GI Board Review – Part IEsophagus, Stomach, and Pancreas

February 21, 2013

Esophagus

A 58-year-old man is evaluated for a 4-week history of progressive difficulty swallowing liquids. The symptom begins immediately with the initiation of a swallow and has recently been associated with coughing. The patient does not have fever or weight loss. His only significant medical history is atherosclerotic cardiovascular disease; his only medications are a β-blocker, a statin, and aspirin. Vital signs are normal, and physical examination shows only crackles at the posterior base of the right lung field.

Which of the following is the most appropriate next diagnostic test in the evaluation of this patient?

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1. Barium esophagram2. CT scan of the chest and abdomen3. Esophageal manometry4. Videofluoroscopy

A 53-year-old man is evaluated after a recent episode of substernal chest pain. He was evaluated in the emergency department for chest pain, and serial electrocardiograms and measurement of cardiac enzymes showed no evidence of myocardial ischemia. An outpatient stress test also showed no evidence of myocardial disease. The patient has a history of medically controlled hypertension, and his only medication is amlodipine.

On physical examination, the patient appears healthy and vital signs are normal. Barium esophagography shows a segmented or “corkscrew” esophagus. Esophageal manometry shows simultaneous contractions in the distal esophagus with 50% of swallows.

Which of the following is the most appropriate therapy for this patient?

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1. Esophageal bougienage2. Laparoscopic myotomy3. Oral anticholinergic therapy4. Oral proton pump inhibitor therapy5. Pneumatic dilatation

A 74-year-old woman is evaluated for 3 years of progressive dysphagia, first for solid foods and now for both solid foods and liquids; she has had frequent episodes of regurgitation of undigested food and has lost 6.8 kg (15 lb) during the past 6 months. Her medical history includes stenting of the left anterior descending coronary artery 1 year ago after which she has had symptomatic residual distal stenosis. She had a cerebrovascular accident 2 years ago and still has mild residual right hemiparesis. Her medications include metoprolol, clopidogrel, enalapril, aspirin, and hydrochlorothiazide.

On physical examination, the patient is thin (BMI 20) and appears ill, although not in distress. Vital signs are normal. Chest radiograph shows a dilated esophagus with an air/fluid level and changes of chronic aspiration in the right lung base. Barium esophagography shows “bird beak” narrowing of the distal esophagus and mega-esophagus with retained fluid in the esophageal body. Esophageal manometry shows aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation with swallowing. On esophagogastroduodenoscopy, the endoscope passes through the lower esophageal sphincter without resistance; there are no masses in the esophagus or the gastric cardia.

Which of the following is the most appropriate therapy for this patient?

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1. Anticholinergic therapy2. Botulinum toxin injection3. Laparoscopic myotomy4. Pneumatic dilatation

Causes of dysphagia

Dysphagia

Oropharyngeal

Usually due to neuromuscular

conditions

Esophageal

Solids (structural lesion)

Intermittent

Esophagel ring; Eosinophilic esophagitis

Progressive with chronic GERD

Peptic stricture

Progressive

Esophageal CA

Solids & Liquids (motility disorder)

Intermittent

Esophageal spasm

Progressive with chronic GERD

scleroderma

Progressive

achlasia

Evaluation of Dysphagia

• History!– Initiation of swallowing or after initiation?

• If oropharyngeal– Dx: video fluoroscopy

• If esophageal– Dx:

1. Esophagram2. EGD3. Manometry

A 44-year-old woman is evaluated for a 6-month history of dyspepsia, regurgitation of sour fluid, and eructation. There is no associated fever, chills, weight loss, or vomiting. The condition failed to respond to a 6-week trial of omeprazole therapy.

The patient’s medical history includes hypertension, type 2 diabetes mellitus, and obesity (BMI 36); her medications are lisinopril, metformin, and insulin glargine. On examination, vital signs are normal; there is mild epigastric tenderness without rebound, and stool is negative for occult blood.

Which of the following is the most appropriate next diagnostic step in the evaluation of this patient?

