AAFP: Gastrointestinal Flashcards
(33 cards)
A 52 yo female with morbid obesity is incidentally noted to have mildly elevated AST (SGOT) levels. She does not consume alcohol and denies using recreational drugs. A workup for chronic viral hepatitis and hemochromatosis is negative. Which one of the following is most likely to improve her hepatic condition?
a. Pentoxifylline
b. Simvastatin (Zocor)
c. L-carnitine
d. Vitamin E
e. Weight loss
e. Weight loss
Nonalcoholic fatty liver disease is characterized by the accumulation of fat in hepatocytes. It is associated with insulin resistance, central adiposity, increased BMI, HTN, and dyslipidemia. An incidentally discovered elevated AST level in the absence of alcohol or drug-induced liver disease strongly suggests the presence of nonalcoholic fatty liver disease. The goal of therapy is to prevent or reverse hepatic injury and fibrosis.
DM, HTN, dyslipidemia, and other comorbid conditions should be appropriately managed. A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance in patients with NFLD.
Weight loss has been shown to both normalize AST levels and improve hepatic histology. Vitamin E has been shown to improve AST levels but has no impact on liver histology.
A 52 yo male presents or routine physical exam. His laboratory results reveal an AST (SGOT) level of 124 U/L (N 10-40) and an ALT (SGPT) level of 36 U/L (N 10-55). His GGT level is also elevated. THe most likely cause of this abnormality is:
a. Hepatitis C
b. Hemochromatosis
c. Nonalcoholic fatty liver disease
d. Alcoholic liver disease
e. Statin-induced liver disease
d. Alcoholic liver disease
An AST/ALT ratio >2 supports dx of alcoholic liver disease. Elevated GGT is also associated with alcohol abuse, especially in a patient with an AST/ALT ratio >2.
A 34 yo female with newly dx diarrhea-predominant IBS presents with worsening abdominal discomfort. Her abdominal discomfort is not severe but it is constant. She has tried dicyclomine (Bentyl) without relief and is intrerested in trying a different approach. The patient has had negative testing for IBD and celiac disease, along with normal blood tests. She asks about specific dietary modifications or medications that may be helpful for her abdominal discomfort. Which one of the following interventions would you recommend?
a. Amitriptyline
b. Clarithromycin (Biaxin)
c. Loperamide (Imodium)
d. Increased intake of insoluble dietary fiber
a. Amitriptyline
TCAs such as amitriptyline have shown benefit in patients with IBS as SSRIs. Because of the anticholinergic properties of TCAs, it is thought that TCAs may be more beneficial than SSRIs in patients with diarrhea-predominant IBS.
A 53 y/o M with HTN, hyperlipidemia, and nonalcoholic fatty liver disease began taking atorvastatin (Lipitor) 3 months ago. His LDL-cholesterol level is now at goal, but he has developed an asymptomatic elevation of his hepatic transaminases to twice-normal levels. Which one of the following is the most appropriate course of action?
a. Continue the atorvastatin at the current dosage
b. Reduce the dosage of atorvastatin by half
c. Discontinue atorvastatin and switch to another statin
d. Order hepatic U/S
a. Continue the atorvastatin at the current dosage
HMG-CoA reductase inhibitors, or statins, play an important role in the mgmt of patients with CV disease and have an excellent safety and tolerability record. The incidence of significant liver injury from statin drugs is about 15, and nonalcoholic fatty liver disease or stable hepatitis B or C infection is not a contraindication to treatment with statins.
Although many patients taking statins experience elevation of hepatic transaminases, these elevations are generally mild and asymptomatic, and often resolve spontaneously even with no changes in treatment.
A 20 yo male presents with complaints of abdominal pain and diarrhea. He says he often has abdominal cramping that is relieved with defecation. The pain is accompanied by frequent loose, mucous stools, and his symptoms tend to get worse with stress. Your evaluation leads to a diagnosis of diarrhea-predominant IBS. Which one of the following would be the most appropriate tx?
a. Fiber supplements
b. Neomycin
c. Citalopram (Celexa)
d. Alosetron (Lotronex)
c. Citalopram (Celexa)
SSRIs and TCAs have shown benefit for IBS treatment.
