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Question 1
Correct
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A 50-year-old man undergoes a colonoscopy and a colonic polyp is identified. It is located on a stalk in the sigmoid colon and has a lobular appearance. What is the most likely cause of this condition?
Your Answer: Dysplasia
Explanation:The majority of colonic polyps mentioned earlier are adenomas, which can be accompanied by dysplasia. The severity of dysplasia is directly proportional to the level of clinical apprehension.
Understanding Colonic Polyps and Follow-Up Procedures
Colonic polyps can occur in isolation or as part of polyposis syndromes, with greater than 100 polyps typically present in FAP. The risk of malignancy is related to size, with a 10% risk in a 1 cm adenoma. While isolated adenomas seldom cause symptoms, distally sited villous lesions may produce mucous and electrolyte disturbances if very large.
Follow-up procedures for colonic polyps depend on the number and size of the polyps. Low-risk cases with 1 or 2 adenomas less than 1 cm require no follow-up or re-colonoscopy for 5 years. Moderate-risk cases with 3 or 4 small adenomas or 1 adenoma greater than 1 cm require a re-scope at 3 years. High-risk cases with more than 5 small adenomas or more than 3 with 1 of them greater than 1 cm require a re-scope at 1 year.
Segmental resection or complete colectomy may be necessary in cases of incomplete excision of malignant polyps, malignant sessile polyps, malignant pedunculated polyps with submucosal invasion, polyps with poorly differentiated carcinoma, or familial polyposis coli. Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy is recommended. Rectal polypoidal lesions may be treated with trans anal endoscopic microsurgery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Correct
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A 15-year-old girl comes to the hospital complaining of severe right upper quadrant pain and vomiting that started 4 hours ago. She has a medical history of depression and anemia and is currently taking iron supplements and the combined oral contraceptive pill. Upon examination, she appears confused and has yellow-tinted sclera. Her prothrombin time is 50 seconds, and her blood results show a pH of 7.1, albumin levels of 18g/L, ALT levels of 150 iu/L, ALP levels of 40 umol/L, bilirubin levels of 76 µmol/L, and yGT levels of 115 u/L. Based on these findings, what is the most likely cause of her presentation?
Your Answer: Paracetamol overdose
Explanation:The most common cause of liver failure in the UK is an overdose of paracetamol. This patient’s symptoms, including vomiting, severe pain in the upper right quadrant, jaundice, confusion, and prolonged prothrombin time, suggest acute liver failure. In this condition, ALT and bilirubin levels are significantly elevated, while yGT and ALP may be normal or elevated. Hypoalbuminemia is also a characteristic feature of acute liver failure.
Given the patient’s history of depression, her risk of self-harm and suicide attempts is higher than that of the general population. However, acute fatty liver of pregnancy is unlikely to be the cause of her liver failure, as she takes the combined oral contraceptive pill, which reduces the chances of pregnancy.
Alcohol is also an unlikely cause of her liver failure, as it takes many years of chronic alcohol abuse to develop alcohol-related liver failure, and this patient is very young.
While testing for hepatitis B antibodies and antigens should be included in the liver screen, paracetamol overdose is a more likely cause of liver failure in the UK.
Understanding Acute Liver Failure
Acute liver failure is a condition characterized by the sudden onset of liver dysfunction, which can lead to various complications in the body. The causes of acute liver failure include paracetamol overdose, alcohol, viral hepatitis (usually A or B), and acute fatty liver of pregnancy. The symptoms of acute liver failure include jaundice, raised prothrombin time, hypoalbuminaemia, hepatic encephalopathy, and hepatorenal syndrome. It is important to note that liver function tests may not always accurately reflect the synthetic function of the liver, and it is best to assess the prothrombin time and albumin level to determine the severity of the condition. Understanding acute liver failure is crucial in managing and treating this potentially life-threatening condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 3
Correct
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A 56-year-old woman arrives at the emergency department complaining of abdominal pain that has been ongoing for two days. The pain is diffuse, sudden in onset, and not radiating. She has a medical history of antiphospholipid syndrome but no cirrhosis.
Upon examination, the patient is visibly jaundiced and her abdomen is noticeably distended. There is painful hepatomegaly and shifting dullness. Abdominal ultrasonography confirms the presence of ascites and venous outflow obstruction.
Which vessel is the most likely culprit for the occlusion?Your Answer: Hepatic vein
Explanation:Budd-Chiari syndrome is caused by thrombosis of the hepatic vein, resulting in symptoms such as painful hepatomegaly, jaundice, and ascites. This patient’s antiphospholipid syndrome increases their risk of thrombosis, making Budd-Chiari syndrome more likely than hepatic portal vein thrombosis. Inferior mesenteric vein thrombosis is an unlikely cause of the patient’s symptoms, while inferior vena cava thrombosis would present differently and is associated with lung malignancy.
Understanding Budd-Chiari Syndrome
Budd-Chiari syndrome, also known as hepatic vein thrombosis, is a condition that is often associated with an underlying hematological disease or another procoagulant condition. The causes of this syndrome include polycythemia rubra vera, thrombophilia, pregnancy, and the use of combined oral contraceptive pills. The symptoms of Budd-Chiari syndrome typically include sudden onset and severe abdominal pain, ascites leading to abdominal distension, and tender hepatomegaly.
To diagnose Budd-Chiari syndrome, an ultrasound with Doppler flow studies is usually the initial radiological investigation. This test is highly sensitive and can help identify the presence of the condition. It is important to diagnose and treat Budd-Chiari syndrome promptly to prevent complications such as liver failure and portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Correct
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You come across a patient in the medical assessment unit who has been admitted with a two-day history of haematemesis. An endoscopy revealed bleeding oesophageal varices that were banded and ligated. The consultant informs you that this patient has cirrhosis of the liver due to excessive alcohol consumption.
What other vein is likely to be dilated in this patient?Your Answer: Superior rectal vein
Explanation:The Relationship between Liver Cirrhosis and Varices
Liver cirrhosis is a condition that occurs in patients with alcohol-related liver disease due to the accumulation of aldehyde, which is formed during the metabolism of alcohol. The excessive amounts of aldehyde produced cannot be processed by hepatocytes, leading to the release of inflammatory mediators. These mediators activate hepatic stellate cells, which constrict off the inflamed sinusoids by depositing collagen in the space of Disse. This collagen deposition increases the resistance against the sinusoidal vascular bed, leading to portal hypertension.
To relieve excess pressure, the portal system forces blood back into systemic circulation at portosystemic anastomotic points. These anastomoses exist at various locations, including the distal end of the oesophagus, splenorenal ligament, retroperitoneum, anal canal, and abdominal wall. The high pressure causes the systemic veins to dilate, becoming varices, because the weak thin walls do not oppose resistance and pressure.
The superior rectal vein is the only vein that forms a collateral blood supply with systemic circulation. Therefore, the pressure from the superior rectal vein is passed onto the systemic veins, causing them to dilate and leading to the formation of haemorrhoids. The other veins listed are part of systemic circulation and have no collateral anastomoses with the portal circulatory system. In summary, liver cirrhosis can lead to varices due to the increased pressure in the portal system, which forces blood back into systemic circulation and causes systemic veins to dilate.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
Incorrect
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A 42-year-old female patient arrives at the emergency department complaining of intense abdominal pain on the right side. Upon further inquiry, she describes the pain as crampy, intermittent, and spreading to her right shoulder. She has no fever. The patient notes that the pain worsens after meals.
Which hormone is accountable for the fluctuation in pain?Your Answer: Vasoactive intestinal peptide
Correct Answer: Cholecystokinin
Explanation:The hormone that increases gallbladder contraction is Cholecystokinin (CCK). It is secreted by I cells in the upper small intestine, particularly in response to a high-fat meal. Although it has many functions, its role in increasing gallbladder contraction may exacerbate biliary colic caused by gallstones in the patient described.
Gastrin, insulin, and secretin are also hormones that can be released in response to food intake, but they do not have any known effect on gallbladder contraction. Therefore, CCK is the most appropriate answer.
Overview of Gastrointestinal Hormones
Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.
One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.
Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.
Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.
In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Correct
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The action of which one of the following brush border enzymes leads to the production of glucose and galactose?
