Small intestinal disorders

1.A 32-year-old man was reviewed in the emergency department with diarrhoea secondary to enteropathogenic Escherichia coli infection. Oral rehydration therapy (ORT) was suggested to improve hydration status.

Through which ion transporter does ORT act?

A. Cystic fibrosis transmembrane conductance regulator (CFTR)

B. Epithelial sodium channel (ENaC)

C. Glucose transporter 1 (GLUT1)

D. Sodium/glucose cotransporter 1 (SGLT1)

E. Sodium/potassium/chloride cotransporter 1 (NKCC1)

2.A 46-year-old woman presented with a 5-month history of profuse diarrhoea despite fasting, and associated abdominal bloating. She complained of increasing fatigue and flushing, and appeared dehydrated.

Investigations:

Haemoglobin	125 g/L
Serum sodium	144 mmol/L
Serum potassium	1.9 mmol/L
Serum urea	7.3 mmol/L
Serum creatinine	136 µmol/L
Plasma viscosity	1.76 mPa/s

Which of the following is the most likely diagnosis?

A. Bile acid diarrhoea

B. Carcinoid syndrome

C. Coeliac disease

D. Vasoactive intestinal polypeptide (VIP)oma

E.Vibrio cholera infection

3.A 37-year-old with diarrhoea was reviewed in outpatients and was interested to understand more about gut hormones.

Regarding gut hormones, which of the following statements is true?

A. Cholecystokinin is produced by I cells of the small intestine in response to ingested carbohydrate

B. Gastrin is produced by G cells of the duodenum in response to raised gastric pH

C. Glucagon-like peptide 1 stimulates glucose-dependent glucagon release from the pancreatic islets

D. Glucagon-like peptide 2 (GLP-2) inhibits gastric emptying and gastric acid production, induces small bowel mucosal growth, and stimulates mesenteric blood flow

E. Somatostatin increases gut motility and stimulates pancreatico-biliary secretions

4.You reviewed a 47-year-old patient in clinic with a body mass index (BMI) of 34 kg/m². They asked for your opinion on the role of leptin in obesity.

Which of these statements is true?

A. Ethnicity exerts a significant effect on leptin concentrations

B. Leptin is a product of the lep gene primarily expressed in adipocytes

C. Most patients with obesity have low serum leptin

D. Overeating reduces circulating leptin levels

E. Supraphysiological doses of leptin may reduce food intake in patients of normal weight

5.A 43-year-old woman with a BMI of 37 kg/m²was referred for gastric bypass surgery. She was consented for a research study investigating satiety hormones in those undergoing bariatric surgery.

Which of the following statements best describes the behaviour of ghrelin?

A. Levels fall before meal ingestion but gradually rise in the subsequent two hours

B. Levels remain unchanged before and after meal ingestion

C. Levels rise sharply before and fall shortly after meal ingestion

D. Levels rise sharply before meal ingestion and remain high afterwards for several hours

E. Levels are unchanged before meal ingestion but fall rapidly afterwards

6.A 47-year-old man presented with intermittent, watery diarrhoea. He had a 25-year history of type I diabetes with retinopathy and peripheral neuropathy requiring an insulin pump. Investigations were unremarkable and autonomic enteropathy was suspected.

Which of the following neurotransmitters is most responsible for activating sensory neurones following stimulation of stretch receptors in the bowel?

E. Vasoactive intestinal peptide (VIP)

7.A 25-year-old scientist was referred for a second opinion due to persistent abdominal pain, nausea, abdominal distension, and weight loss. All investigations had been normal and enteric dysmotility was suspected. She enquired about measuring small bowel contractility.

Which of the following would you recommend as best for measuring small intestinal contractile patterns?

A. Barium follow through

B. Catheter-based manometry

C. Lactulose hydrogen breath test

D. Scintigraphy

E. Wireless motility capsule

8.A 38-year-old man presented with recurrent abdominal pain, every other day, for the previous three months.

Which of the following most favours a diagnosis of irritable bowel syndrome (IBS)?

