GI SA!

A 62-year-old woman has a history of celiac disease for 20 years. She also has a history of autoimmune thyroid disease, osteoarthritis for which she is taking nonsteroidal anti-inflammatory drugs (NSAIDs), and chronic obstructive pulmonary disease. She comes to the clinic complaining of diarrhea. This has been present for the past 8 months. Her appetite is good and she has not lost any weight. She denies nausea, vomiting, hematochezia, or melena. She has always maintained a strict gluten-free diet. Her primary doctor has performed some initial investigations that include an immunoglobulin A (IgA) tissue transglutaminase (tTG), which is normal. She has had an upper endoscopy and colonoscopy, both of which were visually normal. Biopsies from the second part of her duodenum showed normal villi consistent with treated celiac disease, while biopsies from right side of her colon demonstrated an inflammatory infiltrate in the lamina propria, with 25 lymphocytes per 1000 epithelial cells. Biopsies from the left side of her colon were normal. A capsule endoscopy of her small bowel and a computed tomography scan of the abdomen and pelvis were normal. Which of the following diagnoses is the most likely explanation for her current symptoms?

All of the following are extraintestinal manifestations that are associated with ulcerative colitis except

45-year-old obese male has seen a few doctors for fatigue. He has had thyroid function testing, 24-hour urine cortisol, sleep studies, complete blood count test and a comprehensive metabolic panel peformed. The only lab abnormalities are slightly elevated aspartate aminotransferase (AST) and alanine aminotransaminase (ALT) levels. He has also had an ultrasound of the liver that does not show fatty liver. Today you check a transferrin saturation level which comes back at 55%. Even though the transferrin saturation elevation is not a specific test, it suggests underlying hemochromatosis in the setting of elevated liver function tests.

All of the following are true of this condition except:

36-year-old female with hypothyroidism comes to your office and complains of oily, frothy, and foul-smelling diarrhea that she has been experiencing for the past few months. Tissue transglutaminase antibodies is checked on the patient and comes back positive.

Which of the following is least likely to be true regarding her condition?

A 53-year-old woman with a history of cryptogenic cirrhosis presents with hematemesis. An endoscopy is performed that reveals bleeding esophageal varices. All of the following modalities are used in the treatment of acute variceal hemorrhage except

Which of the following scenarios would be an indication for a patient with end stage liver disease to undergo a liver transplant?

An 82-year-old female nursing home resident was admitted with left-sided aspiration pneumonia. She improved quickly on intravenous antibiotics. During her admission, a chest x-ray incidentally revealed a large calcification in the right upper quadrant of the abdomen. Subsequent abdominal ultrasound confirmed the presence of a single large stone in the gallbladder (3 cm in diameter). She denies any abdominal discomfort or pain. What would be the best course of treatment for her gallstone disease?

65-year-old male presents with chronic abdominal pain that radiates to the back. The patient has been experiencing this for the past five months. He says he doesn’t have much of an appetite and as a result has lost about 30 pounds in the past five months. He also notices that he has been itching a lot and his skin color is turning yellow. You order liver function tests that show an elevated total bilirubin level of 12.4mg/dL and alkaline phosphatase level at 700U/L. Physical exam is significant for a cachexic individual. Eyes shows icterus present. Abdomen has diffuse tenderness present. CT abdomen shows a 3.5cm mass in the head of the pancreas and also dilatation of the common bile duct and pancreatic duct. He also has lesions present in the liver that seem to be metastasis of the cancer to the liver. Endoscopic ultrasound is done for confirmation and indeed does confirm that he has pancreatic adenocarcinoma.

Which of the following is the next best step in management at this time?

55-year-old male with a history of diabetes mellitus presents with diarrhea that he has been experiencing for a few months now. He underwent a colonoscopy recently that was unremarkable. Which of the following is not a likely reason that a diabetic patient would develop diarrhea?

