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Flashcards in Esophagus and Stomach - Shelf-Life Deck (24):
1

A septuagenarian man receiving palliative care in an extended care
facility begins to develop recurrent pneumonias. A barium swallow
study is completed and reveals an obvious outpouching within the left
neck between the levels of the pharynx and the esophagus.

Which of the following is the most likely diagnosis?
(A) Meckel diverticulum
(B) Traction mid-esophageal diverticulum
(C) True diverticulum
(D) Zenker diverticulum

The answer is D: Zenker diverticulum . A Zenker diverticulum is an outpouching that occurs at the junction of the pharynx and esophagus, usually seen in the elderly, and typically first noticed secondary to dysphagia. The imaging study shows that the diverticulum is in the proximal esophagus.
Though aspiration resulting in pneumonia is infrequent, it can occur. It is easily
diagnosed with a barium study. Given the weakness of the diverticulum,
endoscopic approaches are avoided.


(A) A Meckel diverticulum (also a true diverticulum) typically presents
in childhood or presents as a bowel obstruction in adults.

(B) Mid-esophageal traction diverticulum is a true diverticulum that can be asymptomatic or present with dysphagia that has a different location than that described.


(C) A Zenker diverticulum is a pulsion (or false) diverticulum and therefore
not a true diverticulum (as is mid-esophageal diverticulum) .

2

A 42 -year-old man with longstanding alcoholism i s brought t o the
emergency department by his family after vomiting large volumes of
bright red blood. B edside esophagoscopy reveals tearing of the mucosa
near the gastroesophageal junction ( G E J). Which of the following statements
regarding this condition is true?


(A) Diagnosis cannot be established without the use of computed
tomography ( CT) scanning
(B) Endoscopy is not only diagnostic but also therapeutic
(C) The disease is usually fatal
(D) The morbidity of this disease typically necessitates surgical intervention
(E) The presentation of this disease is an indication to screen for Helicobacter
pylori

The answer is B : Endoscopy is not only diagnostic but also therapeutic. Mallory-Weiss syndrome is due to mucosal bleeding near the GEJ,
typically due to retching and often seen in patients with alcoholism (or severe
vomiting) . The disease course is fairly benign. This condition can be both diagnosed and treated endoscopically. Endoscopic treatment is typically successful with balloon tamponade, sclerotherapy, banding, hemoclipping, electrocoagulation, or heater probe application.


(A) A CT scan would contribute little to this clinical picture.

(C) Fatality due to Mallory-Weiss syndrome is very rare.

(D) Surgical intervention, which involved ligation, is required only for rare cases that fail endoscopic management.

3

A 50-year-old man presents to the emergency department following
the sudden onset of constant back and abdominal pain following prolonged
vomiting over the past few days. He denies hematemesis. Physical
examination of the oral cavity is unremarkable, but palpation of the chest
reveals crepitus, and auscultation reveals crunching sounds with individual
respirations. Which of the following is the best first step in diagnosis?


(A) CT scan
(B) CT scan with intravenous contrast
(C) Esophagoscopy
(D) Oral contrast study with barium
(E) Oral contrast study with Gastrografin

The answer is E: Oral contrast study with Gastrografin . The physical
examination findings described in this clinical vignette, specifically subcutaneous emphysema and palpable air in the mediastinum (so-called Hamman crunch), are classic for Boerhaave syndrome. Note the similar history to the Mallory-Weiss syndrome described above. In contrast to Mallory-Weiss syndrome, Boerhaave syndrome typically involved full-thickness tears of the
esophagus whose bleeding resolves spontaneously.

While the most common cause of Boerhaave syndrome is iatrogenic secondary to upper endoscopy, it can occur due to similar causes of Mallory-Weiss syndrome (trauma, heaving, retching, etc) . The gold standard for diagnosis of Boerhaave syndrome is an oral contrast study with water-soluble contrast (e.g., Gastrografin) .


(A) While C T can be effective in diagnosing esophageal rupture, the
low cost and high sensitivity of a water-soluble contrast study make CT a less
ideal choice of study.

(B) Not only would CT be less ideal for reasons stated above, but also the use of contrast would contribute little to this scenario.

(C) Upper endoscopy can be effective in determining the extent of damage,
but air introduced into the esophagus can worsen the patient's condition.


(D) Barium should be avoided due to complications involving extravasation
into the mediastinum.

4

A 22-year-old woman is brought by rescue squad to the emergency
department following a failed suicide attempt. You are told on arrival that
she consumed a copious amount of an unidentified household cleaner
and was found covered with vomitus. She is febrile with otherwise normal
vitals, writhing in pain on her stretcher, and unable to provide any information.
Oral examination reveals erythema and hypersalivation. Which
of the following is the most crucial step in treatment of this patient?

(A) Administration of an emetic
(B) Encouragement of oral hydration
(C) Esophagoscopy
(D) Surgical intervention with resection of involved esophageal portions

The answer is C: Esophagoscopy. Esophagoscopy should be performed
first to examine the entire lining of the esophagus and assess the damage done by the offending agent. Assessment of damage can help to determine the treatment plan as well.


