a = new Array(260);
var f = "<FONT FACE=ARIAL SIZE=2>"
a[0] = ""
a[1] = f + "(A) Incorrect. There may be reflux along with inflammation and possible ulceration, but bleeding is not typically massive."
a[2] = f + "(B) CORRECT. The lacerations are induced by the forceful, prolonged vomiting and can extend to submucosal veins that bleed profusely. Esophageal variceal bleeding should also be suspected with such a history. The acute nature of the process means no blood has yet passed through the bowel to the rectum."
a[3] = f + "(C) Incorrect. Diverticula of the esophagus do not often bleed."
a[4] = f + "(D) Incorrect. Barrett mucosa is associated with reflux with inflammation and possible ulceration, but bleeding is not usually massive."
a[5] = f + "(E) Incorrect. Ulceration of the mucosa occurs with carcinoma, but massive bleeding is not common."
a[5.1] = f + "(F) Incorrect. Strictures of the esophagus result from scarring, typically with reflux, or with scleroderma. It is a chronic process without massive hemorrhage."
a[6] = f + "(A) Incorrect. Early gastric carcinoma (EGC) usually does not metastasize."
a[7] = f + "(B) CORRECT. The prognosis with early gastric carcinoma (EGC) is good, compared with other gastric cancers."
a[8] = f + "(C) Incorrect. A signet ring cell pattern is more typical for a poorly differentiated, diffuse type of gastric carcinoma, not an early gastric carcinoma (EGC)."
a[9] = f + "(D) Incorrect. Linitis plastica characterizes a diffuse cancer with a poor prognosis, not an early gastric carcinoma (EGC)."
a[10] = f + "(E) Incorrect. However, in Japan, many of these early gastric carcinomas (EGC) are found because of more intense screening."
a[11] = f + "(A) Incorrect. Iron deficiency anemia may be accompanied in rare instances by development of an esophageal web (Plummer-Vinson syndrome), and there is a small risk for esophageal cancer with these webs. Overall, this is an uncommon risk for esophageal cancer."
a[12] = f + "(B) Incorrect. <I>H. pylori</I> infection is associated with gastritis and peptic ulcer disease. The risk for subsequent gastric adenocarcinoma is increased."
a[13] = f + "(C) CORRECT. Chronic alcoholism and tobacco use are two of the most important risk factors for squamous cell carcinoma of the esophagus in the U.S., specifically related to squamous cell carcinomas of the mid-esophagus, as in this man. Zinc and molybdenum are trace elements in the diet whose absence increases the risk for carcinoma of the esophagus. Food contaminated with <I>Aspergillus</I> also carries a risk, as does food containing nitrosamines."
a[14] = f + "(D) Incorrect. This is not a risk factor for squamous cell carcinoma of the esophagus. Eat your vegetables, too (but don't pickle them)."
a[15] = f + "(E) Incorrect. Esophageal diverticula are not risk factors for squamous cell carcinoma of the esophagus."
a[16] = f + "(A) Incorrect. A carcinoid tumor of this size is likely to be benign and unlikely to metastasize. However, carcinoids can never be completely trusted on gross and microscopic characteristics, regardless of size."
a[17] = f + "(B) CORRECT. This lesion is a carcinoid tumor, and these neoplasms can be multiple. Small carcinoids typically act in a benign fashion. Most of them do not secrete hormones causing clinical symptoms, but some do. They are often incidental findings."
a[18] = f + "(C) Incorrect. Carcinoid tumors are neuroendocrine lesions that can potentially secrete a variety of neuropeptides, including gastrin, but most carcinoids are non-functional."
a[19] = f + "(D) Incorrect. Such a small incidental circumscribed mass is unlikely to be a metastasis, and he is quite young to have pancreatic adenocarcinoma."
a[20] = f + "(E) Incorrect. Mass lesions are not typical for Crohn disease or infections of the small bowel. There is a slight increase in risk for adenocarcinoma with Crohn disease."
a[20.1] = f + "(F) Incorrect. Whipple disease produces a diffuse infiltrate of macrophages containing the organisms. It is quite rare."
a[21] = f + "(A) CORRECT. The gastric antrum is the typical location for a benign peptic ulcer."
a[22] = f + "(B) Incorrect. The size and shape suggest that this ulceration is benign."
a[23] = f + "(C) Incorrect. There is usually decreased acid in patients with peptic ulceration, but not absence of acid."
a[24] = f + "(D) Incorrect. The size is not a reliable clue that it is benign. ALL gastric ulcers seen on endoscopy should be biopsied."
a[25] = f + "(E) Incorrect. The Zollinger-Ellison syndrome, which is a rare cause for gastric ulceration, is typically accompanied by the presence of multiple gastric and duodenal ulcerations."
a[26] = f + "(A) CORRECT. Darkly pigmented gallstones usually contain bilirubin. Hyperbilirubinemia is a consequence of hemolysis. Patients with sickle cell anemia have chronic hemolysis."
a[27] = f + "(B) Incorrect. Yellow to green 'mixed' stones of mainly cholesterol are more likely to form when there is are decreased bile acids from decreased enterohepatic circulation with Crohn disease."
a[28] = f + "(C) Incorrect. Yellow to green stones of mainly cholesterol would be formed in conditions of increased cholesterol."
a[29] = f + "(D) Incorrect. Hypercalcemia leads to gallstone formation with increased calcium combined with cholesterol to produce yellow-white stones."
a[30] = f + "(E) Incorrect. PBC produces an increase in serum cholesterol with cholelithiasis in about 15% of cases, mainly cholesterol stones that are yellow to green."
a[30.1] = f + "(F) Incorrect. Schistosomiasis with <I>S. mansoni</I> or <I>S. japonicum</I> leads to hepatic portal fibrosis and portal hypertension."
