GI and gallbladder

Question 1

69yo M w confusion, abd pain, chills, rectal temp of 94F, jaundice. XRay - air in biliary tree. Dx?

Answer 1

Acute cholangitis

Question 2

Charcot triad? What disease?

Answer 2

RUQ pain, jaundice, fever. Cholangitis

Question 3

Elevated leuk, gallbladder wall thickening, RUQ abd pain. Cholecystitis or biliary colic?

Answer 3

Cholecystitis (elev leuk and GBW thickening)

Question 4

Treatment of acute cholecystitis?

Answer 4

Admit, IVF, NPO, Abx, Cholecystectomy

Question 5

GI bleed, what to do next? (How is it different for massive GI bleed?)

Answer 5

Fluid resuscitate, diagnosis, treat. Early endoscopy. For massive GI bleed, endotracheal tube before endoscopy. CBC, LFT, PT, PTT, type and cross, FFP (coagulopathy) or platelets (thrombocytopenia).

Question 6

Mallory-Weiss tear, where is it?

Answer 6

Proximal gastric mucosa tear from cough/vomit. Self-limited, mild.

Question 7

Dieulafoy erosion, what is it?

Answer 7

Bleed from aberrant submucosal artery in stomach. Prompt endoscopy diagnosis and operation

Question 8

Inject what for nonvariceal upper GI bleed via endoscopy?

Answer 8

Epinephrine followed by thermal therapy, or clips

Question 9

Size cutoff for peptic ulcer to be operated on for recurrent upper GI bleed

Answer 9

> 3cm

Question 10

Which causes anemia but not acute GI hemorrhage?

Gastric ulcer, duodenal ulcer, gastric erosions, esophageal varices, or gastric cancer?

Answer 10

Gastric cancer

Question 11

M is vomiting lots of bright red blood, what do you do first?

Answer 11

Fluid resuscitation

Question 12

Acute hematemesis from bleeding esophageal varices in M with cirrhosis - endoscopic sclerotherapy or balloon tamponade of esophagus?

Answer 12

Endoscopic sclerotherapy effective in 90% of cases. Other therapies include vasopressin or octreotide to dec portal pressure

Question 13

3 most likely causes of acute lower GI bleed in >40yo (painless)

Answer 13

diverticulosis, angiodysplasia, neoplasm

Question 14

4 causes of lower GI bleed with abdominal pain

Answer 14

ischemic bowel, IBD, ruptured abdominal aneurysm, intussusception

Question 15

3 most common causes of overt lower GI bleeds (hematochezia or melena) in children and adolescents

Answer 15

Meckel’s, IBD, polyps

Question 16

79yo F w 1 wk abd distention and pain, 1 day vomiting. Phys exam: no hernias, consistent with distal sm bowel obstruction. Afebrile, WBC 4000. First next step?
Nonoperative tx for 48hr?
Upper GI endoscopy?
Immediate ex lap?
CT scan?

Answer 16

CT scan

Question 17

72yo M with n/v, past appendectomy at age 25. Ab tender and distended. Afebrile, wbc 18000, Na 140, K 4.2, Cl 105, HCO3 14. Best therapy?

NG tube and observe
Colonoscopy for intussusception
Barium enema to relieve volvulus
Abx and supportive care
Surgery

Answer 17

Surgery. Anion gap acidosis, probably from lactic acid reflecting ischemic bowel or fluid depletion. Old people are often afebrile. (If CT was an option, do that first, but most likely these oldies have obstruction or intra-abd sepsis)

Question 18

32yo M with n/v POD20 s/p appendectomy. Ab tender and distended. Afebrile, wbc 18000, Na 140, K 4.2, Cl 105, HCO3 14. Best therapy?

NG tube and observe
Colonoscopy for intussusception
Barium enema to relieve volvulus
Abx and supportive care
Surgery

Answer 18

NG tube. within 30 d s/p ab surgery, SBO often and resolves with NG decompression and supportive care. CT scan can identify cause.

(compare this case to the 72yo)

Question 19

19yo F with 2d RLQ pain, no fever. Tender right adnexal mass, normal WBC, neg HCG, normal UA. What’s next?

CT ab + pelvis
Discharge patient
Diagnostic laparoscopy
Observation with serial labs
Ab+pelvis U/S

Answer 19

Ab+pelvis U/S because patient has findings of pelvic path. CT is less sensitive and specific for pelvic path.

Question 20

24yo M with colicky intermittent umbilical and RLQ pain for 24hr. Anorexia and nausea. T 98F. Most likely diagnosis?

Acute appendicitis
Chronic appendicitis
Gastroenteritis
Acute pancreatitis
Intussusception

Answer 20

Gastroenteritis. Only gastroenteritis and intussusception present with intermittent pain, but intussusception less likely in 24yo M

Question 21

18yo F w 1d worsening lower ab pain, nausea, vomiting, T 99F. Possible right adnexal tenderness. Which test would definitively differentiate PID from acute appy?

CT
MRI
U/S
Laparoscopy
Clinical response to Abx

Answer 21

Laparaoscopy

Question 22

43yo F w 1d right flank and RLQ pain. Has hx of nephrolithiasis but pain is different. T 101.3, ab and right flank tender to deep palpation. UA shows 10-20wbc, 10-20rbc. What next?

Pelvic U/S to r/o ovarian torsion
Hospitalize, IVF, analgesics, Abx for UTI
CT ab
Diagnostic laparoscopy
Cystoscopy and ureteral stent placement

Answer 22

CT ab. Will identify kidney stones, and r/o pyelo, or appy.

Question 23

14yo boy with 2d RLQ ab pain. Had been ill past 10d with cough, runny nose, fever. Ab pain over last 12 hr improving. T 100.4F. Ab tender in RLQ, no masses or peritonitis signs. WBC 11, UA normal. CT shows no inflammatory changes in area of cecum but several prominent lymph nodes in the mesentery of small bowel. Bowel wall not thickened. Diagnosis and treatment?

Answer 23

Mesenteric adenitis. Discharge with follow-up. Common in kids, no Abx needed. NOT lymphoma (which would have diffuse intraabdominal and retroperitoneal adenopathy)