If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 1 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.
This month’s stumper
A 75-year-old man with a history of a protein-losing gastroenteropathy comes to the physician for a follow-up visit and labs. The patient says he has occasional nausea, vomiting and diarrhea. Physical examination shows significant edema of his feet and legs.
An endoscopy is later performed and shows markedly enlarged gastric rugal folds. No ulcerations are seen. Microscopic examination of a biopsy specimen shows no evidence of malignancy.
Which of the following findings is most likely to be seen in the mucosa of the biopsy specimen?
A. Acute inflammation.
B. Chief cell hyperplasia.
C. Chronic inflammation.
D. Mucous cell hyperplasia.
E. Parietal cell hyperplasia.
The correct answer is D.
Kaplan Medical explains why
This patient has Ménétrier disease. Normally, secreted proteins are digested and absorbed with minimal protein loss. However, when the secretion of proteins outpaces absorption and synthesis, hypoproteinemia occurs. Markedly enlarged rugal folds can be seen in several conditions, including infiltrative cancer, lymphoma, hypersecretory gastropathy and Ménétrier disease.
The question specifies a benign process, so infiltrative cancer and lymphoma can be excluded. Hypersecretory gastritis is associated with peptic ulceration and sometimes Zollinger-Ellison syndrome.
Why the other answers are wrong
Choices A and C: Acute and chronic inflammation do not cause large rugal folds, but if prominent enough, may cause erythematous or pale lesions, respectively. There is minimal or no stomach inflammation in Ménétrier disease.
Choices B and E: Marked hyperplasia of chief and parietal cells is a feature of hypersecretory gastritis. Parietal cell hyperplasia can cause mucosal ulcerations.
Tips to remember
Ménétrier disease:
- Hyperplastic gastropathy, enlarged rugal folds.
- Increased proliferation of mucus-producing cells to → protein-losing gastroenteropathy.
- Peripheral edema due to loss of proteins.
For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.
The AMA and Kaplan have teamed up to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. If you're looking for additional resources, Kaplan provides free access to tools for pre-clinical studies, including Kaplan’s Lecture Notes series, Integrated Vignettes, Shelf Prep and more.
