Quiz Gastrointestinal Part 2 Of 2

Gastrointestinal – Part 2

14Mar2009

Gastrointestinal #1 – Histology 1) Which of the following is considered an exocrine function of the liver? a) Thyroxine conversion b) Vitamin D conversion c) Bile production d) Growth hormone releasing factor (GHRH) conversion e) Insulin and glucagon 2) 75% of the liver’s blood supply comes from the hepatic portal vein, a component of the portal triad (with hepatic artery and bile duct). Connecting which of the following veins would act as a portocaval shunt for a patient with portal hypertension? a) Esophageal vein and superficial/inferior epigastric veins b) Left gastric vein and paraumbilical vein c) Middle rectal vein and inferior rectal vein d) Superior rectal vein and superior mesenteric vein e) Left renal vein and splenic vein 3.1) What structural organization of the liver emphasizes the exocrine functions of the liver, mainly bile secretion? a) Classic lobule model b) Portal lobule module c) Liver acinus model d) None of the above 3.2) Which zone in the liver acinus model represents the area that is the first to show ischemic necrosis, the first to show fat accumulation, and the last to respond to toxic substances and bile stasis? (i.e. bile flows opposite of blood flow) a) Zone 1 b) Zone 2 c) Zone 3 d) Zones 1 and 3 e) None of the above 4) Hepatic sinusoids contain specialized cells that function in the final breakdown of red blood cells and are become very useful after a splenectomy. What are these cells called? a) Howell-Jolly bodies b) Goblet cells c) Chief cells d) Kupffer cells e) Crypt cells 5) The space of Disse lies between the basal surfaces of hepatocytes and the basal surfaces of endothelial cells that line the sinusoids. It contains blood-forming cells, which are usually only found in the liver but may present elsewhere in chronic anemia, and hepatic stellate cells (Ito cells). What is the role of these cells in physiologic conditions? a) Vitamin A storage b) Vitamin D storage c) Vitamin D conversion d) Vitamin K storage e) Iron storage 6) What process occurs in hepatic stellate cells in pathologic conditions?

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Gastrointestinal – Part 2

14Mar2009

a) Differentiate into myofibroblasts, synthesize collagen, and cause fibrosis b) Gain a p53 mutation, become cancerous, and cause malignancy c) Differentiate into beta cells, secrete insulin, and cause hypoglycemia d) Lyse, release enzymatic contents, and cause portal hypertension e) Differentiate into alpha cells, secrete glucagon, and cause hyperglycemia Match the binucleated, tetraploid hepatocyte structure or organelle with its function: 7.1) Site of drug/toxin detoxification a) Peroxisomes 7.2) Site or iron (ferritin) storage b) Smooth ER (sER) 7.3) Site of VLDL packaging c) Golgi apparatus 7.4) Site of alcohol detoxification d) Lysosomes 7.5) Site of beta-oxidation, gluconeogenesis, and purine metabolism 8.1) Bile flow begins at the canaliculi, going to the intrahepatic ductules (canals of Hering), then intralobular bile ducts, then left and right hepatic ducts, and finally to the common hepatic duct. What type of cells line the intrahepatic ductules? a) Hepatocytes b) Cuboidal epithelial cells c) Columnar epithelial cells d) Smooth muscle cells e) None of the above 8.2) What type of cells line the common hepatic duct, which connects to the cystic duct, fuses with the common bile duct, and empties into the ampulla of Vater at a thickening of the muscularis externa of the duodenum (sphincter of Oddi)? a) Hepatocytes b) Cuboidal epithelial cells c) Columnar epithelial cells d) Smooth muscle cells e) None of the above 9) Which of the following is NOT true of the gallbladder? a) Has Na/K ATPase on the lateral membranes b) Has secretory vesicles filled with glycoproteins on the apical cytoplasm c) Has a muscularis mucosa, submucosa, and lymphatic vessels in the lamina propria d) Has collagen and elastic fibers among smooth muscle bundles in the muscularis externa layer e) Fat at the proximal duodenum causes hormone secretion that contracts the gallbladder 10) Epithelial cells actively transport Na+, Cl-, and HCO3- from the cytoplasm into the intracellular compartment. This osmotic gradient causes water to move into the intracellular space, concentrating bile. Where does this mechanism occur? a) Liver b) Bile duct c) Hepatic duct d) Gallbladder e) Pancreas 11) The exocrine pancreas is a serous gland, producing all of the following EXCEPT: a) Insulin and glucagon

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Gastrointestinal – Part 2

14Mar2009

b) Trypsinogen and chymotrypsinogen c) Procarboxypeptidase and proaminopeptidase d) Alpha amylase e) Lipase, deoxyribonuclease, and ribonuclease Match the duodenal or endocrine pancreas cell with the secreted substance: 12.1) Insulin a) Ductal cells 12.2) Glucagon b) Acinar cells 12.3) Cholecystokinin c) Alpha cells 12.4) Somatostatin d) Beta cells 12.5) Secretin e) Delta cells 13) Somatostatin inhibits the secretion of insulin and glucagon. Which of the following is a function of glucagon (not insulin)? a) Uptake of glucose b) Glycogen synthesis and storage c) Gluconeogenesis and glycogenolysis d) Phosphorylation and use of glucose (glycolysis) e) Decreases blood glucose levels 14.1) Which of the following is part of Phase I liver metabolism? a) Conjugation with glycine b) Conjugation with taurine c) Conjugation with glucoronic acid d) Oxidation with cytocrome P450 system 14.2) What organ is shown in this photomicrograph? a) Liver b) Gallbladder c) Pancreas d) Spleen e) Duodenum Gastrointestinal #2 – Microbiology 1.1) A patient presents with flu-like symptoms and jaundice after eating green onions at a Mexican restaurant. FDA investigation finds the onions were grown using human manure. Which of the following is most likely? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis D virus (HDV) e) Hepatitis E virus (HEV) 1.2) The hepatitis B vaccine can prevent which of the following? a) Hepatitis B only b) Hepatitis A & B c) Hepatitis C & B d) Hepatitis D & B e) Hepatitis A, B, C, & D 2) Which of the following describes HAV (icosahedral)? a) Positive sense, single stranded RNA (ssRNA), non-enveloped (naked)

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Gastrointestinal – Part 2

14Mar2009

b) Negative sense, single stranded RNA (ssRNA), non-enveloped (naked) c) Positive sense, single stranded RNA (ssRNA), enveloped d) Negative sense, single stranded RNA (ssRNA), enveloped e) Double stranded RNA (dsRNA), non-enveloped 3) HAV replicates in hepatocytes and Kupffer cells. What is its mode of transmission? a) Droplet Contact b) Fecal-Oral Transmission c) Sexual Transmission d) Vertical Transmission e) Iatrogenic Transmission 4) Which of the following is a likely source of HAV infection? a) Rabbits or pigs b) Flying squirrels c) Contaminated shellfish d) Drug user needles e) Mosquitoes 5) A patient tests positive for hepatitis A in the clinic. When will the first become contagious? a) They will not become contagious b) In 3-6 months c) In 10-14 days d) At the onset of jaundice e) 10-14 days prior to symptoms 6) Which of the following is NOT a symptom commonly associated with HAV? a) Pale stools b) Icterus c) Rash d) Jaundice e) Dark urine 7) HAV is diagnosed by finding anti-HAV IgM via ELISA or radioimmunoassay. Infection can be prevents with proper hand washing, especially in daycares, mental institutions, and other care facilities. Which of the following is sufficient to kill the virus? a) Detergents b) Acid pH of 1 c) Chlorination d) High temps (55C) 8) What type of vaccine is currently available for HAV in the United States? a) Live b) Killed c) Subunit (S-antigen) d) Toxoid e) No vaccine exists 9) Which of the following describes the structure of HBV? a) Enveloped RNA b) Enveloped DNA c) Naked RNA

