GASTROENTEROLOGY EXAM 2026 UPDATE
WITH COMPLETE SOLUTIONS.
SECTION 1: ESOPHAGEAL DISEASES
1. A 55-year-old man presents with heartburn, regurgitation, and a chronic
cough. He has had these symptoms for 5 years. What is the most likely
diagnosis?
• A) Achalasia
• B) Gastroesophageal reflux disease (GERD)
• C) Esophageal cancer
• D) Peptic ulcer disease
Correct Answer: B
Rationale: GERD is characterized by heartburn and regurgitation. Chronic cough is
an extraesophageal manifestation. The chronicity (5 years) without alarming
symptoms suggests GERD. Achalasia presents with dysphagia, not heartburn.
Esophageal cancer would have dysphagia and weight loss.
2. A patient with GERD has persistent symptoms despite maximal medical
therapy with a proton pump inhibitor (PPI). What is the most appropriate next
step?
• A) Increase PPI dose
• B) Add a histamine-2 receptor antagonist (H2RA)
• C) Upper endoscopy with biopsy
• D) Esophageal manometry
,Correct Answer: C
Rationale: Persistent GERD symptoms despite PPI therapy warrant upper
endoscopy to rule out complications (Barrett esophagus, erosive esophagitis,
stricture). Esophageal manometry is for motility disorders. Increasing PPI or
adding H2RA may be considered after endoscopy.
3. A patient with long-standing GERD is found to have intestinal metaplasia in
the distal esophagus. What is the most important risk associated with this
condition?
• A) Esophageal stricture
• B) Esophageal adenocarcinoma
• C) Achalasia
• D) Eosinophilic esophagitis
Correct Answer: B
*Rationale: Barrett esophagus (intestinal metaplasia of the esophagus) is a
premalignant condition that increases the risk of esophageal adenocarcinoma.
Surveillance endoscopy is recommended every 3-5 years. Strictures are benign
complications of GERD.*
4. A 40-year-old man presents with progressive dysphagia to solids and liquids,
regurgitation of undigested food, and chest pain. Barium swallow shows a
"bird's beak" appearance at the gastroesophageal junction. What is the most
likely diagnosis?
• A) Esophageal cancer
• B) Achalasia
• C) Diffuse esophageal spasm
• D) Peptic stricture
,Correct Answer: B
Rationale: Achalasia is characterized by absent peristalsis and failure of lower
esophageal sphincter (LES) relaxation. "Bird's beak" on barium swallow is classic.
Dysphagia to both solids and liquids early in the course is typical. Esophageal
manometry is diagnostic.
5. Which of the following is the treatment of choice for achalasia?
• A) Proton pump inhibitors
• B) Botulinum toxin injection
• C) Pneumatic dilation or Heller myotomy
• D) Esophagectomy
Correct Answer: C
Rationale: Pneumatic dilation and Heller myotomy (surgical) are the most effective
treatments for achalasia. Botulinum toxin is used in patients unfit for surgery. PPIs
do not treat the underlying motility disorder. Esophagectomy is reserved for end-
stage disease.
6. A patient presents with intermittent chest pain and dysphagia to solids and
liquids. Manometry shows high-amplitude, prolonged-duration contractions
with normal LES relaxation. What is the most likely diagnosis?
• A) Nutcracker esophagus
• B) Achalasia
• C) Diffuse esophageal spasm
• D) GERD
Correct Answer: A
Rationale: Nutcracker esophagus is a hypercontractile motility disorder with high-
amplitude, prolonged contractions. Diffuse esophageal spasm shows simultaneous
, contractions. Achalasia has absent peristalsis and incomplete LES relaxation. GERD
is a separate condition.
7. A patient with severe GERD is started on a PPI. What is the most important
long-term complication of PPI use?
• A) Hypomagnesemia
• B) Vitamin B12 deficiency
• C) Clostridioides difficile infection
• D) All of the above
Correct Answer: D
*Rationale: Long-term PPI use is associated with hypomagnesemia, vitamin B12
deficiency (decreased absorption), and increased risk of C. difficile infection. Other
risks include osteoporosis, chronic kidney disease, and dementia (controversial).*
8. A patient presents with severe odynophagia, chest pain, and dysphagia.
Endoscopy shows concentric rings and eosinophilic infiltration on biopsy. What
is the most likely diagnosis?
• A) Achalasia
• B) Eosinophilic esophagitis
• C) GERD
• D) Esophageal cancer
Correct Answer: B
*Rationale: Eosinophilic esophagitis (EoE) presents with dysphagia, food
impaction, and odynophagia. Endoscopy shows concentric rings, furrows, or white
plaques. Biopsy shows ≥ 15 eosinophils per high-power field. Treatment includes
topical corticosteroids and dietary elimination.*
WITH COMPLETE SOLUTIONS.
SECTION 1: ESOPHAGEAL DISEASES
1. A 55-year-old man presents with heartburn, regurgitation, and a chronic
cough. He has had these symptoms for 5 years. What is the most likely
diagnosis?
• A) Achalasia
• B) Gastroesophageal reflux disease (GERD)
• C) Esophageal cancer
• D) Peptic ulcer disease
Correct Answer: B
Rationale: GERD is characterized by heartburn and regurgitation. Chronic cough is
an extraesophageal manifestation. The chronicity (5 years) without alarming
symptoms suggests GERD. Achalasia presents with dysphagia, not heartburn.
Esophageal cancer would have dysphagia and weight loss.
2. A patient with GERD has persistent symptoms despite maximal medical
therapy with a proton pump inhibitor (PPI). What is the most appropriate next
step?
• A) Increase PPI dose
• B) Add a histamine-2 receptor antagonist (H2RA)
• C) Upper endoscopy with biopsy
• D) Esophageal manometry
,Correct Answer: C
Rationale: Persistent GERD symptoms despite PPI therapy warrant upper
endoscopy to rule out complications (Barrett esophagus, erosive esophagitis,
stricture). Esophageal manometry is for motility disorders. Increasing PPI or
adding H2RA may be considered after endoscopy.
3. A patient with long-standing GERD is found to have intestinal metaplasia in
the distal esophagus. What is the most important risk associated with this
condition?
• A) Esophageal stricture
• B) Esophageal adenocarcinoma
• C) Achalasia
• D) Eosinophilic esophagitis
Correct Answer: B
*Rationale: Barrett esophagus (intestinal metaplasia of the esophagus) is a
premalignant condition that increases the risk of esophageal adenocarcinoma.
Surveillance endoscopy is recommended every 3-5 years. Strictures are benign
complications of GERD.*
4. A 40-year-old man presents with progressive dysphagia to solids and liquids,
regurgitation of undigested food, and chest pain. Barium swallow shows a
"bird's beak" appearance at the gastroesophageal junction. What is the most
likely diagnosis?
• A) Esophageal cancer
• B) Achalasia
• C) Diffuse esophageal spasm
• D) Peptic stricture
,Correct Answer: B
Rationale: Achalasia is characterized by absent peristalsis and failure of lower
esophageal sphincter (LES) relaxation. "Bird's beak" on barium swallow is classic.
Dysphagia to both solids and liquids early in the course is typical. Esophageal
manometry is diagnostic.
5. Which of the following is the treatment of choice for achalasia?
• A) Proton pump inhibitors
• B) Botulinum toxin injection
• C) Pneumatic dilation or Heller myotomy
• D) Esophagectomy
Correct Answer: C
Rationale: Pneumatic dilation and Heller myotomy (surgical) are the most effective
treatments for achalasia. Botulinum toxin is used in patients unfit for surgery. PPIs
do not treat the underlying motility disorder. Esophagectomy is reserved for end-
stage disease.
6. A patient presents with intermittent chest pain and dysphagia to solids and
liquids. Manometry shows high-amplitude, prolonged-duration contractions
with normal LES relaxation. What is the most likely diagnosis?
• A) Nutcracker esophagus
• B) Achalasia
• C) Diffuse esophageal spasm
• D) GERD
Correct Answer: A
Rationale: Nutcracker esophagus is a hypercontractile motility disorder with high-
amplitude, prolonged contractions. Diffuse esophageal spasm shows simultaneous
, contractions. Achalasia has absent peristalsis and incomplete LES relaxation. GERD
is a separate condition.
7. A patient with severe GERD is started on a PPI. What is the most important
long-term complication of PPI use?
• A) Hypomagnesemia
• B) Vitamin B12 deficiency
• C) Clostridioides difficile infection
• D) All of the above
Correct Answer: D
*Rationale: Long-term PPI use is associated with hypomagnesemia, vitamin B12
deficiency (decreased absorption), and increased risk of C. difficile infection. Other
risks include osteoporosis, chronic kidney disease, and dementia (controversial).*
8. A patient presents with severe odynophagia, chest pain, and dysphagia.
Endoscopy shows concentric rings and eosinophilic infiltration on biopsy. What
is the most likely diagnosis?
• A) Achalasia
• B) Eosinophilic esophagitis
• C) GERD
• D) Esophageal cancer
Correct Answer: B
*Rationale: Eosinophilic esophagitis (EoE) presents with dysphagia, food
impaction, and odynophagia. Endoscopy shows concentric rings, furrows, or white
plaques. Biopsy shows ≥ 15 eosinophils per high-power field. Treatment includes
topical corticosteroids and dietary elimination.*
