examen 2023 digestivo

Whipple Surgery -What Do We Leave?. Fundus. Distal bile duct. Gallbladder. Part of the duodenum. Head of the pancreas.

For a 42-year-old patient with significantly elevated AST and ALT values (both more than 12 times higher than normal), the least likely diagnosis is: a. Autoimmune hepatitis. b. Viral hepatitis. c. Ischemic hepatitis. d. Alcoholic hepatitis. e. Drug-induced liver injury.

A 65-year-old female patient presents for an exam due to bloating and severe vomiting that has lasted for two days. Initially, she vomited bile, but then it turned to foul-smelling, possibly bowel-like content. She reports no specific pain or other issues.Upon examination, the patient is clinically dehydrated, blood pressure 80/60, pulse 130/minute. The abdomen is distended, and the patient has a BMI of 35, making the examination difficult. However, you find a large mass, the size of a small hazelnut, in the right inguinal area or slightly lower, which is not very painful, with overlying red skin. Laboratory results show: CRP 300 (significantly elevated), white blood cells 28 (significantly elevated), creatinine 350, urea 45 (acute kidney failure). What do you do?. a. The patient has septic shock (unclear origin), which also led to kidney failure and vomiting. The palpable mass is likely an enlarged lymph node due to the inflammation. Refer the patient to an infectious disease specialist. b. Refer the patient to a nephrologist due to low blood pressure and kidney failure. c. Request an abdominal ultrasound and a diagnostic puncture of the red mass. d. Admit the patient to the surgical department. Start intravenous fluid therapy, insert a urinary catheter, a nasogastric tube, and begin empirical antibiotic therapy. Schedule an abdominal ultrasound; surgery may be necessary. e. Acute pancreatitis has led to paralytic ileus; refer the patient to a gastroenterologist.

A 59-year-old female presents to the clinic with one day of colicky pain in the epigastrium and under the right ribcage. She has felt nauseous and has vomited three times in the last 24 hours. The symptoms began after she ate two pieces of chocolate cake with hazelnuts. She had a history of peptic duodenal ulcer. She is hemodynamically stable and non-jaundiced. What test would you perform first?. a. Gastroscopy. b. Abdominal ultrasound. c. Breath test for H. pylori infection. d. Abdominal CT. e. MRCP.

Who does not have GERD?. Barrett’s esophagus. Grandfather with heartburn on PPI who is now fine. Some hernia and heartburn. Heartburn and reflux. Reflux.

A 35-year-old male complains of difficulty swallowing hard food, painful swallowing, acidic reflux, and epigastric pain. Endoscopy and histological examination confirmed eosinophilic esophagitis. How do you treat this patient?. a. Prescribe a diet excluding the most allergenic foods (six groups). b. Start proton pump inhibitors (PPIs) in standard doses along with a gradual elimination diet. c. If the elimination diet and PPIs are ineffective, add treatment with systemic glucocorticoids. d. If PPIs are ineffective, add treatment with topical glucocorticoids, then gradually reintroduce the elimination diet. e. No treatment for eosinophilic esophagitis is necessary.

A 47-year-old patient had an abdominal ultrasound for prostate problems, which showed fatty liver and a 4mm polyp in the gallbladder. The patient is very concerned about the polyp and asks for advice. a. He needs cholecystectomy. b. He should have a CT scan with contrast. c. Recommend treatment with ursodeoxycholic acid. d. Recommend ultrasound follow-up, initially every 6 months. e. No treatment is needed.

According to the updated Atlantic classification, we divide acute pancreatitis into three forms: mild, moderately severe, and severe. Which of the following best describes moderately severe pancreatitis?. a. Persistent dysfunction of one or more organs. b. Transient dysfunction of one or more organs. c. Fluid collection near the pancreas. d. Hematocrit >44%. e. Severe epigastric pain (VAS 9/10).

Acute pancreatitis is treated with (choose the correct combination of answers):T5. Fat-free diet for at least the first three days of the diseaseT6. Fasting. a. T2, T3, T4. b. T1, T2, T3. c. T1, T2, T6. d. T2, T4, T5. e. T1, T2, T3, T5. .

