A patient presents to the OPD with recurrent diarrhea, abdominal pain, and foul-smelling stools. The colonoscopy reveals the following findings. What is the most likely diagnosis?
Q1002
A patient underwent a gastrectomy. Which vitamin replacement is required?
Q1003
Mark the correct statement regarding inflammatory bowel disease.
Q1004
A 24-year-old woman presents to her primary care physician with a longstanding history of diarrhea. She reports recurrent, foul-smelling, loose stools and a 35 lb weight loss over the past 3 years. She also states that two months ago, she developed an "itchy, bumpy" rash on her elbows and forearms which has since resolved. She denies recent camping trips or travel outside of the country. On physical exam she appears thin, her conjunctiva and skin appear pale, and her abdomen is mildly distended. Which of the following tests would confirm this patient's diagnosis?
Q1005
A 54-year-old man presents to the clinic for epigastric discomfort during the previous month. He states he has not vomited, but reports of having epigastric pain that worsens after most meals. The patient states that his stool “looks black sometimes.” The patient does not report of any weight loss. He has a past medical history of gastroesophageal reflux disease, diabetes mellitus, peptic ulcer disease, and Crohn’s disease. The patient takes over-the-counter ranitidine, and holds prescriptions for metformin and infliximab. The blood pressure is 132/84 mm Hg, the heart rate is 64/min, the respiratory rate is 14/min, and the temperature is 37.3°C (99.1°F). On physical examination, the abdomen is tender to palpation in the epigastric region. Which of the following is the most appropriate next step to accurately determine the diagnosis of this patient?
Q1006
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?
Q1007
A 45-year-old woman has a history of mild epigastric pain, which seems to have gotten worse over the last month. Her pain is most severe several hours after a meal and is somewhat relieved with over-the-counter antacids. The patient denies abnormal tastes in her mouth or radiating pain. She does not take any other over-the-counter medications. She denies bleeding, anemia, or unexplained weight loss, and denies a family history of gastrointestinal malignancy. Which of the following is the best next step in the management of this patient?
Q1008
A 48-year-old Caucasian woman presents to her primary care provider complaining about difficulties while swallowing with fatigability and occasional palpitations for the past few weeks. Her personal history is relevant for bariatric surgery a year ago and a long list of allergies which includes peanuts, penicillin, and milk protein. Physical examination is unremarkable except for pale skin and mucosal surfaces, koilonychia, and glossitis. Which of the following descriptions would you expect to find in an endoscopy?
Q1009
True about Crohn's disease except
Q1010
Which of the following is included in Celiac sprue diet?
Gastroenterology Indian Medical PG Practice Questions and MCQs
Question 1001: A patient presents to the OPD with recurrent diarrhea, abdominal pain, and foul-smelling stools. The colonoscopy reveals the following findings. What is the most likely diagnosis?
A. Pseudomembranous colitis (Correct Answer)
B. FAP (Familial Adenomatous Polyposis)
C. Ulcerative colitis
D. Acute gastritis
Explanation: ***Pseudomembranous colitis***
- The image clearly shows **yellowish-white plaques or pseudomembranes** scattered over the inflamed colonic mucosa, which are characteristic endoscopic findings of **pseudomembranous colitis**.
- The clinical symptoms of **recurrent diarrhea**, **abdominal pain**, and **foul-smelling stools** are consistent with this diagnosis, often caused by *Clostridioides difficile* infection.
*FAP (Familial Adenomatous Polyposis)*
- FAP is characterized by hundreds to thousands of **adenomatous polyps** throughout the colon, usually **smaller and more uniform** in appearance than the pseudomembranes seen here.
- While it can cause diarrhea and abdominal pain, the endoscopic appearance of discrete polyps rather than diffuse pseudomembranes differentiates it from the image shown.
*Ulcerative colitis*
- Ulcerative colitis typically presents with **continuous inflammation** of the colon, often involving **ulcerations, friability, and loss of haustra**, without the distinct pseudomembranes.
