Gastroenterology Practice Questions

Q: A 16-year-old boy presents with multiple episodes of abdominal pain and a history of passing blood in his stools. On examination, he has darkly pigmented spots on his lips and oral mucosa. Endoscopy reveals multiple hamartomatous polyps in the small intestine. What is the most likely diagnosis?

Peutz-Jeghers Syndrome. ***Peutz-Jeghers Syndrome*** - This is an autosomal dominant disorder characterized by the classic triad of **hamartomatous polyps** in the GI tract (especially the small intestine), **mucocutaneous hyperpigmentation** (dark spots on lips, oral mucosa), and an increased risk of cancer [1]. - The patient's symptoms of abdominal pain and GI bleeding are common complications due to the polyps, which can lead to **intussusception** or ulceration. *Familial Adenomatous Polyposis* - This syndrome is defined by the presence of hundreds to thousands of **adenomatous polyps** in the colon, not hamartomatous polyps as seen in this patient [1]. - It is not associated with the characteristic **perioral mucocutaneous pigmentation** which is a hallmark feature of Peutz-Jeghers syndrome. *Juvenile Polyposis Syndrome* - This condition also involves **hamartomatous polyps**, but they are most commonly found in the colon and rectum, and the syndrome lacks the distinct mucocutaneous pigmentation [1]. - While patients can present with GI bleeding, the combination of small intestine polyps and pigmented lip spots points away from this diagnosis. *Cronkhite-Canada Syndrome* - This is a rare, non-hereditary syndrome typically affecting older adults, characterized by GI polyposis along with ectodermal changes like **alopecia** (hair loss) and **onychodystrophy** (nail changes). - Patients often present with severe diarrhea and **protein-losing enteropathy**, which are not features described in this case.

Q: A follow-up patient of GERD on endoscopy was having a nodule in the 2nd part of the duodenum, which hormone are you suspecting to be raised?

Gastrin. ***Gastrin*** - The presence of a nodule in the second part of the duodenum, a common location within the **gastrinoma triangle** (Passaro's triangle), combined with GERD, strongly suggests a **gastrinoma**. - Gastrinomas cause **Zollinger-Ellison Syndrome (ZES)** by secreting excessive **gastrin**, which leads to gastric acid hypersecretion, resulting in refractory peptic ulcers and severe GERD [1]. *Inulin* - **Inulin** is a polysaccharide, not a hormone, and it is used clinically to measure the **glomerular filtration rate (GFR)**. - If this option meant **insulin**, an insulinoma would cause symptoms of **hypoglycemia**, such as sweating, tremors, and confusion, not GERD. *VIP* - A tumor secreting **Vasoactive Intestinal Peptide (VIPoma)** causes **WDHA syndrome**, characterized by **W**atery **D**iarrhea, **H**ypokalemia, and **A**chlorhydria. - This condition is associated with **low stomach acid** (achlorhydria), which is contrary to the hyperacidity that causes GERD. *Glucagon* - A **glucagonoma** is a tumor that secretes excess glucagon, leading to a syndrome characterized by **diabetes mellitus** and a classic skin rash known as **necrolytic migratory erythema**. - It is not associated with gastric acid hypersecretion or duodenal nodules presenting with GERD.

Q: Which of the following is a recommended treatment for esophageal varices?

Endoscopic ligation. ***Endoscopic ligation*** - This is a first-line endoscopic therapy for both actively bleeding esophageal varices and for the primary and secondary prevention of variceal hemorrhage [1]. - The procedure, also known as **variceal banding**, involves placing small rubber bands around the varices to ligate them, leading to thrombosis and eventual sloughing off [1]. *Transjugular intrahepatic portosystemic shunt (TIPS)* - TIPS is considered a second-line or salvage therapy for variceal bleeding that is refractory to endoscopic and pharmacological treatments [2]. - It is an invasive procedure that creates a shunt to reduce **portal pressure**, but it is reserved for uncontrolled bleeding due to risks such as **hepatic encephalopathy** [2]. *Intravenous labetalol* - While non-selective beta-blockers like **propranolol** or **nadolol** are used for the prophylaxis of variceal bleeding, they are not the treatment for an acute bleed. Vasoactive drugs like **terlipressin** or **octreotide** are used instead [1]. - Labetalol is a beta-blocker primarily used to manage **hypertension** and is not indicated for the acute management of variceal hemorrhage. *Oral amoxicillin* - Antibiotic prophylaxis (typically with intravenous third-generation cephalosporins like **ceftriaxone**) is recommended in patients with cirrhosis and variceal bleeding to prevent **spontaneous bacterial peritonitis (SBP)**. - Antibiotics do not treat the varices directly or stop the bleeding; they are given to reduce mortality associated with infections in this patient population.

