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 Sleisenger and Fordtran’s

Gastrointestinal
and Liver Disease
REVIEW AND ASSESSMENT

r e v i e w a n d a ss e ss m e n t
This page intentionally left blank
Sleisenger and Fordtran’s Ninth Edition

Gastrointestinal
and Liver Disease
REVIEW AND A S S E S S MENT
9th

Edited by
Anthony J. DiMarino, Jr., MD
William Rorer Professor of Medicine
Chief, Division of Gastroenterology and Hepatology
Thomas Jefferson University and Hospital
Philadelphia, Pennsylvania

Robert M. Coben, MD
Associate Professor of Medicine
Academic Coordinator, GI Fellowship Program
Division of Gastroenterology and Hepatology
Thomas Jefferson University and Hospital
Philadelphia, Pennsylvania

Anthony Infantolino, MD
Associate Professor of Medicine
Director, Endoscopic Ultrasound
Division of Gastroenterology and Hepatology
Thomas Jefferson University and Hospital
Philadelphia, Pennsylvania
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

Sleisenger and Fordtran’s GASTROINTESTINAL AND ISBN: 978-1-437-70730-4

LIVER DISEASE: REVIEW AND ASSESSMENT

Copyright © 2010 by Saunders, an affiliate of Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means,
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Notice

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
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Previous editions copyrighted 2007, 1999, 1996

Library of Congress Cataloging-in-Publication Data

Sleisenger and Fordtran’s gastrointestinal and liver disease review and assessment / [edited by]
Anthony J. DiMarino Jr., Robert Coben, Anthony Infantolino—9th ed.
â•…â•… p. ; cm.
â•… Other title: Gastrointestinal and liver disease
â•… Rev. ed. of: Sleisenger & Fordtran’s gastrointestinal and liver disease / edited by Mark
Feldman, Lawrence S. Friedman, Lawrence J. Brandt. 8th ed. c2006.
â•… Includes bibliographical references and index.
â•… ISBN 978-1-4377-0730-4
â•… 1.╇ Gastrointestinal system—Diseases—Examinations, questions, etc.â•… I.╇ DiMarino, Anthony
J.╅ II.╇ Coben, Robert.╅ III.╇ Infantolino, Anthony.╅ IV.╇ Sleisenger, Marvin H.╅ V.╇ Sleisenger &
Fordtran’s gastrointestinal and liver disease.â•… VI.╇ Title: Gastrointestinal and liver disease.
╅ [DNLM:╅ 1.╇ Gastrointestinal Disease.╅ 2.╇ Liver Diseases.╇ WI 140 S6321 2010]
â•… RC801.G384 2010 Suppl.
â•… 616.3′3—dc22
â•…â•…â•…â•…â•…â•… 2010005185

Acquisitions Editor: Druanne Martin

Developmental Editor: Virginia Wilson
Senior Project Manager: David Saltzberg Working together to grow
Design Direction: Steve Stave
libraries in developing countries
Printed in the United States of America. www.elsevier.com | www.bookaid.org | www.sabre.org

Last digit is the print number: 9â•… 8â•… 7â•… 6â•… 5â•… 4â•… 3â•… 2â•… 1â•…
Dedicated to medical students, residents, fellows, and faculty who have a continuing
quest for new knowledge in the field of gastroenterology and hepatology. Special
appreciation to co-editors Robert Coben and Anthony Infantolino and to the section
leaders—Cuckoo Choudhary, Sidney Cohen, Steven Herrine, David Kastenberg,
Howard Kroop, David Loren, and Satish Rattan—and to our gastroenterology fellows,
who participated in this project and raised many important questions and topics.
Recognition is given to Donna Collins and Patricia Shaughnessy for their invaluable
help in making this book a success.

Anthony J. DiMarino, Jr., MD

This page intentionally left blank
 Contributors
Jeffrey A. Abrams, MD Steven M. Greenfield, MD
Clinical Assistant Professor of Medicine, Division of Gas- Assistant Professor of Medicine, Division of Gastroenterol-
troenterology and Hepatology, Department of Medicine, ogy and Hepatology, Department of Medicine, Thomas
Thomas Jefferson University, Philadelphia, Pennsylvania Jefferson University, Philadelphia, Pennsylvania
Kristin Braun, MD Hie-Won L. Hann, MD
Fellow, Division of Gastroenterology and Hepatology, Professor of Medicine; Director, Liver Disease Prevention
Department of Medicine, Thomas Jefferson University, Center, Division of Gastroenterology and Hepatology,
Philadelphia, Pennsylvania Department of Medicine, Thomas Jefferson University,
Philadelphia, Pennsylvania
Cuckoo Choudhary, MD
Assistant Professor of Medicine, Division of Gastroenterol- Nikroo Hashemi, MD
ogy and Hepatology, Department of Medicine, Thomas Fellow, Advanced Hepatology, Division of Gastroenterol-
Jefferson University, Philadelphia, Pennsylvania ogy and Hepatology, Department of Medicine, Thomas
Jefferson University, Philadelphia, Pennsylvania
Robert M. Coben, MD
Associate Professor of Medicine; Academic Coordinator, Christine M. Herdman, MD
GI Fellowship Program, Division of Gastroenterology Fellow, Division of Gastroenterology and Hepatology,
and Hepatology, Department of Medicine, Thomas Department of Medicine, Thomas Jefferson University,
Jefferson University, Philadelphia, Pennsylvania Philadelphia, Pennsylvania
Sidney Cohen, MD Steven K. Herrine, MD
Professor of Medicine; Director of Research Program, Divi- Professor of Medicine; Associate Director, Fellowship
sion of Gastroenterology and Hepatology, Department Program; Associate Medical Director, Liver Transplant
of Medicine, Thomas Jefferson University, Philadelphia, Program, Division of Gastroenterology and Hepatology,
Pennsylvania Department of Medicine, Thomas Jefferson University;
Assistant Dean, Academic Affairs, Jefferson Medical
Mitchell Conn, MD, MBA College, Philadelphia, Pennsylvania
Associate Professor of Medicine; Medical Director, GI/
Transplant Service Line, Division of Gastroenterology Anthony Infantolino, MD, AGAF, FACG, FACP
and Hepatology, Department of Medicine, Thomas Associate Professor of Medicine; Director, Endoscopic
Jefferson University, Philadelphia, Pennsylvania Ultrasound, Division of Gastroenterology and Hepatol-
ogy, Department of Medicine, Thomas Jefferson Univer-
Anthony J. DiMarino, Jr. MD sity, Philadelphia, Pennsylvania
William Rorer Professor of Medicine; Chief, Division
of Gastroenterology and Hepatology, Division of David Kastenberg, MD, FACP, AGAF
Gastroenterology and Hepatology, Department of Associate Professor of Medicine, Division of Gastroenter-
Medicine, Thomas Jefferson University, Philadelphia, ology and Hepatology, Department of Medicine, Thomas
Pennsylvania Jefferson University, Philadelphia, Pennsylvania
Michael C. DiMarino, MD, MMS Leo C. Katz, MD
Clinical Assistant Professor of Medicine, Division of Assistant Professor of Medicine, Division of Gastroenterol-
Gastroenterology and Hepatology, Department of ogy and Hepatology, Department of Medicine, Thomas
Medicine, Thomas Jefferson University, Philadelphia, Jefferson University, Philadelphia, Pennsylvania
Pennsylvania
Bryan Kavanaugh, MD
Bob Etemad, MD Fellow, Division of Gastroenterology and Hepatology,
Medical Director of Endoscopy, Main Line Gastroen� Department of Medicine, Thomas Jefferson University,
terology Associates PC, Main Line Health System, Philadelphia, Pennsylvania
Wynnewood, Pennsylvania
Thomas Kowalski, MD
Jonathan M. Fenkel, MD Associate Professor of Medicine; Director, Gastrointestinal
Fellow, Division of Gastroenterology and Hepatology, Endoscopy, Division of Gastroenterology and Hepatol-
Department of Medicine, Thomas Jefferson University, ogy, Department of Medicine, Thomas Jefferson Uni�
Philadelphia, Pennsylvania versity, Philadelphia, Pennsylvania
Mara Goldstein-Posner, MD Patricia Kozuch, MD
Fellow, Division of Gastroenterology and Hepatology, Assistant Professor of Medicine, Division of Gastroenterol-
Department of Medicine, Thomas Jefferson University, ogy and Hepatology, Department of Medicine, Thomas
Philadelphia, Pennsylvania Jefferson University, Philadelphia, Pennsylvania

vii
viii Contributors

Howard S. Kroop, MD Susie Rivera, MD

Clinical Associate Professor of Medicine, Division of Gas- GI Motility Coordinator, Division of Gastroenterology and
troenterology and Hepatology, Department of Medicine, Hepatology, Department of Medicine, Thomas Jefferson
Thomas Jefferson University, Philadelphia, Pennsylva- University, Philadelphia, Pennsylvania
nia; Chief, Division of Gastroenterology, Department of
Medicine, Underwood Memorial Hospital, Woodbury, Jason N. Rogart, MD
New Jersey Fellow, Advanced Endoscopy, Division of Gastroenterol-
ogy and Hepatology, Department of Medicine, Thomas
David Loren, MD Jefferson University, Philadelphia, Pennsylvania
Assistant Professor of Medicine; Director of Endoscopic
Research, Division of Gastroenterology and Hepatology, Simona Rossi, MD
Department of Medicine, Thomas Jefferson University, Assistant Professor of Medicine, Division of Gastroenterol-
Philadelphia, Pennsylvania ogy and Hepatology, Department of Medicine, Thomas
Jefferson University, Philadelphia, Pennsylvania
Aarati Malliah, MD
Fellow, Division of Gastroenterology and Hepatology, Emily Rubin, RD, BS
Department of Medicine, Thomas Jefferson University, Clinical Dietician, Division of Gastroenterology and
Philadelphia, Pennsylvania Hepatology, Department of Medicine, Thomas Jefferson
University, Philadelphia, Pennsylvania
Victor J. Navarro, MD
Professor of Medicine, Pharmacology and Experimental Ivan Rudolph, MD
Therapeutics; Medical Director, Liver Transplantation, Clinical Assistant Professor of Medicine; Director, Gastro-
Division of Gastroenterology and Hepatology, Depart- enterology Clinic, Division of Gastroenterology and
ment of Medicine, Thomas Jefferson University, Phila- Hepatology, Department of Medicine, Thomas Jefferson
delphia, Pennsylvania University, Philadelphia, Pennsylvania

Nicholas T. Orfanidis, MD Bridget Jennings Seymour, MD

Fellow, Division of Gastroenterology and Hepatology, Fellow, Division of Gastroenterology and Hepatology,
Department of Medicine, Thomas Jefferson University, Department of Medicine, Thomas Jefferson University,
Philadelphia, Pennsylvania Philadelphia, Pennsylvania; Gastroenterologist/Hepa-
tologist, Department of Medicine, Merrimack Valley
Jorge A. Prieto, MD Hospital, Haverhill, Massachusetts; Gastroenterologist/
Clinical Assistant Professor of Medicine, Division of Gas- Hepatologist, Department of Medicine, Anna Jaques
troenterology and Hepatology, Department of Medicine, Hospital, Newburyport, Massachusetts
Thomas Jefferson University, Philadelphia, Pennsylvania
Maya Spodik, MD
Satish Rattan, DVM Fellow, Division of Gastroenterology and Hepatology,
Professor of Medicine; Director of Basic Research, Divi- Department of Medicine, Thomas Jefferson University,
sion of Gastroenterology and Hepatology, Department of Philadelphia, Pennsylvania
Medicine, Thomas Jefferson University, Philadelphia,
Pennsylvania
Marianne Ritchie, MD
Assistant Professor of Medicine, Division of Gastroenterol-
ogy and Hepatology, Department of Medicine, Thomas
Jefferson University, Philadelphia, Pennsylvania
 Preface
The Division of Gastroenterology and Hepatology at Jefferson Medical College and Thomas Jefferson University Hospital
is honored to once again be given the opportunity to prepare this self-assessment text that accompanies the ninth edition
of Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. We are pleased to have worked with Mark Feldman,
MD; Lawrence S. Friedman, MD; Lawrence J. Brandt, MD; and the publisher, Elsevier Inc., to update the self-assessment
companion text.
We hope that the readers will find the questions stimulating. We are happy to receive questions, comments, or
critiques related to the content and hope that this text contributes to the lifelong commitment of obtaining new
knowledge that improves the care of patients with gastrointestinal and liver disease.

ix
This page intentionally left blank
 Contents
CHAPTER 1 CHAPTER 8
Biology of the Gastrointestinal Tract and Liver 151
Liver Disease 1 Steven K. Herrine, Jonathan M. Fenkel,
Satish Rattan and Christine M. Herdman Hie-Won L. Hann, Nikroo Hashemi,
Questions 1 Victor J. Navarro, and Simona Rossi
Answers 4 Questions 151
Answers 167
CHAPTER 2
Nutrition in Gastroenterology 9 CHAPTER 9
David Kastenberg, Leo C. Katz, Emily Rubin, Small and Large Intestine 199
and Maya Spodik Anthony Infantolino, Jeffrey A. Abrams,
Questions 9 Mitchell Conn, Michael C. DiMarino,
Answers 12 Steven M. Greenfield, Patricia Kozuch, and
Nicholas T. Orfanidis
CHAPTER 3 Questions 199
Topics Involving Multiple Organs 19 Answers 236
Cuckoo Choudhary, Aarati Malliah, Marianne Ritchie,
Ivan Rudolph, and Bridget Jennings Seymour CHAPTER 10
Questions 19 Palliative, Complementary, and Alternative
Answers 43 Medicine 306
David Kastenberg, Leo C. Katz, Emily Rubin,
CHAPTER 4 and Maya Spokik
Esophagus 66 Questions 306
Sidney Cohen, Anthony J. DiMarino, Jr., Answers 307
Mara Goldstein-Posner, Christine M. Herdman,
and Susie Rivera Illustration Credits 309
Questions 66
Answers 74

CHAPTER 5
Stomach and Duodenum
Howard S. Kroop, Kristin Braun, Robert M. Coben,
and Jorge A. Prieto
81
Video Contents
Questions 81
Answers 89 Videos available at www.expertconsult.com
CHAPTER 6 Ascaris lumbricoides in the colon
Pancreas 98
David Loren, Bob Etemad, Bryan Kavanaugh, Clonorchis sinensis exiting the ampulla during
Thomas Kowalski, and Jason N. Rogart endoscopic retrograde cholangiopancreatography
Questions 98
Answers 113 Enterobius vermicularis in the colon
CHAPTER 7 Taenia saginata seen on video capsule endoscopy
Biliary Tract 126 Taenia solium seen on colonoscopy
David Loren, Bob Etemad, Bryan Kavanaugh,
Thomas Kowalski, and Jason N. Rogart All videos correspond to chapter 110—“Intestinal
Questions 126 Worms”—from Sleisenger and Fordtran’s Gastrointestinal
Answers 140 and Liver Disease, 9e.

xi
This page intentionally left blank
CHAPTER

1â•…
Biology of the Gastrointestinal
Tract and Liver Disease

Questions 5 The Wnt pathway is important in which of the fol-

lowing processes?
A. Programmed cell death (apoptosis)
1 Several pathways play a role in gastrointestinal
B. Senescence
(GI) tumors. Recently this pathway has been recog-
C. Intestinal epithelial cell (IEC) proliferation
nized as a key regulator in prostaglandin synthesis
D. Pancreatic acinar cell proliferation
that is induced in inflammation and neoplasia. No
mutations have been identified, but inhibition 6 Adrenergic neurons originate in ganglia of the auto-
with aspirin and nonsteroidal anti-inflammatory nomic nervous system and synapse with enteric
drugs is associated with reduced risk of colorectal neurons. Adrenergic neurons only contain which
adenoma and cancer. What is the pathway? of the following?
A. Cyclooxygenase-2 (COX-2) A. Norepinephrine
B. Nuclear factor-κB B. Acetylcholine
C. P13K/Akt C. Neuropeptide Y and somatostatin
D. RAF D. A and C
2 What is the major function of glucagon and gluca- 7 Which of the following neuromodulators has the
gon-like peptide? following characteristics: a potent vasodilator that
A. As a neurotransmitter increases blood flow in the GI tract and causes
B. Mediator of satiety and food intake smooth muscle relaxation and epithelial cell secre-
C. To produce pancreatic fluid and pancreatic tion; is expressed primarily in neurons of the
secretion peripheral/enteric and central nervous systems;
D. To regulate glucose homeostasis has effects on many organ systems, although in
the GI tract stimulates fluid and electrolyte secre-
3 Which of the following is the most populous cell tion from intestinal epithelium and bile duct chol-
of the lamina propria mononuclear cells? angiocytes; causes relaxation of gastric smooth
A. Macrophages muscle and therefore is an important modulator of
B. Dendritic cells sphincters in the GI tract?
C. Immunoglobulin A–positive (IgA+) plasma A. Acetylcholine
cells B. Somatostatin
D. Tumor necrosis factor (TNF)–secreting T cells C. CCK
D. Gastrin
4 During a meal, nutrients interact with cells in the E. Vasoactive intestinal polypeptide
mouth and GI tract to regulate hunger and satiety.
Which of the following does not play a major role 8 T cell differentiation is influenced by the microen-
in this complex interaction? vironment of the gut. This will influence develop-
A. Cholecystokinin (CCK) ment of cells and promotion of cytokines, thereby
B. Glucagon-like peptide 1 promoting or suppressing inflammation. Which of
C. Ghrelin the following cytokines play a role in IgA secretion?
D. Leptin A. Interleukin (IL)-12
E. Lipase B. IL-4

1
2 Biology of the Gastrointestinal Tract and Liver Disease

C. IL-5 C. Large potentially antigenic macromolecules are

D. IL-6 degraded so that potentially immunogenic
E. A and B substances are rendered nonimmunogenic.
F. C and D D. Th3 cells that are activated in Peyer patches

9 CCK and somatostatin are both hormones that are 16 Patients who have celiac disease may have a disrup-
released in the GI tract. They may work as which tion in their oral tolerance. Which of the following
of the following? does not affect the induction of oral tolerance?
A. Endocrine agent A. Genetic factors
B. Paracrine agent B. Nature of the antigen
C. Neurocrine agent C. Ethnicity
D. All of the above D. Age
E. Tolerogen dose
10 The analog of which one of the following is used
to treat conditions of hormone excess produced by 17 Point mutations in this gene have been identified
endocrine tumors (including acromegaly, carcinoid in esophageal squamous carcinoma and adeno-
tumors, islet tumors, and gastrinomas)? carcinoma, gastric carcinoma, pancreatic adeno-
A. Somatostatin carcinoma, hepatocellular carcinoma, and sporadic
B. Gastrin colon cancers. Interestingly, mutations are rarely
C. CCK identified in colonic adenomas. What is the gene?
D. Secretin A. SMAD4
B. TP53
11 Which of the following genes is deleted or mutated C. APC
in pancreatic adenocarcinoma? D. MLH1
A. TP53
B. SMAD4 18 The gut is the largest lymphoid organ in the body.
C. APC It contains billions of organisms. Significant inflam-
D. MLH1 mation is not present in the intestine. What is this
phenomenon known as?
12 What is the phenomenon known as epithelial mes- A. Oral tolerance
enchymal transition? B. The intestinal barrier
A. Polarized epithelial cells no longer recognize C. Relative chemotaxis
boundaries of adjacent epithelial cells and D. Controlled/physiologic inflammation
adopt features of migratory mesenchymal cells.
B. Degradation of the basement membrane fol� 19 This gene is found on chromosome 5q and is associ-
lowed by migration into perivascular stroma ated with Gardner’s syndrome. Both somatic and
and creating capillary sprout germline mutations appear in this gene and contrib-
C. Clonal expansion after formation of a meta� ute to the development of polyps.
static focus A. TP53
D. Genetic pathway used to modulate Wnt B. Multiple endocrine neoplasia (MEN1)
pathway C. E-cadherin1 (CDH1)
D. Adenomatous polyposis coli (APC)
13 Obesity has become an epidemic in the United
States. Much research has been targeted to identify 20 All GI peptides are synthesized via gene transcrip-
the mediators of satiety. Which one of the following tion of DNA into messenger RNA and subsequent
may be the major mediator of satiety and food intake? translation of messenger RNA into precursor pro-
A. Somatostatin teins known as preprohormones. The peptides that
B. Acetylcholine are destined to be secreted begin as proteins that
C. Gastrin are cleaved and the prepropeptide is then prepared
D. CCK for structural modifications. Modifications of the
peptide hormone for the full biological activity
14 The nature and form of the antigen play a large role in occur in which organelle of the cell?
oral tolerance. Which of the following represents an A. Mitochondria
antigen that is most effective at inducing tolerance? B. Golgi apparatus
A. Large amount of soluble carbohydrate C. Endoplasmic reticulum
B. Large amount of aggregate lipids D. Cytoplasm
C. Moderate amount of soluble protein
D. Moderate amount of aggregate protein 21 Which antibody is most abundant in mucosal
secretions?
15 Which of the following statements describes the A. IgA
major contributing mechanism behind the con- B. IgM
trolled inflammation in the gut? C. IgG
A. Lamina propria lymphocytes respond poorly D. IgE
when activated via their T cell receptor, failing
to proliferate and providing a state of activa� 22 This test can be performed on archived colon
tion without expansion. tumor tissue and can be helpful in identifying those
B. Antigen-specific nonresponse to antigens individuals with colon cancer in the setting of
administrated orally hereditary nonpolyposis colorectal cancer.
 Biology of the Gastrointestinal Tract and Liver Disease 3

A. Stool DNA for TP53 B. Activation of nuclear factor-κB by IL-18

B. Germline DNA analysis for PTEN C. Ability of intraepithelial lymphocytes to
C. Microsatellite instability testing secrete cytokines such as IL-7
D. Direct DNA sequencing D. All of the above

23 Which of the following seems to be overexpressed 30 Ras genes are the most commonly detected onco-
in patients with inflammatory bowel disease and genes in the GI tract cancers. The highest frequency
may contribute to activate T lymphocytes? of mutation (90%) is found in which of the follow-
A. Major histocompatibility complex class II ing tumors?
molecules A. Colon cancer
B. Toll-like receptors B. Exocrine pancreas
C. Peroxisome proliferator activated receptor-γ C. Gastric cancer
D. All of the above D. Colon adenoma

