Gastroenterology — MCQs

A 2-month-old infant presents with projectile non-bilious vomiting after each feeding for the past week, weight loss, and constant hunger. On examination, a firm, olive-shaped mass is palpable in the right upper quadrant. Serum electrolytes show hypochloremic hypokalemic metabolic alkalosis. What is the definitive treatment?

Q249

A 6-week-old infant presents with a history of non-bilious, non-projectile vomiting starting at 3 weeks of age. The infant's abdominal examination is normal. Which of the following is the most likely diagnosis?

Q250

A 4-week-old baby presents with non-bilious vomiting and abdominal distension. The radiological image is shown. Among the clinical features, which is the most essential finding in reaching the diagnosis of this condition?

Gastroenterology Indian Medical PG Practice Questions and MCQs

Question 241: A child with diarrhea was eager to drink, and the skin pinch went back slowly. Which of the following categories is the child classified into as per IMNCI?

A. Green
B. None
C. Pink
D. Yellow (Correct Answer)

Explanation: ***Yellow***- This classification applies when the child shows two or more signs of **'Some Dehydration'** according to IMNCI guidelines, which include **eagerly drinking/thirst** and the **skin pinch going back slowly** (less than 2 seconds but noticeably delayed).- The management for the Yellow category involves treating dehydration using **Oral Rehydration Salts (ORS)** (Plan B).*Pink*- The **Pink (Severe Dehydration) category** requires at least two signs such as **lethargy/unconsciousness**, inability to drink/drinking poorly, or the **skin pinch going back very slowly** (≥ 2 seconds).- The child is **eager to drink**, which rules out the severe dehydration sign of being **unable to drink** or **drinking poorly**.*Green*- The **Green (No Dehydration) category** is applied when the child does not exhibit sufficient signs to classify them into the 'Some' or 'Severe' dehydration categories.- Since the child demonstrates two definite signs of dehydration (**thirst** and **slow skin pinch**), the 'No Dehydration' classification is incorrect.*None*- IMNCI provides specific and comprehensive categories (**Green, Yellow, Pink**) for classifying dehydration status based on clinical signs.- The combination of **eager drinking** and **slow skin pinch** definitively places the child in the **Yellow (Some Dehydration)** category.

Question 242: A 2-week-old infant presents with high conjugated (direct) bilirubin, dark-colored urine, and clay-colored stools. On examination, the infant appears jaundiced, but is feeding normally. What is the most likely diagnosis?

A. Biliary atresia (Correct Answer)
B. Crigler-Najjar syndrome
C. Gilbert’s syndrome
D. Physiological jaundice

Explanation: ***Biliary atresia*** - High **conjugated hyperbilirubinemia** combined with characteristic signs of biliary obstruction, such as **acholic (clay-colored) stools** and **dark urine**, is the classic presentation of **biliary atresia** in infants typically presenting after the first week of life. - This condition involves progressive obliteration of the extrahepatic **biliary tree**, requiring urgent diagnosis and treatment (Kasai procedure) before 60 days of age to prevent irreversible **cirrhosis**. *Crigler-Najjar syndrome* - This disorder results from a severe deficiency or absence of **UGT1A1** activity, leading exclusively to severe **unconjugated hyperbilirubinemia** and a high risk of **kernicterus**. - It does not involve excretion issues causing **conjugated hyperbilirubinemia** or evidence of biliary blockage like **acholic stools**. *Gilbert's syndrome* - This syndrome is characterized by **unconjugated hyperbilirubinemia** due to reduced activity of the hepatic enzyme **UDP-glucuronosyltransferase (UGT1A1)**, not the conjugated form seen here. - It is generally an inherited, benign condition that presents later in life (adolescence/adulthood) and does not cause **biliary obstruction** symptoms (clay stools, dark urine). *Physiological jaundice* - **Physiological jaundice** typically presents with **unconjugated hyperbilirubinemia**, begins *after* 24 hours of life, peaks around 3-5 days, and usually resolves by 1-2 weeks. - The presentation at 2 weeks with *conjugated* hyperbilirubinemia (which is always pathological) and signs of obstruction rules out this benign, self-limiting cause.

Question 243: A child presents with abdominal distension and an enlarged liver by 8cm below the costal margin. The liver is smooth on palpation. Which of the following is the most likely diagnosis?

A. Glycogen Storage Disease (GSD) (Correct Answer)
B. Autoimmune Hepatitis
C. Hepatocellular Carcinoma (HCC)
D. Lysosomal Storage Disease (LSD)

Explanation: ***Glycogen Storage Disease (GSD)***- GSDs, particularly Type I (**Von Gierke Disease**), cause massive, **smooth hepatomegaly** due to the accumulation of normal or abnormal glycogen within hepatocytes.- The presentation in childhood with severe abdominal distension and an enlarged, non-tender, **smooth liver** is highly characteristic of these metabolic disorders.*Lysosomal Storage Disease (LSD)*- While LSDs (e.g., Gaucher, Niemann-Pick) can cause hepatomegaly, they often involve the **Reticuloendothelial system**, leading to prominent **splenomegaly** as well, which is not mentioned here.- Clinical features usually include severe **neurological impairment** or **skeletal abnormalities**, differentiating them from GSDs which primarily affect the liver and glucose metabolism initially.*Hepatocellular Carcinoma (HCC)*- HCC usually results in a **firm, nodular, or irregular** liver surface on palpation, reflecting tumor growth, rather than a uniformly smooth enlargement.- Although rare in children, when it occurs, it is typically associated with rapidly worsening symptoms, weight loss, and often underlying conditions like **cirrhosis** or **hepatitis**.*Autoimmune Hepatitis*- This condition involves chronic **inflammation and destruction of hepatocytes**, often leading to symptoms of liver failure (jaundice) and elevated **transaminases**.- Long-standing autoimmune hepatitis progresses to cirrhosis, resulting in a **fibrotic or nodular** liver, rarely presenting as primary, massive, smooth hepatomegaly in a child.

Question 244: A 5 year old boy presented with hematemesis and was found to have splenomegaly, on examination. There was a past history of exchange transfusion in this child for neonatal jaundice. What is the probable diagnosis?

A. Portal vein thrombosis (Correct Answer)
B. Splenic vein thrombosis
C. Liver cirrhosis
D. Budd-Chiari syndrome

Explanation: ***Portal vein thrombosis***- This is the most probable diagnosis because **extrahepatic portal vein thrombosis (EHPVO)** is the most common cause of portal hypertension and variceal bleeding in pediatric patients.- A past history of **exchange transfusion** (which often utilizes umbilical vein catheterization) is a major risk factor for initiating ascending thrombophlebitis that leads to the development of a **portal vein thrombus**.- Manifestations include **splenomegaly** (due to portal hypertension) and **hematemesis** (due to bleeding from esophageal varices).*Splenic vein thrombosis*- **Isolated splenic vein thrombosis** causes *segmental portal hypertension*, typically resulting in localized high pressure leading mainly to **isolated gastric varices**.- While it causes **splenomegaly**, it is less likely to cause the severe, diffuse portal hypertension and extensive esophageal varices responsible for large-volume hematemesis seen in EHPVO.*Budd-Chiari syndrome*- This syndrome involves obstruction of the **hepatic veins** (or suprahepatic inferior vena cava), leading acutely to symptoms like tender **hepatomegaly**, intractable ascites, and often signs of **liver failure**.- The patient's presentation is characterized by isolated signs of *pre-hepatic portal hypertension* (splenomegaly and variceal bleeding), not the typical constellation of liver congestion seen in Budd-Chiari.*Liver cirrhosis*- Although cirrhosis causes portal hypertension, the history in a 5-year-old points toward a specific **pre-hepatic vascular etiology** (PVT) secondary to a neonatal event rather than a parenchymal disease.- Cirrhosis usually is accompanied by signs of chronic liver failure, such as **jaundice**, **synthetic dysfunction**, or **ascites**, which are absent in this typical EHPVO presentation.

Question 245: A child was brought to the casualty with complaints of vomiting and loose stools with a history of laxative use. On examination, arrhythmia is present. What will be the abnormality present?

A. Hypocalcemia
B. Hypokalemia (Correct Answer)
C. Hyperkalemia
D. Hyponatremia

Explanation: ***Hypokalemia*** - **Laxative abuse** leads to significant gastrointestinal losses of fluid and electrolytes, particularly **potassium** - Combined with **vomiting and loose stools**, potassium depletion is further aggravated - **Hypokalemia causes cardiac arrhythmias** through altered myocardial excitability - **ECG changes** include: U waves, T wave flattening, ST segment depression, prolonged QT interval, and risk of ventricular arrhythmias - This is a classic presentation requiring **urgent potassium replacement** *Hypocalcemia* - Presents with **tetany, carpopedal spasm**, and perioral numbness - ECG shows **prolonged QT interval** but not typical arrhythmias seen here - Not primarily associated with laxative abuse *Hyperkalemia* - Causes **peaked T waves, widened QRS**, and bradyarrhythmias - Occurs with **renal failure or potassium retention**, not GI losses - Opposite of what occurs with laxative abuse and diarrhea *Hyponatremia* - Primarily causes **CNS symptoms**: confusion, seizures, altered sensorium - Cardiac arrhythmias are **not a typical feature** - Can occur with fluid losses but doesn't explain the arrhythmia

Question 246: A child has elevated liver enzyme levels. A ring-like structure is noted on ocular examination. Which of the following is the cause for this?

