UPPER GASTROINTESTINAL
TRACT DISORDERS
1. A 46-year-old teacher presented with a 5-month history of profuse diarrhoea despite fasting, and associated abdominal bloating. She complained of increasing fatigue and appeared dehydrated.
Investigations:
  haemoglobin 125 g/L (130–180)
  serum sodium 138 mmol/L (137–144)
  serum potassium 1.9 mmol/L (3.5–4.9)
  serum urea 7.3 mmol/L (2.5–7.0)
  serum creatinine 105 μmol/L (60–110)
  plasma viscosity 1.76 mPa/s (1.50–1.72)
Which of the following is the most likely diagnosis?
A. Bile salt malabsorption
B. Coeliac disease
C. Irritable bowel syndrome
D. Ulcerative colitis
E. VIPoma
2. A 43-year-old housewife with a history of ischaemic heart disease and a body mass index of 37 was referred for gastric bypass surgery. She was included in a research study investigating the eff ects of satiety hormones before Roux-en-Y gastric bypass.
Which of the following statements best describes the behaviour of ghrelin before and after meal ingestion?
A. Ghrelin level falls before meal ingestion but gradually rises in the next 2 hours
B. Ghrelin level remains unchanged
C. Ghrelin level rises sharply before and remains high after meal ingestion
D. Ghrelin level sharply rises before and falls shortly after meal ingestion
E. Ghrelin level unchanged before meal ingestion and fall rapidly afterwards
3. A 46-year-old man was reviewed in clinic with troublesome symptoms of refl ux occurring at any time of day, for the last 2 years. He had a gastroscopy six months ago which was normal. He had taken omeprazole 40 mg BD and metoclopramide 10 mg TDS for eight months. He had previously tried an H2-receptor antagonist in addition to this, with no benefi t. He had no lifestyle risk factors for refl ux.
What is the next most appropriate management step?
A. Ambulatory oesophageal pH and manometry studies
B. Barium swallow
C. Fasting gastrin level
D. Peripheral blood eosinophil count
E. Repeat endoscopy
4. A 58-year-old man underwent an OGD for investigation of refl ux symptoms. Macroscopically he was found to have an area suggestive of Barrett’s oesophagus. This was biopsied and his histology report was returned to you.
Which of the following histological features best supports the endoscopic diagnosis of Barrett’s oesophagus with no dysplasia?
A. Cardiac-type columnar cells bordering squamous mucosa
B. Columnar mucosa with nuclear pleomorphism in all cells seen
C. Gastric-type mucosa with a similarity in nuclear/cytological appearances in the crypt base cells to those at the surface epithelium
D. Increased foci of mitotic activity seen at the gastro-oesophageal junction
E. Intestinal metaplastic glandular mucosa with adjacent oesophageal ducts
5. A 58-year-old woman under surveillance for Barrett’s oesophagus was found to have high-grade dysplasia in four biopsies at gastroscopy. Repeat gastroscopy and further biopsies confi rmed this. The Barrett’s segment appeared uncomplicated macroscopically, and was circumferential and 5 cm in length (Prague C5M5). She was taking a high-dose proton pump inhibitor. She declined surgical intervention.
Which of the following is the most appropriate management step?
A. Argon plasma coagulation
B. Endoscopic mucosal resection
C. Laser ablation
D. Multipolar electrocoagulation
E. Radio-frequency ablation
6. A 72-year-old man presented with a 3-week history of dysphagia and was found to have a large oesophageal adenocarcinoma at 37 cm.
Which of the following is the most signifi cant predisposing factor in the pathogenesis of oesophageal adenocarcinoma?
A. Alcohol excess
B. Helicobacter pylori infection
C. Obesity
D. Smoking
E. Social deprivation
7. A 37-year-old Brazilian man who complained of chest pain was referred to the gastroenterology clinic by cardiology. He had a history of episodic dysphagia and occasional regurgitation; his GP had adequately trialled PPI and prokinetics.
Investigations:
  gastroscopy                 normal
oesophageal pH studies       DeMeester score 11
oesophageal motility studies   simultaneous high-amplitude contractions with 40% of
                             swallows, but intermittently normal peristaltic waves and
                             a high resting pressure at the lower oesophageal sphincter
                             (LOS). There is normal relaxation during swallowing
What is the most likely diagnosis?
