PANCE Exam: Gastrointestinal/Nutritional Review Questions & Answers

Question: A patient presents with chronic, progressive dysphagia of solids and liquids. A barium study shows a dilated esophagus with a distal “bird beak” appearance. What is the likely diagnosis?
Achalasia.

Question: What study is the gold standard for diagnosing achalasia?
Esophageal manometry.

Question: What infectious disease closely mimics idiopathic achalasia?
Chagas disease. It is caused by Trypanosoma cruzi, a parasite that damages the myenteric plexus.

Question: What is the most common symptom of esophageal disease?
Heartburn (pyrosis).

Question: What is the single, best diagnostic study for evaluating a patient with GERD?
EGD (esophagogastroduodenoscopy).

Question: Is odynophagia (painful swallowing) a common symptom of GERD?
No, odynophagia rarely results from GERD. It is normally associated with infectious or eosinophilic esophagitis, malignancy, or ingestion of corrosive agents.

Question: Name four common symptoms of Gastroesophageal reflux disease:
1. Heartburn
2. Regurgitation of gastric juices
3. Dysphagia (difficulty swallowing)
4. Water brash (overproduction of saliva as a response to acid reflux)

List four atypical symptoms associated with GERD:
1. Cough
2. Hiccups
3. Throat clearing
4. Wheezing

Question: A hypotensive lower esophageal sphincter (LES) pressure is just one pathophysiological cause of GERD. Provide four dietary examples that can lower LES pressure:
1. Fatty foods
2. Alcohol
3. Caffeine (coffee, tea, chocolate)
4. Peppermint

Question: List five medicines that can lower LES pressures, thus leading to GERD:
1. Calcium channel blockers
2. Theophylline
3. Diazepam (Valium)
4. Meperidine (Demerol)
5. Morphine

Question: Do all patients with GERD need esophageal function testing?
No, any additional testing beyond an EGD should be reserved for patients who either fail medical therapy and lifestyle modification or in whom the correlation of reflux symptoms are in doubt.

Question: Provide five extraesophageal manifestations of GERD:
1. Asthma
2. Laryngitis/pharyngitis
3. Dental decay
4. Recurrent sinusitis
5. Recurrent otitis media

Question: What are the most serious complications from chronic GERD (gastroesophageal reflux disease)?
Esophageal stricture and Barrett esophagitis.

Question: Barrett esophagitis is associated with which type of cancer?
Esophageal adenocarcinoma.

Question: How often should patients with Barrett esophagitis have routine endoscopic surveillance?
Every 2 to 3 years.

Name four risk factors for the development of esophageal cancer:
1. Smoking
2. Alcohol
3. Uncontrolled, chronic GERD
4. Obesity

Question: What is the most predominant type of cancer of the proximal esophagus?
Squamous cell carcinoma usually involves the proximal esophagus, whereas adenocarcinoma is predominantly of distal esophageal origin.

Question: What percentage of patients with esophageal cancer is also afflicted with distant metastasis?
80%. The 5-year survival rate is 5%.

Question: What is the most common benign esophageal neoplasm?
Leiomyoma.

Question: What is the most common cause of infectious esophagitis?
Candida albicans.

Question: Name three medications that may predispose a patient to fungal esophagitis:
1. Antibiotics
2. Steroids (both systemic and inhaled)
3. H2 blockers/PPIs (acid suppression therapy)

Question: List four medical conditions that are strongly associated with fungal esophagitis:
1. HIV
2. Diabetes mellitus
3. Cushing disease
4. Alcoholism

Question: A globus sensation is a feeling of a “lump in the throat.” Name three potential causes of this symptom:
1. GERD
2. Anxiety disorder
3. Goiter (causing external compression on the hypopharyngeal area)

Question: What is the most common viral cause of infectious esophagitis?
Herpes simplex virus (HSV).

Question: The most common cause of oropharyngeal dysphagia in the elderly is of neuromuscular etiology. Give three examples:
1. Cerebrovascular accident (CVA)
2. Parkinson disease
3. Motor neuron disorders

What is a Zenker diverticulum?
It is a diverticular outpouching usually located posteriorly in the hypopharynx.

Question: List the common symptoms associated with a Zenker diverticulum:
- Halitosis
- Regurgitation of undigested foods
- Lower neck dysphagia

Question: A 24-year-old female patient with dysphagia is found to have an esophageal web on barium studies. What blood disorder should be considered?
Iron deficiency anemia (related to Plummer-Vinson syndrome).

