GI/Nutrition

Question 1

Classic presentation of carcinoid syndrome

Answer 1

Diarrhea, episodic flushing, venous telangiectasias, right heart valve disease (TIPS: tricuspid insufficiency, pulmonic stenosis)

Question 2

Serum marker for carcinoid syndrome

Answer 2

5-HIAA (5-hydroxyindoloacetic acid), a serotonin metabolite

Question 3

Giardia: test? Treatment?

Answer 3

Test: stool antigen assay
Treatment: Metronidazole

Question 4

Neck mass that increases with drinking: diagnosis? test?

Answer 4

Zenker diverticulum.

Test: contrast esophagram

Question 5

Difficulty initiating swallow: diagnosis? test?

Answer 5

Oropharyngeal dysphagia.

Tetst: videofluoroscopid modified barium swallow

Question 6

Risk factors for esophageal adenocarcinoma? SCC?

Answer 6

Adenocarcinoma: GERD (Barrett’s), smoking
SCC: Alcohol abuse, smoking

Question 7

Brief episodes of non-cardiac chest pain with dysphagia during the episode only. Diagnosis? Best test? Initial treatment?

Answer 7

Diagnosis: Diffuse esophageal spasm
Test: manometry
Treatment: CCBs (diltiazem)

Question 8

Initial treatment for low-grade MALT lymphoma due to H. pylori?

Second-line treatment?

Answer 8

Initial treatment: Triple therapy for H. pylori (PPI, clarithromycin, amoxicillin)
Second-line: chemotherapy

Question 9

Three extrahepatic manifestations of hepatitis C

Answer 9

1. Porphyria cutanea tarda (blistering 2-3 days after sun exposure, reddish urine due to porphyrins)
2. Membranoproliferative GN (and so HTN)
3. Mixed cryoglobulinemia (fatigue, arthralgias, palpable purpura, low C4, positive RF)

Question 10

Labs in mixed cryoglobulinemia

Answer 10

1. Low complement, especially C4
2. Positive rheumatoid factor
3. Cryoglobulins

Question 11

Presentation of Wilson’s disease (3)

Answer 11

1. Chronic hepatitis / cirrhosis
2. Neurological signs: tremor, rigidity, ataxia, slurred speech, depression
3. Kayser-Fleisher rings

Question 12

Empiric treatment of SBP

Answer 12

3rd-generation cephalosporin (cover gut flora like E. coli and Klebsiella)

Question 13

Screening for HCC in cirrhotics?

Answer 13

Screening US every 6 months

Question 14

Tumor marker for HCC

Answer 14

Alpha-fetoprotein

Question 15

Liver mass in association with long-term OCP use:

Diagnosis? Test? Treatment?

Answer 15

Diagnosis: hepatic adenoma (usually benign)
Test: US and then CT (do not perform needle biopsy, risk of bleeding)
Treatment: surgical excision

Question 16

Primary biliary cirrhosis and primary sclerosis cholangitis: which is seen more in men, and which in women

Answer 16

PBC: women (9:1)
PSC: men (2-3:1)

Question 17

Antibody associated with primary biliary cirrhosis?

Answer 17

Anti-mitochondrial antibodies

Question 18

Treatment for primary biliary cirrhosis?

Answer 18

Ursodeoxycholic acid

Question 19

What disease is primary sclerosing cholangitis strongly associated with?

Answer 19

Ulcerative colitis

Question 20

Pattern of gastric and duodenal ulcers with respect to meals?

Answer 20

Gastric: worse during meal (acid secretion, movement during meal)
Duodenal: worse 2-3 hours after (food buffer has left unapposed acid behind), often wakes up at night

Question 21

Treatment for H. pylori associated PUD?

Answer 21

Triple therapy: PPI, clarithromycin, and amoxicillin

Question 22

Labs in Zollinger-Ellison syndrome

Answer 22

Markedly elevated serum gastrin (>1000 pg/ml) despite acidic gastric pH (<4)

(Note that lack of stomach acid (e.g. 2/2 PPI) can lead to elevated gastrin, so need to check gastric pH)

Question 23

Febrile diarrhea associated with extra-GI symptoms with small bowel biopsy showing villous atrophy and PAS-positive materials: diagnosis? cause?

Answer 23

Whipple’s disease, infection with Tropheryma whipplei

Question 24

Most common cause of colovesical fistula? Two other causes?

Answer 24

Most common: diverticulitis
Others: Crohn’s disease, colon cancer
(But NOT UC, since it is not transmural)

Question 25

Other conditions associated with angiodysplasia in the colon (3)

Answer 25

1. Renal disease (more likely to bleed) 2. vW disease (more likely to bleed) 3. Aortic stenosis (disrupts vWF and may make more likely to bleed)

Question 26

Pathologic hallmark of ulcerative colitis

Answer 26

Crypt abscess

Question 27

Causes of toxic megacolon (5)

Answer 27

1. Infection (e.g. C. diff, or CMV in AIDS) 2. IBD 3. Ischemic colitis 4. Volvulus 5. Obstructive colon cancer (less common)

Question 28

Treatment for toxic megacolon due to IBD? Due to other causes?

Answer 28

IBD: Antibiotics, NPO, IVF, plus IV corticosteroids Other causes: the same but no steroids Surgery may be required

Question 29

Treatment for mild/moderate C. diff? Severe?

Answer 29

Mild/moderate: oral metronidazole | Severe: oral vancomycin (+/- IV metronidazole)

Question 30

3 types of polyps that may be seen on colonoscopy

Answer 30

1. Adenomas 2. Hyperplastic (benign, nothing needed) 3. Hamartomatous polyps (juvenile polyp, Peutz-Jegher polyps - not pre-malignant, but removed due to bleeding risk)

Question 31

Colon adenoma pathology that is more likely to become malignant? Shape?

Answer 31

Villous pathology more pre-malignant than tubular | Sessile more pre-melignant than pedunculated

Question 32

Cancers seen in Lynch syndrome?

Answer 32

1. Colon cancer (HNPCC) 2. Ovarian cancer 3. Endometrial cancer

Question 33

Serologic marker in autoimmune hepatitis

Answer 33

Anti-smooth muscle antibody

Question 34

Watery diarrhea associated with rice

Answer 34

Bacillus cereus food poisoning

Question 35

Brief watery diarrhea with fever associated with unrefrigerated food

Answer 35

Clostridium perfingens

Question 36

Diarrhea associated with raw or undercooked shellfish

Answer 36

Vibrio vulnificus (can lead to invasive disease in immunocompromised and liver disease)

Question 37

Diarrhea that can lead to hemolytic uremic syndrome

Answer 37

Enterohemorrhagic E. coli (e.g. O157:H7)

Question 38

Bacterial diarrhea that can cause invasive, life-threatening illness in the immunocompromised or thsoe with liver disease

Answer 38

Vibrio vulnificus (associated with undercooked shellfish)

Question 39

Treatment for CACS (cancer-related anorexia/cachexia syndrome)

Answer 39

Progesterone analogs, e.g. megestrol acetate | Corticosteroids can also be used but have more side effects