depression or anxiety. Dx? Test? Rx?

Answer 8

IBS. Rule out everything else. Most pts have had CBC, BMP, TSH, AXR, Upper and lower GI series and Colonoscopy. Rx: 1. Increase fiber 2. Antisposmodics (Hyoscyamine) 3. TCA and psychotherapy 5. Loperamide (anti-motility)

Question 9

Pt presents with abdominal pain and distension with absent bowel sounds. N/V( more feculent then bilious) Can occur s/p surgery. Dx? What is this most commonly associated with? Test? Rx? What would be cause if the emesis was more billious?

Answer 9

Large bowel obstruction. Colon Cancer assume this to ruled out. AXR. Admit, Gastrograffin enema. Surgery if ischemia and necrosis take place. Bilious - Small bowel obstruction.

Question 10

Pt presents with LLQ pain and fever. Dx? Best initial test? Most definitive test? What test to avoid? Rx?

Answer 10

Diverticulitis. CBC (Leukocytosis and anemia. CT scan best initial test. Most accurate is colonoscopy. Avoid the sigmoidscope because it can lead to perforation. NPO, NG, IV and Cipro + Metro

Question 11

1. If pts father died of colon cancer when she get screened? 2. When to start screening for FAP? 3. Screening for HNPCC 4. Screening with a hx of UC? 5. Previous hx of colon cancer in pt?

Answer 11

1. Colonoscopy before age 40 or 10 years from when the pt’s farther contracted it. Which ever occurs first. 2. Start with sigmoidoscopy at age 12 and then do every year. 3. Colonscopy at 25 then every. 4. Every year with Colonoscopy. 5 Colonoscopy at 1 year after resection then every 3-5 yrs.

Question 12

Woman in her 40s or 50s presents with fatigue, itching, Xanthalesma and Osteoperosis. Pt has normal bili and elevated Alk phos and GGTP. Dx? Best initial test? Most accurate? Rx?

Answer 12

Primary Biliary Cirrhosis (autoimmune attack of the intrahepatic ducts causing biliary stasis that leads to cirrhosis) AMA (anti-mitochondrial antibdoy). Liver biopsy (ductopenia due to autoimmune attack on the intrahepatic ducts). Ursodeoxycholic acid and cholestyarmine.

Question 13

Man presents with itching and there is normal bili, elevated alk phos and ggtp. Dx? Most accurate test? Rx?

Answer 13

Primary Scloerosing Cholangitis (onion skinning of the intra and extrahepatic ducts (idopathic disorder.) Associated with UC can occur in Crohns too. ERCP. Urodexoycholic acid and cholestyramine.

Question 14

Rx for Chronic Hep B and C?

Answer 14

1. Adeovir and Lamuvidine. 2. Ribavarin, Interferon and and avir (Telepravir/Brocepirvir).

Question 15

Young women with signs of liver inflammation and positive ANA. Most accurate test? Rx?

Answer 15

Autoimmune Hepatitis. ANA. Anti-Smoth muscle cell antibodies, Anti-kidney and liver microsomal antibodies most accurate. Steroids.

Question 16

Name the type of hernia: 1. Protrusion of abdominal contents through internal and external inguinal ring. 2. Herniation of abdominal contents through floor of Hasselbachs triangle.

Answer 16

1. Indirect hernia (Most common type in bother genders) due to patent processus vaginalis. 2. Direct hernia (due to acquire defect in the transversalis fascia from mechanical breakdown with age.)

Question 17

Pt presents with N/V and RUQ pain thats reproducible upon palpation. Symptoms worsen after eating. Dx? Test? Rx?

Answer 17

Cholethiasis/Biliary Colic causes viscous distenion of the gall bladder. When oddi tries to contract because of the CCK a gallstone prevents the contraction adn the gall bladder dilates this causes pain. US. Elective Cholecystecomy in symptomatic gallstones.

Question 18

Pr presents with fever, chills, NV and RUQ that is palpable upon palpation. Dx? Test? Rx?

Answer 18

Cholecystitis. Zosyn or Unasyn, Carbenem to treat infection. Pts can also have acalous cholescycstitis when stones not seen on US. IV fluids and abx. Elective Cholecystecomy.

Question 19

Acute bacterial infection secondary to gallstones in duct. Dx? Test? Rx? What is Charcot triad? What is Reynolds pentad?

Answer 19

Ascending Cholangitis. RUQ pain, jaudince, fever/chills - Charcot Triad. Additional Shock and AMS is Reynolds pentad. IV fluids and Zosyn or Unasyn, Carbepenem. ERCP/Sphincterotomy it is diagnostic and thearapuetic followed by cholecsytecomy.

