Gastroenterology Practice Questions

Q: A 30-year-old patient presents with loose stools, lower abdominal pain, weight loss, diarrhea and passage of blood and mucus. On sigmoidoscopy this is the presentation of the patient. All of the following statements regarding this condition are true except:

This condition is associated with APC gene of chromosome 4. ***This condition is associated with APC gene of chromosome 4*** - The APC gene is located on **chromosome 5q21-q22**, not chromosome 4. - Mutations in the **APC gene** are responsible for **Familial Adenomatous Polyposis (FAP)**. *More than 100 colonic adenomas are diagnostic of this condition* - The presence of **more than 100 colonic adenomas** (often hundreds to thousands) is the diagnostic criterion for **Familial Adenomatous Polyposis (FAP)**. - The image provided shows a colon segment densely packed with numerous polyps, consistent with FAP. *Associated with ampullary carcinoma* - Patients with FAP have an increased risk of developing **extracolonic manifestations**, including **duodenal adenomas** and **ampullary carcinomas**. - This association is a significant concern in FAP management due to the aggressive nature of these tumors. *This condition is associated with benign mesodermal tumors such as desmoid tumors and osteomas* - **Gardner syndrome**, a phenotypic variant of FAP, is characterized by colonic polyposis along with **extra-intestinal manifestations**, including **osteomas** (especially of the skull and mandible) and **desmoid tumors**. - Desmoid tumors are locally aggressive fibroblast proliferations, often occurring in the abdominal wall or mesentery in FAP patients. *Prophylactic colectomy is recommended due to nearly 100% risk of colorectal cancer* - Patients with FAP have a **nearly 100% lifetime risk** of developing colorectal cancer if untreated. - **Prophylactic colectomy** (total or subtotal) is the standard of care, typically performed in late adolescence or early adulthood. - Surgical options include **total proctocolectomy with ileal pouch-anal anastomosis (IPAA)** or **subtotal colectomy with ileorectal anastomosis**.

Q: All of the following statements regarding this picture are true except:

They are a result of tractional force. **They are a result of tractional force** - Diverticula as visualized in the image are **pulsion diverticula**, formed due to increased intraluminal pressure pushing the mucosa through weak points in the muscular wall. - **Traction diverticula** are true diverticula involving all layers of the bowel wall, and are typically caused by inflammation or scarring pulling the bowel wall outwards (e.g., in tuberculosis or histoplasmosis near the esophagus), which is not the mechanism for colonic diverticula shown. *False diverticulum* - The image depicts multiple outpouchings, which are characteristic of **false diverticula** (pseudodiverticula). - These diverticula involve only the **mucosa and submucosa** herniating through the muscular layer, lacking a complete muscular coat. *Most common site for this defect is sigmoid colon* - **Colonic diverticula** are most commonly found in the **sigmoid colon** due to its smaller diameter and higher intraluminal pressure, which predisposes it to outpouching. - The characteristic appearance of multiple small outpouchings in the image suggests colonic diverticulosis, consistent with the sigmoid colon being the primary location. *High fiber diet will reduce the incidence of this defect* - A **low-fiber diet** is considered a major risk factor for developing diverticulosis, as it leads to harder stools and increased intraluminal pressure. - Conversely, a **high-fiber diet** promotes softer stools, reduces intracolonic pressure, and is therefore believed to **reduce the incidence** and progression of diverticular disease. *Asymptomatic in majority of cases* - **Diverticulosis** (the presence of diverticula) is asymptomatic in approximately **70-80% of cases**. - Most patients are diagnosed incidentally during colonoscopy or imaging performed for other reasons. - Only a minority develop complications such as diverticulitis, bleeding, or perforation.

Q: The following pus was drained from a liver abscess. Which complication(s) is/are seen with this condition?

