LE4 Flashcards
- True about HBsAg, except:
A. Present in the entire icteric phase
B. Present beyond 6 months
C. When HBsAg disappears, anti-HBs appears
D. First virologic marker in acute Hepatitis B infection
B. Present beyond 6 months
Rationale: HBsAg is an indicator of acute Hepatitis B during the symptomatic phase. If it persists beyond 6 months, it indicates chronic infection, not acute. Therefore, this is the incorrect statement.
- True about Hepatitis A infection, except:
A. Virus replication occurs in the liver, bone marrow, and spleen
B. Anti-HAV IgM persists until 3 months of acute infection
C. Anti-HAV IgG persists indefinitely and protects against reinfection
D. Hepatitis A infection leads to chronic disease
A. Virus replication occurs in the liver, bone marrow, and spleen
Rationale: Hepatitis A virus primarily replicates in the liver. It does not replicate in the bone marrow or spleen. Thus, this is the false statement.
- Which of the following is a DNA virus?
A. Hepatitis E
B. Hepatitis C
C. Hepatitis B
D. Hepatitis A
C. Hepatitis B
Rationale: Hepatitis B virus (HBV) belongs to the Hepadnaviridae family and is a DNA virus. Hepatitis A, C, and E are RNA viruses.
- Which of the following causes dose-related centrilobular hepatic necrosis?
A. Acetaminophen
B. Isoniazid
C. Alcohol
D. Valproate
A. Acetaminophen
Rationale: Acetaminophen toxicity causes dose-related centrilobular hepatic necrosis due to the accumulation of its toxic metabolite NAPQI when glutathione is depleted.
- The toxic byproduct of acetaminophen metabolism responsible for centrilobular hepatic necrosis is:
A. NAPQI
B. Glutathione
C. Cytochrome P450
D. Acetic acid
A. NAPQI
Rationale: N-acetyl-p-benzoquinone imine (NAPQI) is the toxic metabolite of acetaminophen that causes hepatic necrosis.
- A 30-year-old female developed jaundice over the past 3 weeks. The following results of her hepatitis profile were noted:
(+) Anti-HAV IgM, (+) HBsAg, (–) Anti-HBc IgM, (–) Anti-HCV. What is your diagnosis?
A. Acute Hepatitis B superimposed on chronic Hepatitis A
B. Acute Hepatitis A superimposed on chronic Hepatitis B
C. Acute Hepatitis A
D. Acute co-infection with Hepatitis A and Hepatitis B
B. Acute Hepatitis A superimposed on chronic Hepatitis B
Rationale: The presence of anti-HAV IgM indicates acute Hepatitis A. The positive HBsAg with a negative anti-HBc IgM suggests chronic Hepatitis B. This indicates acute Hepatitis A superimposed on chronic Hepatitis B.
- A 40-year-old male underwent a hepatitis profile for employment purposes. The following results were noted:
(–) HBsAg, (+) Anti-HBs, (–) Anti-HBc. How will you interpret this?
A. Patient had immunization against Hepatitis B
B. Resolved acute Hepatitis B infection
C. Acute Hepatitis A superimposed on chronic Hepatitis B
D. Chronic Hepatitis B infection
B. Patient had immunization against Hepatitis B
Rationale: A negative HBsAg, a positive anti-HBs, and a negative anti-HBc indicate immunity from vaccination. Natural infection would show both anti-HBs and anti-HBc.
- Anemia associated with bacterial overgrowth syndromes:
A. Normocytic normochromic anemia
B. Macrocytic anemia due to cobalamin deficiency
C. Macrocytic anemia due to folate deficiency
D. Microcytic hypochromic anemia due to iron deficiency
B. Macrocytic anemia due to cobalamin deficiency
Rationale: Bacterial overgrowth in the small intestine can deplete cobalamin (Vitamin B12), leading to macrocytic anemia.
- Symptomatic Hepatic Panlobar Infiltration refers to:
A. Centrilobular distribution typical of smokers
B. Entire acinus involvement, more severe in lower lobes
C. Isolated macrovesicular steatosis
D. Nodular fibrosis without inflammation
B. Entire acinus involvement, more severe in lower lobes
Rationale: “Panlobar” refers to the involvement of the entire acinus, contrasting with centrilobular involvement. It affects the lower lobes more severely, often seen in smokers.
- Differential diagnosis of hepatic disease includes all except:
A. Left-sided heart failure
B. Viral hepatitis
C. Alcoholic hepatitis
D. Primary biliary cholangitis
A. Left-sided heart failure
Rationale: Left-sided heart failure primarily causes pulmonary congestion rather than liver dysfunction. Hepatic congestion is more associated with right-sided heart failure.
- The serologic marker of past Hepatitis B infection, detectable indefinitely, is:
A. HBsAg
B. Anti-HBc IgM
C. Anti-HBs
D. HBeAg
C. Anti-HBs
Rationale: Anti-HBs is the protective antibody formed after recovery from infection or vaccination. It is detectable indefinitely and indicates past infection or immunity.
- Which of the following is consistent with fulminant hepatitis?
A. May present with cerebral hemorrhage and cardiovascular collapse
B. Prothrombin time is excessively shortened
C. The liver is small, and bilirubin levels may be high
D. It is the most feared and most common complication of Hepatitis A
C. The liver is small, and bilirubin levels may be high
Rationale: Fulminant hepatitis leads to rapid hepatic necrosis, causing a small liver (shrunken from cell death) and high bilirubin levels due to impaired liver function.
- Which symptom is not an indication for duodenal ulcer surgery?
A. Chronic gastric pain
B. Bleeding
C. Perforation
D. Obstruction
A. Chronic gastric pain
Rationale: Chronic gastric pain alone is managed medically. Surgical indications include bleeding, perforation, and obstruction.
- What is a complication of parenteral nutrition?
A. Dyslipidemia
B. Renal failure
C. Iron deficiency
D. Liver failure
A. Dyslipidemia
Rationale: Parenteral nutrition can lead to metabolic complications like dyslipidemia, hyperglycemia, and liver issues due to improper nutrient balance.
- Which of the following is not a classic presentation of acute appendicitis?
A. Pain subsequently migrates to the right lower quadrant
B. Vague, intermittent, crampy abdominal pain in the epigastric or periumbilical region
C. Loss of appetite
D. Nausea occurs before the onset of abdominal symptoms
D. Nausea occurs before the onset of abdominal symptoms
Rationale: In acute appendicitis, nausea typically occurs after the onset of abdominal pain, distinguishing it from other gastrointestinal conditions like gastroenteritis.
- Which symptom makes acute appendicitis uncomplicated?
A. Local muscle rigidity and stiffness
B. Patient develops jaundice
C. Pain migrates to the right lower quadrant
D. Patient becomes febrile
C. Pain migrates to the right lower quadrant
Rationale: Migration of pain to the right lower quadrant is a classic sign of uncomplicated appendicitis. Other symptoms like fever and rigidity may indicate complications.
- Which type of hiatal hernia will lead to an upside-down stomach?
A. Type I or Sliding Hernia
B. Type IV
C. Type II and III
D. None of the above
C. Type II and Type III
Rationale: Type II (paraesophageal) and Type III (mixed) hiatal hernias can cause the stomach to invert and herniate into the mediastinum, leading to an upside-down stomach appearance.
- A 40-year-old had intermittent food impaction while eating. Steakhouse syndrome is caused by:
A. Esophageal Atresia
B. Esophageal Web
C. Schatzki Rings
D. None of the above
C. Schatzki Rings
Rationale: Schatzki rings are mucosal rings in the lower esophagus that can cause intermittent dysphagia and food impaction (Steakhouse syndrome) when under-chewed food gets stuck.
