Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed.

SECTION VIII. Disorders of the Gastrointestinal System


DIRECTIONS: Choose the one best response to each question.

VIII-1. The advantages of endoscopy over barium radiography in the evaluation of dysphagia include all of the following EXCEPT:

A.  Ability to intervene as well as diagnose

B.  Ability to obtain biopsy specimens

C.  Increased sensitivity for the detection of abnormalities identified by color, e.g., Barrett’s metaplasia

D.  Increased sensitivity for the detection of mucosal lesions

E.  No meaningful risk to procedure

VIII-2. A 47-year-old man is evaluated in the emergency department for chest pain that developed at a restaurant after swallowing a piece of steak. He reports intermittent episodes of meat getting stuck in his lower chest over the past 3 years, but none as severe as this event. He denies food regurgitation outside of these episodes or heartburn symptoms. He is able to swallow liquids without difficulty and has not had any weight loss. Which of the following is the most likely diagnosis?

A.  Achalasia

B.  Adenocarcinoma of the esophagus

C.  Esophageal diverticula

D.  Plummer-Vinson syndrome

E.  Schatzki’s ring

VIII-3. Which of the following has a well-established association with gastroesophageal reflux?

A.  Chronic sinusitis

B.  Dental erosion

C.  Pulmonary fibrosis

D.  Recurrent aspiration pneumonia

E.  Sleep apnea

VIII-4. A 36-year-old female with AIDS and a CD4 count of 35/mm3 presents with odynophagia and progressive dysphagia. The patient reports daily fevers and a 20-lb weight loss. She has been treated with clotrimazole troches without relief. On physical examination the patient is cachectic with a body mass index (BMI) of 16 and a weight of 86 lb. She has a temperature of 38.2°C (100.8°F) and is noted to be orthostatic by blood pressure and pulse. Examination of the oropharynx reveals no evidence of thrush. The patient undergoes esophagogastroduodenoscopy (EGD), which reveals serpiginous ulcers in the distal esophagus without vesicles. No yellow plaques are noted. Multiple biopsies are taken that show intranuclear and intracytoplasmic inclusions in large endothelial cells and fibroblasts. What is the best treatment for this patient’s esophagitis?

A.  Ganciclovir

B.  Glucocorticoids

C.  Fluconazole

D.  Foscarnet

E.  Thalidomide

VIII-5. A 57-year-old man is evaluated with an esophagogastroduodenoscopy after an episode of hematemesis. The patient reports a history of tobacco use and hypercholesterolemia, but is otherwise healthy. He has had lower back pain for the past month and has been intermittently using acetaminophen 1000 mg for relief. His endoscopy shows a 3-cm duodenal ulcer. Which of the following statements is correct regarding this finding?

A.  The lesion should be biopsied as duodenal ulcers have an elevated risk of being due to carcinoma.

B.  First-line therapy should be discontinuation of acetaminophen use.

C.  The patient is not at risk for any associated cancers.

D.  Poor socioeconomic status is a risk factor for development of this condition.

E.  Antral gastritis is rarely found with this condition.

VIII-6. A 58-year-old man is evaluated for abdominal pain by his primary care physician. He reports severe stress at his job for the last 3 months and has since noted that he has epigastric pain that is relieved by eating and drinking milk. He has not had food regurgitation, dysphagia, or bloody emesis or bowel movements. He denies any symptoms in his chest. Peptic ulcer disease is suspected. Which of the following statements regarding noninvasive testing for Helicobacter pylori is true?

A.  There is no reliable noninvasive method to detect H. pylori.

B.  Stool antigen testing is appropriate for both diagnosis of and proof of cure after therapy for H. pylori.

C.  Plasma antibodies to H. pylori offer the greatest sensitivity for diagnosis of infection.

D.  Exposure to low-dose radiation is a limitation to the urea breath test.

E.  False-negative testing using the urea breath test may occur with recent use of NSAIDs.

VIII-7. A 44-year-old woman complains of 6 months of epigastric pain that is worst between meals. She also reports symptoms of heartburn. The pain is typically relieved by over-the-counter antacid medications. She comes to the clinic after noting her stools darkening. She has no significant past medical history and takes no medications. Her physical examination is normal except for diffuse midepigastric pain. Her stools are heme positive. She undergoes EGD, which demonstrates a well-circumscribed 2-cm duodenal ulcer that is positive for H. pylori. Which of the following is recommended initial therapy given these findings?

A.  Lansoprazole plus clarithromycin plus amoxicillin for 14 days

B.  Pantoprazole plus amoxicillin for 21 days

C.  Pantoprazole plus clarithromycin for 14 days

D.  Omeprazole plus bismuth plus tetracycline plus metronidazole for 14 days

E.  Omeprazole plus metronidazole plus clarithromycin for 7 days

VIII-8. A 57-year-old man with peptic ulcer disease experiences transient improvement with Helicobacter pylori eradication. However, 3 months later symptoms recur despite acid-suppressing therapy. He does not take nonsteroidal anti-inflammatory agents. Stool analysis for H. pylori antigen is negative. Upper GI endoscopy reveals prominent gastric folds together with the persistent ulceration in the duodenal bulb previously detected and the beginning of a new ulceration 4 cm proximal to the initial ulcer. Fasting gastrin levels are elevated and basal acid secretion is 15 meq/h. What is the best test to perform to make the diagnosis?

A.  No additional testing is necessary.

B.  Blood sampling for gastrin levels following a meal.

C.  Blood sampling for gastrin levels following secretin administration.

D.  Endoscopic ultrasonography of the pancreas.

E.  Genetic testing for mutations in the MEN1 gene.

VIII-9. A 23-year-old woman is evaluated by her primary care physician for diffuse, crampy abdominal pain. She reports that she has had abdominal pain for the last several years, but it is getting worse and is now associated with intermittent diarrhea without flatulence. This does not waken her at night. Stools do not float and are not hard to flush. She has not noted any worsening with specific foods, but she does have occasional rashes on her lower legs. She has lost about 5 kg over the last year. She is otherwise healthy and takes no medications. Which of the following is the most appropriate recommendation at this point?

A.  Increased dietary fiber intake

B.  Measurement of antiendomysial antibody

C.  Measurement of 24-hour fecal fat

D.  Referral to gastroenterologist for endoscopy

E.  Trial of lactose-free diet

VIII-10. All of the following are direct complications of short bowel syndrome EXCEPT:

A.  Cholesterol gallstones

B.  Coronary artery disease

C.  Gastric acid hypersecretion

D.  Renal calcium oxalate calculi

E.  Steatorrhea

VIII-11. A 54-year-old man is evaluated by a gastroenterologist for diarrhea that has been present for approximately 1 month. He reports stools that float and are difficult to flush down the toilet; these can occur at any time of day or night, but seem worsened by fatty meals. In addition, he reports pain in many joints that lasts days to weeks and is not relieved by ibuprofen. His wife notes that the patient has had difficulty with memory for the last few months. He has lost 30 pounds and reports intermittent low-grade fevers. He takes no medications and is otherwise healthy. Endoscopy is recommended. Which of the following is the most likely finding on small-bowel biopsy?