a[31] = f + "(A) Incorrect. Hypercholesterolemia is not a risk for pancreatitis. However, hypertriglyceridemia is a cause for pancreatitis, though the triglyceride level must be quite high--probably over 1000 mg/dl."
a[32] = f + "(B) Incorrect. <I>Helicobacter pylori</I> organisms in the gastric mucus produce urease which will break down urea to ammonia and to CO2. The patient drinks a measured quantity of a urea-containing solution with radiolabelled carbon. If organisms are present they metabolize the urea and release the radiolabelled carbon which is detected in exhaled air. However, <I>H. pylori</I> infection is not a cause for pancreatitis."
a[33] = f + "(C) CORRECT. Hypercalcemia is a less common cause for acute pancreatitis that can be found in persons with hyperparathyroidism. Once the pancreatitis has started, the formation of the chalky soap deposits of fat necrosis may draw off calcium to produce hypocalcemia."
a[34] = f + "(D) Incorrect. Florid acute pancreatitis is not a typical complication of cystic fibrosis. The acinar pancreas, however, atrophies over time, with fatty replacement, but it does not typically become markedly acutely inflamed. A 34 year old with cystic fibrosis is typically not healthy, but has chronic lung disease."
a[35] = f + "(E) Incorrect. Viral hepatitis is not a risk for pancreatitis. However, some cases of pancreatitis are caused by other viruses."
a[36] = f + "(A) Incorrect. Rotavirus infection is usually seen in children under age 6. In very young children and infants the fluid loss from the diarrbea can be life-threatening."
a[37] = f + "(B) Incorrect. Shigellosis is a more severe disease, often producing dysentery with bloody stools. <I>Shigella</I> is not likely to be found up in the mountains, but in food/water with fecal contamination."
a[38] = f + "(C) Incorrect. <I>Vibrio cholerae</I> is the cause for cholera, which produces a profuse, watery diarrhea that is life-threatening."
a[39] = f + "(D) CORRECT. Giardiasis is typically a non-life threatening nuisance in immunocompetent persons. The organisms are found in contaminated water, particularly in areas such as apparently pristine, remote, mountains not considered to be a risk for infectious diseases. He had not read his Sierra Club guide in regard to treatment of drinking water while camping."
a[40] = f + "(E) Incorrect. Amebiasis is more common in developing nations. There can be findings mimicking inflammatory bowel disease and some mucosal ulceration may be present."
a[40.1] = f + "(F) Incorrect. Cryptosporidiosis is more likely to occur in immunocompromised patients. It can produce a self-limited diarrhea in immunocompetent persons, and occurs in outbreaks. It is not frequently encountered in the natural environment."
a[40.2] = f + "(G) Incorrect. Salmonellosis (non-typhi) can produce a self-limited diarrheal illness with cramping abdominal pain. It is often acquired via contaminated poultry products."
a[40.3] = f + "(H) Incorrect. Noroviruses are a common cause for epidemic, food-borne diarrheal illness."
a[41] = f + "(A) Incorrect. The secretion of large amounts of gastrin with a neoplasm such as a gastrinoma would lead to multiple ulcerations. This syndrome is rare."
a[42] = f + "(B) Incorrect. This condition is the result of an atrophic gastritis with loss of the parietal cells that secrete the intrinsic factor that complexes with vitamin B12 for absorption."
a[43] = f + "(C) CORRECT. This organism is often seen with chronic gastritis."
a[44] = f + "(D) Incorrect. Adenocarcinomas are mass lesions, or they can present as ulcerations. There is a long-term risk for development of adenocarcinoma with <I>H. pylori</I> infection."
a[45] = f + "(E) Incorrect. Crohn disease involving stomach is quite uncommon. The inflammation with Crohn disease is transmural."
a[45.1] = f + "(F) Incorrect. Autoimmune diseases in general do not often involve the stomach. There is a form of autoimmune gastritis that can lead to gastric mucosal atrophy and pernicious anemia."
a[46] = f + "(A) Incorrect. This is a more typical finding of ulcerative colitis, which would involve the rectum first and extend upward in a continuous fashion."
a[47] = f + "(B) Incorrect. Amebiasis may produce a similar clinical picture, but is usually not so localized."
a[48] = f + "(C) Incorrect. Adenocarcinomas are mass lesions. They are uncommon at this age (but do occur in younger persons)."
a[49] = f + "(D) Incorrect. Fibrosis is more characteristic of collagenous colitis seen in persons over age 30 (mostly women) and associated with autoimmune diseases."
a[50] = f + "(E) CORRECT. This history is most typical for Crohn disease, which is a form of inflammatory bowel disease that tends to involve the bowel in a segmental pattern."
a[50.1] = f + "(F) Incorrect. Vasculitis involving the colon is uncommon. A necrotizing vasculitis can be caused by ANCA-associated granulomatous vasculitis, which often involves multiple organs, but most often pulmonary and/or renal disease preceed the onset of manifestations elsewhere."
a[51] = f + "(A) Incorrect. Ulcerative colitis is not complicated by pancreatic disease."
a[52] = f + "(B) Incorrect. The mucosal ulceration and inflammation does not lead to formation of diverticular disease, which is related to intake of fiber. UC is an idiopathic condition."
a[53] = f + "(C) CORRECT. This patient has ulcerative colitis (UC). One of the extraintestinal manifestations of this form of inflammatory bowel disease is sclerosing cholangitis, which can still occur even after the colon is removed."
a[54] = f + "(D) Incorrect. Appendicitis is more likely to occur in younger persons, as are some cases of ulcerative colitis (UC), but the appendix is not often involved with the inflammation of UC."
a[55] = f + "(E) Incorrect. Fistula formation is more typical for the transmural inflammation of Crohn disease."
