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GI
Board Review
06-01-10
109
A 65-year-old woman was recently discharged from the hospital after treatment of
upper gastrointestinal bleeding secondary to a duodenal ulcer. While hospitalized,
she underwent upper endoscopy, and antral biopsy specimens showed
Helicobacter pylori. The patient was treated with appropriate antibiotics and a
proton pump inhibitor.
When seen for a follow-up visit 6 weeks after completing her medical regimen, she
is asymptomatic, and her hemoglobin is normal.
Which of the following diagnostic studies should be done next?
A
B
C
D
E
Repeat upper endoscopy with antral biopsies
Hydrogen breath test
14C-urea breath test
Serologic testing for H. pylori
No additional studies are indicated
109
The 14C-urea breath test is the most sensitive and specific noninvasive study for
documenting active Helicobacter pylori infection.
A positive serologic test for H. pylori indicates only past exposure to the organism;
this test does not determine active infection.
Because the risk of malignancy is low in duodenal ulcers no repeat EGD is
necessary.
2
A 27-year-old man has a 3-month history of intermittent burning epigastric pain
that is made worse by fasting and improves with meals. Antacids provide
temporary relief. He is otherwise healthy and has no other symptoms. His only
medication is occasional acetaminophen for knee discomfort. Physical
examination discloses only mild epigastric tenderness to palpation; vital signs are
normal.
Which of the following diagnostic studies should be done next?
A
B
C
D
Abdominal ultrasonography
Serologic testing for Helicobacter pylori
Upper endoscopy
Upper gastrointestinal barium study
2
Approximately 70% of patients with gastric
or duodenal ulcer disease also have
Helicobacter pylori infection.
Patients with dyspepsia without alarm
features (vomiting, weight loss, anemia) can
usually be treated empirically for H. pylori
infection.
Nonulcer dyspepsia is the most common
cause of epigastric pain in a young,
otherwise healthy patient.
A trial of a proton pump inhibitor is
warranted in a young patient with a first
episode of nonulcer dyspepsia and a negative
serologic test for Helicobacter pylori.
6
A 36-year-old man has a 6-month history of increasing intermittent
nausea and vomiting. Vomiting occurs at least once every other day, and
the patient has lost approximately 9 kg (20 lb) in the past 2 months. He
has had type 1 diabetes mellitus for 20 years complicated by retinopathy
requiring laser therapy. Current medications are insulin and lisinopril. He
is taking no new medications and has not traveled recently. On physical
examination, the patient appears chronically ill. Pulse rate is 70/min and
regular, and blood pressure is 110/70 mm Hg. The abdomen is soft and
nontender.
An upper gastrointestinal radiographic series shows retained fluid and
particulate matter in the stomach. The duodenum appears normal.
Gastric emptying scintigraphy shows marked delay at 4 hours, with more
than 75% of the markers still retained in the stomach (normal <30%).
In addition to correcting the electrolyte abnormalities, which of the
following is the most appropriate management at this time?
A Small, frequent low-fiber meals at least four to six times daily
B Placement of a venting gastrostomy tube and feeding jejunal tube
C Gut rest and total parenteral nutrition
D Erythromycin, orally twice daily, taken indefinitely
Laboratory Studies
Hemoglobin
10.1 g/dL (101
g/L)
Leukocyte
count
5600/μL (5.6 ×
109/L)
Platelet count
190,000/μL (190
× 109/L)
Plasma glucose 164 mg/dL (9.1
(nonfasting)
mmol/L)
Hemoglobin
A1C
7%
Serum
creatinine
1.6 mg/dL
(141.47 μmol/L)
Serum sodium
136 meq/L (136
mmol/L)
Serum
potassium
3.6 meq/L (3.6
mmol/L)
6
Gastroparesis is a well-recognized complication of diabetes mellitus.
Patients with gastroparesis should be started on small, frequent feedings of a diet
low in fiber, fat, and refined sugar.
