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Gastroenterology and Hepatology Board Review


A 57-year-old man is evaluated because of persistent serum aminotransferase elevations. ... A 53-year-old woman has a 6-month history of increasing diarrhea without ... – PowerPoint PPT presentation

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Title: Gastroenterology and Hepatology Board Review

Gastroenterology and HepatologyBoard Review
  • Jeff Singerman
  • June 13, 2007

Question 1
  • A 57-year-old man is evaluated because of
    persistent serum aminotransferase elevations.
    Medical history is significant for stage II colon
    CA that was resected 6 years ago. There has been
    no evidence of recurrence. The patient has been
    taking atorvastatin for 5 years for management of
    hyperlipidemia. He recently required amox/clav
    for the treatment of acute sinusitis, which has
    resolved. He drinks 3-4 glasses of wine on
    weekends. PE discloses only mild hepatomegaly.
    BMI is 32.
  • Labs Glc-124, LDL-122, HDL-56, Tri-185, AST-92
    (was normal 2 years ago, 87 1 year ago), ALT-104
    (was normal 2 years ago, 106 1 year ago), AP-62,
    Bili-0.7, Albumin-4.5, INR-1.1
  • CT scan of the abdomen shows low-density hepatic

Question 1 continued
  • Which of the following is most likely causing
    this patients elevated serum aminotransferase
  • Recurrence of colon cancer
  • Nonalcoholic fatty liver disease
  • Administration of amoxicillin/clavulanate
  • Primary biliary cirrhosis
  • Alcohol use

Non-Alcoholic Fatty Liver Disease (NAFLD)
  • Spectrum of disorders characterized by
    predominantly macrovesicular hepatic steatosis
    that occur in individuals even in the absence of
    consumption of alcohol.

Non-Alcoholic Fatty Liver Disease (NAFLD)
  • Risk Factors Obesity, DM, dyslipidemia, severe
    weight loss, some drugs
  • Drugs Amiodarone, Tamoxifen, Glucocorticoids,
    synthetic estrogens
  • Evaluation LFTs, Hep B, Hep C, EtOH hx
  • Imaging US, CT, or MRI
  • All can detect steatosis and rule out other
  • Cannot distinguish between fatty liver,
    steatohepatitis, and steatohepatitis with
  • Confirmation Liver biopsy
  • Treatment Weight loss

Non-Alcoholic Steatohepatitis (NASH)
  • Subset of NAFLD
  • Liver bx showing moderate to gross macrovesicular
    fatty changes (with or without fibrosis or
  • Negligible EtOH consumption (lt40 g/week)
  • Absence of infectious hepatitis (Hep B, Hep C)
  • Risk Factors Obesity, DM, hyperlipidemia

Non-Alcoholic Steatohepatitis (NASH)
  • Diagnosis
  • Most are asymptomatic
  • Fatigue, malaise, vague RUQ discomfort
  • Hepatomegaly
  • Elevated LFTs (although can be normal in advanced
  • Confirmation Liver biopsy

Non-Alcoholic Steatohepatitis (NASH)
  • Progression to cirrhosis in 8-26
  • Predictors of fibrosis
  • Age gt 45 or 50
  • BMI gt 28
  • Triglycerides gt 1.7 mmol/L
  • ALT gt 2 x normal
  • ASTALT gt 1
  • Treatment none proven
  • Weight loss
  • Insulin sensitizers metformin, rosiglitazone,

Question 2
  • A 66-year-old woman comes for her annual physical
    examination. She reports only mild fatigue. The
    patient has prediabetes that is managed by diet
    alone. She takes no meds and drinks one glass of
    wine each day. On exam, BP 132/86, BMI is 32,
    otherwise normal.
  • Labs Hb-13.1, Plt-85, Glc (fasting)-119,
    lipids-nl, AST-138, ALT-124, AP-50, Bili-0.8,
    Alb-3.1, Hep A,B,C-negative, Transferrin-nl,
  • Abd US evidence of mild fatty infiltration of
    the liver.

