GI3 Case C Answers

In the triage unit of your ER you find a 37 yo male with past medical h/o of primary hyperparathyroidism status post right inferior parathyroidectomy 1 year ago, hyperlipidemia, HTN, temporal(giant cell) arteritis being treated with prednisone complaining of severe midepigastric abdominal pain that radiates to the back that started a few hours ago and has not abated in intensity since its start. His pain was so severe he's had two episodes of nonbloody, nonbilious vomiting a few hours ago that scared him to come into the ER at 4am. On questioning his activities earlier in the evening, he mentioned he attended his 20 year high school reunion which had a luxurious open bar selection. 

On Physical exam you note a low grade fever, tachypnea, tachycardia, upper abdominal tenderness with guarding but without rebound. You were not able to appreciate any bowel sounds. 

Abdominal Exam of Patient

Name these two physical exam findings:

Cullen's Sign: Bluish discoloration of the periumbilicus

Grey-Turner's sign: Bluish discoloration of the flanks

What is your suspected Dx?

Acute Pancreatitis

Name the 5 risk factors this patient presented with in your initial history of present illness

Hyperlipidemia

Possible recalcitrant hypercalcemia due to an undiscovered abnormal parathyroid gland

Vasculitis

Glucocorticoid Use

Alcohol abuse

Could possibly have cholelithiasis that caused it bc of his h/o hyperlipidemia

What are the two most common causes of your patient's disease?

Alcohol Abuse and Gallstones

Describe the pathophysiology behind the Most Common Cause of your diagnosis.

Alcohol thickens duct secretions and also increases duct permeability to enzymes

What lab study do you want to order to confirm your diagnosis?

Lipase Study

What other lab study, not specific to the diagnosis, will be elevated in this patient? Name four of the five areas in the body that produce this quantifiable lab study. 

Amylase. Also found in salivary glands, small bowel, overies, testes, and skeletal muscle. 

What is the most common cause of this disease in kids?

Seatbelt trauma

What kind of shock can you go into because of this disease? How does it relate to Third Space Fluid?

Hypovolemic Shock due to third space loss of fluids. 

"Third space fluid is sequestered fluid that is unavailable for maintenance of volume in the vascular compartment. In acute pancreatitis, it refers to the peripancreatic collection of fluid that commonly occurs as the pancreas auto-digests itself." Goljam

 What is the mechanism behind acute pancreatitis induced hypoxemia?

Circulating pancreatic phopholipase destroys surfactant…ARDS may occur

Why can you go into DC during pancreatitis?

Activation of prothrombin by trypsin

(Just kidding. Did you really think I'd make you draw it?)

A highlight on histological progression...

"Progressive loss of normal acinar cells (and later islet cells – marked as “*”) as chronic inflammation and fibrosis (light colored material) replaces the normal cells." -Pancreas.org

GI3 Case C

In the triage unit of your ER you find a 37 yo male with past medical h/o of primary hyperparathyroidism status post right inferior parathyroidectomy 1 year ago, hyperlipidemia, HTN, temporal(giant cell) arteritis being treated with prednisone complaining of severe midepigastric abdominal pain that radiates to the back that started a few hours ago and has not abated in intensity since its start. His pain was so severe he's had two episodes of nonbloody, nonbilious vomiting a few hours ago that scared him to come into the ER at 4am. On questioning his activities earlier in the evening, he mentioned he attended his 20 year high school reunion which had a luxurious open bar selection. 

On Physical exam you note a low grade fever, tachypnea, tachycardia, upper abdominal tenderness with guarding but without rebound. You were not able to appreciate any bowel sounds. 

Abdominal Exam of Patient

Name these two physical exam findings:

What is your suspected Dx?

Name the 5 risk factors this patient presented with in your initial history of present illness

What are the two most common causes of your patient's disease?

Describe the pathophysiology behind the Most Common Cause of your diagnosis.

What lab study do you want to order to confirm your diagnosis?

What other lab study, not specific to the diagnosis, will be elevated in this patient? Name four of the five areas in the body that produce this quantifiable lab study. 

What is the most common cause of this disease in kids?

What kind of shock can you go into because of this disease? How does it relate to Third Space Fluid?

What is the mechanism behind acute pancreatitis induced hypoxemia?

