Weight Loss and Cachexia — MCQs
Protein metabolism after trauma is characterized by the following except:
A patient presents with nausea, vomiting, and indigestion after eating fatty foods. Ultrasound reveals gallstones. What is the most appropriate treatment?
According to standard clinical practice guidelines, significant weight loss requiring medical evaluation is defined as:
In a patient who has been in a state of starvation for 72 hours, which of the following is the primary mechanism for maintaining blood glucose levels?
In a patient with esophageal cancer and dysphagia affecting liquid intake, what is the most appropriate intervention to ensure nutritional support?
A 55-year-old man presents with intermittent epigastric pain, relieved by eating, and worsened by fasting. What is the most likely cause?
A patient with complaints of dysphagia for solids who can only take liquids and has a history of smoking and weight loss. What is the most likely diagnosis?
A patient presents to you with fever, night sweats, ptosis, and bilateral facial nerve palsy. Investigations showed leukocytosis and bilateral hilar lymphadenopathy. Which of the following is the most likely diagnosis?
A 50-year-old man presents with chronic abdominal pain and weight loss. A barium study shows a "string sign" in the terminal ileum. What is the most likely diagnosis?
A 24-year-old woman presents to her primary care physician with a longstanding history of diarrhea. She reports recurrent, foul-smelling, loose stools and a 35 lb weight loss over the past 3 years. She also states that two months ago, she developed an "itchy, bumpy" rash on her elbows and forearms which has since resolved. She denies recent camping trips or travel outside of the country. On physical exam she appears thin, her conjunctiva and skin appear pale, and her abdomen is mildly distended. Which of the following tests would confirm this patient's diagnosis?
Weight Loss and Cachexia Indian Medical PG Practice Questions and MCQs
Question 1: Protein metabolism after trauma is characterized by the following except:
- A. Increased liver gluconeogenesis
- B. Increased urinary nitrogen loss
- C. Hepatic synthesis of acute phase reactants
- D. Inhibition of skeletal muscle breakdown by interleukin 1 and tumour necrosis factor (Correct Answer)
Explanation: ***Inhibition of skeletal muscle breakdown by interleukin 1 and tumour necrosis factor*** - After trauma, **interleukin 1 (IL-1)** and **tumor necrosis factor (TNF)** actually **promote** skeletal muscle breakdown (catabolism) to provide amino acids for gluconeogenesis and acute phase protein synthesis. - This statement is incorrect because these cytokines are **pro-catabolic**, not inhibitory, in their effect on muscle protein. *Increased liver gluconeogenesis* - Trauma leads to a significant increase in **liver gluconeogenesis**, primarily to maintain glucose supply for **immune cells** and wound healing, which rely heavily on glucose. - This process utilizes amino acids obtained from muscle breakdown as substrates. *Increased urinary nitrogen loss* - The breakdown of muscle protein releases amino acids, which are then deaminated. The nitrogen waste product, **urea**, is excreted in the urine, leading to **increased urinary nitrogen loss**. - This is a direct consequence of the catabolic state. *Hepatic synthesis of acute phase reactants* - The liver increases the synthesis of **acute phase reactants** (e.g., C-reactive protein, fibrinogen, haptoglobin) in response to inflammatory cytokines like IL-1, **IL-6**, and TNF. - These proteins play a crucial role in the inflammatory response and tissue repair.
Question 2: A patient presents with nausea, vomiting, and indigestion after eating fatty foods. Ultrasound reveals gallstones. What is the most appropriate treatment?
