In Capsule Series Mowafy internal medicine Hepatology revision

II. Gastroenterology MCQ

IBD & IBS
1- 25 year old man is hospitalized for ulcerative colitis. He has now developed severe
abdominal pain, distention, fever, and transverse colonic dilatation on X-ray. Which of
the following is the best next step?
a) 5-amino salicylates preparation
b) Antibiotics and prompt surgical consultation
c) Infliximab
d) Iv steroids
This case is Toxic megacolon :
✓ It is a condition in which the colon becomes atonic & dilated.
✓ Worsening of the patient clinical condition and development of fever, tachycardia &
leukocytosis.
✓ Treatment : antibiotics & prompt surgical consultation
2- A 32- year old female has a history of chronic diarrhea and gallstones and now has
rectovaginal fistula. Which of the following is the most likely diagnosis?
a) Adult onset celiac disease
b) Crohn’s disease
c) Tropical sprue
d) Ulcerative colitis
Fistulas are common with Crohn disease because of its transmural nature but are uncommon in ulcerative
colitis. Gallstones are common in patients with Crohn disease due to ileal bile salt malabsorption and depletion.
3- A 35-year-old woman has chronic crampy abdominal pain and intermittent
constipation and diarrhea, but no weight loss or gastrointestinal bleeding. Her abdominal
pain is usually relieved with defection. Colonoscopy and upper endoscopy with biopsies
are normal, and stool cultures are negative. Which of the following is the most likely
diagnosis?
a) Infectious colitis
b) Irritable bowel syndrome
c) Crohn disease
d) Ulcerative colitis
Irritable bowel syndrome is characterized by intermittent diarrhea and crampy abdominal pain often relieved with
defecation, but no weight loss or abnormal blood in the stool. It is a diagnosis of exclusion once other conditions,
such as inflammatory bowel disease and parasitic infection (eg, giardiasis), have been excluded.
In Capsule Series Mowafy internal medicine Hepatology revision

4- Which one of the following treatments for active ulcerative colitis would be preferable
in male patients who are concerned about fertility?
a) 5-aminosalicylic acid
b) Sulfasalazine
c) Methotrexate
d) Cephalosporin
Notice that Sulfasalazine is a molecule that has two components: 5-aminosalicylate (5-ASA) and
sulfapyridine. The sulfapyridine is responsible for many of the side effects of sulfasalazine, while the 5-ASA
is responsible for many of its beneficial effects in patients with inflammatory bowel disease. This discovery
provided a rationale for the development of a drug that contains only the 5-ASA component. Unfortunately,
the sulfapyridine component is necessary for the beneficial effects of sulfasalazine in patients with
rheumatoid arthritis; thus the 5-ASA drugs are not suitable for those patients.

5- A 31 year old women presents to you with recurrent abdominal pain and frequent
bloody diarrhea. You suspect inflammatory bowel disease and arrange for a colonoscopy
with biopsy. Which one of the following features on biopsy would suggest ulcerative
colitis over a diagnosis of crohn's disease?
a) Skip lesions
b) presence of granulomas
c) Transmural (full thickness) involvement
d) Presence of Crypt abscess
6- Triggers of Crohn disease include all except:
a) Stress
b) Smoking
c) Dietary
d) Infectious enteritis
7- Initial presentation of Crohn disease:
a) May be a medical/surgical emergency
b) Begins with intermittent attacks of relatively mild diarrhea
c) 20% present acutely with left lower quadrant pain
d) Never have bloody diarrhea
8- Features of ulcerative colitis:
a) Transmural inflammation
b) Skip lesions
c) Marked pseudo polyps
d) Mouth to anus distribution
In Capsule Series Mowafy internal medicine Hepatology revision

9- The extra-intestinal symptoms of both ulcerative colitis and Crohn’s disease may
include all EXCEPT:
a) Migratory polyarthritis
b) Ankylosing spondylitis
c) Uveitis
d) Erythema multiforme
10- As regard to IBD, Which seromarker is specific for ulcerative colitis?
a) ASCA
b) ANCA
c) Serum albumin
d) ESR
Anti-Saccharomyces cerevisiae antibodies (ASCA) are found in 39%-69% of CD patients and in 5%-15% of
UC patients. ANCA values ranges from 2%-28% in CD patients,& from 20%-85% of UC patients.

11- In ulcerative colitis only one statement is true

a) Is more common in smokers than in non smokers
b) The first line of treatment is infliximab
c) Commonly involves the ileum
d) Is associated with HLA B27
12- Fistula is most common in
a) Crohn’s disease
b) Ulcerative colitis
c) Infective enterocolitis
d) Celiac sprue
13- A patient is newly diagnosed with mild ulcerative colitis. What type of anti-
inflammatory medication is typically prescribed as first-line treatment for this condition?
a) 5-Aminosalicylates (Sulfasalazine)
b) Immunomodulators (Adalimumab)
c) Corticosteroids (Prednisone)
d) Immunosupressors (Azathioprine)
o 5-Aminosalicylates (Sulfasalazine) are usually prescribed for mild to moderate cases of ulcerative
colitis as first-line treatment. If Aminosalicylates are not working (or the patient is allergic to sulfa)
corticosteroids are prescribed. Corticosteroids may be used in combination with
immunosuppressors. Immunomodulators are used in severe cases of ulcerative colitis when other
medications have not worked.
o Notice that Sulfasalazine is a molecule that has two components: 5-aminosalicylate (5-ASA) and
sulfapyridine. The sulfapyridine is responsible for many of the side effects of sulfasalazine, while
the 5-ASA is responsible for many of its beneficial effects in patients with inflammatory bowel
disease. This discovery provided a rationale for the development of a drug that contains only the 5-
ASA component (e.g. Delzicol).
In Capsule Series Mowafy internal medicine Hepatology revision