Question: Repeated violent bouts of vomiting can result in both Mallory-Weiss tears and Boerhaave syndrome. Differentiate between the two:
Mallory-Weiss tears involve the submucosa and mucosa, typically in the right posterolateral wall of the gastroesophageal junction.
Boerhaave syndrome is a full thickness tear, usually in the unsupported left posterolateral wall of the distal esophagus.

Question: What are the signs and symptoms of Boerhaave syndrome?
Substernal and left-sided chest pain with a history of forceful vomiting, leading to spontaneous esophageal rupture. The abdomen can become rigid and shock may follow.

Question: What is the test of choice to confirm the diagnosis of Boerhaave syndrome?
An esophagram. A water-soluble contrast medium should be used in place of barium to confirm the diagnosis.

Question: What is Hamman sign?
It is air in the mediastinum following an esophageal perforation. This condition produces a “crunching” sound over the heart during systole.

Question: What is the best way to remove a meat bolus causing esophageal obstruction?
Upper endoscopy.

Question: What test must be performed after a food bolus is cleared or passes through spontaneously?
Either a barium study or preferably an endoscopy to check for underlying pathology (e.g., strictures, masses).

Question: What are the most common symptoms of gastritis?
- Dyspepsia (epigastric discomfort or burning)
- Postprandial fullness or bloating
- Nausea
- Vomiting

List three common causes of acute gastritis:
1. NSAIDs
2. Alcohol
3. Biphosphonates

Question: What etiologies are more commonly associated with chronic gastritis?
- H. pylori infection
- Alcohol
- NSAIDs
- Bile acid reflux

Question: What are potential risk factors for exposure to Helicobacter pylori/infection?
Crowded living conditions, suboptimal sanitation, and low socioeconomic status.

Question: List the various methods in which H. pylori can be diagnosed:
- Invasively via endoscopic gastroduodenal biopsies
- Noninvasively via:
- serology (H. pylori antibody)
- urea breath test
- stool antigen test

Question: Does H. pylori play a role in either gastric or duodenal ulcers?
Yes, most gastric ulcers occur in the setting of H. pylori gastritis (˜60%–80%). The association is quite strong with duodenal ulcers as well.

Question: Can H. pylori be considered a “potential suspect” in causing gastric cancer?
Yes, gastric cancer is the second most common cancer in the world and is classified as a group I carcinogen by the World Health Organization (WHO). Patients with H. pylori have a fivefold higher incidence of gastric cancer.

Question: What continents and countries have the highest prevalence of gastric cancer?
Asia and South America have the highest rate of gastric cancer. Japan, Chile, and Costa Rica have the greatest risk.

Question: What lifestyle or dietary factors are suspected to be linked to gastric cancer?
- Highly salted meats or fish
- Smoked meats
- Tobacco smoking

Question: What is the most common type of gastric carcinoma? What percent of these are ulcerative, polypoid, or linitis plastica?
Adenocarcinomas account for 90% of gastric cancers. Of these, 75% are ulcerative, 10% are polypoid, and 15% are diffuse infiltrative (linitis plastica).

Question: What percentage of gastric carcinomas produces a positive hemoccult test?
50%.

What percentage of gastric carcinomas is associated with a palpable mass?
25%.

Question: What is a Krukenberg tumor?
It is a gastric carcinoma that has metastasized to the ovary.

Question: Stomach cancer is associated with the enlargement of what lymph nodes?
Supraclavicular nodes (sentinel nodes).

Question: Is peptic ulcer disease (PUD) more common in men or women?
Men (a 3:1 male-to-female ratio).

Question: Are patients with duodenal PUD usually younger or older?
Younger. Duodenal PUD is more often associated with H. pylori. Older people tend to develop gastric ulcers as a result of NSAID use.

Question: Do gastric or duodenal ulcers heal faster?
Duodenal.

Question: What medical conditions are associated with an increased incidence of peptic ulcer disease?
- COPD
- Cirrhosis
- Chronic renal failure

Question: Are gastric and duodenal perforations more commonly associated with malignant or benign ulcerations?
Benign ulcers.

Question: Is gastrointestinal bleeding common with a perforated ulcer?
No.

Question: After the fluid and blood resuscitation of a bleeding ulcer, what is the most useful diagnostic test?
Upper endoscopy is the most useful test because it can also be therapeutic via cryo- or electrocautery of an arterial bleeder.

