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Question 1
Correct
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A 36-year-old man is being investigated for recurrent gastric and duodenal ulceration diagnosed at endoscopy. He has suffered from bouts of abdominal pain and intermittent diarrhoea although his weight is stable.
Some of his investigations are outlined below.
Basal acid secretion 20 mEq/h (1-5)
Fasting gastrin 200 pg/ml (<100)
Secretin test:
Basal gastrin 200 pg/ml
Post-secretin 500 pg/ml
Which of the following are responsible for the elevated gastrin levels?Your Answer: Gastrinoma
Explanation:This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. The secretin test is a test that can differentiate gastrinoma from other causes of high gastrin levels. Gastrin will rise after secretin injection if the patient has a gastrinoma.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Incorrect
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Which of the following options is true regarding H. pylori bacteria?
Your Answer: It is a Gram positive spiral flagellated organism
Correct Answer: It is the cause of >60% of gastric ulceration
Explanation:It is the cause of gastric ulcers in more than 60% of the cases. It is a gram negative bacteria and does not cause oesophageal carcinoma.
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This question is part of the following fields:
- Gastrointestinal System
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Question 3
Correct
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A 24-year-old presents with diarrhoea. She has had a previous ileal resection for Crohn's Disease. She has also had two recent episodes of loin to groin pain. Her bloods are normal including her inflammatory markers
What is the most likely diagnosis?Your Answer: Short bowel syndrome
Explanation:Given her history of bowel resections, the most likely answer in this case is short bowel syndrome. IBS is a diagnosis of exclusion and less likely. Bacterial overgrowth does not relate to resection history, so unlikely. Celiac disease or a flare of IBD are also less likely than short bowel syndrome in this case, simply given the history. Also her labs are normal making these unlikely. History, history, history!
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Correct
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A 72-year-old male presents complaining of having intermittent trouble with swallowing. He has also been regurgitating stale food material. He sometimes wakes up in the middle of the night feeling like he is suffocating. Choose the most likely diagnosis.
Your Answer: Pharyngeal pouch
Explanation:In benign stricture, oesophageal carcinoma, and systemic sclerosis, there is persistent dysphagia (rather than intermittent). In oesophageal spasm, there is no regurgitation of stale food material. The symptoms described are consistent with pharyngeal pouch.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
Correct
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A 45-year-old male presented with chronic diarrhoea and right lower abdominal pain. On examination he was febrile and there was tenderness over the right lower quadrant and an anal fissure. Which of the following is the most probable cause for his abdominal pain?
Your Answer: Inflammatory bowel disease (IBD)
Explanation:From the given answers, IBD and IBS are the causes for chronic diarrhoea. Pyelonephritis and ureteric colic are associated with urinary symptoms. Tenderness of pyelonephritis is at the loin region. Perianal disease is associated with fifty percent of patients with Crohn’s disease.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Correct
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A 60-year-old man with known ulcerative colitis and diverticular disease comes to clinic complaining of passing faeces per urethra. Cystoscopy confirms a fistula between his bladder and bowel.
Which treatment is most likely to be effective?Your Answer: surgery
Explanation:The best treatment for a colovesicular fistula is surgery. This is the only definitive treatment. If the patient is a poor surgical candidate, there can be an attempt to manage them non-operatively, but this is absolutely NOT the MOST EFFECTIVE therapy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 48-year-old ex-footballer with a long history of alcohol abuse, presents with epigastric pain. Which of the following suggests a diagnosis of peptic ulceration rather than chronic pancreatitis?
Your Answer: Relieved by food
Explanation:Relief of symptoms with food suggests duodenal ulceration, for which the pain gets worse on an empty stomach. In chronic pancreatitis, you would expect worsening of symptoms with food.
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Correct
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A 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?
Your Answer: Transferrin saturation 78% (20-50)
Explanation:A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Correct
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A 62-year-old woman with scleroderma and Raynaud's phenomenon complains of weight loss and has been referred for an opinion. Gastrointestinal associations of progressive systemic sclerosis include which of the following?
