MCQ bank · 37 questions · free
Upper GI & bariatric surgery MCQs with answers
37 single-best-answer questions on peptic ulcer, GI bleeding, oesophagus, stomach and bariatric surgery. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 54-year-old man has had sudden epigastric pain for 6 hours. CT shows free gas and a perforated duodenal ulcer. He is stable after resuscitation. What is the standard operation?
- Total gastrectomy
- Non-operative management for every patient
- Laparoscopic or open omental patch repair, then Helicobacter pylori eradication
- Partial gastrectomy
- Truncal vagotomy and pyloroplasty
Show the answer and explanation
Answer: C. Laparoscopic or open omental patch repair, then Helicobacter pylori eradication. Simple closure with an omental patch, by laparoscopy where expertise allows, is the standard for small perforated ulcers. Test for and eradicate H. pylori, and give a proton pump inhibitor.
Why not the others? Acid-reducing operations are rarely needed in the PPI era. Non-operative treatment is reserved for highly selected patients with a sealed perforation.
References
A 40-year-old man vomited a small amount of blood once after drinking alcohol. He is well: pulse 78, blood pressure 128/80, haemoglobin and urea normal, no melaena or comorbidity. His Glasgow-Blatchford score is 0. What is appropriate?
- Urgent endoscopy within 2 hours
- Discharge, with outpatient endoscopy if needed
- CT angiography
- Admission for intravenous proton pump inhibitor
- Blood transfusion
Show the answer and explanation
Answer: B. Discharge, with outpatient endoscopy if needed. A Glasgow-Blatchford score of 0–1 identifies patients at very low risk who do not need admission or urgent endoscopy and can be managed as outpatients.
Why not the others? Pre-endoscopy intravenous PPI is not recommended by NICE.
References
On the second day after a laparoscopic sleeve gastrectomy, a patient has a heart rate of 126, a temperature of 38.1 °C and mild left upper quadrant pain. The abdomen is soft. What is the most important next step?
- Treat as anxiety
- Reassurance and paracetamol
- Start oral fluids
- Urgent CT with oral contrast, or a return to theatre if unstable, to look for a staple-line leak
- Discharge with antibiotics
Show the answer and explanation
Answer: D. Urgent CT with oral contrast, or a return to theatre if unstable, to look for a staple-line leak. Persistent tachycardia is the most sensitive early sign of a leak after bariatric surgery; obese patients often have few abdominal signs. A leak must be excluded urgently, and unstable patients go back to theatre.
Why not the others? Waiting for peritonitis to develop delays treatment of a life-threatening complication.
References
A 44-year-old woman has a BMI of 32.5 kg/m² and type 2 diabetes that remains poorly controlled despite three drugs. According to the 2022 ASMBS/IFSO guidelines, what do you advise?
- Wait until she needs insulin
- Only endoscopic treatment is allowed
- Surgery is contraindicated below a BMI of 40
- Surgery is possible only above a BMI of 35 with two comorbidities
- Metabolic and bariatric surgery should be considered
Show the answer and explanation
Answer: E. Metabolic and bariatric surgery should be considered. The 2022 guidelines recommend surgery for a BMI of 35 or more regardless of comorbidity, and advise considering it from a BMI of 30 in people with metabolic disease such as type 2 diabetes.
Why not the others? The old 1991 NIH thresholds (40, or 35 with comorbidity) have been replaced.
References
A 34-year-old woman has 1 year of difficulty swallowing both solids and liquids, regurgitation of undigested food and weight loss. Upper endoscopy is normal apart from some retained food. Barium swallow shows a dilated oesophagus with a narrow “bird’s beak” end. Which test confirms the diagnosis?
