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: Why does not every Helicobacter pylori infection lead to ulcers?

Majority of H. pylori infections are asymptomatic. The vast majority of H. pylori infections are asymptomatic or cause only mild gastritis, meaning the organism's presence alone is not sufficient to cause pathology [1]. Only a small percentage (around 10-20%) of individuals infected with Helicobacter pylori will develop a peptic ulcer or gastric malignancy [1]. The organism generally colonizes the gastric antrum, leading to chronic gastritis and potentially ulcers through increased gastrin and acid secretion; however, in most people, this subsequent hypergastrinaemia has no clinical consequences [1]. Host factors and environmental influences determine who develops ulcers, but the baseline state is generally non-ulcerative gastritis. While increased risk of peptic ulcer disease occurs when H. pylori is present with NSAIDs, these are cofactors that damage the mucosal barrier and do not explain the high rate of asymptomatic carriage in the general population.

Q: Which of the following is wrongly matched with its classification?

LA classification - Achalasia. ***LA classification - Achalasia*** - The **Los Angeles (LA) classification** system is used to grade the severity of **reflux esophagitis** (Esme of the gastric mucosa, typically following **Gastroesophageal Reflux Disease (GERD)**). - **Achalasia** is typically classified using the **Chicago Classification** (based on high-resolution manometry findings) [1] or the older **Siewert classification** for surgical staging. ***Boston classification - Colon preparation for colonoscopy*** - The **Boston Bowel Preparation Scale (BBPS)** is a validated, widely used scoring system to assess the quality of **colon preparation** during colonoscopy, ranging from 0 (unprepared) to 3 (excellent) for each segment. - A high BBPS score (typically $\ge$ 7) indicates adequate preparation necessary for accurate polyp detection. ***Mannheim classification - Chronic pancreatitis*** - The **Mannheim Classification System** is used for grading the severity of **acute pancreatitis**, not chronic pancreatitis. - It assesses clinical parameters (e.g., organ failure, complications) to predict the prognosis and guide management of acute pancreatitis. ***Miami classification - Parathyroid adenoma and hyperplasia differentiation*** - The **Miami Criteria** is a histological classification system used to distinguish between **parathyroid adenoma** and **parathyroid hyperplasia** based on architectural and cellular features observed on surgical pathology. - It helps pathologists determine the underlying cause of primary hyperparathyroidism.

Q: A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?

Crohns disease. ***Crohns disease*** - Crohn's disease is characterized by **transmural inflammation**, which can lead to fibrosis and rigidity of the bowel wall, resulting in an ahaustral appearance. Its predilection for the **ileocecal region** makes right-sided colon involvement a classic presentation. - The disease course is chronic with relapsing and remitting symptoms like non-bloody diarrhea and abdominal pain. It is also known for its **skip lesions**, where inflamed segments of the bowel are interspersed with normal tissue. ***Ulcerative colitis*** - While chronic ulcerative colitis can cause an ahaustral or "**lead pipe**" colon, it classically starts in the **rectum** and extends proximally in a continuous manner. Isolated right colon involvement is very rare. - Inflammation in UC is limited to the **mucosa and submucosa**, unlike the transmural inflammation seen in Crohn's disease. ***Tubercular colitis*** - Intestinal tuberculosis commonly affects the **ileocecal region**, mimicking Crohn's disease clinically and radiologically. It can cause bowel wall thickening and strictures. - Differentiating features include the presence of **caseating granulomas** on histology, constitutional symptoms like fever and night sweats, and often a gaping ileocecal valve (**Fleischner sign**). ***Pseudomembranous enterocolitis*** - This is an **acute inflammatory condition** caused by *Clostridium difficile* toxins, usually following antibiotic therapy. It does not present as a chronic illness lasting for months. - Typical CT findings are acute, such as severe colonic wall thickening and edema (the "**accordion sign**"), not the chronic fibrotic changes that lead to an ahaustral appearance.

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: Which one of following statements is correct regarding Budd-Chiari Syndrome (BCS)?

Abdominal discomfort and ascites are the main presenting features.. ***Abdominal discomfort and ascites are the main presenting features.*** - **Budd-Chiari syndrome** is characterized by the obstruction of hepatic venous outflow, leading to increased sinusoidal pressure, liver congestion, and eventually **ascites** and **abdominal discomfort** due to liver enlargement and peritoneal fluid. - The rapid accumulation of **ascites** is a hallmark symptom, often accompanied by hepatomegaly and jaundice. *Venous drainage of the liver is occluded by IVC thrombus.* - While Budd-Chiari syndrome involves obstruction of hepatic venous outflow, the primary site of occlusion is typically the **hepatic veins** themselves, not the **inferior vena cava (IVC)** alone [1]. - Though IVC obstruction can occur, it's not the defining feature of Budd-Chiari syndrome; the key is the involvement of the hepatic veins [1]. *It principally affects young males.* - **Budd-Chiari syndrome** can affect individuals of any age or gender, but it often has a predilection for **young to middle-aged women**, especially those with predisposing conditions like oral contraceptive use or hypercoagulable states. - The clinical presentation is more diverse and not exclusively tied to a specific gender or age group. *Quadrate lobe (Segment 4) undergoes hypertrophy.* - In Budd-Chiari syndrome, typically the **caudate lobe (Segment 1)** is spared from outflow obstruction due to its direct drainage into the IVC, leading to its compensatory hypertrophy. - Other liver segments, including the quadrate lobe (Segment 4), usually experience relative atrophy or normal size compared to the hypertrophied caudate lobe.

