AAFP: Gastrointestinal

Question 1

A 52 yo female with morbid obesity is incidentally noted to have mildly elevated AST (SGOT) levels. She does not consume alcohol and denies using recreational drugs. A workup for chronic viral hepatitis and hemochromatosis is negative. Which one of the following is most likely to improve her hepatic condition?

a. Pentoxifylline
b. Simvastatin (Zocor)
c. L-carnitine
d. Vitamin E
e. Weight loss

Answer 1

e. Weight loss

Nonalcoholic fatty liver disease is characterized by the accumulation of fat in hepatocytes. It is associated with insulin resistance, central adiposity, increased BMI, HTN, and dyslipidemia. An incidentally discovered elevated AST level in the absence of alcohol or drug-induced liver disease strongly suggests the presence of nonalcoholic fatty liver disease. The goal of therapy is to prevent or reverse hepatic injury and fibrosis.

DM, HTN, dyslipidemia, and other comorbid conditions should be appropriately managed. A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance in patients with NFLD.

Weight loss has been shown to both normalize AST levels and improve hepatic histology. Vitamin E has been shown to improve AST levels but has no impact on liver histology.

Question 2

A 52 yo male presents or routine physical exam. His laboratory results reveal an AST (SGOT) level of 124 U/L (N 10-40) and an ALT (SGPT) level of 36 U/L (N 10-55). His GGT level is also elevated. THe most likely cause of this abnormality is:

a. Hepatitis C
b. Hemochromatosis
c. Nonalcoholic fatty liver disease
d. Alcoholic liver disease
e. Statin-induced liver disease

Answer 2

d. Alcoholic liver disease

An AST/ALT ratio >2 supports dx of alcoholic liver disease. Elevated GGT is also associated with alcohol abuse, especially in a patient with an AST/ALT ratio >2.

Question 3

A 34 yo female with newly dx diarrhea-predominant IBS presents with worsening abdominal discomfort. Her abdominal discomfort is not severe but it is constant. She has tried dicyclomine (Bentyl) without relief and is intrerested in trying a different approach. The patient has had negative testing for IBD and celiac disease, along with normal blood tests. She asks about specific dietary modifications or medications that may be helpful for her abdominal discomfort. Which one of the following interventions would you recommend?

a. Amitriptyline
b. Clarithromycin (Biaxin)
c. Loperamide (Imodium)
d. Increased intake of insoluble dietary fiber

Answer 3

a. Amitriptyline

TCAs such as amitriptyline have shown benefit in patients with IBS as SSRIs. Because of the anticholinergic properties of TCAs, it is thought that TCAs may be more beneficial than SSRIs in patients with diarrhea-predominant IBS.

Question 4

A 53 y/o M with HTN, hyperlipidemia, and nonalcoholic fatty liver disease began taking atorvastatin (Lipitor) 3 months ago. His LDL-cholesterol level is now at goal, but he has developed an asymptomatic elevation of his hepatic transaminases to twice-normal levels. Which one of the following is the most appropriate course of action?

a. Continue the atorvastatin at the current dosage
b. Reduce the dosage of atorvastatin by half
c. Discontinue atorvastatin and switch to another statin
d. Order hepatic U/S

Answer 4

a. Continue the atorvastatin at the current dosage

HMG-CoA reductase inhibitors, or statins, play an important role in the mgmt of patients with CV disease and have an excellent safety and tolerability record. The incidence of significant liver injury from statin drugs is about 15, and nonalcoholic fatty liver disease or stable hepatitis B or C infection is not a contraindication to treatment with statins.

Although many patients taking statins experience elevation of hepatic transaminases, these elevations are generally mild and asymptomatic, and often resolve spontaneously even with no changes in treatment.

Question 5

A 20 yo male presents with complaints of abdominal pain and diarrhea. He says he often has abdominal cramping that is relieved with defecation. The pain is accompanied by frequent loose, mucous stools, and his symptoms tend to get worse with stress. Your evaluation leads to a diagnosis of diarrhea-predominant IBS. Which one of the following would be the most appropriate tx?

a. Fiber supplements
b. Neomycin
c. Citalopram (Celexa)
d. Alosetron (Lotronex)

Answer 5

c. Citalopram (Celexa)

SSRIs and TCAs have shown benefit for IBS treatment.