- Mr. C, a 22-year-old male, presents with progressively worsening abdominal pain, initially diffuse and now localized to the right lower quadrant. On examination, he is afebrile but has moderate tenderness without rebound or guarding. What imaging modality is recommended?
A. Abdominal CT Scan
B. Abdominal MRI
C. Abdominal Ultrasound
D. Abdominal Radiograph
A. Abdominal CT Scan
Rationale: CT scan is the most appropriate imaging modality for evaluating suspected appendicitis due to its high specificity and ability to detect complications like an appendicolith or abscess.
- Mr. C, the same patient, is found to have a hypodense fluid collection and an appendicolith on CT scan. Which of the following interventions is NOT indicated in his management?
A. Mechanical Ventilation and Support
B. Initiation of Fluid Restriction
C. Urgent Appendectomy
D. Broad-Spectrum Antibiotics
A. Mechanical Ventilation and Support
Rationale: In the management of appendicitis, mechanical ventilation is unnecessary unless the patient is critically ill or undergoing surgery under anesthesia. Fluid resuscitation, antibiotics, and appendectomy are the appropriate interventions.
- Which of the following is the most common cause of hematochezia in patients older than 60 years?
A. Hemorrhage of Colonic Diverticulum
B. Malignancy
C. Bleeding Internal Hemorrhoids
D. Upper Gastrointestinal Bleeding
A. Hemorrhage of Colonic Diverticulum
Rationale: Diverticular bleeding is the most common cause of hematochezia in older adults, as diverticula are prevalent in this age group.
- Which of the following symptoms is not a common presentation of symptomatic uncomplicated diverticular disease?
A. Left Lower Quadrant Pain
B. Anorexia
C. Fever
D. Constipation
D. Constipation
Rationale: While diverticular disease commonly presents with left lower quadrant pain, fever, and anorexia, constipation is less common and not typically part of uncomplicated cases.
- Which type of hiatal hernia will lead to an upside-down stomach?
A. Type I or Sliding Hiatal Hernia
B. Type IV
C. Type II and Type III
D. None of the above
C. Type II and Type III
- A 40-year-old had intermittent food impaction while eating. Steakhouse syndrome is caused by:
A. Esophageal Webs
B. B Rings
C. Schatzki Rings
D. None of the above
C. Schatzki Rings
- Which of the following does not require antibiotics for an anorectal abscess?
A. Immunocompromised Patients
B. Patients with Coronary Artery Disease
C. Patients with Prosthetic Heart Valves
D. Diabetic Patients
B. Patients with Coronary Artery Disease
Rationale: Antibiotics are warranted for immunocompromised patients, diabetics, or those with prosthetic heart valves. Coronary artery disease alone does not require antibiotics.
- Application of nifedipine ointment is a management for:
A. Anal Fissure
B. Hemorrhoids
C. Fistula-in-Ano
D. Pilonidal Sinus
A. Anal Fissure
Rationale: Nifedipine ointment reduces anal sphincter pressure, promoting healing of chronic anal fissures.
- Which of the following statements is true of irritable bowel syndrome (IBS)?
A. IBS patients may have genetic disorders affecting the serotonin transport system
B. None of the above
C. All of the above
D. IBS patients have increased anxiety and depression
E. The cause of IBS is multifactorial
C. All of the above
Rationale: IBS is multifactorial, involving genetic predisposition, altered serotonin transport, and increased psychological issues like anxiety and depression, all contributing to the condition.
- The most common congenital esophageal anomaly is:
A. Esophageal Atresia
B. Esophageal Web
C. Schatzki Rings
D. Fibroid Polyps
A. Esophageal Atresia
Rationale: Esophageal atresia is the most common congenital anomaly of the esophagus, often associated with tracheoesophageal fistula.
- A recent kidney transplant patient complains of odynophagia and chest pain. Endoscopy shows serpiginous ulcers in the distal esophagus. The ulcer bases had large nuclear and cytoplasmic inclusion bodies. Which of the following treatments is recommended for the described condition?
A. Acyclovir
B. Ganciclovir
C. Oral Prednisolone
D. Swallowed Topical Steroids
B. Ganciclovir
Rationale: The described ulcers with large nuclear and cytoplasmic inclusion bodies indicate CMV (Cytomegalovirus) esophagitis, which is common in immunosuppressed patients and treated with Ganciclovir.
- Which of the following mitigates or lessens the severity of esophagitis?
A. Pancreatic Enzymes
B. Zollinger-Ellison Syndrome
C. Atrophic Gastritis
D. Bile
C. Atrophic Gastritis
Rationale: Atrophic gastritis leads to reduced acid production, which can decrease the severity of esophagitis by reducing acid reflux into the esophagus.
- Which of the following conditions is not associated with Helicobacter pylori infection?
A. Gastric Cancer
B. Duodenal Ulcer
C. Esophageal Squamous Cell Carcinoma
D. MALT Lymphoma
C. Esophageal Squamous Cell Carcinoma
Rationale: H. pylori is associated with gastric cancer, duodenal ulcers, and MALT lymphoma but not with esophageal squamous cell carcinoma.
- Mr. Santos, a cigarette smoker, is awakened at night by pain in the epigastric area that radiates to his back and is relieved by eating. He most likely has:
A. GERD
B. Gastric Ulcer
C. Duodenal Ulcer
D. Gastritis
C. Duodenal Ulcer
Rationale: Duodenal ulcer pain typically improves with food, whereas gastric ulcer pain worsens after eating. Nighttime pain is also characteristic of duodenal ulcers.
- Which of the following is a DNA virus?
A. Hepatitis E
B. Hepatitis C
C. Hepatitis B
D. Hepatitis A
C. Hepatitis B
Rationale: Hepatitis B is a DNA virus from the Hepadnaviridae family. Hepatitis A, C, and E are RNA viruses.
- Which of the following statements about Hepatitis C is incorrect?
A. Hepatitis C co-infects and requires the helper function of Hepatitis B virus for its replication
B. Hepatitis C infection is a leading cause of liver cirrhosis
C. Hepatitis C is an RNA virus transmitted via blood and body fluids
D. Hepatitis C can lead to hepatocellular carcinoma
A. Hepatitis C co-infects and requires the helper function of Hepatitis B virus for its replication
Rationale: This statement is false because Hepatitis D (HDV), not Hepatitis C, requires Hepatitis B for its replication. Hepatitis C is an independent RNA virus.
- Mr. Y underwent surgery and now experiences which of the following as a possible side effect?
A. Constipation
B. Hypertension
C. Increase in blood sugar
D. Diarrhea
D. Diarrhea
Rationale: Post-surgical diarrhea can occur due to dumping syndrome, especially in patients who have undergone gastric or bowel surgeries, as rapid gastric emptying affects the digestive process.
- Mr. Z underwent endoscopy, which revealed ulcers forming. What is the best initial screening test for Helicobacter pylori?
A. Urea Breath Test
B. Biopsy
C. CT Scan
D. MRI
A. Urea Breath Test
Rationale: The urea breath test is a non-invasive and accurate initial screening for H. pylori infection. Biopsy, though definitive, is more invasive and not a screening test.
- A 50-year-old man experiences occasional vomiting. Upper GI endoscopy reveals loss of rugal folds. An upper GI endoscopy 5 years ago revealed chronic inflammation of a small area. What is the most likely condition?