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Gastrointestinal – Part 2

14Mar2009

d) Naked DNA 10) A Dane particle comprises the virion (in larger spherical form) of which of the following? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis D virus (HDV) e) Hepatitis E virus (HEV) 11) Which of the following would be used to determine if HBV is actively replicating? a) HBcAb (core antibody) b) HBsAg (surface antigen) c) HBsAb (surface antibody) d) HBeAg (“e” antigen) e) HBeAb (“e” antibody) 12) Which HBsAg glycoprotein is the major component, self-associating into spherical particles and releasing from cells? a) L b) M c) S 13) Which of the following is true of the HBV replication cycle? a) Makes RNA in the nucleus then uses cell machinery to make DNA b) Makes RNA in the nucleus then uses reverse transcriptase to make DNA c) Replicates in Kupffer cells and is excreted in feces via bile d) Makes DNA in the nucleus then uses cell machinery to make RNA e) Makes DNA in the nucleus then uses polymerase to make RNA 14) Which of the following is true of cell mediated immunity in HBV? a) Causes clinical symptoms b) Resolves the infection c) Is ineffective in resolving infection d) A & B e) A & C 15) HBV is seen in high rates in Italy, Greece, Africa, and Southeast Asia. What is the most common method of transmission, especially in the United States? a) Droplet b) Blood borne c) Fecal-oral d) Direct contact e) Biological vector 16) What is the number one vaccine (HBV) preventable cancer in the United States? a) Squamous cell carcinoma b) Mesothelioma c) Colorectal cancer d) Gastric adenocarcinoma e) Primary hepatocellular carcinoma

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Gastrointestinal – Part 2

14Mar2009

17) In a HBV infection, the antigen and antibody can clump to form an immune complex, which is associated with clinical symptoms. These symptoms include rash, myalgias, and arthritis. What type of hypersensitivity reaction is this? a) Type I b) Type II c) Type III d) Type IV 18) Which of the following surface antigen and antibody combinations would signify that a patient is currently infected with the HBV virus? a) HBsAg positive, HBsAb positive b) HBsAg positive, HBsAb negative c) HBsAg negative, HBsAb positive d) HBsAg negative, HBsAb negative 19) Which of the following surface antigen and antibody combinations would signify that a patient has resolved an acute HBV infection? a) HBsAg positive, HBsAb positive b) HBsAg positive, HBsAb negative c) HBsAg negative, HBsAb positive d) HBsAg negative, HBsAb negative Match the HBV serologic panel with the case scenario: HBcAb HBsAg HBsAb HBeAg HBeAb 20.1) + a) Acute Infected 20.2) + + + b) Acute Resolved 20.3) + c) Window Period 20.4) + + + d) Chronic Active 20.5) + e) Chronic Passive 20.6) + + f) Vaccinated 21) What is the best method of HBV prevention, which is heavily used in the United States? a) Screening blood products b) Safe sexual practices c) Clean IV needles d) Health worker safety e) Vaccination 22) The HBV vaccine is given in a series of three (1 and 6 months after first vaccination). What type of vaccine is available in the United States for HBV? a) Live b) Killed c) Subunit d) Toxoid 23) Which of the following describes HCV? a) Positive sense, single stranded RNA (ssRNA), non-enveloped (naked) b) Negative sense, single stranded RNA (ssRNA), non-enveloped (naked) c) Positive sense, single stranded RNA (ssRNA), enveloped d) Negative sense, single stranded RNA (ssRNA), enveloped e) Double stranded RNA (dsRNA), non-enveloped

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Gastrointestinal – Part 2

14Mar2009

24) HCV in the United States is most commonly seen in: a) Retirement homes b) Alcoholics c) Transfusion patients d) IV drug users e) Athletes who use steroids 25) What is the most common clinical symptom of chronic HCV infection? a) Pruritus b) Jaundice c) Fatigue d) Flu-like symptoms e) Asymptomatic 26) What is currently the most effective treatment for hepatitis C infection? a) Ribavirin b) Interferon alpha c) Interferon beta d) Vaccination e) Supportive only 27) Which of the following describes the structure of HDV? a) Linear RNA, delta agent on ends b) Linear DNA, delta agent on ends c) Circular RNA, delta agent inside d) Circular DNA, delta agent inside 28) Which of the following replicates with the aid or an RNA structure called the ribozyme? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis D virus (HDV) e) Hepatitis E virus (HEV) 29) Superinfections of HBV infected individuals allow for the delta agent to replicate immediately. This results in which of the following? a) Fulminant hepatitis b) Hepatic encephalopathy c) Extensive jaundice d) Massive hepatic necrosis e) Any of the above 30) An HBV positive patient presents with jaundice and signs of hepatic damage. Blood testing shows the patient has hepatitis D. History reveals the patient likely got HDV infection from IV drug use with his friend. Other than HDV, what infection does the patient’s friend likely have? a) HIV b) HBV c) Diabetes d) Thrush e) Herpes simplex 2

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Gastrointestinal – Part 2

14Mar2009

31) What is the major route of transmission for hepatitis E (HEV)? a) Droplet Contact b) Fecal-Oral Transmission c) Sexual Transmission d) Vertical Transmission e) Iatrogenic Transmission 32) What group is at high risk for HEV, with 20% succumbing to the disease? a) AIDS patients b) Diabetic patients c) Transplant patients d) Pregnant patients e) Elderly patients 33) A 55-year-old man from Shanghai, China has had a 10-kg weight loss over the past 3 months and has felt tired. An abdominal CT scan reveals a 10-cm, solid mass in the left lobe of a nodule liver. Laboratory testing reveals that he is hepatitis B surface antigen positive, hepatitis C antibody negative, and hepatitis A antibody negative. A liver biopsy of the lesion reveals a hepatocellular carcinoma. The mechanism that is most likely responsible for development of liver cancer in this patient is: a) Insertion of HBV DNA in the vicinity of the c-myc oncogene b) Inherited mutation in the DNA mismatch repair genes c) Repeated cycles of liver cell necrosis and regeneration caused by HBV d) Development of a hepatic adenoma that accumulates mutations e) Coinfection with Clonorchis sinensis 34) A 40-year-old female donates blood because she cares about helping to alleviate the chronic shortage of blood. Unfortunately, she is found to be positive for HBsAg and is therefore excluded as a blood donor. She feels fine, and liver function test results, including those for total bilirubin, AST, ALT, alkaline phosphatase, and albumin, are normal. Further serologic testing produces negative results for HAV IgM, hepatitis B core antibody, and HCV antibody. Repeat testing 6 months later yields the same results. There are no physical examination findings of significance. What should you tell this patient? a) You acquired this infection through injection drug use b) You will develop clinical overt hepatitis within a year c) You probably have a chronic carrier state from vertical transmission d) These test results are probably erroneous and need to be repeated e) You should get a hepatitis B vaccination series 35) Antibodies to which of the following forms of viral hepatitis do not confer immunity from reinfection? a) HAV b) HBV c) HCV d) HDV e) HEV f) HGV g) None of the above

