Select the ONE answer that is BEST in each case.
A 29-year-old woman complains of dysphagia with both solids and liquids, worse when she is eating quickly or is anxious. Manometry reveals normal basal esophageal sphincter pressure, with no relaxation of the sphincter on swallowing. Which of the following is the most appropriate next step in management?
These findings are characteristic of achalasia. Anticholinergic medications and dietary changes do not provide much help. Successful therapies include nitroglycerine, nifedipine (a calcium channel blocker), botulinum toxin injected endoscopically, balloon dilatation, and esophageal myotomy (not excision).
A 34-year-old woman complains bitterly of heartburn. Physical examination reveals healing lesions of the fingertips that she says were small ulcers, and there are small areas of telangiectasias on her face. Esophageal manometry reveals a decrease in the expected amplitude of smooth muscle contraction. Lower esophageal sphincter tone is subnormal, but relaxes normally with swallowing. Which of the following statements regarding this condition is most likely correct?
These findings are characteristic of scleroderma. If the disease is limited, the prognosis is not necessarily poor. The limited form is characterized by calcinosis, Raynaud’s (often with distal ulceration), esophageal motility disorder, sclerodactyly, and telangiectasia. It has a female preponderance. Renal disease can be severe, but is not the most common cause of death. Esophageal symptoms should be treated aggressively.
A 59-year-old man presents with abdominal pain, anorexia, and nausea. He has lost weight and started to develop pedal edema. Endoscopy reveals large gastric mucosal folds. Which of the following explanations for the edema is most likely correct?
The clinical description suggests Ménétrier’s disease; however, biopsy is essential to rule out lymphoma or carcinoma. The edema is usually secondary to protein-losing enteropathy. Treatment consists of a high protein diet, anticholinergic therapy, and H2-blockers. In some cases, gastrectomy is required.
A 35-year-old White man has a long past history of diarrhea, rectal bleeding, crampy abdominal pain, and the passage of mucus. He now presents with a worsening of his symptoms despite taking his medications. A barium enema is performed and is shown in Fig. Which of the following is the most likely diagnosis of this new complication?
The carcinoma has occurred in a patient with ulcerative colitis. The barium enema shows a long, constricting lesion in the transverse colon, with the whole colon devoid of haustral markings. Some pressure effects are seen in the ileum due to metastases. The diagnosis of ulcerative colitis is made from the clinical symptoms and proctosigmoidoscopic examination of an abnormally inflamed colonic mucosa.
A 45-year-old man with a long history of alcohol intake comes into the emergency room with upper gastrointestinal (UGI) bleeding. Urgent endoscopy reveals the following findings. Which of the following is the most likely diagnosis?
In esophageal varices, the esophageal folds are thick and tortuous, giving rise to a wormy or worm-eaten appearance. The radiographic picture would vary with the severity of the varices, as well as the distention of the esophagus. When varices are severe, they should be appreciated in any projection. The left anterior oblique projection is most ideal for its demonstration.
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A 33-year-old woman develops mild epigastric abdominal pain with nausea and vomiting of 2 days duration. Her abdomen is tender on palpation in the epigastric region, and the remaining examination is normal. Her white count is 13,000/mL, and amylase is 300 U/L (25–125 U/L). Which of the following is the most common predisposing factor for this disorder?
The common causes of acute pancreatitis are alcohol, gallstones, metabolic factors, and drugs. Gallstones still remain the most common cause of pancreat
A 40-year-old taxicab driver presents with worsening epigastric pain. Which of the following is the most likely diagnosis?
In benign gastric ulcer, an ulcer niche is present in the prepyloric area, with folds radiating to and extending up to the margin of the niche with a halo around it. The differentiation between benignity and malignancy may be difficult at times, but proper use of radiographic criteria could boost the accuracy to 98%. In the presence of an ulcer niche, a Hampton line, which is an ulcer collar, or a mound should be sought on a profile view. Endoscopy with biopsy is the gold standard of diagnosis.
A 54-year-old man complains of burning epigastric pain that usually improves after a meal, and is occasionally relieved with antacids. On examination, he appears well and besides some epigastric tenderness on palpation, the rest of the examination is normal. Upper endoscopy confirms a duodenal ulcer. Which of the following statements concerning PUD is most likely correct?
Helicobacter pyloriinfection is the cause of most peptic ulcers, and the usual route of infection is via the water supply. Duodenal ulcer is clinically more common, although the prevalence on autopsy series is similar. Duodenal ulcer does not represent a malignant potential. Gastric ulcers are seen in an older population and can be malignant. Benign peptic gastric ulcers tend to be more distal.
