Hepatology & GIT
1. Causes of liver cirrhosis.
2. Causes of portal hypertension.
3. Causes of hematemesis.
4. Causes of melena.
5. Causes of bleeding per rectum.
6. Causes of ascites.
7. Causes of obstructive jaundice.
8. Causes of hepato-cellular jaundice.
9. Causes of acute viral hepatitis.
10. Complications of acute viral hepatitis.
11. Causes of chronic hepatitis.
12. Causes of dysphagia.
13. Causes of malabsorption.
14. Causes of chronic diarrhea.
15. Precipitating factors for hepatic encephalopathy.
16. Causes of Constipation.
17. Acute pancreatitis.
18. Non-surgical causes of acute abdomen (acute abdominal pain).
19. Adverse effects of Metronidazole.
20. Adverse effects Ciprofloxacin.
21. Causes of hemolytic jaundice.
22. Causes of vomiting.
23. Causes of recurrent jaundice.
24. Causes of intra-hepatic biliary obstruction.
25. Causes of fever with jaundice.
26. Causes of acute diarrhea.
27. Causes of epigastric pain.
1. Clinical manifestations & complications of cirrhosis.
2. Treatment of portal hypertension & its complications.
3. Treatment of bleeding esophageal varices.
4. Treatment hematemesis.
5. The neuropsychiatric manifestations of hepatic encephalopathy.
5. Precipitating factors of hepatic encephalopathy.
6. Clinical manifestations & laboratory findings of liver failure
7. Causes, clinical picture & treatment of acute hepatic failure.
8. Investigations for the cause of cholestatic jaundice.
9. Presentations & complications of GERD.
10. Etiology of chronic duodenal ulcer.
11. Treatment of chronic duodenal ulcer.
12. Management of acute diarrhea.
13. Treatment of Intestinal amoebiasis.
14. Treatment of bacillary dysentery?
15. Diagnosis of irritable bowel syndrome.
16. Treatment of irritable bowel syndrome
17. Prevention & treatment of intestinal schistosomiasis.
18. Treatment of ascites due to liver cirrhosis.
19. Treatment of Giardia lamblia.
20. Diagnosis of ulcerative colitis.
21. Treatment of ulcerative colitis.
22. Diagnosis of Crohn’s disease
23. Treatment of Crohn’s disease
24. Diagnosis of amoebic liver abscess.
25. Treatment of amoebic liver abscess.
26. Diagnosis of tuberculous peritonitis.
27. Treatment of tuberculous peritonitis.
28. Diagnosis & treatment of celiac disease.
A 42 year old male patient, with documented history of Schistosoma mansoni infection 25 years later, is admitted to the hospital with severe hematemesis. His pulse rate is 120/minute, regular but weak; blood pressure 70/40 mmHg & respiratory rate 32/minute. There is a tinge of yellowish discoloration in his sclera and mild pitting ankle edema. The liver is felt 2 fingers in the middle line, firm & tender. The spleen is enlarged three fingers below the left costal margin. There is mild shifting dullness in his abdomen. The second heart sound in the second left intercostal space is loud. There is a grade 2/6 systolic tricuspid murmur exaggerated by deep inspiration.
1. What is the most likely source of his bleeding?
2. Mention 2 other possible causes of hematemesis in this patient.
2. What is the most likely underlying pathology?
5. Mention the available options to arrest the bleeding in this patient?
6. Outline the measures that you would take after having controlled the bleeding to avoid subsequent complications?
A 25 year-old male living in a village near Tanta came to the outpatient clinic complaining of diarrhea and blood in the stools of 1 year duration. The patient had 8 motions per day accompanied by tenesmus. On examination the patient was pale and had an enlarged liver & spleen.
Stool examination was done and it showed diarrhea and blood, but no parasites or ova were detected.
1. What investigations you will ask for?
The patient was treated and the diarrhea & bleeding per rectum stopped.
Five years later the patient developed edema of lower limbs.
On examination there was accentuated S2 over the second left space and left parasternal pulsations.
2. What investigations you will do?
3. Outline treatment of the present condition.
A 40 year-old man complained of easy fatigability of 6 months duration.
Clinical examination did not detect any abnormality. Serum bilirubin was 0.8 mg/dl, serum albumin was 4 gm/dl & prothrombin concentration was 100%. ALT was 80 u/dl (n: 5-37) and AST 70 u/dl (n: 8-40).
1. How to investigate this case?
HCV antibodies were detected in the patient’s serum, while other investigations were normal.
2. What is the natural history of HCV infection?
3. What investigations are needed before starting treatment?
4. What are the drugs you would use in treatment?
5. Enumerate the adverse effects of these drugs?
6. How to investigate the patient during treatment?
7. When to tell the patient that he is cured?
The patient failed to have negative HCV RNA after 12 weeks of therapy, so his doctor decided to stop the treatment of the virus. Five years later the patient went to his doctor complaining of swelling of his lower limbs. Examination revealed signs of liver failure.
8. Enumerate signs of liver failure.
9. What are the investigations you will ask for?
The doctor prescribed the following drugs for the patient:
- Spironolactone: 100 mg/day orally.
- Frusemide: 20 mg/day orally.
- Propranolol: 80 mg/day orally.
10. What is the value of each of these drugs in the case?
11. What are the advices you would give the patient regarding diet?
The patient’s condition was controlled by these lines of treatment for months.
The patient’s relatives phoned his doctor one day and told him that the patient is confused and his speech is abnormal.
12. What is your diagnosis of this new event?
13. Enumerate the precipitating factors for this event?
14. Outline treatment the patient at this point?
The patient recovered from this event and his doctor returned him to the lines of treatment prescribed before the occurrence of this event.
The patient went to his doctor after few months complaining of marked distension of the abdomen, so his doctor increased the dose of diuretics and ordered him to restrict salt in diet completely. No improvement of the abdominal distension occurred for weeks in spite of treatment.
15. Enumerate the possible causes of failure of treatment.
A 25 Year-old woman complains of easy fatigability of several months duration. Liver function tests were: serum bilirubin 1.2 mg/100ml, serum aspartate transferase 80 u/ml (N:8-40) and serum alanine transferase 100 u/ml (N:8-37). Liver biopsy revealed piece-meal necrosis, cellular infiltration of portal tracts and fibrous bridges.
1. What is your diagnosis?
2. Enumerate possible causes for this condition.
3. What other investigations to be done for this case?
4. Outline treatment according to the etiology.
5. What are the possible complications of this case?
A 25 year-old woman developed severe itching during the last trimester of her first pregnancy. She was jaundiced and had no abdominal pain. Within two weeks of delivery, both itching and jaundice disappeared.
1. The most likely diagnosis is:
a. Viral hepatitis.
b. Acute fatty liver of pregnancy.
c. Cholestasis of pregnancy.
d. Calcular cholecystitis.
2. Enumerate causes of this type (not cause) of jaundice.
3. How to investigate this type (not cause) of jaundice?
A 13 year-old boy fails to grow normally despite an excellent appetite. During history taking, the patient said that for years he has frequent motions with excess amounts of loose stool. He noticed that his stools are difficult to flush as they float or stick.
Examination of the patient revealed:
- Under weight.
- Rough skin with prominent hair follicles.
- Angular stomatitis.
- Yellow granules at the naso-labial fold.
- Ecchymotic patches in the skin.
- Stoking & glove hyposthesia.
- Distended abdomen with tympanetic note on percussion.
- Loud intestinal sounds.
1. What is the cause of each of the detected physical signs?
2. What are the investigations you will ask for and why?
After the results of investigations came, the doctor ordered the patient to follow a diet regimen. When the patient followed the diet regimen there was a significant improvement in his condition.
3. What is the diet regimen the doctor ordered the patient to follow?
4. What is the diagnosis of the case?
A 10 year-old boy presented with jaundice and dark urine. He gave a history of fever, anorexia & nausea for the previous 5 days.
1. What is your diagnosis?
2. What are the investigations to confirm diagnosis?
3. What is the most probable causative agent?
4. What is the investigation you do to confirm that?
The investigations for HAV, HEV, HBV and HCV were negative.
5. What were these investigations?
The patient did not improve, so he went to another doctor. When this doctor examined the patient, he detected congestion of the throat, palpable cervical & axillary lymph nodes and moderate degree of hepato-splenomegaly.
6. What would be the most probable diagnosis?
7. What are the investigations to confirm this diagnosis?
A young man complained of pain in the righthypochondrium for 6 days. Examination revealed temperature of 39.5ºC, enlarged tender liver, tenderness & edema of the right lower intercostal spaces. The patient was not jaundiced.
1. What is the most likely diagnosis?
2. How to confirm your diagnosis?
37 year-old male patient developed anorexia, fever & right upper quadrant pain. Two days later he developed nausea, vomiting & darkening of urine. He had been in good health aside from an operation two months previously. Physical examination revealed jaundice & enlarged tender 1iver.
