Gastroenterology Module 3

A 24-year-old woman presents to the emergency department with jaundice, severe abdominal pain, and confusion. Her family reports that she has been increasingly lethargic over the past week. Laboratory tests reveal severe coagulopathy and hepatic encephalopathy. Haemolysis is indicated by a sudden drop in haemoglobin and haptoglobin levels, and her renal function tests show signs of acute kidney injury.

Her liver function tests show moderately elevated aminotransferases, a low alkaline phosphatase, and high bilirubin. Notably, the ratio of alkaline phosphatase (U/L) to total bilirubin (mg/dL) is less than 4, and the aspartate aminotransferase-to-alanine aminotransferase ratio is greater than 2.2.

What is the most likely diagnosis for this patient’s condition?

What is the recommended initial approach for managing metabolic dysfunction-associated steatohepatitis (MASH)?

A 55-year-old woman consults her gastroenterologist because of recent onset of intermittent dysphagia for solids. She has a history of gastro-oesophageal reflux proven by endoscopy, for which she is on proton pump inhibitor therapy. Her health is otherwise good and her reflux symptoms have been well controlled. She has not lost any weight. She is a smoker, but rarely consumes alcohol. The physical examination is unremarkable.

The next most appropriate course of action is:

Which of the following is the most important pathogenic factor in gastro-oesophageal reflux disease?

A 75-year-old woman presents with a three-week history of episodic severe epigastric pain and vomiting. The pain lasts for about three hours and radiates to the right upper quadrant and back. Apart from episodic nausea, she is well between attacks of pain. Past medical history includes a cholecystectomy nine years ago, peptic ulcer disease secondary to non-steroidal anti-inflammatory drugs three years ago, and type 2 diabetes mellitus diagnosed four years ago.

The most likely diagnosis is:

A 60-year-old man presents with worsening dysphagia for solid and liquid food. Manometry shows a failure of the lower oesophageal sphincter (LOS) relaxation, leading to increased residual pressure in the LOS during swallowing.

The most likely diagnosis is:

The most likely diagnosis is:

An otherwise well 55-year-old woman undergoes upper endoscopy for investigation of mild reflux symptoms. Biopsies demonstrate intestinal metaplasia with high-grade dysplasia and no inflammation.

The most appropriate management is:

A previously well 64-year-old man presents with symptoms of gastro-oesophageal reflux disease. He is on no current medications. Gastroscopy demonstrates Barrett’s oesophagus with erosive oesophagitis above the squamocolumnar junction. Random biopsies are reported as demonstrating dysplastic epithelium with features of active inflammation.

The most appropriate next step in management is:

The risk factor with the greatest impact on the development of oesophageal adenocarcinoma is:

A 15-year-old boy with severe spastic quadriplegia is referred for consideration of placement of a gastrostomy tube to aid with feeding. He has scoliosis and chronic lung disease.

Which one of the following factors would be a relative contraindication to percutaneous endoscopic gastrostomy (PEG) tube placement in this patient?

A 38-year-old woman is evaluated for elevated liver chemistry tests detected during evaluation for new-onset fatigue, joint pains, and jaundice. The patient recently started a job in a hospital and received a hepatitis B vaccination. She has a history of hypothyroidism, and her only medications are levothyroxine and a multivitamin. She has never used illicit drugs and does not drink alcohol. Her mother has rheumatoid arthritis.

On physical examination, the patient is afebrile; the blood pressure is 130/75 mmHg, the pulse rate is 80/min, and the respiration rate is 14/min. The BMI is 26. There is scleral icterus; the rest of the examination is normal.

Laboratory studies:

• Leucocyte count: 3400/µL (3.4 × 10⁹/L) with a normal differential
• Bilirubin (total): 6.0 mg/dL (102.6 µmol/L)
• Bilirubin (direct): 3.6 mg/dL (61.6 µmol/L)
• AST: 890 U/L
• ALT: 765 U/L
• ALP: 120 U/L
• Antinuclear antibody (ANA): Titre 1:40
• Anti-smooth muscle antibody (ASMA): Titre 1:640
• Antimitochondrial antibody (AMA): Negative
• Viral serological tests: Negative

Which of the following is the most likely diagnosis?

A 45-year-old man with a family history of ischaemic heart disease is diagnosed with hypertension and hypercholesterolaemia. He is started on aspirin 150 mg daily, atorvastatin 20 mg nocte, and atenolol 50 mg daily. Eight weeks later, he is reviewed and complains of some lethargy and itching. His blood pressure is 120/70 mmHg. He is noted to be icteric. There are no other findings on physical examination.

Blood investigations:

• WCC: 5.6 × 10⁹/L [4.0–9.0]
• Hb: 142 g/L [130–175]
• Platelets: 468 × 10⁹/L [150–450]
• PT-INR: 1.0 [0.9–1.1]
• Bilirubin: 103 µmol/L [3–21]
• ALT: 610 U/L [5–40]
• AST: 358 U/L [5–40]
• ALP: 540 U/L [30–115]
• GGT: 746 U/L [<65]
• Albumin: 40 g/L [38–50]
• HBsAg: Negative
• Anti-HCV: Negative
• Ferritin: 356 µg/L [25–200]
• ANA: Negative; AMA: Negative; ASMA: Negative

Abdominal ultrasound: Non-dilated bile ducts. Normal gallbladder with no calculi.

