Gastroenterology MCQs

1. MCQs
Dr. waqar Azeem Taj
PGR ( Gastroenterology )
BMCH Quetta

2. Dr. Hafeez Yaqoob
PGR Gastroenterology
BMCH Quetta

4. Q#1
• A 21-day-old female neonate presents with persistent
jaundice. The infant’s delivery was uneventful at full term.
Her stools appear clay colored. On physical exam, the liver is
palpable 4 cm below the right costal margin, and there is no
splenomegaly. Serum bilirubin level is 10 mg/dL, with a
direct bilirubin of 7 mg/dL. Imaging suggests biliary atresia.
Exploratory laparotomy with intraoperative cholangiogram
is performed and confirms obliteration of the proximal
extrahepatic biliary tree. Which of the following is the most
appropriate next step in management?
A. Start glucocorticoids
B. Start glucocorticoids and ursodeoxycholic acid
C. Choledochoduodenostomy
D. Hepatoportoenterostomy
E. Begin evaluation for liver transplantation

5. D (S&F ch62
• D (S&F ch62)
A patient with biliary atresia should undergo exploratory
laparotomy with intraoperative cholangiogram to confirm
the site of obstruction. In patients with obliteration of the
proximal extrahepatic biliary tree, the Kasai procedure
(hepatoportoenterostomy) is the preferred treatment. A
jejunal Roux-en-Y limb is anastomosed to the porta hepatis.
Glucocorticoids and ursodeoxycholic acid are commonly
given postoperatively. However, their use remains
controversial due to lack of strong evidence for efficacy. A
choledochoduodenostomy is not an appropriate treatment
for biliary atresia. Liver transplantation may become
necessary if the Kasai procedure fails.

6. Q#2
A 55-year-old woman undergoes elective laparoscopic
cholecystectomy for symptomatic gallstones. She has an uneventful
recovery. On histopathologic examination of the gallbladder, a focus
of adenocarcinoma is found in the mucosa of the gallbladder wall.
The tumor invades the lamina propria. Margins are negative. A CT
scan with intravenous contrast of the abdomen reveals
postoperative changes without abdominal or liver lesions. Which of
the following is the most appropriate next step in management?
A. No further intervention is needed
B. Surgical re-exploration for extended cholecystectomy
C. Surgical re-exploration for right extended
hemihepatectomy
D. Surgical re-exploration for resection of segment Ivb and V
E. Refer for adjuvant chemotherapy

7. A (S&F ch69)
• A (S&F ch69)
This patient is diagnosed incidentally with gallbladder
cancer following cholecystectomy. The tumor invades
the lamina propria, consistent with a T1a tumor. For
these early tumors, simple cholecystectomy is
sufficient. The other surgical procedures listed are
indicated for more advanced tumors. Adjuvant (or
neoadjuvant) chemotherapy is not recommended, as
it does not provide any survival advantage (see figure
and see table at end of chapter).

9. Q#3 : A 40-year-old woman with a history of short bowel syndrome is brought to the
emergency department by her husband with symptoms of confusion and
inappropriate behavior of 1-day duration. The husband says that she has had
extensive small intestinal surgery. She has been depressed lately due to the death
of family pet and has been eating excessive sweets to cope. She takes
diphenoxylate/atropine for her diarrhea and a multivitamin. She is used to
drinking one glass of wine with dinner three times a week for the past 10 years.
On physical examination, the patient is disoriented with an ataxic gait. Eye
examination reveals bilateral nystagmus. Laboratory
values are as follows:
Sodium 145 mEq/L Chloride 98 mmol/L Bicarbonate 15 mmol/l
Potassium 4.0 mEq/L Lactic acid 0.6 mmol/L
Creatinine 2.2 mg/dL
Which of the following is the most likely etiology of the patient’s presentation?
A. Alcohol intoxication
B. Salicylate overdose
C. Fermentation of unabsorbed carbohydrates
D. Dehydration precipitating renal failure
E. Thiamine deficiency

10. C
• C (S&F ch106)
This patient has short bowel syndrome with intact colon, and is
presenting with features of d-lactic acidosis due to increased
fermentation of simple carbohydrates. The patient has recently
increased her intake of simple carbohydrates, which increases
delivery of glucose and other carbohydrates to the colon. These get
fermented by colonic bacteria into d-lactic acid, which is absorbed
into the circulation but poorly metabolized. Symptoms are mainly
neurologic, including ataxia, slurred speech, and confusion. Regular
tests for lactic acid measures l-lactate, which is normal in these
cases, thus the lab should be notified to quantify d-lactic acid.
Salicylate overdose results in tinnitus, vertigo, early respiratory
alkalosis, and later anion gap metabolic acidosis. Dehydration
resulting in renal failure does not explain the neurologic symptoms.
Thiamine deficiency may result in similar neurologic symptoms but
does not lead to anion gap acidosis. Alcohol intoxication is unlikely
in this patient and does not lead to anion gap metabolic acidosis.

