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Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Gastrointestinal and Nutritional Questions based on Chapter 3 of the book Pance Prep Pearls and the release of PANCE AND PANRE QUESTION BOOK. Good luck!!! 1. A 35-‐year-‐old male comes to the clinic for a routine physical examination. During obtaining a history, he tells you his brother was diagnosed with colon cancer at 53-‐years-‐old. Which of the following describes the appropriate colon cancer screening guidelines for this patient? a. Fecal occult blood testing now and colonoscopy every 10 years b. Fecal occult blood testing at age 40 and colonoscopy every 10 years c. Fecal occult blood testing at age 50 and colonoscopy every 10 years d. Fecal occult blood testing at age 50 and colonoscopy every 5 years e. Fecal occult blood testing at age 40 and colonoscopy every 5 years 2. A 45-‐year-‐old male presents with non-‐bloody diarrhea and crampy abdominal pain especially in the right lower quadrant. Rovsing, Obturator and Psoas sign are negative. He undergoes an upper GI series with small bowel follow through and a “string sign” is seen. The patient is saccharomyces cerevisiae antibody positive. Which of the following lab findings would most likely be seen in this patient? a. increased alpha fetoprotein b. increased perinuclear anti-‐neutrophil antibody c. increased smooth muscle antibody d. increased mean corpuscular volume of the red blood cells e. increased endomysial antibodies 3. A 50-‐year-‐old obese female is complaining of multiple episodes of sharp, right upper quadrant pain that is worsened with fatty and fried foods. The patient states the pain radiates to the right shoulder. On physical examination, there is right upper quadrant tenderness, causing the patient to hold their breath in mid-‐ inspiration. There is no fever or jaundice. Which of the following is the most appropriate test at this time? a. HIDA scan b. Endoscopic retrograde cholangiopancreatography c. Ultrasound of the gallbladder d. Abdominal radiograph e. Prothrombin and albumin level
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
4. A 37-‐year-‐old female undergoes an upper endoscopy for epigastric pain. A direct urease test was performed on the specimen and a direct urease test was positive. Which of the following is the management of choice in this patient? a. Lansoprazole 30mg + amoxicillin 500mg + clarithromycin 500mg b. Lansoprazole 30mg c. Lansoprazole 30mg + metronidazole 500mg + clarithromycin 500mg d. Lansoprazole 30mg + ranitidine 300mg e. Misoprostol 200mcg 5. A 43-‐year-‐old otherwise healthy male presents to the gastroenterologist after being referred for chest pain and cough with a negative cardiac workup. An esophagram is performed and shows the following
Which of the following is the most likely diagnosis? a. Zenker’s diverticulum b. Esophageal cancer c. Nutcracker esophagus d. Achalasia e. Diffuse esophageal spasm 6. In evaluating a patient with oral thrush and odynophagia, which of the following endoscopic findings would be most likely seen in this patient? a. Large superficial ulcers b. Columnar cells in the lower esophagus c. Small deep ulcers d. Linear plaques e. Multiple corrugated rings
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
7. In evaluation of a patient, which of the following values would be most consistent with a patient chronic hepatitis B? HBsAG HBsAB HBcAB HBeAG HBeAB A. NEGATIVE POSITIVE POSITIVE NEGATIVE, NEGATIVE (IgG) B. POSITIVE NEGATIVE, POSITIVE NEGATIVE NEGATIVE (IgG) C. POSITIVE NEGATIVE, Positive POSITIVE, NEGATIVE (IGM) D NEGATIVE POSITIVE NEGATIVE NEGATIVE NEGATIVE E. NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE (IgM) 8. A 44-‐year-‐old male comes into the emergency room with crampy abdominal pain, nausea, vomiting and constipation. An abdominal radiograph is performed and shows the following
Which of the following is the most common early physical exam finding in this patient? a. Peritoneal signs b. Bowel sounds with gurgles at about 5-‐15 per minute c. No bowel sounds d. Hyperactive, high-‐pitched tinkling abdominal sounds e. Sausage shaped mass
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