24 All of the following are tumor suppressor genes 31 Chemokines are secreted by IECs and they aid
except: in the regulation of inflammation. Chemokines
A. APC attract which of the following cells to sites of
B. TP53 interest?
C. SMAD4 A. Lymphocytes
D. C-Myc B. Macrophages
C. Dendritic cells
25 IECs are derived from the basal crypts and have many D. A and B
roles. Which of the following is not a role of the IECs? E. All of the above
A. Antigen trafficking
B. Secretion of cytokines and chemokines to con� 32 What modulator is released from the extrinsic and
trol the spread of infection once a pathogen has intrinsic nerves and from the mucosal enterochro-
been recognized mophin cells of the gut? It is important in epithe-
C. Binding of antigens and then transporting to lial secretion, bowel motility, nausea, and emesis.
Peyer patches Identification of this hormone-specific receptor
D. Expression of Toll-like receptors subtype has led to the development of selective
E. IECs play a role in all of the above. agonists and antagonists for the treatment of irri-
table bowel syndrome and chronic constipation
26 Which of the following characteristics is not associ- and diarrhea.
ated with inherited GI cancer syndromes? A. Norepinephrine
A. Individuals are at risk of tumors outside the GI B. Acetylcholine
tract. C. Serotonin
B. Tumors carry a higher mortality. D. Histamine
C. Multiple primary tumors develop within the
target tissue. 33 Two pathways trigger cell apoptosis. One is
D. Tumors in affected individuals typically mediated by activation of TP53 and the other is
appear at a younger age. mediated through death receptors. Which of the
E. Tumor often develops in the absence of predis� following is not a death receptor?
posing environmental factors. A. TNF receptor
B. DR5
27 The PP/PYY/NPY (pancreatic polypeptide/peptide C. Fas
tyrosine tyrosine/neuropeptide Y) family of pep- D. Caspase receptor
tides function as which type of transmitter?
A. Endocrine 34 In animal models, deletion of which of the follow-
B. Paracrine ing leads to colitis?
C. Neurocrine A. TNF
D. All of the above B. IL-6
E. None of the above C. IL-10
D. Transforming growth factor-β
28 Environmental factors play a role in tumorigenesis. E. A and B
Dietary and viral agents play a role in tumor. Which F. C and D
of the following viruses has been linked to gastric
lymphoepithelial malignancies? 35 Polio vaccine is one of the few orally administered
A. Human papillomavirus vaccines that induces active immunity in the gut.
B. Hepatitis B virus Which of the following may contribute to why this
C. Cytomegalovirus oral vaccine provides immunity?
D. Epstein-Barr virus A. The virus binds to IECs.
B. The virus binds to microfold cells (M cells).
29 The lamina propria mononuclear cells and lamina C. Disrupts tight junctions allowing antigen to
propria lymphocytes (LPLs) are involved in several pass into paracellular space
pathways. Which pathway may be defective in D. Activation of regulatory T cells
Crohn’s disease?
A. Resistance of the LPLs to undergo apoptosis 36 True or false: Somatic mutations lead to the expres-
when activated inappropriately sion of a gene in all cells within a tissue.
4 Biology of the Gastrointestinal Tract and Liver Disease

A. True A. Ulcerative colitis

B. False B. Crohn’s disease
C. Celiac disease
37 All of the following are gene mutations that can D. Carcinoid
lead to colon cancer and can be tested for by immu-
nohistochemistry except: 41 Which of the following is the principal regulator
A. MSH2 of cell cycle progression or movement from
B. MLH1 G2 to M phase and G1 to S phase in the cell
C. MYH cycle?
D. LKB1 A. Cyclin
B. Retinoblastoma protein
38 Pain pathways within the GI tract are complex. C. P21
Which of the following participate in pain path- D. Cyclin dependent kinase
ways and modulate inflammation? E. All of the above
A. Substance P F. A and D
B. Calcitonin gene–related peptide
C. Acetylcholine 42 A genetically unstable environment contributes to
D. None of the above the development of cancer. Microsatellite instabil-
E. All of the above (A, B, C) ity involves which of the following?
A. Frequent alterations in smaller tracts of
39 The primary origin of TNF is in the following cell microsatellite DNA
types: B. Aneuploidy
A. Macrophages, Th1, dendritic, endothelial C. Chromosomal deletions
B. Macrophages only D. Chromosomal duplication
C. Th2
D. Epithelial 43 All of the following are oncogenes except:
A. K-ras
40 Nuclear oligomerization domain 2 (NOD2)/CARD15 B. C-Src
polymorphisms are associated with which of the C. β-Catenin
following? D. P53

hormone to have arexigenic effects. Lipase is an

Answers enzyme released from the pancreas and does not
seem to regulate hunger and satiety.
1 A (S&F, ch3)
The COX-2 pathway plays an important role in GI 5 C (S&F, ch3)
tumors. The enzyme COX-2 is a key regulator of The Wnt pathway is one important example of a
prostaglandin synthesis that is induced in inflam- signaling pathway that regulates the cell cycle
mation and neoplasia. Although no mutations machinery to control the proliferation of IECs (see
of COX-2 have been described, overexpression of figure).
COX-2 in colon adenomas and cancers is associated
with tumor progression and angiogenesis, primarily
6 D (S&F, ch1)
through the induction of synthesis of prostaglandin
A single type of neuron contains and releases dif-
E2. Inhibition of COX-2 with a variety of agents
ferent chemical substances (e.g., adrenergic neurons
(aspirin, nonsteroidal anti-inflammatory drugs, and of the enteric nervous system contain not only nor-
COX-2 selective inhibitors) is associated with a epinephrine but also neuropeptide Y and soma-
reduced risk of colorectal adenomas and cancer. tostatin to modulate the smooth muscle intestinal
contraction or secretion).
2 D (S&F, ch1)
Glucagon and glucagon-like peptides are synthe-
sized and released from the cells of the pancreas, 7 E (S&F, ch1)
ileum, and colon and are not neurotransmitters. Vasoactive intestinal peptide has broad signifi-
cance in the GI tract, which is represented by the
3 C (S&F, ch2) listed characteristics.
Lamina propria mononuclear cells are a heteroge-
neous group of cells. The most populous cell type 8 F (S&F, ch2)
is the IgA+ plasma cell, but there are more than 50% IL-5 induces B cells expressing surface IgA to dif-
T and B cells, macrophages, and dendritic cells. ferentiate into IgA-producing plasma cells. IL-6
causes an increase in IgA secretion with little effect
4 E (S&F, ch1) on either IgM or IgG synthesis.
CCK is one of the most studied satiety hormones.
CCK reduces food intake in animals. Glucagon- 9 D (S&F, ch1)
like peptide 1 is produced by the ileum and the CCK and somatostatin are typical examples of
colon. Glucagon-like peptide 1 receptors are found chemical substances that can be released as hor-
in parts of the brain that are important in the regula- mones by the endocrine cells and transported to the
tion of hunger. Leptin is considered a long-term target cells. In addition, these substances may also
regulator of energy balance. Ghrelin is the only GI be released by the nearby cells and quickly act on
 Biology of the Gastrointestinal Tract and Liver Disease 5

Wnt

Frz
β-catenin Frz

DSH
-P
GSK-3β
GSK-3β
Figure for answer 5 Axin
β-catenin Axin
β-catenin APC
APC β-catenin

P β-catenin
β-catenin
+
c-Myc
cyclin D1
β-catenin TCF-4 VEGF

Nucleus
Degradation

the neighboring cells and also be released as neu- 13 D (S&F, ch1)

rotransmitters. Somatostatin is a classic paracrine CCK has a major role in gallbladder contraction. It
hormone, but, depending on where in the GI tract stimulates pancreatic secretion and has been shown
it is released, it can exert endocrine and neural to delay gastric emptying. Low levels of CCK have
effects. been noted in individuals with celiac disease and
bulimia nervosa.
10 A (S&F, ch1)
Because of its varied physiologic effects, somatosta- 14 C (S&F, ch2)
tin has several clinically important pharmacologic Protein antigens are the most tolerogenic, whereas
uses. Many endocrine cells possess somatostatin carbohydrates and lipids are less effective at induc-
receptors and are sensitive to inhibitory regulation. ing tolerance. The way in which the antigen is
Therefore, somatostatin and its analogs are used to delivered is also critical. For example, a protein
treat conditions of hormone excess produced by delivered in soluble form is quite tolerogenic,
endocrine tumors, including acromegaly, carcinoid whereas aggregation of this protein reduces its
tumors, and islet cell tumors. Its ability to reduce potential to induce tolerance. The dose of antigen
splanchnic blood flow and portal venous pressure administered is critical to the form of oral tolerance
led to somatostatin analogs being useful in treating generated; too little or too much is often not the
esophageal variceal bleeding. The inhibitory effects correct dose to induce tolerance.
on secretion have been exploited by using soma-
tostatin analogs to treat some forms of diarrhea and 15 A (S&F, ch2)
reduce fluid output from pancreatic fistulas. Many The failure to produce GI pathology despite the
endocrine tumors express abundant somatostatin activation state of intestinal lymphocytes is prob-
receptors, making it possible to use radiolabeled ably the consequence of regulatory mechanisms.
somatostatin analogs, such as octreotide, to localize The failure of LPLs to generate “normal” antigen
even small tumors throughout the body. receptor-mediated responses is an important factor
in controlled inflammation. LPLs respond poorly
11 B (S&F, ch3) when activated via their T cell receptor, failing to
SMAD4, also designated the deleted in pancreas proliferate, although they still can produce cyto-
cancer 4 gene, is a tumor suppressor gene located kines. This is key to the maintenance of controlled
on chromosome 18q and is deleted or mutated in inflammation. Answers B and C describe the
most pancreatic adenocarcinomas and a subset of concept behind oral tolerance, in which Th3 cells
colon cancers. are thought to play a role.

12 A (S&F, ch3) 16 C (S&F, ch2)

Epithelial mesenchymal transition may be what Factors affecting the induction of oral tolerance are
promotes tumor progression. Clonal expansion the age of the host, genetic factors, the nature of
after metastasis is a “survival of the fittest” model antigen, and the tolerogen’s form and dose. The
in which the metastatic focus proliferates. The Wnt state of the intestinal barrier affects oral tolerance,
pathway is an example of a signaling pathway that and when barrier function is reduced, oral tolerance
regulates the cell cycle machinery to control the decreases as well. Oral tolerance is difficult to
proliferation of IECs. achieve in the neonate, but early on, the intestinal
6 Biology of the Gastrointestinal Tract and Liver Disease

flora and the limited diet likely play a beneficial role 24 D (S&F, ch3)
in preventing a vigorous response to food antigen. The c-Myc protein product is involved in critical
cellular functions such as proliferation, differentia-
17 B (S&F, ch3) tion, apoptosis, transformation, and transcriptional
TP53 is the gene responsible for the p53 protein. activation of key genes. Frequently, c-Myc is over-
The p53 protein was detected in tumors as the expressed in many GI cancers.
product of a mutated gene that was mapped to
chromosome 17p. Point mutations in TP53 have 25 C (S&F, ch2)
been identified in 50% to 70% of sporadic colon Microfold cells bind antigens and transport them to
cancers but only a small subset of colon adenomas. Peyer patches. In addition to their function as a
Mutations in TP53 have also been found in esopha- physical barrier in the gut-associated lymphoid
geal squamous carcinoma and adenocarcinoma, tissue, IECs contribute to both innate and adaptive
gastric carcinoma, pancreatic adenocarcinoma, and immunity in the gut and may play a key role in
hepatocellular carcinoma. maintaining intestinal homeostasis. Classic anti-
gen-presenting cells in the systemic immune system
18 D (S&F, ch2) possess the innate capacity to recognize compo-
nents of bacteria and viruses called pathogen-
19 D (S&F, ch3) associated molecular patterns. Receptors for
Genetic linkage analysis revealed markers on chro- these pathogen-associated molecular patterns are
mosome 5q21 that were tightly linked to polyp expressed both on the cell surface (e.g., Toll-like
development in affected members of kindreds with receptors) and inside the cell. After invasion and
familial adenomatous polyposis and Gardner’s syn- engagement of Toll-like receptor 5, the IECs are
drome. The gene responsible for familial adenoma- induced to secrete cytokines and chemokines that
tous polyposis is the adenomatous polyposis coli attract inflammatory cells to the local environment
(APC) gene. to control spread of infection.

20 B (S&F, ch1) 26 B (S&F, ch3)

For most of the peptides, including CCK, the final Despite the variation in the type of tumor found
modification of the molecule (e.g., sulfation) occurs in different inherited cancer syndromes, a number
in the Golgi apparatus. The endoplasmic reticulum of features are common to all inherited GI cancer
plays a critical role in the formation of the peptide; syndromes. Most importantly, the marked increase
however, further modification occurs in the Golgi in risk of a particular tumor is found in the
apparatus. absence of other predisposing environmental
factors. Multiple primary tumors often develop
21 A (S&F, ch2) within the target tissue, and tumors in these
Secretory IgA is the hallmark of mucosa-associated affected members typically arise at a younger
lymphoid tissue/gut-associated lymphoid tissue age. Finally, affected individuals are sometimes
immune responses. Although IgG is the most abun- at risk of some types of tumors outside the
dant isotype in the systemic immune system, IgA GI tract.
is the most abundant antibody in mucosal secre-
tions. In fact, given the numbers of IgA+ plasma 27 D (S&F, ch1)
cells and the size of the mucosa-associated lym- PP is the founding member of the PP family. The
phoid tissue, IgA turns out to be the most abundant PP family of peptides includes NPY and PYY. PP
antibody in the body. is stored and secreted from specialized pancreatic
endocrine cells (PP cells), whereas NPY is a prin-
22 C (S&F, ch3) cipal neurotransmitter found in the central and
The microsatellite instability test can be performed peripheral nervous systems. PYY has been local-
on archived colon tumor samples and serves as a ized to enteroendocrine cells throughout the GI
useful screening test to identify individuals whose tract but is found in greatest concentrations in the
colon cancers may have developed as a manifesta- ileum and colon. The PP/PYY/NPY family of pep-
tion of Lynch syndrome. Loss of hMSH (human tides functions as endocrine, paracrine, and neu-
Mut S homolog) 2, hMLH1, or hMSH6 protein by rocrine transmitters in the regulation of a number
immunohistochemical staining may provide similar of actions. PP inhibits pancreatic exocrine secre-
information. Emerging data suggest that the micro- tion, gallbladder contraction, and gut motility.
satellite instability status of a colon tumor may be PYY inhibits vagally stimulated gastric acid secre-
predictive of the response to 5-fluorouracil–based tion. NPY is one of the most abundant peptides in
chemotherapy. the central nervous system and, in contrast to
PYY, is a potent stimulant of food intake. Peripher-
23 A (S&F, ch2) ally, NPY affects vascular and GI smooth muscle
Increased expression of major histocompatibility function.
complex class II molecules by IECs has been
reported in patients with irritable bowel disease. 28 D (S&F, ch3)
Such overexpression would be expected to increase Viral agents can lead to disruption of normal genes
their potential to activate T lymphocytes. Drugs by entry into the host genome, which may disrupt
used to treat patients with irritable bowel disease the normal gene sequence. HPV has been linked to
such as 5-aminosalicylic acid preparations may squamous cell cancers of the esophagus and anus.
reduce major histocompatibility complex class II Hepatitis B virus has been linked to hepatocellular
expression on IECs. carcinoma.
 Biology of the Gastrointestinal Tract and Liver Disease 7

29 A (S&F, ch2) increase in the bax-to-bcl-2 ratio. Both pathways

LPLs are more prone to undergo apoptosis com- converge to disrupt mitochondrial integrity and
pared with their peripheral counterparts. This may release of cytochrome c.
be a regulatory mechanism limiting the potentially
inflammatory effects of activated lymphocytes. A 34 F (S&F, ch2)
major defect reported in Crohn’s disease is the TNF and IL-6 are considered to be proinflamma-
resistance of LPLs to undergo apoptosis when acti- tory, while IL-10 and transforming growth factor-β
vated inappropriately. The mechanism underlying are anti-inflammatory.
this apoptotic phenomenon possibly relates to
engagement of the death receptor Fas and its ligand 35 B (S&F, ch2)
on activated LPLs and by the imbalance between Oral tolerance may also be associated with the
the intracellular anti-apoptotic and proapoptotic cells serving as the antigen-presenting cells as well
factors Bcl2 and Bax. Defects in this proapoptotic as the site of antigen uptake. Poliovirus binds to
balance have been reported in patients with Crohn’s M cells, which may account for its ability to stimu-
disease. late active immunity in the gut. The evidence of
this comes from studies in mice. Orally adminis-
30 B (S&F, ch3) tered reovirus type 3 is taken up in mice by M
Virtually all ras mutations in GI malignancies that cells expressing reovirus type 3–specific receptors.
have been identified occur in the K-ras oncogene. This epithelial uptake by M cells induces an active
The highest frequency is found in tumors of the IgA response to the virus. Reovirus type 1 infects
exocrine pancreas; more than 90% of these tumors IECs adjacent to M cells, and this uptake induces
possess mutations in the K-ras gene. Ras genes have tolerance to the virus. Thus, the route of entry
been identified in approximately 50% of colonic (M cell vs. IEC) of a specific antigen may dictate
cancers as well as large benign colon polyps. Less the type of immune response generated (IgA vs.
than 10% of colon adenomas smaller than 1 cm tolerance).
have K-ras mutations.
36 B (S&F, ch3)
31 E (S&F, ch2) Whereas germline mutations may lead to altered
Many of the chemokines secreted in the gut-associ- expression of a gene in all cells within a tissue,
ated lymphoid tissue are produced by IECs. This is subsequent additional somatic mutations generally
especially true in inflammatory bowel diseases in occur only in a small, largely random subpopula-
which the secretion of IEC-derived chemokines and tion of cells.
cytokines is increased, contributing to the augmen-
tation of mucosal inflammation. The chemokines 37 D (S&F, ch3)
have the capacity to attract inflammatory cells, such Immunohistochemistry can determine the presence
as lymphocytes, macrophages, and dendritic cells. or absence of a gene product in a tissue sample.
Gene LKB1 is detected in Peutz-Jeghers syndrome.
32 C (S&F, ch1) Loss of MSH2, MYH, and MLH1 protein can be
The GI tract contains more than 95% of the total detected by immunohistochemical staining.
body serotonin, and serotonin is important in a
variety of processes, including epithelial secretion, 38 E (S&F, ch1)
bowel motility, nausea, and emesis. Serotonin is Bipolar neurons that project to the mucosa and
synthesized from tryptophan and is converted to myenteric plexus act as sensory neurons and
its active form in nerve terminals. Most plasma contain the hormones listed.
serotonin is derived from the gut, where it is found
in mucosal enterochromaffin cells and the enteric 39 A (S&F, ch2)
nervous system. Serotonin mediates its effects by TNF is a cytokine that has its primary origin in
binding to a specific receptor. There are seven dif- macrophages, T cells, dendritic cells, and mesen-
ferent serotonin receptor subtypes (5-HT1 to 5-HT7) chymal cells. It functions to increase apoptosis and
found on enteric neurons, enterochromaffin cells, nuclear factor.
and GI smooth muscle. Serotonin can cause
smooth muscle contraction through stimulation of 40 B (S&F, ch2)
cholinergic nerves or relaxation by stimulating The significance of the ability of IECs to recognize
inhibitory nitric oxide–containing neurons. Sero- pathogen-associated molecular patterns via surface
tonin released from mucosal cells stimulates Toll-like receptors or via intracellular nuclear
sensory neurons, initiating a peristaltic reflex, oligomerization domains 1 and 2 (NOD1, NOD2)
secretion (via 5-HT4 receptors), and the serotonin has been increasingly recognized over the past
released modulates sensation through activation of decade. The latter ability has been shown to con-
5-HT3 receptors. tribute to intestinal inflammation because approxi-
mately 25% of patients with Crohn’s disease have
33 D (S&F, ch3) mutations in the NOD2/CARD15 gene, interfering
One pathway is mediated through membrane- with their ability to mount an appropriate immune
bound death receptors, which include TNF recep- response to bacterial stimuli.
tors, Fas, and DR5, whereas the other pathway
involves activation of TP53 expression by environ- 41 F (S&F, ch3)
mental insults such as ionizing radiation, hypoxia, Regulation of cell cycle progression seems to be
and growth factor withdrawal with the subsequent achieved principally by cyclins and cyclin-
8 Biology of the Gastrointestinal Tract and Liver Disease

dependent kinase activity at the G1/S and G2/M diploid or near-diploid on a chromosomal level but
phase transitions. Dysregulation can promote harbor frequent alterations in smaller tracts of micro�
neoplasia. satellite DNA.

42 A (S&F, ch3) 43 D (S&F, ch3)

Chromosomal instability results in tumor cells that More than 80 oncogenes have been isolated. Most
display frequent aneuploidy, large chromosomal of these genes are widely expressed in many differ-
deletions, and chromosomal duplications. Tumors ent types of tumor cells. Multiple oncogenes are
that display microsatellite instability are often commonly found within a single tumor.
CHAPTER

2â•…

Nutrition in Gastroenterology

A. Marginal ulcer
Questions B. Internal hernia
C. Intestinal obstruction
44 Which of the following is considered protective D. Dumping syndrome
against childhood obesity? E. Cholelithiasis/biliary colic
A. Maternal gestational diabetes
B. Maternal smoking during pregnancy
48 A 30-year-old female executive has frequent lunch
C. Breast-feeding
meetings during which she typically chooses salads
D. Reduced nighttime sleep for young children
and other low-calorie options. However, once a
month, she returns home late at night and con-
45 Human proteins are comprised of amino acids. There
sumes several pints of ice cream, boxes of cookies,
are 20 different amino acids, some of which are
and several cans of soda. Immediately afterward,
considered essential because their carbon skeletons
she becomes very anxious, takes several laxatives,
cannot be synthesized by the body. Which of the fol-
and forces herself to vomit. This pattern has been
lowing amino acids are considered to be essential?
repeating itself for the past 5 years. She is 5 feet 5
A. Histidine
inches tall and weighs 130 pounds. Her diagnosis
B. Glycine
is most likely
C. Serine
A. Bulimia nervosa
D. Alanine
B. Night-eating syndrome
C. Anorexia nervosa
46 A 3-year-old boy presents with crampy abdominal
D. Binge-eating disorder
pain and diarrhea occurring within an hour of eating.
He has a poor appetite and is in the 15th percentile
for height and weight. Both a food-specific immuno- 49 Protein requirements are affected by the adequacy
globulin E (IgE) antibody skin prick test and serum of essential amino acids in the protein source.
food-specific IgE antibody test are performed, and What proportion of total protein requirements
the results are positive. He is diagnosed as having a should be provided in the form of essential amino
gastrointestinal allergy due to IgE-mediated hyper- acids?
sensitivity. Eliminating which of the following A. 5% to 10%
group of foods would most likely reduce this child’s B. 15% to 20%
symptoms? C. 30% to 40%
A. Milk, egg, peanuts D. More than 50%
B. Barley, beef, lamb
C. Soy, wheat, potato 50 A 32-year-old woman is considering bariatric sur�
D. Shellfish, potato, wheat gery. Which of the following would usually be rec-
ommended as part of her preoperative evaluation?
47 A 50-year-old woman lost 60 pounds during the A. CT scan of the abdomen and pelvis
first four months after gastric bypass surgery for B. Abdominal ultrasonography
obesity. She now presents with new epigastric pain C. Esophagogastroduodenoscopy/upper
that begins about 30 minutes after a meal and is not endoscopy
relieved with antacids. What is the most likely D. Colonoscopy
explanation for this patient’s symptoms? E. Esophageal manometry

