Gastroenterology & Hepatology MKSAP 14 Questions 8/11/11

1. A 26-year-old man has a 4-week history of increasingly severe

bloody diarrhea, urgency, tenesmus, and abdominal pain without
fever, chills, or excessive sweating. The patient has an 8-pack-year
smoking history.
On physical examination, he appears well. The abdomen is mildly
tender without guarding or rebound. Rectal examination is normal.
Hemoglobin is 12 g/dL (120 g/L), the leukocyte count is
11,300/L (11.3 109/L), and the erythrocyte sedimentation rate is
38 mm/h. Colonoscopy shows areas of inflammation throughout
the colon associated with friability, granularity, and deep
ulcerations. The inflamed areas are separated by relatively normalappearing mucosa, including normal rectal mucosa. The ileum
appears normal. Biopsy samples from the inflamed areas of the
colon show moderately active chronic colitis without granulomas.
Biopsy samples from the ileum are normal.
Which of the following is the most likely diagnosis?

discloses only mild epigastric tenderness to palpation; vital signs

are normal.
Which of the following diagnostic studies should be done next?
A

Abdominal ultrasonography

Serologic testing for Helicobacter pylori

Upper endoscopy

Upper gastrointestinal barium study

3. A 51-year-old woman is hospitalized because of the acute onset of

moderately severe, constant upper abdominal pain associated with
nausea and vomiting. She has type 2 diabetes mellitus controlled
with an oral hypoglycemic agent. Other medications are a statin
and low-dose aspirin.
On physical examination, the patient is obese. Temperature is
normal. There is moderate upper abdominal tenderness without
rebound.

Crohn's disease

Ulcerative colitis

Laboratory Studies

Microscopic colitis

Serum total bilirubin

0.8 mg/dL (13.68 mol/L)

Yersinia enterocolitis

Ischemic colitis

Serum aspartate
aminotransferase

180 U/L

Serum alanine aminotransferase 285 U/L

2. A 27-year-old man has a 3-month history of intermittent burning
epigastric pain that is made worse by fasting and improves with
meals. Antacids provide temporary relief. He is otherwise healthy
and has no other symptoms. His only medication is occasional
acetaminophen for knee discomfort. Physical examination

Serum alkaline phosphatase

152 U/L

Serum amylase

1010 U/L

Serum lipase

950 U/L
1

Symptomatic treatment for pancreatitis is begun with intravenous

fluids and pain management as needed. On evaluation 12 hours
later, she has minimal symptoms.
Repeat laboratory studies:
Laboratory Studies

Which of the following is the most likely cause of this patient's

symptoms?
A

Gastroesophageal reflux disease

An esophageal motility disorder

Zenker's diverticulum

Serum total bilirubin

0.9 mg/dL (15.39 mol/L)

Pill-induced esophagitis

Serum aspartate
aminotransferase

82 U/L

Peptic ulcer disease

Serum alanine aminotransferase

100 U/L

Serum alkaline phosphatase

130 U/L

Serum amylase

580 U/L

Serum lipase

410 U/L

Which of the following is the most appropriate next step in

managing this patient?

5. A 36-year-old man has a 6-month history of increasing intermittent

nausea and vomiting. Vomiting occurs at least once every other
day, and the patient has lost approximately 9 kg (20 lb) in the past
2 months. He has had type 1 diabetes mellitus for 20 years
complicated by retinopathy requiring laser therapy. Current
medications are insulin and lisinopril. He is taking no new
medications and has not traveled recently. On physical
examination, the patient appears chronically ill. Pulse rate is
70/min and regular, and blood pressure is 110/70 mm Hg. The
abdomen is soft and nontender.

