GI Board Review

Ravi Kapoor, MD, MPH Mount Sinai Hospital Emergency Medicine Residency

Question One

• A 46-year old woman presents with constant abdominal pain with associated nausea that started 8 hours earlier. She appears nontoxic and is lying still on the bed. Blood pressure is normal: pulse rate is 95, respiratory rate is 16, and temperature is 37.8 C ( 100 ), Physical examination is remarkable for RUQ and epigastric tenderness to palpation without rebound or guarding. Laboratory test results reveal elevated ALT, AST, and alkaline phosphatase, normal lipase and total bilirubin, and a negative urine hCG. The next most appropriate management step is:

•

a) acute abdominal series

•

b) CT scan

•

c) general surgery consultation

•

d) oral cholecystography

•

e) RUQ ultrasonography

The answer is E.

• e) RUQ sono has high sens/high spec for biliary disease, and it can be performed at bedside • a) most gallstones are radiolucent, (10 - 20% contain sufficient calcium to be radiopaque • b) CT scan be used to evaluate biliary disease, but should be reserved for situations where cholecystitis is on the differential with other intra-abdominal disorders, low sensitivity (>50%) • c) surgery should be called after sono is done • d) oral cholecystography with iopanoic acid was historically done, but largely discontinued because of non-compliance or impaired hepatic function

Question Two

• Which of the following statements regarding ingested foreign bodies is correct?

• a) all children with a suspected foreign body ingestion should undergo X-ray • b) ipecac can be used safely to dislodge a button battery in the esophagus • c) meat tenderizer can be used safely to dissolve an impacted meat bolus • d) most common site of esophageal foreign body entrapment in pediatric patients is the thoracic inlet • e) objects longer than 5 cm and wider than 2 cm should be removed before they pass through the stomach

The answer is E.

• e) treatment can be expectant once the object passes the pylorus, EXCEPT for objects for objects more than 5 cm x 2 cm and sharp objects which may cause perforation ( most likely at ileocecal valve ) • most ingestions occur in pediatric patients ( approx 80 %) • most ingestions pass on their own ( 80-90 %), • d) in general, if a foreign body lodges in the esophagus, it occurs in the upper esophagus in pediatric patients ( most commonly lodged at cricopharyngeal narrowing at C6 and in the lower esophagus in adults

Question Three

• A 40-year old man presents with severe chest and neck pain. He is otherwise healthy but says that he "threw up really bad" 6 hours earlier at a tailgate party. The neck pain is made worse with swallowing and by flexing his neck. What is the appropriate next management step?

• a) broad-spectrum antibiotics • b) endoscopy • c) laboratory testing, to include lipase • d) soft tissue neck x-ray • e) treatment of H2 blockers

The answer is A.

• a) although the definitive study to do to diagnose Boerhaave's would include esophagram and endoscopy, these measures should not delay antibiotic coverage • b) classically, X-rays may capture mediastinal air, subcutaneous emphysema, left-sided pleural effusions, pneumothorax, and widened mediastinum

Boerhaave’s Syndrome

• describes esophageal perforation following a sudden rise in intra-esophageal pressure • -typically secondary to forceful emesis ( 75 %) • -most common area to perforate is left posterolateral wall of distal esophagus • - men > women, often related to overindulgence of alcohol, can progress to severe chest pain, subcutaneous emphysema, and cardiopulmonary collapse • -most reliable symptom of an esophageal injury is pleuritic pain, exacerbated by swallowing and neck flexion

Question Four

• A 54 year-old man with a history of "alcoholic liver disease" presents with frank hemetemesis, a blood pressure of 80/40, pulse rate of 110, and a respiratory rate of 26. After assessing and managing the airway, which of the following is most likely to provide definitive treatment?

• a) blood products b) emergent endoscopy with sclerotherapy c) normal saline 1 L bolus IV d) Sengstaken-Blakemore tube e) vasopressin

The answer is B.

• Emergent endoscopy indicated in ANY patient with active bleeding that does not clear with lavage, and in any patient who presents with hemodynamic instability in the setting of liver disease • - added benefit of making other therapeutic modalities possible, such as cauterization of bleeding vessels of ulcers, variceal sclerotherapy, and band ligation • -vasopressin (0.2-0.4 U/min IV) is a nonselective vasoconstrictor and may be used in conjunction with endoscopy or as a sole therapy, use caution in patients with CAD or risk of CAD

GI bleed

• peptic ulcer disease ( 40 %), erosive gastritis ( 25% ), varices (20%) and Mallory-Weiss tears (5%) • varices have a one-year mortality rate of 70%

GI bleed

• airway management should be aggressive in patients with patients with bleeding gastric or esophageal varices , especially if patient is hemodynamically unstable, hemetemesis, or altered mental status, consider early intubation

GI Bleed

• Then, attention should turn to circulation, with establishment of 2 large bore IV's and having packed PRBCs and FFP to treat presumed coagulopathy, fluids if hemodynamically unstable, if not improved after 2 L of crystalloid, consider transfusion of blood products

Question Five

• Which of the following is the best statement about the etiology and treatment of Ogilvie's syndrome?

