FRACP PAST PAPERS - GASTROENTEROLOGY

With which of the following drugs is hepatic clearance limited by

blood flow?

A. Pethidine.
B. Warfarin.
C. Cholestyramine.
D. Lignocaine.
E. Propranolol

The cytochrome P450 hepatic microsomal enzyme system

A. is the major metabolic pathway for oxazepam.

B. is induced by phenobarbitone.
C. reacts with liver-kidney microsomal autoantibodies.
D. is inhibited by cimetidine
E. is responsible for the metabolism of bilirubin prior to conjugation

Which gastric cell type has the following features: stimulates gastric acid secretion, works in paracrine fashion,
responds to gastrin, contains histamine and stains +ve with silver:

a. mast cells
b. enterochromaffin-like cell
c. gastrin cells
d. somatostatin cell
e. paneth cell

46 yo Greek male presents with lethargy. Hb = 10.5, MCV = 78, Fe = 8, transferrin = 62, ferritin = 8, ESR = 26,
WCC = 7.3. Next best test would be:

a. flexible sigmoidoscopy
b. colonoscopy
c. faecal occult blood test
d. Hb electrophoresis
e. radiolabelled RBC scan

Elderly male who is a with ischaemic CMP/AF presents with bloody diarrhoea. Endoscopy shows inflammation and
ulceration at the rectosigmoid junction. The most likely diagnosis is:

a. ischaemic colitis
b. UC
c. diverticular disease
d. Crohn’s disease
e. pseudomembranous colitis.

A 61 yo male alcoholic presents with wt loss (18kg) in a few weeks. Bulky pale stool, evidence of prox, myopathy,
obstructive jaundice. CT abdomen is normal. MCV is high. The next best test is:

a. ERCP
b. small bowel series
c. duodenal biopsy
d. secretin test

A 40 yo male presents with recurrent GI bleeding from stomal ulceration following vagotomy/antrectomy at age 17.
Se gastrin 660. The next best Ix is:

a. acid output studies

b. secretin test
c. se Ca++
d. endoscopic US
 e. Ca++ stimulation test.

Elderly female with osteomyelitis treated for three weeks with flucloxacillin, then develops cholestatic jaundice (br
200) ALP/GT markedly elevated. ALT modestly elevated. USS N. The most likely cause is:

a. acute fatty liver

b. sepsis secondary to Staph.
c. flucloxacillin cholestasis
d. pancreatic ca

A 45 yo female presented with RUQ discomfort. CT abdomen shows huge cystic lesion in R lobe of the liver. The
next step in Mgt:

a. FNAB
b. USS upper abdomen
c. FP
d. echinococcus serology
e. stool culture for entamoeba

A 56 yo female with myelofibrosis and hepatosplenomegaly presents with bleeding varices. Following somatostatin
infusion and sclerotherapy, what would be the most appropriate investigations:

a. liver biopsy
b. liver USS
c. liver and spleen scan
d. doppler
e. BMAT

Concerning peptic ulceration:

A. gastric parietal cells have receptors for acetylcholine.

B. omeprazole inhibits gastric acid secretion by blocking cAMP.
C. Ingestion of aspirin is an established risk factor for development of duodenal
ulcer.
D. oral antibiotics are more effective than colloidal bismuth in eliminating Helicobacter pylori
from the gastric mucosa.
E. cytoprotection against ethanol is mediated by prostaglandins in the gastric
mucosa.

Which of the following is/are associated with cigarette smoking?

A. Relaxation of the lower oesophageal sphincter.

B. Increased pancreatic bicarbonate secretion.
C. Increased gastric acid secretory response to gastrin.
D. Reduced heating rate of duodenal ulcers.
E. Increased incidence of carcinoma of the pancreas.

