GI Board Review – Part I
Esophagus, Stomach, and Pancreas
February 21, 2013
Esophagus
A 58-year-old man is evaluated for a 4-week history of progressive difficulty
swallowing liquids. The symptom begins immediately with the initiation of a swallow
and has recently been associated with coughing. The patient does not have fever or
weight loss.
His only significant medical history is atherosclerotic cardiovascular disease; his only
medications are a β-blocker, a statin, and aspirin.
Vital signs are normal, and physical examination shows only crackles at the posterior
base of the right lung field.
100%
Which of the following is the most appropriate next
diagnostic test in the evaluation of this patient?
1.
2.
3.
4.
Barium esophagram
CT scan of the chest and abdomen
Esophageal manometry
Videofluoroscopy
0%
1
0%
2
0%
3
4
A 53-year-old man is evaluated after a recent episode of substernal chest pain. He was
evaluated in the emergency department for chest pain, and serial electrocardiograms
and measurement of cardiac enzymes showed no evidence of myocardial ischemia. An
outpatient stress test also showed no evidence of myocardial disease. The patient has
a history of medically controlled hypertension, and his only medication is amlodipine.
On physical examination, the patient appears healthy and vital signs are normal.
Barium esophagography shows a segmented or “corkscrew” esophagus. Esophageal
manometry shows simultaneous contractions in the distal esophagus with 50% of
swallows.
Which of the following is the most appropriate therapy for this patient?
100%
1.
2.
3.
4.
5.
Esophageal bougienage
Laparoscopic myotomy
Oral anticholinergic therapy
Oral proton pump inhibitor therapy
Pneumatic dilatation
0%
1
0%
0%
2
3
0%
4
5
A 74-year-old woman is evaluated for 3 years of progressive dysphagia, first for solid foods and
now for both solid foods and liquids; she has had frequent episodes of regurgitation of
undigested food and has lost 6.8 kg (15 lb) during the past 6 months. Her medical history includes
stenting of the left anterior descending coronary artery 1 year ago after which she has had
symptomatic residual distal stenosis. She had a cerebrovascular accident 2 years ago and still has
mild residual right hemiparesis. Her medications include metoprolol, clopidogrel, enalapril,
aspirin, and hydrochlorothiazide.
On physical examination, the patient is thin (BMI 20) and appears ill, although not in distress.
Vital signs are normal. Chest radiograph shows a dilated esophagus with an air/fluid level and
changes of chronic aspiration in the right lung base. Barium esophagography shows “bird beak”
narrowing of the distal esophagus and mega-esophagus with retained fluid in the esophageal
body. Esophageal manometry shows aperistalsis of the esophageal body and incomplete lower
esophageal sphincter relaxation with swallowing. On esophagogastroduodenoscopy, the
endoscope passes through the lower esophageal sphincter without resistance; there are no
masses in the esophagus or the gastric cardia.
100%
Which of the following is the most appropriate therapy
for this patient?
1.
2.
3.
4.
Anticholinergic therapy
Botulinum toxin injection
Laparoscopic myotomy
Pneumatic dilatation
0%
1
0%
2
3
0%
4
Causes of dysphagia
Dysphagia
Oropharyngeal
Usually due to
neuromuscular
conditions
Intermittent
Esophagel ring;
Eosinophilic
esophagitis
Esophageal
Solids
Solids & Liquids
(motility disorder)
(structural lesion)
Progressive with
chronic GERD
Peptic stricture
Progressive
Esophageal CA
Intermittent
Esophageal
spasm
Progressive with
chronic GERD
scleroderma
Progressive
achlasia
Evaluation of Dysphagia
• History!
– Initiation of swallowing or after initiation?
• If oropharyngeal
– Dx: video fluoroscopy
• If esophageal
– Dx:
1. Esophagram
2. EGD
3. Manometry
A 44-year-old woman is evaluated for a 6-month history of dyspepsia, regurgitation of
sour fluid, and eructation. There is no associated fever, chills, weight loss, or vomiting.
The condition failed to respond to a 6-week trial of omeprazole therapy.
