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DIRECTIONS: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.

282. A 55-year-old man who is a longtime alcoholic comes to the emergency room after vomiting small amounts of bright red blood four times today. Your differential diagnosis is constructed around causes of bleeding from the a. Colon b. Liver and pancreas c. Kidneys d. Lungs e. Upper gastrointestinal (GI) tract

283. A patient in your office tells you that he had an episode of vomiting bright red blood twice in 1 day about 1 week ago, followed the next day by three or four episodes of vomiting material that looked like coffee grounds. He could not afford to seek medical help then and he said that "it got better except for the pain." The past 3 days he noticed black "sticky" stools and he finally came to see you. What is your first concern?

a. Bleeding colon cancer b. Bleeding from lung cancer c. Crohn's disease d. Cirrhosis e. Bleeding peptic ulcer

284. A 60-year-old patient has epigastric pain and weight loss of a few pounds. The consulting gastroenterologist's evaluation includes upper GI endoscopy, and he discovers a gastric ulcer. Now, the gastroenterologist should a. Biopsy the area of the ulcer b. Cauterize the ulcer c. Do nothing further d. Consult a surgeon to do a partial gastrectomy e. Repeat the upper GI endoscopy in 6 months

285. A 50-year-old woman executive has for the past 3 months experienced abdominal pain that often is relieved by antacids. Because of the persistent abdominal pain, she consults a gastroenterologist. He does an upper GI endoscopy and visualizes a duodenal ulcer. Now, the gastroenterologist should a. Biopsy the ulcer b. Arrange for a surgeon to operate on the ulcer c. Suggest medical treatment of the ulcer d. Cauterize the ulcer e. Order an abdominal CT scan

286. A 70-year-old woman is evaluated with colonoscopy for anemia and intermittently hemoccult-positive stools. A diagnosis of multiple ar-teriovenous malformations (AVMs) is made by which diagnostic procedure?

a. Biopsy b. Visual inspection c. Arteriography d. Venography e. Lymphangiography

287. A 55-year-old alcoholic man has been losing weight for about 6 months and begins to complain of difficulty swallowing. An upper GI endoscopy reveals an esophageal ulcer. The gastroenterologist should a. Biopsy the ulcerated area b. Cauterize the ulcer c. Do nothing further d. Consult a surgeon to do an esophagectomy e. Observe the patient and repeat the upper GI endoscopy in 6 months

288. A patient complaining of chest pain, regurgitation, and dysphagia for several months is thought to have achalasia. The gastroenterologist should a. Order a chest CT scan to rule out tracheoesophageal fistula b. Do an endoscopy to biopsy the lower esophageal sphincter c. Do an endoscopy to dilate the esophagus d. Do an endoscopy to inject botulinum toxin into the lower esophageal sphincter e. Order an abdominal CT scan to make the diagnosis of achalasia

289. Hepatitis C virus is most commonly transmitted by a. Parenteral routes including intravenous drug abuse and promiscuous sex b. Fecal-oral route c. Ingestion of contaminated food or water d. Living in the same household as an infected person e. Inhalation of infected airborne particles

290. The percentage of patients with acute hepatitis C who go on to have chronic disease is a. 5 to 10

291. The extent of liver damage done by chronic hepatitis B or C infection can best be gauged by evaluating a. Symptoms b. Elevation of serum transaminases c. Duration of infection d. Liver biopsy e. Presence or absence of ascites

292. A 45-year-old obese woman with cholelithiasis presents to the emergency room complaining of nausea and vomiting for 2 days, along with severe continuous midabdominal pain. She has a low-grade fever and the ER physician finds that she has a slightly elevated WBC count (12,000) and an elevated serum amylase. The most likely diagnosis is a. Ruptured abdominal aortic aneurysm b. Hepatitis c. Peptic ulcer disease d. Early phase of acute appendicitis e. Acute pancreatitis

293. Chronic pancreatitis may be reliably diagnosed in a patient presenting with a. Calcification in the pancreas detected on a flat plate x-ray of the abdomen b. Abdominal pain c. Diarrhea d. Nausea and vomiting e. Jaundice

294. Acute pancreatitis is caused by a variety of disorders. Which of the following pairs of disorders account for 80 to 90% of cases?

a. Diabetes and viral illness b. Trauma and hyperlipidemia c. Trauma and gallstones d. Hyperlipidemia and alcohol e. Alcohol and gallstones

295. A 70-year-old man with progressive painless jaundice is referred to your office. You order liver function tests that show an abnormal pattern consistent with obstruction. Which procedure will you now suggest?

a. Laparoscopic cholecystectomy b. Endoscopic retrograde cholangiopancreatography (ERCP)

c. Modified barium swallow d. Laparoscopic abdominal exploration e. Upper GI endoscopy

296. In which of the following disorders will esophageal manometry reveal a high-pressure nonrelaxing LES and poor motility in the rest of the esophagus?

a. Hypertensive LES

b. Esophageal spasm c. Obstructive lower esophageal lesion d. Nonspecific motility disorders e. Achalasia

