Gastrointestinal Disorders Past Paper PDF

Module 21 IM GIT EVALS 1 COVERAGE Disorders of the Esophagus...

Module 21 IM GIT EVALS 1 COVERAGE Disorders of the Esophagus Dr. Santi Disorders of the Stomach and Duodenum Dr. Sebollena Diseases of the Small Intestine Dr. Lawenko Diseases of the Colon and Rectum Dr. Gamutan QUESTIONS ANSWERS 1. A 35/F, overweight, complains of intermittent heartburn and Answer: D. GERD regurgitation in the past 3 months. She denies other symptoms. Physical examination was unremarkable. What is the diagnosis? Common symptoms of GERD include heartburn and regurgitation a. Achalasia A is incorrect because achalasia presents with dysphagia (MOST b. Candida esophagitis COMMON), regurgitation, chest pain, vomiting, and weight loss c. Schiatzki ring d. GERD B is incorrect because candida esophangitis is diagnosed with Show white plaques/exudates that when we try flush it out would reveal friability of mucosa underneath on endoscopy and candida hyphae on biopsy C is incorrect because Schiatzki rings or b-rings are usually asymptomatic but can cause steakhouse syndrome wherein a patient would develop intermittent choking, especially after a heavy meal. It is usually located in the distal esophagus Reference: Moodle feedback and Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 2. Based on the recent iteration of the American College of Answer: A. A Gastroenterology guidelines on GERD, which of the following Los Angeles Classification of erosive esophagitis in not sufficient to Grade A is not sufficient due to interobserver variability and sometimes confirm the diagnosis of GERD? can be seen in normal patients during upper GI endoscopy for symptoms other than GERD a. A b. B The rest of the choices are wrong because in the American College of c. C Gastroenterology Guidelines, only Grades B, C, D are diagnostic of GERD d. D Reference: Moodle feedback and Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus: 3. A 35/M obese, consulted the out-patient clinic due to 3 months Answer: C. Proton pump inhibitors intermittent heartburn, regurgitation and water brash. He denies other symptoms. PE was unremarkable. Which of the following This is a young patient ( liquids. PE was unremarkable. Which of the following should be the next best step in This is a patient with alarm symptoms (age >50, weight loss and terms of management? dysphagia). GERD is unlikely hence EGD is the next step. a. Schedule for EGD B is incorrect since CT scan is NOT the first step because it is used to b. CT Scan of the chest assess involvement of distant structures for metastasis. c. pH studies d. Give 8-week trial of PPI C is incorrect since pH studies are done in patients with symptoms of GERD and AFTER an endoscopy is negative for signs of GERD. D is incorrect since trial of PPI is not indicated because of ALARM signs. Reference: Moodle feedback and Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 5. A 46/M with HIV on antiretroviral treatment consulted due to painful Answer: D. Candida Esophagitis swallowing. Which of the following condition is most likely? Odynophagia is a common presentation of infectious esophagitis. The a. GERD patient has HIV making him immunocompromised and at high risk of b. Zenker’s diverticulum developing Candida esophagitis. c. Achalasia d. Candida esophagitis A is incorrect because the common presentation of GERD is heartburn and regurgitation B is wrong because Zenker’s diverticulum are commonly asymptomatic but the common symptoms are halitosis, gurgling in the throat, mass in the neck, regurgitation, and dysphagia C is wrong because Achalasia present with dysphagia, regurgitation, chest pain, vomiting, and weight loss Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 6. Which of the following inflammatory disorders of the esophagus is Answer: C. Eosinophilic esophagitis associated with an immune mediated pathophysiology and is related to allergy? Eosinophilic esophagitis is a chronic immune mediated disorder of the esophagus. Its pathophysiology involves an allergen that triggers the a. Candida esophagitis helper T-cell to release cytokines and other ILs that recruit eosinophils in b. CMV esophagitis the area. For children, it is associated with asthma, rhinitis, and eczema in c. Eosinophilic esophagitis 53% of the patients and for adults, it is associated with atopy and IgE for d. GERD food allergen A is incorrect because Candida esophagitis is an infectious esophagitis and is common for immunocompromised patients. B is incorrect because CMV esophagitis is an infectious esophagitis which is common for immunocompromised patients. D is incorrect because GERD is associated with the weakness of the sphincter of the Esophagogastric junction causing the reflux of gastric contents into the esophagus. Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 7. Which of the following modalities is most sensitive in the Answer: B. HREM diagnosis of esophageal motility disorders? HREM is the most sensitive test in the diagnosis of achalasia, which is a. Barium swallow also the gold standard in the diagnosis of esophageal motility disorder. b. HREM c. CT Scan A is incorrect because Barium swallow is crucial in the evaluation of d. UGIE dysphagia to visualize the mucosa, luminal distensibility, motility, and any anatomic abnormalities Page 2 of 17 IM GIT EVALS 1 C is incorrect for CT Scan has a little role for the diagnosis of achalasia, as it is only useful for assessing common complications D is incorrect for UGIE is only a complimentary test to manometry in the diagnosis and management of esophageal motility disorders such as achalasia Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 8. An 80/M complains of intermittent dysphagia for 3 years associated Answer: B. Zenker’s diverticulum with halitosis and regurgitation. He has no weight loss, vomiting nor chest pain. PE was unremarkable. Esophagogram revealed an Zenker’s diverticulum is a sac-like outpouching of the mucosa and outpouching at the posterior aspect of the pharyngoesophageal submucosa through the Killian’s triangle found at the posterior aspect of junction. What is the diagnosis? the upper esophageal sphincter. It is considered a false diverticulum since the muscular layer is not