9th Annual Review in Internal Medicine
Which of the following patients will require
GASTROENTEROLOGY
9th Annual Review in Internal Medicine
Which of the following patients will require
prophylaxis against upper gastrointestinal bleeding
with proton pump inhibitors? (C57, p277)
A. A 45 year old male who suffered from his first
acute coronary syndrome and will be started on
Aspirin
B. A 75 year old female with no comorbidities who
will take Celecoxib for osteoarthritis
C. A 56 year old male admitted in the surgical
intensive care unit for severe injuries after a brawl
D. A 33 year old male who is a chronic alcoholic
This handout may not be reproduced without permission.
12/02/2018
prophylaxis against upper gastrointestinal bleeding
with proton pump inhibitors? (C57, p277)
A. A 45 year old male who suffered from his first
acute coronary syndrome and will be started on
Aspirin
B. A 75 year old female with no comorbidities who
will take Celecoxib for osteoarthritis
C. A 56 year old male admitted in the surgical
intensive care unit for severe injuries after a brawl
D. A 33 year old male who is a chronic alcoholic
Pharmacologic prophylaxis for stress related mucosal injury
for the following:
• serious trauma
• major surgery
• burns covering more than 1/3 of the BSA
• major intracranial disease
• severe medical illness.
Use of PPI with Aspirin or Coxib indicated when bleeding
develops.
Chronic alcoholics may develop the following:
• Mallory Weiss tears – usually stop spontaneously in 80-90%
of cases
• Varices – Endoscopy + nonselective beta blockers
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9th Annual Review in Internal Medicine 12/02/2018

A 65 year old male underwent upper endoscopy for A 65 year old male underwent upper endoscopy for
melena. A 0.5cm clean-based ulcer was visualized at melena. A 0.5cm clean-based ulcer was visualized at
the gastric antrum. Which of the following describes the gastric antrum. Which of the following describes
gastric ulcers in this location? (C348, p1915-1916) gastric ulcers in this location? (C348, p1915-1916)

A. Associated with duodenal ulcers A. Associated with duodenal ulcers

B. Associated with normal acid production B. Associated with normal acid production
C. Malignancy is rare C. Malignancy is rare
D. Occurs more often in younger subjects D. Occurs more often in younger subjects

9th Annual Review in Internal Medicine

Which of the following is an established risk factor
Gastric Ulcers for NSAID-induced ulcer disease? (C348, p1917)

• Majority attributed to either H. pylori or NSAID-

induced mucosal damage.
• Type I – gastric body, low gastric acid production A. Cigarette smoking
• Type II – antrum, gastric acid low to normal B. Alcohol consumption
• Type III – within 3cm of the pylorus, accompanied C. H. pylori infection
by duodenal ulcers, normal or high gastric acid D. Advanced age
• Type IV – cardia, low gastric acid production

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9th Annual Review in Internal Medicine 12/02/2018

Which of the following is an established risk factor ESTABLISHED risk factors for
for NSAID-induced ulcer disease? (C348, p1917) NSAID-induced ulcers
• Advanced age
• History of ulcer
A. Cigarette smoking
• Concomitant use of glucocorticoids, anticoagulants,
B. Alcohol consumption clopidogrel
C. H. pylori infection • High dose NSAIDs
D. Advanced age • Multiple NSAIDs
• Multisystem disease

9th Annual Review in Internal Medicine

POSSIBLE risk factors for NSAID- The most common indication for liver transplant is:
induced ulcers (C360, p2015)

• Concomitant infection with H. pylori

• Cigarette smoking
A. Hepatitis C
• Alcohol consumption
B. Hepatitis B
C. Alcoholic liver disease
D. Acetaminophen-related liver injury