A male patient, 18 years old, has had a foul-smelling discharge from a small hole in the right lower abdomen for the last 8 weeks. Four months ago, he had an appendectomy due to sudden severe pain in the right lower abdomen and CT signs of appendicitis. What is the most likely diagnosis?. a. Bowel perforation. b. Crohn’s disease. c. Ulcerative colitis. d. Tuberculosis. e. Indeterminate colitis.

A 55-year-old patient, with no known comorbidities, is brought to the ER by ambulance due to syncope. He reports that he passed black, tarry stools two days before the syncope. The day before, he had epigastric pain and nausea, but did not vomit. Upon examination, he is talkative, hypotensive (80/50), tachycardic (130/min), pale, and otherwise in a normal status. Laboratory results show: Hb 90 g/L, urea 29 mmol/L, creatinine 90 mmol/L. After stabilizing his hemodynamics, he receives a proton pump inhibitor bolus, and urgent gastroscopy is scheduled. During the gastroscopy, a duodenal bulb ulcer is seen, which is actively bleeding. The bleeding is managed endoscopically with a combination therapy (injection therapy + hemostatic clips), and biopsies are taken to test for H. pylori infection, which is ruled out. The patient is transferred to the intensive care unit for further observation. Upon admission, he is normotensive (130/75), normocardiac (80/min), and there is a slight drop in hemoglobin: Hb 85 g/L. What is the next best action?. a. Prescribe intravenous proton pump inhibitors in continuous infusion, then switch to oral bolus doses. b. The duodenal ulcer is most likely caused by H. pylori infection, so begin empirical treatment. Also, administer continuous proton pump inhibitors. c. Prescribe proton pump inhibitors orally. d. Administer two bags of transfusion and proton pump inhibitors in continuous infusion. e. Prescribe somatostatin in continuous infusion, proton pump inhibitors parenterally, and broad-spectrum antibiotics.

A 49-year-old patient with alcoholic liver cirrhosis, portal hypertension, and suspected liver tumor (detected by ultrasound) underwent an abdominal CT with contrast. Three foci of hepatocellular carcinoma (HCC) were found in the liver, the largest in the right lobe, measuring 4 cm, and the other two are 2 cm each. Further tests for metastases were negative. The patient can walk long distances, is regularly physically active, has no ascites, and has preserved synthetic liver function (Child A). What is the most appropriate treatment for the patient?. a. Surgical treatment (resection of tumors). b. Liver transplantation. c. Transarterial chemoembolization. d. Systemic therapy. e. Radiofrequency ablation of tumors.

A 49-year-old male with alcoholic liver cirrhosis, portal hypertension, and suspected liver tumor, detected by ultrasound, underwent an abdominal CT with contrast. The CT revealed three HCC foci in the liver, the largest being in the right lobe measuring 4cm, with the other two measuring 2 cm each. Staging tests for metastasis revealed one. The patient is able to walk long distances, is regularly physically active, has no ascites, and has preserved synthetic liver function (Child A). What treatment is mostappropriate for this patient?. a. Surgical treatment (tumor resection). b. Liver transplantation. c. Transarterial chemoembolization. d. Systemic therapy. e. Radiofrequency ablation of tumors.

The patient with atherosclerosis has a distended abdomen: embolization of the superior mesenteric artery. embolization of the inferior mesenteric artery. embolization of the superior mesenteric vein. portal vein embolization.

A 75-year-old patient presents to the emergency department with pruritus. Upon clinical examination, jaundice is noted. Laboratory results are consistent with cholestasis (elevated bilirubin, alkaline phosphatase, and gamma-GT, both transaminases mildly elevated). Due to hip pain, the patient has been on NSAIDs for 2 months. Additionally, the patient is on beta-blockers and an angiotensin-converting enzyme inhibitor for hypertension.T1. Based on the characteristic history, it can be concluded that the liver damage is due to ACE inhibitors, as these inhibit bile conjugation.T2. An ultrasound or CT of the liver is necessary in the diagnostic process, as the clinical presentation could be a sign of biliary obstruction due to pancreatic head cancer.T3. It could be drug-induced liver damage, so the dose of NSAIDs is halved.T4. Among the listed medications, the most likely cause of liver damage is the NSAID. a. T1, T2. b. T2, T4. c. T1, T3. d. T3, T4. e. T1, T4.

