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91 Cards in this Set

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What test(s) diagnose small bowel obstruction?
The most accurate test for small bowel obstruction is a combination of the abdominal X-ray and the abdominal CT scan. There is no blood test to diagnose obstruction and there are no findings on endoscopy.
What does small bowel obstruction look like on abdominal x-ray?
There are multiple air-fluid levels seen throughout the bowel.
When do you use abdominal X-ray?
Suspected small bowel obstruction is the only use for the abdominal X-ray. Look for a patient with abdominal pain and distension; hypoactive or absent bowel sounds, possible electrolyte abnormalities such as potassium; calcium, or magnesium disorders; and failure to pass either stool or flatus. This is normal after abdominal surgery.
What does a barium enima do?
BE creates a "contrast" picture to outline the lining of the retum and colon. BE can be used in detecting colorectal cancers, polyps, diverticulosis, and bowel obstruction and to evaluate the extent of inflammatory bowel disease.
When is BE contraindicated?
Patient's who may have peritonitis or bowel perforation must not undergo this test because the contrast material can leak into the peritoneum through the perforation. BE is also contraindicated in diverticulitis, in which it increases the risk of perforation.
Compare BE and Colonoscopy if you are suspecting a lesion in the colon.
Colonoscopy is superior to enema in that it can directly biopsy lesions or remove polyps. BE is NEVER the right answer to the question, "What is the most accurate test?" if colonoscopy is one of the choices.
What is Capsule Endoscopy?
It is a capsule the size of a large pill, with a camera and a small transmitter. Once swallowed, it begins transmitting images of the inside gastrointestinal tract to a receiver worn by the patient. The doctor can review 6 hours worth of pictures for any abnormalities.
When do you use Capsule Endoscoopy?
Capsule endoscopy is the procedure of choice for suspected small bowel bleeding that was not detected with upper or lower endoscopy.
What are Amylase/Lipase levels?
Amylase and lipase are the initial test in the diagnosis of acute pancreatitis. Lipase is more specific for the pancreas. Amylase can be elevated from damage to the salivary glands, esophagus, or small bowel.
When do you answer amylase and lipase levels?
Answer amylase/lipase for a patient presenting with the acute onset of severe epigastric pain radiating to the back. Such a patient may have a history of alcohol abuse or gallstones.
What is the most accurate test for acute pancreatitis?
Abdominal CT scan. It is more accurate than Ranson's criteria. Pancreatic necrosis on a CT scan is etremely specific for severe pancreatitis and is the main indicator of the need for a pancreatic biopsy.
What is Antiendomysial/ Antigliadin Antibodies?
Serum assay for endomysial and antigliadin antibodies are made against wheat or gluten antigens and the villous (endomysial) lining fo the small intestine. They are used to confirm the diagnosis of celiac disease.
When are Antiendomysial/ Antigliadin Antibodies the answer?
Look for a case of robable celiac disease with oily, greasy diarrhea, foul-smelling stool without evidence of chronic pancreatitis. they are the tests to answer to confirm gluten-sensitive enteropathy after Sudan black stain has confirmed a fat malabsorption.
What is the most accurate test for celiac disease?
Small bowel biopsy. It must be done to exclude lymphoma as well as to diagnose the disease.
What is the Antimitochondrial Antibodies (AMA) test for?
Serum screening for antimitochondrial antibodies is the best initial test to make a specific diagnosis of primary biliary cirrhosis (PBC).
When do you answer AMA?
Look for a middle-aged female presenting with itching (pruritus) and an elevated alkaline phosphatase with a normal bilirubin.
What is the most accurate test for PBC?
Liver biopsy.
What is anti-Smooth Muscle Antibodies?
