ATI LPN
Questions About Gastrointestinal System Questions
Question 1 of 5
A 32-year-old woman presents with a 10-month history of an intermittent burning sensation in the epigastrium that is sometimes related to eating. She has heard about bacteria that can cause gastrointestinal (GI) symptoms. She has had no change in her weight and denies dysphagia. Her laboratory tests are normal. Which of the following would you recommend?
Correct Answer: A
Rationale: The patient presents with dyspepsia. In individuals who are under the age of 45 years and present with no other warning signs (e.g., anemia, weight loss, or dysphagia), a serum qualitative test for H. pylori can be obtained to document H. pylori infection, provided that the patient has no prior history of being treated. A serum IgG can remain positive even after antibiotic eradication. In H. pylori-positive individuals who do not respond to therapy, an upper endoscopy would be the next test. An upper GI series cannot detect H. pylori and is less sensitive than endoscopy in detecting lesions of the esophagus, stomach, and proximal small bowel. Empiric therapy for H. pylori is never recommended.
Question 2 of 5
A 60-year-old African-American woman with a history of GERD and an extensive smoking and alcohol history presents complaining of dysphagia for the past two months. She also reports weight loss of 15 pounds over that span. A barium swallow is done and reveals narrowing of the mid-esophagus. An endoscopy is performed and is consistent with an esophageal tumor, so biopsies are taken and they reveal squamous cell carcinoma. Which of the following statements is correct?
Correct Answer: C
Rationale: The incidence of squamous cell carcinoma is decreasing in the U.S. while the incidence of adenocarcinoma is increasing. The most important risk factors for SCC in this patient are cigarette and alcohol use. Reflux is a risk factor for adenocarcinoma. Esophagectomy is appropriate for less than half of the patients. The five-year survival after esophagectomy is still only $20 \%$. A CT scan of the chest and endoscopic ultrasound are the best tests to determine the extent of regional spread.
Question 3 of 5
A 78-year-old woman presents to you after having a total body CT scan done at a local facility. She was told that she has a few gallstones in her gallbladder and should discuss this with her primary physician. An ultrasound was apparently also done, which revealed the presence of a few 1-cm gallstones but no ductal dilatation or gallbladder thickening. She denies any abdominal discomfort or pain. Her aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase are normal. She is concerned because her mother died of complications from a 'gallbladder attack.' What course of action would you recommend in this patient?
Correct Answer: D
Rationale: Asymptomatic gallbladder stones usually do not require treatment. Only $13 \%$ of patients with silent gallstones will become symptomatic in future. That is why open or laparoscopic cholecystectomy is not indicated for this patient with a silent gallbladder stone. Oral dissolution is only indicated for small gallstones, preferably less than $5 \mathrm{~mm}$ (smaller stones dissolve faster). Stones larger than $2 \mathrm{~cm}$ will rarely be dissolved. Extracorporeal shock wave lithotripsy has a limited rate of success and a high rate of recurrence; it is rarely used in the United States. Direct dissolution of stones is an option in patients with large stones and at high risk for surgery.
Question 4 of 5
A 55-year-old man presents complaining of frequent foul-smelling stools, excess gas, 10-pound weight loss, and unsteadiness of gait. His past history includes multiple prior episodes of small intestinal obstruction arising from adhesions from abdominal surgery for trauma. He still complains of occasional periumbilical pain after eating, and has generalized aches and pains and chronic soreness around his mouth. He takes a proton pump inhibitor for gastroesophageal reflux. Apart from his previous scars, his abdominal exam is normal. He has absent ankle jerks and he is unable to maintain an upright posture gait with his feet together once he closes his eyes. His investigations reveal stool fat levels of $15 \mathrm{~g} / 24$ hours. His labs are notable for macrocytic anemia, an elevated alkaline phosphatase, and a low serum albumin. CT of his abdomen reveals some mildly dilated small bowel loops. Which of the following statements are incorrect?
Correct Answer: D
Rationale: He has fat malabsorption and steatorrhea secondary to bacterial overgrowth from intestinal stasis arising from his adhesions. Bacterial overgrowth leads to vitamin B12 deficiency from bacterial consumption of B12. His B12 deficiency has caused him to develop subacute combined degeneration of the cord with a positive Romberg's sign, stomatitis, and evidence of a peripheral neuropathy. Folic acid levels may increase as folate is produced by luminal bacteria. The reduction in gastric acid by proton pump inhibitors increases intestinal bacteria and is probably exacerbating bacterial overgrowth in this setting. Acid is also needed to release protein-bound vitamin B12 from food, and individuals who take PPIs absorb less vitamin B12 from food but rarely to such an extent that it leads to vitamin B12 deficiency. Many patients with small bowel bacterial overgrowth have mildly abnormal intestinal villi, which occur secondary to the effect of excess bacteria. Since his bacterial overgrowth is related to his anatomy, he will require regular cycles of antibiotics.
Question 5 of 5
A 35-year-old male patient presents with right upper quadrant pain, fever for the past 48 hours, preceded by new onset jaundice over the past few weeks. He states that he has had diarrhea on and off for several years but never had this investigated. A liver ultrasound is negative for gallstones or evidence of cholecystitis. His lab tests reveal total bilirubin 6.2, alkaline phosphatase 450, AST 150, ALT 120, albumin 2.6. The next diagnostic test of choice would be
Correct Answer: B
Rationale: Magnetic resonance cholangiopancreatography to diagnose intrahepatic strictures associated with primary sclerosing cholangitis, and to exclude other causes of intrahepatic cholestasis. The patient likely has undiagnosed ulcerative colitis. If confirmed, an urgent endoscopic retrograde cholangiopancratogram may be helpful to drain any pockets of obstructed bile flow. Liver biopsy is nondiagnostic in PSC, and should not be performed in the setting of acute cholangitis.