GI

Question 1

Cullen’s sign

Answer 1

ecchymosis in the periumbilical region sugges- tive of retroperitoneal hemorrhage in severe acute pancreatitis.

Question 2

Grey Turner sign

Answer 2

ecchymosis in the flank that suggests retroperitoneal hemorrhage accompanying se- vere acute pancreatitis.

Question 3

Murphy’s sign

Answer 3

inspiratory arrest during deep palpation of the right upper quadrant in patients with acute cholecystitis.

Question 4

Courvisier’s sign

Answer 4

palpable nontender gallbladder via common bile duct obstruction by pancreatic head adenocarcinoma

Question 5

New born w/ abd distention, delayed gastric emptying, bloody stools, hepatic portal venous gas and a bubbly appearance of pneumatosis intestinalis (gas within the bowel wall)

Answer 5

Necrotizing Enterocolitis; NG suction w possible resection

Question 6

Newborn w/ bilious vomiting with proximal stomach distention (“double bubble” on X-ray); dx, a/w?

Answer 6

Duodenal atresia. Associated with Down syndrome.

Question 7

Newborn w/ delayed passage of meconium >48hr, abd distention, bilious emesis, barium enema shows dilated proximal bowel and a narrowed distal segment; dx?

Answer 7

Hirschsprung’s disease, lack of ganglion cells on rectal biopsy is diagnostic. a/w RET, Downs; resection

Question 8

1.5 yo baby p/w colicky abd pain, vomiting, currant jelly stools, right lower quadrant mass, dx/rx?

Answer 8

intussusception; Air contrast barium enema showing telescoping of the bowel, therapeutic as well.

Question 9

3yo p/w purpuric rash, arthralgias, abd pain, and glomerular renal involvement (proteinuria, hematuria); dx, a/w?

Answer 9

Henoch-Schönlein purpura (HSP) Vasculitis via IgA complex deposition; a/w IgA nephropathy, intussusception, pancreatitis and cholecystitis.

Question 10

2 week old w/ nonbilious projectile vomiting, palpable olive-shaped, mobile, nontender epigastric mas, hypochloremic-hypokalemic metabolic alkalosis. Dx?

Answer 10

Pyloric stenosis, Barium study shows a narrow pyloric channel “string sign”

Question 11

Abd distension w/ xray absent or abnormal position of the ligament of Treitz

Answer 11

Volvulus

Question 12

Progressive dysphagia of both liquids and solids, “bird’s beak” sign on barrium swallow; dx?

Answer 12

Achalasia; loss of aurbach’s plexus w/ increased LES tone

Question 13

Treatment of H. pylori gastritis

Answer 13

triple therapy, two antibiotics (metronidazole/amoxicillin plus clarithromycin), bismuth compound, and a proton pump inhibitor.

Question 14

Triad of Dysphagia (due to esophageal webs), Iron deficiency anemia, and Glossitis

Answer 14

Plummer-Vinson syndrome

Question 15

Pt p/w abdominal pain, diarrhea (malabsorption), recurrent ulcers in distal duodenum and jejunum; dx? a/w?

Answer 15

Zollinger-Ellison Gastrinoma; Gastrin-secreting tumor of pancreas or duodenum. May be associated with MEN 1.

Question 16

Risk factors for SCC of esophagus

Answer 16

Smoking, alcohol, hot bev/food, nitrosamine, toxins fungi, dietry def, viral inf

Question 17

Risk factors for adenocarcinoma of esophagus

Answer 17

GERD (hiatal hernia), Barret’s esophagus, obesity, smoking

Question 18

Pt p/w dysphagia, aspiration, halithosis, neck mass; dx, rx?

Answer 18

Zenker’s diverticulum, outpuching of esophagus caused by dysmotility and UE sphincter dysfunction; barium esophagogram, surgical correction

Question 19

Pt p/w dysphagia and chest pain a/w emotional or hot/cold food triggers, intermittent regurge, improved sx w/ nitroglycerin but no abn on ecg during episodes; dx/workup?

