Exciting Esophagus
Stomach Stumpers
IBD
Killer Bs(Biliary)
GI Poopurri
100
A 40-year-old woman is referred to you for evaluation of persistent heartburn and regurgitation despite optimized double-dose proton pump inhibitor (PPI) therapy and lifestyle modifications.
She has lost 5 lb, and her body mass index is 21 kg/m2. She has no comorbidities. She recently underwent an upper endoscopy with 96-hour wireless pH monitoring off PPI, which was consistent with nonerosive reflux disease. There was no hiatal hernia.
She is interested in antireflux surgery.
Which of the following should be recommended before antireflux surgery?
A. Additional Weight Loss
B. Esophageal Manometry
C. Gastric Emptying Study
D. Psychology Referral
E. Quadruple-dose PPI trial
B. Esophageal Manometry
This case highlights the importance of excluding a major esophageal motor disorder, such as achalasia, on high-resolution esophageal manometry before proceeding with antireflux surgery, as achalasia is a contraindication to antireflux surgery.
Although weight management is critical to the management of gastroesophageal reflux disease, additional weight loss is unlikely to provide sufficient symptom relief for this patient, who has a normal body mass index.
A gastric emptying study could be considered if gastroparesis was also suspected but is not required before referral for antireflux surgery. Psychology referral could be considered in a patient with functional heart burn and/or reflux hypersensitivity.
Quadruple dose PPI therapy has no established role.
100
Which of the following suppresses gastric acid production?
A) Acetylcholine
B) Gastrin
C) Histamine
D) Somatostatin
D) Somatostatin
Gastric acid is stimulated by 3 substances: gastrin, histamine, and acetylcholine.
Somatostatin acts as a feedback mechanism to suppress acid production, as does acid in the stomach itself
100
A 35-year-old man with Crohn's disease (CD) with history of recent ileocecal resection presents for follow-up to his gastroenterologist.
He is taking infliximab 5 mg/kg every 8 weeks.
Ileocolonoscopy at 6 months after his operation shows 3 ulcers in neo-terminal ileum.
He is asymptomatic.
What is the best management decision at this time?
A) Increase Infliximab dose
B) Change infliximab to ustekinumab
C) Continue Infliximab at current dose
D) Add Azathiopurine
E) Add ciprofloxicin
C) Continue Infliximab at current dose
CD after an operation is assessed using the Rutgeerts score.
Fewer than 5 ulcers (i1) is considered low risk for postoperative recurrence and continuation of current therapy is most appropriate.
More than 5 ulcers would be classified as Rugeerts i2 or greater and medical optimization would be recommended at that time.
100
A 72-year-old woman is seen in the emergency department with acute-onset right upper quadrant abdominal pain.
Upon evaluation, she is noted to have a heart rate of 105 bpm and a temperature of 38.3 °C.
Laboratory tests reveal the results shown (Figure 1).
Right upper quadrant ultrasound reveals a 14 mm diameter common bile duct, cholelithiasis without gallbladder wall thickening, and no pericholecystic fluid.
The patient is administered intravenous Ringers' lactate, admitted to the hospital, and started on parenteral antibiotics.
What is the most appropriate next step in management?
A) Cholecystectomy
B) Endoscopic retrograde cholangiopancreatography with duct clearance and stent placement
C) Endoscopic retrograde cholangiopancreatography with stent placement
D) Magnetic resonance cholangiopancreatography
E) Percutaneous transhepatic biliary drainage
B) Endoscopic retrograde cholangiopancreatography with duct clearance and stent placement
The patient presents with Charcot's triad of fever, jaundice, and abdominal pain, which is consistent with a diagnosis of acute cholangitis.
The appropriate management of suppurative infections of the biliary tree includes supportive care, systemic antibiotics, and source control via biliary decompression. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method of biliary decompression in most patients with conventional upper gastrointestinal anatomy due to high clinical success rate, relatively short length of hospitalization, and lower risk of adverse events than alternatives.
The rationale to perform decompression alone (versus duct clearance) is based upon observational data, which suggest an increased risk of bleeding in patients with cholangitis who undergo biliary sphincterotomy.
Performing concurrent ductal clearance is associated with more rapid clinical and biochemical improvement (normalization of leukocyte count, liver enzymes), shorter hospital length of stay, and need for fewer subsequent ERCP procedures.
Although some circumstances warrant biliary decompression alone (coagulopathy, physiological compromise from cholangitis, ongoing antithrombotic use), combined endotherapy and decompression is favored in patients who are not critically ill, and this strategy is reflected in current guidelines.
