Gastrointestinal Flashcards
1.
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
(C) Gene therapy
(D) Liver transplantation
(E) Multiagent chemotherapy
(F) Resection of mass and gastric antrum
2.
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
(C) Perform an esophagoscopy
(D) Schedule him for elective esophagectomy
(E) Schedule him for emergent Nissen fundoplication
3.
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
(C) Intussusception
(D) Malrotation with volvulus
(E) Pyloric stenosis
4.
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
(C) Eliminating smoking and alcohol consumption
(D) Getting a colonoscopy every 5 years
(E) Taking proton pump inhibitors regularly
5.
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
(C) Proximal colostomy with delayed resection
(D) Sigmoid colectomy
(E) Sigmoidoscopy
6.
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
(C) Increase phenylalanine
(D) Increase tyrosine
(E) Increase vitamin D
7.
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
(C) Endoscopic retrograde cholangiopancre-
atography with dilation of the common bile duct
(D) Exploratory laparotomy
(E) Tissue plasminogen activator followed by
anticoagulation
8.
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
(C) Serum gastrin level measurement
(D) Upper endoscopy
(E) Urease breath test
9.
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
(C) Iatrogenic
(D) Infection
(E) Spicy foods
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
(C) ECG
(D) Schilling test
(E) Upper endoscopy
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
(C) Dubin-Johnson syndrome
(D) Physiologic jaundice
(E) Rotor syndrome
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
(C) Pancreaticogastrostomy
(D) Surgical resection of pancreas
(E) Whipple procedure
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
(C) Immediate ECG
(D) MRI of the chest and abdomen
(E) Room air oxygen saturation
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
(C) Esophageal carcinoma
(D) Mallory-Weiss syndrome
(E) Plummer-Vinson syndrome
(F) Reflux esophagitis
(G) Symptomatic diffuse esophageal spasm
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
(C) Meconium ileus
(D) Meningitis
(E) Necrotizing enterocolitis
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
(C) Endoscopy
(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
(C) Diverticulitis
(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
(C) Endoscopy
(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
(C) Impaired glucose tolerance
(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
(C) Endoscopic retrograde cholangiopancreatography
(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
(C) Tubular adenoma
(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
(C) Low anterior resection
(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
(C) Legionella
(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
(C) Esophageal cancer
(D) Myocardial infarction
(E) Nutcracker esophagus