A. Zinc
B. Copper (Correct Answer)
C. Selenium
D. Iron

Explanation: ***Copper***- The combination of elevated **liver enzymes** (hepatitis/cirrhosis) and the characteristic **Kayser-Fleischer (KF) rings** visible on ocular examination is pathognomonic for **Wilson's disease**.- **Wilson's disease** is an inherited disorder involving defective biliary excretion of **copper**, causing its toxic accumulation in tissues, notably the liver, brain, and cornea.*Zinc*- Zinc is an essential trace element, but its deficiency presents primarily with **acrodermatitis enteropathica**, not hepatic failure and KF rings.- Zinc supplementation is sometimes used as a treatment for Wilson's disease because it inhibits the absorption of **copper** in the gut.*Selenium*- Deficiency of **Selenium** is associated with **Keshan disease** (cardiomyopathy) and impaired antioxidant protection, rather than liver disease with corneal rings.- High levels of selenium, though rare, can lead to hair loss and nail changes (**selenosis**).*Iron*- Excessive accumulation of **Iron** causes **hemochromatosis**, which leads to hepatomegaly, cirrhosis, and **bronze diabetes**.- Iron overload does not result in the formation of **Kayser-Fleischer rings**; these rings are exclusively caused by **copper** deposition in the Descemet membrane.

Question 247: Which of the following is not true about CHPS? CHPS - Congenital hypertrophic pyloric stenosis

A. a.Presents with non-bilious vomiting
B. c.USG is very sensitive in diagnosing this condition
C. d.Hypokalemic metabolic alkalosis seen
D. b.Caused by hypertrophy of longitudinal muscles (Correct Answer)

Explanation: ***b.Caused by hypertrophy of longitudinal muscles***- The defining pathology of congenital hypertrophic pyloric stenosis involves hypertrophy and hyperplasia of the **circular muscle layer** of the pylorus, not the longitudinal muscle layer.- This thickening of the circular muscle narrows the pyloric canal lumen, leading to gastric outlet obstruction.*a.Presents with non-bilious vomiting*- This is a true statement; vomiting is typically **non-bilious** because the obstruction is proximal to the **ampulla of Vater** (where bile enters the duodenum).- The vomiting is often projectile, feeding soon after a meal, and progresses from occasional to nearly every feed.*c.USG is very sensitive in diagnosing this condition*- This is a true statement; ultrasonography is the diagnostic modality of choice due to its high sensitivity and specificity, avoiding radiation exposure.- Diagnosis is confirmed when the **pyloric muscle wall thickness** is >4 mm or the **pyloric channel length** is >16 mm.*d.Hypokalemic metabolic alkalosis seen*- This is a true statement; persistent, massive vomiting leads to the loss of gastric **hydrochloric acid (HCl)**.- The resulting primary loss of H+ ions leads to **metabolic alkalosis**, which is compensated by renal excretion of K+ and retention of HCO3- (leading to secondary **hypokalemia**).

Question 248: A 2-month-old infant presents with projectile non-bilious vomiting after each feeding for the past week, weight loss, and constant hunger. On examination, a firm, olive-shaped mass is palpable in the right upper quadrant. Serum electrolytes show hypochloremic hypokalemic metabolic alkalosis. What is the definitive treatment?

A. Conservative management with thickened feeds
B. Emergency exploratory laparotomy
C. Ranitidine therapy for gastroesophageal reflux
D. Intravenous fluid resuscitation and electrolyte correction followed by pyloromyotomy (Correct Answer)

