GI 3

Question 1

1. Occurs in Old Institutionalized Men (Nursing Home) they presents with abdominal pain, constipation or diarrhea, active bowel sounds and DISTENDED ABDOMEN WITHOUT ANATOMIC Obstruction. Dx?
2. Test?
3. Management?
4. What if no improvement with initial management?
   Whom is it contraindicated ?
5. Next step in Management for those that fail that treatment?

Answer 1

Ogilvie Syndrome. (Risk Factors: medications, dementia, electrolyte disturbance, recent surgery/injury/ trauma.)

2. CT scan shows Dilated Abdomen.

Conduct Serial Abdominal examinations to asses for Perforation

3. NG tube Decompression (Supportive Rx).
4. Give Neostigmine if no improvement after 48 hrs.
   (It is toxic & Contraindicated in Cardiac disease or Active bronchospasm - causes hypotension and bradycardia)
5. Colonoscopic or Surgical Decompression for those who fail neostigimine

Question 2

Pt with Celiac Disease and Poor Adherence to diet. He presents with 3 months of Abdominal Pain, Melena and Diarrhea, Night Sweats and Weightloss ?

Answer 2

Enteropathy-Associated T cell lymphoma. (Small Bowel Lymphoma)

Strict Gluten Free diet reduces risk.

Question 3

What is common in an elderly institutionalized patient with Diffuse Tender Distended Abdomen with Air Filled Sigmoid Colon?

Rx?

What does air under the diaphragm indicate?

Answer 3

Sigmoid Volvulus

Sigmoidoscopy

Perforation

Question 4

1. Vomiting, Preformed toxin in rice?
2. Vomiting, Symptoms occur within 1-6 hrs, preformed toxin? (Picnic)
3. Vomiting, diarrhea due to Raw or Undercooked Shellfish ?
4. Watery diarrhea due to Abx exposure?
5. Watery diarrhea due to Undercooked or Unrefrigerated food
6. Watery diarrhea due to undercooked Poultry & Eggs?
7. Watery diarrhea (bloody if there is shiga-toxin producing due to undercook Beef and Foods contaminated with bovine feces?
8. Bloody diarrhea associated with contaminated food and water especially during travel outside US?
9. Bloody diarrhea associated with Raw and Undercooked Meats/Poultry, seen in Children and Young adults

Answer 4

1. Bacillus Cerus
2. Staph
3. Vibrio
4. C. Diff
5. C. Perfrinigens
6. Salmonella
7. E. Coli, travelers diarrhea
8. Shigella
9. Camplylobacter

Question 5

1. Management of Infected Necrotizing Pancreatitis ?
2. Next step in management if they fail that treatment?

Answer 5

1. Treat empirically with abx (Carbepenem or Levaquin+ Metronidazole ) OR Perform CT-guided FNA to Help direct abx treatment
2. Necrsecotmy (Surgical Debridement)

Question 6

1. What is the initial management of a UC flare?
2. When do you give antibiotics?
3. What happens if they are refractory to initial treatment.

Answer 6

1. Systemic Steroids + High dose 5 aminosalicyclic Acid (Mesalamine)
2. Give Abx in Severe UC when patient has Signs of Systemic Toxicity (Fever, Marked Leukocytosis, Left shift)
3. If improvement transition to Oral steroids.
   When patients are refractory they require Cylosporine or TNF inhibitor, if no improvement after that then Colectomy.

Question 7

Chronic diarrhea and flushing. What is the metabolite associated with this disorder?

Answer 7

Carcinoid Tumor

Serum 5-hydroxyindoleacetic acid (serotonin metabolite)

Question 8

Chronic Abdominal Pain, Flushing, Hypotension, HA, Syncope, fatigue, Pruritus.

Dx?
Rx?

Answer 8

Mastocytosis

Serum Tryptase

Question 9

First initial test for Suspect Ischemic Colitis?

Answer 9

CT scan to r/o extensive bowel injury

Then Colonoscopy (Can see Areas of Petechiae and Bluish Areas)

Question 10

1. First step in management for Acute Upper GI Bleed?
2. What must be completed in first 24 hrs?
3. What are the HIGH RISK features (3) that warrant recurrent bleeding with Admission to Medical Ward on Clear Liquid Diet?

Answer 10

1. NPO, IVF, IV PPI
2. Endoscopy must be completed within 24 hrs
3. Active Bleeding, Adherent Clot, Visible Vessel

Needs hospitalization for atleast 3 days.

Question 11

Screening for Colonoscopy.

What 2 groups are at an increased risk ?

Answer 11

1. First-Degree Relative age < 60 with Colon Cancer or Adenomatous Polyps
2. (2) First Degrees at ANY Age with Adenomatous Polyp or Cancer.