The most likely explanation for the abnormal liver function tests is:

A 20-year-old woman presents with a one-month history of malaise, nausea, abdominal pain, pruritus, and polyarthralgia. She gives no history of recent use of prescribed or illicit drugs. Examination reveals jaundice, multiple bruises, and tender hepatomegaly. Laboratory results are consistent with an acute hepatocellular injury, with a polyclonal increase in IgG of 32 g/L [6.1–15.5].

Serological tests for hepatitis A, B, and C viruses are negative. Histopathological findings on liver biopsy show a periportal mixed mononuclear cell infiltrate of plasma cells, lymphocytes, and eosinophils consistent with autoimmune hepatitis.

Which of the following autoantibodies, if present, is most predictive of a poor clinical and biochemical response to therapy?

A 16-year-old girl presents with jaundice, arthralgia, and pruritus over the past week. She has recently returned from a trip to South-East Asia.

Her liver function and serology results are shown below:

• Bilirubin: 175 µmol/L [0–15]
• ALT: 1350 U/L [<55]
• ALP: 687 U/L [100–350]
• GGT: 425 U/L [0–40]
• Total protein: 70 g/L [57–80]
• Albumin: 24 g/L [33–47]
• EBV-IgG: Positive
• EBV-IgM: Negative
• HAV-IgM: Negative
• HBsAg: Negative
• Anti-HBc: Positive
• Anti-HCV: Negative
• ANA: Negative
• Smooth muscle antibody: Positive

What is the most likely diagnosis?

A 34-year-old woman is evaluated for continued severe mid-epigastric pain that radiates to the back, nausea, and vomiting 5 days after being hospitalised for acute alcohol-related pancreatitis. She has not been able to eat or drink and has not had a bowel movement since being admitted.

On physical examination, the temperature is 38.2°C, blood pressure 132/84 mmHg, pulse 101/min, respirations 20/min. There is no scleral icterus or jaundice. The abdomen is distended and diffusely tender with hypoactive bowel sounds.

Laboratory studies:

• Leucocyte count: 15,400/µL (15.4 × 10⁹/L)
• AST: 189 U/L
• ALT: 151 U/L
• Bilirubin (total): 1.1 mg/dL (18.8 µmol/L)
• Amylase: 388 U/L
• Lipase: 924 U/L

CT scan of the abdomen shows a diffusely oedematous pancreas with multiple peripancreatic fluid collections and no evidence of pancreatic necrosis.

Which of the following is the most appropriate next step in management?

A 72-year-old woman presents with severe diarrhoea. She was commenced on oral amoxicillin for an upper respiratory tract infection five days ago.

Which one of the following tests would best confirm a diagnosis of Clostridioides difficile-induced pseudomembranous colitis?

A physician becomes ill with nausea and vomiting four hours after attending a pharmaceutical company-sponsored dinner.

Which of the following is the likely culprit organism?

A 65-year-old man on chronic haemodialysis complains of crampy lower abdominal pain and passes blood per rectum three times over two hours. Colonoscopy demonstrates normal rectal mucosa and inflammation from the proximal sigmoid to the transverse colon.

The most likely cause of the inflammation is:

What is the purpose of the faecal microbiota oral capsule (SER-109; VOWST) that was approved in 2023?

A 42-year-old woman is evaluated for a 20-year history of constipation. She has approximately one or two bowel movements per week consisting of lumpy or hard stool. She strains at defecation and has a sense of incomplete evacuation after a bowel movement. She does not have bloody stool, abdominal pain or discomfort, weight loss, or diarrhoea. She is otherwise healthy, and her only medication is an occasional over-the-counter laxative or stool softener.

On physical examination, vital signs are normal. Anorectal tone is normal, and on rectal examination, the patient is able to expel the examiner’s finger when asked to mimic a bowel movement. Laboratory studies are normal. Radiopaque marker study shows delayed transit time through the right colon.

Which of the following is the most likely diagnosis?

A 50-year-old man with alcohol-induced cirrhosis and portal hypertension presents with haematemesis. He is found to have grade IV oesophageal varices. Bleeding is controlled by an infusion of octreotide and endoscopic rubber band ligation.

On discharge, which one of the following is least likely to be of benefit with respect to recurrent variceal bleeding?

Which of the following is most predictive of variceal haemorrhage in a patient with oesophageal varices?

A 65-year-old man with cirrhosis has significant (grade 2 of 3) oesophageal varices detected on screening endoscopy. Unfortunately, he did not tolerate the gastroscopy that well and clearly expressed his reluctance to pursue any invasive procedures in the future, unless completely necessary.

Which of the following is the most appropriate initial management?

In the acute management of an oesophageal variceal bleed, which of the following interventions is least likely to control the bleeding?

A 45-year-old man with alcohol-related liver disease presents with his first oesophageal variceal bleed. His acute bleeding is controlled with endoscopic band ligation.

Which one of the following is the most appropriate management strategy to prevent recurrent bleeding?

Which of the following is an absolute contraindication to liver transplant?