The patient’s medical history includes hypertension, type 2 diabetes mellitus, and
obesity (BMI 36); her medications are lisinopril, metformin, and insulin glargine. On
examination, vital signs are normal; there is mild epigastric tenderness without
rebound, and stool is negative for occult blood.
Which of the following is the most appropriate
next diagnostic step in the evaluation of
this patient?
1.
2.
3.
4.
100%
Ambulatory esophageal pH monitoring
Barium esophagography
CT scan of the chest
Esophageal manometry
0%
1
2
0%
3
0%
4
GERD
• Most commonly due to transient relaxation of LES
• Extraesophageal manifestations: cough, asthma, hoarseness, laryngitis
• Diagnosis:
1. 4 week trial of PPI (75% sensitivity; 55% specificity)
2. EGD
3. pH monitor (*gold standard) +/- impedance
• Treament:
– Lifestyle modification
– Meds (PPI, H2 blocker, etc)
– Surgery – Nissen fundoplication (although poor results)
– Endoscopic tx – RFA, injected polymers, etc (lasts up to 1 year at best)
A 42-year-old woman is evaluated in the emergency department for substernal chest
pain of 18 hours’ duration. She describes the pain as a tightening that is not associated
with eating or exertion and that radiates to the neck. The pain is not accompanied by
dyspnea, nausea, or diaphoresis. She had a similar episode 1 month ago, and an
exercise stress test showed no areas of ischemia. The patient’s medical history
includes hypertension and type 2 diabetes mellitus; her medications include ramipril,
metformin, and aspirin.
On physical examination, the patient appears uncomfortable but not acutely ill. The
temperature is 37.2 °C (99.0 °F), the blood pressure is 130/74 mm Hg, the pulse rate is
88/min, and the respiration rate is 16/min; the BMI is 31.5. The lungs are clear; the
heart rate is regular and there are no murmurs. Electrocardiography shows nonspecific
ST and T wave abnormalities, which are unchanged from a previous examination.
100%
Which of the following is the most appropriate
management for this patient?
1. Ambulatory esophageal pH monitoring
2. Esophageal manometry
3. Esophagogastroduodenoscopy
4. Oral proton pump inhibitor therapy
5. Repeat exercise stress test
0%
1
0%
0%
2
3
0%
4
5
Non-Cardiac Chest Pain
• After cardiac causes, esophageal causes are
second most common to cause chest pain
• If due to esophageal cause, GERD is most
common
• Step 1 – rule out cardiac cause
• Step 2 – trial of PPI
• Step 3 –if no improvement, send for pH
monitoring vs manometry vs EGD
A 47-year-old man is evaluated in the emergency department for 7 days of
odynophagia with epigastric pain, nausea and vomiting, diarrhea, and low-grade fever;
he has lost 4.5 kg (10 lb) during the episode. The patient received a kidney transplant
6 months ago for hypertensive kidney disease; his medications are atenolol,
prednisone, tacrolimus, and mycophenolate mofetil. He has no other medical
problems and denies any HIV risk factors.
On physical examination, the temperature is 38.0 °C (100.8 °F), the blood pressure is
148/94 mm Hg, the pulse rate is 90/min, and the respiration rate is 22/min.
Esophagogastroduodenoscopy shows a 2.5-cm esophageal ulcer with raised borders.
The rest of the esophagus appears normal. Biopsy specimen from the base of the ulcer
shows intense inflammatory infiltrates with granulation tissue associated with
100%
occlusion body cells.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Candida albicans esophagitis
Cytomegalovirus esophagitis
HIV esophagitis
Pill-induced esophageal ulcer
0%
1
0%
2
3
0%
4
A 26-year-old woman is evaluated in the emergency department for progressive
odynophagia of 3 days’ duration. The patient has a 6-year history of limited systemic
sclerosis characterized by skin sclerosis limited to the fingers with early contractures,
Raynaud phenomenon, and gastric dysmotility and gastroesophageal reflux disease.
Her medications include nicardipine, omeprazole, erythromycin, acetaminophen and
NSAIDs as needed. Prednisone, 5 mg/d, was recently started to treat increasingly
painful fingers.
