Gastroenterology Practice Questions

Q: Based on the image provided, what is the most appropriate confirmatory investigation?

Manometry. ***Manometry*** - Esophageal manometry is the **gold standard** (confirmatory test) for achalasia, as it directly evaluates the motility and pressure patterns of the esophagus. - It definitively demonstrates the two key pathognomonic findings: **absent esophageal peristalsis** and **incomplete relaxation of the lower esophageal sphincter (LES)**. *pH monitoring* - This test is used primarily to diagnose **Gastroesophageal Reflux Disease (GERD)** by quantifying abnormal acid exposure in the distal esophagus. - It is not relevant for confirming achalasia, which is a **motor disorder** causing functional obstruction, not acid reflux. *Upper GI Endoscopy* - Endoscopy is crucial for **ruling out secondary achalasia** (pseudoachalasia), caused by underlying conditions like malignancy, which can structurally mimic the radiologic findings. - Although mandatory in evaluation, it does not confirm the **functional motor deficit** (aperistalsis and failed relaxation) required for definitive diagnosis of primary achalasia. *Barium swallow study* - The image provided is a Barium swallow study, which serves as the **initial screening tool** for achalasia by showing the classic **"bird-beak" appearance** of the distal esophagus. - While suggestive, this radiological study reports morphology and transit, but **manometry** is required to confirm the associated physiological defect (abnormal pressures and motility).

Q: A person with jaundice presented with a history of bleeding and symptoms normalised after giving Vitamin K injection. The probable cause is?

Biliary obstruction. ***Biliary obstruction*** - **Biliary obstruction** (Cholestasis) prevents the flow of bile into the duodenum, impairing the absorption of **fat-soluble vitamins** (A, D, E, K) [1]. - **Vitamin K** deficiency leads to impaired synthesis of **coagulation factors II, VII, IX, and X** in the liver, causing a coagulopathy (bleeding tendency) that is corrected by parenteral Vitamin K administration [2]. *Alpha antitrypsin deficiency* - This typically causes liver disease (cirrhosis) and emphysema, but the bleeding issues are due to general hepatic synthetic failure, meaning the coagulopathy would usually be **refractory to simple Vitamin K injection** [1]. - The deficiency is mainly linked to **panacinar emphysema** and pediatric/adult liver failure presentations, not primarily a **Vitamin K-responsive coagulopathy**. *Autoimmune hepatitis* - This condition causes chronic inflammation and destruction of hepatocytes, leading to liver failure and cirrhosis; the resulting coagulopathy is due to **synthetic dysfunction**. - Coagulopathy from severe autoimmune hepatitis is typically **not fully corrected** by Vitamin K injection alone, requiring fresh frozen plasma (FFP) if bleeding is severe. *Factor XI deficiency* - This is a rare, **autosomal recessive** congenital deficiency (Hemophilia C) not usually associated with jaundice or liver disease. - The bleeding tendency is **not due to Vitamin K malabsorption** or deficiency, and thus would not be corrected by Vitamin K injection.

Q: A patient presents with recurrent oral lesions and eye redness as shown in the images below. The patient also complains of chronic diarrhea and abdominal discomfort. Which test is recommended for this patient?

Anti-endomysial antibodies. ***Anti-endomysial antibodies*** - The image on the left shows **aphthous stomatitis**, and the one on the right shows **conjunctivitis** with dilated vessels. These two findings, along with other potential symptoms (e.g., GI, arthritis), could indicate **celiac disease**. - **Anti-endomysial antibodies** are highly specific for **celiac disease**, which can manifest with extraintestinal symptoms including recurrent aphthous stomatitis and, less commonly, ocular symptoms. *Anti-endothelial cell antibodies* - These antibodies are associated with **vasculitis** and other autoimmune conditions that primarily affect blood vessels. - While some vasculitides can cause ocular inflammation and oral lesions, they don't typically present with the specific combination and appearance of symptoms seen here. *RBC glutathione reductase levels* - This test measures the activity of the enzyme **glutathione reductase** in red blood cells. - It is primarily used to assess **riboflavin (vitamin B2) deficiency** and has no direct relevance to the conditions suggested by the visual findings. *Serum methylmalonic acid levels* - Elevated **serum methylmalonic acid (MMA)** levels are a sensitive indicator of **vitamin B12 deficiency**. - While vitamin B12 deficiency can cause glossitis (inflammation of the tongue), it doesn't typically cause aphthous stomatitis or conjunctivitis.