Your Answer: Oesophageal stricture
Explanation:Oesophageal stricture is a complication of systemic sclerosis, think of the oesophagus as sclerosing (fibrosing) leading to stricture and you never forget. Based on the clinical presentation of systemic sclerosis this is more likely than pancreatic dysfunction, PSC, lymphoma, or diverticulitis. Additionally, CREST syndrome stands for: calcinosis cutis, Raynaud’s phenomenon (which the patient has), oesophageal dysmotility, sclerodactyly, and telangiectasias), this is a form of systemic sclerosis you should be familiar with.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Correct
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A 32-year-old lady is found to be hepatitis B surface antigen positive. This positive result has persisted for more than six months. Hepatitis B envelope antigen (HBeAg) is negative. HBV DNA is negative. Her liver function tests are all entirely normal.
Which of the following options would be the best for further management?Your Answer: No antiviral therapy but monitor serology
Explanation:Again, remember the Hepatitis B serologies: In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, + anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. IN THIS CASE, the person is HBsAg+ for 6 months and everything else is negative, normal transaminase. They do not need antiviral therapy, but their serology should be monitored serially. There would be no reason to do a liver biopsy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Correct
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A 17-year-old boy presents with a 2 day history of colicky abdominal pain, vomiting and diarrhoea. He has been passing blood mixed with diarrhoea. He has no significant past medical history and takes no regular medication.
On examination he is pyrexial and clinically dehydrated. Cardiorespiratory and abdominal examinations are normal.
What is the most likely diagnosis?Your Answer: Campylobacter infection
Explanation:The patient has bloody diarrhoea that sounds like a food poisoning in the clinical scenario. Campylobacter is the most common cause of this in the United Kingdom. This is then followed by Salmonella and Shigella. The symptoms are usually self limiting. This is more likely to be bacterial from the food than a viral gastroenteritis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Incorrect
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A 48-year-old man with a two year history of ulcerative colitis, has been receiving parenteral nutrition for 4 months. He has developed a dermatitis and has noticed some loss of hair. Serum biochemistry shows a marginally raised glucose concentration and a lower alkaline phosphatase activity.
Which of the following is the most likely?Your Answer: Magnesium deficiency
Correct Answer: Zinc deficiency
Explanation:Zinc deficiency can present with alopecia, dermatitis, poor growth, increased susceptibility to infection, and cognitive deficiency. Magnesium deficiency can cause fatigue, cramping and an irregular EKG. Copper deficiency can present with fatigue and weakness. Chromium deficiency can present with hyperglycaemia.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Incorrect
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A baby born a few days earlier is brought into the emergency with complaints of vomiting, constipation and decreased serum potassium. Which of the following is the most probable cause?
Your Answer:
Correct Answer: Pyloric stenosis: hypokalaemic hypochloraemic metabolic alkalosis
Explanation:In pyloric stenosis a new-born baby presents with a history of vomiting, constipation and deranged electrolytes. Excessive vomiting leads to hypokalaemia. Difficulty in food passing from the stomach to the small intestine causes constipation. Hypokalaemia also causes constipation. None of the other disorders mentioned present with the hypokalaemia, vomiting and constipation triad in a new-born.
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This question is part of the following fields:
- Gastrointestinal System
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Question 14
Incorrect
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Which one of the following has no role in increased gastric acid secretion in patients with peptic ulcer disease?
Your Answer:
Correct Answer: Secretin
Explanation:Secretin is produced in the duodenum in response to a low pH and the presence of carbohydrate and fat. It turns off antral G cell gastrin synthesis. While others that are mentioned such as gastrin, histamine etc. are involved in increased acid secretion.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Incorrect
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An 18-year-old male presented to the OPD with complaints of abdominal pain and diarrhoea. There is a history of pubertal delay. On examination, he has pallor and looks short for his age. Tissue biopsy of the small intestines reveals damaged villi. Which of the following is the most likely cause of this condition?
