Gastroenterology Practice Questions

Q: Which of the following is false about obstructive jaundice?

Unconjugated bilirubin elevation. ***Unconjugated bilirubin elevation*** - In **obstructive jaundice**, the primary issue is the obstruction of bile flow, preventing conjugated bilirubin (which is water-soluble) from entering the GI tract [1]. - This leads to a buildup of **conjugated bilirubin** in the bloodstream, not unconjugated bilirubin, making this statement false [1]. *Pruritus* - **Pruritus**, or itching, is a common symptom of obstructive jaundice due to the accumulation of **bile salts** in the skin. - These bile salts irritate nerve endings, leading to intense itching. *Icterus* - **Icterus**, or jaundice, is the yellow discoloration of the skin and sclera caused by the accumulation of **bilirubin** (primarily conjugated bilirubin in this case) in the tissues [2]. - This is a hallmark sign of both obstructive and non-obstructive jaundice [2]. *Pale stools* - **Pale stools** (acholic stools) are characteristic of obstructive jaundice because **bilirubin** which gives stool its normal brown color, is unable to reach the intestines [1], [2]. - Undigested fats may also contribute to the pale, sometimes greasy appearance of the stool.

Q: Which is not a component of Ranson's criteria for acute pancreatitis?

Serum lipase. ***Serum lipase*** - **Serum lipase** is not a component of Ranson's criteria. While it is a crucial diagnostic marker for acute pancreatitis, Ranson's criteria focus on other clinical and laboratory values for predicting severity. - The criteria were developed before widespread availability and use of lipase as a primary diagnostic marker for pancreatitis. *Age* - **Age** is a component of Ranson's criteria, specifically "Age > 55 years" for admission and initial assessment [1]. - Older age is associated with increased severity and mortality in acute pancreatitis due to decreased physiologic reserve [1]. *Base deficit* - **Base deficit** is a component of Ranson's criteria, specifically "Base deficit > 4 mEq/L" after 48 hours. - A significant base deficit indicates **metabolic acidosis**, which is a marker of severe systemic inflammation and organ dysfunction in acute pancreatitis. *Blood glucose* - **Blood glucose** is a component of Ranson's criteria, specifically "Blood glucose > 200 mg/dL (11.1 mmol/L)" for admission and initial assessment. - Elevated blood glucose can reflect the severity of pancreatic inflammation and insult to the **islet cells**, or systemic stress response.

Q: In acute pancreatitis, organ failure beyond 48 hours indicates:

Severe pancreatitis. ***Severe pancreatitis*** - **Severe pancreatitis** is defined by the presence of **persistent organ failure**, meaning organ failure lasting longer than 48 hours [1]. - This classification is crucial for predicting prognosis and guiding management, as severe pancreatitis carries a significantly higher risk of complications and mortality [1]. *Critical pancreatitis* - "Critical pancreatitis" is not a standard, recognized classification term in the revised Atlanta Classification for acute pancreatitis. - The classification primarily focuses on differentiating between mild, moderately severe, and severe forms based on local and systemic complications, particularly organ failure [1]. *Mild pancreatitis* - **Mild pancreatitis** is characterized by the absence of organ failure and local or systemic complications [1]. - Patients with mild pancreatitis typically have a benign course and recover without significant morbidity. *Moderately severe* - **Moderately severe pancreatitis** is defined by the presence of **transient organ failure** (resolves within 48 hours) or local complications (e.g., fluid collections, necrosis) without persistent organ failure [1]. - While more serious than mild pancreatitis, it does not involve the sustained organ dysfunction seen in severe cases.

Q: A 60-year-old presents with hematochezia, Hb 7g/dl. Upper GI endoscopy normal. Next investigation?

