Transcript GI Board review: Part I

GI BOARD REVIEW:
PART I
By Molly McVey
Esophagus
• Symptoms of esophageal disorders:
• Dysphagia
• Oropharyngeal – diagnostic test is videofluoroscopy
• Esophageal – diagnostic test is upper endoscopy
• Reflux
• Chest pain
• Odynophagia
• Globus sensation
A 35-year-old man is evaluated for a 2-year history of intermittent chest pain. The pain is
retrosternal, lasts for seconds to minutes, is unrelated to exertion, and does not radiate. It is
occasionally associated with swallowing. He reports intermittent dysphagia to solids and
liquids. He denies any reflux symptoms or weight loss. He does not have any risk factors
for cardiac disease.
Physical examination is unremarkable. Upper endoscopy is normal. A barium swallow is
shown.
Which of the following is the most likely dignosis?
A. Achalasia
B. Diffuse esophageal
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C. Eosinophilic esophagitis
D. Schatzki ring
Nonmalignant esophageal disorder
• Hypertonic Motility Disorder
• Achalasia
• Failure of lower esophageal sphincter to relax
• Symptoms don’t respond to empiric PPIs or H2Bs
• Barium swallow: esophageal dilation with “bird’s beak”
distally
• Manometry: esophageal aperistalsis and incomplete
relaxation of LES
• Endoscopy performed to exclude mechanical obstruction
• Treatment: surgical myotomy vs pneumatic balloon
dilatations vs botulinum toxin injections
• Pseudoachalasia
• Diffuse esophageal Spasm
• “corkscrew esophagus” on barium swallow
• Tx: CCB
• Nutcracker esophagus
• distal esophageal pressures of >220mmHg during peristalsis
Nonmalignant esophageal disorder
• Hypotonic Motility Disorders
• “Scleroderma esophagus”
• Aperistalsis on manometry and hypotensive LES
• Tx is acid reflux control
A 25-year-old man is evaluated for a 5-year history of slowly progressive solid-food dysphagia that is
accompanied by a sensation of food sticking in his lower retrosternal area. He has compensated by
modifying his diet and avoiding fibrous meats. He has not lost weight, and he has not had trouble
drinking liquids. He has had episodes of food impaction that he manages by inducing vomiting. He has
had no difficulty initiating a swallow and has not had chest pain, odynophagia, reflux symptoms, or
aspiration of food while swallowing. He has seasonal allergies that are treated with antihistamines and
asthma that is treated with inhaled albuterol.
Physical examination is normal.
Which of the following is the most likely diagnosis?
A. Achalasia
B. Eosinophilic esophagitis
C. Esophageal candidiasis
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D. Esophageal malignancy
Nonmalignant esophageal disorder
• Infectious Esophagitis:
• Candida – white plaques
• Tx: fluconazole
• HSV – multiple superficial ulcers
• Tx: acyclovir
• CMV – isolated esophageal ulcers
• Tx: ganciclovir
• Pill-induced esophagitis
• Common meds assoc: tetracycline (doxycycline), iron sulfate,
bisophosphonates, potassium, NSAIDs and quinidine
• Eosinophilic esophagitis
• Adults, solid food dysphagia and food impaction
• High prevalence of asthma and seasonal allergies
• Dx by >15 eosinophils/hpf on esophageal biopsy
A 50-year-old woman is evaluated for a 1-year history of recurrent left-sided chest pain. The pain is
poorly localized, nonexertional, and occurs in 1-minute episodes. There is no dyspnea, nausea, or
diaphoresis associated with these episodes. She has not had dysphagia, heartburn, weight change, or
other gastrointestinal symptoms. She has no other medical problems and does not smoke cigarettes.
Family history is noncontributory.
On physical examination, vital signs are normal and BMI is 30. The patient's chest pain is not
reproducible with palpation. The cardiac examination reveals normal heart sounds without murmurs or
extracardiac sounds. The remainder of the physical examination is normal.
A lipid panel, fasting plasma glucose test, and chest radiograph are normal. An echocardiogram shows
a normal ejection fraction with no wall motion abnormalities.
