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SECTION VI

 

GASTROINTESTINAL DISEASES

 

1.            ESOPHAGEAL DISEASE:

 

95.1      Progressive dysphagia to solids only is most likely seen with:

 

i.)           Achalasia

ii.)          Peptic stricture

iii.)         Schatski ring

iv.)         Carcinoma of the esophagus

v.)          Diffuse esophageal spasm

 

95.2      In achalasia:

 

i.)           Inadequate relaxation of lower esophageal sphincter

ii.)          There is increased peristalsis in the smooth-muscle portion of the esophageal body

iii.)         Absence of gastric bubble is seen on CXR

iv.)         It can be caused by Chaga's disease or lymphoma

v.)          Heller's extramucosal myotomy of LES may be indicated

 

95.3      Lower esophageal sphincter pressure is decreased by:

 

a.)          Pregnancy

b.)          Calcicum antagonists

c.)          Bethanecol

d.)          Theophylline

e.)          Scleroderma

 

2.            PEPTIC ULCER DISEASE, GASTRITIS AND ZOLLINGER-ELLISON SYNDROME:

 

96.1      Proven risk factors for peptic ulcer disease include:

 

vi.)         Smoking

vii.)       Gastric campylobacter

viii.)      Stress

ix.)         Mastocytosis

x.)          Coffee

 

96.2      Clinical features that favor duodenal ulcer rather than gastric ulcer include:

 

i.)           Pain made worse or unrelated to fofod

ii.)          Pain often nocturnal

iii.)         Weight loss

iv.)         Poor response to standard therapy

v.)          Anorexia and food aversion

 

96.3      Radiographic features suggesting malignancy of gastric ulcer include:

 

i.)           Ulcer within a mass

ii.)          Folds that do not radiate from ulcer margin

iii.)         A large ulcer > 3 cm

iv.)         Anterior location

v.)          Residual contrast seen hours after the procedure

 

96.4      Side effects of cimetidine include:

 

i.)           Constipation

ii.)          Anti-androgen action

iii.)         Confusion

iv.)         Increased hepatic drug metabolism

v.)          Increased serum amino-transferase levels

 

96.5      Tumors of Zollinger-Ellison syndrome are:

 

i.)           Usually pancreatic

ii.)          Often multiple

iii.)         Quickly growing

iv.)         Malignant in > 60% of cases

v.)          Associated with multiple endocrine neoplasia type II

 

3.            PANCREATITIS:

 

97.1      Causes of pancreatitis include:

 

i.)           Abdominal trauma

ii.)          Hyperlipidemia

iii.)         Pancreatic divisum

iv.)         Digoxin

v.)          Hypoparathyroidism

 

97.2      The following statements are correct about acute pancreatitis:

 

i.)           Cullen’s sign is a blue red-purple discoloration of the flanks

ii.)          Three times elevation of serum amylase is diagnostic

iii.)         Abdominal x-ray sentinel loop is seen in over 70% of the cases

iv.)         Hypertriglyceridemia can cause a spuriously normal serum amylase level

v.)          Serum lipase is more specific for pancreatic disease than serum amylase

 

97.3      Pancreatitis pseudocyst is:

 

i.)           Suspected in patients who develop recurrent pain within 7-10 days of onset of pancreaters

ii.)          Signaled by fever and increased leukocyte count

iii.)         Most often due to E. Coli

iv.)         Detected by abdominal ultrasound

v.)          Treated with surgical drainage in most cases

 

97.4      Investigations of chronic pancreatitis:  Mark T or F:

 

i.)           Serum amylase and lipase are often normal

ii.)          Steatorrhea occurs late in the disease

iii.)         Impaired glucose tolerance test is present in almost all cases

iv.)         The Bentiromide test may be helpful

v.)          ERCP often revelas irregular dilation of the main duct and pruning of the branches

 

97.5      Complications of chronic pancreatitis include:

 

i.)           Left sided pleural effusion

ii.)          Diabetes mellitus

iii.)         Encephalopathy

iv.)         Disseminated intravascular coagulation

v.)          Steatorrhea

 

4.            INFLAMMATORY BOWEL DISEASE:

 

98.1      Feature favoring ulcerative colitis (UC) over Crohn’s disease (CD) include:

 

i.)           Transmural inflammation

ii.)          Crypt abscesses

iii.)         Rectum almost always involved

iv.)         Toxic megacolon

v.)          Cobblestone pattern

 

98.2      Features favoring Crohn’s disease over ulcerative colitis include:

 

i.)           Bloody diarrhea

ii.)          Skip areas

iii.)         Pseudopolyps

iv.)         Fissures and fistulas

v.)          Kidney stones

 

98.3      Correct statements about treatment of inflammatory bowel disease include:

 

i.)           The active component of sulfasalazine is 5-amino-salicylic acid

ii.)          Toxicity of sulfasalazine is generally due to its 5-aminosalicylic acid component

iii.)         Intravenous infusion of ACTH may be preferable in the first attack of UC

iv.)         Cyclosporin is useful as a steroid-sparing agent and for intractable cases

v.)          Metronidazole appears to be effective in colonic or refractory perineal CD

