MCQ's in Gastroenterology

Contributor:
Dr. Shivaram Bhat
Gastroenterology Reg.

September 2006

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Question 1:

Regarding dysphagia:

	(a) a barium meal is always the first line investigation
	(b) patients with Barrett's oesophagus should be screened for lower oesophageal basal cell carcinoma
	(c) it is usually associated with abnormal thyroid function tests
	(d) is caused by globus hystericus in the majority of cases
	(e) Oesophageal tumours are most commonly adenocarcinoma or squamous cell carcinoma

Question 2:

In alcohol-related liver disease:

	(a) chronic disease is usually associated with tender palpable hepatomegaly
	(b) patients are unlikely to be smokers
	(c) thiamine has not been proven to prevent memory problems
	(d) decreased tolerance to alcohol indicates progression of disease
	(e) benzodiazepines are contraindicated during alcohol detoxification

Question 3:

In Crohn's disease:

	(a) there is an association with dermatitis herpetiformis
	(b) resection of affected segments of bowel is curative
	(c) Patients are more likely to be smokers than in ulcerative colitis
	(d) inheritance is autosomal recessive
	(e) the small bowel is only affected in the setting of backwash ileitis from the colon

Question 4:

Coeliac disease:

	(a) is the most common cause of mal-absorption in developing countries
	(b) is associated with an increased risk of GI lymphoma
	(c) patients benefit from a diet high in complex carbohydrates such as bread and pasta
	(d) is usually diagnosed on CT abdomen
	(e) patients are at lower risk of osteoporosis than the non-coeliac population

Question 5:

Helicobacter pylori:

	(a) is a Gram positive bacterium
	(b) is associated with over-crowding and lower socio-economic class
	(c) affects < 1% of the UK population
	(d) is rarely eradicated by a combination of proton pump inhibitor and antibiotics
	(e) is a common cause of food poisoning

Question 6:

Ulcerative colitis:

	(a) is more common in smokers than in non-smokers
	(b) is treated first-line with infliximab
	(c) commonly involves the jejunum
	(d) is associated in most patients with psoriasis
	(e) is associated with HLA B27

Question 7:

In irritable bowel syndrome (IBS):

	(a) mucus may be passed rectally
	(b) bloody mucoid diarrhoea is common
	(c) treatment options include 5-ASA compounds
	(d) symptoms are unrelated to stressful life events
	(e) a gluten-free diet is first-line treatment

Question 8:

Colorectal carcinoma:

	(a) is classified by Breslow's criteria
	(b) most commonly metastasizes to the liver
	(c) is most common in those with a high fibre diet
	(d) is more common in females than in males
	(e) patients with disease confined to the bowel mucosa have a 40% 5 year survival rate

Question 9:

A 35 year old man presents with a 3 week history of epigastric pain which is worse prior to meals and at night. He has no other symptoms. You elicit a mildly tender epigastrium on palpation; otherwise examination is normal. You suspect peptic ulcer disease.

With regards to Peptic Ulcer Disease (PUD):

	(a) duodenal ulcers are 10 times more common than gastric ulcers
	(b) the most appropriate initial investigation is testing for Helicobacter pylori
	(c) this patient requires urgent endoscopy
	(d) smoking is not a risk factor for its development
	(e) duodenal ulcers are more common in patients with blood group A

Question 10:

Gastric cancer:

	(a) when shown to be an adenocarcinoma on histology, is associated with Helicobacter pylori
	(b) is usually a squamous cell carcinoma
	(c) usually has a good prognosis
	(d) most commonly presents with haematemesis
	(e) is usually diagnosed on barium swallow

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Answers are:

1	Regarding dysphagia: (e) Oesophageal tumours are most commonly adenocarcinoma or squamous cell carcinoma. Following history and examination, the first line investigation for dysphagia should include a barium swallow to look for an oesophageal malignancy. Barrett's oesophagus is premalignant for adenocarcinoma. Patients with dysplasia on biopsy are screened with interval endoscopy. There are many causes for dysphagia including goitre, however this is not the most common cause. Globus hystericus is a functional disorder of the sensation of a lump in the throat.
2	In alcohol-related liver disease: (d) Decreased tolerance to alcohol indicates progression of disease Chronic alcohol abuse can cause cirrhosis which results in a shrunken liver that is non-tender. Patients are more likely to be smokers than to be non-smokers. Patients are at risk of vitamin deficiencies, particularly deficiencies in B vitamins which can lead to the Wernicke-Korsakoff syndrome. Thiamine supplementation is often used to prevent this. Alcohol withdrawal can lead to delirium tremens and benzodiazepines are used to counteract this.
3	In Crohn's disease: (c) Patients are more likely to be smokers than in ulcerative colitis Coeliac disease is associated with dermatitis herpetiformis. Crohn's disease can affect any part of the GI tract from mouth to anus. Surgical resection of affected areas ('skip lesions') does not prevent disease forming in new areas. The terminal ileum is most commonly involved. Pathogenesis is multifactorial, although there is a genetic component.
4	Coeliac disease: (b) Is associated with an increased risk of GI lymphoma Coeliac disease is the most common cause of malabsorption in developed countries (whereas, giardia is the commonest cause of malabsorbtion worldwide, and hookworm is the most common cause of iron deficiency anaemia in developing countries.) Patients should avoid gluten, which is found in bread and pasta. Diagnosis is made by detecting anti-transglutaminase and anti-endomysial antibodies. It can also be made on jejunal biopsy, which shows subtotal villous atrophy. Patients are at higher risk of osteoporosis than those without the condition.
5	Helicobacter pylori: (b) Is associated with over-crowding and lower socio-economic class Helicobacter pylori is a Gram negative bacterium. It affects between 20 and 50% of the UK population but is asymptomatic in the majority. Eradication using triple therapy comprising a proton pump inhibitor and 2 different antibiotics is successful in over 90% of cases.
6	Ulcerative colitis: (e) Is associated with HLA B27 Ulcerative colitis (UC) is less common in smokers. First line treatment is with steroids in the acute setting. Maintenance therapy is with 5-amino-salicylic acid (ASA) preparations and immunosuppressants, such as azathioprine. Infliximab is a monoclonal antibody used in the treatment of Crohn's disease It is now being used in some cases of UC, but is not first line treatment. UC only affects the large bowel. Some patients will develop psoriasis.
7	In irritable bowel syndrome (IBS): (a) Mucus may be passed PR Bloody mucoid diarrhoea is not a feature of IBS and should be investigated to exclude inflammatory bowel disease or bowel maligancy. Treatment options include dietary modification, anti-spasmodics and cognitive behavioural therapy.
8	Colorectal carcinoma: (b) Most commonly metastasizes to the liver Colorectal carcinoma is classified by the Duke's classification and TNM classification- both of which predict 5 year survival. A low fibre diet is a risk factor for developing the disease. It is more common in males. Patients with disease confined to the bowel mucosa (Duke's A) have >80% 5 yr survival rate.
9	With regards to Peptic Ulcer Disease (PUD): (b) The most appropriate initial investigation is testing for Helicobacter pylori Duodenal ulcers are 2-3 times more common than gastric ulcers. Testing and treatment for Helicobacter pylori is the most appropriate initial step in this case. Peptic ulcer disease is more common in smokers. Duodenal ulcers are more common in patients with blood group O.
10	Gastric cancer: (a) when shown to be an adenocarcinoma on histology, is associated with Helicobacter pylori Gastric cancer is most commonly an adenocarcinoma. It has a poor prognosis due to the usual late presentation of disease. The most common symptom is epigastric pain. Diagnosis is usually made on either gastroscopy or barium meal.