Gastrointestinal Disorders: Diagnosis and Management, Exams of Advanced Education

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CMN 568 Unit 4 Exam Questions and

Answers

When does malrotation occur? - Answer- at about the 10th week of gestation What is a malrotation? - Answer- a congenital abnormality that occurs during the embryonic phase of development when the midgut retracts into the abdominal cavity. The midgut rotates counterclockwise When do infants typically become symptomatic with a malrotation? - Answer- at 3 weeks of life What is the classic sign of a malrotation? - Answer- bilious vomitting How is a malrotation diagnosed? - Answer- upper GI study What are some radiologic findings that are indicative of a malrotation? - Answer- corkscrew appearance with barium swallow; Signs of obstruction (air-fluid levels) may be present, along with an abnormal gas pattern at the stomach and duodenum. What is pyloric stenosis? - Answer- results from hypertrophy of the pyloric sphincter (muscle in the distal stomach), which leads to poor gastric emptying into the duodenum. When does pyloric stenosis usually present? - Answer- At 2-4 weeks of age What are the symptoms of pyloric stenosis? - Answer- vomiting that becomes projectile; typically occurs immediately after feeding, is nonbilious, and the infant is hungry after vomiting. The parents may also report constipation, excessive crying and weight loss, or failure to gain weight What can delay symptoms of pyloric stenosis? - Answer- breastfeeding What is pyloric stenosis usually mistaken for? - Answer- reflux or formula intolerance What is the hallmark finding of pyloric stenosis? - Answer- an olive-shaped mass in RUQ What are typical lab and radiologic findings of a baby with pyloric stenosis? - Answer- hypochloremia, metabolic alkalosis, Hypokalemia. KUB imaging reveals a dilated gastric silhouette. An ultrasound typically reveals a thickened and elongated pylorus, measuring greater than 4 mm.

What is intussusception? - Answer- involves the invagination of a section of the intestine into itself. The most frequent site is at the terminal ileum. What is often a predisposing factor of intussusception? - Answer- A recent viral illness, mesenteric lymphadenitis, Henoch-Schonlein purpura, and cystic fibrosis What is the typical age of onset of idiopathic intussusception? - Answer- 6 to 18 months, with an average age of 7 to 8 months If intussusception occurs beyond 36 mths, it is typically due to a physical abnormality such as? - Answer- meckel's diverticulum or polyps Is intussusception more common in girls or boys? - Answer- boys What is the classic presentation of intussusception? - Answer- colicky abdominal pain, recent viral illness with some vomiting and perhaps diarrhea. The child begins to have episodes of colicky abdominal pain, draws up the knees or stiffens the legs for a brief period, and then becomes quiet for several minutes. The series of events recurs, typically every 15 to 20 minutes, and continues for several hours. The child may have blood in his or her stools, prompting the "currant jelly" descriptor What is typically present on palpation with intussusception? - Answer- A sausage shaped mass typically in the right lower quad What interventions should be considered when intussusception is suspected? - Answer- consult a pediatric surgeon. Initiate intravenous hydration and order an air-contrast enema. Consider an abdominal ultrasound as well What will often diagnose and cure intussusception? - Answer- an air contrast enema What are contraindication s to an air contrast enema? - Answer- perforation, shock, and peritonitits What is usually classic hx of appendicitis? - Answer- abd pain that starts in the periumbilical area and migrates to the right lower quadrant, along with low-grade fever, a small amount of emesis, and anorexia What exacerbates the pain associated with appendicitis? - Answer- movement and the child frequently walks stooped over What does examination of a child with appendicitis usually reveal? - Answer- point tenderness in the right lower quadrant with voluntary guarding, and perhaps some rebound tenderness. He or she will typically move slowly, grimace with sitting up, and grab his or her right side at the first jumping attempt.

