GI: Practice Questions and Answers 2023

GI: Practice Questions and Answers 2023 A 20-year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is A. Indirect inguinal hernia. B. Direct inguinal hernia. C. Obturator hernia. D. Femoral hernia. Answer: A Explanation: An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. It is the result of a weakness in the inguinal external ring. Hernial contents may radiate anteriorly rather than into the scrotum. Obturator hernia's are more commonly seen in elderly women and are rarely palpable in the groin. Femoral hernias are rare in males and do not typically reduce with lying down. Which of the following is consistent with acute cholangitis? A. Jaundice B. Caput medusa C. Bilateral flank bruising D. An enlarged, palpable nontender gallbladder Answer: A Explanation: Jaundice is part of Charcot's triad associated with cholangitis along with fever and biliary colic (RUQ pain). Caput medusa is associated with ascites and cirrhosis. Bilateral flank bruising is associated with hemorrhagic pancreatitis. An enlarged, nontender, palpable gallbladder is associated with cancer of the head of the pancreas. Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct or: A. Cystic duct. B. Pancreatic duct. C. Duodenal ampulla. D. Common hepatic duct. Answer: A Explanation: Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed, the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis. Obstruction of the pancreatic duct leads to development of acute pancreatitis. The duodenal ampulla is the area where the pancreatic duct and the common bile duct empty into the duodenum. Gallstones do not cause obstruction at this distal site. The common hepatic duct from the liver joins the cystic duct from the gallbladder to form the common bile duct. Stone migration occurs along the pathway of the cystic duct to the common bile duct, not along the common hepatic duct. A patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the most appropriate management of this patient? A. Oral analgesics B. Diagnostic peritoneal lavage C. Proton pump inhibitors D. Laparoscopic cholecystectomy Answer: D Explanation: Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice. The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Diagnostic peritoneal lavage is used to detect intraabdominal bleeding from trauma and not to treat acute cholecystitis and may delay appropriate treatment. Proton pump inhibitors are used to treat GERD or PUD. A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer? A. Squamous cell B. Transitional cell C. Adenocarcinoma D. Atypical carcinoid Answer: C Explanation: The most serious complication of Barrett's esophagus is esophageal adenocarcinoma. Transitional cell is a cancer of the bladder. Atypical carcinoid is more typical of lung cancer. The most common cause of esophageal cancer worldwide is squamous cell; however, this normally is located in the upper 1/3 of the esophagus and is usually secondary to tobacco use, not Barrett's esophagus. A 62 year-old male is brought to the emergency department with acute hematemesis. The patient denies a previous history of vomiting. His wife states he has chronic liver disease. Physical examination reveals a distended abdomen without rebound, guarding or organomegaly. There is a fluid wave. Which of the following is the most likely diagnosis? A. Esophageal varices B. Mallory-Weiss tear C. Arteriovenous malformation D. Perforated duodenal ulcer Answer: A Explanation: Esophageal varices are dilated submucosal veins that develop in a patient with underlying portal hypertension. The most common cause of portal hypertension is cirrhosis. A patient with a Mallory-Weiss tear would have a history of retching but would not have a distended abdomen. Most arteriovenous malformations are asymptomatic. If symptomatic they would have symptoms of a slow bleed. A patient with perforated duodenal ulcer would have rebound and guarding on examination. A 32 year-old male with history of tobacco abuse presents with an intermittent burning sensation in his chest for six months, worsening over the past 2 weeks. His wife has noticed episodes of coughing at night. He denies dysphagia, weight loss, hematemesis, or melena. His vital signs are all normal and physical examination is unremarkable. Which of the following is the most likely diagnosis? A. Peptic ulcer disease B. Acute gastritis C. Gastroesophageal reflux disease D. Esophageal stricture Answer: C Explanation: Gastroesophageal reflux disease presents with at least weekly episodes of heartburn and