A 40-year-old woman notes that, increasingly over the past 2 years, her fingers turn blue with exposure to cold. She also has difficulty with fine movement of her fingers, because the skin has become increasingly taut. Her face is mask-like because of skin that is taut and non-wrinkled. She has been gradually losing weight. Laboratory findings include a positive anti-centromere antibody with negative antinuclear antibody and negative rheumatoid factor. Which of the following pathologic findings is she most likely to have?

A Chronic cholecystitis

B Micronodular cirrhosis

C Chronic pancreatitis

D Ischemic enteritis

E Duodenal ulceration

F Diverticulosis

G Esophageal stricture

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A 42-year-old woman has noted generalized pruritis, but no rash, for 4 months. This pruritis is not relieved by application of topical corticosteroid containing creams. She is also bothered by dry eyes and a dry mouth. On physical examination there are no abnormal findings. Laboratory studies show total bilirubin 1.8 mg/dL, direct bilirubin 1.2 mg/dL, AST 55 U/L, ALT 58 U/L, alkaline phosphatase 289 U/L, total protein 6.8 g/dL, albumin 3.4 g/dL, and total cholesterol 344 mg/dL. A liver biopsy is performed and on microscopic examination shows destruction of intrahepatic bile ducts with associated lymphoplasmacytic inflammatory infiltrates of the portal tracts that extend into the adjacent parenchyma. Which additional serologic laboratory test finding is most likely to be positive in this woman?

A Anti-mitochondrial antibody

B Anti-parietal cell antibody

C Anti-centromere antibody

D Anti-ribonucleoprotein

E Anti-double stranded DNA

F Anti-centromere antibody

G Anti-microscomal antibody

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A 47-year-old man has noted increasing abdominal enlargement for the past 5 months. Physical examination reveals no abdominal tenderness, but a fluid wave is present. A paracentesis is performed with removal of 2000 cc of clear, yellow ascitic fluid. Laboratory studies show this fluid has a protein of 2.1 g/dL. Cytologically, the fluid contains a few mesothelial cells and a few mononuclear cells. Which of the following underlying conditions is he is most likely to have?

A Perforated gastric ulcer

B Acute pancreatitis

C Micronodular cirrhosis

D Crohn disease

E Colonic adenocarcinoma

F Chronic ulcerative colitis

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A 23-year-old man has been feeling tired for 3 weeks. On physical examination, there is no abdominal tenderness and no masses are noted. Bowel sounds are present. His stool is positive for occult blood. Laboratory studies show a hemoglobin of 9 g/dL with hematocrit 26.3%, MCV 72 fL, platelet count 189,000/microliter, and WBC count 7500/microliter. A small bowel radiographic series with barium reveals no masses or perforations, only a solitary 2 cm outpouching in the ileum. Which of the following conditions has most likely led to these findings?

A Inheritance of a faulty APC gene

B Ulceration of mucosa by ectopic gastric tissue

C Proliferation of abnormal submucosal veins

D Elaboration of enterotoxin by Escherichia coli

E Antiphospholipid antibody

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A 29-year-old HIV positive woman has lost 10% of her body weight in the past three months. For several weeks, she has had a high-volume watery diarrhea with over 10 non-bloody stools per day. On physical examination she has generalized lymphadenopathy. Her fingernails show onychomycosis. Abdominal examination reveals no masses or organomegaly and no areas of tenderness. Bowel sounds are very active. A stool culture has normal flora. Her current CD4 lymphocyte count is 150/microliter. She has no pets at home. Which of the following organisms is most likely responsible for these findings?

A Campylobacter jejuni

B Cryptosporidium parvum

C Helicobacter pylori

D Staphylococcus aureus

E Pneumocystis carinii (jirovecii)

F Salmonella typhi

G Mycobacterium tuberculosis

H Cytomegalovirus

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A 50-year-old man has the onset of increasing abdominal pain during the past 18 hours. He notes abdominal distension. In the emergency room, the physician's assistant finds that he has diffuse abdominal pain. An old right lower quadrant 8 cm transverse scar is noted. Bowel sounds are high-pitched, faint, and sporadic. A stool sample for occult blood is negative. Abdominal plain film radiographs reveal dilated loops of bowel with air-fluid levels, but no free air. Which of the following conditions most likely predisposed this patient to development of his current problem?