Why can you go into DC during pancreatitis?

Bonus Points: Draw the histologic progression from acute pancreatitis to chronic pancreatitis.

GI3 Case B Answers

A patient comes to your general surgery clinic, unexpectedly, with a number of radiologic/diagnostic studies that was done during a previous hospitalization, when she declined the curative therapy for her disease, due to extenuating circumstances, that has now come back to bother her again.

She hands you the following images.

An ultrasound:

"Four scans of different orientations through the gallbladder shows gallbladder wall thickening, pseudomembrane formation, sludge, and pericholecystic fluid." -Medscape

Your clinical fund of knowledge leads you towards a certain disease process even before the patient describes her story. You take one last look at the other imaging study she brought you and you recall what a normal study looks like.

"Normal cholescintigrams. Normal technetium-99m hepatic iminodiacetic acid (99mTc-HIDA) scans of the liver shows normal gallbladder filling within 45 minutes." -medscape

 Which makes you realize how abnormal her study is. See below.

Technetium-99m hepatic iminodiacetic acid (99mTc-HIDA) scan followed for 1 hour 30 minutes shows no filling of the gallbladder due to cystic duct obstruction.

So you start, as you normally do, by asking her for her story. :)

She said her pain started this morning after breakfast. She went to Hometown Buffet and had a large amount of cheese omelets, hash browns, and fried chicken. It was for her 40th birthday. She wanted to treat herself to an early celebration breakfast before getting treated out again for lunch. But, she never made it to lunch because her pain was so severe, even radiating to her shoulder, that she called your clinic to make a last minute appointment. She was in so much pain she vomited just before lunch and still feels nauseas now. She doesn't even have any appetite at all even though she last ate 8 hours ago. When prompted to point where she feels most of her pain, she moves her hand to the right upper quadrant. 

On physical exam, you note a positive Murphy's sign.

What is her diagnosis?

Acute Cholecystitis with possible obstruction in her cystic duct

You remember back in pathology and realize this woman satisfies many of the "F's" that you used as a mnemonic for memorizing the risk factors for this disease. Name 8 of these "F's" that are risk factors for cholelithiasis.

Female
Fat
Forty
Fertile
Flatulent
Familial
Fibrosis(cystic)
F-Hgb (sickle cell disease)

Name 4 bacteria implicated in overgrowth during stage 2 of this disease process. Which is the most common?

E.coli. Enterococci. Bacteroides fragilis, Clostridium sp

You review with her your diagnosis and she agrees with your plan to admit her and do a laproscopic cholecystectomy in 48-72 hours when her symptoms quiet down.

In your mind, you wonder if her histologic picture now fits a chronic presentation and you recall the following images you reviewed in pathology years ago. You remember the pathology because it predisposes her to a greater chance of perforation.
(Images from UTAS)

 

You get a call from the nurse, asking for more pain medication for your patient. You thought you already gave her an appropriate dose of an opiate analgesic, but you notice that the intern taking care of your patient ordered her morphine. What went wrong?

Morphine causes the sphincter of Oddi to contract and worsens pain. Use Meperidine for PAIN!

GI3 Case B

A patient comes to your general surgery clinic, unexpectedly, with a number of radiologic/diagnostic studies that was done during a previous hospitalization, when she declined the curative therapy for her disease, due to extenuating circumstances, that has now come back to bother her again.

She hands you the following images.

An ultrasound:

Your clinical fund of knowledge leads you towards a certain disease process even before the patient describes her story. You take one last look at the other imaging study she brought you and you recall what a normal study looks like.

 Normal technetium-99m hepatic iminodiacetic acid (99mTc-HIDA) scans 

 Which makes you realize how abnormal her study is. See below.

So you start, as you normally do, by asking her for her story. :)

She said her pain started this morning after breakfast. She went to Hometown Buffet and had a large amount of cheese omelets, hash browns, and fried chicken. It was for her 40th birthday. She wanted to treat herself to an early celebration breakfast before getting treated out again for lunch. But, she never made it to lunch because her pain was so severe, even radiating to her shoulder, that she called your clinic to make a last minute appointment. She was in so much pain she vomited just before lunch and still feels nauseas now. She doesn't even have any appetite at all even though she last ate 8 hours ago. When prompted to point where she feels most of her pain, she moves her hand to the right upper quadrant. 

