1
Q
The combination of symptomatic proximal esophageal webs and iron-deficiency anemia in middle-aged women constitutes
A
Plummer-Vinson or Paterson-Kelly syndrome
2
Q
When the lumen diameter is <13 mm, distal rings are usually associated with episodic solid food dysphagia and are called
A
Schatzki rings
3
Q
the obstruction is a stenotic cricopharyngeus muscle (upper esophageal sphincter), and the hypopharyngeal herniation most commonly occurs in an area of natural weakness proximal to the cricopharyngeus known Killianās triangle
A
Zenkerās diverticula
4
Q
the esophagus is compressed by an aberrant right subclavian artery arising from the descending aorta and passing behind the esophagus
A
Dysphagia lusoria
5
Q
The physiologic abnormality of GERD
A
excessive esophageal exposure to refluxed gastric fluid
6
Q
False diverticula
A
Epiphrenic and hypopharyngeal (Zenkerās diverticula)
7
Q
barium swallow x-ray of achalasia
A
dilated esophagus with poor emptying, an airfluid level, and tapering at the LES giving it a beak-like appearance
8
Q
The only durable therapies for achalasia are
A
pneumatic dilation and LES myotomy
POEM peroral endoscopic myomectomy- endoscopic approach to LES myomectomy
9
Q
Three dominant mechanisms of esophagogastric junction incompetence are recognized:
A
(1) transient LES relaxations, (2) LES hypotension, or
(3) anatomic distortion of the esophagogastric junction inclusive of hiatal hernia
10
Q
the endoscopic hallmark of GERD
A
Erosive esophagitis at the esophagogastric junction
11
Q
most severe histologic consequence of GERD is
A
Barrettās metaplasia
12
Q
salmon-colored mucosa extending proximally from the gastroesophageal junction or histopathologically by the finding of specialized columnar metaplasia, is associated with a significantly increased risk for development of esophageal adenocarcinoma
A
Barrettās metaplasia
13
Q
Specific chronic disorders have been shown to have a strong association with PUD:
A
(1) advanced age, (2) chronic pulmonary disease, (3) chronic renal failure, (4) cirrhosis, (5) nephrolithiasis, (6) a1 antitrypsin deficiency, (7) systemic mastocytosis
14
Q
Disorders with a possible association to PUD are
A
(1) hyperparathyroidism, (2) coronary artery disease, (3) polycythemia vera, (4) chronic pancreatitis, (5) former alcohol use, (6) obesity, (7) African-American race, and (8) three or more doctor visits in a year
15
Q
H pylori treatment
+ PCN allergy -MCL exposure
A
Clarithromycin triple with metronidazole (PCM)
Bismuth quadruple (PBTM)
16
Q
H pylori treatment
+ PCN allergy + MCL exposure d
A
Bismuth quadruple
17
Q
Several nonselective NSAIDs that are associated with a lower likelihood of GI and CV toxicity include
A
naproxen and ibuprofen
18
Q
When should H. pylori eradication should be documented?
A
4 weeks after completing antibiotics.
test of choice for documenting eradication: stool antigen test or a urea breath test (UBT)
* off PPI for 7 days
19
Q
Refractory PUDs
A
A GU that fails to heal after 12 weeks
DU after 8 weeks
20
Q
Chronic gastritis is also classified according to the predominant site of involvement.
