GI-CASEs

Question 1

1. A 40 yo female c/o severe RUQ pain after eating fatty meals intermittently over the past several weeks. On exam she has a soft, obese abdomen with active bowel sounds, negative Murphy’s sign, tender to deep palpation in the RUQ, no HSM or jaundice; her exam is otherwise unremarkable. What diagnostic study should you order to make the diagnosis?

Answer 1

· Abdominal US is the diagnostic study of choice for evaluating biliary colic and diagnosis of cholelithiasis

Question 2

2. A 36 yo female had a baby 6 months ago and reports that she sometimes has blood in her stool. The blood is bright red on the toilet paper, not in the toilet bowl. On examination you do not find any anal fissure, active bleeding or prolapsing hemorrhoids; guaiac is positive. What is the most likely diagnosis?

Answer 2

· Hemorrhoids

Question 3

3. A 60 yo male c/o pain in the middle of his chest, worse at night, for the past few months; it is getting worse. He has tried Tums, which helped initially but no longer help. He eats dinner late and has a few beers after dinner while he watches TV in his recliner. He notes a sour taste in his mouth lately. On exam he has a BMI of 29 and mild epigastric tenderness on deep palpation. What is the pathophysiology of his problem?

Answer 3

· Gastric acid refluxing from the stomach into the esophagus from relaxation/hypotension of the lower esophageal sphincter; may be associated with hiatal hernia

Question 4

4. What is the appropriate management of the above patient?

Answer 4

· PPI or H2 blockers for GERD; lifestyle modifications including decreased alcohol, eating dinner earlier, remain upright after eating, less fatty foods, weight loss

Question 5

5. A 27 yo male comes in for a routine physical exam; he has no complaints, no PMH, no meds, no significant FH; VSS, PE is unremarkable. His labs are normal except a mildly elevated total bilirubin. What is the most likely cause of elevated bilirubin?

Answer 5

· Gilbert’s syndrome

Question 6

6. A 65 yo male presents for his “welcome to Medicare” physical. He heard about recent recommendations for hepatitis testing in his generation. He denies past or present IVDU, he has been in a monogamous marriage for 43 years, he never served in the military or lived abroad, and has been an accountant for 40 years. What do you recommend for hepatitis testing?

Answer 6

· Screening for hepatitis C (with anti-Hep C IgG) is recommended based on his age; hepatitis B risk factors are not present

Question 7

7. The above patient tests positive for the Hep C antibody. What is the next step in his management?

Answer 7

· HCV RNA to determine viral load; refer patient to GI/Hepatologist for genotype, abdominal US, possibly liver biopsy, to determine if treatment is indicated.

Question 8

8. A 34 yo female c/o intermittent diarrhea and constipation, bloating and gas for several months, maybe longer. Her symptoms do not seem related to foods, milk, but may be worse with stress; she has no travel history. No weight loss, blood/mucous in stool, recent antibiotic use. You order labs, including CBC, CMP, TTG, stool culture; all results are normal. What is the most likely diagnosis?

Answer 8

· Irritable bowel syndrome

Question 9

9. A 52 yo male c/o abdominal pain and bloody diarrhea x 2 days; he reports low grade fever, no nausea/vomiting. He had an episode like this a few years ago. No recent travel, antibiotics. On exam he has a tender LLQ, no peritoneal signs, guaiac positive, otherwise unremarkable. What is the best treatment for his current complaint?

Answer 9

· Ciprofloxacin + metronidazole for acute diverticulitis

Question 10

10. A 72 yo alcoholic c/o severe, constant epigastric pain radiating straight through to the back x 1 day. Labs indicate elevated amylase and lipase. What is the pathophysiology of this problem?

Answer 10

· The pathogenesis of chronic pancreatitis appears to be multifactorial, and is probably initiated by two distinct events. The first is a decrease in bicarbonate secretion, due to either functional impairment caused by genetic abnormalities of the ductal cells, or mechanical obstruction such as strictures or tumors. The second involves intraparenchymal activation of digestive enzymes within the pancreatic gland. This may be due to genetic abnormalities (such as those seen in hereditary pancreatitis) that directly cause impairment in enzyme activation and regulation or predispose to toxic injury from environmental exposures, such as alcohol.

