AOA Review: GI Module

1. AOA Review: GI Module Sandeep Patel Andy King

2. Case 1 58 yo male with PMH of CAD s/p CABG presents with intermittent CP x2 days. CP remains substernal and is non-exertional. CP was not relieved with NTG administered in ED. Mild eructation noted. Sx worse at night – pt awakens with food debris in mouth. Returned from tropical trip to Brazil 1 month ago after an 18 hour flight. Denies dyspnea, wt loss, fever, chills, diaphoresis, hematemesis.

3. Differential Dx • MI • PE • GERD • Aortic Dissection • Pneumothorax • Esophageal Spasm • Esophagitis • Barrett’s Esophagus • Esophageal Cancer • Zenker’sDiverticulum • Plummer-Vinson Syndrome • Boerhaave’s Syndrome • Scleroderma – CREST Syndrome • Toxin Ingestion • Esophageal Stricture • Achalasia

4. Question 1 Which of the following tests is most likely to confirm the diagnosis? • CXR • Echocardiogram • Lower Esophageal Manometry • Barium Swallow • CTA • MRI Esophagus • 24 ph monitoring • EGD • 1, 2, 5 • 6, 7, 8 • 4 • 3, 4 • 3, 4, 8

5. Rat Tail Taper on Barium Swallow

6. Manometry

7. Case 2 62 yo female with PMH of DJD, chronic pancreatitis, NSCLC resected 6 yrs ago presents with intermittent, vague epigastric pain that lasts for variable amounts of time after meals. No changes in BM. Denies melena, hematochezia, hematemesis, pruritis. +N/V, 15 kg wt loss in the past 3 months, night sweats, fever, and unilateral supraclavicular LAD on PE. No jaundice.

8. Differential Dx • Acute Gastritis • Chronic Gastritis • Gastric Ulcer • Duodenal Ulcer • Gastric Adenocarcinoma • Achalasia • Lymphoma • GERD • MI • Biliary Colic • Gastrinoma

9. Question 2 Which of the following is the optimal treatment for this patient’s condition? • Omeprazole x3 Months • Adriamycin, Busulfan, Vincristine, Dacarbazin Chemotherapy • Sucralfate • Surgery • Morphine, pravastatin, NTG, ASA, metoprolol • Amoxicillin, macrolide, pantoprazole, bismuth- subsalicylate

10. Urease + Helicobacter Pylori

11. Case 3 42 yo male with PMH of depression tx with SSRI presents with watery diarrhea x6 in 24 hours, acute MS change per male partner. In ED pt noted to be wheezing and complaining of abdominal pain, feculent emesis, and anorexia. PE remarkable for generalized erythematous rash seen most profoundly on face, +III/VI holosystolic at LLSB.

12. Differential Dx • Serotonin Syndrome • Neuroleptic malignant syndrome • Carcinoid Syndrome • Bowel Obstruction • Pheochromocytoma • Infection (parasite, viral, bacterial) • Drugs (meds, illicits) • Endocarditis

13. Question 3 Which of the following is the patient’s most likely diagnosis? • Endocardial Infection • Primary neuroectodermal tumor • IBD • Methamphetamine abuse • Opioid withdrawal syndrome • DT • AIDS

14. Pellagra

15. Case 4 32 yo male with SLE and recent AAA repair presents with multiple necrotic, erosive lesions across his abdomen. He has had them for weeks, but has done nothing about it. Has lower abdominal diffuse tenderness. Never had it before. Has a fever, and mild weight loss. His palms and soles are erythematous from itching. PE: 6 necrotic yellow/black lesions across abdomen. +abd tenderness, guarding, distension, bowel sounds decreased. Heme positive stools.

16. Differential Mesenteric Ischemia Diverticulitis/Diverticulosis Colon Cancer Small Intestinal Tumor Aorto-Enteric Fisutula Syphylitic Gastrointestinal Infection Necrotizing Faschitis Fornier’s Gangrene Rapid Upper GI Bleed Iron and/or Bismuth Subsalicylate Ingestion Shingles/Coxsackie Infection Anthrax Celiac Disease Tropical Sprue Ulcerative Colitis Crohn’s Disease IBS Meckel’s Diverticulum Necrotizing Enterocolitis AVM

17. Question 4 • This patient was known to have colonoscopy done previous to the presentation. Histology is most likely to reveal: • CaseatingGranulomas • Crypt abscesses • Pseudopolyps • Transmural Inflammation • Mucosal inflammation • Rectal Sparing • Cobblestoning • Non-CaseatingGranulomas • Diverticuli • Polyposis • Villous Atrophy • 1,2,3,4 • 4,6,7,8 • 2,3,5 • 5,11 • 4,6,8,10

18. PyodermaGangrenosum

19. Toxic Megacolon

20. Case 5 • 82 yoPMHx of 40 pack year 2 ppd smoking history presenting with foul-smelling stools, depression, and easy bruising. Patient notes multiple painful, red areas across chest. States he had same areas on upper arms day before yesterday and now on chest. Complaining of pruritisand dark urine. Also states that he has not been able to drive a car at night. PE: scleralicterus, palpable mass in RUQ, HSM, +Chvostek’s sign. EKG: Long QT

21. Differential • CBD Stone • Sphincter of Oddi Dysfunction • Cholangiocarcinoma • Cholangitis • PSC • PBC • Cirrhosis – all causes (alcoholic, inherited, iron overload) • Heptocellular Carcinoma • Hepatitis, Parasite infection • Cholecystitis • Biliary Colic • Malabsorption Syndromes • Gallbladder Carcinoma • Previous Antibiotic Use • Hemolytic Anemias • Leukemia • Reye’s Syndrome • Acetaminophen Toxicity

22. Question 5 • The patient’s condition predisposes the dysregulation of which step in cation absorption: • Inhibition of colonic Na+/K+ ATPase • Termination of Fe 2+ oxidation in duodenum • Reduction of 1-alpha hydroxylase activity in kidney D. Impaired Mg 2+ reabsorption in proximal tubule E. Increased Ca2+ absorption secondary to PTHr secretion by Pancreatic cancer

23. Painless Jaundice

24. Case 6 • 18 mo old first born male born at 25 weeks gestation presenting with bloody diapers x 4. Intermittent crying spells. Mother had gestational diabetes. Mother was nursing the child when he suddenly stopped suckling and vomited violently with a brownish-green vomitus. PE: mild fever, palpable elongate mass in RLQ, bloody stools.

25. Differential • Intussception • NEC • Infectious Colitis • Meckel’sDiverticulum • Infantile Colic • GERD • Zollinger-Ellison • Pyloric Stenosis (Unrelated: BiliaryAtresia and Hirschprung’s)

26. Question 6 • Which of the following is the diagnostic test of choice? • Barium or Air enema • Surgery • Upper GI Swallow Study • Colonoscopy • Gastric Nuclear Scan • CT Abdomen • MRI Abdomen • Ultrasound Abdomen • Abdominal X-ray • Pill Endoscopy

27. Question 7 • Patient’s intussusception was diagnosed and treated with Barium enema. The patient continued to have bloody stools. Which of the following is most likely diagnosis? • NEC • Infectious Colitis • Celiac Disease • Meckel’sDiverticulum • Inflammatory Bowel Disease • Food Allergy • Immunization Reaction • GERD • Colonic Malignancy • Sexual Abuse

28. Gross Anatomy