- Symptoms usually include **bloody diarrhea** and tenesmus, which differ from the foul-smelling stools mentioned.
*Acute gastritis*
- Acute gastritis is an inflammation of the **stomach lining**, not the colon, and would not be diagnosed via colonoscopy.
- Symptoms are usually upper GI-related, such as **epigastric pain, nausea, and vomiting**, not recurrent diarrhea and foul-smelling stools.
Question 1002: A patient underwent a gastrectomy. Which vitamin replacement is required?
A. Vitamin A
B. Vitamin C
C. Vitamin D
D. Vitamin B12 (Correct Answer)
Explanation: ***Vitamin B12***
- **Gastrectomy** removes all or part of the stomach, which is the site of **intrinsic factor** production by parietal cells.
- Intrinsic factor is essential for the absorption of **Vitamin B12** (cobalamin) in the terminal ileum; without it, severe B12 deficiency will develop [1].
*Vitamin A*
- Vitamin A (retinol) is a **fat-soluble vitamin** primarily absorbed in the small intestine, and its absorption is generally not directly affected by gastrectomy.
- Deficiency is usually linked to malabsorption syndromes affecting the small intestine or severe hepatic dysfunction.
*Vitamin C*
- Vitamin C (ascorbic acid) is a **water-soluble vitamin** absorbed in the small intestine, and its absorption is largely independent of gastric function.
- While gastrectomy might impact overall nutrient intake, there's no specific mechanism linking it directly to Vitamin C malabsorption.
*Vitamin D*
- Vitamin D is a **fat-soluble vitamin** absorbed in the small intestine, and its absorption is primarily dependent on the presence of bile salts and an intact small bowel.
- Gastrectomy does not directly impair Vitamin D absorption, although general nutritional deficiencies can occur if dietary intake is insufficient post-surgery.
Question 1003: Mark the correct statement regarding inflammatory bowel disease.
A. Skip lesions are present in Crohn's disease (Correct Answer)
B. Inflammatory bowel disease doesn't have a genetic predisposition
C. Crohn's is curable through surgical resection of the affected segment
D. Mucosal layers are involved in Crohn's while transmural involvement seen in ulcerative colitis
Explanation: ***Skip lesions are present in Crohn's disease***
- **Skip lesions** refer to the characteristic patchy, discontinuous areas of inflammation seen in **Crohn's disease**, where affected segments of the bowel are separated by healthy areas.
- This feature is a key differentiator from ulcerative colitis, which typically exhibits **continuous inflammation**.
*Inflammatory bowel disease doesn't have a genetic predisposition*
- **Genetic predisposition** plays a significant role in both Crohn's disease and ulcerative colitis, with multiple genes identified that increase susceptibility.
- A family history of IBD is a well-established risk factor, indicating its genetic component.
*Crohn's is curable through surgical resection of the affected segment*
- Crohn's disease is a **chronic, relapsing condition** that can affect any part of the gastrointestinal tract, and while surgery can remove affected segments, it is not curative.
- Disease often **recurs in other parts** of the GI tract even after surgical resection.
*Mucosal layers are involved in Crohn's while transmural involvement seen in ulcerative colitis*
- This statement is incorrect; **Crohn's disease** is characterized by **transmural inflammation** (involving all layers of the bowel wall).
- **Ulcerative colitis** primarily affects the **mucosal and submucosal layers** of the large intestine.
Question 1004: A 24-year-old woman presents to her primary care physician with a longstanding history of diarrhea. She reports recurrent, foul-smelling, loose stools and a 35 lb weight loss over the past 3 years. She also states that two months ago, she developed an "itchy, bumpy" rash on her elbows and forearms which has since resolved. She denies recent camping trips or travel outside of the country. On physical exam she appears thin, her conjunctiva and skin appear pale, and her abdomen is mildly distended. Which of the following tests would confirm this patient's diagnosis?
