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Question 1
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A 2-year-old presented with symptoms of gastroenteritis. Which of the following signs is the strongest indicator for IV fluid administration?
Your Answer: Capillary refilling time > 4secs
Explanation:Children are very prone to dehydration during an episode of gastroenteritis. Dehydration is detected early by increased capillary filling time.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 2
Correct
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A baby born a few days earlier is brought into the emergency with complaints of vomiting, constipation and decreased serum potassium. Which of the following is the most probable cause?
Your Answer: Pyloric stenosis: hypokalaemic hypochloraemic metabolic alkalosis
Explanation:In pyloric stenosis a new-born baby presents with a history of vomiting, constipation and deranged electrolytes. Excessive vomiting leads to hypokalaemia. Difficulty in food passing from the stomach to the small intestine causes constipation. Hypokalaemia also causes constipation. None of the other disorders mentioned present with the hypokalaemia, vomiting and constipation triad in a new-born.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 3
Correct
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A 1-day-old baby started having pallor and jaundice. The mother's first child did not have jaundice at birth. On clinical investigations, direct Coombs test is positive. Mother's blood group is A negative. Baby's blood group is O positive. What is the most probable cause of the condition of this new-born?
Your Answer: Rhesus incompatibility
Explanation:Jaundice in a new-born on the day of delivery is most likely due to Rh incompatibility. This occurs when the mother is Rh-negative and the baby is Rh-positive. Antibodies in the mother against the Rh factor in the baby will destroy the red blood cells in the baby, increasing the bilirubin in the blood. Breast milk jaundice and Galactosemia do not occur immediately after birth, and congenital rubella syndrome and formula feeding does not cause jaundice in babies.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 4
Correct
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Which of the following immune responses occurs in Coeliac disease?
Your Answer: Type IV hypersensitivity
Explanation:Celiac disease is classified as a Type IV hypersensitivity mediated by T-cell response. Negatively charged gliadin has been shown to induce interleukin 15 in the enteric epithelial cells, stimulating the proliferation of the natural killer cells and intraepithelial lymphocytes to express NK-G2D, a marker for natural killer T lymphocytes.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 5
Correct
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A 9 year old boy was admitted with gastroenteritis. The boy's symptoms started two days ago with profound diarrhoea and emesis. Blood exams show the following: Sodium=148mmol/l, Potassium=2.2mmol/l, Urea=20mmol/l, Glucose=4.3mmol/l. What would be the best management?
Your Answer: V normal saline and potassium supplement
Explanation:The boy needs re-hydration and hydro-electrolytic re-balancing due to fluid losses from the gastroenteritis and subsequent dehydration.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 6
Correct
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An 8-month-old baby was investigated for failure to thrive. On examination, he was irritable with evidence of weight loss. His stools were pale, bulky and malodorous. What is the most appropriate test that can be done to confirm the diagnosis?
Your Answer: Jejunal Biopsy
Explanation:Pale, bulky, malodorous stools are evidence of fat malabsorption syndrome. The diagnostic test is jejunal biopsy to rule out other differential diagnoses such as celiac disease, giardiasis or Crohn’s disease etc.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 7
Incorrect
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A 5 year old girl experiences recurrent abdominal pain that has recently localised in the epigastric region. She occasionally vomits as well. Doctors perform an upper endoscopy and a CLO test which turn out positive. A Helicobacter pylori infection is established. What is the initial most appropriate treatment?
Your Answer: Amoxicillin, metronidazole and omeprazole for 2 weeks
Correct Answer: Amoxicillin, clarithromycin and omeprazole for 1 week
Explanation:European guidelines suggest that triple therapy for 1 week is acceptable and sufficient for H. pylori eradication. Although triple therapy for 2 weeks might have higher therapeutic rates, it also carries a higher risk of side effects. Triple therapy includes amoxicillin and clarithromycin and a proton-pump inhibitor, usually omeprazole.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 8
Correct
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A 6 week old girl presents with back arching and crying. She regurgitates milk after a feed, especially when laying on her back. Doctors suspect gastro-oesophageal reflux (GOR). What is the next most appropriate step?
