Review Topic
  • A 56-year-old man presents to his primary care physician for abdominal pain. His abdominal pain is in the epigastrium and has been persistent. He has had episodes of night sweats and has unintentionally lost 20 pounds over the course of 3 months. He has a past medical history of H. pylori infection and obesity. Physical examination is notable for epigastric abdominal tenderness upon palpation. An upper endoscopy demonstrates an invasive ulcerative lesion in the stomach.
  • Overview
    • gastric adenocarcinoma is the most common type of gastric cancer, accounting for more than 90% of cases 
      • other gastric cancer types include lymphoma, stromal, and carcinoid tumor
    • gastric adenocarcinoma can be divided into intestinal and diffuse types
      • intestinal
        • bulky tumors that have glandular structures (similar to adenocarcinoma of the esophagus and colon)
          • the mass can be exophytic or ulcerated
        • commonly found on the lesser curvature of the stomach
      • diffuse
        • infiltrative tumors composed of signet ring cells (mucin vacuoles that push the nucleus to the periphery)  
        • stiffens the gastric wall, leading to a thickened, leather-like appearance (linitis plastica)
  • Epidemiology
    •  incidence
      • varies significantly in the world
        • most common in Japan, Chile, and eastern Europe
    • risk factors
      • Helicobacter pylori
      • Epstein-Barr virus
      • nitrosamine exposure
      • high salt intake
      • smoking 
      • excessive alcohol use
  • Pathophysiology
    • H. pylori infection
      • results in chronic gastritis secondary to increased production of proinflammator proteins
    • Epstein-Barr virus
      • a rare cause of gastric adenocarcinoma
      • unclear how exactly this virus leads to gastric adenocarcinoma
  • Symptoms
    • persistent abdominal pain
      • typically epigastric
    • dysphagia
      • in cases of gastric cancers arising more proximally in the stomach or in the esophagogastric junction
  • Physical examination
    • weight loss
      • secondary to insuficcient caloric intake
  • Endoscopy
    • indication
      • initial diagnostic study of choice to obtain a tissue diagnosis
  • Barium studies
    • indication
      • although associated with a high false-negative rate, it may be superior to endoscopy in detecting linitis plastica
  • Gastric lymphoma
    • differentiating factors
      • secondary to B-cell lymphoproliferative disorders
      • associated with mucosa-associated lymphoid tissue 
  • Gastric stromal cancer
    • differentiating factors
      • mesechymal in origin
  • Neuroendocrine (carcinoid) tumor
    • differentiating factors
      • arise from neuroendocrine origin
      • leads to release of vasoactive substances, resulting in cutaneous flushing, bronchospasm, colicky abdominal pain, and diarrhea
        • as well as right-sided cardiac valvular fiborosis
  • Treatment is dependent on the stage of the cancer
    • may require resection, adjuvant chemotherapy, and radiation
  • Surgical
    • endoscopic resection
      • indication
        • for local tumors
    • gastrectomy with lymphadenectomy
      • indication
        • for more extensive disease
  • Virchow node
    • left supraclavicular node involvement secondary to metastasis
  • Krukenberg tumor
    • metastasis to the bilateral ovaries
  • Sister Mary Joseph nodule
    • periumbilical metastasis


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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

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(M1.ON.83) A 70-year-old female presents to your office with nausea, vomiting, and 3 months of weight loss. On physical exam, you observe a finding seen in Figure A. You suspect adenocarcinoma, and you immediately order a biopsy to ascertain the extent of metastatic disease. In which of the following organs would you observe the primary tumor with abundant mucus and signet ring cells on biopsy if metastatic disease were present? Review Topic

QID: 101140





















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(M1.ON.9) A 60-year-old Japanese male presents to your office with epigastric pain following 1 month of unintentional weight loss. He reports that he has followed a strict diet of low-fat smoked fish all his life. On physical exam, you note a skin finding similar to Figure A. If this patient undergoes aggressive surgical treatment, which of the following may result? Review Topic

QID: 101066

Cobalamin deficiency




Increased prothrombin time




Acute cellular rejection








Esophageal squamous cell carcinoma




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