(A) Antiemetics should also be avoided as vomiting can "twice-expose"
the esophageal lining and increase the likelihood for perforation of a weakened mucosal lining.

(B) Oral hydration can be dangerous in this situation, where the substance is not identified, and water could cause further damage if proper
neutralizing agents (for acidic or alkaline agents) are not given.

(D) Surgical resection of damaged esophagus may be indicated for stenosis or fistulae, but only after thorough examination and diagnosis via esophagoscopy.

5

An 86-year-old woman post mastectomy returns to your clinic for
scheduled follow-up. On review of systems, you learn that she has had
an unintentional weight loss of 1 5 pounds and has developed acute
onset of dysphagia with occasional regurgitation. Further questioning
reveals that her dysphagia occurs with both solids and liquids, and
that her dysphagic pain is relieved with nitroglycerin that was given
to her by her cardiologist. Her pain is not related to physical exertion.
Physical findings, including a thorough cardiovascular examination,
are normal.

Which of the following is the most likely diagnosis?
(A) Achalasia
(B) Gastroesophageal reflux disorder (GERD)
(C) Stable angina
(D) Type I hiatal hernia
(E) Zenker diverticulum

The answer is A: Achalasia. The symptoms described in this vignette are
classic for those of achalasia, where an aperistaltic esophagus and unrelaxed
lower esophageal sphincter lead to patient complaints. Dysphagia to solids
and liquids, regurgitation, and weight loss secondary to bothersome meals are classic findings. The relief of pain by nitroglycerin is due to the drug's effect on sphincter tone (and can also be a finding in diffuse esophageal spasm). Physical examination is typically normal. The esophagogram shown reveals the infamous "bird's beak deformity:'


(B) Though symptoms of GERD could be similar to those described
here (dysphagia, regurgitation) , this discomfort would not be relieved by nitroglycerin and not be so acute.

(C) While a cardiovascular workup is definitely indicated, this chest pain would not be diagnosed as "stable" angina given it lacks relation to physical exertion.

(D) Most type I hiatal hernias are asymptomatic unless they lead to GERD symptomatology.

(E) Finally, Zenker diverticula are typically asymptomatic unless progressive where they are associated with dysphagia that is localized cervically.

6

A 27 -year-old man presents to your clinic with postprandial retrosternal
burning and nausea. His symptoms occur nightly, are worse after
large meals, and commonly occur when he lies recumbent following
dinner. He has never sought treatment for this apparently new problem.
He has a benign past medical and surgical history. His family history is
noncontributory. He consumes two to three cups of coffee per day and
drinks an occasional beer (one to two per week) with dinner. Which of
the following is the best means to establish this patient's diagnosis?

(A) Electrocardiogram
(B) Esophagogastroduodenoscopy (EGD)
(C) Oral contrast study with barium
(D) Trial of therapy with sublingual nitroglycerin
(E) Twenty-four-hour pH monitoring of the esophagus

The answer is E: Twenty-fou r-hour pH monitori n g of the esophag us.
The young gentleman in this question is presenting with the classic symptoms
of GERD, and the diagnosis is fairly straightforward. The question redirects,
however, to ask means of diagnosis (a redirect commonly used on USMLE
examinations ) .

The gold standard for diagnosing GERD is a 24-hour esophageal
pH monitor, where a pH less than 4.0 for 1 .3 % of the day (proximal
esophagus) or 4.2% of the day (distal esophagus) is sufficient for a diagnosis.


(A) An electrocardiogram (EKG) would be useful to diagnose angina
when it is present (or at least induced with an exercise or pharmacologic stress test).

(B) An EGD would be useful for GERD refractory to treatment, or as a
means to assess longstanding GERD complications (i.e., Barrett esophagus) 


(C) A barium swallow study would b e useful in cases o f GERD attributable
to another cause (e.g., hiatal hernia)

(D) Finally, while a therapeutic trial is useful for GERD in the primary care setting (and typically the USMLE answer of choice given the cost-effectiveness) , an inappropriate medication is listed in this answer.

7

The patient in the previous question stem returns to your clinic following
the outpatient diagnostics you arranged. Which of the following
is the ideal management of this patient assuming that your suspected
diagnosis is confirmed?


(A) Endoscopic dilatation and/or stenting
(B) Nissen total fundoplication
(C) Pharmacologic therapy with ranitidine
(D) Pharmacologic therapy with omeprazole
(E) Watchful waiting

The answer is D : Pharmacologic therapy with omeprazole. We are
told that the patient from the previous question returns with a positive diagnosis for presumptive GERD, and we are asked the ideal treatment for this disease. In addition to conservative measures (avoidance of caffeine, alcohol and smoking, elevating the head of the bed, etc.), medications are the mainstay of treatment. While H2-receptor blockers (e.g., ranitidine) are effective for occasional GERD symptoms, we are told that this patient experiences nightly symptoms.


