GI

Question 1

This patient shows clinical (pruritus, palmar erythema, telangiectasias, gynecomastia, and hypogonadism), laboratory (anemia, thrombocytopenia, hypoalbuminemia, hyperbilirubinemia, increased liver enzymes), and ultrasonographic evidence of compensated cirrhosis.

All patients with cirrhosis should be regularly screened for major complications, in particular, esophageal varices and hepatocellular carcinoma (HCC).

Abdominal ultrasonography shows a nodular liver surface with atrophy of the right lobe of the liver. An upper endoscopy shows no abnormalities.

Next step in management?

Answer 1

Repeat abdominal ultrasound in 6 months

In addition to ultrasound surveillance, all patients with alcoholic cirrhosis should undergo a screening endoscopy to look for esophageal varices and determine the risk of variceal bleeding.

Question 2

A history of immunodeficiency (e.g., caused by HIV infection) and prior human papillomavirus (HPV) infection are major risk factors for this condition.

A history of hematochezia, anal pruritus, painful defecation, and weight loss in a patient with an exophytic, friable, ulcerated mass above the anal verge is suggestive of?

Answer 2

Anal canal cancer

Squamous cell carcinoma is the most common histological type of anal canal cancer and typically arises below the dentate line

Question 3

Which hepatitis antigen is only present during phases of viremia, which occur in acute or active chronic infections?

Answer 3

Envelope antigen

(HBeAg)

Question 4

White plaques on the oral mucosa that can be scraped off (and bleeds) are suggestive of?

Further common findings include pain when eating, loss of taste, and a cottony feeling in the mouth.

Answer 4

oropharyngeal candidiasis

Question 5

Candida albicans infections most commonly affect?

Answer 5

immunocompromised individuals

e.g., patients with hematologic malignancies, or chemo

Question 6

This patient most likely has lower GI bleeding (LGIB), as suggested by the hematochezia and normal esophagogastroduodenoscopy (EGD). He continues to bleed and remains hemodynamically unstable even after fluid resuscitation. Urgent intervention is required to reliably localize and stop the hemorrhage. Management?

Answer 6

Angiography is the recommended procedure in patients with active hematochezia, hemodynamic instability despite resuscitation efforts, and a normal EGD.

Question 7

Angiography is also used in stable patients when other diagnostic methods are inconclusive.

If angiography fails to locate the source of bleeding, what is the next step in management?

Answer 7

colonoscopy

Question 8

This patient’s history of intermittent, crampy abdominal pain, bloating, and nonbloody diarrhea after the consumption of dairy products is suggestive of lactase deficiency.

Given this patient’s history of gastroenteritis, her current condition is likely secondary to?

Answer 8

loss of intestinal brush border

due to mucosal damage following gastroenteritis.

Question 9

lactase deficiency test?

Answer 9

The hydrogen breath test assesses the intestinal absorption of individual carbohydrates. A rise in exhaled hydrogen levels (i.e., a positive hydrogen breath test) occurs when unabsorbed carbohydrates are metabolized by colonic bacteria, producing hydrogen during the process.

Question 10

Symptoms such as abdominal pain, diarrhea, and fever in combination with laboratory evidence of inflammation and CT scan findings of mural thickening and creeping fat are suggestive of?

Answer 10

Crohn disease

Question 11

On biopsy, the presence of transmural inflammation, fissures, and aphthous ulcers would strongly suggest CD.

What else would be seen on biopsy?

Answer 11

Noncaseating granulomas
(granulomatous inflammation)

Question 12

During endoscopy, cranial displacement of the esophagogastric junction (Z line) was observed. Narrow-band imaging of the mucosa distal to the Z line did not show evidence of metaplastic change. Mucosal biopsy specimens obtained from this site showed gastric columnar cells and no goblet cells. DDX?

Answer 12

type I hiatal hernia (asymptomatic)

endoscopic findings of a displaced Z line above the diaphragmatic hiatus with no evidence of paraesophageal herniation

Question 13

type I hiatal hernia (asymptomatic), tx?

Answer 13

conservative management with reassurance and counseling on lifestyle modifications is indicated.