Your Answer:
Correct Answer: Coeliac disease
Explanation:Celiac disease has characteristic shortened intestinal villi. When patients with celiac disease eat products containing gluten, they are unable to absorb the nutrients due to flattened or shortened intestinal villi. The blistering rash present on the patient’s elbows strongly suggests celiac disease. This rash is a sign of the condition Dermatitis Herpetiformis which is associate with celiac disease. Therefore, it is also often called ‘gluten rash’.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Incorrect
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A 26-year-old lawyer presents to the gastroenterology clinic with weight loss, intermittent oily diarrhoea and malaise. Blood testing reveals folate and iron deficiency. There is also mild hypocalcaemia on biochemistry screening.
She has type-1 diabetes of 10 years' duration and is stable on a basal bolus insulin regimen, otherwise her past medical history is unremarkable.
Which of these antibody tests is most specific for making a diagnosis?Your Answer:
Correct Answer: Anti-tissue transglutaminase antibodies
Explanation:The prompt is suggestive of celiac disease as an aetiology. The antibody that is used primarily to suggest this diagnosis is anti-tissue transglutaminase antibody. You can also check anti-gliadin and anti-endomyseal antibodies, although anti-TTG antibodies are now the preferred test. To get an official diagnosis you must have a tissue diagnosis (biopsy). Anti-smooth muscle antibodies would be seen in autoimmune hepatitis. Anti-thyroid antibodies are not at all related to this, and are associated with thyroid. Anti-nuclear antibodies are non-specific.
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This question is part of the following fields:
- Gastrointestinal System
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Question 17
Incorrect
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A 65-year-old, heavily alcohol dependent man came to the hospital with bleeding gums and petechiae upon examination. Which of the following is the likely vitamin deficiency?
Your Answer:
Correct Answer: C
Explanation:Vitamin deficiencies can happen in alcoholics due to malabsorption. Vitamin C deficiency or scurvy can result in bleeding gums and early symptoms including body weakness and lethargy. Other vitamin deficiencies can cause the following:
B1 or thiamine – Wernicke’s encephalopathy
B12 or cyanocobalamin – spinal cord degeneration
Vitamin K – anticoagulant effects
Vitamin E – neuropathies. -
This question is part of the following fields:
- Gastrointestinal System
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Question 18
Incorrect
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A 3-year-old boy has been brought to the hospital by his mother with pallor, lethargy and abdominal enlargement. His mother said she only noticed these symptoms two weeks ago but further questioning reveals that they have been progressively worsening over a longer period of time. The boy was born naturally following an uncomplicated pregnancy. Past and family histories are not significant and the family hasn't been on any vacations recently. However, the mother mentions a metabolic disorder present in the family history but couldn't remember the exact name. Clinical examination reveals generalised pallor, abdominal enlargement, massive splenomegaly and hepatomegaly. The spleen is firm but not tender and there is no icterus or lymphadenopathy. What is the most probable diagnosis?
Your Answer:
Correct Answer: Gaucher's disease
Explanation:Gaucher’s disease is characterized by hepatosplenomegaly, cytopenia, sometimes severe bone involvement and, in certain forms, neurological impairment. The variability in the clinical presentations of GD may be explained by the continuum of phenotypes. However, three major phenotypic presentations can usually be distinguished. Type-1 GD is usually named non-neuronopathic GD; type-2 and type-3 are termed neuronopathic-GD. Gaucher disease (GD, ORPHA355) is a rare, autosomal recessive genetic disorder. It is caused by a deficiency of the lysosomal enzyme, glucocerebrosidase, which leads to an accumulation of its substrate, glucosylceramide, in macrophages.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Incorrect
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A 28-year-old woman is investigated for bloody diarrhoea which started around six weeks ago. She is currently passing 3-4 loose stools a day which normally contain a small amount of blood. Other than feeling lethargic she remains systemically well with no fever or significant abdominal pain. A colonoscopy is performed which shows inflammatory changes in the ascending colon consistent with ulcerative colitis. Bloods show the following:
Hb: 14.2 g/dl
Platelets: 323 * 109/l
WBC: 8.1 * 109/l
CRP: 22 mg/l
What is the most appropriate first-line medication to induce remission?Your Answer:
Correct Answer: Oral aminosalicylate
Explanation:Given she is not showing signs of systemic illness, you do not need to treat for an acute flair (which would be steroids), but you need to put her on maintenance medication. Oral ASA would be the best option for this, it is first line. You cannot give rectal ASA because the location of her disease is in the ascending colon and the enema will not reach.