Abdominal ultrasonography

Laboratory Studies

Cholescintigraphy (HIDA scan)

Hemoglobin

10.1 g/dL (101 g/L)

Endoscopic retrograde cholangiopancreatography

Leukocyte count

5600/L (5.6 109/L)

Laparoscopic cholecystectomy

Platelet count

190,000/L (190 109/L)

Plasma glucose (nonfasting)

164 mg/dL (9.1 mmol/L)

Hemoglobin A1C

7%

Serum creatinine

1.6 mg/dL (141.47 mol/L)

Serum sodium

136 meq/L (136 mmol/L)

Serum potassium

3.6 meq/L (3.6 mmol/L)

4. An 18-year-old man has a 3-day history of pain on swallowing. He

has no heartburn, regurgitation, or weight loss. He has been taking
ibuprofen intermittently for 2 months for relief of elbow pain.
On physical examination, temperature is normal, pulse rate is
80/min, and blood pressure is 110/70 mm Hg. Oropharyngeal
examination is normal. There is no chest wall tenderness.

An upper gastrointestinal radiographic series shows retained fluid

and particulate matter in the stomach. The duodenum appears
normal. Gastric emptying scintigraphy shows marked delay at 4
hours, with more than 75% of the markers still retained in the
stomach (normal <30%).

Serum alkaline phosphatase

190 U/L

Serum total bilirubin

0.7 mg/dL (11.97 mol/L)

Serum amylase

182 U/L

In addition to correcting the electrolyte abnormalities, which of the

following is the most appropriate management at this time?

Abdominal ultrasonography shows several small gallstones. There

is no gallbladder wall thickening or pericholecystic fluid, and no
pain is elicited when the right upper abdominal quadrant is
palpated with the ultrasound probe. The caliber of the common bile
duct measures 7 mm (normal <6 mm).

Small, frequent low-fiber meals at least four to six times

daily

Placement of a venting gastrostomy tube and feeding

jejunal tube

Gut rest and total parenteral nutrition

Acute pancreatitis

Erythromycin, orally twice daily, taken indefinitely

Acute cholecystitis

Choledocholithiasis

Peptic ulcer disease

6. A 38-year-old woman has a 3-month history of intermittent,

moderately severe epigastric pain that is sometimes associated with
nausea and vomiting. The pain typically begins abruptly, lasts for
30 minutes to 2 hours before spontaneously abating, and
sometimes awakens her at night. The pain may be precipitated by
eating. The patient has hypertension treated with
hydrochlorothiazide. Physical examination is unremarkable except
for very mild subjective epigastric tenderness.
Laboratory Studies
Hemoglobin

12.1 g/dL (121 g/L)

Leukocyte count

10,100/L (10.1 109/L)

Serum aspartate
aminotransferase

312 U/L

Serum alanine aminotransferase

468 U/L

Which of the following is most likely causing this patient's pain?

7. A 53-year-old woman has a 6-month history of increasing diarrhea

without bleeding or a sense of urgency. She has three or four
bowel movements daily compared with her previous pattern of two
or three bowel movements each day. The patient has lost 2.7 kg (6
lb) during this time. Medical history is significant for
hypothyroidism, managed with thyroid replacement therapy. The
patient is postmenopausal and has had no abnormal vaginal
bleeding. She has maintained a lifelong milk-free diet.
Physical examination is normal. BMI is 21.
Laboratory Studies
Hemoglobin

9.8 g/dL (98 g/L) (was 13.5 g/dL

[135 g/L] 1 year ago)

Leukocyte count

6500/L (6.5 109/L)

3

Platelet count

250,000/L (250 109/L)

Mean corpuscular volume

85 fL

Red cell distribution width

19 (normal: 11.514.5)

Serum ferritin

10 ng/mL (10 mg/L)

Serum albumin

4.5 g/dL (45 g/L)

Liver chemistry studies

Normal

Serum thyroid-stimulating
hormone

Normal

Antitissue
transglutaminase
antibody assay

Negative

Stool cultures

No growth of pathogens

Stool examination for ova

and parasites

Negative

Stool assay for Clostridium

difficile toxin

Negative

8. A 42-year-old woman has a 1-year history of progressive fatigue

without dyspnea, chest pain, or other systemic symptoms. She
sleeps well at night and does not have features of sleep apnea. The
patient has hypothyroidism, managed with levothyroxine, and
dysmenorrhea, treated with an estrogen/progesterone combination.
On physical examination, the thyroid is slightly enlarged but
nontender. Xanthomas are present on the extensor surfaces.
Abdominal examination discloses mild hepatomegaly.
Laboratory Studies
Complete blood
count

