Gastrointestinal - Practice papers

Question 1

1. Regarding Peutz-Jeghers syndrome:
   a) It is inherited in an autosomal recessive manner
   b) There is an association with intussusception
   c) Polyps are seen in the stomach
   d) Patients are at increased risk of gastrointestinal adenocarcinoma
   e) It is associated with pigmented lesions on the fingers

Answer 1

1
a) False - autosomal dominant
b) True
c) True - polyps are usually in the small bowel, most commonly seen in the jejunum but
polyps are also seen in the colon and stomach
d) True - but polyps themselves are hamartomatous polyps and are benign
f) True - multiple melanin spots are seen on mucous membranes, facial skin, fingers and toes

Question 2

2. The following statements regarding familial adenomatous polyposis syndrome are true:
   a) Its inheritence pattern is autosomal dominant
   b) Clinical symptoms become evident during the 5th-6th decade
   c) Polyps are identified in the stomach in 5% of affected cases
   d) It is associated with peri-ampullary carcinoma
   e) It is associated with alopecia

Answer 2

1
a) True
b) False - usually presents 20-30-year-olds
c) True
d) True
e) False - small bowel polyps, nail atrophy, brown skin pigmentation and alopecia are features
of Canada-Cronkhite syndrome

Question 3

3. Regarding carcinoid tumour:
   a) It is rarely multiple
   b) Carcinoid syndrome is the presentation in only 20-30% of cases
   c) The commonest location for this tumour is the appendix
   d) 50% of tumours greater than 2 cm in size have metastases
   e) Angulation of small bowel loops on small bowel follow through is a diagnostic feature

Answer 3

3
a) False - 33% are multiple
b) False - carcinoid syndrome is the presentation in 7% of cases. Syndrome arises due to
excess serotonin levels
c) True - located in the appendix in 30-45%
d) False - 50% of tumours of 1-2 cm in size have metastases, 85% of tumours greater than 2
cm have metastases
e) True - there is a strong desmoplastic response in the mesentery, resulting in angulation and
kinking of small bowel loops which can cause small bowel obstruction

Question 4

4. The following statements regarding achalasia are correct:
   a) Dilatation of the oesophagus begins in the upper third
   b) Multiple non-peristaltic contractions are seen on barium swallow
   c) There is an association with Plummer-Vinson syndrome
   d) A prominent gastric air bubble is seen on erect CXR
   e) Squamous cell carcinoma of the oesophagus is a recognized complication

Answer 4

4
a) True - progresses to involve the entire length
b) True
c) False
d) False
e) True

Question 5

5. Regarding toxic megacolon:
   a) Ischaemic colitis is the most common underlying pathological cause
   b) Multiple air fluid levels are seen on plain abdominal X-ray
   c) Barium enema is contraindicated
   d) Has a mortality of 5-8%
   e) Can present as bloody diarrhoea

Answer 5

5
a) False - ulcerative colitis
b) False - few air fluid levels are seen. Plain abdominal radiograph appearances of a dilated
transverse colon of greater than 5.5 cm in diameter and pneumatosis coli
c) True
d) False - mortality of 20%
e) True

Question 6

6. The following statements regarding lymphoma of the gastrointestinal tract are true:
   a) There is an increased risk associated with ulcerative colitis
   b) The stomach is the most common site of involvement by non- Hodgkin’s lymphoma
   c) Diffuse involvement of the whole stomach is seen in 10-15%
   d) In the colon the rectum is most commonly involved
   e) Presents with thickened valvulae conniventes in the small bowel

Answer 6

6
a) False - increased risk associated with Crohn’s disease, coeliac disease, AIDS, systemic
lupus erythematosus
b) True
c) False - diffuse involvement in 50%
d) False - caecum is most commonly involved
e) True

Question 7

7. Duodenal ulcers:
   a) Are usually associated with a normal level of gastric acid secretion
   b) Are most likely to be found in the posterior wall of the duodenal bulb
   c) Are usually greater than 2 cm in size
   d) Perforation is a complication in 20-30%
   e) Vagotomy is a recognized treatment

Answer 7

7
a) False - gastric acid levels are usually increased. Gastric ulcers are associated with a normal
or low level of gastric acid
b) False - ulcers are bulbar in 95% and Postbulbar in 3-5%. 50% are located in the anterior
wall
c) False - less than 1 mm in size. Giant duodenal ulcers >2 cm are rare and have a higher risk
of morbidity/mortality
d) False - perforation is a complication in <10%
e) True

