GI med

Question 1

45 yo woman. severe abdominal pain. after meals episodes of epigastric and RUQ pain and nausea. diffuse abdominal tenderness and guarding over upper abdomen. next step in manageemtn?

Answer 1

upright x ray of chest and abdomen!!!

-> perforated peptic ulcer

positive stool guaic test points away from bilary colic

Question 2

In alcoholic liver disease with cirrhosis/ascites, what intervention would most significantly decrease both liver inflammation and portal pressure?

Answer 2

complete alcohol cessation

Question 3

66 yo woman. frequent laxatives for constipation. now develops c difficle positive diarrhe after antibiotics for an infection. other medications include omeprazole and metformin daily. in addition to recent antibiotic use, which other factor most likely predisposed patient to current condition?

Answer 3

gastric acid suppression!!! -> omeprazole

other factors: age>65, recent hospitalisation

note, greatest risk factor = recent antibiotic use

Question 4

36 yo, blood on toilet paper after defecating. no constipation. digital rectal exam normal except for traces of blood on glove. next step in management?

Answer 4

anoscopy!! - minimal bleeding most likely due to hemorrhoids or fissures

note if at least 45 regardless of symptoms, you should have colonoscopy screening

Question 5

Key test used to diagnose lactose intolerance?

Answer 5

hydrogen breath test!!!

also positive STOOL test for reducing substances not urine, low stool pH and increased stool osmotic gap.

Question 6

asymptomatic jaundice in patient

conjugated bilirubin elevated ( so not unconjugated as seen in gilberts!)

and also dark urine/bilirubin in urine and abnormal liver biopsy showing dark, granular pigments in hepatocytes.

mechanism behind condition?

Answer 6

impaired hepatocyte bilirubin excretion!!!

= dubin johnson syndrome

Question 7

In acute GI bleed, what is the hemoglobin threshold for packed rbc transfusion?

Answer 7

Hb <7 !!

or Hb <9 if unstable with ACS or active bleeding and hypovolemia

Question 8

9 year old boy with familial adenomatous polyposis. colonscopy shows several small non dysplastic polyps which are removed. best initial management for patient?

Answer 8

frequent colonoscopic surveillance!!!

(can have elective total proctocolectomy in late teens or twenties)

(urgent proctocolectomy is performed only if high grade dysplasia is noted, hemorrhage, significant increase in polyps between screenings)

Question 9

woman with primary billiary cholangitis is at risk of what complication in addition to HCC?

Answer 9

osteopenia!!!

linked to poor vitamin D absorption due to imparied bile secretion

Question 10

patient being treated for siezure disorder. last siezure 3 months ago. persistent abdominal pain, low grade fever, appetitie loss. CT abdomen shows peripancreatic fluid and fat stranding !! learn image

diagnosis?

Answer 10

drug induced pancreatitis!

Question 11

severely elevated LFTS + signs of hepatic encephalopathy (confusion, somnolence, flapping tremor) and raised INR
been taking hydrocodone-acteminophen for spinal stenosis, and acetaminophen for toothache. drinks 2 shots of whisky daily

most likely diagnosis?

Answer 11

medication induced liver injury!!!

patient has acute liver failure and acetaminophen toxicity is most common cause!!

likely accidental as taking drug from multiple sources

risk of this also increased by chronic alcohol use

NOT hep C as it causes chronic hepatitis. hep A, B,D,E more typical causes of ALF

Question 12

dyspnea. ascites, hepatospleenomegaly. history of bacterial endocarditis due to drug use. but no jugular venous distention.

cause of patients ascites/presentation?

Answer 12

chronic liver disease!!! = most common cause

NOT right sided HF as you would expect raised JVP

Question 13

ascites + stigmata of CLD (spider angioma) + abnormal LFTs = cirrhosis. etiology in this patient is likely chronic alcohol use. has fatigue and intermittent nausea. Abdominal USS shows ascites and shrunken liver with no mass

next step in management?