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9th Annual Review in Internal Medicine
The most common indication for liver transplant is:
(C360, p2015)
A. Hepatitis C
B. Hepatitis B
C. Alcoholic liver disease
D. Acetaminophen-related liver injury
9th Annual Review in Internal Medicine
Which statement is TRUE of hepatitis C infections?
(C360, p 2015-2017)
A. After an episode of acute infection, the likelihood
of progression to chronic infection is low, as
spontaneous viral clearance is the rule.
B. Hepatitis C is mainly a bloodborne infection,
although it may also be transmitted percutaneously
and sexually.
C. The level of HCV RNA is a reliable marker of
disease severity and prognosis.
D. Hepatitis C can be transmitted in breastmilk thus
breastfeeding is contraindicated for infected
patients.
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12/02/2018
Which statement is TRUE of hepatitis C infections?
(C360, p 2015-2017)
A. After an episode of acute infection, the likelihood
of progression to chronic infection is low, as
spontaneous viral clearance is the rule.
B. Hepatitis C is mainly a bloodborne infection,
although it may also be transmitted percutaneously
and sexually.
C. The level of HCV RNA is a reliable marker of
disease severity and prognosis.
D. Hepatitis C can be transmitted in breastmilk thus
breastfeeding is contraindicated for infected
patients.
Which statement is TRUE of hepatitis C infections? (C360, p 2015-2017)
A. After an episode of acute infection, the likelihood of progression to
chronic infection is low, as spontaneous viral clearance is the rule.
Complete clinical & biochemical recovery in Hep A & E.
Hep B – self limited in 95-99%
Hep C – self-limited in 15%
B. Hepatitis C is mainly a bloodborne infection, although it may also be
transmitted percutaneously and sexually.
C. The level of HCV RNA is a reliable marker of disease severity and
prognosis. Not a reliable marker but predicts responsiveness to
antiviral therapy.
D. Hepatitis C can be transmitted in breastmilk thus breastfeeding is
contraindicated for infected patients.
Breastfeeding does not increase the risk of HCV
infection between an infected mother and her infant.
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9th Annual Review in Internal Medicine
A 20 year old female, newly diagnosed with acute
myeloid leukemia, was referred for clearance prior to
initiation of chemotherapy. Her hepatitis profile was as
follows: HbsAg NR, anti-HBs NR, anti-HBc IgG R, anti-HCV
NR; ALT 20 (within normal limits); HBV DNA 100 IU/ml.
What is the appropriate management of this patient?
(C361)
A. No need to start antivirals. Monitor ALT and HBV DNA
every 3 months while on chemotherapy.
B. Start entecavir and continue for at least 6 months.
C. Start dual therapy with PEG-IFN and entecavir for at
least 6 months.
D. Clear for chemotherapy and if reactivation occurs
during treatment, start antivirals.
9th Annual Review in Internal Medicine
Hepatitis B and Chemotherapy
(p 2039-2040)
• Patients with chronic hepatitis B who undergo cytotoxic
chemotherapy for treatment of malignancies as well as patients
treated with immunosuppressive, anticytokine, or antitumor
necrosis factor therapies experience enhanced HBV replication
and viral expression on hepatocyte membranes during
chemotherapy coupled with suppression of cellular immunity.
• When chemotherapy is withdrawn, such patients are at risk for
reactivation of hepatitis B, often severe and occasionally fatal.
• Preemptive treatment prior to the initiation of chemotherapy has
been shown to reduce the risk of such reactivation. The newer,
more potent oral antiviral agents are even more effective.
• The optimal duration of antiviral therapy after completion of
chemotherapy is not known, but a suggested approach is 6
months for inactive hepatitis B carriers and longer-duration
therapy in patients with baseline HBV DNA levels >2 × 103 IU/mL,
until standard clinical endpoints are met.
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12/02/2018
A 20 year old female, newly diagnosed with acute
myeloid leukemia, was referred for clearance prior to
initiation of chemotherapy. Her hepatitis profile was as
follows: HbsAg NR, anti-HBs NR, anti-HBc IgG R, anti-HCV
NR; ALT 20 (within normal limits); HBV DNA 100 IU/ml.
What is the appropriate management of this patient?
(C361)
A. No need to start antivirals. Monitor ALT and HBV DNA
every 3 months while on chemotherapy.
B. Start entecavir and continue for at least 6 months.
C. Start dual therapy with PEG-IFN and entecavir for at
least 6 months.
D. Clear for chemotherapy and if reactivation occurs
during treatment, start antivirals.
A 30 year old male who consumes 6 bottles of Red
Horse everyday was admitted to the ER for
hematemesis. Which of the following supports the
diagnosis of alcoholic liver disease? (C363, p 2053, T
363-2)
A. ALT / AST ratio > 1, with both increased two- to
sevenfold
B. Normal GGTP
C. ALT and AST > 400 IU/L
D. Bilirubin markedly increased despite modest ALP
elevations
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9th Annual Review in Internal Medicine 12/02/2018