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Gastrointestinal – Part 2

14Mar2009

Gastrointestinal #3 – Pharmacology: Anti-Emetic Agents 1.1) Which of the following afferent inputs to the vomiting center complexes experiences such as taste, sight, smell, and memory (anticipatory nausea)? a) Chemoreceptor trigger zone (CTZ) b) Vestibular apparatus c) Gag reflex d) GI tract (ENS) e) Cerebral cortex 1.2) A patient is given morphine in an ambulance and immediately vomits on the EMT. Which area of the vomiting center contains the area postrema, which is outside of the blood brain barrier and therefore is exposed to both blood (e.g. morphine) and CSF? a) Chemoreceptor trigger zone (CTZ) b) Vestibular apparatus c) Gag reflex d) GI tract e) Cerebral cortex 2) Antagonists to what receptor will affect both ends of the vomiting center (peripheral and central) and work well if the emesis is vagally induced? a) Dopamine (D2) b) Muscarinic c) 5-HT3 d) 5-HT4 e) Opioid 3) Which of the following 5-HT3 receptor blockers may need to be reduced in patients with hepatic insufficiency? a) Ondansetron (Zofran) b) Granisetron (Kyrtil) c) Dolasetron (Anzemet) d) All of the above 4) 5-HT3 receptor blockers are most commonly indicated for: a) Opioid-induced nausea and vomiting b) Chemotherapy-induced nausea and vomiting c) Migraine-induced nausea and vomiting d) Gag reflex reduction (during clinical procedures) e) Motion sickness 5) 5-HT3 blockers most commonly cause headache, dizziness, and constipation. Which has the most marked prolongation effect on the QT interval? a) Ondansetron (Zofran) b) Granisetron (Kyrtil) c) Dolasetron (Anzemet) d) None of the above 6) What is the mechanism of action for the phenothiazine anti-emetics, such as prochlorperazine (Compazine), promethazine (Phenergan), and thiethylperazine (Torecan)? a) Dopamine receptor blockers b) Muscarinic receptor blockers

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Gastrointestinal – Part 2

14Mar2009

c) Histamine receptor blockers d) All of the above 7) What is the mechanism of action for butyrophenone anti-emetics, such as droperidol (Inapsine) used for endoscopic procedures and general anesthesia? a) Dopamine receptor blockers b) Muscarinic receptor blockers c) Histamine receptor blockers d) All of the above 8) Butyrophenones should be avoided in which of the following cases? a) Patient taking diphenhydramine (Benadryl) b) Patient has hypertension c) Patient taking benztropine (Cogentin) d) Patient has QT prolongation e) Patient taking trihexyphenidyl (Artane) 9) What is the major mechanism of action for substituted benzamide anti-emetics, such metoclopramide (Reglan) and trimethbenzamide (Tigan), which act in the ENS and CTZ? a) Dopamine receptor blockers b) Muscarinic receptor blockers c) Histamine receptor blockers d) All of the above e) None of the above 10) Substituted benzamides prevent nausea and vomiting, as well as act to stimulate GI motility and prevent GERD. What adverse effect is only seen with metoclopramide? a) Parkinsonism b) Tardive dyskinesia c) Dystonias d) Restlessness 11) Which of the following is a first generation histamine H1 antagonist which can cause dry mouth and urinary retention, and is used for motion sickness and chemotherapyinduced nausea and vomiting? a) Meclizine (Antivert) b) Scopolamine (generic patch) c) Prochlorperazine (Compazine) d) Dimenhydrinate (Dramamine) e) Diphenhydramine (Benadryl) f) Dronabinol (Marinol) 12) What is the prototypical muscarinic receptor antagonist used as the drug of choice for prevention of motion sickness? a) Meclizine (Antivert) b) Scopolamine (generic patch) c) Prochlorperazine (Compazine) d) Dimenhydrinate (Dramamine) e) Diphenhydramine (Benadryl) f) Dronabinol (Marinol)

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Gastrointestinal – Part 2

14Mar2009

13) Which of the following is primarily used for chemotherapy-induced nausea and vomiting, with the beneficial effect of increasing appetite, but may cause euphoria, sedation, dry mouth, and conjunctival injection? a) Meclizine (Antivert) b) Scopolamine (generic patch) c) Prochlorperazine (Compazine) d) Dimenhydrinate (Dramamine) e) Diphenhydramine (Benadryl) f) Dronabinol (Marinol) Gastrointestinal #4 – Pharmacology: Pancreatic Enzyme Supplements 1) Which of the following is NOT a common cause of pancreatic insufficiency? a) Cystic fibrosis b) Chronic pancreatitis c) Gallstones d) Pancreatic resection e) Shwachman-Diamond Syndrome (SDS) 2) Pancrelipase (Ultrase) is the drug of choice for pancreatic insufficiency and is usually well tolerated but may cause diarrhea, stricture, or abdominal pain. Nonenteric-coated capsules must be supplemented with a PPI. Which of the following is NOT a parameter used to determine dosing? a) Age b) Race c) Weight d) Dietary fat intake e) Degree of pancreatic insufficiency Gastrointestinal #5 – Pharmacology: Bile Acid Therapy For Gallstones 1) Ursodiol (Actigall, Urso) is commonly used in patients who refuse surgery or are very poor surgical candidates. What is this drug designed for? a) Cystic fibrosis b) Chronic pancreatitis c) Gallstones d) Post pancreatic resection e) Shwachman-Diamond Syndrome (SDS) Gastrointestinal #6 – Pathology 1) A teenager presents with abdominal pain that began in the periumbilical region then localized to the right lower quadrant. The patient has nausea, mild fever, and says he has vomited. Labs show leukocytosis. Rovsing, Psoas, and Obturator signs are positive. Which of the following is most likely? a) Early acute appendicitis b) Acute suppurative appendicitis c) Acute gangrenous appendicitis d) Suppurative peritonitis e) Bacteremia

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Gastrointestinal – Part 2

14Mar2009

2) What is the most common cause of acute peritonitis? a) Ruptured peptic ulcer b) Diverticulitis c) Acute hemorrhagic pancreatitis d) Acute salpingitis e) Appendicitis 3) Which of the following tumors of the peritoneum is associated with asbestos exposure? a) Carcinoid tumor of the appendix b) Primary tumor (mesothelioma) c) Secondary tumor (carcinomatosis) d) Desmoid round small cell tumor e) Uncommon tumor (retroperitoneal) 4) Hepatic encephalopathy and hepatorenal syndrome are complications that herald the most grave stages of hepatic failure. Which of the following is the most common route to hepatic failure? a) Hepatitis A b) Hepatitis B c) Chronic liver disease d) Drug-induced hepatic necrosis e) Toxin-induced hepatic necrosis f) Hepatic stress due to GI bleeding, infection, or electrolytes 5) Hepatic cirrhosis is among the top ten causes of death in the Western World and is characterized by diffuse fibrosis and parenenchymal nodules. What is the most common cause of cirrhosis? a) Cryptogenic b) Viral hepatitis c) Biliary disease d) Alcoholic liver disease e) Primary hemochromatosis 6) An alcoholic is brought to the Emergency Department with neurologic compromise. Physical exam shows asterixis, rigidity, and hyperreflexia. The patient is confused and seems to be confabulating stories based on a history from that patient’s family. Which of the following may be the underlying cause? a) Decreased thiamin levels b) Elevated blood ammonia levels c) Poor biliary excretion of copper d) Excess storage of iron e) Vitamin A, D, E, and K deficiencies 7) Which of the following is typically the heralding symptoms of hepatorenal syndrome? a) Decrease in urine output b) Decreasing creatinine c) Inability to concentrate urine d) Decreasing urea nitrogen e) Hypoosmolar urine high in proteins and sodium