A. Stool test for ova and parasites
B. Serum anti-tissue transglutaminase antibody assay
C. Stool guaiac test
D. Stool culture
E. Small bowel endoscopy and biopsy (Correct Answer)
Explanation: ***Small bowel endoscopy and biopsy***
- This patient's symptoms of **chronic diarrhea**, **weight loss**, **anemia** (pale conjunctiva/skin), and a history of a **pruritic rash on elbows and forearms** (suggestive of **dermatitis herpetiformis**) are highly indicative of **celiac disease**.
- While initial screening with **serum anti-tissue transglutaminase antibody (tTG-IgA)** is appropriate, **definitive diagnosis of celiac disease requires small bowel biopsy** showing characteristic changes like **villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes** [1].
*Serum anti-tissue transglutaminase antibody assay*
- This is an **excellent screening test** for celiac disease and is typically the first step.
- However, it is an **antibody test** and requires **confirmatory biopsy** for a definitive diagnosis, especially before initiating a lifelong gluten-free diet.
*Stool test for ova and parasites*
- While chronic diarrhea can be caused by **parasitic infections** (e.g., Giardia), the patient's long history, significant weight loss, anemia, and characteristic rash make **celiac disease a more likely diagnosis**.
- She also denies recent camping or travel, making parasitic infections less likely.
*Stool culture*
- A **stool culture** is used to identify **bacterial pathogens** (e.g., Salmonella, Shigella, Campylobacter) causing acute or chronic infectious diarrhea.
- The patient's presentation with a **long-standing history**, associated **rash**, and **malabsorption symptoms** is not typical of bacterial enteritis.
*Stool guaiac test*
- A **stool guaiac test** (or fecal occult blood test) detects **blood in the stool**, which can indicate gastrointestinal bleeding.
- While some GI conditions can cause bleeding, it is not the primary diagnostic tool for celiac disease or for identifying the cause of chronic malabsorptive diarrhea.
Question 1005: A 54-year-old man presents to the clinic for epigastric discomfort during the previous month. He states he has not vomited, but reports of having epigastric pain that worsens after most meals. The patient states that his stool “looks black sometimes.” The patient does not report of any weight loss. He has a past medical history of gastroesophageal reflux disease, diabetes mellitus, peptic ulcer disease, and Crohn’s disease. The patient takes over-the-counter ranitidine, and holds prescriptions for metformin and infliximab. The blood pressure is 132/84 mm Hg, the heart rate is 64/min, the respiratory rate is 14/min, and the temperature is 37.3°C (99.1°F). On physical examination, the abdomen is tender to palpation in the epigastric region. Which of the following is the most appropriate next step to accurately determine the diagnosis of this patient?
A. Treat with PPI, clarithromycin, and amoxicillin before doing lab and imaging tests
B. Urea breath testing
C. Serology for Helicobacter pylori
D. CT abdomen
E. Endoscopy with biopsy (Correct Answer)
Explanation: ***Endoscopy with biopsy***
- Given the patient's age (>50 years), new-onset epigastric pain, history of **peptic ulcer disease**, and "black sometimes" stools suggesting **melena** or **upper gastrointestinal bleeding**, an endoscopy with biopsy is crucial [1].
- This procedure allows direct visualization of the esophageal, gastric, and duodenal mucosa, enabling identification of ulcers, erosions, or masses, and tissue collection for **histopathological examination** (e.g., for *H. pylori* infection, malignancy, or Crohn's disease involvement) [1].
*Treat with PPI, clarithromycin, and amoxicillin before doing lab and imaging tests*
- This approach, known as **"triple therapy,"** is a treatment for **H. pylori infection**, but it should not be initiated without a confirmed diagnosis in this patient presenting with alarm symptoms [2].
- Doing so without a prior diagnosis could mask underlying pathology, such as **malignancy**, and delay appropriate treatment.
*Urea breath testing*
- **Urea breath testing** is a non-invasive method to detect active *H. pylori* infection [2].
- While useful, it does not allow for direct visualization of the mucosa or biopsy collection, which is essential given the patient's **alarm features** like age and potential bleeding [2].