An exercise stress test is normal.
Which of the following is the most appropriate management?
A. Ambulatory pH study
B. Begin an NSAID
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Nonmalignant esophageal disorder
• GERD
• Symptoms: heartburn and regurgitation
• Dx: symptoms, endoscopy or ambulatory pH monitoring
• Empiric tx first
if not effective then endoscopy
• Alarm symptoms (dysphagia, anemia, vomiting or weight loss)
• Endoscopy is first line
• Ambulatory pH monitoring: don’t respond to tx and endoscopy is
unremarkable
• Tx:
• Lifestyle modifications
• Medications: PPI superior to H2Bs
• PPI may increase susceptibility to GI infections (C.diff) and pneumonia
• Unclear data on increase risk of hip fracture
• Fundoplication
A 55-year-old man is evaluated for a 6-year history of typical gastroesophageal reflux
symptoms treated on an as-needed basis with a proton pump inhibitor. However, the
frequency of his reflux symptoms has recently increased and his episodes do not respond
to treatment as completely as in the past. An upper endoscopy is scheduled to evaluate
the cause of this change in his symptoms.
Endoscopy reveals a 4-cm segment of salmon-colored mucosa in the distal esophagus.
Biopsy from the salmon-colored segment reveals intestinal metaplasia and goblet cells
with no dysplasia.
In addition to starting a daily PPI, which of the following is the most appropriate
management?
A. Daily COX-2 inhibitor therapy
B. Endoscopic ablation
C. Fundoplication
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A 75-year-old man is evaluated for a 2-month history of progressive solid-food dysphagia.
He has transitioned from solid to puréed foods and has been able to maintain his weight.
He has a 40-pack-year history of cigarette smoking and a history of alcohol abuse.
On physical examination, vital signs are normal. BMI is 35. There is no evidence of
supraclavicular lymphadenopathy. Cardiopulmonary examination is normal. On abdominal
examination, there is no evidence of mass, tenderness, or hepatomegaly.
A complete blood count reveals a hemoglobin level of 10.9 g/dL (109 g/L). Endoscopy
reveals an obstructive mass in the distal esophagus, and biopsies show invasive
adenocarcinoma.
Which of the following is the most appropriate management?
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A. CT/PET and endoscopic
US
B. Esophagectomy
C. Feeding tube placement
D. Radiation therapy
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Malignant Disorders of the Esophagus
• Barrett Esophagus
• Complication of GERD
• 30-50 fold increased risk of esophageal adenocarcinoma
• Screening is not recommended
• Dx: biopsy
• Tx:
• PPI ? Lower risk of developing high grade dysplasia
• Ablative therapies for high grade dysplasia
• Surveillance:
• No dysplasia: repeat endoscopy in 1 year
• Low grade: repeat endoscopy in 6 months
• High grade: removal of focal lesions
Malignant Disorders of the Esophagus
• Esophageal Carcinoma
• Risk factors for SCC: long term exposure to alcohol and tobacco;
nitrosamine; corrosive injury to the esophagus; dietary deficiencies;
achalasia; tylosis; HPV
• Risk factors for adeno: tobacco, obesity, symptomatic GERD and
BE
• Dx: endoscopy
• Staging: CT, endoscopic US (locoregional staging) and PET
A 44-year-old woman is evaluated for a 1-year history of vague upper abdominal discomfort that occurs
after eating. She is from a rural area in a developing country. She has not had nausea, vomiting,
dysphagia, odynophagia, weight loss, or black or bloody stools. She is otherwise healthy. She has no
personal history of peptic ulcer disease and no family history of gastrointestinal malignancy. Her only
medication is a multivitamin.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 127/82 mm Hg, pulse rate
is 72/min, and respiration rate is 16/min. BMI is 27. There is epigastric tenderness with moderate
palpation but no masses or lymphadenopathy. Complete blood count is normal.
Which of the following is the most appropriate management?