a[55.1] = f + "(F) Incorrect. Chronic ulcerative colitis carries a high risk for development of colonic adenocarcinoma, not lymphoma."
a[56] = f + "(A) Incorrect. Peutz-Jeghers syndrome is an autosomal dominant condition associated with the appearance of hamartomatous polyps of the small bowel, and in some cases in stomach and colon."
a[57] = f + "(B) Incorrect. Ulcerative colitis has a risk for adenocarcinoma. With active ulcerative colitis, there can be 'pseudopolyps' formed from mucosal ulceration."
a[58] = f + "(C) CORRECT. The number of polyps is not great in this case, but a cancer at his age suggests an aggressive course for a polyp. Many polyps and cancers of HNPCC involve the right (ascending) colon. This condition arises from abnormal mismatch repair genes and accounts for perhaps 1 to 3% of all colon cancers."
a[59] = f + "(D) Incorrect. The APC genes are mutated with familial polyposis, and typically by the second decade there are hundreds of colonic polyps."
a[60] = f + "(E) Incorrect. An abnormal APC gene is also present with Gardner syndrome, which is characterized by the appearance of hundreds of colonic polyps, but unlike familial polyposis there are extraintestinal lesions such as osteomas of bone."
a[61] = f + "(A) CORRECT. Adenocarcinoma of the head of pancreas produces extrahepatic biliary obstruction with an elevation predominantly of the direct bilirubin along with an elevation in alkaline phosphatase. This results in the classic finding of 'painless jaundice'."
a[62] = f + "(B) Incorrect. Cystic fibrosis leads to atrophy of pancreatic acinar tissue, but without biliary tract obstruction."
a[63] = f + "(C) Incorrect. Hepatitis would increase the transaminases (AST and ALT) markedly."
a[64] = f + "(D) Incorrect. The AMA would be positive in most cases of PBC."
a[65] = f + "(E) Incorrect. The transaminases would continue to be elevated, though not as high as with acute hepatitis."
a[65.1] = f + "(F) Incorrect. Hemolysis should result in an elevated indirect bilirubin, without liver enzyme elevation. In older persons an autoimmune hemolytic anemia is often of the 'cold' variety with an underlying hematologic malignancy such as a lymphoma."
a[66] = f + "(A) Incorrect. AAT deficiency would lead to small PAS positive hyaline globules deposited in periportal regions."
a[67] = f + "(B) Incorrect. Wilson disease results from toxic accumulations of copper in the liver and can lead to cirrhosis. It is rare."
a[68] = f + "(C) Incorrect. Acute hepatitis produces mainly liver cell necrosis."
a[69] = f + "(D) CORRECT. Big fatty livers are often seen in conjuction with chronic alcoholism. In the absence of a history of chronic alcohol abuse, non-alcoholic fatty liver (NAFL) is the likely cause, and NAFL can be associated with obesity and diabetes mellitus. Microscopically, the pattern will be macrovesicular steatosis, with large lipid vacuoles filling hepatocytes."
a[70] = f + "(E) Incorrect. Lithiasis would lead to obstruction of the biliary tract and hepatic cholestasis."
a[71] = f + "(A) Incorrect. HIV infection can be associated with non-Hodgkin lymphomas and Kaposi sarcoma, both of which can involve the stomach, but not in a diffuse pattern."
a[72] = f + "(B) Incorrect. Cancer risk in the GI tract is not increased with diabetes mellitus."
a[73] = f + "(C) Incorrect. Chronic alcoholism can lead to hepatic cirrhosis which has a risk for hepatocellular carcinoma, but not gastric cancer."
a[74] = f + "(D) CORRECT. This is linitis plastica of the stomach, which typically has a signet ring cell pattern of adenocarcinoma diffusely infiltrating the stomach. Autoimmune gastritis is a risk factor for this condition."
a[75] = f + "(E) Incorrect. A diet containing fruits is recommended to reduce the risk for cancer."
a[75.1] = f + "(F) Incorrect. Use of NSAIDS can lead to gastritis and gastric ulceration, but the risk for malignancy is small."
a[76] = f + "(A) Incorrect. The decreased serum AAT is a feature of alpha-1-antitrypsin deficiency that can lead to hepatic fibrosis and cirrhosis. There can also be a chronic hepatitis, but this condition is far less common than viral hepatitis."
a[77] = f + "(B) CORRECT. This is chronic active hepatitis with hepatitis B infection. This illustrates the wisdom of getting the series of hepatitis B vaccinations."
a[78] = f + "(C) Incorrect. The ferritin is increased with a variety of liver diseases, but marked elevations can suggest hemochromatosis."
a[79] = f + "(D) Incorrect. This is a feature of Wilson disease."
a[80] = f + "(E) Incorrect. This is most typical for primary biliary cirrhosis, a rare disease of middle aged women in which there is autoimmune destruction of bile ducts."
a[81] = f + "(A) Incorrect. The HNPCC syndrome is accompanied by fewer polyps, and with an appearance of the polyps in middle age."
a[82] = f + "(B) Incorrect. Gardner syndrome is another disease associated with the APC gene and includes multiple colonic polyposis, but is less common and is  accompanied by extraintestinal lesions such as osteomas of bone."
a[83] = f + "(C) Incorrect. In Peutz-Jeghers syndrome, the polyps are of the hamartomatous variety, not adenomatous."
a[84] = f + "(D) CORRECT. Persons with familial polyposis caused by abnormal APC genes should have a colectomy for this reason. By late childhood to young adulthood, one or more of the polyps will give rise to a malignancy."
a[85] = f + "(E) Incorrect. The polyps described here are tubular adenomas, and these are not associated with endocrine lesions."
