Gastroenterology & Hepatology — MCQs

Gastroenterology & Hepatology UK Medical PG Practice Questions and MCQs

Question 11: A 64-year-old man presents with painless jaundice and weight loss. CT shows a mass in the head of pancreas. CA 19-9 is markedly elevated. What is the most likely diagnosis?

A. Chronic pancreatitis
B. Pancreatic adenocarcinoma (Correct Answer)
C. Choledocholithiasis
D. Ampullary carcinoma
E. Cholangiocarcinoma

Explanation: ***Pancreatic adenocarcinoma*** - The combination of **painless jaundice**, significant **weight loss**, and a **mass in the head of the pancreas** on CT is highly indicative of pancreatic adenocarcinoma. - A markedly elevated **CA 19-9** level serves as a strong tumor marker, further supporting this diagnosis. *Chronic pancreatitis* - Typically presents with recurrent or chronic **epigastric pain** that often radiates to the back, not primarily painless jaundice. - Imaging usually shows pancreatic atrophy, calcifications, or ductal changes, rather than a discrete solid mass, and CA 19-9 elevation is not usually as dramatic. *Choledocholithiasis* - Jaundice caused by gallstones often presents with **biliary colic** (pain) and may be intermittent, unlike the painless and progressive jaundice seen here. - Imaging would demonstrate **gallstones** within the bile duct, not a solid mass within the pancreatic head. *Ampullary carcinoma* - While also causing obstructive jaundice and weight loss, ampullary carcinomas frequently cause **intermittent jaundice** due to tumor sloughing and bleeding, which is not described here. - Although located in the periampullary region, the description of a mass

Question 12: A 54-year-old man presents with progressive dysphagia and weight loss. Barium swallow shows a smooth, tapered narrowing at the gastroesophageal junction. Manometry confirms absent peristalsis. What is the most likely diagnosis?

A. Esophageal carcinoma
B. Achalasia (Correct Answer)
C. Esophageal stricture
D. Diffuse esophageal spasm
E. Scleroderma

Explanation: ***Achalasia*** - The classic finding of a smooth, tapered narrowing at the **gastroesophageal junction** on barium swallow, commonly known as the **"bird's beak"** sign, is highly characteristic. - Manometry confirming **absent peristalsis** in the esophageal body, combined with failure of the Lower Esophageal Sphincter (LES) to fully relax, is diagnostic for this primary esophageal motility disorder. *Esophageal carcinoma* - While it causes progressive dysphagia and weight loss, barium swallow typically shows an **abrupt, irregular filling deficit** or a shelf-like narrowing, not a smooth taper. - Carcinoma causes a structural stricture, whereas achalasia is a functional disorder; manometry findings would not involve absent body peristalsis. *Esophageal stricture* - Strictures, often peptic, result in a smooth, short-segment narrowing, but the diagnosis is purely anatomical, and esophageal **peristalsis is usually preserved** above the stricture. - Strictures do not typically cause the characteristic **non-relaxing, functional obstruction** seen at the true GE junction in achalasia. *Diffuse esophageal spasm* - This disorder is defined by simultaneous, **high-amplitude contractions** on manometry, not absent peristalsis. - The barium swallow often reveals a **"corkscrew" esophagus** appearance due to irregular tertiary contractions, which is visually distinct from the smooth achalasia narrowing. *Scleroderma* - Scleroderma causes destruction and **atrophy of the smooth muscle** in the distal esophagus, leading to a **hypotensive (weak) LES**. - Manometry would show low LES pressure and absent distal peristalsis, distinct from the typically **hypertensive** and non-relaxing LES seen in achalasia.

Question 13: A 65-year-old man presents with progressive dysphagia to solids over 2 months and 10kg weight loss. He has a 40-year history of heartburn. Endoscopy shows a stricturing lesion in the lower esophagus. What is the most likely diagnosis?