Question 6

A 72 yo white female presents to your office with a 6 week history of “tanned skin.” She initially attributed it to having gone on a cruise 2 months ago, but noticed her skin continued to darken as time passed. She is slender and has lost 11 lb since her last checkup 6 mo ago. She denies fever, malaise, or abdominal pain. Her only medications are HCTZ and aspirin daily. On exam, your suspicion of jaundice is confirmed by the presence of scleral icterus. You also note a single enlarged L supraclavicular lymph node which is nontender. The abdomen is soft and nontender; on deep palpation of the RUQ you feel a smooth, nontender mass. Which one of the following is the most likely dx?

a. Biliary cirrhosis
b. Ascending cholangitis
c. Obstructing pancreatic pseudocyst
d. Carcinoma of the head of the pancreas
e. Hepatocellular carcinoma

Answer 6

d. Carcinoma of the head of the pancreas

The presence of a solitary enlarged L supraclavicular lymph node (Virchow’s node) is associated with a GI malignancy. When combined with painless jaundice and palpable nontender gallbladder (Courvoisier’s sign), pancreatic cancer is the most likely dx.

Pancreatic pseudocyst develops after repeated bouts of pancreatitis and is not directly associated with jaundice.

Biliary cirrhosis and HCC typically present with pain, fatigue, malaise, hepatomegaly, jaundice and eventually ascites.

The jaundice of biliary cirrhosis is generally accompanied by severe pruritis. In neither condition is a palpably enlarged gallbladder present.

Question 7

Mgmt of thrombosed external hemorrhoid presenting within 72 hours of onset of symptoms?

Mgmt of internal hemorrhoids?

Answer 7

External: Elliptical excision of the thrombosed hemorrhoid

Internal: Rubber band ligation of the hemorrhoid

Question 8

AFP

CA 19-9

CA-125

Answer 8

• AFP: hepatoma
• CA 19-9: pancreatic cancer
• CA-125: ovarian carcinoma

Question 9

Which antibodies are positive in 90% of patients with primary biliary cirrhosis.

Answer 9

Antimitochondrial antibodies

This test is the first step in ruling out the disease.

Question 10

A 68 yo female with DM, CAD, fibromyalgia, and dyspepsia presents for follow-up. She has been taking omeprazole (Prilosec) for 10 years. It was started during a hospitalization, and her symptoms have returned with previous trials of discontinuation. Which one of the following adverse events is this patient at risk for as a result of her omeprazole use?

a. Hypermagnesemia
b. UTI
c. Nephrolithiasis
d. Hip fractures

Answer 10

d. Hip fractures

Risks of long-term use of PPIs have emerged:

fractures of the hip, wrist, and spine

CAP

C diff and other enteric infections

Question 11

A 61 yo F tells you that her brother was recently diagnosed with hereditary hemochromatosis and his physician suggested that she get tested. She feels well and has no significant health problems. Which one of the following would be most appropriate for initial screening?

a. Serum transaminases
b. A CBC and a serum iron level
c. Testing for the HFE gene
d. Ferritin and transferrin saturation
e. Total iron binding capacity

Answer 11

d. Ferritin and transferrin saturation

The diagnosis of hereditary hemochromatosis requires a random measurement of serum ferritin and calculation of transferrin saturation. The transferrin saturation is calculated by dividing the serum iron level by the total iron binding capacity. If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is >=45% the HFE gene should be checked.

Question 12

A 44 yo female presents with a 2 week hx of postprandial RUQ abdominal pain. Since yesterday her pain has worsened in intensity and she has been vomiting. The patient does not use tobacco or drink alcohol, and takes no medications. Laboratory findings include a serum lipase level of 105 IU/L (N 14-51), a serum amylase level of 155 U/L (N 36-128), a serum total bilirubin level of 1.5 mg/dL (N 0.0-1.0) and an AP level of 200 IU/L (N 33-96). The recommended initial imaging in this situation is:

a. No routine imaging unless the clinical course becomes complicated
b. Transabdominal U/S
c. Contrast-enhanced CT
d. MRCP
e. MRI

Answer 12

b. Transabdominal U/S

The American College of Gastroenterology recommends transabdominal U/S for all patients with acute pancreatitis. Contrast-enhanced CT and MRI should be reserved for patients who have an unclear dx, are not clinically improving after 48-72 hours, or develop complications.

