MCCQE Part I Gastroenterology Questions: 10 Free Practice MCQs

Ten MCCQE Part I-style gastroenterology questions with the answer and the reasoning behind it. They come from the CA.med bank, which has 24 gastroenterology questions and many more across every topic.

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1. 1 / 10

   A 30-year-old woman is diagnosed with Coeliac disease. She asks about the underlying cause of her condition.

   Which specific HLA haplotypes are most strongly associated with this condition?

   • A. HLA-B27 and HLA-B7
   • B. HLA-DR4 and HLA-DR1
   • C. HLA-DQ2 and HLA-DQ8
   • D. HLA-DR3 alone
   Show answer

   Answer: C. HLA-DQ2 and HLA-DQ8

   Why: Coeliac disease is strongly associated with HLA-DQ2 (95% of cases) and HLA-DQ8 (remaining 5%). Absence of these alleles makes the diagnosis extremely unlikely. Testing is recommended according to gastroenterology guidelines.

   • A. Associated with Ankylosing Spondylitis.
   • B. Associated with Rheumatoid Arthritis and Type 1 Diabetes.
   • D. Associated with SLE and Type 1 Diabetes, though DQ2 is in linkage disequilibrium with DR3.

   Sources: Canadian Association of Gastroenterology Clinical Practice Guidelines

2. 2 / 10

   A 3-year-old girl presents with chronic diarrhoea, abdominal distension, and weight faltering over 12 months after introduction of gluten-containing foods. She is irritable and pale. CBC shows Hb 95 g/L, MCV 72 fL. Stool is bulky, pale, and floats. IgA level is normal.

   Which test is the most appropriate initial investigation for suspected coeliac disease?

   • A. Small bowel biopsy immediately without serological testing
   • B. Serum IgA anti-tissue transglutaminase (anti-TTG IgA)
   • C. Hydrogen breath test for lactose intolerance
   • D. Faecal calprotectin for intestinal inflammation
   Show answer

   Answer: B. Serum IgA anti-tissue transglutaminase (anti-TTG IgA)

   Why: Coeliac disease affects ~1% of the Canadian population. Gluten exposure triggers T-cell mediated intestinal inflammation and villous atrophy in genetically susceptible individuals (HLA-DQ2/DQ8). Presentation: classic (malabsorption, diarrhoea, weight faltering); atypical (anaemia, short stature, dermatitis herpetiformis, elevated LFTs); silent (positive serology with no symptoms). Diagnosis: anti-TTG IgA (sensitive, inexpensive) + total IgA (if IgA deficient, use anti-TTG IgG or anti-DGP IgG). ESPGHAN 2020: can diagnose without biopsy if anti-TTG IgA ≥10× ULN + positive anti-EMA. Treatment: strict lifelong gluten-free diet, wheat, barley, rye must be eliminated.

   • A. Intestinal biopsy (duodenal) remains the gold standard for diagnosis, but ESPGHAN guidelines allow diagnosis without biopsy if anti-TTG IgA is ≥10× upper limit of normal plus positive anti-EMA on a different blood sample. Serology is the appropriate first step.
   • C. Lactose intolerance can cause diarrhoea and bloating but not villous atrophy, iron deficiency anaemia, or the pattern of weight faltering seen here. Coeliac disease is the priority diagnosis to exclude.
   • D. Faecal calprotectin is elevated in coeliac disease and IBD but is non-specific and not the appropriate initial test. Anti-TTG IgA is the recommended screening test per CPS and ESPGHAN guidelines.

   Sources: ESPGHAN 2020 Guidelines for Coeliac Disease; CPS Position Statement: Diagnosis and Management of Celiac Disease

3. 3 / 10

   A 33-year-old man has a two week history of rectal bleeding, tenesmus, and urgency. Flexible sigmoidoscopy shows continuous inflammation confined to the rectum, with no disease more proximally. He is judged to have mild to moderate active ulcerative proctitis.

   What is the recommended first-line therapy?

   • A. Rectal 5-aminosalicylate at a dose of 1 g daily
   • B. Oral prednisone 40 mg daily
   • C. Oral azathioprine
   • D. Rectal corticosteroids as initial therapy
   Show answer

   Answer: A. Rectal 5-aminosalicylate at a dose of 1 g daily

   Why: The Canadian Association of Gastroenterology guideline recommends rectal 5-aminosalicylate at 1 g daily as first-line therapy to induce symptomatic remission in mild to moderate active ulcerative proctitis, and meta-analysis shows rectal 5-aminosalicylate to be superior to rectal corticosteroids for this purpose. Oral corticosteroids are not recommended for maintenance because they are ineffective for that indication and cause significant adverse effects. Thiopurines are used only in selected patients who fail other therapy.