Concerning hepatitis C virus (HCV);

A. it is a single stranded RNA virus.

B. anti-HCV recognises a non-structural protein of the virus.
C. anti-HCV in high titre is a reliable marker for the carrier state
D. false positive results for anti-HCV have been reported in liver diseases.
E. HCV is associated with a high incidence of chronic hepatitis

Hepatitis C:
a/ causes chronic hepatitis in 50%
b/ Ag is a non-structural protein
c/ Ab titre correlates with degree of chronicity
d/ titres are falsely elevated in CAH
e/ is a single stranded RNA virus
HCV transmission
a. increased vertical transmission with high titre anti-HCV antibodies
b. increased vertical transmission with increased maternal hepatic inflammation
c. IVIG is of benefit
d. <15% of infants are affected
e. best diagnosed in the neonate by anti-HCV antibodies

Concerning HCV

a. <10% develop chronic hepatitis

b. is associated with hepatocellular carcinoma
c. is a common cause of fulminant hepatitis
d. prevalence in Australian homosexuals is >10%

Concerning the hepatitis B virus:

A. fulminant hepatic failure is strongly associated (>80%) with failure to secrete HBeAg.
B. the presence of circulating anti-HBe is not associated with progressive liver disease.
C. the currently available vaccines do not afford protection against all strains of the virus.
D. late (>1 year) clearance of HBsAg from the blood occurs in more than 50% of patients responding to treatment
with alpha interferon.
E. the response rate to therapy with alpha interferon is lower in children than in adults.

A 27 year old female presents with a 24 hour history of right upper quadrant pain. Liver function tests show serum
Bb 50mmol/1 (RR 0-20), AlkP 390u/1 (RR 0-135) and AST 60 u/l (RR 0-40).
Which of the following is/are correct?

A. The most appropriate initial screening investigation is ultrasound RUQ

B. Endoscopic extraction of a common bile duct stone is adequate therapy in the presence of gall stones.
C. Chlamydial Infection could account for these findings.
D. Pregnancy could account for these findings.
E. Pancreatitis is unlikely in this setting.

Concerning faecal occult blood screening:

A. the test is negative in over 30% of patients with cooling cancer.

B. 75% of patients with adenomatous polyps have a negative result.
C. guaiac-based tests (e.g. Haemoccult) give a false positive result during vitamin C consumption.
D. the specificity of the test is increased by rehydration of the sample.
E. the test is an inexpensive strategy to prevent deaths from colon cancer.

Concerning maintenance therapy of ulcerative colitis.

A. olsalazine is an azo compound containing two molecules of 5-ASA

B. mesalazine, a delayed release formulation of 5-ASA, is less effective than sulfasalazine.
C. treatment with olsalazine is complicated by diarrhoea in approximately 10% of cases.
D. Heinz body anaemia is observed with enteric coated sulfasalazine.
E. 5-ASA is effective in maintaining remission of left side colitis when administered by

Concerning hyperalimentation:

A. hepatobiliary complications are more common with enteral than parental nutrition.
B. polymeric enteral diets are superior to elemental (chemically defined)
C. hypersmolar formulae account for a minority (20%) of cases of diarrhoea in patents receiving enteral tube
feeding.
D. bolus administration is more effective than Continuous enteral feeding.
E. increased survival has been reported in the majority of controlled trials of parenteral nutrition following major
surgery.

Lithogenecity of bile is increased by:

 a. ageing
b. hypercholesterolaemia
c. Crohn’s disease
d. weight loss
e. obesity.

Hypergastrinaemia occurs in:

a. CRF
b. vagotomy
c. omeprazole
d. antrectomy
e. pernicious anaemia

Physiological mechanisms resulting in an increase in pancreatic fluid and electrolyte secretion include

a. gastric acid
b. VIP
c. CCK
d. secretin
e. CFTR.

A female with CREST has ulcerative oesophagitis on endoscopy. She has no relief of symptoms with 800 mg
cimetidine bd. Manometry shows absent peristalsis and are unable to identify the lower oesophageal sphincter. The
best treatment

a. cisapride
b. omeprazole
c. balloon dilatation of LOS
d. fundoplication

Patients with haemochromatosis and end organ damage are at risk of which infection

a. staph
b. strep
c. Yersinia
d. Shigella
e. Salmonella

. Concerning iron metabolism

a. 10 mL or red cells contains 1 mg of elemental iron

b. average Australian intake of iron is 10 - 20 mg/day
c. 60 kg female has 2.5g of body iron
d iron absorption is increased by vitamin c

Which are correct

a. iron is absorbed in the distal small intestine.

b. heparin needs antithrombin III for optimal activity
c. warfarin needs protein C for optimal activity
d. hepatic vitamin B12 is mainly cyanocobalamin

