Gastroenterology Module 4

Which of the following is the most appropriate indication for initiating treatment in a 25 year old patient with chronic hepatitis B infection?

A 16-year-old male presents with recurrent episodes of obstructive dysphagia. Over the past year, he has required endoscopic removal of impacted food in the upper oesophagus on several occasions. A barium meal is normal.

Which of the following is the most likely diagnosis?

A 21-year-old man presents with dysphagia and regurgitation of undigested food. His barium swallow shows a dilated oesophagus with a smooth tapering at the distal end, producing a “bird beak” appearance at the gastroesophageal junction (GEJ). 

What is the most likely diagnosis?

An obese male patient presents with a 3-month history of reflux symptoms. Endoscopy performed 2 weeks ago was normal.

He undergoes ambulatory pH monitoring which shows an abnormal oesophageal acid exposure time (AET) of  10 percent.

What is the most likely diagnosis?

Which of the following organism is a known cause of secondary achalasia?

A 68-year-old man is referred for a second opinion regarding recurrent iron deficiency anaemia requiring blood transfusion. Over the last three years, he has required an average of 4 units of packed red blood cells every three months despite oral iron supplementation. There is no history of melaena.

Bone marrow examination is normal except for absent iron stores. Gastroscopy and colonoscopy have been negative on three separate occasions, the last being two months ago. Small bowel biopsy is normal. A barium meal and follow-through six months ago was normal. General health is good and he is on no regular medications.

Which of the following investigations is most likely to find the cause of his iron deficiency?

A 45-year-old woman is evaluated for a 2-week history of right leg and flank pain and a slight limp. The patient was diagnosed with Crohn disease at age 20 years when she was evaluated for abdominal pain, nausea, and vomiting, and small-bowel radiographic series revealed a stenotic area in her terminal ileum with proximal dilatation and an enteroenteric fistula.

She had an elective ileocolic resection with a primary anastomosis when her disease proved to be refractory to corticosteroid therapy. She has since been pain-free but has required intermittent courses of antibiotics and mesalamine for diarrheal flares of disease. She has had routine colonoscopic examinations with colonic biopsies showing scattered aphthous ulcerations and biopsy specimens revealing non-necrotizing granulomas in the colon and neo-terminal ileum.

Her most recent colonoscopy was 5 years ago. She is otherwise healthy and takes no medication.

On physical examination, the temperature is 38.0 °C, the blood pressure is 120/80 mm Hg, and the pulse rate 90/min; there is right-sided abdominal tenderness and restricted painful extension of the right hip; otherwise, the range of motion of the hip is normal and without pain. She has an abnormal gait, favoring her right leg.

Which of the following is the most likely diagnosis?

A 57-year-old woman is evaluated for a 1-month history of increased abdominal girth. The patient has a 15-year history of alcohol abuse, drinking a bottle of wine a day. She also has type 2 diabetes mellitus, hypertension, and hyperlipidemia, and her medications are metformin, hydrochlorothiazide, propranolol, simvastatin, and aspirin.

On physical examination, the temperature is 37.1 °C , the blood pressure is 90/50 mm Hg, the pulse rate is 99/min, and the respiration rate is 13/min; the BMI is 21. Examination reveals scleral icterus; bulging flanks; small umbilical hernia; caput medusae; spider angiomata of the face, arms, and chest; and mild asterixis. There is no abdominal tenderness.

Laboratory studies:

• Leukocyte count 5200/µL (5.2 × 109/L) with a normal differential
• Platelet count 65,000/µL (65 × 109/L)
• INR 2.2
• Bilirubin (total) 3.4 mg/dL (58.1 µmol/L)
• Bilirubin (direct) 1.8 mg/dL (30.8 µmol/L)
• Aspartate aminotransferase 120 U/L
• Alanine aminotransferase 65 U/L
• Alkaline phosphatase 196 U/L
• Albumin 2.7 g/dL (27 g/L)
• Creatinine 2.7 mg/dL (206.0 µmol/L)
• Urinalysis Normal
• Blood cultures are negative.

Ultrasonography of the abdomen shows massive ascites, patent vessels, no ductal dilatation, and a shrunken liver with no masses.

Which of the following is the most appropriate management for this patient?

The most common cause of asymptomatic, mildly elevated serum transaminases in Western society is:

Which of the following intervention has the most robust evidence of causing sustained improvement in liver histology in obese patients with metabolic dysfunction-associated steatohepatitis (MASH)?

A 53-year-old man is evaluated after a recent episode of substernal chest pain. He was evaluated in the emergency department for chest pain, and serial electrocardiograms and measurement of cardiac enzymes showed no evidence of myocardial ischaemia. An outpatient stress test also showed no evidence of myocardial disease. The patient has a history of medically controlled hypertension, and his only medication is amlodipine.

On physical examination, the patient appears healthy and vital signs are normal.

Barium oesophagography shows a segmented or corkscrew oesophagus. Oesophageal manometry shows simultaneous contractions in the distal oesophagus with 50% of swallows.

Which of the following is the most appropriate therapy for this patient?

A patient who has undergone bariatric surgery now presents with diarrhoea, bloating, and weight loss.

Upper and lower GI endoscopy: normal. Tissue transglutaminase antibody: negative. Stool culture for ova, cysts, and parasites: negative.

What is the most likely diagnosis?

What is the most common risk factor for oesophageal squamous cell carcinoma?

A 78-year-old man develops sudden onset of projectile vomiting followed by watery diarrhoea which started within 24 hours following his return from a cruise ship in Auckland.

Which is the culprit organism responsible for his current illness?

In the management of hepatic encephalopathy, what is the main therapeutic effect of lactulose?

In patients with Crohn’s, this genetic variant would lead to early initial surgery due to stricturing disease:

In patients with colitis, the cumulative cancer risk is highest after how many years of having the disease?

Which of the following cytokine is not involved in the pathogenesis of Crohn’s disease?

The following are predictors of severity in Crohn’s disease EXCEPT:

A patient is suspected to have colitis. Blood test shows pANCA positive and ASCA negative.

What might be the suggested diagnosis?

A patient with ulcerative colitis has been treated with sulfasalazine for 3 months without achieving disease control.

What is the most appropriate next step in management?

The initial luminal digestion of dietary starch by salivary and pancreatic amylase leads to the formation of which disaccharide?

What is the mode of action of infliximab?

Which of the following is the most common gene mutation seen in HNPCC?

Which one of the following is least associated with hepatocellular carcinoma?

A 35-year-old man presents with rectal bleeding. He describes the blood as being mixed with the stool. He is otherwise well. His brother was diagnosed with bowel cancer at the age of 38. At colonoscopy, he was found to have two exophytic tumours, one at the hepatic flexure, the other in the distal transverse colon. The remainder of the colon was normal. Biopsies of both areas showed adenocarcinoma.

The most likely genetic disorder in this family is:

This particular patient-specific feature is most suggestive of hereditary nonpolyposis colorectal cancer (HNPCC):