CLINICAL PEARLS of IBD:

➢ Ulcerative colitis always involves the rectum and may extend proximally in a continuous
distribution.
➢ Crohn disease most commonly involves the distal ileum, but it may involve any portion of
the gastrointestinal tract and has “skip lesions.” Because of transmural inflammation, Crohn
disease often is complicated by fistula formation.
➢ Toxic megacolon is characterized by dilation of the colon along with systemic toxicity;
failure to improve with medical therapy may require surgical intervention.
➢ Ulcerative colitis is associated with increased risk of colon cancer; the risk increases with
duration and extent of disease.
➢ Both ulcerative colitis and Crohn disease can be associated with extraintestinal
manifestations, such as uveitis, erythema nodosum, pyoderma gangrenosum, arthritis, and
primary sclerosing cholangitis.

14- Which of the following GI conditions would give rise to the finger clubbing?*
a) Ulcerative colitis
b) Irritable bowel syndrome
c) Pancreatic carcinoma
d) Hepatocellular carcinoma
GI causes of clubbing : **
• IBD
• Primary biliary cirrhosis
• Celiac disease
• Esophageal leiyomyoma

15- Which of the following is the most common cause of upper GI bleeding?*
a) Mallory Weiss tear
b) Peptic ulcer
c) Esophagitis
d) Drug induced

16- Which of the following are NOT associated with Crohn’s disease?*
a) Cigarette smoking reduces incidence
b) Fistula formation
c) Non caseating granuloma formation
d) Associated with transmural inflammation
In Capsule Series Mowafy internal medicine Hepatology revision

17- Regarding melena, which is false ?

a) At least 60 ml of blood is required
b) Blood should remain 4 hours within the gut
c) Black tarry semisolid stool
d) Offensive in odor

18- Regarding hematochezia, which is false?*

a) Passage of bright red blood per rectum
b) May be due to ulcerative colitis
c) The blood may not be mixed with stool
d) Bleeding source is proximal to ligament of Treitz

19- Which of the following features is more commonly associated with ulcerative colitis
than with crohn’s disease ?*
a. Fistulas.
b. Rectal bleeding.
c. Segmental involvement.
d. An abdominal mass.
e. Mesenteric lymph node involvement.
20- Commonest extraintestinal complication of ulcerative colitis is*
a) Sclerosing cholangitis
b) Arthritis
c) Pyoderma gangrenosa
d) Uveitis

21- Ulcerative colitis involves the rectal mucosa in*

a) 30-40%
b) 50-60%
c) 70-80%
d) 90-100%

22- Which of the following features is not consistent with the diagnosis of irritable bowel
syndrome?**
a. Abdominal pain relieved with defecation
b. Sensation of incomplete evacuation
c. Passage of mucus
d. Nocturnal awakening with pain or diarrhea
e. Normal bowel habits alternating with either diarrhea or constipation
In Capsule Series Mowafy internal medicine Hepatology revision

23- Presence of diverticulosis is most commonly seen in*

a) Transverse colon
b) Sigmoid colon
c) Descending colon
d) Cecum

24- Abnormal concentration and/or response to which of the following substances is thought to be an
important part of the development of IBS?
a. Serotonin
b. Acetylcholine
c. Substance P
d. Secretin
e. Somatostatin

25- The typical features of the irritable bowel syndrome Include

a. Nocturnal diarrhea and weight loss
b. Onset after the age of 45 years
c. History of abdominal pain in childhood
d. Right iliac fossa pain and urinary frequency
e. Abdominal distension, flatulence and pellety stools

26- In IBS red flag signs include all of the following except:
a) Bleeding/rectum.
b) Loss of weight.
c) Nocturnal pain.
d) Systemic illness.
e) Diarrhea.
27- The initial regimen for a patient with Crhon’s disease is which of the following ?
a. Iron sulfate and tetracycline.
b. Gluten-free diet and prednisone.
c. Folate and tetracycline.
d. Azathioprine and prednisone.

28- A 45-year-old man with a history of ulcerative colitis is admitted to the hospital with 2 to 3 weeks of
right-upper quadrant abdominal pain, jaundice, and pruritus. He has no fever and a normal WBC count.
Endoscopic retrograde cholangiopancreatography (ERCP) shows multifocal strictures of both the
intrahepatic and extrahepatic bile ducts with intervening segments of normal and dilated ducts. Which
of the following is the most likely diagnosis?
a) Acute suppurative cholangitis
b) Cholangiocarcinoma
c) Primary sclerosing cholangitis (PSC)
d) Choledocholithiasis with resultant biliary strictures
The ERCP shows the typical appearance for primary sclerosing cholangitis (PSC), which is associated with
IBD in 75% of cases. Stone-induced strictures should be extrahepatic and unifocal. Cholangiocarcinoma is
less common but may develop in 10% of patients with PSC.
In Capsule Series Mowafy internal medicine Hepatology revision

29- A 28-year-old man with a 15-year history of ulcerative colitis and primary sclerosing
cholangitis has recent worsening of his jaundice. His symptoms of ulcerative colitis have
been in remission for the past year. He now complains of the onset of steatorrhea
approximately 3 months ago and more than 5kg weight loss during that time. Which of
the following would most likely account for this patient's recent symptoms?
a) Bacterial overgrowth
b) Bile salts deficiency
c) Celiac sprue
d) Tropical sprue
This patient has a history of ulcerative colitis and primary sclerosing cholangitis. He has developed steatorrhea as the
result of poor delivery of bile salts into the small intestine. This occurs because of intra- and extrahepatic duct
stricture of the biliary tree.

