Is gastroenterology high yield on the PEBC exam?

Yes. GERD, peptic ulcer disease and H. pylori, constipation, diarrhea, and nausea are everyday community-practice topics, so they come up often. The exact mix is randomized from one sitting to the next, but gastroenterology is consistently worth strong preparation.

What gastroenterology topics should I focus on for the PEBC?

Focus on GERD and dyspepsia stepwise therapy, H. pylori eradication regimens, peptic ulcer disease, the management of constipation, diarrhea, and nausea, the basics of IBD, and the red-flag symptoms that need referral rather than self-care.

Which guidelines should I use for gastroenterology on the PEBC?

The Canadian standard reference is the Canadian Association of Gastroenterology (CAG), along with the Canadian consensus statements for conditions like H. pylori. The PEBC expects the Canadian approach to stepwise therapy and eradication regimens.

How should I study gastroenterology for the PEBC?

Learn the GERD step approach, the H. pylori regimens, and how to manage constipation, diarrhea, and nausea by cause. Then practice spotting the red-flag symptoms that change a self-care answer into a referral.

PEBC Gastroenterology Practice Questions

Gastroenterology is a high-yield, very community-relevant area on the PEBC exam. GERD and dyspepsia, peptic ulcer disease and H. pylori, constipation, diarrhea, nausea, and the basics of IBD all show up, and most questions test the stepwise approach and the red flags that need referral.

The questions below are a sample across those areas. Each explanation argues every option, right and wrong, down to the cause or the patient factor that tips the answer.

Written and reviewed against current Canadian guidelines and references.

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All 4

options explained

full clinical case

How to approach a PEBC gastroenterology question

1For GERD and dyspepsia, know the stepwise approach (lifestyle, then antacids or an H2RA, then a PPI) and when to test for H. pylori.
2Know the H. pylori eradication regimens, and why clarithromycin-based triple therapy is increasingly replaced by quadruple therapy where resistance is a concern.
3For constipation, diarrhea, and nausea, match the agent to the cause and the patient, since pregnancy, opioids, and palliative care each change the answer.
4Anchor on the Canadian Association of Gastroenterology (CAG) guidance.
5Watch for the safety flags: GI bleed risk with NSAIDs, drug-induced causes, and the red-flag symptoms (bleeding, weight loss, dysphagia) that need referral instead of self-care.

Practice questions

Tap an answer to see why each option is right or wrong.

Question 1Nausea & Vomiting

A surgical unit is revising its PONV prevention protocol. One sample patient is female, a non-smoker, has prior motion sickness, and is expected to need postoperative opioids after abdominal surgery. Which protocol step best fits the evidence-based prevention strategy before selecting prophylaxis intensity?

Incorrect · Answer: A

PEBC Yield: Highnon-pharmacological

A) (Correct)

Correct. Address modifiable emetogenic contributors is the best answer because PONV management begins by reducing modifiable risk factors before adding pharmacologic prophylaxis. In this stem, the deciding clue is: A surgical unit is revising its PONV prevention protocol. One sample patient is female, a non-smoker, has prior motion sickness, and is expected to need postoperative opioids after abdominal surgery. Key point: PONV management begins by reducing modifiable risk factors before adding pharmacologic prophylaxis.

Assign a fixed single-agent regimen to each risk group is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which broad PONV strategy addresses modifiable contributors first?, and that points to Address modifiable emetogenic contributors.

Selecting from surgery type can feel protocolized, but it misses patient-specific PONV risk scoring and modifiable contributors. It is not the best answer here because the stem is asking for Which broad PONV strategy addresses modifiable contributors first?, and that points to Address modifiable emetogenic contributors.

Defer prophylaxis selection to the recovery-room assessment is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which broad PONV strategy addresses modifiable contributors first?, and that points to Address modifiable emetogenic contributors.

Question 2Nausea & Vomiting

Which of the following dopamine antagonists has the HIGHEST risk of extrapyramidal symptoms?

