Gastrointestinal

Question 1

1. Dysphagia
   A 47-year-old woman presents to your clinic with a three-month history of
   dysphagia. There is no history of drastic weight loss and the patient experiences
   symptoms when swallowing solids but not liquids. Which of the following is not an
   obstructive cause of dysphagia?
   A. Pharyngeal carcinoma
   B. Oesophageal web
   C. Retrosternal goitre
   D. Peptic stricture
   E. Achalasia

Answer 1

E

Question 2

2. Abdominal pain (1)
   You see a 47-year-old man in clinic with a three-month history of epigastric dull
   abdominal pain. He states that the pain is worse in the mornings and is relieved
   after meals. On direct questioning, there is no history of weight loss and the
   patient’s bowel habits are normal. On examination, his abdomen is soft and
   experiences moderate discomfort on palpation of the epigastric region. The most
   likely diagnosis is:
   A. Gastric ulcer
   B. Gastro-oesophageal reflux disease (GORD)
   C. Duodenal ulcer
   D. Gastric carcinoma
   E. Gastritis

Answer 2

C

Question 3

3. Management of peptic ulcer disease
   A 55-year-old woman is referred by her GP for upper gastrointestinal (GI) endoscopy
   following a four-month history of epigastric pain despite treatment with antacids
   and proton pump inhibitors (PPIs). The results demonstrate a duodenal ulcer
   coupled with a positive campylobacter-like organism (CLO) test. The patient has no
   past medical history and has no known drug allergies. The most appropriate
   treatment is:
   A. Seven-day course of twice daily omeprazole 20 mg, 1 g amoxicillin and
   500 mg clarithromycin
   B. Seven-day course of twice daily omeprazole 20 mg
   C. Seven-day course of twice daily omeprazole 20 mg and 1 g amoxicillin
   D. Seven-day course of twice daily omeprazole 20 mg and 500 mg
   clarithromycin
   E. Seven-day course of twice daily 1 g amoxicillin and 500 mg
   clarithromycin

Answer 3

A

Question 4

4. Peptic ulcer disease
   Which of the following is the most common cause of duodenal ulcers?
   A. NSAIDs
   B. Helicobacter pylori
   C. Alcohol abuse
   D. Chronic corticosteroid therapy
   E. Zollinger–Ellison syndrome

Answer 4

B

Question 5

5. Investigation of gastro-oesophageal reflux disease
   You see a 48-year-old lorry driver, who presents to you with a three-month history
   of heartburn after meals which has not been settling with antacids and PPIs. You
   suspect that the patient has a hiatus hernia. The most appropriate investigation for
   diagnosing a hiatus hernia is:
   A. Computer tomography (CT) scan
   B. Chest x-ray
   C. Upper GI endoscopy
   D. Barium meal
   E. Ultrasound

Answer 5

D

Question 6

6. Complications of gastro-oesophageal reflux disease
   You see a 56-year-old man who was admitted for an elective upper GI endoscopy
   due to longstanding GORD which has failed to improve on antacids and PPIs. Your
   registrar suspects that this patient may have Barrett’s oesophagus and asks you to
   define what this is. The most appropriate description of Barrett’s oesophagus is:
   A. Metaplasia of the squamous epithelium of the lower third of the
   oesophagus to columnar epithelium
   B. Metaplasia of the columnar epithelium of the upper third of the oesophagus
   to squamous epithelium
   C. Metaplasia of the columnar epithelium of the lower third of the
   oesophagus to squamous epithelium
   D. Metaplasia of the squamous epithelium of the upper third of the
   oesophagus to columnar epithelium
   E. Metaplasia of the squamous epithelium of the middle third of
   the oesophagus to columnar epithelium