Your Answer: Reassure the parents
Explanation:Most experts suggest that parents reassurance in case of infantile gastro-oesophageal reflux (GOR) is a sufficient initial measure that involves education about regurgitation and lifestyle changes.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 9
Correct
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A 3-year-old girl presented with faecal incontinence for 2 weeks. Abdominal examination revealed a mass in right lower quadrant. Which of the following is the most appropriate management for this girl?
Your Answer: Laxatives
Explanation:Laxatives have been shown to be beneficial in the treatment of chronic childhood constipation. Studies have shown that polyethylene glycol, mineral oil, magnesium hydroxide, and lactulose are effective and can be used for a prolonged periods without risk.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 10
Correct
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A 16-year-old boy with iron-deficiency anaemia is found to have numerous polyps in his jejunum. On examination, he is also noted to have pigmented lesions on his palms and soles. What is the most probable diagnosis?
Your Answer: Peutz-Jeghers syndrome
Explanation:Based on the clinical scenario provided, the most probable diagnosis is Peutz-Jeghers syndrome.Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles.Genetic basis: It follows an autosomal dominant inheritance, and the gene responsible encodes serine-threonine kinase LKB1 or STK11.Classical features of PJS include:- Hamartomatous polyps in the GI tract (mainly small bowel)- Pigmented lesions on lips, oral mucosa, face, palms and soles- Intestinal obstruction, e.g. intussusception- Gastrointestinal bleedingThe treatment is mainly conservative unless complications develop.Note:Hereditary haemorrhagic telangiectasia can also be associated with mucocutaneous lesions and iron-deficiency anaemia, but intestinal polyps are not a feature.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 11
Correct
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A 8 year old child presents with fresh rectal bleeding. Which of the following statements is true?
Your Answer: Intestinal hamartomatous polyps are seen in Cowden syndrome
Explanation:Colonic Polyposis and neoplasia are often seen in Cowden Syndrome which is a hamartomatous polyposis syndrome. Patients with Cowden syndrome have an increased risk for colorectal cancer.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 12
Correct
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An 11-year-old girl with developmental delay was brought to the clinic with symptoms of abdominal pain, loss of appetite, vomiting and constipation. Her parents notice that she has been eating substances like soil, soap and paper recently. Her blood count and peripheral smear examination reveal a microcytic-hypochromic anaemia with basophilic stippling of RBCs. What is the most probable diagnosis?
Your Answer: Lead poisoning
Explanation:The most probable diagnosis in this patient is lead poisoning.Lead poisoning: While it is not common, it can be potentially fatal. One of the key presenting features here is pica, the ingestion of non-nutritive substances such as soil, soap, paper or wood. Pica can also be observed in children in iron-deficiency anaemia, developmental delay and pregnancy. However, in a child who is exposed to lead in their environment (e.g. from lead paint or pipes), lead poisoning is most likely. It is commonly associated with iron deficiency which in turn increases the lead absorption. Treatment is either with oral D-penicillamine or intravenous sodium calcium edetate.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 13
Correct
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A 19-year-old girl has presented with symptoms suggestive of anorexia nervosa. Following a consult with a dietician, a decision was made to supplement her nutrition through total parenteral nutrition (TPN) via a central line. Which of the following is a common complication associated with TPN?
Your Answer: Deranged liver function tests
Explanation:Total parenteral nutrition (TPN) frequently causes derangement of liver function in children. Other options:- While line sepsis and thromboembolism are recognised complications of TPN, they do not occur frequently. – A child who is on TPN will require regular blood tests because of the potential for the development of electrolyte abnormalities. Need to observe their liver function, in order to provide TPN more accurately.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 14
Correct
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A 12-year-old boy was admitted with profound diarrhoea and low urine output. His mucous membranes seem dry and his skin turgor is low. What is the most appropriate next step?
Your Answer: Fluid replacement
Explanation:Fluid replacement therapy should be initiated immediately because the patient is suffering from severe dehydration as shown by the low urine output, the dry mucous membranes and the low skin turgor.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 15
Correct
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A 16-year-old boy, known case of Crohn's disease presents to the clinic with jaundice. His labs reveal an elevated alkaline phosphatase level. AST, ALT, albumin and clotting are in normal range. Antineutrophil cytoplasmic antibody level is positive. Radiological examination shows multi-focal strictures and irregularity of both intra and extra hepatic bile ducts which has resulted in a 'beads on a string' appearance. Which of the following is the most likely diagnosis?
