2013 GASTROINTESTINAL

SUMMER REVIEW
Barbara D. Bosch, M.D.
References for USMLE Step 1-format questions (with modifications):
Catalano E.
Appleton
&
Lanqe
Review of General
Pathology.
4th ed. McGraw Hill Medical, 2003.
Fenderson BA, Strayer DS, Rubin R, Rubin E. Illustrated Q&A Review of Rubin's
Pathology.
2nd
ed. Lippincott Williams & Wilkins, 2011.
Goldberg J.
Lanqe
Practice Tests USMLE
Step
1. 2nd ed. McGraw Hill Medical, 2006.
Kettering JD, Fletcher HM. PreTest
Microbiology.
12th ed. McGraw Hill Medical, 2007.
King MW.
Lanqe
Q&A USMLE
Step
1.
6,h
ed. McGraw Hill Medical, 2008.
Klatt EC, Kumar V. Robbins and Cotran Review of
Pathology.
3rd ed. Saunders Elsevier, 2010.
Klein RM, Enders GC. PreTest
Anatomy. Histology
& Cell
Biology.
3rd ed. McGraw Hill Medical,
2007.
Le T, Klein J, ShivaramA. First Aid Q&A for the USMLE
Step
1. McGraw Hill Medical, 2007.
Le T, Krause K, Klein J, Shivaram A. First Aid Cases for the USMLE
Step
1. McGraw Hill Medical,
2006.
Mufson M. PreTest
Pathophysiology.
3rd ed. McGraw Hill Medical, 2005.
PreTest Clinical
Vignettes
for the USMLE
Step
1.
4,h
ed. McGraw Hill Medical, 2008.
2013 Gl Summer Review; Barbara D Bosch. MD page 2
A 34 year-old man comes to the emergency department complaining of the sudden onset of vomiting
and epigastric abdominal pain radiating to the back. On physical examination, the patient is afebrile
and has abdominal tenderness; decreased bowel sounds are noted, as is diffuse bruising that he
describes as having appeared suddenly. He also reports continuous epistaxis. Laboratory tests show
a slightly elevated WBC count, thrombocytopenia, increased amylase and lipase activity, increased
prothrombin time (PT) and partial thromboplastin time (PTT), and the presence of fibrin split products.
An abdominal ultrasound performed at the bedside shows a dilated common bile duct. Which of the
following is the most likely etiology of this patient's abnormal coagulation profile?
A. abdominal aortic aneurysm
meag+\,
20?
acute pancreatitis
-
Vv
*
y*
*
C. appendicitis
FK?*> . V
?
\
'
,*
D. gastric ulcer
\
2
!'*>.*,
W
E. gram-negative sepsis
boA

Jf?
Inthe H&E-stained photomicrograph, the arrow points to which of the
following specific structures?
central (hepatic) vein
hepatic artery
5? portal vein
D. sinusoid
E. space of Disse
On the day of the BaL*aaBrcafcQn-in pathology, a 26 year-old medical student notices that her
sclerae have a sfightyellowish color. She has never had a major illness. On physical exam, there are
no significant findings other than the mild scleral icterus. Laboratory studies reveal a total bilirubin of
4.9 mg/dL (normal 0.1-1.0 mg/dL) with a direct bilirubin of 0.8 mg/dL (normal 0.0-0.3 mg/dL). The
scleral icterus resolves within 2 days. Which of the following conditions is most likely to produce
these
findings?
IV
/
A. acute hepatitis A virus infection

y
\
l
B. Dubin-Johnson syndrome
hST
& n
tQ)
Gilbert syndrome

T*
D. ingestion of acetaminophen
-
<&
Ar\W- &bt*-K/)
<
E. primary biliary cirrhosis
--
k>o>

A 60 year-old woman presents to the physician with

painlesy?eddish-brown
blood in heTstooT) Initial
laboratory tests show the following results:
hematocrit: 33% (normal 36-46%)
hemoglobin: 11g/dL (normal 12-16 g/dL)
mean corpuscular volume: 73 pm3 (normal 80-100 pm3)
white blood cell count: 8,000/mm3 (normal 4,500-11,000/mm3)
platelet count: 200,000/mm3 (normal 150,000-400,000/mm3)
Which of the following is the most important next step in the management of this patient?
A. abdominal plain films
colonoscopy
C. CT scan of the abdomen
D. esophagoduodenoscopy
E. pelvic ultrasound
A patient presents to the emergency room withTpper Gl
bleeding"!
Administration of an agonist/
analog
of which of the following agents would inhibit
gastric, ar.id
spr.rpfinn?
*
/K.
acetylcholine
gastrin
-6T histamine
pepsin
somatostatin

i
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 3
A2year-olchild
presents
with_a history ofeonataT
)7nchT
UJ1CV
_
_
_
_ _
as well as
aQhronic
cougand
SluincgFironirdiafrhea
frjthliqhlcolored Joul-smelling stools. A
deTiciency
of
which of the following vitamins could develop?
A. ascorbic acid
B. folate
C. niacin
retinolCvi*
Ay
E. riboflavin
F. thiamine
d\
~
C-Vk-oAWLXj*