If dietary control is ineffective, anti-emetic agents should be given. If gastroparesis
continues, enteral tube feedings, with or without a venting gastrostomy tube, can
be started.
27
A 67-year-old woman has a 3-month history of loose, watery stools four to five
times per day without bleeding, weight loss, urgency, or fecal incontinence. The
patient has not traveled recently. She has a 45-year history of type 1 diabetes
mellitus, managed with insulin, and a 2-year history of gastroesophageal reflux
disease, treated with a proton pump inhibitor. She recently received two courses of
antibiotics for recurrent cystitis, during which time her diarrhea improved. She
has been drinking milk all her life without problems. Screening colonoscopy 1 year
ago was normal.
Physical examination is notable only for peripheral neuropathy and Charcot's
joints. Stool examination for ova and parasites and stool assay for Clostridium
difficile toxin are negative. Stool culture shows no growth of pathogens.
Which of the following dietary changes should be tried at this time?
A
B
C
D
Begin a gluten-free diet
Begin a lactose-free diet
Add Lactobacillus acidophilus to the diet
Increase dietary fiber
27
Patients with diabetes mellitus and associated neuropathy are at increased risk for
development of small bowel bacterial overgrowth.
Patients with small bowel bacterial overgrowth often have secondary lactose
intolerance.
If this is unsuccessful, treatment with antibiotic monotherapy or a regimen of
different antibiotics on a rotating schedule should be considered.
128
A 28-year-old woman has a 10-month history of poor appetite and recurrent nausea.
Symptoms began as mild postprandial nausea, but for the past 6 weeks she has had
early satiety and significant upper abdominal discomfort after eating solid foods. The
discomfort is periodically followed by vomiting of undigested food with some relief of
the abdominal pain. The patient has lost approximately 8.5 kg (18 lb) over the past 6
months. She does not have fever, chills, or night sweats. Medical history includes type
1 diabetes mellitus, renal insufficiency, and migraine headaches. Medications include
insulin, an angiotensin-converting enzyme inhibitor, a statin, low-dose aspirin, and
over-the-counter ibuprofen as needed for the headaches.
On physical examination, vital signs are normal. Abdominal examination discloses
slight epigastric tenderness to palpation with active bowel sounds throughout.
Sensation to monofilament testing of the lower extremities is diminished in a stocking
distribution. Liver chemistry studies are normal.
Which of the following diagnostic studies should be done next?
A
B
C
D
CT scan of the abdomen
Gastroduodenal manometry
Gastric emptying study
Upper endoscopy
128
The initial test in a patient with possible gastric outlet obstruction is upper
endoscopy.
15
A 68-year-old man 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 13.5 kg (30 lb) during this time.
Medical history is unremarkable, and physical examination is normal.
Which of the following diagnostic studies should be done next?
A Barium swallow
B Videofluoroscopy swallow
C Upper endoscopy
D Esophageal motility study
15
Patients with oropharyngeal dysphagia typically have difficulty swallowing both
solid foods and liquids, coughing and choking during meals, and changes in voice
quality.
A videofluoroscopy study is the most appropriate initial test in patients with
suspected oropharyngeal dysphagia.
31
A 46-year-old woman is evaluated because of pain that typically begins in her midchest and radiates to her left arm. The pain can occur after meals, at rest, and
during exertion. The patient does not have dysphagia. Two months ago, cardiac
workup, including coronary angiography, was negative, and upper endoscopy was
normal. Omeprazole, 20 mg twice daily for 2 months, did not improve her
symptoms.
When seen today, the patient appears anxious. Physical examination is otherwise
normal. Complete blood count and chest radiograph are also normal.
Which of the following is the most appropriate next step in managing this patient?
A Begin a low-dose antidepressant
B Resume omeprazole; increase dose to 20 mg three times daily
C Add ranitidine at bedtime
D Schedule barium swallow
E Schedule esophageal motility study
31
Symptoms of noncardiac chest pain frequently mimic those of cardiac chest pain.
