Board Review

Board Review

BOARD REVIEW BILIARY, IBD, DYSPHAGIA Cholelithiasis BILIARY SYSTEM Cholelithiasis Associations Obesity OCP use Ileal disease or resection

Cholelithiasis BILIARY SYSTEM Symptoms RUQ pain lasting 20 60 minutes Not necessarily after a fatty meal Diagnosis RUQ US (90% sensitive)

US inadequate? MRCP or oral cholecystogram HIDA scan Best for acute cystic duct obstruction (i.e., acute cholecystitis) Cholelithiasis BILIARY SYSTEM Treatment

Symptomatic gallstones Elective cholecystectomy Surgery contraindication? Supplemental oral bile acid (ursodeoxycholic acid) Lithotripsy (rarely done) Common Bile Duct Stones ERCP Cholangitis

BILIARY SYSTEM Cholangitis Charcots Triad (pain, fever, jaundice) Reynolds Pentad (pain, fever, jaundice, shock, ams) Treatment IV antibiotics

IV hydration Urgent biliary drainage If ERCP unavailable surgery or transhepatic cholangiography Cholangitis BILIARY SYSTEM Cholangitis Emphysematous cholecystitis

Emergent laparotomy and cholecystectomy Antibiotic Coverage Gram negative organisms Anaerobes Porcelain Gallbladder Calcified outline suggests cancer

Indication for cholecystectomy PBC BILIARY SYSTEM Primary biliary cirrhosis Slow onset, female, middle-aged Bill ducts chronically inflamed cirrhosis Diagnosis Hallmark test: anti-mitochondrial antibody

Liver biopsy PBC BILIARY SYSTEM Treatment Ursodiol (synthetic bile acid) Slows progression, improves symptoms Symptom Management

Pruritus cholestryramine Osteomalacia vitamin D and calcium Malabsorption Decrease dietary fats Late disease: liver transplant PSC BILIARY SYSTEM Primary Sclerosing Cholangitis Slow onset, male, middle-aged Strong association with UC

Colonoscopy indicated after diagnosis of PSC Inflammation and sclerosis of entire biliary tract obstructive jaundice and cirrhosis PSC BILIARY SYSTEM Symptoms Initially asymptomatic Weakness, fatigue, abdominal pain, weakness, fatigue

Diagnosis Elevated bilirubin and alkaline phosphatase Often p-ANCA positive MRCP, ERCP, transhepatic cholangiography (beaded appearance) Liver biopsy: onion skin fibrosis

PSC PSC PSC BILIARY SYSTEM Treatment Liver transplantation Ursodeoxycholic acid INEFFECTIVE Clinical Correlate

Order MRCP or ERCP for a patient with a history of chronic diarrhea or IBD who presents with jaundice and increased alkaline phosphatase BILIARY SYSTEM PBC versus PSC Sex PBC PSC IBD Cancer Ursodiol Effective? BILIARY SYSTEM

PBC versus PSC Sex IBD Cancer Ursodiol Effective? PBC Female No Rare Yes

PSC Male Yes 10-15% lifetime risk of No cholangiocarcinoma MKSAP A 41-year-old woman is evaluated in follow-up after presenting to the emergency department 1 week ago for burning epigastric and chest pain. In the emergency department, a complete blood count and liver chemistry studies were normal, but a radiograph of the chest and upper abdomen demonstrated calcified gallstones.

The pain resolved with administration of a liquid antacid, and omeprazole was started. The pain had been present intermittently for approximately 6 months prior to the emergency department visit. It occurred nearly every day, usually after meals and when recumbent, and had been typically burning in nature at night. The pain has not recurred since she started omeprazole. She has not had dysphagia and has a good appetite and stable weight. Her medical history is notable for obesity. On physical examination, vital signs are normal; BMI is 36. There is no abdominal tenderness, and the liver and spleen are of normal size. Murphy sign is negative. Which of the following is the most appropriate management for this patients gallstones? A. B. C. D. Annual US

Laparoscopic cholecystectomy Ursodiol Clinical observation MKSAP A 41-year-old woman is evaluated in follow-up after presenting to the emergency department 1 week ago for burning epigastric and chest pain. In the emergency department, a complete blood count and liver chemistry studies were normal, but a radiograph of the chest and upper abdomen demonstrated calcified gallstones. The pain resolved with administration of a liquid antacid, and omeprazole was started. The pain had been present intermittently for approximately 6 months prior to the emergency department visit. It occurred nearly every day, usually after meals and when recumbent, and had been typically burning in nature at night. The pain has not recurred since she started omeprazole. She has not had dysphagia and has a good appetite and stable weight. Her medical history is notable for obesity. On physical examination, vital signs are normal; BMI is 36. There is no abdominal tenderness, and the liver and spleen are of normal size. Murphy sign is negative.