Answer 19

Diffuse esophageal spasms, diagnose w/ esophageal manometry

Question 20

Malabsorption with cachexia, wt loss, vitamin deficiency (glossitis, night blindness), SB bx villous atrophy w/ Macs stains PAS (periodic acid-Schiff) at lamina propria

Answer 20

Tropheryma whippelii (whipple dz); may later p/w skin pigmentation, migratory polyarthropy, valvular involvement, heart failure, supranuclear opthalmoplegia

Question 21

Abnormal D-xylose absorption (low urine serum levels post oral xylose); dx?

Answer 21

Proximal intestine malabsorption, celiac sprue (false positive w/ bacterial overgrowth, renal dysfunction, urinary retention)

Question 22

pt p/w abd fullness, epigastric mass, wt loss, salivary gland bx shows proliferation of lymphocytes

Answer 22

mucosa-associated lymphoid tissue (MALT) lymphoma. Treat for H. Pylori; chlorambucil if extensive

Question 23

Abdominal pain, ascites, hepatomegaly

Answer 23

Budd-Chiari syndrome (posthepatic venous thrombosis); thrombolysis followed by anticoagulation, TIPS procedure (transjugular intrahepatic portosystemic shunt)

Question 24

Pt p/w diabetes, hepatomegaly, skin pigmentation changes, arthritis, CHF and hypogonadism.

Answer 24

Hemochromatosis, heredetary AR (HFE) or transfusion (thalassemia); risk of HCC. Increased ferritin/iron/sat%, decreased TIBC.

Question 25

30 yo p/w cirrhosis (AST/ALT elevation), Corneal deposits, Hemolytic anemia, Parkinsonianism, Asterixis, Dementia, Dyskinesia, Dysarthria; dx/rx?

Answer 25

Wilson disease AR (hepatolenticular degeneration) w/ low Ceruloplasmin, Kayser-Fleischer rings, Basal ganglia degeneration, risk of hepatocellular cx; rx penicillamine or trientine

Question 26

Conjugated (direct) hyperbilirubinemia etiology

Answer 26

Biliary tract obstruction: gallstones, pancreatic liver cancer, liver fluke, atresia; Biliary dz: 1 sclerosing cholangitis, 1° biliary cirrhosis Excretion defect: Dubin-Johnson syndrome, Rotor syndrome

Question 27

Unconjugated (indirect) hyperbilirubinemia

Answer 27

Hemolytic, physiologic (newborns), Crigler-Najjar, Gilbert syndrome

Question 28

Mixed (direct and indirect) hyperbilirubinemia

Answer 28

Hepatitis, cirrhosis

Question 29

Asymptomatic or mild jaundice. Elevated unconjugated bilirubin without overt hemolysis. Bilirubin rise with fasting and stress.

Answer 29

Gilbert's; Mildly decrease in UDP-glucuronosyltransferase conjugation activity, decreased bilirubin uptake by hepatocytes.

Question 30

Jaundice, kernicterus (bilirubin deposition in brain), increased unconjugated bilirubin; dx?

Answer 30

Crigler-Najjar (type 1); rx: plasmapheresis and phototherapy; Type II is less severe and responds to phenobarbital, which increases liver enzyme synthesis.

Question 31

Conjugated hyperbilirubinemia due to defective liver excretion. Grossly black liver. Benign.

Answer 31

Dubin-Johnson, problem with excretion of conjugated bilirubin

Question 32

Mild conjugated hyperbilirubinemia, normal liver; dx?

Answer 32

Rotor =syndrome

Question 33

Coffee ground emesis, alcoholic w/ cirrhosis, Hgb\>9; dx/rx?

Answer 33

Variceal bleed; Rx 1: IVF, Octreotide, antibiotics (ceftriaxone); 2- endoscopy w/ ligation; 3- TIPS or shunt surger if needed; beta-blockers for prophylaxis

Question 34

62yom p/w chronic abdominal angina (postprandial abdominal pain resolves in a few hours), recent bloody diarrhea after abd pain, hx CAD, HTN; dx/rx?

