1. A 68-year-old man with a recent history of myocardial infarction
status post stent placement comes to his primary care physician
complaining of black stools and epigastric pain. The pain is
moderate in intensity and gnawing in character. His other medical
problems include untreated type 2 diabetes mellitus and chronic
lumbar back pain. The patient's medications include daily aspirin,
clopidogrel, a multivitamin, and calcium supplements. Testing in
the office shows guaiac-positive stool. He later undergoes
outpatient endoscopy, which shows lesions involving his gastric
mucosa (see image).
These lesions will be defined as erosions if they extend into, but
not completely through, which of the following structures?
A. gastric pits
B. gastric glands
C. muscularis mucosa
D. submucosal layer
E. circumferential smooth muscle
F. longitudinal smooth muscle
Answer: C
Explanation:
,Gastric erosions are defined as mucosal defects that do not fully extend
through the muscularis mucosa (ie, erosions are limited to the mucosal
layer). Gastric ulcers, on the other hand, penetrate through the mucosal
layer and extend into the submucosal layers. Erosions usually occur in
the setting of acute erosive gastropathy, a condition that results from
short-term, severe mucosal injury leading to inflammation and superficial
mucosal destruction. A number of causative agents can cause acute
erosive gastropathy. The use of nonsteroidal anti-inflammatory drugs
(NSAID s), surgical stress, head trauma (Cushing ulcers), burns (Curling
ulcers), smoking, and alcohol consumption are the most common
causes.
NSAID use is very common in the United States and is the second most
common cause of gastric ulcers after Helicobacter pylori. NSAIDs
induce gastric injury by inhibiting prostaglandin synthesis. As a result,
they decrease the stomach's protective abilities by reducing mucin and
bicarbonate secretion, gastric epithelial cell proliferation, and gastric
perfusion. NSAIDs also increase gastric acid secretion and can
penetrate the cells of the gastric mucosa, causing direct cell damage.
,Clinical manifestations of acute erosive gastropathy vary widely; patients
may be asymptomatic or present withlife-
threateninguppergastrointestinalbleeding.
Epigastricdiscomfortorpain,nausea,andvomitingare the most common
symptoms. These symptoms usually subside a few days after withdrawal
of the offending medication.
(Choice A) Gastric pits or foveolae are invaginations of the gastric
mucosal surface that lead to the gastric mucosal glands. They are
damaged when erosions occur.
(Choice B) Gastric glands are located in the lamina propria of gastric
mucosa; they are destroyed when erosions develop.
(Choices D, E, and F) Gastric ulcers can extend into the submucosal
layer and muscularis propria (inner circumferential and outer longitudinal
smooth muscle layers). Erosions, by definition, do not fully penetrate
the muscularis mucosa.
2.A 45-year-old Caucasian male presents to your office with a two year
history of abdominal discomfort, greasy stool and weight loss. He has
been treated for joint pain with ibuprofen. After initial work-up, an
, intestinal biopsy shows multiple macrophages loaded with PAS-positive
granules in the lamina propria. This patient should be treated with:
A. Enzyme supplementation
B. Antibiotics
C. Special diet
D. Parenteral nutrition
E. Aminosalicylic acid derivatives
F. Surgical resection
Answer: B
Explanation:
Caused by the gram-positive actinomycete Tropheryma whippelii,
Whipple disease is a rare systemic illness that involves the small
intestine, joints, and central nervous system. The actinomycete
proliferates only within
the macrophages of these tissues, provoking no inflammatory response
as a consequence. Classic histologic findings include small intestine
mucosa containing enlarged, foamy macrophages packed with both rod-
shaped bacilli and PAS-positive, diastase-resistant granules (which
consist of lysosomes and partially digested bacteria).
Clinically, Whipple disease is most commonly seen in middle-aged
Caucasian males, presenting as malabsorption w ith diarrhea and w
eight loss. Arthropathy, polyarthritis, and psychiatric and cardiac
abnormalities may also be observed. Antibiotic therapy is usually
successful in quickly resolving the illness.
