Educational objective: Emphasize usefulness of contrast radiography in diagnosis of intussusception.
Endoscopy is superior to contrast radiography in that it provides direct visualization, ability to biopsy, and delivers therapeutic interventions. Endoscopy is 90% sensitive and almost 100% specific compared to contrast radiography with 50% sensitivity and 90% specificity. Therefore, answers A, B, C, and E benefit from clearer identification, therapy or biopsy ability.
Intussusception of the small bowel and its intestinal obstruction are not reached by conventional endoscopies. Large bowel intussusception is usually associated with a mucosal lesion such as a neoplasm. But, manipulation prior to surgery and endoscopy in the presence of bowel obstruction are relative contraindications to endoscopy.
Educational objective: Reinforce the most common reason for esophageal reflux.
Although very low LES pressures are associated with esophageal reflux, the concept that one must have an incompetent LES in order to have gastroesophageal reflux disease (GERD) has changed. Ambulatory esophageal manometry has revealed that the majority of GERD occurs in patients with normal pressure lower esophageal sphincters that simply relax inappropriately without stimulation by a swallow or esophageal distention.
Ref: 1. Dent J: Patterns of Lower Esophageal Sphincter Function Associated with Gastroesophageal Reflux. American Journal of Medicine. 103:298-235, 1997. 2. Hunt R H: Importance of pH Control in the Management of GERD. Archives of Internal Medicine. 159:649-57, 1999.
Match the clinical syndrome with its pancreatic endocrine tumor:
Necrolytic migratory erythema, diabetes mellitus, weight loss, anemia, hypoaminoacidema, thromboembolism, diarrhea
Educational Objective: Review pancreatic endocrine tumor syndromes.
Ref: 1-. O’Shea D, Bloom S R: Gastrointestinal Endocrine Tumors. Bailliere’s Clinical Gastroenterology 10:571-766, 1996.
Diabetes mellitus, gallbladder disease, diarrhea, steatorrhea, weight loss
Abdominal pain, diarrhea, esophageal reflux
Diarrhea, hypokalemia, dehydration, hypochlorhydria, flushing, hyperglycemia, hypercalcemia.
Educational objective: Highlight the different diagnostic tests for H. pylori.
Serology will remain positive for a prolonged period, possibly years, after eradication of H. pylori. Histology and culture require repeat endoscopy and biopsy, which is not indicated in duodenal ulcer follow-up. Urea breath test are the proper tests for follow up of H. pylori eradication, but they need a lush growth of bacteria in order to avoid a false-negative test. Proton pump inhibitors suppress the growth of H. pylori; therefore the breath test should only be done if the patient has been off these medications for at least 7 days.
Educational objective: Illustrate some common misconceptions about peptic ulcer disease.
Individuals become infected with H. Pylori during childhood. The rate of infection is higher in developing countries than in the United States. The rate of infection in the United States is falling, along with the rate of peptic ulcer and gastric cancer of the gastric corpus.
Educational objective: Illustrate one difference between MEN-I and MEN-II.
Multiple endocrine neoplasia Type-I involves the pancreatic islets most commonly with a gastrinoma producing Zollinger-Ellison Syndrome (PUD, diarrhea, GERD); up to 5% of Zollinger-Ellison patients will also have ACTH secretion by the gastrinoma. Hyperparathyroidism causes elevation of calcium and renal stones. Tumors of the anterior pituitary can cause elevation of prolactin levels causing galactorrhea.
MEN II is associated with medullary thyroid cancer and pheochromocytoma (hypertension).
Ref: 1. O’Shea D, Bloom S R: Gastrointestinal Endocrine Tumors. Baillier’s Clinical Gastroenterology. 10:571-766, 1996.
This patient has celiac disease or gluten sensitive enteropathy as demonstrated by his positive IgA endomysial antibody. Answer A is seen in Whipple’s disease due to Tropheryma whippelii. Answers C and D are infections that are not associated with a positive IgA endomysial antibody.
Ref: 1- Murray J A: The Widening Spectrum of Celiac Disease. American Journal of Clinical Nutrition. 69:354, 1999.
Mild symptoms, including fatigue and malaise, are common in patients with chronic persistent hepatitis. Each of the other listed findings is more consistent with a diagnosis of chronic active hepatitis than chronic persistent hepatitis.
Autoimmune chronic active hepatitis is common in young women but can occur in both men and women of any age. Hemochromatosis is primarily a disease of men, as is chronic hepatitis B. Patients with chronic hepatitis C are most often between 30 and 70 years of age.
The rise in the incidence of hepatitis B has caused the Center for Disease Control and Prevention to recommend immunization of all infants against hepatitis B. The recommended injection site is the deltoid muscle in adults and anterolateral thigh muscle in infants and neonates.
Vaccine nonresponders will probably fail to respond to repeated vaccine course. Although hepatitis vaccination is useless in hepatitis B virus carriers, there are no adverse effects in this group of patients. The need for booster vaccination in patients in whom antibody level declines with time has not yet been determined.
Treatment alternatives for cholelithiasis include: Oral dissolution therapy – Ursodiol, 8-10 mg/kg/day in 2-3 divided doses. This therapy dissolves only cholesterol stones < 1.5 cm in diameter. Successful therapy may take up to 3 years and gallstone recurrence occurs in at least 50% of patients within 10 years of completed treatment.
Extracorporeal shock wave lithotripsy – This method breaks stones into smaller pieces that may require dissolution with ursodiol, or stones may pass spontaneously into the common duct or dissolve via bile acid. It is usually used in combination with oral dissolution therapy. Method is expensive and associated with high recurrence rate.
Contact dissolution therapy – This is an experimental treatment. Methyl tert-butyl ether is placed into the gallbladder through a percutaneous transhepatic catheter to dissolve radiolucent cholesterol stones of any size or number within hours. Requires great degree of expertise but dissolves stones successfully in up to 95% of patients. Residual debris may persist. Recurrence rate is about 40% in 5 years in solitary stones and 70% if stones are multiple.
