Gastroenterology Prometric exam questions

The Gastroenterology exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Gastroenterology practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Gastrointestinal Bleeding

   A 58-year-old man with cirrhosis has had two episodes of bleeding from isolated fundal varices (IGV1) despite cyanoacrylate injection. Cross-sectional imaging shows a large spontaneous gastrorenal shunt, and he has recurrent hepatic encephalopathy with well-preserved synthetic function. Which intervention is most appropriate?

   1. ARepeat oesophageal band ligation programme
   2. BLong-term octreotide infusion via an ambulatory pump
   3. CTransjugular intrahepatic portosystemic shunt
   4. DBalloon-occluded retrograde transvenous obliteration (BRTO)
   Show answer and explanation

   Correct answer: D. Balloon-occluded retrograde transvenous obliteration (BRTO)

   BRTO occludes the gastrorenal shunt that feeds the fundal varices and is highly effective for refractory gastric variceal bleeding; unlike TIPS it does not divert portal flow away from the liver and therefore does not aggravate hepatic encephalopathy, which makes it particularly suitable here. TIPS would be expected to worsen his encephalopathy. Band ligation addresses oesophageal rather than fundal varices, and chronic octreotide infusion is not an accepted long-term strategy.

   Reference: AASLD Practice Guidance on Portal Hypertensive Bleeding in Cirrhosis, 2021; Baveno VII, J Hepatol 2022

2. Question 2 · Viral Hepatitis, Acute Liver Injury and Transplantation

   A 45-year-old sheep farmer has an 8 cm unilocular hepatic cyst with a detached inner membrane (WHO CE3a) and positive Echinococcus serology. There is no biliary communication on MRCP. Which management approach is most appropriate?

   1. APAIR (puncture, aspiration, injection of a scolicidal agent, re-aspiration) under albendazole cover started before and continued after the procedure
   2. BSimple percutaneous aspiration without any scolicidal agent or antiparasitic cover
   3. CObservation alone with repeat ultrasound in 5 years
   4. DERCP with sphincterotomy as first-line therapy
   Show answer and explanation

   Correct answer: A. PAIR (puncture, aspiration, injection of a scolicidal agent, re-aspiration) under albendazole cover started before and continued after the procedure

   Active (CE1) and transitional (CE3a) hydatid cysts of suitable size without biliary communication are appropriately treated by PAIR combined with albendazole started at least 4 hours to several days before the procedure and continued for about a month afterwards, which reduces recurrence and the consequences of spillage. Aspiration without scolicidal agent or drug cover risks secondary echinococcosis and anaphylaxis. Watchful waiting suits only inactive CE4/CE5 cysts, and ERCP is used for cystobiliary fistula or biliary obstruction, not as primary therapy.

   Reference: WHO Informal Working Group on Echinococcosis: Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis (Acta Tropica, 2010)

3. Question 3 · Gastrointestinal and Hepatobiliary Malignancies

   A 79-year-old woman with multiple comorbidities and an ASA grade IV presents with acute large bowel obstruction from an obstructing sigmoid adenocarcinoma with hepatic metastases. She is haemodynamically stable with no signs of perforation. What is the most appropriate management of her obstruction?

   1. AEmergency Hartmann's procedure
   2. BColonic self-expanding metal stent placement as definitive palliation
   3. CConservative management with nasogastric decompression alone
   4. DLoop ileostomy under general anaesthesia followed by chemotherapy
   Show answer and explanation

   Correct answer: B. Colonic self-expanding metal stent placement as definitive palliation

   In incurable obstructing left-sided colorectal cancer, endoscopic self-expanding metal stent placement is the preferred palliative decompression, offering lower morbidity and mortality and avoiding a stoma compared with emergency surgery, particularly in high-risk patients. Emergency Hartmann's carries high perioperative mortality in an ASA IV patient. Nasogastric decompression alone will not relieve a fixed mechanical obstruction, and a surgical stoma imposes unnecessary operative risk when stenting is feasible.

   Reference: ESGE Guideline: Self-expandable metal stents for obstructing colonic and oesophageal disease (2020/2021 update); WSES/ESCP guidance on obstructing colon cancer

4. Question 4 · Pancreatic Diseases

   A 57-year-old man with necrotising pancreatitis deteriorates on day 21 with rigors and rising inflammatory markers. CT shows a partially encapsulated retroperitoneal collection containing gas bubbles, extending along the left paracolic gutter, without a mature wall adjacent to the stomach. He is on the intensive care unit on low-dose vasopressors. What is the most appropriate management?