You recommend a colonoscopy to a 50 year-old patient. He agrees, but wants you to describe the
procedure and potential risks and complications. You explain that the goal of the procedure is to look
at the entire length of the large intestine with a flexible fiberoptic colonoscope and to biopsy any
observable lesions. You tell him that there is a small risk of perforating the bowel, especially when the
colon takes a sudden turn or twists on itself at regions where it is intraperitoneal rather than attached
to the posterior abdominal wall (retroperitoneal). With your knowledge of anatomy, which of the
following regions of the large intestine pose the greatest risk for perforation to the gastroenterologist?
A. ascending colon, transverse colon and descending colon
B. descending colon, sigmoid colon and rectum
yC> hepatic flexure, splenic flexure and sigmoid colon
D. hepatic flexure, transverse colon and splenic flexure
E. splenic flexure, descending colon and sigmoid colon
A hepatitis panel is ordered for a 27 year-old woman as part of a routine workup for abdominal pain.
Results of serologic testing are negative for HBeAg and HBsAg, but positive for HBsAb and IgG
HBcAb. Which of the following is the appropriate conclusion?
The patient has been exposed to hepatitis B and has completely recovered.
B. The patient has been exposed to hepatitis B and is in the acute disease phase.
C. The patient has been exposed to hepatitis B and is in the window phase.
D. The patient has been exposed to hepatitis B but was not infected.
E. The patient has been exposed to hepatitis B and is now chronically infected.
F. The patient has been successfully vaccinated for hepatitis B.
An overweight, 46 year-old man has complained of heartburn for the
past
is pr
ears. A photomicrograph from a biopsy of his lower esophagus
vided. Which of the following is the most likely diagnosis?
f
Barrett esophagus
Candida esophagitis
C. herpes esophagitis
D. Plummer-Vinson syndrome
E. viral esophagitis
A 67 year-old woman has experienced severe nausea, vomiting, early
satiety, and a 9-kg weight loss over the past 4 months. On physical
examination, she has mild muscle wasting. Upper gastrointestinal
endoscopy shows that the entire gastric mucosa is eroded and erythematous. Upper gastrointestinal
imaging studies reveal that the stomach is small and shrunken. Which of the following is most likely
to tie
founon histologic examination of a gastric biopsy specimen?
jlffi
chronic atrophic gastritis
B. granulomatous inflammation
t

Q
C. intestinal-type adenocarcinoma

D. parietal cell hyperplasia

TV\r~*
0
signet-ring cell
adenocarcinoma,
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 4
Which one of the following is most likely to be present within the smooth endoplasmic reticulum of
hepatocytes?
v
--
-
A. albumin
cholesterol
_

C. fibrinogen
D. glycogen
* ~'a
E. hydrogen peroxide
-
lpcowi<rvvfv_SL
A 67 year-old retiree was employed for many years in the plastics industry where he was exposed to
vinyl chloride. This industrial exposure has increased his likelihood of developing which of the
following hepatic lesions?

J
A. adenoma
'
*
angiosarcoma (/VWfc<>rLr
S-JoV-xjpe) E>i\ia/Wf&4
C. fibroma

-
-
-

D. focal nodular hyperplasia

E. hepatocellular carcinoma

A 27 year-old man has had intermittent cramping abdominal pain and low-volume diarrhea for several
weeks. On physical exam, he is afebrile; there is mild lower abdominal tenderness. A stool sample is
positive for occult blood. The symptoms subside within a week. Six months later, the abdominal pain
recurs with perianal pain. On physical exam, there is now a perirectal fistula. Colonoscopy shows
many areas of
rr\6osal edem5lael-ntC5ration1
alternating with normai-appe
Microscopic examination of a biopsy specimen trom an ulberated area sftows-a-patcbyrcdteand
chronic inflammatory cell infiltrate, crypt abscesses and several non-necrotizing granulomas. Which
of
thejgwing disease processes is most likely?

