Gastroenterology #2 Exam with
Complete Solutions
A 45-year-old African-American woman presents for her routine job screening physical
examination. She is applying to be a security guard at her local airport. She is very
healthy and works out at her local gym on a regular basis.
PAST MEDICAL HISTORY:
Negative except for hospitalizations for birthing her 2 children, which required C-
sections
On no medications
SOCIAL HISTORY: Lives with her husband and 2 sons, ages 15 and 13
Has never smoked
Drinks Mai Tais on a regular basis; 1 q day
FAMILY HISTORY: Father diagnosed at age 48 with colon cancer; died 2 years later
Mother 70, healthy
Brother 42, obese
REVIEW OF SYSTEMS: No headaches
No sore throat
No eye changes
No muscle aches or pains
No chest pain
No cough
No diarrhea
No constipation
No rashes
Poor dentition—has been to dentist multiple times in last few months for cavities
PHYSICAL EXAMINATION: Well-developed, well-nourished woman in no distress
BP 110/70, P 65, - correct Answer-Answer
A. Colonoscopy every 5 years beginning now.
Explanation
A positive family history is the most commonly identified factor that increases the risk of
colorectal cancer. This gets a little confusing, so I will break it down in short paragraphs
for you to "digest" more easily.
1. Persons with a single 1st degree relative with colorectal cancer that was diagnosed
after age 60 experience a risk of colorectal cancer at age 40 that is equivalent to that of
average-risk persons at age 50. Such persons should begin colorectal screening at age
,40 (options for this: 1) colonoscopy every 10 years, or 2) annual fecal occult blood test
plus flexible sigmoidoscopy every 5 years).
2. People at particularly increased risk are those with 2 or more 1st degree relatives
with colorectal cancer or a single 1st degree relative diagnosed with colorectal cancer
under the age of 60 (like this patient's father). The relatives of these affected patients
should begin screening at age 40, or 10 years younger than the youngest affected 1st
degree relative, whichever comes first. So, based on her family history and her dad's
diagnosis at age 48, she should have started screening at age 38. Screening for these
patients should be by colonoscopy at 3-5 year intervals depending on the strength of
the family history.
A 25-year-old woman has a 3-year history of diarrhea and abdominal cramping. These
symptoms seem to worsen with stress, but the diarrhea can wake her. She was told she
had irritable bowel syndrome and was placed on a high-fiber diet. She was also given
dicyclomine as an antispasmodic agent. However, her symptoms did not improve with
these methods, and she is seeking another opinion.
Past Medical History: Negative, and her only medicine is dicyclomine.
Family History: Negative
Social History: Unremarkable
Review of Systems: Significant for a 4-lb. weight loss in the past 3 months. She denies
any fever or chills.
Physical Examination: She is in no apparent distress.
HEENT: Unremarkable
Chest: Clear
Cardiac: Normal
Abdomen: Nondistended with normal bowel sounds. She does have focal tenderness
with some degree of fullness in the R lower quadrant.
You order a colonoscopy, and the colon is normal until entering the r - correct Answer-
Answer
D. Mesalamine 400 mg PO tid
Explanation
This 25-year-old woman has a new diagnosis of Crohn disease. The involvement of the
right colon and ileum is a very typical pattern of involvement. Although the pathologist
does not describe granulomas, the chronic inflammation and ulceration in this setting
would be considered diagnostic. It's not uncommon for these patients to have symptoms
for several years before the diagnosis is made, as was the case in this patient.
,Regarding treatment, there is no reason why one cannot start with the most benign
treatment, from a safety standpoint, and use mesalamine. She may respond well and
become symptom-free. If there was more urgency, in that the symptoms were of greater
severity, then one could use prednisone. Azathioprine can be very helpful in the patient
who is requiring frequent courses of steroids, but her disease may not be severe
enough to require immunosuppressive therapy. Likewise, infliximab can be helpful in the
moderately severe cases of Crohn disease, but this may not be additionally needed.
