Internal medicine - Intestinal diseases Flashcards

1
Q

INT - 6.1
In which section of the small intestine is iron mostly absorbed?
A) the proximal small intestine

B) the central section of the small intestines

C) the distal small intestine

D) the entire small intestines

A

ANSWER
A) the proximal small intestine

EXPLANATION
Different foods can be absorbed from almost the entire small intestine. This is what the clinician is seeing after the removal of certain sections of the small intestine so-called short bowel syndromes. Nevertheless, the absorption of the individual nutrients in the proximal, middle and distal sections of the small intestine is different. Food absorption tests can be used in the clinical practice to determine the absorption capacity of each small bowel section. The typical section for iron absorption is the proximal part of the small intestine.

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2
Q

INT - 6.2
In which section of the small intestines Vitamin B12 is absorbed?
A) the proximal small intestine
B) the central section of the small intestines
C) the distal small intestine
D) the entire small intestines

A

ANSWER
C) the distal small intestine
EXPLANATION
The typical absorption section for vitamin B12 is the distal (terminal) part of the small intestine. Therefore, megaloblastic anemia due to malabsorption of vitamin B12 is registered after ileum resection if parenteral vitamin B12 is not replaced.

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3
Q

INT - 6.3
For which reasons is the absorption of folic acid disturbed in patients with anti-epileptic treatment?
A) Anti-epileptics inhibit folic acid absorption at a receptor level.

B) Anti-epileptic therapy causes calcium absorption disorders.

C) Anti-epileptics cause lipid malabsorption.

D) Lipid malabsorption leads to an inhibition of folic acid absorption.

A

ANSWER
A) Anti-epileptics inhibit folic acid absorption at a receptor level.
EXPLANATION
Different drugs have the ability to modify the digestive and absorption mechanisms of individual nutrients as well as their utilization at the target organ level (both positive and negative). Digestion encompasses all the processes by which individual nutrients transform to a absorbable state; (this sequence of events is called praeabsorptive processes). At this level, all drug effects that alter the breakdown of proteins, fats, and carbohydrates (in the case of sugars, disaccharides) are present. There are drugs that directly modify the absorption processes in the small intestine without affecting these (praeabsorptive) processes by influencing the activity of various enzymes (e.g., ATPase in the active transport system, strophantin, butylbiguanides, etc.) but there are drugs which act at the level of the receptor structure (in the absorptive phase). A significant number of drugs modify (aid or inhibit) the transport of nutrients within the body or effector organ utilization. Antiepileptic drugs inhibit the absorption of folic acid at the receptor level.

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4
Q

INT - 6.4
In which section of the gastrointestinal tract are saturated bile acids absorbed?
A) the proximal small intestine

B) the central section of the small intestines

C) the distal small intestine

D) proximal section of the large intestines

A

ANSWER
C) the distal small intestine
EXPLANATION
The formation of bile acids in the liver and their enterohepatic recirculation are important determinants of fat metabolism (as well as various fat-soluble nutrients such as vitamins D, E, K, A). Bile acids are absorbed from the distal (terminal) part of the small intestine during their enterohepatic recirculation. If for some reason the distal part of the ileum’s function is impaired the bile acids are not absorbed and enter the colon directly. Bile acids are not absorbed from the colon. Due to the mucosal irritation they cause, the transit time of the colon is significantly reduced, resulting in diarrhea. In these cases, the colour of the diarrhea stools is green due to bile dyes.

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5
Q

INT - 6.5
The carbohydrates are absorbed from the gastrointestinal tract almost exclusively as:
A) monosaccharides

B) disaccharides

C) polysaccharides

D) in forms of disaccharides and polysaccharides

A

ANSWER
A) monosaccharides
EXPLANATION
In the human small intestines, sugars are absorbed only as monosaccharides by an active process. The disaccharides (lactose, maltose, sucrose) must be broken down into monosaccharides by the gut enzymes (lactase, maltase, sucrose) to be absorbed. The activity of these enzymes may be impaired due to genetic causes or acquired diseases. Lactase enzyme activity is decreased around 40-50% of gastrointestinal patients in Hungary. Polysaccharides (starches) are absorbed only when α-amylase (primarily pancreatic amylase) breaks it down into monosaccharides (glucose).