A. Atrophic Gastritis
B. Peptic Ulcer Disease
C. Gastric Adenocarcinoma
D. Zollinger-Ellison Syndrome
A. Atrophic Gastritis
Rationale: Loss of rugal folds is characteristic of atrophic gastritis, where chronic inflammation leads to thinning of the gastric mucosa and loss of normal gastric architecture.
- All of the following are risk factors for Alcoholic Liver Disease, except:
A. Gender
B. Fatty Liver
C. HIV Infection
D. HCV Infection
C. HIV Infection
Rationale: HIV infection itself is not a direct risk factor for alcoholic liver disease. Risk factors include gender (males), fatty liver, and HCV infection, which can exacerbate liver damage.
- Which of the following statements is correct regarding the pathogenic mechanism of alcoholic liver disease?
A. Ethanol consumption increases adipose tissue mass by enhancing fat breakdown
B. Intestinal-derived endotoxin initiates a pathogenic process through toll-like receptor 4 and tumor necrosis factor
C. Alcohol acts as a direct hepatotoxin, and malnutrition has a major role
D. Lipogenesis and depression of fatty acid oxidation do not contribute to the development of alcoholic liver disease
B. Intestinal-derived endotoxin initiates a pathogenic process through toll-like receptor 4 and tumor necrosis factor
Rationale: Alcohol increases intestinal permeability, leading to endotoxins entering the portal circulation. These activate toll-like receptor 4 (TLR4) on Kupffer cells, producing tumor necrosis factor (TNF-α), which drives inflammation and liver injury.
- A 43-year-old man has a long history of chronic alcohol abuse. On physical examination, his liver edge is firm on palpation of the abdomen, but liver span does not appear to be increased. An abdominal CT scan reveals a cirrhotic liver. He joins a support group for persons with chronic alcohol abuse and stops drinking. Despite his continued abstinence, he most likely remains at risk for the development of which of the following diseases?
A. Hepatocellular Carcinoma
B. Cholelithiasis
C. Angiosarcoma
D. Hepatic Adenoma
A. Hepatocellular Carcinoma
Rationale: Cirrhosis is the strongest risk factor for developing hepatocellular carcinoma (HCC), regardless of whether the patient continues alcohol consumption or not.
- A recent kidney transplant patient complains of odynophagia and chest pain. Endoscopy reveals serpiginous ulcers in the distal esophagus with large nuclear and cytoplasmic inclusion bodies at the ulcer bases. What is the recommended treatment for this condition?
A. Acyclovir
B. Ganciclovir
C. Oral Prednisone
D. Swallowed Topical Steroids
B. Ganciclovir
Rationale: The described inclusion bodies are characteristic of CMV esophagitis, which is common in immunocompromised patients. Ganciclovir is the first-line treatment.
- Which of the following mitigates or lessens the severity of esophagitis?
A. Pancreatic Enzymes
B. Zollinger-Ellison Syndrome
C. Atrophic Gastritis
D. Bile
C. Atrophic Gastritis
Rationale: Atrophic gastritis causes hypoacidity, which reduces acid reflux and thereby lessens the severity of esophagitis.
- The portal vein is formed by the union of:
A. Gastric Vein and Splenic Vein
B. Hepatic Vein and Gastric Vein
C. Splenic Vein and Inferior Mesenteric Vein
D. Splenic Vein and Superior Mesenteric Vein
D. Splenic Vein and Superior Mesenteric Vein
Rationale: The portal vein is formed by the confluence of the splenic vein and the superior mesenteric vein, which drain blood from the intestines, spleen, pancreas, and stomach.
- Portal hypertension is defined as an elevation of hepatic venous pressure gradient (HVPG) to:
A. > 1 mmHg
B. > 10 mmHg
C. > 3 mmHg
D. > 5 mmHg
D. > 5 mmHg
Rationale: Portal hypertension is diagnosed when the hepatic venous pressure gradient exceeds 5 mmHg, with clinical significance often appearing at higher levels.
- A 55-year-old female presents with jaundice and weight loss. Ultrasound reveals a liver of normal size with a homogeneous echo pattern, a normal-sized gallbladder with polyps, and dilated common bile and hepatic ducts. What is the best management for this case?
A. Cholecystectomy
B. Antibiotic Treatment
C. Hepatectomy
D. Endoscopic Retrograde Cholangiopancreatography (ERCP)
D. Endoscopic Retrograde Cholangiopancreatography (ERCP)
Rationale: ERCP is the gold standard for managing biliary obstruction caused by common bile duct pathology, such as strictures, stones, or tumors.
- A 44-year-old female presents to the emergency room with abdominal pain after eating at her favorite samgyupsal. She is in distress, with a temperature of 38.0°C and tenderness in the right upper quadrant. Ultrasound reveals a distended gallbladder. What is the definitive management for this case?
A. Cholecystectomy
B. Antibiotic Treatment
C. Hepatectomy
D. Endoscopic Retrograde Cholangiopancreatography (ERCP)
A. Cholecystectomy
Rationale: Cholecystectomy (surgical removal of the gallbladder) is the definitive management for symptomatic cholecystitis caused by gallstones, particularly when there is right upper quadrant pain and ultrasound findings of gallbladder distention.
- All of the following conditions require prophylactic cholecystectomy, except:
A. History of treatment for pancreatitis
B. Calcium deposits in the gallbladder
C. Prior episode of cholecystitis
D. None of the above
D. None of the above
Rationale: Prophylactic cholecystectomy is warranted for certain conditions such as recurrent pancreatitis, calcified (porcelain) gallbladder, and prior cholecystitis. If the patient has none of these, reassurance is preferred.
- A 24-year-old female medical student seeks a second opinion due to an incidental finding of cholelithiasis on abdominal ultrasound. She is asymptomatic. What is your course of action?
A. Give ursodeoxycholic acid for stone dissolution
B. Reassurance
C. Prophylactic cholecystectomy
D. Order a CT scan of the abdomen
B. Reassurance
Rationale: Asymptomatic gallstones do not require intervention. Patients should be reassured and observed unless they develop symptoms like biliary colic or complications.
- A 60-year-old male with known liver cirrhosis is found to have gallstones on abdominal ultrasound. What type of stones would most likely be present?
A. Brown pigment stones
B. Cholesterol stones
C. Black pigment stones
D. None of the above
C. Black pigment stones
Rationale: Black pigment stones are commonly seen in conditions involving chronic hemolysis or cirrhosis due to excess unconjugated bilirubin.
- A 52-year-old male presents to the ER with severe epigastric pain radiating to the back after heavy alcohol consumption. He is in distress, with BP 90/70 mmHg, HR 112/min, RR 24/min, T 37.2°C. What is the most important part of your initial management?
A. Adequate pain control
B. Aggressive fluid administration
C. Systemic antibiotics
D. Oxygen supplementation
B. Aggressive fluid administration
Rationale: Early and aggressive fluid resuscitation is critical to prevent worsening organ dysfunction in acute pancreatitis.
- A 52-year-old male presents to the ER with acute epigastric pain radiating to the back. Laboratory results show:
A. ALT and AST 3× the upper limit of normal
B. Elevated ALP
C. Amylase and lipase >3× the upper limit of normal
D. Hematocrit >45
C. Amylase and lipase >3× the upper limit of normal
Rationale: Elevated amylase and lipase are the most indicative laboratory findings in acute pancreatitis. Lipase is more specific.
- A patient is admitted for treatment of acute pancreatitis. After initial treatment, how will you monitor for improvement of the patient’s condition?