Question 8

8. Regarding oesophageal duplication cysts:
   a) The oesophagus is the commonest site for duplication cysts in the alimentary canal
   b) They are more commonly found on the left side
   c) There is an association with spina bifida
   d) 50-60% occur in the mid-oesophagus
   e) On a PA CXR they can be mistaken for a hiatus hernia

Answer 8

8
a) False - found in the ileum 30%, oesophagus 20%, colon 15-30%, stomach 10%
b) False - right
c) True - there is an association with vertebral anomalies - spina bifida, hemivertebra and
fusion defects
d) False - 60% occur in the distal oesophagus, 27% upper and 17% mid
e) True - posterior mediastinal mass +/- air fluid level

Question 9

9. The following features are commoner in Crohn’s disease than in ulcerative colitis:
   a) Toxic megacolon
   b) Increased risk of colonic carcinoma
   c) Formation of vesicocolic fistula
   d) Thickening of the ileocaecal valve
   e) Shallow ulcers

Answer 9

9
a) False
b) False
c) True
d) True - gaping ileocaecal valve In ulcerative colitis
e) False - deep ulcers commoner in Crohn’s disease

Question 10

10. The following drugs reduce gastric emptying:
    a) Buscopan
    b) Glucagon
    c) Metoclopramide
    d) Procyclidine
    e) Indomethacin

Answer 10

10
a) True
b) True
c) False
d) False
e) False

Question 11

11. Giardiasisis is associated with:
    a) Gastric varices ‘
    b) Hypoperistalsis with a reduced transit time
    c) Malabsorption
    d) Thickened small bowel mucosal folds
    e) Ulceration

Answer 11

11
a) False
b) False
c) True
d) True
e) False

Question 12

12. Regarding peritoneal spaces:
    a) The right subhepatic space communicates with the lesser sac
    b) The bare area of the liver is located between reflections of the right and left coronary
    ligaments
    c) The left subphrenic space is separated from the right subphrenic space by the falciform
    ligament
    d) The splenorenal ligament separates the left subphrenic space from the left paracolic gutter
    e) The gastrocolic ligament connects the lesser curve of the stomach to the superior aspect of
    the transverse colon

Answer 12

12
a) True - via the epiploic foramen
b) True
c) True
d) False - phrenicolic ligament attaches the descending colon to the left hemidiaphragm
e) False - greater curve

Question 13

13. Regarding CT colonography:
    a) No preparation is required
    b) Images are acquired with the patient supine and prone
    c) A mass which does not move after changing patient position represents a polyp
    d) Extracolonic findings that require further investigation are found in 10% of patients
    e) The appendix orifice can be differentiated from tumour by coronal reformats

Answer 13

13
a) False - same preparation as barium enema
b) True
c) False - small faecal residue can be adherent to the wall. Small foci of faecal residue may
also not contain gas bubbles, unlike larger foci
d) True
e) True

Question 14

14. Imaging features of acute appendicitis include:
    a) Enlarged appendix >6 mm in diameter
    b) Enlarged mesenteric lymph nodes
    c) Presence of appendicolith
    d) Focal caecal apical wall thickening
    e) Peri-appendiceal fat stranding

Answer 14

14
a) True
b) True
c) True
d) True
e) True

Question 15

15. Regarding gastrointestinal stromal tumours (GIST):
    a) The most significant criteria for predicting malignant potential is tumour size
    b) The commonest location is the sigmoid
    c) It is a cause of haematemesis
    d) There is an association with neurofibromatosis Type 1
    e) Contrast enhancement is invariably uniform

Answer 15

15
a) True
b) False - stomach
c) False
d) True
e) False - heterogenous with significant haemorrhage and necrosis

Question 16

16. Regarding MR imaging of anal cancer:
    a) Anal cancer is associated with infection with human papilloma virus
    b) Anal cancer is usually an adenocarcinoma
    c) The dentate line of the anal canal is identified on MRI
    d) Tumours arising below the dentate line spread to interna! iliac lymph nodes
    e) Primary anal tumours are of high signal intensity on T2 weighted images

Answer 16

16
a) True
b) False - squamous cell carcinoma
c) False - not seen
d) False - tumours below the dentate line spread to the inguinal lymph nodes. Tumours arising
above, spread to perirectal and retroperitoneal nodes
e) True - reduced signal intensity on T1