Laparoscopic cholecystectomy – Most symptomatic patients (up to 95%) can undergo this procedure. It provides total or near total symptom relief in 90% of cases. Also, it offers greatly reduced postoperative pain and discomfort, length of hospitalization, and recovery time. Cosmetically it is superior to traditional surgery. However, it is associated with a slightly higher risk for bile duct injury.
Open subcostal incision – Typically it is only performed on patients who had multiple previous surgeries, with extremely inflamed or gangrenous gallbladders, or with gallbladder cancer. Only about 5% of laparoscopic surgeries revert to an open procedure.
This patient has calcified stones, which precludes dissolution by any means. Also, her history of multiple surgeries in the past in the same abdominal area makes her unsuitable for laparoscopic surgery.
Approximately 95% of patients with acute viral hepatitis will have change in urine color (dark urine). Also, common symptoms include fatigue, anorexia, nausea, itching, diarrhea, drowsiness, arthralgias and fever. These other symptoms are present in about 50% of patients suffering from acute viral hepatitis or less.
The most common malignant tumors of the small intestine are adenocarcinoma (45%), carcinoid (34%) lieomyosarcoma (18%) and lymphoma 3%.
Both ulcerative colitis and Crohn’s disease can involve the rectum but only Crohn’s disease can skip the rectum. Both have an increased cancer risk that depends on the amount of mucosa involved and the duration of disease. Crohn’s disease can show skip lesions but removal of the diseased segment is not curative in Crohn’s disease.
Ref: 1.Fiocchi C: Inflammatory Bowel Disease: Etiology and Pathogenesis. Gastroenterology. 115:182-205, 1998. 2. Das K M: Relationship of Extra-Intestinal Involvements in Inflammatory Bowel Disease: New Insights into Autoimmune Pathogenesis. Digestive Disease and Sciences. 44:1-13, 1999.
Match the following disease to its characteristic:
Rectal sparing
Ref: 1. Fiocchi C: Inflammatory Bowel Disease: Etiology and Pathogenesis. Gastroenterology. 115:182-205, 1998. 2. Das K M: Relationship of Extra-Intestinal Involvements in Inflammatory Bowel Disease: New Insights into Autoimmune Pathogenesis. Digestive Disease and Sciences. 4:1-13, 1999.
Increased cancer risk
Both ulcerative colitis and Crohn's disease can involve the rectum but only Crohn’s disease can skip the rectum. Both have an increased cancer risk that depends on the amount of mucosa involved and the duration of disease. Crohn’s disease can show skip lesions but removal of the diseased segment is not curative in Crohn's disease.
Ref: 1. Fiocchi C: Inflammatory Bowel Disease: Etiology and Pathogenesis. Gastroenterology. 115:182-205, 1998. 2. Das K M: Relationship of Extra-Intestinal Involvements in Inflammatory Bowel Disease: New Insights into Autoimmune Pathogenesis. Digestive Disease and Sciences. 44:1-13, 1999.
Skip lesions
A 52-year-old female has a history or GERD for many years. It is under good symptomatic relief while taking lansoprazole but returns when she attempts to stop therapy. At endoscopy, a biopsy is obtained from the distal esophagus in an area of salmon-pink mucosa. It reveals a columnar epithelium with goblet cells.
She has an increased risk for:
Educational objective: Identify the biopsy and major complications of Barrett’s esophagus.
Barrett’s esophagus is a pre-malignant lesion defined as specialized columnar epithelium lining in the lower esophagus and pre-disposing to adenocarcinoma of the esophagus.
Ref: 1- Morales T G, Sampliner R E: Barrett’s Esophagus: Update on Screening, Surveillance and Treatment. Archives of Internal Medicine. 159:1411-1416, 1999.
Educational objective: Recall various extra-intestinal manifestations of inflammatory bowel diseases.
Arthritis associated with inflammatory bowel diseases (IBD) is a migratory asymmetrical arthritis of the elbows, wrists, hips, knees, and ankles that follows the disease activity in the bowel and responds to therapy of the IBD. Ankylosing spondylitis can be unresponsive to therapy of the IBD and have a relentlessly progressive course.
Ref: 1. Das K M: Relationship of Extra-Intestinal Involvements in Inflammatory Bowel Disease: New Insights into Autoimmune Pathogenesis. Digestive Disease and Sciences. 44:1-13, 1999.
A 24-year-old male presents with complaint of three weeks of diarrhea. He has noted 10 stools per day with mucous and blood but has developed a new fever and right lower quadrant abdominal pain over the last 3 days.
You find him to have a fever of 38.0ºC, blood pressure of 110/70 mm/Hg, respirations 22. His abdomen is soft but diffusely tender. Stool is positive for blood and white cells but cultures and ova and parasite exams are negative. Clostridia difficile toxin is negative. An abdominal series reveals no free air, and multiple air fluid levels and a distended colonic lumen to 6 cm. His white blood count is 15,000.
Treatment for this man could involve all of the following except:
Educational objective: Review contraindications for use of anti-diarrheal agents in inflammatory bowel diseases (IBD).
This patient has a toxic presentation for his first bout of IBD. He has a risk of having a toxic mega-colon, which can be precipitated by using anticholinergics and antidiarrheal agents.
Ref: 1- Roy, M A: Inflammatory Bowel Disease. Surgical Clinics of North America. 77:1419-31, 1997. 2- Sheth, S G, LaMont J T: Toxic Megacolon. Lancet 351: 509-13, 1998.
A 64-year-old woman presents with constant left lower quadrant pain, low-grade fever, urgent loose non-bloody stools, and pneumaturia for one week.
Diagnostic tests that should be pursued at presentation include all of the following except:
Educational objective: Illustrate that endoscopy is contraindicated in acute diverticulitis.