A 27-year-old woman presents with a 3-month history of rectal bleeding, abdominal
cramps, and diarrhea. Colonoscopy was performed, leading to a diagnosis of ulcerative
colitis. She is started on mesalamine at a dose of 2.4 g/day. There is some initial
improvement in her symptoms, but 3 weeks later, she develops a different abdominal
pain: a severe epigastric pain that radiates to the back. The pain is associated with
nausea and vomiting. She came to the Emergency Department, where her amylase was
found to be 3,000 with a lipase of 2,400. Acute pancreatitis was diagnosed. The patient
was made NPO, an NG tube was placed, and IV fluids were administered. Mesalamine
was stopped. The ultrasound done at that time showed a normal gallbladder. After 5
days in the hospital, the patient was discharged with resolution of her symptoms and a
normal amylase and lipase. Two weeks later the patient again presents to the
Emergency De - correct Answer-Answer
D. Treat with conservative measures like bowel rest and IV fluids.
Explanation
This is a typical presentation of a pseudocyst: a recurrence of pain and elevation in the
pancreatic enzymes several weeks after an acute event. One should never do ERCP in
this setting because there will be risk of inducing an infection of the fluid of the
pseudocyst. It is also too early to do surgery or percutaneous drainage of this acute
pseudocyst. The recommended treatment is supportive care with follow-up of the cyst
by CT scan to hopeful resolution. What was the etiology of this patient's initial
pancreatitis? It may well have been secondary to the mesalamine. Mesalamine is one of
the many drugs that have been associated with pancreatitis. Mesalamine probably
should not be restarted in this case. It's also possible that, as in many cases of
pancreatitis, the etiology is a gallstone blocking the common duct. This can be present
even despite a previously negative ultrasound.
A 25-year-old male presents to the office complaining of intermittent chest pain for the
past year. This is a brief pain that lasts only 1-2 minutes in duration. It is unpredictable
and not related to meals. It never wakes him. He says that it can radiate into the left
chest, and he describes it as a sharp stabbing pain. There are no other factors in his
past medical history. He does have a family history of premature coronary artery
disease. In his social history, he admits to significant stress in his job as an IRS auditor.
In review of systems, he denies any dysphagia or any typical reflux symptoms. Physical
examination is normal.
, Stress echo: Normal
EGD: Normal
Esophageal motility: This demonstrated mostly normal peristalsis, but there were
intermittent simultaneous contractions seen. Lower esophageal sphincter pressure was
40, but with complete relaxation. The amplitude in the esophageal body was 140
(normal 40 - correct Answer-Answer
B. 24-hour ambulatory pH probe may reveal abnormal reflux even without typical reflux
symptoms.
Explanation
By definition, this patient's motility shows diffuse esophageal spasm, which is
characterized by intermittent simultaneous contractions amid normal peristalsis. The
upper endoscopy in this case was a very low-yield procedure and probably added little
to the management of this patient. However, a 24-hour ambulatory pH probe may reveal
that some cases of diffuse esophageal spasm are due to reflux, even if the patient does
not have typical reflux symptoms. In these cases, the chest pain will resolve with
aggressive treatment of the reflux. Some cases of diffuse esophageal spasm will have
dysphagia with the chest pain. However, in this case, since there is no dysphagia, there
is no reason to expect the dilatation would help. Probably the most important aspect of
treatment is reassurance of the patient. Nitrates are poorly tolerated on a long-term
basis for this presentation. There may be a role for use of calcium-channel antagonists,
anti-spasm medicines, or tricyclic antidepressants.
A 46-year-old male patient presents to the clinic with complaints of repeated vomiting.
Of greatest concern to the patient is the presence of blood in the emesis.
Which of the following is most specific for peptic ulcer disease as the source for the
vomited blood?
A) Specks of blood with black particulate emesis
B) Large volumes of regurgitated bright blood
C) Bright red blood following an emesis episode
D) Mucoid emesis with streaks of blood - correct Answer-Answer
A. Specks of blood with black particulate emesis
Explanation
Blood in the gastrointestinal tract can originate anywhere from the nose and mouth to
the anal opening. Sources in the upper GI system can lead to blood in the emesis with
vomiting. Though no pattern is pathognomonic for the source of an upper GI bleed,
some characteristics are typical. Vomiting mucous material with streaks of blood
suggests an upper airway irritation with swallowed secretions. Large volumes of
regurgitated blood suggest esophageal varices. Hematemesis that follows an episode of
vomiting suggests a Mallory-Weiss tear. Specks of blood with emesis that is "coffee
Complete Solutions
A 45-year-old African-American woman presents for her routine job screening physical
examination. She is applying to be a security guard at her local airport. She is very
healthy and works out at her local gym on a regular basis.
