Free DHA Gastroenterology mock test

Gastroenterology sample questions with answers

10 more original exam-style Gastroenterology questions, worked in full. They are not real or recalled exam questions, and none of them is in the diagnostic above, so sit that first if you have not.

1. Question 1 · Chronic Liver Disease, Cirrhosis and Portal Hypertension

   A 41-year-old man with severe alcohol-associated hepatitis has completed seven days of prednisolone 40 mg daily. His bilirubin has risen and the Lille score is 0.68. He remains free of sepsis and has strong family support with documented abstinence since admission. What is the most appropriate management?

   1. ADiscontinue corticosteroids and refer for assessment in a structured early liver transplantation programme
   2. BContinue prednisolone for the full 28-day course as planned
   3. CSwitch to pentoxifylline for a further 28 days
   4. DAdd N-acetylcysteine and continue steroids for another three weeks
   Show answer and explanation

   Correct answer: A. Discontinue corticosteroids and refer for assessment in a structured early liver transplantation programme

   A Lille score of 0.45 or more at day 7 identifies corticosteroid non-response; continuing steroids in these patients confers no survival benefit and increases infection risk, so they should be stopped. Selected non-responders with a favourable psychosocial assessment can be considered for early liver transplantation without a mandatory fixed period of abstinence, an approach validated in prospective cohorts. Switching to pentoxifylline after steroid failure has been shown not to improve outcome, and N-acetylcysteine is only ever an adjunct given with steroids from the outset, not a rescue for established non-response.

   Reference: EASL Clinical Practice Guidelines: Management of alcohol-related liver disease, Journal of Hepatology 2018; Mathurin P et al. Early liver transplantation for severe alcoholic hepatitis, New England Journal of Medicine 2011

2. Question 2 · Patient Safety, Professionalism, Ethics and Evidence-Based Practice

   A 45-year-old man with acute liver failure is ventilated in ICU. Following formal testing he fulfils brain death criteria. The family, citing religious concerns, asks whether continuing ventilation is obligatory. Which response is most consistent with mainstream Islamic bioethical rulings applied in the GCC?

   1. AConfirmed brain death, established by the legally recognised procedure, is regarded as death, and continued ventilation is not obligatory
   2. BVentilation must be continued until spontaneous cardiac standstill occurs in all cases without exception
   3. CWithdrawal of ventilation after brain death is regarded as active euthanasia and is prohibited
   4. DThe decision rests entirely with the treating physician and the family's views are not to be sought
   Show answer and explanation

   Correct answer: A. Confirmed brain death, established by the legally recognised procedure, is regarded as death, and continued ventilation is not obligatory

   The Islamic Fiqh Academy has accepted irreversible cessation of all brain function, properly certified, as constituting death, so continued mechanical support after confirmation is not religiously obligatory. Withdrawing support in that setting is discontinuation of futile treatment on a deceased person rather than euthanasia. Family communication and consent processes remain integral to practice in GCC institutions, so excluding the family is neither ethically nor procedurally correct.

   Reference: Islamic Fiqh Academy (OIC) Resolution No. 17 (5/3), 1986; national brain death determination protocols in GCC states

3. Question 3 · Oesophageal Diseases

   A 47-year-old man on long-term high-dose oxycodone for chronic back pain develops dysphagia and chest pain. Endoscopy is normal. High-resolution manometry shows an elevated median integrated relaxation pressure with premature contractions and a distal latency of 3.9 seconds. What is the most appropriate initial management?

   1. AImmediate peroral endoscopic myotomy
   2. BBotulinum toxin injection into the lower oesophageal sphincter
   3. CWithdrawal or substitution of the opioid and repeat manometry
   4. DEmpirical trial of a tricyclic antidepressant
   Show answer and explanation

   Correct answer: C. Withdrawal or substitution of the opioid and repeat manometry

   Chronic opioid use produces opioid-induced oesophageal dysfunction, which mimics type III achalasia or oesophagogastric junction outflow obstruction with impaired sphincter relaxation and premature spastic contractions; the abnormalities frequently resolve after the opioid is stopped. Chicago Classification v4.0 explicitly advises considering opioid effect before diagnosing a primary spastic disorder. Proceeding directly to myotomy or botulinum toxin risks an unnecessary irreversible intervention, and neuromodulators do not address the causative drug.

   Reference: Yadlapati R et al. Chicago Classification version 4.0. Neurogastroenterol Motil 2021; Ratuapli SK et al. Am J Gastroenterol 2015

4. Question 4 · Biliary Tract and Gallbladder Disease

   A 45-year-old woman with known PSC develops worsening pruritus, jaundice and two episodes of cholangitis. MRCP shows a new dominant stricture of the common hepatic duct. Which statement about her management is most accurate?