9. Which of the following is the classic description of a patient with an ascorbic acid (Vitamin C) deficiency. a. Diarrhea, dementia and dermatitis b. Ataxia, oculomotor palsies, global confusion c. The presence of looser lines (zones) d. Hyperkeratosis and perifollicular hemorrhages e. Magenta colored tongue, corneal lesions and scrotal dermatitis 10. A 46-‐year-‐old male with a longstanding history of GERD now has dysphagia to solids, weight loss and anemia. He does not smoke or drink and has not had any recent episodes of vomiting or retching. Which of the following is the most likely diagnosis? a. Barrett’s esophagus b. Diffuse esophageal spasm c. Adenocarcinoma of the esophagus d. Squamous cell carcinoma of the esophagus e. Mallory Weiss tears QUESTION 1 Choice E is correct. A first-‐degree relative is a parent, sibling or offspring. Because his brother was diagnosed at age 53, recommended age is to begin at age 40 (or 10 years before the person was diagnosed which would have been 43 so you use the lower number). The 10 number comes from the thought it takes roughly about 10 years on average for a polyp to become malignant. Average Risk 1st degree relative >60y 1st degree relative <60y
FOBT COLONOSCOPY Annually @ 50y Colonoscopy q10y (flex sig q5y) (up to 80y) Annually @ 40y Colonoscopy q10y Annually @ 40y
Colonoscopy q5y
Choice A is incorrect Choice B (Fecal occult blood testing at age 40 and colonoscopy every 10 years) is recommended in patients whose first degree relative was diagnosed over 60y of age Choice C (Fecal occult blood testing at age 50 and colonoscopy every 10 years) is the standard recommended guidelines. Choice D is incorrect
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
QUESTION 2 Choice D (increased MCV) is the correct answer. The string sign, non-‐bloody diarrhea and right lower quadrant pain is highly suggestive of Crohn’s disease. The terminal ileum is the most common site of Crohn’s disease and since it sits in the right lower quadrant, RLQ pain is a common finding in patients with Crohn’s. Both inflammatory bowel diseases (Crohn’s and Ulcerative Colitis) are thought to arise from an inappropriate autoimmune response to the normal GI flora. Antibodies against the harmless saccharomyces cerevisiae (most likely known to you as Baker’s/Brewer’s yeast used to make ethanol and to allow dough to rise) is seen in about 70% of patients with Crohn’s (and only 10-‐15% of those with ulcerative colitis so that also leads to the diagnosis of Crohn’s. Because Crohn’s most commonly affects the terminal ileum (where B12 is absorbed), patients may develop a B12 deficiency and a subsequent macrocytic anemia with an increased mean corpuscular volume (MCV) of the red blood cell. Choice A (increased alpha fetoprotein) is common in hepatocellular carcinoma and germ cell tumors like nonseminomatous testicular cancer. In utero, alpha fetoprotein is the a dominant serum protein in the fetus (the fetus version of albumin produced by the yolk sac and the liver (this is why it is can be seen in germ cell tumors & produces our serum proteins). Choice B (increased perinuclear anti-‐neutrophil antibody) is commonly seen with ulcerative colitis (commonly associated with bloody diarrhea and left upper quadrant since it the inflammation has contiguous spread from the rectum proximally – so the left side is affected). Cross reference: P-‐ANCA is also seen in Churg-‐Strauss, Primary Sclerosing Cholangitis & microscopic polyangiitis. Choice C (increased smooth muscle antibody) is classically associated with autoimmune hepatitis (but can be seen in chronic hepatitis and cirrhosis). There was no mention of liver symptoms or sequelae in this question to suggest those disorders. Choice E (endomysial antibodies) & transglutaminase antibodies are classically associated with Celiac disease (which can cause a chronic diarrhea) but would be related to the consumption of gluten. QUESTION 3 Choice C (ultrasound of the gallbladder) is correct. This is a classic presentation of acute cholecystitis, making ultrasound the best initial test in the evaluation of suspected cholecystitis. Ultrasound findings will be the presence of stone, thickened gall bladder and a positive sonographic Murphy’s sign while doing the test. Although afebrile in this vignette, patients with acute cholecystitis can be febrile due to the infection. The referred pain to the right shoulder is known as Boas sign (not to be confused with pain that radiates the left shoulder – Kehr’s sign). Both are caused by phrenic nerve irritation. Boas sign is associated with acute cholecystitis and Kehr’s sign is usually associated with splenic injury most commonly, ectopic pregnancy, or kidney stones
