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					Test #16 Q.Id = 80                 Question 1 Of 45                      Division : GIT
                                    Item Review
A 63-year-old man has had difficulty swallowing both solids and liquids for
several months. He describes it as a hesitation at the level of the sternal notch.
He has had occasional oral regurgitations of non-digested food during meals. He
has noted a 3kg(6.6lb)weight loss. His past medical history is remarkable for a
transient ischemic attack 6 months ago, pneumonia twice over the last 3 months,
and long-lasting heartburn treated with over-the-counter antacids. On physical
exam his neck is supple without any masses. Mild epigastric tenderness to deep
palpation is noted. Chest X-ray is normal for his age. The most appropriate next
study should be:

     A. Endoscopy
     B. Barium swallow
     C. Motility studies (manometric recordings)
     D. Emptying scintiscan
     E. 24 hours pH monitoring
Explanation:

Dysphagia accompanied with regurgitation and aspiration could be due to crico-
pharyngeal dysfunction (orpharyngeal disphagia), achalasia, stricture, or tumor.
Dysphagia, for both solids and liquids, suggests motor disorder, in contrast to
organic causes in which the problem would begin with solids and would progress
to liquids. Dysphagia, at the level of the sternal notch (or above), suggests a
disorder of the upper esophagus, in contrast to a disorder of the lower
esophagus in which the complaints would be substernal. This patient probably
has oropharyngeal dysphagia, but other diagnoses cannot be excluded from the
clinical picture alone. Standard assessment of the esophagus usually begins with
a barium swallow (Option B). If it shows no tumor, stricture, or achalasia, motility
of the esophagus will be assessed with a video-esophagogram or Choices C
and D.

Endoscopy (Choice A) may be indicated for this patient but it should be
performed after current esophageal anatomy is known from the barium swallow.
If a Zenker‘s diverticulum is found on the esophagography, endoscopy should be
avoided. 24hr pH monitoring could diagnose gastro-esophageal reflux, but is
nondiagnostic for the dysphagia (Option E).

Educational Objective:
Barium swallow is the initial test of choice for all patients with dysphagia.

40% of people answered this question correctly


Test #16 Q.Id = 1534               Question 2 Of 45                      Division : GIT
                                      Item Review
A 40-year-old male presents to your office complaining of diarrhea with pale,
voluminous, foul smelling stools that are difficult to flush. He states that he has
had this problem on and off for years but has neglected it so far. He admits to
chronic alcohol consumption. He also describes intermittent epigastric pain,
which is worst 15 to 30 minutes after eating. The physical exam is unremarkable.
What would be the best test to confirm fat malabsorption in this patient?

      A. Sudan III stain
      B. 72-hour fecal fat collection
      C. Acid steatocrit
      D. D-xylose test
      E. Lactose tolerance test
Explanation:
This patient presents with symptoms suggestive of chronic pancreatitis and
malabsorption. Quantitative estimation of stool fat (Choice B) is the gold
standard for diagnosis of steatorrhea. Excretion of more than 7g of fat per day
(normal is less than 6 g) is diagnostic of malabsorption, although patients with
steatorrhea usually have values greater than 20g/day. A three to five day
collection of stool reduces errors and variability of this test.

More than 90 percent of patients with clinically significant steatorrhea can be
detected with Sudan stain technique (Choice A). Nevertheless, the overall
sensitivity and reliability is limited due to the variability in the performance and
interpretation of the test.

Steatorrhea can be detected on a spot stool specimen (Choice C) with the help
of acid steatocrit (a gravimetric assay performed on a stool sample) test with a
positive predictive value of 90% as compared to the 72-hour fecal fat collection
as the gold standard.

D-xylose test (Choice D) is a test for carbohydrate malabsorption, not for fat
malabsorption. Besides, absorption is usually normal in pancreatic insufficiency
since pancreatic enzymes are not required for xylose absorption.

Lactose tolerance test (Choice E) can diagnose lactose intolerance, but it is not
a test for fat malabsorption.

Educational objective:
Currently, quantitative estimation of stool fat is the gold standard for diagnosis of
steatorrhea.
39% of people answered this question correctly

Test #16 Q.Id = 86                                         Question 3 Of 45
                                                            Item Review
A 56-year-old woman, with cirrhosis, has had worsening abdominal
distension for several weeks. She has had ascites in the past that
was treated conservatively, with success. She has mild
encephalopathy and esophageal varices without upper
gastrointestinal bleeding. Her cirrhosis is due to chronic hepatitis
type B. She is on sodium, water and protein restriction,
spironolactone, furosemide, and lactulose. Her vital signs are, PR:
80/min; BP: 120/70mm Hg; RR: 30/min; Temperature:
36.6C(97.9F). Her physical exam is positive for flapping tremor,
labored breathing, and marked abdominal distension. Deep
abdominal palpation is impossible because of the distension. Chest
x-ray is unremarkable. Ultraound confirms the peritoneal fluid and
shows splenomegaly, liver hyperechogenicity and nodularity, and
portal vein width of 16 mm. No masses are seen. Management of
the ascites should proceed with:

    A. IV furosemide therapy
       Tapping of some amount of ascites and infusion of albumin
    B.
       solution
    C. Peritoneo-jugular shunt
    D. Distal spleno-renal shunt (selective shunt)
    E. Side-to-side porto-caval shunt (non-selective shunt)
Explanation:

This patient already receives the maximal medical therapy for
ascites. Aggressive diuretic treatment (Choice A) may worsen the
encephalopathy or precipitate hepato-renal syndrome. Slow tapping
of up to 2L ascites daily balanced with infusion of 10g albumin per
liter tapped, is the final conservative measure that has to be
attempted before surgery. The vascular shunts are generally
indicated for symptomatic varices i.e. after first bleeding. Distal
spleno-renal shunt will not improve the ascites and may actually
worsen it. Side-to-side porto-caval shunt will improve the ascites
but may worsen the encephalopathy. Peritoneo-jugular shunt is
designed for treatment of ascites only. Peritonitis, sepsis, and
disseminated intravascular coagulation are its major drawbacks.

Educational Objective:
Slow tapping of ascitic fluid balanced with infusion of albumin per
liter tapped, is the final conservative measure for the treatment of
acsites secondary to cirrhosis that has to be attempted before
surgery.

28% of people answered this question correctly
Test #16 Q.Id = 1631              Question 4 Of 45                       Division : GIT
                                   Item Review
A 45-year-old Caucasian male comes to you because of worsening
heartburn for the last 2 years. He says that the symptoms are worst
when he lies down. He has tried number of over the counter
antacids with no success. You do a detailed investigation of patient
including an endoscopy and come to the diagnosis of hiatus hernia,
however the patient is reluctant to take any sort of treatment. Which
of the following is he at risk if his condition is left untreated?

    A. Peptic ulceration
    B. Squamous cell carcinoma of esophagus
    C. Aspiration pneumonia
    D. Mallory Weiss syndrome
    E. Adenocarcinoma of esophagus
Explanation:

Esophageal cancer is the ninth most common malignancy on
worldwide basis. Two major histological types are Squamous cell
carcinoma (SCC) and Adenocarcinoma. In past two decades, the
incidence of adenocarcinoma of esophagus has been increasing in
western world and today there are equal number of cases of
adenocarcinoma and squamous cell carcinoma of esophagus.

This patient is having symptomatic GERD due to hiatus hernia.
Chronic GERD can lead to metaplastic changes in lower end of
esophagus replacing the normal squamous epithelium with
columnar epithelium. This is called Barrett‘s esophagus and is a
risk factor for adenocarcinoma of esophagus. Patients with Barrett‘s
esophagus have 1% per year of developing adenocarcinoma of
esophagus.

Other risk factors of adenocarcinoma are obesity, high dietary
calories and fat, smoking, medications that promote GERD, etc.
The major risk factors of squamous cell cancer of esophagus are
smoking, alcohol, dietary deficiency of beta carotene, vitamin B1,
zinc, selenium, environmental viral infections, toxin producing fungi,
hot food and beverages, pickled vegetables and food rich in N-
nitroso compound etc.

Educational objective:
Chronic GERD and Barrett‘s esophagus are risk factors for
adenocarcinoma of esophagus. Patients with Barrett‘s esophagus
have 1 % per year risk of developing adenocarcinoma of
esophagus.

54% of people answered this question correctly

Test #16 Q.Id = 67               Question 5 Of 45                       Division : GIT
                                  Item Review
             A 45-year-old male presents with the complaint of
             difficulty swallowing both liquids and solids, which was
             mild initially but has worsened gradually. He also
             complains of nocturnal cough, which disturbs his sleep
             as well as regurgitation of undigested food eaten
             several hours earlier. Physical examination is
             unrevealing. Barium studies are performed which
             shows dilated esophagus, loss of esophageal
             peristalsis, and smooth tapering of the distal
             esophagus. What will be the most appropriate next
             step in the management of this patient?

                 A. Esophagoscopy
                 B. Esophageal manometry
                 C. Esophageal PH monitoring
                 D. Botulinum toxin ingestion
                 E. Pneumatic dilation
             Explanation:

             When a motility disorder of esophagus is suggested by
             contrast studies, the next step is usually
             esophagoscopy to exclude mechanical causes of
             dysphagia like stricture or esophageal cancer.
             Esophagoscopy is then followed by manometry, which
             confirms the diagnosis (Option A and B).

             Esophageal pH monitoring is done in some cases of
             gastroesophageal reflux disease and it is usually not
             indicated to evaluate dysphagia (Option C).

             Botulinum toxin ingestion is a treatment choice for
             achalasia in the elderly and those patients who cannot
             tolerate more invasive procedures like pneumatic
             dilation or surgical myotomy. But before starting any
             treatment, one must exclude other causes of
             dysphagia and diagnosis must be firmly established
             (Option D).
             Pneumatic dilation provides symptomatic relief in most
             patients and is a cost-effective procedure for treatment
             of achalasia (Option E).

             Educational Objective:
             When a motility disorder of esophagus is suggested by
             contrast studies, the next step is usually
             esophagoscopy to exclude mechanical causes of
             dysphagia like stricture or esophageal cancer.

             15% of people answered this question correctly

A 38-year-old woman had undergone a parietal cell vagotomy for
persisting duodenal ulcer. 3-months later, she experienced an
upper gastrointestinal hemorrhage and a recurrent ulcer was
diagnosed. Distal gastrectomy with Billroth II and truncal vagotomy
was performed. 2-days after the operation she has severe
epigastric and back pain. Her vital signs are, PR: 110/min; BP:
120/80mm Hg; RR: 16/min; Temperature: 37C(98.6F). Abdominal
ultrasound shows some swelling of the pancreas.

Laboratory results are:

Hb 13.8gm/dL
WBC 12,300/cmm
Na 142
Cl 110
K 4.1
HCO3 25
Ca 11.4
pH 1.1 mmol/L
Amylase 772

Which of the following studies is the most appropriate?

    A. Acid ouput studies
    B. Gastrin and calcitonin levels
    C. Parathyroid hormone and gastrin levels
    D. Parathyroid hormone and calcitonin levels
    E. Calcitonin and urinary vanillymandelic acid (VMA) levels
Explanation:

Apart from the acute pancreatitis, this patient‘s clinical picture is
highly suspicious of two things: hypergastrinemia (recurrent peptic
ulcers) and hyperparathyroidism (hypercalcemia). So, serum
parathyroid levels and gastrin levels should be performed first
(Option C).

She may have multiple endocrine neoplasia (MEN I) that is
characterized by tumors of anterior pituitary, parathyroid and
pancreatic islet cells. MEN II is less likely, but can‘t be excluded at
this moment as well. MEN II is characterized by
pheochromocytoma, medullary carcinoma of thyroid and
parathyroid tumors. Serum calcitonin (for medullar carcinoma of
thyroid) and VMA will be ordered if there is suspicion of MEN II
(Option E). Acid output studies are not reliable for resected
stomach (Option A).

Educational Objective:
Recurrent peptic ulcers with hypercalcemia are best explained by
MEN type 1.

43% of people answered this question correctly


Test #16 Q.Id = 1793               Question 7 Of 45                       Division : GIT
                                    Item Review
A 45-year-old Mexican male comes to you after noticing traces of
blood on the tissue paper after he wipes for the last couple of days.
He denies having seen any frank blood mixed with stool, but once
had some drops of blood dropping in the toilet pan after he
defecated. His past history and family history are negative for any
cancer or other significant disease. Which of the following is the
most appropriate next step in management of this patient?

    A. Colonoscopy
    B. Fecal occult blood test
    C. Anoscopy
    D. Sigmoidoscopy
    E. Barium enema
Explanation:

This patient is having minimal bright red blood per rectum, also
called ‗scant hematochezia‘ or minimal rectal bleeding. Though
there is no standardized definition for this term, it includes
patient complaints of small amounts of bright red blood on toilet
paper after wiping, a few drops of blood in the toilet bowl after
defecation or small amounts of blood on the surface of the stool.
However, red blood intermixed with stool is not included. Minimal
BRBPR is seen in about 14 - 16 percent of people. Some of the
most common causes are hemorrhoids, anal fissure, polyps,
proctitis, rectal ulcers and even cancer. Hemorrhoids can be
present in anywhere between 27 to 95 percent of cases of minimal
BRBPR.