Normal

Serum thyroidstimulating
hormone

Normal

Serum aspartate
aminotransferase

25 U/L

Serum alanine
aminotransferase

32 U/L

Upper gastrointestinal series with small-bowel follow-through is

normal. Colonoscopy with random biopsies is also normal.

Serum alkaline
phosphatase

278 U/L

Which of the following diagnostic studies should be scheduled

next?

Serum total bilirubin

1.1 mg/dL (18.81 mol/L)

Antiendomysial antibody assay

Serum calcitonin measurement

Upper endoscopy with small bowel biopsies

Serum gastrin measurement

Capsule endoscopy

In addition to a fasting serum lipid profile, which of the following

studies would most likely help establish the diagnosis?
A

Antimitochondrial antibody assay

Serum 25-hydroxyvitamin D

Endoscopic retrograde cholangiopancreatography

Abdominal ultrasonography
4

9. A 42-year-old woman is hospitalized because of pancreatitis. On

physical examination, the patient appears ill and dehydrated.
Temperature is 37.6 C (99.6 F), pulse rate is 110/min, respiration
rate is 19/min, and blood pressure is 120/90 mm Hg. Abdominal
examination discloses diffuse tenderness without rebound.
Laboratory Studies
Hematocrit

54%

Plasma glucose

290 mg/dL (16.1 mmol/L)

Serum triglycerides

1482 mg/dL (16.73 mmol/L)

Serum total bilirubin

0.9 mg/dL (15.39 mmol/L)

Serum aspartate
aminotransferase

220 U/L

Serum alkaline phosphatase

110 U/L

Serum lactate dehydrogenase

540 U/L

Serum amylase

62 U/L

Serum lipase

250 U/L

Serum C-reactive protein

Moderately elevated

The patient is given narcotics as needed for pain control. A CT

scan of the abdomen performed 3 hours after admission shows
marked pancreatic edema and diffuse peripancreatic stranding.
In addition to continuing pain relief as needed, which of the
following is the most appropriate next step in managing this
patient?

Endoscopic ultrasonography

Endoscopic retrograde cholangiopancreatography

10. A 44-year-old man was recently found to have abnormal serologic

test results for viral hepatitis when he attempted to donate blood.
The patient is asymptomatic. He used injection drugs and drank
alcohol excessively for 2 years 25 years ago but has not used either
drugs or alcohol since. Medical history is otherwise unremarkable,
and he takes no medications.
Physical examination discloses a BMI of 23, no stigmata of
chronic liver disease, and a normal-sized liver.
Laboratory Studies
Serum aspartate aminotransferase

53 U/L

Serum alanine aminotransferase

64 U/L

Serum alkaline phosphatase

89 U/L

Serum total bilirubin

0.9 mg/dL (15.39

mol/L)

Hepatitis B surface antigen (HbsAg)

Negative

Antibody to hepatitis B surface antigen

(anti-HBs)

Positive

IgG antibody to hepatitis B core antigen

(IgG anti-HBc)

Positive

IgM antibody to hepatitis B core antigen

(IgM anti-HBc)

Negative

Antibody to hepatitis C virus (anti-HCV) Positive

A

Intravenous hyperalimentation

Vigorous intravenous hydration

Abdominal ultrasonography is normal.

Which of the following diagnostic studies should be done next?
5

Hepatitis B e antigen (HBeAg)

Hepatitis B virus DNA (HBV DNA)

Hepatitis C virus RNA (HCV RNA)

IgM antibody to hepatitis A virus (IgM anti-HAV)

11. A 66-year-old woman has a 2-month history of intermittent

burning epigastric pain that is worse at night and during fasting.
She has mild nausea but no vomiting, melena, or hematochezia.
The patient has lost 1.3 kg (3 lb) during this time. Over-the-counter
antacids have not relieved the pain. She has mild hypertension and
incapacitating degenerative joint disease. Medications include a
daily thiazide diuretic and ibuprofen three times daily.
Physical examination reveals epigastric tenderness to palpation and
degenerative joint changes in the hands. Upper endoscopy
demonstrates several superficial antral erosions and a 7-mm ulcer
in the duodenal bulb. Antral biopsy specimens show chemicalinduced gastropathy and no evidence of Helicobacter pylori. The
patient refuses to stop taking ibuprofen because of the
incapacitating pain in her hands.
Which of the following is the most appropriate next step in
managing this patient?
A

An H2-receptor antagonist

A liquid antacid

A proton pump inhibitor

A prostaglandin-E1 analogue

Sucralfate

12. A 78-year-old man is brought to the emergency department by

family members because of increasing somnolence and not acting

normally for several hours. The patient has dementia,

hypertension, and type 2 diabetes mellitus. Current medications are
hydrochlorothiazide and pioglitazone.
On physical examination, he appears older than his stated age.
Temperature is 38.3 C (101 F), pulse rate is 100/min, and blood
pressure is 110/82 mm Hg. Mild jaundice is present. He is oriented
to person and place but not to year. The remainder of the
examination is unremarkable.
Laboratory Studies
Hemoglobin

12.8 g/dL (128 g/L)

Leukocyte count

18,600/L (18.6 109/L),

with 86% segmented
neutrophils, 2% band
forms, and 12%
lymphocytes

Serum creatinine

1.2 mg/dL (106.1 mol/L)

Serum aspartate aminotransferase 186 U/L

Serum alanine aminotransferase

230 U/L

Serum alkaline phosphatase

260 U/L

Serum total bilirubin

4.1 mg/dL (70.11 mol/L)

Serum albumin

3.4 g/dL (34 g/L)

Abdominal ultrasonography shows normal liver architecture, a

common bile duct caliber of 9 mm (normal <6 mm), multiple
gallstones, and no evidence of cholecystitis. A chest radiograph
shows emphysema.
In addition to beginning broad-spectrum antibiotics, which of the
following is most appropriate at this time?
6

Which of the following is the most appropriate next step in

managing this patient?

CT scan of the abdomen

Biliary scintigraphy (HIDA scan)

Magnetic resonance cholangiopancreatography

Repeat colonoscopy in 3 months

Endoscopic retrograde cholangiopancreatography

Repeat colonoscopy in 1 to 2 years

Administer sulindac

Administer a low-dose corticosteroid

Refer for colectomy

13. A 51-year-old man has recurrent bouts of lightheadedness and mild

confusion. Episodes of hypoglycemia were recently documented
that are improved with ingestion of food. The patient has not had
headache, blurred vision, or double vision. He has gained
approximately 4.5 kg (10 lb) in the past 2 months. Medical and
family history are noncontributory.
Physical examination is normal.
The following laboratory data are obtained after an overnight fast:
plasma glucose 30 mg/dL (1.67 mmol/L), serum insulin 30 mU/L
(215.25 pmol/L), and an elevated serum C-peptide level. CT scan
of the abdomen is normal.

15. A 66-year-old woman comes for her annual physical examination.

She reports only mild fatigue. The patient has prediabetes that is
managed by diet alone. She takes no medications and drinks one
glass of wine each day.
On physical examination, blood pressure is 132/86 mm Hg. BMI is
32. The remainder of the examination is normal.
Laboratory Studies

Which of the following diagnostic studies should be done next?

A

Endoscopic retrograde pancreatography

Endoscopic ultrasonography

MRI of the abdomen

Positron emission tomography

Somatostatin receptor scintigraphy

14. A 40-year-old woman has an 18-year history of ulcerative colitis

that is limited to the left side and has responded well to
mesalamine and occasional corticosteroid enemas. Recent
surveillance colonoscopy with biopsies showed low-grade
dysplasia.