PAST MEDICAL HISTORY:
Negative except for hospitalizations for birthing her 2 children, which required C-
sections
On no medications
SOCIAL HISTORY: Lives with her husband and 2 sons, ages 15 and 13
Has never smoked
Drinks Mai Tais on a regular basis; 1 q day
FAMILY HISTORY: Father diagnosed at age 48 with colon cancer; died 2 years later
Mother 70, healthy
Brother 42, obese
REVIEW OF SYSTEMS: No headaches
No sore throat
No eye changes
No muscle aches or pains
No chest pain
No cough
No diarrhea
No constipation
No rashes
Poor dentition—has been to dentist multiple times in last few months for cavities
PHYSICAL EXAMINATION: Well-developed, well-nourished woman in no distress
BP 110/70, P 65, - correct Answer-Answer
A. Colonoscopy every 5 years beginning now.
Explanation
A positive family history is the most commonly identified factor that increases the risk of
colorectal cancer. This gets a little confusing, so I will break it down in short paragraphs
for you to "digest" more easily.
1. Persons with a single 1st degree relative with colorectal cancer that was diagnosed
after age 60 experience a risk of colorectal cancer at age 40 that is equivalent to that of
average-risk persons at age 50. Such persons should begin colorectal screening at age
,40 (options for this: 1) colonoscopy every 10 years, or 2) annual fecal occult blood test
plus flexible sigmoidoscopy every 5 years).
2. People at particularly increased risk are those with 2 or more 1st degree relatives
with colorectal cancer or a single 1st degree relative diagnosed with colorectal cancer
under the age of 60 (like this patient's father). The relatives of these affected patients
should begin screening at age 40, or 10 years younger than the youngest affected 1st
degree relative, whichever comes first. So, based on her family history and her dad's
diagnosis at age 48, she should have started screening at age 38. Screening for these
patients should be by colonoscopy at 3-5 year intervals depending on the strength of
the family history.
A 25-year-old woman has a 3-year history of diarrhea and abdominal cramping. These
symptoms seem to worsen with stress, but the diarrhea can wake her. She was told she
had irritable bowel syndrome and was placed on a high-fiber diet. She was also given
dicyclomine as an antispasmodic agent. However, her symptoms did not improve with
these methods, and she is seeking another opinion.
Past Medical History: Negative, and her only medicine is dicyclomine.
Family History: Negative
Social History: Unremarkable
Review of Systems: Significant for a 4-lb. weight loss in the past 3 months. She denies
any fever or chills.
Physical Examination: She is in no apparent distress.
HEENT: Unremarkable
Chest: Clear
Cardiac: Normal
Abdomen: Nondistended with normal bowel sounds. She does have focal tenderness
with some degree of fullness in the R lower quadrant.
You order a colonoscopy, and the colon is normal until entering the r - correct Answer-
Answer
D. Mesalamine 400 mg PO tid
Explanation
This 25-year-old woman has a new diagnosis of Crohn disease. The involvement of the
right colon and ileum is a very typical pattern of involvement. Although the pathologist
does not describe granulomas, the chronic inflammation and ulceration in this setting
would be considered diagnostic. It's not uncommon for these patients to have symptoms
for several years before the diagnosis is made, as was the case in this patient.
,Regarding treatment, there is no reason why one cannot start with the most benign
treatment, from a safety standpoint, and use mesalamine. She may respond well and
become symptom-free. If there was more urgency, in that the symptoms were of greater
severity, then one could use prednisone. Azathioprine can be very helpful in the patient
who is requiring frequent courses of steroids, but her disease may not be severe
enough to require immunosuppressive therapy. Likewise, infliximab can be helpful in the
moderately severe cases of Crohn disease, but this may not be additionally needed.