Question 17

17. Regarding small bowel obstruction:
    a) Adhesions are responsible for 20-25% of small bowel obstructions
    b) Right-sided paraduodenal hernias are commoner than the left
    c) Adenocarcinomas of the small bowel usually arise in the ileum
    d) Gas within the bowel wall is an imaging feature of a bowel infarct
    e) Small bowel intussusceptions can occur in coeliac disease

Answer 17

17
a) False - 50-60%
b) False - left are commoner than right. Paraduodenal hernias are the commonest internal
hernias. Small bowel herniates into Landzert’s fossa to the left of the duodenum, which
arises due to a defect in the descending mesocolon
c) False - proximal jejunum or duodenum
d) True
e) True

Question 18

18. Regarding post-transplantation lymphoproliferative disorder (PTLD):
    a) It most commonly occurs in renal transplant patients
    b) PTLD contributes to death in 10-12% of transplant recipients
    c) Mean presentation occurs 40-50 months post-transplantation
    d) Extranodal disease is considerably less common than in lymphoma affecting nonimmunocompromised
    people
    e) The spleen is the most frequently affected organ

Answer 18

18
a) False - least commonly occurs in renal transplant patients. Commonest in heart-lung
recipients
b) False - 1 %
c) True
d) False - considerably more common
e) False - liver

Question 19

19. Causes of disproportionate fat stranding in excess of the degree of bowel wall thickening
    include:
    a) Crohn’s disease
    b) Omental infarction
    c) Diverticulitis
    d) Epiploic appendigitis
    e) Ischaemic bowel

Answer 19

19
a) False
b) True
c) True
d) True - appendicitis is the other cause
e) False

Question 20

20. Regarding oesophageal balloon dilatation and stent placement:
    a) In benign strictures, oesophageal dilatation has technical success in 90-95%
    b) Oesophageal stent placement relieves dysphagia in 50-60%
    c) An oesophageal stricture should be evaluated with endoscopy before dilatation/stent
    placement
    d) Risk of perforation following dilatation is 2-3%
    e) Stents are more likely to migrate proximally

Answer 20

20
a) True - dilatation of oesophageal webs gives highest success rate
b) False - relieves dysphagia in 90%
c) True
d) True
e) False - migration occurs in up to 35%. Stents are more likely to migrate distally and most
commonly occurs when the gastro- oeophageal junction is crossed

Question 21

21. Regarding hepatic adenoma:
    a) It is associated with Type 1 glycogen storage disease
    b) Is located in the left lobe of the liver in 60-75% of cases
    c) Is easily differentiated from hepatocellular carcinoma on MRI
    d) Is hypovasular
    e) Often reduces in size during pregnancy

Answer 21

21
a) True
b) False - right lobe
c) False - indistinguishable on all pulse sequences
d) False - hypervascular. There is a significant risk of bleeding at biopsy
e) False - increases in size during pregnancy

Question 22

22. Causes of hepatic lesions with a central scar include:
    a) Hepatic adenoma
    b) Fibrolamellar hepatocellular carcinoma
    c) Focal nodular hyperplasia
    d) Giant cavernous haemangioma
    e) Hepatic lymphoma

Answer 22

22
a) True
b) True
c) True
d) True
e) False

Question 23

23. Features of an annular pancreas include:
    a) It occurs when part of the dorsal bud fails to atrophy
    b) Associated with an imperforate anus
    c) Usually involves the 3rd part of the duodenum
    d) The ‘double-bubble’ sign is seen on plain abdominal radiograph
    e) There is an increased incidence of peptic ulcers

Answer 23

23
a) False - occurs when part of the ventral bud fails to atrophy
b) True - other associations are tracheo-oesophageal fistula, oesophageal and duodenal atresia,
and Down’s syndrome
c) False - 85% involve the 2nd part of the duodenum, 15% involve 1st and 3rd
d) True
e) True - increased risk of peri-ampullary ulcers

Question 24

24. The following statements regarding primary sclerosing cholangitis is true:
    a) It affects only the intrahepatic bile ducts
    b) The common bile duct is usually spared
    c) Echogenic portal triads are identified on ultrasound
    d) There is a 10-15 times increased risk of developing cholangiocarcinoma
    e) It is associated with positive antimitochondrial antibodies

Answer 24

24
a) False - intra and extrahepatic bile ducts are involved
b) False - almost always involved
c) True
d) True
e) False - feature of primary biliary cirrhosis

Question 25

25. Regarding fibrolamellar hepatocellular carcinoma:
    a) Alcoholic cirrhosis is a recognized risk factor
    b) Commonly occurs in the elderly
    c) Calcification is rare
    d) The central scar is hypointense on T1 and hyperintense on T2 weighted MRI images
    e) Has a good prognosis

Answer 25

25
a) False - no recognized underlying risk factors
b) False - commonly 5-35-year-olds
c) False - central stellate calcification in 30-40%
d) False - reduced signal intensity on T1 and T2 weighted MRI images. In focal nodular
hyperplasia there is reduced signal intensity on T1 and increased on T2
e) False - 90% mortality. Average survival of 6 months

Question 26

26. Features of primary biliary cirrhosis include:
    a) Xanthelasma
    b) Involvement of the intra and extrahepatic bile ducts
    c) Prolongation of hepatic Tc-99m IDA clearance
    d) Non-visualisation of the gallbladder on oral cholecystogram
    e) Affects 30-50-year-old women

Answer 26

26
a) True
b) False - normal extrahepatic ducts
c) True
d) False - normal gallbladder
e) True

Question 27

27. Gastrointestinal features of cystic fibrosis include:
    a) Portal hypertension
    b) Mega-gallbladder
    c) Lipomatous pseudohypertrophy of the pancreas
    d) Increased calibre of colon
    e) Meconium ileus

Answer 27

27
a) True - other liver features: cirrhosis, fatty infiltration, portal hypertension
b) False - hypoplastic gallbladder
c) True - other pancreatic features: calcifications, pancreatic cysts
d) False - microcolon with hyperplastic colonic mucosa
e) True

Question 28

28. With respect to technetium 99m sulphur colloid scan:
    a) Imaging is performed 60 minutes post-IV injection of radioisotope
    b) 85% of the radioisotope accumulates in the liver
    c) In Budd-Chiari syndrome the caudate lobe has relative increased uptake of radioisotope
    d) Colloid shift away from the liver is seen with long-term corticosteroid therapy
    e) Regenerating nodules of cirrhosis appear as focal ‘cold’ liver lesions

Answer 28

28
a) False - 15-30 minutes
b) True - 10% uptake by spleen, 5% bone marrow
c) True - reduced activity in the rest of the liver, so it is a relative hot spot
d) True - colloid shift seen in cirrhosis, hepatitis, chronic passive congestion and
haematopoietic disorders
e) False – hot

Question 29

29. The following statements regarding cavernous haemangioma of the liver are true:
    a) Most lesions are >5 cm in size
    b) They appear uniformly hypoechoic on ultrasound
    c) Are of high signal intensity on T2 weighted MRI images
    d) Arteriovenous shunts supplying them are identified on hepatic angiography
    e) Contrast enhancement on CT usually lasts for only 3 minutes due to rapid flow

Answer 29

29
a) False - less than 5 cm in size in 90%
b) False - hyperechoic, well defined lesions on ultrasound
c) True - reduced signal intensity on T1 weighted and increased on T2 weighted MR images
d) False - normal-sized arteries feeding with no AV shunting/ neovascularity
e) False - nodular peripheral enhancement early with complete filling in over 30 minutes

Question 30

30. The following are true of gallbladder carcinoma:
    a) Cholelithiasis is seen in 70-80% of patients with gallbladder carcinoma
    b) On ultrasound, diffuse thickening of the gallbladder wall may be found
    c) The body of the gallbladder is the commonest site
    d) A haematogenous route is the most likely mode of spread
    e) Most are squamous cell carcinomas

Answer 30

30
a) True
b) True - can be an intraluminal soft tissue mass or focal/diffuse gallbladder wall thickening
c) False - 60% are located in the fundus
d) False - direct extension to the liver is the commonest mode of spread
e) False - 80% are adenocarcinomas

Question 31

31. Regarding pancreatic anatomy:
    a) it lies at the level of L3
    b) Lies anterior to the splenic vein
    c) A main duct measuring 5 mm in diameter is within normal limits
    d) The superior pancreaticoduodenal artery is a branch of the superior mesenteric artery
    e) The accessory duct drains into the duodenum 2 cm distal to the main duct

Answer 31

31
a) False - L1
b) True
c) False - <3-4 mm
d) False - branch of the gastroduodenal artery from coeliac axis
e) False - 2 mm proximal to the main duct

