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Gastroentrology
100

A 42-year-old woman presents with abdominal pain for the last 2 days. She describes the pain as crampy and intermittent in the epigastric area, and she tells you that it is particularly worse after meals. She has a history of Roux-en-Y gastric bypass surgery that occurred 2 years ago.

Upon physical examination, she is afebrile. Her abdomen is soft and nontender with no masses.

Laboratory studies are shown below in the Table.

Laboratory studyValueNormal rangeWBC count7,700/µL3,200-9,800/µLHemoglobin13.2 g/dL11-14 g/dLPlatelets215,000/µL150,000-450,00/µLAlbumin4.3 g/dL3.5-5.5 g/dLAST334 U/L5-52 U/LALT282 U/L7-46 U/LAlkaline phosphatase115 U/L40-100 U/LTotal bilirubin1.7 mg/dL0.2-1.5 mg/dLAmylase42 U/L30-110 U/LLipase24 U/L13-141 U/L

ALT, alanine transaminase; AST aspartate aminotransferase; WBC, white blood cell.

Ultrasonography of the abdomen demonstrates a normal-appearing liver, mild distension of the gallbladder with several stones in the fundus of the gallbladder, and no apparent wall thickening or pericholecystic fluid. The common bile duct is dilated to 1.3 cm.

What is the next most appropriate step in the management of this patient's condition?


a)Manometry of the sphincter of Oddi

b)Surgical referral for cholecystectomy

c)Upper endoscopy with balloon dilation

d)Magnetic resonance cholangiopancreatography (MRCP)

e)Modified endoscopic retrograde cholangiopancreatography (ERCP

e) Educational Objective:

Recognize clinical scenarios in which endoscopic retrograde cholangiopancreatography is appropriate.

Key Point:

In patients likely to be diagnosed with and require treatment for biliary obstruction, ERCP is the preferred method. However, the procedure needs to be modified in order to account for the modified stomach (the procedure is still referred to as an ERCP).

Explanation:

Gallstone formation is common after rapid weight loss, as seen after bariatric surgery. These stones are composed of cholesterol, and, although the exact mechanism is not fully understood, there may be increased biliary stasis due to reduced caloric intake, or saturation of bile with cholesterol due to increased cholesterol mobilization. This patient has elevated transaminases and common bile duct dilation consistent with stones, sludge, or an anatomic obstruction of the common bile duct. Thus, ERCP will aid in both the diagnosis and treatment of a biliary obstruction. Of note, given the patient’s history of prior Roux-en-Y gastric bypass, ERCP may require surgical consultation to endoscopically or laparoscopically access the biliopancreatic limb. Several methods exist to assess the biliary systems via a modified ERCP; if interested, follow this link to an excellent discussion.

https://www.gastroenterologyandhepatology.net/archives/november-2019/approaches-to-ercp-in-patients-with-roux-en-y-gastric-bypass-anatomy/ 

MRCP may also aid in diagnosis, but it does not offer a therapeutic option. Upper endoscopy may be useful to assess for peptic ulcer disease or evidence of an anastomotic stricture, but this patient does not demonstrate symptoms of obstruction or ulcer. Sphincter of Oddi dysfunction can also cause an elevation of transaminases and bile duct dilation, but the presence of a stone or sludge should be ruled out first. There is no gallbladder wall thickening or pericholecystic fluid to suggest acute cholecystitis, so immediate surgical referral for cholecystectomy is not the most appropriate next step.

100

A 56-year-old woman presents with chest pain radiating to the jaw, and she is feeling nauseous and is sweating. In the diagnostic interview she states that her daughter suddenly died the previous day, and her symptoms began to appear shortly after she had the news. Results on electrocardiography (ECG) show a pronounced ST-segment elevation; cardiac biomarkers are pending. Which condition(s) should be suspected? 

A) MI

B) MYOCARDITIS 

C) STRESS INDUCED CARDIOMYOPATHY OR MI 

C) STRESS INDUCED CARDIOMYOPATHY

(C) Educational Objective:

Recognize the importance of ruling out acute myocardial infarction before diagnosing stress-induced cardiomyopathy.

Key Point:

While stress-induced cardiomyopathy, also known as Tako-Tsubo cardiomyopathy, can mimic the symptoms and some ECG findings of myocardial infarction, its diagnosis requires the absence of obstructive coronary disease, specific regional wall motion abnormalities in the left ventricle, and other distinguishing features. An acute myocardial infarction should always be ruled out first given its immediate life-threatening implications.

Explanation:

Stress-induced cardiomyopathy (also known as Tako-Tsubo cardiomyopathy) may indeed be the final diagnosis; however, acute myocardial infarction must be ruled out before this diagnosis can be made with certainty. This condition may occur in postmenopausal women and is commonly--but not always--triggered by a stressful life event, such as the death of a family member.

