SBA - Gastroenterology

Question 1

A 47-year-old woman presents to your clinic with a three-month history of dysphagia. There is no history of drastic weight loss and the patient experiences symptoms when swallowing solids but not liquids. Which of the following is not an obstructive cause of dysphagia?

A. Pharyngealcarcinoma
B. Oesophageal web
C. Retrosternalgoitre
D. Pepticstricture
E. Achalasia

Answer 1

Achalasia

Question 2

You see a 47-year-old man in clinic with a three-month history of epigastric dull abdominal pain. He states that the pain is worse in the mornings and is relieved after meals. On direct questioning, there is no history of weight loss and the patient’s bowel habits are normal. On examination, his abdomen is soft and experiences moderate discomfort on palpation of the epigastric region. The most likely diagnosis is:

A. Gastriculcer
B. Gastro-oesophageal reflux disease (GORD)
C. Duodenalulcer
D. Gastriccarcinoma
E. Gastritis

Answer 2

Duodenal ulcer

Question 3

A 55-year-old woman is referred by her GP for upper gastrointestinal (GI) endoscopy following a four-month history of epigastric pain despite treatment with antacids and proton pump inhibitors (PPIs). The results demonstrate a duodenal ulcer coupled with a positive campylobacter-like organism (CLO) test. The patient has no past medical history and has no known drug allergies. The most appropriate treatment is:

A. Seven-day course of twice daily omeprazole 20mg, 1g amoxicillin and 500 mg clarithromycin
B. Seven-day course of twice daily omeprazole 20 mg
C. Seven-day course of twice daily omeprazole 20mg and 1g amoxicillin
D. Seven-day course of twice daily omeprazole 20mg and 500mg
clarithromycin
E. Seven-day course of twice daily 1g amoxicillin and 500mg
clarithromycin

Answer 3

Seven-day course of twice daily omeprazole 20mg, 1g amoxicillin and 500 mg clarithromycin

Question 4

Which of the following is the most common cause of duodenal ulcers?

A. NSAIDs
B. Helicobacter pylori
C. Alcohol abuse
D. Chronic corticosteroid therapy
E. Zollinger–Ellisonsyndrome

Answer 4

Helicobacter pylori

Question 5

You see a 48-year-old lorry driver, who presents to you with a three-month history of heartburn after meals which has not been settling with antacids and PPIs. You suspect that the patient has a hiatus hernia. The most appropriate investigation for diagnosing a hiatus hernia is:

A. Computer tomography (CT) scan
B. Chest x-ray
C. Upper GI endoscopy
D. Barium meal
E. Ultrasound

Answer 5

Barium meal

Question 6

You see a 56-year-old man who was admitted for an elective upper GI endoscopy due to longstanding GORD which has failed to improve on antacids and PPIs. Your registrar suspects that this patient may have Barrett’s oesophagus and asks you to define what this is. The most appropriate description of Barrett’s oesophagus is:

A. Metaplasia of the squamous epithelium of the lower third of the oesophagus to columnar epithelium
B. Metaplasia of the columnar epithelium of the upper third of the oesophagus to squamous epithelium
C. Metaplasia of the columnar epithelium of the lower third of the oesophagus to squamous epithelium
D. Metaplasia of the squamous epithelium of the upper third of the oesophagus to columnar epithelium
E. Metaplasia of the squamous epithelium of the middle third of the oesophagus to columnar epithelium

Answer 6

Metaplasia of the squamous cell epithelium of the lower ⅓ of the oesophagus, to columnar epithelium

Question 7

You see a 25-year-old woman who presents with a 24-hour history of watery diarrhoea. She states that she has opened her bowels 11 times since her onset of symptoms. Associated symptoms include nausea and vomiting with abdominal cramps and pain which started in the evening following a barbeque meal in the afternoon that day. The patient is alert and orientated and her observations include a pulse rate of 69, blood pressure of 124/75 and temperature of 37.1°C. On examination, her abdomen is soft, there is marked tenderness in the epigastric region and bowel sounds are hyperactive. The patient is normally fit and well with no past medical history. The most likely diagnosis is:

A. Irritable bowel syndrome
B. Gastroenteritis
C. Ulcerative colitis
D. Laxative abuse
E. Crohn’s disease

Answer 7

Gastroenteritis

Question 8

A 35-year-old woman presents with a 24-hour history of watery diarrhoea. She has opened her bowels nine times since the onset of her symptoms. You diagnose gastroenteritis after learning that the patient and her family all ate at a new restaurant and the rest of her family have had similar problems. The most appropriate management is:

A. Oral rehydration advice, anti-emetics and discharge home
B. Oral antibiotic therapy and discharge home
C. Admission for intravenous fluid rehydration
D. Admission for intravenous antibiotic therapy
E. No treatment required

Answer 8

Oral rehydration, anti-emetics?? and discharge

Question 9

A 56-year-old man presents with a 2-week history of diarrhoea which has not settled following an episode of ‘food poisoning’. Which of the following would be the most appropriate investigation?