A 27-year-old woman presents with a 3-month history of rectal bleeding, abdominal
cramps, and diarrhea. Colonoscopy was performed, leading to a diagnosis of ulcerative
colitis. She is started on mesalamine at a dose of 2.4 g/day. There is some initial
improvement in her symptoms, but 3 weeks later, she develops a different abdominal
pain: a severe epigastric pain that radiates to the back. The pain is associated with
nausea and vomiting. She came to the Emergency Department, where her amylase was
found to be 3,000 with a lipase of 2,400. Acute pancreatitis was diagnosed. The patient
was made NPO, an NG tube was placed, and IV fluids were administered. Mesalamine
was stopped. The ultrasound done at that time showed a normal gallbladder. After 5
days in the hospital, the patient was discharged with resolution of her symptoms and a
normal amylase and lipase. Two weeks later the patient again presents to the
Emergency De - correct Answer-Answer
D. Treat with conservative measures like bowel rest and IV fluids.
Explanation
This is a typical presentation of a pseudocyst: a recurrence of pain and elevation in the
pancreatic enzymes several weeks after an acute event. One should never do ERCP in
this setting because there will be risk of inducing an infection of the fluid of the
pseudocyst. It is also too early to do surgery or percutaneous drainage of this acute
pseudocyst. The recommended treatment is supportive care with follow-up of the cyst
by CT scan to hopeful resolution. What was the etiology of this patient's initial
pancreatitis? It may well have been secondary to the mesalamine. Mesalamine is one of
the many drugs that have been associated with pancreatitis. Mesalamine probably
should not be restarted in this case. It's also possible that, as in many cases of
pancreatitis, the etiology is a gallstone blocking the common duct. This can be present
even despite a previously negative ultrasound.
A 25-year-old male presents to the office complaining of intermittent chest pain for the
past year. This is a brief pain that lasts only 1-2 minutes in duration. It is unpredictable
and not related to meals. It never wakes him. He says that it can radiate into the left
chest, and he describes it as a sharp stabbing pain. There are no other factors in his
past medical history. He does have a family history of premature coronary artery
disease. In his social history, he admits to significant stress in his job as an IRS auditor.
In review of systems, he denies any dysphagia or any typical reflux symptoms. Physical
examination is normal.
, Stress echo: Normal
EGD: Normal
Esophageal motility: This demonstrated mostly normal peristalsis, but there were
intermittent simultaneous contractions seen. Lower esophageal sphincter pressure was
40, but with complete relaxation. The amplitude in the esophageal body was 140
(normal 40 - correct Answer-Answer
B. 24-hour ambulatory pH probe may reveal abnormal reflux even without typical reflux
symptoms.
Explanation
By definition, this patient's motility shows diffuse esophageal spasm, which is
characterized by intermittent simultaneous contractions amid normal peristalsis. The
upper endoscopy in this case was a very low-yield procedure and probably added little
to the management of this patient. However, a 24-hour ambulatory pH probe may reveal
that some cases of diffuse esophageal spasm are due to reflux, even if the patient does
not have typical reflux symptoms. In these cases, the chest pain will resolve with
aggressive treatment of the reflux. Some cases of diffuse esophageal spasm will have
dysphagia with the chest pain. However, in this case, since there is no dysphagia, there
is no reason to expect the dilatation would help. Probably the most important aspect of
treatment is reassurance of the patient. Nitrates are poorly tolerated on a long-term
basis for this presentation. There may be a role for use of calcium-channel antagonists,
anti-spasm medicines, or tricyclic antidepressants.
A 46-year-old male patient presents to the clinic with complaints of repeated vomiting.
Of greatest concern to the patient is the presence of blood in the emesis.
Which of the following is most specific for peptic ulcer disease as the source for the
vomited blood?
A) Specks of blood with black particulate emesis
B) Large volumes of regurgitated bright blood
C) Bright red blood following an emesis episode
D) Mucoid emesis with streaks of blood - correct Answer-Answer
A. Specks of blood with black particulate emesis
Explanation
Blood in the gastrointestinal tract can originate anywhere from the nose and mouth to
the anal opening. Sources in the upper GI system can lead to blood in the emesis with
vomiting. Though no pattern is pathognomonic for the source of an upper GI bleed,
some characteristics are typical. Vomiting mucous material with streaks of blood
suggests an upper airway irritation with swallowed secretions. Large volumes of
regurgitated blood suggest esophageal varices. Hematemesis that follows an episode of
vomiting suggests a Mallory-Weiss tear. Specks of blood with emesis that is "coffee