Answer 6

A

Question 7

7. Diarrhoea (1)
   You see a 25-year-old woman who presents with a 24-hour history of watery
   diarrhoea. She states that she has opened her bowels 11 times since her onset of
   symptoms. Associated symptoms include nausea and vomiting with abdominal
   cramps and pain which started in the evening following a barbeque meal in the
   afternoon that day. The patient is alert and orientated and her observations include
   a pulse rate of 69, blood pressure of 124/75 and temperature of 37.1°C. On
   examination, her abdomen is soft, there is marked tenderness in the epigastric
   region and bowel sounds are hyperactive. The patient is normally fit and well with
   no past medical history. The most likely diagnosis is:
   A. Irritable bowel syndrome
   B. Gastroenteritis
   C. Ulcerative colitis
   D. Laxative abuse
   E. Crohn’s disease

Answer 7

B

Question 8

8. Management of diarrhoea
   A 35-year-old woman presents with a 24-hour history of watery diarrhoea. She has
   opened her bowels nine times since the onset of her symptoms. You diagnose
   gastroenteritis after learning that the patient and her family all ate at a new
   restaurant and the rest of her family have had similar problems. The most appropriate
   management is:
   A. Oral rehydration advice, anti-emetics and discharge home
   B. Oral antibiotic therapy and discharge home
   C. Admission for intravenous fluid rehydration
   D. Admission for intravenous antibiotic therapy
   E. No treatment required

Answer 8

A

Question 9

9. Investigation of diarrhoea
   A 56-year-old man presents with a 2-week history of diarrhoea which has not
   settled following an episode of ‘food poisoning’. Which of the following would be
   the most appropriate investigation?
   A. Full blood count
   B. Urea and electrolytes
   C. Stool sample for microscopy, culture and sensitivities
   D. Abdominal x-ray
   E. Liver function tests

Answer 9

C

Question 10

10. Diarrhoea (2)
    You are questioned by your registrar regarding bacteria responsible for causing
    blood-stained diarrhoea. From the list below, select the organism which is not
    responsible for causing blood-stained diarrhoea.
    A. Campylobacter spp.
    B. Salmonella spp.
    C. Escherichia coli
    D. Shigella spp.
    E. Stapylococcus spp.

Answer 10

E

Question 11

11. Hepatomegaly
    A 69-year-old man present with a 2-week history of abdominal pain which has
    worsened over the last few days. On examination, the patient is jaundiced and the
    abdomen is distended with tenderness in the epigastric region. In addition, there is
    a smooth hepatomegaly and shifting dullness. Which of the following is a cause of
    hepatomegaly?
    A. Iron deficiency anaemia
    B. Budd–Chiari syndrome
    C. Ulcerative colitis
    D. Crohn’s disease
    E. Left-sided heart failure

Answer 11

B

Question 12

12. Jaundice (1)
    You see a 19-year-old Caucasian man in your clinic who presents with a history of
    transient jaundice. On direct questioning, you ascertain that the jaundice is
    noticeable after periods of increased physical activity and subsides after a few days.
    The patient has no other symptoms and physical examination is unremarkable. Full
    blood count is normal (with a normal reticulocyte count) and liver function tests
    reveal a bilirubin of 37 μmol/L. The most appropriate management is:
    A. Reassure and discharge
    B. Start on a course of oral steroids
    C. Request abdominal ultrasound
    D. Request MRCP
    E. Refer to Haematology

Answer 12

A

Question 13

13. Jaundice (2)
    You see a 54-year-old woman, referred to accident and emergency through her GP,
    with a week’s history of jaundice and right upper quadrant abdominal pain.
    Associated symptoms include dark urine and pale stools. There is no history of
    weight loss and the patient does not consume alcohol. Her liver function tests
    reveal a bilirubin of 40 μmol/L, ALT of 40 iu/L, AST 50 iu/L and ALP of 350 iu/L. The
    most likely diagnosis is:
    A. Gallstones
    B. Viral hepatitis
    C. Alcoholic hepatitis
    D. Carcinoma of the head of the pancreas
    E. Autoimmune hepatitis