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Gastrointestinal – Part 2

14Mar2009

8) An alcoholic presents with ascities. Examination reveals congestive splenomegaly. If portal venous hypertension is diagnosed, what is the most likely location? a) Pre-hepatic b) Intra-hepatic c) Post-hepatic 9) Ascities usually requires 500mL of peritoneal fluid for clinical detection. Which of the following findings in a peritoneal fluid aspiration would suggest possible disseminated intra-abdominal cancer? a) <3gm/dL of protein, mostly albumin b) Blood concentrations of glucose, sodium and potassium c) Neutrophils d) Erythrocytes e) Mesothelial cells 10) Which of the following would lead to hyperbilirubinemia due to impaired conjugation? a) Hemolytic anemia b) Alimentary tract bleeding c) Physiologic jaundice of the newborn d) Drug interference with membrane carrier systems e) Ineffective erythropoiesis syndromes 11.1) Which of the following congenital causes of hyperbilirubinemia is fatal during the neonatal period and results from an absence of UGT1A1 (uridine diphosphateglucuronyltransferase) activity? a) Crigler-Najjar syndrome, Type I b) Crigler-Najjar syndrome, Type II c) Gilbert syndrome d) Dubin-Johnson syndrome e) Rotor syndrome 11.2) Which of the following congenital causes of hyperbilirubinemia is due to decreased hepatic uptake and storage or bilirubin? a) Crigler-Najjar syndrome, Type I b) Crigler-Najjar syndrome, Type II c) Gilbert syndrome d) Dubin-Johnson syndrome e) Rotor syndrome 11.3) Which of the following congenital causes of hyperbilirubinemia is due to impaired biliary excretion of bilirubin glucuronides and has a black liver on gross appearance? a) Crigler-Najjar syndrome, Type I b) Crigler-Najjar syndrome, Type II c) Gilbert syndrome d) Dubin-Johnson syndrome e) Rotor syndrome 12) Which of the following signs seen in ethanol-related (alcoholic) liver disease signifies irreversible changes? a) Hepatocyte swelling and necrosis b) Mallory bodies

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Gastrointestinal – Part 2

14Mar2009

c) Tough, pale fibrosis (Laennec cirrhosis) d) Neutrophilic reaction e) Hepatic steatosis 13) A 50-year-old man presents with diabetes mellitus and abnormal skin pigmentation. Testing shows micronodular hepatic cirrhosis, hemosiderin deposits, and a defect in the HFE gene on chromosome 6p. Which of the following is most likely? a) GI iron absorption defect b) GI iron excretion defect c) Iron storage defect d) Iron conjugation defect e) Excessive intake of iron (e.g. vitamins) 14) A patient presents with Parkinson disease-like symptoms. Testing shows decreased serum ceruloplasmin and fatty liver changes with hepatitis. Examination reveals abnormally colored rings around the iris. D-penicillamine therapy is started. Which of the following is most likely? a) Biliary copper absorption defect b) Biliary copper excretion defect c) Copper storage defect d) Copper conjugation defect e) Increased total serum copper 15) An adult presents with emphysema and hepatic cirrhosis. Liver biopsy reveals PASpositive, diastase-negative granules. What alpha-1 antitrypsin deficiency (A1AD) phenotype does this patient likely have? a) PiSS b) PiMZ c) PiSZ d) PiZZ 16) A child presents with neurologic problems including vomiting, nightmares, and confusion. Testing shows encephalopathy, increased serum ammonia, and a fatty liver with minimal inflammation. History reveals a recent varicella (chickenpox) infection. What drug was this child given that caused her current syndrome? a) Acetaminophen b) Naproxen c) Aspirin d) Antacid e) Vitamin containing iron 17) An infant presents with jaundice, “coca-cola” colored urine, and light acholic stools. Liver biopsy shows a lobular disarray with focal liver cell necrosis. Also seen is panlobular giant cell transformation of hepatocytes and hepatocyte “rosettes.” Canalicular cholestasis is seen. Electron microscopy reveals phospholipid whorls. Which of the following is most likely? a) Bile duct obstruction b) Extrahepatic biliary atresia c) Cytomegalovirus d) Niemann-Pick disease e) Alpha-1 antitrypsin deficiency

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Gastrointestinal – Part 2

14Mar2009

f) Alagille syndrome 18) Inflammation from biliary obstruction initiates periportal fibrosis, which eventually leads to hepatic scarring and nodule formation, generating biliary cirrhosis. Histology is characterized by coarse fibrous septae that subdivide the liver in a jigsaw-like pattern. What is the most common cause of obstruction in adults, leading to this problem? a) Biliary atresia b) Cystic fibrosis c) Choledochal cysts d) Insufficient intrahepatic bile duct syndrome e) Extrahepatic cholelithiasis 19) A middle-aged woman presents with insidious onset of pruritis and fatigue. Blood tests show increased serum alkaline phosphatase and cholesterol. Circulating antimitochondrial antibodies are presents. Liver biopsy shows destruction of intrahepatic bile ducts. Which of the following is most likely? a) Primary biliary cirrhosis b) Secondary biliary cirrhosis c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic 20) A middle-aged man presents with fatigue and pruritis. Blood tests show elevated serum alkaline phosphatase. No auto-antibodies are seen. Barium radiograph of the intrahepatic and extrahepatic biliary tree show a beading pattern with irregular strictures and dilations. Biopsy shows concentric periductal fibrosis. Which of the following is most likely? a) Primary biliary cirrhosis b) Secondary biliary cirrhosis c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic 21) Which of the following is true of heart failures and the liver? a) Right-sided and left-sided failure cause passive congestion b) Right-sided and left-sided failure cause centrilobular necrosis c) Right-sided failures causes passive congestion and left-sided failure causes centrilobular necrosis d) Right-sided failures causes centrilobular necrosis and left-sided failure causes passive congestion 22) A female athlete is found to have sinusoidal dilation of the liver. She is currently taking danazol for endometriosis, oral contraceptives, and admits to using anabolic steroids. Which of the following is most likely? a) Fatty liver of pregnancy b) Veno-occlusive disease of the liver c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic

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Gastrointestinal – Part 2

14Mar2009

23) A patient with polycythemia vera presents with hepatomegaly and ascities. Testing finds obstruction of three major hepatic veins. Immediate surgery is scheduled for a portocaval shunt. What was the diagnosis? a) Primary biliary cirrhosis b) Veno-occlusive disease of the liver c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic 24) A Jamaican man presents with tender hepatomegaly, ascities, weight gain, and jaundice. History reveals a recent allogeneic marrow transplant. The clinician opts not to do a liver biopsy due to risk, but feels she would have found obliteration of hepatic vein radicles and hemosiderin-laden macrophages. Which of the following is most likely? a) Primary biliary cirrhosis b) Veno-occlusive disease of the liver c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic 25) Which of the following signs signifies that a pregnant patient has moved from preeclampsia to eclampsia? a) Peripheral edema b) Hyperreflexia c) Coagulation abnormalities d) Proteinuria e) Maternal hypertension 26) A mother in her third trimester presents with signs of hepatic failure. Biopsy shows microvesicular steatosis with Sudan stain (acute fatty liver). What is the primary treatment for this patient? a) Penicillamine and transfusion b) Liver transplant and prednisone c) Reduction of fat in the diet d) Supportive e) Termination of the pregnancy 27.1) Which of the following conditions affecting the liver after a bone marrow (or liver) transplant is due to a direct attack of donor lymphocytes on epithelial cells of the liver, resulting in necrosis of hepatocytes and inflammation of the parenchyma and portal tracts without bile duct destruction? a) Oxygen free radical damage and drug toxicity b) Acute graft-versus-host disease c) Chronic graft-versus-host disease d) Acute cellular rejection e) Chronic cellular rejection 27.2) Which of the following conditions affecting the liver after a bone marrow (or liver) transplant is defined by severe obliterative arteritis resulting in ischemic changes? a) Oxygen free radical damage and drug toxicity b) Acute graft-versus-host disease c) Chronic graft-versus-host disease

