Gastroenterology Module 2

According to a recent study on early-onset colorectal cancer (CRC), which group of symptoms were identified as red-flag signs for the disease in individuals younger than 50 years?

The following are risk factors for esophageal adenocarcinoma except?

A 19-year-old woman is evaluated for a 2-week history of nausea andnew-onset jaundice. Six weeks ago she had an uncomplicated cystitis, which resolved after a 3-day course of therapy with trimethoprimsulfamethoxazole.

On physical examination, the temperature is 37.3 C , the blood pressure is 120/85 mm Hg, the pulse rate is 88/min, and the respiration rate is 14/min; the BMI is 31. There is conjunctival icterus, jaundice, and right upper quadrant tenderness on deep palpation. Murphy sign is not elicited, and there is no asterixis or stigmata of chronic liver disease. Stool is negative for occult blood.

Laboratory studies:

• Leukocyte count 7.8 – 109/L with normal differential
• Bilirubin (total) 12.0 mg/dL
• Bilirubin (direct) 5.6 mg/dL
• Aspartate aminotransferase 23 U/L
• Alanine aminotransferase 35 U/L
• Alkaline phosphatase 464 U/L
• Antinuclear antibody titer Negative
• Anti-smooth muscle antibody Negative
• Antimitochondrial antibody Negative

Ultrasonography of the right upper quadrant shows normal caliber of the hepatic ducts, a normal gallbladder without wall thickening, and no cholelithiasis.

What is the most likely diagnosis?

Which of the following drug does NOT have a role in maintaining remission in ulcerative colitis?

Vedolizumab is a novel monoclonal antibody that has been recently approved for the treatment of ulcerative colitis and Crohn’s disease. Which is the main target for this medication?

The following medications are all safe for pregnant patients with IBD in their first and second trimester except?

A 35-year-old woman is evaluated for symptomatic ulcerative colitis. One year ago, she was diagnosed with pan-ulcerative colitis and responded well to initial and maintenance therapy with mesalazine.

However, 2 months ago she developed urgent bloody diarrhea several times a day and lower abdominal cramping; prednisone, 40 mg/d, alleviated her acute symptoms, but her symptoms have returned with prednisone tapering.

The patient is otherwise healthy, and her medications are mesalazine, prednisone, 15 mg/d, and calcium with vitamin D.

On physical examination, vital signs and other findings are normal. Laboratory studies reveal hemoglobin 114 g/L and plasma glucose 7.77 mmol/L.

Stool analysis for Clostridium difficile toxin A and B is negative

Which of the following is the most appropriate next step in the treatment of this patient?

A 35-year-old man with long standing ulcerative colitis has quiescent disease. He is on a maintenance regimen of salazopyrine 1 g bd and azathioprine 100 mg/day. At a routine follow up visit, he reports feeling well, with two formed stools a day and no blood or mucus. The physical examination is normal.

You perform some blood tests and the following results are available the next day:

• bilirubin 20 μmol/L [3-21]
• alkaline phosphatase 549 U/L [30-115]
• gamma glutamyltranspeptidase 980 U/L [<65]
• aspartate transaminase 85 U/L [5-40]
• alanine transaminase 76 U/L [5-40]
• total protein 67 g/L [60-85]
• albumin 37 g/L [40-52]
• white cell count 5.4 x 109/L [4.0-11.0]
• haemoglobin 115 g/L [120-160]
• platelet count 156 x 109/L [150-400]

His liver function tests were normal two years ago. An abdominal ultrasound shows a normal sized liver with non-dilated bile ducts. The gall bladder is normal with no calculi.

The most likely cause for these results is:

A patient with cirrhosis and Child–Pugh class A presents with an acute upper gastrointestinal bleeding without clinical evidence of hemorrhagic shock.

Which of the following intervention would likely lead to increased survival?

A 46-year-old man has had pancolonic ulcerative colitis since age 23. He has had colonoscopies every two years for the last six years. He has been asymptomatic for three years, and has been prescribed sulphasalazine 1 g twice daily which he often forgets to take.

Biopsies show chronic active mucosal inflammation with high grade epithelial dysplasia.

The most appropriate management is:

The use of combination therapy with infliximab and azathioprine for moderate to severe ulcerative colitis is likely to result in the following outcome except?

For which of the following presentations of inflammatory bowel disease is infliximab of most benefit?

A 16-year-old female was diagnosed with ulcerative colitis at the age of 12. Her disease was fairly well controlled, initially with steroids and subsequently on maintenance salazopyrine. Over the last six months she complained of poor concentration, tiredness and vague upper abdominal pain.

Blood investigation done by her general practitioner showed:

• Alanine aminotransferase (ALT) 80 IU/L
• Alkaline phosphatase (ALP) 660 IU/L [30 – 120 IU/L]
• Gamma glutamyltransferase (GGT) 332 IU/L [0 – 40 IU/L]
• Total Bilirubin 6 μmol/L
• Antinuclear antibody (ANA) + ve (titre 1:80)
• Anti-smooth muscle antibody -ve
• Anti-liver kidney microsomes -ve

What condition does this patient most likely have?