Type A
Type B
A
Type A- body-predominant form (autoimmune),
Type B- antral-predominant form (H. pyloriārelated
21
Q
highly sensitive and specific marker for detecting intestinal inflammation
A
Fecal lactoferrin
22
Q
levels correlate well with histologic inflammation, predict relapses, and detect pouchitis
A
Fecal calprotectin
23
Q
Serology in CD and UC
A
CD- ASCA
UC- pANCA
24
Q
Gut flora in IBS
A
decreased proportions of the genera Bifidobacterium and Faecalibacterium
and increased abundance of family Enterobacteriaceae, Lactobacillaceae, and Bacteroides
25
Rome IV criteria in IBS
Recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, associated with ā„2 of the following criteria: 1. Related to defecation
2. Associated with a change in frequency of stool 3. Associated with a change in form (appearance) of stool
26
is the only antibiotic with demonstrated sustained benefit beyond therapy cessation in IBS patients
Rifaximin
550mg 2x a day for 2 weeks
27
Manometrically, uncoordinated (āspasticā) activity in the distal esophagus, spontaneous and repetitive contractions, or high-amplitude and prolonged contractions
Diffuse Esophageal Spasm (DES)
* Radiographically, a ācorkscrew esophagus,ā ārosary bead esophagus,ā pseudodiverticula, or curling can be indicative of DES, but these are also found with spastic achalasia
28
By endoscopy salmon-colored mucosa extending proximally from the gastroesophageal junction or histopathologically by the finding of specialized columnar metaplasia
Barrettās metaplasia
29
Endoscopically, lesions appear as large serpiginous ulcers in an otherwise normal mucosa, particularly in the distal esophagus. Biopsies from the ulcer bases have the greatest diagnostic yield for finding the pathognomonic large nuclear or cytoplasmic inclusion bodies
CMV esophagitis
Tx Ganciclovir/Valganciclovir
30
DU vs GU
A. the presence of antral-predominant gastritis is associated with___ formation
B. gastritis involving primarily the corpus predisposes to the development of ___
duodenAl antral
gastriC corpus, cancer
31
Gastric ulcer classification
Type I
Type II
Type III
Type IV
BAPC
1 Body
2 Antrum
3 Pylorus N/H gastric acid
GU low acid output
DU high acid output
4 Corpus
32
In those without CV risk factors but with a high potential risk (prior GI bleeding or multiple GI risk factors) for NSAID-induced GI toxicity, what do you give?
selective COX-2 inhibitor and co-therapy with high-dose PPI or misoprostol
33
test of choice for documenting eradication is the
laboratory-based validated monoclonal stool antigen test or a urea breath test (UBT)
* patient must be off antisecretory agents for at least 7 days when being tested for eradication of H. pylori with UBT or stool antigen
34
considered pathognomonic of ZES
BAO?
Gastrin?
A BAO >15 meq/h in the presence of hypergastrinemia (>150-200 pg/ml)
35
What is The most sensitive and specific gastrin provocative test for the diagnosis of gastrinoma
Secretin test
* increase in gastrin of >120 pg within 15 min of secretin injection has a sensitivity and specificity of >90% for ZES
36
Chronic gastritis according to predominant site
Type A
Type B
Type A- body predominant (autoimmune)
Type B- antral predominant (bacterial H pylori)
Type A- anti-IF antibodies, pernicious anemia (Parietal cells are the source of IF, the lack of which will lead to vitamin B12 deficiency and its sequelae (megaloblastic anemia, neurologic dysfunction)
37
characterized by large, tortuous mucosal folds, develop a protein-losing gastropathy due to hypersecretion of gastric mucus accompanied by hypoalbuminemia and edema
MĆ©nĆ©trierās Disease
Cetuximab is now considered the first-line treatment for MD
38
What is The initial treatment for cirrhotic ascites?
restriction of sodium intake to 2 g/d
39
What is the ideal combined dose of furosemide and spironolactone in ascites?
40:100, max of 160:400
If gynecomastia is distressing shift spironolactone to amiloride
40
Pharmacologic therapy for refractory ascites
addition of midodrine, an a1-adrenergic agonist, or clonidine, an a2-adrenergic agonist, to diuretic therapy
41
How much infusion of albumin accompanying LVP decreases the risk of āpostparacentesis circulatory dysfunctionā and death
albumin infusions of 6ā8 g/L of ascitic fluid removed
42
What is the Rome IV Criteria for IBS?
Pain 1,2,3 stool, form, frequency
43
Altered gut flora in IBS
decreased Bifidobacterium and Faecalibacterium
and increased abundance of family Enterobacteriaceae, family Lactobacillaceae, and genus Bacteroides
44
In IBS-D patients, the tricyclic antidepressant ____ slows jejunal migrating motor complex transit propagation and delays orocecal and whole-gut transit, indicative of a motor inhibitory effect
imipramine
IBS-D TCA
45
the selective serotonin reuptake inhibitor (SSRI) _____ accelerates orocecal transit, raising the possibility that this drug class may be useful in IBS-C patients
paroxetine
IBS-C SSRI
46
the only antibiotic with demonstrated sustained benefit beyond therapy cessation in IBS patients
Rifaximin
550mg BID x 2 weeks
47
Px with diverticulitis on CT showed pericolic abscess, what is the treatment of choice?