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Gastrointestinal – Part 2

14Mar2009

d) Acute cellular rejection e) Chronic cellular rejection 28.1) During abdominal surgery on a young adult female, the surgeon finds a yellow lesion on the liver. It has a central gray-white, depressed stellate scar that sends septa into the periphery. Which of the following is most likely? a) Hepatic adenoma b) Hepatoblastoma c) Focal nodular hyperplasia d) Nodular regenerative hyperplasia e) Angiosarcoma of the liver 28.2) Which of the following is associated with the development of portal hypertension due to vasculitic conditions and/or organ transplant? a) Hepatic adenoma b) Hepatoblastoma c) Focal nodular hyperplasia d) Nodular regenerative hyperplasia e) Angiosarcoma of the liver 29) A young woman presents with a RUQ mass. Biopsy shows portal tracts are absent and prominent arterial vessels and draining veins are distributed throughout the tumor. A hepatic adenoma is diagnosed. What medication has the patient likely used? a) Aspirin b) Antibiotic c) Loop diuretic d) Anti-emetic e) Oral contraceptive 30) Hepatoblastomas are fatal within a few years if they are not resected. What population are they seen in? a) Third world country b) Diabetics c) Pregnant d) Children e) Elderly 31) Which of the following is associated with exposure to vinyl chloride, arsenic, or Thorotrast and generally has 100% fatality within a year of activation? a) Cholangiocarcinoma b) Hepatoblastoma c) Focal nodular hyperplasia d) Hepatocellular carcinoma e) Angiosarcoma of the liver 32) A Korean patient presents with ill-defined upper abdominal pain and malaise. Blood tests are positive for HBV. Radiographic studies show a unifocal liver mass. What type of cancer is this patient likely developing? a) Cholangiocarcinoma b) Hepatoblastoma c) Focal nodular hyperplasia d) Hepatocellular carcinoma

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Gastrointestinal – Part 2

14Mar2009

e) Angiosarcoma of the liver 33) What type of cancer is associated with a chronic infection by the liver fluke (Opisthorchis sinensis) and can only be treated with aggressive surgery? a) Cholangiocarcinoma b) Hepatoblastoma c) Focal nodular hyperplasia d) Hepatocellular carcinoma e) Angiosarcoma of the liver 34) A patient presents with hepatomegaly, obstruction of the major bile duct, and jaundice. Testing shows nodularity of the free edge of the liver. Where is the LEAST likely originating cancer? a) Breast cancer b) Lung cancer c) Colon cancer d) Lymphoma or leukemia e) Liver (primary neoplasia) 35) Which of the following patients is most likely to have a bilirubin calcium salt (pigment) cholelithiasis, versus a cholesterol gallstone? a) Native American female using sex hormones b) 40-year-old North American female c) Pregnant South American d) Asian male with Crohn disease e) Obese Mexican American 36) A one-month-old infant with cholestasis and acholic stools is found to have a reovirus infection. Which of the following sequela is most likely? a) Sclerosing cholangitis b) Biliary atresia c) Biliary cirrhosis d) Cholangiocarcinoma e) Biliary adenoma 37) A patient presents with fever, chills, abdominal pain, and jaundice. Testing shows E. coli positive ascending cholangitis. What is the most likely cause? a) Cholelithiasis b) Biliary atresia c) Choledocholithiasis d) Cholangiocarcinoma e) Adenocarcinoma of the gallbladder 38) A 70-year-old man presents with abdominal pain, jaundice, anorexia, and nausea. A CT scan shows gallstones and a cauliflower neoplasm of the fundus and neck. The clinician explains to the patient that his five-year survival rate is very low even with the best treatment possible. Which of the following is most likely? a) Cholelithiasis b) Biliary atresia c) Choledocholithiasis d) Cholangiocarcinoma e) Adenocarcinoma of the gallbladder

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Gastrointestinal – Part 2

14Mar2009

39) Which of the following congenital anomalies of the pancreas has the highest incidence and is caused by failure of the fetal duct of the dorsal and ventral pancreatic primordial to fuse, predisposing the patient to chronic pancreatitis? a) Agenesis b) Pancreas divisum c) Annular pancreas d) Ectopic pancreas 40) Acute pancreatitis is mainly caused by biliary tract disease and alcoholism in the Western world. What is the cardinal feature of acute pancreatitis? a) Nausea b) Vomiting c) Diarrhea d) Abdominal pain e) Jaundice 41) A middle-aged man presents with repeated bouts of acute interstitial pancreatitis and steatorrhea. The clinician does not do a biopsy, but feels he would find protein plugs and parenchymal fibrosis. As this is a chronic condition, the clinician warns the patient of the risk of developing pancreatic cancer. What is the most likely cause of this patient’s condition? a) Coxsackie virus b) HBV + HDV c) HCV d) Alcohol use e) High fat diet 42.1) Which of the following always arises in women and presents as painless, slowgrowing masses in the body or tail of the pancreas? a) Serous cystadenoma b) Mucinous cystic neoplasm c) Intraductal papillary mucinous neoplasm (IPMN) d) Solid-pseudopapillary tumor e) Ductal adenocarcinoma 42.2) Which of the following produces cysts containing mucin, is more common in men, and affects the head of the pancreas? a) Serous cystadenoma b) Mucinous cystic neoplasm c) Intraductal papillary mucinous neoplasm (IPMN) d) Solid-pseudopapillary tumor e) Ductal adenocarcinoma 42.3) A patient presents with abdominal pain and migratory thrombophlebitis (Trousseau sign). Testing shows a cancer affecting the head of the pancreas that has created a desmoplastic reaction. The clinician speculates that the cells would show dramatic telomere shortening. The patient is schedules for surgery as this type of cancer has a very high mortality rate. What is the diagnosis? a) Serous cystadenoma b) Mucinous cystic neoplasm c) Intraductal papillary mucinous neoplasm (IPMN)

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Gastrointestinal – Part 2

14Mar2009

d) Solid-pseudopapillary tumor e) Ductal adenocarcinoma Gastrointestinal #7 – Clinical: Commonly Used Liver Tests 1) Which of the following is true of aminotransferases found in hepatocytes? a) ALT (SGPT) is specific for liver injury and AST (SGOT) is found in hepatocytes, skeletal muscle, and cardiac muscle b) AST (SGOT) is specific for liver injury and ALT (SGPT) is found in hepatocytes, skeletal muscle, and cardiac muscle c) ALT & AST are both very specific to liver injury d) ALT & AST are both found in hepatocytes, skeletal muscle, and cardiac muscle e) ALT & AST are not useful tests for pathologic injury 2) To determine the source of alkaline phosphatase, either isoenzymes can be used or GGT (intrahepatic biliary enzyme), which confirms hepatic origin. This test may be important as alkaline phosphatase is also found in the placenta and: a) Smooth muscle b) Cardiac muscle c) Skeletal muscle d) Neural tissue e) Bone 3) Hepatocyte dysfunction or impaired bile produces hyperbilirubinemia that is mostly: a) Conjugated (direct) b) Unconjugate (indirect) 4) Which of the following describes the urine and feces of a patient with liver disease and hyperbilirubinemia? a) Pale urine and dark stools b) Pale urine and pale stools c) Dark urine and pale stools d) Dark urine and dark stools 5) What vitamin would be deficient in abnormalities of PT, inability to absorb fat, celiac disease, severe cholestatic, and use of antibiotics during a period of prolonged fasting? a) Vitamin A b) Vitamin B12 c) Vitamin K d) Folate e) Vitamin C 6) A patient presents with prolonged prothrombin time (PT). Which of the following would signify that the disorder is true hepatocellular dysfunction, not malnutrition? a) Administration of vitamin K shortens PT b) Administration of vitamin K does not change PT c) Administration of warfarin shortens PT d) Administration of warfarin does not change PT e) Administration of warfarin increase PT f) None of the above