• a) immediate laparotomy is needed for reduction of the obstruction b) use of neostigmine has been shown to be an effective treatment c) barium enemas have been shown to relieve the colonic obstruction d) the condition can be misdiagnosed as renal colic

The answer is B.

• Ogilvie's syndrome (pseudo obstruction) • - colonic distention in the immobile, chronically ill and elderly • - on plain films, dilated loops of large bowel WITHOUT air-fluid levels

Question Six

• Which of the following is the most common cause of abdominal pain requiring surgical treatment in the elderly?

• a) appendicitis b) biliary tract disease c) abdominal aortic aneurysm d) bowel obstruction

The answer is B.

• The most common surgical emergency among elderly patients is acute cholecystitis.

Question Seven

• Which of the following statements is NOT considered routine practice in a patient presenting with symptoms suggestive of an esophageal perforation?

• a) the patient should be observed for 4 hours and, if pain improves, discharged home • b) the diagnostic studies of choice are CT and emergency endoscopy • c) appropriate resuscitation includes hemodynamic stabilization, airway protection, and broad-spectrum antibiotics • d) emergent GI and/or surgical consultation should be obtained in every patient with a suspected esophageal perforation

The answer is A.

• Esophageal perforation is associated with high morbidity and mortality • High risk patients include those who have undergone recent endoscopy or recent invasive procedures around esophagus • Typical presentation includes severe, acute, diffuse pain in the neck, chest and upper abdomen, worsened by swallowing

Question Eight

• Which of the following is an important cause of unconjugated hyperbilirubinemia?

• a) viral hepatitis • b) acetaminophen toxicity • c) Amanita toxin • d) hemolytic anemia

The answer is D.

• unconjugated ( indirect ) hyperbilirubinemia is caused by defects in bilirubin uptake/conjugation or by excess bilirubin production • causes include hemolysis, transfusion reactions, neonatal jaundice, and inborn errors of metabolism

• Conjugated hyperbilirubinemia is caused by viral or alcoholic hepatitis; toxins such as acetaminophen, isoniazid, and Amanita mushrooms, and metabolic disorders such as hemochromatosis or Wilson’s disease

Question Nine

• What is the MOST common organism seen in spontaneous bacterial peritonitis?

• a) Streptococcus pneumonias • b) Enterobacteriaceae • c) Anaerobes • d) Pseudomonas aeruginosa

The answer is B.

• Spontaneous bacterial peritonitis is commonly caused by E. Coli and Klebsiella ( 63% ), followed by Streptococcus pneumoniae, enterococci, and anaerobes • Common treatments include third generation cephalosporins, zosyn, and unasyn

Question Ten

• The clinical utility of total WBC count and temperature in the diagnosis of acute appendicitis is best described by which of the following statements?

• a) a higher total WBC count increases the probability of appendicitis significantly b) a normal or low total WBC count effectively eliminates acute appendicitis c) a total WBC count of 14,000 is no more clinically useful than a WBC count of 9,000 d) elevated body temperature is highly predictive of acute appendicitis e) the combination of a total WBC count greater than 12,000 and an elevated body temperature is highly predictive of acute appendicitis

The answer is C.

c) a total WBC count of 14,000 is no more clinically useful than a WBC count of 9,000

Question Eleven

• A 73-year old woman presents complaining of nausea and severe frequent vomiting that began suddenly that afternoon. She felt fine when she woke up that morning and went to a church picnic. About 3 hours later, she developed her current symptoms. She asks a friend to take her to the hospital, but her friend has also become sick. She ate barbecue chicken, potato salad, spinach salad, and cookies. On exam, she is weak and dehydrated. She has no fever, and her stool tests heme-occult negative. What organism is the most likely cause of her symptoms?

• a) Campylobacter jejuni • b) Clostridium perfringens • c) Salmonella typhimurium • d) Shigella flexneri • e) Staphylococcus aureus

The answer is E.

• Staphylococcus aureus: nausea and vomiting MORE THAN cramps and diarrhea, very short incubation period ( 1-6 hours ), associated with potato salad, unrefrigerated meats, egg salads and cream pastries • Treatment: fluids, antiemetics, antidiarrheals

• Campylobacter, Salmonella, and Shigella a severe diarrheal illness 1-3 days after the : exposure and will cause dysentery ( visible blood in stool ), cause leukocytosis in fecal matter typically • Treatment: Although infections in most hosts is self-limited, one strategy to treat symptoms from Campylobacter, Salmonella, and Shigella includes an oral flouroquinolone and loperamide

• Clostridium perfringens also causes watery diarrhea, and symptoms can develop within 24 hours of ingestion, found on precooked foods allowed to cool slowly giving the spores time to germinate • Treatment: self-limited, may add symptomatic oral agent

Question Twelve

• A 58 year old presents with the complaint of stomach discomfort off and on for several months. For the past 2 weeks he has had gnawing, burning sensation between meals and at night. Which of the following recommendations will have the greatest impact on his condition?