typically occurs after meals and upon reclining. Patients may complain of regurgitation, chronic cough, laryngitis, or sore throat. Peptic ulcer disease typically presents with midepigastric pain and is not usually associated with cough. Acute gastritis would have a duration of less than 2 weeks. Esophageal stricture develops from long term gastroesophageal reflux disease. Patients with esophageal stricture usually have dysphagia. A 48-year-old male presents with complaints of heartburn that occurs approximately 45 minutes after eating about three times a week that is relieved by antacids. He claims to have followed advice about elevating the head of the bed, avoiding spicy foods, and losing weight, but continues to have heartburn. Which of the following is the most appropriate next step? A. Ranitidine (Zantac) B. Sucralfate (Carafate) C. Metoclopramide (Reglan) D. Misoprostol (Cytotec) Answer: A Explanation: Ranitidine, an H2 receptor blocker, is indicated for the treatment of mild, intermittent symptoms of GERD. Sucralfate is used in the treatment of duodenal ulcers. Metoclopramide is indicated for the treatment of gastroparesis as a first-line agent. Misoprostol is indicated for the prevention of NSAID-induced gastritis. A 16 day-old male presents in the office with a history of vomiting after feeding for the past 2 days. The vomiting has become progressively worse and the mother describes it as very forceful, sometimes hitting the floor 6 feet away. She says the neonate is always hungry. On physical examination, it is noted that he is 2 ounces below birth weight, and has a small palpable mass (about 1.5 cm) in the epigastrium. The most likely diagnosis is A. Achalasia. B. Tracheoesophageal fistula. C. Pyloric stenosis. D. Meckel's diverticulum. Answer: C Explanation: Pyloric stenosis begins between 2 to 4 weeks of age with vomiting that becomes projectile after each feeding. An olive-size mass can often be felt in the epigastrium. Achalasia is uncommon under the age of 5 and the child presents with retrosternal pain and dysphagia. Tracheoesophageal fistula presents with increased secretions, choking, cyanosis, and respiratory distress within the first few hours of life. Meckel's diverticulum presents with painless rectal bleeding. Vomiting is rare unless obstruction has occurred. A 25-year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is A. acyclovir (Zovirax). B. omeprazole (Prilosec). C. fluconazole (Diflucan). D. penicillin G. Answer: C Explanation: The patient has Candida esophagitis and the treatment of choice is fluconazole. Acyclovir is an antiviral used in the treatment of herpes esophagitis. Omeprazole is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease with esophageal ulceration and peptic ulcer disease and is not indicated in the treatment of infectious esophagitis. Penicillin G is an antibiotic and is not effective against fungal infections. Which of the following is the study of choice to diagnose upper gastrointestinal malignancy? A. Abdominal CT B. Upper endoscopy C. Barium swallow D. Abdominal ultrasound Answer: B Explanation: Upper endoscopy is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis and upper gastrointestinal malignancy. A 62 year-old male presents with complaints of dyspepsia, early satiety, and dysphagia. What diagnostic study would be indicated in his initial workup? A. PET CT scan B. Abdominal ultrasound C. Gastric emptying studies D. Upper endoscopy Answer: D Explanation: Upper endoscopy is indicated for patients over the age of 55 presenting with new-onset symptoms of dyspepsia in order to evaluate for gastric cancer or other serious organic disease. Upper endoscopy is the diagnostic study of choice to diagnose gastroduodenal ulcers, erosive esophagitis, and upper GI malignancy. PET CT scan is used primarily to follow the course of an already diagnosed cancer. Abdominal ultrasonography is performed only when pancreatic or biliary disease is suspected. Gastric emptying studies are valuable only in patients with recurrent vomiting. A 45 year-old male presents with a long history of ulcerative colitis and recent progressive complaints of right upper quadrant pain, weight loss, fever and most recently, a rapid onset of jaundice with pruritus. Labs revealed elevated bilirubin and alkaline phosphatase. Viral serologies were negative. An endoscopic cholangiogram showed areas of stenosis and dilation throughout the bile duct system. What is the most likely diagnosis? A. Choledocholithiasis B. Hepatic carcinoma C. Portal hypertension D. Primary