1.1 What is the best initial test in a patient with complete esophageal obstruction?

a. Barium esophagram

b. Video esophagram

c. Upper endoscopy

d. Chest CT

e. Esophageal manometry

1.2 What is the manometric characteristic of achalasia?

a. Aperistalsis of the esophageal body

b. Diminished amplitude of esophageal body contractions

c. Absence of esophageal body contractile activity

d. Esophageal contractile pressure >240 mmHg

1.3 What is the most common etiology of odynophagia in an immunocompromised patient?

a. Foreign body ingestion

b. Bacterial infection

c. Nonbacterial infection

d. Pill-associated ulceration

2.1 True or false: Esophageal manometry is abnormal in the majority of patients with noncardiac chest pain?

a. True

b. False

2.2 Ergonovine is used to:

a. Treat nutcracker esophagus

b. Test for esophageal sensitivity to acid

c. Test for esophageal spasm

d. Test for coronary artery spasm

e. Treat noncardiac chest pain due to costchondritis

2.3 All the following are consistent with an esophageal source of chest pain except:

a. Symptoms exacerbated by ingesting cold or hot liquids

b. Symptoms awaken the patient from sleep

c. Symptoms brought on by exertion

d. Symptom relief with antacids

e. Pain radiating to the neck

3.1 Endoscopic electrocautery therapy is indicated for which one of the following findings?

a. Gastric ulcer with a flat, red spot

b. Duodenal ulcer with a clean base

c. Gastric ulcer with a visible vessel

d. Colonic ulcer with a flat, red spot

e. Mallory–Weiss tear with a clean base

3.2 Intravenous antibiotics are recommended for which of the following groups?

a. Alcoholics with Mallory–Weiss tears

b. Patients with hepatitis C and peptic ulcer bleeding

c. Patients with Helicobacter pylori-associated peptic ulcer bleeding

d. Patients with cirrhosis and GI bleeding of any cause

e. Patients with diverticular hemorrhage

3.3 Which of the following is not recommended for the treatment of esophageal variceal hemorrhage?

a. Endoscopic sclerotherapy

b. Endoscopic variceal band ligation

c. Transjugular intrahepatic portosystemic shunt

d. Sengstaken–Blakemore tube placement

e. Argon plasma coagulation

4.1 Pharyngitis, gingival erosions, parotid swelling and scarred knuckles are consistent with which of the following causes of weight loss?

a. Anorexia nervosa

b. Bulimia nervosa

c. Alzheimer’s disease

d. Adult rumination syndrome

e. Chronic pancreatitis

4.2 Merycism is characterized by which of the following?

a. Repetitively regurgitating food from the stomach, rechewing it, and then reswallowing it

b. Repetitive binges of overeating followed by acts to avert weight gain

c. Pancreatic calcifications with pancreatic insufficiency

d. Mood changes, sleep disruption, anhedonia, and low self-esteem

e. Distortion of body image, inability to interpret hunger and satiety, with a preoccupation with eating and a sense of ineffectiveness

4.3 In severe malnutrition due to anorexia nervosa, refeeding should be established:

a. At 90% of goal caloric intake and increase by 5% every week until goal is achieved

b. At 110% of goal caloric intake until goal is achieved

c. At 125% of goal caloric intake until goal is achieved

d. At 200 calories above baseline intake and increase by 250 calories every 5 days for a goal of 1.5 kg weight gain per week as an inpatient or 0.75 kg per week as an outpatient

e. At 500 calories above baseline intake and increase by 400 calories every 5 days for a goal of 2.5 kg weight gain per week as an inpatient or 2.0 kg per week as an outpatient

5.1 Which of the following is most appropriate for a 17-year-old man with no significant past medical history, on no medications, who calls the nurse helpline reporting a 1-day history of vomiting with myalgias and diarrhea?

a. Stool studies for ova and parasites

b. Colonoscopy

c. Barium upper GI study

d. No work-up at this time

e. Gastric emptying study

5.2 Which of the following conditions would be most likely to have an associated succussion splash?

a. A pyloric channel ulcer

b. Viral gastroenteritis

c. Psychogenic vomiting

d. Erythromycin-associated vomiting

e. Intracranial hemorrhage

5.3 Which of the following would be most consistent with psychogenic vomiting?

a. Small bowel lumenal dilation on barium radiography

b. Stable weight

c. Feculent emesis

d. Delayed gastric emptying on scintigraphy

e. Tachygastria on electrogastrography

6.1 In a patient with a suspected perforation, what test should be performed as quickly as possible?

a. Abdominal ultrasound

b. Abdominal series radiography (supine and upright or decubitus)

c. Upper endoscopy

d. Upper GI with barium

6.2 A patient presents with abdominal pain and has a positive Carnett sign on physical examination. What is the likely etiology of the patient’s pain?