Hemoglobin

13.1 g/dL (131 g/L)

Platelet count

85,000/L (85 109/L)

Plasma glucose (fasting)

119 mg/dL (6.6 mmol/L)

Serum lipid profile

Normal

Serum aspartate aminotransferase

138 U/L

Serum alanine aminotransferase

124 U/L

Serum alkaline phosphatase

50 U/L

Serum total bilirubin

0.8 mg/dL (13.68 mol/L)

Serum albumin

3.1 g/dL (31 g/L)

Serologic studies for hepatitis A,

B, and C

Negative
7

Serum transferrin saturation

Normal

Urinalysis

Normal

Abdominal ultrasonography shows evidence of mild fatty

infiltration of the liver.
In addition to weight loss, which of the following is the most
appropriate next step for managing this patient's liver chemistry
abnormalities?

electrocardiogram shows more pronounced changes. She receives

four units of packed red blood cells, following which her
symptoms again resolve, her electrocardiographic changes
normalize, and her hemoglobin level increases to 11.4 g/dL (114
g/L). Repeat colonoscopy with intubation of the terminal ileum and
extended upper endoscopy into the proximal jejunum are normal.
Capsule endoscopy (capsule enteroscopy) shows red-tinged fluid
in the midsmall bowel, but no mucosal lesions are identified. Iron
supplementation is increased to twice daily.
Which of the following is the most appropriate next step in
managing this patient?

Rosiglitazone; repeat liver tests in 6 months

Alcohol counseling

Enteroclysis

Liver biopsy

Repeat capsule endoscopy

Evaluation for liver transplantation

Mesenteric angiography

Transfusions as needed

Intraoperative endoscopy

16. A 61-year-old woman is evaluated because of a 2-month history of

progressive fatigue, weakness, dyspnea on exertion, and
intermittent black stools. On physical examination, the patient
appears pale and tired. General examination, including rectal
examination, is normal. A stool specimen is negative for occult
blood. Hemoglobin is 8.0 g/dL (80 g/L), and mean corpuscular
volume is 74 fL. An electrocardiogram shows mild nonspecific
changes, and a chest radiograph is normal. Colonoscopy, upper
endoscopy with small bowel biopsies, small bowel follow-through
barium radiographic studies, and a CT scan of the abdomen are
normal.
Following transfusion of two units of packed red blood cells, the
patient's symptoms resolve, her electrocardiographic changes
normalize, and her hemoglobin level increases to 10.8 g/dL (108
g/L). Once-daily iron supplementation is begun.
Six weeks later, the patient returns because of chest pain and
dyspnea. Hemoglobin is 7.2 g/dL (72 g/L), and the

17. A 39-year-old woman is hospitalized because of blunt abdominal

trauma and bowel infarction sustained in a motor vehicle accident.
Subtotal colectomy and resection of most of the small intestine are
required; 100 cm of duodenum plus the jejunum remain after
surgery.
One week postoperatively, the patient's enterostomy output is over
2000 mL daily. She is currently receiving total parenteral nutrition
and requires intravenous fluids to compensate for her increased
stomal output.
Which of the following is most appropriate for managing this
patient's nutritional and fluid requirements at this time?
A

Cautious introduction of enteral feedings

8

Cholestyramine

A proton pump inhibitor

Oral magnesium supplements

18. A 30-year-old woman is evaluated because of an abnormal serum

total bilirubin level detected when she had a life insurance
examination. Medical history is unremarkable. Her only
medication is an oral contraceptive agent. Physical examination is
normal.

No additional diagnostic studies are indicated

19. A 32-year-old woman has a 2-week history of diarrhea with four to

five semi-liquid stools daily. Stools are of small volume, and she
has a sense of urgency and incomplete evacuation. The patient
does not have fever, rectal bleeding, or weight loss. She has just
returned from a trip to Asia where she met a new sexual partner. A
brother has ulcerative colitis, and her mother developed colon
cancer at 60 years of age.
Which of the following is the most likely explanation for this
patient's clinical presentation?

Laboratory Studies
Hemoglobin

13.9 g/dL (139 g/L)

Mean corpuscular volume

88 fL

Red cell distribution width

10.8%

Serum total bilirubin

2.4 mg/dL (41.04 mol/L)

Serum direct bilirubin

0.2 mg/dL (3.42 mol/L)

Serum aspartate
aminotransferase

23 U/L

Serum alanine
aminotransferase

22 U/L

Serum alkaline phosphatase

82 U/L

Which of the following is the most appropriate management at this

time?
A

Discontinue the oral contraceptive agent

Repeat the liver chemistry tests in 3 months

Evaluate for the presence of hemolysis

Schedule abdominal ultrasonography

Crohn's disease

Villous adenoma

Cryptosporidium parvum infection

Celiac sprue

Neisseria gonorrhoeae colitis

20. A 48-year-old man is hospitalized because of acute severe upper

abdominal pain associated with nausea and vomiting. The patient
has mild hypertension and poorly controlled type 2 diabetes
mellitus (his most recent hemoglobin A1C measurement was 10%).
Medications are glyburide, hydrochlorothiazide, an angiotensinconverting enzyme inhibitor, a statin, and low-dose aspirin, all of
which he has been taking for 3 years. He does not drink alcoholic
beverages and has no recent history of abdominal trauma. There is
no family history of pancreatic disease.
Physical examination discloses only mild epigastric tenderness to
palpation without rebound.
Laboratory Studies
9

Plasma glucose

320 mg/dL (17.76 mmol/L)

Laboratory Studies

Serum calcium

9.1 mg/dL (2.27 mmol/L)

Serum aspartate aminotransferase

63 U/L

Serum phosphorus

3.9 mg/dL (1.26 mmol/L)

Serum alanine aminotransferase

84 U/L

Serum total bilirubin

0.1 mg/dL (1.71 mol/L)

Serum alkaline phosphatase

74 U/L

Serum aspartate
aminotransferase

48 U/L

Hepatitis B surface antigen (HBsAg)

Negative

Serum alanine aminotransferase 61 U/L

Serum alkaline phosphatase

128 U/L

Serum amylase

125 U/L

Serum lipase

390 U/L

Abdominal ultrasonography shows a normal gallbladder without

stones, mild fatty liver disease, and normal bile duct diameter. The
pancreas is not well visualized. A CT scan of the abdomen shows
marked peripancreatic stranding with a small amount of fluid
around the tail of the pancreas.
Which of the following diagnostic studies should be done next?
A

Thyroid function tests

Serum triglyceride measurement

Repeat transabdominal ultrasonography

Endoscopic ultrasonography

21. A 40-year-old woman has a lower extremity rash that has been
present for several months. The patient used injection drugs 18
years ago. She was once told that her liver enzyme values were
abnormal but did not return for follow-up studies. Medical history
is otherwise noncontributory. Physical examination is normal
except for a palpable purpuric rash on her lower extremities.

Antibody to hepatitis B surface antigen (anti- Positive

HBs)
IgG antibody to hepatitis B core antigen
(IgG anti-HBc)

Positive

IgM antibody to hepatitis B core antigen

(IgM anti-HBc)

Negative

Antibody to hepatitis C virus (anti-HCV)

Positive

Which of the following diagnostic studies should be done next?