This patient presents with acute diverticulitis with a colovesicular fistula. Endoscopy is contraindicated in acute diverticulitis due to its potential perforation risk.
CT scan is the test of choice to demonstrate bowel wall thickening and abscess formation.
The abdominal series will evaluate quickly and cheaply for perforation with free air.
The barium enema (done carefully with low pressure) will show bowel edema and possibly the fistula tract.
Retrograde cystopyelography may reveal the fistula tract.
Ref: 1. Ferzolo L B, Raptopoulos V, Silen: Acute Diverticulitis. New England Journal of Medicine. 338:1521-26, 1998. Review Article -- NEJM 1998; 338: 1521-1526 2. Rao P M, Rhea, J t, Novelline R A: Helical CT of Appendicitis and Diverticulitis. Radiologic Clinics of North America. 37:895-910, 1999.
A 58-year old woman presents to the emergency room with acute diffuse abdominal pain. She describes, for many months, a more localized epigastric pain following meals. She has had a significant weight loss because she has avoided meals due to this pain. Her outpatient workup has included a negative upper endoscopy and negative abdominal CT scan. Her physical exam reveals a benign abdomen in spite of her complaints of intense abdominal pain. An abdominal series is unremarkable and she has only a mild leukocytosis.
This patient would benefit the most from emergent:
Educational objective: Illustrate the presentation of acute mesenteric ischemia.
This patient has had food fear due to chronic mesenteric ischemia or "abdominal angina". She has developed an acute event, has precipitated an episode of acute mesenteric ischemia, and has presented early in its course when the symptoms are more severe than physical findings. The single most important step is to do an arteriogram and start vasodilator therapy even before surgery to reverse the vasoconstriction that may persist even after surgical correction of the vascular occlusion.
Reference: 1. Eldrup-Jorgensen J, Hawkins R E, Bredenberg C E: Abdominal Vascular Catastrophes. Surgical Clinics of North America. 77:1305-20, 1997. 2. Montgomery R A, Venbrux A C, Bulkley G B: Mesenteric Vascular Insufficiency. Current Problems in Surgery. 34:941-1025, 1997.
Educational objective: Review vascular lesions of the intestine.
Colonic vascular ectasia or angiodysplasia is the correct answer. They are multiple degenerative lesions of aging and are diagnosed by colonoscopy or angiography. They are caused by obstruction of the submucosal vein and subsequent dilatation of the capillary bed. Hemangiomas are the second most common vascular lesion and are usually small red-purple mounds but may be large and cavernous. Dieulafoy’s ulcer is really a large artery in the mucosa or submucosa that erodes a small area of overlying mucosa and bleeds massively. Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is a familial disease (autosomal dominant) with skin and mucus membrane involvement with telangiectasias. Watermelon stomach is unusual and seen in older women with atrophic gastritis. It is also associated with cirrhosis.
Reference: 1- Reinus J F, Brandt L J: Vascular Ectasias and Diverticulosis Common Causes of Lower Intestinal Bleeding. Gastroenterology Clinics of North America. 23:1-20, 1994.
Educational objective: Review neoplasms of the stomach.
Gastric cancer has been declining in the United States since the 1930’s. However, proximal and distal gastric adenocarcinoma seems to be two different diseases with incidence rates moving in opposite directions. The incidence of gastric cancer in Japan and China is among the highest in the world, and interestingly decreases as populations move from high to low risk areas of the world.
Malt lymphoma or mucosa-associated lymphoid tissue lymphoma is associated with H. Pylori; first line therapy is against this bacteria.
Leiomyosarcoma is a connective tissue tumor and presents as a submucosal mass with ulceration.
Reference: 1- Fuchs C, Mayer R: Gastric Carcinoma. New England Journal of Medicine. 333:32-41, 1995. Review Article -- NEJM 1995; 333: 32-41
Educational objective: Emphasize diabetes mellitus and acromegaly as independent risk factors for development of colonic carcinoma.
There is increasing evidence that diabetes mellitus is an independent risk factor for the development of colorectal cancer. The Nurses’ Health Study is the prospective cohort study of about 120,000 women that found that relative risk for colon cancer in women with diabetes is increased (relative risk – 1.43). This association was maintained even when results were adjusted for age, body mass index, and other covariates.
A possible explanation for this association is in hyperinsulinemia. Insulin is known to be an important growth factor for colonic mucosal cells and a stimulator of colonic tumor cell growth. Other options offered as answers have no association with colorectal cancer.
The only other endocrinologic condition known to increase the risk of colorectal cancer is acromegaly.
Educational objective: Review the dietary factors protective of colon cancer.
Epidemiologic studies show a relatively consistent association between the intake of a diet high in fruits and vegetables and protection from colorectal cancer (risk ratio between highest and lowest intake groups is 0.5). Exactly what it is in the diet that confers this protection is not known.
Folic acid supplementation is shown to be protective. Women taking multivitamin supplementation containing folic acid have a relative risk of 0.25 in comparison to the average population. However, this benefit is evident only after 15 years of use.
In contrast, there was no relationship observed between fiber intake and the risk of colorectal cancer (or adenomas) in the Nurses’ Health Study.
Increased dietary calcium intake also may confer some protection against colorectal cancer, but decreased intake is not shown to be either harmful or beneficial.
Selenium is another dietary factor that may be beneficial, but this is still not proven.
Vitamins D and C are not associated in any way to epidemiology of colorectal cancer.
Educational objective: Review prognostic factors and pathologic staging of colonic cancer.
Prognosis is the most dependent upon pathologic stage at the time of resection. The five-year survival for each stage is as follows:
Astler-Coller modification of Dukes’ staging system for colorectal cancer
There is no relation of prognosis and size of primary tumor; effect of pathohistologic type and location of tumor are much more modest than those of stage.
