Inflammatory Bowel Disease — MCQs
Which of the following is a type of inflammatory bowel disease primarily affecting the small intestine? a) Coeliac disease b) Tropical sprue c) Regional ileitis d) Cystic fibrosis e) Ulcerative colitis
Skip lesions with non-caseating granulomas is characteristic of
Which of the following is a feature of ulcerative colitis?
What is the definition of persistent diarrhea in infants based on duration?
A newborn baby presented with a failure to pass meconium in the immediate postnatal period. The pediatrician also notices visible yet ineffective peristalsis, and abdominal distention. A radiological contrast enema demonstrated a narrow conical segment and a dilated proximal bowel. A diagnosis of Hirschsprung disease was made. Which of the following is a cause of the condition in the patient?
Which surgical procedure has the highest incidence of ureteric injury?
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:
In Still's disease the transient cutaneous rash coincides with the fever spike. The rash is due to:
A 2-year-old presents with chronic diarrhea, failure to thrive, and a distended abdomen. Celiac disease is suspected. What is the most appropriate initial test to confirm the diagnosis?
All are true about Hirschsprung disease Except
Inflammatory Bowel Disease Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is a type of inflammatory bowel disease primarily affecting the small intestine? a) Coeliac disease b) Tropical sprue c) Regional ileitis d) Cystic fibrosis e) Ulcerative colitis
- A. Ulcerative colitis
- B. Cystic fibrosis
- C. Tropical sprue
- D. Regional ileitis (Correct Answer)
- E. Coeliac disease
Explanation: ***Regional ileitis*** - **Regional ileitis** is another name for **Crohn's disease** when it primarily affects the **ileum**, which is part of the small intestine [1]. - Crohn's disease is a type of **inflammatory bowel disease (IBD)** [1] characterized by **transmural inflammation** that can affect any part of the gastrointestinal tract, but most commonly involves the small intestine. *Ulcerative colitis* - **Ulcerative colitis** is an **inflammatory bowel disease** that exclusively affects the **large intestine (colon and rectum)** [2]. - Unlike Crohn's disease, it involves continuous inflammation of the mucosa and submucosa, usually starting in the rectum and extending proximally [2]. *Cystic fibrosis* - **Cystic fibrosis** is a **genetic disorder** that affects the lungs, pancreas, liver, and intestine, leading to the production of **thick, sticky mucus**. - While it can cause malabsorption and intestinal issues due to pancreatic insufficiency, it is not primarily an inflammatory bowel disease in itself. *Tropical sprue* - **Tropical sprue** is a malabsorption syndrome thought to be caused by **environmental factors and microbial changes** in the small intestine, typically affecting individuals in tropical regions [3]. - It results in abnormal small intestinal architecture and nutrient malabsorption, but it is not classified as an inflammatory bowel disease like Crohn's or ulcerative colitis. *Coeliac disease* - **Coeliac disease** is an **immune-mediated condition** triggered by the ingestion of **gluten**, leading to damage of the small intestinal villi [3]. - While it affects the small intestine and involves an immune response, it is distinct from inflammatory bowel diseases which are characterized by chronic, relapsing inflammation of the GI tract.
Question 2: 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 3: Which of the following is a feature of ulcerative colitis?
- A. Spiking fever
- B. Proctitis (Correct Answer)
- C. Fistula formation
- D. Cobble stone mucosa
Explanation: ***Proctitis*** - **Proctitis**, or inflammation of the rectum, is a hallmark feature of ulcerative colitis as the disease always begins in the rectum and can extend proximally [1]. - Patients typically experience **tenesmus**, urgency, and bloody diarrhea due to rectal involvement. *Spiking fever* - While patients with severe ulcerative colitis can experience fever, a **spiking fever** is less common than in other inflammatory conditions or infections. - Fever is a more common and prominent symptom in **Crohn's disease**, particularly with perianal complications or abscesses. *Fistula formation* - **Fistulas** (abnormal connections between organs or to the skin) are a characteristic complication of **Crohn's disease**, not ulcerative colitis. - Ulcerative colitis affects only the **mucosa** and submucosa, making transmural inflammation and fistula formation rare [1]. *Cobble stone mucosa* - **Cobblestone mucosa**, characterized by linear ulcers interspersed with edematous, normal-appearing mucosa, is a classic endoscopic finding in **Crohn's disease**. - In contrast, ulcerative colitis presents with **diffuse, continuous inflammation** and ulceration without skip lesions or cobblestoning [1].