1. What is the most probable diagnosis?
2. What is the most probable etiological agent?
3. What are the 2 investigations to begin with here?
4. What are the investigations to diagnose the etiological agent?
Investigations of the patient revealed:
- Abdominal ultrasonography: normal.
- INR: 1
- Serum albumin: 3.8 gm/dl.
- Total serum bilirubin: 8.5 mg/dl and the direct 4.8 mg/dl.
- ALT: 1200 units/dl and AST 950 units/dl.
- HAV IgM: negative and HAV IgG: positive.
- HEV IgM: negative and HAV IgG: positive.
- HCV antibody: positive.
- HBsAg: positive and HBcIgM: positive.
5. Do these investigations confirm your diagnosis?
6. Explain the significance of the results of each of them.
7. Outline treatment of this patient?
The patient was admitted to the hospital 10 days later unconscious.
- Deep jaundice.
- Ecchymotic patches in the skin.
The results of investigations were:
- INR: 1.8.
- Serum albumin: 3.6 gm/dl.
- Total serum bilirubin: 25.6 mg/dl and the direct 11.2 mg/dl.
- ALT: 120 units/dl and AST 110 mg/dl.
- Blood glucose: 40 mg/dl.
- Serum creatinine: 1.5 mg/dl.
8. What is your diagnosis of this development?
9. Explain the results of the new investigations.
10. How to treat the case?
A 22 year-old man in routine checkup was found to have a total serum bilirubin level of 2.5 mg/dl, with a direct fraction of 0.1mg/dl.
1. Mention 2 possibilities for the diagnosis in this case.
2. Mention 2 investigations to differentiate between the 2 possibilities.
A 50 year old male, went to the doctor complaining of yellow discoloration of his eyes. The patient denied the presence of any type of pain, now or before. The doctor asked for serum bilirubin, which was found to be 18 mg/dl, with the direct part 17 mg/dl.
1. What investigations you will ask for and why?
Further investigations show:
- ALT: 45 (n: 12-37) and AST 45 (n: 12-42).
- HCV antibodies: positive.
- HBsAg: negative.
- Abdominal ultrasonography revealed:
- Dilated intra-hepatic biliary radicals.
- Thick gall bladder wall with stones inside.
- Dilated common bile duct.
- The pancreas was concealed by gas.
2. What is your provisional diagnosis?
The doctor asked the patient to do other investigations to reach final diagnosis, but the patient did not show up. The patient returned to the doctor after one month in a very bad shape, he was very weak, lost 10 kg since his last visit to the doctor, his jaundice became deeper and his skin was full of scratches. He told the doctor that he was treated by honey and some herbal medicines. His bilirubin was found to be 35 mg/dl.
3. What is your clinical diagnosis?
4. How to decrease this high level of bilirubin?
40 year old man is complaining of difficulty in swallowing. He noticed this for the first time 5 years ago, but now it is much worse and he has lost 20 pounds during the past year. He was treated 6 months ago for pneumonia. Barium swallow revealed a markedly dilated esophagus with fine tapering at the cardio-esophageal junction.
1. Enumerate causes of dysphagia. 2. What is your diagnosis of this case?
50 year-old male complains of severe epigastric pain of 2 months duration. There is no vomiting, change in bowel habits, or change in stool color. There is no history of NSAIDs therapy.
1. What would be your response?
a. Treat the patient with a PPI.
b. Treat the patient with an H2 blocker.
c. Treat the patient with a prokinetic drug.
d. Perform upper endoscopy.
The patient was diagnosed by investigations to have a duodenal ulcer.
2. What was the red flag in this patient?
3. What is the most probable cause of DU in this case?
4. How to diagnose this cause?
5. Outline treatment of this patient?
A male cirrhotic patient who was moderately controlled, presents with increasing ascites, abdominal pain, and a deteriorating mental status. His temperature was 38.4ºC & bowel sounds were hypoactive. His peritoneal fluid was obtained and was found to be cloudy & the white cell count was 400/mm3, 80% of which were polymorphs.
1. What is your diagnosis?
2. How to treat this patient
A 42 year-old man was hospitalized for tachycardia. He had black stools for the previous 24 hours. Physical examination suggested chronic liver disease.
1. What is your diagnosis?
2. What is the most probable cause?
3. Outline investigations & treatment of this patient.
A 35 year-old female came to your office because of diarrhea alternating with constipation and lower abdominal pain on and off for 1 year. She has had no weight loss or fever. She has no bleeding per rectum. Physical examination was negative, CBC & Sigmoidoscopy were normal.
1. What is your diagnosis?
2. How to treat the case?
A female patient aged 60 years presented to the outpatient clinic complaining of chronic diarrhea in the last 6 months. The stools were bulky and greasy, there was no tenesmus. She was clearly under weight and showed signs of malnutrition.
1. What are the possible causes for her diarrhea?
2. What further investigations are needed to identify the cause?
3. What are the general lines of treatment?
A 50 year old man, presented with loss of weight over the last year. He gave a history of hematemesis 6 months ago. On examination the liver was shrunken with a sharp border, the spleen was slightly enlarged. There was a tinge of jaundice and palmar erythema was obvious. His serum albumin was 2.5 mg/dl and globulins were 4.5 mg/dl. HCV antibodies were present.
1. What is your diagnosis?
2. What other investigations would you do and their relevance?
Few months later he presented with acute clear deterioration of his general condition, jaundice was deeper, ascites was present, but he was conscious.
3. Mention possible causes of his deterioration.
A male patient aged 42 years, coming from Al-Badrasheen, Giza, presented to the outpatient clinic with general weakness, fatigue & ill health of one year duration. The referring physician suspected that the patient might have chronic active hepatitis.
1. Enumerate causes of chronic hepatitis.
2. Mention the investigations you will ask for.
3. Outline treatment of chronic hepatitis.
4. Enumerate causes of fatigue and ill health of one year duration.
The patient came back after 3 years with with abdominal distention and generalized muscle wasting. On examination the following was found:
- Flappy tremors.
- Edema of both lower limbs & ascites of moderate amount.
- Dilated abdominal wall veins arising from the umbilicus.
- Liver is felt 4 cm below the xiphisternal junction in the middle line.
- Spleen is felt 5 cm below the left costal margin.
5. What is your diagnosis of the current condition?
6. Enumerate causes of Gynoecomastia.
The patient was given a loop diuretic, his abdominal girth diminished markedly, but on the fifth day the patient was found comatosed. He was transferred to the emergency department, where a Ryle tube was put and gastric wash was done that revealed the presence of large amount of blood.
7. What are the complications of loop diuretics?
8. What are the precipitating factors of coma in this patient?
9. Outline treatment of the patient at this stage.
A male patient presented to the casualty with hematemesis and melena.
1. Enumerate 5 common causes of such a condition.
2. Mention 4 drugs that may cause GI bleeding.
Examination of the patient revealed; BP 85/55, pulse rate 120/m, with jaundice and palmar erythema.
3. Comment on the physical signs.
4. What investigations are needed to reach final diagnosis?
5. Describe the lines of treatment of hemorrhage in this patient.
On the second day of admission, hemorrhage stopped, but the patient became comatosed.
6. What is your diagnosis?
7. Outline treatment of coma in this patient.
A male patient 27 years old farmer, complaining of diarrhea of 10 days duration, associated with passage of blood in stools, together with tenesmus.
1. Enumerate 5 common causes for such a condition.
2. Outline investigations and treatment of such a condition.
A boy aged 15 years complaining of anorexia, nausea, vomiting & dark urine followed by yellowish discoloration of the eyes.
1. What is the most probable diagnosis?
After 3 weeks from the onset of the disease, the boy improved markedly regarding his appetite, but jaundice deepened, stool became pale, urine darkened, with diarrhea and itching.
2. What is your diagnosis of the new development?
3. What investigations you would ask for and what are the expected results?
A male patient age 70 years presented to the outpatient with deep jaundice and cachexia . he had a history of epigastric pain lasting for the last 3 months. on examination he was under weight , the liver was firm with a hard nodule felt in the right lobe, the spleen was not felt ,an epigastric mass was suspected.
1. What is the probable diagnosis?
2. How would you investigate him?
3. How would you ttt him?
A 70 year old male presented with jaundice and anorexia of one month duration. He lost 8 kilograms in the last few weeks. On examination he was deeply jaundiced and cachectic. The liver was felt 3 fingers below the costal margin in the mid-clavicular line and was smooth and soft. The spleen was not felt and there was no ascites. Abdominal sonography revealed a distended gall bladder and dilated intra-hepatic biliary radicles and common bile duct, but no stones were present.
