gi board review ravi kapoor, md, mph 2/6/07 mount sinai emergency medicine
TRANSCRIPT
GI BOARD REVIEW
Ravi Kapoor, MD, MPH
2/6/07
Mount Sinai Emergency Medicine
Question One
A 40-year old man presents with severe chest and neck pain. He is otherwise healthy but he says that he “threw up really bad” 6 hours earlier at a tailgate party. The neck pain is made worse by swallowing and by flexing his neck.
A) Broad-spectrum antibioticsB) EndoscopyC) Laboratory testing, including lipaseD) Soft-tissue neck x-ray E) Treatment with H2 blockers
Question One
A 40-year old man presents with severe chest and neck pain. He is otherwise healthy but he says that he “threw up really bad” 6 hours earlier at a tailgate party. The neck pain is made worse by swallowing and by flexing his neck.
A) Broad-spectrum antibioticsB) EndoscopyC) Laboratory testing, including lipaseD) Soft-tissue neck x-ray E) Treatment with H2 blockers
Boerhaave’s Syndrome
Esophageal perforation following a sudden rise in intra-esophageal pressureMechanism: forceful vomiting in 75% of casesClinical course: may include severe pleuritic chest pain, subcutaneous emphysema and cardiopulmonary collapse, although 1/3 of cases present atypically
Treatment
ABC!Broad-spectrum antibioticsVolume replacementNPOSurgical consultationChest X-rayDefinitive study: esophagram and endoscopy
Chest X-ray findings
Mediastinal air (with or without subcutaneous emphysema)
Left-sided pleural effusion
Pneumothorax
Widened mediastinumCaused by irritation of mediastinal tissues
Mallory-Weiss tears
Caused by arterial bleeding from longitudinal mucosal lacerations at the GE junction
Cause of upper GI hemmorhages in 5-15% of cases
Bleeding stops spontaneously in most cases
SEIZURE, TRAUMA, COUGHING
Most common cause of esophageal perforation?
Iatrogenic (endoscopy)
Question Two
What is the most common cause of the condition shown here in the United States?
A) Adhesions
B) Diverticulitis
C) Incarcerated hernia
D) Neoplasm
E) Sigmoid volvulus
Question Two
What is the most common cause of the condition shown here in the United States?
A) Adhesions
B) Diverticulitis
C) Incarcerated hernia
D) Neoplasm
E) Sigmoid volvulus
Small Bowel Obstruction
Upright abdominal X-ray will show
Dilated loops of bowel
Air-fluid levels
Strings of air pockets (“string of beads”)
Colonic gas should be small, may be more in partial SBO’s
Small Bowel Obstruction
Most common cause in US is adhesions status post abdominal surgery
as early as two weeks and as late as years following surgery
Question Three
A 55-year old man with known alcoholic cirrhosis of the liver presents with lethargy, confusion, and asterixis. His vital signs are normal. Which of the following could worsen his condition?
A) Benzodiazepenes
B) Glucose
C) Lactulose
D) Neomycin
E) Thiamine
Question Three
A 55-year old man with known alcoholic cirrhosis of the liver presents with lethargy, confusion, and asterixis. His vital signs are normal. Which of the following could worsen his condition?
A) Benzodiazepenes
B) Glucose
C) Lactulose
D) Neomycin
E) Thiamine
Hepatic encephalopathy
Asterixis often present
Because Wernicke-Korsakoff’s syndrome may also be coexistent, patients should have their glucose checked, and then given thiamine
GI bleed often coexists- DO A RECTAL!
Benzos are poorly metabolized by these patients, may contribute to MS changes
Question Four
A 30-year old man presents with abdominal cramping, flatulence, and frequent pale, loose, foul-smelling stools. Two weeks earlier he went camping in Colorado.
What is the most likely cause of his symptoms?
A) Aeromonas hydrophila
B) Cryptosporidium
C) Giardia
D) Norwalk virus
E) Salmonella
What is the most likely cause of his symptoms?
A) Aeromonas hydrophila
B) Cryptosporidium
C) Giardia
D) Norwalk virus
E) Salmonella
Giardia lamblia
Most common water-borne diarrhea outbreaks in the United States as well as abroad (“traveller’s diarrhea”)
Risk factorsDrinking water from fresh water streams
Close contact with infected individualsDay care exposure, mental institutions
Giardia lamblia
1-3 week incubation period
Non-bloody diarrhea
Tx: metronidazole 250 mg po x 5 d
Check close contacts for O and P in stool
Salmonella
Fever, abdominal pain
24-48 hours after eating contaminated food, limited to 5 day course typically
FECAL LEUKOCYTES seen!
