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 GI/LIVER
SECRETS Plus
FIFTH EDITION
 GI/LIVER
SECRETS Plus
FIFTH EDITION

PETER R. McNALLY, DO, MSRF, MACG

Chief, GI/Hepatology
Evans Army Hospital
Colorado Springs, Colorado
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

GI/LIVER SECRETS PLUS, FIFTH EDITION ISBN: 978-0-323-26033-6

Copyright © 2015 by Saunders, an imprint of Elsevier Inc.

Copyright © 2010, 2006, 2001, 1996 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on how to seek permission, further information
about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for
whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.

Library of Congress Cataloging-in-Publication Data

GI/liver secrets plus / [edited by] Peter R. McNally. – Fifth edition.
p. ; cm. – (Secrets)
Includes bibliographical references and index.
ISBN 978-0-323-26033-6 (pbk.)
I. McNally, Peter R., 1954- , editor. II. Series: Secrets series.
[DNLM: 1. Gastrointestinal Diseases–Examination Questions. 2. Liver Diseases–Examination
Questions. WI 18.2]
RC802
616.30076–dc23
2014027618

Senior Content Strategist: James Merritt

Content Development Specialist: Kelly McGowan
Publishing Services Manager: Hemamalini Rajendrababu
Senior Project Manager: Divya Krishna Kumar
Designer: Steven Stave/Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

The editor dedicates this book to his wife, Cynthia; to his children, Alex, Meghan,
Amanda, Genevieve, and Bridgette; to his grandchildren Charlotte and Xavier;
and to his parents, Jeanette and Rusel.
CONTRIBUTORS

Daphne Antillon, MPH Harikrashna Bhatt, MD

Touro University Nevada Assistant Professor of Medicine
Henderson, Nevada Medicine, Endocrinology
Brown University
Mainor Antillon, MD, MBA, MPH
Providence, Rhode Island
Chairman
Gastroenterology and Hepatology Herbert L. Bonkovsky, MD
Ochsner Clinic Foundation Professor and Senior Advisor for Research
New Orleans, Louisiana Internal Medicine
Fehmi Ates, MD Carolinas Medical Center
Research Fellow Gastroenterology Charlotte, North Carolina;
Hepatology and Nutrition Professor Internal Medicine
Vanderbilt University University of North Carolina
Nashville, Tennessee Chapel Hill and Charlotte, North Carolina;
Professor Internal Medicine
Mary A. Atia, MD University of Connecticut Health Sciences Center
Physician Gastroenterology Farmington, Connecticut
Mayo Clinic Arizona
Scottsdale, Arizona Aaron Brzezinski, MD
Marianne Augustine, MD Gastroenterologist
Fellow Pediatric Gastroenterology Center for Inflammatory Bowel Disease
Hepatology and Nutrition Cleveland Clinic
The Children’s Hospital of Philadelphia Cleveland, Ohio
Philadelphia, Pennsylvania
Carol Ann Burke, MD
Bruce R. Bacon, MD Director, Center for Colon Polyp and Cancer
James F. King MD Prevention
Endowed Chair in Gastroenterology Department of Gastroenterology and Hepatology
Professor of Internal Medicine Cleveland Clinic
Division of Gastroenterology and Hepatology Cleveland, Ohio
Saint Louis University School of Medicine
St. Louis, Missouri Wesley R. Campbell, MD
Fellow in infectious diseases
Ji Young Bang, MD, MPH Walter Reed National Military Medical Center
Fellow in Gastroenterology-Hepatology Bethesda, MD
Indiana University Medical Center
Indianapolis, Indiana Mitchell S. Cappell, MD, PhD
Jamie S. Barkin, MD Chief, Division of Gastroenterology and Hepatology
Professor of Medicine William Beaumont Hospital
University of Miami Royal Oak, Michigan;
Miami, Florida; Professor Medicine
Gastroenterology Oakland University William Beaumont School of
Mt. Sinai Medical Center Medicine
Miami Beach, Florida Royal Oak, Michigan
Devina Bhasin, MD Emily Carey, DO
Transplant Hepatologist Clinical Associate
Piedmont Transplant Institute Gastroenterology and Hepatology
Piedmont Hospital Cleveland Clinic
Atlanta, Georgia Cleveland, Ohio

vii
 viii CONTRIBUTORS

William D. Carey, MD, MACG John C. Deutsch, MD

Professor of Medicine Staff Gastroenterologist
Cleveland Clinic Lerner College of Medicine Medicine
Cleveland, Ohio; Essential Health
Staff Hepatologist Duluth, Minnesota
Cleveland Clinic
Cleveland, Ohio
Ohio Jack A. Di Palma, MD
Professor of Medicine and Director
Joseph G. Cheatham, MD Division of Gastroenterology
Assistant Professor of Medicine University of South Alabama
Uniformed Services University of the Health Sciences Mobile, Alabama
Bethesda, Maryland

