Internal Medicine Exam Gastroenterology Disorders 3 — Questions and Answers
Question 1: A 50-year-old with cirrhosis develops confusion, asterixis, and elevated ammonia. His medications include furosemide and spironolactone. What is the most appropriate immediate treatment for hepatic encephalopathy?
- Lactulose titrated to 2-3 soft stools per day (Correct answer)
- Neomycin IV
- Protein restriction to 0 g/day
- Fresh frozen plasma
Correct answer: Lactulose titrated to 2-3 soft stools per day
Lactulose reduces ammonia production and absorption in the colon and is the first-line treatment for hepatic encephalopathy.
Question 2: A patient with long-standing GERD undergoes EGD showing salmon-colored mucosa extending 4 cm above the gastroesophageal junction. Biopsy confirms intestinal metaplasia. What is the diagnosis and surveillance interval?
- Barrett's esophagus; surveillance EGD every 3-5 years with low-grade dysplasia protocol
- Barrett's esophagus without dysplasia; EGD every 3-5 years (Correct answer)
- Eosinophilic esophagitis; dietary elimination trial
- Esophageal adenocarcinoma; oncology referral
Correct answer: Barrett's esophagus without dysplasia; EGD every 3-5 years
Barrett's esophagus without dysplasia warrants surveillance endoscopy every 3-5 years per ACG guidelines.
Question 3: A 35-year-old woman presents with recurrent watery diarrhea, bloating, and abdominal pain relieved by defecation. Colonoscopy and labs are normal. What is the most likely diagnosis?
- Irritable bowel syndrome (IBS) (Correct answer)
- Microscopic colitis
- Celiac disease
- Crohn's disease
Correct answer: Irritable bowel syndrome (IBS)
IBS is characterized by recurrent abdominal pain associated with defecation and altered stool frequency/form with no structural abnormalities.
Question 4: A 65-year-old with known cirrhosis presents with sudden onset abdominal pain and fever. Paracentesis shows PMN count > 250 cells/µL. What empiric antibiotic is indicated for spontaneous bacterial peritonitis?
- IV cefotaxime or ceftriaxone (Correct answer)
- Oral ciprofloxacin alone
- IV vancomycin plus metronidazole
- Ampicillin-sulbactam
Correct answer: IV cefotaxime or ceftriaxone
Third-generation cephalosporins (cefotaxime, ceftriaxone) are the empiric treatment of choice for SBP due to coverage of gram-negative enteric organisms.
Question 5: A 48-year-old presents with dysphagia to solids and liquids equally from the onset, regurgitation of undigested food, and a "bird-beak" appearance on barium swallow. Manometry shows absent peristalsis and incomplete LES relaxation. What is the diagnosis?
- Achalasia (Correct answer)
- Diffuse esophageal spasm
- Scleroderma esophagus
- Peptic stricture
Correct answer: Achalasia
Achalasia is characterized by absent esophageal peristalsis and failure of LES relaxation, producing the classic bird-beak appearance on barium swallow.
Question 6: A 42-year-old presents with jaundice, right upper quadrant pain, and fever (Charcot's triad). CT shows dilated bile ducts and a stone in the common bile duct. What is the most urgent intervention?
- ERCP with stone extraction (Correct answer)
- Laparoscopic cholecystectomy
- Percutaneous transhepatic cholangiography
- Oral bile acid therapy
Correct answer: ERCP with stone extraction
Choledocholithiasis with cholangitis requires urgent ERCP with biliary decompression and stone extraction.
Question 7: A 55-year-old with a history of NSAID use presents with melena and hematemesis. EGD shows a 1 cm duodenal ulcer with a visible vessel at its base. After endoscopic hemostasis, what is the next best pharmacologic management?
- High-dose IV proton pump inhibitor infusion for 72 hours (Correct answer)
- Oral H2-blocker
- H. pylori eradication therapy immediately
- Sucralfate suspension
Correct answer: High-dose IV proton pump inhibitor infusion for 72 hours
High-risk ulcers treated endoscopically require high-dose IV PPI (bolus + infusion) for 72 hours to reduce rebleeding risk.
Internal Medicine Exam Gastroenterology Disorders 3
A 50-year-old with cirrhosis develops confusion, asterixis, and elevated ammonia.
His medications include furosemide and spironolactone.
What is the most appropriate immediate treatment for hepatic encephalopathy?