Gastroenterology and Hepatology Board Review

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Gastroenterology and HepatologyBoard Review

• Jeff Singerman
• June 13, 2007

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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
  parenchyma.

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Question 1 continued

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

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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.

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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
  causes
• Cannot distinguish between fatty liver,
  steatohepatitis, and steatohepatitis with
  fibrosis
• Confirmation Liver biopsy
• Treatment Weight loss

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NAFLD and NASH
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Non-Alcoholic Steatohepatitis (NASH)

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

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Non-Alcoholic Steatohepatitis (NASH)

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

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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,
  pioglitazone

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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,
  UA-nl
• Abd US evidence of mild fatty infiltration of
  the liver.

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Question 2 continued

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

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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
  infiltration.

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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

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Eosinophilic Esophagitis

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

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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

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Eosinophilic Esophagitis

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

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Eosinophilic Esophagitis
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Eosinophilic Esophagitis

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

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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
  21
• 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

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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

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Celiac Disease

• All testing must be done on a gluten-containing
  diet
• 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
  deficiency

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Celiac Disease
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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.

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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

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Steroids in Alcoholic Hepatitis

• ACG Guidelines
• Corticosteroids should be used in patients with
  severe alcoholic hepatitis and/or hepatic
  encephalopathy
• 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

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Steroids in Alcoholic Hepatitis

• Treatment
• Prednisolone 40mg daily x 4 weeks followed by a
  taper
• 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

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Cholecystectomy inAsymptomatic Cholelithiasis

• There are no indications for cholecystectomy in
  asymptomatic cholelithiasis, with a few
  exceptions
• 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

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Cholecystectomy inAsymptomatic Cholelithiasis

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

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Cholecystectomy inAsymptomatic Cholelithiasis

• Diabetes Mellitus
• Increased risk for developing severe gangrenous
  cholecystitis
• However, prophylactic cholecystectomy is not
  recommended secondary to increased risk of
  surgery.

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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)

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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

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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
  dysplasia
• 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
  removal

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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

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Colon Cancer Screening

• Familial syndromes
• HNPCC
• 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

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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

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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

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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

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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
  patient?
• 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

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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

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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

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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
  colonoscopy.

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Question 10 Continued

• When should the first surveillance colonoscopy be
  performed?
• In 1 year
• In 3 years
• In 5 years
• Only if CEA level increases