LMNS FOR FINALS_GASTRO BLOCK

1. A 9-year-old boy presents with 18 hours of migrating abdominal pain and vomiting. Which statement about pediatric appendicitis is LEAST accurate?

A. The peak incidence occurs a child's first 5 years of life.

B. It is the most common acute surgical condition in children.

C. Variability in presentation contributes to differences in diagnostic and surgical approaches.

D. Laparoscopic appendectomy is the preferred operative management.

A. Appendicitis is uncommon in children

2. A 2-month-old infant has fever, abdominal distension, and poor feeding. Infantile appendicitis can mimic neonatal conditions. Which is LEAST likely to mimic neonatal appendicitis?

A. Clinical sepsis

B. Hirschsprung disease

C. Meconium plug syndrome

D. Neonatal post-maturity syndrome

D. Sepsis, Hirschsprung disease and meconium plug syndrome can present with abdominal distension/feeding problems and mimic appendicitis.

3. A 7-year-old with perforated appendicitis is at risk for postoperative complications. Which is NOT typically associated with increased morbidity?

A. Surgical-site infection

B. Intra-abdominal abscess

C. Delay in required surgical intervention

D. Short duration of antibiotic therapy

D. Complications are associated with perforation, delay and abscess formation. Antibiotic duration should be appropriate to the clinical response.

4. Typical pathophysiologic progression of appendicitis in children:

A. Inflammation Obstruction Abscess Perforation Peritonitis

B. Obstruction Inflammation Perforation Abscess Peritonitis

C. Inflammation Obstruction Perforation Abscess Peritonitis

D. Obstruction Inflammation Abscess Perforation Peritonitis

D. The classic sequence begins with luminal obstruction inflammation suppuration/abscess perforation peritonitis.

5. Which etiology is commonly associated with development of acute appendicitis?

A. Parasitic infections

B. Fecalith formation

C. Radiotherapy-induced appendicitis

D. Genetic predisposition

B. Fecalith/appendicolith obstruction is a classic precipitating factor.

6. A full-term neonate develops abdominal distension, temperature instability and rapid deterioration. Neonatal appendicitis is suspected. Most probable underlying etiology?

A. Intestinal Yersinia infection

B. Coxsackie B viral enteritis

C. Cystic fibrosis

D. Blunt abdominal trauma

C. Neonatal appendicitis is rare and is associated with cystic fibrosis, particularly because of thick intestinal contents and obstruction.

7. A 10-year-old presents after 60 hours of abdominal pain progressing to fever and tachycardia. Which statement regarding pediatric appendicitis is INCORRECT?

A. Risk of perforation rises after 48 hours.

B. Most of these children present with perforation at the ER.

C. Early disease may appear mild with subtle examination findings.

D. Symptoms escalate over 2-3 days with worsening abdominal pain.

B. Perforation becomes increasingly likely with delay, but most children do not necessarily present with perforation.

8. A 6-year-old presents with sepsis and suspected perforated appendicitis. Which vital-sign abnormality is most expected?

A. Bradycardia

B. High-grade fever

C. Hypotension

D. Tachypnea

C. Hypotension indicates significant systemic compromise/septic shock. Tachycardia is also expected but is not an option.

9. During re-evaluation of a child with early appendicitis, which new finding most strongly suggests impending perforation?

A. Periumbilical tenderness

B. Abdominal distention

C. Direct tenderness at McBurney's point

D. Intermittent projectile vomiting

B. Increasing abdominal distention suggests ileus, generalized inflammation and possible perforation.

10. Pain in the LLQ elicited by palpation in a child with suspected appendicitis is known as:

A. Murphy's sign

B. Rovsing's sign

C. Dunphy's sign

D. Psoas sign

B. Rovsing's sign. RLQ appendiceal irritation can cause LLQ palpation to produce RLQ pain.

11. Pain elicited by coughing or abdominal wall movement in a child with RLQ tenderness is known as:

A. Murphy's sign

B. Rovsing's sign

C. Dunphy's sign

D. Psoas sign

C. Dunphy's sign is pain in the right lower quadrant elicited by coughing or any movement of the abdominal wall, indicating localized peritonitis.

12. A child with suspected appendicitis undergoes laboratory testing. Which result would be LEAST expected?

A. Normal WBC count early in the disease

B. Gross hematuria with purpuric rash

C. Elevated C-reactive protein

D. UA showing few WBCS/RBCS

B. A normal WBC count can be seen early in the disease. Elevated CRP and a few WBCS/RBCS on urinalysis are common. Gross hematuria with a purpuric rash is not a typical finding and would suggest a different diagnosis, such as Henoch-Schönlein purpura or a renal disorder.

13. A healthy 4-month-old infant has twice-weekly non-projectile vomiting after feeding, especially during burping. Growth and exam are normal. Best next step?