Hinchey stage Ib
with percutaneous drainage followed by resection with anastomosis about 6 weeks later
48
the single most common risk factor for hepatitis C
Injection drug use
49
Histologic lesions hepatitis
Hepatitis C
Hepatitis D
Hepatitis C
Hep C paucity of inflammation
Hep D microvesicular steatosis
Hep E marked cholestasis
50
the single most common risk factor for hepatitis C
Injection drug use
51
Acute Hepatitis duration of treatment
Hep B
Hep C
Hep B
Until 3 mos after HbsAg conversion or 6 mos after HbeAg conversion
Hep C
8-12 weeks
GP 8 weeks (glecapavir-pibrentasvir)
SofVel 12 weeks (sofosbuvir-velpatasvir)
52
the one factor that appears to improve survival in fulminant hepatitis
Prophylactic antibiotic coverage
53
Tx with anecdotal success in severe acute hep E or acute-in-chronic liver failure
Ribavarin
54
booster doses are recommended when anti-HBs levels fall to
<10 mIU/mL
55
Clinically, the distinction between a hepatocellular and a cholestatic reaction is indicated by the R value, the ratio of alanine aminotransferase (ALT) to alkaline phosphatase values
Hepatocellular
Cholestatic
Mixed
R value >5
R value <2
R value 2-5
56
For chronic hep B, correlates with the level of liver injury and risk of progression
HBV DNA
57
Of the eight approved treatments for chronic hep B, what are recommended as first-line agents
PEG IFN, entecavir, and the two tenofovir preparations (TDF and TAF)
58
What is the current drug of choice in pregnancy for hepatitis
Tenofovir (TDF in CPG)
59
Patient drinking heavily for typically >5 years and until at least 8 weeks before onset of symptoms. They present with rapid onset of jaundice (serum bilirubin >3 mg/dL), often accompanied by fever, malaise, tender hepatomegaly, and clinical signs of hepatic decompensation, such as ascites, bacterial infection, variceal bleeding, and hepatic encephalopathy. What is the expected
AST and ALT elevation
AST/ALT ratio
Serum bilirubi
Patients with alcoholic hepatitis have AST and ALT elevations that do not exceed 400 IU/L, with AST/ALT ratio of >1.5 and serum bilirubin >3 mg/dL
60
Liver stiffness indicating F4 cirrhosis
>12.5 kPa
<6 kPa normal
>8 kPa F3 advanced fibrosis
61
Which patients with alcoholic hepatitis will benefit from glucocorticoid treatment?
Severe AH MDF 32 and above or MELD >20
* Enteral nutrition with a goal of >21 kcal/kg
62
A unique form of hemolytic anemia (with spur cells and acanthocytes) can occur in patients with severe alcoholic hepatitis
Zieveās syndrome
63
Middle aged woman, complaining of significant degree of fatigue out of proportion to either the severity of the liver disease or the age, jaundiced, with features of hyperpigmentation, xanthelasma, and xanthomata, w/u showed cholestatic liver abnormalities and positive for AMA
Dx?
Tx?
Primary Biliary Cholangitis
Ursodeoxycholic acid (UDCA) is the first-line treatment; given in doses of 13ā15 mg/kg per d
64
Typical cholangiographic findings in PSC
multifocal stricturing and beading involving both the intrahepatic and extrahepatic biliary tree
65
Autoantibody positive in 65% of px with PSC
pANCA
Usually also have IBD (UC)
66
Portal hypertension is defined as the elevation of the hepatic venous pressure gradient (HVPG) to
>5 mmHg
*clinically significant portanl HPN 10mmhg and up
At risk for variceal hemorrhage >12mmHg
67
three primary complications of portal hypertension are
gastroesophageal varices with hemorrhage, ascites, and hypersplenism
68
Upper endoscopy schedule for cirrhosis patients
At time of diagnosis
Every 2 yrs if active
Every 3 yrs if inactive
Recommended at time of decompensation
69
Primary prophylaxis by nonselective beta blockade goals
HR 55-60 with SBP >90
Via propanolol/nadolol/carvedilol
*once primary prophylaxis has been initiated, repeat endoscopy for surveillance is unnecessary
70
When ascitic fluid protein is very low, <1.5 g/dL, patients are at increased risk for?
