ITE Gastroenterology and Hepatology 5 — Questions and Answers
Question 1: A 55-year-old man with no prior GI history has a positive fecal immunochemical test (FIT). What is the most appropriate next step?
- Repeat FIT in 1 year
- CT colonography
- Colonoscopy (Correct answer)
- Flexible sigmoidoscopy
Correct answer: Colonoscopy
A positive FIT requires diagnostic colonoscopy to evaluate for colorectal cancer or adenomatous polyps; no alternative testing is appropriate after a positive non-invasive screen.
Question 2: A 60-year-old with known achalasia undergoes esophageal manometry showing aperistalsis and incomplete lower esophageal sphincter relaxation. Which treatment has the lowest risk of GERD as a complication?
- Pneumatic dilation
- Heller myotomy with fundoplication (Correct answer)
- Per-oral endoscopic myotomy (POEM)
- Botulinum toxin injection
Correct answer: Heller myotomy with fundoplication
Heller myotomy combined with partial fundoplication (Dor or Toupet) reduces post-procedural GERD compared to myotomy alone or POEM, which disrupts the anti-reflux barrier without fundoplication.
Question 3: A 38-year-old with Crohn's disease on azathioprine develops a perianal fistula that fails to close with antibiotics. What biologic therapy is FDA-approved for fistulizing Crohn's disease?
- Vedolizumab
- Ustekinumab
- Infliximab (Correct answer)
- Natalizumab
Correct answer: Infliximab
Infliximab is the only biologic with FDA approval specifically for fistulizing Crohn's disease, demonstrated in the landmark ACCENT II trial to induce and maintain fistula closure.
Question 4: A patient with severe acute pancreatitis is being managed in the ICU. CT shows 40% pancreatic necrosis without infection. When should nutritional support be initiated?
- Bowel rest until pain resolves
- Parenteral nutrition within 24 hours
- Early enteral nutrition via nasojejunal tube within 24-48 hours (Correct answer)
- Oral clear liquids when amylase normalizes
Correct answer: Early enteral nutrition via nasojejunal tube within 24-48 hours
Early enteral nutrition via nasojejunal (or nasogastric) tube within 24-48 hours is preferred in severe pancreatitis to maintain gut barrier function and reduce infectious complications compared to TPN.
Question 5: A 72-year-old woman presents with acute onset of bright red blood per rectum, crampy left lower quadrant pain, and tenesmus without systemic symptoms. CT shows segmental colonic wall thickening at the splenic flexure. What is the most likely diagnosis?
- Diverticular hemorrhage
- Ischemic colitis (Correct answer)
- Ulcerative colitis flare
- Colorectal cancer
Correct answer: Ischemic colitis
Ischemic colitis classically affects watershed areas like the splenic flexure in older patients and presents with acute crampy pain and bloody diarrhea; segmental distribution on CT is characteristic.
Question 6: A 45-year-old man with hepatitis B (HBsAg positive, HBeAg positive, HBV DNA 8 log IU/mL, ALT 180) has liver biopsy showing moderate inflammation and bridging fibrosis. Which treatment is most appropriate?
- Monitor without treatment
- Interferon-alpha monotherapy
- Tenofovir disoproxil fumarate (Correct answer)
- Lamivudine
Correct answer: Tenofovir disoproxil fumarate
Tenofovir (TDF or TAF) is the preferred first-line treatment for chronic hepatitis B with significant disease activity and fibrosis due to its potency, high barrier to resistance, and safety profile.
Question 7: A 50-year-old woman with morbid obesity develops sudden-onset severe abdominal pain after bariatric surgery 3 years ago. CT shows dilated small bowel loops with mesenteric swirling. What is the most likely diagnosis?
- Dumping syndrome
- Marginal ulcer
- Internal hernia with small bowel obstruction (Correct answer)
- Adhesive bowel obstruction
Correct answer: Internal hernia with small bowel obstruction
Internal hernia through mesenteric defects created during Roux-en-Y gastric bypass is a well-recognized complication presenting with small bowel obstruction and the CT finding of 'mesenteric swirl.'
ITE Gastroenterology and Hepatology 5
A 55-year-old man with no prior GI history has a positive fecal immunochemical test (FIT).
What is the most appropriate next step?