Question 11

11. A 38 yo female c/o severe RUQ pain x 5 days; it was intermittent and worse after meals but it is constant x 1 day, associated with nausea/vomiting. On exam she has a low grade fever, tenderness in the RUQ with a positive Murphy’s sign, no jaundice or peritoneal signs. What is the most likely diagnosis?

Answer 11

· Acute cholecystitis

Question 12

12. A 24 yo male c/o abdominal pain, fever, nausea and vomiting x 4 days. He was on a kayaking trip in Mexico about a month ago. No medications or PMH. VSS; PE indicates a WDWN, mildly dehydrated male who appears moderately ill but not toxic, skin appears jaundiced, sclera anicteric, abdomen diffusely tender with marked tenderness in the RUQ and mild hepatomegaly, no peritoneal signs, no splenomegaly, negative Murphy’s sign. His AST/ALT are markedly elevated, with the ALT significantly higher. What is the most likely diagnosis?

Answer 12

· Acute hepatitis A

Question 13

13. A 28 yo female with h/o Crohn’s disease presents with acute abdominal pain and diarrhea x 3 days. She admits to dietary indiscretion and stress recently. She is not taking any medications currently. What is the best management of her today?

Answer 13

· Restart sulfasalazine, manage symptoms with anti-diarrheal, have patient follow up with her GI doctor

Question 14

14. What is the pathophysiology of this condition?

Answer 14

· Transmural inflammation and thickened wall of the entire GI tract, often occurring in “skips”

Question 15

15. A 44 yo male with chronic hepatitis B comes in for a routine visit; he had labs done last week and wants to discuss the results. He is HBeAg positive; His AST/ALT are stable, mildly elevated; HBV DNA low. What is the management plan of this patient?

Answer 15

· Monitor LFT’s, HBeAg every 3-6 months; refer to GI if ALT becomes significantly elevated

Question 16

16. A 48 yo male with h/o ulcerative colitis returned 2 days ago from China and c/o abdominal pain and cramping, bloody diarrhea, and malaise. What is the best course of action for this patient?

Answer 16

· Order stool culture, stool O&P; consider starting antibiotic empirically for traveler’s diarrhea (Cipro 500mg po bid x 5 days), possibly oral steroids to control IBD symptoms; have patient follow up with GI doctor

Question 17

17. A 70 yo male c/o dysphagia, difficulty swallowing and regurgitating his food; this problem has been present for about a year, and is getting worse. You order a barium swallow to confirm your suspected diagnosis. What is the pathophysiology of this condition?

Answer 17

· Zenker’s diverticula are outpouchings of the esophageal wall

Question 18

18. A 77 yo female presents to the ED with “coffee ground” emesis x 3 for the past 36 hours. She reports epigastric pain, worse on an empty stomach, for the past several weeks. She takes ibuprofen 600mg tid for arthritis, no other meds, NKDA. She is stable on exam, labs appear normal. What is the diagnostic study to confirm the suspected diagnosis?

Answer 18

· Upper GI endoscopy to evaluate for gastric ulcer/upper GI bleeding

Question 19

19. Mrs. Watson, the above patient, tests positive for H. pylori. What is the recommended initial treatment regimen?

Answer 19

· Standard dose PPI bid + clarithromycin 500mg po bid + amoxicillin 1000mg po bid x 10-14 days

Question 20

20. What are the indications for colonoscopy?

Answer 20

· Signs/symptoms: abnormal imaging, lower GI bleeding, unexplained iron deficiency anemia, lower GI symptoms (eg: chronic diarrhea)
· Screening/surveillance: colon polyp, colon cancer, inflammatory bowel disease
· Therapeutic: polypectomy, localization of lesion, FB removal, decompression of sigmoid volvulus or colonic pseudo-obstruction, balloon dilation of strictures, palliative treatment of bleeding or stenosed neoplasms, placement of percutaneous endoscopic cecostomy tube