Which of the following is the most appropriate management for this patients gallstones? A. B. C. D. Annual US Laparoscopic cholecystectomy Ursodiol Clinical observation KEY POINT Observation is recommended for adult asymptomatic gallstones. Possible exceptions include groups at higher risk for gallbladder carcinoma, such as patients with a calcified (porcelain) gallbladder and patient with gallstones > 3 cm.

Cholecystectomy is the treatment of choice for biliary colic and acute cholecystitis. MKSAP A 58-year-old woman is evaluated for a 6-month history of gradually progressive fatigue and a 1-month history of generalized pruritus without rash. She also has dry eyes and dry mouth. She has not had fever, jaundice, or weight loss. She has a 3-year history of hypercholesterolemia for which she takes simvastatin. She has no other medical problems. On physical examination, vital signs are normal; BMI is 24. Other than excoriations on her arms, legs, and upper back, the physical examination is normal. Right upper quadrant US is normal. Which of the following is the most likely diagnosis? A. Autoimmune hepatitis B. Cholangiocarcinoma C. Primary biliary cirrhosis

D. Primary sclerosing cholangitis MKSAP A 58-year-old woman is evaluated for a 6-month history of gradually progressive fatigue and a 1-month history of generalized pruritus without rash. She also has dry eyes and dry mouth. She has not had fever, jaundice, or weight loss. She has a 3-year history of hypercholesterolemia for which she takes simvastatin. She has no other medical problems. On physical examination, vital signs are normal; BMI is 24. Other than excoriations on her arms, legs, and upper back, the physical examination is normal. Right upper quadrant US is normal. Which of the following is the most likely diagnosis? A. Autoimmune hepatitis B. Cholangiocarcinoma C. Primary biliary cirrhosis D. Primary sclerosing

cholangitis KEY POINT The diagnosis of primary biliary cirrhosis is generally made on the basis of a cholestatic liver enzyme profile in the setting of a positive antimitochondrial antibody test MKSAP A 55-year-old man is evaluated in the emergency department for a 6-hour history of severe epigastric abdominal pain, nausea, and vomiting. In the previous 6 weeks he had two episodes of postprandial right upper quadrant pain. He is otherwise healthy and takes no medications. On physical examination, temperature is 36.8 C (98.2 F), blood pressure is 130/75 mm Hg, pulse rate is 89/min, and respiration rate is 17/min; BMI is 29. Scleral icterus is present. Abdominal examination reveals epigastric abdominal tenderness without guarding or rebound. Bowel sounds are present but hypoactive, and there is abdominal distention. He is admitted to the hospital, and fluid resuscitation is started. Abdominal ultrasound shows cholelithiasis with no gallbladder wall thickening or

pericholecystic fluid. The common bile duct is not dilated. There is no choledocholithiasis. MKSAP Which of the following is the most most appropriate management? A. Cholecystectomy prior to hospital discharge B. Cholecystokinin hepatobiliary (CCK-HIDA) scintigraphy C. Endoscopic retrograde cholangiopancreatography with biliary sphincterotomy D. Intravenous imipenem MKSAP Which of the following is the most most appropriate management? A. Cholecystectomy prior to hospital discharge B. Cholecystokinin hepatobiliary (CCK-HIDA) scintigraphy C. Endoscopic retrograde cholangiopancreatography with biliary sphincterotomy D. Intravenous imipenem

KEY POINT Patients with uncomplicated gallstone-induced pancreatitis should undergo cholecystectomy prior to hospital discharge to prevent recurrent attacks. HIDA is most commonly used for evaluation of cholecystitis, biliary obstruction, and suspected gallbladder dysfunction. This is not appropriate here because the patient has no ultrasound evidence of cholecystitis. Antibiotics should be reserved for treatment of cholangitis and acute cholecystitis. IBD Inflammatory Bowel Disease Crohn Disease

Ulcerative Colitis Microscopic Colitis Collagenous Colitis CD IBD Crohn Disease Most present in 20s 30s

