GI and Nutrition I

Question 1

A positive urine bilirubin assay is typically indicative of a buildup of […] bilirubin.

Answer 1

A positive urine bilirubin assay is typically indicative of a buildup of conjugated bilirubin.

plasma buildup of conjugated bilirubin (water soluble) leaks into urine, causing dark urine

Question 2

A positive urine urobilinogen assay is typically indicative of a buildup of […] bilirubin.

Answer 2

A positive urine urobilinogen assay is typically indicative of a buildup of unconjugated bilirubin.

excess unconjugated bilirubin (water insoluble) undergoes regular conjugation, forming urobilinogen, which is excreted in urine and feces

Question 3

A secretin stimulation test is positive if gastrin levels remain […] after administration of secretin.

Answer 3

A secretin stimulation test is positive if gastrin levels remain elevated after administration of secretin.

Question 4

A serum-ascites albumin gradient (SAAG) […] g/dL indicates that the ascites is due to portal hypertension.

Answer 4

A serum-ascites albumin gradient (SAAG) > 1.1 g/dL indicates that the ascites is due to portal hypertension.

Question 5

A high stool osmotic gap is indicative of […] diarrhea (osmotic or secretory).

Answer 5

A high stool osmotic gap is indicative of osmotic diarrhea (osmotic or secretory).

> 125 mOsm/kg; due to non-absorbed and unmeasured osmotically active agents in the GI tract (e.g. lactose intolerance)

SOG = plasma osmolality - 2 x (stool sodium +stool potassium)

Question 6

A […] stool osmotic gap is indicative of osmotic diarrhea (osmotic or secretory).

Answer 6

A high stool osmotic gap is indicative of osmotic diarrhea (osmotic or secretory)

> 125 mOsm/kg; due to non-absorbed and unmeasured osmotically active agents in the GI tract (e.g. lactose intolerance)

SOG = plasma osmolality - 2 x (stool sodium +stool potassium)

Question 7

A low stool osmotic gap is indicative of […] diarrhea (osmotic or secretory).

Answer 7

A low stool osmotic gap is indicative of secretory diarrhea (osmotic or secretory).

< 50 mOsm/kg; due to increased secretions of ions (e.g. bacterial/viral infection, congenital disorders of ion transport, postsurgical changes)

SOG = plasma osmolality - 2x (stool sodium + stool potassium)

Question 8

A […] stool osmotic gap is indicative of secretory diarrhea (osmotic or secretory).

Answer 8

A low stool osmotic gap is indicative of secretory diarrhea (osmotic or secretory).

< 50 mOsm/kg; due to increased secretions of ions (e.g. bacterial/viral infection, congenital disorders of ion transport, postsurgical changes)

SOG = plasma osmolality - 2x (stool sodium + stool potassium)

Question 9

Acetaminophen toxicity results from overproduction of the toxic metabolite […], which leads to hepatic necrosis.

Answer 9

Acetaminophen toxicity results from overproduction of the toxic metabolite NAPQI, which leads to hepatic necrosis.

normally safely detoxified through glucuronidation in the liver; process may be impaired by chronic alcohol use, which depletes glutathione

Question 10

Acute liver failure is defined as severe acute liver injury (elevated AST/ALT) with […] and impaired synthetic function (INR > 1.5) in a patient without cirrhosis or underlying liver disease.

Answer 10

Acute liver failure is defined as severe acute liver injury (elevated AST/ALT) with encephalopathy and impaired synthetic function (INR > 1.5) in a patient without cirrhosis or underlying liver disease.

the presence of hepatic encephalopathy differentiates acute liver failure from acute hepatitis

Question 11

Acute liver failure is defined as severe acute liver injury (elevated AST/ALT) with encephalopathy and impaired synthetic function (INR > […]) in a patient without cirrhosis or underlying liver disease.

Answer 11

Acute liver failure is defined as severe acute liver injury (elevated AST/ALT) with encephalopathy and impaired synthetic function (INR > 1.5) in a patient without cirrhosis or underlying liver disease.

the presence of hepatic encephalopathy differentiates acute liver failure from acute hepatitis

Question 12

All patients with cirrhosis should have a screening ultrasound every […] (duration) +/- alpha-fetoprotein.

Answer 12

All patients with cirrhosis should have a screening ultrasound every 6 months (duration) +/- alpha-fetoprotein.

Question 13

Angiodysplasia is more common in patients with advanced […] disease and von Willebrand disease.

Answer 13

Angiodysplasia is more common in patients with advanced renal disease and von Willebrand disease.

also may be seen with aortic stenosis due to disruption of vWF multimers as they traverse the turbulent valve space

Question 14

Are hepatic adenomas typically benign or malignant?

Answer 14

Benign

possible long-term complications include progressive growth, rupture, and malignant transformation

Question 15

Ascitic fluid with a PMN count > […]/mm3 and positive peritoneal fluid culture confirm the diagnosis of spontaneous bacterial peritonitis.

Answer 15

Ascitic fluid with a PMN count > 250/mm3 and positive peritoneal fluid culture confirm the diagnosis of spontaneous bacterial peritonitis.

Question 16

Carcinoid tumors are typically not symptomatic until they’ve metastasized to the […] (i.e. carcinoid syndrome).

Answer 16

Carcinoid tumors are typically not symptomatic until they’ve metastasized to the liver (i.e. carcinoid syndrome).

Question 17

Cholesterol emboli may result in GI complications, such as acute […] and mesenteric ischemia.

Answer 17

Cholesterol emboli may result in GI complications, such as acute pancreatitis and mesenteric ischemia.

Question 18

Conjugated hyperbilirubinemia with predominantly elevated […] is suggestive of intra- or extra-hepatic cholestasis.

Answer 18

Conjugated hyperbilirubinemia with predominantly elevated alkaline phosphatase is suggestive of intra- or extra-hepatic cholestasis.

Question 19

Conjugated hyperbilirubinemia with predominantly elevated […] is suggestive of intrinsic liver disease.

Answer 19

Conjugated hyperbilirubinemia with predominantly elevated AST/ALT is suggestive of intrinsic liver disease.

Question 20

Conjugated hyperbilirubinemia with […] AST/ALT and alkaline phosphatase is suggestive of inherited bilirubin metabolism disorders.

Answer 20

Conjugated hyperbilirubinemia with normal AST/ALT and alkaline phosphatase is suggestive of inherited bilirubin metabolism disorders.

Question 21

CXR findings consistent with esophageal perforation include left-sided pleural effusion, subcutaneous emphysema, and […] mediastinum.

Answer 21

CXR findings consistent with esophageal perforation include left-sided pleural effusion, subcutaneous emphysema, and widened mediastinum.

pleural effusion is typically left-sided because the esophagus is positioned on the left anatomically

Question 22

Diagnosis of C. difficile colitis is made by stool assay for […].

Answer 22

Diagnosis of C. difficile colitis is made by stool assay for toxins.

the presence of C. difficile itself does not indicate infection as many individuals (8-15%) are asymptomatic carriers

Question 23

Dilation of the pancreatic duct and common bile duct (double duct sign) may occur with tumors of the […] of the pancreas.

Answer 23

Dilation of the pancreatic duct and common bile duct (double duct sign) may occur with tumors of the head of the pancreas.

i.e. both intra- and extra-hepatic biliary tract dilation

Question 24

Do normal levels of amylase/lipase exclude a diagnosis of chronic pancreatitis?

Answer 24

No

Question 25

Do tumors in the body/tail of the pancreas typically present with jaundice?

Answer 25

No

Question 26

Does achalasia result in dysphagia to solids, liquids, or both?

Answer 26

Both

Question 27

Duodenal ulcers are characterized by pain that [...] with eating (improves or worsens).

Answer 27

Duodenal ulcers are characterized by pain that **improves** with eating (improves or worsens).

Question 28

Elevated titers of antinuclear antibodies and anti-smooth muscle antibodies suggests a diagnosis of [...].

Answer 28

Elevated titers of antinuclear antibodies and anti-smooth muscle antibodies suggests a diagnosis of **autoimmune hepatitis.**

Question 29

Hepatic hydrothorax is a possible complication of cirrhosis that results in transudative pleural effusions due to small defects in the [...], especially on the right.

Answer 29

Hepatic hydrothorax is a possible complication of cirrhosis that results in transudative pleural effusions due to small defects in the **diaphragm**, especially on the right. right-sided due to a less muscular hemidiaphragm; diagnosis of exclusion

Question 30

How do levels of gamma-glutamyltransferase (GGT) and ferritin typically change in alcoholic hepatitis?

Answer 30

Increased GGT is an enzyme found in the liver and other cells; ferritin is an acute phase reactant

Question 31

How do total levels of triiodothyronine (T3) and thyroxine (T4) change in patients with cirrhosis?

