A 52-year-old man with 10 years of heartburn has salmon-pink tongues of mucosa extending above the gastro-oesophageal junction on endoscopy. Which biopsy finding confirms Barrett oesophagus?

Intestinal metaplasia with goblet cells

Squamous mucosa with many eosinophils

Ulcer base with inflamed granulation tissue

Squamous mucosa with basal hyperplasia

Fever, deep jaundice and a tender, enlarged liver develop in a 47-year-old bus conductor after a month of drinking a bottle of rum daily. A liver biopsy shows ballooned hepatocytes containing tangled, ropey eosinophilic inclusions, surrounded by neutrophils. What are these inclusions made of?

Copper bound to metallothionein

GI, liver and pancreas pathology

26 NEET-PG practice questions on GI, liver and pancreas pathology, part of Pathology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Easy
A 52-year-old man with 10 years of heartburn has salmon-pink tongues of mucosa extending above the gastro-oesophageal junction on endoscopy. Which biopsy finding confirms Barrett oesophagus?
1. ASquamous mucosa with many eosinophils
2. BUlcer base with inflamed granulation tissue
3. CIntestinal metaplasia with goblet cells
4. DSquamous mucosa with basal hyperplasia
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Answer: C · Intestinal metaplasia with goblet cells
Barrett oesophagus is the replacement of the distal squamous lining by columnar epithelium; by the definition used in Robbins it requires intestinal metaplasia with goblet cells. It is a response to chronic acid and bile reflux. It is the main precursor of oesophageal adenocarcinoma, through dysplasia, so patients enter endoscopic surveillance with biopsies.
- A: Dense eosinophils in squamous mucosa suggest eosinophilic oesophagitis.
- B: Ulceration with granulation tissue is a complication of reflux, not metaplasia.
- D: Basal hyperplasia of squamous mucosa is reflux oesophagitis, not Barrett.
Question 2 · Hard
A 22-year-old woman has a 9 cm solitary liver mass with a central scar on CT. She has no history of liver disease, takes no oral contraceptives, and her AFP is normal. Biopsy shows large polygonal cells with deeply eosinophilic granular cytoplasm and big nucleoli, separated by parallel bands of dense collagen. What is the diagnosis?
1. AHepatocellular adenoma
2. BFibrolamellar carcinoma
3. CHepatoblastoma
4. DFocal nodular hyperplasia
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Answer: B · Fibrolamellar carcinoma
Fibrolamellar carcinoma is a distinct variant of hepatocellular carcinoma in adolescents and young adults without cirrhosis or viral hepatitis. It is made of large eosinophilic tumour cells with prominent nucleoli separated by lamellar (layered) bands of collagen, and AFP is usually normal. It carries a DNAJB1-PRKACA fusion gene and is often amenable to surgery. Its central scar on imaging can mimic focal nodular hyperplasia.
- A: Hepatocellular adenoma is linked with oral contraceptives and lacks lamellar fibrosis.
- C: Hepatoblastoma occurs in young children and usually raises AFP.
- D: FNH has a central scar but consists of benign hepatocyte nodules with abnormal vessels, not malignant cells.
Question 3 · Medium
A 54-year-old man has diabetes diagnosed 2 years ago, joint pains in the hands, darkening of the skin and hepatomegaly. Serum ferritin is 2,600 ng/mL and transferrin saturation 82%. He has never received blood transfusions. Which stain on his liver biopsy best shows the abnormal deposit?
1. APerls Prussian blue
2. BRhodanine
3. CPAS after diastase
4. DCongo red
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Answer: A · Perls Prussian blue
Diabetes, skin pigmentation, arthropathy and liver disease with very high ferritin and transferrin saturation, without transfusion, point to hereditary haemochromatosis, most often from homozygous C282Y mutation of HFE. Low hepcidin increases iron absorption, and iron is stored first in periportal hepatocytes. Perls Prussian blue stains the haemosiderin blue and allows grading of iron load. Untreated disease leads to cirrhosis and a high risk of hepatocellular carcinoma; regular phlebotomy is the treatment.