sclerosing cholangitis Answer: D Explanation: Primary sclerosing cholangitis (PSC) results in diffuse intra- and extrahepatic duct sclerosing with dilatation proximal to these areas. Choledocholithiasis can most certainly cause elevated bilirubin and other liver function tests when obstruction occurs. It also occurs more often in persons with sclerosed or narrowed bile ducts however it does not generally carry a poor prognosis and can be generally recognized by its typical symptoms. Hepatic carcinoma does not cause areas of varied stenosis and dilation in the biliary tree. Portal hypertension may present with jaundice but generally has significant ascites as well that helps to distinguish this disorder. It also does not result in the bile duct pattern mentioned. A patient with a history of severe peptic ulcer disease is 5 weeks status post gastric bypass surgery. One week ago he restarted his normal diet and has had the onset of severe nausea, abdominal cramping, and light-headedness that occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis? A. Anxiety disorder B. Celiac sprue C. Dumping syndrome D. Irritable bowel syndrome Answer: C Explanation: Dumping syndrome typically occurs after Billroth type I surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars. Anxiety disorders can cause a wide variety of somatic syndromes such as those mentioned, but generally not with such a straightforward dietary trigger. Celiac sprue can cause similar symptoms as those listed, can develop at any age and can be worsened by the ingestion of gluten containing products. The patient's recent surgery makes dumping syndrome a much greater possibility. Irritable bowel syndrome is a diagnosis of exclusion and is associated with alternation in bowel habits. Prolonged use of a proton pump inhibitor can lead to low levels of which of the following nutrients? A. Folic acid B. Magnesium C. Vitamin B6 D. Vitamin B12 Answer: D Explanation: Vitamin B12 requires gastric acid for absorption in the stomach. Prolonged use of a proton pump inhibitor suppresses gastric acid production. Which of the following is suggestive of riboflavin deficiency? A. Ataxia B. Bleeding C. Cheilosis D. Diarrhea Answer: C Explanation: Cheilosis, mucocutaneous lesions at the corners of the mouth, is the result of riboflavin deficiency. Ataxia, mental deficits, horizontal nystagmus, muscle weakness and atrophy, and cardiomegaly are all clinical findings in thiamine deficiency. A deficiency of Vitamin K would result in bleeding and an elevated prothrombin time. A deficiency of niacin will result in diarrhea, dementia, and dermatitis. A 33-year-old man with no past medical history presents with groin mass. He denies pain and trauma to the region. When the patient stands, there is a round swelling in the inguinal area. If the patient is supine, the mass disappears. What is the appropriate intervention in this patient? A. Immediate surgical reapir B. Referral to general surgeon C. Oral antibiotic therapy D. Oral analgesics Answer: B Explanation: Referral to general surgeon is correct. The patient has an inguinal hernia, which can be repaired electively. Immediate surgical repair is incorrect. The patient's hernia should be repaired, but the hernia is not currently incarcerated and can be treated electively. Oral antibiotic therapy is not indicated in the treatment of hernias. Although oral analgesics are appropriate for pain, this patient does not report pain, so this answer choice is incorrect. A 57-year-old woman is undergoing a workup by her primary care provider for abdominal pain. The pain is in her left lower quadrant, intermittent, "crampy," and has been present for about 2 months. As an initial imaging study, she underwent an abdominal ultrasound. The ultrasound was unremarkable except for the presence of a few small (1 cm) stones in her gallbladder. She is currently following up to discuss the results of the ultrasound. What is likely to be suggested for the gallstones? A. No treatment B. Prophylactic elective cholecystectomy C. Oral analgesics D. Urgent cholecystectomy Answer: A Explanation: Gallstones on the patient's ultrasound is an incidental finding and not the cause of the patient's pain. As such, further investigation of the cause of the pain is warranted, and the correct answer is no treatment. If the gallstones were causing symptoms, this would be known as cholecystitis and the patient would have different abdominal problems. Only 5-10% of patients with cholelithiasis actually have cholecystitis, and the symptoms could