Explanation: ***Intravenous fluid resuscitation and electrolyte correction followed by pyloromyotomy*** - This is the **complete definitive treatment** for Infantile Hypertrophic Pyloric Stenosis (IHPS), addressing both immediate stabilization and the underlying pathology - The initial step involves **IV fluid resuscitation** with normal saline to correct dehydration and the characteristic **hypochloremic hypokalemic metabolic alkalosis** that results from prolonged vomiting of gastric contents - Surgery (Ramstedt's pyloromyotomy) is performed only after **hemodynamic stability** and **electrolyte normalization** are achieved, as operating on a dehydrated, alkalotic infant increases surgical risk - **Pyloromyotomy** involves longitudinal splitting of the hypertrophied pyloric muscle while preserving the mucosa, providing a **curative surgical correction** of the gastric outlet obstruction *Conservative management with thickened feeds* - This approach is appropriate for **gastroesophageal reflux disease (GERD)**, not IHPS - IHPS involves a **mechanical obstruction** from hypertrophied pyloric muscle that cannot be overcome by thickening feeds - The pathognomonic **olive-shaped mass** and **projectile vomiting** indicate structural pathology requiring surgical intervention *Emergency exploratory laparotomy* - IHPS is **not a surgical emergency** and does not require exploratory laparotomy - The diagnosis is typically confirmed by **ultrasound** (pyloric muscle thickness >3mm, length >15mm) or clinical examination - A **specific, targeted procedure** (pyloromyotomy) is performed, not an exploratory approach - Stabilization with fluids and electrolyte correction should always precede surgery *Ranitidine therapy for gastroesophageal reflux* - This treats **GERD**, which presents with non-projectile vomiting without an olive mass or severe electrolyte abnormalities - The clinical presentation clearly indicates **IHPS** with its pathognomonic features - Acid suppression therapy would be ineffective against a **mechanical pyloric obstruction**

Question 249: A 6-week-old infant presents with a history of non-bilious, non-projectile vomiting starting at 3 weeks of age. The infant's abdominal examination is normal. Which of the following is the most likely diagnosis?

A. Gastroesophageal reflux disease (GERD) (Correct Answer)
B. Cow Milk Protein Allergy
C. Intestinal obstruction
D. Pyloric stenosis

Explanation: ***Gastroesophageal reflux disease (GERD)*** - This is the most common cause of non-bilious, **non-projectile** vomiting (regurgitation) in healthy infants, often starting early and peaking around 4-5 months of age. - The history is consistent with simple **physiologic reflux**, characterized by non-forceful spitting up and a **normal abdominal examination**. *Pyloric stenosis* - Classically involves **projectile** non-bilious vomiting that becomes progressively worse, which contradicts the non-projectile description. - A physical exam would typically reveal an **olive-like mass** (hypertrophied pylorus) or visible gastric peristalsis, which is stated to be absent. *Cow Milk Protein Allergy* - Although vomiting can occur, it is usually accompanied by other symptoms like **bloody stools**, severe irritability, or **eczema**, which are not mentioned. - Isolated, mild, non-projectile vomiting without systemic signs is less specific for a protein allergy than for GERD. *Intestinal obstruction* - Obstruction distal to the ampulla of Vater (e.g., malrotation, atresia) typically causes **bilious vomiting**, which is absent in this case. - Such conditions usually lead to an **abnormal abdominal examination** or signs of acute illness, which are not present here.

Question 250: A 4-week-old baby presents with non-bilious vomiting and abdominal distension. The radiological image is shown. Among the clinical features, which is the most essential finding in reaching the diagnosis of this condition?

A. Visible peristalsis
B. Projectile vomiting
C. Loss of weight and dehydration
D. Palpation of lump (Correct Answer)

Explanation: ***Palpation of lump*** - In pyloric stenosis, the hypertrophied pylorus can often be palpated as an **olive-shaped mass** in the right upper quadrant or epigastrium. - This palpable mass upon abdominal examination is considered the most **crucial diagnostic finding** for pyloric stenosis. *Visible peristalsis* - While **visible peristaltic waves** (particularly from left to right across the epigastrium) can be a sign of pyloric stenosis, they are not specific or the most essential diagnostic feature. - Visible peristalsis indicates an attempt by the stomach to force contents past an obstruction, but its presence can vary and may not be consistently observed. *Projectile vomiting* - **Projectile non-bilious vomiting** is a classic symptom of pyloric stenosis, suggesting a significant outflow obstruction. - However, symptoms alone are not as definitive for diagnosis as the physical finding of the "olive-shaped" mass, as other conditions can also cause severe vomiting. *Loss of weight and dehydration* - **Weight loss** and **dehydration** are common consequences of persistent vomiting due to pyloric stenosis, indicating disease progression. - These are systemic effects reflecting the severity of the condition rather than a direct diagnostic feature of the underlying anatomical abnormality.

Practice by Chapter

Gastroesophageal Reflux

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Malabsorption Syndromes

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Acute and Chronic Diarrhea

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Constipation and Encopresis

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Gastrointestinal Bleeding

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Intestinal Obstruction

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Liver Diseases in Children

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Pancreatic Disorders

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Pediatric Nutritional Support

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