Increased risk of GI malignancy Keywords Perianal fistulae and abscesses Strictures Inflammatory masses High risk of recurrenence

Osteoporosis commonly associated CD IBD Presentation Fever Abdominal pain Diagnosis Endoscopic findings

Rectal sparing Skin lesions Perianal disease Ileo-cecal involvement String Sign (small-bowel follow through) CD IBD Markers

ASCA (anti-Saccharomyces) Terminal Ileum Problems Calcium oxalate kidney stones Steatorrhea Gallstones (what kind of stones?) B12 deficiency

Hypocalcemia Nutrient malabsorption Bile acid-induced diarrhea (how to treat?) CD IBD Treatment

5-ASA: Initial therapy for mild disease Budesonide: 1st line for mild to moderate disease (of ileum or ileocecal disease) 6-MP / Azathioprine: Cannot be weaned off prednisone (long term use decreases recurrence rates) Infliximab: helpful for fistulas and withdrawal from steroids

Screen all patients for which infections? Prednisone: Used for flares; discourage use > 3 months CD IBD Surgery Intractable disease Complications

Obstruction Perforation Abscesses CD IBD Treatment Scenarios - CD Colon only Only ileum or small bowel involvement 5-ASA or mesalamine Budesonide

Fistula or perianal disease Infliximab (or other immunomodulators) or 6-MP Steroid-dependent 6-MP, azathioprine, mAb Acute flare Corticosteroids UC IBD Ulcerative Colitis

Inflammation starts in rectum and extends proximally Contiguous mucosal inflammation with shallow ulcers Sharp margin of area of involvement p-ANCA positive Diagnose with colonoscopy / sigmoidoscopy with biopsy

Presentation Abdominal pain Bloody diarrhea UC IBD Diagnosis Rule out other infections that cause colitis

C. difficile (most important!) E. coli Shigella Yersinia Campylobacter E. Histolytica UC IBD Extraintestinal Manifestations

RF-negative peripheral polyarthritis Ankylosing spondylitis (HLA-B27+) Iritis, Episcleritis, Unveitis (HLA-B27+) Skin lesions Erythema nodosum Pyoderma gangrenosum

Primary sclerosing cholangitis (HLA-B8+) Aphthous ulcers of mouth UC IBD Risk of Malignancy Rises ~ 8 years after disease onset Risk increased with

Duration of disease Extent (pancolitis has highest risk) Concurrent PSC Persistent mucosal inflammation Dysplasia UC IBD Colonoscopy Pancolitis for 8 years

Left-sided colitis for 15 years Routine colonoscopy every 1-2 years afterwards UC IBD UC IBD Treatment

Colectomy (CURATIVE) Indications Not responding to medical therapy Contraindication to medial therapy Fulminant colitis / toxic megacolon / perforation Steroid dependence Dysplasia in mass lesion High-grade dysplasia in flat mucosa UC IBD Treatment

Mild disease 5-ASA Mesalamine (suppository for proctitis) Hydrocortisone enemas Moderate to severe disease

Oral prednisone (IV with fulminant UC) Infliximab Cyclosporine UC IBD Maintenance Therapy Daily 5-ASA or mesalamine

Azathioprine or 6-MP Immunomodulators IBD IBD Buzzwords: CD versus UC Tenesmus UC Rectal bleeding

UC Fecal soiling CD Hydronephrosis w/o stones CD Pneumaturia CD MKSAP A 40-year-old man is evaluated for several ulcers located near his ostomy site. He has a 15-year history of ulcerative colitis and underwent elective proctocolectomy with ostomy placement 3 months ago to decrease his risk

of colorectal cancer. His ostomy has functioned well without previous problems. The ulcers, which are moderately painful, developed 1 month ago and have failed to respond to topical care, including barrier methods and changing adhesives. He is otherwise healthy and takes no medications. On physical examination, vital signs are normal. BMI is 19. Skin findings are shown. Which of the following is the most appropriate treatment? A. B. C. D. Replace ostomy to opposite side Rituximab Surgical debridement Topical clobetasol

MKSAP A 40-year-old man is evaluated for several ulcers located near his ostomy site. He has a 15-year history of ulcerative colitis and underwent elective proctocolectomy with ostomy placement 3 months ago to decrease his risk of colorectal cancer. His ostomy has functioned well without previous problems. The ulcers, which are moderately painful, developed 1 month ago and have failed to respond to topical care, including barrier methods and changing adhesives. He is otherwise healthy and takes no medications. On physical examination, vital signs are normal. BMI is 19. Skin findings are shown. Which of the following is the most appropriate treatment? A. B. C. D. Replace ostomy to opposite side

