Gastroenterology Practice Questions

Q: Which classification is used for Barrett esophagus?

Prague classification. ***Prague classification***- This classification is specifically designed for the standardized endoscopic assessment and documentation of **Barrett esophagus** (BE).- It uses two main parameters: the maximal extent (M) and the circumferential extent (C) of the columnar-lined esophagus, ensuring consistent reporting for surveillance.*Savary-Miller classification*- This classification system is used to grade the severity of **reflux esophagitis** (erosive esophagitis), not Barrett esophagus.- It categorizes esophageal mucosal injury based on the extent and depth of erosions.*Johnson classification*- This classification is generally not a recognized standard system for classifying key GI pathology like Barrett esophagus, unlike established systems such as the **Prague classification** or **Los Angeles classification** for reflux esophagitis.- *Note: A Johnson classification exists for pediatric hip dysplasia, but it is unrelated to GI endoscopy.* *Forrest classification*- This system is used exclusively to classify the appearance of **peptic ulcer bleeding** (or other upper GI bleed sources) seen during endoscopy.- It helps predict the risk of rebleeding and guides interventions, such as those performed for ulcers with adherent clots or active oozing.

Q: A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?

Lamivudine. Lamivudine - This serological profile (HBsAg+, IgM anti-HBc-, IgG anti-HBc+, HBeAg+) indicates HBeAg-positive chronic Hepatitis B with active viral replication [1] - Among the given options, Lamivudine is the only agent with anti-HBV activity as a nucleoside reverse transcriptase inhibitor (NRTI) that inhibits HBV DNA polymerase - Important Note: While Lamivudine was historically used for chronic HBV, current guidelines (WHO, AASLD, EASL) recommend Tenofovir or Entecavir as first-line therapy due to higher potency and lower resistance rates [2] - Lamivudine is now considered second-line due to high resistance rates (up to 70% after 5 years) Incorrect Option: Ombitasvir - Ombitasvir is an NS5A inhibitor used exclusively for Hepatitis C (HCV) treatment in combination regimens - Has no activity against HBV and is inappropriate for this patient Incorrect Option: Ritonavir - Ritonavir is an HIV protease inhibitor used primarily as a pharmacokinetic booster in antiretroviral therapy - Has no direct anti-HBV activity and is not used for HBV treatment Incorrect Option: Abacavir - Abacavir is an NRTI used for HIV treatment as part of combination ART - Despite being an NRTI class drug, it lacks significant anti-HBV activity and is not approved or effective for chronic Hepatitis B management

Q: A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

b.Acute pancreatitis. ***Acute pancreatitis*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input) - The clinical presentation of severe **epigastric pain radiating to the back**, associated with nausea and vomiting, is classic for **acute pancreatitis** [1]. - **Alcohol abuse** is a major risk factor, and the diagnosis is supported by findings of significantly elevated serum **amylase and/or lipase** levels [1]. *Acute hepatitis* - Typically presents with **jaundice**, fatigue, dark urine, and right upper quadrant discomfort, not the referred back pain seen here. - Key laboratory findings would include severely elevated **liver transaminases (AST/ALT)**, not primarily amylase. *Acute Cholecystitis* - Characterized by acute pain in the **right upper quadrant** or epigastrium, often radiating to the **right shoulder or scapula**, not the back [2]. - This condition is usually associated with gallstones and is diagnosed via imaging showing gallbladder wall thickening and pericholecystic fluid, though amylase can be mildly elevated secondarily. *Acute appendicitis* - Presents typically with periumbilical pain that migrates to the **right lower quadrant (RLQ)**, often associated with low-grade fever and localized tenderness. - The pain is not classically described as severe epigastric pain radiating to the back, and initial lab markers include leukocytosis but not specific elevation of amylase.

Q: Which of the following is not a component of Child-Pugh scoring?

LFT. ***LFT (Correct Answer)*** - **LFT (Liver Function Tests)** is a general term encompassing various biochemical tests such as AST, ALT, ALP, and GGT [1], [2] - These specific liver enzymes are **not components** of the Child-Pugh scoring system - The Child-Pugh score specifically uses only **5 parameters**: Albumin, Bilirubin, Prothrombin Time/INR, Ascites, and Hepatic Encephalopathy - These five components assess both **synthetic function** (albumin, PT/INR) and **clinical manifestations** (ascites, encephalopathy) of chronic liver disease [3] *Albumin (Incorrect)* - Serum **albumin** is one of the five specific components of the Child-Pugh score - It reflects the liver's **synthetic function** capacity - Scoring: >3.5 g/dL (1 point), 2.8-3.5 g/dL (2 points), 3 mg/dL (3 points) - Elevated bilirubin indicates impaired hepatic clearance and correlates with severity of liver disease *Prothrombin Time (Incorrect)* - **Prothrombin Time (PT)** or **INR** measures the liver's ability to synthesize clotting factors [3] - It is a critical component reflecting hepatic **synthetic function** - Scoring: 6 sec or INR >2.3 (3 points) [4] - Prolonged PT/elevated INR indicates severely impaired synthesis of vitamin K-dependent clotting factors [3]

Q: Which of the following is a sensitive and specific marker of intestinal inflammation?

