In an animal experiment, the pancreatic duct is cannulated and different secretory stimuli are applied to the gland.  The following tracings are obtained by measuring pancreatic fluid constituents:

Substance ‘X’ is most likely which of the following?

A 15-year-old girl is hospitalized due to confusion and hematemesis for 2 days.  Medical history is notable for depression over the past year.  Temperature is 37.2 C (99 F), blood pressure is 86/56 mm Hg, pulse is 112/min, and respirations are 20/min; BMI is 23 kg/m2.  She is oriented to person but disoriented to time and place.  The patient quickly deteriorates and dies during hospitalization.  Autopsy examination reveals a nodular liver, esophageal varices, splenomegaly, and atrophy of the basal ganglia with increased copper content.  The most likely cause of this patient’s condition is an abnormality in which of the following physiologic processes?

A 43-year-old woman comes to the emergency room with severe epigastric pain that started after a heavy meal. She has had several milder episodes, noting that they seem to occur after eating fried food. The patient has had no bloating or changes in stool frequency. Other medical problems include a recent ankle sprain for which she takes ibuprofen daily. BMI is 31 kg/m2. Physical examination reveals right upper quadrant tenderness. Which of the following substances most likely contributes to this patient’s recurrent episodes of pain?

A 45-year-old woman comes to the office due to several months of episodic right upper quadrant abdominal pain associated with nausea. The pain is often brought on by fatty meals and subsides in 1-2 hours. The patient has no fever, vomiting, diarrhea, melena, or bright red blood per rectum. Her BMI is 31.2 kg/m2. Physical examination is unremarkable. A cholecystokinin stimulation test is performed and shows slow and incomplete gallbladder emptying. This patient is most likely to have which of the following pathologic findings?

A 26-year-old woman is evaluated for intermittent abdominal discomfort, diarrhea, and melena.  The patient undergoes colonoscopy followed by total colectomy due to significant colonic abnormalities.  Representative colon findings are shown in the image below.

Her sister, who has the same biological parents and has no symptoms, also undergoes screening colonoscopy and has similar findings.  If left untreated, which of the following is the most likely lifetime risk of colon cancer in the patient’s sister?

A 32-year-old man with abdominal pain and periodic diarrhea is found to have heme-positive stools.  Stool cultures show no growth of pathogenic organisms.  Colonoscopy with biopsy of the colonic mucosa is performed.  Light microscopy of the tissue sample is shown in the image below.

This patient most likely suffers from which of the following disorders?

A 24-year-old woman comes to the office due to recurrent bloody diarrhea and right-sided abdominal pain.  She has had these symptoms intermittently for several years but has not sought medical attention until now.  Colonoscopy shows evidence of inflammation and dysplasia.  The patient is started on appropriate medical therapy but her symptoms fail to respond adequately.  She subsequently undergoes a colectomy of the involved region; findings are shown in the image.

The intestinal wall appears thickened.  Which of the following is the most likely diagnosis?

An 81-year-old woman is brought to the emergency department by a neighbor due to abdominal pain.  The pain comes in waves and is associated with nausea and vomiting.  The patient is confused and unable to provide additional information.  Past medical history is unknown, but she comes with a bag containing medications used in type 2 diabetes mellitus, hypercholesterolemia, hypertension, and dementia.  On examination, the patient has a low-grade fever and mild tachycardia.  She appears in distress due to pain.  Mucous membranes are dry, and there is decreased skin turgor.  Abdominal examination shows diffuse tenderness with high-pitched bowel sounds.  Imaging of the abdomen reveals a complete small bowel obstruction.  The patient undergoes laparotomy with extraction of a hard mass obstructing the ileocecal valve.  The cholesterol content of the mass is 85%.  Which of the following radiographic findings is most consistent with this patient’s clinical presentation?