Question 13

A 50 yo female with a hx of refractory HTN presents with abdominal pain. Her laboratory results are significant for a positive H. pylori antibody. You decide to initiate tx for her infection with rabeprazole + amoxicillin, followed by clarithromycin + tinidazole. She is currently on multiple medications for her HTN. Which one of her antihypertensive agents would be most affected by the treatment regimen described?

a. Amlodipine
b. Clonidine transdermal
c. HCTZ
d. Metoprolol tartrate
e. Ramipril

Answer 13

a. Amlodipine

Amlodipine is metabolized by the cytochrome P450 3A4 enzyme. Clarithromycin is a strong 3A4 inhibitor that can slow the metabolism of CCBs metabolized by this enzyme, thus increasing their levels. This can lead to hypotension, edema, and AKI due to decreased renal perfusion.

Question 14

A 48 yo male presents with a 4 week hx of rectal pain associated with minimal rectal bleeding. On exam, there is a small tear of the anorectal mucosa. The most appropriate initial tx would be topical:

a. botulinum toxin
b. clobetasol
c. capsaicin
d. nitroglycerin

Answer 14

d. nitroglycerin

This patient has classic findings for acute rectal fissure. Although patients often require an internal sphincterotomy, nonsurgical measures that relax the sphincter have proven helpful. Drugs that dilate the internal sphincter, including diltiazem, nifedipine, and nitroglycerin ointment, have proven to be beneficial in healing acute fissures.

Question 15

Prophylactic cholecystectomy for asymptomatic gallstones is indicated for patients with which one of the following?

a. Sickle cell disease
b. Renal transplant
c. DM
d. Cirrhosis

Answer 15

a. Sickle cell disease

Asymptomatic gallstones are not usually an indicated for prophylactic cholecystectomy.

Patients with hemoglobinopathies are at significantly increased risk for developing pigmented stones. Gallstones have been reported in up to 70% of SCD patients, up to 85% of hereditary spherocytosis patients, and up to 24% of thalassemia patients.

Question 16

A 50 yo female with no medical problems presents with a 2-day hx of profuse bloody diarrhea, severe abdominal cramping, and fever. She has recently returned from a week-long trip to Thailand. Her stool culture is positive for Campylobacter. Which one of the following is the treatment of choice?

a. Amoxicillin
b. Azithromycin
c. Ciprofloxacin
d. Metronidazole
e. Rifaximin

Question 17

A 70 yo female with a past history of HTN and DM is hospitalized with pneumonia and treated with antibiotics. She subsequently develops two Clostridium difficile infections and is appropriately treated with abx each time. Ten weeks after her initial hospitalization, she has her third episode of C. difficile infection. Which one of the following would be the most appropriate treatment?

a. A 14-day course of linezolid
b. A 14-day course of oral vancomycin and metronidazole
c. A 14-day course of IV vancomycin
d. A 4-week course of clindamycin
e. A 15-week oral vancomycin taper

Answer 17

e. A 15-week oral vancomycin taper

• 1st relapse: 10-14 day course of oral metronidazole for moderate symptoms…. if severe, then oral vancomycin
• 2nd relapse: oral vancomycin taper over approximately 15 weeks

IV vancomycin is NOT effective for C. difficile infections.

Question 18

A 30 yo male presents to your office with a 3-week history of nausea, weight loss, diarrhea, and hematochezia. He states that he has had similar episodes twice in the past and was treated at the local urgent care clinic for infectious diarrhea. Your initial lab workup is negative for enteric pathogens.

On referral for colonoscopy and esophagogastroduodenoscopy, the patient is found to have multiple noncontiguous transmural ulcerations throughout both the small and large intestines. Which one of the following initial mgmt strategies is most likely to induce remission in this patient?

a. Lapartomy with colectomy
b. Flagyl
c. Prednisone
d. Infliximab (Remicade)

Answer 18

c. Prednisone

Crohn’s disease: Corticosteroids & 5-ASA are first line. ANti-TNF agents such as infliximab should be considered in patients with moderate to severe Crohn’s disease who do not respond to initial corticosteroid or immunosuppressive therapy.

Question 19

Which one of the following does the American College of Obstetricians and Gynecologists recommend as first-line treatment for nausea and vomiting in pregnancy?

a. Doxylamine (Unisom) and pyridoxine (vitamin B6)
b. Ondansetron (Zofran)
c. Prochlorperazine
d. Promethazine (Phenergan)
e. Metoclopramide (Reglan)

Answer 19

a. Doxylamine (Unisom) and pyridoxine (vitamin B6)

If n/v are not controlled with dietary modifications, the first-line treatment is vitamin B6 and doxylamine, 3-4 times per day. The other antiemetics can also be used in pregnancy, but vitamin B6 and doxylamine should be tried first because of the balance of safety and efficacy.

