Gastroenterology Practice Questions

Q: A 52-year-old male with chronic hepatitis B presents with progressive abdominal distension and weight loss. Examination reveals ascites and splenomegaly. Serum alpha-fetoprotein is 450 ng/mL (normal <10 ng/mL). Triphasic CT abdomen shows a 6 cm hypervascular lesion in the right lobe with arterial enhancement and washout in portal venous phase. What is the most likely diagnosis?

Hepatocellular carcinoma. ### Hepatocellular Carcinoma (HCC) - The presentation of a patient with **chronic Hepatitis B**, rapidly progressing **ascites**, and an extremely elevated **Alpha-Fetoprotein (AFP)** level (450 ng/mL) is highly suggestive of HCC [1]. - The characteristic finding of a **hypervascular lesion** on Triphasic CT with **arterial phase enhancement** and **washout** in the portal venous phase is the classic radiological hallmark for diagnosing HCC in a cirrhotic liver [1]. *Hepatic Adenoma* - Hepatic adenomas are usually benign, related to **oral contraceptive use** or **anabolic steroid** use, and are less common in men with Hepatitis B. - They typically do not exhibit the classic **washout** pattern seen on dynamic imaging, and AFP levels are usually normal. *Focal Nodular Hyperplasia (FNH)* - FNH is a benign lesion, typically found incidentally, characterized by a **central scar** on imaging, which is not described here, and is driven by vascular malformation. - Unlike HCC, FNH lesions show prolonged, homogeneous enhancement on imaging and are not associated with elevated **AFP** or severe liver function decompensation. *Hepatoblastoma* - Hepatoblastoma is an **embryonal tumor** of the liver, occurring almost exclusively in **children** (usually <3 years old), not in a 52-year-old adult. - While it can cause very high AFP levels, its clinical and radiological presentation is entirely different from a mass developing in a background of chronic viral hepatitis.

Q: The patient presents with fatigue and pruritus. LFT shows gross SALP elevation and elevated conjugated bilirubin. AMA is seen with liver biopsy shows florid bile ductular lesions. Diagnosis is

PBC. ***PBC*** - The presentation of **fatigue** and **pruritus**, severe **SALP elevation** (indicative of cholestasis), and a positive **Anti-Mitochondrial Antibody (AMA)** titer is the classic diagnostic hallmark of Primary Biliary Cholangitis [1], [3]. - The liver biopsy finding of **florid bile ductular lesions** (destruction of small to medium-sized intrahepatic bile ducts) is the pathognomonic histological feature of this disease [3]. *PSC* - While PSC (Primary Sclerosing Cholangitis) also causes cholestasis, it is typically **AMA-negative** and highly associated with Ulcerative Colitis [2], [3]. - Diagnosis of PSC requires imaging (MRCP/ERCP) showing characteristic **bile duct strictures** and **"beading"**, which are not implied by the provided histological description [2]. *UC* - Ulcerative Colitis is an **Inflammatory Bowel Disease (IBD)** affecting the colon, not a primary cholestatic liver disease itself. - Although UC is strongly linked to PSC, it does not explain the patient's **AMA positivity** or the specific destructive **florid bile duct lesions** seen on biopsy [3]. *CD* - Crohn's Disease is also an IBD, characterized by **transmural inflammation** and often affecting the terminal ileum and colon. - The primary features (pruritus, high SALP, AMA+) point directly to PBC, not the common clinical manifestations or liver associations typically seen with **Crohn's Disease**.

Q: Based on the image provided, what is the most appropriate confirmatory investigation?

Manometry. ***Manometry*** - Esophageal manometry is the **gold standard** (confirmatory test) for achalasia, as it directly evaluates the motility and pressure patterns of the esophagus. - It definitively demonstrates the two key pathognomonic findings: **absent esophageal peristalsis** and **incomplete relaxation of the lower esophageal sphincter (LES)**. *pH monitoring* - This test is used primarily to diagnose **Gastroesophageal Reflux Disease (GERD)** by quantifying abnormal acid exposure in the distal esophagus. - It is not relevant for confirming achalasia, which is a **motor disorder** causing functional obstruction, not acid reflux. *Upper GI Endoscopy* - Endoscopy is crucial for **ruling out secondary achalasia** (pseudoachalasia), caused by underlying conditions like malignancy, which can structurally mimic the radiologic findings. - Although mandatory in evaluation, it does not confirm the **functional motor deficit** (aperistalsis and failed relaxation) required for definitive diagnosis of primary achalasia. *Barium swallow study* - The image provided is a Barium swallow study, which serves as the **initial screening tool** for achalasia by showing the classic **"bird-beak" appearance** of the distal esophagus. - While suggestive, this radiological study reports morphology and transit, but **manometry** is required to confirm the associated physiological defect (abnormal pressures and motility).