A 72 yo white female presents to your office with a 6 week history of “tanned skin.” She initially attributed it to having gone on a cruise 2 months ago, but noticed her skin continued to darken as time passed. She is slender and has lost 11 lb since her last checkup 6 mo ago. She denies fever, malaise, or abdominal pain. Her only medications are HCTZ and aspirin daily. On exam, your suspicion of jaundice is confirmed by the presence of scleral icterus. You also note a single enlarged L supraclavicular lymph node which is nontender. The abdomen is soft and nontender; on deep palpation of the RUQ you feel a smooth, nontender mass. Which one of the following is the most likely dx?
a. Biliary cirrhosis
b. Ascending cholangitis
c. Obstructing pancreatic pseudocyst
d. Carcinoma of the head of the pancreas
e. Hepatocellular carcinoma
d. Carcinoma of the head of the pancreas
The presence of a solitary enlarged L supraclavicular lymph node (Virchow’s node) is associated with a GI malignancy. When combined with painless jaundice and palpable nontender gallbladder (Courvoisier’s sign), pancreatic cancer is the most likely dx.
Pancreatic pseudocyst develops after repeated bouts of pancreatitis and is not directly associated with jaundice.
Biliary cirrhosis and HCC typically present with pain, fatigue, malaise, hepatomegaly, jaundice and eventually ascites.
The jaundice of biliary cirrhosis is generally accompanied by severe pruritis. In neither condition is a palpably enlarged gallbladder present.
Mgmt of thrombosed external hemorrhoid presenting within 72 hours of onset of symptoms?
Mgmt of internal hemorrhoids?
External: Elliptical excision of the thrombosed hemorrhoid
Internal: Rubber band ligation of the hemorrhoid
AFP
CA 19-9
CA-125
- AFP: hepatoma
- CA 19-9: pancreatic cancer
- CA-125: ovarian carcinoma
Which antibodies are positive in 90% of patients with primary biliary cirrhosis.
Antimitochondrial antibodies
This test is the first step in ruling out the disease.
A 68 yo female with DM, CAD, fibromyalgia, and dyspepsia presents for follow-up. She has been taking omeprazole (Prilosec) for 10 years. It was started during a hospitalization, and her symptoms have returned with previous trials of discontinuation. Which one of the following adverse events is this patient at risk for as a result of her omeprazole use?
a. Hypermagnesemia
b. UTI
c. Nephrolithiasis
d. Hip fractures
d. Hip fractures
Risks of long-term use of PPIs have emerged:
fractures of the hip, wrist, and spine
CAP
C diff and other enteric infections
A 61 yo F tells you that her brother was recently diagnosed with hereditary hemochromatosis and his physician suggested that she get tested. She feels well and has no significant health problems. Which one of the following would be most appropriate for initial screening?
a. Serum transaminases
b. A CBC and a serum iron level
c. Testing for the HFE gene
d. Ferritin and transferrin saturation
e. Total iron binding capacity
d. Ferritin and transferrin saturation
The diagnosis of hereditary hemochromatosis requires a random measurement of serum ferritin and calculation of transferrin saturation. The transferrin saturation is calculated by dividing the serum iron level by the total iron binding capacity. If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is >=45% the HFE gene should be checked.
