GI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 | ee Cicurrent Review Answered [lj Correct Ml Incorrect 1 Question Category: Gastroenterology & Gl Surgery ‘A-45-year-old male presented with an ongoing history of epigastric pain, postprandial fullness and nausea. Gastroscopy showed sliding hiatal hernia Which of the following is not associated with this condition? O. Relief of symptoms with sitting up and standing, © Anemia ©. Aspiration pneumor O Weightgain ©. Stricture formationMP2s es 6 7 8 2 wo CiCurrent Review /Skip | Answered [J Correct MJ Incorrect Review Question Cong 1. Question Category: Gastroenterology & Gl Surgery ‘A-45-year-old male presented with an ongoing history of epigastric pain, postprandial fullness and nausea. Gastroscopy showed sliding hiatal hernia Which of the following is not associated with this condition? Relief of symptoms with sitting up and standing. Anemia Aspiration pneumonia Weight gain Stricture formation Incorrect Ahiatus hernia refers to herniation of elements of the abdominal cavity through the cesophagal hiatus of the diaphragm Sliding hiatal hernia accounts for more than 95 percent of cases, Other 5 percent of the cases have Para-oesophageal hernias. Ahiatal hernia is usually discovered as a finding on upper gastrointestinal studies or endoscopy. ‘The most common symptoms are an epigastric or substernal pain, postprandial fullness, substernal fullness, nausea, and retching, Relief of symptoms is noted while sitting up and standing. Most complications of a type Ila hernia are reflective of the mechanical problem caused by a hernia Bleeding, although infrequent, occurs from gastric ulceration, gastritis, or erosions (Cameron lesions) within the incarcerated hernia pouch. Chronic inflammation can lead to stricture formation. Respiratory complications result from mechanical compression of the lung by a large hernia or other organs herniating through the hiatus and may include aspiration pneumonia. Endoscopic and radiographic studies suggest that 50 to 94 percent of patients with gastroesophageal reflux disease (GERD) have a type | hiatus hernias. References: ‘Uhttps://wwruptodate.com/contents/hiatus-hernia 2shttps://wwwe.ncbi.nim.nih gov/pmc/articles/PMC3166665/GI #9 Category-wise Questions (NEW!!!) » Gastroenterology > GI#9 CB: ser 8 ew Cicurrent Review/Skip [ll Answered Ml Correct Ml Incorrect 2. Question Category: Gastroenterology & Gl Surgery Which of the following is the symptom of pyloric stenosis due to a duodenal ulcer? ©. Vomiting within 4 hour © Vomiting after 2 hours © Increase appetite O Weight gain O Vomiting immediately after eatingGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 Bs 2567 8 9 (Cicurrent Review/Skip [ll Answered Ml Correct Ml Incorrect 2. Question Category: Gastroenterology & Gl Surgery Which of the following is the symptom of pyloric stenosis due to a duodenal ulcer? ‘Vomiting within 4 hour Vomiting after 2 hours Increase appetite Weight gain Vomiting immediately after eating Correct The pyloric stenosis in adults resulting from duodenal ulcer, is characterized by following symptoms: -Non-bilious vomiting occurring intermittently within 1 hour of a meal and contains undigested food particles. Bloating. Weight loss. Decrease appetite. -Epigastricpa Allother options are incorrect. The pattern of vomiting in infant hypertrophic pyloric stenosis is different from adults, and it is usually characterized by vomiting which is typically forceful, non-bilious and tends to occur immediately after feeding, References: ‘Uhttps://www.uptodate.com/contents/gastric-outlet-obstruction-in-adults NextGI #9 Category-wise Questions (NEW!!!) » Gastroenterology > GI#9 Cicurrent Review/Skip [ll Answered Ml Correct Ml Incorrect Leela Quiz Summary 3, Question Category: Gastroenterology & GI Surgery ‘A.42-year-old man sees you because of obesity. He played football in high school and at age 18 weighed 115 kg. He has gradually gained weight since, Many previous attempts at dieting have resulted in transient weight loss of 4 - 8 kg, which he then rapidly regains. He has been attending Weight Watchers for the last 3 months and has ‘successfully lost 2 kg. Recent attempts at exercise have been limited because of bilateral knee pain and swelling. On examination height is 183 cm, weight 155 kg, BMI 46.3. Blood pressure with a large cuff is 150/95. Baseline laboratory studies including CBC, biochemical profile, thyroid stimulating hormone and lipids are normal with the exception of fasting serum glucose which is 8 mmol/L. What is the next best step? ©. Recommend a 1000 calorie per day diet. ©. Refer toacommercial weight-loss program. ©. Prescribe sibutramine. (© Recommend a low-fat diet ©. Discuss