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 Mayo Clinic Gastroenterology
and Hepatology Board Review
FIFTH EDITION

Editor-in-Chief

Stephen C. Hauser, MD
Consultant, Division of Gastroenterology and Hepatology
Mayo Clinic, Rochester, Minnesota
Associate Professor of Medicine
Mayo Clinic College of Medicine

Associate Editors
Amy S. Oxentenko, MD
Consultant, Division of Gastroenterology and Hepatology
Mayo Clinic, Rochester, Minnesota
Associate Professor of Medicine
Mayo Clinic College of Medicine

William Sanchez, MD
Consultant, Division of Gastroenterology and Hepatology
Mayo Clinic, Rochester, Minnesota
Assistant Professor of Medicine
Mayo Clinic College of Medicine

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To the many persons who have taught, encouraged, and inspired us so that we can provide
the best care for our patients and help educate our colleagues to do the same.
 Preface

Gastroenterology and hepatology encompass a vast anatomical The book is organized by subspecialty topics, including
assortment of organs that have diverse structure and function and esophageal disorders, gastroduodenal disorders, small-bowel
potentially are afflicted by a multiplicity of disease processes. We disease and nutrition, colonic disorders, pancreaticobiliary dis-
have designed the Mayo Clinic Gastroenterology and Hepatology ease, liver disease, and miscellaneous disorders. Numerous
Board Review course and the revised fifth edition of this book color and black-and-white figures support the text. Each subspe-
to assist both physicians-in-training who are preparing for the cialty section concludes with a set of board examination–type,
gastroenterology board examination and the increasing num- single-best-answer multiple-choice questions with annotated
ber of gastroenterologists awaiting recertification. Mayo Clinic answers. (The content of the questions and answers is not included
Gastroenterology and Hepatology Board Review is not intended in the index.) The faculty responsible for the book (at the time it
to replace the many more encyclopedic textbooks of gastroen- was produced) all are Mayo Clinic gastroenterologists and hepa-
terology, hepatology, pathology, endoscopy, nutrition, and radi- tologists who spend the majority of their time caring for patients
ology now available. Nor is this book intended to serve as an but have a commitment to teaching medical students, house offi-
“update” to physicians looking for the newest advances in the cers, fellows, nurses, and physicians. Most of the faculty have
science and art of gastroenterology and hepatology. Instead, this particular interests in subspecialty areas of clinical gastroenterol-
book provides a core of essential knowledge in gastroenterol- ogy and hepatology, which provides broad expertise.
ogy, hepatology, and integral related areas of pathology, endos- We want to thank the staffs of Scientific Publications and
copy, nutrition, and radiology. Clinical knowledge related to Media Support Services at Mayo Clinic and the Mayo School
diagnostic and therapeutic approaches to patient management is of Continuous Professional Development for their contributions.
emphasized. Case-based presentations and short board exami- The support of Mayo Clinic Scientific Press and our publisher,
nation–type, single-best-answer multiple-choice questions with Oxford University Press, are also greatly appreciated. We want
annotated answers are featured. The text is also intended to be to give special thanks to our secretaries and to Vijay H. Shah,
used by medical students and residents during their clerkships MD, for his ongoing enthusiasm and support for our faculty and
in internal medicine and gastroenterology and by gastroenterol- teaching mission.
ogy fellows in training. Physicians in practice should find this
book to be a practical review for consolidating their knowledge Stephen C. Hauser, MD
in gastroenterology. Editor-in-Chief

vii
 Contents

Contributors xi Section IV Miscellaneous Disorders

Section I Esophagus 10 Gastrointestinal Manifestations of Human

Immunodeficiency Virus Infection 113
1 Gastroesophageal Reflux Disease 3 Stephen C. Hauser, MD
Joseph A. Murray, MD
11 Nonvariceal Gastrointestinal Tract Bleeding 120
2 Barrett Esophagus and Esophageal Cancer 17 Jeffrey A. Alexander, MD
Prasad G. Iyer, MD, MS
12 Vascular Disorders of the Gastrointestinal Tract 126
3 Normal and Abnormal Esophageal Motility 26 Stephen C. Hauser, MD
David A. Katzka, MD
13 Gastrointestinal Manifestations of Systemic
Questions and Answers 36 Disease 133
Seth R. Sweetser, MD
Section II Stomach
Questions and Answers 145
4 Peptic Ulcer Disease 43
Stephanie L. Hansel, MD, MS Section V Colon

5 Gastritis and Gastropathy 49 14 Inflammatory Bowel Disease: Clinical Aspects 155

Stephanie L. Hansel, MD, MS David H. Bruining, MD

6 Gastric Neoplasms and Gastroenteric and Pancreatic 15 Inflammatory Bowel Disease: Therapy 160
Neuroendocrine Tumors 57 Darrell S. Pardi, MD
Mark V. Larson, MD
16 Inflammatory Bowel Disease: Extraintestinal
7 Gastrointestinal Motility Disorders 73 Manifestations and Colorectal Cancer 168
Lawrence A. Szarka, MD, Michael Camilleri, MD Laura E. Raffals, MD

