Inflammatory Bowel Disease — MCQs
Toxic megacolon is seen in -
Which is TRUE about granulomas in Crohn's disease?
Skip lesions with non-caseating granulomas is characteristic of
A patient presents to the OPD with recurrent diarrhea, abdominal pain, and foul-smelling stools. The colonoscopy reveals the following findings. What is the most likely diagnosis?
Assertion: Crohn's disease only affects the colon. Reason: Crohn's disease typically involves full-thickness inflammation of the bowel wall.
Crohn's disease can be seen in which of the following locations?
All of the following are true about ulcerative colitis except:
A 25-year-old woman presents with bloody diarrhea and is diagnosed with ulcerative colitis. Which of the following conditions is least likely to be associated with it?
A male infant presented with distension of abdomen shortly after birth with delayed passage of meconium. Subsequently a full-thickness biopsy of the rectum was performed. The rectal biopsy is likely to show:
Which of the following features distinguishes Crohn's disease from Ulcerative colitis?
Inflammatory Bowel Disease Indian Medical PG Practice Questions and MCQs
Question 1: Toxic megacolon is seen in -
- A. Crohn's disease
- B. Colonic diverticulosis
- C. Hamartomatous polyp
- D. Chronic nonspecific ulcerative colitis (Correct Answer)
Explanation: ***Chronic nonspecific ulcerative colitis*** - **Toxic megacolon** is a severe complication of **ulcerative colitis**, characterized by acute toxic symptoms and **colonic dilation**. [1] - It results from inflammation extending into the **muscularis propria**, leading to colonic dysfunction and paralysis. *Crohn's disease* - While Crohn's disease can affect any part of the gastrointestinal tract and cause severe inflammation, **toxic megacolon is rarer** in Crohn's than in ulcerative colitis. [1] - Crohn's disease is more commonly associated with **strictures**, **fistulas**, and **skip lesions**. [1] *Colonic diverticulosis* - **Colonic diverticulosis** refers to the presence of small outpouchings in the colon wall, which can become inflamed (diverticulitis). - It does not typically lead to direct **toxic megacolon**, although severe diverticulitis can rarely cause a localized form of colonic distension. *Hamartomatous polyp* - A **hamartomatous polyp** is a non-neoplastic growth that results from an abnormal mixture of normal tissues. - These polyps are associated with various syndromes (e.g., Peutz-Jeghers syndrome) but are **not a cause of toxic megacolon**.
Question 2: Which is TRUE about granulomas in Crohn's disease?
- A. Caseating
- B. Non-caseating (Correct Answer)
- C. Foreign body type
- D. Suppurative
Explanation: ***Non-caseating*** - **Granulomas** in **Crohn's disease** are typically composed of aggregates of **macrophages**, epithelioid cells, and giant cells without central necrosis [1]. - Their presence is a key **histological feature**, though they are only found in a minority of Crohn's disease cases (about 50%) [1]. *Caseating* - **Caseating granulomas** are characterized by a central area of **necrotic cellular debris** resembling cheese. - They are a hallmark of **tuberculosis** and certain fungal infections, not Crohn's disease [2]. *Foreign body type* - **Foreign body granulomas** form in response to inert foreign material and contain **foreign body giant cells** engulfing the material [3]. - While observed in various conditions, they are not the characteristic type of granuloma seen in Crohn's disease. *Suppurative* - **Suppurative granulomas** feature a central collection of **neutrophils** (pus) surrounded by epithelioid cells. - These are typically associated with certain bacterial or fungal infections and are not characteristic of Crohn's disease. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-367. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, p. 109. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 196-197.