A 30 year old male who consumes 6 bottles of Red

Horse everyday was admitted to the ER for
hematemesis. Which of the following supports the
diagnosis of alcoholic liver disease? (C363, p 2053, T
363-2)

A. ALT / AST ratio > 1, with both increased two- to

sevenfold
B. Normal GGTP
C. ALT and AST > 400 IU/L
D. Bilirubin markedly increased despite modest ALP
elevations

9th Annual Review in Internal Medicine

The only approved therapy with some degree of The only approved therapy with some degree of
efficacy in delaying disease progression in Primary efficacy in delaying disease progression in Primary
Biliary Cirrhosis: (C365, p 2060) Biliary Cirrhosis: (C365, p 2060)

A. Cholestyramine A. Cholestyramine
B. Prednisone B. Prednisone
C. Pentoxyfyline C. Pentoxyfyline
D. Ursodeoxycholic acid D. Ursodeoxycholic acid
Slows the rate of progression but does not
reverse or cure the disease.

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9th Annual Review in Internal Medicine 12/02/2018

Which condition is associated with 50% of cases of Which condition is associated with 50% of cases of
Primary Sclerosing Cholangitis and therefore requires Primary Sclerosing Cholangitis and therefore requires
careful investigation once a diagnosis of PSC is careful investigation once a diagnosis of PSC is
made? (C365, p 2061) made? (C365, p 2061)

A. Ulcerative colitis A. Ulcerative colitis

B. Rheumatoid arthritis B. Rheumatoid arthritis
C. Goodpasture’s syndrome C. Goodpasture’s syndrome
D. Glomerulonephritis D. Glomerulonephritis

9th Annual Review in Internal Medicine

The best therapy for hepatorenal syndrome: (C365, The best therapy for hepatorenal syndrome: (C365,
p2066) p2066)

A. Octreotide A. Octreotide
Prognosis is poor unless transplant can
B. Albumin infusions B. Albumin infusions be achieved within a short period of
C. Liver transplant C. Liver transplant time.
D. Combined liver-renal transplant D. Combined liver-renal transplant

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9th Annual Review in Internal Medicine
A 55 year old alcoholic male was admitted to the
emergency room for severe epigastric pain. Work-up
was consistent with acute pancreatitis. Which of the
following is a risk factor for severe acute
pancreatitis? (C371, p2094, T 371-3)
A. Age < 60 years
B. BMI > 30
C. Recent alcohol intake
D. Absence of comorbid conditions
9th Annual Review in Internal Medicine
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A 55 year old alcoholic male was admitted to the
emergency room for severe epigastric pain. Work-up
was consistent with acute pancreatitis. Which of the
following is a risk factor for severe acute
pancreatitis? (C371, p2094, T 371-3)
A. Age < 60 years
B. BMI > 30
C. Recent alcohol intake
D. Absence of comorbid conditions
In acute pancreatitis, the most important treatment
intervention is: (C371, p 2096)
A. Bowel rest (NPO)
B. Narcotics
C. Intravenous fluid resuscitation
D. Prophylactic antibiotics
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9th Annual Review in Internal Medicine
In acute pancreatitis, the most important treatment
intervention is: (C371, p 2096)
A. Bowel rest (NPO)
B. Narcotics
C. Intravenous fluid resuscitation
D. Prophylactic antibiotics
9th Annual Review in Internal Medicine
Which of the following is TRUE of intestinal
obstructions? (C355, p1983)
A. Patients with distal obstruction tend to present
with greater distension, more discomfort and
delayed emesis compared to proximal obstructions.
B. The most commonly identified cause of functional
bowel obstruction is medication-induced ileus.
C. Volvulus most commonly involves the cecum.
D. Colonic pseudoobstruction will usually respond to
the administration of atropine.
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12/02/2018
Which of the following is TRUE of intestinal
obstructions? (C355, p1983)
A. Patients with distal obstruction tend to present
with greater distension, more discomfort and
delayed emesis compared to proximal obstructions.
B. The most commonly identified cause of functional
bowel obstruction is medication-induced ileus. (ileus
after intraabd surgery)
C. Volvulus most commonly involves the cecum.
D. Colonic pseudoobstruction will usually respond to
the administration of atropine. (neostigmine)
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9th Annual Review in Internal Medicine 12/02/2018