Question: What are some indications for surgery in a bleeding ulcer?
- A visible vessel in the ulcer bed
- More than 6 units of blood transfused in 24 hours
- More than 3 to 4 units transfused per day for 3 days

Question: Name two endocrine problems that can cause PUD:
Zollinger-Ellison syndrome and hyperparathyroidism (hypercalcemia).

A 48-year-old female diabetic patient presents with a multimonth history of chronic nausea, early satiety, and postprandial bloating. What is the most likely diagnosis?
Diabetic gastroparesis.

Question: Define gastroparesis:
It is a motility disorder of the stomach that results in impairment of the normal gastric emptying mechanism. “Delayed gastric emptying.”

Question: What is the most common etiology of gastroparesis?
Idiopathic. Other associated factors may include diabetes, gastric cancer, prior gastric bypass surgery, chronic gastritis, or exposure to viral gastroenteritis.

Question: How prevalent are gallstones in the Western population?
Approximately 10% to 15% of adults have gallstones, with women being twice as likely. Approximately 20% of those adults will develop symptoms.

Question: List the ultrasound findings that are suggestive of acute cholecystitis:
- Formation of gallstones or sludge
- Thickening of the gallbladder wall by more than 5 mm
- Presence of pericholecystic fluid
- A dilated common bile duct (>10 mm may suggest common bile duct obstruction).

Question: A patient with a history of gallstones presents with acute, postprandial RUQ pain. What is the KUB likely to show?
Nothing specific. Only about 10% to 15% of gallstones are radiopaque.

Question: Gallbladder stones are made predominantly of what two materials?
Cholesterol (80%) and bile pigments (20%).

Question: What is the diagnostic test of choice to evaluate a patient suspected to have gallstones?
Abdominal ultrasound has a 95% detection rate for gallstones.

Question: If the abdominal ultrasound is nondiagnostic for gallstones, could the patient still have gallbladder disease? If so, what additional tests can be ordered?
Yes, although structurally things may look normal, a patient may still exhibit symptoms from a functional disorder of the gallbladder. Biliary dyskinesia and acalculous cholecystitis are two examples. The test of choice would be a HIDA scan (radionuclide biliary scan) with cholecystokinin to calculate a gallbladder ejection fraction and to gauge if CCK administration reproduces the patient’s episodic symptoms.

Question: A 54-year-old man, 2 days postop for a right knee replacement, presents with RUQ abdominal pain, nausea, and low-grade fevers. His ultrasound fails to reveal any gallstones or other obvious GB abnormality. What is the probable diagnosis?
Acalculous cholecystitis: This is a condition most often seen in postoperative, posttraumatic, and burn patients secondary to dehydration.

Which types of patients are at greatest risk for gallbladder perforation?
The elderly patients, diabetic patients, and those with recurrent cholecystitis.

Question: What dietary history would be suspicious for underlying biliary disease?
The ingestion of fried, fatty, greasy, oily or rich foods within 20 minutes to 2 hours prior to symptom onset. Patients may describe any of the following: epigastric or RUQ abdominal pain accompanied by nausea and/or vomiting, bloating, belching, and heartburn.

Question: What clinical sign can assist in the diagnosis of cholecystitis?
Murphy sign is pain on inspiration with palpation of the RUQ. As the patient breathes in, the gallbladder is lowered in the abdomen and comes in contact with the peritoneum just below the examiner’s hand. This will aggravate an inflamed gallbladder, causing the patient to abruptly discontinue breathing deeply.

Question: Which ethnic group has the largest proportion of people with symptomatic gallstones?
Native Americans. By the age of 60 years, 80% of native Americans with previously asymptomatic gallstones will develop symptoms as compared to only 30% of Caucasian Americans and 20% of African Americans.

Question: Eight years after cholecystectomy, a woman develops RUQ pain and jaundice. What is the chance of recurrent biliary tract stones developing?
At least 10%; the recurrence may be due to either retained stones or in situ formation by the biliary epithelium.

Question: What is the significance of a porcelain gallbladder?
Defined as intramural calcification of the gallbladder wall that is normally seen on CT or plain radiographs. It has a 20% association with gallbladder carcinoma, and if discovered, cholecystectomy is recommended.

Question: Should the presence of gallbladder polyps necessitate cholecystectomy?
Yes, all lesions >1 cm in size should be removed to rule out malignancy. Smaller lesions should be followed closely with ultrasound every 6 months.

Question: An 11-year-old child with sickle cell anemia presents with fever, RUQ abdominal pain, and jaundice. What is the most likely diagnosis?
Charcot triad suggests ascending cholangitis. The precipitating cause in this case is probably pigment stones resulting from chronic hemolysis.