Clostridium difficile

a. causes 90% of antibiotic associated diarrhoea

b. toxin B has no effect on intact mucosa
c. both toxins can be excreted in large amounts in asymptomatic people
 d. toxin A causes secretory diarrhoea
e. toxin A causes the neutrophil recruitment seen in patients with colitis

Which of the following cause red and white cells in the faeces?

a. campylobacter jejuni
b. campylobacter pylori
c. giardia lamblia
d. shigella flexneri
e. clostridium difficile

Concerning trace elements

a. Zn deficiency causes mucocutaneous infections

b. Zn absorption is regulated by production of Zn binding protein
c. In patients on TPN Zn deficiency is more likely of they have diarrhoea
d. selenium deficiency produces a cardiomyopathy
e. serum copper levels reflect body copper stores

Hyperplasia of enterochromaffin cells in the gastric mucosa is associated with

a. hyperchlorhydria
b. atrophic gastritis
c. small bowel resection
d. antral G cell hyperplasia

Serum bilirubin

a. is decreased by increased concentrations of metalloporphyrins

b. decreases in patients with Gilbert’s consuming <400 cal/day
c. is a powerful antioxidant
d. is covalently bound to albumin
e. is decreased by phototherapy

Cholestatic jaundice has been described in association with:

a/ methotrexate
b/ halothane
c/ flucloxacillin
d/ paracetamol
e/ erythromycin

Regarding a interferon therapy for chronic HBV:

a/ 40% of caucasians become HBeAg neg.
b/ cirrhosis is a contraindication
c/ pts with high transaminases are more likely to respond
d/ therapy less effective in Chinese
e/ corticosteroids required for 6 weeks

Orthotopic liver transplantation:

a/ better prognosis in adults than children

b/ contraindicated in cholangiocarcinoma
c/ liver not viable >12 hr after harvesting
d/ external biliary drainage influences cyclosporin dosage
e/ outcome of Tx is independent of stage of liver disease
Regarding parenteral and enteral hyperalimentation:

a/ polymer formulae superior to synthetic elemental form

b/ hepatobiliary complications assoc enteral > parenteral route
c/ continuous feeding superior to bolus regimens
d/ TPN prolong survival in major surgery

Which are of proven benefit in Crohn's disease:

a/ azathioprine
b/ methotrexate
c/ flagyl
d/ 6-mercaptopurine
e/ cyclosporin A

Risk factors for peptic ulcer disease:

a/ H pylori assoc. GU > DU

b/ smoking is a risk factor for DU
c/ NSAID is a risk for GU
d/ H2-blockers more efficacious bd
e/ 70% risk of recurrence

A male with recurrent retrosternal chest pain and normal angiogram:

a/ pH studies
b/ manometry
c/ Ba meal
d/ endoscopy
e/ CT chest

Regarding colonic carcinoma:

a/ colonic adenomas become malignant in >90% cases

b/ familial polyposis is assoc. with a genetic marker
c/ RIF mass is palpable in 50% of R colonic carcinomas

Concerning hepatotoxic drug reactions:

a/ Severe centrizonal necrosis due to halothane is a predictable effect
b/ flucloxacillin produces evidence of bile duct injury
c/ perhexilene produces microvesicular hepatosteatosis
d/ paracetamol toxicity occurs in the presence of reduced glutathione
e/ hepatic adenomas usually regress post discontinuation of the OCP
Concerning gastrointestinal IgA:

a/ occurs in dimeric form

b/ attached to secretory protein
c/ is derived from plasma IgA
d/ has a J chain
e/ is lytic to enterotoxic bacteria

A 61 yo male alcoholic presents with wt loss (18kg) in a few weeks. Bulky pale stool, evidence of proximal myopathy &
obstructive jaundice. CT abdomen is normal. MCV is high.
The next best test is:

a/ ERCP
b/ small bowel series
c/ duodenal biopsy
 d/ secretin test

0 yo female presents with post-prandial epigastric and chest pain + pain with stooping not responding to H2 blockers
and antacids. Upper GI endoscopy normal as are Bameal and ECG. Which test most useful:

a/ 24hrs pH monitoring
b/ oesophageal manometry
c/ upper GI fluoroscopy
d/ upper abdominal USS
e/ CT scan

28yo female with gallstone pancreatitis becomes very unwell with fever, cholestatic LFTs, hypoxia. CXR shows
bilateral effusions. CT abdomen shows pancreatic
enlargement only. The most appropriate Mx is:

a/ ERCP
b/ antibiotics
c/ V/Q scan
d/ laparotomy and pancreatic debridement
e/ pancreatic aspiration percutaneously

