Académique Documents
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Review
Gastroenterology
Small bowel
Colon
Liver
Esophagus
(1) An 18 year old male has a 3 day history of
pain on swallowing. He has no heartburn,
regurgitation, or weight loss. He has been taking
ibuprofen intermittently for 2 months for elbow
pain. On physical exam, temperature is normal,
pulse is 80, BP is 110/70. Oropharyngeal exam is
normal. There is no chest wall tenderness. Which
of the following is the most likely cause of this
patient’s symptoms?
A) GERD
B) Esophageal motility disorder
C) Zenker’s diverticulum
D) Pill induced esophagitis
E) Peptic ulcer disease
(2) A 28 year old male with longstanding HIV
has a 1 week history of dysphagia and mild
odynophagia and a 5 lb weight loss. He denies
fever or hematemesis. History is significant for
oropharyngeal candidiasis and PCP. The patient
is noncompliant with HAART. Physical exam is
normal without thrush. Most recent CD4 count is
68. Which of the following is the most
appropriate next step in managing this patient?
A) Fluconazole
B) Omeprazole
C) Barium swallow
D) CT scan of the chest
E) EGD
Odynophagia
Infectious (immunocompromised):
– Candida esophagitis
– CMV
– HSV
– HIV associated idiopathic ulcer
Pill induced esophagitis (acute onset, erosions in mid
esophagus)
– Aspirin/NSAIDS
– Bisphosphonates
– Doxycycline
– Iron
– Potassium salts
Radiation
Erosive esophagitis (Overweight middle aged male with
GERD)
Caustic injury
(3) A 68 year old male has a 4 month history of
difficulty swallowing both solids and liquids. He
describes “food sticking high up” (pointing to the
suprasternal notch) and occasionally notes
coughing after a meal with nasal regurgitation of
undigested food. His voice has changed
somewhat and he has lost 30 lbs during this
time. Which of the following diagnostic studies
should be done next?
A) Barium swallow
B) Videofluoroscopy
C) Upper endoscopy
D) Esophageal motility study
Dysphagia
Oropharyngeal Esophageal
– Structural – Structural (solids)
Cervical osteophytes Diverticulum
Cricoid webs Strictures
Webs/rings
– Neurologic
Neoplasm (Red Flags)
ALS
CNS tumor
– Motility
CVA
(solids/liquids)
Achalasia
Myasthenia gravis
DES
Parkinson’s
Scleroderma
A) Ambulatory pH monitoring
B) EGD
C) Barium swallow
D) H. pylori serologies
E) Trial of proton pump inhibitor
GERD Symptoms
Heartburn
Regurgitation
Asthma
Hoarse voice
Chronic cough
Noncardiac chest pain
A) Adenocarcinoma
B) Squamous cell carcinoma
Esophageal Cancer
3:1men: women
Two types:
– Adenocarcinoma
– Squamous cell carcinoma
Symptoms are dysphagia and weight loss
– Always warrant EGD
Staging is with CT/PET and EUS
5 year survival < 10%
Esophageal Cancer
Adenocarcinoma SCC
– Distal esophagus – Proximal esophagus
– More common in white – 3x more common in
men
African Americans
– Incidence increased by
> 300% in last 50 yrs
– Risk factors:
Tobacco
– Risk factors:
BE
ETOH
Tobacco Corrosive injury
GERD
Obesity
Esophageal Cancer
Treatment
– Surgery
5 year survival in pts undergoing surgery
25%
– Neoadjuvant chemoradiation
Benefit controversial
– Palliation
Self-expanding metal stent
PEG tube
intermittent sharp chest pain that occurs
postprandially and at rest, but not with exertion.
He denies dysphagia or regurgitation. He has
HTN treated with HCTZ. He has a 30 pack year
smoking hx. His father died of MI at age 70.
Physical exam is normal. Cardiac stress test and
EGD are normal. An esophageal motility study
shows normal peristalsis and increased/high
amplitude peristaltic waves. Which is the most
appropriate next step in this patient’s
management?
A) Barium swallow
B) Coronary angiogram
C) Ambulatory pH monitoring
D) Pneumatic dilation of the distal
esophagus
(9) A 45 year old male has a 2 year history of
dysphagia to both solids and liquids. He has
intermittent chest pain, retrosternal burning with
occasional regurgitation of food. 10 lb weight
loss over the last 2 years. EGD shows some
retained food in the distal esophagus.
Esophageal motility study shows hypertensive
LES that does not relax fully with swallows and
absent peristalsis. Upper GI series is shown.
Which of the following is likely to result in long-
term benefit for this patient?
