3. Gastroenterology (PACKRAT 10-16)

Which of the following is a common physical examination finding in early intestinal obstruction?

A. high fever.

B. profuse flatulence.

C. rebound tenderness

D. hyperactive, high-pitched bowel sounds

(u) A. Fever and rebound tenderness occur only if a perforation has occurred.

(u) B. Profuse flatulence is not noted in early intestinal obstruction.

(u) C. See A for explanation.

(c) D. Abdominal distention and high-pitched, hyperactive bowel sounds are common in early intestinal obstruction.

Which of the following studies is most appropriate to diagnose celiac disease?

A. Urinary D-xylose test

B. Small bowel biopsy

C. Barium contrast x-ray

D. Schilling test

(u) A. Urinary D-xylose test assesses the proximal small intestinal mucosa's absorption of carbohydrates but is not specific to celiac disease.

(c) B. Definitive diagnosis of celiac disease is made by small bowel biopsy.

(u) C. Barium contrast examination would reveal anatomic abnormalities or blind loop syndrome that may lead to malabsorption but it would not help in the diagnosis of celiac disease.

(u) D. The Schilling test is used to determine the cause of cobalamine malabsorption from pernicious anemia, chronic pancreatitis, achlorhydria and bacterial overgrowth syndrome but has no role in the diagnosis of celiac disease.

Which of the following tumor markers is useful in monitoring a patient for recurrence of colorectal cancer after surgical resection?

A. CA-125

B. Carcinoembryonic antigen

C. 5-hydroxindoleacetic acid

D. Alpha-1-fetoprotein

(u) A. CA-125 tumor marker is useful as a tumor marker in ovarian cancer

(c) B. Carcinoembryonic antigen can be used to monitor a patient for the return of colorectal cancer after treatment.

(u) C. 5-hydroxindoleacetic acid is used as a tumor marker in carcinoid syndrome.

(u) D. Hepatocellular and testicular cancer can be followed by the use of alpha-1-fetoprotein as a tumor marker.

A 14 month-old male who attends day care presents with a two-day history of frequent watery stools. His mother states that he had a fever and vomiting the day before but these have resolved. His mother denies pain in the child. The child is mildly dehydrated but otherwise appears well. Stool samples are free of blood and white blood cells. The lab reports no ova or parasites noted in the stool samples. Which of the following is the most likely diagnosis?

A. Intussusception

B. Viral gastroenteritis

C. Shigella

D. Lactase insufficiency

(u) A. Intussusception may cause diarrhea, however, after two days the stool would have blood present. The absence of pain or discomfort would also argue against this diagnosis.

(c) B. Rotavirus is the most common cause of gastroenteritis in children and this is frequently passed in the daycare setting.

(u) C. Patients with Shigella have dysentery with the passage of bloody stools in a toxic-appearing child

(u) D. Lactase insufficiency would not have caused fever and vomiting.

A patient develops abdominal cramps and watery diarrhea 10 to 12 hours after eating a plate of unrefrigerated meat and vegetables. The patient denies vomiting. The causative agent is most likely

A. Staphylococcus aureus.

B. Clostridium perfringens.

C. Escherichia coli.

D. Salmonella.

(u) A. Staphylococcus aureus has an incubation period of 1 to 6 hours and also characteristically has vomiting associated with it.

(c) B. Food poisoning caused by Clostridium perfringens

has an incubation period of 8 to 14 hours and results frompoorly refrigerated cooked meat.

(u) C. The incubation period for Escherichia coli and Salmonella is greater than 16 hours.

(u) D. See C for explanation.

The most common initial presenting symptom of primary biliary cirrhosis is

A. jaundice

B. palmar erythema

C. pruritus

D. xanthomas

(u) A. Jaundice, palmar erythema and xanthomas appear late in the disease.

(u) B. See A for explanation.

(c) C. Pruritus is the most common initial symptom in primary biliary cirrhosis due to the accumulation of bile salts.

(u) D. See A for explanation.

Which of the following medications used in the treatment of peptic ulcer disease is classified as a proton pump inhibitor?

A. Cimetidine (Tagamet)

B. Sucralfate (Carafate)

C. Omeprazole (Prilosec)

D. Misoprostol (Cytotec)

(u) A. Cimetidine is an H2 receptor antagonist.

(u) B. Sucralfate (Carafate) is a cytoprotective agent.

(c) C. Omeprazole is a proton pump inhibitor.

(u) D. Misoprostol is a prostaglandin analog.

Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?

A. Octreotide (Sandostatin)

B. Sclerotherapy

C. Transjugular intrahepatic portosystemic shunt

D. Sengstaken-Blakemore tube

(u) A. Octreotide is used to control acute variceal bleeding but does not have a role in long-term management.

(c) B. Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.

(u) C. Transjugular intrahepatic portosystemic shunt (TIPS) decreases rebleeding more than sclerotherapy or ligation but is associated with a higher incidence of encephalopathy and has shown no decrease in mortality. TIPS is used in patients who fail endoscopic or pharmacologic therapy.

(u) D. The Sengstaken-Blakemore tube is rarely used today in the treatment of acute variceal bleeding. These are not indicated for long-term use.

A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On exam, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. On exam, the child is alert and responsive, with no focal findings. Which of the following is the most appropriate intervention?

A. Antibiotic therapy

B. Begin soft diet

C. IV fluids

D. Oral rehydration

(u) A. In the US, infectious gastroenteritis is most frequently due to a virus. Antibiotic therapy may be second-line in cases where the causative organism is bacterial, is identified, and symptoms continue.

(u) B. See D for explanation.

(a) C. See D for explanation.

(c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.

Initial pharmacologic treatment of acute hepatic encephalopathy consists of

A. lactulose.

B. omega-3-fatty acids.

C. neomycin.

D. mannitol.

(c) A. Lactulose acts as an osmotic laxative decreasing ammonia absorption and decreases ammonia production by directly affecting bacterial metabolism.

(u) B. Omega-3-fatty acids have no role in the treatment of hepatic encephalopathy.

(u) C. Neomycin, like lactulose, will decrease ammonia production by intestinal bacteria and may have a role in chronic but not acute management of hepatic encephalopathy.

(u) D. Mannitol is used as an osmotic diuretic

A 72 year-old male presents to the ED complaining of acute onset of severe diffuse abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool.Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation,OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis?

A. Acute cholecystitis

B. Mesenteric infarction

C. Perforated duodenal ulcer

D. Small bowel obstruction

(u) A. Acute cholecystitis causes right upper quadrant pain with radiation into the shoulder and does not cause hemoccult positive stools.

(c) B. Acute onset of severe diffuse abdominal pain in a person with atrial fibrillation warrants the suspicion of mesenteric infarction. Vomiting and constipation may be seen, along with occult blood in the stool. Bowel sounds may be normal.

(u) C. Abdominal and chest x-rays would reveal free air under the diaphragm in a ruptured duodenal ulcer and asmall bowel obstruction would reveal air-fluid levels with distended bowel loops.

(u) D. See C for explanation.

An asymptomatic 50 year-old person has no risk factors for colorectal cancer. In addition to yearly hemoccult screening of the stool, how often should flexible sigmoidoscopy be performed?

A. Every year

B. Every other year

C. Every 5 years

D. Every 10 years

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. In a person with no risk factors for colorectal cancer, screening should include annual Hemoccult testing and flexible sigmoidoscopy every 5 years.

(u) D. See C for explanation.

Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease?

A. Prednisone

B. Sulfasalazine

C. Metronidazole

D. Azathioprine (Imuran)

(u) A. Glucocorticoids are used in moderate to severe inflammatory bowel disease.

(c) B. Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.

(u) C. Metronidazole may have a role in Crohn's disease after ileal resection but has no role in the treatment of mild to moderate disease.

(u) D. Azathioprine is used in severe, glucocorticoid-dependent inflammatory bowel disease.

Which of the following treatments is the most appropriate for a patient with an acutely tender, fluctuant perirectal mass?

A. Fistulectomy

B. Drainage of an abscess

C. Antibiotic therapy

D. Removal of an anal fissure

(u) A. There is no fistula present; therefore, a fistulectomy is not indicated.

(c) B. Perirectal abscesses should be treated by drainage as soon as a diagnosis is established.

(u) C. Antibiotic therapy is not indicated unless there is extensive cellulitis, or the patient is immunocompromised, has diabetes mellitus, or has valvular heart disease.

(u) D. Anal fissures are linear tears. Indications for operative management include persistent pain, lack of healing, and recurrence.

Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions?