1. What is the likely diagnosis?
2. What further investigations you would order?
3. Outline the treatment.
A 50 year old male presented with epigastric pain radiating to the back and associated with vomiting. The pain was partially relieved by sitting. On examination he was distressed, mildly hypotensive and tachycardic.
1. What is the most likely diagnosis?
2. What investigations you would order?
3. Mention causes of this condition.
4. How would you treat him?
MCQs Part I
A 47 year old man with diabetes & hypertension travels with his family to Mexico. The next morning after eating out at a local restaurant and despite drinking bottled water, he develops severe crampy abdominal pain and watery, frequent diarrhea.
Which of the following is the best approach for his care?
(A) ciprofloxacin 3 days
(B) penicillin 5 days
(C) tetracycline 3 days
(D) observation of symptoms
(E) metronidazole 10 days
A 30-year-old woman is visiting you in your primary care office as a new patient. Overall, she is healthy. On taking a family history, you learn that her mother was diagnosed with colorectalcancer at the age of 50.
When should this patient start being screened for colorectal cancer?
(A) there is no proven benefit for colorectalcancer screening
(B) at age 40
(C) at age 50
(D) at age 60
(E) at age 30
A 75-year-old man who developed diabetes within the last 6 months was found to be jaundiced. He has remained asymptomatic, except for weight loss of about 10 lbs in 6 months. On physical examination, he is found to have a non-tender, globular, right upper quadrant mass that moves with respiration. A CT scan shows enlargement of the head of the pancreas, with no filling defects in the liver.
What is the most likely cause of his painless jaundice?
(A) malignant biliary structure
(B) carcinoma of the head of the pancreas
(D) cirrhosis of the liver
A 60-year-old previously healthy man presents with massive rectal bleeding. Which of the following is the most likely diagnosis?
(A) diverticulosis of the colon
(B) ulcerative colitis
(C) external hemorrhoid
(D) ischemic colitis
(E) carcinoma of the colon
A 48 year old with pyrexia and left lower quadrant pain is found on CT to have evidence of a diverticular abscess in the pelvis. It measures 5cm in maximum diameter. This is typically managed by
a) resection of the sigmoid colon
b) chemotherapy and radiatiotherapy
c) CT guided drainage
d) transverse colectomy
e) internal sphincterotomy
6 months ago a 36 year old plumber was prescribed cimetidine for his peptic ulcers. Now he presents to his general practitioner because of he has had repeated episodes of diarrhea where his stools failed to flush away properly. On questioning , he admits that the drug treatment is \'not doing me any good\' and he still suffers from severe heart burn. Which of the following syndromes should the physician now be suspecting?
a) Sjorgen's syndrome
b) Peutz jegher's syndrome
c) Zollinger Ellison syndrome
d) Sturge Weber syndrome
e) Steven Johnson syndrome
A 65-year-old man has sudden onset of severe abdominal pain. Physical examination reveals his temperature is 37 C, heart rate 110/minute, respirations 25/minute, and blood pressure 145/100 mmHg. He has diminished pulses in the lower extremities. There is a pulsatile abdominal mass. His serum creatine kinase is not elevated. He has had fasting blood glucose measurements in the range of 140 to 180 mg/dL for over 20 years. Which of the following conditions is he most likely to have?
A - Superior mesenteric artery thrombosis
B - Atherosclerotic aortic aneurysm
C - Polyarteritis nodosa
D - Septic embolization
E - Monckeberg's medial calcific sclerosis
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A 41-year-old man experiences a bout of prolonged vomiting, followed by massive hematemesis. On physical examination his vital signs are T 36.9 C, P 110/min, RR 22/min, and BP 80/40 mm Hg lying down. His heart has a regular rate and rhythm with no murmurs and his lungs are clear to auscultation. There is no abdominal tenderness or distension and bowel sounds are present. Which of the following is the most likely diagnosis?
A Hiatal hernia
B Esophageal laceration (Mallory-Weiss syndrome)
C Esophageal pulsion diverticulum
D Barrett esophagus
E Esophageal squamous cell carcinoma
A 38-year-old man has had upper abdominal pain for 3 months. For the past week he has had nausea. On physical examination a stool sample tested for occult blood is positive. An upper GI endoscopy reveals no esophageal lesions, but there is a solitary 2 cm diameter shallow, sharply demarcated ulceration of the stomach.
Which of the following is most characteristic for this lesion?
A Antral location
B Potential for metastases
C Increased gastric acid production.
D No need for biopsy
E Accompanying pancreatic gastrinoma
A 15-year-old boy from Ghana has the acute onset of right upper quadrant abdominal pain. Abdominal ultrasound reveals a dilated gallbladder with thickened wall and filled with calculi. A laparoscopic cholecystectomy is performed. The pathologist assistant opens the gallbladder to reveal ten multifaceted 0.5 to 1 cm diameter dark, greenish-black gallstones. Which of the following underlying conditions does this boy most likely have?
A Sickle cell anemia
B Crohn disease
A 34-year-old healthy woman develops sudden severe abdominal pain. On physical examination she is afebrile. The pain is centered in the mid-epigastric region, though there is marked diffuse tenderness in all quadrants. Bowel sounds are absent. No masses are palpable. Laboratory studies show her serum amylase is 410 U/L and lipase is 610 U/L.
Which of the following laboratory test findings is most likely to be present in this woman?
B Positive urea breath test
D Elevated sweat chloride
E Positive serology for HBsAg
A 45-year-old man has had vague abdominal pain and nausea for the past 3 years. This pain is unrelieved by antacid medications. He has no difficulty swallowing and no heartburn following meals. On physical examination there are no abnormal findings. Upper GI endoscopy reveals antral mucosal erythema, but no ulcerations or masses. Biopsies are taken, and microscopically there is a chronic non-specific gastritis. Which of the following conditions is most likely to be present in this man?
A Zollinger-Ellison syndrome
B Pernicious anemia
C Helicobacter pylori infection
E Crohn disease
A 25-year-old man has noted cramping abdominal pain for the past week associated with fever and low-volume diarrhea. On physical examination, there is right lower quadrant tenderness. Bowel sounds are present. His stool is positive for occult blood. A colonoscopy reveals mucosal edema and ulceration in the ascending colon, but the transverse and descending portions of the colon are not affected. Laboratory studies show serum anti-Saccharomyces cerevisiae antibodies.
Which of the following microscopic findings is most likely to be present in biopsies from his colon?
A Crypt abscesses
B Entameba histolytica organisms
D Band-like mucosal fibrosis
E Non-caseating granulomas
A 31-year-old woman has a 10 year history of intermittent, bloody diarrhea. She has no other major medical problems. On physical examination there are no lesions palpable on digital rectal examination, but a stool sample is positive for occult blood. Colonoscopy reveals a friable, erythematous mucosa with focal ulceration that extends from the rectum to the mid-transverse colon. Biopsies are taken and all reveal mucosal acute and chronic inflammation with crypt distortion, occasional crypt abscesses, and superficial mucosal ulceration. This patient is at risk for development of which of the following conditions?
A Acute pancreatitis
C Colon Cancer
E Perirectal fistula
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A 72-year-old woman notes increasing jaundice and nausea for the past month. On physical examination she is afebrile, but scleral icterus is present. There is no abdominal pain on palpation. She has active bowel sounds. A stool sample tested for occult blood is negative. Laboratory findings include total protein 6.1 g/dL, albumin 3.3 g/dL, alkaline phosphatase 210 U/L, AST 49 U/L, ALT 40 U/L, total bilirubin 7.2 mg/dL, and direct bilirubin 6.3 mg/dL.. Which of the following conditions is she most likely to have?
A Pancreatic adenocarcinoma
B Cystic fibrosis
C Chronic active hepatitis
D Primary biliary cirrhosis
E Chronic persistent hepatitis
A 44-year-old man, an emergency medical technician, has been feeling fatigued for the past 4 months. He remembers that he had experienced an episode of jaundice about 10 years ago, but that resolved and he has been healthy since. On physical examination there are no remarkable findings. Laboratory studies show his hemoglobin is 14.0 g/dL and serum electrolytes normal, but he has a total protein of 5.4 g/dL, albumin of 2.9 g/dL, ALT 132 U/L and AST 113 U/L with total bilirubin 1.3 mg/dL and direct bilirubin 0.8 mg/dL. A liver biopsy is performed and microscopic examination shows disruption of the limiting plate of hepatocytes with extension of inflammation into the lobules from the triads. There is focal ballooning degeneration of hepatocytes. Which of the following laboratory test findings is most characteristic for his disease?
A Decreased serum alpha-1-antitrypsin
B Positive hepatitis B surface antigen
C Increased serum ferritin
D Decreased serum ceruloplasmin
E Positive antimitochondrial antibody
A 40-year-old man has had mid epigastric pain and nausea for the past 2 months. On physical examination he has no abnormal findings. On upper GI endoscopy a solitary sharply demarcated 2-cm shallow gastric antral ulcer is seen. Which of the following laboratory test findings is most likely to be present in this man?