A. Full blood count
B. Urea and electrolytes
C. Stool sample for microscopy, culture and sensitivities
D. Abdominalx-ray
E. Liver function tests

Answer 9

Stool sample for microscopy, culture and sensitivities

Question 10

You are questioned by your registrar regarding bacteria responsible for causing blood-stained diarrhoea. From the list below, select the organism which is not responsible for causing blood-stained diarrhoea.

A. Campylobacter spp.
B. Salmonella spp.
C. Escherichia coli
D. Shigella spp.
E. Stapylococcus spp.

Answer 10

Staphylocccus spp.

Question 11

A 69-year-old man present with a 2-week history of abdominal pain which has worsened over the last few days. On examination, the patient is jaundiced and the abdomen is distended with tenderness in the epigastric region. In addition, there is a smooth hepatomegaly and shifting dullness. Which of the following is a cause of hepatomegaly?

A. Iron deficiency anaemia
B. Budd–Chiari syndrome
C. Ulcerativecolitis
D. Crohn’s disease
E. Left-sided heart failure

Answer 11

Budd-Chiari syndrome

Question 12

You see a 19-year-old Caucasian man in your clinic who presents with a history of transient jaundice. On direct questioning, you ascertain that the jaundice is noticeable after periods of increased physical activity and subsides after a few days. The patient has no other symptoms and physical examination is unremarkable. Full blood count is normal (with a normal reticulocyte count) and liver function tests reveal a bilirubin of 37 μmol/L. The most appropriate management is:

A. Reassure and discharge
B. Start on a course of oral steroids
C. Request abdominal ultrasound
D. Request MRCP
E. Refer to Haematology

Answer 12

Gilbert’s syndrome - reassure and discharge

Question 13

You see a 54-year-old woman, referred to accident and emergency through her GP, with a week’s history of jaundice and right upper quadrant abdominal pain. Associated symptoms include dark urine and pale stools. There is no history of weight loss and the patient does not consume alcohol. Her liver function tests reveal a bilirubin of 40 μmol/L, ALT of 40 iu/L, AST 50 iu/L and ALP of 350 iu/L. The most likely diagnosis is:

A. Gallstones
B. Viral hepatitis
C. Alcoholic hepatitis
D. Carcinoma of the head of the pancreas
E. Autoimmune hepatitis

Answer 13

Gallstones leading to conjugated hyperbilirubinaemia

Question 14

You are asked by your registrar to request an imaging investigation for a 49-year- old woman with jaundice and abdominal pain. She has a past medical history of gallstones and you suspect this is a recurrence of the same problem. The most appropriate imaging investigation is:

A. Abdominal x-ray
B. Abdominal ultrasound
C. Abdominal CT
D. Magnetic resonance imaging (MRI)
E. Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 14

Abdominal US

Question 15

You see a 47-year-old woman who presents with a 3-day history of jaundice. You assess her liver function tests (LFTs) and see that the ALP iu/L is raised at 350 iu/L, AST 45iu/L, ALT 50iu/L and bilirubin 50iu/L. The patient feels well in herself, although she has noticed that her urine has become quite dark and her stools quite pale. You assess her medication history. Which of the following drugs from the patient’s medication history may be responsible for the cholestasis?

A. Co-amoxiclav
B. Bendroflumethiazide 
C. Ramipril
D. Amlodipine
E. Aspirin

Answer 15

Bendroflumethiazide

Question 16

During your on-call, you are bleeped to see an 80-year-old woman on the ward who has not opened her bowels for the last 4 days. She is not known to have a history of constipation. On examination, her observations are within normal range, the abdomen is soft and there is mild discomfort at the left iliac fossa. Bowel sounds are present and on PR examination, the rectum is empty. You consult your registrar who asks you to prescribe an osmotic laxative. What is the most appropriate treatment?

A. Ispaghulahusk
B. Docusate sodium
C. Lactulose
D. Senna
E. Methylcellulose

Answer 16

Lactulose

Question 17

Which of the following gastroenterological conditions would give rise to finger clubbing?

A. Hepatocellular carcinoma
B. Ulcerative colitis
C. Irritable bowel syndrome
D. Hepatocellular carcinoma
E. Pancreatic carcinoma

Answer 17

Ulcerative colitis

IBDs such as UC and CD known to cause finger clubbing

Question 18

You see an 80-year-old man who presents to accident and emergency with epigastric pain. The pain started 3 days ago and today he noticed that the colour of his stools has changed to a ‘tarry-black’ colour. Associated symptoms include nausea and lethargy. The patient is a smoker of 20 cigarettes a day and has recently finished eradication treatment for a duodenal ulcer. The patient is alert and orientated with a pulse rate of 99 and blood pressure of 98/69, respiratory rate of 18, oxygen saturations of 98 per cent on room air and temperature of 37.2°C. On examination, the abdomen is soft with marked tenderness in the epigastric region and bowel sounds are present. The rectum is empty, on PR examination, with some traces of malaena. The patient has been started on high flow oxygen and has been given some oral analgesia. The most appropriate next step in managing this patient is:

A. Keep nil by mouth and arrange endoscopy
B. Request an erect chest x-ray
C. Intravenous pantoprazole
D. ECG
E. Intravenous cannulation and fluids

Answer 18

IV cannulation and fluids before any investigations to stabilise

Question 19

You see a 75-year-old man with an acute episode of haematemesis, who was admitted the night before and is awaiting an upper GI endoscopy. You are asked on the ward round about the common causes of upper GI bleeding. From the list below, which of the following is the most common cause of upper GI bleeding?

A. Mallory–Weisstear
B. Peptic ulcers
C. Oesophageal varices
D. Drug induced
E. Malignancy

Answer 19

Oesophageal varices

Question 20

A 60-year-old man with alcoholic liver disease was admitted with an upper GI bleed secondary to oesophageal varices. The patient undergoes endoscopic variceal banding and is discharged after 2 weeks in-hospital stay. Which of the following medications would act as prophylaxis in preventing a rebleed from his oesophageal varices?

A. Frusemide
B. Amlodipine
C. Ramipril
D. Propranolol
E. Irbesartan

Answer 20

Propranolol

Question 21

A 46-year-old woman presents to your clinic with a week’s history of jaundice. Her past medical history includes longstanding atrial fibrillation and hypertension. Physical examination reveals hepatomegaly. You assess her liver function which shows a bilirubin of 41iu/L, AST 111iu/L, ALT 55iu/L and ALP98 iu/L. There is no history of travel. You have a look at the patient’s medication history. Which of the following drugs below is likely to have caused the derangement in the patient’s liver function?

A. Aspirin
B. Ramipril
C. Amiodarone
D. Bendroflumethiazide 
E. Amlodipine

Answer 21

Amiodarone

Question 22

A 67-year-old man presents feeling unwell and complaining of general malaise. He mentions a long history of alcohol abuse and his past medical history shows deranged liver function tests. Which of the following clinical signs does not form part of chronic liver disease?

A. Finger clubbing 
B. Palmer erythema
C. Spider naevi 
D. Koilonychia
E. Jaundice

Answer 22

Koilonychia - spooning of the fingers

Question 23

You see a 56-year-old man in your clinic with suspected alcoholic liver disease. Liver function tests reveal a bilirubin of 36iu/L, AST of 150iu/L, ALT 75iu/L and ALP 100iu/L. Which of the following blood test parameters would support a diagnosis of alcoholic-related liver disease?

A. Normal mean cell volume (MCV)
B. Low MCV
C. Normal mean cell haemoglobin (MCH)
D. Low MCH
E. Raised MCV

Answer 23

Raised MCV

Question 24

You see a 52-year-old woman with rheumatoid arthritis in your clinic. She was referred by her GP after her ALP levels were found to be abnormally high at 300iu/L. In addition, she was also found to be serum anti-mitochondrial antibody (AMA) positive. The most likely diagnosis is:

A. Primary biliary cirrhosis (PBC)
B. Wilson’s disease
C. Heriditaryhaemochromotosis
D. Primary sclerosing cholangitis (PSC)
E. Alcoholic liver disease

Answer 24

PBC

Primary biliary cirrhosis associated with +ve serum anti-mitochondrial antibody (AMA)

Question 25

A 47-year-old man presents complaining of weight gain, on examination there is an abdominal distension with a fluid thrill. Which of following is not a cause of ascites secondary to venous hypertension?

A. Congestive heart failure
B. Cirrhosis
C. Constrictivepericarditis
D. Budd–Chiarisyndrome
E. Nephrotic syndrome

Answer 25

Nephrotic syndrome

Question 26

A 56-year-old man, diagnosed with emphysema, presents with a one-month history of jaundice and ascites. Your registrar suspects that this patient may have liver disease secondary to α1-antitrypsin deficiency. Select the most likely mode of inheritance from the list below:

A. Autosomal dominant
B. X-linked dominant
C. Autosomal recessive
D. Polygenic
E. None of the above

Answer 26

Autosomal recessive

Question 27

You see a 56-year-old woman who presents with a two-month history of jaundice. Associated symptoms include lethargy and polyarthralgia. Her LFTs reveal a bilirubin of 46iu/L, AST 200, ALT 175, ALP 104. On examination, the patient is jaundiced and has finger clubbing. There are several spider naevi on the front and back of the trunk. Her abdomen is soft and there is a smooth hepatomegaly. Prior to her onset of symptoms, the patient has been fit and well. Viral serology is normal and anti-soluble liver antigen (SLA) is detected. You decide to start this patient on treatment. The most appropriate treatment is:

A. Liver transplantation 
B. Methotrexate
C. Prednisolone
D. Cyclosporin
E. Antivirals

Answer 27

Prednisolone

Question 28

You are told by your registrar that one of your inpatients has been diagnosed with primary sclerosing cholangitis (PSC). Your registrar suspects that the patient may have an associated condition. Primary sclerosing cholangitis is associated with which of the following diseases?

A. Thyroid disease
B. Systemic sclerosis
C. Rheumatoid arthritis
D. Ulcerative colitis
E. Irritable bowel syndrome

Answer 28

Ulcerative colitis

80-100% of PSC patients have UC

Question 29

A 68-year-old man presents to his GP with signs of drastic weight loss. He is known to have PSC. The GP suspects an underlying malignancy. Which of the following tumours would a patient with primary sclerosing cholangitis be more at risk of developing?

A. Hepatocellular carcinoma 
B. Cholangiocarcinoma
C. Hepatic fibroma
D. Hepatic haemangioma
E. Pancreatic carcinoma

Answer 29

Cholangiocarcinoma

20-30% of PSC patients go on to develop cholangiocarcinoma

Question 30

During a ward round, you are questioned about tumours that may arise from the liver parenchyma. Which of the following liver tumours is considered to be benign?

A. Angiosarcoma
B. Fibrosarcoma
C. Adenoma
D. Hepatoblastoma 
E. Leiyomyosarcoma

Answer 30

Adenoma

Question 31

A patient on your ward is diagnosed with hepatocellular carcinoma. You are asked to perform a tumour marker level on this patient. Which of the following tumour markers are elevated in hepatocellular carcinoma?

A. α-fetoprotein
B. Carcinoembryonic antigen (CEA)
C. CA15-3
D. HcG
E. CA125

Answer 31

α-fetoprotein

Hepatocellular carcinoma - α-fetoprotein
Colorectal cancer - CEA (carcinoembyronic antigen)
Breast cancer - CA15-3
Ovarian cancer - HcG and CA125

Question 32

A 64-year-old woman attends your clinic with a 2-week history of jaundice. Over the last three months the patient has lost 10kg. Associated symptoms include decreased appetite, dark urine and pale stools. On examination, the patient is jaundiced, her abdomen is soft and you can palpate a painless mass in the right upper quadrant. From the list of answers below, select the initial most appropriate investigation that you would request for this patient:

A. Abdominal x-ray
B. Abdominal CT
C. MRI of the abdomen
D. Abdominal ultrasound
E. ERCP

Answer 32

Abdominal ultrasound

Question 33

A 28-year-old man undergoes a sigmoidoscopy for longstanding diarrhoea and weight loss. On visualization of the rectum, the mucosa appears inflamed and friable. A rectal biopsy is taken and the histology shows mucosal ulcers with inflammatory infiltrate, crypt abscesses with goblet cell depletion. From the list of answers below, which is the most likely diagnosis describing the histology report?