Question 12

Management of a patient who Presents with DISTAL Hyperplastic Polyps on Colonoscopy.

What happens if they are Proximal?

Management of young patient with 30 small (< 10mm) Sessile Polyps seen in Fundus on Endoscopy?

Post polypectomy surveillance:

1. 1-2 tubular adenomas
2. 3-10 adenomas , > 10mm, villous histology, high grade dysplasia
3. > 10 adenomas

Answer 12

Colonoscopy every 10 years. Average Risk

If pt presents with > 5 and they are PROXIMAL then concerns for Hyperplastic Polyposis Syndrome (High Risk Cancer.)

Colonoscopy to check for Polyposis in colon genetic testing for FAP.

1. 5-10 yrs
2. 3 yrs
3. < 3 years

Question 13

1. Rx for Fulminant C diff?
2. Rx for C. Diff recurrence?

Answer 13

1. High dose Oral vancomycin and IV Metronidazole
2. Fidoxamicin or Pulse Tapered Vancomycin

Question 14

Difference between Acute onset Mesenteric Ischemia and Chronic Mesenteric Ischemia?

Answer 14

In Acute Mesenteric Ischemia Pain is Acute and Severe.

Associated with elevated lactate and Acidosis, Leukocytosis.

Question 15

Rx of severe UC?

Rx of Steroid Refractory Severe UC?

Answer 15

1. Systemic Steroids and High dose 5-ASA
2. Cyclosporine and TNF-inhibitor (Inflixmab)

Question 16

82 yo person with significant lower GI bleeding, Endoscopy and Colonoscopy reveals NO source of bleeding (No hemorrhoids, Diverticulosis, Malignancy or IBD) .

1. Dx?
2. What is this associated with?

Answer 16

1. Andgiodysplasia or (AVM)
2. Aortic Stenosis
   Seen in elder patients > 60.

Question 17

Pt presents with Abdominal Bloating, Flatulence, Bulky loose stools and Watery diarrhea 3-4x a week.
Pt is s/p Roux-En-Y.

Dx?
Test?

Answer 17

SIBO

Positive Hydrogen Breath Test
OR
Jejunal aspiration and Culture
(Showing high levels of Bacterial Colonization)

Question 18

Diabetic patient presents with watery diarrhea that wakes them up at night, fecal incontinence. Colonoscopy is Normal!

Dx?

Test?

Answer 18

SIBO
Ccommon in Diabetics due to Hypomolilty due to Autonomic Neuropathy - Diabetic Diarrhea

Hydrogen Breath Test
Jejunal Aspiration

Question 19

Pt presents with chronic Watery Diarrhea without bleeding.
Colonoscopy show grossly normal mucosa with lymphocytic infiltrates on biopsy.
Dx?
Initial treatment?
2nd line therapy?

Answer 19

Microscopic Colitis

Anti-diarrheals and stop offending agents (NSAIDs)

Oral Budesnoside

Question 20

Pt presents with Nausea, Vomiting, Lipase Elevation, Inability to Pass Gas, NO stool in rectal vault and NO Abdominal Distention

1. Dx?
2. What is the next step step in management?
3. Treatment for SBO?

Answer 20

1. Small Bowel Proximal Obstruction (Abdomen is distended with more distal disease) (Shows air-fluid levels and distended small bowel loops.)

—- Actual Anatomic Obstruction———

2. Plain upright CXR.
   Can do an CT Abdomen with Oral and IV contrast if AXR is not diagnostic
3. Non OPERATIVE: NPO, Fluid Resuscitation, Electrolyte Repletion and Serial abdominal examinations (Like Oligovie Syndrome)

Question 21

1. When patient presents with Positive Stool Occult Test and Iron Deficiency anemia what is the next step in management?
2. What if those test are negative?

Answer 21

1. Combination Upper Endoscopy and Colonoscopy
2. Conduct Wireless Capsule Endoscopy

Question 22

Hiker presents with Diarrhea, Steatorrhea, abdominal cramps and bloating.

Next step in management?

Answer 22

Stool Microscopy or Stool immunoassay for Giardia Cyst

Question 23

Management of Factious diarrhea:

1. Osmolality < 250?
2. Osmolality > 400?
3. When it is 250-400?

Answer 23

Osmotic gap < 50 = secretory diarrhea

Osmotic gap > 125 = osmotic diarrhea

1. Rule out water being added
2. Rule out urine being added
3. Check osmotic gap : if < 75 saline laxative (senna, Bisacodyl.)
   If > 75 then measure fecal fat and r/o lactulose, sorbitol, mag sulfate, poly glycol

Question 24

Pt presents with Rectal Tenesmus, Purulent Discharge, Small- Volume containing Stools.