A Gastric achlorhydria
B Positive serology for antinuclear antibody
C Positive urea breath test
D Increased plasma cortisol
E Elevated serum gastrin
A 22-year-old woman has had progressive malaise for the past year. She has become increasingly obtunded over the past week. On physical examination she is afebrile. Laboratory studies show a plasma ammonia of 55 micromol/L along with serum total bilirubin of 5.8 mg/dL, direct bilirubin 4.6 mg/dL, AST 110 U/L, and ALT 135 U/L. Her serum ceruloplasmin is 14 mg/dL. The antimitochondrial antibody test is negative. A liver biopsy is performed and microscopic examination reveals increased copper deposition. Which of the following ocular findings is most likely to be present in this woman?
A Bilateral papilledema
B Macular degeneration
C Proliferative retinopathy
D Crystalline lens cataract formation
E Corneal Kayser-Fleischer rings
A 28-year-old woman with recent onset of a major depressive disorder ingests an entire bottle (100 capsules, 500 mg each) of a medication containing acetaminophen. She becomes progressively obtunded over the next 8 hours. Which of the following microscopic findings is most likely to be present in her liver 3 days following this ingestion?
A Normal histology
B Extensive necrosis
C Bridging fibrosis
D Severe steatosis
E Portal chronic inflammation
A 45-year-old woman has noted difficulty swallowing for the past 6 months. On physical examination there are no abnormal findings. A barium swallow reveals an area of stricture in the lower esophagus just above the gastroesophageal junction. She has an upper GI endoscopy performed and biopsies of the lower esophagus are taken which show normal squamous epithelium.. Which of the following is the most likely diagnosis?
A Mallory-Weiss syndrome
C Iron deficiency
D Portal hypertension
E Barrett esophagus
A 25-year-old man complains of a low volume but chronic, foul smelling diarrhea for the past year. He has no nausea or vomiting. On physical examination there is no abdominal pain or masses and bowel sounds are present. His stool is negative for occult blood. Laboratory studies include a quantitative stool fat of 10 g/day. Upper GI endoscopy is performed with biopsies taken of the duodenum, and on microscopic examination show absence of villi, increased surface intraepithelial lymphocytes, and hyperplastic appearing crypts. Which of the following therapies is most likely to be useful for this man?
B Gluten-free diet
C Selective vagotomy
E Segmental duodenal resection
A 39-year-old woman has experienced substernal burning pain following meals for the past 15 years. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and there are 1 to 3 cm long tongues of erythematous mucosa extending from the gastroesophageal junction at the Z line upward into the lower esophagus. Biopsies are performed of this region and microscopic examination shows areas of gastric cardiac-type mucosa and intestinalized mucosa. Which of the following interpretations is most appropriate for this woman's findings?
A She has a congenital anomaly
B Her risk for squamous cell carcinoma is increased
C She has chronic gastroesophageal reflux
D Formation of a diverticulum may occur
E She has iron deficiency anemia
A 54-year-old man has complained for 5 months of upper abdominal pain accompanied by nausea. He does not have hematemesis. On physical examination the only finding is a stool sample positive for occult blood. Upper GI endoscopy is performed and gastric biopsies are taken that on microscopic examination reveal acute and chronic mucosal inflammation along with the presence of Helicobacter pylori organisms. The presence of these organisms is most likely to be associated with which of the following?
A Gastric mucosal invasion with septicemia
B Duodenal peptic ulceration
C Pernicious anemia
E Diffuse large B cell lymphoma
A 54-year-old Asian man has had malaise with a 6 kg weight loss over the past 7 months. On physical examination he has a firm, nodular liver edge. His stool is negative for occult blood. Laboratory studies show a positive serology for hepatitis B surface antigen, but negative serologies for hepatitis B surface antibody, hepatitis A IgG antibody, and hepatitis C antibody. His serum alpha-fetoprotein is 300 ng/mL. Which of the following neoplasms is he most likely to have?
B Hepatic adenoma
C Hepatic angiosarcoma
D Bile duct adenocarcinoma
E Hepatocellular carcinoma
A 30-year-old man has had a low volume, bloody, mucoid diarrhea for 3 weeks accompanied by lower abdominal pain. On physical examination he has no abdominal masses and mild diffuse lower abdominal tenderness. His stool is positive for occult blood. Colonoscopy reveals an erythematous, friable colonic mucosa extending from the rectum to the splenic flexure. Colonic biopsies reveal mucosal ulceration with crypt abscesses. Which of the following complications is he most likely to develop?
A Bowel perforation and peritonitis
B Fistula formation to the skin
C Ischemic bowel necrosis
D Colonic adenocarcinoma
E Hepatic micronodular cirrhosis
A first year medical student fails to use proper disinfection techniques in carrying out his microbiology experiment. Two weeks later, he has spiking fevers and cramping abdominal pain with diarrhea. On physical examination his temperature is 38.3 C, pulse 100/minute, respiratory rate 19/minute, and blood pressure 100/60 mm Hg. He has a palpable spleen tip and diffuse abdominal pain without masses. Laboratory studies show a WBC count of 2330/microliter, Hgb 13.8 g/dL, and platelet count 282,000/microliter. Which of the following organisms was he most likely using in his experiment?
A Aspergillus niger
B Entameba histolytica
C Shigella flexneri
D Clostridium difficile
E Salmonella typhi
A 60-year-old man has worsening dyspnea and swelling of his legs for the past month. On physical examination he has pitting edema to the hips as well as sacral edema. Diffuse rales are present in all lung fields. He is afebrile and normotensive. A chest radiograph shows a markedly enlarged heart along with pulmonary edema and bilateral pleural effusions. He develops abdominal pain in the last two days of life. At autopsy he is found to have patchy mucosal erythema involving 200 cm of small intestine. Which of the following conditions is most likely to produce this finding in his bowel?
B Venous thrombosis
D Incarcerated hernia
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A 70-year-old man was admitted with pallor, light-headedness and loss of energy. On the day prior to admission he had reported loose dark stools. Examination revealed a pulse of 110 per minute and a blood pressure of 106/70 mmHg.
7.2 g/dL (14-18)
72 fL (80-96)
White cell count
480 xl09/L (150-400 xl09)
What is the most appropriate next step in his management?
A- Barium meal
B- Blood transfusion
D- Parenteral iron infusion
E- Proton pump inhibitor therapy
A 70-year-old female is admitted 12 hours after taking an overdose of aspirin.
What is the most appropriate treatment of this patient?
C- Intravenous sodium bicarbonate.
D- Peritoneal dialysis.
E- Urine alkalinization.
Seventeen of twenty-four passengers on a Nile cruise develop bloody diarrhoea on the third day.
Which of the following organisms is the likely cause?
A- Giardia lamblia
B- Vibrio cholerae
C- Shigella dysenterae
D- Schistosoma mansonii
E- Entamoeba histolytica
An 18 year old woman presents three days after allegedly taking 50 Paracetamol tablets (25g).
Which of the following tests measured at this time point would be most helpful in determining the outcome?
A- ALT concentration
B- Bilirubin concentration
C- Creatinine concentration
D- Paracetamol concentration
E- prothrombin time
A patient has just received intravenous ceftazidime. They immediately become flushed and wheezy, with a blood pressure of 80/40 mmHg.
Which of the following is the most appropriate immediate management for this patient?
A- Chlorphenarmine l0mg IV
B- Epinephrine 0.2mls of 1:1000 IV
C- Epinephrine 0.5mg IV
D- Epinephrine 0.5mg i.m.
E- Hydrocortisone l00mg i.v.
A 59-year-old woman has had insulin dependent diabetes mellitus for over two decades. The degree of control of her disease is characterized by the laboratory finding of a HbAlc of 10.1% (3.8-6.4%). She complains of repeated episodes of abdominal pain following meals. These episodes have become more frequent and last for longer periods over the last couple of months. On physical examination, there are no abdominal masses or organomegaly and no tenderness to palpation.
Which of the following findings is most likely to be present?
A- Acute pancreatitis
B- Chronic renal failure
C- Hepatic infarction
D- Mesenteric artery occlusion
E- Ruptured aortic aneurysm
A 63-year-old patient with known alcohol related cirrhosis presented with ascites, abdominal tenderness and peripheral edema. A diagnostic tap revealed a neutrophil count of 400/mm3 (<250mm3).
Which of the following would be of most immediate benefit?
A- fluid restriction and a no added salt diet
B- intravenous antibiotics
C- oral spironolactone
D- therapeutic paracentesis
E- trans-jugular intrahepatic porto-systemic shunt
A 69-year-old male is seen in Outpatients. He reports weight loss of one stone over 3 months but his history is otherwise unremarkable.
