Mock examination

chapter 11


Mock examination


Questions


1.A 50-year-old man with ileocaecal Crohn’s disease (CD) in long-term remission had been taking azathioprine monotherapy 200 mg once a day for the last seven years.


Which pattern of drug-induced liver injury is this most likely to have caused?



2.A 59-year-old man underwent small bowel resection for mesenteric infarction. He was seen in clinic and complained of persistent thirst. He had 130 cm small bowel to an end jejunostomy with a stoma output of 1,300 ml per day.


What is the best management advice for this patient?



3.A 56-year-old man presented with painless jaundice. CT liver and magnetic resonance cholangiopancreatography (MRCP) demonstrated a hilar biliary stricture with subsequent endoscopic retrograde cholangiopancreatography (ERCP) and brushings confirming cholangiocarcinoma.


Which radiological finding is an absolute contraindication to surgical resection?



4.A 29-year-old dancer presented with persistent abdominal pain, nausea, and constipation. She denied taking opiates or anticholinergics but did smoke cannabis once per month. On examination, her body mass index (BMI) was 17.4 kg/m2. She was not diabetic but there was a history of dizziness on standing.


Investigations:




















Gastroscopy Normal
Ileocolonoscopy Normal
MR enterography Normal
Tilt table test Consistent with postural orthostatic tachycardia syndrome
Beighton score 6/9 suggestive of hypermobility

What is the most likely cause of her abdominal symptoms?



5.A 34-year-old man presented with symptoms suggestive of delayed gastric emptying.


With regard to the physiology of gastric emptying, which of the following cells are responsible for controlling the slow-wave phase in the distal stomach?



6.A 19-year-old woman with a history of anorexia nervosa was brought to hospital by her flatmates. She had been withdrawn for several months, eating little and losing weight. Her current weight was 33 kg. She had been running twice daily until the week before, when she had become weaker and had not left her flat since. Physical examination and investigations were performed.


Which finding would indicate that the patient should be deemed high risk in the context of refeeding and rehydration?



7.The management of a 60-year-old man with a new diagnosis of head of pancreas adenocarcinoma was discussed by the multi-disciplinary team.


Which of the following CT findings makes the tumour most likely to be unresectable?



8.A 64-year-old man was admitted with melaena. He had a background of angina and had two drug-eluting coronary stents inserted 10 months previously. His medications comprised aspirin, clopidogrel, bisoprolol, ramipril, and atorvastatin. He had recently been using naproxen for lower back pain.


Investigations:



How should you manage his antiplatelet therapy following the endoscopy?



9.A 56-year-old man presented with pruritus ani.


Which of the following statements is true?



10.


Regarding gastric acid secretion, which of the following statements is true?



11.A 63-year-old lorry driver was referred with a four-month history of bloody diarrhoea 4–6 times per day. He had mild left-sided abdominal pain. There was no history of fevers or weight loss. He denied recent foreign travel. His past medical history included ischaemic heart disease and hypertension.


Investigations:




















Haemoglobin 129 g/L
Platelet count 475 × 109/L
Serum albumin 31 g/L
Serum C-reactive protein (CRP) 25 mg/L
Flexible sigmoidoscopy Confluent colitis to point of insertion (50 cm) consistent with ulcerative colitis (UC)

With respect to inflammatory bowel disease (IBD) in the elderly, which statement is most accurate?



12.A 68-year-old woman was referred with chronic diarrhoea. Her background included hypothyroidism and hypertension for which she took levothyroxine and ramipril. A colonoscopy was indicated but she recalled having had a colonoscopy eight years before and did not tolerate the bowel preparation well.


With respect to bowel preparation, which statement is most accurate?



13.A 45-year-old woman with Child-Pugh C alcohol-related cirrhosis was admitted with a fractured tibia following a fall. She was currently drinking two bottles of wine a day. After 18 hours, she developed severe alcohol withdrawal syndrome (AWS)


Which of the following would be the best treatment option?



14.A 45-year-old man with a history of alcohol excess presented with epigastric pain, vomiting, systemic inflammatory response syndrome, and acute kidney injury.


Investigations:











Serum amylase 1,200 U/L
Abdominal ultrasound Normal

Five weeks after presentation, a computed tomography (CT) scan was performed because of ongoing abdominal pain and fevers.

















CT abdomen 10 cm encapsulated homogenous fluid collection around the head of the pancreas
White cell count 15 × 109/L
Serum C-reactive protein (CRP) 145 mg/L
Serum amylase 205 U/L

What is the most likely diagnosis?