included in the diverticulum. Though a. GERD usually asymptomatic, common symptoms in males in the middle age or b. Zenker’s diverticulum older adults include halitosis, gurgling in the throat, neck mass, c. Achalasia regurgitation, and dysphagia. d. Epiphrenic diverticulum A is incorrect because GERD causes typical symptoms such as regurgitation and heartburn C is incorrect because Achalasia is characterized by insufficient LES relaxation and loss of esophageal peristalsis. Barium swallow would reveal characteristic bird’s beak appearance or rat tail sign. Gold standard in diagnosis is HREM. D is incorrect for Epiphrenic diverticulum is a type of false diverticulum located 4-8 cm above the gastric cardia. Reference: Dr. Esperanza Grace Santi’s Lecture on Disorders of the Esophagus 9. A 26/M with HIV came in due to odynophagia. EGD showed large Answer: A. Ganciclovir serpiginous ulcers in the mid esophagus. Biopsy showed cytoplasmic inclusion bodies (owl-eye appearance). What is the EGD showed large serpiginous ulcers in the mid esophagus and biopsy treatment of choice? showed cytoplasmic inclusion bodies known as owl-eye appearance are both findings in cytomegalovirus (CMV) esophagitis which occurs in a. Ganciclovir immunocompromised patients such as in this case of HIV patient. b. Fluconazole Treatment of choice is ganciclovir for 3-6 weeks or valganciclovir which c. Fluticasone is given until ulcer healing is seen. d. Pantoprazole B is incorrect since Fluconazole is given to patients with candida esophagitis which EGD shows white plaques or exudates and biopsy of candida hyphae. C is incorrect since Fluticasone is given to patients with eosinophilic esophagitis where EGD reveals linear furrows or crepe paper-like, and whitish plaques. Biopsy finding is >15/hpf intraepithelial eosinophils. D is incorrect since Pantoprazole is a proton-pump inhibitor which is given to patients with gastroesophageal reflux disease (GERD). The endoscopic hallmark is erosive esophagitis. Reference: Dr. Santi’s lecture on Disorders of the Esophagus 10. A 23/M arrived at the ER due to one episode of hematemesis. He Answer: D. Mallory-Weiss syndrome came from a party where he had several drinks. His friends noticed that he was retching earlier in the evening before he vomited blood. The patient is a young male with a history of binge drinking and retching He is a non-smoker but a moderate alcoholic beverage drinker. On that preceded hematemesis. This is the most common presenting symptom of Mallory-Weiss syndrome, where the forceful retching has Page 3 of 17 IM GIT EVALS 1 PE, vital signs were normal, palpebral conjunctivae were pink and the caused longitudinal mucosal lacerations in the distal esophagus. abdominal findings were unremarkable. What is the diagnosis? A is incorrect since patients in its early stage are asymptomatic while in a. Squamous cell carcinoma advanced stage, symptoms such as dysphagia to solids, weight loss, b. Pill-esophagitis anemia and hoarseness manifest, indicating that the tumor has spread c. Corrosive esophagitis to adjacent and distant organs. d. Mallory-Weiss syndrome B is incorrect since patients usually present with odynophagia and chest pain due to pill ingestion that fails to traverse the esophagus and gets stuck within the esophageal lumen. C is incorrect since this results from ingestion of caustic agents like alkali or acid either by accident or attempted suicide. Patient immediately vomits upon acid ingestion. Reference: Dr. Santi’s lecture on Disorders of the Esophagus; Moodle feedback 11. The most common location where pill-induced esophagitis or Answer : A. Mid esophagus ulcers can be seen is: Mid Esophagus is the answer because this is where the indentation of the a. Mid esophagus arch of the aorta which is a normal anatomic narrowing. b. Proximal esophagus c. Pharynx B and D are incorrect because these are where the upper esophageal d. Distal esophagus sphincters and Lower esophageal sphincters respectively which in a normal person does not cause obstruction unless there is an underlying problem which will affect the tone of the sphincters. C is incorrect because the pharynx doesn’t cause obstruction unless inflamed. Reference: Dr. Santi’s lecture on Disorders of the Esophagus 12. Which among the following is the most common artery that Answer: B. Gastroduodenal artery bleeds in duodenal ulcer? Gastric and duodenal mucosa is where ulcers are commonly seen so the a. Right gastroepiploic artery artery that supplies the majority of these parts are the gastroduodenal b. Gastroduodenal artery artery, a branch of the common hepatic artery. c. Celiac artery d. Left gastric artery A is incorrect because the right gastroepiploic artery is just a branch of the gastroduodenal artery and only supplies the stomach. C is incorrect because the celiac artery is a short branch from the abdominal aorta that branches off to the common hepatic artery and the left gastric artery. D is incorrect because the left gastric artery only supplies the inner curvature of the stomach. Reference: Dr. Sebollena’s lecture on Disorders of the stomach and duodenum and Harrison's Principles Of internal Medicine 20th edition 13. Which among the following pathophysiologic mechanisms Answer: D. Basal and Stimulated acid secretion is decreased or differentiate gastric ulcer to duodenal ulcer? normal in gastric ulcer. a. H.pylori infection rarely affects the gastric mucosa. Gastric acid output (basal and stimulated) tends to be decreased or b. Basal and Nocturnal acid secretion is increased in duodenal normal in gastric ulcer (GU) patients. When GUs develop in the ulcer. presence of minimal acid levels, impairment of mucosal defense factors c. NSAIDs affect the gastric mucosa more than the duodenum. may be present. GUs have been classified based on their location: d. Basal and Stimulated acid secretion is decreased or normal in Type I occurs in the gastric body and tends to be associated with low gastric ulcer. gastric acid production. Type II occurs in the antrum and gastric acid can vary from low to normal. Page 4 of 17 IM GIT EVALS 1 Type III occurs within 3 cm of the pylorus and are commonly accompanied by duodenal ulcer (DU) and normal or high gastric acid production. Type IV