Patient less than 50 years old, with no other risk factor for colon
cancer, and presenting with minimal BRBPR should have office-
based anoscopy or proctoscopy done first, and if no etiology is
found, colonoscopy or sigmoidoscopy should be considered. Office-
based anoscopy/proctoscopy are simple maneuvers, have high
yield and do not require bowel preparation. Anoscopy has higher
sensitivity for diagnosing hemorrhoids than flexible endoscopy.

(Choice A, D) Colonoscopy and sigmoidoscopy would be the
appropriate first choices, if the patient was more than 50 years
old or had other risk factors for colon cancer.

(Choice B) Occult blood test will be of no further help at this time.
The patient saw the bright red blood; it is of value in cases of
melena or undiagnosed anemia.

(Choice E) Barium enema is not an appropriate first investigation
for this condition.

Educational Objective:
Office-based anoscopy/proctoscopy is the first procedure to be
done in patients less than 50 years old who present with minimal
bright red blood per rectum and do not have any risk factors for
colon cancer. Blood intermixed with stool is not considered in this
category.

35% of people answered this question correctly


Test #16 Q.Id = 1769              Question 8 Of 45                      Division : GIT
                                   Item Review
54-year-old male presents to the ER with complaints of abdominal pain which
has been going on for seven days. He says that he has no appetite, has nausea,
vomiting and a low-grade fever. He denies taking alcohol, but says that he has
been taking a antiseizure medication. His chest and abdominal x-rays are
unremarkable. His abdominal CT scan is shown below. What is the most likely
cause of his abdominal pain?
     A. Gall bladder pathology
     B. Kidney pathology
     C. Pancreas pathology
     D. Air in stomach
     E. Liver pathology
Explanation:

This patient presents with abdominal pain and has been taking antiseizure
medications. The CT scan reveals an inflamed pancreas. One seizure
medication associated with pancreatitis is valproic acid. Drug- induced
pancreatitis accounts for 5% of cases of pancreatitis. Most cases of drug-
induced pancreatitis are mild. The common drugs (important for USMLE) that
can cause pancreatitis are:

   1.   Patient on diuretics — furosemide, thiazides.
   2.   Patient with inflammatory bowel disease — sulphasalazine, 5-ASA.
   3.   Patient on immunosuppressive agents — azathioprine, L-asparaginase.
   4.   Patient with history of seizures or bipolar disorder — valproic acid.
   5.   AIDS patient — think about didanosine, pentamidine.
   6.   Patient on antibiotics — metronidazole, tetracycline

The most common cause of pancreatitis is alcohol, followed by gallstones.
Abdominal pain is the most common symptom. Diagnosis of pancreatitis can be
established by measuring serum amylase and lipase. CT scan will show diffuse
or focal parenchymal changes, edema, necrosis or liquefaction. Treatment for
pancreatitis is supportive care with fluids and electrolyte replacement (Choice
C).

(Choice A) Gallstones which migrate into the bile duct, or at the ampulla of
Vater, can cause obstruction. This can result in gallstone pancreatitis. These
individuals can present with acute pancreatitis, which can be very severe.
Ultrasound can be used to assess gallstone pancreatitis and common bile duct
obstruction. The size and number of stones can be determined by this technique.
In the above patient, the gallbladder shadow is not enlarged and there is no
evidence of gallbladder inflammation on the CT scan. The gallstone may be
removed by ERCP and, once the pancreatitis is resolved, the gallbladder can be
removed. Acute cholecystitis is best diagnosed with a nuclear (HIDA) scan.

(Choice B) The CT scan above shows normal kidneys. Pyelonephritis is a
common infectious condition that can present with abdominal pain, fever, chills
and nausea. It is seen more frequently in women and is usually caused by gram-
negative organisms. Acute pyelonephritis usually responds to antibiotic therapy
for 1 - 2 weeks. Gram-negative sepsis (endotoxic shock) is a serious and
potentially life-threatening complication of untreated urinary tract infection.

(Choice D) The above CT scan shows a distended stomach with air. Air in the
stomach is commonly seen with ileus. The pancreatitis causes an ileus, which
results in stasis of the GI tract. The condition usually resolves on its own. When
a large amount of air is present in the stomach, nausea and vomiting may occur.
In such a case, a nasogastric tube will resolve the ileus.

(Choice E) The liver appears entirely normal in the above CT scan. A CT scan
is very useful for imaging the liver. It can be used to detect liver masses,
nodules, abscesses and hemangiomas. Metastatic lesions from colon cancer
and elsewhere are rapidly diagnosed with a CT scan. The strength of the CT
scan remains in providing a good, detailed overview when assessment of the
whole abdomen and thorax is needed. However, when it comes to
the preoperative differential diagnosis of liver tumors and assessment of
resectability, MRI is the gold standard.

Educational Objective:
Drug-induced pancreatitis is mild and usually resolves with supportive care. CT
scan is diagnostic for pancreatitis. Remember the following scenarios for drug-
induced pancreatitis:

   1.   Patient on diuretics — furosemide, thiazides.
   2.   Patient with inflammatory bowel disease — sulphasalazine, 5-ASA.
   3.   Patient on immunosuppressive agents — azathioprine, L-asparaginase.
   4.   Patient with history of seizures or bipolar disorder —valproic acid.
   5.   AIDS patient — think about didanosine, pentamidine.
   6.   Patient on antibiotics — metronidazole, tetracycline.

22% of people answered this question correctly

Test #16 Q.Id = 1523               Question 9 Of 45                       Division : GIT
                                    Item Review
A 29-year-old male with a 6-year history of HIV infection presents with chronic,
severe diarrhea associated with malaise, nausea, anorexia and abdominal
cramps. His last CD4 count was 80 cells/mm3. A modified acid-fast stain of a
stool specimen shows 4-6 µm oocysts. Which of the following is the most likely
microorganism responsible for his condition?

        A. Mycobacterium avium complex
        B. Cryptosporidium parvum
        C. Isospora belli
        D. Pneumocystis carinii
        E. Microsporidia
Explanation:

The modified acid-fast stain showing oocysts is suggestive of cryptosporidiosis
(Choice B). Cryptosporidium parvum can cause severe diarrheal disease in
both immunocompetent and immunocompromised individuals. It tends to
become persistent in AIDS patients with CD4 counts <180 cells/mm3 as
compared to self-limiting illness in HIV-infected patients with a more preserved
CD4 count.

Although the diagnosis of Isospora belli is made by presence of acid-fast oocysts
in stool as well, infections with Isospora belli (Choice C) are not as common as
Cryptosporidium in the United States.

Mycobacterium avium complex (Choice A) is associated with lung infections in
immunocompetent patients with chronic lung disease, however it causes
disseminated disease with bowel infiltration and malabsorption in patients with
severe immune compromise. Also, they are not characterized by oocysts in
stool.

Pneumocystis carinii (Choice D) is associated with pulmonary disease, not
diarrhea.

The Microsporidia organisms (Choice E), along with Enterocytozoon bieneusi
and Encephalitozoon intestinalis, are rare causes of diarrhea in
immunocompetent hosts. They are however associated with severe
malabsorption and persistent diarrhea in HIV-infected patients. Also,
microsporidiosis is characterized by the presence of spores and not oocysts in
stool.

Educational objective:
Cryptosporidium parvum is a major cause of chronic diarrhea in HIV-infected
patients with a CD4 count less than 180 cells/mm3.

49% of people answered this question correctly


Test #16 Q.Id = 1524             Question 10 Of 45                    Division : GIT
                                   Item Review
A 45-year-old male presents to the family physician for epigastric abdominal pain
associated with diarrhea. Physical exam reveals some abdominal tenderness
without rebound or rigidity. He has been smoking 2 packs per day for the past 10
years. He occasionally drinks alcohol. He denies illegal drug use and multiple
sexual partners. His past history is significant for chronic duodenal ulcers. The
endoscopy shows prominent gastric folds, chronic duodenal ulcer, and upper
jejunal ulceration. What would be the next best step to confirm the diagnosis?
     A. Secretin stimulation test
     B. Gastric acid secretion study
     C. Serum chromogranin A
     D. Calcium infusion study
     E. Serum gastrin concentration
Explanation:

This patient has the endoscopic findings characteristic of Zollinger-Ellison
syndrome (gastrinoma), such as prominent gastric folds and ulcer located
beyond the duodenal bulb.

All patients suspected of having the Zollinger-Ellison syndrome should have
fating serum gastrin levels done (Choice E). A serum gastrin value greater than
1000 pg/mL is diagnostic of the disorder. Measurement of gastric pH on a single
specimen is important to exclude secondary hypergastrinemia due to
achlorhydria.

All patients suspected of having Zollinger-Ellison syndrome and having a
nondiagnostic fasting serum gastrin levels, should have secretin stimulation test
done (Choice A). Serum gastrin concentrations do not rise in patients with other
causes of hypergastrinemia as secretin stimulates the release of gastrin by
gastrinoma cells whereas normal gastric G cells are inhibited by secretin.

Gastric acid secretion studies (Choice B) may play an important role in
diagnosis, however they are no longer performed in most major medical centers
and have been replaced by other diagnostic modalities discussed above.

Serum chromogranin A (Choice C), a general marker for neuroendocrine
tumors, is less sensitive and specific than measurement of serum gastrin, but
may be used as a confirmatory test in difficult cases.

The calcium infusion study (Choice D) is usually reserved for patients with
gastric acid hypersecretion, who are strongly suspected for gastrinoma despite a
negative secretin test. Calcium infusion would lead to an increase in serum
gastrin levels in patients with gastrinoma.

Educational objective:
All patients suspected of having the Zollinger-Ellison syndrome should have
fating serum gastrin levels done. A serum gastrin value greater than 1000 pg/mL
is diagnostic of the disorder. Patients with nondiagnostic fasting serum gastrin
levels, should have secretin stimulation test done.

31% of people answered this question correctly

Test #16 Q.Id = 76                Question 11 Of 45                    Division : GIT
                                      Item Review
A 50-year-old man has had pain in his right arm for 3 hours. It is swollen, ruddy,
and warmer than left arm. He was treated with heparin for superficial
thrombophlebitis of right cephalic and the right saphenous vein 2 wks ago. His
past medical history is remarkable only for back pain for a few months treated
with NSAIDs. Vital signs are: PR: 70/min; BP: 140/80; RR: 10/min; Temperature:
37.0C(98.6F). Apart from the right arm, his thorough physical exam is normal.
Cervical and chest x-rays show no abnormalities.

Laboratory results are:

Hct 50%
WBC 9,600/cmm
Neutrophils 60%
Eosinophils 2%
Basophils 0%
Lymphocytes 31%
Monocytes 7%
Platelets 120,000/cmm
PT 25 sec
PTT 39 sec
Fibrinogen 300 mg/dL
Fibrin split products positive

The next step is:

     A. Protein C, S and antithrombin III level
     B. Perfusion scintigraphy of lungs
     C. Venography of right brachial, axillar and subclavian veins
     D. CT of chest, abdomen and pelvis
     E. CT of thoracic outlet
Explanation:

Migratory thrombophlebitis and atypical venous thromboses are suggestive of
chronic DIC, most probably due to cancer. Laboratory values further confirm this
diagnosis (mild prolongation of PT, high fibrinogen and FSP-positive). Lung,
pancreatic, stomach and prostate malignancies are the most common cause. CT
chest, abdomen and pelvis are indicated for complete workup of malignancy
along with age appropriate cancer screening such as digital rectal exam,
mammography and colonoscopy (Option D).

Protein C, S and antithrombin III level can be ordered for hypercoagulable
workup but they are not very likley in a patient with migratory thrombophlebitis
(Option A) .
V/Q scan is not required in this patient, as he has no symptoms of pulmonary
thromboembolism (Option B).

Again CT of the thoracic outlet doesn‘t tell you the underlying cause of the
hypercoagulable state (Option E).

Educational Objective:
Migratory thrombophlebitis and atypical venous thromboses are suggestive for
chronic DIC, most probably due to some visceral malignancy.

10% of people answered this question correctly

Test #16 Q.Id = 1519               Question 12 Of 45                      Division : GIT
                                     Item Review
A 41-year-old male presents to his family physician for heartburn, gnawing
abdominal pain and diarrhea. He states that he has had these symptoms
intermittently since 5 years. He has tried H-2 blockers without any relief. His past
medical history is suggestive of chronic renal stones. He has an extensive family
history of peptic ulcer disease. Physical exam is unremarkable. What is the most
likely diagnosis in this patient?