A. Reassurance and anticipatory guidance

B. CBC and urinalysis

C. Abdominal radiographs

D. Referral to Pediatric GI

A. This infant has classic physiologic gastroesophageal reflux (GER), which is common and peaks around 4 months of age. In a thriving infant with a normal exam, the best management is reassurance and anticipatory guidance.

14. Based on the case above, what is the MOST likely diagnosis?

A. Upper GI obstruction

B. UTI

C. GERD

D. Infantile physiologic reflux

D. The history of non-projectile, post-prandial regurgitation in a thriving infant with a normal physical exam is characteristic of infantile physiologic reflux (GER). GERD would imply troublesome symptoms or complications, which are absent here.

15. What is the most appropriate management for physiologic reflux in this infant?

A. Surgical referral

B. Antibiotics

C. Upper GI endoscopy

D. Address feeding volume and observe

D. Management of physiologic reflux includes reassurance, feeding advice (e.g., smaller, more frequent feeds), and positioning. Addressing feeding volume and observing is the most appropriate step.

16. An 8-year-old has 2 years of progressive dysphagia initially to solids then liquids. He is cachectic and spits out saliva. Multiple prior consults were misdiagnosed as respiratory tract infection or oropharyngeal disorders. Most likely diagnosis?

A. Achalasia

B. Acute tonsillopharyngitis

C. GERD

D. Cyclic vomiting syndrome

A. Progressive dysphagia to both solids and liquids, along with cachexia and regurgitation of saliva, is a classic presentation of achalasia. The chronicity and progressive nature make other diagnoses less likely.

17. Which additional clinical finding would BEST support suspected achalasia?

A. Chronic cough with under-nutrition

B. Fever and tonsillar exudates

C. Epigastric tenderness

D. Normal exam

A. Chronic cough and under-nutrition are common in achalasia due to regurgitation and aspiration of retained esophageal contents, leading to respiratory symptoms and poor weight gain.

18. Which diagnostic test is MOST appropriate to confirm achalasia?

A. CBC with differential count + throat swab

B. Trial of PPI therapy

C. Contrast enhanced esophageal fluoroscopy

D. No tests required

C. A barium swallow (contrast-enhanced esophageal fluoroscopy) is a key diagnostic test for achalasia, classically showing a "bird's beak" appearance. Esophageal manometry is the most sensitive test.

19. Which diagnostic result MOST strongly supports the diagnosis?

A. Neutrophilic leukocytosis with Gram-positive cocci

B. Improvement on PPI therapy

C. Bird-beak tapering of distal esophagus

D. Normal contrast study

C. The "bird-beak" tapering of the distal esophagus on a barium swallow is the classic, pathognomonic finding for achalasia.

20. What is the normal esophageal length in a newborn at birth?

A. 3-5 cm

B. 8-10 cm

C. 12-15 cm

D. 20-25 cm

B. The esophagus is approximately 8-10 cm in length at birth and grows to about 25 cm by adulthood.

21. Infant gastroesophageal reflux typically peaks at what age?

A. 2 months

B. 4 months

C. 8 months

D. 12 months

B. Physiologic gastroesophageal reflux in infants typically peaks at around 4 months of age and usually resolves by 12 months.

22. Infiltration of how many eosinophils per high-power field (HPF) in the esophageal epithelium is required to diagnose Eosinophilic Esophagitis?

A. 5 or more

B. 10 or more

C. 15 or more

D. 25 or more

C. The diagnosis of eosinophilic esophagitis requires the presence of at least 15 eosinophils per high-power field in esophageal biopsies.

23. Which of the following is NOT considered an alarm sign or symptom in Pediatric GERD?

A. Bulging fontanelle

B. Rumination behavior

C. Heart burns

D. Respiratory symptoms

B. Alarm signs for GERD include bilious vomiting, GI bleeding, failure to thrive, and neurological signs like a bulging fontanelle. Rumination behavior is a separate functional gastrointestinal disorder and is not an alarm sign for GERD. Heartburn and respiratory symptoms are common manifestations of GERD, not necessarily alarm signs, but rumination is a distinct entity.

24. A 10-year-old with suspected pancreatitis undergoes evaluation of enzyme function. Which group digests dietary fats?

A. Trypsin, chymotrypsin, carboxypolypeptidase

B. Lipase, cholesterol esterase, phospholipase

C. Pancreatic amylase

D. Enterokinase

B. Pancreatic lipase, cholesterol esterase, and phospholipase are the primary enzymes responsible for the digestion of dietary fats.

25. Which pancreatic enzyme group digests proteins?

A. Trypsin, chymotrypsin, carboxypolypeptidase

B. Lipase, cholesterol esterase, phospholipase

C. Amylase

D. Enterokinase

A. Trypsin, chymotrypsin, and carboxypolypeptidase are proteolytic enzymes that digest proteins.

26. Which enzyme activates pancreatic zymogens when chyme contacts the duodenum?

A. Trypsin, chymotrypsin, carboxypolypeptidase

B. Lipase, cholesterol esterase, phospholipase

C. Amylase

D. Enterokinase

D. Enterokinase (enteropeptidase), an enzyme secreted by the duodenal mucosa, converts inactive trypsinogen to active trypsin, which then activates other pancreatic zymogens.