Rituximab Surgical debridement Topical clobetasol KEY POINT Recognize pyoderma gangrenosum! Glucocorticoids (oral, topical, intralesional) are first-line therapy for peristomal pyoderma gangrenosum. Pyoderma gangrenosum will worsen after debridement. MKSAP A 29-year-old man is evaluated during a routine examination. His medical history is significant for ulcerative colitis involving the entire colon, which was diagnosed 4 years ago. His symptoms responded to therapy with mesalamine and have remained in remission on this medication. His family history is significant for a maternal uncle who died of colon cancer at the age of 50 years. Physical examination is unremarkable.

Serum alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase levels are normal. Which of the following is the most appropriate interval at which to perform colonoscopy with biopsies in this patient? A. B. C. D. Begin now and repeat annually Begin in 4 years and repeat every 1 to 2 years Begin in 4 years and repeat every 10 years Begin at age 40 years and repeat every 5 years MKSAP A 29-year-old man is evaluated during a routine examination. His medical history is significant for ulcerative colitis involving the entire colon, which was diagnosed 4 years ago. His symptoms responded to

therapy with mesalamine and have remained in remission on this medication. His family history is significant for a maternal uncle who died of colon cancer at the age of 50 years. Physical examination is unremarkable. Serum alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase levels are normal. Which of the following is the most appropriate interval at which to perform colonoscopy with biopsies in this patient? A. B. C. D. Begin now and repeat annually Begin in 4 years and repeat every 1 to 2 years Begin in 4 years and repeat every 10 years Begin at age 40 years and repeat every 5 years

KEY POINT Patients with long-standing colitis associated with IBD are at increased risk for colon cancer an should undergo

surveillance colonoscopy every 1-2 years beginning after 8 10 years of disease MKSAP A 28-year-old woman is evaluated for an 8-week history of increasing lower abdominal crampy pain and diarrhea. She now has 6 to 10 bowel movements per day with one or two nocturnal stools. Stools are loose to watery with intermittent blood streaking. The pain is in the lower abdomen and has increased to 6 to 8 out of 10 in severity over the past week. She has anorexia and nausea but no vomiting or fever. She takes no medications, including NSAIDs. On physical examination, temperature is 37.8 C (100.0 F), blood pressure is 100/54 mm Hg, and pulse rate is 96/min. She appears thin, pale, and in moderate distress. The abdomen is distended with diffuse tenderness that is most prominent in the lower quadrants. There is no rigidity, guarding, rebound tenderness, masses, or organomegaly.

Representative colonoscopy findings seen in a patchy distribution throughout the ascending, transverse, and descending colon are shown. The terminal ileum and rectum show no inflammation. MKSAP MKSAP Which of the following is the most likely diagnosis? A. Collagenous colitis B. Crohn colitis C. Ischemic colitis D. Ulcerative colitis MKSAP Which of the following is the most likely diagnosis? A. Collagenous colitis B. Crohn colitis C. Ischemic colitis

D. Ulcerative colitis KEY POINT In Crohn disease, endoscopic findings vary from superficial aphthous ulcers to discrete, deep ulcers; rectal sparing is typical, as are areas of inflammation separated by normal mucosa (i.e., skip lesions). MKSAP A 38-year-old man is evaluated in follow-up after a diagnosis of ulcerative colitis. Ten days ago he was started on prednisone, 60 mg/d, but his symptoms have not improved. He has six to nine bloody bowel movements per day and moderate abdominal pain. He has decreased his oral intake because eating exacerbates his pain and diarrhea. On physical examination, temperature is 37.0 C (98.6 F), blood pressure is 110/56 mm Hg, and pulse rate is 96/min. He is pale but in no distress. The abdomen is diffusely tender without distention, guarding, or rebound.

