Gi and Nutrition III

Question 1

What is the likely diagnosis in a patient with melena and epigastric abdominal pain that is relieved with eating?

Answer 1

Peptic ulcer disease (duodenal ulcer)

Question 2

What is the likely diagnosis in a patient with obesity and diabetes who presents with hepatomegaly and mildly elevated LFTs in the absence of other causes for secondary hepatic fat accumulation?

Answer 2

Non-alcoholic fatty liver disease (NAFLD)

Question 3

What is the likely diagnosis in a patient with recent travel history who develops foul-smelling stools, abdominal cramps, and bloating?

Answer 3

Giardiasis

common in rural areas and developing countries

Question 4

What is the likely diagnosis in a patient with severe RUQ/shoulder pain that occurs after fatty meals and resolves within 6 hours?

Answer 4

Biliary colic

quick resolution and lack of fever, abdominal tenderness on palpation, and leukocytosis help distinguish this process from acute cholecystitis

Question 5

What is the likely diagnosis in a patient with sudden-onset odynophagia and retrosternal pain with a discrete ulcer in the mid-esophagus?

Answer 5

Pill esophagitis

mid-esophagus most common due to compression by the aortic arch or an enlarged left atrium

Question 6

What is the likely diagnosis in a young patient with liver disease and neuropsychiatric symptoms?

Answer 6

Wilson disease

Question 7

What is the likely diagnosis in a young woman with alternating constipation/diarrhea and chronic abdominal pain that is relieved after a bowel movement?

Answer 7

Irritable bowel syndrome

Question 8

What is the likely diagnosis in an alcoholic who presents with epigastric pain and hematemesis following multiple episodes of vomiting (normal X-ray)?

Answer 8

Mallory-Weiss tear

i.e. a longitudinal tear in the mucosa often near the GE junction; most heal spontaneously

Question 9

What is the likely diagnosis in an elderly man with dysphagia, regurgitation, halitosis, and aspiration?

Answer 9

Zenker’s diverticulum

treatment is generally surgical

Question 10

What is the likely diagnosis in an elderly patient with chronic constipation, LLQ abdominal pain, fever, and leukocytosis?

Answer 10

Acute diverticulitis

Question 11

What is the likely diagnosis in an elderly patient with conjugated hyperbilirubinemia, elevated alkaline phosphatase, and painless jaundice?

Answer 11

Malignant biliary obstruction

Question 12

What is the likely underlying cause of peptic ulcer disease in a patient who has emigrated from a low-income country?

Answer 12

H. pylori infection

symptoms include dyspepsia, nausea, and post-prandial fullness

Question 13

What is the likely underlying etiology of ascites if the serum-ascites albumin gradient (SAAG) is > 1.1 g/dL?

Answer 13

Portal hypertension

Question 14

What is the most common cause of esophageal rupture?

Answer 14

Endoscopy

other common causes include severe retching (Boerhaave syndrome) and penetrating trauma

Question 15

What is the most common cause of gross lower GI bleeding in adults?

Answer 15

Diverticulosis

typically painless but may be associated with lightheadedness and hemodynamic instability with large-volume bleeds; usually resolves spontaneously

Question 16

What is the most common site of colon cancer metastasis?

Answer 16

Liver

Question 17

What is the most common source of liver metastases?

Answer 17

Colorectal cancer

in addition to tumors of the GI tract, lung and breast tumors also commonly metastasize to the liver

Question 18

What is the most significant environmental risk factor for pancreatic cancer?

Answer 18

Smoking

Question 19

What is the next step after an endoscopic biopsy is positive for gastric adenocarcinoma?

Answer 19

CT scan of abdomen/pelvis

imaging helps with disease staging, which determines prognosis and treatment options

Question 20

What is the next step for establishing the diagnosis in a patient with conjugated hyperbilirubinemia and predominantly elevated alkaline phosphatase?