bariatric surgery with the patient.Category: Gastroenterology & GI Surgery ‘A.42-year-old man sees you because of obesity. He played football in high school and at age 18 weighed 115 ke. He has gradually gained weight since. Many previous attempts at dieting have resulted in transient welght loss of 4 - 8 kg., which he then rapidly regains. He has been attending Weight Watchers for the last 3 months and has successfully lost 2 kg, Recent attempts at exercise have been limited because of bilateral knee pain and swelling. On ‘examination height is 183 cm, weight 155 kg, BMI 46.3. Blood pressure with a large cuff is 150/95. Baseline laboratory studies including CBC, biochemical profile, thyroid stimulating hormone and lipids are normal with the exception of fasting serum glucose which is 8 mmol/L. What is the next best step? Recommend a 1000 calorie per day diet. Refer to a commercial weight-loss program. Prescribe sibutramine. Recommend a low-fat diet. Discuss bariatric surgery with the patient. Incorrect This patient has morbid obesity (BMI over 40) and has comorbidities of hypertension. diabetes, and osteoarthritis of the knees. Two large meta-analyses have established that bariatric surgery is more effective than nonsurgical therapy for achieving sustained weight loss and controlling comorbid conditions for patients with morbid obesity. Surgical mortality is low (less than 1%) and associated with long-term sustained weight loss of 20 kg to 30 kg. Several professional organizations, including The Royal Australasian College of Physicians, now recommend bariatric surgery as the treatment of choice for patients with morbid obesity, especially if they have comorbid conditions and have failed dietary therapy. Controlled trials have established. that caloric restriction and physical activity can achieve modest weight reduction, usually on the order of 2% to 896. A review of commercial weight-loss programs demonstrated that Weight Watchers was the most effective with a sustained weight reduction of 3% at 2 years. Anumber of medicatic ns (sibutramine, orlistat, and phentermine) are FDA approved for weight reduction but have demonstrated only modest effectiveness. Sibutramine is associated with dry mouth and can elevate blood pressure and therefore is not a good choice for this patient. This patient has morbid obesity with comorbid conditions and has failed dietary therapy and exercise program. Therefore his physician should discuss the possibility of bariatric surgery for treatment of his obesity. References: ‘Uhttps://www.nebi.nlm.nih gov/books/NBK513285/ 2shttps://www.uptodate.com/contents/bariatric-operations-for-management-of-obesity-indications-and- preoperative-preparation NodGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 goos:.:-» (Cicurrent Review/Skip [ll Answered Ml Correct Ml Incorrect ren <= 4, Question Category: Gastroenterology & Gl Surgery An elderly male with a history of alcoholic cirrhosis and oesophageal varices presents with upper gastrointestinal bleed.Which one of the following is true regarding spontaneous bacterial peritonitis and this condition? © Start on prophylactic antibiotics No antibiotics needed © Start blood transfusion © Dourgent ascitic tap and wait for the neutrophil count © Doanascitic culture and wait for the result = =sGI #9 Category-wise Questions (NEW!!!) » Gastroenterology > GI#9 BO: «722» (Cicurrent (i) Review/Skip [lj Answered [Correct Ml Incorrect 4, Question Category: Gastroenterology & Gl Surgery An elderly male with a history of alcoholic cirrhosis and oesophageal varices presents with upper gastrointestinal bleed.Which one of the following is true regarding spontaneous bacterial peritonitis and this condition? ‘Start on prophylactic antibiotics No antibiotics needed Start blood transfusion Do urgent ascitic tap and wait for the neutrophil count Do an ascitic culture and wait for the result Correct ‘The risk of spontaneous bacterial peritonitis is increased in patients with a history of hepatic cirrhosis and variceal bleeding Prophylaxis against spontaneous bacterial peritonitis is recommended when a patient presents with upper gastrointestinal bleeding. Blood transfusion is only needed if there is a significant drop in haemoglobin after blood loss in such cases However, this is not mentioned in this instance, and it is the incorrect choice. Doing a therapeutic or diagnostic ascitic tap is only needed if the patient has ascites. References: fhttps://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/approach-to-the-patient-with- liver-disease/spontaneous-bacterial-peritonitis-sbp 2shttps://wwueuptodate.com/contents/spontaneous-bacterial-peritonitis-in-adults-treatment-and- prophylaxis DodGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 Gonos: ::» Cicurrent Review /! = <= ip Answered [| Correct MI Incorrect 5. Question Category: Gastroenterology & GI Surgery All of the following features favour the diagnosis of achalasia, except? ©. Regurgitation of food ©. Nocturnal regurgitation ©. Dysphagia of solids © Painful swallowing. Dysphagia of liquids = =Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 goo. ::> Cicurrent i Review/Skip Ml Answered Mi Correct Ml Incorrect 5. Question Category: Gastroenterology & GI Surgery All of the following features favour the diagnosis of achalasia, except? Regurgitation of food Nocturnal regurgitation Dysphagia of solids Painful swallowing Dysphagia of liquids Incorrect alack Achalasia is a neurogenic esophageal motility disorder characterized by impaired esophageal peristal of lower esophageal sphincter relaxation during swallowing, and an elevation of lower esophageal sphincter resting pressure, Achalasia occurs at any age but usually begins between ages 20 and 60. Onset is insidious, and progression is gradual over months or years. Dysphagia for both solids and liquids is the major symptom. Nocturnal regurgitation of undigested food occurs in about 35 percent of patients and may cause cough and pulmonary aspiration When the diagnosis of achalasia is suspected, a barium esophagram with fluoroscopy is the single best diagnostic study. This test will reveal loss of primary peristalsis in the distal two-thirds of the oesophagus with to-and-fro movement in the supine position. (Odynophagia is a condition in which an individual experiences pain each time he or she swalllows.ltis not a feature of achalasia. References: ‘Uhttps://www.uptodate.com/contents/achalasia-pathogenesis-clinical-manifestations-and-diagnosis DogGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 goons: Cicurrent Review /! rn <= ip Answered [| Correct MI Incorrect 6. Question Category: Gastroenterology & GI Surgery ‘70-year-old male presented with acute epigastric pain with background history of cholelithiasis. Blood tests showed a moderate elevation of lipase, amylase, alanine aminotransferase, aspartate aminotransferase. Serum bilirubin is normal, Inflammatory markers are not elevated. Abdominal ultrasound showed the small stone inthe common bile duct with no dilatation. What is the most appropriate next step in management? Intravenous fluids, analgesics and antiemetics © CTabdomen Monitor liver function tests © mrcp © ERCP, = =Review Question Cong 6. Question Category: Gastroenterology & GI Surgery ‘70-year-old male presented with acute epigastric pain with background history of cholelithiasis. Blood tests showed a moderate elevation of lipase, amylase, alanine aminotransferase, aspartate aminotransferase. Serum bilirubin is normal, Inflammatory markers are not elevated.Abdominal ultrasound showed the small stone inthe ‘common bile duct with no dilatation. What is the most appropriate next step in management? Intravenous fluids, analgesics and antiemetics CT abdomen Monitor liver function tests MRCP ERCP Correct This patient has the clinical diagno: ‘of acute pancreatitis secondary to gallstones. However, these is no ‘evidence of acute cholangitis and bile duct obstruction (no fever, no jaundice). Also, there is no evidence of sepsis. There is mild liver function test changes which do not suggest bile duct obstruction. So the best approach would be to manage this patient conservatively and monitor daily progress. The most appropriate next step in his managements to give intravenous fluids, intravenous analgesics and antiemetics. ERCP would be required as an elective procedure ifthe patient remains stable and clinically improved. Indications for ERCP within 24-48 hours (in patients with suspected bile duct stones as the cause of pancreatitis clinically) include: ~ Persistently elevated conjugated bilirubin suggesting biliary obstruction. ~ Clinical deterioration (worsening pain, increasing white cells, worsening vital signs). ~ Stone detected in common bile duct. ~ The presence of fever elevated bilirubin and sepsis References: ‘Uhttps://www.mja.com.au/journal/2015/202/8/acute-pancreatitis-update-management al-resources/clinical-tools/abdo! 2shttps://wwwe.aci health.nsw gov.au/networks/eci/clinical/c emergencies/acute-pancreatitis,GI #9 Category-wise Questions (NEW!!!) » Gastroenterology > GI#9 Begnaos: :» Cicurrent Review /! Rew Gueo =a ip Answered [| Correct MI Incorrect 7. Question Category: Gastroenterology & Gl Surgery A.39-year-old Aboriginal man presented with 6 week history of abdominal pain, nausea, vomiting and fatty stools. ‘Abdominal pain radiates to the back and is constant, and disabling He is chronic