A. Whole abdominal ultrasound
B. Serial examination of amylase and lipase
C. Vital signs, physical examination, urine output
D. CT scan with contrast
C. Vital signs, physical examination, urine output
Rationale: Clinical monitoring with vital signs, physical examination, and urine output is essential for assessing the patient’s improvement and fluid status.
- Acute pancreatitis: Which of the following should be monitored with serial testing?
A. Serum lipase
B. Hematocrit
C. BUN
D. CRP
A. Serum lipase
Rationale: While lipase levels are most useful for diagnosis, monitoring trends can sometimes help, though clinical improvement remains the primary marker.
- After 48 hours of initial management for acute pancreatitis, the patient shows no improvement. What is the next step?
A. Consider alternative diagnosis
B. Order abdominal CT
C. Intensify initial management
D. Perform ERCP
D. Perform ERCP
Rationale: If the etiology is suspected to be gallstones, ERCP can relieve biliary obstruction and improve the clinical course.
- A patient with acute pancreatitis has a well-defined circumferential fluid collection observed on contrast-enhanced CT scan. What is the most likely diagnosis?
A. Acute pancreatic abscess
B. Hemorrhagic pancreatitis
C. Pancreatic pseudocyst
D. Pancreatic necrosis
C. Pancreatic pseudocyst
Rationale: A pancreatic pseudocyst is a well-defined, encapsulated fluid collection that forms as a complication of acute pancreatitis. It is surrounded by a fibrous or granulation tissue wall and lacks an epithelial lining.
- Which of the following is the most important hallmark/characteristic of acute pancreatitis?
A. Increased BUN and serum creatinine
B. Elevated serum lipase or amylase
C. Low serum calcium levels
D. Normal abdominal ultrasound findings
B. Elevated serum lipase or amylase
Rationale: Acute pancreatitis is characterized by a 3-fold increase in serum lipase or amylase levels, which occur within hours of the onset of pain and are the primary diagnostic markers.
- A 60-year-old male, known case of liver cirrhosis, followed up at your clinic with the results of a whole abdominal ultrasound. The ultrasound showed the presence of stones in the gallbladder. What type of stones would most likely be present?
A. Brown pigment stones
B. Cholesterol stones
C. Black pigment stones
D. None of the above
C. Black pigment stones
Rationale: Black pigment stones are common in patients with chronic liver disease or hemolytic conditions, due to increased unconjugated bilirubin in bile.
- A 52-year-old male presents to the emergency room with severe abdominal pain rated 10/10 in the epigastric area radiating to the back after heavy alcohol consumption. He also reports nausea and vomiting. On examination, he is conscious, anxious, in distress with BP 90/70 mmHg, HR 112/min, RR 24/min, T 37.2°C, and SO2 98%. What would be the most important part of your initial management?
A. Adequate pain control
B. Aggressive fluid administration
C. Systemic antibiotics
D. Oxygen supplementation
B. Aggressive fluid administration
Rationale: Early and aggressive fluid resuscitation is essential in acute pancreatitis to prevent complications like hypovolemic shock and organ failure.
- Which of the following increases the risk for vertical transmission of HCV?
A. HIV-coinfected mother with prolonged or difficult labor
B. Early rupture of membranes, internal fetal monitoring, and high maternal viral load
C. AOTA (All of the above)
D. NOTA (None of the above)
C. AOTA (All of the above)
Rationale: Vertical transmission of HCV is more likely with HIV co-infection, prolonged/difficult labor, and high maternal viral load. Early rupture of membranes and invasive monitoring also increase the risk.
- Which virus is associated with autochthonous (indigenous) infections?
A. Hepatitis B virus (HBV)
B. Hepatitis C virus (HCV)
C. Hepatitis D virus (HDV)
D. Hepatitis E virus (HEV)
D. Hepatitis E virus (HEV)
Rationale: Hepatitis E virus (HEV) is known for causing autochthonous infections, particularly in developing regions with poor water sanitation, and in some developed countries due to zoonotic transmission (e.g., undercooked pork).
- A 43-year-old male presents to the emergency department with a 3-day history of abdominal pain graded 9/10, associated with abdominal distention. He had laparoscopic appendectomy 3 months ago. Physical exam shows a distended abdomen, increased bowel sounds, and tenderness in all quadrants. What initial intervention should be provided for this patient?
A. Antibiotic administration
B. Fluid correction
C. Keep the patient NPO
D. Administer proton pump inhibitor
B. Fluid correction
Rationale: In cases of suspected bowel obstruction or ileus, fluid resuscitation is the initial priority to manage dehydration and electrolyte imbalances caused by vomiting and reduced intake.
- A 30-year-old female complains of abdominal distention and vomiting 2 days after recovering from acute gastroenteritis. She denies abdominal pain or tenderness. She has a history of abdominal surgery for appendicitis 3 years ago. Physical exam shows a distended abdomen with decreased bowel sounds and no tenderness. What is the most likely etiology of her abdominal distention?
A. Inadequate fluid correction from acute gastroenteritis
B. Previous abdominal surgery causing obstruction
C. Intestinal ischemia from severe infection
D. Electrolyte disturbances from vomiting
D. Electrolyte disturbances from vomiting
Rationale:
* The patient’s history of vomiting and absence of abdominal pain, fever, or tenderness makes electrolyte imbalance from vomiting a significant
concern.
* Previous abdominal surgery (appendectomy) may predispose the patient to adhesions, which can cause obstruction or ileus. This can result in fluid accumulation and bacterial overgrowth, as seen in the diagram.
* Although obstruction is a possibility, the patient’s stable vitals and lack of tenderness make electrolyte disturbances a likely contributor.
- What is the pathophysiology of strangulation of the bowel in cases of acute intestinal obstruction?
A. Increased gastrointestinal secretions
B. Decreased arterial blood supply from bacterial proliferation
C. Congestion and edema of the vasculature
D. Increased mechanical pressure exceeding arterial pressure
D. Increased mechanical pressure exceeding arterial pressure
Rationale: In strangulation, increased intraluminal pressure impairs venous return and eventually exceeds arterial pressure, leading to ischemia, necrosis, and perforation.
- A 70-year-old male presents with 4 episodes of non-bilious vomiting containing solid food, colicky abdominal pain, and constipation. Abdominal examination reveals a non-distended but tender abdomen. Where is the obstruction most likely located?
A. Rectal
B. Colonic
C. Pyloric
D. Jejunal
C. Pyloric
Rationale: Non-bilious vomiting indicates an obstruction proximal to the ampulla of Vater (e.g., pylorus), where bile is not yet mixed with gastric contents.
- The Child-Pugh score includes all of the following criteria except:
A. Serum bilirubin
B. Serum albumin
C. Ascites
D. AST/ALT
D. AST/ALT
Rationale: The Child-Pugh score assesses liver function using bilirubin, albumin, INR, ascites, and encephalopathy, but AST/ALT levels are not part of the scoring system.
- What is the most significant risk factor for cancer?
A. Smoking
B. Obesity
C. Age
D. Chronic inflammation
C. Age
Rationale: Age is the most significant risk factor for cancer, as genetic mutations accumulate over time, increasing cancer risk with advancing age.
- Squamous cell carcinoma of the esophagus is most commonly located at:
A. Upper and middle esophagus
B. Lower and upper esophagus
C. Lower GEJ
D. Upper and lower GEJ
A. Upper and middle esophagus
Rationale: Squamous cell carcinoma of the esophagus is most commonly located in the upper and middle thirds, while adenocarcinoma occurs near the gastroesophageal junction (GEJ).
