Gastroenterology — MCQs

A 67-year-old woman complains of paresthesias in the limbs. Examination shows loss of vibratory sense, positional sense, and sense of light touch in the lower limbs. She is found to have pernicious anemia. Endoscopy reveals an ulcer in the body of the stomach. What vitamin deficiency does she most likely have?

Gastroenterology Indian Medical PG Practice Questions and MCQs

Question 1331: Which of the following can cause toxic megacolon in a 36-year-old lady?

A. Ulcerative colitis (Correct Answer)
B. Viral diarrhea
C. Amoebic dysentery
D. Irritable bowel syndrome (IBS)

Explanation: ***Ulcerative colitis*** - **Ulcerative colitis** is a well-known cause of **toxic megacolon**, a severe complication characterized by acute colonic distension and systemic toxicity [1]. - The inflammatory process in ulcerative colitis can lead to deep ulcerations and transmural inflammation, compromising the enteric nervous system and causing acute colonic dysfunction. *Amoebic dysentery* - While **amoebic dysentery** can cause severe colonic inflammation and necrosis, it is **less commonly associated with toxic megacolon** compared to inflammatory bowel diseases. - The primary concern with amoebic dysentery is often **amoebic liver abscess** or colonic perforation rather than toxic megacolon. *Irritable bowel syndrome (IBS)* - **IBS** is a **functional gastrointestinal disorder** and does **not cause structural changes or significant inflammation** in the colon. - It is characterized by symptoms like abdominal pain, bloating, and altered bowel habits, but it is **not associated with toxic megacolon**. *Viral diarrhea* - **Viral diarrhea** typically causes **acute, self-limiting gastroenteritis** and does **not involve the severe, transmural inflammation** required to induce toxic megacolon. - The primary concern with viral diarrhea is **dehydration**, especially in vulnerable populations.

Question 1332: Which of the following statements is true regarding gallbladder carcinoma?

A. 30% are squamous cell carcinoma
B. 5-year survival is approximately 25%
C. Most commonly presents with abdominal pain and weight loss
D. 90% associated with gallstones (Correct Answer)

Explanation: 90% associated with gallstones - The vast majority of gallbladder carcinomas are linked to **gallstone disease**, which is considered a major risk factor due to chronic inflammation [2]. - This strong association highlights the role of prolonged irritation in the development of malignancy in the gallbladder. *Most commonly presents with abdominal pain and weight loss* - While **abdominal pain** and **weight loss** can be symptoms, they are non-specific and often present at advanced stages [1]. - Earlier symptoms might include **jaundice** or **right upper quadrant discomfort**, but these are also often vague [1]. *5-year survival is approximately 25%* - The overall 5-year survival rate for gallbladder carcinoma is significantly lower, typically ranging from **5-10%**, making it one of the more lethal cancers. - The poor prognosis is often due to late diagnosis, as symptoms usually appear when the disease is already advanced and has metastasized; death typically occurs within 1 year in symptomatic patients [1]. *30% are squamous cell carcinoma* - The vast majority of gallbladder carcinomas (approximately **90%**) are **adenocarcinomas**. - Squamous cell carcinoma and other rare types represent only a small minority of cases.

Question 1333: In modified Pugh's classification score of 8, what is the line of management?

A. Sclerotherapy
B. Shunt surgery
C. Conservative management (Correct Answer)
D. Orthotopic liver transplant

Explanation: Conservative management - A modified Child-Pugh score of 8 falls into Child-Pugh class B, indicating **moderate liver dysfunction**. - At this stage, **medical management** aimed at addressing complications and improving liver function is the primary line of treatment. *Orthotopic liver transplant* - Liver transplantation is generally considered for patients with **Child-Pugh class C** (scores 10-15) or those with class B who are unresponsive to medical therapy and have a high risk of mortality [1]. - While a score of 8 indicates significant disease, it's not immediately indicative of the need for transplant without failure of conservative measures or other specific indications [1]. *Sclerotherapy* - **Sclerotherapy** is a procedure primarily used to treat **esophageal varices** to prevent or treat bleeding [2]. - It is a targeted intervention for a specific complication of portal hypertension, not a general management strategy for a Child-Pugh score of 8. *Shunt surgery* - **Shunt surgery**, such as a Transjugular Intrahepatic Portosystemic Shunt (TIPS), is used to decompress the **portal venous system** in cases of severe portal hypertension [3]. - It's typically reserved for patients with recurrent variceal bleeding or refractory ascites, and not a primary management for a Child-Pugh score of 8 as a whole [3].

Question 1334: Which of the following is least likely to be a cause of cholecystitis?

A. OCP
B. Estrogen (Correct Answer)
C. Diabetes mellitus
D. Obesity

Explanation: ### Estrogen - While **estrogen** can contribute to the formation of gallstones (cholelithiasis) by increasing cholesterol secretion into bile, it is **least directly implicated** as a primary cause of cholecystitis itself [1]. - Cholecystitis is primarily caused by **gallstone obstruction** of the cystic duct or, less commonly, by acalculous inflammation [1]. ### OCP - **Oral contraceptive pills (OCPs)** contain estrogen, which is a known risk factor for the formation of **gallstones**, leading to cholelithiasis [1]. - Gallstones are the most common cause of **acute cholecystitis** due to obstruction of the cystic duct [1]. ### Diabetes mellitus - **Diabetes mellitus** increases the risk of gallstone formation due to **impaired gallbladder motility** and changes in bile composition. - Diabetic patients are also at higher risk for severe cholecystitis and complications, including **gangrenous cholecystitis** or emphysematous cholecystitis [1]. ### Obesity - **Obesity** is a significant risk factor for the development of **cholesterol gallstones** due to increased cholesterol synthesis and secretion into bile [1]. - The presence of gallstones, or cholelithiasis, is the primary predisposing factor for **acute cholecystitis** [1].

Question 1335: Which extra-intestinal symptom of inflammatory bowel disease worsens with exacerbation of disease activity?

A. Primary sclerosing cholangitis
B. Uveitis
C. Arthritis (Correct Answer)
D. Erythema nodosum

Explanation: ***Arthritis*** - **Peripheral arthritis** associated with inflammatory bowel disease (IBD) often **worsens with intestinal disease exacerbations** and improves with resolution of flares [1]. - This type of arthritis typically affects larger joints and is **non-deforming and asymmetric**. *Erythema nodosum* - **Erythema nodosum**, a skin manifestation, is generally **correlated with IBD activity** and usually improves as the bowel disease is treated [1]. - It presents as **tender, red nodules** on the shins and is not consistently one of the symptoms that *worsens* with exacerbation, but rather is *present* during active disease. *Primary sclerosing cholangitis* - **Primary sclerosing cholangitis (PSC)** is a chronic liver condition that is **associated with IBD**, particularly ulcerative colitis. - However, the progression of PSC is largely **independent of the intestinal disease activity** and does not necessarily worsen during IBD exacerbations. *Uveitis* - **Uveitis**, an inflammation of the eye's middle layer, is an extra-intestinal manifestation of IBD that can occur **independently of intestinal disease activity**. - It does not consistently worsen during IBD exacerbations and may require separate focused treatment.

Question 1336: In a patient with liver disease, which maneuvers may lead to the development of hyperammonemia?

A. The use of loop diuretics. (Correct Answer)
B. Protein restriction may help in managing hyperammonemia.
C. A branched-chain amino acid-enriched protein mixture can help lower ammonia levels.
D. The use of neomycin can help reduce ammonia levels.

Explanation: ***The use of loop diuretics.*** - Loop diuretics can lead to **hypokalemia** and **metabolic alkalosis**, which promotes the conversion of NH4+ to NH3, the un-ionized form that can cross the blood-brain barrier. [2] - They also can induce **prerenal azotemia** due to volume depletion, increasing protein catabolism and ammonia production. *Protein restriction may help in managing hyperammonemia.* - **Protein restriction** is a strategy to *reduce* ammonia production in the gut, especially in patients with hepatic encephalopathy. [1] - This statement describes a management strategy, not a maneuver that *leads* to hyperammonemia. *A branched-chain amino acid-enriched protein mixture can help lower ammonia levels.* - **Branched-chain amino acids (BCAAs)** are often used as nutritional support in liver disease to *improve* nitrogen balance and reduce ammonia levels. - They compete with aromatic amino acids for transport into the brain, which can help in *reducing* ammonia's neurotoxic effects. *The use of neomycin can help reduce ammonia levels.* - **Neomycin** is an antibiotic that *reduces* ammonia production by killing ammonia-producing bacteria in the gut. - Therefore, using neomycin would *decrease* ammonia levels, not cause hyperammonemia.

Question 1337: A 50-year-old gynecologist complains of dysphagia, regurgitation, and weight loss, and reports feeling as if food is stuck at the level of the xiphoid. An upright chest X-ray shows a dilated esophagus with an air-fluid level. Which of the following statements is false regarding achalasia?

A. Upper endoscopy should be avoided because of the risk of complications. (Correct Answer)
B. Medical treatment includes nitrates and calcium channel blockers.
C. A barium swallow will show a "bird's beak" deformity
D. Manometry will demonstrate that the LES fails to relax during swallowing.

Explanation: ***Upper endoscopy should be avoided because of the risk of complications.*** - While upper endoscopy can carry some risks, it is an important diagnostic tool in evaluating **achalasia** and is done safely in many cases. - Avoiding endoscopy overlooks potential treatment options and may delay addressing any **malignancy** or complications associated with achalasia. * A barium swallow will show a "bird's beak" deformity * - This is a classic finding in achalasia; it illustrates the **narrowing of the esophagus** at the distal end. - The "bird's beak" appearance results from **incomplete relaxation** of the lower esophageal sphincter (LES) during swallowing. * Medical treatment includes nitrates and calcium channel blockers. * - Nitrates and calcium channel blockers aim to reduce **LES pressure** and improve esophageal emptying. - However, these treatments do not cure achalasia; they are often only **palliative** and may have limited efficacy. * Manometry will demonstrate that the LES fails to relax during swallowing. * - Esophageal manometry is crucial in confirming achalasia, showing **incomplete relaxation** of the LES during swallowing. - This finding is essential for diagnosis and highlights the **pathophysiology** of achalasia.

Question 1338: A 60-year-old male presents with hypotension (90/50 mm Hg), tachycardia (100 beats per minute), and a history of hypertension and coronary artery disease. He has been passing black, tarry stools while on aspirin, atenolol, and sorbitrate. What is the most likely diagnosis?

A. Gastric ulcer with bleeding (Correct Answer)
B. Acute MI with cardiogenic shock
C. Acute CVA
D. Pulmonary embolism

Explanation: ***Gastric ulcer with bleeding*** - The patient's presentation with **hypotension** and **tachycardia** indicates **hypovolemia**, which is consistent with significant blood loss [1]. - **Black, tarry stools (melena)** are a classic sign of **upper gastrointestinal bleeding**, often originating from a gastric ulcer, especially given the patient's use of **aspirin**, a known risk factor [1]. *Acute MI with cardiogenic shock* - While the patient has a history of coronary artery disease, **cardiogenic shock** would typically present with signs of **poor tissue perfusion** secondary to pump failure, not primarily with melena [2]. - Melena is not a typical symptom of myocardial infarction itself, though GI bleeding can exacerbate cardiac ischemia [1]. *Acute CVA* - An **acute cerebrovascular accident (CVA)** would present with focal neurological deficits, such as hemiparesis, aphasia, or vision changes. - The patient's symptoms of melena, hypotension, and tachycardia are not characteristic of a CVA [1]. *Pulmonary embolism* - A **pulmonary embolism (PE)** typically presents with acute onset of **dyspnea, pleuritic chest pain**, and sometimes hemoptysis. - While it can cause hypotension and tachycardia, **melena is not a symptom** of pulmonary embolism.

Question 1339: All of the following may be features of a silent carcinoma of the body of the stomach except which of the following?

A. Obstructive jaundice
B. Krukenberg's tumours
C. Ascites
D. Dysphagia (Correct Answer)

Explanation: ***Dysphagia*** - **Dysphagia** (difficulty swallowing) is a prominent symptom typically associated with carcinomas of the **cardia** or **fundus** of the stomach, where the tumor directly impedes food passage [1]. - A silent carcinoma of the **body of the stomach** is less likely to cause dysphagia until it has grown extensively or metastasized, making this the exception among the listed options [1]. *Obstructive jaundice* - A silent carcinoma of the stomach body can metastasize to the **liver** or the **porta hepatis** lymph nodes, leading to compression of the bile ducts [1]. - This compression can cause **obstructive jaundice**, characterized by yellow skin and eyes due to bile flow obstruction [1]. *Ascites* - **Ascites**, the accumulation of fluid in the abdominal cavity, can occur with advanced gastric cancer due to **peritoneal carcinomatosis** (spread of cancer cells to the peritoneum) [1]. - This is a common finding in widespread metastatic disease, even from a initially "silent" primary tumor. *Krukenberg's tumours* - These are **metastatic ovarian tumors** originating from a primary gastrointestinal cancer, most commonly the stomach [1]. - A silent gastric carcinoma can present with these secondary tumors as the first noticeable symptom, especially due to **lymphatic spread** to the ovaries [1].

Question 1340: A 67-year-old woman complains of paresthesias in the limbs. Examination shows loss of vibratory sense, positional sense, and sense of light touch in the lower limbs. She is found to have pernicious anemia. Endoscopy reveals an ulcer in the body of the stomach. What vitamin deficiency does she most likely have?

A. Gastric sarcoma
B. Chronic atrophic gastritis
C. Cancer of the stomach (Correct Answer)
D. Deficiency of vitamin B12

Explanation: **Cancer of the stomach** - The presence of **pernicious anemia** with an **ulcer in the body of the stomach** in an elderly patient suggests an increased risk of **gastric adenocarcinoma** [2]. - **Atrophic gastritis** associated with pernicious anemia is a **precursor lesion** for gastric cancer, and a stomach ulcer in this context warrants suspicion for malignancy [2]. *Chronic atrophic gastritis* - While **chronic atrophic gastritis** is the underlying cause of pernicious anemia, the question specifies an **ulcer in the body of the stomach** [3]. - An ulcer in the setting of atrophic gastritis should raise concern for **malignancy**, especially in an older patient, rather than just chronic inflammation [2]. *Gastric sarcoma* - **Gastric sarcomas** are mesenchymal tumors of the stomach, which are **rare** compared to gastric adenocarcinomas. - While they can present as ulcers, the strong association with **pernicious anemia** points more directly towards adenocarcinoma. *Deficiency of vitamin B12* - The patient clearly has **vitamin B12 deficiency** due to pernicious anemia, which explains the neurological symptoms like **paresthesias** and loss of vibratory/positional sense [1]. - However, the question asks what new pathology is suggested by the **ulcer in the stomach body** given the underlying pernicious anemia, rather than about the deficiency itself.

Practice by Chapter

Esophageal Disorders

Practice Questions

Peptic Ulcer Disease

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Inflammatory Bowel Disease

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Irritable Bowel Syndrome

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Malabsorption Syndromes

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Pancreatitis (Acute and Chronic)

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Gastrointestinal Bleeding

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Liver Diseases and Cirrhosis

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Viral Hepatitis

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Biliary Tract Disorders

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Gastrointestinal Motility Disorders

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Gastrointestinal Malignancies

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