GI/ Hepatology Test Review

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

2. Question 1. • D; Serial monitoring of aminotransferases

3. 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)

4. Question 2. • E; No additional studies

5. 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

6. Question 3. • A; Acute mesenteric ischemia

7. 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

8. Question 4. • A; Colonoscopy

9. 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 (gmneg 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

10. Question 5. • B; Diffuse esophageal spasm

11. 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

12. Question 6. • B; Infliximab

13. 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

14. Question 7. • C; Pentoxifylline

15. 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

16. Question 8. • A; Aortic valve replacement

17. 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 Surgery Hormone Angiogenesis inhibitors Aortic valve replacement

18. Question 9. • A; Contrast-enhanced CT

19. Diagnose hepatocellular carcinoma Screening recommendations are the following: Ultrasound imaging every 6 months DO NOT check AFP levels

21. Question 10. • D; Stool studies for Clostridium difficile

22. Manage a flare of UC with testing for Clostridium difficile

23. Question 11. • B; Immediate surgery

24. 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

25. Question 12. • A; Endoscopic ablation

26. 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 resection • NOT • Esophagectomy! • HIGH grade Barrett’s without definitive treatment requires repeat surveillance in 3 months!

27. Question 13. • D; Initiate omeprazole

28. 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

29. Question 14. • D; Initiate omeprazole

30. 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!

31. Question 15. • C; Colonoscopy in 3 years

32. Manage postpolypectomy surveillance

33. Question 16. • D; Lactose malabsorption

34. Diagnose lactose malabsorption Diagnosis: • 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

35. Question 17. • C; Infliximab

36. Treat fistulizingCrohn disease

37. Question 18. • D; Trial of a proton pump inhibitor

38. Manage noncardiac chest pain

39. Question 19. • C; Serial monitoring of aminotransferases

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

42. Question 20. • E; Small intestinal bacterial overgrowth

43. 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 test Hydrogen breath test