On physical examination, the patient appears anxious and uncomfortable. The
temperature is 37.0 °C (98.6 °F), the blood pressure is 132/88 mm Hg, the pulse rate is
80/min, and the respiration rate is 22/min. She has skin tightening and cutaneous
telangiectasia involving the proximal and distal digits. Cardiopulmonary examination is
normal and the abdomen has active bowel sounds and is soft to palpation.
50%
50%
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
5.
Barrett esophagus
Candidal esophagitis
Esophageal stricture
Herpetic esophagitis
Pill-induced esophagitis
0%
1
0%
2
3
0%
4
5
Esophagitis (non-reflux induced)
• Infectious
– Patient will have risk factors (post-transplant or HIV risk factors)
& odynophagia
– EGD needed to visualize lesions
• Pill-induced
– Present with odynophagia
– Big culprits: Tetracyclines, Iron, NSAIDs
– Need EGD to look for lesions (erosions, etc)
• Eosinophilic
– Often will present with food impaction and history of atopy
– Dx: EGD with biopsy
– Tx: inhaled steroids (down esophagus)
Stomach
A 67-year-old woman is evaluated for a 2-month history of epigastric discomfort, a
burning sensation that does not radiate and is not associated with eating. She has had
episodic mild nausea and intermittent bloating but no acid regurgitation, heartburn,
dysphagia, or odynophagia. She has one bowel movement of well-formed stool a day,
and her weight is stable. The patient has a history of osteopenia and gallstone
pancreatitis for which she had a cholecystectomy; her medications include calcium
and vitamin D supplements. Her mother had gastric cancer.
On physical examination, vital signs are normal. There is mild epigastric tenderness,
normal bowel sounds with no bruits, no rebound or guarding, and no hepatomegaly
or lymphadenopathy. Complete blood count and serum chemistry tests, including liver
enzymes, amylase, and lipase, are normal.
100%
Which of the following is the most appropriate
management of this patient?
1.
2.
3.
4.
5.
Endoscopic retrograde cholangiopancreatography
Esophagogastroduodenoscopy
Helicobacter pylori stool antigen assay
Nortriptyline at bedtime
Proton pump inhibitor empiric trial
0%
1
0%
2
3
0%
0%
4
5
Workup of Dyspepsia
Dyspepsia
(discomfort in
mid abdomen)
No NSAID or
Heartburn sx
Heartburn Sx
NSAID use
Alarm
symptoms?
Treat as GERD
Yes
Stop NSAIDS or
add PPI
No
EGD
Test and treat
for H.pylori
Alarm Symptoms: age >55 and new onset sx, weight loss, FHx prox GI cancer,
iron deficiency anemia, odynophagia or progressive dysphagia, persistent
vomiting, jaundice, LAD
A 41-year-old woman is evaluated for a 4-month history of intermittent mid-upper-abdomen
pain, which does not radiate and is not affected by eating. She had GERD when she was pregnant,
but she says that the current symptoms are not like those of reflux or heartburn. She occasionally
feels nauseated and mildly bloated, but she has not vomited, felt early satiety, or lost weight. She
does not have difficulty swallowing or painful swallowing. Her bowel movements are normal. She
has been pregnant twice and had two healthy children, both delivered by cesarean section. Her
medical history also includes a cholecystectomy 5 years ago. Her only current medication is a
multivitamin.
On physical examination, she is afebrile; the pulse rate is 65/min and the blood pressure is
110/65 mm Hg. There is no jaundice or scleral icterus; mild epigastric tenderness is present.
Bowel sounds are normal; there are no abdominal bruits, palpable masses, or lymphadenopathy.
Complete blood count and liver chemistry tests are normal.
100%
Which of the following is the most appropriate next
diagnostic test in the evaluation of this patient?
1.
2.
3.
4.
5.
Abdominal ultrasonography
Esophagogastroduodenoscopy
Gastric scintigraphy
Helicobacter pylori stool antigen
Small-bowel radiograph
0%
1
0%
0%
2
3
0%
4
5
A 38-year-old man is evaluated for persistent dyspepsia 2 months after a duodenal
ulcer was detected and treated. He originally presented with new-onset epigastric
pain, and EGD showed a duodenal ulcer; biopsy specimens showed the presence of
Helicobacter pylori. The patient, who does not use NSAIDs and is penicillin-allergic,
completed a 10-day course of therapy with omeprazole, metronidazole, and
clarithromycin.