In stress-induced cardiomyopathy, ECG abnormalities and clinical manifestations are usually out of proportion to the degree of cardiac biomarker elevation. Given that patients with criteria are brought to the cath lab before the biomarker results are available, this feature can often only be appreciated in hindsight.

The full diagnostic criteria for stress-induced cardiomyopathy specified by the Mayo Clinic are:

  • New ECG abnormalities (either ST-segment elevation and/or T wave inversion) or modest elevation in cardiac troponin
  • Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture (this requires a cardiac catheterization)
  • Transient hypokinesis, akinesis or dyskinesis of the left ventricular mid segments with or without apical involvement. The regional wall motion abnormalities typically extend beyond a single epicardial coronary distribution. A stressful trigger is often--but not always—present (will partially be visible during the cardiac cath with details later visible on echocardiogram)
  • Absence of pheochromocytoma or myocarditis (history of above patient does not match this)
100

A 52-year-old man with severe emphysema is admitted to the hospital with an exacerbation. On hospitalization day 2, his clinical condition worsens with increasing oxygen requirements and significant tachypnea, requiring transfer to the intensive care unit and intubation.

He is started on broad-spectrum antibiotics and initially improves. However, by hospitalization day 7, his white blood cell count is increased to 19,000/µL. Repeat blood cultures do not have any growth by 72 hours, and there is no evidence of urinary or Clostridioides difficile infection. Doppler ultrasonography of the lower extremities does not demonstrate deep venous thrombosis.

Right-upper quadrant ultrasonographic findings demonstrate a thickened, distended gallbladder with no sludge or stones and mild pericholecystic fluid. The common bile duct measures 4 mm. The patient remains on norepinephrine for blood pressure support.

What is the next step in the management of this patient's condition?

A)cholecystostomy

B)endoscopic retrograde cholangiopancreatography (ERCP)

C)continuation of broad-spectrum antibiotics and observation

D)hepatobiliary (HIDA) scan

A) 

Educational Objective:

Assess, diagnose, and treat patients with acalculous cholecystitis.

Key Point:

Patients who are critically ill with a high suspicion of acalculous cholecystitis should undergo percutaneous cholecystostomy to improve their clinical status.

Explanation:

Based on his clinical parameters and gallbladder appearance on ultrasonography, this patient likely has acalculous cholecystitis (AC), which is a necroinflammatory disease of the gallbladder. AC is associated with a high mortality rate among those who are critically ill. The pathogenesis is likely multi-factorial and includes gallbladder stasis, ischemia, and acute inflammation. Predisposing factors may include comorbidities such as coronary disease and diabetes, as well as acute events such as major trauma, sepsis, or TPN.

The definitive therapy of AC is a cholecystectomy. However, in patients who are hemodynamically unstable on vasopressors, a percutaneous cholecystostomy is a lower-risk intervention that can improve the patient’s clinical status and hence this is the management of choice for this patient. He would require cholecystectomy despite his poor hemodynamic status if there was any evidence of necrosis, perforation, or emphysematous cholecystitis on ultrasound.

There are small case reports of endoscopic drainage of the gallbladder, but this method is still investigational. HIDA scan can be useful in confirming the diagnosis of AC; however, patients who are critically ill with a high suspicion for AC should move on to definitive therapy rather than further diagnostic testing.


200

A 37-year-old man presents to the emergency department (ED) with alcohol intoxication and psychiatric disturbances consistent with a psychotic episode. He has a history of alcohol and drug abuse as well as schizophrenia, and he has a history of attempted suicide 2 years ago. Upon questioning, the patient states he has suicidal ideation.

Which of the following factors in the patient's presentation or history is the strongest predictor of his imminent suicide risk?

A) schizophrenia in the context of alcohol abuse 

B) the imminent risk cannot be assessed in an intoxicated patient who is cognitively not able to participate in their care plan. 

C) schizophrenia 

D) alcohol abuse 

(B) Educational Objective:

Recognize pitfalls when assessing suicide risk.

Key Point:

To assess imminent suicide risk, patients must be capable of cognitively participating in their evaluation. A patient who is intoxicated does not qualify as cognitively capable of participation. No data exist to support a particular blood alcohol level at which a patient can undergo a psychiatric evaluation.

Explanation:

An article published in 2016 that is focused on emergency medicine care of suicidal patients summarizes the currently best available approach to suicide risk assessment in the ED.

The starting point is to ensure that the patient expressing suicidal ideation is cognitively able to participate in an assessment of their CURRENT suicidal risk. Current risk is FIRST OF ALL determined by active suicidal ideation; if acute suicidal ideation present, then historical factors will potentiate the active risk.  However, the presence of acute suicidal ideation cannot be determined in an intoxicated patient.