(A) Endoscopic dilatation would be appropriate if other pathology was
reported (achalasia, advanced cancer with compromised function, Schatzki ring, etc.) but there is no indication for this invasive procedure.

(B) A Nissen fundoplication is very effective in correcting and reversing pathology involved with symptomatic hiatal hernias, but again, nothing indicates the presence of such pathology.

(C) Proton pump inhibitors (PPis, e.g., omeprazole) are recommended for daily symptoms and have become the first-line drug for patients with GERD.

(E) Finally, watchful waiting is not appropriate given a confirmed diagnosis of GERD, as complications include Barrett esophagus, a disease state that predisposes to esophageal cancer (specifically esophageal adenocarcinoma) .

8

A 6 1 -year-old Caucasian man has decided to transfer the care of his
esophageal cancer to your facility. Records indicate that this patient was
diagnosed with esophageal adenocarcinoma based on numerous biopsies
collected during EGD 3 weeks prior. He indicates to you that he has an
extensive GERD history that he self-treated with occasional, over-thecounter
antacids for years. An extensive physical examination reveals
lymphadenopathy in his right supraclavicular region. Three nodes measure
greater than 2 em. They are fixed, matted, and hard upon palpation.
Which is the most accurate stage of this man's disease based on the tumor,
nodes and metastasis (TNM) (AJCC) classification system?


(A) Stage I
(B) Stage II
(C) Stage III
(D) Stage IV
(E) Stage V

The answer is D : Stage IV. This is the classic patient for an esophageal cancer (a Caucasian man in his sixth to seventh decade) . He also indicates the classic history for esophageal adenocarcinoma, that is, longstanding, poorly treated GERD. Based on AJCC's TNM staging system, metastatic esophageal cancer in general (adenocarcinoma or squamous cell carcinoma) is noted by the presence of distant organ or nodal involvement (M 1 b) or nodal involvement of the celiac of supraclavicular lymph nodes (M i a) . Typically, metastatic disease (M l or greater) is classified at stage IV disease, which this gentleman unfortunately has. Note that right-sided supraclavicular lymphadenopathy is more associated with esophageal cancers. This patient will likely proceed to palliative chemotherapy, radiation, or combination therapy.


(A) Stage I esophageal cancer lacks nodal involvement and is reserved
for T l disease.

(B) Stage II includes T3 disease without nodal disease, or T2 disease with nodes.

(C) Stage III is diagnosed in the presence of T4 disease
(cancer beyond the adventitia into adj acent structures) or for T3 disease (into
the adventitia only) with nodal involvement.

(E) There is no stage V based on the AJCC classification system.

9

A 47-year-old woman returns to your office following upper endoscopy
secondary to longstanding, refractory GERD. A review of the operative
report indicates that red, velvety patches of esophageal mucosa were
noted at the level of the GEJ. Multiple biopsies were taken. Review of
the corresponding pathology report indicates the presence of Barrett
esophagus. You communicate to the patient her increased risk for
esophageal malignancy and the need for continued medical, possible
surgical, therapy. Which of the following statements most accurately
describes the pathological findings in Barrett esophagus?


(A) Abnormal squamous maturation with numerous intraepithelial
eosinophils
(B) Invasion of dysplastic glandular cells into the lamina propria
(C) Metaplasia from a columnar epithelium to a squamous epithelium
(D) Metaplasia from a squamous epithelium to a columnar epithelium
(E) Multinucleated giant endothelial cells with cystoplasmic inclusion
bodies

The answer is D: Metaplasia from a squamous epithe l i u m to a col u m nar
epithel i u m . This patient undergoes appropriate endoscopic evaluation for
her longstanding refractory GERD symptoms. Endoscopic evaluation reveals
the classic gross description of Barrett esophagus (red, velvety changes near the GEJ) and pathology indicates as such. Barrett esophagus describes metaplasia (cell morphology change) from the native squamous epithelium of the distal esophagus to a columnar lining similar to that of gastric mucosa. Recall that Barrett esophagus predisposes to esophageal adenocarcinoma (not squamous cell carcinoma) .


(A) The presence of eosinophilic infiltrates does not describe Barrett
esophagus but indicates eosinophilic esophagitis, which can be present with
GERD.

(B) Note that an invasion of dysplastic cells into the lamina propria is by
definition invasive disease (i.e., cancer) and not a predisposing lesion such as
B arrett esophagus.

(C) The change of Barrett esophagus occurs with squamous to columnar metaplasia, not columnar to squamous metaplasia.

(E) Finally, multinucleated cells with cellular inclusions are classic for HSV or CMV infection; in this case, viral esophagitis in a likely immunocompromised patient.

10

A 39-year-old man is being followed up by you and your surgical colleagues
for longstanding GERD and a suspected hiatal hernia. His
symptoms include dysphagia and postprandial fullness. He has been
taking omeprazole for 6 months without alleviation of symptoms. No
endoscopic diagnostics have been attempted. Results from his video
barium esophagram reveal a stable GEJ with herniation of the stomach
beyond the diaphragm. Which of the following is the most likely
current working diagnosis?

