This document contains multiple questions about diagnosis and management of gastrointestinal conditions. Question 14 describes a case of a young Hispanic man with early satiety and weight loss found to have extensive thickening of the stomach wall and signet ring cell adenocarcinoma. His two brothers also had early-onset gastric cancer. The underlying genetic defect in this family is a CDH1 gene mutation which causes hereditary diffuse gastric cancer. Question 15 describes a woman with hepatitis C, anemia, and melena found to have findings in her stomach antrum. Biopsy revealed reactive gastropathy and dilated capillaries containing fibrin thrombi. The most appropriate management is proton pump inhibitor therapy.

1. 1. Which statement about diagnostic testing for H. pylori is
correct? 44 S
A. Proton pump inhibitors (PPIs) should be discontinued
2 weeks prior to fecal antigen or serology testing
B. Serological testing has better positive predictive value
for detecting H. pylori infection in the Mexican population
than in the American population
C. The specificity of urea breath testing will decrease if
performed earlier than 4 weeks after completion of
antibiotic therapy
D. The sensitivity and specificity of urea breath testing and
fecal antigen testing is less than 70% to 80% in untreated
patients who are not taking PPIs, bismuth, or antibiotics
E. H. pylori serology can be used to confirm eradication

2. • 2.Patients with antral-predominant H. pylori
infection have increased predisposition to
which of the following conditions?37S
A. Gastric peptic ulcer disease
B. Barrett esophagus
C. Duodenal peptic ulcer disease
D. Pangastritis
E. Gastric adenocarcinoma

3. • 3. A 42-year-old man comes to the physician complaining of
epigastric discomfort for 4 months. He was treated with
proton pump inhibitor therapy, but had no relief in his
symptoms. He has recently developed diarrhea and has
lost 10 pounds unintentionally. EGD is performed, which
shows diffusely thickened rugae with antral sparing. Gastric
biopsy shows exuberant foveolar hyperplasia with
cystic dilation, minimal gastritis, and increased mucus
glands . What is the most likely diagnosis?56S
A. Acute gastritis
B. Eosinophillic gastritis
C. Ménétrier disease
D. Gastric adenocarcinoma
E. Chronic gastritis

4. 4.A 41-year-old morbidly obese woman is seen in your clinic
for retrosternal burning pain for 3 months. The pain seems
to be exacerbated by eating, and is also worse at night. She
currently smokes one half pack per day of cigarettes, and
drinks two glasses of wine every week. Her daughter has
noticed frequent belching and malodorous breath. She
denies recent weight loss, dysphagia, or vomiting blood.
A recent cardiac stress test was negative. Which of the following
is the most appropriate next step in management?39S
A. Upper endoscopy
B. H. pylori stool antigen testing
C. C-14 urea breath test
D. H. pylori serology
E. Proton pump inhibitor (PPI) therapy

5. 5.Which of the following stimulates gastric acid
secretion by the parietal cells?30S
A. Calcitonin gene–related peptide (CGRP)
B. Norepinephrine
C. Somatostatin
D. Acetylcholine
E. Amylin

6. 6.What is the most cost-effective method of
testing for HP infection in a previously untested
or untreated patient?4 MYO
a. Serologic antibody testing
b. Saliva-based antibody testing
c. Urea breath testing
d. Stool antigen
e. Upper endoscopy with gastric biopsies

7. 7.Certain environmental factors likely have a role
in the development of PUD. Which environmental
factor is most associated with PUD?6MYO
a. Obesity
b. High intake of red meat
c. Alcohol abuse
d. Cigarette smoking
e. Coffee consumption

8. 8.ASGE guidelines support endoscopic screening or
surveillance examinations for gastric cancer in which of
the following patient groups?15 MYO
a. Patients with biopsy-proven hyperplastic or
inflammatory gastric polyps
b. Patients whose prior endoscopy demonstrated
intestinal metaplasia
c. All patients with pernicious anemia
d. Patients with a previous partial gastrectomy for PUD
e. Patients with FAP

9. 9.Which of the following is unlikely to pass
through the pylorus?24MYO
a. A 26-mm-diameter coin
b. A 40-mm long soft plastic stirring rod
c. A 35-mm meatball swallowed whole
d. A 15-mm sharp straight pin
e. A 15-mm wooden toothpick

10. 10.Which of the following is correct regarding pertinent laboratory
findings in autoimmune atrophic gastritis?7MYO
a. Positive for antiparietal cell antibody, negative for anti–intrinsic
factor antibody, high gastrin level, low vitamin B12 level
b. Negative for antiparietal cell antibody, positive for anti–intrinsic
factor antibody, normal gastrin level, normal vitamin B12
level
c. Positive for antiparietal cell antibody, positive for anti–intrinsic
factor antibody, high gastrin level, low vitamin B12 level
d. Negative for antiparietal cell antibody, negative for anti–intrinsic
factor antibody, high gastrin level, low vitamin B12 level
e. Positive for antiparietal cell antibody, positive for anti–intrinsic
factor antibody, low gastrin level, high vitamin B12 level

