PANCE Prep GI + Practice Questions and Answers Rated A
Ulcerative Colitis appearance on colonoscopy- achieves good symptomatic relief with a course
Crypt abscesses and if toxic megacolon of an empiric, once-daily proton pump inhibitor,
present loss of haustra and blood vessels therapy may be discontinued after eight to twelve
weeks.
A 63 year-old woman complains of fatigue, loss
of appetite, a sore-red tongue, paresthesias of A 63 year-old woman complains of fatigue, loss
her feet and hands, and unsteadiness of her gait. of appetite, a sore-red tongue, paresthesias of
Which of the following tests is be used to confirm her feet and hands, and unsteadiness of her gait.
the patient's suspected diagnosis? Which of the following tests is be used to confirm
A Anti-intrinsic factor antibodies the patient's suspected diagnosis?
B Antiparietal cell antibodies A Anti-intrinsic factor antibodies
C Coomb's test B Antiparietal cell antibodies
D Schilling Test C Coomb's test
E Serum folate levels- Anti-intrinsic factor D Schilling Test
antibodies E Serum folate levels- Anti-intrinsic factor
A diagnosis of pernicious anemia (PA) can be antibodies
supported through the presence of anti-intrinsic A diagnosis of pernicious anemia (PA) can be
factor antibodies. supported through the presence of anti-intrinsic
Antiparietal (B) cell antibodies aren't associated factor antibodies.
with the development of PA. The Coomb's test Antiparietal (B) cell antibodies aren't associated
(C) is used in the evaluation of hemolytic with the development of PA. The Coomb's test
anemias. Serum folate (D) levels are beneficial in (C) is used in the evaluation of hemolytic
evaluating macrocytic anemias, but will not anemias. Serum folate (D) levels are beneficial in
establish a diagnosis of PA. The Schilling test (D) evaluating macrocytic anemias, but will not
was once commonly used to diagnosis PA, but is establish a diagnosis of PA. The Schilling test (D)
no longer available due to lack of available was once commonly used to diagnosis PA, but is
radiolabeled human intrinsic factor. no longer available due to lack of available
radiolabeled human intrinsic factor.
A 34-year-old male presents to the primary care
office with a complaint of heartburn that has A 28-year-old man presents for a barium enema;
been present for three months. He has he has a 6-month history of abdominal cramping,
symptoms two to three times a week, which pain, tenesmus, bloody diarrhea, and painful
occurs about 30 minutes after eating. He has urgency. He also reports arthralgias, but denies a
tried over-the-counter antacids and they were history of traveling abroad or the use of
helping to relieve his symptoms for a few antibiotics. On physical exam, he has indurated
months, but they are not working well now. He and painful erythematous plaques and nodules
denies dysphagia, odynophagia, or weight loss. on both shins. An abdominal exam reveals a mild
You decide to treat him with a proton pump tenderness in the lower left quadrant (LLQ). Stool
inhibitor at this visit, and he achieves good exam is positive for occult blood and negative for
symptomatic relief with this therapy. What length ova and parasites. Lab analysis reveals mild
of therapy is appropriate in this patient? leukocytosis, microcytic anemia, positive p-ANCA
A Two to four weeks antibodies, and elevated ESR. What would be
B Eight to twelve weeks the most likely result of a barium enema?
C Four to six months Answer Choices
D One year 1 Apple core appearance
E Continue indefinitely- If a patient 2 Cobblestone appearance
,PANCE Prep GI + Practice Questions and Answers Rated A
3 Lead pipe appearance and gross rectal bleeding.
4 String sign
5 Thumb printing- lead pipe appearance on A 15-year-old boy was healthy until 3 months
barium enema ago. He has been having episodes of crampy
Lead pipe colon is the appearance on barium abdominal pain and explosive liquid stools 2-3
enema of a foreshortened, narrow colon with loss times a day. He has had intermittent fevers and
of redundancy and haustral markings. This sign has noted blood in the stool. He has a
is specific for ulcerative colitis (UC), an documented 15-lb weight loss.
inflammatory disease of the rectum and colon. Question
The peak incidence of UC is around 25 to 45 What is the best way to start treatment?
