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CHAPTER 0 | MISCELLANEOUS
and tumourous masses. LGV proctitis mimics inammatory bowel disease (IBD) such as Crohn’s
disease, both clinically and on histopathology. Therefore, one should consider LGV proctitis in MSM
presenting with suspected IBD. Diagnosis of LGV is conrmed by the detection of C.trachomatis
DNA in rectal specimens from anorectal swabs. Treatment includes oral doxycycline (rst line)
and erythromycin (second line). Symptoms tend to resolve within 1– 2 weeks of antibiotic therapy.
Contact tracing, screening for other sexually transmitted infections, and follow- up is conducted by
genitourinary medicine sta.
de Vries HJC, Zingoni Aetal. 203 European guideline in the management of proctitis, proctocolitis
and enteritis caused by sexually transmissible pathogens. Int J STD AIDS. 204;25:465– 474.
Doi:0.77/ 0956462435600.
13. E. There is an increased incidence of AIN in the immunosuppressed
and HIV- positive individuals
• AIN is the precursor lesion to anal squamous cell carcinoma
• AIN is associated with HPV
Table10.4 Sexually transmissible causes ofproctitis and proctocolitis
Causes of distal proctitis Causes of proctocolitis
Neisseria gonorrhoeae
Chlamydia trachomatis:
Genotypes D- K
Genotypes L1- 3 (LGV)
Treponema pallidum
Herpes simplex virus
LGV:lymphogranuloma venereum.
a
In severely immunocompromised patients (in the context of HIV infection with low CD4 Tcell counts). Sometimes in immunocompetent patients (especially in relation to inammatory
bowel syndromes).
Note:It is important to note that several STIs may co- exist.
Shigella spp.
Campylobacter spp.
Salmonella spp.
Escherichia coli
Entamoeba histolytica
Cryptosporidium spp.
Cytomegalovirus
a
• Incidence of AIN is increased in the immunosuppressed and HIV- positive individuals
AIN is a precursor lesion to anal squamous cell carcinoma. Despite lower rates of anal cancer,
it is associated with a signicant morbidity and mortality most likely due to delay in diagnosis.
Ahigh index of suspicion is required for the diagnosis of AIN. Patients may present with perianal
symptoms including pruritus and perianal discharge. The perianal skin appears abnormal. However,
without a high index of suspicion, lesions may easily be missed. Lesions may be at and appear
white, grey, purple, or brown in colour. Low- grade dysplastic AIN lesions have a similar appearance
to anal condyomata. The presence of ulceration in an AIN lesion suggests invasion. Any suspicious
anal lesion warrants a biopsy.
AIN is strongly associated with HPV. The prevalence is thought to be <1%. However, a number of
groups at high risk for AIN include individuals with HIV, immunocompromised patients (e.g. transplant
recipients), long- term corticosteroid users, and those with previous genitourinary condylomata. The
prevalence of AIN in HIV is up to 89%. Literature on the risk of AIN in IBD patients is limited.
Risk of progression of AIN to invasive anal cancer is 10% at ve years. There is currently no role
for screening for AIN. Diagnosis is made by histopathological assessment:grades of AIN are
assigned by the depth of epithelial involvement. Treatment may include local and targeted therapies,
topical cidofovir or imiquimod, and local ablative therapies. Local excision may be suitable for
lesions involving <30% of the anal circumference and are preferable to ablative therapies. Wide
CHAPTER 0 | ANSWERS
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local excision or larger lesions are not usually required. Follow- up of patients with AIN is essential
given that the natural history remains uncertain.
Siddharthan RV, Lanciault C, Tsikitis VL. Anal intraepithelial neoplasia:diagnosis, screening, and
treatment. Ann Gastroenterol. 209;32(3):257– 263. Doi:0.20524/ aog.209.0364.
289
14. B. Anorectal manometry
• Anorectal manometry (ARM) is the rst- line investigation for faecal incontinence (FI) not
responding to conservative measures
• ARM measures rectal sensation, rectal balloon expulsion and anal sphincter resting and
squeeze pressures
• In those with weak sphincter pressures additional tests including endoanal ultrasound, pelvic
magnetic resonance imaging and electromyography can be considered in the work- up for
surgery
The prevalence of FI increases with age and can be debilitating. Causes include traumatic anal
sphincter weakness (obstetric or surgical), idiopathic sphincter degeneration, neuropathy (diabetes
mellitus), pelvic oor disturbance (rectal prolapse), inammatory conditions (radiation proctitis,
IBD) and central nervous system disorders (dementia, stroke). Patients with urge incontinence have
reduced squeeze pressures and experience the desire to defecate but cannot reach the toilet on
time. Patients with passive incontinence have lower resting sphincter pressures and are not aware
of the need to defecate before the incontinent episode. Nocturnal incontinence is rare but can
occur in diabetes mellitus and scleroderma. Anorectal manometry is recommended when local
pathology has been excluded (impacted stool, rectal masses) and when conservative measures
(dietary modication, anti- diarrhoeal agents) have been unsuccessful. ARM simultaneously assesses
rectal sensation, rectal balloon expulsion, and anal sphincter resting and squeeze pressures.