- CT of the chest
- Repeat endoscopy with biopsies of the duodenum
- Gastric emptying study
- High-resolution oesophageal manometry
- 24-hour pH monitoring
Show the answer and explanation
Answer: D. High-resolution oesophageal manometry. High-resolution manometry is the gold standard for achalasia: it shows failed relaxation of the lower oesophageal sphincter and absent peristalsis, and the Chicago classification subtype guides treatment (pneumatic dilatation, Heller myotomy or POEM). Endoscopy comes first to exclude a tumour at the cardia (pseudoachalasia).
Why not the others? pH monitoring is for reflux. CT is used only if malignancy is suspected.
References
A 58-year-old man has 6 cm of Barrett’s oesophagus with intestinal metaplasia and no dysplasia on biopsies. How often should he have surveillance endoscopy?
- Every 3 years
- Every 3 months
- Every 10 years
- Never; surveillance is not useful
- Every year
Show the answer and explanation
Answer: A. Every 3 years. For non-dysplastic Barrett’s, the ACG recommends surveillance every 3 years for segments of 3 cm or more, and every 5 years for shorter segments. Dysplasia changes the plan: low-grade dysplasia is usually treated with endoscopic ablation, and high-grade dysplasia with endoscopic resection and ablation.
Why not the others? Very frequent endoscopy is unnecessary for non-dysplastic disease.
References
After heavy vomiting following a large meal and alcohol, a 50-year-old man has severe chest pain. On examination he has crackling under the skin of his neck. Which investigation is most useful?
- ECG and troponin only, then discharge if normal
- Flexible endoscopy as the first test in every case
- Barium swallow
- Abdominal ultrasound
- CT of the chest and abdomen with oral water-soluble contrast
Show the answer and explanation
Answer: E. CT of the chest and abdomen with oral water-soluble contrast. Vomiting, chest pain and surgical emphysema (Mackler’s triad) suggest spontaneous oesophageal rupture (Boerhaave syndrome). CT with oral contrast shows the leak, mediastinal air and collections, and guides management. Outcome depends on early diagnosis.
Why not the others? An ECG is reasonable, but a normal one must not reassure. Barium causes mediastinitis if it leaks.
References
Two years after a laparoscopic Roux-en-Y gastric bypass and 40 kg of weight loss, a woman has attacks of colicky upper abdominal pain after meals. Today the pain is constant. CT shows a “swirl” of the mesenteric vessels. What do you do?
- Treat as biliary colic
- Repeat CT in 3 months
- Proton pump inhibitor and outpatient endoscopy
- Reassure her that the pain is psychological
- Urgent diagnostic laparoscopy to reduce an internal hernia and close the mesenteric defects
Show the answer and explanation
Answer: E. Urgent diagnostic laparoscopy to reduce an internal hernia and close the mesenteric defects. Internal hernia through a mesenteric defect (such as Petersen’s space) is a leading cause of bowel obstruction after gastric bypass and becomes more likely as weight loss reduces mesenteric fat. Blood tests and even CT can be normal, so a low threshold for laparoscopy is essential. Closing the defects at the primary operation reduces the risk.
Why not the others? Waiting risks strangulation of a long length of small bowel.
References
Endoscopic ultrasound and biopsy show a 3.5-cm gastrointestinal stromal tumour (GIST) in the gastric body with no metastases on CT. What is the standard treatment?
- Radiotherapy
- Complete surgical resection with clear margins, often a laparoscopic wedge resection, without lymphadenectomy
- Observation with endoscopy every 5 years
- Total gastrectomy with D2 lymphadenectomy
- Chemotherapy with 5-FU
Show the answer and explanation
Answer: B. Complete surgical resection with clear margins, often a laparoscopic wedge resection, without lymphadenectomy. GISTs of 2 cm or more are resected with negative margins, avoiding tumour rupture. Lymph node metastases are rare, so lymphadenectomy is not needed. Adjuvant imatinib is considered for high-risk tumours based on size, mitotic rate, site and rupture.
Why not the others? GISTs do not respond to conventional chemotherapy; the effective drug is the tyrosine kinase inhibitor imatinib.
References
Six weeks after a sleeve gastrectomy, a patient who has been vomiting repeatedly becomes confused and unsteady, with nystagmus. What do you give first?
- Oral multivitamins
- Intravenous thiamine, before any glucose-containing fluid
- Vitamin B12 injection
- An antiemetic only
- Intravenous 5% glucose
Show the answer and explanation
Answer: B. Intravenous thiamine, before any glucose-containing fluid. Persistent vomiting after bariatric surgery can rapidly deplete thiamine, causing Wernicke’s encephalopathy (confusion, ataxia, eye signs). High-dose intravenous thiamine is given urgently; glucose given first can precipitate or worsen it. The cause of the vomiting, such as a stricture, must also be investigated.
Why not the others? B12 deficiency develops over months to years, not weeks.
References
A fit 59-year-old man has an adenocarcinoma of the gastro-oesophageal junction staged as T3 N1 M0. What is the standard treatment?
- Multimodal treatment: perioperative chemotherapy (e.g. FLOT) or neoadjuvant chemoradiotherapy, then oesophagectomy or gastrectomy
- Endoscopic mucosal resection
- Surgery alone
- Palliative stent only
- Radiotherapy alone
Show the answer and explanation
Answer: A. Multimodal treatment: perioperative chemotherapy (e.g. FLOT) or neoadjuvant chemoradiotherapy, then oesophagectomy or gastrectomy. Locally advanced gastro-oesophageal adenocarcinoma has better survival when surgery is combined with perioperative chemotherapy (FLOT) or preoperative chemoradiotherapy (CROSS). The choice is made by the multidisciplinary team.
Why not the others? Endoscopic resection is only for early (T1a) cancers.
References
A year after a Roux-en-Y gastric bypass, a woman has palpitations, sweating, cramping and diarrhoea within 30 minutes of eating sweet foods. What is the first-line treatment?
- Dietary changes: small, frequent meals, avoiding simple sugars, separating liquids from solids, and more protein and fibre
- High-sugar drinks when symptoms start
- Proton pump inhibitor
- Insulin
- Reversal of the bypass
Show the answer and explanation
Answer: A. Dietary changes: small, frequent meals, avoiding simple sugars, separating liquids from solids, and more protein and fibre. Early dumping occurs when hyperosmolar food enters the small bowel rapidly, causing fluid shifts and gut hormone release. Most patients improve with dietary changes. Acarbose or octreotide are options if diet fails; surgery is rarely needed. Late dumping (1–3 hours after eating) causes hypoglycaemia.
Why not the others? Sugar worsens dumping.
References
A 72-year-old woman has a large type III para-oesophageal hiatal hernia with post-prandial chest pain, early satiety and iron-deficiency anaemia. She is fit for surgery. What do you advise?
- Proton pump inhibitor only and no surgery
- Elective laparoscopic repair: reduction of the hernia, excision of the sac, crural repair and usually a fundoplication
- Wait for an emergency to occur
- Total gastrectomy
- Endoscopic dilatation
Show the answer and explanation
Answer: B. Elective laparoscopic repair: reduction of the hernia, excision of the sac, crural repair and usually a fundoplication. Symptomatic para-oesophageal hernias should be repaired electively, because emergency surgery for volvulus or strangulation carries much higher morbidity and mortality. Anaemia from Cameron lesions is a common feature. Asymptomatic hernias in older patients may be watched.
Why not the others? A PPI treats reflux but not mechanical symptoms or the risk of volvulus.
References
A 35-year-old with dyspepsia has a positive Helicobacter pylori breath test. He lives in a region with high clarithromycin resistance and has no penicillin allergy. What is the recommended first-line treatment?
- Amoxicillin alone
- 7-day triple therapy with clarithromycin
- Surgery
- 14-day bismuth quadruple therapy (PPI, bismuth, tetracycline and metronidazole)
- PPI alone for 4 weeks
Show the answer and explanation
Answer: D. 14-day bismuth quadruple therapy (PPI, bismuth, tetracycline and metronidazole). Where clarithromycin resistance is common (above 15%), clarithromycin-based triple therapy fails too often. Bismuth quadruple therapy for 14 days is recommended first-line, and eradication should be confirmed with a breath or stool test at least 4 weeks after treatment.