A 25 year old patient who has Hepatitis B infection with advanced liver disease wishes to become pregnant.

Which of the following would be the most appropriate advise for her with regards to treatment for her HBV infection?

A 35-year-old man presents to your office four months after resection of 50 cm of terminal ileum for Crohn’s disease. He has been well, but complains of excessive diarrhoea, especially in the morning. The motion has been watery, but without blood or mucus. A recent colonoscopy failed to show any evidence of colitis or enteritis and the anastomosis appeared healthy. He is currently on no medications. Physical examination reveals a well-healed scar, with no tenderness in the abdomen and normal bowel sounds. Stool cultures are negative.

The most appropriate treatment is:

A patient undergoes a Schilling test because of vitamin B12 deficiency.

The following results are obtained:

• Low vitamin B12 absorption without intrinsic factor
• Normal vitamin B12 absorption with intrinsic factor
• Low vitamin B12 absorption with antibiotic but without intrinsic factor 

The most likely pathology is:

A 69-year-old woman presents with severe pancytopenia and peripheral blood macrocytosis associated with a low serum vitamin B12 level.

Which one of the following investigation results most strongly supports a diagnosis of pernicious anemia?

The lab finding that is most specific for the diagnosis of pernicious anaemia is:

Low serum vitamin B12 levels are least likely to be seen in which one of the following?

Which of the following nutrients is predominantly absorbed in the duodenum and upper small intestine?

A 50 year old female presents with tiredness.Her B12 level is found to be 125 (13-600).

Which of the following is most indicative of clinical B12 deficiency?

Which of the following in not consistent with a functional constipation disorder?

A 36-year-old woman presents with a 12-month history of lassitude, intermittent diarrhoea (described as watery, occurring up to six times a day), colicky abdominal pain, bloating and involuntary weight loss of 12 kg.

Blood tests reveal normal electrolytes, urea, creatinine and liver function tests. Her full blood count reveals a mild anaemia (haemoglobin 110 g/L [120-160]), but other indices are normal. Further blood tests show that she is iron and folate deficient.

Upper and lower gastrointestinal endoscopies are performed and the mucosa appears normal macroscopically. Shown below are sections of small bowel mucosa taken from the duodenum (A), distal to the major papilla, and from the terminal ileum (B).

The most likely diagnosis is:

Which of the following is the most appropriate medication to maintain remission in ileo-colonic Crohn’s disease?

A 45-year-old woman has a history of terminal ileal Crohn’s disease for which she had a terminal ileal resection eight years ago. Surgery was complicated by small bowel leak post operatively, requiring laparotomy and prolonged drainage with bowel rest (total parenteral nutrition). Following recovery she remained well until two weeks ago, when she presented with two episodes of abdominal pain, bloating and vomiting which lasted two to three hours each and then resolved. There has been no change in bowel habit and no fever. She is on no medication.

Examination reveals mild tenderness in the lower abdomen. Bowel sounds are normal.

Which of the following is the most likely cause for her current symptoms?

The most likely condition to adversely affect the liberation of dietary cobalamin from R-proteins is:

A 71-year-old man is evaluated for chronic epigastric discomfort, heartburn, and diarrhea of 4 years duration. His weight has been stable during this time period. The patient has no significant medical history and takes no medications.

On physical examination, there is mild epigastric tenderness but no rebound or guarding. Rectal examination reveals brown stool that is positive for occult blood. Laboratory studies reveal hemoglobin of 12.3 g/dL (123 g/L) with a mean corpuscular volume of 75 fL. Test for serum Helicobacter pylori antibody is negative. Esophagogastroduodenoscopy shows prominent gastric folds, mild linear erosions, and multiple ulcers in the stomach and the duodenum.

Which of the following is the most appropriate next step in the evaluation of this patient?

A 15-year-old girl undergoes gastroscopic examination for persistent epigastric pain. A nodular antral gastritis is found.

Curved gram-negative bacilli are seen on histology of the antral biopsy.

Which gastrointestinal malignancy has been causally linked with this condition?

A 44-year-old woman is evaluated for a 6-month history of dyspepsia, regurgitation of sour fluid, and eructation. There is no associated fever, chills, weight loss, or vomiting. The condition failed to respond to a 6- week trial of omeprazole therapy. The patient’s medical history includes hypertension, type 2 diabetes mellitus, and obesity (BMI 36); her medications are lisinopril, metformin, and insulin glargine.

On examination, vital signs are normal; there is mild epigastric tenderness without rebound, and stool is negative for occult blood.

Which of the following is the most appropriate next diagnostic step in the evaluation of this patient?

The factor most commonly responsible for gastro-oesophageal reflux is: