Gastroenterology Prometric exam questions with answers

1. Question 1Oesophageal Diseaseseasy

   A 24-year-old man with asthma and seasonal rhinitis presents with a food bolus impaction, his third episode of dysphagia to meat this year. Endoscopy shows concentric rings, linear furrows and white exudates. Which histological finding on oesophageal biopsies confirms the most likely diagnosis?

   1. AIntraepithelial neutrophils with basal cell hyperplasia
   2. BIntestinal metaplasia with goblet cells
   3. CAt least 15 eosinophils per high-power field
   4. DMultinucleated giant cells with nuclear inclusions
   Show answer and explanation▾

   Answer: C. At least 15 eosinophils per high-power field

   Eosinophilic oesophagitis is diagnosed by symptoms of oesophageal dysfunction with at least 15 eosinophils per high-power field on oesophageal biopsy, after considering other causes of oesophageal eosinophilia; multiple biopsies from the proximal and distal oesophagus are recommended. Rings, furrows and exudates are its typical endoscopic features. Neutrophilic infiltration suggests reflux or infection, and multinucleated cells with inclusions suggest herpes oesophagitis.

2. Question 2Gastric and Duodenal Diseases and Helicobacter pylorimedium

   A 58-year-old woman with dyspepsia has gastric biopsies showing low-grade marginal zone (MALT) lymphoma confined to the stomach wall, and Helicobacter pylori is present. Staging shows no nodal or distant disease, and there is no t(11;18) translocation. What is the most appropriate first-line treatment?

   1. AH. pylori eradication therapy with endoscopic follow-up
   2. BPartial gastrectomy
   3. CR-CHOP chemotherapy
   4. DInvolved-site radiotherapy before eradication
   Show answer and explanation▾

   Answer: A. H. pylori eradication therapy with endoscopic follow-up

   Localised H. pylori-positive gastric MALT lymphoma regresses in most patients after successful eradication, which is therefore first-line treatment, with repeat endoscopy and biopsies to confirm eradication and lymphoma regression. The t(11;18) translocation predicts resistance to eradication, and radiotherapy is used for persistent disease or H. pylori-negative cases. Surgery is no longer used as primary treatment, and R-CHOP is for transformed or advanced disease.

3. Question 3Gastrointestinal Bleedingmedium

   A 64-year-old man taking naproxen presents with melaena. After resuscitation he is haemodynamically stable. Endoscopy shows a 10 mm duodenal ulcer with a flat pigmented spot and no visible vessel, clot or active bleeding. What is the most appropriate management?

   1. ADual endoscopic therapy with adrenaline injection and clips
   2. BThermal coagulation of the pigmented spot
   3. CRepeat endoscopy at 24 hours to confirm healing
   4. DNo endoscopic therapy, with oral PPI and early feeding
   Show answer and explanation▾

   Answer: D. No endoscopic therapy, with oral PPI and early feeding

   A flat pigmented spot (Forrest IIc) carries a low risk of rebleeding, so endoscopic haemostasis is not indicated; the patient can eat early, take oral proton pump inhibitor therapy and be considered for early discharge, with NSAID withdrawal and H. pylori testing. Endoscopic therapy is indicated for active bleeding (Forrest Ia and Ib) and non-bleeding visible vessels (IIa). Routine second-look endoscopy is not recommended.

4. Question 4Pancreatic Diseasesmedium

   A 46-year-old woman with gallstone pancreatitis develops acute kidney injury on day 1, with creatinine 210 micromol/L, which returns to normal within 24 hours of fluid resuscitation. CT on day 5 shows an acute peripancreatic fluid collection without necrosis. Using the revised Atlanta classification, how should the severity be classified?

   1. AMild acute pancreatitis
   2. BModerately severe acute pancreatitis
   3. CSevere acute pancreatitis
   4. DCritical acute pancreatitis
   Show answer and explanation▾

   Answer: B. Moderately severe acute pancreatitis

   The revised Atlanta classification defines mild pancreatitis as having no organ failure and no local or systemic complications, moderately severe as transient organ failure resolving within 48 hours and/or local or systemic complications, and severe as persistent organ failure lasting more than 48 hours. This patient had transient renal failure and a local complication, so the attack is moderately severe. The critical category belongs to the separate determinant-based classification, not the revised Atlanta system.