9
10 Nutrition in Gastroenterology

51 Which of the following statements regarding cal� C. Dietary protein-induced enteropathy

cium absorption is most accurate? D. Whipple’s disease
A. Calcium absorption occurs primarily in the
distal small intestine. 56 Orlistat (Xenical), an orally administered weight re�
B. Calcium absorption occurs primarily in the duction agent, prevents the absorption of fats from
proximal small intestine. the diet, thereby reducing caloric intake. Which of
C. Calcium absorption occurs throughout the the following statements regarding orlistat is true?
length of the small intestine. A. The mechanism of action is inhibition of pan�
D. Calcium absorption occurs primarily in the creatic lipase.
colon. B. It is available in the United States by prescrip�
tion only.
52 Diarrhea in a chronically malnourished population C. Side effects are mostly related to excellent
is often caused by a combination of factors, includ- absorption of the drug via the GI tract.
ing increased GI secretions, decreased intestinal D. It is effective whether taken before, during, or
transit time, and osmotic stimulation of water secre- after a meal.
tion by unabsorbed contents of the food stream. The
somatostatin analog octreotide acetate (Sandostatin) 57 A 50-year-old woman presents to a primary care
may be used in the management of diarrhea in mal- physician for a routine physical examination. Her
nourished patients. Which of the following state- medical history is significant for hypertension and
ments regarding this medication is most accurate? diet-controlled diabetes. Her BMI is 42. What is her
A. It decreases stool volume, sodium, and chlo� weight classification?
ride output. A. Ideal weight
B. It decreases small intestinal transit time in B. Overweight
patients with short gut syndrome. C. Obese
C. It improves absorption of macronutrients and D. Morbidly obese
micronutrients.
D. It is typically administered by continuous 58 A 17-year-old girl with a history of binging and
infusion. purging is diagnosed with bulimia nervosa. She
reports to her dentist symptoms of heartburn, teeth
53 An 18-year-old girl with bulimia nervosa has a discoloration, and sensitivity to extreme tempera-
body mass index (BMI) of 15. She reports early tures. The dentist observes rounded teeth and some
satiety and postprandial abdominal pain and vomits dents. Which of the following best describes this
twice daily. Over the past two months, she has been complication of bulimia nervosa?
hospitalized twice for these symptoms and has lost A. Dentinogenesis imperfecta
5 pounds. Endoscopy reveals scant food debris in B. Gingivitis
the stomach. Treatment with a proton pump inhibi- C. Bruxism
tor results in minimal clinical improvement. Which D. Perimolysis
diagnostic test would be most helpful at this time?
A. Breath test for bacterial overgrowth 59 A 40-year-old man with a history of rhino�
B. Computed tomography scan of the abdomen conjunctivitis, asthma, and atopic dermatitis pre�
C. Gastric emptying scan sents with heartburn and dysphagia. Twice daily
D. Esophageal manometry treatment with a proton pump inhibitor for six
weeks does not improve his symptoms. Endoscopy
54 A 50-year-old alcoholic man has been homeless for reveals mucosal rings, ulcerations, and strictures
several months. He is evaluated in an emergency throughout the esophagus. What is his most likely
department and found to be confused and ataxic diagnosis?
and to have abnormal eye movements. A computed A. Reflux esophagitis
tomography scan of the head reveals no acute B. Allergic eosinophilic esophagitis
abnormalities, and the results of a drug and alcohol C. Bile reflux
screen are negative. Which of the following vitamin D. Candidal esophagitis
deficiencies best explains these symptoms?
A. Vitamin C deficiency 60 Undernutrition in children differs from that in
B. Riboflavin deficiency adults because it affects growth and development.
C. Niacin deficiency Which of the following is the most distinguishing
D. Pantothenic acid deficiency feature appreciated during physical examination of
E. Thiamine deficiency a child with kwashiorkor compared with a child
with marasmus?
55 A 2-month-old male infant presents with protracted A. Short stature
vomiting and diarrhea. The infant was initially B. Small head circumference
begun on a cow-milk formula and was then switched C. Low weight
to a soy-based formula, which he tolerated for two D. Peripheral edema
days before his symptoms recurred. A small intes-
tine biopsy specimen shows edema and an increased 61 Aggressive nutritional support will not benefit
number of lymphocytes, eosinophils, and mast every acutely ill patient. For which clinical sce-
cells. What is this infant’s most likely diagnosis? nario in a hospitalized patient would aggressive
A. Dietary protein-induced enterocolitis nutritional support be most beneficial?
syndrome A. Acute cholecystitis in an obese but otherwise
B. Celiac disease healthy 45-year-old woman
 Nutrition in Gastroenterology 11

B. Acute alcoholic hepatitis in a 45-year-old man C. Ingest large volumes of fluids with meals.
without any other known medical problems D. Start a prokinetic agent.
C. Acute coronary syndrome in a 60-year-old man
with a history of hypertension 68 A 65-year-old woman with a history of diabetes and
hypertension is admitted to the hospital with severe
62 A 26-year-old woman with a recent diagnosis of nausea, vomiting, and abdominal pain. Acute cho-
diabetes mellitus and a BMI of 43 is referred by her lecystitis is diagnosed based on physical examina-
gynecologist for treatment of obesity. An evaluation tion, imaging, and laboratory studies. Her weight is
for infertility has led to a diagnosis of polycystic 150 pounds and her height is 5 feet 6 inches. Follow-
ovarian syndrome. Which of the following agents ing cholecystectomy, the patient suggests that had
would be most optimal for treating this patient? her weight been lower she would not have devel-
A. Orlistat oped gallbladder disease. Based on her BMI of 24.2,
B. Metformin how would you best describe her nutritional status?
C. Prozac A. Moderately malnourished
D. Wellbutrin B. Normal
C. Overweight
63 Which of the following agents is approved by the D. Obese
U.S. Food and Drug Administration (FDA) for long-
term use in the pharmacologic treatment of obesity? 69 A 45-year-old woman presents for a “health main-
A. Amphetamine tenance” visit to your office. Based on her height
B. Orlistat and weight obtained by your medical assistant, you
C. Fenfluramine calculate her BMI to be 37. The patient informs you
D. Phentermine that she is extremely interested in losing weight
with your help. Which of the following statements
64 A 30-year-old woman with a history of irritable regarding weight reduction agents is correct?
bowel syndrome is seen in a dermatology clinic for A. Fluoxetine is approved by the FDA for weight
evaluation of a papulovesicular rash on her elbows. reduction.
A biopsy is performed and dermatitis herpetiformis B. Fluoxetine is a good option for a long-term
is diagnosed. Her rash is likely to improve by exclud- weight loss.
ing which of the following foods from her diet? C. Wellbutrin has data to support off-label use for
A. Wheat, soy, and dairy short-term weight loss.
B. Wheat, soy, and peanuts D. Topiramate is ineffective for weight reduction.
C. Wheat, rye, and barley
D. Wheat, corn, and peanuts 70 A 19-year-old ballet dancer with a 10-year history
of anorexia nervosa presents to the emergency
65 A continuous supply of energy is required for department with confusion, headache, and diffuse
normal organ function, maintenance of metabolic weakness one day after a performance. The patient
homeostasis, heat production, and performance of severely restricts her daily intake, keeping to a low-
mechanical work. What is the largest contributor to calorie diet for one week before each performance.
the total (daily) energy expenditure (TEE)? Immediately after each performance, she quickly
A. Resting energy expenditure liberalizes her diet and starts eating a lot more calo-
B. Energy expenditure of physical activity ries in the form of carbohydrates. Her height is 5
C. Thermic effect of feeding feet 6 inches, and she weighs 100 pounds. The
emergency department staff suspects refeeding syn-
66 A 48-year-old woman with esophageal cancer has drome. Which laboratory result is most commonly
been undergoing chemotherapy and receives nutri- seen with refeeding syndrome?
tion via a percutaneously placed gastrostomy tube. A. Hyperphosphatemia
She was recently hospitalized for 5 days for treat- B. Hypophosphatemia
ment of pneumonia and subsequently developed C. Hypercalcemia
severe diarrhea. Which one of the following is the D. Hypocalcemia
best treatment for this patient’s diarrhea?
A. Change the enteral feeding formula 71 A 66-year-old man underwent a bariatric surgical
B. Change the gastrostomy tube to a jejunostomy procedure 8 years ago and now presents with
tube fatigue, anemia, and diarrhea in addition to a
C. Metronidazole greater than expected weight loss. Which of the
D. Ciprofloxacin following bariatric surgical procedures is most
likely to lead to serious complications due to
67 A 42-year-old man with a history of antrectomy and excessive malabsorption?
vagotomy for recalcitrant peptic ulcer disease pre� A. Biliopancreatic diversion/duodenal switch
sents with recurrent episodes of nausea, cramping, B. Roux-en-Y gastric bypass
diaphoresis, and palpitations after meals. Upper C. Laparoscopic adjustable gastric banding
endoscopy reveals normal postoperative findings D. Partial and sleeve gastrectomy
without obstruction or peptic ulcer disease. Which
interÂ�vention is most likely to improve this patient’s 72 Sibutramine (Meridia), an orally administered
symptoms? agent for the treatment of obesity, suppresses appe-
A. Ingest frequent small meals. tite. Which of the following statements regarding
B. Ingest simple sugars with meals. sibutramine is true?
12 Nutrition in Gastroenterology

A. It has no side effects. Which of the following statements is the most

B. It acts directly on serotonin receptors in the accurate?
brain. A. The stimulation of α1-adrenergic receptors
C. It is a selective inhibitor of serotonin uptake. increases food intake.
D. It is not considered effective for maintenance B. The stimulation of serotonin receptors in the
of weight loss. brain reduces fat intake, with little or no effect
on the intake of protein or carbohydrates.
73 Protein energy malnutrition affects nearly every C. The stimulation of β2 receptors in the brain
organ system. Which of the following abnormalities increases food intake.
is found in the GI tract of a malnourished patient? D. The stimulation of the H1 receptor in the
A. Proliferation of intestinal villi central nervous system increases food intake.
B. Increased volume of gastric secretions
C. Increased number of facultative and anaerobic 77 A cachectic 56-year-old schizophrenic man has
bacteria in the small bowel been living on the streets for several months and is
D. Increased volume of bile admitted to the hospital with pneumonia. He is
treated with intravenous antibiotics, and total par-
74 A 76-year-old man with a history of biliary obstruc- enteral nutrition is started. He initially demon-
tion due to cholangiocarcinoma presents to his strates clinical improvement but then becomes
primary care physician with fatigue and shortness short of breath despite an improved chest radio-
of breath. He has a long-term indwelling external graph. Which of the following deficiencies best
biliary drain that is functioning well. There is no explains his dyspnea?
scleral icterus. The serum bilirubin level is normal, A. Phosphorous
but the patient is noted to have a severe hypochro- B. Calcium
mic microcytic anemia. Which micronutrient defi- C. Copper
ciency best explains this patient’s anemia? D. Selenium
A. Selenium deficiency E. Zinc
B. Zinc deficiency
C. Copper deficiency 78 Hormonal disturbances may occur with eating
D. Iodine deficiency disorders. In patients with anorexia nervosa and
bulimia nervosa, elevation of which specific
75 An 18-year-old female college freshman is evalu- hormone is most closely associated with secretion
ated at the student health center because she has of growth hormone, stimulation of appetite and
never had a menstrual cycle. An aspiring gymnast, intake, induction of adiposity, and signaling to
she has been preoccupied with maintaining a low the hypothalamic nuclei involved in energy
weight for much of her life. The patient periodi- homeostasis?
cally diets by consuming only vegetables and fruit A. Leptin
for several days. Her current weight is 100 pounds, B. Serotonin
and her height is 5 feet 8 inches. What is her most C. Cholecystokinin
likely diagnosis? D. Ghrelin
A. Bulimia nervosa
B. Purging disorder 79 A 60-year-old woman living in an assisted care
C. Anorexia nervosa facility is admitted to the hospital with a hip frac-
D. Binge-eating disorder ture. During this hospitalization, the patient is
observed to have hyperglycemia. Which micronu-
76 The central nervous system plays an important role trient deficiency best explains this problem?
in regulating food intake by receiving and process- A. Chromium deficiency
ing information from the environment and internal B. Manganese deficiency
milieu. A number of neurotransmitter systems, C. Copper deficiency
including monoamines, amino acids, and neuro- D. Iron deficiency
peptides, are involved in modulating food intake. E. Selenium deficiency

Answers 45 A (S&F, ch4)

Histidine, isoleucine, leucine, lysine, methionine,
44 C (S&F, ch6) phenylalanine, threonine, tryptophan, valine, and
Several factors are linked to postnatal weight and possibly arginine are considered to be essential
lifetime weight gain. Among the risks for obesity amino acids because their carbon skeletons cannot
are maternal smoking and gestational diabetes. be synthesized by the human body. The remaining
Infants who are breast-fed for more than three amino acids (glycine, alanine, serine, cysteine,
months may have a reduced risk of future obesity. cystine, tyrosine, glutamine, glutamic acid, aspara-
Children who get more sleep tend to weigh less gine, and aspartic acid) are nonessential in most
when they enter school than do those who sleep circumstances because they can be made from
less. endogenous precursors or essential amino acids.
 Nutrition in Gastroenterology 13

46 A (S&F, ch9) 52 A (S&F, ch4)

Milk, eggs, and peanuts are the most common The somatostatin analog octreotide acetate (Sand-
foods associated with food allergy due to IgE- ostatin) can decrease small intestine secretions.
mediated hypersensitivity. Symptoms may develop Therapy with octreotide has been shown to decrease
within minutes to two hours of consuming an ostomy or stool volume, decrease sodium and chlo-
implicated food and consist of nausea, abdominal ride output, and prolong small intestine transit
pain, vomiting, and diarrhea. The other food time in patients with short bowel syndrome.
choices are associated with non–IgE-mediated food Octreotide therapy, however, usually does not
hypersensitivities. improve absorption of macronutrients and other
minerals; in fact, it may exacerbate the degree of fat
47 E (S&F, ch7) malabsorption, presumably by inhibiting pancre-
Cholelithiasis is very commonly associated with atic secretions. In addition, octreotide is expensive,
rapid weight loss and occurs in as many as diminishes protein synthesis in the intestinal epi-
one third of patients after weight loss surgery. thelium and exocrine pancreas, and may decrease
Although marginal ulcers may occur and cause appetite and increase the risk of gallstones. It is
postoperative pain in this patient population, cho- usually administered subcutaneously, often several
lelithiasis is much more common and does not times per day.
respond to antacid therapy. Most experts recom-
mend prophylactic treatment with ursodiol for the 53 C (S&F, ch8)
first six months postoperatively to prevent this Gastroparesis is associated with bulimia nervosa
complication. and anorexia nervosa, and presents with early
satiety and postprandial abdominal pain. Upper
48 A (S&F, ch8) endoscopy excluded structural abnormalities, but
Bulimia nervosa is a recurrent binge-eating disor- the finding of food in the stomach did suggest gas-
der accompanied by inappropriate behaviors to troparesis. Therefore, the gastric emptying scan
control weight or purge calories. These behaviors would be the most helpful test at this point (see
may include using laxatives or diuretics, vomiting, table at end of chapter).
and excessive exercise. Binge-eating disorder is
characterized by excessive intake of calories within 54 E (S&F, ch5)
a discrete period of time, without associated in� Thiamine is important for energy transformation as
appropriate compensatory behaviors to prevent well as membrane and nerve conduction. Thiamine
weight gain. Anorexia nervosa is characterized by deficiency may cause Wernicke’s encephalopathy,
an unwillingness to maintain normal weight. Com- which is characterized by altered mental status,
monly, this is described as a failure to exceed 85% ataxia, and abnormal eye movements. Although
of the expected body weight in association with a common in alcoholic patients, this condition may
fear of weight gain. Night-eating syndrome is occur in any severely malnourished patient. Treat-
defined as recurrent bouts of overeating during ment consists of immediate administration of
nighttime awakening, without necessarily binging. thiamine.
The syndrome is not associated with inappropriate
compensatory behaviors to prevent weight gain. 55 A (S&F, ch9)
Dietary protein-induced enterocolitis syndrome
49 B (S&F, ch4) occurs in infants between one and three months
Proteins containing low amounts of essential amino of age, presents with protracted vomiting and diar-
acids are considered to be of low biologic quality. rhea (mild to moderate steatorrhea in ~80%), and
The total protein requirement is higher when the may result in dehydration and poor weight gain.
protein source is of low biologic quality. In normal Cow’s milk sensitivity is the most frequent cause
adults, approximately 15% to 20% of the total of this syndrome, but it also has been associated
protein requirement should be in the form of essen- with sensitivities to soy, eggs, wheat, rice, chicken,
tial amino acids. and fish. Loss of protein sensitivity, with resultant
reduction in clinical reactivity, occurs frequently.
50 C (S&F, ch7) In this case, a rice-based formula would be rec-
Upper endoscopy is generally recommended for ommended. During breast-feeding, infants virtu-
all patients who will be undergoing bariatric ally never develop this syndrome. Celiac disease
surgery. A high percentage of patients considering is due to an immunologic reaction to gliadin,
bariatric surgery will have clinically significant which is found in wheat, rye, and barley. The
findings on endoscopy. The other listed options biopsy typically has an infiltrate limited to lym-
are only indicated for the evaluation of specific phocytes and may demonstrate villous atrophy.
symptoms. A colonoscopy is a reasonable screen- Whipple’s disease is a rare infectious disease
ing test for colon and rectal cancer but is not part resulting in weight loss, incomplete breakdown
of the routine preoperative evaluation for a young of carbohydrates and fats, and immune system
patient. dysfunction. Whipple’s disease is treated with
antibiotics.
51 C (S&F, ch5)
Calcium absorption occurs throughout the length of 56 A (S&F, ch6)
the entire small intestine and is vitamin D depen- Orlistat is taken three times daily and specifically
dent. During periods of restricted calcium intake, before meals. In the United States, orlistat is avail-
the colon may become more involved in calcium able in two strengths: a prescription dose of 120€mg
homeostasis by increasing its absorption. (Xenical) and an over-the-counter dose of 60€ mg
14 Nutrition in Gastroenterology

(Alli). Orlistat is poorly absorbed and acts by inhib- management of polycystic ovarian syndrome. It
iting the enzymatic action of pancreatic lipase. reduces hepatic glucose production, decreases
Subsequently, its side effects are those associated glucose absorption from the GI tract, and enhances
with maldigestion of fats including fecal inconti- insulin sensitivity. As compared to sulfonylureas,
nence, anal leakage, bloating, and borborygmi. clinical trials have demonstrated weight loss with
metformin.
57 A (S&F, ch6)
Over the past 50 years, there has been a steady rise 63 B (S&F, ch6)
in the incidence of obesity. A useful tool for study- Two agents are approved by the FDA for long-term
ing this trend is the BMI, defined as the weight (W) treatment of obesity—sibutramine and orlistat. As
in kilograms divided by the height (H) in meters monotherapy, both agents can produce weight loss
squared (W/H2). A BMI greater than 30 provides a of 8% to 10%. Orlistat promotes weight reduction
useful operating definition of obesity. by inhibiting the enzymatic action of pancreatic
lipase. Sibutramine promotes satiety and possibly
BMI <18 Underweight increases energy expenditure by blocking the
BMI 18-26.5 Ideal weight reduction in metabolic rate that accompanies
weight loss. Fenfluramine increases serotonin
BMI 26.6-29 Overweight
levels, resulting in a sense of fullness and loss of
BMI 30-40 Obese appetite. Phentermine acts on the hypothalamus
BMI >40 Morbidly obese to release norepinephrine and reduces hunger.
Outside the brain, phentermine causes release of
58 D (S&F, ch8) epinephrine, which acts to break down fat in
Chronic vomiting, a feature of bulimia nervosa, adipose tissue, and reduces hunger. Fenfluramine,
may cause dental erosions or perimolysis. Neither and a combination agent consisting of fenfluramine
gingivitis (irritation of the gums) nor bruxism and phentermine (“fen-phen”), were withdrawn
(teeth grinding) is associated with bulimia nervosa from the market after being shown to cause pulmo-
or typically presents with dental erosions. Den- nary hypertension and heart valve abnormalities.
tinogenesis imperfecta is a genetic disorder of
tooth development that causes the teeth to be dis- 64 C (S&F, ch9)
colored (most often a blue-gray or yellow-brown Dermatitis herpetiformis is a chronic blistering
color) and translucent and is not a feature of skin disorder associated with a gluten-sensitive
bulimia nervosa. enteropathy (celiac disease). It is characterized
by a chronic, intensely pruritic, papulovesicular
59 B (S&F, ch9) rash symmetrically distributed over the extensor
The most likely diagnosis is allergic eosinophilic surfaces and buttocks. Although many patients
esophagitis. A biopsy specimen demonstrating a have minimal or no GI symptoms, biopsy of the
high number of eosinophils would be helpful in small bowel generally confirms intestinal involve-
establishing a diagnosis. The symptoms may be ment. Elimination of gliadin, the alcohol-soluble
confused with those of reflux. Endoscopic findings portion of gluten found in wheat, rye, and barley,
include mucosal rings, ulcerations, and strictures. from the diet generally leads to resolution of
The absence of clinical improvement despite proton skin symptoms and normalization of intestinal
pump inhibitor therapy makes reflux esophagitis findings over several months. An increased inci-
less likely. The clinical presentation and endo- dence of celiac disease in individuals previously
scopic findings are not suggestive of bile reflux or diagnosed with irritable bowel syndrome has been
candidal esophagitis. shown.

60 D (S&F, ch4) 65 A (S&F, ch4)

The presence of peripheral edema distinguishes Total (daily) energy expenditure (TEE) is composed
children with kwashiorkor from those with maras- of three components: the resting energy expendi-
mus and nutritional dwarfism. ture (~70% of TEE), the energy expenditure of
physical activity (~20% of TEE), and the thermic
61 B (S&F, ch4) effect of enteral or parenteral nutrition (~10% of
The prevalence of moderate to severe protein TEE).
energy malnutrition is so high among patients
admitted for acute alcoholic hepatitis and other 66 C (S&F, ch5)
forms of decompensated alcoholic liver disease that The most common cause of diarrhea in patients
it is best to assume that all such patients are mal- receiving enteral feeds is Clostridium difficile (C.
nourished. Furthermore, patients with acute alco- difficile)–induced colitis due to concurrent antiÂ�
holic hepatitis usually fall far short of their biotics. Metronidazole is usually an effective treat-
nutritional needs when allowed to eat ad libitum. ment for this infection. Changing the route of
Clinical trials demonstrate that the rates of mor� feeding to the jejunum would likely worsen this
bidity and mortality and the speed of recovery are patient’s diarrhea. Another acceptable option that
improved with prompt institution of enteral or par- was not included as an answer choice is oral van-
enteral nutrition in these patients. comycin. Some patients have diarrhea after antibi-
otic therapy without C. difficile infection. This
62 B (S&F, ch6) subset of patients may improve with probiotic
Metformin is a biguanide that is approved for the supplementation after withdrawal of the original
treatment of diabetes mellitus and often used in antibiotic.
 Nutrition in Gastroenterology 15

67 A (S&F, ch5) complications. All of the other choices, commonly

This patient has symptoms of dumping syndrome, performed in bariatric centers, are reasonable alter-
which is common in patients who have had a gas- natives that are associated with fewer postopera-
trectomy and vagotomy. These symptoms are tive problems.
caused by hypertonic gastric contents emptying
rapidly into the small intestine. This causes a sig- 72 C (S&F, ch6)
nificant amount of the plasma volume to be shifted Sibutramine (Meridia) selectively inhibits reup-
to the small intestine with resultant symptoms due take of serotonin and norepinephrine into neurons
mostly to hypovolemia. Nutritional therapy of this but does not act on any known receptors. Sibutra-
condition aims to deliver a lower osmolarity to the mine promotes satiety but may also increase
small intestine by frequent ingestion of small meals energy expenditure by blocking the reduction in
with limited simple sugars. Fluid intake should be metabolic rate that normally accompanies weight
restricted while eating solid food to avoid rapid loss.
gastric transit.
73 C (S&F, ch4)
68 B (S&F, ch4) Malnutrition is associated with structural and
This patient’s BMI based on her height and weight functional changes within the GI tract. Marked
is 24.2. According to the table, she is considered blunting of the intestinal villi, usually associated
normal (see table at end of chapter). with loss of some or all of the brush border hydro-
lases, is often seen. There is a reduction in gastric
69 C (S&F, ch6) and pancreatic secretions in association with lower
Fluoxetine is a selective serotonin reuptake inhi� concentrations of acid and digestive enzymes,
bitor that blocks serotonin transporters, thus respectively. In addition, the volume of bile, and
prolonging the action of serotonin. Fluoxetine is the concentration of conjugated bile acids within
approved by the FDA for the treatment of depres- the bile, is reduced. Increased numbers of faculta-
sion. Approximately 50% of initial weight loss tive and anaerobic bacteria are found in the proxi-
associated with fluoxitine is regained during the mal small intestine, and this probably explains the
second six months of treatment, making this drug increased proportion of free bile acids within the
inappropriate for long-term treatment of obesity. intestinal lumen.
Bupropion is approved for the treatment of depres-
sion and as an adjunctive agent for smoking 74 C (S&F, ch5)
cessation. Two multicenter clinical trials, one in Copper is necessary for iron utilization, hemoglo-
obese subjects with depressive symptoms and bin formation and production, and survival of
one in uncomplicated overweight patients, evalu- erythrocytes. Copper is excreted in the bile, and
ated the effectiveness of buproprion for weight therefore patients with external biliary drainage are
loss. Nondepressed subjects may respond with at high risk of copper deficiency. The daily copper
more weight loss than those with depressive requirement is 1.5 to 3€µg/day.
symptoms. Topiramate, an antiepileptic drug, was
associated with weight loss in clinical trials for 75 C (S&F, ch8)
epilepsy. Anorexia nervosa is characterized by an unwilling-
ness to maintain normal weight. Commonly, this
70 B (S&F, ch8) is described as failure to exceed 85% of expected
Patients with anorexia nervosa are at risk of body weight in association with fear of gaining
refeeding syndrome, a potentially life-threatening weight and amenorrhea. Bulimia nervosa is defined
condition characterized by fluid and electrolyte as recurrent binge eating accompanied by a variety
disorders including hypophosphatemia, hypomag- of inappropriate purging behaviors, including lax-
nesemia, and hypokalemia. This syndrome typi- atives, excessive exercise, diuretics, or vomiting to
cally occurs within four days of introducing a control weight gained during a binge. These behav-
healthy diet to a patient with anorexia nervosa. iors must occur twice weekly for at least 3 months
As a shift from fat to carbohydrate metabolism to meet diagnostic criteria. Binge-eating disorder
occurs, insulin levels increase, leading to increased is characterized by excessive intake of calories
cellular uptake of phosphate. Associated with within a discrete period of time but is not associ-
intracellular movement of electrolytes is a decrease ated with recurrent inappropriate compensatory
in the serum electrolytes, particularly phosphate, behaviors to prevent weight gain. Purging disorder
potassium, magnesium, glucose, and thiamine. is defined by recurrent purging or elimination
Alteration in serum calcium levels is not com- using laxatives, exercise, diuretics, or vomiting in
monly associated with refeeding syndrome (see the absence of clinically significant binge-pattern
table from answer 53). eating.