Educational objective: Review important features of colon cancer screening methods.
The FOBT is performed by obtaining 6 samples from three consecutive bowel movements after an appropriate diet for 48 hours to avoid false positive (red meat, horseradish) or false negative (Vitamin C) results. Mortality is reduced by approximately one third.
Sigmoidoscopy examines the large bowel up to splenic flexure, and may miss up to 50% of colonic lesions (however it may be performed after only simple bowel preparation and by primary care physician in the office). It has been shown that mortality might be decreased by two thirds in the examined part of the colon.
There are theoretical reasons for combining FOBT and sigmoidoscopy. The FOBT is less sensitive for the detection of colorectal cancer in the distal bowel (bleeding is more common with proximal cancers), while sigmoidoscopy offers the ability to carefully examine the distal bowel. In addition, there are several studies demonstrating better results with the combination than with sigmoidoscopy alone (there are still no randomized studies dealing with this question, however).
A 64-year-old patient underwent a sigmoidoscopy which revealed a 9 mm polyp in the sigmoid. The polyp was removed and sent for histologic examination. No other lesion was detected (patient had adequate bowel preparation). A couple of days later the histologic report showed that the polyp was adenomatous.
Which of the following is the correct management of this patient?
Educational objective: Review appropriate management of patients with colonic polyps.
All polyps discovered by the screening sigmoidoscopy should be biopsied (or removed if possible). If the lesions found prove to be adenomatous adenomas or cancerous, the patient should be offered colonoscopy to remove polyps, treat limited cancerous lesions definitively, and examine the entire colon and rectum for synchronous neoplasms.
Patients who have tubular adenomas smaller than 5 mm should make a decision (guided by physician) whether or not to undergo colonoscopy.
Educational objective: Review the role of CEA in management of patients with colon cancer.
The only laboratory test recommended for routine colorectal cancer surveillance is carcinoembryonic antigen (CEA). This is an oncofetal protein that is often elevated in patients with colorectal cancer (about 70%). It is not useful as a tool for primary screening because of low sensitivity and specificity. However, in patients with established colorectal cancer, CEA may be used to detect relapse (and even to determine prognosis to some extent). Most of the patients with colorectal cancer and elevated CEA have a decrease in CEA postoperatively. A rising CEA concentration after resection may be used as a sign of local recurrence or liver metastases. The estimated sensitivity of the CEA to detect relapse is about 70%, but there is no data that shows that detection of relapse improves outcome. Alpha-fetoprotein and liver function tests are not useful in detection of recurrence, and FOBT is used in primary screening of colorectal cancer but not in secondary surveillance.
A 68-year-old male patient presented with fever, increased white blood count with left shift, pain in left lower abdominal quadrant, and constipation for the last 48 hours. He has a history of several episodes of painless bleeding in the last 5 years. His weight has been stable during this time.
Rectal exam reveals normal sphincter tone and mild tenderness more toward the left side of the abdomen.
Which of the following is the most likely diagnosis?
Educational objective: Review clinical features of acute diverticulitis.
This patient most likely has acute inflammation of the colonic diverticula. Prevalence of diverticulosis in the age group of this patient is about 40%.
About 70% of patients with diverticulosis remain asymptomatic, and the rest develop complications. Bleeding results from injury to the artery supplying this segment of the bowel and it is painless. Most patients have minor or occult bleeding but up to 50% give a history of intermittent passage of maroon or bright red blood per rectum.
Diverticulitis represents micro or macroscopic perforation of diverticulum followed by inflammation and focal necrosis. Left lower quadrant pain is the most common clinical feature (70% of cases). Pain is present more than 24 hours at presentation in 83% of cases. Nausea and vomiting are seen in 20-60% and constipation in 50 percent of patients. Diarrhea and urinary symptoms (dysuria, urgency and frequency) are also seen.
Acute prostatitis usually doesn’t have left lower quadrant pain associated with it; urinary symptoms predominate, and a rectal exam is markedly painful. Appendicitis is less likely because of the localization of pain. This is also an atypical presentation for colorectal cancer; because internal hemorrhoids may become infected, there is marked tenderness on rectal exam in this condition.
Educational objective: Review diagnostic procedures for acute diverticulitis.
The CT scan is the method of choice in investigation of patients suspected of having acute diverticulitis. It is used for diagnosis, assessment of severity, therapeutic intervention, and quantification of resolution of disease. Features of diverticulitis on CT scan are increased soft tissue density within pericolic fat (due to inflammation – 98%), colonic diverticula (84%), thickening of the bowel wall (70%), and soft tissue masses caused by phlegmon, fluid collections, and abscesses (35%). Hence, CT can be used to estimate the extent of inflammation and to follow changes with treatment. In addition it can be used as a guide to percutaneous drainage of abscesses, avoiding emergent surgery, and permitting single-stage elective surgical resection.
A contrast enema is safe if performed in the acute stage and by the single contrast technique. It is absolutely contraindicated in the presence of complications such as pneumoperitoneum or generalized peritonitis (however, water soluble contrast may be used). Compression, high-resolution is a new method with reported sensitivity in the range of 85-98% and specificities from 80-98%, and is still used less frequently than the CT scan.
Routine plain abdominal plate is useful in exclusion of other causes of acute abdominal pain (intestinal obstruction, etc.), rather than in making the diagnosis of diverticulitis. Colonoscopy is to be avoided in the face of a potentially acute surgical abdomen.
Educational objective: Review indications for surgical intervention in patients with acute diverticulitis.
The overall requirement for surgery with the first attack of diverticulitis is 20-30%, and most of these patients have complicated diverticulitis.
Indications for emergency surgery during the acute phase of the disease are free bowel perforation (with generalized peritonitis), obstruction, failure to improve with conservative management (or clinical deterioration), and an abscess that cannot be drained percutaneously.