Cholecystokinin

a. action is mediated by cyclic AMP

b. potentiates the actions of secretin
c. secretion is stimulated by FFA’s in the duodenum
d. secretion is inhibited by pancreatic enzymes in the duodenum
e. stimulates the synthesis of pancreatic enzymes

Which of these drugs are linked to their possible side effects

a. flucloxacillin:hepatocellular jaundice
b. methanol:hepatocellular failure
c. chlor? : hyperthermia
d. DDC:pancreatitis
e. amphotericin:hypokalaemia

Concerning colorectal cancer

a. the risk for an individual with a first degree relative affected by colorectal cancer is 1 in 25
b. increased dietary fat is associated
c. 5FU and levamisole improves mortality in Duke’s stage C
d. radiotherapy reduces recurrence in rectal cancer
e. 10% of cancers found by positive haemoccult testing will be stage A disease

Comparing Crohn’s disease in the elderly (65yrs) and Crohn’s disease in the young

a. distal colonic disease is more likely

b. longer duration of symptoms before diagnosis
c. more likely to die of the disease
d. more likely to have surgery for the disease
e. more likely to be diagnosed on rectal biopsy

In patients with peptic ulcer disease

a. H2 antagonists are more effective when used twice daily than once daily
b. smoking delays healing of a duodenal ulcer
c. NSAID intake is a risk factor for gastric ulcer
d. Helicobacter is more closely associated with gastric than duodenal ulcer
e. there is a 70% recurrence risk irrespective of type of medical treatment

Bleeding oesophageal varices

a. sclerotherapy should be delayed until bleeding is controlled
b. octreotide is more effective than vasopressin in stopping bleeding

Concerning hepatic ascites

a. enhanced renal sodium absorption is unrelated to circulating levels of ANP

b. if net diuresis induced fluid loss exceeds 1 litre/day in a non-oedematous patient, GFR will decrease
c. loop diuretics are more effective than distal diuretics
d. large volume paracentesis with intravenous albumin reduces duration of hospital stay compared with diuretic
therapy
A man with gross ascites and fever with no oedema

a. ascitic neutrophil count >50/mm3 is diagnostic of SBP

b. gentamicin is the treatment of choice
c. fluid in blood culture bottles increases culture rate

Coeliac disease

a. there is an increased incidence in 1st degree relatives

b. gluten-free diet will reduce the risk of oesophageal cancer
c. associated with an increased incidence of intestinal lymphoma
d. anti-gliadin antibodies are diagnostic
e. recognized by abnormalities on duodenal biopsy

Barium swallow in a middle aged woman with intermittent dysphagia for solids and liquids for several months. The
next most useful investigation would be (one answer)

a. upper GI endoscopy and biopsy

b. video fluoroscopy and swallow
c. oesophageal manometry
d. CT scan of the chest

66 yr old Mediterranean with alcohol intake of 30g/day for 30 yrs.

He presents with ascites, spider naevi, splenomegaly and jaundice. Investigations reveal
Hep B sAg +
Hep B eAg +
Hep C Ab +
LFT’s Br 19
ALP and AST elevated (?degree)
The most likely diagnosis is (one answer)

a. chronic hepatitis B
b. hepatitis C
c. alcoholic cirrhosis

60 yr old male with Dukes B colonic carcinoma resected 6 mths previously. Presents with RUQ pain, CT abdo shows
hypodense lesion of 2cm diameter in right lobe liver. The next best investigation would be (one answer)

a. FNA biopsy of the lesion

b. Ultrasound of the liver
c. angiography
d. MRI
e. ERCP
65 yr old male with weight loss and diarrhoea with floating stools for 12 months
Hb normal MCV 105
B12 normal serum folate normal ( red cell folate not given)
fasting glucose 9.3
increased faecal fat 46 (up to 25)
ferritin 300
The most likely diagnosis is (one answer)

a. chronic pancreatitis
b. Crohn’s disease
c. coeliac disease
d. haemochromatosis

22 yr old IV drug user, asymptomatic

hep B sAb +
hep C +
AST 120 ALP mildly increased
bilirubin and other LFT’s normal
Which of the following are true?

