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CHAPTER 6 | SMALL INTESTINALDISORDERS
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 12months 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)
B. Marsh I
C. Marsh 3A
D. Marsh 3C
E. Normal
CHAPTER 6 | QUESTIONS
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13. A 23- year- old patient with coeliac disease was worried about their bone
health.
Which of the following statements is true?
A. Abone density scan does not need to be performed until the age of 50
B. Bone density will not increase during the rst 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 6kg 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
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CHAPTER 6 | SMALL INTESTINALDISORDERS
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 ushing 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 inammation 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)
What is the most likely diagnosis?
A. Multiple endocrine neoplasia (MEN) 1
B. MEN2A
C. MEN2B
D. Thyrotoxicosis
E. Zollinger- Ellison syndrome
523 μmol
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 deciency would best explain the presentation?
A. Cobalamin (B12)
B. Folate (B9)
C. Niacin (B3)
D. Pyridoxine (B6)
E. Thiamine (B1)
CHAPTER 6 | QUESTIONS
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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 deciency?
A. Coeliac disease
B. Crohn’s disease
C. Dietary deciency 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 insuciency
D. Pernicious anaemia
E. Ranitidine
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CHAPTER 6 | SMALL INTESTINALDISORDERS
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 deciency is the most likely cause for his
presentation?
A. Copper
B. Nicotinamide
C. Vitamin C
D. Vitamin D
E. Vitamin K
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 dierent 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
Which micronutrient deciency is the most likely cause for her
presentation?
A. Magnesium
B. Niacin
C. Selenium
D. Vitamin B12
E. Zinc
CHAPTER 6 | QUESTIONS
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21. A 19- year- old woman was reviewed in outpatients for abdominal pain,
diarrhoea, and excessive atulence. Her symptoms were worsened
when drinking milk and lactose intolerance was suspected.
Which of the following statements is true?
A. Lactase persistence in Caucasians is due to a loss- of- function mutation in the lactase gene
B. Lactose malabsorption in adults is most commonly caused by lactase non- persistence
C. SGLT1 and GLUT2 transport the monosaccharides into enterocytes via passive diusion
D. The brush border enzyme, lactase, cleaves lactose into two glucose monosaccharides
E. The diagnosis should be suspected in the presence of a positive lactulose- hydrogen
breath test
22. A 66- year- old man presented with an eight- week history of non- bloody
diarrhoea, atulence, and fatigue. He had a past history of systemic
sclerosis.
Investigations:
Haemoglobin 105 g/ L
MCV 100 fL
Serum folate 18.2 µg/ L
Gastroscopy Normal
Colonoscopy Normal
Duodenal histology Villi of normal height and shape. Focal intraepithelial
lymphocytosis, no increase in chronic inammatory
What is the most appropriate management?
A. Budesonide
B. Co- amoxiclav
C. Creon
D. Gluten- free diet
E. Prednisolone
cells in the lamina propria
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CHAPTER 6 | SMALL INTESTINALDISORDERS
23. A 56- year- old man with a history of Crohn’s disease and previous
ileocaecal resection presented with non- bloody diarrhoea with
urgency. He denied abdominal pain, fever, nausea, vomiting, or weight
loss. Examination was unremarkable. He had no extra- intestinal
manifestations of inammatory bowel disease. He was 178cm tall and
weighed 75kg.
Investigations:
Haemoglobin 130 g/ L
Haematocrit 45%
White cell count 6.5 × 109/ L
Platelet count 278 × 109/ L
Erythrocyte sedimentation rate 12mm/ 1st hr
Serum vitamin B12 350 ng/ L
Red cell folate 410 μg/ L
C- reactive protein (CRP) 9 mg/ L
Which medication is most likely to be eective for treating the
diarrhoea?
A. Budesonide
B. Ciprooxacin
C. Colestyramine
D. Mesalazine
E. Prednisolone
24. A 43- year- old builder was reviewed for abdominal pain and iron
deciency anaemia. He also complained of joint aches and ankle
swelling. He took omeprazole for heartburn but vehemently denied any
other medications.
Investigations:
Gastroscopy Gastritis and multiple duodenal ulcers
Ileocolonoscopy Normal
Magnetic resonance
enterography
Serum gastrin 104 pmol/ L (non- fasting)
Haemoglobin 79 g/ L
MCV 73.8 fL
Serum albumin 29 g/ L
What is the diagnostic test?
A. Echocardiogram
B. Fasting serum gastrin level
C. NSAID metabolites
D. Renal biopsy
E. Vasculitis screen
Widespread ileal ulceration with diaphragm- like
structures
CHAPTER 6 | QUESTIONS
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135
25. A 37- year- old man presented with a two- week history of chills,
abdominal pain, and constipation. There were faint pink macules on his
trunk. He had recently returned from a trekking holiday in Nepal. He
received the oral typhoid vaccine one year ago.
Investigations:
Haemoglobin 120 g/ L
White cell count 3.0 × 109/ L
Platelet count 175 × 109/ L
Serum C- reactive protein (CRP) 120 mg/ L
Serum alanine transferase (ALT) 200 U/ L
Blood cultures (×2) Negative after 48 hours
HIV Negative
Hepatitis A, B, C, E virus serology Negative
Dengue virus serology Negative
Thick and thin lm Negative
Which is the most sensitive diagnostic test for this disease?
A. Blood culture incubation for >72 hours
B. Bone marrow culture
C. Stool cultures
D. Urine culture
E. Widal test
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chapter
SMALL INTESTINALDISORDERS
6
ANSWERS
1. D. SGLT1
• SGLT1 enables absorption of sodium (and water) when coupled with glucose
• Some infections (e.g. enteropathogenic E.coli) inhibit the activity of SGLT1, rendering oral
rehydration therapies less eective
• Targeting ion transporters may provide novel drug therapies for managing infectious diarrhoea
Transporters are transmembrane proteins that mediate transport of ions and other solutes.
