A 28-year-old woman presents with bloody diarrhoea (8 times daily), abdominal pain, and fever (38.5°C). She was diagnosed with ulcerative colitis 3 years ago. Examination shows abdominal tenderness and tachycardia (110 bpm). Blood tests reveal: Hb 98 g/L, WCC 16 × 10⁹/L, platelets 450 × 10⁹/L, CRP 85 mg/L, albumin 25 g/L. Abdominal X-ray shows colonic dilatation of 7 cm. What is the single most important next step in management?
Q102
A 67-year-old man presents with sudden onset severe epigastric pain radiating to the back. He has a history of gallstones. Examination reveals epigastric tenderness and tachycardia. Serum amylase is 1850 U/L (normal <100). Which of the following is the most appropriate severity assessment tool to guide early management and predict mortality?
Q103
A 45-year-old woman with known Crohn's disease presents with fever, right upper quadrant pain, and jaundice. Blood tests show: ALP 450 U/L, GGT 380 U/L, bilirubin 65 μmol/L, ALT 85 U/L. MRCP demonstrates multiple short strictures with bead-like appearance of the intrahepatic and extrahepatic bile ducts. Which complication is she at greatest long-term risk of developing?
Q104
A 32-year-old woman presents with a 6-month history of intermittent abdominal pain, bloating, and alternating bowel habit. She reports relief after defecation. Examination is unremarkable. Blood tests including FBC, CRP, coeliac serology, and thyroid function are normal. Faecal calprotectin is 18 μg/g. What is the most appropriate next step in management?
Q105
A 58-year-old man with a history of heavy alcohol use presents with haematemesis. He is haemodynamically stable. Upper GI endoscopy reveals bleeding oesophageal varices which are successfully banded. His blood tests show: Hb 92 g/L, platelets 78 × 10⁹/L, albumin 28 g/L, bilirubin 45 μmol/L, INR 1.6. What is the most appropriate prophylactic measure to reduce the risk of rebleeding in the first five days?
Gastroenterology & Hepatology UK Medical PG Practice Questions and MCQs
Question 101: A 28-year-old woman presents with bloody diarrhoea (8 times daily), abdominal pain, and fever (38.5°C). She was diagnosed with ulcerative colitis 3 years ago. Examination shows abdominal tenderness and tachycardia (110 bpm). Blood tests reveal: Hb 98 g/L, WCC 16 × 10⁹/L, platelets 450 × 10⁹/L, CRP 85 mg/L, albumin 25 g/L. Abdominal X-ray shows colonic dilatation of 7 cm. What is the single most important next step in management?
A. Commence intravenous ciclosporin 2 mg/kg
B. Arrange urgent surgical review and commence IV hydrocortisone (Correct Answer)
C. Increase oral mesalazine to maximum dose
D. Commence oral prednisolone 40 mg daily
E. Arrange urgent colonoscopy to assess disease severity
Explanation: ***Arrange urgent surgical review and commence IV hydrocortisone***
- The patient presents with **acute severe ulcerative colitis** (Truelove and Witts criteria) complicated by **toxic megacolon** (colonic dilatation >6 cm), which is a medical and surgical emergency.
- Immediate **IV corticosteroids** are the first-line medical therapy, while an **urgent surgical review** is mandatory due to the high risk of colonic perforation and the potential need for an emergency colectomy.
*Commence intravenous ciclosporin 2 mg/kg*
- **Intravenous ciclosporin** or Infliximab is reserved as **rescue therapy** for patients who fail to respond to IV steroids after 3–5 days.
- It is not the initial step, and surgical involvement must take precedence when **toxic megacolon** is already present.
*Increase oral mesalazine to maximum dose*
- Oral 5-ASA medications like **mesalazine** are used for inducing and maintaining remission in mild-to-moderate disease but are ineffective for **acute severe colitis**.
- Absorption and efficacy are compromised in the setting of **severe inflammation** and colonic dilatation.
*Commence oral prednisolone 40 mg daily*
- **Oral prednisolone** is appropriate for moderate flare-ups, but this patient meets the criteria for **hospital admission** and requires **parenteral (IV) steroids**.
- The presence of systemic features (fever, tachycardia) and **toxic megacolon** makes oral therapy insufficient and unsafe.
*Arrange urgent colonoscopy to assess disease severity*
- A full **colonoscopy** is strictly **contraindicated** in acute severe colitis, especially with toxic megacolon, due to the extreme risk of **iatrogenic perforation**.
- A **flexible sigmoidoscopy** with minimal air insufflation might be used later to confirm the diagnosis, but it is not the next step in management for a patient with established megacolon.
Question 102: A 67-year-old man presents with sudden onset severe epigastric pain radiating to the back. He has a history of gallstones. Examination reveals epigastric tenderness and tachycardia. Serum amylase is 1850 U/L (normal <100). Which of the following is the most appropriate severity assessment tool to guide early management and predict mortality?