Lifestyle modifications, including smoking cessation, alcohol cessation, and weight loss, should be discussed with all patients with hiatal hernia.

Question 14

type I hiatal hernia (symptomatic), tx?

Answer 14

If the patient develops symptoms of gastroesophageal reflux disease (GERD), treatment with a proton pump inhibitor (PPI) or histamine H2 receptor antagonist is indicated.

Surgical repair is only necessary if the patient has persistent symptoms despite pharmacological treatment, is not willing or able to take PPIs long-term, or has severe symptoms or complications of GERD (e.g., bleeding, strictures, ulcerations).

Question 15

Combined with a history of loose stools, fatigue, and travel to the Indian subcontinent, features of malabsorption such as steatorrhea (elevated fecal fat content) and vitamin deficiencies (e.g., angular stomatitis, glossitis, macrocytic anemia) are highly suggestive of?

Answer 15

tropical sprue

Question 16

tropical sprue: The abdomen is soft without tenderness. Rectal examination shows no abnormalities.

Stool culture and studies for ova and parasites are negative. Test of the stool for occult blood is negative. Fecal fat content is 22 g/day (N<7). Fecal lactoferrin testing is negative and fecal elastase level is within the reference range. Which of the following is the most appropriate next step in diagnosis?

Answer 16

Endoscopic small bowel biopsy

should be performed in patients with suspected tropical sprue following blood tests, serological antibody testing, and stool analysis.

Question 17

Histological findings include villous atrophy, elongated crypts, and inflammatory cells (plasma cells, lymphocytes, eosinophils). However, these findings are not specific to tropical sprue; they may also be seen in?

Answer 17

celiac disease

(Endoscopic small bowel biopsy also confirms DDX)

Question 18

tropical sprue: the diagnosis is ultimately confirmed by a response to treatment, which usually consists of?

Answer 18

tetracycline in combination with folic acid for 3–6 months.

Question 19

What DDX manifests initially with weight loss and extraintestinal symptoms (e.g., fever, arthralgias arthritis, cardiac (valve insufficiencies), and neurological symptoms (myoclonia, ataxia, impairment of oculomotor function)) before diarrhea occurs; the characteristic histological finding of this condition is PAS-positive foamy macrophages in the lamina propria?

Answer 19

Whipple disease

Can cause malabsorption syndrome, and Endoscopic small bowel biopsy is initial step in DDX

Question 20

This patient has a known diagnosis of hepatitis C, ascites, and portal hypertension, as indicated by a serum-ascites albumin gradient (SAAG) > 1.1.

His portal hypertension, fever, abdominal pain, and a peritoneal > 250 polymorphonuclear leukocytes/mm3 in ascites fluid point to the underlying cause of his current symptoms.

DDX and cause?

Answer 20

spontaneous bacterial peritonitis (SBP)

Caused by bacterial translocation (usually gram-negative rods such as E. coli or Klebsiella spp.)

Question 21

what is bacterial translocation?

Answer 21

Migration of bacteria through the intestinal wall to the peritoneal space and possible colonization of the mesenteric lymph nodes.

Question 22

Tx for bacterial translocation?
(first episode vs later episodes?)

Answer 22

Empiric antibiotic treatment for SBP with a third-generation cephalosporin (e.g., cefotaxime) or a fluoroquinolone (e.g., levofloxacin) should be initiated immediately.

After the first episode of SBP, this patient should start antibacterial prophylaxis with ciprofloxacin or TMP-SMX.

Question 23

The acute mental status changes, signs of liver cirrhosis (e.g., ascites, spider telangiectasias), and asterixis (hands make a flapping motion when they are dorsiflexed) in this patient indicate hepatic encephalopathy.

precipitating factor for this patient’s symptoms?

Answer 23

Hemoglobin in the intestine (e.g., from a gastrointestinal bleed) can precipitate hepatic encephalopathy.

Other common triggers of hepatic encephalopathy include infection, recent transjugular intrahepatic portosystemic shunt placement, sedatives, and metabolic alkalosis.

Question 24

HIV-infected patients with a CD4 count < 50 cells/mm3, presents with watery and explosive diarrhea, and detection of characteristic linear lesions on colonoscopy and owl eye inclusions on biopsy. DDX and Tx?