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A. H.pylori stool antigen testing
B. Initiate an H2 blocker
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C. Initiate empiric treatment for
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Dyspepsia
• PUD and h.pylori
• Alarming symptoms: >50 yo, anemia, dysphagia,
odynophagia, vomiting, weight loss, family history of GI
malignancy, person history of PUD, gastric surgery or GI
malignancy or abdominal mass or LAD on exam
• < 50yo and no alarming symptoms:
• Test and treat for h.pylori if coming from area with high rates of
h.pylori
• Empiric PPI in areas where h.pylori rates are low
• Alarm symptoms then straight to endoscopy
Peptic Ulcer Disease
• Gastric or duodenal mucosal break >5mm
• >90% caused by NSAIDs and H.pylori
• Other causes: gastrinoma (ZE) – multiple ulcers beyond
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duodenal bulb associated with esophagitis and diarrhea,
Crohn disease, mastocytosis, G-cell hyperplasia, viral
infection, infiltrative disease and radiation
Gastric: pain shortly after meals, not relieved as much
with antacids
Duodenal: pain 2-5 hrs after meals and relieved by food
or antacids
Dx: upper endoscopy with biopsy
Complications: bleeding, penetration, perforation and
obstruction
H. pylori
• Infection causes gastritis, PUD, gastric cancer and MALT
• Testing:
• Serology: suboptimal
• Positive IgG shows exposure but not previously treated or eradicated
• Urea breath test: good but more costly
• Fecal antigen: test of choice for initial dx and eradication proof
• >90% sensitivity, specificity and predictive value before and after treatment
***PPIs, H2Bs, antibiotics and bismuth decrease the sensitivity of all H.
pylori test except serology****
• Stop PPIs 2 weeks prior to nonserologic testing
• Stop antibiotics and bismuth 4 weeks before testing
• Stop H2Bs 23-48hr before testing
• Endoscopy: histology, rapid urease test and culture
• Most cost-effective is gastric biopsies with rapid urease testing
• If high suspension and histology negative then send serology test
H. pylori
• Treatment:
• First line:
• clarithromycin, amoxicillin and BID PPI x 10-14 days
• Tetracycline, metronidazole, bismuth and BID PPI x 10-14 days
• Amoxicillin (days 1-5) then clarithromycin and metronidazole or
tinidazole (days 6-10) all along with BID PPI
• Eradication:
• Urea breath test or fecal antigen test 4-6 weeks after treatment
A 26-year-old man is evaluated for a 16-month history of intermittent episodes of abdominal discomfort,
nausea, and vomiting. He is relatively asymptomatic between episodes, which occur every 4 to 6
weeks. Episodes consist of vomiting once every 2 to 4 hours for about 48 hours. The only relieving
factor is hot baths. He currently feels well, but it has been 5 weeks since his last episode. His medical
history is notable for daily marijuana use for the past 2 years.
On physical examination, vital signs are normal. BMI is 25. Abdominal examination is normal.
Laboratory studies reveal a normal complete blood count and normal plasma glucose and thyroidstimulating hormone levels. An abdominal radiograph is normal.
Which of the following is the most likely diagnosis?
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A. Cannabinoid hyperemesis
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B. Chronic intestinal pseudoobstruction
C. Cyclic vomiting syndrome
D. Gastroparesis
Stomach potpourri
• Cannabinoid hyperemesis syndrome: abdominal pain,
nausea and vomiting in patient using marijuana;
associated with compulsive washing
• Gastroparesis: nausea/vomiting/early satiety; dx with
gastric emptying study; tx dietary adjustment and
prokinetic medications
• Gastric polyps: if <40 with numerous gastric fundic polyps
refer for colorectal evaluation for workup of familial
adenomatous polyposis syndrome
• Gastric carcinoid tumor: <2cm then survey every 6-12
months x 3 years
A 34-year-old man is evaluated in the emergency department for confusion. Three weeks ago he
underwent a Roux-en-Y gastric bypass for morbid obesity. He has had poor oral intake since the
surgery because of nausea. Vitamin B12 injections were prescribed, but he has not started them yet. He
recently took hydrocodone for pain, but he has not needed it for several days. His only current
medication is a multivitamin with iron.
