Gastro Questions

Gastroenterology and Hepatology Item 1
A 35-year-old chronic alcoholic man comes to the hospital with bright-red hematemesis and
syncope. You examine him in the emergency department at 11 pm and note that his pulse rate
is 100/min and his blood pressure is 100/60 mm g! and that red-tinged irrigant is present in
the large-bore nasogastric tube that is in place. "he patient has multiple #ascular spider
angiomata and a distended abdomen with shi$ting dullness. %esults o$ his laboratory tests are
not yet a#ailable. e has recei#ed & ' o$ normal saline solution! and an octreotide drip is
running. is #ital signs ha#e stabili(ed.
)hat is the optimal management $or this patient*
+A, -er$orm endoscopy immediately.
+., -er$orm endoscopy in the morning.
+/, -repare the patient $or the operating room $or shunt surgery.
+0, a#e an inter#entional radiologist place a trans1ugular intrahepatic portosystemic shunt
+"2-3,.
A 55-year-old man is admitted to the hospital a$ter experiencing & hours o$ substernal pain
that is $inally relie#ed with morphine in the emergency room. e has this pain regularly and
was admitted $or similar chest pain 6 months ago! at which time a myocardial in$arction was
ruled out. e has occasional heartburn without regurgitation or dysphagia. is older brother
died o$ a myocardial in$arction. e is neither hypertensi#e nor diabetic.
-hysical examination re#eals an obese man who is resting com$ortably. is cholesterol le#el is
&40 mg/d'. 5ther laboratory studies are normal. A radiograph o$ the chest is normal. /ardiac
catheteri(ation re#eals minimal coronary artery disease with no signi$icant stenosis.
)hich o$ the $ollowing diagnostic tests has the highest sensiti#ity to diagnose the cause o$ this
patient6s chest pain*
+A, 7pper endoscopy
+., .ernstein test
+/, Ambulatory &4-hour esophageal p monitoring
+0, 8sophageal motility study
+8, -roton pump inhibitor test
A 95-year-old white woman with a long history o$ osteoarthritis and nonsteroidal anti-
in$lammatory drug +:3A20, use +naproxen, presents to the emergency room with
hematemesis and orthostatic hypotension. A$ter stabili(ation o$ her #ital signs with #olume
replacement! she undergoes upper gastrointestinal endoscopy! which shows a 1.5-cm antral
ulcer with a #isible #essel in the base. "he ulcer is treated with in1ection and coagulation
therapy. "he patient has no $urther bleeding. A rapid urease test $or elicobacter pylori
obtained at the time o$ endoscopy is negati#e.
)hich o$ the $ollowing statements best describes the pathophysiology o$ this patient6s
gastrointestinal bleeding*
+A, 2nhibition o$ prostaglandin-mediated leu;ocyte margination by naproxen! allowing
mucosal in1ury
+., 2nhibition o$ cyclo-oxygenase-& +/5<-&,=dependent prostaglandin production
+/, %eduction o$ gastric mucosal circulation! bicarbonate! and mucus secretion by naproxen
+0, "opical in1ury by naproxen! allowing bac;-di$$usion o$ acid that can be a#oided using
enteric-coated :3A20s
+8, :3A20 exacerbation o$ an . pylori=induced ulcer
A &&-year-old man presents to the outpatient clinic with progressi#e weight loss and diarrhea.
3ix months ago! $ollowing a stab wound to the superior mesenteric artery and extensi#e small
bowel resection! he was le$t with 100 cm o$ small bowel $rom the ligament o$ "reit( to the
ileocecal #al#e. e has $i#e bul;y! greasy bowel mo#ements per day and has lost &0> o$ his
weight since the surgery. -hysical examination re#eals a thin man with a /h#oste;6s sign.
3tool e#aluation re#eals 15 g o$ $at per &4 h on a diet containing 100 g o$ $at per day. is
albumin concentration is &.5 g/d'! and his calcium concentration is 6.6 mg/d'.
)hat is the most appropriate therapy $or this patient*
+A, ?edium-chain triglyceride oil
+., Antacids
+/, .road-spectrum antibiotic therapy
+0, 5ral magnesium oxide
+8, /holestyramine
A 4@-year-old woman +gra#ida 3! para 3, presents with right upper Auadrant pain. 3he has
had three discrete episodes o$ moderate to se#ere right upper Auadrant pain that radiates to
the right scapula and lasts 4 to 5 hours. "he last o$ these episodes occurred 9& hours ago.
"hese attac;s occur 30 minutes to B0 minutes a$ter eating and are associated with nausea!
but not #omiting. er medical history is otherwise unremar;able. -hysical examination re#eals
moderate obesity! and abdominal examination is normal. 3he ta;es no medications.
ow can you best con$irm the diagnosis in this patient*
+A, /omputed tomography
+., 7ltrasonography
+/, epatoiminodiacetic acid +20A, scan
+0, 5ral cholecystography
+8, 7pper endoscopy
A &3-year-old phlebotomist reports to your clinic with complaints o$ malaise! $atigue! myalgia!
and low-grade $e#er. e was pre#iously well and denies illicit drug use! trans$usions! or recent
tra#el but admits to multiple needle-stic; accidents. -hysical examination re#eals 1aundice and
mild hepatomegaly. "here is no spider telangiectasia! palmar erythema! splenomegaly! or
ascites.
%esults o$ laboratory studies are as $ollowsC aspartate aminotrans$erase +A3",! 11&0 7/'D
alanine aminotrans$erase +A'",! &300 7/'D al;aline phosphatase! &34 7/'D total bilirubin! 5
mg/d'D albumin! 3.@ g/d'D prothrombin time! 1&.3 sec +2:%! 1.0,D 2gE antibody to hepatitis A
#irus +2gE anti-AF,! positi#eD 2g? anti-AF! negati#eD hepatitis . sur$ace antigen +.sAg,!
positi#eD 2gE antibody to hepatitis . core antigen +2gE anti-.c,! positi#eD 2g? anti-.c!
positi#eD and antibody to hepatitis / #irus +anti-/F,! negati#e.
"he most li;ely diagnosis isC
+A, /hronic hepatitis A
+., Acute hepatitis .
+/, /hronic hepatitis .
+0, Acute hepatitis /
+8, /hronic hepatitis /
A 35-year-old woman comes to the emergency department with epigastric pain radiating to
the bac; and #omiting. 3he has no signi$icant medical history! ta;es no medications! and
occasionally has a glass o$ wine. "he physical examination is signi$icant $or a temperature o$
3@ G/ +100.4 GH,! pulse rate o$ 104/min! blood pressure o$ 11@/94 mm g! anicteric sclerae!
normal heart and lungs! absence o$ bowel sounds! and se#ere epigastric tenderness with
#oluntary guarding. %esults o$ laboratory studies include the $ollowingC leu;ocyte count!
14!000/I'D amylase! &4@& 7/'D lipase! 1@!956 7/'D al;aline phosphatase! 1@B 7/'D aspartate
aminotrans$erase +A3",! @@ 7/'D total bilirubin! 1.& mg/d'D and normal calcium! magnesium!
phosphate! and triglyceride le#els. An upright chest radiograph is normal.
)hich o$ the $ollowing would be the most appropriate next diagnostic study*
+A, 7pright and supine abdominal radiographs
+., Abdominal ultrasonography
+/, Abdominal computed tomography
+0, 8ndoscopic retrograde cholangiopancreatography +8%/-,
5n screening $lexible sigmoidoscopy! a 60-year-old man is $ound to ha#e a 5-mm polyp in the
rectum. istopathologic examination o$ biopsy specimens demonstrates a hyperplastic
morphology. e has no symptoms! no $amily history o$ colorectal cancer! and no signi$icant
medical history! and ta;es no medications. A six-window $ecal occult blood test is negati#e.
)hat is the most appropriate $ollow-up $or this patient*
+A, %epeat sigmoidoscopy in 1 year
+., /olonoscopy
+/, .arium enema
+0, Yearly $ecal occult blood testing and sigmoidoscopy in 3 to 5 years.
A 36-year-old man is $ound to test positi#e $or antibody to hepatitis / #irus +anti-/F, when
donating blood. Aspartate aminotrans$erase +A3", and alanine aminotrans$erase +A'", le#els
are within normal range on three occasions o#er the subseAuent 6 months. "he patient denies
;nown ris; $actors $or /F! $eels well! has no signi$icant medical history! and has no e#idence
o$ stigmata o$ li#er disease on physical examination. Jualitati#e polymerase chain reaction
+-/%, testing $or /F %:A is positi#e. )hich o$ the $ollowing measures is most appropriate $or
this patient*
+A, %eassure the patient that he does not ha#e chronic /F in$ection and does not reAuire
$urther e#aluation or treatment.
+., %eassure the patient that despite chronic /F in$ection! treatment $or /F in$ection is
not appropriate at this time and that he should be monitored yearly $or de#elopment o$
abnormal li#er en(yme le#els.
+/, %ecommend a li#er biopsy to de$ine the extent o$ li#er in1ury! and predicate decisions
concerning treatment on the histologic $indings.
+0, %ecommend treatment with anti#iral therapy $or chronic /F in$ection.
+8, %ecommend /F Auantitati#e %:A and genotype testing! and predicate treatment
recommendations on the $indings.
A 3@-year-old woman with chronic pancreatitis is re$erred to you $or e#aluation and treatment
o$ chronic abdominal pain. 3he complains o$ a deep ache that radiates through to the bac; o$
6 months6 duration. "he pain is worse a$ter $atty meals and impro#es with acetaminophen and
hydrocodone! which she ta;es on a daily basis. .ecause o$ her pain! she is currently on
medical lea#e $rom her 1ob as a mailroom cler;. 3he has had multiple hospitali(ations $or
episodes o$ acute pancreatitis! most recently @ wee;s ago. 3he dran; alcohol hea#ily $or 15
years! has been sober $or 4 years! and is enrolled in Alcoholics Anonymous. 3he has had
insulin-dependent diabetes mellitus $or & years. er medications include insulin! enteric-coated
pancrelipase A/ and 3! and acetaminophen with hydrocodone. er physical examination
re#eals a chronically ill=appearing woman with normal #ital signs and heart and lung
examinations. 3he has moderate epigastric tenderness. 'aboratory studies re#eal a normal
complete blood count and normal glucose! glycosylated hemoglobin! amylase! and lipase
le#els. A computed tomographic +/", scan re#eals pancreatic parenchymal atrophy and
calci$ications. "here is a 10-mm calci$ied stone impacted within the main duct in the pancreatic
head! with upstream ductal dilation to 10 mm. "he best treatment $or this patient would beC
+A, %eassurance and conser#ati#e management
+., %e$erral $or surgical or endoscopic stone extraction and ductal drainage
+/, -rescription o$ long-acting narcotics
+0, 3witch to a non=enteric-coated pancreatic en(yme preparation
+8, /eliac plexus neurolysis
)hich o$ the $ollowing patients is most li;ely to ha#e autoimmune chronic hepatitis*
+A, A &4-year-old woman with 1aundiceD alanine aminotrans$erase +A'",! 69 7/'D al;aline
phosphatase! 11&4 7/'D antinuclear antibodies +A:A,! positi#eD anti=smooth muscle antibody
+A3?A,! negati#eD antimitochondrial antibody +A?A,! negati#eD 2g?! ele#atedD and 2gE!
normalD li#er biopsy demonstrates lymphocytic destruction o$ bile ducts.
+., A &4-year-old woman with 1aundiceD A'"! BB 7/'D al;aline phosphatase! 569 7/'D A:A!
negati#eD A3?A! negati#eD A?A! positi#eD 2g?! ele#atedD and 2gE! normalD li#er biopsy
demonstrates lymphocytic destruction o$ bile ducts.
+/, A &4-year-old woman with 1aundiceD A'"! &34 7/'D al;aline phosphatase! 119 7/'D A:A!
positi#eD A3?A! positi#eD A?A! negati#eD 2g?! normalD 2gE! ele#atedD li#er biopsy
demonstrates piecemeal necrosis o$ hepatocytes.
+0, A &4-year-old woman with 1aundiceD A'"! &1 7/'D al;aline phosphatase! 345 7/'D A:A!
negati#eD A3?A! negati#eD A?A! negati#eD 2g?! ele#ated! 2gE! normalD li#er biopsy
demonstrates lymphocytic destruction o$ bile ducts.
+8, A &4-year-old woman with 1aundiceD A'"! 44 7/'D al;aline phosphatase! &9@ 7/'D A:A!
negati#eD A3?A! negati#eD A?A! negati#eD 2g?! normalD 2gE! normalD li#er biopsy
demonstrates mild in$lammation with concentric $ibrosis around bile ducts.
A 3&-year-old man presents with upper abdominal pain o$ & years6 duration. is pain has been
intermittent and impro#es with antacids! eating! and o#er-the-counter &-receptor
antagonists. is latest episode began & wee;s ago but resol#ed when proton pump inhibitor
therapy was initiated at that time. You are considering peptic ulcer disease as part o$ the
di$$erential diagnosis and ha#e decided to test $or elicobacter pylori. e has not been tested
or treated $or elicobacter pylori in the past.
2n this patient! the best diagnostic test to detect . pylori isC
+A, 7rea breath test
+., 3erum or whole-blood antibody test
+/, 8ndoscopic rapid urease test
+0, 8ndoscopic biopsy
A 69-year-old man presents to the outpatient clinic with a 3-wee; history o$ hematoche(ia. e
has had up to $i#e loose bowel mo#ements daily with a large amount o$ bright red blood.
"here has been no abdominal pain! $e#er! or weight loss. 5ne month ago! he was treated with
antibiotics $or bronchitis. 5$ note in his medical history is that he recei#ed 40 Ey o$ radiation
therapy $or prostate cancer & years ago. -hysical examination shows normal oropharyngeal
mucosa. %ectal examination re#eals bright red blood. emoglobin is @.6 g/d'. 3tool cultures
are negati#e! and stool neutrophils are absent. "he rectal mucosa seen on $lexible
sigmoidoscopy is shown. .iopsies show capillary proli$eration and $ibrosis in the lamina
propria.
3ee the $igure
"he most li;ely diagnosis in this patient isC
+A, 7lcerati#e colitis
+., 3higellosis
+/, ereditary hemorrhagic telangiectasia +5sler-)eber-%endu disease,
+0, /hronic radiation proctopathy
+8, Antibiotic-associated colitis
A 9&-year-old woman complains o$ $atigue and exercise intolerance. 3he has no other
symptoms and no signi$icant medical or $amily history and ta;es no medications. 3he has a
good appetite! eats a balanced diet! and has had no weight loss. 3he has ne#er had screening
$or colorectal cancer. er physical examination is remar;able $or con1uncti#al pallor and a $aint
systolic $low murmur. %esults o$ laboratory studies include the $ollowingC hematocrit! &@>D
mean corpuscular #olume! 90 $'D $erritin! & ng/m'D trans$errin saturation! 11>D and normal
electrolyte le#els and renal and li#er tests. A six-window $ecal occult blood test is negati#e.
7rinalysis is normal.
)hat is the most appropriate next recommendation*
+A, Hlexible sigmoidoscopy
+., .arium enema
+/, /olonoscopy
+0, 8sophagogastroduodenoscopy +8E0,
+8, /omputed tomography o$ the abdomen
)hich o$ the $ollowing patients is presenting with a well-accepted extrahepatic mani$estation
o$ chronic hepatitis / in$ection*
+A, A 35-year-old man with a recent episode o$ pancreatitis
+., A 5@-year-old woman with de$orming arthritis o$ the proximal interphalangeal 1oints
+/, A 4@-year-old man with proteinuria and an acti#e urinary sediment
+0, A 6&-year-old man with chest pain and di$$use 3"-"-segment ele#ations on
electrocardiogram
+8, A 54-year-old woman with headache! altered mental status! and abnormal results on
lumbar puncture
A 45-year-old woman comes to the doctor6s o$$ice because she read an ad#ertisement saying
that heartburn can be a serious disease. Hor 10 years! she has been ta;ing o#er-the-counter
medications $or heartburn and regurgitation. 2nitially! she too; antacids! but more recently!
she has been ta;ing an &-receptor antagonist. 8#en ta;ing & pills twice a day she has had
only partial relie$.
er brother died o$ cancer o$ the esophagus when he was 45 years old. 3he remembers that
her $ather regularly complained o$ heartburn a$ter meals and dran; mil; $or relie$ o$
symptoms.
)hat inter#ention is li;ely to be most e$$ecti#e in relie#ing this patient6s symptoms*
+A, &-receptor antagonist at double the usual dose
+., -roton pump inhibitor
+/, -romotility agent
+0, 3ucral$ate
+8, 'i$estyle modi$ications
A 6&-year-old asymptomatic woman is $ound to ha#e a prominent aortic pulsation on routine
physical examination and undergoes abdominal ultrasonography $or e#aluation $or a possible
aortic aneurysm. 7ltrasonography shows a normal aorta! as well as a normal abdomen and
pel#isD howe#er! gallstones are detected. "he rest o$ the biliary tree and li#er are normal!
without e#idence o$ ductal dilation or gallbladder wall abnormalities.
"he appropriate management o$ this patient isC
+A, :o treatment at this time
+., 8lecti#e cholecystectomy
+/, 0issolution therapy with ursodeoxycholic acid
+0, 3tone $ragmentation by lithotripsy
+8, 'ow-$at diet
A &9-year-old man with a 3-year history o$ chronic ulcerati#e colitis presents with $e#er and
1aundice. e has two to $our loose bowel mo#ements each day. -hysical examination re#eals
1aundice! hepatosplenomegaly! and mild peripheral edema. "here is no bowel distention!
ascites! or gastrointestinal bleeding.
'aboratory studies re#eal the $ollowingC hemoglobin! 13.4 g/d'D hematocrit! 3B>D leu;ocyte
count! 1&!500/I'D platelet count! &34!000/I'D 2:%! 1.1D albumin! 1.B g/d'D bilirubin! 4.3
mg/d'D al;aline phosphatase! 1564 7/'D aspartate aminotrans$erase +A3",! &34 7/'D alanine
aminotrans$erase +A'",! &9@ 7/'D antinuclear antibody +A:A,! negati#eD anti=smooth muscle
antibody +A3?A,! negati#eD and antimitochondrial antibody +A?A,! negati#e. "hree-way
radiographs o$ the abdomen are unremar;able. 7ltrasonography re#eals an abnormal biliary
tree! with $ocal dilations and intraductal echogenicity.
"he patient is treated with 5-aminosalicylic acid +5-A3A,! $luids! nutritional support! and
antibiotics and impro#es. 5nce stable! li#er biopsy is per$ormed and demonstrates early
cirrhosis. 8ndoscopic retrograde cholangiopancreatography +8%/-, shows $ocal biliary
strictures with a dominant stricture at the bi$urcation o$ the right and le$t hepatic ducts.
"he next step in clinical management o$ this patient isC
+A, -rednisone
+., /olonoscopy
+/, .rush and biopsy o$ the dominant stricture
+0, %e$erral $or li#er transplantation
+8, 7rsodeoxycholate
A 50-year-old man comes to see you $or health maintenance. e has no complaints! has no
signi$icant medical history! ta;es no medications! and has no $amily history o$ colorectal
cancer. is physical examination and complete blood count are normal.
"he most appropriate screening program $or colorectal cancer in this patient isC
+A, 0igital rectal examination with $ecal occult blood testing on the specimen $rom the glo#e
yearly
+., Hecal occult blood testing on spontaneously passed stools yearly and $lexible
sigmoidoscopy e#ery 3 to 5 years
+/, .arium enema e#ery 3 to 5 years
+0, /olonoscopy e#ery 3 to 5 years
)hich o$ the $ollowing patients is an appropriate candidate $or re$erral $or e#aluation $or li#er
transplantation*
+A, A 46-year-old man with hepatitis / #irus +/F, in$ection and alcohol-related cirrhosis
who has been abstinent $rom alcohol $or & years su$$ers his $irst #ariceal bleeding episode. e
has mild ascites and no hepatic encephalopathy. %ele#ant laboratory #alues include the
$ollowingC albumin! 3.6 g/d'D total bilirubin! 1.& mg/d'D and international normali(ed ratio
+2:%,! 1.&.
+., A 4&-year-old mother o$ two children presents with her $irst episode o$ alcoholic hepatitis.
3he promises that she will discontinue drin;ing her three to $our glasses o$ wine per day. 3he
has ascites but no hepatic encephalopathy. %ele#ant laboratory #alues include the $ollowingC
albumin! &.9 g/d'D total bilirubin! 6.& mg/d'D and normal 2:%.
+/, A 39-year-old man with a 3-wee; history o$ malaise and progressi#e 1aundice attributable
to acute hepatitis . presents with no e#idence o$ hepatic encephalopathy. e has no ascites.
%ele#ant laboratory #alues include the $ollowingC alanine aminotrans$erase +A'",! &460 7/'D
albumin! 3.& g/d'D total bilirubin! 9.9 mg/d'D and 2:%! 1.&.
+0, An asymptomatic 50-year-old man with chronic hepatitis . #irus +.F,=related cirrhosis
has recently become .F 0:A=negati#e on lami#udine therapy. e has no ascites or hepatic
encephalopathy. %ele#ant laboratory #alues include the $ollowingC albumin! &.9 g/d'D total
bilirubin! 1.& mg/d'D and 2:%! 1.@.
+8, A 60-year-old woman with a &&-year history o$ autoimmune-related hepatitis treated
with a(athioprine and prednisone presents with mild $atigue. 3he has no ascites or hepatic
encephalopathy. %ele#ant laboratory #alues include the $ollowingC albumin! 3.3 g/d'D total
bilirubin! 1.@ mg/d'D and 2:%! 1.&.
A &4-year-old woman with perirectal /rohn6s disease presents to the outpatient clinic with a
recto#aginal $istula. 3he has about eight watery bowel mo#ements daily! and stool and $latus
are passed through her #agina se#eral times daily. Hlexible sigmoidoscopy shows deep
serpiginous ulcerations in the rectum! with de$inite s;ip areas o$ normal mucosa. 3ix months
o$ treatment with a combination o$ metronida(ole and 6-mercaptopurine ha#e not helped
symptoms.
"he best additional therapy to be considered at this time isC
+A, -rednisone
+., A(athioprine
+/, /yclosporine
+0, Anti=tumor necrosis $actor antibody +in$liximab,
+8, -roctectomy
A 5B-year-old man who has resided in the 7nited 3tates $or his entire li$e de#eloped a
elicobacter pylori=related ulcer that was success$ully treated with a proton pump inhibitor=
based triple therapy as determined by a post- treatment urea breath test. 0uring a
subseAuent $ollow-up o$$ice #isit to discuss his . pylori and ulcer status! he states that some
o$ his ulcer-li;e symptoms are still present.
"he li;elihood that he has become rein$ected with . pylori isC
+A, &5> to 30> per year
+., 15> to &0> per year
+/, 5> to 10> per year
+0, K 1> per year
A 59-year-old woman consults you $or #ague epigastric discom$ort o$ 3 months6 duration. 3he
has ne#er had acute pancreatitis! has no signi$icant medical history! and ta;es no medications.