35-year-old female presents to the hospital with mid-epigastric tenderness that radiates to her back. She has been experiencing this for the past three days. She says the pain is constant and made worse with eating. She also complains of some nausea and vomiting and low grade fevers. Patient denies using NSAIDs, alcohol, or drug use. On physical exam, she is in mild distress from pain and also has mid-epigastric and right upper quadrant tenderness. Liver function tests are done and show elevated transaminase levels with mild elevation in alkaline phosphatase and total bilirubin. Lipase is elevated at 1,500U/L. Which of the following is the best diagnostic test to perform on the patient at this time?

35-year-old female patient has chronic diarrhea for the past two months. Colonoscopy was performed, revealing normal mucosa. Stool studies results include low stool osmolality and high stool osmolar gap. Fasting trial led to persistence of diarrhea.

Which of the following is the likely etiology of the diarrhea?

26-year-old female with history of Hashimoto's hypothyroidism is referred to a gastroenterologist because of newly diagnosed hepatitis C infection. She is upset that she acquired the hepatitis C infection from IV drug use but is hopeful that her treatment will be effective. She is started on pegylated interferon and ribavirin and is told to continue with her levothyroxine. She comes back for a four week follow up and the gastroenterologist notices that HCV RNA has decreased slightly but her transaminase levels are 910U/L at this time. Before she started therapy, both alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were only slightly elevated.

Which of the following is the likely reason for this increase in transaminase levels?

Patient presents to the hospital with massive ascites. Etiology of ascites is unknown at this time but you quickly decide to draw a serum albumin and check an albumin of the fluid. Serum albumin level come back at 3.2g/dL and fluid albumin level is 1.2g/dL.

All of the following choices may be the underlying diagnosis except:

54-year-old- male recently underwent a major surgical procedure. Post-op labs show a total bilirubin of 3.0mg/dL with a direct bilirubin level of 2.8mg/dL. Alkaline phosphatase levels are normal. Which of the following is true of the condition that is most likely affecting the patient?

Which of the following statements is true?

55-year-old male complains of a “lump” in his left submandibular area for several months. He says that when he chews food, there is pain in the left submandibular area. You suspect that he has a salivary gland stone. Which of the following is least likely true of this condition?

A 56-year-old man with chronic hepatitis C infection presents to establish care. He has cirrhosis with edema and mild ascites controlled by low-dose diuretics. He is followed by a hepatologist as well. What preventive measures should you recommend to help reduce morbidity and mortality in patients with cirrhosis?

Patients with autoimmune hepatitis disease may have the following presentations except

A 33-year-old woman with a family history of pancreatitis presents with epigastric pain, nausea, vomiting, and early satiety. Over the last 3 months, she has been hospitalized three times with similar symptoms. She was discharged on total parenteral nutrition (TPN) after her most recent admission. Imaging studies during her hospitalization 2 months ago showed acute pancreatitis and a 5-cm cystic lesion in the tail of the pancreas. On exam, she is afebrile with normal vital signs, and has mild epigastric tenderness, but no rebound or guarding, and no abdominal masses. Laboratory studies show a normal white blood cell count and normal amylase and lipase. A pancreas-protocol computed tomography (CT) scan shows that the cystic lesion is now 11 cm in size and is compressing the gastric wall. She continues to have early satiety, nausea, and abdominal pain during her hospitalization. What is the next step in management?

50-year-old male patient with HIV presents to his internist for follow up visit. The internist reviews the patient’s labs and tells him that his total cholesterol and triglycerides are elevated. The patient is bewildered by the high cholesterol and high triglyceride levels as he eats an extremely healthy diet and avoids fatty and greasy foods. After the internist reviews the patient’s medication list, he explains to the patient that his total cholesterol and high triglyceride levels are not due to his diet but due to a HAART therapy medication he is taking for his HIV.

Which of the following agents could this patient be taking that is causing total cholesterol and triglyceride elevation?