Indications for elective surgery are recurrent symptoms, persistent pericolic mass, inability to exclude carcinoma of the colon, relative (incomplete) obstruction, presence of the fistula (to the skin, urinary bladder etc.), and previous percutaneous drainage of an abscess (drainage allows for elective surgery instead of emergency).
Educational objective: review recommendations for colorectal cancer screening.
The American Cancer Society recommendations for colorectal cancer screening are as follows:
1. Annual digital rectal exam beginning at age 40 2. Annual FOBT beginning at age 50 3. Flexible sigmoidoscopy every 3-5 yrs beginning at age 50
Patients at greater than average risk for colorectal cancer should undergo colonic surveillance which is individualized according to the risk of cancer:
Educational objective: Review diagnostic methods for diagnosis of H. pylori infection.
Serum H. pylori antibody may remain positive for months to years after treatment of H. pylori and hence would not be helpful in documenting eradication of infection. However, it may be useful initially to diagnose H. pylori infection. Though esophagogastroduedonoscopy (EGD) with biopsy and staining for H. pylori would be the most accurate test, it is not cost effective. It is difficult to culture H. pylori.
Educational objective: Review features of acute fatty liver of pregnancy.
Acute fatty liver of pregnancy occurs in the third trimester and is associated with anorexia, nausea, vomiting and increase in AST, hyperbilurubinemia and prolonged prothrombin and partial thromboplastin time. Intrahepatic cholestasis is usually manifested by severe itching and often with steatorrhea and modest hyperbilurubinemia. This entity is treated with cholestyramine.
HELLP syndrome is characterized by hemolysis, elevated liver enzymes and low platelets. Prothrombin time is usually normal. In acute fatty liver of pregnancy and in HELLP syndrome, delivery should be done as soon as feasible.
This patient has the clinical presentation and EGD findings consistent with gastric ulcer. Both malignant and benign gastric ulcers are more common on lesser curvature of the stomach than on greater curvature. Radiation of gastric folds from the edge of the ulcer suggests a benign lesion. Large ulcers (bigger than 3 cm in diameter) are more often malignant than smaller ones. Ulcer located on the mass lesion is also more likely to be malignant. Endoscopic visualization of the ulcer is important (radiographic appearance cannot be used to distinguish between malignant and benign lesions: 1-8% of the benign appearing ulcers on radiography are proven to be malignant on endoscopy and biopsy or surgery). Endoscopy allows definition of the size, location, and determination of histology by the biopsy. To exclude malignancy by endoscopy a total of six biopsy samples should be obtained from the inner margin of the ulcer. Brushings for cytology also should be obtained prior to biopsy. Combination of radiographic, endoscopic, and histologic techniques distinguishes between malignant and benign lesions about 97% of time. Ulcers present with pentagastrin-fast achlorhydria are rare but almost always malignant.
Test for H. pylori should be done (rapid urease test on antral mucosal biopsy specimen) because this organism should be eradicated if present. Benign ulcers usually heal completely within 2-3 months of the start of adequate therapy. Failure to decrease satisfactorily in size and to heal with medical treatment should be taken as a sign of malignancy. Apparently complete healing with potent acid-suppressive therapy does not, however, necessarily mean that lesion is benign, since about 70% of malignant lesions undergo significant (but rarely complete) healing with the treatment.
One gastric ulcer even when large does not suggests presence of the gastrin-secreting tumor. Multiple and/or recurrent gastric and duodenal ulcers are a setting in which this possibility must be entertained for a differential diagnosis.
The picture depicts a longitudinal tear in the mucosa of the distal esophagus (Mallory-Weiss tear). The pathogenesis of this syndrome is not completely understood. Tears are most commonly caused by the sudden increase in intraabdominal pressure. Precipitating events causing Mallory-Weiss tears described in the literature include vomiting (retching), straining at stool, heavy lifting, coughing, epileptic convulsions, hiccups under anesthesia, closed-chest massage, blunt abdominal injury, colonoscopic preparation with polyethylene glycol electrolyte Lavage solution, and gastroscopy (tear was found in 0.13% of patients undergoing gastroscopy).
Positive pressure ventilation has not been associated with development of Mallory-Weiss tears.
A 74-year-old male presents with 2 months of dull right-sided abdominal pain and 12 lb weight loss. He has a history of arthritis and states he has had an increase in his bowel movements to 4 to 5 per day. He has mild right-sided abdominal tenderness and brown, guaiac positive stool to exam. A colonoscopy reveals a normal mucosa in the left colon but this finding in the ascending colon:
The differential diagnosis includes all except:
Educational Objective: Review differential of right-sided colonic ulcers.
Ulcerative colitis involves the colon in an ascending pattern starting at the rectum. This patient has a normal left colon, ruling out ulcerative colitis. This picture is of a patient with NSAID induced colonic ulcer produced by etodolac extended release 400 mg orally every day.
A 47-year-old man was seen in the emergency room for an episode of vomiting some blood. Patient stated that he had a long history of intermittent abdominal pains that were in the past relieved significantly by eating. He denied any weight loss, although he has always been thin. His bowel movements are regular and his stools are usually large, smelly and soft. There is no significant family history of gastrointestinal malignancies, peptic ulcer disease or inflammatory bowel disease that the patient was aware of. He uses ibuprofen occasionally for his chronic left knee pain, which he ascribes to arthritis due to an old sport-related injury. He has taken six 400-milligram tablets within the last week. He is a construction worker and has been under a lot of stress due to the possibility of losing his job because of downsizing in the company.
His initial laboratory data were as follows:
Na – 141 K- 4.1 Cl – 109 CO2 – 28 Cr – 1.1 BUN – 13 Glucose – 89 Albumin – 4.1 Ca – 12.1 AST – 27 ALT – 45 Alk.P – 113 INR – 1.0 Hb – 12.2 Hct – 31 WBC – 9.7 Platelets - 134,000
Endoscopy of the upper gastrointestinal tract revealed a gastric ulcer with a bleeding vessel. Bleeding was successfully stopped by sclerosing the vessel. A mucosal biopsy was performed and the patient was started on a proton pump inhibitor. Which of the following tests is indicated in this patient?
