Internal Medicine - Esophagus and Gastric Diseases

Question 1

The “Alarm” signs of gastroesophageal reflux disease, except:
A) dysphagia
B) nausea
C) weight loss
D) anemia

Answer 1

B) nausea

EXPLANATION
In case of “Alarm” signs, the possibility of an oesophagus-narrowing malignancy should always be considered. These include dysphagia, weight loss and anemia. The exception is nausea.

Question 2

Oesophageal motility disorder in gastroesophageal reflux disease may be characterized as, except:

A) decreased basal tone of the lower oesophageal sphincter
B) transient relaxation of the lower oesophageal sphincter
C) increased clearance of the oesophagus
D) damage to the primary peristalsis function of the oesophagus
E) regular upper oesophageal sphincter relaxation

Answer 2

C) increased clearance of the oesophagus

EXPLANATION
In gastroesophageal reflux disease (GORB) is characterized by oesophageal motility disorders: decreased basal tone of the lower oesophageal sphincter, prolonged relaxation, increased incidence of transient (without swallowing occuring) relaxation, and damage to the primary peristalsis of the esophagus. Taken considered all characteristics above they result in a worsening (decrease) in esophageal clearance. The upper oesophageal sphincter and pharynx region are not affected by the motility disorder.

Question 3

May decrease oesophageal sphincter tone, except:

A) atropine
B) domperidone
C) glucagon
D) cholecystokinin
E) nifedipine

Answer 3

B) domperidone

EXPLANATION
Lower oesophageal sphincter tone is decreased by the other substances listed, with the exception of domperidone.

Question 4

There is no correlation between gastritis Helicobacter pylori gastritis and:

A) adenocarcinoma of the stomach
B) elevated gastrin levels
C) neutrophilic infiltration
D) perniciosis of anemia

Answer 4

D) perniciosis of anemia

EXPLANATION
Helicobacter pylori infection leads to chronic gastritis with neutrophilic granulocyte infiltration in the mucosa upon histological examination predominantly lymphocytic and plasma cell infiltration. Helicobacter-induced chronic gastritis may be associated with atrophy and intestinal metaplasia during progression. Atrophy in chronic gastritis can lead to adenocarcinoma through the following chain of events: atrophy → intestinal metaplasia → dysplasia. Helicobacter pylori infection may be confirmed in more than 50% of gastric adenocarcinomas. Atrophic gastritis in pernicious anemia is also a precancerous condition but the mechanism of its development is not related to Helicobacter pylori infection. Serum gastrin level is elevated in chronic gastritis caused by Helicobacter.

Question 5

The main proteolytic enzyme from gastric enzymes is:

A) gastric lipase
B) motilin
C) secretin
D) pepsin

Answer 5

D) pepsin

EXPLANATION
The main protein-degrading enzyme from gastric enzymes is pepsin. Pepsinogen secreted by the chief cells of the gastric mucosa is the inactive precursor of pepsin, which is converted into active pepsin in an acidic medium. The optimum pepsin effect is between pH 1.5 and 2.0, and primarily cleaves peptide bonds whose amino group is derived from phenylalanine or tyrosine. Gastric lipase, like pancreatic lipase, is a fat-breaking enzyme. Secretin is a hormone in the duodenum that stimulates pancreatic fluid volume and bicarbonate secretion and bile secretion. Motilin is also a gastrointestinal hormone isolated from the small intestinal mucosa. The main physiological effect of the hormone is considered to be the regulation of interdigestive intestinal motility.

Question 6

When are the most of gastric fluids produced from the daily 1,5 L?

A) between meals
B) in the cephalic phase
C) in the gastric phase
D) in the intestinal phase

Answer 6

C) in the gastric phase

EXPLANATION
More than half of the daily amount of gastric fluids are produced after a meal, the so-called gastric phase. The cephalic phase of gastric secretion is triggered by stimulation of the taste receptors in the mouth. The cephalic phase-secreted fluids were named by Pavlov as “appetite fluids.” During the intestinal phase and between meals, the amount of secreted gastric fluids are negligible compared to the gastric and cephalic phases.

