2021 Self Assessment Test COLON CATEGORY QUESTION 1 OF 56 Next > 23-year-old woman is referred to you by her ophthalmologist for a finding that was present in both eyes [figure]. She is in good health and has no medical history. She states that her father was diagnosed and died of colon cancer at age 38. Her mother is 56 years old with no cancer history and had a normal colonoscopy at age 50. What is the most likely cause of the findings? O @B Lynch syndrome © @ Familial adenomatous polyposis s Peutz-Jeghers syndrame © @BPTEN hamartoma tumor syndrome Click the image above to enlarge it COLON CATEGORY QUESTION 1 OF 56 Next >€ Previous COLON CATEGORY QUESTION 2 OF 56 porzi A2d-year-old man with no significant past medical history presented to his primary care provider 6 months ago with symptoms of runny nose, sore throat, cough, and fatigue. These symptoms had been occurring fo 2 weeks and the patient was given azithromycin for 14 days. His upper respiratory symptoms improved but he subsequently developed abdominal pains and watery diarthea. He was having 12 Bristol 7 staols daily and lov-grade fevers. He called his primary care who sent a polymerase chain reaction stool test for C. difficile and it was positive. The patient was prescribed a 10-day treatment course with vancomycin 125 me orally 4 times daily. He felt better while on the treatment and was having 2-3 Bristol § stools daily during treatment and this same pattem continued after therapy. The patient felt clinically improved but was concerned that the infection was not gone. He called his primar care provider who subsequently checked a polymerase chain reaction for C: difficile and this was again positive. The patient was started on treatment with fidaxomicin 200 mg orally 2 times daily. While on therapy, the patient's symptoms remained stable with mild abdominal pains associated with 3-4 Bristol 5 stools daily, After completion of therapy, the patient requests testing to confirm he is cured. Repeat PCR testing is again positive. The primary care provider now refers the patient to you for further assessment anc management. You perform a colonoscopy and find the following macroscopic appearance [figure]. Random biopsies of the right and left colon are normal. What treatment would you consider next for this patient? © B® Vancomycin 125 mg orally 4 times daily for 10 days followed by fecal microbiota transplantation © © Fidaxomicin 200 mg orally 2 times daily © © Loperamide, # tablet once daily © © Vancomycin 125 mg oral 6-week taper with pulse © ©@ Budesonide 9 mg orally once daily for 3 months Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 2 OF 56 pore2021 Self Assessment Test © Previous COLON CATEGORY QUESTION 3 OF 56 Next > A59-year-old woman with a past medical history significant for metastatic rectal cancer following left hemicolectomy with colostomy, currently on a nivolomab immunotherapy clinical trial now has fever, abdominal pain, nausea, and diarrhea for 1 week. C. difficile and stool bacterial and protozoan panels are negative. Colonoscopy through the stoma is performed and shows diffuse ulcerations, erythema, and loss of vascularity [figure]. Biopsies show an apoptotic colopathy pattern. No chronic crypt architectural changes or granulomas are noted. Testing for CMV is negative. What is the most likely diagnosis? © @® immune-mediated checkpoint inhibitor colitis O GC. difficile colitis © @ Inflammatory bowel disease © @ CMV coltis x. Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 3 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 4 OF 56 Next > A 60-year-old woman comes to your office for evaluation of rectal bleeding that began 1 year ago. She saw. her primary care provider for this issue 3 months prior who diagnosed her with hemorthoids and gave her hydrocortisone suppositories. There was no improvement after 2 weeks. Due to her lack of response to treatment, her primary care provider referred her to you. On visual inspection of the anus, you see the following [figures A and B] and on digital examination, you note that there is a hard, tender, 2-cm mass at the posterior anal verge. What is the next step? © @ Star the patient on imiquimod 5% for treatment of peri-anal condylomatosis. © © Peer the patient to a colorectal surgeon for an abdomingperineal resection Check carcinoembryonic antigen (CEA) and refer to an oncologist for treatment of rectal cancer. © @ Peter the patient to a colorectal surgeon for evaluation and biopsy images ick the image above to enlarge it. Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 4 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 5 OF 56 Next > 53-year-old man with familial adenomatous polyposis (FAP) had the following findings on EGD [figure], Six white lesions ranging in sizes from 1-3 mm were found in the examined duodenum. The pa appeared normal. Representative lesions were removed and confirmed to be tubular adenomas. What is the next step? Oo Repeat EGD in 3-6 months. © GB Repeat EGD in 1 year. © ©@ Repeat EGD in 2-3 years ) © Refer to a surgeon Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 5 OF 56 Next >2021 Self Assessment Test © Previous COLON CATEGORY QUESTION 6 OF 56 Next > 42-year-old man presents to the emergency department with excruciating perianal pain. It developed acutely at 3:00 AM and woke him from sleep. He checked in the mirror and noticed a large "purple bulge” emanating from his anal verge. On exam, you identify the lesion seen in the figure. Which of the following & the best next step in the management of his symptoms? © @® Surgical excision of the blood clot © @® Intravenous hydromorphone © © Phenylephrine gel © @B Aral sphincterotomy © ©@ Topical lidocaine Click the image above to enlarge it. € Previous COLON CATEGORY QUESTION 6 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 7 OF 56 Next > 47-year-old man presented with rectal bleeding and had the following lesion removed [figure]. Pathology reported a 15-mm tubular adenoma. He has a 52-year-old brother who has been avoiding colonoscopy. Th older brother has decided to have a multitarget stool DNA test. Which of the following is your recommendation regarding your patient's brother? © @B tis an appropriate test since itis his first screening test. Mutitarget stool DNA test every 3 years is recommended. © © ltis an appropriate test, but the interval should be decreased to annually given the findings in your patient. Multitarget stool DNA test every year is recommended. © @ Itis an inappropriate test because colonoscopy should always be the recommended test for the fir: colorectal cancer screening exam. CT colonography is recommended. © @ ltis an inappropriate test given the findings in your patient. Colonoscopy is recommended. Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 7 OF 56 Next >2021 Self Assessment Test Previous COLON CATEGORY QUESTION 8 OF 56 Next > ‘59-year-old woman with a history of acute myeloid leukemia achieved clinical remission after chemotherapy and allogenic stem cell transplant 6 months ago. She has hypertension and hypothyroidism. She presents to the emergency department with explosive nonbloody diarrhea 4-5 times daily for over 1 week. She also reports lower abdominal bloating but no nausea, vomiting, fevers, or chills. She took bismuth subsalicylate which turned her stools dark. She has no recent history of travel, eating outside, or sick contact. She was treated with a 7-day course of ciprofloxacin for urinary tract infection about 1 month ago by her primary care physician. On arrival, she was febrile to 103°F. heart rate 102 beats per minute, blood pressure 120/65, respiratory rate 16/minute, and oxygen saturation of 96% on room air. Aspergillus and beta-glucan levels, CMV PCR, and EBV PCR were sent to the laboratory. A chest radiograph was unremarkable. She was started on empiric antibiolics-cefepime, metronidazole, and vancomycin. The gastroenterology team was consulted. Colonoscopy showed severe colitis involving the left side of the colon as shown in the figure. Histopatholagy showed focal rare apoptotic crypt epithelial cell along with active colitis with ulceration. What is the most likely diagnosis? OC €D CMV co O © Costridioides difficile colts Graft-versus-host disease (GVHD) O.