   1. AHigh-dose ursodeoxycholic acid at 28-30 mg/kg/day should be started as it improves transplant-free survival
   2. BLong-term indwelling metal stenting is the treatment of choice for dominant strictures
   3. CBrushings and/or cholangioscopic biopsy should be taken to exclude cholangiocarcinoma, and short-term balloon dilation is generally preferred over routine stenting
   4. DDominant strictures in PSC are almost always malignant, so surgical resection should be arranged without tissue sampling
   Show answer and explanation

   Correct answer: C. Brushings and/or cholangioscopic biopsy should be taken to exclude cholangiocarcinoma, and short-term balloon dilation is generally preferred over routine stenting

   A new dominant stricture in PSC mandates exclusion of cholangiocarcinoma with brushings (with FISH) and/or cholangioscopy-directed biopsy, and randomised data show that short-term balloon dilation gives outcomes at least as good as stenting with fewer adverse events. High-dose ursodeoxycholic acid (28-30 mg/kg/day) was associated with worse outcomes in a randomised trial and is not recommended, indwelling metal stents are inappropriate in benign PSC strictures, and although malignancy must be excluded most dominant strictures prove benign.

   Reference: EASL Clinical Practice Guidelines on sclerosing cholangitis (2022); Lindor et al., high-dose UDCA randomised trial (Hepatology, 2009); ESGE guidance on biliary strictures

5. Question 5 · GI Motility, Functional GI Disorders and Nutrition

   A 20-year-old woman with a BMI of 13.8 kg/m2 and a 3-year history of severe food restriction presents with early satiety, bloating and constipation, and is found to have delayed gastric emptying. She also reports intermittent postprandial vomiting and abdominal pain, and CT shows a narrow aortomesenteric angle. What is the most appropriate management priority?

   1. AUrgent duodenojejunostomy for superior mesenteric artery syndrome
   2. BLong-term prokinetic therapy with a gastric emptying study repeated every 3 months
   3. CMultidisciplinary supervised nutritional rehabilitation and weight restoration with refeeding precautions, since both the delayed gastric emptying and the aortomesenteric narrowing are usually reversible consequences of malnutrition
   4. DPlacement of a percutaneous gastrostomy to bypass the delayed gastric emptying
   Show answer and explanation

   Correct answer: C. Multidisciplinary supervised nutritional rehabilitation and weight restoration with refeeding precautions, since both the delayed gastric emptying and the aortomesenteric narrowing are usually reversible consequences of malnutrition

   Severe malnutrition itself causes delayed gastric emptying and loss of the mesenteric fat pad producing a narrow aortomesenteric angle, so both findings are typically secondary and reversible with careful weight restoration; management priority is multidisciplinary nutritional rehabilitation with refeeding syndrome precautions and psychiatric input. Operating for SMA syndrome before nutritional rehabilitation exposes the patient to major surgical risk for a reversible problem. Prokinetics do not address the underlying restriction, and a gastrostomy is an unnecessary invasive intervention when the stomach empties normally once weight is restored.

   Reference: AGA Clinical Practice Update on Management of Disordered Eating and Eating Disorders in Patients with GI Symptoms, Gastroenterology 2022; NICE Guideline NG69: Eating Disorders, 2017

6. Question 6 · Endoscopy Practice, Sedation and Procedural Complications (Miscellaneous)

   After a serious perforation during a routine colonoscopy, the endoscopy unit convenes a review. Which approach best reflects modern patient safety governance?

   1. AIdentify the individual endoscopist responsible and issue a formal disciplinary warning to deter recurrence
   2. BRecord the event in the complications logbook without further analysis, since perforation is a recognised risk of the procedure
   3. CSuspend all colonoscopy in the unit until an external regulator completes an inquiry
   4. DConduct a structured root cause analysis within a just-culture framework, examining system and human factors, generating actionable system changes, feeding findings into the morbidity and mortality meeting, and disclosing openly to the patient
   Show answer and explanation

   Correct answer: D. Conduct a structured root cause analysis within a just-culture framework, examining system and human factors, generating actionable system changes, feeding findings into the morbidity and mortality meeting, and disclosing openly to the patient

   Just culture distinguishes system failure and honest error from reckless behaviour and uses structured root cause analysis with M&M review to produce system-level improvements, coupled with open disclosure to the patient. Blame-first responses suppress reporting and learning; documenting without analysis wastes the learning opportunity; and blanket service suspension is a disproportionate response to a recognised procedural complication.

   Reference: WHO Patient Safety Curriculum Guide; SCFHS Essentials of Patient Safety; ASGE quality indicators for GI endoscopic procedures, Gastrointestinal Endoscopy 2015

7. Question 7 · Gastrointestinal Bleeding

   A 70-year-old woman with atrial fibrillation taking dabigatran 150 mg twice daily presents with massive melaena, a haemoglobin of 5.9 g/dL and persistent hypotension despite transfusion. Her last dose was 4 hours ago and her creatinine clearance is 40 mL/min. Which specific reversal agent is indicated?