Question 20

A 62 yo male has a 1 mo history of intermittent vomiting, early satiety, and a weight loss of 4 kg (9 lb). Initially, he had diarrhea but it has resolved. He does not have abdominal pain or bloody stools. He says that OTC famotidine (Pepcid) has relieved the symptoms somewhat. Which one of the following would be most appropriate at this point?

a. Abdominal radiographs
b. Abdominal U/S
c. Esophagogastroduodenoscopy
d. Famotidine at a higher dosage

Answer 20

c. Esophagogastroduodenoscopy

This patietn has red flag findings of older age and weight loss with chronic vomiting and is at risk for GI malignancy. He should be referred for esophagogastroduodenoscopy (EGD).

Question 21

Which one of the following nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved?

a. Waiting until lipase has normalized before beginning oral intake
b. Early initiation of a clear liquid diet
c. Early initiation of a low-fat diet
d. Early initiation of tube feeding
e. Early initiation of TPN

Answer 21

c. Early initiation of a low-fat diet

Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality.

Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.

TPN should be avoided in patients with mild or severe acute pancreatitis. TPN is associated with infectious and other line-related complications.

Question 22

You are caring for a 60 yo female with Crohn’s disease that is well controlled by infliximab (Remicade). As your staff updates her immunization status, which one of the following should be kept in mind?

a. Hep A vaccine is contraindicated
b. Pneumococcal vaccine is contraindicated
c. Tetanus toxoid is contraindicated
d. Zoster vaccine is contraindicated
e. All routine immunizations are considered safe

Answer 22

d. Zoster vaccine is contraindicated

Zoster vaccine, a live attenuated virus vaccine, is contraindicated in this patient due to her immunocompromised state. The other vaccines listed are safe and particularly recommended for patients with IBD, given their increased susceptibility to infections.

Question 23

A 66 yo female sees you for the first time. She has a history of IDA and chronic diarrhea associated with a dx of celiac disease. This history increases her risk for which one of the following:

a. Diverticulitis
b. UC
c. Crohn’s
d. Colon cancer
e. Osteoporosis

Answer 23

e. Osteoporosis

Patients who are diagnosed with celiac disease are at increased risk of osteoporosis due to bone loss from decreased calcium and vitamin D absorption. These patients are at higher risk for fractures. Patients with celiac disease are not at increased risk for IBD, diverticulitis, or colon cancer.

Question 24

A 69 yo female presents with her first episode of C. diff colitis, which is characterized as severe. Which one of the following is the most appropriate initial therapy?

a. Oral metronidazole
b. IV metronidazole
c. Oral vancomycin
d. IV vancomycin

Answer 24

c. Oral vancomycin

Vancomycin, 125 mg orally 4 times daily for 10-14 days, is recommended for the first severe episode of C. diff colitis. If the first episode is mild to moderate, oral metronidazole, 500 mg 3 times daily for 10-14 days, would be preferred.

Question 25

A 62 yo female presents to your office with diarrhea and signs and symptoms of dehydration. She has a temperature of 101.5 F and WBC count of 17,000/mm^3 (N 5300-10,800). C. diff toxin assay is positive. Because of the severity of her infection, you initiate oral vancomycin, 125 mg 4 times daily. She has a poor clinical response and you decide to alter the abx regimen to include IV coverage. Which one of the following IV abx would be most appropriate?

a. Ciprofloxacin
b. Imipenem/cilastatin (Primaxin)
c. Meropenem
d. Metronidazole
e. Vancomycin

Answer 25

d. Metronidazole

Only metronidazole is effective IV because its biliary excretion and possibly exudation through the colonic mucosa allows it to reach the colon via the bloodstream.

Treatment for this condition with vancomycin and fidaxomicin is oral.