@ bschemic colitis Glick the image above to enlarge it Previous COLON CATEGORY QUESTION 8 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 9 OF 56 Next > A63-year-old woman presents for evaluation of chronic diarrhea. Symptoms developed about 4 months ago, following a hospitalization and total knee replacement surgery. Stool testing about 2 weeks after symptom onset was positive for C. difficile PCR for toxin B. She was treated with a 10-day course of oral vancomycin with no improvement, Repeat stool testing was still positive and she was treated with a course of fidaxomicin with minimal improvement. Since that time, symptoms have persisted and she has received multiple treatment courses for C. difficile, ineluding a prolonged tapering course of oral vancomycin. She has not required hospitalization for any of these episodes and completed her most recent course of anti- CDI therapy about 2 weeks ago and symptoms are unchanged. She has 8-10 watery BMs/day with nocturnal symptoms and fecal incontinence. Stool studies show fecal ealprotectin 96 meg/g and stool studies done most recently were negative for C. difficile toxins A and B by PCR. Colonoscopy to evaluate showed sigmoid diverticulosis, but otherwise normal mucosa throughout including the terminal ileum Random colon biopsies were obtained [figure]. What is the best course of treatment for this patient's condition? © @® Fecal microbiota transplantation © © Budesonide O @@BRifaximin © © Cholestyramine Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 9 OF 56 Next >2021 Self Assessment Test © Previous COLON CATEGORY QUESTION 10 OF 56 Next > 53-year-old post-menopausal woman with hypertension on hydrachlarothiazide undergoes an index screening colonoscopy procedure. She does not have a family history of colon cancer. Boston Bowel Preparation Scale is 7/9 and a single, 3-mm sessile polyp is found [figure] and removed completely from th ascending colon using cold snare polypectomy. Small, nonbleeding internal hemorrhoids are found on retrofiex examination. Pathology confirms a tubular adenoma without dysplasia. When should you recommend this patient retum for surveillance colonoscopy? © @D t year O GB 3 years © © 5 years O @ 10 years Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 10 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 11 OF 56 Next > 55-year-old woman has her first screening colonoscopy. This polyp [figure] is seen in the ascending color and is estimated to be 6 mm. What is the recommended technique for resection? © EB Cold biopsy © GB No resection needed © © Cold snare © @ hot snare EMR © @ Hot biopsy Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 11 OF 56 Next >2021 Self Assessment Test © Previous COLON CATEGORY QUESTION 12 OF 56 Next > 32-year-old man with a past medical history significant for depression presents for evaluation of rectal pain and bright red blood per rectum. He has been diagnosed with IBS, with longstanding, mild symptoms characterized by intermittent, urgent loose stools associated with abdominal pain, especially under periods of strass. Approximately 1 year ago, he was sean by his primary care provider for bright red blood per rectum and diagnosed with external hemorrhoids. He now presents to you with ongoing rectal bleeding anc worsening rectal discomfort. His social history is notable for receptive anal intercourse. He received the HPV vaccine at the age of 26. On exam, you note the following lesion in the posterior midline, which is extremely tender to the touch. What would you recommend next for this patient? © @® Reierral to colorectal surgery for possible surgical treatment © @ Rectal biopsies and urine collection for nucleic acid amplification test (NAAT) © © Colonoscopy for evaluation of possible inflammatory bowel disease © @ Frequent warm sitz baths, stool softeners, and a high-fiber diet Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 12 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 13 OF 56 Next > 67-year-old man with a history of adenomatous colon polyps undergoes surveillance colonoscopy and is found to have a 25-mm, non-pedunculated lesion in the ascending colon [figure - examination with white light (4-B) and NBI with near focus mode (C-D)]. What is the next step in management of this lesion? oO Endoscopic resection using hot snare to remove it in piecemeal fashion © © Muttipie biopsies, tattooing at the base of this polyp and referral for endoscopic resection © © Tattooing distal to the lesion and referral for en bloc endoscopic resection © @B Tattooing at the base of this polyp and referral for endoscopic resection © © Biopsy at the edge of lesion and referral to a surgeon Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 13 OF 56 Next >€ Previous COLON CATEGORY QUESTION 14 OF 56 pox 2) 68-year-old man presents with a 1-month history of increasing frequency and severity of hematochezia. His hemoglobin is measured at 14.4 g/dL (normal: 14-17 g/dL). His past medical history is notable for a normal colonoscopy 3 years ago and combination hormonal and radiation therapy for non-advanced prostate cancer 12 months ago. He is very distressed by these symptoms. Flexible sigmoidoscopy is performed [figure]. Which of the following is the optimal management for this patient? © @® Watchful waiting since his hemoglobin is normal © © Biopsy to exclude infection or chronic inflammation © @@ Argon plasma coagulation in a “painting” fashion throughout the rectum: © @ Pulsed argon plasma coagulation to discrete areas © © hastillation of 100 mL of 4% formalin into the rectum followed by saline irrigation Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 14 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 15 OF 56 Next > 65-year-old man undergoes repeat colonoscopy for polyp screening. Ten years ago, his colonoscopy wat reported as normal. He is a long-term smoker and now has a diagnosis of emphysema. He denies Gl symptoms. In his sigmoid and descending colon, polypoid cysts are found [figure]. Pneumatosis cystoides intestinalis is expected. Which of the following statements regarding pneumatosis cystoides intestinalis is true in this patient? © @® ltis likely related to intestinal ischemia © @ Mis likely related to underlying inflammatory bowel disease. © @&@ In an asymptomatic patient, it is best not ta biopsy. © @ Treatment with antibiotics is indicated. Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 15 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 16 OF 56 Next > 55-year-old female smoker with no significant past medical history presents with left lower quadrant abdominal pain over the last 3 months. She has had recent constipation with intermittent rectal bleeding and notes that her pain is worse with bowel movements. She has never had a colonoscopy. On exam, she is afebrile and has mild left and right lower quadrant tenderness to palpation with mild guarding and no rebound. During colonoscopy, her Boston bowel prep score is 3 and visualization Is difficult. She has distal sigmoid edema and narrowing which cannot be traversed despite multiple attempts. A biopsy of the sigmoir colon is shown in the figure. The scope is withdrawn and in recovery, the patient has worsening abdominal pain. What should you do next? © @® Send her home with a clear liquid diet and tell her the pain will get better after she passes gas. © © Contact a surgeon because this patient has a malignant stricture and needs surgery right away. © @ Get an abdominal CT scan to rule out perforation related to diverticulitis. © @ Perform an upper endoscopy to evaluate the pail © © Give the patient a laxative and perform another colonoscopy in a few weeks. Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 16 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 17 OF 56 Next > 64-year-old woman with a history of class 3 obesity (body mass index 40 kg/m?) and irritable bowel syndrome presents for treatment of her chronic posterior anal fissure which has bean present for the past year. She has been treated with bulking agents, soluble fiber, sitz baths, 0.3% topical nifedipine compounded with 2% lidocaine, 0.2% topical nitroglycerin, and oral nifedipine 20 mg daily without relief. She is afraid to have a bowel movement and, in many circumstances, voluntarily retains stool because itis just too painful to defecate. She admits that this has ruined her quality of life. She is tearful and begging for an alternative form of relief. She previously experienced 3 traumatic vaginal births. Your perianal exam identifies the changes in the figure. Which of the following would be the next most appropriate course of therapy? QO @ Oral diltiazem © © Lateral intemal sphincterotomy (LIS) © © Aral fissurectomy © © Botulinum toxin A injection © GB Anal sphincteroplasty Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 17 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 18 OF 56 Next > 60-year-old woman presents with a 10-week history of watery diarthea. Specifically, she is having 3-6 watery (Bristol 7) stools per day. She has mild abdominal cramping and urgency that are partially relieved by defecation. She has lost 8 lb over the past 10 weeks. Stool studies for C- difficile and ova and parasites are negative. Laboratory studies are normal aside from a mildly elevated sedimentation rate. Fecal calprotectin is 15 tug'mg. Colonoscopy reveals patchy erythema throughout the colon. Representative biopsies of the colon are shown in the figure. Which of the following therapies would you recommend? CO @® Budesonide © @ Mnfiximab © ©@ Oral mesalamine Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 18 OF 56 Next >«Pre COLON CATEGORY QUESTION 19 OF 56 Next > ‘An 82-year-old woman with multiple cardiovascular comorbidities, severe deconditioning and chronic constipation presents from a nursing facility with 3 days of worsening abdominal distension, pain, nausea and vomiting, In the last 24 hours, she has been unable to pass flatus, Her last colonoscopy a year ago noted a redundant colon. Otherwise, the colonic mucosa was normal. Physical examination revealed: temperature 37°C, respiratory rate 18/min, blood pressure 120/70, heart rate 101/min. She is uncomfortabl but nontoxic appearing. Her abdomen is distended with mild tendemess to palpation, without rebound or guarding. Laboratory tests show slight elevation in white blood count but are otherwise unremarkable. Abdominal x-ray shows marked large bowel dilatation. A representative image of the abdomen and pelvis i shown in the figure. There is no pneumatosis, free intraperitoneal air, or small bowel obstruction. A nasogastric decompression tube is placed. What is the best next step for this patient? © @® Immediate surgical consultation for emergent laparotomy © © Flexible sigmoidoscopy or colonoscopy with decompression tube placement © €® Empiric treatment with oral vancomycin, IV