Diagnostic approach to IBD — MCQs

A 33-year-old man has a history of intermittent bloody diarrhea, tenesmus, fever, fatigue, and lower abdominal cramps for the past 2 weeks. On physical examination, he is lethargic and appears lean and pale. He has aphthous stomatitis, red congested conjunctiva, and tender swollen joints. At the doctor’s office, his pulse is 114/min, blood pressure is 102/76 mm Hg, respirations are 20/min, and his temperature is 39.4°C (102.9°F). There is vague lower abdominal tenderness and frank blood on rectal examination. Laboratory studies show: Hemoglobin 7.6 g/dL Hematocrit 33% Total leucocyte count 22,000/mm3 Stool assay for C.difficile is negative Abdominal X-ray shows no significant abnormality He is symptomatically managed and referred to a gastroenterologist, who suggests a colonoscopy and contrast (barium) study for the diagnosis. Which of the following is the most likely combination of findings in his colonoscopy and barium study?

You conduct a medical research study to determine the screening efficacy of a novel serum marker for colon cancer. The study is divided into 2 subsets. In the first, there are 500 patients with colon cancer, of which 450 are found positive for the novel serum marker. In the second arm, there are 500 patients who do not have colon cancer, and only 10 are found positive for the novel serum marker. What is the overall sensitivity of this novel test?

A 31-year-old woman visits the clinic with chronic diarrhea on most days for the past four months. She also complains of lower abdominal discomfort and cramping, which is relieved by episodes of diarrhea. She denies any recent change in her weight. Bowel movements are preceded by a sensation of urgency, associated with mucus discharge, and followed by a feeling of incomplete evacuation. The patient went camping several months earlier, and another member of her camping party fell ill recently. Her temperature is 37° C (98.6° F), respiratory rate is 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Her physical examination is unremarkable. A routine stool examination is within normal limits and blood test results show: Hb% 13 gm/dL Total count (WBC): 11,000/mm3 Differential count: Neutrophils: 70% Lymphocytes: 25% Monocytes: 5% ESR: 10 mm/hr What is the most likely diagnosis?

A 42-year-old woman comes to the physician because of increasing fatigue and difficulty concentrating at work for the last 2 months. She has hypertension and a 22-year history of Crohn disease. She has been hospitalized and treated for acute exacerbations, sometimes involving strictures, multiple times in the past. She has not had significant gastrointestinal symptoms in over a year. Current medications include mesalamine, thiazide, and bisoprolol. Her temperature is 37.2°C (99°F), pulse is 72/min, and blood pressure is 140/90 mm Hg. Examination shows a soft abdomen and pale conjunctivae. Rectal examination is unremarkable. Laboratory studies show: Hemoglobin 9.4 g/dL Mean corpuscular volume 112 fL Mean corpuscular hemoglobin 37.2 pg/cell Leukocyte count 8,700 /mm3 Platelet count 150,000 /mm3 Erythrocyte sedimentation rate 42 mm/h Serum Ferritin 88 ng/mL Iron 117 μg/dL Thyroid-stimulating hormone 3.2 μU/mL Thyroxine 7 μg/dL Further evaluation of this patient is most likely to reveal which of the following findings?

A 31-year-old woman comes to the emergency department because of a 4-day history of fever and diarrhea. She has abdominal cramps and frequent bowel movements of small quantities of stool with blood and mucus. She has had multiple similar episodes over the past 8 months. Her temperature is 38.1°C (100.6°F), pulse is 75/min, and blood pressure is 130/80 mm Hg. Bowel sounds are normal. The abdomen is soft. There is tenderness to palpation in the left lower quadrant with guarding and no rebound. She receives appropriate treatment and recovers. Two weeks later, colonoscopy shows polypoid growths flanked by linear ulcers. A colonic biopsy specimen shows mucosal edema with distorted crypts and inflammatory cells in the lamina propria. Which of the following is the most appropriate recommendation for this patient?

A 65-year-old man comes to the physician because of a 2-week history of dizziness, fatigue, and shortness of breath. He has noticed increased straining with bowel movements and decreased caliber of his stools over the past 3 months. He has no history of medical illness and takes no medications. He appears pale. Physical examination shows mild tachycardia and conjunctival pallor. Test of the stool for occult blood is positive. His hemoglobin concentration is 6.4 g/dL, and mean corpuscular volume is 74 μm3. A double-contrast barium enema study in this patient is most likely to show which of the following?

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A 34-year-old woman with no significant prior medical history presents to the clinic with several days of bloody stool. She also complains of constipation and straining, but she has no other symptoms. She has no family history of colorectal cancer or inflammatory bowel disease. She does not smoke or drink alcohol. Her vital signs are as follows: blood pressure is 121/81 mm Hg, heart rate is 77/min, and respiratory rate is 15/min. There is no abdominal discomfort on physical exam, and a digital rectal exam reveals bright red blood. Of the following, which is the most likely diagnosis?

A 32-year-old man comes to the physician for a follow-up examination. He has a 2-month history of increasing generalized fatigue and severe pruritus. He has hypertension and ulcerative colitis which was diagnosed via colonoscopy 5 years ago. Current medications include lisinopril and rectal mesalamine. He is sexually active with 2 female partners and uses condoms inconsistently. His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 130/84 mm Hg. Examination shows scleral icterus and multiple scratch marks on the trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 11.5 g/dL Leukocyte count 7500/mm3 Platelet count 280,000/mm3 Serum Na+ 138 mEq/L Cl- 101 mEq/L K+ 4.7 mEq/L Urea nitrogen 18 mg/dL Glucose 91 mg/dL Creatinine 0.8 mg/dL Bilirubin Total 1.5 mg/dL Direct 0.9 mg/dL Alkaline phosphatase 460 U/L AST 75 U/L ALT 78 U/L Anti-nuclear antibody negative Antimitochondrial antibodies negative Abdominal ultrasound shows thickening of the bile ducts and focal bile duct dilatation. Which of the following is the most likely diagnosis?

A 22-year-old man presents to the emergency department with abdominal pain. The patient states that he has had right lower quadrant abdominal pain for "a while now". The pain comes and goes, and today it is particularly painful. The patient is a college student studying philosophy. He drinks alcohol occasionally and is currently sexually active. He states that sometimes he feels anxious about school. The patient's father died of colon cancer at the age of 55, and his mother died of breast cancer when she was 57. The patient has a past medical history of anxiety and depression which is not currently treated. Review of systems is positive for bloody diarrhea. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. Abdominal exam reveals diffuse tenderness. A fecal occult blood test is positive. Which of the following is the most likely diagnosis?