developing SBP
71
Malnutrition in cirrhosis
General recommendations include multiple small meals including a late evening snack with total calories of:
25ā30 kcal per kg of ideal body weight per day and 1.2ā1.5 g of protein per kg of ideal body weight per day
72
A mechanically ventilated patient admitted in the ICU is being referred for minimal bowel movement, abdominal distention and tympany on physical examination. On laboratories, he has elevated creatinine and BUN, normokalemia, and normomagnesemia. Chest xray showed new lower lobe pneumonia. He is already on Day 3 of empiric treatment for ventilator associated pneumonia and is prepared to undergo first dialysis. Which of the following co-morbidities is least likely to contribute to his ileus?
a. Uremia
b. Lower lobe pneumonia
c. Sepsis
d. Mechanical ventilation
D. Mechanical ventilation
Ā
Ileus is present when dysmotility prevents intestinal contents from being propelled distally and no mechanical blockage exists. Ileus that occurs after intraabdominal surgery is the most commonly identified form of functional bowel obstruction, although it also most often transient.
73
A 30 year old male from Samar with no history of alcohol abuse sought consultation for 8 month history of abdominal enlargement. There was no associated febrile episodes, abdominal pain or change in stools. On physical examination, he had icteric sclerae and fluid wave but no abdominal tenderness. Liver enzymes ALP and ALT were similarly elevated as well. Further diagnostics workup with following is appropriate EXCEPT for:
a. HBsAg, IgM Anti-HBc, Anti-HCV
b. Ceruloplasmin
c. Ultrasound
d. Ferritin, Fe saturation
A. HBsAg, IgM Anti-HBc, Anti-HCV
Ā
In patients with suspected liver disease and chronic duration of symptoms, or more than 6 months, include workup for HBsAg and Anti-HCV, but not for IgM Anti-HBc, which should be done during the acute phase of symptoms.
74
A patient with known liver cirrhosis was brought to the emergency room due to onset of melena. He had stable vitals, oriented to 3 spheres, with moderate ascites only on examination. His lab tests show CBC Hgb 98 Hct 28 WBC 10 Plt 149, Creatinine 0.7mg/dL, Na 138 K 3.4, ALT 38, Total Bilirubin 2.7mg/dL, Albumin 31, INR 1.5. What are his score and Child Pugh classification?
a. 7, Child Pugh B
b. 6, Child Pugh B
c. 9, Child Pugh C
d. 10. Child Pugh B
A. 7, Child Pugh B
Ā
Patient had moderate ascites, no signs of encephalopathy with total bilirubin at 2.7, Albumin at 31 and INR at 1.5, scoring a total of 7 (2 + 0 + 2 + 2 + 1 respectively)
75
A healthy 30 year old female is accompanied by her father, who was recently diagnosed with Gastric cancer, to your clinic for consultation regarding cancer prevention. She notes that she sometimes has postprandial pain that resolves spontaneously and did not have a check up since. Which of the following scenarios is H. pylori eradication NOT indicated?
a. First degree relatives of family members with gastric cancer
b. Patients with gastric cancer post subtotal resection
c. Patients with gastric acid inhibition > 1 year
d. All of the following are indicated
D. All of the following are indicated
Ā
The Maastricht VI/ Florence Consensus Report evaluated H. pylori treatment in gastric cancer prevention and recommends that eradication should be considered in the following situations:
1) first-degree relatives of family members with gastric cancer
2) patients with previous gastric neoplasm treated by endoscopic or subtotal resection
3) individuals with a risk of gastritis (severe pangastritis or body-predominant gastritis) or severe atrophy
4) patients with gastric acid inhibitionĀ for >1 year
5) individuals with strong environmental risk factors for gastric cancer (heavy smoking; high exposure to dust, coal, quartz, or cement; and/or work in quarries)
6) H. pyloriāpositive patients with a fear of gastric cancer
76
A patient has a history of recurrent abdominal pain and had multiple consults previously diagnosing only Peptic ulcer disease, discharged on PPIs. He noted minimal relief of symptoms, now with associated weight loss and noticed that his feces floats, with greasy look and foul-smelling odor. Suspecting chronic pancreatitis, you order contrast enhanced CT but noted no calcifications in combination with atrophy or dilated duct. What is the next BEST step in management?