297. A 70-year-old man complains of a sensation of food sticking in his lower chest area. This happens when he eats either liquids or solids. He also has a slight weight loss. The most likely diagnosis is a. Achalasia b. Esophageal spasm c. Hypertensive LES

d. Hiatal hernia with GERD

e. Barrett's esophagus

298. A 45-year-old woman has chest pain for which a cardiac cause has been ruled out. Her esophageal motility study shows pressure waves of a very high amplitude lasting 2 to 3 s. The most likely diagnosis is a. Esophageal web b. Esophageal spasm c. Achalasia d. GERD (gastroesophageal reflux disease)

e. T-E (tracheoesophageal) fistula

299. A 40-year-old man with occasional dysphagia and who otherwise feels well undergoes esophageal motility studies that show an LES amplitude of approximately 60 mmHg. The esophagus relaxes completely when he swallows. The most likely diagnosis is a. GERD (gastroesophageal reflux disease)

b. Achalasia c. Hypertensive LES

d. Barrett's esophagus e. Esophageal spasm

300. The presence of gastroesophageal reflux is best diagnosed by a. Computed tomographic (CT) scan of the chest b. Physical examination c. Laboratory evaluation d. Barium swallow e. Medical history

301. The most common location for a gastric ulcer is




Greater curvature







302. Helicobacter pylori is associated with a. Nearly all duodenal ulcers and most gastric ulcers b. Few peptic ulcers c. Most esophageal ulcers, but not many gastric ulcers d. Nearly all gastric ulcers, but very few duodenal ulcers e. Most cases of erosive gastritis

303. When nonsteroidal anti-inflammatory drugs cause ulcers, they are usually











304. A 40-year-old man comes to your office complaining of epigastric pain that is unrelieved by several weeks of antacid therapy. Endoscopy reveals a duodenal ulcer. You recommend a course of treatment. What is the most likely outcome?

a. The ulcer may heal but scarring will cause outlet obstruction b. Eventually the patient will require surgery for control of his symptoms c. The ulcer may heal completely after 8 weeks of H2-blocker therapy d. The symptoms will improve with H2-blocker therapy, but the ulcer won't heal e. The ulcer may heal completely after 6 months of H2-blocker therapy

305. Which one of these ulcers has the lowest incidence of malignancy?










Gastroesophageal junction

306. Osmolality of bowel contents under normal circumstances is a. Isotonic in the jejunum, ileum, and colon and variable in the duodenum b. Variable throughout the small and large intestines c. Isotonic in the colon and hypertonic in the small intestine d. Hypertonic throughout the small and large intestines e. Variable in the jejunum, ileum, and colon and isotonic in the duodenum

307. The digestive enzymes amylase and lipase begin to be secreted and begin to act on ingested food a. In the duodenum, after they are secreted by the pancreas b. In the ileum, after they are secreted by the small intestine c. In the duodenum, after they are secreted from the liver d. In the mouth, after secretion from the salivary and lingual glands e. In the stomach, after they are secreted from the pancreas

308. A 72-year-old woman complains of fatigue, dyspepsia, and shortness of breath. Her daughter tells you that her mother also has some slight memory loss and occasionally complains of numbness in her legs. The laboratory tests you ordered show a hemoglobin of 10.2 g/dL and an MCV of 110. The most likely cause is a. Autoantibodies to thyroglobulin b. Autoantibodies to histones c. Autoantibodies to gastric parietal cells d. Autoantibodies to dsDNA (double-stranded DNA)

e. Autoantibodies to ribosomal P protein

309. A 45-year-old man complains of frequent "heartburn" and a mild chronic cough. On examination, he has gastroesophageal reflux disease (GERD). In addition to prescribing medications, which one of the following dietary recommendations would you make?

a. Avoid high-protein meals because they would increase lower esophageal sphincter (LES) pressure b. Avoid fats, chocolates, and alcohol because they would decrease LES pressure c. Eat high-carbohydrate food to increase overall GI motility d. Eat high-protein meals to decrease LES pressure e. Avoid concentrated carbohydrates to decrease dopamine secretion

310. A 32-year-old man is admitted with a bleeding ulcer. This is his fifth episode of bleeding from gastric ulcers and he also has moderate diarrhea. Each time, his ulcers have been difficult to resolve. Which neoplastic lesion is most likely to be found in this man?

a. Small cell carcinoma of the lung b. Gastric adenocarcinoma c. Small intestinal carcinoid d. Prostate adenocarcinoma e. Gastrinoma

311. Which clinical or laboratory finding is most consistently seen in malabsorption syndromes?

a. Hypercalcemia b. Iron overload c. Elevated zinc levels in serum d. Normal small bowel biopsy e. Steatorrhea

312. In which disorder is malabsorption due to diminished or absent digestive enzymes?

a. Chronic pancreatitis b. Crohn's disease c. Gastric surgery d. Small bowel ischemia e. Sigmoid resection