   • B. Oral corticosteroids are not the recommended first-line therapy for proctitis and are recommended against for maintaining remission.
   • C. Thiopurines are reserved for selected patients who fail other therapy, rather than being initial treatment for proctitis.
   • D. Rectal 5-aminosalicylate is preferred to rectal corticosteroids for inducing symptomatic remission in this setting.

   Sources: Canadian Association of Gastroenterology, Toronto Consensus for the Management of Ulcerative Colitis (2015)

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5. 4 / 10

   A 27-year-old woman was diagnosed with coeliac disease by duodenal biopsy three weeks ago. She has been on a gluten-free diet since then but still has diarrhoea and has lost 4 kg.

   According to the Canadian position paper on gluten-free oats, what is the most appropriate advice about oats?

   • A. Introduce oats now because they contain less prolamin than wheat
   • B. Avoid oats permanently because the avenin they contain causes villous damage in everyone with coeliac disease
   • C. Wait until her symptoms have resolved and she has followed a gluten-free diet for at least 6 months before introducing oats
   • D. Introduce oats after 4 weeks of a gluten-free diet
   Show answer

   Answer: C. Wait until her symptoms have resolved and she has followed a gluten-free diet for at least 6 months before introducing oats

   Why: The Canadian position paper on gluten-free oats recommends a stabilisation phase before uncontaminated oats are introduced into a gluten-free diet. Oats should only be introduced once all symptoms of coeliac disease, including weight loss and growth disturbance, have resolved and the person has followed a gluten-free diet for a minimum of 6 months. Uncontaminated oats are tolerated by most people with coeliac disease, so permanent avoidance is unnecessary, but a few people remain intolerant and need monitoring.

   • A. A stabilisation phase is recommended, so oats are not introduced while symptoms such as weight loss are still present.
   • B. Uncontaminated oats are tolerated by most people with coeliac disease, so permanent avoidance is not the recommended approach.
   • D. The recommended minimum period on a gluten-free diet before oats are introduced is 6 months, not 4 weeks.

   Sources: Canadian Position Paper on Gluten-Free Oats in Coeliac Disease, Canadian Journal of Gastroenterology and Hepatology

6. 5 / 10

   A 40-year-old woman presents with symptoms of heartburn and regurgitation that worsen at night. She has tried over-the-counter antacids with minimal relief. Her physical examination is normal, and her laboratory tests show no evidence of anemia or electrolyte imbalance.

   What is the next step in managing this patient's symptoms?

   • A. Prescribe a proton pump inhibitor
   • B. Order an upper endoscopy
   • C. Recommend lifestyle modifications
   • D. Prescribe an H2 receptor antagonist
   Show answer

   Answer: A. Prescribe a proton pump inhibitor

   Why: The patient's symptoms of heartburn and regurgitation are consistent with gastroesophageal reflux disease. According to the Canadian Association of Gastroenterology guidelines, a proton pump inhibitor is a recommended first-line treatment for patients with gastroesophageal reflux disease. Lifestyle modifications and over-the-counter antacids can be tried initially, but if symptoms persist or worsen, a proton pump inhibitor should be prescribed.

   • B. Although an upper endoscopy may be necessary if the patient's symptoms persist or worsen, it is not the initial step in managing her symptoms.
   • C. Although lifestyle modifications such as weight loss and avoiding trigger foods are important, they are not the next step in managing this patient's symptoms, as she has already tried over-the-counter antacids with minimal relief.
   • D. Although H2 receptor antagonists can be used to treat gastroesophageal reflux disease, they are not as effective as proton pump inhibitors and are not the recommended first-line treatment.

   Sources: Canadian Association of Gastroenterology guidelines

7. 6 / 10

   A 42-year-old man presents with a 6-week history of epigastric burning pain that is relieved by eating and worsened between meals. He is otherwise well, no alarm features (no dysphagia, no weight loss, no vomiting). Urea breath test is positive for H. pylori. Endoscopy shows a clean-base gastric ulcer 0.8 cm. Biopsies are benign.

   What is the most appropriate treatment?