On examination, his abdomen is soft with no
A PR examination is normal.
His blood tests show:
8.0 g/dL (12-16)
70 fL (80-96)
Which of the following is the most appropriate investigation for this patient?
A- Abdominal X-ray and colonoscopy
B- CT scan of the abdomen and upper G1 endoscopy
C- Sigmoidoscopy upper G1 endoscopy
D- Ultrasound scan of abdomen and colonoscopy
E- Upper G1 endoscopy and colonoscopy
A 25-year-old man is admitted with nausea and frequent vomiting four hours after a meal in a restaurant. During review in the ER he vomits a cupful of blood. What is the cause of his hemetemesis?
A- Duodenal ulceration
B- Hemorrhagic Gastritis
C- Mallory-Weiss tear
D- Esophageal varices
A 48-year-old woman complains of pruritus, steatorrhea and bruising. On examination, she is jaundiced, pigmented, with spider nevi and hepatosplenomegaly. What is the most likely underlying diagnosis?
A- autoimmune hepatitis
B- primary biliary cirrhosis
C- alcoholic liver disease
D- alpha-1 antitrypsin deficiency
E- Wilson’s disease
A 35-year-old woman with cirrhosis is admitted with deteriorating encephalopathy and abdominal discomfort. An ascitic tap revealed a polymorphonuclear cell count of 350 cells per mm3.
Which of the following most appropriate therapy?
A- Intravenous amoxicillin
B- Intravenous cefotaxime
C- Intravenous metronidazole
D- Oral neomycin
E- Oral norfloxacin
A 19-year-old student presents with a fifteen week history of diarrhea. He has lost 2kg in weight, and has no recent travel abroad. A smear of a duodenal biopsy reveals many trophozoites.
What is the best treatment option?
B- Gluten free diet
Ciprofloxacin is the drug of choice in a doseof 500 mg bid for 1–3 days because most cases of travelers’ diarrhea are from E. coli. This patient’s symptoms are moderate to severe and warrant antibiotic treatment which will decrease the frequencyof bowel movements and duration of illness. Erythromycin and tetracycline are effective for Vibrio which is an uncommon cause of travelers’ diarrhea. Metronidazole is used for Clostridium difficile enteritis.
Screening should begin approximately 10years before the age of diagnosis of colorectalcancer in a first-degree (parent or sibling) relative. Given that this patient’s mother was diagnosed at age 50, this patient should start screening at age 40. The natural history of a colon polyp to develop into cancer is thought to be 10 years. Colorectal cancer screening has proven mortality benefit.
Adenocarcinoma of the pancreas arises from ductal epithelium. Because of fibrous tissue formation, the terminal bile duct occludes, causing jaundice. Typically, in the early stages, the patient is free of pain. With invasion of retroperitoneal structures, the patient may sometimes have severe and constant pain. Often, patients have a history of weight loss and present with unexplained diabetes. Because of gradual obstruction,the gall bladder distends, unless it has lost its distensibility because of previous scarring.
Malignant biliary stricture, choledocholithiasis, and cirrhosis of the liver are ruled out by the appearance of the CT. Pancreatitis is rarely associated with jaundice and would be painful.
The causes of lower gastrointestinal bleeding include hemorrhoids and anal fissure, diverticulosis, carcinoma, vascular ectasia, colitis, and polyps. Carcinoma of the colon usually causes chronic GI bleeding, resulting in anemia. Diverticulosis and vascular ectasia are common causes of massive GI bleeding in the elderly patient. Inflammatory bowel disease can also cause massive GI bleeding but is more frequent in younger age group patients. Most patients with ischemic colitis will be quite sick and will have had symptoms before the onset of bleeding.
(C) is the correct answer
When a diverticular abscess is identified on CT scan or ultrasound, percutaneous aspiration should be performed if the abscess is larger than 3cm. A pelvic abscess may be drained into the rectum. Smaller abscesses can be treated expectantly with intravenous antibiotics and observation. Most cases will resolve with the above treatment. Once the inflammation has subsided, resection of the diseased segment can be safely performed as a single-stage procedure. If, however, the patient fails to improve clinically, a Hartmann's procedure is required.
CORRECT ANSWER: C
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Zollinger-Ellison syndrome is caused by excessive gastrin production and is usually due to a gastrinoma (90%)of the pancreas.The diagnosis should be suspected in the case of peptic ulcers failing to respond to drug therapy and repeated episodes of diarrhea and steathorrea (as in this case) Antral G cell hyperplasia is present in 10%. The commonest location is the duodenal bulb, followed by the stomach and then the postbulbar dusodenum. Gastro-esophageal reflux (as in this case)is a complication rather than a cause and is present in most of these patients and often complicated by esophagitis.
The aorta involved with an atherosclerotic aneurysm is markedly enlarged and filled with thrombus. Risk factors for atherosclerosis include both diabetes mellitus and hypertension. Atherosclerotic aortic aneurysms are typically located in the abdominal portion below the renal arteries.
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The lacerations are induced by the forceful, prolonged vomiting and can extend to submucosal veins that bleed profusely. Esophageal variceal bleeding should also be suspected with such a history.
The gastric antrum is the typical location for a benign peptic ulcer.
Darkly pigmented gallstones usually contain bilirubin. Hyperbilirubinemia is a consequence of hemolysis. Patients with sickle cell anemia have chronic hemolysis.
Hypercalcemia is a less common cause for acute pancreatitis that can be found in persons with hyperparathyroidism. Once the pancreatitis has started, the formation of the chalky soap deposits of fat necrosis may draw off calcium to produce hypocalcemia.
This organism is often seen with chronic gastritis.
This history is most typical for Crohn disease, which is a form of inflammatory bowel disease that tends to involve the bowel in a segmental pattern.
This patient has ulcerative colitis (UC). This can be complicated by cancer.
Adenocarcinoma of the head of pancreas produces extrahepatic biliary obstruction with an elevation predominantly of the direct bilirubin along with an elevation in alkaline phosphatase. This results in the classic finding of 'painless jaundice'.
This is chronic active hepatitis with hepatitis B infection. This illustrates the wisdom of getting the series of hepatitis B vaccinations.
Helicobacter pyloriorganisms in the gastric mucus produce urease which will break down urea to ammonia and to CO2. For this urea breath test the patient drinks a measured quantity of a urea-containing solution with radiolabelled carbon. If the H. pylori organisms are present they metabolize the urea and release the radiolabelled carbon which is detected in exhaled air. Most gastric ulcers of this size are benign. Bleeding is a common complication of ulcer disease, seen in 25 to 33% of cases.
These rings can be seen with a slit lamp examination. They are characteristic for Wilson disease, an autosomal recessive disorder with muation in the ATP7B gene that encodes for a copper-transporting ATPase. Patients have decreased serum ceruloplasmin, the copper-carrying protein, and increased tissue deposition of copper, particularly in liver, eye, and basal ganglia of brain.
This is a massive overdose of acetaminophen, which causes extensive hepatic necrosis.
Achalasia is failure of relexation of lower esophageal sphincter.
He has celiac disease from ingestion of grains (wheat, rye, barley) that contain gluten with gliaden protein. The enzyme tissue transglutamidase breaks down the gliaden into peptides which, when displayed to antigen presenting cells, activate CD4 lymphocytes that produce the mucosal inflammation.
There is columnar metaplasia in the lower esophagus with Barrett esophagus from esophageal reflux disease. A small percentage of these patients may develop adenocarcinoma.
H. pyloriis present in about 90% of cases of chronic gastritis and nearly 100% of cases of duodenal ulceration. H. pylori is present with increasing frequency with age, whichsuggests that it is an important cause for chronic gastritis in the elderly.
Chronic hepatitis and both micro- and macronodular cirrhosis carry an increased risk for liver cancer. Most often this is hepatocellular carcinoma. Either chronic hepatitis B or C infection increases the risk for primary liver cancer. An elevated AFP is characteristic for hepatocellular carcinoma.
Chronic ulcerative colitis carries a significant risk for development of colonic adenocarcinoma 2 or 3 decades after onset.
He developed typhoid fever. Even though this is an acute bacterial infection, mononuclear inflammation and leukopenia are typical findings.
Hypotension with ischemia is probably the most common cause for ischemic enteritis and/or colitis. This man's heart disease (probably a dilated form of cardiomyopathy with both right and left-sided congestive heart failure) led to reduced cardiac output with reduced tissue perfusion. Though the bowel has a rich anastomosing blood supply, when flow is reduced in all branches, then ischemic can occur.
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B is correct.