A. Hirschsprung's disease

B. Meckel's diverticulum

C. Chagas disease

D. Hashimoto's hypothyroidism

(c) A. Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.

(u) B. Meckel's diverticulum results from the failure of the vitelline duct to separate from the intestine during early gestation leading to an outpouching in the intestinal tract.

(u) C. Chagas disease results from infection with the Trypanosoma parasite. Chronic Chagas disease may lead to the loss of dorsal motor nuclear cells of the vagus nerve, resulting in megaesophagus and megacolon.

(u) D. Ineffective peristalsis of the colon from hypothyroidism may result in constipation but not Hirschsprung disease

A middle-aged patient is being treated for recurrent diarrhea and peptic ulcer disease that is refractory adequate standard therapy. Which of the following is the most likely diagnosis?

A. Achlorhydria

B. Drug resistant H. pylori infection

C. Zollinger-Ellison syndrome

D. Giardiasis

(u) A. The clinical picture of diarrhea with peptic ulcer disease refractory to adequate standard therapy is consistent with gastric acid hypersecretion, not achlorhydria.

(u) B. Drug resistant infection from H. pylori has not been reported and would not explain the associated diarrhea.

(c) C. Zollinger-Ellison syndrome is the result of unregulated release of gastrin resulting in gastric acid hypersecretion. Up to 50% of patients complain of diarrhea along with peptic ulcer disease.

(u) D. Giardiasis causes acute diarrhea but is not associated with peptic ulcer disease.

Which of the following is suggestive of thiamine deficiency?

A. Ataxia

B. Bleeding

C. Cheilosis

D. Diarrhea

(u) A. Ataxia, mental deficits, horizontal nystagmus, muscle weakness and atrophy, and cardiomegaly are all clinical findings in thiamine deficiency.

(u) B. A deficiency of Vitamin K would result in bleeding and an elevated prothrombin time.

(c) C. Cheilosis, mucocutaneous lesions at the corners of the mouth, is the result of riboflavin deficiency.

(u) D. A deficiency of niacin will result in diarrhea, dementia, and dermatitis.

Which of the following would be consistent for a person who has a successful response to the hepatitis B immunization series?

A. HBsAg positive; anti-HBc positive; anti-HBs negative

B. HBsAg negative; anti-HBc positive; anti-HBs positive

C. HBsAg negative; anti-HBc negative; anti-HBs positive

D. HBsAg negative; anti-HBc negative; anti-HBs negative

(u) A. A positive HBsAg and positive anti-HBc with a negative anti-HBs would indicate either acute infection or chronic hepatitis B infection.

(u) B. A negative HBsAg with a positive anti-HBc and a positive anti-HBs would indicate a previous infection of hepatitis B.

(c) C. A person immunized against hepatitis B would have a positive anti-HBs with negative HBsAg and negative anti-HBc.

(u) D. A person with a negative HBsAg, anti-HBc and anti-HBs is nonimmune and has never received the hepatitis B immunization series.

Which of the following presents the greatest risk factor for the development of pancreatic cancer?

A. Alcohol abuse

B. Coffee consumption

C. Cigarette smoking

D. Lean body mass

(u) A. Alcohol abuse, coffee consumption and a lean body mass are not proven risk factors for pancreatic cancer.

(u) B. See A for explanation.

(c) C. Cigarette smoking is the most consistent risk factor for the development of pancreatic cancer.

(u) D. See A for explanation.

The parents of a 16 year-old male presents to the clinic with their son asking that you examine him. Over the past 9-12 months he has developed behavioral problems and emotional lability. Physical examination reveals a well-developed male who is cooperative with exam but tends to be easily distracted. It is noteworthy for dysarthria, a resting tremor and the presence of gray-green pigmentation surrounding each pupil. The most likely diagnosis is

A. drug abuse.

B. hemochromatosis.

C. Wilson's disease.

D. Parkinsonism.

(u) A. Drug abuse would account for the personality changes and possibly the resting tremor. It would not account for the ocular findings.

(u) B. Hemochromatosis has its onset usually after the age of 50 years and would not produce neuropsychiatric symptoms, the tremor or the ocular abnormalities.

(c) C. Wilson's disease results in the excessive deposition of copper in the liver and brain. Kayser-Fleisher rings are the result of granular deposits in the eye and are pathognomonic for Wilson's disease.

(u) D. Parkinsonism would not result in the ocular findings and this would be a very unusual age of onset for Parkinsonism.

The drug of choice in an adult for empirical treatment of an ill-appearing patient with infectious diarrhea who has recently returned from Mexico is

A. amoxicillin.

B. ceftriaxone (Rocephin).

C. ciprofloxacin (Cipro).

D. doxycycline.

(u) A. Due to increasing antibiotic resistance, amoxicillin is no longer recommended in the treatment of infectious diarrhea.

(u) B. See C for explanation.

(c) C. Fluoroquinolones like Ciprofloxacin are the class of drugs used in the empirical treatment of infectious diarrhea. Alternatives include trimethoprim/sulfamethoxazole or erythromycin.

(u) D. See C for explanation.

Which of the following is consistent with acute cholangitis?

A. Jaundice

B. Caput medusa

C. Bilateral flank bruising

D. An enlarged, palpable nontender gallbladder

(c) A. Jaundice is part of Charcot's triad associated with cholangitis along with fever and biliary colic.

(u) B. Caput medusa is associated with ascites and cirrhosis.

(u) C. Bilateral flank bruising is associated with hemorrhagic pancreatitis.

(u) D. An enlarged, nontender, palpable gallbladder is associated with cancer of the head of the pancreas.

A severely dehydrated child with gastroenteritis who is unable to tolerate oral rehydration should receive which of the following intravenous therapies?

A. 10 mg/kg normal saline

B. 20 mg/kg normal saline

C. 10 mg/kg D5W

D. 20 mg/kg D5W

(u) A. See answer B for explanation.

(c) B. In a severely dehydrated child, restoring intravascular volume to insure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after insuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.

(u) C. See answer B for explanation.

(u) D. See answer B for explanation

A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no

pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study?

A. Stool for occult blood

B. Stool cultures

C. Sigmoidoscopy

D. Abdominal CT scan

(c) A. Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test.

(u) B. Stool cultures are indicated in the evaluation of acute diarrhea and not for the evaluation of acute GI bleeding.

(u) C. Melena suggests a source of bleeding that is proximal to the ligament of Treitz, not a lower GI bleed.

Sigmoidoscopy is used to evaluate only lower GI bleeding sources.

(u) D. Abdominal CT scan is indicated for evaluation of obscure bleeding in order to exclude a pancreatic or hepatic source of bleeding if endoscopy fails to identify the source.

A newborn weighs 8 pounds at birth. On average, what should the infant weigh at 1 year of age?

A. 16 pounds

B. 20 pounds

C. 24 pounds

D. 28 pounds

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.

(u) D. See C for explanation.

Which of the following is an indication for vaccination against hepatitis A?

A. Illicit drug users

B. Health care workers

C. Renal dialysis patients

D. Routine vaccination starting at birth

(c) A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a clotting factor disease as well as children and workers in day care settings and institutions.

(u) B. Health care workers, renal dialysis patients and routine vaccination starting at birth are some of the

recommendations for vaccination against hepatitis B, not hepatitis A.

(u) C. See B for explanation.

(u) D. See B for explanation.

Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis?

A.Weight loss

B. Intractable pain

C. Exocrine deficiency

D. To decrease risk of cancer

(u) A. While weight loss is common with chronic pancreatitis, it is not an indication for surgical intervention.

(c) B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient's functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake.

(u) C. While the majority of patients go on to develop diabetes mellitus 25 years after the clinical onset of chronic pancreatitis, this is not an indication for surgical intervention as it would lead to more severe exocrine

deficiency.

(u) D. While the possible presence of pancreatic cancer is an indication for surgery, there is no indication for

prophylactic surgery to decrease the risk of cancer.

A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago.

On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are

unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is

positive. Which of the following is the most appropriate treatment at this time?

A. Schedule for a selective vagotomy and antrectomy

B. Start an antacid along with omeprazole (Prilosec)

C. Schedule elective ulcer excision and start sucralfate (Carafate)

D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori

(u) A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy.

(u) B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test.

(u) C. While sucralfate can be utilized as a cytoprotectant agent in treatment of active ulcer disease or in maintenance of healed ulcers, surgery to remove the ulcer is not warranted as initial therapy.

(c) D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.

A 20 year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that

extends into the scrotum. The patient denies any trauma. The most likely diagnosis is

A. an indirect inguinal hernia.

B. a direct inguinal hernia.

C. an obturator hernia.

D. a femoral hernia.

(c) A. An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum.