Q: A 42-year-old obese chronic smoker complains of dysphagia, retrosternal heart burn along with sour brash for a period of 6 years. What is the diagnosis?

Stricture esophagus. ***Stricture esophagus*** - The long-standing history of **dysphagia**, **retrosternal heartburn**, and **sour brash** in an obese chronic smoker strongly suggests **gastroesophageal reflux disease (GERD)**. - Chronic unmanaged GERD can lead to complications such as **esophageal stricture** due to inflammation and scarring, causing further narrowing and dysphagia. *Schatzki's rings* - These are **mucosal rings** that develop at the **esophagogastric junction**. While they cause dysphagia, they typically don't present with persistent, severe heartburn or sour brash for 6 years as the primary symptoms of GERD, but rather as an anatomical cause of dysphagia. - The image given indicates a longer, more irregular narrowing characteristic of a stricture rather than a thin, circumferential ring. *Plummer Vinson syndrome* - This syndrome is characterized by **iron deficiency anemia**, **dysphagia** (due to esophageal webs), and **glossitis**. - The patient's presentation does not include anemia or glossitis, making this diagnosis less likely. *Esophageal dysmotility* - Esophageal dysmotility disorders (e.g., **achalasia**, **diffuse esophageal spasm**) can cause dysphagia and chest pain. - However, they are less commonly associated with significant, long-standing **sour brash** and **heartburn** as the primary symptoms, which are hallmarks of GERD leading to stricture.

Q: A 28-year-old pregnant female patient complains of hematemesis after an episode of vomiting. On upper GI endoscopy this is the appearance. What is the most common site of this condition?

Lower $1 / 3$ of the esophagus. ***Lower 1/3 of the esophagus*** - The image shown, combined with the history of hematemesis after vomiting in a pregnant patient, is highly suggestive of **Mallory-Weiss tear**. - These tears typically occur in the **mucosa and submucosa** at the **gastroesophageal junction** or the contiguous gastric cardia, most commonly in the lower third of the esophagus. *Middle 1/3 of esophagus* - Tears in the middle esophagus are less common for Mallory-Weiss syndrome, which is primarily a condition of the **distal esophagus** and **gastroesophageal junction**. - While other esophageal pathologies can occur here, such as varices or esophagitis, they are less typically associated with the classic Mallory-Weiss presentation. *Cardia* - While the **gastric cardia** is a possible site for Mallory-Weiss tears, the most common location involves the esophageal side of the **gastroesophageal junction**, extending into the lower esophagus. - The cardia might be involved, but "lower 1/3 of the esophagus" is generally considered the most frequent site of the mucosal tear. *Lesser curvature of stomach* - The lesser curvature of the stomach is a common site for **peptic ulcers**, which can also cause hematemesis. - However, the clinical context of **retching and vomiting followed by hematemesis** points specifically to a Mallory-Weiss tear, which is located more proximally at the gastroesophageal junction.

Q: A 76-year-old male presents to emergency with abdominal pain after binge drinking. The BP on admission is 80/50 mm Hg and pulse rate of 120 BPM. Serum creatinine = 2.5 mg% with elevated liver transaminases. What is the likely diagnosis based on CT image shown below? (AlIMS May 2016)

Severe acute pancreatitis. ***Severe acute pancreatitis*** - The CT image shows marked **peripancreatic fat stranding**, fluid collections (arrowheads), and heterogeneity of the pancreatic parenchyma, consistent with **severe acute pancreatitis**. - The patient's history of **binge drinking**, severe abdominal pain, and signs of **circulatory shock (BP 80/50, HR 120)** along with **elevated liver transaminases** and acute kidney injury (creatinine 2.5 mg%) further support this diagnosis. *Liver abscess* - A liver abscess would typically appear as a **well-defined, hypodense lesion** within the liver parenchyma on CT, often with a rim enhancement; these features are not predominant in the CT provided. - While binge drinking can increase the risk of liver disease, the diffuse pancreatic inflammation and peripancreatic involvement seen are not characteristic of a primary liver abscess. *Acute pancreatitis* - While the CT findings are consistent with acute pancreatitis, the patient's **hypotension, tachycardia**, and acute kidney injury (elevated creatinine) indicate a **severe systemic inflammatory response**, classifying it as severe acute pancreatitis rather than mild or moderate forms. - The extensive fluid collections and significant fat stranding visible on the CT also point towards a more severe disease process. *Acute pyelonephritis* - Acute pyelonephritis would manifest as **renal parenchymal inflammation** and edema on CT, often with wedge-shaped areas of decreased enhancement, usually accompanied by fever and flank pain. - The CT image shows **pancreatic and peripancreatic inflammation**, not primarily renal involvement, and the clinical presentation, while severe, is more indicative of intra-abdominal catastrophe following binge drinking.