27. Why is serum lipase generally more useful than serum amylase when evaluating a pediatric patient several days after onset of abdominal pain?

A. Lipase is secreted by ductal cells, making it immune to salivary interference.

B. Serum lipase remains elevated for >1 week, while serum amylase normalizes within ~24 hours.

C. Amylase rises only in severe necrotizing pancreatitis.

D. Lipase increases exclusively during biliary obstruction.

B. Lipase remains elevated longer than amylase, making it more useful when presentation is delayed.

28. Which criterion is REQUIRED to diagnose recurrent pancreatitis in the pediatric age group?

A. 2 distinct pancreatitis episodes

B. Pain must never recur between episodes

C. First episode must be after age 19

D. Enzymes need not normalize between attacks

A. Recurrent acute pancreatitis requires at least two discrete episodes with resolution between attacks.

29. Which statement about pancreatitis pathophysiology is INCORRECT?

A. Trigger-induced acinar-cell injury initiates disease.

B. Microcirculatory changes worsen injury.

C. Inactivation of trypsin to trypsinogen increases injury.

D. Acinar injury culminates in an inflammatory response.

C. It is activation of trypsinogen to trypsin, not inactivation, that promotes pancreatic autodigestion.

30. What is the primary role of ductal cells in exocrine pancreatic function?

A. Secreting bicarbonate (HCO3-) to neutralize acidic chyme

B. Synthesizing proteases such as trypsinogen

C. Producing pancreatic lipase

D. Releasing glucagon into the bloodstream

A. Pancreatic ductal cells secrete bicarbonate-rich fluid to neutralize gastric acid entering the duodenum.

31. A 14-year-old diagnosed with necrotizing acute pancreatitis 5 weeks ago has a well-defined, encapsulated intra-pancreatic collection containing heterogeneous non-liquid debris. Which term correctly classifies it?

A. Acute peripancreatic collection

B. Pancreatic pseudocyst

C. Walled-off necrosis (WON)

D. Acute necrotic collection

C. Walled-off necrosis develops after ~4 weeks and contains organized necrotic debris.

32. Which describes Cullen's sign?

A. Blood tracking to lateral quadratus lumborum

B. Murphy's law

C. Blood diffusing to the umbilicus

D. Pain with RUQ palpation during inspiration

C. Cullen sign = periumbilical ecchymosis, associated with intra-abdominal/retroperitoneal bleeding.

33. Which describes Gray-Turner's sign?

A. Blood tracking to the lateral quadratus lumborum/flank

B. Murphy's law

C. Blood tracking to the umbilicus

D. Inspiratory arrest on RUQ palpation

A. Gray-Turner sign = flank ecchymosis from retroperitoneal hemorrhage.

34. A 5-week-old male has persistent jaundice and pale-yellow stools, broad forehead, deep-set eyes, pointed chin, peripheral pulmonic stenosis and paucity of intrahepatic bile ducts. Diagnosis and inheritance?

A. Biliary atresia

sporadic

B. Alagille syndrome; autosomal dominant

C. 1-antitrypsin deficiency; autosomal recessive

D. Choledochal cyst type I; autosomal recessive

;B. Alagille syndrome causes paucity of intrahepatic bile ducts plus characteristic facies and cardiac abnormalities; usually AD, JAG1/NOTCH2.

35. A 50-day-old infant has biliary atresia. Parents ask about delaying Kasai until 3 months. Which is most appropriate?

A. Delay does not affect native liver survival.

B. Kasai before 60 days gives better bile-flow success

success falls substantially with delay.

C. Kasai is contraindicated after 45 days.

D. Surgery should be postponed until 90 days.

;B. Earlier Kasai portoenterostomy gives better outcomes; delay increases fibrosis and decreases likelihood of successful bile drainage.

36. A 3-week-old has total bilirubin 10mg/dL, direct bilirubin 3.5mg/dL and indirect bilirubin 6.5mg/dL. Which parameter indicates cholestasis?

A. Total bilirubin >5mg/dL

B. Indirect bilirubin >50% of total

C. Direct bilirubin >20% of total

D. Direct bilirubin

C. Direct bilirubin is 35% of total; conjugated bilirubin >20% of total is abnormal and suggests cholestasis.

37. A 6-week-old infant has deepening jaundice and acholic stools. Ultrasound shows an echogenic fibrotic mass anterior to the portal vein bifurcation and a gallbladder that fails to contract. What is the next confirmatory step?

A. Choledochal cyst

CT abdomen

B. Biliary atresia; percutaneous liver biopsy or intraoperative cholangiogram

C. Neonatal hepatitis; HIDA scan without phenobarbital

D. Alagille syndrome; JAG1 genetic testing as primary imaging

;B. Findings strongly suggest biliary atresia. Intraoperative cholangiography is definitive; biopsy supports the diagnosis.