11. 11.A 20-year-old man is evaluated for epigastric pain that has gradually
increased in severity over 8 months. The pain worsens with eating and is
not relieved by antacids. The patient reports no melena, diarrhea, or
constipation. The patient's personal medical history is unremarkable and
he takes no medication.On physical examination, vital signs are normal.
Epigastrictenderness to palpation is noted. Other findings are normal.
A complete blood count is normal.
Which of the following is the most appropriate next step in
management?52 MKSAP
(A) Initiation of omeprazole
(B) Stool antigen testing for Helicobacter pylori
(C) Ultrasonography of the right upper quadrant
(D) Upper endoscopy

12. 12.A 55-year-old man is evaluated after being hospitalized for epigastric pain of 1
month's duration and melenic stoolsover the past 3 days associated with fatigue. He
reports no hematochezia. hematemesis, chest pain, or shortness of breath. He has
osteoarthritis treated with ibuprofen.He received an intravenous fluid bolus in the
emergency department.
On physical examination, blood pressure is 135/75 mm Hg and other vital signs are
normal, with no orthostatic changes.Abdominal examination reveals epigastric
tenderness but is otherwise unremarkable. No stigmata of chronic liver disease
are seen. Laboratory studies show a hemoglobin level of7.3 g/Dl (73 g/L).Upper
endoscopy shows a 1.5-cm duodenal bulb ulcer
with a clean base.
Which of the following is the most appropriate resuscitation
measure? 83mksap
(A) Transfuse red blood cells to a goal hemoglobin level of 8 g/dL (80 g/L)
(B) Transfuse red blood cells to a goal hemoglobin level of 9 g/dL (90 g/ L)
(C) Transfuse red blood cells to a goal hemoglobin level of lO g/dL (100 g/ L)
(D) No transfusion

13. 13.A 55-year-old woman is evaluated for a 6-month history of throbbing and sometimes
burning epigastric pain. The pain occurs 2 to 3 times per week and often subsides with
eating. She reports no weight loss, nausea, or vomiting, and no bowel symptoms. She
tested negative for Helicobacter pylori infection. Her pain did not respond to a 4-week
trial of omeprazole. The patient also has anxiety, hypothyroidism, and type 2 diabetes
mellitus controlled by diet. Her family medical history is unremarkable. Her medications
are lorazepam and levothyroxine. On physical examination, vital signs are normal.
Epigastric tenderness to palpation is noted. Other findings are normal.
A complete blood count, liver chemistry tests, and thyroid- stimulating hom10ne level are
normal. Hemoglobin level is 6.7%. Upper endoscopy findings are normal. Gastric and
small-bowel biopsies are normal.
Which of the following is the most appropriate next step in
management?86mksap
(A) CT scan of the abdomen
(B) Gastric emptying test
(C) Initiation of a tricyclic antidepressant
(D) Twice-daily proton pump inhibitor therapy
(E) Ultrasonography of the right upper quadrant

14. 14.A 33-year-old Hispanic man with early satiety and
rapid weight loss is found to have extensive induration
and friability in the body and antrum of the stomach
(Fig. 1). Although mucosal biopsies are unremarkable,
endoscopic ultrasound reveals marked thickening of the
wall (Fig. 2) and fine-needle aspiration confirms
adenocarcinoma with signet ring features. Two brothers
also have a history of gastric cancer at 35 and 37 years,
respectively.
Which of the following genetic defects is the underlying
problem in this family?1GISAP
A. CDH1 gene
B. APC gene
C. Mismatch repair gene (PMS)
D. Mismatch repair gene (MLH1)

15. 15.A 40-year-old woman with chronic hepatitis C is referred
for evaluation of iron-deficiency anemia and intermittent
melena. She drinks 18 to 20 cans of beer every week and
takes aspirin once a month for menstrual pain. An EGD
reveals a small amount of fresh blood in the stomach and
the findings in the antrum as shown below. The remainder of
the EGD examination is unremarkable. An endoscopic biopsy
of the antral mucosa reveals reactive gastropathy and dilated
capillaries containing fibrin thrombi.
Which of the following is the most appropriate
management?12 GISAP
A. Transjugular intrahepatic portosystemic shunt (TIPS)
B. Propranolol
C. Proton pump inhibitor
D. Endoscopic thermal therapy