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3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

Gastrointestinal and Nutritional Questions based on Chapter 3 of the book Pance Prep
Pearls and the upcoming release of PANCE AND PANRE QUESTION BOOK. Good luck!!!

1. A 35-year-old male comes to the clinic for a routine physical examination. During
obtaining a history, he tells you his brother was diagnosed with colon cancer at
53-years-old. Which of the following describes the appropriate colon cancer
screening guidelines for this patient?
a. Fecal occult blood testing now and colonoscopy every 10 years
b. Fecal occult blood testing at age 40 and colonoscopy every 10 years
c. Fecal occult blood testing at age 50 and colonoscopy every 10 years
d. Fecal occult blood testing at age 50 and colonoscopy every 5 years
e. Fecal occult blood testing at age 40 and colonoscopy every 5 years

2. A 45-year-old male presents with non-bloody diarrhea and crampy abdominal
pain especially in the right lower quadrant. Rovsing, Obturator and Psoas sign
are negative. He undergoes an upper GI series with small bowel follow through
and a string sign is seen. The patient is saccharomyces cerevisiae antibody
positive. Which of the following lab findings would most likely be seen in this
a. increased alpha fetoprotein
b. increased perinuclear anti-neutrophil antibody
c. increased smooth muscle antibody
d. increased mean corpuscular volume of the red blood cells
e. increased endomysial antibodies

3. A 50-year-old obese female is complaining of multiple episodes of sharp, right
upper quadrant pain that is worsened with fatty and fried foods. The patient
states the pain radiates to the right shoulder. On physical examination, there is
right upper quadrant tenderness, causing the patient to hold their breath in mid-
inspiration. There is no fever or jaundice. Which of the following is the most
appropriate test at this time?
a. HIDA scan
b. Endoscopic retrograde cholangiopancreatography
c. Ultrasound of the gallbladder
d. Abdominal radiograph
e. Prothrombin and albumin level

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

4. A 37-year-old female undergoes an upper endoscopy for epigastric pain. A direct

urease test was performed on the specimen and a direct urease test was positive.
Which of the following is the management of choice in this patient?
a. Lansoprazole 30mg + amoxicillin 500mg + clarithromycin 500mg
b. Lansoprazole 30mg
c. Lansoprazole 30mg + metronidazole 500mg + clarithromycin 500mg
d. Lansoprazole 30mg + ranitidine 300mg
e. Misoprostol 200mcg

5. A 43-year-old otherwise healthy male presents to the gastroenterologist after
being referred for chest pain and cough with a negative cardiac workup. An
esophagram is performed and shows the following

Which of the following is the most likely diagnosis?
a. Zenkers diverticulum
b. Esophageal cancer
c. Nutcracker esophagus
d. Achalasia
e. Diffuse esophageal spasm

6. In evaluating a patient with oral thrush and odynophagia, which of the following
endoscopic findings would be most likely seen in this patient?
a. Large superficial ulcers
b. Columnar cells in the lower esophagus
c. Small deep ulcers
d. Linear plaques
e. Multiple corrugated rings

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

7. In evaluation of a patient, which of the following values would be most consistent

with a patient chronic hepatitis B?


8. A 44-year-old male comes into the emergency room with crampy abdominal pain,
nausea, vomiting and constipation. An abdominal radiograph is performed and
shows the following

Which of the following is the most common early physical exam finding in this
a. Peritoneal signs
b. Bowel sounds with gurgles at about 5-15 per minute
c. No bowel sounds
d. Hyperactive, high-pitched tinkling abdominal sounds
e. Sausage shaped mass

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

9. Which of the following is the classic description of a patient with an ascorbic acid
(Vitamin C) deficiency.
a. Diarrhea, dementia and dermatitis
b. Ataxia, oculomotor palsies, global confusion
c. The presence of looser lines (zones)
d. Hyperkeratosis and perifollicular hemorrhages
e. Magenta colored tongue, corneal lesions and scrotal dermatitis

10. A 46-year-old male with a longstanding history of GERD now has dysphagia to
solids, weight loss and anemia. He does not smoke or drink and has not had any
recent episodes of vomiting or retching. Which of the following is the most likely
a. Barretts esophagus
b. Diffuse esophageal spasm
c. Adenocarcinoma of the esophagus
d. Squamous cell carcinoma of the esophagus
e. Mallory Weiss tears

Choice E is correct. A first-degree relative is a parent, sibling or offspring.
Because his brother was diagnosed at age 53, recommended age is to begin at
age 40 (or 10 years before the person was diagnosed which would have been 43
so you use the lower number). The 10 number comes from the thought it takes
roughly about 10 years on average for a polyp to become malignant.

Average Risk
1st degree relative
1st degree relative <60y

Annually @ 50y Colonoscopy q10y (flex sig q5y) (up to 80y)
Annually @ 40y Colonoscopy q10y
Annually @ 40y

Colonoscopy q5y

Choice A is incorrect

Choice B (Fecal occult blood testing at age 40 and colonoscopy every 10 years) is
recommended in patients whose first degree relative was diagnosed over 60y of

Choice C (Fecal occult blood testing at age 50 and colonoscopy every 10 years) is
the standard recommended guidelines.

Choice D is incorrect

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

Choice D (increased MCV) is the correct answer. The string sign, non-bloody diarrhea
and right lower quadrant pain is highly suggestive of Crohns disease. The terminal
ileum is the most common site of Crohns disease and since it sits in the right lower
quadrant, RLQ pain is a common finding in patients with Crohns. Both inflammatory
bowel diseases (Crohns and Ulcerative Colitis) are thought to arise from an
inappropriate autoimmune response to the normal GI flora. Antibodies against the
harmless saccharomyces cerevisiae (most likely known to you as Bakers/Brewers yeast
used to make ethanol and to allow dough to rise) is seen in about 70% of patients with
Crohns (and only 10-15% of those with ulcerative colitis so that also leads to the
diagnosis of Crohns. Because Crohns most commonly affects the terminal ileum
(where B12 is absorbed), patients may develop a B12 deficiency and a subsequent
macrocytic anemia with an increased mean corpuscular volume (MCV) of the red blood

Choice A (increased alpha fetoprotein) is common in hepatocellular carcinoma and germ
cell tumors like nonseminomatous testicular cancer. In utero, alpha fetoprotein is the a
dominant serum protein in the fetus (the fetus version of albumin produced by the yolk
sac and the liver (this is why it is can be seen in germ cell tumors & remember produces
our serum proteins).

Choice B (increased perinuclear anti-neutrophil antibody) is commonly seen with
ulcerative colitis (commonly associated with bloody diarrhea and left upper quadrant
since it the inflammation has contiguous spread from the rectum proximally so the left
side is affected). Cross reference: P-ANCA is also seen in Churg-Strauss, Primary
Sclerosing Cholangitis & microscopic polyangiitis.

Choice C (increased smooth muscle antibody) is classically associated with autoimmune
hepatitis (but can be seen in chronic hepatitis and cirrhosis). There was no mention of
liver symptoms or sequelae in this question to suggest those disorders.

Choice E (endomysial antibodies) & transglutaminase antibodies are classically
associated with Celiac disease (which can cause a chronic diarrhea) but would be related
to the consumption of gluten.

Choice C (ultrasound of the gallbladder) is correct. This is a classic presentation of
acute cholecystitis, making ultrasound the best initial test in the evaluation of suspected
cholecystitis. Ultrasound findings will be the presence of stone, thickened gall bladder
and a positive sonographic Murphys sign while doing the test. Although afebrile in this
vignette, patients with acute cholecystitis can be febrile due to the infection. The
referred pain to the right shoulder is known as Boas sign (not to be confused with pain
that radiates the left shoulder Kehrs sign). Both are caused by phrenic nerve
irritation. Boas sign is associated with acute cholecystitis and Kehrs sign is usually
associated with splenic injury most commonly, ectopic pregnancy, or kidney stones

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

Choice A is the gold standard test but remember often gold standard tests are most often
not the initial test done. If the question asked for gold standard, then HIDA would have
been correct.

Choice B (ERCP) is used for suspected biliary tract disease. In acute cholecystitis, the
stone is in the cystic duct but bile is still able to flow through the bile ducts (this is why
there are no long-term sequelae in patients who have a cholecystectomy as the bile can
still flow without the gall bladder. In biliary duct diseases, patients usually develop
jaundice with the blocking of the biliary tract.

Choice D (abdominal X ray) would be useful for other disorders, such as small bowel
obstruction but most stones are radiopaque (since they are made of cholesterol) so
wont show up often on abdominal X ray and radiographs wont show the details that
can be seen on ultrasound.

Choice E (PT and albumin levels) is helpful if end stage liver disease is suspected.

Choice A (Lansoprazole 30mg + amoxicillin 500mg + clarithromycin 500mg) triple
therapy is the mainstay of H-pylori peptic ulcer disease.

Choice B can be used for H. pylori negative disease. Proton pump inhibitors (the
azoles) are the most effective drugs against acid production.

Choice C is an alternative in patients who are penicillin allergic (Metronidazole is

Choice E can also be not to treat peptic ulcers. Misoprostol can be used to prevent
recurrence or ulcers particularly in patients with aspirin or NSAID-induced ulcers.
Remember gastric ulcers are due to decreased protective factors (mucous and
bicarbonate). Prostaglandins are responsible for those protective mechanisms and
aspirin and NSAIDs exhibit their anti-inflammatory effects via prostaglandin inhibition.
Misoprostol is a prostaglandin analogue.

Choice D (Achalasia) is correct. Achalasia is a disorder that causes loss of Aurbachs
plexus at the lower esophageal sphincter area. Auerbachs plexus secretes nitric
oxide (which leads to relaxation of the LES). Without Auerbachs plexus, there is an
increased LES pressure, leading to dysphagia. On a Barium swallow (esophagram),
the increased LES tone leads to narrowing of the GE junction and pre narrowing
dilation, leading to the classic bird beak appearance.

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

Choice A (Zenkers) is an out pouching of the pharyngoesophageal pouch, which

doesnt affect the lower esophageal sphincter.

Choice B (Esophageal Cancer) would show a filling defect around the cancer.

Choice C (Nutcracker) is associated with a normal esophagram.

Choice E (Diffuse esophageal spasm) would show a corkscrew appearance on
esophagram due to strong, non-peristaltic contractions of the esophagus.

Choice D (Linear plaques) is correct. Oral thrush is due to candida infection. Candida
esophagitis is associated with linear plaques in the esophagus.

Choice A (Large superficial ulcers) is associated c CMV esophagitis

Choice B (columnar cells in esophagus) is associated with Barretts esophagus ( a pre
malignant condition to esophageal adenocarcinoma). In chronic reflux esophagitis, the
normal squamous cells are replaced by columnar cells from the stomach (which are
better to a higher acidic environment). The would have a had a history of GERD.

Choice C (small deep ulcers) is classic for Herpes Simplex (HSV) esophagitis

Choice E (corrugated rings) is classic for eosinophilic esophagitis

Choice B is correct. Whenever evaluating hepatitis, the quickest way is to look at
surface antigen, surface antibody and the core antibody. I only look at the E if the person
has acute or chronic to determine replication. With that said, Chronic hepatitis is
defined as the presence of the Hepatitis B surface antigen (HBsAg) and the failure to
develop the surface antibodies (HBsAb) in 6 months. Because the person has a chronic
infection, the core antibody would be IgG (would have already switched from making the
acute IgM antibodies).