   1. AImmediate open surgical necrosectomy with continuous lavage
   2. BImmediate EUS-guided transgastric lumen-apposing metal stent placement with direct necrosectomy
   3. CAntibiotics alone and repeat CT in one week
   4. DAntibiotics plus percutaneous catheter drainage, escalating only if he fails to improve
   Show answer and explanation

   Correct answer: D. Antibiotics plus percutaneous catheter drainage, escalating only if he fails to improve

   Gas within the collection with clinical sepsis indicates infected necrosis, which requires antibiotics and drainage, but a step-up approach starting with the least invasive option gives the lowest rate of major complications and death. With no mature wall apposed to the stomach and a deep left paracolic extension, percutaneous drainage is the appropriate first step, with escalation to video-assisted retroperitoneal or endoscopic necrosectomy only if the patient fails to improve; roughly a third avoid necrosectomy altogether. Primary open necrosectomy carries high morbidity and mortality, and antibiotics alone rarely control established infected necrosis.

   Reference: van Santvoort HC et al. PANTER step-up trial (N Engl J Med, 2010); van Brunschot S et al. TENSION trial (Lancet, 2018); ACG Clinical Guideline (2024)

5. Question 5 · Gastric and Duodenal Diseases and Helicobacter pylori

   A 42-year-old woman with multiple duodenal ulcers, diarrhoea and weight loss is suspected of having Zollinger-Ellison syndrome. Her PPI has been withheld for one week. Fasting serum gastrin is 480 pg/mL (normal <100) and gastric pH is 1.8. A secretin stimulation test is performed. Which result best supports the diagnosis?

   1. AA fall in serum gastrin of more than 50% from baseline
   2. BA rise in serum gastrin of more than 120 pg/mL above baseline
   3. CNo change in serum gastrin with a rise in serum chromogranin A
   4. DA rise in serum gastrin only after a protein-rich meal
   Show answer and explanation

   Correct answer: B. A rise in serum gastrin of more than 120 pg/mL above baseline

   Gastrinoma cells paradoxically release gastrin in response to secretin, so a rise of more than 120 pg/mL above baseline is the accepted diagnostic criterion in a patient with hypergastrinaemia and a low gastric pH. Normal antral G cells are suppressed by secretin, so a fall is the expected physiological response and argues against gastrinoma. Chromogranin A is a non-specific neuroendocrine marker and is also raised by PPI use. A meal-stimulated rise is characteristic of G-cell hyperplasia or retained antrum, not gastrinoma.

   Reference: NCCN Neuroendocrine and Adrenal Tumors Guidelines; Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11th ed.

6. Question 6 · Inflammatory Bowel Disease

   A 35-year-old man from a tuberculosis-endemic country has 4 months of abdominal pain, fever, night sweats and weight loss. Colonoscopy shows ulceration of the ileocaecal region with a patulous, gaping ileocaecal valve, and the ulcers are transversely oriented. Which additional finding would most strongly support intestinal tuberculosis rather than Crohn's disease?

   1. ALongitudinal serpiginous ulcers with cobblestoning
   2. BA perianal fistula
   3. CRectal sparing with skip lesions
   4. DConfluent caseating granulomas larger than 400 micrometres located submucosally
   Show answer and explanation

   Correct answer: D. Confluent caseating granulomas larger than 400 micrometres located submucosally

   Large, confluent, caseating granulomas, particularly when submucosal and accompanied by acid-fast bacilli or a positive tissue PCR or culture, are the most specific histological discriminator for intestinal tuberculosis; Crohn's granulomas are small, sparse, non-caseating and mucosal. Transverse ulcers, a patulous ileocaecal valve and a short segment of involvement also favour tuberculosis, whereas longitudinal ulcers, cobblestoning, skip lesions and perianal disease favour Crohn's. Making this distinction is critical because anti-TNF therapy given for misdiagnosed tuberculosis can cause fatal dissemination; where doubt persists, a therapeutic trial of antituberculous therapy with reassessment at 8-12 weeks is standard.

   Reference: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11th edition (2021); Asia Pacific Consensus on Crohn's disease versus intestinal tuberculosis (Journal of Gastroenterology and Hepatology, 2018)

7. Question 7 · Small and Large Intestine Disorders (non-IBD)

   A 55-year-old woman undergoes appendicectomy for presumed appendicitis. Histology reports a low-grade appendiceal mucinous neoplasm with acellular mucin confined within the appendiceal wall, an intact serosa, and a clear resection margin at the base. There was no free mucin in the peritoneal cavity at operation. What is the most appropriate management?

