Gastroenterology & Hepatology — MCQs

Gastroenterology & Hepatology UK Medical PG Practice Questions and MCQs

Question 21: A 55-year-old man with a history of atrial fibrillation presents with sudden onset severe abdominal pain and bloody diarrhea. His CHA₂DS₂-VASc score is 3, but he stopped taking warfarin 3 months ago. What is the most likely diagnosis?

A. Inflammatory bowel disease
B. Ischemic colitis
C. Mesenteric ischemia (Correct Answer)
D. Diverticulitis
E. Colorectal cancer

Explanation: ***Mesenteric ischemia***- The combination of **atrial fibrillation** (a strong source of emboli), cessation of anticoagulation, and the sudden onset of **severe, disproportionate abdominal pain** followed by **bloody diarrhea** is the classic presentation of acute **mesenteric ischemia** secondary to arterial embolism.- Embolic occlusion of the Superior Mesenteric Artery (SMA) leads to widespread bowel infarction and mucosal sloughing, causing the catastrophic pain and subsequent bloody stools.*Inflammatory bowel disease*- This is characterized by chronic or relapsing symptoms (e.g., chronic diarrhea, abdominal cramping, weight loss), not the acute, sudden-onset catastrophic presentation seen here.- The strong risk factor (untreated **atrial fibrillation**) makes an acute vascular etiology far more probable than a new presentation of IBD.*Ischemic colitis*- **Ischemic colitis** typically causes less severe, intermittent, cramping pain, usually localized to the left side or watershed areas (e.g., splenic flexure, rectosigmoid junction).- While it causes bloody diarrhea (hematochezia), it does not usually cause the severe, diffuse, rapid-onset pain and profound systemic illness associated with major vessel occlusion in acute **mesenteric ischemia**. *Diverticulitis*- Diverticulitis typically presents with localized abdominal pain (most commonly **left lower quadrant**), fever, and leukocytosis, often without prominent bloody diarrhea.- The pain is usually localized rather than the diffuse, severe pain characteristic of acute widespread **mesenteric ischemia**. *Colorectal cancer*- Colorectal cancer symptoms are typically insidious, involving changes in bowel habits, chronic occult or low-volume bleeding, and weight loss.- Acute presentation as sudden, severe abdominal pain and bloody diarrhea is rare unless complicated by perforation or acute obstruction, which would present differently than this presumed vascular event.

Question 22: A 54-year-old man presents with sudden onset severe epigastric pain radiating to his back, nausea, and vomiting. His serum amylase is 1200 U/L (normal <100). He drinks 40 units of alcohol per week. What is the most likely diagnosis?

A. Peptic ulcer disease
B. Acute cholangitis
C. Acute pancreatitis (Correct Answer)
D. Myocardial infarction
E. Aortic dissection

Explanation: ***Acute pancreatitis*** - The sudden onset of severe **epigastric pain radiating to the back**, accompanied by nausea, vomiting, and a markedly elevated **serum amylase** (1200 U/L, >3x normal), is highly indicative of acute pancreatitis. - The patient's history of heavy **alcohol consumption** (40 units/week) is a significant and common risk factor for developing acute pancreatitis. *Peptic ulcer disease* - While causing epigastric pain, peptic ulcer disease typically does not present with such a dramatic elevation in **serum amylase** or the characteristic back radiation of pain. - A perforated ulcer would cause diffuse, severe abdominal pain and **peritoneal signs** (e.g., rigidity), not primarily isolated back pain with hyperamylasemia. *Acute cholangitis* - Acute cholangitis presents with **Charcot's triad** of fever, **jaundice**, and right upper quadrant pain, none of which are mentioned in this clinical picture. - Lab abnormalities in cholangitis predominantly involve elevated **bilirubin** and **alkaline phosphatase**, rather than a significant rise in amylase. *Myocardial infarction* - Although an inferior wall myocardial infarction can cause epigastric discomfort, it would not explain the high **serum amylase** level or the specific radiation of pain to the back in this context. - Diagnosis of MI relies on **cardiac biomarkers** (e.g., troponins) and characteristic **ECG changes**, which are not provided. *Aortic dissection* - Aortic dissection presents with sudden, severe, often **tearing** or **ripping** pain in the chest or back, but it does not cause the specific elevation of **serum amylase** observed here. - It is typically associated with risk factors like **hypertension** and may present with pulse deficits or neurological deficits.

Question 23: A 48-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 classic presentation involves **severe, intermittent pain** (colic) in the **right upper quadrant (RUQ)** or epigastrium.- Pain commonly **radiates to the right shoulder or back** and is often precipitated by **fatty meals** as it stimulates gallbladder contraction against a transiently impacted gallstone.*Peptic ulcer disease*- Pain is typically described as a **burning or gnawing sensation** in the epigastrium, often related to *meal timing* but rarely presents as severe, short, radiating episodes.- While ulcers can cause nausea and vomiting, the pattern of severe, radiating pain after fatty meals strongly differentiates it from **Peptic ulcer disease**.*Acute pancreatitis*- Pain is usually **epigastric**, severe, constant, and classically **radiates to the back**, often relieved by leaning forward.- It is nearly always associated with significantly elevated serum **amylase and lipase**, and the pain does not typically resolve completely within a few hours.*Appendicitis*- Typically presents with pain migrating from the **periumbilical region to the right lower quadrant (RLQ)**.- This condition is characterized by a constant progression of pain and signs of systemic illness (**fever**, leukocytosis), not recurrent, short-duration RUQ episodes.*Gastroenteritis*- Usually involves diffuse or crampy **abdominal pain** accompanied by **diarrhea** and vomiting, often lasting days.- Unlike biliary colic, the pain is not localized strictly to the RUQ, does not radiate to the shoulder, and is not specifically linked to the ingestion of **fatty meals**.

Question 24: A 28-year-old woman presents with recurrent episodes of severe abdominal pain, nausea, and confusion. During episodes, her urine turns dark red. Family history reveals similar episodes in her father. What is the most likely diagnosis?

A. Acute intermittent porphyria (Correct Answer)
B. Hereditary coproporphyria
C. Variegate porphyria
D. Erythropoietic protoporphyria
E. Congenital erythropoietic porphyria

Explanation: ***Acute intermittent porphyria*** - The presentation of recurrent **severe abdominal pain**, nausea, and **neuropsychiatric symptoms** (confusion) is the classic triad of an acute hepatic porphyria attack (AIP, HCP, or VP). - The key finding of urine turning **dark red** due to the presence of oxidized **porphobilinogen (PBG)**, coupled with the lack of cutaneous symptoms, makes AIP the most likely diagnosis. *Hereditary coproporphyria* - While this can cause identical acute neuro-visceral attacks, it often also causes **cutaneous photosensitivity** (skin blistering and fragility), which is not described in this patient. - Diagnosis relies on finding excessive **coproporphyrin** in both urine and feces, in addition to elevated ALA and PBG during an attack. *Variegate porphyria* - This porphyria virtually always presents with both **acute neuro-visceral attacks** and **chronic cutaneous photosensitivity** (blistering and scarring) simultaneously. - VP is characterized by high levels of **protoporphyrin** and **coproporphyrin** in the stool, caused by a defect in **protoporphyrinogen oxidase (PPOX)**. *Erythropoietic protoporphyria* - This porphyria presents only with **cutaneous symptoms**, specifically **painful, non-blistering photosensitivity** (burning and stinging) immediately upon sun exposure. - It is classified as an erythropoietic porphyria (affecting red blood cells) and does **not** cause the systemic neurological symptoms or dark urine seen in acute hepatic porphyrias. *Congenital erythropoietic porphyria* - This is a very rare and severe disorder typically presenting in infancy with profound, irreversible **blistering photosensitivity**, hemolysis, and the characteristic feature of **erythrodontia** (red or brown teeth). - The clinical course and onset are incompatible with the recurrent, adult-onset neuro-visceral attacks described in this patient.