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6
Q

INT - 6.6
The following physiological conditions are required for the complete absorption of glucose from the small intestine:
A) intact intestinal villi

B) normal liver function

C) smooth bile production

D) good amylase separation

A

ANSWER
A) intact intestinal villi
EXPLANATION
Glucose is absorbable and thus does not require a digestive phase. Therefore, in everyday clinical practice, 75 g of oral glucose is used to measure absorption from the proximal portion of the small intestine so-called glucose tolerance test. At various times after oral sugar administration serum samples are taken for glucose level measurement. Normally, serum glucose starts at a point below 6 mmol/L, showing a peak between 1-1.5 hours after glucose administration (which is 2-3 mmol/L higher than baseline). At 2 hours after the start of the test, blood glucose levels return to normal. One of the causes of a flat oral sugar tolerance curve may be a damaged intestinal epithelium of the small intestine (e.g. gluten enteropathy) further decreasing the absorbing surface (e.g. jejunum resection) or accelerated gastric emptying and small bowel transit.

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7
Q

INT - 6.7
The absorption of D-xylose can be indirectly measured in the urine because…
A) the renal threshold for the excretion of D-xylose by urine is high.

B) D-xylose binds to serum proteins.

C) D-xylose is absorbed from the small intestine, does not bind to serum proteins, is not metabolized and it’s excreted in the urine.

D) D-xylose absorption requires normal pancreatic and hepatic function.

A

ANSWER
C) D-xylose is absorbed from the small intestine, does not bind to serum proteins, is not metabolized and it’s excreted in the urine.
EXPLANATION
D-xylose is a pentose molecule that is not utilized by our body. However, it is often used in the clinical practice to study absorption processes as well as various drug-nutrient or nutrient-nutrient interactions. D-xylose is absorbed from the proximal part of the small intestine partly actively and partly passively. (Using different drugs, we can also analyze the relationship between active and passive processes.) D-xylose absorbed in the body is not bound to serum protein, is not metabolized and it’s excreted in the urine. The determination of the amount of D-xylose excreted in urine provides an opportunity to study the kinetics of absorption, persistence and excretion.

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8
Q

INT - 6.8
In gluten-sensitive enteropathy, gluten withdrawal should be performed for the following period:
A) for 1 month

B) for 1 year

C) for 10 years

D) throughout the patient’s life

A

ANSWER
D) throughout the patient’s life
EXPLANATION
In gluten-sensitive enteropathy, gluten acts as an antigen to which the body gives a local immune response. As a result of this local immune response is that the intestinal villi get damaged throughout the small intestine. Gluten-sensitive enteropathy is a genetically determined disease in which continuous administration of antigen plays a role as an environmental effect. Patients with gluten-sensitive enteropathy should maintain a gluten-free diet throughout their lives. If the gluten-free diet is discontinued, patients should reckon with a recurrence of the deficiency symptoms and later on the development of malignant diseases (lymphomas, malignant histiocytosis).

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9
Q

INT - 6.9
In chronic terminal ileitis, the color of chronic diarrhea stool is green, and is dilute due to:
A) bile acids are well absorbed

B) bile acids are not absorbed and cause diarrhea by irritation of the colon mucosa

C) bile acids are not absorbed in the distal section of the small intestine, but in the colon

D) bile acids are not absorbed from the proximal section of the small intestine

A

ANSWER
B) bile acids are not absorbed and cause diarrhea by irritation of the colon mucosa
EXPLANATION
In ileitis terminalis the mucosa of the distal part of the small intestine is damaged. Therefore, the absorption of vitamin B12 and bile acids is impaired. Bile acids reach the colon mucosa, irritate it and thus cause diarrhea.

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10
Q

INT - 6.10
Causes of diarrhea, except:
A) taking laxatives
B) taking dopamine antagonist drugs
C) malabsorption
D) indigestion
E) taking dopamine agonist

A

ANSWER
E)taking dopamine agonist
EXPLANATION
Diarrhea occurs for numerous reasons, including laxatives, dopamine antagonist medication, absorption and indigestion. Dopamine agonists cause constipation.

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11
Q

INT - 6.11
Causes of weight loss in patients with diarrhea, except:
A) malabsorption

B) chronic pancreatitis

C) Irritable Bowel Syndrome (IBS)

D) increased nutritional metabolism

A

ANSWER
C) Irritable Bowel Syndrome (IBS)
EXPLANATION
Digestive and absorption disorders of the food cause diarrhea, so the food is not utilized by the human body. With good nutrient digestion and absorption, increased catabolism (increased food metabolism) causes weight loss. Irritable bowel syndrome is a functional disorder that is not characterized by weight loss and is even an alarm symptom.

