AOA Review: GI Module

Sandeep PatelAndy King

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.

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

Question 1Which of the following tests is most likely to confirm the diagnosis?1. CXR2. Echocardiogram3. Lower Esophageal Manometry4. Barium Swallow5. CTA6. MRI Esophagus7. 24 ph monitoring8. EGD

a. 1, 2, 5b. 6, 7, 8c. 4d. 3, 4e. 3, 4, 8

Rat Tail Taper on Barium Swallow

Manometry

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.

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

Question 2

Which of the following is the optimal treatment for this patient’s condition?

a. Omeprazole x3 Monthsb. Adriamycin, Busulfan, Vincristine, Dacarbazin

Chemotherapyc. Sucralfated. Surgerye. Morphine, pravastatin, NTG, ASA, metoprololf. Amoxicillin, macrolide, pantoprazole, bismuth-

subsalicylate

Urease + Helicobacter Pylori

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.

Differential Dx

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

Question 3

Which of the following is the patient’s most likely diagnosis?

a. Endocardial Infectionb. Primary neuroectodermal tumorc. IBDd. Methamphetamine abusee. Opioid withdrawal syndromef. DTg. AIDS

Pellagra

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.

DifferentialMesenteric IschemiaDiverticulitis/DiverticulosisColon CancerSmall Intestinal TumorAorto-Enteric FisutulaSyphylitic Gastrointestinal InfectionNecrotizing FaschitisFornier’s GangreneRapid Upper GI BleedIron and/or Bismuth Subsalicylate IngestionShingles/Coxsackie InfectionAnthraxCeliac DiseaseTropical SprueUlcerative ColitisCrohn’s DiseaseIBSMeckel’s DiverticulumNecrotizing EnterocolitisAVM

Question 4• This patient was known to have colonoscopy done previous to the presentation. Histology is most likely to reveal:1. Caseating Granulomas2. Crypt abscesses3. Pseudopolyps4. Transmural Inflammation5. Mucosal inflammation6. Rectal Sparing7. Cobblestoning8. Non-Caseating Granulomas9. Diverticuli10. Polyposis11. Villous Atrophy

A. 1,2,3,4B. 4,6,7,8C. 2,3,5D. 5,11E. 4,6,8,10

Pyoderma Gangrenosum

Toxic Megacolon

Case 5

• 82 yo PMHx 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 pruritis and dark urine. Also states that he has not been able to drive a car at night. PE: scleral icterus, palpable mass in RUQ, HSM, +Chvostek’s sign. EKG: Long QT

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

Question 5

• The patient’s condition predisposes the dysregulation of which step in cation absorption:

A. Inhibition of colonic Na+/K+ ATPaseB. Termination of Fe 2+ oxidation in duodenumC. Reduction of 1-alpha hydroxylase activity in

kidneyD. Impaired Mg 2+ reabsorption in proximal tubuleE. Increased Ca2+ absorption secondary to PTHr

secretion by Pancreatic cancer

Painless Jaundice

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.

Differential• Intussception• NEC• Infectious Colitis• Meckel’s Diverticulum• Infantile Colic• GERD• Zollinger-Ellison• Pyloric Stenosis

(Unrelated: Biliary Atresia and Hirschprung’s)

Question 6• Which of the following is the diagnostic test of choice?1. Barium or Air enema2. Surgery3. Upper GI Swallow Study4. Colonoscopy5. Gastric Nuclear Scan6. CT Abdomen7. MRI Abdomen8. Ultrasound Abdomen9. Abdominal X-ray10. Pill Endoscopy

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?

1. NEC2. Infectious Colitis3. Celiac Disease4. Meckel’s Diverticulum5. Inflammatory Bowel Disease6. Food Allergy7. Immunization Reaction8. GERD9. Colonic Malignancy10. Sexual Abuse

Gross Anatomy