Gastroenterology Practice Questions

Q: During a routine pre-employment physical examination, an apparently healthy 24-year-old man is found to have increased serum levels of unconjugated bilirubin. Conjugated bilirubin and transaminases are normal. Careful questioning reveals no evidence of recent illnesses. Which of the following is the most likely diagnosis?

Gilbert syndrome. ### Explanation **Gilbert Syndrome** is the most likely diagnosis in this scenario [1]. It is a common, benign autosomal recessive condition characterized by a **reduced activity of the enzyme bilirubin uridine diphosphate-glucuronosyltransferase (UGT1A1)** [1]. This leads to intermittent episodes of mild **unconjugated hyperbilirubinemia**, typically triggered by stress, fasting, illness, or strenuous exercise. **Why it is the correct answer:** The patient is an asymptomatic young adult with isolated unconjugated hyperbilirubinemia and normal liver enzymes (ALT/AST). This "incidental finding" during routine screening is the classic presentation of Gilbert syndrome. Bilirubin levels rarely exceed 4 mg/dL, and the liver architecture remains normal. **Analysis of Incorrect Options:** * **Crigler-Najjar Syndrome:** Type I involves a total absence of UGT1A1 activity, leading to severe, life-threatening jaundice in infancy [1]. Type II (Arias syndrome) involves a severe deficiency (<10% activity) but is still more symptomatic and presents with higher bilirubin levels than Gilbert syndrome. * **Dubin-Johnson Syndrome:** This is a defect in the MRP2 transporter, resulting in **conjugated** hyperbilirubinemia. A key feature is a "black liver" due to pigment deposition. * **Rotor Syndrome:** Similar to Dubin-Johnson, this presents with **conjugated** hyperbilirubinemia due to impaired hepatic storage/uptake of bilirubin, but without the black liver pigmentation. **NEET-PG High-Yield Pearls:** * **Enzyme involved:** UGT1A1 (reduced to ~30% of normal) [1]. * **Trigger factors:** Fasting (the "Fasting Test" was historically used for diagnosis), dehydration, menstruation, and surgery. * **Treatment:** No treatment is required; the prognosis is excellent [1]. * **Differential Diagnosis:** Always rule out hemolysis; however, in Gilbert syndrome, hemoglobin and reticulocyte counts are normal [2].

Q: What is the most common cause of lung abscess?

Oral anaerobes. **Explanation:** The most common cause of lung abscess is the **aspiration of oropharyngeal secretions** [1] containing **oral anaerobes** (e.g., *Peptostreptococcus*, *Fusobacterium*, and *Prevotella*). This typically occurs in patients with predispositions such as poor dentition (gingivitis), altered consciousness (alcoholism, seizures), or swallowing dysfunction [1, 2]. The aspirated material settles in dependent segments of the lung, leading to necrotizing pneumonia and subsequent abscess formation. **Analysis of Options:** * **A. Staphylococcus aureus:** While a common cause of necrotizing pneumonia and multiple small abscesses (especially post-influenza or via hematogenous spread), it is less frequent than anaerobic aspiration in the general population [3]. * **C. Klebsiella:** A classic cause of "Friedlander’s pneumonia" characterized by "currant jelly sputum" and tissue necrosis. It is common in chronic alcoholics but remains less frequent than mixed anaerobic infections [2]. * **D. Tuberculosis:** *Mycobacterium tuberculosis* typically causes "cavitation" rather than a pyogenic abscess. While a major differential in India, it is classified separately from primary lung abscesses [2]. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site:** The **posterior segment of the right upper lobe** and the **superior segment of the right lower lobe** (due to the vertical nature of the right main bronchus). 2. **Clinical Clue:** Foul-smelling (putrid) sputum is highly suggestive of anaerobic infection. 3. **Treatment of Choice:** **Clindamycin** [4] or Beta-lactam/Beta-lactamase inhibitor combinations (e.g., Piperacillin-Tazobactam). 4. **Air-fluid level:** The classic radiological finding on a chest X-ray.

Q: In which of the following conditions is spastic ileus seen?

Porphyria. **Explanation:** **Spastic ileus** is a rare form of intestinal obstruction caused by sustained, uncoordinated contraction of the intestinal smooth muscle, which prevents the normal transit of contents. **1. Why Porphyria is correct:** In **Acute Intermittent Porphyria (AIP)**, the accumulation of porphyrin precursors (PBG and ALA) leads to autonomic neuropathy [1]. This causes an imbalance in the enteric nervous system, resulting in segmental hyper-contraction or "spasms" of the bowel wall. This spasticity leads to severe abdominal pain and functional obstruction (spastic ileus), which is a classic presentation of a porphyric crisis [1]. **2. Why the other options are incorrect:** * **Retroperitoneal abscess:** This typically causes **adynamic (paralytic) ileus**. The inflammatory process near the retroperitoneum triggers a neural reflex that inhibits bowel motility. * **Hypokalemia:** Low potassium levels hyperpolarize the smooth muscle cells of the gut, making them less excitable. This leads to decreased peristalsis and **paralytic ileus**. * **Myocardial Infarction (MI):** An acute MI (especially inferior wall) can cause **paralytic ileus** due to a systemic stress response and sympathetic overactivity, which inhibits intestinal motility. **High-Yield Clinical Pearls for NEET-PG:** * **Paralytic Ileus (Adynamic):** Most common type. Causes include post-operative state, electrolyte imbalances (Hypokalemia, Hypomagnesemia), and drugs (Opioids, Anticholinergics). * **Spastic Ileus:** Rare. Key causes include **Porphyria** [1], **Lead poisoning** [2], and **Uremia**. * **Ogilvie Syndrome:** Acute pseudo-obstruction of the colon (massive dilation) without mechanical cause, often seen in elderly or critically ill patients. * **Classic Triad of AIP:** Abdominal pain, Neuropsychiatric symptoms, and Peripheral neuropathy (often triggered by drugs like Barbiturates or Sulfonamides) [1].

Q: A 32-year-old Caucasian woman with a 12 pack-year history of smoking presents with diarrhea and right lower quadrant colicky pain. Physical examination reveals tender, red nodules on her legs. Radiological examination shows a specific presentation. What is the most likely diagnosis?

Crohn's disease. ***Crohn's disease*** - **Right lower quadrant pain** and **diarrhea** in a young smoker strongly suggests **terminal ileum** involvement, which is characteristic of Crohn's disease. - The **tender red nodules** on legs represent **erythema nodosum**, a common extraintestinal manifestation of Crohn's disease, and **smoking** is a significant risk factor. *Ulcerative colitis* - Typically presents with **bloody diarrhea** and **left lower quadrant pain** due to **rectosigmoid** involvement, not right-sided symptoms. - **Smoking is protective** against ulcerative colitis, unlike in this patient who is a smoker. *Ulcerative tuberculosis* - Usually affects the **ileocecal region** but presents with **systemic symptoms** like **fever**, **night sweats**, and **weight loss**. - More common in **endemic areas** and **immunocompromised patients**, not typically associated with erythema nodosum. *Hirschsprung's disease* - A **congenital condition** presenting in **infancy** with **chronic constipation** and **abdominal distension**. - Caused by **absence of ganglion cells** in the colon, not associated with inflammatory symptoms or erythema nodosum.

Q: Primary sclerosing cholangitis is associated with which of the following conditions?

All of the above. **Explanation:** Primary Sclerosing Cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and obliterative fibrosis of both intrahepatic and extrahepatic bile ducts, leading to a "beaded" appearance on imaging. **1. Why "All of the above" is correct:** PSC is strongly linked to several systemic inflammatory and fibrotic conditions. * **Ulcerative Colitis (UC):** This is the most well-known association. Approximately 70-80% of patients with PSC have co-existing Inflammatory Bowel Disease (IBD), most commonly UC [1], [2]. Conversely, about 4-5% of UC patients develop PSC. * **IgG4-Related Disease (IgG4-RD):** Modern medical literature classifies several fibro-inflammatory conditions under the umbrella of IgG4-RD. PSC (specifically the IgG4-associated variant), **Retroperitoneal Fibrosis**, and **Riedel’s Thyroiditis** are all part of this spectrum of systemic fibrosing syndromes. They share similar histopathological features, including storiform fibrosis and lymphocytic infiltration. **2. Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** MRCP (Magnetic Resonance Cholangiopancreatography) is the initial diagnostic test of choice, showing the classic "string of beads" appearance. * **Antibody Marker:** **p-ANCA** (Perinuclear Anti-Neutrophil Cytoplasmic Antibody) is positive in about 60-80% of cases, though it is not specific [1], [2]. * **Malignancy Risk:** PSC is a major risk factor for **Cholangiocarcinoma** (10-15% lifetime risk) and Gallbladder cancer. * **Treatment:** Liver transplantation is the only definitive treatment for end-stage disease. Ursodeoxycholic acid (UDCA) may improve biochemical markers but does not improve survival. * **Gender Predilection:** Unlike Primary Biliary Cholangitis (PBC), which is more common in females, PSC is more common in **males** (2:1 ratio) [2].

Question 1

Stigmata of chronic liver disease include all of the following, except?

Accepted Answer

Subcutaneous nodules

Answer

Palmar erythema

Answer

Spider nevi

Answer

Testicular atrophy

Question 2

A 56-year-old woman with a history of chronic viral hepatitis B and cirrhosis presents with light-headedness upon standing and dark black stools for 3 days. On examination, her blood pressure is 90/60 mm Hg supine and 76/60 mm Hg standing. Abdominal examination reveals distension with ascites, and multiple bruises are noted on her legs. Her laboratory findings include hemoglobin 9.0 g/dL, platelets 90,000/mL, albumin 3 g/dL, bilirubin 1.3 mg/dL, and an international normalized ratio (INR) of 2.5 (prothrombin time 25 seconds). Which of the following coagulation factors are most likely deficient in this patient?

Accepted Answer

II, V, VII, IX, X, and XI

Answer

V and VIII

Answer

VIII, IX, XI, and XII

Answer

XIII

Question 3

During a routine pre-employment physical examination, an apparently healthy 24-year-old man is found to have increased serum levels of unconjugated bilirubin. Conjugated bilirubin and transaminases are normal. Careful questioning reveals no evidence of recent illnesses. Which of the following is the most likely diagnosis?

Accepted Answer

Gilbert syndrome

Answer

Crigler-Najjar syndrome

Answer

Dubin-Johnson syndrome

Answer

Rotor syndrome

Question 4

What is the most common cause of lung abscess?

Accepted Answer

Oral anaerobes

Answer

Staphylococcus aureus

Answer

Klebsiella

Answer

Tuberculosis

Question 5

In which of the following conditions is spastic ileus seen?

Accepted Answer

Porphyria

Answer

Retroperitoneal abscess

Answer

Hypokalemia

Answer

Myocardial Infarction (MI)

Question 6

A 50-year-old chronic alcoholic and smoker presents with intermittent episodes of epigastric pain, nausea, and vomiting, along with features of malabsorption for the past 6 months. The patient has lost 12 kg over the last year and was hospitalized for acute abdominal pain 3 years ago. Serum amylase and lipase levels are only mildly elevated. A CT scan of the abdomen and MRCP were performed. What is the most likely diagnosis?

Accepted Answer

Chronic pancreatitis

Answer

Acute pancreatitis

Answer

Pancreatic cancer

Answer

Pancreatic pseudocyst

Question 7

A 50-year-old man presented with one episode of hematemesis. On vital examination, HR was 110/min with BP of 110/80 mmHg. Systemic examination shows an enlarged spleen with dilated tortuous veins around the umbilicus. What is the first differential diagnosis?

Accepted Answer

Non-cirrhotic portal fibrosis

Answer

Kala Azar

Answer

Fatty liver

Answer

Non-alcoholic fatty liver disease

Question 8

Heyde's syndrome is characterized by which of the following triad?

Accepted Answer

Aortic stenosis, gastrointestinal bleeding, and angiodysplasia of the colon

Answer

Mitral stenosis, arthritis, and biliary cirrhosis

Answer

Mitral regurgitation, hiatus hernia, and cirrhosis

Answer

Pulmonary arterial hypertension, tricuspid regurgitation, and cirrhosis

Question 9

A 32-year-old Caucasian woman with a 12 pack-year history of smoking presents with diarrhea and right lower quadrant colicky pain. Physical examination reveals tender, red nodules on her legs. Radiological examination shows a specific presentation. What is the most likely diagnosis?

Accepted Answer

Crohn's disease

Answer

Ulcerative colitis

Answer

Ulcerative tuberculosis

Answer

Hirschsprung's disease

Question 10

Primary sclerosing cholangitis is associated with which of the following conditions?

Accepted Answer

All of the above

Answer

Ulcerative colitis

Answer

Retroperitoneal fibrosis

Answer

Reidel's thyroiditis

Gastroenterology — MCQs

Gastroenterology — MCQs

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