Question 20

36 yo female presents with HLD, DM type 2 and presents with RUQ pain. She does not drink alcohol. Physical exam is unremarkbale. AST and ALT are elevted but other test are normal. Serologies are negative. Dx?

Answer 20

Non alcoholic fatty liver hepatitis. Still shows fatty vacoulization of the liver.

Question 21

Pt present with non tender palpable gallbladder. Migratory thrombophlebitis, abdominal pain, obstructive jaundice and weight loss. Dx ? Test?Rx?

Answer 21

Pancreatic adenocarcinoma. Occurs in smokers and chronic pancreatitis. Ct scan. Palliative rx because it presents advanced. If localized the Whipple procedure + chemo.

Question 22

4 complications of Pancreatitis.

Answer 22

Ileus, Pleural effusion, ARDS, Pancreatic pseudocyst/necrosis/abscess.

Question 23

Name 3 drugs cause acute pancreatitis.

Answer 23

Diadonise, Azathioprine, Valproate

Question 24

22 yo males presents with clumpsy gait, rigidity, tremors. Hepatomegaly present but no other findings of cirrhosis present. Ast, Alt, Alk pho elevated. Liver biopsy shows Mallory bodies, necrosis, steatosis, fribrosis and vacuolated hepatocellular nuclei. Dx? Next Step in management?

Answer 24

Wilson Dz. Slit lamp exam + Ceruloplasm levels. Children and young adults tend to present with the psychiatric manifestations of wilsons disease.

Question 25

Explain how TPN leads to Biliary stasis.

Answer 25

Normally fat and proteins stimulate CCK release to contract the gallbladder however when ppl are on artificial nutrion that loose this response and the bilirubin goes no where.

Question 26

Pt presents with epigastric pain, N/V and hematemesis. What are the causes for Type A and Type B Gastritis. How do you diagnose B 12 deficiency and Prenicious anemia.

Answer 26

1. Type A (PA) 2. Type B is (H. Pylori, NSAIDs, Head trauma, Burns, Intubation, Mechanical ventilation.) 3. Megaloblastic anemia or peripheral smear. Check B12 levels and confirm with MAMA level. 4. PA: Ph elevated with increased Gastrin levels and decreased IF levels. Confirm with Anti-parietal cell antibodies or anti IF antibodies.

Question 27

Pt presents with sweating, shaking, palpitations and lightheadedness after a meal. Hx of Vagotomy. Dx? Etiology? Rx?

Answer 27

Dumping Syndrome. Rapid entrance of hypertonic chyme cause intravascular volume depletion with rapid release of insulin causing rapid hypoglycemia due to rapid hyperglycemia from the rapid entrance of food. Eat multiple small meals and octerotide (decrease motility and secretions)

Question 28

When to admit a patient for diarrhea? Management?

Answer 28

They are feverish, hypotensive, abdominal pain, bloody stool. Start on IV fluids and abx (Cipro)

Question 29

2 Organisms found in HIV pts with CD4 < 100. Dx?

Answer 29

Isopora and Cryptospiridia.

Question 30

Pts who ingest contaminated fish and experience N/V diarrhea, flushing, wheezing within minutes. Dx?

Answer 30

Scombroid. Almost sounds like carcinoid but person ate fish prior to this.

Question 31

Oragnaism causes diarrhea and Mimics Appendicitis?

Answer 31

Yersinia RLQ pain. Remember this is associated with hemachromatosis.

Question 32

2-6 hrs after ingestion of large Reef Fish (Coral Reef, NEMO) (Grouper, Red Snapper, Barracuda) Pts develop Diarrhea + Neurological problems ie paresthesia, weakness, reversal of heat and cold. Dx?

Answer 32

Ciguatera-Toxin.

Question 33

Diarrhea associated with raw shelfish, mussels, oysters and clams. Dx?

Answer 33

Virbio parahemolyticus.

Question 34

1. Travel to mexico + dysentry + RUQ pain? CT shows cyst like region. Rx: Metro 2. Interaction with dog + RUQ pain?

Answer 34

1. Amebic Liver Abcess. Rx with metro. 2. Hyadit Cyst.

Question 35

Pt presents with LLQ pain, fever s/p AAA repair. CT scan shows ulcerations and colon thickening. Dx?

Answer 35

Ischemic Colitis.

Question 36

Critically ill patient with gall bladder distention, thickening of the gall bladder wall and pericholecystic fluid. Dx? Next step in management?

Answer 36

Acalous Cholecystitis. Abx and percutaneous cholecysteostomy (Tube.) to drain Once the patient gets better then perform cholecystecomy.