gastroentrology PT 1 2016 modif

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Question 1 of 298

A 26-year-old woman presents to her GP complaining of intermittent abdominal distension
and bloating, which changes with her menstrual cycle, and is interspersed with bouts of loose
motions. She works as a trader in a busy office and finds work stressful: she has previously
taken a course of Prozac® for depression/anxiety. Examination, bloods and sigmoidoscopy
were all normal.
What is the best-fit diagnosis?
A

Chronic pancreatitis

B

Ulcerative colitis

C

Peptic ulcer disease

D

Diverticulitis

E

Irritable bowel syndrome

Explanation
Irritable bowel syndrome
Irritable bowel syndrome has a female to male preponderance of 2:1 and frequently occurs in
patients with underlying problems of anxiety. Examination and investigations are invariably
normal. Any history of weight loss, bleeding, onset > 40 years of age or faecal incontinence
would not fit with this picture, however, and these features should trigger other investigations
if the basic examination/investigations are unremarkable.
Management
Management is with antispasmodics such as peppermint oil (eg Colpermin®), a high-fibre diet
and avoidance of trigger foods (a significant proportion of patients report improvement
when cutting out dairy foods). In many cases, serotonin-reuptake inhibitors such as Prozac®
also have positive effects on symptoms.
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Question 2 of 298

A 48-year-old publican presents with acute-onset confusion and a mild fever. On examination
he has signs of chronic liver disease and ascites and is generally tender over his abdomen.
Blood tests reveal mildly raised aspartate aminotrasferase (AST) and alanine
aminotransferase (ALT) levels and a bilirubin of 186 μmol/l. His creatinine is 145 μmol/l. His
international normalised ratio (INR) is 2 and he has a mixed-picture anaemia with a
haemoglobin of 9.8 g/dl, low platelets and an elevated neutrophil count. Ascitic tap reveals
fluid with a polymorphonuclear cell count of > 250/mm3.
What is the most likely diagnosis?
A

Spontaneous bacterial peritonitis

B

Perforated duodenal ulcer

C

Cholangitis

D

Cholecystitis

E

Acute pancreatitis

Explanation
Spontaneous bacterial peritonitis
This man clearly has alcoholic cirrhosis, which is decompensated with ascites. The ascites has
become infected and spontaneous bacterial peritonitis has developed. Diagnosis is made on
the basis of a white count of > 250 cells/mm3, the presence of bacteria on Gram staining and
a positive ascitic fluid culture. Pathogens are usually Gram negative, and include Escherichia
coli, Klebsiella pneumoniae and enterococci. The treatment of choice includes
piperacillin/tazobactam for severe disease, although ciprofloxacin or ofloxacin might be used
in selected patients.
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Question 3 of 298

An 82-year-old woman is admitted from a nursing home with profuse diarrhoea. She was
discharged 2 weeks earlier from the orthopaedic ward, where she was treated for a fractured
hip. There was some evidence of osteomyelitis during that admission and she was treated
with clindamycin and discharged on tablets. On examination she is drowsy and dehydrated,
with lower abdominal tenderness. She soils the bed with watery diarrhoea during the
examination. Blood tests confirm pre-renal failure.
What is the most likely diagnosis?
A

Salmonellosis

B

Ulcerative colitis

C

Enteric parasitic infection

D

Pseudomembranous colitis

E

Colonic malignancy

Explanation
Pseudomembranous colitis
Pseudomembranous colitis can occur in up to 10% of patients who have received a course of
clindamycin. In addition, it is thought that many nursing-home residents show chronic
carriage of Clostridium difficile (the causative pathogen). Sigmoidoscopy will usually reveal
raised, white-yellow exudative plaques adherent to the colonic mucosa (the
pseudomembrane). The diagnosis is made by the presence of clostridium toxin in the stool.
Treatment is with oral metronidazole or vancomycin for 10–14 days, accompanied by
appropriate rehydration therapy. The mortality rate is as high as 10% in the elderly.
Salmonellosis would not be impossible here but the osteomyelitis associated with this tends
to affect the long bones and typically occurs in patients with sickle cell disease.
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Question 4 of 298