Answer 20

Abdominal imaging (US or CT)

presence of biliary dilatation is suggestive of extrahepatic cholestasis; absence of biliary dilatation suggests intrahepatic

Question 21

What is the next step in management for a patient with acetaminophen toxicity that develops worsening acute liver failure despite N-acetylcysteine treatment?

Answer 21

Refer to liver transplant center

this is an ethically complicated issue, however, if there is no history of psychiatric illness or previous suicide attempt, liver transplantation is typically pursued

Question 22

What is the next step in management for an elderly patient with newly discovered iron deficiency anemia?

Answer 22

colonoscopy and endoscopy

new IDA in an elderly patient is considered to be from GI blood loss until proven otherwise

Question 23

What is the preferred diagnostic test for giardiasis?

Answer 23

Stool antigen assay

stool microscopy for oocysts and trophozoites may be used in resource-poor settings

Question 24

What is the preferred initial study to evaluate patients with suspected oropharyngeal dysphagia?

Answer 24

Videofluroscopic modified barium swallow

evaluates swallowing mechanics, degree of dysfunction, and severity of aspiration

Question 25

What is the recommended management for variceal hemorrhage if there is continued bleeding after endoscopic therapy?

Answer 25

Balloon tamponade (until TIPS or shunt surgery)

Question 26

What is the recommended management for variceal hemorrhage if there is no further bleeding after endoscopic therapy?

Answer 26

Secondary prophylaxis (beta blocker) with repeat endoscopic band ligation 1-2 weeks later

Question 27

What is the standard triple therapy for the treatment of H. pylori infection?

Answer 27

PPI, clarithromycin, and amoxicillin

Question 28

What is the test of choice for confirming the diagnosis of Zenker's diverticulum?

Answer 28

Barium esophagram

Question 29

What is the treatment for acute pancreatitis from uncorrectable causes (e.g. ischemia, atheroemboli)?

Answer 29

analgesics and IV fluids (supportive care)

Question 30

What is the underlying cause of edema in patients with cirrhosis?

Answer 30

Hypoalbuminemia (synthetic dysfunction)

Question 31

What is the underlying cause of esophageal/anorectal varices and caput medusae in patients with cirrhosis?

Answer 31

Portal hypertension

Question 32

What is the underlying cause of fat malabsorption in patients with Zollinger-Ellison syndrome?

Answer 32

pancreatic enzyme inactivation due to excess gastric acid in the small intestine

Question 33

What is the underlying cause of megaloblastic, macrocytic anemia in an alcoholic with elevated methylmalonic acid levels?

Answer 33

Cobalamin (B12) deficiency elevated methylmalonic acid level is more sensitive in detecting B12 deficiency than serum vitamin levels alone

Question 34

What is the underlying cause of megaloblastic, macrocytic anemia in an alcoholic with normal methylmalonic acid levels?

Answer 34

Folate (B9) deficiency

Question 35

What is the underlying cause of splenomegaly in patients with cirrhosis?

Answer 35

Portal hypertension the spleen drains into the portal vein via the splenic vein

Question 36

What is the underlying cause of testicular atrophy and gynecomastia in patients with cirrhosis?

Answer 36

Hyperestrinism other manifestations include spider angiomas, palmar erythema, and loss of sexual hair

Question 37

What is the underlying etiology behind most MALT lymphomas of the stomach?

Answer 37

H. pylori infection those with early-stage MALT lymphoma and confirmed H. pylori infection typically achieve complete remission with antibiotic treatment

Question 38

What is the underlying etiology of gallstones in patients on total parenteral nutrition?

Answer 38

Gallbladder stasis proteins and fatty acids in the duodenum normally stimulate release of CCK which then stimulates gallbladder contraction; this stimulus is absent in TPN (typically manifests after \> 2 weeks of TPN)

Question 39

What musculoskeletal pathologies are associated with primary biliary cholangitis?

Answer 39

osteoporosis/osteomalacia precise etiology is not clear; other complications include malabsorption and hepatocellular carcinoma

Question 40

What pathological finding is found in the CT scan below (arrow)?

