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Gastroenterology MCQs

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1. A 58 year women was referred to the gastroenterology clinic with a history of weight loss. Clinical examination including a breast and rectal examination was normal. A CT scan of the chest, abdomen and pelvis revealed enlarged right axillary lymph nodes only. Excision biopsy of the lymph node revealed adenocarcinoma. The case is being discussed in the cancer MDT. What is the most appropriate next step?

1. Mammogram
2. Tumour markers
3. PET scan
4. Oncology referral
5. Colonoscopy

Explanation :These patients with axillary lymph node metastasis of adenocarcinoma should undergo mammography or breast MRI. Immunohistology for hormone status and c-erb2 should also be checked. These patients with compatible immunohistology (even in the absence of a breast primary) should be treated as breast cancer with lymph node involvement (stage II) This is a cancer with unknown primary (CUP). The median survival of patients with the CUP syndrome is 3 to 6 months. However, certain subgroups of CUP have a good prognosis. Axillary lymph node metastasis of adenocarcinoma in a woman is a CUP with good prognosis.

2. A 65 year old gentleman was found to have a cystic mass in the head of pancreas on a CT scan done for abdominal pain. All of the following are true except:

1. Almost all cystic neoplasm’s of pancreas are symptomatic
2. The differential diagnosis includes serous cyst adenoma, mucinous cyst adenoma or Intraductal papillary mucinous neoplasm (IPMN).
3. EUS and fluid aspirate analysis for CEA and amylase can be diagnostic
4. Serous cyst adenomas are nearly always benign and can be managed conservatively
5. Mucinous cyst adenomas are benign but malignant transformation can occur and hence resection should be considered.

Explanation :50% of patients do not have any symptoms and are detected incidentally at imaging studies performed for unrelated indications. Symptoms (abdominal pain and jaundice) when occur are due to mass effect. It is conceptually useful to think of serous cyst adenoma to be like hyperplastic polyps in colon and mucinous cyst adenoma to be like colonic adenomas.

3. All the following are true about fundic gland polyp (FGP) except :

1. Hamartomatous polyps
2. Associated with PPI use
3. Associated with FAP
4. Sporadic FGP are found exclusively in patients without H.Pylori infection
5. Usually more than 10 mm in size

Explanation :FGP are smooth, glassy, sessile, circumscribed elevations (usually measuring < 5 mm). Sporadic and PPI associated FGPs have low malignant potential and no ominous associations. By contrast, a definite risk of dysplasia (between 30% and 50%) is present in FAP associated FGPs. Thus FGP should be carefully biopsied in FAP. Dysplasia in FGPs is also associated with large polyp size (>1 cm).

4. A 55 year old has been diagnosed with oesophageal adenocarcinoma. You are due to see him in your gastroenterology clinic and refer him to an upper GI surgeon for curative surgery, if appropriate. How is fitness for surgery commonly assessed?

1. ASA classification of physical status
2. Groningen fitness test
3. WHO performance status
4. Echocardiogram
5. 6- minute walk test

Explanation :The previous medical history and concurrent morbidity remain the strongest predictors regarding fitness for surgery. The American Society of Anaesthesiologists (ASA) classification of physical status is well recognised. Perioperative risk increases with increasing ASA score. Only those patients with an ASA score of 3 or less should be considered for surgery.

5. Which one of the following statements regarding treatment of Wilson Disease is false?

1. Adequacy of treatment can be monitored by ensuring nonceruloplasmin-bound copper concentration in normal range, and 24-hour urinary copper repeatedly in the range of 200 to 500 µg (3 to 8 µmoles) per day on treatment.
2. Treatment is lifelong and should not be discontinued and should continue even if liver transplant has been performed
3. Zinc is currently reserved for maintenance treatment after chelator has been used for 1-5 years but can be used as the first line for selected presymtomatic patients.
4. Like penicillamine, trientine promotes copper excretion by the kidneys.
5. Penicillamine use is associated with numerous side effects i.e. sensitivity reactions, nephrotoxicity, lupus like syndrome, bone marrow toxicity and hepatotoxicity

Explanation :Treatment is lifelong and should not be discontinued, unless a liver transplant has been performed. Treatment should be initiated with a chelating agent in both symptomatic and asymptomatic or presymptomatic patients identified through family screening. Zinc may be used as the first agent in presymptomatic patients. After adequate treatment with a chelator (usually for 1-5 years), stable patients may be transitioned to treatment with zinc. They will be clinically well, with normal serum aminotransferases and hepatic synthetic function, nonceruloplasmin-bound copper concentration in normal range, and 24-hour urinary copper repeatedly in the range of 200 to 500 µg (3 to 8 µmoles) per day on treatment. The advantages of long-term treatment with zinc include that it is more selective for removing copper than penicillamine or trientine and is associated with few side effects. Adequate studies regarding the timing of this change-over in treatment are not available. No matter how well a patient appears, treatment should never be terminated indefinitely. Patients who discontinue treatment altogether risk development of intractable hepatic decompensation.

