Question 5.
Which one of the following statements about the appendix is true?
A. taeniae coli are present, merging together at the distal tip of the appendix
B. Absence of muscularis mucosae in section profiles showing lymphoid follicles is a normal finding
C. The circular layer of the muscularis propria is poorly developed
D. The appendix is a retroperitoneal, not an intraperitoneal structure
E. The appendiceal artery does not reach the appendix through the mesoappendix
Question 13.
Which one of the following is not an extra-intestinal manifestation of inflammatory bowel disease?
A. Ankylosing spondylitis
B. Pyoderma gangrenosum
C. Sclerosing cholangitis
D. Calcium oxylate kidney stones
E. Primary biliary cirrhosis


Question 18.
Which one of the following is not associated with an increased risk for colorectal cancer?
A. Brother affected by it at age 45 years
B. Ulcerative colitis of more than ten years duration
C. Personal history of prior adenomas of the colon
D. A positive faecal occult blood test
E. A high dietary fibre intake
Question 19.
The best diagnostic test for colorectal cancer is:
A. Colonoscopy
B. Faecal occult blood test
C. CT colography
D. Abdominal ultrasound
E. Barium enema (double contrast)
Question 20.
Which one is not true for colorectal cancer?
A. It gets more common as people get older and never plateaus in incidence
B. Inherited genetic mutations might increase risk for it
C. It is a disease characterised by acquired genetic mutations
D. Screening for colorectal cancer is not effective in reducing mortality
E. A common presenting symptom can be overt rectal bleeding


Question 25.
Infective causes of proctitis include:
A. Neisseria gonorrhoea
B. Chlamydia pneumoniae
C. Sigatoka fungus
D. Corona virus
E. Leptospirosis

Question 30.
For each of the stems listed below, select an option which best matches. Each option may be used once, more than once, or not at all.
(5 marks)
(1) small bowel villous atrophy can be caused by
(2) bloody diarrhoea can be due to
(3) isolated proctitis can be due to
(4) pseudomembranous colitis is usually due to
(5) peptic ulcers are associated with
A. helicobacter pylori infection
B. schistosomiasis
C. clostridium performens
D. campylobacter jejuni
E. giardiasis
F. neisseria gonorrhoea
G. borrelia burgdorferi
H. clostridium difficile
I. sarcoidosis


Patient presentation
A 27 y.o. Italian bus driver, Mr Urgento Copro presents to your GP surgery with a 4 month history of increasingly frequent stool. He has noticed urgency and occasional blood mixed in with the motion. There is some left lower abdominal discomfort which is relieved with defecation. Passage of stool is painless. His weight is stable. There are no other symptoms except lethargy. He is a non smoker on no medication.
Examination reveals a normal complexion. He is afebrile and has some mild left iliac fossa tenderness. There are no abdominal masses. The rectum is empty on examination.
Question 32.
Mr Copro asks for your opinion. What is your list of possible diagnoses?
(4 marks)
Question 33.
What investigations would you perform and why?
(6 marks)
PART 2 (Total marks 15)
Answer all questions.
Write your answers in booklet marked 'Section C, Part 2’.
Start each question on a new page.
The following investigations were performed:
Stool microscopy and culture: Normal enteric flora, Red blood cells +++, White blood cells +++
A sigmoidoscopy reveals: Inflamed mucosa with contact bleeding from the anal verge to the limit of vision at the rectosigmoid junction.
Haematology Normal Range
HB 12 11.5-16.0 G/DL
PLATELETS 313 150-400 / 109/L
MCV 95.9 80-100 FL
WCC 12 3.5-11 /109/L
ESR 60 < 20 mm/HR
Sodium 142 135-145 mmol/L
Potassium 4.1 3.5-5.0 mmol/L
Bicarbonate 23 20-30 mmol/L
Chloride 105 95-105 mmol/L
Creatinine 83 50-150 mmol/L
Blood sugar 3.6 3.5-7.2 mmol/L
Alk. Phos. 77 35-125 U/L
Bilirubin 10 2-17 umol/L
Alt 23 0-35 U/L
Urea 5.1 2.5-7.0 mmol/L
Ggt 12 0-35 U/L
Albumin 41 36-52 g/L
Phosphate 0.73 0.7-1.4 mmol/L
Calcium 2.30 2.2-2.6 mmol/L
CRP 120 <5 mg/L
Thyroid function: normal
Abdominal xray reveals the right colon to contain stool and the left colon to be empty. Otherwise the bowel pattern appears normal.
Mr Copro is referred to a gastroenterologist who performs a colonoscopy and a small bowel series.
Colonoscopy reveals a confluent colitis to the splenic flexure.
Small bowel series shows a normal small bowel mucosal pattern throughout.
continued next page ...
Question 34.
Do you think the patient has inflammatory bowel disease? (1 mark)
Question 35.
Compare and contrast ulcerative colitis and Crohns disease
(14 marks)
Part 3 (Total marks 15)
Answer all questions.
Write your answers in booklet marked ‘Section C Part 3’.
Start each question on a new page.
Biopsies taken by the gastroenterologist at colonoscopy support a diagnosis of ulcerative colitis.
Question 36.
Describe the usual histology of ulcerative colitis
(5 marks)
Question 37.
Discuss the extracolonic manifestations of inflammatory bowel disease
(10 marks)