a. Irritable bowel syndrome

b. Cholecystitis

c. Rectus sheath hematoma

d. Appendicitis

6.3 A patient is evaluated in the emergency department for worsening RUQ abdominal pain. The patient has a positive Murphy sign on physical exam and has a fever to 39°C. Labs demonstrate a leukocytosis but no LFT abnormalities. What is the next appropriate step in management?

a. Surgery

b. Request interventional radiology to place a percutaneous cholecystostomy tube

c. ERCP

d. IV hydration, pain management, and IV antibiotics

7.1 You diagnose irritable bowel syndrome in a 26-year-old woman based on classic symptoms and normal laboratory tests including hemoglobin/iron, albumin and B₁₂/folate. She complains of increased gas and flatulence and would like your advice about further testing to evaluate her symptoms. The best next step in management is:

a. Glucose hydrogen breath testing

b. SmartPill pH, temperature and pressure measurements

c. Antibody to tissue transglutaminase

d. Reassurance

7.2 Which of the following sources of complex carbohydrate is completely absorbed in healthy individuals?

a. Oat

b. Potato

c. Corn

d. Rice

8.1 What is the best management of a patient who presents with acute small intestinal obstruction?

a. Neostigmine intravenously

b. Water-soluble contrast enema

c. Colonic decompression by colonoscopy

d. Surgery

8.2 What is the optimal initial management for a patient with acute colonic pseudo-obstruction?

a. Surgery

b. Interventional radiology placement of a cecostomy tube

c. Nasogastric tube suctioning, discontinuation of narcotics and other potential exacerbating drugs and correction of potential electrolyte disturbances

d. Neostigmine

8.3 A patient with acute colonic pseudo-obstruction and a cecal diameter of 10 cm is initially treated with nasogastric tube insertion with suctioning, intravenous hydration, frequent position changes and correction of electrolyte disturbances. The next day repeated plain abdominal radiographs reveal a cecum diameter of 12 cm. What is the best management option?

a. Surgery

b. Decompression of colon by colonoscopy

c. Neostigmine

d. Cecostomy tube placement by interventional radiology.

9.1 In a 23-year-old woman with long-standing constipation in the absence of abdominal pain, with normal physical examination and basic laboratory tests, what is the next best step in management?

a. Colonoscopy

b. Flexible sigmoidoscopy

c. CT abdomen and pelvis

d. Empirical trial of polyethylene glycol

9.2 A patient with chronic constipation describes an increase in bowel movements to once every third day with use of polyethylene glycol, but remains concerned about symptoms that include a sensation of “incomplete evacuation” with each movement. What is the next best test to identify the cause of symptoms?

a. Colonic transit test

b. Colonoscopy with biopsies

c. Anorectal manometry

d. CT abdomen and pelvis

9.3 What is the best initial therapy for dyssynergic defecation?

a. Sphincter myotomy

b. Botulinum toxin sphincter injection

c. Biofeedback

d. Nitroglycerin topical ointment

10.1 A 34-year-old woman presents with watery diarrhea. Her stool tests include the absence of red or white cells, negative bacterial culture and C. difficile, and concentrations of sodium of 65 and potassium 15. What is the most likely cause of her diarrhea?

a. Magnesium-containing laxative

b. Irritable bowel syndrome

c. VIP-secreting tumor

d. Senna-containing laxative

10.2 A 19-year-old college student complains of nausea, vomiting and diarrhea since yesterday evening. She and several friends ate at an Asian restaurant in the afternoon and within 6 h, two of the five diners had acute onset of nausea and vomiting, followed by watery diarrhea. Minor abdominal cramping is also noted, but no blood is seen in stool. No travel history is noted. What is the most likely cause of symptoms?

a. Enterotoxigenic E. coli

b. Bacillus cereus

c. Campylobacter jejuni

d. Shigella

11.1 On CT scan, a 45-year-old man was incidentally found to have a well-circumscribed, round, 3 cm mass that appeared to arise from the wall of the stomach. What is the next appropriate step in evaluation?