A 55-year-old male with obesity, a history of elevated triglycerides, diabetes, and daily alcohol use, has the following laboratory results: ALT 3.4 UKat/L, AST 1.99 UKat/L, AF 2.55 UKat/L, total bilirubin 25.6 μmol/L, blood sugar 13.8 mmol/L, platelets 200x10^9/L. A liver biopsy revealed extensive macrovascular steatosis and mild inflammation. What is the most likely cause of this patient's liver disease?. a. Alcoholic hepatitis. b. Non-alcoholic fatty liver disease. c. Autoimmune hepatitis. d. Wilson’s disease. e. Ischemic hepatitis.

What is true about primary biliary cholangitis (PBC) and liver transplantation?. a. The number of liver transplants due to PBC is increasing each year. b. Compared to other etiologies, patients with PBC have lower 1-year and 5-year survival rates post-transplantation. c. PBC recurs in most patients after liver transplantation. d. The presence of AMA antibodies post-transplantation indicates disease recurrence. e. Poor quality of life due to fatigue and persistent pruritus in PBC patients is an indication for liver transplantation.

A 79-year-old patient with liver cirrhosis due to hepatitis C infection presents with no history of gastrointestinal bleeding, ascites, or hepatic encephalopathy in the past. Vital signs: heart rate 64/min, blood pressure 120/70 mmHg. The patient has numerous spider nevi, but otherwise is clinically normal. A gastroscopy to assess varices revealed two small varices in the distal esophagus. What would you recommend for this patient?. a. Nadolol. b. Endoscopic variceal ligation. c. Transjugular intrahepatic portosystemic shunt (TIPS). d. Follow-up gastroscopy in 1 year. e. Follow-up gastroscopy in 3 years.

The most important feature of ascites in spontaneous bacterial peritonitis is (circle the correct answer): a. It is thick, green, and has a characteristic odor. b. The LDH concentration is higher than the serum level. c. Increased concentration of neutrophils. d. Increased protein concentration in ascites. e. The glucose concentration in ascites is at least twice as low as the serum level.

A 55-year-old male with liver cirrhosis due to viral hepatitis C has noticed an increasing abdominal size and weight gain over the past three months. On examination, signs of ascites are present in the abdominal cavity. Laboratory results: sodium 130 mEq/L, BUN 4.3 mmol/L, creatinine 35.4 μmol/L, total bilirubin 22.2 μmol/L, albumin 29 g/L, prothrombin time 13.4 s. What therapy would most effectively prevent the accumulation of ascites?. a. Fluid restriction. b. Restriction of salt intake and use of diuretics. c. Restriction of fluid and salt intake. d. Restriction of salt intake. e. Paracentesis for ascites.

A 24-year-old student has had loose, sometimes watery stools 4-7 times per day for the last four months, waking up at night to defecate. Laboratory results are normal. Infection, celiac disease, and lactose intolerance were excluded in the first week. Gastroscopy and colonoscopy with terminal ileoscopy showed no abnormalities. What would be the appropriate next step?. a. It is a functional issue (irritable bowel syndrome); no further diagnostics are needed. b. Repeat colonoscopy with biopsy from normal mucosa. c. Perform MR enterography. d. Perform abdominal CT with contrast. e. Measure calprotectin concentration in stool.

A 60-year-old male with chronic alcoholic pancreatitis is admitted due to three months of epigastric pain that increases after eating. He has been abstinent for six months. He takes opioid analgesics typically during meals when the pain increases. MRCP showed changes consistent with chronic pancreatitis, with a dilated pancreatic duct (8 mm) and a 4mm stone with a short narrowing in the head and neck of the pancreas. What is the optimal treatment?. a. Use of short-acting opioid analgesics combined with NSAIDs. b. Distal pancreatectomy. c. Replacement therapy with pancreatic enzymes and proton pump inhibitors. d. ERCP dilation of the pancreatic duct and stone removal. e. Endoscopic ultrasound-guided biopsy of the pancreatic parenchyma.