A. Crohn’s disease
B. Pseudomembranous colitis
C. Irritable bowel syndrome
D. Ulcerative colitis
E. No diagnosis – the report is inconclusive

Answer 33

Ulcerative colitis

Question 34

You are told by your registrar that one of the clinic patients has been admitted with a ‘flare up’ of ulcerative colitis (UC) which he reports as being severe. From the list of answers below, select the parameters which are likely to reflect a severe flare up of ulcerative colitis:

A. Fewer than four bowel motions per day with large amounts of rectal bleeding
B. Between four and six bowel motions per day with large amounts of rectal bleeding
C. More than four bowel motions per day with large amounts of rectal bleeding
D. More than five bowel motions per day with large amounts of rectal bleeding
E. More than six bowel motions per day with large amounts of rectal bleeding

Answer 34

More than six bowel motions per day with large amounts of rectal bleeding

Question 35

You read a report which was handwritten in a patient’s medical notes who you suspect has inflammatory bowel disease. The report reads, ‘… there is cobblestoning of the terminal ileum with the appearance of rose thorn ulcers. These findings are suggestive of Crohn’s disease’. Select the most likely investigation that this report was derived from:

A. Colonoscopy
B. Sigmoidoscopy
C. Barium follow through
D. Abdominal CT
E. Abdominal ultrasound

Answer 35

Barium follow through

Barium follow through known to show ‘cobblestoning’ and ‘rose thorn ulcers’.

Colonoscopy and sigmoidoscopy showing visualisation of the colon may show skip lesion appearance

Question 36

You are asked to see a 29-year-old woman diagnosed with ulcerative colitis 18 months ago. Over the last 4 days she has been experiencing slight abdominal cramps, opening her bowels approximately 4–5 times a day and has been passing small amounts of blood per rectum. The patient is alert and orientated and on examination her pulse is 67, blood pressure 127/70, temperature 37.3°C and her abdomen is soft with mild central tenderness. PR examination is nil of note. Blood tests reveal haemoglobin of 13.5g/dL and a CRP of 9mg/L. The most appropriate management plan for this patient is:

A. Admission to hospital for intravenous fluid therapy and steroids
B. Oral steroid therapy + oral 5-ASA + steroid enemas + discharge
C. Admission and refer to surgeons for further assessment
D. Oral steroid therapy and discharge home
E. Reassurance and discharge home with no treatment required

Answer 36

Oral steroid therapy + oral 5-ASA + steroid enemas + discharge

Question 37

A 29-year-old anxious man is diagnosed with mild Crohn’s disease. Due to time constraints, the patient was asked to come back for a follow-up appointment to discuss Crohn’s disease in more detail. The patient returns with a list of complications he researched on the internet. Which of the following are not associated with Crohn’s disease?

A. Cigarette smoking reduces incidence
B. Fistulae formation
C. Abscessformation
D. Non-caseating granuloma formation
E. Associated with transmural inflammation

Answer 37

Cigarette smoking reduces incidence

Cigarette smoking found to be protective in UC

Question 38

You see a 40-year-old woman who was diagnosed with Crohn’s disease ten years ago. Due to a severe attack of Crohn’s which failed to respond to medical therapy, she had a small bowel resection. Your registrar tells you that she is at risk of developing vitamin B12 deficiency as a result of her surgery. Which part of the small bowel is responsible for the absorption of vitamin B12?

A. Jejunum
B. Proximal ileum
C. Duodenum
D. Terminal ileum
E. None of the above

Answer 38

Terminal ileum

Question 39

A 47-year-old woman has been experiencing a four-month history of diarrhoea and bloating. Associated symptoms include lethargy and weight loss. Full blood count reveals haemoglobin of 9.3d/gL and MCV 70fL. Which of the following investigations would be helpful in the patient’s diagnosis?

A. Anti-mitochondrial antibodies (AMA)
B. Anti-smooth muscle antibodies (ASMA)
C. Anti-tissue transglutaminase antibodies (anti-tTGA)
D. Anti-nuclear antibodies (ANA)
E. Anti-neutrophil cytoplasmic antibodies (ANCA)

Answer 39

Anti-tissue transglutaminase antibodies (anti-tTGA)

Question 40

A 65-year-old man attends your clinic with a three-month history of weight loss of approximately 9kg despite a normal appetite. A full blood count reveals that his haemoglobin is 9.0g/dL (previous haemoglobin was 13.5g/dL one year ago) and the MCV is 71 fL. Abdominal examination is unremarkable and per rectum exam is nil of note. The patient states that he has normal bowel habits and has been feeling quite tired lately. The most appropriate management is:

A. Reassure and discharge
B. Arrange an upper and lower GI endoscopy
C. Prescribe iron tablet supplementation
D. Arrange an abdominal ultrasound
E. Arrange an abdominal x-ray

Answer 40

Arrange an upper and lower GI endoscopy