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Choice A is the gold standard test but often gold standard tests are most often not the initial test done. If the question asked for gold standard, then HIDA would have been correct. Choice B (ER) is used for suspected biliary tract disease. In acute cholecystitis, the stone is in the cystic duct but bile is still able to flow through the bile ducts (this is why there are no long-‐term sequelae in patients who have a cholecystectomy as the bile can still flow without the gall bladder. In biliary duct diseases, patients usually develop jaundice with the blocking of the biliary tract. Choice D (abdominal X ray) would be useful for other disorders, such as small bowel obstruction but most stones are radiopaque (since they are made of cholesterol) so won’t show up often on abdominal X ray and radiographs won’t show the details that can be seen on ultrasound. Choice E (PT and albumin levels) is helpful if end stage liver disease is suspected. QUESTION 4 Choice A (Lansoprazole 30mg + amoxicillin 500mg + clarithromycin 500mg) triple therapy is the mainstay of H-‐pylori peptic ulcer disease. Choice B can be used for H. pylori negative disease. Proton pump inhibitors (the “azoles’) are the most effective drugs against acid production. Choice C is an alternative in patients who are penicillin allergic (Metronidazole is substituted). Choice E can also be not to treat peptic ulcers. Misoprostol can be used to prevent recurrence or ulcers particularly in patients with aspirin or NSAID-‐induced ulcers. gastric ulcers are due to decreased protective factors (mucous and bicarbonate). Prostaglandins are responsible for those protective mechanisms and aspirin and NSAID’s exhibit their anti-‐inflammatory effects via prostaglandin inhibition. Misoprostol is a prostaglandin analogue. QUESTION 5 Choice D (Achalasia) is correct. Achalasia is a disorder that causes loss of Aurbach’s plexus at the lower esophageal sphincter area. Auerbach’s plexus secretes nitric oxide (which leads to relaxation of the LES). Without Auerbach’s plexus, there is an increased LES pressure, leading to dysphagia. On a Barium swallow (esophagram), the increased LES tone leads to narrowing of the GE junction and pre narrowing dilation, leading to the classic “bird beak” appearance.
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Choice A (Zenker’s) is an out pouching of the pharyngoesophageal pouch, which doesn’t affect the lower esophageal sphincter. Choice B (Esophageal Cancer) would show a filling defect around the cancer. Choice C (Nutcracker) is associated with a normal esophagram. Choice E (Diffuse esophageal spasm) would show a “corkscrew” appearance on esophagram due to strong, non-‐peristaltic contractions of the esophagus. QUESTION 6 Choice D (Linear plaques) is correct. Oral thrush is due to candida infection. Candida esophagitis is associated with linear plaques in the esophagus. Choice A (Large superficial ulcers) is associated c CMV esophagitis Choice B (columnar cells in esophagus) is associated with Barrett’s esophagus ( a pre malignant condition to esophageal adenocarcinoma). In chronic reflux esophagitis, the normal squamous cells are replaced by columnar cells from the stomach (which are better to a higher acidic environment). The would have a had a history of GERD. Choice C (small deep ulcers) is classic for Herpes Simplex (HSV) esophagitis Choice E (corrugated rings) is classic for eosinophilic esophagitis QUESTION 7 Choice B is correct. Whenever evaluating hepatitis, the quickest way is to look at surface antigen, surface antibody and the core antibody. I only look at the E if the person has acute or chronic to determine replication. With that said, Chronic hepatitis is defined as the presence of the Hepatitis B surface antigen (HBsAg) and the failure to develop the surface antibodies (HBsAb) in 6 months. Because the person has a chronic infection, the core antibody would be IgG (would have already switched from making the acute IgM antibodies). Choice A describes someone who has a distant resolved infection. They developed the surface antibodies and the core antibodies. Choice C denotes acute viral hepatitis, as the surface antigen is positive and the fact that the core is IgM ( from immunology your body first starts making IgM pentamer antibodies before switching to creating IgG antibodies).