Incorrect · Answer: A

PEBC Yield: HighADR-recognitionintraclass-differentiation

A) (Correct)

Correct — haloperidol has the highest EPS risk among dopamine antagonists used as antiemetics. It is a potent D2 antagonist with strong central dopamine blockade. It should be avoided in Parkinson's disease and monitored closely for dystonia, akathisia, and tardive dyskinesia.

Metoclopramide crosses the BBB and has moderate EPS/tardive dyskinesia risk, but it is not the highest-risk agent in this group.

Prochlorperazine (phenothiazine) has some EPS risk, particularly at higher doses, but it is lower than haloperidol.

Domperidone has the LOWEST EPS risk among dopamine antagonists because it does not cross the blood-brain barrier. Its primary concern is QTc prolongation, not EPS.

Question 3Constipation

Which stool-frequency threshold is commonly used when defining constipation in adults?

Incorrect · Answer: B

PEBC Yield: Highdiagnosis-classificationscreeningmonitoringnon-pharmacological

This is too restrictive and would miss patients meeting the usual adult frequency threshold.

B) (Correct)

Correct. Fewer than 3 bowel movements per week is a classic frequency threshold, interpreted against the patient's usual pattern.

This is higher than the usual frequency threshold and may overclassify patients.

This is substantially higher than the usual threshold and is not the standard definition.

Question 4GERD/Dyspepsia/PUD

A student is distinguishing symptom syndromes from mucosal disease. Which definition best matches peptic ulcer disease?

Incorrect · Answer: B

PEBC Yield: Highdiagnosis-classification

Dyspepsia symptoms can come from PUD, but PUD itself requires mucosal injury. It is not the best answer here because the stem is asking for Which definition belongs to peptic ulcer disease?, and that points to Gastroduodenal mucosal break.

B) (Correct)

Correct. Gastroduodenal mucosal break is the best answer because PUD is a mucosal break/erosion in the stomach or duodenum. In this stem, the deciding clue is: A student is distinguishing symptom syndromes from mucosal disease. Which definition best matches peptic ulcer disease? Key point: PUD is a mucosal break/erosion in the stomach or duodenum.

Functional epigastric symptom syndrome is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which definition belongs to peptic ulcer disease?, and that points to Gastroduodenal mucosal break.

Colonic bile-acid malabsorption is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which definition belongs to peptic ulcer disease?, and that points to Gastroduodenal mucosal break.

Question 5GERD/Dyspepsia/PUD

Which definition best matches dyspepsia?

Question 6Constipation

A 44-year-old patient has persistent incomplete evacuation despite stool reaching the rectum. Colonic transit is not delayed, but anorectal testing suggests poor defecatory coordination during attempted bowel movements. Which primary constipation classification best fits?

Incorrect · Answer: C

PEBC Yield: Highdiagnosis-classificationscreeningmonitoringnon-pharmacological

Normal-transit constipation can include incomplete evacuation, but the coordination failure points to pelvic floor dysfunction. It is not the best answer here because the stem is asking for Which primary constipation type matches coordination failure?, and that points to Pelvic floor dysfunction.

Slow-transit constipation is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which primary constipation type matches coordination failure?, and that points to Pelvic floor dysfunction.

C) (Correct)

Correct. Pelvic floor dysfunction is the best answer because Pelvic floor dysfunction is ineffective evacuation from poor defecatory coordination, not normal transit or slow transit. In this stem, the deciding clue is: A 44-year-old patient has persistent incomplete evacuation despite stool reaching the rectum. Colonic transit is not delayed, but anorectal testing suggests poor defecatory coordination during attempted bowel movements. Key point: Pelvic floor dysfunction is ineffective evacuation from poor defecatory coordination, not normal transit or slow transit.

Medication-induced constipation is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which primary constipation type matches coordination failure?, and that points to Pelvic floor dysfunction.

