krok 2 (Gasteroenterology) with explanation part 8

71). 4 hours after having meals a patient with signs of malnutrition and steatorrhea experiences
stomach pain, especially above navel and to the left of it. Diarrheas take turns with constipation
lasting up to 3-5 days. Palpation reveals moderate painfulness in the choledochopancreatic

region. The amylase rate in blood is stable. X-ray reveals some calcifications located above
navel. What is the most likely diagnosis? 
A. Chronic pancreatitis
B. Chronic gastroduodenitis
C. Duodenal ulcer
D. Zollinger-Ellison syndrome
E. Chronic calculous cholecystitis
Explanation :steato

72). A 43-year-old female patient complains of unstable defecation with frequent constipations,
abdominal swelling, headache, sleep disturbance. Body weight is unchanged. What disease are
these clinical presentations typical for?
A. Irritable colon syndrome
B. Chronic enteritis
C. Chronic pancreatitis
D. Chronic atrophic gastritis
E. Colorectal cancer
Explanation : Diagnostic Criteria for Irritable Bowel Syndrome (IBS) :
1) Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months 
Plus two or more of the following
2) Improvement with defecation
3) change in frequency of stool
4) change in stool form(appearance)

Note: There is no pathological changes in bowel.

73). A 23-year-old patient complains of a dull ache, sensation of heaviness and distention in the
epigastrium immediately after meals, foul-smelling eructation; dry mouth, empty stomach
nausea, diarrhea. Objectively: the skin is pale, the patient is of thin build. Abdomen is soft on
palpation, there is epigastric pain. The liver does not extend beyond the costal arch. In blood:
Hb - 110 g/l, RBCs - 3, 4 · 1012/l, WBC count is normal. ESR - 16 mm/h. What is the most
informative study that will allow make a diagnosis?
A. Esophageal gastroduodenoscopy
B. X-ray of digestion organs
C. Study of gastric juice
D. pH-metry
E. Duodenal probing

74). A 49-year-old patient complains of deglutition problems, especially with solid food, hiccups,
voice hoarseness, nausea, regurgitation, significant weight loss (15 kg within 2,5 months).
Objectively: body weight is reduced. Skin is pale and dry. In lungs: vesicular breathing, heart
sounds are loud enough, heart activity is rhythmic. The abdomen is soft, painless on palpation.
Liver is not enlarged. What study is required to make a diagnosis?

A. Esophageal duodenoscopy along with biopsy
B. Clinical blood test
C. X-ray of digestive tract organs
D. X-ray in Trendelenburg’s position
E. Study of gastric secretion
Explanation :-  There is loss of weight, deglutition problem with solid food  thus, patient is suspected to have cancer and the best method of investigation in this case is Esophagogastroduodenoscopy with biopsy.

75) . A 60-year-old patient had eaten too much fatty food, which resulted in sudden pain in the
right subcostal area, nausea, bilious vomiting, strong sensation of bitterness in the mouth. Two
days later the patient presented with jaundice, dark urine. Objectively: sclera and skin are
icteric, abdomen is swollen, liver is increased by 3 cm, soft, painful on palpation, Ortner’s,
Kehr’s, Murphy’s, Zakharyin’s, MayoRobson’s symptoms are positive. Which method should be
applied for diagnosis in the first place?
A. USI of gallbladder and biliary duct
B. Fibrogastroduodenoscopy
C. X-ray of abdominal organs
D. Radionuclide scanning of liver and gallbladder
E. Diagnostic laparotomy
Explanation: Ortner’s, Kehr’s, Murphy’s, Zakharyin’s, MayoRobson’s sign are positive in acute cholecystitis. USG is gold-standard for hepatobiliary  disorder.

76). A 60-year-old woman, mother of 6 children, developed a sudden onset of upper abdominal
pain radiating to the back, accompanied by nausea, vomiting, fever and chills. Subsequently,
she noticed yellow discoloration of her sclera and skin. On physical examination the patient was
found to be febrile with temp of 38, 9oC, along with right upper quadrant tenderness. The most
likely diagnosis is
A. Choledocholithiasis
B. Benign biliary stricture
C. Malignant biliary stricture
D. Carcinoma of the head of the pancreas
E. Choledochal cyst
Explanation: 5F are to risk factors for the development of cholelithiasis in an event of upper abdominal pain:
Fair: more prevalent in Caucasian population(fair)
Fat: BMI >30
Female gender
Fertile: one or more children
Forty: age ≥40

77). A 45-year-old woman, mother of four children, comes to the emergency room complaining
of a sudden onset of the epigastric and right upper quadrant pain, radiating to the back,
accompanied by vomiting. On examination, tenderness is elicited in the right upper quadrant,
bowel sounds are decreased, and laboratory data shows leukocytosis, normal serum levels of
amylase, lipase, and bilirubin. The most likely diagnosis is:
A. Acute cholecystitis
B. Perforated peptic ulcer disease
C. Myocardial infarction
D. Sigmoid diverticulitis
E. Acute pancreatitis

78). During an operation for presumed appendicitis the appendix was found to be normal;
however, the terminal ileum is evidently thickened and feels rubbery, its serosa is covered with
grayish-white exudate, and several loops of apparently normal small intestine are adherent to
it. The most likely diagnosis is:
A. Crohn’s disease of the terminal ileum
B. Perforated Meckel’s diverticulum
C. Ulcerative colitis
D. Ileocecal tuberculosis
E. Acute ileitis
Explanation:Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract from mouth to anus.Mostly affected in crohn's disease is terminal ileum.

79). A female patient has been suffering from pain in the right subcostal area, bitter taste in the
mouth, periodical bile vomiting for a month. The patient put off 12 kg. Body temperature in the
evening is 37, 6oC. Sonography revealed that bile bladder was 5,5х2,7 cm large, its wall - 0,4
cm, choledochus - 0,8 cm in diameter. Anterior liver segment contains a roundish hypoechoic
formation up to 5 cm in diameter and another two up to 1,5 cm each, walls of these formations
are up to 0,3 cm thick. What is the most likely diagnosis?
A. Alveolar echinococcus of liver
B. Liver cancer
C. Liver abscess
D. Cystous liver cancer
E. Paravesical liver abscesses
Explanation: Echinococcosis, also called hydatid disease, It is a parasitic disease of tapeworms of the Echinococcus type. The two main types of the disease are alveolar echinococcosisand  cystic echinococcosis . USG show multiple  hypo-echoic cyst like formation.

80). In autumn a 25-year-old patient developed stomach ache arising 1,5-2 hours after having
meals and at night. He complains of pyrosis and constipation. The pain is getting worse after
consuming spicy, salty and sour food, it can be relieved by means of soda and hot-water bag.
The patient has been suffering from this disease for a year. Objectively: furred moist tongue.
Abdomen palpation reveals epigastrial pain on the right, resistance of abdominal muscles in the
same region. What is the most likely diagnosis?
A. Duodenal ulcer
B. Chronic cholecystitis
C. Diaphragmatic hernia
D. Stomach ulcer
E. Chronic pancreatitis
Explanation: Duodenal ulcer is associated stomach pain that arose  1.5-2.5 hours after having meal and get relief by meal. Spring and autumn are environmental risk factor for duodenal ulcer.
part 9