Gastroenterology & Hepatology — MCQs

A 56-year-old man presents with dyspepsia. He has been taking omeprazole 20 mg daily for 8 weeks with minimal improvement. He has no alarm features. Upper GI endoscopy shows a 4 cm hiatus hernia and grade B oesophagitis (Los Angeles classification). Helicobacter pylori rapid urease test is negative. What is the most appropriate management?

Q93

A 29-year-old woman with ulcerative colitis limited to the rectum and sigmoid colon has been using mesalazine suppositories for 2 years with good symptom control. She now plans pregnancy. What is the most appropriate advice regarding her ulcerative colitis medication?

Q94

A 38-year-old man presents with a 12-month history of epigastric discomfort, early satiety, and bloating. He has no alarm features. He tested positive for Helicobacter pylori and completed 7-day triple therapy (PPI, clarithromycin, amoxicillin) 6 weeks ago. His symptoms have partially improved but persist. Urea breath test remains positive. What is the most appropriate next step?

Q95

A 42-year-old woman presents with acute severe epigastric pain radiating to the back, vomiting, and fever. CT abdomen shows pancreatic inflammation with a 6 cm peripancreatic fluid collection. Serum lipase is 2400 U/L. Despite fluid resuscitation and analgesia, she remains pyrexial at day 5. Repeat CT shows the collection has increased to 8 cm with gas locules. What is the most appropriate management?

Q96

A 62-year-old man with decompensated cirrhosis due to hepatitis C is admitted with confusion. His wife reports personality changes over the past week. Examination shows asterixis and drowsiness (West Haven grade 3). Ammonia level is elevated. He is taking lactulose 20 mL three times daily. Which additional intervention has the strongest evidence for improving outcomes in hepatic encephalopathy?

Q97

A 35-year-old man with Crohn's disease affecting the terminal ileum has been in remission for 2 years on azathioprine. He now presents with a painful perianal swelling. Examination reveals a tender, fluctuant mass lateral to the anus with surrounding erythema. There is no fever. What is the most appropriate immediate management?

Q98

A 48-year-old woman with long-standing GORD presents with progressive dysphagia to solids over 6 months and 8 kg weight loss. Upper GI endoscopy shows a tight oesophageal stricture at 35 cm from the incisors. Multiple biopsies are taken which show intestinal metaplasia but no dysplasia or malignancy. What is the most appropriate initial management?

Q99

A 55-year-old man with alcohol-related cirrhosis presents with increasing abdominal distension. Examination reveals shifting dullness and peripheral oedema. Diagnostic ascitic tap shows: protein 8 g/L, white cells 150/mm³ (80% lymphocytes), serum-ascites albumin gradient (SAAG) 16 g/L. What is the most likely diagnosis?

Q100

A 72-year-old man taking aspirin and diclofenac presents with melaena and dizziness. His pulse is 105 bpm, BP 95/60 mmHg. He receives fluid resuscitation and packed red cells. What is the most appropriate timing for upper GI endoscopy following adequate resuscitation?

Gastroenterology & Hepatology UK Medical PG Practice Questions and MCQs

Question 91: Which of the following is the primary mechanism by which terlipressin reduces portal pressure in variceal bleeding?

A. Inhibition of nitric oxide synthase
B. Splanchnic arterial vasoconstriction reducing portal venous inflow (Correct Answer)
C. Direct vasoconstriction of varices
D. Increased hepatic arterial resistance
E. Increased systemic vascular resistance