313. A 35-year-old woman has had episodes of abdominal pain and bloody diarrhea for 4 to 5 years. Recently, the episodes became increasingly common, and she noted a weight loss of about 10 pounds. She tells you that two of her uncles have had similar symptoms "for years" and recently one of them had colon cancer. On examination, there are no abdominal masses and no fistulas. The most likely findings on colonoscopy with biopsy are a. Normal mucosa b. Patchy inflammatory lesions that extend throughout the bowel wall c. Granulomas and fibrosis d. Continuous inflammatory changes mostly confined to the mucosa e. Patchy inflammation of the mucosa with inflamed mesenteric fat and fibrosis

314. A 20-year-old man has complaints of diarrhea and abdominal pain. He often sees some blood in his stool, but not with every episode of diarrhea. He also complains of easy fatigue and weight loss and for 2 days he has had nausea and vomiting. TWo years ago he was treated for a rectal fissure. On examination, he has a modestly tender mass in the right lower quadrant. The most likely diagnosis is a. Ulcerative colitis b. Appendicitis c. Diverticulitis d. Irritable bowel syndrome e. Crohn's disease

315. You suspect a patient may have gallstones as a cause of her chronic nausea and mild RUQ pain. The best imaging study would be a. Upper abdominal ultrasound b. Abdominal CT scan c. Abdominal MRI

d. Barium swallow e. KUB (flat-plate x-ray of the abdomen)

316. A patient with jaundice complains of RUQ pain. Liver function tests show a bilirubin of 3.0 mg/dL, alkaline phosphatase about four times normal and both AST and ALT increased about 50% above normal. The best imaging test to order first in evaluating this patient would be a. Ultrasound b. Abdominal CT scan c. Abdominal MRI

d. Barium swallow e. KUB (flat-plate x-ray of the abdomen)

317. A patient with colon cancer diagnosed about 2 years ago presents with slight jaundice, nausea, and weight loss. An abdominal CT scan is read as "lesions in the liver; unable to distinguish vascular from possible metastatic areas." What is the best imaging study for this patient?

a. Upper abdominal ultrasound b. Repeat CT scan with spiral technique c. Abdominal MRI

d. Laparoscopy e. Open abdominal exploration

318. A 65-year-old man complains of "trouble swallowing." He is unsure whether his "trouble swallowing" occurs with both liquids and solids because it is intermittent. Sometimes he "chokes" and gets food "in his windpipe." The best imaging study is a. Ultrasound of the neck b. CT scan of the chest c. MRI of the mediastinum d. Barium swallow e. KUB (flat-plate x-ray of the abdomen)

319. Symptoms due to Clostridium difficile infection can be accurately diagnosed by a. Presence of diarrhea b. Stool positive for WBCs c. History of recent antibiotic usage d. Pseudomembranes noted on a sigmoidoscopy e. KUB (flat-plate x-ray of the abdomen)

320. Which term characterizes the frequency of chronic disease following hepatitis A infection?











321. Which of the following laboratory patterns is most consistent with the diagnosis of hemochromatosis?

a. Increased iron, increased TIBC (total iron-binding capacity), and increased ferritin b. Low iron, low TIBC, and low ferritin c. Low iron, low TIBC, and increased ferritin d. Low iron, increased TIBC, and decreased ferritin e. Increased iron, normal TIBC, and low ferritin

322. Which of the following is seen most commonly in association with primary biliary cirrhosis (PBC)?

a. Positive antinuclear antibody (ANA)

b. Increased ceruloplasmin c. Increased ferritin d. Positive hepatitis B surface antigen e. Positive antimitochondrial antibody (AMA)

323. Previously, you treated a 44-year-old man, a former intravenous drug abuser, for acute hepatitis C infection. Several months later, it is clear that the patient has chronic hepatitis and may need therapy with interferon. Which long-term complications of hepatitis C infection must you discuss so that the patient can make an informed decision about treatment?

a. Hepatoma and cirrhosis b. Hepatic adenoma c. Sclerosing cholangitis d. Hemochromatosis e. Lymphoma or leukemia

324. Fatigue, anorexia, orange/brown-colored urine, and an ALT level greater than 10 times normal are clinical features of a. Hepatitis A

b. Any viral hepatitis c. Hepatoma d. Hepatitis B and hepatitis C

e. Hepatitis B, but not hepatitis C

325. Protective vaccines are available for which of the following hepatitis viruses?

326. A man known to be an alcoholic for at least 15 years presents with fever, elevated serum bilirubin, elevated WBC count, and an AST/ALT ratio greater than 2. A liver biopsy shows Mallory bodies, WBCs, and degenerating cells. You should tell this patient that the biopsy findings are a. Consistent with cirrhosis b. Essentially normal c. Consistent with alcoholic hepatitis that may revert to normal if he stops drinking alcohol d. Consistent with alcoholic hepatitis that will progress to cirrhosis e. Not interpretable because of the presence of degenerating cells and it will need to be repeated

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Dieting Dilemma and Skinny Solutions

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