There is only one answer here and that is blood transfusion. He has clearly had a major GI bleed since he presents with symptoms of shock with a high resting heart rate and lowish blood pressure the day after what sounds like melaena. What is more he has a significant microcytic anaemia. He should be resuscitated with blood transfusion and then send for upper GI endoscopy. A barium meal will not help a bleeding vessel. Parenteral iron is for chronic anaemia not acute bleeds and proton pump inhibitors, although widely used, have no supportive evidence and are nowhere near as important as giving blood to this man.
A is correct.
This patient is at major risk of aspirin toxicity as reflected by the excessive aspirin concentration and appears to have developed acute renal failure -is acidotic with an elevated potassium. Bicarbonate is recommended as a supportive therapy but in this patient, Haemodialysis is the treatment of choice. The latter is advised when the plasma-salicylate concentration is greater than 700 mg/litre (5.1 mmol/litre) or in the presence of severe metabolic acidosis.
C is correct.
Dysentery is characterised by the passing of frequent (sometimes very frequent) stools, that may contain blood, mucus or pus. Shigella dysenteriae is responsible for bacillary dysentery, a disease most often associated with crowded, unsanitary conditions. Other species of Shigella may produce milder forms of diarrhoeal disease. Dysentery is an oral infection transmitted via faecal contamination of water or food. During the 1-4 day incubation period, penetration of bacteria into the mucosal epithelial cells of the intestine causes an intense irritation of the intestinal wall, producing cramps and-a watery, bloody diarrhoea.
E is correct.
The patient has ingested a seriously toxic dose of paracetamol. The best determinant of this risk at 72 hours would be a prolonged prothrombin time. Paracetamol concentrations would be rather meaningless at this time point and irrespective she should be treated with N-acetylcysteine.
There are four phases of paracetamol overdose
· Phase 1 (0-24 h) o Asymptomatic o Anorexia o Nausea or vomiting o Malaise o Subclinical rise in serum AST – 12 hours postingestion
· Phase 2 (18-72 h) o Right upper quadrant abdominal pain, anorexia, nausea, vomiting o Continued rise in serum transaminases levels (note this is the time slot for our patient with the ALT rises).
· Phase 3 (72-96 h) o Centrilobular hepatic necrosis with continued abdominal pain o Jaundice o Coagulopathy o Hepatic encephalopathy o Nausea and vomiting o Renal failure o Fatality Rising INR/PT from 3 days.
· Phase 4 (4 d to 3 wk) o complete resolution of symptoms o complete resolution of organ failure.
D is correct.
Immediate treatment of anaphylaxis includes cessation of whatever caused it. Oxygen, fluids and adrenaline/epinephrine 0.5mg i.m or subcutaneously. (checking concentrations of adrenaline is very important especially in high pressure situations). Intravenous adrenaline is potentially hazardous unless diluted appropriately.
D is correct.
Diabetes- especially Type 2 diabetes- is associated with macrovascular disease. Smoking is a further risk factor for macrovascular atherosclerosis. After a meal splanchnic blood flow is increased. If the mesenteric artery is occluded the lack of blood flow to the bowel will produce ischaemic type pain.
B is correct.
This man has spontaneous bacterial peritonitis (SBP). Appropriate treatment is IV - antibiotics. He is likely to have a decreased intravascular volume and require IV albumin as volume expansion.
E is correct.
This man has weight loss and an unexplained microcytic anaemia. The likely site of blood loss is from the GI tract in absence of an alternative explanation. This may be due to an occult GI malignancy and, therefore, the initial investigations of choice are upper and lower G1 endoscopy.
C is correct.
Persistent vomiting can eventually lead to small tears in the oesophagus leading to the vomiting of red blood. Varices would produce large volumes of blood (much more than just a cupful).
B is correct.
She has clinical evidence of chronic liver disease and portal hypertension. The 2 main conditions causing pigmentation and chronic liver disease are primary biliary cirrhosis (PBC) and haemochromatosis. PBC is a chronic cholestatic inflammatory liver disease, the aetiology of which is probably autoimmune. It most commonly affects middle-aged women. There is jaundice with skin pigmentation, risk of developing oesophageal varices and fat malabsorption, leading to deficiency of the vitamins A, D, E, K (hence osteomalacia and also bruising). Serum antimitochondrial antibody is positive in 95-99% cases.
B is correct.
This lady has Spontaneous Bacterial Peritonitis as suggested by the typical history, ascites and raised polymorphonuclear count within the ascitic tap. The causative organism is usually Escherichia coil, Kiebsiella, S Pneumoniae or Enterococci. Initial treatment is with broad spectrum antibiotics such as cefotaxime Norfioxacin is recommended for short term prophylaxis.
C is correct.
The diagnosis here is Giardiasis, caused by Giardia lamblia. Giardia has been reported as a cause of chronic diarrhoea. Most patients respond to oral metronidazole 250-400mg tds for 5 days.
MCQs Part II
Hepatology, Biliary & pancreatic
1-Classical triad in carcinoid syndrome is
A .dyspnoea, flushing , valvular heart disease
B . flushing , diarrhea , valvular heart disease
C .pruritus , wheezing , diarrhea
D . telangiecasia , flushing , diarrhea
A. Purpura, diarrhea, and bronchospasm
2- Which is not included in the classical triad of chronic pancreatitis
a. diabetes mellitus
b. abdominal pain
c. pancreatic calcification
e. Cullen' sign
3- Which of the pancreatic islet cells synthesize glucagon
4. Acute pancreatitis may eventually lead to all the following except
a. acute lung injury
b. fulminant hepatocellular failure
c. disseminated intravascular coagulation
d. renal failure
5- All are recognized complications of acute pancreatitis except
A .pancreatic phlegmon
b. pancreatic pseudocyst
c .pancreatic ascites
d .pancreatic malignancy
E. pancreatic calcification
6-Acute pancreatitis is not associated with
b. billiary tract disease
c. pancreatic carcinoma
d. pancreatic islet cell tumour
7- Which clotting factor retains its activity in hepatocellular disorder
8- Which is a predisposing factor for the development of pancreatic carcinoma
A. cigarette smoking
B . alcohol abuse
C . cholelithiasis
E. diabetes mellitus
9- Venous prominence present in the upper abdomen with direction of flow towards pelvis suggests
A. inferior vena caval obstruction
B. portal hypertension
C. superior vena caval obstruction
D. hepatic vein thrombosis
E. splenic vein thrombosis
10 – Serum alkaline phosphatase level may be increased in all except
A . cholestasis
B . paget’s disease
C . metastasis in liver
D . hypervitaminosis D
11 – A patient is having isolated elevation of serum alkaline phosphatase. The next test to be performed is
A . USG of liver
B . 8-glutamyl transpeptidase (GGT) estimation
C . protein electrophoresis
D . bone scan
E. abdominal sonar
12 – The major immunoglobulin in primary biliary cirrhosis is
A . IgM
B . IgA
C . IgG
D . IgD
13- Which one of the following is false regarding type B hepatitis serology
A . persistence of HBsAg >6 month implies carrier state
B . HbeAg implies high infectivity
C . anti – HBs appears to reflect immunity
D . IgG anti HBc acute hepatitis B virus infection
E. anti HBcAb is important in diagnosing mutant forms
14- Pruritus associated with cholestasis is mostly seen
A. On the palm and soles
B. At daytime
C. After a cold bath
D. In males
15 - Which of the following is not associated with leucocytosis
A . Toxic hepatitis
B . Acute viral hepatitis
C . Portal pyema
D . amoebic liver abscess
E. fulminant hepatitis
16 . Vitamin k absorption in dependent on
A . HCI
B . Bile salts
C . bilirubin
D . succus entericus
17. Bedside diagnosis of obstructive jaundice includes all except
A . generalized pruritus
B . palpable gall bladder
C . dark- colored stool
D . xanthelasmas
E. itching marks
18 – Which of the following drugs is not associated with cholestasis
A . erythromycin stearate
B . chlorpropamide
C . chlorpromazine
D . methyl testosterone
19 – Which is not true so far as definition of cirrhosis of liver is concerned
A . fatty infiltration
B . necrosis
C . fibrosis
D . regeneration
E. diffuse process
20 – Spider nevi
A. are pathognomic of portal hypertension
B. may be seen in some healthy people
C. often seen in first trimester of pregnancy
D. correlates with the amount of urinary oestradiol excetion
E. are seen on the skin in distribution of the IVC
21 – Chronic active hepatitis may have all the following feature except
A . amenorrhoea
B . arthralgia
C . jaundice
D . haematemesis
22 – Commonest microorganism responsible for cholangitis
A . E .coli
B . klebsiella pneumonia
C . heamangioendothelioma
D . sarcoma
E. staphylococcus aureus
23 – In complete biliary obstruction , urinary urobilinogen is
C. remains normal
D. episodic increase and decrease
E. markedly elevated
24 – All of the following are features of hepatocellular failure except
A . Fetor hepaticus
B . ascites
C . flapping tremor
D . hematamesis
E. lower limb edema
25 – Serum of patient contains only anti-HBs; he is
A. acutely infected by type B virus
B . suffering from chronic hepatitis B virus infection
C . low level of HbsAg carrier
D . vaccinated
E. highly infective
26- Chronicity in hepatitis c virus infection is
B . 30%
C . 50%
D . 80%
27- All of the following produces deep jaundice except
A .G6PD deficiency
B .recurrent cholestasis of pregnancy
C .carcinoma of the head of pancreas
D .sclerosing cholangitis
E. primary biliary cirrhosis
28- Enlarged tender liver is found in all except
A .congestive cardiac failure
B Amoebic Liver abscess
C .Large hepatoma.
