• A. IBS – IBS does not cause malabsorption, anaemia, or weight loss.
• C. Crohn’s disease – Can cause weight loss and diarrhoea, but is typically associated with bloody stools, perianal disease, and raised inflammatory markers (CRP).
• D. Lactose intolerance – Causes bloating and diarrhoea, but does not lead to anaemia or weight loss.
• E. Chronic pancreatitis – Causes steatorrhoea, but is associated with alcohol history and pancreatic enzyme insufficiency rather than positive tTG antibodies.

Epigastric pain that is relieved by eating is characteristic of a duodenal ulcer.

Gastric ulcer pain is typically worse with eating. The presence of peptic ulcers is confirmed by endoscopy. Initial management includes PPIs , antibiotics if H-pylori infection is present and conservative measures such as stopping medications that are risk factors for ulcer formation such as NSAID’s as well as caffeine, alcohol and tobacco.

GORD presents with heartburn and regurgitation.

Pancreatitis presents with severe, constant epigastric pain radiating to the back.

Cholecystitis presents with right upper quadrant pain, often after eating fatty foods.

More information:

Scenario: Diagnosis | Management | Peptic ulcers | CKS | NICE

Heartburn and regurgitation that worsen after meals and when lying down are characteristic of GORD. GORD is a common presentation to GP and patients can present reporting chest pain or a chronic cough. Diagnosis is mostly clinical but can involve endoscopy to determine severity especially if concerns of Barretts Oesophagus.

Peptic ulcer disease presents with epigastric pain.

Cholecystitis presents with right upper quadrant pain and fever.

Gastritis presents with epigastric pain and nausea.

Oesophageal spasm presents with chest pain and dysphagia.

More information:

Scenario: Diagnosis | Management | GORD | CKS | NICE 

• Hepatic hydrothorax – This refers to a pleural effusion due to cirrhosis but does not explain the raised neutrophil count in ascitic fluid.
• Hepatorenal syndrome – This presents with acute kidney injury (AKI) in cirrhotic patients but does not cause peritoneal neutrophilia.
• Malignant ascites – Caused by peritoneal carcinomatosis, it leads to low SAAG (<1.1 g/dL) and is often associated with positive cytology for malignant cells.
• Budd-Chiari syndrome – This results from hepatic vein thrombosis, presenting with painful hepatomegaly, ascites, and liver dysfunction, but does not typically cause SBP-like neutrophilia.

This question gives a presentation suggestive of coeliac disease. Coeliac disease is an autoimmune condition in which exposure to gluten causes an immune reaction which creates inflammation of the small intestine. Patients who are diagnosed with T1DM should be screened for coeliac disease on diagnosis as the conditions often present together.

IBS presents with abdominal pain and changes in bowel habits but not weight loss or anaemia.

Crohn's disease and ulcerative colitis present with chronic diarrhoea and abdominal pain but are often associated with bloody stools.

Gastroenteritis presents with acute, not chronic, diarrhoea.

More information:

Scenario: Diagnosis | Management | Coeliac disease | CKS | NICE  

• Peptic ulcer disease – Peptic ulcers can cause epigastric pain but typically present with burning pain that improves with food or antacids. Perforated ulcers cause peritonitis and guarding, which is absent here.
• Acute cholecystitis – This causes right upper quadrant (RUQ) pain, often with fever and positive Murphy’s sign (pain on inspiration when palpating the RUQ). The patient’s pain is epigastric and radiates to the back, making cholecystitis unlikely.
• Gastroesophageal reflux disease (GERD) – GERD presents with retrosternal burning, worse when lying down, but does not typically cause severe epigastric pain or raised inflammatory markers.
• Mesenteric ischaemia – Mesenteric ischaemia can present with severe abdominal pain but is more common in older patients with atrial fibrillation. It typically shows lactic acidosis, which is absent in this case.

• Mallory-Weiss tear – Typically follows forceful vomiting or retching and causes small-volume haematemesis, but it does not cause significant hypotension or melaena.
• Peptic ulcer disease – Peptic ulcers can cause GI bleeding, but they usually present with epigastric pain and positive stool occult blood test, rather than large-volume haematemesis in a cirrhotic patient.
• Gastric cancer – Can cause chronic occult bleeding, leading to anaemia and weight loss, but it is less likely to cause massive haematemesis.
• Angiodysplasia – A cause of occult bleeding or iron-deficiency anaemia, but it does not typically cause massive GI bleeding.

Severe epigastric pain radiating to the back and elevated lipase levels are indicative of pancreatitis. Usually in the Emergency department amylase levels are taken to show pancreatitis however raised lipase levels are more specific for pancreatitis. The most common risk factors for pancreatitis are the presents of gallstones and alcohol consumption. Once pancreatitis is suspected patients should be referred to surgical teams and intravenous fluids, oxygen, intravenous analgesics and antibiotics should be initiated where appropriate.

Gastric and duodenal ulcers present with epigastric pain but not elevated lipase levels.

GERD presents with heartburn and regurgitation.

Cholecystitis presents with right upper quadrant pain and fever.

More information:

Scenario: Diagnosis | Management | Pancreatitis | CKS | NICE 

1A - Constipation.

Constipation is a difficulty passing stool. This can be with pain, discomfort, distension, bloating or excessive straining. It can also be passing infrequent stool - typically less than three times per week. However, it is important to remember every patient is different so it is often just classified as a passage of stool less frequently compared to their usual bowel habits. In the elderly this can lead to confusion, nausea, overflow diarrhoea and urinary retention. Diverticular disease is also common in this age group and can sometimes be a cause of constipation. However this pain typically presents in the left iliac fossa. This may be the underlying cause of this patient's symptoms but this question is focusing on your ability to recognise constipation as it is a very common problem for all age groups. Exam questions often put more than one possible correct answer in the options and it is up to you to recognise the most likely correct option. Diverticulitis occurs when an outpouching caused by diverticular disease becomes inflamed or infected. This often presents with more severe pain and the patient could have other systemic symptoms like a high temperature. Bowel Cancer is not the most likely differential but a change in bowel habits for people over the age of 60 is a red flag and should be investigated. Ileus is where the bowel fails to operate normally and it is often associated with recent surgery.

More information:

https://cks.nice.org.uk/topics/constipation/diagnosis/diagnosis/