The diagnosis of noncardiac chest pain can only be made after a thorough
evaluation has ruled out cardiac causes for the pain.
Low-dose antidepressants may be helpful in treating patients with noncardiac
chest pain.
Patients with chronic pancreatitis often require narcotics for pain control.
84
A 56-year-old woman is evaluated because of continuing symptoms due to
refractory gastroesophageal reflux that have not improved despite lifestyle
modifications and treatment with a twice-daily proton pump inhibitor. The patient
continues to have occasional substernal chest pain associated with some epigastric
burning. She has not had dysphagia, regurgitation, weight loss, or a change in
bowel habits. She has no cardiac risk factors.
Physical examination is normal except for slight overweight. Upper endoscopy is
also normal.
Which of the following is the most appropriate treatment at this time?
A
B
C
D
E
Schedule consultation for evaluation for antireflux surgery
Increase the proton pump inhibitor to three times daily
Change to a different proton pump inhibitor
Add trazodone to the current regimen
Add ranitidine at bedtime to the current regimen
84
A low-dose antidepressant may be effective for treating patients with
nonulcer dyspepsia.
Screening for Barrett’s
Patients over 40 years of age who have had chronic symptoms of gastroesophageal
reflux disease for more than 5 years should undergo screening for Barrett's
esophagus.
Upper endoscopy is the test of choice for patients with gastroesophageal reflux
disease who are undergoing screening for Barrett's esophagus.
97
A 67-year-old woman has an 8- to 10-month history of intermittent dysphagia for
both solid foods and liquids. The dysphagia initially developed over the course of
10 to 14 days. She reports no abdominal symptoms but has lost 13.5 kg (30 lb)
during this time.
An upper gastrointestinal barium radiograph shows a smooth narrowing in the
distal esophagus. An esophageal motility study is consistent with achalasia.
Which of the following is the most appropriate next step in managing this patient?
A
B
C
D
E
Barium swallow
Pneumatic dilation of the esophagus
Laparoscopic Heller myotomy
Upper endoscopy
Sublingual nifedipine before meals
97
Pseudoachalasia may be associated with the presence of a malignant disorder.
Elderly patients with achalasia should undergo upper endoscopy to rule out
pseudoachalasia.
The symptoms of pseudoachalasia may mimic those of idiopathic (benign)
achalasia.
21
A 61-year-old woman is evaluated because of a 2-month history of progressive fatigue, weakness, dyspnea
on exertion, and intermittent black stools. On physical examination, the patient appears pale and tired.
General examination, including rectal examination, is normal. A stool specimen is negative for occult
blood. Hemoglobin is 8.0 g/dL (80 g/L), and mean corpuscular volume is 74 fL. An electrocardiogram
shows mild nonspecific changes, and a chest radiograph is normal. Colonoscopy, upper endoscopy with
small bowel biopsies, small bowel follow-through barium radiographic studies, and a CT scan of the
abdomen are normal.
Following transfusion of two units of packed red blood cells, the patient's symptoms resolve, her
electrocardiographic changes normalize, and her hemoglobin level increases to 10.8 g/dL (108 g/L). Oncedaily iron supplementation is begun.
Six weeks later, the patient returns because of chest pain and dyspnea. Hemoglobin is 7.2 g/dL (72 g/L),
and the electrocardiogram shows more pronounced changes. She receives four units of packed red blood
cells, following which her symptoms again resolve, her electrocardiographic changes normalize, and her
hemoglobin level increases to 11.4 g/dL (114 g/L). Repeat colonoscopy with intubation of the terminal
ileum and extended upper endoscopy into the proximal jejunum are normal. Capsule endoscopy (capsule
enteroscopy) shows red-tinged fluid in the mid–small bowel, but no mucosal lesions are identified. Iron
supplementation is increased to twice daily.
Which of the following is the most appropriate next step in managing this patient?
