A 22-year-old man from Pune has had crampy right lower abdominal pain, non-bloody diarrhoea and weight loss for 8 months, and he now has a perianal fistula. Colonoscopy shows deep ulcers in the terminal ileum and caecum separated by normal mucosa. Biopsy shows transmural inflammation with small non-caseating granulomas, and Xpert MTB/RIF on the tissue is negative. What is the most likely diagnosis?

Ulcerative colitis with backwash ileitis

A 34-year-old woman is admitted with acute gallstone pancreatitis 8 hours after the pain began. Pulse 108/min, BP 112/72 mmHg, haematocrit 45%, and she has no heart or kidney disease. Which fluid strategy is best for the first 24 hours?

Moderate goal-directed Ringer's lactate

Fluid restriction to limit pancreatic oedema

5% albumin as the main resuscitation fluid

Aggressive Ringer's lactate at a fixed high rate

A 38-year-old man comes to casualty 6 hours after a heavy drinking session with severe epigastric pain radiating to the back and repeated vomiting. Pulse 104/min, BP 128/80 mmHg, and the epigastrium is tender. Serum lipase is 5 times the upper limit of normal. What else is needed to establish the diagnosis of acute pancreatitis?

Nothing more; the criteria are already met

Ultrasound showing a swollen pancreas

Contrast-enhanced CT of the abdomen now

Serum amylase in addition to lipase

A 41-year-old woman has recovered from mild acute biliary pancreatitis by day 4. Her LFTs are now normal, and ultrasound shows gallbladder stones with a normal-calibre common bile duct; she never had cholangitis. What is the best plan for her gallbladder?