a. fatty changes on liver biopsy

b. hep C DNA + in >80%
c. anti smooth muscle Ab’s in >80%
d. delta agent should be excluded
e. vaccination for hep B should be performed

Concerning liver function in the elderly

a. hepatic blood flow is decreased

b. cholesterol synthesis is altered ()
c. decreased liver mass
d. increased size in the fifth decade (? doubles)
e. decreased urea

Factors responsible for increased alcohol metabolism in heavy drinkers

a. gastric alcohol dehydrogenase

b. hepatic alcohol dehydrogenase
c. microsomal ethanol oxidising system (MEOS)
d. hepatic acetaldehyde dehydrogenase
e. microsomal P450 catalase
CCK release is inhibited by

a. trypsin
b. lipase
c. secretin
d. FFA
e. acid in the duodenum ?ACh

Regarding mesalasine

a. is degraded into 2 X 5-ASA molecules

b. releases sulfasalasine
c. is degraded bt a pH dependant mechanism
d. is degraded by tryptase

Helicobacter pylori is assoc with

a. GU
b. DU
c. Gastric Ca
d. MALT
e. Atrophic gastritis

Factors contributing to protection of hepatocyte against oxidative stress

a. cyt P4502E6
b. catalase
c. glutatione
d. superoxide dismutase
e. iron

Oxidative metabolism in the liver can produce

a. drug metabolites with toxic actions

b. drug metabolites with increased activity
c. drug metabolites with decreased (?no) activity
d. drug metabolites which are more lipid soluble
e. drug metabolites with ?prolonged excretion half life
Carcinoma of oesophagus is associated with

a. GOR
b. smoking
c. achalasia
d. caustic burns from ingestion of alkali
e. alcohol

. A patient has a liver biopsy which shows macrovesicular steatosis. (not shown)
? more history . Least likely diagnosis

a. obesity
b. diabetes
c. viral hepatitis
d. alcohol
e. panadol overdose

A middle aged female is referred because of two elevated gastrin levels ( 780). She has a past history of dyspepsia
and has been on Ranitidine for years. Recent endoscopy shows atrophic mucosa in the fundus. The most likely cause
for the increased gastrin

a. ranitidine
b. gastrinoma
c. pernicious anaemia
d. helicobacter pylori

A middle aged female presents with arthralgias and lethargy. Her ALP 205 AST 40 ALT 35 Br 20 her liver biopsy is
shown (resembles the picture is Robbins of PBC) - multiple multinucleated giant cells in a granuloma involving all the
portal tract, there are no definite bile ducts seen. The best test for diagnosis

a. serum ACE
b. 1-antitrypsin level
c. anti-smooth muscle antibocy
d. anti-mitochondrial antibodies
e. serum transferrin saturation
A young female has a right hemicolectomy and 60cm terminal ileum resected and has persistent diarrhoea. The best
treatment would be

a. cholestyramine
b. low fat diet
c. codeine
d. loperamide
e. tetracycline

A young male presents with anaemia, RIF pain and a palpable mass. He has a long history of mild watery diarrhoea
and 5kg weight loss. A small bowel series is shown (stricture and oedema in small bowel RIF with inflammatory mass,
matted loops). The next step in management

a. oral prednisone
b. colonoscopy
c. CT abdomen
d. oral metronidazole
e. laparotomy

A 17 yr old girl has had Coeliac disease since the age of 3. She presents with 4 weeks of foul smelling diarrhoea,
flatulence, crampy mid abdominal pain and bloating. Her blood tests are normal (no evidence of malabsorption). Her
upper endoscopy is normal and small bowel biopsy is shown (villous atrophy). You should

a. perform a small bowel series

b. question compliance with diet
c. CT abdomen
d. start treatment with Flagyl

A male alcoholic presents with acute pancreatitis and amylase 1500. He is admitted and settles with conservative
management and goes home. He comes back in 2 weeks later with abdominal fullness. He is afebrile and has normal
WCC, amylase 550. His CT abdomen is shown (huge pseudocyst ). Best management

a. laparotomy
b. aspiration and percutaneous drainage
c. expectant management
d. ERCP
A patient presents with ?hepatitis ??other history . ALT 3500 .
The least likely diagnosis

a. panadol od
b. alcohol
c. Budd Chiari
d. viral hepatitis
e. ischaemic hepatitis