Choice A describes someone who has a distant resolved infection. They developed the
surface antibodies and the core antibodies.

Choice C denotes acute viral hepatitis, as the surface antigen is positive and the fact that
the core is IgM (remember from immunology your body first starts making IgM
pentamer antibodies before switching to creating IgG antibodies).

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

Choice D denotes successful Hepatitis B vaccination. The surface antibody is the only
positive marker in vaccination. People often confuse this with someone with a distant
resolved infection. But think of it this way, if you were infected with hepatitis B, then the
virus would be destroyed by the macrophages, producing antibodies to surface proteins
but also the viral core, so the core would be positive.

Choice E is the classic description of the window period. In someone who is infected, the
window period describes the point where the surface antigen is disappearing (leading to
a negative HBsAg) but the antibodies are not enough yet to be detected by testing (even
though they will eventually increase). So the core IgM antibody is often the sole
serologic marker in the window period.


Choice D (hyperactive bowel sounds) is correct. Crampy abdominal pain, nausea
vomiting and constipation are classic for a small bowel obstruction. Besides, the
abdominal X ray shows the stepladder appearance as fluid and air builds up in the
obstructed bowel since it cannot go forward. In the early stages of obstruction, there is
hyperactive bowel sounds as the bowel proximal to the obstruction fervently contracts
to overcome the obstruction. Later in the disease, hypoactive bowel sounds (choice C)
will prevail but the question specifically states early.

Choice A (peritoneal) is not specific to small bowel obstruction but can be seen if bowel
ischemia is present due to small bowel obstruction or other reasons and can be seen in
many disorders and often not seen in early obstruction.

Choice B (gurgles about 5-15) is considered normal bowel sounds

Choice E (sausage shaped mass) is classically associated with intussusception which
would be associated with a bowel that contains mucous and blood (currant-jelly) and
vomiting. Which is almost exclusively seen in infants. If it occurs in adults, it is often
associated with a lead point such as a malignancy that then causes the telescoping.

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams

Choice D (hyperkeratosis & perifollicular hemorrhages) is correct. Vitamin C is
needed for collagen synthesis. Scurvy (Vitamin C deficiency) is associated with loss of
collagen in blood vessels, leading to perifollicular hemorrhages & purpura among the
other manifestations.

Choice A is classic for pellagra (Vitamin B3/Niacin) deficiency

Choice B is classic for vitamin B1/Thiamin deficiency. Ataxia oculomotor paralysis and
global confusion is the triad of Wernickes encephalopathy.

Choice D (Looser Lines) are associated with adult onset vitamin D deficiency

Choice E ocular-oral-genital involvement is classically associated with riboflavin
(Vitamin B2) deficiency.

Choice C (Esophageal adenocarcinoma) is correct. Chronic acidic contents in the
esophagus of someone with longstanding GERD will develop Barretts esophagus (Choice
A), the precursor to esophageal carcinoma. The fact that he had dysphagia especially to
solids, weight loss and anemia make malignancy the likely cause.

Choice B (diffuse esophageal spasm) is a motility disorder, so both solids and liquids will
cause spasm of the esophagus. The patient will often complain of odynophagia,
classically its a stabbing chest pain that is worse with hot or cold foods AND liquids.

Choice D (Squamous cell carcinoma) is usually seen not in the context of GERD but more
so in patients who drink or smoke (this patient does neither), making Choice C the better

Choice E (Mallory Weiss Tears) are due to repeated vomiting or retching causing
superficial mucosal tears. The usually develop signs of bleeding if they are symptomatic.

Achalasia: By Farnoosh Farrokhi, Michael F. Vaezi. [CC-BY-2.0
(], via Wikimedia Commons

Small Bowel obstruction: By James Heilman, MD (Own work) [CC-BY-SA-3.0-2.5-
(], via Wikimedia Commons

Chapter 3 Question Bank GASTROINTESTINAL - Dwayne A. Williams