are found in the cardia and are associated with low gastric acid production. A is incorrect because H.pylori infection often affects the gastric mucosa. B is incorrect because basal and nocturnal gastric acid secretion appears to be increased in DU patients as compared to controls; however, the level of overlap between DU patients and control subjects is substantial. The reason for this altered secretory process is unclear, but H. pylori infection may contribute. C is incorrect because NSAIDs equally affect the gastric mucosa and the duodenum. As in DUs, the majority of GUs can be attributed to either H. pylori or NSAID-induced mucosal damage. Prepyloric GUs or those in the body associated with a DU or a duodenal scar are similar in pathogenesis to DUs. Reference: Harrison’s Principles of Internal Medicine 20th edition 14. What is the most common complication of peptic ulcer disease? Answer: A. Bleeding a. Bleeding GI bleeding is the most common complication observed in PUD. b. Acid reflux disease Bleeding is estimated to occur in 19.4–57 per 100,000 individuals in a c. Perforation general population or in ~15% of patients. Bleeding and complications of d. Obstruction ulcer disease occur more often in individuals > 60 years of age. B is incorrect because acid reflux disease or GERD is not a common complication of PUD. It presents with classic symptoms such as water brash and substernal heartburn. Persistent GERD can lead to complications, such as esophagitis or Barrett's esophagus which may mimic PUD. C is incorrect because perforation is the second most common complication of PUD. As in the case of bleeding, the incidence of perforation in the elderly appears to be increasing secondary to increased use of NSAIDs. Perforation of duodenal ulcers has become less common in light of the increased rates of H. pylori eradication with NSAID induced gastric ulcers leading to perforation occurring more commonly. D is incorrect because obstruction is the least common ulcer-related complication, occurring in 1–2% of patients. A patient may have relative obstruction secondary to ulcer-related inflammation and edema in the prepyloric region. This process often resolves with ulcer healing. A fixed, mechanical obstruction secondary to scar formation in the prepyloric areas is also possible which requires endoscopic (balloon dilation) or surgical intervention. Reference: Harrison’s Principles of Internal Medicine 20th edition 15. A 28 y/o, female was brought to the ER due to loss of Answer: Bleeding peptic ulcer disease consciousness. BP = 80/60 ; HR = 110 ; RR = 20 ; T = 36. Pale palpebral conjunctiva, soft/non-tender abdomen. She soiled herself Bleeding is the most common complication of peptic ulcer disease. In the while unconscious enroute to the ER. setting of upper gastrointestinal bleeding from peptic ulcer, this manifests as melena or black tarry stools as shown in the image. Since there is internal bleeding, the patient becomes pale from the loss of intravascular volume and presents with hypotension. Compensatory mechanisms of the heart then cause tachycardia. A is incorrect since ascariasis is an intestinal infection from the helminth Page 5 of 17 IM GIT EVALS 1 Ascaris lumbricoides which can either be asymptomatic or symptomatic with abdominal pain, distention, and diarrhea, but NOT melena. B is wrong since dysentery is due to an inflammation of the intestines and would typically present with diarrhea, abdominal cramps, and blood in the stool. Since it often involves the colon, blood is red not black as in melena. C is wrong since typhoid ileitis is an inflammation of the ileum due to Salmonella enterica which typically presents with high grade fever. Reference: Harrison’s Principles of Internal Medicine 20th edition and Dr. Sebollena’s Lecture on Disorders of the Stomach and Duodenum a. Ascariasis b. Dysentery c. Typhoid Ileitis d. Bleeding peptic ulcer disease 16. Which among the following is the MOST appropriate test to Answer: C. Upper Gastrointestinal Endoscopy confirm your diagnosis? In most circumstances, the standard of care for the initial diagnostic a. Abdominal ultrasound evaluation or first line assessment of suspected acute GI bleeding is b. Upper Gastrointestinal Series urgent upper endoscopy and/or colonoscopy, as recommended by c. Upper Gastrointestinal Endoscopy guidelines from the American College of Gastroenterology and the 2010 d. Fecalysis with occult blood International Consensus Recommendations”. It is the most sensitive and specific approach for examining the upper GI tract. A is incorrect because abdominal ultrasound is not the most recommended diagnostic tool to assess melena. Aside from this, it has limited visibility to visualize structures. B is incorrect because upper gastrointestinal series is not typically the first line test for investigating the cause of melena. It cannot directly identify the source of bleeding in the upper GI tract, and it cannot capture active bleeding or provide detailed information about mucosal abnormalities. Upper GI Series are mostly used as a secondary/complementary test to help assess structural abnormalities which can contribute to bleeding. D is incorrect because FOBT is used to check for blood in the stool. Requesting FOBT is not needed because bleeding is obvious. Reference: Harrison’s Principles of Internal Medicine 20th edition 17. A 50 y/o male, sought consult due to… Answer: B. Tramadol plus methylprednisolone Tramadol is an opioid (analgesic) used to treat Osteoarthritis. Unlike other pain relievers such as non‐steroidal anti‐inflammatory drugs (NSAIDs), it does not cause bleeding in the stomach and intestines, or kidney problems. It also does not affect the cartilage at the end of the bones.” A is incorrect because COX-2 Inhibitors like Celecoxib an NSAID, is an approved treatment for osteoarthritis, however it can cause digestive problems such as ulcers. C is incorrect because NSAIDs, like Meloxicam can also be used, however it can cause stomach and intestinal problems such as bleeding and ulcers. PMHx = s/p EGD (Duodenal Ulcer) D is incorrect because Acetaminophen in high doses may induce upper Page 6 of 17 IM GIT EVALS 1 What is the MOST appropriate medication for his condition? GI symptoms such as abdominal pain, heartburn, or nausea especially if taken for a long time. a. COX-2 inhibitor b. Tramadol plus methylprednisolone c. NSAIDS plus proton pump inhibitor Reference: Harrison’s Principles of Internal Medicine 20th edition d. Acetaminophen 18. A 75 y/o, female came in due to vomiting. 