(u) B. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. It is the result of a weakness in the inguinal 3external ring. Hernial contents may radiate anteriorly rather than into the scrotum.

(u) C. Obturator hernia's are more commonly seen in elderly women and are rarely palpable in the groin.

(u) D. Femoral hernias are rare in males and do not typically reduce with lying down.

Which of the following can be a very serious consequence of using antidiarrheals in a patient with inflammatory bowel

disease?

A. Lymphoma

B. Toxic megacolon

C. Bone marrow suppression

D. Delayed serum sickness-like reaction

(u) A. There is suggestion that lymphoma may result from the use of infliximab, an anti-TNF agent, utilized in refractory cases of Crohn's disease; however a clear link between the development of lymphoma and the use

of infliximab has not been established.

(c) B. Antidiarrheals may cause the development of toxic megacolon when used by patients with active severe

inflammatory bowel disease.

(u) C. Bone marrow suppression is a side effect of methotrexate, which is being increasingly used in the treatment of Crohn's disease.

(u) D. Delayed serum sickness-like reaction is another potential side effect of infliximab.

A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated

with?

A. Bladder

B. Stomach

C. Pancreas

D. Small bowel

(u) A. Pain from the bladder, uterus, or colon causes hypogastric pain.

(u) B. Pain from the stomach, duodenum, or pancreas causes epigastric pain.

(u) C. See B for explanation.

(c) D. Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.

Which of the following pathophysiological processes is believed to initiate acute appendicitis?

A. Obstruction

B. Perforation

C. Hemorrhage

D. Vascular compromise

(c) A. Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the

common bile duct or

A. cystic duct.

B. pancreatic duct.

C. duodenal ampulla.

D. common hepatic duct.

(c) A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the

gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis.

(u) B. Obstruction of the pancreatic duct leads to development of acute pancreatitis.

(u) C. The duodenal ampulla is the area where the pancreatic duct and the common bile duct empty into the duodenum. Gallstones do not cause obstruction at this distal site.

(u) D. The common hepatic duct from the liver joins the cystic duct from the gallbladder to form the common bile duct.Stone migration occurs along the pathway of the cystic duct to the common bile duct, not along the common hepatic duct.

A 3 week-old male infant presents with recurrent regurgitation after feeding that has progressed to projectile vomiting in the last few days. The mother states that the child appears hungry all of the time. She denies any diarrhea in the child. Which of the following clinical findings is most likely?

A. Bile-stained vomitus

B. Hemoccult positive stools

C. Olive-sized mass in the right upper abdomen

D. Sausage-shaped mass in the upper-mid abdomen

(u) A. Gastric obstruction, such as that seen with pyloric stenosis, causes vomiting that is not bilious.

(u) B. Blood-streaked vomitus, but not hemoccult positive stools, may be seen in pyloric stenosis.

(c) C. An olive-sized mass may be palpated in the right upper abdomen in pyloric stenosis and if found, is

pathognomonic for pyloric stenosis.

(u) D. A sausage-shaped mass may be noted in intussusception, not pyloric stenosis.

To further assess ascites in a patient, the physician assistant instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver?

A. Testing for shifting of dullness on percussion

B. Shifting of internal organs making percussion easier

C. Trying to elicit any pain while moving

D. Trying to produce a caput medusa

(c) A. In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while

tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.

(u) B. See A for explanation.

(u) C. Pain with movement is associated with peritonitis and not ascites.

(u) D. Caput medusa is the dilation of the superficial abdominal veins due to increased intraabdominal fluid

accumulation. It is visible with the patient standing and does not need a special maneuver for identification.

Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus?

A. Ingestion of mayonnaise-based salads 48 hours earlier

B. Bloody diarrhea with mucus for one week

C. Abdominal cramps and vomiting for 48 hours

D. High fever for 1 week

(u) A. A preformed toxin causes staphylococcal food poisoning; it has a short incubation period of 1-8 hours.

(u) B. Because Staphylococcus aureus does not invade the mucus, blood and mucus are not seen with this

noninflammatory cause of food poisoning.

(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food

poisoning.

(u) D. Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.

A 42 year-old male with a history of constipation presents with complaints of severe pain with defecation described as

feeling like he is "tearing apart." He has also noted occasional small amounts of blood on toilet paper. External examination of the rectum is unremarkable and an internal rectal exam cannot be performed due to severe pain when

attempted. Which of the following is the most likely diagnosis?

A. Proctitis

B. Anal fissure

C. Rectal prolapse

D. Internal hemorrhoids

(u) A. Proctitis is usually caused by anorectal infections that produce symptoms of anorectal discomfort, tenesmus, constipation, and discharge from the rectum.

(c) B. Anal fissures are easily diagnosed from history alone with the classic finding of severe pain upon defecation.Constipation is also a common cause of the trauma that leads to development of a fissure.

(u) C. Rectal prolapse is commonly seen in elderly females with complaints that include an anal mass, rectal bleeding and a change in bowel habits.

(u) D. While internal hemorrhoids may cause rectal bleeding, tearing pain is an uncommon complaint unless there is evidence of thrombosis of irreducible tissue.

Which of the following typical findings would be revealed during a sigmoidoscopy on a patient with Crohn's disease of the intestine?

A. Rectal pseudopolyps

B. Diffuse ulceration and bleeding

C. Sheets of WBCs with inflamed mucosa

D. Intermittent longitudinal mucosal ulcers and fissures

(u) A. Rectal pseudopolyps are associated with ulcerative colitis rather than Crohn's.

(u) B. Diffuse ulcerations and bleeding are more characteristic of ulcerative colitis than Crohn's disease.

(u) C. Sheets of WBCs or "pseudomembranes" can be detected in patients with pseudomembranous colitis.

(c) D. Ulcerations tend to be linear with transverse fissures in Crohn's disease. These skip lesions are common with Crohn's disease.

A 48 year-old male presents with complaints of heartburn that occurs approximately 45 minutes after eating about three times a week that is relieved by antacids. He claims to have followed advice about elevating the head of the

bed, avoiding spicy foods, and losing weight, but continues to have heartburn. Which of the following is the most appropriate next step?

A. Ranitidine (Zantac)

B. Sucralfate (Carafate)

C. Metoclopramide (Reglan)

D. Misoprostol (Cytotec)

(c) A. Ranitidine, an H2 receptor blocker, is indicated for the treatment of mild, intermittent symptoms of

gastroesophageal reflux disease.

(u) B. Sucralfate is used in the treatment of duodenal ulcers.

(u) C. Metoclopramide is indicated for the treatment of gastroparesis as a first-line agent and as a second-line agent in the treatment of refractory gastroesophageal reflux.

(u) D. Misoprostol is indicated for the prevention of NSAID-induced gastritis.

Which of the following is the laboratory test that marks recovery from Hepatitis B infection and non-infectivity?

A. Hepatitis B surface antibody(anti-HBs)

B. Hepatitis B surface antigen (HBsAg)

C. Hepatitis B core antigen (HBcAg)

D. Hepatitis A antibody (anti-HAV)

(c) A. Specific antibody to HBsAg appears in most individuals after clearance of HBsAg which indicates recovery from hepatitis B infection, non-infectivity, and immunity.

(u) B. This test establishes infection with HBV and implies infectivity.

(u) C. Presence of the hepatitis B core antigen reflects active infection.

(u) D. Patients who have immunity to hepatitis A do not have immunity to hepatitis B.

A 32 year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and

vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention?

A. Stool for culture, ova, and parasites

B. Proctosigmoidoscopy

C. Metronidazole (Flagyl)

D. Supportive treatment

(u) A. Stool culture and examination for ova and parasites are indicated when the diarrhea has persisted longer than 3 weeks or is associated with abdominal pain, fever, and/or bloody stools.

(u) B. Proctosigmoidoscopy is indicated when inflammatory bowel disease is suspected on the basis of fever, bloody diarrhea, or abdominal pain.

(u) C. Metronidazole is indicated with a confirmed diagnosis of Giardia lamblia or amebic disease.

(c) D. Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.

A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise

unremarkable. Which of the following is the most likely diagnosis?

A. Viral hepatitis

B. Pancreatic cancer

C. Acute cholecystitis

D. Gilbert's syndrome

(u) A. While viral hepatitis may cause jaundice, the liver is enlarged and tender.

(c) B. Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.

(u) C. While acute cholecystitis may present with jaundice and an enlarged gallbladder, the pain is classically colicky and located in the right upper quadrant. On physical examination with deep inspiration and palpation of the right subcostal area increased pain and respiratory arrest (Murphy's sign) is usually seen.