A
B
C
D
E
Enteroclysis
Repeat capsule endoscopy
Mesenteric angiography
Transfusions as needed
Intraoperative endoscopy
21
Intraoperative endoscopy may be needed for a patient with unexplained severe
recurrent gastrointestinal bleeding that cannot be diagnosed by less invasive
studies.
But study is invasive and should not be performed in sicker pts.
Self-limited hematochezia is a common cause of ischemic colitis in elderly patients.
Diagnostic studies, other than colonoscopy or flexible sigmoidoscopy, are usually
not needed after an episode of ischemic colitis.
130
A 45-year-old man is evaluated because of severe iron deficiency anemia. The
patient has a history of heartburn, which resolved following use of a once-daily
proton pump inhibitor. He also has intermittent dysphagia for solid foods, but
previous upper endoscopic examinations and barium swallow studies have never
documented a stricture or mucosal ring.
Upper endoscopy at this time shows a large hiatal hernia with Cameron's erosions.
Colonoscopy is normal. Iron supplements are begun three times daily, but the
patient is unable to tolerate the iron therapy. The proton pump inhibitor is
increased to twice daily. On follow-up visits 4 and 8 weeks later, the patient's
hemoglobin level is still low.
Which of the following is most appropriate at this time?
A
B
C
D
E
Increase the dose of the proton pump inhibitor
Add metoclopramide
Add a nocturnal H2-receptor antagonist
Begin intravenous iron
Schedule surgical consultation for fundoplication
130
Fundoplication should be considered for a patient with severe iron deficiency
anemia associated with Cameron's erosions who cannot tolerate oral iron therapy.
48
A 32-year-old man comes for an annual health maintenance visit. His mother was
diagnosed with colorectal cancer at 55 years of age. The patient reports no rectal
bleeding or other symptoms. Medical history is noncontributory except for
hypercholesterolemia. Physical examination is normal.
When should this patient first undergo colorectal cancer screening?
A
B
C
D
Now
At age 40 years
At age 45 years
At age 50 years
48
Current guidelines recommend screening average-risk individuals beginning at
age 50 years using any of the following studies: fecal occult blood testing
annually, flexible sigmoidoscopy every 5 years, annual fecal occult blood testing
plus flexible sigmoidoscopy every 5 years, barium enema examination every 5
years, or colonoscopy every 10 years.
A person who has a first-degree relative with colorectal cancer should initially
undergo colorectal cancer screening 10 years before the age of diagnosis of the
affected relative or at age 40 years, whichever comes first.
Repeat colonoscopy in 5 years is recommended for persons with a history of one or
two small (<1 cm) adenomatous polyps with low-risk histologic findings (e.g., a
tubular adenoma).
Patients with a high-risk polypoid lesion detected and removed during screening
colonoscopy should undergo surveillance colonoscopy in 3 years.
93
A 32-year-old man with chronic ulcerative colitis develops a severe disease flare
associated with abdominal pain, frequent bloody diarrhea, mild fever, and weight
loss. He is maintained on mesalamine, 4.8 g/d, and is compliant about taking this
medication. When the patient's symptoms do not respond to oral prednisone, he is
hospitalized and started on intravenous methylprednisolone. Stool studies
obtained on admission showed no evidence of infection.
On hospital day 5, his symptoms have improved, oral prednisone is substituted for
the intravenous methylprednisolone, and discharge is being planned.
In addition to tapering the prednisone, which of the following is the most
appropriate maintenance therapy for this patient?
A Continue mesalamine
B Continue the lowest possible dose of prednisone
C Substitute azathioprine for mesalamine
D Substitute cyclosporine for mesalamine
E Schedule consultation for proctocolectomy
93
Either azathioprine or 6-mercaptopurine provides effective maintenance therapy
following a corticosteroid-induced remission in patients with ulcerative colitis.
103
A 32-year-old woman with distal ileal Crohn's disease has a 2-week history of
increasingly severe right lower quadrant abdominal pain, five or six nonbloody bowel
movements daily, nausea, and anorexia. She has lost 3.2 kg (7 lb) during this time. The
patient has not had vomiting, abdominal distention, fever, chills, or excessive sweating.
