Gastroenterology Module 3

What is the recommended initial approach for managing Metabolic dysfunction- associated steatohepatitis (MASH)?

A 24-year-old woman presents to the emergency department with jaundice, severe abdominal pain, and confusion. Her family reports that she has been increasingly lethargic over the past week. Laboratory tests reveal severe coagulopathy and hepatic encephalopathy. Hemolysis is indicated by a sudden drop in hemoglobin and haptoglobin levels, and her renal function tests show signs of acute kidney injury. 

Her liver function tests show moderately elevated aminotransferases, a low alkaline phosphatase, and high bilirubin. Notably, the ratio of alkaline phosphatase to total bilirubin is less than 4, and the aspartate aminotransferase to alanine aminotransferase ratio is greater than 2.2.

What is the most likely diagnosis for this patient’s condition?

A 55-year-old lady consults her gastroenterologist because of recent onset of intermittent dysphagia for solids. She has a history of gastrooesophageal reflux proven by endoscopy, for which she is on proton pump inhibitor therapy. Her health is otherwise good and her reflux symptoms have been well controlled. She has not lost any weight. She is a smoker, but rarely consumes alcohol. The physical examination is unremarkable.

The next most appropriate course of action is:

Which of the following is the most important pathogenic factor in gastro-oesophageal reflux disease?

A 75-year-old woman presents with a three-week history of episodic severe epigastric pain and vomiting. The pain lasts for about three hours and radiates to the right upper quadrant and back. Apart from episodic nausea, she is well between attacks of pain. Past medical history includes a cholecystectomy nine years ago, peptic ulcer disease secondary to non-steroidal anti-inflammatory drugs three years ago and type 2 (non-insulin-dependent) diabetes mellitus diagnosed four years ago.

The most likely diagnosis is:

A 60-year-old male presents with worsening dysphagia for solid and liquid food. Manometry shows a failure of the lower esophageal sphincter (LES) relaxation, leading to increased residual pressure in the LES during swallowing.

The most likely diagnosis is:

An otherwise well 55-year-old female undergoes upper endoscopy for investigation of mild reflux symptoms. Biopsy demonstrate intestinal metaplasia with high grade dysplasia and no inflammation.

The most appropriate management is:

In the general community, which of the following is the major pathogenic factor for reflux oesophagitis?

A previously well 64-year-old man presents with symptoms of gastrooesophageal reflux disease. He is on no current medications. Gastroscopy demonstrates Barrett’s oesophagus with erosive oesophagitis above the squamocolumnar junction. Random biopsies are reported as demonstrating dysplastic epithelium with features of
active inflammation.

The most appropriate next step in management is

The risk factor with the greatest impact on development of esophageal cancer is:

A 75-year-old presents with progressive dysphagia for solids and liquids over two years. There has been no episodes of bolus impaction. There has been a two-kilogram weight loss over six months. Oesophageal manometry demonstrates increased tertiary wave activity and decreased amplitude of contractions.

What is the most likely diagnosis?

A 13-year-old boy with severe spastic quadriplegia is referred for consideration of placement of a gastrostomy tube to aid with feeding. He has scoliosis and chronic lung disease.

Which one of the following factors would be a relative contraindication to percutaneous endoscopic gastrostomy tube placement in this patient?

A 38-year-old woman is evaluated for elevated results of liver chemistry tests detected in an evaluation for new-onset fatigue, joint pains, and jaundice. The patient recently started a job in a hospital and received a hepatitis B vaccination. She has a history of hypothyroidism, and her only medications are levothyroxine and a multivitamin. She has never used illicit drugs and does not drink alcohol. Her mother has rheumatoid arthritis.

On physical examination, the patient is afebrile; the blood pressure is 130/75 mm Hg, the pulse rate is 80/min, and the respiration rate is 14/min. The BMI is 26. There is scleral icterus; the rest of the examination is normal.

Laboratory studies:

• Leukocyte count 3400/µL (3.4 × 109/L) with a normal differential
• Bilirubin (total) 6.0 mg/dL (102.6 µmol/L)
• Bilirubin (direct)3.6 mg/dL (61.6 µmol/L)
• Aspartate aminotransferase 890 U/L
• Alanine aminotransferase 765 U/L
• Alkaline phosphatase 120 U/L
• Antinuclear antibody Titer 1:40
• Anti-smooth muscle antibody Titer 1:640
• Antimitochondrial antibody Negative
• Viral serologic tests are negative.

Which of the following is the most likely diagnosis?

A 45-year-old man with a family history of ischaemic heart disease is diagnosed with hypertension and hypercholesterolaemia. He is started on aspirin 150 mg daily, atorvastatin 20 mg nocte and atenolol 50 mg daily. Eight weeks later, he is reviewed and complains of some lethargy and itching. His blood pressure is 120/70 mmHg. He is noted to be icteric. There are no other findings on physical examination.

Blood investigations show:

• white cell count 5.6 x 109/L [4.0-9.0] with normal differentials
• haemoglobin 142 g/L [130-175]
• platelet count 468 x 109/L [150-450]
• prothrombin time-international normalised ratio (PT-INR) 1.0 [0.9-1.1]
• bilirubin 103 μmol/L [3-21]
• alanine transaminase (ALT) 610 U/L [5-40]
• aspartate transaminase (AST) 358 U/L [5-40]
• alkaline phosphatase (ALP) 540 U/L [30-115]
• gamma glutamyltranspeptidase (GGT) 746 U/L [<65]
• albumin 40 g/L [38-50]
• sodium 145 mmol/L [139-145]
• potassium 4.5 mmol/L [3.8-4.8]
• urea 3.8 mmol/L [2.5-5.6]
• creatinine 0.10 mmol/L [0.06-0.11]
• hepatitis B surface antigen negative
• hepatitis C antibody negative
• ferritin 356 μg/L [25-200]
• anti-nuclear antibody negative
• anti-mitochondrial antibody negative
• anti-smooth-muscle antibody negative

An abdominal ultrasound shows non-dilated bile ducts. The gall bladder is normal with no calculi. A liver biopsy is performed and two representative sections are shown over.

The most likely explanation for the abnormal liver function test results is:

A 20-year-old female presents with a one month history of malaise, nausea, abdominal pain, itch and polyarthralgia. She gives no history of recent use of prescribed or illicit drugs. Examination reveals jaundice, multiple bruises, and tender hepatomegaly. Laboratory results are consistent with an acute hepatocellular injury, with a polyclonal increase in IgG (immunoglobulin G) of 32g/L (6.1-15.5).

Serological tests for hepatitis A, B, and C viruses are negative. Histopathological findings on liver biopsy are of a periportal mixed mononuclear cell infiltrate of plasma cells, lymphocytes and eosinophils
consistent with an autoimmune hepatitis.

Which of the following autoantibodies, if present, is most predictive of a poor clinical and biochemical response to therapy?

A 14-year-old girl presents with jaundice, arthralgia and pruritus over the past week. She has recently returned from a trip to South-East Asia.

Her liver function and serology results are shown below:

• bilirubin 175 μmol/L [0-15]
• alanine aminotransferase (ALT) 1350 U/L [<55]
• alkaline phosphatase (ALP) 687 U/L [100-350]
• gamma glutamyltransferase (GGT) 425 U/L [0-40]
• total protein 70 U/L [57-80]
• albumin 24 g/L [33-47]
• Epstein-Barr Virus (EBV)-IgG positive
• Epstein-Barr Virus (EBV)-IgM negative
• hepatitis A virus (HAV)-IgM negative
• hepatitis B surface antigen (HBsAg) negative
• anti-hepatitis B core antibody (anti-HBc) positive
• anti-hepatitis C virus antibody (anti-HCV) negative
• antinuclear antibody (ANA) negative
• smooth muscle antibody positive

What is the most likely diagnosis?

A 34-year-old woman is evaluated for continued severe mid-epigastric pain that radiates to the back, nausea, and vomiting 5 days after being hospitalized for acute alcohol-related pancreatitis. She has not been able eat or drink and has not had a bowel movement since being admitted.

On physical examination, the temperature is 38.2 °C (100.8 °F), the blood pressure is 132/84 mm Hg, the pulse rate is 101/min, and the respiration rate is 20/min. There is no scleral icterus or jaundice. The abdomen is distended and diffusely tender with hypoactive bowel sounds.

Laboratory studies:

• Leukocyte count 15,400/µL (15.4 × 109/L)
• Aspartate aminotransferase 189 U/L
• Alanine aminotransferase 151 U/L
• Bilirubin (total) 1.1 mg/dL (18.8 µmol/L)
• Amylase 388 U/L
• Lipase 924 U/L

CT scan of the abdomen shows a diffusely edematous pancreas with multiple peripancreatic fluid collections, and no evidence of pancreatic necrosis.

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

A 72-year-old woman presents with severe diarrhoea. She was commenced on oral amoxycillin for an upper respiratory tract infection five days ago.

Which one of the following tests would best confirm a diagnosis of Clostridium difficile-induced pseudomembranous colitis?

A physician becomes ill with nausea and vomiting four hours, after attending a pharmaceutical company sponsored dinner.

Which of the following is the likely culprit organism?

An 65-year-old man is on chronic haemodialysis. He complains of crampy lower abdominal pain and passes blood per rectum three times over two hours. Colonoscopy demonstrates normal rectal mucosa and inflammation from the proximal sigmoid to transverse colon.

The most likely cause of the inflammation is:

Which of the following antibiotics is the commonest cause of Clostridium difficile colitis?

What is the purpose of the fecal microbiota oral capsule (SER109; Vowst) that was approved in 2023?

A 42-year-old woman is evaluated for a 20-year history of constipation. She has approximately one or two bowel movements a week consisting of lumpy or hard stool. She strains at defecation and has a sense of incomplete evacuation after a bowel movement. She does not have bloody stool, abdominal pain or discomfort, weight loss, or diarrhea. She is otherwise healthy, and her only medication is an occasional over-the-counter laxative or stool softener.

On physical examination, vital signs are normal. The anorectal tone is normal, and on rectal examination, the patient is able to expel the examiner’s finger when asked to mimic a bowel movement. Laboratory studies are normal. Radiopaque marker study shows delayed transit time through the right colon.

Which of the following is the most likely diagnosis?

In patients with cirrhosis and oesophageal varices, the strongest predictor of variceal bleeding is:

A 50-year-old man with alcohol-induced cirrhosis and portal hypertension presents with haematemesis. He is found to have grade IV oesophageal varices. Bleeding is controlled by an infusion of octreotide and endoscopic rubber band ligation.

On discharge, which one of the following is least likely to be of benefit with respect to recurrent variceal bleeding?

Which of the following is most predictive of variceal haemorrhage in a patient with oesophageal varices?

A 65-year-old man with cirrhosis has significant (grade 2 of 3) oesophageal varices detected on screening endoscopy.

Which of the following is the most appropriate initial management?

In the acute management of an oesophageal variceal bleed, which of the following intervention is least likely to control the bleeding?

A 45-year-old alcoholic presents with his first oesophageal variceal bleed. His acute bleeding is controlled with endoscopic band ligation.

Which one of the following is the most appropriate management strategy to prevent recurrent bleeding?

Which of the following is an absolute contraindication to liver transplant?