"he physical examination is unremar;able. "he results o$ laboratory studies are normal.
/omputed tomography +/", re#eals a 6-cm loculated cystic lesion within the pancreatic head.
"he most appropriate inter#ention in this patient isC
+A, 3urgical resection o$ the cystic lesion
+., -ercutaneous transhepatic needle aspiration
+/, 3erum carcinoembryonic antigen +/8A, and /A 1B-B
+0, %epeat /" scan in 6 months
+8, 8ndoscopic retrograde cholangiopancreatography +8%/-,
A 64-year-old woman is admitted to the hospital because o$ bright red blood per rectum and a
postural change in #ital signs $rom a pulse rate o$ 95/min to 105/min and $rom a blood
pressure o$ 140/@0 mm g to B0/60 mm g. 3he has passed blood per rectum $our times in
the last 1& hours.
er general health is good. er only medication is aspirin! @0 mg/day. 3he does not smo;e or
drin; alcohol. 3he has had no abdominal pain! weight loss! or change in bowel habits. -hysical
examination re#eals a normal abdomen and bright-red blood in the rectum. :asogastric tube
aspiration is clear.
A$ter #olume restoration and laboratory assessment! the next diagnostic test should beC
+A, Fisceral angiography
+., :uclear medicine scan
+/, .arium enema
+0, Hlexible sigmoidoscopy
+8, /olonoscopy
You are as;ed to see a 93-year-old woman who was hospitali(ed 1 wee; ago with a stro;e.
3he has a residual hemiparesis but is impro#ing. 3he complains o$ di$$iculty swallowing and
cho;ing while eating. 3he has ne#er had these symptoms be$ore.
5n physical examination! her cranial ner#es are intact! and she has a right hemiparesis.
"he best test to $urther assess her condition isC
+A, 7pper endoscopy
+., 7pper gastrointestinal series
+/, 8sophageal manometry
+0, Fideo$luoroscopic swallowing study
+8, /omputed tomography o$ the nec;
A 1B-year-old woman comes to you $or a second opinion concerning pancreas di#isum
detected incidentally on a magnetic resonance imaging +?%2, scan per$ormed $or e#aluation to
be a renal transplant donor. 3he is asymptomatic! has no signi$icant medical history! is ta;ing
medications! and does not drin; alcohol. er physical examination is normal. A complete blood
count and complete chemistry panel! including amylase and lipase le#els! are normal.
)hat is the most appropriate approach to this patient*
+A, 8ndoscopic retrograde cholangiopancreatography +8%/-, with minor papilla
sphincterotomy
+., 'aparotomy with sphincteroplasty o$ the minor papilla
+/, Abdominal computed tomography
+0, /onser#ati#e management
A 46-year-old man with a history cirrhosis attributable to hepatitis / #irus +/F, in$ection and
alcohol abuse who has been abstinent $rom alcohol $or 4 years presents to the clinic with
recent onset o$ increasing abdominal girth! wasting o$ his upper extremities! swelling o$ his
an;les! and a 30-lb weight gain o#er the last 4 months. -hysical examination demonstrates
moderate ascites! muscle wasting! cutaneous stigmata o$ ad#anced li#er disease! and no sign
o$ hepatic encephalopathy. 'aboratory studies re#eal the $ollowingC albumin! 3.0 g/d'D
aspartate aminotrans$erase +A3",! 66 7/d'D alanine aminotrans$erase +A'",! 9@ 7/d'D total
bilirubin! 1.4 mg/d'D international normali(ed ratio +2:%,! 1.&D sodium! 13& meA/'D
potassium! 3.@ meA/'D serum creatinine! 0.B mg/d'D and 7:a! 15 meA/d. Ascitic $luid $indings
on paracentesis include a leu;ocyte count o$ &90/I' +60> polymorphonuclear leu;ocytes, and
an albumin le#el o$ 1.3 g/d'.
2n addition to a salt-restricted diet! which o$ the $ollowing measures is appropriate to initially
manage this patient6s ascites*
+A, 2nstitution o$ a diet with protein and $luid restriction
+., 3erial repeat large-#olume paracentesis
+/, 2nitiation o$ treatment with a loop diuretic
+0, 2nitiation o$ treatment with spironolactone and a loop diuretic
A 36-year-old woman presents in the outpatient clinic complaining o$ constipation. 3he has
been to multiple physicians to obtain relie$. Hor the last 3 years! she has passed one $ormed
stool per wee;! but only with the help o$ daily stimulant laxati#es and a wee;ly tap-water
enema. "here is abdominal $ullness! but no abdominal pain or weight loss. Hlexible
sigmoidoscopy is normal. A colonic transit study demonstrates 40> o$ mar;ers in the
rectosigmoid area on day 6. Anorectal manometry shows an increased sphincter pressure with
straining.
A trial o$ which o$ the $ollowing therapies should be initiated in this patient*
+A, ?etoclopramide
+., ?isoprostol
+/, 5smotic laxati#es
+0, -syllium
+8, .io$eedbac;
2n which o$ the $ollowing indi#iduals is it appropriate to test $or and treat elicobacter pylori*
+A, A 50-year-old asymptomatic man
+., A 4&-year-old asymptomatic woman with a $amily history o$ gastric cancer
+/, A 3@-year-old patient with abdominal pain but without an ulcer +nonulcer dyspepsia,
+0, A 6&-year-old patient with gastroesophageal re$lux disease
+8, A 45-year-old man with a peptic ulcer
A 34-year-old woman comes to her primary care physician with the complaint o$ regular
heartburn. 3he has tried double-dose o#er-the-counter &-receptor antagonists! with
inadeAuate relie$. er only other medications are birth control pills! calcium! and selenium.
3he is 16&.6 cm +64 in, tall and weighs 49.& ;g +104 lb,.
"he patient is gi#en a prescription $or omepra(ole! &0 mg daily. 3he calls bac; & wee;s later
and complains that her heartburn is no better. er physician tells her to increase the dosage o$
omepra(ole to &0 mg be$ore brea;$ast and &0 mg be$ore dinner. 5ne month later at a $ollow-
up #isit! her symptoms are no better.
"he next step $or this patient isC
+A, 'aparoscopic $undoplication
+., 2ncreased dose o$ proton pump inhibitor
+/, 7pper endoscopy
+0, &4-hour esophageal p recording
An 1@-year-old male college student presents with 1aundice and hepatosplenomegaly. e
denies use o$ intra#enous drugs and cocaine or signi$icant alcohol consumption. "here is no
$amily history o$ li#er disease. 5n physical examination! he is 1@0.3 cm +91 in, tall and weighs
@6 ;g +1B0 lb,. %esults o$ laboratory studies are as $ollowsC international normali(ed ratio
+2:%,! 1.&D albumin! 3.4 g/d'D bilirubin! &.1 mg/d'D al;aline phosphatase! &1& 7/'D aspartate
aminotrans$erase +A3",! 3&5 7/'D alanine aminotrans$erase +A'",! 4&3 7/'D 2gE and 2g?
antibody to hepatitis A #irus + 2gE anti-AF! 2g? anti-AF,! negati#eD hepatitis . sur$ace
antigen +.sAg,! negati#eD antibody to hepatitis . core antigen +anti-.c,! negati#eD antibody
to hepatitis / #irus +anti-/F,! negati#eD antinuclear antibody +A:A,! negati#eD anti=smooth
muscle antibody +A3?A,! negati#eD and anti-li#er-;idney microsomal antibodies +anti-'L?,!
negati#e. 7ltrasonography re#eals hepatosplenomegaly. 'i#er biopsy demonstrates chronic
hepatitis with bridging $ibrosis! a slight increase in stainable iron! and occasional ?allory6s
hyaline.
)hich o$ the $ollowing tests is li;ely to be diagnostic*
+A, 3erum iron le#el! total iron-binding capacity! and $erritin le#el
+., emochromatosis gene test
+/, /eruloplasmin le#el! &4-hr urine copper le#el! and slit-lamp examination o$ cornea
+0, .reath analysis and random urine screens $or alcohol
A healthy 35-year-old woman is planning to tra#el to rural ?exico in & wee;s on a 9-day trip
and see;s your ad#ice regarding prophylaxis against #iral hepatitis. 3he denies any prior
history o$ li#er disease or use o$ illicit drugs and has a monogamous heterosexual relationship.
3he is asymptomatic! and her physical examination is normal. 3erologic testing $or antibody to
hepatitis A #irus +anti-AF, +both 2gE and 2g?, is negati#e.
)hich o$ the $ollowing options is the most appropriate*
+A, ?easure hepatitis . sur$ace antigen +.sAg, and antibody to hepatitis . core antigen
+anti-.c,.
+., Administer immune serum globulin
+/, Administer immune serum globulin +23E, and hepatitis . immune globulin +.2E,
+0, Administer hepatitis A #accine
+8, Administer hepatitis A and . #accines
A 44-year-old woman comes to your o$$ice because she has had two attac;s o$ acute
pancreatitis in the past 1@ months. "hese episodes resulted in 5-day hospitali(ations with
typical symptoms and ele#ated amylase and lipase le#els that resol#ed. 3he is otherwise
healthy! has no other signi$icant medical history! ta;es no medications! has had no trauma or
surgery! has no $amily history o$ pancreatitis! and occasionally drin;s alcohol. er physical
examination is normal. er pre#ious e#aluation was entirely normal! including complete blood
count! chemistry pro$iles! li#er tests! triglycerides! calcium! cystic $ibrosis genotype! abdominal
ultrasonography! and abdominal computed tomographic +/", scan.
)hat is the best approach to this patient*
+A, 8ndoscopic retrograde cholangiopancreatography +8%/-, with bile aspiration
+., epatobiliary scan with gallbladder e1ection $raction
+/, Abdominal magnetic resonance imaging +?%2, scan
+0, /linical obser#ation
5n a six-window $ecal occult blood test on appropriate dietary and medication restrictions! a
63-year-old woman has one positi#e window. 3he is otherwise healthy! has no $amily history o$
colorectal cancer! and ta;es no medications. er physical examination and complete blood
count are normal.
"he most appropriate approach to this patient isC
+A, /olonoscopy
+., 3igmoidoscopy
+/, .arium enema
+0, %epeat $ecal occult blood test
+8, Anoscopy
A 60-year-old man comes to your o$$ice $or ad#ice on pre#ention o$ pancreatic cancer. e is
concerned because his brother-in-law recently died o$ this disease. "he patient has no
symptoms. e drin;s $our cups o$ co$$ee and one or two glasses o$ wine daily! smo;es one and
a hal$ pac;s o$ cigarettes daily! and is employed as a tra#eling salesman. e has no pertinent
medical history and ta;es no medications. is physical examination re#eals moderate obesity.
'aboratory studies show a normal complete blood count and normal electrolyte le#els.
)hat is the most appropriate recommendation $or this patient*
+A, .egin a strict #egetarian diet.
+., 3top drin;ing alcohol.
+/, 3top drin;ing co$$ee.
+0, 3top smo;ing.
+8, 3tart a weight-control regimen.
)hich o$ the $ollowing patients with chronic hepatitis / #irus +/F, in$ection is li;ely to ha#e
the lowest rate o$ progression o$ $ibrosis in the li#er*
+A, A woman who acAuired /F in$ection in her early &06s and does not drin; alcohol
+., A man who acAuired /F in$ection at age 45 years and has $our alcoholic drin;s daily
+/, A man with /F/2F coin$ection that he acAuired in his mid 306s
+0, A woman who is immunosuppressed a$ter li#er transplantation at age 45 years
A &4-year-old woman +E3-&A0, presents at 3& wee;s o$ gestation with nausea! anorexia! mild
abdominal discom$ort! and 1aundice a$ter returning $rom a trip to /entral America. -hysical
examination re#eals 1aundice! no stigmata o$ chronic li#er disease or encephalopathy! and a
uterine si(e o$ 3& wee;s6 gestation.
