Gastroenterology and Hepatology

1. Gastroenterology and Hepatology In-service Review Series

2. A 58-year-old man has a 1-week history of jaundice, dark urine, and vague upper abdominal pain. He has lost 4.5 kg (10 lb) over the past month despite having a good appetite. The patient has a 25-year history of ulcerative colitis that has been in remission since he began taking daily mesalamine 8 years ago. Medical history also includes mild hypertension and obesity. He has had no increase in stool frequency and no rectal bleeding. He has a 3-year history of abnormal liver chemistry test results that have never been evaluated but are attributed to fatty liver. The patient drinks 4 to 6 cans of beer daily. Family history is unremarkable. On physical examination, he is obese and has mild jaundice. Abdominal examination shows only scars from a cholecystectomy and appendectomy. Laboratory Studies Serum aspartate aminotransferase190 U/L Serum alanine aminotransferase212 U/L Serum alkaline phosphatase486 U/L Serum total bilirubin3.9 mg/dL (66.69 �mol/L) Serum albumin3.2 g/dL (32 g/L) A CT scan of the abdomen shows mildly dilated peripheral intrahepatic ducts, mild dilatation of the common hepatic duct, and a normal common bile duct. Which of the following is most appropriate at this time? A) Magnetic resonance cholangiopancreatography B) Endoscopic retrograde cholangiopancreatography C) Measurement of carcinoembryonic antigen and CA 19-9 D) Percutaneous transhepatic cholangiography

3. UC ? PSC ? cholangioCA Patients with longstanding ulcerative colitis and abnormal liver chemistry tests are at risk for developing primary sclerosing cholangitis, which is a well-recognized complication of inflammatory bowel disease. Endoscopic retrograde cholangiopancreatography (ERCP) is warranted to confirm the diagnosis of sclerosing cholangitis and obtain histologic samples from throughout the biliary system. Carcinoembryonic antigen and CA 19-9 values are elevated in patients with cholangiocarcinoma.

4. A 50-year-old woman is evaluated for a routine follow-up visit. Her history includes a diagnosis of stage II colon cancer 2 years ago for which she underwent a surgical resection and received no adjuvant therapy. On physical examination, she appears healthy. Cardiopulmonary and abdominal examinations are normal. Laboratory studies include a serum carcinoembryonic antigen concentration that has increased from a recent baseline measurement of <5 ng/mL (5 �g/L) to 41 ng/mL (41 �g/L). A CT scan of the abdomen shows six hepatic lesions measuring from 2 to 7 cm. Multiple pulmonary nodules of <1 cm are noted on CT scan of the lung. On biopsy, the liver lesions are confirmed as adenocarcinoma consistent with the initial primary tumor. Which of the following is the most appropriate next step in management? A) Abdominal and chest positron emission tomography B) Hepatic resection C) Systemic chemotherapy D) Colonoscopy E) Pulmonary nodule biopsy

5. CRC ? diffuse mets ? chemo Hepatic resection of metastatic colon cancer is indicated only for isolated metastatic disease. The response rate of patients who receive the more modern chemotherapeutic regimens consisting of oxaliplatin, irinotecan, or bevacizumab is significantly better than that achieved with prior treatments. The benefit of hepatic artery infusion (HAI) chemotherapy is unclear. The use of (18)F-2-fluoro-2-deoxy-D-glucose�positron emission tomography (FDG-PET) to detect the cause of the pulmonary lesions is unnecessary. This patient has metastatic disease.

6. A 44-year-old man with a 20-year history of ulcerative colitis continues to have mild symptoms despite taking full-dose 6-mercaptopurine. He has mild abdominal cramps and four to five loose, blood-streaked bowel movements daily with some tenesmus and urgency. Physical examination is significant for mild tenderness to palpation along the left side of the abdomen. Hemoglobin is 12.5 g/dL (125 g/L), and the leukocyte count is 3000/�L (3 � 109/L). Colonoscopy shows mildly active pancolitis without polyps or mass lesions. Surveillance biopsies taken throughout the colon show a focus of low-grade dysplasia. Which of the following is the most appropriate next step in managing this patient? A) Schedule follow-up colonoscopy with biopsies in 6 to 12 months B) Change 6-mercaptopurine to azathioprine C) Add mesalamine to the 6-mercaptopurine D) Add prednisone to the 6-mercaptopurine E) Schedule consultation for proctocolectomy

7. UC ? dysplasia ? colectomy Patients with longstanding ulcerative colitis have an increased risk of developing colorectal cancer. Patients with ulcerative colitis associated with low-grade dysplasia are at high risk for development of concurrent cancer or progression to high-grade dysplasia or cancer within a few years. Follow-up colonoscopy with biopsies is recommended only for patients who refuse surgery or have contraindications to a surgical procedure.