A 49-year-old man comes to the office for evaluation of a dry cough that occurs mainly at night.  His symptoms have been present on and off for several years, but he has not been previously evaluated.  The patient also reports a frequent sore throat and occasional epigastric discomfort.  He has tried a variety of antihistamines and over-the-counter cough medications without relief.  Past medical history is notable for obesity and diet-controlled type 2 diabetes mellitus.  He does not smoke or drink alcohol.  Cardiopulmonary and abdominal examinations are unremarkable.  Chest x-ray reveals no abnormalities, and pulmonary function testing is normal.  The patient undergoes upper gastrointestinal endoscopy with mucosal biopsies.  Microscopic findings on lower esophageal biopsy are shown in the image below.

This patient is at highest risk of which of the following complications?

A 57-year-old man comes to the office due to anorexia, a 4.5 kg (9.9 lb) weight loss, and generalized weakness.  Other medical conditions include psoriasis and cervical spondylosis.  Two years ago, the patient emigrated from Taiwan, where he worked for many years on a maize (corn) farm.  He does not use tobacco, alcohol, or recreational drugs.  Vital signs are within normal limits.  BMI is 23 kg/m².  The patient appears cachectic.  Examination shows a mass in the liver.  There is no splenomegaly or ascites.  Laboratory results are as follows:

Abdominal ultrasound shows a 6-cm mass in the right lobe of the liver; the remainder of the liver appears normal.  Biopsy of the mass shows plates of abnormal cells that are smaller than normal hepatocytes with a high nuclear/cytoplasmic ratio and nuclear pleomorphism.  Which of the following is most likely responsible for this patient’s current condition?

A 53-year-old man comes to the physician with progressively worsening anorexia and abdominal discomfort.  He has lost 14 kg (31 lb) since the onset of his symptoms about 4 months ago.  Physical examination demonstrates nontender hepatomegaly.  Laboratory studies show an elevated serum alkaline phosphatase level and a marginally elevated alanine aminotransferase level.  A CT scan of the abdomen with oral and intravenous contrast is shown below.

Which of the following is the most likely diagnosis?

A 54-year-old man dies from profuse upper gastrointestinal hemorrhage.  An autopsy is performed; gross examination of his liver is shown in the image below.

This patient’s liver findings most likely resulted from which of the following processes?

A 65-year-old man with a history of chronic gastroesophageal reflux comes to the clinic due to dysphagia.  The patient has had difficulty swallowing foods such as steak or hard-boiled eggs but is able to drink hot tea and coffee without any issues.  Increasing the frequency of his proton pump inhibitor to twice daily did not improve symptoms.  He has also lost 6.8 kg (15 lb) over the past 4 months.  The patient has a history of hypertension, hyperlipidemia, and osteoarthritis.  Medications include amlodipine, atorvastatin, and ibuprofen as needed.  He drinks 2 or 3 glasses of wine with dinner most nights but does not use tobacco or illicit drugs.  Vital signs are within normal limits.  BMI is 32 kg/m2.  Physical examination is unremarkable.  Esophagogastroduodenoscopy reveals a 4-cm mass surrounded by a large segment of discolored mucosa in the lower half of the esophagus.  Esophagogastrectomy results are shown in the image below:

Which of the following is the most likely predisposing factor for this patient’s esophageal disease?

A 45-year-old man comes to the emergency department due to epigastric abdominal pain and fatigue.  He has had similar episodes of pain in the past.  Temperature is 37.1 C (98.8 F), blood pressure is 128/69 mm Hg, pulse is 92/min, and respirations are 16/min.  Physical examination shows mild epigastric tenderness and hepatomegaly.  There is no jaundice or lymphadenopathy.  Laboratory results are as follows:

CT scan of the abdomen shows pancreatic calcifications.  Right upper quadrant ultrasound reveals no evidence of gallstones.  Which of the following processes is most likely responsible for this patient’s anemia?

A 50-year-old man with a remote history of alcohol dependence is evaluated in the clinic for chronic diarrhea and weight loss.  The patient has had bloating with daily loose stools for the past 2 years.  His stool is described as greasy and malodorous.  Pancreatic insufficiency is suspected despite normal abdominal imaging.  The patient undergoes a test in which bicarbonate concentration is measured from duodenal aspirates as hormone A is infused intravenously.  The data is plotted in the graph below.

Hormone A is most likely produced by which of the following cell types?