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12
Q

INT - 6.12
Causes of constipation, except:
A) tricyclic antidepressants

B) SSRI type antidepressants

C) diabetes mellitus

D) persistent hypokalaemia

A

ANSWER
B) SSRI type antidepressants
EXPLANATION
Constipation may be caused by the use of tricyclic antidepressants due to an increase in sympathetic tone, a partial manifestation of autonomic neuropathy in diabetes mellitus, and a reduction in the intensity of smooth muscle contractions in persistent hypokalaemia. Antidepressants acting on the serotonin system also increase serotonin levels in the gastrointestinal tract, which, as a transmitter, results in increased contractility.

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13
Q

INT - 6.13
Causes of tetany in patients with steatorrhea, except:
A) decreased calcium absorption

B) the amount of calcium excreted in the faeces increases

C) reduced vitamin D absorption

D) decreased potassium absorption

E) the amount of ionized calcium in the body is reduced

A

ANSWER
D) decreased potassium absorption
EXPLANATION
Patients suffering from digestive disorders who have steatorrhea also have a deficiency in the absorption of calcium, vitamin D, other fat soluble vitamins (A, E, K), in the case of malabsorption, the absorption of other nutrients, vitamins and minerals is impaired. According to clinical practice, total serum calcium is low in severe digestive and absorption disorders. Total calcium level is protein-bound and non-protein-bound, so-called ionized calcium together. Therefore, in severe maldigestion and malabsorption disorders, total calcium levels are reduced. If the serum protein is low due to other disorders, serum calcium may also be low because calcium cannot bind sufficiently to the protein. Hypocalcaemic tetany is caused by a decrease of ionized calcium.

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14
Q

INT - 6.14
Causes of increased bleeding in malabsorption syndrome may be the following, except:
A) the absorption of vitamin K is reduced

B) decreased production of prothrombin in the liver

C) the pathophysiological processes leading to lipid absorption are disturbed

D) activated protein C resistance is increased in these patients

A

ANSWER
D) activated protein C resistance is increased in these patients
EXPLANATION
In patients with digestive and absorption disorders, the absorption of vitamin K is impaired, as well as protein synthesis in the liver.

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15
Q

INT - 6.16
The diagnosis of sprue disease is as follows, except:
A) low serum calcium (ionized and protein bound)
B) low cholesterol
C) low total serum protein
D) microscopic partial (or total) atrophy of the small intestinal mucosa
E) normal B12 absorption

A

ANSWER
E) normal B12 absorption
EXPLANATION
Sprue disease affects the entire small intestinal mucosa in humans. Thus, the absorption of almost all nutrients is impaired as a result of these disorders, the levels of many substances in the serum are reduced. Normal B12 absorption does not support the diagnosis of sprue disease.

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16
Q

INT - 6.17
Suspected sprue disease is characterized by the following symptoms, except:
A) frequent diarrhea
B) anemia might develop
C) steatorrhea
D) slow transit time
E) weight loss

A

ANSWER
D) slow transit time
EXPLANATION
Sprue disease is often associated with diarrhea, steatorrhea, weight loss, anemia, and other deficiency conditions. In Sprue we don’t expect slower transit times.

17
Q

INT - 6.18
Pernicious anemia is characterized by the following symptoms, except:
A) microcyter anemia
B) gastric anacidity
C) mild indirect hyperbilirubinaemia
D) sensory disturbance in the limbs
E) macrocyter anemia

A

ANSWER
A) microcyter anemia
EXPLANATION
B12 vitamin deficiency does not cause microcytaer anemia.