A. Achalasia
B. Chagas disease
C. Diff use oesophageal spasm
D. Gastro-oesophageal refl ux disease
E. Nutcracker oesophagus
8. A 28-year-old Brazilian man who complained of chest pain was referred to the gastroenterology clinic by cardiology. He had a 1-year history of episodic dysphagia and occasional regurgitation; his GP had adequately trialled PPI and prokinetics. You organized gastroscopy, oesophageal manometry, and pH studies, the results of which have been reported as being consistent with achalasia. Protozoal serology is negative.
In this scenario, which of the following is the most appropriate fi rst-line management step?
A. Benznidazole
B. Botulinum toxin injection of the lower oesophageal sphincter
C. Surgery
D. Trial of calcium-channel blockers
E. Weight loss
9. A 70-year-old woman with a WHO performance status of 3 and COPD was found to have a 2 x 6 cm fl at adenocarcinoma of the oesophagus at 35 cm on OGD, not bordering the gastro-oesophageal junction.
Investigations:
  endoscopic ultrasound no evidence of lymphadenopathy
  CT abdomen and pelvis no evidence of lymphadenopathy, no distant metastases
Which is the next best option in her management?
A. Chemoradiotherapy
B. Endoscopic mucosal resection
C. Endoscopic submucosal dissection
D. Radiofrequency ablation
E. Surgery with pre-operative chemotherapy
10. A 56-year-old man presented with a 3-month history of intermittent vomiting. He had no past medical history, drank 10 units of alcohol a week, and was a non-smoker.
Investigations:
  gastroscopy 4 cm antral tumour
  histopathology adenocarcinoma
With regard to the initial staging of gastric cancer, which is the most useful modality as an adjunct to CT scanning?
A. Barium meal
B. Endoscopic mucosal resection
C. Endoscopic ultrasound
D. Laparoscopy
E. Magnetic resonance imaging
11. A 76-year-old man was referred by his GP for endoscopy complaining of a 6-month history of dyspepsia, despite adequate trials of a PPI. His Helicobacter pylori breath test was negative. His stepmother died from gastric carcinoma.
Among patients who are referred for gastroscopy for alarm features, the prevalence of gastric cancer is most appropriately described as:
A. 0.8%
B. 4%
C. 16%
D. 28%
E. 32%
12. A 33-year-old woman of Indian origin was referred for endoscopy with dyspepsia. This had been resistant to omeprazole 20 mg orally daily and metoclopramide 10 mg three times daily, which she was taking at the time of gastroscopy. She was on no other medications.
Investigations:
  gastroscopy antral erosions and three large duodenal
  ulcers in D1 (Forrest class III)
  antral rapid urease test negative
  haemoglobin 138 g/L (130–180)
  plasma viscosity 1.70 mPa/s (1.50–1.72)
  serum C-reactive protein 8 mg/L (< 10)
  plasma gastrin 90 pmol/L (<55)
Which of the following is the most likely diagnosis?
A. Crohn’s disease
B. Helicobacter pylori infection
C. Human immunodefi ciency virus
D. Tuberculosis
E. Zollinger–Ellison syndrome
13. A 75-year-old man with a coff ee ground vomit was referred for an OGD on your list. His notes state that he had a Billroth II procedure 20 years ago.
Which of the following most accurately describes his surgery?
A. Division of the vagus nerve and a gastrojejunostomy
B. Division of the vagus nerve and lateral division of the pylorus, followed by longitudinal resuturing
C. Formation of gastric pouch; small bowel divided at the duodenal-jejunal junction; anastomosis of the jejunum to the gastric pouch; anastamosis of the duodenum to the small bowel distal to the jejunal anastamosis
D. Longitudinal division of the pylorus
E. Resection of gastric antrum, gastrojejunostomy and closure of the fi rst part of the duodenum and gastric outfl ow
14. A 76-year-old man presenting with dysphagia was found to have inoperable oesophageal adenocarcinoma. He has an endoscopically placed oesophageal stent for palliation of his symptoms, but unfortunately found it very painful, and it was removed a few days later. There is no perforation. He asks whether there are any other treatment options to help with his symptoms.
Which of the following modalities is an appropriate fi rst-line treatment option to discuss?
A. Band ligation
B. Botulinum toxin injection
C. Brachytherapy
D. Local ethanol injection
E. Photodynamic therapy
15. A 72-year-old man was admitted with a 1-day history of melaena. He had no relevant past medical history and took no regular medications.
What percentage of patients who are admitted with apparent acute upper gastrointestinal bleeding do not reveal a cause at initial gastroscopy?
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%
16. A previously fi t and well 35-year-old woman, who was on an SSRI for depression, took high doses of ibuprofen for rheumatoid arthritis. She was subsequently diagnosed with an upper GI bleed. At endoscopy she had a bleeding gastric ulcer with an adherent clot which was treated with adrenaline and heater probe. The endoscopist was satisfi ed that haemostasis was optimally achieved. A Helicobacter pylori test was not performed. She was stable following her endoscopy, and returned to the ward.
Regarding her post-endoscopic care, which of the following most accurately represents current guidelines?
A. Change her ibuprofen to naproxen
B. Consider switching from an SSRI to an alternative antidepressant
C. Empirical Helicobacter pylori eradication therapy for 1 week
D. High-dose IV PPI infusion for 48 hours
E. Oral PPI indefi nitely after discharge
17. A 37-year-old woman with stigmata of chronic liver disease was admitted on the acute medical take with fresh red haematemesis. She was adequately fl uid resuscitated and received terlipressin and IV antiobiotics prior to an urgent OGD. She had three bleeding oesophageal varices at endoscopy, and six bands were applied at multiple sites. There were no gastric varices. Post procedure she continued to have fresh haematemesis.
What is the defi nitive treatment of choice?
A. Balloon tamponade
B. H-graft portocaval shunting
C. Laparotomy
D. Repeat endoscopy and radiofrequency ablation
E. Transjugular intrahepatic portosytemic shunt (TIPSS)
18. A 40-year-old man with known gastric varices was admitted with melaena. He was resuscitated with blood and fl uids and started on terlipressin and broad-spectrum antibiotics. His gastric varices were injected with cyanoacrylate glue.
Why is glue considered to be the fi rst-line treatment for bleeding gastric varices?
A. It has a lower risk of mortality than TIPSS
B. It has a lower risk of re-bleeding than TIPSS
C. It is better at achieving haemostasis than TIPSS
D. It is more cost-eff ective than TIPSS
E. It leads to a lower requirement for blood transfusions than TIPSS
19. A 68-year-old man with a background history of Parkinson’s disease on levodopa was admitted with vomiting and abdominal pain.
Which of the following anti-emetics is the fi rst-line treatment for nausea and vomiting in patients with Parkinson’s disease?
A. Domperidone
B. Haloperidol
C. Metoclopromide
D. Ondansetron
E. Prochlorperazine
20. A 45-year-old woman attended her general practitioner with recurrent nausea and vomiting associated with travel. She had tried cyclizine to no eff ect.
What is the next choice of medication for her motion sickness?
A. Betahistine
B. Hyoscine
C. Metoclopromide
D. Ondansetron
E. Prochlorperazine
21. A 32-year-old woman with type 1 diabetes mellitus attended the nutrition outpatient clinic with persistent bloating, nausea, and vomiting. She was diagnosed with gastroparesis on the basis of gastric emptying studies, and had tried prokinetics for the last 3 months, but with only marginal eff ect. She is struggling to maintain her weight. Her most recent HbA1C was 5.8% (range 4.0–6.0%).
What would be the most appropriate next step to consider in management?
A. Botulinum injection to pylorus
B. Gastric pacemaker device
C. Nasojejunal feeding
D. Pancreatic islet cell transplantation
E. Surgical jejunostomy
22. A 34-year-old man presented with symptoms suggestive of delayed gastric emptying.
With regard to the physiology of gastric emptying, which of the following cells are responsible for controlling the slow-wave phase in the distal stomach?
A. Chief cells
B. Enterochromaffi n cells
C. Interstitial cells of Cajal
D. Mucous neck cells
E. Parietal cells