Question Five
Which of the following presentations has the highest mortality rate?
A) 8 y/o M with acute pancreatitis
B) 30 y/o M with acute ETOH pancreatitis
C) 39 y/o M with acute pancreatitis with 3 Ranson’s criteria
D) 42 y/o M with chronic pancreatitis
E) 60 y/o M with WBC 17 and gall stone pancreatitis
Question Five
Which of the following presentations has the highest mortality rate?
A) 8 y/o M with acute pancreatitis
B) 30 y/o M with acute ETOH pancreatitis
C) 39 y/o M with acute pancreatitis with 3 Ranson’s criteria
D) 42 y/o M with chronic pancreatitis
E) 60 y/o M with WBC 17 and gall stone pancreatitis
Pancreatitis
Causes includeGALL STONES and ETOHMedications, toxinsBacteria (mycoplasma)Virus (mumps, coxsackie B, Epstein Barr, rubella)Scorpion, snake bites
HIV patients are at high risk!
Pancreatitis
Medications that can causeAzathioprine
Corticosteroids
Sulfonamides
Thiazides
Furosemides
NSAIDs
Mercaptopurine
Methyldopa
Tetracyclines
Ranson’s Criteria
Evaluated at admission AGE > 55 years
WBC > 16
Glucose > 200
LDH > 350
ALT > 250
Ranson’s Criteria
First 48 hours of hospital courseHct drop > 10%
BUN increase > 5
Ca < 8
Arterial pO2 < 60
Base deficit (24 - HCO3) < 4
Fluid needs > 6L
Ranson’s Criteria
<2 – 1% mortality
3-4 – 15% mortality
5-6 – 40% mortality
> 6 – 100% mortality
Question Six
The most common complication of biliary colic is:
A) Cholangitis
B) Cholecystitis
C) Choledocholithiasis
D) Fluid and electrolyte abnormalities
E) Mallory Weiss tears
Question Six
The most common complication of biliary colic is:
A) Cholangitis
B) Cholecystitis
C) Choledocholithiasis
D) Fluid and electrolyte abnormalities
E) Mallory Weiss tears
Gall stones
Formed fromElevated cholesterol in bile
Intravascular hemolysis (SICKLE CELL, hereditary spherocytosis)
Terminology
Cholangitis - inflammation of the bile duct Ascending cholangitis - inflammation caused by bacterial infection
Choledocholithiasis - presence of a gallstone in the common bile duct.
Cholelithiasis - inflammation of the gallbladder almost always begins without infection, although infection may follow later
inflammation may cause the gallbladder to fill with fluid and its walls to thicken
Acalculous Cholecystitis
Major surgery
Critical illnesses such as serious injuries, major burns, and sepsis
Intravenous feedings for a long time
Fasting for a prolonged time
A deficiency in the immune system
Question Seven
Which of the following statements regarding intussception is correct?
A) If the stool if negative for occult blood, the diagnosis is excludedB) Most patient show profound dehydration at the time of diagnosisC) Mucus-laden, bloody, “currant jelly” stools are seen in most casesD) Post-reduction recurrence is best predicted by patient age and sexE) Ultrasonography is an accepted diagnostic test
Question Seven
Which of the following statements regarding intussception is correct?
A) If the stool if negative for occult blood, the diagnosis is excludedB) Most patient show profound dehydration at the time of diagnosisC) Mucus-laden, bloody, “currant jelly” stools are seen in most casesD) Post-reduction recurrence is best predicted by patient age and sexE) Ultrasonography is an accepted diagnostic test
Intussception
Telescoping of one portion of intestine into an adjacent portion of bowel
Most common location is ileocolic junction
Most common in boys
Most common under 2 years of age (6-12 months)
Intussception
Diagnostic tests includeAir or barium enema (often therapeutic)
May use sono to rule out diagnosis
Question Eight
Which of the following is the most common cause of conjugated hyperbilirubinemia in school-aged children?
A) Amanita toxinB) Bacterial sepsisC) Biliary atresiaD) Familial nonhemolytic jaundice (Gilbert’s syndrome)E) Hepatitis A
Question Eight
Which of the following is the most common cause of conjugated hyperbilirubinemia in school-aged children?
