Internal Medicine Exam Gastroenterology Disorders 2 — Questions and Answers
Question 1: A 45-year-old presents with episodic right upper quadrant pain after fatty meals, nausea, and Murphy's sign on exam. Ultrasound shows gallstones with a thickened gallbladder wall. What is the most appropriate next step?
- Laparoscopic cholecystectomy (Correct answer)
- ERCP with sphincterotomy
- Ursodeoxycholic acid therapy
- IV antibiotics and watchful waiting
Correct answer: Laparoscopic cholecystectomy
Symptomatic cholelithiasis with cholecystitis is best treated with laparoscopic cholecystectomy.
Question 2: A 60-year-old with a history of alcohol use presents with severe epigastric pain radiating to the back, elevated lipase (5x normal), and CT showing pancreatic edema without necrosis. What is the Ranson's criterion finding at admission most predictive of severity?
- Age > 55 (Correct answer)
- WBC > 16,000/µL
- Blood glucose > 200 mg/dL
- LDH > 350 IU/L
Correct answer: Age > 55
All listed findings are Ranson's criteria, but age > 55 is the admission criterion; however, any single criterion predicts severity, and WBC >16,000 is also an admission criterion.
Question 3: A patient with Crohn's disease develops a new perianal fistula. Initial treatment with antibiotics (metronidazole) fails. What is the next best pharmacologic therapy?
- Infliximab (anti-TNF) (Correct answer)
- Azathioprine monotherapy
- Oral prednisone
- Cyclosporine
Correct answer: Infliximab (anti-TNF)
Infliximab is FDA-approved for fistulizing Crohn's disease and is the preferred biologic after antibiotic failure.
Question 4: A 55-year-old undergoes screening colonoscopy revealing a 2 cm sessile polyp in the sigmoid colon. Pathology shows high-grade dysplasia confined to the mucosa without submucosal invasion. What is the next step?
- Endoscopic mucosal resection is curative if completely excised (Correct answer)
- Immediate sigmoid colectomy
- Repeat colonoscopy in 1 year
- CT staging of the abdomen and pelvis
Correct answer: Endoscopic mucosal resection is curative if completely excised
High-grade dysplasia (carcinoma in situ) without submucosal invasion can be managed with complete endoscopic resection.
Question 5: A 40-year-old woman with primary biliary cholangitis (PBC) presents with pruritus and fatigue. Labs show elevated alkaline phosphatase and positive anti-mitochondrial antibodies. What is the first-line treatment?
- Ursodeoxycholic acid (Correct answer)
- Cholestyramine alone
- Liver transplantation
- Corticosteroids
Correct answer: Ursodeoxycholic acid
Ursodeoxycholic acid (UDCA) slows PBC progression and improves biochemical markers and is the established first-line therapy.
Question 6: A 30-year-old with bloody diarrhea, tenesmus, and diffuse colitis on colonoscopy is diagnosed with ulcerative colitis. After failing oral mesalamine, what is the next escalation?
- Oral corticosteroids (Correct answer)
- Infliximab immediately
- Colectomy
- Azathioprine as monotherapy
Correct answer: Oral corticosteroids
Moderate UC failing aminosalicylates is treated with corticosteroids before escalating to biologics or immunomodulators.
Question 7: A 70-year-old presents with painless jaundice, weight loss, and a palpable, non-tender gallbladder (Courvoisier's sign). CT shows a mass at the head of the pancreas. Which statement is most accurate?
- Courvoisier's sign suggests malignant biliary obstruction rather than gallstones (Correct answer)
- This presentation is classic for choledocholithiasis
- The gallbladder is typically tender in pancreatic head cancer
- ERCP is the definitive diagnostic test
Correct answer: Courvoisier's sign suggests malignant biliary obstruction rather than gallstones
Courvoisier's law states that a palpable, non-tender gallbladder with jaundice suggests malignant obstruction, as chronic gallstone disease causes a fibrotic, non-distensible gallbladder.
