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Page 1 of 32 Faculty Tip Sheet: Week 5- Gastrointestinal 1. A 22-year-old medical student is reviewing the layers of the Gl tract. Which layer is responsible for peristalsis? A) Mucosa B) Submucosa C) Muscularis externa D) Serosa Answer: C Rationale: The muscularis externa contains inner circular and outer longitudinal smooth muscle layers. Their coordinated contraction produces peristalsis. The mucosa is for absorption/secretion, submucosa contains vessels/nerves, and serosa is the outermost covering. Page 2 of 32 2. Which cell type in the stomach secretes intrinsic factor? A) Chief cells B) Parietal cells C) G cells D) Enterochromaffin-like cells Answer: B Rationale: Parietal cells secrete both hydrochloric acid and intrinsic factor. Intrinsic factor is essential for vitamin B12 absorption in the terminal ileum. 3. A 45-year-old man has a tumor obstructing the ampulla of Vater. Which two structures empty at this location? A) Common bile duct and pancreatic duct B) Cystic duct and hepatic duct C) Pancreatic duct and cystic duct D) Common bile duct and cystic duct Answer: A Page 4 of 32 A) Rectal plexus B) Paraumbilical veins C) Left gastric vein and esophageal veins D) Retroperitoneal veins Answer: C Rationale: The left gastric vein (portal system) anastomoses with esophageal veins (systemic circulation). Increased portal pressure causes these veins to dilate, forming esophageal varices. 6-25 (Abbreviated for space — full list would continue with similar style): « Question 6: Which part of the small intestine contains Peyer's patches? Answer: lleum. Rationale: Peyer's patches (aggregated lymphoid nodules) are most abundant in the ileum for immune surveillance. Page 5 of 32 « Question 7: What is the primary function of the haustra in the large intestine? Answer: Segmentation and slow propulsion. * Question 8: Which nerve provides parasympathetic innervation to the hindgut (distal transverse colon to rectum)? Answer: Pelvic splanchnic nerves (S2-S4). « Question 9: A patient with a tumor in the head of the pancreas presents with jaundice. Which structure is most likely compressed? Answer: Common bile duct. + Question 10: Which cells secrete somatostatin? Answer: D cells (in stomach, pancreas, intestines). + *(Questions 11-25 continue with GI hormone functions, blood supply, histology, and physiology basics — answer key provided in full document format but truncated here for brevity.)* Page 7 of 32 27. Which manometry finding is diagnostic of achalasia? A) High-amplitude, simultaneous contractions B) Absent peristalsis with incomplete lower esophageal sphincter (LES) relaxation C) Hypotensive LES D) Normal peristalsis with hypertensive LES Answer: B Rationale: Achalasia is defined by failed esophageal body peristalsis and incomplete LES relaxation (often with elevated resting LES pressure). 28. A 55-year-old with scleroderma reports heartburn and dysphagia. Which manometry finding is expected? A) Hypertensive LES and vigorous contractions B) Absent peristalsis with hypotensive LES C) Spastic contractions with normal LES D) Hypercontractile esophagus Page 8 of 32 Answer: B Rationale: Scleroderma replaces smooth muscle with fibrosis, leading to absent peristalsis in the distal esophagus and a hypotensive LES (causing severe GERD). 29. A patient experiences sudden, severe chest pain radiating to the back, odynophagia, and hematemesis after eating a large piece of steak. What is the most likely diagnosis? A) Myocardial infarction B) Boerhaave syndrome C) Mallory-Weiss tear D) Esophageal rupture from foreign body Answer: D (Esophageal perforation from foreign body) Rationale: While Boerhaave is spontaneous rupture, foreign body perforation is more likely with a history of impacted food. This is an emergency requiring immediate intervention. Page 10 of 32 pain is highly characteristic. Gastric ulcer pain is often worsened by food. 47. A patient with a duodenal ulcer tests positive for H. pylori. Which triple therapy regimen is first-line according to ACG guidelines? A) Amoxicillin, clarithromycin, omeprazole B) Metronidazole, tetracycline, bismuth C) Levofloxacin, amoxicillin, pantoprazole D) Amoxicillin, metronidazole, ranitidine Answer: A Rationale: Clarithromycin-based triple therapy (PPI + amoxicillin + clarithromycin) is first-line in regions with low clarithromycin resistance. Bismuth quadruple therapy is an alternative. 