(A) Type I (sliding) hiatal hernia
(B) Type II (paraesophageal) hiatal hernia
(C) Type III (mixed) hiatal hernia
(D) Type IV (mixed with other organ involvement) hiatal hernia

The answer is B: Type II (paraesophageal) hiatal hern ia. This patient
undergoes a barium esophagram study for a suspected hiatal hernia causing
his GERD symptoms. The description of a nonmobile GEJ with herniation
of the stomach into the thorax is the classic description of a paraesophageal
hernia (or a type II hiatal hernia) . Though paraesophageal hernias are rare,
surgical correction is needed to avoid herniation and strangulation.
(A) Note that type I hiatal hernias are typically asymptomatic. (C) By
definition, the GEJ is mobile in type III hiatal hernias. (D) In type IV (mixed)
hiatal hernia, the GEJ is also mobile.

11

A 56-year-old woman with longstanding history of alcohol-induced
end- stage liver disease (ESLD ) presents to the emergency department
with diffuse hematemesis. On admission, her systolic blood pressure
is 85 with an undetected diastolic. On examination, she has altered
mental status, an extensive amount of blood covering her clothing,
and dried blood over her oral mucosa. She appears jaundiced and
cachectic. A report from the emergency department physicians indicates
that she has vomited 750 cc of bright red blood since her arrival
30 minutes prior. Which of the following is the most appropriate next
step in management?


(A) A trial of medical management with continuous intravenous
octreotide
(B) Emergent surgery with creation of a portocaval shunt
(C) Endoscopic balloon tamponade
(D) Endoscopic band ligation of varices
(E) Transjugular intrahepatic portosystemic shunting (TIPS)

The answer is D: Endoscopic band ligation of varices. Here we have
a classic history for an esophageal variceal bleed: a patient with alcoholinduced cirrhosis who presents with hematemesis. Because mortality can be as high as 50% in initial variceal bleeds, and this woman is already exhibiting hypotension secondary to acute bloo d loss, this is an emergent situation. First-line therapy in actively bleeding esophageal varices is endoscopic hemorrhage control with band ligation or sclerotherapy given that effectiveness approaches 80 % .


(A) While octreotide and other somatostatin analogues are effective
pharmacologic agents, their efficacy is most evident when used in conjunction
with endoscopic management; therefore, medical treatment alone is
inappropriate.

(B) Surgical creation of shunts that decrease portal venous hypertension (e.g., portocaval) has mostly been replaced by the less invasive
TIPS procedure.

(C) Endoscopic balloon tamponade is far from first-line therapy, and is recommended when endoscopic, pharmacologic, and transjugular
therapies are not available.

(E) Finally, while TIPS is effective, it is best suited for patients that continue to hemorrhage following attempted endoscopic ligation with octreotide.

12

A 39-year-old woman presents to her primary care physician for heart
burn. She has a medical history of rheumatoid arthritis and systemic
lupus erythematosus (SLE ) , both of which are currently being treated
by her rheumatologist. She reports to you that she is ANA positive.
Prior to conducting your physical examination, which of the following
findings would you expect to find in this patient?


(A) Absence of ganglion cells on rectal biopsy
(B) Bird's beak narrowing on esophagram
(C) Positive antimitochondrial antibodies
(D) Sclerodactyly

The answer is D : Sclerodactyly. Patients with a history of autoimmune
disease (e.g., rheumatoid arthritis, lupus) verified with positive serology
(antinuclear antibo dy (ANA) titers) with esophageal symptoms suggestive of
a dysmotility disorder should be evaluated for CREST syndrome (calcinosis
cutis, Raynaud phenomenon, Esophageal dysmotility, sclerodactyly, telangiectasia)
.

CREST syndrome, or scleroderma in general, causes fibrotic changes
of the esophageal sphincter and leads to aperistalsis with resultant esophageal symptoms. Sclerodactyly is classically found in b oth disease states.


(A) Absence of ganglionic cells in the rectum is p athognomonic for
Hirschsprung disease, a GI malformation commonly diagno sed in children.

( B ) A bird's beak narrowing on barium esophagram is the classic
finding for achalasia, which is p o ssible but less likely given the medical history.


(C) Finally, positive testing of antimitochondrial antibodies describ es
the serology associated with primary biliary cirrhosis which produces no
esophageal symptoms.

13

Your surgery service is consulted to 51 -year-old woman in the emergency
department who is a long-term p atient at a psychiatric institution.
She recently began complaining of the inability to tolerate
oral intake, and proj ectile vomiting associated with meals. CT of the
abdomen obtained in the emergency departments reveals immense
distention of the stomach, which is full of contents including hair.
Which of the following is the most appropriate intervention to be
executed by the surgical team?

