Dr. MurrayPhoto Slide

Case #1Case #1

7 year old withpain vomiting and weight loss. Whatwould you order next?

7 year old withpain vomiting and weight loss. Whatwould you order next?

1. CT scan2. Endoscopy with biopsy3. Barium enema4. Surgical consult5. pH probe

1. CT scan2. Endoscopy with biopsy3. Barium enema4. Surgical consult5. pH probe

Dr. PfeilPhoto Slide

Case #2Case #2

Whatwould yourecommend?

Whatwould yourecommend?

1. Endoscopic removal using a retrieval basket2. Biopsy to determine composition3. Immediate surgical consultation4. No intervention5. Evaluation for blue rubber bleb nevus syndrome

1. Endoscopic removal using a retrieval basket2. Biopsy to determine composition3. Immediate surgical consultation4. No intervention5. Evaluation for blue rubber bleb nevus syndrome

Case #3Case #3

How can you determine whetherthis girl is in trouble?

How can you determine whetherthis girl is in trouble? 1. Weight for age growth curve2. Tanner staging for pubertal maturation3. Bone age4. Albumin5. Triceps skinfold thickness6. Weight-for-height comparison curve

1. Weight for age growth curve2. Tanner staging for pubertal maturation3. Bone age4. Albumin5. Triceps skinfold thickness6. Weight-for-height comparison curve

Case #4Case #4• A 35 year old female patient who works at a

daycare facility presents with a several month history of diarrhea

• Stools are loose but non-bloody

• She reports “gas” and cramping

• No weight loss, fever, or extraintestinal symptoms

• Flexible sigmoidoscopy is unrevealing

Your next recommendationwould be:

Your next recommendationwould be: 1. Begin mesalamine and prednisone as

empiric therapy for Crohn’s disease2. Suggest education about irritable bowel syndrome3. Obtain 3 stool samples for O&P studies4. Begin ciprofloxacin therapy for E. Coli 01575. Suggest a clear liquid diet until symptoms resolve

1. Begin mesalamine and prednisone as empiric therapy for Crohn’s disease2. Suggest education about irritable bowel syndrome3. Obtain 3 stool samples for O&P studies4. Begin ciprofloxacin therapy for E. Coli 01575. Suggest a clear liquid diet until symptoms resolve

Case #5Case #5

Daily emesis in a healthy 3 monthold: how should you treat this patient?

Daily emesis in a healthy 3 monthold: how should you treat this patient? 1. Upright positioning2. Zantac, a histamine blocking antacid3. Thickened feedings with cereal

4. Metoclopramide (Reglan)5. Cisapride (Propulsid)6. Do nothing and reassure the mother

1. Upright positioning2. Zantac, a histamine blocking antacid3. Thickened feedings with cereal

4. Metoclopramide (Reglan)5. Cisapride (Propulsid)6. Do nothing and reassure the mother

Case #6Case #6• A 50 year old woman presents with symptoms of a 30

pound weight loss, diarrhea, and abdominal bloating• Stools are loose, large in volume, and non-bloody

• Initial laboratory studies show the following:

- WBC 5.0 - MCV 79 - Ferritin 2 (normal 82-99)

- Hgb 10.9 - B12 190 - Albumin 2.5 (normal >220)

- Endomysial Ab positive

Your initialrecommendationwould be:

Your initialrecommendationwould be: 1. Colonoscopy2. Stool Cx, O+P, Cdiff

3. Abdominal pelvic CT scan

4. Trial of a lactose free diet

5. Duodenal biopsies (EGD)

1. Colonoscopy2. Stool Cx, O+P, Cdiff

3. Abdominal pelvic CT scan

4. Trial of a lactose free diet

5. Duodenal biopsies (EGD)

Case #6 (con’t.)Case #6 (con’t.)

• Endoscopy and duodenal reveal

- Flattened villi

- Crypt hyperplasia

- Intraepithelial lymphocytes

WhatWould yourecommend?

WhatWould yourecommend? 1. Treatment with steroids for Crohn’s disease 2. Lactose elimination

3. Gluten elimination

4. Empiric antibiotics

5. Referral to oncology

1. Treatment with steroids for Crohn’s disease 2. Lactose elimination

3. Gluten elimination

4. Empiric antibiotics

5. Referral to oncology

Case #7Case #7

Fecal impaction in the Emergency Department:what would be the appropriate treatment?

Fecal impaction in the Emergency Department:what would be the appropriate treatment? 1. Metamucil daily2. A senna laxative twice daily3. Colace, a stool softener4. 1 liter of Golytely, a lavage solution5. Mineral oil by mouth and enema6. Fleet’s phosphosoda enema

1. Metamucil daily2. A senna laxative twice daily3. Colace, a stool softener4. 1 liter of Golytely, a lavage solution5. Mineral oil by mouth and enema6. Fleet’s phosphosoda enema

Case #8Case #8

WhatWould yourecommend?

