Gastroenterology Test 2013
1. A 42 year-old man is evaluated in
follow-up for elevated liver
chemistry tests. He is asymptomatic.
He has a 6-year history of type 2
diabetes mellitus, hyperilipidemia,
and hypertension. His current
medications are metformin,
simvastatin, and lisinopril. He does
not drink alcohol.
On physical exam, temperature is
37.0 C (98.6 F), blood pressure is
130/74 mm Hg, pulse rate is 82/min,
and respiration rate is 14/min. BMI
is 32. Abdominal examination
discloses mild hepatomegaly and
active bowel sounds.
Laboratory studies:
Alkaline phosphatase 90 U/L
Alanine aminotransferase 120 U/L
Aspartate aminotransferase 85 U/L
Total bilirubin 1.1 mg/dL
LDL cholesterol 100 mg/dL
Hemoglobin A1c 7.2%
Iron 75 ug/dL
Total iron-binding capacity 300
ug/dL
Hepatitis B surface antigen:
Negative
Antibody to hepatitis B surface
antigen: Positive
Hepatitis C antibody: negative
Abdominal ultrasound reveals
increased hepatic echo texture
consistent with hepatic steatosis.
Hepatic configuration is otherwise
normal.
In addition to weight loss, which of
the following is the most
appropriate management?
A.
B.
C.
D.
Discontinue simvastatin
Initiate entecavir
Phlebotomy
Serial monitoring of
aminotransferases
2. A 34 year-old woman is evaluated in
an urgent care clinic for a 1-day
history of watery diarrhea and mild
abdominal cramps. She is having four
watery stools per day. She has not
had fever or blood in her stool.
Although she has felt mildly
nauseated, she has been able to stay
hydrated with oral intake. She works
as a banker, and colleagues at work
have had similar gastrointestinal
complaints over recent weeks. She
has no history of recent
hospitalization, antibiotic use, or
medication changes. She has no risk
factors for HIV infection.
On physical examination, temperature
is 36.1 C (97.0 F), blood pressure
is 110/75 mm Hg, pulse rate is
86/min, and respiration rate is
normal. BMI is 24. The mucous
membranes are moist, and there is no
skin tenting. Abdominal examination
reveals mild abdominal tenderness
but normal bowel sounds. There is no
guarding or rebound. A urine
pregnancy test is negative.
Which of the following is the most
appropriate diagnostic test?
A. Clostridium difficile PCR
B. Fecal leukocyte testing
C. Flexible sigmoidoscopy with
biopsies
D. General stool bacterial
cultures
E. No additional studies
3. A 67 year-old man is evaluated in
the emergency department for the
acute onset of severe, diffuse
abdominal pain that began 1 hour
ago. He has a history of
arteriosclerotic cardiovascular
disease, and he underwent threevessel coronary bypass surgery 2
years ago. His current medications
are lisinopril, atenolol,
simvastatin, and aspirin.
On physical examination, temperature
is 36.8 C (98.2 F), blood pressure
is 78/56 mm Hg, pulse rate is
142/min, and respiration rate is
29/min. Abdominal examination
discloses diffuse mild abdominal
tenderness to palpation with no
guarding or rebound and no masses.
Laboratory studies reveal a
leukocyte count of 14,000/uL, a
bicarbonate level of 14 meq/L, and
an elevated serum lactate level. CT
scan shows small-bowel wall
thickening and intestinal
pneumatosis.
Which of the following is the most
likely diagnosis?
A. Acute mesenteric ischemia
B. Crohn disease
C. Intussusception
D. Pancreatitis
4. A 57 year-old woman is evaluated in
follow up for uncomplicated acute
diverticulitis in the sigmoid colon.
Her inpatient treatment included
intravenous antibiotics, and
resulted in defervescence, symptom
improvement, and resumption of oral
diet within 72 hours. She was then
discharged home from the hospital on
a 7-day course of oral antibiotics.
She is doing well and is currently
asymptomatic.
Which of the following is the most
appropriate next step in management?
A. Colonoscopy
B. Elective segmental colon
resection
C. Probiotic therapy
D. No additional testing or
therapy
5. A 35 year-old man is evaluated for a
2-year history of intermittent chest
pain. The pain is retrosternal, lasts
for seconds to minutes, is unrelated
to exertion, and does not radiate. It
is occasionally associated with
swallowing. He reports intermittent
dysphagia to solids and liquids. He
denies any reflux symptoms or weight
loss. He does not have any risk
factors for cardiac disease.
Physical examination is
unremarkable. Upper endoscopy is
normal. A barium swallow is shown.
Which of the following is the most
likely diagnosis?
A.
B.
C.
D.
Achalasia
Diffuse esophageal spasm
Eosinophilic esophagitis
Schatzki ring
6. A 19 year-old woman is evaluated
for a 3-month history of
progressively worsening diarrhea,
abdominal pain, and weight loss.
Her brother was diagnosed with
Crohn disease at age 16 years.
On physical exam, temperature is
37.4 C (99.3 F), blood pressure is
110/65 mm Hg, pulse rate is 90/min,
and respiration rate is 20/min.
Abdominal examination reveals
tenderness to palpation in the right
lower quadrant with no guarding or
rebound tenderness. Perianal and
rectal examinations are normal.
Colonoscopy discloses evidence of
moderately to severe active Crohn
disease involving the terminal
ileum; the diagnosis is confirmed
histologically. Magnetic resonance
enterography shows active
inflammation involving the distal 20
cm of the ileum without other bowel
inflammation or obstruction. There
is no evidence of abscess or
phlegmon.
Which of the following is the most
effective maintenance treatment?
A. Ciprofloxacin and
metronidazole
B. Infliximab
C. Mesalamine
D. Prednisone
E. Surgical resection
7. A 45 year-old man is admitted to
the hospital for new-onset right
upper quadrant pain, ascites,
fever, and anorexia. His medical
history is notable for hypertension
and alcoholism. His only medication
is hydrochlorothiazide.
On physical exam, temperature is
38.1 C, (100.6 F), blood pressure
is 110/50 mm Hg, pulse rate is
92/min, and respiration rate is
16/min. BMI is 24. Spider angiomata
are noted on the chest and neck.
The liver edge is palpable and
tender. There is abdominal
distention with flank dullness to
percussion.
Laboratory studies:
Alkaline phosphatase 210 U/L
Alanine aminotransferase 60 U/L
Aspartate aminotransferase 125 U/L
Total bilirubin 6.5 mg/dL
Creatinine 1.8 mg/dL
The Maddrey discriminant function
score is 36. Ultrasound discloses
coarsened hepatic echotexture,
splenomegaly, and a moderate to
large amount of ascites. Diagnostic
paracentesis reveals spontaneous
bacterial peritonitis, and
intravenous ceftriaxone is
administered. Upper endoscopy is
notable for small esophageal
varices without red wale signs and
no evidence of recent bleeding.
In addition to continuing
ceftriaxone and starting albumin,
which of the following is the most
appropriate treatment?
A.
B.
C.
D.
Etanercept
Infliximab
Pentoxifylline
Prednisolone\
8. A 76 year-old woman is admitted to
the hospital for melena that has been
recurrent over the past several
weeks. She has not used NSAIDS. She
recently had an upper endoscopy that
demonstrated multiple bleeding
angioectasias within the proximal
duodenum. She has a history of aortic
stenosis and has symptoms of
lightheadedness and dyspnea with
exertion. There is no family history
of a bleeding diathesis. She takes no
medications.
On physical examination, vital signs
are normal. There are no cutaneous
signs of angioectasias.
Cardiopulmonary examination
discloses pulses tardus and an early
systolic murmur heard most
profoundly at the right upper
sternal border. Abdominal exam
discloses no tenderness, masses, or
hepatosplenomegaly.
Laboratory studies reveal a
hemoglobin level of 7.2 g/dL and a
normal INR. A comprehensive
metabolic panel is also normal.
Transthoracic echocardiogram
demonstrates severe aortic stenosis
and normal left ventricular size and
function.
Which of the following is the best
long-term management for this
patient’s gastrointestinal bleeding?
A. Aortic valve replacement
B. Endoscopic treatment of
angioectasias
C. Proton pump inhibitor
D. Systemic estrogen therapy
9. A 55 year-old man is evaluated during
a routine follow-up visit for
compensated cirrhosis. He is
currently asymptomatic. His medical
history is significant for chronic
hepatitis B infection and esophageal
varices. He currently takes nadolol.