A. Bloating

B. Early satiety

C. Mucus discharge per rectum

D. Nausea

E. Worsening pain with defecation

9.A 37-year-old woman with a history of functional abdominal pain was referred for a second opinion and was keen to know about options for managing her ongoing pain. She had had no response to antispasmodics, amitriptyline, duloxetine, or hypnotherapy.

Which of the following should you recommend next?

A. Fentanyl patch

B. Gabapentin

C. Oxycodone immediate release

D. Sacral nerve stimulator

E. Sertraline

10.You have been invited to present to the local coeliac disease patient support group about the practicalities of a gluten-free diet.

Which one of the following foods and drinks could be included in a gluten-free diet?

11.A 29-year-old white British nursery worker attended clinic with a two-year history of abdominal bloating, discomfort, and an alternating bowel habit. She had not lost weight, had no rectal bleeding or skin rashes, but was frequently tired. She had a sister with type 1 diabetes.

Investigations:

Haemoglobin	121 g/L
White cell count	5.4 × 10⁹/L
Platelet count	174 × 10⁹/L
Mean corpuscular volume (MCV)	87 fL
Serum ferritin	12 μg/L
Serum C-reactive protein (CRP)	0.2 mg/L
Serum vitamin B12	358 ng/L
Serum folate	1.9 μg/L
Serum vitamin D	51 nmol/L
immunoglobin A tissue transglutaminase antibody (IgA TTG)	<0.2 U/ml
Total IgA	0.05 g/L
human leukocyte antigen (HLA) status	DQ 2.5 heterozygote
Gastroscopy	Macroscopically normal
Duodenal histology	Marsh 3C villous atrophy and crypt hyperplasia with intraepithelial lymphocytosis

What is the most appropriate test to establish a diagnosis?

A. Faecal calprotectin

B.Helicobacter pylori serology

C. HIV serology

D. Periodic-acid Schiff (PAS) staining of duodenal biopsies

E. Serum IgG TTG antibody

12.A 27-year-old man presented to clinic with persistent abdominal discomfort, bloating, and alternating bowel habit. He had been diagnosed with coeliac disease 12 months ago.

Investigations:

	At diagnosis	At present
Haemoglobin	116 g/L	134 g/L
MCV	87 fL	93 fL
Serum ferritin	8 µg/L	42 µg/L
Serum vitamin B12	246 ng/L	283 ng/L
Serum folate	2.2 µg/L	4.9 µg/L
IgA TTG	1800 U/ml	7 U/ml
Duodenal histology	Marsh 3C villous atrophy and crypt hyperplasia with intra-epithelial lymphocytosis	Fig. 6.1

Fig. 6.1 Duodenal histology specimen. See also Plate 11

Image courtesy of Dept of Histopathology, Oxford University Hospitals NHS Foundation Trust

How would you classify the histological features?

A. Enteropathy-associated T-cell lymphoma (EATL)

13.A 23-year-old patient with coeliac disease was worried about their bone health.

Which of the following statements is true?

A. A bone density scan does not need to be performed until the age of 50

B. Bone density will not increase during the first year of a gluten-free diet

C. Calcium intake should be at least 1,000 mg per day

D. Patients with ongoing villous atrophy require annual bone density scans

E. The risk of osteoporosis and bone fracture is not increased in patients with coeliac disease

14.A 25-year-old man presented as an emergency with abdominal pain, distension, vomiting and weight loss of 6 kg in two months. Over the past few days he had occasionally opened his bowels and had noted some blood on the paper when wiping. He had a past history of coeliac disease and insisted he was compliant with a gluten-free diet. Axillary and inguinal lymphadenopathy was present.

Investigations:

Haemoglobin	113 g/L
MCV	79.4 fL
Serum ferritin	13 µg/L
IgA TTG	359 U/ml
Faecal occult blood	Positive

Which of the following is the most likely diagnosis?

A. Coeliac disease exacerbation

B. Colorectal cancer

C. EATL

D. Graves’ disease

E. Lactose intolerance

15.A 51-year-old woman was referred for assessment of diarrhoea. She complained of episodes of abdominal pain, bloating, and vomiting. She was troubled by facial flushing although wondered if this was the menopause. She had a recent diagnosis of asthma, and a history of previous parathyroidectomy and resection of a pituitary microadenoma.