Question 7

They increase the risk of developing gastric cancer, except:

A) anemia perniciosa
B) adenomatous polyp in the stomach
C) previous gastric surgery for ulcer
D) blood type B

Answer 7

D) blood type B

EXPLANATION
The risk of developing gastric cancer is increased by adenomatous polypus in the stomach, atrophic gastritis in pernicious anemia. In cases of gastric resection due to an ulcer 15 to 20 years earlier may lead to so-called gastric stump carcinomas.

Question 8

Determines the prognosis of gastric cancer, except:

A) stage of tumor growth
B) localization of the tumor
C) presence of stromafibrosis in the tumor tissue
D) degree of tumor differentiation

Answer 8

C) presence of stromafibrosis in the tumor tissue

EXPLANATION
The prognosis of gastric cancer is determined by the stage of tumor growth (TNM), tumor localization and histological type, including degree of differentiation.

Question 9

True for gastric lymphoma, except:

A) most of them are diffuse histiocytic lymphoma
B) lymphoma in the stomach is less frequent than in the colon
C) stage is the most important prognostic factor
D) may be associated with chronic gastritis, intestinal metaplasia

Answer 9

B) lymphoma in the stomach is less frequent than in the colon

EXPLANATION
The most common site of appearance of primary extranodal lymphomas is the gastrointestinal tract. In the stomach, lymphoma may be the primary manifestation, but it may be the result of infiltration from another area (approximately 30-50% in total). Low-grade malignancy, so-called MALT lymphomas are associated with chronic gastritis, intestinal metaplasia due to Helicobacter pylori. The regression observed after eradication of Helicobacter pylori emphasizes the pathogenetic role of the pathogen in the etiology of low-grade malignant MALT lymphomas. The most common histological type of gastric lymphoma is the diffuse histiocytic form. The best prognostic factor for the course of the disease is the Ann-Arbor staging established at detection.

Question 10

The following statements are true for gastric carcinoid tumors, except:

A) The stomach is the most common site for carcinoid tumors.
B) Carcinoid tumors of the stomach are randomly detected.
C) Gastric carcinoid tumors produce 5HT (serotonin).
D) Carcinoid tumor develops more frequent in the stomach in case of atrophic gastritis or in association with pernicious anemia.

Answer 10

A) The stomach is the most common site for carcinoid tumors.

EXPLANATION
The detection of gastric carcinoid tumors is random. The incidence of carcinoid in the stomach is rare (2-3% of gastrointestinal carcinoid cases). Carcinoid tumor often develops from atrophic gastritis and may be associated with pernicious anemia. Carcinoid tumors produce 5HT (serotonin).

Question 11

Which condition is not typical for the clinical appearance of Zollinger-Ellison syndrome?

A) Over 60% of patients experience heartburn.
B) Diarrhoea does not occur in the syndrome.
C) Hyperparathyroidism and hypercalcaemia may be associated with increased acid secretion in multiple endocrine neoplasia.
D) Ulcers appear at unusual location in the syndrome.

Answer 11

B) Diarrhoea does not occur in the syndrome.

EXPLANATION
The clinical syndrome caused by gastrin overproduction is called Zollinger-Ellison syndrome, characterized by the clinical triad of severe peptic ulcerations, extreme hyperacidity, and non-β-cell tumor of the pancreas. Gastrinoma grows approx. 50% in the endocrine islet cells of the pancreas, ca. 40% in the wall of the duodenum. The disease can occur at any age, ulcers are multiplex, have atypical localization (deep duodenum, jejunum), may recur after surgical resection, patient may complain about diarrhea or severe heartburn. The Zollinger-Ellison syndrome is part of approx. 20% of patients with multiplex endocrine adenomatosis type 1 (MEN-1). Neoplasm of the parathyroid gland is almost 100% prevalent in MEN-1 syndrome.

Question 12

Medications for gastroesophageal reflux disease, except:

A) proton pump inhibitors
B) prokinetic agents in monotherapy
C) proton pump inhibitors in combination with prokinetic agents
D) H2 receptor antagonists

Answer 12

B) prokinetic agents in monotherapy

EXPLANATION
The most cost-effective treatment for gastroesophageal reflux disease (GORB) is the use of proton pump inhibitors (PPIs). Prokinetic agents are nowadays not used at all in monotherapy. Their combination with PPI in the treatment of certain extraoesophageal manifestations of GORB may be considered. Currently, H2 receptor antagonists are used primarily in the maintenance of mild forms of GORB in the context of a step-down treatment strategy.