A.  Dilated lymphatics

B.  Flat villi with crypt hyperplasia

C.  Mononuclear cell infiltrate in the lamina propria

D.  Normal small-bowel biopsy

E.  PAS-positive macrophages containing small bacilli

VIII-12. A 54-year-old male presents with 1 month of diarrhea. He states that he has 8–10 loose bowel movements a day. He has lost 4 kg during this time. Vital signs and physical examination are normal. Serum laboratory studies are normal. A 24-hour stool collection reveals 500 g of stool with a measured stool osmolality of 200 mosmol/L and a calculated stool osmolality of 210 mosmol/L. Based on these findings, what is the most likely cause of this patient’s diarrhea?

A.  Celiac sprue

B.  Chronic pancreatitis

C.  Lactase deficiency

D.  Vasoactive intestinal peptide tumor

E.  Whipple’s disease

VIII-13. Cobalamin absorption may occur in all of the following diseases EXCEPT:

A.  Bacterial overgrowth syndrome

B.  Chronic pancreatitis

C.  Crohn’s disease

D.  Pernicious anemia

E.  Ulcerative colitis

VIII-14. Which of the following statements regarding the epidemiology of inflammatory bowel disease is correct?

A.  Monozygotic twins are highly concordant for ulcerative colitis.

B.  Oral contraceptive use decreases the incidence of Crohn’s disease.

C.  Persons of Asian descent have the highest rates of ulcerative colitis and Crohn’s disease.

D.  Smoking may decrease the incidence of ulcerative colitis.

E.  Typical age of onset for Crohn’s disease is 40–50 years old.

VIII-15. A 24-year-old woman is admitted to the hospital with a 1-year history of severe abdominal pain and chronic diarrhea, which has been bloody for the past 2 months. She reports a 20-lb weight loss, frequent fevers, and night sweats. She denies vomiting. Her abdominal pain is crampy and primarily involves her right lower quadrant. She is otherwise healthy. Examination is concerning for an acute abdomen with rebound and guarding present. CT shows free air in the peritoneum. She is urgently taken to the operating room for surgical exploration, where she is found to have multiple strictures and a perforation of her bowel in the terminal ileum. The rectum was spared and a fissure from the duodenum to the jejunum is found. The perforated area is resected and adhesions lysed. Which of the following findings on pathology of her resected area confirms her diagnosis?

A.  Crypt abscesses

B.  Flat villi

C.  Noncaseating granuloma throughout the bowel wall

D.  Special stain for Clostridium difficile toxin

E.  Transmural acute and chronic inflammation

VIII-16. A 45-year-old man with ulcerative colitis has been treated for the past 5 years with infliximab with excellent resolution of his bowel symptoms and endoscopic evidence of normal colonic mucosa. He is otherwise healthy. He is evaluated by a dermatologist for a lesion that initially was a pustule over his right lower extremity but has since progressed in size with ulceration. The ulcer is moderately painful. He does not recall any trauma to the area. On examination the ulcer measures 15 cm by 7 cm and central necrosis is present. The edges of the ulcer are violaceous. No other lesions are identified. Which of the following is the most likely diagnosis?

A.  Erythema nodosum

B.  Metastatic Crohn’s disease

C.  Psoriasis

D.  Pyoderma gangrenosum

E.  Pyoderma vegetans

VIII-17. Inflammatory bowel disease (IBD) may be caused by exogenous factors. Gastrointestinal flora may promote an inflammatory response or may inhibit inflammation. Probiotics have been used to treat IBD. Which of the following organisms has been used in the treatment of IBD?

A.  Campylobacter spp.

B.  Clostridium difficile

C.  Escherichia spp.

D.  Lactobacillus spp.

E.  Shigella spp.

VIII-18. Your 33-year-old patient with Crohn’s disease (CD) has had a disappointing disease response to glucocorticoids and 5-ASA agents. He is interested in steroid-sparing agents. He has no liver or renal disease. You prescribe once-weekly methotrexate injections. In addition to monitoring hepatic function and complete blood count, what other complication of methotrexate therapy do you advise the patient of?

A.  Disseminated histoplasmosis

B.  Lymphoma

C.  Pancreatitis

D.  Pneumonitis

E.  Primary sclerosing cholangitis

VIII-19. Which of the following patients requires no further testing before making the diagnosis of irritable bowel syndrome and initiating treatment?

A.  A 76-year-old woman with 6 months of intermittent crampy abdominal pain that is worse with stress and associated with bloating and diarrhea.

B.  A 25-year-old woman with 6 months of abdominal pain, bloating, and diarrhea that has worsened steadily and now awakes her from sleep at night to move her bowels.

C.  A 30-year-old man with 6 months of lower abdominal crampy pain relieved with bowel movements, usually loose. Symptoms are worse during the daytime at work and better on the weekend. Weight loss is not present.

D.  A 19-year-old female college student with 2 months of diarrhea and worsening abdominal pain with occasional blood in her stool.

E.  A 27-year-old woman with 6 months of intermittent abdominal pain, bloating, and diarrhea without associated weight loss. Crampy pain and diarrhea persist after a 48-hour fast.

VIII-20. A 29-year-old woman comes to see you in the clinic because of abdominal discomfort. She feels abdominal discomfort on most days of the week, and the pain varies in location and intensity. She notes constipation as well as diarrhea, but diarrhea predominates. In comparison to 6 months ago, she has more bloating and flatulence than she has had before. She identifies eating and stress as aggravating factors, and her pain is relieved by defecation. You suspect irritable bowel syndrome (IBS). Laboratory data include white blood cell (WBC) count 8000/μL, hematocrit 32%, platelets 210,000/μL, and erythrocyte sedimentation rate (ESR) of 44 mm/h. Stool studies show the presence of lactoferrin but no blood. Which intervention is appropriate at this time?

A.  Antidepressants

B.  Ciprofloxacin

C.  Colonoscopy

D.  Reassurance and patient counseling

E.  Stool bulking agents

VIII-21. After a careful history and physical, and a cost-effective workup, you have diagnosed a 24-year-old female patient with irritable bowel syndrome. What other condition would you reasonably expect to find in this patient?

A.  Abnormal brain anatomy

B.  Autoimmune disease

C.  History of sexually transmitted diseases

D.  Psychiatric diagnosis

E.  Sensory hypersensitivity to peripheral stimuli

VIII-22. A 78-year-old woman is admitted to the hospital with fever, loss of appetite, and left lower quadrant pain. She is not constipated, but has not moved her bowels recently. Laboratory examination is notable for an elevated WBC count. These symptoms began approximately 3 days ago and have steadily worsened. Which of the following statements regarding the use of radiologic imaging to evaluate her condition is true?