Investigations:

Gastroscopy	Normal
Ileocolonoscopy	Normal
CT enterography	There is no small bowel inflammation but there is a suggestion of a mid-ileal small bowel mass. Several poorly characterized liver lesions are seen. MRI liver recommended.
thyroid-stimulating hormone (TSH)	0.38 mU/L
24-hour urinary 5-hydroxyindolacetic acid (5-HIAA)	523 μmol

What is the most likely diagnosis?

A. Multiple endocrine neoplasia (MEN) 1

B. MEN2A

C. MEN2B

D. Thyrotoxicosis

E. Zollinger-Ellison syndrome

16.A 48-year old homeless man was admitted with a one week history of confusion and diarrhoea, passing loose, watery stool several times a day with urgency. He drank approximately 140 units of alcohol a week. He was confused with disorientation to place and time. An Abbreviated Mental Test Score was 2/10. There was no evidence of confabulation. On examination he was alert, but confused, with normal neurological examination and no nystagmus or ophthalmoplegia. He had poor dentition. He had a non-itchy, erythematous, symmetrical rash, predominantly on his face, neck, hands and forearms, with some blebs and blisters.

Which nutritional deficiency would best explain the presentation?

17.A 37-year-old Caucasian woman was referred with fatigue, bloating, and looser stools. She had a history of alcohol excess and ankylosing spondylitis, and was prone to urinary tract infections for which she took long-term prophylactic dose trimethoprim.

Investigations:

Haemoglobin	95 g/L
MCV	105 fL
Serum ferritin	276 µg/L
Serum folate	1.4 µg/L
Serum vitamin B12	358 ng/L
Serum CRP	4.3 mg/L

What is the most likely cause of her folate deficiency?

A. Coeliac disease

B. Crohn’s disease

C. Dietary deficiency in the context of alcohol excess

D. Small intestinal bacterial overgrowth

E. Trimethoprim

18.A 76-year-old man was referred to clinic with abnormal blood tests. There was no history of loose stools, abdominal pain, or weight loss. He had a past medical history of type 2 diabetes. His only medications were metformin, aspirin, and ranitidine when required.

Investigations:

Haemoglobin	98 g/L
MCV	113 fL
Serum ferritin	276 µg/L
Serum folate	2.4 µg/L
Serum vitamin B12	123 ng/L
Intrinsic factor antibodies	Negative

Which is the most likely underlying cause of his presentation?

A. Gastric cancer

B. Metformin

C. Pancreatic insufficiency

D. Pernicious anaemia

E. Ranitidine

19.An 80-year-old man presented with a three-week history of progressive discolouration and oligo-arthralgia of his lower limbs. He denied any history of trauma. He lived alone but had no past medical history and was not on any regular medications. On examination, he appeared frail and unkempt. Widespread ecchymosis of the lower limbs with perifollicular haemorrhage and corkscrew hair was noticed.

Investigations:

Haemoglobin	111 g/L
MCV	77 fL
White cell count	6.0 × 10⁹/L
Platelet count	300 × 10⁹/L
Serum CRP	4 mg/L
Serum ferritin	13 μg/L
Serum folate	8 μg/L
Serum vitamin B12	250 ng/L
Coagulation screen	Normal
Urinalysis	Normal

Which micronutrient deficiency is the most likely cause for his presentation?

20.A 35-year-old woman presented with increasing orthopnoea and breathlessness on minimal exertion. On examination, her jugular venous pressure (JVP) was raised, she had pitting oedema to her thighs, and her breath sounds were reduced bibasally. She had recently arrived in the UK from rural China to visit her cousin. She felt generally weak and her cousin said that her mood was different from usual.

Investigations:

Full blood count	Normal
TSH	5.9 mU/L
Free T4	9.8 pmol/L
Free T3	2.1 pmol/L
Chest radiograph	Blunted costophrenic angles and cardiomegaly
Echocardiogram	Dilated left ventricle, globally reduced systolic function