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100+ Free CMSA Cert Gastroenterology(SA) Paed Practice Questions
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Sample CMSA Cert Gastroenterology(SA) Paed Practice Questions
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1A 12-year-old boy presents with a 4-month history of lethargy, intermittent non-bloody diarrhea, rights-sided lower abdominal pain, and a weight loss of 5 kg. Laboratory investigations reveal microcytic anemia, elevated C-reactive protein (CRP 45 mg/L), and erythrocyte sedimentation rate (ESR 52 mm/hr). Colonoscopy shows patchy aphthous ulceration in the cecum and ascending colon with a normal rectum. Terminal ileoscopy reveals linear ulceration and cobblestoning. Which Paris classification location code best describes his luminal disease distribution?
A.L3 (Ileocolonic)
B.L2 (Colonic)
C.L1 (Ileal)
D.L4a (Upper GI proximal to ligament of Treitz)
Explanation: The Paris classification for paediatric Crohn's disease classifies disease involving both the terminal ileum (or cecum) and any portion of the colon as L3 (Ileocolonic). L1 is isolated ileal disease, L2 is isolated colonic disease, and L4 represents upper GI involvement (L4a proximal to Treitz, L4b distal to Treitz).
2A 4-year-old girl with chronic diarrhea, abdominal distension, and failure to thrive undergoes serological screening for coeliac disease. Her total serum IgA is normal (1.4 g/L). Tissue transglutaminase IgA (tTG-IgA) is 150 U/mL (upper limit of normal 10 U/mL; >=10x ULN). Endomysial antibody IgA (EMA-IgA) tested on a separate blood sample is positive. According to the ESPGHAN 2020 guidelines, what is the most appropriate next management step?
A.Initiate a gluten-free diet without requiring an esophagogastroduodenoscopy (EGD) biopsy
B.Repeat the tTG-IgA assay after 3 months of a normal gluten-containing diet
C.Proceed directly to diagnostic upper GI endoscopy and duodenal biopsies
D.Perform HLA-DQ2/DQ8 genetic testing prior to starting a gluten-free diet
Explanation: According to the updated ESPGHAN 2020 coeliac disease guidelines, a non-biopsy strategy is recommended for diagnosis in children if serum tTG-IgA is >=10 times the upper limit of normal AND EMA-IgA is positive on a second, independent blood sample (with normal total IgA). HLA-DQ2/DQ8 testing is no longer required as part of the initial diagnostic algorithm.
3A 10-year-old girl with known ulcerative colitis presents with severe bloody diarrhea (8 bloody stools/day), nocturnal stooling, temperature of 38.2°C, and tachycardia. Her Paediatric Ulcerative Colitis Activity Index (PUCAI) score is calculated at 75. What is the initial recommended first-line induction therapy?
A.Intravenous methylprednisolone 1 mg/kg/day (maximum 40 mg/day)
B.Oral 5-aminosalicylate (mesalazine) 80 mg/kg/day
C.Infliximab 10 mg/kg single infusion
D.Exclusive Enteral Nutrition (EEN) for 6 weeks
Explanation: A PUCAI score >=65 indicates Acute Severe Colitis (ASC). According to the ECCO/ESPGHAN guidelines, the first-line medical therapy for ASC is intravenous corticosteroid therapy (methylprednisolone 1 mg/kg/day, up to 40 mg/day). Infliximab or ciclosporin are second-line rescue therapies if there is no response by day 3 to 5.
4A 14-month-old infant presents with severe pan-colitis, recurrent perianal abscesses, folliculitis, and refractory failure to thrive since 2 months of age. Genetic evaluation reveals a loss-of-function mutation in the Interleukin-10 Receptor subunit alpha (IL10RA) gene. Which definitive therapeutic modality offers long-term cure for this Very Early Onset IBD (VEO-IBD)?
A.Subtotal colectomy with end ileostomy
B.Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)
C.Long-term dual anti-TNF and anti-integrin biological therapy
D.High-dose intravenous immunoglobulin (IVIG) maintenance
Explanation: Loss-of-function mutations in IL10, IL10RA, or IL10RB impair IL-10 immunoregulatory signaling, leading to severe monogenic Very Early Onset IBD (VEO-IBD) within the first months of life. Traditional immunosuppressants and biologics fail, and allogeneic Hematopoietic Stem Cell Transplantation (HSCT) is the only curative treatment.
5A 13-year-old boy with active Crohn's disease shows significant growth deceleration (height velocity < 3rd centile) despite minimal GI symptoms. Which pro-inflammatory cytokine is primarily responsible for systemic growth impairment by inducing hepatic Insulin-like Growth Factor 1 (IGF-1) resistance?
A.Interleukin-4 (IL-4)
B.Interleukin-6 (IL-6)
C.Interleukin-17 (IL-17)
D.Transforming Growth Factor beta (TGF-beta)
Explanation: Interleukin-6 (IL-6) and TNF-alpha are key systemic inflammatory cytokines in Crohn's disease. Elevated IL-6 suppresses growth hormone receptor signaling in hepatocytes and decreases circulating IGF-1 levels while inducing peripheral IGF-1 resistance, directly inhibiting epiphyseal growth plate chondrocytes.
