Gastroenterology Module 4

The manometric feature most characteristic of achalasia is:

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 images are shown below.

What is the most likely diagnosis?

An obese male patient presents with 3 months history of reflux symptom.Endoscopy done 2 weeks ago was normal. He undergoes an ambulatory pH monitoring.

The result as follow:

What is the most likely diagnosis?

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

A 68-year-old man is sent 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 cells every three months despite oral iron supplements. 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. The patient had a barium meal and follow-through six months ago which 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 neoterminal 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 (101.0 °F), 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 (98.8 °F), 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 for asymptomatic, mildly elevated serum transaminases in Western society is:

This intervention will result in sustained improvement in liver histology in obese patients with non-alcoholic steato-hepatitis:

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 ischemia. An outpatientstress 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 esophagography shows a segmented or corkscrew esophagus. Esophageal manometry shows simultaneous contractions in the distal esophagus 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 diarrhea, bloating and weight loss.

• Upper and lower GI scope normal
• Tissue transglutaminase Ab negative
• Stool culture for ova cyst and parasite negative

What is the most likely diagnosis?

What is the most common precipitant of esophageal squamous cell carcinoma?

A 78 year old man develops sudden onset of projectile vomiting followed by watery diarrhea which started within 24 hours following his return from a Cruise ship in Australia.

Which is the 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 Crohn’s disease, which of the following genetic variants would lead to surgical recurrence?

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 is the most likely diagnosis?

A patient has been diagnosed with ulcerative colitis. He has been on salazopyrine for 3 months now but still not under control.

What is the next step?

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 44-year-old man develops stage C cancer of the caecum. There is no history of colitis but there is a strong family history of bowel cancer in the absence of polyps.
The most likely underlying inherited genetic abnormality is in:

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 extra-colonic malignancy is most strongly associated with HNPCC

This particular patient feature is most suggestive of hereditary nonpolyposis colon cancer (HNPCC):