Internal Medicine Exam Gastroenterology and Hepatology 3 — Questions and Answers
Question 1: A 55-year-old man presents with painless jaundice, 15 lb weight loss, and a palpable, non-tender gallbladder. What is the most likely diagnosis?
- Pancreatic head adenocarcinoma (Correct answer)
- Acute cholecystitis
- Primary sclerosing cholangitis
- Choledocholithiasis
Correct answer: Pancreatic head adenocarcinoma
Courvoisier's sign (palpable non-tender gallbladder with painless jaundice) in an older patient strongly suggests malignant biliary obstruction, most commonly pancreatic head carcinoma.
Question 2: A 40-year-old woman with IBD presents with elevated alkaline phosphatase and fatigue. MRCP shows multifocal strictures and dilations of both intra- and extrahepatic bile ducts. What is the most likely diagnosis?
- Primary sclerosing cholangitis (Correct answer)
- Primary biliary cholangitis
- Autoimmune hepatitis
- Ischemic cholangiopathy
Correct answer: Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) presents with characteristic 'beaded' intra- and extrahepatic biliary strictures on MRCP and is strongly associated with IBD, particularly ulcerative colitis.
Question 3: A 25-year-old man with ulcerative colitis has a colonoscopy showing continuous inflammation from the rectum to the splenic flexure. He has 6 bloody stools per day and a heart rate of 102 bpm. What is the most appropriate next step?
- IV corticosteroids (Correct answer)
- Oral mesalamine
- Emergency colectomy
- Oral prednisone taper
Correct answer: IV corticosteroids
Severe UC (Truelove-Witts criteria: >6 bloody stools/day plus systemic features) requires hospitalization and IV corticosteroids as first-line treatment.
Question 4: A 62-year-old man undergoes upper endoscopy for evaluation of dysphagia. Biopsy of the distal esophagus shows columnar epithelium with goblet cells. What is the most critical next step in management?
- Endoscopic surveillance with biopsies per Barrett's protocol (Correct answer)
- Immediate esophagectomy
- H. pylori eradication therapy
- Fundoplication surgery
Correct answer: Endoscopic surveillance with biopsies per Barrett's protocol
Barrett's esophagus with intestinal metaplasia requires endoscopic surveillance per established protocols (every 3-5 years for non-dysplastic Barrett's) to detect dysplasia early.
Question 5: A 48-year-old woman with known cirrhosis presents with confusion and asterixis after starting a new medication. Which drug is most likely responsible for precipitating hepatic encephalopathy?
- Furosemide causing hypokalemia and alkalosis (Correct answer)
- Lactulose
- Rifaximin
- Zinc supplementation
Correct answer: Furosemide causing hypokalemia and alkalosis
Excessive diuresis with furosemide causes hypokalemia and metabolic alkalosis, which increases ammonia production in the kidney and reduces ammonia excretion, precipitating hepatic encephalopathy.
Question 6: A 33-year-old man presents with recurrent oral ulcers, genital ulcers, and uveitis. He also reports bloody diarrhea. Which GI condition is most strongly associated with this systemic disorder?
- Behçet's disease with GI involvement (Correct answer)
- Crohn's disease
- Ulcerative colitis
- Celiac disease
Correct answer: Behçet's disease with GI involvement
The triad of oral ulcers, genital ulcers, and uveitis defines Behçet's disease, which can cause GI ulceration (most often in the ileocecal region) with bloody diarrhea.
Question 7: A patient with celiac disease continues to have diarrhea and weight loss despite strict gluten-free diet for 12 months. Repeat biopsy shows persistent villous atrophy. What is the most concerning complication to consider?
- Enteropathy-associated T-cell lymphoma (EATL) (Correct answer)
- Microscopic colitis
- Refractory celiac disease type I
- Small intestinal bacterial overgrowth
Correct answer: Enteropathy-associated T-cell lymphoma (EATL)
Refractory celiac disease unresponsive to strict gluten-free diet, particularly type II, carries a high risk of progression to enteropathy-associated T-cell lymphoma (EATL).
Internal Medicine Exam Gastroenterology and Hepatology 3
A 55-year-old man presents with painless jaundice, 15 lb weight loss, and a palpable, non-tender gallbladder.
What is the most likely diagnosis?