Q: The given endoscopy of the patient shows? (NEET Pattern 2018)

Eosinophilic esophagitis. **Eosinophilic esophagitis** - The endoscopic image displays prominent **concentric rings** (trachealization) and **linear furrows**, which are classic findings in eosinophilic esophagitis. - These features result from chronic inflammation and fibrosis caused by an allergic reaction leading to significant eosinophil infiltration in the esophageal wall. *Radiation esophagitis* - Endoscopic findings in radiation esophagitis typically include **erythema**, **edema**, **ulcerations**, or **strictures** in the irradiated field. - The characteristic ringed appearance seen in the image is not typical for radiation-induced injury. *GERD* - Endoscopic signs of GERD often include **erosions**, **ulcerations**, **strictures**, or **Barrett's esophagus**, usually in the distal esophagus. - While chronic GERD can cause inflammation, it typically does not produce the pronounced concentric rings and linear furrows characteristic of eosinophilic esophagitis. *Carcinoma esophagus* - Esophageal carcinoma typically presents with a **mass**, **ulceration**, **stricture**, or an **irregular, friable lesion**. - The image does not show any focal mass or destructive lesion suggestive of malignancy.

Q: A 15-year-old boy presents with abdominal cramps and diarrhea for 8 weeks along with delayed puberty. Perianal examination reveals the following. What is the diagnosis? (NEET Pattern 2018)

Crohn's disease. ***Crohn's disease*** - The combination of **chronic abdominal cramps and diarrhea**, **delayed puberty**, and the presence of **perianal lesions** (like skin tags, fissures, or abscesses, as depicted) is highly indicative of Crohn's disease. - Delayed puberty suggests **malabsorption** and chronic inflammation, which are characteristic systemic effects of Crohn's disease, particularly when it affects the small bowel. *Celiac disease* - While celiac disease can cause **abdominal cramps**, **diarrhea**, and **growth delays** (potentially leading to delayed puberty due to malabsorption), it typically does **not present with perianal lesions**. - It is an **autoimmune response to gluten**, not an inflammatory bowel disease presenting with perianal manifestations. *Ulcerative colitis* - This condition is characterized by **colonic inflammation**, causing symptoms like **bloody diarrhea** and abdominal pain. - While it can manifest with some **extraintestinal symptoms**, **perianal disease** is rare and less severe compared to Crohn's disease, and delayed puberty is less commonly associated. *Irritable bowel syndrome* - IBS is a **functional gastrointestinal disorder** without underlying structural or biochemical abnormalities, presenting with abdominal pain and altered bowel habits. - It does **not cause perianal lesions**, malabsorption, or systemic complications like delayed puberty.

Q: The following appearance of esophagus is seen in:

Eosinophilic esophagitis. ***Eosinophilic esophagitis*** - The image clearly shows **trachealization** of the esophagus, characterized by **concentric rings** and **linear furrows**, which are hallmark endoscopic findings of eosinophilic esophagitis. - This condition is an **allergic inflammatory disorder** involving the esophagus, often leading to dysphagia and food impaction. *GERD* - While GERD can cause inflammation (esophagitis), it typically presents with **erosions**, **strictures**, or **Barrett's esophagus**, but not the characteristic ringed appearance seen here. - The presence of **longitudinal furrows** and a pale, corrugated appearance rather than the distinct circular rings would be less typical for classic GERD. *Stricture* - A stricture would appear as a **localized narrowing** of the esophageal lumen, which is not the predominant feature in this image. - While strictures can occur in chronic eosinophilic esophagitis, the primary morphological feature visualized is the **ringed esophagus**. *Radiation esophagitis* - This condition results from **radiation exposure** to the chest and typically presents with **mucosal edema**, **erythema**, **ulcerations**, or **fibrosis** in acute and chronic phases, respectively. - It does not commonly cause the distinctive **trachealization** or ringed appearance seen in the image.