o
\_
\ \
p
Crohn disease
-
ischemic colitis
pseudomembranous coliti

--

-
-
arcoidosis
cerative colitis
A 55 year-old man visits his family medicine physician complaining
of bloating, cramping abdominal pain, and diarrhea with excessive
flatulence several hours after ingestion of milk or dairy products.
He says that he used to enjoy milk and dairy products without any
problems, but now eating them causes him abdominal distress. In
this disorder, the area shown by the arrows would have a decrease
in whicfrof the following?
fivV*

A. active transport of glycerol '

>
B. glucose/galactose transporter activity .
"
i'.jr
C. passive diffusion of monosaccharides
w'fi
p
specific disaccharidase activity
E. uptake of triglycerides by endocytosis
*
f . A
A 49 year-old man presents to the emergency department corriplaining that "my skin has turned
yellow". Physical examination reveals the man is significarffljaundicedTTe
has no abdominal pain
and has aSecjative MuroWslOaii The physician is concerned that he can feel the patient's
gallbladder and orders a CT scan. What is the most likely cause of this patient's jaundice?
A. acute hepatitis

choledocholithiasis /
cholelithiasis /
pfr
kux>tPWck t-Jr "v\
hemolytic anemia I
~
pancreatic
carcinoma
lv
I
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 5
Inthe accompanying photomicrograph of an H&E-stained tissue section,
the structures indicated by arrows are which of the following?
A. clusters of hepatocytes
B. intralobular ducts
C
islets of Langerhans
D. parasympathetic ganglia
E. serous acini
A 19year-old woman is bothered
by<ytreobat rest,
which becomes
progressively worse over theJiexL6jrionths. She begins to act strangely
and is diagnosed with an<acute
psvchQsIs>On
physical exam, she has sligh<s5eraHete?us.
A slit-
lamp examination shows corneal Kayser-Fleischer rings. Laboratory studies show an elevated total
and direct bilirubin. Which of the following additional serologic test findings is most likely to be found
in this patient?

A. decreased alphaantitrypsin level

decreased ceruloplasmin level
C. increased ferritin level
D. positive antimitochondrial antibody
E. positive HBsAg
Patients with hereditary nonpolyposis colon cancer (HNPCC) have genes with microsatellite
instability; that is, many regions containing abnormal, small loops of unpaired DNA. This is a result of
a mutation affecting which of the following?
A. base excision repair
B. chain break repair
C. depurination repair
i\Q). mismatch repair
E. nucleotide excision repair
Some Asians and Native Americans may flush and feel ill after drinking small amounts of ethanol in
alcoholic beverages. This reaction is due to genetic variation in an enzyme that metabolizes the liver
metabolite of alcohol, which is which of the following?
// acetaldehyde

B. acetone
C. glycerol
D. hydrogen peroxide
E. methanol
A 1 year-old child recently emigrated from Africa exhibits intermittent diarrhea, pallor (pale skin),
extreme tenderness of the bones, "rosary" of lumps along the ribs, nose bleeds, bruising over the
eylfds, and blood in the urine. Which of the following is the most likely cause?
deficiency of niacin due to tryptophan-poor food sources
CLBjTeficiency
of vitamin C because of reliance on a milk-only diet
deficiency of vitamin Ddue to darker skin pigmentation and poor sun exposure
"*l).
deficiency of vitamin K because of neonatal deficiency and continued poor nutrition
E. hypervitaminosis A due to maternal ingestion of beef liver during pregnancy
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 6
A 45 year-old woman presents with intermittent episodes of epigastric pain and is found to have
gallstones on ultrasound. However, she is not jaundiced. During exploratory surgery, one stone is
found to be obstructing a duct. In view of her symptoms, where is the most probable location of the
obstruction?
A. ampulla of
\Zater~~p<
l common bile duct ->>

