GI System

Question 1

Gastroesophageal Reflux

Answer 1

overweight pt with burning retrosternal pain and heartburn from bending over, wearing tight clothes, lying flat in bed at night.
Relieved by antacids or OTC H2 blockers.
Dx: pH monitoring
May get Barrett esophagus or peptic esophagitis.
Dx: endoscopy and biopsies.
Tx: PPI, H2 blockers, antacids, surgery if meds can’t control it or get ulcers (radioablation or Nissen).

Question 2

Motility Problems of Esophagus

Answer 2

crushing pain with swallowing = uncoordinated massive contraction
solids swallowed with less difficulty than liquids = achalasia.

Question 3

Achalasia

Answer 3

usually women
Features: dysphagia worse with liquids, sit straight and wait to allow liquids past sphincter, regurgitation of undigested food.
Dx: x-ray shows megaesophagus, manometry
Tx: balloon dilation via endoscopy

Question 4

Esophageal Cancer

Answer 4

squamous cell in men who smoke and drink.
adenocarcinoma in long-standing GERD.
Features: progression of dysphagia from meat to solids to soft food to liquids to saliva, significant weight loss.
Dx: endoscopy and biopsy, barium swallow to prevent inadvertent perforation, CT scan
Tx: surgery

Question 5

Mallory-Weiss tear

Answer 5

Cause: prolonged forceful vomiting.
Features: hematemesis.
Dx: endoscopy
Tx: photocoagulation

Question 6

Boerhaave Syndrome

Answer 6

Cause: prolonged forceful vomiting with esophageal perforation.
Features: sudden, continuous, severe, wrenching epigastric and low sternal pain followed by fever, leukocytosis, sick patient.
Dx: contrast swallow
Tx: surgery

Question 7

Esophageal perforation

Answer 7

mostly from instrumental perforation.
Features: after endoscopy symptoms suddenly develop. Emphysema in lower neck.
Dx: contrast studies
Tx: surgery

Question 8

Gastric adenocarcinoma

Answer 8

elderly
Features: anorexia, weight loss, vague epigastric distress or early satiety, hematemesis.
Dx: endoscopy and biopsy, CT scan
Tx: surgery

Question 9

Gastric lymphoma

Answer 9

Features: anorexia, weight loss, vague epigastric distress or early satiety, hematemesis
Dx: endoscopy and biopsy
Tx: chemotherapy or radiotherapy, surgery if perforated.
Maltoma reversed if eradicate H pylori

Question 10

Mechanical Intestinal Obstruction

Answer 10

cause: adhesions in those with prior laparotomy
Features: colicky abd pain, protracted vomiting, progressive abd distention, no passage of gas or feces. Early on have high pitched bowel sounds with colicky pain, then silence.
Dx: x-ray shows distended loops ofbowel with air-fluid levels
Tx: NPO, NG suction, IV fluids, watch for strangulation, surgery if necessary

Question 11

Strangulated Obstruction

Answer 11

cause: compromised blood supply
Features: pt with mechanical intestinal obstruction symptoms develops fever, leukocytosis, constant pain, signs of peritoneal irritation, full-blown peritonitis and sepsis.
Tx: surgery

Question 12

Mechanical Intestinal Obstruction from Incarcerated Hernia

Answer 12

Features: pt with mechanical intestinal obstruction symptoms and potential strangulation but on exam have irreducible hernia that was reducible before.
Tx: surgery (emergent if strangulated, elective if viable bowel and reducible).

Question 13

Carcinoid Syndrome

Answer 13

cause: small bowel carcinoid tumor with liver metastases.
Features: diarrhea, facial flushing, wheezing, right sided heart valvular damage (increased JVD)
Dx: 24 hour urinary collection for 5-hydroxyindoleacetic acid

Question 14

Acute Appendicitis

Answer 14

Features: anorexia, then vague periumbilical pain that becomes sharp, severe, constant, and moves to RLQ, tenderness, guarding, rebound in RLQ, fever, leukocytosis in 10,000-15,000, neutrophilia and immature forms.
Dx: CT
Tx: appendectomy

Question 15

Right Colon Cancer

Answer 15

Features: anemia (hypochromic, iron deficiency) in elderly.
Dx: 4+ occult blood in stool, colonoscopy and biopsy
Tx: right hemicolectomy

