Inflammatory Bowel Disease — MCQs
Skip lesions with non-caseating granulomas is characteristic of
Skip lesions seen on macroscopic visualization of the gut wall are characteristic of which condition?
Which statement is true regarding Crohn's disease?
What is the leading cause of death in patients with Crohn's disease?
Which of the following statements is true regarding ulcerative colitis?
Which of the following is a feature of ulcerative colitis?
Emergency management of Ulcerative colitis is by:
Procedure of choice in ulcerative colitis with acute perforation is
A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery
Inflammatory Bowel Disease Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: Skip lesions seen on macroscopic visualization of the gut wall are characteristic of which condition?
- A. Crohn's disease (Correct Answer)
- B. Typhoid
- C. Ischemic bowel disease
- D. Ulcerative colitis
Explanation: ***Crohn's disease*** - **Skip lesions** refer to the discontinuous pattern of inflammation seen in Crohn's disease, where affected areas are interspersed with healthy tissue [1]. - This characteristic macroscopic finding is a key differentiator from other inflammatory bowel conditions, showing **random segmental distribution** throughout the GI tract [1]. *Typhoid* - Typhoid typically causes **rose spots** on the skin, **splenomegaly**, and **ulceration of Peyer's patches** in the ileum, not skip lesions. - The gastrointestinal involvement is usually diffuse rather than segmental. *Ischemic bowel disease* - Ischemic bowel disease results from **reduced blood flow** to the intestines, leading to segmental necrosis. - While it can show segmental involvement, this follows **vascular distribution patterns** (watershed areas like splenic flexure), not the random skip pattern of Crohn's disease. - The appearance depends on the arterial territory affected, not transmural inflammation. *Ulcerative colitis* - Ulcerative colitis is characterized by **continuous inflammation** that starts in the rectum and extends proximally, without skip lesions [1]. - The inflammation is typically superficial, affecting only the mucosa and submucosa, with no intervening normal tissue. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-367.
Question 3: Which statement is true regarding Crohn's disease?
- A. Skip lesions visualized in endoscopy (Correct Answer)
- B. Non-caseating granulomas present
- C. Cobblestone appearance of the intestinal mucosa
- D. Rectum involvement is less common but possible
Explanation: ***Continuous lesion visualized in endoscopy*** - Crohn's disease typically presents with **discontinuous lesions** (skip lesions) [1] rather than continuous ones, which is characteristic of ulcerative colitis [2]. - Therefore, stating that Crohn's disease shows continuous lesions is **incorrect**. *Rectum is not involved* - While Crohn's disease can primarily affect any part of the gastrointestinal tract, it can indeed involve the **rectum** in some cases. - **Ileitis and colitis** are common manifestations [1], and the statement does not hold true universally. *Non caseating granulomas* - Crohn's disease is **characterized by non-caseating granulomas**, which are considered one of its hallmark histopathological features [2]. - This statement is true, making it an incorrect choice for the question. *Cobblestone appearance* - The **cobblestone appearance** is indeed a classic feature seen in Crohn's disease due to the presence of alternating areas of inflammation and ulceration [1]. - Thus, this statement accurately reflects a known characteristic of Crohn's disease; therefore, it does not qualify as not true.
Question 4: What is the leading cause of death in patients with Crohn's disease?
- A. Thromboembolic complication (Correct Answer)
- B. Sepsis
- C. Malignancy
- D. Electrolyte disturbance
Explanation: ***Thromboembolic complication*** - Patients with **Crohn's disease** have a significantly increased risk of venous thromboembolism, including **deep vein thrombosis** and **pulmonary embolism**, due to chronic inflammation and hypercoagulability [2]. - This risk is compounded by factors such as immobility, surgery, and certain medications used to treat Crohn's [2]. *Sepsis* - While **sepsis** is a potential complication in Crohn's disease, particularly in cases of bowel perforation or severe infection, it is not the leading cause of death [1]. - Severe inflammation and compromised bowel integrity can lead to bacterial translocation and systemic infection. *Electrolyte disturbance* - **Electrolyte disturbances** can occur due to severe diarrhea, malabsorption, or fistulas in Crohn's disease but are generally manageable with appropriate medical intervention [1]. - They are rarely a direct cause of mortality unless extremely severe and left untreated. *Malignancy* - Patients with Crohn's disease have an increased risk of certain cancers, particularly **colorectal cancer** and **small bowel adenocarcinoma**, but **thromboembolic events** remain the leading cause of death overall [1]. - The risk of malignancy is often related to the duration and extent of inflammation [1].
