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Gastroenterology Review Questions


Gastroenterology Review Questions

Here are some OLD questions (2 years ago) for the NEW students.

اعرف الحق تعرف أهله

ABIM's picture
by

For those of you who like to review their reading and test themselves in gastroenterology I chose some questions for you

I have to mention that some question are intended for open book review and not fair medical students exams. I hope this will be helpful
1) Which of the following tests evaluate both the anatomy and the function of the esophagus
a) EGD (Esophago-Gastro-Duodenoscopy)
b) Barium swallow esophagogram
c) 24 Hour esophageal PH monitoring
d) Esophageal manometry

2) Thirty six Year old male comes with a chief complaint of progressive dysphagia for both solids and liquids over a period of 3 months. The patient is able to initiate the swallowing process but then feels that the food get stuck in mid sternal area. He frequently wakes up at night with cough and trying to clear his throat. He developed 20 Ib weight loss. His wife mentions that his breath is bad! You think of classic achalasia cardia as a probable diagnosis.
All of the following can been seen in this patient except
a) Strong (high amplitude) coordinated esophageal contractions
b) High resting pressure in the lower esophageal sphincter (LES)
c) Failure of the LES to relax when patient swallows.
d) Symptoms of heartburn and chest pain
e) Increased risk of developing esophageal malignancy

3) After confirming the diagnosis with the suitable tests the best approach is
a) The disease is self limiting and there is no need for any further treatment
b) Proton pump inhibitors are very valuable in controlling the symptoms especially the heartburn in this patient
c) Medical treatment with Ca channel blockers or nitrate is most likely to control the symptoms
d)The patient should be offered surgical treatment with myotomy or dilation to reduce the LES pressure.
e) Injecting Botox( botulism toxin) through out the length of the esophagus is likely to improve the esophageal contractions
.
4) 37 Y female presents with sever burning sensation in mid sternum that gets worse after eating heavy meals. She has been experiencing this problem for 5 months now and lately it has been occurring on a daily basis. She tried some over-the-counter antacids with some relief that did not last long. Her Physical examination is essentially normal.
All the following statement about her disease are true except
a) She has a very common disease with increasing incidence in the US.
b) If she undergoes EGD (esophagogastroduodenoscopy) the most likely finding will be esophagitis with esophageal ulcer.
c) Treatment consists mostly of life style modification in regard to eating habits and pharmacological agents including acid secretion suppressive therapy.
d) If her disease becomes chronic then she is at increased risk of developing precancerous lesions that could lead to adenocarcinoma of the esophagus.
e) Some patients with disease may present with complications associated with progressive dysphagia to solids only
.
5) 67 Y male presents with 2 month history of epigastric pain with early satiety. He describes occasional vomiting and 15 Ib weight loss. Two weeks ago he noticed that his stools became loose and black tarry for 2 days. His examination is positive for epigastric tenderness. The rest of exam is negative.
The most important intial step in approaching this patient is
a) Order an EGD and a 24 H Ph monitoring of the stomach to assess for acid hypersecretion
b) Test his stool for occult GI bleed
c) Obtain careful medication history, assess the hemodynamic status , start an IV line and arrange for blood transfusion if needed
d) Check for H.Pylori antibody in the serum and treat if positive.
e) Start patient on PPI (proton pump inhibitors) and follow up in 6 months to access response to treatment.