Patient Presentation
A 56 year old Irish salesman, Mr Aden O’Mah presents to your GP surgery with a 19 year history of
intermittent bloating and constipation. He has noticed occasional episodes of urgency with loose motion
also. Lower abdominal discomfort that is relieved with defecation is often present. There has been some
altered blood mixed in with the stool of late. Defecation is painless. There are no upper gastrointestinal
symptoms. His weight is stable. He is a non-smoker on no medication.
His father was diagnosed with colorectal cancer recently aged 81. There is no other family history of
gastrointestinal, endometrial, renal, or ovarian malignancy.
Examination reveals a pale complexion. He is normotensive, pulse regular 76 bpm and afebrile. Some
mild left iliac fossa discomfort on deep palpation is present. There are no abdominal masses. The rectum
is empty on examination. The remaining physical examination is normal.
Question 1
List Mr O’Mah’s symptoms and signs.
(5 marks)
Question 2
What is your list of possible diagnoses?
(5 marks)
Part 2 (Total marks 12: suggested writing time 12 minutes)
The following investigations were performed:
A Sigmoidoscopy Reveals:
Normal rectal mucosa
No haemorroids
Stool Microscopy And Culture:
Normal enteric flora, Red blood cells : nil, White blood cells : nil
Haematology Normal Range
HB 110 115-160 G/DL
PLATELETS 313 150-400 / 109/L
MCV 72 80-100 FL
WCC 6 3.5-11 /109/L
SODIUM 142 135-145 MMOL/L
POTASSIUM 4.1 3.5-5.0 MMOL/L
CHLORIDE 103 95-105 MMOL/L
CREATININE 0.083 0.050-0.110 MOL/1
BLOOD SUGAR 3.6 3.5-7.2 MMOL/1
ALK. PHOS. 77 35-125 U/L
ALT 23 0-35 U/L
UREA 5.1 2.5-7.0 MMOL/1
GGT 12 0-35 U/L
ALBUMIN 41 36-52 G/L
PHOSPHATE 0.73 0.7-1.4 MMOL/L
CALCIUM 2.30 2.2-2.6 MMOL/L
CRP 19 <5 MG/L
Iron Studies
Ferritin 25 30-400 μg/L
Serum iron 3 9-27 μmol/L
Transferrin 3.6 1.8-3.7 g/L
Transferrin saturation 6 10-55 %
Question 3
What condition is suggested by the blood results? Explain your reasoning.
(6 marks)
Question 4
Mr O’Mah went on to have a colonoscopy that revealed several lesions as detailed below.
Name each lesion.
(6 marks)
A from the distal sigmoid
B from the ceacum
Part 3 (Total marks 18: suggested writing time 18 minutes)
Answer all questions.
Write your answers in booklet marked ‘Section A, Part 3’.
Start each question on a new page.
Question 5
The cecal carcinoma is depicted diagramatically below.
What is the dukes staging and why?
muscularis propria
(6 marks)
Question 6
Do you think that this patient might have a familial genetic syndrome causing the distal sigmoid polyp
and cancer? Explain your reasoning.
(12 marks)


Question 9
The following are branches of the inferior mesenteric vein:
a. the ileocolic
b. the right colic
c. the upper left colic
d. the jejunal
e. the ileal
Question 10
Regarding intestinal absorption of water and salts:
a. about 100 ml of water is normally lost in faeces daily
b. medium chain fatty acids are the principle colonic cations
c. The large intestine can absorb a maximum of 1000ml daily
d. pancreatic secretions are about 300 ml daily
e. daily saliva production is usually no more than 450ml
Question 11
Which of the following are not classic extra-intestinal manifestations of inflammatory bowel disease?
a. Ankylosing spondylitis
b. Dermatitis herpetiformis
c. Sclerosing cholangitis
d. Calcium oxylate kidney stones
e. Iritis
Question 13
In relation to Inflammatory bowel disease
a. there is no likely genetic basis
b. never causes nocturnal diarrhoea
c. is associated with an increased risk of colonic carcinoma
d. colonic mucosal granuloma suggest ulcerative colitis
e. calcium pyrophosphate stones are associated with ulcerative colitis
Question 15
Which is true for colorectal cancer:
a. It gets more common as people get older and eventually plateaus in incidence
b. Inherited genetic mutations do not increase risk for it
c. Its incidence is not increased in inflammatory bowel disease
d. Screening for colorectal cancer is not effective in reducing mortality
e. A common presenting symptom can be overt rectal bleeding.
Question 20
Functions of the large bowel does not include:
a. Absorption of up to 4 litres of water daily
b. Detoxification of ingested substances.
c. Fermentation by anaerobic bacteria.
d. Controlled evacuation
e. Absorption of vitamin B12