Why not the others? Short courses and single antibiotics have low eradication rates.
References
A day after successful endoscopic treatment of a bleeding duodenal ulcer, the patient has fresh melaena and drops his blood pressure. What is the next step after resuscitation?
- Double the oral PPI and observe
- Repeat endoscopy and endoscopic therapy; if this fails, transcatheter arterial embolisation, with surgery if embolisation is not available or fails
- Tranexamic acid as the main treatment
- Immediate gastrectomy
- CT colonography
Show the answer and explanation
Answer: B. Repeat endoscopy and endoscopic therapy; if this fails, transcatheter arterial embolisation, with surgery if embolisation is not available or fails. Rebleeding after endoscopic haemostasis is managed with a second endoscopic attempt. If that fails, angiographic embolisation is preferred to surgery in many centres, with surgery reserved for when embolisation fails or is unavailable.
Why not the others? High-dose tranexamic acid does not reduce mortality in GI bleeding (HALT-IT) and increases venous thrombosis.
References
Endoscopy in a 60-year-old shows a 1.5-cm, well-differentiated, non-ulcerated intestinal-type gastric cancer confined to the mucosa (T1a) with no nodes on staging. What is the preferred treatment?
- Radiotherapy
- Total gastrectomy with D2 lymphadenectomy
- Observation
- Endoscopic submucosal dissection (en-bloc resection)
- Chemotherapy only
Show the answer and explanation
Answer: D. Endoscopic submucosal dissection (en-bloc resection). Early gastric cancers meeting criteria for very low nodal risk (well-differentiated, intramucosal, non-ulcerated, small) can be cured by en-bloc endoscopic submucosal dissection, preserving the stomach. If the resected specimen shows higher-risk features, surgery follows.
Why not the others? Gastrectomy is for cancers outside these criteria.
References
A 30-year-old man swallowed drain cleaner (strong alkali) 2 hours ago. He has drooling and chest pain but is haemodynamically stable. Which statement is correct?
- Induce vomiting immediately
- Do not induce vomiting or try to neutralise; secure the airway if needed and assess the injury with CT and/or endoscopy to guide surgery
- Pass a nasogastric tube blindly
- Discharge if he can swallow saliva
- Give acid to neutralise the alkali
Show the answer and explanation
Answer: B. Do not induce vomiting or try to neutralise; secure the airway if needed and assess the injury with CT and/or endoscopy to guide surgery. Vomiting re-exposes the oesophagus to the caustic agent, and neutralisation produces heat. Early assessment identifies transmural necrosis that needs emergency resection; patients with lesser injury are treated conservatively and later monitored for strictures and long-term cancer risk.
Why not the others? Blind tube insertion risks perforation.
References
Eighteen months after a Roux-en-Y gastric bypass, a woman who smokes and takes ibuprofen for back pain has epigastric pain on eating. Endoscopy shows an ulcer at the gastrojejunal anastomosis. What is the treatment?
- High-dose proton pump inhibitor (opened capsule or soluble form), stopping smoking and NSAIDs
- Continue ibuprofen with a PPI
- Reversal of the bypass
- Revision surgery immediately
- Antacids only
Show the answer and explanation
Answer: A. High-dose proton pump inhibitor (opened capsule or soluble form), stopping smoking and NSAIDs. Marginal ulcers are linked to smoking, NSAIDs, H. pylori and poor blood supply. Most heal with high-dose PPI and removal of the risk factors. Surgery is for complications (perforation, bleeding, stricture) or non-healing ulcers.
Why not the others? Continuing smoking and NSAIDs leads to recurrence and complications.