6) 59 Y male presented with hematemsis. on urgent EGD he was found to have 4 cm ulcer on the lesser curvature with irregular margins. At the time of endoscopy the ulcer was not bleeding. Biopsies for the margins of the ulcer showed sever inflammation with atypical cells. Patient was tested for H.Pylori by CLO test and was negative while the stomach Ph was 6 . He was treated with PPI for 12 weeks and on repeat endoscopy the ulcer size was 3.5 cm . Biopsies again showed atypical cells and some degree of dysplasia.
What is the best statement to describe his condition?
a) We should repeat testing for H. Pylori because this organism is the most common cause of gastric ulcers and the first test was probably falsely negative.
b) The patient should be continued on PPI for another 12 weeks before any other testing or treatment is considered.
c) The Patient is likely to have malignant gastric ulcer and he should undergo staging of his lesion and be evaluated for resection.
d) Since his H.Pylori was negative then he is not likely to have a malignant ulcer.
e) Gastrinoma is the most likely diagnosis and the best way to confirm it is to order an imaging study like CT abdomen which may show the tumor in the head of the pancreas
.
7) A thirty three year old female comes to you with a chief complaint of episodic epigastric abdominal pain that is lasting about 45 minutes each time. This has recurred about 4 times in the past 2 months. Three of the attacks were after heavy meal the 4th was with no aggravating factors. Despite of feeling of nausea she did not vomit with any of the episodes of pain. There is no radiation of the pain. She required 2 ER visits and received strong pain killer. In between episode she gets rare heartburn and bloating depending on what she eats. On exam there is only mild epigastric and right upper quadrant tenderness.
What is the best response about this patient?
A) She is most likely has Irritable bowel syndrome and mild Gastroesophageal reflux disease.
B) The highest yield of all tests is abdominal ultrasound.
C) PPI (proton pump inhibitors) are likely to give significant relief of here sever epigastric pain.
D) Non-invasive testing for H.Pylori is likely to be the most cost-effective strategy to make a diagnosis and treatment.
E) She should be instructed to avoid fatty foods, spicy large meals, beans and milk since these type of food can exacerbate her pain.

8-A 55 Y old male undergoes colonoscopy for change of bowel habits. On colonoscopy he was found to have 3 polyps’ sizes: 1.5, 0.8, 0.5 cm. All polyps were removed and the largest one was tubulovillous adenoma while the other 2 were hyperplastic. What is the correct statement about this patient?
A- The presence of hyperplastic polyps in this patient increases his risk of polyp recurrence and cancer development.
B- If the tubulovillous adenoma in completely resected then patient will not need any future examination of his colon with colonoscopy.
C- If patient increase his dietary fiber then he will protect himself from colon cancer.
D- Occult blood testing is not helpful in the future follow up of this patient.
E- The family of this patient should be screened for the possibility of polyposis syndromes.

9) A 23 Year old female comes with 3 weeks of bloody diarrhea associated with stool frequency, urgency, cramps and generalized fatigue. On investigation with colonoscopy she was noted to have diffuse contiguous erythema ,edema, friability and pus formation through all segments of the rectum and colon. Biospies showed cryptitis and crypt abscesses with neutrophilic inflirtation in the mucosa. The stool analysis shows >100 WBC’s and 40-60 RBC’s while stool culture and testing for C.diff toxins in negative. All the following is correct about the management of this patient except
A- Mesalamine preparation represent the corner stone in the pharmacological treatment of this patient.
B- After 8-10 years she should undergo colonscopy annually with random biopsies.
C- Steroids are of value in maintaining her disease under remission.
D- Infliximab (anti TNF Ab) were found to be of help in the management of patients with such disease
E- Colectomy can be curative in such disease but the morbidity is high and it is not advised unless patient fails medical treatment or develops a compilcation

10 – All of the following are clearly associated with H.Pylori infection except
A- Atrophic gastritis
B- Adenocarcinoma of the stomach
C- Peptic ulcer disease
D- Peptic strictures of the esophagus
E- MALT lymphoma

11- 46 Y Female come with symptoms of generalized fatigue and new development of jaundice. In her history she is hypothyroid for which she takes thyroxine replacement without any other disease or medications. No family history of liver disease and no alcohol consumption. Her lab investigations shows : ALT :453 ,AST 327. Albumin 3.4, Bilirubin 4.3 (direct 3.5. Globulin 6.5 . ANA is weakly positive and ASMA result is pending. Viral hepatitis work up is negative and abdominal ultrasound is normal.
All of the following is true except
A- liver biopsy is indicated and needed in this patient
B- If she receives the right treatment then most probably she will achieve marked improvement in morbidity as well as survival.
C- She has to be monitored for bone disease (esp osteoprosis) while on treatment.
D- The treatment is suffient often for 6 months or less
E- She should be vaccinated for hepatitis A,B if not already immune to