Question 26
In a patient with a colonic carcinoma staged as Duke’s D:
a. tumour cells will have invaded the lamina propria
b. tumour cells from the cancer will have invaded the submucosa
c. tumour cells from the cancer will have invaded the muscularis propria
d. tumour cells from the cancer will have invaded at least some of the draining lymph nodes
e. tumour cells from the cancer will have invaded the liver or other distant organs


Question 7.
The following is not a risk factor for colorectal cancer:
A. Adenomatous polyps
B. Hyperplastic polyps
C. A family history of colorectal cancer
D. Longstanding (>20 years) ulcerative colitis
E. A high-fat, low-vegetable diet
Question 26.
Inflammatory bowel disease is not associated with:
A. Apthous ulcers of mucosa
B. Sclerosing cholangitis
C. Kidney stones
D. Ankylosing spondylitis
E. Melanosis coli

Question 11.
The following regions of the gut are all termed retroperitoneal, except:
A. The second part of the duodenum
B. The third part of the duodenum
C. The ascending colon
D. The appendix
E. The rectum
Question 12.
A patient is found to have Ulcerative Colitis to the proximal sigmoid colon at flexible sigmoidoscopy. Which of the following agents is not effective in maintenance of remission?
A. Oral Sulphasalazine
B. Oral Mesalazine
C. Hiatus hernia
D. Mesalazine Enema
E. Azathioprine
Question 14.
Which test for colorectal cancer is the most accurate?
A. Colonoscopy
B. CT colonography
C. Barium enema
D. Faecal occult blood test
E. Sigmoidoscopy
Question 17.
Which of the following are not extra-intestinal manifestations of inflammatory bowel disease?
A. Ankylosing spondylitis
B. Pyoderma gangrenosum
C. Sclerosing cholangitis
D. Calcium oxylate kidney stones
E. Malar rash
Question 25.
Which of the following drugs does not have a role in the treatment of Crohn’s Disease?
A. Prednisolone
B. Sulphasalazine
C. Cyclosporine
D. Metronidazole
E. Azathioprine


Mr. Russell Scats is a 23 year old university student who is due to sit his exams in two days time. Twelve hours ago he developed, in his words, “acute watery diarrhoea”. He described the diarrhoea as severe, profuse and the stools as being large and watery. He has passed 3 stools in the 12-hour period. While he experiences urgency he is able to control himself for long enough to reach the toilet. He has some abdominal cramps but otherwise feels quite well.
Question 1.
List the main clinical patterns of diarrhoeal symptomatology and their features. Into which pattern does this patient fit at this time? Explain why.
(10 marks)
Question 2.
Why is the colon/rectum critical in the pathogenesis of diarrhoea?
Explain what occurs in the colon/rectum when diarrhoea is due to:
a primarily small bowel disorder and,
a large bowel disorder.
Feel free to use tables or diagrams to explain fluid shifts.
(10 marks)
Question 3.
At this point in Mr Scats’ presentation, what risk factors for diarrhoea would you be interested in, and in exploring them, what questions would you ask (listed phrases are satisfactory)?
(8 marks)
Total marks: 16 Suggested writing time: 15 minutes
Patient Progress
The next day Mr Scats returns with a mild temperature and persisting diarrhoea. The nature of the diarrhoea has changed in that he has considerable urgency and is passing somewhat smaller, more frequent stools with some blood. The colic persists. On physical examination he has a mildly tender abdomen (generalised) but no guarding or release tenderness, and his temperature is 37.5oC. He has a pulse rate of 110/minute, poor tissue turgor and a dry tongue.
Question 4.
Does the passing of blood, or the temperature, have any significance? If so, what?
(2 marks)
Question 5.
Do you think he is dehydrated and why?
What other steps might you take to confirm its presence?
(4 marks)
Question 6.
What are the principles of treatment for and prevention of dehydration in this man?
What advice would you give a patient presenting with acute severe diarrhoea, in practical lay terms?
Would you give this man a non-specific antidiarrhoeal drug?
Explain briefly the reasoning behind your answers.
(10 marks)
The following results for Mr Scats became available:
(Blood tests and stool analysis performed on initial visit)
Complete Blood Picture Normal Range
Hb 130g/l 130-175
MCV 83fl 80-99
WCC 12,500 x 106/l 4,000-11,000
Platelets 515,000 x 106/l 150,000- 450,000
CRP 22 <6
Stool M&C Blood and pus seen, increased white cells under the microscope but no fat globules. No organism cultured by time of reporting (at 12h).
Sigmoidoscopic examination:
Rectal mucosa is inflamed with erythema, haemorrhagic points and some surface pus and friability. Inflammation extends to the point of instrument insertion.
Question 7.
List the possible diagnoses and carefully categorise these (either by cause, pathophysiology or site of disease). Explain how the clinical picture and test results fit with each of these possibilities.
(10 marks)
Question 8.
Explain the likely clinical course of at least two of these causes, if left untreated.
(6 marks)
Question 11.
The following events in a person represents a clear risk factor (i.e. increased risk) for colorectal cancer either at present or in the future. Indicate whether this is True or False for the following:
a) Adenomatous polyps in the colon.
b) A single small (<10mm) rectal hyperplastic polyp.
c) Colorectal cancer in a second-degree relative only.
d) Longstanding (>20 years) Ulcerative Colitis.
e) A high-fat, low-vegetable diet.
(2.5 marks)
Question 13.
Regarding Inflammatory Bowel Disease, indicate whether the following statements are True or False:
The peak incidence is between the ages of 30 and 45.
Crohn’s disease has a predictable inheritance pattern.
Cigarette smokers are less likely to develop Ulcerative colitis, but former smokers are more likely to develop the disease than those who have never smoked.
The estimated risk of patient’s with Crohn’s disease developing a fistula is 33% and 50% at 10 and 20 years respectively.
All patients with ulcerative colitis have a significantly increased risk of colorectal cancer beginning 8 years from the onset of symptoms, regardless of disease extent.
(2.5 marks)
Question 14.
Irritable Bowel Syndrome is a common medical condition. Please indicate whether these statements are True or False:
It is the most commonly diagnosed gastrointestinal condition.
It has an even gender distribution (M:F =1:1).
It is a diagnosis of exclusion and as such endoscopic investigation is always required for a positive diagnosis.
It is associated with reduced life expectancy.
It is a chronic condition with no specific cure and as such, the management focus should be on symptomatic control with a combination of lifestyle modifications and medications, and addressing the patient’s concerns.
(2.5 marks)