References
A 45-year-old has heartburn that responds to PPIs but wants to stop medication and is considering an anti-reflux operation. What must be done before a fundoplication?
- Only a trial of a higher PPI dose
- CT of the chest
- Barium swallow alone
- Upper endoscopy, ambulatory pH monitoring off PPI, and oesophageal manometry
- No tests if symptoms are typical
Show the answer and explanation
Answer: D. Upper endoscopy, ambulatory pH monitoring off PPI, and oesophageal manometry. Before surgery, reflux must be objectively proven (erosive oesophagitis on endoscopy or abnormal pH monitoring), and manometry excludes major motility disorders such as achalasia, which would be worsened by a fundoplication. Good response to PPI predicts a good surgical result.
Why not the others? Typical symptoms alone are not reliable enough to justify an operation.
References
A 29-year-old woman who had a sleeve gastrectomy 4 months ago asks when it is safe to become pregnant. What do you advise?
- Delay pregnancy for 12–18 months after surgery, use reliable contraception (not relying on oral pills alone), and take nutritional supplements
- Wait 10 years
- Become pregnant immediately
- Pregnancy is never safe after bariatric surgery
- Stop all vitamin supplements during pregnancy
Show the answer and explanation
Answer: A. Delay pregnancy for 12–18 months after surgery, use reliable contraception (not relying on oral pills alone), and take nutritional supplements. During the rapid weight-loss phase, nutritional deficiencies can harm the fetus, so pregnancy is delayed until weight stabilises, usually 12–18 months. Oral contraceptive absorption may be reduced, especially after malabsorptive procedures, so long-acting methods are preferred. Pregnancy after bariatric surgery is generally safe with nutritional monitoring.
Why not the others? Supplements, including folic acid, iron, B12 and vitamin D, become even more important during pregnancy.
References
A 63-year-old man has 6 weeks of progressive difficulty swallowing solids and has lost 5 kg. What is the correct action?
- PPI trial for 8 weeks, then review
- Speech therapy only
- Reassurance
- Urgent direct-access upper GI endoscopy on a suspected cancer pathway
- Barium swallow in 3 months
Show the answer and explanation
Answer: D. Urgent direct-access upper GI endoscopy on a suspected cancer pathway. Dysphagia, especially progressive dysphagia to solids with weight loss, is a red flag for oesophageal or gastric cancer at any age and needs urgent endoscopy. NICE also recommends urgent endoscopy for people aged 55 and over with weight loss plus upper abdominal pain, reflux or dyspepsia.
Why not the others? A PPI trial delays diagnosis and can mask symptoms.
References
A 24-year-old man with asthma has a history of food sticking. Endoscopy shows rings and linear furrows in the oesophagus, and biopsies show more than 15 eosinophils per high-power field. What is the diagnosis and first-line treatment?
- Achalasia; Heller myotomy
- Oesophageal cancer; oesophagectomy
- Barrett’s; ablation
- Eosinophilic oesophagitis; a PPI, topical swallowed steroids (such as budesonide) or dietary elimination
- Candida; antifungals
Show the answer and explanation
Answer: D. Eosinophilic oesophagitis; a PPI, topical swallowed steroids (such as budesonide) or dietary elimination. Eosinophilic oesophagitis is an allergic disease that causes dysphagia and food bolus impaction, often in young men with atopy. First-line treatments are a PPI, topical steroids or dietary therapy, with dilatation for strictures. Biopsies are needed for diagnosis.
Why not the others? Surgery is not a treatment for eosinophilic oesophagitis.
References
A man has had meat stuck in his oesophagus for 4 hours. He cannot swallow his saliva and is drooling. What is the management?
- Meat tenderiser
- Barium swallow
- Wait 48 hours
- Fizzy drinks and discharge
- Urgent endoscopy to remove or gently push the bolus, ideally within 6 hours, with biopsies afterwards to look for an underlying cause
Show the answer and explanation
Answer: E. Urgent endoscopy to remove or gently push the bolus, ideally within 6 hours, with biopsies afterwards to look for an underlying cause. Complete oesophageal obstruction (unable to swallow saliva) needs urgent endoscopy because of the risk of aspiration and pressure necrosis. Afterwards, biopsies look for eosinophilic oesophagitis, and strictures or rings are treated.