A

Mesenteric angiography

Measurement of serum and urine porphyrin

Antinuclear antibody assay

Measurement of serum cryoglobulin

22. A 73-year-old man is brought to the office by his wife after she
found him trying to put his shoes in the refrigerator. The patient
has cirrhosis due to 1-antitrypsin deficiency and has been taking
diuretics for ascites. There is no history of head trauma or
gastrointestinal bleeding.
On physical examination, temperature is 38.4 C (101.1 F). The
patient is disoriented to time and place and has asterixis.
Abdominal examination discloses moderate ascites, and rectal
10

examination demonstrates brown stool. There are no focal

neurologic findings.
Laboratory Studies

23. An 82-year-old woman is hospitalized because of a hemoglobin

level of 9.8 g/dL (98 g/L) associated with chest pain and increasing
shortness of breath. She has noted intermittent black stools over
the past several weeks but has not had abdominal pain, nausea, or
vomiting. Colonoscopy 6 months ago was normal. Medical history
is significant for moderate to severe aortic stenosis, recurrent
congestive heart failure, and chronic obstructive pulmonary
disease. Cardiac catheterization was done several years ago and
was complicated by cholesterol emboli syndrome with emboli to
her kidneys and feet.

Hemoglobin

15.8 g/dL (158 g/L)

Leukocyte count

9400/L (9.4 109/L)

Platelet count

71,000/L (71 109/L)

Serum sodium

128 meq/L (128 mmol/L)

Serum potassium

4.0 meq/L (4.0 mmol/L)

Serum creatinine

1.3 mg/dL (114.95 mol/L)

Serum aspartate
aminotransferase

63 U/L

Serum alanine
aminotransferase

71 U/L

Serum total bilirubin

3.2 mg/dL (54.72 mol/L)

Serum albumin

2.8 g/dL (28 g/L)

Tagged red blood cell scan

INR

1.7

Repeat capsule endoscopy

Mesenteric angiography

Intraoperative endoscopy

Monitoring of the hemoglobin level

Which of the following is most appropriate for managing this

patient at this time?
A

Fluid restriction

Fresh frozen plasma

Platelet transfusion

Paracentesis

CT scan of the head

Blood transfusions are begun, and the patient's symptoms resolve.

Extended upper endoscopy, small bowel follow-through
radiographic studies, and capsule endoscopy (capsule enteroscopy)
are normal. There is no recurrence of melena.
In addition to beginning iron supplementation, which of the
following is the most appropriate next step in managing this
patient?

24. A 69-year-old woman has a 6- to 8-year history of intermittent

lower chest and epigastric pain that occurs soon after eating and is
associated with occasional vomiting. She also describes worsening
early satiety and has lost approximately 4.5 kg (10 lb) over the past
2 years. The patient has gastroesophageal reflux disease that is
well controlled with omeprazole, 20 mg twice daily. A barium
upper gastrointestinal series 2 years ago demonstrated a
paraesophageal hernia.
11

Physical examination is normal. Hemoglobin is 10.2 g/dL (102

g/L), and mean corpuscular volume is 78 fL. Complete blood count
is otherwise normal. Serum electrolytes and liver chemistry studies
are also normal. Upper endoscopy shows only the paraesophageal
hernia with some erosions; small bowel biopsy is normal.
Colonoscopy discloses scattered sigmoid diverticula.
Which of the following is the most appropriate management for
this patient?
A

Increase the dose of omeprazole to 40 mg twice daily

Refer for surgical repair of the hernia

Schedule capsule endoscopy (CT enteroscopy) of the

small bowel

Begin iron supplementation

No interventions at this time; re-evaluate in 3 months

Which of the following diagnostic studies should also be done at

this time?
A

Colonoscopy

Serologic studies for hepatitis B and hepatitis C virus

Upper gastrointestinal series with small bowel followthrough

Measurement of hemoglobin A1C

Measurement of serum vitamin D and calcium

25. A 46-year-old man with diarrhea undergoes upper endoscopy with

small bowel biopsies. Biopsy results are consistent with celiac
sprue.
Laboratory Studies
Complete blood count

Normal

Plasma glucose (fasting)

98 mg/dL (5.44
mmol/L)

Serum aspartate aminotransferase

20 U/L

Serum alanine aminotransferase

18 U/L

Serum alkaline phosphatase

130 U/L

Serum total bilirubin

0.6 mg/dL (10.26

mol/L)
12