Answer 13

Upper GI endoscopy!!!

newly diagnosed cirrhosis is managed by identfying and treating potential complications = variceal hemorrhage!! and HCC

management of decompensated cirrhosis:

1. treat ascites = diuretics = furosemide pluss spirinolactone
2. variceal hemorrhage = beta blocker!!! eg nadolol!!!!!, repeat EGD every year
3. if encephalopathy = lactulose therapy

management of compensated cirrhosis (no ascites, no variceal hemorrhage)
1. US surveillance for HCC + afp level every 6 months
2. EGD varices surveillance

not liver biopsy because etiology is obious as patient drinks.

Question 14

IF basic screening tests are negative and symptoms are IBS like abdominal pain, diarrhea/constipaiton, symptoms worsen or improve with bowel movements, passage of mucus and no alarm features like weight loss or raised CRP.

you dont need a colonoscopy!!!
you can just diagnose IBS

Question 15

hyperestrogenism causes the pathogenesis of what findings in liver cirrhosis?

Answer 15

spider angioma !!
palmar erythema!!
testicular atrophy, gynaecomastia, loss of pubic hair

NOT caput medusae or varices, spleenomegaly, ascities which are caused by portal HTN

Question 16

signs of prerenal aki (no casts etc) in advanced liver disease . no improvement in AKI with IV saline.

most likely mechanism of renal dysfunction?

Answer 16

cirrhosis associated splanchic vasodilation!!!

patient has developed hepatorenal syndrome. liver transplant is the only definitive treatment

NOT intravascular volume depletion as this would respond to IV saline

Question 17

recurrent episodes of cramping rectal pain not associated with defecation or anything else. normal exam. most likely diagnosis?

Answer 17

proctalgia fugax!

not sacral nerve compression = sacral or buttock pain radiating down one leg. urinary, fecal incontinence, sexual dysfunction common

coccndynia is seen in obese women, traumatic injury. rectal exam reveals tenderness on palpation of coccyx

Question 18

management for hereditary hemochromatosis?

Answer 18

phlebotomy!!!

NOT penicillamine! -> used for wilsons disease which has psychiatric manifestations

Question 19

23. nausea, vomiting, full after a few bites. 7kg weight loss. relief after vomiting but worried about weight loss

type 1 diabetes since age 5 and is on insulin

next step in management?

Answer 19

gastric emptying study!!!!! (+ ix for obstruction/endoscopy)

most likely gastroparesis

NOT CBT or SSRI as psych disorders are diagnosis of exclusion

Question 20

in severe cases of acute cholangitis, hypotension and altered mental status can occur!!
and anion gap metabolic acidosis can be present due to lactic acidosis in severe sepsis!!!

Question 21

6 months intermittent abdominal pain + nausea
dull epigastric pain 15-30 minutes after meals
relieved by leaning forward
not releived by antacids
occasional diarrhea
weight loss
smokes and drinks daily

next step in diagnosis?

Answer 21

CT abdomen!!! - will show pancreatic calcifications

clues to chronic pancreatitis =
chronic pain releived by lening forwad!!

malabsorption = wieght loss! and steatorrhea!

late stages - can cause diabetes

NOTE. in a patient with no risk factors for chronic pancreatitis so no huge/extensive alcohol or smoking, and xray of abdomen was normal and a history of mI/ vascular disease -> mesenteric ischemia is more likely diagnosis!!!

Mesenteric ischemia = chronic postprandial pain, food aversion, weight loss. may experience diarrhea!!

Question 22

serum albumin = 3.8
ascitic albumin = 2.5

likley aetiology of asciitis?

Answer 22

portal hypertension!! - increased hydrostatic pressure. SAAG = 1.3 which is >/= 1.1

the pathology of increased capillary permeability is seen in malignant ascites

Question 23

pleural effusion in a patient with cirrhosis and ascites

most liekly cause and mechanism?

Answer 23

hepatic hydrothorax!! = defects in the diaphragm

NOT hepatopulmonary syndrome = intrapulmonary vascular dilations = increased dyspnea/oxygen desaturation whilst upright

Question 24

recent onset constipation in patient with downs syndrome. all vitals and everything else normal. in addition to increased fibre and water, next step in management?

Answer 24

thyroid function studies!!! -> risk of hypothyroidism in downs!!!

also have to check for diabetes and hypercalcemia = other causes

downs = risk for endocrine disorders

Question 25

patient with cirrhosis is on diuretics and develops hepatic encephalopathy low potassium levels on labs in addition to lactulose, what other management is needed?