a. Esophagogastroduodenoscopy

b. Upper GI series with barium

c. Follow-up CT scan in 6 months to assess for interval growth

d. EUS FNA

11.2 A 64-year-old woman presents to her physician with complaints of new-onset jaundice and a 15 lb unintentional weight loss over the past 3 months. LFTs demonstrate elevated bilirubin, alkaline phosphatase, AST, and ALT. CA 19-9 is also elevated. True or false: given the elevated CA 19-9, a diagnosis of pancreatic cancer can be made.

a. True

b. False

12.1 A patient with prolonged jaundice due to primary biliary cirrhosis would be expected to have all of the following except:

a. Vitamin D deficiency

b. Diminished bone density

c. Low cholesterol levels

d. Severe pruritus

12.2 Jaundice in the newborn is often due to physiological neonatal jaundice, breast milk jaundice, or Lucey–Driscoll syndrome. The pathophysiology of these conditions relates to:

a. Impaired hepatocyte secretion of bilirubin

b. Reduced activity of uridine diphosphate glucuronosyltransferase (UGT)

c. Increased destruction of red blood cells

d. Inadequate caloric intake

12.3 A patient has been hospitalized in the intensive care unit for postoperative sepsis, and has been critically ill. Fortunately, he is responding to antibiotics and clinically improving. Of the following, the least likely etiology for persistent hyperbilirubinemia is:

a. Renal failure

b. Covalent binding of bilirubin to albumin

c. Development of gallstones

d. Ongoing use of total parenteral nutrition (TPN)

13.1 Which of the following is true?

a. Antimitochondrial antibody is positive in approximately 50% of patients with PBC

b. Anti-liver kidney microsomal (LKM) antibody is associated with older patients with autoimmune hepatitis

c. Anti-LKM antibodies are associated with a more benign course of autoimmune hepatitis

d. Anti-smooth muscle antibodies may be present in up to 50% of PBC patients

13.2 Which of the following is false regarding the diagnosis of Wilson disease?

a. Ceruloplasmin is a copper storage protein

b. Free serum copper is low in Wilson disease

c. Urinary copper can be markedly elevated in chronic cholestatic liver disease

d. Ceruloplasmin can be low in advanced liver disease of any etiology

13.3 Which of the following diseases is characterized by a low serum alkaline phosphatase level?

a. Primary biliary cirrhosis (PBC)

b. Primary sclerosing cholangitis (PSC)

c. Wilson disease

d. Cholangiocarcinoma

14.1 Routine analysis of ascites fluid should include:

a. Total protein

b. White blood cell count with differential

c. Albumin

d. Glucose

14.2 All the following are associated with high serum-ascites albumin gradient (SAAG), low protein ascites, except:

a. Alcoholic hepatitis

b. Hepatitis C cirrhosis

c. Congestive heart failure

d. Nodular regenerative hyperplasia

14.3 In a patient with tense ascites who develops hepatorenal syndrome (HRS), all the following should be part of management, except:

a. Intravenous fluids and/or albumin

b. Discontinue nephrotoxic medications

b. Increase diuretic doses

c. Consider use of octreotide and midodrine

15.1 Which of the following findings is not typically seen with hypocalcemia?

a. Trousseau sign

b. Hyporeflexia

c. Heart block

d. Seizures

e. Paresthesias

15.2 What is the daily caloric requirement of a 70 kg person who is postoperative?

a. 1400–1750 kcal

b. 1750–2100 kcal

c. 2100–2800 kcal

d. 3000–4000 kcal

15.3 In a patient with an active Crohn’s flare who is unable to tolerate any oral intake, how soon should TPN be initiated?

a. In 14–21 days

b. In 10–14 days

c. In 1–7 days

d. TPN is contraindicated during a Crohn’s flare

16.1 Which of the following is not an accepted indication for performing endoscopy?

a. Surveillance of Barrett esophagus

b. Evaluation of suspected upper GI bleeding

c. Evaluation of suspected perforated duodenal ulcer

d. Evaluation of dysphagia

16.2 A 67-year-old man is scheduled for upper endoscopy for evaluation and management of solid food dysphagia. He is on coumadin for a mechanical heart valve in the mitral position. What is the appropriate management of his anticoagulation therapy?