Question 5: Which of the following statements is true regarding ulcerative colitis?
- A. String sign of kantor positive
- B. Skip lesions are seen
- C. Rectum is always involved (Correct Answer)
- D. Fistulas are common
Explanation: ***Rectum is always involved*** - In **ulcerative colitis (UC)**, inflammation invariably begins in the **rectum** and extends proximally in a continuous fashion [1]. - This **proctitis** is a hallmark feature, making rectal involvement a near-universal finding in UC [1]. *String sign of kantor positive* - The **string sign of Kantor** is typically associated with **Crohn's disease**, particularly in the terminal ileum [2]. - It refers to the severe narrowing of a bowel segment due to inflammation, which is not characteristic of UC [2]. *Skip lesions are seen* - **Skip lesions**, which are areas of normal mucosa interspersed with inflamed areas, are a classic finding in **Crohn's disease**. - Ulcerative colitis, in contrast, presents with **continuous inflammation** extending proximally from the rectum without skip lesions [1]. *Fistulas are common* - While possible, **fistulas** (abnormal connections between organs or to the skin) are much more common in **Crohn's disease** than in ulcerative colitis [3]. - UC primarily causes superficial mucosal inflammation, which rarely leads to transmural involvement and subsequent fistula formation [3].
Question 6: 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 7: Emergency management of Ulcerative colitis is by:
- A. Subtotal colectomy with end ileostomy (Correct Answer)
- B. Right hemicolectomy
- C. Total proctocolectomy with end ileostomy
- D. Left hemicolectomy
Explanation: ***Subtotal colectomy with end ileostomy*** - This is the **standard emergency procedure** for fulminant ulcerative colitis, toxic megacolon, perforation, or massive hemorrhage - Involves removal of the **entire colon** (from ileocecal junction to upper rectum) while **preserving the rectal stump** as a Hartmann's pouch - Creates an **end ileostomy** for fecal diversion - **Proctectomy is avoided** in the emergency setting due to higher morbidity, risk of pelvic sepsis, and technical difficulty in acutely ill patients - The rectal stump can be removed later (2nd stage) with consideration for **ileal pouch-anal anastomosis (IPAA)** after patient stabilization - This staged approach allows for optimization of the patient's condition and future reconstructive options *Total proctocolectomy with end ileostomy* - This involves removal of both the **colon and rectum** with permanent ileostomy - **NOT recommended in emergency settings** as proctectomy adds significant morbidity in critically ill patients - Requires pelvic dissection in inflamed tissues, increasing risk of complications - May be performed electively as a **second-stage procedure** or in patients not candidates for reconstructive surgery *Right hemicolectomy* - Removes only the **right side of the colon** (cecum, ascending colon, and part of transverse colon) - Inappropriate for ulcerative colitis, which is a **pan-colonic disease** that always involves the rectum and extends proximally - Inadequate resection would leave diseased colon in place *Left hemicolectomy* - Removes only the **left side of the colon** (descending colon and part of transverse colon) - Inadequate for ulcerative colitis as it doesn't address the **entire diseased colon** - Would leave inflamed segments and the **always-involved rectum** in place
Question 8: Procedure of choice in ulcerative colitis with acute perforation is
- A. Defunctioning ileostomy
- B. Closure of perforation
- C. Proximal diversion colostomy
- D. Total colectomy and ileostomy (Correct Answer)
Explanation: ***Total colectomy and ileostomy*** - **Acute perforation** in ulcerative colitis is a life-threatening emergency requiring immediate and definitive surgical management. - **Total colectomy** removes the diseased colon, preventing further perforation and systemic toxicity, with an ileostomy providing fecal diversion. *Defunctioning ileostomy* - A defunctioning ileostomy alone would not address the actively perforated and inflamed colon, leaving the source of sepsis intact. - This procedure leads to potentially fatal **peritoneal contamination** and ongoing inflammation. *Closure of perforation* - Direct closure of a colonic perforation in the context of acute ulcerative colitis is generally contraindicated due to the **fragile, inflamed, and friable bowel tissue**, which is prone to dehiscence. - This approach carries a high risk of **re-perforation** and persistent sepsis. *Proximal diversion colostomy* - A proximal diversion colostomy, similar to a defunctioning ileostomy, fails to remove the diseased and perforated segment of the colon. - It would not prevent the continued leakage of bowel contents from the perforation site into the **abdominal cavity**, leading to severe peritonitis.
Question 9: A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
- A. Contrast-enhanced CT scan
- B. Fecal occult blood test
- C. Colonoscopy (Correct Answer)
- D. Ultrasonogram
Explanation: ***Colonoscopy*** - **Colonoscopy** is the gold standard for investigating symptoms like rectal bleeding, altered bowel habits, and tenesmus, as it allows for direct visualization of the entire colon and rectum. - It enables **biopsy of suspicious lesions** for histopathological diagnosis, which is crucial for confirming conditions like colorectal cancer or inflammatory bowel disease. *Contrast-enhanced CT scan* - A **contrast-enhanced CT scan** is primarily used for **staging known malignancies** and assessing for distant metastases, not as a primary diagnostic tool for initial symptoms. - While it can identify large masses, it might miss smaller lesions and does not allow for tissue biopsy. *Fecal occult blood test* - A **fecal occult blood test** screens for blood in the stool, which indicates gastrointestinal bleeding but does not pinpoint the source or cause. - It has **low sensitivity and specificity** for diagnosing underlying conditions like colorectal cancer or inflammatory bowel disease and is mainly a screening tool. *Ultrasonogram* - An **ultrasonogram** is generally not effective for evaluating the colon and rectum due to bowel gas interference. - It is more commonly used for investigating abdominal organs like the liver, gallbladder, and kidneys, or for pelvic pathology, but not the primary investigation for these colorectal symptoms.
Question 10: Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery
- A. 3. Shiny appearance of small bowel wall
- B. 2. Flabby intestinal musculature
- C. 4. Visible pulsation in the mesenteric artery
- D. 1. Visible peristalsis (Correct Answer)
Explanation: ***Visible peristalsis*** - The presence of **visible peristalsis** is the **MOST reliable indicator** of viable small bowel, demonstrating preserved neuromuscular function and tissue vitality. - Among the classical "3 Ps" of bowel viability (Peristalsis, Pulsation, Pink color), **peristalsis is the most direct indicator** as it confirms functional integrity of the bowel wall itself. - This indicates that the muscle layers of the intestine (longitudinal and circular) are functioning properly with intact innervation. *Shiny appearance of small bowel wall* - A **shiny serosa** is indeed a feature of viable bowel, indicating healthy, well-perfused tissue with an intact mesenteric surface. - However, it is a **less specific indicator** compared to peristalsis, as the appearance can be subjective and may not directly correlate with functional viability. *Visible pulsation in the mesenteric artery* - **Visible pulsation** in the mesenteric artery is one of the classical signs of viability and indicates blood flow to the vessel. - However, arterial pulsation alone **does not guarantee adequate tissue perfusion** or venous drainage, and ischemia can still occur despite pulsatile flow (e.g., venous thrombosis). - Peristalsis is more reliable as it confirms both adequate perfusion AND functional integrity. *Flabby intestinal musculature* - **Flabby intestinal musculature** indicates **non-viable bowel** with loss of tone, suggesting ischemia or necrosis. - Viable bowel typically feels **turgid and elastic** with good tone, not flabby.
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