38. A 2-month-old has severe jaundice and dark tea-colored urine. AST 110, ALT 85, ALP 950. What pattern of liver dysfunction is represented?

A. Cholestatic pattern: extrahepatic obstruction/impaired canalicular bile secretion

B. Hepatocellular pattern due to UDP-glucuronosyltransferase defect

C. Hemolytic pattern

D. Metabolic pattern due to failure of hepatocyte uptake

A. Marked cholestasis is characterized by impaired bile formation/flow and disproportionately elevated alkaline phosphatase.

39. A 6-week-old infant is being prepared for HIDA scan to evaluate biliary obstruction. What should be given before the scan and for how long?

A. Phenobarbital 5mg/kg/day for 3-5 days

B. Ursodeoxycholic acid 10mg/kg/day for 2 days

C. Rifampin 10mg/kg/day for 7 days

D. Cholestyramine 240mg/kg/day for 24 hours

A. Phenobarbital enhances bile flow and improves HIDA scan sensitivity for biliary excretion.

40. An infant with intrahepatic cholestasis has severe pruritus and fat malabsorption. What is the first-line choleretic agent and its main expected side effect?

A. Cholestyramine

constipation

B. Phenobarbital; sedation

C. Ursodeoxycholic acid; diarrhea

D. Rifampin; hepatotoxicity

;C. Ursodeoxycholic acid promotes bile flow and is commonly used in cholestatic disease; diarrhea is a known adverse effect.

41. A 5-month-old has abdominal distension, RUQ mass, mild scleral icterus and tenderness. Ultrasound confirms cystic dilation of the common bile duct. Classic presentation?

A. Jaundice, RUQ mass and abdominal pain

B. Jaundice, splenomegaly and butterfly vertebrae

C. Acholic stools, pulmonic stenosis and deep-set eyes

D. Ascites, bilateral cataracts and failure to thrive

A. The classic choledochal cyst triad is abdominal pain + jaundice + palpable abdominal/RUQ mass.

42. A 7-week-old infant with persistent direct hyperbilirubinemia has liver biopsy showing lobular disarray and widespread giant-cell transformation without bile duct proliferation or portal fibrosis. Most likely diagnosis?

A. Biliary atresia

B. Idiopathic neonatal hepatitis

C. Choledochal cyst type IVA

D. 1-antitrypsin deficiency with advanced biliary cirrhosis

B. Neonatal hepatitis classically shows giant-cell transformation and lobular disarray without the ductular proliferation/fibrosis typical of biliary atresia.

43. A 10-day-old breastfed infant is mildly jaundiced but active, feeding well and passing normal yellow stools. Appropriate initial management?

A. Immediate Kasai portoenterostomy

B. Immediate percutaneous liver biopsy

C. Observe for 1 week and re-evaluate

D. Stop breastfeeding and switch to elemental formula

C. Well-appearing breastfed infants with mild jaundice and normal stool color can be monitored, while persistent/worsening jaundice warrants bilirubin evaluation.

44. A 3-week-old develops lethargy, jaundice and poor feeding after cow's-milk formula. Has hepatomegaly, cataracts, E. coli sepsis, and urine positive for reducing substances but negative glucose oxidase. Diagnosis and definitive test?

A. Hereditary fructose intolerance

aldolase B activity

B. Biliary atresia; intraoperative cholangiogram

C. Classic galactosemia; erythrocyte GALT activity

D. Tyrosinemia type 1; serum succinylacetone

;C. Classic galactosemia causes jaundice, liver dysfunction, cataracts and E. coli sepsis. Confirm with RBC GALT activity.

45. A 6-week-old male has persistent direct hyperbilirubinemia, elevated transaminases and failure to thrive. Liver biopsy shows periodic acid-Schiff-positive, diastase-resistant eosinophilic globules in hepatocytes. Genetic etiology?

A. Progressive familial intrahepatic cholestasis type 1 (ATP8B1)

B. Cystic fibrosis (CFTR)

C. 1-antitrypsin deficiency (SERPINA1 PIZZ)

D. Niemann-Pick disease type C (NPC1)

C. 1-antitrypsin deficiency produces characteristic PAS-positive, diastase-resistant globules in hepatocytes.

46. A 10-month-old has 3 days of diarrhea and vomiting. He is irritable, has sunken eyes, drinks eagerly and has slowly returning skin pinch. WHO classification?

A. No dehydration

Plan A

B. Some dehydration; Plan B with ORS

C. Severe dehydration; Plan C with IV fluids

D. Hypovolemic shock requiring vasopressors

;B. Multiple signs - irritability, sunken eyes, eager drinking, slow skin pinch - indicate some dehydration.

