CSOWM ACTUAL EXAM PAPER 2026
QUESTIONS AND SOLUTIONS GRADED A
PLUS
◉ A patient 6 months post-Roux-en-Y gastric bypass presents with
fatigue, glossitis, and elevated MCV. Which deficiency is most likely?
A. Vitamin D
B. Iron
C. Thiamin
D. Vitamin B12
Answer: D. Vitamin B12
Post-Roux-en-Y patients are at high risk for B12 deficiency due to
reduced intrinsic factor and decreased absorption in the terminal
ileum, leading to macrocytic anemia, glossitis, and neurologic
symptoms.
◉ Which mechanism best explains the rapid improvement of type 2
diabetes following bariatric surgery before significant weight loss
occurs?
A. Increased insulin receptor sensitivity from fat loss
B. Decreased hepatic gluconeogenesis from calorie restriction alone
,C. Incretin hormone changes (GLP-1 increase, GIP modulation)
D. Increased skeletal muscle glucose uptake from exercise
Answer: C. Incretin hormone changes
Bariatric surgery rapidly improves glucose control largely due to
increased GLP-1 secretion and altered gut hormone signaling,
improving insulin secretion and sensitivity even before major weight
loss.
◉ Which micronutrient deficiency is most associated with post-
biliopancreatic diversion procedures?
A. Vitamin K
B. Fat-soluble vitamins (A, D, E, K)
C. Vitamin C
D. Folate
Answer: B. Fat-soluble vitamins (A, D, E, K)
Biliopancreatic diversion causes significant fat malabsorption,
making deficiencies of fat-soluble vitamins the most common and
clinically significant long-term complication.
◉ A patient presents with Wernicke's encephalopathy after bariatric
surgery. What is the most appropriate immediate treatment?
A. Oral thiamin with glucose
B. IV thiamin before any carbohydrate administration
C. Oral multivitamin only
,D. High-dose vitamin B12 injection
Answer: B. IV thiamin before any carbohydrate administration
Giving glucose without thiamin can worsen Wernicke's
encephalopathy. Thiamin must be given immediately IV to prevent
irreversible neurologic damage.
◉ What is the primary physiological effect of sleeve gastrectomy
contributing to weight loss?
A. Malabsorption of fats
B. Increased ghrelin suppression due to fundus removal
C. Bile acid malabsorption
D. Pancreatic enzyme inhibition
Answer: B. Increased ghrelin suppression due to fundus removal
The gastric fundus produces ghrelin (hunger hormone). Sleeve
gastrectomy reduces ghrelin levels, decreasing appetite significantly.
◉ Which lab marker is most useful for assessing iron deficiency in a
bariatric patient with inflammation?
A. Serum iron
B. Hemoglobin
C. Ferritin
D. Transferrin saturation alone
Answer: C. Ferritin
, Ferritin reflects iron stores and is the best indicator in inflammatory
states, though it can be elevated in inflammation, making
interpretation context-dependent.
◉ A patient 2 weeks post-op bariatric surgery is vomiting and
cannot tolerate oral intake. What deficiency is most time-sensitive to
prevent neurologic damage?
A. Vitamin D
B. Thiamin
C. Calcium
D. Vitamin A
Answer: B. Thiamin
Thiamin stores deplete quickly (within weeks). Post-op vomiting
dramatically increases risk of Wernicke-Korsakoff syndrome,
making it the most urgent deficiency.
◉ Which condition is most associated with long-term hypoglycemia
after Roux-en-Y gastric bypass?
A. Dumping syndrome
B. Nesidioblastosis
C. Reactive hyperlipidemia
D. Insulin resistance
Answer: B. Nesidioblastosis
QUESTIONS AND SOLUTIONS GRADED A
PLUS
◉ A patient 6 months post-Roux-en-Y gastric bypass presents with
fatigue, glossitis, and elevated MCV. Which deficiency is most likely?
A. Vitamin D
B. Iron
C. Thiamin
D. Vitamin B12
Answer: D. Vitamin B12
Post-Roux-en-Y patients are at high risk for B12 deficiency due to
reduced intrinsic factor and decreased absorption in the terminal
ileum, leading to macrocytic anemia, glossitis, and neurologic
symptoms.
◉ Which mechanism best explains the rapid improvement of type 2
diabetes following bariatric surgery before significant weight loss
occurs?
A. Increased insulin receptor sensitivity from fat loss
B. Decreased hepatic gluconeogenesis from calorie restriction alone
,C. Incretin hormone changes (GLP-1 increase, GIP modulation)
D. Increased skeletal muscle glucose uptake from exercise
Answer: C. Incretin hormone changes
Bariatric surgery rapidly improves glucose control largely due to
increased GLP-1 secretion and altered gut hormone signaling,
improving insulin secretion and sensitivity even before major weight
loss.
◉ Which micronutrient deficiency is most associated with post-
biliopancreatic diversion procedures?
A. Vitamin K
B. Fat-soluble vitamins (A, D, E, K)
C. Vitamin C
D. Folate
Answer: B. Fat-soluble vitamins (A, D, E, K)
Biliopancreatic diversion causes significant fat malabsorption,
making deficiencies of fat-soluble vitamins the most common and
clinically significant long-term complication.
◉ A patient presents with Wernicke's encephalopathy after bariatric
surgery. What is the most appropriate immediate treatment?
A. Oral thiamin with glucose
B. IV thiamin before any carbohydrate administration
C. Oral multivitamin only
,D. High-dose vitamin B12 injection
Answer: B. IV thiamin before any carbohydrate administration
Giving glucose without thiamin can worsen Wernicke's
encephalopathy. Thiamin must be given immediately IV to prevent
irreversible neurologic damage.
◉ What is the primary physiological effect of sleeve gastrectomy
contributing to weight loss?
A. Malabsorption of fats
B. Increased ghrelin suppression due to fundus removal
C. Bile acid malabsorption
D. Pancreatic enzyme inhibition
Answer: B. Increased ghrelin suppression due to fundus removal
The gastric fundus produces ghrelin (hunger hormone). Sleeve
gastrectomy reduces ghrelin levels, decreasing appetite significantly.
◉ Which lab marker is most useful for assessing iron deficiency in a
bariatric patient with inflammation?
A. Serum iron
B. Hemoglobin
C. Ferritin
D. Transferrin saturation alone
Answer: C. Ferritin
, Ferritin reflects iron stores and is the best indicator in inflammatory
states, though it can be elevated in inflammation, making
interpretation context-dependent.
◉ A patient 2 weeks post-op bariatric surgery is vomiting and
cannot tolerate oral intake. What deficiency is most time-sensitive to
prevent neurologic damage?
A. Vitamin D
B. Thiamin
C. Calcium
D. Vitamin A
Answer: B. Thiamin
Thiamin stores deplete quickly (within weeks). Post-op vomiting
dramatically increases risk of Wernicke-Korsakoff syndrome,
making it the most urgent deficiency.
◉ Which condition is most associated with long-term hypoglycemia
after Roux-en-Y gastric bypass?
A. Dumping syndrome
B. Nesidioblastosis
C. Reactive hyperlipidemia
D. Insulin resistance
Answer: B. Nesidioblastosis