Which one of the following statements best describes a feature of irritable bowel syndrome?
A

Characterised by nocturnal diarrhoea

B

If there is nausea and vomiting the diagnosis should be reconsidered

C

Weight loss becomes more evident as the disease runs a chronic course

D

Sigmoidoscopy findings are often diagnostic

E

A diet high in soluble fibre is often prescribed for the treatment of the syndrome

Explanation
Irritable bowel syndrome
Irritable bowel syndrome is a functional disorder of the alimentary tract that is characterised
by altered bowel function, constipation and diarrhoea, with or without abdominal pain,
nausea and vomiting, with no significant physical, laboratory or histological findings.
Anaemia, occult blood in the stool, weight loss or nocturnal symptoms cannot be attributed
to irritable bowel syndrome. A diet high in soluble fibre can be useful in some patients and
others seem to gain benefit from excluding dairy foods.
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Question 5 of 298

Which one of the following pathological changes favours a diagnosis of ulcerative colitis over
Crohn’s disease?
A

Ileal involvement

B

Crypt abscesses

C

Transmural involvement

D

Granulomas

E

Skip lesions

Explanation
Inflammatory bowel diseases
Crohn’s disease
Crohn’s disease can involve any segment in the alimentary canal but distal ileum involvement
is characteristic. The inflammatory process involves all layers of the bowel with the formation

of non-caseating granulomas, ulcers and fistulae. Discontinuity of the inflammatory process
across the bowel (skip lesions) is also characteristic.
Ulcerative colitis
In ulcerative colitis there is diffuse, continuous involvement of the colon with proctitis as an
early feature in 90% of cases. The inflammation is confined to the mucosa and lamina propria
with crypt abscess formation. Ileal involvement is not a common feature of ulcerative colitis
but the distal segment of the ileum can be involved in the inflammatory process from
adjacent inflamed colonic segment (backwash ileitis).
Table of pathological findings;
Crohn's Disease

Ulcerative colitis

Transmural inflammation

Mucosa and submucosa only involved

Mucosal ulcers (in 30% only) Inflammatory cell infiltrate

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Fissuring ulcers

Crypt abscesses

Lymphoid aggregates
Neutrophil infiltrates
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Question 6 of 298

Which one of the following conditions is most likely to be associated with gastric acid
hypersecretion?
A

Pernicious anaemia

B

Large-bowel resection

C

Vasoactive intestinal polypeptide- (VIP-) secreting tumour

D

Systemic mastocytosis

E

Cushing syndrome

Explanation
Gastric acid secretion
In the stomach, parietal cell acid secretion is stimulated by one of the three principal
mediators: gastrin, acetylcholine and histamine.
Several hormones in the small intestine inhibit gastrin and gastric acid secretion in vivo.
Resection of the small bowel leads to the removal of this inhibition and gastric acid
hypersecretion results. (Large-bowel resection has no effect on gastric acid secretion.)
Systemic mastocytosis is associated with increased histamine production.
In pernicious anaemia, gastrin levels are elevated in the presence of mucosal atrophy in
the body of the stomach; acid production is therefore reduced.
Steroid therapy and Cushing syndrome have been associated with peptic ulcer disease;
it has not been demonstrated that this possible relationship is due to gastric acid
hypersecretion, however.
Vasoactive intestinal polypeptide (VIP) inhibits gastric acid secretion and achlorhydria
is a feature of VIP-secreting tumours.
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Question 7 of 298

Which one of the following clinical findings is most suggestive of a pyogenic liver abscess
rather than an amoebic liver abscess?
A