On physical examination, he is afebrile. Blood pressure is 115/80 mm Hg (no orthostatic changes), and
pulse rate is 85/min. The mucous membranes are moist, and there is no skin tenting. He has an ataxic
gait, nystagmus, and a disconjugate gaze. The remainder of the neurologic examination is normal.
Laboratory studies, including a complete blood count, glucose, and electrolytes, are normal.
Which of the following is the most appropriate next step in management?
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A. CT of the head
B. Glucose infusion
C. IV naloxone
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Bariatric Surgery Complications
• Postoperative mortality caused by VTE, anastomotic leak
and exacerbation of preexisting comorbidities
• Nutritional deficiencies:
• Iron - anemia
• Vitamin B12 - anemia
• Folic acid - anemia
• Calcium
• Vitamin D
• Thiamine – Wernicke-Korsakoff syndrome
• Vitamin A
• Vitamin E
A 42-year-old woman is evaluated following hospitalization for acute pancreatitis due to gallstone disease that occurred 8
weeks ago. An admission CT scan demonstrated no evidence of fluid collection or necrosis, and she had an
uncomplicated cholecystectomy prior to discharge. She has no pain, nausea, or anorexia. However, 2 weeks ago she
was evaluated for nephrolithiasis following an episode of renal colic and underwent a CT scan. The CT scan
demonstrated a 4-mm stone in the right ureter and a 6-cm fluid collection adjacent to the pancreatic tail. There was no
evidence of solid debris, and it did not communicate with the main pancreatic duct. There were no mass lesions in the liver
and no pancreatic necrosis. She has since passed the kidney stone and is asymptomatic.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 112/72 mm Hg, pulse rate is 66/min, and
respiration rate is 18/min. BMI is 25. Abdominal examination discloses a nondistended abdomen and active bowel
sounds. There is no tenderness to palpation, hepatosplenomegaly, or masses.
Laboratory studies, including complete blood count, liver chemistry tests, CA 19-9, and alkaline phosphatase, are normal.
Which of the following is the most appropriate next step in management?
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A. Endoscopic US
B. MRCP
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Acute Pancreatitis
• Classified as mild (interstitial) or severe (organ failure or
necrosis/fluid collections)
• Dx: symptoms, elevated amylase and/or lipase and CT
• Prognostic criteria: BUN most accurate predictor of
severity
• Management: IVFs, pain control, bowel rest
• NG not needed unless ileus or bowel obstruction 2/2 pancreatitis
• Antibiotics NOT indicated unless necrosis seen on CT
• ERCP only indicated if cholangitis present or worsening clinical
symptoms with rising liver enzymes
• Complications:
• Fluid collections, pseudocysts, pancreatic duct leak, splenic vein
thrombosis
Chronic Pancreatitis
• Symptoms: abdominal pain, weight loss, diarrhea
• Signs: exocrine and endocrine insufficiencies – fat-soluble
vitamin deficiency, insulin dependence
• Dx: no gold standard; clinical symptoms and imaging
demonstrating pancreatic calcifications, ductal dilatation,
parenchymal atrophy and/or focal inflammatory masses
• Tx: pancreatic enzymes, fat-soluble vitamin replacement
and pain control….surgical therapies saved for failure of
medical management
A 72-year-old man is evaluated for a 2-week history of painless jaundice. He also has pruritus, anorexia, and weight loss of
4.5 kg (10.0 lb) during the same time period. He takes no medications.
On physical examination, vital signs are normal. BMI is 22, and he appears thin. Scleral icterus and jaundice are present.
There is no hepatosplenomegaly and no cutaneous signs of cirrhosis. The gallbladder is palpable.
Laboratory studies:
Complete blood count
Normal
Alkaline phosphatase
522 units/L
Alanine aminotransferase
354 units/L
Aspartate aminotransferase
215 units/L
Total bilirubin
12.1 mg/dL (206.9 µmol/L)
Direct bilirubin
10.7 mg/dL (183.0 µmol/L)
Contrast-enhanced CT scan demonstrates a dilated common bile duct with focal
cutoff in the pancreas head. No focal mass is noted in the head. The pancreas duct
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is dilated. There is no evidence of mass lesions in the liver.
Which of the following is the most appropriate initial management?
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Perform abdominal MRI
Perform endoscopic US of pancreas
Refer for pancreaticoduodenectomy
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Pancreatic Adenocarcinoma
• 5 year survival rate of 5%
• Presentation: painless jaundice, anorexia, weight loss
• >50yo presenting with acute pancreatitis – scan
• Dx/staging: CT, EUS, biopsy
Autoimmune Pancreatitis
• Lymphoplasmacytic infiltrate of IgG4
• Affects the pancreas, biliary tree, salivary glands,
retroperitoneum and lymph nodes
• Present with painless obstructive jaundice
• Imaging: CT shows “sausage-shaped” gland
• Dx: biopsy showing >10 IgG4 positive cells/hpf
• If mass present, want to exclude malignancy
• Tx: steroids
23-year-old woman is evaluated in the hospital for recurrent episodes of hypoglycemia. During
hospitalization, she developed neuroglycopenic symptoms after 8 hours of fasting associated with a
plasma glucose level of 30 mg/dL (1.7 mmol/L) and a corresponding insulin level of 8 µU/mL (58
pmol/L). She does not have diabetes mellitus and does not take oral hypoglycemic agents or insulin.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 90/56 mm Hg, pulse rate
is 110/min, and respiration rate is 22/min. BMI is 22. No tenderness, masses, or hepatosplenomegaly is
found on abdominal examination.
A contrast-enhanced CT scan demonstrates no evidence of a pancreatic mass.
Which of the following is the most appropriate diagnostic test to perform next?
A. Endoscopic US
B. MRI
C. Operative pancreatic
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D. Pentetreotide scintigraphy
Pancreatic Neuroendocrine Tumors
Tumor Type
Gastrinoma
Insulinoma
VIPoma
Glucagonoma
Hormone
Symptoms
Criteria for Diagnosis
Gastrin
Peptic ulcers, diarrhea,
esophagitis (ZollingerEllison syndrome)
Elevated serum gastrin
>1000 pg/mL (1000 ng/L),
secretin stimulation test
Insulin
Hypoglycemia;
associated with MEN-1
Inappropriately high
insulin level during
hypoglycemia
Vasoactive intestinal
peptide
Watery diarrhea,
hypokalemia,
hypochlorhydria (VernerMorrison syndrome)
Elevated serum VIP level
>75 pg/mL (75 ng/L)
Glucagon
Dermatitis (necrolytic
migratory erythema),
diabetes mellitus
Elevated serum glucagon
>1000 pg/mL (1000 ng/L)
MEN-1 = multiple endocrine neoplasia type 1; VIP = vasoactive intestinal peptide.
A 34-year-old woman is evaluated in an urgent care clinic for a 1-day history of watery diarrhea and mild
abdominal cramps. She is having four watery stools per day. She has not had fever or blood in her stool.
Although she has felt mildly nauseated, she has been able to stay hydrated with oral intake. She works
as a banker, and colleagues at work have had similar gastrointestinal symptoms over recent weeks.
She has no history of recent hospitalization, antibiotic use, or medication changes. She has no risk
factors for HIV infection.
On physical examination, temperature is 36.1 °C (97.0 °F), blood pressure is 110/75 mm Hg, pulse rate
is 86/min, and respiration rate is normal. BMI is 24. The mucous membranes are moist, and there is no
skin tenting. Abdominal examination reveals mild abdominal tenderness but normal bowel sounds.
There is no guarding or rebound. A urine pregnancy test is negative.
Which of the following is the most appropriate diagnostic test?
