The answer is a Fauci 14e p 504 Tierney 39e p 650 Vitamin C may cause a falsenegative test The falsepositive rate for FOBT is

1-5%, and patients must be told to abstain from ASA, NSAIDs, poultry, fish, red meat, and vegetables with peroxide activity (horseradish and turnips) for 72 h before testing.

206. The answer is b. (Fauci, 14/e, pp 1592-1593.) The risk factors for gastroesophageal reflux disease (GERD) include obesity, pregnancy, sclero-derma, and diet (caffeine, alcohol, nicotine, chocolate, fatty foods). The most common etiology of GERD is transient lower esophageal sphincter (LES) relaxation, but it may also be due to hiatal hernia and acidic gastric contents. The sour taste of GERD is often referred to as "water brash." A complication of GERD is Barrett's esophagus. Atypical symptoms of GERD may include asthma, chronic cough, chronic laryngitis, sore throat, and chest pain. Peptic ulcer disease (PUD) produces epigastric pain that typi-

cally improves with eating. Patients with lactose intolerance present with bloating, cramps, and diarrhea after ingesting a milk product.

207. The answer is d. (Fauci, 14/e, p 1649. Tintinalli, 5/e, p 847.) Hirschsprung's disease (aganglionic megacolon) is a disorder characterized by the absence of enteric neurons in the submucosal and myenteric plexuses. The contracted segment of bowel is unable to relax and a mass may become palpable. Hirschsprung's disease may lead to megacolon, but resection of the affected bowel is curative. Peutz-Jeghers syndrome is autosomal dominant (AD) and is characterized by hamartomatous polyps in the small intestine and perioral melanin deposits. Gardner syndrome (also AD) is familial adenomatous polyposis syndrome. Gardner syndrome and Peutz-Jeghers syndrome are risk factors for colon cancer. Volvulus (malrotation that leads to gangrene) is usually seen in the first year of life; infants present with bilious vomiting, bloody stools, rigid and discolored abdomen, and shock.

208. The answer is d. (Goldman, 21/e, pp 51-54. Tintinalli, 5/e, pp 1125-1129.) This patient with underlying liver disease probably has fulminant hepatitis from acetaminophen toxicity. Because of his alcohol use, he has insufficient glutathione stores and induced P450 enzymatic activity and is at greater risk for developing toxicity. Patients who survive the complication of fulminant hepatic failure will begin to recover over the following week, but some require liver transplantation. A serum acetaminophen level should be sent and immediate treatment with N-acetylcysteine (NAC), which provides cysteine for glutathione synthesis, is indicated. Signs of alcohol intoxication include euphoria, dysarthria, ataxia, labile mood, lethargy, coma, respiratory depression, and death. Patients with alcohol withdrawal present with a hyperexcitable state (i.e., hypertension, tachycardia, flushing, sweating, and mydriasis) and have tremors, disordered perceptions, seizures, and delirium tremens (DTs). Delirium tremens occur 2-4 days after alcohol abstinence and are characterized by hallucinations, which may be dangerous, combative, and destructive.

209. The answer is b. (Fauci, 14/e, pp 1636-1640.) It is often difficult to clinically distinguish between ulcerative colitis (UC) and Crohn's disease (CD). Patients with CD usually have less rectal bleeding and rarely have tenesmus. The barium enema showing involvement of the colon sup ports UC. Typically, patients with CD have skip lesions and rectal sparing. Patients with irritable bowel syndrome complain of abdominal pain with altered frequency or consistency of stool but have no weight loss or bleeding. More than half of patients with irritable bowel syndrome have psychiatric disorders. Patients with diverticulosis (saclike protrusions of the mucosa through the muscularis) are usually older and asymptomatic; hemorrhage occurs in a small percentage of patients. Giardiasis may be found in immunocompromised patients, day care workers, male homosexuals, individuals who drink from untreated water (hikers and campers), and international travelers (especially to Russia).

210. The answer is c. (Fauci, 14/e, p 1705. Tierney 39/e, p 675.) Patients with cirrhosis may have erythema of the palms, spider angiomas, decreased body hair, gynecomastia, testicular atrophy or menstrual irregularities, and parotid and lacrimal gland enlargement. Many of these changes are due to hormonal disturbances (the production of estrogen). Patients with cirrhosis may also have clubbing of the fingers. Portal hypertension may cause caput medusae (prominent abdominal vasculature), splenomegaly, and ascites. Patients may have jaundice and signs of hepatic encephalopathy (asterixis). Child's classification is a factor that determines survival in patients with end-stage liver disease; the patient described most likely has Child's class C cirrhosis (6-mo survival of 50%).

Child A

Child B

Child C











Easily controlled

Not controlled




Advanced (coma)





211. The answer is e. (Fauci, 14/e, p 1608.) Some patients with a history of ulcer surgery experience the dumping syndrome 30 min after eating. They present with palpitations, tachycardia, lightheadedness, and diaphoresis after eating a meal due to the rapid emptying of hyperosmolar gastric contents into the small intestine.

