Malabsorption Syndromes — MCQs

10 questions

A young man met with a motorbike accident and had injuries to ileum and jejunum. Therefore the entire ileum and partial jejunum were resected. Which of the following would the patient suffer from

Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?

Which of the following statements about celiac disease is false?

A 12 year old girl has history of recurrent bulky stools and abdominal pain since 3 year of age. She has moderate pallor and her weight and height are below the 3rd percentile. Which of the following is the most appropriate investigation to make a specific diagnosis?

What is a feature of short bowel syndrome?

A 55-year-old white woman has had recurrent episodes of alcohol-induced pancreatitis. Despite abstinence, the patient develops postprandial abdominal pain, bloating, weight loss despite good appetite, and bulky, foul-smelling stools. Kidney, ureter, bladder (KUB) x-ray shows pancreatic calcifications. In this patient, you should expect to find which of the following?

A 21-year-old woman comes to the physician because of a 2-month history of fatigue, intermittent abdominal pain, and bulky, foul-smelling diarrhea. She has had a 4-kg (8-lb 12-oz) weight loss during this period despite no changes in appetite. Examination of the abdomen shows no abnormalities. Staining of the stool with Sudan III stain shows a large number of red droplets. Which of the following is the most likely underlying cause of this patient’s symptoms?

Post hepatic Portal Hypertension is caused by

MRP 2 and conjugated hyperbilirubinemia associated with which of the following?

Q10

MRP2 associated with which of the following?

Malabsorption Syndromes Indian Medical PG Practice Questions and MCQs

Question 1: A young man met with a motorbike accident and had injuries to ileum and jejunum. Therefore the entire ileum and partial jejunum were resected. Which of the following would the patient suffer from

A. Vitamin B12 malabsorption due to ileal resection (Correct Answer)
B. Atrophic gastritis unrelated to resection
C. Constipation due to dietary changes
D. No significant symptoms

Explanation: **Vitamin B12 malabsorption due to ileal resection** - The **terminal ileum** is the primary site for the absorption of **vitamin B12** (cobalamin) complexed with intrinsic factor [3]. - Its resection would directly lead to the inability to absorb this vitamin, resulting in **B12 deficiency** and associated symptoms like macrocytic anemia [3]. *Atrophic gastritis unrelated to resection* - **Atrophic gastritis** is a chronic inflammatory condition of the stomach lining leading to loss of glandular tissue and often impaired production of **intrinsic factor**. - While it can cause B12 malabsorption, it is an independent condition and not a direct consequence of ileum and jejunum resection. *Constipation due to dietary changes* - Resection of the ileum and jejunum primarily impacts **nutrient absorption** and can lead to diarrhea due or **short bowel syndrome** [1], rather than constipation. - While diet changes can affect bowel habits, prolonged **severe gastrointestinal resection** is more likely to cause malabsorption-related diarrhea [1], [2]. *No significant symptoms* - The **ileum** and **jejunum** are crucial for the absorption of most nutrients, including vitamins, minerals, fats, and carbohydrates [4]. - Resection of these segments, especially a significant portion, would lead to **malabsorption syndromes** with various severe symptoms, potentially including weight loss, diarrhea, and nutritional deficiencies [1], [4].

Question 2: Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?

A. Bile salts (Correct Answer)
B. Iron
C. Copper
D. Zinc

Explanation: ***Bile salts*** - The **distal ileum** is the primary site for the active reabsorption of **bile salts** back into the enterohepatic circulation. - Their malabsorption leads to **fat malabsorption** and steatorrhea, and can lead to gallstones due to changes in bile composition. *Iron* - The majority of **iron absorption** primarily occurs in the **duodenum** and proximal jejunum, not the distal ileum. - Iron deficiency would typically result from issues higher up in the small intestine or from chronic blood loss. *Copper* - **Copper absorption** mainly occurs in the **stomach** and **duodenum**. - Deficiency typically arises from dietary inadequacy or specific genetic disorders, not distal ileal resection. *Zinc* - **Zinc absorption** occurs throughout the **small intestine**, with significant absorption in the **jejunum**. - While some zinc is absorbed in the ileum, its primary absorption site is not limited to or predominantly in the distal ileum, making malabsorption less likely with isolated distal ileum removal.

Question 3: Which of the following statements about celiac disease is false?