Q: A person with jaundice presented with a history of bleeding and symptoms normalised after giving Vitamin K injection. The probable cause is?

Biliary obstruction. ***Biliary obstruction*** - **Biliary obstruction** (Cholestasis) prevents the flow of bile into the duodenum, impairing the absorption of **fat-soluble vitamins** (A, D, E, K) [1]. - **Vitamin K** deficiency leads to impaired synthesis of **coagulation factors II, VII, IX, and X** in the liver, causing a coagulopathy (bleeding tendency) that is corrected by parenteral Vitamin K administration [2]. *Alpha antitrypsin deficiency* - This typically causes liver disease (cirrhosis) and emphysema, but the bleeding issues are due to general hepatic synthetic failure, meaning the coagulopathy would usually be **refractory to simple Vitamin K injection** [1]. - The deficiency is mainly linked to **panacinar emphysema** and pediatric/adult liver failure presentations, not primarily a **Vitamin K-responsive coagulopathy**. *Autoimmune hepatitis* - This condition causes chronic inflammation and destruction of hepatocytes, leading to liver failure and cirrhosis; the resulting coagulopathy is due to **synthetic dysfunction**. - Coagulopathy from severe autoimmune hepatitis is typically **not fully corrected** by Vitamin K injection alone, requiring fresh frozen plasma (FFP) if bleeding is severe. *Factor XI deficiency* - This is a rare, **autosomal recessive** congenital deficiency (Hemophilia C) not usually associated with jaundice or liver disease. - The bleeding tendency is **not due to Vitamin K malabsorption** or deficiency, and thus would not be corrected by Vitamin K injection.

Q: A patient presents with recurrent oral lesions and eye redness as shown in the images below. The patient also reports a diet poor in dairy and meat products and has noticed increased sensitivity to light. Which test is recommended to confirm the suspected nutritional deficiency in this patient?

Erythrocyte glutathione reductase activation coefficient. ***Erythrocyte glutathione reductase activation coefficient*** - The image on the left shows **glossitis**, and the one on the right shows **ocular inflammation** (conjunctivitis with dilated vessels). These findings are characteristic of **riboflavin (vitamin B2) deficiency**. - **Riboflavin deficiency** classically presents with oral manifestations (glossitis, angular cheilitis) and ocular findings (conjunctivitis, corneal vascularization), along with GI symptoms. - The **erythrocyte glutathione reductase activation coefficient** is the standard test for assessing riboflavin status, as glutathione reductase is a FAD-dependent enzyme whose activity reflects riboflavin availability. *Anti-endothelial cell antibodies* - These antibodies are associated with **vasculitis** and other autoimmune conditions that primarily affect blood vessels. - While some vasculitides can cause ocular inflammation and oral lesions, they don't typically present with the specific combination and appearance of symptoms seen here. *Serum methylmalonic acid levels* - Elevated **serum methylmalonic acid (MMA)** levels are a sensitive indicator of **vitamin B12 deficiency**. - While vitamin B12 deficiency can cause glossitis (inflammation of the tongue), it doesn't typically cause the ocular findings seen here, and MMA is not the appropriate test for the findings depicted. *Anti-endomysial antibodies* - **Anti-endomysial antibodies** are highly specific for **celiac disease**. - The findings depicted — glossitis and ocular inflammation — are more consistent with riboflavin deficiency than with celiac disease, making this test less appropriate in this clinical context.

Q: A 42-year-old obese chronic smoker complains of progressive dysphagia to solids, retrosternal heart burn along with sour brash for a period of 6 years. Based on the barium swallow and endoscopic image provided, what is the diagnosis?