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Gastrointestinal – Part 2

14Mar2009

Gastrointestinal #8 – Clinical: Hepatocellular Disorders 1) What lab finding is characteristically seen in hepatocellular disorders? a) Increase in vitamin K b) Decrease in vitamin K c) Increase in aminotransferases d) Decrease in aminotransferases e) Increase in anti-mitochondrial antibodies 2) What time period differentiates acute hepatic disorders from chronic? a) 1-week b) 3-weeks c) 1-months d) 3-months e) 6-months 3) Which of the following is NOT a common presenting symptom of acute hepatitis? a) Malaise b) Anorexia c) Jaundice d) Abdominal pain e) Pale stools 4) Which of the following is NOT a cause of acute hepatitis? a) Hepatitis A & B b) Acute duct obstruction c) Non-alcoholic steato-hepatitis d) Drug-induced hepatitis e) Alcoholic hepatitis 5) Aminotransferase levels are the highest in which of the following conditions? a) Acetaminophen hepatotoxicity b) Transient bile duct obstruction c) Pancreatitis d) Alcoholic hepatitis 6) What aminotransferase findings are seen in alcoholic hepatitis? a) AST/ALT ratio > 2, AST > 400 U/L b) AST/ALT ratio > 2, AST < 400 U/L c) AST/ALT ratio < 2, AST > 400 U/L d) AST/ALT ratio < 2, AST < 400 U/L 7) How does chronic hepatitis typically present? a) Asymptomatic, fatigue, right upper quadrant pain b) Malaise, anorexia, jaundice, abdominal pain c) Ascities, caput medusea, confusion d) Abdominal pain, fever, abdominal tenderness 8) Which of the following is NOT a cause of chronic hepatitis? a) Hepatitis C & B b) Hemochromatosis c) Alcoholic liver disease d) Ischemic hepatitis e) Autoimmune hepatitis

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Gastrointestinal – Part 2

14Mar2009

Gastrointestinal #9 – Clinical: Cholestatic Disorders 1) A middle-aged woman presents is found to have elevated cholesterol and antimitochondrial antibodies. A cholestatic disorder is diagnosed after finding elevated alkaline phosphatase. Which of the following is most likely? a) Primary biliary cirrhosis b) Primary sclerosing cholangitis c) Infiltrate disorder or malignancy d) Large duct obstruction e) Drug-induced cholestasis Gastrointestinal #10 – Clinical: Jaundice 1) Jaundice occurs when bilirubin concentrations exceed: a) 1mg/dL b) 1.5mg/dL c) 2mg/dL d) 2.5mg/dL e) 3mg/dL 2) What lab finding suggests gallbladder obstruction? a) Fever b) Palpable gallbladder c) Abdominal pain d) Any of the above 3) What is the best non-invasive test to exclude obstructive causes of cholestasis? a) Cholangiography (ERCP or MRCP) b) Antimitochondrial antibody c) Hepatic ultrasonography d) Magnetic resonance imaging e) Serum alkaline phosphatase Gastrointestinal #11 – Clinical: Specific Liver Diseases 1) How is hepatitis A (HAV) most commonly transmitted? a) Droplet Contact b) Fecal-Oral Transmission c) Sexual Transmission d) Vertical Transmission e) Iatrogenic Transmission 2) What is the HAV indication for immune globulin (IgG)? a) Household contacts b) Restaurant workers c) IV drug users d) Diabetics e) Multiple sexual partners 3) Which of the following hepatitis B (HBV) markers means recent infection or “reactivation” of chronic infection? a) HBsAg

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Gastrointestinal – Part 2

14Mar2009

b) IgM anti-HBc c) IgG anti-HBc d) HBeAg e) Anti-HBe 4) A patient presents with fever, arthritis, urticaria (hives), and angioedema. Polyarteritis nodosa (PAN) is diagnosed. What hepatitis infection is associated with this? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis D virus (HDV) e) Hepatitis E virus (HEV) 5) Inability to clear a HBV infection is most common in what population? a) Elderly b) Adults c) Healthy teens d) Healthy children e) Neonates 6) Patients with active chronic HBV are at higher risk for cirrhosis, liver failure, and: a) Squamous cell carcinoma b) Serous cystadenoma c) Ductal adenocarcinoma d) Gastric adenocarcinoma e) Hepatocellular carcinoma 7) HBV patients who are at high risk for developing cancer should have their alphafetoprotein levels tested bi-annually as well as undergo: a) Biopsy b) Radiography c) Ultrasonography d) SPECT scanning e) Cholangiography 8) Which HBV patients are candidates for interferon alpha therapy? a) Non-replicating (passive) infection b) Low levels of aminotransferases c) Abnormal AST levels d) Abnormal ALT levels e) Abnormal alkaline phosphatase 9) Hepatitis D virus (HDV) mainly affects IV drug users and requires what concomitant infection? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis E virus (HEV) e) No other infection is required 10) What is the major risk factor for hepatitis C? a) Health care contact b) Poor hygiene

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Gastrointestinal – Part 2

14Mar2009

c) Blood transfusion d) Sexual contact e) IV drug use 11) Which of the following is NOT recommended for follow-up after a needlestick exposure to hepatitis C? a) Baseline testing for HCV b) Baseline testing of ALT c) Prophylactic immune globulin therapy d) Another follow-up at 4-6 months 12) Which of the following is most likely to become chronic? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis D virus (HDV) e) Hepatitis E virus (HEV) 13) What does the presence of anti-HCV mean? a) Patient was immunized b) Patient is currently infected c) Patient cleared a previous infection d) A & C e) B & C 14) What lab presentation is likely in a patient who is currently infected with HCV? a) Presence of anti-HCV and an abnormal ALT level b) Presence of anti-HCV and an abnormal AST level c) Presence of anti-HBc an abnormal ALT level d) Presence of anti-HBc an abnormal AST level 15) What is the initial test that is performed for anti-HCV determination? a) HCV RIBA test b) ELISA/EIA c) Aspartate aminotransferase (AST) d) Alkaline phosphatase (ALP) e) Alanine aminotransferase (ALT) 16) What is the test used to confirm chronic hepatitis C? a) HCV RIBA test b) ELISA/EIA c) Aspartate aminotransferase (AST) d) Alkaline phosphatase (ALP) e) Alanine aminotransferase (ALT) 17) Chronic hepatitis usually presents with mild to moderate increase in ALT levels and: a) Asymptomatic, fatigue, right upper quadrant pain b) Malaise, anorexia, jaundice, abdominal pain c) Ascities, caput medusea, confusion d) Weight loss, night sweats, fever, nausea e) Bouts of extreme right upper quadrant pain