A) Barium swallow
B) Pneumatic dilation
C) Myotomy
D) EGD
E) Sublingual nifedipine
Esophageal Motility
Disorders
Symptoms
– Dysphagia to solids and liquids
– Chest pain
– Weight loss
Diagnosis
– Esophageal manometry
Esophageal Motility
Disorders
Achalasia
– Degeneration of the myenteric plexus with loss of inhibitory neurons
– LES fails to relax with swallows
– Aperistalsis
– “Bird beak” on esophagography
– Dilated esophagus with tight LES on EGD
– Pneumatic dilation
Improvement in 70% of patients
5% risk of perforation
– Heller myotomy
90% effective
Can be done laparoscopically
– EGD with Botox injections into the LES
Temporary improvement
Used in high risk patients
– Must rule out pseudoachalasia from a tumor
Esophageal Motility
Disorders
Diffuse esophageal spasm
– Simultaneous contractions interspersed with
normal peristalsis
Nutcracker esophagus
– Very high amplitude peristaltic contractions
– Evaluate for GERD
Treatment
– Calcium channel blockers
– Nitrates
– Tricyclic antidepressants
(11) 24 year old male has intermittent
dysphagia for solid foods that has required two
ED visits for food impactions. No weight loss or
heartburn. He has asthma and eczema. EGD
shows some mild ring formation in the mid
esophagus. Biopsy shows eosinophilic infiltration.
What is the most appropriate therapy?
A) PPI
B) Topical swallowed corticosteroids
C) Oral nifedipine
D) Sublingual nifedipine
Stomach and
Duodenum
(12) A 27 year old male has a 3 month hx of intermittent
burning epigastric pain that is made worse by fasting and
improves with meals. Antacids provide temporary relief.
His only medication is occasional Tylenol. Physical exam
discloses only mild epigastric tenderness to palpation; vital
signs are normal. Which of the following studies should be
done next?
A) Abdominal ultrasound
B) Serologic testing for H. Pylori
C) Upper endoscopy
D) Upper GI barium study
(13) A 37 year old female has a 3 month history of
intermittent burning epigastric pain and mild nausea but
no vomiting. The discomfort is made worse by fasting and
improves with meals. Antacids only provide temporary
relief. Weight is stable. No tobacco or alcohol. Physical
exam shows mild epigastric tenderness. Serologic testing
for H. Pylori is negative. What is the most appropriate next
step?
A) IV beta blocker
B) EGD
C) Red blood cell transfusion
D) Endotracheal intubation
E) Transjugular intrahepatic
portosystemic shunt
Upper GI Bleeding
Repeated vomiting followed by seeing blood
Mallory-Weiss tear
Cirrhotic varices, but can be PUD
NSAID user PUD
Hematemesis/melena without big drop in Hgb
erosive esophagitis
Anemia+/- melena /weight loss/abdominal pain
gastric cancer
Large volume hematemesis with normal EGD
Dieulafoy lesion
Anemia and large hiatal hernia Cameron’s erosions
Management of UGIB
Large bore IVs
IVF
Type and cross, transfuse
– (if cirrhotic goal Hgb 9)
PPI gtt
Octreotide gtt if cirrhotic
Plts > 50
INR < 1.5
Hold aspirin/NSAIDS/coumadin
When in doubt, intubate
GI consult
EGD (last step)
If patient is bleeding, you will see it!
(14) A 63 year old male with a 3 month history of
epigastric burning and a 12 lb weight loss. EGD shows a 1
cm gastric ulcer with surrounding erythema. Biopsy
specimens of the ulcer reveal inflammation with intestinal
metaplasia and early dysplasia and presence of H. Pylori.
Successful eradication of H. Pylori will most likely be
associated with which of the following?
A) Reversal of metaplasia
B) Reversal of dysplasia
C) Decreased incidence of ulcer
recurrence
D) Decreased risk of gastric cancer
Helicobacter Pylori
Diseases associated with HP
– PUD
Most common cause
– Antral gastritis
95% of those infected
– Nonulcer dyspepsia
10% will improve with HP eradication
– Gastric Cancer of “intestinal type”
Eradication is unlikely to induce complete resolution
of intestinal metaplasia or to result in a reduced
cancer risk
– MALT
50% have complete regression of the tumor with HP
eradication
Helicobacter Pylori
Diagnosis
– Serum antibody (detects prior infection)
– Stool antigen
– Urea breath test
– Biopsy urease test
– Histology
A) Abdominal ultrasound
B) HIDA scan
C) ERCP
D) Laparoscopic cholecystectomy
Acute Pancreatitis
Etiology Treatment
– Gallstones – Hydration
– Alcohol – Early enteral feeds
– Hyperlipidemia (TG > 1000) – Antibiotics for necrosis
– Medications (Imuran, 6-MP, Complications
thiazides)
– Fluid collections
– Trauma
– – Pseudocysts
Hypercalcemia
– Post ERCP – Pancreatic
pseudoaneurysm
– Hereditary
– Fistulas
Prognostic Factors – Splenic vein thrombosis
– Ranson Gastric varices
– Glasgow – Diabetes
– APACHE
– Chronic pancreatitis
– BMI > 25
– Pancreatic duct leak
– Hct > 50%
Chronic Pancreatitis
Etiology Treatment
– Alcohol – Pancreatic enzymes
– Hereditary – Nerve blocks
– Autoimmune – Surgery
Diagnosis – Narcotics
– Pancreatic calcifications
on radiograph
– CT
– EUS
– ERCP
– Secretin stimulation
(17) A 72 year old male has a 6 week history of
painless jaundice. He has a 40 pound weight loss
over the last 3 months. He was diagnosed with
diabetes two months ago. Bili 6, AST 35, ALT 48,
Alk Phos 350. Which of the following diagnostic
study is the most appropriate at this time?
