Gastric
What is the gold standard dx of PUD
Upper endoscopy
+/- H. pylori testing
What is the Rome IV criteria for functional constipation?
(Does not have to be perfect, but hit timeframe, symptoms, and important r/o)
3 months of 2 or more of the following: straining, lumpy stools, incomplete evacuation, sensation of obstruction, manual maneuvers, fewer than 3 spontaneous bowel movements per week.
Loose stools rarely present w/o laxatives
Insufficient criteria for IBS
This is the MCC of mechanical small bowel obstruction
Adhesions
MCC of brisk hematochezia
diverticular bleeding
What specific type of the MC colonic polyp is a/w the highest risk of malignancy
villous adenomas
Tx of Mucosa Associated Lymphoid Tissue (MALT) centers around
Eradication of H. pylori
A 28-year-old woman presents with a 1-year history of recurrent abdominal cramping associated with altered bowel habits. Her pain improves after defecation and is associated with constipation. She denies nocturnal symptoms, weight loss, hematochezia, or fever. Physical exam is normal and lab results are WNL.
What medication class should be avoided in the long term tx of this condition d/t GI tolerance/dependence?
Stimulant laxatives (Dulcolax/bisacodyl)
A 72-year-old woman with a history of atrial fibrillation presents with sudden-onset, severe diffuse abdominal pain that began 2 hours ago. She reports nausea and one episode of vomiting. On exam, her abdomen is soft with minimal tenderness to palpation and no rebound or guarding. Vital signs show HR 118/min and BP 98/60 mm Hg. Laboratory studies reveal leukocytosis and an elevated serum lactate.
Which of the following is the most appropriate next step in diagnosis?
CT angiography of the abdomen
A 66-year-old man presents with 2 days of progressively worsening left lower quadrant abdominal pain, fever, and nausea. He reports decreased appetite and constipation. His temperature is 38.3°C (100.9°F). On exam, there is focal tenderness in the LLQ with mild guarding. Laboratory studies reveal leukocytosis.
CT scan of the abdomen and pelvis with contrast shows sigmoid colon wall thickening and pericolic fat stranding without abscess or free air.
What is the appropriate initial inpatient tx for this pt?
NPO, IV fluids, and IV abx
(Bonus 50: what should be avoided in this pt at this time?)
What are the overall differences in signs/symptoms of L sided and R sided CRC?
(stool caliber, bowel habits, bleeding, etc)
L sided: tenesmus, obstruction, change in bowel habits, blood streaking in stools, pencil thin stools
R sided: iron deficiency anemia, normal stool caliber, occult bleeding, obstruction is rare
Pt presents with epigastric pain, early satiety, weight loss, and n/v. Physical exam displays abdominal distension and this other PE finding that is also possible in gastric outlet obstruction.
Succussion splash
What are the 4 major classifications of medications for tx of constipation?
Fiber
Bulk forming laxatives
Osmotic laxatives
Stimulant laxatives
(Bonus 50 if example of each group given)
pt presents with mild, diffuse abdominal pain, generalized distension, and decreased bowel sounds 36 hours after intraabdominal surgery. XR and CT show no clear transition points.
What is the likely dx?
acute paralytic ileus
What is the difference in colonoscopy findings between acute and chronic colonic ischemia?
Acute: edematous and patchy necrotic areas
Chronic: atrophy of colonic mucosa
Pt is found to have a positive HNPCC gene mutation leaving them at a significantly increased risk for CRC.
What is the dx and CRC screening protocol for this pt?
Lynch syndrome
annual colonoscopy starting at 25 or 5 years younger than age of youngest family member diagnosis
(Bonus 50: why is Lynch syndrome a/w higher risk of CRC?)
A 58-year-old woman with a 20-year history of type 2 diabetes mellitus presents with early satiety, postprandial fullness, nausea, and intermittent nonbilious vomiting of undigested food several hours after meals. She reports worsening glycemic control despite adherence to her insulin regimen. Physical exam reveals mild epigastric distention without tenderness. An upper endoscopy shows retained food in the stomach but no evidence of mechanical obstruction.
What is the gold standard imaging and tx plan for this suspected condition?