For those with weak pressures, sphincter integrity can be further investigated with endoanal
ultrasound and/ or MRI to help plan for surgery (sphincteroplasty, sacral nerve stimulator). Needle
electromyography of the anal sphincter should be considered in patients with suspected neurogenic
sphincters who may benet from sacral nerve stimulation. MR proctography is useful in investigating
defecatory disorder (diculty evacuating stool), which can co- exist with FI. Irrespective of the
underlying mechanism of incontinence, pelvic oor retraining including biofeedback may be helpful.
Biofeedback allows electronically amplied recordings of sphincter contraction to be visualized by
the patient in response to their attempts at sphincter control.
Wald A.ACG Clinical Guideline:Management of benign anorectal disorders. Am JGastroenterol.
204;09:4– 57. Doi:0.038/ ajg.204.90.
15. B. Arise in breath hydrogen by more than 20 ppm from baseline within 90
minutes would be consistent with a positive test result
• Glucose hydrogen breath testing has low sensitivity and specicity for predicting positive small
bowel bacterial aspirates
• In patients with a high pre- test probability for small intestinal bacterial overgrowth (SIBO), an
empirical trial of antibiotic therapy should be considered
• Abnormal gastric or small intestinal transit time can aect the interpretation of the result
Carbohydrate breath tests indirectly measure the metabolism of a carbohydrate substrate (e.g.
glucose or lactulose) by bacterial ora. This leads to production of an analyte (hydrogen or
methane), which is measured in breath. For the glucose hydrogen breath test, a peak in breath
hydrogen should occur at 2– 3 hours from baseline due to glucose metabolism by colonic bacteria
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CHAPTER 0 | MISCELLANEOUS
in the caecum. In SIBO, an early breath hydrogen peak (≥20 ppm above baseline readings within
90 minutes of glucose ingestion) followed by a second peak due to colonic ora metabolism is
considered diagnostic. Compared with measurement of small bowel bacterial colony via aspiration
as the reference standard, the sensitivity of glucose hydrogen breath testing is 20%– 93% and
specicity 45%– 86%.
UK guidelines recommend that in patients with high pre- test probability for SIBO (e.g. previous
small bowel surgery, or small bowel anatomical abnormalities), an empirical trial of antibiotic
treatment is prescribed, rather than investigation with carbohydrate breath testing.
Arasadnam RP etal. Guidelines for the investigation of chronic diarrhoea in adults:British Society of
Gastroenterology, 3rd edition. Gut. 208;67(8):380– 399. Doi:0.36/ gutjnl- 207- 35909.
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chapter
MOCKEXAMINATION
QUESTIONS
1. A 50- year- old man with ileocaecal Crohn’s disease (CD) in long- term
remission had been taking azathioprine monotherapy 200 mg once a
day for the last seven years.
Which pattern of drug- induced liver injury is this most likely to have
caused?
A. Drug- induced autoimmune hepatitis (AIH)
B. Fibrosis
C. Granulomatous hepatitis
D. Nodular regenerative hyperplasia (NRH)
E. Steatosis
2. A 59- year- old man underwent small bowel resection for mesenteric
infarction. He was seen in clinic and complained of persistent thirst. He
had 130cm small bowel to an end jejunostomy with a stoma output of
1,300 ml per day.
What is the best management advice for this patient?
A. Ensure he has long- term parenteral support
B. Increase oral water intake to at least 1,000 ml per day
C. Restrict hypotonic uid intake to less than 500 ml per day and commence a mix of 20 g
glucose, 3.5 g salt, and 2.5 g sodium bicarbonate in 1 litre water
D. Restrict hypotonic uid intake to less than 500 ml per day and commence Dioralyte™ 5
sachets in 1 litre water
E. Restrict hypotonic uid intake to less than 500 ml per day but add no additional uid
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0011
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CHAPTER | MOCKEXAMINATION
3. A 56- year- old man presented with painless jaundice. CT liver and
magnetic resonance cholangiopancreatography (MRCP) demonstrated
a hilar biliary stricture with subsequent endoscopic retrograde
cholangiopancreatography (ERCP) and brushings conrming
cholangiocarcinoma.
Which radiological nding is an absolute contraindication to surgical
resection?
A. Bilateral involvement of the main left and right hepatic ducts
B. Involvement of the common hepatic duct
C. Locoregional lymphadenopathy
D. Tumour abutting hepatic artery
E. Underlying primary sclerosing cholangitis (PSC)
4. A 29- year- old dancer presented with persistent abdominal pain, nausea,
and constipation. She denied taking opiates or anticholinergics but did
smoke cannabis once per month. On examination, her body mass index
(BMI) was 17.4kg/ m2. She was not diabetic but there was a history of
dizziness on standing.
Investigations:
Gastroscopy Normal
Ileocolonoscopy Normal
MR enterography Normal
Tilt table test Consistent with postural orthostatic tachycardia syndrome
Beighton score 6/ 9 suggestive of hypermobility
What is the most likely cause of her abdominal symptoms?
A. Anorexia nervosa
B. Cannabis excess
C. Diabetic gastroparesis
D. Dysmotility associated with hypermobile- type Ehlers- Danlos syndrome (hEDS)
E. Mitochondrial neurogastrointestinal encephalomyopathy
5. A 34- year- old man presented with symptoms suggestive of delayed
gastric emptying.
With regard to the physiology of gastric emptying, which of the
following cells are responsible for controlling the slow- wave phase in the
distal stomach?
A. Chief cells
B. Enterochroman cells
C. Interstitial cells of Cajal
D. Mucous neck cells
E. Parietal cells
CHAPTER | QUESTIONS
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293
6. A 19- year- old woman with a history of anorexia nervosa was brought
to hospital by her atmates. She had been withdrawn for several
months, eating little and losing weight. Her current weight was 33kg.
She had been running twice daily until the week before, when she had
become weaker and had not left her at since. Physical examination and
investigations were performed.
Which nding would indicate that the patient should be deemed high
risk in the context of refeeding and rehydration?
A. Alanine aminotransferase (ALT) 56 U/ L
B. Blood glucose 4.1mmol/ L
C. Creatinine 109 mol/ L
D. Heart rate (HR) 44 beats per minute (bpm)
E. QT interval 430 ms
7. The management of a 60- year- old man with a new diagnosis of head of
pancreas adenocarcinoma was discussed by the multi- disciplinary team.
Which of the following CT ndings makes the tumour most likely to be
unresectable?
A. Tumour contact with aorta without deformity or stenosis
B. Tumour contact with the common hepatic artery
C. Tumour ≥4cm
D. Tumour contact with one third of the coeliac axis without deformity or stenosis
E. Tumour contact with one third of the superior mesenteric vein not exceeding the inferior
border of duodenum
8. A 64- year- old man was admitted with melaena. He had a background
of angina and had two drug- eluting coronary stents inserted 10months
previously. His medications comprised aspirin, clopidogrel, bisoprolol,
ramipril, and atorvastatin. He had recently been using naproxen for
lower back pain.
Investigations:
Gastroscopy Duodenal ulcer on the anterior wall of the
How should you manage his antiplatelet therapy following the
endoscopy?
A. Restart aspirin after three days, stop clopidogrel
B. Restart aspirin immediately, essential to discuss with cardiology regarding clopidogrel
C. Restart both aspirin and clopidogrel immediately
D. Restart clopidogrel after three days, stop aspirin
E. Stop both aspirin and clopidogrel
duodenal bulb (Forrest classication IIc)
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CHAPTER | MOCKEXAMINATION
9. A 56- year- old man presented with pruritus ani.
Which of the following statements is true?
A. Candida infections are a cause of less than 5% of cases
B. Capsaicin has good evidence for alleviating the condition through eects on histamine
release
C. Most cases are due to a single identiable cause
D. Pinworm is a common cause of the condition in children
E. The use of soap to clean the perianal area should be encouraged
10. Regarding gastric acid secretion, which of the following statements
is true?
A. Enterochroman cells are found in abundance in the gastric antrum
B. Enterochroman cells release histamine when stimulated by gastrin or acetylcholine
C. Gastrin is released from G cells in the body
D. In the presence of intrinsic factor, pepsinogen is converted to the active enzyme, pepsin, in
the stomach lumen
E. Parietal cells secrete hydrochloric acid only
11. A 63- year- old lorry driver was referred with a four- month history of
bloody diarrhoea 4– 6 times per day. He had mild left- sided abdominal
pain. There was no history of fevers or weight loss. He denied recent
foreign travel. His past medical history included ischaemic heart disease
and hypertension.
Investigations:
Haemoglobin 129 g/ L
Platelet count 475 × 109/ L
Serum albumin 31 g/ L
Serum C- reactive protein (CRP) 25 mg/ L
Flexible sigmoidoscopy Conuent colitis to point of insertion (50cm)
consistent with ulcerative colitis (UC)
With respect to inammatory bowel disease (IBD) in the elderly, which
statement is most accurate?