Colonoscopy. ***Colonoscopy*** - **Hematochezia** (bright red blood per rectum) typically indicates **lower GI bleeding**, most commonly from the **colon or rectum**. After normal upper GI endoscopy, colonoscopy is the standard next investigation [1]. - Colonoscopy allows both **diagnostic visualization** of the entire colon and **therapeutic intervention** (e.g., **polypectomy**, **coagulation**) for bleeding lesions like **diverticular bleeding**, **angiodysplasia**, or **colorectal malignancy** [3]. *Push enteroscopy* - Push enteroscopy is indicated for **obscure GI bleeding** only after **both upper endoscopy and colonoscopy** have been performed and found normal [2]. - It evaluates the **proximal small bowel** but would not be the immediate next step when hematochezia suggests a **colonic source** that hasn't been evaluated yet. *Capsule endoscopy* - Capsule endoscopy is reserved for **obscure GI bleeding** after negative upper and lower endoscopy, primarily to evaluate the **entire small bowel** [2]. - It provides only **diagnostic information** without therapeutic capability and would be inappropriate before evaluating the colon in a patient with hematochezia [1]. *CT angiogram* - CT angiogram is useful for **rapid active arterial bleeding** (>0.5-1.0 mL/min) when **contrast extravasation** can be detected, or when endoscopy is not feasible. - It's typically reserved for **hemodynamically unstable** patients or when initial endoscopic evaluation fails to identify the bleeding source.

Q: Assertion: Beta blockers improve survival in cirrhosis with varices. Reason: They reduce cardiac output and splanchnic blood flow.

Both A & R true, R explains A. ***Both A & R true, R explains A*** - **Beta blockers** improve survival in patients with **cirrhosis and varices** by reducing the risk of **variceal bleeding**, a major cause of mortality [1]. - This is achieved by lowering **portal pressure** primarily through reducing **cardiac output** (beta-1 blockade) and causing **splanchnic vasoconstriction** (beta-2 blockade), thereby decreasing splanchnic blood flow. *Both A & R true, R doesn't explain A* - The reasoning provided (reduction in cardiac output and splanchnic blood flow) directly explains the mechanism by which **beta blockers** reduce **portal pressure** and subsequently prevent **variceal bleeding**, thus improving survival [1]. - Therefore, the reason *does* explain the assertion. *A true R false* - The assertion that **beta blockers** improve survival in cirrhosis with varices is **true**. - The reason—that they reduce cardiac output and splanchnic blood flow—is also **true** and describes their key mechanism of action in this context. *A false R true* - The assertion is **true**: non-selective **beta blockers** are a cornerstone in the primary and secondary prophylaxis of **variceal hemorrhage** in **cirrhosis**, improving survival. - The reason is also **true**, as these mechanisms are well-established pharmacological effects of **beta blockers** leading to reduced **portal hypertension** [1].

Q: Which finding best predicts poor outcome in acute pancreatitis at admission?

Ranson score >3. ***Ranson score >3*** - A **Ranson score** greater than 3 on admission is a strong predictor of **severe acute pancreatitis** and increased **mortality** [1]. - The Ranson criteria assess multiple parameters, including age, WBC count, LDH, AST, and glucose, providing a comprehensive risk assessment [1]. *Serum lipase >1000* - An elevated **serum lipase level** is highly diagnostic of acute pancreatitis but does not directly correlate with disease severity or prognosis. - While reflecting pancreatic inflammation, lipase levels often do not predict the development of **organ failure** or **necrotizing pancreatitis** [1]. *Blood glucose >200* - **Hyperglycemia** at admission is one of the Ranson criteria, but as a single parameter, it is not as strong a predictor of poor outcome as the complete score. - Isolated high glucose can be due to stress or pre-existing **diabetes**, contributing to some severity but not sufficient for widespread poor prognosis without other factors. *Pleural effusion* - **Pleural effusion** can be a complication of severe pancreatitis, indicating surrounding inflammation. - However, its presence at admission, without other markers of severity, is less predictive of overall poor outcome than a validated scoring system like the Ranson score which assesses multiple systemic factors.

Q: In a patient with cirrhosis, which finding indicates worst prognosis according to Child-Pugh score?