- B: Rhodanine stains copper, used for Wilson disease and chronic cholestasis.
- C: PAS after diastase shows alpha-1 antitrypsin globules.
- D: Congo red shows amyloid.
Question 4 · Easy
A 14-year-old boy has recurrent colicky abdominal pain from small bowel intussusception. He has brown-black macules on his lips and buccal mucosa. Resected polyps show branching bands of smooth muscle lined by normal-looking intestinal epithelium. Which gene is most likely mutated?
1. ABMPR1A
2. BPTEN
3. CAPC
4. DSTK11
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Answer: D · STK11
Mucocutaneous pigmentation with hamartomatous polyps containing arborising smooth muscle is Peutz-Jeghers syndrome. It is autosomal dominant and caused by mutation of STK11 (LKB1). The polyps are most numerous in the small intestine and can cause intussusception. Patients have a raised lifetime risk of cancers of the colon, pancreas, breast, lung, ovary and other sites, so they need surveillance.
- A: BMPR1A mutation causes juvenile polyposis, with cystic hamartomas.
- B: PTEN mutation causes Cowden syndrome, with hamartomas but no lip pigmentation.
- C: APC mutation gives hundreds of adenomas, not hamartomas with pigmentation.
Question 5 · Easy
Fever, deep jaundice and a tender, enlarged liver develop in a 47-year-old bus conductor after a month of drinking a bottle of rum daily. A liver biopsy shows ballooned hepatocytes containing tangled, ropey eosinophilic inclusions, surrounded by neutrophils. What are these inclusions made of?
1. AHepatitis B surface antigen
2. BCopper bound to metallothionein
3. CFerritin and haemosiderin
4. DCytokeratin 8 and 18 filaments
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Answer: D · Cytokeratin 8 and 18 filaments
The picture is alcoholic hepatitis, and the inclusions are Mallory-Denk bodies. They are clumps of damaged intermediate filaments, mainly cytokeratins 8 and 18, combined with ubiquitin. They are typical of, but not specific to, alcoholic hepatitis; they also occur in non-alcoholic steatohepatitis, Wilson disease and chronic cholestasis. Neutrophils around injured hepatocytes and pericellular fibrosis complete the picture.
- A: HBsAg gives ground-glass hepatocytes in chronic hepatitis B.
- B: Copper accumulates diffusely in Wilson disease and is shown by rhodanine stain.
- C: Haemosiderin is golden-brown iron pigment, stained by Prussian blue.
Question 6 · Hard
A gastroenterology resident lists these statements while counselling a 50-year-old man with newly diagnosed Barrett oesophagus: 1. Long-standing reflux of acid and bile is the main cause. 2. It is the main precursor lesion of oesophageal adenocarcinoma. 3. Most people with Barrett oesophagus eventually develop cancer. 4. The grade of dysplasia on biopsy guides surveillance intervals and therapy. Which statements are correct?
1. A2 and 4 only
2. B1, 2 and 3 only
3. C3 and 4 only
4. D1, 2 and 4 only
Answer and explanation in LearnFree account
Question 7 · Medium
A 66-year-old woman in a Kochi medical OPD has fatigue and breathlessness on exertion for 4 months. She has no change in bowel habit and no visible bleeding. Hb is 7.6 g/dL, MCV 68 fL and ferritin 6 ng/mL; stool occult blood is positive. Upper GI endoscopy is normal. In which part of the colon is a cancer most likely to be causing this picture?
1. ASigmoid colon
2. BRectum
3. CCaecum and ascending colon
4. DDescending colon
Answer and explanation in LearnFree account
Question 8 · Medium
A 26-year-old woman from Hyderabad has had diarrhoea, weight loss and an enterocutaneous fistula. The resected terminal ileum shows cobblestoned mucosa, mesenteric fat wrapping around the bowel and a thickened wall. Microscopy shows transmural lymphoid aggregates, deep fissuring ulcers and small non-caseating granulomas; Ziehl-Neelsen stain and Xpert MTB/RIF on the tissue are negative. What is the diagnosis?
1. AIschaemic enteritis
2. BIntestinal tuberculosis
3. CCrohn disease
4. DUlcerative colitis
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Question 9 · Medium