A 30-year-old man complains of chronic diarrhea for the past 6 months. There is no weight loss, fever, or abdominal pain. He takes no medications and feels fine. His physical examination is completely normal. Further history reveals that this man does not take laxatives; however, in an effort to stay slim he eats a lot of sugar-free gum and sugarless candy. Which of the following explanations is the most likely cause of his diarrhea?
Sugarless gums and candy often contain sorbitol, a sugar that is not absorbed in the gut. It thus produces an osmotic diarrhea if present in sufficient quantity.
Which of the following is a risk factor for Helicobacter pyloriinfection?
Infection usually occurs early in life and is related to classic socioeconomic indicators such as poverty, domestic crowding, unsanitary living conditions, and unclean water. It is much more common in developing countries.
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Which of the following is an established risk factor for nonsteroidal anti-inflammatory disease (NSAID)-induced gastric or duodenal ulceration?
Concomitant steroid use increases the likelihood of ulceration, as does advanced age H. pyloriinfection, smoking, and alcohol use are suspected, but not yet established, risk factors.
A 73-year-old woman presents to the emergency room with black tarry stools and symptoms of presyncope when standing up. Digital rectal examination confirms the presence of melena. She recently started using ibuprofen for hip discomfort. Upper endoscopy confirms the diagnosis of a gastric ulcer. Which of the following is the most likely explanation for the gastric ulcer?
NSAIDs inhibit prostaglandins, which play an important role in maintaining gastroduodenal mucosal integrity and repair.
A 52-year-old woman is experiencing abdominal discomfort after meals as well as early in the morning. There is no weight loss or constitutional symptoms, and she has tried antacids but experienced minimal relief. Upper endoscopy reveals a duodenal ulcer and the biopsy is negative for malignancy. Which of the following is the most appropriate next step in management?
Eradication of H. pyloriis the most effective treatment for duodenal ulcer disease. The most popular regimes include antibiotics and acid suppression medications.
A 34-year-old man is seen for asymptomatic elevations in his AST and ALT. He appears well and the physical examination is normal. There is no prior history of intravenous drug use, blood transfusions, or multiple sex partners. His hepatitis serology is positive for the virus, most likely to lead to chronic infection.
Chronic hepatitis C infection occurs in 80–90% of patients. About 50–70% will have evidence of chronic liver disease. In contrast, only 1–10% of adults infected with hepatitis B will go on to chronic infection.
A 24-year-old woman is pregnant with her first baby at 14 weeks. She feels well and the pregnancy is noncomplicated. Routine screening is positive for chronic viral hepatitis for which perinatal transmission is of major epidemiologic significance.
In neonates, the transmission of hepatitis B results in a 90% probability of developing chronic infection. The ongoing infection (often resulting in hepatoma) is a major cause of morbidity and mortality in many parts of the world.
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A 28-year-old man, who emigrated from North Africa, is evaluated for chronic elevations in liver enzymes (AST and ALT). He has no symptoms of acute hepatitis, and his physical examination is normal with no characteristics of chronic liver disease. His hepatitis serology is positive for a virus that requires presence of another infectious agent before becoming clinically apparent.
Hepatitis D is a defective ribonucleic acid (RNA) virus that requires the helper function of hepatitis B virus (or other hepadnavirus) for its replication and expression.
A 53-year-old man presents to the emergency department with severe epigastric abdominal pain. His temperature is 37.2°C, blood pressure 110/70 mm Hg, pulse 110/min, and respirations 20/min. Examination of the heart and lungs is normal, and his abdomen is tender in the epigastric region. His white count is 15,000/mL and amylase is 450 U/L (25–125 U/L). Which of the following laboratory abnormalities is also most likely to be present?
Hyperglycemia is very common in pancreatitis and is usually multifactorial in origin. Factors involved include decreased insulin release, increased glucagon release, and elevated adrenal glucocorticoids and catecholamines.
A 43-year-old man feels vaguely unwell. Physical examination is unremarkable except for evidence of scleral icterus. The skin appears normal. Which of the following is the most likely explanation for why early jaundice is visible in the eyes but not the skin?
The sclera are high in elastin content, which has an affinity for bilirubin. Therefore, jaundice is usually detected here first. Fluorescent lighting makes recognition more difficult. In some individuals, dark skin color makes jaundice more difficult to detect.
A 25-year-old previously healthy man experiences fatigue and malaise. One week ago he had a “viral”-type illness consisting of a sore throat, fever, and myalgias. He now appears jaundiced, but the rest of the physical examination is normal. His investigations reveal a total bilirubin of 4 mg/dL (0.1–1.0 mg/dL) and a direct bilirubin of 0.3 mg/dL (0.0–0.3 mg/dL). Which of the following is the most likely diagnosis?
