Practice questions A Stomach pathology

Practice questions A
Stomach pathology
Updated: 03/01/2019
© Jun Wang,MD, PhD

1. Use this case for the next two questions. A 35-year-old woman presents with sudden onset of epigastric pain and hematemesis for 2 hours. She does not have fever or sweating. She has had severe headache two days ago and has been taking Ibuprofen since then. Her past medical history is unremarkable. Physical examination reveals a blood pressure of 95/55 mmHg, heart rate of 120 bpm, and her skin appears to be pale. Laboratory tests reveal a hemoglobin of 10.5 g/dl (normal 12-16 g/dl). No other abnormalities are noted. Gastroscopy exam reveals diffuse erythematous changes of gastric mucosa, with a few shallow ulcers. Biopsy reveal benign fundic type gastric mucosa with scattered neutrophilic infiltrate. No significant lymphoplasmacytic infiltrate nor glandular atrophy are noted. Silver stain reveals no evidence of bacteria. What is the diagnosis?
A. Acute gastritis
B. Chronic gastritis, type A
C. Chronic gastritis, type B
D. Curling ulcer
E. Peptic ulcer

2. A 35-year-old woman presents with sudden onset of epigastric pain and hematemesis for 2 hours. She does not have fever or sweating. She has had severe headache two days ago and has been taking Ibuprofen since then. Her past medical history is unremarkable. Physical examination reveals a blood pressure of 95/55 mmHg, heart rate of 120 bpm, and her skin appears to be pale. Laboratory tests reveal a hemoglobin of 10.5 g/dl (normal 12-16 g/dl). No other abnormalities are noted. Gastroscopy exam reveals diffuse erythematous changes of gastric mucosa, with a few shallow ulcers. Biopsy reveal benign fundic type gastric mucosa with scattered neutrophilic infiltrate. No significant lymphoplasmacytic infiltrate nor glandular atrophy are noted. Silver stain reveals no evidence of bacteria. What is most likely associated with her presentations?
A. Auto-antibody against intrinsic factor
B. Bacterial toxin
C. Hyperacidity
D. Inhibition of COX-1 and COX-2
E. Mucinous gland atrophy


3. A 2-year-old boy presents with melanotic stools for 2 days. He has a medulloblastoma that was removed 1 week ago. His past medical history is otherwise unremarkable. Laboratory tests reveals a hemoglobin of 8.5 g/dl (normal 10.5-14.5 g/dl). No other abnormality is noted. Gastroscopy exam reveals 2 ulcers, measuring up to 0.7 cm in diameter in duodenal bulb, and a 0.5 cm ulcer at the lesser curvature of his stomach. The background gastric mucosa has diffuse erythematous changes. What is the diagnosis?
A. Autoimmune gastritis
B. Curling ulcer
C. Cushing ulcer
D. Metastatic medulloblastoma
E. Peptic ulcer

4. Use this case for the next four questions. A 21-year-old man presents with intermittent epigastric pain for 6 months. His past medical history is unremarkable. His family history including multiple family members with gastric cancers. He does not smoke cigarette nor drink alcohol. Physical examination and laboratory test results are unremarkable.  Gastroscopy exam reveals focal erythematous changes at his antrum. No ulcer nor tumor is noted. Biopsy of his antrum mucosa reveals diffuse lymphoplasmacytic infiltrate. Scattered neutrophils are seen within glandular epithelium. No cytological atypia is noted. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. What test is likely to be positive for his antrum biopsy?
A. Acid fast bacilli stain
B. Immunofluorescence studies for anti-K/hydrogen ATPase
C. Immunohistochemistry studies for c-kit
D. Immunohistochemistry studies for gastrin
E. Silver stain for helicobacters

5. A 21-year-old man presents with intermittent epigastric pain for 6 months. His past medical history is unremarkable. His family history including multiple family members with gastric cancers. He does not smoke cigarette nor drink alcohol. Physical examination and laboratory test results are unremarkable.  Gastroscopy exam reveals focal erythematous changes at his antrum. No ulcer nor tumor is noted. Biopsy of his antrum mucosa reveals diffuse lymphoplasmacytic infiltrate. Scattered neutrophils are seen within glandular epithelium. No cytological atypia is noted. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. What is most likely the diagnosis?
A. Acute gastritis
B. Autoimmune gastritis
C. Dieulafoy lesion
D. Helicobacter gastritis
E. MALToma

6. A 21-year-old man presents with intermittent epigastric pain for 6 months. His past medical history is unremarkable. His family history including multiple family members with gastric cancers. He does not smoke cigarette nor drink alcohol. Physical examination and laboratory test results are unremarkable.  Gastroscopy exam reveals focal erythematous changes at his antrum. No ulcer nor tumor is noted. Biopsy of his antrum mucosa reveals diffuse lymphoplasmacytic infiltrate. Scattered neutrophils are seen within glandular epithelium. No cytological atypia is noted. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. What is most likely associated directly to his gastric epithelium injury?
A. Anemia associated with intrinsic factor deficiency
B. Autoantibody mediated cell injury
C. CagA associated mitogenic effects
D. Urease induced mucosal surface hyperacidity
E. VacA associated cell membrane damage