Explanation: ***Splanchnic arterial vasoconstriction reducing portal venous inflow*** - **Terlipressin** is a synthetic analogue of **vasopressin** that acts specifically on **V1 receptors** located on vascular smooth muscle. - By causing **splanchnic arterial vasoconstriction**, it significantly decreases the volume of blood entering the **portal venous system**, which lowers **portal pressure** and stops variceal bleeding. *Inhibition of nitric oxide synthase* - While **nitric oxide (NO)** contributes to the pathological vasodilation seen in **portal hypertension**, terlipressin does not directly inhibit the enzyme **NO synthase**. - Its therapeutic effect is mediated through **receptor-binding (V1)** rather than biochemical inhibition of vasodilatory pathways. *Direct vasoconstriction of varices* - Varices are **distended veins** that lack significant smooth muscle in their walls, making them largely unresponsive to direct pharmacological **vasoconstriction**. - The reduction in bleeding is achieved indirectly by lowering the **portal venous pressure** and the subsequent **portal-systemic pressure gradient**. *Increased hepatic arterial resistance* - Terlipressin primarily targets the **splanchnic mesenteric circulation** rather than the intrahepatic arterial system. - Increasing **hepatic arterial resistance** would be counterproductive as it could theoretically impair liver perfusion in a patient with already compromised **cirrhotic liver function**. *Increased systemic vascular resistance* - While an increase in **systemic vascular resistance (SVR)** can occur as a secondary side effect, it is not the intended **primary mechanism** for controlling variceal hemorrhage. - Excessive systemic vasoconstriction is a potential complication that can lead to **myocardial ischemia** or peripheral tissue hypoxia, not the therapeutic goal.

Question 92: A 56-year-old man presents with dyspepsia. He has been taking omeprazole 20 mg daily for 8 weeks with minimal improvement. He has no alarm features. Upper GI endoscopy shows a 4 cm hiatus hernia and grade B oesophagitis (Los Angeles classification). Helicobacter pylori rapid urease test is negative. What is the most appropriate management?

A. Continue omeprazole 20 mg daily and review in 3 months
B. Increase to omeprazole 40 mg twice daily for 8 weeks (Correct Answer)
C. Switch to ranitidine 300 mg twice daily
D. Refer for laparoscopic fundoplication
E. Arrange 24-hour pH monitoring

Explanation: ***Increase to omeprazole 40 mg twice daily for 8 weeks***- This patient has **Grade B oesophagitis** and **persistent symptoms** despite 8 weeks of standard-dose PPI, indicating the need for **dose escalation**.- A **large hiatus hernia** and **erosive oesophagitis** often require **higher-dose** and **twice-daily PPI** therapy to achieve adequate acid suppression and mucosal healing.*Continue omeprazole 20 mg daily and review in 3 months*- Continuing the current ineffective dose is inappropriate as the patient has already shown **minimal improvement** after an 8-week trial.- Failing to adequately treat **erosive oesophagitis** can lead to complications such as **strictures** or **Barrett's oesophagus**.*Switch to ranitidine 300 mg twice daily*- **H2-receptor antagonists** like ranitidine are significantly **less potent** than PPIs in suppressing gastric acid.- Switching to ranitidine would be a **step down** in therapy and is unlikely to resolve the persistent oesophagitis and symptoms.*Refer for laparoscopic fundoplication*- **Surgical intervention** like fundoplication is usually considered for patients who **fail optimized medical therapy** (high-dose PPI) or have severe complications.- It is premature to consider surgery before attempting a **maximal medical regimen**.*Arrange 24-hour pH monitoring*- **24-hour pH monitoring** is primarily used to confirm the diagnosis of GERD in patients with **atypical symptoms** or when **endoscopy is negative**.- Since the endoscopy already revealed **Grade B oesophagitis**, the diagnosis is confirmed, and pH monitoring is not required at this stage for management.

Question 93: A 29-year-old woman with ulcerative colitis limited to the rectum and sigmoid colon has been using mesalazine suppositories for 2 years with good symptom control. She now plans pregnancy. What is the most appropriate advice regarding her ulcerative colitis medication?

A. Stop mesalazine before conception due to teratogenic risk
B. Switch to oral prednisolone throughout pregnancy
C. Continue mesalazine suppositories as the benefits outweigh risks (Correct Answer)
D. Stop mesalazine and use only dietary modification during pregnancy
E. Switch to azathioprine before conception