a. Coumadin should be held for 2 days and low molecular weight heparin should be administered until the night before the scheduled procedure

b. Coumadin should be held for 5–7 days prior to the procedure and low molecular weight heparin should be administered until the night before the scheduled procedure

c. Coumadin should be held for 5–7 days. No bridge therapy is needed

d. Coumadin should not be held for the procedure

17.1 What is the most common cause of noncardiac chest pain?

a. High-amplitude contractions of the esophageal body

b. Simultaneous contractions of the esophageal body

c. Gastroesophageal acid reflux

d. Hypertensive LES

17.2 Which is the defining characteristic of achalasia?

a. Nonrelaxation of the lower esophageal sphincter

b. Aperistalsis of the esophageal body

c. Absence of esophageal body contractions

17.3 What is the most common cause of oropharyngeal dysphagia?

a. Cerebrovascular accident

b. Parkinson disease

c. Myasthenia gravis

d. Polymyositis

18.1 Which of the following is best able to detect the presence of gastroesophageal reflux?

a. Upper gastrointestinal endoscopy

b. Esophageal impedance

c. Esophageal manometry

d. Ambulatory esophageal pH monitoring

e. Barium esophagram

18.2 What is the most common adverse event associated with PPIs?

a. C. difficile-associated diarrhea

b. Nosocomial pneumonia

c. Bone fracture

d. Myocardial infarction

e. Increased heartburn upon discontinuation of drug

18.3 What is the recommended management of Barrett esophagus with high-grade dysplasia?

a. Esophagectomy

b. Endoscopic surveillance every 3 months

c. Endoscopic therapy

d. Chemoprevention with selective COX-2 inhibitors

18.4 What is the most common cause of heartburn symptoms that persist despite PPI therapy?

a. Excessive gastric acid production

b. Functional heartburn

c. Nonacid reflux

d. Alkaline reflux

18.2 What is the most common endoscopic finding in patients with documented GERD?

a. Normal

b. Barrett esophagus

c. Erosive esophagitis

d. Esophageal stricture

19.1 Which of the following is a strong risk factor for esophageal adenocarcinoma?

a. Alcohol

b. Smoking

c. African-American race

d. Intestinal metaplasia

19.2 Current guidelines recommend which of the following for patients with confirmed Barrett esophagus with high-grade dysplasia?

a. Esophagectomy

b. Intensive endoscopic surveillance

c. Endoscopic therapy

d. Repeated endoscopy with four-quadrant biopsies every 0.5 cm

19.3 Which of the following is associated with esophageal squamous cell carcinoma (ESCC)?

a. White race

b. Heartburn

c. Alcohol

d. Intestinal metaplasia

20.1 For patients with established diabetic gastroparesis, which therapy should be pursued if medical therapy fails to alleviate symptoms?

a. Gastric pacing

b. Venting gastrostomy and feeding jejunostomy

c. Total parenteral nutrition

d. Total gastrectomy

20.2 In patients with early dumping syndrome, what is the best therapy in addition to dietary modifications?

a. Omeprazole 40 mg daily

b. Metoclopramide 10 mg three times daily

c. Octreotide 50 µg three times daily

d. Insulin, regularly titrated to maintain glucose below 130

20.3 Which of the following scintigraphic-based gastric emptying protocols is most accurate for diagnosing gastroparesis?

a. 2-h liquid

b. 2-h solid

c. 4-h liquid

d. 4-h solid

21.1 What is the most common cause of hypergastrinemia in a 24-year-old patient presenting with recurrent duodenal ulcer disease?

a. Gastrinoma (Zollinger–Ellison syndrome)

b. Acid suppression therapy

c. Pernicious anemia

d. Laboratory error

21.2 What is the most clinically expeditious method to differentiate hyper­gastrinemia due to gastrinoma from gastrin elevation due to PPI therapy?

a. Basal and maximal acid output

b. Secretin stimulation

c. Gastric pH

d. Serum chromogranin A

21.3 In addition to a PPI, what is the best retreatment regimen for patients who have persistent H. pylori despite being adherent to a 14-day course of clarithromycin, amoxicillin, and PPI?

a. Clarithromycin and metronidazole

b. Bismuth, metronidazole, and amoxicillin

c. Amoxicillin for 5 days followed by clarithromycin and tinidazole for 5 days

21.4 A 58-year-old man comes to the emergency department with symptoms of melena and epigastric pain for 2 days. His exam is notable for orthostatic hypotension, reduced bowel sounds, and epigastric tenderness with guarding. His rectal examination reveals melena but his nasogastric lavage consists of bile-stained nonbloody fluid. His laboratory tests are notable for a Hb of 7.5 mg/dL, a HCT of 22 and a white blood count of 18.3. He is resuscitated with crystalloid and colloid and an intravenous PPI infusion is initiated. He is no longer orthostatic and repeated Hb is 9.7 mg/dL. What is the next best step in management?