Questions and Answers 82 17 Gastrointestinal Infections, Clostridium difficile–

Associated Disease, and Diverticular Disease 174
Section III Small Bowel and Nutrition Conor G. Loftus, MD

8 Clinical Features of Malabsorptive Disorders, 18 Colorectal Neoplasms 185

Small-Bowel Diseases, and Bacterial Overgrowth John B. Kisiel, MD
Syndromes 89
Amy S. Oxentenko, MD 19 Irritable Bowel Syndrome 192
Seth R. Sweetser, MD, G. Richard Locke III, MD
9 Nutritional Disorders: Vitamins and Minerals 102
Stephen C. Hauser, MD 20 Constipation and Disorders of Pelvic Floor
Questions and Answers 106 Function 197
Adil E. Bharucha, MBBS, MD

ix
x Contents

21 Gastrointestinal Disease and Pregnancy 208 31 Drug-Induced Liver Injury 308

Sunanda V. Kane, MD Michael D. Leise, MD
Questions and Answers 223
32 Autoimmune Hepatitis 317
Kymberly D. Watt, MD, Albert J. Czaja, MD
Section VI Liver
33 Nonalcoholic Fatty Liver Disease 324
22 Approach to the Patient With Abnormal Liver Test Kymberly D. Watt, MD
Results and Acute Liver Failure 237
John J. Poterucha, MD
34 Liver Disease and Pregnancy 332
J. Eileen Hay, MB, ChB
23 Viral Hepatitis 244
John J. Poterucha, MD
35 Liver Transplantation 340
J. Eileen Hay, MB, ChB
24 Clinical Approach to Liver Mass Lesions 252
Lewis R. Roberts, MB, ChB, PhD Questions and Answers 344

25 Alcoholic Liver Disease 265 Section VII Pancreas and Biliary Tree
Robert C. Huebert, MD, Vijay H. Shah, MD
36 Acute Pancreatitis 365
26 Vascular Diseases of the Liver 274 Bret T. Petersen, MD, Randall K. Pearson, MD
William Sanchez, MD, Patrick S. Kamath, MD
37 Chronic Pancreatitis 373
27 Portal Hypertension–Related Bleeding 280 Suresh T. Chari, MD
William Sanchez, MD, Patrick S. Kamath, MD
38 Pancreatic Neoplasms 377
28 Ascites, Hepatorenal Syndrome, and Randall K. Pearson, MD
Encephalopathy 284
J. Eileen Hay, MB, ChB 39 Gallstones 383
Ferga C. Gleeson, MB, BCh
29 Metabolic Liver Disease 293
Questions and Answers 394
William Sanchez, MD

30 Cholestatic Liver Disease 304 Index 399

Jayant A. Talwalkar, MD, MPH
 Contributors

Jeffrey A. Alexander, MD Prasad G. Iyer, MD, MS

Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Associate Professor of Medicine, Clinic, Rochester, Minnesota; Associate Professor of Medicine,
Mayo Clinic College of Medicine Mayo Clinic College of Medicine
Adil E. Bharucha, MBBS, MD Patrick S. Kamath, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic
College of Medicine College of Medicine
David H. Bruining, MD Sunanda V. Kane, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Associate Professor of Medicine, Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic
Mayo Clinic College of Medicine College of Medicine
Michael Camilleri, MD David A. Katzka, MD
Consultant, Division of Gastroenterology and Hepatology, Consultant, Division of Gastroenterology and Hepatology, Mayo
Mayo Clinic, Rochester, Minnesota; Professor of Medicine, Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic
of Pharmacology, and of Physiology, Mayo Clinic College of College of Medicine
Medicine
John B. Kisiel, MD
Suresh T. Chari, MD Senior Associate Consultant, Division of Gastroenterology
Consultant, Division of Gastroenterology and Hepatology, Mayo and Hepatology, Mayo Clinic, Rochester, Minnesota; Assistant
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Professor of Medicine, Mayo Clinic College of Medicine
College of Medicine
Mark V. Larson, MD
Albert J. Czaja, MD Consultant, Division of Gastroenterology and Hepatology, Mayo
Emeritus Professor of Medicine, Mayo Clinic College of Medicine, Clinic, Rochester, Minnesota; Associate Professor of Medicine,
Rochester, Minnesota Mayo Clinic College of Medicine
Ferga C. Gleeson, MB, BCh Michael D. Leise, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Senior Associate Consultant, Division of Gastroenterology
Clinic, Rochester, Minnesota; Associate Professor of Medicine, and Hepatology, Mayo Clinic, Rochester, Minnesota; Assistant
Mayo Clinic College of Medicine Professor of Medicine, Mayo Clinic College of Medicine
Stephanie L. Hansel, MD, MS G. Richard Locke III, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Assistant Professor of Medicine, Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic
Mayo Clinic College of Medicine College of Medicine
Stephen C. Hauser, MD Conor G. Loftus, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Associate Professor of Medicine, Clinic, Rochester, Minnesota; Assistant Professor of Medicine,
Mayo Clinic College of Medicine Mayo Clinic College of Medicine
J. Eileen Hay, MB, ChB Joseph A. Murray, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic
College of Medicine College of Medicine
Robert C. Huebert, MD Amy S. Oxentenko, MD
Senior Associate Consultant, Division of Gastroenterology Consultant, Division of Gastroenterology and Hepatology, Mayo
and Hepatology, Mayo Clinic, Rochester, Minnesota; Assistant Clinic, Rochester, Minnesota; Associate Professor of Medicine,
Professor of Medicine, Mayo Clinic College of Medicine Mayo Clinic College of Medicine
xi
xii Contributors