In the setting of acute cholangitis, further imaging with magnetic resonance cholangiopancreatography is not indicated. Cholecystectomy may eventually be needed, but with bile duct dilatation, the ERCP is more pressing.
Finally, ERCP would lead to less morbidity than transhepatic biliary drainage where a percutaneous tube would be left behind.
100
A 29-year-old woman in her second trimester of pregnancy presents to the emergency department with a 2-day history of melena and hematemesis at the time of presentation.
She has no significant medical history and had a hemoglobin of 12.0 g/dL (reference range, 12-16 g/dL) at her last obstetrician appointment 2 weeks ago.
Today her heart rate is 135 bpm, and her blood pressure is 105/75 mmHg.
Her physical examination is unremarkable other than a gravid uterus.
Her hemoglobin is 10.1 g/dL.
After admitting the patient to the hospital and administering intravenous fluids, what is the best management strategy in this patient?
A) Intravenous famotidine
B) Intravenous pantoprazole
C) Intravenous metoclopramide
D) Urgent upper endoscopy
D) Urgent upper endoscopy
This pregnant patient has signs and symptoms of an active upper gastrointestinal hemorrhage and should be evaluated with an upper endoscopy. (Tachycardia, hypotension, Hgb drop)
Upper endoscopy is the most common endoscopic procedure performed during pregnancy and should be performed when clinically indicated.
200
A 68-year-old woman with chest pain is seen in the emergency department.
She has a history of hypertension, hypothyroidism, diabetes, and osteoporosis. She denies heartburn.
An electrocardiogram is performed and demonstrates normal rate and rhythm without other abnormalities. The troponin level is normal. Computed tomography is performed and shows no acute abnormalities in the chest or abdomen.
An endoscopy is performed and demonstrates esophageal ulceration at 33 cm from the incisors. The Z line is regular without erythema or erosions at 39 cm from the incisors. The remainder of the upper gastrointestinal endoscopy is normal.
What is the most likely etiology of her esophageal ulceration?
A. Eosinophilic Esophagitis
B. Gastroesophageal reflux disease
C. Ischemic Esophagitis
D. Pill-Induced Esophagitis
E. Viral Esophagitis
D. Pill-Induced Esophagitis
The most likely etiology of mid-esophageal ulceration without evidence of distal esophagitis is pill-induced esophagitis.
The most likely etiologies of pill-induced esophagitis include antibiotics, nonsteroidal anti-inflammatory drugs, and bisphosphonates.
Given the patient's history of osteoporosis, the most likely etiology of her ulcerations is a bisphosphonate.
Eosinophilic esophagitis does not typically present with ulceration.
Gastroesophageal reflux disease can cause erosive esophagitis starting at the gastroesophageal junction but does not cause ulcerations more proximally without involvement of the distal esophagus. Ischemic esophagitis is unlikely given the clinical history.
Viral esophagitis can have ulceration, but the patient is not immunosuppressed, so this would be less likely.
200
A 42-year-old man with no chronic medical problems is referred for open-access upper endoscopy for abdominal pain.
He has had no relief with dietary modifications or over-the-counter therapy such as peppermint oil.
His pain is described as burning in character and located in the epigastric area.
He has not had any weight loss, though he does report early satiety.
He previously tried a proton pump inhibitor (PPI) for 4 weeks without benefit.
The mucosa is normal appearing on endoscopy; therefore, what is the best approach for tissue sampling?
A. Biopsy gastric body and antrum in separate jars
B. Biopsy the gastric body, antrum, and incisura
C. Biopsy esophagus, stomach, and duodenum
D. Biopsy the duodenum
B. Biopsy the gastric body, antrum, and incisura
Many patients with dyspepsia symptoms, including epigastric pain and burning, early satiety, and postprandial fullness, undergo upper endoscopy. In immunocompetent patients without an identifiable lesion and in patients with dyspepsia, American Gastroenterological Association (AGA) guidelines recommend against biopsies of the esophagus or esophagogastric junction. They also recommend against obtaining biopsies from the duodenum when no symptoms or signs suggest celiac disease. The AGA does recommend obtaining gastric biopsies in this context, however, to evaluate for Helicobacter pylori infection. Although special stains are not required, biopsies should be obtained according to the Sydney protocol, obtaining samples from the gastric body, antrum, and incisura. The Sydney protocol was shown to identify 100% of H pylori infections in one study. The AGA suggests against using separate jars for the purposes of making a H pylori diagnosis as this is unnecessary and costly in patients with endoscopically normal appearing mucosa. However, recent AGA Clinical Practice Updates provide best practice advice for patients with suspected atrophic gastritis based on endoscopic appearance. In these cases, it is appropriate to obtain biopsies from at least the gastric antrum/incisura and gastric body, placing them in separately labeled jars.
200
A 23-year-old woman with penetrating colonic Crohn's disease with perianal phenotype is now in clinical and endoscopic remission on combination therapy with infliximab and methotrexate. She is interested in becoming pregnant. She asks about her medications.
Which of the following would be most appropriate to manage her Crohn's disease during pregnancy?
A) Stop methotrexate prior to conception and continue infliximab
B) Stop both methotrexate and infliximab prior to conception, use no maintenance medications during pregnancy
C) Continue both methotrexate and infliximab
D) Stop methotrexate now and plan to start mercaptopurine during her pregnancy
E) Start prednisone now and continue during pregnancy to prevent relapse
A) Stop methotrexate prior to conception and continue infliximab
Methotrexate is contraindicated during pregnancy related to neural tube defects associated with its use. Data have consistently shown that infliximab is not associated with congenital abnormalities. Additionally, infliximab has not been associated with other complications in the newborn. Discontinuation of therapy is associated with a risk of relapse of Crohn's disease. Active disease is associated with increased risk of small for gestational age and/or pre-term delivery. Initiation of mercaptopurine is not recommended during pregnancy, related to the rare risk of pancreatitis at initiation. However, if a woman is stable on maintenance mercaptopurine prior to conception, it is now recommended that she continue therapy during pregnancy to prevent disease relapse.
200
A previously healthy, 62-year-old man presented 2 months ago with elevated liver function levels.
An abdominal ultrasound and standard-protocol computed tomography scan of the abdomen revealed moderate intrahepatic biliary dilation and some gallbladder sludge.
An endoscopic retrograde cholangiopancreatography revealed a stricture of the common hepatic duct with diffuse proximal biliary dilation.
Cytologic brushings were obtained and ultimately returned negative for malignancy.
A plastic stent was placed across the stricture.
The patient returns for follow-up today, without complaint.
Which is the best management option?
A) Initiate ursodeoxycholic acid
B) Obtain carcinoembryonic antigen level
C) Perform magnetic resonancecholangiopancreatography
D) Refer for cholecystectomy
E) Repeat endoscopic retrograde cholangiopancreatography with brushing
E) Repeat endoscopic retrograde cholangiopancreatography with brushing
Brushing has an approximately 50% yield. The overall picture is most consistent with a malignant biliary stricture.
Repeat brushing and stent change is required. Initiating ursodeoxycholic acid or performing a Magnetic resonance cholangiopancreatography would not allow sampling of the bile duct cells.
Cholecystectomy would allow examination of the gallbladder but not the common hepatic duct.
200
A 27-year-old woman presents to the emergency department with a history of melena.
Her hemoglobin is noted to be 11.2 g/dL with no prior values for comparison.
Her BUN is not elevated. She denies abdominal pain or weight loss. She has been training for a marathon and so has been taking ibuprofen several days per week.
She is hemodynamically stable. You perform upper endoscopy which reveals a five mm clean-based ulcer in her gastric antrum and so she is discharged from the emergency department.
Biopsies from the ulcer margins show inflammatory changes only and extensive biopsies from the rest of the stomach show no evidence of H. pylori.
Which of the following is the most appropriate management strategy for this patient?
A) Repeat upper endoscopy in 8 weeks to document ulcer healing and rule out malignancy
B) Discontinue NSAIDs and treat her with a proton pump inhibitor for 8 weeks
C) Discontinue NSAIDs and treat with PPI for 6 months
D) Treat with both an H2 receptor antagonist and PPI for 8 weeks
E) Check a urease breath test to make sure H. pylori infection was not missed on biopsy
B) Discontinue NSAIDs and treat her with a proton pump inhibitor for 8 weeks
This patient had a small NSAID-related gastric ulcer the treatment of which should be NSAID cessation and PPI therapy for 8 weeks. As long as the inciting cause (NSAIDs) is removed, she does not need prolonged PPI therapy as she has no other symptoms or risk factors for PUD. Since her ulcer is small, in a typical location, has unremarkable biopsies and has a clear etiology, the risk for associated malignancy is too low to warrant surveillance endoscopy. PPI's have been proven to have higher efficacy for ulcer healing than H2RA's and there are no data that show an additive benefit if these are combined but would result in higher costs and more a more complicated regimen for the patient. With gastric biopsies showing no evidence of H. pylori infection, there is no role for additional H. pylori testing with a urease breath test.