metranidazole © @ Neostigmine admi Click the image above to enlarge it €Previous COLON CATEGORY QUESTION 19 OF 56 Next >2021 Self Assessment Test © Previous COLON CATEGORY QUESTION 20 OF 56 Next > 40-year-old man presents to discuss treatment for his hemorrhoids. He has been consuming 25 grams o soluble fiber a day and soaking in sitz baths 3 times a day. He previously used topical phenylephrine gel and witch hazel but neither has afforded any relief. During the past month, he has bean using hydrocortisone 2.5% suppositories but continues te experience daily pruritis ani and bleeding. On exam you have him bear down and the changes seen in the figure are witnessed at the anal verge. Despite waiting, there is no evidence of spontaneous regression, but these can be reduced manually. Based on these findings, what is the best next course of action? O @® Stapled hemorrhoidapexy © © Hemonhoidectomy Rubber band ligation © ©B Infrared coagulation O @ Sclerotherapy the image above to enlarge it € Previous COLON CATEGORY QUESTION 20 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 21 OF 56 Next > 22-year-old, otherwise healthy woman is referred to you by her primary care physician for bothersome constipation dating back at least to her teens. She describes infrequent, hard bowel movements occurring approximately 4 times per week associated with straining and a sense of anorectal blockage. On rectal examination, she has brown stool in the rectal vault. She has tried a variety of over-the-counter medication including psyllium and polyethylene glycol without benefit. Because she has failed conservative measures you perform an anorectal manometry with the results during simulated defecation shown in the figure. Wha course of action would be recommended next? © @® Treat with a secretagogue or prokinetic agent © @@ Referral for pelvic floor biofeedback therapy © © Colonoscopy © © Stusies to assess colonic transit Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 21 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 22 OF 56 Next > 65-year-old man with a past medical history of metastatic kidney cancer was admitted to the hospital with severe diarthea. He was started on nivolumab 3 mgikg and ipilimumab 1 mg/kg every 3 weeks by oncology He has completed 3 cycles of chemotherapy treatments to date. After the third treatment, he has developer severe diarthea with over 10-15 bowel movements per day. He describes minimal blood in the stools and denies any abdominal pain. Abdominal x-ray on admission showed nonspecific bowel gas pattern without evidence of obstruction. Vital signs were stable with no tendemess on abdominal exam. Stool studies performed for gastrointestinal infection and Clostridicides difficile were negative. Gastroenterology consulted and performed a colonoscopy showing diffuse granularity, erythema, inflammation, and friability consistent with mild to moderate colitis throughout the entire colon [figure]. What is the most likely diagnost in this patient? CO @® Infectious colitis © Bi Newly diagnosed ulcerative colitis © © Metication-induced coltis © @ Ischemic colitis Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 22 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 24 OF 56 Next > A62-year-old man with a history of hypertension, coronary artery disease following stent placement 2 year: ago, and chronic obstructive pulmonary disease presents to the emergency department with acute onset abdominal pain. He takes clopidogrel and lisinopril. His pain is described as a 9/10 on the right side and a sharp band throughout his abdomen. He has watery diarrhea that started when the pain began. He has har 3 bowel movements since the onset of his symptoms and undergoes an initial x-ray [figure]. What is the best next step in the management of this patient? © EB Computed tomography (CT) of the abdomen and pelvis © © Call surgery for an emergency laparotomy © © Computed tomography (CT) of the abdomen and pelvis with angiography @©BD Right upper quadrant sonogram Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 24 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 25 OF 56 Next > A25-year-old man presents to the outpatient gastroenterology clinic with intermittent blood mixed in with hi stools. His symptoms have been occurring on a twice weekly basis for the last 2 months. He usually has 3- formed bowel movements per day. Past medical history is significant for hypertension. He has never undergone gastroscopy or colonoscopy. Blaod work is within normal limits and the patient is hemodynamically stable. Colonoscopy is arranged. Moderate sigmoid diverticulosis is seen. The 1-2-cm polyp with overlying erythema seen in the figure is visualized in the sigmoid colon. The polyp is removed with hot snare polypectomy technique and sent for analysis. Histopathology from the polyp shows fibromuscular hyperplasia of the lamina propria, extension of the muscularis mucosa into the lamina proprié and crypt elongation. There is no dysplasia. Staining is negative for smooth muscle actin, desmin, and c- KIT (CD 117). Based on the clinical presentation, endoscopic appearance, and histopathology, this is what type of polyp? O @® Inflammatory pseudopolyp © @® Inflammatory polyp, prolapse type © © Castrointestinal stromal tumor (GIST) © @ Leiomyoma Click the image above to enlarge it € Previous COLON CATEGORY QUESTION 25 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 26 OF 56 Next> ‘A.48-year-old man presents with 1 week of diarthea with 10-15 loose bowel movements per day. He has Intermitent, difuse abdominal pain and denies fevers. His medical history Is notable for a kidney transplan. 6 months prior due to complications from type 1 diabetes His immunosuppression consists of tacrolimus and mycophenolic acid. He denies eny recent antibiotic use, travel, or sick exposures. CT scan reveals righ colonic wall thickening centered at the hepatic flexure with surrounding mesenteric stranding. Colonoscopy reveals scattered erosions with surrounding erythema and edema [figure A] worse in the proximal colon. ‘The terminal ileum appears normal. Colon biopsies show active inflammation with abnormalities in the lamina propria [figure B], Which of the follow Cryptosporidium parvum OC Mycobacterium tuberculosic © © Cyptocecaue neoformans © © Entomoeds histolytica © © Cytomegalovirus images Click the image above to enlarge it. € Previous COLON CATEGORY QUESTION 26 OF 56 is the most likely pathogen? Next>2021 Self Assessment Test © Previous COLON CATEGORY QUESTION 27 OF 56 Next > A.6-year-old woman with obesity and a history of migreinas, asthma, and anxiety presents to the emergency department (ED) with abdominal pain. She reports intermittent abdominal pain for approximate 5 months and has visited several other EDs during these episodes. She reports that last week she was in another ED and was told that she had some inflammation in a small area of her small bowel. She now statos that the pains are as sovere as last wook, rated as 8/10 intonsity, but more diffuse. Tho wok prior, ‘he pains were focused in her peri-umbilcal erea She reports feeling constipated and has not had a bowel movement in 48 hours. On physical examination, she has some abdominal tenderness without reboune or guarding. Her only medication is an oral contraceptive pill. Hor serologic assessment shows: WBC 20,600/uL (normal: 4,000-10,000/uL) Hemogoobin 12.6 g/dL (normal, 12-16 gid) Platelets 425,000/uL (normal. 150,000-350,000/pL) Sodium 135 moqlL (normal: 126-145 meciL) Potassium 42 magi (normal: 3 5.50 meq Chloride 96 meo/L (normal: 98-106 meq/L) Bicarbonate 18 megjL (normal 23-28 meq/L) Blood urea nitrogen 15 mid. (normal: 8-20 maid) Serum creatinine 0.8 mgldl. (normal. 0.7-1.3 mgidL.) ‘An abdominal x-ay is performed, and the resuks are shown in the figure. The ED cals and asks what you think the next most important step would be for this patient? (© @B Right upper quadrant ultasound with Doppler (© © Obtain 2 CT angiogram © @ Call interventional radiology to discuss angiogrephy. (© © Cal general surgery for emergency laparotomy. (© ©@ Perform a rapic preparation for colonoscopy. age above to enlarge it Previous COLON CATEGORY QUESTION 27 OF 56 pesto2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 28 OF 56 Next > A.45-year-old man presents for further evaluation of his rectal pain and bleeding. These symptoms have been ongoing for a year. He notes that the pain occurs whenever he is having a bowel movement and feels like a “cutting” sensation. Once the stool has passed, he experiences persistent throbbing pain over the subsequent 45 minutes before the pain spontaneously resolves. While he does not identify blood with eact bowel movement, when present, it streaks the stool bright red and is also identified on the toilet paper. He was evaluated by another gastroenterologist approximately 3 months after his symptoms started and was found to have a chronie anterior fissure. His CBC at that time was normal and a subsequent colonoscopy identified scattered diverticulosis in the sigmoid colon and a 2-mm ascending colon sessile serrated polyp Initially, he admitted to symptoms of constipation (straining and incomplete evacuation) but those resolved with the addition of a soluble fiber supplement which he continues to use. He is frustrated because he has tried sitz baths with Epsom salts, topical nifedipine and nitroglycerin, oral diltiazem and none of these have proven effective, He does not report any associated history of fecal incontinence. Which of the following would be the