Answer 13

A

Question 14

14. Investigation of jaundice
    You are asked by your registrar to request an imaging investigation for a 49-yearold
    woman with jaundice and abdominal pain. She has a past medical history of
    gallstones and you suspect this is a recurrence of the same problem. The most
    appropriate imaging investigation is:
    A. Abdominal x-ray
    B. Abdominal ultrasound
    C. Abdominal CT
    D. Magnetic resonance imaging (MRI)
    E. Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 14

A

Question 15

15. Drug-induced cholestasis
    You see a 47-year-old woman who presents with a 3-day history of jaundice. You
    assess her liver function tests (LFTs) and see that the ALP iu/L is raised at 350 iu/L,
    AST 45 iu/L, ALT 50 iu/L and bilirubin 50 iu/L. The patient feels well in herself,
    although she has noticed that her urine has become quite dark and her stools quite
    pale. You assess her medication history. Which of the following drugs from the
    patient’s medication history may be responsible for the cholestasis?
    A. Co-amoxiclav
    B. Bendroflumethiazide
    C. Ramipril
    D. Amlodipine
    E. Aspirin

Answer 15

B

Question 16

16. Constipation
    During your on-call, you are bleeped to see an 80-year-old woman on the ward
    who has not opened her bowels for the last 4 days. She is not known to have a
    history of constipation. On examination, her observations are within normal range,
    the abdomen is soft and there is mild discomfort at the left iliac fossa. Bowel
    sounds are present and on PR examination, the rectum is empty. You consult your
    registrar who asks you to prescribe an osmotic laxative. What is the most appropriate
    treatment?
    A. Ispaghula husk
    B. Docusate sodium
    C. Lactulose
    D. Senna
    E. Methylcellulose

Answer 16

C

Question 17

17. Finger clubbing
    Which of the following gastroenterological conditions would give rise to finger
    clubbing?
    A. Hepatocellular carcinoma
    B. Ulcerative colitis
    C. Irritable bowel syndrome
    D. Hepatocellular carcinoma
    E. Pancreatic carcinoma

Answer 17

B

Question 18

18. Abdominal pain (2)
    You see an 80-year-old man who presents to accident and emergency with
    epigastric pain. The pain started 3 days ago and today he noticed that the colour
    of his stools has changed to a ‘tarry-black’ colour. Associated symptoms include
    nausea and lethargy. The patient is a smoker of 20 cigarettes a day and has
    recently finished eradication treatment for a duodenal ulcer. The patient is alert
    and orientated with a pulse rate of 99 and blood pressure of 98/69, respiratory rate
    of 18, oxygen saturations of 98 per cent on room air and temperature of 37.2°C.
    On examination, the abdomen is soft with marked tenderness in the epigastric
    region and bowel sounds are present. The rectum is empty, on PR examination,
    with some traces of malaena. The patient has been started on high flow oxygen
    and has been given some oral analgesia. The most appropriate next step in
    managing this patient is:
    A. Keep nil by mouth and arrange endoscopy
    B. Request an erect chest x-ray
    C. Intravenous pantoprazole
    D. ECG
    E. Intravenous cannulation and fluids

Answer 18

E

Question 19

19. Causes of upper gastrointestinal bleeding
    You see a 75-year-old man with an acute episode of haematemesis, who was
    admitted the night before and is awaiting an upper GI endoscopy. You are asked on
    the ward round about the common causes of upper GI bleeding. From the list below,
    which of the following is the most common cause of upper GI bleeding?
    A. Mallory–Weiss tear
    B. Peptic ulcers
    C. Oesophageal varices
    D. Drug induced
    E. Malignancy

Answer 19

B

Question 20

20. Management of oesophageal varices
    A 60-year-old man with alcoholic liver disease was admitted with an upper GI
    bleed secondary to oesophageal varices. The patient undergoes endoscopic variceal
    banding and is discharged after 2 weeks in-hospital stay. Which of the following
    medications would act as prophylaxis in preventing a rebleed from his oesophageal
    varices?
    A. Frusemide
    B. Amlodipine
    C. Ramipril
    D. Propranolol
    E. Irbesartan

Answer 20

D

Question 21

21. Jaundice (3)
    A 46-year-old woman presents to your clinic with a week’s history of jaundice. Her
    past medical history includes longstanding atrial fibrillation and hypertension.
    Physical examination reveals hepatomegaly. You assess her liver function which
    shows a bilirubin of 41 iu/L, AST 111 iu/L, ALT 55 iu/L and ALP 98 iu/L. There is no
    history of travel. You have a look at the patient’s medication history. Which of the
    following drugs below is likely to have caused the derangement in the patient’s
    liver function?
    A. Aspirin
    B. Ramipril
    C. Amiodarone
    D. Bendroflumethiazide
    E. Amlodipine

Answer 21

C

Question 22

22. Clinical signs of chronic liver disease
    A 67-year-old man presents feeling unwell and complaining of general malaise. He
    mentions a long history of alcohol abuse and his past medical history shows
    deranged liver function tests. Which of the following clinical signs does not form
    part of chronic liver disease?
    A. Finger clubbing
    B. Palmer erythema
    C. Spider naevia
    D. Koilonychia
    E. Jaundice

Answer 22

D

Question 23

23. Alcoholic liver disease
    You see a 56-year-old man in your clinic with suspected alcoholic liver disease.
    Liver function tests reveal a bilirubin of 36 iu/L, AST of 150 iu/L, ALT 75 iu/L and
    ALP 100 iu/L. Which of the following blood test parameters would support a
    diagnosis of alcoholic-related liver disease?
    A. Normal mean cell volume (MCV)
    B. Low MCV
    C. Normal mean cell haemoglobin (MCH)
    D. Low MCH
    E. Raised MCV

Answer 23

E

Question 24

24. Deranged liver function
    You see a 52-year-old woman with rheumatoid arthritis in your clinic. She was
    referred by her GP after her ALP levels were found to be abnormally high at
    300 iu/L. In addition, she was also found to be serum anti-mitochondrial antibody
    (AMA) positive. The most likely diagnosis is:
    A. Primary biliary cirrhosis
    B. Wilson’s disease
    C. Heriditary haemochromotosis
    D. Primary sclerosing cholangitis
    E. Alcoholic liver disease

Answer 24

A

Question 25

25. Ascites
    A 47-year-old man presents complaining of weight gain, on examination there is
    an abdominal distension with a fluid thrill. Which of following is not a cause of
    ascites secondary to venous hypertension?
    A. Congestive heart failure
    B. Cirrhosis
    C. Constrictive pericarditis
    D. Budd–Chiari syndrome
    E. Nephrotic syndrome

Answer 25

E

Question 26

26. α1-antitrypsin deficiency
    A 56-year-old man, diagnosed with emphysema, presents with a one-month history
    of jaundice and ascites. Your registrar suspects that this patient may have liver
    disease secondary to α1-antitrypsin deficiency. Select the most likely mode of
    inheritance from the list below:
    A. Autosomal dominant
    B. X-linked dominant
    C. Autosomal recessive
    D. Polygenic
    E. None of the above

Answer 26

C

Question 27

27. Chronic liver disease
    You see a 56-year-old woman who presents with a two-month history of jaundice.
    Associated symptoms include lethargy and polyarthralgia. Her LFTs reveal a
    bilirubin of 46 iu/L, AST 200, ALT 175, ALP 104. On examination, the patient is
    jaundiced and has finger clubbing. There are several spider naevi on the front and
    back of the trunk. Her abdomen is soft and there is a smooth hepatomegaly. Prior
    to her onset of symptoms, the patient has been fit and well. Viral serology is normal
    and anti-soluble liver antigen (SLA) is detected. You decide to start this patient on
    treatment. The most appropriate treatment is:
    A. Liver transplantation
    B. Methotrexate
    C. Prednisolone
    D. Cyclosporin
    E. Antivirals

Answer 27

C

Question 28

28. Primary sclerosing cholangitis
    You are told by your registrar that one of your inpatients has been diagnosed with
    primary sclerosing cholangitis (PSC). Your registrar suspects that the patient may
    have an associated condition. Primary sclerosing cholangitis is associated with
    which of the following diseases?
    A. Thyroid disease
    B. Systemic sclerosis
    C. Rheumatoid arthritis
    D. Ulcerative colitis
    E. Irritable bowel syndrome

Answer 28

D

Question 29

29. Complications of primary sclerosing cholangitis
    A 68-year-old man presents to his GP with signs of drastic weight loss. He is known
    to have PSC. The GP suspects an underlying malignancy. Which of the following
    tumours would a patient with primary sclerosing cholangitis be more at risk of
    developing?
    A. Hepatocellular carcinoma
    B. Cholangiocarcinoma
    C. Hepatic fibroma
    D. Hepatic haemangioma
    E. Pancreatic carcinoma

Answer 29

B

Question 30

30. Liver tumours
    During a ward round, you are questioned about tumours that may arise from the
    liver parenchyma. Which of the following liver tumours is considered to be benign?
    A. Angiosarcoma
    B. Fibrosarcoma
    C. Adenoma
    D. Hepatoblastoma
    E. Leiyomyosarcoma

Answer 30

C

Question 31

31. Hepatocellular carcinoma
    A patient on your ward is diagnosed with hepatocellular carcinoma. You are asked
    to perform a tumour marker level on this patient. Which of the following tumour
    markers are elevated in hepatocellular carcinoma?
    A. α-fetoprotein
    B. Carcinoembryonic antigen (CEA)
    C. CA 15-3
    D. HcG
    E. CA 125

Answer 31

A

Question 32

32. Jaundice (4)
    A 64-year-old woman attends your clinic with a 2-week history of jaundice. Over
    the last three months the patient has lost 10 kg. Associated symptoms include
    decreased appetite, dark urine and pale stools. On examination, the patient is
    jaundiced, her abdomen is soft and you can palpate a painless mass in the right
    upper quadrant. From the list of answers below, select the initial most appropriate
    investigation that you would request for this patient:
    A. Abdominal x-ray
    B. Abdominal CT
    C. MRI of the abdomen
    D. Abdominal ultrasound
    E. ERCP

Answer 32

D

Question 33

33. Rectal biopsy
    A 28-year-old man undergoes a sigmoidoscopy for longstanding diarrhoea and
    weight loss. On visualization of the rectum, the mucosa appears inflamed and
    friable. A rectal biopsy is taken and the histology shows mucosal ulcers with
    inflammatory infiltrate, crypt abscesses with goblet cell depletion. From the list of
    answers below, which is the most likely diagnosis describing the histology report?
    A. Crohn’s disease
    B. Pseudomembranous colitis
    C. Irritable bowel syndrome
    D. Ulcerative colitis
    E. No diagnosis – the report is inconclusive

Answer 33

D

Question 34

34. Severity of ulcerative colitis
    You are told by your registrar that one of the clinic patients has been admitted with
    a ‘flare up’ of ulcerative colitis (UC) which he reports as being severe. From the list
    of answers below, select the parameters which are likely to reflect a severe flare up
    of ulcerative colitis:
    A. Fewer than four bowel motions per day with large amounts of rectal
    bleeding
    B. Between four and six bowel motions per day with large amounts of
    rectal bleeding
    C. More than four bowel motions per day with large amounts of rectal
    bleeding
    D. More than five bowel motions per day with large amounts of rectal
    bleeding
    E. More than six bowel motions per day with large amounts of rectal
    bleeding