Laboratory studies reveal a hemoglobin level of 9.7 g/dL (97 g/L) and a leukocyte count of 6300/L (6.3 109/L). Stool culture and Clostridium difficile assay are negative. MKSAP Which of the following is the most appropriate treatment? A. Increased prednisone to 80 mg/d B. Initiate adalimumab C. Initiate ciprofloxacin and metronidazole D. Initiate mesalamine E. Initiate sulfasalazine MKSAP Which of the following is the most appropriate treatment? A. Increased prednisone to 80 mg/d B. Initiate adalimumab C. Initiate ciprofloxacin and metronidazole D. Initiate mesalamine

E. Initiate sulfasalazine KEY POINT Patients with moderate to severe ulcerative colitis whose disease does not respond to oral glucocorticoids should be treated with either IV glucocorticoids or an anti-tumor necrosis factor agent. MKSAP A 28-year-old man is evaluated in follow-up for elevated liver chemistry test results, which were performed to assess a 3-month history of fatigue. He has no history of liver disease and has not had abdominal pain or fever. His medical history is significant for a 3-year history of diarrhea. On physical examination, vital signs are normal; BMI is 24. Spider angiomata and jaundice are absent. Abdominal examination reveals hepatomegaly but no splenomegaly or ascites. Abdominal CT shows a thickened extrahepatic bile duct but no intrahepatic

biliary dilatation and no hepatic or pancreatic mass. Magnetic resonance cholangiopancreatography reveals changes consistent with primary sclerosing cholangitis. MKSAP Which of the following is the most appropriate next step in management? A. Colonoscopy B. Endoscopic retrograde cholangiopancreatography C. Liver biopsy D. Serum IgG4 measurement MKSAP Which of the following is the most appropriate next step in management? A. Colonoscopy B. Endoscopic retrograde cholangiopancreatography C. Liver biopsy

D. Serum IgG4 measurement KEY POINT Eighty percent of patients with primary sclerosing cholangitis have ulcerative colitis. DYSPHAGIA Diagnosis EGD Barium swallow

Follows normal EGD if symptoms persist Precedes endoscopy when Risk of perforation High grade obstruction Video-fluoroscopic swallow

1st test performed Oropharyngeal dysphagia (e.g., coughing, gagging) Esophageal manometry Suspect motility disorders (e.g., solids and liquids) Achalsia DYSPHAGIA Achalasia Neuronal denervation and ganglion cell degeneration of

myenteric plexus Impaired organized peristalsis LES does not relax LES has elevated resting pressures Features Solid AND liquids Long-standing symptoms Regurgitation

Chest pain Achalsia DYSPHAGIA Barium Swallow Dilated and fluid filled Bird-beak narrowing Esophageal Manometry

Done to confirm diagnosis Absence of peristalsis EGD Done to exclude tumor Achalsia DYSPHAGIA Treatment

Pneumatic dilation Surgical myotomy Botox CCB and nitrates for symptom relief DYSPHAGIA Neurologic Dysfunction

Solids and liquids at time of onset Stroke, Parkinsonism, Bulbar Palsy, ALS, MS Video-fluoroscopy swallow study If suspect aspiration Tracheostomy and PEG do not prevent aspiration! DYSPHAGIA

Diffuse Esophageal Spasm Barium swallow corkscrew pattern Manometry excess, simultaneous contractions in distal esophagus Endoscopy used to rule out structural disease If reflux suspected trial PPI or pH recording

Therapy 1st line: diltiazem or imipramine 2nd line: isosorbide or sildenafil 3rd line: Botox at mid and distal esophagus DYSPHAGIA Anatomic Obstruction

Schatzki Ring (LE ring) Malignancy Esophageal Extrinsic compression Peptic stricture

DYSPHAGIA Lower Esophageal Ring (Schatzki Ring) Regurgitate impacted food Associated with hiatal hernia Treatment Dilation PPI following dilation

DYSPHAGIA Malignant Obstruction Esophageal adenocarcinoma Squamous cell carcinoma Extrinsic compression from non-esophageal primary cancers Characteristics

Progression of symptoms: solid liquids Dysphagia with weight loss: malignancy until proven otherwise! DYSPHAGIA Other Causes Plummer-Vinson Syndrome Upper esophageal web Post-menopasual women + iron-deficiency anemia Scleroderma and Systemic Sclerosis

Eosinophilic Esophagitis Men 20-40 years old Associations: allergies, high IgE levels, eosinophilia Scalloped or feline rings in esophagus Treatment: swallowed fluticasone or budesonide DYSPHAGIA Other Causes

Pill-Induced Esophagitis Doxycycline KCl, ASA, NSAIDs Bisphosphanates Zenker Diverticulum Outpouching upper esophagus Foul smelling breath, elderly patients Seen on barium swallow Cricopharyngeal myotomy Infectious

CMV, HSV, Candida DYSPHAGIA DYSPHAGIA Treatment GERD Initial Raise head of bed, weight loss (effective) Small meals, d/c smoking, no alcohol, antacids (less effective) Persistent

PPI more effective than H2 blocker Refractory Fundoplication DYSPHAGIA Proton Pump Inhibitors Side Effects Short term Pneumonia

Long term Increased fracture risk Hypomagnesemia (muscle spasms, arrhythmias, seizures) Increased risk of C. difficile MKSAP A 78-year-old man is evaluated for symptoms of dysphagia that began 2 weeks ago. When he eats, he starts coughing after the first bite of food and occasionally has nasal regurgitation.