Question 13

A 53-year-old man was hospitalized with the following symptoms: epigastric pain, lower extremity oedema, diarrhea. Laboratory findings confirmed iron deficiency anaemia. The gastroscopy shows giant folds in the stomach. The trial breakfast shows reduced acid secretion. Biopsy taken from the deeper layer of the mucosa also shows no malignancy. Which disease is it?

A) Ménétrier disease
B) Stomach lymphoma
C) Zollinger-Ellison syndrome
D) Scleroderma

Answer 13

A) Ménétrier disease

EXPLANATION
Ménétrier disease or exsudative gastropathy is a rare disease of unknown origin, characterized by diffuse thickening of the gastric wall caused by excessive proliferation of the mucous membrane. In the stomach the macroscopic view of the stomach shows a huge, soft, swollen, curving mucous membrane that resembles the cerebral cortex. Microscopic features are elongated, convoluted glandular enlargement, cystic dilation, in which parietal cells are often replaced by cells resembling mucus or intestinal metaplastic cells. One of the most important clinical features is the loss of proteins through gastric lesions. This leads to oedema formation. In addition, patients often complain of epigastric pain and diarrhea. Unlike the Zollinger-Ellison syndrome, there are no multiple ulcers in the stomach. Diagnosis of gastric lymphoma can be confirmed histologically. In scleroderma, lesions develop in the gastrointestinal tract, primarily in the oesophagus and in the distal duodenum and proximal jejunum. It is not characterized by the image of these giant folds in the stomach.

Question 14

Which is the most common anemia after total gastrectomy?

A) iron deficiency
B) vitamin B12 deficiency
C) folate deficiency
D) hemolytic

Answer 14

B) vitamin B12 deficiency

EXPLANATION
The gastric mucosa produces the “intrinsic factor” essential for the absorption of vitamin B12, which is required for the production of red blood cells. Thus, after total gastrectomy, the most common anemia is vitamin B12 deficient anemia. Since iron is absorbed to a lesser extent in the stomach and to a greater extent in the duodenum and upper jejunum, gastrectomy alone does not lead to iron deficient anemia. Iron deficiency can have many causes; most commonly seen after blood loss or in chronic inflammatory or tumorous disease. Less commonly, iron deficiency may develop in intestinal absorption disorders. Folic acid deficiency and hemolytic anemia are also unrelated to total gastrectomy.

Question 15

All but one of the factors listed increase pepsinogen secretion:

A) somatostatin
B) gastrin
C) histamine
D) vagal stimulation

Answer 15

A) somatostatin

EXPLANATION
The most potent stimulus for pepsinogen release is vagal stimulation. Histamine primarily stimulates hydrochloric acid secretion but also significantly enhances pepsinogen secretion. Gastrin also enhances the secretion of pepsinogen. Somatostatin inhibits gastrin release and does not increase pepsinogen release.

Question 16

The key enzyme of hydrochloric acid secretion in the apical part of the capillary cells:

A) Na + -K + -ATPase
B) H + -K + -ATPase
C) tyrosine kinase
D) carbonic anhydrase

Answer 16

B) H + -K + -ATPase

EXPLANATION
The microscopic morphology of parietal cells is characterized by high levels of mitochondria and high levels of energy storage compounds (ATP) in the cells. These cellular components provide the hydrogen ions with about one million fold concentration in the opposite direction to the electron gradient. The proton pump (H + / K + -ATPase) is the enzyme that allows the H + and Cl - ions to be released from the cytosol. The energy required for hydrogen ion secretion is obtained from cells by hydrolysis of ATP. K + and bicarbonate motions also occur in synchronization with the hydrogen ion.

Question 17

The most common type of polyp in the stomach:

A) hyperplasiogen
B) adenomatosus
C) juvenile
D) carcinoid

Answer 17

A) hyperplasiogen

EXPLANATION
Polyps occurring in the stomach can be classified into epithelial and non-epithelial origin. Of the epithelial origin, hyperplasic polyps are the most common, and usually develop in the antrum. During their growth, they might rarely show adenomatous transformation.