(A) Gastrectomy
(B) Splenectomy
(C) Endoscopic therapy
Chapter 5 : Esop hagus and Stomac h 99
(D) Vagotomy and pyloroplasty
(E) Proton pump inhibitors and two antibiotic therapies for 3 weeks

The answer is C : Endoscopic therapy. A bezoar is an accumulation of
undigested gastric material; those that contain hair are referred to as "trichobezoars:' Patients subj ect to trichobezoars include the pediatric population and residents of psychiatric institutions. Large bezoars can present with signs and symptoms of gastric outlet obstruction (as seen in this clinical vignette) . Most bezoars can be roughly debrided with the use o f an endoscope; however, some must be decompacted surgically.


(A) Gastrectomy is a drastic management option regardless of the cause,
and is the least likely correct answer here.

(B) Splenectomy is completed unrelated to the pathophysiology, and we have no reason to believe that the spleen is pathologic (i.e., trauma, hypotension, meningeal sepsis)

(D) Vagotomy and pyloroplasty are reserved for intractable cases of peptic ulcer disease (PUD ) .


( E ) Th e use o f a PPI and antibiotics would be the therapy o f choice for PUD
associated with H. pylori infection, which is not described in this patient.

14

A 63 -year-old woman presents with dull, aching epigastric discomfort
associated with nausea that occurs following meals for the past 1 1 months.
She has noted alleviation with over-the-counter calcium carbonate. Her
past medical history is significant for endometriosis and two cesarean
sections, most recently 28 years prior. Vitals and physical examination
are normal other than vague epigastric tenderness. Her stool guaiac test
is positive. Her colonoscopies, up to date, have all been normal. Which of
the following is the most appropriate next step in management?


(A) Acquisition of serum gastrin levels
(B) Drawing of serology for anti-H. pylori antibodies
(C) Diagnostic laparoscopy
(D) Medical management with omeprazole
(E) Esophagogastroduodenoscopy

The answer is E: Esophagogastrod u odenoscopy. The gold standard in
diagnosis of peptic ulcer disease (PUD ) , which is fairly straightforward given
this patient's history and physical examination, is upper endoscopy. Upper
endoscopy helps to differentiate stomach cancer and PUD, which prevent with similar symptoms along with gastrointestinal bleeding. Endoscopy allows biopsying of active ulcers to rule out malignancy and determine the involvement of H. pylori (commonly causative of PUD) with the Campylobacter-like organism CLO test. The hallmark of PUD management, therefore, is upper endoscopy.

(A) Assessing serum gastrin levels can be diagnostic of Zollinger-Ellison
(ZE) syndrome, which typically presents as refractory PUD with severe, nonhealing ulcers.

(B) Assessing serology for H. pylori infection is an effective means to determine need for triple therapy, but since endoscopy should be
performed, these data will be collected elsewhere.

(C) Diagnostic laparoscopy would determine the extent of this patient's endometriosis, which is a distracter here given that her disease is clearly gastrointestinal-related.

(D) While medical management with omeprazole is likely to follow formal diagnosis, upper endoscopy should first rule out a more serious disease (e.g., gastric adenocarcinoma) before treating presumptive PUD.

 

 

15

The patient in the previous question follows the management plan
you selected. Results following this management plan confirm your
suspected diagnosis, along with infection of H. pylori, the suspected
causative agent. Which of the following is the most appropriate current
treatment for this patient?


(A) Amoxicillin, clarithromycin, and omeprazole for 10 to 14 days
(B) Amoxicillin, clarithromycin, and omeprazole for 30 days
(C) Metronidazole, clarithromycin, and omeprazole for 30 days
(D) Metronidazole, tetracycline, and omeprazole with bismuth for
1 0 to 1 4 days
(E) Metronidazole, tetracycline, and omeprazole with bismuth for
30 days

The answer is A : Amoxicillin , clarithromycin , and omeprazole for
1 0 to 14 days. This question asks for the recommended therapy for eradication of H. pylori.

This patient with diagnosed peptic ulcer disease (PUD) is confirmed to have H. pylori infection, a very common occurrence, and should therefore proceed to triple therapy of a PPI and two antibiotics (commonly amoxicillin and clarithromycin) .

Note that all of the answer choices are viable treatment options, but are not first line.


(B) The typical recommended duration of the medication is 10 to 14 days,
but not as long as 30 days, which would be excessive.

(C) Replacing amoxicillin with metronidazole is done for patients with a penicillin allergy, but we are not told this allergy exists.

(D) Quadruple therapy with bismuth, a PPI, metronidazole, and tetracycline is reserved for H. pylori strains resistant to the first -line triple therapy.

(E) Quadruple therapy is also effective if given for 10 to 14 days, and 30 days of treatment is unnecessary.

16

A 45 -year-old gentleman with past medical history of GERD, PUD,
hypertension, and obesity presents to your clinic for outpatient followup.
He recently underwent therapy for eradication of documented
H. pylori infection and has continued to take omeprazole daily as discussed
with his physician previously. His home stool guaiac tests over the past year have been negative. Which of the following patient symptoms helps to differentiate between gastric and duodenal ulcers in PUD?