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Choice D denotes successful Hepatitis B vaccination. The surface antibody is the only positive marker in vaccination. People often confuse this with someone with a distant resolved infection. But think of it this way, if you were infected with hepatitis B, then the virus would be destroyed by the macrophages, producing antibodies to surface proteins but also the viral core, so the core would be positive. Choice E is the classic description of the window period. In someone who is infected, the window period describes the point where the surface antigen is disappearing (leading to a negative HBsAg) but the antibodies are not enough yet to be detected by testing (even though they will eventually increase). So the core IgM antibody is often the sole serologic marker in the window period. HBsAG HBsAB HBcAB HBeAG HBeAB A. NEGATIVE POSITIVE POSITIVE NEGATIVE, NEGATIVE (IgG) B. POSITIVE NEGATIVE, POSITIVE NEGATIVE NEGATIVE (IgG) C. POSITIVE NEGATIVE, Positive POSITIVE, NEGATIVE (IGM) D NEGATIVE POSITIVE NEGATIVE NEGATIVE NEGATIVE E. NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE (IgM) QUESTION 8 Choice D (hyperactive bowel sounds) is correct. Crampy abdominal pain, nausea vomiting and constipation are classic for a small bowel obstruction. Besides, the abdominal X ray shows the stepladder appearance as fluid and air builds up in the obstructed bowel since it cannot go forward. In the early stages of obstruction, there is hyperactive bowel sounds as the bowel proximal to the obstruction fervently contracts to overcome the obstruction. Later in the disease, hypoactive bowel sounds (choice C) will prevail but the question specifically states early. Choice A (peritoneal) is not specific to small bowel obstruction but can be seen if bowel ischemia is present due to small bowel obstruction or other reasons and can be seen in many disorders and often not seen in early obstruction. Choice B (gurgles about 5-‐15) is considered normal bowel sounds Choice E (sausage shaped mass) is classically associated with intussusception which would be associated with a bowel that contains mucous and blood (“currant-‐jelly”) and vomiting. Which is almost exclusively seen in infants. If it occurs in adults, it is often associated with a lead point such as a malignancy that then causes the telescoping.
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
QUESTION 9 Choice D (hyperkeratosis & perifollicular hemorrhages) is correct. Vitamin C is needed for collagen synthesis. Scurvy (Vitamin C deficiency) is associated with loss of collagen in blood vessels, leading to perifollicular hemorrhages & purpura among the other manifestations. Choice A is classic for pellagra (Vitamin B3/Niacin) deficiency Choice B is classic for vitamin B1/Thiamin deficiency. Ataxia oculomotor paralysis and global confusion is the triad of Wernicke’s encephalopathy. Choice D (Looser Lines) are associated with adult onset vitamin D deficiency (Osteomalacia). Choice E ocular-‐oral-‐genital involvement is classically associated with riboflavin (Vitamin B2) deficiency. QUESTION 1O Choice C (Esophageal adenocarcinoma) is correct. Chronic acidic contents in the esophagus of someone with longstanding GERD will develop Barrett’s esophagus (Choice A), the precursor to esophageal carcinoma. The fact that he had dysphagia especially to solids, weight loss and anemia make malignancy the likely cause. Choice B (diffuse esophageal spasm) is a motility disorder, so both solids and liquids will cause spasm of the esophagus. The patient will often complain of odynophagia, classically it’s a stabbing chest pain that is worse with hot or cold foods AND liquids. Choice D (Squamous cell carcinoma) is usually seen not in the context of GERD but more so in patients who drink or smoke (this patient does neither), making Choice C the better answer. Choice E (Mallory Weiss Tears) are due to repeated vomiting or retching causing superficial mucosal tears. The usually develop signs of bleeding if they are symptomatic. PHOTO CREDIT Achalasia: By Farnoosh Farrokhi, Michael F. Vaezi. [CC-‐BY-‐2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons Small Bowel obstruction: By James Heilman, MD (Own work) [CC-‐BY-‐SA-‐3.0-‐2.5-‐ 2.0-‐1.0 (http://creativecommons.org/licenses/by-‐sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Gastrointestinal and