Question 18

Peptic ulcer diseases, except:

A) NSAID ulcer
B) KCI ulcer
C) Helicobacter-positive ulcer
D) Zollinger-Ellison syndrome

Answer 18

B) KCI ulcer

EXPLANATION
Peptic ulcers include ulcers due to Helicobacter pylori infection, Zollinger-Ellison syndrome, and adverse reactions to non-steroidal anti-inflammatory therapy. In these types of ulcers, despite the various pathogenetic factors, anatomical lesion is due to the digestive action of hydrochloric acid pepsin, and these ulcers are called peptic ulcers. The mechanism of KCl ulcer is different.

Question 19

Factors that are known to play a role in the pathogenesis of classical peptic ulcer disease, except:

A) stress
B) smoking
C) Helicobacter pylori
D) viral infection

Answer 19

D) viral infection

EXPLANATION
Classical peptic ulcer disease is a multifactorial disease, Helicobacter pylori infection is considered one of the most important pathogenetic factors today. In addition, stress, hyperacidity, smoking, etc. play an important role in the development of ulcer disease.

Question 20

Typical site for Helicobacter pylori colonization:

A) antrum
B) antrum-corpus border
C) fundus
D) duodenum

Answer 20

A) antrum

EXPLANATION
A typical site for Helicobacter pylori colonisation is the antrum. Among the pathogenetic factors indispensable for colonisation, the pathogen’s urease activity, appropriate motility and adhesion can be highlighted. The enzyme urease plays a central role in protecting the bacterium from hydrochloric acid and creating the alkaline microenvironment for colonization.

Question 21

Characteristics of NSAID ulcers, except:

A) mild dyspepsic complaints
B) relatively poor symptoms
C) typical hunger pain
D) tendency to bleed, perforate

Answer 21

C) typical hunger pain

EXPLANATION
As a side effect of the widespread use of NSAIDs, the number of drug-induced ulcers has increased remarkably. NSAID ulcers are characterized by a relative asymptomatic appearance, often without any complaints (silent ulcers), or by reference to mild dyspepsic complaints. NSAID ulcers usually appear when complications occur (bleeding and perforation).

Question 22

The most common localization of NSAID ulcers is:

A) esophagus
B) stomach
C) duodenum
D) jejunum

Answer 22

B) stomach

EXPLANATION
NSAID-induced mucosal damage includes erosions and ulcers. The former is common during the initial stages of NSAID treatment, and NSAID-induced ulcers usually occur during prolonged treatment. NSAID-induced ulcers are predominantly found in the stomach, as opposed to more frequent duodenal localization of classical Helicobacter pylori infection, and their duodenal localization is much less frequent.

Question 23

Mechanisms involved in the formation of NSAID ulcers, except:

A) inhibition of the synthesis of protective prostaglandins
B) an increase in the blood supply to the gastric mucosa
C) activation of the lipoxygenase pathway
D) an increase in hydrochloric acid secretion

Answer 23

B) an increase in the blood supply to the gastric mucosa

EXPLANATION
In addition to their anti-inflammatory activity, NSAIDs play an important role in mucosal defense. They inhibit cyclooxygenase isoenzyme activity (COX-1), which is responsible for the synthesis of protective prostaglandins (PGE2, PGI). Damage to protective factors in ulcer formation is a critical mechanism, but activation of the lipoxygenase pathway (formation of leukotrienes) and increased gastric acid secretion also play a role in anatomical lesion formation.

Question 24

The most common localization of gastrinoma is:

A) pancreas
B) duodenum
C) jejunum
D) appendix

Answer 24

A) pancreas

EXPLANATION
Of the neuroendocrine tumors of the gastrointestinal tract, gastrinomas are most frequently (30-60%) located in the pancreas.

Question 25

The most specific diagnostics in Zollinger-Ellison syndrome is:

A) determination of hydrochloric acid secretion
B) X-ray of the stomach
C) secretin-provocation test with serum-gastrin assay
D) endoscopy

Answer 25

C) secretin-provocation test with serum-gastrin assay

EXPLANATION
The most specific diagnostics of Zollinger-Ellison syndrome is the secretin provocation test with serum gastrin.