Question 26

A 35 yo female with a history of chronic abdominal pain and diarrhea develops tender red nodules on her shins. These findings are most consistent with which one of the following:

a. Celiac disease
b. Crohn’s disease
c. Diverticular disease
d. IBS

Answer 26

b. Crohn’s disease

Crohn’s disease is associated with many extra-GI conditions: erythema nodosum, anemia, inflammatory arthropathies, uveitis, and venous thromboembolism

Question 27

A 52 yo healthy male presents with a 2.5 week history of diarrhea, consisting of 4-6 watery stools daily. He is afebrile and his examination is normal. You recommend symptomatic care. Two days later, the laboratory notifies you that Salmonella is growing in his stool culture. You call the patient and he remains free of fever but with ongoing diarrhea. Which one of the following would you recommend?

a. Azithromycin
b. Ciprofloxacin
c. Clindamycin
d. No treatment at this time

Answer 27

d. No treatment at this time

The recommended mgmt for patients who have non-severe Salmonella infection and are otherwise healthy is no treatment. Patients with high-risk conditions that predispose to bacteremia, and those with severe diarrhea, fever, and systemic toxicity or positive blood cultures should be treated with levofloxacin, 500 mg once daily for 7-10 days (or another fluoroquinolone in an equivalent dosage), or with a slow IV infusion of ceftriaxone, 1-2 g once daily for 7-10 days (14 days in patients with immunosuppression).

Question 28

A 30 yo female presents to your office as a new patient and requests a refill of sulfasalazine tablets for maintaining remission of her ulcerative colitis. The initial presentation of her disease was in her teenage years and involved inflammation of the entire colon. She was then started on sulfasalazine, which has worked well for controlling her symptoms. She had one flare when she ran out of medicine 7 years ago. She has not seen a gastroenterologist for many years. What is the appropriate mgmt plan for this patient?

Answer 28

Continue sulfasalazine and arrange for colonoscopy to screen for colon cancer.

UC is a lifelong condition that results in a waxing and waning AI inflammation of the colon. Clinical symptoms are inadequate for assessing the need for ongoing therapy. For this reason, once a pt with UC has achieved remission with a specific medication, that medication should be continued indefinitely unless the disease resurfaces. Sulfasalazine is one of the most effective agents for this purpose, is usually well tolerated, and is considered first-line therapy for UC.

Patients with UC who have had a hx of moderate or extensive involvement of the colon, however, are at markedly increased risk for the development of CRC. Current guidelines recommend beginning screening colonoscopy 10 years after the initial dx and continuing every 2-5 years, with the interval based on the findings.

Question 29

A 66 yo female sees you for the first time. She has a hx of IDA and chronic diarrhea associated with a dx of celiac disease. This hx increases her risk for which one of the following?

a. Diverticulitis
b. UC
c. Crohn’s Disease
d. Colon cancer
e. Osteoporosis

Answer 29

e. Osteoporosis

Due to bone loss from decreased calcium and vitamin D absorption –> pts are at higher risk for fractures

Question 30

76 F presents with a 3 mo hx of watery diarrhea with up to 12 episodes per day. She has no hematochezia and no travel hx. You suspect microscopic colitis. Which one of the following is the test of choice to confirm the dx?

a. Barium enema
b. Stool test for calprotectin
c. Celiac panel
d. Biopsy of the colon
e. Jejunal biopsy

Answer 30

d. Biopsy of the colon

Microscopic colitis is characterized by intermittent secretory diarrhea in older patients, although all ages can be affected. The cause is unknown, but there is some evidence that more than 6 mo of NSAID use increases the risk.

Only a biopsy from the transverse colon can confirm the dx.

Question 31

A 30 yo ICU nurse has been caring for several patients infected with C. diff. She is asymptomatic but is woried that she may also be infected. Which one of the following is the most appropriate recommentation for this nurse?

a. No testing and no treatment
b. Testing for C. diff toxin
c. Testing for C. diff antigen
d. Empiric tx with metronidazole
e. Probiotics

Answer 31

a. No testing and no treatment

Lab testing for C. diff should be done only on symptomatic patients. A dx of C. diff infection requires the presence of diarrhea or radiographic evidence of ileus and toxic megacolon.

In addition, the dx requires a positive stool test for toxigenic C. diff or its toxins, or colonscopic or histopathologic findings showing pseudomembranous colitis.

Question 32

Pt is found to have Barrett’s esophagus on endocscopy. Biopsies do not show any evidence of dysplasia. What is the recommended surveillance of this condition?

Answer 32

Endoscopy every 3 years

Question 33

A 44 yo obese female complains of intermittent RUQ pain that is worse after fatty meals. Which one of the following is the preferred initial imaging modality for evaluating her complaint and confirming the dx?

a. A plain radiograph
b. U/S
c. Cholescintigraphy
d. Contrast-enhanced CT
e. Contrast-enhanced MRI

Answer 33

b. U/S

Preferred initial imaging modality for suspected acute cholecystitis or cholelithiasis