A 72-year-old female with a known pancreatic head carcinoma undergoing gemcitabine therapy presents with jaundice. Her laboratory results show total bilirubin of 127, direct bilirubin of 112. Abdominal ultrasound reveals six liver metastases, up to 3 cm, and dilated bile ducts in the liver. The primary tumor is not visible due to its location, and there are two cysts in the left kidney. What is the most likely cause of jaundice?. a. Liver failure due to liver metastases. b. Obstruction due to pressure from the pancreatic tumor on the bile duct. c. Paraneoplastic autoimmune hemolytic anemia. d. Gilbert's syndrome. e. Gemcitabin-induced cholestatic liver injury.

8.The patient has a Murphy sign that is negative. Laboratory results: low inflammatory parameters, ALT 6.8 ukat/L (10x elevated), AST 4.2 ukat/L (8x elevated), alkaline phosphatase 4.17 ukat/L (3x elevated), total bilirubin 92 μmol/L (4x elevated), lipase 0.4 ukat/L (normal). The ultrasound shows cholecystolithiasis without cholecystitis, the common bile duct is dilated measuring 10 mm. What is the most reasonable next step in managing this patient?. a. ERCP. b. MRCP. c. CT of the abdomen. d. Laparoscopic cholecystectomy without cholangiography. e. Endoscopic ultrasound (EUS).

9.A 70-year-old man with a history of years of risky alcohol consumption presents with severe epigastric pain radiating to his back. Laboratory results: hemoglobin 170 g/L, urea 10.2 mmol/L, triglycerides 7.2 mmol/L, normal bilirubin, alkaline phosphatase 1.02 μkat/L (normal), AST 2.56 μkat/L, ALT 1.2 μkat/L, amylase and lipase more than 3 times the normal values. An abdominal X-ray shows a sentinel loop, and an abdominal ultrasound reveals diffuse parenchymal liver damage, cholecystolithiasis, normal bile ducts, and free fluid around the pancreas. What is the most likely diagnosis?. a. Acute biliary pancreatitis. b. Hyperlipidemic pancreatitis. c. Alcoholic pancreatitis. d. Decompensated liver cirrhosis. e. Alcoholic hepatitis.

10.A 35-year-old woman presents to the urgent care center with nausea, vomiting, and epigastric pain. She has no fever or chills. Symptoms started six hours ago. She has a known history of arterial hypertension and has been taking perindopril for a long time.On examination, her abdomen is tense, with tenderness on deep palpation in the epigastrium. Vital signs: body temperature 36.1°C, heart rate 105/min, respiratory rate 15/min, blood pressure 120/65. Laboratory results: leukocytes 7 x 10^9/L, hemoglobin 140g/L, calcium 1.8 mmol/L, urea 9 mmol/L (all within reference range), bilirubin 74/56 μmol/L (6x above the upper limit), alkaline phosphatase 2.5 ukat/L (mildly elevated), ALT 4.2 ukat/L, AST 3.5 (5x above the upper limit), amylase 30 ukat/L, lipase 45 ukat/L (10x above the upper limit), CRP 10 mg/L. Abdominal ultrasound shows cholecystolithiasis and choledocholithiasis. What is the most likely diagnosis?. a. Acute biliary pancreatitis. b. Acute cholecystitis. c. Cholangitis. d. Hypercalcemic pancreatitis. e. Perindopril-induced pancreatitis.

11.According to the updated Atlantic classification, acute pancreatitis is divided into three forms: mild, moderately severe, and severe.Which of the following best describes moderately severe pancreatitis?. a. Persistent failure of one or more organs. b. Transient failure of one or more organs. c. Fluid collection near the pancreas. d. Hematocrit >44%. e. Severe epigastric pain (VAS 9/10).