   1. ACompletion right hemicolectomy
   2. BAdjuvant systemic chemotherapy with oxaliplatin and capecitabine
   3. CImmediate cytoreductive surgery with hyperthermic intraperitoneal chemotherapy
   4. DSurveillance, as the risk of peritoneal recurrence is very low with disease confined to the appendix and negative margins
   Show answer and explanation

   Correct answer: D. Surveillance, as the risk of peritoneal recurrence is very low with disease confined to the appendix and negative margins

   A low-grade appendiceal mucinous neoplasm confined to the appendix with acellular mucin, an intact serosa and negative margins has a very low risk of peritoneal dissemination, and appendicectomy alone with clinical and imaging surveillance is sufficient. Right hemicolectomy is indicated for appendiceal adenocarcinoma or positive base margins, not for confined LAMN, because lymph node spread is negligible. Cytoreduction with HIPEC and systemic chemotherapy are treatments for established peritoneal disease such as pseudomyxoma peritonei, which is absent here.

   Reference: PSOGI International Consensus on the Classification and Pathologic Reporting of Pseudomyxoma Peritonei and Appendiceal Mucinous Neoplasms (Carr et al., Am J Surg Pathol, 2016)

8. Question 8 · Chronic Liver Disease, Cirrhosis and Portal Hypertension

   A 58-year-old man with cirrhosis and tense ascites has a large umbilical hernia. The overlying skin has ulcerated and clear ascitic fluid is now leaking continuously from the site. What is the most appropriate management?

   1. AUrgent surgical repair with simultaneous control of ascites, intravenous antibiotics and albumin support
   2. BApply a pressure dressing and manage him conservatively as an outpatient
   3. CPlan elective repair in six months once he is nutritionally optimised
   4. DLarge-volume paracentesis alone and discharge with diuretics
   Show answer and explanation

   Correct answer: A. Urgent surgical repair with simultaneous control of ascites, intravenous antibiotics and albumin support

   Spontaneous rupture of an umbilical hernia with ascitic leak (Flood syndrome) carries a high risk of bacterial peritonitis, hypovolaemia and death, so it demands urgent surgical repair together with aggressive control of ascites (diuretics, paracentesis, and TIPS where appropriate), antibiotics and albumin, since uncontrolled ascites is what drives recurrence and wound failure. Conservative dressings do not stop the leak or the infectious risk, and deferring repair for months exposes the patient to that risk throughout. Paracentesis alone temporarily decompresses the abdomen but leaves the fascial defect and ulcerated skin unaddressed.

   Reference: AASLD Practice Guidance on ascites and its complications (Biggins et al., Hepatology 2021); Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11th edition, 2021

9. Question 9 · Patient Safety, Professionalism, Ethics and Evidence-Based Practice

   Three patients who underwent ERCP within a two-week period develop bacteraemia with an identical multidrug-resistant Klebsiella pneumoniae isolate. Which is the most appropriate immediate infection control response?

   1. AContinue the ERCP list unchanged while awaiting further cases to confirm a trend
   2. BQuarantine the implicated duodenoscopes, culture them and review reprocessing records, notify infection control, and undertake look-back to identify other exposed patients
   3. CSwitch all patients to empirical carbapenem prophylaxis before ERCP
   4. DIncrease the concentration of the high-level disinfectant beyond manufacturer specification
   Show answer and explanation

   Correct answer: B. Quarantine the implicated duodenoscopes, culture them and review reprocessing records, notify infection control, and undertake look-back to identify other exposed patients

   A cluster of genetically indistinguishable resistant organisms after ERCP is a presumptive duodenoscope-associated outbreak requiring immediate device quarantine and culture, review of reprocessing practice, notification of infection prevention and control, and a patient look-back with disclosure. Waiting for more cases exposes further patients to harm. Blanket carbapenem prophylaxis treats the symptom rather than the transmission source and drives resistance, and exceeding manufacturer-specified disinfectant concentrations is unvalidated, damages the device and is not a recognised control.