300
A 42-year-old man undergoes upper gastrointestinal endoscopy for evaluation of troublesome heartburn and chest pain that did not respond to an 8-week trial of proton pump inhibitor (PPI) therapy.
Upper gastrointestinal endoscopy shows no erosive esophagitis or peptic stricture.
The squamocolumnar junction is regular without proximal extension of columnar-lined mucosa.
You proceed with 96-hour wireless pH monitoring off proton pump inhibitor therapy, which reveals pathologic acid exposure time (>6.0%) overall with elevated acid exposure across all 4 days of monitoring.
More than 50% of heartburn symptoms reported are associated with an acid reflux event with a positive symptom association probability.
Which of the following is the most likely diagnosis?
A. Achalasia
B. Barrett's Esophagus
C. Erosive Reflux Disease
D. Functional Heartburn
E. Non-erosive Reflux Disease
E. Non-erosive Reflux Disease
This presentation represents nonerosive reflux disease, which is defined as elevated acid exposure on ambulatory reflux monitoring in the presence of normal upper endoscopy findings.
Achalasia is an esophageal motor disorder characterized by inadequate relaxation of the lower esophageal sphincter and the absence of peristalsis. Barrett's esophagus requires the presence of salmon-colored mucosa in the esophagus with histologic confirmation of intestinal metaplasia.
Erosive reflux disease includes severe erosive esophagitis, long-segment Barrett's esophagus, or peptic stricture on upper gastrointestinal endoscopy.
Functional heartburn is defined in the Rome IV criteria as typical heartburn symptoms in the presence of normal upper endoscopy findings, normal ambulatory reflux testing, and negative association between symptoms and reflux events.
300
A 58-year-old man presents with abdominal pain and melena.
Evaluation shows erosive gastritis, and he is found to have Helicobacter pylori (H pylori) infection on gastric biopsy. He is treated appropriately with resolution of symptoms and presents for follow-up 12 weeks later.
He is now off acid suppressive therapy and would like to pursue the single most sensitive test to ensure that he has cleared the H pylori infection.
Which of the following tests would you recommend?
A) Endoscopy with biopsies
B) Serology
C) Stool antigen evaluation
D) Urease breath test
D) Urease breath test
The urease breath test and stool antigen test for H pylori are both believed to be greater than 95% sensitive for detection of active infection, assuming patients are not on acid suppressive therapy at the time of testing.
However, according to a recent Cochrane review and expert opinion, the breath test appears to be slightly more sensitive than the stool antigen test.
Endoscopy is specific but less sensitive than both the breath test and stool antigen test.
Serology is insensitive and has no role in eradication surveillance.
300
A 32-year-old man is diagnosed with primary sclerosing cholangitis due to elevated alkaline phosphatase and MRI/MRCP consistent with small duct disease.
He also has a history of loose stools for the past 3 to 4 years.
He has not seen any blood in his stool and his weight has been stable.
He undergoes colonoscopy and is diagnosed with mild pan-ulcerative colitis.
He has mild backwash ileitis on examination of the terminal ileum.
He is placed on oral mesalamine for therapy.
Which of the following is your recommendation for surveillance colonoscopy in this patient?
A) Colonoscopy every one to two years after 10 years of ulcerative colitis
B) Annual colonoscopy after 10 years of ulcerative colitis
C) Annual colonoscopy starting now at diagnosis of ulcerative colitis
D) Colonoscopy every five years after 10 years of ulcerative colitis
E) Colonoscopy every five years starting at diagnosis of ulcerative colitis
C) Annual colonoscopy starting now at diagnosis of ulcerative colitis
Primary Sclerosing Cholangitis (PSC) is a chronic inflammatory disease that causes fibrosis of the biliary tree. It is closely associated with inflammatory bowel disease, particularly ulcerative colitis, which coexists in approximately three-quarters of northern European patients. Colorectal carcinoma screening should be performed after the diagnosis of PSC in all patients, and surveillance colonoscopy should be performed annually if there is concomitant colitis.
