gastroenterology

A 45-year-old man presents to the emergency department with severe epigastric pain radiating to the back. He has a history of alcohol use disorder and has been drinking heavily over the past week. On examination, he is febrile, tachycardic, and has abdominal tenderness. Laboratory tests reveal elevated serum lipase and amylase levels. What is the most appropriate initial management for this patient?

A 75-year-old male presents with worsening dysphagia. An X-ray is performed (shown). What is the most appropriate initial investigation?

A 45-year-old male with Crohn's presents with persistent right lower quadrant pain. Stool studies are negative. Review the imaging. What is the MOST likely complication?

A 62-year-old presents with jaundice and RUQ pain. The image was obtained during ERCP. What is the MOST appropriate next step?

A 45-year-old male with a known history of Blue Rubber Bleb Naevus Syndrome, characterised by recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions, presents to the emergency department with acute onset severe, colicky abdominal pain, nausea, and vomiting. On examination, his abdomen is distended and diffusely tender with reduced bowel sounds. Vital signs are within normal limits. An urgent abdominal CT scan is performed. Based on the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in management?

A 68-year-old male presents with fatigue, weight loss, and vague abdominal discomfort. His past medical history includes a recent diagnosis of gastric mixed adenoneuroendocrine carcinoma (MANEC). The provided image was obtained as part of his staging workup. Which of the following is the MOST appropriate next step in management?

A 62-year-old male with a history of chronic hepatitis C presents to his general practitioner for a routine check-up. He reports no new symptoms. His liver function tests from 6 months ago were within normal limits. However, recent blood work reveals an elevated alpha-fetoprotein (AFP) level of 600 ng/mL (normal <10 ng/mL). The GP orders a contrast-enhanced ultrasound of the liver, the images from which are shown. Based on the ultrasound findings and the patient's history, what is the MOST appropriate next step in management?

A 68-year-old man presents to the emergency department with fatigue, pallor, and shortness of breath on exertion. His blood tests reveal a hemoglobin level of 7.5 g/dL, mean corpuscular volume (MCV) of 72 fL, and low serum ferritin. He has a history of osteoarthritis and takes ibuprofen regularly. What is the most likely cause of his anemia?

A 32-year-old male with a history of Crohn's disease presents with worsening abdominal pain, diarrhea, and a low-grade fever. He reports that his symptoms have been progressively worsening over the past few months despite being on maintenance therapy with azathioprine. A CT scan of the abdomen and pelvis is performed, as shown. Based on the imaging findings, which of the following is the MOST appropriate next step in management?

A 64-year-old woman with past colicky pain has the ultrasound shown. LFTs are normal. What is the MOST appropriate next investigation?

A 63-year-old man presents with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of GERD. Physical examination reveals decreased breath sounds at the left lung base. An axial CT image is shown. Considering the clinical presentation and imaging findings, what is the MOST appropriate next step in management?

A 65-year-old male presents with a 3-month history of unintentional weight loss and early satiety. Gastroscopy and biopsy confirmed a gastric mixed adenoneuroendocrine carcinoma. Staging CT imaging is shown. Considering the clinical presentation and the findings on the provided imaging, what is the most appropriate initial management strategy?

A 63-year-old woman with a 20-year history of Crohn's disease presents with worsening abdominal pain, bloating, and occasional post-prandial vomiting. She is currently managed with mesalazine and budesonide. Physical examination reveals mild right lower quadrant tenderness. Laboratory tests show a slightly elevated CRP. Given her presentation and the provided imaging, what is the most appropriate next step in her management?

A 70-year-old man presents with a 3-month history of worsening constipation, occasional bright red rectal bleeding, and unexplained fatigue. His GP notes mild pallor. Full blood count reveals a haemoglobin of 105 g/L and low ferritin. A colonoscopy is performed, and the image provided is a representative view of a finding in the sigmoid colon. Biopsies were taken. Considering the clinical context and the endoscopic appearance, which of the following is the most appropriate next step in the management pathway to determine the extent of disease?

A 35-year-old male with a history of multiple cutaneous vascular lesions presents with recurrent episodes of crampy abdominal pain and melena over the past month. His vital signs are stable. An abdominal CT scan is performed. Considering the clinical presentation and the findings demonstrated in the provided image, what is the most appropriate next step in the management of this patient?

A 64-year-old woman presents for a routine health check. She reports intermittent episodes of colicky abdominal pain over the past year, which have resolved spontaneously. She denies any current pain, jaundice, fever, or changes in bowel habits. Her physical examination is unremarkable, with a soft, non-tender abdomen. Liver function tests are within normal limits. An abdominal ultrasound, as shown, was performed. Given the clinical context and the ultrasound findings, what is the MOST appropriate next step in management?

A 58-year-old male presents with fatigue and microcytic anemia. He denies overt bleeding but reports occasional dark stools. Colonoscopy reveals the image shown. Biopsies confirm adenocarcinoma. What is the MOST appropriate next investigation to stage the cancer?