   Reference: US FDA safety communications on duodenoscope-associated infections and ESGE-ESGENA Guideline on reprocessing flexible endoscopes, 2018

10. Question 10 · Oesophageal Diseases

    During balloon dilation of a benign distal oesophageal stricture, a 10 mm full-thickness defect is recognised immediately. The patient is haemodynamically stable, apyrexial and has no pleural collection on urgent CT, which shows only a small volume of mediastinal air. Which management strategy is most appropriate?

    1. AImmediate thoracotomy with primary surgical repair in all cases
    2. BContinue the procedure and arrange an outpatient contrast study in 1 week
    3. CInsert a large-bore nasogastric tube across the defect and start oral feeding after 24 hours
    4. DImmediate endoscopic closure with clips (through-the-scope or over-the-scope) or a covered stent, plus nil by mouth, broad-spectrum antibiotics and close observation
    Show answer and explanation

    Correct answer: D. Immediate endoscopic closure with clips (through-the-scope or over-the-scope) or a covered stent, plus nil by mouth, broad-spectrum antibiotics and close observation

    An iatrogenic perforation recognised immediately in a stable patient without established mediastinal or pleural contamination is ideally managed endoscopically, using clips for small defects or a fully covered self-expanding metal stent for larger ones, combined with nil by mouth, broad-spectrum antibiotics, nutritional support and drainage of any collection. Surgery is reserved for large defects, failed endoscopic closure, established sepsis or clinical deterioration. Ignoring the defect or feeding the patient early would allow mediastinitis to develop.

    Reference: ESGE Position Statement: Diagnosis and management of iatrogenic endoscopic perforations, Endoscopy 2020; WSES position paper 2019

11. Question 11 · Biliary Tract and Gallbladder Disease

    A 46-year-old shepherd with a large hepatic hydatid cyst develops jaundice, fever and biliary colic. Imaging shows cyst rupture into the biliary tree with daughter cysts and membranes in a dilated common bile duct. Which management is most appropriate?

    1. AAlbendazole alone, since endoscopic intervention risks anaphylaxis and is contraindicated
    2. BPercutaneous PAIR of the cyst as the sole treatment
    3. CERCP with sphincterotomy and extraction of daughter cysts and membranes, with albendazole cover and definitive management of the residual cyst
    4. DEmergency liver resection in all cases of cystobiliary fistula
    Show answer and explanation

    Correct answer: C. ERCP with sphincterotomy and extraction of daughter cysts and membranes, with albendazole cover and definitive management of the residual cyst

    Rupture of a hydatid cyst into the biliary tree causes obstruction and cholangitis, and ERCP with sphincterotomy and clearance of membranes and daughter cysts is both effective and the standard first response, with albendazole and subsequent surgical or percutaneous treatment of the residual cavity. PAIR is contraindicated when there is communication with the biliary tree because scolicidal agents can cause sclerosing cholangitis, albendazole alone will not relieve mechanical obstruction, and emergency resection is not required for most cystobiliary fistulae.

    Reference: WHO Informal Working Group on Echinococcosis: expert consensus on cystic echinococcosis (Acta Tropica, 2010); Sleisenger and Fordtran's, 11th edition (2021)

12. Question 12 · Gastric and Duodenal Diseases and Helicobacter pylori

    A 51-year-old man failed bismuth quadruple therapy and then failed a course of PPI, amoxicillin and clarithromycin. He is not penicillin-allergic, susceptibility testing is unavailable, and local fluoroquinolone resistance is reported around 10%. Which salvage regimen is most appropriate?

    1. APPI, amoxicillin and levofloxacin for 14 days
    2. BRepeat the same bismuth quadruple regimen for a further 14 days
    3. CPPI, amoxicillin and metronidazole for 7 days
    4. DPPI and clarithromycin with rifabutin for 14 days
    Show answer and explanation

    Correct answer: A. PPI, amoxicillin and levofloxacin for 14 days

    After failure of both bismuth quadruple and a clarithromycin-containing regimen, a levofloxacin-based triple (or quadruple) regimen for 14 days is a guideline-endorsed salvage option where quinolone resistance is low. Simply repeating an identical failed regimen is discouraged, and clarithromycin should never be re-used after failure because of induced resistance. Rifabutin-containing therapy is generally reserved for later-line use to preserve it and to limit mycobacterial resistance and myelotoxicity risk; a 7-day metronidazole triple is inadequate.

    Reference: ACG Clinical Guideline: Treatment of Helicobacter pylori Infection (Am J Gastroenterol, 2024); Maastricht VI/Florence Consensus (Gut, 2022)

Gastroenterology reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Gastroenterology questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.