Pathology- GIT MCQ's

1) A 60 year old man presents to his physician because of progressive dysphagia, first for solids, then for liquids. Endoscopy reveals a large fungating mass 2 cm above the gastroesophageal junction. Biopsy of the mass demonstrates glands, extending into the muscular layer, containing cells with large hyperchromatic nuclei. Which one of the following conditions is most likely associated with the development of this mass?

A. Barrett's esophagus
B. Esophageal rings
C. Esophageal webs
D. Scleroderma
E. Sliding hernia


The correct answer is A. Biopsy is consistant with esophageal adenocarcinoma which usually arises in aread of gastric or intestinal metaplasia (Barrett's esophagus) in the lower or middle one third of the esophagus. The prognosis for adenocarcinoma is poor, unless caught very early.

Esophageal rings (choice B) are rims of fibrovascular tissue found in the lower esophagus.

Esophgeal webs (choice C) are mucosal ledges in the upper esophagus.

Scleroderma (choice D) can cause fibrosis and impaired motility of the esophagus.

In sliding hiatal hernias (choice E), part of the stomach protrudes above the diaphragm.



2) A 30 year old man with a 15-year history of ulcerative colitis develops intermittent cholestatic jaundice. Ultrasonographic examination fails to reveal gallstones. Liver biopsy demonstrates a large bile duct obstruction. Which of the following would most likely be seen on endoscopic retrograde cholangiopancreatography (ERCP)?

A. Beading of transhepatic bile ducts
B. Markedly dialted common bile duct containing irregular radioluscent masses
C. Mass at the ampulla of Vater
D. Moderately dilated intrahepatic bile ducts and stricture in the bile duct at the lower end of the common bile duct


The correct answer is A. The most likely diagnoses is primary sclerosing cholangitis, a disorder with a probable autoimmune component that is associated with ulcerative colitis (66% correlation). The disease is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, producing alternating strictures and dilatation of the structures. These changes are seen as "beading" on ERCP.

Gallstones in the biliary tree produce irregular radiolucent masses (choice B).

Choice C describes the findings associated with carcinoma of the ampulla of Vater.

Choice D describes the findings associated with carcinoma of the extrahepatic bile ducts.

Choice E describes the findings associated with carcinoma of the pancreas.



3) A patient has had years of intermittent diarrhea and abdominal pain, but has never consulted a physician. Eventually he begins to pass fecal material in his urine and he seeks medical attention. Which one of the following diseases is most likely to cause this complication?

A. Celiac disease
B. Crohn's diease
C. Diverticulitis
D. Ulcerative colitis
E. Whipple disease


The correct answer is B. Passing fecal material in urine strongly suggests the possibility of a fistula between the bowel and bladder. Of the diseases listed, only Crohn's disease commpnly produces fistulas. Fistulas are produced in Crohn's disease because the disease affects the entire thickness of the bowel wall, rathar than being restricted to the mucosa (e.g., ulceratice colitis).

Celiac disease (choice A) is a mucosal disorder of the small intestine caused by intolerance to certain components of gluten from wheat and other grains.

Diverticulitis (choice C) can cause bowel perforation with peritonitis but does not usually cause fistula formation.

Ulcerative colitis (choice D) is much less commonly associated with fistula formation than is Crohn's disease.

Whipple's disease (choice E) is a small intestinal disorder caused by infection with Tropheryma whippelii.



4) A 40 year old man complains of increasing difficulty in swallowing in the past 3 years. He reports a feeling of pressure in the chest occurring 2-3 seconds after swallowing a solid bolus. He also experiences regurgitation of undigested food eaten hours previously. A radiograph taken after swallowing barium shows a distended esophageal body with a smooth tapering at the lower esophageal sphincter. Manometry shows the absence of esophageal peristalsis and a lower esophageal sphincter that fails to relax. What is the most likely diagnosis?

A. Diffuse esophageal spasm
B. Incompetent lower esophageal sphincter
C. Oropharyngeal dysphagia
D. Scleroderma
E. Achalasia


The correct answer is E. Achalasia is an acquired esophageal motility disorder that slowly develops. The motility is abnormal due to the loss of inhibitory enteric neurons of the esophageal body and lower esophageal sphincter. Both vasoactive intestinal peptide and nitric oxide function as inhibitory neurotransmitters here, and the presence of both is decreased in achalasia. Radiographs typically show a dilated esohpagus that tapers at the lower esophageal sphincter, producing the so called "bird's beak". Because of the poor motility, ingested food is regurgitated and can lead to aspiration symptoms. Manometric demonstration of absent peristalsis in the esophageal body and poor relaxation of the lower esophageal sphincter with a swallow confirm the diagnosis.

The primary complaint with diffuse esophageal spasm (choice A) is mid-sternal pain that can be misdiagnosed as cardiac pain. The pain is caused by prolonged contraction of the entire esophageal body. Symptoms can be brought on by eating certain hot or cold meals. A manometric study may show poor peristalsis in the smooth muscle portion of the esophageal body, but lower esophageal sphincter function is unaffected.

The primary complaint with incompetant lower esophageal sphincter (choice B) is heart burn and regurgitation due to gastroesophageal reflux. Endoscopic examination of the esophagus may reveal inflammation, erosions, and even ulcers. A manometric study would show lower than normal resting tone in the lower esophageal sphincter.

The fact that the patient's symptoms do not occur until 2-3 seconds after a swallow suggests that oropharyngeal dysphagia (choice C) is not the diagnosis. The presence of cogh, Hoarseness, or nasal regurgitation commonly occurs with this disorder. Oropharyngeal dysphagia is often due to neurological or muscle disorders like stroke, amyotrophic lateral sclerosis, muscular dystrophy, or myasthenia gravis.

Scleroderma (choice D) is a connective tissue disease in which esophageal smooth muscle is gradually replaced by dense collagenous material. Manometry woud show poor esophageal peristalsis and decreased lower esophageal sphincter tone. Significant acid reflux with resultant esophagitis is almost universal.


More questions to come soon...