Question 26

Methods used nowadays to treat Zollinger-Ellison ulcer, except:

A) total gastrectomy
B) H2 receptor blocking agents
C) proton pump inhibitors (PPIs)
D) removal of the gastrinoma

Answer 26

A) total gastrectomy

EXPLANATION
Methods used to treat ulcer in Zollinger-Ellison syndrome: administration of proton pump inhibitors and H2 receptor blockers, according to the severity of the condition. Due to the efficacy of these drugs, we do not perform total gastrectomy today. In the case of known tumor localization, the causal treatment is removal of the gastrinoma.

Question 27

In gastroesophageal reflux disease, the endoscopic view of the esophagus may be:

1) diffuse mucosal hyperaemia
2) mucosal ulcers in the lower third of the esophagus
3) isolated linear erosion over cardia
4) intact esophageal epithelium

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 27

E) all of the answers are correct

EXPLANATION
In GORB, the endoscopically visible (macroscopic) image of the oesophagus may show intact epithelium (non-erosive reflux disease), oesophagitis of various stages (erosive reflux disease), or gastric mucosa (cardiac metaplasia). Erosive reflux disease can be classified into different stages. The stage classification currently used worldwide is based on the Los Angeles classification.

Question 28

Used for the diagnosis of gastroesophageal reflux disease:

1) proton pump inhibitor test
2) esophageal impedance test
3) 24-hour oesophageal pH monitoring
4) pentagastric test

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 28

A) only answers 1, 2 and 3 are correct

EXPLANATION
In addition to the proton pump inhibitor test, which is a basic method in GORB diagnostics, and the 24-hour intra-oesophageal pH monitoring, the oesophageal function test, which has high specificity, although not yet routine, can be used to confirm both weak acidic and non-acidic reflux. for separating liquid and gas reflux. The pentagastric test, which reveals the acidity of the stomach, is not suitable for the diagnosis of GORB.

Question 29

It may not favorably affect the symptoms of diffuse oesophageal spasm:

1) diltiazem
2) glyceryl trinitrate
3) nifedipine
4) ranitidine

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 29

D) only answer 4 is correct

EXPLANATION
Symptoms of diffuse esophageal spasm may be favorably affected by the listed Ca-channel blocking agents (diltiazem, nifedipine) and NO donor (glyceryl trinitrate). The H2 receptor antagonist ranitidine, which inhibits gastric acid secretion, has no effect on symptoms.

Question 30

Increases the incidence of oesophageal epithelial cell carcinomas:

1) Barrett’s metaplasia
2) achalasia cardiae
3) nutcracker esophagus
4) smoking

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 30

C) only answers 2 and 4 are correct

EXPLANATION
Among the listed answers, achalasia and smoking are factors that increase the incidence of oesophageal epithelial cell carcinomas. Barrett’s metaplasia (intestinal type), on the other hand, is precancerous to adenocarcinoma. Walnut-esophagus is a primary motility disorder of the oesophagus and does not present an increased risk of malignant neoplasm of the oesophagus.

Question 31

Important in staging esophageal carcinomas:

1) chest CT scan
2) oesophageal endosonography
3) endoscopy by histological examination
4) barium swallow test

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 31

A) only answers 1, 2 and 3 are correct

EXPLANATION
Among the listed answers, endoscopic examination supplemented with histological examination and chest CT examination with information on extraluminal propagation play an important role. In addition, the oesophageal endosonographic examination listed here is essential to accurately determine the local extent of the process. Conventional barium swallow testing is irrelevant to staging.

Question 32

Gastrointestinal side effects of NSAIDs include:

1) Non-steroidal anti-inflammatory drugs (NSAIDs) cause gastric mucosal damage by inhibition of protective prostaglandins.
2) Mortality due to gastrointestinal complications is 3-4 times higher in chronic NSAID users.
3) NSAIDs can cause erosions and ulcers.
4) NSAID ulcers always cause intense pain.