- Barrett’s esophagus is a risk factor for:
A. Esophageal adenocarcinoma
B. Squamous cell carcinoma
C. Gastric carcinoma
D. Chronic reflux gastritis
A. Esophageal adenocarcinoma
Rationale: Barrett’s esophagus, a complication of chronic GERD, predisposes to esophageal adenocarcinoma due to metaplastic changes in the esophageal lining.
- Patients with polyps should undergo colonoscopy:
A. Every 5 years
B. Every 3 years
C. Every 2 years
D. Annually
B. Every 3 years
Rationale: After removal of precancerous polyps, a repeat colonoscopy every 3 years is recommended to monitor for recurrence or new polyps.
- Symptoms of a tumor in the ascending colon include all of the following except:
A. Bleeding
B. Angina
C. Fatigue
D. Palpitations
A. Bleeding
Rationale: Tumors of the ascending colon often cause fatigue, palpitations, and angina due to chronic blood loss leading to iron-deficiency anemia. Acute bleeding is rare in ascending colon tumors.
- What is the most common histology of villous adenoma?
A. Pedunculated
B. Sessile
C. Adenomatous
D. Serrated
B. Sessile
Rationale: Villous adenomas are typically sessile (flat-based) and are 3 times more likely to become malignant compared to tubular adenomas.
- A patient with gastric cancer is noted to have a mass in the periumbilical area. What is a metastasis in the periumbilical area called?
A. Krukenberg’s Tumor
B. Sister Mary Joseph Node
C. Blumer’s Shelf
D. None of the above
B. Sister Mary Joseph Node
Rationale: A Sister Mary Joseph Node is a palpable nodule in the periumbilical region due to metastatic spread of abdominal or pelvic malignancies, commonly gastric cancer.
- A 65-year-old male with chronic stable angina is scheduled for upper GI endoscopy and colonoscopy due to suspected GI bleeding and recent anemia. Which of the following statements is part of the management of this case?
A. Give prophylactic antibiotics to prevent infective endocarditis
B. Give prophylactic antibiotics pre- and post-procedure up to seven (7) days post-discharge
C. Prophylactic antibiotics are not recommended even for prevention of infective endocarditis
D. All of the above
C. Prophylactic antibiotics are not recommended even for prevention of infective endocarditis
Rationale:
According to Table 315-1, for “all cardiac conditions” undergoing any endoscopic procedure, prophylactic antibiotics are not indicated for prevention of infective endocarditis. This recommendation aligns with guidelines that antibiotics are not routinely given unless specific high-risk conditions apply.
- A 45-year-old patient with sudden onset of abdominal pain followed by jaundice is scheduled for ERCP with possible partial drainage. Which of the following statements is part of the management of this case?
A. No antibiotic prophylaxis is necessary
B. All of the above
C. Give antibiotic prophylaxis pre-procedure only
D. Provide antibiotic prophylaxis pre- and post-procedure to prevent cholangitis
D. Provide antibiotic prophylaxis pre- and post-procedure to prevent cholangitis
Rationale:
Table 315-1 specifies that for ERCP with anticipated incomplete drainage (e.g., sclerosing cholangitis, hilar strictures), prophylactic antibiotics are recommended, with a note to continue antibiotics after the procedure. This approach reduces the risk of cholangitis, which is a common complication in these scenarios.
- A 50-year-old war veteran is scheduled for colonoscopy to screen for a rectal mass due to a strong family history and recurrent vague abdominal discomfort. His medical history includes no diabetes or hypertension but does include above-knee amputation (AKA) with a metallic prosthetic leg. To prevent septic arthritis, which of the following statements is advisable?
A. Prophylaxis antibiotic is not recommended
B. Prophylactic antibiotics, such as cefazolin, can be given pre-procedure
C. Antibiotic prophylaxis should be given pre- and post-procedure
D. All of the above
A. Prophylaxis antibiotic is not recommended
Rationale:
As per Table 315-1, prophylactic antibiotics for prosthetic joints during any endoscopic procedure are not recommended. Guidelines suggest that there is no significant evidence supporting routine antibiotic prophylaxis for joint infections during these procedures.
- A patient with non-valvular atrial fibrillation is scheduled for EGD and colonoscopy due to suspicion of a GI mass. His medications include rivaroxaban, digoxin, enalapril, and atorvastatin. Which of the following recommendations is correct for this case?
A. Rivaroxaban may be continued or hold the morning dose on the day of the procedure
B. Novel oral anticoagulants such as Dabigatran, Rivaroxaban, Apixaban, and Edoxaban have a low risk of bleeding during the procedure
C. All of the above
D. None of the above
D. All of the above
Rationale:
From Table 315-2, the management of rivaroxaban (a novel oral anticoagulant) is outlined as follows:
1. Option A: “Rivaroxaban may be continued or hold the morning dose on the day of the procedure”
* For low-bleeding risk procedures, rivaroxaban may be continued or the morning dose held.
* However, this case involves EGD and colonoscopy, which can include biopsies, categorizing it as high bleeding risk. For high-risk procedures, rivaroxaban should be discontinued 2-4 days prior to the procedure depending on renal function.
2. Option B: “Novel oral anticoagulants such as Dabigatran, Rivaroxaban, Apixaban, and Edoxaban”
* These drugs are explicitly listed in Table 315-2. Their discontinuation and resumption depend on bleeding risk and renal function.
3. Option C: “Have low risk of bleeding during the procedure”
* While low-bleeding risk procedures allow continuation, colonoscopy/EGD with biopsies are not inherently low-risk. However, if no intervention is planned, the bleeding risk might remain low.
- A chronic valvular atrial fibrillation patient is scheduled for upper GI endoscopy with possible biopsy for suspected Barrett’s esophagus. Her latest INR is 2.2 (therapeutic range). Which of the following recommendations is correct for this case?
A. Continue warfarin; the procedure has a low risk of bleeding
B. Discontinue warfarin for at least 5-7 days to achieve target INR <1.5 and start bridging therapy with LMWH
C. All of the above
D. None of the above
A. Continue warfarin; the procedure has a low risk of bleeding
Rationale:
Table 315-2 states that for low-risk procedures, warfarin can be continued if the INR is therapeutic (e.g., INR ≤ 3). Upper GI endoscopy without interventions (or minimal biopsy) is generally considered a low-risk procedure. Hence, continuing warfarin is acceptable.
Discontinuing warfarin would only be required for procedures with high bleeding risk, which does not apply here.
- The portal vein is formed by the union of:
A. Gastric and splenic vein
B. Hepatic vein and gastric vein
C. Splenic vein and inferior mesenteric vein
D. Splenic vein and superior mesenteric vein
D. Splenic vein and superior mesenteric vein
Rationale:
The portal vein is the largest vessel in the portal venous system, and it is formed by the union of the splenic vein and the superior mesenteric vein. This is clearly highlighted in the provided notes.
- A patient presents with positive IgM anti-HAV. What is the diagnosis?
A. Acute Hepatitis A
B. Chronic Hepatitis A
C. Hepatitis A carrier state
D. Resolved Hepatitis A
A. Acute Hepatitis A
Rationale:
Positive IgM anti-HAV is specific for Acute Hepatitis A infection, indicating a recent or active infection. IgM antibodies appear early during the course of infection.
- A patient presents with positive anti-HBc IgM, positive HBsAg, and positive HBeAg. What is the most likely diagnosis?