5. Question 5Biliary Tract and Gallbladder Diseasemedium

   A 52-year-old woman has biliary colic and mildly deranged liver tests. Transabdominal ultrasound shows gallstones and a 7 mm stone within a 10 mm common bile duct. She has no fever. According to ASGE risk stratification, what is the most appropriate next step?

   1. AMRCP to confirm the stone before any intervention
   2. BEndoscopic ultrasound for further risk stratification
   3. CERCP with stone extraction, followed by cholecystectomy
   4. DLaparoscopic cholecystectomy alone without duct assessment
   Show answer and explanation▾

   Answer: C. ERCP with stone extraction, followed by cholecystectomy

   A common bile duct stone seen on ultrasound places the patient in the high-risk group for choledocholithiasis, so ERCP with stone clearance (or surgical bile duct exploration where expertise exists) is indicated without further imaging, followed by cholecystectomy. MRCP or EUS is recommended for intermediate-risk patients, such as those with abnormal liver tests or a dilated duct but no visualised stone. Cholecystectomy without addressing the duct risks retained stones, cholangitis and pancreatitis.

6. Question 6Biliary Tract and Gallbladder Diseaseeasy

   A 50-year-old man has an incidental 12 mm sessile gallbladder polyp on ultrasound, with no gallstones and no symptoms. What is the most appropriate management?

   1. ACholecystectomy
   2. BRepeat ultrasound in 12 months
   3. CNo further follow-up
   4. DUrsodeoxycholic acid therapy
   Show answer and explanation▾

   Answer: A. Cholecystectomy

   Gallbladder polyps of 10 mm or more carry a meaningful risk of being neoplastic, and cholecystectomy is recommended in fit patients. Polyps under 10 mm are usually managed with ultrasound surveillance, the interval depending on size and risk factors such as age over 50, primary sclerosing cholangitis, Indian ethnicity and sessile morphology. Ursodeoxycholic acid has no effect on polyps.

7. Question 7Chronic Liver Disease, Cirrhosis and Portal Hypertensionmedium

   A 57-year-old man with alcohol-related cirrhosis and ascites presents with abdominal discomfort and confusion. Diagnostic paracentesis shows an ascitic neutrophil count of 520 cells/mm3. Creatinine is 125 micromol/L and bilirubin 70 micromol/L. Intravenous cefotaxime is started. Which additional treatment reduces renal failure and mortality?

   1. ALarge-volume paracentesis to dryness
   2. BIntravenous furosemide
   3. CIntravenous terlipressin
   4. DIntravenous albumin on day 1 and day 3
   Show answer and explanation▾

   Answer: D. Intravenous albumin on day 1 and day 3

   In spontaneous bacterial peritonitis, intravenous albumin 1.5 g/kg at diagnosis and 1 g/kg on day 3 reduces hepatorenal syndrome and mortality, particularly when creatinine or bilirubin is raised. Diuretics should be held during SBP because they increase the risk of renal failure, and large-volume therapeutic paracentesis is avoided in the acute phase. Terlipressin is reserved for established hepatorenal syndrome with acute kidney injury.

8. Question 8Chronic Liver Disease, Cirrhosis and Portal Hypertensionhard

   A 60-year-old man with compensated cirrhosis from metabolic dysfunction-associated steatotic liver disease has a liver stiffness of 32 kPa and a platelet count of 115 x 10^9/L. He has never bled and has no ascites. Following Baveno VII, which management is most appropriate?

   1. AScreening endoscopy, with band ligation only if large varices are found
   2. BStart carvedilol to prevent decompensation
   3. CRepeat elastography in 12 months and treat only if varices bleed
   4. DTransjugular intrahepatic portosystemic shunt to lower portal pressure
   Show answer and explanation▾

   Answer: B. Start carvedilol to prevent decompensation

   A liver stiffness of 25 kPa or more indicates clinically significant portal hypertension in compensated advanced chronic liver disease, and Baveno VII recommends a non-selective beta-blocker, preferably carvedilol, to prevent decompensation rather than solely to prevent variceal bleeding. Patients started on a beta-blocker do not need screening endoscopy unless beta-blockers are contraindicated or not tolerated. TIPS has no role as prophylaxis.

