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Question 1
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 2
Incorrect
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A 26-year-old office worker presents with a 3 year history of epigastric pain, especially 30 minutes after eating. This is associated with nausea and belching. She also describes constipation with occasional explosive diarrhoea. The stools are normally hard with mucus and she needs to strain with every motion. Abdominal pain is relieved after defecation but abdominal bloating persists. She wakes up an hour earlier each morning to finish her breakfast in order to prevent vomiting. She has missed work on a few occasions and feels that her weight has fluctuated. Past medical history includes scarlet fever. She is not on any regular medications except intermittent laxatives over the counter. Abdominal examination is normal. Rectal examination reveals an anal fissure. Investigation results: Haemoglobin (Hb 13.1 g/dL, White blood count (WBC) 6.0 × 109/L, Platelets 180× 109/L, Mean cell volume (MCV) 87 fL, International normalised ratio (INR) 1.0, Na+ 136 mmol/L, K+ 3.9 mmol/L, Urea 3.7 mmol/L, Creatinine 70 μmol/L, Albumin 39 glL. Liver function test normal. Anti-endomysial antibody negative. Thyroid function test normal. Gastroscopy normal. Flexible sigmoidoscopy and biopsy normal. Abdominal and pelvic ultrasound scans are normal. What is the most likely diagnosis to account for her symptoms?
Your Answer:
Correct Answer: Overlap irritable bowel syndrome and functional dyspepsia
Explanation:This is most likely describing irritable bowel syndrome (IBS). Symptoms are either diarrhoea, constipation, or both, abdominal pain, bloating, of varying duration. It is a functional, not an 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.
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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 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 4
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 5
Incorrect
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An 18 year old prospective medical student is tested for hepatitis B. Her liver tests show alanine transaminase (ALT) 120 U/L and serology shows her to be positive for HBsAg, HBcAb and HBeAg, with a viral load of 105 genome equivalents/mL. A liver biopsy is reported as showing early fibrosis with evidence of moderate inflammation. Which of the following treatments should be offered?
Your Answer:
Correct Answer: Interferon alfa 2b
Explanation:Interferon alfa alone, not interferon alfa and ribavirin, has been shown to achieve HBeAg seroconversion for patients with HBeAg-positive chronic hepatitis B.
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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 attends for review. She has a past history of a perianal abscess but nothing else of note. During the past few months she has twice presented to A&E complaining of grumbling abdominal pain. In addition, she has suffered intermittent episodes of bloody diarrhoea. Microcytic anaemia is found on blood testing and she has mild hypokalaemia. Albumin is reduced but other liver function tests are unremarkable. Barium imaging reveals a small bowel stricture with evidence of mucosal ulceration extending into the colon, interspersed with normal looking mucosa ‘skipping’. Given this clinical picture, which is the most likely diagnosis?
Your Answer:
Correct Answer: Crohn’s disease
Explanation:The correct answer based on the clinical scenario is Crohn’s disease. Associated with this disease are abscesses and fistulas in the anorectal region, skip lesions, cobble stoning, stricturing, granulomas, and crypt distortion. The other answer choices are not correct. How to rule out ulcerative colitis: it only involves ileocolorectal regions, and this is above that level. You will not see crypt distortion and cobble stoning; it is a more superficial process.
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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 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 8
Incorrect
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A 53-year-old woman presents with upper GI haemorrhage. She has a history of rheumatoid arthritis for which she is managed with low dose prednisolone, diclofenac and codeine phosphate. On examination in the Emergency ward her BP is 90/60 mmHg, pulse 100/min. You fluid resuscitate her and her BP improves to 115/80 mmHg, with a pulse of 80/min. Investigations; Hb 10.4 g/dL, WCC 6.1 x109/L, PLT 145 x109/L, Na+ 139 mmol/L, K+ 4.9 mmol/L, Creatinine 180 μmol/L, ECG – Lateral ST depression , Upper GI endoscopy reveals a large bleeding ulcer on the posterior aspect of the duodenum. It cannot be easily reached with the endoscope, and you decide to attempt embolization. Which of the following is the artery that should be targeted?
Your Answer:
Correct Answer: Posterior superior Pancreaticoduodenal artery
Explanation:The most common location for a duodenal ulcer bleed is the posterior duodenum (remember: posterior bleeds, anterior perforates). The perfusion to this area is most specifically from the posterior superior pancreaticoduodenal artery.
The anterior superior pancreaticoduodenal artery supplies the anterior region. The gastroepiploic artery supplies mostly the stomach. The splenic artery goes, obviously, toward the spleen, in the other direction. The gastroduodenal artery is a branch of the celiac artery, and it’s branches are the anterior superior pancreaticoduodenal artery and posterior superior pancreaticoduodenal artery.
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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 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 10
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 11
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 12
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 13
Incorrect
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A 54-year-old woman, with a long history of inflammatory bowel disease presents to his GP with abnormal liver function tests. She has a raised alkaline phosphatase level but no symptoms of liver disease. Which of the following options is the best set of investigations to confirm the diagnosis?
Your Answer:
Correct Answer: MRCP and liver biopsy
Explanation:In a patient with abnormal LFTs and UC, think primary sclerosing cholangitis (PSC). MRCP and liver biopsy is the best answer. MRCP will show classically beads on a string – intra and extrahepatic stricturing and dilation. Remember this finding!! Liver biopsy is required for official diagnosis (need tissue!).
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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 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 15
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 16
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 17
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 18
Incorrect
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Hepatitis C is what kind of virus?
Your Answer:
Correct Answer: A variable RNA virus
Explanation:Hepatitis C is a single-stranded positive sense RNA virus. It is variable because of the high rate of error of RNA-dependent RNA polymerase and the pressure from the host immune system has caused HCV to evolve and develop seven genetic lineages.
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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 51-year-old man was brought to the Emergency department for loose stools. He was dehydrated, weak and in shock. He had previously been complaining of large stool volumes for a one month period. Stool colour was normal. There was no history of laxative abuse and no significant past medical history. What is the most likely diagnosis?
Your Answer:
Correct Answer: VIPoma
Explanation:Given that the patient has had large amount, high volume watery diarrhoea in an acute period of time, from the answer choices given, this narrows the diagnosis down to VIPoma or carcinoid syndrome. You would expect with carcinoid syndrome for there to be periodic episodes of diarrhoea, though, with a description of flushing, additionally, associated with these episodes. Thus, VIPoma is the most likely answer here. VIPomas are known to cause hypokalaemia from this large amount of watery diarrhoea. Stool volume should be > 700 ml/day.
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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 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 21
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 22
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 23
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 24
Incorrect
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A 32-year-old man, originally from Pakistan, was admitted with ascites and weight loss. The protein level on ascitic tap was 9 g/l. Which of the following is the most likely cause of this presentation?
Your Answer:
Correct Answer: Hepatic cirrhosis
Explanation:This is a low protein level, indicating the fluid is transudative. The only answer choice that is a transudative fluid is in hepatic cirrhosis. Exudative fluid would be seen in tuberculous peritonitis, peritoneal lymphoma, with liver mets, and with intra-abdominal malignancy.
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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 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 26
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 27
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 28
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 29
Incorrect
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A 26-year-old lawyer presents to the gastroenterology clinic with weight loss, intermittent oily diarrhoea and malaise. Blood testing reveals folate and iron deficiency. There is also mild hypocalcaemia on biochemistry screening. She has type-1 diabetes of 10 years’ duration and is stable on a basal bolus insulin regime, otherwise her past medical history is unremarkable. Which of these antibody tests is most specific for making a diagnosis?
Your Answer:
Correct Answer: Anti-tissue transglutaminase antibodies
Explanation:The prompt is suggestive of celiac disease as an aetiology. The antibody that is used primarily to suggest this diagnosis is anti-tissue transglutaminase antibody. You can also check anti-gliadin and anti-endomyseal antibodies, although anti-TTG antibodies are now the preferred test. To get an official diagnosis you must have a tissue diagnosis (biopsy). Anti-smooth muscle antibodies would be seen in autoimmune hepatitis. Anti-thyroid antibodies are not at all related to this, and are associated with thyroid. Anti-nuclear antibodies are non-specific.
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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 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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SESSION STATS - PERFORMANCE PER SPECIALTY
