AAFP Board Review - GI
A 49-year-old male brings you a copy of his laboratory results obtained during an insurance
examination. The patient says he feels fine, but his bilirubin level was 2.5 mg/dL (N <1.0). He
says he averages 5 alcoholic beverages per week and takes no medications other than occasional
ibuprofen. On examination he is not jaundiced and has no scleral icterus, and the remainder of
the examination is within normal limits, including palpation of the liver and spleen. Laboratory
testing reveals a normal CBC, normal liver enzyme levels, and normal serum haptoglobin.
Bilirubin fractionation reveals an indirect level of 2.0 mg/dL and a direct level of 0.5 mg/dL (N
<0.4).
The most likely diagnosis is
(check one)
A. asymptomatic cholecystitis
B. alcoholic liver disease
C. Gilbert's syndrome
D. hemolytic anemia - Answer-C. Gilbert's syndrome
Gilbert's syndrome is a hereditary condition associated with unconjugated hyperbilirubinemia (usually
with
a bilirubin level <5.0 mg/dL). The bilirubin level increases with infection, exertion, and fasting. Patients
are asymptomatic and have otherwise normal liver function studies.
Not hemolytic anemias, which cause a decrease in serum haptoglobin, an increase in lactate
dehydrogenase and/or CBC abnormalities, particularly on the peripheral smear.
,A 68-year-old female with diabetes mellitus, coronary artery disease, 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?
(check one)
A. Hypermagnesemia
B. Urinary tract infections
C. Nephrolithiasis
D. Hip fractures - Answer-D. Hip fractures
Which one of the following is a significant risk factor for esophageal adenocarcinoma? (check one)
A. Aspirin therapy
B. Ibuprofen therapy
C. Helicobacter pylori infection
D. Obesity
E. Crohn's disease - Answer-D. Obesity
Esophageal adenocarcinoma has become the predominant type of esophageal cancer in North America
and Europe, and gastroesophageal reflux and obesity are the main risk factors.
A 55-year-old female has severe symptoms of gastroesophageal reflux disease. Upper endoscopy with a
biopsy shows severe esophagitis and Barrett's esophagus.
Which one of the following is true regarding this patient?
(check one)
A. The severity of her symptoms is due to the presence of Barrett's esophagus
B. Follow-up screening endoscopy will reduce her risk of death from esophageal cancer
,C. Her risk of developing esophageal adenocarcinoma is >90%
D. Her risk of developing esophageal adenocarcinoma is <1% - Answer-C. Her risk of developing
esophageal adenocarcinoma <1%
The actual risk of adenocarcinoma from Barrett's esophagus is less than 1%. Endoscopy does nothing to
reduce the risk of death. Patients with Barrett's esophagus can have minimal symptoms.
A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and
solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination,
you note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8°C
(100.2°F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg (99 lb) and his
height is 170 cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous
membranes are dry.
You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are
normal. You promptly consult a gastroenterologist, who performs upper endoscopy, which reveals
numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa.
As you continue to investigate, you take a more detailed history. Which one of the following is most
likely to be re - Answer-A. IV drug use
- young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have
HIV infection.
- Intravenous drug use is responsible for over a quarter of HIV infections in the United States.
- Esophageal disease develops in more than half of all patients with advanced infection during the
course of their illness.
- The most common pathogens causing esophageal ulceration in HIV-positive patients include *Candida,
herpes simplex virus, and cytomegalovirus*
- Identifying the causative agent through culture or tissue sampling is important for providing prompt
and specific therapy.
When considering a diagnosis of pancreatitis, amylase levels (check one)
A. can help determine the severity of the disease
B. are less likely to be elevated in alcoholics
, C. are more sensitive and specific than serum lipase levels
D. are less likely to be affected by nonpancreatic conditions such as renal insufficiency - Answer-B.
Amylase and lipase levels are used to help make the diagnosis of acute pancreatitis.
- amylase is less sensitive & specific
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?
(check one)
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 total parenteral nutrition 70 - Answer-D. Early low-fat diet
- bowel rest is associated with intestinal mucosal atrophy and increased infectious complications
because of bacterial translocation from the gut
- 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.
You are covering the inpatient service and following up on a 67-year-old female admitted 3 days
ago for severe pancreatitis. CT on admission showed edema and mild inflammation. Currently
the patient is receiving intravenous fluids, daily laboratory evaluations, and pain medications.
She is NPO and afebrile, with a blood pressure of 130/78 mm Hg and a pulse rate of 88
beats/min.
Which one of the following therapies should be initiated to lower complication rates and shorten
the patient's hospital stay?