     A. Gastric ulcer
     B. Gastrinoma
     C. Duodenal ulcer
     D. GERD
     E. Chronic pancreatitis
Explanation:

Zollinger- Ellison syndrome is seen in up to 1% of patients with peptic ulcer
disease (Choice B). It should be suspected in patients with findings suggestive
of acid hypersecretion (eg, multiple or refractory ulcers, or ulcer location distal to
the duodenum), diarrhea, or a personal or family history of multiple endocrine
neoplasia type 1 (primary hyperparathyroidism, pituitary tumors, and
enteropancreatic tumors such as gastrinoma and insulinoma).

Gastrinomas are non-beta cell pancreatic islet cell tumors. It is characterized by
secretion of a high amount of gastrin, which has trophic action on parietal cells
and histamine-secreting cells leading to high gastric acid output and subsequent
ulcerations.

Gastric (Choice A) and duodenal ulcers (Choice C) are less likely to be
associated with diarrhea and are not associated with renal stones (most likely
due to a history of hyperparathyroidism with secondary nephrocalcinosis).

Given the history of chronic renal stones and family history of peptic ulcer
disease, gastrinoma is more likely to be the cause of his chronic heartburn rather
than GERD (Choice D).

Chronic pancreatitis (Choice E) presents with abdominal pain and diarrhea, but
it is not associated with either renal stones or extensive family history of ulcer
disease.

Educational objective:
Zollinger-Ellison syndrome (gastrinoma) is characterized by multiple, severe,
drug resistant ulcerations of the GI tract.

54% of people answered this question correctly

Test #16 Q.Id = 82                  Question 13 Of 45                     Division : GIT
                                      Item Review
A 76-year old man, with multi-infarct dementia, is brought to the hospital
because of deterioration of his condition. His relatives state that he has been
lethargic in the recent days. His vital signs are, PR: 120/min; BP: 150/95mm Hg;
RR: 26/min; Temperature: 37.8C(101.5F). Past medical histroy is remarkable for
hypertension for 15 yrs, chronic atrial fibrillation for 7 yrs, dementia for 5 yrs, and
frequent respiratory infections for the last year. For the last 6-months, he has
had difficulties with feeding and not infrequently undigested food has drooled out
of his mouth and nose during meals. Physical exam is remarkable for foul
smelling breath, fluctuating mass in the left side of his neck and crackles in the
right lung base. Chest x-ray reveals multiple infiltrates, without cavitation in the
right lower lung field. The patient is admitted, sputum and blood cultures are
sent, and antibiotics are started. What should be planned next?

     A. Puncture of the neck mass
     B. Esophagoscopy
     C. Esophagography
     D. Bronchoscopy
     E. CT of the neck
Explanation:

This patient has oropharyngeal dysphagia, complicated with aspiration
pneumonia. The neck mass is most likely a Zenker‘s diverticulum i.e. herniation
of mucosa through the fibers of cricopharyngeal muscle. This herniation is
associated with failure of the muscle to relax properly. Esophagoscopy (Choice
B) is avoided because of the risk of perforation. Esophagography (Option C) will
demonstrate both the diverticulum and the esophagus better than CT (Choice
E). Bronchoscopy (Choice D) is not needed, in light of the diverticulum. It could
be considered for collection of material for cultures, if the patient fails to respond
to antibiotics or if cavitation-suggesting abscess is present on the x-ray. Puncture
(Choice A) is appropriate for abscess, not for diverticulum.
Educational Objective:
Recognize Zenker‘s diverticulum. Barium esophagogram is the investigation of
choice for confirmation.

18% of people answered this question correctly

Test #16 Q.Id = 73                  Question 14 Of 45                     Division : GIT
                                      Item Review
A 26-year-old man has had intermittent crampy lower abdominal pain, rectal
urgency, and diarrhea with some blood and mucus in the stools for 1 week. For
the last 24 hrs his complaints have worsened. He has vomited several times and
is still nauseated. His past medical history is unremarkable. He denies any
recent travel or antibiotic use. His abdomen is distended and tender to palpation
without rebound and guarding. Bowel sounds are decreased. On the rectal
exam, he has marked rectal tenderness and mucus mixed with blood in the
rectum. His vital signs are, PR: 95/min; BP: 120/80mm Hg; RR: 15/min;
Temperature: 38.5C(102.0 F). The abdominal X-ray shows distended colon filled
with gas.

His laboratory test results are:

RBC 4.0
WBC 19,600/cmm
ESR 34/hr

The next step should be:

     A. Stools for ova, parasites and bacterial cultures
     B. Barium enema
     C. Proctosigmoidoscopy and biopsy
     D. Serology for Entamoeba histolytica
     E. CT of the abdomen
Explanation:

Any young patient with bloody diarrhea should make you think about
inflammatory bowel disease. The differential diagnosis should include infectious
diarrhea, mostly Campylobacter. Most likely this patient has ulcerative colitis with
a fulminant course and development of a toxic megacolon. Barium enema is
contraindicated in acutely ill and toxic patients (Option B).

CT would be uninformative (Option E). Infectious diarrhea caused by invasive
agents is less likely to produce colon distension. Pseudo-membranous colitis
could lead to toxic megacolon but it is highly unlikely in this patient as there is no
previous history of antibiotic use. It also requires proctosigmoidoscopy and
biopsy for diagnosis (Option C).

Educational Objective:
Fulminant colitis is a serious complication of ulcerative colitis and plain
radiography shows distended colon. Proctosigmoidoscopy with biopsy
establishes the diagnosis of ulcerative colitis and it can be performed in acute
settings.

24% of people answered this question correctly

Test #16 Q.Id = 522                 Question 15 Of 45                  Division : GIT
                                      Item Review
Ms. Lee, a 62-year-old Chinese woman, comes with yellowness in her eyes for
the past 6 weeks. She is generally feeling tired, has lost some weight, and
occasionally had some nausea. She denies any altered bowel habits. She is a
non-smoker but drinks 2-3 beers each night. Her dad is suffering from high
cholesterol and also has had stroke. She had a dilatation and curettage for an
abnormal pap smear 15 years ago. Her vitals are stable and she is afebrile. She
has marked scleral icterus. An abdominal examination reveals normal bowel
sounds and no organomegaly. Her stools were occult blood negative. Her liver
function tests and enzymes were ordered and the results are

Total protein 6.1 g/dL
Albumin 3.9 g/dL
AST 67 U/L
ALT 52 U/L
Alkaline phosphatase 290 U/L
Total bilirubin 9.6 mg/dL
Direct bilirubin 8.9 mg/dL
Serum lipase is 46 U/L
Anti-mitochondrial antibodies negative

Which of the following is the most likely cause of these findings?

     A. Primary biliary cirrhosis
     B. Chronic pancreatitis
     C. Viral hepatitis
     D. Pancreatic carcinoma
     E. Hepatocellular carcinoma
Explanation:

Painless obstructive jaundice is more likely to be due to malignancy.
Adenocarcinoma of the head of pancreas causes obstruction of extra hepatic bile
duct leading to elevation of direct bilirubin and marked icterus. It may be
associated with weight loss, dull back pain, and anorexia. There is astronomical
elevation of alkaline phosphatase. Abdominal examination is usually negative
except for mild tenderness in epigastric region. CT scan may help in diagnosis.
The cancer has got very bad prognosis (Option D).

Primary biliary cirrhosis also has increased alkaline phosphatase but it usually
presents with itching and also has characteristic anti-mitochondrial
antibodies detected on antibody assay (Option A).

Chronic pancreatitis alone does not cause elevation of alkaline phosphatase.
The patient also doesn‘t have any chronic abdominal pain or evidence of
malabsorption (Option B).

Viral hepatitis and hepato-cellular carcinoma both causes increase in ALT and
AST (Option C and E).

Educational Objective:
Painless jaundice in an elderly patient should make you think about pancreatic
head carcinoma.

32% of people answered this question correctly

Test #16 Q.Id = 2086              Question 16 Of 45                     Division : GIT
                                    Item Review
A 23-year-old Caucasian male presents to your office with a two-month history of
loose stools, decreased appetite, and weight loss. His past medical history is
insignificant. He is not taking any medications. His temperature is 36.7 C (98F),
blood pressure is 120/76 mmHg, pulse is 90/min, and respirations are
16/min. His lab values are:

Hemoglobin                                      11.2 g/dL
MCV                                             80 fl
Leukocyte count                                 9,500/cmm
          Segmented Neutrophils                 65%
          Bands                                 3%
          Eosinophils                           1%
          Basophils                             0%
          Lymphocytes                           25%
          Monocytes                             6%
Platelets                                       550,000/cmm
ESR                                             50 mm/hr
Serum sodium                                    145 mEq/L
Serum potassium                                 4.0 mEq/L

Stool is positive for occult blood. Which of the following is the most probable
diarrhea type in this patient?
     A. Inflammatory
     B. Secretory
     C. Osmotic
     D. Motor
     E. Factitial
Explanation:

The clinical scenario described is characteristic for inflammatory diarrhea. The
typical cause of inflammatory diarrhea is idiopathic inflammatory bowel disease
(IBD). Infectious causes are less likely with chronic diarrhea (duration > 4 weeks)
than with acute diarrhea. The clues to the correct diagnosis in this case, include
weight loss, anemia, elevated ESR, and reactive thrombocytosis. Positive test for
occult blood is also a very important clue. These inflammatory changes and
blood/leukocyte positive stool are usually absent in the other types of diarrhea
mentioned.

Secretory diarrhea (Choice B) is usually the result of some medication use and
hormonal disturbances.

Osmotic diarrhea (Choice C) is caused by the ingestion of osmotically active,
poorly absorbable substances. Lactose intolerance is a classical example.

Motor diarrhea (Choice D) is exemplified by hyperthyroidism.

Factitial diarrhea (Choice E) is typically associated with psychiatric disturbances.

Educational Objective:
Chronic inflammatory diarrhea is typically associated with inflammatory changes
in blood (anemia, elevated ESR, and acute phase reactants, reactive
thrombocytosis). Blood/leukocyte positive stool is another important finding.

8% of people answered this question correctly

Test #16 Q.Id = 1521               Question 17 Of 45                   Division : GIT
                                     Item Review
A 40-year-old female presents with discomfort centered in the upper abdomen.
She had similar symptoms in the past as well. The symptoms are not related to
meals or fatty food. She denies gastrointestinal bleeding, fatigue, dysphagia, and
weight loss. The patient states her mother has a history of gastric ulcer. What
would be the next best step in management of this patient?

      A. Barium radiography
      B. Endoscopy
      C. Empiric trial of H2 blockers
     D. H. Pylori breath test
     E. Empirical antibiotic trial
Explanation:

Dyspepsia is defined as pain or discomfort centered in the upper abdomen,
which may be intermittent or continuous, and may or may not be related to
meals. 25% of such patients have peptic ulcer disease.

The American Gastroenterological Association (1998) recommends:

Patients with dyspepsia, who are younger than 45 years of age and presenting to
a primary care physician without any alarm symptoms like bleeding, anemia,
dysphagia, and weight loss should have a noninvasive test for H. pylori,
serologic or breath test (Choice D). Eradication antibiotic therapy against
H.pylori is indicated for infected patients only (Choice E).

An empiric trial of antisecretory therapy, like H2 blocker or proton pump inhibitor;
or a prokinetic agent for one month is recommended in young patients without
alarm symptoms who are H. pylori negative (Choice C).

Gasteroenterology referral is required in patients older than 45 years age or
those with alarm symptoms at any age, due to the small risk of gastric cancer.
Such patients should be considered for endoscopy and H. pylori testing.

Barium radiography (Choice A) has little role in the routine evaluation of patients
with dyspepsia. Though it is less expensive than endoscopy for the diagnosis of
peptic ulcer disease, it is less accurate.

Educational objective:
Noninvasive tests for H. pylori should be the first step in the management of
patients with dyspepsia under 45 years of age who do not have alarm symptoms.

13% of people answered this question correctly

Test #16 Q.Id = 2042                 Question 18 Of 45                  Division : GIT
                                       Item Review
A 45-year-old male presents to your office with a 6-month history of periodic
abdominal pain. He tried several over-the-counter medications including H2
blockers and proton pump inhibitors with moderate success. Workup, including
an upper GI series and endoscopy, reveals multiple duodenal ulcers and a single
jejunal ulcer. Stool testing shows occult blood and mild steatorrhea. What is the
most probable cause of impaired fat absorption in this patient?

      A. Pancreatic enzyme deficiency
      B. Pancreatic enzyme inactivation
     C. Reduced bile salt absorption
     D. Defective intestinal absorption
     E. Bacterial proliferation
Explanation:

This patient presents with signs and symptoms suggestive of Zollinger-Ellison
syndrome. The most common cause of this condition is a gastrin-producing
pancreatic tumor. As a result of uncontrolled gastrin secretion, parietal cell
hyperplasia develops and stomach acid production is significantly increased.
Multiple duodenal ulcers are typical, and a jejunal ulcer is almost pathognomic
for this condition. Steatorrhea may develop, because increased production of
stomach acid inactivates pancreatic enzymes.