Educational objective: Review indication for serum gastrin measurement in patients with peptic ulcer disease.
This patient has several features that should raise the possibility of Zollinger-Ellison syndrome (gastrinoma). These are hypercalcemia in the face of peptic ulcer disease, and concomitant bulky, smelly diarrhea.
Indications for measurement of serum gastrin level in patients with peptic ulcer disease include all of the following:
Ref: Harrison’s Principles of Internal Medicine, 14th edition. Part eleven, Disorders of the Gastrointestinal System. 1997:1613-4.
Educational Objective: Review cause of acetaminophen toxicity.
A toxic metabolite of acetaminophen causes liver injury. This metabolite increases with activation of the cytochrome P-450 system as with chronic alcohol use and is detoxified by conjugation with glutathione (which is depleted in chronic alcohol use). N-Acetylcysteine provides cystine for glutathione synthesis.
A 26-year-old woman presented to your office with scleral icterus. Her history revealed that she had been on a lipid-free weight loss diet. She had normal alkaline phosphatase and transaminase levels and negative viral hepatitis serology. Her CBC was normal. Her total bilirubin was 5 mg/dl with a direct fraction of 0.8 mg/dl. You recommended resumption of a normal diet.
Two weeks later her repeat bilirubin is 3.0 mg/dl. Her diagnosis is:
Educational Objective: Review hereditary disorders of bilirubin metabolism.
With presentation in adulthood, this cannot be Crigler-Najjar Type I because all victims of this disease die in infancy from kernicterus. Crigler Najjar Type II usually has bilirubin levels from 6 – 45 and is always jaundiced. In Gilbert’s Syndrome, the bilirubin (unconjugated) is usually < 3; it rises with fasting and falls with phenobarbital. Both Dubin-Johnson and Rotor’s syndrome have about 60% conjugated bilirubin.
Ref: Chalasani N. et al. Kernicterus in an Adult who is Heterozygous for Crigler-Najjar Syndrome and Homozygous for Gilbert-Type Genetic Defect. Gastroenterology. 112:2099-103, 1997.
Educational Objective: Review solitary rectal ulcer syndrome.
Solitary rectal ulcer is most often seen in young women with chronic straining at stool. The biopsy showing a lack of inflammation is consistent with the diagnosis. The therapy is to decrease straining and thereby decrease trauma.
A 23-year-old female graduate student is the latest victim of an epidemic of hepatitis A at her school. She has been jaundiced for 3 days with an ALT liver of about 400 – 500. Her roommate is concerned because the patient is sleeping excessively and cannot concentrate.
You diagnose the most common cause of these symptoms in acute viral hepatitis and obtain which of the following to confirm your diagnosis:
Educational Objective: Review the role of the liver in carbohydrate metabolism.
Hypoglycemia is seen in >50% of patients with acute viral hepatitis without liver failure simply due to failure of glycolytic and gluconeogenic responses.
Educational Objective: Review cases of proctitis.
Gonorrhea is the most common sexually transmitted bacterial infection and therefore is the correct answer in this list of reasons for proctitis.
A 58-year-old man with known well-compensated cirrhosis is brought to your office by his wife. She complains that he has developed new confusion over the last week. You find asterixis and a WBC of 15,000 with no fever. His serum alpha-fetoprotein level is normal. His serum ascites albumin gradient is > 1.1 with 350 polymorphonuclear leukocytes/mm3. Your primary therapy for this condition should be:
Educational Objective: Illustrate subtle presentation of spontaneous bacterial peritonitis.
Any change in a patient with ascites may signal the onset of S.B.P. This patient with new onset encephalopathy, elevated WBC in serum, and ascites has S.B.P. Only 50 – 70% will have positive ascitic cultures and therefore antibiotics should be started when the ascitic WBC is above 250. Peritoneal TB has ascites with a lymphocytic predominance and 80% have a WBC count >500. Therapy of the encephalopathy is not necessary as it usually resolves with treatment of the infection.
Educational Objective: Review a common problem in differential diagnosis of ascites.
Both cirrhosis and heart failure produce ascites as a result of portal hypertension, and the serum-ascites albumin gradient will be >1.1 in both. The ascitic protein level in cirrhosis is typically <2.5 g/dl but in heart failure is >2.5 g/dl.
A 50-year-old post menopausal woman presents to your office with malaise, chest pain, and increasing abdominal girth. She denies alcohol abuse, IV drug use, or transfusion. Her abdominal exam reveals a shifting dullness and a fluid wave. Her chest exam is dull to percussion and has decreased breath sounds over the right lung field. Thoracentesis yields an exudate with a few mononuclear cells.
The most effective therapy in this situation is:
Educational Objective: Illustrate an endocrine cause for ascites. This woman with Meigs’ syndrome (pleural effusion, ascites, and benign ovarian tumor) is best treated with oophorectomy and the ascites and pleural effusion will resolve spontaneously.
Educational Objective: Illustrate differences in varices formed by splenic vein occlusion vs. portal vein hypertension.
This patient has splenic vein occlusion due to her episodes of pancreatitis. The short gastric veins have become dilated, producing gastric and not esophageal varices. Reducing pressure in the portal system by surgery, TIPS, or pharmacology will not help this situation. Sclerotherapy and banding are a poor second-best therapy to splenectomy.
A 65-year-old man has a long history of alcoholism but is now abstinent. He describes frequent episodes of dull, boring epigastric discomfort radiating to his back. His amylase and lipase levels are normal as is his upper endoscopy. A plain film of his abdomen shows midline calcifications. An MRCP shows a normal pancreatic duct and no evidence of biliary stones.