• a) avoid alcohol • b) avoid NSAIDs • c) begin taking a proton pump inhibitor • d) begin treatment for Helicobacter pylori infection • e) stop smoking cigarettes

The answer is D.

• Peptic ulcer disease: • affects one in every 10 people in the US • symptoms often include constant burning, gnawing, and aching pain, primarily epigastric

•

Duodenal ulcers

• DU is five times more common than gastric ulcer • Men are more often affected ( 2 > 1 ) • pain usually occurs between of just before meals and at night •

Gastric ulcers

• pain usually occurs after eating due to the increase in acid production in the stomach in response to food

•

Helicobacter pylori

• -flagellated bacterium that lives between muvus gel and the mucosaof the gastric antrum • -produces urease, cytotoxins, proteases which disrupt proctective mucus gel and produces tissue injury • eradication of H. pylori reduces recurrence rates of 15% to 80% in duodenal ulcers and 10% to 50% of gastric ulcers

• NSAIDS inhibit prostaglandin synthesis, thereby decreasing mucus and bicarbonate production and mucosal blood flow, allowing ulcers • Cigarette smoking is also a known predisposing factor for development of ulcers • Alcohol and caffeine do not increase the risk of developing ulcers

Question Thirteen •

A 68 year old man is brought to the emergency department by paramedics. His wife had called 911 because he collapsed after throwing up blood that morning. He also had had dark stools for 2 days. Past medical history is significant for an aortic graft replacement 6 years earlier and a 3-week history of low grade fever and vague abdominal pain. After 2L of normal saline, vital signs are...

•

BP: 85/60, RR: 16, Temp: 37.2, O 2 sat on room air 96%.

•

What is the next most appropriate management step?

• a) abdominal CT • b) abdominal ultrasonography • c) acute abdominal series • d) emergent laparotomy • e) upper gastrointestinal endoscopy

The answer is D.

• AAA repair with graft complications • graft infection • - low-grade fever, vague abdominal or back pain, can lead to aortoenteric fistula • aortoenteric fistula • - leads to GI bleeding • anastomotic aneurysm (pseudo-aneurysm)

• If aortoenteric fistula is suspected, and the patient is: • unstable ( this patient is hypotensive despite fluids ), patient must go directly to laparotomy • stable, may start with upper GI endoscopy or CT scan

Question Fourteen

• Which of the following statements regarding anal fissures is correct?

•

a) can be seen after frequent episodes of diarrhea

•

b) low relapse rate with medical treatment

•

c) painful only during bowel movements

•

d) rare in pediatric patients

•

e) typically located in the anterior midline

The answer is A.

• Anal fissures is the result of a superficial linear tear in the anal canal •

most frequent cause

of painful rectal bleeding • common among children and young adults • 90% are in posterior midline, 10%-40% in WOMEN are anterior midline • most are caused by passage of hard stools

•

if fissure is elsewhere, consider alternative diagnoses, such as Crohn’s disease, ulcerative colitis, carcinoma of the rectum or anus, lymphoma, syphilis, or a tuberculous ulcer

• symptoms : sharp, searing pain during defecation that can be accompanied by a small amount of bright red blood on the the stool or toilet paper • pain usually subsides between bowel movements • treatment : sitz baths after each bowel movement, addition of bran to diet, analgesic or hydrocortisone-containing ointment • botulinum toxin now being used, but is known to result in reversible fecal incontinence • relapse rate is HIGH ( around 50%) • definitive treatment: anal dilation or surgery

Question Fifteen

• In patients with ulcerative colitis: • a) all three layers of the bowel are affected • b) any part of the gastrointestinal tract can be affected • c) extraintestinal symptoms are rare • d) rectal involvement is seen in 50% of cases • e) toxic megacolon is more common than it is in Crohn disease

The answer is E.

• Inflammatory bowel disease ( UC and Crohn’s disease ) • 10% - 30% of patients with IBD have extraintestinal symptoms • both diseases can cause intra abdominal abscesses, obstruction, massive GI bleeding, perianal complications, toxic megacolon

UC vs Crohn’s

•

Ulcerative Colitis •

30 X increased risk of carcinoma

•

GI hemorrhage, toxic megacolon

•

affects ONLY the colon and rectum

•

affects TWO layers (mucosa, submucosa)

•

continuous lesion

UC vs Crohn’s

• Crohn’s disease

•

3 X increased risk in carcinoma

•

abscesses, obstruction, perianal cx

•

can affect “mouth to anus”

•

affects THREE layers ( serosa )

•

“skip lesions”, cobblestone appearance late in disease process

Thank you!