On physical examination, blood pressure is 135/90 mm Hg, pulse rate is 78/min, and respiration rate is 12/min. Left-sided weakness is noted in both extremities, upper greater than lower. Which of the following is the most appropriate diagnostic test to evaluate this patient's dysphagia? A. B. C. D. Barium swallow Esophageal manometry Upper endoscopy Videofluoroscopy MKSAP A 78-year-old man is evaluated for symptoms of dysphagia that began 2

weeks ago. When he eats, he starts coughing after the first bite of food and occasionally has nasal regurgitation. On physical examination, blood pressure is 135/90 mm Hg, pulse rate is 78/min, and respiration rate is 12/min. Left-sided weakness is noted in both extremities, upper greater than lower. Which of the following is the most appropriate diagnostic test to evaluate this patient's dysphagia? A. B. C. D. Barium swallow Esophageal manometry Upper endoscopy Videofluoroscopy

KEY POINT The initial test of choice for evaluation of oropharyngeal dysphagia is videofluoroscopy. Barium swallow may be helpful in evaluation of esophageal dysphagia following a normal upper endoscopy when mechanical obstruction iss till suspected. Manometry is useful is achalsia (e.g., motility issue) is suspected. MKSAP A 28-year-old man is evaluated in the emergency department for a piece of food stuck in his esophagus. He notes that this has happened in the past, but he was previously able to induce vomiting to relieve the blockage. He has no symptoms of gastroesophageal reflux disease, and he takes no medications. Physical examination findings are unremarkable. Upper endoscopy reveals a food bolus in the mid-esophagus, and gentle pressure with the endoscope passes the food bolus into the stomach. Upper endoscopy findings are shown.

Which of the following is the most likely diagnosis? A. Achalasia B. Barrett esophagus C. Diffuse esophageal spasm D. Eosinophilic esophagitis MKSAP A 28-year-old man is evaluated in the emergency department for a piece of food stuck in his esophagus. He notes that this has happened in the past, but he was previously able to induce vomiting to relieve the blockage. He has no symptoms of gastroesophageal reflux disease, and he takes no medications. Physical examination findings are unremarkable. Upper endoscopy reveals a food bolus in the mid-esophagus, and gentle pressure with the endoscope passes the food bolus into the stomach. Upper endoscopy findings are shown.

Which of the following is the most likely diagnosis? A. Achalasia B. Barrett esophagus C. Diffuse esophageal spasm D. Eosinophilic esophagitis KEY POINT The classic presentation of EoE is a young man with solid-food dysphagia that requires endoscopy for removal. Endoscopy often reveals characteristic findings of EoE such as rings, longitudinal furrows, and sometimes strictures. EoE is diagnosed by the finding of >15 eosinophils/hpf on biopsy and by exclusion of GERD. This can be done by trial of PPI for 8 weeks. Medical therapy of EoE consists of swallowed aerosolized topical glucocorticoids (e.g., fluticasone or budesonide)

MKSAP A 55-year-old man is evaluated in follow-up for acid reflux. He has an 8-year history of heartburn, which was previously well controlled with once-daily pantoprazole. His dosage was increased to twice daily 10 weeks ago because he was having nocturnal heartburn. Despite the increase in medication, he has had minimal improvement in symptoms. The patient verified that he is taking the medication 30 minutes before meals. He takes no other medications. Physical examination is unremarkable. Upper endoscopy findings are normal. What is the most appropriate next step in management? A. B. C. D. Ambulatory pH impedance monitoring Barium esophagogram

Esophageal manometry Fundoplication MKSAP A 55-year-old man is evaluated in follow-up for acid reflux. He has an 8-year history of heartburn, which was previously well controlled with once-daily pantoprazole. His dosage was increased to twice daily 10 weeks ago because he was having nocturnal heartburn. Despite the increase in medication, he has had minimal improvement in symptoms. The patient verified that he is taking the medication 30 minutes before meals. He takes no other medications. Physical examination is unremarkable. Upper endoscopy findings are normal. What is the most appropriate next step in management? A. B. C. D.