'aboratory studies re#eal the $ollowingC international normali(ed ratio +2:%,! 1.1&D blood
glucose! 105 mg/d'D creatinine! 1.0 mg/d'D albumin! 3.& g/d'D bilirubin! 3.6 mg/d'D al;aline
phosphatase! 3&& 7/'D aspartate aminotrans$erase +A3",! 6&@ 7/'D and alanine
aminotrans$erase +A'",! B54 7/'.
)hich test is li;ely to be diagnostic*
+A, 3erologic tests $or hepatitis 8
+., Antibody to hepatitis . sur$ace antigen +Anti-.sAg,
+/, 2gE antibody to hepatitis A #irus +2gE anti-AF,
+0, /omputed tomography o$ the abdomen and li#er
+8, Hetal monitoring
A 54-year-old man has had a 1&-year history o$ intermittent dyspepsia that occurs on a
monthly basis and usually lasts $or 1 to & wee;s. e has had no weight loss associated with
dyspepsia! and he describes his pain as a burning! epigastric-type abdominal pain without
radiation. At a routine o$$ice #isit $or hypertension 6 months ago! he brought up this medical
history. .ased on this history! he had an o$$ice-based serologic antibody test $or elicobacter
pylori. "his test was positi#e! and he was treated $or . pylori. e was well until approximately
6 wee;s ago! when his symptoms returned. A urea breath test was per$ormed at that time!
which was negati#e. A trial o$ a twice-daily prescription-strength &-receptor antagonist was
then instituted! which pro#ided incomplete relie$. is symptoms persist.
"he appropriate step at this time is toC
+A, 3chedule endoscopy.
+., 5btain a /" scan o$ the pancreas.
+/, %etreat $or . pylori in$ection.
+0, 3tart therapy with amitriptyline.
+8, 2nitiate a trial o$ a pro;inetic agent.
A 5@-year-old white man presents to your o$$ice with a history o$ losing 50 lb in the last 3
months. 2n the past month! he has had substernal chest pain and dysphagia $or solid $oods.
Hor 35 years! he has had heartburn at least 3 times per wee;. e used to ta;e bicarbonate $or
relie$ o$ his heartburn.
)hat is the most li;ely diagnosis in this patient*
+A, 8rosi#e esophagitis
+., 8sophageal ulcer
+/, -ill esophagitis
+0, 8sophageal adenocarcinoma
+8, .enign esophageal stricture
A 4&-year-old woman is seen in the emergency room a$ter three episodes o$ melena. er only
medication is a therapeutic nonsteroidal anti-in$lammatory drug +:3A20, $or a long-standing
tennis elbow. 2n the supine position! her pulse rate is @5/min! and her blood pressure is
1&5/@0 mm g. 3itting! her pulse rate is 115/min! and her blood pressure is B0/60 mm g.
"he $irst necessary inter#ention in this patient isC
+A, 0iscontinuation o$ :3A20
+., Figorous #olume replacement
+/, Eastroenterology consultation
+0, 7pper endoscopy
+8, 2ntra#enous administration o$ an &-receptor antagonist
"he next morning the patient in 2tem 40 has a pulse rate o$ @0/min and a blood pressure o$
1&0/95 mm g without orthostatic changes. "he :3A20 has been discontinued. 3he has
passed two large melenic stools. An endoscopic examination shows a 1.0-cm duodenal ulcer
with a clean base +Higure,. A rapid urease test $or elicobacter pylori done at the time o$
endoscopy is positi#e. :o other lesions are seen during endoscopy.
3ee the $igure
"he best treatment approach to this patient isC
+A, )ithhold $ood! and obser#e in the intensi#e care unit $or at least &4 hours.
+., )ithhold $ood! and obser#e on a medical ward $or at least 4@ hours.
+/, 2nitiate early $eeding and high-dose intra#enous &-receptor antagonist therapy.
+0, 2nitiate early $eeding! and discharge with outpatient proton pump inhibitor therapy and
therapy $or eradication o$ . pylori.
+8, 2nitiate early $eeding! and discharge with proton pump inhibitor therapy.
A &0-year-old male college student is diagnosed with acute hepatitis .. e is clinically stable!
without hepatic decompensation! and returns to his dormitory a$ter the clinic #isit. %esults o$
laboratory studies are as $ollowsC alanine aminotrans$erase +A'",! 569 7/'D bilirubin! 1.5
mg/d'D albumin! 3.6 g/d'D international normali(ed ratio +2:%,! 1.0D hepatitis . sur$ace
antigen +.sAg,! positi#eD and 2g? antibody to hepatitis . core antigen +2g? anti-.c,!
positi#e.
epatitis . immune globulin +.2E, and hepatitis . #accine should be administered toC
+A, ?embers o$ his swim team
+., /lassmates in his 8nglish class
+/, ?edical assistant who too; his #ital signs
+0, is cowor;ers at a $ast-$ood restaurant
+8, is roommate
A 4&-year-old woman had a cholecystectomy 1@ months ago $or right upper Auadrant pain
radiating to her shoulder. :o stones were $ound on opening the gallbladder at the operation!
and the pathologic $inding was chronic cholecystitis. 3he continues to ha#e daily attac;s o$
right upper Auadrant pain identical to her pain be$ore the cholecystectomy. "hese attac;s are
not associated with diet or acti#ity.
7ltrasonography and li#er tests during the attac;s! as well as during asymptomatic inter#als!
ha#e been normal. "rials o$ therapy with acid antisecretory agents and pro;inetic agents ha#e
been unsuccess$ul. 7pper intestinal endoscopy is normal.
"he appropriate management o$ this patient at this time isC
+A, 8ndoscopic retrograde cholangiopancreatography +8%/-, with sphincterotomy
+., 3urgical sphincteroplasty
+/, 8%/- with biliary manometry
+0, /holecysto;inin +//L, ultrasonography and hepato-iminodiacetic acid +20A, scan
+8, 3ymptomatic pain management
A 94-year-old man has an @-month history o$ lower abdominal pain! diarrhea! and bleeding.
"he pain is cramping in nature and in both lower Auadrants. e describes approximately three
loose bowel mo#ements per day with blood in most bowel mo#ements. "here has been no
weight loss or $e#er. e has a history o$ atherosclerotic heart disease and hypertension and is
ta;ing diuretics. is abdomen is so$t and nontender! with no masses. 3tool cultures are
negati#e. /olonoscopy shows aphthoid ulcers with an exudate and a narrowed lumen in a
sharply demarcated region o$ the splenic $lexure +Higure,. "here are sigmoid di#erticula and no
other mucosal lesions.
3ee the $igure
"his patient is most li;ely su$$ering $romC
+A, /rohn6s colitis
+., 7lcerati#e colitis
+/, 2schemic colitis
+0, -seudomembranous colitis
+8, /ollagenous colitis
A 49-year-old alcoholic man presents to the emergency department ha#ing had two episodes
o$ hematemesis o#er the pre#ious 3 hours. -hysical examination demonstrates cutaneous
stigmata o$ cirrhosis! splenomegaly! and ascites. "he patient is hemodynamically stable a$ter
intra#enous administration o$ & ' o$ crystalloid.
)hich o$ the $ollowing recommended treatments is appropriate to initiate in the emergency
department be$ore trans$er to the intensi#e care unit*
+A, 2ntra#enous octreotide
+., 2ntra#enous #asopressin
+/, 2ntra#enous nitroglycerin
+0, .alloon tamponade
+8, "rans1ugular intrahepatic portosystemic shunt +"2-3,
A 4&-year-old man comes to your o$$ice complaining o$ diarrhea and weight loss o$ 1@ months6
duration. e has about eight extremely $oul-smelling! tan! oily stools daily. e has se#erely
restricted $ats in his diet because it impro#es his symptoms. is medical history is signi$icant
in that he dran; a pint o$ whis;ey daily $or 19 years. owe#er! he has been abstinent $or 3
years and is acti#e in Alcoholics Anonymous. e has ne#er been diagnosed as ha#ing
pancreatitis! but he had bouts o$ se#ere abdominal pain in his latter years o$ drin;ing. e
ta;es no medications and has had no surgery. 5n physical examination! he is thin! with
temporal muscle wasting. Fital signs are normal! as are examinations o$ the heart! lungs! and
abdomen. %esults o$ laboratory studies include a normal complete blood count! albumin o$ 3.&
g/d'! and normal $asting blood glucose le#el! electrolyte le#els! and renal $unction. A &4-hour
stool collection ta;en a$ter 3 days o$ a diet containing 100 g o$ $at per day has a total weight
o$ 4&0 g and contains && g o$ $at. Abdominal computed tomography +/", re#eals pancreatic
parenchymal atrophy and numerous calci$ications. "he pancreatic duct is not enlarged.
)hat is the best option $or treatment in this patient*
+A, Antidiarrheal medications +loperamide or diphenoxylate, as needed
+., /holestyramine a$ter meals
+/, A gluten-$ree diet
+0, -ancreatic en(yme therapy +pancrelipase,
+8, 'actose-$ree diet
Hollowing 9 days o$ antibiotic therapy $or a urinary tract in$ection! a 3&-year-old woman
de#elops diarrhea $or & days. 3igmoidoscopy is per$ormed +Higure,. 3tool examination is
negati#e $or enteric pathogens and $or /lostridium di$$icile toxin A but is positi#e $or /. di$$icile
toxin .. "reatment with metronida(ole initially helps symptoms! but diarrhea recurs within 5
days o$ its discontinuation.
3ee the $igure
"he most appropriate therapy in this patient isC
+A, A repeat course o$ metronida(ole
+., 5ral #ancomycin
+/, .acitracin
+0, 3accharomyces boulardii
+8, /holestyramine
A 5@-year-old postmenopausal woman presents to the outpatient clinic with $atigue. 3he has a
6-year history o$ iron-de$iciency anemia with low serum iron! low $erritin! high total iron-
binding capacity! and microcytic indices. 3he describes one to two $ormed brown bowel
mo#ements per day! no weight loss! and no hematoche(ia! melena! or hematemesis. 5n
physical examination! her stool is brown and guaiac- negati#e. 7pper endoscopy and
colonoscopy are normal.
)hich o$ the $ollowing is li;ely to be help$ul in determining the diagnosis in this patient*
+A, A therapeutic trial o$ iron
+., A therapeutic trial o$ a gluten-$ree diet
+/, 2gA antiendomysial antibody
+0, ?esenteric angiogram
+8, 3mall bowel radiograph
2n which o$ the $ollowing patients being treated with nonsteroidal anti-in$lammatory drugs
+:3A20s, is prophylactic cotherapy indicated to reduce the ris; o$ :3A20-induced
gastrointestinal bleeding*
+A, A 40-year-old woman with rheumatoid arthritis who is also ta;ing methotrexate
+., A 55-year-old man with an acute attac; o$ gout who is ta;ing allopurinol
+/, A 95-year-old man with osteoarthritis and atrial $ibrillation who is ta;ing war$arin
+0, A 50-year-old woman with $ibromyalgia who has a positi#e serologic test $or elicobacter
pylori
+8, A 45-year-old male marathon runner with chronic ;nee pain
A &@-year-old man with a &&-year history o$ type 1 diabetes mellitus has $reAuent episodes o$
nausea and #omiting! ma;ing glycemic control di$$icult to obtain. A nuclear medicine gastric
emptying study con$irms se#ere gastroparesis with less than &5> gastric emptying at & hours.