12.A 76-year-old patient with hypertension and hypertriglyceridemia presents with 2 days of vomiting, right upper quadrant pain, a distended abdomen, and constipation. He denies fever or jaundice. Laboratory results: Leukocytes 13 x 10^9, AST 1.07 ukat/L, ALT0.95 ukat/L, total bilirubin 16 μmol/L, alkaline phosphatase 2.67 ukat/L, lipase 1.34 ukat/L. Abdominal CT shows gallstones and diffusely dilated small bowel loops.What is the most likely complication of gallstones based on the history and findings?. a. Pancreatitis. b. Small bowel ileus due to gallstones. c. Cholangitis. d. Paralytic ileus. e. Mirizzi syndrome.

13.For pancreatic cancer, which of the following is NOT true?. a. It is more common in men than in women. b. The five-year survival rate is 14%. c. The most common type is tubular adenocarcinoma. d. Most patients are treated surgically. e. If it arises in the head of the pancreas, it typically causes obstructive jaundice.

14.Acute pancreatitis is treated with (choose the correct combination of answers):T1. Antibiotics,T2. Fluid infusions,T3. Analgesics,T4. Calcium channel blockers,T5. Low-fat diet for at least the first three days of illness,T6. Fasting. T2, T3, T6. .

15.Which of the following factors is not associated with a higher risk of pancreatic cancer?. a. Chronic pancreatitis. b. Alcoholism. c. Smoking. d. Cholecystectomy.

16.During a cephalic pancreaticoduodenectomy (Whipple procedure), the surgeons do not remove: a. Part of the duodenum. b. Gallbladder. c. Distal bile duct. d. Head of the pancreas. e. Fundus of the stomach.

17.A 47-year-old patient had an abdominal ultrasound for prostate issues, which described liver steatosis and a 4 mm polyp in the gallbladder. He is very concerned about the polyp and asks for advice. a. He needs a cholecystectomy. b. He should undergo a contrast-enhanced CT scan. c. Ursodeoxycholic acid treatment should be considered. d. He needs an ultrasound control for the polyp. e. Treatment is not necessary.

18.A 49-year-old patient with alcoholic liver cirrhosis, portal hypertension, and suspicion of a liver tumor detected on ultrasound underwent a contrast-enhanced abdominal CT. The CT showed three foci of hepatocellular carcinoma (HCC) in the liver, the largest in the right lobe measuring 4 cm, and the others 2 cm each. Staging scans for metastasis were negative. The patient is able to walk long distances, is regularly physically active, has no ascites, and has preserved liver synthetic function (Child A). What is the most appropriate treatment for this patient?. a. Surgical treatment (resection of the tumors). b. Liver transplantation. c. Transarterial chemoembolization. d. Systemic treatment.

19.A 49-year-old patient with alcoholic liver cirrhosis, portal hypertension, and suspicion of a liver tumor detected on ultrasound underwent a contrast-enhanced abdominal CT. The CT showed three foci of HCC in the liver, the largest in the right lobe measuring 4 cm, and the others 2 cm each. A metastatic lesion was found in the lungs. What is the most appropriate treatment for this patient?. a. Surgical treatment (resection of the tumors). b. Liver transplantation. c. Transarterial chemoembolization. d. Systemic treatment. e. Radiofrequency ablation.

20.A 75-year-old patient presents to the emergency room due to pruritus. Clinical examination reveals jaundice. Laboratory findings are consistent with cholestasis (elevated bilirubin, alkaline phosphatase, and gamma-GT, both transaminases mildly elevated). Due to hip pain, the patient has been taking NSAIDs for 2 months. Additionally, he is on a beta-blocker and an ACE inhibitor for hypertension.T1. Based on the typical history, we can conclude that the liver dysfunction is due to ACE inhibitors, as they interfere with bile conjugation.T2. Further diagnostic workup should include an ultrasound or CT scan of the liver, as the clinical picture could indicate biliary obstruction due to pancreatic head cancer.T3. The liver dysfunction may be drug-induced, so we should reduce the NSAID dose.T4. Of the listed medications, the most likely liver damage is caused by the NSAID. b. T2, T4. .