   • A. H. pylori eradication with clarithromycin-based triple therapy (PPI + amoxicillin + clarithromycin × 14 days), followed by PPI for 4-8 weeks
   • B. PPI alone for 8 weeks, no antibiotic therapy needed
   • C. Bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline) as first-line in Canada, for 7 days only, without PPI continuation
   • D. Repeat endoscopy in 12 weeks to reassess, and delay eradication therapy
   Show answer

   Answer: A. H. pylori eradication with clarithromycin-based triple therapy (PPI + amoxicillin + clarithromycin × 14 days), followed by PPI for 4-8 weeks

   Why: H. pylori and PUD management: all infected patients with PUD should receive eradication. Successful eradication prevents 85-90% of ulcer recurrence. Post-treatment confirmation (urea breath test or stool antigen, not serology) is mandatory, especially for gastric ulcers where repeat endoscopy confirms healing and excludes malignancy. If clarithromycin resistance is suspected or failed first-line, bismuth quadruple or levofloxacin-based triple therapy are alternatives.

   • B. H. pylori eradication is mandatory when detected with peptic ulcer disease, failure to treat doubles the ulcer recurrence rate. PPI monotherapy without eradication is not standard of care.
   • C. Bismuth quadruple therapy is recommended as first-line in areas of high clarithromycin resistance (>15%) or as second-line after failed triple therapy. In most Canadian provinces, it is not first-line unless local resistance data indicates otherwise.
   • D. Repeat endoscopy for gastric ulcer (to confirm healing and rule out malignancy) is recommended at 6-8 weeks, not 12 weeks. Eradication therapy should start immediately, delaying treatment risks ulcer complications.

   Sources: Canadian Association of Gastroenterology (CAG) H. pylori Consensus Update 2016; Choosing Wisely Canada, Gastroenterology

8. 7 / 10

   A 48-year-old man has a duodenal ulcer and a positive stool antigen test for Helicobacter pylori. He has not previously received eradication therapy, and local clarithromycin resistance is known to be high.

   Which regimen is recommended?

   • A. A 7-day proton pump inhibitor triple regimen with clarithromycin and amoxicillin
   • B. A 14-day concomitant nonbismuth quadruple regimen with a proton pump inhibitor, amoxicillin, metronidazole, and clarithromycin
   • C. A 14-day proton pump inhibitor triple regimen with clarithromycin and amoxicillin, as resistance does not matter
   • D. Rifabutin-containing therapy for 14 days
   Show answer

   Answer: B. A 14-day concomitant nonbismuth quadruple regimen with a proton pump inhibitor, amoxicillin, metronidazole, and clarithromycin

   Why: The Canadian Association of Gastroenterology consensus strongly recommends that all Helicobacter pylori eradication regimens be given for 14 days, and it recommends concomitant nonbismuth quadruple therapy or traditional bismuth quadruple therapy as first-line options. Proton pump inhibitor triple therapy is restricted to areas with known low clarithromycin resistance or proven high eradication rates, so it is not appropriate where resistance is high. Rifabutin-containing regimens are reserved for patients who have failed at least three prior options.

   • A. All eradication regimens should now be given for 14 days, so a 7-day course is too short.
   • C. Proton pump inhibitor triple therapy is restricted to areas with known low clarithromycin resistance or proven high eradication rates, neither of which applies here.
   • D. Rifabutin-containing regimens are restricted to patients who have failed at least three prior options.

   Sources: Canadian Association of Gastroenterology, Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults (2016)

9. 8 / 10

   A 57-year-old man with alcoholic liver cirrhosis (Child-Pugh C) is admitted with his second episode of spontaneous bacterial peritonitis (SBP) in 6 months. He recovers with IV cefotaxime. Ascitic fluid WBC was 520 cells/µL with 78% neutrophils at diagnosis. His creatinine remained stable throughout. He will be discharged on lactulose and spironolactone.

   What additional secondary prophylaxis should be prescribed at discharge to prevent SBP recurrence?

   • A. Rifaximin 550 mg twice daily as the only prophylaxis
   • B. IV albumin 1.5 g/kg every 2 weeks indefinitely as the only prophylaxis, without antibiotics
   • C. No prophylaxis needed, restrict alcohol only
   • D. Oral norfloxacin 400 mg once daily (or ciprofloxacin 500 mg OD if norfloxacin unavailable)
   Show answer

   Answer: D. Oral norfloxacin 400 mg once daily (or ciprofloxacin 500 mg OD if norfloxacin unavailable)

   Why: SBP occurs in 10-30% of hospitalised cirrhotic patients with ascites. Diagnosis: PMN >250 cells/µL in ascitic fluid. Treatment: IV cefotaxime 2 g q8h × 5 days + IV albumin (1.5 g/kg day 1, 1 g/kg day 3) to prevent hepatorenal syndrome. Secondary prophylaxis: oral norfloxacin 400 mg OD (ciprofloxacin 500 mg OD if unavailable). Primary prophylaxis with norfloxacin is also indicated in cirrhotic patients with ascitic protein <15 g/L + renal impairment (Cr >88 µmol/L) or Child-Pugh score ≥9 with bilirubin ≥51 µmol/L.

