Postgrad MedJ3 1998;74:573-574 C The Fellowship of Postgraduate Medicine, 1998

Multiple-choice questions

Multiple-choice questions in gastro-enterologyand hepatology

M C Bateson, R Holden

Are the statements listed beneath each question true or false? Answers are given overleaf.

Bishop AucklandGeneral Hospital,Bishop Aukland,County DurhamDL14 6AD, UKM C Bateson

Monklands Hospital,Airdrie, UKR Holden

Accepted 16 December 1997

QUESTION 1

Which cancers are becoming commonerin the United Kingdom:A PancreasB LiverC StomachD DuodenumE Gallbladder

QUESTION 2

A patient with Crohn's disease presentswith an exacerbation of diarrhoea. He istoxic with a slight fever, a right iliac fossamass and right sided loin pain. There areno features of intestinal obstruction.Which ofthe following is true:A Ultrasound examination is helpfulB Treatment with steroids should be startedC Urgent laparotomy is requiredD Metronidazole should be added to the

treatmentE Azathioprine is rapidly effective

QUESTION 3

Characteristic abnormalities of smallbowel are found on peroral biopsy inwhich ofthe following conditions:A Coeliac diseaseB AlactasiaC AmyloidosisD Tropical sprueE Chronic radiation enteritis

QUESTION 4

Acute appendicitis:A Is diagnosed by pain starting in the right

iliac fossa associated with low-grade feverand leucocytosis

B Is commoner in young peopleC Leads to the commonest abdominal opera-

tionD Is linked to severe complications in a

minority irrespective of ageE Is associated with inflammatory bowel

disease

QUESTION 5

Which ofthe following drugs reduce portalpressure in patients with portal hyper-tension:

A NitratesB AspirinC Beta-blockersD SpironolactoneE Chenodeoxycholic acid

QUESTION 6

A 65-year-old man is admitted as anemergency with severe epigastric pain.Next day, 'liver function tests' show abilirubin of 38 ZImolIl (normal < 20), alka-line phosphatase 350 IU/l (<100),y-glutamyl transferase 42 IUll (<50),alanine transaminase 87 IU/l (n<60), albu-min 39 gIl (>35), and globulin 22 gIl (<30).A haemogram was normal with less than1% reticulocytes:A This could be biliary colicB Acute hepatitis is a likely diagnosisC The bilirubin level may reflect Gilbert's

syndromeD Serum calcium should be checkedE Benign intrahepatic cholestasis is a differen-

tial diagnosis

QUESTION 7

The finding ofpigmentation in the colonicmucosa-melanosis coli-in a patient withdiarrhoea suggests which of the followingdiagnoses:A Addison's diseaseB Ulcerative colitisC Bile salt malabsorptionD HaemochromatosisE Laxative abuse

QUESTION 8

In a patient presenting with abdominalpain, weight loss and diarrhoea, which ofthe following investigations suggest pan-creatic insufficiency:A Pancreatic calcification on plain X-ray of

abdomenB Serum albumin 23 g/lC Low serum folateD Abnormal fluorescein dilaurate testE Hypocalcaemia with raised serum alkaline

phosphatase

574 Multiple-choice questions

Answers

QUESTION 1A TrueB TrueC FalseD FalseE FalseCancer of the pancreas is commoner than pri-mary liver cancer but both are increasing infrequency. Overall gastric cancer frequency hasfallen for many years, though this relates onlyto antral and pyloric tumours rather thanproximal ones. The rate of gallbladder cancer isprobably not changing, but diagnosis willclearly depend on the rate of cholecystectomy.Duodenal carcinoma remains very rare.

QUESTION 2

A TrueB TrueC FalseD TrueE FalseUltrasound examination will help in deciding ifthere is abscess present in addition to aninflammatory mass due to adherent loops ofinflamed bowel. Hydronephrosis may occur inthese circumstances and will be seen on ultra-sound. Treatment with steroids and metroni-dazole are appropriate. Azathioprine has noimmediate effect in the treatment of acuteexacerbations of Crohn's disease because of itsslow onset of action, but long-term treatmentmay usefully start in an acute attack. Surgery isnot indicated urgently.

QUESTION 3

A TrueB FalseC TrueD TrueE FalseThere is no morphological abnormality inalactasia. Chronic radiation enteritis producesa submucosal endarteritic lesion and will notusually be detected in the more superficialspecimens obtained by peroral biopsy.

QUESTION 4

A FalseB TrueC TrueD TrueE TrueAppendicitis pain begins centrally. The peakfrequency of appendicectomy is in teenage andthe 20s, though perforation, peritonitis andappendix abscess are distributed throughoutthe age range. A history of appendicectomy iscommoner in Crohn's disease, which might beexplained by confusion of diagnosis. However,it is also commoner in ulcerative colitis wherethe association is harder to explain, but mighthave an immune basis.

QUESTION 5

A TrueB FalseC TrueD TrueE FalseBeta-blockers and nitrates are importantagents for primary and secondary prophylaxisof bleeding from varices. Nitrates used in con-junction with intravenous terlipressin in acutebleeding increase efficacy and reduce periph-eral side-effects. The clinical utility of the effectwith spironolactone is uncertain.

QUESTION 6

A FalseB FalseC TrueD TrueE FalseAlthough serum biochemistry tests are conven-iently grouped under 'liver function tests' theymay not reflect liver disease. Markedly raisedalkaline phosphatase with normal y-glutamyltransferase suggests a non-hepatic problem andPaget's disease is a common cause. Similarly, inbiliary and pancreatic disease these twoenzymes tend to rise together. Bone diseasemay lead to hypercalcaemia, particularly if thepatient is immobilised. The pattern of enzymesobserved is unlike acute hepatitis. The electro-cardiogram showed a inferior myocardialinfarction which had precipitated unconju-gated hyperbilirubinaemia in a patient withGilbert's syndrome and a background ofPaget's disease.

QUESTION 7

A FalseB FalseC FalseD FalseE TrueThe finding of melanosis coli, a distinct black-speckled pigmentation of the colonic mucosa,at sigmoidoscopy indicates regular use of anth-roquinone laxatives.

QUESTION 8

A TrueB FalseC FalseD TrueE FalsePancreatic calcification, when present, is diag-nostic of chronic pancreatitis and indicates adisease duration of greater than 10 years. In thefluorescein dilaurate test pancreatic lipasesplits fluorescein from the dilauric acid, and thefluorescein is absorbed and excreted in theurine where it is measured. Other causes ofmalabsorption are more likely to producehypoproteinamia and vitamin deficiency.