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 32

A) only answers 1, 2 and 3 are correct

EXPLANATION
NSAIDs exert their anti-inflammatory activity by inhibiting the synthesis of prostaglandins. The agents thus also cause inhibition of PGE2 and PGI, which play an important role in protecting the gastrointestinal mucosa. Thus, NSAIDs cause gastric mucosal damage by inhibiting the synthesis of protective prostaglandins. In many cases, chronic NSAID users develop ‘silent ulcers’, and these ulcers are diagnosed only when complications (perforation, bleeding) occur. At this time, mortality due to these complications, especially in the older population, may increase by 3 to 4 times. By inhibiting the synthesis of “protective” prostaglandins, NSAIDs can cause mucosal damage, including erosions and ulcers. NSAID-induced ulcers are usually asymptomatic and often silent. The first 3 statements are true, the last statement is not true.

Question 33

Characteristics of the duodenal ulcer:

1) hunger pain
2) is more common than gastric ulcer with NSAIDs treatment
3) can cause pylorusstenosis
4) never penetrates the surrounding organs

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 33

B) only answers 1 and 3 are correct

EXPLANATION
One of the most common symptoms of duodenal ulcers is hunger pain, which in practice means that the pain usually occurs between 1/2-1 hour after a meal or when the stomach is empty. Gastric acid plays a crucial role in the development of pain. Meals bind stomach acid, and after eating, symptoms typically decrease or disappear. Gastric ulcer is more common than duodenal ulcer with NSAID treatment. Due to the location of the duodenal ulcer, it can cause pylorusstenosis more frequently than gastric ulcers. Duodenal ulcer can mainly penetrate the pancreas. So, answers 1 and 3 are correct.

Question 34

The effects of proton pump inhibitors are true:

1) Proton pump inhibitors act on the H + / K + -ATPase pump.
2) PPIs significantly increase serum gastrin levels.
3) They are among the basic drugs for Helicobacter pylori eradication schemes.
4) It should not be administered with NSAIDs due to drug interactions.

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 34

A) only answers 1, 2 and 3 are correct

EXPLANATION
Proton pump inhibitors act by inhibiting the enzyme H + / K + -ATPase. Because they inhibit the activity of the H + / K + -ATPase enzyme, thus causing the inhibition of hydrochloric acid secretion, which leads to an increase in serum gastrin levels through a feedback mechanism. Proton pump inhibitors are one of the basic drugs for Helicobacter pylori eradication schemes. There is no drug interaction when combining proton pump inhibitors with NSAIDs, and in fact, the most effective treatment for treating NSAID-induced ulcers is the use of proton pump inhibitors. The first 3 answers are correct.

Question 35

In the treatment of peptic ulcer disease:

1) All H2 blocker is effective in treating peptic ulcer.
2) H2 blockers are usually given 3 times a day before main meals.
3) PPIs reduce ulcer pain faster than H2 blockers.
4) PPIs and H2 blockers are usually cured within 2-4 weeks.

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 35

B) only answers 1 and 3 are correct

EXPLANATION
The use of H2 blockers and proton pump inhibitors is both accepted in the treatment of peptic ulcer disease. H2 blockers are usually given twice daily, and in many cases a single evening administration is sufficient. Proton pump inhibitors reduce ulcer pain more rapidly than H2 blockers through a more potent antacid effect and generally heal ulcers faster than H2 blockers. Answers 1 and 3 are correct.

Question 36

Think of malignant stomach cancer:

1) if patient has a history of epigastric pain and significant weight loss.
2) if the patient has meat aversion.
3) if epigastric resistance is palpable.
4) if the patient is anacid and the Virchow gland is palpable.

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 36

E) all of the answers are correct

EXPLANATION
Signs of malignant gastric cancer include history of significant weight loss, meat aversion, epigastric pain, physically palpable epigastric resistance, enlarged supraclavicular lymph node in the left supraclavicular region (Virchow gland) and anacidity based on lab results.

Question 37

In case of suspected recurrent gastric ulcer:

1) it is sufficient to perform an x-ray of the stomach.
2) gastroscopic examination is preformed to confirm Helicobacter pylori infection.
3) anti-ulcer therapy can be started without examination.
4) because of the tendency of ventricular ulcer to malignancy, gastroscopic examination should be performed for histological sampling.

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 37

C) only answers 2 and 4 are correct

EXPLANATION
Gastric ulcer may develop malignancy. In the case of gastric ulcer, a histological examination should always be performed to exclude or confirm the suspicion of malignancy. Of course, this principle also applies to recurrent gastric ulcer. According to the above, an X-ray of the stomach is not sufficient. During gastroscopic examination, it is possible to obtain a sample for the detection of Helicobacter pylori, which may help to establish the etiological diagnosis. Only after these tests have been completed may anti-ulcer therapy be initiated. Answers 2 and 4 are correct.

