AKT – Gastrointestinal health

Samuel White, aged 52, presents with a 6-month history of intermittent upper abdominal pain and bloating, worse after meals. He reports belching and occasional nausea but denies vomiting or weight loss. He drinks two glasses of wine most evenings and smokes 5 cigarettes daily.

He has no known allergies. His only medication is occasional ibuprofen for back pain. No family history of gastrointestinal disease.

On examination, his BMI is 28.3. Abdomen is soft with mild epigastric tenderness, no masses or organomegaly. No jaundice or peripheral stigmata of chronic liver disease.

What is the MOST appropriate initial investigation?

Katherine Moore, aged 34, presents with a 3-week history of loose stools occurring 3–4 times daily, abdominal cramping and urgency. She has no recent travel or antibiotic use. She follows a vegetarian diet and denies blood in stool. No weight loss reported.

She has no significant medical history and takes no regular medications. No family history of bowel disease.

On examination, her vital signs are normal. Mild left lower quadrant tenderness is noted but no guarding or rebound.

Which investigation is MOST likely to confirm the diagnosis?

David Tran, aged 45, presents with fatigue and a recent episode of passing black, tarry stools. He reports feeling dizzy when standing. He is otherwise well and takes no medications. He drinks socially and smokes occasionally.

On examination, he appears pale. BP 100/65 mmHg supine, 85/60 mmHg standing. Pulse 96 bpm. Abdomen is soft with mild epigastric tenderness. Rectal exam confirms melaena.

What is the MOST appropriate next step in management?

Rachel Nguyen, aged 29, presents with recurrent episodes of abdominal bloating, cramping and diarrhoea, particularly after meals. Symptoms improve when she avoids milk and ice cream. She is otherwise well. No weight loss, bleeding or systemic symptoms.

She takes no medications. No relevant family history. No recent travel.

On examination, abdomen is soft, non-tender. Vitals normal. BMI 22.5.

What is the MOST likely diagnosis?

Joseph Makins, aged 61, presents with a 2-month history of change in bowel habit with increasing constipation and occasional pencil-thin stools. He has also noticed some fatigue. He denies overt bleeding. He is an ex-smoker and has a sedentary lifestyle.

No significant past history. No regular medications. His brother was diagnosed with bowel cancer at age 55.

On examination, he appears pale. Abdominal examination reveals mild left lower quadrant tenderness. Digital rectal exam reveals an empty rectum.

What is the MOST appropriate next step in management?

Claire Richardson, aged 37, presents with intermittent right upper quadrant discomfort for the past 3 months, worse after fatty meals. She denies jaundice, weight loss or fever. Bowel habits are normal.

No relevant past medical history. No medications. She has two children and is otherwise healthy.

On examination, BMI is 31. Abdomen is soft, with mild tenderness in the right upper quadrant, no guarding or masses. Murphy’s sign is negative.

What is the MOST appropriate initial investigation?

Tom Deakin, aged 24, presents with a 2-week history of perianal discomfort and bleeding on wiping. He reports bright red blood on toilet paper and occasional anal itching. Bowel motions are regular and not painful. No abdominal pain or weight loss.

No relevant medical history. No medications. Non-smoker, occasional alcohol.

On examination, he is afebrile and well. Perianal inspection reveals a small external skin tag and a visible non-thrombosed external haemorrhoid. Digital rectal exam is unremarkable.

What is the MOST appropriate management?

Angela Vassallo, aged 50, presents with fatigue and mild shortness of breath on exertion. She denies any bleeding, weight loss or changes in bowel habit. Her periods stopped two years ago.

No past history. No medications. No family history of gastrointestinal or gynaecological malignancy.

On examination, she is pale with conjunctival pallor. Vital signs normal. Abdomen unremarkable. FBC shows Hb 93 g/L, MCV 70 fL, ferritin 8 µg/L.

What is the MOST appropriate next step?