All of the above. ***All of the above*** - All listed complications, including **hepatic encephalopathy**, **cardiac tamponade**, **retroperitoneal abscess**, and **pleural effusion**, are potential complications of a liver abscess. - The type of complication often depends on the **location** and **etiology** of the abscess, as well as the host's immune status. *Hepatic encephalopathy* - This can occur if the liver damage from the abscess is severe enough to impair its **detoxification function**, leading to accumulation of toxins like **ammonia**. - While not a direct mechanical complication, severe liver dysfunction post-abscess can precipitate this neurological condition. *Cardiac tamponade* - A liver abscess can rupture into the **pericardial sac**, especially if the abscess is located in the left lobe and close to the diaphragm, leading to **cardiac tamponade**. - This life-threatening condition results from fluid accumulation around the heart, impairing its ability to pump blood. *Retroperitoneal abscess* - A liver abscess, particularly those located on the posterior aspect or inferiorly, can **rupture** or *extend* into the **retroperitoneal space**. - This can lead to a secondary retroperitoneal abscess, causing further severe infection and complications. *Pleural effusion* - The most common complication of liver abscess, occurring in **10-20% of cases**, especially with **right lobe abscesses**. - Results from **diaphragmatic irritation** or direct **rupture** through the diaphragm into the pleural space, which can progress to empyema if infected.

Q: The following pus was drained from a liver abscess. Diagnosis is:

Amoebic liver abscess. ***Amoebic liver abscess*** - The image shows a reddish-brown, thick, and viscous fluid, often described as **"anchovy paste"** or **"chocolate sauce"** like pus, which is highly characteristic of an amoebic liver abscess. - This appearance results from enzymatic liquefaction of liver tissue by *Entamoeba histolytica*, mixed with blood and cellular debris. *Pyogenic liver abscess* - Pyogenic abscesses typically contain **creamy, yellowish-green pus** that may be foul-smelling, depending on the bacterial etiology. - The pus from a pyogenic abscess would not have the characteristic reddish-brown, "anchovy paste" appearance seen in the image. *Hydatid cyst* - Hydatid cysts contain clear, **"water-like" fluid** (cyst fluid) and often "daughter cysts" or **hydatid sand**, which are distinctly different from the thick, hemorrhagic pus shown. - The appearance in the image is not consistent with the sterile, clear fluid typically aspirated from an intact hydatid cyst. *Tuberculosis abscess* - TB liver abscesses typically contain **caseous necrotic material** that is thick and whitish-yellow, not the characteristic reddish-brown "anchovy paste" appearance. - TB abscesses are usually associated with systemic TB symptoms and multiple small lesions rather than a single large abscess. *Cavernous hemangioma* - A cavernous hemangioma is a **benign vascular tumor** filled with blood, not pus. - Aspiration would yield **blood**, not the thick, reddish-brown exudate characteristic of an abscess.

Q: All investigations should be done in this case except:

HIDA scan. ***HIDA scan*** - A HIDA scan evaluates **gallbladder function** and patency of the **biliary system**, which is unrelated to the pathophysiology of **Budd-Chiari syndrome** (hepatic venous outflow obstruction suggested by abdominal distension and prominent veins). - Its primary use is in diagnosing acute cholecystitis, chronic cholecystitis, or biliary obstruction, which are not suggested by the presented image. *Adenosine deaminase* - This is an important marker for **tuberculous peritonitis**, which can present with ascites and abdominal distension, mimicking features of Budd-Chiari in initial stages. - While not directly diagnostic of Budd-Chiari, it's a common investigation to **rule out other causes** of ascites, which are frequently considered in differential diagnosis. *Serum albumin* - Low serum **albumin levels** are indicative of severe liver dysfunction or malnutrition, both of which can be seen in advanced liver disease due to Budd-Chiari syndrome. - It reflects the liver's synthetic capacity and helps assess the **severity of liver damage** and prognosis. *Hepatic venography* - This is considered the **gold standard** for diagnosing Budd-Chiari syndrome, as it directly visualizes the **hepatic veins** and inferior vena cava. - It can identify the site and extent of obstruction, thus confirming the diagnosis suggested by the prominent abdominal veins and acute abdominal distension, which are classic signs of Budd-Chiari. *Doppler ultrasound of hepatic veins* - This is the **initial screening investigation** of choice for Budd-Chiari syndrome, as it can demonstrate reduced or absent flow in hepatic veins and is non-invasive. - It has high sensitivity and specificity for detecting hepatic venous outflow obstruction and can show characteristic findings like reversed flow in portal vein and caudate lobe hypertrophy.