Fecal lactoferrin. ***Fecal lactoferrin***- This is an excellent proxy marker for active intestinal inflammation because **lactoferrin** is a highly concentrated protein released by **activated neutrophils** migrating into the gut lumen [1].- Elevated fecal levels often correlate well with endoscopic and histological evidence of mucosal inflammation [2], making it a sensitive and specific non-invasive test for conditions like **Inflammatory Bowel Disease (IBD)**.*Procalcitonin*- Primarily serves as a highly specific marker for diagnosing and monitoring **sepsis** and severe **systemic bacterial infection**.- It generally reflects systemic inflammatory responses and is not specific for inflammation localized to the **intestinal mucosa**.*Tissue transglutaminase IgA*- This is an autoantibody primarily used for screening and diagnosing **Celiac disease**, an autoimmune condition triggered by **gluten**.- It indicates underlying autoimmunity causing villous atrophy but is not used as a general marker of acute or chronic **intestinal inflammation** (like IBD).*High-sensitivity C-reactive protein*- It is a widely used, but **non-specific**, acute-phase reactant indicating **systemic inflammation** originating from any part of the body [1].- While elevated in IBD, its sensitivity and specificity for identifying isolated or localized intestinal inflammation are inferior to non-invasive **fecal markers** like lactoferrin or calprotectin.

Q: A 25-year-old male presents with mild jaundice noticed during a recent febrile illness. He gives a history of similar episodes in the past following any illness or periods of fasting. Physical examination reveals mild icterus with no hepatosplenomegaly. Lab values are given below: Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1 mg/dL Conjugated bilirubin: 0.3 mg/dL Serum AST and ALT: Normal What is the most likely diagnosis?

Gilbert syndrome. ***Gilbert syndrome*** - It is characterized by isolated, mild, intermittent **unconjugated hyperbilirubinemia** (total bilirubin <4 mg/dL), often triggered by stress, fasting, illness, or dehydration, matching the patient's history of episodes following illness [1]. - The underlying cause is reduced activity (typically 30%) of the enzyme **uridine diphosphoglucuronate glucuronosyltransferase (UGT1A1)**, necessary for conjugating bilirubin, but liver function (AST/ALT) remains normal [1], [3]. *Dubin-Johnson syndrome* - This is characterized by **conjugated (direct) hyperbilirubinemia** due to defective excretion of bilirubin into the bile canaliculi, contrasting with the predominantly unconjugated pattern seen here [2]. - The liver tissue typically shows **black pigmentation** due to epinephrine metabolite accumulation, which is a key pathological feature. *Criggler-Najar type 1 syndrome* - This syndrome involves a severe or complete absence of the **UGT1A1 enzyme**, leading to very high levels of **unconjugated bilirubin** (often >20 mg/dL) that cause **kernicterus** and usually death in infancy, which is not consistent with a history of recurrent mild episodes in an adult [1]. - It requires lifelong treatment, typically with **phototherapy** and **liver transplantation**, due to the severe defect [1]. *Rotor syndrome* - Similar to Dubin-Johnson syndrome, Rotor syndrome also causes **conjugated (direct) hyperbilirubinemia** due to impaired hepatic storage and excretion of conjugated bilirubin, which contradicts the laboratory findings of mostly unconjugated bilirubin.

Q: A 20-year-old male presented with yellowish discoloration of his skin and sclera. He is otherwise normal. He gives a history of viral infection 10 days ago, which was resolved 2 days back. He also gives a history of similar episodes in the past following any illness. Lab values are given below. What is the most likely diagnosis? Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1mg/dL Conjugated bilirubin: 0.3mg/dL Serum AST and ALT: Normal

Gilbert syndrome. ***Gilbert syndrome*** - This condition is characterized by **unconjugated hyperbilirubinemia** (as seen by 2.1 mg/dL unconjugated vs. 0.3 mg/dL conjugated) that is mild, typically <3 mg/dL, and intermittent. [1] The history of similar episodes following **stress**, **vigorous exercise**, or **illness** (like the recent viral infection) is a classic trigger for this condition, which is caused by reduced activity of the **UGT1A1 enzyme**. [1] *Dubin-Johnson syndrome* - This syndrome results in **conjugated (direct) hyperbilirubinemia** due to defective excretion of conjugated bilirubin (MRP2 transporter defect). *Criggler-Najar type 1 syndrome* - This is a severe congenital deficiency of the **UGT1A1 enzyme**, leading to markedly and persistently elevated **unconjugated bilirubin** (often >20 mg/dL) and usually resulting in **kernicterus** and death in infancy. [1] The patient presents later in life (20 years old) with only mild, fluctuating unconjugated hyperbilirubinemia, ruling out Type 1 severity. *Rotor syndrome* - Similar to Dubin-Johnson, Rotor syndrome causes **conjugated (direct) hyperbilirubinemia** due to hepatocyte storage and transport defects, which contradicts the patient's lab findings of predominantly unconjugated bilirubin. Unlike Dubin-Johnson, Rotor syndrome does **not** cause black pigmentation of the liver.

Q: A 52-year-old male with chronic hepatitis B presents with progressive abdominal distension and weight loss. Examination reveals ascites and splenomegaly. Serum alpha-fetoprotein is 450 ng/mL (normal <10 ng/mL). Triphasic CT abdomen shows a 6 cm hypervascular lesion in the right lobe with arterial enhancement and washout in portal venous phase. What is the most likely diagnosis?

Hepatocellular carcinoma. ### Hepatocellular Carcinoma (HCC) - The presentation of a patient with **chronic Hepatitis B**, rapidly progressing **ascites**, and an extremely elevated **Alpha-Fetoprotein (AFP)** level (450 ng/mL) is highly suggestive of HCC [1]. - The characteristic finding of a **hypervascular lesion** on Triphasic CT with **arterial phase enhancement** and **washout** in the portal venous phase is the classic radiological hallmark for diagnosing HCC in a cirrhotic liver [1]. *Hepatic Adenoma* - Hepatic adenomas are usually benign, related to **oral contraceptive use** or **anabolic steroid** use, and are less common in men with Hepatitis B. - They typically do not exhibit the classic **washout** pattern seen on dynamic imaging, and AFP levels are usually normal. *Focal Nodular Hyperplasia (FNH)* - FNH is a benign lesion, typically found incidentally, characterized by a **central scar** on imaging, which is not described here, and is driven by vascular malformation. - Unlike HCC, FNH lesions show prolonged, homogeneous enhancement on imaging and are not associated with elevated **AFP** or severe liver function decompensation. *Hepatoblastoma* - Hepatoblastoma is an **embryonal tumor** of the liver, occurring almost exclusively in **children** (usually <3 years old), not in a 52-year-old adult. - While it can cause very high AFP levels, its clinical and radiological presentation is entirely different from a mass developing in a background of chronic viral hepatitis.

Q: A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?

Crohns disease. ***Crohns disease*** - Crohn's disease is characterized by **transmural inflammation**, which can lead to fibrosis and rigidity of the bowel wall, resulting in an ahaustral appearance. Its predilection for the **ileocecal region** makes right-sided colon involvement a classic presentation. - The disease course is chronic with relapsing and remitting symptoms like non-bloody diarrhea and abdominal pain. It is also known for its **skip lesions**, where inflamed segments of the bowel are interspersed with normal tissue. ***Ulcerative colitis*** - While chronic ulcerative colitis can cause an ahaustral or "**lead pipe**" colon, it classically starts in the **rectum** and extends proximally in a continuous manner. Isolated right colon involvement is very rare. - Inflammation in UC is limited to the **mucosa and submucosa**, unlike the transmural inflammation seen in Crohn's disease. ***Tubercular colitis*** - Intestinal tuberculosis commonly affects the **ileocecal region**, mimicking Crohn's disease clinically and radiologically. It can cause bowel wall thickening and strictures. - Differentiating features include the presence of **caseating granulomas** on histology, constitutional symptoms like fever and night sweats, and often a gaping ileocecal valve (**Fleischner sign**). ***Pseudomembranous enterocolitis*** - This is an **acute inflammatory condition** caused by *Clostridium difficile* toxins, usually following antibiotic therapy. It does not present as a chronic illness lasting for months. - Typical CT findings are acute, such as severe colonic wall thickening and edema (the "**accordion sign**"), not the chronic fibrotic changes that lead to an ahaustral appearance.