Answer 31

Decreased due to decreased thyroxine-binding globulin (TBG); however, free T3 and T4 levels are unchanged

Question 32

How does baseline body temperature change in patients with cirrhosis?

Answer 32

Decreased (hypothermic) thus any temperature \> 100°F (37.8°C) warrants investigation

Question 33

How does the BUN:creatinine ratio change in patients with upper GI bleed?

Answer 33

Increased possibly due to increased urea production (intestinal breakdown of Hb) and increased urea reabsorption (hypovolemia)

Question 34

How often should patients with an average risk for colon cancer be screened if using colonoscopy?

Answer 34

Every 10 years

Question 35

How often should patients with an average risk for colon cancer be screened if using fecal occult blood testing?

Answer 35

Annually

Question 36

How often should patients with an average risk for colon cancer be screened if using flexible sigmoidoscopy with fecal occult blood testing?

Answer 36

sigmoidoscopy every 5 years with FOBT every 3 years

Question 37

In addition to antibiotics, risk factors for C. difficile colitis include age \> 65 and [...] use.

Answer 37

In addition to antibiotics, risk factors for C. difficile colitis include age \> 65 and **PPI** use.

Question 38

In addition to antibiotics, risk factors for C. difficile colitis include age \> [...] and PPI use.

Answer 38

In addition to antibiotics, risk factors for C. difficile colitis include age \> **65** and PPI use.

Question 39

In addition to colon cancer, patients with Lynch syndrome also have increased risk for [...] and ovarian cancer.

Answer 39

In addition to colon cancer, patients with Lynch syndrome also have increased risk for **endometrial** and ovarian cancer. thus, prophylactic hysterectomy and bilateral oophorectomy is recommended at age 40 or after childbearing is complete (patients with a uterus should have annual endometrial biopsies beginning at age 30-35)

Question 40

In addition to colon cancer, patients with Lynch syndrome also have increased risk for endometrial and [...] cancer.

Answer 40

In addition to colon cancer, patients with Lynch syndrome also have increased risk for endometrial and **ovarian** cancer. thus, prophylactic hysterectomy and bilateral oophorectomy is recommended at age 40 or after childbearing is complete (patients with a uterus should have annual endometrial biopsies beginning at age 30-35)

Question 41

Is diarrhea that occurs during fasting/sleeping characteristic of secretory or osmotic diarrhea?

Answer 41

Secretory

Question 42

Is megaloblastic anemia secondary to folate/cobalamin deficiency characterized by sufficient reticulocytosis?

Answer 42

No (low-normal reticulocyte count despite anemia)

Question 43

Is needle biopsy recommended for a patient with a hepatic adenoma? ## Footnote [...]

Answer 43

No (due to risk of bleeding) surgical excision is preferred

Question 44

Lactose intolerance is characterized by a [...] hydrogen breath test (positive or negative).

Answer 44

Lactose intolerance is characterized by a **positive** hydrogen breath test (positive or negative). i.e. rise in the measured breath hydrogen level after the ingestion of lactose

Question 45

Lactose intolerance is characterized by a [...] stool test for reducing substances (positive or negative).

Answer 45

Lactose intolerance is characterized by a **positive** stool test for reducing substances (positive or negative).

Question 46

Lactose intolerance is characterized by low stool pH and [...] stool osmotic gap (low or high).

Answer 46

Lactose intolerance is characterized by low stool pH and **high** stool osmotic gap (low or high). due to fermentation products (stool pH) and unmetabolized lactose and organic acids (osmotic gap)

Question 47

Low serum ceruloplasmin with elevated urinary copper excretion suggests a diagnosis of [...].

Answer 47

Low serum ceruloplasmin with elevated urinary copper excretion suggests a diagnosis of **Wilson disease**. other diagnostic features include Kayser-Fleischer rings and increased copper content on liver biopsy

Question 48

Lung cancer screening via low-dose chest CT is recommended for those between [...] to [...] years old who have a \> 30-pack-year history and are current smokers/quit within the last 15 years.

Answer 48

Lung cancer screening via low-dose chest CT is recommended for those between **55** to **80** years old who have a \> 30-pack-year history and are current smokers/quit within the last 15 years.

Question 49

Lung cancer screening via [...] is recommended for those between 55 to 80 years old who have a \> 30-pack-year history and are current smokers/quit within the last 15 years.

Answer 49

Lung cancer screening via **low-dose chest CT** is recommended for those between 55 to 80 years old who have a \> 30-pack-year history and are current smokers/quit within the last 15 years.