Question 3: Skip lesions with non-caseating granulomas is characteristic of
- A. Hodgkin's lymphoma
- B. Ulcerative colitis
- C. Sarcoidosis
- D. Crohn's disease (Correct Answer)
Explanation: ***Crohn's disease*** - **Skip lesions** involve discontinuous areas of inflammation in the GI tract, which is a hallmark of Crohn's disease, unlike the continuous inflammation seen in ulcerative colitis [2], [3]. - The presence of **non-caseating granulomas** (often referred to as tuberculoid granulomas due to their resemblance to tuberculosis granulomas) is a characteristic histological finding in approximately 50% of Crohn's disease cases [1], [2]. *Hodgkin's lymphoma* - This is a type of cancer originating from lymphocytes and typically presents with **lymphadenopathy** and systemic symptoms. - While granulomas can sometimes be found in association with Hodgkin's lymphoma (secondary granulomas due to immune response), **skip lesions** in the GI tract and primary tuberculoid granulomas are not characteristic diagnostic features. *Ulcerative colitis* - Ulcerative colitis is characterized by **continuous inflammation** that starts in the rectum and can extend proximally through the colon, contrasting with the skip lesions of Crohn's [3]. - It primarily affects the **mucosa and submucosa** and typically does not feature transmural inflammation or the formation of granulomas [3]. *Sarcoidosis* - Sarcoidosis is a systemic inflammatory disease characterized by the formation of **non-caseating granulomas** in multiple organs, most commonly the lungs and lymph nodes [4]. - Although it can rarely affect the GI tract, **skip lesions** specific to the patterns seen in inflammatory bowel disease are not a defining feature; its granulomas are found within affected organs generally rather than as discontinuous intestinal lesions. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 366-367. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-366. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 198-200.
Question 4: A patient presents to the OPD with recurrent diarrhea, abdominal pain, and foul-smelling stools. The colonoscopy reveals the following findings. What is the most likely diagnosis?
- A. Pseudomembranous colitis (Correct Answer)
- B. FAP (Familial Adenomatous Polyposis)
- C. Ulcerative colitis
- D. Acute gastritis
Explanation: ***Pseudomembranous colitis*** - The image clearly shows **yellowish-white plaques or pseudomembranes** scattered over the inflamed colonic mucosa, which are characteristic endoscopic findings of **pseudomembranous colitis**. - The clinical symptoms of **recurrent diarrhea**, **abdominal pain**, and **foul-smelling stools** are consistent with this diagnosis, often caused by *Clostridioides difficile* infection. *FAP (Familial Adenomatous Polyposis)* - FAP is characterized by hundreds to thousands of **adenomatous polyps** throughout the colon, usually **smaller and more uniform** in appearance than the pseudomembranes seen here. - While it can cause diarrhea and abdominal pain, the endoscopic appearance of discrete polyps rather than diffuse pseudomembranes differentiates it from the image shown. *Ulcerative colitis* - Ulcerative colitis typically presents with **continuous inflammation** of the colon, often involving **ulcerations, friability, and loss of haustra**, without the distinct pseudomembranes. - Symptoms usually include **bloody diarrhea** and tenesmus, which differ from the foul-smelling stools mentioned. *Acute gastritis* - Acute gastritis is an inflammation of the **stomach lining**, not the colon, and would not be diagnosed via colonoscopy. - Symptoms are usually upper GI-related, such as **epigastric pain, nausea, and vomiting**, not recurrent diarrhea and foul-smelling stools.
Question 5: Assertion: Crohn's disease only affects the colon. Reason: Crohn's disease typically involves full-thickness inflammation of the bowel wall.
- A. Assertion is false, Reason is true (Correct Answer)
- B. Both Assertion and Reason are true, but Reason does not explain Assertion
- C. Both Assertion and Reason are true, and Reason explains Assertion
- D. Both Assertion and Reason are false
Explanation: ***Assertion is false, Reason is true*** - The assertion is false because **Crohn's disease** can affect **any part of the gastrointestinal tract** from the mouth to the anus, not just the colon [1]. - The reason is true; Crohn's disease is characterized by **transmural inflammation**, meaning it involves all layers of the bowel wall. *Both Assertion and Reason are true, but Reason does not explain Assertion* - This option is incorrect because the **assertion itself is false**, as Crohn's disease can affect any part of the GI tract, not just the colon [1]. - While the reason is true regarding transmural inflammation, the premise of the assertion is flawed, making the relationship between the two irrelevant. *Both Assertion and Reason are true, and Reason explains Assertion* - This option is incorrect because the **assertion is false**; Crohn's disease is not limited to the colon. - Therefore, the reason, though true, cannot explain a false assertion. *Both Assertion and Reason are false* - This option is incorrect because the **reason is true**; Crohn's disease is indeed characterized by **full-thickness (transmural) inflammation** of the bowel wall. - Only the assertion is false.