Q: Which one of the following is considered the gold standard for the diagnosis of oesophageal motility disorders?

High resolution manometry. ***High resolution manometry*** - **High-resolution manometry (HRM)** is considered the **gold standard** for diagnosing oesophageal motility disorders because it provides detailed, real-time pressure topography of the entire oesophagus during swallowing [1]. - It allows for precise identification and classification of conditions such as **achalasia**, diffuse oesophageal spasm, and **scleroderma oesophagus** based on objective metrics [1]. *Upper GI endoscopy* - While essential for evaluating **mucosal abnormalities** and ruling out structural causes (e.g., tumours, strictures), it does not directly assess oesophageal motility [1]. - An **endoscopy** provides visual information but cannot quantify or characterize the contractile function of the oesophageal muscle [1]. *Contrast enhanced CT scan (CECT) oesophagus* - A **CECT scan** is primarily used for evaluating **extramural compression**, mediastinal involvement, or the presence of mass lesions, not for assessing the functional contractions of the oesophagus. - It provides anatomical information but offers very limited insight into the dynamic pressure changes associated with **oesophageal peristalsis**. *Barium swallow* - A **barium swallow** can suggest motility disorders by visualizing the passage of contrast and identifying abnormalities like **tertiary contractions** or delayed emptying, but it is less precise than manometry [1]. - It provides an anatomical overview and may show gross motility disturbances, but it lacks the quantitative and detailed pressure data that **HRM** offers for definitive diagnosis [1].

Q: Which one of the following statements is not correct regarding Gastric outlet obstruction associated with long standing peptic ulcer disease?

Medical therapy has no role in the treatment of this condition.. ***Medical therapy has no role in the treatment of this condition.*** - This statement is incorrect because **medical management**, including **proton pump inhibitors (PPIs)**, can be effective in reducing inflammation and ulcer healing, which may alleviate symptoms of **gastric outlet obstruction (GOO)**, especially in cases where the obstruction is due to an active ulcer and associated edema. - While surgery is often required for persistent or severe obstruction, initial medical therapy can be attempted to confirm the reversibility of the obstruction or to optimize the patient's condition before surgical intervention. *Endoscopic biopsy is essential to exclude malignancy.* [1] - **Endoscopic biopsy** is crucial because **malignancy** (e.g., gastric adenocarcinoma) can present with symptoms similar to peptic ulcer disease and lead to **gastric outlet obstruction**. - Distinguishing between benign and malignant causes is critical for appropriate management, as the treatment strategies differ significantly. [1] *Hypochloraemic alkalosis is the usual metabolic abnormality in such cases.* [1] - **Hypochloremic alkalosis** occurs due to the repeated **vomiting of gastric contents**, which are rich in hydrochloric acid. [1] - This loss of acid and chloride, along with fluid depletion, leads to increased bicarbonate retention by the kidneys and can cause a metabolic alkalosis with low chloride levels. *Operation is frequently required along with a drainage procedure.* [1] - When medical therapy fails or the obstruction is severe due to **scarring and fibrosis** from chronic peptic ulcer disease, surgical intervention is often necessary. - A drainage procedure, such as **gastrojejunostomy**, is performed to bypass the obstructed pylorus and restore gastric emptying.

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

Why does not every Helicobacter pylori infection lead to ulcers?

Accepted Answer

Majority of H. pylori infections are asymptomatic

Answer

H. pylori infects the antrum even in asymptomatic individuals

Answer

Disease associated with host factors and environmental influences

Answer

Increased risk of peptic ulcer disease when H. pylori is present with NSAIDs

Question 3

Which of the following is wrongly matched with its classification?

Accepted Answer

LA classification - Achalasia

Answer

Boston classification - Colon preparation for colonoscopy

Answer

Mannheim classification - Chronic pancreatitis

Answer

Miami classification - Parathyroid adenoma and hyperplasia differentiation

Question 4

A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?

Accepted Answer

Crohns disease

Answer

Ulcerative colitis

Answer

Tubercular colitis

Answer

Pseudomembranous enterocolitis

Question 5

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 6

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 7

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 8

Which one of following statements is correct regarding Budd-Chiari Syndrome (BCS)?

Accepted Answer

Abdominal discomfort and ascites are the main presenting features.

Answer

Venous drainage of the liver is occluded by IVC thrombus.

Answer

It principally affects young males.

Answer

Quadrate lobe (Segment 4) undergoes hypertrophy.

Question 9

Which one of the following is considered the gold standard for the diagnosis of oesophageal motility disorders?

Accepted Answer

High resolution manometry

Answer

Upper GI endoscopy

Answer

Contrast enhanced CT scan (CECT) oesophagus

Answer

Barium swallow

Question 10

Which one of the following statements is not correct regarding Gastric outlet obstruction associated with long standing peptic ulcer disease?

Accepted Answer

Medical therapy has no role in the treatment of this condition.

Answer

Endoscopic biopsy is essential to exclude malignancy.

Answer

Hypochloraemic alkalosis is the usual metabolic abnormality in such cases.

Answer

Operation is frequently required along with a drainage procedure.

Gastroenterology — MCQs

Gastroenterology — MCQs

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