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INTESTINAL DISORDERS MCQs With Answers

INTESTINAL DISORDERS MCQs

1. A 55-year-old housewife had suff ered diarrhoea, bloating, and weight loss for many years. The patient had started a strict gluten-free diet after reading about coeliac disease on the Internet and her symptoms dramatically improved. She had made an appointment to see her GP to discuss this.
Investigations:
haemoglobin 107 g/L (115–165)
mean cell volume 77.2 fL (80–96)
She was referred for a gastroscopy, and duodenal biopsies were taken.
Which one of the following duodenal histological features is most suggestive of a Marsh I classifi cation of coeliac disease?
A. Crypt hyperplasia
B. Flat atrophic mucosa
C. Increased mitotic activity
D. Lymphocytic infi ltration on the lamina propria
E. Villous height/crypt depth ratio reduced

2. A 32-year-old man with well-controlled Crohn’s disease presented with diarrhoea. He had undergone a terminal ileal resection for localized disease 2 years ago, and was not taking any regular medication.
Investigations:
haemoglobin 134 g/L (130–180)
white cell count 9.7 x 10 9 /L (4.0–11.0)
platelet count 235 x 10 9 /L (150–400)
plasma thyroid-stimulating hormone 0.7 mU/L (0.4–5.0)
plasma free T 4 18 pmol/L (10.0–22.0)
serum vitamin B 12 127 ng/L (160–760)
serum ferritin 39 μg/L (15–300)
red cell folate 470 μg/L (160–640)
serum C-reactive protein 6 mg/L (< 10)
faecal elastase 280 μg/g (>200)
SeHCAT scan 5% (> 15%)
Which of the following statements regarding his diagnosis is most accurate?
A. Coeliac disease is commonly associated with this disorder
B. Pancreatic calcifi cation on abdominal X-ray would be expected
C. Symptoms of IBS are unlikely to occur with this disorder
D. Small bowel bacterial overgrowth can give false-positive SeHCAT scan results
E. Treatment with colesevelam could be considered

3. A 57-year-old man presented to hospital with persistent, non-bloody, watery diarrhoea. His GP had trialled management for irritable bowel syndrome, and there had been some improvement with a wheat- and dairy-free diet. He had had severe peptic ulcer disease for which he underwent a Billroth II procedure 10 years previously, after presenting in hypovolaemic shock.
Investigations:
anti-tissue transglutaminase antibodies 12 U/mL (< 15)
faecal calprotectin 36 μg/g (< 50)
faecal elastase 356 μg/g (> 200)
stool microscopy and culture negative
hydrogen breath test (see Figure 2.1)

Which is the most likely diagnosis?
A. Bile salt malabsorption
B. Coeliac disease
C. Lactose intolerance
D. Pancreatic insuffi ciency
E. Small bowel bacterial overgrowth

4. A 47-year-old man with a 25-year history of type I diabetes mellitus presented with intermittent, watery, largely nocturnal, non-bloody diarrhoea with a couple of episodes of faecal incontinence. He had no weight loss, abdominal pain, or fatigue.
Investigations:
haemoglobin 134 g/L (130–180)
white cell count 9.7 x 10 9 /L (4.0–11.0)
platelet count 235 x 10 9 /L (150–400)
serum sodium 143 mmol/L (137–144)
serum potassium 4.6 mmol/L (3.5–4.9)
serum urea 6.8 mmol/L (2.5–7.0)
serum creatinine 123 μmol/L (60–110)
serum HbA1c 7.6% (< 6%)
hydrogen breath test negative
colonoscopy normal
colonic biopsy histology normal
Which of the following neurotransmitters is most responsible for activating sensory neurones and thus the myenteric plexus, following stimulation of stretch receptors in the bowel?
A. Acetylcholine
B. Nitric oxide
C. Serotonin
D. Substance P
E. Vasoactive intestinal peptide

5. A 19-year-old student was referred to clinic with persistent non-bloody diarrhoea, abdominal cramps, and bloating. She was in her fi rst year at university, having returned from her gap year a month earlier. The symptoms started while she was travelling.
Investigations:
haemoglobin 110 g/L (115–165)
white cell count 6.8 x 10 9 /L (4.0–11.0)
platelet count 415 x 10 9 /L (150–400)
MCV 88 fL (80–96)
serum albumin 37 g/L (37–49)
anti-tissue transglutaminase antibodies 11 U/mL (< 15)
plasma thyroid-stimulating hormone 1.7 mU/L (0.4–5.0)
stool microscopy and culture negative
duodenal histopathology villous fl attening, deepening of the crypts,
increased infl ammatory infi ltrate in the lamina
propria. Giardia lamblia organisms seen
Which statement best describes the Giardia lamblia trophozoite cycle?
A. Trophozoites adhere to the mucosal surface, causing cytokine release and consequent fl uid and electrolyte loss
B. Trophozoite colonization is limited to the upper small bowel
C. Trophozoites invade the mucosa and submucosa, causing cytokine release and consequent fluid and electrolyte loss
D. Trophozoites invade tissues and gain entry to the lymphatic system, facilitating systemic spread
E. Upon entry into the duodenum, intestinal bacteria break down the encapsulating cyst, releasing the trophozoite

