Internal Medicine Exam Gastroenterology Disorders 5 — Questions and Answers
Question 1: A 55-year-old woman presents with chronic diarrhea and is found to have a normal colonoscopy but colonic biopsy reveals thickened subepithelial collagen band > 10 µm. What is the diagnosis?
- Collagenous colitis (microscopic colitis) (Correct answer)
- Ulcerative colitis
- Crohn's colitis
- Ischemic colitis
Correct answer: Collagenous colitis (microscopic colitis)
Collagenous colitis is a form of microscopic colitis characterized by a thickened collagen band beneath the epithelium, presenting with chronic watery diarrhea and normal colonoscopy.
Question 2: A 48-year-old man presents with steatorrhea, weight loss, and diabetes. CT abdomen shows pancreatic calcifications. Fecal elastase is markedly low. What is the underlying diagnosis?
- Chronic pancreatitis with exocrine insufficiency (Correct answer)
- Pancreatic adenocarcinoma
- Autoimmune pancreatitis
- Acute recurrent pancreatitis
Correct answer: Chronic pancreatitis with exocrine insufficiency
Pancreatic calcifications, steatorrhea, and low fecal elastase indicate chronic pancreatitis with exocrine insufficiency.
Question 3: A 30-year-old runner presents with bloody diarrhea, abdominal cramping, and sigmoid colonic wall thickening on CT. Symptoms began after running a marathon in hot weather. No fever; WBC is normal. What is the most likely diagnosis?
- Ischemic colitis (Correct answer)
- Infectious colitis
- Ulcerative colitis
- Radiation colitis
Correct answer: Ischemic colitis
Ischemic colitis can occur in young athletes during prolonged exertion due to shunting of blood away from the splanchnic circulation.
Question 4: A 62-year-old presents with intermittent dysphagia to solids only, a lower esophageal ring on barium swallow, and no evidence of malignancy. What is the most appropriate treatment?
- Endoscopic dilation (Correct answer)
- Surgical myotomy
- Proton pump inhibitor therapy alone
- Botulinum toxin injection
Correct answer: Endoscopic dilation
Schatzki ring causing intermittent solid-food dysphagia is treated with endoscopic dilation, which is safe and effective.
Question 5: A patient with Wilson's disease presents with liver disease, Kayser-Fleischer rings, and neuropsychiatric symptoms. Serum ceruloplasmin is low. What is the first-line treatment for symptomatic Wilson's disease?
- D-penicillamine or trientine (copper chelation) (Correct answer)
- Zinc supplementation alone as initial therapy
- Low-copper diet as sole management
- Liver transplantation immediately
Correct answer: D-penicillamine or trientine (copper chelation)
Symptomatic Wilson's disease is treated with copper chelators (D-penicillamine or trientine) to remove excess copper.
Question 6: A 45-year-old presents with dyspepsia, early satiety, and bloating. Upper endoscopy shows a 3 cm submucosal gastric mass with overlying normal mucosa. EUS reveals a hypoechoic lesion arising from the muscularis propria. What is the most likely diagnosis?
- Gastrointestinal stromal tumor (GIST) (Correct answer)
- Gastric adenocarcinoma
- Gastric lymphoma
- Gastric carcinoid
Correct answer: Gastrointestinal stromal tumor (GIST)
GISTs are the most common submucosal gastric tumors, arising from the muscularis propria and appearing hypoechoic on EUS.
Question 7: A 58-year-old with alcoholic cirrhosis has a MELD score of 22 and is listed for liver transplantation. He develops hepatorenal syndrome type 1 with rapidly rising creatinine. What is the bridging pharmacologic therapy while awaiting transplant?
- Terlipressin (or norepinephrine) plus albumin infusion
- Furosemide plus albumin
- Hemodialysis alone
- Midodrine plus octreotide plus albumin (Correct answer)
Correct answer: Midodrine plus octreotide plus albumin
In the US where terlipressin has only recently been approved, midodrine plus octreotide plus IV albumin is the standard bridge therapy for hepatorenal syndrome type 1.
Internal Medicine Exam Gastroenterology Disorders 5
A 55-year-old woman presents with chronic diarrhea and is found to have a normal colonoscopy but colonic biopsy reveals thickened subepithelial collagen band > 10 µm.
What is the diagnosis?