alcoholic and continues to drink alcohol in large amounts. What is the next step in the management? O. Stools examination (Investigations for exocrine function of pancreas Plain abdominal X-ray UltrasoundCiCurrent () Review /Skip ll Answered [J Correct MJ Incorrect Review Question Cong 7. Question Category: Gastroenterology & GI Surgery ‘39-year-old Aboriginal man presented with 6 week history of abdominal pain, nausea, vomiting and fatty stools. ‘Abdominal pain radiates to the back and is constant, and disabling He is chronic alcoholic and continues to drink alcohol in large amounts. What is the next step in the management? Stools examination Investigations for exocrine function of pancreas Plain abdominal X-ray Ultrasound ERCP Incorrect This patient has suspected clinical diagnosis of chronic pancreatitis secondary to chronic alcohol abuse and requires an ultrasound to confirm the diagnosis. Abdominal pain is a dominant feature of chronic pancreatitis.The pain is typically epigastric.often radiates to the back, is occasionally associated with nausea and vomiting, and may be partially relieved by sitting upright or leaning forward In suspected chronic pancreatitis, CT is moderately accurate in diagnosis and is the frst line investigation of choice. However it is not given in the options. ‘The sensitivity and specificity of ultrasound for the diagnosis of chronic pancreatitis are 60 to 70 percent and 80 to 90 percent, respectively. So this can be used in this situation as well. Endoscopic retrograde pancreatography (ERCP) should be reserved for situations where non-invasive moda Calcifications within the pancreatic duct are present on plain film in approximately 30 percent of patients with n. 's aré not available, are equivocal and for intervent chronic pancreatitis and plain film is never a first line investigation to investigate chronic pancreatitis, References: ‘Uhttps://www.racgp.org.au/afpbackissuies/2008/200808/200808grimpen.pdt NextGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 ee Cicurrent Review/Skip [ll Answered Ml Correct Ml Incorrect 8, Question Category: Gastroenterology & GI Surgery ‘A.49-year-old male presents with epigastric pain worse at night and before meals. He drinks 4 to 6 standard drinks of alcohol every night, He also smokes 30 cigarettes per day for the last ten years. He also reports a history of chronic low back pain and often uses on the counter NSAIDS. His BMI is 42. He has prescribed omeprazole 20mg daily for four weeks which has not helped despite his efforts to modify lifestyle. He had hematemesis before coming tosee you. Which of the following is an indication of upper Gl endoscopy? O Haematemesis Smoking O NSAIDS CO Adequate response to omeprazol © Obesity =8. Question Category: Gastroenterology & GI Surgery ‘A.49-year-old male presents with epigastric pain worse at night and before meals. He drinks 4 to 6 standard drinks of alcohol every night, He also smokes 30 cigarettes per day for the last ten years. He also reports a history of chronic low back pain and often uses on the counter NSAIDS. His BMI is 42. He has prescribed omeprazole 20mg daily for four weeks which has not helped despite his efforts to modify lifestyle. He had hematemesis before coming tosee you. Which of the following is an indication of upper Gl endoscopy? Haematemesis ‘Smoking NSAIDS Adequate response to omeprazol Obesity Correct This patient has developed clinical symptoms gastroesophageal reflux and acute gastritis secondary to excessive alcohol abuse, smoking, NSAIDS etc. The red flag in history is hematemesis and need urgent upper Gl endoscopy as well as hospital admission, (Other red flags which would prompt a referral for endoscopy would include: + Anaemia + Malena + Weight loss «Inadequate response to standard PPI therapy + Dysphagia + Vomiting ‘Smoking cessation, weight loss, reduction in alcohol intake will help however would be offered once patient has been stabilized. References: ‘Uhttps://www.racgp.ore.au/afpbackissues/2004/200411/20041128piterman.pdf NidGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 Baaa b» Cicurrent Review /! ip Answered [| Correct MI Incorrect 9. Question Category: Gastroenterology & Gl Surgery ‘A76-year-old male presented with a history of an episode of light-headedness and shortness of breath while bicycling his daily uphill. He otherwise denied any chest pain, palpitations and loss of consciousness. His symptoms Improved after resting at the side-road. Past medical history includes osteoarthritis and ischaemic stroke 2 years ago with no residual weakness. Regular medications include aspirin 150 mg daily, nurofen 200mg twice daily and multivitamins, The examination is unremarkable. Electrocardiogram