Gastroenterology & Renal

A 30-year-old woman has chronic diarrhoea, bloating and iron-deficiency anaemia. Coeliac disease is suspected. What is the most appropriate first-line investigation?

• AColonoscopy with biopsies of the terminal ileum and colon
• BSerum IgA tissue transglutaminase antibody with total IgA✓
• CFaecal calprotectin to look for intestinal inflammation
• DHydrogen breath test for lactose intolerance

Answer: NICE recommends IgA anti-tTG as the first-line test, with total IgA to exclude IgA deficiency, which would give a false negative. The patient must be eating gluten while being tested. A positive result is followed by duodenal biopsy at endoscopy.

A 55-year-old man with alcohol-related cirrhosis vomits fresh blood and is hypotensive. Alongside resuscitation, which drug should be given before endoscopy?

• ATranexamic acid
• BPropranolol
• CTerlipressin✓
• DOmeprazole intravenously

Answer: In suspected variceal bleeding, terlipressin (a vasopressin analogue) is given at presentation along with antibiotics, and endoscopy follows once the patient is resuscitated. Proton-pump inhibitors are for non-variceal bleeding after endoscopy, and propranolol is for prevention rather than acute bleeding.

A 45-year-old woman presents with severe epigastric pain radiating to the back, with vomiting. Her serum amylase is four times the upper limit of normal. What is the most likely diagnosis?

• AAcute cholecystitis
• BPerforated peptic ulcer
• CMyocardial infarction
• DAcute pancreatitis✓

Answer: Epigastric pain radiating to the back with an amylase (or lipase) more than three times the upper limit of normal is diagnostic of acute pancreatitis; gallstones and alcohol are the commonest causes in the UK. A perforated ulcer causes a rigid abdomen and free air on an erect chest X-ray.

A 68-year-old man's creatinine has risen from 90 to 160 µmol/L over 48 hours after starting a new medicine. Which single criterion confirms acute kidney injury?

• AA fall in eGFR of 10% from baseline
• BUrine output below 1 mL/kg per hour for two hours
• CA rise in creatinine of 26 µmol/L or more within 48 hours✓
• DA creatinine above 120 µmol/L at any time

Answer: AKI is defined by a rise in serum creatinine of 26 µmol/L or more within 48 hours, a rise to 1.5 times or more the baseline within seven days, or urine output below 0.5 mL/kg per hour for six hours. A rise of 70 µmol/L in 48 hours meets the first criterion easily.

A 60-year-old man with chronic kidney disease has a potassium of 7.1 mmol/L and peaked T waves on his ECG. What is the first drug to give?

• AOral calcium resonium
• BIntravenous calcium gluconate✓
• CNebulised salbutamol
• DIntravenous insulin with dextrose

Answer: With ECG changes, intravenous calcium gluconate is given first to stabilise the myocardium and protect against arrhythmia; it does not lower potassium. Insulin with dextrose (and salbutamol) then shift potassium into cells, and calcium resonium removes it slowly over hours.

A 19-year-old man has 24 hours of pain that began around the umbilicus and has moved to the right iliac fossa, with nausea and a low-grade fever. What is the most likely diagnosis?

• AMesenteric adenitis
• BCrohn's disease
• CAcute appendicitis✓
• DRenal colic

Answer: Periumbilical pain migrating to the right iliac fossa with anorexia, nausea and low-grade fever is the classic presentation of appendicitis. Renal colic causes loin-to-groin pain, and mesenteric adenitis usually follows a viral illness in younger children.

Which feature distinguishes Crohn's disease from ulcerative colitis?

• AContinuous inflammation starting in the rectum
• BInflammation limited to the mucosa
• CBloody diarrhoea as the dominant symptom
• DTransmural inflammation with skip lesions anywhere from mouth to anus✓

Answer: Crohn's disease is transmural, patchy (skip lesions) and can affect any part of the gut, with fistulae and strictures. Ulcerative colitis is continuous from the rectum, confined to the mucosa, and typically presents with bloody diarrhoea.

A 22-year-old woman took 30 paracetamol tablets four and a half hours ago. Her paracetamol level is above the treatment line on the nomogram. What is the treatment?

• AGastric lavage
• BIntravenous N-acetylcysteine✓
• COral methionine and observation
• DActivated charcoal alone

Answer: N-acetylcysteine replenishes glutathione and prevents liver damage; it is given when the 4-hour level is on or above the treatment line, and regardless of level in staggered overdoses or when timing is unknown. Activated charcoal is useful only within an hour of ingestion, and gastric lavage is not recommended.

A 40-year-old woman has intermittent right upper quadrant pain after fatty meals, with no fever or jaundice. An ultrasound shows gallstones. What is the appropriate management?

• ALong-term ursodeoxycholic acid to dissolve the stones
• BLithotripsy to break up the stones so they can pass
• CUrgent ERCP to remove the stones from the gallbladder
• DElective laparoscopic cholecystectomy✓

Answer: Symptomatic gallstones (biliary colic) are treated by elective laparoscopic cholecystectomy. ERCP is for stones in the common bile duct, and medical dissolution and lithotripsy are rarely used.

A 25-year-old man has bloody diarrhoea six times a day, abdominal pain, fever and a heart rate of 110. He has known ulcerative colitis. What is the appropriate management?

• AStart loperamide to reduce the stool frequency and allow the bowel to rest and recover
• BIncrease his oral mesalazine to the maximum dose and review in the clinic in a week
• CPrescribe a course of oral antibiotics
• DAdmit for intravenous corticosteroids and monitoring for toxic megacolon✓

Answer: Six or more bloody stools a day with systemic features is acute severe ulcerative colitis by the Truelove and Witts criteria; it needs admission, intravenous steroids and surgical review. Antimotility drugs increase the risk of toxic megacolon.

A 65-year-old man has new-onset dyspepsia with weight loss. What is the most appropriate action?

• AUrgent two-week-wait referral for upper GI endoscopy✓
• BTest and treat for Helicobacter pylori, with a breath test to confirm eradication
• CReassurance and antacids, since dyspepsia at his age is almost always benign
• DA trial of a full-dose proton-pump inhibitor for eight weeks, with endoscopy only if it fails

Answer: Dyspepsia with weight loss in a person over 55 is a red-flag combination in NICE's suspected-cancer guidance and needs urgent endoscopy; PPI trials and H. pylori testing are for uncomplicated dyspepsia without alarm features.

A 50-year-old woman with a BMI of 32 has raised ALT and an ultrasound showing fatty liver. She drinks little alcohol. What is the most likely diagnosis and the key management?

• ANon-alcoholic fatty liver disease — weight loss and management of cardiovascular risk factors✓
• BPrimary biliary cholangitis — ursodeoxycholic acid and monitoring of the alkaline phosphatase
• CHepatitis C — antiviral therapy after confirming the genotype
• DAlcoholic hepatitis — abstinence, nutritional support and a course of steroids

Answer: Fatty liver with raised transaminases in a person with obesity who drinks little is non-alcoholic fatty liver disease, the commonest liver condition in the UK; treatment is weight loss and control of diabetes, lipids and blood pressure.