Gastroenterology Practice Questions

Q: A 7-year-old boy presents with recurrent episodes of abdominal pain, diarrhea, and failure to thrive. Laboratory findings show anti-tissue transglutaminase antibodies. What is the most likely diagnosis?

Celiac disease. ***Celiac disease*** - The constellation of **abdominal pain**, **diarrhea**, **failure to thrive**, and specifically **positive anti-tissue transglutaminase (tTG) antibodies** is highly indicative of celiac disease. - **Anti-tTG antibodies** are a sensitive and specific marker for celiac disease, which is an autoimmune disorder triggered by gluten consumption. *Crohn's disease* - While it can cause abdominal pain, diarrhea, and failure to thrive, it typically involves **transmural inflammation** and can affect any part of the gastrointestinal tract. - It is not associated with **anti-tTG antibodies**; instead, it might show elevated **ESR/CRP** and sometimes **anti-Saccharomyces cerevisiae antibodies (ASCA)**. *Ulcerative colitis* - This condition primarily presents with **bloody diarrhea** and **colonic inflammation** starting in the rectum and extending proximally. - It is also not associated with **anti-tTG antibodies** and is characterized by different inflammatory markers and endoscopic findings. *Lactose intolerance* - Primarily causes **abdominal pain**, **bloating**, and **diarrhea** after consuming dairy products due to lactase deficiency. - It does not cause **failure to thrive** or involve **anti-tTG antibodies**, and its symptoms are usually relieved by avoiding lactose.

Q: A young child presents with a palpable mass in the lower right quadrant. Imaging confirms intussusception. Which part of the intestine most commonly acts as the intussusceptum (telescoping segment)?

Ileum. ***Ileum*** - The **ileocolic region** is the most common site for intussusception in children (60-80% of cases), where the **ileum acts as the intussusceptum** (telescoping segment) that invaginates into the cecum/colon (intussuscipiens). - This is particularly true in children aged 6 months to 3 years, often linked to **hypertrophied Peyer's patches** acting as a lead point. - The classic presentation includes a **palpable "sausage-shaped" mass** in the right upper quadrant and **"currant jelly" stools**. *Duodenum* - Duodenal intussusception is **extremely rare** and accounts for less than 1% of cases. - When it occurs, it is usually associated with specific pathological lead points such as **polyps, tumors, or duplication cysts**. *Jejunum* - Jejunojejunal intussusception is possible but **much less frequent** than ileocolic type. - It typically occurs in association with a **pathological lead point** such as Meckel's diverticulum, polyp, or lymphoma. - More common in older children when a lead point is identified. *Colon* - While the colon (cecum) serves as the **receiving segment (intussuscipiens)** in the most common ileocolic type, primary **colocolic intussusception** is relatively uncommon in children. - Colocolic intussusception often suggests a **pathological lead point** such as a polyp, lymphoma, or other mass lesion.

Q: A 6-month-old infant presents with recurrent episodes of sudden-onset crying, drawing up of the legs, and currant jelly stools. What is the most likely diagnosis?

Intussusception. ***Intussusception*** - The classic triad of **sudden-onset intermittent abdominal pain** (crying and drawing up legs), **vomiting**, and **currant jelly stools** (blood and mucus) is highly indicative of intussusception. - This condition is the most common cause of **intestinal obstruction** in infants between 6 months and 3 years of age, often presenting with a **sausage-shaped abdominal mass**. *Volvulus* - Volvulus typically presents with **bilious vomiting** and **abdominal distension**, indicating intestinal obstruction and ischemia. - While it causes acute abdominal pain, the characteristic "currant jelly stools" are not typical of volvulus, and the pain is usually constant, not intermittent. *Necrotizing Enterocolitis* - NEC primarily affects **premature infants** and presents with abdominal distension, feeding intolerance, and bloody stools (often non-currant jelly). - The infant's age (6 months) makes NEC less likely, and the sudden, intermittent pain pattern is not typical. *Hirschsprung Disease* - Hirschsprung disease typically presents with **constipation** from birth, **abdominal distention**, and failure to pass meconium, rather than acute severe intermittent pain. - While it can lead to enterocolitis with bloody stools, the specific "currant jelly stool" appearance and the acute, intermittent nature of the symptoms are not characteristic.

Q: A 5-month-old infant presents with vomiting, diarrhea, and signs of dehydration. On examination, the infant has a sunken fontanelle and poor skin turgor. What is the next best step in management?

Oral rehydration solution. ***Oral rehydration solution*** - The presence of a **sunken fontanelle** and **poor skin turgor** indicates **some dehydration (moderate dehydration)** according to WHO classification. - **Oral rehydration solution (ORS)** is the **first-line treatment** for moderate dehydration as per WHO and IAP guidelines (Plan B therapy). - ORS should be given at **75 ml/kg over 4 hours** with close monitoring for improvement or deterioration. - ORS is effective, safe, and preferred over IV therapy when the child can drink and does not have severe dehydration or shock. *Intravenous fluids* - IV fluids are indicated for **severe dehydration** (lethargy, shock, inability to drink, unconsciousness) or **failure of ORS therapy**. - The clinical signs described (sunken fontanelle, poor skin turgor) without mention of shock, lethargy, or inability to drink suggest moderate, not severe dehydration. - Jumping directly to IV fluids bypasses the safer, equally effective, and less invasive ORS therapy. *Antibiotics* - Antibiotics are not indicated unless there is evidence of a **bacterial infection** such as bloody diarrhea or positive stool culture. - Most cases of acute diarrhea in infants are **viral** (rotavirus, norovirus) and self-limiting. - Routine antibiotic use may lead to resistance and disrupt normal gut flora. *Antidiarrheal medications* - **Antidiarrheal medications are contraindicated in infants** as per WHO and AAP guidelines. - They can prolong infection by preventing pathogen clearance and may cause serious complications like **ileus** or **toxic megacolon**. - Treatment focuses on rehydration, not stopping diarrhea.

Q: A 6-month-old infant presents with projectile vomiting and a palpable olive-shaped mass in the abdomen. What is the most likely diagnosis?

Pyloric stenosis. ***Pyloric stenosis*** - The classic presentation of **projectile vomiting** and a **palpable olive-shaped mass** in an infant is highly characteristic of pyloric stenosis. - This condition involves **hypertrophy of the pyloric muscle**, obstructing gastric outflow. *Gastroesophageal reflux disease* - While common in infants, **GERD** typically presents with spitting up or non-projectile vomiting and does not cause a palpable abdominal mass. - Vomiting in GERD is usually effortless and not forceful as described. *Intussusception* - **Intussusception** presents with intermittent abdominal pain, **currant jelly stools**, and sometimes a sausage-shaped mass, not an olive-shaped mass, and the vomiting is typically bilious, not projectile. - It usually occurs at a slightly older age than pyloric stenosis, often between 6 months and 3 years. *Hirschsprung disease* - **Hirschsprung disease** is characterized by **constipation** and abdominal distension, often presenting with delayed passage of meconium. - Vomiting, if present, is typically bilious or feculent, and there is no palpable olive-shaped mass associated with this condition.

Q: A previously healthy 4-year-old boy presents with sudden onset of abdominal pain and bloody diarrhea after recently returning from a camping trip. What is the most likely diagnosis?

Infectious gastroenteritis. ***Infectious gastroenteritis*** - The combination of **sudden onset bloody diarrhea** and **abdominal pain** following a **camping trip** strongly suggests bacterial gastroenteritis from contaminated food or water. - Common bacterial pathogens include **E. coli O157:H7** (from undercooked meat or contaminated water), **Shigella**, **Salmonella**, and **Campylobacter**. - The epidemiological context (camping) and clinical presentation (acute bloody diarrhea) make this the most likely diagnosis. *Appendicitis* - While appendicitis causes **abdominal pain**, it typically presents with **periumbilical pain** migrating to the right lower quadrant, **fever**, and **anorexia**. - Appendicitis does **not** present with profuse bloody diarrhea as a primary symptom. - The camping trip exposure and diarrhea-predominant presentation make infectious gastroenteritis more likely. *Hemolytic uremic syndrome* - HUS is a **complication** that can develop following infection with **E. coli O157:H7**, characterized by the triad of **thrombocytopenia**, **microangiopathic hemolytic anemia**, and **acute kidney injury**. - While bloody diarrhea is often the **initial prodrome**, HUS represents the subsequent systemic complication, not the acute gastrointestinal illness itself. - The question asks for the most likely diagnosis at this presentation, which is the infectious gastroenteritis, not yet HUS. *Intussusception* - Intussusception typically presents with **intermittent, colicky abdominal pain** (cyclical pattern every 15-20 minutes) and **'currant jelly' stool** (blood mixed with mucus). - Classic age group is **6 months to 3 years**, and patients often appear lethargic between pain episodes. - The **camping trip exposure**, **continuous bloody diarrhea** (rather than intermittent currant jelly stool), and age make infectious gastroenteritis more likely.

Q: A 7-year-old with recurrent abdominal pain, diarrhea, weight loss, joint pain, and a non-pruritic rash presents with laboratory findings of anemia, high ESR, and positive ASCA. What is the most likely diagnosis?

Crohn's disease. ***Crohn's disease*** - The combination of **recurrent abdominal pain**, **diarrhea**, **weight loss**, **joint pain**, and a **non-pruritic rash** (erythema nodosum or pyoderma gangrenosum) is highly suggestive of **Crohn's disease** in a child [1]. - The laboratory findings of **anemia**, **elevated ESR**, and especially **positive ASCA (anti-Saccharomyces cerevisiae antibodies)** strongly support this diagnosis, as ASCA is more specific to Crohn's than ulcerative colitis [1]. *Celiac disease* - While it can cause abdominal pain, diarrhea, and weight loss, celiac disease does not typically present with **joint pain** or a **non-pruritic rash** (dermatitis herpetiformis is pruritic). - It is diagnosed by **IgA anti-tissue transglutaminase (tTG)** and **anti-endomysial antibodies (EMA)**, and does not involve positive ASCA. *Henoch-Schönlein purpura* - Characterized by palpable **purpura**, **arthritis**, **abdominal pain**, and **renal involvement**, but the rash is typically purpuric and the abdominal pain is often colicky with potential for intussusception. - It is an **IgA-mediated vasculitis** and does not present with chronic diarrhea, weight loss, or positive ASCA. *Ulcerative colitis* - Presents with diarrhea (often bloody), abdominal pain, and weight loss, but **joint pain** and **rash** tend to be less common and less severe than in Crohn's [1]. - While it can also be associated with elevated ESR and anemia, **ASCA is typically negative** or weakly positive, and **p-ANCA** is more commonly positive.

Q: A newborn with persistent jaundice and clay-colored stools who is found to have conjugated hyperbilirubinemia is most likely diagnosed with what condition?

Biliary Atresia. ***Biliary Atresia*** - **Conjugated hyperbilirubinemia** in a newborn with **persistent jaundice** and **clay-colored stools** is the classic presentation of biliary atresia. - The absence of bile flow into the intestine due to blocked bile ducts causes the stools to lose their normal color and bilirubin to accumulate in the blood. *Physiological Jaundice* - This is a **common, transient** condition in newborns, characterized by **unconjugated hyperbilirubinemia**. - It resolves spontaneously and typically presents with **normal stool color** as bile flow is unimpaired. *Breast Milk Jaundice* - This condition is also characterized by **unconjugated hyperbilirubinemia** and is generally benign. - While it can persist, it does not typically cause **clay-colored stools** or significant conjugated hyperbilirubinemia. *Hemolytic Disease of the Newborn* - This condition typically presents with **unconjugated hyperbilirubinemia** due to increased red blood cell breakdown. - Stool color would generally be normal, and there would be no direct obstruction of bile flow.

Question 1

A 3-year-old child is brought to the clinic with a history of constipation, abdominal pain, and irritability. Physical examination reveals a palpable abdominal mass. What is the most appropriate next step in management?

Accepted Answer

Abdominal ultrasound

Answer

Barium enema

Answer

Stool softeners

Answer

CT scan of the abdomen

Question 2

A 7-year-old boy presents with recurrent episodes of abdominal pain, diarrhea, and failure to thrive. Laboratory findings show anti-tissue transglutaminase antibodies. What is the most likely diagnosis?

Accepted Answer

Celiac disease

Answer

Crohn's disease

Answer

Ulcerative colitis

Answer

Lactose intolerance

Question 3

A 6-year-old boy presents with fever, abdominal pain, and a palpable mass in the left lower quadrant. An abdominal ultrasound reveals intussusception. What is the most appropriate initial management?

Accepted Answer

Intravenous fluids

Answer

Pneumatic (air) enema reduction under fluoroscopic guidance

Answer

Surgical intervention

Answer

Observation

Question 4

A young child presents with a palpable mass in the lower right quadrant. Imaging confirms intussusception. Which part of the intestine most commonly acts as the intussusceptum (telescoping segment)?

Accepted Answer

Ileum

Answer

Duodenum

Answer

Jejunum

Answer

Colon

Question 5

A 6-month-old infant presents with recurrent episodes of sudden-onset crying, drawing up of the legs, and currant jelly stools. What is the most likely diagnosis?

Accepted Answer

Intussusception

Answer

Volvulus

Answer

Necrotizing Enterocolitis

Answer

Hirschsprung Disease

Question 6

A 5-month-old infant presents with vomiting, diarrhea, and signs of dehydration. On examination, the infant has a sunken fontanelle and poor skin turgor. What is the next best step in management?

Accepted Answer

Oral rehydration solution

Answer

Intravenous fluids

Answer

Antibiotics

Answer

Antidiarrheal medications

Question 7

A 6-month-old infant presents with projectile vomiting and a palpable olive-shaped mass in the abdomen. What is the most likely diagnosis?

Accepted Answer

Pyloric stenosis

Answer

Gastroesophageal reflux disease

Answer

Intussusception

Answer

Hirschsprung disease

Question 8

A previously healthy 4-year-old boy presents with sudden onset of abdominal pain and bloody diarrhea after recently returning from a camping trip. What is the most likely diagnosis?

Accepted Answer

Infectious gastroenteritis

Answer

Appendicitis

Answer

Hemolytic uremic syndrome

Answer

Intussusception

Question 9

A 7-year-old with recurrent abdominal pain, diarrhea, weight loss, joint pain, and a non-pruritic rash presents with laboratory findings of anemia, high ESR, and positive ASCA. What is the most likely diagnosis?

Accepted Answer

Crohn's disease

Answer

Celiac disease

Answer

Henoch-Schönlein purpura

Answer

Ulcerative colitis

Question 10

A newborn with persistent jaundice and clay-colored stools who is found to have conjugated hyperbilirubinemia is most likely diagnosed with what condition?

Accepted Answer

Biliary Atresia

Answer

Physiological Jaundice

Answer

Breast Milk Jaundice

Answer

Hemolytic Disease of the Newborn

Gastroenterology — MCQs

Gastroenterology — MCQs

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