A pathology postgraduate examines a total colectomy specimen from a 31-year-old man with long-standing inflammatory bowel disease and lists findings: 1. Continuous disease starting at the rectum. 2. Transmural lymphoid aggregates. 3. Inflammation largely confined to the mucosa and submucosa. 4. Non-caseating granulomas. Which findings favour ulcerative colitis?
1. A1 and 2 only
2. B3 and 4 only
3. C1 and 3 only
4. D2, 3 and 4 only
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Question 10 · Medium
A 71-year-old woman has had watery, mucus-rich diarrhoea for 4 months, with weakness. Serum potassium is 2.7 mmol/L and creatinine 1.6 mg/dL. Rectal examination shows a large, soft, velvety mass a few centimetres from the anal verge. What is the most likely lesion?
1. AInflammatory pseudopolyp
2. BHyperplastic polyp
3. CVillous adenoma
4. DJuvenile polyp
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Question 11 · Medium
Six years ago a 63-year-old shopkeeper with long-standing reflux was told that endoscopic biopsies showed columnar metaplasia, but he never went back for follow-up. He now has progressive dysphagia to solids and weight loss. Endoscopy shows an ulcerated mass at the gastro-oesophageal junction. What is the most likely histological type?
1. AGastrointestinal stromal tumour
2. BLeiomyoma
3. CAdenocarcinoma
4. DSquamous cell carcinoma
Answer and explanation in LearnFree account
Question 12 · Medium
A 15-year-old girl from Tamil Nadu has a tremor, slurred speech and falling school performance for 6 months. Her ALT is mildly raised, serum ceruloplasmin is low, and slit-lamp examination shows golden-brown rings at the edge of the cornea. What is the normal function of the protein encoded by the mutated gene?
1. AAbsorbing dietary iron from the duodenum
2. BPumping copper into bile and into ceruloplasmin
3. CConjugating bilirubin with glucuronic acid
4. DInhibiting neutrophil elastase in the lungs
Answer and explanation in LearnFree account
Question 13 · Easy
Colonoscopy in an 18-year-old girl, done because rectal bleeding runs in her family, shows several hundred small adenomas carpeting the colon and rectum. Which gene is most likely mutated?
1. ASTK11
2. BAPC
3. CMLH1
4. DSMAD4
Answer and explanation in LearnFree account
Question 14 · Hard
A 58-year-old man with hepatitis B cirrhosis, on 6-monthly ultrasound surveillance, has a new 3.5 cm nodule. Multiphase contrast CT shows that the nodule enhances brightly in the arterial phase and becomes darker than the surrounding liver in the portal venous and delayed phases. AFP is 620 ng/mL. What is the most likely diagnosis?
1. AIntrahepatic cholangiocarcinoma
2. BHepatic haemangioma
3. CLarge regenerative nodule
4. DHepatocellular carcinoma
Answer and explanation in LearnFree account
Question 15 · Medium
A 27-year-old woman has had jaundice and fatigue for 2 months. ALT is 640 U/L and serum IgG is high. Tests for hepatitis A, B, C and E are negative, she takes no drugs or herbal medicines, and anti-smooth muscle antibody is positive at a high titre. Which biopsy finding most supports the diagnosis?
1. AMacrovesicular steatosis with ballooning
2. BFlorid duct lesions with granulomas
3. CPortal lymphoid aggregates with steatosis
4. DInterface hepatitis rich in plasma cells
Answer and explanation in LearnFree account
Question 16 · Hard
A 53-year-old farmer from a humid district who is a long-term HBsAg carrier stores his groundnuts in damp gunny sacks for months before eating them. He now has a 6 cm liver mass, and the AFP is 1,400 ng/mL. Sequencing of the tumour shows a mutation at codon 249 of a tumour suppressor gene. Which gene is it?
1. ATP53
2. BRB1
3. CCTNNB1
4. DCDKN2A
Answer and explanation in LearnFree account
Question 17 · Medium
A 67-year-old man has painless, progressive jaundice, itching and weight loss. The gallbladder is palpable and non-tender, and he has had tender cord-like swellings appearing in different leg veins over the past month. CT shows a mass in the head of the pancreas. Which gene is most frequently mutated in this tumour?