A. Acute Hepatitis B with high infectivity
B. Chronic Hepatitis B with high infectivity
C. Acute Hepatitis B with low infectivity
D. Resolved Hepatitis B
A. Acute Hepatitis B with high infectivity
Rationale:
The presence of anti-HBc IgM indicates an acute phase of Hepatitis B.
* HBAg indicates an active infection.
* HBeAg suggests high viral replication and high infectivity.
- A patient’s serologic profile reveals positive anti-HBs. What does this indicate?
A. Immunization
B. Active Hepatitis B infection
C. Chronic Hepatitis B infection
D. Recent Hepatitis B exposure
A. Immunization
Rationale:
Positive anti-HBs (hepatitis B surface antibody) indicates immunity to Hepatitis B. This can result from vaccination or recovery from a resolved infection. In the absence of other markers like HBsAg or anti-HBc, it is most consistent with immunization.
- Which of the following is not a hepatic cause of portal hypertension?
A. Schistosomiasis
B. Veno-Occlusive Syndrome
C. Alcoholic Hepatitis
D. Budd-Chiari Syndrome
D. Budd-Chiari Syndrome
Rationale:
Budd-Chiari syndrome is classified as a post-hepatic cause of portal hypertension due to hepatic venous outflow obstruction.
The other options (Schistosomiasis, Veno-Occlusive Syndrome, and Alcoholic Hepatitis) are hepatic causes of portal hypertension.
- A 50-year-old obese female presents to the emergency room with abdominal pain, jaundice, fever, and hypotension (BP 80/60 mmHg). She is lethargic and febrile. What is the most likely diagnosis?
A. Acute Suppurative Cholangitis
B. Biliary Colic
C. Acute Cholecystitis
D. None of the Above
A. Acute Suppurative Cholangitis
Rationale:
The triad of symptoms—fever, jaundice, and right upper quadrant pain—is characteristic of Charcot’s triad seen in acute cholangitis. In severe cases, hypotension and altered mental status indicate Reynold’s pentad, consistent
- Which of the following is a DNA virus?
A. Hepatitis E
B. Hepatitis B
C. Hepatitis A
D. SARS-CoV-2
B. Hepatitis B
Rationale:
Hepatitis B is a DNA virus from the Hepadnaviridae family.
Hepatitis A, Hepatitis C, and Hepatitis E are RNA viruses.
SARS-CoV-2 is also an RNA virus.
- The first virologic marker detectable in the serum within 1–12 weeks post-infection is:
A. HBsAg
B. Anti-HBc IgM
C. Anti-HBc IgG
D. Anti-HBs
A. HBsAg
Rationale:
HBsAg (Hepatitis B surface antigen) is the first serologic marker to appear in the blood during acute Hepatitis B infection, usually within 8–12 weeks of exposure.
- A 19-year-old female suspected of acetaminophen overdose is rushed to the emergency room. Which medication may be given to reduce the severity of liver injury?
A. Ribavirin
B. N-acetylcysteine
C. Clopidogrel
B. N-acetylcysteine
Rationale:
N-acetylcysteine (NAC) acts as a precursor to glutathione, which detoxifies the toxic metabolite NAPQI produced by acetaminophen overdose. NAC is the standard treatment for acetaminophen toxicity.
- The toxic byproduct of acetaminophen is:
A. NAPQI
B. Glutathione
C. Cytochrome P450
D. Acetaldehyde
A. NAPQI
Rationale:
NAPQI (N-acetyl-p-benzoquinone imine) is the toxic metabolite of acetaminophen. When glutathione stores are depleted, NAPQI binds to hepatocyte proteins, leading to liver injury.
- Which of the following is a protective antibody?
A. Anti-HBc IgG
B. HBsAg
C. Anti-HBc
D. Anti-HBs
D. Anti-HBs
Rationale:
Anti-HBs (Hepatitis B surface antibody) is the protective antibody that provides immunity against Hepatitis B. It appears after recovery from infection or immunization. The presence of anti-HBs indicates protection against reinfection.
- The first virologic marker detectable in the serum 1–12 weeks post-infection is:
A. HBsAg
B. Anti-HBs
C. Anti-HBc IgG
D. Anti-HBc IgM
A. HBsAg
Rationale:
The first marker to appear in the serum during acute Hepatitis B infection is HBsAg (Hepatitis B surface antigen), typically detectable within 8–12 weeks. It indicates an active infection and precedes clinical symptoms and liver enzyme elevations.
- For which of the following drugs is N-acetylcysteine effective in reducing the severity of hepatic necrosis?
A. Paracetamol
B. Isoniazid
C. Ibuprofen
D. Oxaliplatin
A. Paracetamol
Rationale:
N-acetylcysteine is the antidote for paracetamol (acetaminophen) overdose. It replenishes glutathione levels, detoxifies the harmful metabolite NAPQI, and reduces hepatic necrosis if administered within 8 hours of ingestion.
- Which condition presents with the triad of biliary pain, jaundice, and striking fever?
A. Acute Pancreatitis
B. Ascending Cholangitis
C. Cholecystitis
D. Hepatic Abscess
B. Ascending Cholangitis
Rationale:
The classic triad of biliary pain, jaundice, and fever is known as Charcot’s triad, which is diagnostic of ascending cholangitis. It is caused by infection of the bile ducts, often due to obstruction (e.g., gallstones).
- Which of the following provides diagnoses of pancreatic and biliary diseases?
A. Capsule Endoscopy
B. ERCP
C. Ultrasound
D. Upper Endoscopy
E. CT Scan
B. ERCP
Rationale:
ERCP (Endoscopic Retrograde Cholangiopancreatography) is a procedure that diagnoses and treats conditions of the liver, gallbladder, bile ducts, and pancreas. It combines endoscopy and fluoroscopy to visualize and intervene in these areas.
- Malabsorption syndrome associated with peripheral edema, decreased albumin and globulin without liver or kidney disease is called:
A. Protein-Losing Enteropathy
B. Celiac Disease
C. Short Bowel Syndrome
D. Crohn’s Disease
E. Whipple’s Disease
A. Protein-Losing Enteropathy
Rationale:
Protein-losing enteropathy (PLE) occurs when albumin and other protein-rich materials leak into the intestine, leading to hypoalbuminemia and peripheral edema without liver or kidney involvement.
- The portal vein is formed by the union of:
A. Gastric and Splenic Vein
B. Hepatic and Gastric Vein
C. Splenic and Inferior Mesenteric Vein
D. Splenic and Superior Mesenteric Vein
E. Renal Vein and Superior Mesenteric Vein
D. Splenic and Superior Mesenteric Vein
Rationale:
The portal vein is formed behind the neck of the pancreas by the union of the splenic vein and the superior mesenteric vein. It is a key vessel in the portal circulation system.
- The most important risk factor for alcoholic liver disease is:
A. Type of Alcohol Consumed
B. Duration and Quantity of Alcohol Intake
C. Gender
D. Hepatitis C Coinfection
B. Duration and Quantity of Alcohol Intake
Rationale:
The most critical determinants of alcoholic liver disease (ALD) are the duration and quantity of alcohol consumed. The type of alcohol or gender is less significant compared to the total cumulative intake.
- The following may be differential diagnoses to hepatitis infection, except:
A. Acute Cholecystitis
B. Left-Sided Heart Failure
C. Alcoholic Hepatitis
D. None of the Above
B. Left-Sided Heart Failure
Rationale:
While hepatitis may mimic several conditions like acute cholecystitis and alcoholic hepatitis, left-sided heart failure is not typically considered a differential diagnosis. Right-sided heart failure, however, can cause hepatic congestion.