D .wilson s disease
E. acute hepatitis
29- secondary carcinoma of liver should not have
E. portal vein thrombosis
30- Commonest cause of portal hypertension is
A .acute viral hepatitis
B . chronic active hepatitis
C .cirrhosis of liver
D .carcinoma of liver
31- Rapid diminution in the size of liver is seen in
A .cholangio - hepatitis
B .fulminant hepatic failure
C .carcioma of liver
D .acute alcoholic hepatitis
32- The kayser-fleischer ring is
A .broader laterally and medially
B .the inferior pole of cornea is first affected
C .copper deposition in descemet’s membrane
D .hampers vision
E. causes double vision
33- Definitive test for diagnosis of hemochromatosis is
A . Plasma iron > 300 mg / dl
B . liver biopsy
C . TIBC < 200 mg / dl
D . hepatic iron index > 1.5
E. urinary iron
34- Superficial venous flow in portal hypertension is
A .away from the umbilicus
B .below upwards
C .towards umbilicus
D .above downwards
E. lateral to medial
35- Which is false regarding hemochromatosis
A .pancreatic iron deposition lead to diabetes
B .most common cardiac manifestation is congestive heart failure
C .melanin and iron deposition give rise to bronzing of skin
D .hypogonadism results from iron deposition in testes
E. may be secondary or hereditary
36- Commonest cause of post - transfusion hepatitis is
A .hepatitis b
B .hepatitis c
C .hepatitis d
D .hepatitis e
E. delta hepatitis
37- Commonest hepatic lesion in hemochromatosis is
A .fatty liver
B .macronodular cirrhosis
C .micronodular cirrhosis
E. hepatic fibrosis
38- All are characteristic features of wilson's disease except
B .sensory loss
D .slurred speech
E. winging upper limb movements
39- Absolute contraindication for liver biopsy is
A . cirrhosis of liver
C .haemangioma of liver
d .amoebic liver abscess
40- Which one of the following is false regarding primary biliary cirrhosis
A .female preponderance
B .starts with pruritus
C .moderate to server jaundice
E. no Intrahepatic biliary radical dilatation
41- All of the following may develop into chronic active hepatitis except
42- Congestive gastropathy in portal hypertension is treated by
B . somatostatin
43- Commonest cause of jaundice in pregnancy is
A .toxaemia of pregnancy
B .acute fatty liver of pregnancy
C .acute viral hepatitis
D .use of hepatotoxic drugs
E. portal pyemia
44- Commonest cause of hepatoma is
A .α1 – antitrypsin deficiency
B . haemochromatosis
C . alcohol
D . cirrhosis of liver
45- Tumour of liver found predominantly in females is
B .hepatocellular carcinoma
46- Commonest organism causing pyogenic liver abscess is
C .streptococcus faecalis
D . E.coli
47- In HBV infection, which serological maker is present in the "window period" as an evidence of recent HBV infection
A .HB eAg
B .IgG anti- HBc
C .IgM anti - HBc
D . HBV DNA
E. anti HBsAb
48- Regarding non-acoholic steato-hepatosis (NASH), all are true except
A .occasionally progresses to cirrhosis and liver failure
B .typically occurs in overweight, diabetic, hyperlipidemic subjects
C .jejunoileal by-pass may be an aetiology
D .glucocorticoid helps cure
E. may be caused by certain drugs
49- Acute pancreatitis is caused by all except
D .blunt trauma
50- In acute infection with HBV, first thing to appear or rise in blood is
A . HbsAg
51- Continued infectivity in HBV infection is diagnosed by
A . IgM Anti-HBc
C .HBV DNA
52 - Which vitamin deficiency occurs in obstructive jaundice
A .folic acid
B . vitamin A
C .vitamin C
D .vitamin B 12
E. vitamin K
53- Morphine is contraindicated in
A .Acute myocardial infarction
B . Terminal cancer pain
C .Biliary colic
D .Acute left ventricular failure
E. Acute pancreatitis
54 - Pregnancy predisposes to all except
A .acute hepatic failure
B .chronic hepatitis
E. sclerosing cholangitis
55 - All are 'medical causes of acute abdomen' except
A .apical pnumonia
B .sickle cell anaemia
C .acute myocardial infarction
D .lead poisoning
E. diabetic ketoacidosis
Part II Gastroenterology
1-Raspberry tongue is found in
A. scarlet fever
B. Glandular fever
C. Yellow fever
D. Rheumatic fever
E. infective endocarditis
2-All of the following are examples of psychiatric illness
associated with profound weight loss except
A. Anorexia nervosa
C. Sheehan's syndrome
3-Hepatocelluar jaundice does not result from
B. Copper sulphate
4- serum-ascites albumin gradient (SAAG) is > 1.1 g/dL in all except
A. Tuberculous peritonitis
B. Congestive cardiac Failure
C. Cirrhosis of liver
D. Budd-chiari syndrome
E. Portal vein thrombosis
5-All of the following are associated with obstructive jaundice except
A. Oral contraceptives
C. Grigler-Najjar type II
D. Secondary carcinoma of liver
E. Acetaminophen toxicity
6- Secretory diarrhea has no association with
A. pancreatic insufficiency
B. Zollinger-Ellison syndrome
C. Villous adenoma of rectum
D. Medullary carcinoma of thyroid
E. Carcinoid syndrome
7-WBC in stool is not found in
D. Entero-invastive E.coli
E. Viral gastroenteritis
8-Latent jaundice may be a feature of all except
A. Pernicious anemia
B. Acute pulmonary thromboembolism
C. tropical sprue
D. Congestive cardiac failure
9- Regarding hematochezia which one is false:
A . Passage of bright red blood per rectum
B . May be due to rectal polyp, ulcerative colitis
or angiodysplasia of colon
C . The blood may not be mixed with stool
D . Bleeding source is proximal to ligament of Treitz
E. Diverticulitis is the commonest cause
10-Which is not a member of familial non-hematolytic
A. Rotor syndrome
B. Reye's syndrome
C. Dubin-johnsin syndrome
D. Gilbert's syndrome
E. Grigler-najar syndrome type II
11-Regarding melena which statement is false
A. At least 60 ml of blood is required
B. Blood should remain at least 4 hours within the gut
C .Black tarry semisolid stool
D .Offensive in odour
E. It may occur due to colonic lesions
12- Manometric study of lower esophagus is important in all, except
A .Mallory-weiss syndrome
C. Diffuse esophageal spasm
D. Achalasia of the cardia
E. Crhon's disease
13-Achalasia of the cardia gives rise to all except
A. Chest pain
14-achalasia of the cardia may lead to all except
B. Lung abscess
D. Fibrosis of the lung
E. Pleural effusion
15- Serum alkaline phosphates is increased in all, except
A. Paget’s disease of bone
C. Sclerosing cholangitis
16- Regarding H.pylori, which statement is false
A. Gram –negative bacillus
C. It penetrates within the epithelia cell the of stomach
D. Often resides in the dental plaques of the patient
E. Diagnosed at endoscopy
17- Pyloric stenosis is commonly associated with all except
A. Bilious vomiting
B. Obliteration of traube’s space tympanicity
C. distension of upper abdomen with succession splash
18-Wich statement is false regarding duodenal ulcer
A. More common in first degree relatives of duodenal ulcer patient
B. Increased frequency of blood group O and of the non-secretor status
C. Increased incidence of HLA-B5 antigen
D. An increase in serum pepsinogen II level
E. H.pylori has no role
19-H.pylori is usually not associated with
A. Zollinger-ellison syndrome
B. Antral gasritis
C. Non-ulcer dyspepsia
D. Gastric lymphoma
E. Gastric outlet obstruction
20- Regarding diffuse oesophageal spasm which of the following is true
A. Usually a disease of teen age
B. Chest pain mimics angina pectoris
C. Invariably requires surgery
D. Nutcracker’s esophagus is the mildest form
21- Which of the following does not gives rise to haematemesis
A. Carcinoma of the stomach
B. Duodenal diverticula
C. Mallory-wiess syndrome
E. Peptic ulcer
22- The weight of normal daily stool of healthy adult is
A. 100-200 g
C. 500-600 g
D. 700-800 g
E. up to 240g
23- All of the following are methods for detection of
H. pylori except
B. endoscopic view
C. polymerase chain reaction
D. rapid urease test
E. Serum ELIZA test
24- All are absorbed maximally in the upper small intestine except
25-Gastrin is predominantly secreted from
A. Antral mucosa
B. Fundus of the stomach
C. 2nd part of the duodenum
26- Late dumping syndrome may be manifested by all except
C. Postural hypertension
