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)

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