CME: Gastroenterology (134430): self-assessment questionnaire ============================================================= * Anton Emmanuel * Tahseen A Chowdhury ## SAQs and answers are ONLINE for RCP fellows and collegiate members **Format** Candidates are asked to choose the best answer from the five possible answers. This best of five format is used in many medical examinations; however, the questions are not intended to be representative of those used in the MRCP(UK) Part 1 or Part 2 Written Examinations. **The answering process** 1. **Go to [https://cme.rcplondon.ac.uk](https://cme.rcplondon.ac.uk)** 2. **Log on using your usual RCP username and password** 3. **Select the relevant CME question paper** 4. **Answer all 10 questions by selecting the best answer from the options provided** 5. **Once you have answered all the questions, click on Submit** **Registering your external CPD credits** Carrying out this activity allows you to claim two external CPD credits. These will be automatically transferred to your CPD diary, where you can review the activity and claim your points. 1. **A 60-year-old man presented with abdominal pain. He had coeliac serology performed while on a gluten containing diet: immunoglobulin A – tissue transglutaminase antibodies (IgA-tTG) >128 U/mL (normal range 0–7) and total serum IgA 2.3 g/L (normal range 0.8–3.0).** ***Which would be the next appropriate step in management?*** 1. Commence a lifelong gluten free diet. 2. Perform human leukocyte antigen (HLA) typing. 3. Perform IgA – anti-endomysial antibodies (EMA). 4. Perform IgG-EMA. 5. Refer for gastroscopy. 2. **A 25-year-old woman presented to secondary care with symptoms of a ‘foggy mind’ a few hours after consuming gluten. She self-imposed a gluten free diet for the previous 6 weeks and was unwilling to re-introduce gluten. Bloods tests including a full blood count, haematinics, vitamin D and thyroid stimulating hormone (TSH) were normal. Coeliac serology was performed on a gluten free diet: IgA-TTG 2 U/mL (normal range 0–7) and total serum IgA 2.0 g/L (normal range 0.8–3.0).** ***Which next step would most reliably exclude coeliac disease in this scenario?*** 1. Colonoscopy. 2. Gastroscopy. 3. HLA typing. 4. IgG-tTG. 5. Sustained improvement of symptoms on gluten free diet. 3. **A 32-year-old woman with established coeliac disease, who had been on a gluten free diet for 5 years, presented to secondary care for evaluation of her chronic bloating of 4 months duration. She was seen by a dietitian who stated she had excellent adherence to a gluten free diet. Blood tests including full blood count, haematinics, vitamin D and TSH were normal. Coeliac serology while on a gluten free diet showed IgA-tTG 5 U/mL (normal range 0–7) and total serum IgA 1.9 g/L (normal range 0.8–3.0).** ***Which is the next appropriate investigation?*** 1. Colonoscopy. 2. Faecal elastase. 3. Gastroscopy. 4. Hydrogen breath test. 5. SeHCAT. 4. **A 35-year-old woman had watery stools, up to eight times daily, for 12 years, with urgency but no evidence of bleeding or weight loss. Routine blood tests were normal, and she had had two ileo-colonoscopies with normal terminal ileal and colonic biopsies.** ***Which test was most likely to be positive?*** 1. Ascending colonic biopsies. 2. Coeliac disease serology. 3. Faecal calprotectin. 4. Magnetic resonance imaging (MRI) of the abdomen. 5. SeHCAT 7-day retention. 5. **A 65-year-old woman with arthritis presented with fatigue. She had no other symptoms but had been taking ibuprofen regularly for 6 months. Blood tests revealed haemoglobin 6.8 g/dL (12–15), mean corpuscular volume (MCV) 72 fL (80–100), neutrophils 11.2 × 109/L (2.5–8.0), ferritin 18 ng/L (20–120), erythrocyte sedimentation rate (ESR) 18 mm/hour (1–20). Her liver and renal function were within the normal range. Oesophago-gastro-duodenoscopy (OGD), colonoscopy and urinalysis were normal.** ***Which of the following tests are most likely to reveal the cause of the anaemia?*** 1. Computed tomography (CT) of the abdomen. 2. Haemolysis screen. 3. Magnetic resonance enterography. 4. Serum and urine protein electrophoresis. 5. Small bowel capsule endoscopy. 6. **A 72-year-old woman with hypertension and rheumatoid arthritis presented with new symptoms of oesophageal dysphagia, regurgitations and some weight loss.** ***What is the most appropriate initial diagnostic step?*** 1. Cross sectional chest imaging. 2. High resolution manometry. 3. OGD with multiple oesophageal biopsies. 4. Offer her a trial of proton pump inhibitors (PPIs). 5. Timed barium swallow. 7. **A 48-year-old man with no previous significant medical history presented with a long history of dysphagia to solids and liquids. Recently, symptom severity worsened and the patient reported vomiting and weight loss. Previous trials of PPIs were not helpful. OGD has shown a dilated oesophagus with food.** ***What is the most likely diagnosis?*** 1. Achalasia. 2. Eosinophilic oesophagitis. 3. Gastro-oesophageal reflux disease. 4. Jackhammer oesophagus. 5. Oesophageal malignancy. 8. ***Which of the following findings are most likely to represent ulcerative colitis?*** 1. Cobblestone appearance on endoscopy. 2. Granulomas on histology. 3. Inflammation confined to the left side of the colon. 4. Perianal fistula. 5. Small bowel stricture. 9. ***Which of the following drugs are currently licensed to be used in ulcerative colitis?*** 1. Etrasimod. 2. Etrolizumab. 3. Faecal microbiota transplantation. 4. Ozanimod. 5. Tofacitinib. 10. ***In which of the following situations would you avoid using high-dose tofacitinib?*** 1. Chronic obstructive airway disease. 2. Diabetes. 3. History of ischaemic heart disease. 4. Non-responder to infliximab. 5. Previous thromboembolic disease. #### CME Rheumatology SAQ **Answers to the CME SAQ published in *Clinical Medicine* in November 2020** | **Q1** | **Q2** | **Q3** | **Q4** | **Q5** | **Q6** | **Q7** | **Q8** | **Q9** | **Q10** | || | (d) | (e) | (a) | (a) | (b) | (e) | (e) | (d) | (a) | (e) | * © Royal College of Physicians 2021. All rights reserved.