At this time, urea breath testing for H. pylori shows persistent infection.
In addition to a proton pump inhibitor, which of the following regimens is indicated for
this patient?
50%
1.
2.
3.
4.
5.
50%
Amoxicillin and levofloxacin
Bismuth subsalicylate, metronidazole, and tetracycline
Clarithromycin and amoxicillin
Clarithromycin and metronidazole
Trimethoprim–sulfamethoxazole and erythromycin
0%
1
0%
2
3
0%
4
5
H. pylori - complications
H. pylori
*Antral gastritis
*Duodenal ulcer
Nonatrophic
pangastritis
MALT
Gastric Ulcer
Corpus gastritis
Gastric
Adenocarcinoma
• 80% of duodenal ulcers and 50% of gastric ulcers are associated with
H. pylori
• 75% of MALT lymphoma cases are H. pylori +
• Treat bacteria = regression of tumor in 70-80%
• In all of these pathways, patient can also have asymptomatic disease!
H. pylori - Diagnosis
• Testing indications:
– PUD, low-grade MALT lymphoma, post-resection for early gastric cancer,
<55yo with dyspepsia and no alarm symptoms
• Diagnosis:
– Endoscopic:
• Biopsy/histology
• Urease test (affected by PPI – up to 2 weeks, bismuth/abx – up to 4 weeks)
– Nonendoscopic:
• Stool Antigen
• Urea breath test (affected by PPI, bismuth, abx)
• Serum Ab
• Confirmation of eradication
– Only if: H. pylori associated ulcer, persistent dyspepsia despite test/treat
approach, H. pylori assoc MALT lymphoma, previous gastric CA
– 4 weeks after completing therapy -> stool Ag or urease breath test
H. pylori - Treatment
• Triple Therapy x10-14 days:
– PPI + Clarithromycin + Amoxicillin
• If treatment failure:
– Quadruple therapy x7-14d
PPI + Flagyl + Tetracycline + Bismuth
– Driven by specific susceptibilities
– Salvage Therapy
PPI + Amoxicillin +Levo/Rifabutin/Furazolidone
– Sequential Therapy
PPI + Amox x5d, then PPI + Clarithro + Tinidazole
A 65-year-old woman is evaluated 1 week after having had an EGD for persistent
abdominal pain. The procedure showed a 1-cm, clean-based ulcer in the duodenal
bulb and scattered antral erosions. Biopsy specimens from the stomach showed
nonspecific gastritis but no evidence of Helicobacter pylori infection. Serum antibody
testing for H. pylori was also negative. Proton pump inhibitor therapy was started, and
the patient’s symptoms were alleviated. The patient has a history of mild
osteoarthritis and osteoporosis, and her medications include a nonprescription
analgesic for arthritis and a calcium supplement, vitamin D, and alendronate.
On physical examination, vital signs are normal. The abdominal examination reveals no
tenderness, hepatomegaly, or palpable masses. Complete blood count is normal.
100%
Which of the following is the most appropriate
next step in the management of this patient?
1.
2.
3.
4.
5.
Measure serum gastrin
Perform fecal antigen test for Helicobacter pylori
Repeat EGD with biopsy of the ulcer
Review the nonprescription arthritis analgesic
Stop alendronate therapy
0%
1
0%
0%
2
3
0%
4
5
PUD
• Gastric ulcer – gets better with food
• Duodenal ulcer – gets worse with food
• Etiologies:
– NSAIDs, H. pylori, Crohn’s, malignancy, Zollinger-Ellison, Viral
(CMV), drugs (cocaine)
• Complications:
– Bleeding, perforation, outlet obstruction (typically from ulcer in
prepyloric area)
• Therapy:
– Eval for H. pylori and stop NSAIDs
– Start PPI
– Surgery only if failure to respond to acid suppression or if life
threatening disease
• Vagotomy (to decrease Ach thus decreasing acid secretion) vs
A 37-year-old woman is evaluated for diffuse musculoskeletal pain at her 1-year
follow-up after a Roux-en-Y gastric bypass for medically complicated obesity. She has
lost 36.4 kg (80 lb) since surgery but she thinks that her weight has stabilized over the
past few months. She has two to three bowel movements of well-formed stool a day.