47. A 9-kg infant has lethargy, very sunken eyes, inability to drink and very slow skin pinch. Most appropriate immediate management?

A. Home oral fluids

B. Supervised ORS

C. Immediate IV isotonic fluid therapy (Plan C)

D. Empiric antibiotics before fluid replacement

C. Inability to drink + lethargy + markedly delayed skin recoil indicate severe dehydration Plan C.

48. A 15-month-old had a pre-illness weight of 10 kg and current weight of 8.9 kg. Degree of dehydration?

A. No dehydration

B. Mild dehydration

C. Moderate dehydration

D. Severe dehydration

D. Weight loss = 1.1 kg / 10 kg = 11%, which is severe dehydration.

49. A 14-month-old receiving ORS vomits once after several small aliquots. Best next step?

A. Stop ORS permanently

B. Change immediately to IV fluids

C. Restart ORS slowly after a brief pause

D. Administer loperamide

C. Vomiting during ORS is common. Pause briefly, then restart more slowly rather than abandoning oral rehydration.

50. An 18-month-old malnourished child has acute watery diarrhea. Which intervention reduces stool output and shortens illness duration?

A. Corticosteroids

B. Zinc supplementation

C. Proton-pump inhibitors

D. Routine antibiotics

B. Zinc supplementation reduces duration and severity of childhood diarrhea.

51. A 2-year-old is successfully rehydrated after acute gastroenteritis. When should feeding resume?

A. Withhold feeds 24-48 hours

B. Clear fluids only for 3 days

C. Resume normal age-appropriate feeding immediately

D. Avoid milk products indefinitely

C. Early refeeding maintains nutrition and does not prolong uncomplicated diarrhea.

52. Liver biopsy in a 2-month-old with neonatal cholestasis shows marked bile duct proliferation, portal tract expansion, portal fibrosis and bile plugs. Most likely diagnosis?

A. Neonatal hepatitis

B. Biliary atresia

C. Galactosemia

D. Progressive familial intrahepatic cholestasis

B. Biliary duct proliferation + portal fibrosis + bile plugs strongly support biliary atresia.

53. A 5-week-old has persistent jaundice, hepatomegaly and conjugated hyperbilirubinemia. Biopsy shows multinucleated giant-cell transformation, lobular disarray and hepatocellular inflammation. Diagnosis?

A. Biliary atresia

B. Choledochal cyst

C. Neonatal hepatitis

D. Alagille syndrome

C. Giant-cell transformation and lobular disarray are characteristic of neonatal hepatitis.

54. A 7-week-old infant with biliary atresia has cholestatic jaundice. Which treatment offers the greatest likelihood of restoring bile flow and delaying cirrhosis?

A. Ursodeoxycholic acid alone

B. Kasai portoenterostomy performed as early as possible

C. High-dose corticosteroids

D. Phototherapy

B. Early Kasai portoenterostomy is the definitive initial treatment for biliary atresia.

55. A cholestatic infant has easy bruising and prolonged prothrombin time. Fat malabsorption is present. Which vitamin deficiency is most likely?

A. Vitamin A

B. Vitamin C

C. Vitamin D

D. Vitamin K

D. Cholestasis impairs absorption of fat-soluble vitamins A, D, E and K; vitamin K deficiency causes coagulopathy.

56. A 1-month-old with conjugated hyperbilirubinemia undergoes hepatobiliary scintigraphy. The scan shows uptake by the liver but no excretion into the intestine. Which diagnosis remains a major concern?

A. Neonatal hepatitis

B. Biliary atresia

C. Breast milk jaundice

D. Gilbert syndrome

B. Failure of tracer to reach the intestine strongly suggests biliary obstruction, particularly biliary atresia.

57. A 4-week-old infant has persistent jaundice and direct bilirubin of 3 mg/dL. Most appropriate next step?

A. Reassure family that jaundice is physiologic

B. Repeat bilirubin at 6 months

C. Prompt evaluation for neonatal cholestasis

D. Begin phototherapy

C. Conjugated hyperbilirubinemia is never physiologic and requires prompt evaluation for cholestasis.

58. Which statement best differentiates neonatal hepatitis from biliary atresia?

A. Both are primarily diseases of extrahepatic bile duct obstruction.

B. Neonatal hepatitis is characterized by hepatocellular injury, whereas biliary atresia involves progressive obliteration of the extrahepatic biliary tree.

C. Kasai portoenterostomy is treatment of choice for neonatal hepatitis.

D. Neither causes conjugated hyperbilirubinemia.

B. Neonatal hepatitis is predominantly hepatocellular, whereas BA is a progressive obstructive/obliterative biliary disease.

59. A 4-year-old has fever, abdominal cramps and grossly bloody stools. Parents request antibiotics. Which statement best reflects current management principles?