71 A (S&F, ch7) 76 B (S&F, ch6)

Biliopancreatic diversion/duodenal switch may Stimulation of α1-adrenergic receptors reduces
result in serious complications due to excessive all food intake, whereas stimulation of serotonin
malabsorption resulting in malnutrition and a receptors in the brain selectively reduces fat intake,
variety of vitamin deficiencies. This may present with little or no effect on the intake of protein or
as excessive weight loss, anemia, and even diar- carbohydrate. Stimulation of β2 receptors in the
rhea. This procedure has thus fallen out of favor brain decreases food intake, and stimulation of the
because there are several other options that are H1 receptor in the central nervous system reduces
highly effective with fewer long-term nutritional feeding.
16 Nutrition in Gastroenterology

77 A (S&F, ch5) secretion of growth hormone. Leptin is associated

Phosphorous deficiency may occur in malnour- with longer-term regulation of body fat stores
ished patients who abruptly begin adequate nutri- and affects satiety through its binding to the ven-
tion. In these patients, the delivery of a glucose load tromedial nucleus of the hypothalamus, an area
after a period of starvation causes an increased known as the “satiety center.” Altered serotonin
serum insulin level. Insulin drives phosphorous, function contributes to dysregulation of appetite
magnesium, and potassium into cells, with resul- as well as mood and impulse control in eating
tant very low serum levels of these electrolytes. disorders. This abnormality persists after recovery
This disorder is called refeeding syndrome, and from anorexia nervosa and bulimia nervosa,
may be life-threatening. Severe hypophosphatemia suggesting possible premorbid vulnerability. In
causes skeletal muscle dysfunction, and this effect bulimia nervosa, a blunted postprandial cholecys-
may be most evident in the chest leading to tokinin (CCK) response impairs satiety. The find-
hypoventilation and eventual tissue hypoxia. ings regarding a relationship between pre- and
Severely malnourished patients should initially postprandial CCK levels and anorexia nervosa are
receive a reduced glucose load at a slow rate with inconsistent.
close monitoring of all serum electrolytes.
79 A (S&F, ch5)
78 D (S&F, ch8) Chromium is necessary for the synthesis of glucose
Ghrelin affects all of these regulatory functions tolerance factor, a cofactor for insulin action. A
and is elevated in anorexia nervosa and bulimia deficiency in chromium can thus lead to glucose
nervosa. The other hormones listed do not affect intolerance and elevated glucose levels.
 Tables

Table for answer 53 Selected Clinical Features and Complications of Behaviors in Patients with Eating Disorders

CLINICAL FEATURE OR COMPLICATION

ASSOCIATED WITH WEIGHT LOSS AND ASSOCIATED WITH PURGING OR REFEEDING

FOOD RESTRICTION OR BINGE-EATING IN BEHAVIORS IN ANOREXIA NERVOSA, BULIMIA
SYSTEM AFFECTED ANOREXIA NERVOSA NERVOSA, OR EDNOS
Cardiovascular Arrhythmia Ventricular arrhythmia
Bradycardia Cardiomyopathy (with ipecac use)
Congestive heart failure (in refeeding syndrome) Prolonged QT interval
Decreased cardiac size Orthostasis
Diminished exercise capacity Syncope
Dyspnea
Hypotension
Mitral valve prolapse
Orthostasis
Prolonged QT interval
QT dispersion
Syncope
Dermatologic Brittle hair Russell’s sign (knuckle lesions from repeated
Dry skin scraping against the incisors)
Hair loss
Hypercarotenemia
Lanugo
Oral, pharyngeal Cheilosis Dental erosion and caries
Sialadenosis
Pharyngeal and soft palatal trauma
Angular cheilitis
Perimolysis
Vocal fold pathology
Gastrointestinal* Anorectal dysfunction Abdominal pain
Delayed gastric emptying Acute gastric dilatation
Elevated liver enzyme levels Barrett’s esophagus
Elevated serum amylase levels Bloating
Gastroesophageal reflux Constipation
Hepatic injury Delayed gastric emptying
Pancreatitis Diarrhea
Prolonged whole-gut transit time Dysphagia
Rectal prolapse Elevated liver enzyme levels
Slow colonic transit Elevated serum amylase levels
Superior mesenteric artery syndrome Esophageal bleeding
Esophageal ulcers, erosions, stricture
Gastroesophageal reflux
Mallory-Weiss tear
During refeeding:
Acute gastric dilatation, necrosis, and perforation Gastroesophageal reflux
Elevated liver enzyme levels Gastric necrosis and perforation
Hepatomegaly Hematemesis
Pancreatitis Pancreatitis
Prolonged intestinal transit time
Rectal bleeding
Rectal prolapse
Continued
18 Nutrition in Gastroenterology

Table for answer 53 Selected Clinical Features and Complications of Behaviors in Patients with Eating Disorders—Cont’d

CLINICAL FEATURE OR COMPLICATION

ASSOCIATED WITH WEIGHT LOSS AND ASSOCIATED WITH PURGING OR REFEEDING

FOOD RESTRICTION OR BINGE-EATING IN BEHAVIORS IN ANOREXIA NERVOSA, BULIMIA
SYSTEM AFFECTED ANOREXIA NERVOSA NERVOSA, OR EDNOS
Endocrine and Amenorrhea Hypercholesterolemia
metabolic Euthyroid sick syndrome Hyperphosphatemia
Hypercholesterolemia Hypochloremia
Hypocalcemia Hypoglycemia
Hypoglycemia Hypokalemia
Hyponatremia Hypomagnesemia
Hypothermia Hyponatremia
Low serum estradiol, low serum testosterone Hypophosphatemia
levels Metabolic acidosis
Osteopenia, osteoporosis Metabolic alkalosis
Pubertal delay, arrested growth Secondary hyperaldosteronism
As part of the refeeding syndrome:
Hypomagnesemia
Hypophosphatemia
Acute kidney injury Abnormal menses
Genitourinary and Amenorrhea Azotemia
reproductive Atrophic vaginitis Pregnancy complications (including low birth weight
Breast atrophy infant)
Infertility
Pregnancy complications (including low birth
weight, premature birth, and perinatal death)
Neurologic Cognitive changes Stroke (associated with ephedra use)
Cortical atrophy Neuropathy (with ipecac use)
Delirium (in refeeding syndrome) Reduced or absent gag reflex
Peripheral neuropathy
Ventricular enlargement
Hematologic Anemia
Leukopenia
Neutropenia
Thrombocytopenia
EDNOS, eating disorder, not otherwise specified.
*Gastrointestinal complications associated with binge pattern eating in any of the eating disorders, are not all listed, and include weight gain,
acute gastric dilatation, gastric rupture, gastroesophageal reflux, increased gastric capacity, and increased stool volume.

Table for answer 68 Classification of Nutritional Status by Body Mass Index in Adults

BODY MASS INDEX (KG/M2) NUTRITIONAL STATUS

<16.0 Severely malnourished
16.0-16.9 Moderately malnourished
17.0-18.4 Mildly malnourished
18.5-24.9 Normal
25.0-29.9 Overweight
30.0-34.9 Obese (class I)
35.0-39.9 Obese (class II)
≥40 Obese (class III)
CHAPTER

3â•…
Topics Involving
Multiple Organs

Questions 84 A 20-year-old white woman who had hematochezia

when she was five days old is seeking a second
opinion. She has multiple cutaneous vascular
80 A 32-year-old nurse presents with symptoms of
lesions that have been present since five days of
dizziness, jittery behavior, and headaches before
age. She has received blood transfusions on three
meals. Which of the following supports the diagno-
occasions after hematochezia episodes. An emer-
sis of factitious hypoglycemia?
gent exploratory laparotomy showed a large pelvic
A. Elevated sulfonylurea levels
vascular malformation, which was not treated. On
B. Normal proinsulin levels
physical examination, she is asthenic and appears
C. Normal C-peptide levels
pale but in no distress. She has multiple, bluish,
D. Plasma insulin-to-glucose ratio <0.3
nodular, soft, compressible, nontender lesions on
E. All of the above
her face, soft palate, arms, legs, hands, and trunk.
No abdominal or rectal abnormalities are found on
81 Foreign bodies and/or food boluses can lodge in the
examination, and she is not orthostatic. All of the
esophagus in any of the following four areas of
following statements about this young woman’s
narrowing except:
diagnosis are true except:
A. Hiatal hernia
A. Gastrointestinal (GI) bleeding is a rare feature
B. Upper esophageal sphincter
of this condition.
C. Level of the aortic arch
B. Intussusception may be a presenting feature.
D. Level of the mainstem bronchus
C. It can be transmitted in an autosomal
E. Gastroesophageal junction
dominant fashion.
D. The cutaneous nodules are venous
82 Hypoproteinemia and edema are the principal
malformations, for which no treatment is
clinical manifestations of protein-losing gastroen-
needed.
teropathy. Hypoproteinemia, the most common
clinical sequela, manifests as a decrease in serum
levels of albumin, fibrinogen, lipoproteins, α1- 85 All of the following statements about eosinophilic
antitrypsin, transferrin, and ceruloplasmin, and the gastroenteritis are true except:
following gamma globulins except: A. It commonly presents between 20 and 60 years
A. Immunoglobulin A (IgA) of age.
B. IgM B. Peripheral eosinophilia is present in a majority
C. IgE of patients.
D. IgG C. It most commonly affects the stomach and
small bowel, but also can extend to the
83 Which of the following is the most common com- esophagus, colon, and rectum.
plication after colonoscopy with polypectomy? D. It affects primarily mucosa and pyloric
A. Perforation of the hollow viscus obstruction and usually indicates alterative
B. Infection disease.
C. Immediate postoperative bleeding
D. Cardiorespiratory complications 86 Which of the following statements regarding hepa-
E. Delayed postoperative bleeding titis B infection in pregnancy is true?

19
20 Topics Involving Multiple Organs

A. Most women of childbearing age with chronic panel, thyroid-stimulating hormone level, or pro-
hepatitis B have a high risk of the develop� thrombin time/partial thromboplastin time. He
ment of complications of their disease during reports taking 81€mg of aspirin daily for cardiopro-
gestation. tective reasons and enalapril (Vasotec) for control
B. Maternal-fetal transmission is responsible for of mild hypertension. Colonoscopy is performed to
most cases of hepatitis B worldwide. the cecal tip without difficulty and shows scattered
C. Mothers who test negative for the hepatitis B diverticula in the left and transverse colon and
e-antigen cannot transmit the virus to their a lesion in the cecum (see figure). Which of the
fetuses. following is a true statement about this lesion?
D. Women with hepatitis B can be treated with A. It should be treated with a heater probe to
interferon during pregnancy. prevent occurrence of lower GI bleeding.
E. Women with hepatitis B should not be treated B. It indicates that the patient should undergo
with lamivudine during pregnancy. angiography after the colonoscopy to confirm
that he does not have other similar lesions.
87 Typhlitis can be the presenting manifestation of or C. It indicates that the patient should be offered
be associated with hormonal therapy.
A. Yersinia infection D. It should be treated with argon plasma coagu�
B. Acute leukemia lation because this kind of lesion is a common
C. Crohn’s disease cause of recurrent lower GI bleeding.
D. Cecal superinfection with cytomegalovirus E. It does not require any treatment because the
(CMV) risk of bleeding from this lesion is very small.
E. B and D

88 All of the following statements about esopha�

geal dilation during upper endoscopy are true
except:
A. Patients with eosinophilic esophagitis (EE)
should not undergo dilation because they are
at very high risk of perforation.
B. The esophageal stricture should always be
dilated to the size of an uninvolved lumen for
symptom relief.
C. The greatest risk of esophageal dilation is
perforation.
D. The type of dilator used during the procedure
is a very important determinant of the risk of
perforation.
E. Proximal esophageal strictures are more likely
to perforate than mid or distal strictures. Figure for question 91

89 Early mucosa-associated lymphoid tissue (MALT)

lymphomas of the stomach can be difficult to dis- 92 A 54-year-old man who has undergone bilateral
tinguish from marked Helicobacter pylori gastritis. lung transplantation presents with midepigastric
Histologic features of the mucosa to assist the pain and nausea. He takes high-dose glucocorti-
differentiation include which of the following? coids and cyclosporine for acute rejection as well
A. Follicular colonization and invasion of germi� as a proton pump inhibitor (PPI). Which one of the
nal centers of lymphoid follicles following studies should be performed next?
B. Destruction of gastric folds by lymphoid infil� A. Upper GI series
trate (lymphoepithelial lesion) B. Upper endoscopy
C. Presence of plasma cells with Dutcher bodies C. Computed axial tomography (CAT) scan of the
(periodic acid–Schiff–positive intranuclear abdomen
inclusions) D. Gastric-emptying scan
D. All of the above
93 In polymyositis and dermatomyositis
90 In a patient with a history of food bolus impaction, A. Involvement is limited to skeletal muscle
symptoms of retrosternal chest pain can localize fibers.
the level of impaction to the middle of the B. Perforation of the esophagus and duodenal
esophagus. diverticulosis are frequent complications.
A. True C. Dermatomyositis is associated with an
B. False increased prevalence of malignancy.
D. Malabsorption and pseudo-obstruction occur
91 A 54-year-old white man presents for a screening commonly.
colonoscopy. He has not noticed any change in his E. The pathology is a result of antibodies against
bowel habits or any blood in the stool. He does not smooth muscle fibers.
have any GI symptoms. His family history is signifi-
cant for his father having colon cancer at 75 years 94 A 21-year-old man presents to the hospital emer-
of age. His laboratory test results show no abnor- gency department with food impaction while eating
mality in his complete blood count, metabolic a steak dinner. As upper endoscopy is performed,
 Topics Involving Multiple Organs 21

the bolus spontaneously passes. Esophagogastro� 98 All of the following statements regarding hyper-
duodenoscopy (EGD) shows no stenosis but longi- emesis gravidarum are true except:
tudinal furrows in the distal esophagus with A. It occurs in >15% of all pregnancies.
punctate white patches scattered over the mucosal B. It is defined by the presence of ketonuria and a
surface. There is no history of preceding heartburn, 5% decrease in prepregnancy weight.
but he has had multiple allergies in the past. All of C. As many as 20% of affected patients will have
the following statements about his diagnosis are symptoms until delivery.
true except: D. Symptoms may be exacerbated by higher
A. Dilation of the distal esophagus can be readily levels of human chorionic gonadotropin (HCG)
performed to prevent further impaction. such as with multiple gestations, trophoblastic
B. Biopsy specimens of the distal and midesoph� disease, and trisomy 21.
agus are expected to show >15 eosinophils E. Symptomatic treatment and hydration are the
per high-power field. mainstays of therapy.
C. Treatment with swallowed fluticasone should
be effective. 99 Which of the following treatments is the least
D. There is a personal history of atopy in 50% of appropriate treatment of gastroesophageal reflux
these patients. disease (GERD) in a pregnant patient?
A. Pantoprazole
95 A 32-year-old woman of Ashkenazi Jewish descent B. Omeprazole
who is 15 weeks pregnant was just admitted by the C. Ranitidine
high-risk obstetrics group because of multiple skin D. Sucralfate
lesions and odynophagia. She denies abdominal E. Lifestyle modifications
pain, but has had nausea for two weeks. She has
some constipation but has not noticed any blood in 100 When considering GI bacterial infections in patients
the stool. She states that she “was doing fine till with acquired immunodeficiency syndrome (AIDS),
three weeks ago when the skin lesions started.” Her all of the following are true except:
medical history is significant for appendectomy. A. Small bowel bacterial overgrowth is common
She is otherwise healthy and takes prenatal vita- in AIDS patients.
mins. On physical examination, she is afebrile. B. Salmonella, Shigella, and Campylobacter have
There are multiple erosions and pustules over the higher rates of bacteremia and antibiotic
skin on the arms, chest, abdomen, and thighs. resistance.
Similar lesions are seen in the oral cavity and C. They are more frequent and more virulent in
gingiva. All of the following statements about this human immunodeficiency virus (HIV)–infected
illness are true except: patients.
A. A definitive diagnosis of this condition is D. The most common bacterial infection is
made by biopsy and demonstration of antibody Clostridium difficile.
and complement in the basement membrane E. Mycobacterial infection most commonly
zone by immunofluorescence. involves the duodenum and may be suspected
B. Intravenous IgG has been used in the treatment at endoscopy by the presence of yellow
of this disorder. mucosal nodules, seen in the clinical setting of
C. Patients with serum IgG and IgA antibodies are malabsorption, bacteremia, and systemic
less likely to respond to medications. infection.
D. Oral ulcerations are present in 100% of
patients with this condition. 101 All of the following are useful in the staging of
E. Glucocorticoid medications, both topical and MALT lymphoma except:
systemic, have been used to treat this A. Endoscopic ultrasonography
condition. B. CT scan of the chest and abdomen
C. Upper airway examination
96 A 38-year-old woman who has been on oral contra- D. Bone marrow biopsy
ceptive pills for 18 years presents with abdominal E. Positron emission tomography
pain. A computed tomography (CT) scan shows
peritoneal nodules, and laparoscopy reveals mul- 102 All of the following statements about the relation-
tiple small, rubbery nodules along the peritoneum. ship between somatostatin and carcinoid tumors
What is the most appropriate treatment? are true except:
A. Hormone withdrawal A. Somatostatin and its analogs inhibit synthesis
B. Chemotherapy and release of peptides produced by carcinoid
C. Surgical debulking tumors.
D. Radiation B. They do not block the effects of amines and
peptides on target tissue.
97 Which of the following is/are true regarding esoph- C. Their role in carcinoid heart disease is
ageal strictures resulting from caustic ingestion? unclear.
A. They commonly develop two months after D. They have several side effects and are not very
injury. well tolerated by patients.
B. Primary treatment is frequent dilation. E. They are not effective in the treatment of
C. As many as 50% eventually need operative abdominal pain due to carcinoid tumor.
intervention.
D. A and B 103 A 46-year-old woman with type 2 diabetes, hyper-
E. All of the above tension, and gastroparesis was recently started on
22 Topics Involving Multiple Organs

nifedipine by her physician. She now presents with which she has started taking pain medication. She
a vague feeling of epigastric distress and worsening has no significant medical history, and before this,
early satiety. Her physical examination findings her only routine medication was a prenatal vitamin.
are unremarkable. An endoscopy performed two On physical examination, she is alert and oriented
months earlier for dyspepsia showed no abnormali- but appears uncomfortable and has a temperature
ties, but an upper GI series with barium contrast of 99.6°F. She has multiple lace-like lesions in
shows a gastric-filling defect. What is the most her oral cavity with overlying ulcerations and small
likely diagnosis? to medium, flat-topped pruritic and violaceous
A. Gastric ulcer papules all over her skin. All of the following state-
B. Gastric cancer ments about her condition are true except:
C. Lymphoma A. Upper GI endoscopy will likely show
D. Pharmacobezoar erythema, ulcers, and webs in the proximal
E. None of the above esophagus.
B. The condition should be treated with topical
104 A 60-year-old man is four months post–orthotopic and systemic glucocorticoids.
liver transplantation (OLT). He presents with C. The condition is associated with an increased
fever, malaise, myalgia, and an occasional cough. prevalence of chronic liver disease.
He is found to have elevated liver enzymes. D. Treatment of this condition will decrease the
His only medication is mycophenolate mofetil risk of the development of esophageal cancer.
(MMF). Which treatment should be started for his
condition? 108 A fragile, underweight 70-year-old woman is
A. Valgancyclovir brought to the emergency department with right
B. Ganciclovir lower abdominal pain. An obstructive series sug-
C. Acyclovir gests small bowel obstruction. An astute resident
D. Voriconazole notes that her pain is felt into the medial aspect of
the thigh with associated paresthesias. Hip flexion
105 A 16-year-old college student presents with symp- improves the pain, whereas extension of the hip
toms of abdominal pain, vomiting, and sporadic and medial rotation increase the pain. What is her
diarrhea. He has a serum albumin level of 2.3€g/dL most likely diagnosis?
and a creatinine level of 0.9€ mg/dL. His blood A. Unrecognized hip fracture
smear shows microcytosis and peripheral eosino- B. Femoral hernia
philia. The stool specimen will most likely show C. Obturator hernia
which of the following? D. Sciatic foramen hernia
A. C. difficile toxin
B. Charcot-Leyden crystals 109 What is the most common gastric lesion causing
C. Giardia severe protein loss?
D. Ova and parasites A. Ménétrier’s disease
B. H. pylori gastritis
106 A consult is requested on a hospitalized 24-year- C. Allergic gastroenteropathy
old white man with anemia and stools positive D. Systemic lupus erythematosus
for occult blood. He had been admitted to the gastroenteropathy
hospital because of a nonhealing ulcer over the
left medial malleolus that had not improved after 110 Which one of the following diseases causes
surgery for varicose veins on the left leg three constipation?
years ago. His medical history is significant for A. Addison’s disease
recurrent ulcer over the left medial malleolus, and B. Hyperparathyroidism
the patient’s parents report that he walks with a C. Hyperthyroidism
limp. On physical examination, there are multiple D. Medullary carcinoma of the thyroid
varicose veins over the left lower limb. There is
predominant left lower limb hypertrophy, with the 111 True statements regarding the relationship between
left limb being longer and larger. An x-ray shows carcinoid tumor of the gut and urine levels of
distinct soft tissue and osteohypertrophy of the 5-hydroxyindoleacetic acid (5-HIAA) include all of
left lower limb. A duplex scan of the left lower the following except:
limb shows massive superficial venous varicosities A. Urine excretion rates of 5-HIAA of
and multiple anastomoses between the superficial >25€mg/24€hr are diagnostic.
and deep venous systems. An angiogram shows B. The excretion rate of 5-HIAA in the urine
multiple arteriovenous fistulas. What is the most corresponds well with a carcinoid tumor mass.
likely diagnosis? C. Midgut carcinoid tumors are associated with
A. Klippel-Trénaunay syndrome an increased excretion rate of 5-HIAA in urine.
B. Blue rubber bleb nevus syndrome D. Foregut carcinoids may be associated with
C. Parkes Weber syndrome normal urinary levels of 5-HIAA.
D. Diffuse intestinal hemangiomatosis E. All of these statements are true.
E. None of the above
112 Which of the following statements regarding man-
107 A 29-year-old white woman who is 24 weeks preg- agement of carcinoid syndrome is most accurate?
nant presents with dysphagia and odynophagia that A. Serotonin antagonists such as methysergide,
started about a week ago and have progressed in ondansetron, and cyproheptadine provide
severity. She has pruritus and severe oral pain, for excellent control of flushing episodes.
 Topics Involving Multiple Organs 23

B. Hypertension is best treated with angiotensin- A. It is inherited.

converting enzyme inhibitors. B. It is characterized by telangiectasias that occur
C. Bronchospasm is best treated with β-adrenergic more commonly in the stomach and small
receptor agonists. intestines than in the colon.
D. Ondansetron is very effective in controlling C. The diagnosis is usually made by endoscopy.
diarrhea due to carcinoid syndrome. D. Vascular involvement of the liver can present
E. Glucocorticoids should not be given to a as a giant hemangioma.
patient with carcinoid syndrome in whom
hypotension develops. 118 The presence of H. pylori by histology in cases of
gastric MALT lymphoma is
113 Which of the following lists the correct sequence A. 90%
of damage to intestinal epithelium after ingestion B. 75%
of a caustic substance? C. 60%
A. Necrosis, ulceration, fibrosis, stricture, D. 50%
carcinoma
B. Ulceration, necrosis, fibrosis, stricture, 119 Ascites in multiple myeloma
carcinoma A. Usually results from portal hypertension caused
C. Necrosis, fibrosis, ulceration, stricture, by tumor infiltration
carcinoma B. Can result from tuberculous peritonitis
D. Ulceration, fibrosis, necrosis, stricture, C. Can be secondary to dissemination of myeloma
carcinoma cells into the peritoneal cavity
E. None of the above D. Can be secondary to congestive heart failure
E. All of the above
114 A 29-year-old man with AIDS whose last CD4 count
was 58 presents to the emergency department with 120 A 49-year-old woman with a somatostatinoma that
a history of diarrhea for several days. He has not is being treated with octreotide presents with severe
been taking his highly active antiretroviral therapy right upper quadrant and midepigastric pain along
(HAART) medications. The diarrhea is large with fever and chills. Which treatment is most
volume, nonbloody, and associated with nausea, likely to benefit her?
but not with abdominal pain. What is the most A. Discontinuation of medications
likely cause of the patient’s diarrhea? B. Emergent laparotomy
A. Campylobacter species C. Cholecystectomy
B. Microsporidium D. Insulin infusion
C. Escherichia coli E. None of the above
D. Salmonella
E. Shigella 121 A 69-year-old white man is transferred from another
hospital with severe diarrhea, abdominal pain,
115 Subacute periumbilical abdominal pain develops weight loss, electrolyte disorder, and malnutrition.
in a 30-year-old woman taking glucocorticoids for On physical examination, he appears well devel-
systemic lupus erythematosus. The pain is most oped and well nourished and his vital signs are
likely due to which of the following? stable, but his mucous membranes are dry. He
A. Peritonitis states that he was fine before the onset of symptoms
B. Budd-Chiari syndrome six weeks ago and has never noticed gross blood in
C. Mesenteric ischemia the stool. The most notable findings on physical
D. Pancreatitis examination include alopecia, onycholysis, and
E. Any of the above shedding of some of the nails. His wife has noticed
increased pigmentation on the patient’s upper arms
116 All of the following statements about post-traumatic and thighs. The patient’s brother had colon cancer
diaphragmatic hernias are correct except: at the age of 70 years. Medical records from the
A. They occur immediately after the trauma and outside hospital indicate that he had upper and
should present within one week afterward lower endoscopies that showed multiple gastric
when symptoms are not masked by other and colon polyps; analysis of the multiple biopsy
injury. specimens that were taken indicated that these
B. Eighty percent are due to blunt trauma, typi� were hyperplastic in nature. The most likely diag-
cally motor vehicle accidents. nosis is which of the following?
C. The other 20% are due to penetrating trauma A. Cowden’s syndrome
such as knife wounds to the chest below T4 to B. Gardner’s syndrome
the umbilicus. C. Muir-Torre syndrome
D. Spinal CT is useful in making the diagnosis. D. Peutz-Jeghers syndrome
E. Cronkhite-Canada syndrome
117 A 40-year-old white man comes to the emergency F. Symptoms that can be associated with portal
department because of melena of two days’ dura- hypertension and variceal bleeding
tion and dizziness. He has been taking over-the-
counter nonsteroidal anti-inflammatory drugs 122 A 40-year-old woman is admitted with a two-day
(NSAIDs) for three days for a sports-related injury. history of nausea, vomiting, and abdominal disten-
He has multiple cherry-red spots on his lips and tion. An obstruction series shows dilated loops of
tongue. All of the following statements about this small bowel. On examination, the abdomen is soft
patient’s condition are true except: with no local tenderness. A 2- to 3-cm indurated,
24 Topics Involving Multiple Organs

tender nodule is felt in the right groin. The most likely D. Large cell lymphoma discovered early may
diagnosis is which of the following? respond to antibiotic therapy occasionally.
A. Obstructing small bowel neoplasm with lymph
node metastasis 128 Bouts of jaundice and upper abdominal pain with
B. Lymphoma presenting with inguinal adenopathy elevated liver enzymes in patients with sickle cell
and perhaps small bowel involvement disease can be attributable to all of the following
C. Incarcerated femoral hernia except:
D. Small bowel obstruction with incidental A. Ischemic liver injury
inguinal adenopathy B. Hepatitis B infection
C. Hepatitis C infection
123 GI stromal tumors (GISTs) can present in all of the D. Zinc deficiency
following ways except: E. Cholecystitis
A. Asymptomatic abdominal mass
B. Enlarged left supraclavicular (Virchow’s) node 129 PETs are associated with all of the following inher-
C. Gastric outlet obstruction ited disorders except:
D. GI bleeding (intraluminal) A. Multiple endocrine neoplasia type I (MEN-I)
E. Intraperitoneal bleeding B. Osler-Weber-Rendu disease
C. von Hippel-Lindau disease
124 All of the following statements regarding nonfunc- D. Tuberous sclerosis
tioning pancreatic endocrine tumors (PETs) are true E. Neurofibromatosis 1 (NF1)
except:
A. An elevated plasma pancreatic polypeptide 130 A 32-year-old man with acute myelogenous leuke-
level establishes the diagnosis. mia underwent hematopoietic cell transplantation
B. Treatment is directed at the tumor itself and (HCT) 20 days ago. He is now reporting severe pain
includes surgical resection. near the anal canal, and this pain is worse with
C. The prognosis depends on the size of the defecation. External examination of the perineum
tumor and presence of metastasis. shows no abnormalities. Laboratory test results are
D. The median survival is 75% at 4.5 years. significant for neutropenia. What should be done
E. The majority are located in the pancreatic head. next?
A. Start acyclovir
125 A 45-year-old man who recently completed neoad- B. Start ganciclovir
juvant chemotherapy and radiation treatment for C. Obtain a CAT of the abdomen/pelvis
gastric cancer presents with symptoms of increased D. Perform a flexible sigmoidoscopy
abdominal girth, fatigue, and right upper quadrant
abdominal pain. His examination reveals tender 131 Which of the following statements about anorectal
hepatomegaly, shifting dullness, and anicteric disease in homosexual AIDS patients is true?
sclera. Laboratory findings are significant for an A. There is a higher frequency of anorectal
alkaline phosphatase level of 680€U/L, an aspartate squamous cell cancer in homosexual men than
aminotransferase (AST) level of 120€U/L, an alanine in others with AIDS.
aminotransferase (ALT) level of 180€ U/L, and a B. The risk of squamous cell cancer increases as
total bilirubin level of 1.2€ mg/dL. The remainder the HIV infection progresses.
of the laboratory test results are normal. A CT scan C. Neoplasms result from human papillomavirus
of the abdomen demonstrates no mass lesions or infections via sexual contact.
biliary obstruction. What is the most likely diag- D. All of the above are true.
nosis in this patient? E. A and B
A. Metastatic gastric cancer
B. Acalculous cholecystitis 132 Eosinophils in the GI tract can be caused second-
C. Radiation-induced liver disease arily by other conditions, which must be excluded
D. Hepatic abscess before a diagnosis of primary eosinophilic GI
E. Primary biliary cirrhosis disease can be made. These possibilities include all
the following except:
126 Cholelithiasis, diarrhea, steatorrhea, diabetes, and A. Parasite infection
hypochlorhydria are associated with which of these B. Inflammatory bowel disease
syndromes? C. Lymphoma of small bowel
A. VIPoma D. Medications
B. Somatostatinoma E. Post-transplantation
C. Glucagonoma
D. Insulinoma 133 Match each of the following skin disorders with its
E. None of the above associated GI pathology.

127 All of the following statements about the pathology Skin Disorder GI Pathology
of diffuse, large B cell lymphoma of the stomach 1.╇ Dermatitis A.╇ Pancreatic tumor
are true except: herpetiformis (DH) B. Crohn’s disease
A. TP53 and P16 mutations are found. 2.╇ Porphyria cutanea tarda C. Celiac disease
B. Initially these tumors can be confined to the 3.╇ Necrolytic migratory D. Hepatitis C
mucosa. erythema infection
C. Some areas of low-grade MALT lymphoma 4.╇ Erythema nodosum E. Gastric cancer
can be recognized intermixed with a predom� 5.╇ Sister Mary Joseph
inantly large B cell population. nodule
 Topics Involving Multiple Organs 25

134 The treatment of Mediterranean lymphoma (alpha D. The tumor secretes a polyclonal
heavy-chain disease) consists of which of the fol- immunoglobulin.
lowing methods?
A. Surgery + radiation 140 Which of the following is the most common clinical
B. Radiation + chemotherapy manifestation of protein-losing gastroenteropathy
C. Antibiotics + chemotherapy besides hypoproteinemia?
D. Surgery + chemotherapy A. Dependent edema
B. Anasarca
135 A 60-year-old man presents to the emergency C. Increased susceptibility to infections
department with a one-day history of epigastric and D. Coagulopathy
right chest pain of abrupt onset. It was accompa-
nied by retching, with only a small amount of 141 Bacterial overgrowth can manifest in which of the
mucoid blood produced. He is unable to swallow following?
food or fluids. There is no history of exertional A. Scleroderma
chest pain. A chest x-ray and abdominal films show B. Marfan syndrome
a retrocardiac air-filled structure. A nasogastric C. Chronic renal failure
tube could not be passed. The epigastrium is mildly D. Fabry disease
tender, but no abdominal guarding is observed. E. All of the above
What is the best management at this time?
A. Direct admission to the cardiac care unit 142 Which of the following is considered a useful tool
B. Surgical consult and close observation for in the diagnosis of insulinoma?
what may evolve into a surgical emergency A. Detailed history
C. Intravenous PPI and a liquid diet B. Hypoglycemia associated with fasting
D. Intravenous fluids and close observation on C. Fasting glucose, insulin, and C peptide
the medical ward D. Plasma proinsulin
E. Laparoscopic cholecystectomy E. All of the above

136 All of the following lymphomas are considered 143 A 65-year-old man presents to his primary care
to be non–immunoproliferative small intestinal physician reporting nocturnal regurgitation of food
diseases except: for several months. Symptoms have recently become
A. Alpha heavy-chain disease (Mediterranean worse, waking him up at night. He denies any dys-
lymphoma) phagia or odynophagia. His wife also noticed that
B. Diffuse large B cell lymphoma his voice has been changing and has told him often
C. Mantle cell lymphoma that he has severe halitosis. He states that he has
D. Burkitt’s lymphoma no other medical problems, but his current symp-
E. Follicular lymphoma toms have affected his quality of life. Which of the
following is the most useful diagnostic study?
137 What should patients with MEN-I/Zollinger-Ellison A. Endoscopy
syndrome (ZES) be advised regarding surgery for B. Barium swallow
their disease? C. pH monitoring for 24 hours
A. All patients should undergo an exploratory D. Esophageal manometry
surgery for resection. E. CT scan of the chest
B. All metastatic lesions to the liver are con�
sidered nonoperable. 144 A 40-year-old alcoholic man is hospitalized with
C. Patients should undergo a gastrectomy. typical physical and radiographic findings of right
D. A vagotomy is indicated. lower lobe pneumonia. He has been started on an
E. Surgical exploration is recommended if lesions antibiotic medication. Gram-positive cocci are
greater than 2€cm are identified. seen. On the second hospital day, he appears
slightly jaundiced, and jaundice is worse the
138 A 48-year-old woman who underwent OLT pre�sents following day. Liver function test results are as
with three weeks of watery diarrhea. She is main- follows: alkaline phosphatase, twice normal; AST,
tained on MMF for immunosuppression. The patient 55€ U/L; ALT, 70 U/L; bilirubin, 5€ mg% (direct,
has no abdominal pain and is afebrile, and her stool 3.5€ mg%); gamma glutamyl transferase, twice
study results are negative. What is the next step? normal. An ultrasound scan of the liver is unre-
A. Colonoscopy markable. What is the best next step in managing
B. Stop MMF this patient’s condition?
C. Give loperamide (Imodium) A. Test for hepatitis A and B, CMV, Epstein-Barr
D. Reduce the dose of MMF virus, and herpes simplex virus.
B. Perform urgent endoscopic retrograde
139 Which of the following statements about alpha cholangiopancreatography (ERCP).
heavy-chain disease (Mediterranean lymphoma) is C. Observe and reevaluate liver function daily.
incorrect? D. Perform magnetic resonance imaging (MRI)
A. It is most prevalent in North Africa, Israel, the and MRI with cholangiopancreatography.
Middle East, and other Mediterranean E. Immediately change to another antibiotic
countries. medication.
B. It is associated with a lack of sanitation and
poor socioeconomic status. 145 An 84-year-old man has had a prolonged hospital
C. It has been reported to be associated with course in the intensive care unit after penetrating
Campylobacter jejuni infection. abdominal trauma sustained during a motor-vehicle
26 Topics Involving Multiple Organs

accident that caused a splenic laceration. He was schedule. He also reports an intermittent, sudden
initially treated with broad-spectrum antibiotics feeling of “warmth” and is concerned about his
with improvement. However, 10 days into his hos- thyroid gland, especially because his mother had
pital stay, recurrent fevers develop. A repeat CT Graves disease. Physical examination reveals mild
scan shows the development of a 3.5- × 4.6-cm periumbilical tenderness and hyperactive bowel
intra-abdominal abscess. Which of the following sounds. Rectal examination is normal, but he is
are the bacteria most likely associated with this heme occult positive. Laboratory testing that was
infection? performed elsewhere revealed all levels including
A. Resistant gram-negative organisms, Enterococ� thyroid-stimulating hormone to be normal, but the
cus species, and yeast patient wonders if there was a laboratory error.
B. E. coli and Bacteroides What is the next indicated study?
C. Candida A. Mesenteric angiography
D. Gram-positive staining and Enterococcus B. Positron emission tomography
species C. Upper GI radiographic examination with small
bowel follow-through
146 True statements about perforation during upper D. Enteroclysis
endoscopy include which of the following? E. None of the above
A. Patients with large cervical osteophytes are at
an increased risk of perforation. 150 All of the following statements about the various
B. The incidence of perforation in upper purgatives used before colonoscopy are true except:
endoscopy is 2 to 3 per 10,000 procedures. A. Polyethylene glycol solutions are very well
C. Most perforations in the neck can be managed tolerated because they do not cause fluid shifts
conservatively. during colonoscopy preparation.
D. Perforation is more likely to occur if the B. Electrolyte abnormalities are common side
stricture is in the proximal esophagus. effects of all purgatives currently given before
E. All of the above colonoscopy.
C. Sodium phosphate should not be given to
147 A 25-year-old G1P0 at 30 weeks’ gestation is patients in renal failure.
brought to the emergency department by her D. Patients with severe diseases should be
husband after he noted jaundice and mild confu- prepared for colonoscopy gradually over
sion. Her prenatal course had been uneventful hours.
thus far. Laboratory test results reveal a normal
blood count with the exception of a hemoglobin 151 A 33-year-old patient with acute myelogenous leu-
level of 10.9. Chemistries are normal; however, her kemia who underwent an allostem cell transplanta-
prothrombin time is 18.6, AST 900 U/L, and ALT tion five months earlier presents with dysphagia,
860. She undergoes a liver biopsy, which reveals poor appetite, some weight loss, retrosternal pain,
intracytoplasmic inclusion bodies and areas of and occasional aspiration of gastric contents. You
focal hemorrhage. What would likely be the most perform an upper endoscopy. There is desquama-
effective treatment for this patient? tion of squamous epithelium of the distal esopha-
A. Immediate delivery of the baby gus and diffuse mucosal edema and erythema in the
B. Supportive care gastric antrum. What is the most likely diagnosis?
C. Steroids A. CMV esophagitis
D. Acyclovir B. Graft-versus-host disease (GVHD)
E. Lamivudine C. Herpes simplex virus (HSV) esophagitis
D. Mucositis
148 A 37-year-old woman with AIDS who is receiving
antiretroviral therapy presents with increasing 152 A 48-year-old woman reports progressive swelling
abdominal girth and fullness. She has a tempera- in her hands and feet, numbness in her hands and
ture of 100.8°F and ascites. Diagnostic paracentesis other symptoms of carpal tunnel syndrome, and
is performed, and straw-colored fluid is withdrawn. intermittent galactorrhea. MRI of the head fails to
The patient’s serum-to-ascites albumin gradient is reveal any pituitary abnormality, but there is a mass
0.9; she has a low glucose level of 18 g/dL; and her in the abdomen. What is the appropriate treatment
white blood cell (WBC) count is 540,000 with 68% for this patient?
lymphocytes. Which of the following tests may A. Streptozocin
help arrive at a diagnosis in this case? B. Doxorubicin
A. CA 125 C. Octreotide
B. Cytology of ascites fluid D. Surgical exploration
C. Laparoscopy E. Bromocriptine
D. B and C
E. A and B 153 A 44-year-old woman presents with a two-month
history of worsening watery diarrhea and cramps
149 A 23-year-old medical student reports “very embar- in the lower extremities. She describes passing
rassing loud noises in the stomach” that are worse large amounts of watery stool that is the color of
after eating. He has no abdominal pain, his appetite diluted tea. Stool studies fail to reveal any WBCs
is good, and he feels well without any other symp- or infection, but the stool osmolar gap is <50. A
toms. On questioning, he admits that he has lost VIPoma is suspected. What other laboratory abnor-
about 12 pounds in the past six months, which he malities would be expected if this diagnosis is
attributes to skipping meals because of a very busy correct?
 Topics Involving Multiple Organs 27

A. Hyperglycemia A. Stomach or duodenum

B. Hypochlorhydria B. Liver
C. Hypokalemia C. Colon
D. Hypercalcemia D. Subcutaneous abdominal fat pad
E. All of the above
159 A 52-year-old man presents with four daily epi-
154 A 50-year-old woman five months post–kidney transÂ� sodes of watery diarrhea for 18 months. There is no
plantation presents with anorexia, nausea, and vom� blood or mucus, abdominal pain, nausea, or vomit-
iting. She is maintained on tacrolimus. The patient ing. Symptoms have been accompanied by fatigue
undergoes EGD (see figure). What is her most likely and a 15-pound weight loss. Laboratory test results
diagnosis? reveal a hemoglobin of 11 with a mean corpuscular
A. HSV volume of 76 and a Ca+ of 11. EGD demonstrates
B. CMV antral ulcers. All of the following laboratory tests
C. Candida infection could be used to confirm the diagnosis except:
D. GVHD A. Chromogranin A
B. Parathyroid hormone
C. Gastrin level
D. Serum protein electrophoresis
E. Neuron-specific enolase

160 All of the following statements about the adverse

effects of imatinib are true except:
A. It has not been reported to cause
myelotoxicity.
B. Diarrhea, myalgias, and skin rash reportedly
occur in 30% to 45% of patients receiving the
drug.
C. Its adverse effects tend to lessen with contin�
ued treatment.
D. GI hemorrhage from shrinking tumor masses
has been noted in 5% of patients receiving this
medication.

Figure for question 154 161 A 66-year-old woman presents with the symptoms
of weight loss and a rash. On examination, there are
several raised erythematous lesions with central
blistering. They appear to be in several stages of
155 Which of the following is the preferred treatment healing with associated hyperpigmented areas
for diffuse large B cell lymphoma of the stomach? and bullous crusted lesions. Laboratory test results
A. Rituximab reveal normocytic anemia, an elevated serum glu�
B. Radiation alone cose, and a glucagon level of 1200. What is the diag�
C. Surgery alone nosis most likely to be?
D. Chemotherapy alone A. Type 2 diabetes
E. A, B, and D B. Cirrhosis
C. Glucagonoma
156 Which of the following techniques reduces the like- D. Celiac disease
lihood of radiation enteritis? E. Hepatitis B
A. Using only anterior and posterior fields for
pelvic radiation 162 Gold therapy for rheumatoid arthritis has been
B. Administering radiotherapy in the supine associated with which of the following?
position A. Diarrhea
C. Maintaining an empty bladder during radiation B. Enterocolitis
therapy C. Toxic megacolon
D. Using misoprostol suppositories in patients D. Death
undergoing radiation E. All the above

157 The majority of gastric, and as many as 30% of 163 Which of the following statements regarding be�
esophageal, foreign bodies in children are asymp- zoars is/are true?
tomatic, but symptoms that raise suspicion would A. They develop after surgery due to delayed gastric
include which of the following? emptying, decreased gastric accommodation,
A. Failure to thrive and reduced acid-peptic activity.
B. Choking B. They can cause gastric ulceration secondary to
C. Drooling pressure necrosis.
D. Not wanting to eat C. Rapunzel syndrome can lead to pancreatitis/
E. All the above jaundice.
D. Trichobezoars typically require surgery more
158 For the diagnosis of amyloidosis, it is advisable to often than phytobezoars.
biopsy all of the following sites except: E. All of the above
28 Topics Involving Multiple Organs

164 A 37-year-old woman presents with episodic 168 Protein-losing enteropathy should be treated by
arthralgias, pleuritic chest pain, and vague abdomi- A. Replacing lost protein through albumin
nal pain. Her parents and one of her cousins expe- infusion
rienced similar symptoms. Which of the following B. Aggressive protein nutritional resuscitation
treatments should be initiated? C. Treating the underlying disease
A. Diagnostic laparoscopy D. H2 receptor antagonists, anticholinergic agents,
B. Prednisone and octreotide
C. Colchicine
D. Melphalan 169 Which of the following is the most common site of
E. No treatment gastrinoma?
A. The first portion of the duodenum
165 Metabolic derangements in glucagonoma patients B. The third portion of the duodenum
include all of the following except: C. Pancreatic tail
A. Thromboembolic events D. Pancreatic head
B. Anemia E. Jejunum
C. Increased amino acid production
D. Hyperglycemia 170 Which of the following statements about rectal car-
E. Anorexia cinoid tumors is true?
A. The rectum is a very rare site of carcinoid
166 Which of the following is the most common site of tumors.
extranodal GI lymphoma in developed countries? B. Rectal carcinoid tumors are more common in
A. Colon female than in male patients.
B. Small intestine C. Carcinoid syndrome is a common feature of
C. Prednisone rectal carcinoid tumors.
D. Stomach D. Radical resection via a low anterior or abdom�
inoperineal approach is the treatment of choice
167 A 48-year-old woman who is ten days post-HCT in cases of rectal carcinoid tumor.
presents with nausea and vomiting for three days. E. The primary determinant of the prognosis for
Laboratory test results are significant for neutrope- patients with rectal carcinoid tumor is the
nia and thrombocytopenia. Her symptoms have underlying tumor biology.
resolved with an antiemetic. However, she now
reports severe retrosternal pain and painful swal- 171 Which of the following statements about post-ERCP
lowing. A barium swallow is shown in the figure. pancreatitis is false?
Given the findings, what is the most likely cause of A. Pancreatitis is the most common complication
her symptoms? of ERCP.
A. Esophageal malignancy B. Risk factors for post-ERCP pancreatitis have
B. Intramural hematoma been well defined and include both patient
C. Infectious esophagitis and procedural factors.
D. Esophageal stricture C. The only definitive way to minimize the
complication rate is to avoid performing ERCP
for diagnostic purposes.
D. Treatment of post-ERCP pancreatitis is
supportive.
E. Using pure cutting current for sphincterotomy
will decrease the risk of pancreatitis.