Intestinal epithelial cells control the absorption and secretion of electrolytes through various ion
transporters to maintain uid balance. Infectious causes of diarrhoea may aect both secretory
and/ or absorptive transporters. Oral rehydration therapies typically comprise combinations of
glucose, salt, and water, and take advantage of the preservation of SGLT1 function in infectious
diarrhoea. Therefore, sodium and uid absorption can be achieved if glucose is provided while the
(usually self- limiting) infection resolves. Novel forms of oral rehydration therapies include starch (to
drive sodium absorption in the colon by providing short chain fatty acids) and zinc (which may work
through altering chloride homeostasis). Enteropathogenic E.coli can inhibit the activity of SGLT1,
and patients with this infection are less responsive to oral rehydration therapies.
Other ion transporters include the EnaC, which functions in the distal colon to mediate sodium
absorption. This is decreased in murine Salmonella infections. (NKCC1 is located on the basolateral
membrane and supplies chloride for secretion. Expression of this transporter may be increased
in Salmonella and some E.coli infections. CFTR mediates chloride eux from the apical surface
of intestinal epithelial cells and is an attractive target for novel drug therapies. GLUT1 is a glucose
transporter alone and has no role in the function of oral rehydration therapies.
Das S, Jayaratne R, Barrett KE. The role of ion transporters in the pathophysiology of infectious
diarrhea. Cell Mol Gastroenterol Hepatol. 208;6():33– 45. Doi:0.06/ j.jcmgh.208.02.009.
2. D. Vasoactive intestinal polypeptide (VIP)oma
• Typical features of VIPoma include secretory diarrhoea, hypokalaemia, and dehydration
• It is a rare type of functioning neuroendocrine tumour, typically pancreatic
• Somatostatin analogues and surgery form part of management
Patients with VIPoma, or Verner– Morrison syndrome, complain of high- volume diarrhoea despite
fasting and are found to have hypochlorhydria, hypokalaemia (serum potassium <3mmol/ L),
hyperglycaemia, and hypercalcaemia with signs of dehydration. Flushing occurs in 20% of patients
and abdominal pain, fatigue, and bloating may also be present.
VIP stimulates uid and electrolyte secretion from intestinal epithelium and bile duct cholangiocytes.
VIPoma is a rare form of functioning neuroendocrine tumour that aects an estimated 1 in
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0006
CHAPTER 6 | ANSWERS
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137
10million people per year. They are typically pancreatic (over 90%) and are usually diagnosed in
adults, age 30– 50years, and more commonly in women. VIPoma should be suspected in patients
with >700 mL/ day secretory diarrhoea and conrmed with serum VIP greater than 75 pg/ mL.
Cross- sectional imaging may reveal the primary tumour but an octreotide scan or endoscopic
ultrasound may be needed. Management involves uid rehydration with potassium and the use of a
somatostatin analogue (e.g. octreotide) to decrease secretion of VIP. Surgical resection may be needed
but over 50% may be metastatic at the point of diagnosis. Median survival is 96months from diagnosis.
Flushing and diarrhoea can be associated with carcinoid syndrome but it is unusual to develop
profound hypokalaemia. The history is too long for Vibrio cholera infection. Bile acid diarrhoea and
coeliac disease are unlikely in this case.
Farina DA, Krogh KM, Boike JR. Chronic diarrhoea secondary to newly diagnosed VIPoma. Case Rep
Gastroenterol. 209;3:225– 229. Doi:0.59/ 000494554.
3. D. Glucagon-like peptide 2 (GLP-2) inhibits gastric emptying and gastric acid
production, induces small bowel mucosal growth, and stimulates mesenteric
blood ow
• GLP- 2 is intestinotrophic and released in response to luminal nutrients
• GLP- 2 analogues (e.g. teduglutide) are used for the management of short bowel syndrome.
See Table 6.1 for details on gastrointestinal hormones
Table6.1 Gastrointestinal hormones
Hormone Site of production Release pattern Action
Cholecystokinin I cells, small intestine Stimulated by ingested fat and
Gastrin G cells, stomach Stimulated by high pH, high- grade
Glucagon- like
peptide 1
Glucagon- like
peptide 2
Somatostatin D cells, stomach, small
L cells, small intestine Stimulated by carbohydrate
L cells, small intestine Stimulated by carbohydrate
intestine, pancreas
protein
gastric distension, amino acids,
histamine, acetylcholine;
inhibited by somatostatin,
carbohydrate and fat
ingestion
ingestion
Stimulated by gastrin, gastric acid,
vasoactive intestinal polypeptide,
low- grade gastric distension,
acetylcholine;
inhibited by catecholamines
Delays gastric emptying,
stimulates gallbladder
contraction
Stimulates gastric acid
production, gastric
hypertrophy
Inhibits gastric emptying,
glucagon release, and appetite;
stimulates glucose- dependent
insulin release
Inhibits gastric emptying and
gastric acid production;
stimulates small bowel mucosal
growth, increases mesenteric
blood ow
Inhibits production of most
gut hormones including
gastrin production, reduces
pancreatico- biliary secretions,
reduces gastrointestinal
motility and gallbladder
contraction
Ahmed M, Ahmed S.Functional, diagnostic and therapeutic aspects of gastrointestinal hormones.
Gastroenterology Res. 209;2(5):233– 244. Doi:0.4740/ gr29.
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