Ambulatory pH impedance monitoring Barium esophagogram Esophageal manometry Fundoplication KEY POINT Ambulatory pH impedance testing while not taking a PPI is useful in patients who have atypical symptoms of GE reflux to determine if reflux is the cause of the symptoms; it is also useful in patients who are symptomatic while on a PPI to determine if there is continued acid exposure. MKSAP A 58-year-old man is evaluated for a 10-year history of intermittent difficulty swallowing both solids and liquids. Over the last 6 months the symptoms have worsened and now include

regurgitation and weight loss of 4.5 kg (10.0 lb). He has tried antacids but has had no improvements in his symptoms. Physical examination is unremarkable. Laboratory studies are normal. A barium radiograph is shown. Upper endoscopy reveals no luminal mass. demonstrates Esophageal aperistalsis and

manometry incomplete lower esophageal sphincter relaxation. MKSAP Which of the following is the most likely diagnosis? A. Achalsia B. Diffuse esophageal spasm C. Esophageal hypomotility D. Nutcracker esophagus MKSAP Which of the following is the most likely diagnosis? A. Achalsia B. Diffuse esophageal spasm C. Esophageal hypomotility D. Nutcracker esophagus

KEY POINT The primary screening test for achalasia is a barium esophagogram, which demonstrates dilation of the esophagus and narrowing at the gastroesophageal junction, described as a birds beak.

Recently Viewed Presentations

  • Sequencing of Mammalian Genomes Predicts 30,000 genes 2001

    Sequencing of Mammalian Genomes Predicts 30,000 genes 2001

    What is the Proteome All the proteins expressed in a particular cell or tissue. By definition this will vary by tissue and cell type. Cardiovascular Neuromuscular Islet cell Endothelial cell Muscle cell Why Study Proteomics? Gives a better understanding of...
  • Flashback - owen.k12.ky.us

    Flashback - owen.k12.ky.us

    Flashback 9-20-12 An industrial cleaner is manufactured using only the 3 secret ingredients A, B, and C, which are mixed in the ratio of 2:3:5, respectively, by weight. How many pounds of secret ingredient B are in a 42-pound (net...
  • CASE STUDY  408 PERMITTING AND LEVEE ACCREDITATION FOR

    CASE STUDY 408 PERMITTING AND LEVEE ACCREDITATION FOR

    Project Approach . Problems and Challenges . Lessons Learned. Just West of Omaha. West Bank of Elkhorn River. Population 728. Levee Constructed in 1967 by USACE. Entire Village is in Protected Area. Levee history and background. Enrolled in USACE PL...
  • Y T I C A C N A

    Y T I C A C N A

    Notes from presentation. Counselor Assignments. ... Mr. Reid Last Name ending K-Z. Warrior Pride: Where learners become leaders. What does Warrior pride look like? ... Physical Education Mr. mortonmrs. Lafferty-john. Your teachers. Technology mr.courtney.
  • The Cold War - Warren Hills Regional School District

    The Cold War - Warren Hills Regional School District

    Describes the Cold War as an epic struggle between "the idea of freedom" and the "idea of slavery under the grim oligarchy of the Kremlin." The NSA originated as an agency that was responsible for deciphering communications during WWII, and...
  • PowerPoint - Culinary Kitchen Math Calculations

    PowerPoint - Culinary Kitchen Math Calculations

    Bakers, chefs and cooks use math skills to adjust recipe yields, weigh ingredients and adjust cooking times and temperatures for different foods. Managers use math skills to take care of the business side of the food service industry such as...
  • Towards Esthetic and Reconstructive Dentistry : Bridging ...

    Towards Esthetic and Reconstructive Dentistry : Bridging ...

    Interrelationships โดย.. อ.อาณาจักร์ ฉันทนะสุขศิลป์
  • Chapter 4: Divide-and-Conquer

    Chapter 4: Divide-and-Conquer

    * Divide-and-Conquer Technique (cont.) subproblem 2 of size n/2 subproblem 1 of size n/2 a solution to subproblem 1 a solution to the original problem a solution to subproblem 2 a problem of size n A. Levitin "Introduction to the...