9. Question 9Viral Hepatitis, Acute Liver Injury and Transplantationhard

   A 64-year-old man with diffuse large B-cell lymphoma is to start R-CHOP. Hepatitis B serology shows HBsAg negative, anti-HBc positive and anti-HBs positive, with undetectable HBV DNA. Liver tests are normal. What is the most appropriate management?

   1. ANo action, as anti-HBs indicates immunity
   2. BA hepatitis B vaccine booster before chemotherapy
   3. CProphylactic entecavir or tenofovir during and after rituximab therapy
   4. DHBV DNA monitoring starting after chemotherapy is complete
   Show answer and explanation▾

   Answer: C. Prophylactic entecavir or tenofovir during and after rituximab therapy

   Anti-CD20 therapy such as rituximab carries a high risk of hepatitis B reactivation even in HBsAg-negative, anti-HBc-positive patients, and the presence of anti-HBs does not reliably prevent it. Guidelines recommend prophylaxis with a high-barrier antiviral such as entecavir or tenofovir, started before or with chemotherapy and continued for at least 12 months after the last rituximab dose. Monitoring without prophylaxis is reserved for lower-risk regimens, and vaccination does not prevent reactivation.

10. Question 10Inflammatory Bowel Diseasehard

    A 29-year-old woman with acute severe ulcerative colitis is on day 3 of intravenous hydrocortisone 100 mg four times daily. She has 9 bloody stools a day and a CRP of 62 mg/L. Infection, including CMV and C. difficile, has been excluded and an abdominal radiograph shows no colonic dilatation. What is the most appropriate next step?

    1. ARescue therapy with infliximab or ciclosporin, with surgical review
    2. BContinue intravenous steroids and reassess on day 7
    3. CSwitch to high-dose oral prednisolone and discharge
    4. DAdd oral mesalazine and rectal steroid foam
    Show answer and explanation▾

    Answer: A. Rescue therapy with infliximab or ciclosporin, with surgical review

    By the Oxford criteria, more than 8 stools a day, or 3 to 8 stools with CRP over 45 mg/L, on day 3 of intravenous steroids predicts a high colectomy rate, so rescue therapy with infliximab or ciclosporin should be started with joint surgical review in case colectomy is needed. Continuing intravenous steroids for several more days without response delays effective treatment and increases surgical risk. Oral steroids and aminosalicylates are inadequate for steroid-refractory acute severe colitis.

11. Question 11Inflammatory Bowel Diseaseeasy

    A 26-year-old man with moderate-to-severe Crohn disease is about to start infliximab. Which pre-treatment screening tests are most important?

    1. AThiopurine methyltransferase activity and serum lipase
    2. BFaecal calprotectin and anti-Saccharomyces antibodies
    3. CSerum ferritin and vitamin B12
    4. DLatent tuberculosis testing and hepatitis B serology
    Show answer and explanation▾

    Answer: D. Latent tuberculosis testing and hepatitis B serology

    Anti-TNF therapy increases the risk of reactivating latent tuberculosis and hepatitis B, so all patients should be screened with an interferon-gamma release assay or tuberculin skin test (with chest radiograph as indicated) and HBV serology before starting, and latent TB should be treated. Varicella, HIV and hepatitis C status and vaccinations are also reviewed. TPMT activity is relevant to thiopurines, not to infliximab.

12. Question 12Small and Large Intestine Disorders (non-IBD)medium

    A 64-year-old woman taking lansoprazole and sertraline has 3 months of watery, non-bloody diarrhoea up to 8 times daily, including at night. Colonoscopy is macroscopically normal, and random biopsies show a thickened subepithelial collagen band over 10 micrometres. A stool infection screen is negative. What is the most effective induction treatment?

