GI

Question 1

initial presenting signs of pancreatic cancer

Answer 1

weight loss, food intolerance, steatorrhea (due to poor secretion of enzymes into duodenum), epigastric pain, jaundice/scleral icterus (due to obstruction of common bile duct and subsequent cholestasis)

Question 2

steps for working up dysphagia

Answer 2

oropharyngeal vs. esophageal dysphagia; if esophageal is it solids AND liquids or solids THEN liquids
solids AND liquids –> motility –> barium swallow, potential manometry
solids THEN liquids –> mech obst –> barium swallow, possible endoscopy if esophageal tissue not compromised (radiation, prior surgery etc)

Question 3

what long-term complication do you have to monitor for in patients with pernicious anemia

Answer 3

gastric cancer due to anti-intrinsic factor antibody-associated atrophic gastritis

Question 4

foreign body in the esophagus of a child should involve which treatment if

1. asymptomatic, ingestion recently
2. symptomatic, ingestion time unknown

Answer 4

1. observation over 24 hours if passes to the stomach

2. flexible endoscopy

Question 5

how is gastric adenocarcinoma staged

Answer 5

CT of abdomen and pelvis

Question 6

describe the pathophysiology of acalculous cholecystitis

Answer 6

cholestasis and gallbladder ischemia lead to edema and necrosis of gallbladder (usually develops in severely ill patients)

Question 7

abdominal distension, high pitched hyperactive bowel sounds and dilated bowel loops with air-fluid levels is suggestive of what condition

Answer 7

small bowel obstruction

Question 8

what is the gold standard for diagnosis and treatment of biliary atresia

Answer 8

intraoperative cholangiogram

kasai procedure and eventually liver transplant

Question 9

what’s the rule of 2’s

Answer 9

for Meckel’s diverticulum:

• 2% prevalence
• 2% are symptomatic at age 2
• 2:1 male to female ratio
• located within 2 feet of ileocecal valve

Question 10

what does the x-ray look like for malrotation with midgut volvulus

Answer 10

gasless abdomen since gas cannot pass duodenal obstruction

Question 11

how can you estimate fluid loss in a child using his/her weight

Answer 11

1kg of acute weight loss= approx 1L of fluid loss

Question 12

describe the categories of dehydration in children

Answer 12

1. mild (3-5% volume loss)= minimal or no symptoms
2. moderate (6-9%)= decreased skin turgor, dry mucus membranes, tachycardia, cap refill 2-3 sec, irritable
3. severe (10-15%)= sunken eyes, sunken fontanelles, lethargic, cap refill >3sec, tachycardia, sometimes hypotension

Question 13

what should be given for IV fluid resuscitation for a child

Answer 13

20mL/kg/hr of normal saline (no dextrose, dextrose is for maintenance ONLY)

Question 14

which levels of severity of dehydration get oral rehydration vs. IV rehydration

Answer 14

mild-moderate= oral rehydration
moderate-severe= IV rehydration

Question 15

non-caseating granulomas are pathognomonic to which type of IBD

Answer 15

Crohn’s (also has skip lesions, creeping fat, transmural inflammation, cobblestone appearing colon, fistulas and perianal disease)

Question 16

a child with poor weight gain, sinopulmonary infections, and greasy stools should be given what diagnostic tests

Answer 16

sweat chloride, genotyping and fecal elastase for CF

Question 17

how do you diagnose boerhave’s

Answer 17

gastrograffin esophogram or water-soluble CT esophagogram

Question 18

what makes Dubin-Johnson and Rotor Syndromes similar? different?

Answer 18

Dubin-Johnson and Rotor cause CONJUGATED hyperbilirubinemia; Dubin-Johnson has an abnormally high proportion of coproporphyrin I and dark pigemented granules in hepatocytes while Rotor syndrome does not

Question 19

what 3 criteria from a diagnostic paracentesis can allow you to diagnose spontaneous bacterial peritonitis

Answer 19

1. PMN count >250/microliter
2. serum-ascities albumin gradient > 1.1 suggests portal hypertension and higher likelihood of SBP (as opposed to cirrhosis)
3. positive ascites fluid culture

Question 20

what two screenings are routine management for a patient with cirrhosis

Answer 20

1. surveillance abdominal US +/- alpha fetoprotein for HCC every 6 months
2. EGD to check for varices

Question 21

how does achalasia present on manometry

Answer 21

decreased LES relaxation

Question 22

how do you manage C.diff that is:
moderate?
severe?

