Gastroenterology Practice Questions

Q: An eight month old male child is brought to the emergency with recurrent episodes of screaming and drawing up of legs. The child appears to be listless in between the attacks. Local examination of abdomen reveals feeling of emptiness in the right iliac fossa and blood stained mucus is found on the finger on rectal examination. The most probable clinical diagnosis in this child is

Acute intussusception. ***Acute intussusception*** - The classic triad of symptoms in an infant – **intermittent abdominal pain** (screaming, drawing up legs), **vomiting**, and **currant jelly stools** (blood-stained mucus) – is highly indicative of intussusception. - The presence of a **"dance sign"** (emptiness in the right iliac fossa due to the displacement of the cecum) and a palpable sausage-shaped mass (though not explicitly stated, implied by emptiness) further supports this diagnosis. *Rectal prolapse* - While rectal prolapse can present with crying and blood in the stool, it would typically involve the **visible protrusion of rectal tissue from the anus**, which is not described. - It does not cause the intermittent severe abdominal pain and listlessness consistent with an acute intestinal obstruction. *Midgut volvulus* - Midgut volvulus typically presents with **bilious vomiting** and signs of acute intestinal obstruction and ischemia (e.g., severe abdominal distension, peritonitis, shock). - While it can cause bloody stools due to ischemia, the characteristic **intermittent pain and asymptomatic periods** between attacks, along with the specific rectal findings, are more characteristic of intussusception. *Caecal volvulus* - Caecal volvulus is more common in **older children or adults** and presents with acute abdominal pain, distension, and signs of large bowel obstruction. - It would not typically present with the intermittent episodes of pain and the classic **"currant jelly" stools** or the "dance sign" seen in intussusception in an infant.

Q: A child presents with itchy lesions and diarrhea and has been advised to follow a gluten-free diet. What is the most likely etiology of this condition?

Celiac disease. ***Celiac disease*** - **Celiac disease** is an autoimmune condition triggered by **gluten ingestion**, leading to small intestine damage and nutrient malabsorption. - The combination of **itchy lesions** (dermatitis herpetiformis, a skin manifestation of celiac disease), **diarrhea**, and improvement on a **gluten-free diet** are highly characteristic. - Since the question asks for the **underlying etiology**, celiac disease is the correct answer as it causes both the skin and GI manifestations. *Whipple's disease* - This is a rare systemic infection caused by the bacterium **Tropheryma whipplei**, presenting with **arthralgia, fever, malabsorption, and lymphadenopathy**. - While it can cause diarrhea and malabsorption, it is not associated with itchy skin lesions and does not respond to a gluten-free diet. *Crohn's disease* - **Crohn's disease** is a type of inflammatory bowel disease affecting any part of the GI tract, causing **abdominal pain, diarrhea, and weight loss**. - It is not associated with dermatitis herpetiformis and does not improve with a gluten-free diet (though some patients may have gluten sensitivity). *Dermatitis herpetiformis* - **Dermatitis herpetiformis** is the **cutaneous manifestation of celiac disease**, presenting as intensely itchy, vesicular lesions. - While DH explains the itchy lesions in this case, it is a **symptom/manifestation**, not the underlying **etiology**—the root cause is celiac disease itself, which produces both the intestinal damage (diarrhea) and the skin manifestations (DH).

Q: An 11-year-old boy was brought to the outpatient clinic with intention tremor and poor scholastic performance. His sister has similar complaints. On examination, hepatomegaly is seen. The eye finding is shown in the image. What is the probable diagnosis?

Wilson's disease. ***Wilson's disease*** - The combination of **intention tremor**, **poor scholastic performance** (indicating neurological involvement), **hepatomegaly**, and the **eye finding** (Kayser-Fleischer ring seen in the image) points strongly to Wilson's disease. The sister having similar complaints suggests an **autosomal recessive** inheritance pattern, consistent with Wilson's disease. - The image shows **Kayser-Fleischer ring**, a golden-brown ring at the corneal limbus due to **copper deposition in Descemet's membrane**, which is pathognomonic for Wilson's disease with neurological involvement. - Wilson's disease is caused by mutations in the **ATP7B gene**, leading to impaired copper excretion and accumulation in the liver, brain, and cornea. *Glutaric aciduria* - This is a rare **autosomal recessive metabolic disorder** that primarily affects the brain, leading to **dystonia** and **developmental delay**. - While it can cause neurological symptoms, it typically does not present with **hepatomegaly** or **Kayser-Fleischer rings** as prominent features. *Hepatitis A* - **Hepatitis A** is an acute viral infection of the liver, causing symptoms like fever, fatigue, nausea, vomiting, and **jaundice**. - However, it typically does not cause **intention tremor**, **poor scholastic performance**, or have a familial pattern suggesting an inherited neurological disorder. It also does not cause Kayser-Fleischer rings. *Huntington's chorea* - **Huntington's chorea** is an **autosomal dominant neurodegenerative disorder** characterized by **chorea**, psychiatric symptoms, and cognitive decline, typically manifesting in adulthood. - It does not present with **hepatomegaly** or **Kayser-Fleischer rings** at this age and is not associated with the constellation of liver and neurological symptoms described.

Q: A 6-year-old child is brought with high fever with rigors for 5 days with pain in right hypochondrium. On examination, the patient is anicteric and tenderness is noted in right upper quadrant. What is the best investigation for this case?

USG. ***USG*** - A **ultrasound** is the preferred initial investigation, especially in children, for evaluating abdominal pain in the **right hypochondrium** with fever. - It can effectively identify common causes like **cholecystitis**, **hepatitis**, or **liver abscess**, which fit the clinical presentation. *SGOT/LFT* - **Liver function tests (LFTs)** like SGOT/AST and SGPT/ALT provide information about liver inflammation or damage but do not help localize the pathology. - They are useful for assessing liver function but are not the primary diagnostic tool to identify the cause of the pain or fever. *CECT* - **Contrast-enhanced computed tomography (CECT)** is a more advanced imaging technique, often used after initial screening or when ultrasound findings are inconclusive. - It involves radiation exposure and contrast risks, making it less suitable as a first-line investigation for a child with these symptoms. *Serology* - **Serological tests** detect antibodies or antigens related to specific infections (e.g., viral hepatitis) but do not provide immediate anatomical information. - While they can confirm an infectious cause, they cannot identify the source of the pain or rule out other non-infectious pathologies immediately.

Q: Most common cause of cholestatic jaundice in newborn is

Biliary atresia. ***Biliary atresia*** - This is the **most common cause of cholestatic jaundice** requiring surgical intervention in otherwise healthy full-term newborns. - It involves the **progressive obliteration or absence of extrahepatic bile ducts**, leading to bile flow obstruction, conjugated hyperbilirubinemia, and ultimately liver damage if untreated. - Incidence is approximately **1 in 10,000-15,000 live births**, and early diagnosis (before 60 days of age) is critical for optimal surgical outcomes with Kasai portoenterostomy. *Neonatal hepatitis* - While it can cause **cholestatic jaundice** in newborns, biliary atresia remains the leading **surgical cause** requiring urgent intervention. - It describes a diverse group of conditions leading to inflammation of the liver, which can be **idiopathic** or caused by infections (TORCH), metabolic disorders, or genetic conditions. - Unlike biliary atresia, neonatal hepatitis may improve with supportive care and treatment of underlying causes. *Physiological* - **Physiological jaundice** is characterized by **unconjugated hyperbilirubinemia** and is typically transient, resolving without intervention. - It does not cause cholestatic jaundice, which involves **conjugated hyperbilirubinemia** and indicates an underlying pathological process. *Choledochal cyst* - A **choledochal cyst** is a congenital dilation of the bile ducts and can cause cholestatic jaundice, but it is a **rarer cause** compared to biliary atresia. - Symptoms often include an **abdominal mass**, pain, and recurrent cholangitis, which may differ from the typical presentation of early biliary atresia.

Q: Acquired megacolon in children is most commonly due to-

Bad bowel habit. ***Bad bowel habit*** - **Chronic constipation** due to poor bowel habits or stool withholding is a common cause of acquired megacolon in children. - This leads to **fecal impaction**, stretching of the rectal and sigmoid colon, and eventual loss of muscle tone. *Chagas disease* - Chagas disease, caused by *Trypanosoma cruzi*, is a significant cause of **acquired megacolon** but primarily in **endemic regions** of Latin America and is less common in children as an initial presentation of megacolon. - It leads to destruction of the **myenteric plexuses**, causing aperistalsis and dilation of the colon, which typically manifests in adulthood after a long latent period. *Psychological problems* - While psychological issues like **anxiety** or **stress** can contribute to altered bowel habits and constipation, they are usually not the **direct primary cause** of acquired megacolon without an underlying functional or behavioral component. - Psychological factors often **exacerbate** existing bowel dysfunction rather than solely initiating the anatomical changes leading to megacolon. *Hirschsprung's disease* - Hirschsprung's disease is a **congenital absence of ganglion cells** in the distal colon, leading to a functional obstruction and *proximal dilation*, which is a **congenital megacolon**, not an acquired one. - It typically presents in infancy with **failure to pass meconium** and chronic constipation from birth, differentiating it from acquired causes in older children.

Q: In a child, which of the following diseases is commonly misdiagnosed as appendicitis?

All of the options. ***All of the options*** - **Intussusception**, **lymphadenitis**, and **gastroenteritis** can all present with symptoms mimicking appendicitis in children, leading to potential misdiagnosis. - The similarities in abdominal pain, fever, and vomiting can make differentiation challenging without further diagnostic imaging or clinical evaluation. **Intussusception** - This condition involves the **telescoping of one segment of the intestine** into another, causing abdominal pain, vomiting, and sometimes a palpable mass. - While it can cause symptoms similar to appendicitis, classic signs like **currant-jelly stools** and an abdominal mass are often differentiating features. - Can present with colicky abdominal pain and guarding that mimics acute appendicitis. **Lymphadenitis (Mesenteric)** - **Mesenteric lymphadenitis** is an inflammation of the abdominal lymph nodes, often following a viral infection, causing generalized or right lower quadrant pain. - Its presentation can closely mimic appendicitis, and is one of the most common appendicitis mimics in children. - It typically lacks the progressive periumbilical pain migrating to the right lower quadrant that is typical of appendicitis, though this differentiation can be subtle. **Gastroenteritis** - **Gastroenteritis** presents with diffuse abdominal pain, vomiting, and diarrhea, which can sometimes be localized enough to suggest appendicitis, especially if pain is predominantly in the right lower quadrant. - However, the presence of significant diarrhea and more generalized abdominal discomfort often helps distinguish it from the focused pain of appendicitis. - In early presentations before diarrhea develops, differentiation can be particularly challenging.

Q: A baby with diarrhea presented with restlessness but is able to drink water. Skin turgor goes back in 2 seconds. The baby is communicating properly. What is the best management?

Plan B. ***Plan B*** - The baby shows **some signs of dehydration** (restlessness, able to drink, skin turgor goes back in 2 seconds), which indicates a need for **oral rehydration therapy (ORT)** according to WHO Plan B. - Plan B involves administering a specific amount of **Oral Rehydration Solution (ORS)** over 4 hours in a healthcare setting based on the child's weight and then reassessing the hydration status. - **Clinical features of some dehydration**: restlessness/irritability, sunken eyes, drinks eagerly/thirsty, skin pinch goes back slowly (within 2 seconds). *IV fluid therapy* - Intravenous fluid therapy is reserved for **severe dehydration (Plan C)**, characterized by lethargy or unconsciousness, inability to drink, very slow skin turgor (>2 seconds), and weak or absent pulse. - The baby is alert, able to drink, and communicating properly, so IV fluids are not indicated. *Plan A* - Plan A is for **no signs of dehydration**, where the goal is to prevent dehydration by continuing feeding, offering extra fluids, and providing education to caregivers. - The baby's restlessness and decreased skin turgor (2 seconds) indicate more than just no dehydration, requiring active rehydration with ORS. *Plan C* - Plan C is for **severe dehydration**, characterized by lethargy or unconsciousness, sunken eyes, inability to drink or drinking poorly, and skin pinch goes back very slowly (>2 seconds), necessitating urgent **intravenous fluid administration**. - The baby is restless (not lethargic), communicating properly, and able to drink, indicating this is not severe dehydration.

Q: Most common cause of significant lower GI bleeding (hematochezia) in children is

Meckel's diverticulum. ***Meckel's diverticulum*** - **Meckel's diverticulum** is the most common congenital malformation of the gastrointestinal tract and the most common cause of **painless rectal bleeding (hematochezia)** in children. - It contains **ectopic gastric or pancreatic tissue** which can cause ulceration and bleeding in adjacent healthy small bowel mucosa. *Rectal polyp* - While a cause of hematochezia in children, **rectal polyps** are typically less common than Meckel's diverticulum as the most frequent cause of significant bleeding. - They usually present with **painless, intermittent bright red blood** per rectum, often streaking the stool. *Acute gastritis* - **Acute gastritis** rarely causes significant hematochezia in children; it typically presents with **epigastric pain, nausea, and vomiting**, and if bleeding occurs, it is usually melena (black, tarry stools). - Bleeding from gastritis is often due to inflammation or ulceration in the upper GI tract, leading to digested blood in stool. *Necrotizing enterocolitis* - **Necrotizing enterocolitis** primarily affects **premature or low-birth-weight infants** and is a serious condition involving inflammation and necrosis of the bowel, often leading to bloody stools. - While it causes hematochezia, it is not the most common cause in the broader pediatric population and is typically seen in a specific demographic with other severe systemic symptoms.

Q: A 5 year old boy is detected to be HBsAg positive on two separate occasions during a screening program for hepatitis B. He is otherwise asymptomatic. Child was given three doses of recombinant hepatitis B vaccine at the age of 1 year. His mother was treated for chronic hepatitis B infection around the same time. The next relevant step for further investigating the child would be to –

Obtain HBeAg and anti-HBe levels. **Obtain HBeAg and anti–HBe levels** - Given the child is **HBsAg positive** on two separate occasions and has a mother with **chronic hepatitis B**, evaluating **HBeAg** and **anti-HBe levels** is crucial to determine if the child is in a high replicative immune tolerant phase or an immune clearance phase. - This information helps differentiate between persistent infection, risk of vertical transmission, and guides subsequent management, including the potential for antiviral therapy and monitoring requirements. *Repeat another course of Hepatitis B vaccine* - Repeating the vaccine is not indicated as the child is already **HBsAg positive**, indicating an active infection or carrier state, not a need for further immunization. - Vaccination aims to prevent infection, but in this case, the child is already confirmed to be infected. *Repeat HBsAg* - The question states the child was detected to be **HBsAg positive on two separate occasions**, making another repeat unnecessary for confirmation of infection. - The next step should aim to characterize the infection rather than re-confirm its presence. *Obtain anti HBs levels* - **Anti-HBs antibodies** indicate immunity from vaccination or resolved infection. Since the child is **HBsAg positive**, indicating active infection, anti-HBs levels would likely be negative or low and would not provide critical information about the current stage of infection. - The focus should be on characterizing the active infection, not assessing protective immunity.

Question 1

An eight month old male child is brought to the emergency with recurrent episodes of screaming and drawing up of legs. The child appears to be listless in between the attacks. Local examination of abdomen reveals feeling of emptiness in the right iliac fossa and blood stained mucus is found on the finger on rectal examination. The most probable clinical diagnosis in this child is

Accepted Answer

Acute intussusception

Answer

Rectal prolapse

Answer

Midgut volvulus

Answer

Caecal volvulus

Question 2

A child presents with itchy lesions and diarrhea and has been advised to follow a gluten-free diet. What is the most likely etiology of this condition?

Accepted Answer

Celiac disease

Answer

Whipple's disease

Answer

Crohn's disease

Answer

Dermatitis herpetiformis

Question 3

An 11-year-old boy was brought to the outpatient clinic with intention tremor and poor scholastic performance. His sister has similar complaints. On examination, hepatomegaly is seen. The eye finding is shown in the image. What is the probable diagnosis?

Accepted Answer

Wilson's disease

Answer

Glutaric aciduria

Answer

Hepatitis A

Answer

Huntington's chorea

Question 4

A 6-year-old child is brought with high fever with rigors for 5 days with pain in right hypochondrium. On examination, the patient is anicteric and tenderness is noted in right upper quadrant. What is the best investigation for this case?

Accepted Answer

USG

Answer

SGOT/LFT

Answer

CECT

Answer

Serology

Question 5

Most common cause of cholestatic jaundice in newborn is

Accepted Answer

Biliary atresia

Answer

Neonatal hepatitis

Answer

Physiological

Answer

Choledochal cyst

Question 6

Acquired megacolon in children is most commonly due to-

Accepted Answer

Bad bowel habit

Answer

Chagas disease

Answer

Psychological problems

Answer

Hirschsprung's disease

Question 7

In a child, which of the following diseases is commonly misdiagnosed as appendicitis?

Accepted Answer

All of the options

Answer

Intussusception

Answer

Lymphadenitis

Answer

Gastroenteritis

Question 8

A baby with diarrhea presented with restlessness but is able to drink water. Skin turgor goes back in 2 seconds. The baby is communicating properly. What is the best management?

Accepted Answer

Plan B

Answer

IV fluid therapy

Answer

Plan A

Answer

Plan C

Question 9

Most common cause of significant lower GI bleeding (hematochezia) in children is

Accepted Answer

Meckel's diverticulum

Answer

Rectal polyp

Answer

Acute gastritis

Answer

Necrotizing enterocolitis

Question 10

A 5 year old boy is detected to be HBsAg positive on two separate occasions during a screening program for hepatitis B. He is otherwise asymptomatic. Child was given three doses of recombinant hepatitis B vaccine at the age of 1 year. His mother was treated for chronic hepatitis B infection around the same time. The next relevant step for further investigating the child would be to –

Accepted Answer

Obtain HBeAg and anti-HBe levels

Answer

Repeat another course of Hepatitis B vaccine

Answer

Repeat HBsAg

Answer

Obtain anti HBs levels

Gastroenterology — MCQs

Gastroenterology — MCQs

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