Pancreatic enzyme deficiency (Choice A) is characteristic for chronic
pancreatitis and is typically alcohol-related.

Reduced bile salt absorption (Choice C) may develop after ileal resection.

Defective intestinal absorption (Choice D) causes malabsorption in various
intestinal diseases including non-tropical sprue.

Bacterial proliferation (Choice E) can also cause malabsorption, usually during
diabetes-related intestinal dysmotility.

Educational Objective:
Inactivation of pancreatic enzymes by increased production of stomach acid may
lead to malabsorption in patients with Zollinger-Ellison syndrome.

6% of people answered this question correctly

Test #16 Q.Id = 70                  Question 19 Of 45                   Division : GIT
                                      Item Review
A 49-year-old white female was hospitalized with a diagnosis of urosepsis. The
patient was started on amoxicillin and sulbactam as empirical therapy. The
patient recovered and was discharged with oral amoxicillin, plus clavulonic
acid. Three days after the discharge she developed profuse foul smelling watery
diarrhea, and abdominal pain. Her vitals are, PR: 110/min; RR: 15/min;
Temperature: 38.8C(101.9F); BP: 110/70mm Hg. Abdominal examination shows
tenderness in the left lower quadrant. CBC shows WBC count of 25,000/microl.
She is started on IV fluids. What will be the most appropriate next step in the
management of this patient?

      A. Continue rehydration
      B. Start oral metronidazole
      C. Discontinue antibiotics
     D. Discontinue antibiotics and start oral metronidazole
     E. Discontinue antibiotics and start oral vancomycin
Explanation:

The patient presented in this vignette has developed severe watery diarrhea,
abdominal pain, and fever while taking antibiotics for prolonged duration. She is
most likely suffering from severe pseudomembrane colitis caused by clostridium
difficile.

When diarrhea caused by clostridium difficile is mild, discontinuation of the
antibiotic alone is sufficient to relieve the patient‘s symptoms (Option C).

When diarrhea caused by clostridium difficile is severe, administration of
metronidazole is also needed along with discontinuation of the offending
antibiotic (Option D).

Oral vancomycin is effective for the treatment of pseudomembrane colitis but it is
used as an alternative to metronidazole when there is intolerance to the latter
(Option E). Metronidazole is the drug of choice for pseudomembrane colitis. It is
a preferred drug over the vancomycin because it is very cheap and it reduces the
chances of vancomycin resistance to other microbial organisms.

Educational Objective:
When diarrhea caused by clostridium difficile is severe, administration of
metronidazole is also needed along with discontinuation of the offending
antibiotic.

56% of people answered this question correctly

Test #16 Q.Id = 544                Question 20 Of 45                   Division : GIT
                                     Item Review
A 50-year-old woman comes to clinic because of having several episodes of
severe watery diarrhea in the last 15 days. There is 4/10 pain all over her
abdomen but she has not noticed any blood in her stools. She is having her
normal diet and has not traveled anywhere recently. She denies any one around
her having similar complaints. She also had occasional cramps in her leg
muscles and feels dehydrated. She smokes one to two cigarettes a day and
drinks socially. Her temperature is 36.8 C (98.1 F), blood pressure is 108/64 mm
Hg, pulse is 118/min, and respirations are 18/min. On examination her abdomen
is slightly tender. Labs are as under.

WBC: 5600mm3
Hemoglobin: 13.6
Hematocrit: 41%,
Platelets: 209,000mm3
Sodium: 138 mEq/L
Potassium: 2.1 mEq/L
Bicarbonate: 35 mEq/L
Blood urea nitrogen: 16 mg/dL
Creatinine: 0.8 mg/dL
Glucose: 106 mg/dL

A CT abdomen is ordered which shows a mass in the head of pancreas. What is
the most probable diagnosis?

     A. Pancreatic adenocarcinoma
     B. Glucagonoma
     C. Insulinoma
     D. VIPoma
     E. Gastrinoma
Explanation:

The patient has a rare pancreatic tumor called VIPoma. VIPomas are cancerous
tumors that affect cells in the pancreas that produce vasoactive intestinal peptide
(VIP). VIPomas cause diarrhea, hypokalemia resulting in leg cramps, and a
decrease in the amount of acid in the stomach. The cause is not known.
VIPomas are diagnosed most commonly at age 50 or so. Women are more likely
to be affected than men. Other symptoms include dehydration, abdominal pain
and cramping, weight loss, facial flushing and redness. High level of VIP
(vasoactive intestinal peptide) in the blood is diagnostic. A CT scan or MRI is
ordered to determine the location of the tumor (Option D).

The first goal of treatment is to correct dehydration. Intravenous (IV) fluids are
often required to replace fluids lost in diarrhea. The next goal is to slow the
diarrhea. Some medications can help control the diarrhea, such as octreotide. If
the tumor has not metastasized surgery can often cure it.

Glucagonoma presents with narcotizing dermatitis, weight loss, anemia, and
persistent hyperglycemia (Option B).

Insulinoma is a rare beta-cell tumor that releases Insulin and causes
hypoglycemia (Option C).

24% of gastrinomas are found in pancreas. They cause increased gastrin
release and multiple gastric ulcers (Option E).

Pancreatic carcinoma can present with diarrhea but severe watery diarrhea is
hallmark of VIPomas (Option A).

Educational Objective:
Remember the pancreatic cholera – VIPoma.

48% of people answered this question correctly

Test #16 Q.Id = 2034              Question 21 Of 45                      Division : GIT
                                    Item Review
A 64-year-old white male had undergone an elective repair for an abdominal
aortic aneurysm. He also has a history of stable angina and peripheral vascular
disease. The postoperative course was complicated by hypotension, which was
treated successfully; however, a few hours later, he started having abdominal
pain followed by bloody diarrhea. His temperature is 37.8 C (100 F), blood
pressure is 110/60 mmHg, pulse is 110/min, and respirations are 20/min. On
examination, abdominal findings are minimal. Labs show a WBC count of
15,000/cmm with 7% bands. The lactic acid level is elevated. A CT scan is
ordered. Which of the following part of the colon will most likely show abnormal
findings?

     A. Sigmoid colon
     B. Splenic flexure
     C. Ascending colon
     D. Mid transverse colon
     E. Hepatic flexure
Explanation:

This is a patient with ischemic colitis following aortic surgery. Ischemic colitis is
seen in about 1-7% of patients following aortoiliac surgery. Patients with
extensive atherosclerotic vascular disease are at particularly high risk, especially
if their hospital course is complicated by hypotension, which may be due to
increased perioperative fluid loss or excessive use of diuretics. Ischemic colitis
may be seen following cardiopulmonary surgery, cardiac embolism,
hemodialysis, mesenteric vein thrombosis, or acquired/hereditary thrombotic
disease.

Patients with ischemic colitis generally present with acute onset of lower
abdominal pain followed by bloody diarrhea within 12-24 hours. Fever, nausea,
vomiting, and extreme leukocytosis with left shift are often seen. The most
common involved segment of the colon is the splenic flexure, because it is
supplied by end arteries. The splenic flexure is a 'watershed' line between the
territory of the superior and inferior mesenteric artery (Choice B).

There are two watershed zones in the colon. (1) The splenic flexure supplied by
narrow terminal branches of the superior mesenteric artery, and (2) the recto-
sigmoid junction supplied by narrow terminal branches of the inferior mesenteric
artery. These two watershed areas are most vulnerable to ischemia during
systemic hypotension. There is no specific marker for ischemic colitis.
Sometimes, elevated lactic acid is helpful. Radiographs are non-specific but may
show classic "thumb printing." It is important to distinguish ischemic colitis from
infectious colitis, inflammatory bowel disease, and, at times, even colon cancer.

Educational Objective:
Suspect ischemic colitis in patients with evidence of atherosclerotic vascular
disease who present with abdominal pain, followed by bloody diarrhea, and
minimal abdominal exam findings. The most common involved segment of the
colon is the splenic flexure, because it is supplied by end arteries.

13% of people answered this question correctly


Test #16 Q.Id = 2028               Question 22 Of 45                   Division : GIT
                                     Item Review
A 50-year-old male underwent a vagotomy and pyloroplasty for a peptic ulcer
perforation. Early postoperative course was complicated with a fever and
hypotension, treated with broad-spectrum antibiotics and IV fluid support. He
recovered well. However, on the 6th day of hospitalization, the patient complains
of nausea, vomiting, abdominal pain, and diffuse, watery diarrhea. His
temperature is 38.9 C (102 F), blood pressure is 110/70 mmHg, pulse is
120/min, and respirations are 18/min. Abdominal examination reveals
tenderness in the sigmoidal area. Fecal occult blood test is negative. Lab results
are:

Hb                                 11.5g/dL
Platelet count                     180,000/cmm
Leukocyte count                    17,500/cmm
       Segmented neutrophils       75%
       Bands                       10%
       Eosinophils                 1%
       Lymphocytes                 14%

What is the next best step in the management of this patient?

     A. Blood cultures
     B. Colonoscopy
     C. Stool cultures
     D. Cytotoxin essay in the stool
     E. Observation
Explanation:

This patient was treated with antibiotics perioperatively; therefore, he is
predisposed to having antibiotic-associated diarrhea. Clostridium difficile is the
typical cause of antibiotic-associated diarrhea, although other causes should not
be overlooked (E.coli, Shigella, Salmonella). The clinical scenario described is
characteristic for Clostridium difficile-induced colitis: diffuse, watery diarrhea
(usually non-bloody), abdominal cramps, fever, and abdominal tenderness.
Pathogenesis of this condition involves secretion of toxin by C. difficile that is
toxic to intestinal epitheliocytes. The cytotoxin can be detected in the stool with
high sensitivity. Pseudomembranes in the rectosigmoid area form in about 50%
of cases of antibiotic-associated diarrhea that can be visualized with endoscopy
(Choice B).

The treatment of choice is oral/IV metronidazole. Oral (not IV) vancomycin can
also be used; however, vancomycin use is associated with emergence of
vancomycin-resistant enterococci, and it is also expensive compared to
metronidazole.

Stool cultures are usually positive for Clostridium difficile, but they are very time-
consuming (Choice C).

Blood cultures (Choice A) are usually obtained in patients who are hospitalized
and develop a fever of unknown origin or any evidence of bacteremia; however,
this patient most likely has Clostridium difficle diarrhea, which is not identified by
blood cultures.

Failure to institute appropriate treatment (Choice E) is dangerous with mortality
approaching 20% in moderate-to-severe cases of pseudomembranous colitis.

Educational Objective:
Consider clostridium difficle diarrhea in all patients who had received antibiotics
and develop, nausea, vomiting, abdominal pain, diarrhea, and elevated white
count. Clostridium difficile is the typical cause of antibiotic-associated diarrhea.
Cytotoxin essay in the stool is a highly sensitive test to diagnose this condition.

*Extremely high yield question for USMLE!!!

27% of people answered this question correctly


Test #16 Q.Id = 2102               Question 23 Of 45                      Division : GIT
                                     Item Review
A 65-year-old Caucasian male presents to your office with a four week history of
weakness and vague postprandial epigastric pain. His past medical history is
insignificant. He is not taking any medications. He smokes 1½ packs a day and
consumes alcohol occasionally. Stool is positive for occult blood. A
gastroduodenoscopy is performed that reveals an antral ulcer. Four of seven
biopsies taken from the margins of the ulcer returned positive for malignancy.
Which of the following is the best next step in the management of this patient?
     A. Serum albumin
     B. Serologic markers
     C. A CT scan
     D. Laparoscopy
     E. Exploratory laparotomy
Explanation:

Early detection of gastric cancer has crucial importance in successful
management of gastric cancer because surgical removal of the affected tissues
remains the mainstay of the therapy. Unfortunately, almost 90% of patients with
gastric cancer are diagnosed at stages III-IV; radical resection is very
complicated or impossible in these patients. Evaluation of the extent of the
disease after the diagnosis has been made is important in choosing an
appropriate management strategy. A CT scan is commonly employed for staging
the disease and revealing metastases, especially liver metastases.

Laparoscopy (Choice B) can be used to evaluate the patients further and can
detect up to 20% of peritoneal metastases missed by a CT scan.

Laparotomy (Choice E) is required eventually in most of the patients for radical
or palliative surgery with the exception of the patients with unresectable disease.

Hypoalbuminemia (Choice A) is sometimes detected in patients with gastric
cancer, but it has little diagnostic significance. Serologic markers (Choice B) are
of negligible use in these patients.

Educational Objective:
A CT scan is a standard diagnostic tool employed in patients with newly
diagnosed gastric cancer to evaluate the extent of the disease. In most of the
patients, surgery is the treatment of choice.

*Extremely high yield question for USMLE!!!