21.A 55-year-old male with obesity, a history of elevated triglycerides, diabetes, and daily alcohol consumption presents with the following laboratory results: ALT 3.4 ukat/L, AST 1.99 ukat/L, alkaline phosphatase 2.55 ukat/L, total bilirubin 25.6 μmol/L, blood sugar 13.8 mmol/L, platelets 200x10^9/L. Liver biopsy shows extensive macrovascular steatosis and mild inflammation. What is the most likely cause of the liver disease?. b. Non-alcoholic fatty liver disease. .

22.What is true regarding primary biliary cholangitis (PBC) and liver transplantation?. e. Poor quality of life due to fatigue and chronic pruritus is an indication for liver transplantation in PBC patients. .

23.A 79-year-old patient with a long history of alcohol use presents with ascites and peripheral edema. He denies jaundice or fever. The patient has a history of cirrhosis, treated for variceal bleeding 2 years ago, with no current bleeding. Laboratory results: hemoglobin 100 g/L, white blood cells 4.0 x 10^9/L, platelets 120 x 10^9/L, albumin 19 g/L, sodium 127 mmol/L, creatinine 50 μmol/L, prothrombin time 70%, bilirubin 22 μmol/L, alkaline phosphatase 3.2 ukat/L. Based on the laboratory results, the most likely diagnosis is: a. Primary biliary cholangitis. b. Hepatitis B. c. Cholangiocarcinoma. d. Cirrhosis with ascites and portal hypertension.

24.A 63-year-old patient with diabetes presents with a history of upper abdominal pain, nausea, and weight loss over the past few weeks. A CT scan shows a pancreatic mass. The tumor marker CA 19-9 is elevated at 600 U/mL. Based on the clinical presentation and imaging findings, the most likely diagnosis is: a. Pancreatic adenocarcinoma. b. Acute pancreatitis. c. Chronic pancreatitis. d. Gastric ulcer.

26.A 45-year-old man with primary sclerosing cholangitis and cirrhosis comes to us due to increased pruritus and the onset of jaundice. He noticed that he has unintentionally lost 7 kg in the last few months. He denies abdominal pain and is afebrile. Laboratory results: ALP 10.7 μkat/L, total bilirubin 99 μmol/L, AST 2.03 μkat/L, ALT 2.04 μkat/L, INR 1.3, hematocrit 0.320, leukocytes 5.0 x 10^9, Ca 19-9 533 U/mL, AFP 23 ng/mL. What is the most appropriate next step in management?. a. Liver biopsy. b. Start treatment with appropriate parenteral antibiotic therapy. c. Prepare the patient for a liver transplant. d. MRCP and liver MRI. e. ERCP.

27.A 55-year-old man with liver cirrhosis due to viral hepatitis C has noticed his abdomen has increased in size, and he has gained weight over the last three months. Upon examination, signs of ascites are present in the abdominal cavity. Laboratory results:sodium 130 mEq/L, BUN 4.3 mmol/L, creatinine 35.4 μmol/L, total bilirubin 22.2 μmol/L, albumin 29 g/L, prothrombin time 13.4 s. Which therapy will most effectively prevent the accumulation of ascites?. a. Fluid restriction. b. Salt restriction and use of diuretics. c. Restriction of both fluid and salt intake. d. Salt restriction. e. Paracentesis of ascites.

28.A 24-year-old student has had loose, occasionally watery stools 4-7 times per day for the last four months, and wakes up at night due to the need to defecate. Laboratory results are normal. Infection was ruled out in the first week, then celiac disease, lactose intolerance, gastroscopy, and colonoscopy with terminal ileoscopy were done, all showing no abnormalities. What would be the appropriate next step?. a. It is a functional issue (irritable bowel), no further diagnostics are needed. b. Repeat colonoscopy with biopsies of normal mucosa. c. Perform MR enterography. d. Perform a contrast-enhanced abdominal CT. e. Measure fecal calprotectin concentration.

29.An 18-year-old student presents to the clinic due to bloody diarrhea, which started 3 days ago. He has been healthy until now, but finished antibiotic treatment (amoxicillin + clavulanic acid) 7 days ago for a root canal infection. a. The patient is very likely to have ulcerative colitis, so he should be referred for colonoscopy with biopsies. b. It is most likely hemorrhoidal bleeding, so the patient should be referred to a proctologist for hemorrhoid ligation. c. It could be infectious colitis, so prescribe ciprofloxacin. d. It could be antibiotic-associated diarrhea, so test for Clostridium difficile and toxin A/B in the stool. e. Due to hematochezia, the patient needs inpatient care for endoscopic diagnosis.