Stricture esophagus. ***Stricture esophagus*** - The long-standing history of **progressive dysphagia to solids**, **retrosternal heartburn**, and **sour brash** in an obese chronic smoker strongly suggests **gastroesophageal reflux disease (GERD)**. - Chronic unmanaged GERD can lead to complications such as **esophageal stricture** due to inflammation and scarring, causing further narrowing and dysphagia. - The barium swallow image shows a focal, circumferential esophageal narrowing in the mid-esophagus with mild dilatation proximal to it, and the endoscopic image reveals a concentric narrowing with inflamed, irregular mucosa — findings characteristic of a peptic stricture. *Schatzki's rings* - These are **mucosal rings** that develop at the **esophagogastric junction**. While they cause dysphagia, they typically don't present with persistent, severe heartburn or sour brash for 6 years as the primary symptoms of GERD, but rather as an anatomical cause of dysphagia. - The image given indicates a longer, more irregular narrowing characteristic of a stricture rather than a thin, circumferential ring. *Plummer Vinson syndrome* - This syndrome is characterized by **iron deficiency anemia**, **dysphagia** (due to esophageal webs), and **glossitis**. - The patient's presentation does not include anemia or glossitis, making this diagnosis less likely. *Esophageal dysmotility* - Esophageal dysmotility disorders (e.g., **achalasia**, **diffuse esophageal spasm**) can cause dysphagia and chest pain. - However, they are less commonly associated with significant, long-standing **sour brash** and **heartburn** as the primary symptoms, which are hallmarks of GERD leading to stricture.

Q: A 28-year-old pregnant female patient complains of hematemesis after an episode of vomiting. On upper GI endoscopy this is the appearance. What is the most common site of this condition?

Cardia. ***Cardia*** - The image shown, combined with the history of hematemesis after vomiting in a pregnant patient, is highly suggestive of **Mallory-Weiss tear**. - These tears typically occur at the **gastroesophageal junction**, most commonly on the gastric side in the **adjacent gastric cardia**. *Lower 1/3 of esophagus* - While Mallory-Weiss tears can extend into the lower esophagus, the most common location is the gastroesophageal junction on the gastric side, i.e., the cardia, rather than the esophageal side. - The lower third of the esophagus is a less frequent site compared to the gastric cardia. *Middle 1/3 of esophagus* - Tears in the middle esophagus are less common for Mallory-Weiss syndrome, which is primarily a condition of the **gastroesophageal junction** and **gastric cardia**. - While other esophageal pathologies can occur here, such as varices or esophagitis, they are less typically associated with the classic Mallory-Weiss presentation. *Lesser curvature of stomach* - The lesser curvature of the stomach is a common site for **peptic ulcers**, which can also cause hematemesis. - However, the clinical context of **retching and vomiting followed by hematemesis** points specifically to a Mallory-Weiss tear, which is located more proximally at the gastroesophageal junction and gastric cardia.

Q: A 76-year-old male presents to emergency with abdominal pain after binge drinking. The BP on admission is 80/50 mm Hg and pulse rate of 120 BPM. Serum creatinine = 2.5 mg% with elevated liver transaminases. The hypotension and renal failure persisted for more than 48 hours despite adequate resuscitation. What is the likely diagnosis based on CT image shown below? (AlIMS May 2016)

Severe acute pancreatitis. ***Severe acute pancreatitis*** - The CT image shows marked **peripancreatic fat stranding**, fluid collections (arrowheads), and heterogeneity of the pancreatic parenchyma, consistent with **severe acute pancreatitis**. - Under the revised Atlanta classification, **severe acute pancreatitis** is defined by **persistent organ failure lasting more than 48 hours**. In this patient, both **circulatory failure (BP 80/50, HR 120)** and **renal failure (creatinine 2.5 mg%)** persisted for more than 48 hours despite adequate resuscitation, fulfilling the criteria for severe acute pancreatitis. *Liver abscess* - A liver abscess would typically appear as a **well-defined, hypodense lesion** within the liver parenchyma on CT, often with a rim enhancement; these features are not predominant in the CT provided. - While binge drinking can increase the risk of liver disease, the diffuse pancreatic inflammation and peripancreatic involvement seen are not characteristic of a primary liver abscess. *Mild acute pancreatitis* - Mild acute pancreatitis is characterized by the **absence of organ failure** and the absence of local or systemic complications under the revised Atlanta classification. - This patient has **persistent organ failure (cardiovascular and renal) lasting more than 48 hours**, which excludes mild acute pancreatitis and classifies the disease as severe. *Acute pyelonephritis* - Acute pyelonephritis would manifest as **renal parenchymal inflammation** and edema on CT, often with wedge-shaped areas of decreased enhancement, usually accompanied by fever and flank pain. - The CT image shows **pancreatic and peripancreatic inflammation**, not primarily renal involvement, and the clinical presentation, while severe, is more indicative of intra-abdominal catastrophe following binge drinking.