6. A 65-year-old woman presented to her GP with a 4-year history of watery diarrhoea. Her only comorbidity was depression, which was managed with sertraline.
Investigations:
haemoglobin 132 g/L (115–165)
white cell count 4.6 x 10 9 /L (4.0–11.0)
platelet count 470 x 10 9 /L (150–400)
MCV 88.1 fL (80–96)
serum sodium 137 mmol/L (137–144)
serum potassium 3.8 mmol/L (3.5–4.9)
serum urea 7.1 mmol/L (2.5–7.0)
serum creatinine 89 μmol/L (60–110)
anti-tissue transglutaminase antibodies 9 U/mL (< 15)
plasma thyroid-stimulating hormone 3.4 mU/L (0.4–5.0)
stool microscopy, culture, and sensitivities negative
faecal elastase 405 μg/g (> 200)
colonoscopy normal
colonic histopathology pending
Which of the following histological fi ndings would be most in keeping with a diagnosis of collagenous colitis?
A. > 20 eosinophils per high-powered fi eld
B. > 20 lymphocytes per 100 epithelial cells
C. Focal active cryptitis
D. Preservation of crypt architecture
E. Subepithelial collagen layer 6 μm in thickness

7. An 82-year-old diabetic woman was referred to the acute medical take with severe diarrhoea and abdominal pain. She was resident in a nursing home and had had a recent course of clindamycin for a chronic infection of her third metatarsal.
Which of the following is the gold standard method of determining clinically signifi cant Clostridium diffi cile ?
A. Cell culture cytotoxicity assay
B. Enzyme-linked immunosorbent assay
C. Glutamate dehydrogenase antigen testing
D. Polymerase chain reaction
E. Stool microscopy and culture

8. A 67-year-old man was referred to the gastroenterology clinic with diarrhoea, fresh rectal bleeding, lower abdominal pain, and pain on defecation. He had undergone chemoradiotherapy for rectal cancer, and radiotherapy was last carried out 12 months earlier. His bowel symptoms were getting worse and he had lost 8 kg in weight.
Investigations:
CT abdomen and pelvis no evidence of recurrence of colorectal cancer colonoscopy no evidence of malignant recurrence; erythematous friable rectum
Which of the following is the most appropriate fi rst-line treatment?
A. Corticosteroid enema
B. Hyperbaric oxygen
C. Mesalazine
D. Metronidazole
E. Sucralfate enema

9. A 25-year-old girl with constipation-predominant irritable bowel syndrome (C-IBS) was referred to clinic with ongoing anal pain. She described excruciating pain on defecation with hard stools. On rectal examination her GP had identifi ed an anal fi ssure. Treatment with warm baths, stool softeners, and topical anaesthetic gels had failed to provide relief.
What would be the next most appropriate treatment?
A. Botulinum toxin injections
B. Lateral sphincterotomy
C. Topical diltiazem
D. Topical glyceryl trinitrate
E. Topical hydrocortisone

10. A 39-year-old homosexual man was referred to clinic. He had a 6-month history of rectal pain, tenesmus, and a mucopurulent, occasionally bloody, anal discharge. He had lost 6 kg in weight and developed widespread lymphadenopathy. He had had three new sexual partners during the last year.
Investigations:
flexible sigmoidoscopy distal proctitis, pus in rectum colonic histopathology possible Crohn’s disease
Which of the following most closely resembles Crohn’s disease on histopathology specimens?
A. Chlamydia lymphogranuloma venereum (LGV)
B. Chlamydia trachomatis
C. Herpes simplex virus
D. Neisseria gonorrhoeae
E. Treponema pallidum

11. A 19-year-old British man spent July and August working at an American summer camp as a water-sports instructor. He was fi t and well with no medical conditions. He presented to his general practitioner the following April complaining of an intermittent patch of raised itchy skin, which appeared and disappeared in a matter of hours, at diff erent sites on his back. He had had an area of infl amed skin between his toes while in the USA; he attributed this to a fungal infection. He had also suff ered from travellers’ diarrhoea while abroad.
Investigations:
haemoglobin 156 g/L (130–180)
MCV 92 fL (80–96)
white cell count 10.2 x 10 9 /L (4.0–11.0)
neutrophil count 6.5 x 10 9 /L (1.5–7.0)
lymphocyte count 1.7 x 10 9 /L (1.5–4.0)
eosinophil count 1.6 x 10 9 /L (0.04–0.40)
basophil count 0.04 x 10 9 /L (< 0.1)
platelet count 420 x 10 9 /L (150–400)
stool microscopy and culture negative x 3
Which treatment is the most appropriate?
A. Corticosteroids
B. Filaricides
C. Ivermectin
D. Metronidazole
E. Tiabendazole

12. A 40-year-old man presented for the fi rst time to your outpatient clinic. He had recurrent abdominal pain which improved with defecation, and mushy stools up to three times a day for the last 4 months. He denied weight loss, rectal bleeding, or a family history of colorectal cancer.
Investigations:
stool microscopy, culture, and sensitivity negative for ova, cysts, and parasites
Which of the following is the next most appropriate management step?
A. Abdominal ultrasound
B. Colonoscopy
C. Flexible sigmoidoscopy
D. Thyroid function test
E. Tissue transglutaminase

13. A 38-year-old man presented to the gastroenterology outpatient clinic for the fi rst time. He complained of recurrent abdominal pain, every other day, for the last 3 months.
Which of the following symptoms most favours a diagnosis of irritable bowel syndrome?
A. Episodes of abdominal pain every 2 months
B. Full sensation, even after a small meal
C. Improvement with defecation
D. Mucus discharge per rectum
E. Nausea

14. A 42-year-old male patient attended your outpatient clinic. He was diagnosed with acromegaly in his early twenties. He did not complain of any bowel symptoms, but has read about an increased risk of developing colorectal cancer.
His screening colonoscopy at age 40 years demonstrated one 3 mm hyperplastic polyp which was completely excised from the sigmoid colon. He is otherwise healthy and his body mass index is 25 kg/m 2 .
Investigations:
thyroid-stimulating hormone 2.4 mU/L (0.4–5.0 mU/L)
insulin-like growth factor-1 42.6 nmol/L (7.5–37.3 nmol/L)
fasting plasma glucose 4.9 mmol/L (3.0–6.0 mmol/L)
Which of the following is the most appropriate with regard to ongoing surveillance?
A. Annual colonoscopy
B. Colonoscopy at age 60 years on the national bowel cancer screening programme
C. 5-yearly colonoscopy
D. 10-yearly colonoscopy
E. 3-yearly colonoscopy

15. A 63-year-old patient underwent a colonoscopy to investigate a change in bowel habit. The colonoscopy report read as follows:
‘The instrument was inserted to the terminal ileum, adequate bowel prep. In the rectum two 2 mm polyps were hot biopsied. A 4 mm rectal sessile polyp was excised and retrieved. In the sigmoid colon a pedunculated polyp of 15 mm was removed by snare polypectomy. A polyp of 7 mm and a polyp of 12 mm were found in the descending colon; these were snared and retrieved. Macroscopically all polyps were completely excised.’
The histology report described four adenomatous polyps and two rectal hyperplastic polyps that were 2 mm in diameter.
What is the most appropriate follow-up for this patient?
A. Colonoscopy in 1 year’s time
B. Colonoscopy in 3 years’ time
D. Colonoscopy in 3 months’ time
C. Colonoscopy in 5 years’ time
E. Colonoscopy in 6 months’ time

16. A 35-year-old woman presented with a history of loose stools over the last 2 months. She was referred for a colonoscopy. Multiple polyps (around 50) were found in the ascending and transverse colon. You asked about her family history and she revealed that her grandfather’s brother died of bowel cancer, and her nephew recently had bowel surgery for polyps. Both of her parents, aged 65 and 70 years, and her two brothers, aged 45 and 42 years, are healthy.
Which of the following is the most likely diagnosis?
A. Familial adenomatous polyposis
B. Juvenile polyposis syndrome
C. Hereditary non-polyposis colorectal cancer
D. MUTYH-associated polyposis
E. Peutz–Jeghers syndrome

17. A 20-year-old man presented to the gastroenterology outpatient clinic. He is an only child whose father was diagnosed with hereditary non-polyposis colorectal cancer at the age of 40 years, and died of colorectal cancer. No other family history is available. He is well and not complaining of any symptoms.
What is the next most appropriate step in his management?
A. Colonoscopy and gastroduodenoscopy
B. Colonoscopy from age 25 years
C. Colonoscopy with dye spray
D. 5-yearly colonoscopy from age 50 to 75 years
E. Genetic testing