11% of people answered this question correctly

Test #16 Q.Id = 87                Question 24 Of 45                    Division : GIT
                                    Item Review
A 52-year-old woman, with cirrhosis, has had worsening abdominal distension.
She had been on spironolactone and sodium and water restriction. Furosemide
was added to her therapy recently. 3-days later, the distension persists and she
is very somnolent. She has passed almost no urine the last day. Her past
medical histroy is remarkable for chronic hepatitis type B, cirrhosis,
encephalopathy, and 2 bleeding episodes from esophageal varices, controlled
with sclerotherapy. Her vital signs are, PR: 80/min; BP: 90/60 mm Hg; RR:
12/min; Temperature: 36.5C(97.6F). Abdomen is distended and non-tender.
Shifting dullness is present. Bowel sounds are normal. Kidney ultrasonogram is
unremarkable.

Laboratory reveals:

Hb 11.5gm/dL
Hct 33%
WBC 3,200/cmm
AST 12mg/dL
ALT 8mg/dL
Bilirubin 2.1mg/dL
PT 18sec
PTT 54sec
Protein 5.0mg/dL
Albumin 2.5mg/dL
BUN 60
Creatinine 2.4

Na 125
K 5.7
Cl 93

Urinalysis: 2 RBC and 3 WBC/hpf; hyaline casts are seen. Protein is negative (-);
Bilirubin (-); Urobilinogen is normal. The next step should be:

     A. Increase the dose of furosemide to its maximal
     B. Careful volume loading and discontinuation of furosemide and spironolactone
     C. Tapping of ascites
     D. Renal biopsy
     E. Intravenous pyelography
Explanation:

Hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis in a
patient with severe liver disease are suggestive of hepato-renal syndrome. This
is a functional renal failure associated with hepatic failure most probably due to
renal arteriolar vasoconstriction. It could be precipitated (but not caused) by
hypovolemia due to diuretics, bleeding, and tapping of large volume of ascites
without concomitant infusion of albumin. The exact pathogenesis is not clear. No
treatment is available. Measures are taken to withhold all possible precipitating
factors and to optimize, if possible, the liver function. The renal failure may be
due to other reasons such as, hypovolemia alone (without hepato-renal
syndrome) or acute tubular necrosis due to hypovolemia. Therefore, initial
management also includes careful volume load to see whether the renal function
will improve (Option B). Acute tubular necrosis is less likely (though not
excluded) in this patient because urinalysis is normal.

Renal biopsy and intravenous pyelography are normal in hepato-renal syndrome
(Option D and E).

Educational Objective:
Hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis in a
patient with severe liver disease are suggestive of hepato-renal syndrome.
Measures are taken to withhold all possible precipitating factors and initial
management includes careful volume load.

31% of people answered this question correctly

Test #16 Q.Id = 1525              Question 25 Of 45                   Division : GIT
                                    Item Review
A 37-year-old male with a history of peptic ulcer disease is brought by the
paramedics to the emergency room for an alleged episode of hematemesis. A
nasogastric tube lavage yields coffee-ground-like material. Physical examination
reveals pallor and delayed capillary refill, without cyanosis. His vitals are, BP:
85/40 mm Hg, PR: 125/min, RR: 18/min, T: 36.7C(98F). What should be the first
step in management of this patient?

     A. I.V Octreotide
     B. Upper GI endoscopy
     C. Surgical intervention
     D. I.V Omeprazole
     E. Fluid resuscitation
Explanation:

Upper GI bleeding commonly presents with hematemesis with or without melena.
Blood or coffee-ground-like material on nasogastric lavage, confirms this clinical
diagnosis, however, lavage may not be positive if bleeding has ceased or arises
beyond a closed pylorus.

Assessment of hemodynamic stability and the necessity for fluid resuscitation
should be the first step in evaluation of patients with upper GI bleeding (Choice
E). In this case, the patient is pale, hypotensive, tachycardic with delayed
capillary refill. He needs fluid resuscitation.

Endoscopy (Choice B) is the procedure of choice for the diagnosis and
treatment of active upper GI bleeding and also for the prevention of re bleeding.
The benefits include ease of use, wide availability, and low cost as compared to
angiographic or surgical methods (Choice C). The majority of peptic ulcer bleed
will stop spontaneously and most will not re bleed during hospitalization.
Studies have shown significantly less recurrent bleeding in patients receiving
omeprazole (Choice D), however, studies on H2 antagonists have been
disappointing. It is a part of the management but not the first step.

Somatostatin or its long-acting analogue octreotide (Choice A) acts by reducing
splanchnic blood flow, inhibiting gastric acid secretion, and exerting gastric
cytoprotective effects. Somatostatin or octreotide can thus be used when
endoscopy is unsuccessful, contraindicated, or unavailable, or as an adjunctive
before endoscopy.

Educational objective:
The initial evaluation of the patient with upper GI bleeding involves an
assessment of hemodynamic stability and the necessity for fluid resuscitation.

68% of people answered this question correctly

Test #16 Q.Id = 83                 Question 26 Of 45                  Division : GIT
                                     Item Review
A 42-year-old man has had heartburn for 2 yrs. Most commonly, it occurs after
heavy meals and in a supine position. His symptoms have gradually increased
with time. He has treated himself with various over-the-counter antacids but they
have become ineffective in the last 2-months. He also has had epigastric pain
and occasional vomiting recently, especially in the morning. He denies having
dysphagia and odynophagia. He eats junk food and drinks two cups of coffee
daily. He admits that he regularly drinks grape brandy and smokes 1 pack of
cigarettes/day. His physical exam is remarkable for epigastric tenderness on
palpation. Abdominal ultrasound is unremarkable and stools are negative for
occult blood. The next most appropriate action is:

     A. Treatment with ranitidine
     B. Upper endoscopy
     C. Upper barium studies
     D. Manometric studies
     E. Reassurance and consultation about healthy life-style
Explanation:

Apart from reflux esophagitis this man could have other problems such as:
Barrett‘s esophagus; peptic ulcer disease; gastritis; or even tumor. Of the listed
studies, endoscopy is the most informative for all these possibilities. Provided
that the patient doesn‘t have dysphagia, it can be performed without preceding
contrast study (Choice C). If endoscopy is negative, manometry (Choice D) may
be indicated. It is better to start treatment (Choices A and E) after a clear
diagnosis is made.

Educational Objective:
Recognise when to order upper endoscopy in the management of
gastroesophageal reflux disease.


35% of people answered this question correctly

Test #16 Q.Id = 85               Question 27 Of 45                   Division : GIT
                                   Item Review
A 56-year-old man has had abdominal pain and increasing distension for 20
hours. He hasn‘t passed flatus since that time. He has nausea without vomiting.
His past medical histroy is remarkable for cirrhosis due to chronic alcoholism.
His therapy includes spironolactone and neomycin. His vital signs are, PR:
100/min; BP: 120/70mm Hg; RR: 24/min; Temperature: 38.0C(101.3F). He
appears slightly confused and a flapping tremor is noted. Breathing is labored
and lungs are clear to auscultation. His abdomen is distended, tender to
palpation with rebound, and no guarding. Fluctuating wave and shifting dullness
are present. Auscultation is positive for splashing and markedly decreased bowel
sounds. Chest x-ray is normal. Abdominal x-ray shows gas in small and large
bowels without air-fluid levels. The next diagnostic step should be:

     A. Barium enema
     B. Sigmoidoscopy
     C. Ultrasound of abdomen
     D. Diagnostic peritoneal lavage
     E. Diagnostic paracentesis
Explanation:

Abdominal pain with guarding and fever in a patient with ascites is always a
suspect for primary (spontaneous) peritonitis. Most likely this patient has
peritonitis with secondary paralytic ileus. He has clear signs of peritoneal fluid
(fluctuating waving and shifting dullness), so the diagnostic paracentesis (Option
E) is the simplest test to perform. It may reveal signs of exudate: turbid fluid,
>250 leucocytes/mcL; protein >2.5 g/L; serum-to-ascitic albumin gradient <1.1;
and specific gravidity >1.016 g/L. Gram stain and cultures also should be done.
Diagnostic peritoneal lavage (Choice D) is performed for abdominal trauma and
rarely, if ever, for overt peritoneal fluid. Choices A and B may be helpful for
diagnosis of intestinal obstruction. They may be considered if the paracentesis is
negative. USG (Option C), as well as CT, may show peritoneal abscess and
again may be considered depending on the result of the paracentesis.

Educational Objective:
Paracentesis provides useful diagnostic information in patients with ascites.

43% of people answered this question correctly
Test #16 Q.Id = 1515              Question 28 Of 45                    Division : GIT
                                    Item Review
A 50-year-old white male presents to the family physician for weight loss and
abdominal pain. He also complains of diarrhea with bulky, foul smelling stools,
abdominal distension and flatulence. Upon questioning he also describes
arthralgias and chronic cough. Physical examination reveals generalized
lymphadenopathy, skin hyperpigmentation and a diastolic murmur in the aortic
area. His BP is 120/80 mm Hg, PR is 80/min, RR is 18/min, and Temperature is
37.8C (100F). Small bowel biopsy is done which shows numerous PAS-positive
materials in lamina propria with villous atrophy. What is the most likely diagnosis
in this patient?

     A. Celiac disease
     B. Tropical sprue
     C. Crohn’s disease
     D. Whipple’s disease
     E. Cystic fibrosis
Explanation:

Whipple‘s disease (Choice D) is a rare multi systemic illness, most commonly
seen in white men in fourth to sixth decade of life and often presents with weight
loss. It is an infectious disease caused by bacillus Tropheryma whippelii.

Gastrointestinal symptoms of Whipple‘s disease include abdominal pain,
diarrhea, and malabsorption with distension, flatulence, and steatorrhea. Extra
intestinal manifestations include migratory polyarthropathy, chronic cough, and
myocardial or valvular involvement leading to congestive failure or valvular
regurgitation. Later stages of disease may be characterized with dementia and
other central nervous system findings such as supranuclear ophthalmoplegia
and myoclonus. Intermittent low-grade fever, pigmentation and lymphadenopathy
may also be occasionally seen in Whipple ‗s disease.

Celiac disease (Choice A), although associated with malabsortion, is not
associated with pigmentation and lymphadenopathy. Also, PAS positive material
in lamina propria of small intestine is a classical biopsy finding of Whipple‘s
disease.

Tropical sprue (Choice B) is a chronic diarrheal disease, possibly of infectious
origin that should be considered in patients who have lived for more than a
month in a tropical area.

Crohn‘s disease (Choice C) can be associated with malabsorption, abdominal
pain, fever and arthralgias, but would not explain skin hyperpigmentation, chronic
cough and the biopsy findings in this patient.
Cystic fibrosis (Choice E) can be associated with chronic cough and
malabsorption. It is not associated with arthralgias or skin hyperpigmentation.

Educational Objective:
Whipple‘s disease is a multi systemic illness characterized by arthralgias, weight
loss, fever, diarrhea and abdominal pain. PAS positive material in lamina propria
on small intestine is a classical biopsy finding of Whipple‘s disease.

56% of people answered this question correctly

Test #16 Q.Id = 1520              Question 29 Of 45                    Division : GIT
                                    Item Review
A 50-year-old female presents to the family physician for severe abdominal pain
and diarrhea. She has had these symptoms for about 3 years, but she did not
see a physician. Her symptoms have been progressively worse, which is the
reason why she decided to come to the office. At endoscopy, she has multiple
ulcerations of the duodenum and prominent gastric folds. She has a positive
secretin stimulation test with increased gastrin secretion. Her condition could be
associated with which of the following?

     A. Medullary thyroid cancer
     B. Pheochromocytoma
     C. Primary hyperparathyroidism
     D. Neuromas
     E. Marfanoid habitus
Explanation:

Gastrinomas (Zollinger-Ellison syndrome) are a type of non-beta cell pancreatic
islet cell tumors characterized by the secretion of a high amount of gastrin.
Abdominal pain and diarrhea are the usual presenting symptoms. Endoscopy
shows multiple ulcerations and prominent gastric folds. The secretin stimulation
test is one of the diagnostic tools for gastrinoma.

Personal or family history of multiple endocrine neoplasia type 1 (MEN I) may be
present in patients with Zollinger-Ellison syndrome. MEN I consist of primary
hyperparathyroidism (Choice C), pituitary tumors, and pancreatic tumors such
as insulinoma and VIP-oma.

Medullary thyroid cancer (Choice A) and pheochromocytoma (Choice B) are
characteristic of MEN 2A and MEN 2 B, not of MEN I.

Neuromas (Choice D) and marfanoid status (Choice E) are also characteristic
for MEN 2B, not for MEN I.

Educational objective:
Zollinger-Ellison syndrome (gastrinoma) is associated with MEN I (primary
hyperparathyroidism, pituitary tumors and enteropancreatic tumors).