A. CRP level at 72 hours
B. Ranson's criteria at 48 hours
C. Modified Glasgow score at 48 hours (Correct Answer)
D. APACHE-II score at admission
E. CT severity index within 48 hours
Explanation: ***Modified Glasgow score at 48 hours***
- The **Modified Glasgow (Imrie) score** is a well-established and widely used tool for assessing the severity of **acute pancreatitis**, applicable to both **biliary and alcoholic causes**. It is most accurately prognostic when assessed at **48 hours** after admission.
- This score helps predict outcomes by evaluating parameters such as age, WBC count, blood glucose, LDH, AST, albumin, and calcium. A score of **3 or more** indicates **severe pancreatitis** and is associated with increased morbidity and mortality, guiding early management decisions.
*CRP level at 72 hours*
- While an elevated **CRP level** (e.g., >150 mg/L) is a marker of inflammation and can indicate severe pancreatitis, its peak typically occurs at **48-72 hours**, making it less useful for immediate early management decisions.
- CRP is a single inflammatory marker and does not provide a comprehensive assessment of organ dysfunction or systemic complications, unlike multi-parameter scoring systems.
*Ranson's criteria at 48 hours*
- **Ranson's criteria** involve parameters collected at admission and again at **48 hours**, making it somewhat cumbersome for quick, early assessment and ongoing dynamic evaluation.
- This scoring system was primarily developed and validated for **alcoholic pancreatitis** and may be less accurate or universally applicable for other etiologies, such as biliary pancreatitis (as in the patient's case with gallstones).
*APACHE-II score at admission*
- The **APACHE-II score** is a general critical illness severity score, highly comprehensive and useful for predicting mortality in **critically ill patients** across various conditions, not just pancreatitis. However, its calculation is complex and requires numerous physiological parameters, making it time-consuming.
- While it can be applied at admission, its complexity makes it less practical for routine use in guiding *early management* specifically for pancreatitis on a general ward, where a more specialized and simpler tool like the Glasgow score is preferred.
*CT severity index within 48 hours*
- **CT imaging** performed within the first **48-72 hours** of acute pancreatitis onset often *underestimates* the extent of pancreatic necrosis or fluid collections, as these changes may not yet be fully developed.
- CT scans are primarily indicated for diagnosing complications (e.g., necrosis, pseudocyst, abscess) or when the diagnosis of pancreatitis is unclear, rather than for the initial **severity assessment** to guide medical management and predict mortality, which is better done with clinical scoring systems.
Question 103: A 45-year-old woman with known Crohn's disease presents with fever, right upper quadrant pain, and jaundice. Blood tests show: ALP 450 U/L, GGT 380 U/L, bilirubin 65 μmol/L, ALT 85 U/L. MRCP demonstrates multiple short strictures with bead-like appearance of the intrahepatic and extrahepatic bile ducts. Which complication is she at greatest long-term risk of developing?
A. Hepatocellular carcinoma
B. Cholangiocarcinoma (Correct Answer)
C. Pancreatic adenocarcinoma
D. Gallbladder carcinoma
E. Colorectal adenocarcinoma
Explanation: ***Cholangiocarcinoma***
- The clinical triad of fever, RUQ pain, and jaundice along with **MRCP findings of a beaded appearance** (multi-focal strictures) confirms a diagnosis of **Primary Sclerosing Cholangitis (PSC)**.
- Patients with PSC have a significantly elevated lifetime risk (10–15%) of developing **cholangiocarcinoma**, requiring regular surveillance with **CA 19-9** and imaging.
*Hepatocellular carcinoma*
- Risk for primary liver cancer is generally only increased in PSC patients if the disease progresses to **cirrhosis**.
- Unlike Hepatitis B or C, PSC is not primarily associated with **Hepatocellular carcinoma** in the absence of end-stage liver disease.
*Pancreatic adenocarcinoma*
- While there is a slight association between **IgG4-related disease** (which mimics PSC) and pancreatic issues, there is no established link with PSC.
- This malignancy arises from the **exocrine pancreas**, not the biliary tree pathology seen in this patient.
*Gallbladder carcinoma*
- Patients with PSC do have an increased risk of **gallbladder polyps** and subsequent **gallbladder carcinoma**.
- However, the risk for **cholangiocarcinoma** is statistically much higher and represents the more classic, high-weight complication of PSC.
*Colorectal adenocarcinoma*
- While PSC is strongly associated with **Inflammatory Bowel Disease (IBD)**, which increases colon cancer risk, the specific long-term risk of the **biliary disease** itself is cholangiocarcinoma.
- The question focuses on the biliary complications following the **MRCP findings**, making the biliary tract malignancy the most specific answer.
Question 104: A 32-year-old woman presents with a 6-month history of intermittent abdominal pain, bloating, and alternating bowel habit. She reports relief after defecation. Examination is unremarkable. Blood tests including FBC, CRP, coeliac serology, and thyroid function are normal. Faecal calprotectin is 18 μg/g. What is the most appropriate next step in management?