a[86] = f + "(A) CORRECT. Sclerosing cholangitis is one of the extra-intestinal manifestations of inflammatory bowel disease and is seen most frequently with ulcerative colitis. The colectomy was probably performed because of his increasing risk for adenocarcinoma, but even after colectomy extraintestinal manifestations of UC can occur."
a[87] = f + "(B) Incorrect. SLE is not associated with sclerosing cholangitis."
a[88] = f + "(C) Incorrect. Wilson disease can produce chronic hepatitis and fibrosis, but not sclerosing cholangitis."
a[89] = f + "(D) Incorrect. Hepatitis B infections can produce chronic hepatitis and cirrhosis, but not sclerosing cholangitis."
a[90] = f + "(E) Incorrect. PBC can lead to loss of smaller bile ducts, but there is no marked fibrosis."
a[90.1] = f + "(F) Incorrect. AAT deficiency can lead to chronic hepatitis and cirrhosis, but not sclerosing cholangitis."
a[91] = f + "(A) Incorrect. Both acid and pepsin must be present (though not increased in amount) for peptic ulceration to occur. Achlorhydria is more typical for chronic atrophic gastritis."
a[92] = f + "(B) Incorrect. Gastric involvement with autoimmune diseases is uncommon. Autoimmune gastritis tends to have atrophy with loss of parietal cells and, hence, lack of ulceration."
a[93] = f + "(C) CORRECT. <I>Helicobacter pylori</I> organisms in the gastric mucus produce urease which will break down urea to ammonia and to CO2. For this urea breath test the patient drinks a measured quantity of a urea-containing solution with radiolabelled carbon. If the <I>H. pylori</I> organisms are present they metabolize the urea and release the radiolabelled carbon which is detected in exhaled air. Most gastric ulcers of this size are benign. Bleeding is a common complication of ulcer disease, seen in 25 to 33% of cases."
a[94] = f + "(D) Incorrect. Gastric irritants such as NSAIDS and cortisol tend to produce multiple gastric ulcerations."
a[95] = f + "(E) Incorrect. Gastrinomas that produce the Zollinger-Ellison syndrome are often associated with multiple gastric ulcerations."
a[96] = f + "(A) Incorrect. Such adenomas, which are rare, are more often related to oral contraceptive use in women."
a[97] = f + "(B) Incorrect. Focal nodular hyperplasia is a rare finding not associated with chronic alcoholism."
a[98] = f + "(C) Incorrect. Lithiasis does not typically complicate cirrhosis."
a[99] = f + "(D) Incorrect. Angiosarcomas are quite rare and have been linked to environmental exposure to vinyl chloride."
a[100] = f + "(E) CORRECT. Hepatocellular carcinoma occurs most often in the setting of cirrhosis (which is most often from chronic alcoholism and from chronic viral hepatitis B and C)."
a[100.1] = f + "(F) Incorrect. Non-Hodgkin lymphomas are not associated with alcohol abuse. Extranodal lymphomas most often occur in immunocompromised persons."
a[100.2] = f + "(G) Incorrect. Hemangiomas are common incidental findings in the liver. They are not associated with alcohol abuse."
a[101] = f + "(A) Incorrect. The serum ceruloplasmin is decreased with Wilson disease, which is accompanied by hepatolenticular degeneration. The basal ganglia are affected by atrophy, without mass effect"
a[102] = f + "(B) Incorrect. Macular degeneration is most often age-related."
a[103] = f + "(C) Incorrect. Proliferative retinopathy is most characteristic for diabetes mellitus."
a[104] = f + "(D) Incorrect. Cataracts can be seen with increased frequency in aging and with diabetes mellitus, among others."
a[105] = f + "(E) CORRECT. These rings can be seen with a slit lamp examination. They are characteristic for Wilson disease, an autosomal recessive disorder with muation in the ATP7B gene that encodes for a copper-transporting ATPase. Patients have decreased serum ceruloplasmin, the copper-carrying protein, and increased tissue deposition of copper, particularly in liver, eye, and basal ganglia of brain."
a[105.1] = f + "(F) Incorrect Occlusion of the canal of Schlemm where acqueous humor is reabsorbed leads to glaucoma. This does not occur with Wilson disease."
a[106] = f + "(A) Incorrect. Acetaminophen produces liver cell necrosis. The amount of necrosis depends upon the amount of drug taken."
a[107] = f + "(B) CORRECT. This is a massive overdose of acetaminophen, which causes extensive hepatic necrosis."
a[108] = f + "(C) Incorrect. Bridging fibrosis is more typical of chronic hepatitis after many months."
a[109] = f + "(D) Incorrect. Fatty change is more typical for liver cell injury with alcoholism."
a[110] = f + "(E) Incorrect. This is more typical for cholangitis."
a[110.1] = f + "(F) Incorrect. Pure cholestasis is more often drug-related, such as use of oral contraceptives, anabolic steroids, chlorpromazine, or erythromycin."
a[111] = f + "(A) Incorrect. This would have caused problems much earlier in life. Half of all occurrences of duodenal atresia are seen in association with Down syndrome (trisomy 21)."
a[112] = f + "(B) Incorrect. The child is not fine with necrotizing enterocolitis."
a[113] = f + "(C) Incorrect. This is an esophageal laceration from forceful vomiting in an adult."
a[114] = f + "(D) Incorrect. This is colonic dilation due to an aganglionic segment."
a[115] = f + "(E) Incorrect. There are several variations of T-E fistula, which can include esophageal atresia. The vomiting should be apparent from birth, not a month later. T-E fistula is often present with other congenital anomalies. An example is the VATER association."
a[115.1] = f + "(F) CORRECT. The male sex, age, and symptoms are all quite typical for pyloric stenosis, a condition that exhibits the genetic feature called the 'threshold of liability' in which males are more likely to have the disease (lower threshold) if born into a family with girls affected (higher threshold, and thus, more genetic tendencies for the disease to pass on)."