and chest X-ray both are normal. Full blood count shows haemoglobin 84 g/L (120-160g/L). What is the next best step in the management? ©. Transfuse 2 units of red blood cells O Withhold aspirin and nurofen until haemoglobin is stable ©. Given iron transfusion © Stress echocardiography ©. Urgent inpatient colonoscopyTransfuse 2 units of red blood cells Withhold aspirin and nurofen until haemoglobin is stable Given iron transfusion Stress echocardiography Urgent inpatient colonoscopy Incorrect Low-dose aspirin use is associated with an increased risk for gastrointestinal ulceration and bleeding. At-risk low-dose aspirin users are therefore recommended to take proton-pump inhibitors. However, itis poorly understood which aspirin users are at risk to develop such complications. It is assumed that the known risk factors for NSAID-induced upper gastrointestinal events also apply to low-dose aspirin users. The conventional risk factors for upper gastrointestinal complications associated with aspirin therapy include: (1) a history of peptic ulcer disease or gastrointestinal bleeding, (2) older age, (3) concomitant use of NSAIDs, including coxibs, (4) concomitant use of anticoagulants or other platelet aggregation inhibitors, (5) the presence of severe co-morbidities, and (6) high aspirin dose. In patients with a history of peptic ulcer disease, Helicobacter pyloriinfection should be assessed and treated. ‘This patient has been on aspirin for secondary prevention of stroke and NSAIDs for pain control in oesteoarthritis. He is at a very high risk of developing gastrointestinal bleed secondary to gastric mucosal irritation caused by both aspirin and NSAIDs (the blocking the Cox-1 enzyme and disrupting the production of prostaglandins in the stomach) Approximately 70 percent of peptic ulcers are asymptomatic. Patients with silent peptic ulcers may later present with ulcer-related complications such as hemorthage or perforation. Between 43 and 87 percent of patients with bleeding peptic ulcers present without antecedent dyspepsia or other heralding gastrointestinal symptoms. Older adults and individuals on nonsteroidal anti-inflammatory drugs are more likely to be asymptomatic from their ulcers and later present with ulcer complication in which is seen in this patient. ‘The symptoms of anaemia are unmasked with exercise and improve when patient do have some rest. At this stage, this patient does not have critically low (less than 70 g/L) to mandate blood transfusion. Iron transfusion will be only be required if serum ferritin and iron level, are low on iron studies. In such situation, both aspirin and nurofen should be discontinued and no other antiplatelet (clopidogrel) should be commenced until haemoglobin is stable. An cesophagogastroduodenoscopy should be scheduled to rule out peptic ulcer disease or any upper GI malignancy. A non-urgent outpatient colonoscopy would be also required to rule out bowel cancer in this age group. Reference: ‘VU httpsi//wwwsciencedirect.corn/science/article/abs/pii/S15216918120001217via%3Dihub 2/ https://www.uptodate.comn/contents/nsaids-including-aspirin-secondary-prevention-of gastroduodenal: toxicity NextGI #9 Category-wise Questions (NEW!!!) > Gastroenterology > GI#9 Cicurrent Review/Skip [ll Answered Ml Correct Ml Incorrect 10. Question Category: Gastroenterology & GI Surgery Which of the following is not an indication of urgent surgical intervention? © Tender abdominal mass and hypotension (. Massive bowel distention (colon > 12 em) (© Septicemia and abdominal findings © Progressive distension of abdomen © Localized peritonitisCategory-wise Questions (NEW!!!) > Gastroenterology > GI#9 8 @ 85 Cicurrent (i) Review/Skip [lj Answered [Correct MJ Incorrect Review Question QuizSummary 10. Question Category: Gastroenterology & GI Surgery Which of the following is not an indication of urgent surgical intervention? Tender abdominal mass and hypotension Massive bowel distention (colon > 12 cm) Septicemia and abdominal findings Progressive distension of abdomen Localized peritonitis Incorrect Indications for urgent abdominal surgical interventions include: 1 Diffuse peritonitis(localized peritonitis is not always an indication). 2-Severe or increasing localized tenderness. abdominal distension. 3-Progre: 4-Tender mass with fever or hypotension (abscess). 5-Septicemia and abdominal findings. 7-Bleeding and abdominal findings. 8-Suspected bowel ischemia (acidosis fever tachycardia). 9-Massive bowel dilatation more than 12cm. Localized peritonitis is not an indication for urgent surgical intervention and can be managed conservatively. Hence it is the correct answer. References: ‘AUphttps://wwwencbi.nlm.nih.gov/books/NBK333506/