She has some diffuse musculoskeletal pain but otherwise feels well.
Her medical history includes the gastric bypass, a cholecystectomy, diet-controlled
type 2 diabetes mellitus, and hypothyroidism. Her medications include levothyroxine,
a multivitamin containing iron, vitamin B12 by injection, and over-the-counter calcium
and vitamin D. Physical exam is benign including normal muscle strength with no
focal muscle tenderness. Laboratory studies show a serum alkaline phosphatase of
314 U/L; all other tests, including complete blood count,
100%
aminotransferases, bilirubin, γ-glutamyltranspeptidase,
serum thyroid-stimulating hormone, free thyroxine, and
calcium, are normal.
Which of the following is the most appropriate next
step in the evaluation of this patient?
1. Anti–smooth muscle antibody test
2. Measurement of 25-hydroxyvitamin D
3. Measurement of serum creatine kinase
4. Measurement of triiodothyronine
5. Ultrasonography of the liver
0%
1
0%
2
3
0%
0%
4
5
Complications of bariatric surgery
• Roux-en-Y
– Early complications:
• Anastamotic leak, bowel
obstruction, hemorrhage,
VTE, wound infection
– Late complications:
• Anastomotic stricture,
bacterial overgrowth,
incisional hernia, marginal
ulcer, nutritional
deficiencies (iron, B12,
folate, Ca, Vit D, thiamine)
• Gastric Resection
– Dumping syndrome
– Afferent Loop syndrome (seen
with Billroth II)
A 39-year-old woman is evaluated for a 6-week history of nausea and intermittent vomiting,
which began after a 3-day episode of severe nausea, vomiting, and diarrhea. At the same time,
her school-age children had a similar episode that resolved spontaneously. However, since that
time, the patient has had daily nausea worsened by eating, early satiety, bloating, and vomiting
of large volumes of nonbilious food. She does not have abdominal pain, but in the past 6 weeks,
she has lost 4.5 kg (10 lb). The patient’s medical history includes a transsphenoidal resection of a
nonfunctioning pituitary adenoma 3 years ago and two deliveries by cesarean section. Her
mother has depression, and her father has primary sclerosing cholangitis.
On physical examination, she is thin (BMI 19); vital signs are normal. She responds appropriately
and makes normal eye contact; there is no jaundice or scleral icterus. There is mild abdominal
distention and normal bowel sounds without succussion splash or tenderness. Laboratory
studies, including liver enzymes, are normal. EGD reveals retained gastric contents but no
100%
obstruction. Radiograph of the small bowel is normal.
Which of the following is the most appropriate
next step in the evaluation of this patient?
1.
2.
3.
4.
5.
Biliary ultrasonography
Gastric scintigraphy
MRI of the head
Referral for biofeedback training
Viral culture of stool
0%
1
0%
2
3
0%
0%
4
5
Gastric Motility Disorders
• 20-40% of DM1; 25-40% of functional dyspepsia
• Symptoms: n/v, bloating, early satiety, postprandial
fullness
• Need EGD or esophagram to rule out obstruction prior to
motility study
• Dx: gastric scintigraphy of radiolabeled meal
– Retention of >10% at 4 hours is abnormal
• Causes of gastroparesis:
– Idiopathic (33%), DM (25%), post-op (20%), post-viral,
neuromuscular disorders, paraneoplastic conditions, CTD
*Note: succussion splash is a sloshing sound heard through
stethescope during sudden movement of the patient upon abd
auscultation. Indicates gastric outlet obstruction.
Pancreas
A 34-year-old woman is evaluated for continued severe mid-epigastric pain that radiates to the
back, nausea, and vomiting 5 days after being hospitalized for acute alcohol-related pancreatitis.
She has not been able eat or drink and has not had a bowel movement since being admitted.