Answer 24

CMV infection (including CMV colitis)

Tx: foscarnet, ganciclovir, and cidofovir.

Question 25

Tender hepatomegaly with signs and symptoms of cholestasis (jaundice, dark urine, pale stools, pruritus, direct hyperbilirubinemia, elevated transaminases and alkaline phosphatase), preceded by fever, nausea, and vomiting, suggest a specific type of **acute hepatitis**. What antibody is present? (in **HepA**)

Answer 25

Anti-HAV **IgM** antibodies

Question 26

This woman with poorly controlled diabetes (**glucosuria**) presents with **subacute flank pain**, **fever**, and **increased pain with extension of the hip**, all of which suggest a certain diagnosis. DDX?

Answer 26

**Psoas muscle abscess**

Question 27

**Primary psoas abscesses** are most common, and **diabetes** is an important risk factor for primary abscess formation. Definitive diagnosis requires?

Answer 27

imaging with **MRI** or **CT** ultrasound may allow for identification of a large abscess.

Question 28

This patient's history of **constipation** and **left lower quadrant pain** together with CT findings of **segmental colonic wall thickening** with multiple **diverticula** and surrounding **fat stranding** suggest **acute diverticulitis**. The > 4.0-cm low-attenuating fluid collection is consistent with a **large pelvic abscess**, which has developed as a complication of diverticulitis. There are no signs that suggest peritonitis (e.g., guarding, rebound tenderness, rigid abdomen). Intravenous antibiotics alone are highly unlikely to resolve this patient's condition. Mx?

Answer 28

**CT-guided percutaneous drainage** is the treatment of choice for patients, like this one, with acute diverticulitis complicated by large abscesses and no indications for emergent surgery (e.g., signs of peritonitis).

Question 29

Chronic **bloody diarrhea** and abdominal cramps in early adulthood, colonoscopy findings of **linear ulcers** and polyps (likely inflammatory **pseudopolyps**) with **crypt abscesses** (mucosal edema with distorted crypts) on biopsy are characteristic features of?

Answer 29

**ulcerative colitis (UC)**

Question 30

patients with **long-standing inflammatory bowel disease** (**UC/Crohn's**) are at increased risk of developing colorectal cancer (CRC). Surveillance for dysplasia should be initiated ________________ following the onset of symptoms, which is when the incidence of CRC begins to rise significantly Then performing a colonoscopy with biopsy every **# years**?

Answer 30

Surveillance for dysplasia initiated **8–10 years after onset of sx** Then **colonoscopy biopsy** every **1-5 years**

Question 31

After MVA (severe trauma), the presence of acute nausea, vomiting, bloating, **absent bowel sounds**, and **dilated bowel loops with a uniform gas pattern** is diagnostic of?

Answer 31

paralytic ileus

Question 32

Trauma patients may develop **paralytic ileus** for a variety of reasons (e.g., treatment with opioids). The association of this patient's ileus with **bilateral flank pain**, **seatbelt sign**, **Grey Turner sign**, **obliteration of the psoas outline on x-ray**, and fluid-responsive hemodynamic changes make trauma-associated, ddx?

Answer 32

**retroperitoneal hemorrhage**

Question 33

The most appropriate next step in the management of uncomplicated paralytic ileus is to make the patient?

Answer 33

**NPO**, place a **nasogastric tube** for decompression, and **provide IV fluid** (and possibly blood product) resuscitation

Question 34

A pt wirh **extensive burn injury** (i.e., ≥ 30% of total body surface area), **tarry stools**, **hypotension**, and **tachycardia** prior to her death suggest an acute upper gastrointestinal bleed that was precipitated by her burns. underlying cause of the patient's tarry black stools?

Answer 34

**Curling ulcers** - Decreased gastric blood flow A subtype of stress gastritis seen in patients with **extensive burns** and occur due to hypovolemia and subsequent **hypoperfusion** of the stomach.

Question 35

What should be administered in patients with **extensive burns** to *prevent* the formation of **Curling ulcers**?