Vivian Cheng, MD John E. Eaton, MD

Gastroenterology Division Instructor of Medicine
Beth Israel Deaconess Medical Center Department of Internal Medicine. Division of
Boston, Massachusetts Gastroenterology and Hepatology
Mayo Clinic
Reena V. Chokshi, MD Rochester, Minnesota
Assistant Professor of Medicine
Department of Medicine Shahan Fernando, MD
Division of Gastroenterology and Hepatology Fellow Pediatric Gastroenterology
University of Connecticut Health Center Hepatology and Nutrition
Farmington, Connecticut Digestive Health Institute
Vito V. Cirigliano, DO, CPT(P), MC Children’s Hospital Colorado
Fellow Gastroenterology Aurora, Colorado
Walter Reed National Military Medical Center
Bethesda, Maryland James E. Fitzpatrick, MD
Professor, Department of Dermatology
John O. Clarke, MD University of Colorado Denver
Assistant Professor Medicine Aurora, Colorado
Johns Hopkins University
Baltimore, Maryland
Michael G. Fox, MD
Elizabeth Coss, MD, MSc Associate Professor
Fellow Gastroenterology Radiology and Medical Imaging
University of Texas Southwestern University of Virginia
Dallas, Texas Charlottesville, Virginia
Byron Cryer, MD
Professor of Medicine Joshua Friedman, MD, PhD
Digestive Diseases Assistant Professor, Pediatrics
University of Texas Southwestern Medical School Perelman School of Medicine at the University of
Dallas, Texas Pennsylvania
The Children’s Hospital of Philadelphia
Scott E. Cunningham, MD, CPT(P), MC Philadelphia, Pennsylvania
USA Gastroenterology Fellow National Capital
Consortium
Bethesda, Maryland Glenn T. Furuta, MD
Professor, Pediatrics
Albert J. Czaja, MD University of Colorado School of Medicine
Professor Emeritus of Medicine Aurora, Colorado;
Gastroenterology and Hepatology Digestive Health Institute
Mayo Clinic College of Medicine Children’s Hospital Colorado
Rochester, Minnesota Aurora, Colorado
Amar R. Deshpande, MD
Associate Professor of Medicine Phillip S. Ge, MD
Division of Gastroenterology Fellow in Gastroenterology
Department of Medicine Division of Digestive Diseases David Geffen School
University of Miami Miller School of Medicine of Medicine at UCLA
Miami, Florida Los Angeles, California
 CONTRIBUTORS ix

John S. Goff, MD David P. Jones, DO, FACP, FACG, FASGE

Rocky Mountain Gastroenterology Gastroenterology Consultants of San Antonio,
Lakewood, Colorado Private Practice San Antonio, Texas;
Associate Professor of Medicine
Stevan A. Gonzalez, MD, MS Medicine/Gastroenterology
Attending Physician Hepatology University of Texas Health Sciences Center
Annette C. and Harold C. Simmons San Antonio, Texas
Transplant Institute
Fort Worth, Texas Bonnie Jortberg, PhD, RD, CDE
Geetha Gopalakrishnan, MD Assistant Professor, Family Medicine
Program Director, Clinical Fellowship in Endocrinology University of Colorado School of Medicine
Diabetes and Metabolism Aurora, Colorado
Brown University
Hallett Center for Diabetes and Endocrinology Ryan Kaliney, MD
East Providence, Rhode Island Radiologist
Jefferson Radiology
Carlos Guarner, MD, PhD Hartford, CT
Director, Liver Unit
Hospital de la Santa Creu i Sant Pau Hayoon Kim, MD
Autonomous University of Barcelona Resident
Barcelona, Spain VCU-St. Francis Family Medicine Program
Ramiro L. Gutiérrez, MD, MPH, CDR, MC (UMO), USN Christopher D. Knudsen, DO
Deputy Head Clinical Instructor, Gastroenterology
Enterics Diseases Department University of South Alabama College of Medicine
Naval Medical Research Center Mobile, Alabama
Silver Spring, Maryland;
Assistant Professor of Medicine Cynthia W. Ko, MD, MS
Uniformed Services University of the Health Sciences Associate Professor of Medicine
Bethesda, Maryland University of Washington
Seattle, WA
Christina Hanson, NP-C
South Denver Gastroenterology Georgios Kokosis, MD
Englewood, Colorado Surgical Resident
Stephen A. Harrison, MD Department of Surgery
Chief of Hepatology Duke University Medical Center
Medicine Durham, North Carolina
Division of Gastroenterology
Brooke Army Medical Center Kimi L. Kondo, DO
Fort Sam Houston, Texas Associate Professor
Department of Radiology
Jorge L. Herrera, MD Division of Interventional Radiology
Professor of Medicine University of Colorado Anschutz Medical Campus
Division of Gastroenterology Aurora, Colorado
University of South Alabama College of Medicine
Mobile, Alabama Burton I. Korelitz, MD, MACG
Emeritus Chief
Brenda Hoffman, MD Director Clinical Research
Professor of Medicine Division of Gastroenterology
Division of Gastroenterology and Hepatology Department of Medicine
Medical University of South Carolina Lenox Hill Hospital
Charleston, SC New York, New York
Henry A. Horton, MD
Staff Physician Marcelo Kugelmas, MD
Department of Internal Medicine Gastroenterologist and Hepatologist
Cedars-Sinai Medical Center South Denver Gastroenterology
Los Angeles, CA Englewood, Colorado