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1. Ambulatory esophageal pH monitoring2. Barium esophagography3. CT scan of the chest4. Esophageal manometry

GERD• Most commonly due to transient relaxation of LES• Extraesophageal manifestations: cough, asthma, hoarseness, laryngitis• Diagnosis:

1. 4 week trial of PPI (75% sensitivity; 55% specificity)2. EGD3. pH monitor (*gold standard) +/- impedance

• Treament:– Lifestyle modification– Meds (PPI, H2 blocker, etc)– Surgery – Nissen fundoplication (although poor results)– Endoscopic tx – RFA, injected polymers, etc (lasts up to 1 year at best)

A 42-year-old woman is evaluated in the emergency department for substernal chest pain of 18 hours’ duration. She describes the pain as a tightening that is not associated with eating or exertion and that radiates to the neck. The pain is not accompanied by dyspnea, nausea, or diaphoresis. She had a similar episode 1 month ago, and an exercise stress test showed no areas of ischemia. The patient’s medical history includes hypertension and type 2 diabetes mellitus; her medications include ramipril, metformin, and aspirin.

On physical examination, the patient appears uncomfortable but not acutely ill. The temperature is 37.2 °C (99.0 °F), the blood pressure is 130/74 mm Hg, the pulse rate is 88/min, and the respiration rate is 16/min; the BMI is 31.5. The lungs are clear; the heart rate is regular and there are no murmurs. Electrocardiography shows nonspecific ST and T wave abnormalities, which are unchanged from a previous examination.

Which of the following is the most appropriate management for this patient?

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1. Ambulatory esophageal pH monitoring2. Esophageal manometry3. Esophagogastroduodenoscopy4. Oral proton pump inhibitor therapy5. Repeat exercise stress test

Non-Cardiac Chest Pain

• After cardiac causes, esophageal causes are second most common to cause chest pain

• If due to esophageal cause, GERD is most common

• Step 1 – rule out cardiac cause• Step 2 – trial of PPI• Step 3 –if no improvement, send for pH

monitoring vs manometry vs EGD

A 47-year-old man is evaluated in the emergency department for 7 days of odynophagia with epigastric pain, nausea and vomiting, diarrhea, and low-grade fever; he has lost 4.5 kg (10 lb) during the episode. The patient received a kidney transplant 6 months ago for hypertensive kidney disease; his medications are atenolol, prednisone, tacrolimus, and mycophenolate mofetil. He has no other medical problems and denies any HIV risk factors.

On physical examination, the temperature is 38.0 °C (100.8 °F), the blood pressure is 148/94 mm Hg, the pulse rate is 90/min, and the respiration rate is 22/min. Esophagogastroduodenoscopy shows a 2.5-cm esophageal ulcer with raised borders. The rest of the esophagus appears normal. Biopsy specimen from the base of the ulcer shows intense inflammatory infiltrates with granulation tissue associated with occlusion body cells.

Which of the following is the most likely diagnosis?

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1. Candida albicans esophagitis2. Cytomegalovirus esophagitis3. HIV esophagitis4. Pill-induced esophageal ulcer

A 26-year-old woman is evaluated in the emergency department for progressive odynophagia of 3 days’ duration. The patient has a 6-year history of limited systemic sclerosis characterized by skin sclerosis limited to the fingers with early contractures, Raynaud phenomenon, and gastric dysmotility and gastroesophageal reflux disease. Her medications include nicardipine, omeprazole, erythromycin, acetaminophen and NSAIDs as needed. Prednisone, 5 mg/d, was recently started to treat increasingly painful fingers.

On physical examination, the patient appears anxious and uncomfortable. The temperature is 37.0 °C (98.6 °F), the blood pressure is 132/88 mm Hg, the pulse rate is 80/min, and the respiration rate is 22/min. She has skin tightening and cutaneous telangiectasia involving the proximal and distal digits. Cardiopulmonary examination is normal and the abdomen has active bowel sounds and is soft to palpation.

Which of the following is the most likely diagnosis?

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1. Barrett esophagus2. Candidal esophagitis3. Esophageal stricture4. Herpetic esophagitis5. Pill-induced esophagitis

Esophagitis (non-reflux induced)

• Infectious– Patient will have risk factors (post-transplant or HIV risk factors) &

odynophagia– EGD needed to visualize lesions

• Pill-induced– Present with odynophagia– Big culprits: Tetracyclines, Iron, NSAIDs– Need EGD to look for lesions (erosions, etc)

• Eosinophilic– Often will present with food impaction and history of atopy– Dx: EGD with biopsy– Tx: inhaled steroids (down esophagus)

Stomach

A 67-year-old woman is evaluated for a 2-month history of epigastric discomfort, a burning sensation that does not radiate and is not associated with eating. She has had episodic mild nausea and intermittent bloating but no acid regurgitation, heartburn, dysphagia, or odynophagia. She has one bowel movement of well-formed stool a day, and her weight is stable. The patient has a history of osteopenia and gallstone pancreatitis for which she had a cholecystectomy; her medications include calcium and vitamin D supplements. Her mother had gastric cancer.