48% of people answered this question correctly

Test #16 Q.Id = 1516              Question 30 Of 45                     Division : GIT
                                    Item Review
A 46-year-old white male presents to the family physician for chronic diarrhea,
abdominal distention, flatulence, and weight loss. He also complains of
arthralgias and bulky, frothy stools. He has never had any blood transfusion,
tattooing or high-risk sexual behaviors. Physical examination reveals generalized
lymphadenopathy and skin hyperpigmentation. His BP is 130/90 mm Hg, PR is
84/min, RR is 16/min, and his temperature is 38.3C (101F). The best test to
confirm the diagnosis is:

     A. Serum TSH
     B. Antinuclear antibody (ANA) titer
     C. Gamma glutamyl transpeptidase levels
     D. ELISA for anti-HIV antibodies
     E. Endoscopy with small bowel biopsy
Explanation:

The diagnosis of Whipple's disease can be readily made with PAS staining of
small intestinal biopsies (Choice E), which would show characteristic PAS-
positive material in the lamina propria and villous atrophy. However, electron
microscopy to demonstrate the Whipple bacillus may be required to confirm the
diagnosis in doubtful cases.

Whipple‘s disease can mimic many illnesses like hyperthyroidism, connective
tissue diseases, alcoholism and AIDS, thus it should be suspected in all patients
with fever of unknown origin, generalized lymphadenopathy, arthralgias, weight
loss, abdominal pain and diarrhea.
In this case hyperthyroidism (Choice A) is unlikely given the arthralgias, low-
grade fever, and generalized lymphadenopathy.

Connective tissue diseases (Choice B) would be less likely to be associated with
chronic diarrhea, abdominal distention, flatulence, and skin hyperpigmentation.
However, workup should be performed if the small intestinal biopsy is negative.

Alcoholism (Choice C) could present with symptoms of malnutrition, but lacks
the other clinical findings in this case.

AIDS (Choice D) could present with low-grade fever, lymphadenopathy,
diarrhea, malnutrition, but it is less likely due to the skin hyperpigmentation and
lack of risk factors.

Educational Objective:
Diagnosis of Whipple‘s disease can be confirmed with upper gastrointestinal
endoscopy with biopsy of the small intestine.

54% of people answered this question correctly

Test #16 Q.Id = 1535               Question 31 Of 45                      Division : GIT
                                     Item Review
A 12-year old girl with a history of bulky, floating, foul smelling stools, flatulence
and meteorism presents to the office complaining of chronic weight loss and
fatigue. She also complains of bone pain and easy bruising. The laboratory
report shows that she is anemic with serum iron: 25 ug/dL, ferritin: 25 ng/mL and
serum total iron binding capacity: 600 ug/dL (normal 300-360 ug/dL). PT is 16
sec. Physical examination reveals loss of subcutaneous fat, pallor,
hyperkeratosis and abdominal distension with hyperactive bowel sounds. Which
of the following is likely to be associated with her condition?

       A. Anti-endomysial antibodies
       B. Anti-Scl-70 antibodies
       C. Antinuclear antibodies
       D. Anticentromere antibodies
       E. Anti-mitochondrial antibodies
Explanation:
The clinical presentation of this patient is highly suggestive of celiac disease.
Celiac disease presents with symptoms and signs of malabsorption, which
includes characteristically bulky, foul smelling, and floating stool, loss of muscle
mass or subcutaneous fat, pallor due to iron deficiency anemia, bone pain due to
osteomalacia, easy bruising due to vitamin K deficiency and hyperkeratosis due
to vitamin A deficiency. Fatigue and weight loss is a common complaint.

The diagnosis of celiac disease is confirmed with serological studies like ELISA
for IgA antibodies to gliadin and the immunofluorescence test for IgA antibodies
to endomysium, the presence of which is virtually pathognomonic for celiac
disease (Choice A). Also, antibodies against tissue transglutaminase are highly
sensitive and specific.

(Choice B) Anti-Scl-70 antibodies are associated with scleroderma. Patients
usually presents with dysphagia rather than malabsorption.

(Choice C) Antinuclear antibodies (ANA) are associated with autoimmune
hepatitis and SLE.

(Choice D) Anti-centromeric antibodies are associated with CREST syndrome.
(Choice E) Anti-mitochondrial antibodies are associated with primary biliary
cirrhosis.

Educational objective:
Celiac disease is associated with anti-endomysial antibodies. Suspect celiac
disease in any patient who presents with malabsorption and iron deficiency
anemia.
49% of people answered this question correctly

Test #16 Q.Id = 1949               Question 32 Of 45                 Division : GIT
                                     Item Review
A 66-year-old man comes to your office with a several month history of
increasing back pain and severe constipation. He has no weakness or sensory
symptoms in the legs. He is taking acetaminophen to relieve his back pain,
hydrochlorothiazide for high blood pressure, and an over-the-counter fiber
supplement for constipation. He had a screening colonoscopy five years ago,
and it was negative. Rectal examination shows no abnormalities. Test of the
stool for occult blood is negative. His blood pressure is 135/80 mmHg and heart
rate is 80/min. Abdominal examination is insignificant. Lab results are:

Hb                     10.5 g/dL
WBC                    7,000/cmm
Platelets              300,000/cmm
BUN                    28 mg/dL
Serum Creatinine       1.9 mg/dL
ESR                    80/hr

What is the most probable cause of this patient‘s constipation?

     A. Mechanical obstruction
     B. Medication effect
     C. Electrolyte disturbances
     D. Hormonal disturbances
     E. Neurologic dysfunction
Explanation:

The clinical scenario described is suggestive of multiple myeloma. The
combination of back pain, anemia, renal dysfunction, and elevated ESR is very
typical for this disorder. Another very characteristic finding is hypercalcemia.
Bone lysis caused by plasmocyte-released humoral factors and expanding
plasma cell mass results in the increase in serum calcium level. Hypercalcemia
may manifest as severe constipation, anorexia, weakness, increased urination,
or neurologic abnormalities (like confusion or lethargy). Sometimes
hypercalcemia-induced symptoms may dominate in the clinical picture of multiple
myeloma. In this patient with a clinical scenario typical for multiple myeloma,
hypercalcemia is the most probable cause of constipation.

Other common causes of persistent constipation may include mechanical
obstruction, like colon cancer (Choice A), a side effect of some medications,
especially anticholinergic agents (Choice B), hormonal disturbances like
hypothyroidism (Choice D), and some neurologic abnormalities (Choice E). The
signs and symptoms in this patient are not suggestive of any of these problems.

Educational Objective:
Hypercalcemia is a common finding in a patient with multiple myeloma.
Hypercalcemia may cause severe constipation, anorexia, weakness, renal
tubular dysfunction, and neurologic symptoms.

*You may get a similar scenario from metastatic bone cancers such as lung,
breast, renal, thyroid, etc. Always look for hypercalcemia as a cause of
constipation.

*Extremely high yield question for USMLE!!!

12% of people answered this question correctly

Test #16 Q.Id = 1536              Question 33 Of 45                    Division : GIT
                                    Item Review
A 55-year-old male presents to the family physician with a history of diarrhea,
weight loss, bloating, and excess flatulence. The patient states that these
symptoms have started soon after his ―stomach surgery‖ two years ago. He
admits to a history of gastric ulcers. Physical examination reveals scarring
associated with past surgery, and abdominal distention with identifiable
succussion splash. Laboratory examination shows anemia with MCV of 100fl.
The most likely diagnosis is:

     A. Short bowel syndrome
     B. Bacterial overgrowth
     C. Peptic ulcer disease
     D. Crohn’s disease
     E. Ulcerative colitis
Explanation:

The clinical manifestations of bacterial overgrowth (Choice B) depend upon
underlying cause (most likely a Billroth II gastrojejunostomy with stagnation in
the afferent limb, in this case), and the severity of disease.

Symptoms of bacterial overgrowth may be nonspecific and include abdominal
pain, watery diarrhea, dyspepsia, and weight loss. In severe and advanced
cases, patients may present with tetany (hypocalcemia due to vitamin D
deficiency), night blindness (due to vitamin A deficiency), neuropathy (due to
vitamin B12 deficiency), dermatitis, arthritis, and hepatic injury.

Physical examination may reveal abdominal distention with identifiable
succussion splash due to palpable soft, fluid-filled loops of bowel. Macrocytic
anemia due to vitamin B 12 malabsorption can be seen on laboratory
examination.

The history of peptic ulcer disease with abdominal surgery makes Crohn‘s
disease (Choice D) and ulcerative colitis (Choice E) less likely. Despite his
history, the presenting symptomatology is not consistent with peptic ulcer
disease (Choice C). Short bowel syndrome (Choice A) is less likely since
surgery for peptic ulcer disease usually does not remove significant segments of
the small intestine.

Educational objective:
Bacterial overgrowth is a malabsorption syndrome, which can be associated with
a history of abdominal surgery.

19% of people answered this question correctly

Test #16 Q.Id = 77                 Question 34 Of 45                   Division : GIT
                                     Item Review
A 48-year-old woman has had right subcostal heaviness, intermittent pain, and
food intolerance for 2 months. The pain has increased and shifted to her back.
She has lost 6kg (13.2lb). One week ago she experienced jaundice and low-
grade fever. Past medical history is remarkable for perforated appendicitis and
peritonitis 20 yrs ago. She has epigastric tenderness and a round mass is
palpable 5 cm below the right costal line. Murphy‘s sign is negative. Abdominal
ultrasound is positive for enlarged gall bladder, without stones, and widening of
hepatic ducts. Her pancreas is not visualized because of gas collections in the
bowels.

Laboratory results are:

WBC 11,000/cmm
Bilirubin total/direct 2.0/1.1 mg/dL
ALT 87mg/dL
AST 56mg/dL
Alkaline phosphatase 210mg/dL
Amylase 140

Which of the following is the most appropriate next step in the management?

      A. Plain abdominal film
     B. Endoscopic retrograde cholangiopancreatography
     C. Percutaneous transhepatic cholangiography
     D. CT of abdomen
     E. HIDA scan
Explanation:

The above patient is having obstructive jaundice along with enlarged gall
bladder. Features that suggest obstructive jaundice in the above patient are
elevated direct bilirubin and disproportionate elevation of serum alkaline
phosphatase. Obstructive jaundice in the above patient may be due to gallstones
in the bile duct or due to carcinoma of head of pancreas. With distended gall
bladder, most likely cause of obstructive jaundice is carcinoma of head of
pancreas for which CT scan is the best initial test (Option D). Further imaging
studies, such as ERCP and PTC may be required, depending on the results of
the CT and biopsy (Option B and C).

Plain abdominal film would be more appropriate if long standing chronic
(indurative) pancreatitis with possible calcifications was suspected (Option A).

HIDA scan is used for the diagnosis of acute cholecystitis, which is a distinct
possibility here (Option E).

Educational Objective:
Abdominal CT scan is the next diagnostic test when abdominal ultrasound does
not explain cholestatic jaundice.

33% of people answered this question correctly


Test #16 Q.Id = 16                  Question 35 Of 45                  Division : GIT
                                      Item Review
An 83-year-old woman has had generalized crampy abdominal pain after eating,
since 1 year. Bloating, nausea, vomiting, diarrhea, and constipation on various
occasions have accompanied the pain. The pain has worsened over the time
and she admits that she began avoiding food because of it. She has lost 15 kg
(33lb) during this time. Recently, she noticed that her stools are bulky, foamy,
and greasy. She has had fatigue, exertional chest discomfort, shortness of
breath, and occasional attacks of dizziness for several months. Her abdominal x-
ray and CT scan are unremarkable. What is the most likely diagnosis?

      A. Chronic pancreatitis
      B. Atherosclerosis of the mesenteric arteries
      C. Crohn’ s disease
      D. Irritable bowel syndrome
     E. Celiac disease
     F. Symptomatic cholelithiasis
     G. Amyloidosis
     H. Intestinal lymphoma
Explanation:

Numerous disorders may lead to malabsorption manifested by weight loss and
change in the character of the stools. Many of them are associated with
dyspeptic symptoms, but only some with severe abdominal pain. Worsening
postprandial pain that leads to avoidance of food is characteristic of chronic
occlusion of visceral arteries (abdominal angina). The described patient has
symptoms of generalized atherosclerosis that further raise the suspicion for this
diagnosis (Option B). Routine imaging studies are usually not informative.
Diagnosis requires angiography or a Doppler ultrasound.

Pain accompanied by malabsorption may be due to chronic pancreatitis or
Crohn‘s disease. However, these diseases usually produce abnormal CT and X-
Ray findings (Option A and C).

Irritable bowel syndrome (IBS) doesn‘t lead to weight loss. IBS is a diagnosis of
exclusion. You should not make this diagnosis especially with the above
presentation (Option D).

Cholelithiasis presents with right upper quadrant pain and fatty food intolerance.
It does not cause chronic diarrhea and weight loss (Option F).

Celiac disease (Option E) is due to gluten sensitivity and it usually presents
between 10-40 years of age. These patients present with features of
malabsorption like chronic diarrhea, steatorrhea and flatulence. Abdominal
angina is not a feature of this entity.

Amyloidosis and intestinal lymphoma are unlikely in the above patient (Option G
and H).