Cholecystectomy during the same admission

Ursodeoxycholic acid without surgery

ERCP with sphincterotomy before discharge

GI bleeding, IBD and pancreatitis

22 NEET-PG practice questions on GI bleeding, IBD and pancreatitis, part of General Medicine. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Easy
A 22-year-old man from Pune has had crampy right lower abdominal pain, non-bloody diarrhoea and weight loss for 8 months, and he now has a perianal fistula. Colonoscopy shows deep ulcers in the terminal ileum and caecum separated by normal mucosa. Biopsy shows transmural inflammation with small non-caseating granulomas, and Xpert MTB/RIF on the tissue is negative. What is the most likely diagnosis?
1. AYersinia ileocolitis
2. BUlcerative colitis with backwash ileitis
3. CCrohn's disease
4. DIntestinal tuberculosis
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Answer: C · Crohn's disease
Skip lesions, transmural inflammation, non-caseating granulomas and perianal fistula are the hallmarks of Crohn's disease, which can affect any part of the gut but most often the terminal ileum. In India, intestinal tuberculosis is the main mimic, so tissue is sent for Xpert, culture and histology before immunosuppression. Treatment depends on extent and severity, with steroids for induction and thiopurines or biologics to maintain remission. Smoking worsens Crohn's disease, and stopping it is part of treatment.
- A: Yersinia causes an acute self-limiting ileitis, not 8 months of illness with fistula.
- B: Ulcerative colitis is continuous, mucosal, starts in the rectum and does not cause fistulae.
- D: Tuberculosis gives large caseating granulomas, and the Xpert test was negative.
Question 2 · Medium
A 34-year-old woman is admitted with acute gallstone pancreatitis 8 hours after the pain began. Pulse 108/min, BP 112/72 mmHg, haematocrit 45%, and she has no heart or kidney disease. Which fluid strategy is best for the first 24 hours?
1. AFluid restriction to limit pancreatic oedema
2. BModerate goal-directed Ringer's lactate
3. C5% albumin as the main resuscitation fluid
4. DAggressive Ringer's lactate at a fixed high rate
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Answer: B · Moderate goal-directed Ringer's lactate
Early fluids correct the hypovolaemia caused by third-space loss, but aggressive fixed-rate fluids caused more fluid overload without better outcomes in a recent randomised trial. Current practice is moderate, goal-directed resuscitation with Ringer's lactate, adjusted to heart rate, urine output, haematocrit and urea at frequent reviews. Ringer's lactate is preferred to normal saline because it may reduce systemic inflammation and avoids hyperchloraemic acidosis. Fluid overload, especially in older patients, is watched for.
- A: Restriction worsens hypovolaemia and pancreatic hypoperfusion and may promote necrosis.
- C: Colloids such as albumin give no advantage over crystalloid.
- D: High fixed rates increased fluid overload without better outcomes.
Question 3 · Easy
A 38-year-old man comes to casualty 6 hours after a heavy drinking session with severe epigastric pain radiating to the back and repeated vomiting. Pulse 104/min, BP 128/80 mmHg, and the epigastrium is tender. Serum lipase is 5 times the upper limit of normal. What else is needed to establish the diagnosis of acute pancreatitis?
1. AUltrasound showing a swollen pancreas
2. BNothing more; the criteria are already met
3. CContrast-enhanced CT of the abdomen now
4. DSerum amylase in addition to lipase
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Answer: B · Nothing more; the criteria are already met
By the revised Atlanta criteria, acute pancreatitis is diagnosed when two of three are present: typical upper abdominal pain, serum lipase or amylase at least 3 times the upper limit, and characteristic imaging. He has the first two, so imaging is not needed for the diagnosis. Early CT is kept for doubtful diagnoses, and contrast CT for complications is best done after 72 hours in a patient who is not improving. An abdominal ultrasound is still done, but to look for gallstones as the cause.
- A: Ultrasound looks for gallstones; it is not needed to make the diagnosis here.
- C: CT on admission adds nothing when the diagnosis is clear and may underestimate necrosis.
- D: Lipase is enough; amylase adds no diagnostic value once lipase is clearly raised.
Question 4 · Medium
A 45-year-old man with alcohol-related acute pancreatitis has hypotension and a serum creatinine of 2.4 mg/dL on admission, amounting to organ failure. With IV fluids both resolve within 30 hours. Contrast CT on day 5 shows an acute peripancreatic fluid collection without necrosis. By the revised Atlanta classification, how severe is his pancreatitis?
1. ACritical
2. BMild
3. CModerately severe
4. DSevere
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Answer: C · Moderately severe
The revised Atlanta classification has three grades. Mild disease has no organ failure and no local or systemic complications; moderately severe has transient organ failure (resolving within 48 hours) and/or local complications; severe has persistent organ failure beyond 48 hours. His organ failure lasted 30 hours and he has a local complication, so he is moderately severe. Most acute peripancreatic fluid collections resolve without drainage.
- A: 'Critical' belongs to the determinant-based classification, not the revised Atlanta grades.
- B: Mild disease has no organ failure and no local complications; he had both.
- D: Severe disease needs organ failure persisting beyond 48 hours.
Question 5 · Medium