Question: What is the difference between cholelithiasis, cholangitis, cholecystitis, and choledocholithiasis?
Cholelithiasis: Gallstones within the gallbladder sac.
Cholangitis: Inflammation of the common bile duct, often caused by infection or choledocholithiasis.
Cholecystitis: Inflammation of the gallbladder.
Choledocholithiasis: Gallstones that have migrated from the gallbladder sac into the common bile duct.

Question: What is the most frequent complication of choledocholithiasis?
Cholangitis (60%). Other complications include bile duct obstruction, pancreatitis, biliary enteric fistula, and hemobilia. Cholangitis is a medical emergency when fever exceeds 101°F or is associated with sepsis, hypotension, peritoneal signs, or a bilirubin level >10 mg/dL. CT or abdominal ultrasonography is supportive of the diagnosis.

What is the most likely diagnosis for a patient who presents with epigastric pain that radiates to the back and is partially relieved by sitting up?
Pancreatitis.

Question: What are the major causes of acute pancreatitis?
Alcoholism (40%) and gallstone disease (40%). The other causes of acute pancreatitis are familial inheritance, hyperparathyroidism, infection, hypertriglyceridemia, drugs, trauma, and protein deficiency.

Question: Name two metabolic causes of acute pancreatitis:
Hypertriglyceridemia and hypercalcemia

Question: What are some of the drugs known to cause pancreatitis?
Sulfonamides, estrogens, tetracyclines, thiazides, furosemide, and valproic acid.

Question: What are some of the infectious causes of pancreatitis?
Mumps, viral hepatitis, Coxsackie virus group B, and mycoplasma.

Question: What is the most common cause of chronic pancreatitis in Western society?
Chronic alcohol abuse.

Question: Does acute pancreatitis commonly progress to chronic pancreatitis?
No, only rarely.

Question: What are the laboratory abnormalities associated with pancreatitis?
Leukocytosis, hyperglycemia, elevated amylase, elevated lipase, hepatic enzyme elevation, hypoxemia, and prerenal azotemia.

Question: What are some abdominal X-ray findings associated with acute pancreatitis?
- A sentinel loop (either of the jejunum, transverse colon, or duodenum)
- A colon cutoff sign (an abrupt cessation of gas in the mid or left transverse colon)
- Calcification of the pancreas

Question: Serum amylase is frequently elevated in acute pancreatitis. What other conditions can cause a similar rise in amylase?
Salivary stones, renal failure, mumps, cholecystitis, bowel infarction, perforated ulcer, ovarian disorders, pancreatic cancer, and macroamylasemia.

Question: When is surgery indicated in pancreatitis?
When a patient has an infected pancreatic necrosis or an abscess that cannot be adequately drained and treated.

Should immediate surgery be performed in gallstone-induced pancreatitis?
NO, it should be performed after the pancreatitis has subsided.

Question: What is Cullen sign?
Periumbilical ecchymosis indicative of pancreatitis, severe upper GI bleeding, or ruptured ectopic pregnancy.

Question: What is Courvoisier sign?
It is a palpable, distended gallbladder in the RUQ of patients with jaundice. It is usually the result of a malignant bile duct.

Question: Where is the most common site of pancreatic cancer?
The pancreatic duct system (˜80%) found in the head of the pancreas.

Question: With regards to pancreatic cancer, distinguish between periampullary lesions and lesions of the body and tail.
Periampullary lesions most commonly develop at the head of the pancreas. These lesions are usually adenocarcinomas and are associated with jaundice, weight loss, and abdominal pain.
Lesions in the body and tail tend to be much larger at presentation because of their retroperitoneal location and their distance from the common bile duct. Weight loss and pain are typical.

Question: What are the risk factors for pancreatic cancer?
- Smoking
- High-fat diet
- Chronic pancreatitis

Question: What are the associated symptoms of pancreatic cancer?
- Weight loss
- Abdominal pain
- Nausea and anorexia
- Easy fatigability
- Painless jaundice

Question: What is the tumor marker that can assist in diagnosing pancreatic cancer?
CA 19-9.

Question: What is the survival rate for pancreatic cancer?
<20% survive beyond 1 year from their initial diagnosis and <30% survive longer than 5 years.

