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GASTROENTEROLOGY BOARD REVIEW QUESTIONS

Muthoka L. Mutinga and Robert S. Burakoff

QUESTION 1. A 57-year-old woman presents with a 2-month history of pruritus and mild fatigue. Her skin examination reveals excoriations but no visible rash. Laboratory examination reveals an alkaline phosphatase elevated to three times normal, with otherwise normal liver biochemical tests. Her thyroid-stimulating hormone (TSH) is also elevated, and she has a positive antithyroid microsomal antibody test.

    What is the most likely diagnosis, and what treatment is indicated?

    A. Primary sclerosing cholangitis; ursodiol

    B. Primary biliary cirrhosis; prednisone

    C. Primary sclerosing cholangitis; liver transplantation

    D. Primary biliary cirrhosis; ursodiol

    E. Congenital hepatic fibrosis; liver transplantation

QUESTION 2. A patient with persistent mild elevation of hepatic transaminases and a distant history of intravenous drug use is diagnosed with chronic hepatitis C (HCV), confirmed with a HCV RNA test. A liver biopsy is performed, and subsequently, treatment with Pegylated interferon and ribavirin is initiated.

    Which of the following factors does NOT influence the chance of response to therapy?

    A. Viral genotype

    B. Quantitative HCV RNA level (viral load)

    C. Degree of hepatic transaminase elevation

    D. Duration of hepatitic C infection

    E. Degree of fibrosis noted on liver biopsy

QUESTION 3. A 55-year-old man presents with a 4-month history of intermittent, watery diarrhea, severe heartburn, and epigastric pain. He is diagnosed with four duodenal ulcers on endoscopic evaluation. He denies aspirin or nonsteroidal anti-inflammatory drug (NSAID) use. Gastric antral biopsy testing for Helicobacter pylori bacteria is negative. His symptoms fail to respond to an acid suppression regimen consisting of omeprazole, 20 mg twice daily. A fasting serum gastrin level is 1850 pg/mL.

    Which of the following is true of his likely diagnosis?

    A. The patient most likely has a somatostatinoma.

    B. Omeprazole may falsely lower serum gastrin levels.

    C. The tumor responsible for this disorder is most often located in the duodenum.

    D. The tumor responsible for this disorder is usually benign.

    E. The duodenal ulcers will not respond to any level of acid suppression therapy.

QUESTION 4. Which of the following is NOT an extraintestinal manifestation of Crohn’s disease?

    A. Sacroiliitis

    B. Uveitis

    C. Renal calculi

    D. Erythema nodosum

    E. Thyroiditis

QUESTION 5. A patient with cirrhosis due to alcohol abuse is found to have large esophageal varices on upper endoscopy. There is no history of prior upper gastrointestinal bleeding.

    What is the appropriate therapy to prevent future variceal bleeding?

    A. Ursodiol

    B. Interferon

    C. Nonselective beta blocker

    D. Endoscopic sclerotherapy

    E. Proton pump inhibitor therapy (e.g., omeprazole)

QUESTION 6. Ascites is classified according to the serum ascites albumin gradient (SAAG), which is calculated by subtracting the albumin level in the ascites from that in the serum.

    Which of the following conditions is associated with low gradient (SAAG <1.1 mg/dL ascites)?

    A. Budd-Chiari syndrome

    B. Cirrhosis due to hepatitis C

    C. Peritoneal carcinomatosis

    D. Congestive heart failure

    E. Acute alcoholic hepatitis

QUESTION 7. A 47-year-old woman presents with a 4-month history of watery diarrhea and 24-lb weight loss. Laboratory examination is notable for mild iron deficiency anemia and a low serum calcium level. Stool cultures and examination for ova and parasites are unremarkable. Thyroid laboratory testing is normal. A colonoscopy is performed, and the examination is normal, including inspection of the terminal ileum and histologic evaluation of random colon biopsies to assess for microscopic colitis. A tissue transglutaminase antibody is strongly positive.

    Which of the following statements regarding this disorder is FALSE?