A. Benign esophageal stricture
B. Esophageal adenocarcinoma (Correct Answer)
C. Esophageal squamous cell carcinoma
D. Achalasia
E. Eosinophilic esophagitis

Explanation: ***Esophageal adenocarcinoma***- The patient's long history of **heartburn (GERD)** predisposes him to **Barrett's esophagus**, which is the precursor to adenocarcinoma, typically arising in the **lower esophagus**.- **Progressive dysphagia to solids** over a short duration (2 months), coupled with significant **weight loss** (10kg), are classic red flag symptoms for advanced esophageal malignancy.*Benign esophageal stricture*- While benign strictures result from chronic **acid reflux** and cause dysphagia, they usually present insidiously without the rapid, considerable **weight loss** characteristic of cancer.- Endoscopy would likely reveal a smooth, symmetric narrowing, which is less suspicious than a rapidly progressive, stricturing **lesion** suggesting malignancy.*Esophageal squamous cell carcinoma*- This cancer type is strongly linked to **smoking** and **alcohol use** (etiologies not emphasized here) and typically affects the **middle or upper esophagus**.- Given the history of GERD and the location in the lower esophagus, adenocarcinoma is the much more probable diagnosis.*Achalasia*- Achalasia causes disordered motility leading to dysphagia for **both solids and liquids** simultaneously, which differentiates it from the solid-only dysphagia of a stricture.- It involves failure of the **lower esophageal sphincter (LES)** relaxation, typically showing proximal dilation rather than a discrete, rapidly progressing stricturing lesion seen in malignancy.*Eosinophilic esophagitis*- This condition primarily affects **younger adults** and commonly presents with intermittent dysphagia or food impactions, not rapid, severe **weight loss** in an elderly patient.- Endoscopy would typically show vertical **furrows** or **multiple rings**, and biopsies would show eosinophilic infiltration, not a stricturing lesion indicative of malignancy.

Question 14: A 25-year-old man presents with bloody diarrhea, abdominal pain, and weight loss over 3 months. Colonoscopy shows skip lesions with deep ulceration and cobblestone appearance. Histology shows transmural inflammation with granulomas. What is the most likely diagnosis?

A. Ulcerative colitis
B. Crohn's disease (Correct Answer)
C. Infectious colitis
D. Ischemic colitis
E. Radiation colitis

Explanation: ***Crohn's disease***- The core presentation—chronic bloody diarrhea, abdominal pain, and weight loss—combined with the specific findings of **skip lesions**, **deep ulceration**, and **cobblestone appearance** on colonoscopy, is highly characteristic.- Histologically, the presence of **transmural inflammation** (affecting all layers of the bowel wall) and **non-caseating granulomas** confirms the diagnosis of Crohn's disease.*Ulcerative colitis*- UC causes continuous inflammation confined to the **mucosa** and superficial submucosa, contrasting sharply with the transmural involvement seen in this patient.- UC typically lacks both **skip lesions** and the characteristic **granulomas** seen in Crohn's disease.*Infectious colitis*- Infectious colitis is typically an **acute** process; a presentation lasting 3 months suggests a chronic condition like IBD.- While some infections can cause chronic symptoms, the specific endoscopic findings of **skip lesions** and the histological finding of **granulomas** rule against a typical infectious etiology.*Ischemic colitis*- Ischemic colitis is generally seen in older patients with vascular risk factors and presents acutely with sudden pain and bloody stools.- It primarily affects the **mucosa** and **submucosa** but does not feature the **granulomas** or chronic **cobblestone appearance** seen here.*Radiation colitis*- This type of colitis is limited to patients with a history of radiation therapy and presents with ulceration and atrophy related to the **radiation field**.- It lacks the diffuse distribution, **skip lesions**, and **granulomas** that define Crohn's disease.

Question 15: A 50-year-old man presents with progressive dysphagia to both solids and liquids, chest pain, and regurgitation of undigested food. Barium swallow shows a dilated esophagus with smooth tapering at the gastroesophageal junction ("bird's beak" appearance). What is the most likely diagnosis?

