Gastroenterology Flashcards
1
Q
According to current national guidelines, which ONE of the following is considered the FIRST choice serological test to diagnose coeliac disease?
A. Immunoglobulin A (IgA) tissue transglutaminase (tTGA)
B. Immunoglobulin A (IgA) endomysial antibodies (EMA)
C. Immunoglobulin A (IgA) anti-gliadin antibodies (AGA)
D. Human leukocyte antigen (HLA) DQ2 / DQ8
E. Immunoglobulin A (IgA)
A
Answer: A. Immunoglobulin A (IgA) tissue transglutaminase (tTGA)
Justification: IgA tissue transglutaminase is the first-choice serological test, with IgA EMA used if IgA tTGA is weakly positive.
Resource: NICE. Coeliac Disease: recognition, assessment and management. NG20. 2015.
2
Q
Which of the following is the SINGLE MOST likely food to trigger an abnormal mucosal immune response in coeliac disease?
A. Egg
B. Milk
C. Cheese
D. Peanut
E. Rye
A
Answer: E. Rye
Justification: Dietary proteins (glutens) are present in barley, rye and wheat.
Resource: RCGP. Diagnosis and management of coeliac disease and its immunological comorbidities.
3
Q
A 27-year-old man had acute gastroenteritis six weeks ago while on holiday in Morocco. He now has early morning low back pain improving with movement.
What is the SINGLE MOST appropriate initial treatment?
A. Metronidazole
B. Codeine phosphate
C. Naproxen
D. Ciprofloxacin
E. Prednisolone
A
Answer: C. Naproxen
Justification: Suggests reactive arthritis. First-line treatment is a non-steroidal anti-inflammatory drug.
Resource: RCGP Learning.
4
Q
A 47-year-old man has recurrent anal pain on defaecation with fresh rectal bleeding. He has tried topical anaesthetic ointment without relief.
What is the SINGLE MOST appropriate initial topical medication to prescribe?
A. Miconazole 2% cream
B. Ibuprofen gel 5%
C. Cinchocaine hydrochloride 0.5%, hydrocortisone 0.5% ointment
D. Glyceryl trinitrate (GTN) ointment 0.4%
E. Diltiazem cream 2%
A
Answer: D. Glyceryl trinitrate (GTN) ointment 0.4%
Justification: For adults with primary anal fissure not resolving, GTN ointment is recommended.
Resource: NICE CKS. Anal fissure management.
5
Q
A 43-year-old woman has severe epigastric pain radiating to the back, relieved by sitting forward. Gallstones confirmed on ultrasound.
What is the SINGLE MOST likely diagnosis?
A. Biliary colic
B. Acute cholecystitis
C. Ascending cholangitis
D. Acute pancreatitis
E. Acute hepatitis
A
Answer: D. Acute pancreatitis
Justification: Gallstones are a common cause of pancreatitis. Pain relieved by sitting forward is typical.
Resource: RCGP Learning.
6
Q
A 54-year-old man has persistently abnormal LFTs with no obvious cause found.
What is the SINGLE MOST appropriate next management step?
A. Referral to specialist liver clinic
B. Annual monitoring of LFTs
C. DEXA scan
D. Upper GI endoscopy
E. CT scan of abdomen
A
Answer: A. Referral to specialist liver clinic
Justification: Persistently abnormal LFTs require specialist assessment for liver fibrosis.
Resource: NICE Guidance on abnormal liver tests.
7
Q
A 60-year-old woman with RA and past NSAID-related duodenal ulcer wants to restart NSAIDs.
What is the SINGLE MOST appropriate treatment option?
A. Diclofenac and misoprostol
B. Must not take any NSAID again
C. Naproxen and ranitidine
D. Ibuprofen and omeprazole
E. Celecoxib and lansoprazole
A
Answer: E. Celecoxib and lansoprazole
Justification: For high ulcer risk, combine COX-2 inhibitor with PPI.
Resource: NICE. Gastro-Oesophageal Reflux Disease and Dyspepsia. CG184. 2014 (updated 2019).
8
Q
A 22-year-old has recurrent bloody diarrhoea and erythema nodosum.
What is the SINGLE gold standard diagnostic test?
A. Sigmoidoscopy and biopsy
B. CT colonography
C. Faecal elastase
D. Faecal calprotectin
E. Colonoscopy and biopsy
A
Answer: E. Colonoscopy and biopsy
Justification: Gold standard for ulcerative colitis diagnosis.
Resource: Andrews C. Ulcerative colitis. InnovAiT 2019; 12(9): 501–506.
9
Q
A 30-year-old woman has flushing, dizziness, diarrhoea and facial rash after eating tuna.
What is the SINGLE MOST likely diagnosis?
A. Botulism
B. Scombroid food poisoning
C. Staphylococcal food poisoning
D. Campylobacter enteritis
E. Food allergy
A
Answer: B. Scombroid food poisoning
Justification: Caused by histamine release after eating spoiled scombroid fish (e.g. tuna).
Resource: RCGP Learning.
10
Q
A 30-year-old woman with microcytic anaemia and abdominal symptoms is tested for coeliac disease.
What is the FIRST choice serological test used?
A. IgG EMA
B. HLA DQ2/DQ8
C. IgG tTGG
D. IgA EMA
E. IgA tTGA
A
Answer: E. IgA tissue transglutaminase (tTGA)
Justification: First-line coeliac test; followed by EMA if equivocal or IgA deficient.
Resource: NICE. Coeliac Disease: NG20. 2015.
11
Q
Which one of the following statements is TRUE regarding non-alcoholic fatty liver disease (NAFLD)?
A. It is commonly manifest by an isolated raised alkaline phosphatase
B. The prognosis is benign
C. Ultrasound can accurately assess any hepatic fibrosis
D. ALT twice normal, stable over a year with steatosis on US can be managed in primary care
E. People with type 1 diabetes are especially at risk
A
Answer: D. ALT twice normal, stable over a year with steatosis on US can be managed in primary care
Justification: Stable liver enzymes and imaging support primary care management in selected low-risk NAFLD.
Resource: NICE. NAFLD: assessment and management. NG49. 2016.
12
Q
According to national guidelines, which of the following patients should be offered serological testing for coeliac disease?
A. Acromegaly
B. Cushing’s disease
C. Insulinoma
D. Type 1 diabetes mellitus
E. Type 2 diabetes mellitus
A
Answer: D. Type 1 diabetes mellitus
Justification: NICE recommends testing at diagnosis of type 1 diabetes.
Resource: NICE. Coeliac Disease: recognition, assessment and management. NG20. 2015.
13
Q
A 52-year-old woman presents with a tender lump in the groin, inferior and lateral to the pubic tubercle.
What is the SINGLE MOST likely diagnosis?
A. Inguinal lymphadenopathy
B. Inguinal hernia
C. Spigelian hernia
D. Saphena varix
E. Femoral hernia
A
Answer: E. Femoral hernia
Justification: More common in females; high risk of strangulation; located inferior/lateral to pubic tubercle.
Resource: RCGP Learning.
14
Q
According to NICE, which condition should be tested for coeliac disease?
A. Sjögren’s syndrome
B. Graves’ disease
C. Down syndrome
D. Addison’s disease
E. Cushing’s syndrome
A
Answer: B. Graves’ disease
Justification: NICE includes autoimmune thyroid disease as an indication for testing.
Resource: NICE. Coeliac Disease: NG20. 2015.
15
Q
For which of the following patients is URGENT direct access upper GI endoscopy recommended?
A. 50-year-old man with treatment resistant dyspepsia
B. 43-year-old man with recurrent dyspepsia
C. 60-year-old woman with vomiting and lower abdominal pain
D. 58-year-old man with nausea and thrombocytosis
E. 48-year-old woman with dysphagia
A
Answer: E. 48-year-old woman with dysphagia
Justification: Urgent referral for any adult with dysphagia regardless of age.
Resource: NICE. Suspected Cancer: recognition and referral. NG12. 2015 (updated 2021).
16
Q
A 35-year-old man was treated for H. pylori 8 weeks ago and is now asymptomatic.
What is the SINGLE MOST appropriate next step in management?
A. Endoscopic biopsy
B. No testing required
C. Breath test
D. Stool antigen
E. Serology
A
Answer: B. No testing required
Justification: NICE does not recommend routine testing for eradication unless symptoms persist.
Resource: NICE CG184; RCGP Dyspepsia EKU15 (2022).
17
Q
A 30-year-old woman with hepatitis C drinks 36 units of alcohol per week.
What is the SINGLE MOST relevant factor increasing her risk of cirrhosis?
A. BMI
B. Alcohol consumption
C. Female gender
D. Age at diagnosis
E. Smoking history
A
Answer: B. Alcohol consumption
Justification: Alcohol significantly increases progression to cirrhosis in hepatitis C.
Resource: RCGP Learning.
18
Q
A 50-year-old man has reflux symptoms. He takes amlodipine and bendroflumethiazide.
What is the SINGLE MOST appropriate intervention?
A. Cease amlodipine
B. Cease bendroflumethiazide
C. Start Gaviscon Advance
D. Start lansoprazole
E. Start triple therapy
A
Answer: A. Cease amlodipine
Justification: Review medications that may be contributing to symptoms before initiating PPI.
Resource: NICE CG184; RCGP Dyspepsia EKU15 (2022).
19
Q
A woman with NAFLD asks about risk of progressive liver disease.
What is the SINGLE BEST estimate of her risk?
A. 1%
B. 5%
C. 10%
D. 15%
E. 20%
A
Answer: B. 5%
Justification: 5–6% of NAFLD patients develop progressive disease such as NASH.
Resource: NICE. NAFLD: assessment and management. NG49. 2016.
20
Q
A 68-year-old man is referred urgently for suspected pancreatic cancer.
What is the SINGLE MOST reliable investigation for detection?
A. Clinical examination
B. CT scan
C. CA 19-9
D. Exploratory laparotomy
E. Abdominal ultrasound
A
Answer: B. CT scan
Justification: Best method for detecting and staging pancreatic cancer.
Resource: RCGP Learning.
21
Q
A 68-year-old woman has severe pruritus and mild jaundice following co-amoxiclav. LFTs: bilirubin 68, ALP 454, GGT 268, ALT 40.
Which is the SINGLE MOST likely diagnosis?
A. Gilbert’s syndrome
B. Steatohepatitis
C. Hepatitis C
D. Adverse drug effect
E. Haemochromatosis
A
Answer: D. Adverse drug effect
Justification: Cholestatic LFT pattern (high ALP, GGT) following antibiotic use suggests drug-induced liver injury.
Resource: RCGP Learning
22
Q
Which one of the following is the SINGLE MOST likely symptom of opioid-induced bowel dysfunction (OIBD)?
A. Dysphagia
B. Diarrhoea
C. Sialorrhoea
D. Taste disturbance
E. Abdominal pain
A
Answer: E. Abdominal pain
Justification: OIBD includes symptoms such as bloating, hard stools, delayed digestion, anorexia, and abdominal pain.
Resource: RCGP Learning
23
Q
Akiba, 44, with BMI 36, elevated ALT, AST, and GGT, normal bilirubin and ALP, ultrasound shows echogenic liver.
What is the SINGLE MOST likely diagnosis?