Explanation: ***Continue mesalazine suppositories as the benefits outweigh risks*** - **Mesalazine (5-ASA)** is considered safe during pregnancy with no significant evidence of increased **congenital malformations** or adverse fetal outcomes. - Maintaining **remission** of ulcerative colitis is a priority, as active disease poses a higher risk of **preterm birth** and **low birth weight** than the medication itself. *Stop mesalazine before conception due to teratogenic risk* - Mesalazine is not classified as a **teratogen**; discontinuing it increases the risk of a disease **flare**, which is harmful to the pregnancy. - Unlike certain drugs like methotrexate, **5-aminosalicylates** do not require a washout period before conception. *Switch to oral prednisolone throughout pregnancy* - **Corticosteroids** are used to induce remission during active flares but are not recommended for **maintenance therapy** due to side effects like gestational diabetes. - Switching a well-controlled patient from a topical treatment to systemic **prednisolone** unnecessarily increases fetal and maternal exposure to steroids. *Stop mesalazine and use only dietary modification during pregnancy* - **Dietary modification** alone is insufficient to maintain remission in ulcerative colitis and lacks the evidence-based efficacy of pharmacological therapy. - Stopping effective maintenance therapy carries a high risk of **relapse**, which can negatively impact maternal and fetal health. *Switch to azathioprine before conception* - **Azathioprine** is generally safe in pregnancy, but there is no clinical indication to switch a patient whose disease is already **well-controlled** on mesalazine. - Introduction of new medications before pregnancy should be avoided if the current **lower-potency** regimen is effective.

Question 94: A 38-year-old man presents with a 12-month history of epigastric discomfort, early satiety, and bloating. He has no alarm features. He tested positive for Helicobacter pylori and completed 7-day triple therapy (PPI, clarithromycin, amoxicillin) 6 weeks ago. His symptoms have partially improved but persist. Urea breath test remains positive. What is the most appropriate next step?

A. Repeat the same triple therapy regimen for 14 days
B. Arrange urgent upper GI endoscopy
C. Switch to bismuth-based quadruple therapy (Correct Answer)
D. Switch to PPI, metronidazole, and clarithromycin for 14 days
E. Commence long-term PPI therapy without further eradication attempt

Explanation: ***Switch to bismuth-based quadruple therapy*** - After a failed first-line **H. pylori** eradication attempt, guidelines recommend using a second-line therapy that avoids antibiotics used previously, such as **clarithromycin**, due to likely resistance. - **Bismuth-based quadruple therapy** (PPI, bismuth, metronidazole, and tetracycline) for 14 days is the preferred rescue regimen to achieve higher eradication rates. *Repeat the same triple therapy regimen for 14 days* - Repeating the same antibiotics (especially **clarithromycin**) is ineffective because the initial failure strongly suggests the presence of **antibiotic-resistant** bacterial strains. - Extending the duration to 14 days does not overcome the biological resistance already established against the specific agents used. *Arrange urgent upper GI endoscopy* - This patient is young (under 55-60) and lacks **alarm features** such as weight loss, anemia, or dysphagia, making an urgent endoscopy unnecessary at this stage. - Persistent symptoms following one failed treatment round are managed by **second-line eradication** before considering invasive imaging. *Switch to PPI, metronidazole, and clarithromycin for 14 days* - This regimen is inappropriate because it reuses **clarithromycin**, which has a high risk of acquired resistance following the first treatment failure. - Effective second-line strategies must pivot to different antibiotic classes or include **bismuth** to disrupt bacterial defenses. *Commence long-term PPI therapy without further eradication attempt* - Failing to eradicate **H. pylori** increases the long-term risk of developing **peptic ulcer disease** and **gastric adenocarcinoma**. - Managing symptoms with **PPI monotherapy** alone does not address the underlying infection or the associated mucosal inflammation.

Question 95: A 42-year-old woman presents with acute severe epigastric pain radiating to the back, vomiting, and fever. CT abdomen shows pancreatic inflammation with a 6 cm peripancreatic fluid collection. Serum lipase is 2400 U/L. Despite fluid resuscitation and analgesia, she remains pyrexial at day 5. Repeat CT shows the collection has increased to 8 cm with gas locules. What is the most appropriate management?

