Git MRCGP 2015

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Question 1 of 117
A 28-year-old woman is diagnosed with constipation predominant irritable bowel syndrome. She
occasionally experiences spasms of pain in the left iliac fossa.
Which one of the following is LEAST likely to help her symptoms?
A. Mebeverine
B. Ispaghula
C. Methylcellulose
D. Sterculia
E. Lactulose
Next question
NICE recommend avoiding lactulose in the management of IBS
Irritable bowel syndrome: management

The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between
patients. NICE issued guidelines in 2008
First-line pharmacological treatment - according to predominant symptom
pain: antispasmodic agents

constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to
selective serotonin reuptake inhibitors
Other management options
psychological interventions - if symptoms do not respond to pharmacological treatments after

12 months and who develop a continuing symptom profile (refractory IBS), consider referring
for cognitive behavioural therapy, hypnotherapy or psychological therapy
complementary and alternative medicines: 'do not encourage use of acupuncture or
reflexology for the treatment of IBS'
General dietary advice
have regular meals and take time to eat

avoid missing meals or leaving long gaps between eating
drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as
herbal teas
restrict tea and coffee to 3 cups per day
reduce intake of alcohol and fizzy drinks
consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and
breads, cereals high in bran, and whole grains such as brown rice)
reduce intake of 'resistant starch' often found in processed foods
limit fresh fruit to 3 portions per day
for diarrhoea, avoid sorbitol
for wind and bloating consider increasing intake of oats (for example, oat-based
breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
Question 2 of 117
Next
You are asked to review a 78-year-old woman with a non-healing leg ulcer by the practice nurse.
You notice she is very thin. What is the most appropriate tool to screen for malnutrition?
A. GPMS
B. MN-10
C. MUST
D. GP-MN
E. MSPC
Next question
Malnutrition
Malnutrition is an important consequence of and contributor to chronic disease. It is clearly a
complex and multifactorial problem that can be difficult to manage but there are a number of key
points to remember for the exam.
NICE define malnutrition as the following:
a Body Mass Index (BMI) of less than 18.5; or

unintentional weight loss greater than 10% within the last 3-6 months; or
a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6
months
Around 10% of patients aged over 65 years are malnourished, the vast majority of those living
independently, i.e. not in hospital or care/nursing homes.
Screening for malnutrition if mostly done using MUST (Malnutrition Universal Screen Tool). A link is
provided to a copy of the MUST score algorithm.
it should be done on admission to care/nursing homes and hospital, or if there is concern.

For example an elderly, thin patient with pressure sores
it takes into account BMI, recent weight change and the presence of acute disease
categorises patients into low, medium and high risk
Management of malnutrition is difficult. NICE recommend the following points:
dietician support if the patient is high-risk

a 'food-first' approach with clear instructions (e.g. 'add full-fat cream to mashed potato'),
rather than just prescribing oral nutritional supplements (ONS) such as Ensure
if ONS are used they should be taken between meals, rather than instead of meals
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Question 3 of 117
A 35-year-old man who is usually fit and well presents to his GP with a 2 month history of
indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is
unremarkable. Of the following options, what is the most suitable initial management?
A. Urea breath testing and non-urgent referral for endoscopy
B. H pylori eradication therapy and full-dose proton pump inhibitor for three
months
C. Full-dose Proton pump inhibitor and immediate referral for endoscopy
D. Three month course of a standard-dose proton pump inhibitor
E. One month course of a full-dose proton pump inhibitor
Next question
This question highlights the NICE guidelines for the management of dyspepsia.
There is no evidence currently to suggest whether a one month course of a PPI or 'test and treat'
strategy should be adopted first line. Many clinicians prefer to test for H pylori first as this cannot be
done within 2 weeks of acid-suppression therapy, as false-negative results may occur
Given the options available, only the answer is in line with current NICE guidelines
Dyspepsia
In 2014 NICE updated their guidelines for the management of dyspepsia. These take into account
the age of the patient (whether younger or older than 55 years) and the presence or absence of
'alarm signs':
chronic gastrointestinal bleeding

progressive unintentional weight loss
progressive difficulty swallowing
persistent vomiting
iron deficiency anaemia
epigastric mass
suspicious barium meal
Deciding whether urgent referral for endoscopy is needed

Urgent referral (within 2 weeks) is indicated for patients with any alarm signs irrespective of age
Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without
alarm signs is not necessary, however
Patients aged 55 years and over should be referred urgently for endoscopy if dyspepsia symptoms
are:
recent in onset rather than recurrent and

unexplained (e.g. New symptoms which cannot be explained by precipitants such as
NSAIDs) and
persistent: continuing beyond a period that would normally be associated with self-limiting
problems (e.g. Up to four to six weeks, depending on the severity of signs and symptoms)
Managing patients who do not meet referral criteria ('undiagnosed dyspepsia')

This can be summarised at a step-wise approach
1. Review medications for possible causes of dyspepsia

2. Lifestyle advice
3. Trial of full-dose PPI for one month*
4. 'Test and treat' using carbon-13 urea breath test
*it is unclear from studies whether a trial of a PPI or a 'test and treat' should be used first
1/3
Question 4-6 of 117
Theme: Hepatobiliary disease and related disorders

A. Ascending cholangitis
B. Duodenal ulcer
C. Biliary colic
Next
D. Amoebic liver abscess

E. Pancreatic cancer
F. Viral hepatitis
G. Congestive hepatomegaly
H. Cholangiocarcinoma
I. Gallstone ileus
J. Acute pancreatitis
For each of the following scenarios please select the most likely diagnosis:
4.
A 57-year-old woman with a history of gallstones presents with progressive right upper quadrant pain,
rigors and jaundice.
Ascending cholangitis
This is a classical presentation of ascending cholangitis.
5.
A 62-year-old presents with upper abdominal pain. She has recently been discharged from hospital where
she underwent an ERCP to investigate cholestatic liver function tests. The pain is severe. On examination
she is apyrexial and has a pulse of 96 / min.
You answered Ascending cholangitis
The correct answer is Acute pancreatitis
Pancreatitis may develop following an ERCP.
6.
A 76-year-old woman presents with abdominal pain, distension and vomiting. She recently had an
episode of acute cholecystitis and is awaiting a cholecystectomy. She feels her symptoms have returned
over the past few days. On examination her abdomen is distended.
The correct answer is Gallstone ileus
This patient has developed small bowel obstruction secondary to an impacted gallstone.
Next question
Hepatobiliary disease and related disorders
The table below gives characteristic exam question features for conditions causing hepatobiliary
disease and related disorders:
Viral hepatitis
Common symptoms include:
nausea and vomiting, anorexia

myalgia
lethargy
right upper quadrant (RUQ) pain
Questions may point to risk factors such as foreign travel or intravenous drug use.
Congestive
hepatomegaly
The liver only usually causes pain if stretched. One common way this can occur is as a
consequence of congestive heart failure. In severe cases cirrhosis may occur.
Biliary colic
RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur
after eating. Nausea is common.
It is sometimes taught that patients are female, forties, fat and fair although this is obviously a
generalisation.
Acute cholecystitis
Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or
right shoulder.
The patient may be pyrexial and Murphy's sign positive (arrest of inspiration on palpation of
the RUQ)
An infection of the bile ducts commonly secondary to gallstones. Classically presents with a
triad of:
Gallstone ileus
fever (rigors are common)

RUQ pain
jaundice
This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a
fistula forms between a gangrenous gallbladder and the duodenum.
Abdominal pain, distension and vomiting are seen.
Cholangiocarcinoma
Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A
palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy
(Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
Acute pancreatitis
Usually due to alcohol or gallstones

Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is
described but rare
Pancreatic cancer
Painless jaundice is the classical presentation of pancreatic cancer. However pain is actually a
relatively common presenting symptom of pancreatic cancer. Anorexia and weight loss are
common
Amoebic liver abscess
Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be
mild and jaundice is uncommon.
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Question 7 of 117
Which one of the following features is more common in Crohn's disease than ulcerative colitis?
A. Abdominal mass palpable in the right iliac fossa
B. Tenesmus
C. Bloody diarrhoea
D. Faecal incontinence
E. Abdominal pain in the left lower quadrant
Next question
Inflammatory bowel disease: key differences
The two main types of inflammatory bowel disease are Crohn's disease and Ulcerative colitis. They
have many similarities in terms of presenting symptoms, investigation findings and management
options. There are however some key differences which are highlighted in table below:
Crohn's disease (CD)
Ulcerative colitis (UC)
Features
Diarrhoea usually non-bloody

Weight loss more prominent
Upper gastrointestinal symptoms, mouth
ulcers, perianal disease
Abdominal mass palpable in the right iliac
fossa
Bloody diarrhoea more common

Abdominal pain in the left lower quadrant
Tenesmus
Extraintestinal
Gallstones are more common secondary to

reduced bile acid reabsorption
Primary sclerosing cholangitis more common
Oxalate renal stones*

Complications
Obstruction, fistula, colorectal cancer
Risk of colorectal cancer high in UC than CD
Pathology
Lesions may be seen anywhere from the

mouth to anus
Inflammation always starts at rectum and never

spreads beyond ileocaecal valve
Skip lesions may be present
Continuous disease
Inflammation in all layers from mucosa to

serosa
No inflammation beyond submucosa (unless

fulminant disease) - inflammatory cell infiltrate in
lamina propria
Histology
increased goblet cells

granulomas
neutrophils migrate through the walls of

glands to form crypt abscesses
depletion of goblet cells and mucin from
gland epithelium
granulomas are infrequent
Endoscopy
Deep ulcers, skip lesions - 'cobble-stone'

appearance
Widespread ulceration with preservation of adjacent

mucosa which has the appearance of polyps
('pseudopolyps')
Radiology
Small bowel enema
Barium enema
high sensitivity and specificity for

examination of the terminal ileum
strictures: 'Kantor's string sign'
proximal bowel dilation
'rose thorn' ulcers
fistulae
loss of haustrations
superficial ulceration, 'pseudopolyps'
long standing disease: colon is narrow and
short -'drainpipe colon'
*impaired bile acid rebsorption increases the loss calcium in the bile. Calcium normally binds
oxalate.
Question 8 of 117
Next
A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has no past
medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day
and drinks 20 units of alcohol per week. Ileocolonoscopy shows features consistent with Crohn's
disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the
most important intervention to reduce the chance of further episodes?
A. Infliximab
B. Stop drinking
C. Stop smoking
D. Mesalazine
E. Budesonide
Next question
Crohn's disease: management

Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and
colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the
management of Crohn's disease in 2012.
General points
patients should be strongly advised to stop smoking
some studies suggest an increased risk of relapse secondary to NSAIDs and the combined
oral contraceptive pill but the evidence is patchy
Inducing remission
glucocorticoids (oral, topical or intravenous) are generally used to induce remission.

Budesonide is an alternative in a subgroup of patients
enteral feeding with an elemental diet may be used in addition to or instead of other
measures to induce remission, particularly if there is concern regarding the side-effects of
steroids (for example in young children)
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as
effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission
but is not used as monotherapy. Methotrexate is an alternative to azathioprine
infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on
azathioprine or methotrexate
metronidazole is often used for isolated peri-anal disease
Maintaining remission
as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may
help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission

methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Surgery
around 80% of patients with Crohn's disease will eventually have surgery
*assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
Next
Question 9 of 117
Which one of the following is the most effective screening tool for harmful alcohol drinking and
alcohol dependence?
A. Liver ultrasound
B. CAGE questionnaire
C. FAST questionnaire
D. Combination of MCV and gamma GT blood test
E. AUDIT questionnaire
Next question
Alcohol - problem drinking: detection and assessment

Screening
AUDIT
10 item questionnaire, please see the link

takes about 2-3 minutes to complete
has been shown to be superior to CAGE and biochemical markers for predicting alcohol
problems
minimum score = 0, maximum score = 40
a score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of
hazardous or harmful alcohol consumption
a score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol
dependence
AUDIT-C is an abbreviated form consisting of 3 questions
FAST
4 item questionnaire

the score for hazardous drinking is 3 or more
with relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
if the answer to the first question is 'never' then the patient is not misusing alcohol
if the response to the first question is 'Weekly' or 'Daily or almost daily' then the patient is a
hazardous, harmful or dependent drinker. Over 50% of people will be classified using just
this one question
MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
How often during the last year have you been unable to remember what happened the night before because you
had been drinking?
How often during the last year have you failed to do what was normally expected of you because of drinking?
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or
suggested you cut down?
CAGE
well known but recent research has questioned it's value as a screening test
two or more positive answers is generally considered a 'positive' result
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink in the morning to get rid of a hangover (Eye opener)?
Diagnosis
ICD-10 definition - 3 or more needed
compulsion to drink
difficulties controlling alcohol consumption

physiological withdrawal
tolerance to alcohol
neglect of alternative activities to drinking
persistent use of alcohol despite evidence of harm
Question 10 of 117
Next
A 35-year-old female presents with abdominal pain associated with bloating for the past 6 months,
Which one of the following symptoms is least associated with a diagnosis of irritable bowel
syndrome?
A. Feeling of incomplete stool evacuation
B. Weight loss
C. Back pain
D. Lethargy
E. Nausea
Next question
Weight loss is not a feature of IBS and underlying malignancy or inflammatory bowel disease needs
to be excluded
Irritable bowel syndrome: diagnosis
NICE published clinical guidelines on the diagnosis and management of irritable bowel syndrome
(IBS) in 2008
The diagnosis of IBS should be considered if the patient has had the following for at least 6 months:
abdominal pain, and/or

bloating, and/or
change in bowel habit
A positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation
or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
altered stool passage (straining, urgency, incomplete evacuation)

abdominal bloating (more common in women than men), distension, tension or hardness
symptoms made worse by eating
passage of mucus
Features such as lethargy, nausea, backache and bladder symptoms may also support the
diagnosis
Red flag features should be enquired about:
rectal bleeding
unexplained/unintentional weight loss

family history of bowel or ovarian cancer
onset after 60 years of age
Suggested primary care investigations are:
full blood count

ESR/CRP
coeliac disease screen (tissue transglutaminase antibodies)
Next
Question 11 of 117
A 54-year-old woman presents with jaundice shortly after being discharged from hospital. Liver
function tests are reported as follows:
Albumin
49 g/l
Bilirubin
89 mol/l
Alanine transferase (ALT)
66 iu/l
Alkaline phosphatase (ALP)
245 mol/l
Gamma glutamyl transferase (yGT) 529 u/l
Which of the following antibiotics is she most likely to have received?