Question: What are the two most common causes of ascites?
- Chronic liver disease
- Peritoneal carcinomatosis

What are the two main mechanisms of liver injury?
Hepatocellular injury indicates damage or destruction of the liver cells; most often due to viral hepatitis, autoimmune hepatitis, and drugs/toxins.
Cholestatic injury indicates impaired transport of bile. This may be caused by
- Extrahepatic obstruction (gallstones)
- Intrahepatic duct narrowing (primary sclerosing cholangitis)
- Bile duct damage (primary biliary cirrhosis)

Question: How is cholestatic injury best detected?
By an elevated alkaline phosphatase (AP) level. However, keep in mind that alkaline phosphatase can be derived from other body tissue (e.g., bone, intestine), so a concurrent elevation of GGT or 5' -nucleosidase helps to support a cholestatic mechanism.

Question: What is the test of choice to assess for hepatocellular injury?
ALT level. The AST level may also be elevated but is not as specific.

Question: Name the two most common causes of drug-induced liver disease:
Alcohol and acetaminophen.

Question: What recreational drugs are associated with hepatotoxicity?
Cocaine and ecstasy.

Question: How are hepatitis viruses transmitted?
- A and E = fecal, oral route
- B, C, D = blood borne

Question: Name four other viruses, other than Hepatitis A through E, which can affect the liver:
1. Cytomegalovirus
2. Herpes simplex virus
3. Epstein-Barr virus
4. Arthropod-borne flaviviruses (e.g., dengue, yellow fever)

Question: What are the predominant characteristics of autoimmune hepatitis?
This condition affects mostly women (˜70%) and is typically diagnosed in the fourth to fifth decade of life. It is essentially an idiopathic, unresolving inflammation of the liver, which can lead to cirrhosis, portal hypertension, liver failure, or even death.

Question: Differentiate primary biliary cirrhosis (PBC) with primary sclerosing cholangitis (PSC):
- Primary biliary cirrhosis mainly affects women in their fifties and is characterized by destruction of the septal bile ducts.
- Primary sclerosing cholangitis mainly affects men in their forties and involves diffuse inflammation and fibrosis of the entire biliary tree.
Both are chronic cholestatic liver diseases of unknown etiology that can eventually progress to end-stage liver disease.

What other gastrointestinal condition is strongly associated with primary sclerosing cholangitis?
Inflammatory bowel disease.

Question: What is hemochromatosis?
It is a disease of iron overload in the liver and other organs with the most likely defect occurring in a regulatory mechanism for iron absorption in the small intestine.

Question: What is the most common screening test for hemochromatosis?
Serum ferritin—an elevated level >400 mg/dL suggests the possibility of iron overload, but unfortunately serum ferritin can be an acute phase reactant. Thus, supportive testing (e.g., iron saturation, genetic testing, or liver biopsy) is needed to confirm the diagnosis.

Question: What is the treatment for genetic hemochromatosis?
Phlebotomy, with removal of 1 to 2 units per week.

Question: A 52-year-old patient presents with tremor, ataxia, dementia, cirrhosis, and grey-green rings around the edge of the cornea. What is the diagnosis?
Wilson disease—this is a disorder of copper storage and is associated with deficiency of an enzyme derived from hepatic cells. Deposition of copper may be seen in the eye (Kayser-Fleischer rings) and in parts of the brain.

Question: How is Wilson disease accurately diagnosed?
A diminished serum ceruloplasmin level is strongly suggestive of Wilson disease. A quantitative copper level in liver tissue from liver biopsy should provide a definitive diagnosis.

Question: List six extra hepatic manifestations of alcoholic liver disease:
1. Ascites
2. Spider angiomata
3. Asterixis
4. Palmar erythema
5. Korsakoff syndrome
6. Wernicke encephalopathy

Question: What are the most common vascular tumors of the liver?
Hemangiomas.

Question: What is the most common cause of jaundice in pregnancy?
Viral hepatitis.

Question: What is the most common liver disorder related to pregnancy?
Intrahepatic cholestasis.

What is the most common clinical symptom of intrahepatic cholestasis of pregnancy?
Severe pruritus in the third trimester.

Question: Nonalcoholic steatohepatitis (NASH) is becoming a growing concern in the United States. What other clinical conditions are associated with primary NASH?
- Morbid obesity
- Non-insulin–dependent diabetes
- Hyperlipidemia

Question: What is the most common laboratory abnormality in patients with NASH?
A two- to threefold increase in the serum AST and ALT.

Question: What is the most specific imaging technique used to evaluate NASH?
Hepatic ultrasound.