Hemolysis results in predominantly unconjugated bilirubin. Unconjugated hyperbilirubinemia is caused by overproduction, decreased uptake, or decreased conjugation.
Which of the following is most likely to cause protein-losing enteropathy?
Ménétrier’s disease, an uncommon disease involving the stomach, is characterized by large gastric folds. Intravenous administration of radioactive-labeled albumin may show up to a 40% loss in the GI tract in protein-losing enteropathy, but is not available for routine clinical use. Treatment of protein-losing enteropathy is usually directed at the underlying condition.
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| 25. A 29-year-old woman complains of dysphagia with both solids and liquids, worse when she is eating quickly or is anxious. Manometry reveals normal basal esophageal sphincter pressure, with no relaxation of the sphincter on swallowing. Which of the following is the most appropriate next step in management?
(A) beta-blocker therapy (B) partial esophagectomy (C) anticholinergic drugs (D) calcium channel blockers (E) dietary modification |
| 26. A 34-year-old woman complains bitterly of heartburn. Physical examination reveals healing lesions of the fingertips that she says were small ulcers, and there are small areas of telangiectasias on her face. Esophageal manometry reveals a decrease in the expected amplitude of smooth muscle contraction. Lower esophageal sphincter tone is subnormal, but relaxes normally with swallowing. Which of the following statements regarding this condition is most likely correct?
(A) characterized by systemic signs of inflammation (B) predominantly treated symptomatically (C) characterized by a poor prognosis (D) usually more frequent in men (E) characterized by death secondary to a renal crisis |
| 27. A 59-year-old man presents with abdominal pain, anorexia, and nausea. He has lost weight and started to develop pedal edema. Endoscopy reveals large gastric mucosal folds. Which of the following explanations for the edema is most likely correct?
(A) hypoalbuminemia secondary to malnutrition (B) hypoalbuminemia secondary to protein loss (C) impaired hepatic synthesis of albumin (D) humorally mediated cardiac disease (E) constrictive pericarditis |
| 28. A 35-year-old White man has a long past history of diarrhea, rectal bleeding, crampy abdominal pain, and the passage of mucus. He now presents with a worsening of his symptoms despite taking his medications. A barium enema is performed and is shown in Fig. 4–1. Which of the following is the most likely diagnosis of this new complication?
(A) toxic megacolon (B) amoebic colitis (C) appendicitis (D) ischemic colitis (E) annular carcinoma |
| 29. A 45-year-old man with a long history of alcohol intake comes into the emergency room with upper gastrointestinal (UGI) bleeding. Urgent endoscopy reveals the following findings (Fig. 4–2). Which of the following is the most likely diagnosis?
(A) esophageal varices (B) esophageal carcinoma (C) foreign body (D) tertiary waves (E) Barrett’s esophagus |
| 30. A 33-year-old woman develops mild epigastric abdominal pain with nausea and vomiting of 2 days duration. Her abdomen is tender on palpation in the epigastric region, and the remaining examination is normal. Her white count is 13,000/mL, and amylase is 300 U/L (25–125 U/L). Which of the following is the most common predisposing factor for this disorder?
(A) drugs (B) gallstones (C) malignancy (D) alcohol (E) hypertriglyceridemia |
| 31. A 40-year-old taxicab driver presents with worsening epigastric pain (Fig. 4–3). Which of the following is the most likely diagnosis?
(A) gastric ulcer (B) achalasia (C) duodenal ulcer (D) normal (E) hiatus hernia |
| 32. A 54-year-old man complains of burning epigastric pain that usually improves after a meal, and is occasionally relieved with antacids. On examination, he appears well and besides some epigastric tenderness on palpation, the rest of the examination is normal. Upper endoscopy confirms a duodenal ulcer. Which of the following statements concerning PUD is most likely correct?
(A) duodenal ulcer is seen more often in older people than is gastric ulcer (B) clinically, gastric ulcers are more common than duodenal ulcers (C) duodenal ulcers can frequently be malignant (D) infection can cause both types of peptic ulcer (E) peptic gastric ulcers are usually quite proximal in the stomach |
| 33. A 30-year-old man complains of chronic diarrhea for the past 6 months. There is no weight loss, fever, or abdominal pain. He takes no medications and feels fine. His physical examination is completely normal. Further history reveals that this man does not take laxatives; however, in an effort to stay slim he eats a lot of sugar-free gum and sugarless candy. Which of the following explanations is the most likely cause of his diarrhea?
(A) direct stimulant effect of chemicals in the candies (B) lack of fiber in his diet (C) pancreatic insufficiency secondary to chronic protein-calorie malnutrition (D) secondary intestinal mucosal atrophy (E) nonabsorbed carbohydrates |
| 34. Which of the following is a risk factor for Helicobacter pyloriinfection?