Your Answer: Lactase
Explanation:Enzymes play a crucial role in the breakdown of carbohydrates in the gastrointestinal system. Amylase, which is present in both saliva and pancreatic secretions, is responsible for breaking down starch into sugar. On the other hand, brush border enzymes such as maltase, sucrase, and lactase are involved in the breakdown of specific disaccharides. Maltase cleaves maltose into glucose and glucose, sucrase cleaves sucrose into fructose and glucose, while lactase cleaves lactose into glucose and galactose. These enzymes work together to ensure that carbohydrates are broken down into their simplest form for absorption into the bloodstream.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 54-year-old male visits his GP complaining of sudden and severe abdominal pain that extends to his back. He has a history of heavy alcohol consumption, osteoarthritis, and asthma, and is a smoker. He is currently taking a salbutamol and corticosteroid inhaler. During the examination, his BMI is found to be 35kg/m².
What is the most probable reason for his symptoms?Your Answer: Heavy alcohol use
Explanation:Pancreatitis is most commonly caused by heavy alcohol use and gallstones, while osteoarthritis and smoking are not direct contributors. However, the use of a steroid inhaler and a high BMI may also play a role in the development of pancreatitis by potentially leading to hypertriglyceridemia.
Acute pancreatitis is a condition that is primarily caused by gallstones and alcohol consumption in the UK. However, there are other factors that can contribute to the development of this condition. A popular mnemonic used to remember these factors is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine. CT scans can show diffuse parenchymal enlargement with oedema and indistinct margins in patients with acute pancreatitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Correct
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A 65-year-old man is scheduled for a splenectomy. What is the most posteriorly located structure of the spleen?
Your Answer: Lienorenal ligament
Explanation:The phrenicocolic ligament provides the antero-lateral connection, while the gastro splenic ligament is located anteriorly to the lienorenal ligament. These ligaments converge around the vessels at the splenic hilum, with the lienorenal ligament being the most posterior.
Understanding the Anatomy of the Spleen
The spleen is a vital organ in the human body, serving as the largest lymphoid organ. It is located below the 9th-12th ribs and has a clenched fist shape. The spleen is an intraperitoneal organ, and its peritoneal attachments condense at the hilum, where the vessels enter the spleen. The blood supply of the spleen is from the splenic artery, which is derived from the coeliac axis, and the splenic vein, which is joined by the IMV and unites with the SMV.
The spleen is derived from mesenchymal tissue during embryology. It weighs between 75-150g and has several relations with other organs. The diaphragm is superior to the spleen, while the gastric impression is anterior, the kidney is posterior, and the colon is inferior. The hilum of the spleen is formed by the tail of the pancreas and splenic vessels. The spleen also forms the apex of the lesser sac, which contains short gastric vessels.
In conclusion, understanding the anatomy of the spleen is crucial in comprehending its functions and the role it plays in the human body. The spleen’s location, weight, and relations with other organs are essential in diagnosing and treating spleen-related conditions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Correct
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A 65-year-old male is undergoing a Whipples procedure for adenocarcinoma of the pancreas. During the mobilisation of the pancreatic head, the surgeons come across a large vessel passing over the anterior aspect of the uncinate process. What is the probable identity of this vessel?
Your Answer: Superior mesenteric artery
Explanation:The origin of the superior mesenteric artery is the aorta, and it travels in front of the lower section of the pancreas. If this area is invaded, it is not recommended to undergo resectional surgery.
Anatomy of the Pancreas
The pancreas is located behind the stomach and is a retroperitoneal organ. It can be accessed surgically by dividing the peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head is situated in the curvature of the duodenum, while its tail is close to the hilum of the spleen. The pancreas has various relations with other organs, such as the inferior vena cava, common bile duct, renal veins, superior mesenteric vein and artery, crus of diaphragm, psoas muscle, adrenal gland, kidney, aorta, pylorus, gastroduodenal artery, and splenic hilum.
The arterial supply of the pancreas is through the pancreaticoduodenal artery for the head and the splenic artery for the rest of the organ. The venous drainage for the head is through the superior mesenteric vein, while the body and tail are drained by the splenic vein. The ampulla of Vater is an important landmark that marks the transition from foregut to midgut and is located halfway along the second part of the duodenum. Overall, understanding the anatomy of the pancreas is crucial for surgical procedures and diagnosing pancreatic diseases.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Correct
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An 80-year-old man who frequently drinks alcohol presents to his doctor with symptoms of productive cough, fever, and chills. Upon examination, a chest x-ray reveals a distinct cavity in the right lower lobe with an air-fluid level. The patient's sputum is sent for culture and sensitivity, and he is prescribed clindamycin.