Nutritional Questions based on Chapter 3 of the book Pance Prep Pearls and the release of PANCE AND PANRE QUESTION BOOK. Good luck!!! 1. A 35-‐year-‐old male comes to the clinic for a routine physical examination. During obtaining a history, he tells you his brother was diagnosed with colon cancer at 53-‐years-‐old. Which of the following describes the appropriate colon cancer screening guidelines for this patient? a. Fecal occult blood testing now and colonoscopy every 10 years b. Fecal occult blood testing at age 40 and colonoscopy every 10 years c. Fecal occult blood testing at age 50 and colonoscopy every 10 years d. Fecal occult blood testing at age 50 and colonoscopy every 5 years e. Fecal occult blood testing at age 40 and colonoscopy every 5 years 2. A 45-‐year-‐old male presents with non-‐bloody diarrhea and crampy abdominal pain especially in the right lower quadrant. Rovsing, Obturator and Psoas sign are negative. He undergoes an upper GI series with small bowel follow through and a “string sign” is seen. The patient is saccharomyces cerevisiae antibody positive. Which of the following lab findings would most likely be seen in this patient? a. increased alpha fetoprotein b. increased perinuclear anti-‐neutrophil antibody c. increased smooth muscle antibody d. increased mean corpuscular volume of the red blood cells e. increased endomysial antibodies 3. A 50-‐year-‐old obese female is complaining of multiple episodes of sharp, right upper quadrant pain that is worsened with fatty and fried foods. The patient states the pain radiates to the right shoulder. On physical examination, there is right upper quadrant tenderness, causing the patient to hold their breath in mid-‐ inspiration. There is no fever or jaundice. Which of the following is the most appropriate test at this time? a. HIDA scan b. Endoscopic retrograde cholangiopancreatography c. Ultrasound of the gallbladder d. Abdominal radiograph e. Prothrombin and albumin level
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
4. A 37-‐year-‐old female undergoes an upper endoscopy for epigastric pain. A direct urease test was performed on the specimen and a direct urease test was positive. Which of the following is the management of choice in this patient? a. Lansoprazole 30mg + amoxicillin 500mg + clarithromycin 500mg b. Lansoprazole 30mg c. Lansoprazole 30mg + metronidazole 500mg + clarithromycin 500mg d. Lansoprazole 30mg + ranitidine 300mg e. Misoprostol 200mcg 5. A 43-‐year-‐old otherwise healthy male presents to the gastroenterologist after being referred for chest pain and cough with a negative cardiac workup. An esophagram is performed and shows the following
Which of the following is the most likely diagnosis? a. Zenker’s diverticulum b. Esophageal cancer c. Nutcracker esophagus d. Achalasia e. Diffuse esophageal spasm 6. In evaluating a patient with oral thrush and odynophagia, which of the following endoscopic findings would be most likely seen in this patient? a. Large superficial ulcers b. Columnar cells in the lower esophagus c. Small deep ulcers d. Linear plaques e. Multiple corrugated rings
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
7. In evaluation of a patient, which of the following values would be most consistent with a patient chronic hepatitis B? HBsAG HBsAB HBcAB HBeAG HBeAB A. NEGATIVE POSITIVE POSITIVE NEGATIVE, NEGATIVE (IgG) B. POSITIVE NEGATIVE, POSITIVE NEGATIVE NEGATIVE (IgG) C. POSITIVE NEGATIVE, Positive POSITIVE, NEGATIVE (IGM) D NEGATIVE POSITIVE NEGATIVE NEGATIVE NEGATIVE E. NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE (IgM) 8. A 44-‐year-‐old male comes into the emergency room with crampy abdominal pain, nausea, vomiting and constipation. An abdominal radiograph is performed and shows the following
Which of the following is the most common early physical exam finding in this patient? a. Peritoneal signs b. Bowel sounds with gurgles at about 5-‐15 per minute c. No bowel sounds d. Hyperactive, high-‐pitched tinkling abdominal sounds e. Sausage shaped mass
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