6. Which one of the following statements regarding (WE) Wernicke's encephalopathy is true?

1. Daily requirement of B1 is only 100mg
2. Atrophy of mamillary body is highly specific finding and is seen within 24 hours.
3. Commonest clinical presentation is with oculomotor symptom/sign
4. Thiamine is a cofactor for several key enzymes important in energy metabolism and production of ATP-TRUE
5. WE is a irreversible condition

Explanation :WE is a reversible biochemical lesion of the CNS caused by overwhelming metabolic demands being made upon depleted B-vitamin reserves, in particular thiamine (B1). Malnourished hospitalized patients on IV dextrose is also prone to develop WE and must be on the differential diagnosis if they become confused. Dietary requirement of thiamine is only 1-2 mg daily. Atrophy of the mamillary bodies on MRI is a highly specific finding in WE and Korsakoff syndrome and is present in most cases and can be detected within a week of onset of WE. Mental changes- confusion, disorientation, inattentiveness, drowsiness, obtundation, semi coma, coma. Mental changes are most common and may be the only sign of WE. These changes are however non specific and may be caused by alcohol intoxication or withdrawal.

7. Which one of the following statements regarding Hepatorenal syndrome (HRS) is true?

1. No improve of creatinine with fluid challenge
2. Both in prerenal azotaemia and HRS -Urinary spot Na remains low <10
3. Urinary spot Na is high in ATN ( acute tubular necrosis) >30
4. Urine sediment test is positive in ATN
5. All of the above

8. Which one of the following statements regarding hereditary haemochromatosis is true?

1. Normal men have approximately 1 g of iron stores. As a result, 4-5 phlebotomies will produce an iron deficient state
2. Screening is recommended in 1st degree relatives (parents, siblings and children).
3. Screening tests for HH are transferrin saturation, ferritin and HFE gene analysis
4. HCC accounts for about 30% of all deaths in HH,
5. All above

Explanation :Normal men have approximately 1 g of iron stores. As a result, 4-5 phlebotomies will produce an iron deficient state (microcytosis or hypochromia with anaemia). In contrast, patients with significant iron loading usually have at least 5-20g of iron stores, requiring at least 20 units of phlebotomy to induce iron deficiency. Screening is recommended in 1st degree relatives (parents, siblings and children). The ideal age of screening is 18-30yrs of age, during which the condition can be detected. Screening tests- TS, Ferritin and HFE gene analysis. The major causes of death are decompensated cirrhosis, hepatocellular carcinoma (HCC), diabetes mellitus, and cardiomyopathy. HCC accounts for about 30% of all deaths in HH, whereas other complications of cirrhosis account for an additional 20%. HCC is exceedingly rare in noncirrhotic HH.

9. 1.Which one of the following statements regarding non alcoholic fatty liver disease (NAFLD) is false?

1. Microvesicular steatosis is more dangerous than macrovesicular steatosis
2. Diabetic patients with age>45yrs are at increased risk for progressive fibrosis from NASH
3. Fibroscan reading of >7 kPa is suggestive of fibrosis
4. Insulin sensitizers like pioglitazone has been used in NASH
5. Metabolic syndrome X consists of obesity, hypertension and IHD.

Explanation :Metabolic syndrome X requires three of the five criteria Glucose >= 5.6mmol/Lor drug treatment for elevated blood glucose HDL cholesterol <1.0mmol/L in men and <1.3mmol/L in women or drug treatment for low HDL-C Triglyceride >= 1.7 mmol/L or drug treatment for elevated triglycerides Obesity Waist 102 cm (men) or 88 cm (women) Hypertension 130/85 mmHg or drug treatment for hypertension Fibroscan uses a ultrasonic transducer, to send a vibration of low frequency (50 Mhz) and amplitude is into the liver. The vibration wave induces an elastic shear wave that propagates through the organ. The velocity of this wave correlates directly with tissue stiffness- the stiffer the tissue the faster the wave.Results are expressed in kilopascals (kPa). Normal value is less than 7

10. Which one of the following statements regarding TIPS is false?

1. This is a end to side porto-caval shunt
2. Typically portal decompression is considered to be adequate if gradient (portal vein- IVC) falls to 15mm Hg or less ( ideally below 12mm Hg)
3. Mean pulmonary pressure of more than 45mm Hg is a contraindication for TIPS
4. 30 day mortality post TIPS is typically in the range of 10-15%.
5. The incidence of new or worsening encephalopathy following TIPS is 20-31%.

Explanation :TIPS is a side-to-side portacaval shunt that is placed by an interventional radiologist or a hepatologist usually under local anaesthesia. The purpose of a TIPS is to decompress the portal venous system and therefore prevent rebleeding from varices or stop or reduce the formation of ascites. Typically portal decompression is considered to be adequate if gradient (portal vein- IVC) falls to 15mm Hg or less ( ideally below 12mm Hg) and varices on contrast injection are no longer demonstrated. Absolute contraindications include congestive heart failure, severe tricuspid regurgitation and severe pulmonary hypertension (mean pulmonary pressures of more than 45 mm Hg) as these patients are not candidates for a liver transplant). TIPS is contraindicated only if the hepatic encephalopathy is uncontrollable. The incidence of new or worsening encephalopathy following TIPS is 20-31%.

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