13. Q#5
A 61-year-old man undergoes an upper endoscopy for
abdominal pain. A 4 cm gastric ulcer in noted on the lesser
curvature of the stomach. Biopsies from the antrum are
positive for H. pylori infection. The patient is seen back in
your office after taking the prescribed therapy for H. pylori
eradication. His symptoms have resolved. which of the
following is the best next step in management?
A. Discharge from clinic
B. Continue proton pump inhibitor (PPI) indefinitely and
observe
C. Repeat endoscopy
D. Repeat noninvasive H. pylori testing
E. Stop PPI and test for H. pylori in 2 weeks

14. Ans : C
• C (S&F ch51)
H. pylori-associated gastric ulcer requires
confirmatory endoscopy after a course of
eradicative treatment to document ulcer healing.
Since this is a large gastric ulcer that was not
biopsied on previous exam, it is important to
confirm healing by endoscopy and in addition
biopsies can be obtained for H. pylori testing to
confirm eradication. Although noninvasive testing
can help confirm H. pylori eradication, it is
important to document the gastric ulcer healing.

15. Q #6
A 35-year-old woman with new onset abdominal epigastric burning
and nausea has a positive stool H. pylori antigen. She is treated with
conventional triple therapy for 2 weeks, but her symptoms do not
improve. She has no alarming symptoms such as weight loss, black
stool, or hematemesis. On physical exam there is mild epigastric
tenderness. The rest of the exams are within normal limits.
Laboratory results are as follows:
Hemoglobin 13 g/dL
WBC 7200/μL
Platelet count 380,000/μL
A repeat stool H. pylori antigen is negative. What is the next best course of action?
A. Computed tomography (CT) of the abdomen
B. Upper endoscopy
C. Quadruple therapy
D. Reassurance and follow-up in 3 months
E. Tricyclic antidepressants

16. B (S&F ch51)
• B (S&F ch51)
Since the patient has not responded to H. pylori
treatment, it is important to investigate her
symptoms with an upper endoscopy. At this point, a
refractory gastric or duodenal ulcer, which may or
may not be associated with H. pylori, must be
excluded. Addition of a nighttime proton pump
inhibitor maybe useful; particularly if she had
refractory gastroesophageal reflux disease.

17. Q#7
• A 50-year-old man with hepatitis C–related cirrhosis is seen in
your clinic for routine follow-up. His only complaint is mild
alteration in his sense of taste, which has been bothering him in
the last 3 months. Despite that, his appetite is good and he tries
to keep a balanced diet. He does not have history of heavy
alcohol use in his life. Hepatitis C infection was successfully
treated with triple therapy last year. Within the last 12 months,
he had 2 episodes of mild hepatic encephalopathy, but he denies
any signof gastrointestinal (GI) bleeding. His ascites is well
controlled with furosemide 40 mg and spironolactone 100 mg
daily by mouth. On physical exam, he is alert and oriented. Mild
icterus is noted. Abdominal exam shows minimal ascites without
any tenderness. No asterixis is noted. His model of end stage
liver disease score has been stable at 8. Which of the following
nutritional statements is correct in this patient?

18. A. Reducing daily protein intake by 25% decreases the chance of
hepatic encephalopathy
B. There is no role for thiamine supplementation for this patient
C. He should use branched-chain amino acids as the only source of
protein
D. Hypermagnesemia may be the cause of the change in his taste
E. Vitamin A deficiency may increase the chance of hepatocellular
carcinoma in this patient

19. Ans # E
E (S&F ch6)
Vitamin A deficiency can be seen in cirrhosis and has been shown to be a
risk factor for hepatocellular carcinoma. It has been found that diet with a
normal protein intake does not worsen hepatic encephalopathy and
limiting protein intake can lead to protein-calorie malnutrition in this
group of individuals with increased protein needs. Branched-chain amino
acids (leucine, isoleucine, and valine) are not metabolized in the liver and
could be used in patients with “liver failure.” Also, some clinical trials have
found a significant decline in hepatic encephalopathy or refractory ascites
in patients with “advanced cirrhosis” who were only on branched-chain
amino acids. However, due to their high cost and poor tastiness, they are
not routinely recommended. Thiamine deficiency is not only seen in
alcoholics but also in patients with hepatitis C–related cirrhosis. For this
reason, thiamine supplementation is recommended in all patients with
cirrhosis to prevent Wernicke’s encephalopathy and Korsakoff’s dementia.
Hypomagnesemia (not hypermagnesemia) could be seen in this cirrhotic
patient on diuretics and potentially could be associated with dysgeusia
(alteration in the sense of taste).