Question 7Diarrhea

U.J., a 28-year-old non-pregnant female on oral contraceptives, develops moderate-to-severe watery diarrhea with cramping while visiting Thailand. She has no bloody stools or high fever. Which antibiotic is the preferred first-line agent?

Incorrect · Answer: B

PEBC Yield: Hightraveler's diarrheaantibiotic selectionregional resistance

Metronidazole targets parasitic infections like Giardia and Entamoeba. It is not appropriate as empiric therapy for bacterial traveler's diarrhea.

B) (Correct)

Azithromycin is the preferred first-line antibiotic for moderate-to-severe traveler's diarrhea acquired in Asia due to high fluoroquinolone resistance rates in the region.

TMP-SMX is used for empiric therapy in children with infectious diarrhea. It is not first-line for adult traveler's diarrhea in any region.

Tempting since fluoroquinolones are effective for traveler's diarrhea in Latin America and Africa, but high Campylobacter resistance rates in Asia make ciprofloxacin unreliable there.

Question 8Diarrhea

C.D., a 16-year-old male recovering from influenza, presents with mild acute non-bloody diarrhea. He takes no regular medications. His mother asks about using Pepto-Bismol. What is the most important concern with bismuth subsalicylate in this patient?

Incorrect · Answer: A

PEBC Yield: Highbismuth subsalicylatecontraindicationsReye syndrome

A) (Correct)

Bismuth subsalicylate contains salicylates. In children and adolescents under 18 with or recovering from viral infections like influenza or varicella, salicylates carry the risk of Reye syndrome.

QT prolongation is associated with certain antimicrobials and antiarrhythmics. Bismuth subsalicylate does not affect cardiac conduction.

Serotonin syndrome requires serotonergic drug exposure. Bismuth subsalicylate has no serotonergic activity and does not pose this risk.

Constipation rebound can occur with antidiarrheals but is a minor, self-limiting concern. It is not the primary safety issue in a teenager recovering from influenza.

Question 9Pancreatitis

C.P., a 42-year-old female admitted with acute pancreatitis has persistent epigastric pain rated 9/10 despite acetaminophen and ibuprofen. She is vomiting and cannot reliably tolerate oral medication. Which analgesic approach best fits the pain severity?

Incorrect · Answer: A

PEBC Yield: Highacute-pancreatitispain-managementopioidsanalgesia

A) (Correct)

Correct. Parenteral hydromorphone or fentanyl for rapid titration is the best answer because Moderate to severe acute pancreatitis pain is treated with parenteral opioids such as hydromorphone or fentanyl. In this stem, the deciding clue is: C.P., a 42-year-old female admitted with acute pancreatitis has persistent epigastric pain rated 9/10 despite acetaminophen and ibuprofen. She is vomiting and cannot reliably tolerate oral medication. Key point: Moderate to severe acute pancreatitis pain is treated with parenteral opioids such as hydromorphone or fentanyl.

Maximum-dose acetaminophen or scheduled NSAID therapy is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which analgesic step matches severe acute pancreatitis pain?, and that points to Parenteral hydromorphone or fentanyl for rapid titration.

Gabapentin 300 mg three times daily or pregabalin titration is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which analgesic step matches severe acute pancreatitis pain?, and that points to Parenteral hydromorphone or fentanyl for rapid titration.

Tramadol can be a lower-potency opioid for chronic pancreatitis pain, but severe acute admission pain requires parenteral opioid treatment. It is not the best answer here because the stem is asking for Which analgesic step matches severe acute pancreatitis pain?, and that points to Parenteral hydromorphone or fentanyl for rapid titration.

Question 10Pancreatitis

Z.M., a 62-year-old male with chronic pancreatitis uses acetaminophen and tramadol for chronic abdominal pain but still has function-limiting flares. The prescriber wants an adjunct that may reduce opioid requirements. Which class fits the next pain-ladder step?