3 months PTC, she Answer: D. Gastric Neoplasm started to experience early satiety and subsequent weight loss. Then 2 weeks PTC, she started to experience vomiting. Consult done and The patient has a history of ulcer bleeding wherein gastric outlet Esomeprazole and oral nutritional supplementation was prescribed obstruction is one of the common complications. This process often which offered no improvement. On PE, pale conjunctiva, 3x3cm resolves with ulcer healing. A fixed, mechanical obstruction secondary to nodular mass noted at the left supraclavicular area. Abdominal PE = scar formation in the peripyloric areas is also possible, symptoms develop scaphoid abdomen, non-tender with note of a palpable mass, slowly and include early satiety, bloating, nausea, vomiting, epigastric characterized as firm and nodular noted at epigastric area. PMHx = pain shortly after eating, and weight loss. Presence of non-tender admitted 40 yrs ago due to ulcer bleeding. Blood transfusion was palpable mass, characterize as firm and nodular at the epigastric area done. What is the CORRECT clinical impression? during abdominal PE is suggestive of gastric neoplasm a. Pancreatic Neoplasm A is incorrect because pancreatic neoplasm presents with abdominal b. Abdominal wall hernia pain and weight loss with or without jaundice. The pain is midepigastric c. Hepatoma (sometimes described as a “boring-like” pain) and often the pain is in the d. Gastric Neoplasm back. B is incorrect because abdominal wall hernia is protrusion of abdominal wall contents through the abdominal wall. C is incorrect because hepatoma is the most common malignancy in the liver that commonly presents with weight loss, abdominal discomfort, signs related to advanced liver dysfunction such as jaundice. Reference: Harrison’s Principles of Internal Medicine 20th edition 19. Which among the following abdominal PE maneuvers will you Answer: A. Succussion splash perform to confirm your impression? Presence of a succussion splash indicates retained fluid in the stomach, a. Succussion splash suggesting gastric outlet obstruction. b. Murphy’s sign c. Fluid wave B is incorrect because this is elicited in cholecystitis. d. Ballottement C is incorrect because this is done to check for ascites. D is incorrect because this is done to check for free fluid in the abdomen. Reference: Harrison’s Principles of Internal Medicine 20th edition and Dr. Dina Gonzales lecture on History taking and PE skills & special maneuvers. 20. Which among the following medications is BEST for peptic ulcer Answer: D. Esomeprazole disease? Esomeprazole is a proton pump inhibitor (PPI), which is the drug of a. AlOH+MgOH choice for peptic ulcer disease. It inhibits all phases of acid secretion and b. Ranitidine has a rapid onset of action, usually 2-6 hours maximum inhibition. It lasts c. CaCO3 for 72-96 hours and is taken before meals for maximized efficacy. d. Esomeprazole Treatment duration for duodenal ulcer is 4-6 weeks while it is 6-8 weeks for gastric ulcer. A and C are incorrect because antacids are rarely used as primary therapeutic agents. Instead, they used by patients for symptomatic relief of dyspepsia. B is incorrect because Ranitidine, an H2 receptor antagonists, is not considered as the drug of choice for PUD. Page 7 of 17 IM GIT EVALS 1 Reference: Valle J (2022). Peptic ulcer disease and related disorders. Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D, & Jameson J(Eds.), Harrison's Principles of Internal Medicine, 21e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=3095&sectionid=265427594 21. A 70y/o, male with COPD in severe exacerbation was referred due Answer: B. CXR-PA to severe abdominal pain and board like rigidity of the abdomen. What is the BEST imaging modality to confirm your impression? Based on the presentation, the patient may have a perforation. a. EGD “An urgent erect chest X-ray and serum amylase/lipase is a basic b. CXR-PA essential test in a patient with acute upper abdominal pain. 75% of c. Abdominal CT-scan perforated peptic ulcer have free air under diaphragm on erect chest d. Diagnostic laparoscopy X-ray.” Furthermore, it is recommended to perform chest/abdominal X-ray as the initial routine diagnostic assessment. A is incorrect because use of EGD can increase the risk of perforation. C is incorrect because despite being known to have high accuracy, CT scan is not usually indicated for acute abdominal pain. D is incorrect because diagnostic laparoscopy is contraindicated for pulmonary failure (COPD). Reference: Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer - an update. World journal of gastrointestinal surgery, 9(1), 1–12. https://doi.org/10.4240/wjgs.v9.i1.1 Tarasconi, A., Coccolini, F., Biffl, W.L. et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 15, 3 (2020). https://doi.org/10.1186/s13017-019-0283-9 de Burlet, K. J., MacKay, M., Larsen, P., & Dennett, E. R. (2018). Appropriateness of CT scans for patients with non-traumatic acute abdominal pain. The British journal of radiology, 91(1088), 20180158. https://doi.org/10.1259/bjr.20180158 22. A 60y/o, male, s/p angioplasty 2 weeks ago came in due to Answer: B. Continue anti-platelet regimen and add PPI. melena. What is the BEST treatment option? Although angioplasty is a common and safe medical procedure, it still a. Increase dose of statins. predisposes the patient to bleeding, as seen in the presence of melena. b. Continue anti-platelet regimen and add PPI. Therefore, the best course of action would be to initiate c. Perform EGD and do injection sclerotherapy. pharmacotherapy that has cytoprotective benefits to promote the d. Discontinue anti-platelet medications. healing on the site of G.I. bleed (e.g. PPIs like omeprazole) and control the bleeding (e.g. anti-platelets). Despite the negative interaction between PPIs and anti-platelet drugs, the findings from those studies are usually mixed, inconclusive and only a small increase of mortality