Diarrhea & malabsorption

1- Mechanisms of diarrhea include the following except: *

a) Malabsorption.
b) Increased fluid intake.
c) Mucosal injury
d) Motility disorder.
2- Osmotic Gap increase in: *
a) Malabsorption diarrhea
b) Motility disorder.
c) Secretory diarrhea.
d) Osmotic diarrhea.

3- In a patient with suspected bacterial overgrowth of the small bowel, which is the best of the following
investigations: *
a) C13 urea breath test
b) Pancreolauryl test
c) Serum trypsinogen
d) C14 glycocholic acid breath test (GCA)
Glycocholic acid is one of the bile acids. In the C14-GCA breath test, radiolabeled glycocholic acid is
deconjugated by bacteria in the bowel, and 14CO2 produced is measured in breath samples
collected over the next 4 to 8 hours.

4- Select the organism which is NOT responsible for causing bloody diarrhea.
a) Campylobacter spp.
b) Salmonella spp.
c) E coli
d) Staphylococcus spp.
In Capsule Series Mowafy internal medicine Hepatology revision

5- Diarrhea may be associated with all except :*

a) Clindamycin
b) Sucralfate
c) Digitalis
d) Colchicine
6- Secretory diarrhea has no association with :*
a) Pancreatic insufficiency
b) Zollinger Ellison syndrome
c) Villous adenoma of rectum
d) Medullary carcinoma of thyroid
7- Which of the following is not a variety of osmotic diarrhea? *
a) Whipple’s disease
b) Celiac disease
c) Lactase deficiency
d) Laxative abuse
8- Which part of the small bowel is responsible for the absorption of vit B12 ?
a) Jejunum
b) Proximal ilium
c) Terminal ilium
d) Duodenum
o Terminal ilium is responsible for absorption of vit B12
o Proximal ilium is responsible for absorption of vit B2, vit C
o Jejunum is responsible for absorption of vit D, folic acid & B3
o Duodenum is responsible for absorption of Ca & iron

9- The water content of adult stool is

a) 20-30%
b) 40-50%
c) 5-10%
d) More than 60%

10- A normal fecal fat is :

a) < 6g/d
b) < 9g/d
c) < 12g/d
d) < 15g/d
11- The most specific treatment in celiac disease is :
a) Gluten free diet
b) Antibiotics
c) Corticosteroids
d) Folic acid
In Capsule Series Mowafy internal medicine Hepatology revision

12- Which one of the following diagnostic studies for malabsorption is usually normal in persons who
have bacterial overgrowth syndrome ?
a) Fecal fat quantitation ( 24h )
b) Stage II Schilling test ( intrinsic factor giving with vitamin B12 )
c) D-Xylose absorption test.
d) Lactulose breathe test.

13- The most common and specific radiological feature in barium meal follow-through in a patient of
malabsorption is
a) Segmentation and clumping
b) Coarsening of mucosal folds
c) Dilatation
d) Loss of mucosal pattern
14- Which of the following is NOT dependent on bile salts for its absorption?
a) Vitamin A.
b) Vitamin B.
c) Vitamin K.
d) Vitamin D.

15- The initial regimen for a patient with tropical sprue is which of the following ?
a. Folate and niacin.
b. Iron sulfate and tetracycline.
c. Gluten-free diet and prednisone.
d. Folate and tetracycline.
e. Azathioprine and prednisone.
16- Which of the following is true regarding cholecystokinin ?

a. In excess, it precipitates gallstones.

b. It causes delayed gastric emptying through its action as a smooth muscle relaxant.
c. It is found in higher concentrations following cholecystectomy.
d. It stimulates pancreatic exocrine secretion.

17- A patient presents with a history of diarrhea of several weeks' duration. All of the
following may be the cause EXCEPT: ☺
a) Entamoeba histolytica
b) Yersinia enterocolitica
c) Enterotoxigenic Escherichia coli
d) Clostridium difficile
e) Giardia lamblia
Diarrhea due to enterotoxigenic E coli is usually brief although the associated illness may be severe
and even fatal because of complications such as hemolytic uremic syndrome and ischemic colitis.
In Capsule Series Mowafy internal medicine Hepatology revision

18- The maximum absorption of fluid in GIT occurs in *

a) Stomach
b) Jejunum
c) Ileum
d) Colon
19- Water is minimally absorbed from
a) Cecum
b) Ascending colon
c) Transverse colon
d) Descending colon
20- The causative agent of tropical sprue is
a) Shigella
b) Campylobacter
c) Yersinia
d) Unknown
21- Case of 3 D’s: diarrhea, dermatitis, dementia is most probably :
a) Thiamine (vit B1) deficiency (Beriberi)
b) Vitamin A deficiency
c) Niacin (vit B3) deficiency
d) Vit C deficiency
22- Which of the following findings is more consistent with an osmotic, rather than a secretory,
diarrhea?
a. The diarrhea persists despite a 48-hour fast.
b. Stool osmolality = 290 mOsm, stool Na = 95 mOsm, stool K = 15 mOsm.
c. Diarrhea is large volume and watery, and is accompanied by paroxysms of flushing and
wheezing.
d. Profuse, painless “rice-water” stool in a patient in a cholera-endemic area