A. Continue conservative management as collections typically resolve by 4 weeks
B. Arrange CT-guided drainage immediately (Correct Answer)
C. Commence broad-spectrum antibiotics and reassess in 48 hours
D. Arrange urgent surgical debridement
E. Arrange endoscopic cystogastrostomy

Explanation: ***Arrange CT-guided drainage immediately*** - The presence of **gas locules** within a peripancreatic collection on CT is pathognomonic for **infected pancreatic necrosis**, which carries a high mortality rate without source control. - Current guidelines advocate for a **step-up approach**, starting with minimally invasive **percutaneous drainage** as the first-line intervention to stabilize the patient and potentially avoid open surgery. *Continue conservative management as collections typically resolve by 4 weeks* - While sterile collections can be managed expectantly, the development of **persistent fever** and **intraluminal gas** indicates a life-threatening infection that requires immediate intervention. - Waiting for 4 weeks for a collection to mature into a **pseudocyst** or for resolution is dangerous in the context of active sepsis and macroscopic gas locules. *Commence broad-spectrum antibiotics and reassess in 48 hours* - Although **broad-spectrum antibiotics** are indicated for suspected infection, antibiotics alone are insufficient to treat a large, **infected necrotic collection** with gas. - Reassessment without drainage ignores the critical need for **source control**, as antibiotics have poor penetration into large areas of avascular necrotic tissue. *Arrange urgent surgical debridement* - **Open necrosectomy** was historically the standard but is now associated with higher morbidity and mortality compared to the **step-up approach** which prioritizes drainage. - Immediate surgery should be avoided in the acute phase (day 5) when the necrotic tissue is not yet well-demarcated or **walled-off**, unless minimally invasive methods fail or abdominal compartment syndrome is present. *Arrange endoscopic cystogastrostomy* - This procedure is specifically used for internal drainage of **Walled-Off Necrosis (WON)** or mature pseudocysts, which typically take **4 to 6 weeks** to form a distinct wall. - Attempting this in the acute phase (day 5) is inappropriate because the collection lacks the necessary **mature wall** for safe and effective endoscopic stent placement.

Question 96: A 62-year-old man with decompensated cirrhosis due to hepatitis C is admitted with confusion. His wife reports personality changes over the past week. Examination shows asterixis and drowsiness (West Haven grade 3). Ammonia level is elevated. He is taking lactulose 20 mL three times daily. Which additional intervention has the strongest evidence for improving outcomes in hepatic encephalopathy?

A. L-ornithine L-aspartate infusion
B. Metronidazole 400 mg three times daily
C. Rifaximin 550 mg twice daily (Correct Answer)
D. Neomycin 500 mg four times daily
E. Branched-chain amino acid supplements

Explanation: ***Rifaximin 550 mg twice daily*** - **Rifaximin** is a non-absorbable antibiotic that reduces ammonia-producing gut bacteria, making it an effective adjunct to **lactulose** for **hepatic encephalopathy (HE)**. - It has strong evidence for preventing recurrent HE and improving cognitive function, with a favorable safety profile compared to other antibiotics. *L-ornithine L-aspartate infusion* - **L-ornithine L-aspartate (LOLA)** helps detoxify ammonia by stimulating the **urea cycle** and glutamine synthesis in the muscle and liver. - While used as an adjunctive therapy, especially in acute settings, its long-term efficacy and impact on major outcomes are generally considered less robust than **rifaximin** for recurrent HE prevention. *Metronidazole 400 mg three times daily* - **Metronidazole** is an antibiotic that can reduce colonic ammonia production, but its long-term use is limited by the risk of **peripheral neuropathy** and other systemic side effects. - Its efficacy in comparison to **rifaximin** for chronic management of HE is less established and it is not the preferred choice due to safety concerns. *Neomycin 500 mg four times daily* - **Neomycin** is an aminoglycoside antibiotic that reduces gut bacteria, thus lowering ammonia production; however, it has significant systemic absorption. - Its use is largely superseded by **rifaximin** due to risks of **ototoxicity** and **nephrotoxicity**, making it unsuitable for long-term use in patients with cirrhosis. *Branched-chain amino acid supplements* - **Branched-chain amino acids (BCAAs)** are thought to improve nitrogen metabolism and may benefit patients with HE by counteracting amino acid imbalances. - While they can be used as nutritional support, especially in malnourished patients, they are not a primary therapy for managing acute, decompensated HE with elevated ammonia and grade 3 symptoms, nor do they have the same evidence base as **rifaximin** for preventing recurrence.

