MCQs on Paediatric Gastroenterology

Written by Dr. Emily Chang (MBBS, FRACP) – Paediatrician

Question 1

A 6-week-old infant is brought to the GP by her mother due to frequent vomiting after feeds. The infant is otherwise thriving with normal weight gain, is alert, and has no signs of respiratory distress or feeding aversion. Physical examination is normal. The mother is concerned because the baby “spits up” after nearly every feed, although the baby seems content afterward.

What is the most appropriate next step in management?

A) Start a proton pump inhibitor trial
B) Refer to a paediatric gastroenterologist
C) Reassure the mother and provide feeding advice
D) Order an abdominal ultrasound
E) Change to a hydrolysed formula

Correct Answer: C) Reassure the mother and provide feeding advice

This infant shows signs of uncomplicated gastroesophageal reflux (GOR), which is common and physiological in infants due to immature lower oesophageal sphincter function. The key features supporting this are normal weight gain, absence of irritability, respiratory symptoms, or feeding refusal.

In such cases, reassurance and feeding advice (e.g. smaller, more frequent feeds, keeping the baby upright after feeding) are appropriate. No further investigations or medications are required unless there are red flags suggestive of gastroesophageal reflux disease (GORD), such as failure to thrive, haematemesis, irritability, or feeding refusal.

PPIs (Option A) are only indicated for confirmed GORD with complications.
Referral (Option B) and imaging (Option D) are not needed unless there are red flags.
Hypoallergenic formula (Option E) is considered if cow’s milk protein allergy is suspected, which is not the case here.

Question 2

A 3-month-old exclusively formula-fed infant presents with frequent vomiting, loose mucousy stools, and intermittent blood-streaked diarrhoea for the past 2 weeks. The infant is otherwise well and gaining weight appropriately. Physical examination is normal. There is no family history of atopy. The mother recently switched from one standard cow’s milk-based formula to another due to cost.

What is the most appropriate next step in management?

A) Start oral antibiotics
B) Order stool culture and full blood count
C) Switch to an extensively hydrolysed formula
D) Start an amino acid-based formula
E) Advise switching back to the previous formula

Correct Answer: C) Switch to an extensively hydrolysed formula

This infant likely has non-IgE mediated cow’s milk protein allergy (CMPA), which commonly presents in early infancy with gastrointestinal symptoms such as vomiting, diarrhoea, mucus and blood in the stool. The infant is otherwise well and growing normally, which is typical of mild-to-moderate non-IgE CMPA.

The first-line treatment is to eliminate cow’s milk protein by switching to an extensively hydrolysed formula (EHF). Amino acid-based formula (Option D) is generally reserved for severe or refractory cases, or if there is failure to thrive.

Antibiotics (Option A) are not indicated as there is no evidence of bacterial infection.
Stool cultures (Option B) may be considered in cases with fever or systemic symptoms, but are not first-line here.
Switching back to the previous formula (Option E) will not help if the cause is cow’s milk protein.

Question 3

A 6-year-old girl is brought to the GP with concerns about poor growth. Her height and weight are both below the 3rd percentile. The mother reports that the child has frequent abdominal bloating, flatulence, and foul-smelling, bulky stools. She appears pale and tires easily. There is no history of vomiting or acute diarrhoea. On examination, she has a distended abdomen and reduced muscle mass.

Which of the following is the most appropriate initial investigation?

A) Anti-tissue transglutaminase (anti-TTG) IgA and total serum IgA
B) Small bowel biopsy via endoscopy
C) Faecal calprotectin
D) Genetic testing for HLA-DQ2/DQ8
E) Trial of a gluten-free diet

Correct Answer: A) Anti-tissue transglutaminase (anti-TTG) IgA and total serum IgA

This presentation is classic for coeliac disease in children, including failure to thrive, abdominal distension, and steatorrhoea. The most appropriate initial investigation is serological testing, specifically anti-TTG IgA, which is the most sensitive test, along with total serum IgA to rule out selective IgA deficiency (which can give a false-negative result).

If positive, a small bowel biopsy (Option B) is typically performed to confirm the diagnosis, although in some paediatric cases with very high titres and positive anti-endomysial antibodies, biopsy may be omitted under ESPGHAN guidelines.

Faecal calprotectin (Option C) is used to evaluate for inflammatory bowel disease.
HLA-DQ2/DQ8 testing (Option D) has high negative predictive value but is not useful as an initial test since a large proportion of the general population carries these genes.
A gluten-free diet trial (Option E) should not be started before diagnostic testing, as it may interfere with the accuracy of results.

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15. Paediatrics Module

15.1 Neonatology

15.2 Growth and Development

15.3 Paediatric Neurology

15.4 Paediatric Cardiology

15.5 Paediatric Respiratory

15.6 Paediatric Gastroenterology

15.7 Paediatric Nephrology

15.8 Paediatric Infections

15.9 Other Paediatric Disorders

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