(A) Alleviation of symptoms with dietary modifications
(B) Elimination of ulcerative lesions following H. pylori eradication
(C) Relationship between the severity of pain and the consumption of food
(D) Results from radiologic tests

The answer is C: Relationship between the severity of pain and the
consu m ption of food. The classic subjective information that distinguishes
duodenal and gastric ulcers (for board examinations, at least) is whether the
patient's epigastric pain is alleviated with food (duodenal ulcers) or exacerbated by food (gastric ulcers) .

Note that none of the information provided about this patient is necessary to answer the question.


(A) Dietary modifications are not considered to be effective in PUD as
they are in GERD.

(B) While elimination of H. pylori can be more successful
in treating duodenal ulcers (where H. pylori is more commonly attributable)
, eradication can effectively treat both, making this a less ideal answer.

(D) Radiologic testing would contribute very little to the diagnosis of PUD,
although radionuclide scans may eventually help to determine the source of a
gastrointestinal bleed.

17

An 87-year- old Japanese woman with a history of gastric adeno carcinoma
status post p artial gastrectomy presents with increasing fatigue. On examination, vitals are stable and notable for a heart rate of 1 1 7 beats/min. She has notable p allor compared to previous visits and her mucosa is strikingly p ale throughout. Which of the following statements would accurately describe the results of the Schilling test
in this patient?


(A) Administration of oral radiolabeled B12 with intramuscular B12
results in urine excretion of 30%


(B) Administration of radiolabeled vitamin B12 with intrinsic factor (IF) results in urine excretion of 30%


(C) Administration of radiolabeled vitamin B12 following 1 0 days of
antibiotic therapy results in urine excretion of 30%


(D) Administration of radiolabeled vitamin B12 with 5 days of oral
pancreatic enzymes results in urine excretion of 30%

The answer is B : Administration of radiolabeled vitamin B
12 with intrinsic factor (IF) results in urine excretion of 30%. Undiagnosed
anemia in a patient status postgastrectomy is classic for pernicious anemia, a
megaloblastic anemia caused by deficiency of IF. IF is a cofactor necessary for B12 absorption that is normally produced by the parietal cells of the stomach.

The Schilling test is the classically tested diagnostic measure in pernicious anemia management. Administration of radiolabeled vitamin B 12 along with an intramuscular administration normally results in urinary excretion between
1 0% and 40% (indicating sufficient oral absorption, as in choice A).

However, in patients with pernicious anemia, urinary excretion is usually less than 1 0% , indicating p o o r absorption of the oral dose (presumably due t o IF absence) . Administration of B12 with IF corrects excretion t o a normal range in patients with pernicious anemia, making choice B the correct answer.

(A) Again, this would be a normal result, since urine excretion between
1 0% and 40% indicates sufficient absorption from the intestine.

(C) Those patients who restore normal B 12 excretion following antibiotic treatment are diagnosed with bacterial overgrowth syndromes.

(D) Patients who respond to pancreatic enzyme administration suffer from chronic pancreatitis and/or pancreatic insufficiency.

18

The patient in question 1 8 undergoes your initial assessment, and your
findings suggest advanced-stage gastric adenocarcinoma. Which of the
following is the best means of formally confirming the diagnosis?


(A) Abdominopelvic CT scan
(B) Oral barium study
(C) Serum tumor marker studies
(D) Upper endoscopy

 

The answer is D: Upper endoscopy. Following a thorough history and
physical examination, gastric adenocarcinoma is best diagnosed by upper
endoscopy with biopsy, considered the gold standard for diagnosis. CT scans
for gastric adenocarcinoma are typically used for preoperative evaluation
following diagnosis.


(A) The poor assessment of primary tumor invasion by CT makes it a
poor initial diagnostic measure. 

(B) While barium studies can indicate filling mdefects along with infiltrating lesions of the gastric mucosa, it appears that endoscopy offers greater rates of sensitivity and specificity, and is therefore preferred. 

(C) Serum tumor markers for gastric adenocarcinoma include CEA
and CA- 1 2 5 . Based on a lack of evidence, neither carcinogenic embryonic
antigen (CEA) nor CA- 1 2 5 has been shown to have sufficient diagnostic value (nor staging value for that matter) to affect clinical decision making.

19

25 -year-old man who has recently undergone upper endoscopy
for chronic dyspepsia and diarrhea was diagnosed with duodenal
ulcer disease. Biopsies revealed no malignant involvement, and his
Campylobacter-like organism (CLO ) test was negative. One year following
avoidance of nonsteroidal antiinflammatory agent (NSAID)
and treatment with a PPI, his symptoms are unchanged. Which of the
following results would confirm a suspected diagnosis of ZE syndrome?


(A) A marked increased in serum gastrin following administration of
secretin
(B) Fasting serum gastrin levels greater than 1 ,000 pg/mL
(C) Gastric acid secretion measurements corresponding to the disease
(D) Nonfasting serum gastrin levels greater than 1 ,000 pg/mL

The answer is B : Fasting serum gastrin levels g reater than 1 ,000 pg/m l.
ZE (Zollinger-Ellison) syndrome is a condition whereby an underlying gastrinoma in the pancreas or small intestine contributes to gastric acid hypersecretion with complications including refractory PUD. Workup for multiple endocrine neoplastic (MEN) syndromes, specially MEN I, is required.