   1. AVitamin K 10 mg intravenously
   2. BIdarucizumab
   3. CAndexanet alfa
   4. DFour-factor prothrombin complex concentrate as the agent of choice
   Show answer and explanation

   Correct answer: B. Idarucizumab

   Idarucizumab is a monoclonal antibody fragment that binds dabigatran with very high affinity and is the specific reversal agent for life-threatening dabigatran-associated bleeding. Andexanet alfa reverses the factor Xa inhibitors apixaban and rivaroxaban, not dabigatran. Prothrombin complex concentrate is only a non-specific fallback when idarucizumab is unavailable, and vitamin K has no effect on direct oral anticoagulants.

   Reference: Pollack CV et al., NEJM 2017 (RE-VERSE AD); ACG-CAG Guideline on Anticoagulants and Antiplatelets During Acute GI Bleeding, 2022

8. Question 8 · Viral Hepatitis, Acute Liver Injury and Transplantation

   A 44-year-old man has acute liver failure from a non-paracetamol cause. Which combination best fulfils the King's College criteria for emergency liver transplantation in non-paracetamol acute liver failure?

   1. AArterial pH <7.30 after adequate fluid resuscitation
   2. BINR >6.5 (prothrombin time >100 s) alone, or any three of: age <10 or >40 years, unfavourable aetiology, jaundice-to-encephalopathy interval >7 days, INR >3.5, bilirubin >300 micromol/L
   3. CCreatinine >300 micromol/L with grade III-IV encephalopathy
   4. DSerum lactate >3.5 mmol/L 4 hours after fluid resuscitation
   Show answer and explanation

   Correct answer: B. INR >6.5 (prothrombin time >100 s) alone, or any three of: age <10 or >40 years, unfavourable aetiology, jaundice-to-encephalopathy interval >7 days, INR >3.5, bilirubin >300 micromol/L

   The non-paracetamol King's College criteria are an INR above 6.5 alone, or any three of the five listed variables (extremes of age, unfavourable aetiology such as drug-induced or seronegative hepatitis, jaundice-to-encephalopathy interval exceeding 7 days, INR above 3.5, and bilirubin above 300 micromol/L). Arterial pH below 7.30, the combination of creatinine, INR and encephalopathy grade, and the lactate variants all belong to the paracetamol arm of the criteria.

   Reference: O'Grady et al., Gastroenterology 1989 (King's College criteria); EASL Clinical Practice Guidelines on acute (fulminant) liver failure (2017)

9. Question 9 · Gastrointestinal and Hepatobiliary Malignancies

   A patient with a metastatic, somatostatin receptor-positive grade 2 midgut neuroendocrine tumour has progressive disease and worsening symptoms despite an adequately dosed long-acting somatostatin analogue. Gallium-68 DOTATATE PET shows intense uptake in all lesions. What is the most appropriate next therapeutic option?

   1. APeptide receptor radionuclide therapy with lutetium-177 DOTATATE
   2. BSwitch to a proton pump inhibitor and dietary serotonin restriction
   3. CCisplatin and etoposide combination chemotherapy
   4. DImmune checkpoint inhibitor monotherapy with pembrolizumab
   Show answer and explanation

   Correct answer: A. Peptide receptor radionuclide therapy with lutetium-177 DOTATATE

   The NETTER-1 trial established lutetium-177 DOTATATE peptide receptor radionuclide therapy as effective in progressive, somatostatin receptor-positive midgut neuroendocrine tumours, and intense DOTATATE uptake confirms suitability. Platinum-etoposide is reserved for poorly differentiated neuroendocrine carcinoma. Checkpoint inhibitors have limited activity in well-differentiated NETs, and dietary measures do not control tumour progression.

   Reference: Strosberg et al., NETTER-1 trial, New England Journal of Medicine (2017); ENETS Consensus Guidelines (2023)

10. Question 10 · Pancreatic Diseases

    A 52-year-old man with painful chronic pancreatitis has a main pancreatic duct dilated to 8 mm throughout, with multiple strictures and stones, and no inflammatory head mass. He has already had two courses of endoscopic therapy with only transient benefit. What does randomised evidence suggest is the best next option?

    1. AFurther repeated endoscopic stenting, as it is equivalent to surgery over the long term
    2. BSurgical pancreaticojejunostomy (Puestow-type drainage), which gives superior long-term pain relief
    3. CBilateral thoracoscopic splanchnicectomy as the preferred definitive procedure
    4. DTotal pancreatectomy with islet autotransplantation as the standard next step
    Show answer and explanation

    Correct answer: B. Surgical pancreaticojejunostomy (Puestow-type drainage), which gives superior long-term pain relief

    Randomised trials comparing endoscopic therapy with surgical drainage in obstructive chronic pancreatitis with a dilated duct have consistently favoured surgery for durable pain relief and fewer subsequent procedures, and surgical drainage is recommended after failed endoscopic therapy. Thoracoscopic splanchnicectomy is rarely used and gives inconsistent results. Total pancreatectomy with islet autotransplantation is reserved for selected patients with small-duct disease refractory to all other measures, and it renders the patient surgically diabetic and pancreatic-insufficient.

    Reference: Cahen DL et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis (N Engl J Med, 2007); Issa Y et al. ESCAPE randomised trial (JAMA, 2020)