- Which of the following statements is true regarding gastric secretion?
A. Basal acid production occurs in a circadian pattern, with highest levels occurring during the day and lowest at night
B. Gastric acid is the only gastric secretory product with a physiologic role in protein digestion and absorption of iron, calcium, and vitamin B12
C. Basal acid production levels occur in a circadian pattern, with lowest levels in the morning and highest levels at night
D. Pepsinogen is the only principal gastric secretory product capable of inducing mucosal injury
C. Basal acid production levels occur in a circadian pattern, with lowest levels in the morning and highest levels at night
Rationale:
Gastric acid secretion follows a circadian rhythm, with the lowest levels in the morning and highest levels during the night. This circadian pattern is influenced by neural and hormonal factors.
- A 43-year-old obese man with chronic alcohol consumption presents with RUQ pain and nausea. Physical examination reveals spider nevi and hepatomegaly on ultrasound. All of the following lab test results may be expected except:
A. Hyperbilirubinemia
B. Hypoalbuminemia
C. Hyperalbuminemia
D. Elevated liver enzymes
C. Hyperalbuminemia
Rationale:
Chronic liver disease, including alcoholic liver disease, often leads to hypoalbuminemia due to
reduced hepatic synthetic function.
* Hyperbilirubinemia occurs due to impaired bilirubin excretion.
* Elevated liver enzymes (AST/ALT, GGT) reflect liver injury.
* Hyperalbuminemia is not expected in liver disease.
- A 52-year-old male presents to the ER with severe epigastric pain rated 10/10 radiating to the back, occurring after heavy alcohol consumption. He is in distress with BP 90/70 mmHg and SO₂ 98%. What is the initial intervention?
A. Aggressive fluid administration
B. Antibiotics
C. Oxygen administration
D. Pain control
A. Aggressive fluid administration
Rationale:
In acute pancreatitis, aggressive fluid resuscitation is the most critical initial intervention to prevent hypovolemia, organ failure, and shock. Lactated Ringer’s solution or normal saline is used.
- A 60-year-old male with liver cirrhosis is found to have gallstones on abdominal ultrasound. What type of stones are most likely present?
A. Cholesterol stones
B. Black pigment stones
C. Brown pigment stones
D. Mixed stones
B. Black pigment stones
Rationale:
Black pigment stones are associated with chronic liver disease, hemolysis, and cirrhosis. They are formed from calcium bilirubinate due to impaired bilirubin metabolism.
- A 43-year-old man with a long history of chronic alcohol abuse has a cirrhotic liver on CT scan. He joins a support group and stops drinking alcohol. Despite his abstinence, he remains at risk for the development of which disease?
A. Hepatocellular carcinoma
B. Cholelithiasis
C. Angiosarcoma
D. Hepatic adenoma
A. Hepatocellular carcinoma
Rationale:
Cirrhosis, regardless of alcohol cessation, significantly increases the risk for hepatocellular carcinoma (HCC). Regular surveillance is necessary to detect HCC early.
- Mr. Z underwent endoscopy and was found to have ulcers. What is the best initial screening test for H. pylori?
A. Urea breath test
B. Biopsy
C. CT scan
D. MRI
A. Urea breath test
Rationale:
The urea breath test is the preferred non-invasive test for detecting active H. pylori infection. It is simple, quick, and accurate. Biopsy is more invasive and reserved for endoscopic evaluation.
- Mr. Y, who recently had surgery for a peptic ulcer, may experience which of the following complications?
A. Constipation
B. Hypertension
C. Diarrhea
D. Increased blood sugar
C. Diarrhea
Rationale:
Post-surgical complications, such as postvagotomy diarrhea, are common following procedures like truncal vagotomy. It occurs due to motility issues and loss of vagal input to the gut.
- Reduced prostaglandins secondary to NSAID use causes:
A. Decreased gastric mucosal blood flow
B. Gastric hypomotility
C. Increase in nitric oxide
D. Decrease in pro-inflammatory mediators
A. Decreased gastric mucosal blood flow
Rationale:
NSAIDs inhibit COX enzymes, reducing prostaglandin production. Prostaglandins play a key role in maintaining gastric mucosal blood flow and protecting the gastric lining. Decreased blood flow leads to mucosal injury and ulcers.
- Which symptom is uncommon in reflux esophagitis and raises the possibility of an esophageal infection?
A. Odynophagia
B. Chest Pain
C. Regurgitation
D. Dysphagia
A. Odynophagia
Rationale:
Odynophagia (painful swallowing) is uncommon in GERD but is characteristic of infectious esophagitis (e.g., candida, herpes). Dysphagia, chest pain, and regurgitation are more typical of reflux esophagitis.
- A 43-year-old male presents to the emergency department with a 3-day history of abdominal pain graded 9/10, associated with abdominal distention. His last stool passage was 4 days ago, and he underwent laparoscopic appendectomy 3 months prior. Abdominal exam reveals a distended abdomen, increased bowel sounds, and tenderness over all quadrants. What is your initial assessment based on the history and physical examination?
A. Adhesions
B. Ischemic Bowel Disease
C. Intestinal Perforation
D. Abdominal Neoplasm
A. Adhesions
Rationale:
Postoperative adhesions are the most common cause of small bowel obstruction (SBO), especially after abdominal surgeries like appendectomy. The symptoms of abdominal pain, distention, constipation, and increased bowel sounds support this diagnosis.
- A 43-year-old male presents to the emergency department with a 3-day history of abdominal pain graded 9/10, associated with abdominal distention. His last stool passage was 4 days ago, and he underwent laparoscopic appendectomy 3 months prior. Abdominal exam reveals a distended abdomen, increased bowel sounds, and tenderness over all quadrants. What is the initial diagnostic test you may request?
A. Barium Enema
B. Abdominal Ultrasound
C. CT Scan of the Abdomen
D. Scout Film of the Abdomen
D. Scout Film of the Abdomen
Rationale:
An abdominal scout film (plain upright X-ray) is the initial diagnostic test for suspected bowel obstruction. It can quickly identify signs such as:
* Dilated bowel loops (>2.5 cm in small bowel obstruction).
* Air-fluid levels.
* Absence of gas distal to the obstruction.
This test is quick, inexpensive, and non-invasive, making
- A 43-year-old male presents to the emergency department with a 3-day history of abdominal pain graded 9/10, associated with abdominal distention. His last stool passage was 4 days ago, and he underwent laparoscopic appendectomy 3 months prior. Abdominal exam reveals a distended abdomen, increased bowel sounds, and tenderness over all quadrants. What initial intervention should you provide for this patient?
A. Antibiotic Administration
B. Fluid Correction
C. Feed the Patient
D. Administer Proton Pump Inhibitor (PPI)
B. Fluid Correction
Rationale:
In cases of intestinal obstruction, the immediate priority is:
1. Fluid resuscitation to correct dehydration, electrolyte imbalance, and maintain hemodynamic stability.
2. Rest the bowel by keeping the patient NPO (nothing per mouth).
3. Nasogastric decompression if needed.
Antibiotics and PPls are not the first interventions in this context, and feeding the patient would worsen the obstruction.
- A 30-year-old female returns to your clinic complaining of abdominal distention for 2 days, accompanied by episodes of vomiting. She denies symptoms such as abdominal pain or tenderness. You previously treated her for acute gastroenteritis 1 week prior, and her past medical history reveals abdominal surgery for appendicitis 3 years ago. Physical exam reveals a distended abdomen with decreased bowel sounds and no tenderness. What is the etiology of the patient’s abdominal distention?