)hich o$ the $ollowing therapeutic recommendations is the best long-term treatment $or her
gastroparesis*
+A, ?etoclopramide
+., 8rythromycin
+/, /isapride
+0, HreAuent! small! low-$at! low-$iber $eedings
A &@-year-old man with a &&-year history o$ type 1 diabetes mellitus has $reAuent episodes o$
nausea and #omiting! ma;ing glycemic control di$$icult to obtain. A nuclear medicine gastric
emptying study con$irms se#ere gastroparesis with less than &5> gastric emptying at & hours.
)hich o$ the $ollowing therapeutic recommendations is the best long-term treatment $or her
gastroparesis*
+A, ?etoclopramide
+., 8rythromycin
+/, /isapride
+0, HreAuent! small! low-$at! low-$iber $eedings
A 3@-year-old woman presents with a complaint o$ intermittent right upper Auadrant
abdominal discom$ort. 3he denies use o$ alcohol! intra#enous drugs! or other illicit substances.
3he has ne#er recei#ed a trans$usion! has no tattoos! and wor;s in the ba;ery at her local
supermar;et. 5n physical examination! she is 160 cm +63 in, tall and weighs B5.3 ;g +&10 lb,.
Abdominal examination re#eals a nontender right upper Auadrant.
'aboratory studies re#eal the $ollowingC international normali(ed ratio +2:%,! 1.0D random
blood glucose! &05 mg/d'D albumin! 3.B g/d'D bilirubin! 1.0 mg/d'D al;aline phosphatase! 19@
7/'D aspartate aminotrans$erase +A3",! 134 7/'D and alanine aminotrans$erase +A'",! 149
7/'. %e#iew o$ records indicates similar persistent ele#ations in li#er en(yme le#els $or the last
4 years.
7ltrasonography demonstrates increased echogenicity o$ the li#er! with a normal biliary tract.
'i#er biopsy demonstrates micro#esicular and macro#esicular steatosis! scattered
polymorphonuclear leu;ocytes! and ?allory6s hyaline! and a mild increase in portal and lobular
$ibrosis. 2ron stains are negati#e.
"he most li;ely diagnosis isC
+A, Alcoholic li#er disease
+., epatitis /
+/, :onalcoholic steatohepatitis +:A3,
+0, emochromatosis
+8, Autoimmune chronic hepatitis
"he appropriate initial management $or the patient described in 2tem 51 isC
+A, %e$erral to an alcohol rehabilitation program
+., 2nter$eron
+/, )eight loss and close monitoring $or disease progression
+0, -hlebotomy
+8, -rednisone
A 3B-year-old woman is hospitali(ed with acute gallstone pancreatitis. )ithin &4 hours! she
de#elops hypotension! a(otemia! acute respiratory distress syndrome reAuiring mechanical
#entilation! and 1aundice. %esults o$ laboratory studies include the $ollowingC leu;ocyte count!
1@!000/I'! with @0> granulocytesD total bilirubin! 10 mg/d'D al;aline phosphatase! 465 7/'D
aspartate aminotrans$erase +A3",! B& 7/'D and normal hematocrit! platelet count! and
prothrombin and partial thromboplastin times. 3he is recei#ing broad-spectrum antibiotics and
is currently hemodynamically stable in the intensi#e care unit.
)hat is the optimal approach to this patient*
+A, /ontinuation o$ current therapy
+., 7rgent percutaneous cholecystostomy
+/, 7rgent endoscopic retrograde cholangiopancreatog-raphy +8%/-,
+0, 7rgent cholecystectomy and bile duct exploration
A 65-year-old man complains o$ intermittent red blood on the toilet tissue and mixed with the
stool $or the past 3 months. e has a &0-year history o$ hemorrhoids. e has no signi$icant
medical history and ta;es no medications. is physical examination shows external
hemorrhoids! and a complete blood count is normal.
)hat is the most appropriate recommendation $or this patient*
+A, Hecal occult blood testing to #eri$y bleeding
+., Hecal occult blood testing yearly and sigmoidoscopy e#ery 3 to 5 years
+/, 3igmoidoscopy
+0, /olonoscopy
+8, Anoscopy
)hich o$ the $ollowing patients is an appropriate candidate $or placement o$ a trans1ugular
intrahepatic portosystemic shunt +"2-3,*
+A, A 45-year-old cirrhotic man with persistent moderate ascites despite treatment with
$urosemide! 40 mg/d! and spironolactone! 100 mg/d
+., A 5&-year-old cirrhotic woman with persistent large ascites! a rising serum creatinine
le#el! and an ascitic $luid polymorphonuclear leu;ocyte +-?:, count o$ 400/I' despite
treatment with $urosemide! @0 mg/day! and spironolactone! &00 mg/day
+/, A 59-year-old man with recurrent right cirrhotic hydrothorax despite two therapeutic
thoracenteses and treatment with $urosemide! @0 mg/d! and spironolactone! &00 mg/d
+0, A 4B-year-old man with /hild--ugh class A cirrhosis who has stabili(ed a$ter initial
endoscopic treatment o$ a $irst episode o$ #ariceal hemorrhage
+8, A 5B-year-old man with complete portal #ein occlusion! a normal alpha-$etoprotein le#el!
and no e#idence o$ a hepatic mass on imaging o$ the li#er
A 34-year-old woman presents with a 3-month history o$ heartburn. 3he has heartburn
postprandially nearly e#ery day! with substernal chest pain radiating upward. 3he has no
dysphagia! odynophagia! pulmonary symptoms! or weight loss. 3he is ta;ing no medications!
including o#er-the-counter remedies. 5n physical examination! she is 160 cm +63 in, tall and
weighs 4B.B ;g +110 lb,. 3he does not smo;e or drin; alcohol. 3he runs 5 miles 3 days a
wee;. er laboratory e#aluation is normal. )hat is the most appropriate $irst step in her
e#aluation*
+A, 8ndoscopy
+., Ambulatory &4-hour esophageal p monitoring
+/, 7pper gastrointestinal series
+0, 8sophageal motility study
+8, 8mpiric acid antisecretory therapy
A 4&-year-old man originally presented with new dyspeptic symptoms o$ a month6s duration.
An o$$ice-based whole-blood antibody test $or elicobacter pylori was positi#e! and he was
treated with omepra(ole and amoxicillin and clarithromycin +5A/, twice daily $or 10 days. e
now returns B wee;s later $or a $ollow-up #isit because o$ persistent dyspeptic symptoms. e
$elt better while ta;ing his . pylori therapy! but his symptoms returned 3 wee;s ago and
remain bothersome.
)hich o$ the $ollowing diagnostic tests is optimal to determine i$ this patient has persistent .
pylori in$ection*
+A, 5$$ice-based whole-blood Aualitati#e antibody assay
+., %e$erence laboratory serum Auantitati#e antibody assay
+/, 7rea breath test

+0, 8ndoscopic biopsy
+8, Hecal antigen test
A 9@-year-old man presents with 1aundice and weight loss. e has no abdominal discom$ort
and no ris; $actors $or hepatobiliary or pancreatic disease. 'aboratory studies re#eal an
al;aline phosphatase le#el o$ 1&00 7/'! with a total bilirubin le#el o$ 13.5 mg/d' +direct
$raction o$ 1&,. "ransaminase le#els are normal. /omputed tomography is per$ormed and
re#eals intrahepatic biliary ductal dilation! e#idence o$ a mass in the porta hepatis! and two
small hypoechoic areas in the li#er thought to represent metastatic tumor. "he extrahepatic
biliary tree and pancreas are normal.
"he best management o$ this patient isC
+A, 3urgical therapy with an hepatico1e1unostomy
+., -ercutaneous transhepatic cholangiography +-"/, and stent placement in %adiology
+/, 8ndoscopic retrograde cholangiopancreatography +8%/-, with stent placement
+0, %adiation therapy to the tumor
+8, /hemotherapy
A 50-year-old man is hospitali(ed with pancreatitis due to hypertriglyceridemia. 5#er B6
hours! he de#elops hypotension! renal $ailure! acute respiratory distress syndrome! and
disseminated intra#ascular coagulation. e has recei#ed prophylactic imipenem! is on a
mechanical #entilator in the intensi#e care unit! and has no e#idence o$ gallstones or biliary
obstruction.
)hat is the most appropriate inter#ention*
+A, 7rgent endoscopic retrograde cholangiopancreatog-raphy +8%/-,
+., -eritoneal la#age
+/, 3urgical debridement
+0, /ontrast-enhanced computed tomography +/", with aspiration o$ necrosis
A &5-year-old primipara presents at &9 wee;s o$ gestation with new onset o$ mild intermittent
pruritus. -hysical examination is negati#e $or 1aundice or $eatures o$ underlying chronic li#er
diseaseD uterine si(e is 30 wee;s6 gestation.
%esults o$ laboratory studies are as $ollowsC international normali(ed ratio +2:%,! 0.BD albumin!
3.3 g/d'D bilirubin! 1.0 mg/d'D al;aline phosphatase! &69 7/'D aspartate aminotrans$erase
+A3",! &6 7/'D alanine aminotrans$erase +A'",! &9 7/'D and gamma-glutamyltrans$erase
+EE",! 49 7/'. 7ltrasonography o$ the li#er and biliary tree is normal.
Appropriate initial management o$ this patient6s pruritus would beC
+A, %eassurance with $reAuent outpatient monitoring o$ symptoms! li#er tests! and $etal
acti#ity
+., /holestyramine
+/, 0iphenhydramine hydrochloride +.enadryl,
+0, -henobarbital
+8, 2nduction o$ labor
A 9&-year-old woman is brought to the emergency room with recent onset o$ lightheadedness
and passage o$ red blood $rom her rectum. er pulse rate is 1&&/min! and her blood pressure
is B0/5& mm g. Abdominal examination demonstrates no masses! organomegaly! or
tenderness. A$ter #olume restoration and hemodynamic stabili(ation! upper endoscopy re#eals
a nonbleeding #isible #essel in a duodenal ulcer +Higure,.
3ee the $igure
)hat is the most appropriate therapy $or this patient*
+A, 3urgical inter#ention
+., 2ntra#enous &-receptor antagonist
+/, 2ntra#enous #asopressin
+0, 8ndoscopic in1ection and/or thermal coagulation therapy
A 55-year-old man goes to his primary care physician $or symptoms o$ gastroesophageal
re$lux. e has been ha#ing heartburn $or 15 years and heard about the ris; o$ esophageal
cancer.
"he patient has no other symptoms and is ta;ing no medication. is physical examination is
normal! and he is re$erred to a gastroenterologist. "he gastroenterologist per$orms an
endoscopy and sends a report to the primary care physician! including the picture shown here.
3ee the $igure
"o ensure that the correct diagnosis has been made the $ollowing criterion needs to be
documentedC
+A, Abnormal &4-hour esophageal p recording
+., Abnormal lower esophageal sphincter pressure
+/, 2ntestinal metaplasia on esophageal biopsy
+0, Abnormal barium swallow
A 6@-year-old woman is $ound to ha#e a gastric mass on endoscopy. 3he was re$erred $or
endoscopy because o$ weight loss and early satiety. .iopsy o$ the mass and surrounding
mucosa re#eals low-grade gastric mucosa-associated lymphoid tissue +?A'", lymphoma and
elicobacter pylori in$ection. 3taging by computed tomography and endoscopic
ultrasonography detects no e#idence o$ ad#anced disease.