A 58-year-old woman with cholangitis undergoes ERCP. The image is obtained. What intervention is MOST appropriate at this time?

A 68-year-old man with known alcoholic cirrhosis presents for routine surveillance. He reports mild fatigue but no other symptoms. Liver function tests are within his baseline. Alpha-fetoprotein is 150 ng/mL (normal <10). The provided images are obtained. Considering the clinical context and the findings demonstrated in the images, what is the most appropriate immediate next step in this patient's management?

A patient has a pathogenic variant in MLH1 identified via genetic testing. What cancer screening is most strongly indicated?

A 6-month-old baby has abdominal swelling and vomiting. An abdominal X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

A 32-year-old male presents to the emergency department with a 3-day history of worsening abdominal pain, primarily localized to the right lower quadrant. He reports associated nausea and decreased appetite but denies vomiting or diarrhea. His past medical history is significant for Crohn's disease, diagnosed 8 years ago, managed with intermittent courses of oral corticosteroids and azathioprine. He admits to poor adherence to his azathioprine regimen over the past year. On examination, he is afebrile with a heart rate of 92 bpm, blood pressure of 120/80 mmHg, and oxygen saturation of 98% on room air. Abdominal examination reveals tenderness to palpation in the right lower quadrant with guarding. Bowel sounds are normoactive. Laboratory investigations reveal a white blood cell count of 11,500/µL with neutrophilia, a C-reactive protein (CRP) of 45 mg/L, and normal liver function tests. A CT scan of the abdomen and pelvis with IV contrast is performed, the relevant images of which are shown. Given the patient's presentation and imaging findings, which of the following is the MOST appropriate next step in management?

A 45-year-old male presents with intermittent abdominal pain, bloating, and melena. He has a history of multiple cutaneous hemangiomas. A CT scan of the abdomen is performed, as shown. What is the MOST likely underlying cause of the patient's presentation?

A 45-year-old male presents with intermittent abdominal pain and melena. The provided image was obtained. What is the most appropriate next step in management?

A 70-year-old male with known gastric MANEC presents with worsening jaundice and ascites. The provided CT scan was performed. Which of the following serum markers would be MOST useful in monitoring disease progression in this patient?

A 35-year-old man presents with 3 weeks of anal pain after defecation, blood on wiping, and constipation (firm stool every 2-3 days). What is the likely diagnosis?

A 62-year-old male presents with jaundice and right upper quadrant pain. Initial labs show elevated bilirubin and alkaline phosphatase. An ERCP is performed, and the image is obtained. What is the MOST appropriate next step in management?

A 70-year-old male with known cirrhosis secondary to non-alcoholic fatty liver disease is undergoing routine surveillance. His recent surveillance ultrasound identified a new 3 cm lesion in segment VIII. His alpha-fetoprotein level is 45 ng/mL (previously normal). A contrast-enhanced ultrasound is performed, with representative images shown. Based on the clinical context and the findings demonstrated in the images, what is the most appropriate immediate next step in this patient's management?

A 72-year-old presents with acute cholangitis (fever, jaundice, RUQ pain). LFTs show obstructive pattern. ERCP is performed for biliary decompression and stone extraction. Following successful cannulation and cholangiography, the image is obtained. Based on the findings demonstrated in the image, what is the most appropriate immediate next step during this procedure?

A 45-year-old male presents with intermittent abdominal pain and melena. He has multiple cutaneous hemangiomas. The provided image was obtained. What is the MOST likely underlying cause of the patient's presentation?

A 62-year-old male with a history of chronic hepatitis C presents with right upper quadrant pain, weight loss, and jaundice. Physical examination reveals hepatomegaly and mild ascites. Laboratory investigations include elevated alpha-fetoprotein (AFP) levels. Imaging is performed as shown. Considering the clinical context and the findings demonstrated in the imaging, which of the following factors is MOST critical in determining this patient's eligibility for potentially curative surgical resection?

A 62-year-old male with cirrhosis presents for routine surveillance. AFP is elevated. The provided image was obtained. What is the MOST appropriate next step in management?

A 65-year-old male with Hepatitis C cirrhosis is undergoing routine surveillance. A liver lesion was identified on initial ultrasound, prompting a contrast-enhanced ultrasound study. Considering the findings demonstrated in the provided images, what is the most appropriate next step in the management of this patient?

A 62-year-old male with a history of hepatitis C presents with new onset jaundice and abdominal distension. Ascites is confirmed on examination. The patient denies alcohol use. An ultrasound with contrast is performed, as shown. What is the MOST appropriate next step in management?

A 62-year-old male with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is elevated. A CT scan of the abdomen with and without contrast is performed, as shown. What is the MOST appropriate next step in management?

A 65-year-old male presents with left lower quadrant abdominal pain for 3 days, associated with constipation. He denies fever. An abdominal CT scan is performed, the axial view is shown. What dietary advice is MOST appropriate at discharge?