A 44 yo female presents with a 2 week hx of postprandial RUQ abdominal pain. Since yesterday her pain has worsened in intensity and she has been vomiting. The patient does not use tobacco or drink alcohol, and takes no medications. Laboratory findings include a serum lipase level of 105 IU/L (N 14-51), a serum amylase level of 155 U/L (N 36-128), a serum total bilirubin level of 1.5 mg/dL (N 0.0-1.0) and an AP level of 200 IU/L (N 33-96). The recommended initial imaging in this situation is:
a. No routine imaging unless the clinical course becomes complicated
b. Transabdominal U/S
c. Contrast-enhanced CT
d. MRCP
e. MRI
b. Transabdominal U/S
The American College of Gastroenterology recommends transabdominal U/S for all patients with acute pancreatitis. Contrast-enhanced CT and MRI should be reserved for patients who have an unclear dx, are not clinically improving after 48-72 hours, or develop complications.
A 50 yo female with a hx of refractory HTN presents with abdominal pain. Her laboratory results are significant for a positive H. pylori antibody. You decide to initiate tx for her infection with rabeprazole + amoxicillin, followed by clarithromycin + tinidazole. She is currently on multiple medications for her HTN. Which one of her antihypertensive agents would be most affected by the treatment regimen described?
a. Amlodipine
b. Clonidine transdermal
c. HCTZ
d. Metoprolol tartrate
e. Ramipril
a. Amlodipine
Amlodipine is metabolized by the cytochrome P450 3A4 enzyme. Clarithromycin is a strong 3A4 inhibitor that can slow the metabolism of CCBs metabolized by this enzyme, thus increasing their levels. This can lead to hypotension, edema, and AKI due to decreased renal perfusion.
A 48 yo male presents with a 4 week hx of rectal pain associated with minimal rectal bleeding. On exam, there is a small tear of the anorectal mucosa. The most appropriate initial tx would be topical:
a. botulinum toxin
b. clobetasol
c. capsaicin
d. nitroglycerin
d. nitroglycerin
This patient has classic findings for acute rectal fissure. Although patients often require an internal sphincterotomy, nonsurgical measures that relax the sphincter have proven helpful. Drugs that dilate the internal sphincter, including diltiazem, nifedipine, and nitroglycerin ointment, have proven to be beneficial in healing acute fissures.
Prophylactic cholecystectomy for asymptomatic gallstones is indicated for patients with which one of the following?
a. Sickle cell disease
b. Renal transplant
c. DM
d. Cirrhosis
a. Sickle cell disease
Asymptomatic gallstones are not usually an indicated for prophylactic cholecystectomy.
Patients with hemoglobinopathies are at significantly increased risk for developing pigmented stones. Gallstones have been reported in up to 70% of SCD patients, up to 85% of hereditary spherocytosis patients, and up to 24% of thalassemia patients.
A 50 yo female with no medical problems presents with a 2-day hx of profuse bloody diarrhea, severe abdominal cramping, and fever. She has recently returned from a week-long trip to Thailand. Her stool culture is positive for Campylobacter. Which one of the following is the treatment of choice?
a. Amoxicillin
b. Azithromycin
c. Ciprofloxacin
d. Metronidazole
e. Rifaximin
A 70 yo female with a past history of HTN and DM is hospitalized with pneumonia and treated with antibiotics. She subsequently develops two Clostridium difficile infections and is appropriately treated with abx each time. Ten weeks after her initial hospitalization, she has her third episode of C. difficile infection. Which one of the following would be the most appropriate treatment?
a. A 14-day course of linezolid
b. A 14-day course of oral vancomycin and metronidazole
c. A 14-day course of IV vancomycin
d. A 4-week course of clindamycin
e. A 15-week oral vancomycin taper
e. A 15-week oral vancomycin taper
- 1st relapse: 10-14 day course of oral metronidazole for moderate symptoms…. if severe, then oral vancomycin
- 2nd relapse: oral vancomycin taper over approximately 15 weeks
IV vancomycin is NOT effective for C. difficile infections.
A 30 yo male presents to your office with a 3-week history of nausea, weight loss, diarrhea, and hematochezia. He states that he has had similar episodes twice in the past and was treated at the local urgent care clinic for infectious diarrhea. Your initial lab workup is negative for enteric pathogens.