172 Which of the following statements regarding treat-

ment of Zenker’s diverticula is true?
A. All patients with Zenker’s diverticula should
be offered surgery regardless of the size of the
diverticulum and symptoms.
B. An open surgical approach is not recom�
mended for patients with large diverticula
that extend into the thorax.
C. Compared with endoscopic techniques, there
is a higher recurrence rate with open surgical
procedures.
D. Compared with endoscopic techniques, there
is a lower complication rate with open surgical
procedures.
E. Upper esophageal sphincter myotomy should
always be a part of the procedure.

173 A 23-year-old man with Crohn’s disease is admitted

with abdominal pain, increased WBC count, and
fever. A CT scan of the abdomen and pelvis is
shown in the figure. What is the next best step in
Figure for question 167 his management?
 Topics Involving Multiple Organs 29

178 The sensitivity of free air on an upright chest x-ray

in detecting a perforated viscous is
A. 60%
B. 10%
C. More than 90%
D. 35%
E. None of the above

179 The majority of patients with esophageal food

impaction have an underlying predisposing esoph-
ageal pathology that might include all the following
except:
A. Schatzki’s ring
B. Eosinophilic esophagitis
Figure for question 173 C. Candida esophagitis
D. Altered surgical anatomy
E. Motility disorders
A. Stat surgical consult
B. Intravenous antibiotics 180 When evaluating GI symptoms in AIDS, all of the
C. Oral antibiotics following are true except:
D. Antibiotics and percutaneous catheter A. Because of HAART, GI symptoms are most
aspiration/drainage often drug induced or nonopportunistic.
B. A CD4 count >200/mm favors common bac�
174 Factors predisposing to incisional hernias include teria and other nonopportunistic infections.
all of the following except: C. A CD4 count <100/mm favors CMV, fungi,
A. Obesity Mycobacterium avium complex (MAC), and
B. History of aneurysm unusual protozoa.
C. Ascites D. Chronic liver disease, most often due to hepa�
D. Smoking titis C, is a leading cause of illness requiring
E. Postoperative wound infection hospitalization and death.
E. Clinical signs and symptoms frequently
175 The following statements about imatinib therapy suggest a specific diagnosis.
are true except:
A. In patients with advanced disease, treatment is 181 Which of the following is the treatment of choice
lifelong. for the management of food bolus impactions and
B. Increasing the dose from 400 to 800€mg/day foreign bodies?
will improve survival. A. Flexible endoscopy
C. Positron emission tomography not only B. Foley catheter extraction under fluoroscopy
identifies tumor, but can predict the response C. Glucagon
to imatinib by the intensity of uptake. D. Nifedipine
D. Imatinib will work favorably in GISTs with a E. Gas-forming agents including sodium
KIT mutation as well as in the 5% of GISTs bicarbonate
with a PDGFRA mutation.
182 Which of the following statements regarding radia-
176 False-positive elevations of 5-HIAA levels in urine tion-induced enteritis is true?
can result from ingestion of all of the following A. Symptoms of radiation-induced enteritis may
except: appear within a week of radiation therapy.
A. Melatonin B. Younger patients are affected more than older
B. Methyldopa patients.
C. Walnuts C. Concurrent chemotherapy has not been shown
D. Rifampin to intensify the effects of radiation therapy.
E. Isoniazid D. Colonoscopy is the diagnostic test of choice for
radiation enteritis.
177 A 54-year-old woman with a history of radiation E. Symptoms such as abdominal pain and
therapy and chemotherapy for colon cancer reports diarrhea will not subside after discontinuation
that there is leakage of fluid from a small lesion on of radiation.
her abdominal wall. Although the leakage is small,
it is continuous and causes her skin to become irri- 183 A 35-year-old white woman presents to the emer-
tated. Imaging confirms a distal enterocutaneous gency department with right lower quadrant
fistula. She otherwise appears well nourished. What abdominal pain, anorexia, nausea, and vomiting.
is the next best step to manage her symptoms? She has a temperature of 101°F. Based on her
A. Refer her for surgical management. symptoms, physical examination findings, and
B. Place a wound vacuum-assisted closure over abdominal CT scan findings, a diagnosis of acute
the fistula. appendicitis is made. The patient undergoes emer-
C. Provide assurance and ask her to continue gency appendectomy and is discharged home.
enteral feeds. Histopathologic examination of the appendix
D. Keep the patient on nothing by mouth and results in discovery of a 2.5-cm carcinoid tumor,
start total parenteral nutrition (TPN). and she is referred to a gastroenterologist. Which
30 Topics Involving Multiple Organs

of the following statements regarding this patient A. Keep the patient on nothing by mouth and
is true? start TPN.
A. She had a carcinoid tumor of the appendix B. Keep the patient on nothing by mouth and
that was cured by appendectomy. insert a nasoenteral feeding tube.
B. She may have metastatic disease and needs to C. Start him on a liquid diet and advance him to
undergo CT of the abdomen and pelvis every a regular diet in 24 to 48 hours.
three months. D. Perform a barium swallow before allowing oral
C. She is likely to have a recurrence of the tumor. intake.
D. Her prognosis is poor; the five-year survival E. None of the above
rate for patients with carcinoid tumor is 10%.
E. She should undergo right hemicolectomy. 190 There is an increased risk of esophageal cancer after
alkaline caustic ingestion. All of the following state�
184 Which of the following factors predict fibrosis and ments are true except:
progression to cirrhosis in patients with hepatitis C A. There is an increased risk of squamous cell
who are also infected with HIV? cancer.
A. Higher ALT levels B. There is an increased risk of adenocarcinoma.
B. Older age at infection C. Lye ingestion leads to a 1000-fold increase in
C. Higher inflammatory activity cancer risk.
D. Alcohol consumption of >50€g/day D. There is an approximately 40-year lag time
E. All of the above between ingestion and cancer onset.
E. Endoscopic surveillance every one to three
185 Anorexia, nausea, and intermittent vomiting de� years should begin 20 years after ingestion.
velop one month after a 32-year-old woman has
undergone a successful liver transplantation for 191 A 50-year-old woman with diverticulosis presents
primary biliary cirrhosis. Her immunosuppressant with lower left quadrant abdominal pain. A CAT
regimen includes tacrolimus and prednisone. What scan of the abdomen reveals a 1- × 1.2-cm abscess
is the next best step? in the lower left quadrant. What is the next best
A. Perform an endoscopy. step in her management?
B. Reduce the tacrolimus dose. A. Perform CT-guided percutaneous catheter
C. Add a PPI. drainage.
D. Stop tacrolimus and add MMF. B. Perform ultrasound-guided percutaneous
catheter drainage.
186 All of the following statements regarding carcinoid C. Intravenous antibiotics
syndrome are true except: D. Surgery
A. Atypical carcinoid syndrome is caused by
foregut carcinoids. 192 All of the following are considered treatment
B. Flushing and diarrhea are the first symptoms options for insulinoma except:
of carcinoid syndrome. A. Resection
C. Typical carcinoid syndrome is caused by B. Chemotherapy
midgut carcinoids. C. Radiation therapy
D. Patients with atypical carcinoid syndrome D. Dietary control
have normal serotonin levels. E. Diazoxide
E. Patients with typical carcinoid syndrome
have increased rates of urine 5-HIAA 193 A 50-year-old man who has received a cadaveric
excretion. kidney transplant for polycystic kidney disease
presents to the emergency department reporting left
187 Polyarteritis nodosa, Churg-Strauss syndrome, and lower quadrant crampy pain and a bloody bowel
Henoch-Schönlein purpura are vasculitides. All movement. He has a low-grade temperature and a
three conditions can cause each of the following GI WBC count of 15. Which of the following is the
manifestations except: most likely diagnosis?
A. Pancreatitis A. CMV colitis
B. Ischemic bowel B. Ischemic colitis
C. Cholecystitis C. Infectious colitis
D. Appendicitis D. Diverticular bleeding
E. Eosinophilic gastroenteritis
194 The best way to establish the malignant potential
188 What is the most common group that unintention- of GISTs is by which of the following criteria?
ally ingests foreign bodies? A. A diameter greater than 4€cm
A. Older adults B. The number of mitoses per high-power field
B. Children C. Irregular borders on endoscopic
C. College students playing “quarters” ultrasonography
D. Demented patients D. The cystic area in the tumor by endoscopic
E. Intoxicated patients ultrasonography
E. All of the above
189 A 22-year-old man comes to the emergency depart-
ment after ingesting an alkaline substance. He has 195 A 53-year-old man received a liver transplant for
no symptoms. Upper GI endoscopy reveals grade hepatitis C–related liver disease. Approximately
IIA injury. What should be done next? four months following the transplantation, he is
 Topics Involving Multiple Organs 31

C. Sepsis with multiorgan failure

D. Complications of parenteral feeding

199 Match the following disorders of the oral cavity to

the treatment:

Oral Cavity Condition Treatment

1.╇ Xerostomia A.╇ Topical tretinoin gel
2.╇ Black hairy tongue B. Topical anesthetics
3.╇ Oral thrush C. Oral acyclovir
4.╇ Oral hairy D. Oral mycostatin
leukoplakia (HL) E. Oral cevimeline
5.╇ Geographic tongue

200 All of the following statements about resistance to

imatinib are true except:
A. The incidence of resistance is <20%.
B. For patients intolerant or resistant, sunitinib
50€mg/day is available.
C. The response rate to sunitinib in these patients
is only 6.8%.
D. These patients are beyond any further surgical
help.

201 Hereditary syndromes with GISTs are associated

with all of the other neoplasms listed except:
A. Pulmonary chondroma
B. Extra-adrenal paragangliomas
C. MEN-I syndrome
D. NF

202 Flushing is a symptom commonly associated with

Figure for question 195 carcinoid syndrome. Other conditions in which
flushing can occur include all of the following
except:
admitted with cholangitis. ERCP findings are shown A. Pheochromocytoma
in the figure. Multiple biliary casts are seen as well. B. VIPoma
Which of the following should be performed? C. Amyloidosis
A. Ultrasound scan to assess for hepatic artery D. Medullary carcinoma of the thyroid
patency E. Anaphylaxis
B. Surgical revision
C. Long-term antibiotic therapy 203 What is the optimal test to measure for intestinal
D. Repeat ERCP in two weeks protein loss?
A. Measurement of the fecal loss of radiolabeled,
196 A 60-year-old diabetic man has had chronic renal intravenously administered macromolecules
failure for 10 years and has been on hemodialysis for such as 51Cr albumin.
three years. Recurrent bouts of melena have required B. Measurement of concentration of α1-antitrypsin
continuous oral iron supplementation plus Epogen in the stool
(epoetin alfa) every two weeks. Upper and lower C. Measure the clearance of α1-antitrypsin from
endoscopy have not revealed a source for bleeding. the plasma during a 72-hour stool collection
What is the most likely source of bleeding? D. 99mTc-labeled dextran scintigraphy
A. Small bowel neoplasm
B. Angiodysplasia of small bowel 204 All of the following statements about umbilical
C. Meckel’s diverticulum hernias are true except:
D. Pyloric channel ulcer overlooked at endoscopy A. They should be repaired in the neonate to
E. Dieulafoy’s lesion avoid the risk of incarceration.
B. They are more common in African-American
197 Which solid organ transplant has the highest inci- children.
dence of fungal infections? C. They may rupture in cirrhotic patients with
A. Kidney and pancreas ascites.
B. Heart and lung D. Strangulation may occasionally occur after
C. Liver rapid reduction in ascites.
D. Intestinal
205 A 32-year-old G2P1 at 37 weeks’ gestation presents
198 What is the main cause of mortality from GI with intense pruritus for several weeks, which is
fistulas? worse at night and most severe over her palms
A. Arrhythmias due to electrolyte imbalance and soles. She is without jaundice or rashes and
B. Underlying disease such as cancer states that she experienced itching during her last
32 Topics Involving Multiple Organs

pregnancy as well. She has no history of any other presents with mildly abnormal transaminase levels
underlying liver disease. Which of the following and multiple new hepatic masses seen on imaging.
interventions is most likely to result in the safe In addition, he is also found to have periportal
resolution of her symptoms? lymphadenopathy, which appears stable in size
A. Delivery of the baby when compared with previous imaging. What is his
B. Cholestyramine most likely diagnosis?
C. Steroids A. Hepatocellular carcinoma recurrence,
D. Ursodeoxycholic acid multifocal
E. Phenobarbital B. Focal nodular hyperplasia
C. Post-transplantation lymphoproliferative
206 A 50-year-old woman presents to your office with disorder of the liver
3€ L of stool per day and hypochlorhydria and is D. Post-transplantation lymphoproliferative dis�
requiring 200 mEq/day of potassium to maintain order of the liver and periportal lymph nodes
her electrolyte balance. Her symptoms persist
without fasting, endoscopic evaluation findings are 212 Gastric antral vascular ectasia (GAVE), also called
negative, and steatorrhea is absent. Which one of watermelon stomach, is a vascular lesion of the
the following is the most likely medical therapy to gastric antrum that can present as both an acute and
help her condition? chronic gastrointestinal bleed. All of the following
A. Prednisone 60€mg/day statements about this condition are true except:
B. Clonidine A. It is predominantly seen in females.
C. Indomethacin B. It is often associated with certain connective
D. Octreotide tissue diseases.
E. Phenothiazine C. It is thought to be the result of accelerated
gastric emptying, which is an associated
207 Surgery should be considered in which of the fol- phenomenon seen in this group of patients.
lowing cases? D. GAVE can be caused by hepatic venous
A. When a foreign body is sharp or pointed and occlusive disease.
fails to progress after three days E. Some believe that GAVE and portal
B. When ingested coupling magnets cannot be hypertensive gastropathy are different
retrieved, to avoid fistula/perforation manifestations of the same process.
C. When there is an esophageal perforation after
ingestion of a caustic fluid 213 Typical immunophenotype staging of gastric MALT
D. A and C lymphoma cells includes which of the following?
E. All of the above A. CD19
B. CD20
208 A 56-year-old man with a recent diagnosis of gluca- C. CD10
gonoma presents with symptoms of diarrhea, weight D. A and B only
loss, and new onset of shortness of breath. Which
of the following conditions should be ruled out? 214 A 36-year-old patient presents with symptoms of
A. Steatorrhea abdominal pain increasing in intensity in the right
B. Metastatic disease lower quadrant. She has associated nausea, vomit-
C. Pulmonary emboli ing, and fevers. Examination demonstrates rebound
D. Anemia and guarding. Laboratory test results show leuko-
cytosis. Which of the following is the recommended
209 Which of the following statements about hemolytic treatment for this patient?
uremic syndrome (HUS) is true? A. Glucocorticoids
A. It includes renal failure, hemolytic anemia, B. Fluid resuscitation and antibiotic therapy
and thrombocytosis. followed by urgent laparotomy or laparoscopy
B. Adriamycin is the chemotherapy most C. Fluid resuscitation and antibiotic therapy
commonly implicated as a cause. D. Vasopressors such as dopamine
C. It usually leads to permanent dialysis. E. None of the above
D. It is associated with enteric pathogens such as
Salmonella, Shigella, Campylobacter, Yersinia, 215 Long-term cyclosporine therapy may also lead to
and hemorrhagic 0157:H7 E. coli. which of the following?
E. In adults, idiopathic and sporadic cases have A. Thrombocytopenia
been described. B. Congestive heart failure
C. Hyperlipidemia
210 In gastroparesis diabeticorum, the only symptom D. Gallstones/biliary disease
shown to be an independent predictor of delayed
gastric emptying is which of the following? 216 A 24-year-old man is brought to the emergency
A. Nausea department by the police because after his arrest for
B. Vomiting suspected drug dealing, he swallowed a few packets
C. Abdominal bloating/fullness of white powder that were believed to contain
D. Early satiety cocaine. The patient is completely asymptomatic,
E. Weight loss and the results of his physical examination show
no abnormalities. Abdominal radiographs show
211 A 56-year-old man with a history of alcoholism multiple sausage-shaped radiopaque areas in the
underwent OLT for cirrhosis complicated by small intestine. What is the next step in the man-
hepatocellular carcinoma nine months earlier. He agement of this patient?
 Topics Involving Multiple Organs 33

A. Emergency surgery A. Flushing occurs due to the release of a number

B. Emergency endoscopic removal of the foreign of polypeptide hormones.
bodies in the intestine B. Many studies have found a direct correlation
C. Inpatient observation with a clear liquid diet between serotonin levels and degree of flushing.
D. None of the above C. Norepinephrine levels are not correlated with
E. All of the above flushing episodes.
D. Flushing in carcinoid syndrome is not
217 All of the following are techniques used to mini- worsened by emotional or physical stress.
mize GI side effects of radiation therapy except:
A. Early treatment with 5-hydroxytryptamine 3 223 Ingested bread bag clips are associated with a high
antagonists risk of GI tract complications. All of the following
B. Concomitant chemotherapy are true except:
C. PPIs A. Ingestion can result in bleeding, obstruction,
D. Viscous lidocaine and perforation.
E. Early treatment with dexamethasone B. The small bowel is the most common site of
impaction.
218 A 39-year-old woman reports progressive swelling C. The arms of the clip grasp the mucosa.
in her hands and feet, numbness in her hands and D. The clips are radiopaque and detected easily
other symptoms of carpal tunnel syndrome, and by conventional radiography.
intermittent galactorrhea. MRI of the head fails to E. Operative intervention is commonly required.
reveal any pituitary abnormality, but there is a mass
in the abdomen. What is the appropriate treatment 224 Factors that predispose to recurrent inguinal hernia
for this patient? include all of the following except:
A. Streptozocin A. Alcoholism
B. Doxorubicin B. Smoking
C. Octreotide C. Extension into the scrotum
D. Surgical exploration D. Steroid therapy
E. Bromocriptine E. Liver or renal failure

219 A 42-year-old man presents one month after 225 A 64-year-old man with a history of hypertension,
attempting suicide by drinking a caustic agent. He diabetes mellitus, and prostate cancer, status post-
has been experiencing early satiety and progressive radiation therapy six weeks earlier presents with
emesis that have resulted in a 5-pound weight loss. diarrhea, bloating, belching, and a 10-pound weight
Upper endoscopy of the stomach is performed and loss. An appropriate approach to this patient’s
reveals antral stenosis. What is the appropriate next symptoms includes which of the following?
step in the treatment of this patient? A. Lactose-free diet
A. Endoscopic dilation B. Loperamide
B. Referral to a surgeon for antrectomy C. Cholestyramine
C. Referral to a surgeon for vagotomy and D. Treatment for bacterial overgrowth
antrectomy E. All of the above
D. Referral to a surgeon for pyloroplasty and
gastroenterostomy 226 A 23-year-old man with a history of Crohn’s disease
E. Referral to a surgeon for subtotal gastrectomy presents with increased diarrhea, abdominal pain,
fever, and increased leukocyte count. He undergoes
220 A 62-year-old woman presents with dysphagia for a CT scan of the abdomen that shows an intra-
solids for the past two weeks. Her medical history abdominal abscess. Subsequently, he undergoes
includes hypertension, diabetes, and hypothyroid- percutaneous catheter drainage of the abscess. Four
ism. She also underwent chemotherapy and radia- days later, he reports improvement in the diarrhea.
tion for lung cancer approximately six months ago. Laboratory test results are significant for a decrease
What is the most likely finding on barium swallow? in the WBC count. However, he continues to have
A. Esophageal stricture high output from the drain, which is his main
B. Esophageal stenosis symptom. What is the next best step to arrive at a
C. Esophageal dysmotility diagnosis?
D. Esophageal ulceration A. Repeat abdominal imaging
B. Removal of the drain
221 Which of the following best describes protein- C. Perform a catheter study
losing enteropathy? D. Referral to a surgeon
A. Excessive protein catabolism
B. Malabsorption of digested amino acids 227 Which of the following is the most common cause
C. Excessive leakage of plasma proteins into the of death in celiac disease?
lumen of the GI tract A. Ulcerative jejunitis
D. Lack of pancreatic digestion of dietary proteins B. Lymphoma
C. Sepsis due to immunoglobulin deficiency
222 Flushing is a distinctive feature of carcinoid syn- D. Malnutrition
drome and is present in 30% to 94% of patients
with carcinoid syndrome at some time during the 228 All of the following are true about the association
course of their illness. All of the following are between DH and celiac disease except:
incorrect statements about the proposed etiology of A. More than 80% of patients with celiac disease
flushing except: will have DH.
34 Topics Involving Multiple Organs