Answer 25

repletion of potassium!! in hypokalemia, K+ ions are excreted by cells and replaced by H+ ions, increasing NH3+/ammonia production

Question 26

16 YO with constipation, cold intolerance and bradycardia. BUT BMI is 18 and there is hypotension feels her stomach is puffing up (distorted body image) most likely diagnosis?

Answer 26

anorexia nervosa!!! -> classic signs

Question 27

nausea, postprandial vomiting reflux and dysphagia following gastric bypass surgery next step in management?

Answer 27

EGD !! -> to diagnose stomal stenosis not avoidance of simple carbs -> this helps in dumping syndrome. another complication of bypass whcih in addition to abdominal pain nausea and diarrhea, has hypotension, tachycardia, diaphoresis, dizziness not a gastric emptying scan!! -> this is used for diagnosing gastroparesis which presents with postprandial pain, vomiting and early satiety. in light of recent. bypass... egd is more imortant to rule out stenosis.

Question 28

fecal urgency, 6 bowel movements a day. ocasionally at night (chronic non bloody diarrhea) takes nsaids fo arthritis!!! (History of autoimmune disease) no other symptoms lymphocytic infiltration of lamina propria and thickened subepithelial collagen band on colonoscopy most likely diagnosis?

Answer 28

microscopic colitis!! not laxative misues -> colonoscopy in this case may show brown discoloration!!!!!! and C diff will have psuedomembranes/white plaques on colonsoscopy and fever

Question 29

diarrhea and steatorrhea. low urinary d-xylose on d-xylose administration test after treatment with rifaximin the test is repeated and urinary d-xylose still low. most likely diagnosis?

Answer 29

coeliac disease!!! (dxylose absorbed in small bowel) normal levels would point to malabsorption due to enzyme deficiencies eg chronic pancreatitis! bacterial overgrowth/SIBO causes falsely low levels of d-xylose but this is treated with rifaximin

Question 30

watery diarrhea after returning from holiday in belize. labs and bloods all fine except for raised creatinine and BUN most likley pathogen?

Answer 30

travellers ecoli!! loss of volume from diarrhea -> pre renal aki!! not shiga toxin ecoli = bloody diarrhea!, anemia, thrombocytopenia. and intrinsic kidney damage so BUN/cr ratio <20

Question 31

duodenal ucler treatment?

Answer 31

antibiotics + omeprazole!!! antibiotics needed for hypylori eradication

Question 32

most important fluid analysis to do on ascitic fluid?

Answer 32

cell count and differential! albumin total protein

Question 33

gonococcal proctitis -> mucopurulent anal discharge, itchiness, tenesmus

Question 34

learn the birds beak sign on barium swallow for achalasia

Question 35

Septic shock and then developed liver transaminases in the thousandss, most likely diagnosis?

Answer 35

ischemic hepatitis

Question 36

nausea early satiety abdominal discomfort after eating that is relieved by vomiting!!! history of T2DM!!! Endoscopy demonstrates partially digested food medical management? diagnosis?

Answer 36

metoclopramide!!!- in addition to glycemic control, small frequent meals (diabetic) gastroparesis!! Postprandial vomiting and retained food on endoscopy is not typical of chronic pancreatitis. pancreatitis also has steatorrhea

Question 37

Variceal bleed. In addition to IV saline and antibiotics, what do you give next?

Answer 37

octreotide infusion! (or telipressin) then after you do endoscopy

Question 38

IBS symptoms with constipation not diarrhea next step in management?

Answer 38

Trial of psyllium!!! (soluble fibre) coeliac disease testing and fecal calprotectin only indicated for those with IBS-D to rule out IBD, and coeliac disease

Question 39

athralgias + diarrhea + positive PAS in small bowel + murmur most likely diagnosis?

Answer 39

whipples disease NOT tropical sprue unless youve been in tropics

Question 40

pain on right side of abdomen recently completed a course of chemo abdominal exam normal lightly brushing the skin to the right of the umbilicus elicits intense pain what else is patient most likely to develop?

Answer 40

skin lesions!! shingles reactivation

Question 41

pruritus, jaundice, all liver enzymes elevated and positive anti smooth muscle antibody next step in management?