(Choice A) Digestive enzyme supplementation is appropriate for
patients with diminished exocrine pancreatic function .
status post stent placement comes to his primary care physician
complaining of black stools and epigastric pain. The pain is
moderate in intensity and gnawing in character. His other medical
problems include untreated type 2 diabetes mellitus and chronic
lumbar back pain. The patient's medications include daily aspirin,
clopidogrel, a multivitamin, and calcium supplements. Testing in
the office shows guaiac-positive stool. He later undergoes
outpatient endoscopy, which shows lesions involving his gastric
mucosa (see image).
These lesions will be defined as erosions if they extend into, but
not completely through, which of the following structures?
A. gastric pits
B. gastric glands
C. muscularis mucosa
D. submucosal layer
E. circumferential smooth muscle
F. longitudinal smooth muscle
Answer: C
Explanation:
,Gastric erosions are defined as mucosal defects that do not fully extend
through the muscularis mucosa (ie, erosions are limited to the mucosal
layer). Gastric ulcers, on the other hand, penetrate through the mucosal
layer and extend into the submucosal layers. Erosions usually occur in
the setting of acute erosive gastropathy, a condition that results from
short-term, severe mucosal injury leading to inflammation and superficial
mucosal destruction. A number of causative agents can cause acute
erosive gastropathy. The use of nonsteroidal anti-inflammatory drugs
(NSAID s), surgical stress, head trauma (Cushing ulcers), burns (Curling
ulcers), smoking, and alcohol consumption are the most common
causes.
NSAID use is very common in the United States and is the second most
common cause of gastric ulcers after Helicobacter pylori. NSAIDs
induce gastric injury by inhibiting prostaglandin synthesis. As a result,
they decrease the stomach's protective abilities by reducing mucin and
bicarbonate secretion, gastric epithelial cell proliferation, and gastric
perfusion. NSAIDs also increase gastric acid secretion and can
penetrate the cells of the gastric mucosa, causing direct cell damage.
,Clinical manifestations of acute erosive gastropathy vary widely; patients
may be asymptomatic or present withlife-
threateninguppergastrointestinalbleeding.
Epigastricdiscomfortorpain,nausea,andvomitingare the most common
symptoms. These symptoms usually subside a few days after withdrawal
of the offending medication.
(Choice A) Gastric pits or foveolae are invaginations of the gastric
mucosal surface that lead to the gastric mucosal glands. They are
damaged when erosions occur.
(Choice B) Gastric glands are located in the lamina propria of gastric
mucosa; they are destroyed when erosions develop.
(Choices D, E, and F) Gastric ulcers can extend into the submucosal
layer and muscularis propria (inner circumferential and outer longitudinal
smooth muscle layers). Erosions, by definition, do not fully penetrate
the muscularis mucosa.
2.A 45-year-old Caucasian male presents to your office with a two year
history of abdominal discomfort, greasy stool and weight loss. He has
been treated for joint pain with ibuprofen. After initial work-up, an
, intestinal biopsy shows multiple macrophages loaded with PAS-positive
granules in the lamina propria. This patient should be treated with:
A. Enzyme supplementation
B. Antibiotics
C. Special diet
D. Parenteral nutrition
E. Aminosalicylic acid derivatives
F. Surgical resection
Answer: B
Explanation:
Caused by the gram-positive actinomycete Tropheryma whippelii,
Whipple disease is a rare systemic illness that involves the small
intestine, joints, and central nervous system. The actinomycete
proliferates only within
the macrophages of these tissues, provoking no inflammatory response
as a consequence. Classic histologic findings include small intestine
mucosa containing enlarged, foamy macrophages packed with both rod-
shaped bacilli and PAS-positive, diastase-resistant granules (which
consist of lysosomes and partially digested bacteria).
Clinically, Whipple disease is most commonly seen in middle-aged
Caucasian males, presenting as malabsorption w ith diarrhea and w
eight loss. Arthropathy, polyarthritis, and psychiatric and cardiac
abnormalities may also be observed. Antibiotic therapy is usually
successful in quickly resolving the illness.
(Choice A) Digestive enzyme supplementation is appropriate for
patients with diminished exocrine pancreatic function .