most appropriate next step in his care? © © CTenterography to evaluate for evidence of Crohn's disease © @ Oral nifedipine 20 mg twice a day © © Botulinum toxin (20 units) injected on either side of the anal fissure © @ Fissurectomy © ©@ Lateral internal sphincterotomy € Previous COLON CATEGORY QUESTION 28 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 29 OF 56 Next > A 24-year-old woman with no significant past medical history presents to your office for evaluation of 1 yeat of abdominal pain, 3 times weekly, associated with episodes of frequent, loose stools. Her symptoms started shorly after a Caribbean cruise, where many passengers came down with an acute, presumed infectious gastroenteritis characterized by fever, nausea, vorniting, and diarrhea. Since experiencing these symptoms on the cruise herself, she notes that her bowels "have never been the same." She was empirically treated with a course of antibiotics shortly after arriving back home. Her family history is unremarkable, and she has no melena, hematochezia, or weight loss. Based on guidelines, which of the following diagnostic tests is the most appropriate next step in her workup? © @ Celiac serologies, stool ova and parasites, and fecal calprotectin © © Caliac serologies, fecal calprotectin, and C-reactive protein (CRP) © ©@ Stool testing for enteric and viral pathogens © @ Colonoscopy with random colon biopsies to assess for microscopic colitis © Previous COLON CATEGORY QUESTION 29 OF 56 Next >2021 Self Assessment Test Previous COLON CATEGORY QUESTION 30 OF 56 Next> Ahealthy 57-year-old man returns from M: after a 2-week business trip. He visited several rural agricultural areas. He ate at local food establishments and in the homes of his potential business partners. Just prior to leaving Mexico he developed severe, non-bloody diarrhea, In addition, he experienced low- grade fever and abdominal cramps. At the time of his office visit, 1 week after returning home, his symptoms seemed to be improving, He's lost 10 Ib, but abdominal cramping and diarrhea are now less severe. You order a multiplex PCR stool pathogen test which is positive for Escherichia coli O157:H7 as well as Cyclospora cayetanensis. Based on these results, what is your next step? oO Antibiotics to treat Escherichia colt © @P Antibiotics to treat Cyclospora cayetanensis Repeat multiplex stool pathogen test © @D Supportive care ‘ Previous COLON CATEGORY QUESTION 30 OF 56 Next>€ Previous ‘COLON CATEGORY QUESTION 31 OF 56 Next > A58-year-old woman with no prior history of colonoscopy undergoes multi-target DNA-fecal immunochemical test (FIT) screening for colorectal neoplasia, and the test is reported as positive. At colonoscopy, there are approximately 30 lesions identified proximal to the splenic flexure, of which 7-10 are larger than 1 cm with most of these polyps appearing serrated by endoscopic criteria. There is ne lesion involving the appendiceal orifice. Additionally, more than 20 lesions, also appearing serrated by endoscopic evaluation, are identified in the rectosigmoid, though none appear larger than 1 cm. What is the best and safest treatment approach for this patient? © @® Subtotal colectomy followed by endoscopic clearance of the rectum or rectum and distal sigmoid © @B@ Endoscopic submucosal dissection (ESD) of the large proximal colon lesions, followed by cold snare polypectomy of the remaining lesions © @ Hot endoscopic mucosal r snare polypectomy of the rem ection (EMR) of the larger proximal colon lesions, followed by cold ing lesions, © @B Cold EMR of the large lesions, followed by cold snare polypectomy of the remaining lesions € Previous ‘COLON CATEGORY QUESTION 31 OF 56. Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 32 OF 5 [Next of rectal fullness and tenesmus. She has been constipated most of her life having a bowel movement even, 2.3 days. More recently, she has been moving her bowels every 4-5 days with hard and sometimes difficult to pass stools. She describes a small amount of blood coating her stools about once a week. She is not taking any new medications and review of systems was negative. Rectal examination is unremarkable and initial serologic assessment was unrevealing. The patient undergoes an anorectal manometry study showing mild dyssynergia. A colonoscopy reveals 3, 1-2-cm ulcerations, 5-10 om from the anal verge. Biopsy of the ulcerations reveal smooth muscle hyperplasia in the lamina propia between colonic glands, and surface ulceration with associated chronic inflammatory infiltrates. She is started on conservative measures including minimizing time on the commode, high-fiber diet, and bulk laxatives. What is the next step in the management of this patient? © @® Saminosalicylate O © Biofeedback therapy © © Magnetic resonance defecography O @ Surgical rectopexy © © Surgical perineal proctectomy € Previous COLON CATEGORY QUESTION 32 OF 56 Next >2021 Self Assessment Test Previous COLON CATEGORY QUESTION 33 OF 56 Next > Which of the following lesions is most likely to be caused by human papillomavirus (HPV) type 167 © @® Squamous cell carcinoma of the anus © @G® Tubular adenoma of the rectum & Condyloma in the anal canal © @ Low-grade squamous intraepithelial lesion (LSIL) of the anus € Previous COLON CATEGORY QUESTION 33 OF 56 Next >2021 Self Assessment Test € Previous COLON CATEGORY QUESTION 34 OF 56 Next > 78-year-old woman develops profuse watery diarthea with fecal incontinence a few days after completinc a course of clindamycin for a dental infection. She presents to the emergency depariment where she is afebrile and mildly tachycardic with blood pressure 138/80. Abdominal exam is nondistended and nontende with nomal pitched bowel sounds. Stool testing shows positive glutamate dehydrogenase antigen and positive C. difficile enzyme immunoassay for toxins A and B. Blood work shows WBC 18, 000/UL (normal 4,000-10,000/uL) and creatinine is 1.7 mg/dL (baseline: 0.8 mg/dL). The patientis treated with a 10-day course of oral vancomycin and symptoms resolved. Afew days after completing the course of anti-C. difficile infection (CDI) therapy, she again developed the same symptoms of watery diarrhea and tested C. difficile positive. This second episode was treated with a course of fidaxomicin and again resolved. However, within a few days of completing this course, she again developed symptoms reminiscent of her prior CDI episodes and stool testing was again positive. Which of the following would have the best evidence for successful treatment of this third episode (second recurrence) in this patient? © @® Vancomycin 125 mg 4 times a day for 10 days, followed by a 4-week tapering course © © Vancomycin 125 mg 4 times a day for 10 days, followed by fecal microbiota transplantation (FMT) administered at colonoscopy © © Fidaxomicin 200 mg twice a day for 10 days, followed by pulse-dosed fidaxomicin for anather 6 weeks © © Vancomycin 125 mg 4 times a day for 14 days, followed by a rifaximin “chaser” 400 mg 3 times a day for 14 days € Previous COLON CATEGORY QUESTION 34 OF 56 Next >2021 Self Assessment Test € Previous ‘COLON CATEGORY QUESTION 35 OF 56 Next > Which of the following is an effective, evidence- and population-based strategy for increasing colorectal cancer screening rates? © @® Mailed fecal immunochemical testing outreach © @® Small financial incentive(s) Oo Blood-based screening © @) Free colonoscopy among an insured population € Previous COLON CATEGORY QUESTION 35 OF 56 Next >Previous COLON CATEGORY QUESTION 36 OF 56 Next > A 52-year-old man comes to your clinic after his first attack of uncomplicated diverticulitis. His symptoms responded prompily to antibiotics. A colonoscopy following the first episode showed only diverticulosis. He has degenerative joint disease for which he takes ibuprofen regularly. On physical exam, he is in no distress. His BMI is 24 kg/m?. His abdomen is non-tender with normal bowel sounds. He wonders how he might prevent future episodes. What advice should you give him? © @B Avoid nonstercidal anti-inflammatory drugs. oO Start probiotics. QO Start mesalamine. © @® Eliminate nuts and seeds from his diet. Previous COLON CATEGORY QUESTION 36 OF 56 Next >© Previous COLON CATEGORY QUESTION 37 OF 56 Next > A451-year-old man undergoes colorectal cancer (CRC) screening with multitarget stool DNA test, which is positive. A colonoscopy is performed, complete to the cecum with good preparation, and is normal. Whatis the best next step in future recommendations for CRC screening/surveillance? oO Repeat the multitarget stool DNA test in 1 year. © @® Perform and EGD and a CT abdomen now. oO Repeat CRC screening in 10 years © @B Repeat colonoscopy in 1 year. © Previous COLON CATEGORY QUESTION 37 OF 56 Next >Previous ‘COLON CATEGORY QUESTION 38 OF 56 Next > A 52-year-old man is seen in clinic for concerns with dyspepsia and bloating. On chart review, he is due for colorectal cancer screening. You discuss the options with him and he chooses to undergo a fecal immunochemical test (FIT). Two weeks later, you get a laboratory alert that the FIT is positive. What is the best next step? © @® Schedule a colonoscopy within 2 months. © Gp Repeat the FIT. oO Confirm with multitarget stool DNA. © @ Wait 1 year for further screening. * Previous ‘COLON CATEGORY QUESTION 38 OF 56 Next >€ Previous COLON CATEGORY QUESTION 39 OF 56 Next > 56-year-old woman presents for screening colonoscopy. She has had 2 previous attempts at colonoscop that were unable to be completed due to tortuosity of the colon. Those procedures were terminated in the transverse