A. Glandular fever
B. Non-alcoholic fatty liver disease
C. Autoimmune hepatitis
D. Haemochromatosis
E. Malignancy
A
Answer: B. Non-alcoholic fatty liver disease
Justification: Obesity, raised ALT/AST, and echogenic liver on ultrasound are classic for NAFLD.
Resource: RCGP Learning
24
Q
A 24-year-old woman with Crohn’s disease and recurrent flare-ups and fistulas despite steroids and azathioprine.
What is the SINGLE MOST appropriate treatment option?
A. Infliximab
B. Budesonide
C. Sulfasalazine
D. Ciclosporin
E. Mesalazine
A
Answer: A. Infliximab
Justification: NICE recommends biologics (infliximab) for severe, refractory or fistulising Crohn’s disease.
Resource: NICE NG129. Crohn’s Disease: management (2019).
25
Which is the SINGLE MOST likely malignant complication of untreated coeliac disease?
A. Osteosarcoma
B. Renal cancer
C. Leukaemia
D. Lymphoma
E. Breast cancer
Answer: D. Lymphoma
Justification: Coeliac disease increases risk of intestinal lymphoma and small bowel adenocarcinoma.
Resource: RCGP. Diagnosis and management of coeliac disease.
26
A 22-year-old man has abdominal pain relieved by defecation.
Which TWO additional symptoms MOST support IBS diagnosis?
A. Altered stool passage
B. Rectal bleeding
C. Symptoms worse after eating
D. Vomiting
E. Weight loss
Answer: A. Altered stool passage; C. Symptoms worse after eating
Justification: NICE defines IBS as pain relieved by defecation with ≥2 of: altered stool passage, bloating, mucus in stool, symptoms triggered by food.
Resource: NICE CG61 (updated 2017).
27
51-year-old woman with ulcerative colitis, diarrhoea and bleeding controlled on sulfasalazine. Still has pain.
What is the SINGLE MOST appropriate pain relief?
A. Ibuprofen
B. Celecoxib
C. Codeine
D. Paracetamol
E. Tramadol
Answer: D. Paracetamol
Justification: NSAIDs and opiates should be avoided in IBD due to risk of flare or toxic megacolon.
Resource: RCGP Learning
28
A 60-year-old woman with Crohn’s disease on azathioprine requires shared care.
Which monitoring is correct?
A. Liver + thyroid function
B. Liver function only
C. Full blood count, renal, and liver function
D. Renal function only
E. No monitoring
Answer: C. Full blood count, renal, and liver function
Justification: Azathioprine monitoring includes FBC, LFTs and renal function.
Resource: BNF. Azathioprine
29
39-year-old man with painless rectal bleeding for 3 weeks on wiping. No change in bowel habit.
What is the SINGLE MOST likely diagnosis?
A. IBS
B. IBD
C. Haemorrhoids
D. Anal fissure
E. Angiodysplasia
Answer: C. Haemorrhoids
Justification: Bleeding on wiping without pain or change in habit is typical of haemorrhoids.
Resource: RCGP Learning
30
27-year-old man had gastroenteritis 6 weeks ago. Now has early morning low back pain improved by movement.
What is the SINGLE MOST appropriate initial treatment?
A. Codeine phosphate
B. Metronidazole
C. Prednisolone
D. Naproxen
E. Ciprofloxacin
Answer: D. Naproxen
Justification: Likely reactive arthritis; NSAIDs are first-line.
Resource: RCGP Learning
31
55-year-old woman with diarrhoea and weight loss. Suspect coeliac disease.
What is the MOST appropriate first-line investigation?
A. Small bowel biopsy
B. Serum IgG DGP
C. Serum IgG EMA
D. Serum IgA EMA
E. Serum IgA tTGA
Answer: E. Serum IgA tTGA
Justification: First-line coeliac test; biopsy follows positive serology.
Resource: Eggink A et al. Coeliac disease. InnovAiT 2023.
32
45-year-old man with fatty liver on ultrasound and ALT 58 IU/L.
Which test should be regularly monitored in ADDITION to LFTs?
A. Autoantibody screen
B. Full blood count
C. HbA1c
D. Thyroid function
E. Urea and electrolytes
Answer: C. HbA1c
Justification: NAFLD is associated with insulin resistance and diabetes.
Resource: RCGP Learning
33
24-year-old woman with lower abdo pain, bloody diarrhoea and urgency for 2 weeks. Similar past episodes.
What is the SINGLE MOST likely diagnosis?
A. Diverticular disease
B. Rectal polyps
C. Salmonella
D. Haemorrhoids
E. Ulcerative colitis
Answer: E. Ulcerative colitis
Justification: Relapsing-remitting bloody diarrhoea, urgency and nocturnal symptoms suggest UC.
Resource: RCGP Learning
34
63-year-old woman with groin lump lateral and below pubic tubercle.
What is the SINGLE MOST likely diagnosis?
A. Femoral hernia
B. Inguinal lymph node
C. Lumbar hernia
D. Direct inguinal hernia
E. Indirect inguinal hernia
Answer: A. Femoral hernia
Justification: Occurs below and lateral to pubic tubercle, more common in females.
Resource: Rance C, Jones A. InnovAiT 2021.
35
Which vitamin deficiency is MOST associated with coeliac disease?
A. Vitamin A
B. Vitamin B6
C. Vitamin D
D. Vitamin E
E. Vitamin K
Answer: C. Vitamin D
Justification: Malabsorption in coeliac disease commonly causes vitamin D deficiency.
Resource: RCGP. Coeliac disease and its comorbidities.
36
40-year-old woman with IBS has abdominal pain relieved by defecation.
Which is a 'red flag' symptom requiring referral?
A. Blood in stools
B. Incomplete evacuation
C. Constipation
D. Loose stools
E. Mucus in stools
Answer: A. Blood in stools
Justification: Red flags include weight loss, anaemia, blood in stool, age >50, change in habit.
Resource: NICE CG61 (2017).
37
Young woman with diarrhoea and weight loss. IgA tTGA and EMA negative.
What is the NEXT most useful test if suspicion remains?
A. Serum Free Light Chains
B. IgE
C. Paraproteins
D. IgG
E. IgM
Answer: D. IgG
Justification: IgA deficiency can cause false negative results; IgG tTGA or EMA is next step.
Resource: RCGP Learning
38
34-year-old woman with IBS not responding to general diet/lifestyle changes.
What is the MOST appropriate diet to try next?
A. Low glycaemic-index
B. Atkins
C. Mediterranean
D. Low FODMAP
E. Paleo
Answer: D. Low FODMAP
Justification: Recommended in patients unresponsive to general dietary advice.
Resource: NICE CG61 (2017).
39
35-year-old man on lansoprazole for dyspepsia. Never tested for H. pylori.
What is the SINGLE MOST appropriate testing advice?
A. Continue PPI and test with serology
B. Continue PPI and stool test
C. Continue PPI, breath test in 2 weeks
D. Stop PPI, breath test after 2 weeks
E. Switch to ranitidine for 4 weeks, then stool test
Answer: D. Stop PPI, breath test after 2 weeks
Justification: PPI affects test accuracy; stop for at least 2 weeks before testing.
Resource: RCGP Dyspepsia & GORD EKU15.
40
24-year-old with GI symptoms. Which test best differentiates IBD from IBS?
A. Faecal calprotectin
B. Faecal elastase
C. Stool culture
D. ESR
E. CRP
Answer: A. Faecal calprotectin
Justification: Best non-invasive marker of gut inflammation in IBD vs IBS.
Resource: Qazi U. InnovAiT 2022.
41
A 50-year-old woman with coeliac disease presents with an itchy rash and poor compliance with her gluten-free diet.
What is the SINGLE MOST appropriate management for this patient’s rash?
A. Immunoglobulins
B. Tacrolimus
C. Emollients
D. Gluten-free diet
E. Aciclovir
Answer: D. Gluten-free diet
Justification: Dermatitis herpetiformis responds to a gluten-free diet, though resolution may take up to a year. Dapsone may be considered as an adjunct, with monitoring for haemolysis.
Resource: RCGP Learning
42
A 57-year-old man with dyspepsia and nausea for two months has thrombocytosis. No weight loss or alarm symptoms.
What is the SINGLE MOST appropriate management option?
A. High-dose omeprazole
B. Lifestyle changes
C. Non-urgent direct-access endoscopy referral
D. Urgent 2WW referral
E. H. pylori stool antigen test
Answer: C. Non-urgent direct-access endoscopy referral
Justification: NICE recommends endoscopy in patients over 55 with raised platelets and dyspepsia symptoms.
Resource: NICE NG12 (2023)
43
A 19-year-old woman with 4-week history of bloody diarrhoea and severe abdominal pain. Abdo x-ray shows toxic megacolon.
What is the SINGLE MOST likely underlying diagnosis?
A. Coeliac disease
B. Colorectal cancer
C. Crohn’s disease
D. Salmonella gastroenteritis
E. Ulcerative colitis
Answer: E. Ulcerative colitis
Justification: Toxic megacolon is a recognised complication of UC, especially with opiate use.
Resource: RCGP Learning
44
A 45-year-old man with UC on mesalazine has recent back pain and took ibuprofen. Now has looser stools.
What is the SINGLE MOST appropriate drug adjustment?
A. Add rectal prednisolone
B. Increase mesalazine
C. Add loperamide
D. Add oral prednisolone
E. Stop ibuprofen
Answer: E. Stop ibuprofen
Justification: NSAIDs may precipitate flares in UC and should be avoided.
Resource: RCGP Gastroenterology Curriculum Guide (2019)
45
A 60-year-old man had a positive FIT but normal colonoscopy.
What is the SINGLE MOST appropriate recommendation?
A. FIT testing every two years
B. Colonoscopy every two years
C. FIT testing every year
D. Colonoscopy every three years
E. Colonoscopy every year
Answer: A. FIT testing every two years
Justification: Normal colonoscopy returns patient to routine screening pathway.
Resource: RCGP Learning
46
A man on long-term omeprazole recently treated for H. pylori now has green watery diarrhoea.
What is the SINGLE MOST likely causative organism?
A. Campylobacter
B. E. coli
C. Shigella
D. Rotavirus
E. Clostridium difficile
Answer: E. Clostridium difficile
Justification: PPIs and antibiotics both increase risk of C. diff infection.
Resource: RCGP Learning
47
A 67-year-old man with sudden colicky abdo pain, vomiting, distension and empty rectum.
History of diverticular disease.
What is the SINGLE MOST likely diagnosis?
A. Bowel obstruction
B. Perforated bowel
C. Gastroenteritis
D. Ischaemic bowel
E. Diverticulitis
Answer: A. Bowel obstruction
Justification: Classical signs plus history of diverticulitis suggest obstruction.
Resource: Webster P. InnovAiT 2020; 13(8): 484–489.
48
A 61-year-old woman with right-sided abdominal pain, loose stools, mild anaemia and positive FIT.
What is the SINGLE MOST appropriate management?
A. Abdominal CT scan
B. Urgent haematology referral
C. Urgent respiratory referral
D. Conservative monitoring
E. Urgent colorectal referral
Answer: E. Urgent colorectal referral
Justification: Meets NICE NG12 criteria for suspected colorectal cancer referral.
Resource: NICE NG12 (2023)
49
Which is the SINGLE MOST likely presentation of acute hepatitis C infection?
A. Fatigue and myalgia
B. Persistent diarrhoea
C. Bleeding disorder
D. Jaundice
E. Asymptomatic
Answer: E. Asymptomatic
Justification: Most acute HCV cases are asymptomatic, requiring screening of at-risk groups.