Your Answer: Primary sclerosing cholangitis
Explanation:Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts which normally allow bile to drain from the gallbladder. Early cholangiographic changes can include fine or deep ulcerations of the common bile duct. As PSC progresses, segmental fibrosis develops within the bile ducts, with saccular dilatation of the normal areas between them, leading to the typical beads-on-a-string appearance seen on cholangiography. Although these strictures can be found anywhere on the biliary tree, the intrahepatic and extrahepatic bile ducts are simultaneously involved in the vast majority of cases.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 16
Correct
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A male infant is brought to the emergency department by his parents. He was born at 34 weeks by spontaneous vaginal delivery and was discharged 4 weeks ago. He is not on any regular medication. Parents said that he brings up small volumes of milk after feeds. This happens approximately twice a day. Observations are all within normal range and examination is unremarkable.Which of the following is the most likely diagnosis?
Your Answer: Gastro-oesophageal reflux
Explanation:Gastroesophageal reflux occurs in almost all infants, manifesting as wet burps after feeding. The spit-ups appear effortless and not particularly forceful.Infants in whom reflux has caused GERD have additional symptoms, such as irritability, feeding refusal, and/or respiratory symptoms such as chronic recurrent coughing or wheezing and sometimes stridor. Much less commonly, infants have intermittent apnoea or episodes of arching the back and turning the head to one side (Sandifer syndrome). Infants may fail to gain weight appropriately or, less often, lose weight.Incidence of gastroesophageal reflux increases between 2 months and 6 months of age (likely due to an increased volume of liquid at each feeding) and then starts to decrease after 7 months. Gastroesophageal reflux resolves in about 85% of infants by 12 months and in 95% by 18 months.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 17
Correct
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A 17-year-old Caucasian woman presents with lethargy and chronic nausea. Her mother is worried she may be depressed. On examination, there are signs of chronic liver disease and a gold-yellow ring at the periphery of the iris in both eyes. Her serum copper level is low. What is the most likely diagnosis?
Your Answer: Wilson’s disease
Explanation:This patient has Wilson’s disease. They Kayser-Fleischer ring (ring that encircles the iris) is diagnostic of this. Low serum copper is seen in Wilson’s disease. With the Kayser-Fleischer ring, this makes all of the other answer choices incorrect.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 18
Incorrect
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A 5-month-old baby presents with symptoms of irritability, blood in the stools and vomiting. Examination reveals a rigid abdomen and drawing of knees upon palpation. Which is the most appropriate action you should take for this baby?
Your Answer: Abdominal x ray
Correct Answer: Refer to paediatric surgeons
Explanation:Intussusception is the most suggested case here based on the child’s symptoms. The urgent course of treatment is to bring the child to a paediatric surgical unit. If air reduction attempts fail, surgery will have to be done. Risk factors for intussusception include viral infection and intestinal lymphadenopathy.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 19
Incorrect
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A 10-year-old girl presents to the hospital with complaints of weight loss, diarrhoea, and abdominal pain. Her food intake has drastically reduced but she is drinking normally. She also complains that she feels tired all the time.On examination, the presence of aphthous ulcers and generalized abdominal tenderness was noted. Considering the clinical presentation, what could be the most probable underlying disorder causing the child's symptoms?
Your Answer: Ulcerative colitis
Correct Answer: Crohn’s disease
Explanation:The most probable diagnosis for this patient would be Crohn’s disease.Crohn’s disease:An inflammatory bowel disease which can affect any part of the bowel from the mouth to the anus. Symptoms include abdominal pain, diarrhoea, pyrexia and weight loss. Extra-intestinal manifestations include arthritis, uveitis, fatigue, anaemia and rashes including pyoderma gangrenosum and erythema nodosum.Other options:- Anorexia nervosa is an important diagnosis to consider. There are no indicators in the description that she has a fear of gaining weight or a strong desire to be thin.- Diabetic ketoacidosis is incorrect because there is no polydipsia or polyuria. A patient in DKA is more likely to present with vomiting and not diarrhoea.- Recurrent aphthous stomatitis is not a correct answer because it does not explain all of the symptoms described, only the mouth ulcers.- Ulcerative colitis (UC) is also incorrect. UC is a form of inflammatory bowel disease that causes inflammation in the colon. The main symptom is bloody stools, which is not mentioned as a feature in history.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 20
Correct
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A routine vitamin D screening test reveals low calcium levels in a 3-year-old child.Which of the following could cause low calcium levels due to an artefact?