Question 6: Crohn's disease can be seen in which of the following locations?
- A. Jejunum only
- B. Colon only
- C. Terminal ileum and right side
- D. Mouth to anus (Correct Answer)
Explanation: ***Mouth to anus*** - Crohn's disease is a **transmural inflammatory condition** that can affect any part of the gastrointestinal tract, from the mouth to the anus [1]. - This pan-GI involvement is a key characteristic, distinguishing it from other inflammatory bowel diseases [1]. *Jejunum only* - While Crohn's can affect the **jejunum**, it is rarely confined to this segment alone [1]. - Such limited involvement is atypical for the widespread nature of Crohn's disease [1]. *Colon only* - If inflammation were restricted to the **colon only**, it would be more suggestive of **ulcerative colitis**, not Crohn's disease [1]. - Crohn's disease often presents with "skip lesions," meaning affected areas are interspersed with healthy tissue, which is uncommon in diffuse colonic involvement [1]. *Terminal ileum and right side* - Involvement of the **terminal ileum and right colon** is the most common presentation of Crohn's disease [1]. - However, it is not the *only* location, nor does it encompass the full potential extent of the disease throughout the GI tract [1].
Question 7: All of the following are true about ulcerative colitis except:
- A. Surgery is required in a subset of severe cases.
- B. Extra-intestinal problems of UC are managed medically
- C. The highest risk of UC requiring surgery in 1st year
- D. Steroid dependent cases need surgery (Correct Answer)
Explanation: ***Steroid dependent cases need surgery*** - While **steroid dependency** in ulcerative colitis (UC) indicates a need for alternative or escalate medications, it does not automatically necessitate surgery [1]. - Many steroid-dependent patients can be managed effectively with **immunomodulators** or **biologic therapies**, avoiding surgery. *Surgery is required in a subset of severe cases.* - **Severe ulcerative colitis** that is refractory to medical therapy, or complicated by toxic megacolon, perforation, or severe bleeding, often requires surgical intervention [1]. - This statement is true, as surgery can be curative for UC by removing the affected colon [1]. *Extra-intestinal problems of UC are managed medically* - **Extra-intestinal manifestations** of ulcerative colitis, such as arthritis, skin lesions (erythema nodosum), and eye inflammation (uveitis), are typically managed with medications specific to those conditions, often in conjunction with UC treatment [1], [2]. - This statement is true, as these manifestations rarely require surgical intervention themselves. *The highest risk of UC requiring surgery in 1st year* - The risk of surgery in ulcerative colitis is indeed highest in the **first year after diagnosis**, particularly for patients presenting with severe disease. - This initial period often determines the disease course and responsiveness to medical treatment.
Question 8: A 25-year-old woman presents with bloody diarrhea and is diagnosed with ulcerative colitis. Which of the following conditions is least likely to be associated with it?
