August 2012 - Gastroenterology

12 Questions | By Dstevens | Last updated: Feb 22, 2013 | Total Attempts: 560

Questions

Settings

Questions and Answers

1.

A 44-year-old man is evaluated in the hospital for 3-day history of five or six watery stools a day 3 months after surgical resection of the small bowel. The patient was recently diagnosed with a desmoid tumor involving the right transverse colon and ileum, and the tumor was resected, requiring removal of the proximal colon and 80 cm of distal ileum. The remaining small bowel was anastomosed to the mid-transverse colon. Vital signs and physical examination are normal. Which of the following is the most appropriate therapy for this patient?
- A.
  
  Antibiotics
- B.
  
  Cholestyramine
- C.
  
  Prednisone
- D.
  
  Tincture of opium
2.

A 55-year-old woman is evaluated for a 4-month history of progressive fatigue and pruritus. She is otherwise healthy and takes no medications. On physical examination, vital signs are normal; BMI is 25. Examination reveals mild hepatomegaly and excoriations of the skin. There is no jaundice, rash, or skin eruption. Laboratory studies: Bilirubin (total) 1.5 mg/dL (25.6 µmol/L) Aspartate aminotransferase 60 U/L Alanine aminotransferase 75 U/L Alkaline phosphatase 470 U/L Albumin 4.0 g/dL (40 g/L) Hepatitis C virus antibody Negative Hepatitis B surface antigen Negative Ultrasonography of the abdomen is normal with no bile duct dilatation. Which of the following is the most appropriate next step in the diagnosis of this patient?
- A.
  
  A1 - Antitrypsin phenotype
- B.
  
  Liver biopsy
- C.
  
  Measurement of serum antimitochondrial antibody
- D.
  
  Serum protein electrophoresis
3.

A 58-year-old man is evaluated for a 3-month history of epigastric pain. The pain varies in intensity and is not aggravated by eating; it is not associated with nausea, vomiting, bloating, or weight loss. He started pantoprazole therapy 1 month ago without relief. The patient has a history of resolved peptic ulcer 3 years ago and osteoarthritis of the hands and knees, and his medications are ibuprofen as needed for arthritic pain and pantoprazole. On physical examination, vital signs are normal. There is mild epigastric tenderness, normal bowel sounds, and no hepatomegaly or lymphadenopathy. Complete blood count and serum chemistry tests, including liver enzymes, are normal. Esophagogastroduodenoscopy shows mild erythema and a few superficial erosions throughout the distal stomach and a 1-cm pedunculated polyp in the antrum of the stomach that is biopsied but not removed. Biopsy specimens of the erythematous gastric mucosa show chronic active gastritis and the presence of Helicobacter pylori; specimens of the polyp show a tubular adenoma with low-grade dysplasia. Eradication therapy for H. pylori is begun. Which of the following is the most appropriate additional management of this patient?
- A.
  
  Endoscopic ultrasonography
- B.
  
  Esophagogastroduodenoscopy with polypectomy now
- C.
  
  Esophagogastroduodenoscopy in 3 years
- D.
  
  Surgical resection
- E.
  
  No further intervention
4.

A 57-year-old woman is evaluated in the emergency department for acute left lower quadrant pain, an episode of nonbloody diarrhea, and mild nausea without vomiting that began 1 day ago; her temperature at the time was 38.1 °C (100.6 °F). She has been able to eat and maintain her hydration with oral fluids. She had been previously healthy and has no significant medical history. On physical examination, the temperature is 38.1 °C (100.6 °F), the blood pressure is 115/76 mm Hg, the pulse rate is 98/min, and the respiration rate is 14/min. There is tenderness of the left lower quadrant with no rebound, guarding, or palpable masses. Leukocyte count is 14,900/µL (14.9 × 109/L); all other laboratory results are normal. Contrast-enhanced CT scan of the abdomen and pelvis shows diverticula of the sigmoid colon with pericolic fatty infiltration and thickening of the bowel wall consistent with diverticulitis; there is no abscess, obstruction, or fistula. Which of the following is the most appropriate next step in the management of this patient?
- A.
  
  Flexible sigmoidoscopy
- B.
  