A Chronic persistent hepatitis

B Ileal adenocarcinoma

C Entameba histolytica infection

D Adhesions from prior surgery

E Meckel diverticulum

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A 30-year-old healthy woman with a BMI of 27 goes on a crash diet to lose weight, eating less than 500 calories per day. After two weeks, she notices scleral icterus and sees her physician. On physical examination there are no abnormal findings. Laboratory testing shows a total bilirubin 3.5 mg/dl with direct bilirubin 0.3 mg/dl. Which of the following is the most likely diagnosis?

A Hepatic steatosis

B Biliary atresia

C Rotor syndrome

D Choledocholithiasis

E Gilbert syndrome

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A clinical study is peformed with subjects who had an acute abdomen with severe abdominal pain for more than a day and evidence for ileus noted on abdominal plain film radiographs. The outcomes of these patients are recorded with and without surgical intervention. For which of the following conditions should surgery most likely be avoided?

A Intussusception

B Volvulus

C Regional enteritis

D Incarcerated hernia

E Superior mesenteric artery thrombosis

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A 27-year-old previously healthy man feels nauseated one morning and does not eat breakfast. By mid-morning, he feels worse, with periumbilical abdominal pain. He goes to the emergency room, where physical examination reveals a normal head, neck, and chest exam, but he has a temperature of 38.7 C. He has right lower quadrant abdominal pain with rebound tenderness. Bowel sounds are present. His abdomen is not distended. His stool is negative for occult blood. An abdominal plain film radiograph reveals no free air. Which of the following laboratory tests will most likely have the greatest usefulness to determine further therapy for this man?

A White blood cell count

B Sedimentation rate

C Serum amylase

D Stool culture

E Urinalysis

F Fine needle aspiration cytology

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A clinical study is performed with subjects who have a history of chronic alcohol abuse of more than 20 years who developed micronodular cirrhosis and a control group of subjects without cirrhosis. The medical histories of these patients are reviewed. Which of the following conditions is most likely to be seen with equal frequency in both study and control groups?

A Hemorrhoids

B Ascites

C Splenomegaly

D Vasculitis

E Hepatic encephalopathy

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Although he made 8 seconds for a score of 78, a cowboy is kicked in the abdomen just below the xyphoid process after being tossed from the rankest bull in the pen for the rodeo that night at Frontier Days in Cheyenne. On physical examination soon thereafter, he has marked abdominal pain. Which of the following injuries has he most likely received?

A Ileal rupture

B Duodenal hematoma

C Gastric laceration

D Cecal perforation

E Gallbladder rupture

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A 1-month-old baby girl is noted to be increasingly icteric. On physical examination the infant is afebrile. Laboratory studies show a serum total protein of 6.7 g/dL, albumin 3.1 g/dL, alkaline phosphatase 122 U/L, AST 202 U/L, ALT 212 U/L, and total bilirubin 3.8 mg/dL. A liver biopsy is performed and microscopic examination reveals periportal chronic inflammation with minimal piecemeal necrosis, a few giant cells, and small periportal PAS-positive hyaline globules. The child develops cirrhosis by the age of 10. Which of the following genetic abnormalities is most likely to be present in this girl?

A C282Y mutation

B Galactose-1-phosphate uridyl transferase deficiency

C DeltaF508 mutation

D Glycogenosis type IV

E PiZZ genotype

F RET gene mutation

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A 30-year-old man has suffered through occasional bouts of bloating and diarrhea since childhood. These transient episodes 2 to 6 hours and then subside. On physical examination there are no abnormal findings. He is advised to abstain from milk products in his diet for a month, and he experiences no episodes during that time. Which of the following is the most likely diagnosis?

A Cystic fibrosis

B Crohn disease

C Celiac disease

D Short bowel syndrome

E Lactase deficiency

F Irritable bowel syndrome

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A 30-year-old man has experienced bloating and diarrhea for the past 10 years. However, his major illnesses over the years have been bouts of pneumonia with Pseudomonas aeruginosa. On physical examination there are rales over both lower lung fields. Laboratory studies show that his quantitative stool fat is 10 g/day. He also has an elevated sweat chloride. Which of the following pathologic abnormalities is most likely to be present in this man?

A Meconium ileus

B Mesenteric artery atherosclerosis

C Pancreatic acinar atrophy

D Multiple gastric and duodenal ulcerations

E Periampullary adenocarcinoma

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A 31-year-old man has complained of burning substernal chest pain following meals for the past 6 years. He has no nausea or vomiting. On physical examination there are no abnormal findings, and a stool sample is negative for occult blood. An upper GI endoscopy is performed and there is some erythema of the lower esophagus noted. Esophageal biopsies from this area are performed an on microscopic examination show neutrophils infiltrating a hyperplastic squamous epithelium. Which of the following is the most likely diagnosis?