15.A 35-year-old woman was referred to clinic with deranged liver function tests. She reported lifelong abstinence from alcohol, which was corroborated by her husband. She had a background of hypertension and type 2 diabetes. She was taking ramipril, metformin, and had completed a course of trimethoprim 2 weeks before for a urinary tract infection.


Investigations:


























Serum bilirubin 10 µmol/L
Serum alanine transferase (ALT) 87 U/L
Serum alkaline phosphatase (ALP) 100 U/L
Serum albumin 42 g/L
Serum ferritin 545 µg/L
Anti-smooth muscle antibody positive
Liver histology (Fig. 11.1)



image


Fig. 11.1 Liver histology specimen. See also Plate 18


Image courtesy of Dr Eve Fryer, OUH NHS Foundation Trust, Oxford


What is the most likely diagnosis?



16.A 43-year-old-man is reviewed in clinic with nine months of upper abdominal pain. He has a history of smoking 20 cigarettes a day for the past 15 years.


Investigations:



What would be the next best management for his pain?



17.A 20-year-old man presented to the gastroenterology outpatient clinic. He was an only child whose father was diagnosed with hereditary non-polyposis CRC at the age of 40 years and died of CRC. No other family history was available. The patient was asymptomatic.


What is the next most appropriate step in his management?



18.


Which statement regarding primary sclerosing cholangitis/inflammatory bowel disease (PSC/IBD) is true?



19.A 19-year-old student was referred to clinic with persistent non-bloody diarrhoea, abdominal cramps, and bloating. She returned from her gap year a month earlier.


Investigations:











Faecal microscopy and culture Negative
Faecal polymerase chain reaction (PCR) Positive for Giardia lamblia

Which statement best describes the Giardia lamblia trophozoite cycle?



20.A 42-year-old presented with non-specific abdominal discomfort and proceeded to endoscopy.


Investigations:














Gastroscopy There was a 1 cm, pale yellow, sessile polypoid lesion located at 36 cm from the incisors. The lesion was firm but passable with the endoscope and appeared submucosal. The appearances of the upper GI tract were otherwise normal
Endoscopic ultrasound (EUS) At 36 cm there is a smooth-edged, hypoechoic, homogenous appearing lesion arising from the submucosa
Histology of polyp Polygonal cells with granular eosinophilic cytoplasm

What is the most likely diagnosis?



21.A 35-year old woman with extensive UC was admitted to hospital with 16 bloody, loose stools per day.


Investigations:








Flexible sigmoidoscopy Continuous inflammation to 35 cm with deep ulceration, complete obliteration of vascular pattern and free liquid blood in the lumen

What is the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score?



22.An 87-year-old man with progressive dysphagia was referred urgently for endoscopy. The endoscope was introduced into the oesophagus with some difficulty, and the view shown in (Fig. 11.2) was seen at 31 cm.




image


Fig. 11.2 Endoscopic image of oesophagus. See also Plate 19


Which of the following is most appropriate?




23. 0Variants in which gene are the most common cause of hereditary pancreatitis?



24.A 45-year-old man was diagnosed with ulcerative pancolitis and concurrent PSC one year ago. He returned for his first annual follow-up appointment. He was asymptomatic.


Investigations:


























Serum bilirubin 15 µmol/L
Serum alkaline phosphatase (ALP) 125 U/L
Serum alanine aminotransferase (ALT) 25 U/L
Serum albumin 37 g/L
Serum CA 19-9 20 U/ml
Colonoscopy Quiescent UC
Abdominal ultrasound 8 mm polyp posterior wall of the gallbladder

What is the best next step in this patient’s management?



25.A 36-year-old ex-offender was referred to the gastroenterology clinic with nausea, vomiting, abdominal pain, and early satiety. He reported 6 kg unintentional weight loss recently. He gave a history of previous substance misuse.


Which recreational drug is associated with delayed gastric emptying?



26.A 48-year-old man with PSC was reviewed in clinic. He had some fatigue but otherwise felt well. He had concomitant UC, which was in clinical remission. His medications were ursodeoxycholic acid (UDCA) 500 mg twice a day and mesalazine 2 g once a day.


Investigations:












































Serum bilirubin 16 µmol/L
Serum alkaline phosphatase (ALP) 195 U/L
Serum alanine transferase (ALT) 285 U/L
Serum albumin 39 g/L
Full blood count Normal
INR 1.0
Antinuclear antibody Positive
Antinuclear cytoplasmic antibody Positive
Anti-mitochondrial antibody Negative
Anti-smooth muscle antibody Negative
IgA 1.8 g/L
IgG 19 g/L
IgM 1.5 g/L

What investigation would you order next?



