Gastrointestinal

A 54-year-old man with known cirrhosis presents with large-volume hematemesis, hypotension, and tachycardia. He is afebrile.

A 47-year-old woman has epigastric pain and melena after weeks of NSAID use. She is stable; Hgb 10.2 g/dL.

A 32-year-old man with dyspepsia and no alarm features has been taking a PPI for 2 weeks. You plan noninvasive H. pylori testing.

A 45-year-old woman with confirmed H. pylori–positive peptic ulcer requires first-line eradication in an area with high clarithromycin resistance.

A 58-year-old man with chronic GERD reports new-onset dysphagia and 5-kg weight loss.

A 36-year-old woman has progressive dysphagia to solids and liquids, regurgitation of undigested food, and weight loss. Barium swallow shows bird-beak narrowing.

A 27-year-old man develops severe chest pain and subcutaneous emphysema after repeated vomiting from binge drinking.

A 50-year-old man with severe epigastric pain radiating to the back, nausea, and vomiting. Lipase is 960 U/L (≥3× ULN).

A 62-year-old woman with acute pancreatitis has ALT 320 U/L and gallstones on ultrasound.

A 41-year-old woman has RUQ pain, fever, and Murphy sign. WBC 14,000.

A 72-year-old man presents with fever, jaundice, and RUQ pain; hypotensive and confused.

A 49-year-old woman with metabolic syndrome has elevated ALT/AST (ALT>AST), ultrasound shows hepatic steatosis.

A 24-year-old man’s hepatitis B panel: HBsAg positive, anti-HBc IgM positive, HBeAg positive.

A 56-year-old woman has positive anti-HCV antibody on screening.

A 64-year-old man with cirrhosis and tense ascites; Na 130 mEq/L.

A 59-year-old woman with cirrhosis has confusion, asterixis, and elevated ammonia.

A 63-year-old man with cirrhosis and fever develops abdominal pain. Paracentesis: PMN 520 cells/mm³.

A 57-year-old man with compensated cirrhosis asks about preventing his first variceal bleed.

A 50-year-old average-risk man asks about colorectal cancer screening.

A 62-year-old woman had colonoscopy with 2 small (<10 mm) tubular adenomas removed.

A 48-year-old man with LLQ pain, fever, and leukocytosis. CT abdomen shows uncomplicated sigmoid diverticulitis. Hemodynamically stable, tolerating PO.

A 69-year-old woman develops watery diarrhea after clindamycin; WBC 16,000; creatinine mildly elevated.

A 29-year-old woman has recurrent abdominal pain relieved by defecation, with constipation and normal labs; colonoscopy normal.

A 33-year-old man with chronic bloody diarrhea, urgency, and tenesmus; colonoscopy shows continuous inflammation from rectum proximally.

A 28-year-old woman with perianal fistula, weight loss, and abdominal pain. Colonoscopy shows skip lesions and cobblestoning.

A 35-year-old man with chronic diarrhea, iron deficiency anemia, and pruritic papulovesicular rash on elbows.

A 70-year-old man with AF develops severe, diffuse abdominal pain out of proportion to exam; lactate elevated.

A 75-year-old woman with atherosclerosis develops LLQ pain and hematochezia after hypotensive episode; CT shows segmental colonic wall thickening.

A 59-year-old man with chronic NSAID use has epigastric pain improved by meals; stool guaiac negative.

A 22-year-old woman experiences bloating and diarrhea after dairy; symptoms resolve with avoidance. Hydrogen breath test positive.

A 26-year-old atopic man has recurrent food impactions and dysphagia. Endoscopy shows esophageal rings and furrows; biopsies show eosinophils.

A 45-year-old woman has bright red rectal bleeding with bowel movements and pruritus; exam reveals nonthrombosed internal hemorrhoids.

A 29-year-old man has severe anal pain during defecation and small amounts of bright red blood; exam shows posterior midline fissure.

A 25-year-old man presents with migratory periumbilical pain localizing to RLQ, anorexia, low-grade fever; rebound at McBurney point.

A 67-year-old woman with bloating, flatulence, and chronic diarrhea after jejunoileal bypass years ago; B12 low, folate high.

A 22-year-old man with tremor, dysarthria, and elevated transaminases; low ceruloplasmin; Kayser–Fleischer rings present.

A 55-year-old man with hyperpigmentation, diabetes, arthropathy, and hepatomegaly; ferritin 1200 ng/mL, transferrin saturation 65%.

A 48-year-old woman with pruritus and fatigue; alkaline phosphatase elevated, antimitochondrial antibodies positive.

A 35-year-old man with ulcerative colitis has cholestatic LFTs; MRCP shows multifocal strictures and beading of intra/extrahepatic ducts.

A 60-year-old man with chronic hepatitis C cirrhosis asks about liver cancer surveillance.

