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Select the ONE answer that is BEST in each case.
A 28-year-old man presents with symptoms of frequent bowel movements, crampy abdominal pain, and the passage of mucus. There is no history of any bloody diarrhea, but recently, he developed joint discomfort in his hands, knees, and back. On examination he is thin, and his abdomen is soft with voluntary guarding in the left lower quadrant. His joints are not actively inflamed and there is an asymmetric distribution. Which of the following is the most likely diagnosis?
Joint involvement in inflammatory bowel disease may involve sacroiliitis or specific large joint peripheral arthritis. The latter type of arthritis parallels the course of the bowel disease. The sacroiliitis (spondylitic) variety follows an independent course.
A 57-year-old man, recently discharged from the hospital, develops severe diarrhea and abdominal pain. Sigmoidoscopy reveals a granular friable mucosa. Which of the following is the most common cause of this syndrome?
This likely represents diarrhea secondary toClostridium difficileinfection. It is mediated by toxins, not by direct bacterial invasion. Cephalosporins, because they are so widely used, are the most common cause of the disease. On a per case basis, however, clindamycin is the most likely antibiotic to cause the disease.
A 42-year-old previously well woman presents with pruritus. She is not taking any medications, and only drinks alcohol on a social basis. Her physical examination is entirely normal with no signs of chronic liver disease or jaundice. Laboratory evaluation reveals an alkaline phosphatase level of three times normal, and an ultrasound of the liver and gallbladder is normal. Which of the following is the most appropriate next step in diagnosis?
The patient with primary biliary cirrhosis (PBC) is typically a middle-aged woman with itching. Patients are often asymptomatic and diagnosed only on routine blood work. The cause of PBC is unknown, but a disordered immune response may be involved. A positive antimitochondrial antibody test is found in over 90% of symptomatic patients.
A 53-year-old man has weight loss, chronic diarrhea, and steatorrhea. He undergoes diagnostic investigations including small bowel biopsies. The biopsy report reveals normal small bowel mucosa. Which of the following is the most likely diagnosis?
Postgastrectomy steatorrhea does not result from mucosal abnormality. The mucosa is also normal in pancreatic steatorrhea. Postgastrectomy maldigestion and malabsorption is caused by rapid gastric emptying, reduced dispersion of food in the stomach, reduced luminal levels of bile, rapid transit of food, and impaired pancreatic secretory response.
A 22-year-old man with inflammatory bowel disease is noted to have a “string sign” in the ileal area on barium enema. In which of the following conditions is this sign most often seen?
The string sign represents long areas of circumferential inflammation and fibrosis. It is seen in the stenotic and nonstenotic phase of Crohn’s disease. In addition to the string sign, abnormal puddling of barium and fistulous tracts are other helpful x-ray signs of ileitis. Other radiologic findings in Crohn’s disease include skip lesions, rectal sparing, small ulcerations, and fistulas.
A 22-year-old woman presents with chronic diarrhea. She has no abdominal discomfort, feels well, and reports no weight loss or systemic symptoms. Physical examination reveals a healthy young woman who is 5’7” tall and weighs 150 lb. The complete physical examination is normal. Which of the following is the most likely cause of a secretory diarrhea in this young woman?
Although carcinoid tumor can cause diarrhea, it is very uncommon. This young woman is overweight, suggesting an eating disorder, which is associated with laxative abuse. Abuse of stimulant laxatives such as senna can cause a secretory diarrhea. Magnesium-based laxatives will cause an osmotic diarrhea.
A 59-year-old man presents with abdominal distention and a decrease in bowel movements. He has had previous abdominal surgery. Which of the following findings is most likely to favor large bowel obstruction over small bowel obstruction?
Colonic obstruction usually causes less pain and vomiting than small bowel obstruction. Fever is usually absent in both. The stepladder pattern is characteristic of small bowel obstruction, as are hiccups.
A 57-year old man comes to the office with a complaint of food “sticking on the way down.” Which of the following characteristics suggests a benign problem is causing the dysphagia?
Episodic dysphagia to solids of several years’ duration suggests a benign disease, and is characteristic of a lower esophageal ring. Motor dysphagia presents with dysphagia to solids and liquids. Dysphagia due to obstruction starts with solids and can progress to liquids as well. Hoarseness following the onset of dysphagia can be caused by an esophageal cancer extending to involve the recurrent laryngeal nerve or because of laryngitis secondary to gastroesophageal reflux. Severe weight loss suggests malignancy, and hiccups are a rare occurrence in distal problems of the esophagus.
A 70-year-old man is investigated for symptoms of dysphagia with solids, but not with liquids. There is no history of weight loss, and his physical examination is normal. Investigations reveal a Zenker’s diverticulum of the esophagus. Which of the following historical characteristics suggests a Zenker’s diverticulum?
