ITE Gastroenterology and Hepatology 3 — Questions and Answers
Question 1: A 70-year-old man presents with dysphagia to solids progressively worsening over 3 months with a 15-pound weight loss. What is the most appropriate initial evaluation?
- Barium swallow
- Upper endoscopy (Correct answer)
- CT chest/abdomen
- Esophageal manometry
Correct answer: Upper endoscopy
Upper endoscopy (EGD) is the preferred initial test for progressive dysphagia with alarm features because it allows direct visualization and biopsy to evaluate for malignancy.
Question 2: A 55-year-old woman with obesity and type 2 diabetes has AST 78 and ALT 92. Ultrasound shows echogenic liver. Which histologic finding distinguishes NASH from simple steatosis?
- Macrovesicular fat deposits
- Lobular inflammation and hepatocyte ballooning (Correct answer)
- Portal fibrosis only
- Bile duct proliferation
Correct answer: Lobular inflammation and hepatocyte ballooning
NASH is distinguished from simple steatosis by the presence of lobular inflammation and hepatocyte ballooning injury, which drive fibrosis progression and risk of cirrhosis.
Question 3: A 28-year-old man has recurrent episodes of jaundice after fasting and during illness. All liver enzymes are normal except indirect bilirubin of 3.5 mg/dL. What is the most likely diagnosis?
- Dubin-Johnson syndrome
- Crigler-Najjar syndrome type I
- Gilbert syndrome (Correct answer)
- Rotor syndrome
Correct answer: Gilbert syndrome
Gilbert syndrome presents with isolated unconjugated hyperbilirubinemia triggered by fasting, stress, or illness, with otherwise normal liver function and benign prognosis.
Question 4: A 50-year-old man with known esophageal varices presents with hematemesis. He is hemodynamically stable after resuscitation. What is the most appropriate endoscopic treatment?
- Sclerotherapy
- Band ligation (Correct answer)
- Coagulation therapy
- Hemostatic clips
Correct answer: Band ligation
Endoscopic variceal band ligation (EVL) is the preferred endoscopic treatment for acute esophageal variceal bleeding due to its superior efficacy and lower complication rate compared to sclerotherapy.
Question 5: Which of the following best describes the mechanism of action of ursodeoxycholic acid (UDCA) in primary biliary cholangitis?
- Immunosuppression of autoreactive T cells
- Displacement of toxic bile acids and hepatoprotection (Correct answer)
- Inhibition of TNF-alpha synthesis
- Bile acid synthesis inhibition
Correct answer: Displacement of toxic bile acids and hepatoprotection
UDCA works by replacing toxic hydrophobic bile acids, stimulating bile secretion, and providing cytoprotection to cholangiocytes, slowing disease progression in PBC.
Question 6: A 40-year-old woman has chronic diarrhea, flushing, and wheezing. Urinary 5-HIAA is markedly elevated. Which imaging study is most appropriate to localize the primary tumor?
- CT abdomen with contrast
- Octreotide scan (somatostatin receptor scintigraphy) (Correct answer)
- PET scan with FDG
- MRI liver
Correct answer: Octreotide scan (somatostatin receptor scintigraphy)
Somatostatin receptor scintigraphy (octreotide scan or Ga-68 DOTATATE PET/CT) is the preferred functional imaging modality to localize carcinoid tumors expressing somatostatin receptors.
Question 7: A patient is found to have H. pylori infection on urea breath test after completing a PPI plus clarithromycin-based triple therapy. What is the best next step?
- Repeat the same triple therapy regimen
- Bismuth quadruple therapy (Correct answer)
- Metronidazole monotherapy
- Endoscopy with biopsy culture
Correct answer: Bismuth quadruple therapy
After failure of clarithromycin-based triple therapy, bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) is recommended as salvage treatment.
ITE Gastroenterology and Hepatology 3
A 70-year-old man presents with dysphagia to solids progressively worsening over 3 months with a 15-pound weight loss.
What is the most appropriate initial evaluation?