Answer 34

Acute mesenteric ischemia, surgical resection

Question 35

Hep B acute w/ clinical cirrhosis or HepB DNA\>20,000? Rx?

Answer 35

Entecavir or Tenofovir, or interferon alpha if not decompensated

Question 36

Hep C treatment?

Answer 36

Interferon alpha (pegylated) and Ribavarin (add Telaprivir if type1)

Question 37

Hepatic encephalopathy: cirrhosis causes portosystemic shunts, lower NH3 metabolism, manifests neuropsychiatric dysfunction. Rx?

Answer 37

Lactulose (decreased NH4+ generation), low-protein diet, and rifaximin (kills intestinal bacteria).

Question 38

30 yoF on OCP p/w abd pain, distension, elevated GGT and AlkPhos, normal ALT/AST, liver bx atypical hepatocytes containing lipids and glycogen; dx?

Answer 38

Hepatic adenoma, benign, w/ bleeding and malignant transformation potential

Question 39

Refractory hypokalemia despite oral supplementation in alcoholic; dx?

Answer 39

Hypomagnesemia (also may see hypophosphatemia)

Question 40

Diabetic w/ gastroparesis (sx anorexia, nausea, early satiety, abd bloating), rx?

Answer 40

Metoclopramide (SE extrapyramidal sx), also erythromycin

Question 41

Ulcerative Colitis, screening?

Answer 41

Start 8 years after diagnosis w colonoscopy (w/ multiple biopsies) then every 1-2 years

Question 42

Lactose intolerence tests?

Answer 42

Positive hydrogen/acid breath test, stool test w increased reduced products, increased osmolar gap, decreased pH

Question 43

γ-glutamyl transpeptidase (GGT)

Answer 43

various liver and biliary diseases (just as ALP can), but not in bone disease; associated with alcohol use

Question 44

Alkaline phosphatase (ALP)

Answer 44

Obstructive hepatobiliary disease, HCC, bone disease

Question 45

Aminotransferases (AST and ALT) (often called “liver enzymes”)

Answer 45

Viral hepatitis (ALT \> AST) Alcoholic hepatitis (AST \> ALT)

Question 46

Lipase

Answer 46

Acute pancreatitis (most specific)

Question 47

Amylase

Answer 47

Acute pancreatitis, mumps

Question 48

Ceruloplasmin

Answer 48

Wilson disease

Question 49

Alcoholic w/ N&V, epigastric pain w/ some relief leaning forward, tachycardic, tachypnic; dx/complications?

Answer 49

Alcoholic acute pancreatitis; elevated amylase/lipase, pleural effusion, ARDS, ileus, pseudocyst/abcess/necrosis

Question 50

Paracentesis of ascitic fluid w/ Neutrophils \>250, protein 50 g/dL, SAAG (serum albumin minus ascites albumin) \>1.1; dx/rx?

Answer 50

Spontaneous bacterial peritonitis usually via E Coli or Klebsiella; rx Cefotaxime

Question 51

SAAG\>1.1g/dL (serum-ascites albumin gradient)?

Answer 51

Hydrostatic - Portal HTN: cardiac ascites, cirrhosis, Budd-Chiari

Question 52

SAAG\<1.1g/dL (serum-ascites albumin gradient)?

Answer 52

Absense of portal HTN: TB, pertoneal carcinomatosis, pancreatic ascites, nephrotic sx

Question 53

High protein ascites \>2.5?

Answer 53

Constrictive pericarditis, CHF, TB, peritoneal carcinomatosis, Budd-Chiari, fungal perotinitis

Question 54

Low protein ascites

Answer 54

Cirrhosis, nephrotic sx

Question 55

Emphysema and liver involvement w/ hepatocytes that are PAS positive and Diastase resistant; dx?

