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gastroenterology

Practice targeted AMC-style multiple-choice questions on gastroenterology.

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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

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

A. Esophageal manometry
B. 24-hour pH monitoring
C. Upper endoscopy
D. CT chest
E. Barium swallow
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents for follow-up after experiencing intermittent episodes of right upper quadrant colicky pain over the past year, which have since resolved. She denies any current pain, fever, jaundice, or changes in bowel habits. Physical examination is unremarkable, and recent liver function tests are within normal limits. An elective abdominal ultrasound was performed, yielding the image shown. Considering the clinical context and the findings demonstrated, what is the most appropriate next step in her management?

A. Discharge with advice to return if symptoms recur
B. ERCP for stone extraction
C. Initiate ursodeoxycholic acid therapy
D. MRCP to further delineate the biliary anatomy
E. Elective laparoscopic cholecystectomy
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A 28-year-old male presents to the emergency department with severe abdominal pain, fever, and bloody diarrhea for the past 2 days. He has a known history of Crohn's disease, diagnosed 5 years ago, and has been managed with azathioprine. He admits to inconsistent adherence to his medication regimen over the past year due to feeling well. On examination, he is febrile (38.9°C), tachycardic (110 bpm), and hypotensive (90/60 mmHg). His abdomen is distended and tender to palpation, particularly in the lower quadrants, with guarding. Laboratory investigations reveal a white blood cell count of 18,000/mm³ with a left shift, hemoglobin of 10 g/dL, platelets of 450,000/mm³, albumin of 28 g/L, and C-reactive protein (CRP) of 150 mg/L. An abdominal X-ray shows dilated loops of bowel. Which of the following is the MOST appropriate next step in the management of this patient?

A. Perform a colonoscopy to assess the extent of the inflammation and obtain biopsies
B. Administer intravenous corticosteroids and anti-diarrheal medications
C. Increase the dose of azathioprine and monitor the patient's symptoms
D. Intravenous fluids, broad-spectrum antibiotics, and urgent surgical consultation
E. Start infliximab infusion immediately after blood cultures are taken
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 38-year-old male presents to the emergency department with a 2-day history of intermittent abdominal pain, nausea, and vomiting. He reports passing dark, tarry stools. He has a known history of multiple cutaneous hemangiomas since childhood. On examination, his abdomen is distended and tender to palpation, particularly in the periumbilical region. Bowel sounds are hyperactive. Vitals are: HR 110 bpm, BP 100/60 mmHg, RR 20 breaths/min, SpO2 97% on room air, Temp 37.2°C. A CT scan of the abdomen and pelvis is performed, and a representative image is shown. Given the clinical presentation and imaging findings, what is the MOST appropriate initial management strategy?

A. Endoscopic evaluation with possible cauterization
B. Initiation of high-dose corticosteroids
C. Administration of intravenous antibiotics
D. Surgical exploration
E. Observation with serial abdominal examinations
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents for review in the outpatient clinic. She reports a history of intermittent, self-resolving episodes of right upper quadrant colicky pain over the past year, but is currently asymptomatic. She denies fever, jaundice, or other systemic symptoms. Her physical examination is unremarkable, and recent liver function tests are within the normal reference range. An elective abdominal ultrasound was performed, yielding the image shown. Based on the clinical presentation and the findings demonstrated, what is the most appropriate next step in her management?

A. Trial of ursodeoxycholic acid
B. Reassurance and discharge with advice to return if symptoms recur
C. Elective laparoscopic cholecystectomy
D. Further investigation with CT abdomen
E. Referral for endoscopic retrograde cholangiopancreatography (ERCP)
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Following successful management of this acute episode, what is the most appropriate next step regarding long-term assessment of the colon?

A. Repeat CT scan in 3 months to assess resolution.
B. Refer for surgical consultation for elective colectomy.
C. Schedule a colonoscopy within 6-8 weeks.
D. Perform a barium enema to assess the extent of diverticular disease.
E. Advise a high-fibre diet and no further investigation unless symptoms recur.
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

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 likely underlying pathology responsible for the patient's symptoms and the observed bowel findings?

A. Mesenteric adenitis triggering intussusception
B. Inflammatory strictures leading to obstruction
C. Lymphoid hyperplasia causing transient intussusception
D. Malignant polyps causing intussusception
E. Intestinal haemangiomas acting as lead points
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 72-year-old woman presents with a long history of heartburn, regurgitation, and recently developed a chronic cough, particularly at night. Physical examination is unremarkable. A chest radiograph is obtained. Considering the radiographic findings in the context of the patient's presentation, what is the most likely pathophysiological mechanism contributing to her chronic cough?