Those intoxicated with alcohol or drugs are considered incapable of meaningful participation and should be observed and then have their cognitive capacity reassessed before the ED physician attempts to assess their risk for suicide.

Once a patient is judged to be cognitively able to participate in a suicide risk assessment, 2 questions must be answered in the ED:

  1. Does the patient need a formal psychiatric evaluation prior to disposition?
    • This question can be answered with an assessment tool developed in 2016 by a consensus panel specifically for suicide risk assessment in the ED. This tool can be found in Figure 1 of the original article. Most patients who present with suicidal ideation will "fail" this questionnaire, which leads to asking the second question.

If this first assessment toll yields the answer "yes" to this first question (does the patient need a formal psychiatric evaluation prior to disposition?), then the next question is:

  1. Does this patient need psychiatric admission, or can he/she be discharged after psychiatric evaluation in the ED?
    • Ideally, the psychiatrist on call will answer this question. However, if no psychiatrist is available, then ED physicians can use an assessment tool to conduct a formally endorsed, mini-assessment to determine whether a psychiatric admission is required or whether discharge is appropriate. This tool creates a matrix of 3 key areas to consider:
      • Risk factors (acute psychiatric exacerbation is the most significant risk)
      • Patient suicidality (eg, active attempt, specific plan)
      • Protective factors (eg, good social support system)
    • Follow this link to Figure 2 in the same article previously mentioned to view the second tool. In general, patients with both moderate- and high-risk profiles are admitted to the hospital.

Experts warn that assessing suicide risk remains an inaccurate science. They also emphasize that most acute suicide crises are short-lived and that the best care of a current crisis still cannot prevent future attempts, and that is true whether or not a patient is admitted to the hospital.

300

A 39-year-old man is evaluated for several months of progressive fatigue, a 10-pound weight loss, and dark urine output for the past 2 weeks. He is not on any medications, does not smoke, and enjoys a couple of beers every day. He has had no operations. A review of systems does not uncover any other symptoms.


On physical examination, he is noted to have slight scleral icterus and a mildly prominent liver edge. He does not appear to have any other stigmata of long-term liver disease. He is not currently on any medications other than methotrexate and folic acid.


Laboratory testing is performed, and the results are shown in the Table.


Laboratory study    Value    Normal range

WBC count    7700/µL    4,500-10,000/µL

Hemoglobin    11.8 g/dL    11-14 g/dL

Platelets    150,000/µL    150,000-450,00/µL

Albumin    3.6 g/dL    3.5-5.5 g/dL

AST    78 U/L    5-52 U/L

ALT    92 U/L    7-46 U/L

Alkaline phosphatase    275 U/L    40-100 U/L

Total bilirubin    4.8 mg/dL     0.2-1.5 mg/dL

INR    1.3    0.8-1.2

ALT, alanine transaminase; AST aspartate aminotransferase; INR, international normalized ratio; WBC, white blood cell.


Given these findings, magnetic resonance cholangiopancreatography is ordered. The results demonstrate a hypertrophied caudate lobe with mild intrahepatic biliary ductal dilatation with several areas of ductal narrowing. No other masses are seen. Liver biopsy is performed and is notable for epithelial cell necrosis, ductopenia, and concentric fibrosis around the bile ducts.


Other than initiating treatment with ursodeoxycholic acid (UDCA), what else should be recommended at this time?





A) Prophylactic cholecystectomy

B) Colonoscopy

C) D-penicillamine therapy

D) Endoscopic retrograde cholangiopancreatography (ERCP) for biliary stenting

B) Colonoscopy


Educational Objective:


Describe the conditions associated with primary sclerosing cholangitis.


Key Point:


Inflammatory bowel disease is found in 75% of patients with primary sclerosing cholangitis. There is also an increased risk of colon cancer.


Explanation:


The patient above has radiographic, laboratory, histologic, and clinical findings consistent with primary sclerosing cholangitis (PSC), which is a long-term, autoimmune inflammatory disease that leads to inflammation and scarring of both intra- and extrahepatic bile ducts. Males are twice as commonly affected as females. Approximately 50% of patients with PSC will develop cholangiocarcinoma within 2 years of diagnosis. The prevalence of PSC is unknown, but approximately 75% of patients with PSC have concurrent inflammatory bowel disease (usually ulcerative colitis [UC]). Not only do these patients have a high incidence of UC, but they also have a risk for colon cancer higher than the average population with UC. For these reasons, all patients newly diagnosed with PSC should be offered a colonoscopic evaluation. Although PSC is associated with gallbladder disease, there is no indication for cholecystectomy at this time. Neither high-dose steroids nor D-penicillamine has been shown to be effective therapies for PSC. ERCP with stenting can be considered in cases of dominant large duct strictures, but not with predominantly small to medium duct disease.


