Internal Medicine Exam Gastroenterology and Hepatology 4 — Questions and Answers
Question 1: A 58-year-old man with alcoholic cirrhosis (Child-Pugh C) develops a variceal bleed. After stabilization with octreotide and endoscopic band ligation, what is the most important next step to prevent recurrent bleeding?
- Non-selective beta-blocker plus repeat band ligation (Correct answer)
- TIPS procedure immediately
- Surgical portosystemic shunt
- Propranolol monotherapy only
Correct answer: Non-selective beta-blocker plus repeat band ligation
Secondary prophylaxis of variceal bleeding requires combination therapy with non-selective beta-blockers (nadolol or propranolol) plus endoscopic variceal ligation, which is superior to either alone.
Question 2: A 45-year-old man presents with nausea, right upper quadrant pain, and AST/ALT >1000 U/L after a camping trip where he consumed wild mushrooms. What toxin is most likely responsible?
- Amatoxin from Amanita phalloides (Correct answer)
- Muscarine from Amanita muscaria
- Psilocybin from Psilocybe species
- Orellanine from Cortinarius species
Correct answer: Amatoxin from Amanita phalloides
Amatoxin (alpha-amanitin) from Amanita phalloides causes severe hepatotoxicity by inhibiting RNA polymerase II; it is the most common cause of fatal mushroom poisoning.
Question 3: A 30-year-old woman presents with iron deficiency anemia, bloating, and a positive tissue transglutaminase IgA antibody. Small bowel biopsy shows subtotal villous atrophy. What is the first-line treatment?
- Strict lifelong gluten-free diet (Correct answer)
- Corticosteroids
- Azathioprine
- IV iron infusion alone without dietary change
Correct answer: Strict lifelong gluten-free diet
A strict lifelong gluten-free diet is the cornerstone of celiac disease treatment and leads to mucosal healing, resolution of symptoms, and correction of nutritional deficiencies.
Question 4: A 65-year-old man with a 3 cm hepatocellular carcinoma (HCC) on a background of cirrhosis has a Child-Pugh A score and no extrahepatic spread. Which staging criteria determines treatment eligibility for curative resection?
- Barcelona Clinic Liver Cancer (BCLC) criteria (Correct answer)
- Milan criteria
- Pittsburgh modified TNM
- Edmondson-Steiner grading
Correct answer: Barcelona Clinic Liver Cancer (BCLC) criteria
The BCLC staging system is the most widely used guideline for HCC that links staging to prognosis and treatment allocation, including candidacy for resection.
Question 5: A 52-year-old woman is found to have a 2 cm polyp in the sigmoid colon on colonoscopy. Pathology shows a tubulovillous adenoma with high-grade dysplasia. When should the next surveillance colonoscopy be performed?
- 3-6 months to verify complete removal, then 1 year (Correct answer)
- 5 years
- 10 years
- 2 years
Correct answer: 3-6 months to verify complete removal, then 1 year
After resection of high-grade dysplasia or large adenomas, a short-interval colonoscopy (3-6 months) confirms complete removal, followed by surveillance at 1 year per current guidelines.
Question 6: A 40-year-old man presents with epigastric pain, early satiety, and iron deficiency anemia. Upper endoscopy shows large gastric folds in the fundus and body. Biopsy demonstrates marked foveolar hyperplasia without hypergastrinemia. What is the most likely diagnosis?
- Ménétrier's disease (Correct answer)
- Zollinger-Ellison syndrome
- Gastric lymphoma
- Hypertrophic hypersecretory gastropathy
Correct answer: Ménétrier's disease
Ménétrier's disease is characterized by giant gastric rugae, foveolar hyperplasia, protein-losing gastropathy, and normal or low gastrin levels, distinguishing it from Zollinger-Ellison syndrome.
Question 7: A 66-year-old man presents with melena and hemodynamic instability. Upper endoscopy reveals a 1 cm duodenal ulcer with a visible vessel. After endoscopic hemostasis, which pharmacologic regimen best reduces rebleeding risk?
- High-dose IV pantoprazole infusion (80 mg bolus then 8 mg/hr for 72 hours) (Correct answer)
- Oral omeprazole 20 mg daily
- IV ranitidine 50 mg every 8 hours
- Sucralfate suspension every 6 hours
Correct answer: High-dose IV pantoprazole infusion (80 mg bolus then 8 mg/hr for 72 hours)
High-dose IV PPI infusion (bolus followed by continuous infusion for 72 hours) significantly reduces rebleeding, need for surgery, and mortality after endoscopic hemostasis of high-risk stigmata.
Internal Medicine Exam Gastroenterology and Hepatology 4
A 58-year-old man with alcoholic cirrhosis (Child-Pugh C) develops a variceal bleed.
After stabilization with octreotide and endoscopic band ligation, what is the most important next step to prevent recurrent bleeding?