212-213. The answers are 212-c, 213-a. (Seidel, 4/e, pp 531-533.) Tympany is a drumlike sound heard over hollow organs, such as a gas-filled stomach or bowel. Dullness to percussion is a thudlike sound heard over fluid or solid tissue, such as the liver. Hyperresonance (a sound whose pitch is somewhere between tympany and dullness) is heard over a hyperinflated area, such as an emphysematous lung or a pneumothorax. A flat sound is a very dull sound heard with percussion over muscle.

214-216. The answers are 214-b, c, d, f, 215-a, e, 216-a. (Fauci, 14/e, pp 1684-1690.) Hepatitis A, C, D, E, and G are all RNA viruses, while hepatitis B is a DNA virus. Hepatitis A (HAV) is almost exclusively transmitted via the fecal-oral route and is spread from person to person. Outbreaks have been traced to contaminated food, water, milk, and shellfish. Hepatitis B (HBV) is transmitted sexually, perinatally, and through blood products. Hepatitis C (HCV) is transmitted primarily via blood products. Perinatal transmission and sexual transmission of HCV is <5%. HCV is the most common cause of chronic hepatitis in the United States. Hepatitis D (HDV) is endemic in patients with HBV in the Mediterranean countries, but in the United States it is confined to blood products. HDV was probably introduced into the United States by intravenous drug abusers. Hepatitis E (HEV) resembles HAV (fecal-oral route) but is found primarily in India, Africa, Asia, and Central America. Hepatitis G (HGV) is bloodborne and its mode of transmission parallels that of HCV. 217-218. The answers are 217-c, 218-a. (Seidel, 4/e, pp 543-545.) Shifting dullness and a positive fluid wave are the best physical examination findings for diagnosing ascites. In patients with ascites, the border of dullness shifts (shifting dullness) to the dependent side (approaches the midline) as the fluid resettles with gravity when the patient rolls to the side. A "shock wave" (fluid wave) occurs when a sharp tap at one end of the abdomen is felt on the other side. The patient places his or her hand in the middle of the abdomen to stop the transmission through adipose tissue. Asking the patient to go into the uncomfortable position of being on all fours and percussing the umbilicus for dullness is the puddle sign (low sensitivity and specificity). Bulging flanks (flanks are pushed outward) are seen in obese patients as well as in patients with ascites. 219-224. The answers are 219-b, 220-c, 221-e, 222-f, 223-a, 224-g. (Goldman, 21/e, pp 724, 801, 1130-1133.) Sclerosing cholangitis is a complication of ulcerative colitis; patients have fibrosing inflammation of the intrahepatic and extrahepatic bile ducts that is best diagnosed by ERCP. Patients present with the Charcot triad of fever, jaundice, and RUQ pain.

The Charcot triad occurs in 70% of cases of acute cholangitis. The Reynolds pentad is the Charcot triad with shock and altered mental status. Sclerosing cholangitis is a life-threatening illness requiring emergency bile duct decompression. Patients with primary biliary cirrhosis (PBC) often present with generalized pruritus, asymptomatic cholestasis, or an isolated alkaline phosphatase level. It occurs most frequently in women, and antimitochondrial antibodies (AMAs) are present in over 90% of affected patients. Wilson's disease is diagnosed by a low ceruloplasmin level and hemochromatosis is diagnosed by an elevated serum iron level, an elevated ferritin level, and an elevated transferrin saturation (>55%). Patients with Wilson's disease have Kayser-Fleischer rings (yellow-brown) in the Descemet membrane and neurologic involvement. Patients with hemochromatosis present with suntan-like pigmentation, degenerative arthritis of the hands and fingers (proximal PIPs), impotence, amen-orrhea, testicular atrophy, cardiac disease, liver disease, and glucose intolerance. Zollinger-Ellison syndrome should be considered in patients with a history of recurrent duodenal ulcer disease. Serum gastrin levels are typically elevated (>150 pg/mL). Gastrinomas may be single or multiple, and up to two-thirds are malignant. Twenty-five percent are associated with multiple endocrine neoplasia (MEN) type 1 and may be found in the pancreas or duodenum. a antitrypsin deficiency is characterized by liver disease and emphysema. AST is elevated by twice as much as ALT in alcoholic hepatitis because alcohol inhibits ALT synthesis more than AST synthesis. Budd-Chiari syndrome is occlusion of the inferior vena cava or hepatic veins. The most common malignancy of the liver is metastatic (in order of decreasing frequency: colon, pancreas, breast, and lung). 225-226. The answers are 225-e, 226-a. (Fauci, 14/e, pp 1673-1675.) Gilbert's disease is the most common cause of mild unconjugated hyper-bilirubinemia. It is found in up to 10% of the population and is due to a partial deficiency of glucuronosyltransferase. Patients with Dubin-Johnson syndrome develop jaundice with stress, but it is primarily conjugated bilirubin. Rotor syndrome is similar to Dubin-Johnson syndrome, but in Dubin-Johnson syndrome there is black pigment in the hepatocytes and in Rotor syndrome there is no pigment. Crigler-Najjar type 1 syndrome is severe (absence of glucuronosyltransferase), and patients typically have bilirubin levels of >20 mg/dL. Crigler-Najjar type 2 syndrome is a relatively benign disorder due to partial deficiency of glucuronosyltransferase; patients present as adolescents with bilirubin levels of 6-20 mg/dL.

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