On physical examination, vital signs are normal. There is mild epigastric tenderness, normal bowel sounds with no bruits, no rebound or guarding, and no hepatomegaly or lymphadenopathy. Complete blood count and serum chemistry tests, including liver enzymes, amylase, and lipase, are normal.

Which of the following is the most appropriate management of this patient?

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1. Endoscopic retrograde cholangiopancreatography2. Esophagogastroduodenoscopy3. Helicobacter pylori stool antigen assay4. Nortriptyline at bedtime5. Proton pump inhibitor empiric trial

Workup of DyspepsiaDyspepsia (discomfort in mid abdomen)

Heartburn Sx

Treat as GERD

No NSAID or Heartburn sx

Alarm symptoms?

Yes

EGD

No

Test and treat for H.pylori

NSAID use

Stop NSAIDS or add PPI

Alarm Symptoms: age >55 and new onset sx, weight loss, FHx prox GI cancer, iron deficiency anemia, odynophagia or progressive dysphagia, persistent vomiting, jaundice, LAD

A 41-year-old woman is evaluated for a 4-month history of intermittent mid-upper-abdomen pain, which does not radiate and is not affected by eating. She had GERD when she was pregnant, but she says that the current symptoms are not like those of reflux or heartburn. She occasionally feels nauseated and mildly bloated, but she has not vomited, felt early satiety, or lost weight. She does not have difficulty swallowing or painful swallowing. Her bowel movements are normal. She has been pregnant twice and had two healthy children, both delivered by cesarean section. Her medical history also includes a cholecystectomy 5 years ago. Her only current medication is a multivitamin.

On physical examination, she is afebrile; the pulse rate is 65/min and the blood pressure is 110/65 mm Hg. There is no jaundice or scleral icterus; mild epigastric tenderness is present. Bowel sounds are normal; there are no abdominal bruits, palpable masses, or lymphadenopathy. Complete blood count and liver chemistry tests are normal. Which of the following is the most appropriate next diagnostic test in the evaluation of this patient?

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1. Abdominal ultrasonography2. Esophagogastroduodenoscopy3. Gastric scintigraphy4. Helicobacter pylori stool antigen5. Small-bowel radiograph

A 38-year-old man is evaluated for persistent dyspepsia 2 months after a duodenal ulcer was detected and treated. He originally presented with new-onset epigastric pain, and EGD showed a duodenal ulcer; biopsy specimens showed the presence of Helicobacter pylori. The patient, who does not use NSAIDs and is penicillin-allergic, completed a 10-day course of therapy with omeprazole, metronidazole, and clarithromycin.

At this time, urea breath testing for H. pylori shows persistent infection.

In addition to a proton pump inhibitor, which of the following regimens is indicated for this patient?

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1. Amoxicillin and levofloxacin2. Bismuth subsalicylate, metronidazole, and tetracycline3. Clarithromycin and amoxicillin4. Clarithromycin and metronidazole5. Trimethoprim–sulfamethoxazole and erythromycin

H. pylori - complicationsH. pylori

*Antral gastritis

*Duodenal ulcer

Nonatrophic pangastritis

MALT

Corpus gastritis

Gastric Ulcer

Gastric Adenocarcinoma

• 80% of duodenal ulcers and 50% of gastric ulcers are associated with H. pylori

• 75% of MALT lymphoma cases are H. pylori +• Treat bacteria = regression of tumor in 70-80%

• In all of these pathways, patient can also have asymptomatic disease!