20. Q#8
A 24-year-old female graduate student is brought to you by her parents for
evaluation. They are concerned that she has “anorexia,” and they request
your opinion on further management. After obtaining a history with the
parents present, you ask them to leave the room to obtain a history from
the patient herself. In discussing her eating habits, she typically eats 1600
kcal/day; however, during periods of the spring and summer, she will limit
herself to 1000 kcal/day for a few months. Since she enrolled in college at
age 18, she would go to a different fast food chain and eat over 2500 kcal at a
time at least twice a week. After doing so, she feels ashamed and employs an
over-the-counter laxative to help prevent weight gain. You ask what she
thinks of her weight, and she confesses she feels “chubby” and far too
overweight for her personal goals. You note a body mass index of 21 kg/m2.
Which pharmacologic agent is best suited to treat this condition?
A. Fluoxetine 20 mg daily
B. Fluoxetine 60 mg daily
C. Olanzapine 2.5 mg daily
D. Olanzapine 10 mg daily
E. Topiramate 25 mg daily

21. Ans #B
B (S&F ch9)
The patient meets diagnostic criteria for bulimia nervosa (BN)
(normal weight/overweight, restrictive eating pattern can occur,
binge eating pattern at least once a week for 3 months, purging
once a week, and excess concern with body weight). The
management of eating disorders is multidisciplinary and
challenging. It begins with an evaluation and education of the
patient and any caregivers. Primary care providers, dieticians,
and mental health providers must all work closely together to
monitor symptoms and progress. Various forms of psychotherapy
can be employed. For BN, fluoxetine 60 mg daily is the only FDA-
approved pharmacotherapy. Studies on the efficacy of
Olanzapine in anorexia nervosa show conflicting results.
Topiramate has shown efficacy in reducing binge and purge
symptoms in two randomized controlled trials,
but more evidence is needed.

22. Q#9
A 64-year-old man presents to the emergency department with
complaints of constant, dull left lower quadrant abdominal pain for the
past 2 days. He reports a temperature of 102° F at home with
associated chills. He has not had a bowel movement in three days. On
examination, his temperature is 101° F, respiratory rate is 94 breaths/
min, blood pressure is 150/70 mm Hg. Physical exam is significant for
tenderness in the left lower quadrant. Laboratory exam was significant
for leukocytosis. A computed tomography (CT) scan of abdomen was
obtained, which showed evidence of diverticulitis of the sigmoid colon
with a localized pericolic abscess (Hinchey grade I). What is the next
best step in the management of this patient?
A. Discharge with oral antibiotics
B. Admit to the hospital for intravenous (IV) antibiotics and hydration
C. Emergent surgery
D. Call interventional radiology for CT-guided drain placement
E. Perform colonoscopy

23. ANS #B
• B (S&F ch11)
This patient has an acute sigmoid diverticulitis. Approximately 80%
of affected patients are older than 50 years of age. Hinchey grading
is used to grade the severity of diverticulitis on CT scan. Hinchey
grade I diverticulitis (localized inflammation or pericolic abscess)
necessitates admission to hospital with IV antibiotics. Outpatient
management is suggested in patients with mild disease having no
comorbid conditions, and with no CT findings of perforation.
Patients with Hinchey grade II diverticulitis (pelvic, intraabdominal,
or retroperitoneal abscess) should undergo CT-guided drainage of
the abscess and receive a course of broad-spectrum intravenous
antibiotics. Patients with Hinchey grade III (generalized purulent
peritonitis) and grade IV (generalized fecal peritonitis) diverticulitis
frequently require emergency surgery. Colonoscopy is
contraindicated with acute diverticulitis

25. Q#10
A 56-year-old woman is referred to your clinic for a 6-month
history of nonprogressive and intermittent dysphagia to solids.
Despite chewing her food thoroughly, she still experiences a
foreign body sensation with large boluses. She denies
odynophagia, regurgitation, halitosis, and weight loss. The patient
admits to a 3-year history of reflux disease, presenting as
dyspepsia, initially treated with ranitidine 150 mg by mouth per
day. One month ago she switched to over-thecounter omeprazole
40 mg daily to control her symptoms. Her past medical history was
otherwise negative.The patient does not smoke and drinks a
maximum of one glass of wine with dinner. Her physical exam is
unremarkable, except the macular skin lesions at both of her
wrists (see figure). The skin lesions developed about 2 months
ago; they are not pruritic and have not increased in size. Besides
scheduling an EGD, what other serology tests would be indicated
and most likely be positive?