A. Diagnosis requires duodenal biopsy showing villous atrophy
B. Diarrhea, Malabsorption, iron deficiency anaemia
C. Celiac disease is caused by a viral infection. (Correct Answer)
D. Patients express HLA DQ2 or DQ8 haplotypes

Explanation: ### Celiac disease is caused by a viral infection - Celiac disease is an **autoimmune disorder**, not a viral infection, triggered by the ingestion of **gluten** in genetically predisposed individuals [1]. - The immune response causes inflammation and damage to the **small intestinal lining**. ### Diarrhea, Malabsorption, iron deficiency anaemia - These are **classic symptoms** and common complications of celiac disease due to the damage to the small intestinal villi, impairing nutrient absorption [1]. - **Malabsorption** leads to various deficiencies, including iron deficiency anemia [2]. ### Diagnosis requires duodenal biopsy showing villous atrophy - A definitive diagnosis typically involves an **endoscopic biopsy** of the small intestine, which reveals characteristic findings like **villous atrophy**, crypt hyperplasia, and increased intraepithelial lymphocytes [1]. - This **histological evidence** is crucial for confirming the diagnosis. ### Patients express HLA DQ2 or DQ8 haplotypes - The presence of **HLA-DQ2 or HLA-DQ8 Class II major histocompatibility complex (MHC) allelic variants** is a strong genetic predisposition for celiac disease [1]. - While necessary, these **haplotypes** are not sufficient for diagnosis, as many individuals with these genes never develop the condition.

Question 4: A 12 year old girl has history of recurrent bulky stools and abdominal pain since 3 year of age. She has moderate pallor and her weight and height are below the 3rd percentile. Which of the following is the most appropriate investigation to make a specific diagnosis?

A. Barium studies
B. Small intestinal biopsy (Correct Answer)
C. 24-hour fecal fat estimation
D. Urinary d-xylose test

Explanation: ***Small intestinal biopsy*** - This clinical presentation of **chronic bulky stools**, **growth retardation** (weight and height <3rd percentile), **pallor**, and abdominal pain since early childhood strongly suggests **celiac disease** - Small intestinal biopsy is the **gold standard for definitive diagnosis** of celiac disease, showing characteristic features: **villous atrophy**, **crypt hyperplasia**, and **increased intraepithelial lymphocytes** (Marsh classification) - While serological testing (anti-tTG IgA) is typically performed first in modern practice, among the given options, **biopsy provides the specific histological diagnosis** required - Biopsy allows differentiation from other causes of villous atrophy (tropical sprue, Giardia infection, cow's milk protein allergy) *Barium studies* - May show **non-specific findings** like dilated bowel loops, flocculation of barium, or jejunization of ileum in malabsorption - **Not diagnostic** for the specific underlying cause of malabsorption - Involves **radiation exposure** in a pediatric patient - Requires follow-up with more specific investigations for definitive diagnosis *24-hour fecal fat estimation* - Quantifies **steatorrhea** and confirms fat malabsorption (normal <7g/day in children) - Useful for **documenting the presence** of malabsorption but **does not identify the etiology** - Cannot differentiate between celiac disease, chronic pancreatitis, or other causes of malabsorption - Non-specific screening test rather than a diagnostic investigation *Urinary d-xylose test* - Assesses **small intestinal mucosal absorptive function** for carbohydrates - Abnormal in conditions affecting mucosa (celiac disease, tropical sprue, Crohn's disease) - **Not specific** for any particular disease entity - Less commonly used in modern practice due to availability of better diagnostic modalities

Question 5: What is a feature of short bowel syndrome?

A. Hypergastrinemia & high gastric secretion is seen
B. Diarrhea, dehydration and malnutrition
C. Chronic TPN dependence
D. Malabsorption leading to diarrhea, dehydration, and malnutrition. (Correct Answer)

Explanation: ***Malabsorption leading to diarrhea, dehydration, and malnutrition.*** [1], [2] - The primary characteristic of short bowel syndrome is **reduced intestinal surface area**, leading to inadequate absorption of nutrients, water, and electrolytes [1]. - This malabsorption manifests as **chronic diarrhea**, which can cause significant **dehydration** and **malnutrition** due to nutrient deficiencies [2]. *Diarrhea, dehydration and malnutrition* - While these are prominent symptoms, they are consequences of the underlying **malabsorption**, which is the fundamental process. - This option describes symptoms but doesn't fully explain the root physiological mechanism as comprehensively as the correct answer. *Chronic TPN dependence* - **Total Parenteral Nutrition (TPN)** dependence can be a severe consequence for patients with very short or severely damaged bowel segments, but it is not a feature inherent to all cases of short bowel syndrome. - Many patients can manage with oral or enteral nutrition, especially if a significant portion of the small bowel remains functional. *Hypergastrinemia & high gastric secretion is seen* - This can occur in certain cases of short bowel syndrome, particularly if there is a loss of the **duodenum** (which normally inhibits gastrin release) or if there's extensive ileal resection. - However, it's not a universal or defining feature for all patients and is secondary to the primary problem of malabsorption.