A. Co-amoxiclav
B. Gentamicin
C. Ciprofloxacin
D. Trimethoprim
E. Ceftazidime
Next question
Co-amoxiclav is a well recognised cause of cholestasis
Drug-induced liver disease

Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed. There is
however considerable overlap, with some drugs causing a range of changes to the liver
The following drugs tend to cause a hepatocellular picture:
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
The following drugs tend to cause cholestasis (+/- hepatitis):
oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*

anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
Liver cirrhosis
methotrexate
methyldopa
amiodarone
*risk may be reduced with erythromycin stearate
Question 12 of 117
Next
A 22-year-old man presents with a three week history of diarrhoea. He says his bowels have not
been right for the past few months and he frequently has to run to the toilet. These symptoms had
seemed to be improving up until three weeks ago. For the past week he has also been passing
some blood in the stool and reports the feeling of incomplete evacuation after going. He has lost no
weight and has a good appetite. Examination of his abdomen demonstrates mild tenderness in the
left lower quadrant but no guarding. What is the most likely diagnosis?
A. Diverticulitis
B. Colorectal cancer
C. Crohn's disease
D. Ulcerative colitis
E. Infective diarrhoea
Next question
Ulcerative colitis
Ulcerative colitis (UC) is a form of inflammatory bowel disease. Inflammation always starts at rectum
(hence it is the most common site for UC), never spreads beyond ileocaecal valve and is continuous.
The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65
years.
The initial presentation is usually following insidious and intermittent symptoms. Features include:
bloody diarrhoea
urgency
tenesmus
abdominal pain, particularly in the left lower quadrant
extra-intestinal features (see below)
Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are common:
Common to both Crohn's disease (CD) and

Notes
Related to disease
activity
Arthritis: pauciarticular, asymmetric

Erythema nodosum
Episcleritis
Osteoporosis
Arthritis is the most common extra-intestinal

feature in both CD and UC
Episcleritis is more common in CD
Unrelated to disease
activity
Arthritis: polyarticular, symmetric

Uveitis
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis
Primary sclerosing cholangitis is much more

common in UC
Uveitis is more common in UC
Pathology
red, raw mucosa, bleeds easily

no inflammation beyond submucosa (unless fulminant disease)
widespread ulceration with preservation of adjacent mucosa which has the appearance of
polyps ('pseudopolyps')
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses

depletion of goblet cells and mucin from gland epithelium
Barium enema

long standing disease: colon is narrow and short -'drainpipe colon'
Next
Question 13 of 117
A 78-year-old woman develops profuse, offensive watery diarrhoea following a course of coamoxiclav. A diagnosis of Clostridium difficile diarrhoea is made. On examination she is
haemodynamically stable, apyrexial and has no abdominal signs. What is the most appropriate firstline therapy?
A. Oral vancomycin for 7 days
B. Oral metronidazole for 10-14 days
C. Oral metronidazole + vancomycin for 10-14 days
D. Oral metronidazole for 7 days
E. Probiotic yoghurt for 14 days
Next question
Clostridium difficile
Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an
exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous

colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum
antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology
has evolved significantly over the past 10 years. Second and third generation cephalosporins are
now the leading cause of Clostridium difficile.
Features
diarrhoea
abdominal pain
a raised white blood cell count is characteristic
if severe toxic megacolon may develop
Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool

Management
first-line therapy is oral metronidazole for 10-14 days

if severe or not responding to metronidazole then oral vancomycin may be used
for life-threatening infections a combination of oral vancomycin and intravenous
metronidazole should be used
Question 14 of 117
Next
A 42-year-old woman is investigated for lethargy and diarrhoea. Investigations reveal positive antiendomysial antibodies. Each of the following food stuffs should be avoided, except:
A. Beer
B. Rye
C. Maize
D. Bread
E. Pasta
Next question
Coeliac disease: management

The management of coeliac disease involves a gluten-free diet. Gluten containing cereals include:
wheat: bread, pasta, pastry
barley*: beer
rye
oats**
Some notable foods which are gluten-free include:
rice
potatoes
corn (maize)
Tissue transglutaminase antibodies may be checked to check compliance with a gluten free diet.
*whisky is made using malted barley. Proteins such as gluten are however removed during the
distillation process making it safe to drink for patients with coeliac disease
**some patients with coeliac disease appear able to tolerate oats
Question 15 of 117
Next
A 31-year-old woman who initially presented with abdominal pain and constipation is diagnosed with
irritable bowel syndrome. Which one of the following bits of dietary advice is it least suitable to give?
A. Avoid missing meals
B. Restrict tea and coffee to 3 cups per day
C. Increase the intake of fibre such as bran and wholemeal bread

D. Reduce intake of alcohol
E. Drink at least 8 cups of fluid per day
Next question
Insoluble sources of fibre such as bran and wholemeal should be avoided in IBS




herbal teas

Next
Question 16 of 117
A 65-year-old man with liver cirrhosis of unknown cause is reviewed in clinic. Which one of the
following factors is most likely to indicate a poor prognosis?
A. Alanine transaminase > 200 u/l
B. Caput medusae
C. Ascites
D. Gynecomastia
E. Splenomegaly
Next question
Child-Pugh classification of liver cirrhosis

The Child-Pugh classification is a scoring system to assess the severity of liver cirrhosis
Score
Bilirubin (mol/l)
<34
34-50
>50
Albumin (g/l)
>35
28-35
<28
Prothrombin time,
prolonged by (s)
<4
4-6
>6
Encephalopathy
none
mild
marked
Ascites
none
mild
marked
Summation of the scores allows the severity to be graded either A, B or C:
<7=A
7-9 = B
>9=C
Question 17 of 117
Next
A 42-year-old dentist presents to his GP complaining of persistent lethargy. Routine bloods show
abnormal liver function tests so a hepatitis screen is sent. The results are shown below:
Anti-HAV IgG negative
HBsAg
negative
Anti-HBs
positive
Anti-HBc
negative
Anti-HCV
positive
What do these results most likely demonstrate?

A. Hepatitis B infection
B. Hepatitis C infection
C. Previous vaccination to hepatitis B and C
D. Hepatitis C infection with previous hepatitis B vaccination
E. Hepatitis B and C infection
Next question
Given the deranged liver function tests these results most likely indicate previous hepatitis B
vaccination with active hepatitis C infection. However, around 15% of patients exposed to the
hepatitis C virus clear the infection. It would therefore be necessary to perform a HCV PCR to see if
the virus is still present.
There is currently no vaccination for hepatitis C.
Interpreting hepatitis B serology:
surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs
HBsAg normally implies acute disease (present for 1-6 months)

if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic
disease
Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent
hepatitis B infection and is present for about 6 months
HbeAg results from breakdown of core antigen from infected liver cells as is therefore a
marker of infectivity
Hepatitis C
Hepatitis C is likely to become a significant public health problem in the UK in the next decade. It is
thought around 200,000 people are chronically infected with the virus. At risk groups include
intravenous drug users and patients who received a blood transfusion prior to 1991 (e.g.
haemophiliacs).
Pathophysiology
hepatitis C is a RNA flavivirus
incubation period: 6-9 weeks
Transmission
the risk of transmission during a needle stick injury is about 2%

the vertical transmission rate from mother to child is about 6%
breast feeding is not contraindicated in mothers with hepatitis C
the risk of transmitting the virus during sexual intercourse is probably less than 5%
Features
after exposure to the hepatitis C virus less than 20% of patients develop an acute hepatitis
Complications
chronic infection (80-85%) - only 15-20% of patients will clear the virus after an acute
infection and hence the majority will develop chronic hepatitis C
cirrhosis (20-30% of those with chronic disease)
hepatocellular cancer
cryoglobulinaemia
porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in
patients with hepatitis C, especially if there are other factors such as alcohol abuse
Management of chronic infection
currently a combination of pegylated interferon-alpha and ribavirin are used

up to 55% of patients successfully clear the virus, with success rates of around 80% for
some strains
the aim of treatment is sustained virological response (SVR), defined as undetectable
serum HCV RNA six months after the end of therapy

Complications of treatment
ribavirin - side-effects: haemolytic anaemia, cough. Women should not become pregnant
within 6 months of stopping ribavirin as it is teratogenic
interferon alpha - side-effects: flu-like symptoms, depression, fatigue, leukopenia,
thrombocytopenia
Question 18 of 117
Next
Which one of the following drinks contains the nearest to one unit of alcohol:
A. A 125ml glass of red wine (ABV 12%)
B. A half a pint of beer (ABV 5%)
C. A 25ml single measure of spirits (ABV 40%)
D. A pint of low strength beer (ABV 3.4%)
E. A 125ml glass of white wine (ABV 14%)
Next question
The January 2010 AKT feedback report stated 'Candidates performed poorly in several items
related to alcohol. The subject areas included alcohol units, nutrition, treatments for alcohol
dependence and complications of alcohol abuse other than liver disease. The NHS
Confederation has recently highlighted the increasing burden to the NHS of alcohol related
problems and Candidates require a broad knowledge of this topic. '
Alcohol: units
The government currently recommend the following:
men: should drink no more than 21 units of alcohol per week (and no more than 4 units in
any one day)

women: should drink no more than 14 units of alcohol per week (and no more than 3 units in
any one day)
One unit of alcohol is equal to 10 ml of alcohol. The 'strength' of an alcoholic drink is determined by
the 'alcohol by volume' (ABV).
Examples of one unit of alcohol:
25ml single measure of spirits (ABV 40%)

a third of a pint of beer (ABV 5 to 6%)
half a 175ml 'standard' glass of red wine (ABV 12%)
To calculate the number of units in a drink multiply the number of millilitres by the ABV and divide by
1,000. For example:
half a 175ml 'standard' glass of red wine = 87.5 * 12 / 1000 = 1.05 units
one bottle of wine = 750 * 12 / 1000 = 9 units
one pint of 5% beer or lager = 568 * 5 / 1000 = 2.8 units
Question 19 of 117
Next
A 43-year-old man with type 2 diabetes mellitus presents with lethargy. His current medications
include metformin and gliclazide, although the gliclazide may soon be stopped due to his obesity. A
number of blood tests are ordered which reveal the following:
HbA1c
8.2%
Ferritin 204 ng/ml
Bilirubin 23 mol/l
ALP
162 u/l
ALT
120 u/l
AST
109 u/l
On discussing these results he states that he does not drink alcohol. What is the most likely cause of
these abnormal results?
A. Metformin-induced steatohepatitis
B. Haemochromatosis
C. Acute hepatitis secondary to gliclazide
D. Cryptogenic cirrhosis
E. Non-alcoholic fatty liver disease
Next question
Obese T2DM with abnormal LFTs - ? non-alcoholic fatty liver disease
By far the most likely diagnosis in an obese type 2 diabetic is non-alcoholic fatty liver disease. This
patient will require a liver screen, ultrasound and liver biopsy to confirm the diagnosis.
A normal ferritin makes a diagnosis of haemochromatosis unlikely, although it should always be
considered in patients with both abnormal LFTs and diabetes.
Non-alcoholic fatty liver disease
Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the
developed world. It is largely caused by obesity and describes a spectrum of disease ranging from:
steatosis - fat in the liver

steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH), see below
progressive disease may cause fibrosis and liver cirrhosis
NAFLD is thought to represent the hepatic manifestation of the metabolic syndrome and hence
insulin resistance is thought to be the key mechanism leading to steatosis
Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen
in alcoholic hepatitis in the absence of a history of alcohol abuse. It is relatively common and though
to affect around 3-4% of the general population. The progression of disease in patients with NASH
may be responsible for a proportion of patients previously labelled as cryptogenic cirrhosis
Associated factors
obesity
hyperlipidaemia
type 2 diabetes mellitus
jejunoileal bypass
sudden weight loss/starvation
Features
usually asymptomatic
hepatomegaly
ALT is typically greater than AST
increased echogenicity on ultrasound
Management
the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring
there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g.
Metformin)
Question 20 of 117
Next
A 31-year-old man with ulcerative colitis presents with a worsening of his symptoms. He is passing
around four loose stools a day which do not contain blood. He has also experienced some urgency
and tenesmus but is otherwise systemically well. What is the most appropriate management?
A. Rectal mesalazine
B. Oral metronidazole
C. Rectal corticosteroids
D. Observe with review in 7 days time
E. Oral loperamide
Next question
Ulcerative colitis: management