6A 11-year-old girl is diagnosed with mild-to-moderate luminal Crohn's disease of the terminal ileum and ascending colon. According to ESPGHAN/ECCO paediatric Crohn's guidelines, what is the recommended first-line induction therapy?
A.Oral Azathioprine 2.5 mg/kg/day monotherapy
B.Oral Budesonide 9 mg/day for 12 months
C.Infliximab infusions at 0, 2, and 6 weeks
D.Exclusive Enteral Nutrition (EEN) for 6–8 weeks
Explanation: Exclusive Enteral Nutrition (EEN) for 6–8 weeks is recommended as the first-line therapy to induce remission in children with active luminal Crohn's disease. EEN achieves equivalent clinical remission rates to oral corticosteroids while promoting superior mucosal healing, growth, and nutritional recovery without steroid toxicity.
7A 14-year-old boy with Crohn's disease receiving infliximab maintenance therapy (5 mg/kg every 8 weeks) experiences clinical relapse with rising faecal calprotectin (850 mcg/g). Therapeutic drug monitoring reveals a serum infliximab trough level of 1.2 mcg/mL (target 5–10 mcg/mL) and high titers of anti-infliximab antibodies. What is the most appropriate management plan?
A.Add oral mesalazine 3 g/day to the current infliximab regimen
B.Switch class to Adalimumab monotherapy
C.Shorten the infliximab infusion interval to every 4 weeks at 10 mg/kg
D.Switch to an alternative biologic class (e.g., Ustekinumab) combined with an immunomodulator
Explanation: The presence of high-titer anti-drug antibodies combined with low trough levels and secondary loss of response indicates immune-mediated pharmacokinetic failure. Dose escalation of the same anti-TNF agent is ineffective when high-titer neutralizing antibodies are present. Switching out-of-class (e.g., Ustekinumab or Vedolizumab) with co-prescription of an immunomodulator to prevent immunogenicity is the optimal approach.
8A 5-year-old boy evaluated for chronic diarrhea and failure to thrive has a total serum IgA level of 0.05 g/L (below age-adjusted lower limit of detection, indicating selective IgA deficiency). Which serological screening test combination is necessary to accurately assess for coeliac disease in this child?
A.Faecal calprotectin and serum anti-saccharomyces cerevisiae antibodies (ASCA)
B.IgA endomysial antibody (EMA-IgA) and HLA-DQ2/DQ8
C.IgG tissue transglutaminase (IgG-tTG) and IgG deamidated gliadin peptides (IgG-DGP)
D.Standard IgA tissue transglutaminase (tTG-IgA) only
Explanation: Selective IgA deficiency occurs in 2-3% of coeliac patients (10-15x higher than the general population). Standard IgA-based serology (tTG-IgA, EMA-IgA) yields false-negative results. Diagnostic testing in IgA-deficient individuals requires IgG-based serology, specifically IgG-tTG and IgG-DGP.
9A 15-year-old girl with Crohn's disease presents with painful perianal discharge and a complex high transsphincteric fistula identified on pelvic MRI. An Examination Under Anaesthesia (EUA) is performed. Which combination therapy represents the gold standard evidence-based medical and surgical approach?
A.Fistula plug insertion combined with high-dose oral corticosteroids
B.Long-term oral Metronidazole monotherapy for 12 months
C.Surgical fistulotomy alone without medical therapy
D.Non-cutting seton placement combined with anti-TNF (Infliximab) therapy
Explanation: Management of complex perianal Crohn's fistulae requires combined surgical and medical therapy. Surgical placement of a non-cutting seton maintains drainage and prevents recurrent abscess formation, while Infliximab (anti-TNF) induces mucosal and fistulous healing. Surgical fistulotomy of high transsphincteric fistulae risks sphincter disruption and incontinence.
10A 12-year-old boy admitted with Acute Severe Colitis is treated with IV methylprednisolone 1 mg/kg/day. On Day 3 of admission, his PUCAI score is 70 (stool frequency 7/day, 4 bloody, severe nocturnal stooling). According to ECCO/ESPGHAN criteria, what is the most appropriate action?
A.Prepare for second-line rescue therapy (Infliximab or Ciclosporin) if PUCAI remains >45 on Day 3 to 5
B.Discharge on oral Prednisolone 2 mg/kg/day and 5-ASA
C.Immediately perform emergency total colectomy
D.Continue IV methylprednisolone unchanged until Day 7
Explanation: A PUCAI score >45 on Day 3 of IV corticosteroid therapy predicts steroid failure in up to 85% of paediatric acute severe colitis cases. Guidelines recommend screening for infection (CMV, C. difficile), obtaining abdominal radiology, and initiating second-line rescue therapy with Infliximab (or IV Ciclosporin) on Day 3 to 5.
About the CMSA Cert Gastroenterology(SA) Paed Practice Questions
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