WhatWould yourecommend? 1. Discontinuation of herbal

laxatives 2. Immediate surgical consultation

3. Search for primary melanoma

4. Discontinuance of excess coffee ingestion 5. Screen for toxic metals

1. Discontinuation of herbal laxatives 2. Immediate surgical consultation

3. Search for primary melanoma

4. Discontinuance of excess coffee ingestion 5. Screen for toxic metals

Case #9Case #9

3 year old with pain, gas, bloating, and night-timevomiting. What test would you order next?

3 year old with pain, gas, bloating, and night-timevomiting. What test would you order next? 1. Upper GI barium study2. Liver function tests3. Stool cultures

4. Ova and parasite exams X 35. Endoscopy with biopsies

1. Upper GI barium study2. Liver function tests3. Stool cultures

4. Ova and parasite exams X 35. Endoscopy with biopsies

Case #10Case #10

What is themost likelydiagnosis?

What is themost likelydiagnosis? 1. Reflux esophagitis 2. Pill induced esophagitis

3. Herpetic infection

4. HIV infection with solitary esophageal ulceration 5. Candida esophagitis

1. Reflux esophagitis 2. Pill induced esophagitis

3. Herpetic infection

4. HIV infection with solitary esophageal ulceration 5. Candida esophagitis

Case #11Case #11

16 month old with vomiting and diarrhea:what is the most likely treatment?

16 month old with vomiting and diarrhea:what is the most likely treatment? 1. Lytes, CBC, and urine2. Gatorade, 1 ounces every 3 hours3. Frequent sips of Isomil4. Pedialyte, an oral rehydration solution5. I.V. saline, 20 cc / kg bolus6. Imodium AD, 0,5 mg twice daily

1. Lytes, CBC, and urine2. Gatorade, 1 ounces every 3 hours3. Frequent sips of Isomil4. Pedialyte, an oral rehydration solution5. I.V. saline, 20 cc / kg bolus6. Imodium AD, 0,5 mg twice daily

Case #12Case #12

A 4 year old with mild diarrhea:what would you advise?

A 4 year old with mild diarrhea:what would you advise? 1. Keep NPO until diarrhea resolves2. Offer a soy formula

3. Pedialyte, an oral rehydration solution4. An elemental formula

5. BRAT diet (Bananas, Rice, Applesauce and Toast)6. Regular diet for age

1. Keep NPO until diarrhea resolves2. Offer a soy formula

3. Pedialyte, an oral rehydration solution4. An elemental formula

5. BRAT diet (Bananas, Rice, Applesauce and Toast)6. Regular diet for age

Case #13Case #13• 13 year old girl is seen for weight loss

• 5 feet 4 inches, she has gone from 135 pounds to her current 102 pounds

• Feels fit and even participated in soccer camp last month, but she’s wrapped in a sweatshirt in August

• Her resting heart rate is 42

Whatwould youdo next?

Whatwould youdo next? 1. CT scan of the abdomen: r/o cancer2. Thyroid screen: r/o hypertension3. Admit to hospital4. Upper GI films: r/o Inflammatory Bowel Disease5. A psychiatric evaluation for an eating disorder

1. CT scan of the abdomen: r/o cancer2. Thyroid screen: r/o hypertension3. Admit to hospital4. Upper GI films: r/o Inflammatory Bowel Disease5. A psychiatric evaluation for an eating disorder

Case #14Case #14

• A 25 year old previously healthy college student presents with symptoms of:

- Nausea - Early satiety - 10 pound weight loss - EDG is normal

Whatwould yourecommend?

Whatwould yourecommend? 1. Upper GI X-ray2. Gastric emptying study3. Colonoscopy4. 24 hour pH study5. Referral to the student counseling service

1. Upper GI X-ray2. Gastric emptying study3. Colonoscopy4. 24 hour pH study5. Referral to the student counseling service

BonusBonus

• A 25 year old in the ICU for

2 weeks ventilated with multiple organ system failure

• Today she vomited bright red blood and coffee grounds

• She has no prior history of GI complaints

What is themost likely diagnosis?

What is themost likely diagnosis? 1. Excessive acidity

2. Gastro-esophageal reflux and esophagitis3. Gastric ulcer4. Stress ulcers5. Bile reflux gastritis6. Mallory-Weiss tear of the cardia

1. Excessive acidity2. Gastro-esophageal reflux and esophagitis3. Gastric ulcer4. Stress ulcers5. Bile reflux gastritis6. Mallory-Weiss tear of the cardia

In this patient,which treatment would be most helpful?

In this patient,which treatment would be most helpful? 1. A psychiatric evaluation

2. Phenergan3. Parenteral nutriction (TPN)4. Enteral nutrition5. Prilosec made up as a liquid6. Misoprostel (Prostaglandin E2)

1. A psychiatric evaluation2. Phenergan3. Parenteral nutriction (TPN)4. Enteral nutrition5. Prilosec made up as a liquid6. Misoprostel (Prostaglandin E2)