(u) D. Gilbert's syndrome is the most common of the hereditary hyperbilirubinemias. It is most often diagnosed near puberty or adult life based on results of a comprehensive metabolic panel.

A 16 year-old male is brought into your office by his girlfriend. She states that "he hasn't been himself lately" and seems to fluctuate from being almost "euphoric" to being depressed and irritable. The patient states that "he is really

okay" and that he "just feels a little irritable occasionally." On physical examination his pulse is 120 beats/minute, blood pressure is 180/110 mmHg, he is sweating and his pupils are widely dilated. Which of the following is the most

likely diagnosis?

A. Opiate abuse

B. Acute anxiety attack

C. Cocaine intoxication

D. Bipolar affective disorder

(u) A. Opiate abuse would be suspected with the presence of euphoria, drowsiness, and constricted pupils. More severe cases present with bradycardia, hypotension, coma, or respiratory arrest.

(u) B. While acute anxiety disorder may present with tachycardia, agitation, diaphoresis, and hypertension, this diagnosis should be a diagnosis of exclusion. Failure to diagnose cocaine intoxication could lead to severe consequences.

(c) C. Cocaine is a stimulant and presenting clinical manifestations of intoxication include agitation, tachycardia,hypertension, diaphoresis, and dilated pupils.

(u) D. While the history may suggest the diagnosis of bipolar affective disorder, the physical exam findings do not support this diagnosis.

A 25 year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is

A. acyclovir (Zovirax).

B. omeprazole (Prilosec).

C. fluconazole (Diflucan).

D. penicillin G.

(u) A. Acyclovir is an antiviral used in the treatment of herpes esophagitis.

(u) B. Omeprazole is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease with

esophageal ulceration and peptic ulcer disease and is not indicated in the treatment of infectious esophagitis.

(c) C. The patient has Candida esophagitis and the treatment of choice is fluconazole.

(u) D. Penicillin G is an antibiotic and is not effective against fungal infections.

A 53 year-old man who had previously been in good health presents to the emergency department with a history of passing approximately 300 cc of bright red blood from the rectum 45 minutes ago. From which of the following anatomical sites is the bleeding most likely originating?

A. rectosigmoid

B. duodenum

C. stomach

D. esophagus

(c) A. Rectosigmoid is the most common site leading to hematochezia.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

A 40 year-old female complains of acute right upper quadrant pain radiating to the back and low grade fever. Laboratory evaluation indicates the presence of urinary bilirubin and an elevation of serum alkaline phosphatase.

Which of the following is the most likely diagnosis?

A. cholecystitis

B. viral hepatitis

C. Gilbert's syndrome

D. Dubin-Johnson syndrome

(c) A. The presence of urinary bilirubin indicating conjugated hyperbilirubinemia coupled with the elevation of serum alkaline phosphatase suggests biliary obstruction that may lead to cholecystitis.

(u) B. Although viral hepatitis presents with conjugated hyperbilirubinemia, aminotransferase elevation would

predominate, not alkaline phosphatase.

(u) C. Gilbert's syndrome presents as unconjugated hyperbilirubinemia so urinary bilirubin would be absent.

(u) D. Although this hereditary disorder presents with conjugated hyperbilirubinemia, liver enzymes would not be elevated.

Which of the following signs is positive in the presence of ascites?

A. shifting dullness

B. CVA tenderness

C. ballottment sign

D. cutaneous hypersensitivity

(c) A. Shifting dullness or the presence of a fluid wave is noted in patients with ascites.

(u) B. CVA tenderness is noted in patients with pyelonephritis.

(u) C. Ballottment test is used to assess a floating mass in the abdomen.

(u) D. Cutaneous hypersensitivity is used to identify a specific zone of peritoneal irritation.

A patient presents with a concern about an upcoming trip. He states he is traveling to Mexico and has a question about how to treat diarrhea should it develop. In addition to promoting fluid intake which of the following is

recommended?

A. kaolin-pectin

B. ciprofloxacin

C. simethicone

D. doxycycline

(u) A. Kaolin-pectin is not indicated in the treatment of traveler's diarrhea.

(c) B. Ciprofloxacin is indicated in the treatment of traveler's diarrhea.

(u) C. Simethicone is used in the treatment of intestinal gas.

(u) D. Doxycycline is not indicated in the treatment of traveler's diarrhea due to increasing resistance.

At birth an infant weighs 8 pounds. The optimal weight for this infant at 1 year would be

A. 16 pounds.

B. 20 pounds.

C. 24 pounds.

D. 28 pounds.

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. An infants birth weight should double by 4-5 months of age and triple by 1 year of age.

(u) D. See C for explanation.

A patient presents complaining of vague anal discomfort. On examination, the patient is noted to have a few small external hemorrhoids and edema in the anal region. Which of the following is the most appropriate intervention?

A. proctoscopy followed by a hemorrhoidectomy

B. increased dietary fiber and sitz baths

C. hemorrhoidal banding

D. inject a sclerosing agent

(u) A. Hemorrhoidectomy should be used for permanently prolapsed internal hemorrhoids.

(c) B. Most hemorrhoids respond well to conservative treatment such as fiber and sitz baths.

(u) C. Banding and injection of sclerosing agents are used if mild prolapse, enlargement, or intermittent bleeding is present.

(u) D. See C for explanation.

Which of the following subtypes of viral hepatitis requires the presence of the hepatitis B virus for replication?

A. hepatitis A

B. hepatitis C

C. hepatitis D

D. hepatitis E

(u) A. Hepatitis A is transmitted almost exclusively by the fecal-oral route and does not require the presence of the hepatitis B virus for replication.

(u) B. While hepatitis C may occur in IV drug users, it does not require the presence of the hepatitis B virus for

replication.

(c) C. In the United States, hepatitis D is most commonly seen in persons exposed frequently to blood or blood

products, such as drug addicts. It requires the presence of hepatitis B virus for its replication and expression.

(u) D. Hepatitis E resembles hepatitis A in its enteric mode of transmission and does not require the presence of the hepatitis B virus for replication.

A 62 year-old patient with arthritis is on daily naproxen therapy. Which of following medications is used to protect against GI complications?

A. diphenoxylate (Lomotil)

B. sulfasalazine (Azulfidine)

C. metoclopramide (Reglan)

D. misoprostol (Cytotec)

(u) A. Diphenoxylate is used in the treatment of diarrhea.

(u) B. Sulfasalazine is used in the treatment of inflammatory bowel disease.

(u) C. Metaclopramide is used in the treatment of nausea and vomiting.

(c) D. Misoprostol is an analog of prostaglandins and used in the treatment of NSAID induced ulcer disease.

The initial manifestation of acute pancreatitis is often

A. generalized pruritus.

B. epigastric pain.

C. epigastric mass.

D. anorexia.

(u) A. Pruritus presents as a symptom only when acute pancreatitis occurs as a result of obstruction of the distal common bile duct.

(c) B. The typical findings in acute pancreatitis include nausea, vomiting, and abdominal pain. Epigastric pain,

generally abrupt in onset, is steady and severe.

(u) C. Epigastric mass is more common in pancreatic cancer.

(u) D. Anorexia is a common finding with chronic pancreatitis, but uncommon with acute pancreatitis.

Which of the following is the mechanism of action of infliximab (Remicade)?

A. block lymphocyte proliferation

B. direct effect on smooth muscle

C. monoclonal antibody that binds to tumor necrosis factor

D. 5-HT antagonist

(u) A. The immunomodulators (6-MP) work by blocking lymphocyte proliferation.

(u) B. The mechanism of action of mebeverine is direct effect on smooth muscle in irritable bowel syndrome.

(c) C. Infliximab is a monoclonal antibody that binds to tumor necrosis factor.

(u) D. The anti-nausea and vomiting medications like ondansetron work by blocking 5-HT receptors.

Ulcerative colitis usually presents with which of the following?

A. bloody diarrhea

B. toxic megacolon

C. fever and left quadrant pain

D. alternating constipation and diarrhea

(c) A. Ulcerative colitis typically presents with episodic bloody diarrhea, lower abdominal cramps, and urgency to defecate.

(u) B. Toxic megacolon is a complication of ulcerative colitis, but it is not a common presentation.

(u) C. Left lower quadrant pain and a palpable mass accompanied by fever is classic for diverticulitis.

(u) D. Irritable bowel syndrome usually presents with constipation, painless diarrhea with mucous, or alternating constipation and diarrhea.

