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mcq Dr.Noaman  Internal Medicine - NMU Malabsorption 1. Which of the following gut hormones stimulates acid secretion in the stomach? a. Cholecystokinin b. Gastrin c. Polyprptide P d. Secretin e. VIP 2. An 18...

mcq Dr.Noaman  Internal Medicine - NMU Malabsorption 1. Which of the following gut hormones stimulates acid secretion in the stomach? a. Cholecystokinin b. Gastrin c. Polyprptide P d. Secretin e. VIP 2. An 18 year old man presented acutely to the Emergency Department with a food bolus obstruction after a steak meal. On further questioning, he said that he had suffered similar symptoms in the past, but they usually passed after a few hours. Apart from eczema, he was otherwise fit and well, with no other previous gastrointestinal symptoms. What is the most likely diagnosis? 1. Achalasia cardia 2. Eosinophilic oesophagitis 3. Gastro-oesophageal reflux disease 4. Hiatus hernia 5. Nutcracker oesophagus 3. A 72 year old woman with longstanding hip osteoarthritis presents complains of constipation and loose stool. She undergoes a sigmoidoscopy. A rectal biopsy shows pigment-laden macrophages in the lamina propria. What is the most likely cause? a. Non-steroidal anti-inflammatory drugs b. Crohn's disease c. Diverticular disease d. Whipple's disease e. Laxative abuse 4. A 40 year old man has symptoms of lethargy, joint pains and jaundice which have occurred over the past 8 months. Four years later he became diabetic and was referred to our hospital clinic. He was noted to be pigmented.Haemochromatosis was confirmed by an iron saturation of 93.4%, a ferritin concentration of 1050 µg/l, and typical pre-cirrhotic changes in a liver biopsy specimen. What is the recommended management? a. Venesection b. Haemodialysis c. Liver transplant d. Phenoxybenzamine e. Glucagon Dr.Noaman  Internal Medicine - NMU Malabsorption 5. A 60 year old woman presents with diarrhoea. She had a past history of radiotherapy for ovarian cancer. Small intestine biopsy reveals villous atrophy, crypt hypertrophy, chronic inflammatory cell infiltrate of lamina propria and increase in intraepithelial lymphocytes. What is the likely diagnosis? A. Radiation enteropathy B. Coeliac disease C. Ischaemic colitis D. Crohn's disease E. Tropical Sprue 6. A 55 year old man with a history of heavy alcohol intake presents with acute confusion. A diagnosis of hepatic encephalopathy is made and treatment with lactulose is commenced. What is its mode of action in this context? A. Reduces absorption of chlordiazepoxide B. Inhibits proliferation of ammonia forming organisms in the gut C. Absorbed from gut D. Contraindicated in diabetes mellitus E. Causes hypermagnesaemia 7. A 35 year old lady has sudden onset right upper quadrant pain and abdominal distension. She was well until 5 weeks ago, when over several days she rapidly developed abdominal distension and pain. She was also nauseous and vomiting.On examination, temperature was 37.1°C, her JVP was not raised and breath sounds were clear. Abdominal examination revealed tender hepatomegaly, jaundice and gross ascites. There was also bilateral ankle oedema. What is the likely diagnosis? A. Dubin Johnson syndrome B. Gilbert's syndrome C. Budd Chiari syndrome D. Lymphoma E. Myeloma 8. A 40 year old man who usually drinks only 2 units of alcohol a day went on an alcohol binge with his friends. On that day, he vomited 10 times and was brought to hospital feeling very unwell. He has not previously had any symptoms of dyspepsia or abdominal pains. During physical assessment, he vomits a large bowlful of blood. What is the likely cause of his haemetemesis? A. Oesophageal varices B. Duodenal ulcer C. Mallory Weiss tear D. Gastritis E. Gastric outlet obstruction Dr.Noaman  Internal Medicine - NMU Malabsorption 9. A 30 year old lady has altered bowel habit. At the gastroenterology clinic, her symptoms are reviewed. She has a 2 year history of bloating and abdominal pains. Some weeks she is constipated and during others she