A. Colonoscopy to exclude inflammatory bowel disease
B. CT abdomen and pelvis with contrast
C. Trial of low FODMAP diet and reassurance (Correct Answer)
D. Commence mesalazine 800 mg three times daily
E. Hydrogen breath test for lactose intolerance
Explanation: ***Trial of low FODMAP diet and reassurance***
- The patient presents with classic symptoms of **Irritable Bowel Syndrome (IBS)**, including chronic abdominal pain, bloating, and altered bowel habits with relief after defecation, in the absence of **red flag symptoms** or abnormal lab results.
- Normal **FBC, CRP, coeliac serology, thyroid function**, and a very low **faecal calprotectin** (18 μg/g, well below the 50 μg/g cutoff) effectively rule out **Inflammatory Bowel Disease (IBD)** and other organic pathologies, making dietary intervention the appropriate next step.
*Colonoscopy to exclude inflammatory bowel disease*
- **Colonoscopy** is an invasive procedure generally not indicated in patients with classic **IBS symptoms** and a normal **faecal calprotectin**, especially without red flags like weight loss, rectal bleeding, or anemia.
- The normal faecal calprotectin has a high **negative predictive value** for ruling out significant colonic inflammation, making IBD highly unlikely.
*CT abdomen and pelvis with contrast*
- **CT imaging** is not part of the diagnostic algorithm for suspected **IBS** and is generally reserved for situations where there is concern for structural abnormalities, **acute abdomen**, or complications of inflammatory conditions.
- This investigation would expose the patient to unnecessary **ionizing radiation** without clear clinical indication given the benign presentation and normal lab results.
*Commence mesalazine 800 mg three times daily*
- **Mesalazine (5-ASA)** is an anti-inflammatory drug primarily used in the management of **Ulcerative Colitis** and sometimes Crohn's disease to induce and maintain remission.
- It has no proven efficacy or role in the treatment of **Irritable BowSowel Syndrome (IBS)**, and prescribing it would be inappropriate given the lack of evidence for IBD.
*Hydrogen breath test for lactose intolerance*
- While **lactose intolerance** can contribute to IBS-like symptoms, a **low FODMAP diet** is a broader dietary intervention that includes restriction of lactose, fructose, and other fermentable carbohydrates.
- The **hydrogen breath test** is specific for lactose malabsorption, but a trial of the comprehensive low FODMAP diet often provides better overall symptom relief for IBS patients and is a more practical initial approach before specific testing.
Question 105: A 58-year-old man with a history of heavy alcohol use presents with haematemesis. He is haemodynamically stable. Upper GI endoscopy reveals bleeding oesophageal varices which are successfully banded. His blood tests show: Hb 92 g/L, platelets 78 × 10⁹/L, albumin 28 g/L, bilirubin 45 μmol/L, INR 1.6. What is the most appropriate prophylactic measure to reduce the risk of rebleeding in the first five days?
A. Propranolol 40 mg twice daily
B. Terlipressin 2 mg four times daily for 5 days (Correct Answer)
C. Ciprofloxacin 500 mg twice daily for 7 days
D. Pantoprazole 40 mg twice daily
E. Sengstaken-Blakemore tube insertion
Explanation: ***Terlipressin 2 mg four times daily for 5 days***- **Terlipressin** is a vasopressin analogue that causes **splanchnic vasoconstriction**, which effectively reduces **portal venous pressure** and the risk of early variceal rebleeding.- International guidelines (like Baveno) recommend continuing vasoactive drugs for up to **5 days** after successful endoscopic haemostasis to stabilize the patient during the highest-risk period.*Propranolol 40 mg twice daily*- **Non-selective beta-blockers** are vital for **long-term secondary prophylaxis**, but they are contraindicated in the acute phase due to the risk of **hypotension** and masking tachycardia.- These agents should only be initiated once the patient is stable, typically several days after the bleeding has been controlled.*Ciprofloxacin 500 mg twice daily for 7 days*- While **antibiotic prophylaxis** is mandatory in patients with variceal hemorrhage to prevent **spontaneous bacterial peritonitis**, it does not provide the vasoactive control needed to prevent rebleeding.- Though it reduces mortality and infection rates, it functions as an **adjunct therapy** rather than a direct mechanical or physiological preventative for variceal pressure.*Pantoprazole 40 mg twice daily*- **Proton pump inhibitors (PPIs)** are used for **peptic ulcer disease** bleeding but have no physiological effect on reducing **portal hypertension** or variceal bleeding.- They may be used briefly to promote healing of **post-banding ulcers**, but they are not a primary prophylactic measure for varices.*Sengstaken-Blakemore tube insertion*- This is a **rescue therapy** used for **uncontrolled or massive bleeding** that cannot be managed by endoscopy alone.- It is not indicated for a patient who is **haemodynamically stable** and has already undergone successful **endoscopic band ligation**.