A 70 year old male with acute atrial fibrillation
underwent colonoscopy for hematochezia and
abdominal pain. Endoscopic findings revealed
ulcerations and areas of necrosis consistent with
intestinal ischemia at the descending colon and
sigmoid. Mesenteric embolism was then suspected.
On CT angiography, which vessel would be expected
to have a filling defect? (C354, p1979)
A 70 year old male with acute atrial fibrillation
underwent colonoscopy for hematochezia and
abdominal pain. Endoscopic findings revealed
ulcerations and areas of necrosis consistent with
intestinal ischemia at the descending colon and
sigmoid. Mesenteric embolism was then suspected.
On CT angiography, which vessel would be expected
to have a filling defect? (C354, p1979)

A. Superior mesenteric artery A. Superior mesenteric artery

B. Inferior mesenteric artery B. Inferior mesenteric artery
C. Celiac artery C. Celiac artery
D. Internal iliac artery D. Internal iliac artery

9th Annual Review in Internal Medicine

In ulcerative colitis, which histologic feature suggests
chronicity? (C351, p1951)

Griffith’s point – SMA

Sudeck’s point - IMA
A. Granulomas
B. Eosinophilic infiltrates
C. Distortion of the crypts
D. Crypt abscesses

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9th Annual Review in Internal Medicine 12/02/2018

In ulcerative colitis, which histologic feature suggests A 25 year old female recently presented with
chronicity? (C351, p1951) minimal blood-streaked stools and 3 bowel
movements per day. On physical examination, her
2 histologic signs of vitals were as follows: HR 88 RR 16 T 37C. On
chronicity in UC: colonoscopy, there was note of fine granularity and
1. Distortion of crypt patchy erythema of the colon. Histopathologic
A. Granulomas examination of the mucosa was consistent with
architecture
B. Eosinophilic infiltrates 2. Basal plasma cells and
ulcerative colitis. What is the severity of her disease?
(C351, p1952, T 351-4)
C. Distortion of the crypts multiple basal lymphoid
aggregates
D. Crypt abscesses
A. Mild
B. Moderate
C. Severe
D. Fulminant

9th Annual Review in Internal Medicine

A 25 year old female recently presented with
minimal blood-streaked stools and 3 bowel
movements per day. On physical examination, her
vitals were as follows: HR 88 RR 16 T 37C. On
colonoscopy, there was note of fine granularity and
patchy erythema of the colon. Histopathologic
examination of the mucosa was consistent with
ulcerative colitis. What is the severity of her disease?
(C351, p1952, T 351-4)

A. Mild
B. Moderate
C. Severe
D. Fulminant

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9th Annual Review in Internal Medicine 12/02/2018

Which test is a highly sensitive and specific marker Which test is a highly sensitive and specific marker
for detecting intestinal inflammation? (C351, p1952) for detecting intestinal inflammation? (C351, p1952)
Lactoferrin – highly
sensitive and specific for
A. FIT A. FIT inflammation

B. Fecal lactoferrin B. Fecal lactoferrin Calprotectin correlates with

C. Fecal calprotectin C. Fecal calprotectin histologic inflammation,
predict relapses, detect
D. ESR D. ESR pouchitis.

ESR – acute phase reactant

to determine active disease

9th Annual Review in Internal Medicine

When performing endoscopy on patients with When performing endoscopy on patients with
suspected Crohns disease, which finding represents suspected Crohns disease, which finding represents
the earliest mucosal change in this condition? (C351, the earliest mucosal change in this condition? (C351,
p1954) p1954)

A. Linear erythema A. Linear erythema

B. Loss of mucosal vascularity B. Loss of mucosal vascularity
C. Pinpoint hemorrhages C. Pinpoint hemorrhages
D. Aphthous ulcers D. Aphthous ulcers

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9th Annual Review in Internal Medicine 12/02/2018

The definitive diagnosis of primary sclerosing The definitive diagnosis of primary sclerosing
cholangitis is established by: (C365, p 2061) cholangitis is established by: (C365, p 2061)

A. Elevated ALP and transaminases A. Elevated ALP and transaminases

B. Endoscopic ultrasound B. Endoscopic ultrasound
Cholangiographic imaging is
C. MRI with MRCP C. MRI with MRCP
needed to diagnose
D. Histopathology D. Histopathology definitively.