Serum assay detection of anti-smooth muscle antibodies (ASMA) is the best initial test for atuoimmunie hepatitis.
When do you answer ASMA?
Answer ASMA when you are shown a young female with a liver disease who does not drink or have inflammatory bowel disease or infectious hepatitis.
What other immune markers are associates with autoimmune hepatitis?
Autoimmune hepatitis is associated with antinuclear antibodies (ANA) and antibodies to liver/kidney microsome type 1 (anti-LKM1).
What is the most accurate test for autoimmune hepatitis?
Liver biopsy is the most accurate test for autoimmune hepatitis and most other liver diseases.
For which clinical condition is Barium Esophagram the best initial test?
Barium esophagram is, generally, the best initial test for dysphagia. This is not in scenarios where there are clear signs of obstruction, for which upper endoscoopy would be the best initial test. For achalasia, barium esophagram shows a "bird's beak" at the gastroesophageal junction. In diffuse esophageal spasm barium esophagram shows a "corkscrew" pattern at the time of spasm.
For which conditions is Barium Esophagram the most accurate test?
Barium esophagram is the most accurate test for esophageal rings, webs, and idverticuli.
What is the most acurate test for abnormalities detected with a barium esophagram?
In achalasia, esophageal spasm, and nutcracker esophagus, the most accurate test is manometry. With cancer, the most accurate test is endoscopy for a biopsy.
What is a Bernstein Test?
The Bernstein test is to diagnose gastroesophageal reflux disease.
How is a Bernstein Test done?
The Bernstein test involves the placement of a nasogastric tube into the esophagus with the tip at the end of the esophagus near the gastroesophageal junction. Dilute hydrochloric acid is instilled or dripped into the esophagus in an attempt to reproduce the symptoms of reflux disease. This is a older test that has been made obsolete by the use of empiric trials of PPIs or the 24-hour pH monitor.
When is a Bernstein Test the right answer?
The Bernstein test is always WRONG to do. When you see it in the answers as a diagnostic test, do not choose it.
What is a Bleeding Scan?
The bleeding scan, or technetium-labled RBC scanning, is performed in a patient with small amounts of active lower GI bleeding in which the bleeding site could not be identified with endoscopy. Bleeding scan is sensitive, but not specific. If the bleeding scan is positive, you cannot identify the precise etiology of the bleeding. Angiography is another diagnostic option for the patint with persistent, severe GI bleeding wihtout an identified source.
When do you answer bleeding scan?
Look for a patient who presents with severe gastrointestinal bleeding in whom the lower endoscopy is unable to find a source. The bleeding continues and the patient may still require transfusions.
What is Ceruloplasmin?
Serum ceruloplasmin levels and the presence of Kayser-Fleischer rings on exam are the best initial tests for Wilson's disease.
When do you answer ceruloplasmin?
Look for a patient wiht the convination of unexplained hepatic and psychiatric abnormalities with a movement disorder.
Is a high or low value abnormal?
An exremely low serum ceruloplasmin level should be taken as strong evidence for the diagnosis of Wilson's disease.
What additional tests would confirm the diagnosis?
Twenty-four-hour urine copper excretion will be abnormally high. The most accurate test is the liver biopsy. Wilson's disease is a disease of copper overload. this is because of the inability of the liver to incorporate copper into the protein ceruloplasmin for excretion into the bile. This leads to hepatic copper accumulation and injury. This eventually spills into the bloodstream and deposits into the brain (behavior and movement changes), kidneys (renal insufficiency), and cornea (Kayser-Fleischer rings).
When do we use colonoscopy as a screen?
General Population: Every 10 years for patients over age 50. Colonoscopy is superior to occult blood test or simoidoscopy.