Treatment can be divided into inducing and maintaining remission. NICE released guidelines on the
management of ulcerative colitis in 2013.
The severity of UC is usually classified as being mild, moderate or severe:
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset

severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia,
anaemia, raised inflammatory markers)
Inducing remission
treatment depends on the extent and severity of disease
rectal (topical) aminosalicylates or steroids: for distal colitis rectal mesalazine has been
shown to be superior to rectal steroids and oral aminosalicylates
oral aminosalicylates
oral prednisolone is usually used second-line for patients who fail to respond to
aminosalicylates. NICE recommend waiting around 4 weeks before deciding if first-line
treatment has failed
severe colitis should be treated in hospital. Intravenous steroids are usually given first-line
oral aminosalicylates e.g. mesalazine
azathioprine and mercaptopurine

methotrexate is not recommended for the management of UC (in contrast to Crohn's
disease)
there is some evidence that probiotics may prevent relapse in patients with mild to moderate
disease
Question 21 of 117
Next
A 72-year-old woman is reviewed following a course of oral flucloxacillin for right lower limb cellulitis.
The local protocol suggest oral clindamycin should be used next-line. Which one of the following
side-effects is it most important to warn her about?
A. Heartburn or indigestion
B. Jaundice
C. Sore throat, bruising or lethargy
D. Avoid any food or drink containing alcohol
E. Diarrhoea
Next question
Features
diarrhoea
abdominal pain

Management

Next
Question 22 of 117
Coeliac disease should be excluded in all patients who are diagnosed with:
A. Splenomegaly
B. Pancreatitis
C. Colon cancer
D. Type 2 diabetes mellitus
E. Graves' disease
Next question
Coeliac disease
Coeliac disease is caused by sensitivity to the protein gluten. Repeated exposure leads to villous
atrophy which in turn causes malabsorption. Conditions associated with coeliac disease include
dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1
diabetes mellitus and autoimmune hepatitis). It is strongly associated with HLA-DQ2 (95% of
patients) and HLA-B8 (80%) as well as HLA-DR3 and HLA-DR7
In 2009 NICE issued guidelines on the investigation of coeliac disease. They suggest that the
following patients should be screened for coeliac disease:
Signs and symptoms
Chronic or intermittent diarrhoea

Failure to thrive or faltering growth (in children)
Persistent or unexplained gastrointestinal symptoms
including nausea and vomiting
Prolonged fatigue ('tired all the time')
Recurrent abdominal pain, cramping or distension
Sudden or unexpected weight loss
Unexplained iron-deficiency anaemia, or other
unspecified anaemia
Conditions
Autoimmune thyroid disease

Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes
First-degree relatives (parents, siblings or
children) with coeliac disease
Complications
0/3
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than
vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies
Question 23-25 of 117
Next
Theme: Dysphagia
A. Pharyngeal pouch
B. Achalasia
C. Kaposi's sarcoma
D. Systemic sclerosis
E. Oesophageal cancer
F. Myasthenia gravis
G. Oesophagitis
H. Motor neuron disease
I. Oesophageal candidiasis
J. Plummer-Vinson syndrome
For each one of the following scenarios please select the most likely diagnosis:
23.
An 40-year-old man presents with dysphagia. He reports being reasonably well in himself other than an
occasional cough. The dysphagia occurs with both liquids and solids. Clinical examination is normal.
You answered Pharyngeal pouch

The correct answer is Achalasia
Of course patients like this should be referred to exclude a carcinoma. Achalasia typically presents
between the ages of 25-40 years.
24.
A 55-year-old woman presents with swallowing difficulties for the past 5 weeks. She has also noticed
some double vision
The correct answer is Myasthenia gravis
25.
A 42-year-old haemophiliac who is known to be HIV positive presents with pain on swallowing for the
past week. He has been generally unwell for the past 3 months with diarrhoea and weight loss
The correct answer is Oesophageal candidiasis
Unfortunately many haemophiliacs contracted HIV and hepatitis C in the 1980's from blood
transfusions. Immunocompromised patients are prone to oesophageal candidiasis. This patient requires
an urgent endoscopy to confirm the diagnosis.
Next question
Dysphagia
The table below gives characteristic exam question features for conditions causing dysphagia:
Oesophageal
cancer
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use
Oesophagitis
May be history of heartburn

Odynophagia but no weight loss and systemically well
Oesophageal
There may be a history of HIV or other risk factors such as steroid inhaler use
candidiasis
Achalasia
Dysphagia of both liquids and solids from the start

Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
Pharyngeal pouch
More common in older men

Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may
occasionally be seen
Systemic sclerosis
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon,
oEsophageal dysmotility, Sclerodactyly, Telangiectasia
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased.
This contrasts to achalasia where the LES pressure is increased
Myasthenia gravis
Other symptoms may include extraocular muscle weakness or ptosis

Dysphagia with liquids as well as solids
Globus hystericus
May be history of anxiety

Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further investigation for organic causes
Question 26 of 117
Primary biliary cirrhosis is most characteristically associated with:
A. Anti-nuclear antibodies
B. Anti-ribonuclear protein antibodies
C. Anti-mitochondrial antibodies
D. Rheumatoid factor
Next
E. Anti-neutrophil cytoplasmic antibodies

Next question
Primary biliary cirrhosis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
Primary biliary cirrhosis

Primary biliary cirrhosis is a chronic liver disorder typically seen in middle-aged females
(female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an
autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process
causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation
is itching in a middle-aged woman
Associations
Sjogren's syndrome (seen in up to 80% of patients)

rheumatoid arthritis
systemic sclerosis
thyroid disease
Diagnosis
anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are
highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM
Management
pruritus: cholestyramine
fat-soluble vitamin supplementation

ursodeoxycholic acid
liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can
occur but is not usually a problem
Next
Question 27 of 117
You wish to screen a patient for hepatitis B infection. Which one of the following is the most suitable
test to perform?
A. HBcAg
B. HBsAg
C. Hepatitis B viral load
D. anti-HBs
E. HBeAg
Next question
A positive anti-HBs would imply immunity through either previous immunisation or disease. A
positive HBsAg implies either acute or chronic hepatitis B.
Hepatitis B serology
Interpreting hepatitis B serology is a dying art form which still occurs at regular intervals in medical
exams. It is important to remember a few key facts:
disease
hepatitis B infection and is present for about 6 months. IgG anti-HBc persists
Example results
previous immunisation: anti-HBs positive, all others negative
previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative
previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive
0/3
Theme: Diarrhoea
A. Gastroenteritis
B. Crohn's disease
C. Ulcerative colitis
D. Colorectal cancer
E. Laxative abuse
F. Constipation causing overflow
G. Lactose intolerance
H. Diverticulitis
I. Irritable bowel syndrome
J. Coeliac disease
28.
A 24-year-old smoker presents with intermittent diarrhoea for the past 6 months. She feels bloated,
especially around her periods. Bloods tests are normal.
You answered Gastroenteritis
Next
The correct answer is Irritable bowel syndrome

Irritable bowel syndrome is by far the most likely diagnosis here.
29.
A 23-year-old student is admitted due to a two-week history of bloody diarrhoea. He is normally fit and
well and has not been abroad recently. His CRP is raised at 56 on admission.
The correct answer is Ulcerative colitis
The duration of his symptoms make a diagnosis of gastroenteritis less likely. The presence of blood in
the diarrhoea points to a diagnosis of ulcerative colitis rather than Crohn's.
30.
A 72-year-old woman presents with a two day history of diarrhoea and pain in the left iliac fossa. Her
temperature is 37.8C. She has a past history of constipation.
The correct answer is Diverticulitis
This is a typical history of diverticulitis
Next question
Diarrhoea
The table below gives characteristic features for conditions causing diarrhoea:
Usually acute
Gastroenteritis
May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis
Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy
More common with broad spectrum antibiotics

Clostridium difficile is also seen with antibiotic use
Constipation causing overflow
A history of alternating diarrhoea and constipation may be given

May lead to faecal incontinence in the elderly
Usually chronic
Irritable bowel
syndrome
Extremely common. The most consistent features are abdominal pain, bloating and change in bowel
habit. Patients may be divided into those with diarrhoea predominant IBS and those with
constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative colitis
Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal
urgency and tenesmus may be seen
Crohn's disease
Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis.
Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction
Colorectal
cancer
Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and
constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease
In children may present with failure to thrive, diarrhoea and abdominal distension
In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may
coexist
Other conditions associated with diarrhoea include:
thyrotoxicosis
laxative abuse
appendicitis
Question 31 of 117
A 23-year-old man develops watery diarrhoea whilst travelling in Egypt.
Which one of the following is the most likely responsible organism?
Next
A. Salmonella
B. Shigella
C. Campylobacter
D. Escherichia coli
E. Bacillus cereus
Next question
E. coli is the most common cause of travellers' diarrhoea
Gastroenteritis
Gastroenteritis may either occur whilst at home or whilst travelling abroad (travellers' diarrhoea)
Travellers' diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without
one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common
cause is Escherichia coli
Another pattern of illness is 'acute food poisoning'. This describes the sudden onset of nausea,
vomiting and diarrhoea after the ingestion of a toxin. Acute food poisoning is typically caused
by Staphylococcus aureus, Bacillus cereus orClostridium perfringens.
Stereotypical histories
Infection
Typical presentation
Escherichia coli
Common amongst travellers

Watery stools
Abdominal cramps and nausea
Giardiasis
Prolonged, non-bloody diarrhoea
Cholera
Profuse, watery diarrhoea
Severe dehydration resulting in weight loss

Not common amongst travellers
Shigella
Bloody diarrhoea
Vomiting and abdominal pain
Staphylococcusaureus
Severe vomiting
Short incubation period
Campylobacter
A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which
may be bloody
Complications include Guillain-Barre syndrome
Bacillus cereus
Two types of illness are seen
Amoebiasis
vomiting within 6 hours, stereotypically due to rice

diarrhoeal illness occurring after 6 hours
Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several
weeks
Incubation period
1-6 hrs: Staphylococcus aureus, Bacillus cereus*
12-48 hrs: Salmonella, Escherichia coli

48-72 hrs: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis
*vomiting subtype, the diarrhoeal illness has an incubation period of 6-14 hours
Question 32 of 117
Next
A 54-year-old man is investigated for dyspepsia. An endoscopy shows a gastric ulcer and a CLO
test done during the procedure demonstrates H. pylori infection. A course of H. pylori eradication
therapy is given. Six weeks after completing treatment the patients comes for review. Unfortunately
his symptoms have not improved. What is the most appropriate test to confirm H. pylori eradication?
A. Culture of gastric biopsy
B. H. pylori serology
C. Hydrogen breath test
D. Urea breath test
E. Stool culture
Next question
It is important to remember that H. pylori serology remains positive following eradication.
A stool antigen test, not culture, may be an appropriate alternative.
Helicobacter pylori: tests
Urea breath test
patients consume a drink containing carbon isotope 13 (13C) enriched urea
urea is broken down by H. pylori urease

after 30 mins patient exhale into a glass tube
mass spectrometry analysis calculates the amount of 13C CO2
should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks
of an antisecretory drug (e.g. a proton pump inhibitor)
sensitivity 95-98%, specificity 97-98%
Rapid urease test (e.g. CLO test)
biopsy sample is mixed with urea and pH indicator

colour change if H pylori urease activity
Serum antibody
remains positive after eradication
sensitivity 85%, specificity 80%
Culture of gastric biopsy
provide information on antibiotic sensitivity

Gastric biopsy
histological evaluation alone, no culture

Stool antigen test
Question 33 of 117
Next
A 26-year-old woman who is known to have type 1 diabetes mellitus presents with a three-month
history of diarrhoea, fatigue and weight loss. She has tried excluding gluten from her diet for the past
4 weeks and feels much better. She requests to be tested so that a diagnosis of coeliac disease is
confirmed. What is the most appropriate next step?
A. Check her HbA1c
B. No need for further investigation as the clinical response is diagnostic
C. Check anti-endomysial antibodies
D. Arrange a jejunal biopsy
E. Ask her to reintroduce gluten for the next 6 weeks before further testing
Next question
Serological tests and jejunal biopsy may be negative if the patient is following a gluten-free diet. The
patient should eat some gluten in more than one meal every day for at least 6 weeks before further
testing.
Coeliac disease: investigation
diabetes mellitus and autoimmune hepatitis).
Diagnosis is made by a combination of immunology and jejunal biopsy. Villous atrophy and
immunology normally reverses on a gluten-free diet.
NICE issued guidelines on the investigation of coeliac disease in 2009. If patients are already taking
a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to
testing.
Immunology
tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE

endomyseal antibody (IgA)
anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
anti-casein antibodies are also found in some patients
Jejunal biopsy
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
Rectal gluten challenge has been described but is not widely used
Question 34 of 117
Next
A 44-year-old man is diagnosed with a duodenal ulcer. CLO testing performed during the
gastroscopy is positive for Helicobacter pylori. What is the most appropriate management to
eradicate Helicobacter pylori?
A. Lansoprazole + clindamycin + metronidazole
B. Lansoprazole + amoxicillin + clindamycin
C. Lansoprazole + amoxicillin + clarithromycin
D. Omeprazole + amoxicillin + clindamycin
E. Omeprazole + penicillin + metronidazole
Next question
H. pylori eradication:
PPI + amoxicillin + clarithromycin, or

PPI + metronidazole + clarithromycin
The BNF recommends a regimen containing amoxicillin and clarithromycin as first-line therapy
Helicobacter pylori
Helicobacter pylori is a Gram negative bacteria associated with a variety of gastrointestinal
problems, principally peptic ulcer disease
Associations
peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)

gastric cancer
B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of
patients)
atrophic gastritis
The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear - there is currently no
role in GORD for the eradication of H pylori
Management - eradication may be achieved with a 7 day course of
a proton pump inhibitor + amoxicillin + clarithromycin, or

a proton pump inhibitor + metronidazole + clarithromycin
Question 35 of 117
Next
A 27-year-old woman presents for review. She describes herself as having 'IBS' and for the past two
years has suffered intermittent bouts of abdominal pain, bloating and loose stools. For the past two
weeks however her symptoms have been much worse. She is now passing around 3-4 watery, grey,
'frothy' stools per day. Her abdominal bloating and cramps have also worsened and she is suffering
from excessive flatulence. Judging by the fitting of her clothes she also feels that she has lost
weight. Some blood tests are ordered:
Hb
10.9 g/dl
Platelets
199 * 109/l
WBC
7.2 * 109/l
Ferritin
15 ng/ml
Vitamin B12 225 ng/l

Folate
2.1 nmol/l
What is the most likely diagnosis?