   • A. Rifaximin is primarily used for hepatic encephalopathy prophylaxis; while it may have some benefit for SBP prevention as an adjunct, oral norfloxacin or ciprofloxacin is the established first-line secondary SBP prophylaxis per AASLD and EASL guidelines.
   • B. IV albumin at 1.5 g/kg on day 1 and 1 g/kg on day 3 of acute SBP reduces renal impairment and mortality (Sort et al trial); however, it is not the ongoing secondary prophylaxis, oral fluoroquinolone is the standard prophylaxis regimen.
   • C. SBP recurrence without prophylaxis is approximately 70% at 1 year in Child-Pugh C patients; alcohol abstinence alone does not prevent SBP. Antibiotic secondary prophylaxis is mandatory after a first SBP episode.

   Sources: AASLD Practice Guideline: Management of Adult Patients with Ascites 2012 (updated 2021); CASL Cirrhosis Guidelines

10. 9 / 10

    A 38-year-old woman has a three month history of epigastric discomfort and early satiety. She reports no weight loss, dysphagia, vomiting, or anaemia, and she does not take nonsteroidal anti-inflammatory drugs.

    What is the recommended initial management?

    • A. Non-invasive testing for Helicobacter pylori, with treatment if the test is positive
    • B. Urgent upper endoscopy to exclude upper gastrointestinal cancer at any age
    • C. Empirical proton pump inhibitor therapy before any testing
    • D. Abdominal ultrasound to assess the pancreas
    Show answer

    Answer: A. Non-invasive testing for Helicobacter pylori, with treatment if the test is positive

    Why: The Canadian Association of Gastroenterology dyspepsia guideline recommends that patients under 60 years of age have a non-invasive test for Helicobacter pylori and treatment if positive. Empirical proton pump inhibitor therapy is recommended for those who are Helicobacter pylori negative or who remain symptomatic after eradication, and endoscopy is not recommended to investigate alarm features in patients under 60. This woman has no alarm features and is under 60, so test and treat is the appropriate initial strategy.

    • B. Endoscopy is not recommended to investigate alarm features in dyspepsia patients under the age of 60.
    • C. Empirical proton pump inhibitor therapy is recommended for those who are Helicobacter pylori negative or who remain symptomatic after eradication, not before testing.
    • D. Abdominal ultrasound is not the recommended first step for uninvestigated dyspepsia in a patient without alarm features.

    Sources: Canadian Association of Gastroenterology, Clinical Practice Guideline on Dyspepsia (2017)

11. 10 / 10

    A 29-year-old woman with ileal Crohn disease reports abdominal pain and three loose stools daily. Her faecal calprotectin is 480 ug/g. She has had two previous intestinal resections and has a perianal fistula.

    How should the severity of her Crohn disease be determined?

    • A. By her symptom score alone
    • B. By the faecal calprotectin level alone
    • C. By the number of bowel movements per day, since three loose stools daily indicates mild disease regardless of history
    • D. By combining her symptoms with objective measures of inflammation and factors that predict a higher risk of complications
    Show answer

    Answer: D. By combining her symptoms with objective measures of inflammation and factors that predict a higher risk of complications

    Why: The Canadian Association of Gastroenterology guideline recommends that the severity of Crohn disease be determined from a combination of symptoms, objective measures of inflammation, and factors that predict an increased risk of complications. In this patient, the calprotectin, the previous resections, and the perianal fistula all point to a higher risk of complications, so symptoms alone would understate the severity. Decisions about therapy should follow that combined assessment rather than a single symptom or laboratory value.

    • A. Symptoms alone are not a sufficient basis for judging severity, because they correlate poorly with mucosal inflammation and with the risk of complications.
    • B. A single objective marker is a useful surrogate for inflammation, but it does not by itself capture disease extent or the risk of complications.
    • C. Bowel frequency is one symptom among several and does not reflect the inflammatory burden or the disease course.

    Sources: Canadian Association of Gastroenterology, Clinical Practice Guideline: Luminal Crohn's Disease (2019)

Exam-style questions written by MedHub for practice. They are not official exam questions.