A. All children with diarrhea require antibiotics.

B. Antibiotics should always precede rehydration.

C. Antibiotics depend on suspected pathogen and severity of illness.

D. Antibiotics are never indicated in childhood diarrhea.

C. Antibiotics are selective, based on pathogen, clinical severity and risk of complications.

60. A 5-year-old develops large-volume watery diarrhea while traveling, without fever, abdominal tenderness or blood. Most likely organism?

A. Shigella species

B. Enterotoxigenic E. coli (ETEC)

C. Campylobacter jejuni

D. Entamoeba histolytica

B. ETEC is a classic cause of traveler's diarrhea with watery, nonbloody diarrhea.

61. A 10-month-old develops profuse watery diarrhea and vomiting during a daycare outbreak. Afebrile

no blood or fecal leukocytes. Mechanism?

A. Mucosal invasion causing ulceration/exudation

B. Secretory diarrhea caused by enterocyte dysfunction and impaired absorption

C. Protein-losing enteropathy from lymphatic obstruction

D. Pancreatic enzyme deficiency

;B. Watery, noninflammatory diarrhea is typical of secretory/toxin-mediated enteric disease.

62. A 2-year-old has fever, abdominal pain, tenesmus and frequent bloody/mucoid stools. Stool microscopy shows numerous leukocytes. Pathologic process?

A. Enterotoxin-induced chloride secretion

B. Villous atrophy without inflammation

C. Invasive inflammatory colitis with mucosal destruction

D. Congenital disaccharidase deficiency

C. Blood, mucus, tenesmus and fecal leukocytes indicate invasive inflammatory colitis.

63. A 13-year-old has chronic abdominal pain, diarrhea, poor weight gain, delayed puberty, perianal skin tags, anemia and elevated inflammatory markers. Colonoscopy shows patchy inflammation with normal mucosa between areas

biopsy shows noncaseating granulomas. Which characteristic explains perianal disease and growth failure?

A. Disease limited to superficial mucosa

B. Continuous inflammation confined to colon

C. Transmural inflammation involving the full bowel wall

D. Isolated rectal inflammation

;C. Crohn disease is transmural and can produce fistulas, strictures and perianal disease; chronic inflammation also impairs growth.

64. A 14-year-old girl has 6 weeks of bloody diarrhea, urgency, tenesmus and lower abdominal cramps. Colonoscopy shows continuous erythematous friable mucosa from rectum to splenic flexure. Which histopathologic finding supports the diagnosis?

A. Transmural granulomatous inflammation

B. Focal skip lesions

C. Mucosal crypt abscesses with continuous involvement

D. Deep fissuring ulcers of terminal ileum

C. Ulcerative colitis causes continuous mucosal inflammation beginning at the rectum; crypt abscesses are characteristic.

65. A child with chronic diarrhea, abdominal pain and fatigue. Which noninvasive test would most strongly support the presence of intestinal inflammation?

A. Stool culture

B. Serum amylase

C. Fecal calprotectin

D. Fecal fat quantification

C. Fecal calprotectin is a useful noninvasive marker of intestinal mucosal inflammation, particularly in suspected IBD.

66. A child with known Crohn disease develops progressively worsening postprandial abdominal pain, nausea and vomiting. MRE demonstrates a markedly narrowed bowel segment with proximal bowel dilatation. Which complication has most likely developed?

A. Stricture

B. Intussusception

C. Colonic perforation

D. Primary sclerosing cholangitis

A. Crohn disease can cause transmural inflammation and fibrosis, producing strictures with proximal dilation and obstructive symptoms.

67. A child with inflammatory bowel disease develops painful swollen knees and tender erythematous lesions. These findings are most appropriately classified as:

A. Infectious complications of immunosuppressive therapy

B. Primary nutritional deficiencies

C. Extraintestinal manifestations of inflammatory bowel disease

D. Malignant transformation associated with chronic colitis

C. Arthritis and erythema nodosum are classic extraintestinal manifestations of inflammatory bowel disease.

68. A child has recurrent nocturnal epigastric pain. Endoscopy reveals a duodenal ulcer and biopsy confirms H. pylori infection. Most appropriate initial treatment strategy?

A. PPI monotherapy for 8 weeks

B. Antacid and dietary modification

C. H. pylori eradication regimen followed by confirmation of eradication

D. Immediate surgery

C. Pediatric H. pylori-associated ulcer disease requires eradication therapy, followed by testing to confirm eradication.

69. A child with juvenile idiopathic arthritis has received naproxen continuously for 6 months and develops a gastric ulcer. Most appropriate management?

A. Increase NSAID dosage and continue monitoring

B. Continue NSAID therapy and add antacids

C. Minimize NSAID exposure and initiate proton-pump inhibitor therapy

D. Give anti-H. pylori therapy without further evaluation

C. NSAIDs inhibit prostaglandins, reducing mucosal protection. Remove/minimize NSAID exposure + PPI promotes healing.

70. A child with an H. pylori-associated gastric ulcer completes eradication therapy. Which test is most appropriate to confirm treatment success?