and readmission rate for coronary related events. Additionally, there are meta-analyses that showed inverse relationship between these drugs; hence, it is still recommended by the experts for these kinds of patients. Another recommendation is to take these drugs with a 12 hour difference as to decrease their competition for CYP450. A is incorrect because the mechanism of action of the statins is to inhibit the HMG-CoA reductase, which subsequently lowers the cholesterol levels. C is incorrect because EGD and injection sclerotherapy is indicated for acute esophageal variceal bleeding. D is incorrect because as mentioned earlier, the medical professionals still recommends to take anti-platelets and PPIs on patients who experienced bleeding after a coronary surgical procedure as long as they are taken with a 12 hour time window from each other. Reference: American Heart Association. (n.d.). Statin toxicity | circulation research - AHA/ASA Journals. Statin Toxicity. https://www.ahajournals.org/doi/full/10.1161/CIRCRESAHA.118.312782 Page 8 of 17 IM GIT EVALS 1 Dr. Bautista's lecture on Surgical Disorders of the Esophagus Valle J (2022). Peptic ulcer disease and related disorders. Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D, & Jameson J(Eds.), Harrison's Principles of Internal Medicine, 21e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=3095&sectionid=265427594 University of Michigan. (2016, July 20). Coronary angioplasty and stenting: Cardiac surgery: Michigan medicine. Cardiac Surgery. https://medicine.umich.edu/dept/cardiac-surgery/patient-information/adult-cardiac-surgery/adult-conditions- treatments/coronary-angioplasty-stenting 23. A 31/M developed watery diarrhea which became quickly bloody Answer: D. Cytotoxin associated with abdominal pain and fever. Which of the following is the most likely pathobiology or agent causing his diarrhea? The rest of the choices present with watery diarrhea a. Enteroadherence Agents Incubation Diarrhea b. Preformed toxin Period c. Enterotoxin d. Cytotoxin Enteroadherent Enteropathogenic and 1-8 d 1-2+, watery, mushy enteroadherent E.coli, Giardia organisms, cryptosporidiosis, helminths Preformed Toxin B.cereus, S.aureus 1-8 h 3-4+, watery C.perfringens 8-24 h Enterotoxin V.cholerae, enterotoxigenic 8-72 h 3-4+, watery E.coli, K.pneumoniae, Aeromonas spp. Reference: Camilleri M, & Murray J.A. (2022). Diarrhea and constipation. Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D, & Jameson J(Eds.), Harrison's Principles of Internal Medicine, 21e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=3095&sectionid=262790621 24. The most likely pathogen involved in a patient presenting with Answer: B. Norovirus watery diarrhea, abdominal pain, and fever 1 day after eating raw mussels is: The rest of the choices predominantly present with bloody diarrhea. a. Shigella Agents Incubation Diarrhea b. Norovirus Period c. Campylobacter d. Salmonella Rotavirus and Norovirus 1-3 d 1-3+, watery Salmonella, Campylobacter, 12 h-11 d 1-4+, watery or bloody and Aeromonas species, Vibrio parahaemolyticus, Yersinia Shigella species, 12 h-8 d 1-2+, bloody enteroinvasive E.coli, Entamoeba histolytica Reference: Harrison”s Principles of Internal Medicine (20th ed.) pg. 262 25. Which of the following may cause acute diarrhea in a patient Answer: D. Antacids treated for peptic ulcer disease? Side effects from medications are probably the most common a. H2 blockers noninfectious causes of acute diarrhea, and etiology may be suggested b. Bismuth subsalicylate by a temporal association between use and symptom onset. Although c. Alginates innumerable medications may produce diarrhea, some of the more d. Antacids frequently incriminated include antibiotics, cardiac antidysrhythmics, antihypertensives, nonsteroidal anti-inflammatory drugs (NSAIDs), certain antidepressants, chemotherapeutic agents, bronchodilators, antacids, Page 9 of 17 IM GIT EVALS 1 and laxatives. Reference: Harrison”s Principles of Internal Medicine (20th ed.) pg. 261 26. A 33/F presents with 1 day history of watery diarrhea and crampy Answer: A. Observation and oral rehydration salts abdominal pain. The patient denies fever, chills, or night sweats. On physical examination: Based on the case, the patient has mild dehydration from acute diarrhea (less than 2 weeks) with no alarm features. BP 112/72, HR 82bpm, Temp 37.9°C Conscious, coherent with dry mucous membranes Abdomen is flat, no guarding, no tenderness What is the most appropriate next management step? a. Observation and oral rehydration salts b. Admission for intravenous hydration c. Colonoscopy d. Oral ciprofloxacin for 5 days B is incorrect because Intravenous hydration or IV fluids are only indicated in patients with moderate to severe dehydration or those with vomiting. C is incorrect because Colonoscopy is not included in the algorithm for acute diarrhea. Instead, it is used in chronic diarrhea (more than 4 weeks), which is indicated when there is blood per rectum. D is incorrect because Ciprofloxacin is the drug of choice in Shigellosis and can also be used as an empiric treatment (Ciprofloxacin 750mg OD OR 500 mg BID for 3 days). Empiric Treatment Ciprofloxacin 750 mg OD OR Azithromycin 1 g x 1 dose OR 500 mg BID x 3 days 500 mg OD x 3 days Norfloxacin 800 mg 1 dose OR Rifaximin 200 mg TID x 3 days 400 mg BID x 3 days Page 10 of 17 IM GIT EVALS 1 Specific Treatment DOC Alternative Cholera Doxycycline Azithromycin, Ciprofloxacin Shigellosis Ciprofloxacin Ceftriaxone Amebiasis Metronidazole - Giardiasis Metronidazole Tinidazole Campylobacter Azithromycin Ciprofloxacin C. difficile Vancomycin Metronidazole Reference: Harrison”s Principles of Internal Medicine (20th ed.),.Figure 42-2, pg. 262. Dr. Lawenko’s lecture on Small Intestinal Diseases/Disorders 27. A 30/M, heavy alcoholic, complains of 6 weeks of painless, watery Answer: D. Secretory diarrhea that occurs anytime during the day or night. He has no comorbid illnesses, nor does he take any supplements. He denies Secretory Diarrhea is the result of abnormal fluid and electrolyte transport any food triggers. His CBC was normal and fecalysis was negative for across the mucosa secondary to bacterial toxins, inflammatory mediators, WBC nor RBC. The most likely