Resource: RCGP Learning
50
A 53-year-old man with GORD symptoms and BMI 31, hiatus hernia, COPD and male sex.
Which is LEAST likely to be a risk factor for GORD?
A. Age >50
B. COPD
C. Hiatus hernia
D. Male sex
E. Obesity
Answer: B. COPD
Justification: No direct established link between COPD and increased GORD risk.
Resource: RCGP Learning
51
Which presenting symptom is MOST predictive of oesophagogastric cancer based on likelihood ratios?
A. Dyspepsia
B. Nausea/vomiting/bloating
C. Reflux
D. Weight loss
Answer: D. Weight loss
Justification: Weight loss has the highest positive likelihood ratio with statistically significant CI.
Resource: BJGP study; RCGP Learning
52
A 37-year-old man with vomiting and abdominal pain for 2 days, temp 37.7°C, generalised tenderness.
What is the SINGLE MOST likely diagnosis?
A. Intra-abdominal adhesions
B. Colorectal cancer
C. Gastroenteritis
D. Intussusception
E. Coeliac disease
Answer: C. Gastroenteritis
Justification: Most common cause in young healthy patients with acute pain and vomiting.
Resource: RCGP Learning
53
A 66-year-old man with liver cirrhosis becomes confused, lethargic and has asterixis.
What is the SINGLE MOST appropriate first-line medication?
A. Flumazenil
B. Dopamine agonists
C. Diazepam
D. Co-amoxiclav
E. Lactulose
Answer: E. Lactulose
Justification: Lactulose reduces ammonia load in hepatic encephalopathy.
Resource: RCGP Learning
54
A 55-year-old woman with rapid-onset severe left-sided abdominal pain and rectal bleeding. PMH: AF and HTN.
What is the SINGLE MOST likely diagnosis?
A. Coeliac disease
B. Acute gastroenteritis
C. Ischaemic colitis
D. Crohn’s disease
E. Diverticular disease
Answer: C. Ischaemic colitis
Justification: AF raises embolic risk. Sudden pain and rectal bleeding are typical.
Resource: Bonner & Pickering. InnovAiT 2022; 15(11): 629–633.
55
What is the SINGLE BEST test for differentiating UC from Crohn’s disease?
A. Barium follow-through
B. Ileo-colonoscopy
C. Faecal calprotectin
D. MRI
E. Abdominal X-ray
Answer: B. Ileo-colonoscopy
Justification: Endoscopy with biopsies allows clear diagnosis and extent assessment.
Resource: Qazi U. InnovAiT 2022; 15(2): 97–105.
56
A 65-year-old man with severe prolonged diarrhoea tests positive for Campylobacter.
What is the SINGLE MOST appropriate antibiotic?
A. Vancomycin
B. Trimethoprim
C. Co-amoxiclav
D. Metronidazole
E. Clarithromycin
Answer: E. Clarithromycin
Justification: First-line for severe Campylobacter enteritis.
Resource: RCGP Learning
57
A 64-year-old man with NAFLD is diagnosed with advanced fibrosis.
What is the SINGLE MOST appropriate management option?
A. Vitamin D
B. Ursodeoxycholic acid
C. Refer to secondary care
D. Pentoxifylline
E. Metformin
Answer: C. Refer to secondary care
Justification: Pharmacologic therapy should be under specialist supervision.
Resource: NICE NG49 (2016)
58
A 52-year-old woman has a tender right groin lump lateral to pubic tubercle.
What is the SINGLE MOST likely diagnosis?
A. Femoral hernia
B. Sarcoma
C. Spigelian hernia
D. Inguinal hernia
E. Saphena varix
Answer: A. Femoral hernia
Justification: Located below/lateral to pubic tubercle, more common in females.
Resource: RCGP Learning
59
Which gastroenterological condition are probiotics MOST likely to benefit?
A. Lactose intolerance
B. GORD
C. Bile acid malabsorption
D. IBS
E. Crohn’s disease
Answer: D. IBS
Justification: BSG suggests trialling probiotics for up to 12 weeks in IBS.
Resource: Lawton T. InnovAiT 2022; 15(10): 567–572.
60
A 41-year-old woman on methotrexate has isolated ALT of 154 U/L but is asymptomatic.
What is the MOST appropriate management option?
A. Retest as normal
B. MRI liver
C. Increase folic acid
D. Discuss with rheumatologist
E. Refer to hepatologist
Answer: D. Discuss with rheumatologist
Justification: ALT >3x upper limit on methotrexate requires urgent review with specialist.
Resource: Tang C-M. InnovAiT 2019; 12(9): 507–515.
61
In addition to upper-abdominal pain, which of the following is the SINGLE MOST common symptom of a possible gastric cancer diagnosis?
A. Nausea
B. Weight loss
C. Melaena
D. Dysphagia
E. Sweats
Answer: B. Weight loss
Justification: Typical patients with gastric cancer are male smokers aged 60–84 years presenting with upper abdominal pain and weight loss. Less common symptoms include nausea, dysphagia, and melaena.
Resource: RCGP Learning
62
Which is the SINGLE MOST likely risk factor for developing non-alcoholic fatty liver disease (NAFLD)?
A. Hypertension
B. Gallstones
C. Chronic kidney disease
D. Type 2 diabetes
E. Bulimia
Answer: D. Type 2 diabetes
Justification: The prevalence of NAFLD is highest in metabolic syndrome and type 2 diabetes.
Resource: RCGP Learning
63
Patient scenarios for cancer diagnosis:
- A woman with 3-month history of anorexia, epigastric discomfort, weight loss, dysphagia and vomiting.
- A woman with abdo pain and distension, vomiting, loose stools, high-pitched bowel sounds.
- A woman with 6-month abdo pain, bloating, fullness in right fornix, no response to IBS treatment.
What are the SINGLE MOST likely diagnoses?
Answers:
1. Oesophageal carcinoma
2. Colorectal carcinoma
3. Ovarian carcinoma
Justification: Dysphagia, anorexia and vomiting point to oesophageal cancer. Bowel obstruction with loose stools suggests colorectal cancer. Persistent non-specific GI and pelvic symptoms suggest ovarian carcinoma.
Resources: NICE NG12; RCGP Curriculum Gastroenterology 2019; SIGN 126; NICE NG83
64
A 60-year-old woman with proctitis is advised oral mesalazine.
Which ONE of the following statements concerning her monitoring is correct?
A. Renal function monitored at baseline, 3 months, 6 months
B. Renal function monitored at baseline, 3 months, then annually
C. Monitoring before starting only
D. No checks needed
E. Monitoring before starting and at 3 months only
Answer: B. Renal function monitored before starting, at 3 months, then annually
Justification: According to BSG and BNF, monitor FBC, U&E, creatinine, LFTs before treatment, at 3 months, and then annually.
Resource: BNF; RCGP Learning
65
According to the MHRA, which of the following PPIs should not be prescribed concomitantly with clopidogrel?
A. Rabeprazole
B. Pantoprazole
C. Omeprazole
D. Lansoprazole
E. All PPIs should be avoided
Answer: C. Omeprazole
Justification: Omeprazole and esomeprazole reduce clopidogrel effectiveness. Avoid unless benefits outweigh risks.
Resource: Kumar M. InnovAiT 2019; 12(9): 526–530
66
A 68-year-old woman with 2-month rectal bleeding, normal weight, exam and no family history.
What is the MOST appropriate next investigation per NICE?
A. Barium meal
B. CT colonography
C. Abdo ultrasound
D. Colonoscopy
E. Faecal immunochemical test
Answer: E. Faecal immunochemical test
Justification: NICE recommends FIT for patients over 50 with unexplained rectal bleeding.
Resources: NICE DG56; NICE NG12; Bonner C. InnovAiT 2022
67
A 58-year-old woman presents with tiredness, bloating, distension, urinary frequency and raised CA125.
What is the SINGLE MOST useful imaging from the options below?
A. Cystoscopy
B. Ultrasound abdo and pelvis
C. Colonoscopy
D. Chest X-ray
E. Abdominal X-ray
Answer: B. Ultrasound abdomen and pelvis
Justification: CA125 >35 and suggestive symptoms require urgent ultrasound per NICE NG12.
Resource: NICE NG12
68
A 72-year-old woman returns from visiting grandchildren. Flu-like symptoms, nausea, RUQ pain, mild jaundice.
What blood test is MOST in keeping with hepatitis A?
A. AST
B. ALP
C. Amylase
D. GGT
E. MCV
Answer: A. AST
Justification: Hepatitis A causes hepatocellular damage leading to raised ALT/AST.
Resource: RCGP Gastroenterology Curriculum 2019
69
A 35-year-old woman with IBS, well-controlled hypothyroidism, fractured humerus and recent URTI.
Bloods: Hb 105, platelets 497, MCV 78, ferritin 10
What is the SINGLE MOST likely explanation for her raised platelets?
A. Hypothyroidism
B. Iron-deficiency anaemia
C. IBS
D. Fracture
E. URTI
Answer: B. Iron-deficiency anaemia
Justification: Reactive thrombocytosis is commonly due to iron-deficiency.
Resource: RCGP Learning
70
A 53-year-old woman has pruritus and mild jaundice. Bloods: Bilirubin 95, ALP 654, GGT 432, AST/ALT normal.
What is the SINGLE MOST likely diagnosis?
A. NAFLD
B. Primary biliary cholangitis
C. Haemochromatosis
D. Hepatitis C
E. Steatohepatitis
Answer: B. Primary biliary cholangitis
Justification: Raised ALP and GGT with pruritus suggests cholestasis. Check antimitochondrial antibodies.
Resource: RCGP Learning
71
A 35-year-old woman with chronic lethargy has: Hb 12.4, ferritin 35, TSH 3.5, positive IgA tTGA, negative AGA.
What is the SINGLE MOST appropriate NEXT management option?
A. Check folate
B. Repeat blood tests in 4 weeks
C. Refer to gastroenterologist
D. Start gluten-free diet
E. No action
Answer: C. Refer to gastroenterologist
Justification: Positive serology requires endoscopic confirmation. Do not start gluten-free diet until after biopsy.
Resource: NICE NG20
72
72-year-old man with recurrent Clostridium difficile infections is on multiple medications.
Which SINGLE medication is MOST likely implicated in recurrent enteric infections?
A. Methotrexate
B. Ibuprofen
C. Amlodipine
D. Omeprazole
E. Prednisolone
Answer: D. Omeprazole
Justification: PPIs disrupt gut microbiome, increasing C. difficile risk.
Resource: Lawton T. InnovAiT 2022; 15(10): 567–572
73
43-year-old man with dyspepsia and severe oesophagitis confirmed on endoscopy.
What is the SINGLE MOST appropriate management?
A. Trial of prokinetic
B. 8-week trial of PPI
C. Lifestyle advice
D. 4-week trial of PPI
E. Urgent gastro referral
Answer: B. 8-week trial of PPI
Justification: NICE CG184 recommends 8 weeks of PPI for confirmed oesophagitis.
Resource: NICE CG184 (2014, updated 2019)
74
According to BNF, which ONE drug is recommended for abdominal pain in IBS after first-line treatment fails?
A. Duloxetine
B. Ondansetron
C. Codeine
D. Amitriptyline
E. Rifaximin
Answer: D. Amitriptyline
Justification: Second-line, unlicensed indication for IBS-related pain. SSRIs are also recommended.