On physical examination, the temperature is 38.2 °C (100.8 °F), the blood pressure is 132/84 mm
Hg, the pulse rate is 101/min, and the respiration rate is 20/min. There is no scleral icterus or
jaundice. The abdomen is distended and diffusely tender with hypoactive bowel sounds
WBC: 15,400
AST: 189
ALT: 151
Bili: 1.1
Amylase: 388
Lipase: 924
100%
CT scan of the abdomen shows a diffusely edematous
pancreas with multiple peripancreatic fluid collections,
and no evidence of pancreatic necrosis.
Which of the following is the most appropriate next
step in the management of this patient?
1.
2.
3.
4.
Enteral nutrition by nasojejunal feeding tube
Intravenous imipenem
Pancreatic debridement
Parental nutrition
0%
1
2
0%
3
0%
4
A 44-year-old man with a long history of alcohol abuse is evaluated on the sixth day of
hospitalization for acute pancreatitis. On admission to the hospital, he was afebrile, the blood
pressure was 150/88 mm Hg, the pulse rate was 90/min, and the respiration rate was 16/min.
Abnormal findings were limited to the abdomen, which was flat and tender to palpation without
peritoneal signs. Bowel sounds were normal. Plain abdominal and chest radiographs were
normal. Abdominal ultrasonography revealed a diffusely enlarged, hypoechoic pancreas without
evidence of gallstones or dilated common bile duct. He was treated with aggressive intravenous
hydration and opioid analgesia. For the past 2 days, the patient has had repeated febrile
episodes, persistent severe abdominal pain, and increasing shortness of breath.
On physical examination, the temperature is 38.6 °C (101.5 °F), the blood pressure is 98/60 mm
Hg, the pulse rate is 112/min, and the respiration rate is 22/min; oxygen saturation is 92% with
the patient breathing oxygen 3 L/min. Breath sounds are decreased at the base of both lungs. The
abdomen is distended and diffusely tender with hypoactive bowel sounds. Laboratory studies
reveal leukocyte count of 19,800/µL (19.8 × 109/L), creatinine 1.4 mg/dL (106.8 µmol/L), amylase
100%
388 U/L, and lipase 842 U/L
Which of the following is the most appropriate next step in the
evaluation of this patient?
1. CT scan of the abdomen with intravenous contrast
2. Endoscopic retrograde cholangiopancreatography
3. Endoscopic ultrasonography
4. Stool chymotrypsin
0%
1
2
0%
3
0%
4
55-year-old woman is evaluated in the hospital for a 2-day history of epigastric abdominal pain,
nausea and vomiting, and anorexia. The patient has no significant medical history and takes no
medications.
On physical examination, the temperature is 38.0 °C (100.5 °F), the blood pressure is 124/76 mm
Hg, the pulse rate is 99/min, and the respiration rate is 16/min. There is scleral icterus and a slight
yellowing of the skin. There is mid-epigastric and right upper quadrant tenderness. There is no
palmar erythema, spider angiomata, or other evidence of chronic liver disease
WBC: 14,900
AST: 656
ALT: 567
Bili: 5.6
Amylase: 1284
Lipase: 6742
Abdominal ultrasound shows a biliary tree with dilated
common bile duct of 12mm and cholelithiasis but no
choledocholithiasis.
1.
2.
3.
4.
Which of the following is the most appropriate next step
in the management of this patient?
CT scan of the abdomen and pelvis with pancreatic protocol
Endoscopic retrograde cholangiopancreatography
0%
Hepatobiliary iminodiacetic acid (HIDA) scan
1
Magnetic resonance cholangiopancreatography
100%
0%
2
3
0%
4
42-year-old woman is evaluated in the emergency department for the acute onset of epigastric
pain that radiates to the back and is associated with nausea and vomiting. The patient had
previously been healthy and has no history of alcohol or tobacco use. Her only medication is an
oral contraceptive pill.
On physical examination, the temperature is 37.2 °C (99 °F), the blood pressure is 158/90 mm Hg,
the pulse rate is 101/min, and the respiration rate is 20/min. There is no scleral icterus or
jaundice. The abdomen is distended with mid-epigastric tenderness without rebound or guarding
and with hypoactive bowel sounds.