A. Crohn's disease
B. Coeliac disease
C. Infective exacerbation of irritable bowel syndrome
E. Bacterial overgrowth syndrome
Next question
The main clues is this question are the anaemia and low ferritin/folate levels, all characteristic of
coeliac disease. The description of the diarrhoea is also typical although some patients may have
more overtly 'fatty' stools.
Why not irritable bowel syndrome? Common things are common and atypical presentations of
common conditions are seen more than typical presentations of less common conditions. The main
reason is the bloods - a low ferritin and folate would not develop with IBS +/- gastroenteritis. Even if
the woman suffered from menorrhagia this would not explain the low folate although it may account
for the anaemia/low ferritin.
Coeliac disease is more common than Crohn's by a factor of around 100. In exams there are also
usually more clues to point towards a diagnosis of Crohn's (e.g. mouth ulcers etc).
Coeliac disease
Signs and symptoms

unspecified anaemia
Complications
Conditions

Type 1 diabetes
hyposplenism
lactose intolerance
Question 36 of 117
Next
A 59-year-old female presents to her GP with a two month history of indigestion. She is otherwise
well, has not had a similar episode before and takes no regular medication. Of note there is no
recent weight loss or vomiting and abdominal examination is unremarkable. What is the most
appropriate initial management?
A. Long-term course of a H2 receptor antagonist
B. Lifestyle advice with follow-up appointment in one month
C. Urgent referral for endoscopy
D. One month course of a full-dose proton pump inhibitor
E. Urea breath testing and treat for H pylori if positive
Next question
This patient meets the criteria for urgent referral for endoscopy as she is older than 55 years, has
recent onset, persistent and unexplained symptoms
Dyspepsia
'alarm signs':

persistent vomiting
epigastric mass

are:

NSAIDs) and


2. Lifestyle advice
Next
Question 37 of 117
A 36-year-old man is reviewed in clinic. He has recently been started on mesalazine 400mg tds for
ulcerative colitis. Which one of the following adverse effects is least likely to be attributable to
mesalazine?
A. Interstitial nephritis
B. Headaches
C. Acute pancreatitis
D. Agranulocytosis
E. Infertility
Next question
Oligospermia is seen in patients taking sulphasalazine due to the sulphapyridine moiety, which is not
present in mesalazine
Aminosalicylate drugs
5-aminosalicyclic acid (5-ASA) is released in the colon and is not absorbed. It acts locally as an antiinflammatory. The mechanism of action is not fully understood but 5-ASA may inhibit prostaglandin
synthesis
Sulphasalazine
a combination of sulphapyridine (a sulphonamide) and 5-ASA

many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache,
Heinz body anaemia, megaloblastic anaemia
other side-effects are common to 5-ASA drugs (see mesalazine)
Mesalazine
a delayed release form of 5-ASA

sulphapyridine side-effects seen in patients taking sulphasalazine are avoided
mesalazine is still however associated with side-effects such as GI upset, headache,
agranulocytosis, pancreatitis*, interstitial nephritis
Olsalazine
two molecules of 5-ASA linked by a diazo bond, which is broken by colonic bacteria
*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine
Question 38 of 117
Next
A 31-year-old woman is reviewed in surgery with an 8 month history of abdominal discomfort

associated with bloating. Which one of the following tests is it least useful to perform before making
a positive diagnosis of irritable bowel syndrome?
A. Erythrocyte sedimentation rate
B. Thyroid function tests
C. Full blood count
D. C-reactive protein
E. Tissue transglutaminase antibodies
Next question
NICE recommends that thyroid function tests are not necessary prior to making a positive diagnosis
of IBS. Erythrocyte sedimentation rate and C-reactive protein may help exclude inflammatory bowel
disease.
(IBS) in 2008
bloating, and/or
passage of mucus
diagnosis
rectal bleeding
full blood count

ESR/CRP
Question 39 of 117
Next
A 30-year-old woman presents with a three month history of indigestion. There is no history of
weight less, anorexia, dysphagia, vomiting or change in bowel habit and abdominal examination is
unremarkable. Which one of the following may decrease the accuracy of a 13C-urea breath test?
A. Use of Gaviscon around 10 days ago

B. Use of ranitidine stopping 4 weeks ago
C. Course of amoxicillin stopping 3 weeks ago
D. Use of lansoprazole stopping 6 weeks ago
E. Current use of the combined oral contraceptive pill
Next question
Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks

Urea breath test


Serum antibody


Gastric biopsy

Stool antigen test
Question 40 of 117
A 54-year-old female presents to her GP with fatigue and xerostomia. Bloods tests reveal the
following:
Hb
13.9 g/dl
WBC
6.1 *109/l
Platelets 246 *109/l
Bilirubin 33 mol/l
ALP
292 u/l
ALT
47 u/l

A. Systemic lupus erythematous
Next
B. Infectious mononucleosis
C. Primary biliary cirrhosis
D. Autoimmune hepatitis
E. Primary Sjogren's syndrome
Next question
IgM
Middle aged females
The dry mouth is this patient is due to sicca syndrome, which occurs in 70% of cases of primary
biliary cirrhosis. The raised alkaline phosphatase point towards a diagnosis primary biliary cirrhosis
rather than primary Sjogren's syndrome.
Primary biliary cirrhosis: features
Primary biliary cirrhosis is chronic liver disorder typically seen in middle-aged females (female:male
ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune
condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing
progressive cholestasis, which may eventually progress to cirrhosis. The classic presentation is
itching in a middle-aged woman
Clinical features
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly
late: may progress to liver failure
Complications
malabsorption: osteomalacia, coagulopathy
sicca syndrome occurs in 70% of cases

portal hypertension: ascites, variceal haemorrhage
hepatocellular cancer (20-fold increased risk)
Question 41 of 117
Next
A 35-year-old woman is noticed to be jaundiced. As part of a liver screen the following results are
obtained:
Anti-HBs
Positive
Anti-HBc
Positive
HBs antigen Negative
Anti-HBs = Hepatitis B Surface Antibody; Anti-HBc = Hepatitis B Core Antibody; HBs antigen = Hepatitis
B Surface Antigen
What is the patient's hepatitis B status?

A. Previous immunisation to hepatitis B
B. Chronic hepatitis B - highly infectious
C. Previous hepatitis B infection, not a carrier
D. Chronic hepatitis B - not infectious
E. Acute hepatitis B infection
Next question
A positive anti-HBs shows that the patient has been exposed to hepatitis B in the past (infection or
immunisation) and has developed immunity. The negative HBs antigen supports the fact that they
are not carriers and do not have chronic disease. The presence of anti-HBc implies previous
infection, rather than immunisation.

disease
Example results
0/3


B. Acute cholecystitis
C. Biliary colic
F. Viral hepatitis
G. Congestive hepatomegaly
I. Gallstone ileus
Next
42.
A woman who is know to have gallstones presents with pain in her right upper quadrant. On
examination she is not jaundiced and has a temperature of 37.8C. Palpating under the right costal
margin causes her to catch her breath.
The correct answer is Acute cholecystitis
This scenario describes Murphy's sign.
43.
A 72-year-old man who is known to have heart failure and type 2 diabetes mellitus presents with a
persistent dull ache in his right upper quadrant. Blood tests show a mild elevation of the alanine
aminotransferase level.
The correct answer is Congestive hepatomegaly
This patient is likely to have congestive hepatomegaly secondary to heart failure.
44.
A 23-year-old student who has recently returned from a trip to North Africa presents with anorexia,
nausea, mild right upper quadrant pain and lethargy. Blood tests show a marked elevation of his alanine
aminotransferase level.
The correct answer is Viral hepatitis
Next question
Viral hepatitis

myalgia
lethargy
Congestive
hepatomegaly
Biliary colic
generalisation.
Acute cholecystitis
right shoulder.
the RUQ)
triad of:
Gallstone ileus

RUQ pain
jaundice
Cholangiocarcinoma
Acute pancreatitis

Vomiting is common
described but rare
Pancreatic cancer
common
Question 45 of 117
Next
What is the most appropriate advice to give a man with regards to alcohol intake?
A. No more than 14 units of alcohol per week (and no more than 2 units in any
one day)
B. No more than 14 units of alcohol per week (and no more than 4 units in any
one day)
C. No more than 21 units of alcohol per week (and no more than 4 units in any
one day)
D. No more than 21 units of alcohol per week
E. No more than 21 units of alcohol per week (and no more than 3 units in any
one day)
Next question
Alcohol: units
any one day)
any one day)

1,000. For example:
Question 46 of 117
A 45-year-old man with a history of alcohol excess is diagnosed as having grade 3 oesophageal
varices during an outpatient endoscopy. Of the following options, what is the most appropriate
management to prevent variceal bleeding?
A. Propranolol
Next
B. Isosorbide mononitrate
C. Endoscopic sclerotherapy
D. Terlipressin
E. Lansoprazole
Next question
Endoscopic sclerotherapy now has little role in the prophylaxis of variceal haemorrhage.
Oesophageal varices
Acute treatment of variceal haemorrhage
ABC: patients should ideally be resuscitated prior to endoscopy

correct clotting: FFP, vitamin K
vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is
supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and
preventing rebleeding. Octreotide may also be used although there is some evidence that
terlipressin has a greater effect on reducing mortality
prophylactic antibiotics have been shown in multiple meta-analyses to reduce mortality in
patients with liver cirrhosis
endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE
recommend band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
Prophylaxis of variceal haemorrhage
propranolol: reduced rebleeding and mortality compared to placebo

endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be
performed at two-weekly intervals until all varices have been eradicated. Proton pump
inhibitor cover is given to prevent EVL-induced ulceration
Next
Question 47 of 117
You are doing a new patient consultation for an 81-year-old man who has recently joined the
practice. You notice that he is very thin and wonder if he may be malnourished. According to NICE,
what is the cut-off body mass index (BMI) for diagnosing malnutrition?
A. < 17 kg/m
B. < 17.5 kg/m
C. < 18 kg/m
D. < 18.5 kg/m
E. < 19 kg/m
Next question
Malnutrition

months

Question 48 of 117
Next
According to recent NICE guidelines, which one of the following may have a role in the management
of irritable bowel syndrome?
A. Reflexology
B. Acupuncture
C. Aloe vera
D. Homeopathy
E. Hypnotherapy
Next question




herbal teas
Next
Question 49 of 117
Which one of the following regarding the FAST questionnaire for alcohol misuse is correct?
A. May be stopped after first question depending on the answer
B. The minimum score is 4
C. Consists of 5 questions
D. The maximum score is 20
E. The score for hazardous drinking is 7 or more
Next question

Screening
AUDIT

problems
dependence
FAST
this one question
had been drinking?
CAGE
Diagnosis
compulsion to drink
Next
Question 50 of 117
Which one of the following antibiotics is most likely to cause pseudomembranous colitis?
A. Cefaclor
B. Penicillin V
C. Erythromycin
D. Trimethoprim
E. Doxycycline
Next question
Cephalosporins, not just clindamycin, are strongly linked to Clostridiumdifficile
Features
diarrhoea
abdominal pain

Management

Next
Primary sclerosing cholangitis is most associated with:
A. Primary biliary cirrhosis
B. Crohn's disease
C. Hepatitis C infection
E. Coeliac disease
Next question

Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by
inflammation and fibrosis of intra and extra-hepatic bile ducts
Associations
ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
Crohn's (much less common association than UC)
HIV
Features
cholestasis: jaundice and pruritus
right upper quadrant pain

fatigue
Investigation
ERCP is the standard diagnostic tool, showing multiple biliary strictures giving a 'beaded'
appearance
ANCA may be positive
there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often
described as 'onion skin'
Complications
cholangiocarcinoma (in 10%)

increased risk of colorectal cancer
Question 52 of 117
Next
Which one of the following patients is most likely to require screening for hepatocellular carcinoma?
A. A 45-year-old man with liver cirrhosis secondary to hepatitis C
B. A 33-year-old man with HIV. He is taking antiretroviral therapy
C. A 22-year-old man with alpha-1 antitrypsin deficiency. He has no evidence of

current liver disease
D. A 52-year-old woman with alcohol-related liver cirrhosis who is still drinking
E. A 75-year-old man who drinks 100 units / week. He has no current signs of
liver disease
Next question
Patients with liver cirrhosis secondary to hepatitis C have a 3-5% annual incidence of hepatocellular
carcinoma.
Hepatocellular carcinoma
Hepatocellular carcinoma (HCC) is the third most common cause of cancer worldwide. Chronic
hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most
common cause in Europe.
The main risk factor for developing HCC is liver cirrhosis, for example secondary* to hepatitis B & C,
alcohol, haemochromatosis and primary biliary cirrhosis. Other risk factors include:
alpha-1 antitrypsin deficiency

hereditary tyrosinosis
glycogen storage disease
aflatoxin
drugs: oral contraceptive pill, anabolic steroids
porphyria cutanea tarda
male sex
diabetes mellitus, metabolic syndrome
Features
tends to present late

features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly,
pruritus, splenomegaly
possible presentation is decompensation in a patient with chronic liver disease
Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:
patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis

men with liver cirrhosis secondary to alcohol
Management options
early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
sorafenib: a multikinase inhibitor
*Wilson's disease is an exception
Next
Question 53 of 117
A 30-year-old man comes for review. He returned from a holiday in Egypt yesterday. For the past
two days he has been passing frequent bloody diarrhoea associated with crampy abdominal pain.
Abdominal examination demonstrates diffuse lower abdominal tenderness but there is no guarding
or rigidity. His temperature is 37.5C. What is the most likely causative organism?
A. Giardiasis
B. Enterotoxigenic Escherichia coli
C. Staphylococcus aureus
D. Salmonella
E. Shigella
Next question
Enterotoxigenic Escherichia coli infections do not usually cause bloody diarrhoea. A differential
diagnosis would be amoebic dysentery, enterohemorrhagicEscherichia coli and
possibly Campylobacter.
Gastroenteritis
Infection
Escherichia coli

Watery stools
Giardiasis
Cholera

Shigella
Bloody diarrhoea
Severe vomiting
Campylobacter
may be bloody
Bacillus cereus

Amoebiasis
weeks
Incubation period

Question 54 of 117
Next
Which one of the following statements regarding hepatitis C is correct?

A. Cannot be transmitted vertically from mother to child
B. Interferon-alpha and ribavirin are the treatments of choice
C. It is more infectious than hepatitis B following a needle stick injury
D. Breast feeding is contraindicated in mothers with hepatitis C
E. HCV RNA is the initial investigation of choice for at-risk groups
Next question
Hepatitis C
haemophiliacs).
Pathophysiology

Transmission

Features
Complications
cryoglobulinaemia

some strains


thrombocytopenia
Next
Question 55 of 117
A 31-year-old woman presents with symptoms consistent with coeliac disease. Which one of the
following tests should be used first-line when screening patients for coeliac disease?
A. Anti-casein antibodies
B. Tissue transglutaminase antibodies
C. Anti-gliadin antibodies
D. Xylose absorption test
E. Anti-endomyseal antibodies
Next question
Coeliac disease - tissue transglutaminase antibodies are the first-line test
Tissue transglutaminase antibodies are recommended as the first-line serological test according to
NICE.
Coeliac disease: investigation
diabetes mellitus and autoimmune hepatitis).
Diagnosis is made by a combination of immunology and jejunal biopsy. Villous atrophy and
immunology normally reverses on a gluten-free diet.

NICE issued guidelines on the investigation of coeliac disease in 2009. If patients are already taking
a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to
testing.
Immunology
tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE

endomyseal antibody (IgA)
anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
anti-casein antibodies are also found in some patients
Jejunal biopsy
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
Rectal gluten challenge has been described but is not widely used
Next
A 22-year-old male blood donor is noted to have the following blood results:
Bilirubin
ALP
ALT
Albumin
41 mol/L
84 U/L
23 U/L
41 g/L
Dipstick urinalysis normal

He has recently complained of coryzal symptoms and a non-productive cough. What is the most
likely diagnosis?
A. Gilbert's syndrome
B. Dubin-Johnson syndrome
C. Rotor syndrome
D. Hepatitis C infection
E. Infectious mononucleosis
Next question
An isolated hyperbilirubinaemia in a 22-year-old male is likely to be secondary to Gilbert's syndrome.
The normal dipstix urinalysis excludes Dubin-Johnson and Rotor syndrome as these both produce a
conjugated bilirubinaemia. Viral infections are common triggers for a rise in the bilirubin in patients
with Gilbert's
Gilbert's syndrome
Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a
deficiency of UDP glucuronyl transferase. The prevalence is approximately 1-2% in the general
population
Features
unconjugated hyperbilinaemia (i.e. not in urine)

jaundice may only be seen during an intercurrent illness
Investigation and management
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid

no treatment required
*the exact mode of inheritance is still a matter of debate
Question 57 of 117
Next
Your next patient is a 34-year-old man who is known to have an alcohol problem. He has drunk
around 100 units per week for the past five years. He regularly misses meals and smokes 20
cigarettes per day. What vitamin supplementation, if any, should you recommend?
A. Oral vitamin B compound
B. Oral thiamine
C. Oral vitamin B compound + multivitamins
D. No supplementation is advised. Give standard dietary advice
E. Oral thiamine + vitamin D
Next question
Whilst vitamin B compound is widely prescribed it is not recommended in recent guidelines, for
example SIGN.
Alcohol - problem drinking: management
Nutritional support
SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be
deficient'
Drugs used
benzodiazepines for acute withdrawal

disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of
acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol
(e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications
include ischaemic heart disease and psychosis
acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves
abstinence in placebo controlled trials
Next
Question 58 of 117
A 27-year-old female presents with alternating loose and hard stools associated with abdominal
discomfort and bloating. Which one of the following is it most important to do before making a
positive diagnosis of irritable bowel syndrome?
A. Arrange ultrasound abdomen
B. Flexible sigmoidoscopy
C. Ask about family history of ovarian cancer
D. Use a standardised screening tool for depression
E. Perform thyroid function tests
Next question

(IBS) in 2008
bloating, and/or

passage of mucus
diagnosis
rectal bleeding
full blood count

ESR/CRP
Question 59 of 117
Next
A 51-year-old woman is investigated for lethargy and pruritus. Her appetite is normal and she has
not lost weight. On examination she is not clinically jaundiced and there is no organomegaly. Bloods
tests are reported as follows:
Hb
12.8 g/dl
Platelets 188 * 109/l

WBC
6.7 * 109/l
Na+
140 mmol/l
K+
3.9 mmol/l
Urea
6.2 mmol/l
Creatinine 68 mol/l
Bilirubin 30 mol/l
ALP
231 u/l
ALT
38 u/l
GT
367 u/l
Albumin 39 g/l
What further test is most likely to reveal the diagnosis?

A. Anti-nuclear antibodies
B. Liver ultrasound
C. Anti-mitochondrial antibodies
D. Ceruloplasmin
E. Ferritin
Next question
IgM
Middle aged females
The demographic (middle-aged female), history (lethargy, pruritus) and liver function tests (rise in
ALP and GT) all point to a diagnosis of primary biliary cirrhosis (PBC). Anti-mitochondrial antibodies
are found in 98% of patients with PBC.
Primary biliary cirrhosis
Primary biliary cirrhosis is a chronic liver disorder typically seen in middle-aged females
(female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an
autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process
causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation
is itching in a middle-aged woman
Associations
Sjogren's syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
Diagnosis
anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are
highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM
Management
pruritus: cholestyramine
fat-soluble vitamin supplementation
ursodeoxycholic acid
liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can
occur but is not usually a problem
Question 60 of 117
Next
A 27-year-old woman with chronic left iliac fossa pain and alternating bowel habit is diagnosed with
irritable bowel syndrome. Initial treatment is tried with a combination of antispasmodics, laxatives
and anti-motility agents. Unfortunately after 6 months there has been no significant improvement in
her symptoms. According to recent NICE guidelines, what is the most appropriate next step?
A. Low-dose tricyclic antidepressant
B. Cognitive behavioural therapy
C. Refer for sigmoidoscopy
D. Trial of probiotics
E. Selective serotonin reuptake inhibitor

Next question
NICE recommend considering psychological interventions after 12 months. Tricyclic antidepressants
should be used in preference to selective serotonin reuptake inhibitors




herbal teas
Question 61 of 117
Next
What is the most common extra-intestinal manifestation of Crohn's disease?

A. Episcleritis
B. Erythema nodosum
C. Arthritis
D. Uveitis
E. Clubbing
Next question
Arthritis is the most common extra-intestinal feature in both Crohn's and UC
Crohn's disease
colon but may be seen anywhere from the mouth to anus.
Pathology
cause is unknown but there is a strong genetic susceptibility
inflammation occurs in all layers, down to the serosa. This is why patients with Crohn's are
prone to strictures, fistulas and adhesions
Crohn's disease typically presents in late adolescence or early adulthood. Features include:
presentation may be non-specific symptoms such as weight loss and lethargy
diarrhoea: the most prominent symptom in adults. Crohn's colitis may cause bloody
diarrhoea
abdominal pain: the most prominent symptom in children
perianal disease: e.g. Skin tags or ulcers
extra-intestinal features are more common in patients with colitis or perianal disease

Notes
Related to disease
activity

Erythema nodosum
Episcleritis
Osteoporosis

activity

Uveitis
Clubbing

common in UC
Question 62 of 117
Next
A 29-year-old man is reviewed. Four weeks ago he presented with a one month history of bloody
diarrhoea. He was previously fit and well prior to this episode. When initially reviewed he was
passing on average four loose stools a day with some visible blood. He was haemodynamically
stable with no fever and bloods showed the following:
Hb
15.2 g/dl
Platelets 298 * 109/l

WBC 8.6 * 109/l
CRP
15 mg/l
Colonoscopy showed extensive inflammatory changes consistent with ulcerative colitis. He was
started on oral mesalazine and a review appointment was made for today. Unfortunately there has
been no significant change in his symptoms. He is still passing around four bloody stools a day
although he remains systemically well. What is the most appropriate course of action?
A. Add oral prednisolone

B. Stop oral mesalazine and start oral prednisolone
C. Rectal corticosteroids
D. Admit for intravenous corticosteroids
E. Add oral azathioprine
Next question
This patient with mild/moderate ulcerative colitis has not responded to the appropriate first-line
therapy of oral aminosalicylates. He should therefore be offered oral prednisolone to help induce
remission.
As he remains systemically well there is no need to admit.

Inducing remission


disease)
disease
Question 63 of 117
Which of the following drugs is least likely to cause cholestasis?
A. Gliclazide
B. Amiodarone
C. Chlorpromazine
D. Oral contraceptive pill
Next
E. Co-amoxiclav
Next question

paracetamol
MAOIs
halothane
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

sulphonylureas
fibrates
Liver cirrhosis
methotrexate
methyldopa
amiodarone
Question 64 of 117
Next
At what age does ulcerative colitis most typically present?

