GI Board Review 06-01-10

1. GI Board Review 06-01-10

2. 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 Repeat upper endoscopy with antral biopsies B Hydrogen breath test C 14C-urea breath test D Serologic testing for H. pylori E No additional studies are indicated

3. 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.

4. 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 Abdominal ultrasonography B Serologic testing for Helicobacter pylori C Upper endoscopy D Upper gastrointestinal barium study

5. 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. 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

7. 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.

8. 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 Begin a gluten-free diet B Begin a lactose-free diet C Add Lactobacillus acidophilus to the diet D Increase dietary fiber

9. 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.

10. 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 CT scan of the abdomen B Gastroduodenal manometry C Gastric emptying study D Upper endoscopy

11. 128 The initial test in a patient with possible gastric outlet obstruction is upper endoscopy.

12. 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

13. 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.

14. 31 A 46-year-old woman is evaluated because of pain that typically begins in her mid-chest 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

15. 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.

16. 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 Schedule consultation for evaluation for antireflux surgery B Increase the proton pump inhibitor to three times daily C Change to a different proton pump inhibitor D Add trazodone to the current regimen E Add ranitidine at bedtime to the current regimen

17. 84 A low-dose antidepressant may be effective for treating patients with nonulcer dyspepsia.

18. 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.

19. 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 Barium swallow B Pneumatic dilation of the esophagus C Laparoscopic Heller myotomy D Upper endoscopy E Sublingual nifedipine before meals

20. 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. 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). Once-daily 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 Enteroclysis B Repeat capsule endoscopy C Mesenteric angiography D Transfusions as needed E Intraoperative endoscopy

22. 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.

23. 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 Increase the dose of the proton pump inhibitor B Add metoclopramide C Add a nocturnal H2-receptor antagonist D Begin intravenous iron E Schedule surgical consultation for fundoplication

24. 130 Fundoplication should be considered for a patient with severe iron deficiency anemia associated with Cameron's erosions who cannot tolerate oral iron therapy.

25. 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 Now B At age 40 years C At age 45 years D At age 50 years

26. 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.

27. 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

28. 93 Either azathioprine or 6-mercaptopurine provides effective maintenance therapy following a corticosteroid-induced remission in patients with ulcerative colitis.

29. 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 Prednisone B Balsalazide C Metronidazole D Budesonide E 6-Mercaptopurine

30. 103 Budesonide is the drug of choice for treating a Crohn's disease flare that is limited to the ileum.

31. 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 Repeat colonoscopy in 3 months B Repeat colonoscopy in 1 to 2 years C Administer sulindac D Administer a low-dose corticosteroid E Refer for colectomy

32. 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.

33. 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 Cautious introduction of enteral feedings B Cholestyramine C A proton pump inhibitor D Oral magnesium supplements

34. 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.

35. 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 A long-term proton pump inhibitor B Topical swallowed corticosteroids C Oral nifedipine before meals D Sublingual nifedipine before meals

36. 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.

37. 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 Fluconazole B Omeprazole C Barium swallow D CT scan of the chest E Upper endoscopy

38. 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.

39. 25 A 32-year-old woman has a 2-week history of diarrhea with four to five semi-liquid 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

40. 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.

41. 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

42. 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.

44. 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

45. 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.