John D. Horwhat, MD Clark Kulig, MD

Assistant Professor of Medicine Director, Porter Center for Liver Care
Uniformed Services Transplant Service
University of the Health Sciences Porter Adventist Hospital
Bethesda, MD Denver, Colorado
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 x CONTRIBUTORS

Ryan M. Kwok, MD Anthony Lembo, MD

Gastroenterology Fellow Director of GI Motility Center
Department of Medicine Beth Israel Deaconess Medical Center
Gastroenterology Boston, Massachusetts;
Walter Reed National Military Medical Center Associate Professor
Bethesda, Maryland; Medicine Harvard Medical School
Teaching Fellow, Internal Medicine Boston, Massachusetts
Uniformed Service University of the Health Sciences
Bethesda, Maryland Carole Macaron, MD
Cleveland Clinic
Anthony J. LaPorta, MD, FACS Gastroenterology and Hepatology
Clinical Professor of Surgery Digestive Disease Institute
University of Colorado Health Sciences Center Cleveland, Ohio
Aurora, Colorado
Catherine S. Manolakis, MD
Nicholas F. LaRusso, MD Fellow Gastroenterology
Medical Director, Center for Connected Care University of South Alabama College of Medicine
Mayo Clinic Mobile, Alabama
Rochester, Minnesota;
Charles H. Weinman Professor of Medicine Richard W. McCallum, MD, FACP, FRACP (Aust), FACG
Biochemistry and Molecular Biology Professor and Founding Chair of Medicine
Mayo Clinic College of Medicine Department of Internal Medicine
Rochester, Minnesota; Director
Distinguished Investigator Center for Neurogastroenterology and GI Motility
Mayo Foundation Texas Tech University Health Sciences Center
Rochester, Minnesota Paul L. Foster School of Medicine
Bret A. Lashner, MD El Paso, Texas
Professor of Medicine
Gastroenterology and Hepatology Martin D. McCarter, MD
Cleveland Clinic Professor GI, Tumor, and Endocrine Surgery
Cleveland, Ohio University of Colorado School of Medicine
Aurora, Colorado
Sum P. Lee, MD, PhD
Professor & Dean of Medicine Peter R. McNally, DO, MSRF, MACG
Li Ka Shing Faculty of Medicine Chief, Gastroenterology/Hepatology
University of Hong Kong Evans Army Hospital
Professor Emeritus Colorado Springs, Colorado;
Division of Gastroenterology Center for Human Simulation
University of Washington University of Colorado School of Medicine
School of Medicine Aurora, Colorado
Seattle, Washington
Gil Y. Melmed, MD, MS
Linda S. Lee, MD Director, Clinical Inflammatory Bowel Disease
Assistant Professor of Medicine Department of Medicine
Harvard Medical School Cedars-Sinai Medical Center
Director, Endoscopic Education, Women’s Health in Los Angeles, California
GI, IMPACT (Interdisciplinary Management of
Pancreatic Cystic Tumors) Fouad Joseph Moawad, MD, FACG
Clinic Brigham and Women’s Hospital Director of Motility and Reflux Testing Lab
Boston, Massachusetts Walter Reed National Military Medical Center
Bethesda, Maryland
Daniel A. Leffler, MD, MS
Director of Clinical Research Enrique Molina, MD
Celiac Center Gastroenterologist and Hepatologist
Beth Israel Deaconess Medical Center Gastroenterology Consultants
Boston, Massachusetts; Memorial Healthcare System
Director of Quality Assurance Hollywood, Florida
Gastroenterology
Beth Israel Deaconess Medical Center Klaus E. Mönkemüller, MD, PhD
Boston, Massachusetts; Director Hirschowitz Endoscopy Center
Associate Professor Division of Gastroenterology & Hepatology
Medicine Harvard Medical School Professor of Medicine, University of Alabama
Boston, Massachusetts Birmingham, Alabama
 CONTRIBUTORS xi