9th Annual Review in Internal Medicine

A 0.4cm duodenal ulcer with a flat pigmented spot A 0.4cm duodenal ulcer with a flat pigmented spot
was noted on endoscopy. Which is the appropriate was noted on endoscopy. Which is the appropriate
management for this patient? (C57, p278) management for this patient? (C57, p278)

A. Admit to the ward for 2-3 days.
B. Start Pantoprazole IV for 3 days.
C. Put patient on NPO for at least 2 days.
D. Inject the area with epinephrine during
endoscopy.
A. Admit to the ward for 2-3 days.
B. Start Pantoprazole IV for 3 days.
C. Put patient on NPO for at least 2 days.
D. Inject the area with epinephrine during
endoscopy.

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9th Annual Review in Internal Medicine 12/02/2018

A 60 year old male was rushed to the emergency

room after presenting with an estimated 1 L of
bloody stools the day prior. His vitals were as
follows: BP 80/50, HR 120s, RR 22. His blood
pressure improved to 100/60 after giving 2L of
crystalloids at the ER. Which diagnostic modality is
the appropriate initial step? (C57, p279, Fig 57-2)

A. Esophagogastroduodenoscopy
B. Colonoscopy
C. CT angiography
D. RBC tagging

9th Annual Review in Internal Medicine

A 60 year old male was rushed to the emergency
room after presenting with an estimated 1 L of
bloody stools the day prior. His vitals were as
follows: BP 80/50, HR 120s, RR 22. His blood
pressure improved to 100/60 after giving 2L of
crystalloids at the ER. Which diagnostic modality is
the appropriate initial step? (C57, p279, Fig 57-2)

A. Esophagogastroduodenoscopy
B. Colonoscopy
C. CT angiography
D. RBC tagging

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9th Annual Review in Internal Medicine 12/02/2018

Which of the following is a prokinetic agent which Which of the following is a prokinetic agent which
can be given prior to endoscopy to improve can be given prior to endoscopy to improve
visualization in cases of upper GI bleeding? (C57, p visualization in cases of upper GI bleeding? (C57, p
278) 278)

A. Domperidone A. Domperidone
B. Metoclopramide B. Metoclopramide
C. Hyoscine-N-butyl bromide C. Hyoscine-N-butyl bromide
Provides small but significant increase in
D. Erythromycin D. Erythromycin diagnostic yield and decrease in
subsequent endoscopies. No effect on
decrease in bleeding or death.

9th Annual Review in Internal Medicine

A 40 year old male presented with recurrent A 40 year old male presented with recurrent
hematochezia requiring repeated transfusions for the hematochezia requiring repeated transfusions for the
past 6 months. He underwent several upper and past 6 months. He underwent several upper and
lower endoscopies, which were negative for a source lower endoscopies, which were negative for a source
of bleeding. What is the likely source for the obscure of bleeding. What is the likely source for the obscure
GI bleeding in this patient? (C57, p277) GI bleeding in this patient? (C57, p277)
Obscure GI bleeding
Most common cause in
children – Meckel’s
A. Meckel’s diverticulum A. Meckel’s diverticulum Most common cause in
B. Small bowel tumor B. Small bowel tumor adults – small bowel
tumors
C. Vascular ectasia C. Vascular ectasia
D. Small bowel ulcerations D. Small bowel ulcerations

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9th Annual Review in Internal Medicine
A 65 year old male was started on rosuvastatin after
suffering from acute ST-segment elevation myocardial
infarction. His physician ordered for AST and ALT 3
months after initiation of treatment, and noted a 2-fold
increase in the transaminases. Physical examination was
unremarkable. Hepatitis serologies were all negative and
an ultrasound showed a normal-looking hepatic
parenchyma. Which is the next step in the management
of this patient? (C361, p 2030)
A. Repeat the AST and ALT after 3 months. If still
elevated, discontinue statin.
B. Shift to a less potent statin such as simvastatin.
C. Discontinue the statin immediately.
D. Since patient is asymptomatic, there is no need for
AST/ALT monitoring. The statin may be continued.
9th Annual Review in Internal Medicine
Recommendation of the National
Lipid Association’s Safety Task Force
• Liver test monitoring not necessary in patients
taking statins
• Statin therapy need not be discontinued in patients
found to have asymptomatic isolated
aminotransferase elevations during therapy
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12/02/2018
A 65 year old male was started on rosuvastatin after
suffering from acute ST-segment elevation myocardial
infarction. His physician ordered for AST and ALT 3
months after initiation of treatment, and noted a 2-fold
increase in the transaminases. Physical examination was
unremarkable. Hepatitis serologies were all negative and
an ultrasound showed a normal-looking hepatic
parenchyma. Which is the next step in the management
of this patient? (C361, p 2030)
A. Repeat the AST and ALT after 3 months. If still
elevated, discontinue statin.
B. Shift to a less potent statin such as simvastatin.
C. Discontinue the statin immediately.
D. Since patient is asymptomatic, there is no need for
AST/ALT monitoring. The statin may be continued.
A 20 year old female was brought to the ER for
vomiting and abdominal pain. She had a history of
depression and suicidal attempts, therefore a drug
overdose was suspected. On work-up, there was
note of extremely high aminotransferases levels but
with low bilirubin levels. Which of the following
medications, when taken in overdose, present with
this characteristic laboratory finding during
hyperacute liver injury? (C361, p2027)
A. Isoniazid
B. Rifampicin
C. Paracetamol
D. Carbamazepine
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9th Annual Review in Internal Medicine 12/02/2018