a. Upper gastrointestinal endoscopy

b. Interventional radiology embolization

c. CT scan of the abdomen

d. H. pylori serology

22.1 A 28-year-old woman is referred to your office for symptoms of epigastric discomfort, nausea, and bloating. The symptoms do not wake her from sleep, are not associated with weight loss, and have been constant for the past several months. She takes oral contraceptives but no other prescription or over-the-counter medication. Her examination is normal and her laboratory tests reveal a normal complete blood count and liver tests. What is the next best step in management?

a. Proton pump inhibitor

b. H. pylori eradication

c. Upper endoscopy

d. CT scan of the abdomen

22.2 The patient in question 22.1 responds initially to a 4-week trial of PPI but her symptoms recur while still taking the medication. H. pylori stool antigen testing is negative. Upper endoscopy is performed. What is the most likely finding?

a. Gastric ulcer

b. Duodenal ulcer

c. Erosive esophagitis

d. Normal

22.3 The patient in questions 22.1 and 22.2 remains symptomatic on PPI therapy. What is the next best step in management?

a. Abdominal CT scan

b. Gallbladder scintigraphy with ejection fraction

c. Magnetic resonance angiography

d. Reassurance

22.4 The patient remains symptomatic. What is the next best therapeutic option?

a. Sequential therapy for H. pylori eradication

b. High-dose proton pump inhibitor

c. Metoclopramide

d. Tricyclic antidepressant (TCA)

23.1 Which of the following is not a high-risk feature in evaluation of a gastrointestinal stromal tumor?

a. >10 mitosis/50 HPF

b. Tumor diameter >10 cm

c. Tumor with mucosal ulceration and GI bleeding

d. Tumor diameter >5 cm with >5 mitosis/50 HPF

23.2 A patient underwent EGD to evaluate epigastric pain and was found to have evidence of a 3 cm malignant-appearing ulcer with biopsies demonstrating intestinal-type gastric adenocarcinoma. Which is the next most appropriate test?

a. EUS

b. PET

c. CT

d. Upper GI series

24.1 Which of the following grains is tolerated by most patients with celiac disease?

a. Wheat

b. Barley

c. Oats

d. Rye

e. Malt

24.2 Which of the following tests is no longer recommended as part of the diagnostic evaluation of suspected celiac disease?

a. Anti-tTG IgA

b. Antiendomysial antibody

c. Total IgA

d. Antigliadin antibodies

e. Small intestinal biopsy

24.3 All the following are true statements about celiac disease except:

a. Celiac disease is more common in Caucasians than in Asians or people of African descent

b. Celiac disease is associated with dermatitis herpetiformis

c. A gluten-free diet will result in recovery of normal intestinal histology within 48 h

d. A gluten-free diet is considered to be protective against the development of lymphoma

e. Histological findings on small bowel biopsy may be milder than expected due to gluten restriction in the diet or use of immunosuppressant medications

25.1 What is the most likely composition of nephrolithiasis in a patient with short bowel syndrome?

a. Calcium oxalate

b. Calcium phosphate

c. Sodium hydroxyapatite

d. Calcium urate

25.2 A patient with short bowel syndrome suddenly becomes obtunded after eating a pizza. A significant metabolic acidosis with respiratory alkalosis is revealed. What is the most likely etiology of this presentation?

a. New-onset diabetic ketoacidosis

b. Alcoholic ketoacidosis

c. Salicylate overdose

d. D-lactic acidemia

25.3 How should the patient in question 25.2 be treated?

a. Intravenous insulin and fluids

b. N-acetylcysteine

c. Antibiotics

d. Bicarbonate infusion

25.4 What type of fat source is best absorbed in a patient with short bowel syndrome?

a. Short-chain triglycerides

b. Medium-chain triglycerides

c. Long-chain triglycerides

26.1 Patients with familial adenomatous polyposis (FAP) syndrome should have which of the following performed every 1–2 years for surveillance purposes?

a. Double balloon enteroscopy

b. CT scan

c. Side-viewing upper endoscopy

d. Standard upper endoscopy

26.2 Which lab test should be orderd if carcinoid syndrome is suspected?

a. CA 19-9

b. CEA

c. Urinary 5-HIAA

d. Liver function panel

27.1 Which of the following statements about diverticular disease is true?

a. Approximately half of diverticular hemorrhage emanates from the right colon

b. Diverticulosis is more common in the proximal colon (i.e. cecum, ascending and transverse colon) than in the sigmoid colon

c. Diverticulitis is precipitated by seeds, corn or nuts