B. DH presents as papulovesicular lesions that C. In patients with mechanical heart valves who
are symmetrical and involve the extensor are taking warfarin, low-molecular-weight
surfaces of the extremities, trunk, buttock, heparin can be safely substituted for warfarin
scalp, and neck. before and after the procedure.
C. Withdrawal of gluten reverses the condition in D. This complication should always be discussed
six to 12 months. during the process of obtaining informed
D. Although the exact pathogenesis of DH consent.
remains unclear, it is thought that antibodies E. The incidence of bleeding postpolypectomy is
to gluten that are formed in the small intestine 1.5% to 3% of all cases.
are deposited at the dermoepidermal junction.
E. DH is rarely diagnosed in childhood. 234 Abdominal pain, nausea, fevers, and chills develop
at home in a 33-year-old woman with a history of
229 All of the following statements about Behçet’s Crohn’s disease with ileal involvement and a history
disease are true except: of recent fistula surgery (ileocolonic fistula). In the
A. It should be in the differential diagnosis when emergency department, her temperature is 101°F,
patients present with Budd-Chiari syndrome. her blood pressure is 110/80€ mm Hg, and her
B. Surgical intervention is highly successful. heart rate is 100 beats per minute. On physical
C. As in Crohn’s disease, the ileocecal region is examination, she appears quite ill. Physical exami-
the most commonly affected by ulceration. nation is notable for tenderness in the right lower
D. GI involvement occurs in as many as 50% of quadrant with rebound. What is the most optimal
cases. study for this patient at this time?
E. “Punched-out” ulcerations are seen on A. MRI of the abdomen and pelvis
colonoscopy. B. Abdominal ultrasound scan
C. Small bowel series
230 A 40-year-old man who recently immigrated from D. CAT scan of the abdomen/pelvis with intra�
India presents with increased abdominal girth and venously and orally administered contrast
fevers for the past several weeks. An ultrasound medium
scan of the abdomen reveals no evidence of cirrho-
sis and patent hepatic vasculature. Paracentesis 235 A 35-year-old obese woman had a Roux-en-Y gastric
reveals a protein count of 6.2 and a serum ascites bypass two years ago. She has not been well since
albumin gradient of 0.5, as well as 568 WBCs with shortly after surgery, with recurrent bouts of mid�
87% lymphocytes. What would be the most appro- abdominal pain and vomiting every couple of
priate next test to help determine the diagnosis? weeks. A CT scan in the emergency department
A. CA 125 shows dilated loops of jejunum. What is the most
B. Cross-sectional imaging of the pelvis likely diagnosis?
C. Peritoneal fluid cytology A. Anastomotic stenosis
D. Peritoneal adenosine deaminase levels B. Internal hernia
E. Laparoscopy C. Marginal ulcer
D. Small bowel obstruction due to postoperative
231 Traction diverticula of the esophagus are often adhesions
related to all of the following except:
A. Motility disorders 236 In which of the following cases is gastric antral
B. Enlarged mediastinal lymph nodes from lung vascular ectasia (GAVE), also called watermelon
malignancies stomach, least likely to be the diagnosis?
C. Achalasia A. A 49-year-old white woman with iron
D. Inflammation associated with tuberculosis and deficiency anemia for five years and
histoplasmosis rheumatoid arthritis
E. Trauma B. A 50-year-old man with atrophic gastritis and
heme-positive stools
232 Which of the following statements regarding MAC C. A 47-year-old white man with cirrhosis
in the GI tract is true? secondary to hepatitis C, anemia, and possibly
A. MAC is the most commonly identified recurrent blood transfusions
organism in patients with chronic diarrhea and D. A 65-year-old African-American man with a
low CD4 counts. history of frequent NSAID use who presents
B. Many patients with MAC infection will have with hematemesis and anemia
asymptomatic infection of the gut. E. A 27-year-old white woman with systemic
C. Duodenal involvement is common. sclerosis and anemia for four years
D. The diagnosis of MAC infection is best made
by endoscopic biopsy. 237 Tumors that may stain positive for CD117 beside
E. All statements are true. GISTs include which of the following?
A. Ewing’s sarcoma
233 Regarding postpolypectomy bleed, all of the follow- B. Small cell lung cancer
ing statements are true except: C. Melanoma
A. Patients taking warfarin are at increased risk of D. Seminoma
postpolypectomy bleeding. E. All of the above
B. Drugs such as aspirin, NSAIDs, ticlopidine,
and clopidrogel have been clearly shown to 238 All of the following are histologic characteristics of
increase the risk of postpolypectomy bleeding. PETs except:
 Topics Involving Multiple Organs 35

A. Homogeneity A. 60%
B. Crypt distortion B. 75%
C. Small round cells C. Nearly universal
D. Mitotic figures D. 25%
E. Electron-dense granules
245 Which of the following techniques is contraindi-
239 Analogous to the role of H. pylori in stimulating B cated in the endoscopic management of food
cell activity in gastric MALT lymphoma, the fol- impaction?
lowing bacteria have been implicated in immuno- A. Forceful blinded pushing
proliferative small intestinal disease: B. Using forceps to disrupt and debulk the bolus
A. E. coli C. Insufflation and distention of the esophageal
B. Bacteroides lumen
C. C. jejuni D. Use of an overtube
D. Yersinia enterocolitica E. None of the above

240 A 30-year-old man with AIDS presents with a one- 246 When diagnosing foreign body ingestion, appropri-
week history of progressive dysphagia and odyno- ate steps include all of the following except:
phagia that has resulted in a five-pound weight A. Thorough history and physical examination
loss. On examination, he is afebrile, and there is no B. Anteroposterior and lateral radiographs of the
evidence of thrush or ulcers in the oropharynx, but chest and abdomen
his mucous membranes are dry. Which of the fol- C. Endoscopy
lowing is the most likely finding on endoscopy? D. Barium studies
A. Extensive, deep ulcerations throughout the E. CT scan
esophagus
B. Diffuse, shallow ulcerations with areas of 247 Which of the following is the least harmful to
vesicles pregnant patients and their fetuses during an
C. Friability and ulceration of the distal esophagus endoscopy?
D. Focal or diffuse white plaques in association A. Fluoroscopy
with mucosal hyperemia and friability B. Meperidine
E. A foreign body C. Morphine
D. Benadryl
241 All of the following are adaptive physiologic E. Benzodiazepines
changes that occur in the GI system during preg-
nancy except: 248 A 64-year-old man with a history of diverticulosis
A. An increase in maternal blood volume by presents with left lower quadrant abdominal pain.
50%, resulting in a relative anemia His CAT scan reveals a 2- × 1.2-cm abscess. The
B. A decrease in plasma protein production patient is started on intravenous antibiotics. A
C. Alteration in bile acid composition, resulting repeat CT scan is performed four days later and
in crystal/stone formation reveals that the abscess is enlarging and now mea-
D. An increase in the absorption of amino acids, sures 4.0 × 4.2€cm. What is the next step in manage-
calcium, and vitamins due to an increase in ment of the patient?
small bowel weight and villous height A. Perform surgical resection and débridement.
E. A decrease in GI motility B. Change antibiotics as he might have developed
resistance to the existing ones.
242 Progressive systemic sclerosis (scleroderma) is char� C. Perform percutaneous drainage with catheter
acterized by vasculitis and fibrosis of multiple or� placement.
gans. All of the following are true except: D. Perform colonoscopy to evaluate the colon.
A. GI manifestations occur in approximately 90%
of patients. 249 What is the most common PET?
B. Esophagitis approaches 100% in patients with A. Gastrinoma
severe cutaneous involvement. B. VIPoma
C. Esophageal dysmotility correlates with the C. Somatostatinoma
development of interstitial lung disease. D. Glucagonoma
D. Malabsorption is attributed only to bacterial E. GRFoma
overgrowth.
E. Calcific pancreatitis and ischemic pancreatic 250 All of the following modalities for treatment of
necrosis have been reported. advanced (stage II E) MALT lymphoma are advis-
able except:
243 What is the percentage of cases of stage I MALT A. Chemotherapy
lym�phomas responding completely to H. pylori B. Radiation therapy
eradication? C. Surgery
A. 90% D. Immunotherapy with rituximab
B. 75%
C. 60% 251 The risk of cancer in long-lived transplant recipi-
D. 50% ents is higher than in the general population for
which of the following malignancies?
244 What is the rate of recurrence of hepatitis C virus A. Lymphomas
in the allograft? B. Skin cancers
36 Topics Involving Multiple Organs

C. Anal cancers B. Stop NSAIDs and discharge the patient with a

D. Kaposi sarcoma prescription for an oral PPI medication twice
E. All of the above daily.
C. Admit the patient, continue administration of
252 Adverse effects of imatinib (Gleevec) include all the intravenous fluids, start intravenous admin�
following except: istration of a PPI medication, and repeat the
A. Edema (mostly periorbital) EGD with a pediatric endoscope the next day.
B. Diarrhea D. Admit the patient, continue IV fluid administra�
C. Myalgia tion, start IV administration of a PPI medication,
D. Myelotoxicity and perform a CT scan of the abdomen stat.
E. Photophobia E. None of the above.

253 Regarding Zenker’s diverticula, all of the following 256 Significant risk factors for the development of
are true except: severe upper GI events in patients with rheumatoid
A. They are acquired. arthritis include all of the following except:
B. The opening of the upper esophageal sphincter A. Use of NSAIDs
is impaired. B. Age older than 65 years
C. They generally present in the seventh or C. History of peptic ulcer disease
eighth decade of life. D. Severe rheumatoid arthritis
D. Adenocarcinoma may develop in the E. Use of cyclooxygenase-2 inhibitors
diverticulum.
E. Aspiration of retained food may complicate 257 All of the following regarding food impaction are
induction of anesthesia. true except:
A. Food impaction is the most common ingested
254 Which of the following tumors may cause “foreign body” in the United States.
hypergastrinemia? B. The increased risk of complication is
A. Ovarian cancer proportional to the duration of the esophageal
B. Bronchogenic carcinoma food impaction.
C. Acoustic neuroma C. Endoscopic intervention should be achieved
D. All of the above at the latest within 48 hours of onset of
E. None of the above symptoms.
D. Success rates with the push method exceed
255 A 70-year-old man with a history of hyperten- 90%.
sion, diabetes mellitus, and coronary artery disease E. Eosinophilic esophagitis is increasingly
presents to the emergency department with two associated with esophageal food impactions.
episodes of melena in the past 24 hours. He
thinks that he may have had a dark, black stool 258 Acquired defects that allow internal hernias to occur
two to three days ago but is unsure. He had develop after which of the following procedures?
dizziness earlier in the day but never lost con- A. Billroth II gastrectomy
sciousness. He feels fine now. He is accompanied B. Roux-en-Y gastric bypass
by his wife who has a list of the medications C. Colectomy/ileostomy
that he is taking, which include oral hypoglycemic D. Tear in the sigmoid mesentery
agents, an angiotensin-converting enzyme inhibi- postcolonoscopy
tor, a β-adrenergic blocker, and NSAIDs for arthri- E. All of the above
tis. His medical history includes an appendectomy
several years ago, an abdominal aortic aneurysm 259 You are asked to provide a second opinion on a
repair 20 years ago, and a cardiac catheterization 45-year-old woman with an 11-year history of
a year ago. He appears pale but is alert and Crohn’s disease. She tells you that she was found to
oriented. His vital signs are pulse, 90 beats/minute; have multiple enteroenteric fistulas during a recent
blood pressure, 105/80 mm Hg; respiratory rate, workup for diarrhea. Her main symptom is volu�
22 to 24 breaths/minute; and temperature, 100.2°F. minous nonbloody diarrhea. She has been treated
He does not have orthostatic hypotension, abdomi- with antibiotics without significant relief. She was
nal pain, nausea, vomiting, or hematemesis. During placed on TPN but without significant improve-
evaluation in the emergency department, he has ment. Her gastroenterologist decides to start her on
another episode of melena. An intravenous infu- octreotide, and she wants to know why. You tell her
sion is started, and a blood sample is obtained that you agree with her primary gastroenterologist
in preparation for an upper endoscopy. His hemo- and explain to her that she is being started on octreo-
globin is 9.6€ g% with a normal mean corpuscular tide for all the following reasons except:
volume; however, his bicarbonate level is 16 A. Octreotide inhibits the release of gastrin,
mEq/L. EGD performed in the emergency depart- cholecystokinin, secretin, motilin, and other GI
ment shows a single, small, white-based ulcer in hormones.
the duodenal bulb. There is no blood in the B. Octreotide relaxes intestinal smooth muscle,
stomach or visualized portions of the duodenum. thereby allowing for a greater intestinal
The patient now feels much better. Which of the capacity.
following is the best approach at this point? C. Octreotide increases intestinal water and
A. Stop NSAIDs, admit the patient, continue electrolyte absorption.
administration of intravenous fluids, and begin D. Octreotide decreases abdominal distention and
intravenous administration of a PPI. pain.
 Topics Involving Multiple Organs 37

260 Mixed connective tissue disease shares all of the abdomen and buttocks. Which one of the following
following similarities with scleroderma, systemic hormones will be produced by this lesion?
lupus erythematosus, and polymyositis except: A. Somatostatin
A. Abnormal esophageal motility B. Insulin
B. Impaired gastric emptying C. Glucagon
C. Intestinal pseudo-obstruction D. Vasoactive intestinal polypeptide
D. Pancreatitis
E. Abnormal esophageal motility improvement 265 A 67-year-old man with a history of migraines
with the use of glucocorticoids treated with ergotamine preparations presents with
symptoms of abdominal pain, nausea, vomiting,
261 For each of the following circumstances, answer and abdominal distention. A CT scan demonstrates
this statement with true or false: “Antibiotic pro- dilated loops of small bowel, air–fluid levels,
phylaxis should be given before this GI procedure.” inflammatory changes of the mesentery and retro-
A. A 57-year-old white man who is about to peritoneum, and medial displacement of the ure�
undergo esophageal stricture dilation had his ters. A possible treatment option for this disorder
left hip replaced two years ago. includes which of the following?
B. A 49-year-old man with a history of alcohol A. Ureteral stenting
abuse, recurrent pancreatitis, and pancreatic B. Steroids
pseudocyst is about to undergo ERCP and C. Azathioprine
possible pseudocyst drainage. D. Decompressive nasogastric tube
C. A 90-year-old nursing home patient transferred E. All of the above
for percutaneous endoscopic gastrostomy
(PEG) tube placement 266 A 60-year-old obese woman who underwent surgi-
D. A 45-year-old white woman with mitral valve cal repair of a large incisional hernia a few hours
prolapse and a 10-year history of ulcerative previously is noted to be tachypneic and in respira-
colitis who takes antibiotics before dental tory distress. Her electrocardiogram shows no
procedures and is about to undergo surveil� change from her preoperative electrocardiogram
lance colonoscopy and a ventilation/perfusion scan of the lungs shows
E. A 50-year-old African-American man who no embolism. What would be a likely mechanism
had a defibrillator placed six months ago for her symptoms?
and is now admitted with painless A. Decreased venous return to the heart
obstructive jaundice and is about to B. Small undetected pulmonary embolism
undergo ERCP C. Compression of the lungs due to increased
abdominal volume and pressure postrepair
262 A 45-year-old woman who underwent kidney trans- D. Previously undiagnosed chronic obstructive
plantation three years ago has been experiencing pulmonary disease
fatigue and nonbloody, crampy diarrhea. Her stool E. A and C
studies are negative for C. difficile, but there are
WBCs in the stool. Colonoscopy reveals mild patchy 267 A 35-year-old woman has small bowel Crohn’s
erythema throughout the transverse, descending, disease for five years. She has recently gone from
and sigmoid colon. Biopsy specimens reveal eosin- her usual four to five bowel movements per day to
ophilic infiltrates. Which of the following medica- 10 to 15 episodes of voluminous diarrhea (>1€ L
tions is most likely responsible for the findings? output). She reports weakness and says that she
A. Tacrolimus and cyclosporine frequently feels light-headed. What should be done
B. MMF next to evaluate her symptoms?
C. Prednisone A. Small bowel series
D. Ganciclovir B. CAT scan of the abdomen and pelvis
C. Colonoscopy
263 True statements about the cutaneous manifesta- D. Capsule endoscopy
tions of inflammatory bowel disease include all of
the following except: 268 When compared with the general population,
A. Cutaneous lesions are more common in people patients who survive more than 10 years follow�
with Crohn’s disease than in people with ing HCT have what risk for developing a new
ulcerative colitis. solid malignancy?
B. Erythema nodosum can occur in those with A. 20-fold
Crohn’s disease or ulcerative colitis. B. Twofold
C. Treatment of the underlying disease usually C. Eightfold
improves the skin lesions. D. No increase in risk
D. Pyoderma gangrenosum presents as painless
ulcers in 5% of patients with ulcerative colitis 269 A 38-year-old woman who has undergone HCT has
and 1% of patients with Crohn’s disease. a history of chronic GVHD. She recently began
E. Pyostomatitis vegetans may occur years before tapering her immunosuppression medication. She
the onset of GI symptoms in those with irrit� now presents with nausea, fatigue, and an AST
able bowel disease (IBD). level of 3000 U/L. What is the next step?
A. Check the blood for viral hepatitis.
264 A 40-year-old man presents with diarrhea, weight B. Perform a liver biopsy to exclude HSV,
loss, and episodic blistery rash noted over his lower varicella-zoster virus, or viral hepatitis.
 Another Random Document on
Scribd Without Any Related Topics
The Project Gutenberg eBook of Peter Parley's
Visit to London, During the Coronation of
Queen Victoria
This ebook is for the use of anyone anywhere in the United States
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Title: Peter Parley's Visit to London, During the Coronation of Queen

Victoria

Author: Samuel G. Goodrich

Release date: October 22, 2013 [eBook #43995]

Most recently updated: October 23, 2024

Language: English

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*** START OF THE PROJECT GUTENBERG EBOOK PETER PARLEY'S

VISIT TO LONDON, DURING THE CORONATION OF QUEEN
VICTORIA ***
 PETER PARLEY'S
VISIT TO LONDON.

LONDON:
CLARKE, PRINTERS, SILVER STREET, FALCON SQUARE.
Madeley lith. 3, Wellington St. Strand.
THE CORONATION OF HER MAJESTY QUEEN
VICTORIA.

PETER PARLEY'S
VISIT TO LONDON,
 DURING THE
CORONATION OF QUEEN VICTORIA.

LONDON:
CHARLES TILT, FLEET STREET.
MDCCCXXXIX.

TO THE GOOD

LITTLE BOYS AND GIRLS

Of Great Britain,
 PETER PARLEY

DEDICATES THESE PAGES.

 CONTENTS.

CHAPTER I.
Page
PARLEY ARRIVES IN LONDON
1

CHAPTER II.
PARLEY GOES TO SEE THE NEW CROWN 6

CHAPTER III.
PARLEY VISITS WESTMINSTER ABBEY AND HYDE-PARK.—PREPARATIONS FOR
11
THE FAIR

CHAPTER IV.
PARLEY SEES THE QUEEN, AND RELATES SOME ANECDOTES OF HER MAJESTY 16

CHAPTER V.
PARLEY CONTINUES HIS ANECDOTES OF THE QUEEN 28

CHAPTER VI.
PARLEY DESCRIBES WESTMINSTER ABBEY ON THE MORNING OF THE
CORONATION, AND RELATES THE LEGENDS CONNECTED WITH ST. EDWARD'S 40
CHAIR

CHAPTER VII.
PARLEY DESCRIBES THE PROCESSION TO WESTMINSTER ABBEY 52

CHAPTER VIII.
PARLEY DESCRIBES THE CORONATION IN WESTMINSTER ABBEY 65
 CHAPTER IX.
PARLEY CONTINUES HIS DESCRIPTION OF THE CORONATION IN WESTMINSTER
81
ABBEY

CHAPTER X.
PARLEY GIVES AN ACCOUNT OF THE ILLUMINATIONS, AND OF THE GRAND
92
DISPLAY OF FIRE-WORKS

CHAPTER XI.
PARLEY ATTENDS A REVIEW IN HYDE PARK, AND RELATES SOME PASSAGES IN
103
THE LIFE OF MARSHAL SOULT.—CONCLUSION

PETER PARLEY'S
VISIT TO LONDON.
 CHAPTER I.
PARLEY ARRIVES IN LONDON.

"Well, my little friends, here is your old acquaintance, Peter Parley,

come to tell some more of his amusing Tales. You wonder, I dare
say, what could tempt such a frail old man as I am to leave home,
and come so far. You shall hear.
"A Coronation, you must know, is a sight not to be seen every day
in the United States, where we have neither King nor Queen, so
thinks I to myself, I hear a great deal about the grandeur of the
spectacle which is to be exhibited at the crowning of Queen Victoria,
and though I have seen many grand sights in my day, I have never
seen a Coronation, so I shall just get into one of these new steam
ships which take one across the Atlantic Ocean so quickly, and have
a look at the affair. I shall, besides, have an opportunity of seeing
the kind London friends who treated me so handsomely when I was
last in England, and then I shall have such lots of new stories for my
young friends. I must—I shall go!
"Peter Parley is not a man to spend much time in idling after
having formed a resolution, so the very next day, having bid my old
housekeeper good bye, I was on my way to New York.
"As soon as I arrived at New York, I made enquiries about the
steam ships, and, finding that the 'Great Western' was to sail very
soon, I secured my passage in her, and then went to visit my friends
in that city, for I always like to fulfil the old adage, and finish my
work before I begin to play.
"Every body was surprised at my undertaking, and some kind
folks wanted to persuade me to stay at home, thinking to frighten
me by telling me about the length of the voyage, &c. They did not
know Peter Parley. One wag, who wished to be very witty, asked me
why I did not wait and take my passage in the new American ship,
the 'Horse-Alligator,' which was to sail on the 25th of June, and
arrive in London the day before! I could not help laughing at the
idea, but I told him that steam was quick enough for me.
"I have already told you about my voyages across the Atlantic, so
I need do no more now than make just one passing remark on the
splendour of the fitting-up, and the admirable arrangements of the
'Great Western.' We passed a great many vessels as we came along,
especially when we were not far distant from the American and
English shores. They had no chance with us. Sometimes we
discovered them far a-head, like mere specks on the ocean. In an
hour or two we came up with them, and, in as much more time, left
them far behind. The steady and untiring whirl of the steamer's
paddles carried every thing before it.
"We reached Bristol in thirteen days, and, as I had nothing to
detain me there, I hurried on to London, and arrived in the middle of
the grand preparations.
"Every body was as busy as a bee.—Nothing was talked of but the
Coronation. 'Oh! Mr. Parley, have you come to see the Coronation
too?' was my first salute from every lip. My kind old friend, Major
Meadows, insisted on my taking up my quarters in his house, and
promised that I should see every thing that was to be seen, and
hear every thing that was to be heard. This was just what I wanted
to be at, so I fixed myself with him at once."
 CHAPTER II.
PARLEY GOES TO SEE THE NEW CROWN.

"After paying a few visits, and renewing old friendships, I set myself,
in good earnest, to see what was to be seen.
"The most attractive object, connected with the Coronation,
exhibiting at the time, was the new crown made for the occasion. I
accordingly made the best of my way into the city, to the shop of
Messrs. Rundell and Bridge, her Majesty's goldsmiths, on Ludgate
Hill, who, with the greatest liberality, had thrown open their rooms
that the public might have an opportunity of inspecting the crown.
"So great was the crowd, all anxious to have a peep, that it was
some time before I could press forward to the door of the shop.
Carriages were so busy taking up and setting down company, that
the street was quite blocked up. At length, however, by dint of
perseverance, Peter Parley managed to squeeze in.
"After traversing the shop, all round which are ranged articles of
the most massive and costly description, we were ushered into an
interior apartment, in which, in glass cases, were deposited the
precious curiosities.
"In the centre, the admired of all beholders, was the Royal
Crown. It is beautifully designed, and formed in the most costly and
elegant manner, and so covered with precious stones, as almost to
dazzle the eyes of old Peter Parley. It is composed of hoops of silver,
enclosing a cap of deep purple velvet. The hoops are completely
covered and concealed by precious stones, the whole surmounted by
a ball covered with small diamonds, and having a Maltese cross of
brilliants on the top of it. The body of the crown is wreathed with
fleurs-de-lis and Maltese crosses; the one in the front being
ornamented with a very large heart-shaped ruby, once, I was
informed, a principal ornament in the crown of Edward the Black
Prince, and which he is said to have worn at the battle of Cressy.
Peter Parley cannot remember all the details, for besides these,
there are many other precious stones in the crown. The rim is
surrounded with ermine, and it certainly struck me as being one of
the finest things I had ever seen.
"Close beside the crown were the coronets of the Royal Dukes
and Duchesses, but though they also were made of costly materials,
the attractions of the crown were so great as to throw the others
quite into the back ground. I had hardly time to turn my eyes toward
the case containing the Orb and Sword of state, before I was hurried
away by the pressure of the crowd behind, which kept pouring in in
undiminished numbers.
"As I moved towards the door behind the shop, which was set
apart for visitors retiring, I passed a table on which was displayed a
service of massive gold utensils, to be used in the consecration
service.
"When I reached the street, I found it still densely crowded. I
wanted to go to St. Paul's, which stands close by, but was afraid to
venture into such a crowd, so I directed my steps to Westminster
Abbey, making my way with some difficulty down Ludgate Hill and
along Fleet Street, and passing beneath Temple Bar, which marks
the boundary of the City."
 CHAPTER III.
PARLEY VISITS WESTMINSTER ABBEY AND
HYDE-PARK. PREPARATIONS FOR THE FAIR.