27.A 46-year-old female with a history of CD attended clinic. She underwent an ileocaecal resection four years ago and was on no maintenance therapy. She continued to smoke 15 cigarettes/day. She underwent a colonoscopy for symptoms of loose stool.


Investigation:








Colonoscopy Insertion to neo-terminal ileum. Ileocolic anastomosis patent. Colon normal. Diffuse aphthous ileitis with diffusely inflamed mucosa. No evidence of stenosis or large ulcers.

What is her Rutgeerts score?



28.A 37-year-old male presented with a five-week history of fevers, non-productive cough, bloody diarrhoea, and myalgia. Four weeks ago, he returned to the UK from travelling in rural India where he had been in contact with fresh water lakes. On close questioning, he had developed an itchy rash at the start of his symptoms, which had resolved within 3–4 days.


Investigations:



































Haemoglobin 130 g/L
White cell count 7.0 × 109/L
Platelet count 180 × 109/L
Eosinophil count 0.6 × 109/L
Serum C-reactive protein (CRP) 30 mg/L
Serum alanine transferase (ALT) 34 U/L
Serum alkaline phosphatase (ALP) 110 U/L
Serum bilirubin 10 µmol/L
Faecal microscopy and culture Negative including ova, cysts, and parasites
Chest radiograph Ill-defined nodular pulmonary infiltrates

Which is the next most appropriate diagnostic test?



29.A 65-year-old woman with alcohol-related cirrhosis is seen with her husband in the hepatology clinic. She has been abstinent from alcohol for two years. Her husband is concerned that she is not her usual self. She appears oriented to time and place.


Which of the following is correct in the diagnosis of hepatic encephalopathy (HE)?



30.A 37-year-old man with UC had required multiple courses of oral corticosteroids over the past two years. Bowel symptoms recurred whenever prednisolone was reduced below 15 mg daily. Azathioprine was therefore recommended.


Investigation:








Thiopurine methyltransferase 16 U/L

Which of the following statements about thiopurine methyltransferase (TPMT) levels is most accurate?



31. A 65-year-old man with Child-Pugh C (10) alcohol-related cirrhosis presents with Grade 3 ascites. Routine blood tests and a diagnostic paracentesis are performed.


Investigations:


























Serum bilirubin 58 µmol/L
Serum creatinine 105 µmol/L
Serum sodium 129 mmol/L
Ascites white cell count 410 cells/µL
Ascites neutrophil count 220 cells/µL
Ascites albumin 5 g/L
Ascites total protein 9 g/L

The patient has been referred for consideration of liver transplantation (LT) or transjugular intrahepatic portosystemic shunt (TIPSS) and in the interim repeated large volume paracentesis is performed.


Which of the above would be an indication for long-term antibiotic prophylaxis?



32.A 56-year-old man presented with a three-month history of intermittent vomiting and weight loss. He had no past medical history, drank 10 units of alcohol a week, and was a non-smoker.


Investigations:











Gastroscopy 4 cm antral tumour
Histology Adenocarcinoma

With regard to the initial staging of gastric cancer, which is the most useful modality as an adjunct to CT scanning?



33.A 28-year-old Iranian farmer, who had recently immigrated to the UK, was referred to clinic with persistent diarrhoea. He also complained of hair loss, taste disturbance, and a superficial scaling erythematous patchy rash that was most prominent in intertriginous areas and periorally. There was no cognitive impairment.


Which is the most likely nutrient deficiency?



34.A 68-year-old woman attended for a gastroscopy having been referred by her GP with anaemia, 4 kg weight loss, and abdominal discomfort. No melaena had been witnessed, although she reported occasional dark stools.


Investigations:





























Haemoglobin 122 g/L
White cell count 4.6 × 109/L
Mean corpuscular volume 76 fL
Platelet count 209 × 109/L
Serum ferritin 6 µg/L
Serum folate 2.6 µg/L
Serum vitamin B12 178 ng/L
Serum C-reactive protein (CRP) 16 mg/L

The endoscopic images demonstrated the findings shown in (Fig. 11.3).




image


Fig. 11.3 Endoscopic image of stomach. See also Plate 20


Which of the following is the most appropriate next step?



35.A 47-year-old woman presented to the emergency department with recurrent episodes of right upper quadrant pain. She underwent an elective laparoscopic cholecystectomy six months before for similar ‘attacks’ despite no evidence of biliary calculi found on imaging. Her serum liver enzymes and amylase have always been within the normal limit with each episode.


Investigations:














Gallbladder histology Chronic cholecystitis with no gallstones
MRCP Common bile duct (CBD) diameter 4.9 mm, main pancreatic duct diameter 1.2 mm, no features of chronic pancreatitis
EUS CBD 4.5 mm, no evidence of biliary microlithiasis or sludge

What is the next most appropriate management strategy?



36.A 56-year-old woman presented with progressive dysphagia to solids but not liquids. She took omeprazole 20 mg twice daily for heartburn.


Investigations:








Gastroscopy Impassable stricture at 34 cm which appeared endoscopically benign

Which of the following is true with regards to dilatation of benign-appearing peptic strictures?



37.A 78-year-old woman was reviewed in outpatients for dysphagia. She described intermittent difficulties swallowing for several years associated with occasional regurgitation and a sensation of ‘bubbling’ at the back of her throat. She had a persistent cough and friends had commented that her breath smelt foul. She had a hospital admission with pneumonia a year ago but had fully recovered. Her only medication was amlodipine 5 mg once a day for hypertension.


Investigation:








Barium swallow (Fig. 11.4)



image


Fig. 11.4 Barium swallow


Image courtesy of Dr Horace D’Costa, Consultant Radiologist, Oxford University Hospitals NHS Foundation Trust



Given the diagnosis, which of the following would provide definitive management?



38.An 18-year-old woman with a three-month history of abdominal discomfort and unintentional weight loss presented with right-sided abdominal pain and vomiting. Her blood pressure was 110/70 mmHg and pulse 110 beats per minute.


Investigations:




















Haemoglobin 104 g/L
White cell count 13.1 × 109/L
Platelet count 430 × 109/L
Serum C-reactive protein (CRP) 112 mg/L
CT abdomen and pelvis 12-cm length of terminal ileal stricturing with an adjacent intra-abdominal collection. There are proximal loops of dilated small bowel. Three closely spaced mid-ileal strictures, each about 3 cm, are demonstrated proximal to the dilated loops. Appearances are compatible with active CD.

What is the most likely surgical procedure?



39.A 54-year-old businessman was referred from the rheumatology clinic with a two-year history of migratory arthralgia of the large joints. He had developed episodic non-bloody diarrhoea and crampy abdominal pain. He had lost weight. On examination, a pericardial rub was audible and there was small volume ascites.


Investigations:






































Rheumatoid factor Negative
IgA tissue transglutaminase antibody Negative
Thyroid stimulating hormone (TSH) Normal
Faecal microscopy and culture Negative
Faecal ova, cysts, and parasites Negative
HIV Negative
Gastroscopy Normal
Duodenal histology Mild duodenal villous blunting
Colonoscopy Normal
Colonic histology Normal
MR enterography No evidence of small bowel inflammation

What is the diagnostic test?



40.A 48-year-old woman with primary biliary cholangitis (PBC) attended annual clinic follow-up suffering from severe fatigue.


Investigations:




















Platelet count 170 × 109/L
Liver stiffness measurement (LSM) 10.8 kPa
Serum alkaline phosphatase (ALP) 180 U/L
Serum bilirubin 45 µmol/L
Liver ultrasound Coarse irregular heterogenous liver, no focal lesion, normal portal vein flow, no ascites, spleen size 12 cm

Which of the following is true about PBC?



41.A 40-year-old woman was reviewed on the ward 24 hours after LT for alcohol-related cirrhosis. The organ donor was positive and the recipient was negative for cytomegalovirus (CMV) (D+/R−).


What is the most appropriate management regarding CMV infection post-transplantation?



42.A 43-year-old female was admitted from the mental health unit having reportedly swallowed a foreign object. She denied any symptoms but refused to say what she had ingested.


Which of the following objects may be safely considered for conservative management?



43.A 34-year-old man with complex ileocolonic CD developed a secondary loss of response to infliximab. He had evidence of active disease at recent ileocolonoscopy. His background included psoriasis for which he was under the dermatologists.


Which novel therapy is most appropriate to introduce?


Stay updated, free articles. Join our Telegram channel

Aug 3, 2021 | Posted by in GASTROENTEROLOGY | Comments Off on Mock examination

Full access? Get Clinical Tree

Get Clinical Tree app for offline access