years. P-ANCA antibodies are associated with Answer Choices
UC. Iron deficiency can lead to microcytic 1 Diphenoxylate hydrochloride with atropine
anemia. Common extra intestinal manifestations sulfate
of UC are erythema nodosum (described as 2 Eliminate lactose-containing foods
erythematous plaques and nodules on pretibial 3 Loperamide HCL
areas), arthritis, pyoderma gangrenosum, uveitis, 4 Eliminate all high fiber foods
episcleritis, and sclerosing cholangitis. 5 Sulfasalazine- Sulfasalazine
Toxic megacolon is a complication of UC This patient has ulcerative colitis. Therefore, it
characterized by the dilation of the colon; there is would be most appropriate to start treatment with
a risk of perforation. There is an increased sulfasalazine at 50-75 mg/kg/day in 2-4 divided
incidence of colon cancer (10%) after 10 years of doses. Sulfasalazine is a sulfa drug that has
this disease. The inflammation involves the important anti-inflammatory properties because it
mucosal tissues only, which are friable and show inhibits the synthesis of mediators of the
ulcerations on colonoscopy. There is also a inflammatory response. In some patients,
characteristic continuous involvement and sulfasalazine is poorly tolerated, in which case
pseudopolyp appearance caused by mucosal mesalamine (50-100 mg/kg/day) and balsalazide
regeneration. Sulfapyridine, mesalamine, (110-175 mg/kg/day) are preferable treatments.
corticosteroids, 6-mercaptopurine, and Diphenoxylate hydrochloride with atropine sulfate
azathioprine are used for treatment. Colectomy is at 1-2 mL t.i.d. and loperamide HCl at 0.04-0.08
curative and is indicated for intractable disease, mg/kg/day in 2-4 divided doses are
or in the case of dysplasia. contraindicated because they would suppress the
An apple core appearance on barium enema is symptoms of ulcerative colitis without
seen in patients with colon cancer. This sign amelioration of the underlying cause of the
refers to the shouldered margins of the stricture condition. Elimination of lactose-containing food
caused by the neoplasmic invasion. would have no effect because the patient is
A cobblestone appearance and string sign are lactose-tolerant. In addition, elimination of dietary
characteristic for Crohn's disease, another fiber would not have any effect.
inflammatory disease of the digestive tract. The
cobblestone appearance refers to the A 15-year-old girl presents with a 1-year history
discontinuous areas of inflammation separated of intermittent abdominal pain with nausea and
by healthy bowel. String sign, seen in the small occasional bloody diarrhea. She denies fever or
bowel series, is the appearance caused by weight loss, as well as any travel history. Past
stricture areas. medical history is significant only for migraines.
Thumb printing is a radiological sign seen in She takes a multivitamin. Her vital signs are
ischemic colitis, a disease most likely found in within normal limits. She has mild diffuse
elderly patients with left lower abdominal pain abdominal tenderness to palpation and guaiac-
,PANCE Prep GI + Practice Questions and Answers Rated A
positive stool. Her exam is otherwise normal. Her urine appears very yellow.
hemoglobin is 9.7, hematocrit is 28%, and her Question
WBC is 12,000/uL. What is the most likely the diagnosis?
Question Answer Choices
What finding would indicate a possible cure if a 1 Gilbert's syndrome
colectomy is performed? 2 Intravascular hemolysis
Answer Choices 3 Chronic viral hepatitis
1 Skip lesions, transmural involvement on 4 Crigler-Najjar syndrome
colonoscopy 5 Budd-Chiari syndrome- Gilbert's disease
2 Crypt abscesses, superficial mucosal Your patient most probably has Gilbert's
involvement on colonoscopy syndrome (GS), also known as Gilbert-
3 Ileal disease Meulengracht syndrome. It is a relatively
4 Fistulas, fissures common genetic disease found in up to 5% -
5 Mouth ulcers- Crypt abscesses, 10% of the population and generally does not
superficial mucosal involvement on colonoscopy need special treatment. Inherited non-haemolytic
Crypt abscesses and superficial mucosal hyperbilirubinemic conditions include Dubin-
involvement are colonoscopy findings associated Johnson, Rotor, and GB syndromes, and all are
with ulcerative colitis. A colectomy is performed important differential diagnoses indicating benign
for severe and intractable disease. A colectomy disease that requires no immediate treatment.