Francis C. Okeke, MD, MPH University of South Florida

Postdoctoral Clinical Fellow Tampa, Florida;
Gastroenterology (Neurogastroenterology) Director Joy McCann Culverhouse Center for
Johns Hopkins University Swallowing Disorders
Baltimore, Maryland University of South Florida
Tampa, Florida
Kiyoko Oshima, MD
Associate Professor Mark S. Riddle, MD, MPH&TM, DrPH
Pathology Enteric Diseases Department
Medical College of Wisconsin Naval Medical Research Center
Milwaukee, Wisconsin Silver Spring, Maryland
Theodore N. Pappas, MD Jason R. Roberts, MD
Professor of Surgery Assistant Professor, Gastroenterology
Chief, Division of General & Advanced GI Surgery Hepatology and Nutrition
Duke University Medical Center University of Louisville School of Medicine
Durham, North Carolina Louisville, Kentucky
Angelo H. Paredes, MD
Arvey I. Rogers, MD, FACP, MACG
Gastroenterology, Internal Medicine
Professor Emeritus, Internal Medicine
Walter Reed Army Medical Center
Gastroenterology
Bethesda, Maryland
Miller School of Medicine
Gail Pearson, FNP-C University of Miami
Nurse Practitioner Miami, Florida
South Denver Gastroenterology USA
Englewood, Colorado Suzanne Rose, MD, MSEd
Shajan Peter, MD Senior Associate Dean for Education
Associate Professor of Medicine Professor of Medicine
Division of Gastroenterology-Hepatology University of Connecticut School of Medicine
University of Alabama School of Medicine Farmington, Connecticut
Birmingham, Alabama
Kevin Rothchild, MD
Lori D. Prok, MD Assistant Professor
Assistant Professor GI, Tumor, and Endocrine Surgery
Pediatric Dermatology and Dermatopathology University of Colorado Hospital
University of Colorado Denver Aurora, Colorado
Aurora, Colorado
Bruce A. Runyon, MD
Siobhan Proksell, BS, MD Director of Hepatology
Resident, Internal Medicine Santa Monica-UCLA Medical Center
Post Graduate Year 3 Clinical Professor of Medicine
University of Pittsburgh Medical Center Division of Digestive Diseases David Geffen School of
Pittsburgh, Pennsylvania Medicine at UCLA
Ramona O. Rajapakse, MD, FRCP(UK) Los Angeles, California
Associate Professor of Clinical Medicine
Medicine Paul D. Russ, MD
Division of Gastroenterology Professor Radiology
Stony Brook University Hospital University of Colorado School of Medicine
Stony Brook, New York Aurora, CO

Francisco C. Ramirez, MD Mark W. Russo, MD, MPH, FACG

Professor of Medicine Medical Director of Liver Transplantation
Gastroenterology Hepatology
Mayo Clinic Carolinas Medical Center
Scottsdale, Arizona Charlotte, North Carolina

Michael Reiter, DO Travis J. Rutland, MD

Associate Professor of Clinical Radiology Digestive Health Specialists
Stony Brook University Hospital Dothan, Alabama
Stony Brook, New York
Davinder Sandhu, MBBCh, FRCP
Joel E. Richter, MD, FACP, MACG Fellow Division of Gastroenterology
Professor and Director University of Washington
Division of Digestive Diseases and Nutrition Seattle, WA
 xii CONTRIBUTORS

Lawrence R. Schiller, MD Christina M. Surawicz, MD

Attending Physician Professor Medicine
Digestive Health Associates of Texas Division of Gastroenterology
Baylor University Medical Center University of Washington
Dallas, Texas Seattle, Washington
Jonathan A. Schoen, MD Jayant A. Talwalkar, MD, MPH
Assistant Professor of Surgery Professor of Medicine
GI, Tumor, and Endocrine Surgery Gastroenterology/Hepatology
University of Colorado Hospital Mayo Clinic
Aurora, CO Rochester, Minnesota
Raj J. Shah, MD, FASGE, AGAF Shalini Tayal, MD
Associate Professor of Medicine Associate Professor
Gastroenterology Department of Pathology
University of Colorado School of Medicine Denver Health Medical Center
Aurora, Colorado; Denver, Colorado
Director Pancreaticobiliary Endoscopy and Medical University of Colorado School of Medicine
Co-Director Digestive Health Center Aurora, Colorado
Gastroenterology
University of Colorado Anschutz Medical Campus John J. Tiedeken, MD
Aurora, Colorado General Surgeon
Roshan Shrestha, MD Tiedeken General Surgery
Chairman, Department of Transplantation Sacramento, California
Medical Director of Liver Transplantation Dawn M. Torres, MD
Piedmont Transplant Institute, Atlanta, GA Chief Hepatology, Walter Reed National Military
Clinical Professor of Medicine Medical Center
Mercer University School of Medicine Bethesda, Maryland
Savannah, Georgia
George Triadafilopoulos, MD, DSc
Won S. Song, MD
Clinical Professor of Medicine
Chief, Nuclear Medicine Service
Division of Gastroenterology and Hepatology
Department of Radiology
Stanford University School of Medicine
Womack Army Medical Center
Stanford, California
Fort Bragg, North Carolina
Luca Stocchi, MD James F. Trotter, MD
Staff Surgeon Medical Director of Transplant
The Story-Garschina Chair in Colorectal Hepatology
Surgery Baylor University Medical Center
Colorectal Surgery Dallas, Texas
Digestive Disease Institute Michael F. Vaezi, MD, PhD, MS
Cleveland Clinic Professor of Medicine
Cleveland, Ohio Clinical Director
Lisa Strate, MD, MPH Division of Gastroenterology and Hepatology
Associate Professor of Medicine Vanderbilt UniversityMedical Center
Department of Medicine Director, Center for Swallowing and Esophageal
Division of Gastroenterology Disorders
University of Washington School of Medicine Director, Clinical Research
Seattle, Washington Vanderbilt University Medical Center
Nashville, Tennessee
Joseph K. Sunny, Jr., MD
Senior Fellow Nimish B. Vakil, MD, FACP, FACG, AGAF, FASGE
Division of Gastroenterology, Hepatology and Nutrition, Clinical Professor of Medicine
Texas Tech University Health Sciences Center University of Wisconsin School of Medicine
Paul L. Foster School of Medicine and Public Health
El Paso, Texas Madison, Wisconsin
 CONTRIBUTORS xiii