A Barrett esophagus

B Scleroderma

C Mild reflux esophagitis

D Herpes simplex infection

E Congenital atresia

F Achalasia

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A clinical study is performed with subjects who developed abdominal pain of more than one days' duration. The clinical findings, laboratory studies, and pathologic diagnoses of the conditions causing the pain are analyzed. Which of the following pathologic conditions is most likely to be associated with a negative stool occult blood test?

A Sigmoid diverticular disease

B Acute appendicitis

C Meckel diverticulum

D Pseudomembranous colitis

E Adenomatous polyp

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A 44-year-old woman has developed worsening pruritis over the past 3 months. On physical examination there are no abnormal findings. Laboratory studies show a total protein of 5.9 g/dL, albumin 3.4 g/dL, alkaline phosphatase 487 U/L, AST 66 U/L, ALT 55 U/L, total bilirubin 0.9 mg/dL, and direct bilirubin 0.7 mg/dL. A liver biopsy is performed and on microscopic examination shows destruction of intrahepatic bile ducts with associated lymphoplasmacytic inflammatory infiltrates of the portal tracts that extend into the adjacent parenchyma. Which of the following is the most likely diagnosis?

A Pancreatic adenocarcinoma

B Viral hepatitis C infection

C Chronic alcoholism

D Congestive heart failure

E Primary biliary cirrhosis

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A 29-year-old woman has been plagued by diarrhea for 9 years along with abdominal distension and bloating. She has no nausea, vomiting, or abdominal pain. On physical examination her BMI is 18. Laboratory studies show a quantitative stool fat of 8 g/day. The D-xylose absorption test is abnormal. A stool for occult blood is negative. Upper GI endoscopy is performed and the esophagus and stomach appear normal, but the duodenum has mucosal flattening. Biopsy of the duodenum is performed and on microscopic examination reveals blunting of villi, increased surface intraepithelial lymphocytes, and hyperplastic appearing crypts. Which of the following serologic tests is most likely to be positive in this woman?

A Anti-mitochondrial antibody

B Antinuclear antibody

C Anti-endomysial antibody

D Anti-microsomal antibody

E Anti-parietal cell antibody

F Anti-centromere antibody

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A male infant is born at term with no complications of delivery and no congenital anomalies noted at the time of birth. Two weeks later he has failure to thrive. He has not had vomiting or diarrhea. On physical examination he is icteric. A liver biopsy is performed and on microscopic examination shows giant multinucleated hepatocytes and portal tract infiltrates of chronic inflammatory cells. Which of the following is the most likely diagnosis?

A Biliary atresia

B Neonatal hepatitis

C Alpha-1-antitrypsin deficiency

D Primary biliary cirrhosis

E Sclerosing cholangitis

F Congenital hepatitis B infection

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A 45-year-old woman has noted increasing bronze pigmentation of her skin for the past 2 months even though she has not been out in the sun during that time. Physical examination reveals a palpable spleen tip and a firm liver edge. Arrhythmias are noted on electrocardiography. Laboratory studies show a fasting serum glucose of 160 mg/dl. Which of the following is the most likely diagnosis?

A Chronic alcoholism

B Wilson disease

C Budd-Chiari syndrome

D Hemochromatosis

E Gilbert disease

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A 23-year-old woman with acute myelogenous leukemia undergoes allogeneic bone marrow stem cell transplantation. She received pre-transplant total body radiation with busulfan and cyclophosphamide therapy. Three weeks post-transplantation, she had sudden weight gain of 4 kg. On physical examination she has hepatic enlargement and an abdominal fluid wave. Laboratory studies show a serum bilirubin of 17 mg/dL. Which of the following is the most likely diagnosis?

A Acute viral hepatitis B

B Micronodular cirrhosis

C Focal nodular hyperplasia

D Extrahepatic biliary obstruction

E Hepatic veno-occlusive disease

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A 75-year-old woman had had abdominal discomfort for the past 6 months. On physical examination she has tenderness to palpation of the right upper quadrant. An abdominal CT scan shows a 3 x 10 cm mass in the region of the gallbladder and enlarged lymph nodes at the hepatic hilum. The liver appears normal in size and has a uniform consistency. A fine needle aspiration biopsy of the mass is performed and cytologic examination reveals cells present consistent with adenocarcinoma. Which of the following pathologic abnormalities is most likely to accompany her disease process?