Question 25: A 41-year-old man presents with recurrent episodes of severe epigastric pain radiating to his back. He drinks 60 units of alcohol per week. CT shows pancreatic calcification and pseudocyst formation. What is the most likely diagnosis?

A. Acute pancreatitis
B. Chronic pancreatitis (Correct Answer)
C. Pancreatic carcinoma
D. Peptic ulcer disease
E. Biliary colic

Explanation: ***Chronic pancreatitis***- Recurrent episodes of severe epigastric pain radiating to the back, combined with a history of **heavy alcohol use** (60 units/week), are classic features of chronic pancreatitis.- The CT findings of **pancreatic calcification** (indicating irreversible fibrosis and parenchymal damage) and **pseudocyst formation** are definitive diagnostic markers for chronic pancreatitis.*Acute pancreatitis*- Acute pancreatitis presents as a sudden, severe episode of pain, typically with significantly elevated **serum lipase** and amylase.- While recurrent acute episodes can occur, the presence of **pancreatic calcification** and pseudocysts on CT indicates irreversible structural changes, distinguishing it from a sole acute episode.*Pancreatic carcinoma*- Pancreatic carcinoma can cause abdominal pain, but it often presents with **painless jaundice**, significant **weight loss**, and new-onset diabetes.- The extensive history of alcohol abuse and the specific CT findings of diffuse **pancreatic calcification** are more characteristic of chronic pancreatitis than carcinoma.*Peptic ulcer disease*- Peptic ulcer disease pain is typically epigastric and may radiate, but it is less commonly described as severe pain radiating to the entire back and is often relieved by antacids or food.- It does not cause **pancreatic calcification** or **pseudocyst formation**, which are specific to pancreatic pathology.*Biliary colic*- Biliary colic presents as intermittent, severe **right upper quadrant** or epigastric pain, often triggered by fatty meals, and typically resolves within hours.- It is caused by gallstone obstruction and is not associated with the **pancreatic structural changes** like calcification or pseudocysts seen in this patient.

Question 26: A 38-year-old man presents with acute severe epigastric pain radiating to his back. He has a history of gallstones. Serum amylase is 1800 U/L. CT shows pancreatic inflammation with fluid collection. What is the most appropriate initial management?

A. Immediate surgery
B. ERCP
C. Conservative management with IV fluids (Correct Answer)
D. Percutaneous drainage
E. Antibiotics

Explanation: ***Conservative management with IV fluids***- Initial management for acute pancreatitis is universally **supportive**, focusing on aggressive **intravenous (IV) fluid resuscitation** to maintain pancreatic perfusion and correct third-spacing losses.- Pain control (usually opioids) and NPO status are essential components of this approach, especially in cases likely related to **biliary stone passage**.*Immediate surgery*- Surgery is **contraindicated** in the acute phase of pancreatitis unless there are specific, rare complications such as generalized peritonitis or hemorrhage.- Definitive treatment for gallstones (cholecystectomy) is typically planned *after* the acute inflammatory process has completely resolved.*ERCP*- ERCP (Endoscopic Retrograde Cholangiopancreatography) is indicated acutely only if there is evidence of concurrent **acute cholangitis** or persistent **biliary obstruction** (e.g., rising **bilirubin**).- Routine use of ERCP in stable, non-jaundiced patients with gallstone pancreatitis does not improve outcomes and may introduce risks.*Percutaneous drainage*- This procedure is reserved for managing later complications, such as symptomatic, persistent, or **infected pancreatic collections** (e.g., walled-off necrosis or pseudocysts).- It is not a component of the initial stabilization phase for acute pancreatitis.*Antibiotics*- Prophylactic antibiotics are **not recommended** in acute pancreatitis as they do not reduce overall mortality or the rate of infected necrosis.- Antibiotics should only be initiated when there is strong clinical suspicion or confirmation of **infected necrosis** or extrapancreatic infection.

