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Question 1
Incorrect
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A social worker has been diagnosed with hepatitis C infection. Which test will conclusively establish the presence of this infection?
Your Answer:
Correct Answer: HCV RNA
Explanation:The most sensitive test for detecting Hepatitis C infection (acute) is HCA RNA; it can be detected 1-2 weeks after infection. Anti-HCV antibodies take at least 6 weeks to develop and be positive.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Incorrect
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A 43-year-old man is reviewed in the gastroenterology clinic. He has had troublesome dyspepsia for the past six months which has not settled with proton pump inhibitor (PPI) therapy. During the review of his systems he also reports passing 6-7 watery stools per day. An OGD 3 weeks ago showed gastric erosions and ulcers.
Which one of the following investigations is most likely to be diagnostic?Your Answer:
Correct Answer: Fasting gastrin
Explanation:This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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Which of the following is the most common route of hepatitis B transmission worldwide?
Your Answer:
Correct Answer: Perinatal transmission
Explanation:Perinatal transmission is the most common cause of Hepatitis B infection worldwide. Post-exposure prophylaxis should be provided, which consists of hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. Without this, about 40% will develop chronic infection.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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A 45-year-old man was referred for abnormal liver biochemistry. Investigations showed he had an ALT of 98 U/l and was Hep B surface antigen positive.
Which of the following is true of chronic active hepatitis due to the hepatitis B virus?Your Answer:
Correct Answer: It carries an increased risk of subsequent hepatocellular carcinoma
Explanation:Chronic hepatitis B patients have an increased risk of hepatocellular carcinoma. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have+HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. It is important to remember these serologies, it will get you a lot of points on the test.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Incorrect
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A 55-year-old male is admitted with vomiting. He has a long history of alcohol abuse, appears slightly jaundiced and is dishevelled and unkempt. He was started on an intravenous glucose infusion and diazepam and he symptomatically improved.
One day later he becomes confused, develops vomiting, diplopia and is unable to stand. What is the most likely diagnosis?Your Answer:
Correct Answer: Vitamin B deficiency
Explanation:The most likely diagnosis is Wernicke’s encephalopathy. This presents in a long time alcoholic from vitamin BI deficiency. Symptoms include confusion and confabulation, oculomotor symptoms/signs, and ataxia.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Incorrect
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A 24-year-old woman presents as an emergency to her GP with acute vomiting which began some 3–4 hours after attending an afternoon meeting. Cream cakes were served during the coffee break.
Which of the following organisms is the most likely cause of this acute attack of vomiting?Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Staph. aureus is the most likely cause. It is found in foods like dairy products, cold meats, or mayonnaise. It produces a heat-stable ENDOTOXIN (remember this) that causes nausea, vomiting, and diarrhoea 1-6 hours after ingestion of contaminated food. B. cereus is classically associated with fried rice being reheated. Salmonella is typical with raw eggs and undercooked poultry. Campylobacter which is most commonly associated with food poisoning, is seen with poultry 50% of the time. Yersinia enterocolitica is seen with raw or undercooked pork, and may be a case presenting with mesenteric adenitis.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Incorrect
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A 55-year-old obese woman presents to casualty. She has rigors and reports a fever. On examination there is jaundice and tenderness over the right upper quadrant of her abdomen.
She has an elevated white blood cell count and a markedly raised alkaline phosphatase level; transaminases and bilirubin are also abnormal.
Which of these diagnoses best fits the clinical picture?Your Answer:
Correct Answer: Ascending cholangitis
Explanation:This question describes Charcot’s triad– fever, RUQ pain, and jaundice, which is seen in ascending cholangitis. Reynold’s pentad is a worsened version of this, where you have RUQ pain, fever, jaundice, hypotension, and altered mental status. Risk factors for gallstones are the 4F’s- female, fat, forty, and fertile. You would not have the elevated bilirubin, ALP, transaminases with a kidney stone or in peptic ulcer disease. Hepatitis would not cause elevation of bilirubin.
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This question is part of the following fields:
- Gastroenterology
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Question 8
Incorrect
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A 62-year-old woman with scleroderma and Reynaud’s phenomenon complains of weight loss and has been referred for an opinion. Gastrointestinal associations of progressive systemic sclerosis include which of the following?
Your Answer:
Correct Answer: Oesophageal stricture
Explanation:Oesophageal stricture is a complication of systemic sclerosis, think of the oesophagus as sclerosing (fibrosing) leading to stricture and you never forget. Based on the clinical presentation of systemic sclerosis this is more likely than pancreatic dysfunction, PSC, lymphoma, or diverticulitis. Additionally, CREST syndrome stands for: calcinosis cutis, Raynaud’s phenomenon (which the patient has), oesophageal dysmotility, sclerodactyly, and telangiectasias), this is a form of systemic sclerosis you should be familiar with.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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A 74-year-old man presents with left-sided lower abdominal pain. He is obese and admits to a dislike of high fibre foods. The pain has been grumbling for the past couple of weeks and is partially relieved by defecation. He has suffered intermittent diarrhoea.
Blood testing reveals a neutrophilia, and there is also a microcytic anaemia. Barium enema shows multiple diverticula, more marked on the left-hand side of the colon.
Which diagnosis fits best with this clinical picture?Your Answer:
Correct Answer: Diverticular disease
Explanation:Given that he has diverticula in the clinical scenario combined with his presenting symptoms, it is likely that he has diverticular disease. A low fibre diet would support this diagnosis. Acute diverticulitis would require treatment with antibiotics. Depending on the severity (Hinchey classification) would determine if he needs oral or IV antibiotics, hospital admission or outpatient treatment. Sometimes abscesses or micro perforations occur, which typical require drainage and possibly surgical intervention. Diverticular disease is clearly a better answer than other possible answer choices, simply based on the symptoms presented in the prompt (and mention of low fibre).
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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A 33-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophageal variceal haemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 104/60 mmHg and his pulse is 84/min. What is the most appropriate intervention?
Your Answer:
Correct Answer: Endoscopic variceal band ligation
Explanation:The correct course of action after giving terlipressin and resuscitating with IV fluids is to perform an EGD with endoscopic variceal band ligation. According to NICE: ‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices. There are serious complications of a TIPS procedure and it is not the first line treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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A 34-year-old HIV positive man is referred to gastroenterology due to jaundiced sclera. Liver function tests are as follows:
Albumin 34 g/l
ALP 540 iu/l
Bilirubin 67 µmol/L,
ALT 45 iu/l
What is the most likely diagnosis?Your Answer:
Correct Answer: Sclerosing cholangitis
Explanation:HIV can cause strictures in the biliary tract (see source for details of the disease). This makes the diagnosis of primary sclerosing cholangitis most likely given the clinical presentation and lab values. Due to its association with HIV this is more likely than all of the other answer choices. Know this association.
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This question is part of the following fields:
- Gastroenterology
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Question 12
Incorrect
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A 16-year-old female presents with a two day history of right iliac fossa pain, nausea and loss of appetite. You suspect that she has acute appendicitis. Which scoring system could you use to lend support to your diagnosis?
Your Answer:
Correct Answer: Alvarado score
Explanation:The prompt is suggestive of acute appendicitis. The Alvarado score is a clinical scoring system used to determine the likelihood of appendicitis, so this is the correct answer. A score greater than 6 is generally considered at risk for having acute appendicitis. It has 8 different criteria included (symptoms, signs, and lab results) and divides patients into appendicitis unlikely, possible, probable, and definite. The Center Score is a score to access the likelihood that pharyngitis is due to Strep. The Child-Pugh score predicts prognosis in liver cirrhosis. The Glasgow score is two different scores– the Glasgow coma score in trauma, which estimates level of consciousness, essentially, and The Glasgow Imrie Criteria which determines the severity of acute pancreatitis based on 8 lab values. The MELD score predicts the severity of end-stage liver disease.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 28-year-old patient presents with inflammatory bowel disease. 5-ASA would be most appropriate in treating which condition?
Your Answer:
Correct Answer: Maintenance therapy for ulcerative colitis
Explanation:5-ASA is not an acute treatment; it is for maintenance therapy for ulcerative colitis and/or Crohn’s. The most benefit is seen in patients with ulcerative colitis.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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Which of the following stimulates the secretion of gastrin?
Your Answer:
Correct Answer: Amino acids
Explanation:Gastrin is released from G cells in the antrum of the stomach after a meal. It stimulates parietal cells to release HCl. Gastrin is stimulated by a number of things: antrum distention, vagal stimulation, peptides (especially amino acids) in the stomach, hypercalcemia. Gastrin release is inhibited by acid, SST, GIP, VIP, secretin, glucagon, and calcitonin.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Incorrect
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A 32-year-old lady is found to be hepatitis B surface antigen positive. This positive result has persisted for more than six months. Hepatitis B envelope antigen (HBeAg) is negative. HBV DNA is negative. Her liver function tests are all entirely normal.
Which of the following options would be the best for further management?Your Answer:
Correct Answer: No antiviral therapy but monitor serology
Explanation:Again, remember the Hepatitis B serologies: In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, + anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. IN THIS CASE, the person is HBsAg+ for 6 months and everything else is negative, normal transaminase. They do not need antiviral therapy, but their serology should be monitored serially. There would be no reason to do a liver biopsy.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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Which of the following statements is true concerning gastrin?
Your Answer:
Correct Answer: Release is triggered by GI luminal peptides
Explanation:Gastrin is released by G cells in the antrum of the stomach. It stimulates secretion of gastric acid (HCl) by the parietal cells of the stomach and also aids in gastric motility. It is released in response to the following stimuli: vagal stimulation, antrum distention, hypercalcemia. It is inhibited by the following: presence of acid in stomach, SST, secretion, GIP, VIP, glucagon, calcitonin.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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A 54-year-old plumber presents with general deterioration. He drinks approximately 25 units of alcohol each week and is a smoker of five cigarettes daily. Examination reveals that he is jaundiced, has numerous spider naevi on his chest and he has a temperature of 37.2°C. Abdominal examination reveals hepato-splenomegaly.
Investigations reveal:
Bilirubin 100 micromol/L (1-22),
Alkaline phosphatase 310 iu/l (45 – 105),
ALT 198 iu/l (5 – 35),
AST 158 iu/l (1 – 31),
Albumin 25 g/L (37 – 49),
Hepatitis B virus surface antigen positive,
Hepatitis B virus e antigen negative,
Hepatitis B virus DNA awaited.
What is the most likely diagnosis?Your Answer:
Correct Answer: Chronic hepatitis B infection
Explanation:The clinical scenario describes a man in liver failure. Given the serological results, he is most likely to have a chronic hepatitis B infection. In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, +anti-HBc, +IgM anti-HBc, and negative anti-HBs. in immunity due to natural infection, you have negative HBsAg, +anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. While he could have a superimposed hepatitis D infection on top of hepatitis B, there is no mention of hepatitis D serology, make this an incorrect answer. The other choices do not involve hepatitis serologies.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Incorrect
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A 29-year-old woman presents to clinic complaining of intermittent diarrhoea and constipation. Full blood count and viscosity were normal. Flexible sigmoidoscopy was unremarkable.
What is the next most appropriate management step?Your Answer:
Correct Answer: High-fibre diet
Explanation:This is most likely describing irritable bowel syndrome (IBS). Symptoms are either diarrhoea, constipation, or both, abdominal pain, bloating, with various durations. It is a functional, not organic, problem, as far as research shows at this point. It is essentially a diagnosis of exclusion. Treatment is a high fibre diet with fluids. Caffeine should be avoided as this can worsen symptoms. Full colonoscopy is not warranted at this time, neither is a barium enema. A wheat-free diet is not likely to help as there is no evidence they have an allergy to this.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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A 45-year-old man who had a liver transplant just over 3 months ago, now has primary sclerosing cholangitis. He complains of fever, abdominal pain and diarrhoea, which has come on over the last week. He has a platelet count of 60 x 109/L and alanine transaminase (ALT) of 300 U/L with a normal bilirubin.
He is taking tacrolimus and prednisolone for immunosuppression, and tells you that he recently stopped taking valganciclovir.