    1. AOral mesalazine
    2. BOral budesonide
    3. CLoperamide alone
    4. DOral metronidazole
    Show answer and explanation▾

    Answer: B. Oral budesonide

    Collagenous colitis, a form of microscopic colitis, is common in older women and is associated with PPIs, SSRIs and NSAIDs, which should be reviewed and stopped where possible. Oral budesonide is the most effective treatment for inducing and maintaining remission. Mesalazine was not superior to placebo in trials, and loperamide may ease mild symptoms but does not induce histological remission.

13. Question 13Gastrointestinal and Hepatobiliary Malignanciesmedium

    A 63-year-old man with hepatitis C cirrhosis on 6-monthly surveillance has a new 25 mm liver observation. Multiphase CT shows non-rim arterial phase hyperenhancement, non-peripheral washout in the portal venous phase and an enhancing capsule. What is the most appropriate next step?

    1. APercutaneous biopsy to confirm the diagnosis
    2. BRepeat CT in 3 months
    3. CTreat as hepatocellular carcinoma without biopsy, via the multidisciplinary team
    4. DContrast-enhanced ultrasound before any decision
    Show answer and explanation▾

    Answer: C. Treat as hepatocellular carcinoma without biopsy, via the multidisciplinary team

    In a patient with cirrhosis, an observation of 20 mm or more with non-rim arterial hyperenhancement and washout or capsule is LI-RADS 5, definite hepatocellular carcinoma, which can be diagnosed non-invasively without biopsy. Staging and treatment planning should proceed through a multidisciplinary tumour board. Biopsy is reserved for indeterminate lesions or non-cirrhotic livers and carries small risks of bleeding and tract seeding, and repeat imaging only delays treatment.

14. Question 14GI Motility, Functional GI Disorders and Nutritioneasy

    A 28-year-old woman has recurrent abdominal pain with altered bowel habit. Which description satisfies the Rome IV criteria for irritable bowel syndrome?

    1. APain at least 1 day a week for 3 months, linked to defecation and stool form change, onset 6 months or more earlier
    2. BDiscomfort at least 3 days a month for 3 months, relieved by defecation, onset 3 months or more earlier
    3. CBloating on most days for 6 months with nocturnal diarrhoea and weight loss over the same period
    4. DPain at least monthly for 1 year with rectal bleeding that is relieved by defecation
    Show answer and explanation▾

    Answer: A. Pain at least 1 day a week for 3 months, linked to defecation and stool form change, onset 6 months or more earlier

    Rome IV defines IBS as recurrent abdominal pain on average at least 1 day per week in the last 3 months, associated with two or more of relation to defecation, change in stool frequency or change in stool form, with symptom onset at least 6 months before diagnosis. Discomfort and the 3 days per month threshold belonged to the older Rome III criteria. Nocturnal diarrhoea, weight loss and rectal bleeding are alarm features that require investigation for organic disease.

15. Question 15Endoscopy Practice, Sedation and Procedural Complications (Miscellaneous)hard

    A 70-year-old woman with a mechanical mitral valve replacement taking warfarin (target INR 3.0) needs colonoscopic endoscopic mucosal resection of a 25 mm polyp. Following BSG/ESGE guidance, how should her anticoagulation be managed?

    1. AContinue warfarin and proceed if INR is within the therapeutic range
    2. BStop warfarin 5 days before and bridge with low-molecular-weight heparin
    3. CStop warfarin 5 days before without bridging
    4. DSwitch to apixaban for 2 weeks before the procedure
    Show answer and explanation▾

    Answer: B. Stop warfarin 5 days before and bridge with low-molecular-weight heparin

    EMR of a large polyp is a high bleeding risk procedure, so warfarin is stopped 5 days beforehand. A mechanical mitral valve is a high thrombotic risk condition, so low-molecular-weight heparin bridging is started 2 days after stopping warfarin, with the last dose at least 24 hours before the procedure, and warfarin is resumed the same evening. Stopping without bridging risks valve thrombosis, and direct oral anticoagulants are contraindicated with mechanical heart valves.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.