Q: A 25 -year-old shepherd presents with continuous discomfort in right hypochondrium and on examination shows presence of enlarged liver 8 cm below costal margins. The probable diagnosis is:

Hydatid cyst. ***Hydatid cyst*** - The patient's occupation as a **shepherd** points to an increased risk of exposure to **Echinococcus granulosus**, the parasite responsible for hydatid cysts. - Hydatid cysts are typically **space-occupying lesions** in the liver, which can cause continuous discomfort due to mass effect and lead to hepatomegaly. *Amebic liver abscess* - While amebic liver abscesses can cause right hypochondrial pain and hepatomegaly, they are typically associated with a history of **dysentery** or travel to endemic areas, and not specifically with animal exposure. - These abscesses often present with fever and leukocytosis, which are not mentioned here. *Pyogenic liver abscess* - Pyogenic liver abscesses usually present with acute symptoms such as **high fever**, chills, and severe abdominal pain. - They are often associated with underlying infections like **cholangitis** or diverticulitis, which are not suggested by the patient's history. *Hepatic adenoma* - Hepatic adenomas are **benign tumors** of the liver, more common in women using oral contraceptives, and often discovered incidentally. - While they can cause pain if large or if there is hemorrhage, the patient's occupation and continuous discomfort make a parasitic etiology more likely. *Hepatocellular carcinoma* - HCC typically occurs in patients with **chronic liver disease** (cirrhosis from hepatitis B/C, alcohol) or in older age groups. - The **young age** (25 years) and absence of risk factors make this diagnosis unlikely. - The occupational history strongly favors a parasitic etiology.

Question 1

A 34-year-old woman is evaluated for a 4-month history of fatigue, pallor, and exertional dyspnea. She has a history of systemic lupus erythematosus managed with hydroxychloroquine. Laboratory results show hemoglobin 7.8 g/dL, MCV 88 fL, reticulocyte count 8.2% (corrected reticulocyte index 3.9), total bilirubin 3.4 mg/dL (indirect 2.9 mg/dL), LDH 520 U/L, and haptoglobin less than 10 mg/dL. Urinalysis reveals 1+ proteinuria with no RBC casts. Direct antiglobulin test (DAT) is positive for IgG. Which of the following is the most appropriate first-line treatment?

Accepted Answer

Initiate high-dose prednisone at 1 mg/kg/day

Answer

Schedule urgent plasmapheresis to remove circulating antibodies

Answer

Transfuse packed red blood cells and add folic acid supplementation

Answer

Start rituximab infusion as first-line immunosuppressive therapy

Answer

Initiate eculizumab to block terminal complement activation

Question 2

A 67-year-old woman with a history of hypertension and type 2 diabetes presents to the emergency department with 3 hours of epigastric discomfort, diaphoresis, and mild dyspnea. She denies chest pain. Her blood pressure is 148/92 mmHg, heart rate 98 bpm, respiratory rate 20/min, and oxygen saturation 94% on room air. ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. Troponin I is 2.4 ng/mL (reference <0.04). The cath lab is available. Which of the following is the most appropriate next step in management?

Accepted Answer

Administer aspirin and ticagrelor, then proceed to emergent percutaneous coronary intervention

Answer

Administer IV morphine, nitroglycerin, and arrange urgent echocardiography

Answer

Administer aspirin, start IV heparin, and arrange stress testing within 24 hours

Answer

Administer IV alteplase and admit to the coronary care unit for monitoring

Answer

Obtain serial troponins every 3 hours and repeat ECG before deciding on intervention

Question 3

A 45-year-old woman presents with a 6-week history of fatigue, pallor, and jaundice. She has no significant past medical history and takes no medications. Laboratory results show: hemoglobin 7.2 g/dL, MCV 92 fL, reticulocyte count 8%, total bilirubin 3.8 mg/dL (indirect 3.1 mg/dL), LDH 780 U/L, haptoglobin undetectable, and platelet count 48,000/µL. A peripheral blood smear is shown above, demonstrating schistocytes and helmet cells consistent with microangiopathic hemolytic anemia. Direct antiglobulin test (DAT) is negative. Which of the following is the most likely underlying mechanism responsible for this patient's anemia?

