GI/Hepatology Test Review Brenda Shinar, MD May 2013.

GI/Hepatology Test Review

Brenda Shinar, MDMay 2013

Question 1.

• D; Serial monitoring of aminotransferases

Manage nonalcoholic steatohepatitis

• 30% of adults in US have NAFLD and 20% of these patients have NASH

• Risk factors for progession to cirrhosis:– Age > 50 years– BMI > 28– Serum triglycerides >150– ALT > 2x ULN

• Treatment for all:– Weight loss– Monitor AST/ALT q 3-6

months– Statins are okay

• AASLD Guidelines For Biopsy Proven NASH:– Diabetics: Pioglitazone 45

mg/day (1B)– Non-diabetics: Vitamin E

800 U/ day (1B)

Question 2.

• E; No additional studies

Manage acute diarrhea

• Definition:– Acute < 14 days– Chronic > 4 weeks

• Osmotic, secretory, inflammatory or malabsorptive

• Most acute cases of diarrhea are self-limited and require no further evaluation

• FEATURES that require additional evaluation:– Fever> 38.5 C (101.3 F)– Bloody stool– Pregnancy– Elderly or

immunocompromised– Hospitalized– Food handler – Recent antibiotics– Volume depleted– Severe abdominal pain

Question 3.

• A; Acute mesenteric ischemia

Diagnose acute mesenteric ischemia

• 1) Acute arterial mesenteric ischemia

– Pain out of proportion– Afib, unanticoagulated– Thromboembolus to SMA– Known vasculopath– High mortality: dead bowel

• 2) Chronic arterial mesenteric ischemia

– Hungry– Afraid to eat due to pain– Weight loss– Known vasculopath

• 3) Subacute venous-hypertension related mesenteric ischemia

– Unusual hypercoagulable state– Polycythemia Vera, Paroxysmal

Nocturnal Hemoglobinuria (PNH)– Occlusive portal vein clot propagates

to SMV

• 4) Colonic ischemia – Elderly– Hypotension /Dehydration event– Mucosal ischemia especially

watershed areas (splenic flexure and sigmoid)

– Increase perfusion pressure to treat; avoid hypotension

– No need for angiogram

Question 4.

• A; Colonoscopy

Manage recently resolved acute diverticulitis

• Diverticulosis:– Intrinsic weakness where vessel

penetrates the colon wall– Simultaneous or excessive haustral

contractions– Inadequate dietary fiber– COMMON in Western populations – 40% by age 60 and 60% by age 80

• Diverticulitis: (fever, LLQ pain, WBC) (1 in 5 with diverticulosis):

– Uncomplicated– Recurrent uncomplicated– Complicated– Smoldering

• CT is diagnostic test of choice

• Management decisions:– Outpatient or inpatient– Antibiotics (gm neg and anaerobes)– Bowel rest

• *Following resolution (2-6 weeks later) the entire colon needs endoscopic evaluation to look for mimickers, ie. cancer/polyps

• Preventing future episodes:– Surgical resection of diseased segment– High fiber diet– No association between seeds, nuts, or

popcorn consumption

Question 5.

• B; Diffuse esophageal spasm

Diagnose diffuse (distal) esophageal spasm

• RARE:– 3% of patients with chest

pain – 3% of patients with

dysphagia

• Pathophysiology:– Excessive number of

simultaneous contractions of normal or high amplitude in the distal

esophagus

• Diagnosis:– Clinical history: worse with cold

liquids– Manometry– Barium swallow is not sensitive

• Treatment:– Diltiazem– Trazodone or Imipramine– Botulism toxin– Sildenafil– Hot water– Peppermint oil

Question 6.

• B; Infliximab

Treat new-onset Crohn disease• Diagnosis of Crohn disease

– 80% involve small bowel– Transmural inflammation

• 5-ASA tx ineffective– Skip lesions– Mouth to anus

• Assess severity clinically and endoscopically– Crohn Disease Activity Index

(CDAI) or Harvey-Bradshaw index (see right)

• Initiate treatment– Step up vs. Top down

• ANTI-TNF THERAPY WITH OR WITHOUT 6-MP OR AZATHIOPRINE RESULTED IN HIGHEST REMISSION RATES

(SONIC trial; NEJM September,2010) • Alternative is to start simultaneous

azathioprine or 6-MP and steroids with goal of stopping steroids in 3 months

Question 7.