(A) excess exposure to antibiotics (B) female sex (C) alpha1-antitrypsin deficiency (D) low socioeconomic indicators (E) proton pump inhibitor therapy |
| 35. Which of the following is an established risk factor for nonsteroidal anti-inflammatory disease (NSAID)-induced gastric or duodenal ulceration?
(A) Helicobacter pyloriinfection (B) cigarette smoking (C) alcohol consumption (D) glucocorticoids (E) age under 30 |
| 36. A 73-year-old woman presents to the emergency room with black tarry stools and symptoms of presyncope when standing up. Digital rectal examination confirms the presence of melena. She recently started using ibuprofen for hip discomfort. Upper endoscopy confirms the diagnosis of a gastric ulcer. Which of the following is the most likely explanation for the gastric ulcer?
(A) increasing acid production (B) causing direct epithelial cell death (C) promoting replication of Helicobacter pylori (D) an antiplatelet effect (E) inhibiting mucosal repair |
| 37. A 52-year-old woman is experiencing abdominal discomfort after meals as well as early in the morning. There is no weight loss or constitutional symptoms, and she has tried antacids but experienced minimal relief. Upper endoscopy reveals a duodenal ulcer and the biopsy is negative for malignancy. Which of the following is the most appropriate next step in management?
(A) 6–8 weeks of omeprazole or ranitidine (B) long-term acid suppression with omeprazole (C) antibiotic therapy (D) antibiotic therapy with omeprazole (E) bismuth citrate therapy |
| 41. A 34-year-old man is seen for asymptomatic elevations in his AST and ALT. He appears well and the physical examination is normal. There is no prior history of intravenous drug use, blood transfusions, or multiple sex partners. His hepatitis serology is positive for the virus, most likely to lead to chronic infection. (SELECT ONE)
(A) hepatitis A virus (B) hepatitis B virus (C) hepatitis C virus (D) hepatitis D virus (E) hepatitis E virus |
| 43. A 24-year-old woman is pregnant with her first baby at 14 weeks. She feels well and the pregnancy is noncomplicated. Routine screening is positive for chronic viral hepatitis for which perinatal transmission is of major epidemiologic significance. (SELECT ONE)
(A) hepatitis A virus (B) hepatitis B virus (C) hepatitis C virus (D) hepatitis D virus (E) hepatitis E virus |
| 45. A 28-year-old man, who emigrated from North Africa, is evaluated for chronic elevations in liver enzymes (AST and ALT). He has no symptoms of acute hepatitis, and his physical examination is normal with no characteristics of chronic liver disease. His hepatitis serology is positive for a virus that requires presence of another infectious agent before becoming clinically apparent. (SELECT ONE)
(A) hepatitis A virus (B) hepatitis B virus (C) hepatitis C virus (D) hepatitis D virus (E) hepatitis E virus |
| 46. A 53-year-old man presents to the emergency department with severe epigastric abdominal pain. His temperature is 37.2°C, blood pressure 110/70 mm Hg, pulse 110/min, and respirations 20/min. Examination of the heart and lungs is normal, and his abdomen is tender in the epigastric region. His white count is 15,000/mL and amylase is 450 U/L (25–125 U/L). Which of the following laboratory abnormalities is also most likely to be present?
(A) hypoglycemia (B) hypercholesterolemia (C) hyperglycemia (D) hypercalcemia (E) hypercarbia |
| 47. A 43-year-old man feels vaguely unwell. Physical examination is unremarkable except for evidence of scleral icterus. The skin appears normal. Which of the following is the most likely explanation for why early jaundice is visible in the eyes but not the skin?
(A) the high type II collagen content of scleral tissue (B) the high elastin content of scleral tissue (C) the high blood flow to the head with consequent increased bilirubin delivery (D) secretion via the lacrimal glands (E) the lighter color of the sclera |
| 48. A 25-year-old previously healthy man experiences fatigue and malaise. One week ago he had a “viral”-type illness consisting of a sore throat, fever, and myalgias. He now appears jaundiced, but the rest of the physical examination is normal. His investigations reveal a total bilirubin of 4 mg/dL (0.1–1.0 mg/dL) and a direct bilirubin of 0.3 mg/dL (0.0–0.3 mg/dL). Which of the following is the most likely diagnosis?
(A) hemolysis (B) gallstones (C) alcoholic liver disease (D) pancreatic carcinoma (E) Dubin-Johnson syndrome |
| 49. Which of the following is most likely to cause protein-losing enteropathy?
(A) scleroderma (B) amyloidosis (C) disaccharidase deficiency (D) ischemic colitis (E) Ménétrier’s disease |