Answer 40

Porcelain gallbladder

Question 41

What pharmaceutical therapy is recommended for prophylactic treatment of non-bleeding esophageal varices?

Answer 41

Non-selective beta blockers (e.g. propanolol, nadolol) endoscopic variceal ligation can be used as an alternate primary prevention therapy in patients with contraindications to beta blockers or those with large esophageal varices

Question 42

What pharmaceutical treatment is helpful for delaying the progression of primary biliary cholangitis?

Answer 42

Ursodeoxycholic acid should be initiated as soon as the diagnosis of PBC is made; patients with advanced disease may require liver transplantation

Question 43

What procedure should be done prior to endoscopic treatment in patients with upper GI bleed who have a depressed level of consciousness and continued hematemesis?

Answer 43

Endotracheal intubation these patients are at high risk for aspiration and must have their airway protected before upper endoscopy

Question 44

What serologic marker for HBV is indicative of infectivity?

Answer 44

HBeAg

Question 45

What serologic marker for HBV remains positive throughout the window period?

Answer 45

IgM anti-HBc may be the only diagnostic marker for acute HBV infection during this time

Question 46

What serologic markers (2) should be measured to diagnose acute HBV infection?

Answer 46

HBsAg and IgM anti-HBc both are elevated during the initial infection and anti-HBc

Question 47

What surgical procedure is preferred for biliary drainage for patients with acute cholangitis?

Answer 47

ERCP with sphincterotomy other options include percutaneous transhepatic cholangiography and open surgical decompression

Question 48

What test can be used to evaluate for gastrinoma in patients with non-diagnostic serum gastrin levels?

Answer 48

Secretin stimulation test a rise in gastrin levels following secretin administration indicates gastrinoma

Question 49

What test is most accurate for diagnosis of achalasia?

Answer 49

Esophageal manometry findings include high LES resting pressure and incomplete LES relaxation; barium esophagram is sometimes used as an initial test

Question 50

What test is used to differentiate between achalasia and pseudo-achalasia?

Answer 50

Endoscopy thus, endoscopy is recommended to exclude malignancy in all patients with suspected achalasia

Question 51

What test is used to establish the diagnosis of diffuse esophageal spasm?

Answer 51

Esophageal manometry findings include repetitive, non-peristaltic, high-amplitude contractions

Question 52

What test is used to establish the diagnosis of spontaneous bacterial peritonitis?

Answer 52

Paracentesis diagnostic criteria: positive ascites fluid culture and PMN \> 250/mm3; should be done before antibiotic therapy, which often results in negative ascites cultures

Question 53

What test/imaging study is used for diagnosis of acute diverticulitis?

Answer 53

Abdominal CT scan (oral and IV contrast) sigmoid- and colonoscopy are contraindicated due to risk of perforation

Question 54

What test/imaging study is used to diagnose a Mallory-Weiss tear?

Answer 54

Endoscopy

Question 55

What test/imaging study is used to diagnose esophageal cancer?

Answer 55

Endoscopy with biopsy may use CT or PET/CT for staging

Question 56

What test/procedure is used to exclude malignancy in patients diagnosed with achalasia?

Answer 56

Endoscopy

Question 57

What tuberculosis drug is most commonly associated with liver injury?

Answer 57

Isoniazid idiosyncratic injury with histological features similar to those seen with viral hepatitis (e.g. hepatic cell necrosis, mononuclear infiltration)

Question 58

What tuberculosis drug occasionally causes pellagra?

Answer 58

Isoniazid isoniazid may interrupt niacin metabolism secondary to vitamin B6 deficiency

Question 59

What vaccinations are especially important in patients with chronic HCV infection?

Answer 59

HAV and HBV helps prevent further liver damage

Question 60

What vitamin/mineral supplements (2) are associated with pill esophagitis?

Answer 60

potassium chloride and iron

Question 61

Which diuretics (2) are first-line therapy for cirrhotic ascites?