• C; Pentoxifylline

Treat severe alcoholic hepatitis• Diagnosis:

– AST/ALT 2-3:1– Transaminases NOT over 500– Bilirubin and Coags increasing– WBC may be very high

• General Management for ALL patients– Alcohol abstinence– Prevention and treatment of

withdrawal– Fluid management– Nutritional support– Infection surveillance– Prophylaxis against

gastrointestinal bleeding

• Maddrey discriminant function > 32 = severe– Prednisolone 40 mg q day x 28 days– Stop after 7 days if no

improvement in bili and DF– Pentoxifylline NOT helpful in those

who fail steroids– Pentoxifylline in those in whom

steroids are contraindicated• Infection (SBP)• Renal failure• GI bleeding

• Mortality @ 1 month– SEVERE 25-25% mortality– MILD- MOD <10% mortality

Question 8.

• A; Aortic valve replacement

Manage obscure GI bleeding associated with aortic stenosis

Angiodysplasia of the GI tract

Ectatic, thin-walled, tortuous dilated vessels

lined by only endothelium in the submucosa

• THREE associated conditions:– End-stage renal disease– Von Willebrand disease– Aortic stenosis

• Acquired VW disease?

• Treatment:Endoscopic

SurgeryHormone

Angiogenesis inhibitorsAortic valve replacement

Question 9.

• A; Contrast-enhanced CT

Diagnose hepatocellular carcinoma

Screening recommendations are the following:Ultrasound imaging every 6 months

DO NOT check AFP levels

Question 10.

• D; Stool studies for Clostridium difficile

Manage a flare of UC with testing for Clostridium difficile

Question 11.

• B; Immediate surgery

Manage toxic megacolon in a patient with ulcerative colitis: early surgery prevents mortality from 22% to 1.2%

• Radiologic dilatation PLUS– Maximum colon diameter > 6 cm– Usually right sided/transverse

• Clinical presentation– Fever >38⁰C– Heart rate > 120 bpm– WBC > 10,500– Anemia

• PLUS One of the following:– Altered sensorium– Hypotension– Dehydration– Electrolyte abnormalities

Question 12.

• A; Endoscopic ablation

Manage high-grade dysplasia in a patient with Barrett esophagus

American Gastrointestinal Association Guidelines 2011 for Management of High-Grade Barrett’s dysplasia is to

undergo Endoscopic Ablation:

• Radiofrequency ablation• Photodynamic Therapy

• Endoscopic mucosal resectionNOT

• Esophagectomy!

• HIGH grade Barrett’s without definitive treatment requires repeat

surveillance in 3 months!

Question 13.

• D; Initiate omeprazole

Manage short-bowel syndrome with acid suppression therapy

Likelihood or resuming an oral diet

– Amount of bowel remaining– Type of bowel remaining– Presence of a colon and

ileocecal valve– Intestinal adaptation

Citrulline concentration– < 20 micromol/Liter predicts

permanent intestinal failure – 95% PPV, 86% NPV

Treatment of short bowel syndrome

– PPI or H2 blocker for gastric acid suppression (oversecretors)

– Replacement of stomal/fecal fluid losses

– Electrolyte replacement– Loperamide– Thickeners

Question 14.

• D; Initiate omeprazole

Treat a patient at risk for NSAID-induced GI toxicity with a PPI

Patients with ONE or MORE of the MODERATE risk factors should be given PPI therapy for PRIMARY prevention of

gastrointestinal toxicity to NSAIDS!

Question 15.

• C; Colonoscopy in 3 years

Manage postpolypectomy surveillance

Question 16.

• D; Lactose malabsorption

Diagnose lactose malabsorptionDiagnosis:

– Osmotic diarrhea– Stool osm= 290- 2x (stool sodium

+ stool potassium– >100 mosm/kg = osmotic

diarrhea

Prevalence of Lactase Deficiency in Adults:

– Caucasian: 7-20%– Hispanic: 50%– African American: 60-75%– Native American: 80-95%– >90% Eastern Asia

Question 17.

• C; Infliximab

Treat fistulizing Crohn disease

Question 18.

• D; Trial of a proton pump inhibitor

Manage noncardiac chest pain

Question 19.

• C; Serial monitoring of aminotransferases

Manage Hep B virus infection in a patient in the immune-tolerant phase

Question 20.

• E; Small intestinal bacterial overgrowth

Diagnose small intestinal bacterial overgrowth

Symptoms of SIBO:• Bloating, flatulance• Abdominal pain• Watery diarrhea• Dyspepsia• Weight loss

• Macrocytic anemia due to B12 malabsorption

Diagnosis:Jejunal aspirate (gold standard)

14-C d-xylose breath testHydrogen breath test