Resources: BNF; BSG Guidelines, Gut 2021
75
What is the SINGLE MOST common cause of upper GI bleeding in the UK?
A. Peptic ulcer disease
B. Mallory–Weiss tears
C. Congenital bleeding disorder
D. Oesophageal varices
E. GI malignancy
Answer: A. Peptic ulcer disease
Justification: PUD causes 35–50% of UGIB cases, often due to NSAIDs.
Resource: Lumley E. InnovAiT 2021; 14(8): 484–489
76
66-year-old man with chronic duodenal ulcer on NSAIDs, H. pylori positive, treated.
Symptoms recur.
What is the SINGLE MOST appropriate test to confirm H. pylori eradication?
A. Serology
B. Faecal calprotectin
C. Breath test
D. Endoscopy
E. Stool antigen
Answer: C. Breath test
Justification: Carbon-13 urea breath test is gold standard post-treatment.
Resource: NICE CG184
77
28-year-old man with diarrhoea-predominant IBS.
Which ONE of the following should he AVOID?
A. Linseeds
B. Sorbitol
C. Probiotics
D. Herbal teas
E. Oats
Answer: B. Sorbitol
Justification: Sorbitol worsens diarrhoea in IBS. Soluble fibres like oats may help.
Resource: NICE CG61 (2017)
78
64-year-old man with liver cirrhosis and ascites.
Which SINGLE blood test is most useful for prognosis?
A. ALT
B. ALP
C. GGT
D. Hep B status
E. Total bilirubin
Answer: E. Total bilirubin
Justification: Part of Child–Pugh score (bilirubin, albumin, INR, ascites, encephalopathy).
Resource: RCGP Learning
79
19-year-old woman with anorexia, diarrhoea, weight loss, perianal pain, RIF mass, BMI 18.
What is the SINGLE MOST likely diagnosis?
A. Ileal TB
B. UC
C. Crohn’s disease
D. Anorexia nervosa
E. Coeliac disease
Answer: C. Crohn’s disease
Justification: Features suggest Crohn’s: perianal pain, RIF mass, weight loss.
Resource: RCGP Learning
80
Which ONE treatment is recommended by NICE and BSG for refractory IBS?
A. Acupuncture
B. Cannabis oil
C. Hypnotherapy
D. Reflexology
E. Homeopathy
Answer: C. Hypnotherapy
Justification: Recommended after 12 months refractory symptoms or earlier if available/preferred.
Resources: NICE CG61; Gut 2021; BSG Guidelines
81
You see a 34-year-old patient recently diagnosed with mild to moderate ulcerative colitis.
What is the SINGLE MOST appropriate first-line management option?
A. Intramuscular corticosteroids
B. Ciclosporin
C. Oral corticosteroids
D. Aminosalicylates
E. Thiopurines
Answer: D. Aminosalicylates
Justification: Aminosalicylates are the first-line treatment for mild to moderate active ulcerative colitis. Mesalazine is commonly used and can be given orally or topically. Studies show a synergistic effect when both routes are used.
Resource: Qazi U. Inflammatory bowel disease in adults. InnovAiT 2022; 15(2): 97–105.
82
A 42-year-old man has had bright red rectal bleeding for a week.
What is the SINGLE MOST appropriate management option?
A. Arrange an urgent suspected cancer referral
B. Organise a CT scan
C. Refer for routine colonoscopy
D. Reassure and manage conservatively
E. Prescribe two weeks of prednisolone
Answer: D. Reassure and manage conservatively
Justification: In patients under 50 without other red flags, rectal bleeding is usually benign and self-limiting.
Resource: NICE. Suspected cancer: recognition and referral. NG12. 2015 (updated 2023).
83
A 25-year-old woman who injects heroin is hepatitis C RNA positive.
What is the SINGLE MOST appropriate management plan?
A. Review bloods in six months
B. Monitor clinically over the next three months
C. Refer to specialist care
D. Start Interferon therapy
E. Stabilise illicit drug taking
Answer: C. Refer to specialist care
Justification: Early referral is important; treatment during the acute phase improves outcomes.
Resource: RCGP. Screening, care & treatment of persons with hepatitis C infection. EKU 15.
84
A 47-year-old woman presents with tiredness and pruritus. Positive anti-mitochondrial antibodies.
What is the SINGLE MOST likely diagnosis?
A. Autoimmune hepatitis
B. Haemochromatosis
C. Coeliac disease
D. Primary biliary cirrhosis
E. Wilson’s disease
Answer: D. Primary biliary cirrhosis
Justification: Typical symptoms and anti-mitochondrial antibodies support this diagnosis.
Resource: Downes TJ et al. Infectious hepatitis. InnovAiT 2022; 15(11): 621–628.
85
A 47-year-old man has recurrent anal pain and fresh rectal bleeding.
What is the SINGLE MOST appropriate initial topical medication to prescribe?
A. Proctosedyl®
B. Miconazole 2% cream
C. GTN ointment 0.4%
D. Ibuprofen gel 5%
E. Diltiazem cream 2%
Answer: C. GTN ointment 0.4%
Justification: GTN ointment is first-line for anal fissures persisting beyond a week.
Resource: NICE CKS; RCGP Learning
86
Which co-infection MOST significantly accelerates the progression of hepatitis C-associated liver disease?
A. EBV
B. TB
C. HIV
D. Hepatitis B
E. Influenza A
Answer: C. HIV
Justification: Co-infection with HIV is the most significant in accelerating liver disease.
Resource: RCGP. Screening, care & treatment of HCV. EKU 15.
87
A 29-year-old woman has 4-month history of abdominal pain and constipation, relieved by defecation, with rectal mucus.
What is the MOST likely diagnosis?
A. Coeliac disease
B. Ovarian cancer
C. IBS
D. Hypothyroidism
E. IBD
Answer: C. IBS
Justification: Pain relieved by defecation, rectal mucus, bloating are typical of IBS.
Resource: Sutcliffe M. IBS. InnovAiT 2019; 12(9): 497–500.
88
Which statement is TRUE regarding NAFLD?
A. Prognosis is benign
B. Raised ALP is typical
C. Risk is higher in type 1 diabetics
D. Ultrasound accurately assesses fibrosis
E. FIB-4 estimates advanced fibrosis risk
Answer: E. FIB-4 estimates advanced fibrosis risk
Justification: FIB-4 is recommended by NICE for assessing advanced fibrosis.
Resource: NICE NG49. NAFLD: assessment and management. 2016.
89
30-year-old woman has nausea, cramps, diarrhoea, flushing and had a tuna sandwich.
What is the SINGLE MOST likely diagnosis?
A. Food allergy
B. Staph food poisoning
C. Botulism
D. Campylobacter enteritis
E. Scombroid food poisoning
Answer: E. Scombroid food poisoning
Justification: Rapid onset flushing and diarrhoea after scombroid fish is typical.
Resource: RCGP Learning
90
A woman in her 30s has had haematemesis. What is the earliest sign of decompensated hypovolaemia?
A. Pulse rate
B. Lying BP
C. Respiratory rate
D. Temperature
E. Standing BP
Answer: A. Pulse rate
Justification: Tachycardia is the earliest compensatory response to hypovolaemia.
Resource: RCGP. Urgent and unscheduled care. 2019.
91
What is the GOLD standard test for diagnosing coeliac disease?
A. Endoscopy
B. Small bowel biopsy
C. Skin biopsy
D. Serum IgA EMA
E. Serum IgA tTGA
Answer: B. Small bowel biopsy
Justification: Duodenal biopsy while on a gluten-containing diet is the gold standard.
Resource: Eggink A et al. Coeliac disease. InnovAiT 2023; 16(7): 332–336.
92
A 61-year-old man has 2 months of weight loss and nausea. Fasting glucose 9.1, HbA1c 50.
What is the SINGLE MOST appropriate management?
A. Urgent CT abdomen
B. Routine gastro referral
C. Urgent ultrasound
D. Weigh and review in 4 weeks
E. Urgent abdominal X-ray
Answer: A. Urgent CT abdomen
Justification: NICE recommends urgent CT for patients over 60 with weight loss and any GI symptom.
Resources: NICE NG12; Mortimer M. Pancreatic cancer. InnovAiT 2019; 12(9): 492–496.
93
22-year-old man has RIF pain, rebound tenderness and positive Rovsing’s sign.
What is the SINGLE MOST appropriate initial management?
A. Surgical team referral
B. Watch and wait
C. Urgent abdominal ultrasound
D. Send MSU
E. Start trimethoprim
Answer: A. Surgical team referral
Justification: Classic signs of acute appendicitis require urgent surgical assessment.
Resource: RCGP Learning
94
Which is the SINGLE MOST likely biochemical abnormality in NAFLD?
A. Isolated raised ALT
B. Raised AST
C. Raised GGT
D. ALP > ALT
E. ALT > AST
Answer: E. ALT > AST
Justification: ALT is typically raised more than AST early in NAFLD.
Resource: RCGP Learning
95
35-year-old man has severe oesophagitis.
What is the SINGLE MOST appropriate initial treatment?
A. 8 weeks lansoprazole 30 mg daily
B. 4 weeks lansoprazole 30 mg daily
C. 4 weeks lansoprazole 60 mg BID
D. 8 weeks lansoprazole 30 mg BID
E. 4 weeks lansoprazole 30 mg BID
Answer: A. 8 weeks lansoprazole 30 mg daily
Justification: NICE recommends full-dose PPI for 8 weeks for severe oesophagitis.
Resource: NICE CG184. 2014 (updated 2019)
96
43-year-old woman tests positive for H. pylori.
What is the SINGLE MOST appropriate treatment?
A. Omeprazole, amoxicillin, clarithromycin
B. Lansoprazole, amoxicillin, erythromycin
C. Ranitidine, amoxicillin, clarithromycin
D. Omeprazole, flucloxacillin, clarithromycin
E. Omeprazole, amoxicillin, metoclopramide
Answer: A. Omeprazole, amoxicillin, clarithromycin
Justification: Standard triple therapy is omeprazole + amoxicillin + clarithromycin.
Resource: Sivakumar A, Stubbs B. Peptic ulcer disease. InnovAiT 2021; 14(6): 372–378.
97
75-year-old woman has LLQ pain, constipation, diarrhoea and weight loss.
What is the SINGLE MOST likely diagnosis?
A. Diverticulitis
B. Coeliac disease
C. IBS
D. Colorectal cancer
E. IBD
Answer: D. Colorectal cancer
Justification: Red flags include change in bowel habit and weight loss in older patient.
Resource: RCGP Learning
98
46-year-old man with GORD and oesophagitis needs antibiotics.
Which drug may exacerbate oesophagitis?
A. Amoxicillin
B. Co-amoxiclav
C. Erythromycin
D. Doxycycline
E. Levofloxacin
Answer: D. Doxycycline
Justification: Tetracyclines like doxycycline can cause pill-induced oesophagitis.
Resource: Evans V, King H. GI bleeding. InnovAiT 2021; 14(12): 757–765.
99
55-year-old vegetarian woman asks about dietary vitamin B12 sources.
Which is the BEST dietary source?
A. Bread
B. Carrots
C. Eggs
D. Nuts
E. Pulses
Answer: C. Eggs
Justification: B12 is found in animal products like meat, dairy and eggs.
Resources: NHS. Vitamin B12 (2020); The Vegan Diet (2022).
100
Which electrolyte imbalance is MOST associated with high-output stomas?
A. Hyperkalaemia
B. Hypomagnesaemia
C. Hypokalaemia
D. Hypocalcaemia
E. Hypophosphataemia
Answer: B. Hypomagnesaemia
Justification: High stoma output leads to losses of sodium and magnesium.
Resources: Nightingale J. Frontline Gastroenterology 2022; Thomas M et al. InnovAiT 2021; BIFA 2023.
101
A 28-year-old man has routine bloods for insurance. Bilirubin is elevated, all other liver markers and FBC are normal.
Which is the SINGLE MOST likely diagnosis?
A. Infectious mononucleosis
B. Hepatitis C
C. HIV primary infection
D. Haemochromatosis
E. Gilbert’s syndrome
Answer: E. Gilbert’s syndrome
Justification: Most common cause of isolated elevated unconjugated bilirubin.
Resource: RCGP Learning
102
A 50-year-old man with reflux-type symptoms for a few weeks and no alarm signs. On amlodipine and bendroflumethiazide.
What is the SINGLE MOST appropriate action now?
A. Modify lifestyle
B. Cease bendroflumethiazide
C. Commence Gaviscon Advance
D. Commence lansoprazole
E. Commence triple therapy
Answer: A. Modify lifestyle
Justification: NICE recommends reviewing lifestyle and medications before starting PPI.
Resource: NICE CG184 (2014, updated 2019); RCGP EKU15
103
A 37-year-old woman has colicky RUQ pain radiating to right shoulder, worse after fatty meals.
What is the SINGLE MOST appropriate investigation?
A. Erect chest X-ray
B. OGD
C. MRCP
D. Abdominal ultrasound scan
E. MRI abdomen
Answer: D. Abdominal ultrasound scan
Justification: First-line for suspected gallstones.
Resource: RCGP Learning
104
Which is the SINGLE MOST likely food to trigger coeliac disease?
A. Egg
B. Milk
C. Cheese
D. Peanut
E. Rye
Answer: E. Rye
Justification: Gluten proteins in wheat, barley, and rye cause mucosal immune reaction.
Resource: RCGP. Coeliac disease and immunological comorbidities
105
A 24-year-old woman has IBS with diarrhoea despite several drug trials.
What is the SINGLE MOST appropriate therapy now?
A. CBT
B. Aromatherapy
C. Massage therapy
D. Acupuncture
E. Reflexology
Answer: A. CBT
Justification: NICE recommends CBT, hypnotherapy or psychological therapies for refractory IBS.
Resource: NICE CG61 (2008, updated 2017)
106
A 32-year-old woman with IBS not helped by drugs and declined CBT.
Which complementary therapy is recommended?
A. Reflexology
B. Chiropractic
C. Art therapy
D. Acupuncture
E. Hypnotherapy
Answer: E. Hypnotherapy
Justification: NICE supports hypnotherapy after failed pharmacological management.
Resource: NICE CG61 (2008, updated 2017)
107
A 52-year-old man with abnormal LFTs undergoes liver screen.
What is the SINGLE MOST appropriate additional investigation?
A. Calcium and vitamin D
B. U&Es
C. Serum cortisol and ACTH
D. Serum ferritin and transferrin saturation
E. Zinc and magnesium
Answer: D. Serum ferritin and transferrin saturation
Justification: Key part of liver screen for iron overload.
Resource: RCGP Learning
108
24-year-old man with recurrent lower abdo pain and loose stools.
Which symptom supports diagnosis of IBS?
A. Pain relieved by defaecation
B. Symptoms for three months
C. Pain worsened by defaecation
D. Symptoms for two weeks
E. Symptoms for six weeks
Answer: A. Pain relieved by defaecation
Justification: One of core NICE diagnostic criteria for IBS.
Resource: NICE CG61 (2008, updated 2017)
109
A 67-year-old with stoma and COPD has bulge at stoma site.
What is the SINGLE MOST likely diagnosis?
A. Parastomal haematoma
B. Peristomal abscess
C. Parastomal hernia
D. Peristomal fistula
E. Prolapse
Answer: C. Parastomal hernia
Justification: Common complication, especially with raised intra-abdominal pressure.
Resource: Thomas M et al. InnovAiT 2021
110
22-year-old with diarrhoea, weight loss and low ferritin.
What is the MOST appropriate test to confirm IBD?
A. tTGA
B. Faecal calprotectin
C. WCC
D. Transferrin saturation
E. IgA
Answer: B. Faecal calprotectin
Justification: Non-invasive marker of bowel inflammation.
Resource: NICE CG61; RCGP Learning
111
A 59-year-old post-gastrectomy patient is seen for review.
Which supplement is he MOST likely to need lifelong?
A. Thiamine
B. Iron
C. Vitamin K
D. Potassium
E. Vitamin B12
Answer: E. Vitamin B12
Justification: Gastrectomy impairs intrinsic factor production—lifelong B12 needed.
Resource: RCGP Learning
112
A 31-year-old woman post forceps delivery has abdo distension, constipation and soft tympanic abdomen.
What is the SINGLE MOST likely diagnosis?
A. Pseudo-obstruction
B. Diverticulitis
C. Intra-abdominal adhesions
D. Colorectal carcinoma
E. Gastroenteritis
Answer: A. Pseudo-obstruction
Justification: Ogilvie’s syndrome—acute intestinal pseudo-obstruction post surgery.
Resource: RCGP Learning
113
38-year-old woman has Lynch syndrome.
What is the SINGLE MOST appropriate screening protocol?
A. Gastroscopy
B. Pelvic ultrasound
C. CT pancreas
D. Colonoscopy
E. Endometrial biopsy
Answer: D. Colonoscopy
Justification: 2-yearly colonoscopy from age 25–35 based on variant.
Resource: Stewart L. InnovAiT 2021
114
72-year-old man with jaundice, weight loss, pruritus, palpable gallbladder.
What is the MOST likely diagnosis?
A. Gallstones
B. Hepatitis B
C. Choledochal cyst
D. Acute cholecystitis
E. Pancreatic carcinoma
Answer: E. Pancreatic carcinoma
Justification: Classic features include Courvoisier’s sign, pruritus and weight loss.
Resource: RCGP Pancreatic Cancer Update 2023
115
58-year-old man with fatigue, ALT 84, normal bilirubin/ALP, ferritin 1222.
What is the MOST likely diagnosis?
A. Haemochromatosis
B. Malignancy
C. Autoimmune hepatitis
D. Glandular fever
E. NAFLD
Answer: A. Haemochromatosis
Justification: High ferritin, abnormal LFTs, classic early signs.
Resource: NICE QS152 (2017)
116
Patient admitted with decompensated alcoholic liver disease.
Which feature has the WORST prognosis?
A. Hepatocellular carcinoma
B. Thrombocytopaenia
C. Jaundice
D. Spontaneous bacterial peritonitis
E. Hepatorenal syndrome
Answer: E. Hepatorenal syndrome
Justification: Terminal event with median survival ~12 days.
Resource: RCGP Learning
117
Patient 1: 72M with RIF tenderness, anaemia, positive FIT
Patient 2: 66M with dark urine, pale stools, jaundice
Patient 3: 47M with flank pain, hypokalaemia, acne, HTN
What are the SINGLE MOST likely diagnoses?
Answers:
1. Colorectal carcinoma
2. Pancreatic carcinoma
3. Adrenal carcinoma
Justification: Classic malignancy presentations based on systemic and local signs.
Resources: NICE NG12 (2023); RCGP Curriculum Guides
118
30-year-old woman with bloating, LIF pain, mucus in stool.
What is the SINGLE MOST appropriate dietary advice?
A. Increase black tea
B. Increase pasta
C. Increase fizzy drinks
D. Increase oats
E. Increase wholemeal bread
Answer: D. Increase oats
Justification: Oats help with wind and bloating; avoid caffeine/fizzy drinks.
Resource: NICE CG61 (2008, updated 2017)
119
59-year-old man with epigastric pain post meals, weight loss, night waking, vomiting.
What is the MOST appropriate investigation?
A. Abdominal US
B. Barium meal
C. H. pylori test
D. Serum amylase
E. Upper GI endoscopy
Answer: E. Upper GI endoscopy
Justification: Urgent endoscopy indicated with alarm features.
Resource: NICE CG184; NG12
120
72-year-old man with weight loss, scleral icterus, RUQ palpable gallbladder.
What is the SINGLE MOST appropriate management?
A. Routine US
B. ED referral
C. Review in 4 weeks
D. Suspected cancer pathway referral
E. Routine specialist referral
Answer: D. Suspected cancer pathway referral
Justification: NICE recommends urgent referral for jaundice and weight loss.
Resource: NICE NG12 (2025)
121
In patients with which ONE of the following recurring oral conditions would it be MOST appropriate to test for coeliac disease?
A. Geographic tongue
B. Candidiasis
C. Lichen planus
D. Herpes simplex
E. Mouth ulcers
Answer: E. Mouth ulcers
Justification and Feedback: A large number of conditions, including recurrent mouth ulcers, warrant consideration for testing for coeliac disease.
Resource: NICE. Coeliac Disease: recognition, assessment and management. NG20. 2015.
122
A 60-year-old woman with a history of duodenal ulcer now wishes to restart NSAIDs for her rheumatoid arthritis. What is the SINGLE MOST appropriate treatment?
A. Naproxen 500 mg twice-daily and ranitidine
B. Must not take any NSAID again
C. Diclofenac 50 mg three times daily and misoprostol
D. Celecoxib 100 mg twice-daily and lansoprazole
E. Ibuprofen 600 mg three times daily and omeprazole
Answer: D. Celecoxib 100 mg twice-daily and lansoprazole
Justification and Feedback: For people at high risk of ulceration, consider a cox-2 inhibitor or low-dose ibuprofen in combination with a PPI.
Resource: NICE. Gastro-Oesophageal Reflux Disease and Dyspepsia in Adults: CG184. 2014 (updated 2019).
123
Which investigation is the SINGLE best method for detecting pancreatic cancer?
A. Computed tomography (CT) scan
B. Tumour marker CA 19-9
C. Clinical examination
D. Abdominal ultrasound scan
E. Exploratory laparotomy
Answer: A. Computed tomography (CT) scan
Justification and Feedback: CT imaging is the best method for detecting pancreatic neoplasms and assessing prognosis and staging.
Resource: None explicitly given, but supported by clinical guidelines.
124
Which symptom in a patient with worsening dyspepsia indicates the need for a two-week-wait referral for OGD?
A. Dysphagia
B. Vomiting
C. Dyspepsia
D. Weight gain
E. Upper abdominal pain
Answer: A. Dysphagia
Justification and Feedback: Dysphagia at any age should prompt urgent two-week wait referral.
Resource: NICE. Suspected Cancer: recognition and referral. NG12. 2015 (updated 2023).
125
What is the SINGLE MOST appropriate investigation to diagnose gastric cancer in a symptomatic 65-year-old woman?
A. Double contrast barium enema
B. Endoscopic ultrasound
C. Computed tomography of the abdomen
D. Gastroscopy
E. Full blood count
Answer: D. Gastroscopy
Justification and Feedback: Gastroscopy is the gold standard for diagnosing gastric cancer.
Resource: Baxter KA, Chillarge GS, Wajed S. Gastric cancer. InnovAiT 2022; 15(9): 520–523.
126
Which is the SINGLE MOST appropriate way of confirming compliance with a gluten-free diet in a patient with coeliac disease?
A. HLA DQ2/DQ8
B. Weight monitoring
C. Full blood count
D. Food diary
E. Immunoglobulin A (IgA) tissue transglutaminase
Answer: E. Immunoglobulin A (IgA) tissue transglutaminase
Justification and Feedback: tTGA is used to confirm compliance. HLA testing is not suitable for monitoring compliance.
Resources: RCGP. Diagnosis and management of coeliac disease; NICE. NG20. 2015.
127
What is the SINGLE MOST appropriate antibiotic regime for H. pylori eradication in a penicillin-allergic patient with no prior antibiotic exposure?
A. Clarithromycin and metronidazole
B. Cefalexin and metronidazole
C. Metronidazole and levofloxacin
D. Metronidazole and oxytetracycline
E. Clarithromycin and levofloxacin
Answer: A. Clarithromycin and metronidazole
Justification and Feedback: Use clarithromycin and metronidazole in penicillin allergy unless prior clarithromycin use.
Resource: British National Formulary – Helicobacter pylori infection.
128
A patient tests positive for Hepatitis A IgM and negative for IgG. What is the SINGLE MOST appropriate management option?
A. Advice and reassurance
B. Arrange sexual contact tracing
C. Repeat hepatitis serology in three months
D. Routine referral to gastroenterology
E. Refer for abdominal ultrasound scan
Answer: A. Advice and reassurance
Justification and Feedback: Acute hepatitis A is usually self-limiting. Hepatitis A is a notifiable disease.
Resource: RCGP Learning
129
Which of the following warrants URGENT direct access upper GI endoscopy?
A. A 43-year-old man with recurrent episodes of dyspepsia
B. A 48-year-old woman with dysphagia
C. A 50-year-old man with treatment-resistant dyspepsia
D. A 58-year-old man with nausea and raised platelets
E. A 60-year-old woman with vomiting and lower abdominal pain
Answer: B. A 48-year-old woman with dysphagia
Justification and Feedback: Urgent referral is warranted for any adult with dysphagia.
Resource: NICE. NG12. 2015 (updated 2023).
130
Which is the SINGLE MOST appropriate drug to prescribe for short-term constipation in an adult with poor fibre intake?
A. Senna
B. Ispaghula husk
C. Glycerol suppository
D. Lactulose
E. Sodium picosulfate
Answer: B. Ispaghula husk
Justification and Feedback: Begin with a bulk-forming laxative like ispaghula.
Resource: RCGP. Constipation in the elderly blog.
131
Which test would you expect the lab to carry out FIRST to diagnose coeliac disease?
A. HLA DQ2/DQ8
B. IgG EMA
C. IgA tTGA
D. IgG tTGG
E. IgA EMA
Answer: C. IgA tissue transglutaminase (IgA tTGA)
Justification and Feedback: First-line test is IgA tTGA. If IgA deficiency, then IgG tests follow.
Resource: NICE NG20 (2015)
132
What is the MOST appropriate second-line treatment for IBS unresponsive to antispasmodics and loperamide?
A. Reflexology
B. Trial of FODMAP diet
C. Gabapentin
D. Acupuncture
E. Low-dose amitriptyline
Answer: E. Low-dose amitriptyline
Justification and Feedback: NICE recommends low-dose tricyclic antidepressants for refractory IBS.
Resources: NICE CG61 (2008, updated 2017); CKS 2022; Sutcliffe M. InnovAiT 2019.
133
What is the SINGLE MOST likely cause of large bowel obstruction in a 64-year-old man with weight loss and rectal bleeding?
A. Diverticular disease
B. Inflammatory bowel disease
C. Colorectal cancer
D. Ischaemic bowel
E. Sigmoid volvulus
Answer: C. Colorectal cancer
Justification and Feedback: Colorectal cancer causes 60% of large bowel obstructions.
Resource: Webster P. Bowel obstruction. InnovAiT 2020; 13(8): 484–489.
134
A 52-year-old woman with type 1 diabetes and hypothyroidism has angular stomatitis, clumsiness, tiredness, irritability.
Which vitamin is deficient?
A. A
B. B
C. C
D. D
E. K
Answer: B12
Justification and Feedback: Classic signs of B12 deficiency including neurological and mucosal symptoms.
135
Which investigation is MOST appropriate for a 45-year-old woman with mild anaemia and family history of cancer?
A. FIT
B. CA125 blood test
C. CEA tumour marker
D. Faecal calprotectin
E. Amylase
Answer: B. Cancer antigen 125 (CA125)
Justification and Feedback: CA125 should be used when persistent abdominal/pelvic symptoms occur.
Resource: NICE NG12. 2015 (updated 2023)
136
After H. pylori treatment, which test confirms eradication?
A. Stool antigen test
B. C urea breath test
C. Finger prick near-patient test
D. OGD and biopsy
E. ELISA serology
Answer: B. C urea breath test
Justification and Feedback: Most accurate post-treatment. Requires stopping PPI for 14 days.
Resource: NICE H. pylori guidance
137
Which test helps to exclude IBD in a 25-year-old with diarrhoea, abdominal pain and mucus?
A. CRP
B. Stool culture
C. FBC
D. LFTs
E. Faecal calprotectin
Answer: E. Faecal calprotectin
Justification and Feedback: Non-invasive biomarker to rule out IBD.
Resource: NICE IBD diagnostic pathway
138
What should be done for a NAFLD patient on atorvastatin 40 mg with mildly raised LFTs?
A. Switch to ezetimibe
B. Continue atorvastatin
C. Increase to 80 mg
D. Reduce to 20 mg
E. Stop statin
Answer: B. Continue atorvastatin
Justification and Feedback: NICE supports statin continuation unless LFTs double within 3 months.
Resource: NICE NG49 (2016)
139
Which test is MOST appropriate for monitoring liver fibrosis in a 43-year-old man with NAFLD?
A. Alpha-fetoprotein
B. ELF test
C. Fibroscan
D. GGT
E. Ultrasound
Answer: B. Enhanced liver fibrosis (ELF) test
Justification and Feedback: NICE recommends ELF test 3-yearly in adults with NAFLD.
Resource: NICE NG49 (2016)
140
A 54-year-old man with T2DM, lethargy, impotence, and hepatomegaly is suspected of having haemochromatosis.
What is the most appropriate investigation?
A. Hepatitis serology
B. Autoantibody screen
C. HIV serology
D. Iron studies
E. Copper studies
Answer: D. Iron studies
Justification and Feedback: First-line for suspected haemochromatosis; shows raised ferritin, low TIBC.
Resource: NICE Haemochromatosis guidance
141
An 81-year-old man has recovered from acute diverticulitis but cannot tolerate high-fibre diet.
Which is the SINGLE MOST appropriate medication to reduce recurrence?
A. Ispaghula husk
B. Low-dose amoxicillin
C. Macrogol
D. Mebeverine
E. Mesalazine
Answer: A. Ispaghula husk
Justification: Bulk-forming laxatives like ispaghula should be considered when high-fibre diets are insufficient or not tolerated.
Resource: NICE guidance
142
Which SINGLE scoring system should be used first in upper GI bleeding?
A. Modified Rockall
B. Glasgow–Blatchford
C. Oakland
D. Full Rockall
E. Edinburgh
Answer: B. Glasgow–Blatchford
Justification: NICE recommends the Blatchford score for initial assessment; full Rockall score follows endoscopy.
Resource: NICE CG141 (2012, updated 2016); Lumley E and Peter B. InnovAiT 2021; 14(8): 484–489.
143
A 30-year-old woman with IBS and frequent diarrhoea.
What is the SINGLE MOST appropriate INITIAL therapy?
A. Domperidone
B. Citalopram
C. Codeine phosphate
D. Amitriptyline
E. Loperamide
Answer: E. Loperamide
Justification: First-line antimotility agent for diarrhoea in IBS; patients should adjust dose to response.
Resource: NICE CG61 (2008, updated 2017)
144
A 46-year-old man with malaise, memory problems, bronze skin and low libido.
Ferritin 500, transferrin saturation 55%, normal LFTs.
What is the SINGLE MOST likely diagnosis?
A. Wilson’s disease
B. Amyloidosis
C. Excessive alcohol use
D. Polycythaemia rubra vera
E. Genetic haemochromatosis
Answer: E. Genetic haemochromatosis
Justification: Raised ferritin and transferrin saturation without abnormal LFTs are typical.
Resource: Hannaway L, Wellman S. InnovAiT 2020; 13(6): 353–360.
145
A 40-year-old woman returns from holiday with fatigue, pruritus, mild liver tenderness, positive AMA.
What is the SINGLE MOST likely diagnosis?
A. Primary biliary cirrhosis
B. Haemochromatosis
C. Alcoholic liver disease
D. CBD gallstone
E. Pancreatic cancer
Answer: A. Primary biliary cirrhosis
Justification: Positive antimitochondrial antibodies and symptoms are diagnostic.
Resource: RCGP Gastroenterology Curriculum (2019)
146
68-year-old woman with rectal bleeding and iron-deficiency anaemia.
What is the gold standard investigation for colorectal cancer?
A. CT abdomen
B. Colonoscopy
C. PET scan
D. MRI abdomen
E. Ultrasound abdomen
Answer: B. Colonoscopy
Justification: Gold standard for diagnosis and biopsy.
Resource: Harris C. InnovAiT 2022; 15(6): 349–353.
147
35-year-old woman with suggestive symptoms of coeliac disease. IgA tTGA is negative.
What is the NEXT investigation?
A. Total serum IgA
B. IgG tTGA
C. IgG anti-gliadin antibodies
D. Autoantibody screen
E. IgG EMA
Answer: A. Total serum IgA
Justification: Needed to assess for IgA deficiency, which may cause false negative tTGA.
Resource: NICE NG20 (2015)
148
25-year-old man with recurrent diarrhoea, RIF pain, weight loss, raised CRP and positive calprotectin.
What is the SINGLE MOST likely diagnosis?
A. IBS
B. Colorectal cancer
C. Crohn’s disease
D. Gastroenteritis
E. Diverticulitis
Answer: C. Crohn’s disease
Justification: Classic presentation with raised inflammatory markers and faecal calprotectin.
Resource: RCGP Learning
149
51-year-old woman with bloating, no weight loss or bowel habit change.
Discomfort relieved by bowel movements.
Which investigation is appropriate?
A. Faecal elastase
B. H. pylori serology
C. Serum IgG
D. Lactose tolerance test
E. CA125
Answer: E. CA125
Justification: NICE recommends CA125 in women >50 with persistent GI symptoms due to ovarian cancer risk.
Resources: NICE CG61, NG12, BSG IBS guidelines
150
55-year-old man with new onset GORD symptoms.
Which is NOT recommended by NICE?
A. Managing stress/depression
B. HbA1c testing
C. Targeted behaviour change
D. Trial of omeprazole
E. Medication review
Answer: B. HbA1c testing
Justification: Screening for diabetes is not routinely recommended in GORD management.
Resource: NICE CG184 (2014, updated 2019)
151
30-year-old man with anal fissure and soft stools.
What is the SINGLE MOST appropriate INITIAL treatment for pain?
A. Bisacodyl
B. Codeine phosphate
C. Diltiazem cream
D. GTN ointment
E. Local anaesthetic ointment
Answer: E. Local anaesthetic ointment
Justification: First-line for fissure pain; GTN is used if symptoms persist.
Resource: RCGP Learning
152
59-year-old postmenopausal woman with bloating and loss of appetite.
No rectal bleeding or bowel habit change. All bloods normal.
What is the most relevant cancer diagnosis to consider?
A. Colon cancer
B. Pancreatic cancer
C. Bladder cancer
D. Ovarian cancer
E. Endometrial cancer
Answer: D. Ovarian cancer
Justification: NICE advises investigation in women >50 with IBS-like symptoms.
Resources: NICE CG122 (2011); Knapp S et al. InnovAiT 2021
153
Match the most likely diagnosis to each GI scenario:
1. 29F with pain, loose stools, rectal bleeding, skip lesions
2. 63M with LIF pain, constipation, iron-deficiency anaemia
3. 33M with anal pain and bright red bleeding, constipation
4. 56F with RUQ pain radiating to back after meals, tender RUQ
Answers:
1. Crohn’s disease
2. Colorectal carcinoma
3. Anal fissure
4. Biliary colic
Justification: Clinical scenarios reflect classic GI presentations.
Resource: RCGP Learning
154
22-year-old with recurrent bloody diarrhoea, urgency, tenesmus, erythema nodosum.
What is the SINGLE MOST likely diagnosis?
A. Intussusception
B. Colon cancer
C. Viral gastroenteritis
D. Diverticulitis
E. Ulcerative colitis
Answer: E. Ulcerative colitis
Justification: Classic features including extra-intestinal signs (e.g. erythema nodosum).
Resource: Andrews C. InnovAiT 2019; 12(9): 501–506
155
67-year-old man with learning difficulties, abdominal pain and distension.
Absolute constipation. Previous CT normal.
What is the SINGLE MOST likely diagnosis?
A. Gastroenteritis
B. Diverticulitis
C. Coeliac disease
D. Sigmoid volvulus
E. Intra-abdominal adhesions
Answer: D. Sigmoid volvulus
Justification: Longstanding constipation leads to redundancy and volvulus in sigmoid.
Resource: RCGP Learning
156
78-year-old man with recurrent dyspepsia.
What is the SINGLE MOST common cause of dyspepsia in adults?
A. Peptic ulcer disease
B. Gastroparesis
C. Hiatus hernia
D. Barrett’s oesophagus
E. Functional dyspepsia
Answer: E. Functional dyspepsia
Justification: Most common cause without clear underlying pathology.
Resource: RCGP Learning
157
25-year-old woman with 4 months of alternating bowel habits, abdominal pain, bloating.
Pain relieved by defecation.
What is the MOST likely diagnosis?
A. IBS
B. UC
C. Coeliac disease
D. Ovarian cancer
E. H. pylori infection
Answer: A. IBS
Justification: Classic functional GI disorder pattern.
Resource: Lawton T. InnovAiT 2022; 15(10): 567–572
158
Match cause of jaundice to case:
1. 40M with UC, fatigue, pruritus, marked jaundice
2. 24M on methadone, tired, joint aches, jaundice
3. 45M with T2DM, arthritis, pruritus, high ferritin
Answers:
1. Primary sclerosing cholangitis
2. Hepatitis C
3. Haemochromatosis
Justification: Match presentations to typical pathologies.
Resource: RCGP Learning
159
What is the SINGLE MOST significant risk factor for advanced NAFLD?
A. Age <45
B. Hypertension
C. BMI 25–30
D. Gout
E. Female sex
Answer: B. Hypertension
Justification: Alongside T2DM and obesity, HTN predicts progression.
Resource: NICE CKS NAFLD risk factors (2021)
160
35-year-old man with chronic hepatitis C referred for treatment.
What is the LIKELY cure rate of modern therapy?
A. 10%
B. 30%
C. 50%
D. 70%
E. 95%
Answer: E. 95%
Justification: Direct-acting antivirals cure ~95% of HCV cases.
Resource: WHO Hepatitis C Fact Sheet (2022)
161
You visit a 76-year-old lady with a two-day history of constipation, abdominal pain, vomiting, and inability to pass flatus.
Past history: hysterectomy at 64. On exam: distended, tender abdomen, absent bowel sounds, empty rectum.
What is the SINGLE MOST likely diagnosis?
A. Perforated duodenal ulcer
B. Chronic constipation
C. Intestinal obstruction
D. Gastroenteritis
E. Acute pancreatitis
Answer: C. Intestinal obstruction
Justification: SBO is common post-abdominal surgery. Symptoms: diffuse pain, distension, nausea, vomiting.
Resource: RCGP Learning
162
47-year-old woman with pancreatitis: history of HTN (ramipril, amlodipine), T2DM (gliclazide, metformin), Crohn's (azathioprine).
Which drug is the MOST LIKELY cause of pancreatitis?
A. Gliclazide
B. Azathioprine
C. Ramipril
D. Metformin
E. Amlodipine
Answer: B. Azathioprine
Justification: Azathioprine is a known cause of drug-induced pancreatitis.
Resource: RCGP Learning
163
13-year-old with abdominal pain, diarrhoea, weight loss, raised inflammatory markers, calprotectin 250 µg/g.
What is the SINGLE MOST likely diagnosis?
A. IBS
B. Coeliac disease
C. Colon cancer
D. Gastroenteritis
E. Crohn’s disease
Answer: E. Crohn’s disease
Justification: Classic IBD presentation in children.
Resource: Yasin F, Hibberd O. InnovAiT 2024; 17(11-12): 495–499
164
37-year-old with IBD and stoma has inflamed, painful ulcers around stoma with purple edges.
What is the SINGLE MOST likely diagnosis?
A. Squamous cell carcinoma
B. Pyoderma gangrenosum
C. Tinea corporis
D. Erythema multiforme
E. Irritant contact dermatitis
Answer: B. Pyoderma gangrenosum
Justification: Severe peristomal skin damage, linked to IBD, requires specialist care.
Resource: Thomas M et al. InnovAiT 2021; 14(10): 623–628
165
24-year-old with jaundice and RUQ pain after eating street food. Vaccinated against Hep A.
What is the SINGLE MOST likely diagnosis?
A. Hepatitis A
B. Hepatitis B
C. Hepatitis E
D. Gallstones
E. Hepatitis D
Answer: C. Hepatitis E
Justification: Hep E is faecal-oral and common in travel-related infections when Hep A immunity exists.
Resource: Downes TJ et al. InnovAiT 2022; 15(11): 621–628
166
53-year-old man with intense perianal itching, worse at night. Normal exam.
What is the SINGLE MOST appropriate treatment?
A. Hydrocortisone cream
B. Ibuprofen gel
C. Lidocaine gel
D. Fusidic acid cream
E. Daktarin cream
Answer: A. Hydrocortisone cream
Justification: Short-course topical steroid appropriate for idiopathic pruritis ani.
Resource: Damisa J et al. InnovAiT 2022; 15(6): 336–341
167
24-year-old with tiredness, constipation, diarrhoea, no weight change. Normal FBC.
What is the SINGLE MOST appropriate initial investigation?
A. Endomysial antibodies
B. Anti-gliadin antibodies
C. IgA tissue transglutaminase
D. Total IgG
E. Protein electrophoresis
Answer: C. IgA tissue transglutaminase
Justification: First-line test for coeliac disease. Test IgA level simultaneously.
Resource: NICE NG20 (2015)
168
32-year-old man with dyspepsia for a month, worse post-food. Tried Gaviscon® and omeprazole.
What is the SINGLE MOST appropriate management?
A. H. pylori test
B. Blood tests
C. Endoscopy
D. CT abdomen
E. Barium swallow
Answer: A. H. pylori test
Justification: NICE suggests H. pylori test if PPI fails and no alarm symptoms.
Resource: NICE CG184 (2014, updated 2019); Sivakumar A, Stubbs B. InnovAiT 2021
169
Which ONE statement about GGT is true?
A. It is produced by hepatocytes
B. Marker for cirrhosis
C. Specific to alcohol
D. Not useful in liver disease
E. Drugs rarely elevate it
Answer: A. It is produced by hepatocytes
Justification: GGT is liver-derived and elevated by alcohol, drugs, and liver injury.
Resource: RCGP Learning
170
Who should be offered FIT testing? (Select all that apply)
A. 42F with weight loss + abdo pain
B. 51F with persistent bloating
C. 54M with family Hx colorectal cancer
D. 60F with anaemia and normal ferritin
E. 62M with iron deficiency anaemia
Answers: A, D, E
Justification: NICE recommends FIT in these presentations to guide colorectal cancer referral.
Resource: NICE NG12 (Updated 2023)
171
Patient with suspected primary biliary cholangitis and pruritis.
What is the SINGLE MOST appropriate first-line management?
A. Colestyramine
B. Ursodeoxycholic acid
C. Obeticholic acid
D. Lactulose
E. Creon
Answer: B. Ursodeoxycholic acid
Justification: First-line for slowing disease progression and improving liver biochemistry.
Resource: Perry M, Pathak A. InnovAiT 2022; 15(10): 581–588
172
54M with mild diverticulitis and LIF pain. Stable obs.
What is the SINGLE MOST appropriate analgesia?
A. Tramadol
B. Paracetamol
C. Morphine
D. Codeine
E. Naproxen
Answer: B. Paracetamol
Justification: Avoid NSAIDs and opioids due to perforation risk. Paracetamol is safest.
Resource: RCGP Learning
173
34M with 3-month history of epigastric pain, reflux, no red flags.
Tried OTC antacids.
What is the SINGLE MOST appropriate PPI regimen?
A. 4 weeks low dose
B. 4 weeks full dose
C. 4 weeks double dose
D. 8 weeks low dose
E. 8 weeks full dose
Answer: B. 4 weeks full dose
Justification: NICE recommends 4-week trial of full-dose PPI + test for H. pylori.
Resource: NICE CG184 (2014, updated 2019)
174
32M with rectal bleeding, cramps, vomiting for 3 months.
What is the SINGLE MOST appropriate investigation?
A. Rectal swab
B. Abdominal US
C. Abdominal X-ray
D. CEA blood test
E. Faecal calprotectin
Answer: E. Faecal calprotectin
Justification: Used to confirm/exclude IBD.
Resource: RCGP Learning
175
Which electrolyte is MOST commonly disturbed in refeeding syndrome?
A. Salt & water depletion
B. Hypophosphatemia
C. Thiamine overload
D. Hypermagnesaemia
E. Hyperkalaemia
Answer: B. Hypophosphatemia
Justification: Intracellular phosphate shift upon refeeding leads to hypophosphatemia.
Resource: Hjalmarsson C, Daniels NF. InnovAiT 2021
176
54M with persistently abnormal LFTs, normal BMI/alcohol, no aetiology found.
What is the SINGLE MOST appropriate next step?
A. DEXA scan
B. Annual monitoring
C. CT upper abdomen
D. OGD
E. Refer to liver clinic
Answer: E. Refer to liver clinic
Justification: Referral needed for persistent abnormal LFTs with no clear cause.
Resource: RCGP Learning
177
49M with bilirubin 64, normal other LFTs and fasting glucose.
What is the SINGLE MOST likely diagnosis?