A Cirrhosis

B Flukes

C Gallstones

D Helicobacter pylori infection

E Vasculitis

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A 40-year-old woman with idiopathic dilated cardiomyopathy receives an orthotopic cardiac transplant. One month later she has increasing dyspnea. On physical examination her heart rate is irregular. An endomyocardial biopsy is performed and on microscopic examination shows acute cellular rejection. Her immunosuppressive therapy is increased. She then develops bacterial and fungal sepsis. She is treated with antimicrobial therapy, including clindamycin. One week later she develops a marked diarrhea. A colonoscopy is performed that shows diffuse colonic erythema with an overlying friable tan-green exudate. Which of the following abnormalities is now most likely to be present in this woman?

A Positive Clostridium difficile toxin assay

B Stool specimen containing Entameba histolytica cysts

C Numerous crypt abscesses on colonic mucosal biopsy

D Blood culture positive for Salmonella typhi

E Abdominal CT scan showing an aortic aneurysm

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It is traditional for the person making a batch of chocolate chip cookies to be unable to resist sampling the batter prior to baking the cookies. A 30-year-old woman follows this dictum. Two days later, she develops cramping abdominal pain with diarrhea and a low grade fever. On physical examination her temperature is 37.6 C. Her abdomen is diffusely and mildly tender to palpation, but there is no distension and no masses. Bowel sounds are active. A stool sample is negative for occult blood. Which of the following infections has she most likely acquired?

A Giardia lamblia

B Shigella sonnei

C Salmonella enteritidis

D Cryptosporidium parvum

E Entameba histolytica

F Norovirus

G Bacillus cereus

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A 48-year-old man has an episode of hematemesis. On physical examination there are no abnormal findings. He undergoes upper GI endoscopy, and a 1.5 cm sharply demarcated ulceration is noted in the gastric antrum. A biopsy of the adjacent gastric mucosa is performed and on microscopic examination shows many organisms with the appearance of short, curved rods in the overlying mucus of the gastric pits. Which of the following problems is he most likely to develop?

A Duodenal ulceration

B Gastrointestinal stromal tumor

C Megaloblastic anemia

D Malabsorption with weight loss

E Gastroesophageal reflux disease

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A 33-year-old man has had odynophagia for the past week. On physical examination he appears cachectic, with a BMI of 17. Upper GI endoscopy is performed and there are several 0.5 cm "punched out" ulcerations noted in the lower esophagus. Biopsies are taken and on microscopic examination show multinucleated cells and cells with intranuclear inclusions seen in epithelium at the ulcer margin. Which of the following underlying conditions is this man most likely to have?

A Chronic reflux esophagitis

B Ingestion of a caustic substance

C Chronic alcoholism

D Hiatal hernia

E Scleroderma

F Acquired immunodeficiency syndrome

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Soon after birth, a neonate is noted not to be passing stool. The baby is irritable and feeding poorly. On physical examination there is abdominal distension along with tenderness, but no masses palpable. A plain film radiograph reveals dilated loops of small bowel and free air. A laparotomy is performed and there is a perforation noted in the ileum along with greenish staining to the peritoneal surfaces. Which of the following is the most likely diagnosis?

A Hirschsprung disease

B Galactosemia

C Cystic fibrosis

D Malrotation

E Meckel diverticulum

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A 66-year-old woman has a history of congestive heart failure and osteoarthritis. She has been hospitalized for 3 weeks for treatment of bronchopneumonia. She then develops a severe diarrhea and becomes extremely ill. A colonoscopy is performed and there is a tan to green exudate overlying an erythematous but non-ulcerated mucosa. Which of the following pharmacologic agents is most likely to have contributed to the development of these findings?

A Acetaminophen

B Digoxin

C Clindamycin

D Ibuprofen

E Procainamide

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A 31-year-old man has had cramping abdominal pain with tenesmus for the past week. He has been passing a small amount of mucoid stool. On physical examination there are no abnormal findings. Colonoscopy is perrformed and there is marked mucosal ulceration with remaining pseudopolyps extending from the rectum to the splenic flexture. Which of the following explanations for his illness is most likely suggested by these findings?