can be a relative cure since the disease is limited
GB can be diagnosed by clinical presentation,
to the colon. biochemistry, and genotyping, and is significant
Skip lesions, transmural involvement, fistulas, because of the presence of the disposition
and fissures are all associated with colonoscopy towards drug-associated toxicity. A major
findings in Crohn's disease. Crohn's disease can characteristic is jaundice, caused by elevated
also affect any structure of the alimentary tract levels of unconjugated bilirubin in the
from the mouth to anus, causing ileal disease bloodstream. The cause of this
and mouth ulcers. hyperbilirubinemia is the reduced activity of the
enzyme glucuronyltransferase, which conjugates
A 13-year-old boy presents with a long history of both bilirubin and some lipophilic molecules,
intermittent jaundice without other signs and including drugs.
symptoms. Yesterday he took several Intravascular hemolysis, with resulting
paracetamol tablets, and the headache and hemoglobinemia, hemoglobinuria, and
jaundice appeared again. His parents have a bilirubinemia, will show fragments of the red
consanguineous marriage, and nobody in the blood cells ("schistocytes") and sometimes
family has similar symptoms. His physical spherocytes in peripheral blood smear,
examination today is within normal limits, except reticulocytosis, elevated unconjugated bilirubin
for mild scleral icterus. The initial laboratory that may lead to jaundice, elevated lactate
examinations show: RBC 4.5mill/mm3; WBC dehydrogenase (LDH) in the blood, and
6000/mm3; total bilirubin 2.2 mg/dl; indirect decreased haptoglobin levels. If the direct
bilirubin 2.0 mg/dl; direct bili 0.2 mg/dl; liver Coombs test is positive, hemolysis is caused by
enzymes, serum copper, and all other an immune process. Hemosiderin in the urine
parameters are normal; hepatitis B (-); and the indicates chronic intravascular hemolysis. There
full set of his autoimmune markers (-) and is also urobilinogen in the urine.
Coombs test (-). Blood smear is normal. Viral hepatitis with jaundice will have elevated
Ultrasonography of liver, gallbladder, pancreas, liver function tests (AST and ALT elevated out of
spleen, and for both kidneys are normal. His proportion to alkaline phosphatase, usually with
, PANCE Prep GI + Practice Questions and Answers Rated A
hyperbilirubinemia), and viral serologic testing elevated total iron-binding capacity (TIBC) is
will be positive. diagnostic of iron deficiency. Lack of iron inhibits
Crigler-Najjar syndrome is a rare inherited form hemoglobin synthesis, thereby reducing the
of non-hemolytic jaundice, which results in high volume and hemoglobin concentration of
levels of unconjugated bilirubin and often leads erythrocytes. Some patients have
to brain damage in infancy. thrombocytosis. The mechanism is unclear, but
Budd-Chiari syndrome is caused by occlusion of hypotheses include stimulation by high circulating
the hepatic veins. It presents with the classical erythropoietin concentrations or circulating
triad of abdominal pain, ascites, and cytokines. Besides asthenia and pallor, other
hepatomegaly. The syndrome can be fulminant, symptoms include pagophagia (craving ice or
acute, chronic, or asymptomatic. cold foods), pica (clay eating), and leg cramps;
physical examination may reveal esophageal
A 52-year-old Caucasian man presents with easy webbing, koilonychia (spoon-shaped nails),
fatigability, poor concentration, and "stronger glossitis, angular stomatitis, and gastric atrophy.
than usual" effort-related palpitations. He denies New-onset anemia with hypochromia and
any constipation or weight loss. His past medical microcytosis in an adult should be considered
history includes type II diabetes, which was secondary to gastrointestinal bleeding until
diagnosed 10 years ago; it is well controlled with proved otherwise. The most common etiologies
diet and metformin, and there are no are diverticular disease, angiodysplasia, colitis
complications. Both his parents are in good (including from NSAIDs), and colon cancer,
health; his sister had a malignant breast nodule particularly left-sided colon cancer. Testing for
removed 2 years ago, but she showed no signs occult blood in a stool specimen is the initial
of metastatic disease. His physical examination diagnostic method of choice. If the fecal occult
shows mild obesity (BMI 32 kg/m2), but it is blood test is positive, the patient should undergo
otherwise normal. upper endoscopy and colonoscopy examinations.