How can pain in the RLQ be illicited in a child that has suspected appendicitis? - Answer- Hitting the soles of the feet and jumping up and down What findings would be indicative of an appendix rupture? - Answer- peritoneal signs: decreased bowel sounds, a distended abdomen, and tenderness and guarding in all quadrants with palpation and percussion What should you order if you suspect appendicitis, and what should you initiate? - Answer- CBC, electrolytes, and a u/a. Aggressive IV hydration. What difference is seen in the cbc of a child with appendicitis vs. a ruptured appendix? - Answer- mildly elevated white blood count (WBC) with a left shift vs. a white count is often markedly elevated, with a left shift and an increased band count What can often mimic appendicitis? - Answer- ovarian torsion The menstruating child will often be midcycle with an ovarian torsion? T/F - Answer- T What should you order if you suspect an ovarian torsion? - Answer- A CT or U/S and surgery consult What reflex will be absent in a testicular torsion? - Answer- cremasteric reflex Any male child that presents with abdominal pain - Answer- A child who present to the ED with testicular pain requires what? - Answer- u/a and u/s If the manual reduction of an incarcerated inguinal hernia is unsuccessful and there is blood in the stool upon rectal exam, or if the hernia has been incarcerated for more than 12 hours, what should you do? - Answer- order surgical consult What are 2 serious causes of hematochezia? - Answer- meckel's diverticulum and intussusception The patient with Meckel's diverticulum often has no abdominal pain but may become profoundly __________? - Answer- anemic What labs should be ordered in a pt. with suspected meckel's diverticulum? - Answer- H/H and type and crossmatch What is the most useful method of detecting Meckel's diverticulum? - Answer- technetium-99m pertechnetate scanning What is celiac disease? - Answer- an inherited autoimmune disorder involving the small bowel that results from an inflammatory reaction to gliadin (wheat, rye, and barley)

What occurs in the small intestine due to inflammation in celiac disease? - Answer- targets mucosa of the small intestine and leads to crypt hyperplasia and villous atrophy causing decreased nutrient absorption and increased solute and water excretion What are typical symptoms of celiac disease? - Answer- weight loss, chronic diarrhea, abd. distention, and growth retardation What is the only known tx. of celiac disease? - Answer- gluten free diet What conditions would warrant screening for celiac disease? - Answer- osteopenia, osteoporosis, and unexplained iron deficiency anemia, autoimmune hepatitis, down syndrome, primary biliary cirrhosis How is celiac disease diagnosed through serology? What is the gold standard for dx? - Answer- IgA tissue transglutiminase antibody testing (tTG); Small intestinal mucosal biopsy In children, what is more accurate that the glidian IgA when testing for celiac? - Answer- glidian IgG In patients with severe protein deficiency, what is necessary to test for celiac disease? - Answer- biopsy What should a patient with positive serology and normal biopsies have done if celiac disease is suspected? - Answer- be put on a gluten free diet trial A person who tests neg. for serology and biopsy, but responds clinically to a gluten free diet may have what? - Answer- gluten sensitivity Epigastric pain or burning, early satiety, or post-prandial fullness are s/s of what? - Answer- dyspepsia What diagnostic procedure is warranted in patients with alarm features or in those older than 55? - Answer- endoscopy In patients without alarm features,<55 y/o, and s/s of dyspepsia, what should first be done? - Answer- Testing for H. Pylori and a 4 week trial of PPI What is the most common cause of chronic dyspepsia? - Answer- functional dyspepsia What is the typical profile of functional dyspepsia? - Answer- younger, report a variety of abdominal and extraGI complaints, show signs of anxiety or depression, or has a hx. of psychotropic medication use

In patients older than 55 with c/o symptoms associated with dyspepsia, what lab tests should initially be done? - Answer- CBC, electrolytes, liver enzymes, calcium, and thyroid tests, urea breath test (or other noninvasive tests for H. Pylori) In most clinical settings, a test for what should initially be done in patients with c/o of dyspepsia? - Answer- H. Pylori What are 3 noninvasive tests for H. Pylori? - Answer- urea breath test, fecal antigen, and IgG serology What are "alarm features"? - Answer- weight loss, dysphagia, recurrent vomiting, evidence of bleeding, or anemia What is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis, or upper GI malignancies? - Answer- upper endoscopy what is warranted when symptoms of dyspepsia fail to respond to initial empiric management strategies within 4-8 weeks or when frequent symptoms relapse occurs after d/c of antisecretory therapy? - Answer- endoscopy If a patient has symptom relapse after discontinuation of a 4 week empiric trial of PPIs, what should be done next? - Answer- test for H. Pylori and tx if positive What patient education should be included in the treatment and management of patients with functional dyspepsia? - Answer- Avoid alchohol and caffeine. Consume small, low-fat meals What pharmacologic agents are used to tx. functional dyspepsia? - Answer- 4-8 weeks of PPIs, low doses of antidepressants What black box warning is associated with metoclopramide when used for more than 3 months? who is at the most risk? - Answer- high incidence of tardive dyskinesia; the elderly The acute onset of severe pain and vomiting suggests what? - Answer- peritoneal irritation, acute gastric or intestinal obstruction, or pancreaticobiliary disease What does persistent vomiting suggest? - Answer- pregnancy, gastric outlet obstruction, gastroparesis, intestinal dysmotility, psychogenic disorders, or CNS or systemic disorders Vomiting that occurs in the morning suggests what? - Answer- pregnancy, uremia, alcohol intake, and Increased ICP What diagnostic tool is best used to determine the cause of gastric outlet obstruction? - Answer- upper endoscopy

