Internal Medicine Exam Gastroenterology Disorders 4 — Questions and Answers
Question 1: A 25-year-old presents with fatigue, iron-deficiency anemia, bloating, and diarrhea. Tissue transglutaminase IgA antibody is markedly elevated. Small bowel biopsy shows villous atrophy and crypt hyperplasia. What dietary modification is curative?
- Strict gluten-free diet (Correct answer)
- Lactose-free diet
- Low-FODMAP diet
- Low-fat diet
Correct answer: Strict gluten-free diet
Celiac disease is an immune-mediated enteropathy triggered by gluten; strict lifelong gluten avoidance leads to mucosal healing.
Question 2: A 68-year-old develops profuse, watery, non-bloody diarrhea after a 10-day course of clindamycin for a skin infection. Stool PCR is positive for C. difficile toxin. This is his first episode. What is the first-line treatment?
- Oral vancomycin or fidaxomicin (Correct answer)
- IV metronidazole
- Oral metronidazole
- Fecal microbiota transplant
Correct answer: Oral vancomycin or fidaxomicin
Updated guidelines (IDSA 2021) recommend oral vancomycin or fidaxomicin over metronidazole for initial C. difficile infection due to superior cure rates.
Question 3: A 60-year-old with alcoholic cirrhosis develops increasing abdominal girth. Ultrasound confirms ascites. Serum-ascites albumin gradient (SAAG) is 1.5 g/dL. What does this SAAG indicate?
- Portal hypertension-related ascites (Correct answer)
- Malignant ascites
- Tuberculous peritonitis
- Nephrotic syndrome
Correct answer: Portal hypertension-related ascites
SAAG ≥ 1.1 g/dL indicates portal hypertension as the cause of ascites with 97% accuracy.
Question 4: A 45-year-old with autoimmune hepatitis presents with elevated ALT/AST (10x normal) and positive anti-smooth muscle antibodies. What is the standard induction therapy?
- Prednisone with or without azathioprine (Correct answer)
- Ursodeoxycholic acid
- Pegylated interferon
- Mycophenolate mofetil alone
Correct answer: Prednisone with or without azathioprine
Autoimmune hepatitis is treated with prednisone alone or combined with azathioprine to induce remission.
Question 5: A 50-year-old with known esophageal varices presents with acute hematemesis. After resuscitation, what pharmacologic therapy should be started immediately before endoscopy?
- IV octreotide (somatostatin analogue) (Correct answer)
- IV pantoprazole
- Oral propranolol
- IV vasopressin alone
Correct answer: IV octreotide (somatostatin analogue)
Octreotide reduces portal pressure by inhibiting splanchnic vasodilation and should be initiated immediately in suspected variceal bleeding.
Question 6: A patient presents with 8 weeks of dyspepsia unresponsive to antacids. Urea breath test is positive. What is the most appropriate treatment regimen?
- Clarithromycin-based triple therapy (PPI + clarithromycin + amoxicillin) for 14 days (Correct answer)
- PPI alone for 4 weeks
- Bismuth quadruple therapy as first-line in all patients
- Amoxicillin monotherapy for 7 days
Correct answer: Clarithromycin-based triple therapy (PPI + clarithromycin + amoxicillin) for 14 days
Clarithromycin-based triple therapy for 14 days is a standard first-line H. pylori eradication regimen in areas with low clarithromycin resistance.
Question 7: A 70-year-old man is found to have a 2 cm hepatic mass on ultrasound. He has a history of hepatitis C cirrhosis and AFP of 450 ng/mL. Dynamic CT shows arterial enhancement with venous washout. What is the most likely diagnosis?
- Hepatocellular carcinoma (Correct answer)
- Hepatic hemangioma
- Metastatic colorectal cancer
- Focal nodular hyperplasia
Correct answer: Hepatocellular carcinoma
Arterial enhancement with venous-phase washout on CT in a cirrhotic patient with elevated AFP is diagnostic of hepatocellular carcinoma per AASLD criteria.
Internal Medicine Exam Gastroenterology Disorders 4
A 25-year-old presents with fatigue, iron-deficiency anemia, bloating, and diarrhea.
Tissue transglutaminase IgA antibody is markedly elevated.
Small bowel biopsy shows villous atrophy and crypt hyperplasia.
What dietary modification is curative?