*Serology for Helicobacter pylori*
- **H. pylori serology** detects antibodies to *H. pylori*, indicating past or present infection [2].
- It cannot differentiate between active and past infection and, importantly, does not provide information about the **mucosal integrity** or allow for biopsy of suspicious lesions [2].
*CT abdomen*
- A **CT scan of the abdomen** can visualize abdominal organs and detect masses or significant inflammation.
- However, it is not the primary diagnostic tool for evaluating the **upper gastrointestinal mucosa** and cannot directly identify ulcers, erosions, or provide tissue for biopsy in the same way an endoscopy can.
Question 1006: 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 1007: A 45-year-old woman has a history of mild epigastric pain, which seems to have gotten worse over the last month. Her pain is most severe several hours after a meal and is somewhat relieved with over-the-counter antacids. The patient denies abnormal tastes in her mouth or radiating pain. She does not take any other over-the-counter medications. She denies bleeding, anemia, or unexplained weight loss, and denies a family history of gastrointestinal malignancy. Which of the following is the best next step in the management of this patient?
A. Barium swallow
B. Urease breath test (Correct Answer)
C. Esophageal pH monitoring
D. Empiric proton pump inhibitor therapy
E. Upper endoscopy with biopsy of gastric mucosa
Explanation: ***Urease breath test***
- The patient's symptoms of **epigastric pain** that is worse several hours after a meal and relieved by antacids are highly suggestive of a **peptic ulcer**.
- Given her age (45) and the absence of alarm symptoms (bleeding, weight loss, dysphagia), testing for **_H. pylori_ infection** with a non-invasive method like the **urease breath test** [1] is the most appropriate initial step.
- Identifying and eradicating _H. pylori_ is the cornerstone of therapy for peptic ulcers to relieve symptoms and prevent recurrence [1].
*Barium swallow*
- A **barium swallow** is primarily used to evaluate **structural abnormalities** of the esophagus, stomach, and duodenum.
- It is less effective for diagnosing **mucosal pathology** like peptic ulcers or _H. pylori_ infection compared to endoscopy or breath tests.
*Esophageal pH monitoring*
- **Esophageal pH monitoring** is the gold standard for diagnosing **gastroesophageal reflux disease (GERD)**.
- The patient's symptoms are more consistent with peptic ulcer disease, especially the pain pattern and relief with antacids, rather than typical GERD symptoms like heartburn or regurgitation.
*Empiric proton pump inhibitor therapy*
- While empiric PPI therapy can be considered for **GERD** or **dyspepsia**, it's generally not the first line when **_H. pylori_** is a strong possibility, especially in a patient with symptoms suggestive of a peptic ulcer.
- Identifying and eradicating _H. pylori_ is crucial for ulcer healing and preventing recurrence, and this would be missed with just empiric PPI therapy [1].
*Upper endoscopy with biopsy of gastric mucosa*
- **Upper endoscopy** is indicated when **alarm symptoms** (e.g., GI bleeding, unexplained weight loss, dysphagia, anemia) [2] are present, or in older patients (>60 years) with new-onset dyspepsia.
- For a 45-year-old with non-alarming symptoms, a **non-invasive _H. pylori_ test** is preferred initially before proceeding to endoscopy.
Question 1008: A 48-year-old Caucasian woman presents to her primary care provider complaining about difficulties while swallowing with fatigability and occasional palpitations for the past few weeks. Her personal history is relevant for bariatric surgery a year ago and a long list of allergies which includes peanuts, penicillin, and milk protein. Physical examination is unremarkable except for pale skin and mucosal surfaces, koilonychia, and glossitis. Which of the following descriptions would you expect to find in an endoscopy?
A. Luminal protruding concentric diaphragms (Correct Answer)
B. Luminal eccentric membranes
C. Changes in the epithelial lining of the esophagus
D. Hiatus hernia
E. Pharyngeal pouch
Explanation: The patient's symptoms (dysphagia, fatigue, palpitations, pallor, koilonychia, glossitis) and history of bariatric surgery strongly suggest iron deficiency anemia. In a subpopulation of patients with iron deficiency anemia, particularly women, a rare complication known as Plummer-Vinson syndrome (also known as Paterson-Kelly syndrome or sideropenic dysphagia) can develop, which is characterized by the presence of esophageal webs. These webs appear as concentric diaphragms on endoscopy.
*Luminal eccentric membranes*
- This typically refers to Schatzki rings, which are mucosal rings at the gastroesophageal junction. While they cause dysphagia, they are usually eccentric or asymmetric, and not typically described as concentric diaphragms. Schatzki rings are often associated with hiatal hernias and are not usually a direct sequela of iron deficiency anemia [1].
*Changes in the epithelial lining of the esophagus*
- This is a very general description and could refer to various conditions such as esophagitis, Barrett's esophagus, or Candida esophagitis.
*Hiatus hernia*
- A hiatus hernia involves the protrusion of the stomach into the thorax through the esophageal hiatus [1]. While it can cause dysphagia and is common, it does not directly explain the other specific symptoms like koilonychia and glossitis, nor is it a direct consequence of iron deficiency anemia in this clinical picture. Endoscopically, a hiatus hernia appears as a widening of the diaphragmatic hiatus and upward displacement of the gastric cardia, not luminal diaphragms.
*Pharyngeal pouch*
- A pharyngeal pouch (Zenker's diverticulum) is an outpouching of the posterior pharyngeal wall, typically causing dysphagia, regurgitation of undigested food, and halitosis [2]. It would be located higher in the pharynx, not in the esophagus, and would appear as a diverticulum, not a concentric diaphragm. It is not associated with the signs of iron deficiency noted.
Question 1009: True about Crohn's disease except
A. Transmural
B. Recurrence is more common
C. Rectum is involved (Correct Answer)
D. Fissures are formed
Explanation: ***Rectum is involved***
- While Crohn's disease can affect any part of the gastrointestinal tract from mouth to anus, **rectal involvement is much less common** and often spares the rectum in typical cases, especially when compared to ulcerative colitis. [1]
- The disease typically exhibits **skip lesions**, meaning there are healthy segments of the bowel between affected areas, and the rectum is frequently one of these spared regions. [1]
*Transmural*
- Crohn's disease is characterized by **transmural inflammation**, meaning the inflammation extends through all layers of the bowel wall, from the mucosa to the serosa. [1]
- This transmural involvement can lead to complications such as **fistulas, strictures, and abscesses**.
*Recurrence is more common*
- **Recurrence after surgery is very common** in Crohn's disease, with many patients experiencing disease relapse within a few years post-operation.
- This high recurrence rate often necessitates ongoing medical management and sometimes further surgical interventions.
*Fissures are formed*
- Due to the **transmural inflammation** and chronic nature of Crohn's disease, patients often develop **fissures**, which are deep cracks or excoriations, particularly in the perianal area.
- These fissures can be quite painful and complicated by **fistula formation** or abscesses.
Question 1010: Which of the following is included in Celiac sprue diet?
A. Wheat
B. Quinoa (Correct Answer)
C. Barley
D. Rye
Explanation: ***Quinoa***
- Quinoa is a **naturally gluten-free grain** and is therefore safe for individuals with Celiac disease.
- It serves as an excellent source of **protein, fiber, and essential nutrients**, making it a healthy and suitable staple in a gluten-free diet.
*Wheat*
- Wheat contains **gluten**, a protein that triggers an autoimmune response in individuals with Celiac disease [1].
- Consumption of wheat leads to damage of the **small intestinal villi**, causing malabsorption and various symptoms [2].
*Barley*
- Barley also contains **gluten**, making it unsuitable for a Celiac sprue diet [1].
- It is often found in various food products, including malt, and must be strictly avoided to prevent **intestinal damage** [1].
*Rye*
- Rye is another grain that contains **gluten** and is thus prohibited for individuals with Celiac disease [1].
- Similar to wheat and barley, consuming rye can provoke an **immune reaction** that damages the small intestine [2].