Answer 35

**Proton pump inhibitors** Tx in patients with extensive burns to prevent the formation of Curling ulcers.

Question 36

Vital signs and physical examination are unremarkable. This condition that is often caused by **chronic alcohol use** + history of **recurrent epigastric pain**, and **vomiting**. When large enough, this can manifest with a **palpable epigastric mass** and **bilious vomiting** (due to extrinsic compression of the distal duodenum) or **nonbilious vomiting** (due to gastric outlet obstruction). DDX?

Answer 36

**pancreatic pseudocyst** which is a complication of acute or chronic pancreatitis, is caused by **leakage of pancreatic exocrine secretions** from damaged ducts.

Question 37

This patient presents with constitutional symptoms and iron deficiency anemia, in the setting of an **ulcerative, bleeding growth in the colon**. These findings are highly suggestive of?

Answer 37

colorectal cancer

Question 38

Which **GI polyp** has the strongest predisposing factor for **malignant transformation** based on the histological subtype of the lesion? (followed by its size, location, and gross appearance)

Answer 38

**Adenomatous polyps** (tubular adenoma, tubulovillous adenoma, villous adenoma) carry the highest risk of malignant transformation.

Question 39

which **Adenomatous polyps** (tubular adenoma, tubulovillous adenoma, villous adenoma) has the highest risk of malignant transformation?

Answer 39

**villous adenomatous polyp** has the highest risk (∼ 50%)

Question 40

**Melena** (black, tarlike stool) is usually caused by **upper gastrointestinal bleeding** (UGIB), although it can also stem from lesions in the small bowel or the colon. EGD normal, what's next?

Answer 40

**colonoscopy** to evaluate the lower GI tract. Should the colonoscopy also be normal, the small bowel needs to be examined (e.g., via **push enteroscopy**, **push-and-pull enteroscopy**, **capsule endoscopy**).

Question 41

This woman has several risk factors (obesity, female, multiparity, age > 40 years) for gallstones. Additionally, she presents with right upper quadrant (RUQ) pain and elevated markers of cholestasis (alkaline phosphatase, bilirubin). Next step in DDX and DDX?

Answer 41

**Transabdominal ultrasonography** is the best next step to diagnose **choledocholithiasis**.

Question 42

A combination of **symmetric oligoarthritis**, **loose stools**, features of **malabsorption** (weight loss, iron deficiency anemia), **cardiac symptoms** (valve insufficiency), ***hyperpigmentation***, and generalized lymphadenopathy indicates?

Answer 42

Whipple's disease

Question 43

**Whipple's disease** - A biopsy specimen of the duodenum is likely to show which of the following?

Answer 43

PAS-positive macrophages

Question 44

Whipple's disease is treated with?

Answer 44

**IV ceftriaxone** for **2 weeks** followed by *maintenance treatment* with **oral trimethoprim-sulfamethoxazole** for **1 year.**

Question 45

**Linear ulcers** and **aphthous mucosa** defects are biopsy findings expected in a patient with?

Answer 45

Crohn's disease

Question 46

**diffuse abdominal pain** and **change in bowel habits**, no symptoms of malabsorption. DDX and biopsy results?

Answer 46

**normal duodenal mucosa** is the biopsy finding in patients with **irritable bowel syndrome (IBS).**

Question 47

A **caseating granuloma** is a local accumulation of activated **macrophages** ***around*** a center of **necrosis**. It can be found in a number of diseases, including? (3)

Answer 47

**tuberculosis** **fungal infections** **leprosy**

Question 48

**Villous atrophy** and **crypt hyperplasia** are the typical biopsy findings in patients with?

Answer 48

with **celiac disease**.

Question 49

A **noncaseating granuloma** is a local area of inflammation comprised of activated **macrophages**, ***without*** an area of **central necrosis**. In the duodenal wall, noncaseating granulomas may be a sign of several diseases, including? (2)

Answer 49

**sarcoidosis** and **Crohn's disease**

Question 50

patient's **skin hyperpigmentation**, **generalized lymphadenopathy**, **neurological symptoms** and **aortic regurgitation**. DDX?

Answer 50

**Whipple's disease** **PAS-positive macrophages** in gastrointestinal biopsy specimens are a hallmark finding

Question 50

patient's **skin hyperpigmentation**, **generalized lymphadenopathy**, **neurological symptoms** and **aortic regurgitation**. DDX?