What diagnostic tool is best used to determine small intestinal obstruction? - Answer- CT A colonic transit time of what is considered significantly abnormal? - Answer- 72 hours What are "alarm" s/s of constipation? - Answer- hematochezia, weight loss, anemia, or

• occult blood tests How is tx of constipation with laxatives usually initiated? - Answer- with osmotic laxatives Who should magnesium containing laxatives NOT be given to? - Answer- patients with chronic renal insufficiency What is the onset of action of osmotic agents? - Answer- 24 hours What is the onset of action of stimulant laxatives? - Answer- orally 6-12 hours; rectally 15-60 min. What medication is approved for the treatment of opioid induced constipation? - Answer- methylnaltrexone Diarrhea of less than 2 weeks duration is most commonly caused by what? - Answer- invasive or noninvasive pathogens and their enterotoxins What characteristics are associated with acute noninflammatory diarrhea? - Answer- watery, nonbloody stools Diagnostic evaluation is limited to patients with acute noninflammatory diarrhea that what? - Answer- is severe or persists beyond 7 days what characteristics are associated with acute inflammatory diarrhea? - Answer- blood or pus and fever what routine diagnostic evaluations are recommended in all patients presenting with acute inflammatory diarrhea? - Answer- stool bacterial cx (including e. coli) in all and testing as clinically indicated for c.diff, and ova and parasites When should stool samples be sent for fecal leukocyte or lactoferrin determination, ovum and parasite evaluation, and bacterial culture? - Answer- If diarrhea worsens or persists for more than 7 days Antidiarrheal agents should not be used in who? - Answer- patients with bloody diarrhea, high fever, or systemic toxicity

What agent reduces symptoms in travelers diarrhea and also reduced vomiting associated with viral enteritis? - Answer- pepto-bismol (bismuth subsalicylate) What agents are contraindicated in acute diarrhea bc of the rare precipitation of toxic megacolon? - Answer- anticholinergic agents What is the oral drug of choice in patients with acute diarrhea? - Answer- fluoroquinolones for 5-7 days What alternative abx can be used for acute diarrhea besides fluoroquinolones in adults?

• Answer- Bactrim and doxycycline What med is used for empiric tx. of noninflammatory traveler's diarrhea? - Answer- Rifazimin How long should diarrhea persist to be considered as chronic diarrhea? - Answer- longer than 4 weeks What is the most common cause of chronic diarrhea in young adults? - Answer- IBS What stool appearance is indicative of a malabsorption disorder? - Answer- greasy or malodorous What stool appearance is indicative of an inflammatory disorder? - Answer- containing blood or pus What tests are recommended in the evaluation of most patients with chronic diarrhea and all patients with signs of malabsorption? - Answer- serologic testing for celiac sprue with tTG test What are the most common s/s of an acute upper GI bleed? - Answer- hematemesis (bright red blood or coffee ground appearance) & melena (black tarry feces) What is used to determine the severity of blood loss with an acute upper GI bleed? What is a poor early indicator of blood loss? - Answer- volume status; hct What is the initial step in the evaluation and tx. of an acute upper GI bleed? - Answer- assessment of the hemodynamic status What are the clinical predictors of increased risk of bleeding and death from an acute GI bleed? - Answer- > 60 y/o, comorbidities, systolic bp < 100, HR >100, and bright red blood in ng aspirite or on rectal exam What is the most common symptom of lower GI bleed? - Answer- hematochezia