Single family member with colon cancer: Start at age 40 or 10 years earlier than thefamily member's diagnosis, whichever is earlier.

Hereditary non-polyposis cancer syndrome (HNPCC or Lynch syndrome): Tree family members, two generations, one prmature. Premature means the cancer was before age 50. Start at age 25 and repeat every 1-2 years.
What is D-Xylose Test?
D-xylose testing is used in determining the etiology of different malabsorption syndromes. D-xylose is used to differentiate between intestinal malabsorption and chronic pancreatitis. Celiac disease is the most common cause of intestinal malabsorption. D-xylose is a sugar that should be absorbed if the small bowel mucosa is intact. It does not require digestive pancreatic enzymes. A low D-xylose level in the urine indicates that the intestinal mucosa is defective and that D-xylose was not absorbed.
When do you answer D-xylose testing?
Look for a patient with foul-smelling stool without blood, who has weight loss, malnutrition, fat in stool, and a positive Sudan black stain.
What is the most accurate test for malabsorption syndromes?
The most accurate test of the small bowel mucosa is a biopsy to assess histology and architecture.
What disease will make D-xylose abnormal?
D-xylose test is abnormal with celiac disease, tropical sprue, and Whipple's disease.
What is an endoscopic Retrograde Cholangiopancreatography (ERCP)?
ERCP is a direct visualization of hte biliary tract.
For which condition is an ERCP most accurate?
ERCP is the most accurate diagnostic test for stones in teh biliary system. ERCP is also the most accurate test for primary sclerosing cholangitis (PSC).
What are the characteristics lesion of sclerosing cholangitis?
In sclerosing cholangitis there are multiple intrahepatic and / or extrahepatic strictures of the biliary tract on cholangiography This gives the biliarry radicles a "beaded" appearance.
When do I answer ERCP?
The strongest indication for ERCP is when the patient has high fever, chills, right upper-quadrant abdominal pain, and jaundice. ERCP is both diagnostic and therapeutic because you can remove the stone.

For PSC, look for a patient with a history of ulcerative colitis complaining of pruritus and jaundice with a negative hepatitis profile and negative abdominal sonogram.
What is Esophageal manometry used for?
Esophageal monometry isused to establish the diagnosis of dysphagia or unexplained chest pain when there is no mechanical obstruction.
How is Esophageal manometry done?
Esophageal manometry consists of a transducer placed in teh esophagus to record pressure
When do you answer esoophageal manometry?
Look for a case of dysphagia with an inconclusive barium radiograph or upper endoscopy.

If the stem of the question clearly describes a motility problem, you do not have to do either endoscopy or barium prior to doing the manometry; for example, achalasia, diffuse esophageal spasm, or nutcracker esophagus.
What is fecal occult blood testing?
Fecal occult blood testing (FOBT) is the screening of normal brown stool for microscopic amounts of blood not grossly visible. Gross blood or dark stool, such as melena, does not occur until >100ml of blood has been lost in the bowel. The FOBT will detect as lettle as 5-10ml of blood.
When is fecal occult blood testing the right answer?
FOBT is a screening test for occult blood in the stool. FOBT is an option for screening for colon cancer in those above the age of 50. In colon cancer screening the three methods of screening, are: colonoscopy every 10 years, sigmoidoscopy every 3-5 years, FOBT every year after age 50.
What do you do for a positive fecal occult blood test?
A positive FOBT should be investigated with a colonoscopy.
What is Fecal Leukocytes a test for?
Fecal leukocytes are used to assess the etiology of acute diarrhea.
What diseases is Fecal Leukocytes associated with?
Invasive and inflammatory causes of iarrhea can give both blood as well as fecal leukocytes. Diseases such as Salmonella, Shigella, Campylobacter, etc., can give both blood as well as white cells in the stool.
When do you answer fecal leukocytes?
Look for a patient with diarrhea with no blood in whom you are trying to see if there is an invasive form of diarrhea. Fecal leukocytes are not found with diarrhea secondary to viruses, most protozoans, or pre-formed toxins such as Bacillus cereus or staph.
What is the Gastrin level?
Serum gastrin levels should be measured when you suspect Zollinger-Ellison syndrome (ZES).
When do you answer gastrin level as the best initial test?
Look for ulcers that are large (>1cm), rcurrent, distal, and multiple. A gastrin level greater than 1,000 pg/ml is diagnostic.

REMEMBER: Everyone on a PPI has a high gastrin level.
What additional test would you like if this is not diagnostic?
The secretin stimulation test can confirm ZES when serum gastrin concentration testing is nondiagnostic. In ZES, gastrin levels do not go down with secretin.
What disease is the syndrome part of?
ZES is associated with MEN I:

Hyperharathyroidism
Pituitary adenomas
Pancreatic islet cell/gastrointestinal adenomas
What is gastrograffin?
Gastrograffin is a water-soluble form of radio-opaque constrast material that is used when there is the possibility that there has been organ perforation and the material may leak through into the peritoneum. Gasrograffin is used as the diagnostic test of choice for Boerhaave's syndrome, or esophageal perforation, because barium going through a perforation causes inflammation.
When do you answer gastrograffin?
Look for a patient presenting with a recent history of severe retching followerd by severe chest pain, dyspnea, shock, and possible crepitation. Initial chest X-ray would show free air in teh mediastinum or peritoneum.
What is the most accurate test for Boerhaave's syndrome?
The most accurate test is a CT scan.
What is HFE gene, and C282Y mutation?
The HFE gene and C282Y mutation both lead to the overabsorption of iron in teh duodenum. They are confirmatory tests for hemochromatosis. These genetic tests and an MRI can eliminate the need for liver biopsy to diagnose hemochromatosis.
When do you answer HFE gene, or C282Y mutation?
Answer HFE gene and C282Y mutation when you are shown a patient with the characteristics of hemochromatosis and abnormal iron studies consistent with hemochromatosis. The patient will have liver disease, skin hyperpigmentation, joint pain, diabetes, and infertility. The iron and ferritin levels will be elevated and the iron-binding capacity will be markedly dimished.
What is HIDA Scanning?
HIDA scan is used when you suspect acute cholecystitis with a nondiagnostic ultrasonography.
When do you answer HIDA scan?
Answer HIDA scan when you see either:

Gallstones without gallbladder edema and ultrasound Murphy's sign, or

Gallbladder edema and ultrasound Murphy's sign without gallstones.
How does HIDA scan work?
HIDA is taken up by hepatocytes and excreted into bile and concentrated in teh gallbladder. If the gallbladder does not opacify, it means that there is an obstruction of the cystic duct. Leakage into the pericholecystic space suggests perforation. On a normal scan the gallbladder should opacify.
When is the HIDA scan the most common wrong answer?
The HIDA is not recommended in critically ill patients who should be taken to the operating room. If the diagnosis is obvious, the HIDA scan is not necessary, surgery is necessary.
What is PAS staining used for?
PAS staining on a small bowel biopsy specimen is the most accurate test for Whipple's disease.
When do you answer PAS staining?
Look for chronic multisystem illness, initially rheumatological (80%), then with fat malabsorption (75%), fever (50%), and ocular and neurological complaints..
How do you treat Whipple disease?
Initial course of Ceftriaxone followed by trimethoprim-sulfamethoxazole for 1 year.
What is 24-Hour pH monitoring used for?
Twenty-four -hour esophageal pH recording is indicated to document abnormal esophageal acid exposure.
When do you answer 24-Hour pH monitoring?
It is the appropriate test in the following scenarios:

1) Persistent symptoms of gastroesophageal reflux disease (GERD) after at least 4 weeks of treatment with a PPI.
2) To exclude GERD in a patient with unexplained chest pain
3) GERD sysptoms wit a negative upper endoscopy wen you are considering antireflux surgical repair.
4) To assess the efficacy of antireflux surgery
5) To evaluate patients with laryngitis, pharyngitis, chronic cough, nonallergic asthma (reflux-induced asthma)
For what diseases do you answer secretin stimulation testing?
Secretin stiulation is a rarely used test for two completely separate diseases:

Zollinger-Ellison syndrome (ZES) and chronic pancreatitis.
What is secretin stimulation testing?
ZES: You inject secretin intravenously and measure the level of gastrin in blood. Secretin should inhibit gastrin and lower the levels of gastrin in a normal person. In ZES, there is a failure to suppress gastrin levels.

Chronic pancreatitis: Normally, secretin should induce a large release of bicarbonate from the pancreas into the duodenum and measure the release of bicarbonate from the sphincter of Oddi. With chronic pancreatitis, the pancreas is too burned out and tired to do anything.
When do you answer secretin stimulation test?
Answer secretin stimulation testing in ZES when the patient has large, recurrent, and multiple ulcers, but has a nondiagnostic fasting serum gastrin concentration.