A 49-year-old male brings you a copy of his laboratory results obtained during an insurance
examination. The patient says he feels fine, but his bilirubin level was 2.5 mg/dL (N <1.0). He
says he averages 5 alcoholic beverages per week and takes no medications other than occasional
ibuprofen. On examination he is not jaundiced and has no scleral icterus, and the remainder of
the examination is within normal limits, including palpation of the liver and spleen. Laboratory
testing reveals a normal CBC, normal liver enzyme levels, and normal serum haptoglobin.
Bilirubin fractionation reveals an indirect level of 2.0 mg/dL and a direct level of 0.5 mg/dL (N
<0.4).
The most likely diagnosis is
(check one)
A. asymptomatic cholecystitis
B. alcoholic liver disease
C. Gilbert's syndrome
D. hemolytic anemia - Answer-C. Gilbert's syndrome
Gilbert's syndrome is a hereditary condition associated with unconjugated hyperbilirubinemia (usually
with
a bilirubin level <5.0 mg/dL). The bilirubin level increases with infection, exertion, and fasting. Patients
are asymptomatic and have otherwise normal liver function studies.
Not hemolytic anemias, which cause a decrease in serum haptoglobin, an increase in lactate
dehydrogenase and/or CBC abnormalities, particularly on the peripheral smear.
,A 68-year-old female with diabetes mellitus, coronary artery disease, 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?
(check one)
A. Hypermagnesemia
B. Urinary tract infections
C. Nephrolithiasis
D. Hip fractures - Answer-D. Hip fractures
Which one of the following is a significant risk factor for esophageal adenocarcinoma? (check one)
A. Aspirin therapy
B. Ibuprofen therapy
C. Helicobacter pylori infection
D. Obesity
E. Crohn's disease - Answer-D. Obesity
Esophageal adenocarcinoma has become the predominant type of esophageal cancer in North America
and Europe, and gastroesophageal reflux and obesity are the main risk factors.
A 55-year-old female has severe symptoms of gastroesophageal reflux disease. Upper endoscopy with a
biopsy shows severe esophagitis and Barrett's esophagus.
Which one of the following is true regarding this patient?
(check one)
A. The severity of her symptoms is due to the presence of Barrett's esophagus
B. Follow-up screening endoscopy will reduce her risk of death from esophageal cancer
,C. Her risk of developing esophageal adenocarcinoma is >90%
D. Her risk of developing esophageal adenocarcinoma is <1% - Answer-C. Her risk of developing
esophageal adenocarcinoma <1%
The actual risk of adenocarcinoma from Barrett's esophagus is less than 1%. Endoscopy does nothing to
reduce the risk of death. Patients with Barrett's esophagus can have minimal symptoms.
A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and
solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination,
you note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8°C
(100.2°F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg (99 lb) and his
height is 170 cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous
membranes are dry.
You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are
normal. You promptly consult a gastroenterologist, who performs upper endoscopy, which reveals
numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa.
As you continue to investigate, you take a more detailed history. Which one of the following is most
likely to be re - Answer-A. IV drug use
- young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have
HIV infection.
- Intravenous drug use is responsible for over a quarter of HIV infections in the United States.
- Esophageal disease develops in more than half of all patients with advanced infection during the
course of their illness.
- The most common pathogens causing esophageal ulceration in HIV-positive patients include *Candida,
herpes simplex virus, and cytomegalovirus*
- Identifying the causative agent through culture or tissue sampling is important for providing prompt
and specific therapy.
When considering a diagnosis of pancreatitis, amylase levels (check one)
A. can help determine the severity of the disease
B. are less likely to be elevated in alcoholics
, C. are more sensitive and specific than serum lipase levels
D. are less likely to be affected by nonpancreatic conditions such as renal insufficiency - Answer-B.
Amylase and lipase levels are used to help make the diagnosis of acute pancreatitis.
- amylase is less sensitive & specific
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?
(check one)
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 total parenteral nutrition 70 - Answer-D. Early low-fat diet
- bowel rest is associated with intestinal mucosal atrophy and increased infectious complications
because of bacterial translocation from the gut
- 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.
You are covering the inpatient service and following up on a 67-year-old female admitted 3 days
ago for severe pancreatitis. CT on admission showed edema and mild inflammation. Currently
the patient is receiving intravenous fluids, daily laboratory evaluations, and pain medications.
She is NPO and afebrile, with a blood pressure of 130/78 mm Hg and a pulse rate of 88
beats/min.
Which one of the following therapies should be initiated to lower complication rates and shorten
the patient's hospital stay?