Liam O’Connor, aged 19, presents with a 4-week history of abdominal pain, bloating and loose stools. He reports increased fatigue and has had two episodes of mouth ulcers. No travel history. His uncle has Crohn’s disease.

No medications. Non-smoker. Otherwise healthy.

On examination, he appears pale. BMI 19. Oral ulcers noted. Abdomen is soft, mildly tender in the right lower quadrant. No perianal findings.

Which investigation is MOST likely to support the diagnosis?

Martin Russo, aged 67, presents with persistent early satiety, weight loss of 5 kg over 2 months, and mild epigastric discomfort. He denies vomiting or overt bleeding. No prior endoscopy history.

He takes aspirin for secondary prevention post-stent. He has smoked for 30 years and drinks moderately.

On examination, BMI is 21. Abdominal exam reveals mild epigastric tenderness. No masses or organomegaly. Rectal exam NAD.

What is the MOST appropriate next step?

Natasha Goldstein, aged 32, presents with intermittent rectal bleeding and mucus in the stool for 2 months. She has mild cramping abdominal pain, tenesmus, and increased bowel frequency. No recent travel. She denies weight loss but reports fatigue.

No medications. Non-smoker. Family history negative for bowel disease.

On examination, she is well-appearing. Abdomen is soft with mild left lower quadrant tenderness. Rectal exam reveals trace blood on glove.

What is the MOST likely diagnosis?

Edward Zhang, aged 44, presents with persistent heartburn, retrosternal discomfort and regurgitation, especially after meals. He often takes antacids. He has a 10-year history of smoking and drinks alcohol occasionally. No dysphagia or weight loss.

No regular medications. No family history of GI malignancy.

Examination is unremarkable. BMI 27. Vital signs normal.

What is the MOST appropriate initial management?

Sophie Akbar, aged 26, presents with recurrent nausea and upper abdominal pain. She has been treated twice in the past year for peptic ulcer disease with PPIs. She does not use NSAIDs or smoke. No history of alcohol use.

No significant past history. She has no current medications. Her father had a history of duodenal ulcers.

On examination, vitals are normal. Mild epigastric tenderness noted. No signs of anaemia or weight loss.

What is the MOST likely underlying cause?

Mark Stevens, aged 59, presents with vague upper abdominal discomfort, early satiety and a 6 kg weight loss over the past 3 months. He also reports occasional dark urine and pruritus. He denies overt jaundice, vomiting or altered bowel habits.

No history of liver disease. He takes ramipril for hypertension. Smoked 20/day until last year.

On examination, scleral icterus is noted. Abdomen shows a palpable non-tender gallbladder in the right upper quadrant.

What is the MOST likely diagnosis?

Annette Brody, aged 39, presents with persistent bloating, flatulence and foul-smelling stools. She has noticed unintentional weight loss and fatigue. Her stools are bulky and difficult to flush. No travel history. Her diet is healthy and she does not smoke or drink.

On examination, BMI is 19. She has a smooth tongue and pale conjunctivae. Abdomen is mildly distended. No organomegaly.

What is the MOST appropriate initial investigation?

George Nikolic, aged 48, presents with sudden onset severe epigastric pain radiating to the back, accompanied by nausea and vomiting. He has a history of heavy alcohol use but no previous similar episodes. No recent trauma or medication use.

On examination, he is tachycardic and febrile. Abdomen is tender in the epigastric region with reduced bowel sounds. No guarding or rebound.

Serum lipase is elevated to 1600 U/L (normal <160).

What is the MOST appropriate initial management?

Helen Fraser, aged 67, presents with a 3-month history of intermittent abdominal discomfort, bloating and a sense of incomplete bowel emptying. She has also noted alternating constipation and diarrhoea. No bleeding or weight loss. No family history of malignancy.

She takes ramipril and simvastatin. Non-smoker. No recent travel.

On examination, abdomen is soft, non-tender. No masses or organomegaly. Digital rectal exam normal.

What is the MOST appropriate next step?

Sami Rahman, aged 30, presents with ongoing nausea and early satiety for the past month. He denies vomiting, weight loss or abdominal pain. His symptoms worsen after large meals. He has type 1 diabetes diagnosed 12 years ago.

His glycaemic control has been suboptimal. He is on a basal-bolus insulin regimen.

On examination, BMI is 24. Abdomen is soft and non-tender. No organomegaly.

What is the MOST likely diagnosis?

Patrick Wilson, aged 21, presents with sharp right lower quadrant abdominal pain that started 24 hours ago and has gradually worsened. He reports nausea but no vomiting or diarrhoea. No urinary symptoms. No history of similar pain previously.

On examination, his temperature is 37.9°C. There is tenderness in the right iliac fossa with rebound and guarding. Rovsing’s sign is positive.

What is the MOST likely diagnosis?

Linda Rose, aged 58, presents with several weeks of painless jaundice, dark urine and pale stools. She denies abdominal pain, fever or weight loss. Her appetite remains normal. She has no history of liver disease or recent travel.

On examination, she is jaundiced. There is a palpable non-tender gallbladder. No hepatomegaly. No ascites or stigmata of chronic liver disease.

Liver function tests show elevated bilirubin, ALP and GGT, with normal ALT and AST.

What is the MOST likely diagnosis?

Brian Sykes, aged 54, presents with worsening fatigue and lethargy over 3 months. He also reports decreased libido and darkening of his skin. No GI bleeding. He drinks minimal alcohol and is not on any medications.

On examination, he appears tanned despite limited sun exposure. BP is 105/65 mmHg. Abdomen is soft with mild hepatomegaly. No splenomegaly or ascites.

Initial bloods show elevated liver enzymes, ferritin 1300 µg/L, and transferrin saturation of 65%.

What is the MOST likely diagnosis?

Ana Costa, aged 31, presents with nausea, vomiting and upper abdominal discomfort. She recently returned from Fiji where she consumed seafood. She reports a fever and generalised malaise.

On examination, she is febrile, scleral icterus is present, and her RUQ is tender without guarding. No rash or lymphadenopathy. No hepatomegaly.

Liver function tests show AST 890 U/L, ALT 960 U/L, ALP 180 U/L, bilirubin 86 µmol/L.

What is the MOST likely diagnosis?

Monica Daley, aged 46, presents with a 4-month history of increased burping, postprandial bloating and nausea. She reports occasional early satiety. Her diet is balanced, and she takes no medications. No red flag symptoms.

On examination, she appears well. Abdomen is soft, non-tender. BMI is 26. No palpable masses.

Which of the following is the MOST appropriate initial management?

Joshua Leonard, aged 60, presents for review of long-standing gastro-oesophageal reflux symptoms. He has been using over-the-counter antacids for years but reports worsening regurgitation, especially at night. He denies dysphagia or weight loss.

On examination, BMI is 32. Abdomen is unremarkable. No anaemia or lymphadenopathy.

What is the MOST appropriate management at this stage?

Felicity Adams, aged 73, presents with increasing confusion, lethargy, and abdominal distension. She has a history of cirrhosis secondary to hepatitis C. She was recently treated for a urinary tract infection.

On examination, she is drowsy but rousable. Asterixis is present. Abdomen is distended with shifting dullness. No fever. No focal neurological signs.

Which of the following is the MOST appropriate immediate treatment?

Nathan Jury, aged 42, presents with abdominal pain and a distended abdomen. He has a known history of Crohn’s disease and has been poorly adherent to medications. He last opened his bowels 2 days ago. No vomiting but has had nausea and bloating.

On examination, his abdomen is distended with hyperactive bowel sounds and generalised tenderness without guarding. Vitals are normal.

What is the MOST appropriate investigation?

Marie Callaghan, aged 64, presents with a 6-week history of anorexia, weight loss and dull epigastric discomfort. She has a past history of H. pylori infection treated years ago. She reports early satiety and denies vomiting or bleeding.

On examination, BMI is 20, abdomen is non-tender, no masses. No lymphadenopathy.

What is the MOST appropriate next step in management?

Daniela Brooks, aged 39, presents with persistent fatigue and bloating. Blood tests reveal iron deficiency anaemia with Hb 98 g/L and ferritin 12 µg/L. She has regular menses and no GI bleeding or overt symptoms of malabsorption.

She follows a vegetarian diet. No NSAID use. No family history of coeliac or colorectal disease.

What is the MOST appropriate investigation?

Peter Wallace, aged 59, presents with rectal bleeding, which he describes as bright red and mixed with stool. He has also noted an alteration in bowel habits with intermittent constipation. No family history of colorectal cancer. No weight loss or abdominal pain.

Examination reveals external haemorrhoids but no masses on DRE. Vitals are normal.

What is the MOST appropriate next step?

Jason Tran, aged 22, presents with severe cramping abdominal pain, watery diarrhoea and fever. He returned from Southeast Asia 5 days ago. He has passed up to 8 stools daily, with some containing blood and mucus. He is able to drink fluids.

On examination, T 38.2°C, BP 110/70, HR 88. Abdomen soft with LLQ tenderness. No rebound. No peritonism.

What is the MOST appropriate treatment?

Mohammed Khalil, aged 29, presents with upper abdominal pain and vomiting for the last 12 hours. He has a history of recurrent gastric ulcers. He describes the pain as constant, severe, and worse when lying flat. He has not passed flatus or stool since yesterday.

On examination, he is tachycardic and febrile. Abdomen is rigid with rebound tenderness. Bowel sounds are absent.

What is the MOST likely diagnosis?

Grace Wu, aged 35, presents with mild abdominal pain and rectal bleeding. She describes the bleeding as streaks of bright red blood on the outside of the stool. Bowel motions are otherwise normal. She is 4 months postpartum and has recently returned to work.

On examination, perianal inspection reveals a small linear tear at the posterior anal verge.

What is the MOST appropriate management?

Linda Ford, aged 62, presents with progressive dysphagia to solids and liquids over 2 months and has lost 5 kg unintentionally. She denies odynophagia or reflux. No history of neurological disease or recent travel.

On examination, she appears thin but is otherwise normal. No lymphadenopathy. No neurological signs.

What is the MOST appropriate next step in investigation?

Aaron Doyle, aged 51, presents with ongoing flatulence and abdominal bloating. He reports foul-smelling stools that are difficult to flush. No weight loss or rectal bleeding. He had a small bowel resection 3 years ago for Crohn’s disease.

On examination, abdomen is soft with mild distension. No tenderness or organomegaly. BMI is 20.3.

What is the MOST likely diagnosis?

Emma Shaw, aged 27, presents with intermittent upper abdominal pain and bloating. She is otherwise well and takes the oral contraceptive pill. She is planning a pregnancy in the next year. Coeliac serology is positive (tTG IgA elevated).

What is the MOST appropriate next step?

Emily Fraser, aged 42, presents with a 3-month history of bloating, constipation, and lower abdominal discomfort. She reports increased stress at work. Bowel motions are infrequent but relieved with laxatives. No bleeding, weight loss, or nocturnal symptoms.

Examination is normal. BMI is 24. No abdominal masses or organomegaly. FBC and coeliac serology are normal.

What is the MOST likely diagnosis?

Michael Barnes, aged 73, presents with confusion and increasing abdominal girth. He has known cirrhosis and takes frusemide and spironolactone. He has missed recent follow-ups. No fever or pain reported.

On examination, he is disoriented. Abdomen is tense with shifting dullness. No peritonism. Temp 37.6°C.

Ascitic tap shows neutrophils >250 cells/mm³, culture pending.

What is the MOST appropriate next step?

James Lin, aged 55, presents with persistent iron deficiency anaemia. He has had multiple normal upper GI scopes and negative FOBTs. He has no abdominal symptoms and takes no NSAIDs. Family history is non-contributory.

What is the MOST appropriate next investigation?

Leah Kennedy, aged 38, presents with persistent perianal pain and discharge for 2 months. She describes occasional bleeding and discomfort when sitting. She denies systemic symptoms.

On examination, there is a small external opening near the anus with surrounding induration and some purulent discharge.

What is the MOST likely diagnosis?

Tristan Yuen, aged 50, presents with nausea and jaundice. He drinks 6–8 beers daily. No prior liver investigations. He reports recent unintentional weight loss and fatigue.

On examination, he has scleral icterus, palmar erythema and mild hepatomegaly. No ascites. No encephalopathy.

LFTs show AST 280, ALT 110, GGT 420, bilirubin 90. INR is elevated. Platelets are low.

What is the MOST likely diagnosis?

Rachel Howard, aged 44, presents with a 2-day history of severe epigastric pain radiating to the back, vomiting, and fever. She drinks moderately and has no surgical history.

On examination, she is febrile and tender in the epigastrium. Lipase is 1450 U/L. ALT is 210 U/L. Ultrasound shows gallstones without bile duct dilation.

What is the MOST likely cause of her symptoms?

Ben Carter, aged 37, presents with 5 months of bloating, loose stools and fatigue. He has recently become vegetarian. Blood tests show low ferritin, low B12, and elevated tTG IgA. BMI is 18.6.

What is the MOST appropriate next step?

Victor Li, aged 60, presents with persistent heartburn, regurgitation and a chronic cough. He has been taking over-the-counter antacids but without relief. He denies weight loss or dysphagia.

On examination, BMI is 31. No abnormalities noted.

What is the MOST appropriate management at this stage?

Alice Petrova, aged 70, presents with new-onset constipation and intermittent abdominal discomfort. She denies bleeding, weight loss, or changes in appetite. She takes amlodipine, paracetamol and calcium carbonate supplements.

On examination, abdomen is soft, mildly distended. DRE reveals firm stool in rectum. FBC is normal.

What is the MOST likely cause?

Karen Miles, aged 47, presents with a 3-day history of fever, abdominal pain and diarrhoea. She recently attended a barbecue where others also became unwell. She reports blood in her stool today.

On examination, she is febrile and has mild LLQ tenderness. No peritonism. Stool MCS is pending.

What is the MOST appropriate management while awaiting results?

Robert Singh, aged 34, presents with burning epigastric pain relieved by food but returning within a few hours. He takes NSAIDs for chronic back pain. No bleeding or vomiting. No weight loss.

What is the MOST likely diagnosis?

Mei Chen, aged 66, presents with painless rectal bleeding. She noticed bright red blood coating the stool. No change in bowel habit. No weight loss or abdominal pain. Past history includes diverticular disease.

On examination, vitals are normal and abdomen is soft. Rectal exam reveals some bright blood but no masses.

What is the MOST likely cause?

Sandra White, aged 58, presents with right upper quadrant pain and recent onset jaundice. She has known gallstones. No fever or vomiting. Pain is steady and radiates to the shoulder.

On examination, she is jaundiced. Murphy’s sign is positive. LFTs show elevated bilirubin, ALP and mildly raised AST/ALT.

What is the MOST likely diagnosis?

Damien Hall, aged 40, presents with 2 days of diarrhoea after starting antibiotics for sinusitis. He has abdominal cramps and 4 loose stools per day. No blood or vomiting. He completed amoxicillin-clavulanate yesterday.

What is the MOST appropriate next step?

Kyle Johnson, aged 45, presents with dysphagia that has gradually progressed from solids to liquids. He also reports regurgitation of undigested food. No weight loss or reflux symptoms. No neurological history.

What is the MOST likely diagnosis?