Why not the others? Barium coats the bolus and obstructs endoscopic view; meat tenderisers can damage the oesophagus.
References
A patient is discharged after a Roux-en-Y gastric bypass. Which long-term supplements are required?
- None after 6 months
- Lifelong multivitamin with minerals, vitamin B12, iron, calcium and vitamin D, with regular blood monitoring
- Only vitamin C
- Only protein shakes for 1 month
- Supplements only if symptoms appear
Show the answer and explanation
Answer: B. Lifelong multivitamin with minerals, vitamin B12, iron, calcium and vitamin D, with regular blood monitoring. Bypass reduces absorption of iron, calcium, vitamin D and B12, and reduces intake of other micronutrients. Deficiencies can cause anaemia, neuropathy and bone disease, so lifelong supplementation and annual blood tests are required.
Why not the others? Deficiencies often develop silently before symptoms appear.
References
A 50-year-old with achalasia (type II on manometry) asks about treatment. Which statement is correct?
- Botulinum toxin gives permanent cure
- Only PPIs are effective
- Pneumatic dilatation, laparoscopic Heller myotomy with partial fundoplication, and POEM are all effective; botulinum toxin is reserved for patients unfit for these
- Nifedipine cures achalasia
- Oesophagectomy is first-line
Show the answer and explanation
Answer: C. Pneumatic dilatation, laparoscopic Heller myotomy with partial fundoplication, and POEM are all effective; botulinum toxin is reserved for patients unfit for these. The definitive treatments (pneumatic dilatation, Heller myotomy, POEM) disrupt the lower oesophageal sphincter. POEM causes more reflux than Heller with fundoplication. Botulinum toxin works for months only.
Why not the others? Medications are weak and short-acting.
References
A 76-year-old has regurgitation of undigested food, halitosis and a gurgling neck. Barium swallow shows a pouch posteriorly at the pharyngo-oesophageal junction. What is the treatment if symptoms are troublesome?
- PPI only
- Division of the cricopharyngeus (endoscopic or open myotomy), with or without pouch excision
- Oesophagectomy
- Repeated dilatation of the pouch
- Antibiotics
Show the answer and explanation
Answer: B. Division of the cricopharyngeus (endoscopic or open myotomy), with or without pouch excision. A Zenker’s (pharyngeal) diverticulum forms above a tight cricopharyngeus muscle. Dividing the muscle relieves the obstruction; endoscopic techniques (rigid or flexible) are widely used, especially in older patients.
Why not the others? Blind endoscopy can perforate the pouch, so it is done carefully.
References
A 70-year-old with incurable distal gastric cancer has vomiting from gastric outlet obstruction. His expected survival is several months and he is fairly fit. Which palliative option gives better long-term relief?
- Gastrojejunostomy (surgical bypass), with endoscopic stenting better suited to those with very short expected survival
- Radiotherapy alone
- Total gastrectomy
- Nasogastric tube for life
- Antiemetics only
Show the answer and explanation
Answer: A. Gastrojejunostomy (surgical bypass), with endoscopic stenting better suited to those with very short expected survival. In the SUSTENT trial, stents relieved symptoms faster, but gastrojejunostomy gave longer-lasting relief with fewer recurrent obstructions in patients expected to live longer. The choice depends on life expectancy and fitness; endoscopic ultrasound-guided gastroenterostomy is a newer option.
Why not the others? Antiemetics do not relieve a mechanical obstruction.
References
Ten weeks after a sleeve gastrectomy, a patient has a persistent leak at the top of the staple line with a small, drained collection. She is stable. What is the usual management?