has diarrhoea. What is the likely diagnosis? A. Whipple's disease B. Tropical sprue C. Coeliac disease D. Irritable bowel syndrome E. Ulcerative colitis 10. A 60 lady has symptoms of intermittent abdominal pain and loose stool which have occurred over 1 year. Investigations reveal: Hb 8.5 g/dl MCV 85 fl WCC 6 x 109/l Iron 11 (14-29) μmol/l Ferritin 20 (15-200) µmol/l Folate 2 (3-20) ng/ml What investigation should be done? A. Ultrasound of abdomen B. Small bowel biopsy C. Smooth muscle antibodies D. ERCP E. Rigid sigmoidoscopy 11. A 36 year old lady has noticed mild jaundice, worsening joint pains and iscomplaining of itching on her skin for the past 8 months. On examination, she has palpable hepatomegaly and a bronze pigmentation on her skin.Her liver function tests show a bilirubin of 25 μmol/l, ALT 100 U/l, ALP 480 U/l. ANA is negative,anti-mitochondrial antibody is positive at 1/320. Which of the following medications is helpful? A. Desferrioxamine B. Hydrocortisone C. Propanolol D. Ursodeoxycholic acid E. Tranexemic acid 12. A 45 year old man has a diagnosis of coeliac disease. He presents with a one month history of intermittent, colicky, central abdominal pain and weight loss of 5 kg. There is positive faecal occult blood. What is the most appropriate investigation? A. Duodenal biopsy B. Barium enema C. Surgical exploration D. CT scan of abdomen E. Colonoscopy Dr.Noaman  Internal Medicine - NMU Malabsorption 13. A 30 year old psychology lecturer has deranged liver function tests. She also hasjaundice, pruritus and xanthelasmata.Blood tests reveal elevated levels of conjugated bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase and positive anti-mitochondrial antibody. She seeks advice about the associations of the disease. Which one of the following is likely to be associated? A. Raised IgA B. Osteomalacia C. Hyperparathyroidism D. Nephrotic syndrome E. Vitamin A deficiency 14. A 35 year old man presents with 2 bowls full of haemetemesis. He drinks 10 pints of beer a day and has done so for 10 years. Upper GI endoscopy reveals oesophageal varices. Which of the following is effective in reducing the rates of rebleeding in the future? A. Lisinopril B. Propanolol C. Simvastatin D. Ranitidine E. Naproxen 15. Which of the following is true in the investigation of a 30-year-old man with a 2- month history of diarrhoea and weight loss? A. Anormal C-reactive protein (CRP) excludes inflammatory bowel disease B. Hydrogen breath testing for small-bowel bacterial overgrowth is a first- line investigation C. IgA anti-endomysial antibody determination is mandatory D. Stool examination is most likely to identify a cause E. The absence of a travel history precludes an infectious aetiology 16. A 75 year old woman was admitted on the acute medical take with a two-day history of non-bloody diarrhoea. She had a history of ischaemic heart disease, type 2 diabetes mellitus, and dyspepsia. Stool analysis was positive for Clostridium difficile toxin. Which of her medications is most likely to predispose her to this condition? A. Aspirin B. Domperidone C. Metformin D. Nicorandil E. Omeprazole Dr.Noaman  Internal Medicine - NMU Malabsorption 17. A 42 year old woman who had undergone orthotopic liver transplantation 5 years earlier for primary sclerosing cholangitis presented with intermittent abdominal pain and bloody diarrhoea. What is the most likely cause for her symptoms? A. Adhesions B. Recurrent Primary Sclerosing Cholangitis C. Side effects of immunosuppression D. Stomach cancer E. Ulcerative colitis 18. A 34-year-old HIV positive man, poorly compliant with treatment, presents to the gastroenterologists with diarrhoea. Sigmoidoscopy revealed mucosal inflammation with focal haemorrhage, oedematous folds and polypoid lesions. Inclusion bodies were visible on examination of a biopsy. What is the most likely cause of his symptoms and signs? A. Amoebiasis B. Cryptosporidiosis C. Cytomegalovirus (CMV) colitis D. Disseminated mycobacterium avium intracellulare (MAI) E. Ulcerative colitis. 