A. Inadequate fluid correction from acute gastroenteritis
B. Previous abdominal surgery
C. Intestinal ischemia from severe infection
D. Electrolyte disturbances from vomiting
D. Electrolyte disturbances from vomiting
Rationale:
Frequent vomiting can lead to electrolyte imbalances, particularly hypokalemia and hypochloremia. These disturbances impair intestinal motility, resulting in abdominal distention and decreased bowel sounds. The absence of pain and tenderness further supports this etiology.
- What is the pathophysiology of strangulation of the bowel in cases of acute intestinal obstruction?
A. Increased GI secretions
B. Decreased arterial blood supply from bacterial proliferation
C. Congestion and edema of the vasculature
D. Increased mechanical pressure exceeding arterial pressure
D. Increased mechanical pressure exceeding arterial pressure
Rationale:
In bowel strangulation, the intraluminal pressure increases beyond arterial pressure, compromising blood flow. This leads to ischemia, necrosis, and subsequent perforation of the bowel.
- A 64-year-old male presents to the emergency room with abdominal pain of 6 hours duration, graded 10/10, and associated with nausea, vomiting, and bloody stools. His medical history includes hypertensive cardiovascular disease, coronary artery disease, and rheumatic heart disease. Physical exam reveals hypotension, tachycardia, and hypoactive bowel sounds. What is the gold standard for diagnosing his condition?
A. CT angiography
B. Laparotomy
C. Duplex imaging
D. Colonoscopy
A. CT angiography
Rationale:
CT angiography is the gold standard for diagnosing mesenteric ischemia. It allows for visualization of mesenteric vessels, identification of arterial occlusion, and assessment of bowel viability. Laparotomy is typically reserved for unstable patients or as a therapeutic intervention.
- A 64-year-old male presents to the emergency room with severe abdominal pain of 6 hours duration (graded 10/10), associated with nausea, vomiting, and bloody stools. His medical history includes hypertensive cardiovascular disease, coronary artery disease, and rheumatic heart disease. A scout film of the abdomen reveals intramural gas in the intestinal segments. This radiographic finding is known as:
A. Pneumoperitoneum
B. Pneumoretroperitoneum
C. Pneumatosis intestinalis
D. Pneumopericardium
C. Pneumatosis intestinalis
Rationale:
Pneumatosis intestinalis refers to the presence of gas within the bowel wall. It is seen in conditions like mesenteric ischemia and necrotizing enterocolitis and indicates bowel ischemia or perforation.
- What is the mechanism for the development of intramural gas in the intestinal segments seen in mesenteric ischemia?
A. Disruption of mucosal integrity leading to gas-forming bacteria intramurally
B. Increased swallowed air due to patient distress
C. Increased oxygen extraction from the blood
D. Increased mechanical pressure from the pulmonary system during stress
A. Disruption of mucosal integrity leading to gas-forming bacteria intramurally
Rationale:
In mesenteric ischemia, mucosal integrity is compromised, allowing gas-forming bacteria to invade and produce gas within the bowel wall. This results in the characteristic finding of pneumatosis intestinalis.
- A patient with cardiogenic or septic shock, or cocaine overdose, presents with ischemia. What type of ischemia is most likely?
A. Non-occlusive ischemia
B. Arterio-occlusive mesenteric ischemia
C. Mesenteric venous thrombosis
D. Chronic intestinal ischemia
A. Non-occlusive ischemia
Rationale:
Non-occlusive mesenteric ischemia (NOMI) occurs in states of low-flow, such as cardiogenic shock, septic shock, or vasospasm (e.g., from cocaine use). There is no physical obstruction, but mesenteric perfusion is reduced, leading to ischemia.
- True about Hepatitis A infection, except:
A. Virus replication occurs in the liver, bone marrow…
B. Anti-HAV IgM persists until 3 months of acute infection
C. Anti-HAV IgG persists indefinitely and protects against reinfection
A. Virus replication occurs in the liver, bone marrow…
Rationale:
Hepatitis A virus replication is limited to the liver. The virus is present in the liver, bile, stool, and blood during the late incubation period. It does not replicate in the bone marrow.
- Which of the following is a DNA virus?
A. Hepatitis E
B. Hepatitis C
C. Hepatitis B
D. Hepatitis A
C. Hepatitis B
Rationale:
Hepatitis B virus (HBV) is the only DNA virus among the hepatitis viruses. It belongs to the Hepadnavirus family. Hepatitis A, C, and E are all RNA viruses.
- Which of the following statements about Hepatitis C is incorrect?
A. It coinfects and requires the function of Hepatitis B virus for its replication
B. HCV RNA can be detected within a few days of exposure to HCV before the appearance of anti-HCV
C. The most sensitive indicator of HCV infection is the presence of HCV RNA detected through PCR amplification
D. It is an RNA virus
A. It coinfects and requires the function of Hepatitis B virus for its replication
Rationale:
Hepatitis C virus is an independent RNA virus and does not require HBV for replication. This statement applies to Hepatitis D virus, which needs HBV to replicate.
- Which of the following statements about Hepatitis C is incorrect?
A. HCV RNA can be detected within a few days of exposure to HCV before the appearance of anti-HCV
B. It is an RNA virus
C. The most sensitive indicator of HCV infection is the presence of HCV RNA detected through PCR amplification
D. It coinfects and requires the helper function of Hepatitis B virus for its replication
D. It coinfects and requires the helper function of Hepatitis B virus for its replication
Rationale:
* Hepatitis C virus (HCV) is an independent RNA virus. It does not need the Hepatitis B virus (HBV) for its replication.
* Hepatitis D virus (HDV) is the defective virus that requires HBV for replication and expression, as it lacks the necessary proteins to complete its life cycle.
The other options about HCV are correct:
* HCV RNA can be detected early in infection (Option A).
* It is classified as an RNA virus (Option B).
* PCR amplification is the most sensitive method for detecting HCV RNA (Option C).
- True about the mechanism of drug-induced liver injury, except:
A. Inhibition of mitochondrial function
B. Disrupted sodium homeostasis
C. Apoptosis
D. None of the above
B. Disrupted sodium homeostasis
Rationale:
The correct mechanism involves disruption of calcium homeostasis, not sodium. Drug-induced liver injury affects intracellular calcium levels, mitochondrial function, and induces apoptosis.
- A 22-year-old male reports abdominal pain that began as a pressure-like sensation in the middle of the abdomen. On physical exam, applying gentle pressure in the left lower quadrant produces pain in the right lower quadrant. What is this sign called?
A. Murphy’s Sign
B. Psoas Sign
C. Rovsing’s Sign
D. Obturator Sign
C. Rovsing’s Sign
Rationale:
Rovsing’s sign occurs when pressure applied to the left lower quadrant elicits pain in the right lower quadrant. It is a classic sign of appendicitis.
- A 22-year-old male presents with abdominal pain, initially pressure-like in the middle of the abdomen, now more severe and localized to the right lower quadrant. On exam, he is afebrile, with moderate tenderness but no rebound or guarding. Which imaging modality is recommended?
A. Abdominal CT Scan
B. Abdominal MRI
C. Abdominal Ultrasound
D. Abdominal Radiograph
A. Abdominal CT Scan
Rationale:
CT scan of the abdomen is the most reliable imaging modality for diagnosing appendicitis. It provides detailed visualization of the appendix and surrounding structures, helping confirm inflammation or complications like abscesses or perforation.