PSC is a long-term, cholestatic liver disease that can shorten life and may require liver transplantation. The cause is unknown, although it is commonly associated with colitis. There is no approved or proven therapy, although UDCA is sometimes used on an empiric basis. Complications, including portal hypertension, fat-soluble vitamin deficiency, metabolic bone diseases, and the development of cancers of the bile duct or colon, can occur.

400

An 87-year-old man with pneumonia and significant shortness of breath arrives from a nursing home at the emergency department. His accompanying records contain a physician's orders for life-sustaining treatment (POLST), which he signed 4 years ago. The form indicates he does not want to be intubated. The patient is mentally alert and oriented and able to communicate. He is obviously struggling, and respiratory failure is likely to develop within the next few hours.

What is the medically correct approach to this situation?

A) The POLST form is invalid because it is older than 12 months. 

B) The patient’s surrogate decision maker should be contacted to confirm the content of the POLST form before withholding life-saving treatments. 

C) Provide comfort measures but do not intubate the patient based on the preferences indicated on the POLST form. 

D) Allow the patient to voice any changes in treatment preferences, which will override those indicated on the POLST form. 

D)

A patient with intact decision-making capacity has the authority to override ANY previous advance planning documents. Clinicians should give patients who have decision-making capacity an opportunity to voice any changes in their treatment preferences that deviate from their POLST form or any other advance directive form, such as a “do not attempt resuscitation” (DNAR) form. Neither POLST forms nor DNAR forms expire.

Review:

  • Two Categories of End-Of-Life Care Forms: End-of-life care documents can be separated into those that are standing (portable) physician orders and those that are patient wishes not linked to a physician order.
    1. Portable Physician Order Documents:
      • POLST, DNAR, and DNI are all examples of end-of-life portable physician orders.
        • In some states, the POLST form is known by other names, such as medical orders for scope of treatment (MOST), medical orders for life-sustaining treatment (MOLST), physician orders for scope of treatment (POST), or transportable physician orders for patient preferences (TPOPP).
      • These forms are only intended for patients with terminal, life-limiting illnesses (there are some exceptions).
      • These forms require a physician signature on a state-approved form.
      • These forms are binding for both physician and nonphysician caretakers unless overridden by the patient him/herself (assuming competent decision making).
      • In an emergency situation, any procedures normally required by law of emergency personnel (e.g. CPR) are overridden by the treatment preferences indicated on an end-of-life portable physician order form.
    2. Patient Wishes Documents:
      • Advance directives and living wills are examples of forms that document patient wishes without doctor orders.
      • These forms are available to patients at any point in their lives.
      • These forms do not contain binding physician orders; nonphysician caretakers must follow their respective institution’s medical protocols rather than a patient’s advance directive wishes until a physician provides an individualized medical order to follow the advance directive.
      • Physicians can consider a patient’s advance directive as they make treatment decisions (often in discussion with an appointed representative); however, this does not free the treating physician from the duty to decide on a case-by-case basis between 2 conflicting ethical principles, ie, tending to the patient’s body vs the patient’s will as expressed in the advanced directive.
400

A 61-year-old man has been hiking on the Appalachian trail northbound from Georgia through North Carolina, Tennessee, Virginia, and West Virginia for the last month. Five days ago he developed fever, chills, headache, myalgia, nausea, vomiting, and diarrhea. After admission, he became hypotensive and went into respiratory failure.

Laboratory findings include a white blood cell count of 27,300/mm3, a hemoglobin level of 20.0 g/L, a platelet count of 65,000/mm3, and a creatinine level of 6.8 mg/dL. A chest X-ray revealed bilateral diffuse infiltrates.

The most likely source of this infection is which of the following?

A) arthropod bite 

B) contact with water contaminated with animal urine 

C) contact with bat droppings

D) inhalation of contaminated dust 

E) contact with rodent excreta 

E)

Correct!

This patient has Hantavirus pulmonary syndrome (HPS) caused by the Sin Nombre virus. Human infection occurs when a person inhales droplets of urine, saliva, or respiratory secretions from rodents. Ingesting food contaminated with rodent secretions or the contamination of cutaneous injuries have also been described.

Other hemorrhagic fevers, such as yellow and dengue fevers, may be transmitted via mosquitoes, but they will not be acquired in North America. Leptospirosis is transmitted by contact with water contaminated with animal urine, and it is common among athletes and adventure travelers. Histoplasmosis may be acquired by contact with bat droppings. Q fever and coccidioidomycosis can occur after a person inhales contaminated dust.

Sin Nombre is the prevalent virus that causes HPS in North America, whereas the Andes virus is more common in South America. The disease usually presents with a prodrome of fever and unspecific symptoms. It is then followed by rapidly progressive, noncardiogenic pulmonary edema and marked hemoconcentration, with a hemoglobin level around 20 mg/dL.