Dx?

Organism?

Answer 24

Proctitis

N. Gonorrhoeae

Question 25

What is the preferred treatment for anal fissures?

Answer 25

Topical Nitroglycerin Cream (It improves blood floor to promote wound healing)

Question 26

Give Prophylaxis Recommendations for each: 1. Cirrhosis WITHOUT Varices or Small NonBleeding Varices 2. Medium Large Varices 3. Small Varices with Red Wale sign or Decompensated cirrhosis

Answer 26

1. No beta blockers Every 2-3 years in Compensated Disease Yearly in Decompensated 3. Endoscopic Variceal Ligation or Beta blocker (Propanolol, Nadolol), Yearly EGD 4. Beta blocker & Yearly EGD

Question 27

Asymptomatic Isolated Unconjugated Hyperbilirubinemia with Normal LFTS Dx? Rx?

Answer 27

Gilbert Syndrome No further testing or treatment needed

Question 28

Name 3 Extra-hepatic Causes of elevated LFTs?

Answer 28

1. Celiac Disease 2. Hypothyroidism 3. Muscle Disorders

Question 29

1. Initial Management when a patient presents with Ascites? 2. What is the next step if SAAG > 1.1. ? 3. What if Sodium is < 120 4. What if NO improvement and Serum Sodium > 120? 5. Management in Refractory Cases?

Answer 29

1. Rule out infection (PMN> 250) and calculate SAAG. (Serum Albumin- Ascitic Albumin ) 2. Due to Portal Hypertension Sodium Restrict Avoid NSAIDs, ACE Alcohol Cessation (Can cause AKI/Pre-renal Azotemia.) 3. Hypertonic Saline, Vasopressin 4. High dose Spironolactone and Oral Lasix 5. Large Volume Paracentesis, TIPS or Liver Transplant.

Question 30

Pt with hx of Chronic Peritoneal Dialysis presents with diffuse abdominal pain x 1 day, fever, abdominal tenderness, peritoneal fluid shows 110 WBCs. Next step in management?

Answer 30

Intraperitoneal Vancomycin and Cefepime

Question 31

Pt hospitalized for CAP develops Jaundice and Scleral icterus on day 4. D Bili and Alk phos are elevated. Dx?

Answer 31

Think Drug-induced Cholestasis Stop the offending agent

Question 32

22 yo M with Hx of Crohns disease presents with Diarrhea. 3 months ago he had Small bowel Obstruction that lead to Ileal resection. Since surgery he has had 4-5 loose bowel movements a day that disrupts his daily life. Dx? Rx?

Answer 32

Ileal resection leads to B12 and Bile Salt Malabsorption (Causes Secretory Diarrhea.) Cholestyramine

Question 33

66 yo M presents with abdominal pain and nausea. Yesterday he had a colonoscopy and 2 polyps were removed. His abdomen is tender in the periumbilical left lower quadrant areas. AXR shows no free air under the diaphragm. Dx? Next Step in Management?

Answer 33

Perforation CT Scan of Abdomen with Water Soluble Contrast. AXR can miss subtle changes.

Question 34

What is a Refractory Celiac Sprue? Why is this concerning?

Answer 34

Pt with persistent intestinal pathological changes despite strict Glute Free Diet. Pt do not present with B symptoms or Bloody Diarrhea. Refractory sprue can progression to EATL

Question 35

1. What is the initial screening test for Celiac Dz? 2. What is commonly order since it is also often associated with Celiac Dz? 3. What is the next step for patients with Positive serologies or Highly Suggestive Symptoms ? 4. What other test can be diagnostic? 5. What other things are associated with Celiac Dz?

Answer 35

1. Order Anti-transglutaminase IgA or Anti-endomysial IgA antibodies 2. Total serum IgA levels (IgA deficiency is commonly associated) 3. Small Bowel Enterosocpy with Biopsy ( Gluten free diet only after test is completed to prevent False Negatives) 4. Cutaneous Biosy to check for Dermatitis Hepetiformis. 5. Iron deficiency, Hypothyroidism, Osteoporosis

Question 36

1. Treatment for Mild Gallstone Pancreatitis? 2. Treatment for Severe Gallstone Pancreatitis? 3. Initial Treatment for Acute Cholangitis ?

Answer 36

1. IVF, Pain Medications (Stone will pass on its on) 2. IVF, Pain Medications --->ERCP (To help Remove Stone) and ---->then Cholecystectomy when inflammation has calmed down 3. IVF, Pain and Abx. Then ERCP, Then Cholecystectomy