- Observation without drainage
- Immediate total gastrectomy
- Proton pump inhibitor only
- Endoscopic treatment (for example internal drainage with pigtail stents or a covered stent) together with drainage, nutrition and antibiotics
- Oral diet and discharge
Show the answer and explanation
Answer: D. Endoscopic treatment (for example internal drainage with pigtail stents or a covered stent) together with drainage, nutrition and antibiotics. Chronic leaks after sleeve gastrectomy usually occur near the angle of His. In stable patients, they are managed with drainage, nutritional support and endoscopic treatment. Revisional surgery is considered for failure of these measures.
Why not the others? Unstable patients with peritonitis still need early surgery.
References
A patient with an upper GI bleed has been resuscitated and is haemodynamically stable. When should endoscopy be done?
- After 72 hours
- Within 24 hours of presentation
- Only if he rebleeds
- Within 1 hour in every case
- After 2 weeks of PPI
Show the answer and explanation
Answer: B. Within 24 hours of presentation. For most patients with upper GI bleeding, endoscopy within 24 hours after resuscitation is recommended. Very early endoscopy (within 6 hours) in high-risk patients did not reduce mortality in a randomised trial. Patients who remain unstable despite resuscitation need more urgent endoscopy.
Why not the others? Resuscitation comes before endoscopy.
References
CT staging of a gastric adenocarcinoma shows a locally advanced tumour (T3) with no distant metastases. Which investigation is recommended before starting treatment?
- MRI brain
- No further tests
- Bone scan for all
- Barium meal
- Staging laparoscopy with peritoneal washings, to look for peritoneal metastases missed on CT
Show the answer and explanation
Answer: E. Staging laparoscopy with peritoneal washings, to look for peritoneal metastases missed on CT. Peritoneal metastases are often too small for CT. Staging laparoscopy with cytology changes management in a significant proportion of patients with locally advanced gastric cancer, sparing them futile surgery.
Why not the others? PET-CT can help, but laparoscopy is the best test for peritoneal disease.
References
A patient with a BMI of 42, type 2 diabetes and severe erosive reflux oesophagitis is choosing between sleeve gastrectomy and Roux-en-Y gastric bypass. Which is generally preferred because of the reflux?
- Gastric band
- No surgery is possible
- Roux-en-Y gastric bypass, because sleeve gastrectomy can worsen or cause reflux
- Sleeve gastrectomy, because it cures reflux
- Both are equal for reflux
Show the answer and explanation
Answer: C. Roux-en-Y gastric bypass, because sleeve gastrectomy can worsen or cause reflux. Sleeve gastrectomy creates a high-pressure tube and can worsen reflux, with new oesophagitis and Barrett’s oesophagus reported. Roux-en-Y gastric bypass diverts acid and bile away from the oesophagus and is preferred for patients with significant reflux.
Why not the others? Sleeve-related reflux is a common reason for conversion to bypass.
References
A 16-year-old has a BMI of 41 with type 2 diabetes, despite a structured lifestyle programme. Which statement about bariatric surgery is correct?
- Only liposuction is possible
- Diet alone always works
- Surgery must wait until bone growth stops at 21
- Bariatric surgery is never allowed before 25
- Metabolic and bariatric surgery can be considered in adolescents with severe obesity (BMI 35 or more with comorbidity, or 40 or more) in a specialist multidisciplinary centre
Show the answer and explanation
Answer: E. Metabolic and bariatric surgery can be considered in adolescents with severe obesity (BMI 35 or more with comorbidity, or 40 or more) in a specialist multidisciplinary centre. Studies show sustained weight loss and remission of diabetes after bariatric surgery in adolescents, and guidelines support it in specialised programmes, with careful assessment of psychological readiness, family support and long-term nutritional follow-up.
Why not the others? Age alone is not a contraindication in a specialist setting.
References
Endoscopy shows a 1-cm superficial squamous cell carcinoma of the oesophagus limited to the mucosa (T1a), with no nodes on staging. What is the preferred treatment?