Answer 22

moderate C.diff: oral metronidazole, send stool C.Diff PCR

severe: oral vanc or IV metronidazole

Question 23

if your patient has malabsorption and iron deficiency anemia along with villous atrophy on biopsy, but negative tissue-transglutaminase, what is the cause of symptoms?

Answer 23

Celiac’s! Even though the tissue transglutaminase is negative, these patients often have IgA deficiency which would lead to a false negative

Question 24

what is the quickest way to reverse warfarin therapy for a patient who needs emergent surgery

Answer 24

FFP (not vitamin K which requires time for liver metabolism)

Question 25

vesicles and erosions on the dorsum of the hands associated with intermittent arthralgias and transaminitis would make you think of what underlying disease process

Answer 25

HCV: porphyria cutanea tarda (vesicle erosions on dorsum of hand and photosensitivity) and mixed cryoglobulinemia (intermittent arthralgias, palpable purpura and membranoproliferative glomerulonephritis)

Question 26

how do you differentiate between breastfeeding failure jaundice and breastmilk jaundice

Answer 26

breastfeeding failure jaundice is due to inadequate feeding so look for signs of dehydration or poor feeding whereas breast milk jaundice is due to high levels of beta-glucoronidase in the breast milk causing increased enterohepatic circulation

Question 27

recurrent intussusception in a child should make you think of what predisposing condition

Answer 27

Meckel's diverticulum | if it is the first occurence think hypertrophied Peyer's patches

Question 28

discuss the management algorithm for severe rectal bleeding (bright red blood per rectum)

Answer 28

initial evaluation and stabalization, NG tube aspiration, if negative for blood and pos for bile then do colonoscopy, if no source seen and bleeding is stopped do small bowel studies, if bleeding continues do arteriogram +/- labeled RBC scintigraphy then surgery if NG tube pos for blood then do upper endoscopy

Question 29

what about TPN predisposes a patient to cholelithiasis

Answer 29

prolonged fasting --> gallbladder stasis

Question 30

how should you treat milk or soy protein allergy in infants

Answer 30

eliminate milk or soy feeds and replace with hydrolyzed milk; breastfeeding is encouraged if mother can eliminate all dairy or soy from diet

Question 31

what are the symptoms of pancreatic adenocarcinoma

Answer 31

constitutional (weight, appetite), epigastric/ back pain, jaundice (head tumors), migratory thrombophlebitis (aka Trousseau's sign), diabetes onset

Question 32

thickened gastric mucosa, multiple gastric ulcers, jejunal ulcers and ulcers refractory to PPI should make you think

Answer 32

Zollinger Ellison Syndrome: note that jejunal ulcers suggest gastric hypersecretion rather than tumor invasion

Question 33

what laboratory findings would you see in a patient with lactose intolerance

Answer 33

- positive hydrogen breath test - reducing substances in the stool - low stool pH - increased osmotic gap in the stool

Question 34

foul smelling diarrhea with bloating, malabsoprtion and flatulence should make you think; what's the empiric therapy

Answer 34

Giardia | empiric therapy= oral metronidazole

Question 35

how can you differentiate diverticulosis from hemorrhoids as a cause of bright red bleeding

Answer 35

hemorrhoids can be felt on rectal exam and generally cause less severe bleeding than diverticulosis

Question 36

pneumatosis intestinalis in a neonate should make you think of what condition

Answer 36

necrotizing enterocolitis

Question 37

what is the pathognomonic finding seen with jejunal atresia?

Answer 37

triple bubble

Question 38

how does ursodeoxycholic acid work

Answer 38

it decreases hepatic secretion and intestinal absorption of cholesterole and helps dissolve gallstones to reduce their size; used to treat gallstones in patients who don't want surgery, also used to treat PBC and PSC

Question 39

what are the extrahepatic manifestations of primary biliary cirrhosis

Answer 39

xanthoma/xanthelasma | osteoporosis

Question 40

acute swelling and pain of the sacrococcygeal skin and subcuntaneous fat is most likely due to what

Answer 40

pilonidal cyst or abscess

Question 41

what is panendoscopy and when is it indicated

Answer 41

panendoscopy= triple endoscopy= esophagoscopy, bronchoscopy and laryngoscopy; =best initial test for suspected squamous cell carcinoma of the head and neck

Question 42

what is Charcot's triad

Answer 42

fever, jaundice, RUQ pain | =seen in acute ascending cholangitis

Question 43

cyanosis that worsens with feeding and resolves with crying should make you think of what condition

Answer 43

choanal atresia: failure of the posterior nasal bridge to canalize completely causes there to be a bony or membranous obstruction to the nasal airway failure to pass an NG tube through the nasopharynx is suggestive; CT imaging confirms diagnosis

Question 44

what are the three major pathologic stages of alcoholic liver disease

Answer 44

1) fatty liver (acute ingestion leading to steatosis) 2) hepatitis (Mallory bodies and neutorphil infiltration after chronic ingestion) 3) cirrhosis (liver fibrosis; irreversible)

Question 45

what is tropic sprue

Answer 45

chronic diarrhea found in tropical regions thought to be infectious in origin; leads to malabsorption and B12 deficiency

Question 46

list the stepwise approach to managing ascites

Answer 46

1. salt and water restriction (

Question 47

what drugs can cause esophagitis

Answer 47

tetracyclines, NSAIDs/ aspirin, alendronate, potassium chloride, quinidine, iron

Question 48

what endocrine disorders are associated with celiac's disease

Answer 48

autoimmune hyper or hypothyroidism | type 1 diabetes

Question 49

a neck mass that varies in size with intake of liquids is likely what condition

Answer 49

Zenker diverticulum

Question 50

what is the pathophysiology of Reye's syndrome

Answer 50

MICROvesicular fatty infiltration and hepatic mitochondrial dysfunction

Question 51

what are the diagnostic criteria for cyclic vomiting syndrome

Answer 51

- 3 or more episodes in 6 months - recurrent recognizable pattern - episodes last 1-10 days - vomiting 4 times/hour at peak - no identifiable cause of vomiting

Question 52

macrosomia, macroglossia, and hemihyperplasia should make you think of what condition

Answer 52

Beckwith-Weidemann Syndrome: an overgrowth disorder caused by mutation of chromosome 11q15 leading to growth abnormalities and various cancers (e.g. Wilm's tumor and hepatoblastoma)

Question 53

what is the best management after diagnosing a patient with MALT lymphoma

Answer 53

triple therapy for H. pylori as the tumor tends to regress after eradication of H. pylori; if the tumor does not regress then move on to chemotherapy

Question 54

what diagnostic study should you do in a patient presenting with abdominal pain and diarrhea due to IBD flare

Answer 54

abdominal CT, do not do invasive testing like colonoscopy or sigmoidoscopy due to risk of perforation

Question 55

what are the radiologic (upper GI series) findings that suggest midgut malrotation? volvulus?

Answer 55

midgut malrotation: Ligament of Treitz on right abdomen | volvulus: corkscrew pattern of contrast in small bowel

Question 56

what happens to GGT and ferritin in alcoholic hepatitis? | AST and ALT?

Answer 56

alcoholic hepatitis: increased GGT and ferritin (acute phase reactant) AST and ALT in the low 100's, AST: ALT ratio >2

Question 57

what are the symptoms of small intestines bacterial overgrowth and how do you diagnose it

Answer 57

diarrhea, malabsorption, vitamin deficiencies, flatulence, bloating, anemia diagnosed via endoscopy with jejunal aspirate showing >10^5 organisms/mL

Question 58

what are the risk factors for a polyp progressing to malignancy

Answer 58

villous adenoma, sessile adenoma, size >2.5cm

Question 59

which liver neoplasm is seen in women with prolonged OCP usage

Answer 59

hepatic adenoma (a benign tumor with adenoma cells filled with glycogen and lipids that can be complicated by hemorrhage or malignant transformation)

Question 60

what drugs commonly cause acute pancreatitis

Answer 60

``` diuretics: furosemide, thiazides IBD drugs: sulfasalazine, 5-ASA azathioprine HIV drugs: didanosine, pentamidine Abx: metronidazole, tetracycline ```

Question 61

what does a positive urine urobilinogen test suggest? | what does a positive urine bilirubin test test suggest?

Answer 61

positive urine urobilinogen: unconjugated hyperbilirubinemia positive urine bilirubin: conjugated hyperbilirubinemia

Question 62

in a neonate with bilious emesis after abdominal x-ray shows dilated bowel and you suspect meconium ileus what should you do

Answer 62

water-soluble contrast enema (NOT SURGERY) | contrast enema may loosen the inspissated meconium and be therapeutic, if contrast enema fails then go to surgery

Question 63

if you suspect pancreatic carcinoma what test should you order

Answer 63

abdominal CT; if CT or x-ray nondiagnostic --> ERCP (invasive)

Question 64

hepatic hydrothorax due to cirrhosis usually occurs on which side of the thorax

Answer 64

right sided hydrothorax (makes sense since that's where the liver is)

Question 65

what process leads to the development of Zenker diverticulum

Answer 65

cricopharyngeal dysfunction and esophageal dysmotility