300
A 62-year-old man is referred for a second opinion regarding primary sclerosing cholangitis. He presented with jaundice and vague abdominal discomfort three months prior, and PSC was diagnosed after characteristic features were noted on ERCP. His medical history is otherwise remarkable for coronary artery disease and excisional biopsy of an enlarged supraclavicular lymph node one year ago with nonspecific findings on pathology. He is up to date with cancer screening and had an unremarkable colonoscopy two years ago. His physical examination is remarkable for jaundice. His laboratory evaluation is as follows:
• Hemoglobin 13.4 g/dL
• Leukocytes 7,500/μl
• ESR 62
• AST 35 U/L
• ALT 39 U/L
• ALP 555 U/L
• Total bilirubin 5.4 mg/dL
• CA 19-9 18 U/L
You recommend MRCP which reveals stricturing of the extrahepatic common bile duct, a prominent distal bile duct stricture, and enlargement of the pancreas.
What is the next best step in evaluation of this patient?
A) Check serum IgG4 level
B) ERCP with biliary brushings for cytology and FISH
C) Endoscopic ultrasound to assess pancreatic head and distal common bile duct
D) PET scan
E) Refer for hepaticojejunostomy
A) A) Check serum IgG4 level
This patient presents with jaundice and imaging features suggestive of sclerosing cholangitis. The presence of a prominent pancreas on imaging and history of lymphadenopathy is suggestive of IgG4- related disease. IgG4 related sclerosing disease is a systemic disease characterized by extensive tissue infiltration by IgG4 positive plasma cells and T cells, which cause fibrotic lesions associated with obliterative phlebitis. IgG4-related disease can affect the pancreas, bile duct, gallbladder, salivary glands, kidney, lung, prostate, and retroperitoneum. Lymphadenopathy is also common. The disease occurs more often in older men and is often characterized by elevated IgG4 levels. The patient's history of lymphadenopathy with imaging features of sclerosing cholangitis and enlargement of the pancreas make IgG4 related sclerosing disease the most likely diagnosis.
300
A 63-year-old woman is admitted to the hospital with nausea and odynophagia.
She underwent bone marrow transplant 6 months ago.
An upper gastrointestinal endoscopy shows multiple small (<5 mm), shallow ulcerations in the esophagus from 33 to 36 cm from the incisors. A slight yellow exudate is present on several of the ulcerations.
Biopsies demonstrate multinucleated giant cells.
What is the most likely diagnosis?
A) Candida Esophagitis
B) Eosinophilic Esophagitis
C) Peptic Esophagitis
D) Pill-Induced Esophagitis
E) Viral esophagitis
E) Viral Esophagitis
Viral esophagitis (herpes esophagitis) is the most likely etiology when esophageal ulcerations are noted in the presence of multinucleated giant cells.
Candida esophagitis and eosinophilic esophagitis do not typically cause esophageal ulcerations. Peptic esophagitis is seen at the gastroesophageal junction progressing proximally.
Pill-induced esophagitis occurs most often with antibiotics, nonsteroidal antiinflammatory drugs, and bisphosphonates.
400
A 43-year-old man is referred to you for 8 months of progressive dysphagia to solids and liquids, as well as bland regurgitation, chest pain, and a 6 lb weight loss.
He has no comorbidities and is not on any medications.
His upper gastrointestinal endoscopy was normal other than mild resistance to the endoscope on passage across the esophagogastric junction (EGJ).
He undergoes an esophageal high-resolution manometry, which reveals an elevated median integrated relaxation pressure (IRP), 100% failed peristalsis, and 30% panesophageal pressurization (representative swallow in Figure 1 below).
A. Absent Contractility
B. Achalasia type 1
C. Achalasia type 2
D. Achalasia type 3
E. EGJ outflow Obstruction
C. Achalasia type 2
This case represents a manometric presentation of achalasia type 2, which is characterized by inadequate lower esophageal sphincter relaxation (elevated median IRP), 100% failed peristalsis with panesophageal pressurization in 20% or more of swallows.
In absent contractility, lower esophageal sphincter relaxation is intact with 100% failed peristalsis.
In achalasia type 1, the median IRP is elevated with 100% failed peristalsis but without panesophageal pressurization.
In achalasia type 3, the median IRP is elevated with 20% or more of swallows with premature contraction (distal latency <4.5 seconds) and the remaining swallows failed.
In EGJ outflow obstruction, the median IRP is elevated in both supine and upright positions, intrabolus pressurization is noted in at least 20% of swallows, and peristalsis does not meet criteria for achalasia.
400
Which type of Gastrointestinal Metaplasia confers the highest risk of developing gastric cancer?