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This question is part of the following fields:
- Gastrointestinal System
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Question 20
Incorrect
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A 70-year-old male presented in the OPD with a complaint of abdominal pain and blood in his stools for the last two days. He reports that the stools are black in colour and sometimes accompanied by fresh blood. There is also a history of significant weight loss. Blood tests revealed elevated CA 19-9. What is the patient most likely suffering from?
Your Answer:
Correct Answer: Colorectal carcinoma
Explanation:The patient’s symptoms along with his age indicates a diagnosis of colorectal cancer. Blood test marker CA-19-9 is a prognostic index for colorectal cancer which confirms the suspicion.
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This question is part of the following fields:
- Gastrointestinal System
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Question 21
Incorrect
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A 55-year-old man known with Barrett's oesophagus and oesophagitis now complains of a six-week history of gradual dysphagia with solids. Which is the most likely diagnosis?
Your Answer:
Correct Answer: Carcinoma of the oesophagus
Explanation:Barrett’s oesophagus is the abnormal (metaplastic) change in the mucosal cells lining the lower portion of the oesophagus, from normal stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells, normally present only in the colon. This change is considered to be premalignant and is associated with a high incidence of transition to oesophageal adenocarcinoma. Clinical features of carcinoma of the oesophagus include: loss of weight, hoarseness of voice, dysphagia, and cough. Barium swallow and oesophagoscopy with biopsy should be done.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Incorrect
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Which of the following is most commonly associated with the development of pseudomembranous colitis?
Your Answer:
Correct Answer: Cefuroxime
Explanation:Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Incorrect
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A 42-year-old man presented with bloody diarrhoea and weight loss. Which one of the following would favour the diagnosis of Crohn's disease on rectal biopsy?
Your Answer:
Correct Answer: Patchy inflammation
Explanation:The correct answer is patchy inflammation. Superficial ulceration as well as non-patchy inflammation are seen in ulcerative colitis (UC) in the colon and rectum; you would expect to see transmural inflammation in Crohn’s disease and it can be patchy and located anywhere from mouth to anus. Crypt distortion and crypt abscesses are seen in both UC and Crohn’s, however they are more common in ulcerative colitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 24
Incorrect
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Which of the following does the inferior mesenteric artery supply?
Your Answer:
Correct Answer: From the splenic flexure to the first third of the rectum
Explanation:The coeliac axis supplies the liver and stomach and from the oesophagus to the first half of the duodenum.
The second half of the duodenum to the first two thirds of the transverse colon is supplied by the superior mesenteric artery.
The inferior mesenteric supplies the last third of the transverse colon (approximately from the splenic flexure) to the first third of the rectum.
The last two thirds of the rectum are supplied by the middle rectal artery.
The greater curvature of the stomach is supplied by branches of the splenic artery, which itself comes from the coeliac axis. -
This question is part of the following fields:
- Gastrointestinal System
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Question 25
Incorrect
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In over 70% of the cases, inflammatory bowel disease associates which of the following?
Your Answer:
Correct Answer: Primary sclerosing cholangitis
Explanation:More than 70% of cases with inflammatory bowel disease are associated with primary sclerosing cholangitis. The most common association is that of ulcerative colitis, in which case it progresses independently.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Incorrect
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Cholecystokinin is secreted from:
Your Answer:
Correct Answer: I cells in upper small intestine
Explanation:Cholecystokinin (CCK) was discovered in 1928 in jejunal extracts as a gallbladder contraction factor. It was later shown to be member of a peptide family, which are all ligands for the CCK1 and CCK2 receptors. CCK peptides are known to be synthetized in the small intestinal endocrine I-cells and cerebral neurons.