Incorrect · Answer: A

PEBC Yield: Highchronic-pancreatitispain-managementadjunctive-therapyopioid-minimization

A) (Correct)

Correct. Gabapentinoid adjuncts is the best answer because When chronic pancreatitis pain requires opioids, adjunctive agents such as TCAs, SSRIs/SNRIs, or gabapentinoids may be added to reduce opioid needs. In this stem, the deciding clue is: Z.M., a 62-year-old male with chronic pancreatitis uses acetaminophen and tramadol for chronic abdominal pain but still has function-limiting flares. The prescriber wants an adjunct that may reduce opioid requirements. Key point: When chronic pancreatitis pain requires opioids, adjunctive agents such as TCAs, SSRIs/SNRIs, or gabapentinoids may be added to reduce opioid needs.

Pancreatic enzymes treat malabsorption and may help symptoms, but evidence for pain reduction is limited and they are not the Step 3 adjunct class. It is not the best answer here because the stem is asking for Which adjunct class belongs to the chronic pancreatitis pain ladder?, and that points to Gabapentinoid adjuncts.

Long-term prophylactic antibiotics is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which adjunct class belongs to the chronic pancreatitis pain ladder?, and that points to Gabapentinoid adjuncts.

High-dose proton pump inhibitors is in the same topic area, so it is worth considering before choosing. It is not the best answer here because the stem is asking for Which adjunct class belongs to the chronic pancreatitis pain ladder?, and that points to Gabapentinoid adjuncts.

Want the full bank?

These are a sample. The full bank adds full-length cases and timed mock exams.

Sample full case

One patient with several linked questions, the format the real exam uses for case clusters.

RM is a 61-year-old man (72 kg) with Child-Pugh B alcohol-related cirrhosis, recently hospitalized for spontaneous bacterial peritonitis (completed ceftriaxone 2 g IV q24h x 5 days). He had a terminal ileal resection of approximately 50 cm for Crohn's complication 8 months ago. He now presents for outpatient follow-up complaining of fatigue, paresthesias in his feet, and 6 kg unintentional weight loss over 3 months. His uncontrolled T2DM has an A1C of 9.6%.

Home medications:

Drug	Dose	Frequency
Spironolactone	100 mg	PO daily
Metformin	500 mg	PO BID
Lansoprazole	30 mg	PO daily
Multivitamin	1 tablet	PO daily

Recent labs:

Parameter	Value
Hemoglobin	11.2 g/dL
MCV	103 fL (macrocytic)
Vitamin B12	148 pmol/L (low)
Folate	normal
Albumin	28 g/L
Potassium	4.0 mmol/L
Sodium	132 mmol/L
SCr	98 umol/L, eGFR 68
INR	1.4
Bilirubin	38 umol/L
A1C	9.6%

Question 1Cirrhosis

Which of the following supplementation strategies is most appropriate for RM at this visit?

Incorrect · Answer: B

PEBC Yield: Highdrug-selectionvitamin-supplementationmalabsorptionterminal-ileum-resectionb12-deficiency

Thiamine is tempting as a reflex in patients with alcohol-related cirrhosis to prevent Wernicke encephalopathy, but RM has no confusion, ophthalmoplegia, or ataxia, and his documented macrocytic anemia + low B12 + paresthesias point specifically to B12 deficiency from ileal resection. Would be correct if the patient presented with acute confusion, ataxia, and nystagmus suggestive of Wernicke encephalopathy.

B) (Correct)

Vitamin B12 absorption occurs almost exclusively at the terminal ileum via the intrinsic factor-B12 complex; resection of the terminal ileum abolishes enteral absorption, making parenteral replacement necessary. RM's macrocytic anemia (MCV 103) with low B12 (148 pmol/L), paresthesias, and recent ileal resection fit a classic post-ileectomy B12 deficiency picture. Standard replacement is cyanocobalamin 1000 mcg IM monthly after a loading phase. Would be incorrect if the terminal ileum were intact, intrinsic factor were preserved, and oral B12 could be absorbed.