Question 38

The following diseases and conditions may be associated with gastroparesis:

1) multiple sclerosis
2) diabetes mellitus
3) hypokalaemia
4) Parkinson’s disease

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 38

E) all of the answers are correct

EXPLANATION
It is known that hypokalaemia can lead to an increase in muscle weakness to paralysis, which can affect both the striated and smooth muscles, leading to gastroparesis. Gastroparesis can also be observed in diabetes mellitus, in which both diabetic neuropathy and the high blood glucose-depressant effect on gastric emptying play a role. In rare cases, gastroparesis is also found in neurological diseases (multiple sclerosis and Parkinson’s disease). All 4 answers are correct.

Question 39

Most important things to do in case of upper gastrointestinal bleeding:

1) stabilizing the circulation with fluid and, if necessary, blood supplementation
2) gastric tube insertion, gastric lavage
3) gastroscopy to localize the source of bleeding, if possible
4) immediate administration of PPI or H2 blocker orally to reduce acid secretion

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 39

A) only answers 1, 2 and 3 are correct

EXPLANATION
In the case of upper gastrointestinal bleeding, the most important thing is to compensate for the volume loss caused by the bleeding and to stabilize the circulation with fluid and, if necessary, blood supplementation. In addition, it is important to insert the gastric tube to clean the stomach and drain stagnant blood. Subsequently, after proper preparation, gastroscopy can be performed to localize the source of the bleeding and for possible endoscopic intervention. In the case of gastric bleeding, oral antacid therapy is ineffective and unnecessary. If a secretory inhibitor treatment is to be used, it should be administered parenterally. The first 3 answers are correct.

Question 40

If gastric ulcer perforation is suspected:

1) gastroscopic examination should be performed immediately
2) physical examination shows the absence of liver dullness
3) barium gastric x-ray should be performed immediately
4) native abdominal imaging should be performed immediately

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 40

C) only answers 2 and 4 are correct

EXPLANATION
In the case of suspected gastric ulcer perforation, native abdominal imaging is the diagnostic method of choice, confirming perforation of the hollow organ by detecting abdominal open air. Physical examination shows the disappearance of liver dullness. In the case of suspected perforation, barium (non-absorbable contrast) radiology is contraindicated. We do not perform endoscopic examination either.

Question 41

In case of haematemesis oesophageal varices should be considered in the following diseases:

1) cirrhosis hepatis
2) v. portae thrombosis
3) an advanced stage of Budd-Chiari syndrome
4) oesophageal cancer

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 41

A) only answers 1, 2 and 3 are correct

EXPLANATION
The most common source of haematemesis is oesophageal haemorrhagic rupture in cirrhosis hepatitis, venous portae thrombosis, and Budd-Chiari syndrome.

Question 42

The disturbance of gastric emptying may be caused by:

1) pylorus stenosis caused by duodenal ulcer
2) antrum tumor spreading to pylorus
3) large pancreas pseudocyst
4) liver cirrhosis

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 42

A) only answers 1, 2 and 3 are correct

EXPLANATION
The most common organic diseases causing disturbance in the emptying of the stomach are scarring caused by duodenal ulcer, pylorusstenosis due to oedemic spasm, gastric malignancies that infiltrate the pylorus and the antrum. Large pancreatic pseudocysts due to extraventricular compression may also lead to disturbance of gastric emptying.

Question 43

The following substances enhance gastric secretion:

1) gastrin
2) caffeine
3) histamine
4) somatostatin

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 43

A) only answers 1, 2 and 3 are correct

EXPLANATION
Gastric acid secretion is enhanced by gastrin, histamine and caffeine. In clinical practice, pentagastrin is used nowadays to quantitatively determine gastric acidity conditions, which has replaced the trial of histamine or caffeine. Somatostatin inhibits gastric acid secretion and the release of several gastrointestinal hormones, including gastrin.