  Oral ciprofloxacin and metronidazole therapy
- C.
  
  Oral cephalexin therapy
- D.
  
  Surgical resection
5.

An 81-year-old woman is evaluated for a 3-month history of abdominal and back pain. She also has anorexia and has lost 11.4 kg (25 lb). For the past 2 weeks she has had progressive pruritus and a yellow tint to her skin. On physical examination, the patient appears ill; the temperature is 37.2 °C (99 °F), the blood pressure is 104/62 mm Hg, the pulse rate is 98/min, and the respiration rate is 16/min. There is scleral icterus, jaundiced skin, and generalized abdominal tenderness. Laboratory studies reveal a leukocyte count of 13,200/µL (13.2 × 109/L), total bilirubin 12.4 mg/dL (212 µmol/L), alkaline phosphatase 748 U/L, and CA 19-9 822 U/L. CT scan shows a 3.2-cm lesion in the head of the pancreas with dilation of the pancreatic and bile ducts and multiple lesions throughout the liver that are consistent with metastases. Endoscopic ultrasonography biopsy specimen of the mass is positive for adenocarcinoma. Which of the following is the most appropriate next step in the management of this patient?
- A.
  
  Biopsy of a liver lesion
- B.
  
  Placement of a metal biliary stent
- C.
  
  Radiation to the pancreas and liver lesions
- D.
  
  Surgical resection of the pancreatic lesion and adjuvant chemotherapy
6.

A 35-year-old woman is evaluated for a 6-month history of right upper quadrant abdominal pain that has slowly increased in intensity and is worse on deep inspiration. The patient is otherwise well, and her only medication is an oral contraceptive pill that she has taken for 15 years. She drinks alcohol socially but has no history of heavy alcohol use, injection drug use, or blood transfusion. On physical examination, vital signs are normal; BMI is 26. There is slight hepatomegaly with mild discomfort on deep palpation in the right upper quadrant and mid-epigastrium. There is no jaundice or ascites. The lungs are clear. Complete blood count and serum biochemistry studies, including aminotransferases, bilirubin, and α-fetoprotein, are normal. Ultrasonography shows a solitary hyperechoic 9-cm lesion in the right lobe of the liver. CT scan shows a well-demarcated lesion with peripheral enhancement after injection of intravenous contrast; there is no central scar. Liver biopsy specimen reveals sheets of hepatocytes, with no bile ducts or Kupffer cells. Which of the following is the most likely diagnosis?
- A.
  
  Focal nodular hyperplasia
- B.
  
  Hepatic adenoma
- C.
  
  Hepatocellular carcinoma
- D.
  
  Simple hepatic cyst
7.

A 63-year-old man is evaluated for a 2-day history of left lower quadrant abdominal pain. The pain is constant and is not relieved by a bowel movement or by positional changes. The patient is slightly nauseated and has no appetite but is not vomiting. He has never had a similar episode. The patient’s medical history includes hypertension, and his only medication is hydrochlorothiazide. On physical examination, the temperature is 38.0 °C (101.1 °F), the blood pressure is 125/85 mm Hg, the pulse rate is 95/min, and the respiration rate is 14/min. There is fullness and tenderness of the left lower quadrant with no rebound or guarding; bowel sounds are decreased. Rectal examination is normal; examination of stool for occult blood is negative. Leukocyte count is 14,000/µL (14 × 109/L); all other laboratory results are normal. A plain abdominal radiograph is unremarkable, and a chest radiograph shows no free air beneath the diaphragms. Which of the following is the most appropriate next step in the evaluation of this patient?
- A.
  
  Barium enema
- B.
  
  Colonoscopy
- C.
  
  Contrast-enhanced CT scan of the abdomen and pelvis
- D.
  
  Small-bowel radiographic series
8.

A 25-year-old man is evaluated after being turned down as a blood donor because of abnormal liver chemistry tests. The patient is healthy, takes no medications, does not smoke, and drinks alcohol socially. His parents and siblings are alive and healthy; his maternal grandfather developed type 2 diabetes mellitus at age 75 years. The review of systems is normal. On physical examination, vital signs and BMI are normal. Laboratory studies: Hemoglobin 11.9 g/dL (119 g/L) Mean corpuscular volume 76 fL Cholesterol (total) 155 mg/dL (4.01 mmol/L) LDL cholesterol 85 mg/dL (2.2 mmol/L) HDL cholesterol 33 mg/dL (0.85 mmol/L) Bilirubin (total) 0.5 mg/dL (8.55 µmol/L) Aspartate aminotransferase 25 U/L Alanine aminotransferase 58 U/L Alkaline phosphatase 110 U/L Serologic tests for hepatitis virus infection are normal. Which of the following is the most appropriate diagnostic test for this patient?
- A.
  
  Anti-tissue transglutaminase antibody
- B.
  
  α1-Antitrypsin concentration
- C.
  
  Blood alcohol level
- D.
  
  Liver biopsy
9.

A 72-year-old man has a 6-week history of epigastric discomfort that is not relieved with over-the-counter antacids. He does not have fever, heartburn, jaundice, or change in bowel habits but believes that his clothes are becoming loose, although he has not weighed himself recently. The patient has a 15-year history of hypertension, treated with a thiazide diuretic, and a several-month history of type 2 diabetes mellitus, treated with an oral hypoglycemic agent. He also takes a statin and low-dose aspirin. Physical examination reveals a thin, elderly man who appears uncomfortable. Vital signs and abdominal examination are normal. There is no scleral icterus. Laboratory Studies Hemoglobin 11.8 g/dL Glucose 145 mg/dL Total bilirubin 2.8 mg/dL Aspartate aminotransferase 35 U/L Alanine aminotransferase 48 U/L Alkaline phosphatase 350 U/L Amylase 140 U/L Which of the following diagnostic studies is most appropriate at this time?
- A.
  
  Endoscopic retrograde cholangiopancreatography
- B.
  
  Endoscopic ultrasonography
- C.
  
  Helical CT scan of the abdomen
- D.
  
  Mesenteric angiography
10.

A 63-year-old woman has a 3-month history of gradually increasing abdominal distention and fatigue. She has no other symptoms, and medical history is noncontributory. On physical examination, the patient has jaundice and evidence of mild muscle wasting. Xanthelasma and spider angiomata are present. Abdominal examination discloses hepatosplenomegaly and moderate ascites. Laboratory Studies Aspartate aminotransferase 53 U/L Alanine aminotransferase 47 U/L Alkaline phosphatase 123 U/L Total bilirubin 3.2 mg/dL Albumin 2.9 g/dL Abdominal ultrasonography shows hepatomegaly, a coarse echotexture of the liver, patent portal and hepatic veins, mild splenomegaly, moderate ascites, and no bile duct dilatation. Paracentesis is performed. The ascitic fluid leukocyte count is 80/μL, protein is 1.4 g/dL, and albumin is 0.7 g/dL. Which of the following is the most likely cause of the ascites?
- A.
  
  Budd-Chiari syndrome
- B.
  
  Cirrhosis
- C.
  
  Heart failure
- D.
  
  Peritoneal carcinomatosis
11.

A 66-year-old man presents with vague epigastric “gnawing” discomfort that occasionally awakens him from sleep. There has been no melena, hematochezia, fever, chills or weight loss. Past medical history includes asthma, a TI, and peptic ulcer disease many years prior. Medications are aspirin and beclomethasone inhaler. Physical examination reveals a soft abdomen, mildly tender in the epigastrium. A recent abdominal ultrasound is normal. What is the best initial test in the evaluation of this patient?
- A.
  
  Upper gastrointestinal series
- B.
  
  Upper endoscopy
- C.
  
  MRI of the abdomen
- D.
  
  CT scan with IV contrast
- E.
  
  Serology for H. Pylori
12.

Endoscopy shows a 1-cm ulcer in the gastric antrum. If biopsies show mucosa-associated lymphoid tissue (MALT) lymphoma, what is the best initial treatment?
- A.
  
  5-FU/cisplatin
- B.
  
  Surgical resection
- C.
  
  Lansoprazole, amoxicillin, clarithromycin
- D.
  
  External beam radiation