(90) A pathologic study of liver biopsies is conducted and the microscopic findings correlated with the clinical diagnosis. One group of liver biopsies reveals varying degrees of liver cell swelling and necrosis with cholestasis and portal inflammation. Giant multinucleated hepatocytes are also present. Which of the following is the most likely diagnosis?

(91) A pathologic study of liver biopsies is conducted and the microscopic findings correlated with the clinical diagnosis. One group of liver biopsies reveals that there are small round red globules that stain strongly with PAS in hepatocytes near the portal tracts. The patient goes on to develop cirrhosis. Which of the following is the most likely diagnosis?

A Hemochromatosis

B Gilbert syndrome

C Primary biliary cirrhosis

D Veno-occlusive disease

E Neonatal hepatitis

F Hepatitis A infection

G Wilson disease

H Alpha-1-antitrypsin deficiency

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(92) A 44-year-old woman with alpha-1-antitrypsin deficiency and hepatic failure receives a liver transplant. Two months later she has increasing malaise. On physical examination she is icteric and there is right upper quadrant tenderness on palpaption. Laboratory studies show a serum AST of 195 U/L with ALT of 276 U/L. Which of the following infectious agents is most likely causing her graft to fail?

(93) A 41-year-old man has had malaise and nausea for the past 14 months. He now becomes severely ill. On physical examination he is markedly icteric. There is right upper quadrant tenderness on palpation. Laboratory studies show his AST is 920 U/L with ALT 1001 U/L. Which of the following infectious agents is most likely causing this worsening liver disease?

A Hepatitis A virus

B Hepatitis B virus

C Hepatitis C virus

D Hepatitis D virus

E Cytomegalovirus

F Epstein-Barr virus

G HIV

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(94) After a potluck meal with pastries, sliced meats, and salad, several members of the office staff develop vomiting and an explosive diarrhea 2 to 4 hours later. They recover fully by the evening. Which of the following infectious agents most likely caused their illness?

(95) After eating a 9 kg undercooked thanksgiving turkey at a family dinner, several persons at a family reunion develop a minimal watery diarrhea with cramping abdominal pain two days later. They recover fully 3 days later. Which of the following infectious agents most likely caused their illness?

A Giardia lamblia

B Salmonella enteritidis

C Entameba histolytica

D Staphylococcal enterotoxin

E Vibrio parahemolyticus

F Mycobacterium avium-complex

G Cytomegalovirus

H Bacillus cereus

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(96) A 28-year-old man has experienced pain in his anal region for the past month. On physical examination there is a perirectal fistula. Which of the following diseases is most likely to literally cause this man's "pain in the butt"?

(97) A 30-year-old woman has had fever and abdominal pain for the past 4 days. On physical examination she has diffuse abdominal pain but no masses. Bowel sounds are present. Her stool is negative for occult blood. Laboratory studies show Hgb 13.8 g/dL, Hct 41.7%, platelet count 196,700/microliter, and WBC count 2840/microliter. A plain film radiograph of the abdomen shows free air. At laparotomy, a segment of perforated terminal ileum is resected and on gross dissesion shows longitudinal ulcers. Which of the folloowing is the most likely diagnosis?

A Shigellosis

B Crohn disease

C Diverticulosis

D Ulcerative colitis

E Ischemic colitis

F Typhoid fever

G Pseudomembranous colitis

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(98) A 21-year-old man has a total colectomy performed because of a family history of colon cancer. 10 years later develops a periampullary carcinoma and osteomas of the skull and femur. Which of the following types of polyp was most likely found in his total colectomy specimen?

(99) A 9-year-old boy is brought to the physician for a routine examination. He is noted to have flat, freckle-like areas of brown pigmentation on his face and on his buccal mucosa. At age 13 he develops severe abdominal pain. On physical examination his abdomen is distended and bowel sounds are absent. An abdominal CT scan reveals small bowel obstruction with intusussception. At laparotomy a small intestinal polyp is found at the leading edge of the intususscepted bowel. Which of the following types of polyp was most likely found in his resected bowel?