Answer 55

Alpha1-antitrypsin deficiency

Question 56

22yo p/w muscular rigidity, unsteady gait, resting tremors, slurred speech, elevated AST/ALT, liver bx macrovesicular steatosis, Mallory bodies, vacuolated hepatocellular nuclei, potal fibrosis and hepatocyte necrosis; dx?

Answer 56

Wilson's disease; dx via low ceruloplasmin and Kayser-Fleisher corneal rings on slit lamp

Question 57

50yoF p/w pruritis, xanthomia on eyelids, HSM, elevated alkPhos, cholesterol and IgM, slightly elevated ALT/AST; dx/confirmation/rx?

Answer 57

Primary biliary cirrhosis w/ lymphocytic destruction of biliary tract; a/w sjogrens, scleroderma, RA, celiacs; anti-mitochondrial ab; rx Ursodeoxycholic acid

Question 58

Ursodeoxycholic acid use?

Answer 58

Bile acid salt that decreased cholestrol content of bile and may dissolve radiolucent stones, used in Primary biliary cirrhosis or pts awaiting cholecystectomy

Question 59

Terminal ileum and colon. Skip lesions, rectal sparing. Transmural inflammation w/ fistulas. Cobblestone mucosa, creeping fat, bowel wall thickening (“string sign” on barium swallow), linear ulcers, fissures. Noncaseating Granulomas and lymphoid aggregates (Th1 mediated). dx, a/w, rx?

Answer 59

Crohn's dz; Strictures (leading to obstruction), fistulas, perianal disease, malabsorption, nutritional depletion, colorectal cancer, gallstones. Diarrhea that may or may not be bloody. Migratory polyarthritis, erythema nodosum, ankylosing spondylitis, pyoderma gangrenosum, aphthous ulcers, uveitis, kidney stones. Corticosteroids, azathioprine, methotrexate, infliximab, adalimumab.

Question 60

Continuous colonic lesions, always with rectal involvement. Mucosal and submucosal inflammation only. Friable mucosal pseudopolyps with freely hanging mesentery. Loss of haustra “lead pipe” appearance on imaging. Crypt abscesses and ulcers, bleeding, NO granulomas (Th2 mediated). dx, a/w, rx?

Answer 60

Ulcerative Colitis; Malnutrition, sclerosing cholangitis, toxic megacolon, colorectal carcinoma (worse with right-sided colitis or pancolitis). Bloody diarrhea. Pyoderma gangrenosum, erythema nodosum, 1° sclerosing cholangitis, ankylosing spondylitis, apthous ulcers, uveitis. ASA preparations (sulfasalazine), 6-mercaptopurine, infliximab, colectomy.

Question 61

Ulcerative colitis causes ULCCCERS:

Answer 61

Ulcers, Large intestine, Continuous, Colorectal carcinoma, Crypt abscesses, Extends proximally, Red diarrhea Sclerosing cholangitis

Question 62

Anorexic girl is put on NG tube feeds, develops intermittent Vtach, hypotension, tachycardia, JVD, bibasilar crackles, decreased K, Mg, P; dx?

Answer 62

Refeeding sx from increased Insulin, causing intracellular shift in K, Mg, P, leading to arrhythmias and HF w/ volume overload

Question 63

Chronic Hep C treatment? Confirmed HCV RNA, compensated INR3.4, no ascites), bx (bridgin fibrosis)

Answer 63

Pegilated interferon + Ribavirin (type 1 add Telaprevir or Bocaprevir)

Question 64

First Gen antihistamines with anticholinergic property (may cause urinary retention, dry eyes..)?

Answer 64

Diphenhydramine, chlorpheniramine, hydoxizine, doxepine

Question 65

Cirrhosis with eosinophilic inclusion bodies?

Answer 65

Alpha-1 antitrypsin liver failure

Question 66

Child post URI w/ elevated ALT/AST, PT/PTT, Ammonia, Microvesicular fatty liver; dx?

Answer 66

Reye sx via ASA ingestion