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Gastrointestinal – Part 2

14Mar2009

18) Approximately 1-4% of patients with chronic hepatitis C develop hepatoma each year. Approximately what percent develop end stage renal cirrhosis after 20-25 years of infection? a) 2% b) 5% c) 7% d) 12% e) 25% 19) Treatment of chronic HCV infection is aimed at: a) Curing the disease b) Preventing future complications c) Alleviating right upper quadrant pain d) Preventing disease spread e) There are no treatment options 20) Which of the following is seen in the Far East, Africa, and Central America and poses a high risk for fulminant hepatitis in pregnant patients? a) Hepatitis A virus (HAV) b) Hepatitis B virus (HBV) c) Hepatitis C virus (HCV) d) Hepatitis D virus (HDV) e) Hepatitis E virus (HEV) 21) A 14-year-old girl presents with rapid onset of jaundice and a firm hepatomegaly. Testing shows thyroiditis, positive ANA, anti-dsDNA, smooth muscle antibody (SMA), and ANCA. Which of the following is most likely? a) Alcoholic liver disease b) Hepatitis C virus c) Autoimmune chronic hepatitis d) Fatty liver of pregnancy e) Nonalcoholic fatty liver disease (NAFLD) 22) Treatment of the above 14-year-old patient is aimed at decreasing serum levels of aminotransferases below five times normal. Which of the following is used to accomplish this goal? a) Ribavirin b) Interferon alpha c) Interferon beta d) Vaccination e) Prednisone 23) A middle-aged man presents icteric and critically ill. He complains of weight loss, anorexia, nausea, vomiting, and abdominal pain. Exam reveals hepatomegaly, ascities, and fever. Liver biopsy shows fatty change with degeneration and necrosis with the presence of Mallory bodies. Labs show leukocytosis and increased AST that is less than 400U/L. The AST/ALT ratio is greater than 2. Which of the following is most likely? a) Alcoholic liver disease b) Hepatitis C virus c) Autoimmune chronic hepatitis d) Fatty liver of pregnancy

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Gastrointestinal – Part 2

14Mar2009

e) Nonalcoholic fatty liver disease (NAFLD) 24) Which of the following is a marker of poor prognosis in alcoholic liver disease? a) Encephalopathy b) Spider angiomata c) Prolonged PT d) Bilirubin > 20mg/dL e) All of the above 25) An obese patient with a history of diabetes and hyperlipidemia presents with abdominal pain. Labs show mildly abnormal aminotransferase levels. Based mostly on the risk factors, which of the following is most likely? a) Alcoholic liver disease b) Hepatitis C virus c) Autoimmune chronic hepatitis d) Fatty liver of pregnancy e) Nonalcoholic fatty liver disease (NAFLD) Gastrointestinal #12 – Chronic Cholestatic Liver Diseases 1) A middle-aged woman presents is found to have elevated cholesterol and antimitochondrial antibodies. A cholestatic disorder is diagnosed after finding elevated alkaline phosphatase. Which of the following is most likely? a) Primary biliary cirrhosis b) Secondary biliary cirrhosis c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic 2) A patient with a history of ulcerative cholitis presents with fatigue, jaundice, and pruritis. Cholangiography shows a beaded appearance of the bile ducts. Which of the following is most likely? a) Primary biliary cirrhosis b) Secondary biliary cirrhosis c) Primary sclerosing cholangitis d) Budd-Chiari syndrome e) Peliosis hepatic Gastrointestinal #13 – Hereditary Liver Diseases 1) What is the mechanism by which iron is deposited in the tissues in patients with hemochromatosis (HFE gene defect)? a) Inability to excrete iron via GI tract b) Excess absorption of iron via GI tract c) Inability to release iron from stores d) Excess storage of normal iron e) Inability to excrete iron via biliary tract 2) Why is hemochromatosis less commonly identified in women? a) No genetic defect b) Less muscle mass for iron storage c) Menstruation loss of iron

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Gastrointestinal – Part 2

14Mar2009

d) Iron release during exercise e) Secondary iron excretion pathway 3) Hemochromatosis should be considered in patients presenting with: a) Arthritis b) Diabetes c) Cardiac arrhythmias d) Sexual dysfunction e) All of the above 4) Which of the following diagnostic tests generally shows little disturbance in patients with hemochromatosis? a) Transferrin saturation b) Serum iron levels c) Serum ferritin levels d) Liver biochemistry studies e) Liver biopsy and HFE (C282Y) gene testing 5) What is the genetic inheritance pattern for Wilson disease? a) Autosomal dominant b) Autosomal recessive c) Autosomal dominate with incomplete penetrance d) X-linked dominant e) X-linked recessive 6) What is the only treatment option for fulminant Wilson disease? a) Zinc b) Penicillamine c) Trientine (Syprine) d) Liver transplant 7) What alpha-1 antitrypsin deficiency (A1AD) phenotype is the most destructive? a) SS b) MZ c) SZ d) ZZ e) MM Gastrointestinal #14 – Clinical: Fulminant Hepatic Failure 1) A patient develops liver failure and encephalopathy within 8-weeks of developing jaundice. What is the treatment of choice? a) Penicillamine b) Prednisone c) Acetaminophen d) Biliary resection e) Liver transplant Gastrointestinal #15 – Clinical: Liver Tumors 1) Which of the following disease states is NOT associated with hepatocellular cancer (hepatoma)? a) Autoimmune hepatitis

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Gastrointestinal – Part 2

14Mar2009

b) Hemachromatosis c) HCV d) HBV e) HAV 2) What is the most common cause of hepatoma in the United States? a) Alpha-1 antitrypsin deficiency b) Alcoholic liver disease c) HCV d) Autoimmune hepatitis e) Hemochromatosis 3) Which of the following findings in a cirrhotic patient is diagnostic for hepatoma? a) Very high alkaline phosphatase b) Bloody ascities c) Alpha-fetoprotein > 400 d) RUQ bruit and tender hepatomegaly e) Increased hematocrit levels and hypercalcemia 4) What is the treatment of choice for patients with hepatoma? a) Penicillamine b) Prednisone c) Interferon alpha d) Lactulose e) Liver transplant Gastrointestinal #16 – Clinical: Ascities 1.1) Which of the following serum-ascitic fluid gradient (SAAG) results would be seen in a patient with right heart failure? a) Serum/Ascities Albumin > 1.1 & Ascities T protein < 2.5 b) Serum/Ascities Albumin > 1.1 & Ascities T protein > 2.5 c) Serum/Ascities Albumin < 1.1 & Ascities T protein < 2.5 d) Serum/Ascities Albumin < 1.1 & Ascities T protein > 2.5 1.2) Which of the following serum-ascitic fluid gradient (SAAG) results would be seen in a patient with cirrhosis, liver failure, or portal hypertension? a) Serum/Ascities Albumin > 1.1 & Ascities T protein < 2.5 b) Serum/Ascities Albumin > 1.1 & Ascities T protein > 2.5 c) Serum/Ascities Albumin < 1.1 & Ascities T protein < 2.5 d) Serum/Ascities Albumin < 1.1 & Ascities T protein > 2.5 1.3) Which of the following serum-ascitic fluid gradient (SAAG) results would be seen in a patient with nephritic syndrome, pancreatitis, or TB peritonitis? a) Serum/Ascities Albumin > 1.1 & Ascities T protein < 2.5 b) Serum/Ascities Albumin > 1.1 & Ascities T protein > 2.5 c) Serum/Ascities Albumin < 1.1 & Ascities T protein < 2.5 d) Serum/Ascities Albumin < 1.1 & Ascities T protein > 2.5 2) What is the main treatment for ascities? a) Paracentesis b) Prostaglandins c) Aminoglycosides