colon. Today, with the help of pressure, the scope is passed with general ease to the cecum. She has 3, 1-2-mm sessile polyps resected with a cold biopsy forceps. Following the procedure, the patien feels well and is discharged. She calls you about 2 hours later stating that she is having excruciating abdominal pains. You return her eall and advise her to go to the emergency department (ED). In the ED, th abdominal x-ray reveals air below the diaphragm. What is the most common and likely location for this complication of colonoscopy in this patient? OB cecum © @B Ascending colon © @ Transverse colon © © Descending colon © ©@ Sigmoid colon € Previous COLON CATEGORY QUESTION 39 OF 56 Next >€ Previous COLON CATEGORY QUESTION 40 OF 56 Next > A 45-year-old man living with HIV diagnosed at age 29 presents to his gastroenterologist for follow-up of hi: chronic GERD. His CD4 T lymphocyte count upon diagnosis was 79 cells/mm? (normal range: 500-1,200 cells/mm®*) and he initiated antiretroviral therapy upon diagnosis. During his visit, he denies anal pain or rectal bleeding. He is currently sexually active with his long-term male partner. His most recent CD4+ T lymphocyte count was 950 cells/mm? and his HIV viral load is undetectable. What would you offer for anal high-grade squamous intraepithelial lesion (HSIL) screening? © @® Do not offer screening; his risk for anal cancer is low. © @® Perform a flexible sigmoidoscopy. ee Perform a digital anorectal examination with anal cytology. a Perform a colonoscopy. Previous COLON CATEGORY QUESTION 40 OF 56 Next >€ Previous ‘COLON CATEGORY QUESTION 41 OF 56 Next > A 36-year-old woman presents with the acute onset of severe diarrhea. She has never had this before and she reports no new medications, recent travel, sick contacts, or changes in diet. Serologic and stool studie: are unremarkable but colonoscopic evaluation indicates collagenous colitis. The patient is started on therapy with relief of her symptoms. At a follow-up office visit, the patient inquiries about other disorders associated with this disease. You discuss that you will obtain further bloodwork to assess her risk for associated disease. When you send a serologic assessment, which af the following tests is most likely to b positive? © GP Anti-smooth muscle antibody © @® Deaminated gliadin antibody © @BAnI-SS-A (Roy/Anti-SS-B (La) © GQ Anttiver kidney microsomal antibody € Previous ‘COLON CATEGORY QUESTION 41 OF 56 Next >€ Previous COLON CATEGORY QUESTION 42 OF 56 Next > 43-year-old man with a history of hypertension and chronic obstructive pulmonary disease presents to th emergency department (ED) with abdominal pain and bloody diarrhea. Over the last week, he describes having a sore throat, runny nose, and cough. For these symptoms, he started taking pseudoephedrine. He reported eating chicken about 2 hours prior to presenting to the ED, and recalls a history of food poisoning due to undercooked food. In the ED, he describes acute onset of cramping, peri-umbilical and left upper quadrant pain beginning 6 hours ago, rated 7 out of a scale of 10, lasting 15-30 minutes followed by numerous bloody bowel mavements including bload clots. He is currently hemodynamically stable and notes improvement in his abdominal pain. His serologic assessment shows a normal complete blood count, electrolytes, and liver tests. What is the best next test to diagnose this patient's condition? © @B CT scan of the abdomen and pelvis with oral and IV contrast © © Colonoscopy © @® Flexible sigmoidoscopy © @ Stool culture © @ Stool ova and parasites € Previous COLON CATEGORY QUESTION 42 OF 56 Next >Previous COLON CATEGORY QUESTION 43 OF 56 Next > ‘A48-year-old man undergoes a screening colonoscopy due to family history of colon cancer. At colonoscopy, a 50-mm granular, lateral-spreading lesion is identified in the proximal ascending colon. The lesion occupies approximately one-third of the luminal circumference and extends over 2 haustral folds Postprocedure, the findings are discussed and the patient is referred to a regional center for endoscopic resection. At the regional center, the patient undergoes hot piecemeal endoscopic mucosal resection (EMR). At the end of snare resection, there is no evidence of residual polyp. Which of the following best describes the evidence-based steps that should take place next? © © Clip closure of the EMR defect, followed by repeat colonoscopy in 6 months © © Snare tip soft coagulation treatment of the margins, followed by clip closure if feasible, followed by repeat colonoscopy in 6 months © © Snare resection of the margins, followed by clip closure if feasible, followed by repeat colonoscopy in 6 months © © Snare tip soft coagulation treatment of the margins, followed by coagulation of all exposed blood vessels in the base of the EMR defect, followed by clip closure if feasible, followed by repeat colonoscopy in 6 months © Previous COLON CATEGORY QUESTION 43 OF 56 Next +Previous COLON CATEGORY QUESTION 44 OF 56 Next > A30-year-old patient presents to clinic for gastroesophageal reflux disease. During the exam, he asks about colorectal cancer (CRC) screening. He reports that his father was diagnosed with colon cancer at ag 70. There is no other family history of CRC or advanced adenomas. Which of the following is the best option? © @® Perform a colonoscopy now. © @® Start screening at age 40 oO Order a FIT now. © @ Defer screening discussion for 1 year. * Previous ‘COLON CATEGORY QUESTION 44 OF 56 Next >€ Previous COLON CATEGORY QUESTION 45 OF 56 Next > A68-year-old woman undergoes colonoscopy for a positive fecal immunochemical test (FIT). She is American Society of Anesthesiologists risk class 1 (ASA 1), At colonoscopy 7 adenomas are removed, the largest of which is a pedunculated polyp at 30 cm in the sigmoid colon. The lesion is removed en bloc followed by placement of a clip on the residual stalk. Pathologic examination of the polyp demonstrates well-differentiated adenocarcinoma invading the stalk and extending to a distance of .6 mm from the resection line. There is no lymphovascular invasion. Baseline carcinoembryonic antigen (CEA) is normal and CT scans of chest, abdomen, and pelvis with IV contrast show no evidence of disease. Which of the following is most appropriate? © @® Surgical resection of the sigmoid colon © @B Repeat colonoscopy in 3 years © © Repeat colonoscopy in 6-12 months © © Repeat colonoscopy now Previous ‘COLON CATEGORY QUESTION 45 OF 56 Next >€ Previous ‘COLON CATEGORY QUESTION 46 OF 56 Next > You are asked to consult on a 58-year-old woman admitted ta the hospital with 2 days of left lower quadran pain and malaise. She has no nausea or vomiting but does have some anorexia. Her past medical history i otherwise notable for uterine fibroids. On physical examination, her temperature is 37_9°C, her heart rate is $2 bpm, and her bload pressure is 128/86 mmHg, There is focal tendemess with some guarding in the left lower quadrant. Bowel sounds are normal and there is no evidence of a palpable mass. Laboratory tests are remarkable for an elevated WBC. at 14,000/uL (normal: 4,000-10,000/yL). ACT scan of the abdomen and pelvis demonstrates a 5-10 cm segment of sigmoid colon wall thickening with fat stranding in an area ¢ diverticulosis. There is no abscess or extra-luminal air visualized. Which of the following is the most appropriate next step for this patient? © @® WV antibiotics © DB No antibiotics oO Surgery © @ Colonoscopy € Previous ‘COLON CATEGORY QUESTION 46 OF 56. Next >Previous ‘COLON CATEGORY QUESTION 47 OF 56 Next > A 50-year-old woman with no family history of colon cancer or advanced adenomas has an index screening colonoscopy. This exam finds a 1.5-cm descending colon polyp, removed with a cold snare. Pathology shows tubular adenoma. Subsequent high-quality surveillance colonascopies at age 53 and 530 do not sho. any polyps. What is the next appropriate step in her colon cancer surveillance regimen? © @® Colonoscopy at age 61 (3 years) © B® Colonoscopy at age 63 (5 years) oO Colonoscopy at age 68 (10 years) © @ Yearly FIT testing beginning at age 68 (10 years) * Previous ‘COLON CATEGORY QUESTION 47 OF 56 Next >© Previous COLON CATEGORY QUESTION 48 OF 56 Next > A2T-year-old woman in previous good health developed rectal bleeding. On colonoscopy, 4 tubular adenomas were seen in the transverse and descending colon ranging from 4-15 mm. In addition, a 6-cm circumferential rectal cancer was detected. What is the next step in her care? oO Refer for genetic counseling. © @@y Test for DNA mismatch repair deficiency. oO Refer to gynecology. © @ Perform thyroid ultrasound © Previous COLON CATEGORY QUESTION 48 OF 56 Next >Previous ‘COLON CATEGORY QUESTION 49 OF 56 Next > A60-year-old Hispanic woman presents to your clinic as a self-referral to discuss colorectal cancer (CRC) screening. She reports that she is asymptomatic, has not previously had CRC screening, and does not have a family history of CRC. Her physical examination is normal. There are no available laboratory tests. She is most likely to adhere to a CRC screening approach if you adopt which of the following strategies? © @® Offer stool-based testing only. © @® Offer CT colonography. oO Offer either stool-based testing or colonoscopy. © @ Offer colonoscopy only. * Previous ‘COLON CATEGORY QUESTION 49 OF 56 Next >€ Previous COLON CATEGORY QUESTION 50 OF 56 Next > A457-year-old man with Crohn's disease currently on vedolizumab monotherapy has a history of a past C. difficile infection. At the time of diagnosis, he was treated with a 10-day