Rohini R. Vanga, MBBS, MD Division of Rheumatology

Fellow Gastroenterology University of Colorado School of Medicine
Baylor College of Medicine Aurora, Colorado
Houston, Texas
Shyam Varadarajulu, MD C. Mel Wilcox, MD, MSPH
Medical Director, Center for Interventional Endoscopy Professor of Medicine
Florida Hospital Orlando, Florida; Division of Gastroenterology and Hepatology
Professor of Medicine University of Alabama at Birmingham
University of Central Florida College of Medicine Birmingham, Alabama
Orlando, Florida
Stephen M. Vindigni, MD, MPH Cemal Yazici, MD
Fellow of Gastroenterology Fellow in Gastroenterology and Hepatology
University of Washington School of Medicine Division of GI-Hepatology
Seattle, Washington Department of Medicine
University of Illinois at Chicago
Jill M. Watanabe, MD, MPH Chicago, Illinois
Associate Professor of Medicine
Division on General Internal Medicine
University of Washington School of Medicine; Patrick E. Young, MD
Harborview Medical Center Fellowship Program Director Gastroenterology
Seattle, Washington Walter Reed National Military Medical Center
Bethesda, Maryland;
Sterling G. West, MD, MACP, FACR Associate Professor Medicine
Professor of Medicine Uniformed Services University of Health Sciences
Department of Medicine Bethesda, Maryland
PREFACE

To practice the art of medicine, one must learn the secrets of pathophysiology, diagnosis and therapy. In this text, you
will find the answers to many questions about the hepatic and digestive diseases. We hope that medical students,
residents, fellows, and, yes, even attending physicians will find the fifth edition of GI/Liver Secrets Plus instructive and
insightful.
As editor, I wish to thank James Merritt, Kelly McGowan and the staff at Elsevier for their wonderful support of
this project and their courage and determination to make this book available on the web. I am most appreciative of all
my contributing authors who have shared their invaluable secrets and made this book an enjoyable, as well as an
educational, experience.