A. Pulmonary oedema secondary to cardiac dysfunction
B. Interstitial lung disease causing restrictive ventilatory defect
C. Compression of the left main bronchus by an enlarged lymph node
D. Bronchial hyperreactivity triggered by inhaled allergens
E. Chronic aspiration of gastric contents
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with dysphagia and early satiety. His BMI is 21. A CT scan is performed. Based on the image, and assuming conservative measures have failed, what surgical approach is MOST appropriate?

A. Partial gastrectomy
B. Esophagectomy
C. Endoscopic dilation
D. Laparoscopic Nissen fundoplication with hiatal hernia repair
E. Heller myotomy
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

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. Referral to medical oncology for systemic chemotherapy
B. Surgical resection of the affected liver segments
C. Initiation of palliative care and symptom management
D. Administration of intravenous antibiotics for presumed liver abscesses
E. Percutaneous ethanol ablation of the largest lesion
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 63-year-old woman with a 20-year history of Crohn's disease presents with a one-month history of worsening abdominal pain, bloating, and occasional vomiting, associated with a 3kg weight loss. She is currently managed with mesalazine and azathioprine. Her vital signs are stable, and physical examination reveals mild right lower quadrant tenderness. Imaging is performed. Considering the clinical presentation and the provided images, which of the following represents the most appropriate next step in this patient's management?

A. Provide symptomatic relief and arrange follow-up in the outpatient clinic.
B. Surgical consultation for assessment of operative management.
C. Repeat cross-sectional imaging in three months to monitor disease progression.
D. Perform a colonoscopy to assess disease activity and extent.
E. Initiate a course of oral corticosteroids and optimise immunosuppression.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old presents with projectile vomiting after feeds. An ultrasound is performed (shown). What is the MOST appropriate next step in management?

A. Trial of thickened feeds
B. Upper endoscopy with biopsy
C. Reassurance and close follow-up
D. Start erythromycin
E. Surgical consultation for pyloromyotomy
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

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. Increase the dose of azathioprine
B. Perform a colonoscopy with biopsy
C. Initiate anti-TNF therapy
D. Prescribe a course of oral corticosteroids
E. Start a trial of antibiotics for possible infectious colitis
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with iron deficiency anemia. The provided CT was performed. What is the MOST likely cause of his anemia?

A. Cameron lesions
B. Vitamin B12 deficiency
C. Gastric malignancy
D. Hookworm infestation
E. Pernicious anemia
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with increasing postprandial fullness. The provided image was obtained. What is the MOST appropriate next step in management?

A. Barium swallow study
B. Surgical repair
C. PPI therapy
D. Endoscopic surveillance
E. H. pylori testing
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

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. Obtain an urgent abdominal MRI for better soft tissue detail
B. Surgical consultation for potential exploration
C. Conservative management with IV fluids and observation
D. Urgent colonoscopy to assess the bowel lumen
E. Attempt hydrostatic reduction with barium enema
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 62-year-old male with cirrhosis presents for routine surveillance. His AFP is elevated at 450 ng/mL. The provided image was obtained. What is the MOST appropriate next step in management?

A. Repeat AFP in 3 months
B. Initiate sorafenib therapy
C. MRI of the abdomen with contrast
D. Percutaneous liver biopsy
E. Referral for liver transplant evaluation
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

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. Referral for liver transplant assessment
B. Initiate treatment with transarterial chemoembolisation (TACE)
C. Percutaneous biopsy of the lesion
D. Commence systemic therapy with Sorafenib
E. Repeat imaging with MRI liver in 4 weeks
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A patient has a pathogenic variant in MLH1 identified via genetic testing. What cancer screening is most strongly indicated?

A. Colonoscopy every 1-2 years from age 25
B. Gastroscopy every 3-5 years from age 50
C. Annual mammography from age 30
D. Renal ultrasound every 2 years from age 30
E. Annual PSA testing from age 40
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A 28-year-old woman presents for a check-up, reporting occasional mild abdominal discomfort. Her father was diagnosed with colorectal cancer at age 48, and his tumour showed microsatellite instability. A paternal aunt had endometrial cancer at 55. Physical exam is normal. What is the most appropriate next step regarding genetic testing?

A. Order a colonoscopy immediately.
B. Test for FAP-associated genes.
C. Order faecal occult blood testing.
D. Offer genetic counselling and testing for Lynch syndrome.
E. Reassure and advise standard screening at age 50.
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

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. Surgical resection of affected bowel segments
B. Perform colonoscopy to rule out other causes of bleeding
C. Initiate a trial of high-dose corticosteroids
D. Prescribe iron supplementation and monitor hemoglobin levels
E. Start empiric antibiotic therapy for suspected bacterial overgrowth
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

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. Amylase
B. Chromogranin A
C. CEA
D. Alpha-fetoprotein
E. CA 19-9
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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

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. Terminate the procedure and schedule surgery
B. Attempt stone extraction with a balloon catheter
C. Administer intravenous antibiotics and observe
D. Perform a sphincterotomy
E. Insert a biliary stent
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with dysphagia and epigastric discomfort. A CT scan is performed, as shown. What is the MOST likely long-term complication?

A. Pneumonia
B. Barrett's esophagus
C. Iron deficiency anemia
D. Gastric volvulus
E. Esophageal stricture
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 5-week-old male infant presents to the emergency department with a 3-day history of non-bilious, projectile vomiting after each feed. He is otherwise well-appearing and afebrile. His mother reports that he is feeding well but seems increasingly hungry after vomiting. On examination, the infant is alert and active, with slightly dry mucous membranes. Abdominal examination is unremarkable, with no palpable masses. An ultrasound of the abdomen is performed, the image of which is shown. What is the most appropriate next step in the management of this patient?

A. Surgical consultation for pyloromyotomy
B. Administer intravenous ondansetron and observe
C. Upper gastrointestinal endoscopy with biopsy
D. Discharge home with instructions for frequent small-volume feeds
E. Initiate a trial of thickened feeds
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

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. Peutz-Jeghers syndrome
B. Blue rubber bleb nevus syndrome
C. Gardner syndrome
D. Henoch-Schönlein purpura
E. Osler-Weber-Rendu syndrome
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

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. Absolute value of serum alpha-fetoprotein
B. Genotype of hepatitis C virus
C. Tumour size and number
D. Patient's chronological age
E. Presence of clinically significant portal hypertension
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents for an elective abdominal ultrasound. Several months ago, she experienced a few episodes of intermittent, moderate-to-severe right upper quadrant pain that resolved spontaneously within a few hours each time. She denies any associated fever, chills, nausea, vomiting, or jaundice during those episodes or currently. She has no significant past medical history other than well-controlled hypertension. On examination today, she is afebrile, her vital signs are stable, and her abdomen is soft and non-tender. Routine blood tests performed prior to the ultrasound, including full blood count, liver function tests (bilirubin, alkaline phosphatase, AST, ALT, GGT), amylase, and lipase, are all within their respective normal reference ranges. The provided image is a representative view obtained during her ultrasound examination. Considering the patient's history, current clinical status, and the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?

A. Elective laparoscopic cholecystectomy alone.
B. Immediate endoscopic retrograde cholangiopancreatography (ERCP).
C. Initiate medical dissolution therapy with ursodeoxycholic acid and review in 3 months.
D. Observation with regular clinical follow-up and repeat abdominal ultrasound in 6 months.
E. Elective endoscopic retrograde cholangiopancreatography (ERCP) followed by elective laparoscopic cholecystectomy.
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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

A 72-year-old male presents with fever, jaundice, and right upper quadrant pain. Investigations confirm acute cholangitis secondary to choledocholithiasis. He is taken for urgent ERCP. Following successful cannulation of the common bile duct and injection of contrast, the image is captured. Considering the findings visualised in the image, which of the following interventions is the most appropriate immediate next step to enable successful management of the underlying pathology during this procedure?

A. Attempt stone extraction using a balloon catheter
B. Place a temporary biliary stent
C. Perform an endoscopic sphincterotomy
D. Attempt stone extraction using a Dormia basket
E. Abandon the ERCP and proceed to surgical exploration
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

Mr. Arthur Jenkins, a 72-year-old retired accountant, presents to his GP complaining of a change in bowel habit over the past 4 months, now experiencing increased frequency and occasional loose stools mixed with some mucus. He also reports intermittent small amounts of bright red blood on the toilet paper, which he initially attributed to haemorrhoids. He denies significant weight loss or abdominal pain. His past medical history includes hypertension well-controlled on medication and osteoarthritis. On examination, his abdomen is soft and non-tender, and digital rectal examination is unremarkable. Routine blood tests, including FBE and LFTs, are within normal limits. A faecal occult blood test is positive. Given these findings, a colonoscopy is arranged. The image provided was captured during the procedure. Considering the patient's presentation and the findings observed during the colonoscopy as depicted in the image, what is the most appropriate immediate next step in the management plan?

