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Self-Assessment Questions


Gastrointestinal Infections: Review Questions

Douglas G. Adler, MD

Dr. Adler is an assistant professor of medicine and director of therapeutic endoscopy, Huntsman Cancer Center, University of Utah, Salt Lake City, UT.

Choose the single best answer for each question.

1. A 45-year-old man is admitted to the hospital for an elective cholecystectomy. The surgery is complicated by a bile leak and an infected biloma requiring drainage and fluoroquinolone antibiotics. On hospital day 8, the patient develops profuse watery diarrhea with leukocytosis and a low-grade fever. Clostridium difficile is the suspected cause of his diarrhea. What is the next best step in the management of this patient?
  1. Empirically begin metronidazole therapy
  2. Empirically begin vancomycin therapy
  3. Observation to see if the diarrhea is self- limited
  4. Obtain a colonoscopy to evaluate for colonic pseudomembranes
  5. Send stool samples for C. difficile toxin analysis
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2. A 19-year-old man on vacation with his family drinks water from a stream in Yellowstone National Park. Forty-eight hours later, the patient develops profuse watery, malodorous diarrhea, severe abdominal cramps, vomiting, and fatigue. The patient is clinically diagnosed with Giardia lamblia and treated empirically with metronidazole. The patient improves initially, but over the next 4 weeks, he develops a more chronic picture of intermittent bloating, gas, and watery diarrhea after eating and returns for further management. What is the most likely cause of this patient’s ongoing symptoms?

  1. Chronic Giardia infection
  2. Crohn’s disease
  3. Lactose intolerance
  4. Misdiagnosis with ongoing parasitic infection from a non-Giardia organism
  5. Ulcerative colitis
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Questions 3 and 4 refer to the following case.

A 34-year-old woman from Mexico presents with a history of right upper quadrant pain and jaundice. A right upper quadrant ultrasound demonstrates common bile duct dilation to 15 mm and an echogenic structure, which is interpreted as a stone. The patient is referred for endoscopic retrograde cholangio-
pancreatography. After inserting the duodenoscope into the second duodenum, a large worm is seen partially obstructing the lumen of the ampulla of vater. The worm is retrieved endoscopically (Figure), and no other worms are seen in the biliary or pancreatic ducts. The patient’s liver function tests rapidly improve.

3. What is the most likely causative organism in this case?

  1. Ascaris lumbricoides
  2. Diphyllobothrium latum
  3. Necator americanus
  4. Plasmodium falciparum
  5. Plasmodium ovale
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4. How should this patient be managed?

  1. Biliary sphincterotomy to prevent further worms from obstructing the biliary tree
  2. Capsule endoscopy to evaluate for more worms in the small bowel
  3. Colonoscopy to evaluate for more worms in the large bowel
  4. Empiric treatment with albendazole
  5. No further treatment is required
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5. A 22-year-old man presents to the emergency department with severe abdominal cramping and bloody stools. He states that he initially had nonbloody diarrhea for several days. He has mild, diffuse abdominal pain and a low-grade fever. He has marked leukocytosis and is also found to be in acute renal failure, likely from dehydration. He is admitted to the intensive care unit where aggressive supportive therapy is instituted. Studies of stool specimens demonstrate infection with enterohemorrhagic Escherichia coli 0157:H7. Which of the following antibiotics should be used to treat this organism?

  1. Ceftriaxone
  2. Ciprofloxacin
  3. Levofloxacin
  4. Trimethoprim-sulfamethoxazole
  5. No antibiotic therapy should be instituted
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6. A 45-year-old woman presents for evaluation of dysphagia. The patient states that she often has a sensation of food sticking in her throat, has very foul breath, and on several occasions has awakened with undigested food on her pillow in the morning. Upper endoscopy reveals a dilated esophagus with copious amounts of old food and a tight lower esophageal sphincter. A thorough review of systems reveals that 25 years ago when the patient was a college student, she traveled to Argentina for a semester abroad, during which time she toured urban and rural areas extensively. Which of the following organisms is the likely cause of her symptoms?

  1. Ancylostoma caninum
  2. Enterobius vermicularis
  3. Isospora belli
  4. Opisthorchis sinensis
  5. Trypanosoma cruzi
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