Patient usually aged over 60

B

Recent bowel surgery

C

Raised white cell count

D

History of recent biliary colic and fever

E

Solitary abscess in the right lobe of the liver

Explanation
Liver abscess
In developed countries, liver abscess (commonly of bacterial origin) usually complicates
pre-existing biliary and gastrointestinal tract infections.
Pyogenic liver abscess is caused by enteric flora (Escherichia coli,Klebsiella) and
Staphylococcus aureus.
Unlike amoebic liver abscess, the symptoms of pyogenic abscess are those of a
systemic febrile illness lasting for only days to weeks and multiple abscesses are usually
identified on ultrasound examination of the liver.
A raised white cell count and other acute-phase reactants are common in both
conditions.
A solitary abscess in the right lobe of the liver is typical of amoebic liver abscess.
A history of chronic diarrhoea might be elicited in patients with amoebic liver abscess.
A history of recent biliary colic and fever is much more suggestive of cholecystitis.
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Question 8 of 298

Which one of the following disorders is most strongly associated with Helicobacter pylori
infection?
A

Non-ulcer dyspepsia

B

Reflux oesophagitis

C

Coeliac disease

D

Gastric lymphoma

E

Achalasia of the cardia

Explanation
Associations of Helicobacter pylori infection
Consequences of Helicobacter pylori infection include duodenal and gastric ulcer and their
complications (eg bleeding and perforation), atrophic gastritis, gastric cancer and mucosaassociated lymphoid tissue (MALT) lymphoma. Epidemiological studies have shown that 95%
of low-grade gastric MALT lymphomas are associated with H. pylori, and these lymphomas
have been shown to arise from B-cell clones at the site of H. pylori gastritis. Eradication of H.
pylori can produce clinical and histological remission of these tumours in 70–80% of cases,
but treated patients must be followed closely for residual or recurrent lymphoma.
Patients with a variety of upper gastrointestinal symptoms that have been called ‘non-ulcer
dyspepsia’ may or may not be infected with H. pylori; at present, however, there is no
generally recognised association of non-ulcer dyspepsia with H. pylori infection.
Several mechanisms operate in the pathogenesis of reflux oesophagitis but there is no
recognised association with H. pylori infection. More recently, it has also become evident that
individuals without H. pylori are at greater risk for gastroesophageal reflux disease and its
sequelae, Barrett’s oesophagus and adenocarcinoma of the oesophagus. Achalasia of the
cardia is a motility disorder leading to failure of relaxation of the lower end of the
oesophagus and is not associated with H. pylori infection. Coeliac disease is a malabsorption
syndrome due to gluten sensitivity; it is an autoimmnune disorder and is not associated with
H. pylori infection.

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Question 9 of 298

Which one of the following is accurate with regard to alcoholic liver disease?
A

Men are more susceptible than women

B

In alcoholic hepatitis the aspartate aminotransferase to alanine aminotransferase
(AST:ALT) ratio is 2:1

C

Hepatic iron overload is indicative of concomitant heterozygote haemochromatosis

D

Alcoholic fatty infiltration is irreversible once established

E

Unlike other causes of liver cirrhosis, alcoholic cirrhosis does not progress to
hepatoma

Explanation
Alcoholic liver disease
Alcoholic liver diseases include acute alcoholic hepatitis, chronic active hepatitis and
alcoholic cirrhosis.
Alcoholic liver disease is the most common cause of cirrhosis in developed countries.
Women are more susceptible to alcohol-related liver disease than men, even when
consumption is corrected for body weight.
Unlike viral hepatitis, alcoholic hepatitis is associated with a reversed AST:ALT ratio of
2:1.
Transferrin saturation and serum ferritin are commonly increased in alcoholic liver
disease and minor degrees of iron overload are common.
Alcoholic hepatitis and alcoholic fatty infiltration are reversible with abstinence and
adequate nutrition.

