Gastroenterology Practice Questions

Q: A 60-year-old presents with hematochezia, Hb 7g/dl. Upper GI endoscopy normal. Next investigation?

Colonoscopy. ***Colonoscopy*** - **Hematochezia** (bright red blood per rectum) typically indicates **lower GI bleeding**, most commonly from the **colon or rectum**. After normal upper GI endoscopy, colonoscopy is the standard next investigation [1]. - Colonoscopy allows both **diagnostic visualization** of the entire colon and **therapeutic intervention** (e.g., **polypectomy**, **coagulation**) for bleeding lesions like **diverticular bleeding**, **angiodysplasia**, or **colorectal malignancy** [3]. *Push enteroscopy* - Push enteroscopy is indicated for **obscure GI bleeding** only after **both upper endoscopy and colonoscopy** have been performed and found normal [2]. - It evaluates the **proximal small bowel** but would not be the immediate next step when hematochezia suggests a **colonic source** that hasn't been evaluated yet. *Capsule endoscopy* - Capsule endoscopy is reserved for **obscure GI bleeding** after negative upper and lower endoscopy, primarily to evaluate the **entire small bowel** [2]. - It provides only **diagnostic information** without therapeutic capability and would be inappropriate before evaluating the colon in a patient with hematochezia [1]. *CT angiogram* - CT angiogram is useful for **rapid active arterial bleeding** (>0.5-1.0 mL/min) when **contrast extravasation** can be detected, or when endoscopy is not feasible. - It's typically reserved for **hemodynamically unstable** patients or when initial endoscopic evaluation fails to identify the bleeding source.

Q: Assertion: Beta blockers improve survival in cirrhosis with varices. Reason: They reduce cardiac output and splanchnic blood flow.

Both A & R true, R explains A. ***Both A & R true, R explains A*** - **Beta blockers** improve survival in patients with **cirrhosis and varices** by reducing the risk of **variceal bleeding**, a major cause of mortality [1]. - This is achieved by lowering **portal pressure** primarily through reducing **cardiac output** (beta-1 blockade) and causing **splanchnic vasoconstriction** (beta-2 blockade), thereby decreasing splanchnic blood flow. *Both A & R true, R doesn't explain A* - The reasoning provided (reduction in cardiac output and splanchnic blood flow) directly explains the mechanism by which **beta blockers** reduce **portal pressure** and subsequently prevent **variceal bleeding**, thus improving survival [1]. - Therefore, the reason *does* explain the assertion. *A true R false* - The assertion that **beta blockers** improve survival in cirrhosis with varices is **true**. - The reason—that they reduce cardiac output and splanchnic blood flow—is also **true** and describes their key mechanism of action in this context. *A false R true* - The assertion is **true**: non-selective **beta blockers** are a cornerstone in the primary and secondary prophylaxis of **variceal hemorrhage** in **cirrhosis**, improving survival. - The reason is also **true**, as these mechanisms are well-established pharmacological effects of **beta blockers** leading to reduced **portal hypertension** [1].

Q: Which finding best predicts poor outcome in acute pancreatitis at admission?

Ranson score >3. ***Ranson score >3*** - A **Ranson score** greater than 3 on admission is a strong predictor of **severe acute pancreatitis** and increased **mortality** [1]. - The Ranson criteria assess multiple parameters, including age, WBC count, LDH, AST, and glucose, providing a comprehensive risk assessment [1]. *Serum lipase >1000* - An elevated **serum lipase level** is highly diagnostic of acute pancreatitis but does not directly correlate with disease severity or prognosis. - While reflecting pancreatic inflammation, lipase levels often do not predict the development of **organ failure** or **necrotizing pancreatitis** [1]. *Blood glucose >200* - **Hyperglycemia** at admission is one of the Ranson criteria, but as a single parameter, it is not as strong a predictor of poor outcome as the complete score. - Isolated high glucose can be due to stress or pre-existing **diabetes**, contributing to some severity but not sufficient for widespread poor prognosis without other factors. *Pleural effusion* - **Pleural effusion** can be a complication of severe pancreatitis, indicating surrounding inflammation. - However, its presence at admission, without other markers of severity, is less predictive of overall poor outcome than a validated scoring system like the Ranson score which assesses multiple systemic factors.

Q: In a patient with cirrhosis, which finding indicates worst prognosis according to Child-Pugh score?

Grade 3 encephalopathy. ***Grade 3 encephalopathy*** - According to the **Child-Pugh score**, **grade 3 or 4 encephalopathy** is assigned the highest score (3 points) in the encephalopathy category, indicating the severest form and poorest prognosis [1]. - Higher grades of encephalopathy reflect significant **neurological dysfunction** due to impaired liver detoxification [1]. *PT prolonged by 4 seconds* - A **prothrombin time (PT)** prolongation of 4-6 seconds beyond control receives 2 points, while PT prolonged >6 seconds beyond control receives 3 points in the Child-Pugh score [1]. - While significant, a 4-second prolongation (2 points) is less severe than grade 3 encephalopathy (3 points). *Serum albumin 2.8 g/dL* - A **serum albumin level** between 2.8 and 3.5 g/dL receives 2 points in the Child-Pugh score [1]. - This value indicates moderate liver dysfunction but is not the highest score achievable within the Child-Pugh system. *Moderate ascites* - **Moderate ascites** that is responsive to diuretics receives 2 points in the Child-Pugh score [1]. - **Refractory ascites** receives 3 points, but "moderate ascites" alone typically implies a milder form with a better prognosis than grade 3 encephalopathy due to its lower score [1].

Q: A patient with cirrhosis develops spontaneous bacterial peritonitis. Which factor most strongly predicts poor prognosis?

Serum creatinine >2 mg/dL. ***Serum creatinine >2 mg/dL*** - Elevated **serum creatinine** in the context of spontaneous bacterial peritonitis (SBP) indicates **renal impairment** or **acute kidney injury**, which is a strong predictor of poor prognosis and increased mortality [1]. - Renal dysfunction significantly complicates the management of cirrhosis and SBP, leading to higher rates of complications and reduced survival [1]. *Ascitic protein >2.5 g/dL* - A low ascitic protein level ( 2.5 g/dL might indicate a secondary bacterial peritonitis or other causes of ascites, but it is not typically a predictor of poor prognosis in SBP itself [2]. *Total count >25000/mm3* - While a high total white blood cell count in ascitic fluid (specifically **polymorphonuclear (PMN) count >250 cells/mm3**) is diagnostic of SBP, an extremely high total count (like >25,000/mm3) is not the strongest predictor of *poor prognosis* compared to renal dysfunction. - It might suggest a more severe infection, but **renal compromise** has a greater impact on mortality. *Positive blood culture* - A positive blood culture in SBP indicates **bacteremia**, which is associated with a more severe infection and higher mortality rates than SBP without bacteremia. - However, **renal impairment** (serum creatinine >2 mg/dL) typically carries a *graver prognostic significance* as it reflects organ system failure beyond the infection itself [1].

Q: Most specific serological marker for celiac disease?

Anti-tissue transglutaminase. ***Anti-tissue transglutaminase*** - **Anti-tissue transglutaminase (tTG) antibodies**, especially the IgA class, are the **most sensitive and specific serological test** for diagnosing celiac disease. - They target the enzyme **tissue transglutaminase**, which deamidates gliadin peptides, making them more immunogenic. *Anti-gliadin antibody* - **Anti-gliadin antibodies (AGA)**, both IgA and IgG, were historically used but have **lower sensitivity and specificity** compared to newer markers. - Their primary role today is limited, particularly in children under 2 years old or in cases with IgA deficiency, where **IgG-AGA** might be considered. *Anti-reticulin antibody* - **Anti-reticulin antibodies (ARA)** are another serological marker for celiac disease, but they have **lower sensitivity and specificity** than anti-tTG and anti-endomysial antibodies. - Due to their lower diagnostic accuracy, they are **rarely used** in routine clinical practice for celiac disease screening. *Anti-endomysial antibody* - **Anti-endomysial antibodies (EMA)** are highly specific for celiac disease, with nearly 100% specificity, but they are **less sensitive** than anti-tTG antibodies. - The test is **operator-dependent** and typically performed by indirect immunofluorescence on primate esophagus, making it more expensive and less readily available than anti-tTG.

Q: A chronic alcoholic patient came to emergency with severe pain in epigastrium and multiple episodes of vomiting. On examination, guarding was present in upper epigastrium. Chest X-ray was normal. What is the next best step?

Serum lipase. ***Serum lipase*** - The patient's presentation with acute epigastric pain, vomiting, guarding, and a history of chronic alcoholism strongly suggests **acute pancreatitis** [1]. - **Serum lipase** is highly sensitive and specific for diagnosing acute pancreatitis, with levels typically elevated to at least three times the upper limit of normal. *CECT* - While **CECT (Contrast-Enhanced Computed Tomography)** is excellent for assessing the severity and complications of pancreatitis, it is generally not the initial diagnostic test for suspected acute pancreatitis [1]. - CT scans are usually performed if the diagnosis is unclear or if complications like **necrosis** or **fluid collections** are suspected after initial laboratory tests. *Alcohol breath test* - An **alcohol breath test** would confirm recent alcohol consumption but does not directly diagnose the cause of the patient's acute abdominal pain [2]. - While chronic alcoholism is a risk factor for pancreatitis, this test does not provide specific information about the underlying medical emergency. *Upper GI endoscopy* - **Upper GI endoscopy** is primarily used to evaluate conditions affecting the esophagus, stomach, and duodenum, such as **ulcers** or **gastritis**. - It would not be the initial diagnostic step for suspected pancreatitis, as it does not directly visualize the pancreas and carries risks in an acutely ill patient.

Q: A 30-year-old female presents with jaundice and itching. MRCP reveals stricturing of the intrahepatic bile ducts with beading. What is the most likely diagnosis?

Primary sclerosing cholangitis. ***Primary sclerosing cholangitis*** - The classic imaging finding of **stricturing** and **beading** in the **intrahepatic bile ducts** on MRCP is highly characteristic of **primary sclerosing cholangitis (PSC)** [1]. - **Jaundice** and **itching** are common symptoms of cholestasis, which occurs due to progressive fibrosis and inflammation of the bile ducts in PSC [2]. *Choledocholithiasis* - This condition involves **stones in the common bile duct**, which would typically appear as filling defects on MRCP rather than diffuse stricturing and beading. - While it can cause jaundice and itching, it does not explain the characteristic diffuse bile duct changes seen. *Pancreatic cancer* - Pancreatic cancer typically causes **distal common bile duct obstruction**, which would appear as an abrupt cutoff or stricture, often with upstream dilation, rather than widespread intrahepatic stricturing and beading. - Symptoms like **unexplained weight loss** and **new-onset diabetes** are more typical. *Cholangiocarcinoma* - While cholangiocarcinoma is a malignancy of the bile ducts, it usually presents as a **focal stricture** or a **mass lesion** within the bile duct system. - The widespread "beading" pattern points more towards an inflammatory-fibrotic process like PSC, although cholangiocarcinoma can sometimes develop in the context of PSC.

Q: All of the following are risk factors for gastric cancer except?

Duodenal ulcer. ***Duodenal ulcer*** - A history of **duodenal ulcers** is generally protective against gastric cancer, possibly due to the increased acid production in the duodenum or differences in the distribution of *H. pylori* strains [1]. - While *H. pylori* can cause both duodenal ulcers and gastric cancer, specific strains associated with duodenal ulcers may be less virulent in terms of oncogenic potential for the stomach [1]. *Diet high in pickled vegetables* - Diets high in **salted and pickled foods** are associated with an increased risk of gastric cancer. - These foods often contain **nitrosamines** and other carcinogenic compounds that can directly damage gastric mucosa. *Smoking* - **Smoking** is a well-established and significant risk factor for gastric cancer, increasing the risk by 1.5 to 2.5 times compared to non-smokers. - Carcinogens in tobacco smoke can reach the stomach mucosa, promoting cellular damage and malignant transformation. *Helicobacter pylori infection* - **Chronic *Helicobacter pylori* infection** is the strongest known risk factor for gastric cancer, particularly for the intestinal type [2]. - It causes chronic inflammation and atrophy of the gastric mucosa, leading to a cascade known as Correa's pathway (chronic gastritis → atrophic gastritis → intestinal metaplasia → dysplasia → carcinoma) [2].

Q: A 45-year-old male presents with upper abdominal pain, weight loss, and early satiety. Endoscopy reveals antral thickening, and biopsy shows H. pylori. What is the next step in management?

Eradication of H. pylori. ***Eradication of H. pylori*** - The presence of **H. pylori** in a patient with upper abdominal symptoms, weight loss, and **antral thickening** mandates treatment before further investigations for malignancy [1]. - Eradication of *H. pylori* is crucial as it is a major risk factor for **PUD**, **gastric adenocarcinoma**, and **MALT lymphoma**, and treatment can significantly improve symptoms and prevent disease progression [1], [2]. *Endoscopic ultrasound* - This procedure is typically used for **local staging of gastric cancer** or to evaluate submucosal lesions, but it's not the immediate next step without first addressing the *H. pylori* infection [2]. - While it could be considered later if symptoms persist despite *H. pylori* eradication, definitive diagnosis of malignancy requires deeper tissue investigation often guided by symptoms and initial findings. *CT abdomen* - A **CT scan** is primarily used for **staging gastric cancer** and detecting distant metastases, which might be considered if initial *H. pylori* treatment fails or suspicion of malignancy remains high. - It would be premature to perform a CT scan as the initial next step, given an identifiable and treatable cause (*H. pylori*) has been found. *Surgical resection* - **Surgical resection** is thedefinitive treatment for **gastric cancer**, but it is a major intervention that should only be performed after a confirmed diagnosis of malignancy and appropriate staging workup. - Performing surgery without addressing the *H. pylori* infection and fully evaluating the nature of the antral thickening would be inappropriate and potentially harmful.

Question 1

A 60-year-old presents with hematochezia, Hb 7g/dl. Upper GI endoscopy normal. Next investigation?

Accepted Answer

Colonoscopy

Answer

Capsule endoscopy

Answer

CT angiogram

Answer

Push enteroscopy

Question 2

Assertion: Beta blockers improve survival in cirrhosis with varices. Reason: They reduce cardiac output and splanchnic blood flow.

Accepted Answer

Both A & R true, R explains A

Answer

Both A & R true, R doesn't explain A

Answer

A true R false

Answer

A false R true

Question 3

Which finding best predicts poor outcome in acute pancreatitis at admission?

Accepted Answer

Ranson score >3

Answer

Serum lipase >1000

Answer

Blood glucose >200

Answer

Pleural effusion

Question 4

In a patient with cirrhosis, which finding indicates worst prognosis according to Child-Pugh score?

Accepted Answer

Grade 3 encephalopathy

Answer

PT prolonged by 4 seconds

Answer

Serum albumin 2.8 g/dL

Answer

Moderate ascites

Question 5

A patient with cirrhosis develops spontaneous bacterial peritonitis. Which factor most strongly predicts poor prognosis?

Accepted Answer

Serum creatinine >2 mg/dL

Answer

Ascitic protein >2.5 g/dL

Answer

Total count >25000/mm3

Answer

Positive blood culture

Question 6

Most specific serological marker for celiac disease?

Accepted Answer

Anti-tissue transglutaminase

Answer

Anti-gliadin antibody

Answer

Anti-reticulin antibody

Answer

Anti-endomysial antibody

Question 7

A chronic alcoholic patient came to emergency with severe pain in epigastrium and multiple episodes of vomiting. On examination, guarding was present in upper epigastrium. Chest X-ray was normal. What is the next best step?

Accepted Answer

Serum lipase

Answer

CECT

Answer

Alcohol breath test

Answer

Upper GI endoscopy

Question 8

A 30-year-old female presents with jaundice and itching. MRCP reveals stricturing of the intrahepatic bile ducts with beading. What is the most likely diagnosis?

Accepted Answer

Primary sclerosing cholangitis

Answer

Choledocholithiasis

Answer

Pancreatic cancer

Answer

Cholangiocarcinoma

Question 9

All of the following are risk factors for gastric cancer except?

Accepted Answer

Duodenal ulcer

Answer

Diet high in pickled vegetables

Answer

Smoking

Answer

Helicobacter pylori infection

Question 10

A 45-year-old male presents with upper abdominal pain, weight loss, and early satiety. Endoscopy reveals antral thickening, and biopsy shows H. pylori. What is the next step in management?

Accepted Answer

Eradication of H. pylori

Answer

Endoscopic ultrasound

Answer

CT abdomen

Answer

Surgical resection

Gastroenterology — MCQs

Gastroenterology — MCQs

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