mechanism for his diarrhea is: and hormones such as gastrin. It is characterized by diarrhea that is painless, watery, and large volume that persists with fasting. a. Inflammatory b. Dysmotility A is incorrect because Inflammatory diarrhea usually presents with c. Osmotic abdominal pain, fever, and bleeding. In addition, the stool exam will d. Secretory show positive leukocytes, leukocyte-derived protein and/or RBC - which is absent in the patient. B is incorrect because Dysmotility is the rapid transit as secondary or contributing phenomenon such as: Hypermotility due to: hyperthyroidism, carcinoid syndrome, drugs such as prokinetic, prostaglandin Bacterial overgrowth secondary to stasis due to: primary visceral neuromyopathies, idiopathic acquired intestinal pseudo obstruction Dysmotility due to: diabetes mellitus, irritable bowel syndrome None of which are present in the patient. Furthermore, primary dysmotility is unusual. C is incorrect because Osmotic diarrhea ceases with fasting. The patient reports to have diarrhea anytime during the day and night. Reference: Dr. Lawenko’s lecture on the Diseases of the Small Intestines 28. A 39/F with known allergic rhinitis, and skin atopy presents with 3 Answer: C. Eosinophilic gastroenteritis months history of bloody diarrhea. Subsequent stool analysis showed presence of Charcot-Leyden crystals suggestive of which of Eosinophilic gastroenteritis and colitis is due to eosinophil infiltration the following conditions? which causes varying degrees of inflammation. Charcot-Leyden crystals in the stool exam are usually extruded eosinophil contents. It can be a. Radiation enteritis associated with parasitic infections, atopic drug reactions, or atopic b. Ulcerative colitis diseases,such as asthma. c. Eosinophilic gastroenteritis d. Lymphocytic colitis A is incorrect because radiation enteritis is radiation that leads to vascular ectasia (development of prominent blood vessels). B is incorrect because ulcerative colitis occurs only in the inner lining or inner mucosa of the colon and its major symptoms include chronic diarrhea, rectal bleeding, tenesmus, and crampy abdominal pain. D is incorrect because lymphocytic and collagenous colitis happens when lymphocytes or collagen is abnormally increased in the mucosa, leading to bowel edema. Reference: Dr. Lawenko’s lecture on Small Intestinal Diseases/Disorders Page 11 of 17 IM GIT EVALS 1 29. A 51/M comes to your clinic complaining of 4 weeks of crampy Answer: D. Colonoscopy abdominal pain, watery occasionally bloody diarrhea and low-grade fever. He has lost 10 lb during that time. What is the most appropriate Chronic Diarrhea diagnostic test for this patient? - >4 weeks, duration warrants evaluation to exclude serious underlying pathology a. Quantitative fecal fat measurement - Non infectious and differentials, guided by mechanism involved: b. CT scan of the abdomen osmotic, secretory, inflammatory, dysmotility, miscellaneous c. Small bowel biopsy d. Colonoscopy Approach to Chronic Diarrhea - If blood per rectum → colonoscopy - If fatty diarrhea → small bowel: imaging, biopsy, aspirate - If pain aggravated before BM → suspect IBS - If no blood, or malabsorption → functional diarrhea or diet A, B and C are incorrect because those are tests for steatorrhea Steatorrhea - fat malabsorption, greasy, foul-smelling, difficult to flush diarrhea associated with weight loss and nutritional deficiencies - Diarrhea due to osmotic effect of fatty acid; defined as stool fat >7g/dL D is correct, as colonoscopy is warranted due to age, inflammatory-type diarrhea and weight loss Inflammatory - Usually abdominal pain, fever and bleeding - Due to exudation: Fat malabsorption, disrupted fluid and electrolyte derived protein and/or RBC - Some causes involves inflammatory bowel disease, radiation enteritis, GI malignancy, lymphocytic and collagenous colitis and eosinophilic gastroenteritis and colitis, primary or secondary forms of immunodeficiency, and hypogammaglobulinemia Reference: Doc Lawenko’s lecture on Small Intestinal Diseases and Disorder Trams 2025 30. 45/M consults for 8 months history of low-grade fever, weight loss Answer: B. Trimethoprim/Sulfamethoxazole and frequent, loose, difficult to flush stools. No comorbids were identified and the physical exam was normal. A subsequent Moodle Feedback: p.1347 – clinical symptoms show malabsorption endoscopy with duodenal biopsy showed villous atrophy and PAS + consistent w/ Whipple's disease confirmed by presence of foamy foamy macrophages. He was given Ceftriaxone IV for 2 weeks. Which macrophages. After induction with Ceftriaxone, maintenance is usually of the following should be prescribed to the patient for the given with either TMP-SMX, Doxycycline, Minocycline to prevent relapse. long-term? A, C, and D are not recommended. a. Rifaximin b. Trimethoprim/Sulfamethoxazole c. Dapsone d. Mebendazole Reference: Doc Lawenko’s lecture on Small Intestinal Diseases and Disorder Trams 2025 31. What is the most likely diagnosis in a patient with chronic watery, Answer: D. Small intestinal bacterial overgrowth clay-colored, foul-smelling diarrhea and a positive hydrogen breath test? The patient’s clinical picture as well as a positive breath test is indicative of SIBO. a. Tropical sprue b. Celiac disease A is incorrect because Tropical Sprue hallmark of diagnosis is abnormal c. Whipple’s disease small-intestinal mucosal biopsy and evidence of malabsorption in a patient d. Small intestinal bacterial overgrowth with chronic diarrhea who is either residing or has recently lived in a tropical country. Gluten-free diet/avoidance does not result in either clinical or histologic improvement B is incorrect because the symptoms of Celiac disease include diarrhea, Page 12 of 17 IM GIT EVALS 1 steatorrhea, weight loss, and consequences of nutrient deficiencies, such as anemia and metabolic bone disease and the hallmark of diagnosis is abnormal small intestinal biopsy and response of the condition, including symptoms and histology after removing gluten from the diet C is incorrect because Whipple disease most commonly occurs in middle-aged men.It is defined by presence of arthralgias, weight loss, diarrhea, and abdominal pain. CNS involvement and cardiac involvement