A.  Air-fluid levels are commonly seen on plain abdominal films.

B.  Barium enema should not be performed because of the risk of perforation.

C.  Lower gastrointestinal bleeding will likely be visualized on CT angiography.

D.  A thickened colonic wall is not required on CT for the diagnosis of her likely condition.

E.  Ultrasound of the pelvis is the best modality to visualize the likely pathologic process.

VIII-23. Which of the following patients is MOST appropriate for surgical management of their acute diverticulitis?

A.  A 45-year-old woman with rheumatoid arthritis treated with infliximab and prednisone.

B.  A 63-year-old woman with diverticulitis in the descending colon and a distal stricture.

C.  A 70-year-old woman with end-stage renal disease with colonic wall thickening of 8 mm on CT scan.

D.  A 77-year-old man with two episodes of diverticulitis in the past 2 years.

E.  None of the above patients requires surgical management.

VIII-24. A 67-year-old man is evaluated in the emergency department for blood in the toilet bowl after moving his bowels. Blood was also present on the toilet paper after wiping. He reports straining and recent constipation. He has a history of systemic hypertension and hyperlipidemia. Vital signs are normal and he is not orthostatic. Anoscopy shows external hemorrhoids. Hematocrit is normal and bleeding does not recur during his 6-hour emergency department stay. Which of the following is the most appropriate management?

A.  Ciprofloxacin and metronidazole

B.  Cortisone suppositories, fiber supplementation

C.  Hemorrhoidal banding

D.  Operative hemorrhoidectomy

E.  Upper endoscopy

VIII-25. Which of the following statements regarding anorectal abscess is true?

A.  Anorectal abscess is more common in diabetic patients.

B.  Anorectal abscess is more common in women.

C.  Difficulty voiding is uncommon and should prompt further evaluation of anorectal abscess.

D.  Examination in the operating room under anesthesia is required for adequate exploration in most cases.

E.  The peak incidence is the seventh decade of life.

VIII-26. An 88-year-old woman is brought to your clinic by her family because she has become increasingly socially withdrawn. The patient lives alone and has been reluctant to visit or be visited by her family. Family members, including seven children, also note a foul odor in her apartment and on her person. She has not had any weight loss. Alone in the examining room, she only complains of hemorrhoids. On mental status examination, she has signs of depression. Which of the following interventions is most appropriate at this time?

A.  Head CT scan

B.  Initiate treatment with an antidepressant medication

C.  Physical examination including genitourinary and rectal examination

D.  Screening for occult malignancy

E.  Serum thyroid-stimulating hormone

VIII-27. A 37-year-old woman presents with abdominal pain, anorexia, and fever of 4 days’ duration. The abdominal pain is mostly in the left lower quadrant. Her past medical history is significant for irritable bowel syndrome, diverticulitis treated 6 months ago, and status post-appendectomy. Since her last bout of diverticulitis she has increased her fiber intake and avoids nuts and popcorn. Review of systems is positive for weight loss, daily chills and sweats, and “bubbles” in her urinary stream. Her temperature is 39.6°C. A limited CT scan shows thickened colonic wall (5 mm) and inflammation with pericolic fat stranding. She is admitted with a presumptive diagnosis of diverticulitis. What is the most appropriate management for this patient?

A.  A trial of rifaximin and a high-fiber diet

B.  Bowel rest, ciprofloxacin, metronidazole, and ampicillin

C.  Examination of the urine sediment

D.  Measurement of 24-hour urine protein

E.  Surgical removal of the affected colon and exploration

VIII-28. An 85-year-old woman is brought to a local emergency department by her family. She has been complaining of abdominal pain off and on for several days, but this morning states that this is the worst pain of her life. She is able to describe a sharp, stabbing pain in her abdomen. Her family reports that she has not been eating and seems to have no appetite. She has a past medical history of atrial fibrillation and hypercholesterolemia. She has had two episodes of vomiting and in the ER experiences diarrhea that is hemoc-cult positive. On examination she is afebrile, with a heart rate of 105 beats/min and blood pressure of 111/69 mmHg. Her abdomen is mildly distended and she has hypoactive bowel sounds. She does not exhibit rebound tenderness or guarding. She is admitted for further management. Several hours after admission she becomes unresponsive. Blood pressure is difficult to obtain and at best approximation is 60/40 mmHg. She has a rigid abdomen. Surgery is called and the patient is taken for emergent laparotomy. She is found to have acute mesenteric ischemia. Which of the following is true regarding this diagnosis?

A.  Mortality for this condition is greater than 50%.

B.  Risk factors include low-fiber diet and obesity.

C.  The “gold standard” for diagnosis is CT scan of the abdomen.

D.  The lack of acute abdominal signs in this case is unusual for mesenteric ischemia.

E.  The splanchnic circulation is poorly collateralized.

VIII-29. All of the following are potential causes of appendix obstruction and appendicitis EXCEPT:

A.  Ascaris infection

B.  Carcinoid tumor

C.  Cholelithiasis

D.  Fecalith

E.  Measles infection

VIII-30. Which of the following organisms is most likely to be causative in acute appendicitis?

A.  Clostridium species

B.  Escherichia coli

C.  Mycobacterium tuberculosis

D.  Staphylococcus aureus

E.  Yersinia enterocolitica

VIII-31. A 32-year-old woman is evaluated in the emergency department for abdominal pain. She reports a vague loss of appetite for the past day and has had progressively severe abdominal pain, initially at her umbilicus, but now localized to her right lower quadrant. The pain is crampy. She has not moved her bowels or vomited. She reports that she is otherwise healthy and has had no sick contact. Exam is notable for a temperature of 100.7°F, heart rate of 105 beats/min, and otherwise normal vital signs. Her abdomen is tender in the right lower quadrant and pelvic examination is normal. Urine pregnancy test is negative. Which of the following imaging modalities is most likely to confirm her diagnosis?

A.  CT of the abdomen without contrast

B.  Colonoscopy

C.  Pelvic ultrasound

D.  Plain film of the abdomen

E.  Ultrasound of the abdomen

VIII-32. A 38-year-old male is seen in the urgent care center with several hours of severe abdominal pain. His symptoms began suddenly, but he reports several months of pain in the epigastrium after eating, with a resultant 10-lb weight loss. He takes no medications besides over-the-counter antacids and has no other medical problems or habits. On physical examination temperature is 38.0°C (100.4°F), pulse 130 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/50 mmHg. His abdomen has absent bowel sounds and is rigid with involuntary guarding diffusely. A plain film of the abdomen is obtained and shows free air under the diaphragm. Which of the following is most likely to be found in the operating room?

A.  Necrotic bowel

B.  Necrotic pancreas

C.  Perforated duodenal ulcer

D.  Perforated gallbladder

E.  Perforated gastric ulcer

VIII-33. Which of the following is the source of the peritonitis of the patient in question VIII-32?

A.  Bile

B.  Blood

C.  Foreign body

D.  Gastric contents

E.  Pancreatic enzymes

VIII-34. Which of the following is the most common symptom or sign of liver disease?