a[116] = f + "(A) Incorrect. This is esophageal mucosal laceration, usually with marked vomiting in alcoholics."
a[117] = f + "(B) CORRECT. Patients with progressive systemic sclerosis with either the limited form of the disease (sometimes called CREST syndrome) or diffuse scleroderma have fibrosis in the gastrointestinal tract, most often involving the esophagus. An endoscopic procedure to dilate the esophagus may need to be performed periodically."
a[118] = f + "(C) Incorrect. Iron deficiency anemia can be associated with esophageal webs. This is called Plummer-Vinson syndrome and it is quite rare."
a[119] = f + "(D) Incorrect. Portal hypertension leads to the appearance of esophageal varices in the lower esophagus that can erode and bleed profusely."
a[120] = f + "(E) Incorrect. This is a columnar metaplasia of the esophageal epithelium that occurs with chronic reflux."
a[121] = f + "(A) CORRECT. The elevation in the alkaline phosphatase in the absence of an elevated bilirubin suggests focal hepatic obstruction, which could occur with metastases. The positive stool guaiac suggests a colonic primary."
a[122] = f + "(B) Incorrect. Wilson disease can lead to hepatic fibrosis with cirrhosis, but the alkaline phosphatase is not typically elevated by a large amount."
a[123] = f + "(C) Incorrect. Acute viral hepatitis with hepatitis A almost always produces a mild disease with mild elevations in AST, ALT, and bilirubin."
a[124] = f + "(D) Incorrect. Acetaminophen toxicity produces extensive hepatocyte necrosis with marked elevation of AST and ALT without a high alkaline phosphatase."
a[125] = f + "(E) Incorrect. CHF can produce hepatic centrilobular congestion and, if severe, centrilobular necrosis with elevation of AST and ALT, but not the rise in alkaline phosphatase."
a[125.1] = f + "(F) Incorrect. Complications of alcohol abuse include hepatic steatosis and hepatic cirrhosis. In neither case would the laboratory findings point to obstruction with an elevated alkaline phosphatase."
a[125.2] = f + "(G) Incorrect. Complications of non-alcoholic fatty liver include hepatic steatosis and hepatic cirrhosis. In neither case would the laboratory findings point to obstruction with an elevated alkaline phosphatase."
a[126] = f + "(A) Incorrect. He does not have tropical sprue, which occurs in some visitors to tropical areas such as the Caribbean and India. The histologic changes with tropical sprue are not usually as marked (less mucosal flattening) and respond to antibiotic therapy."
a[127] = f + "(B) CORRECT. He has celiac disease from ingestion of grains (wheat, rye, barley) that contain gluten with gliaden protein. The enzyme tissue transglutamidase breaks down the gliaden into peptides which, when displayed to antigen presenting cells, activate CD4 lymphocytes that produce the mucosal inflammation."
a[128] = f + "(C) Incorrect. Vagotomy used to be part of surgical therapy for peptic ulcer disease, but is rarely used because of effective pharmacologic therapies. It is not indicated for a gluten enteropathy."
a[129] = f + "(D) Incorrect. Corticosteroid therapy is not indicated, except in the 10% of cases of celiac disease that have marked fibrosis, or 'collagenous' sprue. About half of these respond to corticosteroid therapy."
a[130] = f + "(E) Incorrect. This inflammatory process of the mucosa does not warrant resection."
a[130.1] = f + "(F) Incorrect. Alternative and complimentary medical therapies will not eradicate the autoimmune inflammation causing his disease. Alternative therapies are best employed as an adjunct to improve patient outlook, attitude, and adherence to therapy."
a[131] = f + "(A) Incorrect. If disease arising in the appendix is the cause for the inflammation, there should be both mucosal and mural inflammation, not just serosal inflammation."
a[132] = f + "(B) Incorrect. Do not make this diagnosis."
a[133] = f + "(C) Incorrect. A vasculitis would be present with polyarteritis nodosa, which can affect the bowel via involvement of mesenteric arterial branches."
a[134] = f + "(D) CORRECT. If only the serosa is inflamed, then something other than the appendix led to the inflammation -- possibly a perforation, and this should be communicated to the surgeon, because the causative condition must be diagnosed and treated."
a[135] = f + "(E) Incorrect. Although surgeons can have a 5 to 10% false positive rate for acute appendicitis (it is best to err on the side of false positive, not false negatives in cases of suspected acute appendicitis) this specimen did show inflammation."
a[136] = f + "(A) CORRECT. This is the typical appearance for a tubular adenoma, also called an adenomatous polyp. Small ones are likely to be benign, and they can easily be removed. This is the value of screening."
a[137] = f + "(B) Incorrect. These polyps contain mixed inflammation and collagenization. They are uncommon."
a[138] = f + "(C) Incorrect. Peutz-Jeghers syndrome has associated hamartomatous polyps of bowel."
a[139] = f + "(D) Incorrect. The pseudopolyps of ulcerative colitis are the result of surrounding mucosal ulceration. They are not true polyps and are not neoplasms."
a[140] = f + "(E) Incorrect. Hyperplastic polyps are quite small. The mucosa is increased in amount, but shows no changes of neoplasia."
a[140.1] = f + "(F) Incorrect. Crohn disease most often produces ulceration, transmural inflammation, and bowel wall thickening. Polyps are not a feature of Crohn disease."
a[141] = f + "(A) Incorrect. Islet cell adenomas are not cystic. They are often so small that they are difficult to image. Most are non-functional, but some may secrete hormones such as insulin or gastrin."
a[142] = f + "(B) Incorrect. An acute pancreatitis leads to inflammation with swelling, necrosis, and hemorrhage of the pancreas, but not a pseudocyst."
a[143] = f + "(C) CORRECT. A pseudocyst is a complication of chronic pancreatitis seen most frequently in persons with a history of chronic alcoholism. The pseudocyst is an area of necrosis with a wall composed of granulation tissue."
a[144] = f + "(D) Incorrect. Metastases are most often multiple solid masses."
a[145] = f + "(E) Incorrect. A primary adenocarcinoma of the pancreas is usually a solid mass. Development of pancreatic adenocarcinoma is not related to alcoholism."
a[146] = f + "(A) Incorrect. Barrett esophagus is an acquired condition."
a[147] = f + "(B) Incorrect. However, the risk for adenocarcinoma is increased with Barrett mucosa."
a[148] = f + "(C) CORRECT. There is columnar metaplasia in the lower esophagus with Barrett esophagus from esophageal reflux disease. A small percentage of these patients may develop adenocarcinoma."
a[149] = f + "(D) Incorrect. Stricture from ulceration may lead to a pulsion diverticulum, but formation of Barrett mucosa would be independent of this process."
a[150] = f + "(E) Incorrect. Esophageal webs are associated with iron deficiency anemia."
a[150.1] = f + "(F) Incorrect. The limited form of scleroderma (sometimes called CREST syndrome) is associated with esophageal stricture from fibrosis, not from reflux."
a[150.2] = f + "(G) Incorrect. Chronic alcoholism increases the risk for esophageal squamous carcinoma, typically higher in the esophagus."
a[151] = f + "(A) Incorrect. <I>H. pylori</I> growth is limited to the mucus layer overlying the gastric mucosa."
a[152] = f + "(B) CORRECT. <I>H. pylori</I> is present in about 90% of cases of chronic gastritis and nearly 100% of cases of duodenal ulceration. <I>H. pylori</I> is present with increasing frequency with age, which suggests that it is an important cause for chronic gastritis in the elderly."
a[153] = f + "(C) Incorrect. The gastritis that precedes development of pernicious anemia is typically autoimmune in etiology, with mucosal atrophy, and antiparietal cell antibodies can often be detected."
a[154] = f + "(D) Incorrect. Gastric acid levels with <I>H. pylori</I> are typically increased, particularly when duodenal peptic ulcers are present."
a[155] = f + "(E) Incorrect. <I>H. pylori</I> is associated with mucosa associated lymphoid tumor (MALT) lesions, which tend to regress with eradication of the H. pylori. The chronic gastritis induced by <I>H. pylori</I> drives lymphoid proliferation, out of which arises a monoclonal proliferation."
a[156] = f + "(A) Incorrect. Celiac sprue will respond to a gluten-free diet, but Whipple disease will not."
a[157] = f + "(B) Incorrect. Corticosteroids are indicated for some idiopathic inflammatory bowel diseases, but not Whipple disease."
a[158] = f + "(C) CORRECT. Whipple disease is rare. It can affect multiple organs, including the brain. The organisms causing Whipple disease are actinomycetes (<I>Tropheryma whippelii</I>). The foamy macrophages can be in the small intestinal submucosa, adjacent lymph nodes, or at extraintestinal sites."
a[159] = f + "(D) Incorrect. Macrophages filled with bacilli can be found elsewhere in such places as synovium, brain, and heart valves. Whipple disease is systemic, so bowel resection is not indicated."
a[160] = f + "(E) Incorrect. Whipple disease is a systemic infection, not a disease of increased gastric acid production."
a[160.1] = f + "(F) Incorrect. Alternative and complimentary medical therapies will not eradicate the organisms causing his disease. Alternative therapies are best employed as an adjunct to improve patient outlook, attitude, and adherence to therapy."
a[161] = f + "(A) Incorrect. Corticosteroid therapy is useful for autoimmune diseases, but this is a genetic disorder."
a[162] = f + "(B) Incorrect. Postmenopausal estrogen therapy is not detrimental to the liver."
a[163] = f + "(C) Incorrect. Interferon therapy is used for treating chronic hepatitis C, which does not have iron overload."
a[164] = f + "(D) Incorrect. The diabetes mellitus in her case is a consequence, not a cause, of iron overload, with extensive islet of Langerhans iron deposition. The skin pigmentation leads to the term 'bronze diabetes'."
a[165] = f + "(E) CORRECT. The markedly elevated serum ferritin suggests extensive iron overload with hereditary hemochromatosis, a condition in which excessive iron absorbtion results in progressive accumulation of iron stores, often over 20 g by her age, particularly affecting liver, heart, joints, skin, and pancreas. Siblings may also carry an HFE gene mutation, most often the homozygous C282Y mutation. Phlebotomy will remove 250 mg of iron per unit of blood."
a[166] = f + "(A) Incorrect. Hemangioma is the most common neoplasm of the liver, present in at least 1 in 50 persons, but most are small (<1 cm) incidental findings. There is no relationship to viral hepatitis."
a[167] = f + "(B) Incorrect. Hepatic adenomas are rare. Some are associated with oral contraceptive use. They act in a benign fashion. They do not arise in the setting of cirrhosis."
a[168] = f + "(C) Incorrect. Angiosarcomas of the liver are rare. Some have been reported in associated with exposure to vinyl chloride."
a[169] = f + "(D) Incorrect. Bile duct carcinomas may arise with chronic infection by liver flukes."
a[170] = f + "(E) Incorrect. Cholangiocarcinoma is less common than hepatocellular carcinoma, but has many of the same risks, including chronic infection with hepatitis B or C. The AFP would not be elevated with cholangiocarcinoma. However, some primary hepatic cancers are mixtures of cholangiocarcinoma and hepatocellular carcinoma."
a[170.1] = f + "(F) CORRECT. Chronic hepatitis and both micro- and macronodular cirrhosis carry an increased risk for liver cancer. Most often this is hepatocellular carcinoma. Either chronic hepatitis B or C infection increases the risk for primary liver cancer. An elevated AFP is characteristic for hepatocellular carcinoma."
a[170.2] = f + "(G) Incorrect. Non-Hodgkin lymphoma arising in the liver is uncommon. It may occur in patients with AIDS."
a[171] = f + "(A) Incorrect. Carcinoid tumors are histologically similar to islet cell tumors. Carcinoids are more common in the intestine. A carcinoid this small is unlikely to produce enough 5HIAA to produce symptoms of flushing, headache, and diarrhea with carcinoid syndrome."
a[172] = f + "(B) CORRECT. A variety of hormones can potentially be elaborated by islet cell adenomas, but the most common is insulin, leading to hypoglycemia. This hypoglycemia may occur periodically. Often, the adenoma is so small that it is difficult to detect by radiologic imaging techniques."
a[173] = f + "(C) Incorrect. Adenocarcinoma of the pancreas is malignant and unlikely to be such a small, circumscribed mass. The most common paraneoplastic syndrome associated with adenocarcinoma is Trousseau syndrome causing a hypercoagulable state."
a[174] = f + "(D) Incorrect. Pseudocysts occur as a complication of pancreatitis, which produces abdominal pain. Pseudocysts are a focus of necrotizing inflammation and have irregular borders."
a[175] = f + "(E) Incorrect. Pheochromocytomas can produce headaches with hypertension from catecholamine release. Most arise in the adrenal medulla. The pancreas is not a site for extra-adrenal pheochromocytoma."
a[175.1] = f + "(F) Incorrect. Neuroendocrine carcinomas of the GI tract are not common, and most arise in the colon. Their poor differentiation makes them unlikely to produce endocrine effects."
a[176] = f + "(A) Incorrect. Aspirin ingestion has been associated with the rare Reye syndrome, which typically occurs in children follows an upper respiratory tract infection."
a[177] = f + "(B) Incorrect. Non-steroidal anti-inflammatory drugs (NSAISs) are more often associated with ulcerations in the GI tract, not acute liver failure."
a[178] = f + "(C) Incorrect. Indomethacin is not typically associated with liver failure."
a[179] = f + "(D) CORRECT. The elevated AST and ALT point to liver necrosis. Chronic alcoholism makes acetaminophen toxicity more likely by depleting the glutathione that helps detoxify the metabolites."
a[180] = f + "(E) Incorrect. Rofecoxib is a cyclo-oxygenase-2 (COX-2) inhibitor that has anti-inflammatory effects and can be complicated by GI tract bleeding and ulceration."
a[180.1] = f + "(F) Incorrect. Morphine is an opioid analgesic with the major side effect of respiratory depression."
a[180.2] = f + "(G) Incorrect. Meperidine is a narcotic analgesic with the major side effect of respiratory depression."
a[181] = f + "(A) Incorrect. <I>H. pylori</I> is associated with chronic gastritis. Ulcerations associated with gastric reflux could appear similarly, but would be less likely than herpetic ulcers, given the setting."
a[182] = f + "(B) Incorrect. <I>Candida</I> may be invasive, but produces irregular ulceration of the mucosa along with exudates."
a[183] = f + "(C) CORRECT. Herpes esophagitis often has 'punched out' ulcerations. It is seen in immunocompromised patients, including those with HIV/AIDS."
a[184] = f + "(D) Incorrect. MAC involving the GI tract most often produces yellow-tan plaques in the small intestine as a consequence of ill-defined granuloma formation."
a[185] = f + "(E) Incorrect. Cytomegalovirus can produce ulcerations in immunocompromised patients, but they are usually small and irregular."
a[185.1] = f + "(F) Incorrect. HHV-8 is associated with development of Kaposi sarcoma, usually in males having sex with other males. Kaposi sarcoma appears as nodular tumor masses."
a[185.2] = f + "(G) Incorrect. Cryptococcosis can be widely disseminated with AIDS, but it usually forms small granulomas, not ulcerations."
a[186] = f + "(A) Incorrect. Ulcerative colitis (UC) is most often a mucosal process without a significant risk for fissures and perforation. Rarely, a toxic megacolon can complicate UC."
a[187] = f + "(B) Incorrect. Ulcerative colitis is typically limited to the mucosa. Crohn disease is more likely to produce transmural inflammation that predisposes to fistulous tracts between bowel loops or between bowel and skin."
a[188] = f + "(C) Incorrect. Inflammatory bowel diseases, including both ulcerative colitis and Crohn disease, do not affect the arterial supply to the bowel."
a[189] = f + "(D) CORRECT. Chronic ulcerative colitis carries a significant risk for development of colonic adenocarcinoma 2 or 3 decades after onset."
a[190] = f + "(E) Incorrect. The majority of patients with primary sclerosing cholangitis also have ulcerative colitis, but this does not produce cirrhosis."
a[191] = f + "(A) Incorrect. Chronic passive congestion from right-sided heart failure does not typically lead to hyperbilirubinemia."
a[192] = f + "(B) Incorrect. Viral hepatitis severe enough to cause jaundice should be accompanied by some hepatocyte necrosis."
a[193] = f + "(C) Incorrect. Extrahepatic biliary atresia is a cause for biliary tract obstruction in a neonate."
a[194] = f + "(D) Incorrect. Veno-occlusive disease can result in marked hyperbilirubinemia, but this is a rare disease."
a[195] = f + "(E) CORRECT. The bile stasis results from blockage of the biliary tract drainage. The source of the calculi is likely the gallbladder. Though most gallstones remain in the gallbladder, some may escape and travel into the common bile duct (choledocholithiasis)."
a[196] = f + "(A) Incorrect. Aspergillosis may produce bowel infection in immunocompromised persons. In this case, the leukopenia is a consequence, not a cause, of the infection."
a[197] = f + "(B) Incorrect. Amebiasis does not usually have pronounced systemic symptoms, though it may rarely produce hepatic abscesses weeks after the lower GI symptoms."
a[198] = f + "(C) Incorrect. Shigellosis produces diarrhea with red cells and white cells. Leukopenia would not be present."
a[199] = f + "(D) Incorrect. <I>C. difficile</I> overgrowth produces a pseudomembranous colitis that follows broad spectrum antibiotic usage."
a[200] = f + "(E) Incorrect. <I>Y. enterocolitica</I> infection can produce abdominal pain from a 'pseudoappendicitis'."
a[200.1] = f + "(F) Incorrect. <I>S. aureus</I> is best known as a cause for food poisoining from elaboration of an enterotoxin, producing acute but limited abdominal pain, nausea, vomiting, and diarrhea."
a[200.2] = f + "(G) Incorrect. Rotavirus in adults produces a limited watery diarrhea. In young children the fluid loss can be more devastating."
a[200.3] = f + "(H) CORRECT. He developed typhoid fever. Even though this is an acute bacterial infection, mononuclear inflammation and leukopenia are typical findings."
a[201] = f + "(A) Incorrect. Viral hepatitis is not typically accompanied by alcoholic hyaline or by acute inflammation."
a[202] = f + "(B) Incorrect. This disease produces inflammation and sclerosis of small bile ducts."
a[203] = f + "(C) CORRECT. This is the typical appearance of acute sclerosing hyaline necrosis with alcoholic hepatitis. It is usually seen in the setting of chronic alcoholism with a superimposed recent episode of binge drinking. It is the one condition intrinsic to liver in which many neutrophils are present."
a[204] = f + "(D) Incorrect. Chronic B viral hepatitis does not have neutrophilic infiltrates or Mallory hyaline."
a[205] = f + "(E) Incorrect. Acetaminophen mainly produces extensive necrosis, without the other features described."
a[206] = f + "(A) Incorrect. HPV infection affects squamous epithelium, and could be responsible for dysplasias and carcinomas of the anorectal region."
a[207] = f + "(B) Incorrect. This cancer is unlikely to be related to inflammatory bowel disease at his age."
a[208] = f + "(C) CORRECT. This is a colonic adenocarcinoma. At his age, this is likely a sporadic type of colon cancer, not an inherited condition nor a complication of inflammatory bowel disease, particularly in view of no past history of bowel disease. Increased fat intake and obesity are controversial as risk factors for cancer, but probably play a role. Reducing fat intake and maintaining an ideal body weight are good ways to help prevent cancers in general."
a[209] = f + "(D) Incorrect. Diverticulosis is common, but there is no long term risk for cancer."
a[210] = f + "(E) Incorrect. Prior abdominal surgery predisposes to formation of adhesions that can increase the risk for bowel obstruction, but not carcinoma."
a[211] = f + "(A) CORRECT. A megacolon at this age is typical for Hirschsprung disease in which the submucosal and myenteric plexuses lack ganglion cells."
a[212] = f + "(B) Incorrect. Malrotation usually occurs when there has been an abdominal wall defect (omphalocele or gastroschisis)."
a[213] = f + "(C) Incorrect. Volvulus in infants usually involves the small intestine with twisting of the mesentery. Cecal volvulus is more characteristic for adults. In any case, volvulus is rare."
a[214] = f + "(D) Incorrect. Lack of bowel movements, vomiting of bilious material, and abdominal tenderness would be more typical for intussusception."
a[215] = f + "(E) Incorrect. This condition is typically present at birth, usually in association with cystic fibrosis, and most often involves the small bowel."
a[215.1] = f + "(F) Incorrect. Bowel obstruction from neoplasia is rare in infancy and childhood. A rhabdomyosarcoma is one of the more common childhood neoplasms, but is most often occurs in the pelvis or the head & neck region."
a[216] = f + "(A) Incorrect. Adenocarcinomas of the colon typically do not compromise circulation and do not produce ischemic enteritis."
a[217] = f + "(B) Incorrect. Venous thrombosis can occur in the presence of sepsis and hypercoagulable states, but it is a rare cause for ischemic bowel."
a[218] = f + "(C) Incorrect. Volvulus can cause ischemia, but it does not occur frequently, and it has an acute onset with bowel obstruction."
a[219] = f + "(D) Incorrect. An incarcerated hernia can cause ischemia in the segment of trapped bowel, but it is also likely to present as bowel obstruction."
a[220] = f + "(E) CORRECT. Hypotension with ischemia is probably the most common cause for ischemic enteritis and/or colitis. This man's heart disease (probably a dilated form of cardiomyopathy with both right and left-sided congestive heart failure) led to reduced cardiac output with reduced tissue perfusion. Though the bowel has a rich anastomosing blood supply, when flow is reduced in all branches, then ischemic can occur."
a[221] = f + "(A) CORRECT. Hemorrhoids form in the setting of chronic constipation. (Actually, this is probably the worst direct consequence of opiate usage; most of the serious health problems arise from nonsterile injection of the drug with risk for infections such as hepatitis and HIV, as well as bacterial sepsis). Hemorrhoids are quite common in the population as a whole and become more frequent with aging."
a[222] = f + "(B) Incorrect. Megacolon more commonly occurs in the presence of aganglionic segments of colon."
a[223] = f + "(C) Incorrect. Angiodysplasia is a focus of dilated submucosal veins (telangiectasia), usually in the right colon. These veins are prone to rupture and cause significant bleeding."
a[224] = f + "(D) Incorrect. Fistulae are usually seen in association with Crohn disease."
a[225] = f + "(E) Incorrect. Neoplasia does not occur in this setting."