A Sensitivity to gluten

B Easting the salad at the office party

C Idiopathic condition

D Not enough fiber in the diet

E Advanced atherosclerosis

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A 70-year-old woman has had lower abdominal pain for the past week, accompanied by a change in bowel habits, with more frequent stools of narrower caliber. On physical examination she has diffuse but mild left lower quadrant abdominal pain. Bowel sounds are present. Her stool is positive for occult blood, but no masses are palpable on digital rectal examination. An abdominal CT scan shows many small outpouchings with air and stool involving the rectosigmoid region. Which of the following conditions is most likely to have contributed to the development of her disease process?

A Inflammatory bowel disease

B Faulty mismatch repair genes

C Decreased dietary fiber

D Hypercholesterolemia

E Infection with Shigella flexneri

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A 5-year-old child becomes very ill with a bloody diarrhea that develops over 3 days. On physical examination she has a temperature of 37.7 C. Laboratory studies show her serum urea nitrogen is 42 mg/dL and creatinine 4.6 mg/dL. A peripheral blood smear shows schistocytes. Stool sent for culture reveals no Shigella or Salmonella organisms. However, her stool sample is positive for the Shiga-like toxin of E. coli serotype 0157:H7. Ingestion of which of the following foods is most likely to have produced her acute illness?

A Unpasteurized milk products

B Raw egg

C Salad with stale dressing

D Poorly cooked beef

E Bread made with wheat flour

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A 22-year-old primigravida gives birth at 35 weeks gestation to a girl infant. A fetal ultrasound prior to delivery suggested that malrotation of the intestine was present. Amniocentesis with chromosome analysis of fetal cells showed a 47, XX, +18 karyotype. The newborn examination shows a small face, overlapping fingers, and rocker-bottom feet. Which of the following abnormalities is this infant most likely to have?

A Omphalocele

B Imperforate anus

C Meconium ileus

D Meckel diverticulum

E Jejunal duplication

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An 84-year-old woman dies from hepatic encephalopathy. She is found at autopsy to have a 750 gm cirrhotic liver with nodules averaging 2 to 3 mm in diameter. On microscopic examination the liver shows regenerative nodules with extensive fibrosis between portal regions along with scattered portal lymphocytes and bile duct proliferation. Which of the following is the most likely etiology for her liver disease?

A Alpha-1-antitrypsin deficiency

B Hepatitis B infection

C Biliary atresia

D Veno-occlusive disease

E Chronic alcoholism

F Wilson disease

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A 63-year-old woman has a 70 pack year history of smoking. She also has a 15 year history of chronic arthritis for which she has used analgesics. She dies from pneumonia. At autopsy her liver is slightly enlarged and grossly shows a "nutmeg" pattern on sectioning. On microscopic examination there is centrilobular congestion and necrosis, but no inflammation or fibrosis. Which of the following is the most likely cause of her hepatic pathologic findings?

A Cor pulmonale

B Uncontrolled diabetes mellitus

C Alpha-1-antritrypsin deficiency

D Chronic hepatitis C

E Acetaminophen ingestion

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An 11-month-old previously healthy girl infant of normal height and weight for age develops a watery diarrheal illness that has persisted for the past two days. On physical examination she is afebrile and she has no abdominal distension or appreciable abdominal pain. Her stool is negative for occult blood. She appears dehydrated and receives intravenous fluids. She recovers over the next 11 days, with no sequelae. Which of the following infectious agents is most likely to have caused her illness?

A Shigella flexneri

B Mycobacterium bovis

C Rotavirus

D Entameba histolytica

E Candida albicans

F Staphylococcus aureus

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A 45-year-old woman complains of vague upper abdominal pain of 4 days' duration. On physical examination she has right upper quadrant tenderness on palpation. An ultrasound examination of the abdomen shows calculi within the gallbladder. Which of the following statements regarding this finding is most appropriate?

A The presence of gallstones means that cholecystitis is also present

B She has a markedly increased risk for development of adenocarcinoma of the gallbladder

C A hemolytic anemia is probably present

D The gallstones probably contain cholesterol with bile and calcium salts

E Stones are probably also present in the intrahepatic bile ducts

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A 56-year-old man from Shanghai, China has had a 6 kg weight loss over the past 3 months and has felt increasingly tired. On physical examination there are no abnormal findings. An abdominal CT scan reveals a 10 cm solid mass in the left lobe of a nodular liver. Laboratory studies show that he is hepatitis B surface antigen positive, hepatitis C antibody negative, and hepatitis A antibody negative. A liver biopsy of the lesion is most likely to show which of the following pathologic abnormalities?

