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Question 1
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: Urea breath test for Helicobacter pylori
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 2
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: Check anti-endomysial antibodies
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 3
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: Acute therapy for Crohn’s Disease
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 4
Correct
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A 36-year-old lady presents to the emergency department with right upper quadrant pain. She has also noticed that her skin seems slightly yellower over the last week or so and you notice a yellow tinge to her sclera. On further questioning, she complains of itching of her arms. Her only past medical history of note includes ulcerative colitis for which she takes mesalazine. Given her presentation, what is the best investigation to diagnose the most likely underlying condition?
Your Answer: ERCP (endoscopic retrograde cholangiopancreatography)
Explanation:With biliary obstructive symptoms in a patient with ulcerative colitis, one should immediately think of primary sclerosing cholangitis (PSC). PSC is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic ducts. The best diagnostic test for PSC is ERCP. ANCA antibiotics may be positive, but not the best test to DIAGNOSE THE CONDITION. The same can be said of serum transaminase levels– they will be abnormal but nonspecific. While a liver ultrasound may be helpful, it is not the best test. Liver biopsy would be used to stage the PSC later.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Correct
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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: 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 6
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: Watchful waiting, with 6 monthly checks of the ferritin level
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 7
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: Hepatitis B
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 8
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: Superficial ulceration
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 9
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: Primary Sjogren's syndrome
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 10
Incorrect
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Which of the following is most commonly associated with the development of pseudomembranous colitis?
Your Answer: Erythromycin
Correct Answer: Cefuroxime
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.
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This question is part of the following fields:
- Gastroenterology
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