7. A 21-year-old man presents with intermittent epigastric pain for 6 months. His past medical history is unremarkable. His family history including multiple family members with gastric cancers. He does not smoke cigarette nor drink alcohol. Physical examination and laboratory test results are unremarkable.  Gastroscopy exam reveals focal erythematous changes at his antrum. No ulcer nor tumor is noted. Biopsy of his antrum mucosa reveals diffuse lymphoplasmacytic infiltrate. Scattered neutrophils are seen within glandular epithelium. No cytological atypia is noted. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. What risk associated with these finding does this patient have?
A. Diffuse type adenocarcinoma
B. Hodgkin lymphoma
C. Intestinal type adenocarcinoma
D. Metastasis
E. Pernicious anemia


8. Use this case for the next four questions. A 61-year-old woman presents with fatigue, clumsiness and vague upper abdominal discomfort for 6 months. She has a history of Hashimoto thyroiditis and is currently taking thyroxine. Her history is otherwise unremarkable. Physical examination reveals mildly pale skin. The vital signs are normal. Neurological examination reveals unsteady gait. Laboratory test results include a hemoglobin of 8 g/dl (normal 12-16 mg/dl), MCV of 112 fL (normal 80-95 fL), white count of 4 x 109/L (normal 4.5-10.5 x 109/L), and platelet count of 132 x 109/L (normal 150-450 x 109/L). Peripheral blood smear reveals slightly enlarged red cells, and many neutrophils with 5 to 6 segments. No immature blood cells are seen. Gastroscopic examination reveals pale smooth gastric mucosa. No ulcer nor tumor is seen. Biopsy of the fundus and body reveal sheets of lymphoplasmacytic infiltrate. No neutrophils are seen. The glandular components appear to be shorter than normal. Many columnar cells with greyish cytoplasm are seen among normal appearing gastric glandular cells. No significant cytological atypia is note. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. Biopsy from the antrum is unremarkable. What is the diagnosis?
A. Acute gastritis
B. Autoimmune gastritis
C. Diffuse large B cell lymphoma
D. Helicobacter gastritis
E. MALToma

9. A 61-year-old woman presents with fatigue, clumsiness and vague upper abdominal discomfort for 6 months. She has a history of Hashimoto thyroiditis and is currently taking thyroxine. Her history is otherwise unremarkable. Physical examination reveals mildly pale skin. The vital signs are normal. Neurological examination reveals unsteady gait. Laboratory test results include a hemoglobin of 8 g/dl (normal 12-16 mg/dl), MCV of 112 fL (normal 80-95 fL), white count of 4 x 109/L (normal 4.5-10.5 x 109/L), and platelet count of 132 x 109/L (normal 150-450 x 109/L). Peripheral blood smear reveals slightly enlarged red cells, and many neutrophils with 5 to 6 segments. No immature blood cells are seen. Gastroscopic examination reveals pale smooth gastric mucosa. No ulcer nor tumor is seen. Biopsy of the fundus and body reveal sheets of lymphoplasmacytic infiltrate. No neutrophils are seen. The glandular components appear to be shorter than normal. Many columnar cells with greyish cytoplasm are seen among normal appearing gastric glandular cells. No significant cytological atypia is note. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. Biopsy from the antrum is unremarkable. What is the cause of these findings?
A. Auto-antibody against K/H ATPase
B. CagA
C. Hyperacidity
D. Inhibition of COX-1 and COX-2
E. Urease

10. A 61-year-old woman presents with fatigue, clumsiness and vague upper abdominal discomfort for 6 months. She has a history of Hashimoto thyroiditis and is currently taking thyroxine. Her history is otherwise unremarkable. Physical examination reveals mildly pale skin. The vital signs are normal. Neurological examination reveals unsteady gait. Laboratory test results include a hemoglobin of 8 g/dl (normal 12-16 mg/dl), MCV of 112 fL (normal 80-95 fL), white count of 4 x 109/L (normal 4.5-10.5 x 109/L), and platelet count of 132 x 109/L (normal 150-450 x 109/L). Peripheral blood smear reveals slightly enlarged red cells, and many neutrophils with 5 to 6 segments. No immature blood cells are seen. Gastroscopic examination reveals pale smooth gastric mucosa. No ulcer nor tumor is seen. Biopsy of the fundus and body reveal sheets of lymphoplasmacytic infiltrate. No neutrophils are seen. The glandular components appear to be shorter than normal. Many columnar cells with greyish cytoplasm are seen among normal appearing gastric glandular cells. No significant cytological atypia is note. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. Biopsy from the antrum is unremarkable. What blood test might be abnormal for this patient?
A. Antibody against helicobacter
B. Auto-antibody against intrinsic factor
C. Folate
D. Iron
E. Total iron binding capacity