Educational Objective:
Learn the clinical presentation of mesenteric artery thrombosis.Always
consider abdominal angina in a patient with risk factors for atherosclerotic
vascular disease.

28% of people answered this question correctly

Test #16 Q.Id = 84                 Question 36 Of 45                      Division : GIT
                                     Item Review
A 56-year-old woman has had dysphagia and odynophagia for 2-months. She
has difficulty with initiation of swallowing and pain in the throat. For the past 5-
months, she has felt extreme fatigue, shortness of breath, and palpitations on
exertion. Her past medical history is remarkable for partial gastrectomy and
Billroth II for gastric ulcer 15 yrs ago. Her conjunctiva are pale. Her tongue is
smooth and bright red. Oral and pharyngeal mucosa is markedly red also. Heart
sounds and lungs are clear to auscultation without any abnormal findings. Vital
signs are, PR: 110/min; BP: 110/60mm Hg; RR: 14/min; Temperature:
36.5C(97.5F). Barium swallow shows filling defects in the hypopharynx and large
erythematous webs are seen on endoscopy. The rest of these studies are
consistent with status post gastric resection with atrophic changes of the
residium. Stools are negative for occult blood. The rest of her laboratory results
are pending. Most likely these webs will require:

     A. Vit. B12 therapy
     B. Iron therapy
     C. Dilatation
     D. Segment resection
     E. Endoscopic resection
Explanation:

This patient has Plummer-Vinson syndrome i.e. atrophic glossitis, stomatitis, and
upper esophageal webs associated with iron-deficiency anemia. Spoon-shaped
nails may also be present. Usually these webs don‘t regress with conservative
treatment and require dilatation. Gastric resection and atrophy may lead to iron
deficiency or vit. B12 deficiency. The latter could cause similar changes in
tongue and mouth but without esophageal webs.

Educational Objective:
Plummer-Vinson syndrome is characterized by atrophic glossitis, stomatitis, and
upper esophageal webs associated with iron-deficiency anemia. Usually these
webs don‘t regress with conservative treatment and require dilatation.

11% of people answered this question correctly

Test #16 Q.Id = 1457             Question 37 Of 45                    Division : GIT
                                   Item Review
A 73-year-old female from a nursing home is admitted to your service with a
diagnosis of diverticulitis. The CT scan done at another hospital revealed
inflamed sigmoid colon. She had a fever and abdominal pain for two days. Her
WBC count is 22,000/cmm. She was started on IV antibiotics and administered
IV fluids. Over the ensuing few days her WBC started to come down and she
had no nausea, vomiting or fever. Her abdominal exam revealed guarding and
tenderness in the left quadrant. She developed a coughing spell and an upright
chest x-ray was done the following day. It revealed free air under the left
diaphragm, some air fluid levels in the large bowel and an ileus pattern in the
small bowel. The next step in her management is:
       A. CT scan
       B. Colonoscopy
       C. Barium enema
       D. Continue antibiotics with observation
       E. Surgery consult
Explanation:
This patient was admitted with acute diverticulitis. She appears to be getting
better but her abdominal pain still persists. A chest x-ray reveals free air. This is
very significant and suggests bowel perforation. Even in the absence of nausea,
vomiting and a WBC, which is getting better, free air underneath the left
diaphragm indicates bowel perforation. This patient needs to go to the OR. In
the acute situation, the bowel is not prepped and cleaned and thus the patient
will get a resection of her perforated bowel and a proximal colostomy.

Choice A: Obtaining another CT scan is redundant. The initial CT revealed an
inflamed colon and now has free air underneath the diaphragm, suggesting a
perforation. A CT scan will not change the management of the patient. Patients
with free air underneath the left diaphragm require surgery. Two organs that
frequently present with free air underneath the diaphragm are the stomach (from
perforated peptic ulcer) and colon (from diverticulitis).

Choice B, C: Colonoscopy and barium enema are contraindicated when bowel
perforation is suspected. Colonoscopy can result in worsening of the injury,
especially during acute diverticulitis. Barium enema is injected under pressure
and can result in abdominal spillage of barium if there is bowel perforation. Both
these procedures are done on an elective basis after the acute episode of
diverticulitis has subsided.

Choice D: Observation with antibiotic therapy is hazardous if free air has been
identified. The inevitable result is massive sepsis with death if surgery is not
undertaken. However, the patient must continue the antibiotics until after
surgery is done. The antibiotics should cover gram positive, negatives and
anaerobes.

Educational objective:
Free air underneath the left diaphragm signifies bowel perforation and requires
an urgent surgical consult.
65% of people answered this question correctly

Test #16 Q.Id = 1400              Question 38 Of 45                     Division : GIT
                                    Item Review
A 56-year-old man is admitted with left lower quadrant abdominal pain, fever and
an elevated WBC. He said that he has had this pain for the last 48 hours but it
became unbearable. He took a few laxatives but did not get better. He says he
is a meat eater and hardly eats any vegetables. He does not have regular bowel
movements and has been constipating for a few weeks. On examination, his
vitals are stable but he does have a low-grade fever. He is tender to palpation in
the left lower quadrant, with some guarding. Rectal exam is negative. His WBC
is 16,400/cmm. He is admitted and started on IV antibiotics. Forty-eight hours
later, the symptoms persist and he has not improved in spite of antibiotic
therapy. The diagnostic evaluation most helpful in this setting is:

      A. Abdominal x-rays
      B. Flexible sigmoidoscopy
      C. Colonoscopy
      D. CT scan
      E. Barium enema
Explanation:
The diagnosis of uncomplicated acute diverticulitis of the colon can usually be
made clinically. These patients generally have a history of constipation and
having little fiber in their diet. They present with pain in the left lower quadrant
and may have fever. These patients are best treated with IV antibiotics until the
symptoms resolve. However, when patients fail to respond to antibiotics, a
complication of diverticulitis must be suspected. These complications may
include formation of abscess, a fistula to the bladder or frank perforation. The
best diagnostic test to evaluate complications of diverticulitis is a CT scan. CT
scan is relatively non-invasive and highly sensitive and specific for diverticulitis,
especially when there is accompanied by perforation or abscess.

Choice A: Plain x-rays are frequently normal in patients with diverticulitis, save
for one exception. Sometimes the diverticulitis will cause a perforation of the
colon, and free air may be seen underneath the diaphragm on an upright x-ray.
The plain x-ray in a simple bout of diverticulitis does not yield much.

Choice C: Colonoscopy can be disastrous in the presence of acutely inflamed
bowel. The endoscope can perforate the fragile bowel and lead to massive
contamination of the abdominal cavity with fecal material. Colonoscopy is
generally delayed until the patient‘s inflammatory signs and symptoms have
subsided.

Choice D: Although sigmoidoscopy and colonoscopy are abnormal in these
patients, these procedures should not be done, as the risk of perforation of colon
is very high.

Choice E: Similarly barium enema should not be done during an acute episode
of diverticulitis, as the risk of perforation is as high.

Educational objective:
The diagnostic test to evaluate the abdomen during an acute episode of
diverticulitis is a CT scan.
46% of people answered this question correctly


Test #16 Q.Id = 519              Question 39 Of 45                    Division : GIT
                                   Item Review
A 49-year-old woman comes with complaints of lower abdominal pain and
severe diarrhea for the last 2 weeks. The stools are watery and she has not
noticed any blood or mucus in it. She also describes that recently she started
having intermittent episodes of flushing. There is no history of travel and she
denies any fever. The pain is mild and is unrelated to her stools. She had a
surgery for a fracture in her right leg 3 years ago. She does not smoke nor drinks
alcohol. Her vitals are, Temperature: 36.6C (97.8F); PR: 103/min; RR: 20/min;
BP: 106/68mm of Hg; and Oxygen saturation is 99% on room air. Her face looks
flushed and there are expiratory wheezes on lung examination. A
prominent jugular venous pulse is also noted. What is the most probable
diagnosis of this patient?

     A. Diverticulosis
     B. Infectious gastroenteritis
     C. Inflammatory bowel disease
     D. Carcinoid syndrome
     E. Irritable bowel syndrome
Explanation:

Carcinoid syndrome is the pattern of symptoms, which are exhibited by people
with carcinoid tumors. These tumors can occur in the small intestine, colon,
bronchial tubes, and appendix. This patient has got classical triad of carcinoid
syndrome: Flushing, diarrhea, and wheezing. Episodic flushing is the clinical
hallmark of the carcinoid syndrome, and occurs in about 85 % of patients.
Severe flushes are associated with hypotension and tachycardia. Upto 80%
patients develop secretory diarrhea (often with abdominal cramps), and
sometimes it is a very debilitating symptom. Flushing episode are also commonly
associated with wheezing and dyspnea in upto 25% of patients. Additional
symptoms include intermittent abdominal pain, heart palpitations, and
hypotension.

Carcinoid tumors secrete excessive amounts of the hormone serotonin as well
as other chemicals that cause the blood vessels to dilate. Surgery with complete
removal of the tumor tissue is usually the first line treatment. It can result in
permanent cure if it is possible to remove the tumor entirely. The mainstay of
treatment for advanced carcinoid tumors that cannot be removed surgically is
octreotide injections. In many cases, this anti-hormone drug inhibits and
sometimes reverses the growth of the tumors. Pathognomonic plaque-like
deposits of fibrous tissue occur most commonly on the endocardium on the right
side of the heart (Option D).

There is no history of blood or mucous in the stools so diverticulosis and
inflammatory bowel disease go down in the list of probable diagnosis (Option C
and A). Again episodic flushing is quite characteristic for carcinoid syndrome.

There is no fever and nothing to suggest that it can be an infection (Option B).

Irritable bowel syndrome is a diagnosis of exclusion and the patient certainly
does not have classical history of irritable bowel syndrome (Option E).

Educational Objective:
Carcinoid syndrome is characterized by a classical triad of symptoms: Flushing,
diarrhea, and wheezing.

77% of people answered this question correctly

Test #16 Q.Id = 1526               Question 40 Of 45                   Division : GIT
                                     Item Review
A 45-year-old nurse practitioner presents to the emergency room for painful
abdominal cramps and watery diarrhea. Patient reports about 10 to 20 bowel
movements a day. She also complains of nocturnal bowel movements. The
patient has had multiple hospitalizations in the past for similar problems without
a definite diagnosis. A lower GI endoscopy during a previous hospitalization
showed dark brown discoloration of the colon with lymph follicles shining through
as pale patches. What is the most likely diagnosis?

     A. Factitious diarrhea
     B. Irritable bowel syndrome
     C. Celiac disease
     D. Infectious diarrhea
     E. Non-Hodgkin’s lymphoma
Explanation:

Laxative abuse (Choice A) is characterized by watery diarrhea that is high in
frequency and volume and is often associated with painful abdominal cramps.
Diarrhea is generally profuse with about 10 to 20 bowel movements a day and
may be associated with nocturnal bowel movement, which is not characteristic of
functional diarrhea, such as irritable bowel syndrome (Choice B).

Factitious diarrhea is more frequently seen in women from higher socioeconomic
class and many of them are employed in medical field. Such patients generally
have history of multiple hospital admissions in an effort to establish the cause of
the diarrhea.
Melanosis coli typically occurs with the use of anthraquinone-containing
laxatives, such as bisacodyl. It generally develops within four months of the
onset of laxative ingestion and can disappear in the same amount of time if
laxative use in discontinued. On endoscopy it is seen as a dark brown
discoloration of the colon with lymph follicles shining through as pale patches. An
alternative means of diagnosis is histological evidence of pigment in the
macrophages of the lamina propria.

Melanosis coli is not characteristic for celiac disease (Choice C), infectious
diarrhea (Choice D), or non-Hodgkin‘s lymphoma (Choice E).

Educational objective:
Laxative abuse is characterized by high frequency watery and nocturnal diarrhea
and characteristic dark brown discoloration of the colon with lymph follicles
shining through as pale patches confirms the diagnosis.

41% of people answered this question correctly

Test #16 Q.Id = 88                Question 41 Of 45                     Division : GIT
                                    Item Review
A 58-year-old man presents with complaints of diarrhea for the last one-year,
which is watery in nature and accompanied by abdominal cramps. He denies
any history of fever, blood per rectum, and foul smelling stools. He took various
herbal medicines for the treatment of the diarrhea but nothing seemed to help.
General examination shows an elderly patient who appears ill. Physical
examination showed hepatomegaly of 3cm below the right costal margin, mild
shifting dullness, and no abdominal tenderness. Examination of the chest
reveals a 2/6 systolic murmur on the left lower sternal border. He also gives a
history of frequent episodes of dizziness, accompanied flushing, and a feeling of
warmth. He is depressed about his illness and feels hopeless that his disease
might not get diagnosed and treated.

You send his routine laboratory studies, which were as follows

Hb 13gm/dL
MCV 90
WBC 6,100/cmm
Platelet 210,000/cmm
AST 101mg/dL
ALT 99mg/dL
Alkaline Phosphatase 400mg/dL

This patient is at risk of developing deficiency of which vitamin or mineral?