26. The skin lesions

27. what other serology tests would be indicated and most likely be
positive?
A. Hepatitis C and antimitochondrial antibody
B. Anti–Sacchoaromyces cerevisiae antibodies
(ASCA) and perinuclear antineutrophil cytoplasmic
antibody (p-ANCA)
C. Tissue transglutaminase (tTG) antibody and
antiendomysial antibody
D. C-reactive protein and erythrocyte sedimentation
rate
E. Immunoglobulin (Ig)G4 and liver function tests

28. ANS#A
• A (S&F ch24)
The image shows the finding of lichen planus. A recent
meta-analysis from 2010 has shown that patients with
lichen planus are five times more likely to be infected
with hepatitis C in comparison to control subjects. In
addition to skin, lichen planus can affect mucous
membranes, hair, and nails. Thus, it is pertinent to
thoroughly examine the patient for additional foci of this
skin manifestation. ASCA and p-ANCA are used for the
workup of IBD. tTG antibody and antiendomysial
antibody make the diagnosis of celiac disease. C-reactive
protein and erythrocyte sedimentation rate are
nonspecific acute phase markers. IgG4 and liver function
tests are used in diagnosing autoimmune pancreatitis.

29. Q#11: A 62-year-old man presents to clinic with a 2-week history
of a metallic taste in his mouth and oropharyngeal dysphagia for
3 months duration. He denies lymph node swelling, weight loss,
regurgitation, halitosis, and odynophagia. His sleep is irregular
with frequent awakenings at night, and his wife complains about
her husband snoring excessively, in particular when lying on his
back. His past medical history is remarkable for long-standing
rheumatoid arthritis (RA) treated with methotrexate 25 mg
intramuscularly once a week and ibuprofen 400 mg twice a day
as needed. Last year the patient underwent a colonoscopy that
was consistent with a sessile serrated adenoma at the hepatic
flexure, measuring 1.5 cm in diameter, which was completely
excised. An upper gastroenterological series ordered by his
primary care physician was reported as normal. Previously
ordered laboratory exams revealed a hematocrit of 38%, mean
corpuscular volume of 79 fL, creatinine 2.5 mg/dL, and alanine
aminotransferase 67 IU. Examination of his oropharynx revealed
the following physical finding (see figure). What is the next step
in the workup of this patient?

31. What is the next step in the workup of this
patient?
A. Liver biopsy with trichrome and reticulin
connective tissue stains
B. EGD with biopsies from esophagus and stomach
C. Biopsy of tongue with stains for Congo red
D. Immediate referral to otolaryngology for
fiberoptic exam of oropharynx with biopsies
E. Computed tomography (CT) of the head, neck, and
chest for staging purposes

32. ANS #C
• C (S&F ch 24)
The image shows tongue nodules suspicious for isolated
tongue amyloidosis, and therefore, a biopsy with Congo
red staining is appropriate in this setting. In a recent case
series of six patients, it was shown that isolated tongue
amyloidosis is a rare disorder, usually not associated
with systemic disease. However, it still requires extensive
workup to exclude systemic manifestations of amyloidosis.
Recommended tests are bone marrow biopsy, fat aspiration,
and serum and urine protein immunoelectrophoresis.
The other tests, including liver biopsy

34. Q#12
A 63-year-old woman presents to her primary care physician for
weight loss and abdominal discomfort for the past 6 months. She
reports persistent watery diarrhea that occasionally wakes her up
at night. An upper endoscopy is performed, which shows gastric
erythema and edema. Colonoscopy reveals normal mucosa. Biopsy
specimens from the stomach, duodenum, and colon reveal dense
eosinophilic infiltration, suggestive of eosinophilic gastroenteritis.
Due to her persistent symptoms, you are considering oral
prednisone treatment. Which of the following infections have to
be ruled out prior to beginning therapy?
A. Giardia lamblia
B. Helicobacter pylori
C. Methicillin-resistant Staphylococcus aureus (MRSA)
D. Strongyloides stercoralis
E. Escherichia coli

35. ANS #D
D (S&F ch29)
Prior to long-term immunosuppression for treatment
of eosinophilic GI disorders (EGID), all patients should
be evaluated for Strongyloides stercoralis infection.
This infection can become life threatening in the setting
of systemic immunosuppression. MRSA and E. coli may
all be found in the stool without leading to clinical
symptoms or requiring therapy. Testing for G. lamblia
and H. pylori is not required prior to initiating steroid
therapy.