A Pseudopolyp

B Adenomatous polyp

C Hamartomatous polyp

D Inflammatory fibroid polyp

E Hyperplastic polyp

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(100) A male neonate in the second week of life is noted to become increasingly icteric. Physical examination reveals no abdominal distension or masses. There is no tenderness to palpation. Bowel sounds are present. No congenital anomalies are noted. Laboratory studies show a neonatal bilirubin of 12.2 mg/dL. Which of the following is the most likely diagnosis?

(101) A male neonate in the first week of life is noted by his mother not to have passed any stool for 5 days' time. He is not feeding well. Physical examination reveals a tender abdomen with mild distension, but no masses are noted. No congenital anomalies are noted. The baby has an elevated sweat chloride test. Which of the following is the most likely diagnosis?

A Biliary atresia

B Acute pancreatitis

C Meconium ileus

D Choledocholithiasis

E Pyloric stenosis

F Duodenal atresia

G Persistent cloaca

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(102) A 40-year-old man has a history of chronic alcohol abuse. He develops marked abdominal pain over the last 3 days. On physical examination there is marked tenderness with board-like rigidity of abdominal musculature. His stool is negative for occult blood. Laboratory studies show a serum lipase of 463 U/L. Which of the following complications of his illness is he most likely to develop?

(103) A 40-year-old woman has noted abdominal pain for the past 2 days. On physical examination there is rebound tenderness in her right lower quadrant. An abdominal CT scan shows marked dilation of the appendix. An appendectomy is performed and a cystadenoma is present. Which of the following complications is most likely to occur if this condition is not treated?

A Pseudopolyposis

B Hemoperitoneum

C Pseudocyst

D Mucocele

E Fibrous adhesions

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(104) A 67-year-old man has had abdominal pain for the past 3 days. He has not had a bowel movement for 2 days. On physical examination there is marked abdominal tenderness. An abdominal plain film radiograph shows dilated loops of small bowel with air-fluid levels, but no free air. Laboratory studies show his serum calcium is 15.2 mg/dL with a serum albumin of 4.1 g/dL and serum phosphorus of 2.1 mg/dL. Which of the following is the most likely diagnosis?

(105) A 55-year-old man with a long history of chronic alcohol abuse develops severe mid abdominal pain over the past day. On physical examination he has marked tenderness to palpation of the upper abdomen. The spleen tip is palpable. Laboratory studies show AST 111 U/L and ALT 108 U/L, alkaline phosphatase 68 U/L, LDH 660 U/L, and amylase 808 U/L. Which of the following is the most likely diagnosis?

A Chronic hepatitis B infection

B Acute pancreatitis

C Hereditary hemochromatosis

D Hepatocellular carcinoma

E Small intestinal obstruction

F Perforated peptic ulcer

G Volvulus

H Ileal adenocarcinoma

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(106) During the exam
abdominal discomfort:
students then pass on.

(107) In the springtime runs
a mild diarrheal illness:
but children get well.

A Duodenal peptic ulcer

B Celiac sprue

C Irritable bowel syndrome

D Menetrier disease

E Rotavirus infection

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(108) A 32-year-old previously healthy man has noted increasing jaundice and nausea for the past 2 weeks. On physical examination he has mild right upper quadrant tenderness. Laboratory studies show his ALT is 330 U/L, AST 287 U/L, alkaline phosphatase 82 U/L, total protein 7.1 g/dL, albumin 5.0 g/dL, total bilirubin 4.8 mg/dL, and direct bilirubin 3.4 mg/dL. He recovers in 3 weeks. Which of the following is the most likely diagnosis?

(109) A 66-year-old woman has had malaise for the past 6 months along with dull, constant mid abdominal pain. She has noted passing pale, clay-colored stools for the past 2 weeks. On physical examination she is icteric. Laboratory studies show a total bilirubin of 5.4 mg/dL with a direct bilirubin of 4.9 mg/dL. Which of the following is the most likely diagnosis?

