Internal Medicine Exam Gastroenterology and Hepatology 5 — Questions and Answers
Question 1: A 55-year-old woman with type 2 diabetes has persistently elevated liver enzymes. Liver biopsy shows hepatocyte ballooning, lobular inflammation, and pericellular fibrosis without significant alcohol use. What is the most likely diagnosis?
- Nonalcoholic steatohepatitis (NASH) (Correct answer)
- Alcoholic hepatitis
- Drug-induced liver injury
- Autoimmune hepatitis
Correct answer: Nonalcoholic steatohepatitis (NASH)
NASH is defined by steatohepatitis (ballooning + lobular inflammation + steatosis) in a patient without significant alcohol use and is strongly associated with metabolic syndrome and type 2 diabetes.
Question 2: A 38-year-old man presents with watery diarrhea (10 stools/day), hypokalemia, and achlorhydria. CT shows a 3 cm pancreatic tail tumor. Which peptide is most likely secreted by this tumor?
- Vasoactive intestinal peptide (VIP) (Correct answer)
- Gastrin
- Glucagon
- Somatostatin
Correct answer: Vasoactive intestinal peptide (VIP)
VIPoma (Verner-Morrison syndrome or WDHA syndrome) presents with watery diarrhea, hypokalemia, and achlorhydria due to excess VIP secretion from a pancreatic neuroendocrine tumor.
Question 3: A 30-year-old woman with autoimmune hepatitis is in remission on azathioprine monotherapy. She wishes to become pregnant. What is the most appropriate counseling regarding her medications?
- Azathioprine can be continued during pregnancy as the risk of relapse outweighs fetal risk (Correct answer)
- Azathioprine must be stopped immediately before conception
- Switch to mycophenolate mofetil for safer pregnancy use
- Discontinue all immunosuppression once pregnant
Correct answer: Azathioprine can be continued during pregnancy as the risk of relapse outweighs fetal risk
Azathioprine is considered relatively safe in pregnancy and should be continued to prevent AIH relapse, which poses greater risk to mother and fetus than the medication itself; mycophenolate is teratogenic.
Question 4: A 72-year-old man with known diverticulosis presents with acute bright red blood per rectum that stops spontaneously. Colonoscopy shows diverticulosis throughout the colon without active bleeding. What is the most common site of diverticular bleeding?
- Right colon (cecum and ascending colon) (Correct answer)
- Sigmoid colon
- Rectum
- Transverse colon
Correct answer: Right colon (cecum and ascending colon)
Despite diverticula being most prevalent in the sigmoid colon, diverticular bleeding occurs most commonly from right-sided (cecal/ascending) diverticula due to their wider necks and exposed vasa recta.
Question 5: A 48-year-old man is diagnosed with Wilson's disease presenting as acute liver failure. Which finding on labs would be most characteristic?
- Low serum alkaline phosphatase with Coombs-negative hemolytic anemia (Correct answer)
- Markedly elevated alkaline phosphatase
- High serum ceruloplasmin
- Elevated serum ferritin >1000 ng/mL
Correct answer: Low serum alkaline phosphatase with Coombs-negative hemolytic anemia
Wilson's disease presenting as acute liver failure characteristically shows paradoxically low alkaline phosphatase (released copper inhibits bone isoform) combined with Coombs-negative hemolytic anemia.
Question 6: A patient develops C. difficile infection after a course of clindamycin. He is treated with oral vancomycin for 10 days but has his third recurrence within 8 weeks. What is the most effective treatment for recurrent C. difficile infection?
- Fecal microbiota transplantation (FMT) (Correct answer)
- Extended oral fidaxomicin pulse-taper regimen
- IV metronidazole
- Bezlotoxumab infusion alone
Correct answer: Fecal microbiota transplantation (FMT)
FMT achieves cure rates of >85-90% for recurrent C. difficile infection and is now recommended by guidelines after multiple recurrences, superior to antibiotic regimens.
Question 7: A 44-year-old woman presents with episodic diarrhea, flushing, and a new heart murmur. 24-hour urine shows markedly elevated 5-HIAA. CT reveals a 1.5 cm ileal mass and multiple hepatic lesions. What is the first-line therapy for symptom control?
- Octreotide LAR (long-acting somatostatin analog) (Correct answer)
- Surgical resection of the primary tumor
- Systemic chemotherapy with streptozocin
- High-dose corticosteroids
Correct answer: Octreotide LAR (long-acting somatostatin analog)
Somatostatin analogs (octreotide LAR or lanreotide) are first-line for controlling carcinoid syndrome symptoms and have also demonstrated anti-proliferative effects in well-differentiated neuroendocrine tumors.
Internal Medicine Exam Gastroenterology and Hepatology 5
A 55-year-old woman with type 2 diabetes has persistently elevated liver enzymes.
Liver biopsy shows hepatocyte ballooning, lobular inflammation, and pericellular fibrosis without significant alcohol use.
What is the most likely diagnosis?