are common and occur later in the disease.The hallmark of diagnosis is PAS+ macrophages with characteristic organism. Reference: Doc Lawenko’s lecture on Small Intestinal Diseases and Disorder Trams 2025 and Moodle Feedback:p.2462 32. A 46/F consults for unintentional weight loss. After a recent trip in Answer: D. Small intestinal mucosal biopsy the Caribbean, she noted pale, foul-smelling loose stools. Physical exam showed glossitis, cheilosis, and stomatitis. To confirm The patient has malabsorption/steatorrhea most likely tropical sprue; PE diagnosis, which of the following is recommended? findings are consistent with vitamin b9 and b12 deficiency; diagnosis is best based on small intestinal mucosal biopsy. a. Stool culture b. Anti-TTG B is incorrect because Anti-TTG is used for diagnosis of Celiac disease. c. Abdomen CT scan d. Small intestinal mucosal biopsy A and C are not recommended for Diagnosis of Tropical Sprue. Reference: Doc Lawenko’s lecture on Small Intestinal Diseases and Disorder Trams 2025 and Moodle Feedback:p.2465 33. A 49/F female has had multiple small bowel resections for Crohn’s Answer: B. Teduglitide disease 3 years ago. She is on lifetime parenteral nutrition due to inadequate oral nutrition. Which of the following is a specific Moodle feedback: medication recommended for her condition? Teduglutide is the only medication that is specific for short-bowel syndrome and advised for patients dependent on parenteral nutrition. a. Proton pump inhibitor b. Teduglitide A is incorrect because Proton Pump Inhibitor or H2B is to treat gastric c. Loperamide hypersecretion d. Rifaximin C is incorrect because Loperamide is given to reduce stool output or diarrhea D is incorrect because Rifaximin is an antimicrobial treatment for acute diarrhea Reference: Doc Lawenko’s lecture on Small Intestinal Diseases and Disorder Trams 2025 and Moodle Feedback:p.2466 34. A 39-year-old female consulted because of recurrent abdominal Answer: B. Rome IV pain once a week for the past 4 months associated with change in stool frequency and stool form/appearance. PE and all work ups were Moodle feedback: unremarkable. To diagnose the above case, what criteria should be Rome IV criteria for the diagnosis of IBS, with abdominal pain, normal PE used? and all work ups a. Baveno A is incorrect because Baveno is a criteria used in patients with liver b. Rome IV cirrhosis to predict high-risk varices in patients with liver cirrhosis c. Los Angeles d. Montreal C is incorrect because Los Angeles grade of reflux esophagitis (A to D) is assumed to reflect severity of the underlying GERD D is incorrect because Montreal Classification of inflammatory bowel disease is used primarily to classify the severity of ulcerative colitis and Crohn disease Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trans 2025 Page 13 of 17 IM GIT EVALS 1 35. Which of the following abnormal digital exam (DRE) findings is Answer: B. Perianal abscess most likely present in a 29-year-old female with Crohn’s disease? Moodle Feedback: a. Smooth rectal mucosa The rest of the choices are normal rectal exams. About one third of b. Perianal abscess Crohn's disease has perianal lesions/abscess. c. Rectal vault not collapse d. Presence of stool on the examining finger Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 36. What is the best diagnostic work-up for a 68-year-old male, Answer: Ct Scan of the abdomen hypertensive, with two days history of left lower quadrant pain associated with fever and obstipation? Moodle Feedback: This is a case of acute diverticulitis which is common among hypertensive a. Abdominal X Ray elderly patients. CT scan is the best diagnostic modality for acute b. Colonoscopy diverticulitis. c. Ct Scan of the abdomen d. Ultrasound of the abdomen Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 37. Multiple outpouchings of the sigmoid mucosa were discovered Answer: B. High fiber diet upon screening colonoscopy in a 60-year-old asymptomatic male. This is best managed by Moodle Feedback: One risk factor for colonic diverticulosis is constipation or lack of fibers in a. Antibiotics the diet. High fiber diet is therefore a management for diverticulosis b. High fiber diet c. Probiotics A is incorrect because Antibiotics are usually given to patients with d. Anti Inflammatory agents Uncomplicated Diverticulitis and Complicated Diverticulitis. C is incorrect because Probiotics are used for treating Symptomatic Uncomplicated Diverticular Disease (SUDD). D is incorrect because Anti inflammatory agents are used for patients with Inflammatory Bowel Disease (IBD). Reference: Dr. Andal-Gamutan & Dr. Sebollena’s Lecture on Disease of the Colon and Rectum 38. What is the best medication to give to a 40-year-old female known Answer: A. Loperamide case of irritable bowel syndrome with Bristol Stool chart types 6-7? Moodle Feedback: a. Loperamide Bristol stool chart type 6-7 is diarrhea, so the treatment is an antidiarrheal b. Hyoscine agent like loperamide. c. Senna d. Ranitidine B is incorrect because Hyoscine aka Scopolamine is an antiemetic C is incorrect because Senna is a stimulant laxative that aids constipation D is incorrect because Ranitidine is an H2 receptor blocker prototype indicated for Peptic ulcer disease Page 14 of 17 IM GIT EVALS 1 Reference: Dr. Andal-Gamutan & Dr. Sebollena’s Lecture on Disease of the Colon and Rectum 39. Mesalazine, an aminosalicylate agent, is best given to which of Answer: D. 30-year old male with chronic diarrhea secondary to the following cases? inflammatory bowel disease a. 30-year old female with abdominal pain because of irritable Moodle feedback: bowel syndrome Aminosalicylate agent like Mesalazine is a treatment for Inflammatory b. 30-year old female with left lower quadrant pain due to acute bowel disease diverticulitis c. 30-year old male with hematochezia secondary to sigmoid diverticular bleeding d. 30-year old male with chronic diarrhea secondary to inflammatory bowel disease Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 40. What is the Bristol stool chart type of a 39-year-old female with Answer: C. 6-7 Irritable bowel syndrome predominantly complaining of watery stool Moodle feedback: a. 8 Bristol stool chart types 6-7 is diarrhea b. 4 c. 6-7 d. 1-2 Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 41. What is the most likely diagnosis in a 30-year old male with Answer: C. Inflammatory bowel disease intermittent diarrhea for 2 months and further work ups revealed an elevated lactroferrin and calprotectin? In diagnosing active inflammatory bowel disease, there is rise in C-reactive protein (CPR), platelet count, erythrocyte sedimentation rate a. Irritable bowel syndrome (ESR). Biomarkers of active intestinal inflammation include elevated fecal b. Bleeding diverticulosis leukocytes, fecal lactoferrin, and fecal calprotectin. c. Inflammatory bowel disease d. Colonic polyposis A is incorrect because diagnosing irritable bowel syndrome (IBS) relies on clinical features such as recurrence of lower abdominal pain with altered bowel habits. There are no tests to definitely diagnose IBS. B is incorrect because diagnosing bleeding diverticulosis requires the use of the following: CT scan (can reveal sigmoid diverticula), colonoscopy (for patients who are bleeding that is manifested as hematochezia), and/or angiography (option for massive diverticular bleeding). C is incorrect because diagnosing colonic polyps requires the use of colonoscopy to examine the rectum and lower bowel to detect swollen, irritated tissues, or polyps. For average-risk individuals, stool-based tests such as Fecal Occult Blood Test (FOBT), and Fecal Immunochemical Test (FIT) are requested. Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 Page 15 of 17 IM GIT EVALS 1 42. Which of the following medications is best given in a 36-year-old Answer: A. Laxatives female with irritable bowel syndrome complaining constipation? Moodle Feedback: a. Laxatives Relieving the symptoms is one management for irritable bowel syndrome. b. Antiemetics Laxatives can be given for constipation. c. Probiotics d. Antispasmodic In patients with IBS, the management plan for patients is to give symptomatic treatment which is individualized and the medications given are depending on the complaint of the patient. TREATMENT FOR IBS Complaint Treatment Constipation High Fiber Diet Laxatives ○ Senna ○ Bisacodyl ○ Lactulose Stool bulking Prokinetics Chloride channel activators Abdominal pain and Antispasmodic bloating Anti Flatulence Serotonin receptor antagonists Modulation of gut flora ○ Rifaximin ○ Neomycin Diarrhea Loperamide Racecadotril Rifaximin (antibacterial) Mental Disorder Antidepressants Consultation to Psychiatrist B, C, and D do not help with constipation. Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 43. A 65-year-old male with a history of colonic diverticulosis came to Answer: D. Surgery the ER because of severe abdominal pain. An upright chest x-ray revealed pneumoperitoneum. This is best managed by? Moodle feedback: The presence of pneumoperitoneum indicates perforated diverticulitis, a. Therapeutic endoscopy thus surgery is the best management for this case. b. Radiologic intervention c. Medical management d. Surgery Reference: Doc Gamutan’s lecture on Diseases of the Colon and Rectum Trams 2025 44. Based on the DOH Cancer prevention program, at what age do we Answer: D. 50 y/o screen average risk individuals for colorectal cancer? ALL asymptomatic individuals age 50 years old and above a. 45y/o → High-risk individuals b. 40y/o → Male c. 60y/o → Obesity d. 50y/o → Smoker → Increased consumption of red meat/processed meats → Alcohol abuse → Physical inactivity → Family history (first degree relatives) Page 16 of 17 IM GIT EVALS 1 Alarm symptoms → Anemia → Weight loss → Changes in bowel habits → Hematochezia/melena → Anorexia Reference: Doc Gamutan and Doc Sebollena’s lecture on Diseases of the Colon and Rectum Trams 2025 45. A 60y/o, male sought consult due to low hemoglobin detected Answer: C. Colonoscopy during his annual check-up. Patient is asymptomatic. Previous smoker. Non-alcoholic beverage drinker. s/p Colonoscopy with Screening is recommended for ALL asymptomatic individuals age 50 polypectomy 2015. What is the next BEST course of action? years or older, high-risk individuals, and those with risk factors such as smoker, male, obese, and family history of colorectal cancer. a. Treat with FeSo4 and repeat CBC after 30 days. b. Whole abdomen CT-scan Since the patient has low hemoglobin, it can be said that he has anemia. c. Colonoscopy Unlike in females, anemia is uncommon in males and if present this d. Barium enema requires further tests since it is suspicious for malignancy, especially in elderly. In this case, the patient is a high-risk individual due to his age, sex (male), previous smoker, and previous history of polyp. Repeat colonoscopy is recommended for high-risk individuals. A is incorrect because giving FeSO4 and repeating CBC after 30 days can be done for anemia BUT further tests are still needed to rule out malignancy since anemia is an alarm symptom. B is incorrect since whole abdomen CT scan is the best diagnostic workup for patients presenting with severe abdominal pain and direct and rebound tenderness, in which colonoscopy is contraindicated. D is incorrect since barium enema is not the next best step because if there is something suspicious found, the patient will still need to undergo colonoscopy. Reference: Doc Gamutan and Doc Sebollena’s lecture on Diseases of the Colon and Rectum Trams 2025 46. A 25 y/o pregnant woman in her third trimester consulted at your Answer: D. Give Amoxicillin clavulanic 625mg tablet BID x 7 days clinic for second opinion regarding her urine culture and sensitivity yielding E.coli of more than 100,000 cfu/ml. She has no dysuria, Antibiotics for AUC in Pregnancy hematuria, frequency, suprapubic tenderness or flank pain. What is Nitrofurantoin, Ampicillin and Cephalosporins are safe in early pregnancy the recommended treatment for this patient based on local Sulfonamides and Fluoroqinolones are avoided guidelines? 1st trimester –teratogenic effects Near term –possible role in development of kernicterus A. No need to treat since she is asymptomatic A is incorrect because while she is seemingly asymptomatic, she has B. Give her Cotrimoxazole 850mg tablet BID x 7 days significant bacteriuria (more than 100,00 cfu/mL) which warrants C. Give her Ciprofloxacin 500mg tablet BID x 7 days