12- A 45 year old patient comes to your clinic very disturbed about the results of his liver tests that show ALT 81, AST 67 (around 2 fold increase) despite him being free of any complaint. He was checked for viral hepatitis ,ANA, Ferritin and Fe sat% all of which were normal. He denied consuming alcohol or any other medications/herbs. None of his family are known to have a similar problem. Even his abdominal ultrasound is reported normal except mild hepatomegaly with increased echogenicity of the liver (bright liver).
On examination he is healthy looking with stable vital signs .His BMI is 32. You did some routine labs for him that showed LDL of 211, Blood sugar while fasting 117. All of the following is correct except
A- The cause of patient elevated liver enzymes is actually the most common reason for liver enzymes to be raised
B- His liver prognosis is excellent although cirrhosis could develop in minority of patients (about 5%)
C- Weight reduction is very effective in reducing enzyme elevation
D- Statin therapy (HMG co reductase inhibitors) for hypercholesterolemia should be avoided due to the risk of liver failure in such patients with elevated liver enzymes.
E- Patient presentation is recognized as metabolic syndrome which is believed to be due to Insulin resistance

13- Compared to hepatitis B, hepatitis C has all the following features except
A- Higher infectivity and sexual transmission
B- Lower risk of Hepatocellular carcinoma
C- Higher likelihood of chronic infection and cirrhosis
D- The major determinant of treatment success is genotype (as compared to the degree of liver enzyme elevation)
E- Higher change of sustained virological response (cure of the infection) on treatment

14- All the above are standard of care for patients of cirrhosis except
A- Every patient with cirrhosis (esp. with low platelets) should undergo screening for esophageal varices by endoscopy and if present then start on beta-blockers
B- Patients with cirrhosis should be screened for Hepatocellular carcinoma by periodic alpha feto protein and abdominal ultrasound
C- Patients with ascitis should have paracentesis for documentation of portal hypertension and evaluation for spontaeuos bacterial peritonitis for treatment and primary / secondary prophylaxis
D- Albumin infusion has no role in treatment of large volume ascitis
E- Patients should be screened for: hepatic encephalopathy, fluid overload and all types of viral hepatitis (A,B,C) with vaccination for A,B if needed

15- 55 year old woman comes to the hospital with sever progressive epigastric pain radiating to the bad for the last 24 hours associated with vomiting. She has no known medical history but admit getting occasional episodic right upper quadrant abdominal pain. She takes no medications and no previous surgeries. Her exam shows fever and tachycardia, jaundice and epigastric tenderness but soft abdomen with diminished bowel sounds. Her lipase is 3422 , ALT 324, AST 156 Alk Phos is 544 with bilirubin of 5.6. Ultrasound of the abdomen shows multiple gallbladder stones and dilated CBD to 8 mm but not stones seen in side and the pancreas was not clear due to gas. The best action is
A- Arrange for laparoscopic cholecystectomy next day
B- Obtain a CT scan of the abdomen to assess the severity of her pancreatitis
C- Start patient on IV fluids 200cc/hr , pain control and ERCP (endoscpic retrograde cholangiopancreatography)as soon as possible
D- Start her on urosodeoxycholic acid to try to desolve the Gallbaldder stones

ABIM's picture
ABIM


I tried,I 'm not sure,CORRECT ME PLEASE,THANKS
1-B
2-A
3-D
4-B
5-C
6-C
7-B
8-E!
9-E!
10-A!
11-D
12-D
13-A
14-D
15-C

soos's picture
soos
بعد التخرج


First thanx again Doctor ,Nice questions
1-b
2-d
3-d
4-b
5-c
6-c
7-d
8-d
9-d
10-d
11-d
12-e
13-a
14-d
15-c

jaseko's picture
jaseko
السنة الرابعة


I change my mind ....for the q7-ultrasound would be easier to rule out gallbladder stones first

jaseko's picture
jaseko
السنة الرابعة


Soos
12/15

jaseko
12/15 (which is excellent for 4th year )

ABIM's picture
ABIM


1- b
2- a
3- d
4- b
5- a?
6- a?
7- b
8- c?
9- a?
10- d
11- a
12- d
13- b
14- a?
15- c

thank u doctor

abooofaroook
بعد التخرج


8/15

Abooofaroook: You are allowed to open the book espcially on the topics and questions you are not sure of.

ABIM's picture
ABIM


ooooooooooops!
it seems like I should be more concentrated
well after opening up2date and my favorite book NMS:

5- c
I've read it he had the melena for the last two DAYS not weeks

6- cccccccc

8- dddddd

9- still confused, it could E ??

11- ddddd
I thought we have to choose the right choice

14- ddddd

thanks again doctor Very Happy

abooofaroook
بعد التخرج


13/15

the new score after correction for abooofaroook
(the highest so far)

I will post the answers with explanation by the weekend
I noticed that there are 151 views of this post but only 3 people tried to answer the questions. Is this because the question format is not attractive to students or is it the fear of getting wrong answers or is it lack of interest all together. I really like to have an explanation so I / we (as a scientific team) can improve to expand the benefit and knowledge sharing.

ABIM's picture
ABIM

Apparently this questions idea is not very popular. Anyhow it is good to realize that.
Here are the answers as I promised
have to mention that some question are intended for open book review and not fair medical students exams. I hope this will be helpful
1) Which of the following tests evaluate both the anatomy and the function of the esophagus
a) EGD (Esophago-Gastro-Duodenoscopy)
b) Barium swallow esophagogramc) 24 Hour esophageal PH monitoring
d) Esophageal manometry

2) Thirty six Year old male comes with a chief complaint of progressive dysphagia for both solids and liquids over a period of 3 months. The patient is able to initiate the swallowing process but then feels that the food get stuck in mid sternal area. He frequently wakes up at night with cough and trying to clear his throat. He developed 20 Ib weight loss. His wife mentions that his breath is bad! You think of classic achalasia cardia as a probable diagnosis.
All of the following can been seen in this patient except
a) Strong (high amplitude) coordinated esophageal contractions They are UNcoordiated contractions
b) High resting pressure in the lower esophageal sphincter (LES)
c) Failure of the LES to relax when patient swallows.
d) Symptoms of heartburn and chest pain
e) Increased risk of developing esophageal malignancy

3) After confirming the diagnosis with the suitable tests the best approach is
a) The disease is self limiting and there is no need for any further treatment
b) Proton pump inhibitors are very valuable in controlling the symptoms especially the heartburn in this patient
c) Medical treatment with Ca channel blockers or nitrate is most likely to control the symptoms
d)The patient should be offered surgical treatment with myotomy or dilation to reduce the LES pressure.e) This is the standard of care. Botox injection is done only at the LES (not all of the esophagus and it has short lived results
Injecting Botox( botulism toxin) through out the length of the esophagus is likely to improve the esophageal contractions
.
4) 37 Y female presents with sever burning sensation in mid sternum that gets worse after eating heavy meals. She has been experiencing this problem for 5 months now and lately it has been occurring on a daily basis. She tried some over-the-counter antacids with some relief that did not last long. Her Physical examination is essentially normal.
All the following statement about her disease are true except
a) She has a very common disease with increasing incidence in the US.
b) If she undergoes EGD (esophagogastroduodenoscopy) the most likely finding will be esophagitis with esophageal ulcer. The most common finding on endoscopy with GERD patients is NORMAL
c) Treatment consists mostly of life style modification in regard to eating habits and pharmacological agents including acid secretion suppressive therapy.
d) If her disease becomes chronic then she is at increased risk of developing precancerous lesions that could lead to adenocarcinoma of the esophagus.
e) Some patients with disease may present with complications associated with progressive dysphagia to solids only
.
5) 67 Y male presents with 2 month history of epigastric pain with early satiety. He describes occasional vomiting and 15 Ib weight loss. Two weeks ago he noticed that his stools became loose and black tarry for 2 days. His examination is positive for epigastric tenderness. The rest of exam is negative.
The most important intial step in approaching this patient is
a) Order an EGD and a 24 H Ph monitoring of the stomach to assess for acid hypersecretion
b) Test his stool for occult GI bleed
c) Obtain careful medication history, assess the hemodynamic status , start an IV line and arrange for blood transfusion if needed It is very important to pay attention for hemodynamic condition before you do anything else
d) Check for H.Pylori antibody in the serum and treat if positive.
e) Start patient on PPI (proton pump inhibitors) and follow up in 6 months to access response to treatment.

6) 59 Y male presented with hematemsis. on urgent EGD he was found to have 4 cm ulcer on the lesser curvature with irregular margins. At the time of endoscopy the ulcer was not bleeding. Biopsies for the margins of the ulcer showed sever inflammation with atypical cells. Patient was tested for H.Pylori by CLO test and was negative while the stomach Ph was 6 . He was treated with PPI for 12 weeks and on repeat endoscopy the ulcer size was 3.5 cm . Biopsies again showed atypical cells and some degree of dysplasia.
What is the best statement to describe his condition?
a) We should repeat testing for H. Pylori because this organism is the most common cause of gastric ulcers and the first test was probably falsely negative.
b) The patient should be continued on PPI for another 12 weeks before any other testing or treatment is considered.
c) The Patient is likely to have malignant gastric ulcer and he should undergo staging of his lesion and be evaluated for resection. Any refractory gastric ulcer showed raised suspicion of malignancy whehter patient has aH. Pylori or not
d) Since his H.Pylori was negative then he is not likely to have a malignant ulcer.
e) Gastrinoma is the most likely diagnosis and the best way to confirm it is to order an imaging study like CT abdomen which may show the tumor in the head of the pancreas
.
7) A thirty three year old female comes to you with a chief complaint of episodic epigastric abdominal pain that is lasting about 45 minutes each time. This has recurred about 4 times in the past 2 months. Three of the attacks were after heavy meal the 4th was with no aggravating factors. Despite of feeling of nausea she did not vomit with any of the episodes of pain. There is no radiation of the pain. She required 2 ER visits and received strong pain killer. In between episode she gets rare heartburn and bloating depending on what she eats. On exam there is only mild epigastric and right upper quadrant tenderness.
What is the best response about this patient?
A) She is most likely has Irritable bowel syndrome and mild Gastroesophageal reflux disease.
B) The highest yield of all tests is abdominal ultrasound.
patient is most likely to have Gallbladder stones since she has EPISODIC SEVER PAIN
C) PPI (proton pump inhibitors) are likely to give significant relief of here sever epigastric pain.
D) Non-invasive testing for H.Pylori is likely to be the most cost-effective strategy to make a diagnosis and treatment.
E) She should be instructed to avoid fatty foods, spicy large meals, beans and milk since these type of food can exacerbate her pain.

8-A 55 Y old male undergoes colonoscopy for change of bowel habits. On colonoscopy he was found to have 3 polyps’ sizes: 1.5, 0.8, 0.5 cm. All polyps were removed and the largest one was tubulovillous adenoma while the other 2 were hyperplastic. What is the correct statement about this patient?
A- The presence of hyperplastic polyps in this patient increases his risk of polyp recurrence and cancer development.
B- If the tubulovillous adenoma in completely resected then patient will not need any future examination of his colon with colonoscopy.
C- If patient increase his dietary fiber then he will protect himself from colon cancer.
D- Occult blood testing is not helpful in the future follow up of this patient.
You follow polyps with colonscopy not with occult blood testing in stool.
E- The family of this patient should be screened for the possibility of polyposis syndromes.

9) A 23 Year old female comes with 3 weeks of bloody diarrhea associated with stool frequency, urgency, cramps and generalized fatigue. On investigation with colonoscopy she was noted to have diffuse contiguous erythema ,edema, friability and pus formation through all segments of the rectum and colon. Biospies showed cryptitis and crypt abscesses with neutrophilic inflirtation in the mucosa. The stool analysis shows >100 WBC’s and 40-60 RBC’s while stool culture and testing for C.diff toxins in negative. All the following is correct about the management of this patient except
A- Mesalamine preparation represent the corner stone in the pharmacological treatment of this patient.
B- After 8-10 years she should undergo colonscopy annually with random biopsies.
C- Steroids are of value in maintaining her disease under remission.
This is the frequent mistake by almost everybody . Steroids help bring the disease under remission but are NOT helpful in maintenance and prevention of relapses.
D- Infliximab (anti TNF Ab) were found to be of help in the management of patients with such disease
E- Colectomy can be curative in such disease but the morbidity is high and it is not advised unless patient fails medical treatment or develops a compilcation

10 – All of the following are clearly associated with H.Pylori infection except
A- Atrophic gastritis
B- Adenocarcinoma of the stomach
C- Peptic ulcer disease
D- Peptic strictures of the esophagus
H.Polori leads to disease in the stomach only not the esophagus
E- MALT lymphoma