Question 2 continued
  • In addition to weight loss, which of the
    following is the most appropriate next step for
    managing this patients liver chemistry
  • Rosiglitazone repeat liver tests in 6 months
  • Alcohol counseling
  • Liver biopsy
  • Evaluation for liver transplantation

Question 3
  • A 24-year-old man has intermittent dysphagia for
    solid foods that has required two visits to the
    emergency department in the past 6 years for
    endoscopic removal of pieces of chicken. The
    patient has no weight loss or heartburn. He has
    always been a slow eater. He has mild asthma and
    uses a beta-agonist inhaler intermittently. On
    exam, the patient is well developed. General
    exam is normal. EGD reveals some mild ring
    formation in the mid-esophagus. Esophageal
    biopsy specimens show intense eosinophilic

Question 3 continued
  • Which of the following is the most appropriate
    therapy for this patients dysphagia?
  • A long-term PPI
  • Topical swallowed corticosteroids
  • Oral nifedipine before meals
  • Sublingual nifedipine before meals

Eosinophilic Esophagitis
  • A new diagnosis with accelerating incidence
  • Characterized by eosinphilic infiltration of the
  • Unclear etiology allergic?

Eosinophilic Esophagitis
  • Epidemiology In adults, most commonly seen in
    males, age 20-30
  • Clinical Characteristics
  • Dysphagia morphologic abnormalities
  • Strictures (most common, usually proximal)
  • Rings (occasionally multiple)
  • Linear furrows
  • Feline esophagus
  • Too-small esophagus
  • Food impaction
  • Esophageal dysmotility (occasionally)
  • History of asthma and peripheral eosinophilia

Eosinophilic Esophagitis
  • Diagnosis consensus not yet achieved
  • 1) Presence of characteristic clinical findings
  • 2) Presence of large number of eosinophils in the
  • Usually gt 20 eos/hpf (GERD usually lt 5 eos/hpf)
  • 3) Exclusion of other causes

Eosinophilic Esophagitis
Eosinophilic Esophagitis
  • Treatment
  • Swallowed Steroids (fluticasone MDI)
  • Esophageal Dilation (carefully)
  • Elimination Diets (unclear utility in adults)
  • Acid suppression usually not helpful

Question 4
  • A 53-year-old woman has a 6-month history of
    increasing diarrhea without bleeding or a sense
    of urgency. She has 3 or 4 bowel movements daily
    compared with her previous pattern of two or
    three bowel movements each day. The patient has
    lost 6 pounds during this time. Medical history
    is significant for hypothyroidism, managed with
    thyroid replacement therapy. The patient is
    post-menopausal and has had no abnormal vaginal
    bleeding. She has maintained a lifelong
    milk-free diet. Physical exam is normal. BMI is
  • Labs Hb-9.8 (was 13.5 1 year ago), WBC-6.5,
    Plt-250, MCV-85, RDW-19 (elevated), Ferritin-10,
    Alb-4.5, LFTs-nl, TSH-nl, Anti-TTG Ab-negative,
    Stool cultures/c. dif/O and P are negative
  • Upper GI series with small-bowel follow-through
    is normal. Colonoscopy with random biopsies is
    also normal

Question 4 continued
  • Which of the following diagnostic studies should
    be scheduled next?
  • Antiendomysial antibody assay
  • Serum calcitonin measurement
  • Upper endoscopy with small bowel biopsies
  • Serum gastrin measurement
  • Capsule endoscopy

Celiac Disease
  • All testing must be done on a gluten-containing
  • Serum Antibody Assays
  • IgA Endomysial Ab
  • Sensitivity 85-98, Specificity 97-100
  • IgA TTG Ab
  • Sensitivity 93, Specificity 99
  • IgA Antigliadin Ab
  • Sensitivity 75-90, Specificity 82-95
  • IgG Antigliadin Ab
  • Sensitivity 69-85, Specificity 73-90
  • Antigliadin antibodies no longer recommended for
    screening or diagnosis except in cases of IgA

Celiac Disease
Celiac Disease
  • Anemia and Celiac Disease
  • Iron deficiency is common (can be the only
    manifestation of celiac in adults).
  • Due to malabsorption rather than GI blood loss
  • Macrocytic anemia can be seen as well
  • Usually secondary to folate deficiency, B12
    deficiency is rare
  • With both entities, can see a normocytic anemia
    with an increased RDW.