      A. Vitamin A
      B. Iron
     C. Niacin
     D. Calcium
     E. Vitamin K
Explanation:

The classic triad of flushing, valvular heart disease, and diarrhea indicates that
this patient has carcinoid syndrome. Carcinoid syndrome is associated with
carcinod tumors with hepatic metastasis. Isolated tumors without metastasis do
not produce carcinoid syndrome. These tumors secrete serotonin and various
other products. Elevated serotonin and its metabolites 5-hydroxy indole acetiic
acid (5-HIAA) are present in the blood and urine of most patients with this
syndrome. 5-hydroxy tryptophan is degraded in the liver to functionally inactive
5HIAA. That‘s the reason that these syndromes are common in the setting of
hepatic metastasis. Tryptophan is the precursor of serotonin (5
hydroxytryptamine). You may recall from your biochemistry classes that
tryptophan is the amionoacid utilized in the synthesis of niacin. Patients with
carcinoid syndrome are at risk of developing niacin deficiency owing to increased
formation of serotonin from tryptophan. As a result, supply of tryptophan is
decreased and hence patients can develop diarrhea, dermatitis, and dementia
(3D‘s, 4th D can be death) (Option C).

Choice A: Vitamin A deficiency is not related to carcinoid syndrome. Steatorrhea
from any cause can result in Vitamin A deficiency.

Choice B: Iron deficiency is highly unlikely given that the patient MCV is within
normal limits.

Choice D and E: Calcium and Vitamin E deficiency are also highly unlikely in
this scenario.

Educational Objective:
Patients with carcinoid syndrome are at risk of developing niacin deficiency
owing to increased formation of serotonin from tryptophan.

27% of people answered this question correctly

Test #16 Q.Id = 2022              Question 42 Of 45                    Division : GIT
                                    Item Review
A 55-year-old obese male presents to his physician for a routine annual physical
examination. A review of systems is insignificant, except for constipation, which
has been present for several years. He does not have any major medical
problems and is not on any prescription or over-the-counter medications. He has
smoked one-and-a-half packs of cigarettes daily for 30 years. He drinks 4 oz of
alcohol daily. Physical examination is unremarkable. As part of the routine
screening, a colonoscopy is done, which shows multiple diverticuli at the sigmoid
colon. He is concerned about the diverticulosis. What would be the next
best step in regards to diverticulosis?

     A. Advise him to stop smoking
     B. Advise him to stop drinking alcohol
     C. Increase dietary fiber intake
     D. Explain about the surgical option
     E. Educate about prophylactic antibiotics
Explanation:

This patient presents with diverticulosis as evidenced by his history of chronic
constipation and the presence of multiple diverticuli detected during
colonoscopy. Diverticulosis is most often asymptomatic, but can also present
with symptoms like constipation and abdominal pain. The incidence of
diverticular disease increases with advancing age. A diverticulum, by definition,
is a sac-like protrusion of the colonic wall, which develops at points of weakness.
Constipation causes increased pressure in the colon, and this excess pressure
can lead to weak spots, thus predisposing to formation of diverticuli.
Uncomplicated diverticulosis is best treated by increasing the intake of dietary
fiber. The resultant large, bulky stools decrease the possibility of development of
diverticuli by increasing the width of the colon. Bulk laxatives are also helpful.

(Choices A and B) In general, cutting down on cigarette smoking and alcohol
will have maximum benefits; however, they do not have any effect on
diverticulosis.

(Choice D) Surgery is indicated only in the event of complications, like
diverticular bleeding, perforation, or peritonitis.

(Choice E) Bowel rest and antibiotics are administered to patients with
uncomplicated diverticulitis. Diverticulosis is differentiated from diverticulitis by
absence of fever, leukocytosis, or other signs of peritoneal inflammation.
Diverticulosis is best treated only with dietary recommendations.

Educational Objective:
Asymptomatic diverticulosis needs only dietary modifications in the form of high
fiber intake.

57% of people answered this question correctly


Test #16 Q.Id = 2021                Question 43 Of 45                      Division : GIT
                                      Item Review
An elderly Caucasian male brings in his wife, a 65-year-old lady to their family
physician with complaints of painless intermittent rectal bleeding. She describes
the bleeding as bright red in color. She denies any abdominal pain, nausea, or
vomiting. Her medical history is significant for hypertension, diabetes mellitus,
and hypercholesterolemia. Her temperature is 36.7 C (98 F), blood pressure is
140/80 mmHg, pulse is 80/min, and respirations are 16/min. On physical
examination, an ejection systolic murmur is detected in the right second
intercostal space. The remainder of the examination shows no abnormalities.
Sigmoidoscopy is unremarkable. Which of these is the most likely diagnosis in
this patient?

     A. Vascular ectasia
     B. Diverticulosis
     C. Ischemic colitis
     D. Carcinoma colon
     E. Hemorrhoids
Explanation:

The most common cause of lower GI bleed in elderly patients is diverticulosis.
The second most common cause is vascular ectasia or angiodysplasia.
Angiodysplasia typically presents in an elderly patient with painless bleeding.
There has been a well-defined association of aortic stenosis and angiodysplasia.
The other well recognized association is renal failure. Even though these
ectasias can present throughout the colon, most often the bleeding originates
from the cecum or ascending colon.

Angiodysplasia and diverticulosis are both common causes of lower GI bleeding
in patients who are age 65 years and above. It is difficult to differentiate between
the two, as both can present with painless GI bleeding; however, colonoscopy is
diagnostic in both. Angiodysplasia is seen as a cherry red fern-like pattern of
blood vessels that appear to radiate from a central feeding vessel; whereas,
multiple diverticuli will be detected with a diverticular bleed.

(Choice B) Most of diverticula are located in the sigmoid colon; so,
sigmoidoscopy would have shown these, and the association with aortic stenosis
makes angiodysplasia more likely.

(Choice C) Ischemic colitis is unlikely in the absence of abdominal pain.
Findings on colonoscopy are friable, edematous mucosa, especially in the region
of splenic flexure.

(Choice D) Even though colon cancer is a possibility, sigmoidoscopy did not
show any mass, and the association with aortic stenosis makes angiodysplasia
the more likely diagnosis.

(Choice E) Hemorrhoids would be a likely diagnosis in a younger patient. Also,
her physical examination is normal, except for an ejection systolic murmur.
Educational Objective:
The two most common causes of painless GI bleeding in an elderly patient over
65 years of age are diverticulosis and angiodysplasia. There has been a well-
defined association of aortic stenosis and angiodysplasia.

*Extremely high yield question for USMLE!!!

14% of people answered this question correctly

Test #16 Q.Id = 81                Question 44 Of 45                     Division : GIT
                                    Item Review
A 30-year-old businesswoman has had episodic retrosternal pain radiating to the
interscapular region on many occasions over the past 5 months. It is precipitated
by emotional stress and typically lasts 15 minutes. She also has similar pain
when she swallows cold or hot food. Her relative gave her nitroglycerine tablets
which alleviates the pain when taken sublingually during these episodes. Her
past medical history is unremarkable and she doesn‘t take other medications.
Her vital signs and physical exam are normal and so are her EKG and lipid
profile. A stress test failed to reproduce the symptoms and to induce ST
changes. So chest x-rays, esophagography, and echocardiography (including
transesophageal) are performed and also showed no abnormalities. What of the
listed studies should be done next?

     A. CT with contrast of the chest
     B. Esophageal motility studies (manometric recordings)
     C. Aorto-coronarography
     D. Acid perfusion (Bernstein) test
     E. Pulmonary perfusion/ventilation scintigraphy
Explanation:

Serious cardiovascular causes, such as ischemia, cardiomyopathy, valve
dysfunction and aortic dissection are nearly excluded from both the clinical
picture and the tests performed in this patient. It is wise to look for other causes
for the symptoms. Most likely, this woman has diffuse esophageal spasm
(spontaneous pain and odynophagia, in this case for cold and hot food). Nitrates
(and Ca cannels blockers) relax not only the myocytes in the vessels but also all
others including those in the esophagus alleviating the pain. Esophagography
may or may not show anomalies such as, corkscrew shape. Esophageal
manometry should reveal repetitive, nonperistaltic, high amplitude contractions
either spontaneous or after Ergonovine stimulation (Opton B).

Esophageal reflux (Choice D) most commonly causes burning (heartburn),
rather than pain. The radiation of the pain to the back, and its precipitation by
emotional stress, makes the diagnosis of motility disorder more likely than
gastroesophageal reflux disease.
Repetitive pulmonary embolism (Choice E) is unlikely with normal vital signs. If
esophageal motility disorder is disproved, further studies for diagnosing
cardiovascular disease (Choices A and C) may be needed.

Educational Objective:
Manometry establishes the diagnosis of diffuse esophageal spasm.

50% of people answered this question correctly

Test #16 Q.Id = 1522                 Question 45 Of 45                 Division : GIT
                                       Item Review
A 50-year old female presents for heartburn and gnawing abdominal pain. She
was diagnosed with peptic ulcer disease 3 years ago, but she has been non-
compliant with her medications. She asks you if her non-compliance puts her at
increased risk of any complication. Which one of the following is the most
common complication of peptic ulcer disease?

     A. Perforation
     B. Penetration
     C. Gastric outlet obstruction
     D. Hemorrhage
     E. Atrophic gastritis
Explanation:

Hemorrhage (Choice D) is the most common and serious complication of peptic
ulcer disease. Upper GI bleeding commonly presents with hematemesis with or
without melena. Massive upper GI bleeding may also present with
hematochezia, which is usually a sign of a lower GI bleeding. Blood or coffee-
ground like material on nasogastric tube lavage would confirms this clinical
diagnosis; however, lavage may be negative if bleeding has ceased or if it arises
beyond a closed pylorus.

Most of the bleeding peptic ulcers will stop bleeding spontaneously and will not
rebleed during hospitalization. Most of the bleeding ulcers can be managed with
fluid and blood resuscitation, medical therapy, and endoscopic intervention, as
appropriate.

There are three other major complications of peptic ulcer: perforation (Choice
A), penetration (Choice B) and obstruction (Choice C). However, they are less
common than bleeding.

Atrophic gastritis (Choice E) is not a complication of peptic ulcer disease.

Educational objective:
Hemorrhage is the most common complication of peptic ulcer disease.

36% of people answered this question correctly

Test #16 Q.Id = 1518               Question 46 Of 45                     Division : GIT
                                     Item Review
A 56-year old female with a history of alcohol abuse and chronic pancreatitis
presents to your office for chronic recurrent epigastric pain, occasionally
associated with nausea and vomiting. She also complains of weight loss (15 lbs
over the past 3 months). Physical examination reveals jaundice. The laboratory
report shows: pancreatic amylase 200 U/L, lipase 200 U/L, alkaline phosphatase
180U/L, total bilirubin 3.5 mg/dL, direct bilirubin 2.5 mg/dL, AST 30 U/L, ALT 30
U/L. What would be the next most important step in management of this patient?

     A. ERCP
     B. CT scan of the abdomen
     C. MRI of the abdomen
     D. Plain abdominal radiography
Explanation:

Chronic pancreatitis is characterized by mild elevations in the serum
concentrations of amylase and lipase. An elevated level of serum bilirubin and
alkaline phosphatase is suggestive of compression of the intrapancreatic portion
of the bile duct by edema, fibrosis, or pancreatic cancer.

Pancreatic cancer should always be considered in patients with chronic
pancreatitis. Both of them may present with epigastric pain, however findings
suggestive of malignancy includes older age and weight loss. Patient in this
clinical vignette is elderly female with jaundice, weight loss and epigastric pain,
which is highly suggestive of pancreatic cancer.

Abdominal ultra sonogram is the initial investigation of choice in patients with
jaundice. Sonographic findings suggestive of pancreatic tumor include dilated
bile ducts or the presence of a mass in the head of the pancreas.

For the diagnosis of pancreatic cancer, CT scan (Choice B) has a higher
sensitivity and equal specificity to USG. Thus, it is the investigation of choice for
the patient in this clinical vignette. Also, as compared to USG, it is particularly
useful in non-jaundiced patients, and in those in whom intestinal gas interferes
with USG.

ERCP (Choice A) is most useful for patients in whom chronic pancreatitis is a
strong suspicion or in cases where CT or USG fails to reveal a mass lesion
within the pancreas.
MRI (Choice D) is the investigation of choice in patients in whom ERCP is not
possible due to pancreatic duct obstruction.

Plain abdominal radiographs may be helpful in diagnosing chronic pancreatitis by
showing calcifications, however, they are not useful in the diagnosis of
pancreatic cancer.

Educational Objective:
Pancreatic cancer is the primary differential diagnosis that must be considered in
patients with chronic pancreatitis. Abdominal ultra sonogram is the initial
investigation of choice in patients with jaundice. However, CT scan has higher
sensitivity for suspected pancreatic cancer.

47% of people answered this question correctly

				
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