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Question 1
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 2
Incorrect
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A 47-year-old man with a history of alcohol induced liver disease is admitted to the gastroenterology ward. He has developed tense ascites again and a plan is made to site an ascitic drain. His renal function after 2 days is as follows:
Na+ 131 mmol/L,
K+ 3.8 mmol/L,
Urea 12.2 mmol/L,
Creatinine 205 µmol/L,
Which of the following pathophysiological changes is most likely to be responsible for the declining renal function?Your Answer:
Correct Answer: Splanchnic vasodilation
Explanation:Hepatorenal syndrome is renal vasoconstriction that cannot overcome the effects of splanchnic vasodilation. Vasoactive mediators cause this splanchnic vasodilation, reducing SVR, which is sensed by the juxtaglomerular apparatus, activating the RAAS system, leading to renal vasoconstriction. However, the overall splanchnic vasodilation effect is greater than this renal vasoconstriction effect.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following:
Hb 13.9 g/dL,
WBC 6.1 *109/L,
Platelets 246 *109/L,
Bilirubin 33 µmol/L,
ALP 292 u/l
ALT 47 u/l
What is the most likely diagnosis?Your Answer:
Correct Answer: Primary biliary cirrhosis
Explanation:With a bilirubin of 33, automatically the diagnosis from the choices listed is primary biliary cirrhosis or autoimmune hepatitis, not SLE, mono, or Primary Sjogren’s Syndrome. With autoimmune hepatitis, however, you would not expect such a high bilirubin and would expect very high AST/ALT, which here is just mildly elevated. This makes primary biliary cirrhosis the most likely answer. The classic presentation is itching in a middle-aged woman. The dry mouth is likely due to Sicca Syndrome, which occurs in 70% of cases of PBC, but with these liver function tests, PBC is most the likely answer.
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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 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 5
Incorrect
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With respect to liver cirrhosis, which of the following statements is correct?
Your Answer:
Correct Answer: The final common pathway of hepatic fibrosis is mediated by the hepatic stellate cell
Explanation:The development of hepatic fibrosis reflects an alteration in the normally balanced processes of extracellular matrix production and degradation. [6] The extracellular matrix, the normal scaffolding for hepatocytes, is composed of collagens (especially types I, III, and V), glycoproteins, and proteoglycans. Increased collagen in the space of Disse (space b/w sinusoids and hepatocytes) leads to capillarization of sinusoids, and stellate cells also have contractile properties when activated. This is fibrosis processes. This can lead to the development of portal hypertension.
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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 28-year-old woman presents with intermittent episodes of diarrhoea, constipation, abdominal bloating and flatulence. Clinical examination is unremarkable. Faecal occult bloods are negative and haematological and biochemical investigations are unremarkable.
Which of the following is the next most appropriate management step?Your Answer:
Correct Answer: Trial of dairy-free diet
Explanation:The best next step is to try a dairy-free diet, many patients may develop this in their lifetime. IBS is a diagnosis of exclusion, and one would need to rule lactose intolerance out as a potential aetiology first. She is only 28, and without overt bleeding or signs/sxs/labs suggestive of obstruction or inflammation; colonoscopy, flex sig and a barium enema are not indicated.
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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 27 year old woman presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. Her inflammatory markers are normal. What is the most likely cause of her diarrhoea?
Your Answer:
Correct Answer: Bile Acid Malabsorption
Explanation:The question describes a patient who has had an ileal resection. Bile acids are reabsorbed in the distal ileum. Since this has been resected in this patient, one would expect her to have malabsorption of bile acids, causing her diarrhoea. This is a more likely correct answer than a Crohn’s flare, bacterial overgrowth, gastroenteritis, or tropical sprue, given the details included in the question prompt.
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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 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 9
Incorrect
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A 17-year-old boy presents with a 2 day history of colicky abdominal pain, vomiting and diarrhoea. He has been passing blood mixed with diarrhoea. He has no significant past medical history and takes no regular medication.
On examination he is pyrexial and clinically dehydrated. Cardiorespiratory and abdominal examinations are normal.
What is the most likely diagnosis?Your Answer:
Correct Answer: Campylobacter infection
Explanation:The patient has bloody diarrhoea that sounds like a food poisoning in the clinical scenario. Campylobacter is the most common cause of this in the United Kingdom. This is then followed by Salmonella and Shigella. The symptoms are usually self limiting. This is more likely to be bacterial from the food than a viral gastroenteritis.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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Which of the following forms of acute viral hepatitis has a much higher mortality in pregnant than non-pregnant females?
Your Answer:
Correct Answer: Hepatitis E
Explanation:Pregnant patient in a third world country with hepatitis: The answer is most likely Hepatitis E. The mortality for Hepatitis E in pregnant women is very high. It is transmitted faecal-orally. There is no hepatitis G. Hepatitis C, B, A are less likely to be the correct answer than E given it’s classic association with pregnancy and poor living conditions.
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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 53-year-old man is brought into the emergency department by the paramedics. He collapsed oat home suffering from a myocardial infarction and was subsequently resuscitated following a cardiac arrest. Blood tests show impaired liver function (ALT 1400 u/l). He is on a statin, and at his appointment last week his LFT was normal. There is nothing to note on examination and he is currently not complaining of any pain.
Given this man's presentation, what is the most likely cause of his impaired liver function tests?Your Answer:
Correct Answer: Ischaemic hepatitis
Explanation:When you have abnormal liver function tests after a cardiac arrest, the most likely aetiology, barring history that is known or given excluding this diagnosis, would be ischemia. Chronic alcohol abuse would not see an acute elevation like this. Hepatitis B is just unlikely given the clinical picture, ischemia is much more likely. The same is for Budd-Chiari syndrome (venous thrombosis) and Wilson’s disease.
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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 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 13
Incorrect
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A 32-year-old lady, known with a history of Type 1 diabetes presents to the clinic with increasing tiredness, mild upper abdominal discomfort and itching. The GP has arranged some investigations prior to her clinic visit.
Investigations;
Hb 13.2 g/dL,
WCC 5.0 x109/L,
PLT 240 x109/L,
Na+ 140 mmol/L,
K+ 4.9 mmol/L,
Creatinine 90 μmol/L,
HbA1c 8.3%,
Anti-Smooth muscle antibody: positive,
Immunoglobulins increased.
Which of the following would be the next appropriate investigation?Your Answer:
Correct Answer: Liver function testing
Explanation:The key to this question is anti-smooth muscle antibodies. This is a finding of autoimmune hepatitis, which can be seen in type I diabetics. This also fits with her clinical picture. If you know these two facts, you should get every question correct regarding autoimmune hepatitis. Liver function testing is the best answer, then and should be elevated to indicate inflammation of the liver. Hepatic US, CK, thyroid function testing, short synacthen test are not helpful in the diagnosis of autoimmune hepatitis.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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A 62-year-old lady is referred with painless jaundice and weight loss. Bilirubin is 214 mmol/L, alanine transaminase (ALT) 62 U/L, alkaline phosphatase (ALP) 605 U/L, albumin 34 g/L and prothrombin time 17 seconds. Ultrasound of the abdomen shows a grossly dilated biliary tree and a dilated pancreatic duct, but no mass is seen.
What is the next most appropriate step in her management?Your Answer:
Correct Answer: Abdominal CT scan
Explanation:This scenario is suggestive of a pancreatic head mass with obstructive jaundice and US showing a ‘double duct’ sign. A CT Scan would be recommended to evaluate for a pancreatic head mass. If a mass was found, the next step would then be to do an ERCP with EUS to obtain a biopsy of the mass for tissue diagnosis. Laparoscopy would not be recommended. CA19-9 would not be diagnostic.
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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 33-year-old lady who is known hepatitis C positive comes to your clinic. She is 28 weeks pregnant and her obstetrician wants you to assess her and provide medical advice for the mother and child.
Which of the following statements concerning hepatitis C are most accurate in her case?Your Answer:
Correct Answer: Breast-feeding does not increase the risk of transmission
Explanation:Breast feeding has not been shown to increase the risk of transmission of HCV from mother to baby. This is simply a fact to memorize. The other answer choices are not the most accurate as there is no evidence-proven way to decrease the chance that baby will get HCV from the mother during the birth. About 5 out of every 100 infants born to HCV infected mothers become infected.
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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 56-year-old woman has a family history of haemochromatosis and is homozygous for the C282Y mutation. Her ferritin is 927 mg/L (normal range 15-150), haemoglobin 12.5 g/dL (normal range 11.5-16) and aspartate aminotransferase 87 U/L (normal range <40).
Which is the best course of action?Your Answer:
Correct Answer: Weekly venesection to drop her ferritin into the low-normal range
Explanation:Venesection should be done (essentially blood-letting) to decrease the too-high ferratin level. IV Desterrioxamine would have the opposite effect. ASA does not have to do with ferritin. You do not just watch this and recheck. And you do not want to make the patient anaemic.
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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 48-year-old man with a two year history of ulcerative colitis, has been receiving parenteral nutrition for 4 months. He has developed a dermatitis and has noticed some loss of hair. Serum biochemistry shows a marginally raised glucose concentration and a lower alkaline phosphatase activity.
Which of the following is the most likely?Your Answer:
Correct Answer: Zinc deficiency
Explanation:Zinc deficiency can present with alopecia, dermatitis, poor growth, increased susceptibility to infection, and cognitive deficiency. Magnesium deficiency can cause fatigue, cramping and an irregular EKG. Copper deficiency can present with fatigue and weakness. Chromium deficiency can present with hyperglycaemia.
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This question is part of the following fields:
- Gastroenterology
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Question 19
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 20
Incorrect
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A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?
Your Answer:
Correct Answer: Transferrin saturation 78% (20-50)
Explanation:A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.
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This question is part of the following fields:
- Gastroenterology
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Question 21
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 22
Incorrect
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A 50 year old man undergoes a colonoscopy due to the finding of blood in his stools. The colonoscopy revealed four polyps which were variable in size from one at 0.5cm, 2 at approximately 1.5cm and one at 2 cm.
When should this patient have a follow up colonoscopy?Your Answer:
Correct Answer: 3 years
Explanation:For the question, you need knowledge of the British Society of Gastroenterology guidelines. This patient has 3-4 adenomas with 3 of them > 1 cm. This places him at medium risk and the recommendation if for a 3-year follow up period.
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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 one of the following is not associated with non-alcoholic steatohepatitis?
Your Answer:
Correct Answer: Type 1 diabetes mellitus
Explanation:There are two types of Non-alcoholic fatty liver disease (NAFLD); simple fatty liver and non-alcoholic steatohepatitis (NASH). Simple fatty liver and NASH are two separate conditions.
Simple fatty liver, also called non-alcoholic fatty liver (NAFL), is a form of NAFLD in which you have fat in your liver but little or no inflammation or liver cell damage. Simple fatty liver typically does not progress to cause liver damage or complications.
Non-alcoholic steatohepatitis (NASH)
NASH is a form of NAFLD in which you have hepatitis and liver cell damage, in addition to fat in your liver. Inflammation and liver cell damage can cause fibrosis, or scarring, of the liver. NASH may lead to cirrhosis or liver cancer. Type I diabetes is not associated with NASH (non-alcoholic steatohepatitis), but type II diabetes is. Hyperlipidaemia, obesity, sudden weight loss/starvation and jejunoileal bypass are all associated with NASH. This is the most common cause of liver disease in the developed world. -
This question is part of the following fields:
- Gastroenterology
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Question 24
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 25
Incorrect
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A 76-year-old woman is admitted with a productive cough and pyrexia. Chest x-ray shows a pneumonia and she is commenced on intravenous ceftriaxone. Following admission a stool sample is sent because of diarrhoea. This confirms the suspected diagnosis of Clostridium difficile diarrhoea and a 10-day course of oral metronidazole is started. After 10 days her diarrhoea is ongoing but she remains clinically stable. What is the most appropriate treatment?
Your Answer:
Correct Answer: Oral vancomycin for 14 days
Explanation:When a patient fails treatment with metronidazole (Flagyl) treatment, the next course of action is to change to oral vancomycin, which is shown to be effective in the treatment of c diff colitis. Oral rifampicin is not a treatment for c diff. Oral metronidazole is not resolving her symptoms so is not the correct answer. clindamycin is a cause of c diff colitis, not a treatment. IV Vanc is not active in the gut so is not the treatment; oral is active in the gut.
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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 42-year-old man with alcoholic liver disease is admitted with pyrexia. He has been unwell for the past three days and has multiple previous admissions before with variceal bleeding. Examination shows multiple stigmata of chronic liver disease, ascites and jaundice.
Paracentesis is performed with the following results: Neutrophils 487 cells/ul.
What is the most appropriate treatment?Your Answer:
Correct Answer: Intravenous cefotaxime
Explanation:This describes a clinical scenario of spontaneous bacterial peritonitis. The diagnosis is made when fluid removed (ascites) is found to have > 250/mm cubed of PMNs (polymorphonuclear leukocytes). Cefotaxime or another third generation cephalosporin is the treatment of choice.
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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 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 28
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 29
Incorrect
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In which part of the body is conjugated bilirubin metabolised to urobilinogen?
Your Answer:
Correct Answer: Large intestine
Explanation:Urobiligen is produced by the action of bacteria on bilirubin in the intestine. As a reminder, unconjugated bilirubin becomes conjugated in the hepatocyte. Conjugated bilirubin goes through enterohepatic circulation. About half of the urobiligen is reabsorbed and excreted by the kidneys in the urine. The rest is converted to stercobilinogen –> stercobilin, which is excreted in stool, giving it its brown colour.
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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 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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SESSION STATS - PERFORMANCE PER SPECIALTY