H. pylori - Diagnosis• Testing indications:

– PUD, low-grade MALT lymphoma, post-resection for early gastric cancer, <55yo with dyspepsia and no alarm symptoms

• Diagnosis:– Endoscopic:

• Biopsy/histology• Urease test (affected by PPI – up to 2 weeks, bismuth/abx – up to 4 weeks)

– Nonendoscopic:• Stool Antigen• Urea breath test (affected by PPI, bismuth, abx)• Serum Ab

• Confirmation of eradication– Only if: H. pylori associated ulcer, persistent dyspepsia despite test/treat

approach, H. pylori assoc MALT lymphoma, previous gastric CA– 4 weeks after completing therapy -> stool Ag or urease breath test

H. pylori - Treatment

• Triple Therapy x10-14 days:– PPI + Clarithromycin + Amoxicillin

• If treatment failure:– Quadruple therapy x7-14d

PPI + Flagyl + Tetracycline + Bismuth

– Driven by specific susceptibilities– Salvage Therapy

PPI + Amoxicillin +Levo/Rifabutin/Furazolidone

– Sequential TherapyPPI + Amox x5d, then PPI + Clarithro + Tinidazole

A 65-year-old woman is evaluated 1 week after having had an EGD for persistent abdominal pain. The procedure showed a 1-cm, clean-based ulcer in the duodenal bulb and scattered antral erosions. Biopsy specimens from the stomach showed nonspecific gastritis but no evidence of Helicobacter pylori infection. Serum antibody testing for H. pylori was also negative. Proton pump inhibitor therapy was started, and the patient’s symptoms were alleviated. The patient has a history of mild osteoarthritis and osteoporosis, and her medications include a nonprescription analgesic for arthritis and a calcium supplement, vitamin D, and alendronate.

On physical examination, vital signs are normal. The abdominal examination reveals no tenderness, hepatomegaly, or palpable masses. Complete blood count is normal.

Which of the following is the most appropriate next step in the management of this patient?

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1. Measure serum gastrin2. Perform fecal antigen test for Helicobacter pylori3. Repeat EGD with biopsy of the ulcer4. Review the nonprescription arthritis analgesic5. Stop alendronate therapy

PUD• Gastric ulcer – gets better with food• Duodenal ulcer – gets worse with food• Etiologies:

– NSAIDs, H. pylori, Crohn’s, malignancy, Zollinger-Ellison, Viral (CMV), drugs (cocaine)

• Complications:– Bleeding, perforation, outlet obstruction (typically from ulcer in

prepyloric area)• Therapy:

– Eval for H. pylori and stop NSAIDs– Start PPI– Surgery only if failure to respond to acid suppression or if life

threatening disease• Vagotomy (to decrease Ach thus decreasing acid secretion) vs

A 37-year-old woman is evaluated for diffuse musculoskeletal pain at her 1-year follow-up after a Roux-en-Y gastric bypass for medically complicated obesity. She has lost 36.4 kg (80 lb) since surgery but she thinks that her weight has stabilized over the past few months. She has two to three bowel movements of well-formed stool a day. She has some diffuse musculoskeletal pain but otherwise feels well.

Her medical history includes the gastric bypass, a cholecystectomy, diet-controlled type 2 diabetes mellitus, and hypothyroidism. Her medications include levothyroxine, a multivitamin containing iron, vitamin B12 by injection, and over-the-counter calcium and vitamin D. Physical exam is benign including normal muscle strength with no focal muscle tenderness. Laboratory studies show a serum alkaline phosphatase of 314 U/L; all other tests, including complete blood count, aminotransferases, bilirubin, γ-glutamyltranspeptidase, serum thyroid-stimulating hormone, free thyroxine, and calcium, are normal.

Which of the following is the most appropriate next step in the evaluation of this patient?

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1. Anti–smooth muscle antibody test2. Measurement of 25-hydroxyvitamin D3. Measurement of serum creatine kinase4. Measurement of triiodothyronine5. Ultrasonography of the liver

Complications of bariatric surgery• Roux-en-Y

– Early complications:• Anastamotic leak, bowel

obstruction, hemorrhage, VTE, wound infection

– Late complications:• Anastomotic stricture,

bacterial overgrowth, incisional hernia, marginal ulcer, nutritional deficiencies (iron, B12, folate, Ca, Vit D, thiamine)

• Gastric Resection– Dumping syndrome– Afferent Loop syndrome (seen

with Billroth II)

A 39-year-old woman is evaluated for a 6-week history of nausea and intermittent vomiting, which began after a 3-day episode of severe nausea, vomiting, and diarrhea. At the same time, her school-age children had a similar episode that resolved spontaneously. However, since that time, the patient has had daily nausea worsened by eating, early satiety, bloating, and vomiting of large volumes of nonbilious food. She does not have abdominal pain, but in the past 6 weeks, she has lost 4.5 kg (10 lb). The patient’s medical history includes a transsphenoidal resection of a nonfunctioning pituitary adenoma 3 years ago and two deliveries by cesarean section. Her mother has depression, and her father has primary sclerosing cholangitis. On physical examination, she is thin (BMI 19); vital signs are normal. She responds appropriately and makes normal eye contact; there is no jaundice or scleral icterus. There is mild abdominal distention and normal bowel sounds without succussion splash or tenderness. Laboratory studies, including liver enzymes, are normal. EGD reveals retained gastric contents but no obstruction. Radiograph of the small bowel is normal.