A 20 year old female was brought to the ER for

vomiting and abdominal pain. She had a history of Acetaminophen Hepatotoxicity
depression and suicidal attempts, therefore a drug
overdose was suspected. On work-up, there was
note of extremely high aminotransferases levels but • Hyperacute injury
with low bilirubin levels. Which of the following • extremely high aminotransferase levels
medications, when taken in overdose, present with • low bilirubin levels
this characteristic laboratory finding during
hyperacute liver injury? (C361, p2027)

A. Isoniazid
B. Rifampicin
C. Paracetamol
D. Carbamazepine

9th Annual Review in Internal Medicine

Which drug used in ulcer treatment acts as a Which drug used in ulcer treatment acts as a
physicochemical barrier and binds to sites of active physicochemical barrier and binds to sites of active
ulceration? (C348, p 1922) ulceration? (C348, p 1922)

A. Bismuth subsalicylate A. Bismuth subsalicylate Mechanism: unclear

B. Sucralfate B. Sucralfate
C. Misoprostol C. Misoprostol Mechanism: enhancement of
mucosal defense and repair
D. Gaviscon D. Gaviscon

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9th Annual Review in Internal Medicine
A 25 year old male was admitted for severe abdominal
pain, nausea and anorexia for the past 2 days. On
physical examination, there was direct and rebound
tenderness over the right lower quadrant. Which of the
following classic signs of appendicitis is correctly
described? (C356, p 1987, T356-4)
A. Rovsing’s sign: palpation of the right lower quadrant
elicits direct tenderness
B. Obturator sign: internal rotation of the hip causes
pain
C. Iliopsoas sign: flexion of the right hip causes
posterolateral back and hip pain
D. Carney’s sign: asking the patient to tense the
abdomen elicits generalized abdominal pain
9th Annual Review in Internal Medicine
This handout may not be reproduced without permission.
12/02/2018
A 25 year old male was admitted for severe abdominal
pain, nausea and anorexia for the past 2 days. On
physical examination, there was direct and rebound
tenderness over the right lower quadrant. Which of the
following classic signs of appendicitis is correctly
described? (C356, p 1987, T356-4)
A. Rovsing’s sign: palpation of the right lower quadrant
elicits direct tenderness
B. Obturator sign: internal rotation of the hip causes
pain
C. Iliopsoas sign: flexion of the right hip causes
posterolateral back and hip pain
D. Carney’s sign: asking the patient to tense the
abdomen elicits generalized abdominal pain
A 36 year old female was admitted to the ER with a
consideration of acute appendicitis. On physical
examination, a tender RLQ mass was palpated. On CT
scan, a 5.5cm hypodense focus with slightly hyperdense
borders and surrounding fat stranding was visualized.
Complicated appendicitis with abscess formation was
considered. Which is the appropriate management of
this patient? (C356, p 1987)
A. Refer to Surgery for emergent appendectomy.
B. Refrain from giving pain medications so serial
abdominal examinations are not altered by analgesia.
C. Refer to Interventional Radiology for drainage.
D. Start clear liquids.
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9th Annual Review in Internal Medicine 12/02/2018

A 36 year old female was admitted to the ER with a Management of Acute

consideration of acute appendicitis. On physical
examination, a tender RLQ mass was palpated. On CT Appendicitis
scan, a 5.5cm hypodense focus with slightly hyperdense
borders and surrounding fat stranding was visualized. • Uncomplicated – laparoscopic or open
Complicated appendicitis with abscess formation was appendectomy
considered. Which is the appropriate management of
this patient? (C356, p 1987) • Presence of mass, phlegmon, or abscess
• Treat with broad spectrum antibiotics
• Drain if abscess is > 3 cm in diameter
A. Refer to Surgery for emergent appendectomy.
• Parenteral fluids
B. Refrain from giving pain medications so serial
abdominal examinations are not altered by analgesia. • Appendix removed more safely 6-12 weeks later when
inflammation has diminished
C. Refer to Interventional Radiology for drainage.
D. Start clear liquids.