0
C. common heoatic duct

C. common hepatic duct

D. cystic duct
-t>duct
of Santorini
--
rx-rn
Over the past 3 months, a 41 year-old man has noticed that his skin has become progressively more
yellow. On physical exam, he is afebrile but has scleral icterus and generalized jaundice. Laboratory
studies show a total serum bilirubin of 8.9 mg/dL (normal 0.1-1.0 mg/dL) with a direct bilirubin of 6.8
mg/dL (normal 0.0-0.3 mg/dL). Serum ALT and AST levels are normal. A liver biopsy shows
histologic features of sclerosing cholangitis. Which of the following diseases is most likely to coexist
with the liver disease?
A. celiac sprue
B. chronic pancreatitis
C. Crohn disease
D. diverticulosis
ulcerative colitis
A 22 year-old woman has had several episodes of aspiration of food associated with difficulty
swallowing during the past year. A barium swallow shows markeoreiobhaaeal dilation abovS the
leybl of thedower esophageal
sphincteft
A biopsy specimen from the lower esophagus shows an
sence of the
mventprir.
gangTlgfTATHat
js
the most likely diagnosis?
achalasia
B. Barrett esophagus
C. Boerhaave syndrome
D. Plummer-Vinson syndrome
E. Schatzki ring
A 55 year-old man presents with generalized back pain. X-ray
examination of the spine reveals two wedged thoracic vertebrae,
T7 and T8. He is found to be anemic with a normal peripheral
blood smear. However, examination of his bone marrow shows
an increased number of the type of cells indicated by arrows in
this photomicrograph of the small intestine. These cells
synthesize which of the following?
collagen
B. heparin and histamine
C. histaminase
(> IgA
E. myeloperoxidase
A 3 week-old boy presents to his pediatrician because his mother has noticed that he "looks yellow".
On questioning, she elaborates that the jaundice began several days after birth and has been
associated with dark urine and acholic stools. Laboratory studies show a direct bilirubin level of 5.0
mg/dL (normal 0.0-0.3 mg/dL) and a total bilirubin level of 5.5 mg/dL (normal 0.1-1.0 mg/dL). Which
of the
following
is the most likely diagnosis?
- \oMt\ihK\
jQ/ <3congenital extrahepatic biliary atresia
- ju
Al
V Crigler-Najjar syndrome type I"1
C. Gilbert syndrome C. Gilbert syndrome
D. hereditary spherocytosis
E. physiological jaundice
i
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 7
A 25 year-old man with acquired immunodeficiency disease (AIDS) has malabsorption, chronic
abdominal pain, low-grade fever, and nonbloody diarrhea. Infecal smears, large numbers of oocysts
containing four sporozoites are observed. Which of the following organisms is the most likely etiologic
agent?
Cryptosporidiumparrum
/ B. Entamoeba histolytica
j
C. Giardia lamblia
\J D. Taenia solium
E. Toxoplasma gondii
A 30 year-old woman sees her physician because she has had diarrhea and fatigue, as well as a 3-kg
weight loss over the past 6 months. On physical examination, she is afebrile and has mild muscle
wasting, but her motor strength is normal. Laboratory studies show no occult blood, ova or parasites
inthe stool. A biopsy specimen from the upper jejunum is obtained. The patient is placed on a
special diet with no wheat or rye grain products. This dietary change produces dramatic
improvement. Which of the following microscopic features was most likely seen on the biopsy
specimen?
A. crypt abscesses
/

B. foamy macrophages within the lamina propria

I
/ C. lymphatic obstruction
\y
D. non-necrotizing granulomas
villous blunting and flattening
A 26 year-old man has recently aten raw
oystersjon
three
occasions1
The patient has always been
healthy, but now has the sudden onset of fatigue, loss of appetite, nausea, vomiting, abdominal pain,
and fever. Which of the following viral pathogens is most likely responsible for this clinical
Presen,aj9~s
/ff hepatitis B virus
rotavirus
A 63 year-old man who had worsening congestive heart failure with cardiac dysrhythmias in the last
year of his life died of pneumonia. At autopsy, his pancreas is small and hard. Microscopic
examination shows extensive atrophy of the acini with abundant collagenous interstitial fibrosis, but
the islets of Langerhans appear normal. Inspissated proteinaceous secretions are present in
branches of the pancreatic duct. The heart weighs 500 g (normal 300-350 g), and all four chambers
are dilated. What condition is most likely to account for these findings?
blunt trauma to the abdomen
B. cholelithiasis
t
chronic alcoholism

diabetes mellitus
E. hypercholesterolemia
A 42 year-old woman has to undergo(emergency choiecystecto
fo
due to
intense
surgery is indie
wing arrows?
$
\
C. 3
/L
T 4
5
'he structure to be removed during
Accompanying radiograph by which of the
2013 Gl Summer Review; Barbara D Bosch, M.D. page 8
A full-term neonate presents to the pediatrician with failure to pass meconium. Digital examination of
the rectum results in a gush of retained fecal material. Which of the following is the most likely
diagnosis in this infant?
carcinoma of the colon
Chagas disease
Hirschprung disease
imperforate anus
necrotizing enterocolitis
of
Plasma
The figure to the right shows a gastric parietal cell with selected
membrane transporters and channels. What do X, Y and Z
represent?
Y Z
IT K+
K* IT
CI'
hco3-
Na+ IT
IT K+
Prlliptrjt
lll
HCO-s
atr
Lumen
C. H
D. K+
E. Na+
The symptoms of thiamine deficiency were first described over 4000 years ago. In adults, these
symptoms commonly include polyneuropathy of the distal extremities, resulting in paresthesias and
motor dysfunction. In addition to neuropathy, how else can isolated thiamine deficiency present in
adults?
A. chronic infections .