A 48-year-old man with multiple cutaneous hemangiomas presents with crampy abdominal pain and guaiac-positive stools. The provided image was obtained. What is the MOST appropriate initial diagnostic test to identify the source of bleeding?

A 62-year-old male with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is markedly elevated. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A 64-year-old woman reports intermittent RUQ pain. She denies jaundice or fever. An abdominal ultrasound was performed, image shown. Besides referral for surgery, what is the MOST appropriate next step in management?

A 32-year-old male with a 10-year history of Crohn's disease presents with worsening abdominal pain and diarrhea despite being on maintenance infliximab. He denies fever or blood in his stool. Physical exam reveals mild tenderness in the right lower quadrant. The provided imaging was obtained. What is the MOST appropriate next step in management?

A 68-year-old male with known Hepatitis B related cirrhosis and a history of alcohol excess presents for routine surveillance. His alpha-fetoprotein (AFP) level, which has been stable at 15 ng/mL for the past two years, is now noted to be 185 ng/mL. A screening ultrasound performed three months prior was reported as showing diffuse parenchymal changes consistent with cirrhosis but no focal lesions. Due to the elevated AFP, a repeat ultrasound was performed, which identified a 2.5 cm nodule in segment VIII. To further characterise this lesion, a contrast-enhanced ultrasound (CEUS) was performed, and the images provided are representative findings from this study. The patient has well-compensated cirrhosis (Child-Pugh A) and no significant comorbidities. His liver function tests are within normal limits except for a slightly elevated GGT. Given the clinical context and the findings demonstrated in the provided images, what is the most appropriate next step in the management of this patient?

A 62-year-old male presents with rectal bleeding and altered bowel habits. Colonoscopy findings are shown. What is the MOST appropriate next step?

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with subjective fever and chills. He denies nausea, vomiting, or change in bowel habits. On examination, he is afebrile, heart rate 85 bpm, blood pressure 130/80 mmHg. Abdominal examination reveals tenderness in the left iliac fossa without guarding or rebound. White cell count is 14 x 10^9/L, CRP 80 mg/L. A CT scan of the abdomen and pelvis is performed, the relevant axial image is shown. Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management strategy?

A 62-year-old male presents to the emergency department complaining of worsening abdominal pain, fatigue, and a 10kg unintentional weight loss over the past 3 months. He reports a history of peptic ulcer disease treated with long-term proton pump inhibitors. Physical examination reveals mild hepatomegaly and trace ascites. Initial laboratory investigations show elevated alkaline phosphatase and gamma-glutamyl transferase (GGT), with normal bilirubin and transaminases. A CT scan of the abdomen and pelvis with contrast is performed, and relevant images are shown. Given the clinical presentation and the findings on the imaging, which of the following is the MOST appropriate next step in management?

A 68-year-old woman presents to the emergency department with a 2-day history of right upper quadrant abdominal pain, fever, and yellowing of her eyes. Her vital signs are stable, but laboratory investigations reveal elevated inflammatory markers and liver function tests consistent with biliary obstruction and infection. An ERCP is performed, and the image is obtained. Following successful intervention to relieve the obstruction, the patient's symptoms begin to improve. Considering the likely underlying cause of this presentation and the findings during the procedure, what is the MOST appropriate next step in managing this patient's condition?

A 4-week-old male presents with projectile vomiting after feeding. He is irritable and appears dehydrated. An upper GI series is performed, as shown. After addressing immediate concerns, what is the MOST appropriate next step?

A 62-year-old male with a history of poorly controlled diabetes presents with fever, RUQ pain, and recent travel to a rural area. Lab results show elevated ALP and GGT. Imaging is performed. What is the MOST appropriate next step in management?

A 45-year-old patient with a long history of recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions presents with acute onset severe abdominal pain, nausea, and distension. Physical examination reveals a distended, mildly tender abdomen. Bowel sounds are reduced. Vital signs are stable. Imaging is performed. Considering the patient's presentation and the findings demonstrated in the image, which of the following represents the most appropriate initial management approach?

A 68-year-old man presents to his GP with a 4-month history of increasing constipation alternating with loose stools, occasional rectal bleeding, and a feeling of incomplete evacuation. He reports fatigue but denies significant weight loss. His physical examination, including digital rectal examination, is normal. Full blood count shows a haemoglobin of 115 g/L with low ferritin. A colonoscopy is performed, and the image provided is a representative view from the procedure. Considering the clinical presentation and the finding observed during the colonoscopy, what is the most appropriate immediate next step in the management of this patient?

A 65-year-old man presents to the emergency department with a 2-day history of worsening left lower quadrant abdominal pain, associated with fever and chills. He reports a change in bowel habit with increased constipation. On examination, he is febrile at 38.6°C and has significant tenderness and guarding in the left iliac fossa. His white cell count is 18 x 10^9/L. A CT scan of the abdomen and pelvis is performed (image provided). Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management step in addition to intravenous antibiotics?