Question 50

Non-alcoholic fatty liver disease is associated with peripheral [...] resistance.

Answer 50

Non-alcoholic fatty liver disease is associated with peripheral **insulin** resistance. leads to increased peripheral lipolysis and thus increased hepatic uptake of fatty acids

Question 51

PAS-positive material in the lamina propria of the small intestine is a classic biopsy finding of [...].

Answer 51

PAS-positive material in the lamina propria of the small intestine is a classic biopsy finding of **Whipple's disease**.

Question 52

Patients who complain of persistent abdominal pain after cholecystectomy should be evaluated for [...] syndrome.

Answer 52

Patients who complain of persistent abdominal pain after cholecystectomy should be evaluated for **post-cholecystectomy** syndrome. evaluated via abdominal imaging (e.g. ultrasound) followed by direct visualization (e.g. ERCP, MRCP) to find the causative factor; etiologies include both biliary (e.g. retained CBD) or extra-biliary (e.g. pancreatitis) causes

Question 53

Patients with enzyme deficiencies (e.g. pancreatic insufficiency) will have [...] levels of urinary D-xylose.

Answer 53

Patients with enzyme deficiencies (e.g. pancreatic insufficiency) will have **normal** levels of urinary D-xylose. D-xylose is a monosaccharide that only depends on viable mucosa (not enzymatic breakdown) for absorption in the proximal small bowel

Question 54

Patients with hepatopulmonary syndrome typically have increased dyspnea or O2 desaturation while [...] (lying down or upright).

Answer 54

Patients with hepatopulmonary syndrome typically have increased dyspnea or O2 desaturation while **upright** (lying down or upright). known as platypnea and orthodeoxia, respectively

Question 55

Patients with small intestinal mucosal disease (e.g. Celiac) will have [...] levels of urinary D-xylose.

Answer 55

Patients with small intestinal mucosal disease (e.g. Celiac) will have **decreased** levels of urinary D-xylose. D-xylose is a monosaccharide that only depends on viable mucosa (not enzymatic breakdown) for absorption in the proximal small bowel

Question 56

Pellagra is due to vitamin [...] deficiency.

Answer 56

Pellagra is due to vitamin **B3 (niacin)** deficiency. often seen with impaired nutritional intake (developed countries) or in developing countries that subsist primarily on corn products

Question 57

Pharmaceutical treatment for Wilson disease includes zinc and [...].

Answer 57

Pharmaceutical treatment for Wilson disease includes zinc and **copper chelators (e.g. D-penicillamine, trientine).**

Question 58

Pleural fluid analysis in Boerhaave syndrome is typically exudative with low PH and very high [...] (\> 2,500 IU/L).

Answer 58

Pleural fluid analysis in Boerhaave syndrome is typically exudative with low PH and very high **amylase** (\> 2,500 IU/L). due to saliva in the esophageal contents

Question 59

Porcelain gallbladder is associated with an increased risk for [...] and usually requires cholecystectomy.

Answer 59

Porcelain gallbladder is associated with an increased risk for **gallbladder adenocarcinoma** and usually requires cholecystectomy. often found in patients with chronic cholecystitis

Question 60

Primary biliary cholangitis is an autoimmune disease characterized by destruction of [...]-hepatic bile ducts.

Answer 60

Primary biliary cholangitis is an autoimmune disease characterized by destruction of **intra**-hepatic bile ducts.

Question 61

Rotor syndrome and Dubin-Johnson syndrome are characterized by elevated levels of [...] bilirubin with normal LFTs and CBC.

Answer 61

Rotor syndrome and Dubin-Johnson syndrome are characterized by elevated levels of **conjugated** bilirubin with normal LFTs and CBC. due to a defect in hepatic secretion of conjugated bilirubin into the biliary system

Question 62

Serum triglycerides generally must be \> [...] mg/dL to cause pancreatitis.

Answer 62

Serum triglycerides generally must be \> **1,000** mg/dL to cause pancreatitis. can also cause eruptive xanthomas; diagnosis confirmed with a fasting serum lipid profile

Question 63

Should patients with cirrhosis undergo a screening endoscopy for varices?

Answer 63

Yes

Question 64

Small intestinal bacterial overgrowth may be diagnosed via carbohydrate breath testing or [...] aspirate/culture.

Answer 64

Small intestinal bacterial overgrowth may be diagnosed via carbohydrate breath testing or **jejunal** aspirate/culture.