A laboratory workup shows glucose 91 mg/dL, Colonoscopy is a useful exam for identifying
Na+ 138 mEq/L, K+ 4.9 mEq/L, Cl- 100 mEq/L, sources of occult gastrointestinal bleeding. It is
hemoglobin 11 g/dL, hematocrit 32%, mean more sensitive than barium enema or CT scans
corpuscular volume(MCV) 82 fl, mean for early lesions and permits biopsy when
corpuscular hemoglobin concentration (MCHC) indicated (e.g., lesions suspicious for malignancy
24 pg/mL, leukocytes 7,400 /mm3 w/normal or colitis). However, none of these are cost-
differential. Platelets 310,000 /mm3, ferritin 29 effective screening examinations.
ng/L (25-300 ng/mL), and a total iron binding Bone marrow biopsy can evaluate bone marrow
capacity of 450 ng/dL. iron stores and reveal erythroid hyperplasia.
Question However, it has been practically abandoned in
What is the most appropriate next step in the workup of iron-deficiency anemia, as there is
diagnosis? considerable interobserver variability and assays
Answer Choices for iron, ferritin, and TIBC permit evaluation of the
1 Fecal occult blood testing (FOBT) body's iron stores less invasively.
2 Full colonoscopy Capsule endoscopy is the most sensitive method
3 Bone marrow biopsy for diagnosing small-bowel bleeding. However,
4 Double-contrast barium enema small-bowel bleeding is much less common than
5 Capsule endoscopy- The correct upper (proximal to the angle of Treitz) or colonic
response is fecal occult blood testing. bleeding. Therefore, it should only be undertaken
The pattern of low mean corpuscular volume and after colonoscopy and upper endoscopy are
hemoglobin concentration, low ferritin, and negative.
Ulcerative Colitis appearance on colonoscopy- achieves good symptomatic relief with a course
Crypt abscesses and if toxic megacolon of an empiric, once-daily proton pump inhibitor,
present loss of haustra and blood vessels therapy may be discontinued after eight to twelve
weeks.
A 63 year-old woman complains of fatigue, loss
of appetite, a sore-red tongue, paresthesias of A 63 year-old woman complains of fatigue, loss
her feet and hands, and unsteadiness of her gait. of appetite, a sore-red tongue, paresthesias of
Which of the following tests is be used to confirm her feet and hands, and unsteadiness of her gait.
the patient's suspected diagnosis? Which of the following tests is be used to confirm
A Anti-intrinsic factor antibodies the patient's suspected diagnosis?
B Antiparietal cell antibodies A Anti-intrinsic factor antibodies
C Coomb's test B Antiparietal cell antibodies
D Schilling Test C Coomb's test
E Serum folate levels- Anti-intrinsic factor D Schilling Test
antibodies E Serum folate levels- Anti-intrinsic factor
A diagnosis of pernicious anemia (PA) can be antibodies
supported through the presence of anti-intrinsic A diagnosis of pernicious anemia (PA) can be
factor antibodies. supported through the presence of anti-intrinsic
Antiparietal (B) cell antibodies aren't associated factor antibodies.
with the development of PA. The Coomb's test Antiparietal (B) cell antibodies aren't associated
(C) is used in the evaluation of hemolytic with the development of PA. The Coomb's test
anemias. Serum folate (D) levels are beneficial in (C) is used in the evaluation of hemolytic
evaluating macrocytic anemias, but will not anemias. Serum folate (D) levels are beneficial in
establish a diagnosis of PA. The Schilling test (D) evaluating macrocytic anemias, but will not
was once commonly used to diagnosis PA, but is establish a diagnosis of PA. The Schilling test (D)
no longer available due to lack of available was once commonly used to diagnosis PA, but is
radiolabeled human intrinsic factor. no longer available due to lack of available
radiolabeled human intrinsic factor.