Peter R. McNally, DO, MSRF, MACG

xv
TOP 100 SECRETS
Peter R. McNally, DO, MSRF, MACG

1. Runyon criteria for diagnosis of secondary bacterial peritonitis (based on presence of two the following
three ascitic fluid criteria):
• Total protein more than 1 g/dL
• Glucose less than 50 mg/dL
• Lactate dehydrogenase (LDH) more than 225 mU/mL (or > upper limit of normal [ULN] for serum)
It is important to differentiate spontaneous bacterial peritonitis (SBP) from secondary bacterial peritonitis in
cirrhotic patients, because treatment for SBP is medical, whereas treatment for secondary bacterial
peritonitis is usually surgical. Patients with Runyon criteria for secondary bacterial peritonitis must be
evaluated promptly by abdominal computed tomography imaging and early surgical consultation.
2. In Central and South America, Chagas disease is a multisystem infectious disease caused by the protozoan
Trypanosoma cruzi and transmitted by bites from the Reduvid (kissing) bug. Ganglion cells are destroyed
throughout the body, resulting in megaesophagus, duodenum, colon, and rectum. Esophageal Chagas
disease is identical to idiopathic achalasia.
3. ALL individuals born in between 1945 and 1965 should have a once in a lifetime test for hepatitis C virus
(HCV) exposure, regardless of risk factors (HCV Cohort Screening).
4. Suspected variceal bleeding requires additional preendoscopic medical therapy with antibiotics and
octreotide.
5. Eighty-five percent of cases of lower gastrointestinal bleeding are self-limited and uncomplicated, and
urgent colonoscopy versus elective colonoscopy has not been proven to change clinical or cost outcomes.
6. Dysphagia is common after a stroke (at least 25% of patients) and is a risk factor for pneumonia and
aspiration. In most stroke patients dysphagia will improve and percutaneous gastrostomy should be
avoided for at least the first 2 weeks.
7. Aspiration of amebic abscess should be considered under the following circumstances:
• When pyogenic abscess or secondary infection of an amebic abscess cannot be excluded
• When the patient does not respond to 5 to 7 days of adequate therapy
• When the abscess is very large, usually greater than 5 cm, or in the left lobe, which are risk factors for
rupture and causes severe pain
8. The combination of ulcerative colitis (UC) and primary sclerosing cholangitis (PSC) is more often associated
with pancolitis, less endoscopic activity, backwash ileitis, rectal sparing, an increased risk of pouchitis,
peristomal varices after proctocolectomy with ileostomy, and colon cancer when compared with chronic
UC not associated with PSC.
9. Symptoms of esophageal obstructive dysphagia have been shown to correlate with luminal diameter
smaller than 13 mm, and symptoms are unlikely at luminal diameter larger than 20 mm.
10. Vertical transmission of HCV occurs in 2% to 10% for infants born of HCV-RNA positive mothers. The risk
for vertical transmission increases dramatically with mothers coinfected with HCV and human
immunodeficiency virus and those with HCV RNA of more than 1 million copies. There is no evidence
that HCV is transmitted in breast milk.
11. Scleroderma is associated with esophageal motility disorders in greater than 90% of patients.
12. Colonoscopy colon cancer screening recommendations, by risk group:
Patients with average risk and asymptomatic screening:
• All men and women 50 years or older
• Exception: African Americans 45 years or older
• Repeat colonoscopy every 10 years, after a negative examination
For patients found to have multiple or large polyps:
• Colonoscopy at the time of initial polyp diagnosis.
• If 1 to 2 small adenomatous polyps with low grade abnormality, repeat in 5 to 10 years.

1
2 TOP 100 SECRETS

• If 3 to 10 adenomatous polyps or 1 adenomatous polyp greater than 1 cm, repeat colonoscopy within
3 years after polyp removal.
• With certain types of polyps or with high-grade abnormality, repeat colonoscopy within 3 years. If normal,
repeat again in 5 years.
• If more than 10 adenomatous polyps, repeat in less than 3 years.
• If polyps are permanently attached and not on a stem and are removed in portions, repeat colonoscopy
in 2 to 6 months to verify complete polyp removal.
Patients with prior surgery for colorectal cancer:
• Colonoscopy within 1 year after surgery; if normal, repeat in 3 years; if still normal, repeat in 5 years.
Persons with family history of colon cancer:
• Colonoscopy at age 40 or 10 years before the age that the index family member was diagnosed with
cancer or colon adenomatous polyps, whichever is earlier; if normal, repeat every 5 years.
Persons with a family history of familial adenomatous polyposis:
• At age 10 to 12, annual flexible sigmoidoscopy.
• If positive genetic test, colon removal should be considered because of very high risk of colorectal
cancer.
People with a family history of hereditary nonpolyposis colon cancer (Lynch syndrome):
• Colonoscopy every 1 to 2 years, starting at age 20 to 25 or 10 years before age that immediate family
member had cancer, whichever is earlier.
• Genetic testing should be offered to first-degree family members.
Persons with inflammatory bowel disease (IBD):
• Colonoscopy every 1 to 2 years, starting 8 years after the start of pancolitis (involvement or the entire
colon) or 12 to 15 years after the start of left-sided colitis.
13. Antimitochondrial antibodies (AMA) are highly specific (95%-98%) for primary biliary cirrhosis (PBC). When
clinical suspicion for PBC is high and AMA is negative, a liver biopsy should be performed to establish
the diagnosis of AMA (–) PBC.
14. Autoimmune pancreatitis is associated with other autoimmune disorders such as autoimmune hepatitis,
PSC, PBC, Sjögren’s syndrome, and scleroderma. It is characterized by the presence of autoantibodies,
increased serum immunoglobulin (Ig) levels, elevated Ig4 levels in the serum (usually above 140 mg/dL), and
a response to administration of corticosteroids. There is a recurrence rate of approximately 41% upon
discontinuation of steroids.
15. Acetaminophen hepatotoxicity is the most common cause of acute liver failure in the United States. Risk
factors for poor prognosis associated with acetaminophen hepatotoxicity include pH of less than 7.3 or
international normalized ratio of more than 6.5, creatinine of more than 3.4, and grade 3 or higher
encephalopathy. The N-acetylcysteine antidote should be given in all cases of potential acetaminophen
overdose.
16. Vedolizumab is a highly selective monoclonal antibody targeting the α 4β 7 integrin receptor found on the
surface of T-cell honing to the lymphoid tissues of the gastrointestinal tract. It has been shown to be
effective in inducing response and remission of ulcerative colitis.
17. A combined esophageal pH/impedance catheter performed off proton pump inhibitors can help distinguish
acid reflux from non–acid reflux and esophageal hypersensitivity from functional heartburn.
18. The diagnosis of achalasia should be entertained in young women with suspected eating disorders and
patients with intractable gastroesophageal reflux disease (GERD) symptoms and a stricture not responding
to dilation.
19. Metastatic carcinoma to the esophagus is unusual, but melanoma and breast cancer are the most
common.
20. Liver transplantation will definitively cure an underlying hypercoagulable state caused by protein C, protein
S, or antithrombin deficiency. Patients with other underlying hypercoagulable states require long-term
anticoagulation.
21. Endoscopic ultrasound (EUS) fine-needle aspiration should not be performed with suspected
pheochromocytomas because of the risk of hypertensive crisis, and possible hepatic carcinoid metastases
should not be sampled, because of the risk of profound hypotension.
22. Avoid antibiotics when Escherichia coli such as O157:H7 infection is suspected because of the risk of
hemolytic uremic syndrome.
23. The diagnosis of insulinoma is suggested by the presence of Whipple’s triad (i.e., symptoms of
hypoglycemia, blood sugar levels of less than 70 mg/dL, and resolution of symptoms with food).
 TOP 100 SECRETS 3