A. 25-35 years
B. 10-20 years
C. Bimodal: 25-35 years + 55-65 years
D. Bimodal: 15-25 years + 35-45 years
E. Bimodal: 15-25 years + 55-65 years
Next question
Ulcerative colitis
Ulcerative colitis (UC) is a form of inflammatory bowel disease. Inflammation always starts at rectum
(hence it is the most common site for UC), never spreads beyond ileocaecal valve and is continuous.
The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65
years.
The initial presentation is usually following insidious and intermittent symptoms. Features include:
bloody diarrhoea
urgency
tenesmus
abdominal pain, particularly in the left lower quadrant
extra-intestinal features (see below)

Notes
Related to disease
activity

Erythema nodosum
Episcleritis
Osteoporosis

activity

Uveitis
Clubbing

common in UC
Pathology
red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)

widespread ulceration with preservation of adjacent mucosa which has the appearance of
polyps ('pseudopolyps')
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
Barium enema
long standing disease: colon is narrow and short -'drainpipe colon'
Question 65 of 117
Next
A 54-year-old female presents with a 3 month history of dysphagia affecting both food and liquids
from the start, along with symptoms of heartburn. What is the most likely underlying diagnosis?
A. Pharyngeal pouch
B. Gastric adenocarcinoma
C. Benign stricture
D. Oesophageal cancer
E. Achalasia
Next question
Dysphagia affecting both solids and liquids from the start - think achalasia
This is a classic history of achalasia with dysphagia affecting both solids and liquids from the start
Achalasia
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to
degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated.
Achalasia typically presents in middle-age and is equally common in men and women.
Clinical features
dysphagia of BOTH liquids and solids

typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
Investigations
manometry: excessive LOS tone which doesn't relax on swallowing - considered most
important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance
CXR: wide mediastinum, fluid level
Treatment
intra-sphincteric injection of botulinum toxin

Heller cardiomyotomy
balloon dilation
drug therapy has a role but is limited by side-effects
Image used on license from Radiopaedia
This film demonstrates the classical 'bird's beak' appearance of the lower oesophagus that is seen in achalasia. An
air-fluid level is also seen due to a lack of peristalsis
Mediastinal widening secondary to achalasia. An air-fluid level can sometimes be seen on CXR but it is not visible on
this film
Barium swallow - grossly dilated filled oesophagus with a tight stricture at the gastroesophageal junction resulting in a
'bird's beak' appearance. Tertiary contractions give rise to a corkscrew appearance of the oesophagus
Question 66 of 117
A 54-year-old female is presents to surgery one week following a cholecystectomy with profuse
diarrhoea. What is the most likely diagnosis?
A. Campylobacter
B. E. coli
C. Clostridium difficile
D. Salmonella
Next
E. Staphylococcus aureus
Next question
Clostridium difficile is the most likely cause as the patient would have been given broad-spectrum
antibiotics at the time of the operation
Features
diarrhoea
abdominal pain

Management

Question 67 of 117
Next
A 36-year-old man presents with dyspepsia. No alarm symptoms are present. This is his first
episode and he has no significant medical history of note. A test-and-treat strategy is agreed upon.
What is the most appropriate investigation to test for Helicobacter pylori?
A. Gastric aspiration + culture
B. CLO test (rapid urease test)
C. Stool culture
D. Hydrogen breath test
E. 13C-urea breath test
Next question
The urea breath test is highly sensitive, specific and non-invasive. There is no indication for an
endoscopy. Stool antigen, rather than culture, is an alternative.
Urea breath test


Serum antibody

Gastric biopsy

Stool antigen test
Question 68 of 117
Next
Which one of the following causes of gastroenteritis has the longest incubation period?
A. Campylobacter
B. Bacillus cereus
C. Shigella
D. Giardiasis
E. Salmonella
Next question
Gastroenteritis
Infection
Escherichia coli

Watery stools
Giardiasis
Cholera

Shigella
Bloody diarrhoea
Severe vomiting
Campylobacter
A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea
which may be bloody
Bacillus cereus
Amoebiasis

Infection
weeks
Incubation period

Question 69 of 117
Next
A 52-year-old woman is diagnosed with non-alcoholic steatohepatitis following a liver biopsy. What is
the single most important step to help prevent the progression of her disease?
A. Stop smoking
B. Start statin therapy
C. Eat more omega-3 fatty acids
D. Start sulfonylurea therapy
E. Weight loss
Next question


Associated factors
obesity
hyperlipidaemia
jejunoileal bypass
Features
hepatomegaly
Management
Metformin)
Question 70 of 117
Next
You are discussing alcohol intake with a middle-aged man who has just been discharged from
hospital after an episode of acute pancreatitis. He currently drinks around 2 litres of cider (ABV 5%)
a day. How many units is that a week?
A. 25 units
B. 70 units
C. 10 units
D. 80 units
E. 100 units
Next question
Alcohol units = volume (ml) * ABV / 1,000
2000 ml x 5% = 10,000
Divide this figure by 1,000 to get the number of units = 10,000/1,000 = 10 units/day
10 units/day x 7 days = 70 units
problems and candidates require a broad knowledge of this topic. '
Alcohol: units
any one day)
any one day)

1,000. For example:
Question 71 of 117
Next
You review a 34-year-old man who has had ulcerative colitis for the past 20 years. He describes a
one week history of passing three bloody stools per day. Despite this he is eating well and denies
abdominal pain. Abdominal examination is unremarkable. What is this episode most likely to
represent?
A. Severe exacerbation of ulcerative colitis
B. Infective exacerbation of ulcerative colitis
C. Mild exacerbation of ulcerative colitis
D. Moderate exacerbation of ulcerative colitis
E. Colorectal cancer secondary to longstanding ulcerative colitis
Next question
Ulcerative colitis: flares

Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
Mild
Moderate
Severe
Fewer than four stools daily, with

or without blood
Four to six stools a day, with

minimal systemic disturbance
More than six stools a day, containing blood

Evidence of systemic disturbance, e.g.
No systemic disturbance
Normal erythrocyte sedimentation
rate and C-reactive protein values
fever
tachycardia
abdominal tenderness, distension or
reduced bowel sounds
anaemia
hypoalbuminaemia
Patients with evidence of severe disease should be admitted to hospital.
Question 72 of 117
Next
A nurse undergoes primary immunisation against hepatitis B. Levels of which one of the following
should be checked four months later to ensure an adequate response to immunisation?
A. Anti-HBs
B. Anti-HBc
C. Hepatitis B viral load
D. HbeAg
E. HBsAg
Next question
It is preferable to achieve anti-HBs levels above 100 mIU/ml, although levels of 10 mIU/ml or more
are generally accepted as enough to protect against infection

disease
Example results

Question 73 of 117
Which one of the following extra-intestinal manifestations of inflammatory bowel disease is much
more common in ulcerative colitis than in Crohn's disease?
A. Pauciarticular arthritis
B. Osteoporosis
C. Episcleritis
D. Erythema nodosum
Next
E. Primary sclerosing cholangitis

Next question
Inflammatory bowel disease: key differences

The two main types of inflammatory bowel disease are Crohn's disease and Ulcerative colitis. They
have many similarities in terms of presenting symptoms, investigation findings and management
options. There are however some key differences which are highlighted in table below:
Crohn's disease (CD)
Features
Diarrhoea usually non-bloody

Weight loss more prominent
Upper gastrointestinal symptoms, mouth
ulcers, perianal disease
Abdominal mass palpable in the right iliac
fossa
Bloody diarrhoea more common

Abdominal pain in the left lower quadrant
Tenesmus
Extraintestinal
Gallstones are more common secondary to

reduced bile acid reabsorption
Primary sclerosing cholangitis more common
Oxalate renal stones*

Complications
Obstruction, fistula, colorectal cancer
Risk of colorectal cancer high in UC than CD
Pathology
Lesions may be seen anywhere from the

mouth to anus
Inflammation always starts at rectum and never

spreads beyond ileocaecal valve
Skip lesions may be present
Continuous disease
Inflammation in all layers from mucosa to

serosa
No inflammation beyond submucosa (unless

fulminant disease) - inflammatory cell infiltrate in
lamina propria
Histology
increased goblet cells

granulomas
neutrophils migrate through the walls of

glands to form crypt abscesses
depletion of goblet cells and mucin from
gland epithelium
Endoscopy
Deep ulcers, skip lesions - 'cobble-stone'

appearance
Widespread ulceration with preservation of adjacent

mucosa which has the appearance of polyps
('pseudopolyps')
Radiology
Small bowel enema
Barium enema
high sensitivity and specificity for

examination of the terminal ileum
strictures: 'Kantor's string sign'
proximal bowel dilation
'rose thorn' ulcers
fistulae
long standing disease: colon is narrow and
short -'drainpipe colon'
*impaired bile acid rebsorption increases the loss calcium in the bile. Calcium normally binds
oxalate.
Next
Question 74 of 117
You are reviewing a 33-year-old man who was diagnosed with coeliac disease two years ago. He
complains of ongoing diarrhoea, feeling tired and bloating. You suspect poor compliance with a
gluten-free diet but he reports being 'very consistent'. Which one of the following is the most
appropriate method to ascertain this
A. Food diary
B. Tissue transglutaminase antibodies
C. Faecal calprotectin measurement
D. Refer for a duodenal biopsy
E. Anti-endomysial antibodies
Next question
A food diary is unlikely to be useful if the patient already reports following a gluten free diet.
It is of course important to consider referring such patients if they are shown to have good
compliance. Complications such as small bowel lymphoma may need to be excluded.
Coeliac disease: management
The management of coeliac disease involves a gluten-free diet. Gluten containing cereals include:
wheat: bread, pasta, pastry

barley*: beer
rye
oats**
Some notable foods which are gluten-free include:
rice
potatoes
corn (maize)
Tissue transglutaminase antibodies may be checked to check compliance with a gluten free diet.
*whisky is made using malted barley. Proteins such as gluten are however removed during the
distillation process making it safe to drink for patients with coeliac disease
**some patients with coeliac disease appear able to tolerate oats
Question 75 of 117
Next
A baby is born to a mother who is known to have chronic hepatitis B. The mothers latest results are
as follows:
HBsAg Positive
HBeAg Positive
What is the most appropriate strategy for reducing the vertical transmission rate?
A. Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
B. Give the newborn hepatitis B vaccine
C. Give the newborn hepatitis B immunoglobulin

D. Give the mother intravenous zidovudine during labour
E. Give the mother hepatitis B immunoglobulin shortly before birth + the
newborn hepatitis B vaccine
Next question
HBeAg is a marker of infectivity. The Green Book guidelines advise giving both the vaccine and
immunoglobulin in this situation. If the patient had antibodies against HBe (anti-HBe), rather than the
HBe antigen as in this scenario, then only the vaccine would need to be given. Please see the link
for more details.
Hepatitis B and pregnancy
Basics
all pregnant women are offered screening for hepatitis B

babies born to mothers who are chronically infected with hepatitis B or to mothers who've
had acute hepatitis B during pregnancy should receive a complete course of vaccination +
hepatitis B immunoglobulin
studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the
latter part of pregnancy
there is little evidence to suggest caesarean section reduces vertical transmission rates
hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
Question 76 of 117
Next
Which one of the following statements best describes the prevention and treatment of hepatitis C?
A. No vaccine is available and treatment is only successful in around 10-15% of
patients
B. No vaccine and no treatment is available
C. A vaccine is available and treatment is successful in around 50% of patients
D. A vaccine is available but no treatment has been shown to be effective

E. No vaccine is available but treatment is successful in around 50% of patients
Next question
Hepatitis C
haemophiliacs).
Pathophysiology

Transmission

Features
Complications
cryoglobulinaemia
some strains

thrombocytopenia
Question 77 of 117
Next
A 23-year-old female with a history of diarrhoea and weight loss has a colonoscopy to investigate
her symptoms. A biopsy is taken and reported as follows:
Pigment laden macrophages suggestive of melanosis coli

A. Intestinal melanoma
B. Haemochromatosis
D. Laxative abuse
E. Colorectal cancer
Next question
Melanosis coli
Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden
macrophages
It is associated with laxative abuse, especially anthraquinone compounds such as senna
Question 78 of 117
Next
A 36-year-old former intravenous drug user is to commence treatment for hepatitis C with interferonalpha and ribavirin. Which of the following adverse effects are most likely to occur when patients are
treated with interferon-alpha?
A. Diarrhoea and transient rise in ALT
B. Cough and haemolytic anaemia
C. Flu-like symptoms and transient rise in ALT
D. Haemolytic anaemia and flu-like symptoms
E. Depression and flu-like symptoms
Next question
Interferon
Interferons (IFN) are cytokines released by the body in response to viral infections and neoplasia.
They are classified according to cellular origin and the type of receptor they bind to. IFN-alpha and
IFN-beta bind to type 1 receptors whilst IFN-gamma binds only to type 2 receptors.
IFN-alpha
produced by leucocytes
antiviral action
useful in hepatitis B & C, Kaposi's sarcoma, metastatic renal cell cancer, hairy cell leukaemia
adverse effects include flu-like symptoms and depression
IFN-beta
produced by fibroblasts
antiviral action
reduces the frequency of exacerbations in patients with relapsing-remitting MS
IFN-gamma
produced by T lymphocytes & NK cells

weaker antiviral action, more of a role in immunomodulation particularly macrophage
activation
may be useful in chronic granulomatous disease and osteopetrosis
Question 79 of 117
Next
A 29-year-old woman develops severe vomiting four hours after having lunch at a local restaurant.
What is the most likely causative organism?
A. Escherichia coli
B. Shigella
C. Campylobacter
D. Salmonella
E. Staphylococcus aureus
Next question
The short incubation period and severe vomiting point to a diagnosis ofStaphylococcus aureus food
poisoning.
Gastroenteritis
Infection
Escherichia coli

Watery stools
Giardiasis
Cholera

Shigella
Bloody diarrhoea
Severe vomiting
Campylobacter
may be bloody

Bacillus cereus
Amoebiasis

weeks
Incubation period

0/3

B. Acute cholecystitis
C. Biliary colic
F. Viral hepatitis
G. Gastric ulcer
I. Duodenal ulcer
Next
80.
A 56-year-old woman who is known to have gallstones presents with severe epigastric pain and
vomiting. On examination she is apyrexial and tender in the epigastrium.
The correct answer is Acute pancreatitis
Gallstones and alcohol are the two most common causes of acute pancreatitis. The site of pain and
absence of fever point away from a diagnosis of acute cholecystitis.
81.
A 63-year-old man presents with weight loss and anorexia. He denies any abdominal pain but says his
stools have become pale and difficult to flush away. On examination he is noticed to have jaundiced
sclera.
The correct answer is Pancreatic cancer
Whilst painless jaundice is the classical presentation of pancreatic cancer most studies suggest pain is a
relatively common presenting symptom.
82.
An overweight 47-year-old woman presents with recurrent episodes of pain in the right upper quadrant
which is brought on by eating fatty food.
The correct answer is Biliary colic
Patients with gallstones are stereotypically fat, female and in their forties.
Next question
Viral hepatitis

myalgia
lethargy
Congestive
hepatomegaly
Biliary colic
generalisation.
Acute cholecystitis
right shoulder.
the RUQ)
triad of:
Gallstone ileus