A 65 year-old patient with adenocarcinoma of the colon in remission presents for follow-up. Which of the following tumor markers should be monitored?

A. AFP

B. CEA

C. CA 19-9

D. CA-125

(u) A. AFP is used to monitor recurrence of hepatocellular carcinoma.

(c) B. CEA is used to monitor recurrence of colon carcinoma.

(u) C. CA 19-9 is used to monitor recurrence of pancreatic carcinoma.

(u) D. CA-125 is used to monitor recurrence of ovarian carcinoma.

The main complication with the use of transjugular intrahepatic portosystemic shunt (TIPS) procedure is which of the

following?

A. increased portal pressures resulting in further esophageal varices

B. increased portal pressures resulting in a worsening of cirrhosis

C. Budd-Chiari syndrome

D. increased risk of encephalopathy

(u) A. TIPS procedures are performed in order to shunt blood away from the liver parenchyma which in essence

lowers portal pressures lessening the risk for esophageal varices.

(u) B. TIPS procedures, since they cause of bypass of the liver parenchyma, result in a lessening of the blood flow

into the liver which does not cause cirrhosis to progress.

(u) C. Budd-Chiari syndrome is a thrombosis of the hepatic vein. It is not a common complication of the TIPS procedure.

(c) D. TIPS procedures involve the placement of a stent in the liver in order to shunt blood away from the portal vein into the hepatic vein which bypasses the cirrhotic liver parenchyma. Its main complication is encephalopathy from the accumulation of toxic substances in the brain since the liver no longer acts as a filter.

A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting?

A. scopolamine (Scopace)

B. meclizine (Antivert)

C. ondansetron (Zofran)

D. loperamide (Imodium)

(u) A. Scopolamine and meclizine are effective against motion sickness, but ineffective against substances that act directly on the chemoreceptor trigger zone.

(u) B. See A for explanation.

(c) C. Ondansetron selectively blocks 5-HT3 receptors in the periphery (visceral afferent fibers) and in the brain

(chemoreceptor trigger zone). It is indicated for use in chemotherapy induced nausea and vomiting.

(u) D. Loperamide has low anti-emetic potency.

A 45 year-old female presents with a ten pound weight loss and recurrent greasy stools mixed with diarrhea. The patient notes that these symptoms are worse with certain foods. Which of the following laboratory tests should initially

be ordered?

A. anti-endomysial antibodies

B. anti-mitochondrial antibodies

C. anti-glomerular basement membrane antibodies

D. anti-phospholipid antibodies

(c) A. Patients with celiac sprue disease are likely to have anti-endomysial antibody formation.

(u) B. Anti-mitochondrial antibodies are present with hypothyroid disease and other autoimmune disease processes.

(u) C. Anti-glomerular basement disease occurs in the kidney and lungs and these antibodies are positive in patients with Goodpasture's disease.

(u) D. Anti-phospholipid antibodies are seen in patients who have systemic lupus erythematosus.

Which of the following is used to screen for malabsorption disorders of the intestines?

A. serum gastrin level

B. urea breath test

C. fecal eosinophils

D. stool fecal fat

(u) A. Serum gastric level is elevated in Zollinger-Ellison syndrome.

(u) B. Urea breath test is used in the diagnosis of H. pylori infection.

(u) C. Eosinophils are elevated in inflammatory diarrhea due to eosinophilic gastroenteritis.

(c) D. Stool fecal fat is the gold standard test for the evaluation of patients with malabsorption of the intestine.

A patient presents with abdominal pain. On deep palpation of the left lower quadrant the patient notes increased pain in the right lower quadrant. This is noted as a positive

A. Psoas sign.

B. Murphy's sign.

C. Rovsing's sign.

D. Obturator sign.

(u) A. A psoas sign is positive when the supine patient notes pain with flexion of the hip against resistance.

(u) B. A Murphy's sign is positive when the patient experiences abrupt cessation of deep breathing with palpation of the gallbladder.

(c) C. A Rovsing's sign is positive when the patient experiences right lower quadrant pain with deep palpation of the left lower quadrant.

(u) D. The obturator sign is positive when the supine patient experiences pain when the right leg is flexed at the hip and knee and the hip is externally and internally rotated.

The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is

A. nasogastric decompression.

B. invasive hemodynamic monitoring.

C. abdominal exploration.

D. administration of antibiotics.

(c) A. Nasogastric decompression is indicated in all but mild cases of obstruction to prevent distal passage of

swallowed air and minimize distension.

(u) B. Invasive hemodynamic monitoring is needed only if the patient has underlying cardiac, pulmonary, or renal disease.

(u) C. Abdominal exploration is considered only if the obstruction does not resolve in 24 to 48 hours or if peritoneal findings, fever, or rapidly progressing abdominal pain occur.

(u) D. Antibiotics are given only if surgery is to be done.

A 65 year-old patient with known history of alcohol and tobacco abuse presents with solid food dysphagia. The patient also has a 24 lb weight loss over the past 6 months. Which of the following is the most appropriate

intervention?

A. endoscopy with biopsy

B. chest x-ray

C. barium esophagogram

D. CT scan of the thorax

(c) A. Endoscopy with biopsy establishes the diagnosis of esophageal cancer with a high degree of reliability.

(u) B. Chest x-ray may show adenopathy, a pulmonary or bony metastases or sign of tracheoesophageal fistula.

Barium esophagogram is obtained as the first study to evaluate the dysphagia. CT scan should be obtained once the diagnosis of carcinoma has been made to evaluate for pulmonary or hepatic metastases, lymphadenopathy, and local tumor extension. None of these tests will reveal the diagnosis of carcinoma.

(u) C. See B for explanation.

(u) D. See B for explanation.

A patient is hospitalized with a change in mental status. Examination reveals that he is unable to maintain dorsiflexion of the wrists after pronating his arms in front of his body. Which of the following is the most likely diagnosis?

A. cocaine overdose

B. hyperthyroidism

C. hepatic encephalopathy

D. Parkinson's disease

(u) A. Tremor and agitation are part of acute cocaine intoxication, not asterixis.

(u) B. Hyperthyroidism causes a fine resting tremor, not asterixis.

(c) C. This is the description for asterixis that is seen with hepatic encephalopathy, uremia, and carbon dioxide narcosis.

(u) D. Parkinson's disease has resting tremor, rigidity, akinesia, and postural hypotension, not asterixis.

A 23 year-old female presents with a 24-hour history of watery diarrhea, nausea and vomiting after returning from a cruise. On exam, the vitals reveal HR 120, BP 90/60, and RR 20. The abdomen is soft and non-tender, with

hyperactive bowel sounds. Which of the following is the most appropriate management at this time?

A. loperamide (Imodium)

B. IV hydration

C. bismuth sulfate (Pepto bismol)

D. ciprofloxacin (Cipro)

(u) A. Loperamide is not indicated for acute infectious gastroenteritis in the vomiting patient.

(c) B. This is most likely a self-limiting viral gastroenteritis and is treated with hydration and supportive care.

(u) C. Bismuth sulfate is useful for treating diarrhea but is not helpful while the patient is vomiting.

(u) D. Antibiotics, like ciprofloxacin, are not indicated for viral infections.

A 3 year-old presents with a 24-hour history of diarrhea. The patient is afebrile and the stool is noted to be loose and watery. No blood is noted in the stool. Fecal WBC is negative. Which of the following is the most likely diagnosis?

A. viral gastroenteritis

B. toxic megacolon

C. ulcerative colitis

D. intussusception

(c) A. Patients with viral gastroenteritis are afebrile and noted to have loose, watery, non-bloody diarrhea. Fecal WBC is negative.

(u) B. Toxic megacolon is a complication of ulcerative colitis and presents with diarrhea, fever, tachycardia, and leukocytosis.

(u) C. Ulcerative colitis presents with bloody diarrhea, abdominal pain, and fever.

(u) D. Intussusception is more common in children age 1-2 years and presents with crampy abdominal pain, vomiting, and currant jelly stool.

A 16 day-old male presents in the office with a history of vomiting after feeding for the past 2 days. The vomiting has become progressively worse and the mother describes it as very forceful, sometimes hitting the floor 6 feet away. She says the neonate is always hungry. On physical examination, it is noted that he is 2 ounces below birth weight, and has a small palpable mass (about 1.5 cm) in the epigastrium. The most likely diagnosis is

A. achalasia.

B. tracheoesophageal fistula.

C. pyloric stenosis.

D. Meckel's diverticulum.

(u) A. Achalasia is uncommon under the age of 5 and the child presents with retrosternal pain and dysphagia.

