Foundations CBR20 – Gastrointestinal Exam
Questions With Answers
What pain medication is best for biliary colic?
NSAIDS, it is prostaglandin mediated pain
US with +gallstone and dilated common bile duct
Choledocolithiasis, ± Jaundice, Rx: ERCP
Gold standard for diagnosing choledocolithiasis?
MRCP. ERCP and endoscopic US are good as well but they are invasive.
How sensitive if Murphy's sign for Acute Cholecystitis?
65-70%
What are possible US findings in Acute Cholecystitis?
Gallstones, gallbladder wall thickening (>3mm), pericholecystic fluid, sonographic Murphy's
Who is most at risk for Acalculous Cholecystitis?
Inflammed GB but NO stone; typically in very sick (hospitalized) or elderly
Fever + RUQ pain + Jaundice
Charcot's Triad; Reynold's Pentad: add AMS, hypotension; Cholangitis: biliary obstruction with
ascending bacterial infection; HIGH Mortality, Rx: abx, ERCP vs surgery
Chronic RUQ abd pain, Jaundice, Weight Loss
Cholangiocarcinoma
What is the risk of cancer in patients with a Porcelain Gallbladder?
25%
What arthropod is associated with pancreatitis?
Scorpion
Abdominal pain with bruising around the flank and umbilicus?
Hemorrhagic Pancreatitis; Ecchymosis of left flank (Grey-Turner sign), umbilical ecchymosis (Cullen
sign)
Does lipase level coorelate with severity of disease in Pancreatitis?
No
What are the components of Ranson's Criteria in Acute Pancreatitis?
Predicts mortality; At admission: Age > 55, WBC > 16k, Glucose >200, LDH > 350, AST > 250; At 48hr:
Ca < 8, Hct drop > 10%, PO2 < 60, BUN increase >5, Neg base excess > 4, Fluid sequestration > 6L
, What is a potential consequence of Chronic Pancreatitis?
Malabsorption when 90% affected
Painless jaundice and palpable gallbladder (Courvoisier sign)
Pancreatic Cancer; most common at head of pancreas, high mortality, high CA 19-9; also may have
"Trousseau's sign" (migratory thrombophlebitis)
What is the difference between incarcerated and strangulated hernias?
Incarcerated: stuck; Strangulated: ischemic (requires surgery)
What is the underlying pathology in Achalasia?
Impaired relaxation of the lower esophageal sphincter (LES), absence of peristalsis; most common
esophageal motility disorder. Pts will present with dysphagia and they will "raise their arms above
their heads" or "straighten their backs" after eating to increase intraesophageal pressure
Chest pain after vomiting, ill-appearing
Boerhaave's Syndrome: full-thickness perforation of esophagus causing mediastinitis; Mackler's Triad:
SQ emphysema + chect pain + vomiting; "Hamman's Crunch" (crunching sound around heart); Dx:
esophagram (water soluble) or CT w/ contrast; Rx: abx, surgical consult
On what side of the esophagus is rupture most common
Left side (distal posterolateral esophagus)
What condition predisposes to spontaneous rupture of the esophagus?
Esophageal Candidiasis (consider in HIV patient); Rx: oral fluconazole, IV fluconazole if pt is septic or
cannot tolerate PO.
Regurgitating food and recurrent aspiration pneumonia
Esophageal Diverticula (Zenker's is pharyngeal mucosa above UES)
Kid with witnessed choking episode
Esophageal (or tracheal) foreign body; do thorough workup so this is not missed
What is the most common location of obstruction in esophageal foreign body ingestion?
Cricopharyngeus (C6) > Aortic Arch (T4) > GE junction (T11)
What foreign bodies in the esophagus require immediate/emergent removal?
Button batteries, sharp objects, multiple objects. OR has been present in the esophagus 24hrs or
more, airway compromised or evidence of perforation.
What is the appropriate management for a Food Impaction?
EGD. You can try Glucagon 1mg IV (relaxes LES and causes vomiting) while you wait for GI; if glucagon
works, patients must followup for endoscopy after to r/o underlying structural abnormality
Questions With Answers
What pain medication is best for biliary colic?