Your Answer: Albumin
Explanation:The accuracy of the test for calcium levels in the blood is affected by the blood level of albumin. If albumin levels are low, the calcium level can also appear low.This is termed as pseudohypocalcemia.Hypocalcaemia usually presents with muscle spams. These can include spasms of voluntary muscle but also smooth muscle such as in the airways (causing bronchospasm) and in the heart (causing angina).
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 21
Correct
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A 8 year old child presents with acute abdominal pain. Last time he used the restroom, he noticed fresh blood after wiping. Doctors suspect an intussusception. What is the most probable cause?
Your Answer: Gastrointestinal polyp
Explanation:Gastrointestinal polyps are common in children and may result in intussusception due to polyp traction. Treatment is usually surgical with enterotomy and removal of the polyp or of a segment of the bowel.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 22
Correct
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A 15-day old baby was brought to the emergency department with constipation for 4 days. On examination, the abdomen of the baby was found to be distended and tender all over. No bowel sounds were heard. A sigmoid colon biopsy was carried out, which showed absent ganglion cells. What is the diagnosis?
Your Answer: Hirschsprung’s disease
Explanation:Hirschsprung’s disease is characterized by congenital absence of the autonomic plexus (Meissner’s and Auerbach’s plexus) in the intestinal wall. Usually limited to the distal colon, it can occasionally involve the entire colon or even the small bowel. There is abnormal or absent peristalsis in the affected segment, resulting in continuous spasm of smooth muscle and partial/complete obstruction. This causes accumulation of intestinal contents and dilatation of proximal segment. Skip lesions are highly uncommon. This disease is seen early in life with 15% patients presenting in first month, 60% by 1 year of age and 85% by the age of 4 years. Symptoms include severe and complete constipation, abdominal distension and vomiting. Patients with involvement of ultra-short segments might have mild constipation with intervening diarrhoea. In older children, symptoms include failure to thrive, anorexia, and lack of an urge to defecate. On examination, an empty rectum is revealed with stool palpable high up in the colon. If not diagnosed in time, it can lead to Hirschsprung’s enterocolitis (toxic megacolon), which can be fulminant and lead to death. Diagnosis involves a barium enema or a rectal suction biopsy. Barium enema shows a transition in diameter between the dilated, normal colon proximal to the narrowed, affected distal segment. It is to be noted that barium enema should be done without prior preparation, which can dilate the abnormal segment, leading to a false-negative result. A 24-hour post-evacuation film can be obtained in the neonatal period – if the colon is still filled with barium, there is a high likelihood of Hirschsprung’s disease. Full-thickness rectal biopsy is diagnostic by showing the absence of ganglion cells. Acetylcholinesterase staining can be done to highlight the enlarged nerve trunks. Abnormal innervation can also be demonstrated by rectal manometry.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 23
Incorrect
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Conjugated bilirubin is converted and metabolised into urobilinogen before excretion. This metabolism takes place in which part of the body?
Your Answer: Hepatic sinusoids
Correct Answer: Large intestine
Explanation:Unconjugated bilirubin is conjugated to glucuronic acid in the hepatocyte. Conjugated bilirubin passes into the enterohepatic circulation and the bilirubin which evades this system is metabolised by bacteria, primarily in the large intestine, to urobilinogen, then stercobilinogen and eventually oxidised to stercobilin. Stercobilin gives faeces its brown colour.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 24
Correct
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An 8 month old baby is admitted with vomiting. He is crying but is afebrile. Clinical examination reveals a diffusely tender abdomen, however, the doctor does not detect any palpable masses. Which of the following should you exclude first?
Your Answer: Intussusception
Explanation:Intussusception is an urgent condition that must be excluded first as it may lead to life-threatening complications.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 25
Incorrect
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A 6-month-old baby boy presented to the paediatrician with yellow discolouration of his skin and sclera. His mother says his stools are pale. On examination, he was found to be below average weight. What is a likely diagnosis?