    A. Dietary modification decreases the risk of small intestinal lymphoma.

    B. This disease is more common in patients with diabetes mellitus.

    C. This disease is seen most commonly in patients of Mediterranean background.

    D. Small intestinal biopsies will reveal villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes.

    E. There is an association with autoimmune thyroid disease.

QUESTION 8. A 35-year-old woman is found to have abnormal results of iron studies on a routine physical examination. Her liver biochemical tests are normal, and her physical examination is unremarkable. She does not consume alcohol or over-the-counter medications or supplements. Her iron studies are as follows:

    Serum iron 186 μg/dL

    Total iron binding capacity (TIBC) 255 μg/dL

    Serum ferritin 300 ng/mL (normal 25–240 ng/mL)

    What is the next test that should be ordered to facilitate the diagnosis?

    A. Percutaneous liver biopsy

    B. Serum B₁₂ and folate levels

    C. Glucose tolerance testing

    D. Gene testing for hereditary hemochromatosis

    E. Abdominal computed tomography (CT) scan with intravenous contrast

QUESTION 9. Which of the following is NOT a feature of the hereditary nonpolyposis colon cancer syndrome (HNPCC)?

    A. The mean age of first developing colon cancer is 40 years.

    B. There is a predominance of distal colon cancers (distal to the splenic flexure).

    C. The incidence of synchronous colon cancer is estimated to be nearly 20%.

    D. There may be a family history of adenocarcinoma of the ovary, endometrium, or stomach.

    E. The disorder is transmitted in an autosomal dominant fashion.

QUESTION 10. All of the following statements regarding hepatitis E are true EXCEPT:

    A. The virus is endemic in India and Southeast Asia.

    B. The clinical features of hepatitis E are similar to those of hepatitis A.

    C. The virus is transmitted primarily via percutaneous blood exposure.

    D. Hepatitis E is associated with a high rate of fulminant hepatic failure in pregnant women.

    E. There is no effective vaccine available to prevent hepatitis E.

QUESTION 11. All of the following may be atypical manifestations of gastroesophageal reflux disease (GERD) EXCEPT:

    A. Hoarseness

    B. Chronic cough

    C. Nocturnal asthma

    D. Chronic diarrhea

    E. Atypical chest pain

QUESTION 12. A 46-year-old man presents with a complaint of intermittent dysphagia for 10 years. He reports that food “sticks in my chest” approximately one or two times per month and that he needs to either wash down the bolus with water or regurgitate it. He has symptoms only with solid foods, primarily meat, rice, and bread. He has never had difficulty swallowing liquids. He has had no symptoms of odynophagia and has not experienced weight loss.

    What is the most likely cause of his symptoms?

    A. Schatzki’s ring

    B. Esophageal cancer

    C. Achalasia

    D. Diffuse esophageal spasms

    E. Peptic stricture of the esophagus

QUESTION 13. All of the following are sequelae of H. pylori infection of the stomach, EXCEPT:

    A. Gastric cancer

    B. Atrophic gastritis

    C. Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

    D. Duodenal adenocarcinoma

    E. Duodenal ulcer

QUESTION 14. A 21-year-old presents for routine health examination. His family history is notable for colon cancer in his mother (age 45), maternal uncle (age 52), and maternal grandmother (age 56). The patient is asymptomatic, routine laboratory tests are normal, and the physical examination including a test for occult blood in the stool is unremarkable.

    Which of the following represents appropriate recommendations for colorectal cancer screening for this patient?

    A. Colonoscopy every 3–5 years beginning at age 40

    B. Colonoscopy no less than every 10 years beginning at age 50

    C. Colonoscopy every 2 years beginning at age 21, then annually beginning at age 40

    D. Annual flexible sigmoidoscopy beginning at puberty

QUESTION 15. A 42-year-old man with a 15-year history of inflammatory bowel disease presents with new-onset jaundice, right upper quadrant pain, and fever. An ultrasound reveals a dilated common bile duct, and an endoscopic retrograde cholangiopancreatography (ERCP) reveals multiple strictures of the common bile duct (CBD) and intrahepatic bile ducts. A distal CBD stricture is dilated, and the patient’s symptoms resolve, although his serum alkaline phosphatase remains persistently elevated at three times the upper limit of normal.

    Which of the following statements regarding this disorder is TRUE?

    A. This disorder is more common in Crohn’s disease.

    B. Liver biopsy is the definitive diagnostic test for this disorder.

    C. Ursodiol has been proven to be effective in treating this disorder.

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