Appropriate therapy at this time isC
+A, 3urgical gastrectomy
+., %adiation o$ the in#ol#ed area
+/, Abdominal radiation and ad1uncti#e chemotherapy
+0, "herapy $or . pylori in$ection
A 59-year-old man presents to the emergency room with a 3-month history o$ wea;ness and
#oluminous diarrhea. e has had loose bowel mo#ements $or 3 years! but symptoms ha#e
recently become much more se#ere. e passes more than ten watery! light-brown bowel
mo#ements per day and is constantly drin;ing $luids. e is $ound to ha#e orthostatic
hypotension and is admitted to the hospital. As an inpatient! his diarrhea persists despite
$asting and intra#enous hydration. e passes 3 ' o$ stool per day! with stool e#aluation
demonstrating a sodium concentration o$ @0 meA/'! a potassium concentration o$ 60 meA/'!
and an osmolality o$ &@0 m5sm/'. 3tool culture and laxati#e screen are negati#e. :asogastric
suction dramatically decreases stool output to less than 1 ' per day.
At this time! this patient should be treated withC
+A, 5ctreotide
+., 'operamide
+/, 0eodori(ed tincture o$ opium
+0, -roton pump inhibitor
+8, &-receptor antagonist
You ha#e been $ollowing a 59-year-old woman who su$$ered acute pancreatitis due to a motor
#ehicle accident with a steering-wheel in1ury @ months ago. 3he was hospitali(ed $or & wee;s
and recei#ed parenteral nutrition at home $or another 3 wee;s be$ore ha#ing a symptomatic
reco#ery. 3he remains totally asymptomatic. 3he has no signi$icant medical history! ta;es no
medications! and does not drin; alcohol. "he physical examination re#eals only epigastric
$ullness to deep palpation! without pain or tenderness. %esults o$ laboratory studies include an
amylase le#el o$ 1@0 7/'. 3erial computed tomographic +/", scans demonstrate se#ere
in$lammation that has e#ol#ed into an @-cm cystic lesion with a well-de$ined capsule in the
mid-pancreatic body. "he lesion has not changed in 6 months.
"he best management option $or this patient isC
+A, /onser#ati#e management
+., -ercutaneous catheter drainage
+/, 8ndoscopic retrograde cholangiopancreatography +8%/-, with internal drainage
+0, 3urgical drainage
+8, %einstitution o$ parenteral nutrition
A 35-year-old man comes to you $or routine health maintenance. e has no complaints and no
signi$icant medical history and ta;es no medications. is $amily history is signi$icant $or colon
cancer in his mother at age 5& years! his brother at age 4& years! and his sister at age 40
years. is physical examination is normal. )hat is the most appropriate recommendation $or
this man*
+A, Yearly $ecal occult blood testing and sigmoidoscopy e#ery 3 to 5 years beginning at age
50 years
+., /olonoscopy e#ery 5 years beginning at age 50 years
+/, /olonoscopy immediately
+0, .arium enema yearly beginning immediately
All o$ the $ollowing patients ha#e a history o$ exposure to hepatitis / #irus +/F, &0 to &5
years ago and ha#e moderate in$lammation +grade &/4, and bridging $ibrosis +stage 3/4, on
li#er biopsy.
2n which patient is inter$eron-based therapy appropriate*
+A, A 44-year-old woman with a remote history o$ mild depression
+., A 5&-year-old acti#ely alcoholic man with a history o$ poor medication compliance
+/, A 35-year-old man with poorly controlled insulin-dependent diabetes mellitus and
psoriasis
+0, A 40-year-old man who currently uses intra#enous drugs
+8, A 3@-year-old woman with a post-traumatic sei(ure disorder reAuiring chronic
anticon#ulsant therapy
A &&-year-old woman presents in the outpatient clinic complaining o$ many years o$ bloating!
diarrhea! and cramping abdominal pain. 3he describes three loose or watery bowel
mo#ements per day with bloating! distention! and cramping be$ore each bowel mo#ement.
-eriods o$ $asting completely relie#e symptoms. "here has been no weight loss! $e#ers! or
hematoche(ia. -hysical examination is unremar;able. Hlexible sigmoidoscopy and stool
cultures are normal. 3tool e#aluation shows a sodium concentration o$ 30 meA/'! a potassium
concentration o$ 40 meA/'! and an osmolality o$ 300 m5sm/'.
"he best therapy $or this patient isC
+A, 'operamide
+., yoscyamine
+/, -syllium
+0, -rednisone
+8, 'actose-$ree diet
A 6@-year-old woman with a history o$ peptic ulcer disease has been on maintenance
cimetidine $or ulcer prophylaxis $or the last 13 years. An o$$ice-based whole-blood antibody
test $or elicobacter pylori is obtained and is positi#e! and anti=. pylori therapy is initiated.
"he most e$$ecti#e regimen $or eradicating . pylori in this patient isC
+A, -epto-.ismol! tetracycline! and metronida(ole
+., -epto-.ismol! tetracycline! and metronida(ole plus a proton pump inhibitor
+/, A proton pump inhibitor! amoxicillin! and clarithromycin
+0, A proton pump inhibitor and clarithromycin
A 33-year-old man who has undergone renal transplantation is on maintenance
immunosuppression with cyclosporine! a(athioprine! and prednisone. e $reAuently tra#els to
A$rica and is interested in recei#ing hepatitis A #accination. is physical examination is
otherwise normal. %esults o$ laboratory studies are as $ollowsC alanine aminotrans$erase +A'",!
15 7/'D bilirubin! 1.0 mg/d'D albumin! 3.5 g/d'D international normali(ed ratio +2:%,! 0.BD
hepatitis . sur$ace antigen +.sAg,! negati#eD antibody to hepatitis . core antigen +anti-.c,!
negati#eD and antibody to hepatitis / #irus +anti-/F,! positi#e.
)hich o$ the $ollowing is true regarding the use o$ hepatitis A #accine in this patient*
+A, e should be #accinated because it is sa$e and he may mount a protecti#e antibody
response.
+., e should not be #accinated because he has chronic hepatitis / and #accination could
precipitate li#er $ailure.
+/, e should not be #accinated because the #accine is ine$$ecti#e in immunosuppressed
patients.
+0, e does not need to be #accinated because he is not li;ely to be exposed to hepatitis A.
A 5@-year-old man is $ound to ha#e a 3-cm sessile lesion in the sigmoid colon at screening
sigmoidoscopy! and histologic examination o$ biopsy specimens re#eals adenocarcinoma. "he
patient has no symptoms or signi$icant medical history! and the physical examination and
complete blood count are normal. You recommend surgery! and the patient agrees.
"he most appropriate preoperati#e test in this patient isC
+A, 'i#er en(yme studies
+., /omputed tomography o$ the abdomen
+/, /olonoscopy
+0, 8ndoscopic ultrasonography
A 50-year-old woman with a remote history o$ blood trans$usions is $ound on a screening
physical examination to ha#e spider angiomas and palpable splenomegaly. 3he is otherwise
healthy. 'aboratory test abnormalities are limited to mild aminotrans$erase ele#ations and a
platelet count o$ 110!000/I'. 3ubseAuent e#aluation re#eals that she is positi#e $or antibody
to hepatitis / #irus +anti-/F,! and li#er biopsy re#eals cirrhosis. 3creening endoscopy
demonstrates large distal esophageal #arices.
"he most appropriate treatment recommendation would beC
+A, :onselecti#e beta-bloc;er
+., .and ligation
+/, .and ligation and sclerotherapy
+0, 0ietary protein restriction
+8, 2sosorbide mononitrate
A &B-year-old woman had a cholecystectomy 5 years ago $or biliary-type pain and sludge
detected in her gallbladder by ultrasonography. 3ince that time! she has had $our to $i#e
attac;s o$ biliary-type pain per year! described as right upper Auadrant pain that radiates to
her right scapula. "he pain is similar to that she had prior to her cholecystectomy. 0uring
asymptomatic periods! ultrasonography and li#er tests are normal! but during attac;s! her
li#er en(yme le#els become ele#ated! with an al;aline phosphatase le#el three times normal
and transaminase le#els three to $our times normal. "hese laboratory abnormalities normali(e
$ollowing resolution o$ her pain. 8ndoscopic retrograde cholangiopancreatography +8%/-, and
biliary manometry are per$ormed. 8%/- is normal! but biliary manometry re#eals biliary
sphincter pressures ele#ated to @5 mm g +normal! K 40 mm g,.
Appropriate management o$ this patient isC
+A, 8ndoscopic sphincterotomy
+., /holedochoenterotomy
+/, :itrates and/or calcium channel bloc;ers
+0, 2n1ection o$ botulinum toxin into the sphincter.
+8, .alloon dilation o$ the sphincter
A 64-year-old woman has disabling le$t ;nee pain secondary to osteoarthritis. er medical
history is signi$icant $or a bleeding peptic ulcer reAuiring a trans$usion o$ @ units o$ blood when
she was 5& years old. -hysical examination re#eals a nonin$lammatory 1oint. 'aboratory
e#aluation re#eals a normal complete blood count! and both a elicobacter pylori antibody test
and a urea breath test are negati#e $or in$ection. ?anagement o$ osteoarthritis! including
physical therapy! exercise! and 1oint in1ection! is discussed with this patient. At this time! she
reAuests simple analgesia.
)hich o$ the $ollowing analgesics would you choose $or this patient at this time*
+A, 2bupro$en
+., -iroxicam
+/, 3tandard-dose aspirin
+0, 'ow-dose aspirin
+8, Acetaminophen
A 6&-year-old man has had di$$iculty swallowing $or 6 wee;s. Hoods such as meat and bread
stic; at his mid-sternum. e is able to get the $ood down with liAuid. e has lost 6 lb in the
last 3 wee;s. e has smo;ed 1 pac; o$ cigarettes per day $or 45 years. e has been a
reco#ering alcoholic $or 5 years. e denies a history o$ re$lux symptoms.
5n physical examination! his #ital signs are normal. e has no adenopathy! a clear chest! and
normal heart sounds. is abdominal examination is normal! and no muscle wasting is
apparent.
"he highest-yield $irst e#aluation $or this patient isC
+A, 7pper endoscopy
+., /omputed tomography o$ the chest and abdomen
+/, 7pper gastrointestinal series
+0, 3urgery consultation
A 63-year-old woman presents with mild pruritus. -hysical examination re#eals
hyperpigmentation o$ the s;in! xanthelasma! and hepatosplenomegaly. %esults o$ laboratory
studies are as $ollowsC 2:%! 1.1D albumin! 3.6 g/d'D bilirubin! 1.3 mg/d'D al;aline
phosphatase! &1&3 7/'D aspartate aminotrans$erase +A3",! 9@ 7/'D alanine aminotrans$erase
+A'",! B@ 7/'D and antimitochondrial antibody +A?A,! positi#e +M 1C&560,. 7ltrasonography
re#eals hepatosplenomegaly and gallstones! but no biliary dilation.
'i#er biopsy demonstrates lymphocytic portal in$iltrates! reduced number o$ bile ducts! and
cirrhosis.
)hich o$ the $ollowing measures should be considered in the initial management o$ this
patient*
+A, 'ow-protein diet
+., 1!&5-dihydroxy#itamin 0 therapy
+/, 7rsodeoxycholate
+0, ?ethotrexate
+8, %e$erral $or cholecystectomy
A 4@-year-old man is hospitali(ed with acute pancreatitis! which resol#es a$ter @ days. e has
no signi$icant medical history! ta;es no medications! and has ne#er used alcohol hea#ily.
%esults o$ his e#aluation include a normal blood count! normal li#er tests! and normal
abdominal ultrasonography.