RUQ pain
jaundice
Cholangiocarcinoma
Acute pancreatitis

Vomiting is common
described but rare
Pancreatic cancer
common
Next
Question 83 of 117
How many units of alcohol are in a 750ml bottle of red wine with an alcohol by volume of 12%?
A. 6 units
B. 7 units
C. 8 units
D. 9 units
E. 10 units
Next question
Alcohol units = volume (ml) * ABV / 1,000
problems and candidates require a broad knowledge of this topic. '
Alcohol: units
any one day)
any one day)

1,000. For example:

Question 84 of 117
Which one of the following is not associated with oesophageal cancer?
A. Achalasia
B. Smoking
Next
C. Gastro-oesophageal reflux disease

D. Helicobacter pylori
E. Alcohol
Next question
Helicobacter pylori may actually be protective against oesophageal cancer.
Oesophageal cancer
Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but
the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of
oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal
reflux disease (GORD) or Barrett's.
The majority of tumours are in the middle third of the oesophagus.
Risk factors
smoking
alcohol
GORD
Barrett's oesophagus
achalasia
Plummer-Vinson syndrome
rare: coeliac disease, scleroderma
Barium swallow - 5cm irregular narrowing of the mid-thoracic oesophagus with proximal shouldering
Fluoroscopy - a region of fixed, irregular stricturing is seen in the distal oesophagus
Question 85 of 117
Next
A patient presents with gastrointestinal symptoms. Which one of the following features in the history
would be least consistent with making a diagnosis of irritable bowel syndrome?
A. Urgency to open bowels
B. Symptoms made worse by eating
C. 62-year-old female
D. Passage of mucous with stool
E. Bladder symptoms
Next question
Onset after 60 years of age is considered a red flag in the new NICE guidelines.
(IBS) in 2008

bloating, and/or
passage of mucus
diagnosis
rectal bleeding
full blood count
ESR/CRP
Question 86 of 117
Next
A 38-year-old woman is noticed to be jaundiced. As part of a liver screen the following results are
obtained:
Anti-HBs
Negative
Anti-HBc
Positive
HBs antigen
Positive
IgM anti-HBc Negative
Anti-HBs = Hepatitis B Surface Antibody; Anti-HBc = Hepatitis B Core Antibody; HBs antigen = Hepatitis
B Surface Antigen
What is the patient's hepatitis B status?

A. Probable hepatitis D infection
B. Acute hepatitis B infection
C. Previous immunisation to hepatitis B
D. Chronic hepatitis B
E. Previous hepatitis B infection, not a carrier
Next question
The negative IgM anti-HBc points to a chronic rather than acute infection.

disease
Example results
0/3
Theme: Diarrhoea
A. Gastroenteritis
B. Crohn's disease
D. Colorectal cancer
E. Laxative abuse
F. Constipation causing overflow
G. Lactose intolerance
H. Diverticulitis
I. Irritable bowel syndrome
J. Coeliac disease
Next
87.
A 41-year-old man with cerebral palsy is admitted with abdominal pain and diarrhoea. His carers report
him passing 5-6 watery stools per day for the past four days. On examination he has a mass in the left
side of the abdomen.
The correct answer is Constipation causing overflow
88.
A 37-year-old woman presents with a three week history of diarrhoea and crampy abdominal pains. On
examination she is noted to have a number of perianal skin tags.
The correct answer is Crohn's disease
89.
A 4-year-old boy is investigated for chronic diarrhoea, abdominal bloating and failure to thrive.
The correct answer is Coeliac disease
These are typical presenting features of coeliac disease in children.
Next question
Diarrhoea
The table below gives characteristic features for conditions causing diarrhoea:
Usually acute
Gastroenteritis
May be accompanied by abdominal pain or nausea/vomiting
Diverticulitis
Classically causes left lower quadrant pain, diarrhoea and fever
Antibiotic therapy
More common with broad spectrum antibiotics
Clostridium difficile is also seen with antibiotic use

Constipation causing overflow
A history of alternating diarrhoea and constipation may be given

May lead to faecal incontinence in the elderly
Usually chronic
Irritable bowel
syndrome
Extremely common. The most consistent features are abdominal pain, bloating and change in bowel
habit. Patients may be divided into those with diarrhoea predominant IBS and those with
constipation predominant IBS.
Features such as lethargy, nausea, backache and bladder symptoms may also be present
Ulcerative colitis
Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal
urgency and tenesmus may be seen
Crohn's disease
Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis.
Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction
Colorectal
cancer
Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and
constitutional symptoms e.g. Weight loss and anorexia
Coeliac disease
In children may present with failure to thrive, diarrhoea and abdominal distension
In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may
coexist
Other conditions associated with diarrhoea include:
thyrotoxicosis
laxative abuse
appendicitis
Question 90 of 117
Next
Which one of the following statements regarding malnutrition is correct?

A. MUST gives a score out of 10
B. An alternative screening tool to MUST should be used for Asian patients
C. It is not designed to be used in the community
D. MUST includes questions about a patients activity levels
E. Around 10% of patients aged over 65 years are malnourished
Next question
Malnutrition

months


Next
Question 91 of 117
Which one of the following patients would it be most suitable to offer a screening test for coeliac
disease to?
A. A patient who is 'tired all the time'
B. A patient with rheumatoid arthritis
C. A patient who has a family history of inflammatory bowel disease
D. A patient with type 2 diabetes mellitus
E. A patient who develops erythema nodosum
Next question
Coeliac disease
Signs and symptoms

Persistent or unexplained gastrointestinal
symptoms including nausea and vomiting
unspecified anaemia
Conditions

Type 1 diabetes
Complications

hyposplenism
lactose intolerance
Question 92 of 117
Next
Which of the following is not known to cause acute pancreatitis?

A. Hypocalcaemia
B. Hypothermia
C. Mumps
D. Hypertriglyceridaemia
E. Steroids
Next question
Hypercalcaemia, not hypocalcaemia is a recognised cause of acute pancreatitis

Acute pancreatitis: causes
The vast majority of cases in the UK are caused by gallstones and alcohol
Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia,Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide,
pentamidine, steroids, sodium valproate)
Next
Question 93 of 117
Which one of the following regarding the AUDIT questionnaire for alcohol misuse is correct?
A. A score of 12 in a man is likely to indicate a low risk of alcohol misuse
B. Consists of 10 items
C. Asks about thoughts of self harm
D. Maximum score is 30
E. Is less sensitive than the CAGE questionnaire
Next question

Screening
AUDIT

problems
dependence
FAST
this one question
had been drinking?
CAGE
Diagnosis
compulsion to drink
Question 94 of 117
Next
A 62-year-old woman with a history of scleroderma is reviewed. For the past few months she has
suffered with recurrent bouts of diarrhoea. During these bouts her stools are pale, bulky and
offensive. She drinks 14 units of alcohol/week. Bloods show the following:
Hb
10.8 g/dl
Platelets
231 * 109/l
WBC
5.4 * 109/l
Ferritin
14 ng/ml
Vitamin B12 170 ng/l

Folate
2.2 nmol/l
Na+
142 mmol/l
K+
3.4 mmol/l
Urea
4.5 mmol/l
Creatinine 77 mol/l
Bilirubin 21 mol/l
ALP
88 u/l
ALT
21 u/l
GT
55 u/l
Albumin 36 g/l
Which one of the following complications is most likely to have occurred?

A. Whipple's disease
B. Colonic hypomotility
C. Chronic pancreatitis
D. Malabsorption syndrome
E. Ileal stenosis
Next question
Malabsorption syndrome is a very common complication of scleroderma (systemic sclerosis). The
bloods show evidence of impaired absorption of some vitamins (B12, folate), nutrients (iron) and
protein (low albumin).
Malabsorption
Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly
divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production
or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats)
Intestinal causes of malabsorption
coeliac disease
Crohn's disease
tropical sprue
Whipple's disease
Giardiasis
brush border enzyme deficiencies (e.g. lactase insufficiency)
Pancreatic causes of malabsorption
chronic pancreatitis
cystic fibrosis
pancreatic cancer
Biliary causes of malabsorption
biliary obstruction
primary biliary cirrhosis
Other causes
bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop)

short bowel syndrome
lymphoma
Next
Question 95 of 117
A 29-year-old man presents with a 12 day history of watery diarrhoea that developed one week after
returning from India. He had travelled around northern India for two months. On examination he is
apyrexial and his abdomen is soft and non-tender. What is the most likely causative organism?
A. Amoebiasis
B. Giardiasis
C. Campylobacter
D. Shigella
E. Salmonella
Next question
The incubation period and prolonged, non-bloody diarrhoea point towards giardiasis
Gastroenteritis
Infection
Escherichia coli

Watery stools
Giardiasis
Cholera

Shigella
Bloody diarrhoea
Severe vomiting
Campylobacter
may be bloody
Bacillus cereus
Amoebiasis

weeks
Incubation period

Question 96 of 117
Next
A patient who was an intravenous drug user in the 1990s asks for a hepatitis C test. What is the
most appropriate action?
A. Refer him for pre-test counselling to discuss the pros and cons of testing
B. Advise him that no accurate test is currently available but that he should
undertake normal precautions
C. Arrange an anti-HCV antibody test
D. Arrange a HCV RNA test
E. Refer him to gastroenterology for a liver biopsy
Next question
HCV RNA tests are normally only ordered following a positive antibody test.
Hepatitis C
haemophiliacs).
Pathophysiology

Transmission

Features
Complications
cryoglobulinaemia

some strains

thrombocytopenia
Question 97 of 117
Next
A 45-year-old man is noted to have non-tender, smooth hepatomegaly associated Dupuytren's

contracture and parotid enlargement. He recently returned from a holiday in Thailand. What is the
likely diagnosis?
A. Primary hepatoma
B. Hydatid disease
C. Alcoholic liver disease

D. Viral hepatitis
E. Tricuspid regurgitation
Next question
Both Dupuytren's contracture and parotitis are associated with alcoholic liver disease. Whilst a
history of alcohol excess would normally be volunteered it should be remembered many patients will
lie about their alcohol intake
The recent holiday in Thailand is a distractor.
Hepatomegaly
Common causes of hepatomegaly
Cirrhosis: if early disease, later liver decreases in size. Associated with a non-tender, firm
liver
Malignancy: metastatic spread or primary hepatoma. Associated with a hard, irregular. liver
edge
Right heart failure: firm, smooth, tender liver edge. May be pulsatile
Other causes
viral hepatitis
glandular fever
malaria
abscess: pyogenic, amoebic
hydatid disease
haematological malignancies
haemochromatosis
primary biliary cirrhosis
sarcoidosis, amyloidosis
Question 98 of 117
Next
A man presents with severe vomiting. He reports not being able to keep fluids down for the past 12
hours. You suspect a diagnosis of gastroenteritis and on discussing possible causes he mentions
reheating curry with rice the night before. What is the most likely causative organism?
A. Escherichia coli
B. Campylobacter
C. Salmonella
D. Shigella
E. Bacillus cereus
Next question
Bacillus cereus infection most commonly results from reheated rice.
Gastroenteritis
Infection
Escherichia coli

Watery stools
Giardiasis
Cholera

Shigella
Bloody diarrhoea
Severe vomiting
Campylobacter
may be bloody
Bacillus cereus
Amoebiasis

weeks
Incubation period

Question 99 of 117
Which one of the following causes of diarrhoea has the shortest incubation period?
A. Salmonella
Next
B. Shigella
C. Campylobacter
D. Escherichia coli
E. Bacillus cereus
Next question
Gastroenteritis
Infection
Escherichia coli

Watery stools
Giardiasis
Cholera

Shigella
Bloody diarrhoea
Severe vomiting
Campylobacter
may be bloody
Bacillus cereus
Amoebiasis

weeks
Incubation period

Question 100 of 117

Which of the following drugs is least likely to cause cholestasis?
A. Anabolic steroids
B. Erythromycin
C. Prochlorperazine
D. Methylphenidate
Next
E. Flucloxacillin
Next question

paracetamol
MAOIs
halothane
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

sulphonylureas
fibrates
Liver cirrhosis
methotrexate
methyldopa
amiodarone
Next
Question 101 of 117
Each one of the following is a recognised complication of gastro-oesophageal reflux disease, except:
A. Oesophageal carcinoma
B. Barrett's oesophagus
C. Anaemia
D. Achalasia
E. Benign strictures
Next question
Gastro-oesophageal reflux disease: management

Gastro-oesophageal reflux disease (GORD) may be defined as symptoms of oesophagitis
secondary to refluxed gastric contents
NICE recommend that GORD which has not been investigated with endoscopy should be treated as
per the dyspepsia guidelines
Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months

if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited
number of repeat prescriptions
if no response then H2RA or prokinetic for one month
Complications
oesophagitis
ulcers
anaemia
benign strictures
Barrett's oesophagus
oesophageal carcinoma
Next
Question 102 of 117