A Micronodular cirrhosis from alcohol abuse

B Hemoglobinopathy with hemolysis

C Multiple hepatic metastases

D Acute hepatitis A infection

E Wilson disease

F Alpha-1-antitrypsin deficiency

G Adenocarcinoma of the pancreatic head

H Reye syndrome

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(110) A 54-year-old man goes to his physician for a routine examination. On physical examination there are no abnormal findings. Laboratory studies show that he has a positive serologic test for hepatitis B surface antigen and hepatitis B core antibody, with negative hepatitis A IgM antibody and negative hepatitis C antibody. Which of the following mass lesions of the liver is he at greatest risk for developing?

(111) A 32-year-old woman has a history of oral contraceptive use for the past 15 years. On physical examination there are no abnormal findings. Which of the following mass lesions of the liver is he at greatest risk for developing?

A Hepatoblastoma

B Hepatic adenoma

C Focal nodular hyperplasia

D Bile duct adenoma

E Hepatocellular carcinoma

F Angiosarcoma

G Cholangiocarcinoma

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(112) A 38-year-old man has a history of injection drug usage. He has become increasingly icteric for the past week. On physical examination there are needle tracks in his right antecubital fossa. His temperature is 37.5 C. Which of the following is the most likely diagnosis?

(113) A 25-year-old man has a history of ulcerative colitis. He has become increasingly icteric for the past month. On physical examination he has scleral icterus. He is afebrile. Laboratory studies show total bilirubin 6.6 mg/dL, alkaline phosphatase 201 U/L, AST 77 U/L, and ALT 88 U/L. Which of the following is the most likely diagnosis?

A Acute viral hepatitis

B Biliary atresia

C Primary biliary cirrhosis

D Adenocarcinoma of ampulla of Vater

E Sclerosing cholangitis

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A 58-year-old man is admitted to hospital because of the sudden onset of hematemesis. He dies following massive upper gastrointestinal hemorrhage that cannot be controlled, despite administration of 10 units of packed red blood cells. At autopsy, the gross and microscopic appearances of his liver demonstrate micronodular cirrhosis with macrovesicular steatosis. Which of the following is most likely to be present?

A Gastric adenocarcinoma

B Ascites

C Barrett esophagus

D Sclerosing cholangitis

E Hemoperitoneum

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A 55-year-old man has the acute onset of abdominal pain over the past day. He had an appendectomy for acute appendicitis in his 20's, but no other major medical problems since then. On physical examination, he has abdominal distension, and high-pitched tinkling bowel sounds are heard. A stool guaiac is negative. There is no fluid wave and no masses are felt. He is afebrile. His WBC count is 10,140/microliter with differential count of 68 segs, 3 bands, 20 lymphs, and 9 monos. Which of the following is the most likely diagnosis?

A Intussusception

B Entameba histolytica infection

C Tropical sprue

D Peritoneal fibrous adhesions

E Ileal adenocarcinoma

F Diverticulitis

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A 71-year-old woman has noted a vague upper abdominal pain with nausea and a feeling of fullness, even after eating very little food, for the past 5 months. On physical examination she appears cachectic. Upper GI endoscopy is performed and there is an ill-defined 6 cm mass on the lesser curve in the body of the stomach. Biopsy of the lesion is performed and on microscopic examination shows numerous signet ring cells infiltrating into the muscularis. Which of the following conditions is most likely to have contributed to the development of her disease:

A Inflammatory bowel disease

B Atrophic gastritis

C Ibuprofen use for arthritis

D Consumption of coffee

E Chronic alcoholism

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For the past year a 37-year-old woman has periodic fainting episodes that are preceded by periods of mental confusion and a feeling of weakness. These have occurred for the past year. She is otherwise healthy. Physical examination reveaals no abnormal findings. A CBC and serum chemistry panel reveal no abnormal findings. Which of the following is the most likely diagnosis?