A Metastatic adenocarcinoma

B Large B cell lymphoma

C Focal nodular hyperplasia

D Hepatocellular carcinoma

E Hepatic adenoma

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A 25-year-old woman has had low volume diarrhea for 3 weeks. The quality of her stool has been noted to be mucoid and, at times, blood-tinged. The diarrhea is accompanied by tenesmus. These problems are beginning to interfere with her work as a computer networking consultant when she travels to Miami. On physical examination she is afebrile. There is mild lower abdominal pain on palpation, but no masses are noted. Her stool is positive for occult blood. Which of the following is the most likely diagnosis?

A Ulcerative colitis

B Amebiasis

C Campylobacter infection

D Collagenous colitis

E Irritable bowel syndrome

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A 50-year-old man has experienced abdominal pain for the past month. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and shows a periampullary mass. He had a total colectomy performed 15 years previously because of polyposis. Which of the following is the most likely diagnosis for his periampullary mass?

A Primary adenocarcinoma

B Ectopic pancreatic tissue

C Sclerosing cholangitis

D Metastatic colonic adenocarcinoma

E Pancreatic adenocarcinoma

F MALT lesion

G Gastrointestinal stromal tumor

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A 27-year-old man has had episodes of abdominal pain with low volume diarrhea for the past 3 years. He now has persistent pain in the rectal area, particularly with defecation. On physical examination the perirectal region shows erythema of the skin along with a deep fissure. There are no palpable masses on digital rectal exam. Stool culture is negative for pathogens. Which of the following diseases is he most likely to have?

A Adenocarcinoma

B Diverticulosis with diverticulitis

C Chronic ulcerative colitis

D Shigellosis

E Crohn disease

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A 26-year-old student incurs a needlestick injury while starting an IV on a combative patient in the emergency room. He thinks no more about it, but 25 years later, he has increasing malaise along with a 5 kg weight loss over 5 monts' time. On physical examination his liver edge is firm. An abdominal CT scan shows a 7 cm mass in the right lobe of his liver. Which of the following neoplasms is he most likely to have?

A Hepatoblastoma

B Hepatocellular carcinoma

C Hepatic angiosarcoma

D Cholangiocarcinoma

E Hepatic adenoma

F Large B cell lymphoma

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For as long as his wife can remember, her 60-year-old husband has complained of heartburn after eating dinner. He says it is her cooking. She tells him to shut up and take an antacid medication. She says he must like something she cooks, because he keeps gaining weight. He has no significant findings on physical exam. His CBC and serum chemistry panel are normal. Upper GI endoscopy is peformed. Which of the following is most likely to be seen on endoscopy in this man?

A A circumferential mid-esophageal web

B A large ulcerating mass of the mid-esophagus

C Tongues of erythematous epithelium above the Z-line

D Complete lack of gastric rugal folds

E Large dilated submucosal veins just above the gastroesophageal junction

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A 40-year-old woman has had mild abdominal pain and nausea for 5 months. There are no abnormal physical examination findings. Upper GI endoscopy is performed and there is an irregular 3 x 5 cm area with loss of rugal folds near the antrum. Biopsies from this area are taken and on microscopic examination show extensive mucosal and submucosal infiltration by a monoclonal population of B lymphocytes. She is given antibiotic therapy and the lesion resolves. Which of the following infectious agents is most likely to be associated with these findings?

A Human immunodeficiency virus

B Salmonella typhi

C Human papillomavirus

D Aspergillus fumigatus

E Epstein-Barr virus

F Herpes simplex virus

G Helicobacter pylori

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A 57-year-old woman with a BMI of 30 has diabetes mellitus type II. She has increasing malaise for 3 months. On physical examination there are no abnormal findings. Laboratory studies show total protein 6.1 g/dL, albumin 4.0 g/dL, alkaline phosphatase 31 U/L, AST 67 U/L, ALT 59 U/L, total bilirubin 1.2 mg/dL, and direct bilirubin 0.3 mg/dL. Her malaise persists for another 9 months. An abdominal CT scan now reveals decreased attenuation of the entire liver. No mass lesions are noted, but the liver is diffusely enlarged. A liver biopsy is performed. Which of the following microscopic findings is her liver biopsy most likely to show?

A Hepatocellular carcinoma

B Intracanalicular bile stasis

C Macrovesicular steatosis

D Centrilobular congestion

E Piecemeal necrosis

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