11- 46 Y Female come with symptoms of generalized fatigue and new development of jaundice. In her history she is hypothyroid for which she takes thyroxine replacement without any other disease or medications. No family history of liver disease and no alcohol consumption. Her lab investigations shows : ALT :453 ,AST 327. Albumin 3.4, Bilirubin 4.3 (direct 3.5. Globulin 6.5 . ANA is weakly positive and ASMA result is pending. Viral hepatitis work up is negative and abdominal ultrasound is normal.
All of the following is true except
A- liver biopsy is indicated and needed in this patient
B- If she receives the right treatment then most probably she will achieve marked improvement in morbidity as well as survival.
C- She has to be monitored for bone disease (esp osteoprosis) while on treatment.
D- The treatment is suffient often for 6 months or less
treatment of autoimune hepatitis is life-long (sometimes : rarely you can withdraw all treatments but not before 2 years)
E- She should be vaccinated for hepatitis A,B if not already immune to

12- A 45 year old patient comes to your clinic very disturbed about the results of his liver tests that show ALT 81, AST 67 (around 2 fold increase) despite him being free of any complaint. He was checked for viral hepatitis ,ANA, Ferritin and Fe sat% all of which were normal. He denied consuming alcohol or any other medications/herbs. None of his family are known to have a similar problem. Even his abdominal ultrasound is reported normal except mild hepatomegaly with increased echogenicity of the liver (bright liver).
On examination he is healthy looking with stable vital signs .His BMI is 32. You did some routine labs for him that showed LDL of 211, Blood sugar while fasting 117. All of the following is correct except
A- The cause of patient elevated liver enzymes is actually the most common reason for liver enzymes to be raised
B- His liver prognosis is excellent although cirrhosis could develop in minority of patients (about 5%)
C- Weight reduction is very effective in reducing enzyme elevation
D- Statin therapy (HMG co reductase inhibitors) for hypercholesterolemia should be avoided due to the risk of liver failure in such patients with elevated liver enzymes.
Quite opposite . statins are indicated in the tretment of NASH (nonalcoholic steatohepatitis)
E- Patient presentation is recognized as metabolic syndrome which is believed to be due to Insulin resistance

13- Compared to hepatitis B, hepatitis C has all the following features except
A- Higher infectivity and sexual transmission
Hep C has tendency for person to person infectivity through needle prick and sexual transmission compared to hep B
B- Lower risk of Hepatocellular carcinoma
C- Higher likelihood of chronic infection and cirrhosis
D- The major determinant of treatment success is genotype (as compared to the degree of liver enzyme elevation)
E- Higher change of sustained virological response (cure of the infection) on treatment

14- All the above are standard of care for patients of cirrhosis except
A- Every patient with cirrhosis (esp. with low platelets) should undergo screening for esophageal varices by endoscopy and if present then start on beta-blockers
B- Patients with cirrhosis should be screened for Hepatocellular carcinoma by periodic alpha feto protein and abdominal ultrasound
C- Patients with ascitis should have paracentesis for documentation of portal hypertension and evaluation for spontaeuos bacterial peritonitis for treatment and primary / secondary prophylaxis
D- Albumin infusion has no role in treatment of large volume ascitis
Albumin infusion is important in large volume paracentesis to avoid hepatorenal syndrome
E- Patients should be screened for: hepatic encephalopathy, fluid overload and all types of viral hepatitis (A,B,C) with vaccination for A,B if needed

15- 55 year old woman comes to the hospital with sever progressive epigastric pain radiating to the bad for the last 24 hours associated with vomiting. She has no known medical history but admit getting occasional episodic right upper quadrant abdominal pain. She takes no medications and no previous surgeries. Her exam shows fever and tachycardia, jaundice and epigastric tenderness but soft abdomen with diminished bowel sounds. Her lipase is 3422 , ALT 324, AST 156 Alk Phos is 544 with bilirubin of 5.6. Ultrasound of the abdomen shows multiple gallbladder stones and dilated CBD to 8 mm but not stones seen in side and the pancreas was not clear due to gas. The best action is
A- Arrange for laparoscopic cholecystectomy next day
B- Obtain a CT scan of the abdomen to assess the severity of her pancreatitis
C- Start patient on IV fluids 200cc/hr , pain control and ERCP (endoscpic retrograde cholangiopancreatography)as soon as possible
In gallstone pancreatitis ERCP is indicated when there is jaundice to remove the CBD stone and help decrease the severity of pancreaitis espcialy is there is ascending cholangitis
D- Start her on urosodeoxycholic acid to try to desolve the Gallbaldder stones

___________

The END

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ABIM
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