(u) B. Tracheoesophageal fistula presents with increased secretions, choking, cyanosis, and respiratory distress

within the first few hours of life.

(c) C. Pyloric stenosis begins between 2 to 4 weeks of age with vomiting that becomes projectile after each feeding. An olive-size mass can often be felt in the epigastrium.

(u) D. Meckel's diverticulum presents with painless rectal bleeding. Vomiting is rare unless obstruction has occurred.

A 30 year-old patient presents with weight loss, diarrhea, and steatorrhea. Labs reveal that the antiendomysial antibody (AEA) is positive. What is the most likely diagnosis?

A. Celiac sprue

B. Ulcerative colitis

C. Whipple's disease

D. Zollinger-Ellison syndrome

(c) A. Celiac sprue is not only characterized by these classic symptoms. The antiendomysial antibody has a 90-95% sensitivity and 90-95% specificity for celiac sprue.

(u) B. Ulcerative colitis could be responsible for the symptoms mentioned however antiendomysial antibody (AEA) would not be positive.

(u) C. Whipple's disease is an infectious disorder known to cause diarrhea and weight loss. It also results in arthralgia and symptoms involving both the central nervous and cardiac systems that are not easily missed due to their severity. Diagnosis involves biopsies of the involved tissues looking for PAS-positive macrophages.

(u) D. Zollinger-Ellison syndrome (ZE) is a hypersecretory disorder. Diarrhea can occur but will not generally be the predominant symptom.

Which of the following is the most important intervention in acute pancreatitis?

A. IV fluid administration

B. Antibiotic administration

C. Calcium replacement

D. Antiemetics

(c) A. The mainstay of management in acute pancreatitis is fluid resuscitation. Isotonic solutions are best to maintain renal perfusion and urine output > 100 ml/hour.

(u) B. 90% of patients will recover with supportive measures only. Parenternal antibiotics are not indicated in acute pancreatitis.

(u) C. Hypocalcemia is a marker of prognosis, but correction of hypocalcemia does not supercede the importance of fluid resuscitation from the overwhelming inflammatory response.

(u) D. Other supportive measures in acute pancreatitis include pain management and antiemetics, but the mainstay is fluid resuscitation.

As a rule, solid foods such as cereal and fruits are best introduced into an infant's diet at approximately

A. 1 to 3 weeks.

B. 4 to 8 weeks.

C. 4 to 6 months.

D. 10 to 14 months.

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. The inclusion of solid foods in the diet is best done at approximately 4-6 months. Before 4 to 6 months of age does not contribute significantly to the infant's health and it increases their risk of allergies and atopy.

(u) D. After 6 months, meat, eggs, and starchy foods can be introduced.

Which of the following laboratory tests, if positive, would be most indicative of Crohn's disease?

A. Antineutrophil cytoplasmic antibodies (ANCA)

B. Antiendomysial antibodies (AEA)

C. Antinuclear antibodies (ANA)

D. Anti-Saccharomyces cerevisiae antibodies (ASCA)

(u) A. Antineutrophil cytoplasmic antibodies is positive in 60-70% of patients with ulcerative colitis while only 5-10% of Crohn's disease patients have positive results.

(u) B. The antiendomysial IgA antibodies are directed against tissue transglutaminase and has a 90-95% specificity for celiac sprue.

(u) C. Antinuclear antibodies are elevated in a wide variety of autoimmune disorders and therefore are a nonspecific finding.

(c) D. About 60-70% of patients with Crohn's disease are positive for these antibodies which are directed at the cell walls of S. cerevisiae while only 10-15% of ulcerative colitis is found to be positive.

In a patient with metabolic acidosis due to ingestion of methanol, which substance below is considered therapeutic?

A. Salicylates

B. Paraldehyde

C. Ethylene glycol

D. Ethanol

(u) A. Salicylates, paraldehyde, ethylene glycol all cause metabolic acidosis with an elevated anion gap.

(u) B. See A for explanation.

(u) C. See A for explanation.

(c) D. Ethanol, along with hemodialysis and supportive measures, is indicated for metabolic acidosis caused by

methanol ingestion.

What is the term for blue discoloration about the umbilicus?

A. Cullen's sign

B. Murphy's sign

C. Rovsing's sign

D. Turner sign

(c) A. Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic pancreatitis and results from hemoperitoneum.

(u) B. Murphy's sign is seen in liver and gallbladder disease by which the patient abruptly halts deep inspiration due to pain in the right upper quadrant while the examiner's hand is keeping stable pressure to the area.

(u) C. Rovsing's sign is positive when the patient experiences right sided abdominal pain with palpation to the left side. This is generally seen in those with appendicitis.

(u) D. Turner sign is also seen in severe, acute pancreatitis but is represented by a green-brown discoloration of bilateral flanks.

Which of the following medications decreases the exchange of hydrogen for potassium by inhibiting hydrogen,

potassium-ATPase?

A. Ranitidine (Zantac)

B. Misoprostol (Cytotec)

C. Sucralfate (Carafate)

D. Omeprazole (Prilosec)

(u) A. Ranitidine is an H2 receptor antagonist.

(u) B. Misoprostol is a prostaglandin analogue.

(u) C. Sucralfate is a coating agent.

(c) D. Omeprazole, a proton pump inhibitor, works by inhibiting hydrogen, potassium-ATPase.

A patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the most

appropriate management of this patient?

A. Oral analgesics

B. Diagnostic peritoneal lavage

C. Proton pump inhibitors

D. Laparoscopic cholecystectomy

(u) A. See D for explanation.

(h) B. Diagnostic peritoneal lavage is used to detect intraabdominal bleeding from trauma and not to treat acute cholecystitis and may delay appropriate treatment.

(u) C. Proton pump inhibitors are used to treat GERD or PUD.

(c) D. The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.

A patient presents uncertain as to whether he has completed the Hepatitis B vaccination series. What laboratory test would be most helpful in determining his immunization status?

A. Anti-HBs

B. HBeAg

C. HBsAg

D. Anti-HBc

(c) A. Anti-HBs is the circulating antibody that develops to surface antigen in response to either past Hepatitis B

infection or to Hepatitis B immunization. It represents immunity to the Hepatitis B virus in otherwise

immunocompetent patients.

(u) B. HBeAg is seen with active disease and not from immunization.

(u) C. The surface antigen to Hepatitis B (HBsAg) is most often used to show acute infection and not immunity.

(u) D. Anti-HBc is seen with active disease and not from immunization.

A patient with a history of severe peptic ulcer disease is 5 weeks status post Billroth I surgery. One week ago he restarted his normal diet and has had the onset of severe nausea, abdominal cramping, and light-headedness that

occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis?

A. Anxiety disorder

B. Celiac sprue

C. Dumping syndrome

D. Irritable bowel syndrome

(u) A. Anxiety disorders can cause a wide variety of somatic syndromes such as those mentioned, but generally not with such a straightforward dietary trigger.

(u) B. Celiac sprue can cause similar symptoms as those listed, can develop at any age and can be worsened by the ingestion of gluten containing products. The patient's recent surgery makes dumping syndrome a much greater possibility.

(c) C. Dumping syndrome typically occurs after Billroth type I surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars.

(u) D. Irritable bowel syndrome is a diagnosis of exclusion and is associated with alternation in bowel habits.

A patient presents with abdominal pain in the right lower quadrant, examination reveals increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This commonly known as which of the following?

A. Psoas sign

B. Murphy's sign

C. Rovsing's sign

D. Obturator sign

(u) A. Psoas sign is right lower quadrant pain with right leg extension.

(u) B. Murphy's sign is seen in liver and gallbladder disease in which the patient abruptly halts deep inspiration due to discomfort as the examiners hand applies pressure to the right upper quadrant.

(c) C. A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain occurs in the right lower quadrant upon palpation of the left lower quadrant.

(u) D. Obturator sign is right lower quadrant pain with internal rotation of the hip.

A 45 year-old male presents with a long history of ulcerative colitis and recent progressive complaints of right upper quadrant pain, weight loss, fever and most recently, a rapid onset of jaundice with pruritus. Labs revealed elevated

bilirubin and alkaline phosphatase. Viral serologies were negative. An endoscopic cholangiogram showed areas of stenosis and dilation throughout the bile duct system. What is the most likely diagnosis?

A. Choledocholithiasis

B. Hepatic carcinoma

C. Portal hypertension

D. Primary sclerosing cholangitis

(u) A. Choledocholithiasis can most certainly cause elevated bilirubin and other liver function tests when obstruction occurs. It also occurs more often in persons with sclerosed or narrowed bile ducts however it does not generally carry a poor prognosis and can be generally recognized by its typical symptoms.