On physical exam, you note a positive Murphy's sign.

What is her diagnosis?


You remember back in pathology and realize this woman satisfies many of the "F's" that you used as a mnemonic for memorizing the risk factors for this disease. Name 8 of these "F's" that are risk factors for cholelithiasis.


Name 4 bacteria implicated in overgrowth during stage 2 of this disease process. Which is the most common?


You review with her your diagnosis and she agrees with your plan to admit her and do a laproscopic cholecystectomy in 48-72 hours when her symptoms quiet down.

In your mind, you wonder if her histologic picture now fits a chronic presentation and you recall the following images you reviewed in pathology years ago. You remember the pathology because it predisposes her to a greater chance of perforation. Think about what that might look like? Better yet, describe it? Even better than that? Draw it.


You get a call from the nurse, asking for more pain medication for your patient. You thought you already gave her an appropriate dose of an opiate analgesic, but you notice that the intern taking care of your patient ordered her morphine. What went wrong?

GI3 Case A Answers

As the pathologist you receive the following specimen from autopsy.

Diagnose the disease process using the following photo:

Pancreatic Adenocarcinoma

Here is a list of some of the causes of the disease process you've just diagnosed. Name the most common cause.

Diabetes Mellitus.

Hereditary Pancreatitis

High Saturated Fat Diet

Smoking
Chronic Pancreatitis

Even before you see the histological slide that your 4th year medical student labeled their findings for you, you already came up with a litany of questions to pimp your student on this disease. You look at the following slide, and then you start asking her questions.

What do you think the most common clinical presentation is for this disease process? Use the following photo to help you and name your clinical finding.

Your patient mostly likely complained of epigastric pain with associated unintentional weight loss with a new presentation of jaundice. Using the above photo; scleral icterus.

Describe the unifying pathophysiolgy behind these three common presentations of this disease process and its relation to the most common location of this disease.

Jaundice
Light Colored Stools
Palpable Gallbladder (Courvoisier's Sign)

Common bile duct obstruction (carcinoma of the head of the pancreas)

Name these physical findings and the cancers associated with it.

Virchow's Node
Pancreatic and Stomach Cancer

Sister Mary Joseph's Sign
Pancreatic and Stomach Cancer

What is the gold standard tumor marker associated with this disease?

CA19-9

GI3 Case A

As the pathologist you receive the following specimen from autopsy.

Diagnose the disease process using the following photo: (work backwards from the other questions just as if you were taking the exam and couldn't tell where this was in the body. Hint: Always use the entire photo to orient yourself)

Here is a list of some of the causes of the disease process you've just diagnosed. Name the most common cause.

Diabetes Mellitus.

Hereditary Pancreatitis

High Saturated Fat Diet

Smoking
Chronic Pancreatitis

Even before you see the histological slide that your 4th year medical student labeled their findings for you, you already came up with a litany of questions to pimp your student on this disease. You look at the following slide, and then you start asking her questions.

What do you think the most common clinical presentation is for this disease process? Use the following photo to help you and name your clinical finding.

Describe the unifying pathophysiolgy behind these three common presentations of this disease process and its relation to the most common location of this disease.

Jaundice
Light Colored Stools
Palpable Gallbladder (Courvoisier's Sign)



Name these physical findings and the cancers associated with it.

What is the gold standard tumor marker associated with this disease?

GI1 Case C Answers

A patient comes to your primary care clinic, Ms. Spyz Curry, complaining of chest pain. The pain feels like heartburn she's felt before. She's noticed that she's had this nagging nocturnal cough that hasn't gone away even though she doesn't feel sick. Her dentist has recently commented on the gradual disappearance of enamel to her teeth most proximal to her throat. She often feels bloated after belching.

You get an EKG:

NORMAL EKG

Based on the history and EKG, you believe Ms. Spyz Curry has what?

GERD

On Physical exam, you also note bowel sounds heard over the left lung base. This changes your initial diagnosis in what way?