Question 16

Left Colon Cancer

Answer 16

Features: bloody bowel movements, constipation, narrow stools.
Dx: flexible proctosigmoidoscopic exam and biopsy, colonoscopy, CT
Tx: chemotherapy and radiation, surgery

Question 17

Colonic Polyps

Answer 17

can be premalignant
range: most to least likely for malignancy
1. familial polyposis
2. familial multiple inflammatory polyps
3. villous adenoma
4. adenomatous polyp
non malignant: 
juvenile, Peutz-Jeghers, isolated inflammatory, hyperplastic

Question 18

Chronic Ulcerative Colitis

Answer 18

surgical indications:
disease >20yr
severe interference with nutritional status
multiple hospitalizations
need for high dose steroids or immunosuppressants
develop toxic megacolon
Tx: remove affected colon and rectal mucosa

Question 19

Toxic Megacolon

Answer 19

Features: abd pain, fever, leukocytosis, epigastric tenderness, distended transverse colon on x-ray with gas in colon wall

Question 20

Pseudomembranous Enterocolitis

Answer 20

cause: overgrowth of C. difficile in pt on antibiotics (historically clindamycin and cephalosporins)
Features: profuse watery diarrhea, crampy abd pain, fever, leukocytosis
Dx: toxin in stool
Tx: discontinue antibiotic, start metronidazole or vancomycin. colectomy if unresponsive to tx, WBC >50,000, and serum lactate over 5.

Question 21

Hemorrhoids

Answer 21

Internal: bleed
when prolapsed can be painful and itch.
Tx: rubber band ligation

External: hurt
Tx: conservative tx, surgery if fails

Question 22

Anal Fissure

Answer 22

young women
fissure usually posterior and midline.
cause: tight sphincter
Features: pain with defecation, blood streaked stool, avoid bowel movements, constipated, refuse anal exam
Tx: stool softeners, topical nitroglycerin, local botox injection, forceful dilation, lateral internal sphincterotomy.
CCB such as diltiazem ointment 2% TID topically 6 weeks

Question 23

Crohn Disease

Answer 23

affects anal area frequently
Features: fissures, fistulas, small ulceration, suspect when fail to heal or worse with surgery.
Tx: treat fistula with setons and remicade

Question 24

Ischiorectal Abscess

Answer 24

aka perirectal abscess
Features: febrile, perirectal pain where can’t sit or have BM, signs of abscess lateral to anus btw rectum and ischila tuberosity.
Tx: I & D, r/o cancer, if diabetic then watch for necrotizing soft tissue infection

Question 25

Fistula-In-Ano

Answer 25

in patient with previous ischiorectal abscess
cause: epithelial migration from anal crypts and perineal skin form permanent tract.
Features: fecal soiling, perineal dicsomfort, opening lateral to anus, cordlike tract felt, discharge.
Rule out necrotic and draining tumor
Tx: fistulotomy

Question 26

Squamous Cell Carcinoma of Anus

Answer 26

in HIV and homosexuals who receive.
Features: fungating mass grows from anus, metastatic inguinal nodes.
Dx: biopsy
Tx: Nigro chemoradiation then surgery if still there

Question 27

Hematemesis

Answer 27

usually upper GI source.

Dx: upper GI endoscopy

Question 28

Melena

Answer 28

shows digested blood

Dx: upper GI endoscopy

Question 29

Hematochezia

Answer 29

1. pass NG tube to aspirate gastric contents
   - blood shows upper GI source, do upper GI endoscopy
   - no blood and fluid is white means source is duodenum or below, do upper GI endoscopy
   - no blood and fluid is green excludes all upper GI

Question 30

Hematochezia, no upper GI bleeding

Answer 30

1. anoscopy - rule out hemorrhoids
2. rate of bleeding > 2mL/min => angiogram
3. rate of bleeding < 0.5mL/min => wait for bleeding to stop, colonoscopy
4. rates between 0.5-2mL/min => tagged red-cell study

Question 31

Hematochezia in kid

Answer 31

work up for Meckel diverticulum

Dx: technetium scan

Question 32

Massive upper GI bleed

Answer 32

In stressed, multiple trauma, complicated post-op patient is usually stress ulcer
Dx: endoscopy
Tx: angiographic embolization, maintain gastric pH above 4