Question 6: A 55-year-old white woman has had recurrent episodes of alcohol-induced pancreatitis. Despite abstinence, the patient develops postprandial abdominal pain, bloating, weight loss despite good appetite, and bulky, foul-smelling stools. Kidney, ureter, bladder (KUB) x-ray shows pancreatic calcifications. In this patient, you should expect to find which of the following?

A. Diabetes mellitus (Correct Answer)
B. Malabsorption of fat-soluble vitamins D and K
C. Courvoisier sign
D. Positive fecal occult blood test

Explanation: Diabetes mellitus - Chronic pancreatitis, especially due to recurrent alcohol-induced episodes, often leads to the destruction of pancreatic islet cells, resulting in impaired insulin production and consequently, diabetes mellitus [1]. - The combination of pancreatic calcifications and symptoms like weight loss despite good appetite, and malabsorption due to pancreatic insufficiency, makes diabetes a strong expected complication [1]. Malabsorption of fat-soluble vitamins D and K - While chronic pancreatitis often causes steatorrhea and malabsorption of fat-soluble vitamins (A, D, E, K), the question asks what one should expect to find, and diabetes mellitus is a more direct and universally expected consequence of widespread pancreatic damage from recurrent pancreatitis [1]. - The symptoms described, such as bulky, foul-smelling stools, are indicative of fat malabsorption, which leads to deficiencies in fat-soluble vitamins, but the direct mention of diabetes mellitus reflects a more advanced stage of pancreatic destruction [2]. Positive fecal occult blood test - A positive fecal occult blood test suggests gastrointestinal bleeding, which is not a direct or typical consequence of chronic pancreatitis itself. - While complications like peptic ulcers or pancreatic cancer (a long-term risk of chronic pancreatitis) could cause GI bleeding, it's not an expected finding directly associated with the pancreatitis symptoms described. Courvoisier sign - Courvoisier sign (a palpable, non-tender gallbladder with jaundice) is typically associated with obstruction of the common bile duct due to a malignancy in the head of the pancreas or other periampullary tumors. - It is not a characteristic finding in uncomplicated chronic pancreatitis, especially without mention of jaundice.

Question 7: A 21-year-old woman comes to the physician because of a 2-month history of fatigue, intermittent abdominal pain, and bulky, foul-smelling diarrhea. She has had a 4-kg (8-lb 12-oz) weight loss during this period despite no changes in appetite. Examination of the abdomen shows no abnormalities. Staining of the stool with Sudan III stain shows a large number of red droplets. Which of the following is the most likely underlying cause of this patient’s symptoms?

A. Ulcerative colitis
B. Lactose intolerance
C. Amebiasis
D. Celiac disease (Correct Answer)
E. Carcinoid syndrome

Explanation: ***Celiac disease*** - The combination of **fatigue, abdominal pain**, weight loss, and **bulky, foul-smelling diarrhea** suggests malabsorption [1]. - **Sudan III stain** revealing red droplets indicates **steatorrhea** (fat in stool), a hallmark of malabsorption, often seen in celiac disease due to damage to the small intestinal villi from **gluten exposure** [1]. *Ulcerative colitis* - Characterized by **bloody diarrhea**, tenesmus, and urgency, which are not described in this patient. - Primarily affects the **colon** and typically does not present with significant steatorrhea [2]. *Lactose intolerance* - Causes watery diarrhea, bloating, and gas after consuming dairy products due to **lactase deficiency** [2]. - Does not typically lead to significant weight loss or steatorrhea with bulky, foul-smelling stools. *Amebiasis* - An infection with *Entamoeba histolytica* causing **bloody, mucoid diarrhea** (dysentery), abdominal pain, and fever. - While it can cause weight loss, it does not typically present with steatorrhea or bulky, foul-smelling stools, and the diarrhea is often bloody. *Carcinoid syndrome* - Presents with symptoms such as **flushing, diarrhea**, and bronchospasm, often due to serotonin overproduction. - While diarrhea is a prominent symptom, it is usually watery and secretory, not typically bulky, foul-smelling, or associated with steatorrhea.