(u) B. Hepatic carcinoma does not cause areas of varied stenosis and dilation in the biliary tree.

(u) C. Portal hypertension may present with jaundice but generally has significant ascites as well that helps to

distinguish this disorder. It also does not result in the bile duct pattern mentioned.

(c) D. Primary sclerosing cholangitis (PSC) results in diffuse intra- and extrahepatic duct sclerosing with dilatation proximal to these areas.

Which of the following is the most effective prophylaxis for traveler's diarrhea?

A. Metronidazole

B. Ciprofloxacin

C. Tetracycline

D. Ampicillin

(u) A. Ampicillin, tetracycline, and metronidazole do not cover the common causes of traveler's diarrhea.

(c) B. Options for prophylaxis of traveler's diarrhea include norfloxacin, ciprofloxacin, ofloxacin, or

trimethoprim/sulfamethoxazole.

(u) C. See A for explanation.

(u) D. See A for explanation.

A 30 year-old female presents with a one to two year history of daily bouts of mid-abdominal crampy pain and bloating that are briefly relieved with defecation. Loose to watery bowel movements occur four to five times daily. She

denies any nocturnal symptoms. Previous laboratory studies, abdominal CT scans and a colonoscopy have all been normal. Attempted dietary changes, exercise and probiotics have provided no relief. What is the next step in

treatment for this patient?

A. Nortriptyline (Pamelor)

B. Omeprazole (Prilosec)

C. Polyethylene glycol (Miralax)

D. Promethazine (Phenergan)

(c) A. Nortriptyline, and other tricyclic antidepressants (TCAs), is an appropriate choice for someone with diarrhea predominant irritable bowel syndrome due to their numerous mechanisms of action.

(u) B. Omeprazole, a proton pump inhibitor, works on parietal cells in the stomach lining to reduce production of hydrochloric acid. Though beneficial for peptic ulcer and reflux disease it would provide no relief of symptoms in a patient with IBS.

(u) C. Polyethylene glycol is commonly used in constipation predominant IBS but would probably worsen this patient's symptoms.

(u) D. The anticholinergic properties of the promethazine might be helpful even though its somnolent effects would be significant and would not be superior to nortriptyline. Promethazine's strength is in nausea control and less often its antihistamine affects.

A male patient presents for a routine physical examination. He denies chronic health problems, regular medication use or previous surgeries. He exercises 4-5 times weekly, does not use tobacco products, and consumes alcohol in moderation. His last intake of alcohol was two weeks ago while on a trip to Mexico. His review of systems and physical examination are both negative. Routine labs were drawn which were significant for the following:

Total serum bilirubin 3.5 mg/dL (0.3-1.0 mg/dL),

direct bilirubin 0.2 mg/dL (0.1-0.3 mg/dL),

AST 35 U/L (0-35 U/L),

ALT 30 U/L (0-35 U/L),

Alkaline Phosphatase 48 U/L (30-120 U/L)

GGT 12 U/L (1-94 U/L).

What is the most likely diagnosis in this patient?

A. Alcoholic hepatitis

B. Crigler-Najjar syndrome

C. Gilbert's syndrome

D. Wilson's disease

(u) A. Alcoholic hepatitis presents with elevated ALT and AST.

(u) B. The Crigler-Najjar syndrome is typified by an isolated elevation in the unconjugated serum bilirubin and usually causes the bilirubin to be elevated at higher levels (6-45 mg/dL).

(c) C. Gilbert's syndrome is a relatively common cause of mild isolated elevations in indirect serum bilirubin.

(u) D. Wilson's disease is a disorder of impaired biliary copper excretion which among many other problems will cause a rise in total serum bilirubin but also significant elevations in AST.

What is the pathologic mechanism of Hirschsprung's disease?

A. Pyloric circular muscle hypertrophy causing gastric outlet obstruction

B. Absence of ganglion cells in the mucosal and muscular layers of the colon

C. A defect in the diaphragm leading to protrusion of the abdominal viscera into the thoracic cavity

D. Absence of relaxation of the lower esophageal sphincter and lack of peristalsis in the esophageal body

(u) A. Pyloric circular muscle hypertrophy causing gastric outlet obstruction describes pyloric stenosis.

(c) B. Hirschsprung's disease results from an absence of ganglion cells in the mucosal and muscular layers of the

colon.

(u) C. A defect in the diaphragm leading to protrusion of the abdominal viscera into the thoracic cavity describes

congenital diaphragmatic hernia.

(u) D. Absence of relaxation of the lower esophageal sphincter and lack of peristalsis in the esophageal body

describes achalasia of the esophagus.

A pregnant female presents at 32 weeks gestation with painless rectal bleeding and a bulging perianal mass when straining which goes away. Which of the following is the most appropriate management of this patient?

A. Hemorrhoidectomy

B. Metronidazole (Flagyl)

C. Psyllium (Metamucil)

D. Sclerotherapy

(u) A. Hemorrhoidectomy and sclerotherapy are reserved for severe Grade III and IV hemorrhoids.

(u) B. Metronidazole is not indicated in the treatment of hemorrhoids.

(c) C. Dietary fiber or psyllium bulk laxatives can be used to decrease straining with defecation.

(u) D. See A for explanation.

A patient presents with a long history of dyspepsia refractory to maximum appropriate therapy. A recent upper GI series revealed multiple gastric and duodenal ulcerations with prominent mucosal folds. What diagnostic study would be confirmatory of this patient's suspected diagnosis?

A. EGD with duodenal biopsy

B. Serum gastrin level

C. Helicobacter pylori serology

D. Abdominal CT scan

(u) A. An endoscopic biopsy of the duodenum may be necessary in some cases to ensure the absence of cancer, etc., but a biopsy in this area is not confirmatory for Zollinger-Ellison Syndrome, which is highly suspect, nor does it allow samples of the gastric mucosa to be studied.

(c) B. Serum gastrin levels can be elevated for many reasons; however significant elevations in a fasting state as well as with the secretin stimulation test are confirmatory for Zollinger-Ellison syndrome which is highly suspect in this case.

(u) C. Helicobacter pylori can cause symptoms refractory to medical management and an infection can occur

concomitantly with Zollinger-Ellison syndrome, but it does not confirm the diagnosis of a gastrinoma or similar hypersecretory disease.

(u) D. An abdominal CT scan is not specific enough to confirm the diagnosis of Zollinger-Ellison syndrome.

Which of the following is best described as a hard nodule in the periumbilical region?

A. Hodgkin's lymphoma

B. Gastric bezoar

C. Sister Mary Joseph nodule

D. Virchow's node

(u) A. Hodgkin's lymphoma will more likely affect intra-abdominal lymph nodes.

(u) B. Gastric bezoar can present as a palpable abdominal mass, but is not indicative of intra-abdominal/intra-pelvic cancer.

(c) C. The Sister Mary Joseph nodule can occur with metastatic gastric and pancreatic cancers. The nodule is

generally minimally to non-tender to palpation.

(u) D. Virchow's node is found in cases of metastatic disease, but is represented by a left supraclavicular lymph node.

A person presenting with bleeding esophageal varicies should be treated with which of the following while awaiting arrival of endoscopy?

A. Carafate (Sucralfate)

B. Octreotide (Sandostatin)

C. Omeprazole (Prilosec)

D. Enoxaparin (Lovenox)

(u) A. Carafate is not indicated in acute gastrointestinal bleeding.

(c) B. Octreotide is a vasoacctive drug used in the treatment of GI bleeding as well as somatostatin, vasopressin, and terlipressin. Somatostatin and octreotide are preferred due to safety and less incidence of serious side effects.

(u) C. Omeprazole, a proton pump inhibitor, is not indicated in acute gastrointestinal hemorrhage.

(h) D. Enoxaparin will increase bleeding and therefore contraindicated in GI bleeding.

What is considered the most common physical examination finding for intestinal obstruction?

A. Distention

B. Fluid wave

C. Rigidity

D. Tenderness

(c) A. Abdominal distention is the most common hallmark of all kinds of intestinal obstructions though its presence can be variable depending on the duration and exact location of the obstruction.

(u) B. Fluid wave is noted with ascites, not intestinal obstruction.

(u) C. Rigidity is most often minimal to absent except in the most extreme of late presenting strangulated obstructions and is more commonly found early in the course of peritonitis and related phenomenon.

(u) D. Tenderness, like rigidity, is not a predominant finding in obstructed bowel until very late in the course of advancing, untreated cases. At this time distention and symptoms of shock will also be present and command the clinical picture.