A 68-year-old man presents with painless jaundice, dark urine, pale stools, and weight loss. Exam shows a nontender palpable gallbladder.

A 44-year-old woman has epigastric pain radiating to the back, lipase 1200 U/L, hypotension, BMI 34. CT shows no necrosis.

A 58-year-old man with recurrent steatorrhea, weight loss, epigastric pain; CT shows pancreatic calcifications.

A 37-year-old man has multiple refractory duodenal ulcers and chronic diarrhea; fasting gastrin is markedly elevated; gastric pH is very low.

A 64-year-old woman with melena is stable. Glasgow-Blatchford score is 9.

A 72-year-old man with large-volume hematochezia and hypotension; NG lavage is clear.

A 66-year-old man with cirrhosis has tense ascites. Ascitic fluid: SAAG 1.6 g/dL, total protein 1.0 g/dL.

A 55-year-old woman with acute ulcer bleeding treated endoscopically asks about preventing recurrence on aspirin for CAD.

A 29-year-old traveler returns with watery diarrhea, cramps, and low fever; no blood.

A 61-year-old woman has chronic watery diarrhea; colonoscopy normal; biopsies show lymphocytic infiltration of the lamina propria.

A 47-year-old man has chronic watery diarrhea after cholecystectomy; stool studies negative.

A 39-year-old woman with Crohn disease develops fever, abdominal pain, and dilated colon on X-ray (diameter 7.5 cm).

A 34-year-old man with ulcerative colitis in clinical remission asks about cancer surveillance.

A 41-year-old woman with signs of autoimmune hepatitis: AST/ALT 10× ULN, high IgG, positive ANA/SMA, no viral markers.

A 28-year-old man ingests large dose of acetaminophen 6 hours ago.

A 63-year-old woman with alcohol use presents with jaundice, fever, RUQ pain; AST 220, ALT 90, bilirubin 7 mg/dL, INR 1.8, WBC high.

A 36-year-old pregnant woman at 20 weeks has pruritus and elevated bile acids; LFTs mildly elevated.

A 52-year-old man with RUQ pain and jaundice; ALP and GGT elevated; ultrasound: dilated common bile duct, no gallbladder (prior cholecystectomy).

A 73-year-old man with colicky abdominal pain, distension, obstipation; X-ray shows “coffee-bean” sign pointing to the pelvis.

A 24-year-old woman has odynophagia and oral thrush; CD4 count 120/µL.

A 59-year-old man with GERD and biopsy-proven Barrett’s esophagus without dysplasia asks about surveillance.

A 62-year-old woman with Barrett’s and low-grade dysplasia confirmed twice.

A 70-year-old man with progressive dysphagia to solids, long smoking/alcohol history, weight loss; barium shows irregular narrowing mid-esophagus.

A 50-year-old woman has recurrent solid-food dysphagia; barium shows a circumferential mucosal ring at the GE junction.

A 45-year-old man with hematochezia and hypotension; angiography localizes active diverticular bleeding.

A 38-year-old woman with long-standing Crohn disease and recurrent perianal fistulas.

A 32-year-old man with acute abdominal pain, vomiting; CT shows small-bowel obstruction due to adhesions; no peritonitis.

A 53-year-old man with weight loss, new-onset diabetes, and depression; CT shows hypodense mass in pancreatic tail.

A 40-year-old woman with refractory constipation, abdominal distension; colonoscopy shows massively dilated colon without mechanical obstruction.

A 26-year-old man with chronic malabsorption and arthralgias; PAS-positive macrophages in small bowel biopsy.

A 48-year-old woman has postprandial epigastric pain and early satiety; H. pylori negative; gastric emptying study delayed.

A 35-year-old man with chronic pancreatitis has worsening postprandial pain; MRCP shows pancreatic ductal stricture and stones.

A 60-year-old man with long-standing cirrhosis develops acute kidney injury with low urine sodium, bland sediment; no improvement after fluids and diuretic withdrawal.

A 52-year-old woman has persistent RUQ pain and fever 72 hours after starting antibiotics for acute cholecystitis; ultrasound still thickened wall and pericholecystic fluid; high surgical risk.

A 42-year-old man with longstanding GERD has peptic stricture causing progressive dysphagia; no alarm weight loss.

A 33-year-old woman with iron deficiency anemia and negative EGD/colonoscopy. Next step?

A 49-year-old man with family history of early colon cancer meets Amsterdam criteria.

A 65-year-old woman with anemia and positive FIT has weight loss; colonoscopy shows apple-core lesion in sigmoid colon.

A 57-year-old man with chronic pancreatitis and intractable pain despite endoscopic therapy; imaging shows dilated main pancreatic duct.

A 46-year-old woman with peptic ulcer perforation presents with sudden severe pain; upright CXR shows free air under diaphragm.