A) Amanita toxinB) Bacterial sepsisC) Biliary atresiaD) Familial nonhemolytic jaundice (Gilbert’s syndrome)E) Hepatitis A
Conjugated hyperbilirubinemia
Unconjugated Hyperbilirubinemia
Question Nine
A 32 year old man vacationing in Florida presents 12 hours after eating seafood and rice. He is complaining of nausea, vomiting, a sensation that cold objects feel warm and paresthesias. What is the most likely cause of symptoms?
A) Bacillus cereusB) CiguateraC) Clostridium perfringesD) ScombroidE) Vibrio parahaemolyticus
Question Nine
A 32 year old man vacationing in Florida presents 12 hours after eating seafood and rice. He is complaining of nausea, vomiting, a sensation that cold objects feel warm and paresthesias. What is the most likely cause of symptoms?
A) Bacillus cereusB) CiguateraC) Clostridium perfringesD) ScombroidE) Vibrio parahaemolyticus
Ciguatoxin
Stored in fish that have eaten dinoflagellate Gambeirdiscus toxicus½ of all fish-related poisonings in US2-24 hrs after ingestionTx: supportive
Bacillus cereus
Aerobic, spore-forming G+, found in soil
Found in raw, uncooked food (rice)
Spores survive boiling
10 hours of diarrhea
Tx: supportive
Clostridium perfringens
Most common cause of acute food poisoning in US
Poultry or meat contaminated with enterotoxin produced by C. perfringes spores
Scombroid
Ingestion of heat-stable toxins from bacterial action on dark meat of fish
Toxins have histidine decarboxylase activity, causing histamine toxidrome
Peppery, metallic, bitter taste
Tx: benadryl
Question Ten
A 74 year old woman with known peripheral vascular disease presents with a complaint of sudden onset severe abdominal pain that started 5 hours earlier, along with nausea and vomiting. Physical examination of the abdomen is unremarkable. An ECG reveals atrial fibrillation. Which of the following tests should be ordered to confirm the diagnosis?
A) Abdominal CTB) Acute abdominal seriesC) AngiographyD) Duplex ultrasonographyE) HIDA scan
Question Ten
A 74 year old woman with known peripheral vascular disease presents with a complaint of sudden onset severe abdominal pain that started 5 hours earlier, along with nausea and vomiting. Physical examination of the abdomen is unremarkable. An ECG reveals atrial fibrillation. Which of the following tests should be ordered to confirm the diagnosis?
A) Abdominal CTB) Acute abdominal seriesC) AngiographyD) Duplex ultrasonographyE) HIDA scan
Acute mesenteric ischemia
Can be from arterial or venous occlusion
Mean age – 70 years
2/3 are women
May also be caused without physical obstruction
Shock, vasopressor therapyTx: laparotomy
Question Eleven
A mother brings her 14-month old son to the emergency department. For the past 4-5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct?
A) affects girls more often than boysB) is associated with cystic fibrosis and malnutritionC) requires excision of the lesion in the emergency departmentD) requires proctosigmoidoscopyE) requires referral for surgical correction
Question Eleven
A mother brings her 14-month old son to the emergency department. For the past 4-5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct?
A) affects girls more often than boysB) is associated with cystic fibrosis and malnutritionC) requires excision of the lesion in the emergency departmentD) requires proctosigmoidoscopyE) requires referral for surgical correction
Rectal prolapse (procidentia)
Affects VERY OLD and VERY YOUNG
Younger than 2 yearsDue to loose connection of mucosa to submucosa and the laxity of anal sphincter.
BOYS > girls
Question Twelve
A 58-year old presents with the complaint of stomach discomfort off and on for several months. For the past 2 weeks he has had gnawing, burning sensation between meals and at night. Which of the following recommendations will have the greatest impact on his condition?
A) Avoid alcoholB) Avoid NSAIDSC) Begin taking a proton pump inhibitorD) Begin treatment for Helicobacter pylori infectionE) Stop smoking cigarettes
Question Twelve
A 58-year old presents with the complaint of stomach discomfort off and on for several months. For the past 2 weeks he has had gnawing, burning sensation between meals and at night. Which of the following recommendations will have the greatest impact on his condition?