11. A 61-year-old woman presents with fatigue, clumsiness and vague upper abdominal discomfort for 6 months. She has a history of Hashimoto thyroiditis and is currently taking thyroxine. Her history is otherwise unremarkable. Physical examination reveals mildly pale skin. The vital signs are normal. Neurological examination reveals unsteady gait. Laboratory test results include a hemoglobin of 8 g/dl (normal 12-16 mg/dl), MCV of 112 fL (normal 80-95 fL), white count of 4 x 109/L (normal 4.5-10.5 x 109/L), and platelet count of 132 x 109/L (normal 150-450 x 109/L). Peripheral blood smear reveals slightly enlarged red cells, and many neutrophils with 5 to 6 segments. No immature blood cells are seen. Gastroscopic examination reveals pale smooth gastric mucosa. No ulcer nor tumor is seen. Biopsy of the fundus and body reveal sheets of lymphoplasmacytic infiltrate. No neutrophils are seen. The glandular components appear to be shorter than normal. Many columnar cells with greyish cytoplasm are seen among normal appearing gastric glandular cells. No significant cytological atypia is note. Immunohistochemistry studies reveals a mixed T and B cell population with normal kappa/lambda ratio. Biopsy from the antrum is unremarkable. What is the cause of her pancytopenia?
A. Bone marrow stem cell failure
B. Folate deficiency
C. Iron deficiency
D. Neoplastic process involving marrow
E. Vitamin B12 deficiency


12. A 45-year-old man presents with epigastric discomfort and mild diarrhea for 1 year. She denies other constitutional symptoms. She has a history of asthma and reflux esophagitis. Physical examination and laboratory tests are unremarkable. Parasitological and bacteriologic studies are negative. Endoscopic examination reveals normal appearing esophagus and focal erythematous changes of the antral mucosa. No ulcer nor tumor is noted. Antral biopsy reveal predominantly mucinous glands with numerous eosinophils in stroma. No neutrophils are seen. There is no intestinal metaplasia. Silver stain is negative for helicobacters. What is the diagnosis?
A. Acute gastritis
B. Autoimmune gastritis
C. Eosinophilic gastritis
D. Gastric antral vascular ectasia
E. Lymphocytic gastritis

13. Use this case for the next two questions. A 31-year-old man presents with intermittent epigastric pain for 2 months. The pain is dull, and tends to be worse at night, or 2-3 hours after meal. He does not have nausea or vomiting. His past medical history is unremarkable. He has a 10 pack-year history of cigarette smoking. He denies alcohol or other recreational drug use. Physical examination reveals epigastric tenderness. No other abnormalities are noted. Laboratory tests are unremarkable. Gastroscopic examination reveals a 1.5 cm deep ulcer at distal lesser curvature. The ulcer has sharp edge without induration. A few foci of his antral mucosa have erythematous changes. Biopsy of the ulcer reveals proteinaceous debris and granulation tissue. No cytological atypia is noted. Biopsies from the antrum reveal antral mucosa with diffuse lymphoplasmacytic infiltrate. Silver stain reveals groups of short curved rod. What is the diagnosis for the ulcer?
A. Curling ulcer
B. Cushing ulcer
C. Diffuse type adenocarcinoma
D. Intestinal type adenocarcinoma
E. Peptic ulcer

14. A 31-year-old man presents with intermittent epigastric pain for 2 months. The pain is dull, and tends to be worse at night, or 2-3 hours after meal. He does not have nausea or vomiting. His past medical history is unremarkable. He has a 10 pack-year history of cigarette smoking. He denies alcohol or other recreational drug use. Physical examination reveals epigastric tenderness. No other abnormalities are noted. Laboratory tests are unremarkable. Gastroscopic examination reveals a 1.5 cm deep ulcer at distal lesser curvature. The ulcer has sharp edge without induration. A few foci of his antral mucosa have erythematous changes. Biopsy of the ulcer reveals proteinaceous debris and granulation tissue. No cytological atypia is noted. Biopsies from the antrum reveal antral mucosa with diffuse lymphoplasmacytic infiltrate. Silver stain reveals groups of short curved rod. What is the most likely cause of the ulcer?
A. Cigarette smoking
B. Helicobacter pylori
C. Hyperacidity
D. Hypergastrinemia
E.  Monoclonal lymphocytic proliferation


15. A 22-year-old man presents with severe sharp epigastric pain and vomiting for 2 hours. He has had intermittent epigastric discomfort for a year. His past medical history including helicobacter gastritis. The patient appears to be in pain. He has a heart rate of 120 bpm with regular rhythm. Other vital signs are within normal range. Physical examination reveals guarding, rigidity, tenderness and rebound tenderness at upper left abdomen and periumbilical area. Laboratory tests reveal a white cell count of 14 x 109/L (normal 4.5-10.5 x 109/L) with left shift. Peripheral blood smear reveals no significant morphological abnormalities, except toxic granulation of neutrophils. Other blood tests, including amylase, liver and kidney function tests, are within normal range. Fecal occult blood test is positive. Abdominal X-ray reveals intraperitoneal air. What is likely the diagnosis?
A. Acute appendicitis
B. Acute cholecystitis
C. Acute leukemia
D. Acute pancreatitis
E. Perforated peptic ulcer



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