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A. C.diff PCR
B. Fecal leukocyte testing
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E. No additional studies
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Diarrhea
• Definition: Increased frequency or liquidity of stool or stool
weight >200g/d
• Classifications:
• Duration:
• Acute <14 days (think infectious)
• Subacute 14 days-4 weeks
• Chronic >4 weeks (good history, stool studies, endoscopic eval, imaging
• Feature:
• Osmotic: volume <1L/d, stool improves when fasting; stool osmotic gap
<50mOsm/kg
• Secretory: large volume, electrolyte disturbances, no improvement with
fasting; stool osmotic gap >100mOsm/kg
• Inflammatory: blood or mucus in stool
• Malabsorptive: loss of nutrients, fat, carbohydrate or protein
A 26-year-old man is evaluated for fatigue and has been newly diagnosed with iron-deficiency anemia.
The patient has Down syndrome, and details of his clinical history are provided by his mother. There is
no history of melena, hematochezia, or hematuria. His hemoglobin level was checked 2 years ago and
was normal. His bowel movements are regular, and his weight is unchanged. He has no abdominal
problems.
On physical examination, temperature is 36.3 °C (97.3 °F) and pulse rate is 88/min. Other vital signs are
normal. BMI is 29. Mild skin pallor is noted. Abdominal and rectal examinations are normal.
Serum tissue transglutaminase IgA antibody testing is negative. Colonoscopy and upper endoscopy are
unremarkable.
Which of the following is the most appropriate diagnostic test to perform next?
A. Meckel scan
B. Push enteroscopy
C. Repeat upper endoscopy with
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D. Small-bowel capsule endoscopy
E. Stool guaiac examination
Malabsorption
• Fat malabsorption: diarrhea and weight loss
• Fecal fat collection for 48-72 hours
• Pancreatic insufficiency
• Celiac disease
• Autoimmune enteropathy
• Small intestinal bacterial overgrowth
• Carbohydrate malabsorption: diarrhea, bloating, excess
flatus but NO weight loss
• Lactose
• Protein malabsorption: diarrhea, edema, ascites,
anasarca
• Stool alpha 1 antitrypsin clearance test
• Ex: C.diff infection, IBD, celiac dz, Whipple dz, constrictive
pericarditis, lymphangiectasia and lymphatic obstruction
Celiac disease
• Symptoms: diarrhea, bloating and weight loss
• Extraintestinal: anemia, osteopenia/porosis, dematitis
herpetiformis…
• Associated with Down syndrome, type 1 DM, juvenile RA,
thyroid dz and AI liver conditions
• Dx: tTG IgA antibody (false negative in IgA deficiency)
• Tx: gluten-free diet
A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional
nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematocheziabut notes an
occasional oily appearance to the stool. She has lost 6.8 kg (15.0 lb) during this time period. Results of a colonoscopy 1 year ago were normal. She
has not had recent travel, antibiotic use, or medication changes. She does not think consumption of dairy products alters hersymptoms. She has a
history of systemic sclerosis for which she takes omeprazole for symptoms of gastroesophagealreflux disease.
On physical examination, vital signs are normal. BMI is 22. Facial telangiectasiasare present, and there is bilateral skin thickening of the hands. The
abdomen is mildly distended, and bowel sounds are normal. Rectal examination is normal, with normal resting and squeeze tone.There are no
palpable mass lesions.
Laboratory studies:
Hemoglobin
10.8 g/dL (108 g/L)
Mean corpuscular volume
104 fL
Serum electrolytes
Normal
Folate
63 ng/mL (143 nmol/L)
Glucose
Normal
Thyroid-stimulating hormone
Normal
Vitamin B12
118 pg/mL (87 pmol/L)
Tissue transglutaminase antibody
Normal
Stool cultures, including an ova and parasite examination, are normal.
Which of the following is the most likely diagnosis?
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Celiac disease
IBS
Lactose malabsorption
Microscopic colitis
Small intestinal bacterial overgrowth
Ce
lia
A.
B.
C.
D.
E.
Bacterial Overgrowth
• Symptoms: diarrhea, bloating and weight loss
• Signs: macrocytosis 2/2 B12 def, elevated serum folate
• Common risk factors: altered gastric acid, structural
abnormalities and intestinal dysmotility
• Dx: hydrogen breath test or upper endoscopy with culture