30.A 23-year-old woman with Crohn’s disease comes for a routine check-up. She feels well and tolerates biological medications well. She wants to conceive but is concerned about the side effects of medications on her child and would like to stop the medications before pregnancy. a. She can stop the medication because it is better for the child not to be exposed to immunosuppressive drugs during pregnancy, even if the disease reactivates. b. Pregnancy is not advised because there is a high chance the child willinherit the disease. c. Biological drugs cross the placenta, but due to the risk of disease reactivation if the medication is stopped, treatment should continue during pregnancy, as studies have not shown significant side effects on the child. d. Women on biological drugs are recommended to use contraception, as treatment should be stopped 2-4 half-lives before conception. e. Biological drugs do not cross the placenta, so stopping treatment is unnecessary.

31.A 45-year-old female with known celiac disease comes for a regular check-up. She reports persistent symptoms of diarrhea, bloating, and abdominal pain but has not lost weight. Celiac disease was diagnosed two years ago, and she has strictly followed a gluten-free diet. Despite this, symptoms persist. You decide to repeat serological testing (IgA tTG), which is highly elevated. What is the most likely cause of her symptoms?. a. Ulcerative jejunitis. b. Refractory celiac disease. c. Incorrect diagnosis of celiac disease. d. Gluten consumption (contamination with gluten). e. Microscopic colitis.

32.A 51-year-old woman comes to your clinic, reporting light-colored stools and jaundice over the past year. She is also more tired and reports pruritus. Laboratory results show elevated alkaline phosphatase, gamma-GT, and conjugated bilirubin. You suspect cholestasis, which may be associated with a deficiency in certain vitamins. Which of the following problems is most likely due to hypovitaminosis in this woman?. a. Prolonged prothrombin time. b. Hair loss. c. Megaloblastic anemia. d. Dermatitis. e. Koilonychia.

33.A 72-year-old man was brought to the urgent care unit due to nausea and severe, sudden abdominal pain. Upon clinical examination, his abdomen was soft, and palpation did not worsen the pain. Laboratory results did not show significant deviations from normal values. The ECG revealed atrial fibrillation. Due to suspicion of acute mesenteric ischemia, you decide to perform a CT angiography. What is the most likely cause of mesenteric ischemia?. Embolism of the celiac trunk. Embolism of the superior mesenteric artery. Thrombosis of the superior mesenteric vein. Thrombosis of the superior mesenteric artery. Thrombosis of the inferior mesenteric artery.

34.The most common risk factor for gastric adenocarcinoma among those listed is: Acute gastritis. Chronic atrophic gastritis due to Helicobacter pylori. Alcoholism. Fundic gland polyps. Cholecystectomy.

35.A 55-year-old man with no known comorbidities is brought to the emergency room due to syncope. He reports that for the last two days, he has been passing black, tarry stools and brings a sample with him. The day before, he had epigastric pain, felt nauseous but did not vomit. On examination, he is talkative, hypotensive (80/50), tachycardic (130/min), pale, but otherwise without any significant findings. Laboratory results show: Hb 85 g/L, urea 29 mmol/L, creatinine 90 μmol/L. What is the most appropriate management?. The patient should receive somatostatin, a proton pump inhibitor bolus, antibiotics, and after hemodynamic stabilization, urgent gastroscopy. He should receive a blood transfusion, a prescription for proton pump inhibitors, and a referral for gastroscopy within one week. The patient should be hemodynamically stabilized, followed by an urgent colonoscopy. The patient should be hemodynamically stabilized, receive a proton pump inhibitor bolus, and then undergo urgent gastroscopy. A rectal exam should be performed, a stool hematest conducted, and the patient should be referred for urgent gastroscopy.