On physical exam, temperature is
37.6 C (99.7 F), blood pressure is
120/70 mm Hg, pulse rate is 68/min,
and respiration rate is 16/min. BMI
is 31. Spider angiomata are noted on
the neck and upper chest. The spleen
tip is palpable.
Screening abdominal ultrasound
discloses a nodular-appearing liver,
splenomegaly, and intra-abdominal
venous collaterals consistent with
portal hypertension. A 1.6 cm lesion
is noted in the right hepatic lobe;
the lesion was not present on
ultrasound done 6 months ago.
Which of the following is the most
appropriate diagnostic test to
perform next?
A. Contrast-enhanced triple
phase CT
B. Liver biopsy
C. Repeat ultrasound in 6 months
D. Serum carcinoembryonic
antigen level
10. A 45 year-old man is evaluated for
a 1-week history of non-bloody
diarrhea that occurs 10 times per
day and is accompanied by mild
abdominal cramping. He has a 5-year
history of ulcerative colitis for
which he takes mesalamine.
On physical examination, temperature
is 37.9 C (100.2 F), blood pressure
is 110/80 mm Hg (no orthostatic
changes), and pulse rate is 100/min.
Abdominal examination reveals
hyperactive bowel sounds and mild
diffuse tenderness but no peritoneal
signs.
Laboratory studies:
Hemoglobin Normal
Leukocyte count 23,000/uL
Platelet count Normal
Blood urea nitrogen 15 mg/dL
C-reactive protein 32 mg/dL
Creatinine 1.0 mg/dL
Potassium 2.9 meq/L
An acute abdominal radiograph series
is normal.
Which of the following is the most
appropriate diagnostic test to
perform next?
A. Abdominal CT
B. Colonoscopy
C. Right upper quadrant
ultrasound
D. Stool studies for Clostridium
difficile
11. A 37 year-old woman is evaluated in
the emergency department for the
acute onset of pain after 2 weeks
of bloody diarrhea. The diarrhea
has escalated to 15 times per day.
She has ulcerative colitis that was
diagnosed 2 years ago. She
currently takes azathioprine.
On physical exam, she appears ill.
Following aggressive fluid
resuscitation, temperature is 38.9 C
(102.0 F), blood pressure is 70/40
mm hg, pulse rate is 148/min, and
respiration rate is 35/min.
Abdominal examination discloses
absent bowel sounds, distention, and
diffuse marked tenderness with mild
palpation.
Laboratory studies reveal a
leukocyte count of 16,800/uL.
Abdominal radiograph is shown.
Which of the following is the most
appropriate management?
A.
B.
C.
D.
CT scan
Immediate surgery
Start infliximab
Start IV hydrocortisone
12. A 75 year-old man is evaluated in
follow-up after recent surveillance
endoscopy for Barrett esophagus.
Biopsy from the salmon-colored
columnar segment shows high-grade
dysplasia. His gastroesophageal
reflux disease symptoms are well
controlled with proton pump inhibitor
therapy. His medical history is
significant for New York Heart
Association functional class III
heart failure (ejection fraction
30%). His medications are
pantoprazole, furosemide, digoxin,
metoprolol,enalapril, and
spironolactone.
On physical exam, he is afebrile,
blood pressure is 100/50 mm Hg,
pulse rate is 62/min, and
respiration rate is 12/min; BMI is
35. There is no evidence of jugular
venous distention. Cardiac rhythm is
regular, with a soft S3 at the
cardiac apex. The lungs are clear.
No peripheral edema is present.
Which of the following is the most
appropriate management?
A.
B.
C.
D.
Endoscopic ablation
Esophagectomy
Fundoplication
Repeat endoscopic
surveillance in 3 years
13. A 64 year-old man was admitted to
the hospital 4 days ago for severe,
acute abdominal pain and was found
to have acute mesenteric ischemia.
He underwent massive small bowel
resection, with 180 cm of small
bowel remaining, and his colon was
able to be salvaged. Over the past
4 days since surgery, he has been
on parenteral nutrition with
gradual progression of oral intake.