9. Which of the following is the classic description of a patient with an ascorbic acid (Vitamin C) deficiency. a. Diarrhea, dementia and dermatitis b. Ataxia, oculomotor palsies, global confusion c. The presence of looser lines (zones) d. Hyperkeratosis and perifollicular hemorrhages e. Magenta colored tongue, corneal lesions and scrotal dermatitis 10. A 46-‐year-‐old male with a longstanding history of GERD now has dysphagia to solids, weight loss and anemia. He does not smoke or drink and has not had any recent episodes of vomiting or retching. Which of the following is the most likely diagnosis? a. Barrett’s esophagus b. Diffuse esophageal spasm c. Adenocarcinoma of the esophagus d. Squamous cell carcinoma of the esophagus e. Mallory Weiss tears QUESTION 1 Choice E is correct. A first-‐degree relative is a parent, sibling or offspring. Because his brother was diagnosed at age 53, recommended age is to begin at age 40 (or 10 years before the person was diagnosed which would have been 43 so you use the lower number). The 10 number comes from the thought it takes roughly about 10 years on average for a polyp to become malignant. Average Risk 1st degree relative >60y 1st degree relative <60y
FOBT COLONOSCOPY Annually @ 50y Colonoscopy q10y (flex sig q5y) (up to 80y) Annually @ 40y Colonoscopy q10y Annually @ 40y
Colonoscopy q5y
Choice A is incorrect Choice B (Fecal occult blood testing at age 40 and colonoscopy every 10 years) is recommended in patients whose first degree relative was diagnosed over 60y of age Choice C (Fecal occult blood testing at age 50 and colonoscopy every 10 years) is the standard recommended guidelines. Choice D is incorrect
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
QUESTION 2 Choice D (increased MCV) is the correct answer. The string sign, non-‐bloody diarrhea and right lower quadrant pain is highly suggestive of Crohn’s disease. The terminal ileum is the most common site of Crohn’s disease and since it sits in the right lower quadrant, RLQ pain is a common finding in patients with Crohn’s. Both inflammatory bowel diseases (Crohn’s and Ulcerative Colitis) are thought to arise from an inappropriate autoimmune response to the normal GI flora. Antibodies against the harmless saccharomyces cerevisiae (most likely known to you as Baker’s/Brewer’s yeast used to make ethanol and to allow dough to rise) is seen in about 70% of patients with Crohn’s (and only 10-‐15% of those with ulcerative colitis so that also leads to the diagnosis of Crohn’s. Because Crohn’s most commonly affects the terminal ileum (where B12 is absorbed), patients may develop a B12 deficiency and a subsequent macrocytic anemia with an increased mean corpuscular volume (MCV) of the red blood cell. Choice A (increased alpha fetoprotein) is common in hepatocellular carcinoma and germ cell tumors like nonseminomatous testicular cancer. In utero, alpha fetoprotein is the a dominant serum protein in the fetus (the fetus version of albumin produced by the yolk sac and the liver (this is why it is can be seen in germ cell tumors & produces our serum proteins). Choice B (increased perinuclear anti-‐neutrophil antibody) is commonly seen with ulcerative colitis (commonly associated with bloody diarrhea and left upper quadrant since it the inflammation has contiguous spread from the rectum proximally – so the left side is affected). Cross reference: P-‐ANCA is also seen in Churg-‐Strauss, Primary Sclerosing Cholangitis & microscopic polyangiitis. Choice C (increased smooth muscle antibody) is classically associated with autoimmune hepatitis (but can be seen in chronic hepatitis and cirrhosis). There was no mention of liver symptoms or sequelae in this question to suggest those disorders. Choice E (endomysial antibodies) & transglutaminase antibodies are classically associated with Celiac disease (which can cause a chronic diarrhea) but would be related to the consumption of gluten. QUESTION 3 Choice C (ultrasound of the gallbladder) is correct. This is a classic presentation of acute cholecystitis, making ultrasound the best initial test in the evaluation of suspected cholecystitis. Ultrasound findings will be the presence of stone, thickened gall bladder and a positive sonographic Murphy’s sign while doing the test. Although afebrile in this vignette, patients with acute cholecystitis can be febrile due to the infection. The referred pain to the right shoulder is known as Boas sign (not to be confused with pain that radiates the left shoulder – Kehr’s sign). Both are caused by phrenic nerve irritation. Boas sign is associated with acute cholecystitis and Kehr’s sign is usually associated with splenic injury most commonly, ectopic pregnancy, or kidney stones