include right upper quadrant abdominal pain, epigastric abdominal pain, nausea, vomiting, indigestion, or fatty food intolerance. Since this patient is not experiencing symptoms related to the stones, the stones are under 2-3 cm, and the gallbladder is not reported as "calcified" in general, she does not need to undergo treatment for the incidental finding of cholelithiasis. Prophylactic elective cholecystectomy is incorrect. Treatment is not needed for asymptomatic stones. If her stones were greater than 2-3 cm, if her gallbladder were calcified (risk for gallbladder cancer), or if she had recurrent pancreatitis secondary to microlithiasis, a prophylactic cholecystectomy would be indicated. Oral analgesics is incorrect. The patient has noted pain, but the source has not yet been determined. Whether the patient receives oral analgesics for the left lower quadrant pain while undergoing further workup would be up to the provider. However, analgesics would not be warranted for the cholelithiasis, as the stones are asymptomatic. Urgent cholecystectomy is typically performed for patients who have severe symptoms, particularly pain that is intolerable or severe vomiting. Cholecystectomy is usually performed electively (for reasons discussed in "prophylactic elective cholecystectomy") and very rarely needs to be done on an urgent basis. Oral dissolution therapy is very rarely used today and was much more popular 10-20 years ago. Oral dissolution therapy consists of taking bile acid in pill form to try to dissolve stones. It can work on a small percentage of patients with small cholesterol gallstones, but it has significant negative aspects that have taken the therapy out of popular use. It can be very expensive, can take several years, and has a high recurrence rate. As this patient's stones are asymptomatic, the best choice is to watch the stones conservatively. A 38-year-old man presents with a 2-day history of a mass and severe pain in his scrotum. Physical examination reveals that his right testicle appears much larger than his left. On palpation, you note a small hole in his inguinal canal, and you are unable to place the contents into the canal. The contents of the hernia appear ischemic. What is the best description of this hernia? A. Reducible B. Irreducible C. Strangulated D. Incarcerated Answer: C Explanation: The clinical picture suggests an inguinal hernia. A strangulated hernia occurs due to impaired blood flow (ischemia); the evidence of ischemia on exam means this hernia is strangulated. An incarcerated hernia is irreducible (hernial contents cannot be returned to their normal site) with manual pressure, which can result in ischemia, which can progress to infarction and necrosis. In a reducible hernia, the contents would be able to be placed back into the abdominal cavity with simple manipulation. A 57-year-old man presents with intermittent heaviness and pain in his groin over the last 2 months. He works in construction and states his symptoms are worsened by the end of the day. He denies any nausea/vomiting, constipation, dysuria, or urinary frequency. He smokes 1-1.5 packs daily for the last 40 years. During physical assessment, a single sac is found protruding just lateral to the inferior epigastric vessels. What is the most likely diagnosis? A. Direct inguinal hernia B. Femoral hernia C. Hiatal hernia D. Indiret inguinal hernia Answer: D Explanation: This patient's presentation is consistent with a hernia: the protrusion of an organ through another tissue such as the abdominal wall. Risk factors for hernias include male sex, increasing age, increased intra-abdominal pressure (such as a history of chronic constipation or history of chronic cough), smoking history, family history, or previous history of hernia. Symptoms most commonly include a fullness at the hernia site and a dull aching pain most noticeable with increased intra-abdominal pressure or with prolonged standing. Hernias can be congenital secondary to patent processus vaginalis or acquired secondary to weakness of abdominal wall. The most common physical exam finding is a painless bulge. Classification of hernias is based on the anatomic position in which they occur. This patient's hernia is found lateral to the inferior epigastric vessels, which is consistent with an indirect inguinal hernia. Opposite to this, a direct inguinal hernia would occur medially to the inferior epigastric vessels or within Hasselbach's triangle (formation of inferior epigastric vessels, rectus abdominal muscle, and inguinal ligament).