)hich o$ the $ollowing diagnostic tests could identi$y the cause o$ this patient6s pancreatitis*
+A, Hasting serum triglyceride le#el and a serum calcium le#el
+., 3erum cholesterol
+/, Elucose tolerance test
+0, 3erum /A 1B-B
A 46-year-old man presents with hemodynamically stable upper gastrointestinal bleeding
+mani$ested by melena,. e is admitted to the hospital! and on the $ollowing day! he
undergoes endoscopy! which demonstrates a nonbleeding! clean-based gastric ulcer. e uses
ibupro$en chronically $or low bac; pain. A whole-blood antibody test $or elicobacter pylori is
positi#e. e is discharged a$ter an une#ent$ul 4@-hour hospital stay. e now returns $or an
o$$ice $ollow-up #isit.
)hat is the appropriate long-term management o$ this patient6s ulcer disease*
+A, 0iscontinue use o$ all nonsteroidal anti-in$lammatory drugs +:3A20s,! and ma;e no other
changes in therapy.
+., 3ubstitute celecoxib or ro$ecoxib $or ibupro$en.
+/, "reat his . pylori in$ection prior to restarting :3A20 therapy.
+0, "reat his . pylori in$ection! and discontinue :3A20 therapy.
+8, Add misoprostol! and continue his :3A20 therapy.
A 3@-year-old woman is admitted to the medical ser#ice with 1aundice and mental con$usion.
3he admits to drin;ing 1 Auart o$ #od;a per day $or the last 3 wee;s. 5n physical examination!
she has a temperature o$ 39.@ G/ +100.04 GH,! with 1aundice! spider telangiectasia! a tender
and enlarged li#er! and a protuberant abdomen with $luid wa#e. 3he has asterixis.
'aboratory studies
emoglobin 10.1 g/d'
ematocrit 31>
'eu;ocyte count 19!000/I' +95> polymorphonuclear leu;ocytes! 5> band neutrophils,
-latelet count 1@9!000/I'
2nternational normali(ed ratio +2:%, &.1 +prothrombin time! &0 sec,
.lood urea nitrogen &4 mg/d'
/reatinine 1.@ mg/d'
Albumin &.6 g/d'
.ilirubin 19.& mg/d'
Al;aline phosphatase &@@ 7/'
Aspartate aminotrans$erase +A3", 11@ 7/'
Alanine aminotrans$erase +A'", 4@ 7/'
Eamma-glutamyltrans$erase +EE", 34& 7/'
7ltrasonography con$irms hepatomegaly and ascites. -aracentesis is per$ormed! and ascitic
$luid studies show a leu;ocyte count o$ 150/I' +@0> polymorphonuclear leu;ocytes, and an
albumin le#el o$ 1.3 g/d'.
)hich therapy is most appropriate in the management o$ this patient*
+A, "reatment with haloperidol as prophylaxis against sei(ures
+., -rednisone
+/, Hluid restriction and diuretic therapy
+0, 8mpiric antibiotics
+8, 8ndoscopic retrograde cholangiopancreatography +8%/-, and papillotomy
5ne year a$ter total proctocolectomy with ileal pouch=anal anastomosis $or ulcerati#e colitis! a
&&-year-old woman is seen in the outpatient clinic complaining o$ a 4-day history o$ diarrhea!
bleeding! and $e#er. .owel mo#ements ha#e increased $rom $our per day to ten per day! with
blood in e#ery bowel mo#ement. He#ers ha#e reached 3@ G/ +100.4 GH, daily. 3tool cultures
are negati#e $or enteric pathogens. 8ndoscopic examination o$ the pouch re#eals di$$use!
super$icial ulcerations with $riability and granularity. "he a$$erent limb is normal in appearance.
"his patient should be treated withC
+A, -rednisone
+., 3ul$asala(ine
+/, 5-Aminosalicylic acid enemas
+0, ydrocortisone enemas
+8, ?etronida(ole
A 5@-year-old woman has recently mo#ed to your city and see;s consultation with you
because she has a history o$ a colonic polyp. 3he underwent a complete colonoscopy 10
months ago $or a positi#e $ecal occult blood test. 3he was $ound to ha#e a 1&-mm
adenomatous polyp in the descending colon. "he polyp was completely remo#ed. 3he has no
other signi$icant medical history! and her physical examination is normal.
+A, Hecal occult blood testing yearly and sigmoidoscopy e#ery 3 to 5 years
+., /olonoscopy 1 year a$ter the polypectomy and then at 3 to 5 year inter#als
+/, /olonoscopy 3 years a$ter the polypectomy and then at 3- to 5-year inter#als i$ no
$urther lesions are $ound
+0, .arium enema e#ery 3 to 5 years.
+8, Hlexible sigmoidoscopy in 1 year.
A &5-year-old man with a &-month history o$ ulcerati#e colitis presents to the emergency
department with $atigue! abdominal pain! bleeding! and diarrhea. 3ince his diagnosis! he has
been treated with prednisone! &0 mg/day! and sul$asala(ine! & g/day. Hor the last wee;! he
has had about ten bloody bowel mo#ements per day and cramping abdominal pain. e is
admitted to the hospital! where hydration and intra#enous glucocorticoids are gi#en. 2n the
last & hours! approximately &4 hours a$ter admission! the abdominal pain has become worse!
he has not had a bowel mo#ement! and he has de#eloped abdominal distention. 5n physical
examination! he has a temperature o$ 3@ G/ +100.4 GH,! his pulse rate is 110/min! and his
abdomen is distended and di$$usely tender without rebound tenderness. An abdominal $lat-
plate radiograph is obtained +Higure,.
3ee the $igure
"he most appropriate therapy $or this patient isC
+A, Anti=tumor necrosis $actor antibody +in$liximab,
+., 2ntra#enous cyclosporine
+/, 6-?ercaptopurine
+0, 2ntramuscular methotrexate
+8, 3ubtotal colectomy
Hor the past 5 years! a 64-year-old woman with a &0-year history o$ poorly controlled type &
diabetes mellitus has noted intermittent episodes o$ nausea! which are worse upon awa;ening
in the morning and are $ollowed by #omiting. "hese episodes originally occurred e#ery $ew
months! would last & to 3 days! and were correlated with periods o$ poor glycemic control.
"hese episodes now occur biwee;ly! last 4 to 5 days! and are not associated with
hyperglycemia.
3he has also had concomitant e#idence o$ peripheral neuropathy and an autonomic
dys$unction mani$ested by postural hypotension.
"he best test to diagnose the cause o$ this patient6s nausea and #omiting isC
+A, 7pper gastrointestinal series with barium
+., :uclear medicine gastric emptying study
+/, 7pper intestinal endoscopy
+0, 8lectrogastrography +8EE,
A 49-year-old woman who underwent orthotopic li#er transplantation $or autoimmune chronic
acti#e hepatitis 3 months ago presents to your clinic with malaise. -hysical examination
re#eals the abdominal scar $rom the transplant! but there is no 1aundice! ascites! edema!
gastrointestinal bleeding! or encephalopathy. 'aboratory studies re#eal the $ollowingC
hematocrit! 30>D leu;ocyte count! 9@00/I'D platelet count! 115!000/I'D 2:%! 1.0D albumin!
3.3 g/d'D bilirubin! 1.@ mg/d'D al;aline phosphatase! @B 7/'D aspartate aminotrans$erase
+A3",! @B 7/'D and alanine aminotrans$erase +A'",! 114 7/'.
er transplant surgery was uncomplicatedD she had an une#ent$ul reco#ery and was
discharged @ days a$ter the transplant. er doses o$ immunosuppressi#e medications ha#e
been progressi#ely lowered by the transplant team. /urrent immunosuppression consists o$
cyclosporine! 150 mg twice dailyD prednisone! 10 mg/dD and a(athioprine! 50 mg/d. 'e#els o$
cyclosporine ha#e been in the lower end o$ the therapeutic range. You discuss the $indings with
the transplant team! and the decision is to proceed with a li#er biopsy the next morning.
)hich o$ the $ollowing diagnoses is most li;ely*
+A, epatic artery thrombosis
+., -ortal #ein thrombosis
+/, /ytomegalo#irus +/?F, hepatitis
+0, epatotoxicity $rom cyclosporine and a(athioprine
+8, Allogra$t re1ection
A 94-year-old woman comes to your o$$ice with a &-wee; history o$ anorexia! weight loss! and
1aundice. 3he has no other symptoms! ta;es no medications! and has had no surgery. "he
physical examination is remar;able only $or scleral icterus and mild 1aundice. %esults o$
laboratory studies include a normal complete blood count and electrolyte le#els! total bilirubin
o$ B mg/d'! al;aline phosphatase o$ 5@6 7/'! alanine aminotrans$erase +A'", o$ B6 7/'! and
albumin o$ 3.& g/d'. 7ltrasonography shows no stones but re#eals ductal dilation proximal to
the head o$ the pancreas.
"he most appropriate next diagnostic step isC
+A, 3erum carcinoembryonic antigen +/8A,
+., Abdominal computed tomography
+/, 8ndoscopic retrograde cholangiopancreatography +8%/-,
+0, -ercutaneous transhepatic cholangiography
+8, /A 1B-B
A 35-year-old woman comes to see you $or health maintenance. 3he has no symptoms and no
signi$icant medical history and ta;es no medications. er $ather died o$ colon cancer at age 46
years. :o other $amily members ha#e colon cancer. er physical examination is normal.
)hat is the most appropriate sur#eillance program $or this patient*
+A, Hecal occult blood testing yearly and $lexible sigmoid-oscopy e#ery 3 to 5 years beginning
at age 40 years
+., Hecal occult blood testing yearly and $lexible sigmoid-oscopy e#ery 3 to 5 years beginning
at age 50 years
+/, /olonoscopy e#ery 3 to 5 years beginning at age 36 years
+0, Hlexible sigmoidoscopy
A 40-year-old woman contracted chronic hepatitis / #irus +/F, in$ection $rom a blood
trans$usion more than &0 years ago. er physical examination re#eals no signs o$ ad#anced
li#er disease! and the only abnormalities on her complete blood count and li#er chemistry
panel are a modestly ele#ated aspartate aminotrans$erase +A3", le#el +95 7/', and alanine
aminotrans$erase +A'", le#el +110 7/',. A li#er biopsy per$ormed 1 year ago demonstrated
moderately acti#e inter$ace hepatitis and $ocal bridging $ibrosis. 3he is interested in
combination riba#irin- inter$eron therapy a$ter reading about it on the 2nternet.
)hat is the most appropriate test to per$orm be$ore initiating combination inter$eron-riba#irin
treatment in this patient*
+A, %epeat li#er biopsy
+., %ecombinant immunoblot assay +%2.A,
+/, Jualitati#e /F %:A
+0, Juantitati#e /F %:A by polymerase chain reaction
+8, /F %:A genotype
A 5&-year-old woman is hospitali(ed with acute pancreatitis and cholelithiasis with a normal
bile duct on ultrasonography. 3he has no signi$icant medical history! does not drin; alcohol!
and has normal serum li#er tests! chemistry panel! and lipid le#els. 3he reco#ers $rom her
symptoms a$ter 4 days o$ treatment with intra#enous hydration and analgesics and $eels $it
and hungry.
)hat is the most appropriate treatment $or this patient*
+A, /onser#ati#e management
+., 8ndoscopic retrograde cholangiopancreatography +8%/-,
+/, /holecystectomy
+0, 8xtracorporeal shoc;-wa#e lithotripsy +83)',
A 33-year-old woman complains o$ a 3-year history o$ daily lower abdominal pain and
diarrhea. "he pain is cramping in nature! is in both lower Auadrants! and is relie#ed with a
bowel mo#ement. -ain and abdominal distention occur while eating and are relie#ed with a
loose! nonbloody bowel mo#ement $ollowing each meal. "here has been no incontinence!
weight loss! $e#ers! nausea! or #omiting. A lactose-$ree diet has not helped. 5$ note in her
social history is that $or the last 3 years! she has been the primary caregi#er $or her mother!
who has Al(heimer6s disease. -hysical examination is normal. -re#ious e#aluation in the last 6
months has included normal stool cultures and a normal $lexible sigmoidoscopy.