A 34-year-old male presents to the primary care
office with a complaint of heartburn that has A 28-year-old man presents for a barium enema;
been present for three months. He has he has a 6-month history of abdominal cramping,
symptoms two to three times a week, which pain, tenesmus, bloody diarrhea, and painful
occurs about 30 minutes after eating. He has urgency. He also reports arthralgias, but denies a
tried over-the-counter antacids and they were history of traveling abroad or the use of
helping to relieve his symptoms for a few antibiotics. On physical exam, he has indurated
months, but they are not working well now. He and painful erythematous plaques and nodules
denies dysphagia, odynophagia, or weight loss. on both shins. An abdominal exam reveals a mild
You decide to treat him with a proton pump tenderness in the lower left quadrant (LLQ). Stool
inhibitor at this visit, and he achieves good exam is positive for occult blood and negative for
symptomatic relief with this therapy. What length ova and parasites. Lab analysis reveals mild
of therapy is appropriate in this patient? leukocytosis, microcytic anemia, positive p-ANCA
A Two to four weeks antibodies, and elevated ESR. What would be
B Eight to twelve weeks the most likely result of a barium enema?
C Four to six months Answer Choices
D One year 1 Apple core appearance
E Continue indefinitely- If a patient 2 Cobblestone appearance
,PANCE Prep GI + Practice Questions and Answers Rated A
3 Lead pipe appearance and gross rectal bleeding.
4 String sign
5 Thumb printing- lead pipe appearance on A 15-year-old boy was healthy until 3 months
barium enema ago. He has been having episodes of crampy
Lead pipe colon is the appearance on barium abdominal pain and explosive liquid stools 2-3
enema of a foreshortened, narrow colon with loss times a day. He has had intermittent fevers and
of redundancy and haustral markings. This sign has noted blood in the stool. He has a
is specific for ulcerative colitis (UC), an documented 15-lb weight loss.
inflammatory disease of the rectum and colon. Question
The peak incidence of UC is around 25 to 45 What is the best way to start treatment?
years. P-ANCA antibodies are associated with Answer Choices
UC. Iron deficiency can lead to microcytic 1 Diphenoxylate hydrochloride with atropine
anemia. Common extra intestinal manifestations sulfate
of UC are erythema nodosum (described as 2 Eliminate lactose-containing foods
erythematous plaques and nodules on pretibial 3 Loperamide HCL
areas), arthritis, pyoderma gangrenosum, uveitis, 4 Eliminate all high fiber foods
episcleritis, and sclerosing cholangitis. 5 Sulfasalazine- Sulfasalazine
Toxic megacolon is a complication of UC This patient has ulcerative colitis. Therefore, it
characterized by the dilation of the colon; there is would be most appropriate to start treatment with
a risk of perforation. There is an increased sulfasalazine at 50-75 mg/kg/day in 2-4 divided
incidence of colon cancer (10%) after 10 years of doses. Sulfasalazine is a sulfa drug that has
this disease. The inflammation involves the important anti-inflammatory properties because it
mucosal tissues only, which are friable and show inhibits the synthesis of mediators of the
ulcerations on colonoscopy. There is also a inflammatory response. In some patients,
characteristic continuous involvement and sulfasalazine is poorly tolerated, in which case
pseudopolyp appearance caused by mucosal mesalamine (50-100 mg/kg/day) and balsalazide
regeneration. Sulfapyridine, mesalamine, (110-175 mg/kg/day) are preferable treatments.
corticosteroids, 6-mercaptopurine, and Diphenoxylate hydrochloride with atropine sulfate
azathioprine are used for treatment. Colectomy is at 1-2 mL t.i.d. and loperamide HCl at 0.04-0.08
curative and is indicated for intractable disease, mg/kg/day in 2-4 divided doses are
or in the case of dysplasia. contraindicated because they would suppress the
An apple core appearance on barium enema is symptoms of ulcerative colitis without
seen in patients with colon cancer. This sign amelioration of the underlying cause of the
refers to the shouldered margins of the stricture condition. Elimination of lactose-containing food
caused by the neoplasmic invasion. would have no effect because the patient is
A cobblestone appearance and string sign are lactose-tolerant. In addition, elimination of dietary
characteristic for Crohn's disease, another fiber would not have any effect.
inflammatory disease of the digestive tract. The
cobblestone appearance refers to the A 15-year-old girl presents with a 1-year history
discontinuous areas of inflammation separated of intermittent abdominal pain with nausea and
by healthy bowel. String sign, seen in the small occasional bloody diarrhea. She denies fever or
bowel series, is the appearance caused by weight loss, as well as any travel history. Past
stricture areas. medical history is significant only for migraines.