A. Esophageal carcinoma
B. Achalasia (Correct Answer)
C. Esophageal stricture
D. GERD
E. Esophageal spasm

Explanation: ***Achalasia***- The classic presentation includes progressive dysphagia to **both solids and liquids**, chest pain, and regurgitation of undigested food, indicating a motility disorder.- The barium swallow finding of a **dilated esophagus** with smooth tapering at the **gastroesophageal junction** (the "**bird's beak**" appearance) is pathognomonic, resulting from impaired relaxation of the **lower esophageal sphincter** and absent esophageal **peristalsis**.*Esophageal carcinoma*- Dysphagia in esophageal carcinoma typically begins with **solids** and progresses later to include liquids, unlike the simultaneous dysphagia seen here.- Barium swallow would usually show an **irregular, constricting lesion** or a shelf-like defect, rather than a smooth, symmetric tapering.*Esophageal stricture*- While esophageal strictures cause dysphagia, it is predominantly to **solids** and tends to be more consistent rather than the progressive nature to both solids and liquids.- Barium swallow would show a **focal narrowing** with proximal dilation, but typically not the classic smooth "bird's beak" tapering seen in achalasia.*GERD*- Gastroesophageal reflux disease (GERD) primarily presents with **heartburn** and acid regurgitation, with dysphagia being a less common or secondary symptom, often due to esophagitis or stricture.- Barium swallow may show reflux or a **peptic stricture**, but not the diffuse esophageal dilation or the characteristic smooth "bird's beak" appearance of achalasia.*Esophageal spasm*- Esophageal spasm typically causes **intermittent chest pain** and dysphagia to both solids and liquids, but symptoms are often unpredictable and not consistently progressive.- Barium swallow in esophageal spasm might show a **"corkscrew" esophagus** or uncoordinated contractions, which differs from the persistent dilation and smooth tapering of achalasia.

Question 16: A 35-year-old woman presents with recurrent episodes of severe abdominal pain, nausea, and vomiting. The pain is in the right upper quadrant and radiates to the right shoulder. Episodes last 2-3 hours and often occur after fatty meals. What is the most likely diagnosis?

A. Peptic ulcer disease
B. Acute pancreatitis
C. Biliary colic (Correct Answer)
D. Appendicitis
E. Gastroenteritis

Explanation: ***Biliary colic***- The presentation of recurrent, severe spasmodic pain in the **right upper quadrant (RUQ)** that radiates to the **right shoulder** is highly characteristic of biliary colic.- The pain, which is short-lived (2-3 hours) and often precipitated by **fatty meals** (triggering gallbladder contraction), indicates temporary obstruction of the cystic duct by a gallstone.*Peptic ulcer disease*- Pain is typically dull, gnawing, or burning, located in the **epigastrium**, and often associated with meal timing (relief or worsening, depending on the ulcer location).- PUD rarely presents with acute, intermittent, severe RUQ pain radiating to the shoulder.*Acute pancreatitis*- Pain is characteristically severe, constant, located in the **epigastrium**, and often radiates straight through to the **back**.- This condition causes severe, sustained inflammation, not the intermittent, 2-3 hour episodes typical of colic.*Appendicitis*- Pain classically starts as periumbilical discomfort before localizing to the **right lower quadrant (RLQ)** (McBurney's point).- The pain is usually constant, rapidly escalating, and is not intermittent or triggered by food ingestion.*Gastroenteritis*- Symptoms typically involve diffuse abdominal cramping, significant **diarrhea**, and generalized vomiting.- Gastroenteritis does not cause localized, severe, recurrent RUQ pain triggered consistently by fatty meals.

Question 17: A 55-year-old man presents with progressive jaundice, weight loss, and epigastric pain radiating to his back. On examination, he has a palpable gallbladder. CA 19-9 is markedly elevated. What is the most likely diagnosis?