What is the most likely diagnosis?Your Answer:
Correct Answer: Donor-acquired cytomegalovirus
Explanation:The fact that he has recently stopped taking his valganciclovir, anti-viral, is key to the answer to this question. This makes the answer quite plainly donor-acquired CMV infection over all of the other answer choices. He needs to stay on prophylaxis against this, particularly in the first 3 months after transplant. Symptoms and presentations of CMV infection can include fever, abdominal pain, diarrhoea, pneumonitis, hepatitis, hematologic abnormalities, retinitis, and esophagitis.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 42-year-old man presented with bloody diarrhoea and weight loss. Which one of the following would favour the diagnosis of Crohn’s disease on rectal biopsy?
Your Answer:
Correct Answer: Patchy inflammation
Explanation:The correct answer is patchy inflammation. Superficial ulceration as well as non-patchy inflammation are seen in ulcerative colitis (UC) in the colon and rectum; you would expect to see transmural inflammation in Crohn’s disease and it can be patchy and located anywhere from mouth to anus. Crypt distortion and crypt abscesses are seen in both UC and Crohn’s, however they are more common in ulcerative colitis.
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This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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A 69-year-old man on the cardiology ward who is hypotensive, and tachycardic is having profuse melaena. He was commenced on dabigatran 150mg bd by the cardiologists 48 hours earlier for non-valvular atrial fibrillation. Following appropriate resuscitation which of the following treatments is most likely to improve his bleeding?
Your Answer:
Correct Answer: Idarucizumab (Praxbind)
Explanation:Idarucizumab (Praxbind) is a newer antidote for dabigatran, the first of its kind. It is a monoclonal antibody fragment that binds dabigatrin with a higher affinity than thrombin. It is very expensive.
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This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 24-year-old woman who is known to have type 1 diabetes mellitus, presents with a three month history of diarrhoea, fatigue and weight loss. She has tried excluding gluten from her diet for the past 4 weeks and feels much better. She requests to be tested so that a diagnosis of coeliac disease can be confirmed. What is the most appropriate next step?
Your Answer:
Correct Answer: Ask her to reintroduce gluten for the next 6 weeks before further testing
Explanation:The patient likely has celiac’s disease, but if she has been avoiding gluten, a biopsy may be negative. Even though a biopsy is the gold standard for diagnosis, she will need to re-introduce gluten into her diet prior to undergoing the biopsy.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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Which is the most common type of inherited colorectal cancer:
Your Answer:
Correct Answer: Hereditary non-polyposis colorectal carcinoma
Explanation:Hereditary non-polyposis syndrome (HNPCC) is the most common type of inherited colorectal cancer. It often presents in younger and younger generations down a family. FAP presents with 100’s-1000’s of polyps and is less common. Li-Fraumeni syndrome and Fanconi syndrome are rare. For Peutz-Jeghers syndrome, the thing you will look for in the question stem is discoloured spots on the lips, this is classic.
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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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A 55-year-old lady, known with rheumatoid arthritis, complains of increasing numbness and tingling in her feet and hands. She has recently developed an ulcer on her left heel, after having burnt her foot in a hot bath. A number of depigmented areas are readily seen over her upper limbs.
She is currently taking low-dose prednisolone (7.5 mg daily), alendronic acid, lansoprazole, paracetamol, indomethacin, methotrexate and rituximab.
Her blood tests demonstrate:
Haemoglobin 9.9 g/l,
MCV 102 fl,
Platelets 410 x 109/L,
White blood cells 12.3 x 109/L,
Vitamin B12 97 pg/ml,
Folate 12.3ng/ml,
Random blood glucose 9.9 mmol/L,
Thyroid-stimulating hormone 4.7 mU/ml,
Thyroxine 12.8 pmol/L.
Which autoantibody would be most diagnostic for the underlying disease?Your Answer:
Correct Answer: Anti-intrinsic factor (IF)
Explanation:This clinical scenario describes pernicious anaemia. Anti-intrinsic factor (IF) antibodies are most specific for pernicious anaemia. Antigastric parietal cell antibodies have a higher sensitivity but are less specific for pernicious anaemia. The other antibodies listed are not related to pernicious anaemia. Anti-TTG is seen with Celiac’s disease, anti-TPO is seen with thyroid disease, GAD is seen with type I diabetes, but this does not explain her anaemia.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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A 20-year-old student presents to the university health service complaining of flu-like symptoms, lethargy and jaundiced sclerae and an inability to eat due to a sore throat. He remembered that his father may have suffered from a liver condition. On further questioning a history of intravenous drug use on two occasions is identified.
