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Internal Medicine Board

Review
Gastroenterology

Andrew Bain, M.D.


January 28, 2010
Overview
 Esophagus
 Stomach/duodenum
 Pancreas
 Biliary system

 Small bowel
 Colon
 Liver
Esophagus
(1) An 18 year old male has a 3 day history of
pain on swallowing. He has no heartburn,
regurgitation, or weight loss. He has been taking
ibuprofen intermittently for 2 months for elbow
pain. On physical exam, temperature is normal,
pulse is 80, BP is 110/70. Oropharyngeal exam is
normal. There is no chest wall tenderness. Which
of the following is the most likely cause of this
patient’s symptoms?

A) GERD
B) Esophageal motility disorder
C) Zenker’s diverticulum
D) Pill induced esophagitis
E) Peptic ulcer disease
(2) A 28 year old male with longstanding HIV
has a 1 week history of dysphagia and mild
odynophagia and a 5 lb weight loss. He denies
fever or hematemesis. History is significant for
oropharyngeal candidiasis and PCP. The patient
is noncompliant with HAART. Physical exam is
normal without thrush. Most recent CD4 count is
68. Which of the following is the most
appropriate next step in managing this patient?

A) Fluconazole
B) Omeprazole
C) Barium swallow
D) CT scan of the chest
E) EGD
Odynophagia
 Infectious (immunocompromised):
– Candida esophagitis
– CMV
– HSV
– HIV associated idiopathic ulcer
 Pill induced esophagitis (acute onset, erosions in mid
esophagus)
– Aspirin/NSAIDS
– Bisphosphonates
– Doxycycline
– Iron
– Potassium salts
 Radiation
 Erosive esophagitis (Overweight middle aged male with
GERD)
 Caustic injury
(3) A 68 year old male 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 30 lbs during this
time. Which of the following diagnostic studies
should be done next?

A) Barium swallow
B) Videofluoroscopy
C) Upper endoscopy
D) Esophageal motility study
Dysphagia
 Oropharyngeal  Esophageal
– Structural – Structural (solids)
 Cervical osteophytes  Diverticulum
 Cricoid webs  Strictures
 Webs/rings
– Neurologic
 Neoplasm (Red Flags)
 ALS
 CNS tumor
– Motility
 CVA
(solids/liquids)
 Achalasia
 Myasthenia gravis
 DES
 Parkinson’s
 Scleroderma

Videofluorocopy “swallow study” EGD then Esophageal manometry


(4) A 46 year old woman is evaluated because of
pain in her mid chest that radiates to her left
arm. The pain can occur after meals, at rest, and
during exertion. The patient does not have
dysphagia. 2 months ago, cardiac work up
including cath was negative. EGD is normal.
Omeprazole BID for 2 months did not improve
her symptoms. When seen today the patient
appears anxious. CXR normal. Which of the
following is the most appropriate next step in
managing this patient?

A) Low dose antidepressant


B) Resume omeprazole and increase dose to
TID
C) Add ranitidine at bedtime
D) Barium swallow
E) Esophageal motility study
Noncardiac Chest Pain
 Always rule out cardiac causes first
 Trial of proton pump inhibitor
 Viceral hypersensitivity
– May respond to low-dose tricyclic
 Consider esophageal manometry
(5) A 45 year old obese male presents to your
office with 2 months of postprandial substernal
burning and regurgitation. He denies weight loss,
anemia, or dysphagia. What is the appropriate
next step in managing this patient?

A) Ambulatory pH monitoring
B) EGD
C) Barium swallow
D) H. pylori serologies
E) Trial of proton pump inhibitor
GERD Symptoms
 Heartburn
 Regurgitation
 Asthma
 Hoarse voice
 Chronic cough
 Noncardiac chest pain

