GASTROENTEROLOGY ESSENTIALS

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1 GASTROENTEROLOGY ESSENTIALS Practical Gastroenterology 8/25/2018 Jahnavi Koppala, MBBS Abdullah Abdussalam, MD A 48-year-old male was evaluated for noncardiac chest pain. Treatment with PPI twice daily for 2 months was not helpful. The patient underwent an esophageal manometry revealing nutcracker esophagus. What is the best therapeutic approach to improve his symptoms? A. Continue PPI twice daily (am and pm) for an additional 2 months B. Nitrates C. Calcium channel blocker D. A benzodiazepine E. Serotonin-norepinephrine reuptake inhibitor (SNRI) 1

2 If a proton pump inhibitor is prescribed once daily to treat GERD, the best time to take it is: A. Before bedtime B. Before breakfast C. Before dinner D. In the morning, 3-4 hours before the first meal E. Before lunch Metoclopramide is approved for treatment of gastroparesis. How long of a treatment course is metoclopramide approved for? A. 2 weeks B. 6 weeks C. 6 months D. no duration limitation 2

3 A 51-year-old obese woman who underwent Roux-en-Y gastric bypass 3 months ago presented with persistent epigastric pain, nausea, and vomiting. Given her symptoms, she underwent an upper endoscopy, which showed a 1 cm, clean-based ulcer at the gastrojejunal anastomosis. Which of the following factors most likely increased her risk of developing this condition? A. Age > 50. B. Chronic use of proton pump inhibitors (PPI) for 5 years. C. History of H. pylori infection. D. Smoking. E. Alcohol use. A 21-year-old college student presents to you for evaluation. She is worried she has celiac disease because two women in her dormitory have celiac disease and she has similar symptoms. She describes intermittent diarrhea and abdominal bloating as well as fatigue. She denies weight loss. She has placed herself on a gluten-free diet and thinks her symptoms may have improved. She asks you to test her for celiac disease. Which of the following should you recommend in order to determine whether or not she has celiac disease? A. Check IgA tissue transglutaminase and total IgA now B. Resume a gluten-containing diet and see if symptoms return C. Perform upper endoscopy with small bowel biopsies now D. Resume a gluten-containing diet and check IgA tissue transglutaminase and total IgA in a month E. Resume a gluten-containing diet and perform an upper endoscopy with small bowel biopsies in a month 3

4 Which of the following agents has a direct effect on intestinal chloride channels? A. Linaclotide B. Lubiprostone C. Misoprostol D. Colchicine E. Prucalopride Which of the following drugs for inflammatory bowel disease is contraindicated during pregnancy? A. 6-mercaptopurine B. Infliximab C. Adalimumab D. Methotrexate E. Sulfasalazine 4

5 A 32 year old man with long-standing left-sided ulcerative colitis well-controlled on aminosalicylates and azathioprine presents in clinic with change in bowel habit. He normally has 1-2 formed bowel movements a day but now is having 5-6 watery bowel movements a day associated with urgency and nocturnal bowel movements. He has no pain or fever and has not taken any non-steroidals recently. However, 2 weeks ago he was prescribed antibiotics for pneumonia and stool tests are now positive for clostridium difficile toxin. What would you do next? A. Admit patient B. Start metronidazole C. Start vancomycin D. Start metronidazole and vancomycin E. Refer for fecal transplant A 42-year-old female presents to the emergency department with a several hour history of epigastric pain radiating to the back. She denies alcohol use. She is afebrile and normotensive. Her laboratory evaluation reveals: T. bili 0.8 MG/DL, AST 285 U/L, ALT 546 U/L, Lipase U/L, renal function normal. No evidence of anemia or leukocytosis. An abdominal ultrasound shows numerous small gallstones and common bile duct 6 mm. The patient is admitted and given aggressive intravenous fluids and analgesics. The following morning her labs are as follows: T. bili 0.6 MG/DL, AST 74 U/L, ALT 128 U/L, Lipase 1238 U/L. Her pain is improved and she is clinically stable. What is most appropriate next step? A. Repeat abdominal ultrasound B. MRCP C. ERCP D. Cholecystectomy within the week E. Cholecystectomy in 6 weeks 5

6 A 65-year-old man with a history of alcoholism is admitted with a 24-hour history of epigastric pain. On exam, the patient is afebrile, with a blood pressure of 110/50 mmhg and tachycardia to 110 bpm. Physical exam is also notable for epigastric tenderness to palpation without rebound. Admission labs are notable for a WBC count of 19,000/mm3, hematocrit of 47%, BUN of 40 mg/dl, lipase of 3200 U/L (normal < 60). A diagnosis of acute pancreatitis is made. Which of the following is NOT a predictor that the patient will develop severe disease? A. The patient s age B. Presence of SIRS (systemic inflammatory response syndrome) C. Degree of lipase elevation D. White blood cell count E. BUN elevation A 21 year old healthy male returns from a 2 week vacation in Mexico with his family complaining of watery diarrhea and abdominal cramps. His family members are all well. He does not take medications and does not drink alcohol. In the ER, he looks well and is afebrile. His blood tests (complete blood count and complete metabolic profile) are normal except for an elevated amylase of 500 U/L. A CT scan of the abdomen shows mild thickening of the small intestine and colon but is otherwise unremarkable. What would you do next? A. Check lipase B. Diagnose him with acute pancreatitis, check an alcohol level and admit patient. C. Order magnetic resonance cholangiopancreaticogram (MRCP) for better delineation of pancreatic anatomy and ducts. D. Order ultrasound scan to evaluate for gall stones as a possible cause of acute pancreatitis E. None of the above 6

7 A 56 year old was admitted yesterday evening with his first episode of acute pancreatitis. Although his liver tests are normal, his amylase and lipase are both elevated and a CT scan shows evidence of acute pancreatitis with no evidence of necrosis, calcifications or fluid collections. His amylase and lipase are still elevated today but patient appears to be clinically improving. His nurse asks you when he can start eating. What would you do next? A. Daily amylase/lipase levels until normal before feeding patient B. Start enteral feeding (tip of feeding tube in stomach) now and check amylase/lipase daily until normal before feeding patient orally C. Start enteral feeding (tip of feeding tube distal to ampulla) now and check amylase/lipase daily until normal before feeding patient orally D. Start feeding patient when hungry and pain free E. Start TPN and check amylase/lipase daily- when levels normal, start feeding patient orally A 56 year old male patient with a history of injection drug use was recently informed by his primary care provider his hepatitis C (HCV) antibody test was positive. He has a prior history of heavy alcohol use for several years but has been abstinent for the last year. He is otherwise healthy and is not on any medications. Which of the following investigations should be performed before treating him for hepatitis C? A. HCV RNA B. HCV genotype C. HIV and HBV, iron studies (iron, total iron binding capacity, ferritin) D. Ultrasound of abdomen E. All of the above. 7

8 A 45yo lady was recently diagnosed with biopsy-proven cirrhosis from nonalcoholic steatohepatitis after undergoing a bariatric surgical procedure. What preventive measures would you recommend for her? A. Hepatitis A and B vaccinations B. EGD to screen for varices C. Influenza and pneumococcal vaccinations D. Hepatitis A and B vaccinations, annual influenza vaccinations, pneumococcal vaccinations, EGD to screen for varices and 6 monthly ultrasound scans for hepatoma surveillance. E. 6 monthly ultrasound scans for hepatoma surveillance. Questions? 8