19. A 45 year old man has had a 5 year history of severe sharp, epigastric pains and diarrhoea. He gets 2-3 episodes of these symptoms a day. His GP has prescribed proton pump inhibitors which has helped partly, but he still complains that the symptoms are severe. Which one of the following might confirm the diagnosis? A. Amylase B. ERCP C. C-peptide D. Insulin E. Gastrin level 20. A 30 year old man has had a 10 year history of chronic diarrhea. He has developed episodes of abdominal pain after eating wheat products, and is suspected of having celiac disease. Which one of the following is most likely to be associated? A. Increased serum ferritin B. Osteomalacia C. Anti double stranded DNA antibodies D. Anal ulcers E. Anti-Ro antibodies Dr.Noaman  Internal Medicine - NMU Malabsorption 21. An obese 55 year old woman with Type II diabetes is referred as she has been found to have raised ALT and AST levels. She does not have a history of pruritus or jaundice. She is not on any medication and does not take alcohol. On examination, she has a smooth hepatomegaly of 3 cm edge. There are no xanthelasmata and she does not have signs of chronic liver disease. What is the likely diagnosis? A. Non-alcoholic fatty liver disease B. Neuroacantocythosis C. Chronic hepatitis D. Hepatocellular carcinoma E. Hepatorenal syndrome 22. A 60 year old man complains of a 6 month history of lethargy, fever, weight loss,arthralgia and diarrhoea. Jejunal biopsy reveals flattened mucosa with evidence of periodic acid Schiff (PAS) positive macrophages. What is the diagnosis? A. Tuberculosis B. Tropical sprue C. Whipple's disease D. Helminthic infection E. Ulcerative colitis 23. A 40 year old man has recurrent episodes of bloody diarrhea and lower abdominal cramping. Histologic evaluation of a biopsy from flexible sigmoidoscopy reveals acute inflammation without architectural distortion consistent with ulcerative colitis. Which of the following conditions is associated with the condition? A. Gallstones B. Sclerosing cholangitis C. Erythema nodosum D. Renal calculi E. Vitamin B12 deficiency 24. A 35 year old lady has developed worsening pruritus and jaundice over the past year. Investigations revealed a positive antimitochondrial antibody and a liver biopsy confirmed the diagnosis of primary biliary cirrhosis. Which of the following is associated with the condition? A. Raised IgA B. Male C. Xanthelasma D. Anti gliadin antibody E. Diverticular disease Dr.Noaman  Internal Medicine - NMU Malabsorption 25. A 35 year old man has HIV infection. Recently his CD4 count has dropped to 250 from 600 and viral load has dropped from 10,000 copies to 2000 copies /ml. He has now developed diarrhoea. Which one of the following is likely to cause diarrhoea in a HIV positive patient? A. Staph aureus B. Strep pyogenes C. Cryptosporidium D. Mycobacterium tuberculosis E. Neisseria meningitidis 26. A 70 year old man is admitted with pruritus, lethargy and jaundice. He has not drunk any alcohol for five years. One month ago, he completed a course of CoAmoxiclav which was prescribed by his GP. He also takes diclofenac for osteoarthritis. Investigations reveal: Albumin 37 g/L, Bilirubin 180 umol/L (1-22), AST 220 iu/L (1-30), Alkaline Phosphatase 210 iu/L (1-250), Abdominal ultrasound reveals gallsones without biliary duct dilatation. What is the likely cause of his jaundice? A. Hepatitis C infection B. Diclofenac C. Cholangiocarcinoma D. Co-Amoxiclav E. Alcoholic cirrhosis 27. A 40 year old man presents with slurring of his speech and unsteadiness. He has a coarse tremor in his hands and ataxic, shuffling gait on examination. His blood tests show normal renal function. AST is 250 (1-30) U/l, ALP is 350 (1-250) U/l and Bilirubin is 45 (1-22). Which is the best investigation to confirm a diagnosis? A. Hepatitis screen B. Serum Cu and caeruloplasmin C. MRI of brain D. Serum ferritin E. IT 15 gene test for Huntington's 28. A 35 year old man has who has a history of heavy alcohol intake presents with hematemesis and melena. On