8#aluation and management o$ this patient should includeC
+A, /olonoscopy
+., Anorectal manometry
+/, 'actose breath test
+0, -sychiatry consultation
+8, %eassurance that no organic disease is present
A 56-year-old man has had heartburn and regurgitation since he graduated $rom college. 2n
the last 5 years! he has had these symptoms almost daily! e#en with ta;ing a prescription &-
receptor antagonist twice daily. e is o#erweight. e exercises regularly and cannot seem to
lose the last 10 pounds. e is ta;es @0 mg o$ aspirin daily and neither smo;es nor drin;s
alcohol. e does not eat $or 3 hours prior to going to bed.
5n endoscopy! he is $ound to ha#e erosi#e esophagitis. "herapy was changed $rom an &-
receptor antagonist to a proton pump inhibitor. )ithin 3 wee;s o$ initiation o$ proton pump
inhibitor therapy! his gastroesophageal re$lux symptoms are totally resol#ed.
At his 3-month $ollow-up #isit! what inter#ention is appropriate*
+A, /ontinue proton pump inhibitor therapy.
+., -er$orm $ollow-up endoscopy to document healing o$ esophagitis.
+/, /hange medication to &-receptor antagonist $or maintenance therapy.
+0, 5btain &4-hour esophageal p recording to document esophageal acid control.
+8, /hange medication to a pro;inetic agent.
A 4@-year-old male recipient o$ a li#er allogra$t presents 1 year a$ter transplantation with
abnormal li#er test results. is pretransplant diagnosis was chronic hepatitis /. -hysical
examination is unremar;able. 'aboratory studies re#eal the $ollowingC 2:%! 0.B5D albumin! 3.@
g/d'D bilirubin! 1.0 mg/d'D al;aline phosphatase! 1@9 7/'D aspartate aminotrans$erase +A3",!
&13 7/'D and alanine aminotrans$erase +A'",! 314 7/'. 'i#er biopsy re#eals chronic
in$lammation in portal tracts! with piecemeal necrosis and scattered lobular in$lammation.
"he most li;ely cause o$ the abnormal li#er en(yme le#els is*
+A, %ecurrent hepatitis /
+., Allogra$t re1ection
+/, epatic artery thrombosis
+0, epatotoxicity due to cyclosporine or tacrolimus
+8, .iliary stricture
A &@-year-old man is hospitali(ed with acute pancreatitis! which has resol#ed. e is able to eat
a normal diet. is medical history is signi$icant $or /rohn6s disease o$ the ileum and colon since
age 1@ years. e has had problems with perianal $istulas! which are much impro#ed a$ter &
months o$ therapy with a(athioprine and 3 wee;s o$ treatment with cipro$loxacin. is
medications include mesalamine! 4 g dailyD cipro$loxacin! 500 mg twice dailyD a(athioprine!
150 mg dailyD and a multi#itamin. e does not drin; alcohol. %esults o$ all laboratory tests are
normal! and abdominal ultrasonography is normal.
)hat is the most appropriate inter#ention*
+A, 0iscontinue the mesalamine.
+., 0iscontinue the cipro$loxacin.
+/, 0iscontinue the a(athioprine.
+0, 0iscontinue the multi#itamin.
An 6@-year-old man presents to the emergency room with a &-day history o$ diarrhea. e has
recently returned $rom a #acation to :ew 5rleans with his $amily! and his daughter also
de#eloped diarrhea. A$ter 1 day o$ watery bowel mo#ements! hematoche(ia de#eloped! as well
as cramping abdominal pain and #omiting. -hysical examination re#eals orthostatic
hypotension. At presentation! his blood urea nitrogen +.7:, is 30 mg/d'! creatinine is 1.5
mg/d'! and hemoglobin is 11.5 g/d'. e is admitted to the hospital $or rehydration. 3tool
cultures $or routine enteric pathogens are negati#e. "wo days later! his .7: is 50 mg/d'!
creatinine is 3.0 mg/d'! hemoglobin is @.5 g/d'! and platelet count is 55!000/I'.
"his patient is most li;ely su$$ering $rom in$ection withC
+A, 3higella
+., 3almonella
+/, Fibrio cholerae
+0, 8nterotoxigenic 8scherichia coli
+8, 8. coli 5159C9
A 4B-year-old woman has had persistent! but intermittent! dyspepsia $or the last 10 years.
3he denies heartburn! regurgitation! nausea! #omiting! weight loss! or other gastrointestinal
symptoms. 7pper intestinal endoscopy is normal! but a rapid urease test per$ormed on a
normal-appearing gastric biopsy specimen is positi#e $or elicobacter pylori. Abdominal
ultrasonography shows no e#idence o$ hepatobiliary or pancreatic disease.
2$ treated $or . pylori in$ection! what is the li;elihood that this patient will show symptom
impro#ement at 1 year*
+A, 95>
+., 50>
+/, &5>
+0, 0>
A 3&-year-old man presents to the outpatient clinic with diarrhea and hematoche(ia o$ 4
months6 duration. e has been diagnosed with ulcerati#e colitis in the past! with disease
extending $rom the rectum to the hepatic $lexure. e has been maintained on 5-aminosalicylic
acid therapy. e smo;es cigarettes. "his current $lare has not responded to prednisone.
/olonoscopy shows in$lammation in the colon $rom the rectum to the hepatic $lexure. "he
ulcerations are deep and serpiginous with an exudate! and the areas between the ulcers are
less in#ol#ed with in$lammation. "he rectum is much less ulcerated than the remainder o$ the
in#ol#ed colon. "he terminal ileum is normal. A perinuclear antineutrophil cytoplasmic antibody
+p-A:/A, test is negati#e! and an anti=3accharomyces cere#isiae antibody +A3/A, test is
positi#e.
"he most li;ely diagnosis in this patient isC
+A, 7lcerati#e colitis
+., /rohn6s colitis
+/, 2n$ectious colitis
+0, /ollagenous colitis
+8, -seudomembranous colitis
)hich o$ the $ollowing patients with chronic hepatitis / #irus +/F, in$ection is most
appropriate to consider $or inter$eron-based treatment*
+A, A 65-year-old woman with $atigue! thrombocytopenia! and cirrhosis on biopsy with no
e#idence o$ hepatic dys$unction
+., A 60-year-old woman with $atigue who recei#ed blood trans$usions at age &0 years and
who has mild chronic hepatitis and no e#idence o$ $ibrosis on li#er biopsy
+/, A 45-year-old asymptomatic man in$ected in his late &06s in whom a li#er biopsy re#eals
moderate in$lammation and bridging $ibrosis
+0, A 45-year-old asymptomatic woman with persistently normal li#er en(yme le#els who
recei#ed blood trans$usions at age &5 years
+8, A 45-year-old man who was in$ected in his early &06s who has a serum albumin le#el o$
&.@ g/d'! 2:% o$ 1.5! and thrombocytopenia and in whom a li#er biopsy demonstrates
cirrhosis.
You see a 6@-year-old man who underwent resection o$ an adenocarcinoma o$ the trans#erse
colon 6 months ago. "here was adeAuate resection and nodal dissection. :either in#asion o$
other organs nor lymph node metastases were $ound. "he patient $eels $it! with no complaints!
and he has no signi$icant medical history. "he physical examination and complete blood count
are normal.
+A, 'i#er tests yearly
+., Abdominal computed tomography yearly
+/, Hecal occult blood testing yearly and sigmoidoscopy e#ery 3 to 5 years
+0, /olonoscopy 1 year a$ter resectionD i$ no lesions are $ound! repeat colonoscopy 3 years
later and then at 5-year inter#als.
A &B-year-old man presents to the outpatient clinic with 1aundice. e has a 10-year history o$
panulcerati#e colitis. is colitis is currently in remission! and he is maintained on &.4 g/day o$
5-aminosalicylic acid. Hor the last month! he has been told o$ ha#ing yellow sclerae. e has
had two recent episodes o$ $e#er! chills! and worsening 1aundice. is al;aline phosphatase
concentration is 650 7/'! bilirubin concentration is 3.3 mg/d'! and transaminase
concentrations are normal. %ight upper Auadrant ultrasonography shows no hepatic lesions! no
ductal dilation! no stones! and no ascites. 8ndoscopic retrograde cholangiopancreatography
+8%/-, shows NbeadingO o$ the extrahepatic and intrahepatic bile ducts! with no stone and no
dominant stricture +Higure,.
3ee the $igure
"he next step that should be considered in this patient isC
+A, 2ncreasing the dose o$ 5-aminosalicylic acid
+., 2nitiation o$ treatment with prednisone
+/, 2nitiation o$ treatment with 6-mercaptopurine
+0, "otal proctocolectomy
+8, 8#aluation $or li#er transplantation
An @@-year-old man is brought by his $amily to see you $or a &0-lb weight loss! anorexia!
$atigue! depression! se#ere pruritus! and 1aundice. e has no other signi$icant medical or
surgical history. 5n physical examination! he is alert and oriented and cachectic and has a
hard epigastric mass. -ertinent laboratory #alues include total bilirubin o$ &@ mg/d'! al;aline
phosphatase o$ 94& 7/'! and albumin o$ &.4 g/d'. /omputed tomography +/", shows a large
mass in the region o$ the pancreatic head encasing the great #essels! with smaller masses
consistent with metastases to the li#er and peritoneum. A$ter extensi#e discussion with the
patient and his $amily! it is decided that some palliati#e measure be ta;en.
"he most appropriate therapy isC
+A, :aloxone
+., 'aparotomy with biliary bypass
+/, -ercutaneous transhepatic cholangiogram with drains
+0, 8ndoscopic retrograde cholangiopancreatography +8%/-, with stent placement
A 4@-year-old man with ;nown cirrhosis on prior li#er biopsy complains o$ increasing an;le
edema and a 5-lb weight gain. e admits to a signi$icant alcohol historyC 4 to 10 coc;tails
each day as part o$ the social aspects o$ his business $or 15 years. e denies binge drin;ing!
dri#ing under the in$luence! or incarceration related to alcohol. e denies intra#enous drug
use! cocaine use! tattoos! or blood trans$usion. e has been abstinent $rom alcohol $or 3 years
since enrollment in a rehabilitation program. e is married! wor;s $ull time! and has &
children. 5n physical examination! he exhibits a $ew spider telangiectasias! hepatomegaly with
a $irm edge! a palpable spleen! no de$inite ascites! and an;le edema bilaterally. eart sounds
are normal! without rub or gallopD he has a grade 22/F2 systolic murmur along the le$t sternal
border. "here is no clubbing or cyanosis.
%esults o$ laboratory studies are as $ollowsC international normali(ed ratio +2:%,! 1.5D albumin!
3.1 g/d'D bilirubin! &.& mg/d'D al;aline phosphatase! &&4 7/'D aspartate aminotrans$erase
+A3",! 45 7/'D alanine aminotrans$erase +A'",! 4B 7/'D and gamma-glutamyltrans$erase
+EE",! 55 7/'. Firal and autoimmune serologic tests are negati#e! and iron studies are
normal. 'i#er biopsy re#eals micro-nodular cirrhosis without steatosis! ?allory6s hyaline! or
in$lammation. /hest radiograph and electrocardiogram are normal. -ulse oximetry at rest and
with exercise was B9> on room air.
)hat is the appropriate treatment $or this patient*
+A, /aptopril $or alcoholic cardiomyopathy
+., 'i#er transplantation
+/, Elucocorticoid therapy
+0, -rostacyclin in$usion $or treatment o$ pulmonary hypertension.

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