course of vancomycin. While on therapy, his diarrhea resolves. He is now back in your office with 3 days of diarrhea. The patient undergoes testing for C. difficile 4 weeks after completing his initial course of vancomycin 125 mg 4 times a day. The stool testing, using a 2-step method, returns positive and confirms a recurrent infection. For this patient's first recurrence of C. difficile infection, which is the best treatment course? © @® Vancomycin taper and/or pulse © @B Metronidazole 500 mg 3 times a day & Fecal microbiota transplantation Gi Watchful waiting Previous COLON CATEGORY QUESTION 50 OF 56 Next >Previous ‘COLON CATEGORY QUESTION 51 OF 56 Next > A 50-year-old man undergoes a screening colonascopy with excellent bowel prep. He has 3 polyps removed, a 7-mm tubular adenoma from the cecum, an 8-mm sessile serrated adenoma from the transverse colon, and a 2-mm hyperplastic palyp from the sigmoid colon. According to the most recent USMSTF guidelines, into what interval should his surveillance recommendation fall? © @® 1-3 years © Gp 35 years oO 5-10 years © @) 7-10 years * Previous ‘COLON CATEGORY QUESTION 51 OF 56 Next >© Previous COLON CATEGORY QUESTION 52 OF 56 Next > A455-year-old man with a history of diabetes and end-stage renal disease on peritoneal dialysis presents te your office to discuss diagnostic colonoscopy following a positive FIT screening test. Which of the following is recommended to reduce the incidence of postprocedural peritonitis? oO IV ampicillin plus aminoglycoside © @ Ciprofloxacin oO Doxycycline © @ No antibiotic prophylaxis is indicated. © Previous COLON CATEGORY QUESTION 52 OF 56 Next >€ Previous ‘COLON CATEGORY QUESTION 53 OF 56 Next > A73-year-old man with several severe comorbidities including heart failure on hame oxygen underwent surveillance colonoscopy after a recent EMR. On prior colonoscopy, a 5-cm lateral spreading tumor-NG lesion was seen at the splenic flexure and piecemeal removal was performed. At that time, he was deemec to be at high surgical risk for colonic resection. Due to the COVID pandemic. he opted to defer his. surveillance for 18 months after his initial colonoscopy. On the surveillance colonoscopy, a 3-cm sessile lesion at the previous EMR site with significant fibrosis was noted. Biopsies showed tubular adenoma with high-grade dysplasia. What would be the best next step in management of this polyp? © @ Referral for colorectal surgery © @® Endoscopic submucosal dissection © @® Endoscopic mucosal resection © @} Endoscopic full-thickness resection € Previous ‘COLON CATEGORY QUESTION 53 OF 56 Next >Previous COLON CATEGORY QUESTION 54 OF 56 Next > A 56-year-old Caucasian woman with a family history of kidney and colon cancer and a personal history of obesity, long segment Barrett's esophagus, and sebaceous adenomas is under EGD surveillance for Barrett's esophagus. On EGD, a 12-mm nodule in the duodenum was observed. Endoscopic resection revealed duodenal adenocarcinoma. Lack of MSH2 protein expression on immunohistochemistry is demonstrated. Based upon the most likely scenario, what do you inform the patient? © @B This cancer is likely an isolated sporadic cancer. © @® No chemoprevention is available to decrease her risk of colon cancer a She should consider total hysterectomy and bilateral salpingo-oophorectomy. © @ She has a high risk of breast cancer. Previous COLON CATEGORY QUESTION 54 OF 56 Next >‘€ Previous ‘COLON CATEGORY QUESTION 55 OF 56 Next > A 50-year-old man recently underwent a first-time screening colonoscopy during Colorectal Cancer Awareness Month. He has no known family history of colon cancer or polyps. On his colonoscopy, he was. found to have a 24-mm sessile polyp requiring piecemeal resection. The pathology showed a sessile serrated adenoma. What is the recommended surveillance interval based on the latest U.S. Multi-Society Task Force guidelines (2020)? O @B tyear © GB 3 years oa 5 years CO @D7 years © GB 6 months © Previous ‘COLON CATEGORY QUESTION 55 OF 56 Next 2Previous COLON CATEGORY QUESTION 56 OF 56 Next > A 52-year-old woman undergoes colonoscopy to evaluate a positive family history of colorectal cancer. Her mother developed colorectal cancer at age 57. Colonoscopy reveals 2 conventional adenomas measuring and 7 mm in size, removed with cold snare. Pathology demonstrates tubular adenomas with low-grade dysplasia. The quality of the bowel preparation is excellent. When should this patient undergo repeat colonascopy? © @B 3 years © Gp 5 years CO QT years © Gp 10 years Previous COLON CATEGORY QUESTION 56 OF 56 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 1 OF 20 pox 2) 56-year-old woman is referred for colonoscopy to remove a 1.2-cm polyp in the ascending colon. visualized on CT colonography [figure]. She reports occasional small volume hematochezia over the last month but has no family history of colon cancer. Her medications include metoprolol for hypertension, simvastatin for hypercholesterolemia, and apixaban for paroxysmal non-valvular atrial fibrillation. She is otherwise well, and laboratory test results reveal no evidence of anemia or impaired kidney function with ar estimated glomerular filtration rate >60 mL/min. Regarding the planned colonoscopy, which of the following would be most appropriate recommendation for this patient? © @® Deter colonoscopy, possibly up to 12 months © © Continue apixaban at the time of colonoscopy. © ©@ Discontinue apixaban 5 days before the procedure. © @ Discontinue apixaban 2 days before the procedure. Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 1 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 2 OF 20 pox 2) A78-year-old Chinese woman undergoes an upper endoscopy for dyspepsia. She has a history of hyperlipidemia. Her medications are atorvastatin and omeprazole. The endoscopy reveals a 1.5-cm nonulcerated depressed lesion with slightly elevated component (Paris 0-lic#lla) at the incisura angularis 0 the stomach [figure: the lesion on white light (WL) and narrow band imaging (NBI)]. Biopsy of this lesion revealed intramucosal adenocarcinoma with minute focus of poorly differentiated malignant neoplasm arising in a background of gastric mucosa with high-grade dysplasia and intestinal metaplasia (incomplete and complete types). Gastric mapping biopsy for immunohistochemical staining for H. pylori is negative. C7 scan abdomen and pelvis with contrast shows no evidence of lymph nades or distal metastasis. What is tht most appropriate next step in management? © @® Cap-assisted EMR © GB Band-assisted EMR © ©@ Endoscopic submucosal dissection © @ Peierral for surgical resection with lymph node dissection © © Endoscopic full thickness resection Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 2 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 3 OF 20 pox 2) An 83-year-old woman presents to the emergency department with recurrent rectal bleeding. Past medical history is significant for scleroderma, iron deficiency anemia, and pulmonary hypertension. CT of the abdomen and pelvis with IV and oral contrast shows a nodular liver, splenomegaly, reversed flow in the portal vein, and prominent collateral vessels. Blood work is notable for hemoglobin 10 g/dL (normal: 12-16 g/dL), prothrombin time 15 seconds (normal: 11-13 seconds). and platelet count 100,000/UL (normal: 150,000-350,000/uL). AST, ALT, and ALP are within normal limits. She has never undergone EGD or colonoscopy. Colonoscopy is arranged and the rectal findings are as seen in the figure. What is the best next step for the patient? O @@ EUS-guided cyanoacrylate glue injection © © Epinephrine injection and bipolar cautery © ©@ Bipolar cautery and endoscopic clipping © © Surgical resection Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 3 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 4 OF 20 pox 2) An 84-year-old woman with a remote history of possible ulcer disease presented to the emergency department with 5 days of melena following a week's intake of an NSAID for low back pain. She reported n other significant past medical history, and no cardio-tespiratory complaints; the physical exam is normal Initial hemoglobin is 7.5 g/dL (normal: 12-16 gidL), with platelets of 375,000/uL (normal: 150,000-350,000/ uL), and an INR of 1.03 (normal: <1.4). After stabilization and transfusion of 1 unit of packed RECs, an EGI was performed. A 2-cm duodenal ulcer with a very firm fibrotic base was noted and was treated with epinephrine injection and endoclips. The next day, the patient has a bout ef red blood hematemesis and after stabilization, an EGD is repeated. Epinephrine injection, thermal coagulation, and further clips application are attempted but there is persistent bleeding (endoscopic appearance shown in the figure) Over-the-scope clip expertise is not available at your institution. What would you do now? © @® Endoscopic application of hemostatic powder followed by trans-arterial embolization by interventional radiology © © Endoscopic application of hemostatic powder and no further intervention © © Monitor closely on continuous intravenous infusion of high-dose proton-pump inhibitor. © @B Send to surgery for oversewing of the duodenal ulcer. Question 3, Figure 1 Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 4 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 5 OF 20 pox 2) 48-year-old man with early gastric adenocarcinoma diagnosed on endoscopic biopsy with T1a (M) depth of invasion on pathology [figure] is requesting referral for gastric endoscopic submucosal dissection (ESD). What can you confidently tell the