24. The risk of cancer in Barrett’s esophagus is 0.5% per year, which means that approximately 1 in 200
patients with Barrett’s esophagus will develop esophageal cancer each year.
25. The central scar in focal nodular hyperplasia is hyperintense on T2-weighted (T2-w) images, but in
fibrolamellar hepatocellular carcinoma (HCC), it is hypointense on T2-w images.
26. Magnetic resonance imaging is accurate in differentiating HCC from dysplastic nodules, with HCC usually
having increased T2-w signal and dysplastic nodules having decreased T2-w signal.
27. Hallmarks of ischemic hepatitis (shock liver) include marked elevations in aspartate transferase (AST),
alanine aminotransferase (ALT) (10 times the ULN), bilirubin, prothrombin time (PT), and LDH levels after an
episode of systemic hypotension or decreased cardiac output.
28. A patient presenting with chest pain and crepitus after an episode of persistent vomiting and retching
should prompt a diagnosis of Boerhaave’s syndrome.
29. Evaluate for HCC in cirrhotic patients with a new diagnosis of portal vein thrombosis.
30. The two most common causes of acute cholestatic hepatitis are hepatitis A and drug-induced liver injury.
31. Plummer-Vinson syndrome is a triad of an esophageal web, iron deficiency anemia, and glossitis.
32. The most important studies to order on ascitic fluid are cell count and differential, gram stain and bacterial
culture, albumin, total protein, and cytologic examination (only when peritoneal carcinomatosis is
suspected).
33. Combination therapy with Ledipasvir and Sofosbuvir has been shown to be extremely effective in the
treatment of chronic hepatitis C. Sustained virologic response rates of 99% have been reported after
12 weeks of treatment with this combination of NS5A and NS5B inhibitors.
34. EUS fine needle aspiration should not be performed with suspected pheochromocytomas because of
the risk of hypertensive crisis, and possible hepatic carcinoid metastases should not be sampled because
of the risk of profound hypotension.
35. Patients with cirrhosis who consumed raw oysters were 80 times more likely to develop Vibrio vulnificus
infection and 200 times more likely to die of the infection.
36. Women with IBD have higher rates of cervical dysplasia and cancer-causing human papillomavirus (HPV)
serotypes, particularly if on immunosuppression for longer than 6 months. The HPV vaccine is
recommended for women and men ages 9 to 26 years.
37. In patients with acute severe (fulminant) autoimmune hepatitis, treat with prednisolone alone because
prednisone is a prodrug and azathioprine has a slow onset of action.
38. Acute onset diarrhea during hospitalization is most likely due to Clostridium difficle.
39. Patients should be considered for liver transplantation if they have a Model of End-Stage Liver Disease
score of 15 or more, or life-threatening complications such as ascites, encephalopathy, portal hypertensive
bleeding, jaundice, weight loss, or HCC.
40. Frontline therapy with budesonide in combination with azathioprine has the strongest rationale in
asymptomatic, noncirrhotic patients with mild autoimmune hepatitis disease and no concurrent immune
diseases or in older adults with osteopenia.
41. Endoscopy is the most valuable procedure for evaluation of upper and lower gastrointestinal symptoms in
patients with acquired immune deficiency syndrome.
42. The serum-ascites albumin gradient (SAAG) is calculated by:

SAAG ¼ albuminserum  albuminascites

The SAAG is a useful tool in the classification of ascites. Patients with gradients of 1.1 g/dL or more
have portal hypertension, whereas patients with gradients less than 1.1 g/dL do not have portal
hypertension.
43. A leiomyoma is benign proliferation of spindled smooth muscle cells that strongly react with smooth muscle
actin (SMA) and desmin, but are negative for CD117. A gastrointestinal stromal tumor (GIST) is composed
of a proliferation of spindle cells that react strongly with CD117 and CD34. Malignant potential for GIST
depends on the extent of mitotic activity, necrosis, and cytological atypia.
44. The treatment of vasculitis caused by hepatitis B or C infection must include antiviral therapy to eliminate the
antigenemia.
4 TOP 100 SECRETS

45. The most common causes of acute liver failure in the United States are acetaminophen (46%),
indeterminate (14%), drug-induced (11%), hepatitis B (6%), autoimmune hepatitis (6%), ischemia (4%),
hepatitis A (3%), and other (9%).
46. All patients with an inflammatory small joint arthritis, positive rheumatoid factor, and elevated liver-
associated transaminase levels should have chronic hepatitis C infection ruled out before receiving the
diagnosis of rheumatoid arthritis.
47. Helicobacter pylori infection is believed to be acquired during childhood and is associated with low
socioeconomic status. The presence of the H. pylori cagA gene is associated with more severe
gastroduodenal disease (i.e., ulcers).
48. Type I hepatorenal syndrome is characterized by a rapid and progressive reduction of renal function,
defined by a doubling of the initial serum creatinine to a level greater than 2.5 mg/dL or a 50% reduction in
the initial 24-hour creatinine clearance to a level less than 20 mL/min in less than 2 weeks. Clinical
presentation is acute renal failure.
49. Elevated gastrin level and a gastric carcinoid suggest that achlorhydria is likely. Check a vitamin B12 level.
50. The ascitic fluid neutrophil count is the single most important test for detecting bacterial infection of
peritoneal fluid. An absolute neutrophil count of 250 cells/mm3 or more warrants empiric antibiotic
treatment with cefotaxime.
51. Refractory celiac disease (RCD) is defined by persistent or recurrent malabsorptive symptoms and signs
with villous atrophy despite a strict gluten-free diet for more than 12 months. RCD is uncommon, affecting
1% to 2% of patients with celiac disease (CD). Type I RCD is identified by polyclonal intraepithelial
lymphocyte infiltration in the small intestinal mucosa similar to that seen in untreated CD. Type II RCD is
recognized by monoclonal aberrant CD3 positive T lymphocytes that lack expression of CD8. Traditional
treatment for both type I and II RCD, consists of systemic corticosteroids, budesonide or azathioprine. Type
II RCD carries a less favorable prognosis because of the risk for malignant transformation to enteropathy-
associated T-cell lymphoma.
52. Essential mixed cryoglobulinemia is due to chronic hepatitis C infection in more than 90% of patients.
53. All patients with a systemic medium or small vessel vasculitis should be evaluated for chronic hepatitis B
and C infection.
54. Antibiotic therapy for H. pylori can cure a large proportion of patients with MALT lymphoma, even in the
absence of documented Helicobacter infection.
55. JAK2 mutations are strongly implicated in the pathogenesis of myeloproliferative disorders and
hypercoagulability. Anywhere from 30% to 50% of patients with Budd Chiari syndrome exhibit JAK2
mutation.
56. Botox therapy for achalasia can provide clinical improvement within 1 month in more than 80% of patients,
but less than 60% are in remission at 1 year.
57. Hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccines are strongly recommended in patients with
cirrhosis as concomitant infection dramatically increases morbidity and mortality.
58. Key predictors of the malignant potential for GISTs are size larger than 3 cm and more than 10 mitotic
figures per high powered field.
59. Herpes simplex hepatitis can be fulminant during pregnancy and associated with high mortality rates.
Patients present in the third trimester with fever, systemic symptoms, and possibly vesicular cutaneous
rash. Associated pneumonitis or encephalitis may be present. Liver biopsy is characteristic, showing
necrosis and inclusion bodies in viable hepatocytes, along with few or no inflammatory infiltrates. Response
to acyclovir therapy is prompt; there is no need for immediate delivery of the baby.
60. Sixty percent of patients with gastroparesis have concomitant small intestinal bacterial overgrowth (SIBO)
based on breath testing data. Some symptoms of postprandial bloating in gastroparesis may be explained
by SIBO and responsive to therapy with antibiotics, probiotics, and promotility agents.
61. Gilbert’s syndrome is common benign disorder seen in the United States ( 5% white population). It is
characterized by elevations of unconjugated bilirubin (2-7 mg/dL), which is often more pronounced after
fasting or illness. There is no increased risk for liver disease with Gilbert’s Syndrome.
62. Chronic pancreatitis may lead to splenic vein thrombosis in approximately 12% of patients.
63. Kayser-Fleischer (KF) rings are virtually always present when there are neurologic features of Wilson
disease. Demonstration of KF rings often requires a slit lamp examination. The absence of KF rings
does not exclude Wilsonian liver disease and KF rings have rarely been reported in other conditions (e.g., PBC).
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