He has significant diarrhea that
wakes him up at night. He has been
afebrile and has not had recurrent
or worsening abdominal pain. His
medications are low-dose lowmolecular weight heparin,
ciprofloxacin, and metronidazole.
He is also taking loperamide four
times daily.
On physical exam, temperature is
36.2 C (97.2 F), blood pressure is
118/60 mm hg, pulse rate is 68/min
and regular, and respiration rate is
12/min. BMI is 25. Abdominal exam
discloses a large scar from his
recent surgery that is healing well.
Bowel sounds are very active and
there is mild tenderness throughout,
as is expected postoperatively.
Laboratory studies, including serum
electrolyte, glucose, and thyroidstimulating hormone levels, are
normal. Stool cultures and
Clostridium difficile polymerase
chain reaction are normal.
Which of the following is the most
appropriate management?
A. Decrease the lipids in his
parenteral nutrition
B. Increase the loperamide
C. Initiate cholestyramine
D. Initiate omeprazole
E. Stop oral intake
14. A 63 year-old man is evaluated for
long-standing history of
osteoarthritis that primarily causes
pain in the base of the thumbs,
fingers, and left knee. He had a
balloon angioplasty after a
myocardial infarction 10 years ago.
His medications are high-dose
naproxen, non-enteric coated aspirin,
lisinopril, and atorvastatin. He has
tried other medications for his joint
disease, including acetaminophen and
other NSAIDs, but has not had
significant relief. He tried tramadol
for his joint pain but stopped
because of nausea.
The physical examination is
unremarkable except for findings
consistent with osteoarthritis.
Laboratory studies reveal a normal
complete blood count and creatinine
level.
Which of the following is the most
appropriate treatment?
A. Change aspirin to an entericcoated aspirin
B. Change naproxen to low-dose
celecoxib
C. Discontinue aspirin
D. Initiate omeprazole
15. A 68 year-old man is evaluated during
a routine examination. He is
generally healthy and has no
gastrointestinal symptoms. His last
screening colonoscopy 10 years ago
was normal. His mother was diagnosed
with colorectal cancer at age 65
years.
Physical examination is normal.
Colonoscopy to the terminal ileum
discloses a 1.5-cm polyp in the
ascending colon (villous adenoma,
low-grade dysplasia)and a 6-mm polyp
in the sigmoid colon (tubular
adenoma, low grade dysplasia.) The
polyps are completely removed.
Which of the following is the most
appropriate management for this
patient?
A.
B.
C.
D.
Colonoscopy
Colonoscopy
Colonoscopy
Colonoscopy
in
in
in
in
2 to 6 months
1 year
3 years
10 years
16. A 37 year-old woman is evaluated
for diarrhea that has been present
since a presumed food-borne illness
1 month ago. She reports that, at
that time, she had 2 days of
nausea, vomiting, and watery
diarrhea. Although her symptoms
improved after several days, she
continued to have episodic
diarrhea. She has three to four
water stools per day, often
following meals. She has had
excessive flatus and bloating over
the past month. She has not had
nocturnal stools, weight loss,
fever, or obvious blood in her
stool. She has not recently used
antibiotics. Her medical history is
notable for a cholecystectomy 2
years ago.
On physical examination, vital signs
are normal. There is no wheezing.
Abdominal examination discloses
normal bowel sounds and a nontender
abdomen. Rectal examination is
normal. A complete blood count with
differential is normal. Fecal
leukocytes, general stool studies
(including Clostridium difficile,
ova and parasites), and Giardia
antigen are all negative. Stool
sodium is 40 meq/L; stool potassium
is 20 meq/L.
Which of the following is the most
likely diagnosis?
A.
B.
C.
D.
E.
Bile-salt induced diarrhea
Eosinophilic gastroenteritis
Irritable bowel syndrome
Lactose malabsorption
Microscopic colitis
17. A 37 year old man is evaluated for
a 1-month history of stool leakage.
In the past week he has developed
perianal pain and low-grade fevers.
He was diagnosed 4 years ago with
Crohn disease involving the small
bowel and colon. He takes 6mercaptopurine.
On physical exam, temperature is
37.9 C (100.2 F), blood pressure is
140/90 mm hg, pulse rate is 88/min,
and respiration rate is 20/min.