Answer 41

prednisolone!!! NOT ursodeoxycholic acid = for PBC presents with +ve antimitochondrial antibodies

Question 42

coeliac disease can cause peripheral neuropathy

Question 43

ambdominal cramps, loos stools weight loss. foul smelling stools. no blood works in a day care centre/nursing home! next step in management?

Answer 43

stool antigen testing!!!!! or PCR!!! = Giardiasis bloating, loose oily, foul smelling stools NOT stool cultures as no abdominal tenderness or fevers so bacterial gastroenteritis unlikely

Question 44

post prandial abdominal pain, bloating and nausea. nothing else of note next step in evaluation?

Answer 44

lactose hydrogen breath test -> lactose intolerance!! NOT rifaximin as this is used for SIBO and there are no risk factors eg intestinal surgery, scleroderma

Question 45

Splenic infarct shown on CT. patient has long standing arthralgia and thrombocytopenia on bloods. next step in management?

Answer 45

ANA antibodies -> rule out lupus not infectious mono, doesnt cause infarct but causes spleenomegaly.

Question 46

diarrhea that persists while fasting and occurs at night. low stool osmotic gap what type of diarrhea does patient have? history of gunshot wound to abdomen

Answer 46

secretory diarrhea! -> in this case most likely due to unabsorbed bile acids due to post surgical changes toxins, VIPomas, CF are other causes of secretory diarrhea not intestinal dysmotility as associated with nausea and vomiting

Question 47

dyspnea, macrocytic anemia and hypersegmented neutrophils on blood smear. normal methylmalonic acid levels!! severe alcohol use!!! most likely diagnosis?

Answer 47

folate deficiency!! *pancytopenia can occur!! *and also hyperhomocysteinemia not cobalamin deficiency as methylmalonic acid levels would be high!

Question 48

episodes of chest pain precipitated by emotional stress or hot or cold food + episodes of regurgitation. next step in management?

Answer 48

esophogeal motility studies/ monemetry diffuse esophageal spasm

Question 49

drugs causing pancreatitis and should be stopped if suspected

Answer 49

hydrochlorothiazide, furosemide

Question 50

drinking several beers at a party. experimenting with cocaine and then took several apsirins for hangover. single episode of vomiting with blood most likely cause?

Answer 50

gastric mucosal erosion!!! NOT partial esophageal tear - less likely from 1 episode of vomiting

Question 51

differentiate acute colonic ischemia vs stress ulcer findings after shock

Answer 51

acute colonic ischemia = crampy left abdominal pain and hematochezia stress ulcer = occult or gross bleed. no abdominal pain usually

Question 52

first line ix for acute pancreatitis?

Answer 52

serum lipase and amylase!! CT only done if diagnostic uncertainty

Question 53

Aortic stenosis + renal impairment + painless Gi bleed most likely cause?

Answer 53

angiodysplasia!! as and renal impairment are associations treat with cautery

Question 54

episodic pounding sensation in neck (due to flushiing) + chronic diarhea + tricuspid regurg most likely diagnosis?

Answer 54

carcinoid syndrome also bronchospasm and telangiectasia can occur!! urinary 5HIAA test

Question 55

anemia of chronic disease is not associated with osteoarthritis!! so if a patient with OA has anemia and is on naproxen. most likely cause?

Answer 55

IDA -> gi bleed

Question 56

diarrhea for long number of days but negative extensive workup next step in management?

Answer 56

stool osmolality!! also stool electolytes and osmotic gap factitious diarrhea!

Question 57

somnolent patient and continuous hematemesis. next step in management?

Answer 57

endotracheal intubation! have to secure airway

Question 58

Non alcohol fatty liver disease pathogenesis?

Answer 58

insulin resistance!!!! which causes increasedd peripheral lipolysis

Question 59

a question on RUQ pain and jaundice. what is most useful in establishing the diagnosis. answer was NOT USS but it was substance use disorder history!!! -> because of the AST to ALT ratio!!!

Question 60

Zenker diverticulum signs (dysphagia, regurgitation of undigested food, fluctuant neck mass) mechanism behind this. Distraction was patient also had GERD.

Answer 60

Abnormal esophageal motor function (Ambos ppq)

Question 61

Most common type of TEF?

Answer 61

Esophageal atresia with tracheoseophageal fistula to the DISTAL esophageal segment