A) Complete gastric intestinal metaplasia(GIM), antrum only
B) Complete GIM, antrum and body
C) Incomplete GIM, antrum
D) Incomplete GIM, antrum and body
D) Incomplete GIM, antrum and body
Extensive GIM involves both the antrum and corpus or corpus alone, versus limited GIM involving only the antrum or incisura. Complete GIM resembles small intestinal epithelium phenotype on hematoxylin and eosin (H&E) staining, and incomplete GIM resembles colonic epithelium phenotype on H&E staining.
The American Gastroenterological Association (AGA) technical review of GIM found that, among patients with GIM, incomplete GIM was associated with a 3.3-fold (relative risk [RR], 3.33; 95% confidence interval [CI], 1.96-5.64) higher risk of incident gastric cancer compared with complete GIM during follow-up ranging from 3 to 12.8 years.
This same review identified extensive GIM associated with a nonstatistically significant 2-fold increased risk of progression compared with limited GIM (RR, 2.07; 95% CI, 0.97-4.42).
Based on these data, a patient with extensive GIM with histopathology showing an incomplete phenotype would be at the highest risk of progression.
400
A 40-year-old man with a history of left-sided ulcerative colitis was in remission on maintenance infliximab 5mg/kg every eight weeks as mono therapy for the last year. Prior to infliximab, he failed mesalamine and azathioprine therapies. He now presents with bloody diarrhea and abdominal pain for the past 2 weeks.
Laboratory assessment reveals microcytic anemia with elevated C-reactive protein.
Stool studies are negative for any infectious process.
Therapeutic drug monitoring reveals a trough infliximab level of 15mcg/ ml with no detectable antibodies to infliximab.
Ileocolonoscopy reveals a normal terminal ileum and moderate to severe inflammatory changes involving the entire colonic mucosa. You start a prednisone taper at 40 mg daily with good clinical response.
Which of the following is most appropriate next step in management?
A) Reduce the frequency of infliximab infusions to every 4 weeks
B) Switch to adalimumab mono therapy
C) Switch to vedolizumab 300 mg at weeks 0, 2, 6 and then every 8 weeks
D) Add methotrexate, 25 mg IM injections weekly
E) Continue the current dose of infliximab and monitor symptoms while tapering the prednisone
C) Switch to vedolizumab 300 mg at weeks 0, 2, 6 and then every 8 weeks
This patient has moderate to severe disease activity despite adequate trough infliximab levels (more than 5 mcg/ml). This suggests a mechanistic failure of infliximab and therefore switching to a drug of different class is recommended. Continuing the same dose of infliximab, reducing the infusions intervals, or switching to adalimumab, another TNF-inhibitor, are not appropriate options. Methotrexate has not been shown to be effective in inducing or maintaining remission for patients with ulcerative colitis. Vedolizumab is an anti-integrin agent with proven efficacy in moderate to severe ulcerative colitis and is an appropriate choice for this patient.
400
A 55-year-old woman presents with lightheadedness, increasing right upper quadrant (RUQ) pain, and melena 12 hours after percutaneous liver biopsy was performed to evaluate abnormal liver serologies.
On physical examination blood pressure is 85/55 mmHg sitting and 105/60 mmHg supine. Heart rate is 98 bpm. Abdominal examination is significant for RUQ tenderness to palpation. After receiving 1 L of fluid resuscitation intravenously, her blood pressure is 85/52 mmHg sitting and 105/65 mm Hg supine with heart rate of 108 bpm.
Laboratory results are shown in the table (Figure 1).
Which of the following investigations should be performed next?
A) Angiography
B) Endoscopic retrograde cholangiopancreatography
C) Right upper quadrant ultrasound
D) Tagged red blood cell scan
E) Upper endoscopy
A) Angiography
This patient has evidence of gastrointestinal bleeding after percutaneous liver biopsy.
The most likely cause is hemobilia, resulting from injury to liver vasculature.
Angiography (arteriography) to demonstrate the hepatic artery and its branches is the most direct way to confirm hemobilia due to arterial injury from liver biopsy.
If the local anatomy is favorable, therapeutic embolization of the offending vessel can stop the bleeding. Endoscopic retrograde cholangiopancreatography has no role in the management of hemobilia.
If the diagnosis is in doubt, direct inspection of the duodenal papilla using a side-viewing endoscope (duodenoscope) can be helpful. Standard upper endoscopy using an end-viewing instrument may fail to visualize the duodenal papilla. Ultrasound and computed tomography scanning are typically unhelpful in this situation.