Typical patient: Overweight, middle age, white male


GERD Diagnosis
 Response to trial of ppi
 Who gets diagnostic testing:
– Fail to respond to ppi trial
– Longstanding symptoms >5 to 10 years
– Older than 50
– Red flags
 Weight loss
 Dysphagia
 Anemia
GERD Diagnosis
 Role of EGD:
– Suggest dx of GERD by distal esophagitis
– Monitor for complications of GERD
 Peptic strictures
 Barrett’s esophagus
 Esophageal adenocarcinoma
 Role of ambulatory esophageal pH testing:
– Gold standard
– Atypical symptoms
– Failed to respond to ppi trial
GERD Treatment
 Lifestyle modification
– Weight loss
– Dietary modification
– Quit smoking/ETOH
– Avoid overeating
– Elevate the head of bed
 Acid suppression
– PPI (daily or BID)
– Can add qhs dose of H2 blocker
 Laparoscopic Nissen fundoplication
– Most effective in patients who respond to medical tx
– Does not permanently relieve reflux symptoms or
prevent complications of GERD
(6) A 57 year old male has a 7 year history of
daily heartburn and frequent belching that have
recently begun to awaken him at night. He does
not have dysphagia or weight loss and has
actually gained 30 lbs over the past year. The
patient has a 20 pack year smoking history and
drinks ETOH occasionally. Physical exam shows
obesity. At follow up visit, he reports that he is
responding well to treatment with a ppi and is
attempting to stop smoking and lose weight.
Which of the following would also be appropriate
for this patient at this time?
A) Esophageal motility study
B) Barium swallow
C) Upper endoscopy
D) Ambulatory esophageal pH study
(7) A 55 year old male has a several year history
of daily heartburn without dysphagia or weight
loss. He has tried OTC antacids and intermittent
OTC PPIs but still has breakthrough symptoms.
EGD is performed and results are shown below.
Esophageal biopsies show intestinal metaplasia.
What are the most appropriate long-term
treatments for this patient?

A) Carafate suspension QID


B) H2 blocker
C) Schedule lap fundoplication
D) Lifelong PPI
E) Repeat EGD with biopsies to exclude
dysplasia
Barrett’s Esophagus
 Results from longstanding GERD
– Acid exposure in the distal esophagus
 Most commonly in middle age white men
– 10% of patients with chronic GERD symptoms
– 1% of asymptomatic population
 Diagnosis is both endoscopic and pathologic
– Proximal displacement of the squamocolumnar
junction
– Specialized intestinal metaplasia with goblet cells
Barrett’s Esophagus
 Who should be screened with EGD?
– All patients with GERD symptoms > 5 years
– Screening not shown to improve survival
 Risk of esophageal cancer in those with
Barrett’s esophagus is increased 30-fold
 Surveillance EGD with biopsy
– Benefit is controversial
– Appropriate intervals unknown
Barrett’s Esophagus
ACG ASGE AGA
2008 2006 2005
No 2 EGD w/in 2 EGD w/in 2 EGD w/in
Dysplasia 1yr, repeat 1yr, repeat 1yr, repeat
q3yr q3yr q5yr

LGD Repeat Repeat Repeat


EGD 6mo, EGD 6mo, EGD 1yr,
then q1yr then q1yr then q1yr
HGD EGD q3mo EGD q3mo EGD q3mo
Barrett’s Esophagus
Risk of cancer progression/year
Barrett’s Esophagus
 Treatment
– Proton pump inhibitors (BID lifelong)
– Anti-reflux surgery does not alter the natural history
– BE without dysplasia
 PPI and surveillance
– BE with LGD
 PPI and surveillance
– BE with HGD
 PPI
 Esophagectomy vs endoscopic ablation (RFA)
(7) A 60 year old African American male with
long history of smoking and regular ETOH abuse
presents for evaluation of dysphagia and a 30
pound weight loss over 4 months. EGD shows a
malignant appearing mass at 28 cm (mid
esophagus). Biopsies of the lesion are likely to
show the following.