A) ERCP
B) Mesenteric angiography
C) EUS
D) CT scan of the abdomen
Pancreatic Adenocarcinoma
Etiology Diagnosis
– Sporadic – CT
– Familial (10%) – EUS-FNA
FAP
Peutz-Jeghers
Treatment
Von Hippel-Lindau – Whipple if resectable
Hereditary pancreatitis – ERCP with stent if
biliary obstruction
Risks present
– Age
– Chronic pancreatitis
– African American
– Smoking
– Diets high in fats and
meat
Cystic Neoplasms of the
Pancreas
Mucinous cystadenomas/cystadenocarcinomas
– Middle aged women
– Body or tail
– Frequently lead to invasive cancer
Intraductal papillary mucinous neoplasms
– Men 60 years or older
– May present with pancreatitis
– Main duct cause main PD dilation
70% incidence of malignancy
– Side branch cause side branch dilation
25% incidence of malignancy
Serous cystadenomas
– Malignant transformation < 1%
– Followed with imaging
Pancreatic Endocrine
Syndrome
Tumors
Hormone Clinical
Findings
Gastrinoma Gastrin Abd pain, PUD,
GERD, MEN 1
(ZES)
Insulinoma Insulin Hypoglycemia
A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
(19) A 52 year old obese female presents with 3
weeks of intermittent postprandial right upper
quadrant abdominal pain which over the last 2
days has become more constant. Bili 0.9, AST 45,
ALT 65, Alk Phos 85, Lipase 25. Ultrasound shows
gallstones in the gallbladder, gallbladder wall
thickening with moderate percholecystic fluid, no
biliary dilation. What does this patient have?
A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
(20) A 52 year old obese female presents with 3
weeks of intermittent postprandial right upper
quadrant abdominal pain which over the last 2
days has become more constant. Bili 4, AST 125,
ALT 179, Alk Phos 225, Lipase 25. She is afebrile
with a WBC of 6K. Ultrasound shows gallstones in
the gallbladder, with moderate intrahepatic and
extrahepatic biliary dilation. What does this
patient have?
A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
(21) A 78 year old male presents with right
upper quadrant abdominal pain, fever, and
jaundice. Bili 9, AST 125, ALT 179, Alk Phos 400,
Lipase 25. Physical exam reveals that the
patient is diaphoretic, febrile to 102 degrees, and
confused. WBC is 15K. Ultrasound shows
gallstones in the gallbladder, with moderate
intrahepatic and extrahepatic biliary dilation.
What does this patient have?
A) Biliary colic
B) Acute cholecystitis
C) Gallstone pancreatitis
D) Cholangitis
(22) A 52 year old obese female presents with 1
day of severe epigastric pain. Bili 4, AST 125, ALT
179, Alk Phos 225, Lipase 1300. She is afebrile
but has an elevated WBC of 12K. Ultrasound
shows gallstones in the gallbladder, with
moderate intrahepatic and extrahepatic biliary
dilation. What does this patient have?
A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
evaluation of 3 months worth of increasing
jaundice. She denies abdominal pain. She has
lost 30 pounds. She complains of generalized
pruritis. CT scan shows a normal appearing
pancreas, no gallstones present in the
gallbladder, severe intrahepatic biliary dilation
and moderate dilation of the common hepatic
bile duct with normal caliber distal common bile
duct. She is afebrile with a normal white blood
cell count. What disease is likely causing this
patient’s symptoms?
A) Gallstone pancreatitis
B) Cholangitis
C) Pancreatic cancer
D) Mirizzi’s syndrome
E) Cholangiocarcinoma
(24) A 24 year old female is post op day #1 from
a laparoscopic cholecystectomy and develops
severe abdominal pain. Physical exam reveals
diffuse tenderness to palpation with rebound and
guarding. CT scan shows a 7 cm by 5 cm fluid
collection in the GB fossa. Antibiotics are
initiated. IR is consulted and places a
percutaneous drain into the fluid collection with
bilious output. What is the next step in
management?
A) EUS
B) MRCP
C) HIDA
D) ERCP with stent placement
E) Exploratory laparotomy
(24) A 24 year old female is post op day #1 from
a laparoscopic cholecystectomy and develops
right upper quadrant abdominal pain. Physical
exam reveals moderate right upper quadrant
tenderness to palpation without rebound or
guarding. Ultrasound shows intra and
extrahepatic biliary dilation. Bili 5, Alk Phos 250,
AST 245, ALT 200. Pre-op LFTs were normal. What
is the next step in management?
HIDA scan
MRCP
ERCP
Exploratory laparotomy
Biliary Colic
Gallstones
Choledocholithiasis
Cholecystitis
Choledocholithiasis
with possible
pancreatitis