Answer 50

**Whipple's disease** **PAS-positive macrophages** in gastrointestinal biopsy specimens are a hallmark finding

Question 51

patients who are **hemodynamically unstable**. *CT scan of chest* findings include **pneumomediastinum**, **esophageal wall thickening**, **pneumothorax**, **pneumoperitoneum**, **subcutaneous emphysema**, and **pleural effusion**. DDX?

Answer 51

**Boerhaave syndrome** - spontaneous esophageal rupture

Question 52

Based on his **right upper quadrant pain**, nausea, vomiting, close contact with a **dog**, **eosinophilia**, and **focal cyst** within the liver, the diagnosis in this patient is most likely?

Answer 52

**hydatid cyst disease** The contents of a hydatid cyst are highly antigenic.

Question 53

during a procedure, your pt develops **hypotension**, **tachycardia**, **decreased oxygen saturation**, and **severe bronchospasm** (as evident by a sudden decrease in end tidal CO2 and absent breath sounds). Tx?

Answer 53

**Epinephrine** is the treatment of choice for anaphylaxis.

Question 54

**hydatid cyst disease** Laboratory tests: mild **eosinophilia** Serology: **positive ELISA** Imaging: Ultrasonography would show?

Answer 54

**Eggshell calcifications** within the wall of a hydatid cyst

Question 55

intermittent abdominal tenderness and cramps, **watery diarrhea**, **cutaneous flushing** (facial redness), **telangiectasia** (tiny blood vessels), **tachycardia** (sudden palpitations), and **wheezing**. DDX?

Answer 55

**Carcinoid tumors** usually occur in the gastrointestinal tract and are often **asymptomatic** due to hepatic metabolism of neuroendocrine substances (particularly **serotonin**) that the tumors produce.

Question 56

carcinoid tumors become symptomatic when?

Answer 56

tumors that have **metastasized to the liver** (indicated by **elevation of transaminases** in this patient) the **increased serotonin** that **bypasses hepatic first-pass metabolism**

Question 57

Pt from **Tiawan**, Esophagogastroduodenoscopy shows an **ulcerated mass with raised irregular edges** in the body of the **stomach at the lesser curvature.** DDX and cause?

Answer 57

** gastric adenocarcinoma** **nitrosamine compounds** (e.g., dimethylnitrosamine) - smoked, dried, fried, and preserved foods (especially meat)

Question 58

Risk factors for localized gastric adenocarcinoma include? (4)

Answer 58

***obesity*** **Helicobacter pylori** tobacco smoking alcohol consumption

Question 59

On the **barium enema**, an **apple core sign** (also called napkin ring sign) is seen in the distal descending colon, which suggests **annular constriction** due to? Seen with what DDX?

Answer 59

**colorectal carcinoma** seen with **UC**

Question 60

As **UC** is restricted to the colon and rectum, what is the only potentially curative treatment for both UC and colorectal carcinoma?

Answer 60

**proctocolectomy with an ileal pouch-anal anastomosis** or **ileostomy**

Question 61

This patient has **AIDS** (CD4+ T-lymphocytes < 200 cells/mm3), **watery, secretory diarrhea**, **modified acid-fast stain** on a stool sample reveals **oocysts**, part of life cycle of some parasitic protozoans. DDX?

Answer 61

**Cryptosporidium parvum** a very common enteric parasite that **sheds acid-fast oocysts** in the feces. symptoms begin **within 10 days of infection**.

Question 62

Acute presentation with **oral pain**, **odynophagia** (painful swallowing), **heavy salivation**, and **chest pain** should raise concern for ingestion of which caustic agent?

Answer 62

**alkaline caustic agent**, such as **Potassium hydroxide**, that is a common component of drain and toilet cleaners.

Question 63

Caustic ingestion of **alkali substances** (e.g., **potassium hydroxide, sodium hydroxide**) can cause?

Answer 63

**Liquefactive necrosis** with **deep mucosal ulcerations**. Esophageal caustic injury can be complicated by **perforation of the esophageal wall**, which can result in **mediastinitis** or **peritonitis**.