A. H. pylori IgG antibody level

B. CBC

C. H. pylori stool antigen test

D. Serum gastrin level

C. Stool antigen can demonstrate active infection and is appropriate for post-treatment confirmation.

71. A child has recurrent upper abdominal discomfort and is being evaluated for functional dyspepsia. Which finding would most strongly suggest peptic disease instead?

A. Gastrointestinal bleeding

B. Completely normal physical examination

C. Intermittent postprandial fullness

D. Absence of nocturnal symptoms

A. GI bleeding is an alarm feature and argues against uncomplicated functional dyspepsia.

72. A child with chronic peptic ulcer disease develops progressive postprandial vomiting and early satiety. Endoscopy reveals a markedly narrowed pyloric channel. Which complication has occurred?

A. Pyloric spasm

B. Acute gastritis

C. Gastric outlet obstruction

D. Dumping syndrome

C. Chronic ulceration and edema/scarring can narrow the pylorus, causing gastric outlet obstruction.

73. A child has recurrent epigastric pain that frequently awakens him at night and improves temporarily after meals. Endoscopy shows a duodenal ulcer. What is the most likely explanation for temporary relief after meals?

A. Increased gastric acid secretion

B. Delayed gastric emptying

C. Reduced duodenal bicarbonate secretion

D. Food temporarily buffers gastric acid

D. Duodenal ulcer pain may improve after eating because food temporarily neutralizes/buffers gastric acid.

74. A child has a duodenal ulcer with confirmed H. pylori infection. What is the long-term benefit of eradication therapy?

A. Permanent cure of all gastrointestinal symptoms

B. Elimination of the need for future endoscopy

C. Reduction in recurrent peptic ulcer disease

D. Prevention of celiac disease development

C. Eradication of H. pylori markedly reduces ulcer recurrence and prevents further infection-related mucosal injury.

75. A child admitted to the pediatric intensive care unit develops hematemesis. Endoscopy shows diffuse gastric mucosal lesions. Which mechanism is most responsible for development of this lesion?

A. Mucosal ischemia from reduced gastric/splanchnic blood flow

B. Direct bacterial invasion of the gastric pits

C. Autoimmune destruction of parietal cells

D. Primary hypersecretion of gastrin by a G-cell tumor

A. Stress-related mucosal disease is driven largely by splanchnic hypoperfusion mucosal ischemia impaired mucosal defenses and acid-related injury.

76. A 14-year-old adolescent taking high-dose ibuprofen for chronic musculoskeletal pain develops a gastric ulcer. The ulcer most likely resulted from:

A. Increased gastrin secretion

B. Inhibition of prostaglandin synthesis

C. Enhanced mucus production

D. Gastric bacterial overgrowth

B. NSAIDs inhibit COX decreased prostaglandin synthesis decreased mucus/bicarbonate and mucosal blood flow, causing ulceration.

77. A child with recurrent peptic ulcer disease develops multiple ulcers beyond the duodenal bulb and has markedly elevated serum gastrin. Diagnosis?

A. Functional dyspepsia

B. Celiac disease

C. Zollinger-Ellison syndrome

D. Crohn disease

C. Gastrinoma excessive gastrin marked gastric acid hypersecretion multiple/refractory ulcers.

78. An 8-year-old presents with hematemesis and melena. Upper GI bleeding secondary to a gastric ulcer is suspected. Which diagnostic procedure also provides an opportunity for therapeutic intervention?

A. Abdominal ultrasonography

B. Upper GI endoscopy

C. Barium contrast study

D. Gastric emptying scintigraphy

B. Upper endoscopy directly visualizes bleeding and permits therapeutic hemostasis.

79. A pediatric patient with peptic ulcer disease improves after proton-pump inhibitor therapy. What is the primary mechanism of PPIs?

A. Neutralization of existing gastric acid

B. Histamine H2-receptor blockade

C. Irreversible inhibition of the H+/K+-ATPase pump

D. Enhancement of gastric motility

C. PPIs irreversibly inhibit the parietal-cell H+/K+-ATPase, the final step in acid secretion.

80. After completion of therapy for H. pylori-associated peptic ulcer disease, confirmation testing is requested. Which characteristic is most important?

A. Ability to identify previous exposure only

B. Ability to confirm resolution of active infection

C. Ability to measure gastric acid secretion

D. Ability to evaluate gastric motility

B. Follow-up testing should identify active infection, not merely prior exposure; therefore antibody testing is inadequate.

81. A child with known peptic ulcer disease develops sudden severe abdominal pain, generalized abdominal rigidity and free air under the diaphragm. Which complication occurred?

A. Gastric outlet obstruction

B. Gastric bezoar formation

C. Intussusception

D. Perforated peptic ulcer

D. Free intraperitoneal air + acute abdomen strongly indicates perforation of a hollow viscus, here a peptic ulcer.

82. A 3-month-old has persistent jaundice, severe pruritus and poor weight gain. He has a prominent forehead, deep-set eyes, pointed chin, cardiac murmur and paucity of interlobular bile ducts. Diagnosis?