What is the main symptom of GERD, and what exacerbates it? - Answer- heartburn; meals, bending, or recumbency 30-60 minutes after meals Patients with typical symptoms of heartburn and regurgitation should be tx with what? - Answer- PPI for 4-8 weeks What condition occurs in which the squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet cells and columnar cells? - Answer- Barrett esophagus What is the most serious complication of Barrett esophagus? - Answer- esophageal adenocarcinoma What is the recommended interval that people with Barrett esophagus should have endoscopy? - Answer- every 3-5 years How long should patients with GERD be instructed to avoid lying down after eating? - Answer- 3 hours What is the preferred treatment of acute and chronic GERD? - Answer- PPIs Patients will usually experience relapse of GERD symptoms in 3 months after discontinuation of PPIs? T/F - Answer- T Who is at most risk for infectious esophagitis? - Answer- immunocompromised What are the most common symptoms of infectious esophagitis? - Answer- odynophagia and dysphagia What is the name of the disorder in which food or environmental anitgens are thought to stimulate an inflammatory response? - Answer- eosinophilic esophagitis Most children with eosinophilic esophagitis have other coexisting _______________ ____________ - Answer- atopic disorders What does esophageal varices develop secondary to? - Answer- portal htn What condition is found in 50% of people with cirrhosis? - Answer- esophageal varices How is dx of esophageal varices established? - Answer- by upper endoscopy What is the most common cause of portal htn? - Answer- cirrhosis What is used to reduce the incidence of rebleeding in patients with esophageal varices?

• Answer- beta blockers and band ligation

What is achalasia? - Answer- an idiopathic motility disorder characterized by loss of peristalsis in the smooth muscle What are s/s of achalasia? - Answer- gradual, progressive dysphagia for solids and liquids, regurgitation of undigested food What may be seen on a barium esophagram in a patient with achalasia? - Answer- "bird's beak" in the distal esophagus What confirms the dx of achalasia? - Answer- esophageal manometry Who is gastropathy most commonly seen in? - Answer- alcoholic or critically ill patients, or pts taking NSAIDs Prior to testing for H. Pylori, what should be discontinued? - Answer- PPIs for 7-14 days and abx for atleast 28 days At what agesdoes duodenal ulcers most commonly occur? - Answer- 30- At what age does gastric ulcers most commonly occur? - Answer- 55- What are the 2 major causes of peptic ulcer disease? - Answer- NSAIDS and chronic H pylori infection What is the diagnostic procedure of choice in most patients with PUD? - Answer- upper endoscopy with gastric biopsy for H pylori What is the hallmark symptom of PUD? - Answer- epigastric pain Long-term use of PPIs may lead to what? - Answer- mild decreases in vit. B12 and calcium absorption In areas of low clarithromycin resistance (U.S.), what is the recommended tx for H.Pylori? - Answer- A 14 day course of "triple therapy" with an PPI, clarithromycin, and amoxicillin BID What "quadruple therapy" is recommended in patients with H.Pylori? - Answer- PPI, bismuth, tetracycline, and metronidazole for 14 days When is quadruple therapy for h.pylori recommended? - Answer- in areas of high clarithromycin resistance, in patients who have preciously been tx with a macrolide, or as a second-line when first-line fails After completion of H. pylori eradication therapy, what tx. should be continued if ulcer is large or complicated? - Answer- PPI once daily for 4-6 weeks

What should be done to confirm successful eradicataion of h. pylori? when? - Answer- urea breath test, fecal antigen test, or endoscopy with biopsy 4 weeks after completion of abx treatment and 1-2 weeks after PPI tx. What is the most common cause of ulcer nonhealing? - Answer- noncompliance What is mandatory after 2-3 months of therapy in all nonhealed ulcers to look for malignancy or infection? - Answer- repeat ulcer biopsy What is the most sensitive and specific method for identifying Zollinger-Ellison syndrome? - Answer- demonstration of an increased fasting serum gastrin concentration What are atypical symptoms of celiac disease? - Answer- dermatitis herpetiformis, iron deficiency anemia, and osteoporosis Most patients with celiac disease also have what? - Answer- lactose intolerance How is diagnosis confirmed for lactase deficiency? - Answer- hydrogen breath test Smoking may lessen symptoms in what conditions? - Answer- ulcerative colitits What is Murphy's sign and what condition is it seen in? - Answer- pain in RUQ on inspiration, seen with inflammed gallbadder. can be illicited by palpating RUQ on inspiration What is the most sensitive test for diagnosing acute abdominal pain? - Answer- CT What are alarm markers for herniations in infants? - Answer- onset of colicky abd pain, N/V, and edema or discoloration at site What are s/s of ulcerative colitis? - Answer- bloody diarrhea, lower abd. cramps and fecal urgency, anemia, low albumin, neg. stool cx What is the key to dx of ulcerative colitis? - Answer- sigmoidoscopy What condition inevitably causes colon cancer? - Answer- familial adenomatous polyposis Where is pain usually felt in patient with cholelithiasis (gallstones)? - Answer- biliary pain characterized by infrequent episodes of steady severe pain in epigastrium or right upper quadrant with radiation to right scalpula How are gallstones detected? - Answer- u/s What is used to relieve biliary pain? - Answer- NSAIDS