patient about why he should consider gastric ESD over surgical gastrectomy? O @@ Higher rates of en bloc and curative resection than surgical gastrectomy © @ Better disease-free survival rate compared to surgical gastrectomy © ©@ Lower risk of overall complications and procedure-related death compared with surgical gastrectomy © @ Higher rates of lymph node metastasis for T1a (M) invasion Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 5 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 6 OF 20 ee ‘68-year-old man with paroxysmal atrial fibrillation reports 3 days of dark black stool. He has been on aspirin 81 mg daily and warfarin for the last 2 years for a significant thromboembolic history. He has experienced 2 DVTs and 1 stroke within the last 4 years, with the most recent embolic event occurring 18 months ago. Over the last week, he reports using regularly scheduled ibuprofen 600 mg 3 times a day for the treatment of tennis elbow. His hemoglobin has declined from 13.5 g/dl. to 8.4 g/dL and his INRis 4.5, and a 4-factor prothrombin complex is provided to normalize his INR. You proceed to EGD and find an adherent clot that is dislodged using water irrigation revealing a bleeding visible vessel. You place 2 mechanical clips but note some residual oozing at the site which you inject with epinephrine [fiqures A and B], What is the optimal recommendation for warfarin in this patient? © @® Resume 10-14 days following the endoscopy, © @ Resume within 4-7 days following discontinuation of the warfarin. © © Resume imme © © Discontinue. images Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 6 OF 20 plex.€ Previous ENDOSCOPY CATEGORY QUESTION 7 OF 20 ee A73-year-old woman with a history of constipation is complaining of left upper quadrant pain with radiation to her left shoulder 6 hours after undergoing an outpatient screening colonoscopy. The uneventful colonoscopy was performed with air insufflation that demonstrated adequate bowel preparation, did not require patient positional manipulation, or abdominal pressure, and no polypectomies or biopsies were performed. In the emergency department, the patient reported dizziness and her vital signs showed a bloot pressure of 90/40 mmHg, heart rate of 113 beats/minute, and she was saturating 98% on room air. Laboratory values showed a hemoglobin of 11.7 g/dl. (baseline: 13.9 g/dL), serum creatinine 0.75 mg/dL (normat: 0.7-1.3 mg/dL), and normal liver chemistries. A bedside ultrasound revealed some free intra- abdominal fluid and representative images from a computed tomography (CT) scan of her abdomen and pelvis are demonstrated in figures A and B. What is the most likely diagnosis? © Colonic perforation 2 @ Splenic laceration Post-polypectomy syndrome D @ Gas explo: images Click the image above to enlarge it € Previous ENDOSCOPY CATEGORY QUESTION 7 OF 20 Next>Previous ENDOSCOPY CATEGORY QUESTION 8 OF 20 Next > In the patient in the previous question, the CT scan demonstrated a large amount of hemoperitoneum, and active extravasation was demonstrated in the left upper quadrant. The patient received 2 L of normal saline and her blood pressure is now 110/60 mmHg, heart rate is 90 beats/minute. She reports continued left upper quadrant pain but denies any dizziness. What is the best next step in her management? © @® Exploratory laparotomy and splenectomy © GP Exploratory laparotomy with splenectomy and distal pancreatectomy oO Monitoring with no further interventions © @Angiogram with splenic artery embolization * Previous ENDOSCOPY CATEGORY QUESTION 8 OF 20 Next >Previous ENDOSCOPY CATEGORY QUESTION 9 OF 20 Next> A51-year-old man presents with recurrent hematemesis associated with hypotension. His past history is significant for chronic pancreatitis, diabetes mellitus, and hypertension. There is no history of cirrhosis. EG! is performed after resuscitation and shows isolated varices in the gastric fundus (IGV1). No other varices 0 other sources of bleeding are noted. Which of the following can be considered the most optimal therapy for this patient? © @® Variceal banding oO Variceal sclerotherapy S Splenectomy © @® Octreotide © Previous ENDOSCOPY CATEGORY QUESTION 9 OF 20 Next>€ Previous ENDOSCOPY CATEGORY QUESTION 10 OF 20 Next > 72-year-old patient with non-ischemic cardiomyopathy status post-left ventricular assistive device and atrial fibrillation on warfarin, non-sustained ventricular tachycardia on amiodarone, and recently diagnosed monilial esophagitis on fluconazole presents following the sudden onset of large-volume hematochezia. He is feeling dizzy and faint and is resuscitated with fluids. Admission laboratory test results reveal hemoglobir of 6.6 g/dL (decreased from his baseline of 11.1 g/dL), hematocrit of 32.7% (normal: 41-51%), creatinine of 2.3 mg/dL (normal: 0.7-1.3 mg/dL), and an INR of 6.6 (normal: <1.4). What is the optimal approach for managing this patient's supratherapeutic INR in the pre-procedural setting? © @ Large-volume fresh frozen plasma transfusion © @® Aactor prothrombin complex © @® Platelet transfusion © @ Transfusion of 4 units of packed red blood cells € Previous ENDOSCOPY CATEGORY QUESTION 10 OF 20 Next >© Previous ENDOSCOPY CATEGORY QUESTION 11 OF 20 Next > A 62-year-old man presents in consultation for possible resection of a 5-cm T1a colonic malignancy in the right colon, approximately half the circumference of the colonic lumen. He is otherwise in good health. Whe is the best therapeutic option for this patient? oO Endoscopic submucosal dissection (ESD} © @ Right hemicolectomy oO Endoscopic mucosal resection (EMR) © @ Piecemeal snare resection © Previous ENDOSCOPY CATEGORY QUESTION 11 OF 20 Next >© Previous ENDOSCOPY CATEGORY QUESTION 12 OF 20 Next > A66-year-old woman is admitted to the hospital with 6 hours of hematochezia. She has a past medical history notable far diverticular bleeding. She takes regular ibuprofen for arthritis and levothyroxine for hypothyroidism. She is otherwise healthy. On presentation, she is orthostatic and her initial hemoglobin is £ gidL (normal: 12-16 g/dL). Anasogasitric tube lavage reveals yellowish-green liquid. She stabilizes after receiving IV fluids. Four liters of PEG solution are given overnight in preparation for a colonoscopy the nex! day. In the morning, she again begins to have hematachezia but remains stable. An additional 1 liter of PEt solution is given and she undergoes a colonoscopy. A diverticulum with a bleeding visible vessel is found ir the transverse colon. What is the most appropriate approach to this patient's findings? © © Consut interventional radiology for angiography and embolization. © @B Mniect epinephrine around the lesion and no further therapy is needed © @ No endoscopic treatment: monitor with blood transfusion as needed. © @D Apply through-the-scope endoscopic clips directly to the vessel € Previous ENDOSCOPY CATEGORY QUESTION 12 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 13 OF 20 Next > 63-year-old man with atrial fibrillation on apixaban and chronic kidney disease due to longstanding diabetes presents to the emergency department with 3 bouts of hematemesis over the past 6 hours. On presentation, he is hemodynamically stable with blood pressure 145/85, heart rate 92, respiratory rate 20 94% 2 on room air. There are no stigmata of possible chronic liver disease on physical examination. An initial hemoglobin is 8 g/dL (normal: 14-17 g/dL), that is stable when repeated 2 hours later, platelets 250,000/uL (normal: 180,000-380,000/uL), and INF 1.1 (normal: <1.4). Other laboratory results are unremarkable except for a serum creatinine 1.9 mg/dL (normal: 0.7-1.3 mg/dL) and fasting glucose 150 mg/dL (normal: 70-100 mgidL). The patient has 1 more bout of coffee ground hematemesis in the emergency depariment (ED). He has now been in the ED for 2 hours. What is the best next step in the management of this patient? © @DEGCD within 24 hours once stabilized © @BDEGCD within 6 hours once stabilized © © Administer andexanet alfa to reverse apixaban. © © Transfuse to a hemoglobin of 12 g/dL before EGD © Previous ENDOSCOPY CATEGORY QUESTION 13 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 14 OF 20 Next > A66-year-old man with non-valvular atrial fibrillation on rivaroxaban and low-dose aspirin, hypertension, and hyperlipidemia is admitted with congestive heart failure precipitated by 24 hours of melena. After appropriate resuscitation, the patient continues to pass dark, tarry stools and the emergency department doctor calls you to discuss the use of a reversal agent before sending the patient to the Gl endoscopy unit for urgent endoscopy. You suggest measuring the anticoagulant effect of rivaroxaban before using a reversal agent. Your lab does not have a drug-specific toxicity assay for rivaroxaban. Which other serum assay can be used to exclude a toxic level (ie., excessive anticoagulant effect) of rivaroxaban? © @ Prothrombin time (PT) © @Activated partial thromboplastin time (aP TT) © @@® Dilute thrombin time (TT) © @ Ecarin clotting time (ECT) € Previous ENDOSCOPY CATEGORY QUESTION 14 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 15 OF 20 Next You are on call for the weekend and receive a call from the emergency department at 3:00 pm on Friday regarding a 72-year-old man with hematochezia. The patient had several large, maroon stools with clots earlier in the day but none for the past 6 hours. He denies abdominal pain, diarrhea, lightheadedness, or other symptoms. He has a history of hypertension and coronary artery disease. He had a colonoscopy 10 years prior