For therapy of this man’s pain you should order:
Educational Objective: Illustrate therapeutic options for chronic pancreatitis.
This patient with chronic pancreatitis and normal ductal diameter would not be helped by procedures designed to alleviate ductal pressure such as stents (temporary) or longitudinal pancreaticojejunostomy. Pancreatic enzymes can inhibit cholecystokinin release but only if a rapid release formula is used and its degradation is decreased by acid suppression.
Your patient has been hospitalized for two weeks with severe pancreatitis. He has fever, abdominal pain, and a persistently elevated WBC. A dynamic CT scan has revealed an area of pancreatic necrosis and a fine needle aspiration of the area has been done.
If the gram stain is negative you would:
Educational Objective: Review the management of pancreatic necrosis.
If the necrotic area is sterile it still has a 40% chance of becoming infected in the future. Treatment with antibiotics lowers this risk. Pancreatic necrosis resolves without complications in 60% of patients.
If the necrotic area is infected, it carries a 60 to 100% mortality treated medically; therefore, surgical debridement is the therapy of choice and can lower mortality to about 20%.
A 62-year-old man with his first episode of pancreatitis has been in the hospital under your care for the last two weeks. His pain has been difficult to control. He has a low-grade fever and his WBC’s have not decreased below 16,000.
You decide to:
Educational Objective: Review the evaluation of pancreatic necrosis. Up to 80% of patients with severe pancreatitis will develop pancreatic necrosis. The usual time of onset is during the second or third week. Symptoms and signs are pain, fever, and elevated WBC. The diagnosis is made by using a bolus infusion of contrast material during CT scan to demonstrate necrotic areas of the gland.
Educational Objective: Review the evaluation of pancreatic necrosis.
Up to 80% of patients with severe pancreatitis will develop pancreatic necrosis. The usual time of onset is during the second or third week. Symptoms and signs are pain, fever, and elevated WBC. The diagnosis is made by using a bolus infusion of contrast material during CT scan to demonstrate necrotic areas of the gland.
A 57-year-old woman presents with new onset, sudden epigastric pain and low-grade fever. She takes no routine medications and has one to two glasses of wine per day. Her past surgical history includes cholecystectomy for stone disease one year ago. She has the following lab values:
WBC 18,000 HCT 42% AST 100 ALT 150 Total Bilirubin 2.5 Alkaline phosphatase 150 Amylase 350 Glucose 200 BUN 50 Calcium 7.6
You next intervention should be:
Educational Objective: Review positive biochemical score for obstructive pancreatitis.
This patient has a retained common bile duct stone following cholecystectomy that has been impacted at the ampulla of Vater and has caused severe pancreatitis. An ultrasound may show a dilated CBD but this is not unusual following cholecystectomy. She has an elevated alkaline phosphatase and total bilirubin. Her ALT/AST ratio is greater than 1.0 and the ALT is greater than 1.5 times normal. You are not given that her gamma glutamyl transferase is also >2 times normal.
She also has severe pancreatitis based on her poor prognostic factors with AGE>55, WBC>16,000, Glucose >200, BUN>45, Calcium <8. Therefore, she needs a therapeutic ERCP to remove the stone.
Educational Objective: Illustrate that not all elevations of amylase are pancreatic.
This patient has mesenteric ischemia in the “quiet time” before gross abdominal symptoms begin. Elevated amylase is also seen in pancreatic pseudocyst, hollow viscus perforation, and brain injury.
Educational Objective: Emphasize that 90% of pancreatitis seen during pregnancy is due to stone disease in the 3rd trimester.
Educational Objective: Review causes of pancreatic injury.
The perfusion of the pancreatic duct with activated pancreatic enzymes after acetylsalicylic acid or ethanol ingestion or in the presence of hypercalcemia or ductal obstruction causes acute pancreatic injury.
Pancreatic injury also occurs when zymogens are activated by lysosomal hydrolases within the pancreatic acinar cell itself instead of within the intestinal lumen.
Educational Objective: Illustrate the normal control of zymogen granule release.
Secretin stimulates the addition of water and electrolytes to the pancreatic juices. Enterokinase, found in the duodenal mucosa, cleaves trypsinogen to form trypsin. Trypsin and lipase are among the many proteolytic, amylolytic, and lipolytic enzymes secreted by the pancreas. Cholecystokinin triggers the release of these pancreatic enzymes. (Cholecystokinin release is triggered by long-chain fatty acids, gastric acid, and certain essential amino acids.) Gastrin is also a weak stimulus for zymogen release.
Educational Objective: Review therapy of diabetes in cystic fibrosis.
Endocrine pancreatic dysfunction is seen in about 7% of cystic fibrosis as the pancreas is destroyed by chronic pancreatitis. Because the primary defect is loss of the islets of Langerhans, therapies with agents that treat insulin resistance or stimulate more insulin production are doomed to failure.
A 65-year-old man presents to your office with mid-back pain incurred by lying on his side with his knees drawn up. He is a smoker and weighs 170 lbs after a 20 lb weight loss over the last 4 months. You find his fasting glucose elevated and his sclera icteric.
The single most reliable test to evaluate resectability of the patient’s lesion is:
Educational Objective: Review current staging techniques in pancreatic cancer.
Endoscopic ultrasound is more sensitive for detecting lymph node and vascular involvement of pancreatic cancer.
Educational Objective: Review differences in therapy of rectal versus colonic cancer.
Rectal cancer has a radio-sensitivity not seen in more proximal colon cancer. Pre-operative chemotherapy and radiation therapy can shrink the original lesion and make surgical resection more successful.
Educational Objective: Review improved survival of Dukes C lesions with chemotherapy.
Dukes C lesions with local lymph node involvement have an improved survival following chemotherapy with 5 FU and leucovorin. Colon cancer outside of the rectum is relatively radio resistant.
