Gastrointestinal Flashcards by Kaivalya Tallam

A 54-year-old man presents to his primary care

provider with the complaint of upper abdomi-

nal fullness and pain. He states that he has lost

3-4.6 kg (5-10 lb), but denies other symp-
toms. Physical examination reveals a firm mass

in the epigastric area. Ultrasonography reveals

a mass in the gastric antrum. A salivary gland

biopsy reveals the pathology shown in the im-

age. Which of the following therapies is ex-

pected to be part of his treatment plan?

A) Antibiotic therapy

(B) Bone marrow transplantation

(D) Liver transplantation

(E) Multiagent chemotherapy

(F) Resection of mass and gastric antrum

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A 55-year-old white man with a 20-year history

of gastroesophageal refl ux visits the clinic for

worsening refl ux symptoms over the past 18

months. His last visit was 7 years ago and he

claims to be otherwise in good health. He has

been compliant with his antirefl

ux medications, including an H2-blocker and a proton

pump inhibitor. Which of the following is the

best next step in management?

(A) Double the dose of his H2-blocker and

schedule him for follow-up in 4 weeks

(B) Double the dose of his proton pump in-

hibitor and schedule him for follow-up in 4 weeks

(D) Schedule him for elective esophagectomy

(E) Schedule him for emergent Nissen fundoplication

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The physician on call is paged to the well-baby

nursery because a full-term, 3-hour-old boy has

had green emesis twice, once after each of his

feedings. He is being breast-fed. He was born

by spontaneous vaginal delivery following a

pregnancy complicated by polyhydramnios.

His Apgar scores were 8 and 9 at 1 and 5 min-

utes, respectively. His temperature is 37°C

(98.6°F), blood pressure is 70/50 mm Hg,

pulse is 150/min, and respiratory rate is 24/

min. His upper abdomen is distended, soft, and

without palpable masses. Air is visualized in

the duodenum and the stomach on x-ray.

Which of the following is the most likely diagnosis?

(A) Duodenal atresia

(B) Hirschsprung’s disease

(D) Malrotation with volvulus

(E) Pyloric stenosis

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A 68-year-old African-American man presents

to his primary care physician for a check-up.

He has not been to the physician’s office in

over 15 years. He reports that he is fine but that

his wife keeps telling him that he has to “go see

the doctor.” He says he has never been sick, de-

spite smoking three packs of cigarettes per day

for over 40 years. He also says that he drinks

2–3 beers a night but never had a problem with

that either. He’s as healthy “as a bull,” he says.

His wife is in the room and says that he re-

cently has had some problems swallowing food

and that he is losing weight. He laughs and

says, “I just need to chew more and eat more.”

His vitals signs are normal, as are his laboratory

values. The physician is concerned and orders

an endoscopy, which reveals a biopsy positive

for squamous cell carcinoma of the esophagus.

Which of the following most likely could have

prevented this condition?

(A) Avoiding fruits and vegetables

(B) Eating more meats, especially smoked meats

(D) Getting a colonoscopy every 5 years

(E) Taking proton pump inhibitors regularly

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A 58-year-old man comes to the emergency de-

partment complaining of colicky abdominal

pain over the past 3 days that suddenly became

more severe and constant over the past 6 hours.

A contrast study is performed and results are

shown in the image. What is the first-line treat-

ment after fluid resuscitation and nasogastric

tube placement?

(A) Colonoscopy

(B) Hemicolectomy

(D) Sigmoid colectomy

(E) Sigmoidoscopy

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A full-term 6-day-old boy presents to a physi-

cian’s office for routine care. He is tolerating

breast milk well. He is urinating, defecating,

and sleeping normally. Physical examination

reveals an alert newborn with mild eczema,

good skin turgor, normal reflexes, and a musty

odor. His newborn laboratory screen is notable

for phenylketones in the urine. What is the

best advice to give his parents regarding the

boy’s diet?

(A) Increase iron

(B) Increase niacin

(D) Increase tyrosine

(E) Increase vitamin D

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A 59-year-old woman with renal cell carcinoma

presents to the emergency department with se-

vere right upper quadrant (RUQ) pain. She is

afebrile, acutely tender in the RUQ, and has

shifting dullness and a palpable liver edge.

Murphy’s sign is negative. Laboratory studies show:

Na+: 138 mEq/L

K+: 3.6 mEq/L

Glucose: 80 mg/dL

Aspartate aminotransferase: 50 U/L

Alanine aminotransferase: 43 U/L

Alkaline phosphatase: 138 U/L

Total protein: 6.4 g/dL

Albumin: 3.8 g/dL

Total bilirubin: 1.1 mg/dL

Imaging demonstrates a spider web of collat-

eral veins in the liver. Although extensive mea-

sures are taken, the patient dies 6 hours after

arriving. Which of the following was the most

likely initial treatment?

(A) β-Blocker followed by lactulose

(B) Cholecystectomy

atography with dilation of the common bile duct

(D) Exploratory laparotomy

(E) Tissue plasminogen activator followed by

anticoagulation

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A 65-year-old man presents to his physician

complaining of difficulty swallowing, occa-

sional chest pain, and regurgitation of food.

Over the past 2 months he has lost about 7 kg

(15 lb). Results of a barium swallow study are

shown in the image. What test should be per-

formed to look for possible causes of his condition?

(A) 24-hour pH monitoring

(B) Esophageal manometry

(D) Upper endoscopy

(E) Urease breath test

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A 60-year-old man with no past medical history

undergoes upper endoscopy and biopsy for an

upset stomach that is worsened by eating. He is

found to have infl ammation predominantly in

the antrum of the stomach. Which of the fol-

lowing is the most likely etiology of this condition?

(A) Alcohol abuse

(B) Cigarette smoking

(D) Infection

(E) Spicy foods

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10.

A 21-year-old man presents to the clinic feeling

tired and generally unwell. He has fallen sev-

eral times over the past month and has devel-

oped a slight tremor in both hands. Physical

examination is significant for scleral icterus,

ankle edema, and a distended and tense abdo-

men. Laboratory studies show:

Hemoglobin: 7 g/dL

Reticulocyte count: 7%

Total bilirubin: 3.1 mg/dL

Aspartate aminotransferase: 84 U/L

Alanine aminotransferase: 92 U/L

Ceruloplasmin: 5 mg/dL (normal:20–45 mg/dL)

Results of a Coombs’ test are negative. Which

of the following is an appropriate preventive

management step after chelation therapy?

(A) Blood protein electrophoresis

(B) Colonoscopy

(D) Schilling test

(E) Upper endoscopy

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11.

A full-term 5-day-old African-American girl is

taken to the pediatrician because her “eyes

look yellow.” She is being exclusively formula-

fed with an iron-rich formula. She has six wet

diapers a day and stools twice a day. The preg-

nancy was uncomplicated and she was deliv-

ered by spontaneous vaginal delivery. Her Ap-

gar scores were 9 and 10 at 1 and 5 minutes,

respectively. Her temperature is 37°C (98.6°F),

her head circumference is in the 50th percen-

tile, and her weight is 3420 g (3 g below her

birth weight). Her sclerae are icteric. There is

no hepatomegaly or splenomegaly. Her total

bilirubin is 9 mg/dL and her conjugated biliru-

bin is 0.2 mg/dL. Hemoglobin is 15 g/dL.

Which of the following is the most likely diagnosis?

(A) α1-Antitrypsin deficiency

(B) Biliary atresia

(D) Physiologic jaundice

(E) Rotor syndrome

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12.

A 76-year-old man who has had multiple epi-

sodes of pancreatitis presents to his physician’s

office with mild epigastric pain and 9.1-kg

(20.0-lb) weight loss over the past 6 months.

The patient also describes daily foul-smelling

stools that “float” in the toilet bowl. The physi-

cian pulls up his electronic medical record and

fi nds that the patient presented to the emer-

gency department last week for the same symp-

toms. During that visit he had a CT of the ab-

domen (see image). Which of the following is

the most appropriate treatment?

(A) Endoscopic retrograde cholangiopancreatography

(B) Pancreatic enzyme replacement

(D) Surgical resection of pancreas

(E) Whipple procedure

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13.