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This question is part of the following fields:
- Gastrointestinal System
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Question 27
Incorrect
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A 47-year-old man is seen in clinic with a 3 month history of chronic epigastric discomfort. The pain comes and goes and radiates to his back and his right shoulder tip at times. It is worse after meals but there is no relieving factor. He feels nauseous most of the time and has foul-smelling stools. He has lost 2 stones in weight. He also complains of intermittent light-headedness. He drinks a bottle of wine on most nights and smokes 20 cigarettes /day.
On examination, he is thin and looks neglected. His abdomen is soft, but tender on deep palpation in the epigastric area. He has a 2 cm non-tender liver edge. He also has decreased sensation to light touch on both feet.
Bloods:
sodium 131 mmol/l
potassium 4.2 mmol/l
creatine 64 μmol/l
amylase 35 U/l
alanine aminotransferase (ALT) 104 U/l
alkaline phosphatase (ALP) 121 U/l
bilirubin 24 μmol/l
calcium 2.01 mmol/l
whole cell count (WCC) 12.1 × 109/l
haemoglobin (Hb) 10.2 g/dl
platelets 462 × 109/l
abdominal X-ray (AXR) normal
oesophago-gastro duodenoscopy (OGD) mild gastritis
Campylobacter-like organism (CLO) test negative
ultrasound abdomen mildly enlarged liver with fatty change
spleen and kidneys normal
pancreas partially obscured by overlying bowel gas
72-h stool fat 22 g in 72 h
He is referred for a secretin test:
volume collected 110 ml
bicarbonate 52 mEq/l
What is the most likely diagnosis?Your Answer:
Correct Answer: Chronic pancreatitis
Explanation:The question describes an alcohol abusing man with chronic epigastric discomfort, radiating into his back, worse with meals, and foul-smelling stools, weight loss, as well as chronic nausea. This is likely, thus chronic pancreatitis due to alcohol abuse. Hepatomegaly and peripheral neuropathy secondary to anaemia support the diagnosis of long term alcohol abuse. Bacterial overgrowth may present with diarrhoea and is a less likely diagnosis than pancreatitis. Celiac disease is a less likely diagnosis than pancreatitis, and you would also expect mention of diarrhoea. VIPoma would also likely present with diarrhoea. Cecal carcinoma would more than likely present with blood in the stool.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Incorrect
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A 45-year-old male complains of abdominal pain and loose stools. On endoscopy, multiple ulcers were seen from the oesophagus until the stomach. What will be the next best investigation for this patient?
Your Answer:
Correct Answer: Serum gastrin estimation
Explanation:Serum gastrin level will helps in the diagnosis of Zollinger-Ellison syndrome, which is characterised by a history of recurrent and multiple gastric ulcers, due to increase gastrin secretion by the cells.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Incorrect
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A 45-year-old female develops profuse watery diarrhoea with lower abdominal pain seven days after undergoing laparoscopic cholecystectomy. What is the most likely diagnosis?
Your Answer:
Correct Answer: Pseudomembranous colitis
Explanation:Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly. This woman would have received antibiotics prophylactically before her surgery, predisposing her to a possible c difficile infection. This is a much better answer choice than pseudo obstruction, abdominal sepsis, bile acid diarrhoea, and campylobacter gastroenteritis simply based on history of present illness.
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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Incorrect
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A woman complains of diarrhoea, experiencing watery stools 10 daily. She also complains of abdominal bloating, cramps, flatulence, and recent weight loss. She has now developed signs of iron deficiency anaemia. What is the most likely cause of her condition?
Your Answer:
Correct Answer: Malabsorption
Explanation:Diarrhoea, iron deficiency anaemia and folic acid deficiency are suggestive of malabsorption. Malabsorption leads to a decrease in the solid content of the stools resulting in diarrhoea. Decrease in the absorption of folic acid causes folic acid deficiency, and iron deficiency in the body leads to iron deficiency anaemia.
Jejunal villous atrophy is characterized with pain and weight loss as well, which this patient does not have.
A patient with increased catabolism has sudden weight loss along with deficiencies of nutrients. -
This question is part of the following fields:
- Gastrointestinal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