A. Attempt endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of the lesion.
B. Advise the patient on dietary modifications to increase fibre intake and schedule a follow-up appointment in 3 months.
C. Prescribe a course of antibiotics for presumed infectious colitis and repeat colonoscopy in 6 weeks.
D. Refer the patient directly for urgent surgical consultation for a potential sigmoid colectomy.
E. Obtain multiple biopsies from the lesion for histological examination and arrange for CT staging of the chest, abdomen, and pelvis.
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A 45-year-old man presents to the clinic with a 3-month history of progressive difficulty swallowing both solids and liquids. He also reports regurgitation of undigested food and occasional chest pain. He has lost 5 kg over this period. On examination, there are no abnormalities noted. A barium swallow study shows a 'bird-beak' appearance of the lower esophagus. What is the most likely diagnosis?

A. Gastroesophageal reflux disease (GERD)
B. Achalasia
C. Diffuse esophageal spasm
D. Esophageal stricture
E. Esophageal cancer
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 28-year-old female presents to her general practitioner with a 6-month history of intermittent abdominal pain, predominantly in the right lower quadrant. She describes the pain as cramping and associated with occasional episodes of non-bloody diarrhea. She denies fever, weight loss, or recent travel. Her past medical history is significant for well-controlled asthma, for which she uses an inhaled corticosteroid as needed. Physical examination reveals mild tenderness to palpation in the right lower quadrant, but is otherwise unremarkable. Bowel sounds are normal. Initial laboratory investigations, including a complete blood count and comprehensive metabolic panel, are within normal limits. Stool studies for ova and parasites, bacterial culture, and Clostridium difficile toxin are negative. Given her persistent symptoms, the GP refers her for further evaluation. A CT enterography is performed, and relevant images are shown. Based on the clinical presentation and imaging findings, which of the following is the MOST likely long-term complication this patient is at increased risk of developing?

A. Toxic megacolon
B. Fulminant colitis
C. Small bowel obstruction
D. Erosive esophagitis
E. Primary sclerosing cholangitis
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A 25-year-old woman presents to the clinic with a 2-week history of abdominal pain and diarrhea. She reports that the pain is crampy and occurs mostly in the lower abdomen. She has also noticed some blood in her stool. She has no significant past medical history and is not on any medications. On examination, she has mild tenderness in the lower abdomen but no rebound tenderness or guarding. What is the most likely diagnosis?

A. Diverticulitis
B. Ulcerative colitis
C. Irritable bowel syndrome
D. Celiac disease
E. Gastroenteritis
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 62-year-old male presents with a 3-month history of rectal bleeding and altered bowel habits. Colonoscopy was performed, and a representative image is shown. What is the MOST appropriate next step in management?

A. Surgical resection
B. Initiate high-dose corticosteroids
C. Repeat colonoscopy in 1 year
D. Prescribe a high-fiber diet
E. Administer intravenous antibiotics
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Considering the clinical context and the findings demonstrated in the provided image, what is the most appropriate recommendation regarding subsequent investigation of the colon following resolution of the acute symptoms?

A. Barium enema within 3 months.
B. Flexible sigmoidoscopy within 1 week.
C. Urgent colonoscopy within 24 hours.
D. No further colonic investigation is necessary.
E. Colonoscopy within 6-8 weeks.
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A 28-year-old male with Crohn's disease presents with increased abdominal pain, fever, and bloody stools. He is on azathioprine. What is the most appropriate next step?

A. Prescribe a high-fibre diet.
B. Start a course of oral metronidazole.
C. Increase the dose of azathioprine.
D. Order a CT scan of the abdomen and pelvis.
E. Reassure the patient and schedule a follow-up appointment.
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A 32-year-old woman presents to her general practitioner complaining of severe anal pain during and after bowel movements, along with bright red blood on the toilet paper. She reports constipation and straining during defecation. Examination reveals a visible longitudinal tear in the anal mucosa at the 6 o'clock position. Which of the following is the MOST appropriate initial management strategy, according to Australian guidelines?

A. Recommend regular sitz baths with antiseptic solution.
B. Prescribe oral antibiotics to treat potential infection.
C. Advise increased fluid and fibre intake, stool softeners, and topical application of a local anaesthetic and a topical nitrate ointment.
D. Refer for surgical lateral internal sphincterotomy.
E. Order a colonoscopy to rule out inflammatory bowel disease.
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 68-year-old male with a history of reflux presents with epigastric pain and vomiting. An X-ray is performed (shown). What is the most likely complication?

A. Gastric volvulus
B. Pericarditis
C. Esophageal stricture
D. Aortic dissection
E. Pneumonia
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 58-year-old male presents with fatigue and iron deficiency anemia. Colonoscopy reveals the image shown. Biopsies are taken. Assuming pathology confirms malignancy, what is the MOST appropriate next investigation to determine disease stage?