Scintigraphy displaying delayed gastric emptying
Diet/hydration, optimization of glycemic control, prokinetics (bonus 50 if you can name the one mentioned in class), and antiemetics
A full-term newborn fails to pass meconium within the first 48 hours of life and develops progressive abdominal distension with bilious vomiting. Rectal exam results in explosive passage of stool and flatus. Contrast enema shows a transition zone between a narrowed distal colon and a dilated proximal segment.
What is the definitive test to confirm the diagnosis?
Rectal biopsy w/ absence of ganglion cells
A 46-year-old man presents with intermittent, crampy abdominal pain, nausea, and episodes of vomiting for the past several weeks. He reports unintentional weight loss and occasional maroon-colored stools. Physical exam reveals a mildly distended abdomen with diffuse tenderness but no peritoneal signs. CT scan displays a sausage like mass in the RLQ.
What is the biggest RF in this pt population for the suspected pathology?
Underlying intestinal tumor resulting in intussusception
A 68-year-old man with a history of coronary artery disease, hyperlipidemia, and a 40-pack-year smoking history presents with recurrent crampy abdominal pain that begins about 20–30 minutes after meals and resolves over the next hour. Because of this, he has developed a fear of eating and reports a 15-lb unintentional weight loss over the past 3 months.
What is the tx of choice for this condition?
Revascularization of the mesenteric arteries via stenting or bypass
Pt undergoes routine upper endoscopy for their known Familial Adenomatous Polyposis. Rope like masses are appreciated around the upper curvature of the stomach and elevated serum gastrin is seen on bloodwork.
What type of benign gastric polyp is this and what medication is a/w it's increased prevalence?
Fundic gland polyp
PPIs
A 45-year-old man presents with a 6-month history of severe epigastric pain and chronic diarrhea. The pain is burning in quality, occurs both during the day and at night, and is only partially relieved by high-dose proton pump inhibitors. He has been treated multiple times for recurrent peptic ulcer disease despite adherence to therapy. Upper endoscopy reveals multiple ulcers in the duodenum extending into the proximal jejunum. He denies NSAID use and Helicobacter pylori testing is negative. Lab studies shows markedly elevated fasting serum gastrin and a low gastric pH.
What is the most likely cause of this pt's symptoms?
Zollinger-Ellison Syndrome
A 72-year-old man is hospitalized following hip fracture surgery. On hospital day 4 he develops progressive abdominal distension, nausea, and decreased bowel movements. He is passing minimal flatus. He is afebrile and has mild, diffuse abdominal tenderness without peritoneal signs. CT scan shows marked colonic dilation without a mechanical obstruction, and the cecal diameter measures 14 cm. Conservative efforts and neostigmine have failed.
What is the most appropriate next step in management?
Colonoscopic decompression
An 81-year-old woman with a history of recurrent episodes of biliary colic presents with abdominal distension, nausea, and multiple episodes of bilious vomiting for 2 days. She has not passed flatus or had a bowel movement during this time. On exam, her abdomen is distended with high-pitched bowel sounds and mild diffuse tenderness.
Abdominal CT scan shows small bowel obstruction, air within the biliary tree, and a calcified mass in the distal ileum.
What is the likely dx based on this pt's presentation?
Gallstone ileus resulting in small bowel obstruction
A 57-year-old woman presents with 2 days of left lower quadrant abdominal pain and low-grade fever. She reports mild nausea but is tolerating oral intake. She denies vomiting or changes in mental status. Her past medical history is significant for chronic constipation. On exam, she has focal LLQ tenderness without rebound or guarding. Laboratory studies show a mild leukocytosis. CT scan of the abdomen and pelvis with contrast demonstrates sigmoid diverticula with localized bowel wall thickening and pericolonic fat stranding, without abscess, perforation, fistula, or obstruction.
What is the tx for this pt?
outpatient metronidazole and ciprofloxacin or augmentin + clear liquid diet
A 52-year-old man presents with fatigue and intermittent melena for the past 4 months. He denies abdominal pain, weight loss, or change in bowel habits. Upper endoscopy and colonoscopy are both normal. Laboratory studies reveal iron deficiency anemia.
Capsule endoscopy identifies a well-circumscribed submucosal mass in the jejunum without mucosal ulceration. CT enterography shows a homogeneous, enhancing intramural lesion without lymphadenopathy.
What is the most likely type of benign small bowel tumor seen above?
Leiomyoma - a benign tumor that arises from the submucosa and extends extraluminally causing obstruction