18
Q

INT - 6.19
Chronic pancreatitis is characterized by the following laboratory parameters:
1) great mass of stool
2) normal lipiodol absorption
3) the color of the stool is shining
4) stool weight is less than 300 g

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
B) only answers 1 and 3 are correct
EXPLANATION
Patients with chronic pancreatitis defecate a great mass of stool with a shining surface. In the absence of the lipase enzyme, decomposition of the Lipiodol testsubstance is abnormal in chronic pancreatitis and stool weight is less than 300 g

19
Q

INT - 6.20
Malabsorption of carbohydrates is characterized by:
1) low sugar tolerance curve
2) diarrhea occurs during lactose tolerance test
3) flat starch tolerance curve
4) during lactulose tolerance test, the amount of hydrogen in the exhaled air increases

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct
EXPLANATION
Carbohydrate absorption disorders (at different levels) are characterized by all the options listed in the question

20
Q

INT - 6.21
Crohn’s disease can be confirmed by the following tests:
1) erythrocyte sedimentation rate may be increased, CRP levels may be elevated
2) ultrasound shows that the intestinal wall is segmentally thickened
3) histological picture of intestinal biopsy confirms non-specific granuloma
4) double contrast small bowel examination shows several sections of the small intestine narrowed

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct
EXPLANATION
Each of these options strenghten the diagnosis of Crohn’s disease.

21
Q

INT - 6.22
The following laboratory tests can confirm malabsorption syndrome:
1) flat sugar tolerance curve
2) flat iron load curve
3) schilling test value less than 10%
4) increased orocoecal transit time

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
A) only answers 1, 2 and 3 are correct
EXPLANATION
Patients with malabsorption syndrome have a flat sugar tolarence and iron load curve and impaired B12 absorption. The orocoecal transit time does not increase.

22
Q

INT - 6.23
An essential part of treating patients with gluten-sensitive enteropathy:
1) steroid treatment
2) administration of vitamins
3) providing abundant nutrition
4) gluten withdrawal

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
D) only answer 4 is correct
EXPLANATION
Gluten withdrawal is an essential part of treating patients with gluten-sensitive enteropathy.

23
Q

INT - 6.24
Gluten-sensitive enteropathy patient’s mucosal recovery should be checked after gluten withdrawal despite the resolution of symptoms:
1) one month after gluten withdrawal
2) half a year after gluten withdrawal
3) one year after gluten withdrawal
4) no biopsy is required

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
D) only answer 4 is correct
EXPLANATION
Once the diagnosis of gluten-sensitive enteropathy has been made in a professionally established manner, small intestinal biopsy is not required for checkup when the patient is on a gluten-free diet, without complaints, and has a laboratory confirmed deficiency.

24
Q

INT - 6.25
In conditions with diarrhea, gallstone formation occurs due to:
1) a higher amount of bile is excreted in the faeces
2) endogenous cholesterol production increase
3) loss of bile acid via stool
4) the lithogenicity of the bladder increase

A) only answers 1, 2 and 3 are correct
B)only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct
EXPLANATION
In conditions with diarrhea all of the above are involved in contribution of gallstone formation; particularly important is the loss of bile acid, which contributes to the lithogenicity of the bladder.

25
Q

INT - 6.26
The presence of an anti-endomysium antibody confirms the following diagnosis (diagnoses):
1) M. Crohn
2) ulcerosa colitis
3) hepatitis C
4) gluten-sensitive enteropathy

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
D) only answer 4 is correct
EXPLANATION
The anti-endomysium antibody confirms the diagnosis of gluten-sensitive enteropathy.

26
Q

INT - 6.27
Possible clinical manifestations of Crohn’s disease:
1) the distal section of the colon
2) the proximal section of the small intestine
3) the proximal section of the colon
4) the distal section of the small intestine
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct
EXPLANATION
Crohn’s disease can be localized to all sections of the gastrointestinal tract.

27
Q

INT - 6.28
A 2 meters long middle section of the small intestine was removed by the surgeon due to mesenteric thrombosis. Then the following typical absorption disorders occur:
1) iron malabsorption
2) folic acid malabsorption
3) vitamin B12 malabsorption
4) fat malabsorption
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
D) only answer 4 is correct
EXPLANATION
From the middle section of the small intestine, removal of approx. 2-meter-long small intestine primarily causes fat malabsorption.

28
Q

INT - 6.29
In acute pancreatitis, serum calcium levels drop abruptly for the following reasons:
1) the patient receives only an isotonic infusion of NaCl2
2) pancreatic tissue is disolves
3) acute pancreatitis is accompanied by low serum calcium levels
4) due to fat necrosis, calcium stearates are formed
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
C) only answers 2 and 4 are correct
EXPLANATION
A sudden decrease in serum calcium in severe acute pancreatitis means that a significant amount of pancreatic tissue has fallen apart. Because pancreatic tissue is high in fat, endogenous soap (calcium stearate) is formed with calcium. This results in a rapid decrease in calcium levels (characteristic of haemorrhagic and necrotizing pancreatitis).

29
Q

INT - 6.30
The following laboratory results clearly prove complete posthepatic biliary obstruction:
1) direct bilirubin increases
2) increase in serum alkaline phosphatase
3) increase in serum gamma-GT
4) urobilinogen cannot be detected in urine
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
E) all of the answers are correct
EXPLANATION
In posthepatic biliary obstruction, serum alkaline phosphatase and γ-GT are elevated, bilirubin is elevated (serum bilirubin is predominantly direct), and urobilinogen cannot be detected in urine. In the case of complete obstruction, the enterohepatic recirculation of intestinal metabolites from the bile dye does not occur and therefore no urobilinogen is excreted in the urine.

30
Q

INT - 6.31
The following symptomatic treatment may be used in conditions with diarrhea:
1) prokinetic agents
2) loperamide
3) antispasmodics
4) diosmectite
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
C) only answers 2 and 4 are correct
EXPLANATION
The most commonly used symptomatic treatments for reducing diarrhea in diarrhea are loperamide and diosmectite.

31
Q

INT - 6.32
The following medications are used successfully in the treatment of giardiasis:
1) antispasmodics
2) tetracyclin derivatives
3) analgesics
4) tinidazole derivatives
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
D) only answer 4 is correct
EXPLANATION
Tinidazole derivatives can be used successfully in the treatment of giardiasis.

32
Q

INT - 6.33
The correct indications for jejunal (enteral) nutrition are as follows:
1) oesophagus stenosis due to tumor
2) acute pancreatitis
3) stomach outwards stenosis
4) the patient is unable to eat orally for less than 6 weeks

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
C) only answers 2 and 4 are correct
EXPLANATION
The most common indications for jejunal feeding tube in addition to severe, acute pancreatitis are the difficulty or impossibility of oral nutrition. In the latter case, the situation needs to be considered and resolved as soon as possible. If oral feeding was not restored, PEG insertion is well-founded. In the case of oesophagus stenosis due to tumor the implantation of an expandable metal stent, which is endoscopically placed, restores or significantly improves oral feeding.

33
Q

INT - 6.34
Characteristic(s) for Crohn’s disease:
1) may affect any section of the gastrointestinal tract
2) Crohn’s disease is a psychosomatic disease
3) non-specific inflammatory lesions
4) Crohn’s disease is caused by motility disorders
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
B) only answers 1 and 3 are correct
EXPLANATION
Crohn’s disease can be localized to any section of the gastrointestinal tract (including the oral cavity and oesophagus, the latter localities are rare). Inflammatory lesions histologically confirm non-specific chronic inflammation.

34
Q

INT - 6.35
The following clinical symptoms are characteristic of dumping syndrome:
1) constipation
2) consuming more sweets causes symptoms
3) lactose intolerance
4) food entering the small intestine triggers the vago-vagal reflex
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
C) only answers 2 and 4 are correct
EXPLANATION
Dumping syndrome is characterized as after Billrot II. surgery, the function of regulating gastric emptying as a modifying factor is missing during eating. In such cases, when patients consume a larger amount of sweets (or are undergoing a glucose tolerance test at the time of examination), glucose is essentially delivered directly to the intestine, which initiates insulin secretion. However, in the absence of the antrum and pylorus, glucose is rapidly absorbed from the gastrointestinal tract as it is delivered directly to the small intestine (duodenum). Relative hyperinsulinemia and low blood glucose (hypoglycaemic episodes) develop temporarily - approximately 90 to 120 minutes afterwards. Clinical symptoms include: weakness, paleness, dizziness, sweating, tachycardia. (This is the so-called late dumping syndrome) In other cases, shortly after a meal the food (mostly liquid foods) that enter directly the duodenum due to vago-vagal reflex (esophageal wall distension) leads to the symptoms above (this is known as explanation and symptoms of the early dumping syndrome).

35
Q

INT - 6.36
Where does lymphoma most frequently develop in the gastrointestinal tract?
1) colon
2) rectum
3) esophagus
4) stomach
A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

A

ANSWER
D) only answer 4 is correct
EXPLANATION
In the gastrointestinal tract, the stomach is the most common localization for a lymphoma from the organs listed in this question.