Question 8: Post hepatic Portal Hypertension is caused by

A. Portal vein thrombosis
B. Budd-Chiari syndrome (Correct Answer)
C. Veno occlusive disease
D. Congenital hepatic fibrosis
E. Chronic hepatic venous congestion
F. Right heart failure

Explanation: ***Budd-Chiari syndrome*** - This syndrome involves **hepatic vein obstruction**, leading to **outflow blockade** from the liver, causing blood to back up into the sinusoids and portal system. - The obstruction occurs **distal to the hepatic sinusoids** but **proximal to the inferior vena cava**, classifying it as a post-hepatic cause of portal hypertension. *Portal vein thrombosis* - This condition involves a **clot in the portal vein**, which is located **before the liver sinusoids**. - It consequently causes **pre-hepatic portal hypertension**, as the blockage occurs upstream from the liver itself. [1] *Veno occlusive disease* - This condition affects the **small intrahepatic venules**, often caused by **toxins or chemotherapy**. [2] - It is considered a **sinusoidal** or **intrahepatic cause** of portal hypertension, not a post-hepatic cause affecting the main hepatic veins. [2] *Congenital hepatic fibrosis* - This is a developmental disorder characterized by **malformed portal tracts** and **fibrosis** within the liver. - It causes **intrahepatic portal hypertension** due to increased resistance to blood flow within the liver parenchyma. *Chronic hepatic venous congestion* - This refers to a general state of sustained high pressure in the hepatic veins, often due to **systemic causes**. - While it reflects impaired outflow, Budd-Chiari syndrome is the specific, acute or chronic **obstruction of the hepatic veins** themselves, making it a more precise and direct cause of post-hepatic portal hypertension. *Right heart failure* - **Right heart failure** causes systemic venous congestion, leading to increased pressure in the **inferior vena cava (IVC)** and, subsequently, the hepatic veins. [2] - This is an **extrinsic cause** of increased pressure transmitted to the hepatic veins, but the primary pathology lies within the heart, rather than an intrinsic obstruction of the hepatic veins as seen in Budd-Chiari syndrome. [2]

Question 9: MRP 2 and conjugated hyperbilirubinemia associated with which of the following?

A. Criggler Najjar syndrome type II
B. Dubin Johnson syndrome (Correct Answer)
C. Rotor syndrome
D. Criggler Najjar syndrome type I

Explanation: ***Dubin Johnson syndrome*** - It is characterized by a defect in the **MRP2 (multidrug resistance-associated protein 2)** transporter, which is responsible for the excretion of **conjugated bilirubin** and other organic anions from hepatocytes into bile. - This defect leads to the accumulation of conjugated bilirubin in the liver and its regurgitation into the bloodstream, causing **conjugated hyperbilirubinemia** [2]. *Criggler Najjar syndrome type II* - This syndrome involves a partial deficiency of **UDP-glucuronosyltransferase 1A1 (UGT1A1)**, the enzyme responsible for conjugating bilirubin [1]. - It results in primarily **unconjugated hyperbilirubinemia**, not conjugated. *Rotor syndrome* - Rotor syndrome also presents with **conjugated hyperbilirubinemia** but is characterized by impaired hepatic uptake and storage of conjugated bilirubin, rather than a defect in the MRP2 transporter. - Unlike Dubin-Johnson, it does not involve the characteristic **black liver** pigmentation. *Criggler Najjar syndrome type I* - This is a severe, complete deficiency of **UDP-glucuronosyltransferase 1A1 (UGT1A1)**, leading to profound **unconjugated hyperbilirubinemia** and often requiring phototherapy or liver transplantation [1]. - It is not associated with defects in the MRP2 transporter or conjugated bilirubin metabolism.

Question 10: MRP2 associated with which of the following?

A. Rotor syndrome
B. Dubin-Johnson syndrome (Correct Answer)
C. Crigler-Najjar syndrome
D. Gilbert syndrome

Explanation: No changes were made to the original explanation because the available references provided insufficient evidence to support the specific claims about the MRP2 gene and the characteristic 'dark liver' appearance of Dubin-Johnson syndrome. While the references discuss hyperbilirubinemia and mentions Gilbert and Crigler-Najjar syndromes [1], they do not explicitly detail the MRP2 mutation or the pathology of Dubin-Johnson and Rotor syndromes necessary for high-accuracy medical citation [2].

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