Kaplan USMLE Step 1: Patient with protein-losing gastroenteropathy

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.

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.

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.

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.