Question: Patients with cirrhosis or chronic active hepatitis should have what routine testing performed to screen for hepatomas?
Alpha-fetoprotein levels and a hepatic ultrasound should be performed every 6 months. These patients have a higher risk for developing hepatic cancer.

Question: A 43-year-old patient presents with a 6-week history of frequent, malodorous diarrhea that leaves an oily sheen to the surface of the toilet water. You suspect a malabsorption disorder. What is the best study to screen for fat malabsorption?
A microscopic stool examination using Sudan stain; it has 100% sensitivity and 96% specificity.

Question: What is the best test to differentiate malabsorption caused by small bowel versus pancreatic etiology?
d-Xylose test.

Question: What is the most sensitive and specific serum marker for celiac disease?
Tissue transglutaminase (tTG).

Question: What condition should be considered in a celiac patient who had previously responded well to a gluten-free diet, but now has developed refractory symptoms?
Small bowel lymphoma.

Question: What are the signs and symptoms of Whipple disease?
- Weight loss
- Diarrhea
- Arthralgias
- Cardiac involvement

Question: What gastrointestinal disease is most commonly associated with Dermatitis Herpetiformis?
Celiac disease (gluten enteropathy).

List the signs and symptoms of Crohn disease:
- Abdominal pain (especially RLQ)
- Perianal fistulas
- Weight loss
- Arthritis
- Diarrhea
- Hematochezia
- Fever

Question: What other diseases can mimic Crohn disease?
- Ischemic colitis
- Diverticulitis
- Colorectal cancer
- Infection with Yersinia species

Question: Name five potential treatment options for Crohn disease:
1. 5-Aminosalicylic acid (5ASA) agents
2. Immunosuppressant therapy (azathioprine, 6-mercaptopurine)
3. Steroids (prednisone)
4. Biologic therapy
5. Surgery

Question: What effect does smoking have on Crohn disease and ulcerative colitis?
- Crohn disease: detrimental effect; cigarette smokers are more likely to develop Crohn, have a worse prognosis, and have an increased number of recurrent flares.
- Ulcerative colitis: protective effect; the incidence of ulcerative colitis is higher in non- and ex-smokers than in current smokers.

Question: What is the greatest risk factor for ulcerative colitis?
Family history. Approximately 15% of patients with ulcerative colitis have a first-degree relative with the disease.

Question: What are the signs and symptoms of ulcerative colitis?
- Diarrhea
- Rectal bleeding (hematochezia)
- Tenesmus
- Passage of mucus

Question: Name five extraintestinal manifestations of ulcerative colitis:
1. Arthritis
2. Erythema nodosum
3. Uveitis
4. Ankylosing spondylitis
5. Primary Sclerosing cholangitis

Question: What is the least common site of primary gastrointestinal cancer?
Small bowel. Although it contains 75% of the length and 90% of the mucosal surface area, the small bowel only accounts for 1% to 2% of GI cancers. Adenocarcinoma remains the most prevalent type followed by lymphoma.

Define carcinoid syndrome:
Carcinoid syndrome refers to systemic symptoms resulting from the secretion of humoral factors by the Carcinoid (neuroendocrine) tumor. These symptoms may include:
- Episodic flushing of the face and upper trunk
- Watery diarrhea
- Bronchospasm

Question: What is the most likely distribution of carcinoid tumors?
Carcinoid tumors are slow growing and can occur anywhere along the GI tract. Most are found incidentally, thus at the time of discovery, most patients are asymptomatic. Only 5% of patients with carcinoid tumors have carcinoid syndrome (see above). Common sites for carcinoid growth include the appendix (most common), followed by the ileum, then stomach, rectum, colon, and pancreas.

Question: If carcinoid syndrome is strongly suspected, what is the best initial diagnostic study to pursue?
A urine analysis for 5-HIAA (hydroxyindoleacetic acid) will be increased. If the urine for 5-HIAA is increased then a CT of the abdomen and pelvis or an Octreoscan (Octreotide scintigraphy) should identify the primary site of the tumor in 80% of cases.

Question: What is the most common cancer arising in the colon?
Adenocarcinoma.

Question: How does colorectal cancer rank in mortality for the population of the United States?
Second, behind lung cancer.

Question: Considering those within the U.S. population who do not have a significant family history of colorectal cancer, at what age should general screening begin?
Caucasians and other races = age 50 years
African Americans = age 45 years

Question: What two clinical conditions should raise the suspicion for the presence of colon cancer?
1. An unexplained iron deficiency anemia
2. Sepsis with Streptococcus bovis

Question: What percentage of colon cancer is related to genetic inheritance?
15%.