Tagged red blood cell scans are used as the standard for active lower GI bleeding.
400
A 28-year-old G2P1 female at 21 weeks' gestation presents with new-onset right upper quadrant pain, nausea, vomiting, jaundice, and pruritus. Laboratory studies are notable for:
• AST 600 U/L
• ALT 725 U/L
• Total bilirubin 6 mg/dL
• Alkaline phosphatase 320 U/L
• Platelets 150 k/μL
• Serum creatinine 1.30 mg/dL
• Prothrombin time 18 sec
Which of the following is the most likely etiology for the patient's presentation?
A) Hyperemesis Gravidarum
B) Intrahepatic cholestasis of pregnancy
C) Acute hepatitis A infection
D) Pre-eclampsia
E) Choledocholithiasis
A) Acute Hepatitis A infection
Acute viral hepatitis is the most common cause of jaundice in pregnancy. Hyperemesis gravidarum typically occurs in the first trimester of pregnancy; mild elevations in aminotransferases are most commonly seen, although AST and ALT levels have been observed to rise to as high as 700 to 1000 U/L in some patients. Pre-eclampsia is typically seen in the second trimester of pregnancy; biochemical changes include the presence of liver enzyme abnormalities, including 10- to 20-fold elevations in aminotransferases, elevations in alkaline phosphatase that are above what is typically observed in pregnancy, and mild elevations in bilirubin up to 5 mg/dL. The hallmark symptom of intrahepatic cholestasis of pregnancy is pruritus; jaundice occurs in about 10-25% of patients and usually does not occur until after about two to four weeks after the onset of pruritus.
500
A 32-year-old male with a history of eosinophilic esophagitis has presented to the emergency department three times over the past year for a food impaction. He comes to you for a second opinion, and reports intermittent dysphagia, but no pyrosis.
He is taking swallowed fluticasone 440 mcg twice daily and pantoprazole 40 mg daily.
His last endoscopy two months ago showed a stricture at 25 cm, which would not allow passage of the scope. The remainder of his esophagus revealed mild linear furrowing, but no other dominant strictures or fixed rings. Biopsies of the stricture and proximal esophagus did not have any eosinophils.
What is the next best step in the management of this patient?
A. Increase Fluticasone to 880 mcg swallowed twice daily
B. Change pantoprazole to omeprazole
C. Dilate the stricture using an 8-10 mm balloon through the scope balloon
D. Dilate the stricture using a 54 French Savory Dilator
E. Dilate the stricture using an 18-20 mm through the scope balloon
C. Dilate the stricture using an 8-10 mm through the scope balloon
This patient has EoE with a fixed ring/stricture, that is causing recurrent food impactions. There is no evidence of active inflammation or eosinophilic infiltration, thus there is no indication to alter his medical management. Dilation therapy does not alter the underlying inflammatory process, but is recommended for dominant strictures/rings, as long as the inflammation is decently controlled. If care is taken to avoid excessive dilation in any one treatment session, the risk of perforation is less than 1%. The passage of single large-caliber (54–60 French) bougies to treat a seemingly isolated distal ring in EoE can be hazardous, because endoscopically unrecognized stenoses may coexist proximally; dilation with graduated balloon catheters is safer in this instance. Since this patient's esophageal diameter is less than 9 mm (the approximate outer diameter of standard upper endoscope), it is reasonable to begin with an 8 mm balloon. Given the fibrotic nature of the esophageal mucosa in EoE, excessive dilation is not recommended, and can lead to perforation or large rents causing significant chest pain; therefore, choice E is incorrect.
500
A 65-year-old patient with longstanding type 2 diabetes mellitus complicated by neuropathy and retinopathy presents to the clinic for evaluation of progressive early satiety, lack of appetite, nausea, and weight loss.
What is the most appropriate next step?
A) Gastric Scintigraphy
B) Helicobacter pylori test
C) Omeprazole Trial
D) Upper endoscopy
D) Upper Endoscopy
This patient is elderly with several alarm findings including weight loss.
Although diabetic gastroparesis certainly is high on the differential diagnosis, endoscopy is a critical first step to exclude neoplasm, peptic ulcer disease, gastric outlet obstruction, or other mucosal findings before evaluating for less ominous diagnoses.
In this situation, neither Helicobacter pylori testing, nor empiric medication trials would be appropriate given the alarm findings—unless pursued as a bridge before endoscopy can logistically be arranged.