A) Adenocarcinoma
B) Squamous cell carcinoma
Esophageal Cancer
 3:1men: women
 Two types:
– Adenocarcinoma
– Squamous cell carcinoma
 Symptoms are dysphagia and weight loss
– Always warrant EGD
 Staging is with CT/PET and EUS
 5 year survival < 10%
Esophageal Cancer
 Adenocarcinoma  SCC
– Distal esophagus – Proximal esophagus
– More common in white – 3x more common in
men
African Americans
– Incidence increased by
> 300% in last 50 yrs
– Risk factors:
 Tobacco
– Risk factors:
 BE
 ETOH
 Tobacco  Corrosive injury
 GERD
 Obesity
Esophageal Cancer
 Treatment
– Surgery
 5 year survival in pts undergoing surgery
25%
– Neoadjuvant chemoradiation
 Benefit controversial
– Palliation
 Self-expanding metal stent
 PEG tube
intermittent sharp chest pain that occurs
postprandially and at rest, but not with exertion.
He denies dysphagia or regurgitation. He has
HTN treated with HCTZ. He has a 30 pack year
smoking hx. His father died of MI at age 70.
Physical exam is normal. Cardiac stress test and
EGD are normal. An esophageal motility study
shows normal peristalsis and increased/high
amplitude peristaltic waves. Which is the most
appropriate next step in this patient’s
management?

A) Barium swallow
B) Coronary angiogram
C) Ambulatory pH monitoring
D) Pneumatic dilation of the distal
esophagus
(9) A 45 year old male has a 2 year history of
dysphagia to both solids and liquids. He has
intermittent chest pain, retrosternal burning with
occasional regurgitation of food. 10 lb weight
loss over the last 2 years. EGD shows some
retained food in the distal esophagus.
Esophageal motility study shows hypertensive
LES that does not relax fully with swallows and
absent peristalsis. Upper GI series is shown.
Which of the following is likely to result in long-
term benefit for this patient?

A) Botox injection into the LES


B) Sublingual nifedipine
C) BID PPI
D) Pneumatic dilation of distal
esophagus
(10) A 67 year old female has a 10 month hx of
intermittent dysphagia to solids and liquids. She
has lost 30 lbs. An upper GI barium radiograph
shows smooth tapering in the distal esophagus.
An esophageal motility study is consistent with
achalasia. Which of the following is the most
appropriate next step?

A) Barium swallow
B) Pneumatic dilation
C) Myotomy
D) EGD
E) Sublingual nifedipine
Esophageal Motility
Disorders
 Symptoms
– Dysphagia to solids and liquids
– Chest pain
– Weight loss
 Diagnosis
– Esophageal manometry
Esophageal Motility
Disorders
 Achalasia
– Degeneration of the myenteric plexus with loss of inhibitory neurons
– LES fails to relax with swallows
– Aperistalsis
– “Bird beak” on esophagography
– Dilated esophagus with tight LES on EGD
– Pneumatic dilation
 Improvement in 70% of patients
 5% risk of perforation
– Heller myotomy
 90% effective
 Can be done laparoscopically
– EGD with Botox injections into the LES
 Temporary improvement
 Used in high risk patients
– Must rule out pseudoachalasia from a tumor
Esophageal Motility
Disorders
 Diffuse esophageal spasm
– Simultaneous contractions interspersed with
normal peristalsis
 Nutcracker esophagus
– Very high amplitude peristaltic contractions
– Evaluate for GERD
 Treatment
– Calcium channel blockers
– Nitrates
– Tricyclic antidepressants
(11) 24 year old male has intermittent
dysphagia for solid foods that has required two
ED visits for food impactions. No weight loss or
heartburn. He has asthma and eczema. EGD
shows some mild ring formation in the mid
esophagus. Biopsy shows eosinophilic infiltration.
What is the most appropriate therapy?

A) PPI
B) Topical swallowed corticosteroids
C) Oral nifedipine
D) Sublingual nifedipine
Stomach and
Duodenum
(12) A 27 year old male has a 3 month hx of intermittent
burning epigastric pain that is made worse by fasting and
improves with meals. Antacids provide temporary relief.
His only medication is occasional Tylenol. Physical exam
discloses only mild epigastric tenderness to palpation; vital
signs are normal. Which of the following studies should be
done next?

A) Abdominal ultrasound
B) Serologic testing for H. Pylori
C) Upper endoscopy
D) Upper GI barium study
(13) A 37 year old female has a 3 month history of
intermittent burning epigastric pain and mild nausea but
no vomiting. The discomfort is made worse by fasting and
improves with meals. Antacids only provide temporary
relief. Weight is stable. No tobacco or alcohol. Physical
exam shows mild epigastric tenderness. Serologic testing
for H. Pylori is negative. What is the most appropriate next
step?

A) Begin an antispasmodic agent


B) Begin a PPI
C) EGD
D) Upper GI barium study
Dyspepsia
 Dyspepsia:
– Chronic discomfort in the upper abdomen
– Differential includes:
 GERD
 PUD
 Nonulcer dyspepsia
 Biliary disease
 Gastric cancer
 Pancreatitis
 Management:
– EGD if alarm symptoms present or > 50
– Assess for pancreatico-biliary disease (LFTs, amylase, lipase,
imaging)
– Stop NSAIDS
– H. Pylori serologies, treat if positive
– Trial of PPI
– If above fails, endoscopy
Peptic Ulcer Disease
 90% due to NSAIDS or H. Pylori
 Burning or gnawing epigastric pain
– Gastric increase with eating
– Duodenal decrease with eating
 Complications of PUD
– GI bleeding (15%)
– Perforation (7%)
– Gastric outlet obstruction (1%)
 Solitary gastric ulcer should have repeat
EGD +/- biopsy to document healing and
exclude malignancy
(13) A 48 year old male with a history of alcohol abuse is
brought to the ED for evaluation of hematemesis. He has
no other medical problems and takes no medications. The
patient is intoxicated and barely arousable. Pulse rate is
115/min, and BP is 80/40. Spider angiomata are present.
Abdominal exam reveals splenomegaly. IV fluids are begun
but before blood samples are drawn the patient vomits a
profuse amount of red blood. Which of the following is the
most appropriate management at this time?

A) IV beta blocker
B) EGD
C) Red blood cell transfusion
D) Endotracheal intubation
E) Transjugular intrahepatic
portosystemic shunt
Upper GI Bleeding
 Repeated vomiting followed by seeing blood 
Mallory-Weiss tear
 Cirrhotic  varices, but can be PUD
 NSAID user  PUD
 Hematemesis/melena without big drop in Hgb 
erosive esophagitis
 Anemia+/- melena /weight loss/abdominal pain 
gastric cancer
 Large volume hematemesis with normal EGD 
Dieulafoy lesion
 Anemia and large hiatal hernia  Cameron’s erosions
Management of UGIB
 Large bore IVs
 IVF
 Type and cross, transfuse
– (if cirrhotic goal Hgb 9)
 PPI gtt
 Octreotide gtt if cirrhotic
 Plts > 50
 INR < 1.5
 Hold aspirin/NSAIDS/coumadin
 When in doubt, intubate
 GI consult
 EGD (last step)
If patient is bleeding, you will see it!
(14) A 63 year old male with a 3 month history of
epigastric burning and a 12 lb weight loss. EGD shows a 1
cm gastric ulcer with surrounding erythema. Biopsy
specimens of the ulcer reveal inflammation with intestinal
metaplasia and early dysplasia and presence of H. Pylori.
Successful eradication of H. Pylori will most likely be
associated with which of the following?

A) Reversal of metaplasia
B) Reversal of dysplasia
C) Decreased incidence of ulcer
recurrence
D) Decreased risk of gastric cancer
Helicobacter Pylori
 Diseases associated with HP
– PUD
 Most common cause
– Antral gastritis
 95% of those infected
– Nonulcer dyspepsia
 10% will improve with HP eradication
– Gastric Cancer of “intestinal type”
 Eradication is unlikely to induce complete resolution
of intestinal metaplasia or to result in a reduced
cancer risk
– MALT
 50% have complete regression of the tumor with HP
eradication
Helicobacter Pylori
 Diagnosis
– Serum antibody (detects prior infection)
– Stool antigen
– Urea breath test
– Biopsy urease test
– Histology

 Treatment with combination therapy (PPI BID,


clarithromycin, and amoxicillin) for 2 weeks

 Verification of eradication 4 weeks after treatment


in those with ulcer complications (bleeding) and
with co-morbid conditions
(15) A 36 year old male has a 6 month history of
increasing intermittent nausea and vomiting. Vomiting
occurs at least once every day and he has lost 20 lbs. He
has had type 1 diabetes for 20 years and complicated by
retinopathy. EGD shows retained food in the stomach.
Gastric emptying scintigraphy shows marked delay at 4
hours. What is the most appropriate management at this
time?