Steroids in Alcoholic Hepatitis
  • Controversial
  • 12 controlled trials performed
  • 5 showed reduced mortality vs. placebo
  • 7 showed no difference vs. placebo
  • 3 metanalyses
  • 2 showed a beneficial effect
  • 1 showed benefit or harm depending on subgroup

Steroids in Alcoholic Hepatitis
  • ACG Guidelines
  • Corticosteroids should be used in patients with
    severe alcoholic hepatitis and/or hepatic
  • Severe described by prothrombin discriminate
    function gt 32
  • 4.6 x (prothrombin time above control in
    seconds) Bili
  • The efficacy of steroids has not been adequately
    studied in patients with severe alcoholic
    hepatitis who also have
  • Concomitant pancreatitis
  • Renal failure
  • GI bleeding
  • Active infection
  • Histological confirmation of alcoholic hepaititis
    optimizes the selection of these patients.
    However, must be weighed against risk of
    performing biopsy

Steroids in Alcoholic Hepatitis
  • Treatment
  • Prednisolone 40mg daily x 4 weeks followed by a
  • Prednisone is not used as is converted to
    predisolone in the liver
  • Reduces mortality by 25
  • Although mortality remains as high as 44 in
    patients receiving steroids
  • NNT 7

Cholecystectomy inAsymptomatic Cholelithiasis
  • There are no indications for cholecystectomy in
    asymptomatic cholelithiasis, with a few
  • Many patients at increased risk for biliary CA
    should get prophylactic cholecystectomy or
    incidental cholecystectomy at time of other
    intra-abdominal surgery.
  • Choledocal cysts
  • Carolis Disease
  • Anomalous pancreatic ductal drainage (into CBD)
  • Gallbladder adenomas
  • Porcelain gallbladder

Cholecystectomy inAsymptomatic Cholelithiasis
  • Sickle Cell Disease
  • Pigmented stones are common and often
  • Not an indication for prophylactic
    cholecystectomy, but may be taken out
    incidentally during another procedure
  • Hereditary Spherocytosis
  • Bilirubin stones
  • Indication for prophylactic or incidental
  • Gastric Bypass Surgery
  • Incidental cholecystectomy recommended at the
    time of surgery

Cholecystectomy inAsymptomatic Cholelithiasis
  • Diabetes Mellitus
  • Increased risk for developing severe gangrenous
  • However, prophylactic cholecystectomy is not
    recommended secondary to increased risk of

Colon Cancer Screening
  • Average risk patients
  • Offer one of the following beginning at age 50
  • FOBT yearly
  • Sigmoidoscopy q5yrs
  • Combined FOBT/Sigmoid q1yr/q5yrs
  • Colonoscopy q10yrs (no trials)
  • Double Contrast Barium Enema q5yrs (no trials)

Colon Cancer Screening
  • Family history of colon CA
  • 1st degree relative with colon CA or adenomatous
    polyps on bx age lt 60 OR two 1st degree relatives
    dx with colorectal CA at any age
  • Colonoscopy at age 40 or 10 years earlier that
    the earliest diagnosis in their family, whichever
    comes first
  • Repeat colonoscopy every 5 years
  • 1st degree relative with colon CA or adenomatous
    polyp dx age gt 60 OR two 2nd degree relatives
    with colon cancer
  • Screen like average risk patients but start at
    age 40

Colon Cancer Screening
  • Personal History of Polyps
  • 1-2 small (lt1 cm) tubular adenomas with only
    low-grade dysplasia
  • Colonoscopy every 5-10 years
  • 3-10 adenomas or any adenoma gt 1cm, or any
    adenoma with villous features or hi-grade
  • Colonoscopy every 3 years
  • gt10 adenomas
  • Colonoscopy more frequent than every 3 years,
    determined by clinical judgment
  • Sessile adenomas that are removed piecemeal
  • Colonoscopy at 2-6 months to verify complete

Colon Cancer Screening
  • Personal History of Colon CA resection
  • Pre-op or peri-op colonoscopy on all patients
  • Subsequent colonoscopies at 3 years post surgery
    and then, if normal, every 5 years
  • For those patients with an obstructing mass
  • Full colonoscopy within 6 months of surgery