On referral for colonoscopy and esophagogastroduodenoscopy, the patient is found to have multiple noncontiguous transmural ulcerations throughout both the small and large intestines. Which one of the following initial mgmt strategies is most likely to induce remission in this patient?
a. Lapartomy with colectomy
b. Flagyl
c. Prednisone
d. Infliximab (Remicade)
c. Prednisone
Crohn’s disease: Corticosteroids & 5-ASA are first line. ANti-TNF agents such as infliximab should be considered in patients with moderate to severe Crohn’s disease who do not respond to initial corticosteroid or immunosuppressive therapy.
Which one of the following does the American College of Obstetricians and Gynecologists recommend as first-line treatment for nausea and vomiting in pregnancy?
a. Doxylamine (Unisom) and pyridoxine (vitamin B6)
b. Ondansetron (Zofran)
c. Prochlorperazine
d. Promethazine (Phenergan)
e. Metoclopramide (Reglan)
a. Doxylamine (Unisom) and pyridoxine (vitamin B6)
If n/v are not controlled with dietary modifications, the first-line treatment is vitamin B6 and doxylamine, 3-4 times per day. The other antiemetics can also be used in pregnancy, but vitamin B6 and doxylamine should be tried first because of the balance of safety and efficacy.
A 62 yo male has a 1 mo history of intermittent vomiting, early satiety, and a weight loss of 4 kg (9 lb). Initially, he had diarrhea but it has resolved. He does not have abdominal pain or bloody stools. He says that OTC famotidine (Pepcid) has relieved the symptoms somewhat. Which one of the following would be most appropriate at this point?
a. Abdominal radiographs
b. Abdominal U/S
c. Esophagogastroduodenoscopy
d. Famotidine at a higher dosage
c. Esophagogastroduodenoscopy
This patietn has red flag findings of older age and weight loss with chronic vomiting and is at risk for GI malignancy. He should be referred for esophagogastroduodenoscopy (EGD).
Which one of the following nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved?
a. Waiting until lipase has normalized before beginning oral intake
b. Early initiation of a clear liquid diet
c. Early initiation of a low-fat diet
d. Early initiation of tube feeding
e. Early initiation of TPN
c. Early initiation of a low-fat diet
Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality.
Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.
TPN should be avoided in patients with mild or severe acute pancreatitis. TPN is associated with infectious and other line-related complications.
You are caring for a 60 yo female with Crohn’s disease that is well controlled by infliximab (Remicade). As your staff updates her immunization status, which one of the following should be kept in mind?
a. Hep A vaccine is contraindicated
b. Pneumococcal vaccine is contraindicated
c. Tetanus toxoid is contraindicated
d. Zoster vaccine is contraindicated
e. All routine immunizations are considered safe
d. Zoster vaccine is contraindicated
Zoster vaccine, a live attenuated virus vaccine, is contraindicated in this patient due to her immunocompromised state. The other vaccines listed are safe and particularly recommended for patients with IBD, given their increased susceptibility to infections.
A 66 yo female sees you for the first time. She has a history of IDA and chronic diarrhea associated with a dx of celiac disease. This history increases her risk for which one of the following:
a. Diverticulitis
b. UC
c. Crohn’s
d. Colon cancer
e. Osteoporosis
e. Osteoporosis
Patients who are diagnosed with celiac disease are at increased risk of osteoporosis due to bone loss from decreased calcium and vitamin D absorption. These patients are at higher risk for fractures. Patients with celiac disease are not at increased risk for IBD, diverticulitis, or colon cancer.
A 69 yo female presents with her first episode of C. diff colitis, which is characterized as severe. Which one of the following is the most appropriate initial therapy?
a. Oral metronidazole
b. IV metronidazole
c. Oral vancomycin
d. IV vancomycin
c. Oral vancomycin
Vancomycin, 125 mg orally 4 times daily for 10-14 days, is recommended for the first severe episode of C. diff colitis. If the first episode is mild to moderate, oral metronidazole, 500 mg 3 times daily for 10-14 days, would be preferred.