A lower tract source of gross hematuria in the absence of infection is most commonly from what? - Answer- urothelial cell carcinoma of the bladder microscopic hematuria in the male is most commonly from what? - Answer- bph What organisms are the most commonly associated with acute cystitis? - Answer- coliform bacteria (e.coli) and gram + bacteria (enterococci) who are considered candidates for prophylactic abx therapy to prevent recurrence of UTIs? - Answer- women who have 3 or more episodes of cystitis per year What are the most common prophylactic abx used to prevent acute cystitis? - Answer- bactrim, nitrofurantoin, and cephalexin at bedtime or at time of intercourse What are the doc for uncomplicated cystitis? - Answer- cephalexin, nitrofurantoin, and flouroquinolones What are the abx of choice for the tx of acute pylonephritis? - Answer- cipro, ofloxacin, and bactrim How are urinary stone dx? - Answer- CT or u/s What are most urinary stones composed of? - Answer- calcium What are the most important factors in the development of urinary stones? - Answer- high protein and salt intake as well as inadequate hydration What is the most common causes of constipation in adults? - Answer- inadequate fiber or fluid intake, poor bowel habits What are some examples of osmotic laxatives? - Answer- MOM, Miralax Give an example of a noninflammatory cause of diarrhea? - Answer- norovirus and rotavirus Give an example of an inflammatory cause of diarrhea? - Answer- CMV When is diagnostic evaluation necessary for acute noninflammatory diarrhea? - Answer- patients with diarrhea that is severe or persists for more than 7 days What are clues to osmotic diarrhea? - Answer- stool volume decreases with fasting; increased stool osmotic gap What are clues to secretory diarrhea? - Answer- large volume; little change with fasting

What are clues to inflammatory diarrhea? - Answer- fever, hematochezia, abd. pain What are clues to malabsorption syndrome? - Answer- weight loss, abnormal lab values, fecal fat > 10g/24h What are clues to motility disorders? - Answer- systemic disease or prior abd. surgery How long is pharmacotherapy for H.Pylori recommended? - Answer- 14 days What are possible causes of active ulcers NOT attributed to H.Pylori? - Answer- Zollinger-Ellison syndrome, NSAIDs, and gastric malignancies How long should uncomplicated duodenal ulcers be tx with PPIs for? - Answer- 4 weeks How long should uncomplicated gastric ulcers be tx with PPIs for? - Answer- 8 weeks How is confirmation of H.Pylori eradication done and when? - Answer- urea breath test, fecal antigen, or biopsy at least 4 weeks after completion of abx and 1-2 weeks after PPI tx. What are the preferred drugs for complicated ulcers? - Answer- PPIs How are NSAID induced ulcers prevented in at risk patients? - Answer- PPI QD Cox-2 selective NSAID (Celecoxib-don't given if cv disease) Misoprostol What long-term "maintnence" therapy is recommended for patients with recurrent ulcers who either are H Pylori neg. or who have failed eradication? - Answer- PPIs QD What are 3 drugs used to treat acute pyelo? - Answer- ofloxacin, cipro, and bactrim What 5 drugs are used to tx acute cystitis? - Answer- cephalexin, nitrofurantoin, cipro, norfloxacin, ofloxacin Patients with severe PUD who are neg. for H. Pylori and NSAID use should be tested for what? - Answer- Zollinger-Ellison syndrome How is ulcerative colitis managed? - Answer- regular diet, limited caffeine and gas producing vegetables and antidiarrheal agents as needed How is traveler's diarrhea treated? - Answer- pepto and flagyl Difference between cystitis and pyelo? - Answer- fever What abx are prescribed in the medical management of diverticulitis? - Answer- augmentin or flagyl PLUS bactrim or cipro