a. Magnetic resonance cholangiopancreatography
b. Endoscopic ultrasound
c. Pancreas function test (secretin)
d. Discharge patient, patient does not have chronic pancreatitis
A. Magnetic resonance cholangiopancreatography
Ā
Figure 347-2 highlights the stepwise diagnostic approach to patients with suspected chronic pancreatitis. In contrast enhanced CT scan (step 1), the presence of calcification plus atrophy or dilated duct would be suggestive of chronic pancreatitis. If not, we proceed to step 2 which is to order an MRCP
77
A 60 year old male complaining of abdominal distention and severe abdominal pain was brought in to the ER. He was hypotensive at 80/50, HR 110 RR 25 T38 O298%, He had a history of alternating diarrhea and constipation, eventually progressing to no bowel movement over 1 week. Suspecting colonic obstruction, a CT scan was ordered. Which of the following areas of the intestine are more prone to colonic ischemia should the pathology occur near this point?
a. Hepatic flexure
b. Splenic flexure
c. Ileocecal junction
d. Arc of Rolan
B. Splenic flexure
Ā
The blood supply to the intestines is supplied by the celiac artery, SMA, and inferior mesenteric artery. Extensive collateralization occurs between major mesenteric trunks and branches of the mesenteric arcades. Collateral vessels within the small bowel are numerous and meet within the duodenum and the bed of theĀ pancreas. Collateral vessels within the colon meet at the splenic flexure and descending/sigmoid colon. These areas, which are inherently at risk for decreased blood flow, are known as Griffithsā point and Sudeckās point,Ā respectively, and are the most common locations for colonic ischemia
78
A 32 year old male from Samar consulted at the clinic for 6 month history of increasing abdominal girth. He noted easy fatigability but denies fever, jaundice, abdominal pain. On examination, the abdomen was distended but soft, no tympany and no guarding. If one of the considerations is schistosomiasis, under which category would the cause fall under?
a. Prehepatic
b. Presinusoidal
c. Sinusoidal
d. Post sinusoidal
B. Presinusoidal
Ā
Table 344-3 highlights the subcategories of the causes of portal hypertension which may lead to onset of ascites. The hepatic causes of portal hypertension is divided into presinusoidal, sinusoidal and post sinusoidal causes. The life cycle of Schistosomiasis in the liver contributes to the development of presinusoidal causes of portal hypertension
79
A patient with secondary biliary cirrhosis was able to find a suitable donor for liver transplant and you were tasked to screen the patient. The following are absolute contraindications to liver transplant except:
a. Metastatic malignancy
b. Prior extensive hepatobiliary surgery
c. AIDS
d. Alcohol abuse
B. Prior extensive hepatobiliary surgery
Ā
Prior extensive hepatobiliary surgery is only a relative contraindication to liver transplant as listed in table 345-2 with metastasis, AIDS and active alcohol abuse among the absolute contraindications
80
Which of the following patients has a condition known to increase the risk of both arterial and venous thrombosis?
a. A 45-year-old man with class II obesity who presents for lifestyle counseling and has no other comorbidities.
b. A 62-year-old woman receiving chemotherapy for metastatic colon cancer who presents with new left leg swelling and unexplained fatigue.
c. A 28-year-old man in the ICU for septic shock, currently on broad-spectrum antibiotics and vasopressors.
d. A 32-year-old pregnant woman at 28 weeks gestation with mild bilateral ankle edema on routine prenatal visit.
Ans. B. A 62-year-old woman receiving chemotherapy for metastatic colon cancer who presents with new left leg swelling and unexplained fatigue.
Ā
Ā Obesity, infection, and pregnancy increase risk of venous thrombosis only.