A. CT scan of the abdomen and pelvis
B. PET-CT scan
C. Endoscopic ultrasound
D. MRI of the abdomen and pelvis
E. Carcinoembryonic antigen (CEA) level
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

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. Start a course of oral budesonide
B. Initiate treatment with vedolizumab
C. Perform a colonoscopy with biopsy
D. Prescribe a course of oral metronidazole and ciprofloxacin
E. Increase the dose of infliximab
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 32-year-old male with a 10-year history of Crohn's disease presents with worsening abdominal pain and increased frequency of bowel movements. He reports no fever or weight loss. Physical examination reveals mild tenderness in the right lower quadrant. His inflammatory markers are elevated. Review the provided imaging. What is the MOST appropriate next step in management?

A. Initiate anti-TNF therapy
B. Perform a colonoscopy with biopsy
C. Recommend a low-FODMAP diet
D. Start a trial of antibiotics for possible infection
E. Prescribe a course of oral corticosteroids
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A 45-year-old man presents to the emergency department with severe epigastric pain radiating to his back, which started suddenly a few hours ago. He has a history of alcohol use disorder and has been drinking heavily over the past week. On examination, he is diaphoretic and in distress. His vital signs show a blood pressure of 100/60 mmHg, heart rate of 110 bpm, respiratory rate of 22 breaths per minute, and temperature of 37.8°C. Laboratory tests reveal elevated serum lipase and amylase levels. An abdominal ultrasound shows no gallstones. Which of the following is the most appropriate initial management step for this patient?

A. Nasogastric tube insertion
B. Intravenous fluid resuscitation
C. Initiation of broad-spectrum antibiotics
D. Immediate surgical consultation
E. Oral rehydration therapy
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the most appropriate next step in management?

A. Increase dietary fiber intake
B. Surgical resection of the affected bowel segment
C. Flexible sigmoidoscopy
D. IV antibiotics and bowel rest
E. Stool culture for C. difficile
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A 50-year-old man presents to the general practice with a 3-month history of persistent heartburn and regurgitation, especially after meals. He has tried over-the-counter antacids with minimal relief. He denies any weight loss, dysphagia, or gastrointestinal bleeding. What is the most appropriate next step in the management of this patient?

A. Prescribe H2 receptor antagonists
B. Refer to a gastroenterologist
C. Order an upper endoscopy
D. Advise dietary modifications only
E. Start a proton pump inhibitor
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

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. Urgent upper and lower endoscopy to identify bleeding source.
B. Initiation of systemic medical therapy targeting vascular malformations.
C. Further imaging with mesenteric angiography.
D. Laparotomy for reduction or resection of affected bowel segments.
E. Non-operative management with nasogastric tube decompression and intravenous fluids.
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 58-year-old male, on chronic immunosuppressants, presents with vague abdominal pain. The images are shown. What is the MOST likely causative organism?

A. Klebsiella pneumoniae
B. Echinococcus multilocularis
C. Escherichia coli
D. Staphylococcus aureus
E. Entamoeba histolytica
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 62-year-old male with cirrhosis presents for routine surveillance. His AFP is elevated at 450 ng/mL. The provided image was obtained. What is the MOST appropriate next step in management?

A. Repeat AFP in 3 months
B. Initiate sorafenib therapy
C. Schedule a follow-up CT scan in 6 months
D. Referral for liver transplant evaluation
E. Order a liver biopsy
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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

A 62-year-old woman presents with right upper quadrant pain, fever, and jaundice. 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. Ursodeoxycholic acid administration
B. Cholecystectomy
C. Observation with serial liver function tests
D. Sphincterotomy and stone extraction
E. Percutaneous transhepatic biliary drainage
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents to his GP with a 6-month history of intermittent postprandial fullness and mild dysphagia, particularly with solid foods. He reports occasional regurgitation but denies significant heartburn or chest pain. His vital signs are stable, and physical examination is unremarkable. Recent blood tests show mild iron deficiency anaemia. The provided image is from a CT scan of the chest and upper abdomen performed as part of his investigation. Considering the clinical presentation and the significant anatomical finding demonstrated in the image, what is the most appropriate next step in the management of this patient?

A. Urgent upper gastrointestinal endoscopy to assess for malignancy.
B. Initiation of high-dose proton pump inhibitor therapy.
C. Prescription of iron supplements and dietary advice.
D. Barium swallow study to further characterise the anatomy.
E. Referral for surgical assessment and consideration of operative repair.
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with inconsolable crying and drawing up his legs. Stool sample is positive for blood. The ultrasound is shown. What is the next step?

A. Observation
B. Air enema
C. IV antibiotics
D. Stool culture
E. Appendectomy
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