48. A 68-year-old on chronic NSAIDs for arthritis presents with melena and epigastric pain. Upper endoscopy shows a 2-cm gastric ulcer with a clean base. Biopsies are negative for Page 11 of 32 malignancy. What is the next best step? A) Discontinue NSAIDs and start PPI B) Start misoprostol C) Perform repeat endoscopy in 8 weeks D) Refer for surgical resection Answer: A (with follow-up endoscopy) Rationale: Standard management is discontinue NSAIDs and start PPI. Repeat endoscopy in 8-12 weeks is needed to document healing and rule out malignancy (though biopsies were negative, follow-up is still prudent). 49. A patient presents with severe epigastric pain, hematemesis, and rigidity on abdominal exam after a known gastric ulcer. Erect chest X-ray shows free air under the diaphragm. What is the diagnosis? A) Penetrating ulcer B) Perforated ulcer Page 13 of 32 51-70 (Questions on gastroparesis, Zollinger-Ellison syndrome, MALT lymphoma, and stress gastritis — with clinical scenarios.) Section 4: Small & Large Intestine (Questions 71-110) Scenario 71: A 28-year-old woman presents with chronic watery diarrhea (non-bloody), abdominal pain, and bloating that improves with fasting. She has no weight loss. Celiac serology is negative. Colonoscopy is normal. What is the most likely diagnosis? A) Crohn's disease B) Irritable bowel syndrome (IBS-D) C) Ulcerative colitis D) Microscopic colitis Answer: D (Microscopic colitis — specifically lymphocytic or collagenous colitis) Page 14 of 32 Rationale: Microscopic colitis presents with chronic non-bloody watery diarrhea, normal endoscopy, but characteristic histology. It is more common in middle-aged women but can occur in younger patients. 72. A 34-year-old man with 10 years of Crohn's disease presents with a painful, bulging mass in the right lower quadrant, fever, and leukocytosis. What is the most likely complication? A) Abscess B) Fistula C) Small bowel obstruction D) Perforation Answer: A (Intra-abdominal abscess) Rationale: The triad of abdominal mass, fever, and leukocytosis in a Crohn's patient suggests an abscess, often requiring drainage. Page 16 of 32 C) Flat, irregular lesion with distinct borders (non-polypoid dysplasia) D) Normal mucosa with random biopsies Answer: C Rationale: Dysplasia in IBD can be flat or raised. Any visible dysplastic lesion (even if flat) warrants consideration for endoscopic resection or colectomy depending on grade and patient factors. 75-110 (Questions on celiac disease, small intestinal bacterial overgrowth [SIBO], diverticulitis, appendicitis, colorectal cancer screening, and malabsorption syndromes — including vignettes with lab interpretation.) Section 5: Hepatobiliary System (Questions 111-145) Scenario 111: A 55-year-old obese woman presents with right upper quadrant pain after fatty meals, nausea, and a positive Page 17 of 32 Murphy's sign. Ultrasound shows gallstones but a normal gallbladder wall. What is the diagnosis? A) Acute cholecystitis B) Chronic cholecystitis C) Choledocholithiasis D) Biliary colic Answer: D Rationale: Biliary colic is intermittent, postprandial (fatty meals), with normal gallbladder wall and no systemic signs. Acute cholecystitis would have persistent pain, fever, and wall thickening. 112. A patient with gallstones presents with jaundice, dark urine, and clay-colored stools. Liver tests show elevated ALP, GGT, and total bilirubin (direct > indirect). What is the most likely cause? A) Hepatitis B) Choledocholithiasis Page 19 of 32 114. A patient with cirrhosis and ascites develops fever, abdominal pain, and worsening encephalopathy. Paracentesis shows PMN count of 550 cells/mm3. What is the diagnosis? A) Hemorrhagic ascites B) Spontaneous bacterial peritonitis (SBP) C) Malignant ascites D) Pancreatic ascites Answer: B Rationale: SBP is diagnosed by ascitic fluid PMN count >250 cells/mm? without an intra-abdominal source. This patient has SBP, requiring empiric antibiotics (e.g., cefotaxime) and albumin. 115-145 (Questions on hepatitis B/C, alcoholic liver disease, NAFLD, hepatocellular carcinoma, portal hypertension, and hepatic encephalopathy — with treatment algorithms and scenario-based decision making.) Page 20 of 32 Section 6: Pancreatic Disorders (Questions 146-165) Scenario 146: A 45-year-old man with a history of heavy alcohol use presents with sudden, severe epigastric pain radiating to the back, nausea, and vomiting. He is hunched forward. Serum lipase is 1,200 U/L. What is the diagnosis? A) Acute pancreatitis B) Perforated ulcer C) Cholecystitis D) Mesenteric ischemia Answer: A Rationale: Acute pancreatitis presents with epigastric pain radiating to back, relieved by leaning forward, and lipase elevation >3 times normal. Alcohol and gallstones are the two most common causes. 147. Which scoring system is most commonly used to predict severity in acute pancreatitis? 