GERD 2/2 to a Possible Hiatal Hernia

How do you treat Sliding Hiatal Hernias through pharmacologic and nonpharmacologic means? (Goljan)

Pharma

1. H2 Antagonist

2. PPI

3. Prokinetic Agents

NonPharma
1. Reduce foods/drugs that lower esophageal tone sphincter tone like coffee, chocolate, and calcium channel blockers

2. Avoid large quantities of food (no more buffets)

3. Sleep with head of bed elevated
4. Possible Surgery

Besides your clinical gestalt, name 3 other ways you can diagnose GERD?
1.  24hr esophageal pH monitoring
2. Esophageal Endoscopy
3. Manometry (LES pressure <10mmHg)

Using the following image, name this complication of uncontrolled GERD:

"These two endoscopic views demonstrate Barrett esophagus areas of mucosal erythema of the lower esophagus, with islands of normal pale esophageal squamous mucosa. If the area of Barrett mucosa extends less than 2 cm above the normal squamocolumnar junction, then the condition is called "short segment" Barrett esophagus, as shown below." -UTAH Path


Describe the following image, retrieved from the distal esophagus, in pathological terms:

"Another cause for inflammation is a so-called "Barrett's esophagus" in which there is gastric-type mucosa above the gastroesophageal junction. Note the columnar epithelium to the left and the squamous epithelium at the right. This is "typical" Barrett's mucosa, because there is intestinal metaplasia as well (note the goblet cells in the columnar mucosa)." -UTAH Path

Name 2 Complications of Barrett's Esophagus:

1. Ulceration with stricture formation
2. Glandular dysplasia leading to distal adenocarcinoma

GI1 Case C

A patient comes to your primary care clinic, Ms. Spyz Curry, complaining of chest pain. The pain feels like heartburn she's felt before. She's noticed that she's had this nagging nocturnal cough that hasn't gone away even though she doesn't feel sick. Her dentist has recently commented on the gradual disappearance of enamel to her teeth most proximal to her throat. She often feels bloated after belching.

You get an EKG:

Based on the history and EKG, you believe Ms. Spyz Curry has what?

On Physical exam, you also note bowel sounds heard over the left lung base. This changes your initial diagnosis in what way?

How do you treat Sliding Hiatal Hernias through pharmacologic and nonpharmacologic means? (Goljan)

Besides your clinical gestalt, name 3 other ways you can diagnose GERD?

Using the following image, name this complication of uncontrolled GERD:

Describe the following image, retrieved from the distal esophagus, in pathological terms:

Name 2 Complications of Barrett's Esophagus:

GI1 Case B Answers

A 26 yo immigrant from Venezuela presents to your GI clinic because his dentist was not able to "cure" his constant complaint of halitosis. In addition to halitosis, he's started to have a hard time swallowing solid foods and is most noticeable when he's eating his favorite marinated meat that his mom prepares. He complains of more frequent "heartburn" during meals and uncontrollable hiccuping without the ability to burp. He's come to you today because he believes whatever is going on is interfering with his ability to the best foodie he can be and has started to take away some of the joy he normally gets from eating food.

On esophageal manometry, you note abnormalities. On barium swallow, you see the following? What is your leading diagnosis?

Achalasia.

Name 4 different routes to the pathogenesis of this disease:
1. Incomplete relaxation of the LES
2. Destruction of Ganglion cells in the myenteric plexus
3. Dilatation of esophagus proximal smooth muscle contraction
4. Acquired cause is Chagas's Disease

Name 3 pharmacologic treatments to this disorder:
1. Long-acting Nitrates
2. Ca Channel Blockers
3. Botulinum Toxin Injection

What type of cancer is this patient at risk for? Use the following image to help you.

Squamous Cell Carcinoma of the Esophagus

Name three risk factors for this cancer:
1. Smoking (MCC-Most Common Cause)
2. Alcohol abutse, lye strictures (Substance)
3. Achalasia, Plummer-Vinson Syndrome (Mechanical)

Where do these cancers usually reside in the esophagus?