- A. Cholecystectomy (Correct Answer)
- B. H2 receptor blockers
- C. Liver biopsy
- D. Proton pump inhibitors
Explanation: ***Cholecystectomy*** - **Cholecystectomy** (surgical removal of the gallbladder) is the definitive treatment for symptomatic **gallstones**, as seen in this patient with nausea, vomiting, and indigestion after fatty meals. - Removing the gallbladder eliminates the source of the stones and prevents recurrent symptoms and potential complications like cholecystitis or pancreatitis. *H2 receptor blockers* - **H2 receptor blockers** are used to reduce stomach acid production and are appropriate for conditions like **GERD** or **peptic ulcers**. - They would not address the underlying issue of gallstones causing the patient's symptoms. *Liver biopsy* - A **liver biopsy** is an invasive diagnostic procedure used to evaluate various liver diseases, such as **hepatitis** or **cirrhosis**. - It is not indicated for the management of symptomatic gallstones, as the diagnosis is clear from the ultrasound. *Proton pump inhibitors* - **Proton pump inhibitors (PPIs)** are powerful acid suppressants used for conditions like **GERD**, **peptic ulcers**, and **Zollinger-Ellison syndrome**. - They would not resolve the mechanical obstruction or inflammation caused by gallstones.
Question 3: According to standard clinical practice guidelines, significant weight loss requiring medical evaluation is defined as:
- A. 5% weight loss in 1-2 months
- B. 10% weight loss in 2-3 months (Correct Answer)
- C. 5% weight loss in 2-3 months
- D. 10% weight loss in 1-2 months
Explanation: ***10% weight loss in 2-3 months*** - **Unexplained weight loss** of **10%** or more of usual body weight over a period of **2-3 months** is generally considered a significant amount requiring medical evaluation. - This degree of weight loss can be indicative of underlying serious medical conditions like cancer, gastrointestinal disorders, endocrine disorders, or chronic infections [1]. *5% weight loss in 1-2 months* - While any unexplained weight loss should be noted, a **5% loss** in this timeframe is usually not considered immediately "significant" enough to warrant an aggressive workup unless other concerning symptoms are present. - It might be due to minor lifestyle changes, temporary illness, or benign factors. *5% weight loss in 2-3 months* - A **5% weight loss** over **2-3 months** is a less critical threshold than 10% for initiating an extensive medical evaluation for serious underlying disease. - This level of weight change could be due to a variety of less severe causes or even normal fluctuations. *10% weight loss in 1-2 months* - While a **10% weight loss** is significant, the **1-2 month** timeframe is generally considered slightly too short to immediately classify it as "requiring medical evaluation" in the strictest sense compared to the 2-3 month period which allows for better observation. - Rapid weight loss over a very short period might sometimes be related to acute illness or dehydration rather than chronic underlying conditions, though still warrants attention.
Question 4: In a patient who has been in a state of starvation for 72 hours, which of the following is the primary mechanism for maintaining blood glucose levels?
- A. Increased gluconeogenesis (Correct Answer)
- B. Increased protein degradation
- C. Increased glycogenolysis
- D. Increased ketosis due to breakdown of fats
Explanation: ***Increased gluconeogenesis*** - After 72 hours of starvation, **hepatic glycogen stores** are completely depleted, making gluconeogenesis the primary and essential mechanism to maintain **blood glucose levels**. - This process synthesizes glucose from non-carbohydrate precursors like **amino acids** (mainly alanine and glutamine), **lactate**, and **glycerol** to supply glucose for obligate glucose-dependent tissues like **red blood cells** and the **renal medulla**, and provides baseline glucose for the brain. - Gluconeogenesis occurs primarily in the **liver** and to a lesser extent in the **kidney cortex** during prolonged fasting. *Increased protein degradation* - While **protein degradation** does occur to supply amino acids for gluconeogenesis, the body actively minimizes this to preserve muscle mass, especially after prolonged starvation. - The initial phase of starvation (first 24-48 hours) sees more significant protein breakdown, but its rate decreases substantially after 72 hours as the body becomes increasingly **protein-sparing** and shifts to fatty acid oxidation and ketone body production. *Increased glycogenolysis* - **Hepatic glycogen stores** are typically depleted within **12-24 hours** of starvation. - After 72 hours, there is essentially no glycogen remaining to break down, so **glycogenolysis** cannot contribute to maintaining blood glucose at this stage. *Increased ketosis due to breakdown of fats* - **Ketosis** does dramatically increase after 72 hours of starvation as the body shifts to using **fatty acids** for energy and producing **ketone bodies** (β-hydroxybutyrate and acetoacetate) for the brain and other tissues. - However, while ketone bodies serve as an alternative fuel source for the brain (providing up to 60-70% of its energy needs), they **cannot replace glucose entirely** because certain tissues (red blood cells, renal medulla) are obligate glucose users and cannot utilize ketones. - The question specifically asks about maintaining **blood glucose levels**, which requires gluconeogenesis, not ketone production.
Question 5: In a patient with esophageal cancer and dysphagia affecting liquid intake, what is the most appropriate intervention to ensure nutritional support?
- A. Total parenteral nutrition
- B. Nasogastric tube feeding
- C. Esophageal stent placement
- D. Placement of a percutaneous endoscopic gastrostomy tube (Correct Answer)
Explanation: ***Placement of a percutaneous endoscopic gastrostomy tube*** - The question tests the principle that **gastrostomy tube feeding offers long-term nutritional support** for patients with esophageal obstruction and **dysphagia**, ensuring adequate caloric intake directly into the stomach. - Gastrostomy tubes are preferred over nasogastric tubes for **long-term feeding** (>4-6 weeks) due to better patient comfort, reduced risk of aspiration, and ease of care. - **Clinical Note:** In severe esophageal obstruction, a true PEG (percutaneous endoscopic gastrostomy) may not be technically feasible due to inability to pass the endoscope. In such cases, **radiologically inserted gastrostomy (RIG)** or **surgical gastrostomy** would be performed instead, but the principle of enteral feeding via gastrostomy remains the same. - The **functioning gastrointestinal tract** should always be utilized when possible (enteral feeding preferred over parenteral). *Total parenteral nutrition* - **TPN is reserved for patients with non-functional gastrointestinal tracts** or those who cannot tolerate enteral feeding, which is not applicable here as the stomach and intestines remain functional. - It carries **higher risks of infection, hepatic complications, metabolic derangements**, and is significantly more expensive compared to enteral feeding. - Following the principle: **"If the gut works, use it"** - enteral nutrition is always preferred when feasible. *Nasogastric tube feeding* - **Nasogastric tubes cannot be passed through an obstructing esophageal tumor** and are typically only suitable for short-term feeding (less than 4-6 weeks). - They are uncomfortable for patients and pose a **higher risk of aspiration pneumonia**. - Not appropriate for long-term nutritional support in malignancy. *Esophageal stent placement* - Esophageal stents are **palliative interventions primarily used to alleviate dysphagia** and restore oral intake in malignant obstruction. - While stents may allow some oral nutrition, they **do not guarantee adequate or reliable nutritional support**, especially as disease progresses. - Stents can lead to complications such as **tumor overgrowth, stent migration, fistula formation, or chest pain**, which may further compromise nutritional intake. - When the primary goal is **ensuring adequate nutritional support** rather than just relieving dysphagia, a feeding gastrostomy is more reliable.
Question 6: A 55-year-old man presents with intermittent epigastric pain, relieved by eating, and worsened by fasting. What is the most likely cause?
- A. Cholelithiasis
- B. Chronic pancreatitis
- C. Peptic ulcer disease (Correct Answer)
- D. Gastroesophageal reflux disease (GERD)
Explanation: ### Peptic ulcer disease - The classic presentation of **duodenal ulcers**, a common type of peptic ulcer, includes epigastric pain that is **relieved by eating** and **worsens with fasting** [1]. - This pattern is due to the buffering effect of food on gastric acid and the increased acid secretion during fasting, which irritates the ulcer. *Cholelithiasis* - Characterized by **biliary colic**, which is typically severe, intermittent right upper quadrant pain, often radiating to the back or shoulder, and frequently triggered by fatty meals. - Pain relief with eating is not a typical feature, and it does not usually worsen with fasting. *Chronic pancreatitis* - Presents with persistent or recurrent **epigastric pain** that often **radiates to the back** [2], and can be worsened by eating fatty foods. - The pain is usually not relieved by eating, and symptoms like steatorrhea and diabetes development are common later in the disease [2]. *Gastroesophageal reflux disease (GERD)* - Primarily causes **heartburn** (burning sensation behind the sternum) and **regurgitation**, which often worsen after meals, when lying down, or bending over. - Pain is typically not relieved by eating, nor does it characteristically worsen with fasting; instead, it is often associated with acid reflux.
Question 7: A patient with complaints of dysphagia for solids who can only take liquids and has a history of smoking and weight loss. What is the most likely diagnosis?
- A. Achalasia cardia
- B. Carcinoma esophagus (Correct Answer)
- C. Esophageal stricture
- D. Barrett's esophagus
Explanation: ***Carcinoma esophagus*** - Progressive dysphagia starting with **solids** and progressing to **liquids** is a classic symptom of esophageal carcinoma, indicating mechanical obstruction that worsens over time. - History of **smoking** is a major risk factor for esophageal squamous cell carcinoma. - Unexplained **weight loss** is a red flag sign of malignancy, commonly seen in advanced esophageal cancer. - This triad (progressive dysphagia, smoking, weight loss) strongly suggests malignancy. *Achalasia cardia* - In achalasia, dysphagia typically occurs for both **solids and liquids simultaneously** from the onset due to impaired relaxation of the lower esophageal sphincter. - The pattern is non-progressive or paradoxical (sometimes liquids are more difficult than solids). - While weight loss can occur, smoking is not a risk factor for achalasia. *Esophageal stricture* - Benign esophageal strictures usually occur secondary to **chronic GERD** or caustic injury. - While they cause progressive dysphagia for solids, the absence of reflux history and presence of significant **weight loss** and **smoking history** make malignancy more likely. - Strictures typically have a more chronic, stable course without the constitutional symptoms seen here. *Barrett's esophagus* - Barrett's esophagus is a **pre-malignant condition** characterized by intestinal metaplasia of the esophageal mucosa. - It is typically **asymptomatic** or presents with GERD symptoms, not progressive dysphagia. - While it can progress to adenocarcinoma, Barrett's itself does not cause mechanical obstruction or dysphagia. - The clinical presentation here suggests established malignancy, not a pre-malignant condition.
Question 8: A patient presents to you with fever, night sweats, ptosis, and bilateral facial nerve palsy. Investigations showed leukocytosis and bilateral hilar lymphadenopathy. Which of the following is the most likely diagnosis?
- A. Sarcoidosis (Correct Answer)
- B. Tuberculosis
- C. Lymphoma
- D. Hypersensitive pneumonitis
Explanation: ***Sarcoidosis*** - The combination of **fever**, **night sweats**, **bilateral facial nerve palsy**, **ptosis**, and **bilateral hilar lymphadenopathy** is highly suggestive of **neurosarcoidosis** manifesting as Heerfordt's syndrome (uveoparotid fever) [1]. - **Leukocytosis** is a non-specific finding but can be present due to inflammatory processes in sarcoidosis. *Tuberculosis* - While tuberculosis can cause **fever**, **night sweats**, and **hilar lymphadenopathy** [2] [3], it is less likely to present with **bilateral facial nerve palsy** and **ptosis** simultaneously. - Pulmonary tuberculosis often shows specific patterns like **apical infiltrates** or cavitations, rather than solely bilateral hilar lymphadenopathy, especially without other classic symptoms like productive cough. *Lymphoma* - Lymphoma can cause **fever**, **night sweats**, and **lymphadenopathy** (including hilar) [4]. - However, **bilateral facial nerve palsy** and **ptosis** are not typical primary manifestations of lymphoma and would require other evidence of direct mass effect or widespread infiltration. *Hypersensitive pneumonitis* - This condition is characterized by **inflammation of the lung alveoli** and small airways due to repeated exposure to inhaled antigens, leading to symptoms like cough, dyspnea, and fever. - It typically does **not cause neurological symptoms** such as facial nerve palsy or ptosis, nor is it prominently associated with hilar lymphadenopathy.