A. Cholangiocarcinoma
B. Pancreatic carcinoma (Correct Answer)
C. Choledocholithiasis
D. Chronic pancreatitis
E. Hepatocellular carcinoma

Explanation: ***Pancreatic carcinoma***- This presentation, including progressive **jaundice**, weight loss, and epigastric pain radiating to the back, is the classic triad for **pancreatic head adenocarcinoma**.- The presence of a palpable, non-tender gallbladder (**Courvoisier's sign**) is highly indicative of malignant obstruction of the distal common bile duct, usually caused by pancreatic cancer, supported by the marked elevation of **CA 19-9** (tumor marker).*Cholangiocarcinoma*- While cholangiocarcinoma causes obstructive **jaundice** and elevated CA 19-9, it rarely causes the classic epigastric pain radiating to the back characteristic of a pancreatic mass.- These tumors usually originate within the bile ducts (perihilar or distal), often lacking associated features like the distinctive **Courvoisier's sign** seen with pancreatic head masses.*Choledocholithiasis*- This typically causes intermittent, severe colicky pain (**biliary colic**) rather than progressive, painless jaundice or constant back-radiating pain.- Obstruction due to gallstones does not usually lead to the marked elevation of a tumor marker like **CA 19-9** or the significant **weight loss** associated with malignancy.*Chronic pancreatitis*- Chronic pancreatitis causes significant, recurrent **epigastric pain** that often radiates to the back and is associated with malabsorption and weight loss.- However, it less commonly presents solely with progressive, textbook obstructive **jaundice** and a palpable gallbladder (**Courvoisier's sign**).*Hepatocellular carcinoma*- HCC typically presents in a patient with underlying **cirrhosis** and involves direct liver mass effects, often causing portal hypertension or signs of liver failure.- While it causes weight loss, **CA 19-9** is not the primary tumor marker; **AFP** (alpha-fetoprotein) is the key marker, and the presenting features do not specifically localize the pathology to the pancreas/bile duct outflow tract.

Question 18: A 22-year-old woman presents with a 6-month history of abdominal pain, diarrhea with blood and mucus, and weight loss. Colonoscopy shows continuous inflammation from rectum to sigmoid colon with ulceration. What is the most likely diagnosis?

A. Crohn's disease
B. Ulcerative colitis (Correct Answer)
C. Irritable bowel syndrome
D. Infectious colitis
E. Colorectal cancer

Explanation: ***Ulcerative colitis***- The presentation of chronic abdominal pain, diarrhea with **blood and mucus**, weight loss, and colonoscopy findings of **continuous inflammation** from the **rectum** to the sigmoid colon with ulceration is highly characteristic of **ulcerative colitis** (UC).- UC inflammation is typically limited to the **mucosa** and **submucosa**, spreads proximally in a **confluent** manner, and commonly presents with **tenesmus** and bloody stools.*Crohn's disease*- Crohn's disease is characterized by inflammation that is **transmural** (full-thickness) and typically involves **skip lesions** (discontinuous areas of affected and unaffected tissue).- While it can cause abdominal pain and bloody diarrhea, it often affects the **terminal ileum** and colon, and is associated with **fistulas**, strictures, and **perianal disease**, which are not described.*Irritable bowel syndrome*- IBS is a functional disorder that causes chronic abdominal pain and altered bowel habits without any demonstrable **structural abnormalities** or inflammation.- It does not cause features such as **grossly bloody stools**, significant **weight loss**, or **ulceration** visible on colonoscopy.*Infectious colitis*- Infectious colitis is usually **acute** in onset, often accompanied by systemic symptoms like fever, and typically resolves spontaneously or with short-term treatment.- The patient's **6-month history** of symptoms points toward a chronic inflammatory process, making acute infectious colitis highly unlikely.*Colorectal cancer*- While colorectal cancer can cause blood in stool and weight loss, it is extremely rare in a **22-year-old** without known predisposing factors.- Colonoscopy would typically reveal a localized **mass** or **polypoid lesion**, not the diffuse, continuous inflammatory pattern observed here.

Question 19: A 70-year-old man presents with progressive dysphagia to solids over 2 months, associated with weight loss of 8kg. He has a history of heartburn for many years. What is the most appropriate investigation?