Q: A 20-year-old man with history of melena and abdominal pain has pigmentation of lips. Probable diagnosis is:

Peutz Jeghers syndrome. ***Peutz Jeghers syndrome*** - The combination of **mucocutaneous pigmentation** (especially on the lips and buccal mucosa, as seen in the image) with gastrointestinal symptoms like **melena** (due to bleeding from polyps) and abdominal pain is characteristic of Peutz-Jeghers syndrome. - This syndrome is also associated with an increased risk of various cancers, including gastrointestinal cancers. *Incontinentia pigmenti* - This is a rare **X-linked dominant genetic disorder** primarily affecting the skin, nervous system, eyes, and teeth. - It presents with **linear or whorled skin lesions**, typically developing in infancy, and does not cause gastrointestinal polyps or bleeding. *Cronkhite Canada Syndrome* - This syndrome is characterized by generalized gastrointestinal **hamartomatous polyposis** combined with ectodermal abnormalities including **alopecia**, onychodystrophy (nail changes), and cutaneous pigmentation. - While it involves gastrointestinal symptoms and pigmentation, the specific mucocutaneous pigmentation pattern seen in the image and absence of other ectodermal features make Peutz-Jeghers more likely. *Brooke Spiegler syndrome* - This is a rare autosomal dominant disorder characterized by the development of **multiple adnexal tumors**, such as cylindromas, trichoepitheliomas, and spiradenomas. - It primarily affects the skin, particularly on the head and neck, and does not typically involve gastrointestinal symptoms or mucocutaneous pigmentation as described.

Question 1

Based on the image provided, what is the most appropriate confirmatory investigation?

Accepted Answer

Manometry

Answer

Barium swallow study

Answer

Upper GI Endoscopy

Answer

pH monitoring

Question 2

A person with jaundice presented with a history of bleeding and symptoms normalised after giving Vitamin K injection. The probable cause is?

Accepted Answer

Biliary obstruction

Answer

Autoimmune hepatitis

Answer

Alpha antitrypsin deficiency

Answer

Factor XI deficiency

Question 3

A patient presents with recurrent oral lesions and eye redness as shown in the images below. The patient also complains of chronic diarrhea and abdominal discomfort. Which test is recommended for this patient?

Accepted Answer

Anti-endomysial antibodies

Answer

Anti-endothelial cell antibodies

Answer

RBC glutathione reductase levels

Answer

Serum methylmalonic acid levels

Question 4

A 42-year-old obese chronic smoker complains of dysphagia, retrosternal heart burn along with sour brash for a period of 6 years. What is the diagnosis?

Accepted Answer

Stricture esophagus

Answer

Schatzki's rings

Answer

Plummer vinson syndrome

Answer

Esophageal dysmotility

Question 5

A 28-year-old pregnant female patient complains of hematemesis after an episode of vomiting. On upper GI endoscopy this is the appearance. What is the most common site of this condition?

Accepted Answer

Lower $1 / 3$ of the esophagus

Answer

Middle $1 / 3$ of esophagus

Answer

Cardia

Answer

Lesser curvature of stomach

Question 6

A 76-year-old male presents to emergency with abdominal pain after binge drinking. The BP on admission is 80/50 mm Hg and pulse rate of 120 BPM. Serum creatinine = 2.5 mg% with elevated liver transaminases. What is the likely diagnosis based on CT image shown below? (AlIMS May 2016)

Accepted Answer

Severe acute pancreatitis

Answer

Liver abscess

Answer

Acute pancreatitis

Answer

Acute pyelonephritis

Question 7

The given endoscopy of the patient shows? (NEET Pattern 2018)

Accepted Answer

Eosinophilic esophagitis

Answer

Radiation esophagitis

Answer

GERD

Answer

Carcinoma esophagus

Question 8

A 15-year-old boy presents with abdominal cramps and diarrhea for 8 weeks along with delayed puberty. Perianal examination reveals the following. What is the diagnosis? (NEET Pattern 2018)

Accepted Answer

Crohn's disease

Answer

Celiac disease

Answer

Ulcerative colitis

Answer

Irritable bowel syndrome

Question 9

The following appearance of esophagus is seen in:

Accepted Answer

Eosinophilic esophagitis

Answer

GERD

Answer

Stricture

Answer

Radiation esophagitis

Question 10

A 20-year-old man with history of melena and abdominal pain has pigmentation of lips. Probable diagnosis is:

Accepted Answer

Peutz Jeghers syndrome

Answer

Incontinentia pigmenti

Answer

Cronkhite Canada Syndrome

Answer

Brooke Spiegler syndrome

Gastroenterology — MCQs

Gastroenterology — MCQs

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