 

5.            TUMORS OF THE INTESTINAL TRACT:

 

99.1      Risk factors of esophageal carcinoma include:

 

i.)           Ethanol abuse

ii.)          Smoking

iii.)         Lye ingestion

iv.)         Stricture

v.)          Tylosis

 

99.2      In esophageal carcinoma:

 

i.)           Females are more frequently affected

ii.)          The 5-year survival rate is < 5%

iii.)         The lower two-thirds is most commonly affected

iv.)         Adenocarcinoma usually arises in the region of Barett’s esophagus

v.)          Iron deficiency anemia is a common clinical feature

 

99.3      Match the following:

 

i.)           Numerous hamartomatous polysp of the entire GI tract, more prevalent in small bowel, GI bleeding is common

ii.)          Diffuse pancolonic adenomatous polyposis, autosomal dominant

iii.)         Multiple colonic and small bowel hamartomas, abdominal pain, diarrhea, intususception

iv.)         Polyposis associated with soft tissue tumors (sebaceous cysts, osteomas, lipomas)

v.)          Sessile lesions, high risk of malignancy, associated with potassium-rich secretary diarrhea

 

1.)          Gardner’s syndrome

2.)          Villous adenoma

3.)          Familial polyposis coli

4.)          Peutz-Jedgers syndrome

5.)          Juvenile polyposis

 

99.4      In colon cancer:

 

i.)           Histology is nearly always adenocarcinoma

ii.)          75% are located proximal to the splenic flexure

iii.)         Degree of differentiation usually correlates with course of the disease

iv.)         Degree of invasiveness at surgery is the single best predictor of prognosis

v.)          Tumors of the rectosigmoid area are prone to early metastasis to the lung

 

99.5      In colon cancer:

 

i.)           Incidence increases above age 40

ii.)          Determination of serum CEA is a useful diagnostic tool

iii.)         Risk is increased in patients with narcotic abuse

iv.)         Screening of asymptomatic persons allows earlier detection

v.)          Routine fecal occult blood testing is shown to reduce the overall mortality

 

6.            COLONIC AND ANORECTAL DISEASES:

 

100.1           Correct statements about irritable bowel syndrome (IBS) include:

 

i.)           Decreased resting colonic motility

ii.)          Onset often before age 30

iii.)         Pencil-thin stools with mucus and blood

iv.)         Diagnosis often made by history

v.)          Treatment includes avoidance of dietary bulk

 

100.2           The following statements are correct:

 

i.)           Diverticular disease most commonly occurs at the sigmoid colon

ii.)          Abdominal angina is post-pradial periumbilical pain due to acute mesenteric ischemia

iii.)         Thumb printing seen on abdominal x-ray is a known feature of ischemic colitis

iv.)         Intestinal pseudo-obstruction is a manifestation of  familial visceral neuropathy

v.)          Anal fissures are caused by increased hypdrostatic pressure in the anal venous plexus

 

7.            CHOLELITHIASIS, CHOLECYSTITIS AND CHOLANGITIS:

 

101.1           Elective cholecystectomy should be reserved     for:

 

i.)           Symptomatic patients despite dietary restriction

ii.)          Patients with previous complications of cholelithiasis

iii.)         Asymptomatic patients with diabetes mellitus

iv.)         Asymptomatic patients with radiolucent gallstones

v.)          Patients who develop side-effects to the oral dissolution agents

 

101.2           Incidence of gallstone is increased with:

 

i.)           Hyperalimentation

ii.)          Diabetes mellitus

iii.)         Pregnancy

iv.)         Hypertriglyceridemia

v.)          Tropical sprue

 

101.3           The following statements are correct:

 

i.)           Radioisotope scan (HIDA) may identify cystic duct obstruction

ii.)          In acute cholecystitis surgery should be performed with 24-48 hour of admission

iii.)         In chronic cholecycstitis, serum alkaline phosphatase is persistently elevated

iv.)         Most cases of acute choleclystitis are of the acalculous type

v.)          Ultrasonography is very sensitive in detecting common bile duct stones

 

101.4           Primary sclerosing cholangitis.  Mark T or F.

 

i.)           Males are more affected than females

ii.)          It may progress to cirrhosis with portal hypertesnion

iii.)         Stenosis of intrahepatic ducts and dilatation of extrahepatic ducts is a common feature

iv.)         About 60% of cases are associated with Crohn’s disease

v.)          Liver transplantation should be considered in patients with end-stage cirrhosis

 

8.            TUMORS OF THE PANCREAS AND  HEPATOBILIAIRY TREE:

 

102.1           In pancreatic carcinoma:

 

i.)           Incidence increased in smokers

ii.)          About 90% of cases occur in the head of the pancreas

iii.)         Tumor is almost always ductal adenocarcinoma

iv.)         Hypoglycemia is a late complication

v.)          Combination chemotherapy in patients with inoperable disease improves survival