A. Alcoholic liver disease
B. Primary biliary cholangitis
C. Gilbert’s syndrome
D. NAFLD
E. Autoimmune hepatitis
Answer: C. Gilbert’s syndrome
Justification: Isolated raised unconjugated bilirubin with no other abnormal LFTs.
Resource: BSG Guidelines (2021)
178
38F with persistent dyspepsia. Omeprazole helped but symptoms returned.
What is the next best step?
A. H. pylori testing
B. Maintain on lowest dose PPI
C. Routine gastro referral
D. Famotidine trial
E. Endoscopy
Answer: A. H. pylori testing
Justification: NICE recommends test if symptoms recur post-PPI.
Resource: Donnelly H, Nolan T. InnovAiT 2019
179
42F with RUQ pain radiating to chest and back. Worse on deep inspiration.
What is the SINGLE MOST likely diagnosis?
A. Oesophageal spasm
B. Tietze’s syndrome
C. Cholecystitis
D. Pancreatitis
E. PE
Answer: C. Cholecystitis
Justification: RUQ pain with positive Murphy’s sign typical of cholecystitis.
Resource: Stone C. InnovAiT 2023; 16(3): 120–125
180
18M with IBS and pain not responding to loperamide, laxatives, antispasmodics.
What is the NEXT most appropriate treatment?
A. Amitriptyline
B. Codeine
C. Gabapentin
D. Sertraline
E. Venlafaxine
Answer: A. Amitriptyline
Justification: TCAs are second-line for IBS, used for analgesic effect.
Resource: NICE CG61 (2008, updated 2017)
181
You see a 24-year-old female patient with recurrent lower abdominal pain associated with rectal bleeding. The bleeding is mixed with the stools and associated with weight loss. Her faecal calprotectin stool sample is positive.
What is the SINGLE MOST likely diagnosis?
A. Carcinoma of the colon
B. Crohn’s disease
C. Diverticular disease
D. Ulcerative colitis
E. Haemorrhoids
Answer: D. Ulcerative colitis
Justification: The clinical picture is suggestive of inflammatory bowel disease. Bleeding is less common with Crohn’s but almost universal in UC, which typically presents with diarrhoea and rectal bleeding in patients aged 15–25.
Resource: Bonner C, Pickering GAE. Rectal bleeding. InnovAiT 2022; 15(11): 629–633.
182
You see a 62-year-old man who complains of dyspepsia for 2 months. He has tried antacids without much effect. PMH: osteoporosis, gout, hypertension.
Which of the following medications is MOST likely to be contributing to his dyspepsia?
A. Allopurinol
B. Indapamide
C. Ramipril
D. Alendronic acid
E. Doxazosin
Answer: D. Alendronic acid
Justification: Bisphosphonates like alendronic acid are known to cause dyspepsia.
Resource: Stone C. Assessment of chest pain. InnovAiT 2023; 16(3): 120–125.
183
A 34-year-old man with a history of ulcerative colitis attends complaining of abdominal pain, increased stool frequency and rectal bleeding.
Which ONE of the following scales is used to determine the severity of ulcerative colitis?
A. Dukes’ staging criteria
B. Ranson’s severity score
C. Bristol stool scale
D. Truelove and Witts’ severity index
E. Carr–Hill formula
Answer: D. Truelove and Witts’ severity index
Justification: This index is used to categorise UC as mild, moderate, or severe.
Resource: NICE. Ulcerative colitis: management. NG130. 2019.
184
You see a 57-year-old man with troublesome gastric reflux, intermittent upper abdominal pain, dysphagia, vomiting and 1 kg weight loss.
What is the SINGLE MOST likely diagnosis?
A. Pharyngeal pouch
B. Hiatus hernia
C. Cholecystitis
D. Gastric cancer
E. Acute pancreatitis
Answer: D. Gastric cancer
Justification: Dysphagia, upper abdominal pain and weight loss are red flags for upper GI cancer.
Resources: NICE. Suspected cancer: recognition and referral. NG12 (2023); Baxter KA et al. InnovAiT 2022; 15(9): 520–523.
185
A 53-year-old woman has worsening left lower quadrant pain for 24 hours. Systemically well.
What is the SINGLE MOST appropriate next step?
A. Amoxicillin
B. No antibiotic indicated
C. Ciprofloxacin
D. Co-amoxiclav
E. Metronidazole
Answer: B. No antibiotic indicated
Justification: NICE recommends no antibiotics for uncomplicated diverticulitis in well patients.
Resource: NICE CKS. Acute diverticulitis (2023).
186
A 29-year-old man’s peripheral blood film shows Howell–Jolly bodies.
What is the SINGLE MOST likely cause?
A. Splenectomy
B. Renal failure
C. Myeloma
D. Iron deficiency anaemia
E. Hereditary elliptocytosis
Answer: A. Splenectomy
Justification: Howell–Jolly bodies are nuclear remnants seen post-splenectomy.
Resource: RCGP Learning
187
A 52-year-old man has a long history of dyspepsia, unresponsive to therapy. PMH: HTN, CHD, hay fever.
Which medication is MORE LIKELY to contribute to dyspepsia?
A. Atorvastatin
B. Spironolactone
C. Isosorbide mononitrate
D. Losartan
E. Cetirizine
Answer: C. Isosorbide mononitrate
Justification: Nitrates are known to cause dyspepsia by relaxing lower oesophageal sphincter.
Resource: RCGP Learning
188
A 21-year-old presents with recurrent bloody diarrhoea, colicky abdominal pain, tenesmus and erythema nodosum.
What is the gold standard test?
A. Sigmoidoscopy and biopsy
B. Faecal elastase
C. CT colonography
D. Colonoscopy and biopsy
E. Faecal calprotectin
Answer: D. Colonoscopy and biopsy
Justification: Gold standard for diagnosing ulcerative colitis.
Resource: Andrews C. Ulcerative colitis. InnovAiT 2019; 12(9): 501–506.
189
62-year-old woman with RA and hypothyroidism, on levothyroxine and PPI, has upper abdominal pain, itching, mild jaundice. LFTs: ALT 176, bilirubin 62, normal ALP. ANA raised.
What is the SINGLE MOST likely diagnosis?
A. Malignancy
B. Glandular fever
C. NAFLD
D. Autoimmune hepatitis
E. Haemochromatosis
Answer: D. Autoimmune hepatitis
Justification: Raised ALT, ANA, associated autoimmune diseases and polyclonal IgG.
Resource: RCGP Learning
190
40-year-old woman completed H. pylori eradication therapy 1 day ago.
What is the correct timing for test of eradication?
A. Urea breath test at 4 weeks
B. Urea breath test at 1 week
C. Stool antigen at 1 week
D. Serology at 1 week
E. Serology at 4 weeks
Answer: A. Urea breath test at 4 weeks
Justification: Accurate and recommended method post-treatment; avoid early testing.
Resource: NICE CG184 (2014, updated 2019).
191
53-year-old man with epigastric pain radiating to back, vomiting, tenderness, and Cullen’s sign. Known alcohol excess.
What is the SINGLE MOST appropriate next step?
A. Arrange ultrasound scan
B. Urgent same-day admission
C. H. pylori stool antigen test
D. Urgent gastroscopy
E. Advice and discharge
Answer: B. Urgent same-day admission
Justification: Classic presentation of acute pancreatitis; needs hospitalisation and supportive care.
Resource: Gibbs R, Gibbs W. Alcoholic pancreatitis. InnovAiT 2021; 14(8): 479–483.
192
56-year-old on long-term PPIs for GORD is asymptomatic and wishes to stop.
What is the SINGLE MOST appropriate management?
A. Refer for endoscopy
B. Continue PPIs
C. Offer cover with alternative for 4 weeks
D. Refer to gastroenterology
E. Do H. pylori stool antigen test
Answer: C. Offer cover with alternative for 4 weeks
Justification: Cover with H2RA or alginate therapy prevents rebound hypersecretion.
Resource: Kumar M. PPIs and upper GI cancers. InnovAiT 2019; 12(9): 526–530.
193
71-year-old woman with 3-month history of LIF pain, bloating, and constipation. No red flags. Normal CA125.
What is the SINGLE MOST likely diagnosis?
A. Diverticular disease
B. Gastroenteritis
C. Ovarian carcinoma
D. Diverticulitis
E. Ischaemic colitis
Answer: A. Diverticular disease
Justification: Typical chronic symptoms without systemic features suggest uncomplicated diverticular disease.
Resource: RCGP Learning
194
44-year-old woman with 5-month history of bloating, loose stools, weight loss, malaise. Hb 10.7, MCV 68.
What is the SINGLE MOST likely initial diagnosis?
A. Bleeding peptic ulcer
B. Diverticulitis
C. Endometriosis
D. Coeliac disease
E. IBS
Answer: D. Coeliac disease
Justification: Symptoms with microcytic anaemia and hypothyroidism suggest coeliac disease.
Resource: RCGP Learning
195
30-year-old woman with chronic hepatitis C, BMI 20, smokes, drinks 36 units alcohol/week.
What is the SINGLE MOST relevant risk factor for cirrhosis?
A. Smoking history
B. Age at diagnosis
C. Body mass index
D. Alcohol consumption
E. Female gender
Answer: D. Alcohol consumption
Justification: Alcohol doubles cirrhosis risk in hepatitis C.
Resource: RCGP Learning
196
68-year-old with generalised abdo pain, vomiting, not opened bowels in 4 days. Distended abdomen, absent bowel sounds.
What is the SINGLE MOST likely diagnosis?
A. Bowel obstruction
B. IBS
C. Gastroenteritis
D. Diverticulitis
E. Coeliac disease
Answer: A. Bowel obstruction
Justification: Distension, vomiting, and absent bowel sounds suggest large bowel obstruction.
Resource: RCGP Learning
197
Which patient needs URGENT referral (within 2 weeks)?
A. 43F with soft reducible right groin lump below pubic tubercle
B. 68M with incisional hernia
C. 36M with bilateral groin hernias
D. 3-month-old with umbilical hernia
E. 29M with hard irreducible left groin lump and vomiting
Answer: A. 43F with soft reducible right groin lump below pubic tubercle
Justification: Likely femoral hernia in woman — urgent 2-week referral advised.
Resource: RCS Hernia Commissioning Guide (2013)
198
Which presenting symptom is MOST predictive of oesophagogastric cancer?
A. Dyspepsia
B. Nausea/vomiting/bloating
C. Reflux
D. Weight loss
Answer: D. Weight loss
Justification: Highest positive likelihood ratio with significant confidence interval.
Resource: RCGP Learning
199
53-year-old man with GORD symptoms. PMH: HTN, COPD, hiatus hernia. BMI 31.
Which is LEAST likely a risk factor for GORD?
A. Age >50
B. COPD
C. Hiatus hernia
D. Male sex
E. Obesity
Answer: B. COPD
Justification: Not a recognised direct risk factor for GORD unlike the others.
Resource: RCGP Learning
200
63-year-old woman with 3 cm groin lump, below and lateral to pubic tubercle.
What is the SINGLE MOST likely diagnosis?
A. Inguinal lymph node
B. Direct inguinal hernia
C. Indirect inguinal hernia
D. Femoral hernia
E. Lumbar hernia
Answer: D. Femoral hernia
Justification: Typical anatomical location in a woman.
Resource: Rance C, Jones A. Abdominal wall hernias. InnovAiT 2021; 14(6): 379–385.