Q: The given endoscopy of the patient shows? (NEET Pattern 2018)

Eosinophilic esophagitis. **Eosinophilic esophagitis** - The endoscopic image displays prominent **concentric rings** (trachealization) and **linear furrows**, which are classic findings in eosinophilic esophagitis. - These features result from chronic inflammation and fibrosis caused by an allergic reaction leading to significant eosinophil infiltration in the esophageal wall. *Radiation esophagitis* - Endoscopic findings in radiation esophagitis typically include **erythema**, **edema**, **ulcerations**, or **strictures** in the irradiated field. - The characteristic ringed appearance seen in the image is not typical for radiation-induced injury. *GERD* - Endoscopic signs of GERD often include **erosions**, **ulcerations**, **strictures**, or **Barrett's esophagus**, usually in the distal esophagus. - While chronic GERD can cause inflammation, it typically does not produce the pronounced concentric rings and linear furrows characteristic of eosinophilic esophagitis. *Carcinoma esophagus* - Esophageal carcinoma typically presents with a **mass**, **ulceration**, **stricture**, or an **irregular, friable lesion**. - The image does not show any focal mass or destructive lesion suggestive of malignancy.

Question 1

A 52-year-old male with chronic hepatitis B presents with progressive abdominal distension and weight loss. Examination reveals ascites and splenomegaly. Serum alpha-fetoprotein is 450 ng/mL (normal <10 ng/mL). Triphasic CT abdomen shows a 6 cm hypervascular lesion in the right lobe with arterial enhancement and washout in portal venous phase. What is the most likely diagnosis?

Accepted Answer

Hepatocellular carcinoma

Answer

Liver metastasis

Answer

Hepatic adenoma

Answer

Focal nodular hyperplasia

Question 2

A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon, asymmetric mural thickening, skip lesions with terminal ileal involvement, and creeping fat along the mesenteric border. What is the most likely diagnosis?

Accepted Answer

Crohns disease

Answer

Ulcerative colitis

Answer

Tubercular colitis

Answer

Pseudomembranous enterocolitis

Question 3

The patient presents with fatigue and pruritus. LFT shows gross SALP elevation and elevated conjugated bilirubin. AMA is seen with liver biopsy shows florid bile ductular lesions. Diagnosis is

Accepted Answer

PBC

Answer

UC

Answer

CD

Answer

PSC

Question 4

Based on the image provided, what is the most appropriate confirmatory investigation?

Accepted Answer

Manometry

Answer

Barium swallow study

Answer

Upper GI Endoscopy

Answer

pH monitoring

Question 5

A person with jaundice presented with a history of bleeding and symptoms normalised after giving Vitamin K injection. The probable cause is?

Accepted Answer

Biliary obstruction

Answer

Autoimmune hepatitis

Answer

Alpha antitrypsin deficiency

Answer

Factor XI deficiency

Question 6

A patient presents with recurrent oral lesions and eye redness as shown in the images below. The patient also reports a diet poor in dairy and meat products and has noticed increased sensitivity to light. Which test is recommended to confirm the suspected nutritional deficiency in this patient?

Accepted Answer

Erythrocyte glutathione reductase activation coefficient

Answer

Anti-endothelial cell antibodies

Answer

Serum methylmalonic acid levels

Answer

Anti-endomysial antibodies

Question 7

A 42-year-old obese chronic smoker complains of progressive dysphagia to solids, retrosternal heart burn along with sour brash for a period of 6 years. Based on the barium swallow and endoscopic image provided, what is the diagnosis?

Accepted Answer

Stricture esophagus

Answer

Schatzki's rings

Answer

Plummer vinson syndrome

Answer

Esophageal dysmotility

Question 8

A 28-year-old pregnant female patient complains of hematemesis after an episode of vomiting. On upper GI endoscopy this is the appearance. What is the most common site of this condition?

Accepted Answer

Cardia

Answer

Middle $1 / 3$ of esophagus

Answer

Lower $1 / 3$ of the esophagus

Answer

Lesser curvature of stomach

Question 9

A 76-year-old male presents to emergency with abdominal pain after binge drinking. The BP on admission is 80/50 mm Hg and pulse rate of 120 BPM. Serum creatinine = 2.5 mg% with elevated liver transaminases. The hypotension and renal failure persisted for more than 48 hours despite adequate resuscitation. What is the likely diagnosis based on CT image shown below? (AlIMS May 2016)

Accepted Answer

Severe acute pancreatitis

Answer

Liver abscess

Answer

Mild acute pancreatitis

Answer

Acute pyelonephritis

Question 10

The given endoscopy of the patient shows? (NEET Pattern 2018)

Accepted Answer

Eosinophilic esophagitis

Answer

Radiation esophagitis

Answer

GERD

Answer

Carcinoma esophagus

Gastroenterology — MCQs

Gastroenterology — MCQs

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