Which of the following is the most appropriate next step in the evaluation of this patient?

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1. Biliary ultrasonography2. Gastric scintigraphy3. MRI of the head4. Referral for biofeedback training5. Viral culture of stool

Gastric Motility Disorders• 20-40% of DM1; 25-40% of functional dyspepsia• Symptoms: n/v, bloating, early satiety, postprandial fullness• Need EGD or esophagram to rule out obstruction prior to

motility study• Dx: gastric scintigraphy of radiolabeled meal

– Retention of >10% at 4 hours is abnormal• Causes of gastroparesis:

– Idiopathic (33%), DM (25%), post-op (20%), post-viral, neuromuscular disorders, paraneoplastic conditions, CTD

*Note: succussion splash is a sloshing sound heard through stethescope during sudden movement of the patient upon abd auscultation. Indicates gastric outlet obstruction.

Pancreas

A 34-year-old woman is evaluated for continued severe mid-epigastric pain that radiates to the back, nausea, and vomiting 5 days after being hospitalized for acute alcohol-related pancreatitis. She has not been able eat or drink and has not had a bowel movement since being admitted.

On physical examination, the temperature is 38.2 °C (100.8 °F), the blood pressure is 132/84 mm Hg, the pulse rate is 101/min, and the respiration rate is 20/min. There is no scleral icterus or jaundice. The abdomen is distended and diffusely tender with hypoactive bowel sounds

WBC: 15,400AST: 189ALT: 151Bili: 1.1Amylase: 388Lipase: 924

CT scan of the abdomen shows a diffusely edematous pancreas with multiple peripancreatic fluid collections,and no evidence of pancreatic necrosis.

Which of the following is the most appropriate next step in the management of this patient?

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0%0%0%1. Enteral nutrition by nasojejunal feeding tube2. Intravenous imipenem3. Pancreatic debridement4. Parental nutrition

A 44-year-old man with a long history of alcohol abuse is evaluated on the sixth day of hospitalization for acute pancreatitis. On admission to the hospital, he was afebrile, the blood pressure was 150/88 mm Hg, the pulse rate was 90/min, and the respiration rate was 16/min. Abnormal findings were limited to the abdomen, which was flat and tender to palpation without peritoneal signs. Bowel sounds were normal. Plain abdominal and chest radiographs were normal. Abdominal ultrasonography revealed a diffusely enlarged, hypoechoic pancreas without evidence of gallstones or dilated common bile duct. He was treated with aggressive intravenous hydration and opioid analgesia. For the past 2 days, the patient has had repeated febrile episodes, persistent severe abdominal pain, and increasing shortness of breath.

On physical examination, the temperature is 38.6 °C (101.5 °F), the blood pressure is 98/60 mm Hg, the pulse rate is 112/min, and the respiration rate is 22/min; oxygen saturation is 92% with the patient breathing oxygen 3 L/min. Breath sounds are decreased at the base of both lungs. The abdomen is distended and diffusely tender with hypoactive bowel sounds. Laboratory studies reveal leukocyte count of 19,800/µL (19.8 × 10 9/L), creatinine 1.4 mg/dL (106.8 µmol/L), amylase 388 U/L, and lipase 842 U/L

Which of the following is the most appropriate next step in the evaluation of this patient?

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1. CT scan of the abdomen with intravenous contrast2. Endoscopic retrograde cholangiopancreatography3. Endoscopic ultrasonography4. Stool chymotrypsin

55-year-old woman is evaluated in the hospital for a 2-day history of epigastric abdominal pain, nausea and vomiting, and anorexia. The patient has no significant medical history and takes no medications.

On physical examination, the temperature is 38.0 °C (100.5 °F), the blood pressure is 124/76 mm Hg, the pulse rate is 99/min, and the respiration rate is 16/min. There is scleral icterus and a slight yellowing of the skin. There is mid-epigastric and right upper quadrant tenderness. There is no palmar erythema, spider angiomata, or other evidence of chronic liver disease

WBC: 14,900AST: 656ALT: 567Bili: 5.6Amylase: 1284Lipase: 6742Abdominal ultrasound shows a biliary tree with dilated common bile duct of 12mm and cholelithiasis but no choledocholithiasis.