38.A 38-year-old woman comes for an examination because she developed non-bloody diarrhea after returning from a trip to Russia, which has lasted more than two months and is accompanied by cramping abdominal pain and weight loss. She is referred for gastroscopy and colonoscopy. Aftous changes are seen in the antrum of the stomach, and there are ulcers in the terminal ileum and throughout the colon, with areas of healthy mucosa. The pathological report describes active inflammation and non-caseating granulomas. What is the most likely diagnosis?. Lactose intolerance. Crohn's disease. Ulcerative colitis. Irritable bowel syndrome.

A 35-year-old woman who gave birth three months ago presents with epigastric pain, nausea, and vomiting. The symptoms last for 6 hours. On examination, she denies smoking, but says she drinks a few beers on weekends. mmHg. Vital signs: TT 38.3 °C, heart rate 110/min, respiratory rate 14/min, blood pressure 100/55 The abdomen is tense, painful on deep palpation in the epigastrium, percussion is tympanic. Laboratory values: leukocytes 14 x 10°/L, hemoglobin 150 g/L, lipase 8.3 µkat/L, AST 0.67, ALT 0.58 µkat/L, bilirubin 34/14, creatinine 70 µmol/L. Which of the investigations will you do first?. Abdominal CT with KS. MR z MRCP. Next to the stomach. endoscopic ultrasound.

40.Who does not have GERD?. Several patients had symptoms of heartburn, but one specifically reported having Barrett's esophagus, so I think this last one is the correct answer.There were also a lady with asymptomatic heartburn, a gentleman with gastroesophageal reflux disease (GERD) on proton pump inhibitors due to heartburn, etc.41. .

An 18-year-old man has been experiencing foul-smelling discharge from the perianal foramen in the right lower quadrant of his abdomen for the past 8 weeks. He had an appendectomy 4 months ago because of sudden severe right lower quadrant pain and CT scan findings of appendicitis. What is the most likely diagnosis: a) intestinal perforation. b) Crohn's disease. c) Ulcerative colitis. d) Tuberculosis. e) Indeterminate colitis.

A 62-year-old man visits the emergency department because of 2 days of constant sharp pain in the left lower quadrant of the abdomen. He denies nausea, vomiting, weight loss, diarrhea, and hemostasis. He has a fever of 38 degrees C, pulse 105/min, and blood pressure of 110/55 mmHg. The abdomen is soft and very tender to palpation in the left lower quadrant. In the laboratory, we detect leukocytosis and an elevated CRP value, and the hemoglobin value is normal. We refer the patient for a CT scan of the abdominal organs. What do we find?. appendicitis. ulcerative colitis. Meckel's diverticulum. colon malignancy. diverticulitis.

43.Surgical treatment of pancreatic cystic lesions is necessary in: Intraductal papillary mucinous neoplasm (IPMN) with side branch involvement. A 4 cm mucinous cystadenoma –I think this is the correct one. A 4 cm large asymptomatic pseudocyst. A 2 cm pancreatic cyst where the CA in the cystic content is very low (CA distinguishes serous cysts from mucinous ones; since CA is very low, this is a serous cyst, and no further action is needed). A 1 cm cyst found incidentally on a transabdominal ultrasound (radiologist tells us it's a typical cyst).

44.A 24-year-old woman was referred for a colonoscopy by her primary care physician due to 2 months of hematochezia, where numerous adenomas were found throughout the colon. Genetic testing confirmed familial adenomatous polyposis (FAP). The patient comes for a consultation regarding further management and treatment options. Which statement is NOT correct?. a. Treatment is surgical. b. Preventive colectomy should be performed before the age of 40. c. After total colectomy, further endoscopic examinations are no longer needed. d. An endoscopy of the upper gastrointestinal tract should also be performed. e. Screening genetic testing of relatives should be performed.

Who receives chemotherapy after colon cancer surgery?. An 89-year-old with metastases after ileus surgery. A 50-year-old with T1N0M. A 42-year-old with T3N1M, is this possible?. Another with a malignant polyp T1, which was removed; it was written here that itmetastasized, so maybe this one?. None.

46.A gentleman with some problems has elevated ANA levels. Diagnosis?. Primary biliary cholangitis?. .