Question 32

32. The following statements regarding percutaneous ‘ transhepatic cholangiography are true:
    a) Hydatid disease is a contraindication
    b) A 22-gauge Chiba needle is used
    c) No patient preparation is required
    d) Access is gained at the right mid-clavicular line
    e) If a duct is not entered after 4 attempts, the procedure is terminated

Answer 32

32
a) True - other contraindications: biliary tract sepsis and bleeding tendency
b) True
c) False - patient preparation with nil by mouth 5 hours prior to procedure, prophylactic
antibiotics and check prothrombin time/platelets
d) False - mid-axillary
e) False - may be attempted up to 10 times

Question 33

33. Regarding ultrasound of the gallbladder:
    a) Patient preparation with fasting for at least 6 hours is advised
    b) A 3-5 MHz ultrasound transducer is used
    c) A normal gallbladder wall measures <3 mm
    d) An internal diameter measurement of the adult common hepatic duct of 8 mm is within
    normal limits
    e) The common bile duct lies anterior to the hepatic artery in 15 - 20%

Answer 33

33
a) True
b) True
c) True
d) False - less than 4 mm is normal. Common bile duct should measure 6 mm or less in an
adult
e) True

Question 34

34. The following are causes of fatty replacement of the pancreas:
    a) Diabetes mellitus
    b) Haemochromatosis
    c) Chronic pancreatitis
    d) Cushing’s disease
    e) Malnutrition

Answer 34

34
a) True
b) True
c) True
d) True
e) True

Question 35

35. Regarding splenic angiosarcoma:
    a) Is the most common primary neoplasm of the spleen
    b) Is associated with toxic exposure to vinyl chloride
    c) 70% metastasise to the liver
    d) Most commonly found in adults >70 years of age
    e) Spontaneous rupture occurs in one third of cases

Answer 35

35
a) False - very rare
b) False - this is associated with liver angiosarcoma
c) True
d) False - 50-60 years
e) True

Question 36

36. The following statements regarding emphysematous cholecystitis are true:
    a) There is a predisposition in diabetics
    b) Clostridium perfringens is a recognized causative organism
    c) The white cell count is rarely elevated
    d) Gas appears 4-5 days after onset of symptoms
    e) Pneumobilia is a common sign on plain film

Answer 36

36
a) True
b) True
c) False - can be normal in 30%
d) False - 24-48 hours
e) False - rare

Question 37

37. Imaging features of a failure of a transjugular intrahepatic portosystemic shunt (TIPS) are:
    a) Shunt velocity of 90 cm/s
    b) Retrograde flow in the right hepatic vein
    c) Increased pulsatility of portal flow
    d) Reversal of portal venous flow direction
    e) Developing ascites

Answer 37

37
a) False - this is normal. Abnormal <60 cm/s
b) True
c) False - loss of pulsatility of portal flow is a sign of TIPS failure
d) True
e) True

Question 38

38. Imaging features of cirrhosis of the liver include:
    a) Hypertrophy of the lateral segment of the left lobe
    b) Increased hepatic parenchymal echogenicity on ultrasound
    c) Dampened oscillations of the hepatic vein on Doppler ultrasound
    d) Regenerating nodules are of reduced intensity on T2 weighted MRI images
    e) Constriction of hepatic arteries

Answer 38

38
a) True - hypertrophy of caudate lobe and segments 2 and 3. Shrinkage of right lobe and
segments 4a and 4b
b) True - due to fatty infiltration
c) True - Doppler images resemble portal vein flow
d) True - with hyperintense septa
e) False - dilatation of the hepatic arteries

Question 39

39. The following statements regarding the anatomy of the oesophagus are true:
    a) It pierces the diaphragm at level of T10
    b) The lower third is supplied by the right gastric artery
    c) The aberrant right subclavian artery passes anterior to the oesophagus
    d) The Z line identifies the squamocolumnar junction
    e) The oesophageal mucosa is angled in longitudinal folds which normally measure 3-4 mm
    thickness

Answer 39

a) True
b) False - left gastric artery which is a branch of the coeliac axis. The inferior thyroid artery
supplies the upper third and branches from the descending aorta supplies the middle third
c) False - posterior
d) True
e) True

Question 40

40. The following are causes of colonic thumbprinting:
    a) Ulcerative colitis
    b) Behçet’s disease
    c) Cytomegalovirus in renal transplant patients
    d) Pseudomembranous colitis
    e) Lymphoma

Answer 40

40
a) True
b) False
c) True
d) True
e) True - other causes are ischaemic colitis, shistosomiasis, metastases to colon