NSAIDS, it is prostaglandin mediated pain
US with +gallstone and dilated common bile duct
Choledocolithiasis, ± Jaundice, Rx: ERCP
Gold standard for diagnosing choledocolithiasis?
MRCP. ERCP and endoscopic US are good as well but they are invasive.
How sensitive if Murphy's sign for Acute Cholecystitis?
65-70%
What are possible US findings in Acute Cholecystitis?
Gallstones, gallbladder wall thickening (>3mm), pericholecystic fluid, sonographic Murphy's
Who is most at risk for Acalculous Cholecystitis?
Inflammed GB but NO stone; typically in very sick (hospitalized) or elderly
Fever + RUQ pain + Jaundice
Charcot's Triad; Reynold's Pentad: add AMS, hypotension; Cholangitis: biliary obstruction with
ascending bacterial infection; HIGH Mortality, Rx: abx, ERCP vs surgery
Chronic RUQ abd pain, Jaundice, Weight Loss
Cholangiocarcinoma
What is the risk of cancer in patients with a Porcelain Gallbladder?
25%
What arthropod is associated with pancreatitis?
Scorpion
Abdominal pain with bruising around the flank and umbilicus?
Hemorrhagic Pancreatitis; Ecchymosis of left flank (Grey-Turner sign), umbilical ecchymosis (Cullen
sign)
Does lipase level coorelate with severity of disease in Pancreatitis?
No
What are the components of Ranson's Criteria in Acute Pancreatitis?
Predicts mortality; At admission: Age > 55, WBC > 16k, Glucose >200, LDH > 350, AST > 250; At 48hr:
Ca < 8, Hct drop > 10%, PO2 < 60, BUN increase >5, Neg base excess > 4, Fluid sequestration > 6L
, What is a potential consequence of Chronic Pancreatitis?
Malabsorption when 90% affected
Painless jaundice and palpable gallbladder (Courvoisier sign)
Pancreatic Cancer; most common at head of pancreas, high mortality, high CA 19-9; also may have
"Trousseau's sign" (migratory thrombophlebitis)
What is the difference between incarcerated and strangulated hernias?
Incarcerated: stuck; Strangulated: ischemic (requires surgery)
What is the underlying pathology in Achalasia?
Impaired relaxation of the lower esophageal sphincter (LES), absence of peristalsis; most common
esophageal motility disorder. Pts will present with dysphagia and they will "raise their arms above
their heads" or "straighten their backs" after eating to increase intraesophageal pressure
Chest pain after vomiting, ill-appearing
Boerhaave's Syndrome: full-thickness perforation of esophagus causing mediastinitis; Mackler's Triad:
SQ emphysema + chect pain + vomiting; "Hamman's Crunch" (crunching sound around heart); Dx:
esophagram (water soluble) or CT w/ contrast; Rx: abx, surgical consult
On what side of the esophagus is rupture most common
Left side (distal posterolateral esophagus)
What condition predisposes to spontaneous rupture of the esophagus?
Esophageal Candidiasis (consider in HIV patient); Rx: oral fluconazole, IV fluconazole if pt is septic or
cannot tolerate PO.
Regurgitating food and recurrent aspiration pneumonia
Esophageal Diverticula (Zenker's is pharyngeal mucosa above UES)
Kid with witnessed choking episode
Esophageal (or tracheal) foreign body; do thorough workup so this is not missed
What is the most common location of obstruction in esophageal foreign body ingestion?
Cricopharyngeus (C6) > Aortic Arch (T4) > GE junction (T11)
What foreign bodies in the esophagus require immediate/emergent removal?
Button batteries, sharp objects, multiple objects. OR has been present in the esophagus 24hrs or
more, airway compromised or evidence of perforation.
What is the appropriate management for a Food Impaction?
EGD. You can try Glucagon 1mg IV (relaxes LES and causes vomiting) while you wait for GI; if glucagon
works, patients must followup for endoscopy after to r/o underlying structural abnormality