A 72-year-old man with a known duodenal ulcer presents 12 hours after endoscopic clipping with recurrent melena and tachycardia. Hemoglobin drops from 10.1 to 8.3 g/dL. He is hemodynamically stable after fluids.

An 81-year-old man with aortic stenosis develops recurrent painless maroon stools. Colonoscopy shows multiple flat, bleeding lesions in the cecum.

A 58-year-old man presents with hematochezia and hypotension. NG lavage returns blood.

A 67-year-old woman with fever and LLQ pain has CT showing sigmoid diverticulitis with a 4.5-cm pericolic abscess.

A 72-year-old man reports pneumaturia and fecaluria after multiple diverticulitis episodes.

A 76-year-old woman has SBO with air in the biliary tree and an ectopic gallstone seen on CT.

A 49-year-old man 6 weeks after acute pancreatitis has early satiety and persistent epigastric pain; CT shows a 7-cm encapsulated fluid collection abutting the stomach.

A 61-year-old man with severe pancreatitis has fever and leukocytosis; CT shows necrosis with intralesional gas.

A 30-year-old woman with chronic diarrhea, iron deficiency, and dermatitis herpetiformis has negative tTG-IgA; total IgA is low.

A 28-year-old man with biopsy-proven celiac disease has persistent symptoms after 9 months on a gluten-free diet; tTG remains elevated.

A 24-year-old woman develops jaundice, INR 2.2, and confusion 3 days after massive acetaminophen ingestion.

A 52-year-old man with chronic hepatitis B has ALT elevation and HBV DNA 1.2×10⁶ IU/mL; HBeAg positive.

A 41-year-old HBV carrier acutely worsens with severe hepatitis after exposure to contaminated needles. HDV IgM positive.

A 60-year-old man with hemochromatosis asks about diet.

A 19-year-old man with Wilson disease develops acute hemolytic anemia and rising bilirubin with hepatic failure.

A 55-year-old woman with NAFLD asks how to reverse fibrosis. BMI 35, T2DM.

A 49-year-old woman with primary biliary cholangitis has severe pruritus despite cholestyramine.

A 38-year-old man with PSC and ulcerative colitis asks about cancer surveillance.

A 63-year-old man with cirrhosis has a 2.3-cm arterial-enhancing liver lesion with venous washout on multiphase CT.

A 58-year-old cirrhotic presents with acute abdominal pain and fever. Doppler ultrasound shows lack of portal vein flow with echogenic thrombus.

A 32-year-old postpartum woman on OCPs develops RUQ pain, hepatomegaly, ascites; Doppler shows absent hepatic vein flow.

A 64-year-old man recovered from SBP (PMN 600) asks about prevention.

A 58-year-old man with cirrhosis has impaired driving and sleep–wake inversion; psychometrics show minimal HE.

A 45-year-old woman completed H. pylori bismuth quadruple therapy. She asks about test-of-cure.

A 63-year-old man with recent variceal bleed underwent band ligation. He asks about preventing rebleed.

A 36-year-old woman has hematemesis after forceful retching; hemodynamically stable. EGD shows a linear mucosal tear at the GE junction.

A 2-year-old swallows a button battery; X-ray shows it lodged in the esophagus.

A 25-year-old man ingests a strong alkali; oropharynx is painful; he is stable.

A 40-year-old man with 120 cm of small bowel remaining after resection has steatorrhea, kidney stones, and B12 deficiency.

A 68-year-old man has a 2.5-cm pancreatic head cyst with enhancing mural nodule and main pancreatic duct dilation.

A 59-year-old woman rebleeds 36 hours after ulcer clipping and epinephrine injection; second endoscopy fails to control spurting vessel.

A 52-year-old man fails clarithromycin triple therapy for H. pylori. No prior bismuth therapy, macrolide exposure likely.

A 37-year-old man with refractory ulcers and chronic diarrhea is diagnosed with gastrinoma.

A 64-year-old man with painless jaundice has diffusely enlarged “sausage-shaped” pancreas on imaging and elevated serum IgG4.

A 70-year-old man presents with recurrent migratory superficial thrombophlebitis and weight loss; CT shows a pancreatic mass.

A 45-year-old man with PSC develops rising bilirubin and CA 19-9 with a dominant extrahepatic duct stricture.

A 52-year-old woman has an incidental 12-mm gallbladder polyp and gallstones; she is symptomatic with biliary colic.

A 26-year-old pregnant woman (20 weeks) with RLQ pain and leukocytosis; US non-diagnostic.

A 7-year-old boy has painless hematochezia; technetium-99m pertechnetate scan is positive in the RLQ.

A 69-year-old woman has ongoing brisk hematochezia and hypotension despite resuscitation. Colonoscopy prep is inadequate.