Until her current symptoms developed, she had been maintained in remission on
mesalamine.
On physical examination, she appears mildly ill. Vital signs are normal. Abdominal
examination discloses mild right lower quadrant tenderness without masses, guarding,
or rebound. CT enterography shows mural edema, hyperenhancement, and
hypervascularity in the distal 15 cm of ileum with some inflammatory stranding around
the ileum. No phlegmon, abscess, or lymphadenopathy is noted. Colonoscopy shows
fissuring ulcers and cobblestoning in the distal ileum with no evidence of colitis.
Which of the following medications is most appropriate for the acute management of
this patient's disease flare?
A
B
C
D
E
Prednisone
Balsalazide
Metronidazole
Budesonide
6-Mercaptopurine
103
Budesonide is the drug of choice for treating a Crohn's disease flare that is limited
to the ileum.
19
A 40-year-old woman has an 18-year history of ulcerative colitis that is limited to
the left side and has responded well to mesalamine and occasional corticosteroid
enemas. Recent surveillance colonoscopy with biopsies showed low-grade
dysplasia.
Which of the following is the most appropriate next step in managing this patient?
A
B
C
D
E
Repeat colonoscopy in 3 months
Repeat colonoscopy in 1 to 2 years
Administer sulindac
Administer a low-dose corticosteroid
Refer for colectomy
19
In patients with chronic ulcerative colitis, the finding of low-grade dysplasia on
surveillance colonoscopy is associated with an increased risk of progression to
high-grade dysplasia or cancer.
Patients with chronic ulcerative colitis and dysplasia of any grade detected on
surveillance colonoscopy should be referred for colectomy.
22
A 39-year-old woman is hospitalized because of blunt abdominal trauma and
bowel infarction sustained in a motor vehicle accident. Subtotal colectomy and
resection of most of the small intestine are required; 100 cm of duodenum plus the
jejunum remain after surgery.
One week postoperatively, the patient's enterostomy output is over 2000 mL daily.
She is currently receiving total parenteral nutrition and requires intravenous
fluids to compensate for her increased stomal output.
Which of the following is most appropriate for managing this patient's nutritional
and fluid requirements at this time?
A
B
C
D
Cautious introduction of enteral feedings
Cholestyramine
A proton pump inhibitor
Oral magnesium supplements
22
Patients with short bowel syndrome associated with <115 cm of small intestine in
the absence of a colon will most likely require continuous total parenteral
nutrition.
A proton pump inhibitor or an H2-receptor antagonist may help reduce excessive
gastric secretions and stomal fluid losses in patients with short bowel syndrome.
74
A 24-year-old man has intermittent dysphagia for solid foods that has required
two visits to the emergency department in the past 6 years for endoscopic removal
of pieces of chicken. The patient has no weight loss or heartburn. He has always
been a slow eater. He has mild asthma and uses a β-agonist inhaler intermittently.
On physical examination, the patient is well developed. General examination is
normal. Upper endoscopy reveals some mild ring formation in the mid-esophagus.
Esophageal biopsy specimens show intense eosinophilic infiltration.
Which of the following is the most appropriate therapy for this patient's
dysphagia?
A
B
C
D
A long-term proton pump inhibitor
Topical swallowed corticosteroids
Oral nifedipine before meals
Sublingual nifedipine before meals
74
Eosinophilic esophagitis is occurring more often in adults, especially those with
other atopic disorders.
Treatment of eosinophilic esophagitis includes an elemental diet and either oral or
topical corticosteroids.
36
A 28-year-old man with longstanding HIV infection has a 1-week history of
dysphagia and mild odynophagia and a 2.3-kg (5-lb) weight loss. He has not had
fever or hematemesis. History is significant for oropharyngeal candidiasis and
Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia. The patient is
noncompliant about taking his highly active antiretroviral therapy (HAART).