Question 97: A 35-year-old man with Crohn's disease affecting the terminal ileum has been in remission for 2 years on azathioprine. He now presents with a painful perianal swelling. Examination reveals a tender, fluctuant mass lateral to the anus with surrounding erythema. There is no fever. What is the most appropriate immediate management?

A. Incision and drainage under general anaesthetic with seton placement (Correct Answer)
B. Commence oral metronidazole and ciprofloxacin
C. Increase azathioprine dose
D. Commence infliximab infusion
E. MRI pelvis prior to any intervention

Explanation: ***Incision and drainage under general anaesthetic with seton placement***- The patient's presentation of a **tender, fluctuant mass** lateral to the anus is diagnostic of a **perianal abscess**, which requires urgent surgical drainage to prevent local tissue destruction and systemic sepsis.- In **Crohn's disease**, an examination under anesthesia (EUA) is preferred to ensure complete drainage and to place a **non-cutting seton** if a fistula is found, as this prevents premature closure and recurrent abscess formation.*Commence oral metronidazole and ciprofloxacin*- While **antibiotics** are useful adjuncts in managing perianal Crohn's disease, they cannot penetrate or adequately treat a localized, **walled-off abscess collection**.- Delaying surgical drainage while attempting medical therapy alone significantly increases the risk of the infection spreading and forming complex **anorectal fistulae**.*Increase azathioprine dose*- **Azathioprine** is a maintenance therapy for Crohn's disease that takes several weeks to reach therapeutic efficacy and is not indicated for the management of an **acute septic complication**.- Increasing immunosuppression in the presence of an **undrained abscess** is contraindicated as it may impair the body's ability to localize the infection.*Commence infliximab infusion*- **Anti-TNF agents** like infliximab are highly effective for healing **draining fistulae**, but they must not be started until any underlying **abscess/sepsis** has been fully drained and controlled.- Starting biologics while a collection is present can lead to **septicemia** or the worsening of the localized infection.*MRI pelvis prior to any intervention*- While **MRI pelvis** is the gold standard for mapping complex anatomy in perianal Crohn's, it should not delay the **immediate surgical management** of a clinically obvious abscess.- Imaging is typically reserved for cases where clinical findings are ambiguous or for planning **definitive fistula surgery** after the acute infection has been resolved.

Question 98: A 48-year-old woman with long-standing GORD presents with progressive dysphagia to solids over 6 months and 8 kg weight loss. Upper GI endoscopy shows a tight oesophageal stricture at 35 cm from the incisors. Multiple biopsies are taken which show intestinal metaplasia but no dysplasia or malignancy. What is the most appropriate initial management?

A. Refer for oesophagectomy
B. Arrange endoscopic mucosal resection
C. Commence high-dose PPI and arrange endoscopic dilatation (Correct Answer)
D. Arrange radiofrequency ablation of Barrett's mucosa
E. Commence oral corticosteroids for eosinophilic oesophagitis

Explanation: ***Commence high-dose PPI and arrange endoscopic dilatation*** - This patient has a **peptic stricture** due to **long-standing GORD**, indicated by progressive dysphagia and the presence of **intestinal metaplasia** without dysplasia or malignancy. - **Endoscopic dilatation** is the primary treatment for symptomatic peptic strictures, providing immediate relief from dysphagia, while **high-dose PPIs** are crucial for healing the inflammation, preventing stricture recurrence, and managing the underlying GORD. *Refer for oesophagectomy* - **Oesophagectomy** is a radical surgical procedure primarily reserved for **oesophageal carcinoma** or high-grade dysplasia refractory to endoscopic management. - Given that biopsies showed only **intestinal metaplasia** without malignancy or dysplasia, such an invasive surgery is not appropriate at this stage for a benign stricture. *Arrange endoscopic mucosal resection* - **Endoscopic mucosal resection (EMR)** is a technique used to remove **superficial neoplastic lesions**, such as visible nodules, high-grade dysplasia, or early intramucosal carcinoma in Barrett's oesophagus. - It is not indicated as a primary treatment for a **benign peptic stricture** or non-dysplastic Barrett's, as it does not address the underlying stricture effectively. *Arrange radiofrequency ablation of Barrett's mucosa* - **Radiofrequency ablation (RFA)** is an endoscopic therapy used to eradicate **dysplastic Barrett's oesophagus** to prevent its progression to adenocarcinoma. - The patient's biopsies showed **non-dysplastic intestinal metaplasia**, for which RFA is generally not recommended, and it would not mechanically open a tight oesophageal stricture. *Commence oral corticosteroids for eosinophilic oesophagitis* - **Eosinophilic oesophagitis (EoE)** is characterized by **dysphagia** and often a **"ringed" oesophagus**, with biopsy showing significant **eosinophilic infiltration**. - This patient's biopsies revealed **intestinal metaplasia**, a feature of Barrett's oesophagus, not EoE; therefore, corticosteroids specific for EoE are inappropriate.

