Gastroenterology Module 2

According to a recent study on early-onset colorectal cancer (CRC), which group of symptoms were identified as red-flag signs for the disease in individuals younger than 50 years?

The following are risk factors for oesophageal adenocarcinoma EXCEPT:

A 19-year-old woman is evaluated for a 2-week history of nausea and new-onset jaundice. Six weeks ago, she had an uncomplicated cystitis, which resolved after a 3-day course of therapy with trimethoprim-sulfamethoxazole.

On physical examination, the temperature is 37.3°C, the blood pressure is 120/85 mmHg, the pulse rate is 88/min, and the respiration rate is 14/min; the BMI is 31. There is conjunctival icterus, jaundice, and right upper quadrant tenderness on deep palpation. Murphy sign is not elicited, and there is no asterixis or stigmata of chronic liver disease. Stool is negative for occult blood.

Laboratory studies:

• Leukocyte count: 7.8 × 10⁹/L (normal differential)
• Total bilirubin: 205 μmol/L [<20]
• Direct bilirubin: 96 μmol/L [<5]
• Aspartate aminotransferase (AST): 23 U/L
• Alanine aminotransferase (ALT): 35 U/L
• Alkaline phosphatase (ALP): 464 U/L [30-115]
• Antinuclear antibody (ANA): Negative
• Anti-smooth muscle antibody (ASMA): Negative
• Antimitochondrial antibody (AMA): Negative

Ultrasonography of the right upper quadrant shows normal calibre hepatic ducts, a normal gallbladder without wall thickening, and no cholelithiasis.

What is the most likely diagnosis?

Which of the following drug does NOT have a role in maintaining remission in ulcerative colitis?

Vedolizumab is a monoclonal antibody approved for the treatment of ulcerative colitis and Crohn’s disease. What is the primary target of this medication?

The following medications are all considered low risk for pregnant patients with IBD EXCEPT:

A 35-year-old woman is evaluated for symptomatic ulcerative colitis. One year ago, she was diagnosed with pan-ulcerative colitis and responded well to initial and maintenance therapy with mesalazine.

However, 2 months ago she developed urgent bloody diarrhoea several times a day and lower abdominal cramping; prednisone, 40 mg/d, alleviated her acute symptoms, but her symptoms have returned with prednisone tapering.

The patient is otherwise healthy. Her medications are mesalazine, prednisone 15 mg/d, and calcium with vitamin D.

On physical examination, vital signs and other findings are normal. Laboratory studies reveal haemoglobin 114 g/L and plasma glucose 7.77 mmol/L.

Stool analysis for Clostridioides difficile toxin A and B is negative.

Which of the following is the most appropriate next step in the treatment of this patient?

A 35-year-old man with longstanding ulcerative colitis has quiescent disease. He is on a maintenance regimen of sulfasalazine 1 g bd and azathioprine 100 mg/day. At a routine follow-up visit, he reports feeling well, with two formed stools a day and no blood or mucus. Physical examination is normal.

Blood tests reveal:

• Bilirubin: 20 μmol/L [3–21]
• Alkaline phosphatase: 549 U/L [30–115]
• Gamma-glutamyltransferase (GGT): 980 U/L [<65]
• Aspartate transaminase (AST): 85 U/L [5–40]
• Alanine transaminase (ALT): 76 U/L [5–40]
• Total protein: 67 g/L [60–85]
• Albumin: 37 g/L [40–52]
• White cell count: 5.4 × 10⁹/L [4.0–11.0]
• Haemoglobin: 115 g/L [120–160]
• Platelet count: 156 × 10⁹/L [150–400]

His liver function tests were normal two years ago. Abdominal ultrasound shows a normal-sized liver with non-dilated bile ducts. The gallbladder is normal with no calculi.

The most likely cause for these results is:

A patient with cirrhosis and Child–Pugh class A presents with acute upper gastrointestinal bleeding without clinical evidence of haemorrhagic shock.

Which of the following interventions would likely lead to improved survival?

A 46-year-old man has had pancolonic ulcerative colitis since age 23. He has had colonoscopies every two years for the last six years. He has been asymptomatic for three years, and has been prescribed sulfasalazine 1 g twice daily, which he often forgets to take.

Biopsies show chronic active mucosal inflammation with high-grade epithelial dysplasia.

The most appropriate management is:

The combination of infliximab and azathioprine for moderate-to-severe ulcerative colitis, as demonstrated in the UC-SUCCESS trial, was shown to result in all of the following EXCEPT:

For which of the following presentations of inflammatory bowel disease is infliximab of most established benefit?

A 16-year-old female was diagnosed with ulcerative colitis at the age of 12. Her disease was fairly well controlled, initially with steroids and subsequently on maintenance sulfasalazine. Over the last six months, she has complained of poor concentration, tiredness, and vague upper abdominal pain.

Blood investigations:

• ALT: 80 IU/L [<40]
• ALP: 660 IU/L [30–120]
• GGT: 332 IU/L [<40]
• Total Bilirubin: 6 μmol/L [<20]
• ANA: Positive (titre 1:80)
• Anti-smooth muscle antibody: Negative
• Anti-liver kidney microsomal antibody: Negative

What condition does this patient most likely have?