Q: Which classification is used for Barrett esophagus?

Prague classification. ***Prague classification***- This classification is specifically designed for the standardized endoscopic assessment and documentation of **Barrett esophagus** (BE).- It uses two main parameters: the maximal extent (M) and the circumferential extent (C) of the columnar-lined esophagus, ensuring consistent reporting for surveillance.*Savary-Miller classification*- This classification system is used to grade the severity of **reflux esophagitis** (erosive esophagitis), not Barrett esophagus.- It categorizes esophageal mucosal injury based on the extent and depth of erosions.*Johnson classification*- This classification is generally not a recognized standard system for classifying key GI pathology like Barrett esophagus, unlike established systems such as the **Prague classification** or **Los Angeles classification** for reflux esophagitis.- *Note: A Johnson classification exists for pediatric hip dysplasia, but it is unrelated to GI endoscopy.* *Forrest classification*- This system is used exclusively to classify the appearance of **peptic ulcer bleeding** (or other upper GI bleed sources) seen during endoscopy.- It helps predict the risk of rebleeding and guides interventions, such as those performed for ulcers with adherent clots or active oozing.

Q: A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?

Lamivudine. Lamivudine - This serological profile (HBsAg+, IgM anti-HBc-, IgG anti-HBc+, HBeAg+) indicates HBeAg-positive chronic Hepatitis B with active viral replication [1] - Among the given options, Lamivudine is the only agent with anti-HBV activity as a nucleoside reverse transcriptase inhibitor (NRTI) that inhibits HBV DNA polymerase - Important Note: While Lamivudine was historically used for chronic HBV, current guidelines (WHO, AASLD, EASL) recommend Tenofovir or Entecavir as first-line therapy due to higher potency and lower resistance rates [2] - Lamivudine is now considered second-line due to high resistance rates (up to 70% after 5 years) Incorrect Option: Ombitasvir - Ombitasvir is an NS5A inhibitor used exclusively for Hepatitis C (HCV) treatment in combination regimens - Has no activity against HBV and is inappropriate for this patient Incorrect Option: Ritonavir - Ritonavir is an HIV protease inhibitor used primarily as a pharmacokinetic booster in antiretroviral therapy - Has no direct anti-HBV activity and is not used for HBV treatment Incorrect Option: Abacavir - Abacavir is an NRTI used for HIV treatment as part of combination ART - Despite being an NRTI class drug, it lacks significant anti-HBV activity and is not approved or effective for chronic Hepatitis B management

Q: A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

b.Acute pancreatitis. ***Acute pancreatitis*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input) - The clinical presentation of severe **epigastric pain radiating to the back**, associated with nausea and vomiting, is classic for **acute pancreatitis** [1]. - **Alcohol abuse** is a major risk factor, and the diagnosis is supported by findings of significantly elevated serum **amylase and/or lipase** levels [1]. *Acute hepatitis* - Typically presents with **jaundice**, fatigue, dark urine, and right upper quadrant discomfort, not the referred back pain seen here. - Key laboratory findings would include severely elevated **liver transaminases (AST/ALT)**, not primarily amylase. *Acute Cholecystitis* - Characterized by acute pain in the **right upper quadrant** or epigastrium, often radiating to the **right shoulder or scapula**, not the back [2]. - This condition is usually associated with gallstones and is diagnosed via imaging showing gallbladder wall thickening and pericholecystic fluid, though amylase can be mildly elevated secondarily. *Acute appendicitis* - Presents typically with periumbilical pain that migrates to the **right lower quadrant (RLQ)**, often associated with low-grade fever and localized tenderness. - The pain is not classically described as severe epigastric pain radiating to the back, and initial lab markers include leukocytosis but not specific elevation of amylase.

Q: Which of the following is not a component of Child-Pugh scoring?

LFT. ***LFT (Correct Answer)*** - **LFT (Liver Function Tests)** is a general term encompassing various biochemical tests such as AST, ALT, ALP, and GGT [1], [2] - These specific liver enzymes are **not components** of the Child-Pugh scoring system - The Child-Pugh score specifically uses only **5 parameters**: Albumin, Bilirubin, Prothrombin Time/INR, Ascites, and Hepatic Encephalopathy - These five components assess both **synthetic function** (albumin, PT/INR) and **clinical manifestations** (ascites, encephalopathy) of chronic liver disease [3] *Albumin (Incorrect)* - Serum **albumin** is one of the five specific components of the Child-Pugh score - It reflects the liver's **synthetic function** capacity - Scoring: >3.5 g/dL (1 point), 2.8-3.5 g/dL (2 points), 3 mg/dL (3 points) - Elevated bilirubin indicates impaired hepatic clearance and correlates with severity of liver disease *Prothrombin Time (Incorrect)* - **Prothrombin Time (PT)** or **INR** measures the liver's ability to synthesize clotting factors [3] - It is a critical component reflecting hepatic **synthetic function** - Scoring: 6 sec or INR >2.3 (3 points) [4] - Prolonged PT/elevated INR indicates severely impaired synthesis of vitamin K-dependent clotting factors [3]

Q: Which of the following is a sensitive and specific marker of intestinal inflammation?

Fecal lactoferrin. ***Fecal lactoferrin***- This is an excellent proxy marker for active intestinal inflammation because **lactoferrin** is a highly concentrated protein released by **activated neutrophils** migrating into the gut lumen [1].- Elevated fecal levels often correlate well with endoscopic and histological evidence of mucosal inflammation [2], making it a sensitive and specific non-invasive test for conditions like **Inflammatory Bowel Disease (IBD)**.*Procalcitonin*- Primarily serves as a highly specific marker for diagnosing and monitoring **sepsis** and severe **systemic bacterial infection**.- It generally reflects systemic inflammatory responses and is not specific for inflammation localized to the **intestinal mucosa**.*Tissue transglutaminase IgA*- This is an autoantibody primarily used for screening and diagnosing **Celiac disease**, an autoimmune condition triggered by **gluten**.- It indicates underlying autoimmunity causing villous atrophy but is not used as a general marker of acute or chronic **intestinal inflammation** (like IBD).*High-sensitivity C-reactive protein*- It is a widely used, but **non-specific**, acute-phase reactant indicating **systemic inflammation** originating from any part of the body [1].- While elevated in IBD, its sensitivity and specificity for identifying isolated or localized intestinal inflammation are inferior to non-invasive **fecal markers** like lactoferrin or calprotectin.

Q: A 25-year-old male presents with mild jaundice noticed during a recent febrile illness. He gives a history of similar episodes in the past following any illness or periods of fasting. Physical examination reveals mild icterus with no hepatosplenomegaly. Lab values are given below: Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1 mg/dL Conjugated bilirubin: 0.3 mg/dL Serum AST and ALT: Normal What is the most likely diagnosis?

Gilbert syndrome. ***Gilbert syndrome*** - It is characterized by isolated, mild, intermittent **unconjugated hyperbilirubinemia** (total bilirubin <4 mg/dL), often triggered by stress, fasting, illness, or dehydration, matching the patient's history of episodes following illness [1]. - The underlying cause is reduced activity (typically 30%) of the enzyme **uridine diphosphoglucuronate glucuronosyltransferase (UGT1A1)**, necessary for conjugating bilirubin, but liver function (AST/ALT) remains normal [1], [3]. *Dubin-Johnson syndrome* - This is characterized by **conjugated (direct) hyperbilirubinemia** due to defective excretion of bilirubin into the bile canaliculi, contrasting with the predominantly unconjugated pattern seen here [2]. - The liver tissue typically shows **black pigmentation** due to epinephrine metabolite accumulation, which is a key pathological feature. *Criggler-Najar type 1 syndrome* - This syndrome involves a severe or complete absence of the **UGT1A1 enzyme**, leading to very high levels of **unconjugated bilirubin** (often >20 mg/dL) that cause **kernicterus** and usually death in infancy, which is not consistent with a history of recurrent mild episodes in an adult [1]. - It requires lifelong treatment, typically with **phototherapy** and **liver transplantation**, due to the severe defect [1]. *Rotor syndrome* - Similar to Dubin-Johnson syndrome, Rotor syndrome also causes **conjugated (direct) hyperbilirubinemia** due to impaired hepatic storage and excretion of conjugated bilirubin, which contradicts the laboratory findings of mostly unconjugated bilirubin.

Q: A 20-year-old male presented with yellowish discoloration of his skin and sclera. He is otherwise normal. He gives a history of viral infection 10 days ago, which was resolved 2 days back. He also gives a history of similar episodes in the past following any illness. Lab values are given below. What is the most likely diagnosis? Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1mg/dL Conjugated bilirubin: 0.3mg/dL Serum AST and ALT: Normal

Gilbert syndrome. ***Gilbert syndrome*** - This condition is characterized by **unconjugated hyperbilirubinemia** (as seen by 2.1 mg/dL unconjugated vs. 0.3 mg/dL conjugated) that is mild, typically <3 mg/dL, and intermittent. [1] The history of similar episodes following **stress**, **vigorous exercise**, or **illness** (like the recent viral infection) is a classic trigger for this condition, which is caused by reduced activity of the **UGT1A1 enzyme**. [1] *Dubin-Johnson syndrome* - This syndrome results in **conjugated (direct) hyperbilirubinemia** due to defective excretion of conjugated bilirubin (MRP2 transporter defect). *Criggler-Najar type 1 syndrome* - This is a severe congenital deficiency of the **UGT1A1 enzyme**, leading to markedly and persistently elevated **unconjugated bilirubin** (often >20 mg/dL) and usually resulting in **kernicterus** and death in infancy. [1] The patient presents later in life (20 years old) with only mild, fluctuating unconjugated hyperbilirubinemia, ruling out Type 1 severity. *Rotor syndrome* - Similar to Dubin-Johnson, Rotor syndrome causes **conjugated (direct) hyperbilirubinemia** due to hepatocyte storage and transport defects, which contradicts the patient's lab findings of predominantly unconjugated bilirubin. Unlike Dubin-Johnson, Rotor syndrome does **not** cause black pigmentation of the liver.

Question 1

A 16-year-old boy presents with multiple episodes of abdominal pain and a history of passing blood in his stools. On examination, he has darkly pigmented spots on his lips and oral mucosa. Endoscopy reveals multiple hamartomatous polyps in the small intestine. What is the most likely diagnosis?

Accepted Answer

Peutz-Jeghers Syndrome

Answer

Cronkhite-Canada Syndrome

Answer

Juvenile Polyposis Syndrome

Answer

Familial Adenomatous Polyposis

Question 2

A follow-up patient of GERD on endoscopy was having a nodule in the 2nd part of the duodenum, which hormone are you suspecting to be raised?

Accepted Answer

Gastrin

Answer

Inulin

Answer

Glucagon

Answer

VIP

Question 3

Which of the following is a recommended treatment for esophageal varices?

Accepted Answer

Endoscopic ligation

Answer

Transjugular intrahepatic portosystemic shunt (TIPS)

Answer

Intravenous labetalol

Answer

Oral amoxicillin

Question 4

Which classification is used for Barrett esophagus?

Accepted Answer

Prague classification

Answer

Johnson classification

Answer

Forrest classification

Answer

Savary-Miller classification

Question 5

A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?

Accepted Answer

Lamivudine

Answer

Ritonavir

Answer

Ombitasvir

Answer

Abacavir

Question 6

A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

Accepted Answer

b.Acute pancreatitis

Answer

a.Acute hepatitis

Answer

d.Acute appendicitis

Answer

c.Acute Cholecystitis

Question 7

Which of the following is not a component of Child-Pugh scoring?

Accepted Answer

LFT

Answer

Albumin

Answer

Bilirubin

Answer

Prothrombin Time

Question 8

Which of the following is a sensitive and specific marker of intestinal inflammation?

Accepted Answer

Fecal lactoferrin

Answer

Procalcitonin

Answer

High-sensitivity C-reactive protein

Answer

Tissue transglutaminase IgA

Question 9

A 25-year-old male presents with mild jaundice noticed during a recent febrile illness. He gives a history of similar episodes in the past following any illness or periods of fasting. Physical examination reveals mild icterus with no hepatosplenomegaly. Lab values are given below:

Serum bilirubin: 2.4 mg/dL
Unconjugated bilirubin: 2.1 mg/dL
Conjugated bilirubin: 0.3 mg/dL
Serum AST and ALT: Normal

What is the most likely diagnosis?

Accepted Answer

Gilbert syndrome

Answer

Dubin-Johnson syndrome

Answer

Rotor syndrome

Answer

Criggler-Najar type 1 syndrome

Question 10

A 20-year-old male presented with yellowish discoloration of his skin and sclera. He is otherwise normal. He gives a history of viral infection 10 days ago, which was resolved 2 days back. He also gives a history of similar episodes in the past following any illness. Lab values are given below. What is the most likely diagnosis? Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1mg/dL Conjugated bilirubin: 0.3mg/dL Serum AST and ALT: Normal

Accepted Answer

Gilbert syndrome

Answer

Criggler-Najar type 1 syndrome

Answer

Rotor syndrome

Answer

Dubin-Johnson syndrome

Gastroenterology — MCQs

Gastroenterology — MCQs

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