"As I approached the venerable pile I found all in bustle and

confusion. Every where carpenters were busily engaged fitting up
galleries for the accommodation of spectators of the procession on
the day of the coronation. Ranges of such erections lined the whole
course of the street through which the procession was to pass, up to
the very door of the Abbey; even the church-yard was lined with
them. These I was told were the speculations of tradesmen, who let
the sittings according to the value of the situation, at prices varying
from half-a-sovereign up to a couple of guineas. For some very
choice places even five guineas was asked.
"Peter Parley could not help smiling at the fine names which had
been given to some of these erections; such as the 'Royal Victoria
Gallery,' the 'Royal Kent Gallery,' &c., &c.
"By order of the Earl Marshal no visitors were permitted to enter
the Abbey; but as good luck would have it, just as I happened to be
passing the western grand entrance I met a gentleman connected
with the Board of Works, whom I had seen at Major Meadows's the
day before, and who most obligingly offered to introduce me.
"I gladly availed myself of his invitation, and was much struck
with the grandeur and extent of the preparations.
"At the western entrance to the Abbey a suite of apartments for
robing-rooms for her Majesty and the members of the Royal Family
had been erected. So completely did this structure harmonize
externally with the rest of the antique building, that I should not
have observed that it was a temporary erection had it not been
pointed out to me. The chamber set apart for her Majesty was fitted
up in the most gorgeous manner—the walls beautifully ornamented,
and the furniture, all of the richest and most magnificent description.
Though less costly the apartments for the Royal Family were equally
chaste.
"The interior of the Abbey presented a scene at once animated
and beautiful. Workmen were busily engaged in various parts
finishing the preparations. I will have occasion to tell you about the
interior of the Abbey by and by, so I may as well say nothing about
it at present.
"Peter Parley now proceeded to Hyde-Park to see the preparations
for the grand fair which was to be held in that noble pleasure-
ground on this joyous occasion.
"Already many booths displayed themselves on the plain, and
many more were in the act of being erected. Richardson, who Peter
Parley understood is one of the most famous of the show-folks, had
erected a large and handsome theatre, which even thus early
seemed to have considerable attractions for the multitude who had
gathered round it in great numbers.
"Peter Parley having seen all that was worth seeing in the fair was
beginning to feel tired, and was directing his steps homeward, when
all of a sudden his attention was attracted to a particular part of the
Park to which people seemed to be hastening from all quarters.
Peter Parley hurried to the spot and was most agreeably surprised to
find that it was Queen Victoria, accompanied by her suite, taking her
accustomed airing in her carriage."
 CHAPTER IV.
PARLEY SEES THE QUEEN, AND RELATES SOME
ANECDOTES OF HER MAJESTY.

"'What a dear sweet lady!' were the first words of Peter Parley
when the Royal cavalcade had passed.

Madeley lith. 3, Wellington St. Strand.

HER MAJESTY LEAVING BUCKINGHAM PALACE ON THE MORNING OF
THE CORONATION.

"'She is a dear sweet lady, Mr. Parley, and, what is more, she is as
good as she is sweet,' said my friend, Major Meadows, who, afraid
lest I should overwalk myself in my zeal for sight-seeing, had
followed me from Westminster Abbey and luckily fallen in with me in
the park, and he went on to relate many very interesting anecdotes
of the young Queen, which Peter Parley took good care to remember
because he knew they would gratify his young friends."
"'Her Majesty is doatingly fond of children, Mr. Parley,' said he,
'and that you know is always the sign of a good heart. Nothing can
be finer than the traits of character exhibited in a little anecdote
which Lady M—— told me a day or two ago.
"'Not long since, her Majesty commanded Lady Barham, one of
the ladies in waiting, to bring her family of lovely children to the new
palace. They were greatly admired and fondly caressed by the
Queen; when a beautiful little boy about three years of age artlessly
said—
"'I do not see the Queen; I want to see the Queen;' upon which
her Majesty, smiling, said—
"'I am the Queen, love;' and taking her little guest into her arms
repeatedly kissed the astonished child.
"This little anecdote warmed old Peter Parley's heart towards the
young Queen; nor did any of the stories which Major Meadows told
me tend to lessen my regard for her. Peter Parley was pleased to
hear that she has a proper sense of the importance of the station to
which she has been called by Divine Providence.
"On the day on which she was proclaimed Queen of Great Britain
she arrived in company with her royal mother at St. James's Palace
for the purpose of taking part in the important ceremony. As they
drove towards the palace the party received the most affectionate
demonstrations of loyalty and attachment, the people following the
carriages with a continuous cry of 'Long live the Queen'—'God bless
our youthful Queen, long may she live,' &c. Yet, exciting and
exhilirating as were these acclamations, her Majesty's countenance
exhibited marks only of anxiety and grief.
 "They arrived at St. James's Palace a little before ten o'clock.
When the old bell of the palace-clock announced that hour, the band
struck up the National Anthem, the Park and Tower guns fired a
double royal salute, and the young and trembling Queen, led by the
Marquis of Lansdowne, President of the Council, appeared at an
open window looking into the great court of the Palace. At the
fervent and enthusiastic shout of the people who had come to
witness the ceremony, her Majesty burst into tears, and, in spite of
all her efforts to restrain them, they continued to flow down her pale
cheeks all the time she remained at the window. Her emotions did
not, however, prevent her from returning her acknowledgments for
the devotedness of her people.
"Some of the most interesting anecdotes which Peter Parley
heard, however, related to an earlier period of the Queen's life, when
she was Princess Victoria.
"'Here is an anecdote which I heard at a Missionary Meeting, Mr.
Parley,' said Major Meadows, 'and I assure you it told with great
effect.'"
"A poor but truly pious widow, placed in charge of a lighthouse on
the south coast of the Mersey, had resolved to devote the receipts of
one day in the year, during the visiting season, to the Missionary
cause. On one of these days, a lady in widow's weeds and a little girl
in deep mourning came to see the lighthouse; sympathy in
misfortune led to conversation, and before the unknown visitor took
her departure they had most probably mingled their tears together.
The lady left behind her a sovereign. The unusually large gratuity
immediately caused a conflict in the breast of the poor woman, as to
whether she was absolutely bound to appropriate the whole of it to
the Missionary-box or not. At length she compromised, by putting in
half-a-crown. But conscience would not let her rest: she went to
bed, but could not sleep; she arose, took back the half-crown, put in
the sovereign, went to bed and slept comfortably. A few days
afterwards, to her great surprise, she received a double letter,
franked, and on opening it, was no less astonished than delighted to
find twenty pounds from the widow lady, and five pounds from the
little girl in deep mourning. And who were that lady and that little
girl, do you think? No other than her Royal Highness the Duchess of
Kent and our present rightful and youthful sovereign."
"During one of the summer seasons of the Princess's childhood
the Duchess of Kent resided in the neighbourhood of Malvern, and
almost daily walked on the Downs. One day the Princess and her
beautiful little dog Pero, of which she was uncommonly fond,
happening considerably to outstrip the Duchess and governess, she
overtook a little peasant girl about her own age. With the
thoughtless hilarity of youth she made up to her, and without
ceremony, said to her—
"'My dog is very tired, will you carry him for me if you please?'
"The good-natured girl, quite unconscious of the rank of the
applicant, immediately complied, and tripped along by the side of
the Princess for some time in unceremonious conversation. At length
she said,
"'I am tired now, and cannot carry your dog any farther.'
"'Tired!' cried her Royal Highness, 'Impossible! Think what a little
way you have carried him!'
"'Quite far enough,' was the homely reply; 'besides, I am going to
my aunt's, and if your dog must be carried, why cannot you carry
him yourself?'
"So saying, she placed Pero on the grass, and he again joyfully
frisked beside his royal mistress.
"'Going to your aunt's;' rejoined the Princess, unheeding Pero's
gambols; 'pray who is your aunt?'
"'Mrs. Johnson, the miller's wife.'
"'And where does she live?'
 "'In that pretty little white house which you see just at the bottom
of the hill, there;' said the unconscious girl, pointing it out among
the trees; and the two companions stood still that the Princess might
make sure that she was right, thus giving the Duchess and her
companion time to come up.
"'Oh, I should like to see her!' exclaimed the light-hearted
Princess; 'I will go with you, come let us run down the hill together.'
"'No, no, my Princess,' cried the governess, coming up and taking
her Royal Highness's hand, 'you have conversed long enough with
that little girl, and now the Duchess wishes you to walk with her.
"The awful words 'Princess' and 'Duchess' quite confounded the
little peasant girl; blushing and almost overcome, she earnestly
begged pardon for the liberties she had taken, but her fears were
instantly allayed by the Duchess, who, after thanking her for her
trouble in carrying Pero, recompensed her by giving her half-a-
crown.
"Delighted, the little girl curtsied her thanks, and running on
briskly to her aunt's, she related all that had passed, dwelling
particularly on the apprehension she had felt when she discovered
that it was the Princess whom she had desired to carry her dog
herself. The half-crown was afterwards framed and hung up in the
miller's homely parlour, as a memento of this pleasing little
adventure."
"This is but a childish story, but Peter Parley loves to hear stories
of good children, and he knows that his little friends love to hear
them too."
 CHAPTER V.
PARLEY CONTINUES HIS ANECDOTES OF THE
QUEEN.

"There was one anecdote of the Queen from which Peter Parley
derived much pleasure, because it showed that, notwithstanding her
high station, she is not unmindful of Him by whom 'Kings reign, and
Princes decree justice.'
"A noble lord, one of her Majesty's ministers of state, not
particularly remarkable for his observance of holy ordinances,
recently arrived at Windsor Castle late one Saturday night.
"'I have brought down for your Majesty's inspection,' he said,
'some papers of importance, but as they must be gone into at length
I will not trouble your Majesty with them to-night, but request your
attention to them to-morrow morning.'
"'To-morrow morning!' repeated the Queen; 'to-morrow is Sunday,
my lord.'
"'But business of state, please your Majesty—'
"'Must be attended to, I know,' replied the Queen, 'and as of
course you could not come down earlier to-night, I will, if those
papers are of such vital importance, attend to them after we come
from church to-morrow morning.'
"To church went the royal party; to church went the noble lord,
and much to his surprise the sermon was on 'The duties of the
Sabbath!'
 "'How did your lordship like the sermon?' enquired the young
Queen.
"'Very much, your Majesty,' replied the nobleman, with the best
grace he could.
"'I will not conceal from you,' said the Queen, 'that last night I
sent the clergyman the text from which he preached. I hope we
shall all be the better for it.'
"The day passed without a single word on the subject of the
'papers of importance,' and at night, when her Majesty was about to
withdraw, 'To-morrow morning, my lord,' she said, 'at any hour you
please, and as early as seven if you like, we will go into these
papers.'
"His lordship could not think of intruding at so early an hour on
her Majesty; 'Nine would be quite time enough.'
"'As they are of importance, my lord, I would have attended to
them earlier, but at nine be it;' and at nine her Majesty was seated
ready to receive the nobleman, who had been taught a lesson on
the duties of the sabbath, it is hoped, he will not quickly forget.
"Exemplary as the young Queen is in her religious duties,
however, Peter Parley was pleased to find that she does not allow
her religion to consist in mere theory, but that in reality she clothes
the poor and feeds the hungry.
"On one occasion when her Majesty, accompanied by her suite,
was taking an airing on horseback, in the neighbourhood of Windsor,
she was overtaken by a heavy shower, which forced the royal party
to seek shelter in an outhouse belonging to a farm yard, where a
poor man was busily employed making hurdles. Her Majesty entered
into conversation with the man (who was totally ignorant who he
was addressing), and finding that he had a large family and no
means of supporting them beyond what he gained by making these
hurdles, her Majesty enquired where he lived, and on taking her
departure presented him with a sovereign. Next day she went,
accompanied by her Royal Mother, to the cottage of the poor man,
and finding his statement to be correct, immediately provided some
good warm clothing for his wife and children. Her Majesty seemed
very much pleased with the neatness and regularity of the cottage,
and on taking her departure presented the poor woman with a five-
pound note.
"There was no end to stories of this description, but I can only
afford room for two or three more; one of which, in particular, shows
how early the Queen has been taught to look up to the only source
of real comfort in affliction.
"An old man who once served in the capacity of porter to the
Duke of Kent, and who, in his old age and infirmity, has long since
been pensioned by the Duchess, is not a little gratified at receiving a
nod of recognition from her Majesty whenever her carriage chances
to pass his cottage. The aged man has a daughter much afflicted,
and who has been confined to bed for eight or ten years. On the
evening of the late king's funeral this young woman was equally
surprised and delighted at receiving from the Queen a present of the
psalms of David in which was a marker worked by herself with a
dove, the emblem of peace, in the centre. It pointed to the forty-first
psalm, which her Majesty requested she would read, at the same
time expressing a hope that its frequent perusal might bring an
increase of peace to her mind.
"Another poor man named Smith, who had for several years
swept the crossing opposite the avenue leading to Kensington
palace, and whom her Majesty always kindly noticed, rarely passing
through the gates without throwing him some silver from the
carriage window, received a message on the morning after the
Queen's accession informing him that her Majesty had ordered that
a weekly allowance of eight shillings should be regularly paid him.
The poor man, however, did not long enjoy his pension, dying within
six months from its commencement.
 "Short and brilliant as has been her Majesty's career however, and
fondly and carefully as she has been watched over, her life affords a
very striking instance of providential preservation.
"During one of their summer excursions on the southern coast of
England, the Royal party sailed in the Emerald yacht, and proceeding
up the harbour at Plymouth for the purpose of landing at the dock-
yard, the yacht unfortunately, from the rapidity of the tide, ran foul
of one of the hulks which lay off the yard. The shock was so great
that the mainmast of the royal yacht was sprung in two places, and
her sail and gaff (or yard by which the sail is supported) fell
instantaneously upon the deck.
"The Princess happened unfortunately to be standing almost
directly under the sail at the moment, and the most fatal
consequences might have ensued, had not the master of the yacht,
with admirable presence of mind, sprung forward and caught her in
his arms and conveyed her to a place of safety. The alarm and
confusion caused by the accident was for a time heightened by the
uncertainty as to the fate of her Royal Highness, who had been
preserved from injury by the blunt but well-timed rescue of the
honest sailor.
"'There is one thing which pleases me mightily, Mr. Parley,' said
Major Meadows, 'and it is this, that with all this goodness our young
Queen has a truly British heart. Often and often has she manifested
this, and when quite a girl though perfectly acquainted with several
European languages, and particularly with French and German, she
never could be prevailed upon to converse in them as a habit,
always observing that 'she was a little English girl and would speak
nothing but English.' There is a healthiness of feeling in this, Mr.
Parley, which is quite delightful.'
"Long before Major Meadows had finished his anecdotes about
the Queen we had reached home. As it is the custom to dine late in
London, we dined after our return, and during the repast, the Queen
and the spectacle of to-morrow formed the chief subject of
conversation, my friend continuing from time to time to give interest
by some new anecdote, of which his store seemed to be
inexhaustible.
"Peter Parley is fond of early hours, so we retired to bed betimes,
which was the more necessary, because by sun-rise to-morrow we
must be up and away to Westminster Abbey."
 CHAPTER VI.
PARLEY DESCRIBES WESTMINSTER ABBEY ON
THE MORNING OF THE CORONATION, AND
RELATES THE LEGENDS CONNECTED WITH ST.
EDWARD'S CHAIR.

"Early in the morning, Peter Parley was up and dressed. He had

hardly finished his devotions when, early though it was, Major
Meadows knocked at the door of his room to enquire if he was
stirring.
"After partaking of a hurried breakfast we got into a carriage and
drove to the Abbey. As we passed along, we found people, even at
such an early hour, already begun to congregate in the streets, and
to take up stations from which they expected to obtain the best view
of the day's proceedings.
 Madeley lith. 3, Wellington St. Strand.
HER MAJESTY LEAVING HER PRIVATE APARTMENTS IN
WESTMINSTER ABBEY.

"Peter Parley was pleased to find, on our arrival at the Abbey, that
the doors had been opened a short time before, and the crowd of
eager expectants who had been waiting, some of them upwards of
an hour, had been already admitted. We were thus saved the
necessity of exposing ourselves to being crushed by stronger and
more energetic claimants for admission.
 "On entering the venerable building I was struck mute with
astonishment at the magnificence of the preparations which now
burst upon the sight with all their breadth and effect; though I had
seen it so recently, I was not at all aware of the greatness of the
scale on which they had been undertaken.
"The approach to the theatre was by six broad steps leading from
the vestibule under the music gallery. At the termination of the choir,
just where it is intersected by the north and south transepts, a
similar number of steps led to a large platform, covered with a
splendid carpet in rich puce and gold colours. Upon this platform
was raised a second of a smaller size, approached by four broad
steps, each covered with carpeting of the most magnificent
description. The fifth step, which formed the platform, was covered
with cloth of gold, and in the centre was placed a splendid throne of
a rich gilt ground, tastefully embellished with rose-coloured sprigs at
short intervals, and the royal initials in the centre.
"A little further in advance of this splendid throne, and nearer the
altar, stood a chair of a more humble bearing, but far more
interesting, from the legendary stories connected with it. This was
St. Edward's chair, of which Peter Parley must say a few words.
"The chair is made of solid oak, and beneath the seat is deposited
a large stone, on which the Scottish kings used to be crowned. The
legendary history of this stone is very curious. It commences as
early as the time of Jacob, who is said to have rested his head on it
in the plain of Luz, when, as you will recollect, he fled from the
anger of his brother Esau. It was afterwards carried to Spain, by the
Scythians, whence it found its way into Ireland in the time of
Romulus and Remus, the founders of Rome. Here, it seems, from all
accounts, first to have exhibited miraculous powers—making a
'prodigious noise, and being surprisingly disturbed,' whenever a
prince of the Scythian line was seated upon it. Peter Parley would
not have you believe any of these marvellous legends, none of which
are true, but which are interesting nevertheless, as they serve to
show in what manner the people of former times were misled by the
silly and ridiculous legends of the darker ages.
"From Ireland this singular stone was carried into Scotland, and
placed in the Abbey of Scone, where the coronation of the Kings of
Scotland usually took place. One of the Scottish kings caused an
inscription to be cut upon it, an ancient prophecy, as it was said, but
more probably an invention of some monkish chronicler of the time:
—
"If Fate speak sooth, where'er this stone is
found,
The Scots shall monarch of that realm be
crown'd."
"When Edward I. dethroned Baliol, he sent this celebrated stone,
on the possession of which the Scots set great value, to London,
along with the Scottish regalia. In the following year, the monarch
presented these trophies at the shrine of St. Edward the Confessor;
and it appears soon afterwards to have been placed in the
coronation chair, where it has remained ever since.
"Peter Parley has heard that the ancient prophecy, to which even
at so late a period the more superstitious amongst the Scottish
nation clung, was held to be fulfilled when James I. ascended the
throne of England; and it is also said not to have been without a
certain influence in reconciling many of the people to the Union with
England.
"But we must not forget the coronation in Westminster Abbey, in
our interest in the legend connected with St. Edward's chair.
"On each side of the platform on which the thrones stood, were
the galleries appropriated for Peers and Peeresses and their friends,
also those for the Lord Mayor, Aldermen, and Privy Councillors.
"There were two other galleries rising above these on each side,
the highest quite among the vaultings of the roof, which were
appropriated indiscriminately to the rest of the visitors.
"The whole of these extensive galleries were covered with
crimson cloth, and trimmed with gold fringe, which had a very rich
effect when contrasted with the sombre colours and antique stone
walls of the building.
"The decorations of the chancel and altar were of the most
gorgeous description; the draperies being of the richest purple silk,
brocaded in the most sumptuous pattern with gold. Behind the altar
the decorations were of a still more delicate character than the rest,
both the ground-work and the gold being of a lighter shade. Against
the compartment behind the altar stood six massive gold plateaux,
two of them being of very large dimensions. The table itself was
loaded with a gold communion service, as well as with other articles
used in the ceremony.
"Peter Parley had time to notice all these things from being in the
Abbey so early in the morning, before the visitors were so
numerous, and the place so crowded as it afterwards became. The
good sense and knowledge of Major Meadows led him to select a
seat from which, while we could see as much of the ceremony as
nine-tenths of those within the Abbey, we could readily retire to the
roof, from which we could obtain an admirable view of the
procession outside.
"By six o'clock in the morning the visitors began to arrive in the
interior of the Abbey, and bustle and confusion began to prevail,
where, but an hour before, all had been stillness and silence; the
rich and elegant dresses of the ladies giving an air of gaiety to the
scene. An hour later the Peers and Peeresses began to make their
appearance, and the attention was kept completely on the alert by
some new arrival of a distinguished personage, or of a rich or
picturesque costume."
 "At length the sound of the Park guns announced that the Queen
had entered her carriage and was on her way to the Abbey. This
joyful announcement seemed to inspire every one present with joy
and animation. The Peers, who had hitherto dispersed themselves
over various parts of the building, giving, by their rich and
picturesque costumes, additional brilliancy and variety to the already
gorgeous scene, now retired to their appointed places, and a certain
degree of order began to prevail within the Abbey.
"As the procession began to draw near, Peter Parley took
advantage of Major Meadows' foresight, and, with some little
difficulty, made his way to the roof, to view its approach."
 CHAPTER VII.
PARLEY DESCRIBES THE PROCESSION TO
WESTMINSTER ABBEY.

"From this elevated and commanding position Peter Parley had a

most admirable view of the procession, and of the immense
multitude of spectators which lined the streets and crowded every
window and roof from which even the most distant and casual view
of it could be obtained.
"Far as the eye could reach was one dense mass of human
beings. The deafening cheers of the populace, the waving of ten
thousand handkerchiefs, the clang of martial music, and the novelty
and singularity of the whole scene, well nigh turned the head of
poor Peter Parley.
"He had hardly time to satisfy his old eyes with gazing on the
immense assemblage when the procession began to approach.
"Peter Parley will not attempt to give you an exact list of the
procession, for he knows very well that a simple catalogue of names
would not at all interest you; he will therefore merely run hastily
over the principal parts of it, and show you drawings of several of
the most striking scenes, which he knows very well will give you by
one glance a clearer idea of it than if he were to spend hours in
mere description.
"Preceded by a squadron of horse-guards, whose gallant and
warlike bearing excited general admiration, came the carriages of
the foreign ministers resident in this country. Even in the midst of so
much bustle, Peter Parley could not help moralizing on the
singularity of the scene. Here were the representatives of every
power on the face of the globe gathered together in one harmonious
congregation; and the feelings to which their passing thus in review,
in a living panorama as it were, gave rise were of the most peculiar
description. Here were all separate and rival interests for the
moment buried in oblivion, and people from the east, from the west,
and from the north, and from the south, came to assist in doing
honour to England's Queen.
"Immediately behind the resident ministers followed the
ambassadors extraordinary, that is, those who had been sent by
their respective governments for the express purpose of taking part
in the solemnity. Some of the carriages and trappings of these
ambassadors excited the greatest attention and admiration. Those in
particular of Marshal Soult, the French ambassador, one of the ablest
opponents of the Duke of Wellington during the peninsular war, were
rich almost beyond description. In colour his carriage was of a rich
cobalt relieved with gold, the panels most tastefully ornamented
with his Excellency's armorial bearings, at the back of which was a
field-marshal's baton. It was furnished at each corner with a lamp
surmounted by a massive silver coronet, and the raised cornices with
which it was ornamented were of silver, deep and richly chased.
These, with the beautiful harness (of white—the furniture was also
of silver exquisitely chased), gave an air of richness and beauty to
the whole equipage which was quite unequalled in the procession.
Peter Parley thought he should never have done gazing at the rich
and splendid equipage.
"The carriages and attendants of the ambassador from the
Sultan, though far less richly caparisoned, were objects of equal
curiosity, partly on account of the eastern dress in which Ahmed Fetij
Pasha appeared, and partly because of that undefined idea of
romance which exists in the popular mind in connection with the
crescent and the rising sun, the emblems of Turkish power.
"The carriage was of a rich lake colour, with the emblems which
Peter Parley has just mentioned richly emblazoned on the panels.
Inside it was lined with crimson and yellow silk, in rich festoons; the
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