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Choice A is the gold standard test but often gold standard tests are most often not the initial test done. If the question asked for gold standard, then HIDA would have been correct. Choice B (ER) is used for suspected biliary tract disease. In acute cholecystitis, the stone is in the cystic duct but bile is still able to flow through the bile ducts (this is why there are no long-‐term sequelae in patients who have a cholecystectomy as the bile can still flow without the gall bladder. In biliary duct diseases, patients usually develop jaundice with the blocking of the biliary tract. Choice D (abdominal X ray) would be useful for other disorders, such as small bowel obstruction but most stones are radiopaque (since they are made of cholesterol) so won’t show up often on abdominal X ray and radiographs won’t show the details that can be seen on ultrasound. Choice E (PT and albumin levels) is helpful if end stage liver disease is suspected. QUESTION 4 Choice A (Lansoprazole 30mg + amoxicillin 500mg + clarithromycin 500mg) triple therapy is the mainstay of H-‐pylori peptic ulcer disease. Choice B can be used for H. pylori negative disease. Proton pump inhibitors (the “azoles’) are the most effective drugs against acid production. Choice C is an alternative in patients who are penicillin allergic (Metronidazole is substituted). Choice E can also be not to treat peptic ulcers. Misoprostol can be used to prevent recurrence or ulcers particularly in patients with aspirin or NSAID-‐induced ulcers. gastric ulcers are due to decreased protective factors (mucous and bicarbonate). Prostaglandins are responsible for those protective mechanisms and aspirin and NSAID’s exhibit their anti-‐inflammatory effects via prostaglandin inhibition. Misoprostol is a prostaglandin analogue. QUESTION 5 Choice D (Achalasia) is correct. Achalasia is a disorder that causes loss of Aurbach’s plexus at the lower esophageal sphincter area. Auerbach’s plexus secretes nitric oxide (which leads to relaxation of the LES). Without Auerbach’s plexus, there is an increased LES pressure, leading to dysphagia. On a Barium swallow (esophagram), the increased LES tone leads to narrowing of the GE junction and pre narrowing dilation, leading to the classic “bird beak” appearance.
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Choice A (Zenker’s) is an out pouching of the pharyngoesophageal pouch, which doesn’t affect the lower esophageal sphincter. Choice B (Esophageal Cancer) would show a filling defect around the cancer. Choice C (Nutcracker) is associated with a normal esophagram. Choice E (Diffuse esophageal spasm) would show a “corkscrew” appearance on esophagram due to strong, non-‐peristaltic contractions of the esophagus. QUESTION 6 Choice D (Linear plaques) is correct. Oral thrush is due to candida infection. Candida esophagitis is associated with linear plaques in the esophagus. Choice A (Large superficial ulcers) is associated c CMV esophagitis Choice B (columnar cells in esophagus) is associated with Barrett’s esophagus ( a pre malignant condition to esophageal adenocarcinoma). In chronic reflux esophagitis, the normal squamous cells are replaced by columnar cells from the stomach (which are better to a higher acidic environment). The would have a had a history of GERD. Choice C (small deep ulcers) is classic for Herpes Simplex (HSV) esophagitis Choice E (corrugated rings) is classic for eosinophilic esophagitis QUESTION 7 Choice B is correct. Whenever evaluating hepatitis, the quickest way is to look at surface antigen, surface antibody and the core antibody. I only look at the E if the person has acute or chronic to determine replication. With that said, Chronic hepatitis is defined as the presence of the Hepatitis B surface antigen (HBsAg) and the failure to develop the surface antibodies (HBsAb) in 6 months. Because the person has a chronic infection, the core antibody would be IgG (would have already switched from making the acute IgM antibodies). Choice A describes someone who has a distant resolved infection. They developed the surface antibodies and the core antibodies. Choice C denotes acute viral hepatitis, as the surface antigen is positive and the fact that the core is IgM ( from immunology your body first starts making IgM pentamer antibodies before switching to creating IgG antibodies).
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
Choice D denotes successful Hepatitis B vaccination. The surface antibody is the only positive marker in vaccination. People often confuse this with someone with a distant resolved infection. But think of it this way, if you were infected with hepatitis B, then the virus would be destroyed by the macrophages, producing antibodies to surface proteins but also the viral core, so the core would be positive. Choice E is the classic description of the window period. In someone who is infected, the window period describes the point where the surface antigen is disappearing (leading to a negative HBsAg) but the antibodies are not enough yet to be detected by testing (even though they will eventually increase). So the core IgM antibody is often the sole serologic marker in the window period. HBsAG HBsAB HBcAB HBeAG HBeAB A. NEGATIVE POSITIVE POSITIVE NEGATIVE, NEGATIVE (IgG) B. POSITIVE NEGATIVE, POSITIVE NEGATIVE NEGATIVE (IgG) C. POSITIVE NEGATIVE, Positive POSITIVE, NEGATIVE (IGM) D NEGATIVE POSITIVE NEGATIVE NEGATIVE NEGATIVE E. NEGATIVE NEGATIVE POSITIVE NEGATIVE NEGATIVE (IgM) QUESTION 8 Choice D (hyperactive bowel sounds) is correct. Crampy abdominal pain, nausea vomiting and constipation are classic for a small bowel obstruction. Besides, the abdominal X ray shows the stepladder appearance as fluid and air builds up in the obstructed bowel since it cannot go forward. In the early stages of obstruction, there is hyperactive bowel sounds as the bowel proximal to the obstruction fervently contracts to overcome the obstruction. Later in the disease, hypoactive bowel sounds (choice C) will prevail but the question specifically states early. Choice A (peritoneal) is not specific to small bowel obstruction but can be seen if bowel ischemia is present due to small bowel obstruction or other reasons and can be seen in many disorders and often not seen in early obstruction. Choice B (gurgles about 5-‐15) is considered normal bowel sounds Choice E (sausage shaped mass) is classically associated with intussusception which would be associated with a bowel that contains mucous and blood (“currant-‐jelly”) and vomiting. Which is almost exclusively seen in infants. If it occurs in adults, it is often associated with a lead point such as a malignancy that then causes the telescoping.
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
QUESTION 9 Choice D (hyperkeratosis & perifollicular hemorrhages) is correct. Vitamin C is needed for collagen synthesis. Scurvy (Vitamin C deficiency) is associated with loss of collagen in blood vessels, leading to perifollicular hemorrhages & purpura among the other manifestations. Choice A is classic for pellagra (Vitamin B3/Niacin) deficiency Choice B is classic for vitamin B1/Thiamin deficiency. Ataxia oculomotor paralysis and global confusion is the triad of Wernicke’s encephalopathy. Choice D (Looser Lines) are associated with adult onset vitamin D deficiency (Osteomalacia). Choice E ocular-‐oral-‐genital involvement is classically associated with riboflavin (Vitamin B2) deficiency. QUESTION 1O Choice C (Esophageal adenocarcinoma) is correct. Chronic acidic contents in the esophagus of someone with longstanding GERD will develop Barrett’s esophagus (Choice A), the precursor to esophageal carcinoma. The fact that he had dysphagia especially to solids, weight loss and anemia make malignancy the likely cause. Choice B (diffuse esophageal spasm) is a motility disorder, so both solids and liquids will cause spasm of the esophagus. The patient will often complain of odynophagia, classically it’s a stabbing chest pain that is worse with hot or cold foods AND liquids. Choice D (Squamous cell carcinoma) is usually seen not in the context of GERD but more so in patients who drink or smoke (this patient does neither), making Choice C the better answer. Choice E (Mallory Weiss Tears) are due to repeated vomiting or retching causing superficial mucosal tears. The usually develop signs of bleeding if they are symptomatic. PHOTO CREDIT Achalasia: By Farnoosh Farrokhi, Michael F. Vaezi. [CC-‐BY-‐2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons Small Bowel obstruction: By James Heilman, MD (Own work) [CC-‐BY-‐SA-‐3.0-‐2.5-‐ 2.0-‐1.0 (http://creativecommons.org/licenses/by-‐sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Chapter 3 Question Bank – GASTROINTESTINAL -‐ www.pancepreppearls.com Dwayne A. Williams
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