27-the most common gastrointestinal disorder in community is
B. Duodenal ulcer
D.Irritable bowel syndrome
E. peptic ulcer
28-Incidence of stress ulcer in acutely traumatized patient is
29-wich of the following surgical procedures in peptic ulcer most commonly gives rise to recurrent ulceration
B. Vagotomy with pyloroplasty
C. Three-quarter gastric resection
D. Vagotomy with gastroenterostomy
E. Highly selective vagotomy
30-Commonest cause of antral gasritis is
D.Herpes virus infection
31-All of the following are true in respect Zollinger-Ellison syndrome except
A. Pancreatic gastrinomas are most common in the head of the pancreas
B. Solitary primary tumors are very common
C. Duodenum , hilum of the spleen and rarely the stomach may have gastrinomas
D. Majority of tumors are biologically malignant
E. A common cause of recurrent peptic ulcer
32-In gastroparesis, the following drugs are helpful except
33-Malabsorption may produce all of the following except
C . Peripheral neuropathy
D . Loss of libido
E. gall stones
34-A normal faecal fat is defined as
A. < 6 g for 24 hrs
B. < 9 g for 24 hrs
C. < 12 g for 24 hrs
D. < 15 g 24 hrs
E. < 17g 24 h
35-Which cardiovascular disorder is not associated with steatorrrhoea
B. Congestive cardiac failure
C. Left atrial myxoma
D. Mesenteric vascular insufficiency
E. Pericardial effusion
36- All of the following may be associated with diarrhea except
A . amitripitiline
B . colchicines
C . sorbitol
D . theophylline
37-Steatorrhoea accompanying diabetes mellitus may be due to all except
A. Exocrine pancreatic insufficiency
C. Coexistent celiac sprue
D. Abnormal bacterial proliferation in proximal intestine
38- The basic defect in celiac sprue lies in
A. Protein metabolism
B. Fat metabolism
C. Carbohydrte metabolism
D. Vitamins and minerals absorption
E. Mucosal defect
39- Lactose intolerance with lactase deficiency may be present in all except
A. Crohn's disease
C. Cystic fibrosis
E. Celiac disease
40- The most specific treatment in celiac sprue is
A. Gluten-free diet
D. Folic acid
E. Vitamin B12
41- Hepatic amoebiasis is associated with all except
A. May lead to development of amoebic liver abscess
B. Right lower intercostals tenderness
C. Abscess commonly affects the right lobe
D. Quinolones are the treatment of choice
42- Treatment of choice in correcting anaemia of 'blind loop syndrome' is
B. Broad-spectrum antibiotics
C. Vitamin B12
D. Folic acid
43- The major site of bile salt absorption is
C. Proximal small intestine
D. Distal small intestine
44- All are recognized complications of inflammatory bowel disease except
a .gallstone formation
b .pyoderma gangrenosum
c .aphthous stomatitis
d . erythema marginatum
45- Regarding ulcerative colitis which is true
A . segmental involvement is common
B . granuloma and fistula formation are characteristic
C . crypt abscesses are typical
D . malignancy never follows even in long-standing disease
E. Bleeding is rare
46- which segment of the GI tract is most susceptible to volvulus
B. Sigmoid colon
C. Small intestine
47- Crohn's disease may be complicated by all except
D. Chronic cholecystitis
48- "String sign' in Crohn's disease is due to
D. Small ulceration
49- Regarding Meckel's diverticulum which one is false
A. Present in 2% population
B. Usually 5 cm long
C. Present within 100 cm of the lleocaecal valve
D. May contain oesophageal or rectal mucosa
E. Common cause of peptic ulcer disease
50- Peritonitis may be complicated by all except
A. Renal failure
B. Acute lung injury
C. Pelvic abscess
D. Haemorrhagic pancreatitis
51- Which is true in respect to irritable bowel syndrome
A. Most common GI disorder in practice
B. Commonly affects males
C. Easily treatable
D. Nocturnal diarrhea is common
E. Precancerous condition
52- Commonest complaint by a patient in carcinoma of the rectum is
B. Pain abdomen
D. Anal pain
E. Anal fistula
53- All of the following are true in irritable bowel syndrome except
A. Usually have 3 clinical components: spastic, diarrhoeal and both
B. Altered intestinal motility and increased visceral perception are the main pathophysiologic abnormalities
C. Rectal ampulla is empty but tender sigmoid is full of faeces
D. Sigmoldoscopy shows multiple small discrete ulcers often covered with slough
E. Symptoms often change over time
54- Crohn's disease may produce all of the following except
A. Vesicovaginal flstula
B. Rectovesical flstula
C. Perianal flstula
D. Jejunocolic flstula
E. Enterocutaneous fistulas
55- Commonest extraintestinal complication of ulcerative colitis is
A. Sclerosing cholangitis
C. Pyoderma gangrenosum
E. Sjogren's syndrome
56- Symptoms in carcinoma of the left colon include all except
A. Cramps in the abdomen
C. Low back pain
D. Alteration of bowel habit
57- Which is true regarding irritable bowel syndrome
A. Pain abdomen usually lasts for 1/2 hour
B. Temporary relief of pain by passage of flatus or stool
C. Nocturnal pain abdomen is frequent complaint
D. Periodicity is common
E. Positive occult blood in stools is common
58- Crohn's disease is caused by
A. Nutritional deficiency
B. Toxin elaborated by infectious microorganisms
D. Not known
59- Ulcerative colitis involves the rectal mucosa in
E. less than 10%
60- Which one is false regarding irritable bowel syndrome
A .sense of complete evacuation
B .abdominal distension
C .colicky pain abdomen
D .mucous diarrhea or pencil-like pasty stool
E. coexisting minor psychiatric illness
61- All of the following are true regarding diverticulitis except
A. Males are affected more than females
B. Right side of colon is less affected than left
C. Perforation is a serious complication
D. Massive rectal bleeding is very common
E. Diagnosed by colonoscopy
62- All of the following are true regarding right-sided colonic carcinoma except
C. Pain abdomen
D. Alteration of bowel habit
63- Which of the following may develop into intestinal lymphoma
A. Coeliac disease
B. Ulcerative colitis
C. Eosinophilic enteritis
D. Intestinal lymphangiectasia
E. Tropical sprue
64- Melanosis coli indicates
A. Anthraquinone laxative abuse
B. Hypereosinophilic enteritis
C. Crohn's disease
D. Melanoma affecting colon
E. Excess melatonin secretion
65- Hour- glass stomach is usually produced
C. developmental anomaly
D. gastric ulcer
E. linitus plastica
66- Bacillary dysentery can be differentiated form ulcerative colitis by:
A. barium enema
B. stool culture
C. stool smear
E. rectal snip
67-commonest site of carcinoma of the stomach is
B . lesser curvature
C . greater curvature
D . body of the stomach
68-which one of the following is not an ocular complication of ulcerative colitis
B . cataract
C . scleromalacia perforans
D . episcleritis
69- commonest sites of carcinoid tumour is
A . Stomach
C . appendix
D . colon
70- Desire for defecation is initiated by
A . Distention of the sigmoid colon
B . Contraction of the rectum
C . Distention of the rectum
D . Contraction of the internal anal sphincter
E. Relaxation of the external anal sphincter
71- presence of diverticulosis is most commonly seen In
A .transverse colon
B. sigmoid colon
c. descending colon
72- Diabetic diarrhea may be encountered in the presence of
73-which is not effective to eradicate H.pylori
74- Most reliable method of measuring steatorroea is
b.D-xylose absorption test
c.faecal fat estimation
d.small intestinal mucosal biopsy
75- carcinoma of the large intestine is mostly found in
B . sigmoid colon
C . transverse colon
D . ascening colon
E. descending colon
76- gluten- free diet is beneficial in
E. chronic gastritis
77-mucosal immunity is mainly due to
E. Ig A
78-anti-saccharomyces cerevisiae antibody (ASCA) is classically present in
a.primary sclerosing cholangitis
c. wegener’s granulomatosis
E. crhon's disease
79-hyperdefaecation is characteristic of all except
a. irritable bowel syndrome
80- constipation may develop from all except
d. calcium-channel blocker
81-which of the following does not produce secretory diarrhea
B .medullary carcinomia of the thyroid gland
C .carcinoid syndrome
D .zollinger-ellison syndrome