A.  Fatigue

B.  Itching

C.  Jaundice

D.  Nausea

E.  Right upper quadrant pain

VIII-35. In women, what is the average amount of reported daily alcohol intake that is associated with the development of chronic liver disease?

A.  1 drink

B.  2 drinks

C.  3 drinks

D.  6 drinks

E.  12 drinks

VIII-36. Elevations in all of the following laboratory studies would be indicative of liver disease EXCEPT:

A.  5′-nucleotidase

B.  Aspartate aminotransferase

C.  Conjugated bilirubin

D.  Unconjugated bilirubin

E.  Urine bilirubin

VIII-37. A 61-year-old male is admitted to your service for swelling of the abdomen. You detect ascites on clinical examination and perform a paracentesis. The results show a white blood cell count of 300 leukocytes/μL with 35% polymorphonuclear cells. The peritoneal albumin level is 1.2 g/dL, protein is 2.0 g/dL, and triglycerides are 320 mg/dL. Peritoneal cultures are pending. Serum albumin is 2.6 g/dL. Which of the following is the most likely diagnosis?

A.  Congestive heart failure

B.  Peritoneal tuberculosis

C.  Peritoneal carcinomatosis

D.  Chylous ascites

E.  Bacterial peritonitis

VIII-38. A 26-year-old male resident is noticed by his attending physician to have yellow eyes after his 24-hour call period. When asked, the resident states he has no medical history, but on occasion he has thought he might have mild jaundice when he is stressed or has more than 4–5 alcoholic drinks. He never sought medical treatment because he was uncertain, and his eyes would return fully to normal within 2 days. He denies nausea, abdominal pain, dark urine, light-colored stools, pruritus, or weight loss. On examination he has a body mass index of 20.1 kg/m2, and his vital signs are normal. Scleral icterus is present. There are no stigmata of chronic liver disease. The patient’s abdomen is soft and nontender. The liver span is 8 cm to percussion. The liver edge is smooth and palpable only with deep inspiration. The spleen is not palpable. Laboratory examinations are normal except for a total bilirubin of 3.0 mg/dL. Direct bilirubin is 0.2 mg/dL. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase are normal. Hematocrit, lac-tate dehydrogenase (LDH), and haptoglobin are normal. Which of the following is the most likely diagnosis?

A.  Autoimmune hemolytic anemia

B.  Crigler-Najjar syndrome type 1

C.  Choledocholithiasis

D.  Dubin-Johnson syndrome

E.  Gilbert’s syndrome

VIII-39. What is the next step in the evaluation and management of the patient in question VIII-38?

A.  Genotype studies

B.  Peripheral blood smear

C.  Prednisone

D.  Reassurance

E.  Right upper quadrant ultrasound

VIII-40. A 34-year-old man presents to the physician complaining of yellow eyes. For the past week, he has felt ill with decreased oral intake, low-grade fevers (~100°F), fatigue, nausea, and occasional vomiting. With the onset of jaundice, he has noticed pain in his right upper quadrant. He currently uses marijuana and ecstasy, and has a prior history of injection drug use with cocaine. He has no other past medical history, but he was unable to donate blood 4 years previously for reasons that he cannot recall. His social history is remarkable for working as a veterinary assistant. On sexual history, he reports five male sexual partners over the past 6 months. He does not consistently use condoms. On physical examination, he appears ill and has obvious jaundice with scleral icterus. His liver is 15 cm to percussion and is palpable 6 cm below the right costal margin. The edge is smooth and tender to palpation. The spleen is not enlarged. There are no stigmata of chronic liver disease. His AST is 1232 U/L, ALT is 1560 U/L, alkaline phosphatase is 394 U/L, total bilirubin is 13.4 mg/dL, and direct bilirubin is 12.2 mg/dL. His INR is 2.3, and aPTT is 52 seconds. Hepatitis serologies are sent and reveal the following:

Hepatitis A IgM negative

Hepatitis A IgG negative

Hepatitis B core IgM positive

Hepatitis B core IgG negative

Hepatitis B surface antigen positive

Hepatitis B surface antibody negative

Hepatitis B e antigen positive

Hepatitis B e antibody negative

Hepatitis C antibody positive

What is the cause of the patient’s current clinical presentation?

A.  Acute hepatitis A infection

B.  Acute hepatitis B infection

C.  Acute hepatitis C infection

D.  Chronic hepatitis B infection

E.  Drug-induced hepatitis

VIII-41. In the scenario described in question VIII-40, what would be the best approach to prevent development of chronic hepatitis?

A.  Administration of anti-hepatitis A virus IgG.

B.  Administration of lamivudine.

C.  Administration of pegylated interferon α plus ribavirin.

D.  Administration of prednisone beginning at a dose of 1 mg/kg daily.

E.  Do nothing and observe, as 99% of individuals with this disease recover.

VIII-42. Which of the following viral causes of acute hepatitis is most likely to cause fulminant hepatitis in a pregnant woman?

A.  Hepatitis A

B.  Hepatitis B

C.  Hepatitis C

D.  Hepatitis D

E.  Hepatitis E

VIII-43. A 16-year-old woman had visited your clinic 1 month ago with jaundice, vomiting, malaise, and anorexia. Two other family members were ill with similar symptoms. Based on viral serologies, including a positive anti-hepatitis A virus (HAV) IgM, a diagnosis of hepatitis A was made. The patient was treated conservatively, and 1 week after first presenting, she appeared to have made a full recovery. She returns to your clinic today complaining of the same symptoms she had 1 month ago. She is jaundiced, and an initial panel of laboratory tests returns elevated transaminases. Which of the following offers the best explanation of what has occurred in this patient?

A.  Coinfection with hepatitis C

B.  Inappropriate treatment of initial infection

C.  Incorrect initial diagnosis; this patient likely has hepatitis B

D.  Reinfection with hepatitis A

E.  Relapse of hepatitis A

VIII-44. A 26-year-old woman presents to your clinic and is interested in getting pregnant. She seeks your advice regarding vaccines she should obtain, and in particular asks about the hepatitis B vaccine. She works as a receptionist for a local business, denies alcohol or illicit drug use, and is in a monogamous relationship. Which of the following is true regarding hepatitis B vaccination?

A.  Hepatitis B vaccine consists of two IM doses 1 month apart.

B.  Only patients with defined risk factors need to be vaccinated.

C.  Pregnancy is not a contraindication to the hepatitis B vaccine.

D.  This patient’s hepatitis serologies should be checked before vaccination.

E.  Vaccination should not be administered to children under 2 years old.

VIII-45. An 18-year-old man presents to a rural clinic with nausea, vomiting, anorexia, abdominal discomfort, myalgias, and jaundice. He describes occasional alcohol use and is sexually active. He describes using heroin and cocaine “a few times in the past.” He works as a short-order cook in a local restaurant. He has lost 15.5 kg since his last visit to the clinic and appears emaciated and ill. On examination he is noted to have icteric sclerae and a palpable, tender liver below the right costal margin. In regard to acute hepatitis, which of the following is true?