A 62-year-old woman is transferred to the med-

ical service with an appendiceal mass serendip-

itously picked up at the edge of an x-ray taken

of a broken femur in the emergency depart-

ment. Otherwise, the patient has no significant

past medical history and no current symptoms.

Which of the following studies is most likely

to be useful?

(A) Arterial blood gas

(B) CT of the chest and abdomen

(D) MRI of the chest and abdomen

(E) Room air oxygen saturation

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14.

A 55-year-old white woman with a history of

iron deficiency anemia has had intermittent

trouble swallowing solids for the past few years.

She denies alcohol or tobacco use. Her vital

signs are stable. Her iron level is 40 μg/dL and

total iron binding capacity is 500 μg/dL. Other

laboratory tests are within normal limits.

Which of the following is the most likely diagnosis?

(A) Achalasia

(B) Barrett’s esophagus

(D) Mallory-Weiss syndrome

(E) Plummer-Vinson syndrome

(F) Reflux esophagitis

(G) Symptomatic diffuse esophageal spasm

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15.

A premature newborn is being treated in the

neonatal intensive care unit. On the sixth day of

life he is noted to be lethargic and in mild respi-

ratory distress. His heart rate is 162/min, blood

pressure is 55/38 mm Hg, and respiratory rate is

56/min. In addition to a distended abdomen, he

has guaiac-positive stools. X-ray of the abdomen

shows gas bubbles within the bowel wall. From

what potentially life-threatening condition is this

patient most likely suffering?

(A) Bowel obstruction

(B) Intussusception

(D) Meningitis

(E) Necrotizing enterocolitis

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16.

A 45-year-old white man is brought to the

emergency department by ambulance. He is

waving wildly, trying to hit the “flying bats”

that are all around him. He is very agitated and

smells strongly of alcohol. The ambulance

crew said they found the patient bleeding from

the mouth outside a bar. They could not find

any laceration on his mouth or lips and believe

that the bleeding is internal. The patient

screams that he will not stand for this maltreat-

ment any longer and tries to stand up, at which

point he begins to vomit. Blood pours out of

his mouth, and the patient says, “Here we go

again.” The ambulance crew tells the physi-

cian that there was also a lot of vomit at the bar

where he was found. The physician is able to

subdue the patient to obtain his vital signs. His

blood pressure is 118/78 mm Hg, pulse is 98/

min, respiratory rate is 22/min, and tempera-

ture is 37.2°C (98.9°F). The physician is un-

able to obtain a history on the patient or con-

tact any relatives or friends. No signs of obvious

trauma are observed. Which of the following is

the best next step in diagnosis?

(A) Barium swallow

(B) Electrocardiogram

(D) Esophageal manometry

(E) X-ray of the chest

17.

A 65-year-old man comes to the emergency de-

partment complaining of left lower abdominal

pain that began the prior morning. He became

concerned when he developed bloody diarrhea

overnight. He has experienced similar pain, al-

though to a lesser degree, over the past 2

months, especially after eating. The pain usu-

ally resolved within 1–2 hours, and he never

had bloody diarrhea. His past medical history is

significant for coronary artery disease and hy-

pertension. He has smoked one pack of ciga-

rettes per day for the past 30 years. On physical

examination he is afebrile, heart rate is 90/min,

and blood pressure is 135/85 mm Hg. He is vis-

ibly uncomfortable but in no apparent distress.

His abdominal examination is significant for

left lower quadrant tenderness but no guarding

or rebound. Which of the following is the most

likely diagnosis?

(A) Acute mesenteric ischemia

(B) Colon cancer

(D) Infectious colitis

(E) Inflammatory bowel disease

18.

A 70-year-old man with a history of constipa-

tion has been experiencing intermittent left-

sided abdominal pain and fevers for 2 days. He

came to the emergency department immedi-

ately after he noticed blood in his toilet this

morning. His heart rate is 110/min, blood pres-

sure is 90/50 mm Hg, respiratory rate is 18/

min, and oxygen saturation is 95% on room air.

On physical examination the physician notes

copious amounts of bright red blood per rec-

tum. The physician immediately places two

large bore intravenous lines, administers fluid,

and sends blood for type and screen. Which of

the following is the best next step in management?