- Radiotherapy alone
- Oesophagectomy for every case
- Observation
- Chemotherapy alone
- Endoscopic resection (typically endoscopic submucosal dissection)
Show the answer and explanation
Answer: E. Endoscopic resection (typically endoscopic submucosal dissection). Mucosal (T1a) cancers have a low risk of lymph node spread and can be cured by endoscopic resection, avoiding oesophagectomy. If the resected specimen shows deeper invasion or adverse features, further treatment follows.
Why not the others? Oesophagectomy carries significant morbidity and is not needed for most T1a tumours.
References
A patient has multiple ulcers in the duodenum and jejunum, chronic diarrhoea and recurrent ulcers despite H. pylori eradication. He takes no NSAIDs. What should be checked?
- Nothing; increase the PPI
- Fasting serum gastrin (off PPI if safe) to look for a gastrinoma (Zollinger–Ellison syndrome), plus calcium for MEN1
- Faecal calprotectin only
- Thyroid antibodies
- Serum amylase
Show the answer and explanation
Answer: B. Fasting serum gastrin (off PPI if safe) to look for a gastrinoma (Zollinger–Ellison syndrome), plus calcium for MEN1. Ulcers in unusual places, multiple or recurrent ulcers, and diarrhoea suggest gastrinoma. A very high fasting gastrin with acid secretion confirms it. About a quarter are associated with MEN1, so calcium and PTH are checked.
Why not the others? PPIs raise gastrin, so interpretation must account for them.
References
Endoscopic biopsy shows a localised low-grade gastric MALT lymphoma in a patient with Helicobacter pylori infection. What is the first-line treatment?
- Observation without treatment
- Total gastrectomy
- H. pylori eradication therapy
- Chemotherapy as first-line
- Radiotherapy in every case
Show the answer and explanation
Answer: C. H. pylori eradication therapy. Most localised gastric MALT lymphomas are driven by H. pylori, and eradication alone leads to remission in many patients. Endoscopic follow-up is required. Radiotherapy is used for those who do not respond or are H. pylori-negative.
Why not the others? Surgery is not first-line for MALT lymphoma.
References
After a night of heavy drinking and repeated vomiting, a 25-year-old vomits a small amount of fresh blood. He is stable. Endoscopy shows a linear tear at the gastro-oesophageal junction that is not bleeding. What is the management?
- CT angiography
- Mallory–Weiss tear: supportive care with antiemetics and PPI; most heal without intervention
- Oesophagectomy
- Emergency surgery
- Balloon tamponade
Show the answer and explanation
Answer: B. Mallory–Weiss tear: supportive care with antiemetics and PPI; most heal without intervention. Mallory–Weiss tears are mucosal tears caused by retching. Most stop bleeding spontaneously and heal within days. Endoscopic therapy (clips, adrenaline) is used for active bleeding. Unlike Boerhaave syndrome, the tear does not go through the full wall.
Why not the others? Severe chest pain and surgical emphysema would suggest full-thickness rupture instead.
References
Three years after a Roux-en-Y gastric bypass, a woman has cholangitis from a common bile duct stone. Standard ERCP cannot reach the papilla. Which approaches can clear the duct?
- Laparoscopy-assisted transgastric ERCP (through the gastric remnant), EUS-directed transgastric ERCP, or surgical bile duct exploration
- Reverse the bypass first in every case
- Standard ERCP through the mouth always works
- Observation
- Antibiotics only, forever
Show the answer and explanation
Answer: A. Laparoscopy-assisted transgastric ERCP (through the gastric remnant), EUS-directed transgastric ERCP, or surgical bile duct exploration. After Roux-en-Y bypass, the papilla is reached through the bypassed stomach. Access through the remnant stomach, assisted by laparoscopy or EUS, allows a standard duodenoscope to be used. Percutaneous drainage is used for urgent drainage when needed.
Why not the others? Gallstones are common after rapid weight loss.
References