1. AKRAS
2. BAPC
3. CRET
4. DBRAF
Answer and explanation in LearnFree account
Question 18 · Easy
A 24-year-old man from Meerut has had jaundice and anorexia for 10 days during a local outbreak of hepatitis. ALT is 1,620 U/L. A liver biopsy, done because the diagnosis was initially unclear, shows ballooned hepatocytes and scattered round, deeply eosinophilic bodies with or without nuclear fragments. What are these bodies?
1. AMallory-Denk bodies
2. BGround-glass hepatocytes
3. CApoptotic hepatocytes
4. DRussell bodies
Answer and explanation in LearnFree account
Question 19 · Medium
A 45-year-old man who received multiple injections from an unlicensed practitioner in his village 20 years ago is found to have HCV RNA in his blood. ALT is mildly raised and his body mass index is normal. Which combination of findings would be most characteristic on his liver biopsy?
1. AGround-glass hepatocytes with HBcAg-stained nuclei
2. BPlasma cell interface hepatitis with rosettes
3. CPeriportal hepatocytes with PAS-positive globules
4. DPortal lymphoid aggregates with steatosis
Answer and explanation in LearnFree account
Question 20 · Hard
During a monsoon outbreak of jaundice in a town where sewage has seeped into the municipal water pipeline, a 24-year-old woman at 32 weeks of pregnancy becomes drowsy 6 days after the jaundice began. Her INR is 3.2 and ALT 2,100 U/L. Several non-pregnant adults in her street recovered from the same illness. Which virus is the most likely cause of her liver failure?
1. AHepatitis A virus
2. BHepatitis B virus
3. CLeptospira interrogans
4. DHepatitis E virus
Answer and explanation in LearnFree account
Question 21 · Easy
A 42-year-old man has been HBsAg positive for 12 years. A liver biopsy shows portal inflammation and many hepatocytes with finely granular, pale, homogeneous eosinophilic cytoplasm. What do these cells contain?
1. AHepatitis B surface antigen in the endoplasmic reticulum
2. BMisfolded alpha-1 antitrypsin globules
3. CGlycogen within the cytoplasm
4. DCytokeratin filament aggregates
Answer and explanation in LearnFree account
Question 22 · Hard
A 74-year-old woman with no family history of cancer has a mucinous adenocarcinoma of the ascending colon. The tumour is MSI-high, immunohistochemistry shows loss of MLH1 and PMS2, and the tumour carries a BRAF V600E mutation. What is the most likely mechanism of her mismatch repair deficiency?
1. AGermline MLH1 mutation (Lynch syndrome)
2. BSomatic hypermethylation of the MLH1 promoter
3. CGermline APC mutation with beta-catenin activation
4. DBiallelic germline MUTYH mutation
Answer and explanation in LearnFree account
Question 23 · Medium
A 52-year-old man with alcohol-related liver disease has a liver biopsy that shows bridging fibrous septa surrounding small regenerative nodules of uniform size. Collagen is laid down in the space of Disse. Which cell is chiefly responsible for producing this scar?
1. APortal fibroblast
2. BKupffer cell
3. CSinusoidal endothelial cell
4. DHepatic stellate cell
Answer and explanation in LearnFree account
Question 24 · Medium
A 68-year-old man with no previous heart disease is admitted with fever and a new mitral regurgitant murmur. Three blood cultures grow Streptococcus gallolyticus (formerly S. bovis biotype I), and echocardiography shows a mitral vegetation. Besides treating the endocarditis, which investigation is most important?
1. AUltrasound of the gallbladder
2. BUpper GI endoscopy
3. CColonoscopy
4. DCT scan of the brain
Answer and explanation in LearnFree account
Question 25 · Medium
A 38-year-old man has a right-sided colon cancer. His mother had endometrial cancer at 46 and his maternal uncle had colon cancer at 41. The tumour is mucinous, with many tumour-infiltrating lymphocytes, and immunohistochemistry shows loss of MSH2 and MSH6. What is the basic defect in this family?
1. AInherited loss of the APC gatekeeper gene
2. BInherited defect in nucleotide excision repair
3. CInherited defect in DNA mismatch repair
4. DInherited defect in homologous recombination
Answer and explanation in LearnFree account