Diagnosis of ZE syndrome occurs when fasting serum gastrin levels are found to be greater than 1 ,000 pg/mL.

(A) The secretin stimulation test is useful for patients with indeterminate
results of serum gastrin levels (where an increase in serum gastrin following
secretin is diagnostic of ZE syndrome) .

(C) The use of gastric acid secretion measurements is largely outdated in the diagnosis of ZE syndrome.

(D) Finally, fasting (not nonfasting) gastrin levels are preferred for collection on three separate occasions, given the high variability of gastrin concentrations throughout the day.

20

A 6 1 -year- old African American woman has a history of refractory
GERD. Her symptoms include dysphagia, heartburn, and nausea
and have been consistent for 4 years . She has tried a numerous
over-the- counter and prescription medications without relief. She
reports a pertinent family history of gastric adenocarcinoma. Upper
GI endoscopy reveals several p olpyoid lesions throughout the gastric
mucosa. Pathology reveals hyperplastic polyps. Which of the following
statements is true regarding this condition?


(A) Rates of concurrent adenocarcinoma are as high as 20%
(B) They are commonly associated with familial polyposis syndromes
(C) They are associated with a large artery that erodes the mucosa and
causes massive hematemesis and hypovolemia
(D) Nitrate consumption is a risk factor for their development
(E) Resolution occurs with successful eradication of H. pylori

The answer is E: Resol ution occurs with successful erad ication of
H. pylori. Hyperplastic polyps are a benign tumor of the stomach that commonly arise secondary to chronic atrophic gastritis. They are small ( <2 em) , rarely undergo malignant transformation ( 1 % to 3 % ) , and respond with
eradication of H. pylori. The incorrect answers in this question refer to other pathologies involving the stomach.


(A) Rates of adenocarcinoma as high as 20% are found in adenomatous
polyps.

(B) Stomach polyps commonly found in familial polyposis syndromes
describe fundic gland polyps, a pathology that lacks malignant potential altogether.

(C) An artery eroding through the gastric mucosa and contributing to a
potentially dangerous bleed describes a Dieulafoy lesion.

(D) And, finally, nitrate consumption (a substance found in smoked meats common to the Japanese diet) is a risk factor for the development of malignant adenocarcinoma.

21

A 59-year-old man with a history of hypertension, obstructive sleep
apnea, and type II diabetes mellitus presents with chronic complaints of
reflux, belching, and excessive salivation with meals. His current medications
include metformin, hydrochlorothiazide, and a multivitamin.
He underwent laparoscopic cholecystectomy at age 48 years. He has
no smoking history and drinks four to five beers on weekends. Which
pharmacologic action is the mechanism of action for the most appro priate
therapy for this patient?

(A) Decreased production of prostaglandins via inhibition of COX- 1
and COX-2 enzymes
(B) Formation of a viscous gel along the gastric lining for protection
against ulceration
(C) Histaminergic antagonist that decreases volume and concentration
of gastric acid
(D) Irreversible blocking of the H+ /K+ -ATPase exchange pump at the
gastric parietal cell
(E) Synthetic prostaglandin analogue that decreases acid secretion and
increases bicarbonate secretion

The answer is D: Irreversible blocki n g of the H+/K+·ATPase exchange
pump at the gastric parietal cell . This patient appears to have a fairly
straightforward case of GERD, and we are told in the question that he is pro ceeding to medical management. While many drugs are useful for GERD, PPis
have become the first-line drug for patients with GERD based on efficacy. This
question asks, therefore, for the mechanism of action of PPis, with distracters
being his medication list and past medical history. PPis work by binding
irreversibly to the H+ -K+ -ATPase exchange and reduce gastric acid secretion.


Their efficacy is largely based on the fact that they act on the terminal source
of acid secretion in the stomach (as opposed to H2 antagonists, for example,
which exert their mechanism upstream of hydrogen ion pumps) .
(A) Decreased production of prostaglandins via inhibition of COX - 1 and
COX-2 enzymes describes nonsteroidal antiinflammatory agents (NSAIDs)
causal link to gastritis, which is an adverse effect, and not a therapeutic mechanism.


(B) Formation of a viscous gel along the gastric lining for protection
against ulceration is the mechanism of action of sucralfate (a cytoprotective
GERD drug) .

(C) A histaminergic antagonist that decreases gastric acid secretion
would describe any H2-receptor blockers.

(E) Finally, a synthetic prostaglandin analogue that decreases acid secretion and increases bicarbonate secretion would be misoprostol (a prostaglandin E 1 (PGE) analogue) .

22

A 48-year-old man presents to his primary care physician for his annual
follow-up. He has a past medical history of gastroesophageal reflux,
hypertension, and hypercholesterolemia. He underwent a right inguinal
hernia repair 14 years prior. Review of systems reveals the onset
of dark tarry stools 6 months prior. His most recent laboratory results
reveal a hemoglobin level of 9 . 7 g/dL. His stool guaiac test is positive.
What is the most likely explanation for these findings?