 

102.2           Risk factors for hepatoma includes:

 

i.)           Hemochromatosis

ii.)          Tyrosinosis

iii.)         Diet high in grilled meats

iv.)         Ingested fungal metabolies

v.)          Cystic fibrosis

 

102.3           In hepatocellular carcinoma:

 

i.)           Neonatal infection with hepatitis B carries a lower risk of subsequent carcinoma than infection in adulthood

ii.)          Male:female ratio 2.1:4.1

iii.)         Presentation with mild to moderate jaundice is common

iv.)         Serum alpha-fetoprotein is elevated in 10% of the cases

v.)          Intra-arterial chemotherapy is of proven benefit

 

9.            ACUTE HEPATITIS:

 

103.1           Correct features of hepatitis B virus are:

 

i.)           42-nm hepadnavirus

ii.)          Outer surface coat HbsAg

iii.)         Inner nucleocapsid core HbeAb

iv.)         Single stranded RNA genome

v.)          DNA polymerase

 

103.2   Hepatitis D (Delta Agent):

 

i.)           Is endemic among Hepatitis B virus carries in the Mediterranean areas

ii.)          Is commonly transmitted by the fecal-oral route

iii.)         Requires HBV for its replication

iv.)         Either co-infects with HBV or superinfects a chronic HBV carrier

v.)          Decreases severity of HBV infection in the early phase of the illness

 

103.3           Toxic or drug-induced hepatitis can be caused by:

 

i.)           Benzene derivatives

ii.)          Imipenem

iii.)         Halothane

iv.)         Mushroom poisoning

v.)          Poison ivy

 

103.4           In acute hepatic failure:

 

i.)           Massive hapatic necrosis with coma occurring within 8-12 weeks of onset of the illness

ii.)          Acute fatty liver of pregnancy may be a predecessor

iii.)         Decerebrate rigidity is a known clinical manifestation

iv.)         Prolongation of PT is an adverse prognostic factor

v.)          Mannitol, Dexamethazone and intracranial pressure monitoring are the  mainstay of management

 

10.         CHRONIC HEPATITIS:

 

104.1           Findings that favor chronic active hepatitis over chronic persistent hepatitis include:

 

i.)           Piecemeal necrosis

ii.)          Bridging necrosis

iii.)         Portal zone infiltrate of lymphocytes and plasma cells

iv.)         Multilobular necrosis

v.)          HbsAg positivity

 

104.2           Finding in idiopathic chronic active hepatitis include:

 

i.)           The majority of affected patients are women

ii.)          The 5 year mortality is > 50% if untreated

iii.)         Hemolytic anemia is a known clinical manifestations

iv.)         Hypogammaglobulinemia is a known serologic abnormality

v.)          Prednisone is indicated for symptomatic disease

 

11.         CIRRHOSIS AND ALCHOLOL LIVER DISEASE:

 

105.1           Causes of cirrhosis include:

 

i.)           Non A, Non B hepatitis

ii.)          Fatty liver

iii.)         Chronic dilated cardiomyopathy

iv.)         IgA hypogammaglobulinemia

v.)          Alpha-1 anti-trypsin deficiency

 

105.2           Adverse prognostic factors in alcoholic liver disease include:

 

i.)           Portal hypertension

ii.)          Tender hepatomegaly

iii.)         Bilirubin > 10 mg/dl

iv.)         Hypoalbuminemia

v.)          PT > above control despite vitamin K

 

105.3   In primary biliary cirrhosis:

 

i.)           Destructive intrahepatic and extrahepatic cholangitis occurs

ii.)          Post-menopausal women are commonly affected

iii.)         Xanthelasma and xanthomata are known clinical manifestations

iv.)         Anti-mitochondrial antibodies are positive in 50-60% of the cases

v.)          Dietary fat with medium chain triglycerides may reduce steatorrhea

 

105.4           Absolute contraindications for liver trans-plantation include:

 

i.)           Portal vein thrombosis

ii.)          Age > 55

iii.)         Extension previous abdominal surgery

iv.)         Hepatorenal syndrome

v.)          Hypoxemia (PO2 < 60 mmHg)

 

12.         PORTAL HYPERTENSION:

 

106.1   In esophageal varices:

 

i.)           Risk of bleeding correlates with variceal size

ii.)          Mortality from variceal bleeding correlates with hepatic reverse

iii.)         Endoscopic scleropathy is not suitable for gastric varices

iv.)         Propranolol is least effective in well compensated cirrhosis

v.)          Prognosis (but not surgical risk) correlates with classification of “Child” and “Turcofle”

 

106.2   Hepatic encephalopathy.  Mark T or F.

 

i.)           Day-night reversal of sleep cycle

ii.)          Characteristic EEG abnormalities

iii.)         Blood ammonia correlates with clinical status in almost all patients

iv.)         False neurotransmitters are the main factor leading to disturbed mental status

v.)          Combination of Lactulase and neomycin therapy is not recommended