Grade 3 encephalopathy. ***Grade 3 encephalopathy*** - According to the **Child-Pugh score**, **grade 3 or 4 encephalopathy** is assigned the highest score (3 points) in the encephalopathy category, indicating the severest form and poorest prognosis [1]. - Higher grades of encephalopathy reflect significant **neurological dysfunction** due to impaired liver detoxification [1]. *PT prolonged by 4 seconds* - A **prothrombin time (PT)** prolongation of 4-6 seconds beyond control receives 2 points, while PT prolonged >6 seconds beyond control receives 3 points in the Child-Pugh score [1]. - While significant, a 4-second prolongation (2 points) is less severe than grade 3 encephalopathy (3 points). *Serum albumin 2.8 g/dL* - A **serum albumin level** between 2.8 and 3.5 g/dL receives 2 points in the Child-Pugh score [1]. - This value indicates moderate liver dysfunction but is not the highest score achievable within the Child-Pugh system. *Moderate ascites* - **Moderate ascites** that is responsive to diuretics receives 2 points in the Child-Pugh score [1]. - **Refractory ascites** receives 3 points, but "moderate ascites" alone typically implies a milder form with a better prognosis than grade 3 encephalopathy due to its lower score [1].

Q: A patient with cirrhosis develops spontaneous bacterial peritonitis. Which factor most strongly predicts poor prognosis?

Serum creatinine >2 mg/dL. ***Serum creatinine >2 mg/dL*** - Elevated **serum creatinine** in the context of spontaneous bacterial peritonitis (SBP) indicates **renal impairment** or **acute kidney injury**, which is a strong predictor of poor prognosis and increased mortality [1]. - Renal dysfunction significantly complicates the management of cirrhosis and SBP, leading to higher rates of complications and reduced survival [1]. *Ascitic protein >2.5 g/dL* - A low ascitic protein level ( 2.5 g/dL might indicate a secondary bacterial peritonitis or other causes of ascites, but it is not typically a predictor of poor prognosis in SBP itself [2]. *Total count >25000/mm3* - While a high total white blood cell count in ascitic fluid (specifically **polymorphonuclear (PMN) count >250 cells/mm3**) is diagnostic of SBP, an extremely high total count (like >25,000/mm3) is not the strongest predictor of *poor prognosis* compared to renal dysfunction. - It might suggest a more severe infection, but **renal compromise** has a greater impact on mortality. *Positive blood culture* - A positive blood culture in SBP indicates **bacteremia**, which is associated with a more severe infection and higher mortality rates than SBP without bacteremia. - However, **renal impairment** (serum creatinine >2 mg/dL) typically carries a *graver prognostic significance* as it reflects organ system failure beyond the infection itself [1].

Q: Most specific serological marker for celiac disease?

Anti-tissue transglutaminase. ***Anti-tissue transglutaminase*** - **Anti-tissue transglutaminase (tTG) antibodies**, especially the IgA class, are the **most sensitive and specific serological test** for diagnosing celiac disease. - They target the enzyme **tissue transglutaminase**, which deamidates gliadin peptides, making them more immunogenic. *Anti-gliadin antibody* - **Anti-gliadin antibodies (AGA)**, both IgA and IgG, were historically used but have **lower sensitivity and specificity** compared to newer markers. - Their primary role today is limited, particularly in children under 2 years old or in cases with IgA deficiency, where **IgG-AGA** might be considered. *Anti-reticulin antibody* - **Anti-reticulin antibodies (ARA)** are another serological marker for celiac disease, but they have **lower sensitivity and specificity** than anti-tTG and anti-endomysial antibodies. - Due to their lower diagnostic accuracy, they are **rarely used** in routine clinical practice for celiac disease screening. *Anti-endomysial antibody* - **Anti-endomysial antibodies (EMA)** are highly specific for celiac disease, with nearly 100% specificity, but they are **less sensitive** than anti-tTG antibodies. - The test is **operator-dependent** and typically performed by indirect immunofluorescence on primate esophagus, making it more expensive and less readily available than anti-tTG.

Q: A chronic alcoholic patient came to emergency with severe pain in epigastrium and multiple episodes of vomiting. On examination, guarding was present in upper epigastrium. Chest X-ray was normal. What is the next best step?