A. Barium swallow
B. CT chest and abdomen
C. Upper GI endoscopy (Correct Answer)
D. PET scan
E. 24-hour pH monitoring

Explanation: ***Upper GI endoscopy*** - This patient presents with **alarm features** for esophageal malignancy, including new-onset progressive **dysphagia to solids**, **significant weight loss**, and a long history of **heartburn** (increasing risk for Barrett's esophagus and adenocarcinoma). - **Upper GI endoscopy** with **biopsy** is the **gold standard** for directly visualizing the esophageal lumen, identifying any lesions or strictures, and obtaining tissue for histological diagnosis. *Barium swallow* - While a **barium swallow** can identify structural abnormalities like strictures or masses, it is an indirect imaging study that cannot differentiate benign from malignant causes. - It also does not allow for **biopsy**, which is crucial for definitive diagnosis in a patient with **alarm symptoms** suggesting malignancy. *CT chest and abdomen* - A **CT scan** is primarily a **staging investigation** to assess for local invasion or distant metastasis once a diagnosis of esophageal cancer has been made or strongly suspected. - It is not the initial diagnostic test to identify the primary lesion and obtain a **histological diagnosis**. *PET scan* - A **PET scan** is mainly used for **staging** and detecting metastatic disease in patients with known or highly suspected malignancy. - It is not the appropriate first-line investigation for the **initial diagnosis** of the cause of dysphagia with alarm features. *24-hour pH monitoring* - **24-hour pH monitoring** is used to diagnose or quantify **gastroesophageal reflux disease (GERD)** by measuring esophageal acid exposure. - It is not indicated for investigating new-onset dysphagia with **alarm features** like weight loss and progressive dysphagia, which strongly suggest a **mechanical obstruction**, likely malignant, requiring direct visualization.

Question 20: A 45-year-old woman presents with a 3-month history of abdominal pain, bloating, and alternating diarrhea and constipation. Colonoscopy and inflammatory markers are normal. What is the most likely diagnosis?

A. Inflammatory bowel disease
B. Irritable bowel syndrome (Correct Answer)
C. Colorectal cancer
D. Celiac disease
E. Thyroid dysfunction

Explanation: ***Irritable bowel syndrome***- The constellation of **chronic abdominal pain**, **bloating**, and **alternating diarrhea and constipation** over 3 months is classic for IBS. - A **normal colonoscopy** and **normal inflammatory markers** are key diagnostic criteria, as IBS is a **functional gastrointestinal disorder** without structural abnormalities or inflammation.*Inflammatory bowel disease*- IBD is characterized by **chronic inflammation** of the gastrointestinal tract, which would present with abnormal findings on colonoscopy (e.g., ulcers, strictures) and elevated inflammatory markers like CRP or ESR.- While symptoms can overlap, the **normal colonoscopy** and **inflammatory markers** effectively rule out IBD in this case.*Colorectal cancer*- Although possible at this age, **colorectal cancer** would typically be detected during colonoscopy as a **polyp or mass**.- Other common symptoms include **rectal bleeding**, unexplained **weight loss**, or **anemia**, which are not mentioned here.*Celiac disease*- Celiac disease is an **autoimmune reaction to gluten** causing small intestinal damage, usually manifesting as diarrhea, bloating, and malabsorption.- A normal colonoscopy does not specifically exclude celiac disease (which affects the small bowel), but without specific mention of gluten-related symptoms or serological testing, it's less likely to be the primary diagnosis given the typical IBS presentation.*Thyroid dysfunction*- Thyroid disorders can affect bowel motility (e.g., **constipation in hypothyroidism**, diarrhea in hyperthyroidism), but they typically involve a broader range of **systemic symptoms**.- The primary presentation of **abdominal pain and bloating** with alternating bowel habits points more specifically to a gastrointestinal functional disorder rather than an endocrine cause.

Practice by Chapter

Acute pancreatitis

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Cirrhosis and complications

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Dyspepsia and GORD

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Inflammatory bowel disease

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Irritable bowel syndrome

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Upper GI bleeding

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