A. Biliary atresia

B. Alagille syndrome

C. Neonatal hepatitis

D. Choledochal cyst

B. Alagille syndrome = paucity of intrahepatic bile ducts + characteristic facies + cardiac abnormalities + cholestasis.

83. A 2-year-old with Alagille syndrome develops severe growth failure, refractory pruritus, xanthomas and progressive liver dysfunction despite optimal medical treatment. What treatment may ultimately be required?

A. Kasai portoenterostomy

B. Cholecystectomy

C. Liver transplantation

D. Splenectomy

C. Severe progressive Alagille liver disease may ultimately require liver transplantation.

84. A child presents with abdominal pain, jaundice and a palpable RUQ mass. This classic triad is most closely associated with:

A. Choledochal cyst

B. Alagille syndrome

C. Acute viral hepatitis

D. Biliary atresia

A. The classic triad of a choledochal cyst is abdominal pain, jaundice and a palpable abdominal mass.

85. A 6-year-old with a choledochal cyst undergoes further imaging to define biliary anatomy before surgery. Which imaging modality is most useful?

A. Chest radiograph

B. Barium swallow

C. Magnetic resonance cholangiopancreatography (MRCP)

D. Intravenous pyelography

C. MRCP noninvasively delineates the biliary tree and is useful for surgical planning.

86. A 4-year-old is diagnosed with a Type I choledochal cyst. Preferred definitive treatment?

A. Observation only

B. Endoscopic drainage alone

C. Complete cyst excision with biliary reconstruction

D. Corticosteroid therapy

C. Type I choledochal cysts require complete excision because of obstruction, complications and malignancy risk, followed by biliary reconstruction.

87. Why should a choledochal cyst be completely excised? What major long-term concern exists if untreated?

A. Sclerosing cholangitis

B. Cholangiocarcinoma

C. Chronic pancreatitis

D. Duodenal obstruction

B. Choledochal cysts carry a significant long-term risk of malignant transformation, particularly cholangiocarcinoma.

88. (Note: Number 88 in the document source contains no question text.)

89. A 6-week-old infant with hypertrophic pyloric stenosis has pH 7.56, chloride 82 mEq/L and potassium 2.9 mEq/L. Most likely acid-base disturbance?

A. Metabolic acidosis

B. Respiratory alkalosis

C. Hypochloremic, hypokalemic metabolic alkalosis

D. Mixed respiratory and metabolic acidosis

C. Persistent vomiting of gastric HCl causes hypochloremic metabolic alkalosis, with potassium depletion.

90. A 5-week-old infant is suspected of having hypertrophic pyloric stenosis. Which investigation is the diagnostic study of choice?

A. Plain abdominal radiograph

B. Contrast enema

C. Abdominal ultrasonography

D. CT scan

C. Ultrasound is the preferred noninvasive diagnostic test for hypertrophic pyloric stenosis.

91. A dehydrated infant with confirmed hypertrophic pyloric stenosis is prepared for surgery. What is the most important initial management?

A. Immediate pyloromyotomy

B. Correction of fluid and electrolyte abnormalities

C. Empiric antibiotics

D. Nasogastric feeding

B. Surgery is performed after correcting dehydration and metabolic abnormalities, especially hypochloremic alkalosis.

92. A newborn develops vomiting within several hours of birth. Vomitus is bilious. Abdominal radiograph shows a "double-bubble" sign with little distal bowel gas. Diagnosis?

A. Hypertrophic pyloric stenosis

B. Gastroesophageal reflux

C. Duodenal atresia

D. Intussusception

C. Bilious vomiting + double-bubble sign + minimal distal gas = duodenal atresia.

93. A newborn has persistent bilious vomiting and upper abdominal distension. Radiography shows a classic double-bubble appearance. Embryologic basis of most cases of duodenal atresia?

A. Failure of neural crest migration

B. Failure of recanalization of the duodenum

C. Abnormal rotation of the midgut

D. Persistence of the vitelline duct

B. Duodenal atresia results from failure of recanalization of the embryonic duodenal lumen.

94. A 2-day-old infant with duodenal atresia has significant gastric distension and repeated vomiting. Appropriate initial management?

A. Immediate oral feeding

B. Nasogastric decompression and IV fluids

C. Antidiarrheal therapy

D. High-fiber-formula feeding

B. Initial stabilization requires NPO, NG decompression and IV fluid/electrolyte replacement, followed by surgery.

95. Which clinical feature best differentiates duodenal atresia from hypertrophic pyloric stenosis?

A. Presence of vomiting

B. Failure to thrive

C. Bilious vomiting

D. Dehydration

C. Bilious vomiting indicates obstruction distal to the ampulla, characteristic of duodenal atresia; pyloric stenosis causes nonbilious projectile vomiting.