Internal Medicine Exam Gastroenterology and Hepatology 2 — Questions and Answers
Question 1: A 45-year-old man with alcoholic cirrhosis develops tense ascites. Paracentesis reveals 4.5 L of fluid removed. Which intervention is most important to prevent post-paracentesis circulatory dysfunction?
- Administer IV albumin 6-8 g per liter removed (Correct answer)
- Administer IV normal saline 500 mL
- Start oral midodrine immediately after procedure
- Restrict sodium to less than 1 g per day
Correct answer: Administer IV albumin 6-8 g per liter removed
IV albumin (6-8 g/L of ascites removed) is the standard of care to prevent post-paracentesis circulatory dysfunction after large-volume paracentesis exceeding 5 L.
Question 2: A 60-year-old woman presents with dysphagia to solids and liquids simultaneously from the onset. Barium swallow shows a 'bird-beak' appearance at the lower esophageal sphincter. What is the most likely diagnosis?
- Achalasia (Correct answer)
- Diffuse esophageal spasm
- Esophageal carcinoma
- Scleroderma esophagus
Correct answer: Achalasia
Achalasia classically presents with dysphagia to both solids and liquids simultaneously and shows a bird-beak deformity at the lower esophageal sphincter on barium swallow.
Question 3: A 35-year-old woman presents with recurrent episodes of right upper quadrant pain after fatty meals. HIDA scan shows a gallbladder ejection fraction of 20%. What is the most appropriate management?
- Laparoscopic cholecystectomy (Correct answer)
- Ursodeoxycholic acid therapy
- Low-fat diet alone
- Endoscopic sphincterotomy
Correct answer: Laparoscopic cholecystectomy
Biliary dyskinesia with an ejection fraction below 35-40% and typical biliary symptoms is best treated with laparoscopic cholecystectomy.
Question 4: A 50-year-old man with chronic HCV infection has a serum-ascites albumin gradient (SAAG) of 1.8 g/dL. Which condition does this SAAG value indicate?
- Portal hypertension (Correct answer)
- Peritoneal carcinomatosis
- Tuberculosis peritonitis
- Nephrotic syndrome
Correct answer: Portal hypertension
A SAAG ≥1.1 g/dL indicates portal hypertension as the cause of ascites with 97% accuracy; a value of 1.8 g/dL confirms this etiology.
Question 5: A 28-year-old man with Crohn's disease on azathioprine develops fever, right lower quadrant pain, and a palpable mass. CT reveals a 4 cm periappendiceal abscess. What is the best initial management?
- Percutaneous CT-guided drainage and IV antibiotics (Correct answer)
- Immediate surgical resection
- IV antibiotics alone without drainage
- Increase azathioprine dose
Correct answer: Percutaneous CT-guided drainage and IV antibiotics
Abdominal abscesses in Crohn's disease are best managed initially with percutaneous drainage and antibiotics, allowing inflammation to resolve before elective surgery.
Question 6: A 70-year-old man presents with steatorrhea, weight loss, and a fasting serum glucose of 160 mg/dL. CT shows diffuse pancreatic atrophy and calcifications. What is the most likely underlying diagnosis?
- Chronic pancreatitis (Correct answer)
- Pancreatic adenocarcinoma
- Autoimmune pancreatitis
- Cystic fibrosis
Correct answer: Chronic pancreatitis
Diffuse pancreatic calcifications with atrophy on CT are pathognomonic of chronic pancreatitis, which causes both exocrine insufficiency (steatorrhea) and endocrine dysfunction (diabetes).
Question 7: A patient with primary biliary cholangitis (PBC) is started on ursodeoxycholic acid (UDCA). Which lab trend best indicates an adequate biochemical response?
- Decrease in alkaline phosphatase by >40% from baseline (Correct answer)
- Normalization of serum bilirubin within 1 month
- Decrease in anti-mitochondrial antibody titer
- Reduction in ALT to below 2x upper limit of normal
Correct answer: Decrease in alkaline phosphatase by >40% from baseline
The Paris-I and Paris-II criteria use alkaline phosphatase reduction (>40% or to normal) as the primary indicator of adequate UDCA response in PBC.
Internal Medicine Exam Gastroenterology and Hepatology 2
A 45-year-old man with alcoholic cirrhosis develops tense ascites.
Paracentesis reveals 4.5 L of fluid removed.
Which intervention is most important to prevent post-paracentesis circulatory dysfunction?