B. diarrhea, dermatitis and dementia

C. Tjerirritability, seizures and jaundice

peripheral edema and congestive heart failure

__
E. renal failure
An obese 43 year-old white woman presents to the emergency department with right upper quadrant
pain, fever and jaundice. Abdominal examination reveals right upper quadrant tenderness without
peritoneal signs. Endoscopic retrograde cholangiopancreatography shows several stones in the
common bile duct. Laboratory testing reveals a WBC count of 14,200/mm3 (normal 4,500-
11,000/mm3), with 74% segmented neutrophils, and a serum amylase level of 78 U/L (normal 25-125
U/L). Which of the following is the most likely diagnosis for this patient?
A. acute appendicitis
acute pancreatitis
acute viral hepatitis
bacterial cholangitis
cholesterolosis
A
E.
Recanalization of the bile duct after the 13th week of development allows for bile produced in the liver
to reach the duodenum.
Howeve<jf7ecanalizatjon fails to occi)f-aothis cannot be corrected
surgically, the affected infant will needa liver transplant. Uurihg embryologic development, the liver
arises from which of the following?
I
_ _
foregut
B.
hindgutVj(A>r*juM
C. midgut"
D. yfJIeuroperitoneal membrane
/septum
transversum
5>
I
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 9
A 36 year-old woman is inthe sixth month of her pregnancy, but she is unsure of her dates because
she was taking oral contraceptives at the time she became pregnant. She experiences the sudden
onset of severe abdominal pain. On physical exam, she is afebrile and normotensive. There is right
upper quadrant tenderness on palpation. An ultrasound scan of the abdomen shows a well-
circumscribed, 7-cm subcapsular hepatic mass. Paracentesis yields bloody fluid. At surgery, the
mass in the liver, which has ruptured through the capsule, is removed. The remaining liver appears
unremarkable. Which of the following is the most likely diagnosis?
cholangiocarcinoma*
3

fibrolamellar hepatocellular carcinoma

hepatic adenoma osa

hepatocellular carcinoma

metastatic carcinoma

testae., \ VvesfcH

I
C\r
A 32 year-old man presents with diarrhea and symptoms of peptic ulcer disease. Endoscopy reveals
two ulcers, one in the first portion of the duodenum and one in the mid-duodenum. However, they do
not respond to the usual peptic ulcer treatment programs. The most likely explanation for the findings
in this patient is which of the following?
-autoantibodies
to intrinsic
factor
ectopic hypersecretion of gastrin
gastric mucosal atroohv
_
c.il

Menetrier disease
pressure ulceration from
y. vascular abnormality
A pathologist views the tissues inthe
accompanying photomicrographs in a
biopsy specimen. She determines that
the tissues are normal. The presence
of both of these tissues indicates that
the sample was taken from the region
of the junction between which of the
following?
Ar"mouth and esophagus
/& esophagus and stomach
itomach and duodenum
Ileum and colon
rectum and anus
A Syarlold manjresents to the clinic with
ffieral
icterusipatosplenomegaly$|scites>and
a
history of episodes of
feundice
over'the oast
th'fgg"vear&7
He was involved in an auto accident when
A LTrVteT
he was 21, for which he require<(surge?nc(blood
transfusion
His laboratory results are as
follows:
aspartate aminotransferase (AST): 734 U/L (normal 8-20 U/L)
alanine aminotransferase (ALT): 846 U/L (normal 8-20 U/L)
direct bilirubin: 6.1 mg/dL (normal 0.0-0.3 mg/dL)
indirect bilirubin: 7.6 mg/dL (normal 0.1-0.7 mg/dL)
Assuming a viral etiology, which of the following is the most likely cause of this patient's illness?
hepatitis A
B.
hepatitis B
hepatitis C
hepatitis D
hepatitis E
2013 Gl Summer Review; Barbara D. Bosch, M D. page 10
A 43 year-old man living in Mexico presents to a clinic complaining of constipation and stomach pains
for several months. On cardiac examination, the physician discovers a laterally displaced point of
maximal impact. Radiological studies reveal pulmonary congestion, cardiomegaly and megacolon.
Sadly, the physician can offer the patient only symptomatic treatment. What insect is the most likely
route of transmission for this patient's illness?
Anopheles mosquito
Ixodestick v
reduviid bug
sandfly
Ef.
tsetse fly
/yfvT
A 45 year-old homeless man developed severe abdominal pain and was
transported to the emergency roomwhere he was found to be hypotensive and
in shock. He was unresponsive to therapy and died two days later. Based upon
this history and the accompanying photomicrograph, which of the following most
likely
initiated
this sequence of events?
A
acute viral hepatitis
jffi) acute pancreatitis
,
Spsophageal
varices
%
-ir[hosis
, y-f.
splenic infarct