Question 27: A 48-year-old man presents with acute onset severe epigastric pain radiating to his back. CT shows acute pancreatitis with pancreatic necrosis involving >50% of the gland. What is the most appropriate management?

A. Conservative management with IV fluids (Correct Answer)
B. Immediate surgical debridement
C. Endoscopic necrosectomy
D. Percutaneous drainage
E. Total pancreatectomy

Explanation: ***Conservative management with IV fluids*** - The initial management for **acute necrotizing pancreatitis**, even when severe and involving extensive necrosis, is aggressive **supportive care** including IV fluids, analgesia, and nutritional management. - Early invasive interventions are associated with high mortality; procedures are typically delayed until necrosis is **infected** or appropriately **walled off** (usually 4-6 weeks after onset). *Immediate surgical debridement* - Early surgical debridement (within the first few weeks) significantly increases morbidity and mortality due to the friability of tissues and extent of the inflammatory response. - Intervention is typically reserved for confirmed **infected necrosis** that fails to respond to antibiotics, or specific acute complications such as abdominal compartment syndrome. *Endoscopic necrosectomy* - This is a minimally invasive technique used to debride **walled-off pancreatic necrosis (WOPN)**, and requires the collection to be mature, which takes several weeks. - It is inappropriate for managing acute, immature necrosis during the initial severe inflammatory phase. *Percutaneous drainage* - Percutaneous drainage is mainly indicated for acutely managing **infected fluid collections** or **abscesses**, or as a temporizing measure in critically ill patients with infected necrosis. - It is generally insufficient for definitive management of extensive **solid necrotic tissue**. *Total pancreatectomy* - **Total pancreatectomy** is a procedure of last resort, reserved only for catastrophic complications such as uncontrollable hemorrhage or devastating pancreatic parenchymal destruction. - It is never indicated as the primary or initial management strategy for acute pancreatitis, regardless of the extent of necrosis.

Question 28: A 55-year-old woman presents with progressive dysphagia and weight loss over 3 months. She has a history of Barrett's esophagus. Upper endoscopy shows a stricturing lesion in the lower esophagus. What is the most likely diagnosis?

A. Benign peptic stricture
B. Esophageal adenocarcinoma (Correct Answer)
C. Achalasia
D. Eosinophilic esophagitis
E. Candida esophagitis

Explanation: ***Esophageal adenocarcinoma*** - This presentation—**progressive dysphagia** and **weight loss** over a short period—is highly suggestive of malignancy, especially given the history of **Barrett's esophagus**. - **Barrett's esophagus** is a well-established precursor lesion that undergoes metaplasia-dysplasia-carcinoma sequence, leading to adenocarcinoma, typically found in the lower third of the esophagus. *Benign peptic stricture* - Although benign peptic strictures cause dysphagia, the presence of associated **substantial weight loss** strongly favors a malignant etiology. - Benign strictures usually result from long-standing reflux and present with dysphagia that is often less rapid in progression and typically affects primarily solids. *Achalasia* - Achalasia presents with **dysphagia to both solids and liquids** due to failure of LES relaxation and typically lacks the rapid weight loss associated with cancer. - Endoscopically, achalasia presents as a dilated esophagus leading to a narrow, symmetric LES (the **"bird's beak"** sign on barium swallow), not typically a discrete stricturing mass. *Eosinophilic esophagitis* - This condition is typically characterized by intermittent dysphagia and food impaction, often in patients with associated **atopy** or allergies. - Endoscopic findings usually include **multiple rings** (trachealization) or linear furrows, rather than a significant stricturing mass in the distal esophagus causing rapid weight loss. *Candida esophagitis* - Candida esophagitis primarily causes **odynophagia** (painful swallowing) and tends to occur in immunocompromised patients (e.g., HIV, diabetes). - Endoscopy shows characteristic **white, adherent plaques** or pseudomembranes lining the esophagus, which is distinct from a stricturing malignant lesion.