23- Which one of the following types of diarrhea resolves during a period of fasting?*
a. Inflammatory
b. Secretory
c. Osmotic
d. Altered motility
24- Which of the following does not produce secretory diarrhea?
a) Hyperparathyroidism
b) Medullary carcinoma of the thyroid gland
c) Carcinoid syndrome
d) Zollinger-Ellison syndrome
25- What is the gold standard test for SIBO (small intestine bacterial overgrowth)?
a) Small bowel culture
b) Endoscopy
c) ERCP
d) CBC
Small bowel culture :positive test ≥105 cfu/mL
In Capsule Series Mowafy internal medicine Hepatology revision

26- What is the most sensitive test for exocrine pancreatic function?
a) Direct pancreatic tests by Secretin or cholecystokinin stimulation test
b) D- xylose breath test
c) Schilling test
d) Serum amylase
o Pancreatic function can be measured directly by using endoscopy or the Dreiling tube method after
stimulation with secretin or cholecystokinin (CCK).
o Either secretin or cholecystokinin (CCK) is given, and pancreatic secretions are collected via the tube and
analyzed. When CCK is administered, pancreatic lipase is measured & when secretin is administered,
pancreatic bicarbonate is measured.

27- A 60 year old female presents with progressive fatigue & paraesthesia of both lower
limbs. Examination revealed pallor & impaired deep sensation of lower limbs. Laboratory
tests showed hemoglobin 8 gm/dl, MCV 115 fL. The specific diagnostic test in this case is
a. Reticulocytic count
b. Schilling test
c. Serum ferritin
d. Transferrin saturation

28- As regard to Schilling test, which is correct?

a) A normal result shows at least 10% of the radiolabeled vit B12 in the urine over the
first 24 hours
b) In stage III Schilling test antibiotics are added to b12
c) In stage IV Schilling test IF is added to B12
d) In stage IV, pancreatic enzymes are added to B12
In Schiling test :
A saturating dose (1mgIM) vit B12 followed by an oral dose of 0.5-2 ug radiolabeled
vit B12. Then urine is collected over the 1st 24 hours.
Stages : MCQ

o Stage I : B12.
o Stage II : B12 + IF.
o Stage III: B12 + pancreatic enzymes.
o Stage IV : B12+ antibiotics
In Capsule Series Mowafy internal medicine Hepatology revision

Choose the one diagnosis that best matches with the most likely clinical situation:

29- 3 D’s (diarrhea, dermatitis, dementia) Niacin deficiency (vit B3 deficiency)

30- Diarrhea plus anemia with ↑ MCV, Puerto Rico Tropical sprue
31- Diarrhea and recurrent abdominal pain; Churg-Strauss syndrome
asthma
32- Diarrhea / steatorrhea with weight loss and Somatostatinoma
diabetes; pancreatic mass & gallstones
33- Diarrhea, ↓ K+, pancreatic mass, gastric VIPoma “vasoactive intestinal peptide secreting
achlohydria pancreatic endocrine tumor”
34- Small gastric tumor, right-sided congestive Carcinoid syndrome
heart failure; flushing; ↑ serum chromogranin A
35- Diarrhea oral ulcers, anterior uveritis, genital Bachet disease
ulcers, terminal ileal ulcers; it’s not Crohn disease –
what is it?
36- Small gastric tumor, right-sided congestive Carcinoid syndrome
heart failure; flushing; ↑ serum chromogranin A
37- Abdominal pain, progressive weight loss in an Pancreatic cancer
alcoholic; glucose intolerance; mental depression;
skin rash (superficial migratory thrombophlebitis;
abnormal ultrasound)
In Capsule Series Mowafy internal medicine Hepatology revision

Esophagus & stomach

1- Oropharyngeal dysphagia occurs in
a) Myasthenia gravis
b) Bulbar palsy
c) Multiple sclerosis
d) Motor neuron disease
e) All of the above
Oropharyngeal dysphagia occurs when there is difficulty moving the food from the oral cavity to the esophagus.
2- Which of the following is seen in achalasia?
a) High LES pressure
b) Non relaxation of LES
c) Poor contractility of the body of esophagus
d) All of the above
3- Management of achalasia is by
a) Pneumatic balloon dilatation
b) Myotomy
c) Botulinum toxin injection
d) All of the above
4- Causes of acute gastritis include all except
a) Alcohol
b) Stress
c) NSAIDs
d) Uremia
e) Menetrier disease
Menetrier disease is a rare disorder characterized by massive overgrowth of mucous cells in the mucous membrane lining
the stomach, resulting in large gastric folds.

5- NSAIDs causes gastric erosion by

a) Directly toxic to gastric mucosa
b) Reduce bicarbonate secretion, thus loss of alkalinity
c) Reduce epithelial cell turnover by decreasing prostaglandin
d) All of the above
6- H. Pylori association is strongest with except
a) Gastric ulcer
b) Gastric lymphoma
c) Duodenal ulcer
d) Gastric cancer
e) Zollinger Ellison syndrome

7- The following is false of esophageal pain

a) It can occur in the absence of heartburn
b) It can mimic the pain of myocardial infarction
c) It can be relieved by glyceryl trinitrate
d) It is usually precipitated by exercise
In Capsule Series Mowafy internal medicine Hepatology revision

8- Typical features of achalasia include except

a) Recurrent pneumonia
b) Predispose to esophageal carcinoma
c) Heartburn and acid reflux
d) Symptomatic response to pneumatic balloon dilatation
Acid reflux is prevented by the non-relaxing LES
9- Perforation of a peptic ulcer is typically associated with except
a) Chronic rather than acute ulcers
b) Duodenal more often than gastric ulcers
c) Abdominal pain radiating to the shoulder tip
d) The absence of nausea and vomiting
10- Complications of partial gastrectomy include
a) Iron deficiency anemia
b) Reactive hypoglycemia
c) Vomiting & diarrhea soon after meals
d) All of the above
11- The following are true of neoplastic disease in stomach except
a) Menetrier disease is due to metaplasia of the gastric mucosa
b) Helicobacter pylori infection is an essential risk factor of gastric cancer
c) Gastric carcinoma produces abdominal pain that is often worse after eating
d) The most common gastric carcinoma is squamous cell origin
12- What is TRUE in achalasia?
a) The most common symptom is dysphagia.
b) In the early stages, dysphagia is more for solids than liquids.
c) The incidence of sarcoma is increased.
d) Endoscopic dilatation should be avoided.
Dysphagia in esophageal achalasia is described as liquids > solids. There are numerous reports of an increased
incidence of carcinoma in achalasia, ranging from 3% to 10%. The treatment is surgical myotomy or endoscopic
dilatation.
13- Which of the following is a risk factor for developing gastric cancer?
a) Exposure to ionizing radiation
b) Blood group B
c) A diet high in fiber
d) H. pylori infection
H. Pylori infection, smoking, and a high salt intake are all risk factors for gastric cancer. A diet high in fruits,
vegetables, and fiber may lower the risk for gastric cancer.
14- Gastrin is predominantly secreted from
a) Antral mucosa
b) Fundus of the stomach
c) 2nd part of duodenum
d) Jejunum
15- All of the following are method for detection of H. pylori except
a) Histology
b) Endoscopic view
c) Polymerase chain reaction
d) Rapid urease test
In Capsule Series Mowafy internal medicine Hepatology revision

16- What percentage of Zollinger-Ellison syndrome are malignant?

a) 20%
b) 30%
c) 40%
d) 60%

17- NSAIDs induced ulcers are best treated by

a) Proton pump inhibitors
b) H2 receptor antagonists
c) Sucralfate
d) Prostaglandins like misoprostol
18- A 64-year-old man underwent a gastrectomy 20 years earlier. He is more likely to show which of the
following?
a) Porphyria
b) Hemosiderosis
c) Aplastic anemia
d) Hemolytic anemia
e) Iron deficiency anemia

19- A 63-year-old man underwent gastric resection for severe peptic ulcer disease. He had complete
relief of his symptoms but developed “dumping syndrome.” This patient is most likely to complain of
which of the following?
a) Gastric intussusception
b) Repeated vomiting
c) Severe diarrhea
d) Severe vasomotor symptoms after eating
e) Intestinal obstruction
Dumping syndrome is a symptom complex occurring after gastric surgery. It is characterized by fatigue, abdominal
distension, pain, and vasomotor symptoms caused by the rapid entry of food into the small intestine. Tachycardia,
sweating, and feeling lightheaded after eating are symptoms patients may feel.

20- What is TRUE about H. pylori? ***

a) Active organisms can be diagnosed by serology.
b) It is protective against gastric carcinoma.
c) It is associated with chronic gastritis.
d) It causes gastric ulcer but not duodenal ulcer.
e) It can be detected by the urea breath test in <60% of cases
o H. pylori is associated with chronic gastritis, duodenal ulcers, gastric ulcers, and gastric cancer.
o Serology can accurately detect H. pylori but remains positive for up to 1 year post treatment.
o The urea breath test is highly sensitive (96%) and specific (94%).
o In 2005, Barry Marshall and J. Robbin Warren won the Nobel Prize in medicine for their work on H. pylori and
its role in gastritis and peptic ulcer disease ☺
 In Capsule Series Mowafy internal medicine Hepatology revision

21- Investigations of a 43-year-old woman to determine if a gastrinoma (ZES) is present. The serum
gastrin level is slightly elevated. Further assessment to establish the diagnosis can be made by repeating
the serum gastrin level after stimulation with which of the following?
a) Phosphate
b) Potassium
c) Calcium
d) Chloride
e) Magnesium
In ZES gastrin levels may be only mildly elevated but can be increased with provocation with intravenous calcium or
secretin. Most patients with gastrinoma have serum gastrin levels that exceed 500 pg/mL. When the range is lower
than 200–500 pg/mL, a stimulation test is performed to confirm the diagnosis. A rise of 200 pg/mL after 15 minutes,
or a doubling of the fasting level is diagnostic.
22- A 67-year-old woman complains of paresthesia in the limbs. Examination shows loss of vibratory
sense, positional sense, and sense of light touch in the lower limbs. She is found to have pernicious
anemia. Endoscopy reveals an ulcer in the body of the stomach. What does she most likely have?
a) Excess of vitamin B12
b) Deficiency of vitamin K
c) Cancer of the stomach
d) Esophageal varices
Patients with pernicious anemia have achlorhydria and an increased risk (about 5%) of developing gastric carcinoma.
There is a deficiency in vitamin B12 that leads to megaloblastic anemia and neurologic involvement.
23- Achalasia cardia gives rise to all except
a) Chest pain
b) Diarrhea
c) Dysphagia
d) Regurgitation

24- Regarding carcinoma of esophagus, all are true except

a) Trachea-esophageal fistula may occur in advanced disease
b) Dysphagia starts with solid foods
c) Painless obstruction to the passage of a food bolus.
d) Odynophagia (painful swallowing) may be a symptom
e) Commonest site of affection is lower third
o Squamous carcinoma is more likely to occur in the middle third of the esophagus.
o Painless obstruction may occur due to destruction of the mucosal innervation
25- Achalasia cardia may lead to all except
a) Pneumonia
b) Lung abscess
c) Emphysema
d) Fibrosis of the lung
26- Carcinoma of esophagus may be predisposed by all except
a) Lye ingestion
b) Chronic achalasia
c) Plummer-Vinson syndrome
d) Hypervitaminosis A
In Capsule Series Mowafy internal medicine Hepatology revision

27- In Barrett’s esophagus

a) Hiatal hernia may be present in 20% of patients
b) Metaplasia of normal esophageal squamous epithelium to columnar epithelium
c) A consequence of achalasia cardia
d) Risk of adenocarcinoma decreased
28- Regarding GERD, all are true except ***
a) 50% of patients with GERD present with nonerosive reflux (NERD) with normal endoscopic
findings.
b) Esophageal pH monitoring is the gold standard investigation & it’s not a routine investigation
c) In a case of typical symptoms, start PPIs without endoscopy
d) Eosinophilic esophagitis usually respond to PPIs
29- Carcinoma of the stomach is associated with
a) Chronic hypochlorhydria
b) H. pylori
c) Menetrier’s disease (hypertrophic gastritis)
d) All of the above
30- The most common cause of duodenal ulcer is
a) NSAIDs
b) Helicobacter pylori
c) Alcohol abuse
d) Chronic cortisone therapy
31- You see a 47-year-old man with a 3 month history of epigastric dull abdominal pain. He states that
the pain is worse in the morning and is relieved after meals. There is no history of weight loss and the
patient’s bowel habits are normal. On examination, his abdomen is soft and experiences moderate
discomfort on palpation of the epigastric region. The most likely diagnosis is :
a) Gastric ulcer
b) Gastritis
c) Duodenal ulcer
d) Cancer stomach
32- The most appropriate description of Barrett esophagus is :
a) Metaplasia of the squamous epithelium of the lower third of esophagus to columnar epithelium
b) Metaplasia of the columnar epithelium of the lower third of esophagus to squamous epithelium
c) Metaplasia of the squamous epithelium of the upper third of esophagus to columnar epithelium
d) Metaplasia of the columnar epithelium of the upper third of esophagus to squamous epithelium
33- Which of the following is not effective to eradicate H. pylori?
a) Clarithromycin
b) Pantoprazole
c) Tinidazole
d) Cefotaxime
34- Lower esophageal sphincter is relaxed by
a) Gastrin
b) B agonist
c) Metoclopramide
d) Protein meal
In Capsule Series Mowafy internal medicine Hepatology revision

35- A 55- year - old male smoker presents with burning epigastric pain several hours after a meal, which
is relieved by antacids. Upper gastrointestinal endoscopy discloses an ulcer with a well-demarcated
border at the duodenal bulb. Histologic examination of a biopsy specimen of the ulcer crater reveals
esinophilic necrosis with surrounding fibrosis without evidence of malignancy. Furthermore, analysis of
a histologic section involving the gastric mucosa reveals invasion with a gram-negative rod. Which of the
following is the most appropriate therapy?
a. Mylanta.
b. Ranitidine.
c. Omeprazole.
d. Bismuth plus metronidazole.
e. Omeprazole plus clarithromycin plus metronidazole.
It is a case of Helicobacter pylori, baby
36- Which of the following is the most effective in the treatment of gastro-esophageal reflux disease ?
a. Ranitidine 300 mg BD.
b. Omeprazole 20 mg OD.
c. Bismuth TDS.
d. Mg trisilicate .
e. Aluminium hydroxide.
37- Which of the following is the most accurate statement regarding H pylori infection?
a. It is associated with the development of colon cancer.
b. Eradication of H pylori eliminates most cases of nonulcer dyspepsia.
c. The route of transmission is believed to be sexually transmitted.
d. It is a cause of both duodenal and gastric ulcers
38- A 48 year old man presents to you with a 3 month history of heartburn after meals which has not
been settling with antacid and omeprazole. You suspect that the patient has a hiatus hernia. The
most appropriate investigation in a case of hiatus hernia is :*
a) CT
b) Chest X ray
c) Barium meal
d) Upper GI endoscopy
e) Ultrasound
39- In a patient with severe symptoms of gastro-esophageal reflux which of the following is false?
a) Cigarette smoking will exacerbate the problem
b) Cisapride is effective at relieving symptoms
c) Ambulatory pH monitoring will show long periods with pH less than 4
d) Dysphagia may occur
Cigarette smoking reduces lower esophageal sphincter pressure and will worsen the problem.
Cisapride is a gastroprokinetic agent, a drug that increases motility in the upper gastrointestinal tract.
It acts directly as a serotonin 5-HT4 receptor agonist & it has been either withdrawn from the market
or had its indications limited due to incidences of serious cardiac side-effects. Although cisapride, H2
receptor antagonists and proton pump inhibitors have all been shown to improve symptoms, only
proton pump inhibitors are reliably effective in patients with severe symptoms.
In Capsule Series Mowafy internal medicine Hepatology revision

40- H. Pylori is usually not associated with

a) Zollinger Ellison syndrome
b) Antral gastritis
c) Non ulcer dyspepsia
d) Gastric lymphoma
41- A 37-year-old woman presents with complaints of severe heartburn with or without meals. She has a
history of hypertension, which has been treated with captopril. She also has a history of Raynaud
disease, multiple facial telangiectasias, and very taut skin on the dorsum of both hands. She has failed to
obtain relief for her heartburn with large doses of antacids, ranitidine, or omeprazole. Esophageal
manometry is ordered. Which of the following would be the most likely results of this test?
a) Decreased esophageal peristalsis and decreased LES pressure
b) Decreased esophageal peristalsis and increased LES pressure
c) Increased esophageal peristalsis and increased LES pressure
d) Normal esophageal peristalsis and normal LES pressure
- This patient has the classic presentation of gastroesophageal reflux disease (GERD) in association with
scleroderma. These patients have the deposition of collagen in the body of the esophagus, as well as the
lower esophageal sphincter (LES). This results in the typical pattern of decreased esophageal peristalsis
and the reduced ability of the LES to maintain its high pressures between swallowing. These patients are
therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's
esophagus. Although there is no corrective therapy to improve esophageal motility or increase LES
pressure, aggressive treatment is generally aimed at reducing acid production with the use of high doses of
proton pump inhibitors. Nevertheless, many of these patients develop the long-term consequences of
GERD.

- Choice B suggests achalasia, in which impaired esophageal peristalsis is often accompanied by a lack of
lower esophageal sphincter relaxation.

42- Which of the following statements about achalasia is correct ?

a. The underlying abnormality appears to be defective innervation of the esophagus and lower gastric
sphincter.
b. Dysphagia, chest pain and regurgitation are the predominant symptoms.
c. Chest x-ray often reveal a large gastric air bubble.
d. Manometry reveals a normal or elevated pressure of the lower gastric sphincter.
e. Omeprazole is effective in controlling the symptoms in many patients.
o Manometry reveals a normal or elevated LES pressure and reduced or absent swallow-induced
relaxation.
o A decreased number of ganglion cells are noted in the esophageal body and LES of patients with
achalasia, suggesting that defective innervations of these areas is the underlying abnormality.
o Dysphagia , chest pain and regurgitation are the predominant symptoms.
o The chest x-ray often reveals absence of the gastric air bubble, and the barium swallow reveals a
dilated esophagus.
In Capsule Series Mowafy internal medicine Hepatology revision

43- A 70 year-old woman with a history of aspirin-induced gastritis 5 years ago now has severe
knee and hip pain that is thought to be due to osteoarthritis. She requires treatment with
non steroidal anti-inflammatory agents, which of the following agents would be most
helpful for prophylaxis against recurrent gastrointestinal bleeding ?

a. Omeprazole.
b. Misoprostol.
c. Nizatidine.
d. Sucralfate.
e. Atropine.
Gastric mucosal injury, potentially resulting in ulcers and erosive gastritis , may be produced by aspirin
and nonsteroidal anti-inflammatory drugs including indomethacin , ibuprofen and naproxen. These
agents may be directly toxic to the gastric mucosa by depleting protective endogenous mucosal
prostaglandins. Moreover, they more directly interrupt the mucosal barrier , allowing back diffusion of
hydrogen ions as well as reducing gastric mucus secretion and increasing gastric acid secretion. The
prostaglandin E analogue misoprostol is effective in preventing ulcers and gastritis caused by NSAIDs.
Its mechanism of action is believed to be stimulation of gastric mucus and duodenal bicarbonate
secretion as well as the maintenance of the gastric mucosal barrier via epithelial cell restitution.

44 - Which of the following statements concerning the relationship of duodenal ulcer and H.
pylori infection is correct ?

a. Virtually all patients with a duodenal ulcer harbor H. pylori.

b. Most patients infected with H. pylori will develop an ulcer.
c. H. pylori invades the gastric mucosa.
d. The demonstration of H. pylori as a causative feature in a given patient with a duodenal
ulcer requires biopsy.
e. The relapse rate for duodenal ulcer is equivalent whether H. pylori eradication therapy or
H2 receptor antagonists are used.

Although only 15 - 20% of persons infected with the spiral shaped , gram negative bacillus H. pylori will
develop an ulcer 95 - 100% of those with a documented duodenal ulcer can be shown to have H. pylori
infection. Typically the organism is found in the deep portion of the mucus gel. Although bacteria may
adhere to the luminal surfaces of the gastric epithelial cells , they do not invade the muscosa . It appears
that the bacteria activate inflammatory cells that produce mucosal damage and release enzymes such as
proteases and phospholipases which degrade the mucus gel layer . The prevalence of gastric colonization
with H. pylori increases with age and with lower socioeconomic status. There are multiple ways to
diagnose H. pylori infection including histologic examination , culture measurement of urease activity
and serologic studies. The most effective way to decrease the relapse rate for duodenal ulcer is to institute
therapy that successfully eradicates H. pylori . The relapse rate is much higher if H2 receptor antagonists
are used alone.
In Capsule Series Mowafy internal medicine Hepatology revision

GIT collections
1- Presence of diverticulosis is most commonly seen in*
a) Transverse colon
b) Sigmoid colon
c) Descending colon
d) Cecum
2- The inheritance of cystic fibrosis is
a) Sex linked recessive
b) Sex linked dominant
c) Autosomal recessive
d) Autosomal dominant
3- A 58-year-old man presents to the emergency room with a temperature of 39°C,
abdominal pain localizing to the left lower quadrant, and mild rebound tenderness.
Which of the following diagnostic tests is the best next step?*
a. Barium enema
b. Flexible sigmoidoscopy
c. CT imaging of the abdomen
d. Laparoscopic examination
CT imaging is the modality of choice in evaluating diverticulitis. Barium enema and endoscopy tend to increase
intraluminal pressure and can worsen diverticulitis or lead to colonic rupture. Colonoscopy is also contraindicated in
the acute setting and should be delayed to 6 weeks after to rule out a neoplasm.