A) Small frequent low fiber meals at


least 4 to 6 times per day
B) Venting gastrostomy and jejunal
feeding tube
C) Gut rest and TPN
D) Erythromycin, orally twice daily,
indefinitely
Gastroparesis
 Symptoms
– Nausea
– Vomiting
– Abdominal pain
– Early satiety
 Diagnosis
– EGD or Upper GI series to rule out structural cause
– Gastric emptying study
 Treatment
– Hydration, electrolyte correction
– Frequent, small volume, low fat/fiber meals
– Metoclopramide, Erythromycin IV, Cisapride, Domperidone
– Venting gastrostomy with jejunal feeding tube
– Gastric pacer Refractory cases
– TPN
Pancreas
(16) A 51 year old female is hospitalized
because of acute onset of moderately severe,
constant upper abdominal pain with nausea and
vomiting. On physical exam the patient is obese
with moderate upper abdominal tenderness.
Initial labs show a Bili 3, AST 180, ALT 285, Alk
Phos 152, Lipase 950. Labs 12 hours later show,
Bili 0.9, AST 82, ALT 100, Alk Phos 130. Which of
the following is the most appropriate step in
management?

A) Abdominal ultrasound
B) HIDA scan
C) ERCP
D) Laparoscopic cholecystectomy
Acute Pancreatitis
 Etiology  Treatment
– Gallstones – Hydration
– Alcohol – Early enteral feeds
– Hyperlipidemia (TG > 1000) – Antibiotics for necrosis
– Medications (Imuran, 6-MP,  Complications
thiazides)
– Fluid collections
– Trauma
– – Pseudocysts
Hypercalcemia
– Post ERCP – Pancreatic
pseudoaneurysm
– Hereditary
– Fistulas
 Prognostic Factors – Splenic vein thrombosis
– Ranson  Gastric varices
– Glasgow – Diabetes
– APACHE
– Chronic pancreatitis
– BMI > 25
– Pancreatic duct leak
– Hct > 50%
Chronic Pancreatitis
 Etiology  Treatment
– Alcohol – Pancreatic enzymes
– Hereditary – Nerve blocks
– Autoimmune – Surgery
 Diagnosis – Narcotics
– Pancreatic calcifications
on radiograph
– CT
– EUS
– ERCP
– Secretin stimulation
(17) A 72 year old male has a 6 week history of
painless jaundice. He has a 40 pound weight loss
over the last 3 months. He was diagnosed with
diabetes two months ago. Bili 6, AST 35, ALT 48,
Alk Phos 350. Which of the following diagnostic
study is the most appropriate at this time?

A) ERCP
B) Mesenteric angiography
C) EUS
D) CT scan of the abdomen
Pancreatic Adenocarcinoma
 Etiology  Diagnosis
– Sporadic – CT
– Familial (10%) – EUS-FNA
 FAP
 Peutz-Jeghers
 Treatment
 Von Hippel-Lindau – Whipple if resectable
 Hereditary pancreatitis – ERCP with stent if
biliary obstruction
 Risks present
– Age
– Chronic pancreatitis
– African American
– Smoking
– Diets high in fats and
meat
Cystic Neoplasms of the
Pancreas
 Mucinous cystadenomas/cystadenocarcinomas
– Middle aged women
– Body or tail
– Frequently lead to invasive cancer
 Intraductal papillary mucinous neoplasms
– Men 60 years or older
– May present with pancreatitis
– Main duct cause main PD dilation
 70% incidence of malignancy
– Side branch cause side branch dilation
 25% incidence of malignancy
 Serous cystadenomas
– Malignant transformation < 1%
– Followed with imaging
Pancreatic Endocrine
Syndrome
Tumors
Hormone Clinical
Findings
Gastrinoma Gastrin Abd pain, PUD,
GERD, MEN 1
(ZES)
Insulinoma Insulin Hypoglycemia

Glucagonoma Glucagon DM, Dermatitis, DVT,


Depression
VIPoma VIP Diarrhea,
hypokalemia,
achlorhydria
Somatostatinoma Somatostatin Abd pain,
Cholelithiasis, weight
loss, DM, diarrhea
Gallbladder and Bile
Ducts
(18) A 52 year old obese female presents with 3
days of intermittent right upper quadrant
abdominal pain lasting for 15 minutes after
meals. Bili 0.9, AST 24, ALT 30, Alk Phos 85,
Lipase 25. Ultrasound shows gallstones in the
gallbladder, otherwise normal gallbladder, no
biliary dilation. What does this patient have?