A Hepatitis C infection

B Colonic adenocarcinoma

C Scleroderma

D Crohn disease

E Carcinoid tumor

F Islet cell adenoma

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A 67-year-old man has felt well for most of his life. Over the past 10 years he has had several episodes of lower abdominal pain. On one of those occasions, a physical examination was performed and his stool was positive for occult blood, but he did not return for further evaluations. He now has had worsening lower abdominal pain for the past week. On physical examination, there is now diffuse lower abdominal tenderness, most marked on the left. Bowel sounds are reduced. An abdominal plain film radiograph shows slightly dilated loops of small bowel. An abdominal CT scan shows a pelvic abscess adjacent to the sigmoid colon, which is narrowed and has a thickened, inflamed wall. Which of the following is the most likely diagnosis?

A Diverticulitis

B Adenocarcinoma

C Amebiasis

D Appendicitis

E Volvulus

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A clinical study is performed involving subjects who presented to their physician with sudden, severe abdominal pain. The clinical and laboratory findings are analyzed, along with outcomes of both medical and surgical therapies for their diseases. Which of the following diseases is most likely to respond best to medical therapy and not to prompt surgical intervention?

A Volvulus

B Intussusception

C Acute pancreatitis

D Incarcerated hernia

E Perforated duodenal ulcer

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A 41-year-old man has complained of cramping abdominal pain with bloating, occasional diarrhea, and increased flatus for the past 2 years. On physical examination there are no abnormal findings. Laboratory studies show AST 31 U/L, ALT 27 U/L, alkaline phosphatase 73 U/L, total bilirubin 0.9 mg/dL, total protein 6.8 g/dL, and albumin 5.3 g/dL. A CBC shows Hgb 13.8 g/dL, Hct 41.6%, MCV 90 fL, platelet count 241,000/microliter, and WBC count 6640/microliter. An ultrasound scan of the abdomen reveals a 2 cm rounded gallstone. Which of the following is the most likely diagnosis associated with this man's gallstone?

A Incidental finding

B Hemoglobinopathy

C Adenocarcinoma

D Inflammatory bowel disease

E Parathyroid adenoma

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A 68-year-old woman noted a change in the caliber of her stool over a period of 6 weeks. On physical examination there is no mass palpable by digital rectal examination, but the stool is positive for occult blood. A sigmoidoscopy is performed and there is an ulcerated 7 cm mass that partially encircles the sigmoid colon at 19 cm above the anal verge, narrowing the lumen. Which of the following diseases is the most likely risk factor for development of this woman's colonic mass lesion?

A Diverticulosis

B Clostridium difficile infection

C Collagenous colitis

D Ischemic colitis

E Tubular adenoma

F Shigellosis

G Prior CT scan

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A 22-year-old man develops icterus over the past week, but does not complain of abdominal pain. On physical examination, bowel sounds are present. No masses are palpable. A stool for occult blood is negative. Laboratory studies show his total serum bilirubin is 4.9 mg/dL with direct serum bilirubin 0.4 mg/dL. An abdominal ultrasound reveals the presence of gallstones. Which of the following diseases is this man most likely to have?

A Ulcerative colitis

B Hemolytic anemia

C Hepatitis A infection

D Ampullary adenocarcinoma

E Choledocholithiasis

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A 34-year-old woman has had nausea, vomiting, and fatigue for 4 months On physical examination there are no abnormal findings. Laboratory studies show that the AST is 119 U/L and ALT is 130 U/L. Her hepatitis B surface antigen is negative, hepatitis B surface antibody negative, hepatitis B core antibody negative, hepatitis A antibody-IgM negative, and the hepatitis C antibody is positive. Which of the following is the most likely interpretation of these findings?

A She will recover in a few weeks with no sequelae

B The patient is at risk for development of chronic hepatitis

C There is no risk for development of hepatocellular carcinoma

D Infection could not have come from a blood transfusion

E She was infected via unprotected sexual intercourse a week ago

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A 32-year-old woman comes to the emergency department with worsening lower abdominal pain for the past 12 hours. On examination she has right lower quadrant pain. Her WBC count is 12,330/microliter. A laparoscopic appendectomy is performed. Microscopic examination of the appendix shows serosal acute vasculitis with neutrophils and fibrinoid necrosis, but no neutrophils are present in the mucosa or muscular wall of the appendix. Which of the following laboratory tests is most likely to be positive in this situation?