Aspiration, unrelated to swallowing, is seen in a Zenker’s diverticulum, achalasia, or gastroesophageal reflex.
A 27-year-old man with HIV complains of pain every time he swallows (odynophagia). He is not on any antiretroviral therapy and otherwise feels well. Examination of the mouth and pharynx are normal. Which of the following is the most likely diagnosis?
Painful swallowing can be caused by candida or herpes infection or pill-induced esophagitis. Patients with immunodeficiency states (e.g., AIDS) may have herpetic, candidal, or CMV esophagitis, as well as tumors (lymphoma, Kaposi sarcoma).
A 33-year-old woman is recently diagnosed with primary biliary cirrhosis (PBC). She is inquiring about available treatments for this condition, including if there is a cure for the disease. Which of the following treatments is most likely to “cure” her PBC?
There is no known effective therapy to prevent progression of liver disease in PBC. In patients with end-stage liver failure, liver transplantation is “curative,” since recurrence after transplantation is rare. The other therapies listed have been reported as effective in small case series but not in controlled trials. Ursodeoxycholic acid seems effective in providing at least symptomatic improvement, and may even delay liver transplantation. Replacement of fat-soluble vitamins (e.g., vitamin A to prevent night blindness) is an important part of therapy, as is replacement of calcium and vitamin D to prevent osteoporosis.
A 47-year-old woman complains of food sticking every time she eats anything solid. She has lost 10 lb since the symptoms started, and points to her midthorax as the site where she feels the food is sticking. If this is due to mechanical obstruction, this historical information suggests which of the following locations?
The history is helpful. The site of obstruction is usually at or below where the patient says the sticking occurs.
A 52-year-old man has episodes of severe chest pain associated with dysphagia. He has been seen twice in the emergency room, and both times the symptoms responded to sublingual nitroglycerin. He then had a full cardiac evaluation including electrocardiogram (ECG), cardiac biomarkers, and an exercise stress test, which were all normal. Which of the following is the most likely diagnosis?
Severe chest pain is characteristic of diffuse esophageal spasm and related motor disorders. The symptoms can mimic that of cardiac chest pain and can be difficult to distinguish one from the other, since both conditions respond to nitrates. Cardiac conditions should be ruled out before noncardiac conditions are considered.
A 16-year old girl has recently been referred to your family practice. She is a recent immigrant from Southeast Asia, and has been taking isoniazid (INH) and rifampin for uncomplicated tuberculosis. Routine blood tests are unremarkable, except for an elevated direct bilirubin. Other liver enzymes and function tests are completely normal. Which of the following is the most likely diagnosis?
Rotor’s syndrome is one of the two rare inherited disorders causing elevations in direct bilirubin. The other is Dubin-Johnson syndrome, and both have an excellent prognosis. Hemolytic anemia causes elevation in indirect bilirubin, and hematologic changes would be expected. INH causes elevation in liver enzymes, and although Rifampin can cause isolated hyperbilirubinemia, it is of the indirect kind. CriglerNajjar type I is a severe disorder of neonates with elevated indirect bilirubin.
A 45-year-old woman presents with a 1-week history of jaundice, anorexia, and right upper quadrant discomfort. On examination she is icteric, with a tender right upper quadrant and liver span of 14 cm. There is no shifting dullness or pedal edema and the heart and lungs are normal. On further inquiry, she reports consuming one bottle of wine a day for the past 6 months. Which of the following laboratory tests is most likely to be characteristic of a patient with jaundice secondary to alcoholic hepatitis?
In alcoholic hepatitis, the AST:ALT ratio is usually >2, and the level of AST is usually <300. When viral hepatitis or toxin-induced hepatitis causes jaundice, the AST:ALT ratio is usually 1 or less, and the transaminases are usually >500.
Which of the following medications causes predictable, dose-dependent hepatocellular injury?
Acetaminophen reliably produces hepatocellular damage when taken in large doses. Daily doses should not exceed 4 g a day, and accidental or intentional overdoses of 10–15 g will result in liver injury. Fatal fulminant disease is usually seen with ingestions over 25 g.
Which of the following is the mostly likely mechanism of acetaminophen hepatotoxicity toxicity?
An active metabolite of acetaminophen is hepatotoxic. It is detoxified by binding to glutathione, and when hepatic glutathione stores are depleted, severe liver damage can occur.
Blood-filled lesions in the liver (peliosis hepatis) are most likely to be seen with which of the following medications?
Anabolic steroids usually cause cholestasis and jaundice without inflammation. Sinusoidal dilatation and peliosis occur less frequently, and there have been deaths linked to peliosis. The other medications also cause various types of liver disease, but not peliosis.