Physical examination is normal; there is no thrush. His most recent CD4 cell count
was 68/μL (0.068 × 109/L).
In addition to emphasizing the need to adhere to his HAART regimen, which of
the following is the most appropriate next step in managing this patient's current
findings?
A
B
C
D
E
Fluconazole
Omeprazole
Barium swallow
CT scan of the chest
Upper endoscopy
36
Candidiasis is the most common esophageal disorder in patients with HIV
infection.
Patients with HIV infection associated with dysphagia and odynophagia should
receive an empiric trial of fluconazole.
25
A 32-year-old woman has a 2-week history of diarrhea with four to five semiliquid stools daily. Stools are of small volume, and she has a sense of urgency and
incomplete evacuation. The patient does not have fever, rectal bleeding, or weight
loss. She has just returned from a trip to Asia where she met a new sexual partner.
A brother has ulcerative colitis, and her mother developed colon cancer at 60 years
of age.
Which of the following is the most likely explanation for this patient's clinical
presentation?
A Crohn's disease
B Villous adenoma
C Cryptosporidium parvum infection
D Celiac sprue
E Neisseria gonorrhoeae colitis
25
Tenesmus (a sensation of incomplete evacuation of the bowels) indicates the
presence of proctitis.
Neisseria gonorrhoeae infection should be considered as a cause of proctitis in
sexually active patients.
134
A 46-year-old man is evaluated in the office because of
a 4-day history of left lower quadrant abdominal pain,
fever, and two or three loose stools daily. He does not
have nausea, vomiting, or blood in his stools. Medical
history is unremarkable.
On physical examination, temperature is 37.8 °C (100
°F), pulse rate is 80/min, and blood pressure is 140/85
mm Hg. Abdominal examination discloses mild left
lower quadrant tenderness without guarding or
rigidity. The remainder of the examination is normal.
Which of the following is the most appropriate next
step in managing this patient?
A Schedule CT scan of the abdomen
B Begin a high-fiber diet
C Begin empiric oral antibiotics
D Schedule colonoscopy or barium enema
examination in 1 week
Laboratory Studies
Hemoglobin
13.1 g/dL (131
g/L)
Leukocyte count
14,000/μL (14 ×
109/L)
Platelet count
285,000/μL (285
× 109/L)
Serum
electrolytes
Normal
Liver chemistry
studies
Normal
134
Patients with acute diverticulitis who are able to take liquids and are not
dehydrated can usually be managed on an outpatient basis.
The initial steps in managing outpatients with acute diverticulitis are
administration of oral antibiotics and re-evaluation in several days.
1
A 26-year-old man has a 4-week history of increasingly severe bloody diarrhea,
urgency, tenesmus, and abdominal pain without fever, chills, or excessive
sweating. The patient has an 8-pack-year smoking history.
On physical examination, he appears well. The abdomen is mildly tender without
guarding or rebound. Rectal examination is normal. Hemoglobin is 12 g/dL (120
g/L), the leukocyte count is 11,300/μL (11.3 × 109/L), and the erythrocyte
sedimentation rate is 38 mm/h. Colonoscopy shows areas of inflammation
throughout the colon associated with friability, granularity, and deep ulcerations.
The inflamed areas are separated by relatively normal-appearing mucosa,
including normal rectal mucosa. The ileum appears normal. Biopsy samples from
the inflamed areas of the colon show moderately active chronic colitis without
granulomas. Biopsy samples from the ileum are normal.
Which of the following is the most likely diagnosis?
A Crohn's disease
B Ulcerative colitis
C Microscopic colitis
D Yersinia enterocolitis
E Ischemic colitis
1
Crohn's disease is more common in current smokers, whereas ulcerative colitis
occurs more often in former smokers and nonsmokers.
Colonoscopic findings in Crohn's disease include deep ulcerations separated by
areas of normal mucosa (skip lesions) and rectal sparing.
Colonoscopic findings in ulcerative colitis include continuous inflammation,
typically including the rectum, but without deep ulcerations or skip lesions.