A 41-year-old woman has recovered from mild acute biliary pancreatitis by day 4. Her LFTs are now normal, and ultrasound shows gallbladder stones with a normal-calibre common bile duct; she never had cholangitis. What is the best plan for her gallbladder?
1. ACholecystectomy after 6 weeks
2. BCholecystectomy during the same admission
3. CUrsodeoxycholic acid without surgery
4. DERCP with sphincterotomy before discharge
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Answer: B · Cholecystectomy during the same admission
After mild gallstone pancreatitis, cholecystectomy during the same admission markedly reduces recurrent biliary events, including further pancreatitis, compared with waiting several weeks. In necrotising pancreatitis, surgery is deferred until collections resolve or mature. ERCP is needed only for cholangitis or persistent bile duct obstruction, and endoscopic sphincterotomy is an option for patients unfit for surgery. Dissolution therapy has no role in preventing recurrence.
- A: Waiting weeks allows recurrent pancreatitis and other gallstone events.
- C: Ursodeoxycholic acid rarely dissolves stones and does not prevent recurrence.
- D: ERCP is for cholangitis or duct obstruction, which she does not have.
Question 6 · Easy
A 23-year-old engineering student comes to casualty after vomiting a small amount of streaky blood following a night of repeated retching after a party. He has no melaena or syncope and no liver or heart disease. Pulse 84/min, BP 124/78 mmHg, haemoglobin 14.6 g/dL, blood urea 4.8 mmol/L (29 mg/dL), so his Glasgow-Blatchford score is 0. What is the most appropriate management?
1. AAdmit for endoscopy within 12 hours
2. BTransfuse one unit of packed red cells
3. CDischarge with outpatient follow-up
4. DAdmit and start an IV pantoprazole infusion
Answer and explanation in LearnFree account
Question 7 · Hard
A 31-year-old man is on day 3 of IV methylprednisolone for acute severe ulcerative colitis. He still passes 10 bloody stools a day and his CRP is 72 mg/L. Stool C. difficile toxin and sigmoidoscopic biopsy for CMV are negative, the transverse colon measures 4.5 cm on X-ray, and screening for latent TB and hepatitis B is negative. What is the next best step?
1. AAdd azathioprine and continue IV steroids
2. BChange to oral prednisolone and discharge
3. CContinue IV steroids for 7 more days
4. DRescue therapy with infliximab or ciclosporin
Answer and explanation in LearnFree account
Question 8 · Medium
A 35-year-old man with a severe flare of ulcerative colitis is on day 2 of IV hydrocortisone. A night resident gave him loperamide for frequent stools. He now has abdominal distension, fewer stools and reduced bowel sounds. Temperature 39°C, pulse 122/min, BP 100/64 mmHg. Abdominal X-ray shows the transverse colon dilated to 8 cm with loss of haustra and no free gas. What is the most likely diagnosis?
1. AToxic megacolon
2. BSigmoid volvulus
3. CColonic perforation
4. DAcute colonic pseudo-obstruction
Answer and explanation in LearnFree account
Question 9 · Medium
A 27-year-old woman with known ulcerative colitis is admitted with 9 bloody stools a day. Temperature 38.2°C, pulse 104/min, haemoglobin 9.8 g/dL, ESR 52 mm/h, CRP 64 mg/L. Abdominal X-ray shows no colonic dilatation, and stool is sent for C. difficile toxin. What is the next best step in management?
1. AIV corticosteroids
2. BHigher-dose oral mesalamine
3. COral budesonide MMX
4. DEmergency subtotal colectomy
Answer and explanation in LearnFree account
Question 10 · Medium
A 25-year-old woman from Lucknow with steroid-dependent ileocolonic Crohn's disease is to start infliximab. She has no cough or fever and no previous TB treatment. Which screening is essential before her first infusion?
1. ABaseline echocardiography
2. BLatent tuberculosis and hepatitis B screening
3. CRepeat colonoscopy with biopsy
4. DThiopurine methyltransferase activity
Answer and explanation in LearnFree account
Question 11 · Medium
A 28-year-old man from Bihar has ileocaecal ulceration on colonoscopy, and the team must separate Crohn's disease from intestinal tuberculosis before starting steroids. Consider these findings: 1. Necrotic mesenteric lymph nodes on CT. 2. Longitudinal ulcers with skip lesions. 3. Large confluent caseating granulomas on biopsy. 4. Perianal fistula. Which findings favour Crohn's disease?
1. A1, 2, 3 and 4
2. B2, 3 and 4 only
3. C2 and 4 only
4. D1 and 3 only
Answer and explanation in LearnFree account
Question 12 · Medium
A 52-year-old man with acute pancreatitis predicted to be mild has less pain on day 2, no nausea or vomiting, and is asking for food. Bowel sounds are present, and lipase is still raised. What is the best approach to feeding him?
1. AFeed by nasojejunal tube for a week
2. BKeep nil by mouth until lipase is normal
3. CStart total parenteral nutrition
4. DStart a low-fat oral diet now
Answer and explanation in LearnFree account
Question 13 · Hard
A 61-year-old man comes to casualty with two episodes of melaena since last night. He has had no syncope and has no known liver disease or heart failure. Pulse 106/min, BP 104/68 mmHg, haemoglobin 11.4 g/dL and blood urea 9.2 mmol/L (55 mg/dL). What is his Glasgow-Blatchford score?
1. A7 points
2. B9 points
3. C10 points
4. D8 points
Answer and explanation in LearnFree account
Question 14 · Hard
Six months after an episode of severe acute pancreatitis, a 44-year-old man has a large haematemesis. Endoscopy shows isolated gastric fundal varices with no oesophageal varices. LFTs, liver stiffness and liver ultrasound are normal, and the spleen is enlarged. What is the most likely cause, and its definitive treatment?
1. APortal vein thrombosis; anticoagulation
2. BSplenic vein thrombosis; splenectomy
3. CCirrhosis; transjugular portosystemic shunt
4. DBudd-Chiari syndrome; hepatic vein stenting
Answer and explanation in LearnFree account
Question 15 · Medium
A 50-year-old man is admitted with acute pancreatitis. The resident lists findings he believes predict a severe course: 1. Haematocrit 47% on admission. 2. Blood urea rising over the first 24 hours despite fluids. 3. Serum lipase 20 times the upper limit of normal. 4. SIRS persisting beyond 48 hours. Which of these predict severe disease?
1. A2 and 4 only
2. B1, 2 and 4 only
3. C1, 2 and 3 only
4. D1, 2, 3 and 4
Answer and explanation in LearnFree account
Question 16 · Medium
A 46-year-old man is admitted with melaena after taking diclofenac for a week for back pain. After 1 litre of crystalloid his pulse is 92/min and BP 118/76 mmHg; he has no heart disease. Haemoglobin is 8.1 g/dL, and endoscopy is planned within 24 hours. What is the best approach to red cell transfusion?
1. AGive fresh frozen plasma with red cells
2. BTransfuse only if haemoglobin falls below 7 g/dL
3. CTransfuse 1 unit before endoscopy
4. DTransfuse 2 units now to reach 10 g/dL
Answer and explanation in LearnFree account
Question 17 · Medium
A 32-year-old man with poorly controlled type 2 diabetes is admitted with acute pancreatitis. His blood sample looks milky, serum triglycerides are 2,450 mg/dL, glucose 340 mg/dL and serum amylase is only mildly raised. He drinks no alcohol, and ultrasound shows no gallstones. Which treatment lowers his triglycerides fastest in the acute phase?
1. AIV insulin infusion
2. BOmega-3 fatty acid capsules
3. COral fenofibrate
4. DOral atorvastatin
Answer and explanation in LearnFree account
Question 18 · Hard
A 47-year-old man is in the fourth week of necrotising alcohol-related pancreatitis. He had been improving but now has fever of 39°C and rising leucocyte count and procalcitonin. Contrast CT shows a 12 cm walled-off necrotic collection in the pancreatic body containing gas bubbles. He is haemodynamically stable. What is the best management?
1. AAntibiotics, then step-up endoscopic or percutaneous drainage
2. BObservation alone, as the collection is walled off
3. CSomatostatin infusion to reduce pancreatic secretion
4. DImmediate open surgical necrosectomy
Answer and explanation in LearnFree account
Question 19 · Medium
A 34-year-old woman from Kolkata has iron-deficiency anaemia (haemoglobin 7.8 g/dL) with intermittent black stools for 6 months despite oral iron. Her periods are not heavy, coeliac serology is negative, and both upper GI endoscopy and colonoscopy with ileal intubation are normal. She is haemodynamically stable. What is the investigation of choice now?
1. ATechnetium-99m labelled red cell scan
2. BMesenteric catheter angiography
3. CBarium meal follow-through
4. DVideo capsule endoscopy
Answer and explanation in LearnFree account
Question 20 · Medium
A 40-year-old woman had 110 cm of terminal ileum resected for stricturing Crohn's disease 3 years ago; her colon is intact. Consider these possible long-term problems: 1. Vitamin B12 deficiency. 2. Calcium oxalate kidney stones. 3. Cholesterol gallstones. 4. Hypercalcaemia. Which is she at increased risk of?
1. A1 and 2 only
2. B1, 2 and 3 only
3. C1 and 3 only
4. D1, 2, 3 and 4
Answer and explanation in LearnFree account
Question 21 · Medium
A 76-year-old man has had three admissions in a year for melaena with iron-deficiency anaemia. Upper GI endoscopy and colonoscopy were normal, but capsule endoscopy shows several small-bowel angiodysplasias. He has an ejection systolic murmur radiating to the carotids, and echocardiography shows severe calcific aortic stenosis. What links his bleeding to the valve disease?
1. ALow cardiac output causing gut ischaemia
2. BLoss of large von Willebrand factor multimers
3. CPlatelet destruction on the calcified valve
4. DHepatic congestion lowering clotting factors
Answer and explanation in LearnFree account
Question 22 · Easy
A 30-year-old woman with ulcerative pancolitis has been in remission on mesalamine for two years. Routine tests show ALP 410 U/L (reference 40-130), GGT 280 U/L and a normal bilirubin. She has no pain or fever. MRCP shows multifocal strictures alternating with dilatations of the intrahepatic and extrahepatic bile ducts. What is the most likely diagnosis?
1. ACommon bile duct stones
2. BPrimary sclerosing cholangitis
3. CPrimary biliary cholangitis
4. DMesalamine-induced hepatitis
Answer and explanation in LearnFree account

GI bleeding, IBD and pancreatitis

A 34-year-old woman is admitted with acute gallstone pancreatitis 8 hours after the pain began. Pulse 108/min, BP 112/72 mmHg, haematocrit 45%, and she has no heart or kidney disease. Which fluid strategy is best for the first 24 hours?

A 41-year-old woman has recovered from mild acute biliary pancreatitis by day 4. Her LFTs are now normal, and ultrasound shows gallbladder stones with a normal-calibre common bile duct; she never had cholangitis. What is the best plan for her gallbladder?

A 25-year-old woman from Lucknow with steroid-dependent ileocolonic Crohn's disease is to start infliximab. She has no cough or fever and no previous TB treatment. Which screening is essential before her first infusion?

A 52-year-old man with acute pancreatitis predicted to be mild has less pain on day 2, no nausea or vomiting, and is asking for food. Bowel sounds are present, and lipase is still raised. What is the best approach to feeding him?

A 61-year-old man comes to casualty with two episodes of melaena since last night. He has had no syncope and has no known liver disease or heart failure. Pulse 106/min, BP 104/68 mmHg, haemoglobin 11.4 g/dL and blood urea 9.2 mmol/L (55 mg/dL). What is his Glasgow-Blatchford score?