- A. Iritis
- B. Ankylosing spondylitis
- C. Pancreatitis (Correct Answer)
- D. Sclerosing cholangitis
Explanation: ***Pancreatitis*** - While **pancreatitis** can occur with inflammatory bowel disease, it is generally considered a less common extraintestinal manifestation of **ulcerative colitis**. [1] - Other conditions like primary sclerosing cholangitis and ocular/arthritic manifestations have a stronger and more frequent association. [2] *Sclerosing cholangitis* - **Primary sclerosing cholangitis (PSC)** is strongly associated with ulcerative colitis, affecting a significant portion of patients. [3] - It involves progressive inflammation and fibrosis of the **bile ducts**, leading to cholestasis and liver damage. [3] *Iritis* - **Iritis** (anterior uveitis) is a known extraintestinal manifestation of inflammatory bowel disease, including ulcerative colitis. [2] - It presents with **eye pain, redness, and photophobia**, and requires prompt ophthalmologic evaluation. [2] *Ankylosing spondylitis* - **Ankylosing spondylitis** is a seronegative spondyloarthropathy that has a strong association with ulcerative colitis. [4] - It causes **chronic inflammatory back pain** and stiffness, predominantly affecting the spine and sacroiliac joints. [4]
Question 9: A male infant presented with distension of abdomen shortly after birth with delayed passage of meconium. Subsequently a full-thickness biopsy of the rectum was performed. The rectal biopsy is likely to show:
- A. Lack of ganglion cells (Correct Answer)
- B. Fibrosis of submucosa
- C. Thickened muscularis propria
- D. Hyalinization of the muscular coat
Explanation: ***Lack of ganglion cells*** - The clinical presentation of **abdominal distension** and **delayed meconium passage** in a neonate is highly suggestive of **Hirschsprung disease** [1]. - **Hirschsprung disease** is characterized by the **absence of ganglion cells** in the myenteric (Auerbach's) and submucosal (Meissner's) plexuses of the distal bowel, starting from the anus and extending proximally to varying degrees [1], [2]. *Fibrosis of submucosa* - While some chronic inflammatory conditions can lead to submucosal fibrosis, it is **not the primary histopathological feature** of Hirschsprung disease. - Submucosal fibrosis is more typically seen in conditions like **Crohn's disease** or chronic infectious colitis. *Thickened muscularis propria* - A **thickened muscularis propria** can be an indirect finding in Hirschsprung disease, occurring as a result of **hypertrophy** of the muscle layers proximal to the aganglionic segment, due to increased effort to propel stool past the obstructed area. - However, the **primary diagnostic feature** on biopsy is the absence of ganglion cells, not muscle thickening, which is a secondary change [2]. *Hyalinization of the muscular coat* - **Hyalinization** refers to a glassy, eosinophilic appearance of tissue, often due to protein accumulation or degeneration. - This is **not a characteristic finding** in Hirschsprung disease and is typically associated with conditions like vascular injury or aging changes. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 94-95. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 759.
Question 10: Which of the following features distinguishes Crohn's disease from Ulcerative colitis?
- A. Lymphocyte infiltrate
- B. Mucosal edema
- C. Pseudopolyps
- D. Transmural involvement (Correct Answer)
Explanation: ***Transmural involvement*** - **Crohn's disease** is characterized by **transmural inflammation**, meaning the inflammation extends through all layers of the bowel wall [1]. This deep inflammation can lead to complications like **fistulas**, **strictures**, and **abscesses** [1], [3]. - In contrast, **Ulcerative colitis** typically involves inflammation limited to the **mucosa and submucosa** [4]. *Lymphocyte infiltrate* - Both Crohn's disease and Ulcerative colitis involve a **lymphocyte infiltrate** as part of the chronic inflammatory process [2]. This feature is not specific enough to differentiate between the two conditions. - The presence of lymphocytes, plasma cells, and other inflammatory cells is common in any chronic inflammatory bowel condition. *Mucosal edema* - **Mucosal edema** can be found in both Crohn's disease and Ulcerative colitis due to the inflammatory process. It is a general sign of inflammation rather than a specific differentiating feature. *Pseudopolyps* - **Pseudopolyps** are characteristic of **Ulcerative colitis**, forming as islands of regenerating mucosa in areas of severe inflammation and ulceration [4]. - While they can occasionally be seen in chronic Crohn's disease, they are much more common and prominent in Ulcerative colitis, representing a reparative process rather than primary disease activity. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-366. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 366-367. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 809.
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