Middle Third

Name the etiology/implications of these clinical presentations
1. Dysphagia for liquids (Progressive disease. Initial presentation is usually dysphagia for solids)
2. Dry Cough/Hemoptysis (probable invasion of the trachea)
3. Hoarseness (probable invasion of the recurrent laryngeal)
4. Hypercalcemia (paraneoplastic syndrome from PTH production)

Histopathological Highlight from UTAS____________________________

GI1 Case B

A 26 yo immigrant from Venezuela presents to your GI clinic because his dentist was not able to "cure" his constant complaint of halitosis. In addition to halitosis, he's started to have a hard time swallowing solid foods and is most noticeable when he's eating his favorite marinated meat that his mom prepares. He complains of more frequent "heartburn" during meals and uncontrollable hiccuping without the ability to burp. He's come to you today because he believes whatever is going on is interfering with his ability to the best foodie he can be and has started to take away some of the joy he normally gets from eating food.

On esophageal manometry, you note abnormalities. On barium swallow, you see the following? What is your leading diagnosis?

Name 4 different routes to the pathogenesis of this disease:

Name 3 pharmacologic treatments to this disorder:

What type of cancer is this patient at risk for? Use the following image to help you.

Name three risk factors for this cancer:


Where do these cancers usually reside in the esophagus?



Name the etiology/implications of these clinical presentations
1. Dysphagia for liquids
2. Dry Cough/Hemoptysis
3. Hoarseness
4. Hypercalcemia

Histopathological Highlight from UTAS____________________________

 (see answers)

GI1 Case A 10 year Follow Up Answers

Mr. Harper comes to your office after 10 years. The last time you saw him, you prescribed him triple therapy antibiotics for his H. pylori infection and counseled him on the his use of NSAIDS and its role in exacerbating his disease process. He now returns to you again on the urge of his doting wife. While she initially believed Mr. Harper was on a new routine because of his noticeable weight loss, she now fears he looks emaciated and does not understand why. On questioning him, you find out the Mr. Harper finished his course of antibiotics, but did not take it on the schedule you prescribed; eventually taking them on a prolonged self-directed course. He now has regular epigastric pain. You confirm with Mr. Harper that he has continued his lifestyle of alcohol abstinence.

On physical exam, you are struck by these abnormal findings. Name each in clinical terms.

Ancanthosis Nigracans

Virchow's Node

Sister Mary Joseph Sign

Sign of Leser-Trelat

What is your top diagnosis?

Possible Intestinal Type Gastric Adenocarcinoma. Most Common gastric carcinoma.

What are 6 risk factors for your top diagnosis? (Goljan)

1. Intestinal metaplasia due to H. pylori (most important)

2. Nitrosamines

3. Smoked Foods (Japan)

4. Diets lacking fruits and vegetables (med school diet?)

5. Type A Chronic Atrophic Gastritis

6.  Menetriere's Disease

What are the most common locations of this disease in the stomach?

Lesser curvature of pylorus and antrum (50-60%)

Which of the two following images matches your diagnosis? Discuss why the other photo does not match your diagnosis/clinical picture. (See Answers for pathologic slides of your diagnosed disease process)

A

B

Photo B correlates to your diagnosis of Intestinal type of Gastric Adenocarcinoma.
Photo A is describes a Diffuse type of gastric adenocarcinoma by it's histologically unique "SIGNET RING" cells. This cancer is NOT associated with H. Pylori. It is sometimes called Linitis Plastica. It also has the potential to produce Krukenberg tumors of the ovaries. 

Linitis Plastica

_________
Highlight on Pathology of Gastric Adenocarcinoma

GI1 Case A 10 Year Follow Up

Mr. Harper comes to your office after 10 years. The last time you saw him, you prescribed him triple therapy antibiotics for his H. pylori infection and counseled him on the his use of NSAIDS and its role in exacerbating his disease process. He now returns to you again on the urge of his doting wife. While she initially believed Mr. Harper was on a new routine because of his noticeable weight loss, she now fears he looks emaciated and does not understand why. On questioning him, you find out the Mr. Harper finished his course of antibiotics, but did not take it on the schedule you prescribed; eventually taking them on a prolonged self-directed course. He now has regular epigastric pain. You confirm with Mr. Harper that he has continued his lifestyle of alcohol abstinence.

On physical exam, you are struck by these abnormal findings. Name each in clinical terms.

What is your top diagnosis?

What are 6 risk factors for your top diagnosis? (Goljan)

What are the most common locations of this disease in the stomach?

Which of the two following images matches your diagnosis? Discuss why the other photo does not match your diagnosis/clinical picture. (See Answers for pathologic slides of your diagnosed disease process)

A

B