A 24-year-old man with a history of depression is brought to the emergency room because of a drug overdose. He is experiencing some nausea and vomiting, but no other symptoms. Physical examination and vital signs are normal. Six hours prior to presentation, he intentionally took 40 tablets of acetaminophen (500 mg/tablet). Which of the following is the most appropriate next step in management?
N-acetylcysteine probably acts by providing a reservoir of sulfhydryl groups to bind the toxic metabolite of acetaminophen. Narcan is effective for narcotic overdose, and ethanol is the antidote for methanol intoxication.
A 16-year-old girl is referred to the office because of chronic diarrhea and weight loss. She is experiencing large-volume watery diarrhea that is painless. The symptoms persist even when she is fasting, and there is no relationship to foods or liquids. She is not on any medications, and there is no travel history or other constitutional symptoms. Her physical examination is normal. Which of the following is the most likely diagnosis?
Secretory diarrhea is caused by a derangement in fluid and electrolyte transport across the gut mucosa. The resultant diarrhea is watery, large volume, painless, and persists even when the patient fasts.
A 52-year-old man has suffered with chronic diarrhea for several years, but has refused to see a doctor. He finally comes because he is having trouble driving at night, because of difficulty seeing. Physical examination reveals a slender, pale, unwell-looking man. He has a microcytic anemia, low calcium, and albumin levels. Which of the following is the most likely cause for his diarrhea?
His anemia and general appearance are compatible with chronic inflammatory bowel disease as well, but his night blindness suggests vitamin A deficiency, which is much more likely in a malabsorption syndrome.
. A 49-year-old woman is being investigated for chronic diarrhea and weight loss. Malabsorption is suspected. Which of the following investigations is most likely to make a definitive diagnosis?
The osmotic gap is a characteristic of osmotic diarrhea in particular. Stool fat, D-xylose testing, and Schilling tests help establish the diagnosis of malabsorption, but not the etiology. The most common cause of such diffuse malabsorption, celiac disease, has a characteristic biopsy pattern with short or absent villi. Confirmation of the disease requires response to a gluten-free diet.
A 67-year-old man is admitted to the intensive care unit (ICU) because of respiratory failure from pneumonia. He requires artificial ventilation and inotropic support. On the third day in the ICU, he develops melena and a drop in his hemoglobin. Urgent upper endoscopy is performed and it reveals three gastric ulcers in the fundus and body of the stomach. Appropriate treatment is started.
Acute erosive gastritis is most commonly seen in critically ill hospitalized patients. Ischemia of the gastric mucosa with breakdown of the normal protective barriers of the stomach is a key factor in the syndrome.
A 70-year-old man has a long history of heartburn and dyspepsia. He has tried many medications but the symptoms always return. His upper endoscopy is normal with no ulcers. Routine biopsies of the gastric mucosa report “gastritis.”
Type B chronic gastritis is a more common cause of chronic gastritis. It becomes more common with advancing age and is uniformly associated with H. pyloriinfection. Eradication ofH. pyloriproduces histologic improvement, but is not routinely recommended unless peptic ulcer or mucosa-associated lymphoid tissue (MALT) lymphoma occurs.
A 57-year-old woman experiences frequent symptoms of heartburn. She reports no weight loss, diarrhea, or dysphagia symptoms. Past medical history is significant for B12 deficiency treated with monthly injections. She appears well, and the examination is normal, except for some patches on her arms where she has lost all the skin pigmentation. Her upper endoscopy is normal, except for gastric biopsies commenting on gastritis.
Type A chronic gastritis may lead to pernicious anemia. Antibodies to parietal cells and to intrinsic factor are frequently seen in the sera, suggesting an immune or autoimmune pathogenesis. These patients can also have autoimmune thyroid disease and vitiligo.
A 54-year-old man is investigated for weight loss, epigastric pain, nausea, and vomiting. He appears ill; on examination, there is epigastric tenderness and marked peripheral edema. Upper endoscopy reveals large mucosal folds in the body and fundus of the stomach. Biopsies are consistent with a diagnosis of Ménétrier’s disease.
Ménétrier’s disease is not a true gastritis, as inflammation is not present on histologic examination. It is characterized by large, tortuous gastric mucosal folds and usually presents with abdominal pain. Protein-losing enteropathy often develops, resulting in hypoalbuminemia and edema.
A 65-year-old man has developed abdominal pain, early satiety, nausea, and vomiting. He reports no weight loss or change in bowel habits. He had a partial gastrectomy 30 years ago for a bleeding gastric ulcer. Upper endoscopy finds erythema of the gastric remnant, and biopsies report epithelial injury and minimal inflammation (gastritis).
Gastric surgery seems to accelerate the development of asymptomatic gastritis with progressive parietal cell loss. However, some patients develop bile reflux gastritis with symptoms of pain, nausea, and vomiting.
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