Question: What is the “gold standard” for identifying colorectal cancer?
Colonoscopy.

Question: Name two metabolic disorders that can cause constipation:
1. Hypothyroidism
2. Diabetes mellitus

A 72-year-old female patient presents with a 2-day history of progressively worsening LLQ abdominal pain associated with constipation and “chills.” What is the most likely diagnosis?
Diverticulitis.

Question: What are potential complications of diverticulitis?
- Abscess formation
- Perforation leading to peritonitis
- Diverticular bleeding
- Obstruction from diverticular strictures or luminal narrowing

Question: List three risk factors for diverticulosis:
1. Increasing age
2. Chronic constipation that leads to increased luminal pressures
3. Westernized diet—low in fiber and high in refined carbohydrates

Question: What groups are most at risk for perforation of appendicitis?
- Children younger than 5 years of age
- Elderly patients
- Diabetic patients
- Immunosuppressed patients

Question: What is the most common tumor of the appendix?
Carcinoid tumor.

Question: What antibiotics are commonly associated with Clostridium difficile colitis?
C. difficile colitis can occur with any antibiotic, even a single dose preop. But the most likely suspects remain clindamycin, ampicillin, and third-generation cephalosporins.

Question: What is the first-line treatment of C. difficile colitis?
Metronidazole (Flagyl). Improvement should begin with 2 to 4 days and resolution of diarrhea by 2 weeks. If the patient does not respond to metronidazole, then vancomycin should be considered.

Question: List the most common sources of upper gastrointestinal bleeding:
- Duodenal ulcers
- Gastric erosions
- Gastric ulcers
- Esophagitis

Question: What is the most likely source of acute hematemesis in a 43-year-old male patient with a history of cirrhosis?
Esophageal varices (50%).

Question: What is the most common cause of hematochezia (bright red rectal bleeding) or lower GI bleeding in adults?
Internal hemorrhoids.

List four other causes of lower GI bleeding:
1. Diverticulitis
2. Vascular ectasias
3. Neoplasms
4. Ischemic colitis

Question: What is the most common cause of lower GI bleeding in children?
Meckel diverticulum—located in the ileum, it is the most common congenital abnormality of the gut.

Question: What is the most common complication of a Meckel diverticulum?
Bleeding. It presents with painless melena or hematochezia described as “currant jelly” like stools. Diagnosis is established via a Meckel scan (technetium-99m scintiscan).

Question: An 82-year-old male patient presents with an acute onset of crampy LLQ abdominal pain with the urge to defecate and expulsion of bloody diarrhea. Associated symptoms include nausea, fever, and tachycardia. Plain film abdominal X-rays reveal “thumbprinting” changes. What is the most likely diagnosis?
Ischemic colitis.

Question: A differential diagnosis for bloody diarrhea would include:
- Ischemic colitis
- Infectious colitis
- Radiation proctitis
- Inflammatory bowel disease (UC or Crohn disease)
- Meckel diverticulum

Question: How much blood is needed to produce a positive hemoccult (fecal occult blood test)?
As little as 2 mL.

Question: What is the test of choice to accurately diagnose celiac sprue (gluten enteropathy)?
Upper endoscopy with biopsies obtained from the duodenum that demonstrates flattened small bowel villi in association with increased epithelial lymphocytes.

Question: Name two methods used to diagnose lactose intolerance:
1. Dietary history and response to empiric therapy
2. Hydrogen breath test

Question: What are the four types of stimuli for abdominal pain?
1. Stretching or tension
2. Inflammation
3. Ischemia
4. Neoplasms

What is the single best test to evaluate HIV-infected patients who present with abdominal pain?
CT of the abdomen and pelvis.

Question: What gastrointestinal symptoms may occur in patients with pheochromocytoma?
- Weight loss
- Anorexia
- Abdominal pain due to cholelithiasis

Question: What is the significance of Sister Mary Joseph node?
It is an umbilical metastasis manifesting as periumbilical lymphadenopathy from an internal malignancy. It usually indicates advanced disease with an average survival time of up to 10 months.

Question: What other type of node may represent an intra-abdominal malignancy?
Virchow node, presenting as a supraclavicular mass, may indicate a bowel carcinoma.

Question: What is a common cause of acute abdominal pain in illicit drug users?
Acute mesenteric ischemia (“crack belly”) can be seen in cocaine abusers.