Abdominal examination is normal.
Perianal examination discloses two
fistula orifices right anterolateral
to the anus with expression of white
material with gentle palpation. A
fluctuant, tender region that is 1.5
cm in diameter is noted left
posterolateral to the anus.
In addition to examination under
anesthesia and appropriate surgical
treatment of abscess cavities and
fistula tracts, which of the
following is the appropriate
management?
A.
B.
C.
D.
Ciprofloxacin
Corticosteroids
Infliximab
Metronidazole
18. A 50 year-old woman is evaluated for
a 1-year history of recurrent leftsided chest pain. The pain is poorly
localized, nonexertional, and occurs
in 1-minute episodes. There is no
dyspnea, nausea, or diaphoresis
associated with these episodes. She
has not had dysphagia, heartburn,
weight change, or other
gastrointestinal symptoms. She has no
other medical problems and does not
smoke cigarettes.
On physical exam, vital signs are
normal and BMI is 30. The patient’s
chest pain is not reproducible with
palpation. The cardiac examination
reveals normal heart sounds without
murmurs or extracardiac sounds. The
remainder of the physical exam is
normal.
A lipid panel, fasting plasma
glucose test, and chest radiograph
are normal. An echocardiogram shows
a normal ejection fraction with no
wall motion abnormalities.
An exercise stress test is normal.
Which of the following is the most
appropriate management?
A.
B.
C.
D.
Ambulatory pH study
Begin an NSAID
Endoscopy
Trial of a proton pump
inhibitor
19. A 26 year-old woman is evaluated
after recently undergoing community
screening for viral hepatitis. She is
currently asymptomatic. She is of
Laotian descent, and she has two
older symptoms with hepatitis B virus
(HBV) infection. There is no family
history of malignancies. She takes no
medications.
On physical examination, vital signs
are normal. BMI is 22.
Laboratory studies:
INR 0.9
Alkaline phosphatase 90 U/L
Alanine aminotransferase 18 U/L
Aspartate aminotransferase 14 U/L
Albumin 4.2 g/dL
Total bilirubin 2.2 mg/dL
Direct bilirubin 0.2 mg/dL
HBV serology:
Hepatitis B surface antigen:
Positive
Antibody to hepatitis B surface
antigen: Negative
Hepatitis B core antibody: positive
Hepatitis B e antigen: positive
Antibody to hepatitis B e antigen:
negative
HBV DNA >200,000 units/mL
Which of the following is the most
appropriate next step in management?
A. Immunization against
hepatitis B virus
B. Liver biopsy
C. Serial monitoring of
aminotransferases
D. Tenofovir
20. A 51 year-old woman is evaluated
for a 6-month history of diarrhea
and bloating. She reports four to
six bowel loose stools per day,
with occasional nocturnal stools.
She has had a few episodes of
incontinence secondary to urgency.
She has not had melena or
hematochezia but notes an
occasional oily appearance to the
stool. She has lost 6.8 kg (15 lb)
during this time period. Results of
a colonoscopy 1 year ago were
normal. She has not had recent
travel, antibiotic use, or
medication changes. She does not
think consumption of dairy products
alters her symptoms. She has a
history of systemic sclerosis for
which she takes omeprazole for
symptoms of gastroesophageal reflux
disease.
On physical exam, vital signs are
normal. BMI is 22. Facial
telangiectasias are present, and
there is bilateral skin thickening
of the hands. The abdomen is mildly
distended, and bowel sounds are
normal. Rectal examination is
normal, with normal resting and
squeeze tone. There are no palpable
mass lesions.
Laboratory studies:
Hemoglobin 10.8 g/dL
Mean corpuscular volume 104 fL
Serum electrolytes normal
Folate 63 ng/mL
Glucose Normal
Thyroid-stimulating hormone: normal
Vitamin B12 118 pg/dL
Tissue transglutaminase antibody
normal
Stool cultures, including ova and
parasite examination, are normal.
Which of the following is the most
likely diagnosis?
A.
B.
C.
D.
E.
Celiac disease
Irritable bowel syndrome
Lactose malabsorption
Microscopic colitis
Small intestinal bacterial
overgrowth