A 33 year-old patient returns from a community picnic that was held on a hot July day. The patient developed severe explosive diarrhea, nausea, vomiting and abdominal cramps six hours after having homemade potato salad and hot dogs. Multiple people who ate at this picnic have similar symptoms. There is no associated fever. What is the most likely causative organism for these symptoms?

A. Clostridium perfringens

B. Campylobacter jejuni

C. Shigella

D. Staphylococcus aureus

(u) A. Clostridium perfringens has a 12 to 24 hour incubation period and symptoms are limited to diarrhea and crampy abdominal pain but nausea and vomiting are unusual.

(u) B. Campylobacter jejuni, the most common cause of acute bacterial diarrhea, has a prodrome period of 12 to 24-hours with headache, fever, and malaise that is followed by crampy abdominal pain and diarrhea.

(u) C. Shigella infection causes bacterial dysentery in tropical regions most commonly and transmission is usually from person to person rather than from food-borne spread. Nausea and vomiting are unusual.

(c) D. Staphylococcus aureus is an acute illness caused by the ingestion of enterotoxin-producing organism. It is the only common acute ingestion of a preformed toxin. The clinical picture in the question is the classic presentation for this illness. Foods most responsible for this infection are ham, cream, custard pastries, and mayonnaise-based salads.

A 62 year-old male is brought to the emergency department with acute hematemesis. The patient denies a previous history of vomiting. His wife states he has chronic liver disease. Physical examination reveals a distended abdomen without rebound, guarding or organomegaly. There is a fluid wave. Which of the following is the most likely diagnosis?

A. Esophageal varices

B. Mallory-Weiss tear

C. Arteriovenous malformation

D. Perforated duodenal ulcer

(c) A. Esophageal varices are dilated submucosal veins that develop in a patient with underlying portal

hypertension. The most common cause of portal hypertension is cirrhosis.

(u) B. A patient with a Mallory-Weiss tear would have a history of retching but would not have a distended

abdomen.

(u) C. Most arteriovenous malformations are asymptomatic. If symptomatic they would have symptoms of a slow bleed.

(u) D. A patient with perforated duodenal ulcer would have rebound and guarding on examination.

Which of the following medications is most useful in maintaining remission in a patient with ulcerative colitis?

A. Oral corticosteroids

B. Corticosteroid enemas

C. Sulfasalazine

D. Macrodantin

(u) A. Corticosteroids, given orally or via enema preparations, are used for acute flare-up of ulcerative colitis but are not effective when given as prophylactic agents.

(u) B. See A for explanation.

(c) C. Sulfasalazine, olsalazine, and mesalamine are effective in maintaining remission in patients with ulcerative colitis.

(u) D. Long-term antibiotic therapy with Macrodantin is used as a prophylactic agent to prevent urinary tract infections and has no role in the treatment or prevention of ulcerative colitis.

A 50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. Which of the following is the most likely diagnosis?

A. Abdominal aortic aneurysm

B. Perforated duodenal ulcer

C. Acute myocardial infarction

D. Cholecystitis

(u) A. A patient with an abdominal aortic aneurysm may present with pain radiating to the back, however would not have coffee ground emesis or an acute abdomen.

(c) B. Perforation of a duodenal ulcer causes sudden, severe pain, with rebound tenderness and rigid abdomen on physical examination. It is often associated with coffee ground emesis.

(u) C. A patient with an acute myocardial infarction may have pain radiating to the back, however would not have

hematemesis or an acute abdomen.

(u) D. Cholecystitis presents with right upper quadrant pain and is not typically associated with coffee ground

emesis or rebound tenderness.

A patient presents with nausea, vomiting, and fever for one day. She describes periumbilical abdominal pain which has settled in her right lower quadrant. On examination she has right lower quadrant pain with deep left lower

quadrant palpation. This finding is known as which of the following?

A. Psoas sign

B. Rebound tenderness

C. Rovsing's sign

D. Obturator sign

(u) A. Abdominal pain with flexion of the right hip against pressure is a psoas sign.

(u) B. Right lower quadrant pain with quick withdrawal of the right lower quadrant palpation is rebound

tenderness.

(c) C. Right lower quadrant pain with deep left lower quadrant palpation is Rovsing's sign.

(u) D. Right lower quadrant pain with internal rotation of the right hip while both the hip and knee are flexed is

obturator sign.

Which of the following is the study of choice to diagnose upper gastrointestinal malignancy?

A. Abdominal CT

B. Upper endoscopy

C. Barium swallow

D. Abdominal ultrasound

(u) A. See B for explanation.

(c) B. Upper endoscopy is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis and upper gastrointestinal malignancy.

(u) C. See B for explanation.

(u) D. See B for explanation.

An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal injury. Physical examination is unremarkable. Chest radiograph reveals a radiopaque

round object at the distal esophagus. Which of the following is the most appropriate treatment option?

A. Observation for 24 hours

B. Esophagoscopy for removal

C. Barium swallow

D. Bronchoscopy

(h) A. Batteries must be removed as they can induce mucosal injuries in as little as one hour of contact time.

(c) B. Esophagoscopy is the procedure of choice for acutely ingested foreign bodies.

(u) C. A barium swallow is a diagnostic option but will not provide treatment.

(u) D. Bronchoscopy would be the procedure of choice for an airway foreign body, not esophageal.

A 40 year-old male presents with several months of abdominal pain and nausea. Endoscopy reveals an irregular 1 x

2 cm area of loss of rugal folds near the antrum. Biopsies show extensive mucosal and submucosal infiltration by Blymphocytes.

The patient is given appropriate treatment and the lesion resolves. Which infectious agent is most likely to be associated with these findings?

A. Aspergillus fumigatus

B. Helicobacter pylori

C. Human papilloma virus

D. Salmonella typhi

(u) A. A. fumigatus would be associated with pulmonary, not gastrointestinal disease.

(c) B. H. Pylori causes gastric mucosal inflammation with PMN's and lymphocytes. Infection causes nausea and

abdominal pain. Inflammation may be confined to the superficial gastric epithelium or may extend deeper

resulting in varying degrees of gland atrophy. Eradication of H. Pylori with appropriate therapy leads to

resolution of the chronic gastritis.

(u) C. Human papilloma virus is primarily a urogenital disorder.

(u) D. Salmonella typhi infection would present with fevers, malaise, vomiting, and other symptoms. This diagnosis is best made with blood cultures.

A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not

today. On examination, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. The child is alert and responsive, with no focal findings. Which of the following is the most appropriate

intervention?

A. Antibiotic therapy

B. Loperamide (Imodium)

C. 3% normal saline IV infusion

D. Oral rehydration

(u) A. In the US, infectious gastroenteritis is most frequently due to a virus. Antibiotic therapy may be second-line in cases where the causative organism is bacterial, is identified, and symptoms continue.

(u) B. Loperamide may lead to toxic megacolon.

(h) C. 3% normal saline infusion may cause hypernatremia and central pontine myelinosis.

(c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids.

The birth weight of an infant has usually tripled by

A. the second and third month.

B. the fourth and fifth month.

C. the seventh and eighth month.

D. one year.

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. See D for explanation.

(c) D. A child triples his/her birthweight by one year.

A 66 year-old female presents to your office complaining of progressive difficulty swallowing over the last 6 months. Initially she had difficulty only with meats, but now she has dysphagia with other foods as well. Which of the following is the most appropriate initial diagnostic study?

A. Barium swallow

B. Endoscopy

C. CT scan

D. Urea breath test

(u) A. Barium swallow may be used in the evaluation of dysphagia, but does not allow for biopsy to be performed.

(c) B. Endoscopy is the diagnostic study of choice in a patient with progressive dysphagia because of its ability to obtain tissue for diagnosis.

(u) C. See B for explanation.

(u) D. See B for explanation.

Which of the following is considered to be the treatment of choice for the pruritus that occurs with primary biliary cirrhosis?

A. Colchicine (Colzalide)

B. Atorvastatin (Lipitor)

C. Cholestyramine (Questran)

D. Enalapril (Vasotec)

(u) A. Colchicine is used to improve the biochemical abnormalities which may slow the progression of the disease.

(u) B. Statins have a role in the management of hyperlipidemia but are not effective in this disease.

(c) C. Cholestyramine, a bile salt sequestrant, is able to decrease the pruritus that occurs from the bile stasis and granulomas.

(u) D. ACE inhibitors are effective as antihypertensives and in preserving renal function in those with proteinuria, but they have no role in the management of primary biliary cirrhosis.