Gastroenterology, Liver, Blood and Cancer for PRES Level 2

Why this domain deserves more time than its weight suggests

Our weight is a split of the whole paper, and the sample questions suggest that the gastrointestinal and liver strand is well represented. Five of the topics the Council chose to publish in its sample paper sit here. Haematology and oncology add emergencies that every general doctor must handle. If your background is surgery or a non-medical specialty, expect this domain to need more than its share.

What is tested

• Upper gastrointestinal. Dyspepsia and peptic ulcer disease with H. pylori testing, upper gastrointestinal bleeding and variceal haemorrhage, dysphagia and oesophageal cancer.
• Lower gastrointestinal. Crohn's disease and ulcerative colitis, coeliac disease and malabsorption, irritable bowel syndrome and the red flags in altered bowel habit, colorectal cancer and diverticular disease.
• Liver and pancreas. Acute and chronic liver disease, cirrhosis and ascites, jaundice (obstructive versus hepatic), pancreatitis and pancreatic cancer.
• Blood. Iron deficiency, macrocytic and haemolytic anaemias, bleeding and clotting disorders, warfarin and direct oral anticoagulant reversal.
• Blood cancers. Leukaemias, lymphomas and myeloma: presentation and first investigation.
• Oncological emergencies. Neutropenic sepsis, spinal cord compression and hypercalcaemia.
• Palliative care. Symptom control, including pain, nausea, breathlessness and agitation, and the principles of end-of-life care.

Local guideline points

• Cancer screening. BowelScreen and BreastCheck are HSE National Screening Service programmes. Learn the test, the age band and the interval for the bowel programme from the HSE page, since the age band has been changing and we have not checked it for this page.
• Referral pathways. Red-flag symptoms prompt urgent referral to a symptomatic service in the public system. Know the red flags, not the pathway name.
• End of life and treatment limits. Decisions about resuscitation and treatment limitation fall under the Medical Council's Guide and the capacity Act. See professionalism, ethics, law and prescribing.
• Prescribing. Opioid conversion, anti-emetic choice and drug interactions follow the Irish Medicines Formulary.

How the questions are framed

Gastrointestinal stems often describe a pattern: pain and weight loss, painless jaundice, difficulty swallowing solids then liquids, or diarrhoea with a family history. The question asks for the next investigation or the most likely diagnosis. Haematology stems pair a blood count with a symptom and ask which type of anaemia or which test comes next. Emergency items give a patient on chemotherapy with a fever, or a patient with cancer and back pain, and the correct answer is time-critical.

Three typical traps

1. Treating a neutropenic fever like an ordinary infection. The correct answer is immediate empirical treatment under sepsis principles, not waiting for results.
2. Mixing up the first test for obstructive and hepatic jaundice. Imaging for obstruction and blood tests for a hepatic cause come in different orders. Read the pattern of the liver tests in the stem.
3. Reversing the wrong anticoagulant. Warfarin and direct oral anticoagulants have different reversal agents. A stem that mentions the drug name is testing exactly this.

How to revise it

1. Build a jaundice and liver-test table. Pattern, likely cause, first investigation.
2. Write a one-page red-flag sheet for dysphagia, change in bowel habit, weight loss and anaemia.
3. Learn the three oncological emergencies as short checklists: recognise, investigate, treat.
4. Review anaemia by red cell size. Microcytic, normocytic and macrocytic, with the cause and test for each.
5. Add palliative prescribing to your drug sheet, since pain and symptom control questions are practical.

This domain overlaps with surgery and emergency, where the acute abdomen and gastrointestinal bleeding appear, and with endocrine and renal, for electrolyte problems in cancer.

Subtopic notes: the decision behind each topic

• Dyspepsia and H. pylori. Who needs investigation and who needs a test-and-treat approach, and which alarm features mean urgent endoscopy.
• Upper gastrointestinal bleeding. Resuscitate first, then endoscopy, with special steps if varices are suspected.
• Dysphagia. Solids then liquids points to a mechanical cause, while both together points to a motility problem. Weight loss escalates the urgency.
• Inflammatory bowel disease. Crohn's versus ulcerative colitis by pattern and test, and the treatment of a severe flare.
• Coeliac disease. The serology that is sent while the patient still eats gluten, and why a gluten-free diet before testing spoils the result.
• Liver disease. Causes of cirrhosis, complications such as ascites and encephalopathy, and the first response to each.
• Jaundice. Prehepatic, hepatic and obstructive patterns from the liver tests, and the first image to order.
• Pancreatitis and pancreatic cancer. Diagnosis, severity and supportive care, and the presentation of painless jaundice.
• Anaemia. Classify by cell size, find the cause, and know when an iron-deficient adult needs a search for bleeding.
• Bleeding disorders and reversal. Which test shows which abnormality, and the reversal agent for each anticoagulant.
• Haematological cancers. Presentations and first tests for leukaemia, lymphoma and myeloma, including hypercalcaemia and renal failure.
• Palliative care. Symptom control at the end of life, route of administration and the principles of communication.

Revising across two weeks

Take gastroenterology and liver disease in the first week and blood and cancer in the second. Use a table for every pattern-based topic and a checklist for every emergency. Because the sample paper favours gastrointestinal topics, finish the first week with a timed block of 30 gastrointestinal questions. At the end of the second week, do a block that mixes the oncological emergencies with sepsis and electrolyte problems, since they overlap in practice. Re-read your red-flag sheets on the morning of any full-length practice paper.