A.  A distinction between viral etiologies cannot be made using clinical criteria alone.

B.  Based on age and risk factors, he is likely to have hepatitis B infection.

C.  He does not have hepatitis E virus, as this infects only pregnant women.

D.  This patient cannot have hepatitis C because his presentation is too acute.

E.  This patient does not have hepatitis A because his presentation is too fulminant.

VIII-46. A 36-year-old male presents with fatigue and tea-colored urine for 5 days. Physical examination reveals jaundice and tender hepatomegaly, but is otherwise unremarkable. Laboratories are remarkable for an aspartate aminotransferase (AST) of 2400 U/L and an alanine aminotransferase (ALT) of 2640 U/L. Alkaline phosphatase is 210 U/L. Total bilirubin is 8.6 mg/dL. Which of the following diagnoses is least likely to cause this clinical picture and these laboratory abnormalities?

A.  Acute hepatitis A infection

B.  Acute hepatitis B infection

C.  Acute hepatitis C infection

D.  Acetaminophen ingestion

E.  Budd-Chiari syndrome

VIII-47. Which of the following drugs has a direct toxic effect on hepatocytes?

A.  Acetaminophen

B.  Chlorpromazine

C.  Halothane

D.  Isoniazid

E.  Rosuvastatin

VIII-48. A 32-year-old woman is admitted to the intensive care unit following an overdose of acetaminophen with coingestion of alcohol. She was known to be alert and interactive about 4 hours before her presentation when she had a fight with her boyfriend who then left the home. When he returned 6 hours later, he found an empty bottle of acetaminophen 500 mg capsules as well as an empty vodka bottle. The exact number of pills in the bottle is unknown but the full bottle held as much as 50 capsules. The patient was unresponsive and had vomited, so her boyfriend called 911. Upon arrival to the emergency department, the patient is stuporous. Her vital signs are as follows: pulse 109 beats/min, respiratory rate 20 breaths/min, blood pressure 96/52 mmHg, and oxygen saturation 95% on room air. Her examination shows mild nonspecific abdominal pain with palpation. The liver is not enlarged. Her initial laboratory values show a normal CBC, and normal electrolytes and kidney function. The AST is 68 U/L, ALT is 46 U/L, alkaline phosphatase is 110 U/L, and total bilirubin is 1.2 mg/dL. Glucose and coagulation studies are normal. The serum alcohol level is 210 g/dL. The acetaminophen level is 350 μg/mL. What is the most appropriate next step in the treatment of this patient?

A.  Administration of activated charcoal or cholestyramine.

B.  Administration of N-acetylcysteine 140 mg/kg followed by 70 mg/kg every 4 hours for a total of 15–20 doses.

C.  Continued monitoring of liver function, glucose, and coagulation studies every 4 hours with administration of N-acetylcysteine if these begin to change.

D.  Do nothing as normal liver function tests and coagulation studies are indicative of only a minor ingestion.

E.  Initiate hemodialysis for toxin clearance.

VIII-49. A 38-year-old woman is evaluated for elevated transaminase levels that were identified during routine laboratory testing for life insurance. She is originally from Thailand and immigrated to the United States 10 years previously. She has been married to an American for the past 12 years, having met him while he was living abroad for business. She previously worked in Thailand as a deputy tourism minister for the government, but is not currently employed. She has no significant past medical history. She had one uncomplicated pregnancy at the age of 22. When queried about risk factors for liver disease, she denies alcohol intake or drug abuse. She has never had a blood transfusion. She recalls an episode of jaundice that she did not seek evaluation for about 15 years ago. It resolved spontaneously. She currently feels well, and her husband wished to have her added to his life insurance policy. There are no stigmata of chronic liver disease. Her laboratory studies reveal an AST of 346 U/L, ALT of 412 U/L, alkaline phosphatase of 98 U/L, and total bilirubin of 1.5 mg/dL. Further workup includes the following viral studies: hepatitis A IgG +, hepatitis B surface antigen +, hepatitis B e antigen +, anti-HBV core IgG +, and hepatitis C IgG negative. The HBV DNA level is 4.8 × 104 IU/mL. What treatment do you recommend for this patient?

A.  Entecavir.

B.  Pegylated interferon.

C.  Pegylated interferon plus entecavir.

D.  No treatment is necessary.

E.  Either A or C.

VIII-50. A 46-year-old man is known to have chronic hepatitis C virus (HCV) infection. He is a former IV drug user for more than 20 years who has been abstinent from drug use for 1 year. He is asking whether he should receive treatment for his HCV infection. He has a prior history of hepatitis B virus (HBV) and has positive antibody to HBV surface antigen. He was treated for tricuspid valve endocarditis 3 years previously. He has no other medical history. He does not know when he acquired HCV. His laboratory studies show a positive HCV IgG antibody with a viral load of greater than 1 million copies. The virus is genotype 1. His AST is 62 U/L, and his ALT is 54 U/L. He undergoes liver biopsy, which demonstrates a moderate degree of bridging fibrosis. What do you tell him regarding his likelihood of progression and possibilities regarding treatment?

A.  As he is infected with genotype 1, the likelihood of response to pegylated interferon and ribavirin is less than 40%.

B.  Following 12 weeks of treatment, the expected viral load should be undetectable.

C.  Given his normal liver enzymes on laboratory testing, he is unlikely to develop progressive liver injury.

D.  If the patient elects to undergo treatment, the best regimen for individuals with genotype 1 disease is pegylated interferon and ribavirin for 24 weeks.

E.  The presence of bridging fibrosis on liver biopsy is the most predictive factor of the development of cirrhosis over the next 10–20 years.

VIII-51. A 34-year-old woman is evaluated for fatigue, malaise, arthralgias, and a 10-lb weight loss over the past 6–8 weeks. She has no past medical history. Since feeling poorly, she has taken approximately one or two tablets of acetaminophen 500 mg daily. On physical examination, her temperature is 100.2°F, respiratory rate is 18 breaths/min, blood pressure is 100/48 mmHg, heart rate is 92 beats/min, and oxygen saturation is 96% on room air. She has scleral icterus. Her liver edge is palpable 3 cm below the right costal margin. It is smooth and tender. The spleen is not enlarged. She has mild synovitis in the small joints of her hands. Her AST is 542 U/L, ALT is 657 U/L, alkaline phosphatase is 102 U/L, total bilirubin is 5.3 mg/dL, and direct bilirubin is 4.8 mg/dL. Which of the following tests would be LEAST likely to be positive in this diagnosis?

A.  Antinuclear antibodies in a homogeneous pattern

B.  Anti-liver/kidney microsomal antibodies

C.  Antimitochondrial antibodies

D.  Hypergammaglobulinemia

E.  Rheumatoid factor

VIII-52. In chronic hepatitis B virus (HBV) infection, the presence of hepatitis B e antigen (HBeAg) signifies which of the following?