Investigations reveal:
Alanine transaminase (ALT) 23 U/l,
Aspartate transaminase (AST) 28 U/l,
Bilirubin 78 μmol/L,
Albumin 41g/l.
Which of the following diagnoses fits best with this clinical picture?Your Answer:
Correct Answer: Gilbert’s syndrome
Explanation:When a patient presents with an illness (unrelated to the liver) or a stressful event on the body, and develops asymptomatic jaundice, think Gilbert’s syndrome. It is autosomal dominant. It is an unconjugated hyperbilirubinemia from impaired glucuronyl transferase. Classically, Crigler-Najjar would be in infants, and it would be symptomatic. It is also an unconjugated hyperbilirubinemia.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Incorrect
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A 55-year-old man develops central abdominal pain a few hours after having an Endoscopic Retrograde Cholangiopancreatography (ERCP) performed. Investigations reveal the following:
Amylase: 545 u/dL,
Erect chest x-ray: Normal heart and lungs and no free air noted.
What is the most appropriate management?Your Answer:
Correct Answer: Intravenous fluids + analgesia
Explanation:A very common complication after ERCP is post-ERCP pancreatitis, which based on the clinical scenario , this man has. The treatment for this is pain control, lots of intravenous fluids, and traditionally bowel rest, although more recent evidence suggests early feeding is better.
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This question is part of the following fields:
- Gastroenterology
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Question 27
Incorrect
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A 25-year-old man presents with bloody diarrhoea associated with systemic upset. Blood tests show the following:
Hb 13.4 g/dL,
Platelets 467 * 109/L,
WBC 8.2 * 109/L,
CRP 89 mg/l
A diagnosis of ulcerative colitis is suspected. Which part of the bowel is most likely to be affected?Your Answer:
Correct Answer: Rectum
Explanation:The most COMMON site of inflammation from ulcerative colitis is the rectum, making this the correct answer. This is simply a fact you need to memorize. In general, ulcerative colitis only occurs in colorectal regions– nothing in the small bowel (unless there is backwash into the terminal ileum) and nothing further up the GI tract. In Crohn’s it can affect the entire GI tract from mouth to anus.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A 45-year-old female develops profuse watery diarrhoea with lower abdominal pain seven days after undergoing laparoscopic cholecystectomy. What is the most likely diagnosis?
Your Answer:
Correct Answer: Pseudomembranous colitis
Explanation:Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly. This woman would have received antibiotics prophylactically before her surgery, predisposing her to a possible c difficile infection. This is a much better answer choice than pseudo obstruction, abdominal sepsis, bile acid diarrhoea, and campylobacter gastroenteritis simply based on history of present illness.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 35-year-old gentleman with a history of alcohol excess presents to hospital with progressive abdominal distension. He now complains of early satiety and abdominal discomfort as a result of the distension. Examination reveals a significantly distended abdomen with shifting dullness. A diagnostic ascitic tap is performed and the fluid sent for analysis.
What is the most appropriate first line treatment for his ascites?Your Answer:
Correct Answer: Paracentesis
Explanation:The first line treatment for ascites that is symptomatic is paracentesis. If it is not symptomatic, treatment could be with salt and fluid restriction as well as spironolactone. If spironolactone maximum dosage is reached, you can use furosemide additionally. Amiloride is not a diuretic that is recommended in this case.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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A baby is born to a mother who is known to have chronic hepatitis B. The mothers latest results are as follows: HBsAg: Positive, HBeAg: Positive.
What is the most appropriate strategy for reducing the vertical transmission rate?Your Answer:
Correct Answer: Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
Explanation:The Green Book guidelines report in an active infection (HBeAg+ and HBsAg+) to give the vaccine as well as immunoglobulin. If antibodies are present it is not active infection (anti-Hbe) and then in that case only the vaccine, and no immunoglobulin, would be given. The presence of HBeAg means a person is infectious and can transmit to other people.
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This question is part of the following fields:
- Gastroenterology
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SESSION STATS - PERFORMANCE PER SPECIALTY
