Internal Medicine Essentials Questions: Gastroenterology and Hepatology

Question 1

Give the criteria for diagnosing IBS.

Answer 1

The Rome criteria:
•At least three days of abdominal pain each month for the last three months
•At least two of the following:
- Improvement with defecation
- Onset of pain associated with change in the consistency or frequency of stool

Also, they must not have any alarm symptoms: fever, onset after age 50, hematochezia, melena, family history of colon cancer, weight loss, and recent antibiotic use.

Question 2

Acute mesenteric ischemia can be caused by systemic hypotension or ______________.

Answer 2

thrombosis to either mesenteric artery

Question 3

A 50-year-old has acute lower-left quadrant abdominal pain and transmural inflammation of the colon on CT. What is this?

Answer 3

Diverticulitis! Don’t be tricked.

Treat with ciprofloxacin and metronidazole.

Question 4

Describe the features of dyspepsia and symptoms that warrant further workup.

Answer 4

• Early satiety
• Postprandial epigastric burning
• Lack of features on endoscopy (if done)
• Duration of symptoms lasting at least 3 months

Alarm symptoms:

• Onset after age 50
• Vomiting
• Weight loss
• Odynophagia
• Dysphagia
• History of PUD or gastric surgery
• FMH of gastric malignancy
• Lymphadenopathy or abdominal masses on exam

Question 5

GERD with dyspeptic features (early satiety, bloating, etc.) should be managed with ________________.

Answer 5

a PPI

Question 6

Describe the treatment and follow-up of H. pylori ulcer.

Answer 6

• Triple therapy for 14 days (omeprazole, amoxicillin, and clarithromycin)
• Omeprazole for another 14 days
• Follow-up with fecal antigen testing after completion of therapy

Question 7

Which ulcers need to be biopsied?

Answer 7

All of them

Even small, benign-appearing ulcers can harbor malignancy.

Question 8

A patient has painless jaundice and a cholestatic liver pattern. What is the proper initial diagnostic?

Answer 8

Abdominal ultrasound

If the US shows a dilated bile duct, then an ERCP should be done for removal of presumed gallstone.

Question 9

Give the criteria for metabolic syndrome.

Answer 9

Any three of the following:
•Triglycerides greater than 150
•HDL less than 50 in men and 40 in women
•Fasting glucose greater than 110
•BP greater than 130/85
•Waist greater than 40 inches in men and 35 in women

Question 10

NAFLD should be treated with ________________.

Answer 10

lifestyle interventions: diet and exercise

Question 11

Alcoholic hepatitis causes what vital sign abnormality?

Answer 11

Fever

Question 12

When is HCV treatment indicated?

Answer 12

When the patient has a detectable viral load and some kind of consequence of HCV infection (e.g., cirrhosis, transaminitis, liver inflammation on US)

Question 13

A patient from SE Asia has chronic HBV infection (indicated by HbSAg positivity and lack of HbSAg antibody). Describe how you should approach management.

Answer 13

•Draw LFTs.

• If the liver function is normal and there is no elevation of transaminases, then this person likely has immune-tolerant HBV. This is a classic pattern of perinatally-acquired HBV. In this case, monitor with serial transaminases.
• If the liver function labs are abnormal, biopsy the liver and start treatment with IFN-alpha and tenofovir.

Question 14

Describe how to calculate SAAG.

Answer 14

Serum albumin - ascites albumin

A value greater than 1.1 is suggestive of ascites.

Question 15

What is the recommended management of asymptomatic gallstones (that is, gallstones discovered incidentally)?

Answer 15

Observation

50% remain asymptomatic

Question 16

Those with ulcerative colitis and PSC are at increased risk of colorectal cancer and which other type of cancer?

Answer 16

Cholangiocarcinoma

Think of this if a patient with PSC presents with worsening jaundice.

Question 17

True or false: elevated bilirubin in a patient with gallstones is likely choledocholithiasis.

Answer 17

True, but cholecystitis can also cause mild elevations in bilirubin.

Question 18

List the two treatment strategies for cholangitis.

Answer 18

• ERCP (to remove the stone, if present)

* Antibiotics

Question 19

Describe the management of acute pancreatitis.

Answer 19

•Morphine
•IVF
•NPO
•Resume oral intake when symptoms improve
- If they can’t eat in 96 hours then consider NJ tube feeding.

Question 20

Which lab finding is suggestive of poor prognosis in pancreatitis?

Answer 20

Elevated BUN

Question 21

Severe C. diff infection should be treated with ____________.

Answer 21

oral vancomycin and intravenous metronidazole

Question 22

Malabsorption, diarrhea, and bloating after a Roux-en-Y bypass are suggestive of ________________.

Answer 22

small intestinal bacterial overgrowth (SIBO)

Decreasing the amount of time that food spends in the gastric acid (which a bypass does) leads to increased risk of SIBO.

Question 23

Explain the screening guidelines for colonoscopy in those with ulcerative colitis.

Answer 23

Starting 10 years after diagnosis, screen every 1 to 2 years.

The rate of colon cancer in those with UC for 10 years or more is 1% per year.

Question 24

One cause of mid-gut GI bleed –meaning not detected on colonoscopy or endoscopy –is _____________, particularly common in the elderly.

Answer 24

small bowel angiectasia

Question 25

Most experts agree that those older than _________ with rectal bleeding should be screened with colonoscopy for colon cancer.

Answer 25

40