Answer 34

E

Question 35

35. Investigating inflammatory bowel disease
    You read a report which was handwritten in a patient’s medical notes who you
    suspect has inflammatory bowel disease. The report reads, ‘… there is cobblestoning
    of the terminal ileum with the appearance of rose thorn ulcers. These findings are
    suggestive of Crohn’s disease’. Select the most likely investigation that this report
    was derived from:
    A. Colonoscopy
    B. Sigmoidoscopy
    C. Barium follow through
    D. Abdominal CT
    E. Abdominal ultrasound

Answer 35

C

Question 36

36. Management of ulcerative colitis
    You are asked to see a 29-year-old woman diagnosed with ulcerative colitis 18
    months ago. Over the last 4 days she has been experiencing slight abdominal
    cramps, opening her bowels approximately 4–5 times a day and has been passing
    small amounts of blood per rectum. The patient is alert and orientated and on
    examination her pulse is 67, blood pressure 127/70, temperature 37.3°C and her
    abdomen is soft with mild central tenderness. PR examination is nil of note. Blood
    tests reveal haemoglobin of 13.5 g/dL and a CRP of 9 mg/L. The most appropriate
    management plan for this patient is:
    A. Admission to hospital for intravenous fluid therapy and steroids
    B. Oral steroid therapy + oral 5-ASA + steroid enemas + discharge
    C. Admission and refer to surgeons for further assessment
    D. Oral steroid therapy and discharge home
    E. Reassurance and discharge home with no treatment required

Answer 36

B

Question 37

37. Crohn’s disease
    A 29-year-old anxious man is diagnosed with mild Crohn’s disease. Due to time
    constraints, the patient was asked to come back for a follow-up appointment to
    discuss Crohn’s disease in more detail. The patient returns with a list of complications
    he researched on the internet. Which of the following are not associated with
    Crohn’s disease?
    A. Cigarette smoking reduces incidence
    B. Fistulae formation
    C. Abscess formation
    D. Non-caseating granuloma formation
    E. Associated with transmural inflammation

Answer 37

A

Question 38

38. Vitamin B12 deficiency
    You see a 40-year-old woman who was diagnosed with Crohn’s disease ten years
    ago. Due to a severe attack of Crohn’s which failed to respond to medical therapy,
    she had a small bowel resection. Your registrar tells you that she is at risk of
    developing vitamin B12 deficiency as a result of her surgery. Which part of the
    small bowel is responsible for the absorption of vitamin B12?
    A. Jejunum
    B. Proximal ileum
    C. Duodenum
    D. Terminal ileum
    E. None of the above

Answer 38

D

Question 39

39. Diarrhoea (3)
    A 47-year-old woman has been experiencing a four-month history of diarrhoea
    and bloating. Associated symptoms include lethargy and weight loss. Full blood
    count reveals haemoglobin of 9.3 d/gL and MCV 70 fL. Which of the following
    investigations would be helpful in the patient’s diagnosis?
    A. Anti-mitochondrial antibodies
    B. Anti-smooth muscle antibodies
    C. Anti-tissue transglutaminase antibodies
    D. Anti-nuclear antibodies
    E. Anti-neutrophil cytoplasmic antibodies

Answer 39

C

Question 40

40. Weight loss
    A 65-year-old man attends your clinic with a three-month history of weight loss of
    approximately 9 kg despite a normal appetite. A full blood count reveals that his
    haemoglobin is 9.0 g/dL (previous haemoglobin was 13.5 g/dL one year ago) and
    the MCV is 71 fL. Abdominal examination is unremarkable and per rectum exam is
    nil of note. The patient states that he has normal bowel habits and has been feeling
    quite tired lately. The most appropriate management is:
    A. Reassure and discharge
    B. Arrange an upper and lower GI endoscopy
    C. Prescribe iron tablet supplementation
    D. Arrange an abdominal ultrasound
    E. Arrange an abdominal x-ray

Answer 40

B