100%
WBC: 13,500
AST: 131
ALT: 567
Bili: 1.1
Amylase: 824
Lipase: 1432
Radiography of the abdomen shows mild ileus
Which of the following is the most appropriate next
step in evaluation of this patient?
1.
2.
3.
4.
CT scan of abdomen/pelvis
ERCP
Esophagogastroduodenoscopy
Ultrasound of the abdomen
0%
1
0%
2
3
0%
4
A 35-year-old man is evaluated in the emergency department for the acute onset of abdominal
pain and nausea; he does not have diarrhea or other changes in bowel habits. The patient has a
17-year history of Crohn disease, which was managed with long-term corticosteroid therapy until
he began therapy with azathioprine 4 months ago; his disease has been stable since that time
until the current episode. He takes no other medications.
On physical examination, the temperature is 37.0 °C (98.5 °F), the blood pressure is 108/76 mm
Hg, the pulse rate is 110/min, and the respiration rate is 19/min. There is no scleral icterus. There
is mild epigastric tenderness, but the rest of the examination is normal. Right upper quadrant
abdominal ultrasonography is normal
100%
Hgb: 17.2
WBC: 4,500
AST: 20
ALT: 22
Bili: 0.9
Amylase: 1500
Lipase: 1630
What is the most likely diagnosis?
1. Azathioprine-induced pancreatitis
2. Crohn disease flare
3. Gallstone pancreatitis
4. Helicobacter pylori-associated gastritis
5. Peptic ulcer disease
1
0%
0%
2
3
0%
0%
4
5
Acute Pancreatitis
• Etiology:
– EtOH (35%), stones (45%), idiopathic (10%), viral
infection, hypertrigliceridemia, hypercalcemia,
drugs (azathioprine, sulfa, flagyl, didanosine),
obstruction
• Management:
– Early NJ feeds
– Abx (Carbapenem) only if necrosis
– CT scan with contrast to look for necrosis only if
not improving or fever >3-5 days
Acute Pancreatitis - Complications
• Pseudocyst - maturing collection of pancreatic juice encased by
reactive granulation tissue, occurring in or around the pancreas as a
consequence of inflammatory pancreatitis or ductal leakage
– walls formed by adjacent structures such as the stomach, transverse
mesocolon, gastrocolic omentum, and pancreas. The lining of the
pseudocysts consists of fibrous and granulation tissue
– Take 4 weeks to form, often resolve on their own and usually
asymptomatic
– Can cause pain/obstruction by pressing on other organs
• Treat with perc drainage or endoscopic/surgical drainage
– Abscess = infected pseudocyst
• Worsening abd pain, fever, increasing WBC count
• Perc or surgical drainage + Abx
• Tract leaks/fistulas
– Lead to pancreatic ascites
– Bowel rest + endoscopic stenting or surgery
• Splenic Vein Thrombosis
– Lead to gastric varices and bleeding
A 51-year-old man is evaluated for an 8-month history of mid-epigastric pain that is worse after
eating, six to eight bowel movements a day usually occurring after a meal, and loss of 6.8 kg (15
lb) over the past 6 months. The patient drinks six to eight cans of beer a day. He takes no
medications.
On physical examination, the patient is thin (BMI 21) and has normal bowel sounds, midepigastric tenderness, but no evidence of hepatosplenomegaly or masses. Rectal examination
reveals brown stool that is occult blood negative. The remainder of the examination is normal.
Plain radiograph of the abdomen shows a normal bowel gas pattern and is otherwise normal
WBC 6800
Plt 69,000
Fasting glc 154
AST 191
ALT 82
Amylase 122
Lipase 289
50%
50%
Which of the following tests is most likely to
establish the diagnosis in this patient?
1.
2.
3.
4.
Colonoscopy
CT scan of the abdomen
Measurement of serum antiendomysial Abs
Stool for leukocytes, culture, ova, and parasites
0%
1
2
3
0%
4
A 42-year-old man is evaluated in the hospital for a 1-year history of postprandial
abdominal pain that radiates to the back and that is worse after eating and is
associated with nausea. He has not had vomiting, weight loss, or change in bowel
habits. The patient has had at least five alcohol-containing drinks a day for 20 years;
he has reduced his intake in the past year because of continued abdominal pain.