For chronic pancreatitis, look for a patient with fat malabsorbtion with no evidence of celiac disease and a normal D-xylose test.
Who should upper endoscopy screening be offered to?
Screening upper endoscopy should be performed in patients with gastroesophageal reflux disease (GERD) in whom the symptoms have been present for more than 5 years. You are screening to see if there is Barrett's esophagus, which is when the lower esophagus is transforming form squamous to columnar epithelium. Screening for the presence of esophageal varices should be done in those with cirrhosis.
What is the treatment for an abnormal upper endoscopy?
Barrett's esophagus is treated with proton pump inhibitors with a repeat upper endoscopy every 2-3 years. Low-grade esophageal dysplasia is treated with PPIs with a repeat upper endoscopy in 6 months. Those with varices should receive propranolol to decrease the risk of bleeding.
What is a 72-Hour Fecal Fat test used for?
The 72-hour fecal fat collection is an old test for intestinal malabsorption. As the name implies, you are supposed to collect 3 days' worth of stool in order to have a very sensitive test for fat malabsorption. A single test of a Sudan black stain of the stool for the presence of fat is usually sufficient.
When do you answer 72 -hour fecal fat test?
The 72-hour fecal fat collection is the single most accurate test for fat malabsorption; however, it is virtually never done and is most often a WRONG answer on your test. The 72-hour fecal fat is the answer if you strongly suspect fat malabsorption and the Sudan black stain is negative.
What is a string test?
The string test is an old test for giardiasis. The string test samples the duodenal mucosa without the need of endoscopy. A string is swallowed and left in place with one end in the duodenum and the other end hanging out through the patient's mouth.
When is a string test the answer?
String test is always the WRONG answer. Stool ova and parasite testing is sufficiently sensitive and less invasive. Stool Giardia antigen testing by ELISA is the single most accurate test for Giardia and is considerably less invasive.
What is a Sudan Black Stain?
Stool staining with Sudan black is used to detect steatorrhea as a sign of fat malabsorption.
What is the most accurate test for fat malabsorption.
Seventy-two-hour quantitative estimation of stool fat is the most accurate test because of increased sensitivity. The 72-hour estimation is almost always the wrong answer.
When do I answer Sudan black stain?
Answer Sudan black stain when you see a patient with chronic pale, greasy, malodorous diarrhea, and no evidence of infection.
What is Fasting Transferrin saturation?
Serum measurement of fasting transferrin saturation is the best initial test to diagnose hereditary hemochromatosis (HH) as well as the screening test for asymptomatic family members. Fasting transferrin saturation = (serum iron/TIBC)
When do you answer fasting transferrin saturation?
Answer fasting transferrin satruation when you see a ase of liver disease with oint pain, diabetes, cardiomyopathy, skin hyperpigmentation, and infertility.
How would you confirm an abnormal test of fasting transferrin saturation?
Liver biopsy is the most accurate test.
What is the pathogenesis of hereditary hemochromatosis (HH)?
The pathogenesis is genetically determined abnormal increase in intestinal absorption of iron.
When is the optimal timing of screening for HH?
The optimal timing for screening family members is between the ages of 18 and 30, before organ damage (e.g., cirrhosis) has occurred.
What is serum trypsinogen concentration used for?
Serum assay of trypsinogen is used when you suspect chronic pancreatitis in a patient with steatorrhea. This is the only test that is specific for steatorrhea of pancreatic origin. Trypsinogen levels are low if the fat malabsorption is form a burned-out pancreas.
When is serum trypsinogen concentration the answer?
Answer trypsinogen level only after Sudan black stin has confirmed a fat malabsorption.

Antigliadin and anti-endomysial antibodies should be normal. Low trypsinogen levels are specific but not sensitive for chronic pancretitis.
What is the urea breath test?
Urea breath testing is the measurement of radiolabled carbon dioxide after the oral ingestion of labeled urea. H. pylori splits urea wuth urease. The labeled carbon is in the urea and is released as labeled carbon dioxide.
When is the urea breath test used?
Urea breth testing is best used to confirm the eradication of H. pylori immediately after treatment. Serology does not rapidly improve after treatment. If an ulcer is found at endoscopy, the test of choice will be biopsy, not the urea breth test.
When do you answer urea breath test?
Answer urea breath test with a patient with epigastric pain that does not improve or that recurs after a proton pump inhibitor and antibiotics have been given. There is no routine test of cure for H. pylori. You do not do the test if the patient feels better after treatment.