Darrell S. Pardi, MD William Sanchez, MD

Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Clinic, Rochester, Minnesota; Assistant Professor of Medicine,
College of Medicine Mayo Clinic College of Medicine
Randall K. Pearson, MD Vijay H. Shah, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Chair, Division of Gastroenterology and Hepatology, Mayo Clinic,
Clinic, Rochester, Minnesota; Associate Professor of Medicine, Rochester, Minnesota; Professor of Medicine and of Physiology,
Mayo Clinic College of Medicine Mayo Clinic College of Medicine
Bret T. Petersen, MD Seth R. Sweetser, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Clinic, Rochester, Minnesota; Assistant Professor of Medicine,
College of Medicine Mayo Clinic College of Medicine
John J. Poterucha, MD Lawrence A. Szarka, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Clinic, Rochester, Minnesota; Assistant Professor of Medicine,
College of Medicine Mayo Clinic College of Medicine
Laura E. Raffals, MD Jayant A. Talwalkar, MD, MPH
Senior Associate Consultant, Division of Gastroenterology Consultant, Division of Gastroenterology and Hepatology, Mayo
and Hepatology, Mayo Clinic, Rochester, Minnesota; Assistant Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic
Professor of Medicine, Mayo Clinic College of Medicine College of Medicine
Lewis R. Roberts, MB, ChB, PhD Kymberly D. Watt, MD
Consultant, Division of Gastroenterology and Hepatology, Mayo Consultant, Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic Clinic, Rochester, Minnesota; Associate Professor of Medicine,
College of Medicine Mayo Clinic College of Medicine
 I

Esophagus
 1

Gastroesophageal Reflux Diseasea

JOSEPH A. MURRAY, MD

Gastroesophageal reflux is the reflux of gastric contents other Factors Contributing to GERD
than air into or through the esophagus. Gastroesophageal reflux
Barrier Function of the Lower Esophageal
disease (GERD) refers to reflux that produces frequent symptoms
Sphincter
or results in damage or dysfunction to the esophageal mucosa or
contiguous organs of the upper aerodigestive system and occa- The lower esophageal sphincter and its attached structures form
sionally the lower respiratory tract. a barrier to reflux of material across the esophagogastric junction
and are the central protection against pathologic reflux of gas-
tric contents into the esophagus. This barrier has several compo-
Etiology nents, including the smooth muscle lower esophageal sphincter,
the gastric sling fibers, and the striated muscle crural diaphragm.
Gastroesophageal reflux results from several factors that lead to The lower esophageal sphincter maintains tone at rest and relaxes
symptoms or injury of the mucosa of the esophagus or the air- with swallowing and gastric distention as a venting reflex. This
way by reflux of corrosive material from the stomach (Box 1.1). relaxation is TLESR. In persons with mild reflux disease, acid
These factors include a weak or defective sphincter, transient liquid contents instead of air alone are vented, resulting in many
lower esophageal sphincter relaxations (TLESRs), hiatal her- episodes of acid reflux. In patients with severe reflux, the resting
nia, poor acid clearance from the esophagus, diminished sali- pressure of the lower esophageal sphincter usually is diminished
vary flow, reduced mucosal resistance to injury, increased acid and easily overcome.
production, delayed gastric emptying of solids, and obstructive The presence of hiatal hernia has an important role in defec-
sleep apnea (Figure 1.1). The relative contribution of these var- tive barrier function, both by removing the augmentation that the
ies from patient to patient. crural diaphragm provides the lower esophageal sphincter and by
lowering the threshold for TLESR to occur.

Acid Clearance
The clearance of acid from the esophagus is a combination of
mechanical volume clearance (gravity and peristalsis) and chemi-
a
Portions of this chapter were adapted from Szarka LA, DeVault KR, cal neutralization of the lumen contents (saliva and mucosal buff-
Murray JA. Diagnosing gastroesophageal reflux disease. Mayo Clin ering). This may be delayed in patients with reflux because of
Proc. 2001 Jan; 76(1):97-101. Used with permission. either impaired esophageal peristalsis or reduced buffering effects
Abbreviations: CREST, calcinosis cutis, Raynaud phenomenon, of swallowed saliva. The defective peristalsis can be a primary
esophageal dysfunction, sclerodactyly, and telangiectasia; GERD, idiopathic motor disorder or, occasionally, it can result from a con-
gastroesophageal reflux disease; H2, histamine2; NERD, nonerosive nective tissue disorder such as CREST (calcinosis cutis, Raynaud
reflux disease; TLESR, transient lower esophageal sphincter relaxation phenomenon, esophageal dysfunction, sclerodactyly, and
3
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