A\V-

"V
A 35 year-old man has had an outbreak of pruritic lesions over the extensor surfaces of the elbows
and knees during the past month. He has a history of malabsorption that requires himto eat a special
diet, but he has had no previous skin problems. On physical examination, the lesions are 0.4 to 0.7-
cm vesicles. A 3-mm punch biopsy of one of the lesions over the elbow is performed. Microscopic
examination of the biopsy specimen shows the accumulation of neutrophils at the tips of dermal
papillae and formation of small blisters owing to separation at the dermoepidermal junction.
Immunofluorescence studies performed on this specimen show granular deposits of IgA localized to
the tips of dermal papillae. Laboratory studies show serum antigliadin antibodies. What is the most
likely diagnosis?
bullous pemphigoid

---

,dermatitis
herpetiformis
C. erythema multiforme /
izscCG_,\7Z_
D. granuloma annulare
E. pemphigus vulgaris
The branching structures shown in
micrograph of hepatocytes are involved in which of the
following?
i&R. bile flow
B. blood flow
C. communication between hepatocytes
D. preventing substrates from passing between
adjacent hepatocytes
E. spot welds between hepatocytes
i
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 11
A 56 year-old man who is a health care worker presents to his physician with vague abdominal
discomfort. A physical examination reveals a tender liver, palpable to 6 cm belowthe costal margin,
and scleral icterus. His laboratory studies are significant for an aspartate aminotransferase (AST)
level of 200 U/L (normal 8-20 U/L), an alanine aminotransferase (ALT) level of 450 U/L (normal 8-20
U/L), and an alkaline phosphatase level of 245 U/L (normal 20-70 U/L). A CT scan of the abdomen
shows a dominant solid nodule in the liver. The tumor marker
mjst likely to be elevated inthis patient
is also agobd indicator of which of the following malignancies?
Sh. choriocarcinoma .
//
colorectal carcinoma
clSK
SCuroZstoma QtU,
prostatic carcinoma
-V-n
n
.
Vo,k
sac tUmor
yf

A 28 year-old recently divorced man with no significant past medical history presents with progressive
lower abdominal pain and cramping over the past 4 days, which are relieved by defecation. He has uVir
suffered from
substantigkgTooand mucoid
diarrhea\jiring
th'g
time. His
temperature
is
Lab studies reveal
arylevited WBC
courSt and'tgiTerythrocyte
sedimentation
Sigmoidoscopy reveaWextensrveTectaTand sigmoid hyperemia aTid edema, numerous superficial
ulcerations, and small focal mucosal hemorrhages, many of which have suppurative centers. These
B. Crohn disease
C. cytomegalovirus enterocolitis
hP&9*0
A
pseudomembranous colitis
-erative colitis
A 30 year-old man seeks help because
heJ]tesLiLrfeels(full
afterating55lcsmal>
<SmhTorfoottrHe
is diagnosed with
(gdeiavlrrqastric emptvihSr
hormones
has at physiological levels the strongest effect in inhibiting gastric emptying?
iholecystokinin
gastrin
insulin
motilin
xf? pancreatic polypeptide
flf.
secretin
A patient presents with an acute abdomen including fever, marked abdominal distention, acidosis, and
leukocytosis. Laparoscopy reveals that large portions of the small intestine are necrotic and, as a
coi sequence, the entire ileum is resected. It is expected that very soon after the surgery the patient
wil
haveonsiderable
problems resulting from the malabsorption of which of the following?
bile acids
*\J
iron
fit
protein
sodium
s%l.
vitamin
B12
.\ei
VvJfOfcVv
2013 Gl Summer Review; Barbara D. Bosch. M.D. page 12
A 39 year-old woman presents with dyspnea, fatigue, pallor, and tachy
cardia. Laboratory results reveal a hematocrit of 32% (normal 36-44%),
a red cell mean corpuscular volume of 102 fL (normal 78-98 fL), and a
vitamin
B12
level of 95 pg/mL (normal 200-900 pg/mL) due to impaired
absorption. Autoantibodies are detected to a cell type which produces
intrinsic factor. Referring to the accompanying diagram, in which region
woulft
those cells be found?
V
A 44 year-old woman has noticed increasingly severe fatigue and generalized pruritus for the past 8
months. Serum levels of alkaline phosphatase and cholesterol are elevated; antimitochondrial
antibody titer is elevated, but ANAs are not present. The serum total bilirubin concentration is slightly
elevated. A liver biopsy is performed revealing granulomatous destruction of small intrahepatic bile
ducts. Which of the following conditions is most likely?
_
A. autoimmune hepatitis
B. choledocholithiasis <*>
'n.rve'W.r.oA ft*
C. hepatitis B
primary biliary cirrhosis
E. primary sclerosing cholangitis
F. Wilson disease
w
VA

A 66 year-old man presents with a 3-month history of intermittent

dysphagia that has now become constant and is accompanied by
pain and weight loss. X-rays of the esophagus with barium
swallow show structural and filling defects, and reduced peristalsis.
A biopsy is taken, from which a representative photomicrograph is
provided. The best diagnosis is which of the following?
fd'
adenocarcinomaCTT0*9
-
BrBarrett
esophagus
~

Candida esophagitis
fibrous stricture
<B
squamous cell carcinoma
A 24 year-old woman comes to the physician complaining of recurrent upper abdominal pain that gets
worse with food intake. She denies any history of vomiting, nausea or diarrhea. A urease breath test
is positive. Which of the following organisms is most likely responsible for this woman's symptoms?
. A. Clostridiumdifficile
\/
B. Escherichia coli 0157:H7 v
o
Helicobacter pylori kAn
LA
-x
D. Proteus mirabilisUTl
>
Oc\\zo\L
E. Vibrio cholerae
0
-v
ajHA//,**
-
,
.
>*
*
v

at; >
u
,l*
v
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 13
inaseVsefes
-
**#*&*>,&
-'
1>. . J.
_

v Iv
r-'

r

-
'--.
C-Jysozyme
mucus and
HCOV
"

pepsinogen
A 52 year-old woman is referred to a gastroenterologist for persistent
abdominal
is performed.
of normal tissue
structures
A.
B. enterokina;
An 18 year-old woman presents with a one-week history of
fever
and malaise>She has mildjaundice
and a (ffightly Hemoglobin is 13.8 g/dL (normaM3M(fg/dL);
WBC count is
13,000/mm (normal 4,500-11,000/mm3). SeruiTLJubinJs
mg/dL (normal 0.1-1.0
mg/dl_) and is 95% unconjugated
bilirubinLiver enzyme
tests arenona
Which of the following is
the most likely cause of this patient's signs and symptoms?
jC
alcohol abuse
c\
decreased glucuronyl transferase
hemolysis
<X
\ iL
increased lactate dehydrogenase
NutXZr
E. obstruction of bile flow
A 19 year-old man is advised by other family members to see his physician because a genetic
disease has been detected in other family members. On physical examination, a stool sample is
positive for occult blood. A colonoscopy is performed, which reveals hundreds of polyps which are
found to be adenomatous polyps. Molecular analysis of this patient's normal fibroblasts is most likely
to show a mutation in which of the following genes?
/4pmvc
v
c. p53
D. RAS
E. VHL
A 50 year-old man develops nonbloody watery diarrhea while working as an aid worker in a refugee
camp
in Central Africa. A stool smear shows no white blood cells. He subsequently develops
clecfroivte abnormalities)eading
ttfjlr&iac and renal failuTg) Which of the following organisms is
mosUejTresponsiblefor this
mas
enterocolitis? ,

/K
Bacillus cereus
.SWiI
Clostridiumdifficile

X
Helicobacter pylori

JZ-Salmonella species
-
&s*<Vv<3ey-
E. Vibrio cholerae ,
Approximately 6 months ago, a 59 year-old man developed dull, continuous abdominal pain that
radiated to the right upper quadrant and was relieved by bending forward. He has also had recurrent
thrombophlebitis. He now develops jaundice. Of the following, which is the condition that most likely
all of these findings?
alcoholic cirrhosis
cholecystitis
C. cholelithiasis
pancreatic adenocarcinoma?} ,v
n T\ .
viral hepatitis D
-jthrombof
__explamss
B.
2013 Gl Summer Review; Barbara D Bosch, M.D page 14
Jaundice caused by common bile duct obstruction is usually characterized by which of the following
laboratory findings?
Urine Urine
Bilirubin Urobilinogen
A. t
B. T
-gP
T
D. Normal
E. Normal
F. Normal
T
Normal
1
t
Normal
i
A 13 month-old child is brought to the emergency department after his parents found blood in his
stool. They state that he did not appear distressed at the time, although he now displays some
tenderness to abdominal pressure. Other than this tenderness, there are no significant findings on
physical examination. After performing radionuclide imaging using "mTc pertechnetate, the doctor
makes a diagnosis and recommends surgery to correct the problem. What is the probable source of
this child's condition?
A. blockage of the intestine due to folding of the distal ileum into the proximal colon
B. breakdown of the gastric mucosal barrier with erosion of the underlying mucosa
damage to the intestinal epithelium due to ingestion of coins