8. A 42-year-old man has a 1-month history of ascites. He emigrated from Laos to the United States 2 years ago. Medical history is noncontributory. His mother died of liver failure 10 years ago. Physical examination is notable for spider angiomata, moderate muscle wasting, moderate ascites, splenomegaly, and mild peripheral edema. Laboratory Studies Hemoglobin12.0 g/dL (120 g/L) Platelet count56,000/�L (56 � 109/L) Serum aspartate aminotransferase84 U/L Serum alanine aminotransferase103 U/L Serum total bilirubin3.4 mg/dL (58.14 �mol/L) Serum albumin3.2 g/dL (32 g/L) INR 1.5 Serum a-fetoprotein1.4 ng/mL (1.4 �g/L) Hepatitis B surface antigen (HBsAg)Positive IgG antibody to hepatitis B core antigen (IgG anti-HBc)Positive Hepatitis B e antigen (HBeAg)Positive Antibody to hepatitis B e antigen (anti-HBe)Negative Hepatitis B virus DNA (HBV DNA)1.2 million copies/mL Antibody to hepatitis C virus (anti-HCV)Negative Abdominal ultrasonography shows a small liver without masses, moderate ascites, splenomegaly, and a patent portal vein. Paracentesis demonstrates clear yellow fluid with a protein of 1.2 g/dL (12 g/L) and a leukocyte count of 80/�L (0.08 � 109/L). Upper endoscopy shows small esophageal varices. Diuretic therapy is initiated, and the ascites improves. Which of the following is the most appropriate therapy at this time? A) Pegylated interferon and ribavirin B) Pegylated interferon C) Entecavir D) Propranolol E) Transjugular intrahepatic portosystemic shunt

9. Hep B + cirrhosis ? oral agent Chronic hepatitis B with cirrhosis is indicative of advanced liver disease. Because the patient has active viral replication, as evidenced by the presence of hepatitis B e antigen (HBeAg) and a high HBV DNA level, treatment with entecavir or one of the other oral agents such as lamivudine or adefovir is indicated. The oral agents are preferable to pegylated interferon because interferon is associated with significant risks in patients with cirrhosis. These include infectious complications and a 5% to 10% risk of inducing a flare of hepatitis that could result in further hepatic decompensation. Propranolol is used for prophylaxis against variceal bleeding in patients with large varices.

10. A 53-year-old man with hepatitis C and cirrhosis comes for a follow-up office visit. He feels fatigued but has no other new signs or symptoms. The patient has a history of alcohol abuse but has been abstinent for 8 months following a treatment program. He now attends weekly Alcoholics Anonymous meetings. Complications of the hepatitis C and cirrhosis have included ascites and encephalopathy, both of which are controlled by medications. Physical examination discloses mild jaundice, spider angiomata, splenomegaly, and mild peripheral edema. Laboratory Studies Hemoglobin13.3 g/dL (133 g/L) Platelet count84,000/�L (84 � 109/L) Serum aspartate aminotransferase73 U/L Serum alanine aminotransferase64 U/L Serum alkaline phosphatase119 U/L Serum total bilirubin3.2 mg/dL (54.72 �mol/L) Serum albumin3.6 g/dL (36 g/L) INR1.4 Serum a-fetoproteinNormal Abdominal ultrasonography discloses a coarse echotexture of the liver, mild ascites, and a 2.2-cm hyperechoic hepatic mass that was not seen on previous imaging studies. A CT scan of the liver shows vascular enhancement of the mass. Which of the following is the most likely diagnosis? A) Metastatic cancer B) Focal nodular hyperplasia C) Hepatocellular carcinoma D) Cavernous hemangioma E) Regenerative nodule

11. Cirrhosis ? HCC Patients with hepatitis C and cirrhosis are at increased risk for developing hepatocellular carcinoma, and the finding of a new hepatic mass with vascular enhancement in such patients almost certainly indicates hepatocellular carcinoma. Focal nodular hyperplasia and cavernous hemangiomas are unusual.

12. A 40-year-old man, who was diagnosed with chronic hepatitis B and cirrhosis 2 years ago, comes for a follow-up office visit. At the time of diagnosis, he had a positive assay for hepatitis B e antigen (HBeAg) and a high hepatitis B virus DNA (HBV DNA) viral load and was placed on lamivudine. The patient has had a good response to therapy and has no new signs or symptoms at today's visit. Physical examination is notable for spider angiomata and splenomegaly. Laboratory Studies Platelet count78,000/�L (78 � 109/L) Serum aspartate aminotransferase22 U/L Serum alanine aminotransferase24 U/L Serum bilirubin2.4 mg/dL (41.04 �mol/L) Serum albumin3.2 g/dL (32 g/L)INR1.2 Serum a-fetoprotein440 ng/mL (440 �g/L) HBV DNAUndetectable Abdominal ultrasonography shows a 3-cm hypoechoic hepatic mass and a small amount of ascites. A CT scan of the abdomen demonstrates that the mass is hypervascular and confirms the presence of mild ascites. The CT scan also shows splenomegaly with multiple collateral vessels throughout the abdomen, consistent with portal hypertension. Which of the following is most appropriate for managing this patient at this time? A) Surgical consultation for resection of the hepatic mass B) Biopsy of the hepatic mass C) Ultrasound-guided ethanol ablation of the hepatic mass D) Evaluation for liver transplantation E) Repeat abdominal ultrasonography and serum a-fetoprotein measurement in 6 months

13. HCC ? transplant Because the presence of a hypervascular hepatic mass in a patient with cirrhosis and a high serum a-fetoprotein level is essentially diagnostic of hepatocellular carcinoma. Evaluation for liver transplantation is indicated for a patient with advanced liver disease and one lesion of hepatocellular carcinoma measuring <5 cm or up to three lesions with the largest measuring <3 cm. Surgical resection of the cancer with partial hepatectomy is associated with a very high risk of causing hepatic decompensation. A false-negative biopsy report is possible, and the procedure may cause bleeding or needle-track seeding of malignant cells. Ultrasound-guided ethanol ablation is only palliative. Repeating the abdominal ultrasonography and serum a-fetoprotein determination in 6 months delays appropriate treatment.

14. A 35-year-old man is diagnosed with HIV infection after he sought testing because of sexual exposure to another man approximately 5 years ago who he subsequently learned was HIV-infected. The patient is asymptomatic. Medical history is unremarkable, and he takes no medications. On physical examination, he appears healthy. Vital signs and general examination are normal. The liver and spleen are not enlarged. Laboratory Studies CD4 cell count184/�L (0.184 � 109/L) Plasma HIV RNA viral load13,043 copies/mL Serum aspartate aminotransferase63 U/L Serum alanine aminotransferase85 U/L Serum alkaline phosphatase88 U/L Serum total bilirubin0.9 mg/dL (15.39 �mol/L) Antibodies to hepatitis C virus (anti-HCV)Negative Hepatitis B surface antigen (HBsAg)Positive Antibodies to hepatitis B core antigen (anti-HBc) Positive Antibodies to hepatitis B surface antigen (anti-HBs)Negative Which of the following is the most appropriate antiretroviral therapy at this time? A) Delay treatment until the patient becomes symptomatic B) Delay treatment until the patient's HIV RNA viral load exceeds 100,000 copies/mL C) Begin treatment with zidovudine, didanosine, and nelfinavir D) Begin treatment with lamivudine, efavirenz, and tenofovir

15. HIV + Hep B Although this patient has asymptomatic HIV infection, his CD4 cell count is less than 200/�L (0.2 � 109/L). He is therefore at risk for AIDS-related complications, and antiretroviral therapy is indicated now. The patient also has chronic hepatitis B, as evidenced by the positive hepatitis B surface antigen and core antibody. In addition, his mildly elevated serum aminotransferase levels suggest active hepatitis. Both regimens listed are either preferred or alternative regimens for initial therapy in an antiretroviral treatment�na�ve patient. However, lamivudine, efavirenz, and tenofovir are preferred because lamivudine and tenofovir also have activity against chronic hepatitis B.

16. A 44-year-old man was recently found to have abnormal serologic test results for viral hepatitis when he attempted to donate blood. The patient is asymptomatic. He used injection drugs and drank alcohol excessively for 2 years 25 years ago but has not used either drugs or alcohol since. Medical history is otherwise unremarkable, and he takes no medications. Physical examination discloses a BMI of 23, no stigmata of chronic liver disease, and a normal-sized liver. Laboratory Studies Serum aspartate aminotransferase53 U/L Serum alanine aminotransferase64 U/L Serum alkaline phosphatase89 U/L Serum total bilirubin0.9 mg/dL (15.39 �mol/L) Hepatitis B surface antigen (HbsAg)Negative Antibody to hepatitis B surface antigen (anti-HBs)Positive IgG antibody to hepatitis B core antigen (IgG anti-HBc)Positive IgM antibody to hepatitis B core antigen (IgM anti-HBc)Negative Antibody to hepatitis C virus (anti-HCV)Positive Abdominal ultrasonography is normal. Which of the following diagnostic studies should be done next? A) Hepatitis B e antigen (HBeAg) B) Hepatitis B virus DNA (HBV DNA) C) Hepatitis C virus RNA (HCV RNA) D) IgM antibody to hepatitis A virus (IgM anti-HAV)

17. + anti-HCV Ab ? check RNA This patient has elevated serum aminotransferase values and positive antibodies to hepatitis C virus (anti-HCV). In a patient with a history of injection drug use, these findings are highly suggestive of hepatitis C. Positive tests for antibody to hepatitis B surface antigen (anti-HBs) and IgG antibody to hepatitis B core antigen (IgG anti-HBc) are consistent with immunity from prior infection.

18. A 45-year-old woman is undergoing evaluation to determine the cause of iron deficiency anemia. The patient is otherwise healthy, and family history is unremarkable. Colonoscopy shows a 2-cm villous adenoma in the sigmoid colon; the adenoma is removed during the procedure. In addition to counseling regarding screening of family members, which of the following is most appropriate at this time? A) Repeat colonoscopy in 6 months B) Repeat colonoscopy in 3 years C) Repeat colonoscopy in 10 years D) Annual fecal occult blood testing E Referral for left hemicolectomy

19. High-risk polyp ? 3 years High-risk lesions include large polyps (>1 cm), polyps with villous histologic features, and those with high-grade dysplasia. Multisociety consortium guidelines recommend surveillance colonoscopy 3 years from the time of initial colonoscopy for patients with these findings. Complete removal of the polyp at the time of colonoscopy is considered curative.

20. A 69-year-old man has a 6-week history of loose bowel movements associated with urgency and the presence of mucus and bright red blood per rectum. He underwent resection of rectosigmoid colon cancer 14 months ago. Two of 14 regional lymph nodes were positive for adenocarcinoma; there were no distant metastases. The patient received chemotherapy and radiation therapy for 2 months postoperatively. Two weeks ago, he was treated with levofloxacin for community-acquired pneumonia, which has since resolved. He takes no other medications. General physical examination is normal. Rectal examination discloses the presence of blood-tinged mucus. Flexible sigmoidoscopy shows friable granular mucosa with scattered telangiectasias in the distal rectum. Which of the following is the most likely diagnosis? A) Recurrent colorectal cancer B) Radiation colitis C) Ischemic colitis D) Ulcerative colitis E) Clostridium difficile colitis

21. Colitis after XRT Based on this patient's history and sigmoidoscopic findings, he most likely has radiation colitis, which accounts for 1% to 5% of all cases of lower gastrointestinal bleeding. Radiation colitis generally occurs from 9 months to 4 years after radiation therapy for prostate, gynecologic, or other pelvic malignancies and is characterized by tenesmus, diarrhea, and hematochezia. Endoscopic findings include friable colonic mucosa and telangiectasias.