18 . A 23-year-old man attended the gastroenterology clinic for advice. His brother was recently diagnosed with familial adenomatous polyposis, and genetic testing identifi ed a germ-line mutation. He asked for your advice on further management.
What would be the most appropriate next step?
A. Colonoscopy
B. Flexible sigmoidoscopy
C. Genetic testing
D. Oesophagogastroduodenoscopy and colonoscopy
E. Prophylactic surgery

19. A 40-year-old female patient presented to your outpatient clinic with a history of intermittent central abdominal pain. Examination revealed freckles on her lips, buccal mucosa, and eyelids. Her past medical history included breast cancer, which was diagnosed 1 year ago.
What would be the most appropriate next step?
A. Colonoscopy and genetic testing for breast cancer susceptibility gene 1 and breast cancer susceptibility gene 2
B. Colonoscopy and genetic testing for serine/threonine kinase 11 gene mutation
C. Colonoscopy and mammogram
D. Colonoscopy under the 2-week wait rule
E. CT of the chest, abdomen, and pelvis

20 . A 20-year-old patient presented with iron-defi ciency anaemia and intermittent abdominal pain. His brother had been diagnosed with juvenile polyposis syndrome.
Which investigation is the most appropriate next step?
A. Colonoscopy and further surveillance
B. CT colonography
C. Genetic testing and colonoscopy
D. Oesophagogastroduodenoscopy
E. Video capsule endoscopy

21. A 35-year-old woman complained of constipation for the last 8 months. She was treated with movicol and sodium docusate at the maximum doses; this did not improve her symptoms.
Which is the most appropriate next drug to try?
A. Glycerol suppositories
B . Lactulose
C. Poloxamer drops
D. Prucalopride
E. Sodium phosphate enemas

22. A 53-year-old woman was referred to your outpatient clinic. She complained of accidental leakage of solid and also liquid stools for the last 2 years. She denied any short-term diarrhoeal illness during that time. She was 167 cm tall and weighed 87 kg. There was no history of infl ammatory bowel disease and she had been diagnosed with irritable bowel syndrome. She has smoked 20 cigarettes a day for 35 years. She had a vaginal forceps delivery at the age of 27 years and a cholecystectomy at the age of 40 years. On examination she was obese, but the physical examination was otherwise normal.
What is the weakest independent risk factor for faecal incontinence in this woman?
A. Cholecystectomy
B. Forceps-assisted delivery
C. High body mass index
D. Irritable bowel syndrome
E. Smoking

23. A 72-year-old woman underwent a colonoscopy because of abdominal bloating and discomfort. The colonoscopy revealed brownish discoloration of the colonic wall. The histological fi nding is shown in Figure 2.2a/Colour Plate 1 and Figure 2.2b/Colour Plate 2.

The pigmentation found in the submucosa is most likely:
A. Haemosiderin
B. Iron sulphide
C. Lipofuscin
D. Melanin
E. Silicate

24. This 51-year-old patient presented with a history of abdominal symptoms for 2 years. She opened her bowels every 4 to 5 days, passing hard and lumpy stool; she also complained of abdominal pain and bloating. She denied any weight loss, fever, or bloody stools. There was no family history of infl ammatory bowel disease and she had no past medical history of note.

Investigations:
haemoglobin 125 g/L (115–165)
white cell count 5.6 x 10 9 /L (4.0–11.0)
platelet count 290 x 10 9 /L (150–400)
MCV 88.1 fL (80–96)
serum sodium 139 mmol/L (137–144)
serum potassium 3.9 mmol/L (3.5–4.9)
serum urea 6.7 mmol/L (2.5–7.0)
serum creatinine 89 μmol/L (60–110)
anti-tissue transglutaminase antibodies 9 U/mL (< 15)
plasma thyroid-stimulating hormone 3.4 mU/L (0.4–5.0)
stool microscopy, culture, and sensitivities negative
faecal elastase 405 μg/g (> 200)
colonoscopy normal
colonic histopathology normal
ano-rectal manometry normal

Which of the following is the most likely fi nding on a bowel transit study?
A. Constipation-predominant irritable bowel syndrome
B. Dyssynergic defecation
C. Normal-transit constipation
D. Slow-transit constipation
E. Slow-transit constipation and dyssynergic defecation

25. A 35-year-old woman is diagnosed with dyssynergic defecation. Which of the following is the most effi cacious treatment modality?
A. Biofeedback therapy
B. Diet
C. Laxatives
D. Myectomy of the anal sphincter
E. Botulinum toxin injection

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