A 25-year-old patient with chronic hepatitis B infection and advanced liver disease (cirrhosis) wishes to become pregnant.

Which of the following is the most appropriate advice regarding her HBV treatment?

A 35-year-old man presents to your office four months after resection of 50 cm of terminal ileum for Crohn’s disease. He has been well but complains of excessive diarrhoea, especially in the morning. The motions have been watery, without blood or mucus.

A recent colonoscopy showed no evidence of colitis or enteritis, and the anastomosis appeared healthy. He is currently on no medications.

Physical examination reveals a well-healed scar, no tenderness in the abdomen, and normal bowel sounds. Stool cultures are negative.

The most appropriate treatment is:

The Schilling test was historically used to determine the cause of vitamin B12 malabsorption. Unfortunately, it is no longer commercially used due to the unavailability of radiolabelled cobalt and for practical reasons.

However, assuming a patient undergoes a Schilling test because of vitamin B12 deficiency and the following results are obtained:

• Low vitamin B12 absorption without intrinsic factor
• Normal vitamin B12 absorption with intrinsic factor
• Low vitamin B12 absorption with antibiotic but without intrinsic factor

What could be the underlying pathology?

A 69-year-old woman presents with severe pancytopenia and peripheral blood macrocytosis associated with a low serum vitamin B12 level.

Which one of the following investigation results most strongly supports a diagnosis of pernicious anaemia?

The laboratory finding that is most specific for the diagnosis of pernicious anaemia is:

Low serum vitamin B12 levels are LEAST likely to be seen in which one of the following?

Which of the following nutrients is predominantly absorbed in the duodenum and upper small intestine?

A 50-year-old female presents with tiredness. Her B12 level is found to be 125 pmol/L [130–600].

Which of the following is most indicative of clinical B12 deficiency?

Which of the following is NOT consistent with a diagnosis of functional constipation (Rome IV criteria)?

A 36-year-old woman presents with a 12-month history of lassitude, intermittent diarrhoea (watery, up to six times a day), colicky abdominal pain, bloating, and involuntary weight loss of 12 kg.

Blood tests reveal normal electrolytes, urea, creatinine, and liver function tests. Full blood count reveals mild anaemia (haemoglobin 110 g/L [120–160]); other indices are normal. Further tests show iron and folate deficiency.

Upper and lower gastrointestinal endoscopies are performed, and the mucosa appears normal macroscopically. Biopsies of the small bowel mucosa from the duodenum and terminal ileum shows villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes

What is the most likely diagnosis?

Which of the following is the most appropriate medication to maintain remission in moderate to severe ileo-colonic Crohn’s disease?

A 45-year-old woman has a history of terminal ileal Crohn’s disease for which she had a terminal ileal resection eight years ago. Surgery was complicated by small bowel leak postoperatively, requiring laparotomy and prolonged drainage with bowel rest (total parenteral nutrition).

Following recovery, she remained well until two weeks ago, when she presented with two episodes of abdominal pain, bloating, and vomiting lasting two to three hours each, then resolving spontaneously. There has been no change in bowel habit and no fever. She is on no medication.

Examination reveals mild tenderness in the lower abdomen. Bowel sounds are normal.

The most likely cause for her current symptoms is:

The most likely condition to adversely affect the liberation of dietary cobalamin from R-proteins (haptocorrins) is:

A 71-year-old man is evaluated for chronic epigastric discomfort, heartburn, and diarrhoea of 4 years’ duration. His weight has been stable. He has no significant medical history and takes no medications.

On physical examination, there is mild epigastric tenderness without rebound or guarding. Rectal examination reveals brown stool positive for occult blood. Laboratory studies reveal haemoglobin 123 g/L with a mean corpuscular volume of 75 fL. Helicobacter pylori serology is negative.

Oesophagogastroduodenoscopy shows prominent gastric folds, mild linear erosions, and multiple ulcers in the stomach and duodenum.

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

A 15-year-old girl undergoes gastroscopy for persistent epigastric pain. Nodular antral gastritis is found.

Curved gram-negative bacilli are seen on histology of the antral biopsy.

Which gastrointestinal malignancy has been most directly causally linked with this infection?

A 44-year-old woman is evaluated for a 6-month history of dyspepsia, regurgitation of sour fluid, and eructation. There is no associated fever, chills, weight loss, or vomiting. The symptoms failed to respond to a 6-week trial of omeprazole therapy. Her medical history includes hypertension, type 2 diabetes mellitus, and obesity (BMI 36). Medications: lisinopril, metformin, insulin glargine.

On examination, vital signs are normal; there is mild epigastric tenderness without rebound; stool is negative for occult blood.

She recently underwent an outpatient gastroscopy which was mostly unremarkable.

Which of the following is the most appropriate next diagnostic step?

The factor most commonly responsible for gastro-oesophageal reflux is: