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GI BOARD REVIEW

GI BOARD REVIEW. Ravi Kapoor, MD, MPH 2/6/07 Mount Sinai Emergency Medicine. Question One.

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GI BOARD REVIEW

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  1. GI BOARD REVIEW Ravi Kapoor, MD, MPH 2/6/07 Mount Sinai Emergency Medicine

  2. Question One A 40-year old man presents with severe chest and neck pain. He is otherwise healthy but he says that he “threw up really bad” 6 hours earlier at a tailgate party. The neck pain is made worse by swallowing and by flexing his neck. A) Broad-spectrum antibiotics B) Endoscopy C) Laboratory testing, including lipase D) Soft-tissue neck x-ray E) Treatment with H2 blockers

  3. Question One A 40-year old man presents with severe chest and neck pain. He is otherwise healthy but he says that he “threw up really bad” 6 hours earlier at a tailgate party. The neck pain is made worse by swallowing and by flexing his neck. A) Broad-spectrum antibiotics B) Endoscopy C) Laboratory testing, including lipase D) Soft-tissue neck x-ray E) Treatment with H2 blockers

  4. Boerhaave’s Syndrome Esophageal perforation following a sudden rise in intra-esophageal pressure Mechanism: forceful vomiting in 75% of cases Clinical course: may include severe pleuritic chest pain, subcutaneous emphysema and cardiopulmonary collapse, although 1/3 of cases present atypically

  5. Treatment ABC! Broad-spectrum antibiotics Volume replacement NPO Surgical consultation Chest X-ray Definitive study: esophagram and endoscopy

  6. Chest X-ray findings Mediastinal air (with or without subcutaneous emphysema) Left-sided pleural effusion Pneumothorax Widened mediastinum Caused by irritation of mediastinal tissues

  7. Mallory-Weiss tears Caused by arterial bleeding from longitudinal mucosal lacerations at the GE junction Cause of upper GI hemmorhages in 5-15% of cases Bleeding stops spontaneously in most cases SEIZURE, TRAUMA, COUGHING

  8. Most common cause of esophageal perforation?

  9. Iatrogenic (endoscopy)

  10. Question Two What is the most common cause of the condition shown here in the United States? A) Adhesions B) Diverticulitis C) Incarcerated hernia D) Neoplasm E) Sigmoid volvulus

  11. Question Two What is the most common cause of the condition shown here in the United States? A) Adhesions B) Diverticulitis C) Incarcerated hernia D) Neoplasm E) Sigmoid volvulus

  12. Small Bowel Obstruction Upright abdominal X-ray will show Dilated loops of bowel Air-fluid levels Strings of air pockets (“string of beads”) Colonic gas should be small, may be more in partial SBO’s

  13. Small Bowel Obstruction Most common cause in US is adhesions status post abdominal surgery as early as two weeks and as late as years following surgery

  14. Question Three A 55-year old man with known alcoholic cirrhosis of the liver presents with lethargy, confusion, and asterixis. His vital signs are normal. Which of the following could worsen his condition? A) Benzodiazepenes B) Glucose C) Lactulose D) Neomycin E) Thiamine

  15. Question Three A 55-year old man with known alcoholic cirrhosis of the liver presents with lethargy, confusion, and asterixis. His vital signs are normal. Which of the following could worsen his condition? A) Benzodiazepenes B) Glucose C) Lactulose D) Neomycin E) Thiamine

  16. Hepatic encephalopathy Asterixis often present Because Wernicke-Korsakoff’s syndrome may also be coexistent, patients should have their glucose checked, and then given thiamine GI bleed often coexists- DO A RECTAL! Benzos are poorly metabolized by these patients, may contribute to MS changes

  17. Question Four A 30-year old man presents with abdominal cramping, flatulence, and frequent pale, loose, foul-smelling stools. Two weeks earlier he went camping in Colorado.

  18. What is the most likely cause of his symptoms? A) Aeromonas hydrophila B) Cryptosporidium C) Giardia D) Norwalk virus E) Salmonella

  19. What is the most likely cause of his symptoms? A) Aeromonas hydrophila B) Cryptosporidium C) Giardia D) Norwalk virus E) Salmonella

  20. Giardia lamblia Most common water-borne diarrhea outbreaks in the United States as well as abroad (“traveller’s diarrhea”) Risk factors Drinking water from fresh water streams Close contact with infected individuals Day care exposure, mental institutions

  21. Giardia lamblia 1-3 week incubation period Non-bloody diarrhea Tx: metronidazole 250 mg po x 5 d Check close contacts for O and P in stool

  22. Salmonella Fever, abdominal pain 24-48 hours after eating contaminated food, limited to 5 day course typically FECAL LEUKOCYTES seen!