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GI, liver and pancreas pathology

A 52-year-old man with 10 years of heartburn has salmon-pink tongues of mucosa extending above the gastro-oesophageal junction on endoscopy. Which biopsy finding confirms Barrett oesophagus?

A 54-year-old man has diabetes diagnosed 2 years ago, joint pains in the hands, darkening of the skin and hepatomegaly. Serum ferritin is 2,600 ng/mL and transferrin saturation 82%. He has never received blood transfusions. Which stain on his liver biopsy best shows the abnormal deposit?

A 14-year-old boy has recurrent colicky abdominal pain from small bowel intussusception. He has brown-black macules on his lips and buccal mucosa. Resected polyps show branching bands of smooth muscle lined by normal-looking intestinal epithelium. Which gene is most likely mutated?

Fever, deep jaundice and a tender, enlarged liver develop in a 47-year-old bus conductor after a month of drinking a bottle of rum daily. A liver biopsy shows ballooned hepatocytes containing tangled, ropey eosinophilic inclusions, surrounded by neutrophils. What are these inclusions made of?

A 71-year-old woman has had watery, mucus-rich diarrhoea for 4 months, with weakness. Serum potassium is 2.7 mmol/L and creatinine 1.6 mg/dL. Rectal examination shows a large, soft, velvety mass a few centimetres from the anal verge. What is the most likely lesion?

Colonoscopy in an 18-year-old girl, done because rectal bleeding runs in her family, shows several hundred small adenomas carpeting the colon and rectum. Which gene is most likely mutated?

A 27-year-old woman has had jaundice and fatigue for 2 months. ALT is 640 U/L and serum IgG is high. Tests for hepatitis A, B, C and E are negative, she takes no drugs or herbal medicines, and anti-smooth muscle antibody is positive at a high titre. Which biopsy finding most supports the diagnosis?

A 45-year-old man who received multiple injections from an unlicensed practitioner in his village 20 years ago is found to have HCV RNA in his blood. ALT is mildly raised and his body mass index is normal. Which combination of findings would be most characteristic on his liver biopsy?

A 42-year-old man has been HBsAg positive for 12 years. A liver biopsy shows portal inflammation and many hepatocytes with finely granular, pale, homogeneous eosinophilic cytoplasm. What do these cells contain?

A 74-year-old woman with no family history of cancer has a mucinous adenocarcinoma of the ascending colon. The tumour is MSI-high, immunohistochemistry shows loss of MLH1 and PMS2, and the tumour carries a BRAF V600E mutation. What is the most likely mechanism of her mismatch repair deficiency?

A 52-year-old man with alcohol-related liver disease has a liver biopsy that shows bridging fibrous septa surrounding small regenerative nodules of uniform size. Collagen is laid down in the space of Disse. Which cell is chiefly responsible for producing this scar?

A 38-year-old man has a right-sided colon cancer. His mother had endometrial cancer at 46 and his maternal uncle had colon cancer at 41. The tumour is mucinous, with many tumour-infiltrating lymphocytes, and immunohistochemistry shows loss of MSH2 and MSH6. What is the basic defect in this family?