Which of the following is the most appropriate next step in the management of this patient?

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1. CT scan of the abdomen and pelvis with pancreatic protocol2. Endoscopic retrograde cholangiopancreatography3. Hepatobiliary iminodiacetic acid (HIDA) scan4. Magnetic resonance cholangiopancreatography

42-year-old woman is evaluated in the emergency department for the acute onset of epigastric pain that radiates to the back and is associated with nausea and vomiting. The patient had previously been healthy and has no history of alcohol or tobacco use. Her only medication is an oral contraceptive pill.

On physical examination, the temperature is 37.2 °C (99 °F), the blood pressure is 158/90 mm Hg, the pulse rate is 101/min, and the respiration rate is 20/min. There is no scleral icterus or jaundice. The abdomen is distended with mid-epigastric tenderness without rebound or guarding and with hypoactive bowel sounds.

WBC: 13,500AST: 131ALT: 567Bili: 1.1Amylase: 824Lipase: 1432Radiography of the abdomen shows mild ileus

Which of the following is the most appropriate next step in evaluation of this patient?

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1. CT scan of abdomen/pelvis2. ERCP3. Esophagogastroduodenoscopy4. Ultrasound of the abdomen

A 35-year-old man is evaluated in the emergency department for the acute onset of abdominal pain and nausea; he does not have diarrhea or other changes in bowel habits. The patient has a 17-year history of Crohn disease, which was managed with long-term corticosteroid therapy until he began therapy with azathioprine 4 months ago; his disease has been stable since that time until the current episode. He takes no other medications.

On physical examination, the temperature is 37.0 °C (98.5 °F), the blood pressure is 108/76 mm Hg, the pulse rate is 110/min, and the respiration rate is 19/min. There is no scleral icterus. There is mild epigastric tenderness, but the rest of the examination is normal. Right upper quadrant abdominal ultrasonography is normal

Hgb: 17.2WBC: 4,500AST: 20ALT: 22Bili: 0.9Amylase: 1500Lipase: 1630

What is the most likely diagnosis?

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1. Azathioprine-induced pancreatitis2. Crohn disease flare3. Gallstone pancreatitis4. Helicobacter pylori-associated gastritis5. Peptic ulcer disease

Acute Pancreatitis

• Etiology:– EtOH (35%), stones (45%), idiopathic (10%), viral

infection, hypertrigliceridemia, hypercalcemia, drugs (azathioprine, sulfa, flagyl, didanosine), obstruction

• Management:– Early NJ feeds– Abx (Carbapenem) only if necrosis– CT scan with contrast to look for necrosis only if not

improving or fever >3-5 days

Acute Pancreatitis - Complications• Pseudocyst - maturing collection of pancreatic juice encased by reactive

granulation tissue, occurring in or around the pancreas as a consequence of inflammatory pancreatitis or ductal leakage– walls formed by adjacent structures such as the stomach, transverse mesocolon,

gastrocolic omentum, and pancreas. The lining of the pseudocysts consists of fibrous and granulation tissue

– Take 4 weeks to form, often resolve on their own and usually asymptomatic– Can cause pain/obstruction by pressing on other organs

• Treat with perc drainage or endoscopic/surgical drainage

– Abscess = infected pseudocyst• Worsening abd pain, fever, increasing WBC count• Perc or surgical drainage + Abx

• Tract leaks/fistulas– Lead to pancreatic ascites– Bowel rest + endoscopic stenting or surgery

• Splenic Vein Thrombosis– Lead to gastric varices and bleeding

A 51-year-old man is evaluated for an 8-month history of mid-epigastric pain that is worse after eating, six to eight bowel movements a day usually occurring after a meal, and loss of 6.8 kg (15 lb) over the past 6 months. The patient drinks six to eight cans of beer a day. He takes no medications.

On physical examination, the patient is thin (BMI 21) and has normal bowel sounds, mid-epigastric tenderness, but no evidence of hepatosplenomegaly or masses. Rectal examination reveals brown stool that is occult blood negative. The remainder of the examination is normal. Plain radiograph of the abdomen shows a normal bowel gas pattern and is otherwise normal

WBC 6800Plt 69,000Fasting glc 154AST 191ALT 82Amylase 122Lipase 289

Which of the following tests is most likely to establish the diagnosis in this patient?