A.  Development of liver fibrosis leading to cirrhosis.

B.  Dominant viral population is less virulent and less transmissible.

C.  Increased likelihood of an acute flare in the next 1–2 weeks.

D.  Ongoing viral replication.

E.  Resolving infection.

VIII-53. A 32-year-old woman is admitted to the hospital with fever, abdominal pain, and jaundice. She drinks approximately 6 beers daily and has recently increased her alcohol intake to more than 12 beers daily. She has no other substance abuse history and has no history of alcoholic liver disease or pancreatitis. She is not taking any medications. On physical examination, she appears ill and disheveled with a fruity odor to her breath. Her vital signs are as follows: heart rate 122 beats/min, blood pressure 95/56 mmHg, respiratory rate 22 breaths/min, temperature 101.2°F, and oxygen saturation 98% on room air. She has scleral icterus, and spider angiomata are present on the trunk. The liver edge is palpable 10 cm below the right costal margin. It is smooth and tender to palpation. The spleen is not palpable. No ascites or lower extremity edema is present. Laboratory studies demonstrate an AST of 431 U/L, ALT of 198 U/L, bilirubin of 8.6 mg/dL, alkaline phosphatase of 201 U/L, amylase of 88 U/L, and lipase of 50 U/L. Total protein is 6.2 g/dL, and albumin is 2.8 g/dL. The prothrombin time is 28.9 seconds. What is the best approach to treatment of this patient?

A.  Administer IV fluids, thiamine, and folate, and observe for improvement in laboratory tests and clinical condition.

B.  Administer IV fluids, thiamine, folate, and imipenem while awaiting blood culture results.

C.  Administer prednisone 40 mg daily for 4 weeks before beginning a taper.

D.  Consult surgery for management of acute cholecystitis.

E.  Perform an abdominal CT with IV contrast to assess for necrotizing pancreatitis.

VIII-54. A 48-year-old woman presents complaining of fatigue and itching. She has been tired for the past 6 months and has recently developed diffuse itching. It is worse in the evening hours, but it is intermittent. She does not note it to be worse following hot baths or showers. Her past medical history is significant only for hypothyroidism for which she takes levothyroxine 125 μg daily. On physical examination, she has mild jaundice and scleral icterus. The liver is enlarged to 15 cm on palpation and is palpable 5 cm below the right costal margin. Xanthomas are seen on both elbows. Hyperpigmentation is noticeable on the trunk and arms where the patient has excoriations. Laboratory studies demonstrate the following: WBC 8900/μL, hemoglobin 13.3 g/dL, hematocrit 41.6%, and platelets 160,000/μL. The creatinine is 1.2 mg/dL. The AST is 52 U/L, ALT is 62 U/L, alkaline phosphatase is 216 U/L, total bilirubin is 3.2 mg/dL, and direct bilirubin is 2.9 mg/dL. The total protein is 8.2 g/dL, and albumin is 3.9 U/L. The thyroid-stimulating hormone is 4.5 U/mL. Antimitochondrial antibodies are positive. P-ANCA and C-ANCA are negative. What is the most likely cause of the patient’s symptoms?

A.  Lymphoma

B.  Polycythemia vera

C.  Primary biliary cirrhosis

D.  Primary sclerosis cholangitis

E.  Uncontrolled hypothyroidism

VIII-55. A 63-year-old man presents to the emergency department complaining of hematemesis. The vomiting began abruptly and was not preceded by any abdominal pain or other symptoms. He describes the vomiting as about 500 mL of bright red blood. He has not had melena or bright red blood per rectum. He has known alcoholic cirrhosis and continues to drink at least 12 beers daily. He does not seek regular medical care, and he has not previously had an endoscopy to screen for varices. When he is initially evaluated in the emergency department, he is noted to be tachycardic with a heart rate of 125 beats/min and a blood pressure of 76/40. After 1 L of IV saline, his blood pressure increases to 92/56. He has an additional 300 mL of hematemesis upon arriving in the emergency department. The initial hematocrit is 32%. All of the following should be a part of the initial management of this patient EXCEPT:

A.  Administration of octreotide 100 μg/h by continuous IV infusion

B.  Administration of propranolol 10 mg four times daily

C.  Emergent GI consult for upper endoscopy

D.  Ongoing volume resuscitation with saline and packed red blood cells as needed to maintain adequate blood pressure

E.  Placement of large-bore IV access in the antecubital fossae or large central vein

VIII-56. A 42-year-old man with cirrhosis related to hepatitis C and alcohol abuse has ascites requiring frequent large-volume paracentesis. All of the following therapies would be indicated for this patient EXCEPT:

A.  Fluid restriction to less than 2 L daily

B.  Furosemide 40 mg daily

C.  Sodium restriction to less than 2 g daily

D.  Spironolactone 100 mg daily

E.  Transjugular intrahepatic portosystemic shunt if medical therapy fails

VIII-57. Which of the following statements about cardiac cirrhosis is TRUE?

A.  AST and ALT levels may mimic the very high levels seen in acute viral hepatitis.

B.  Budd-Chiari syndrome cannot be distinguished clinically from cardiac cirrhosis.

C.  Echocardiography is the gold standard for diagnosing constrictive pericarditis as a cause of cirrhosis.

D.  Prolonged passive congestion from right-sided heart failure results first in congestion and necrosis of portal triads, resulting in subsequent fibrosis.

E.  Venoocclusive disease can be confused with cardiac cirrhosis and is a major cause of morbidity and mortality in patients undergoing liver transplantation.

VIII-58. You are asked to consult on a 62-year-old white female with pruritus for 4 months. She has noted progressive fatigue and a 5-lb weight loss. She has intermittent nausea but no vomiting and denies changes in her bowel habits. There is no history of prior alcohol use, blood transfusions, or illicit drug use. The patient is widowed and had two heterosexual partners in her lifetime. Her past medical history is significant only for hypothyroidism, for which she takes levothyroxine. Her family history is unremarkable. On examination she is mildly icteric. She has spider angiomata on her torso. You palpate a nodular liver edge 2 cm below the right costal margin. The remainder of the examination is unremarkable. A right upper quadrant ultrasound confirms your suspicion of cirrhosis. You order a complete blood count and a comprehensive metabolic panel. What is the most appropriate next test?