that was normal by report. He takes aspirin and lisinopril. His heart rate on admission was in the low 100s with a blood pressure of 130/85 mmHg. His tachycardia resolved with 1,000 cc of normal saline. His physical exam is unremarkable except for maroon stool in the rectal vault. His baseline hemoglobin is 14 g/dL (normal: 12-18 g/dL}. His hemoglobin on admission is 11 g/dL. His blood urea nitrogen and creatinine are normal. Which of the following should be the next step in his management? © © Perform an urgent colonoscopy without bowel preparation © @B Perform an urgent upper endoscopy. © © Prep overnight in preparation for a colonoscopy the next day. © @B Refer the patient to Interventional Radiology for a possible angiogram € Previous ENDOSCOPY CATEGORY QUESTION 15 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 16 OF 20 Next > AT3-year-old man presents with 2 days of melena. He has complained of a week of epigastric pain following intake of NSAIDs for chronic recurring back pains. He does not have any other gastrointestinal or cardiorespiratory concerns. His only other medication intake is a statin. He is followed for type II diabetes mellitus controlled by diet alone. He reports no other chronic illnesses. On presentation, blood pressure is 130/85mmHg, heart rate is 94/min and regular, respiratory rate 20, 94% 02 on room air. Physical examination yields some tenderness in the epigastrium with no rebound or guarding. A rectal examination yields black-colored stool. Initial laboratory tests are unremarkable, including hemoglobin 15 g/dL (normal 14-17 gidL) repeated twice 4 hours apart, and a normal blood urea nitrogen 8 mg/dL (normal: 8-20 mgidL) You are consulted to assess the patient. Which of the following is the best next step in the management of this patient? © @® Insert nasogastric tube for appropriate risk stratification © @B Discharge home and perform EGD as urgent outpatient. © © Admit patient and ESD now © @ Start high-dose proton pump inhibitor, admit patient, and perform EGD now. © Previous ENDOSCOPY CATEGORY QUESTION 16 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 17 OF 20 Next An 82-year-old man with non-valvular atrial fibrillation is prescribed apixaban for stroke prophylaxis. He wa: switched from warfarin to apixaban after a Gl bleed related to a supratherapeutic INR. His history is significant for pancolonic diverticulosis, asthma, and type 2 diabetes. Shortly after taking his moming dose of anticoagulant, he experienced 3 large-volume, painless rectal bleeds with clots. His wife called EMS anc in the emergency department, he was resuscitated with 2 L of normal saline but continues to be tachycardi- and there is a 12-point drop in systolic blood pressure when going from a supine to standing position. His hemoglobin has dropped from a baseline of 13-4 g/dL (last year) to 8.2 g/dL, INR is normal, and the estimated glomerular filtration rate is modestly impaired at 52 mL/min. Which of his risk factors for anti- coagulant-related Gl bleeding is associated with the greatest risk? © @@ History of Gl bleeding © Gi4ge © @® History of stroke © @ Impaired renal function € Previous ENDOSCOPY CATEGORY QUESTION 17 OF 20 Next >Previous ENDOSCOPY CATEGORY QUESTION 18 OF 20 Next > 81-year-old man is brought to the emergency department by ambulance. He experienced several large volume maroon stools at his assisted living facility over the past day and had a syncopal event. He has a history of hypertension, atrial fibrillation, a cerebral vascular accident and type 2 diabetes. He takes apixaban but his last dose was almost 24 hours ago. On arrival, his heart rate is 115 and his systolic blood pressure is 90. He is pale and diaphoretic. His abdomen is soft and non-tender. The remainder of the exarr is unremarkable. His hemoglobin is 7 g/dL (normal: 14-17 g/dL}; platelets are 200,000/uL (normal: 150,000 350,000/uL); prothrombin time is 12.7 (normal: 11-13); aPTT and INR are normal. His apixaban level is 50 (below trough range). His creatinine is 0.8 mg/dL (normal: 0.7-1.3 mg/dL), his blood urea nitrogen is 18 mg/dL (normal: 8-20 mg/dL), and his creatinine clearance is calculated to be >60. He receives 2 units of packed red blood cells and his blood pressure retums to the normal range, but he remains mildly tachycardic and passes another bloody bowel movement. A CT angiogram is performed and shows an active bleeding site near the hepatic flexure. What is the best next step for this patient? © EP Conventional angiogram with embolization © @B Upper endoscopy © © Surgery, possible hemicolectomy © @D Urgent colonoscopy after giving an apixaban reversal agent € Previous ENDOSCOPY CATEGORY QUESTION 18 OF 20 Next >Previous ENDOSCOPY CATEGORY QUESTION 19 OF 20 Next > ‘You are performing a screening colonoscopy on a 53-year-old woman. A 30-mm nonulcerated polyp (Paris lla, Kudo pit pattern IIIL) is seen in the ascending colon extending across a fold. No depressed areas are seen in the lesion. You are not sure if you will be able to resect this lesion endoscopically. What is the best strategy for managing this lesion? © @ Partially resect the lesion to reduce the size, and schedule full resection at a future date. © @ Refer the patient for right hemicolectomy. oO Refer the patient to an advanced endoscopist (© Tattoo into the lesion for future identification. * Previous ENDOSCOPY CATEGORY QUESTION 19 OF 20 Next >€ Previous ENDOSCOPY CATEGORY QUESTION 20 OF 20 Next 51-year-old woman presents for her first screening colonoscopy. She denies abdominal pain. changes in bowel habit, weight loss, family history of colon cancer, melena, hematochezia, or bright red blood per rectum. Her past medical history is only significant for total abdominal hysterectomy and bilateral salpingo- oophorectomy for endometrial adenocarcinoma 10 years ago. Her physical examination is remarkable for < well-healed surgical scar in the lower abdomen. Her laboratory examination is unremarkable. While performing colonoscopy, you encounter difficulty in passing the scope through the rectosigmoid colon but are able to reach the cecum where a 2-cm sessile polyp is found. After performing saline injection-assisted endoscopic mucosal resection, a 5-mm perforation is noted. What would be your first step in managing this situation? © Call surgery consult © @B Perform endoscopic suturing © © Confirm COzis used and position the patient in a non-water-dependent position © @B Perform over-the-scope clip (OTSC) placement. € Previous ENDOSCOPY CATEGORY QUESTION 20 OF 20 Next >€ Previous ESOPHAGUS CATEGORY QUESTION 4 OF 34 Next > A 33-year-old man presents for the evaluation of dysphagia ongoing for 1 year. His dysphagia began after : serious car accident, in which he suffered multiple cervical vertebral fractures, resulting in chronic pain. He currently describes dysphagia primarily to solids. His only daily medications are pantoprazole and acetaminophen-hydrocodone. He undergoes an EGD with biopsy; pathology shows 4-6 eosinophilsihpt. Because of some resistance to scope passage at the lower esophageal sphincter (LES), a high-resolution esophageal manometry and endoscopic ultrasound are performed. EUS demonstrates no submucosal lesion. A representative swallow of his high-resolution manometry is shown [figure]. Based on the information presented, which of the following is the next appropriate step in management? © @® Cessation of culprit medications and assessment of response © © Empiric trial of botulinum toxin A 100 U into the LES © © Pneumatic dilation © @ Peroral endoscopic myotomy (POEM) © © Through-the-scope (TTS) balloon dilation for presumed esophageal stricture 0 8615) 0 (20S Time ick the image above to entarge it € Previous ESOPHAGUS CATEGORY QUESTION 1 OF 34 Next >¢ Previous ESOPHAGUS CATEGORY QUESTION 2 OF 34 Next > AS-year-old man presents with 1 year of dysphagia and chest pain. He has no significant past medical history and is otherwise healthy. Workup has been negative for a cardiac etiology for his chest pain. Upper endoscopy showed no evidence of esophageal stricture, mass, or esophagitis. The gastroesophageal junction was snug and was traversed with moderate resistance. Barium esophagram findings are shown in the figure. Esophageal manometry was performed next and was consistent with type 3 achalasia with a 14 em spastic segment in the esophagus. What is the best next step in managing this patient? O @BEndoscopi jection of botulinum toxin at the GE junction © @BPeroral endoscopic myotomy (POEM) © © Endoscopic balloon dilation to 20 mm. © @ Surgical Heller myotomy Cliek the image above to enlarge it € Previous ESOPHAGUS CATEGORY QUESTION 2 OF 34 Next >© Previous ESOPHAGUS CATEGORY QUESTION 3 OF 34 Next > A75-year-old man with a history of hypertension presents for a history of chronic dysphagia and regurgitation. His symptoms started with solid food but have now progressed to involve liquids. His only medication is hydrochlorothiazide and pantoprazole. He has been on pantoprazole for several years for suspected gastroesophageal reflux disease. An upper endoscopy shows a mildly tortuous esophagus without any other significant findings. Random esophageal biopsies obtained during endoscopy show normal squamous esaphageal mucosa. Esophageal manometry is depicted in the figure. What is the recommended interval for esophageal squamous cell carcinoma screening for this patient? O GD Every 10 years OB Every 5 years. © © Every 4 year © © Screening is not recommended Click the image above to enlarge it. € Previous ESOPHAGUS CATEGORY QUESTION 3 OF 34 Next >