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1. Colonoscopy2. CT scan of the abdomen3. Measurement of serum antiendomysial Abs4. Stool for leukocytes, culture, ova, and parasites

A 42-year-old man is evaluated in the hospital for a 1-year history of postprandial abdominal pain that radiates to the back and that is worse after eating and is associated with nausea. He has not had vomiting, weight loss, or change in bowel habits. The patient has had at least five alcohol-containing drinks a day for 20 years; he has reduced his intake in the past year because of continued abdominal pain.

On physical examination, vital signs are normal; BMI is 24. There is mild epigastric tenderness with no guarding or rebound and normal bowel sounds. Laboratory studies reveal normal complete blood count, fasting glucose, and liver chemistry tests; amylase is 221 U/L and lipase 472 U/L. Radiography, ultrasonography, and CT scan of the abdomen are normal, as is esophagogastroduodenoscopy.

Which of the following is the most appropriate next step in the evaluation of this patient?

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1. Biliary scintigraphy2. Colonoscopy3. Endoscopic retrograde cholangiopancreatography4. Measurement of stool elastase

Chronic Pancreatitis• Chronic inflammation -> fibrosis -> destruction of both endocrine and

exocrine function– Loss of both beta cells (insulin producing) and alpha cells (glucagon producing) ->

brittle DM• Clinical: epigastric pain, postprandial diarrhea (due to malabsorption), and

diabetes• Diagnosis (via imaging):

– ERCP = gold standard, esp for early disease (95% sensitivity)– EUS or MRCP – just as good as ERCP and may even be better for moderate to

advanced disease– CT scan (90% sensitivity)

• Treatment:– Careful glycemic control– Low fat diet and enzyme supplementation– Pain control (including celiac plexus block, surgery, stone removal)

A 72-year-old man is evaluated for a 2-month history of epigastric discomfort associated in the past 6 weeks with a 4.6-kg (10 lb) weight loss; he has had 2 weeks of dark urine and light stool. The patient has no significant medical history and takes no medications.

On physical examination, vital signs are normal. There is scleral icterus, visibly jaundiced skin, and mild epigastric tenderness. Laboratory studies are significant for total bilirubin of 8.2 mg/dL (140.2 µmol/L) and alkaline phosphatase of 648 U/L. CT scan of the abdomen shows fullness in the head of the pancreas and biliary dilation but no evident pancreatic mass.

Which of the following is the most appropriate next step in the management of this patient?

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1. Endoscopic ultrasonography2. Measurement of CA 19-9 concentration3. Surgical exploration4. Ultrasonography of the abdomen5. Visceral angiography

An 81-year-old woman is evaluated for a 3-month history of abdominal and back pain. She also has anorexia and has lost 11.4 kg (25 lb). For the past 2 weeks she has had progressive pruritus and a yellow tint to her skin.

On physical examination, the patient appears ill; the temperature is 37.2 °C (99 °F), the blood pressure is 104/62 mm Hg, the pulse rate is 98/min, and the respiration rate is 16/min. There is scleral icterus, jaundiced skin, and generalized abdominal tenderness. Laboratory studies reveal a leukocyte count of 13,200/µL (13.2 × 109/L), total bilirubin 12.4 mg/dL (212 µmol/L), alkaline phosphatase 748 U/L, and CA 19-9 822 U/L. CT scan shows a 3.2-cm lesion in the head of the pancreas with dilation of the pancreatic and bile ducts and multiple lesions throughout the liver that are consistent with metastases. Endoscopic ultrasonography biopsy specimen of the mass is positive for adenocarcinoma.

Which of the following is the most appropriate next step in the management of this patient?

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1. Biopsy of a liver lesion2. Placement of a metal biliary stent3. Radiation to the pancreas and liver lesions4. Surgical resection of the pancreatic lesion and adjuvant chemotherapy

Pancreatic Cancer

• Presentation:– **Painless jaundice (if head mass)– Epigastric pain (if in body or tail)– Elevated LFTs in cholestatic pattern (if mass causing obstruction)

• Diagnosis:– Spiral CT abdomen – EUS (much better than CT if <2cm lesion, plus can get biopsy and

nodal staging)• Treatment:

– Localized/resectable – Whipple (if in head) + chemo/XRT– Locally advanced – chemo/XRT– Metastatic (85%) – palliative +/- chemo