On physical examination, vital signs are normal; BMI is 24. There is mild epigastric
tenderness with no guarding or rebound and normal bowel sounds. Laboratory
studies reveal normal complete blood count, fasting glucose, and liver chemistry tests;
amylase is 221 U/L and lipase 472 U/L. Radiography, ultrasonography, and CT scan of
the abdomen are normal, as is esophagogastroduodenoscopy.
50%
50%
Which of the following is the most appropriate next
step in the evaluation of this patient?
1.
2.
3.
4.
Biliary scintigraphy
Colonoscopy
Endoscopic retrograde cholangiopancreatography
Measurement of stool elastase
0%
1
0%
2
3
4
Chronic Pancreatitis
• Chronic inflammation -> fibrosis -> destruction of both endocrine
and exocrine function
– Loss of both beta cells (insulin producing) and alpha cells (glucagon
producing) -> brittle DM
• Clinical: epigastric pain, postprandial diarrhea (due to
malabsorption), and diabetes
• Diagnosis (via imaging):
– ERCP = gold standard, esp for early disease (95% sensitivity)
– EUS or MRCP – just as good as ERCP and may even be better for
moderate to advanced disease
– CT scan (90% sensitivity)
• Treatment:
– Careful glycemic control
– Low fat diet and enzyme supplementation
– Pain control (including celiac plexus block, surgery, stone removal)
A 72-year-old man is evaluated for a 2-month history of epigastric discomfort
associated in the past 6 weeks with a 4.6-kg (10 lb) weight loss; he has had 2 weeks of
dark urine and light stool. The patient has no significant medical history and takes no
medications.
On physical examination, vital signs are normal. There is scleral icterus, visibly
jaundiced skin, and mild epigastric tenderness. Laboratory studies are significant for
total bilirubin of 8.2 mg/dL (140.2 µmol/L) and alkaline phosphatase of 648 U/L. CT
scan of the abdomen shows fullness in the head of the pancreas and biliary dilation
but no evident pancreatic mass.
Which of the following is the most appropriate next step in the management of this
50%
50%
patient?
1.
2.
3.
4.
5.
Endoscopic ultrasonography
Measurement of CA 19-9 concentration
Surgical exploration
Ultrasonography of the abdomen
Visceral angiography
0%
1
2
3
0%
0%
4
5
An 81-year-old woman is evaluated for a 3-month history of abdominal and back pain. She also
has anorexia and has lost 11.4 kg (25 lb). For the past 2 weeks she has had progressive pruritus
and a yellow tint to her skin.
On physical examination, the patient appears ill; the temperature is 37.2 °C (99 °F), the blood
pressure is 104/62 mm Hg, the pulse rate is 98/min, and the respiration rate is 16/min. There is
scleral icterus, jaundiced skin, and generalized abdominal tenderness. Laboratory studies reveal a
leukocyte count of 13,200/µL (13.2 × 109/L), total bilirubin 12.4 mg/dL (212 µmol/L), alkaline
phosphatase 748 U/L, and CA 19-9 822 U/L. CT scan shows a 3.2-cm lesion in the head of the
pancreas with dilation of the pancreatic and bile ducts and multiple lesions throughout the liver
that are consistent with metastases. Endoscopic ultrasonography biopsy specimen of the mass is
positive for adenocarcinoma.
50%
50%
Which of the following is the most appropriate next
step in the management of this patient?
1.
2.
3.
4.
Biopsy of a liver lesion
Placement of a metal biliary stent
Radiation to the pancreas and liver lesions
Surgical resection of the pancreatic lesion and adjuvant chemotherapy
0%
1
2
3
0%
4
Pancreatic Cancer
• Presentation:
– **Painless jaundice (if head mass)
– Epigastric pain (if in body or tail)
– Elevated LFTs in cholestatic pattern (if mass causing obstruction)
• Diagnosis:
– Spiral CT abdomen
– EUS (much better than CT if <2cm lesion, plus can get biopsy
and nodal staging)
• Treatment:
– Localized/resectable – Whipple (if in head) + chemo/XRT
– Locally advanced – chemo/XRT
– Metastatic (85%) – palliative +/- chemo