(A) Arteriography

(B) Colonoscopy

(D) Nasogastric tube aspiration

(E) Surgical consultation

19.

A 3-year-old boy is brought to the pediatrician

because his mother noticed a reddish-purple

rash on his buttocks and thighs (see image).

She notes that he has not seemed well since he

had a mild cold 2 weeks earlier; he has been

complaining of aches and pains in his legs and

a stomach ache. Urinalysis shows 10–20 RBCs/

mm³ and 2+ proteinuria. Which of the follow-

ing is associated with this patient’s disease process?

(A) Hemoptysis

(B) High antistreptolysin O titer

(D) Intussusception

(E) Malar rash

20.

A 63-year-old man with diabetes is called by his

primary care physician because of abnormal

liver function test results, as follows:

Aspartate aminotransferase: 85 U/L

Alanine aminotransferase: 102 U/L

Alkaline phosphatase: 180 U/L

Total bilirubin: 1.9 mg/dL

On physical examination his liver is enlarged.

His skin has a slightly yellow hue, especially on

his face. The review of symptoms is significant

for some weight loss, weakness, arthritis in his

hands, and inability to achieve an erection.

What test would generate the most likely diag-

nosis and should be done first?

A) Blood smear

(B) CT scan of the abdomen

(D) Fasting transferrin saturation levels

(E) Liver biopsy

21.

A 50-year-old woman undergoes screening

colonoscopy at her primary care physician’s

recommendation. She has no family history of

colorectal cancer. A single lesion is removed

during the procedure and sent for pathologic

examination. Which of the following findings

carries the greatest risk of malignancy?

(A) Lymphoid polyp

(B) Peutz-Jeghers polyp

(D) Tubulovillous adenoma

(E) Villous adenoma

22.

A 61-year-old man in previously excellent

health presents to his physician with com-

plaints of hematochezia, tenesmus, and rectal

pain. On work-up the physician discovers that

he has a rectal tumor that is 5 cm (2.0 in) from

the anal verge. Which of the following is the

most appropriate treatment?

(A) Abdominoperineal resection

(B) Imatinib

(D) Radiation alone

(E) Radiation plus chemotherapy

23.

A 45-year-old HIV-positive woman comes to

her primary care physician complaining of a

2-day history of bloody diarrhea. She states that

she has been feeling well until 2 days ago,

when she developed abdominal pain. She de-

nies fevers, chills, night sweats, nausea, or vom-

iting. She admits to feeling tired over the last

couple of weeks and has had a 2.3-kg (5-lb)

weight loss over the past 2 weeks. Her stool

sample shows WBCs and RBCs. Her Gram

stain is shown in the image. Her CD4+ cell

count is 201/mm³. Which of the following is

the most likely cause of this woman’s symptoms?

(A) Escherichia coli

(B) Kaposi’s sarcoma

(D) Mycobacterium avium complex

(E) Mycobacterium tuberculosis

24.

A 64-year-old white woman presents to her pri-

mary care physician complaining of difficulty

and pain with swallowing, as well as occasional

chest pain. She has a history of breast cancer

treated with lumpectomy and radiation, hyper-

tension, high cholesterol, and ovarian polyps.

She indicates that her current problem started

with liquids, but has progressed to solids, and

that the food “just gets stuck in my throat.” The

chest pain was once so bad that she took one of

her husband’s nitroglycerin pills and the pain

subsided, but it has since occurred many times.

The physician orders an x-ray of the chest, but

it is not diagnostic. Manometry is conducted,

and it shows uncoordinated contractions.

Which of the following is the most likely diagnosis?

(A) Breast cancer relapse

(B) Diffuse esophageal spasm

(D) Myocardial infarction

(E) Nutcracker esophagus

25.