Educational Objective: Review multiple gene defect principle of metastatic colon cancer.
Colon cancer begins as adenomatous “dysplastic” epithelium and, through multiple genetic defects to this dysplastic tissue, advances through multiple stages from early to late adenoma, carcinoma and metastatic disease.
Educational Objective: Review the Peutz-Jeghers syndrome.
Peutz-Jeghers syndrome is an autosomal dominant syndrome with benign hamartomatous polyps from the esophagus to the rectum. It is associated with melanotic spots on the lips, hands, feet, face, perianal, genital, and buccal mucosa. These patients also may have nasal, bronchial, gallbladder, and urinary tract polyps.
Ref: Boaroman LA et al. Increased Risk for Cancer in Patients with Peutz-Jeghers Syndrome. Annals of Internal Medicine. 128:896-899, 1998.
Educational Objective: Review the increased risk of extra-intestinal cancers in HNPCC.
Hereditary non-polyposis colorectal cancer carries an increased risk for cancer of the pancreas, ovary, uterus, stomach, and ureter.
Educational Objective: Review the definition of HNPCC.
HNPCC is a highly penetrant autosomal dominant trait with defects in mismatch repair genes on chromosome 2, 3, or 7.
A 16-year-old male in good health presents to you for a school physical. His family history reveals that his father died of colon cancer at age 37. Your physical exam reveals a healthy young man with several lipomas on his back and legs and a nodule on his jaw.
You should:
Educational Objective: Review Gardner’s Syndrome.
Gardner’s Syndrome is similar to familial adenomatous polyposis except that it is associated with benign extra intestinal growths such as lipomas and ostromas. The colonic polyps start to grow in the second decade of life and uniformly deteriorate into colon cancer by the age of 40. This young man needs a yearly flexible sigmoidoscopy until he shows his first polyps; then he needs a total colectomy.
Educational Objective: Review management of a malignant polyp.
A malignant polyp carries a 5% risk of local lymph node involvement with any of these poor prognostic features: involvement of the margin; poorly differentiated histology; vascular or lymphatic invasion; penetration of the muscularis mucosa. The risk of a partial colectomy is about 2% mortality; therefore this patient should have surgery.
Ref: Rudy D R, Zoun M J. Update on Colorectal Cancer. American Family Physician. 61:1759-70, 1773-4, 2000 (Mar 15).
Educational Objective: Illustrate hepatotoxic effect of amiodarone.
Twenty to thirty percent of patients on amiodarone will have a transient elevation of their aminotransferase levels. If it is prolonged or about twice normal levels they should have the drug discontinued or undergo a liver biopsy looking for progressive non-alcoholic steatohepatitis which may progress to micronodular cirrhosis.
A 34-year-old female patient presents with lower abdominal pain that is very intense and started one hour ago after jogging. She is otherwise healthy and very physically active (she is training for a marathon). On examination she is obviously in intense pain and pale. She is afebrile. Abdomen is soft on palpation, but there is voluntary guarding. Bowel sounds are present. There are no palpable masses or organomegaly. Rectal examination reveals normal sphincter tone and no masses. Stool in the rectum is brown and negative for occult blood. She cannot pass any urine at this time. This is the first such episode.
All of the following are appropriate studies to order for this patient at this time except:
Educational objective: Review differential diagnosis of acute lower abdominal pain.
This patient presents with a clinical picture for which the most important differential diagnosis includes renal stone, bleeding into the kidney, ectopic pregnancy, acute intestinal obstruction, aortic aneurysm, appendicitis and pyelonephritis.
Renal stone is an obvious cause of acute lower abdominal pain and has been described in long distance runners in whom it is caused by dehydration during physical exertion.
Bleeding within the kidney may produce a clot, causing obstruction. Bleeding due to renal cell carcinoma or injury has also been implicated as a cause of renal colic. Glomerular bleeding does not lead to clot formation or renal colic.
Ectopic pregnancy is obviously a part of the differential diagnosis in sexually active females of childbearing age and should be excluded by the means of HCG testing and/or pelvic ultrasound. Patients with abdominal aortic aneurysms may occasionally present with acute abdominal pain and although it is a rare condition (especially in this age group) it should be considered because of its potentially fatal outcome.
Ectopic pregnancy is obviously a part of the differential diagnosis in sexually active females of childbearing age and should be excluded by the means of HCG testing and/or pelvic ultrasound. Patients with abdominal aortic aneurysms may occasionally present with acute abdominal pain and although it is a rare condition (especially in this age group) it should be considered because of its potentially fatal outcome. Acute intestinal obstruction should be evaluated by means of a flat abdominal plate. Acute intestinal obstruction should be evaluated by means of a flat abdominal plate. Appendicitis and pyelonephritis also should be considered even in the case of afebrile patients. Sigmoidoscopy has no place in the initial evaluation of acute abdominal pain.
Enterotoxigenic Escherichia coli usually gives a noninflammatory diarrhea (acute watery diarrhea without fever/dysentery). The following organisms give an invasive/ inflammatory infection: •Shigella species •Campylobacter species •Salmonella species •Enteroinvasive Ecoli •Enterohemorrhagic E coli •E coli O157:H7 •V parahaemolyticus •Yersinia enterocolitica •Entamoeba histolytica
The following organisms commonly present as non-inflammatory: •Enterotoxigenic Escherichia coli •Giardia species •Vibrio cholerae •Enteric viruses (astroviruses, noroviruses, other caliciviruses, enteric adenovirus, rotavirus) •Cryptosporidium species •Cyclospora cayetanensis
Campylobacter species does not usually cause systemic symptoms. The list that does is as follows: •Listeria monocytogenes •Brucella species •Trichinella spiralis •Toxoplasma gondii •Vibrio vulnificus •Hepatitis A and E viruses •Salmonella typhi and Salmonella paratyphi •Amebic liver abscess