Question 9: A 50-year-old man presents with chronic abdominal pain and weight loss. A barium study shows a "string sign" in the terminal ileum. What is the most likely diagnosis?
- A. Crohn's disease (Correct Answer)
- B. Diverticulitis
- C. Irritable bowel syndrome
- D. Ulcerative colitis
Explanation: ***Crohn's disease*** - The **"string sign"** observed in the barium study indicates narrowed, inflamed terminal ileum typical of Crohn's disease [1]. - Presents with **chronic abdominal pain** and weight loss, aligning with the patient's symptoms [1]. *Diverticulitis* - Characterized by **inflammation of diverticula**, usually presenting with **left lower quadrant pain** and fever, not a "string sign". - Barium studies typically reveal **diverticula**, not the strictures seen in Crohn's. *Irritable bowel syndrome* - IBS presents with **crampy abdominal pain** and changes in bowel habits, but not with severe **weight loss** or strictures. - There are no specific findings like the **"string sign"** in imaging studies for IBS. *Ulcerative colitis* - Primarily affects the **colon** with continuous lesions and presents with bloody diarrhea, not with a "string sign". - Does not typically cause **narrowing** of the intestines like seen in Crohn's disease [2].
Question 10: A 24-year-old woman presents to her primary care physician with a longstanding history of diarrhea. She reports recurrent, foul-smelling, loose stools and a 35 lb weight loss over the past 3 years. She also states that two months ago, she developed an "itchy, bumpy" rash on her elbows and forearms which has since resolved. She denies recent camping trips or travel outside of the country. On physical exam she appears thin, her conjunctiva and skin appear pale, and her abdomen is mildly distended. Which of the following tests would confirm this patient's diagnosis?
- A. Stool test for ova and parasites
- B. Serum anti-tissue transglutaminase antibody assay
- C. Stool guaiac test
- D. Stool culture
- E. Small bowel endoscopy and biopsy (Correct Answer)
Explanation: ***Small bowel endoscopy and biopsy*** - This patient's symptoms of **chronic diarrhea**, **weight loss**, **anemia** (pale conjunctiva/skin), and a history of a **pruritic rash on elbows and forearms** (suggestive of **dermatitis herpetiformis**) are highly indicative of **celiac disease**. - While initial screening with **serum anti-tissue transglutaminase antibody (tTG-IgA)** is appropriate, **definitive diagnosis of celiac disease requires small bowel biopsy** showing characteristic changes like **villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes** [1]. *Serum anti-tissue transglutaminase antibody assay* - This is an **excellent screening test** for celiac disease and is typically the first step. - However, it is an **antibody test** and requires **confirmatory biopsy** for a definitive diagnosis, especially before initiating a lifelong gluten-free diet. *Stool test for ova and parasites* - While chronic diarrhea can be caused by **parasitic infections** (e.g., Giardia), the patient's long history, significant weight loss, anemia, and characteristic rash make **celiac disease a more likely diagnosis**. - She also denies recent camping or travel, making parasitic infections less likely. *Stool culture* - A **stool culture** is used to identify **bacterial pathogens** (e.g., Salmonella, Shigella, Campylobacter) causing acute or chronic infectious diarrhea. - The patient's presentation with a **long-standing history**, associated **rash**, and **malabsorption symptoms** is not typical of bacterial enteritis. *Stool guaiac test* - A **stool guaiac test** (or fecal occult blood test) detects **blood in the stool**, which can indicate gastrointestinal bleeding. - While some GI conditions can cause bleeding, it is not the primary diagnostic tool for celiac disease or for identifying the cause of chronic malabsorptive diarrhea.
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