Oral B12 is tempting because high-dose PO cyanocobalamin (1-2 mg daily) can work in patients with intact ileal absorption via passive diffusion, but post-ileectomy patients lose the intrinsic-factor-dependent and passive absorption reliably enough that parenteral route is preferred. Would be correct if the patient retained the terminal ileum and oral high-dose trial were being monitored with B12 level recheck at 1-2 months.

Folic acid is tempting because it also corrects macrocytic anemia, but RM's folate level is normal and his B12 is low, so folate supplementation would mask B12 deficiency while allowing neurologic progression. Would be correct if folate were deficient and B12 normal, or in pregnancy/pre-conception prophylaxis.

Question 2Cirrhosis

Three weeks later, RM returns for follow-up. His A1C remains 9.5% despite metformin, he reports an additional 2 kg weight loss, and new-onset post-prandial diarrhea 3-4 times per day. He asks about dietary strategies given his multiple GI and metabolic problems. Which of the following referrals is most appropriate?

Incorrect · Answer: D

PEBC Yield: Mediumreferralmultidisciplinary-caremalnutritiondiabetes-managementmedical-nutrition-therapy

Social work referral is tempting because multiple chronic conditions affect quality of life and adherence, but RM's dominant problem is biomedical (malabsorption + uncontrolled DM + weight loss), not psychosocial. Would be correct if RM had disclosed food insecurity, inability to afford medications, or housing instability driving his clinical decline.

Repeat colonoscopy is tempting because new diarrhea in a cirrhotic raises concern for infectious or malignant causes, but RM's post-ileectomy status makes bile acid malabsorption the most probable cause and a trial of therapy is reasonable first-line. Would be correct if stool studies suggested infection, if there were red flags (blood, weight loss beyond what's explained), or if BAM had already been ruled out.

Endocrinology referral is tempting because A1C 9.5% is above target despite metformin, but insulin initiation in a patient with active malabsorption and weight loss risks hypoglycemia and misses the underlying malnutrition. Nutritional assessment should precede or accompany endocrine escalation. Would be correct if nutritional assessment were already completed and glycemic targets remained unmet on optimal oral therapy.

D) (Correct)

In complex patients with overlapping GI malabsorption, uncontrolled diabetes, and progressive weight loss, a registered dietitian-led medical nutrition therapy assessment addresses the competing nutritional demands before therapeutic escalation. RM needs macronutrient and micronutrient reassessment (post-ileectomy malabsorption, uncontrolled DM, cirrhosis protein needs) before insulin or further workup is rational. The RD can also coordinate with GI and endocrine teams on next steps. Would be incorrect if RM had acute red-flag features (hematemesis, melena, severe dehydration) requiring ED or direct specialty referral first.

Question 3Cirrhosis

RM's dietitian refers him back for targeted therapy. Stool studies are negative for C. difficile and ova/parasites; a SeHCAT scan confirms bile acid malabsorption attributable to his prior ileal resection. Diarrhea is non-bloody, post-prandial, 4 times per day. Which of the following is the most appropriate pharmacologic therapy?

Incorrect · Answer: B

PEBC Yield: Mediumdrug-selectionbile-acid-malabsorptioncholestyraminepost-ileectomychronic-diarrhea

Loperamide is tempting because it slows transit and would reduce stool frequency symptomatically, but as monotherapy it does not treat the underlying BAM and is generally used cautiously in cirrhotics given hepatic clearance concerns and the risk of masking progression. Would be correct as short-term symptom control adjunct once BAM is being treated with cholestyramine, or in non-cirrhotic functional diarrhea without BAM.

B) (Correct)

Cholestyramine is an anion-exchange bile acid sequestrant that binds unabsorbed bile acids in the colon, preventing the osmotic and secretory diarrhea of bile acid malabsorption. It is the mechanism-specific therapy for BAM confirmed on SeHCAT, especially post-ileectomy where the terminal ileum no longer reabsorbs bile acids. Separation from other medications (1 h before / 4-6 h after) is essential because the resin binds many drugs non-selectively. Would be incorrect if the diarrhea were infectious (CDI), purely functional (IBS-D without BAM), or if the patient had complete biliary obstruction.