A.  24-hour urine copper

B.  Antimitochondrial antibodies (AMA)

C.  Endoscopic retrograde cholangiopancreatography (ERCP)

D.  Hepatitis B serologies

E.  Serum ferritin

VIII-59. A 58-year-old man is evaluated for a new diagnosis of cirrhosis. The patient has a medical history of diabetes mellitus, hypertriglyceridemia, and hypertension. He takes pioglitazone, rosuvastatin, lisinopril, and atenolol. He is a lifetime nonsmoker and has never used IV drugs. He drinks about one glass of wine weekly. For about 4–8 years in his 20s, he admits to binge drinking as much as 12–18 beers on the weekends, but has not drunk more than two glasses of wine weekly for many years. He has never had a blood transfusion and has been in a monogamous sexual relationship for 30 years. He has no family history of liver disease. He works as a machinist in a factory making airplane engines. He denies chemical exposures. His physical examination is notable for a body mass index of 45.9 kg/m2. He has stigmata of chronic liver disease including spider angiomata and caput medusa. Moderate ascites is present. Workup has shown no evidence of viral hepatitis, hemochromatosis, Wilson’s disease, autoimmune hepatitis, or α1 antitrypsin deficiency. He undergoes liver biopsy, which shows fibrosis in a perivenular and perisinusoidal distribution. Which of the following statements is TRUE regarding the cause of the patient’s cirrhosis?

A.  As opposed to individuals with metabolic syndrome alone, these individuals do not show significant insulin resistance.

B.  The aspartate aminotransferase is commonly elevated to more than twice the alanine aminotransferase level.

C.  The lack of steatohepatitis on liver biopsy rules out nonalcoholic fatty liver disease as a cause of the patient’s cirrhosis.

D.  The prevalence of the milder form of this disorder is between 10 and 20% in the United States and Europe, with as much as 10–15% of affected individuals developing cirrhosis in some series.

E.  Treatment with ursodeoxycholic acid and HMG-CoA reductase inhibitors has been demonstrated to improve outcomes in this disorder.

VIII-60. Which of the following statements regarding liver transplantation is TRUE?

A.  Individuals with cholangiocarcinoma should be referred early for consideration of liver transplantation.

B.  Living donor transplantation is only performed in children.

C.  Reinfection with hepatitis B typically occurs in 35% or more of patients with liver transplantation.

D.  The 5-year survival rate for orthotopic liver transplantation is about 50%.

E.  The most common indication for liver transplantation is chronic hepatitis B infection.

VIII-61. A 55-year-old male with cirrhosis is seen in the clinic for follow-up of a recent hospitalization for spontaneous bacterial peritonitis. He is doing well and finishing his course of antibiotics. He is taking propranolol and lactulose. Besides complications of end-stage liver disease, he has well-controlled diabetes mellitus and had a basal cell carcinoma resected 5 years ago. The cirrhosis is thought to be due to alcohol abuse, and his last drink of alcohol was 2 weeks ago. He and his wife ask if he is a liver transplant candidate. He can be counseled in which of the following ways?

A.  Because he had a skin cancer he is not a transplant candidate.

B.  Because he has diabetes mellitus he is not a transplant candidate.

C.  He is appropriate for liver transplantation and should be referred immediately.

D.  He is not a transplant candidate as he has a history of alcohol dependence.

E.  He is not a transplant candidate now, but may be after a sustained period of proven abstinence from alcohol.

VIII-62. A 44-year-old woman is evaluated for complaints of abdominal pain. She describes the pain as a postprandial burning pain. It is worse with spicy or fatty foods and is relieved with antacids. She is diagnosed with a gastric ulcer and is treated appropriately for Helicobacter pylori. During the course of her evaluation for her abdominal pain, the patient had a right upper quadrant ultrasound that demonstrated the presence of gallstones. Following treatment of H. pylori, her symptoms have resolved. She is requesting your opinion regarding whether treatment is required for the finding of gallstone disease. Upon review of the ultrasound report, there were numerous stones in the gallbladder, including in the neck of the gallbladder. The largest stone measures 2.8 cm. What is your advice to the patient regarding the risk of complications and the need for definitive treatment?

A.  Given the size and number of stones, prophylactic cholecystectomy is recommended.

B.  No treatment is necessary unless the patient develops symptoms of biliary colic frequently and severely enough to interfere with the patient’s life.

C.  The only reason to proceed with cholecystectomy is the development of gallstone pancreatitis or cholangitis.

D.  The risk of developing acute cholecystitis is about 5–10% per year.

E.  Ursodeoxycholic acid should be given at a dose of 10–15 mg/kg daily for a minimum of 6 months to dissolve the stones.

VIII-63. A 62-year-old man has been hospitalized in intensive care for the past 3 weeks following an automobile accident resulting in multiple long-bone fractures and acute respiratory distress syndrome. He has been slowly improving, but remains on mechanical ventilation. He is now febrile and hypotensive, requiring vasopressors. He is being treated empirically with cefepime and vancomycin. Multiple blood cultures are negative. He has no new infiltrates or increasing secretions on chest radiograph. His laboratory studies demonstrated a rise in his liver function tests, bilirubin, and alkaline phosphatase. Amylase and lipase are normal. A right upper quadrant ultrasound shows sludge in the gallbladder, but no stones. The bile duct is not dilated. What is the next best step in the evaluation and treatment of this patient?

A.  Discontinue cefepime.

B.  Initiate treatment with clindamycin.

C.  Initiate treatment with metronidazole.

D.  Perform hepatobiliary scintigraphy.

E.  Refer for exploratory laparotomy.

VIII-64. All of the following are associated with an increased risk for cholelithiasis EXCEPT:

A.  Chronic hemolytic anemia

B.  Female sex

C.  High-protein diet

D.  Obesity

E.  Pregnancy

VIII-65. A 41-year-old female presents to your clinic with a week of jaundice. She notes pruritus, icterus, and dark urine. She denies fever, abdominal pain, or weight loss. The examination is unremarkable except for yellow discoloration of the skin. Total bilirubin is 6.0 mg/dL, and direct bilirubin is 5.1 mg/dL. AST is 84 U/L, and ALT is 92 U/L. Alkaline phosphatase is 662 U/L. CT scan of the abdomen is unremarkable. Right upper quadrant ultrasound shows a normal gallbladder but does not visualize the common bile duct. What is the most appropriate next management step?

A.  Antibiotics and observation

B.  Endoscopic retrograde cholangiopancreatography (ERCP)

C.  Hepatitis serologies

D.  HIDA scan

E.  Serologies for antimitochondrial antibodies

VIII-66. A 27-year-old woman is admitted to the hospital with acute-onset severe right upper quadrant pain that radiates to the back. The pain is constant and not relieved with eating or bowel movements. Her labs show a marked elevation in amylase and lipase, and acute pancreatitis is diagnosed. Which of the following is the best first test to demonstrate the etiology of her pancreatitis?

A.  Right upper quadrant ultrasound

B.  Serum alcohol level

C.  Serum triglyceride level

D.  Technetium HIDA scan

E.  Urine drug screen

VIII-67. A 58-year-old man with severe alcoholism is admitted to the hospital with acute pancreatitis. His symptoms have been present for 3 days and he has continued to drink heavily. He now has persistent vomiting and feels dizzy upon standing. On examination he has severe epigastric and right upper quadrant tenderness and decreased bowel sounds, and appears uncomfortable. A faint blue discoloration is present around the umbilicus. What is the significance of this finding?