Answer 61

furosemide and spironolactone

Question 62

Which form of dysphagia, oropharyngeal or esophageal, is characterized by coughing, choking, or nasal regurgitation on swallowing?

Answer 62

Oropharyngeal

Question 63

Which form of inflammatory bowel disease is characterized by continuous colonic involvement?

Answer 63

Ulcerative colitis

Question 64

Which form of inflammatory bowel disease is characterized by mucosal inflammation and crypt abscesses on biopsy?

Answer 64

Ulcerative colitis

Question 65

Which form of inflammatory bowel disease is characterized by non-continuous colonic involvement (skip lesions)?

Answer 65

Crohn disease can involve any part of the GI tract from mouth to anus

Question 66

Which form of inflammatory bowel disease is characterized by transmural inflammation and non-caseating granulomas on biopsy?

Answer 66

Crohn disease

Question 67

Which form of inflammatory bowel disease may present with aphthous ulcers and perianal skin tags/fissures?

Answer 67

Crohn disease

Question 68

Which form of inflammatory bowel disease typically spares the rectum?

Answer 68

Crohn disease

Question 69

Which is more common, primary liver cancer or metastasis to the liver?

Answer 69

Metastasis to the liver the most common sources of metastasis are the GI tract, lung, and breast

Question 70

Which laboratory value, amylase or lipase, is more sensitive (and useful) for diagnosis of acute pancreatitis?

Answer 70

Lipase

Question 71

Which side of the colon (right or left) does angiodysplasia typically occur?

Answer 71

Right versus diverticulosis, which typically arises on the left

Question 72

Which trace mineral deficiency manifests as brittle hair, neurologic dysfunction, and sideroblastic anemia?

Answer 72

Copper deficiency risk factors for deficiency include malabsorption, bowel resection, poor nutritional intake, and parenteral nutrition

Question 73

Which trace mineral deficiency manifests as impaired taste, alopecia, and pustular skin rash?

Answer 73

Zinc deficiency other features of zinc deficiency include hypogonadism, impaired wound healing, and immune dysfunction; risk factors for deficiency include malabsorption, bowel resection, poor nutritional intake, and parenteral nutrition

Question 74

Which trace mineral deficiency manifests as thyroid dysfunction and cardiomyopathy?

Answer 74

Selenium deficiency risk factors for deficiency include malabsorption, bowel resection, poor nutritional intake, and parenteral nutrition

Question 75

Which type of esophageal cancer is associated with GERD, Barrett esophagus, and obesity?

Answer 75

Adenocarcinoma

Question 76

Which type of esophageal cancer is associated with smoking and heavy alcohol consumption?

Answer 76

Squamous cell carcinoma

Question 77

Zenker diverticulum occurs due to posterior herniation between the fibers of the [...] muscle.

Answer 77

Zenker diverticulum occurs due to posterior herniation between the fibers of the **cricopharyngeal** muscle. immediately above the upper esophageal sphincter

Question 78

[...] syndrome results from intrapulmonary vascular dilations in the setting of chronic liver disease.

Answer 78

**Hepatopulmonary** syndrome results from intrapulmonary vascular dilations in the setting of chronic liver disease.

Question 79

[...] describes a narrowing of the distal esophagus secondary to causes other than denervation.

Answer 79

**Pseudo-achalasia** describes a narrowing of the distal esophagus secondary to causes other than denervation. e.g. malignancy; clues pointing to pseudo-achalasia include significant weight loss, rapid symptom onset (\< 6 months), presentation at age \> 60

Question 80

Cholesterol emboli may result in skin complications, such as [...] (pictured below) and blue toe syndrome.

Answer 80

Cholesterol emboli may result in skin complications, such as **livedo reticularis** (pictured below) and blue toe syndrome.

Question 81

[...] emboli may result in skin complications, such as livedo reticularis (pictured below) and blue toe syndrome.

Answer 81

**Cholesterol** emboli may result in skin complications, such as livedo reticularis (pictured below) and blue toe syndrome.