Question 4: What is the definition of persistent diarrhea in infants based on duration?
- A. 14 days
- B. More than 14 days (Correct Answer)
- C. Less than 14 days (Acute diarrhea)
- D. 7 days
Explanation: ***Correct: More than 14 days*** - Persistent diarrhea is defined as diarrhea lasting **more than 14 days** according to WHO and standard pediatric guidelines - This classification is crucial for differentiating it from acute diarrhea and guiding management strategies - Persistent diarrhea carries increased risk of **malnutrition, dehydration, and micronutrient deficiencies** - Requires different management approach including nutritional rehabilitation and evaluation for underlying causes *Incorrect: 14 days* - Diarrhea lasting **exactly 14 days** is at the boundary but does not meet the criterion for persistent diarrhea - The definition requires duration to **exceed** 14 days, not just reach it *Incorrect: Less than 14 days (Acute diarrhea)* - Diarrhea lasting **less than 14 days** is classified as **acute diarrhea** - Acute diarrhea typically has different etiology (mostly viral) and is generally self-limiting - Management focuses on rehydration and rarely leads to the severe nutritional complications seen in persistent cases *Incorrect: 7 days* - 7 days is well within the acute diarrhea range - Has no special significance in the classification of diarrhea duration - Most acute diarrheal episodes resolve within 5-7 days
Question 5: A newborn baby presented with a failure to pass meconium in the immediate postnatal period. The pediatrician also notices visible yet ineffective peristalsis, and abdominal distention. A radiological contrast enema demonstrated a narrow conical segment and a dilated proximal bowel. A diagnosis of Hirschsprung disease was made. Which of the following is a cause of the condition in the patient?
- A. Persistence of embryonic structures in the bowel wall
- B. Congenital obstruction due to external factors
- C. Failure of migration of neural crest cells (Correct Answer)
- D. Abnormal peristalsis due to neural dysfunction
Explanation: ***Failure of migration of neural crest cells*** - Hirschsprung disease is characterized by the **absence of ganglion cells** (specifically **Auerbach's and Meissner's plexuses**) in the distal bowel. - This aganglionosis results from the **failure of neural crest cells to migrate** completely into the intestinal wall during embryonic development. *Persistence of embryonic structures in the bowel wall* - This mechanism is associated with conditions like **Meckel's diverticulum**, where a remnant of the **vitelline duct** persists. - It does not explain the absence of ganglion cells or the functional obstruction seen in Hirschsprung disease. *Congenital obstruction due to external factors* - This would involve conditions such as an **annular pancreas**, **bands**, or **malrotation with volvulus**, creating a physical barrier. - Hirschsprung disease is a **functional obstruction** due to neuromuscular dysfunction, not an external compression or blockage. *Abnormal peristalsis due to neural dysfunction* - While there is abnormal peristalsis, the underlying cause is not just **"neural dysfunction"** in a general sense, but specifically the **absence of entire ganglion cell plexuses** within the bowel wall. - This option is too broad and doesn't pinpoint the precise developmental defect.
Question 6: Which surgical procedure has the highest incidence of ureteric injury?
- A. Vaginal hysterectomy
- B. Anterior colporraphy
- C. Abdominal hysterectomy
- D. Radical hysterectomy (Correct Answer)
Explanation: ***Radical hysterectomy*** - This procedure involves extensive dissection to remove the uterus, cervix, and surrounding parametrial tissue, which places the **ureters at high risk of injury** due to their close proximity to the surgical field. - The **ureter** runs directly through the **parametrium** (cardinal and uterosacral ligaments), which are ligated and excised during a radical hysterectomy, making it the procedure with the highest incidence of ureteral injury. *Vaginal hysterectomy* - While ureteric injury can occur, it is generally less common than in radical hysterectomy due to the less extensive dissection and different angle of approach. - The risk is present during clamping and ligating the **uterosacral and cardinal ligaments** but is typically lower than with a radical approach. *Anterior colporraphy* - This procedure primarily involves the anterior vaginal wall and bladder, usually without deep pelvic dissection that would place the ureters at significant risk. - The main risks are typically related to the bladder itself, rather than the ureters, as the dissection is superficial to the ureteral course. *Abdominal hysterectomy* - While there is a risk of ureteric injury, especially during the ligation of the **uterine arteries** and cardinal ligaments, the dissection is less extensive than in a radical hysterectomy. - Standard abdominal hysterectomy involves less parametrial dissection, thus exposing the ureters to a lower, though still present, risk of injury compared to radical procedures.