4- Which one of the following diagnostic studies for malabsorption is usually normal in
persons who have bacterial overgrowth syndrome ?

a. Fecal fat quantitation ( 24h )

b. Stage II Schilling test ( intrinsic factor giving with vitamin B12 )
c. D-Xylose absorption test.
d. Lactulose breath test.
e. Quantitative cultures of jejuna aspirates.
Malabsorption caused by bacterial overgrowth results from bacterial utilization of ingested vitamins
and the deconjugation of bile salts by bacteria in the proximal jejunum. The bacteria also separate
vitamin B 12 from the intrinsic factor, thus interfering with its absorption from the ileum. persons with
bacterial overgrowth have steatorrhea, anabnormal Schilling test (even with the administration of
intrinsic factor ), increased metabolism of non absorbable carbohydrates ( lactulose ) and increased
bacterial concentrations in jejunal aspirates. Absorption of D- Xylose , a simple carbohydrate , is often
normal.
In Capsule Series Mowafy internal medicine Hepatology revision

5- A 55- year - old male smoker presents with burning epigastric pain several hours after a
meal, which is relieved by antacids. Upper gastrointestinal endoscopy discloses an ulcer with a
well-demarcated border at the duodenal bulb.Histologic examination of a biopsy specimen of
the ulcer crater reveals eosinophilic necrosis with surrounding fibrosis without evidence of
malignancy. Furthermore, analysis of a histologic section involving the gastric mucosa reveals
invasion with a gram-negative rod. Which of the following is the most appropriate therapy?

a. Mylanta.
b. Ranitidine.
c. Omeprazole.
d. Bismuth plus metronidazole.
e. Omeprazole plus clarithromycin plus metronidazole.

This patient has the classic clinical symptoms and endoscopic findings of a duodenal ulcer. It is now a
recommendation that H. pylori infection should be eradicated in patients with documented peptic ulcer
disease. No single or double agent regimen has been reliably effective in eradicating the organism. In
general, a combination of two antibiotics plus a proton pump inhibitor (omeprazole) is required to achieve
a high likelihood of eradication. Such triple therapy is effective in eradicating the organism in
approximately 90 & of the cases.

6- Which of the following is true regarding cholecystokinin ?

a) In excess, it precipitates gallstones.

b) It causes delayed gastric emptying through its action as a smooth muscle relaxant.
c) It is found in higher concentrations following cholecystectomy.
d) It releases the ‘ileal brake’
e) It stimulates pancreatic exocrine secretion.
In Capsule Series Mowafy internal medicine Hepatology revision

7 - A 64-year-old man presents to his primary care physician with a complaint of

foul-smelling diarrhea, which he has had for the past 4 to 5 months. He has three or
four stools a day, which he describes as oily in nature. He denies experiencing a
change in the caliber of his stools, and he also denies having abdominal pain,
melena, or blood per rectum. His appetite is still fairly good, but he describes weight
loss & fatigue. His medical history is notable for hypertension, hyperlipidemia, type
2 diabetes with retinopathy and mild neuropathy, and gastroesophageal reflux
disease. His medications include metformin, insulin, atenolol, simvastatin, aspirin,
and omeprazole. The neurologic examination is notable only for mild stocking-glove
neuropathy, and an S4 is heard on cardiac examination. Laboratory tests reveal
macrocytic anemia and mild hypoalbuminemia.
Which of the following is the most likely diagnosis for this patient?

a. Crohn disease.
b. Intestinal lymphoma.
c. Bacterial overgrowth syndrome.
d. Hemochromatosis.
e. Chronic pancreatitis.
This patient has a subacute to chronic presentation with steatorrhea and likely folate defideficiency,
vitamin B12 deficiency or both. He has diabetes mellitus, which can cause stasis through autonomic
neuropathy. Anything that causes intestinal stasis allows a proliferation of bacteria, which leads to changes
in bile salt metabolism and impaired absorption, primarily of vitamin B12. In addition, this patient is taking
proton pump inhibitor, which can reduce motility of the proximal small bowel, often precipitating
symptoms in a predisposed patient. Therapy usually entails repeated courses of antibiotics active against
anaerobes.

8- A 30 year-old man has had a low volume, mucoid diarrhea for 3 weeks accompanied by lower
abdominal pain. On examination he has no abdominal masses. His stool is positive for occult blood.
Colonoscopy reveals an erythematous, friable colonic mucosa extending from the rectum to the splenic
flexure. Colonic biopsies reveal mucosal ulceration with crypt abscesses. Which of the following
complications is the most likely to develop?

a. Bowel perforation.
b. Fistula formation to the skin.
c. Ischemic bowel necrosis.
d. Colonic adenocarcinoma.
Ulcerative colitis carries a significant risk for development of colonic adenocarcinoma 2-3 decades after
onset.