A Peripheral anti-neutrophil cytoplasmic autoantibody (P-ANCA)

B Anti-centromere antibody

C Anti-mitochondrial antibody (AMA)

D Anti-parietal cell antibody (APCA)

E Anti-DNA topoisomerase I antibody

F Anti-endomysial antibody

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A 44-year-old woman has experienced 10 episodes of sudden abdominal pain over the last 3 months. Late one afternoon at work, she has another attack, and this time the pain is severe. She feels light-headed and severely nauseated. She goes to the emergency room. The examining physician determines that her abdominal pain is worst in the right upper quadrant. Bowel sounds are present, and her abdomen is non-distended. A stool for occult blood is negative. An abdominal plain film radiograph reveals no free air. Which of the following additional radiographic findings is most likely to be present in this woman?

A Lithiasis of the gallbladder by ultrasound

B Hepatic cirrhosis by MR imaging

C Superior mesenteric arterial occlusion by angiography

D Intussusception by CT scan

E Cecal mass on barium enema

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A 30-year-old man experiences an episode of hematemesis. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and there is a diffusely hyperemic gastric mucosa. Biopsies are taken and microscopic examination shows mucosal hemorrhage. Which of the following is the most likely diagnosis?

A CREST syndrdome

B Use of NSAIDS

C Diabetes mellitus, type I

D Helicobacter pylori infection

E Zollinger-Ellison syndrome

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A 24-year-old G4 P3 woman gives birth at term following an uncomplicated pregnancy to a 2840 gm male infant. He has not passed any stool by day 3 of life and has vomiting. On physical examination his abdomen is distended and an ultrasound scan shows a dilated colon. Laboratory studies show a normal sweat chloride test. A mutation involving which of the following genes is most likely to be present in this infant?

A CFTR

B HFE

C KRAS

D RET

E TP53

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A 41-year-old man has felt an epigastric burning pain along with nausea for the past 6 months. He has lost 2 kg during that time. He has this pain upon eating, but not often in-between meals or at night. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and there are two sharply demarcated ulcerations, 0.8 cm and 1.6 cm in diamter, located in the antrum. Which of the following drugs used by this man is most likely to have caused his illness?

A Acetaminophen

B Cimetidine

C Clindamycin

D Cocaine

E Ferrous sulfate

F Ibuprofen

G Isoniazid

H Omeprazole

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A 38-year-old woman has been bothered by both constipation and diarrhea, accompanied by episodic cramping mid-abdominal pain, for the past 7 years. The diarrhea consists of low volumes of loose stools and often there is flatulence during the days when the diarrhea is present. The abdominal pain abates following defecation. On physical examination there are no abnormal findings. Her stool is negative for occult blood. Her condition improves with desipramine and avoidance of legumes in the diet. Which of the following is the most likely diagnosis?

A Chronic ulcerative colitis

B Collagenous colitis

C Crohn disease

D Diverticulosis

E Irritable bowel syndrome

F Ischemic bowel disease

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A 3-year-old girl has become increasingly lethargic over the past 3 days. She had vomiting 2 days ago. She had an upper respiratory infection a week ago, with only a mild fever and cough. She received aspirin for the fever but no antibiotic therapy. On physical examination, there is an increased liver span. She is afebrile. Laboratory studies show total protein 7.2 g/dL, albumin 4.7 g/dL, alkaline phosphatase 140 U/L, AST 89 U/L, ALT 96 U/L, and total bilirubin 1.0 mg/dL. A liver biopsy is performed and on microscopic examination shows microvesicular steatosis. The child's condition worsens. Her blood ammonia increases to 45 micromol/L a day later. Which of the following is the most likely diagnosis?

A Alpha-1-antitrypsin deficiency

B Budd-Chiari syndrome

C Hepatitis A infection

D Hepatoblastoma

E Primary sclerosing cholangitis

F Reye syndrome

G Wilson disease

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