A) Avoid alcoholB) Avoid NSAIDSC) Begin taking a proton pump inhibitorD) Begin treatment for Helicobacter pylori infectionE) Stop smoking cigarettes
Peptic ulcer disease
Gastric UlcersH. Pylori in 80%
Duodenal UlcersH. Pylori in 95%
5 X as common as GU
MEN > women 2:1
Pain BETWEEN meals or AT NIGHT
Peptic Ulcer Disease
Most common source of significant upper GI bleed
NSAIDS and cigarettes predispose
ETOH and coffee have no association to PUD
Question Thirteen
Regarding treatment of diverticulitis:A) A 3-cm abscess requires surgical interventionB) A high-fiber diet is helpful but rarely prevents recurrenceC) Morphine sulfate may be used safely for pain reliefD) Patients with abscesses require admissionE) Simple presentations can be managed with diet restrictions and outpatient followup alone
Question Thirteen
Regarding treatment of diverticulitis:A) A 3-cm abscess requires surgical interventionB) A high-fiber diet is helpful but rarely prevents recurrenceC) Morphine sulfate may be used safely for pain reliefD) Patients with abscesses require admissionE) Simple presentations can be managed with diet restrictions and outpatient followup alone
Diverticulitis
1/3 of population over 50 has diverticular diseaseDiverticulitis occurs in 10% - 25% of those who have diverticulosisHigh-fiber diet is important to initiate before diverticula developMorphine may increase intraluminal pressure of bowel, increasing risk of perforationAbscess > 5 cm require drainage, < 5 cm need only IV antibiotics
Question Fourteen
A 4-year old girl is brought to the emergency department at 3:00 AM by her concerned parents because she has been scratching her bottom all night. Cellophane tape swabbing of her anus reveals ova on microscope. Which of the following describes the most likely etiology and correct treatment?
A) Ascaris lumbricoides, pyrantel pamoateB) Enterobius vermicularis, mebendazoleC) Necator americanus, praziquantelD) Strongyloides, ivermectinE) Trichuris trichiura, albendazole
Question Fourteen
A 4-year old girl is brought to the emergency department at 3:00 AM by her concerned parents because she has been scratching her bottom all night. Cellophane tape swabbing of her anus reveals ova on microscope. Which of the following describes the most likely etiology and correct treatment?
A) Ascaris lumbricoides, pyrantel pamoateB) Enterobius vermicularis, mebendazoleC) Necator americanus, praziquantelD) Strongyloides, ivermectinE) Trichuris trichiura, albendazole
Enterobius (pinworm)
Fecal-oral transmission
Gravid females leave anus at night and deposit eggs in perineal area
Tx: mebendazole 100 mg po x 1 or albendazole 400 mg po x 1
Recommended to repeat dose in 2 weeks
Question Fifteen
Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children?
A) anal fissures
B) infectious diarrhea
C) juvenile polyps
D) milk-protein allergy
E) vitamin K deficiency
Question Fifteen
Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children?
A) anal fissures
B) infectious diarrhea
C) juvenile polyps
D) milk-protein allergy
E) vitamin K deficiency
Bloody diarrhea
Predominantly caused by Campylobacter E. Coli Salmonella Shigella (course may be shortened by antibiotics (bactrim)
Antibiotics are rarely indicated in well-appearing school-aged children, even with a clear bacterial source
Prolongs the carrier state in cases of Salmonella, increase the frequency of HUS in E. Coli
Quickies!
Sigmoid Volvulus
May be related to ConstipationResidence in a long-term facilityNeurologic disordersPsychiatric disorders
LOSS OF HAUSTRABENT-INNER TUBE appearance
Contrast enema – “bird’s beak appearance”
UC vs Crohns (regional enteritis)
Inflammatory bowel disease ( UC and Crohn’s disease )
10% - 30% of patients with IBD have extraintestinal symptoms
both diseases can cause intra-abdominal abscesses, obstruction, massive GI bleeding, perianal complications, toxic megacolon
Ulcerative Colitis
GI hemorrhage, toxic megacolon
affects ONLY the colon and rectum
affects TWO layers (mucosa, submucosa)
continuous lesion
30X chance of carcinoma
Crohn’s Disease
3 X increased risk in carcinoma
abscesses, obstruction, perianal cx
can affect “mouth to anus”
affects THREE layers ( serosa )
“skip lesions”, cobblestone appearance late in disease process