500
The emergency department calls you for advice on a 40-year-old woman who presents for evaluation of bloody diarrhea. The emergency department doctor tells you that she has been having 4 months of bloody diarrhea up to 20 bowel movements (BMs) daily, including nocturnal BMs. She has significant nausea and abdominal pain and is not able to tolerate any oral intake; therefore, they are going to admit her to the hospital. They order a stool Clostridium difficile test, which is pending.
Her laboratory test results are below in Figure 1.
You see her and arrange for a lower endoscopic evaluation the next day. This is what you see, via Figure 2 below, on the examination: Rushed pathology confirms a diagnosis of ulcerative colitis (UC).
You start her on intravenous methylprednisolone 20 mg every 8 hours. After 24 hours, she notes minor improvement, now reporting 15 BMs daily, but all still had blood in them. After 48 hours, she notes her abdominal pain improved from 10 to 9. After 72 hours of intravenous steroids, she remains with 15 bloody BMs daily and 8 or 9 on a scale of 10 in abdominal pain
What is the next best step in management?
A) Start infliximab
B) Start tofacitinib
C) Increase methylprednisolone to 100 mg intravenous three times daily
D) Start ciprofloxacin and metronidazole
E) Start vedolizumab
A) Start Infliximab
Patients who are hospitalized for severe acute UC and unresponsive to intravenous corticosteroid therapy should be treated with infliximab or cyclosporine.
Tofacitinib may be used for the management of severe acute UC only after infliximab failure.
Increasing corticosteroid dose will not result in significant benefit if an optimal dose was used initially.
Antibiotics are not empirically indicated for the treatment of severe acute UC.
Vedolizumab has a much slower onset of action and therefore is not appropriate for severe acute UC not responsive to intravenous corticosteroids.
500
A healthy 43-year-old woman presents to the clinic as a referral from her primary care physician with intermittent abdominal pain.
A right upper quadrant ultrasound demonstrates bile duct dilation to 12 mm.
Her liver function test results are normal.
You obtain magnetic resonance imaging, which demonstrates the image (Figure 1).
What is the next step in management?
A) Cholecystectomy referral
B) Continued observation
C) Endoscopic Ultrasound
D) Endoscopic retrograde cholangiopancreatography with sphincterotomy
E) Magnetic resonance cholangiopancreatography in 6 months
The patient has a type 3 choledochal cyst.
The appropriate management is endoscopic retrograde cholangiopancreatography with sphincterotomy to open the cyst and decrease risk of pancreatitis and malignancy.
Cholecystectomy and observation would not alleviate the abdominal pain caused by the cyst no remove the risk of development of biliary cancer.
Endoscopic ultrasound and magnetic resonance cholangiopancreatography would be only diagnostic and not provide additional data than the imaging provided.
500
A 77-year-old woman returns in follow-up to the gastroenterology clinic for ongoing evaluation of abdominal pain. Her description of the pain is somewhat vague. When you ask where it is located, she draws her finger in circles around her umbilicus.
She does not report constipation, diarrhea, or blood in the stool. She says pain is worse after eating, and she sometimes feels nauseated. She has lost about 15 pounds (current body weight, 112 pounds) in the past 12 months, which she thinks is because she worries that eating will cause the pain.
She takes enalapril for hypertension and levothyroxine for hypothyroidism. She does not take nonsteroidal anti-inflammatory drugs or opiates.
Laboratory studies including complete blood count, liver tests, and Helicobacter pylori stool antigen have been unrevealing. Screening sigmoidoscopy 2 years ago was negative.
You recommend computed tomography of the abdomen/pelvis.
What do you expect to find?
A) Mass in the cecum
B) Ulcer in the antrum
C) Intrahepatic biliary dilation
D) Narrow angle between the superior mesenteric artery and the aorta
E) Stenosis of the superior mesenteric artery
Many diagnoses could account for post-prandial abdominal pain, but in this patient, the most concern is for chronic mesenteric ischemia.
Periumbilical location suggests a midgut source.
Lack of vomiting makes superior mesenteric artery syndrome less likely.
In this elderly patient, risk factors for vascular disease, midgut pain, weight loss, and food fear strongly suggest chronic mesenteric ischemia.
It would be particularly useful to obtain a computed tomography angiography in this patient to better delineate the vascular anatomy.
If significant stenosis is seen in the celiac and/or superior mesenteric artery, the patient should be referred to a vascular surgeon.