Question 44

It is true that:

1) CEA and AFP play a prominent role in the early diagnosis of gastric cancer.
2) Ectopic gastric mucosa can occur in almost any area of the gastrointestinal tract without clinical significance.
3) Gastric cancer has characteristic early symptoms.
4) Gastric cancer may be classified into two main groups according to its histological division: intestinal and diffuse gastric cancer.

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 44

D) only answer 4 is correct

EXPLANATION
Gastric cancer is a malignant disease that develops without characteristic early symptoms. Tumor markers (CEA, AFP) have no role in early diagnosis. Gastric cancers fall into two main histopathological groups: intestinal and diffuse gastric cancers.

Question 45

Which of the following is the most likely diagnosis?

A 48-year-old non-smoking, abstinent woman turns to you for having increased swallowing difficulties for half a year, weight loss, unpleasant mouth odor and frequent regurgitation of undigested food.

A) corrosive stricture
B) bulbar palsy
C) gastroesophageal reflux disease
D) achalasia cardiae
E) nutcracker esophagus

Answer 45

D) achalasia cardiae

EXPLANATION
Of these, the most likely diagnosis is achalasia cardiae. This primary esophageal dysfunction of the esophagus, for unknown reasons, is characterized by cardiac relaxation failure and severe damage to the esophageal peristalsis due to the destruction of neurons of the myenteric plexus. Most frequent age of onset is from 3rd to 6th decades of life. Common symptoms include difficulty in swallowing, regurgitation of undigested food, unpleasant mouth odor, and weight loss due to malnutrition. The onset of the disease is independent of anamnestic alcohol consumption and smoking. According to anamnesis, corrosive stricture is unlikely to be consumed according to the lack of corrosive material consumption in the patient’s history. Bulbar parlsy would be characterized by the icterus-like onset and very frequent aspiration. Reflux disease is unlikely by the absence of heartburn and acid regurgitation and diagnosis of a nutcracker oesophageal is unlikely due to the absence of chest pain during swallowing and frequent regurgitation of undigested food.

Question 46

What did your barium swallow test result show based on the above diagnosis?

A 48-year-old non-smoking, abstinent woman turns to you for having increased swallowing difficulties for half a year, weight loss, unpleasant mouth odor and frequent regurgitation of undigested food.

1) dilated esophagus
2) spastic esophageal contractions
3) cardia for drinking cold, cold water
4) uneven constriction over cardia

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 46

B) only answers 1 and 3 are correct

EXPLANATION
Diagnosis of Achalasia cardiae is confirmed when a barium swallow test confirms dilated, aperistaltic esophageal body and narrow, upon cold water drinking opening cardia. The uneven narrowing of the cardia in itself but in combination with vigorous (spastic) progressive contractions, further raises the possibility of a malignant process. Intermittent, non-progressive, spastic contractions with preserved cardiac function may indicate other primary esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus).

Question 47

What further examinations may confirm the above diagnosis?

A 48-year-old non-smoking, abstinent woman turns to you for having increased swallowing difficulties for half a year, weight loss, unpleasant mouth odor and frequent regurgitation of undigested food.

1) endoscopy
2) standard acid reflux test
3) esophageal manometry
4) 24-hour oesophageal pH monitoring

A) only answers 1, 2 and 3 are correct
B) only answers 1 and 3 are correct
C) only answers 2 and 4 are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 47

B) only answers 1 and 3 are correct

EXPLANATION
Diagnosis of achalasia cardiae is confirmed by endoscopic examination to exclude malignant stenosis. Oesophageal manometry can be used to confirm motility disorder, thus the test is the cornerstone of diagnosis.

Question 48

Possible means of treatment, except:
A 48-year-old non-smoking, abstinent woman turns to you for having increased swallowing difficulties for half a year, weight loss, unpleasant mouth odor and frequent regurgitation of undigested food.

A) diltiazem
B) pneumatic dilatation
C) metoprolol
D) nitroglycerin
E) cardiomyotomy

Answer 48

C) metoprolol

EXPLANATION
Among the listed answers, Ca-channel blocking diltiazem, NO donor nitroglycerin are elements of conservative drug therapy, pneumatic dilation, invasive endoscopic therapy and cardiomyotomy are elements of surgical management. The cardioselective β-receptor blocker metoprolol has no effect on cardiac or oesophageal function and is therefore not expected to have a therapeutic effect on achalasia cardiae.