Thumb printing is a radiological sign seen in She takes a multivitamin. Her vital signs are
ischemic colitis, a disease most likely found in within normal limits. She has mild diffuse
elderly patients with left lower abdominal pain abdominal tenderness to palpation and guaiac-
,PANCE Prep GI + Practice Questions and Answers Rated A
positive stool. Her exam is otherwise normal. Her urine appears very yellow.
hemoglobin is 9.7, hematocrit is 28%, and her Question
WBC is 12,000/uL. What is the most likely the diagnosis?
Question Answer Choices
What finding would indicate a possible cure if a 1 Gilbert's syndrome
colectomy is performed? 2 Intravascular hemolysis
Answer Choices 3 Chronic viral hepatitis
1 Skip lesions, transmural involvement on 4 Crigler-Najjar syndrome
colonoscopy 5 Budd-Chiari syndrome- Gilbert's disease
2 Crypt abscesses, superficial mucosal Your patient most probably has Gilbert's
involvement on colonoscopy syndrome (GS), also known as Gilbert-
3 Ileal disease Meulengracht syndrome. It is a relatively
4 Fistulas, fissures common genetic disease found in up to 5% -
5 Mouth ulcers- Crypt abscesses, 10% of the population and generally does not
superficial mucosal involvement on colonoscopy need special treatment. Inherited non-haemolytic
Crypt abscesses and superficial mucosal hyperbilirubinemic conditions include Dubin-
involvement are colonoscopy findings associated Johnson, Rotor, and GB syndromes, and all are
with ulcerative colitis. A colectomy is performed important differential diagnoses indicating benign
for severe and intractable disease. A colectomy disease that requires no immediate treatment.
can be a relative cure since the disease is limited
GB can be diagnosed by clinical presentation,
to the colon. biochemistry, and genotyping, and is significant
Skip lesions, transmural involvement, fistulas, because of the presence of the disposition
and fissures are all associated with colonoscopy towards drug-associated toxicity. A major
findings in Crohn's disease. Crohn's disease can characteristic is jaundice, caused by elevated
also affect any structure of the alimentary tract levels of unconjugated bilirubin in the
from the mouth to anus, causing ileal disease bloodstream. The cause of this
and mouth ulcers. hyperbilirubinemia is the reduced activity of the
enzyme glucuronyltransferase, which conjugates
A 13-year-old boy presents with a long history of both bilirubin and some lipophilic molecules,
intermittent jaundice without other signs and including drugs.
symptoms. Yesterday he took several Intravascular hemolysis, with resulting
paracetamol tablets, and the headache and hemoglobinemia, hemoglobinuria, and
jaundice appeared again. His parents have a bilirubinemia, will show fragments of the red
consanguineous marriage, and nobody in the blood cells ("schistocytes") and sometimes
family has similar symptoms. His physical spherocytes in peripheral blood smear,
examination today is within normal limits, except reticulocytosis, elevated unconjugated bilirubin
for mild scleral icterus. The initial laboratory that may lead to jaundice, elevated lactate
examinations show: RBC 4.5mill/mm3; WBC dehydrogenase (LDH) in the blood, and
6000/mm3; total bilirubin 2.2 mg/dl; indirect decreased haptoglobin levels. If the direct
bilirubin 2.0 mg/dl; direct bili 0.2 mg/dl; liver Coombs test is positive, hemolysis is caused by
enzymes, serum copper, and all other an immune process. Hemosiderin in the urine
parameters are normal; hepatitis B (-); and the indicates chronic intravascular hemolysis. There
full set of his autoimmune markers (-) and is also urobilinogen in the urine.