Accepted Answer

Mechanical fragmentation of red blood cells within small vessel thrombi

Answer

Antibody-mediated destruction of red blood cells by splenic macrophages

Answer

Impaired globin chain synthesis leading to ineffective erythropoiesis

Answer

Decreased erythropoietin production due to subclinical renal insufficiency

Answer

Intravascular hemolysis triggered by complement activation on the red cell surface

Question 4

A 55-year-old man with a 30-pack-year smoking history presents with progressive dyspnea over 3 years, now limiting him to walking less than one block (mMRC grade 3; CAT score 24). He has a chronic productive cough. He is not currently on any maintenance inhaler therapy and uses only a short-acting beta-agonist as needed. Spirometry shows a post-bronchodilator FEV1/FVC of 0.58, FEV1 of 44% of predicted, and FVC of 76% of predicted, consistent with an obstructive pattern and scooped expiratory limb on the flow-volume loop. His blood eosinophil count is 320 cells/µL. He has had two exacerbations requiring oral steroids in the past year but no hospitalizations. Which of the following is the most appropriate change to his maintenance therapy?

Accepted Answer

Add an inhaled corticosteroid plus a long-acting beta-agonist combination inhaler and a long-acting muscarinic antagonist

Answer

Add inhaled corticosteroid monotherapy and schedule pulmonary rehabilitation

Answer

Add a long-acting muscarinic antagonist alone, given that dual bronchodilation is preferred over triple therapy when eosinophil counts are below 100 cells/µL

Answer

Initiate daily oral prednisone at 10 mg and add a long-acting beta-agonist

Answer

Add a phosphodiesterase-4 inhibitor as monotherapy and refer for lung volume reduction surgery evaluation

Question 5

A 30-year-old patient presents with loose stools, lower abdominal pain, weight loss, diarrhea and passage of blood and mucus. On sigmoidoscopy this is the presentation of the patient. All of the following statements regarding this condition are true except:

Accepted Answer

This condition is associated with APC gene of chromosome 4

Answer

More than 100 colonic adenomas are diagnostic of this condition

Answer

Associated with ampullary carcinoma

Answer

This condition is associated with benign mesodermal tumors such as desmoid tumors and osteomas

Answer

Prophylactic colectomy is recommended due to nearly 100% risk of colorectal cancer

Question 6

All of the following statements regarding this picture are true except:

Accepted Answer

They are a result of tractional force

Answer

False diverticulum

Answer

Most common site for this defect is sigmoid colon

Answer

High fiber diet will reduce the incidence of this defect

Answer

Asymptomatic in majority of cases

Question 7

The following pus was drained from a liver abscess. Which complication(s) is/are seen with this condition?

Accepted Answer

All of the above

Answer

Hepatic encephalopathy

Answer

Cardiac tamponade

Answer

Retroperitoneal abscess

Answer

Pleural effusion

Question 8

The following pus was drained from a liver abscess. Diagnosis is:

Accepted Answer

Amoebic liver abscess

Answer

Pyogenic liver abscess

Answer

Hydatid cyst

Answer

Cavernous hemangioma

Answer

Tuberculosis abscess

Question 9

All investigations should be done in this case except:

Accepted Answer

HIDA scan

Answer

Adenosine deaminase

Answer

Serum albumin

Answer

Hepatic venography

Answer

Doppler ultrasound of hepatic veins

Question 10

A 25 -year-old shepherd presents with continuous discomfort in right hypochondrium and on examination shows presence of enlarged liver 8 cm below costal margins. The probable diagnosis is:

Accepted Answer

Hydatid cyst

Answer

Amebic liver abscess

Answer

Pyogenic liver abscess

Answer

Hepatic adenoma

Answer

Hepatocellular carcinoma

Gastroenterology — MCQs

Gastroenterology — MCQs

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