Psyllium is tempting because it's a bulking agent that can normalize stool consistency, but bulking does not address the bile acid-driven osmotic/secretory mechanism of BAM. Would be correct if the diarrhea were IBS-D functional pattern without BAM, where a fibre trial is reasonable.

Probiotics are tempting because they are often used for post-antibiotic or infectious diarrhea, but Saccharomyces boulardii has not been shown to treat BAM and does not address the bile acid mechanism. Would be correct if the patient had C. difficile recurrence prevention or antibiotic-associated diarrhea without an ileectomy history.

Question 4Cirrhosis

Six weeks later, RM presents with worsening abdominal distension. Weight is up 4 kg, ascites is tense on exam, and his spironolactone has been titrated to 400 mg daily over the past month with no response. Potassium 4.4 mmol/L, sodium 134, SCr 102, eGFR 65. Adherence is verified. Which of the following is the most appropriate next addition to his ascites regimen?

Incorrect · Answer: B

PEBC Yield: Highdrug-selectionascitesdiuretic-therapystep-up-therapycirrhosis-management

Amiloride is tempting as another potassium-sparing diuretic, but it shares spironolactone's mechanism and distal-tubule site, so adding it does not provide new natriuretic action - it is a same-class substitute, not a step-up. Would be correct if spironolactone were causing intolerable gynecomastia, in which case amiloride could replace it at equivalent potassium-sparing effect.

B) (Correct)

Guideline-preferred second-line management for diuretic-refractory cirrhotic ascites is combination spironolactone + furosemide at a 100:40 ratio, which maintains potassium balance while adding loop-level natriuresis. The ratio preserves K+ because spironolactone-induced retention offsets furosemide-induced loss, protecting against hypokalemia that would precipitate hepatic encephalopathy. RM's K+ 4.4, eGFR 65, and adherence make this the appropriate step-up. Would be incorrect if K+ were <3.5 (suggesting active hypokalemia requiring dose reduction) or if worsening hepatic encephalopathy were present.

Metolazone is tempting because sequential nephron blockade works in other edematous states (heart failure), but in cirrhotic ascites it adds significant hypokalemia risk without clear benefit over loop combination and is not guideline-recommended second-line. Would be correct in decompensated heart failure with diuretic resistance where HF guidelines endorse thiazide-loop sequential blockade.

Switching to loop monotherapy is tempting because spironolactone 'failed,' but loop monotherapy in cirrhosis loses K+ and H+ balance, precipitates hypokalemia, and increases HE risk - the combination at 100:40 is preferred. Would be correct if spironolactone were contraindicated (severe hyperkalemia, severe renal impairment) and no K-sparing option existed.

Full-length cases like this, across every PEBC domain, live in the question bank.

Frequently asked questions

Is gastroenterology high yield on the PEBC exam?: Yes. GERD, peptic ulcer disease and H. pylori, constipation, diarrhea, and nausea are everyday community-practice topics, so they come up often. The exact mix is randomized from one sitting to the next, but gastroenterology is consistently worth strong preparation.
What gastroenterology topics should I focus on for the PEBC?: Focus on GERD and dyspepsia stepwise therapy, H. pylori eradication regimens, peptic ulcer disease, the management of constipation, diarrhea, and nausea, the basics of IBD, and the red-flag symptoms that need referral rather than self-care.
Which guidelines should I use for gastroenterology on the PEBC?: The Canadian standard reference is the Canadian Association of Gastroenterology (CAG), along with the Canadian consensus statements for conditions like H. pylori. The PEBC expects the Canadian approach to stepwise therapy and eradication regimens.
How should I study gastroenterology for the PEBC?: Learn the GERD step approach, the H. pylori regimens, and how to manage constipation, diarrhea, and nausea by cause. Then practice spotting the red-flag symptoms that change a self-care answer into a referral.