9th Annual Review in Internal Medicine

A 30 year old female underwent laparoscopic
cholecystectomy. On examination of the operative
specimen, multiple pigment stones were extracted.
Which is a predisposing factor for this type of stone?
(C369, p2078, T 369-1)
A 30 year old female underwent laparoscopic
cholecystectomy. On examination of the operative
specimen, multiple pigment stones were extracted.
Which is a predisposing factor for this type of stone?
(C369, p2078, T 369-1)

A. Rapid weight loss A. Rapid weight loss

B. Alcoholic liver cirrhosis B. Alcoholic liver cirrhosis
C. high-calorie diet C. high-calorie diet
D. oral contraceptive use D. oral contraceptive use

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9th Annual Review in Internal Medicine 12/02/2018

9th Annual Review in Internal Medicine

The procedure of choice for detection of The procedure of choice for detection of
cholelithiases: (C369, p2079, T 369-2) cholelithiases: (C369, p2079, T 369-2)

A. Ultrasound A. Ultrasound
B. Abdominal CT scan B. Abdominal CT scan
C. MRI with MRCP C. MRI with MRCP
D. Radioisotope scans such as HIDA D. Radioisotope scans such as HIDA

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9th Annual Review in Internal Medicine 12/02/2018

Small (<5mm) radiolucent gallstones may be

managed conservatively with UDCA. What is the
recommended dose of UDCA? (C369, p2080)

A. 2-5 mg/kg/day
B. 6-8 mg/kd/day
C. 10-15 mg/kg/day
D. 20-25mg/kg/day

9th Annual Review in Internal Medicine

Small (<5mm) radiolucent gallstones may be Therapeutic Options for
managed conservatively with UDCA. What is the
recommended dose of UDCA? (C369, p2080)
Gallstones
• Surgical Therapy
• Presence of symptoms frequent or severe enough to interfere
A. 2-5 mg/kg/day with general routine
B. 6-8 mg/kd/day • Presence of prior complication of gallstone disease
• Presence of underlying condition predisposing to
C. 10-15 mg/kg/day complication (calcified/porcelain gallbladder, previous attack)
D. 20-25mg/kg/day • Medical Therapy
• Functioning gallbladder and radiolucent stones < 10 mm in
diameter (for good results, offer therapy to those with stones
< 5mm in diameter)
• Complete dissolution in 50% within 6 months to 2 years
• UDCA 10-15 mg/kg/day

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9th Annual Review in Internal Medicine 12/02/2018

Which of the following is NOT part of the triad of Which of the following is NOT part of the triad of
symptoms highly suggestive of acute cholecystitis? symptoms highly suggestive of acute cholecystitis?
(C369, p2080) (C369, p2080)

A. Fever A. Fever
B. RUQ tenderness B. RUQ tenderness
C. Leukocytosis C. Leukocytosis Ranges from 10,000-15,000
D. Jaundice D. Jaundice

9th Annual Review in Internal Medicine

In assessing patients with possible chronic In assessing patients with possible chronic
pancreatitis, what is the initial diagnostic imaging of pancreatitis, what is the initial diagnostic imaging of
choice? (C370, p2088, Fig 370-1) choice? (C370, p2088, Fig 370-1)
Order of imaging
A. CT scan A. CT scan modalities in chronic
pancreatitis
B. MRI with MRCP B. MRI with MRCP 1. CT Scan
C. ERCP C. ERCP 2. MRI/MRCP
3. EUS
D. Endoscopic ultrasound D. Endoscopic ultrasound
4. Pancreas Function
Test
5. ERCP

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9th Annual Review in Internal Medicine 12/02/2018

Which is the cornerstone of management of Which is the cornerstone of management of

alcoholic liver disease? (C307, p2591) alcoholic liver disease? (C307, p2591)

A. Glucocorticoids A. Glucocorticoids
B. Pentoxifylline B. Pentoxifylline
C. Abstinence C. Abstinence
D. Nutritional support D. Nutritional support

9th Annual Review in Internal Medicine

The gold standard for establishing the diagnosis of The gold standard for establishing the diagnosis of
acute mesenteric arterial occlusion is: (C354, p1980) acute mesenteric arterial occlusion is: (C354, p1980)

A. Laparotomy A. Laparotomy
B. CT angiography B. CT angiography
C. Duplex ultrasound C. Duplex ultrasound
D. MR angiography (MRA) D. MR angiography (MRA)

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9th Annual Review in Internal Medicine 12/02/2018

Portal hypertension is a significant complication of Portal hypertension is a significant complication of

decompensated cirrhosis and is responsible for the decompensated cirrhosis and is responsible for the
development of which complications? (C365, p2058) development of which complications? (C365, p2058)

A. Thrombocytopenia and jaundice A. Thrombocytopenia and jaundice

B. Varices and ascites B. Varices and ascites
C. Coagulation disorders and encephalopathy C. Coagulation disorders and encephalopathy
D. Hypoalbuminemia and osteopenia D. Hypoalbuminemia and osteopenia
Portal hypertension – responsible for development of ascites and
bleeding from esophageal varices

Loss of hepatocellular function results in jaundice, coagulation

disorders, and hypoalbuminemia.

9th Annual Review in Internal Medicine

Which patient with UGIB would benefit from Which patient with UGIB would benefit from
prophylactic antibiotics? (C51, p278) prophylactic antibiotics? (C51, p278)

A. A 45 year old cirrhotic admitted for hematemesis
B. A 60 year old male who underwent epinephrine
injection and hemoclipping for a Forrest IIA ulcer
C. A 70 year old female in the Neurology ICU who
was referred for coffee-ground output per NGT
D. A 22 year old male admitted for bloody vomiting
after a binge
A. A 45 year old cirrhotic admitted for
hematemesis Antibiotics decrease bacterial infections,
rebleeding, and mortality in cirrhotic
patients.
B. A 60 year old male who underwent epinephrine
injection and hemoclipping for a Forrest IIA ulcer
C. A 70 year old female in the Neurology ICU who
was referred for coffee-ground output per NGT
D. A 22 year old male admitted for bloody vomiting
after a binge

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9th Annual Review in Internal Medicine 12/02/2018

Which of the following is NOT a complication of Which of the following is NOT a complication of
chronic Gastroesophageal Reflux Disease? (C347, chronic Gastroesophageal Reflux Disease? (C347,
p1907) p1907)

A. Barrett’s esophagus A. Barrett’s esophagus

B. Erosive esophagitis B. Erosive esophagitis
C. Esophageal squamous cell carcinoma C. Esophageal squamous cell carcinoma
D. Esophageal adenocarcinoma D. Esophageal adenocarcinoma
Complications are related to chronic esophagitis.

Esophagits
Strictures
Barrett’s metaplasia  adenocarcinoma

9th Annual Review in Internal Medicine

Which is a mainstay of therapy for mild to moderate Which is a mainstay of therapy for mild to moderate
UC? (C351, p1959) UC? (C351, p1959)

A. Prednisone A. Prednisone
B. Sulfasalazine B. Sulfasalazine
C. Metronidazole C. Metronidazole
D. Methotrexate D. Methotrexate

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9th Annual Review in Internal Medicine
Which patient fulfills an indication for surgery in
Crohn’s disease? (C351, p1963, T 351-8)
A. A 35 year old male with obstipation and
abdominal distension for the past 3 days
B. A 30 year old female newly diagnosed with CD
with a significant perineal involvement about to start
medications
C. A 40 year old female with blood-streaked stools
for the 4 months
D. A 22 year old male with severe weight loss and
diarrhea
9th Annual Review in Internal Medicine
This handout may not be reproduced without permission.
12/02/2018
Which patient fulfills an indication for surgery in
Crohn’s disease? (C351, p1963, T 351-8)
A. A 35 year old male with obstipation and
abdominal distension for the past 3 days
B. A 30 year old female newly diagnosed with CD
with a significant perineal involvement about to start
medications
C. A 40 year old female with blood-streaked stools
for the 4 months
D. A 22 year old male with severe weight loss and
diarrhea
GASTROENTEROLOGY
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