admission, he was in a preshock state with severe anemia and was resuscitated with blood and fresh frozen plasma. Endoscopic examination identified bleeding from the varices in the second portion of the duodenum. Which one of the following drugs can be used for treatment? A. Octreotide B. Vitamin C C. Simvastatin D. Carbimazole E. Bromocriptine Dr.Noaman  Internal Medicine - NMU Malabsorption 29. A 50 year old man has returned from India recently and presents with diarrhoea. Which of the following is the commonest cause of traveller's diarrhoea? A. Giardia Lamblia B. Yersinia enterocolitica C. E. Coli D. Shigella Flexneri E. Entamoeba Histolytica 30. A 35 year old man presents with jaundice. He has been on a drug which was prescribed by his GP for several weeks. His blood tests show a bilirubin of 34μmol/L (1-22), ALP of 450 U/l and AST 50 U/l. Which one of the following drugs is likely to cause cholestatic jaundice? A. Chlorpromazine B. Paracetamol C. Ibuprofen D. Allopurinol E. Colchicine 31. A 20 year old patient has recently returned from travelling in South Africa, and is unwell with diarrhoea. She had a 2-week history of profuse loose brown stools, lethargy, weakness, nausea and abdominal discomfort. The diarrhoea had initially settled with loperamide, but then recurred again. A faecal specimen was collected for microscopy and culture, and it subsequently grew Giardia lamblia. What medication should be used for treatment? A. Amoxycillin B. Albendazole C. Metronidazole D. Erythromycin E. Gentamicin 32. A 60 year old woman presents with a 12 month history of chest pain, dysphagia when consuming both solids and liquids. She smokes 15 cigarettes per day and drinks 12 units of alcohol per week. Clinical examination was normal. What is the likely diagnosis? A. Oesophagitis B. Oesophageal web C. Pharyngeal pouch D. Achalasia E. Oesophageal carcinoma 33. A 50 year old man has 5 year history of bloody diarrhoea mixed with mucus. He had lost 2 stones in weight over this time. Flexible sigmoidoscopy showed loss of vascular appearance, erythema, and superficial ulceration consistent with ulcerative colitis. Which one of the following features is associated with the condition? A. Rheumatoid arthritis B. Acromegaly C. Osteomalacia D. Megaloblastic anaemia E. Episcleritis Dr.Noaman  Internal Medicine - NMU Malabsorption 34. A 45 year old woman presents with jaundice and several weeks before had pruritus all over her body. Her only past medical history is Hashimoto's thyroiditis. On examination, she has jaundice, xanthelasmata and hepatomegaly. Which of the following is the most likely cause of the jaundice? A. Cholecystitis B. Primary biliary cholangitis C. Systemic lupus erythematosus D. Hepatitis C E. Cholangiocarcinoma 35. A 35 year old woman has abdominal pain, jaundice and worsening ascites. She drinks 20 units of alcohol each week, and takes the oral contraceptive Pill. Which of the following findings would make a diagnosis of Budd Chiari syndrome likely? A. Encephalopathy B. Tender hepatomegaly C. Ascites fluid protein of 42 g/L D. Alanine aminotransferase of 150 U/L E. Ankle oedema 36. A 50 year old lady complains of epigastric burning pains due to stress. She finally undergoes an OGD which shows gastro-oesophageal reflux. Which medication is the most effective for her condition? A. Nizatidine B. Bismuth C. Gaviscon D. Magnesium trisilicate E. Pantoprazole 37. A 45 year old man presents with haematemesis and melaena. He gives a history of drinking 20 units of alcohol a day for more than 15 years. On examination he has spider naevi, Dupuytren's contracture, jaundice and ascites. Whilst awaiting endoscopy the initial management of this patient should be: A. Propanolol B. Nasogastric tube C. Intravenous pantoprazole D. Terlipressin E. Lactulose 38. A 60 year man presents with malaise, weight loss, diarrhoea and pain in the joints. He is pigmented, has clubbing and lymphadenopathy. He has ascites and ophthalmoplegia. Investigations show that he is anaemic. ECG shows a right bundle branch block and paracentesis abdominis reveals chylous ascites. What is the likely diagnosis? A. Wilson's disease B. Tropical sprue C. Whipple's disease D. Coeliac disease E. Crohn's disease Dr.Noaman  Internal Medicine - NMU Malabsorption 39. A 45 year old man presents with epigastric pain and vomiting. He had pain located at the upper abdomen for the last 8 hours prior to admission. The patient also complained of nausea and two episodes of vomiting. He has an amylase of 500 (60-180) U/l. Ultrasound of the abdomen showed a pancreas with enhanced echogenicity. Which of the following is a poor prognostic indicator? A. White cell count of 10 x 109/L B. Urea of 7 mmol/l C. Glucose of 8 mmol/l D. AST of 350 U/l E. Calcium of 2.8 mmol/l 40. A 60 year old woman has recently been treated with amoxycillin for a tooth abscess. Since then, she has developed diarrhoea for up to 15 times a day. There is blood in the stools. Her Hb is 13 g/dl, WCC 13 x 109/l, platelets 500 x 109/L. Her CRP is 80 mg/l. What is the likely infective organism? A. Clostridium difficile B. Cyclospora C. Cryptospridium D. Clostridium tetani E. Campylobacter 41. A 48 year old man with Child's grade C cirrhosis presents with haematemesis. Which one of the following drugs, administered immediately intravenously, would be appropriate? A. Propranolol B. Sodium Nitroprusside C. Isosorbide dinitrate D. Pabrinex E. Somatostatin 42. A 20 year old man is well but jaundiced. His urine colour is normal. His liver function tests show bilirubin 45 μmol/l(1-22), ALT 26 U/l, AST 25 U/l, GGT 40 U/l and ALP 80 U/L. Ultrasound scan of abdomen shows normal parenchymal texture of the liver. Which diagnosis is most likely? A. Dubin Johnson syndrome B. Crigler Najjar syndrome C. Gilbert's syndrome D. Infectious mononucleosis E. Haemochromatosis 43. A 23 year old man has recently travelled back from the Middle East. He has previously been well and there is no past medical history. He has a 5 day history of bloody diarrhoea and has acute abodminal pains. On examination, he has a temperature of 38°C and a tender lower abdomen. What is the likely causative organism? A. Cryptosporidium B. Shigellosis C. Rota virus D. Giardiasis E. Cholera Dr.Noaman  Internal Medicine - NMU Malabsorption 44. A 48 year old man presents with lethargy and pruritus. He has lost one stone in weight over the past two years. He does not smoke. There is no family history of bowel malignancy. On examination he looks pale but is not jaundiced. There is no hepatomegaly and there are no signs of chronic liver disease. Liver ultrasound shows small gallstones. The gallbladder is not inflamed. There is no biliary duct dilatation. Bilirubin is 18, ALT is 180 U/l, ALP is 800 U/l. ANA and AMA are negative but pANCA is positive. What is the diagnosis? A. Primary biliary cirrhosis B. Cholangiocarcinoma C. Primary sclerosing cholangitis D. Wilson's disease E. Gallstones 45. A 44 year old man presents with frequent diarrhoea and upper abdominal pains. He has had a partial gastrectomy 3 years ago for upper GI bleeding. He is now on high dose omeprazole regularly. A repeat endoscopy now shows two oesopnageal ulcers. What is the appropriate investigation? A. Barium enema B. Insulin tolerance test C. H. pylori serology D. Colonoscopy E. Gastrin levels 46. A 35 year man has abdominal pains, weight loss and diarrhoea. He was subsequently found to be lactose intolerant and a small bowel biopsy showed changes consistent with in coeliac disease. He has also noticed that he is developing itchiness and a generalised rash. Which one of the following skin conditions is it likely to be? A. Erythema marginatum B. Dermatitis herpetiformis C. Erythema chronicum migrans D. Pityriasis rosea E. Tinea versicolor 47. A 40 year old man presented with a 5 day history of bloody diarrhoea. On examination, he was apyrexial, jaundiced and pale. There was no organomegaly but there was mild lower abdominal tenderness.Investigations reveal:Haemoglobin 8.1 g/dL. White cell count 17.5 x 109/L. Platelets 70 x 109/L. urea 11 μmol/l. creatinine 220 μmol/l. aspartate aminotransferase 110 IU/L. Prothrombin time 12s (11.5-15.5). Blood film shows fragmented red cells. What is the likely diagnosis? A. Ulcerative colitis B. Escherichia coli 0157 colitis C. Salmonella enterocolitis D. Campylobecter colitis E. Yersinia colitis Dr.Noaman  Internal Medicine - NMU Malabsorption 48. A 40 year old man visit his GP with symptoms of flushing and dizziness. He also has watery diarrhoea several times a month. On examination he has a systolic murmur in the tricuspid area and a parasternal heave over the left sternal edge. A 24 hour urine shows raised 5HT levels. What is the diagnosis? A. Tropical Sprue B. Crohn's disease C. Phaeochromocytoma D. Carcinoid syndrome E. Pernicious anaemia 49. A 50 year old alcoholic patient presents with confusion and severe derangement of liver function. He has signs of spider naevi, jaundice and gross ascites. Which one of the following features defines fulminant acute hepatic failure? A. Spider naevi B. Leukonychia C. Jaundice D. Ascites E. Encephalopathy 50. A 78-year-old woman was admitted on take because she was unable to cope at home. She said that she felt generally weak, but admitted to no other symptoms. On examination she looked as though she has lost a lot of weight and was jaundiced, but there were no other abnormal physical signs. The most likely diagnosis is: A. Carcinoma of the pancreas B. Carcinoma of the stomach C. Chronic pancreatitis D. Gall stones E. Lymphoma 51. A 32 year old man had recently been diagnosed with ulcerative colitis, which was steroid responsive but frequently relapsed when the dose was reduced. A limited flexible sigmoidoscopy showed erythema, friability and ulcers consistent with mild to moderate colitis. He was started on azathioprine and his colitis appeared to be improving when he suddenly developed acute central abdominal pain and was admitted to hospital. What is most likely diagnosis? A.Acute hepatitis B.Acute pancreatitis C.Colonic perforation D.Fulminant ulcerative colitis E. Renal colic Dr.Noaman  Internal Medicine - NMU Malabsorption 52. A 53- year- old woman with alcohol- related cirrhosis was admitted with hepatic encephalopathy (HE). Her medications were lactulose 20 ml three times a day and carvedilol 3.75 mg once a day. Investigations:  Serum sodium 130 mmol/ L  Serum potassium 4.7 mmol/ L  Serum urea 1.6 mmol/ L  Serum creatinine 90 μmol/ L  Serum creatinine five days previously 40 μmol/ L  Serum bilirubin 50 μmol/ L  Serum ALT 30 U/ L  Serum ALP 150 U/ L  Serum albumin 20 g/ L  INR 1.4  Haemoglobin 13 g/ L  Liver ultrasound Irregular liver edge, moderate ascites, normal portal vein flow, spleen 15 cm. Renal ultrasound Normal. Full septic screen Negative What is the most appropriate next management step for the patient’s renal dysfunction? a. Infusion of crystalloid 1L over eight hours b. Large volume paracentesis with human albumin replacement. c. Monitor renal function d. Terlipressin (1 mg four times a day) e. Twenty per cent human albumin solution (1 g/ kg) for two consecutive days 53. Which of the following is the earliest feature in the pathogenesis of HRS- AKI? a. Activation of the renin– angiotensin– aldosterone system (RAAS) b. Reduced cardiac output c. Renal vasoconstriction d. Splanchnic arterial vasodilation e. Systemic inflammatory response syndrome 54. A 46- year- old man was reviewed in clinic with a two- year history of heartburn and regurgitation. His symptoms persisted despite omeprazole 40 mg twice daily. Investigations:  Gastroscopy..... No evidence of erosive oesophagitis  Oesophageal histology..... Four eosinophils per high- power field What is the next most appropriate step? 6. Barium swallow 7. Fasting gastrin level 8. Long- term metoclopramide 9. Oesophageal pH/ impedence studies 10. Trial of swallowed budesonide Dr.Noaman  Internal Medicine - NMU Malabsorption 55. A 59- year- old man with NASH cirrhosis and diuretic- intolerant ascites presented to the emergency department with abdominal pain. On examination, he had tense ascites and diffuse abdominal tenderness. He had a temperature of 38°C, heart rate 105 beats per minute and blood pressure 90/ 59 mm/ Hg. He was treated empirically with intravenous ceftriaxone and a diagnostic paracentesis was performed. Investigations:  Ascitic fluid cell count 1,555 cells/ mm3 (90% neutrophils)  Ascitic fluid culture at 24 hours  Clostridium perfringens  Bacteroides vulgatus  Enterococcus faecalis What is the next best approach to management? a. Continue ceftriaxone and add metronidazole b. Continue ceftriaxone and repeat diagnostic paracentesis in 48 hours c. Give 1.5 g/ kg human albumin solution d. Perform large volume paracentesis E. Request computed tomography (CT) abdomen and pelvis 56. A 66- year- old woman with a history of peptic ulcer disease (PUD) and ischaemic heart disease was diagnosed with rheumatoid arthritis. She was prescribed regular ibuprofen (400 mg three times daily) and methotrexate.In view of her history of peptic ulcer disease. which of the following is the most appropriate precaution to take? a. Add Omeprazole 20 mg od b. Commence Helicobacter pylori (H. pylori) eradication therapy c. Gastroscopy d. Switch to celecoxib e. Urea breath test 57. A 33- year- old woman of Indian descent was referred with dyspepsia. This had been resistant to omeprazole 20 mg daily and metoclopramide 10 mg three times daily, which she was taking at the time of her gastroscopy. She was on no other medications & Investigations:  Gastroscopy Antral erosions and three large duodenal ulcers in D1 (Forrest class III)  Antral rapid urease test Negative  Haemoglobin 138 g/ L  Plasma viscosity 1.70 mPa/ s  Serum C- reactive protein (CRP) 8 mg/ L  lasma gastrin 90 pmol/ L Which of the following is the most likely diagnosis? a. Crohn’s disease b. H. pylori infection c. Human immunodeficiency virus (HIV) d. Tuberculosis e. Zollinger– Ellison syndrome (ZES) Dr.Noaman  Internal Medicine - NMU Malabsorption 58. A 44-year old woman from Pakistan presented to the emergency department with new ascites. Investigations:  Haemoglobin 120 g/ L  White cell count 9.6 × 109/ L  Platelet count 150 × 109/ L  Serum bilirubin 30 μmol/ L  Serum ALP 120 U/ L  Serum ALT 25 U/ L  Serum creatinine 75 μmol/ L  Serum albumin 30 g/ L  Serum Ca 125 200 U/ mL  Ascitic fluid white cell count 100 cells/ mm3 (75% neutrophils)  Ascitic fluid albumin 15 g/ L  Ascitic fluid protein 20 g/ L  Ascitic fluid Gram stain No organisms What is the most likely diagnosis? a. Cirrhosis b. Gynaecological malignancy c. heart failure d. Nephrotic syndrome e. Tuberculosis 59. A 37- year- old woman with type 1 diabetes mellitus presented to the emergency department with a four- hour history of severe epigastric pain radiating through to the back. Investigations:  Serum bilirubin 36 μmol/ L  Serum alanine aminotransferase (ALT) 152 U/ L  Serum alkaline phosphatase (ALP) 168 U/ L  Serum albumin 30 g/ L  Serum amylase 1,200 U/ L HbA1c 72 mmol/ mol  Serum triglycerides 9 mmol/ L What is the most likely aetiology of this patient’s acute pancreatitis? a. Alcohol b. Drug induced c. Gallstone related d. Hypertriglyceridemia e. Tumour at the ampulla Dr.Noaman  Internal Medicine - NMU Malabsorption 60. A 50 year old patient has a 2 year history of weight loss and diarrhoea. He also gives a history of episodes of flushing. VIP syndrome is considered by the admitting physician. Which one of the following is a feature of VIPoma syndrome? a. Hypoglycaemia b. Hypokalaemia c. Induction of VIP release by somatostatin d. Anaemia e. Increased gastric acid seceretion 61. A 65 year old woman presents with dysphagia and intermittent vomiting. Endoscopy shows a tight lower oesophageal sphincter suggestive of achalasia. Which of the following medical therapies is most effective? a. Diltiazem b. Bismuth c. Glyceryltrinitrate d. Botulinumtoxin e. Glypressin 62. A 55 year old man is suspected of having a duodenal ulcer recurrence despite being on omeprazole. Which of the following is the most sensitive test in detecting ongoing infection with Helicobacter pylori? a. The(13C)ureabreathtest b. Theureasetestonagastricbiopsy c. Agastricfundalbiopsyculture d. Helicobacterpyloriserology e. Stoolculture 63. A 45 year old man has had a 5 year history of severe sharp, epigastric pains and diarrhoea. He gets 2-3 episodes of these symptoms a day. His GP has prescribed proton pump inhibitors which has helped partly, but he still complains that the symptoms are severe. Which one of the following might confirm the diagnosis? a. Amylase b. ERCP c. C-peptide d. Insulin e. Gastrin level 64. A 45 year old asian man presents with epigastric pains of burning nature. This was worst at night. He was prescribed Gaviscon for a year and but this did not relieve his symptoms entirely. He had an endoscopy which did not show any significant abnormalities 3 months ago. Which is the best test for futher investigation? a. Repeatendoscopy b. Ureasebreathtest c. Gastricbiopsy d. 24 hour oesophageal pH study e. Amylase Dr.Noaman  Internal Medicine - NMU Malabsorption 65. A 46 year old man is known to have alcoholic liver cirrhosis. He drinks 60 units of alcohol per week. He presents unwell and confused. Temperature is 38 C and blood pressure is 96/50 mmHg. Abdominal palpation reveals hepatomegaly and ascites. What should be done next? a. Albumin infusion b. Blood cultures c. Diagnostic ascitic tap d. Liver biopsy e. Transjugular intrahepatic shunting 66. A 45 year old man has painless jaundice. He has pale stools and dark urine. On examination he is deeply jaundiced and has scratch marks all over his body. On palpation of the abdomen Courvoisier's sign is positive. Where is the level of biliary obstruction? a. Bile canaliculi b. Intrahepatic ducts c. Hepatic duct d. Accessory duct e. Common bile duct 67. A 60 year old woman presents with a 12 month history of chest pain, dysphagia when consuming both solids and liquids. She smokes 15 cigarettes per day and drinks 12 units of alcohol per week. Clinical examination was normal. What is the likely diagnosis? a. Oesophagitis b. Oesophageal web c. Pharyngeal pouch d. Achalasia e. Oesophageal carcinoma 68. A 43 year male presents with weight loss and watery diarrhoea for several weeks. Investigations reveal hypokalaemia. Which of the following would support a diagnosis of a VIPoma? a. Hypoglycaemia b. Raised Insulin levels c. Pellagra d. Achlorhydria e. Erythema nodosum 69. A 65 year old man presents with dysphagia of solids for the past three months. There is a history of 10 kg weight loss in 4 months following loss of appetite. He has had symptoms of indigestion and heartburn for 10 years. He regularly takes Gaviscon and milk of magnesia. He is a heavy smoker. He undergoes endoscopy, which reveals a small tumour at the lower part of the oesophagus. What is the likely aetiological cause? a. Barrett'soesophagus b. Helicobacterpylori c. Oesophagealpouch d. Familyhistory e. Coloniccarcinomametastases Dr.Noaman  Internal Medicine - NMU Malabsorption 70. A 40 year old woman with epigastric pain undergoes upper GI endoscopy. A biopsy was taken and it revealed a diagnosis of mucosal associated lymphoid tissue. What should be done initially? a. Bilroth'soperation b. Protonpumpinhibitor c. Hpylorieradication d. Radiotherapy e. Chemotherapy 71. A 44 year old man presents with frequent diarrhoea and upper abdominal pains. He has had a partial gastrectomy 3 years ago for upper GI bleeding. He is now on high dose omeprazole regularly. A repeat endoscopy now shows two oesopnageal ulcers. What is the appropriate investigation? a. Barium enema b. Insulin tolerance test c. H. pylori serology d. Colonoscopy e. Gastrin levels 72. A 45 year old woman has been a heavy alcoholic for 20 years, but has cut down on drinking for the past year. She has abdominal pains, malaise and nausea. On examination she had moderate amounts of ascites and generalised abdominal tenderness. Investigations show : Haemoglobin 12 g/dL WCC 14 x 109/L prothrombin time 22 s (