Serum lipase. ***Serum lipase*** - The patient's presentation with acute epigastric pain, vomiting, guarding, and a history of chronic alcoholism strongly suggests **acute pancreatitis** [1]. - **Serum lipase** is highly sensitive and specific for diagnosing acute pancreatitis, with levels typically elevated to at least three times the upper limit of normal. *CECT* - While **CECT (Contrast-Enhanced Computed Tomography)** is excellent for assessing the severity and complications of pancreatitis, it is generally not the initial diagnostic test for suspected acute pancreatitis [1]. - CT scans are usually performed if the diagnosis is unclear or if complications like **necrosis** or **fluid collections** are suspected after initial laboratory tests. *Alcohol breath test* - An **alcohol breath test** would confirm recent alcohol consumption but does not directly diagnose the cause of the patient's acute abdominal pain [2]. - While chronic alcoholism is a risk factor for pancreatitis, this test does not provide specific information about the underlying medical emergency. *Upper GI endoscopy* - **Upper GI endoscopy** is primarily used to evaluate conditions affecting the esophagus, stomach, and duodenum, such as **ulcers** or **gastritis**. - It would not be the initial diagnostic step for suspected pancreatitis, as it does not directly visualize the pancreas and carries risks in an acutely ill patient.

Question 1

Which of the following is false about obstructive jaundice?

Accepted Answer

Unconjugated bilirubin elevation

Answer

Pruritus

Answer

Icterus

Answer

Pale stools

Question 2

Which is not a component of Ranson's criteria for acute pancreatitis?

Accepted Answer

Serum lipase

Answer

Age

Answer

Base deficit

Answer

Blood glucose

Question 3

In acute pancreatitis, organ failure beyond 48 hours indicates:

Accepted Answer

Severe pancreatitis

Answer

Critical pancreatitis

Answer

Mild pancreatitis

Answer

Moderately severe

Question 4

A 60-year-old presents with hematochezia, Hb 7g/dl. Upper GI endoscopy normal. Next investigation?

Accepted Answer

Colonoscopy

Answer

Capsule endoscopy

Answer

CT angiogram

Answer

Push enteroscopy

Question 5

Assertion: Beta blockers improve survival in cirrhosis with varices. Reason: They reduce cardiac output and splanchnic blood flow.

Accepted Answer

Both A & R true, R explains A

Answer

Both A & R true, R doesn't explain A

Answer

A true R false

Answer

A false R true

Question 6

Which finding best predicts poor outcome in acute pancreatitis at admission?

Accepted Answer

Ranson score >3

Answer

Serum lipase >1000

Answer

Blood glucose >200

Answer

Pleural effusion

Question 7

In a patient with cirrhosis, which finding indicates worst prognosis according to Child-Pugh score?

Accepted Answer

Grade 3 encephalopathy

Answer

PT prolonged by 4 seconds

Answer

Serum albumin 2.8 g/dL

Answer

Moderate ascites

Question 8

A patient with cirrhosis develops spontaneous bacterial peritonitis. Which factor most strongly predicts poor prognosis?

Accepted Answer

Serum creatinine >2 mg/dL

Answer

Ascitic protein >2.5 g/dL

Answer

Total count >25000/mm3

Answer

Positive blood culture

Question 9

Most specific serological marker for celiac disease?

Accepted Answer

Anti-tissue transglutaminase

Answer

Anti-gliadin antibody

Answer

Anti-reticulin antibody

Answer

Anti-endomysial antibody

Question 10

A chronic alcoholic patient came to emergency with severe pain in epigastrium and multiple episodes of vomiting. On examination, guarding was present in upper epigastrium. Chest X-ray was normal. What is the next best step?

Accepted Answer

Serum lipase

Answer

CECT

Answer

Alcohol breath test

Answer

Upper GI endoscopy

Gastroenterology — MCQs

Gastroenterology — MCQs

On this page

Practice by Chapter

Want unlimited practice?