Question 29: A 58-year-old man presents with progressive dysphagia and weight loss. Upper endoscopy shows a stricturing lesion in the mid-esophagus. He has a history of caustic ingestion 20 years ago. What is the most likely diagnosis?

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

Explanation: ***Esophageal squamous cell carcinoma*** - A history of **caustic ingestion** is a significant risk factor for **esophageal squamous cell carcinoma (ESCC)**, often with a latency period of decades, and it commonly affects the **mid-esophagus**. - **Progressive dysphagia** and **weight loss** are classic alarm symptoms indicative of an underlying malignancy in the esophagus. *Esophageal adenocarcinoma* - Typically arises from **Barrett's esophagus**, which is a complication of chronic **gastroesophageal reflux disease (GERD)**, and is usually located in the **distal esophagus**. - There is no mention of GERD or Barrett's, and the location in the mid-esophagus along with caustic ingestion history makes adenocarcinoma less likely. *Benign stricture* - While caustic ingestion can cause benign strictures, the presence of **progressive dysphagia** and significant **weight loss** strongly suggests a malignant transformation rather than a solely benign process. - Benign strictures usually do not lead to such rapid or severe weight loss unless extremely advanced, and the overall clinical picture points to malignancy. *Achalasia* - Characterized by impaired relaxation of the **lower esophageal sphincter (LES)** and loss of esophageal peristalsis, typically presenting with dysphagia to both solids and liquids and regurgitation. - Endoscopy in achalasia usually shows a **dilated esophagus** with a normal-appearing LES, not a stricturing lesion in the mid-esophagus. *Eosinophilic esophagitis* - An inflammatory condition often associated with **atopic diseases** (e.g., asthma, allergies) and presents with dysphagia, food impaction, and chest pain. - Endoscopic findings typically include **esophageal rings**, linear furrows, and exudates, and it is not linked to prior caustic ingestion or the degree of weight loss seen here.

Question 30: A 29-year-old man presents with acute severe abdominal pain and vomiting. He has a strong family history of similar episodes. Serum amylase is normal. Urinary porphobilinogen is elevated. What is the most likely diagnosis?

A. Acute pancreatitis
B. Acute intermittent porphyria (Correct Answer)
C. Familial Mediterranean fever
D. Hereditary angioedema
E. Inflammatory bowel disease

Explanation: ***Acute intermittent porphyria*** - The presentation with acute severe **abdominal pain**, vomiting, and a strong **family history** of similar episodes is characteristic of an acute porphyric crisis. - The elevated urinary **porphobilinogen** confirms the diagnosis, as it is a key accumulated intermediate in heme synthesis during these attacks, while **normal serum amylase** rules out acute pancreatitis. *Acute pancreatitis* - The diagnosis is definitively excluded by the **normal serum amylase** (and lipase), which would be significantly elevated (typically >3 times the upper limit of normal) in acute pancreatitis. - While it causes acute severe abdominal pain and vomiting, it is not associated with elevated urinary **porphobilinogen** levels. *Familial Mediterranean fever* - FMF attacks classically involve **recurrent fever** and **serositis** (peritonitis, pleuritis, or arthritis), typically resolving spontaneously within days, which are not the primary focus here. - It is an **autoinflammatory syndrome** not involving abnormalities in the heme synthesis pathway or elevation of porphobilinogen. *Hereditary angioedema* - This condition causes recurrent, painful, non-pruritic episodes of localized **submucosal edema**, including abdominal pain due to bowel wall swelling. - It is a disorder of the **complement system** (e.g., C1 inhibitor deficiency) and is not linked to elevated urinary **porphobilinogen**. *Inflammatory bowel disease* - IBD typically presents with chronic or subacute symptoms such as **diarrhea**, rectal bleeding, or weight loss, rather than acute, episodic, severe attacks with a strong family history. - While acute flares can cause severe pain, IBD is characterized by intestinal inflammation and not by elevated **porphyrin precursors** like PBG.

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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