Question 65

The absolute values of AST and ALT in alcoholic hepatitis are almost always [] IU/L.

Answer 65

The absolute values of AST and ALT in alcoholic hepatitis are almost always **less than** 500 IU/L. usually \< 300 IU/L (versus other causes of hepatitis, which cause much greater elevations)

Question 66

The Charcot triad for acute cholangitis consists of [...], [...], and [...].

Answer 66

The Charcot triad for acute cholangitis consists of **fever, jaundice**, and **RUQ pain**. also may have hypotension and altered mental status (Reynolds pentad)

Question 67

The Charcot triad for [...] consists of fever, jaundice, and RUQ pain.

Answer 67

The Charcot triad for **acute cholangitis** consists of fever, jaundice, and RUQ pain. also may have hypotension and altered mental status (Reynolds pentad)

Question 68

The diagnosis of carcinoid syndrome can be confirmed by elevated 24-hour urinary [...] in most patients.

Answer 68

The diagnosis of carcinoid syndrome can be confirmed by elevated 24-hour urinary **5-HIAA** in most patients.

Question 69

The diagnosis of esophageal perforation is confirmed with Gastrografin-contrast esophagram or [...] (if esophagram results are equivocal).

Answer 69

The diagnosis of esophageal perforation is confirmed with Gastrografin-contrast esophagram or **CT** (if esophagram results are equivocal). ## Footnote Gastrografin is water-soluble contrast that is preferred over barium (barium can induce an inflammatory response)

Question 70

The most common causes of acute liver failure are [...] and acute viral hepatitis.

Answer 70

The most common causes of acute liver failure are **drug toxicity** and acute viral hepatitis.

Question 71

The most common causes of acute liver failure are drug toxicity and [...].

Answer 71

The most common causes of acute liver failure are drug toxicity and **acute viral hepatitis**.

Question 72

The presence of an "abdominal succussion splash" suggests a diagnosis of [...].

Answer 72

The presence of an "abdominal succussion splash" suggests a diagnosis of **gastric outlet obstruction**. the physician places the stethoscope over the upper abdomen and rocks the patient back and fourth at the hips; definitive diagnosis requires endoscopy

Question 73

The presence of elevated serum gastrin (\> 1000 pg/mL) with normal gastric acid (pH \< 4) suggests a diagnosis of [...] syndrome.

Answer 73

The presence of elevated serum gastrin (\> 1000 pg/mL) with normal gastric acid (pH \< 4) suggests a diagnosis of **Zollinger-Ellison** syndrome. a gastrin level \< 110 pg/mL rules out gastrinoma; values in between 110 - 1000 pg/mL require secretin stimulation testing

Question 74

The presence of IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly predictive of [...] disease.

Answer 74

The presence of IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly predictive of **celiac** disease. absence does not rule out celiac disease as many patients have concurrent selective IgA deficiency

Question 75

The presence of pancreatic calcifications on abdominal imaging helps establish a diagnosis of [...].

Answer 75

The presence of pancreatic calcifications on abdominal imaging helps establish a diagnosis of **chronic pancreatitis**.

Question 76

The primary inciting event of acute cholecystitis is typically a gallstone obstructing the [...], with subsequent inflammation and infection.

Answer 76

The primary inciting event of acute cholecystitis is typically a gallstone obstructing the **cystic duct**, with subsequent inflammation and infection.

Question 77

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: [...] F: Flushing D: Diarrhea R: Right-sided heart disease

Answer 77

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: **Bronchospasm** F: Flushing D: Diarrhea R: Right-sided heart disease

Question 78

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: Bronchospasm F: [...] D: Diarrhea R: Right-sided heart disease

Answer 78

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: Bronchospasm F: **Flushing** D: Diarrhea R: Right-sided heart disease

Question 79

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: Bronchospasm F: Flushing D: [...] R: Right-sided heart disease

Answer 79

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: Bronchospasm F: Flushing D: **Diarrhea** R: Right-sided heart disease

Question 80

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: Bronchospasm F: Flushing D: Diarrhea R: [...]

Answer 80

The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR": ## Footnote Be: Bronchospasm F: Flushing D: Diarrhea R: **Right-sided heart disease**

Question 81

The symptoms of pellagra can be remembered as the "3 D's": ## Footnote D: [...] D: Diarrhea D: Dementia

Answer 81

The symptoms of pellagra can be remembered as the "3 D's": D: **Dermatitis (hyperpigmented, scaly skin in sun-exposed areas)** D: Diarrhea D: Dementia