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Question 10 of 298

Which one of the following conditions is expected to be associated with normal urinary Dxylose test findings?
A

Coeliac disease

B

Chronic pancreatitis

C

Blind loop syndrome

D

Chronic renal failure

E

Liver cirrhosis with ascites

Explanation
D-xylose test
This test distinguishes between malabsorption due to small-intestinal diseases and
malabsorption due to pancreatic exocrine insufficiency. A 5-hour urinary excretion of 5 g or
greater is normal following the oral administration of 25 g of D-xylose to a well-hydrated
subject.
Decreased xylose absorption and excretion are found:
In patients with damage to the proximal small intestine
When there is bacterial overgrowth in the small intestine (the bacteria catabolise the
xylose)
Patients with pancreatic steatorrhoea usually have normal xylose absorption. Abnormal
results might be encountered in renal failure, in the elderly and in patients with ascites due to
an excretion defect rather than malabsorption.
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Question 11 of 298

In a patient with liver cirrhosis, which one of the features listed below is characteristic of
portal hypertension?
A

Jaundice

B

Gynaecomastia

C

Spider telangiectases

D

Hepatomegaly

E

Oesophageal varices

Explanation
Portal hypertension
The liver receives approximately 1500 ml of blood each minute, two-thirds of which is
provided by the portal vein. Portal hypertension is present when the wedged hepatic vein
pressure is more than 5 mmHg higher than the inferior vena cava pressure. Because the veins
in the portal system lack valves, increased resistance to flow at any point between the
splanchnic venules and the heart will increase the pressure in all vessels on the intestine site
of the obstruction. This is manifest clinically by the development of porto-systemic collaterals
(oesophageal varices), splenomegaly and/or ascites.
Spider telangiectases, jaundice, hepatomegaly and gynaecomastia are manifestations of
abnormal liver cell function.
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Question 12 of 298

You are asked by a GP to review a 16-year-old girl who appears tremulous, with some
evidence of ataxia. She also has dysarthria, which has developed over time. Otherwise she
appears relatively well. You carry out some screening tests: the alanine aminotransferase
(ALT) is elevated, the serum caeruloplasmin is low and there is increased urinary copper
excretion.
Which diagnosis fits best with this clinical picture?
A

Abuse of alcohol

B

Wilson’s disease

C

Menke’s disease

D

Drug abuse

E

Haemochromatosis

Explanation
Wilson’s disease
Wilson’s disease has a prevalence of 1 in 30,000, with an equal sex distribution. The onset of
symptoms has been described in patients aged between 3 and 40 years. They can present
acutely with so-called ‘fulminant Wilson’s disease’, with a hepatitic picture, malaise, anorexia,
nausea and jaundice. Alternatively, they can present with a more chronic picture, with
neurological symptoms (as in this case), symptoms of chronic cirrhosis, or occasionally with
psychiatric disorders such as depression or obsessive-compulsive disorder.
Diagnosis and treatment
The diagnosis is based on abnormal liver function tests, increased urinary copper excretion
and decreased serum caeruloplasmin. Liver biopsy at an early stage might reveal focal
necrosis and hepatic steatosis. Late biopsy reveals cirrhosis. The liver copper content is
usually more than five times the upper limit of normal. Wilson’s disease is treated with
penicillamine, which acts as a copper chelator.
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Question 13 of 298

A 34-year-old publican was admitted from the Emergency Department. His wife said that he
had been suffering from confusion for around 24–48 hours. On examination, there were
obvious signs of chronic liver disease as well as nystagmus and cerebellar ataxia. He
appeared very confused. Investigations showed an abnormal alanine aminotransferase (ALT),
mildly raised bilirubin levels and an alkaline phosphatase level just above the upper limit of
normal. His full blood count and glucose are normal.
Which diagnosis fits best with this clinical picture?
A

Wernicke’s encephalopathy

B

Acute alcohol poisoning

C

Drug abuse

D

Urinary sepsis

E

Subdural haematoma

Explanation
Wernicke’s encephalopathy
This neurological picture, with no localising signs but in the presence of signs of chronic liver
disease, is likely to be related to Wernicke’s encephalopathy. The precipitating cause in this
case is probably chronic liver disease secondary to alcohol abuse. If there had been a history
of head injury, subdural haematoma would have been an alternative diagnosis. Computed
tomography often reveals evidence of cerebral atrophy secondary to chronic alcoholism in
patients with Wernicke’s encephalopathy.
Management is 100 mg thiamine, intravenously or intramuscularly, followed by oral thiamine
replacement to correct the thiamine deficiency. Untreated, this condition can become
chronic.
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