A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
(19) A 52 year old obese female presents with 3
weeks of intermittent postprandial right upper
quadrant abdominal pain which over the last 2
days has become more constant. Bili 0.9, AST 45,
ALT 65, Alk Phos 85, Lipase 25. Ultrasound shows
gallstones in the gallbladder, gallbladder wall
thickening with moderate percholecystic fluid, no
biliary dilation. What does this patient have?

A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
(20) A 52 year old obese female presents with 3
weeks of intermittent postprandial right upper
quadrant abdominal pain which over the last 2
days has become more constant. Bili 4, AST 125,
ALT 179, Alk Phos 225, Lipase 25. She is afebrile
with a WBC of 6K. Ultrasound shows gallstones in
the gallbladder, with moderate intrahepatic and
extrahepatic biliary dilation. What does this
patient have?

A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
(21) A 78 year old male presents with right
upper quadrant abdominal pain, fever, and
jaundice. Bili 9, AST 125, ALT 179, Alk Phos 400,
Lipase 25. Physical exam reveals that the
patient is diaphoretic, febrile to 102 degrees, and
confused. WBC is 15K. Ultrasound shows
gallstones in the gallbladder, with moderate
intrahepatic and extrahepatic biliary dilation.
What does this patient have?

A) Biliary colic
B) Acute cholecystitis
C) Gallstone pancreatitis
D) Cholangitis
(22) A 52 year old obese female presents with 1
day of severe epigastric pain. Bili 4, AST 125, ALT
179, Alk Phos 225, Lipase 1300. She is afebrile
but has an elevated WBC of 12K. Ultrasound
shows gallstones in the gallbladder, with
moderate intrahepatic and extrahepatic biliary
dilation. What does this patient have?

A) Biliary Colic
B) Acute cholecystitis
C) Choledocholithiasis
D) Gallstone pancreatitis
E) Cholangitis
evaluation of 3 months worth of increasing
jaundice. She denies abdominal pain. She has
lost 30 pounds. She complains of generalized
pruritis. CT scan shows a normal appearing
pancreas, no gallstones present in the
gallbladder, severe intrahepatic biliary dilation
and moderate dilation of the common hepatic
bile duct with normal caliber distal common bile
duct. She is afebrile with a normal white blood
cell count. What disease is likely causing this
patient’s symptoms?

A) Gallstone pancreatitis
B) Cholangitis
C) Pancreatic cancer
D) Mirizzi’s syndrome
E) Cholangiocarcinoma
(24) A 24 year old female is post op day #1 from
a laparoscopic cholecystectomy and develops
severe abdominal pain. Physical exam reveals
diffuse tenderness to palpation with rebound and
guarding. CT scan shows a 7 cm by 5 cm fluid
collection in the GB fossa. Antibiotics are
initiated. IR is consulted and places a
percutaneous drain into the fluid collection with
bilious output. What is the next step in
management?

A) EUS
B) MRCP
C) HIDA
D) ERCP with stent placement
E) Exploratory laparotomy
(24) A 24 year old female is post op day #1 from
a laparoscopic cholecystectomy and develops
right upper quadrant abdominal pain. Physical
exam reveals moderate right upper quadrant
tenderness to palpation without rebound or
guarding. Ultrasound shows intra and
extrahepatic biliary dilation. Bili 5, Alk Phos 250,
AST 245, ALT 200. Pre-op LFTs were normal. What
is the next step in management?

 HIDA scan
 MRCP
 ERCP
 Exploratory laparotomy
Biliary Colic
Gallstones

Choledocholithiasis

Cholecystitis

Choledocholithiasis
with possible
pancreatitis