Colon Cancer Screening
  • Familial syndromes
  • Begin at age 20-25, or 10 years earlier than
    youngest age of colon CA dx in the family,
    whichever comes first
  • Colonoscopy every 1-2 years
  • FAP
  • Begin at age 10-12 and continue until age 35-40
    if negative
  • Flex sig or colonoscopy yearly
  • Classic FAP always isolated to rectosigmoid,
    attenuated FAP can be right sided
  • /- genetic counseling and testing

Colon Cancer Screening
  • Inflammatory Bowel Disease
  • Ulcerative Colitis
  • AGA colonoscopy after 8 years of diagnosis in
    patients with pancolitis and 15 years in patients
    with only left sided involvement Repeat every
    1-2 years
  • ACG annual colonoscopy beginning after 8-10
    years of diagnosis in patients who are surgical
    candidates. Evidence of definite dysplasia
    warrants referral for colectomy.
  • Crohns Disease
  • AGA same as for UC
  • ACG insufficient evidence for guidelines

Question 5
  • A 40-year old woman has an 18-year history of UC
    that is limited to the left side and has
    responded well to therapy. Recent surveillance
    colonoscopy with biopsies showed low-grade
    dysplasia. Which of the following is the most
    appropriate next step?
  • Repeat colonoscopy in 3 months
  • Repeat colonoscopy in 1-2 years
  • Administer sulindac
  • Administer a low-dose corticosteroid
  • Refer for colectomy

Question 6
  • A 32-year-old man comes for an annual health
    maintenance visit. His mother was diagnosed with
    colorectal cancer at 55 years of age. The
    patient reports no rectal bleeding or other
    symptoms. Medical history is noncontributory
    except for hypercholesterolemia. PE is normal.
    When should this patient first undergo colorectal
    cancer screening?
  • Now
  • At age 40 years
  • At age 45 years
  • At age 50 years

Question 7
  • A 65-year-old woman underwent initial colonoscopy
    1 month ago for colorectal cancer screening. A
    6mm tubular adenoma of the sigmoid colon was
    found and removed. The patient has no family
    history of colorectal cancer. Which of the
    following is the most appropriate recommendation
    for colorectal cancer surveillance for this
  • Repeat colonoscopy in 1 year
  • Repeat colonoscopy in 3 years
  • Repeat colonoscopy in 5 years
  • Flexible sigmoidoscopy in 5 years
  • Virtual colonoscopy (CT colonography) in 5 years

Question 8
  • A 50-year-old man comes for an annual health
    maintenance visit. He feels well, and medical
    history is unremarkable. There is no family
    history of colorectal cancer. Physical
    examination and routine labs are normal. Which
    of the following is the most appropriate
    recommendation for colorectal cancer screening
    for this patient?
  • FOBT now, repeat every 2-3 years
  • Flex sig now, repeat every 2-3 years
  • Barium enema now, repeat every 2-3 years
  • Colonoscopy now, repeat every 10 years
  • Virtual colonoscopy now, repeat every 10 years

Question 9
  • Three months ago, a 62-year-old man underwent
    segmental sigmoid colon resection for a
    near-obstructing colorectal cancer found of
    flex-sig. Surgery was considered curative, and
    the patient did not require post-op chemo or
    radiation. He has no family history of
    colorectal cancer or polyps. On follow-up exam
    today, he feels well. PE is normal. Which of
    the following is the most appropriate colorectal
    cancer surveillance procedure for this patient?
  • Colonoscopy now
  • Colonoscopy in 1 year
  • Colonoscopy in 3 years
  • CT scan of the abdomen now
  • CT scan of the abdomen in 3 years

Question 10
  • A 67-year-old man undergoes diagnostic
    colonoscopy after he has a positive FOBT. A
    sigmoid colon CA is found. The remainer of the
    colonoscopic exam is normal. A CT of the abdomen
    shows no mets. CEA is slightly elevated. The
    patient undergoes resectino of the sigmoid with
    good results. Post-op recommendations include
    follow-up office visits every 3 months for 3
    years, CEA measurement, and surveillance

Question 10 Continued
  • When should the first surveillance colonoscopy be
  • In 1 year
  • In 3 years
  • In 5 years
  • Only if CEA level increases