Your Answer: G6PD deficiency
Correct Answer: Biliary atresia
Explanation:Pale stools suggest obstructive jaundice. Initially, the symptoms of biliary atresia are indistinguishable from those of neonatal jaundice, a usually harmless condition commonly seen in infants. However, infants with biliary atresia develop progressive conjugated jaundice, pale white stools and dark urine.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 26
Incorrect
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What is the most likely cause for bloody diarrhoea of 3 days duration in a 10-year-old child?
Your Answer: E. coli 0157:H7
Correct Answer: Campylobacter
Explanation:The most common cause for acute bloody diarrhoea in a 10-year-old child is Campylobacter.Note:Campylobacter is the most common bacterial cause of gastroenteritis in the UK. It typically presents with bloody diarrhoea, fever, abdominal pain and vomiting. The primary source of Campylobacter is uncooked poultry. Treatment is generally supportive unless the child is immunosuppressed or the symptoms are persistent.Other options:- E. coli 0157:H7: It causes acute haemorrhagic diarrhoea, usually afebrile. It can lead to haemolytic uremic syndrome (haemolytic anaemia, acute renal failure and thrombocytopenia), which is the commonest cause of acute renal failure in children.- Rotavirus: It rarely causes bloody diarrhoea.- Salmonella and Yersinia: While they can cause bloody diarrhoea, they are much less common compared to Campylobacter.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 27
Incorrect
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A 12 year old girl presented with pallor and a rash over her lower limbs after 4 days of bloody diarrhoea. Lab investigations showed proteinuria and deranged renal function. The most likely diagnosis will be?
Your Answer: Henoch-Schonlein purpura (HSP)
Correct Answer: Haemolytic Uremic Syndrome (HUS)
Explanation:Haemolytic Uremic Syndrome affects children and is characterised by abdominal pain, a purpuric rash over the body, generalized pallor, haematuria and bloody diarrhoea. There is always a history of preceding diarrhoea caused usually by E.coli and it affects the renal system causing haematuria and deranged renal function tests.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 28
Correct
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A 6 year old child suffers from pain located in his right iliac fossa. Doctors suspect appendicitis. The appendix derives from which of the following embryological structures:
Your Answer: Midgut
Explanation:From the midgut derives most of the small intestine as well as some parts of the large intestine, including the appendix. The appendix is at the base of caecum, up to 10cm long and mainly comprised of lymphoid tissue (Hence mesenteric adenitis may mimic appendicitis).
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 29
Correct
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An 18-month-old boy of Asian descent and a product of non-consanguineous marriage presents to the clinic with a history of swelling of both wrists. He has been complaining of painful legs and his parents are concerned about his bandy legs. The child was breastfed until 6 months of age, with solids being introduced in the diet later. At 12 months of age the child suffered from a non-stick fracture of the radius after falling at the nursery. Which condition is the child most likely suffering from?
Your Answer: Vitamin D-deficient rickets
Explanation:The signs and symptoms of vitamin D-dependent rickets begin within months after birth, and most are the same for all types of the condition. The weak bones often cause bone pain and delayed growth and have a tendency to fracture. When affected children begin to walk, they may develop abnormally curved (bowed) legs because the bones are too weak to bear weight. Impaired bone development also results in widening of the metaphysis, especially in the knees, wrists, and ribs. Some people with vitamin D-dependent rickets have dental abnormalities such as thin tooth enamel and frequent cavities. Poor muscle tone (hypotonia) and muscle weakness are also common in this condition, and some affected individuals develop seizures.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 30
Correct
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A 3 year old girl presents with a 2 day history of GI symptoms whenever she eats cauliflower. Her mother is concerned that she may be allergic, and has kept a food diary and a record of her symptoms. Which of these is LEAST likely to be associated with food allergies?
Your Answer: Polycythaemia
Explanation:Polycythaemia is a condition in which there is an increased red cell mass and increasing blood viscosity, which decreases its ability to flow. It is not associated with food allergies, but is fundamentally caused by either an overproduction of red blood cells, or a reduction in the volume of plasma. Abdominal pain, constipation, loose and frequent stools, and pallor are all non IGE mediated symptoms of food allergy according to NICE guidelines in the UK.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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SESSION STATS - PERFORMANCE PER SPECIALTY