81
Which physical examination maneuver for splenomegaly is described? Percussion begins at the lower level of pulmonary resonance in the posterior axillary line and proceeds diagonally along a perpendicular line toward the lower midanterior costal margin. The upper border of dullness is normally 6ā8 cm above the costal margin.
a. Traube's method
b. Nixon's method
c. Barkun's method
d. Castell's method
Ans. B. Nixon's Method
Ā
Nixon's method: The patient is placed on the right side so that the spleen lies above the colon and stomach. Percussion begins at the lower level of pulmonary resonance in the posterior axillary line and proceeds diagonally along a perpendicular line toward the lower midanterior costal margin. The upper border of dull- ness is normally 6-8 cm above the costal margin. Dullness >8 cm in an adult is presumed to indicate splenic enlargement.
Castell's method: With the patient supine, percussion in the lowest intercostal space in the anterior axillary line (8th or 9th) produces a resonant note if the spleen is normal in size. This is true during expiration or full inspiration. A dull percussion note on full inspiration suggests splenomegaly.
Percussion of Traube's semilunar space: The borders of Traubes space are the sixth rib superiorly, the left midaxillary line laterally, and the left costal margin inferiorly. The patient is supine with the left arm slightly abducted. During normal breathing, this space is percussed from medial to lateral margins, yielding a normal resonant sound. A dull percussion note suggests splenomegaly.
HPIM Chapter 66 P461
82
Which of the following conditions by itself is NOT sufficient to cause severe and prolonged megaloblastic anemia?
a. Gluten induced enteropathy
b. Stagnant loop syndrome
c. Partial gastrectomy
d. Ileocolic fistula
Ans. A. Gluten induced enteropathy
83
For patients with myelodysplastic syndrome, the finding of a 5q deletion is associated with good prognosis as it is potentially curable without hematopoietic stem cell transplantation. Which of the following medications can be given to improve the genetic profile of these patients?
a. Azacitadine
b. Decitabine
c. Thalidomide
d. Lenalidomide
Ans. D. Lenalidomide
Ā Lenalidomide, a thalidomide derivative with a more favorable toxicity profile, is particularly effective in reversing anemia in MDS patients with 5q- syndrome; not only do a high proportion of these patients become transfusion independent with normal or near-normal hemoglobin levels, but their cytogenetics also become normal.
84
Which of the following is a risk factor for post ERCP pancreatitis?
a. Age > 60 years old
b. Major papilla sphincterotomy
c. Pancreatic duct stent insertion
d. Suspected sphincter of Oddi dysfunction
D. Suspected sphincter of Oddi dysfunction
HPIM21 CH348 P2658
Option C is actually a protective factor for post ERCP pancreatitis. Option A and B is incorrect, risk factors for post ERCP pancreatitis include minor papilla sphincterotomy and age < 60 y/o.
85
A 35-year-old female consults with Ultrasound results of Cholelithiasis. Which of the following clinical features may predispose her to cholesterol gallstone formation?
a. Atorvastatin therapy
b. Japanese descent
c. Oral Contraceptive Use
d. Cystic Fibrosis
C. Oral Contraceptive Use
Source: HPIM 21st ed Ch 346 p2644 Table 346-1
Clofibrate therapy and not Atorvastatin increases biliary secretion of cholesterol. Patients of Japanese descent have the lowest familial predisposition. Cystic fibrosis is a risk factor for pigment stone formation.
86
21-year-old male complained o f a burning sensation i n his chest accompanied
by a feeling o f liquid backwashing from his stomach t o his throat. What
extrasophageal syndromes have established association to his condition?
A. Acute cough
B. COPD
C. Dental erosions
D. Pharyngitis
C. Dental erosions
Established association with GERD
chronic cough
Laryngitis
Asthma
Dental erosions
87
65/F with obesity and dyslipidemia came in for painless hematochezia of 3 episodes. Her diet consists mostly of processed food. Her vital signs were stable, physical exam was normal aside from bloody stool per examining
finger. Colonoscopy revealed blood clot filled diverticula in the sigmoid region. What risk factor does the patient have that increases her risk for diverticular bleed?
a. Age > 60
b. Dyslipidemia
c. Low fiber diet
d. Obesity
D. Obesity
Factors for increased risk of bleeding:
ā¢ Hypertension
ā¢ Presence of atherosclerosis
ā¢ Patients with regular use o f antithrombotic therapy
ā¢ Regular use of NSAIDs
ā¢ Obesity
ā¢ Diabetes mellitus
PSBIM 2026 šÆāāļø
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