Question 7: 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 8: In Still's disease the transient cutaneous rash coincides with the fever spike. The rash is due to:
- A. Lymphocyte infiltration in the dermis
- B. Neutrophil infiltration in the dermis (Correct Answer)
- C. Eosinophil infiltration in the dermis
- D. None of the options
Explanation: ***Neutrophil infiltration in the dermis*** - The characteristic rash of Still's disease (juvenile idiopathic arthritis systemic onset or adult-onset Still's disease) is a **transient, salmon-pink, macular or maculopapular eruption** that typically appears during **febrile spikes**. - Histologically, this rash is characterized by a **superficial perivascular infiltrate of neutrophils** and sometimes lymphocytes, without significant epidermal changes. *Lymphocyte infiltration in the dermis* - While lymphocytes can be present, the predominant inflammatory cell type associated with the classic rash of Still's disease during fever spikes is the **neutrophil**. - Conditions like chronic dermatitis or viral exanthems are more commonly associated with prominent lymphocytic infiltrates. *Eosinophil infiltration in the dermis* - Eosinophils are typically associated with **allergic reactions**, parasitic infections, or certain drug eruptions. - Their presence is not a primary feature of the rash seen in Still's disease. *None of the options* - This option is incorrect because **neutrophil infiltration** is the recognized histological feature of the rash in Still's disease.
Question 9: A 2-year-old presents with chronic diarrhea, failure to thrive, and a distended abdomen. Celiac disease is suspected. What is the most appropriate initial test to confirm the diagnosis?
- A. Positive stool culture
- B. Elevated ESR
- C. Anti-tTG antibodies (Correct Answer)
- D. Serum IgA levels
Explanation: ***Anti-tTG antibodies*** - **Anti-tissue transglutaminase (anti-tTG) antibodies** are the primary serological test used to screen for **celiac disease** in children and adults. - A positive result, especially when several fold above the upper limit of normal, is highly suggestive of celiac disease and often followed by a **small bowel biopsy** for definitive diagnosis. *Positive stool culture* - A **positive stool culture** identifies bacterial or viral infections of the gastrointestinal tract, which can cause acute diarrhea. - While it can explain diarrhea, it does not confirm a diagnosis of **celiac disease**, which is an autoimmune condition triggered by gluten. *Elevated ESR* - **Elevated erythrocyte sedimentation rate (ESR)** is a general marker of inflammation and can be seen in many conditions, including infections, autoimmune diseases, and malignancies. - It is not specific to **celiac disease** and does not confirm the diagnosis. *Serum IgA levels* - Measuring **total serum IgA levels** is crucial alongside anti-tTG testing to rule out **IgA deficiency**, which can lead to a false-negative anti-tTG result. - However, IgA levels alone do not diagnose celiac disease; they are a preliminary check before interpreting IgA-based antibody tests.
Question 10: All are true about Hirschsprung disease Except
- A. Absence of ganglion cells within the affected segment
- B. The rectum is never affected (Correct Answer)
- C. Dilation proximal to the affected segment.
- D. Hirschsprung disease typically presents with a failure to pass meconium in the immediate postnatal period.
Explanation: ***The rectum is never affected*** - Hirschsprung disease always involves the **rectum** and extends proximally for a variable distance. - The aganglionic segment uniformly includes the **distal rectum**. *Absence of ganglion cells within the affected segment* - The primary defect in Hirschsprung disease is the **absence of ganglion cells** (Meissner and Auerbach plexuses) in the affected intestinal segment. - This **aganglionosis** leads to a functional obstruction. *Dilation proximal to the affected segment* - Due to the functional obstruction from the aganglionic segment, the normal bowel **proximal** to it becomes dilated and hypertrophied. - This dilation occurs as the bowel tries to overcome the obstruction. *Hirschsprung disease typically presents with a failure to pass meconium in the immediate postnatal period* - A classic presentation of Hirschsprung disease is the failure to pass **meconium** within the first 24-48 hours of life. - This symptom is due to the lack of peristalsis in the aganglionic segment.
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