Q: The patient presents with fatigue and pruritus. LFT shows gross SALP elevation and elevated conjugated bilirubin. AMA is seen with liver biopsy shows florid bile ductular lesions. Diagnosis is

PBC. ***PBC*** - The presentation of **fatigue** and **pruritus**, severe **SALP elevation** (indicative of cholestasis), and a positive **Anti-Mitochondrial Antibody (AMA)** titer is the classic diagnostic hallmark of Primary Biliary Cholangitis [1], [3]. - The liver biopsy finding of **florid bile ductular lesions** (destruction of small to medium-sized intrahepatic bile ducts) is the pathognomonic histological feature of this disease [3]. *PSC* - While PSC (Primary Sclerosing Cholangitis) also causes cholestasis, it is typically **AMA-negative** and highly associated with Ulcerative Colitis [2], [3]. - Diagnosis of PSC requires imaging (MRCP/ERCP) showing characteristic **bile duct strictures** and **"beading"**, which are not implied by the provided histological description [2]. *UC* - Ulcerative Colitis is an **Inflammatory Bowel Disease (IBD)** affecting the colon, not a primary cholestatic liver disease itself. - Although UC is strongly linked to PSC, it does not explain the patient's **AMA positivity** or the specific destructive **florid bile duct lesions** seen on biopsy [3]. *CD* - Crohn's Disease is also an IBD, characterized by **transmural inflammation** and often affecting the terminal ileum and colon. - The primary features (pruritus, high SALP, AMA+) point directly to PBC, not the common clinical manifestations or liver associations typically seen with **Crohn's Disease**.

Question 1

Which classification is used for Barrett esophagus?

Accepted Answer

Prague classification

Answer

Johnson classification

Answer

Forrest classification

Answer

Savary-Miller classification

Question 2

A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?

Accepted Answer

Lamivudine

Answer

Ritonavir

Answer

Ombitasvir

Answer

Abacavir

Question 3

A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

Accepted Answer

b.Acute pancreatitis

Answer

a.Acute hepatitis

Answer

d.Acute appendicitis

Answer

c.Acute Cholecystitis

Question 4

Which of the following is not a component of Child-Pugh scoring?

Accepted Answer

LFT

Answer

Albumin

Answer

Bilirubin

Answer

Prothrombin Time

Question 5

Which of the following is a sensitive and specific marker of intestinal inflammation?

Accepted Answer

Fecal lactoferrin

Answer

Procalcitonin

Answer

High-sensitivity C-reactive protein

Answer

Tissue transglutaminase IgA

Question 6

A 25-year-old male presents with mild jaundice noticed during a recent febrile illness. He gives a history of similar episodes in the past following any illness or periods of fasting. Physical examination reveals mild icterus with no hepatosplenomegaly. Lab values are given below:

Serum bilirubin: 2.4 mg/dL
Unconjugated bilirubin: 2.1 mg/dL
Conjugated bilirubin: 0.3 mg/dL
Serum AST and ALT: Normal

What is the most likely diagnosis?

Accepted Answer

Gilbert syndrome

Answer

Dubin-Johnson syndrome

Answer

Rotor syndrome

Answer

Criggler-Najar type 1 syndrome

Question 7

A 20-year-old male presented with yellowish discoloration of his skin and sclera. He is otherwise normal. He gives a history of viral infection 10 days ago, which was resolved 2 days back. He also gives a history of similar episodes in the past following any illness. Lab values are given below. What is the most likely diagnosis? Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1mg/dL Conjugated bilirubin: 0.3mg/dL Serum AST and ALT: Normal

Accepted Answer

Gilbert syndrome

Answer

Criggler-Najar type 1 syndrome

Answer

Rotor syndrome

Answer

Dubin-Johnson syndrome

Question 8

A 52-year-old male with chronic hepatitis B presents with progressive abdominal distension and weight loss. Examination reveals ascites and splenomegaly. Serum alpha-fetoprotein is 450 ng/mL (normal <10 ng/mL). Triphasic CT abdomen shows a 6 cm hypervascular lesion in the right lobe with arterial enhancement and washout in portal venous phase. What is the most likely diagnosis?

Accepted Answer

Hepatocellular carcinoma

Answer

Liver metastasis

Answer

Hepatic adenoma

Answer

Focal nodular hyperplasia

Question 9

A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?

Accepted Answer

Crohns disease

Answer

Ulcerative colitis

Answer

Tubercular colitis

Answer

Pseudomembranous enterocolitis

Question 10

The patient presents with fatigue and pruritus. LFT shows gross SALP elevation and elevated conjugated bilirubin. AMA is seen with liver biopsy shows florid bile ductular lesions. Diagnosis is

Accepted Answer

PBC

Answer

UC

Answer

CD

Answer

PSC

Gastroenterology — MCQs

Gastroenterology — MCQs

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