A.  A CT of the abdomen is likely to show severe necrotizing pancreatitis.

B.  Abdominal plain film is likely to show pancreatic calcification.

C.  Concomitant appendicitis should be ruled out.

D.  He likely has a pancreatico-aortic fistula.

E.  Pancreatic pseudocyst is likely present.

VIII-68. A 36-year-old man is admitted to the hospital with acute pancreatitis. In order to determine the severity of disease and risk of mortality, the BISAP (Bedside Index of Severity in Acute Pancreatitis) is calculated. All of the following variables are used to calculate this score EXCEPT:

A.  Age greater than 60 years

B.  BUN greater than 35

C.  Impaired mental status

D.  Pleural effusion

E.  White blood cell count greater than 15,000 leukocytes/μL

VIII-69. A 54-year-old man is admitted to the intensive care unit with severe pancreatitis. His BMI is 30 or above and he has a prior history of diabetes mellitus. A CT of the abdomen is obtained and shows severe necrotizing pancreatitis. He is presently afebrile. Which of the following medications has been shown to be effective in the treatment of acute necrotizing pancreatitis?

A.  Calcitonin

B.  Cimetidine

C.  Glucagon

D.  Imipenem

E.  None of the above

VIII-70. Which of the following statements is true regarding enteral feeding in acute pancreatitis?

A.  A patient with persistent evidence of pancreatic necrosis on CT 2 weeks after acute presentation should be maintained on bowel rest.

B.  All patients with elevations of amylase and lipase and CT evidence of pancreatitis should be fasted until amylase and lipase normalize.

C.  Enteral feeding with a nasojejunal tube has been demonstrated to have fewer infectious complications than total parenteral nutrition in the management of patients with acute pancreatitis.

D.  Patients requiring surgical removal of infected pancreatic pseudocysts should be treated with total parental nutrition.

E.  Total parenteral nutrition has been shown to maintain integrity of the intestinal tract in acute pancreatitis.

VIII-71. A 47-year-old woman presents to the emergency department with severe mid-abdominal pain radiating to her back. The pain began acutely and is sharp. She denies cramping or flatulence. She has had two episodes of emesis of bilious material since the pain began, but this has not lessened the pain. She currently rates the pain as a 10 out of 10 and feels the pain is worse in the supine position. For the past few months, she has had intermittent episodes of right upper and mid-epigastric pain that occurs after eating but subsides over a few hours. This is associated with a feeling of excess gas. She denies any history of alcohol abuse. She has no medical history of hypertension or hyperlipidemia. On physical examination, she is writhing in distress and slightly diaphoretic. Vital signs are as follows: heart rate 127 beats/min, blood pressure 92/50 mmHg, respiratory rate 20 breaths/min, temperature 37.9°C, and 88% oxygen saturation on room air. Her body mass index is 29 kg/m2. The cardiovascular examination reveals a regular tachycardia. The chest examination shows dullness to percussion at bilateral bases with a few scattered crackles. On abdominal examination, bowel sounds are hypoactive. There is no rash or bruising evident on inspection of the abdomen. There is voluntary guarding on palpation. The pain with palpation is greatest in the periumbilical and epigastric areas without rebound tenderness. There is no evidence of jaundice, and the liver span is about 10 cm to percussion. Amylase level is 750 IU/L, and lipase level is 1129 IU/L. Other laboratory values include aspartate aminotransferase (AST) 168 U/L, alanine aminotransferase (ALT) 196 U/L, total bilirubin 2.3 mg/dL, alkaline phosphatase level 268 U/L, lactate dehydrogenase (LDH) 300 U/L, and creatinine 1.9 mg/dL. The hematocrit is 43%, and white blood cell (WBC) count is 11,500/μL with 89% neutrophils. An arterial blood gas shows a pH of 7.32, PCO2 of 32 mmHg, and a PO2 of 56 mmHg. An ultrasound confirms a dilated common bile duct with evidence of pancreatitis manifested as an edematous and enlarged pancreas. A CT scan shows no evidence of necrosis. After 3 L of normal saline, her blood pressure comes up to 110/60 mmHg with a heart rate of 105 beats/min. Which of the following statements best describes the pathophysiology of this disease?

A.  Intrapancreatic activation of digestive enzymes with autodigestion and acinar cell injury

B.  Chemoattraction of neutrophils with subsequent infiltration and inflammation

C.  Distant organ involvement and systemic inflammatory response syndrome related to release of activated pancreatic enzymes and cytokines

D.  All of the above

VIII-72. A 25-year-old female with cystic fibrosis is diagnosed with chronic pancreatitis. She is at risk for all of the following complications EXCEPT:

A.  Vitamin B12 deficiency

B.  Vitamin A deficiency

C.  Pancreatic carcinoma

D.  Niacin deficiency

E.  Steatorrhea

VIII-73. A 64-year-old man seeks evaluation from his primary care physician because of chronic diarrhea. He reports that he has two or three large loose bowel movements daily. He describes them as markedly foul smelling, and they often leave an oily ring in the toilet. He also notes that the bowel movements often follow heavy meals, but if he fasts or eats low-fat foods, the stools are more formed. Over the past 6 months, he has lost about 18 kg. In this setting, he reports intermittent episodes of abdominal pain that can be quite severe. He describes the pain as sharp and in a mid-epigastric location. He has not sought evaluation of the pain previously, but when it occurs he will limit his oral intake and treat the pain with nonsteroidal anti-inflammatory drugs. He notes the pain has not lasted for more than 48 hours and is not associated with meals. His past medical history is remarkable for peripheral vascular disease and tobacco use. He currently smokes one pack of cigarettes daily. In addition, he drinks 2–6 beers daily. He has stopped all alcohol intake for up to a week at a time in the past without withdrawal symptoms. His current medications are aspirin 81 mg daily and albuterol metered dose inhaler (MDI) on an as-needed basis. On physical examination, the patient is thin but appears well. His body mass index is 18.2 kg/m2. Vital signs are normal. Cardiac and pulmonary examinations are normal. The abdominal examination shows mild epigastric tenderness without rebound or guarding. The liver span is 12 cm to percussion and palpable 2 cm below the right costal margin. There is no splenomegaly or ascites present. There are decreased pulses in the lower extremities bilaterally. An abdominal radiograph demonstrates calcifications in the epigastric area, and CT scan confirms that these calcifications are located within the body of the pancreas. No pancreatic ductal dilatation is noted. Amylase level is 32 U/L, and lipase level is 22 U/L. What is the next most appropriate step in diagnosing and managing this patient’s primary complaint?

A.  Advise the patient to stop all alcohol use and prescribe pancreatic enzymes.

B.  Advise the patient to stop all alcohol use and prescribe narcotic analgesia and pancreatic enzymes.

C.  Perform angiography to assess for ischemic bowel disease.

D.  Prescribe prokinetic agents to improve gastric emptying.

E.  Refer the patient for endoscopic retrograde cholangiopancreatography (ERCP) for sphincterotomy.