A 50-year-old man with a long history of alcohol use disorder is admitted to the hospital with difficulty breathing.  Blood pressure is 90/40 mm Hg, pulse is 114/min, respirations are 22/min, and pulse oximetry is 92% on room air.  Physical examination shows bilateral basal crackles, increased jugular venous pressure, hepatomegaly, ascites, and peripheral pitting edema.  Chest x-ray demonstrates cardiomegaly.  Scattered ecchymoses are present across each extremity.  Laboratory results are as follows:

The patient is given intramuscular vitamin K.  Two days later, his laboratory results are unchanged.  Which of the following is the most likely cause of this patient’s laboratory abnormality?

Researchers measure the serum insulin levels of healthy volunteers after equivalent loads of oral and intravenous glucose.  The following curves are observed:

Which of the following endogenous substances best explains the difference between the curves?

A 22-year-old woman comes to the office for a routine examination.  The patient reports mild fatigue but is otherwise asymptomatic.  She has no chronic medical conditions and takes no medications.  She does not use tobacco, alcohol, or recreational drugs.  The patient is not sexually active and has received all age-appropriate vaccinations.  BMI is 30 kg/m².  Blood pressure is 120/80 mm Hg and pulse is 78/min.  Examination shows truncal obesity but is otherwise normal.  Fasting laboratory results are as follows:

If left untreated, this patient is at increased risk for which of the following complications?

A 3-hour-old girl is being evaluated in the neonatal intensive care unit due to respiratory distress and an episode of cyanosis.  Endotracheal and orogastric tubes are inserted.  An umbilical venous catheter is placed.  Chest radiograph is shown in the image below:

Which of the following is most likely present in this patient?

A 54-year-old man comes to the office due to epigastric pain and unexpected weight loss.  Medical and family history are unremarkable.  Vital signs are within normal limits.  The abdomen is tender to palpation over the epigastrium.  Abdominal CT demonstrates a multinodular mass in the pancreas, which is subsequently biopsied.  The histologic specimen is shown in the image below:

Immunohistochemical staining for synaptophysin and chromogranin A is diffusely positive.  Which of the following is the most likely diagnosis?

A 45-year-old woman comes to the hospital due to a weeklong history of right upper quadrant pain, anorexia, jaundice, and dark urine.  She has not recently traveled outside of the United States.  The patient has no chronic medical conditions and takes no medications.  She usually drinks 2 or 3 beers a day but has been drinking 8-10 beers daily for the past 6 months.  The patient does not use intravenous drugs and is not sexually active.  Family history is unremarkable.  Temperature is 38.1 C (100.6 F), blood pressure is 122/74 mm Hg, pulse is 98/min and regular, and respirations are 15/min.  BMI is 24 kg/m2.  The patient is jaundiced but in no apparent distress.  She is oriented to person, place, and date.  The liver is enlarged and tender to palpation.  There is no splenomegaly.  The remainder of the physical examination shows no abnormalities.  Laboratory results are as follows:

If a liver biopsy is performed, which of the following pathologic findings would most likely be identified in this patient?

A 54-year-old man comes to the emergency department after an episode of bloody vomiting.  He has had no fever, chills, abdominal pain, diarrhea, or constipation.  The patient has a history of alcohol abuse with multiple previous hospital admissions due to alcohol withdrawal and generalized tonic-clonic seizures.  He also has a history of intravenous drug abuse and is currently enrolled in a methadone maintenance program.  Blood pressure is 96/62 mm Hg and pulse is 102/min.  On examination, the patient appears comfortable but develops dizziness when asked to sit up.  There is no jugular venous distension.  The abdomen is distended with dullness to percussion at both flanks.  The liver is enlarged on palpation, and the tip of the spleen is also palpable.  There is trace pedal edema.  Laboratory studies show:

Item 1 of 2

Histopathologic examination of this patient’s spleen is most likely to show which of the following?

Item 2 of 2

After initial stabilization with intravenous fluids and blood products, the patient develops another bout of bloody emesis.  Urgent upper gastrointestinal endoscopy confirms esophageal varices.  Which of the following peptides is most likely to immediately decrease the portal venous pressure in this patient?