(A) Gastric adenocarcinoma
(B) GERD
(C) Epistaxis
(D) Low-dose daily aspirin
(E) Peptic ulcer disease

The answer is E : Peptic ulcer disease . The most common cause of an
upper GI bleed regardless of age is PUD, which is causative as often as 40% of cases. This patient's previous diagnosis of GERD could simply be a misdiagnosis, which would explain the progression of his PUD to melena as well as anemia. His situation deserves a workup with upper endoscopy with biopsy, and likely, triple therapy.


(A) Gastric adenocarcinoma is undoubtedly included on this patient's differential, albeit at much lower rates compared to PUD.

(B) While GERD is not a typical cause of an upper GI bleed, progression of GERD to Barrett esophagus may cause subtle blood loss via the GI tract.

(C) Epistaxis is not a common cause of GI bleeds as this adult patient presents; however, it can be a source of massive, acute, intractable hemorrhages in patients with severe cirrhosis.


(D) While low-dose daily aspirin as secondary prevention for cardiovascular
disease is not a common cause of GI bleeding, it does have noteworthy risk
in terms of GI bleeds, particularly in repeat GI bleeds and its risk, therefore,
should be assessed per patient circumstances.

23

A 65 -year-old woman undergoes upper endoscopy secondary to
chronic dyspepsia, epigastric pain, weight loss, and melena. Endoscopic
exploration reveals multiple small ulcerative erosions, one larger than
the remainder. Biopsies are undertaken and reveal chronic gastritis and
the presence of H. pylori. The largest lesion appears as a "dense infiltrate
of lymphocytes in the lamina propria with reactive B -cell follicles;' and
immunohistochemical staining is positive for CD 1 9 and CD20. What
is the most appropriate management for this patient?


(A) PET scan to determine extent of disease
(B) Radiation therapy
(C) Repeat endoscopic biopsy based on improper collection site
(D) Surgical resection of underlying malignancy
(E) Treatment of underlying infectious process

The answer is E: Treatment of underlying infectious process. The
pathology describes a gastric MALToma (mucosa-associated lymphoid tissue),
the most common extranodal lymphoma. Gastric MALTomas may transform
into widespread malignant disease, but their pathophysiology is strongly
related to chronic gastritis as well as H. pylori infection. Surprisingly, eradication of H. pylori successfully treats most patients and exhibits low rates of recurrence. Eradication of this infectious process, therefore, is the first -line
form of treatment given that the disease only involves the lamina propria.


(A) A PET scan would be effective if metastatic disease was present (i.e.,
examination or biopsy suggested lymphomatous spread outside of the stomach

(B) Radiation therapy is effective for MALTomas and is an option for
early-stage disease, but it is typically reserved for H. pylori-negative gastric MALTomas.

(C) While MALTomas can resemble the Peyer patches of the
small intestine, we can be fairly certain given this patient's history and symp toms that this biopsy was obtained from the correct area.

(D) Finally, surgical resection is rarely advised for gastric MALToma given the success of H. pylori treatment and radiation; furthermore, advanced disease proceeds to immune or chemotherapy, not surgery.

24

A 3 5 -year-old male bariatric patient who underwent Roux-en-Y gastric
bypass 9-weeks prior presents for follow-up. Now he complains
of sweating, lightheadedness, and chills after each meal. He seems
disturbed when he informs you that during the last occurrence, he
fainted while rushing to the bathroom to vomit. What is the most likely
explanation for these findings?


(A) Anastomotic ulceration with subsequent leakage
(B) Conversion disorder
(C) Dumping syndrome
(D) Partial small bowel obstruction

The answer is C: Dumping syndrome. Dumping syndrome describes
a common condition secondary to gastric bypass surgery, particularly the
Roux-en-Y bypass. Symptoms are similar to those described here. Dumping
syndrome is thought to be caused by rapid dumping of food into the Rauxen-
Y limb with rapid distention of the small intestine with hyperosmolar food
content that rapidly bypasses the stomach. It commonly occurs during this
postoperative time period ( 1 0 weeks ) . Foods that provoke symptoms (sugarladen foods) can be avoided for initial conservative measures, or antimotility drugs that slow the passage of food through the stomach can be used.


(A) Anastomotic ulceration is a rare complication of Roux-en-Y gastric
bypass, but patients develop the complication quickly (within days) with signs
of peritonitis and/or sepsis.

(B) Conversion disorder as an answer choice entertains the idea that undergoing gastric bypass surgery is a maj or physiologic and psychiatric adjustment for the patient. Depression, not conversion disorder,
can be a serious nonsurgical patient issue.

(D) A bowel obstruction due to iatrogenic causes (postoperative adhesions) would be expected to occur much later than dumping syndrome; additionally, the presentation would be similar to any bowel obstruction (and thus different from this patient's symptoms) .