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Gastrointestinal – Part 2

14Mar2009

d) 2L diuresis e) Salt and water restriction Gastrointestinal #17 – Clinical: Spontaneous Bacterial Peritonitis 1) What are the classic symptoms of spontaneous bacterial peritonitis (SBP)? a) Asymptomatic, fatigue, right upper quadrant pain b) Malaise, anorexia, jaundice, abdominal pain c) Ascities, caput medusea, confusion d) Abdominal pain, fever, abdominal tenderness e) Bouts of extreme right upper quadrant pain 2) What is the initial diagnostic test for SBP? a) Paracentesis b) CBC with differential c) Aminotransferase levels d) Lumbar puncture e) CT scan 3) Which of the following would be considered appropriate drug therapy for SBP? a) Penicillin G b) Ceftriaxone c) Norfloxacin d) Amoxicillin e) Vancomycin 4) What is the approximate mortality rate associated with SBP? a) 50% b) 40% c) 30% d) 20% e) 10% 5) In patients at high risk for recurrence of SBP, who have cirrhosis, and are hospitalized for GI bleeding, what is the prophylactic therapy of choice? a) Penicillin G b) Ceftriaxone c) Norfloxacin d) Amoxicillin e) Vancomycin f) Metronidazole g) Doxycycline Gastrointestinal #18 – Clinical: Hepatorenal Syndrome 1) Which of the following is associated with hepatorenal (oliguric) syndrome? a) NSAIDs b) Diuretics c) Aminoglycosides d) IV contrast e) All of the above

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Gastrointestinal – Part 2

14Mar2009

Gastrointestinal #19 – Clinical: Portal Systemic Encephalopathy 1) A patient with a history of liver disease presents with personality changes, asterixis, and slowed speech. Serum ammonia levels are elevated. What is the treatment of choice? a) Penicillamine b) Prednisone c) Interferon alpha d) Lactulose e) Liver transplant 2) Which of the following, along with increased dietary protein and constipation, may be a precipitating event for hepatic encephalopathy? a) NSAID use b) Sedative use c) Tylenol use d) Diuretic use e) H2 blocker use Gastrointestinal #20 – Clinical: Variceal Hemorrhage 1) Which of the following decreases venous pressure and should be given for acute variceal bleeding? a) Nadolol b) Propranolol c) Octreotide d) Lactulose e) Prednisone 2) Transjugular intrahepatic portosystemic shunt (TIPS) procedure is indicated in patients with variceal hemorrhage who: a) Continue to drink alcohol b) Refuse to take nadolol or propranolol c) Have refractory rebleeding d) Are allergic to octreotide Gastrointestinal #21 – Clinical: Biliary Tract Disease 1) What type of gallstones are the most common in the United States? a) Cholesterol b) Pigment 2) Which of the following would suggest cholecystitis? a) Gaseousness b) Food intolerance c) Constant abdominal pain d) Severe right upper quadrant pain 3) What is the diagnostic test of choice for gallstones? a) Radiograph b) Ultrasound c) ERCP d) Liver panel e) MRI

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Gastrointestinal – Part 2

14Mar2009

4) What is the therapy of choice for asymptomatic gallstones? a) Percutaneous cholecystostomy b) Cholecystectomy c) Sphincterotomy d) Antibiotics e) No therapy is needed 5) What is the test of choice when clinical suspicion is high for a bile duct stone? a) Ultrasound b) MRCP c) ERCP d) Endoscopic ultrasound e) MRI 6) A patient is found to have a calcified (porcelain) gallbladder, putting them at high risk for gall bladder carcinoma. What is the treatment of choice? a) Percutaneous cholecystostomy b) Cholecystectomy c) Sphincterotomy d) Antibiotics e) No therapy is needed Gastrointestinal #22 – Extra: Management of Acetaminophen Toxicity 1) Toxic acetaminophen (paracetamol) dosages are 7.5g in adults and 140-150mg/kg in children. What is the normal acetaminophen dosage for a patient with jaundice? a) 20mg/kg b) 15mg/kg c) 10mg/kg d) 5mg/kg e) 1mg/kg 2) What is the daily maximum adult dosage of acetaminophen? a) 1g b) 2g c) 3g d) 4g e) 5g 3) Which of the following accumulates in acetaminophen overdose, leading to hepatocyte destruction? a) N-acetyl-p-benzo-quinone imine (NAPQI) b) N-acetylcysteine (NAC) c) Glutathione d) Glucuronide e) Sulfate conjugates 4) Which of the following is characteristic of stage 2 acetaminophen toxicity? a) Nausea, vomiting, diaphoresis, malaise b) Nausea, vomiting, malaise, jaundice, CNS symptoms c) No signs, liver function values abnormal d) No signs or symptoms and rarely hepatic dysfunction

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Gastrointestinal – Part 2

14Mar2009

5) What is the diagnostic hallmark of acetaminophen poisoning in a patient who has ingested alcohol or taken other drugs that affect hepatic metabolism? a) Increased prothrombin time b) Increased transaminase levels c) Increased bilirubin d) Severe vomiting e) Unconsciousness 6) What is the treatment of choice for acetaminophen overdose, which should not be used with activated charcoal? a) N-acetyl-p-benzo-quinone imine (NAPQI) b) N-acetylcysteine (NAC) c) Glutathione d) Glucuronide e) Sulfate conjugates 7) Which of the following is NOT true of NAC therapy? a) Loading dose is 140mg/kg b) Requires 17 additional doses over three days c) Has a pleasant odor and should be taken without dilution d) Should be given as soon as possible e) Is safe for pregnant patients James Lamberg

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Gastrointestinal – Part 2 AnswerKey GI #1 1) C 2) E 3.1) B 3.2) C 4) D 5) A 6) A 7.1) B 7.2) D 7.3) C 7.4) A 7.5) A 8.1) B 8.2) C 9) C 10) D 11) A 12.1) D 12.2) C 12.3) B 12.4) E 12.5) A 13) C 14.1) D 14.2) C GI #2 1.1) A 1.2) D 2) A 3) B 4) C 5) E 6) C 7) C 8) B 9) B 10) B 11) D 12) C 13) B 14) D 15) B 16) E

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14Mar2009 17) C 18) B 19) C 20.1) C 20.2) D 20.3) F 20.4) E 20.5) A 20.6) B 21) E 22) C 23) C 24) D 25) E 26) B 27) C 28) D 29) E 30) B 31) B 32) D 33) C 34) C 35) C GI #3 1.1) E 1.2) A 2) C 3) A 4) B 5) C 6) D 7) A 8) D 9) A 10) B 11) D 12) B 13) F GI #4 1) C 2) B

GI #5 1) C GI #6 1) B 2) E 3) B 4) C 5) D 6) B 7) A 8) B 9) D 10) C 11.1) A 11.2) E 11.3) D 12) C 13) A 14) B 15) D 16) C 17) D 18) E 19) A 20) C 21) C 22) E 23) D 24) B 25) B 26) E 27.1) B 27.2) E 28.1) C 28.2) D 29) E 30) D 31) E 32) D 33) A 34) E 35) D 36) B 37) C 38) E

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Gastrointestinal – Part 2 39) B 40) D 41) D 42.1) B 42.2) C 42.3) E GI #7 1) A 2) E 3) A 4) C 5) C 6) B GI #8 1) C 2) D 3) E 4) C 5) A 6) B 7) A 8) D GI #9 1) A GI #10 1) D 2) D 3) C GI #11 1) B 2) A 3) B 4) B 5) E 6) E 7) C 8) D 9) B 10) E 11) C 12) C

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14Mar2009 13) E 14) A 15) B 16) A 17) A 18) E 19) B 20) E 21) C 22) E 23) A 24) E 25) E

4) A 5) C

GI #12 1) A 2) C

GI #21 1) A 2) D 3) B 4) E 5) C 6) B

GI #13 1) B 2) C 3) E 4) D 5) B 6) D 7) D GI #14 1) E

GI #18 1) E GI #19 1) D 2) B GI #20 1) C 2) C

GI #22 1) D 2) D 3) A 4) C 5) B 6) B 7) C

GI #15 1) E 2) B 3) C 4) E GI #16 1.1) B 1.2) A 1.3) D 2) E GI #17 1) D 2) A 3) B

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