Question 99: A 55-year-old man with alcohol-related cirrhosis presents with increasing abdominal distension. Examination reveals shifting dullness and peripheral oedema. Diagnostic ascitic tap shows: protein 8 g/L, white cells 150/mm³ (80% lymphocytes), serum-ascites albumin gradient (SAAG) 16 g/L. What is the most likely diagnosis?

A. Spontaneous bacterial peritonitis
B. Portal hypertension-related ascites (Correct Answer)
C. Malignant ascites
D. Tuberculous peritonitis
E. Pancreatic ascites

Explanation: ***Portal hypertension-related ascites*** - A **Serum-Ascites Albumin Gradient (SAAG)** of 16 g/L (≥11 g/L) is highly indicative of **portal hypertension**, which is common in patients with **alcohol-related cirrhosis**. - The ascitic fluid protein of **8 g/L** (<25 g/L) and **low total white cell count** (150/mm³) with a **low neutrophil count** (30/mm³) are consistent with uncomplicated transudative ascites. *Spontaneous bacterial peritonitis* - This diagnosis requires an ascitic fluid **polymorphonuclear (PMN) count >250/mm³**, which is not met as the patient has only 30 neutrophils/mm³. - Patients with SBP often present with **fever**, abdominal pain, or worsening encephalopathy, none of which are described here. *Malignant ascites* - Malignant ascites typically presents with a **low SAAG (<11 g/L)**, as it results from increased capillary permeability, not portal hypertension. - Ascitic fluid in malignancy usually shows a **high protein content** (>25 g/L) and may have positive cytology for malignant cells. *Tuberculous peritonitis* - While it can be **lymphocyte-predominant**, it typically has a **low SAAG (<11 g/L)** and a significantly higher protein level (>25 g/L). - The total ascitic white cell count is usually much higher, often exceeding 500/mm³, and the clinical picture includes chronic constitutional symptoms. *Pancreatic ascites* - This condition is characterized by a **low SAAG (<11 g/L)** and very high levels of **ascitic amylase**. - It typically results from a disrupted pancreatic duct or pseudocyst, occurring in the setting of acute or chronic pancreatitis.

Question 100: A 72-year-old man taking aspirin and diclofenac presents with melaena and dizziness. His pulse is 105 bpm, BP 95/60 mmHg. He receives fluid resuscitation and packed red cells. What is the most appropriate timing for upper GI endoscopy following adequate resuscitation?

A. Within 2 hours
B. Within 12 hours
C. Within 24 hours (Correct Answer)
D. Within 48 hours
E. Within 72 hours

Explanation: ***Within 24 hours***- Following adequate resuscitation, current guidelines (e.g., **NICE** or **ACG**) recommend performing upper GI endoscopy within **24 hours** for patients with acute upper GI bleeding.- This timeframe allows for optimal **hemodynamic stabilization** while providing timely diagnosis and therapeutic intervention to reduce the risk of rebleeding.*Within 2 hours*- Endoscopy within 2 hours is reserved for patients with **severe, ongoing bleeding** or those who remain **hemodynamically unstable** despite aggressive resuscitation efforts.- Given the scenario specifies

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Upper GI bleeding

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