Coombs test (-). Blood smear is normal. Viral hepatitis with jaundice will have elevated
Ultrasonography of liver, gallbladder, pancreas, liver function tests (AST and ALT elevated out of
spleen, and for both kidneys are normal. His proportion to alkaline phosphatase, usually with
, PANCE Prep GI + Practice Questions and Answers Rated A
hyperbilirubinemia), and viral serologic testing elevated total iron-binding capacity (TIBC) is
will be positive. diagnostic of iron deficiency. Lack of iron inhibits
Crigler-Najjar syndrome is a rare inherited form hemoglobin synthesis, thereby reducing the
of non-hemolytic jaundice, which results in high volume and hemoglobin concentration of
levels of unconjugated bilirubin and often leads erythrocytes. Some patients have
to brain damage in infancy. thrombocytosis. The mechanism is unclear, but
Budd-Chiari syndrome is caused by occlusion of hypotheses include stimulation by high circulating
the hepatic veins. It presents with the classical erythropoietin concentrations or circulating
triad of abdominal pain, ascites, and cytokines. Besides asthenia and pallor, other
hepatomegaly. The syndrome can be fulminant, symptoms include pagophagia (craving ice or
acute, chronic, or asymptomatic. cold foods), pica (clay eating), and leg cramps;
physical examination may reveal esophageal
A 52-year-old Caucasian man presents with easy webbing, koilonychia (spoon-shaped nails),
fatigability, poor concentration, and "stronger glossitis, angular stomatitis, and gastric atrophy.
than usual" effort-related palpitations. He denies New-onset anemia with hypochromia and
any constipation or weight loss. His past medical microcytosis in an adult should be considered
history includes type II diabetes, which was secondary to gastrointestinal bleeding until
diagnosed 10 years ago; it is well controlled with proved otherwise. The most common etiologies
diet and metformin, and there are no are diverticular disease, angiodysplasia, colitis
complications. Both his parents are in good (including from NSAIDs), and colon cancer,
health; his sister had a malignant breast nodule particularly left-sided colon cancer. Testing for
removed 2 years ago, but she showed no signs occult blood in a stool specimen is the initial
of metastatic disease. His physical examination diagnostic method of choice. If the fecal occult
shows mild obesity (BMI 32 kg/m2), but it is blood test is positive, the patient should undergo
otherwise normal. upper endoscopy and colonoscopy examinations.
A laboratory workup shows glucose 91 mg/dL, Colonoscopy is a useful exam for identifying
Na+ 138 mEq/L, K+ 4.9 mEq/L, Cl- 100 mEq/L, sources of occult gastrointestinal bleeding. It is
hemoglobin 11 g/dL, hematocrit 32%, mean more sensitive than barium enema or CT scans
corpuscular volume(MCV) 82 fl, mean for early lesions and permits biopsy when
corpuscular hemoglobin concentration (MCHC) indicated (e.g., lesions suspicious for malignancy
24 pg/mL, leukocytes 7,400 /mm3 w/normal or colitis). However, none of these are cost-
differential. Platelets 310,000 /mm3, ferritin 29 effective screening examinations.
ng/L (25-300 ng/mL), and a total iron binding Bone marrow biopsy can evaluate bone marrow
capacity of 450 ng/dL. iron stores and reveal erythroid hyperplasia.
Question However, it has been practically abandoned in
What is the most appropriate next step in the workup of iron-deficiency anemia, as there is
diagnosis? considerable interobserver variability and assays
Answer Choices for iron, ferritin, and TIBC permit evaluation of the
1 Fecal occult blood testing (FOBT) body's iron stores less invasively.
2 Full colonoscopy Capsule endoscopy is the most sensitive method
3 Bone marrow biopsy for diagnosing small-bowel bleeding. However,
4 Double-contrast barium enema small-bowel bleeding is much less common than
5 Capsule endoscopy- The correct upper (proximal to the angle of Treitz) or colonic
response is fecal occult blood testing. bleeding. Therefore, it should only be undertaken
The pattern of low mean corpuscular volume and after colonoscopy and upper endoscopy are
hemoglobin concentration, low ferritin, and negative.