A. Elderly- onset UC is more common in women
B. Elderly UC patients have a higher risk of being hospitalized, especially with their rst are
C. In elderly CD patients, ileal involvement is more common than colonic involvement
D. Isolated proctitis is most common and left- sided disease is less common in the elderly UC
population
E. Older age is not an independent risk factor for adverse events to medications
CHAPTER | QUESTIONS
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295
12. A 68- year- old woman was referred with chronic diarrhoea. Her
background included hypothyroidism and hypertension for which she
took levothyroxine and ramipril. Acolonoscopy was indicated but
she recalled having had a colonoscopy eight years before and did not
tolerate the bowel preparation well.
With respect to bowel preparation, which statement is most accurate?
A. All bowel preparations are associated with dehydration and electrolyte imbalances
B. Extended bowel preparation is recommended in patients with constipation
C. High- volume polyethylene glycol (PEG) is not safe in the setting of renal impairment
D. Lower adenoma detection rates correlate with inadequate bowel preparation
E. Split- dose low- volume PEG is superior to split- dose low- volume PEG preparations
13. A 45- year- old woman with Child- Pugh C alcohol- related cirrhosis
was admitted with a fractured tibia following a fall. She was currently
drinking two bottles of wine a day. After 18 hours, she developed severe
alcohol withdrawal syndrome (AWS)
Which of the following would be the best treatment option?
A. Intramuscular haloperidol
B. Intravenous diazepam
C. Intravenous lorazepam
D. Oral baclofen
E. Oral chlordiazepoxide
14. A 45- year- old man with a history of alcohol excess presented with
epigastric pain, vomiting, systemic inammatory response syndrome,
and acute kidney injury.
Investigations:
Serum amylase 1,200 U/ L
Abdominal ultrasound Normal
Five weeks after presentation, a computed tomography (CT) scan was
performed because of ongoing abdominal pain and fevers.
CT abdomen 10cm encapsulated homogenous uid collection
around the head of the pancreas
White cell count 15 × 109/ L
Serum C- reactive protein (CRP) 145 mg/ L
Serum amylase 205 U/ L
What is the most likely diagnosis?
A. Acute necrotic collection (ANC)
B. Acute peripancreatic uid collection
C. Interstitial oedematous pancreatitis (IOP)
D. Pancreatic pseudocyst
E. Walled- o necrosis (WON)
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CHAPTER | MOCKEXAMINATION
15. A 35- year- old woman was referred to clinic with deranged liver function
tests. She reported lifelong abstinence from alcohol, which was
corroborated by her husband. She had a background of hypertension
and type 2 diabetes. She was taking ramipril, metformin, and had
completed a course of trimethoprim 2 weeks before for a urinary tract
infection.
Investigations:
Serum bilirubin
Serum alanine transferase (ALT) 87 U/ L
Serum alkaline phosphatase (ALP) 100 U/ L
Serum albumin 42 g/ L
Serum ferritin 545 µg/ L
Anti- smooth muscle antibody Positive
Liver histology (Fig. 11.1)
10 µmol/ L
Fig.11.1 Liver histology specimen. See also Plate 18
Image courtesy of Dr Eve Fryer, OUH NHS Foundation Trust, Oxford
What is the most likely diagnosis?
A. AIH
B. Drug- induced liver injury
C. Haemochromatosis
D. Non- alcoholic steatohepatitis
E. Wilson’s disease
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297
16. A 43- year- old- man is reviewed in clinic with nine months of upper
abdominal pain. He has a history of smoking 20 cigarettes a day for the
past 15years.
Investigations:
MRCP Marked parenchymal atrophy of the pancreas.
Irregular and beaded main pancreatic duct with
6mm calculi in the mid- pancreatic duct with
moderate proximal dilatation
What would be the next best management for his pain?
A. ERCP and pancreatic duct stenting
B. ERCP and stone extraction
C. Extracorporeal shock wave lithotripsy
D. Pancreatectomy
E. Pancreatic enzyme supplementation
17. A 20- year- old man presented to the gastroenterology outpatient clinic.
He was an only child whose father was diagnosed with hereditary nonpolyposis CRC at the age of 40years and died of CRC. No other family
history was available. The patient was asymptomatic.
What is the next most appropriate step in his management?
A. Colonoscopy and gastroscopy
B. Colonoscopy from age 25years
C. Colonoscopy with dye spray
D. Five- yearly colonoscopy from age 50 to 75years
E. Genetic testing
18. Which statement regarding primary sclerosing cholangitis/ inammatory
bowel disease (PSC/ IBD) is true?
A. CRC incidence in primary sclerosing cholangitis/ ulcerative colitis (PSC/ UC) is fourfold
greater than in UC alone
B. IBD is detected at colonoscopy in 50% of patients with PSC
C. Mesalazine is considered an ineective rst- line therapy in PSC/ UC
D. PSC is associated with an increased incidence of small bowel CD
E. Screening for CRC should begin 8– 10years after PSC/ IBD diagnosis.
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