You are reviewing a patient with Crohn's disease. Which one of the following extra-intestinal
manifestations of Crohn's disease is related to disease activity?
A. Uveitis
B. Erythema nodosum
C. Primary sclerosing cholangitis
D. Clubbing
E. Pyoderma gangrenosum
Next question
Crohn's disease
colon but may be seen anywhere from the mouth to anus.
Pathology
cause is unknown but there is a strong genetic susceptibility

inflammation occurs in all layers, down to the serosa. This is why patients with Crohn's are
prone to strictures, fistulas and adhesions
Crohn's disease typically presents in late adolescence or early adulthood. Features include:
presentation may be non-specific symptoms such as weight loss and lethargy
diarrhoea: the most prominent symptom in adults. Crohn's colitis may cause bloody
diarrhoea
abdominal pain: the most prominent symptom in children
perianal disease: e.g. Skin tags or ulcers
extra-intestinal features are more common in patients with colitis or perianal disease

Notes
Related to disease
activity

Erythema nodosum
Episcleritis
Osteoporosis

activity

Uveitis
Clubbing

common in UC
Question 103 of 117
Next
You review a 24-year-old female who has recently been diagnosed with left-sided ulcerative colitis.
Five days ago she was started on high-dose oral mesalazine by the gastroenterologists. There has
yet to be any change in her stool pattern of passing around 3-4 loose motions/day, which have small
amounts of blood in them. She remains systemically well and abdominal examination is
unremarkable. How long should the initial mesalazine treatment be taken for before deciding
whether it has been successful?
A. 7 days
B. 2 weeks
C. 4 weeks
D. 2 months
E. 4 months
Next question


Inducing remission


disease)
disease
Question 104 of 117
Next
A 68-year-old woman comes back for review. Two weeks ago she presented with pain in her left
knee not responding to paracetamol and was commenced on diclofenac 50mg tds and lansoprazole
30mg od. Shortly afterwards she developed some indigestion which seems to resolve if she skips
the diclofenac dose. She is otherwise asymptomatic and got good pain relief from diclofenac. Clinical
examination is normal. What is the most appropriate action?
A. 13C-urea breath test
B. Stop diclofenac, continue lansoprazole + review in 1 week
C. Switch diclofenac to ibuprofen, continue lansoprazole
D. Refer urgently for endoscopy
E. Admit
Next question
When NICE first published their dyspepsia guidelines there was a policy of referral for any older
patients with new onset dyspepsia. This led to a deluge of referrals and amended guidelines were
published in 2004. This modified approach seems to be supported by a large trial demonstrating a
minimal effect on mortality of routine referral.
This question gives an example of a scenario where NICE would recommend not initially referring a
patient when there is an obvious trigger (NSAID use).
Dyspepsia
'alarm signs':

persistent vomiting
epigastric mass

are:

NSAIDs) and


2. Lifestyle advice

Next
Which one of the following is not associated with non-alcoholic steatohepatitis?
A. Hyperlipidaemia
B. Obesity
C. Sudden weight loss or starvation
D. Jejunoileal bypass
E. Type 1 diabetes mellitus
Next question
Obese T2DM with abnormal LFTs - ? Non-alcoholic fatty liver disease


Associated factors
obesity
hyperlipidaemia
jejunoileal bypass
Features
hepatomegaly
Management
Metformin)
Question 106 of 117
Next
What advice should you give a non-pregnant woman who asks how much alcohol can she drink?
A. Should drink no more than 14 units of alcohol per week (and no more than 2
units in any one day)
B. Should drink no more than 14 units of alcohol per week (and no more than 3
C. Should drink no more than 7-14 units of alcohol per week (and no more than 2
D. Should drink no more than 21 units of alcohol per week (and no more than 3
E. Should drink no more than 7 units of alcohol per week (and no more than 2
Next question
Alcohol: units
any one day)
any one day)

1,000. For example:
Question 107 of 117
Next
You follow-up a 42-year-old man who has just completed a two week course
ofHelicobacter pylori therapy for dyspepsia. How soon can you perform a urea breath test to test for
eradication, assuming he has stopped his eradication therapy today and is taking no other
medication?
A. Straight away
B. In 1 weeks time
C. In 2 weeks time
D. In 4 weeks time
E. In 8 weeks time
Next question

Urea breath test


Serum antibody


Gastric biopsy

Stool antigen test
Question 108 of 117

One of your patients who is an intravenous drug user contracts the hepatitis C virus. What
percentage of such patients will become chronically infected with hepatitis C?
A. 30-35%
B. 80-85%
Next
C. 50-60%
D. 5-10%
E. 15-20%
Next question
Hepatitis C - 80-85% become chronically infected
Hepatitis C
haemophiliacs).
Pathophysiology

Transmission

Features
Complications
cryoglobulinaemia

some strains


thrombocytopenia
Question 109 of 117
Next
A 55-year-old business man presents with a 15 day history of watery, non-bloody diarrhoea
associated with anorexia and abdominal bloating. His symptoms started 4 days after returning from
a trip to Pakistan. On examination he is apyrexial with dry mucous membranes but normal skin
turgor. What is the most likely causative organism?
A. Salmonella
B. Giardia lamblia
C. Shigella
D. Escherichia coli
E. Norovirus
Next question
Although Escherichia coli is the most common cause of travellers' diarrhoea, in this particular case
the length of illness and nature of symptoms (bloating, watery diarrhoea) points to a diagnosis of
Giardiasis.
Giardiasis
Giardiasis is caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route
Features
often asymptomatic
lethargy, bloating, abdominal pain
non-bloody diarrhoea
chronic diarrhoea, malabsorption and lactose intolerance can occur
stool microscopy for trophozoite and cysts are classically negative, therefore duodenal fluid
aspirates or 'string tests' (fluid absorbed onto swallowed string) are sometimes needed
Treatment is with metronidazole
Question 110 of 117

Which one of the following drugs used in the management of diabetes mellitus is most likely to
cause cholestasis?
A. Metformin
B. Gliclazide
C. Acarbose
D. Rosiglitazone
Next
E. Insulin
Next question

paracetamol
MAOIs
halothane
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

sulphonylureas
fibrates
Liver cirrhosis
methotrexate
methyldopa
amiodarone
Next
Question 111 of 117

A 25-year-old man with a history of Crohn's disease is reviewed. Over the past week he has
developed painful perianal ulcers. On examination numerous shallow ulcers can be seen with a
small number of skin tags. What is the most appropriate first-line treatment?
A. Topical mesalazine
B. Oral metronidazole
C. Barrier creams + laxatives
D. Oral prednisolone
E. Oral mesalazine
Next question
Crohn's - perianal disease: oral metronidazole is first-line
Please see the British Society of Gastroenterology guidelines for more details.
Crohn's disease: management
colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the
management of Crohn's disease in 2012.
General points
patients should be strongly advised to stop smoking

some studies suggest an increased risk of relapse secondary to NSAIDs and the combined
oral contraceptive pill but the evidence is patchy
Inducing remission
glucocorticoids (oral, topical or intravenous) are generally used to induce remission.

Budesonide is an alternative in a subgroup of patients
enteral feeding with an elemental diet may be used in addition to or instead of other
measures to induce remission, particularly if there is concern regarding the side-effects of
steroids (for example in young children)
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as
effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission
but is not used as monotherapy. Methotrexate is an alternative to azathioprine
infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on
azathioprine or methotrexate
metronidazole is often used for isolated peri-anal disease
as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may
help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Surgery
around 80% of patients with Crohn's disease will eventually have surgery
*assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
0/3
Theme: Dysphagia
A. Pharyngeal pouch
B. Achalasia
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C. Globus hystericus
D. Systemic sclerosis
E. Oesophageal cancer
F. Myasthenia gravis
G. Oesophagitis
H. Motor neuron disease
I. Oesophageal candidiasis
J. Plummer-Vinson syndrome
112.
A 54-year-old man presents with a 3 month history of 'heartburn'. He has noticed that swallowing is
painful, particularly when he eats meat or bread. After eating and at night he has an 'unpleasant'
retrosternal sensation. Clinical examination is unremarkable
The correct answer is Oesophagitis
113.
A 67-year-old woman presents with a 5 week history of food getting stuck. She is currently treated for
COPD and was recently noted to have a macrocytosis on routine bloods. On a number of occasions
she has vomited during the meal and says she has no taste for food any more.
The correct answer is Oesophageal cancer
Smoking (COPD) and alcohol (macrocytosis) are risk factors for oesophageal cancer
114.
A 43-year-old woman with a history of anxiety complains of problems swallowing. On examination

she is noted to have a number of small white lumps on her hands and telangiectasia on her face
The correct answer is Systemic sclerosis
Next question
Dysphagia
The table below gives characteristic exam question features for conditions causing dysphagia:
Oesophageal
cancer
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use
Oesophagitis
May be history of heartburn

Odynophagia but no weight loss and systemically well
Oesophageal
candidiasis
There may be a history of HIV or other risk factors such as steroid inhaler use
Achalasia
Dysphagia of both liquids and solids from the start

Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
Pharyngeal pouch
More common in older men

Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may
occasionally be seen
Systemic sclerosis
Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon,
oEsophageal dysmotility, Sclerodactyly, Telangiectasia
As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased.
This contrasts to achalasia where the LES pressure is increased
Myasthenia gravis
Other symptoms may include extraocular muscle weakness or ptosis

Dysphagia with liquids as well as solids
Globus hystericus
May be history of anxiety

Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further investigation for organic causes
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Question 115 of 117
A 30-year-old woman presents with abdominal pain that is associated with alternating diarrhoea and
constipation. Which one of the following symptoms is least consistent with a diagnosis of irritable
bowel syndrome?
A. Feeling of incomplete stool evacuation
B. Waking at night due to the pain
C. Abdominal bloating
D. Faecal urgency
E. Passage of mucous with stool
Next question
Pain which wakes a patient at night is not a feature that would be expected in irritable bowel
syndrome.
(IBS) in 2008

bloating, and/or

passage of mucus
diagnosis
rectal bleeding
full blood count

ESR/CRP
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Question 116 of 117

A 34-year-old male is admitted with central abdominal pain radiating through to the back and
vomiting. The following results are obtained:
Amylase 1,245 u/dl
Which one of the following medications is most likely to be responsible?

A. Phenytoin
B. Sodium valproate
C. Metoclopramide
D. Sumatriptan
E. Pizotifen
Next question
Sodium valproate induced pancreatitis is more common in young adults and tends to occur within
the first few months of treatment. Asymptomatic elevation of the amylase level is seen in up to 10%
of patients
Acute pancreatitis: causes
The vast majority of cases in the UK are caused by gallstones and alcohol
Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia,Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide,
pentamidine, steroids, sodium valproate)
Question 117 of 117

Which of the following is not a recognised complication of coeliac disease?
A. Hypersplenism
B. Lymphoma of the small intestine
C. Osteoporosis
D. Oesophageal cancer
E. Subfertility
Hypo-, not hypersplenism is seen in coeliac disease

Coeliac disease
Signs and symptoms

unspecified anaemia
Conditions

Type 1 diabetes
Complications
hyposplenism
lactose intolerance

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NICE recommend avoiding lactulose in the management of IBS

Irritable bowel syndrome: management

pain: antispasmodic agents

Second-line pharmacological treatment

Other management options

psychological interventions - if symptoms do not respond to pharmacological treatments after

General dietary advice

have regular meals and take time to eat

a Body Mass Index (BMI) of less than 18.5; or

it should be done on admission to care/nursing homes and hospital, or if there is concern.

Management of malnutrition is difficult. NICE recommend the following points:

dietician support if the patient is high-risk

chronic gastrointestinal bleeding

Deciding whether urgent referral for endoscopy is needed

recent in onset rather than recurrent and

Managing patients who do not meet referral criteria ('undiagnosed dyspepsia')

1. Review medications for possible causes of dyspepsia

Question 4-6 of 117

Theme: Hepatobiliary disease and related disorders

D. Amoebic liver abscess

Hepatobiliary disease and related disorders

Common symptoms include:

nausea and vomiting, anorexia

fever (rigors are common)

Usually due to alcohol or gallstones

Amoebic liver abscess

Inflammatory bowel disease: key differences

Crohn's disease (CD)

Ulcerative colitis (UC)

Diarrhoea usually non-bloody

Bloody diarrhoea more common

Gallstones are more common secondary to

Primary sclerosing cholangitis more common

Oxalate renal stones*

Obstruction, fistula, colorectal cancer

Risk of colorectal cancer high in UC than CD

Lesions may be seen anywhere from the

Inflammation always starts at rectum and never

Skip lesions may be present

Inflammation in all layers from mucosa to

No inflammation beyond submucosa (unless

increased goblet cells

neutrophils migrate through the walls of

Deep ulcers, skip lesions - 'cobble-stone'

Widespread ulceration with preservation of adjacent

Small bowel enema

high sensitivity and specificity for

Crohn's disease: management

patients should be strongly advised to stop smoking

glucocorticoids (oral, topical or intravenous) are generally used to induce remission.

azathioprine or mercaptopurine is used first-line to maintain remission

*assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine

Alcohol - problem drinking: detection and assessment

10 item questionnaire, please see the link

minimum score = 0, maximum score = 16

Have people Annoyed you by criticising your drinking?

Have you ever felt bad or Guilty about your drinking?

difficulties controlling alcohol consumption