Gastroenterology Q #4

Gastroenterology Q #4

CY MD

A 40-year-old man with long-standing alcohol abuse complains of abdominal swelling, which has been progressive over several months. He has a history of gastrointestinal bleeding. On physical examination, there are spider angiomas and palmar erythema. Abdominal collateral vessels are seen around the umbilicus. There is shifting dullness, and bulging flanks are noted. Which of the following is the most important first step in the patient’s evaluation?

a. Diagnostic paracentesis
b. Upper GI series
c. Ethanol level
d. CT scan of the abdomen
e. Examination of peripheral blood smear

Answer 

The answer is a. 

Paracentesis is required to evaluate new-onset ascites. While cirrhosis and portal hypertension are most likely in this patient, complicating diseases such as tuberculous peritonitis and hepatoma are ruled out by analysis of ascitic fluid. An ultrasound or CT scan can be used to demonstrate ascitic fluid in equivocal cases. A serum albumin minus ascitic fluid albumin greater than 1.1 suggests portal hypertension alone as a cause for ascites. Tuberculosis, pancreatitis, and malignancy would cause inflammation and increased capillary permeability, causing protein to leak into the ascitic fluid. This would result in a gradient between the serum and ascitic fluid of less than 1.1. Upper GI radiographs are less useful than endoscopy in demonstrating the esophageal varices that may be associated with cirrhosis. Neither serum ethanol level nor an evaluation of the peripheral blood smear for evidence of folate deficiency would specifically address the ascites.

Gastroenterology Q #3

Gastroenterology Q #3

CY MD

A 56-year-old woman becomes the chief financial officer of a large company and, several months thereafter, develops upper abdominal pain that she ascribes to stress. She takes an over-the-counter antacid with temporary benefit. She uses no other medications. One night she awakens with nausea and vomits a large volume of coffee grounds-like material; she becomes weak and diaphoretic. Upon hospitalization, she is found to have an actively bleeding duodenal ulcer. Which of the following statements is true?

a. The most likely etiology is adenocarcinoma of the duodenum.
b. The etiology of duodenal ulcer is different in women than in men.
c. The likelihood that she harbors Helicobacter pylori is greater than 50%.
d. Lifetime residence in the United States makes H pylori unlikely as an etiologic agent.
e. Organisms consistent with H pylori are rarely seen on biopsy in patients with
duodenal ulcer.

Answer

The answer is c.

Duodenal ulcer is more common in men than women, but H pylori is present in 70% of patients (men and women) who have a duodenal ulcer not associated with NSAID ingestion. In gastric ulcer disease, the incidence of H pylori is 30 to 60%. H pylori is more common in developing countries but is often seen in the United States. It is more common in patients with low socioeconomic status, in particular those with unsanitary living conditions, which suggests that H pylori is transmitted by fecal-oral or oral-oral routes. In patients with duodenal ulcer, organisms consistent with H pylori are frequently seen on biopsy. Before the discovery of H pylori, most duodenal ulcers would reoccur. Adenocarcinoma of the duodenum is a rare cause of upper gastrointestinal bleeding.

Gastroenterology Q #2

Gastroenterology Q #2

CY MD

60-year-old woman with depression and poorly controlled type 2 diabetes mellitus complains of episodic vomiting over the last three months. She has constant nausea and early satiety. She vomits once or twice almost every day. In addition, she reports several months of mild abdominal discomfort that is localized to the upper abdomen and that sometimes awakens her at night. She has lost 5 lb of weight. Her diabetes has been poorly
controlled (glycosylated hemoglobin recently was 9.5). Current medications are glyburide, metformin, and amitriptyline. Her physical examination is normal except for mild abdominal distention and evidence of a peripheral sensory neuropathy. Complete blood
count, serum electrolytes, BUN, creatinine, and liver function tests are all normal. Gallbladder sonogram is negative for gallstones. Upper GI series and CT scan of the abdomen are normal. What is the best next step in the evaluation of this patient’s symptoms?

a. Barium esophagram
b. Scintigraphic gastric emptying study
c. Colonoscopy
d. Liver biopsy
e. Small bowel biopsy

Answer

The answer is b.

Delayed gastric emptying (gastroparesis) is a common cause of recurrent vomiting, nausea, early satiety, and weight loss in poorly controlled diabetics. Abdominal discomfort is often
nonspecific, but may be localized to the upper abdomen and often awakens the patient at night. Drugs with anticholinergic properties may aggravate the problem. The best diagnostic test is a scintigraphic gastric emptying study, which will show delay in gastric emptying. Treatment includes withdrawal of aggravating drugs such as opiates and those that have anticholinergic properties, good diabetes control, and drug therapy with metoclopropamide or erythromycin. The patient’s symptoms are not those of esophageal disease (dysphagia, odynophagia), so a barium esophagram would not be useful. Her symptoms also do not suggest colonic pathology; in the absence of iron deficiency, colonoscopy would not be indicated. You would not order a liver biopsy in a patient with normal liver enzymes and CT scan of the abdomen. Small bowel biopsy would be indicated if her symptoms suggest intestinal malabsorption.

Gastroenterology Q #1

Gastroenterology Q #1

CY MD

A 35-year-old alcoholic man is admitted with nausea, vomiting, and abdominal pain that radiates to the back. He has had several previous episodes of pancreatitis presenting with the same symptoms. Which of the following laboratory values suggests a poor prognosis in this patient?

a. Elevated serum lipase
b. Elevated serum amylase
c. Leukocytosis of 20,000/μm
d. Diastolic blood pressure greater than 90 mm Hg
e. Heart rate of 100 beats/minute

Answer 

The answer is c.

The Ranson criteria are used to determine prognosis in acute pancreatitis. Factors that adversely affect survival include age greater than 55 years, leukocytosis greater than 16, 000/μm, glucose greater than 200 mg/dL, LDH greater than 400 U/L, and AST greater than 250 U/L. After the initial 48 hours, a decrease in hematocrit, hypocalcemia, hypoxemia, an increase in BUN, and hypoalbuminemia predict a poor prognosis. Hypotension with systolic BP less than 90 mm Hg is also a poor prognostic sign; diastolic hypertension is not correlated with prognosis. Although serum amylase and lipase elevations are important in the diagnosis of pancreatitis, the degree of elevation is not prognostic. Tachycardia is frequently associated with the pain of pancreatitis but is not a risk factor in the Ranson criteria.