A 32-year-old man with Crohn’s disease pre sents

to the emergency department with acute-onset

diffuse abdominal pain and emesis. The patient

states these symptoms are different than his

usual Crohn’s disease fl are-ups. The pain is se-

vere (10/10) and is cramping in nature. He says

his abdomen feels larger than usual. His Crohn’s

disease has been well managed on 6-mercap-

topurine for the past 6 months. The patient de-

nies any recent sick contacts or eating underpre-

pared foods. He states he had a bowel

movement and fl atus since the abdominal pain

began. In addition to Crohn’s disease, the pa-

tient had appendicitis for which he underwent

an appendectomy 12 years ago. His temperature

is 37.1°C (98.7°F), blood pressure is 135/86 mm

Hg, pulse is 84/min, and respiratory rate is 14/

min. On physical examination the abdomen is

distended and diffusely tender with high-pitched

bowel sounds. There is rebound tenderness

throughout the abdomen along with guarding.

The remainder of the physical examination is

noncontributory. An x-ray of the abdomen

shows dilated small loops of bowel along with

absence of gas in the colon. What is the best

next step in management?

(A) Bowel rest only

(B) Intravenous fluids and antibiotics only

(D) MRI of the abdomen

(E) Ultrasound

26.

A 39-year-old Japanese-American woman with

insulin-dependent diabetes and asthma pre-

sents to her primary care physician complain-

ing of trouble swallowing for the past few

months. She explains that it started with solids,

and then progressed to liquids. She states it

now is hard even to swallow water and that she

is often very thirsty. She says she has lost about

2 kg (7 lb), but says she is working out fre-
quently. Her blood pressure is 118/76 mm Hg,

pulse is 86/min, respiratory rate is 16/min, and

temperature is 37.2°C (98.9°F). Laboratory

tests show

Na+: 144 mEq/L

K+: 4.0 mEq/L

Cl−: 100 mEq/L

Carbon dioxide: 22 mmol/L

Blood urea nitrogen: 18 mg/dL

Creatinine: 1.0 mg/dL

Glucose: 88 mg/dL

Her hemoglobin A1c level, measured 3 months

earlier, was 6.1%. A barium swallow is per-

formed, which reveals a dilated esophagus, es-

pecially distally, that flares out near the lower

esophageal junction. Still not completely sure

of the diagnosis, esophageal manometry is per-

formed, which reveals abnormal peristalsis and

increased lower sphincter pressure. Which of

the following is the most appropriate management?

(A) Cholinergic agents

(B) Glucose pharmacotherapy

foods, and consider a histamine blocker

(D) Pneumatic dilation

(E) Surgery to remove diverticula

27.

A 75-year-old woman with a history of diabetes

and coronary heart failure presents to the

emergency department because of increasing

abdominal girth. In recent months she has

been feeling increasingly fatigued, and al-

though she has had decreased appetite, she has

gained weight. Her heart rate is 100/min and

blood pressure is 112/70 mm Hg. She has

scleral icterus; the skin over her face, neck, and

lower legs is slightly bronze in color; she has

palmar erythema; and she has numerous ec-

chymoses over her body. Her abdominal exam-

ination is significant for ascites. Laboratory tests show:

Aspartate transaminase: 102 U/L

Alanine transaminase: 97 U/L

Alkaline phosphatase: 300 U/L

Total bilirubin: 1.9 mg/dL

Albumin: 2.9 g/dL

Prothrombin time: 22 sec

Partial thromboplastin time: 42 sec

An ultrasound of her abdomen shows a

shrunken and nodular liver. A liver biopsy us-

ing Perls Prussian blue stain is shown in the

image. Which of the following is the most

likely complication of her disease?

A) Acute pancreatitis

(B) Amyloidosis

(D) Hepatocellular carcinoma

(E) Splenomegaly

28.

A term boy with Apgar scores of 9 and 9 at 1

and 5 minutes has failed to pass meconium at

72 hours. He has had no episodes of emesis,

and his abdomen is only mildly distended to

palpation. The patient’s mother reports that

her older son had the same problem at birth.

A plain radiograph of the abdomen shows a

small bowel obstruction with numerous air-

filled loops of bowel. The patient is treated

with a diatrizoate meglumine (Gastrografin)

enema, with good results. Which of the fol-

lowing is the most likely mechanism for this

infant’s acute intestinal problem?

(A) Congenital aganglionosis of the colon

(B) Deficiency of pancreatic enzymes

(D) Total absence of the small bowel

(E) Volvulus of the transverse colon

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