Question 20.
Chronic diarrhoea in patients is a common reason for presentation to medical practitioners in Australia. Please indicate whether the statements below are True or False:
The presence of nocturnal diarrhea is often an indicator of non-organic aetiology.
The passage of non-bloody mucus is very suggestive of Inflammatory Bowel Disease.
Cholestyramine is used in the treatment of secretory diarrhea due to bile acid malabsorption.
Small bowel bacterial overgrowth is a cause of steatorrhea.
The most common infectious cause is giardiasis.
(2.5 marks)


Question 15.
With regards to colorectal cancer (CRC), please indicate which one of the following statements is CORRECT:
a) Hereditary Non Polyposis Colorectal Cancer (HNPCC) and Familial Adenomatous Polyposis (FAP) account for 17% of all CRC diagnoses.
b) High fibre intake does not offer protection against development of CRC.
c) Only a small percentage of CRCs develop from benign precursor lesions, or adenomas.
d) Reduced consumption of processed meat and avoidance of charring of red meat may reduce the risk of development of CRC.
e) Asymptomatic individuals with a first degree relative who was diagnosed with CRC before the age of 50 do not require any form of colorectal cancer surveillance.
Question 16.
A 75 year-old male presents with tiredness and lethargy, and shortness of breath on exertion. There is no obvious cardiovascular or respiratory abnormality but he returns the following results; Hb 91 g/L,
MCV 72 (80-98), platelets 510,00 (210,000-450,000), WCC 6,500. On enquiry he has not noticed any bleeding but he says he never looks at his stools. He lives by himself and his diet is poor, eating mainly tea and toast with little meat, vegetables or whole grain foods.
Indicate which of the following statements is CORRECT:
a) The anaemia is likely to be due to diet and it would be sufficient to improve his diet, measure haematinics in his blood and observe the response.
b) The anaemia is likely to be due to acute GI bleeding.
c) The anaemia is likely to be due to chronic GI bleeding.
d) Endoscopy alone is sufficient, colonoscopy is not indicated.
e) Folate deficiency is the likely cause.
Question 25.
In terms of faecal occult blood test (FOBT), please indicate which one of these statements is CORRECT:
a) In the setting of colorectal cancer screening, if an asymptomatic patient returns a positive FOBT, the test should be repeated because of high false positive rate.
b) The probability of detection of colorectal neoplasia from a positive FOBT is 10%.
c) The faecal immunochemical tests require the patient to adhere to dietary restrictions.
d) The guaic based FOBT is not affected by diet or medications.
e) In a patient presenting with possible upper GI bleeding, FOBT has no role in clinical assessment.