  23. Question Five Which of the following presentations has the highest mortality rate? A) 8 y/o M with acute pancreatitis B) 30 y/o M with acute ETOH pancreatitis C) 39 y/o M with acute pancreatitis with 3 Ranson’s criteria D) 42 y/o M with chronic pancreatitis E) 60 y/o M with WBC 17 and gall stone pancreatitis

  24. Question Five Which of the following presentations has the highest mortality rate? A) 8 y/o M with acute pancreatitis B) 30 y/o M with acute ETOH pancreatitis C) 39 y/o M with acute pancreatitis with 3 Ranson’s criteria D) 42 y/o M with chronic pancreatitis E) 60 y/o M with WBC 17 and gall stone pancreatitis

  25. Pancreatitis Causes include GALL STONES and ETOH Medications, toxins Bacteria (mycoplasma) Virus (mumps, coxsackie B, Epstein Barr, rubella) Scorpion, snake bites HIV patients are at high risk!

  26. Pancreatitis Medications that can cause Azathioprine Corticosteroids Sulfonamides Thiazides Furosemides NSAIDs Mercaptopurine Methyldopa Tetracyclines

  27. Ranson’s Criteria Evaluated at admission AGE > 55 years WBC > 16 Glucose > 200 LDH > 350 ALT > 250

  28. Ranson’s Criteria First 48 hours of hospital course Hct drop > 10% BUN increase > 5 Ca < 8 Arterial pO2 < 60 Base deficit (24 - HCO3) < 4 Fluid needs > 6L

  29. Ranson’s Criteria <2 – 1% mortality 3-4 – 15% mortality 5-6 – 40% mortality > 6 – 100% mortality

  30. Question Six The most common complication of biliary colic is: A) Cholangitis B) Cholecystitis C) Choledocholithiasis D) Fluid and electrolyte abnormalities E) Mallory Weiss tears

  31. Question Six The most common complication of biliary colic is: A) Cholangitis B) Cholecystitis C) Choledocholithiasis D) Fluid and electrolyte abnormalities E) Mallory Weiss tears

  32. Gall stones Formed from Elevated cholesterol in bile Intravascular hemolysis (SICKLE CELL, hereditary spherocytosis)

  33. Terminology Cholangitis - inflammation of the bile duct Ascending cholangitis - inflammation caused by bacterial infection Choledocholithiasis - presence of a gallstone in the common bile duct. Cholelithiasis - inflammation of the gallbladder almost always begins without infection, although infection may follow later inflammation may cause the gallbladder to fill with fluid and its walls to thicken

  34. Acalculous Cholecystitis Major surgery Critical illnesses such as serious injuries, major burns, and sepsis Intravenous feedings for a long time Fasting for a prolonged time A deficiency in the immune system

  35. Question Seven Which of the following statements regarding intussception is correct? A) If the stool if negative for occult blood, the diagnosis is excluded B) Most patient show profound dehydration at the time of diagnosis C) Mucus-laden, bloody, “currant jelly” stools are seen in most cases D) Post-reduction recurrence is best predicted by patient age and sex E) Ultrasonography is an accepted diagnostic test

  36. Question Seven Which of the following statements regarding intussception is correct? A) If the stool if negative for occult blood, the diagnosis is excluded B) Most patient show profound dehydration at the time of diagnosis C) Mucus-laden, bloody, “currant jelly” stools are seen in most cases D) Post-reduction recurrence is best predicted by patient age and sex E) Ultrasonography is an accepted diagnostic test

  37. Intussception Telescoping of one portion of intestine into an adjacent portion of bowel Most common location is ileocolic junction Most common in boys Most common under 2 years of age (6-12 months)

  38. Intussception Diagnostic tests include Air or barium enema (often therapeutic) May use sono to rule out diagnosis

  39. Question Eight Which of the following is the most common cause of conjugated hyperbilirubinemia in school-aged children? A) Amanita toxin B) Bacterial sepsis C) Biliary atresia D) Familial nonhemolytic jaundice (Gilbert’s syndrome) E) Hepatitis A

  40. Question Eight Which of the following is the most common cause of conjugated hyperbilirubinemia in school-aged children? A) Amanita toxin B) Bacterial sepsis C) Biliary atresia D) Familial nonhemolytic jaundice (Gilbert’s syndrome) E) Hepatitis A

  41. Conjugated hyperbilirubinemia

  42. Unconjugated Hyperbilirubinemia

  43. Question Nine A 32 year old man vacationing in Florida presents 12 hours after eating seafood and rice. He is complaining of nausea, vomiting, a sensation that cold objects feel warm and paresthesias. What is the most likely cause of symptoms? A) Bacillus cereus B) Ciguatera C) Clostridium perfringes D) Scombroid E) Vibrio parahaemolyticus

  44. Question Nine A 32 year old man vacationing in Florida presents 12 hours after eating seafood and rice. He is complaining of nausea, vomiting, a sensation that cold objects feel warm and paresthesias. What is the most likely cause of symptoms? A) Bacillus cereus B) Ciguatera C) Clostridium perfringes D) Scombroid E) Vibrio parahaemolyticus

  45. Ciguatoxin Stored in fish that have eaten dinoflagellate Gambeirdiscus toxicus ½ of all fish-related poisonings in US 2-24 hrs after ingestion Tx: supportive

  46. Bacillus cereus Aerobic, spore-forming G+, found in soil Found in raw, uncooked food (rice) Spores survive boiling 10 hours of diarrhea Tx: supportive

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