ectopic gastric epithelium in a persistent omphalomesenteric duct

E. incomplete bowel rotation resulting in obstruction of the superior mesenteric artery
A 2 year-old girl with a lifelong history of malabsorptive and foul-
smelling diarrhea, weakness and general failure to thrive has just
undergone a small intestine biopsy (see accompanying photomicro
graph). Her parents believe her problems began at 6 months of
age, when she started eating solid foods, but have significantly
worsened over the past few months. The only recent change in her
diet is that she eats a bowl of cereal every morning with her parents
before they go to work. She tried a dairy-free diet a month ago, but
it did not improve her symptoms. Which of the following js the
likely diagnosis?
/yA.
abetalipoproteinemia
/'
>.
celiac disease
cystic fibrosis
pQ- lactase deficiency
viral enteritis
F/Vhipple disease
1
'
'mmm
'
'MS
s-:v
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 15
A healthy volunteer received a continuous infusion of physiological
gastrin concentrations before and after treatment with peptide X. The
production of gastric acid and pancreatic bicarbonate secretion was
monitored before and after administration of peptide X (at arrow).
Peptide X is most likely to have been which of the following hormones?
angiotensin II
cholecystokinin
motilin
secretin
somatostatin
Last': =sf;iJs i FfcMhc
HCDj
B.
C.
E.
aarc*Mlc
HZO
unrc
H
I r~ il
Qutotfl :<p3& v mivci a'xr piflcc
"irr>c imnas'i
Gaffrn
A 53 year-old man who presented to a gastroenterologist with the chief complaint of a 9-month history
of progressively worsening epigastric pain and feelings of early satiety was found on endoscopy to
have an area of thickened rugal folding inthe stomach with a central ulceration. Biopsy revealed the
presence of a monomorphic population of large, poorly-differentiated cells in the lamina propria and
the submucosa, with an accompanying eosinophilic infiltrate and significant destruction of gastric
glands. Histochemical staining for mucin was negative. Based on these findings, what is the most
likely diagnosis?
J\. adenocarcinoma
lymphoma
GrMenetrier disease
oeptic ulcer disease
:ype A chronic gastritis
iWl
(k62 year-old ma with a 25-year history of cigarette smokiha presents
to~fiis primary care physician with a 3-month history of a gradually
enlarging, painless mass in his
jgfcpreznfficular
facial aTtee. Physical
examination demonstrates
<lT-cifCumsci1beS75-cmass-ofthe
(jnpfiifiriefifaSfe; inspectionof the
rrjoutfTreveals
protrusion of me
mas;slntglhe-left4onsillar piltar. Past medical history is significant for
Qaomgeal carclnorTOriTbe-patient's latejorties, which was treated with
surgical excision and radiation. A biopsy of the mass is shown. Based
on this information, what is the most likely diagnosis?
eomorphic adenoma
,/tKrecurrent
laryngeal carcinoma
A 39 year-old man who has had ulcerative colitis for many years now presents with pruritus and
jaundice. Laboratory tests reveal increased levels of total bilirubin and alkaline phosphatase.
Endoscopic retrograde cholangiopancreatography (ERCP) shows a characteristic beading of the bile
ducts. A liver biopsy shows periductal fibrosis with a lymphocytic infiltrate. Which of the following is
tfje most likely diagnosis?
A. ascending cholangitis
B. choledochal cysts
C. polycystic liver disease
D. primary biliary cirrhosis
tTrimary
sclerosing cholangitis
2013 Gl Summer Review; Barbara D. Bosch, M.D. page 16
A 23 year-old man has been complaining of intermittent diarrhea,
fever and abdominal pain for several months. A radiograph of the
small bowel reveals several separatg_areas of luminal narrowing.
A photomicrograph of this patienVCiieal bfopsy is shown. What is
the most likely diagnosis?

-r""
abetalipoproteinemia
*
tvlvAvH
carcinoid tumor
A.
B.
E.
F.
celiac disease
Crohn disease
ulcerative colitis
Whipple disease
,r>;
/'
'
l'

' r .< /i"

Jaundice caused by hemolysis is usually characterized by which of the following laboratory findings?
Urine
Bilirubin
Urine
Urobilinogen
T
T
Normal
Normal
Normal
T
Normal
I
T
Normal
I