Question: What is the differential diagnosis of yellowish discoloration of the skin?
- Jaundice
- Hypercarotemia (overingestion of carotene, e.g., carrots, squash)
- Lycopenoderma (overingestion of lycopenes, e.g., red veggies, tomatoes)
- Profound hypothyroidism

Question: What type of gastroenteritis is closely associated with the consumption of seafood?
Vibrio parahaemolyticus.

Question: What is the most common cause of gastroenteritis in the United States?
Viruses.

Question: What is the most common cause of childhood diarrhea?
Rotavirus.

Question: Ordering stool cultures is appropriate in patients presenting with what characteristics?
- Bloody diarrhea
- High fever
- Presence of fecal leukocytes
- Immunocompromised patients
- Diarrhea persisting longer than 72 hours

Name the most common bacterial causes of infectious diarrhea in the United States:
Remember C, C, S, S, Y, and sometimes E:

Campylobacter

Clostridium

Salmonella

Shigella

Yersinia

E. coli O157:H7

Question: What is the most common bacterial source to infectious diarrhea in the United States?
Campylobacter jejuni.

Question: What is the most common parasitic diarrhea infection in the United States? In the world?
Giardia lamblia is the most common in the United States
Amebiasis (Entamoeba histolytica) is the most common in the world.

Question: Deficiency of what two vitamins can cause a macrocytic anemia?
Folate and B12.

Question: What is the leading cause of death in bulimia nervosa?
Cardiac arrhythmia.

Question: What proportion of adults in the United States is obese?
Approximately one-third.

Question: What vitamin deficiency does the Schilling test evaluate?
Vitamin B12.

Question: Pellagra is caused primarily by a deficiency of what nutrient?
Niacin.

Question: What are the three D’s of pellagra?

Dermatitis

Diarrhea

Dementia

Question: What is the most common dermatologic finding in patients with hemochromatosis?
Bronze pigmentation of the skin.

Question: What two dermatologic signs may assist in the diagnosis of acute pancreatitis?

1. Cullen sign (periumbilical bruising)

2. Grey Turner sign (flank bruising)

What is a possible finding on an upper GI series from a woman with telangiectasias, tight knuckles, and acid indigestion?
Aperistalsis. The defective peristalsis can be associated with connective tissue disorders such as scleroderma, or in this clinical scenario, a CREST syndrome:

Calcinosis cutis

Raynaud phenomenon

Esophageal dysfunction

Sclerodactyly

Telangiectasias

Question: Rickets is associated with a deficiency of what vitamin?
Vitamin D.

Question: A 38-year-old male patient presents with anorexia, lethargy, arthralgias, and swollen gums. What vitamin deficiency may be present?
Vitamin C (scurvy).

Question: Deficiencies in either of these two micronutrients may cause paresthesias, tetany, seizures, or arrhythmia:
Calcium or magnesium.

Question: Night blindness may be associated with what vitamin deficiency?
Vitamin A.

Question: What is the most common risk factor for hepatitis C?
Intravenous drug abuse accounts for 43% of cases.

Question: List four factors that increase the risk for colorectal cancer:

1. Increasing age

2. Family history of polyps or CRC

3. Inflammatory bowel disease

4. Diets high in fat and low in fiber

Question: What are three basic mechanisms of weight loss?

1. Decreased food intake (e.g., esophageal stricture)

2. Increased metabolism (e.g., hyperthyroidism)

3. Increased loss of energy (e.g., intestinal malabsorption with steatorrhea)

Question: What are the leading causes of unexplained weight loss in the elderly?
- Psychiatric
- Malignancy
- Gastrointestinal disorders

What is the most common digestive complaint in the United States?
Constipation.

Question: List four common causes of acute abdominal pain in the elderly from most to least prevalent:

1. Biliary tract disease

2. Bowel obstruction

3. Incarcerated hernias

4. Appendicitis

Question: Identify six causes of chronic hiccups:

1. Abdominal distention

2. Brain stem lesion

3. Gastric malignancy

4. Pleural irritation

5. Pancreatitis

6. Chronic renal failure


REFERENCES
Edmundowicz, SA. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill; 2002.
Feldman M, Friedman LS, Sleisenger MH. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 7th ed. Philadelphia, PA: W.B. Saunders; 2002.
Hauser, S. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. Florence, KY: Mayo Clinic Scientific Press and Informa Healthcare; 2008.
McNally PR. GI/Liver Secrets. 2nd ed. Philadelphia, PA: Hanley & Belfus; 2001.
Schilling-McCann. Professional Guide to Signs and Symptoms. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2004.