After ten days, the patient reports experiencing watery diarrhea 3-4 times a day and abdominal pain. He has not experienced any fever or weight loss, and his vital signs are normal. What is the initial medication recommended for his condition?Your Answer: Vancomycin
Explanation:The preferred antibiotic for treating C. difficile infection is oral vancomycin. However, in the case of a patient with clinical features and radiological findings indicative of a lung abscess, who also has a history of alcohol consumption that increases the risk of aspiration and lung abscesses, clindamycin was used as a treatment. Unfortunately, this led to the development of a C. difficile infection, which can be confusing when considering the antibiotics involved in causing and treating the infection.
Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Incorrect
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A 9-month-old baby girl is brought to the clinic by her parents who recently moved from the Philippines. The baby has a noticeable mass in her abdomen, resembling a sausage shape. During questioning, the father mentions that the baby had vomited green substance a few hours ago. The baby is immediately referred to the hospital. What is the probable diagnosis?
Your Answer: Meckel's diverticulum
Correct Answer: Intussusception
Explanation:Understanding Intussusception
Intussusception is a medical condition where one part of the bowel folds into the lumen of the adjacent bowel, usually around the ileocecal region. This condition is most common in infants between 6-18 months old, with boys being affected twice as often as girls. Symptoms of intussusception include severe, crampy abdominal pain, inconsolable crying, vomiting, and bloodstained stool, which is a late sign. During a paroxysm, the infant will draw their knees up and turn pale, and a sausage-shaped mass may be felt in the right upper quadrant.
To diagnose intussusception, ultrasound is now the preferred method of investigation, which may show a target-like mass. Treatment for intussusception involves reducing the bowel by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema. If this method fails, or the child has signs of peritonitis, surgery is performed. Understanding the symptoms and treatment options for intussusception is crucial for parents and healthcare professionals to ensure prompt and effective management of this condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Incorrect
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An 80-year-old man presents to the emergency department with severe abdominal pain and haematochezia. The patient localises the pain to the umbilical region. He has a past medical history of atrial fibrillation, stroke and is currently being treated for multiple myeloma.
His observations show a heart rate of 122/min, a respiratory rate of 29/min, a blood pressure of 119/93 mmHg, an O2 saturation of 97%, and a temperature of 38.2 ºC. His chest is clear. Abdominal examination identify some mild tenderness with no guarding. An abdominal bruit is heard on auscultation.
Which segment of the gastrointestinal tract is commonly affected in this condition?Your Answer: Hepatic flexure
Correct Answer: Splenic flexure
Explanation:Ischaemic colitis most frequently affects the splenic flexure.
Understanding Ischaemic Colitis
Ischaemic colitis is a condition that occurs when there is a temporary reduction in blood flow to the large bowel. This can cause inflammation, ulcers, and bleeding. The condition is more likely to occur in areas of the bowel that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries, such as the splenic flexure.
When investigating ischaemic colitis, doctors may look for a sign called thumbprinting on an abdominal x-ray. This occurs due to mucosal edema and hemorrhage. It is important to diagnose and treat ischaemic colitis promptly to prevent complications and ensure a full recovery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Correct
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A 36-year-old female patient presents with persistent dyspepsia of 6 months duration. She failed multiple trials of conservative treatment by her GP, therefore, she was referred for the gastroenterologist for further review.
Investigations were done and her urea breath test was negative for Helicobacter pylori. Gastroscopy revealed multiple gastroduodenal ulcers. What type of cells are affected by the high levels of fasting gastrin detected?Your Answer: Gastric parietal cells
Explanation:The secretion of gastrin hormone from G cells in the antrum of the stomach is responsible for increasing the secretion of H+ by gastric parietal cells. Additionally, chief cells secrete pepsin, which is a proteolytic enzyme, while D cells in the pancreas and stomach secrete somatostatin hormone. Gastrin hormone is released in response to distension of the stomach and vagal stimulation.
Overview of Gastrointestinal Hormones
Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.
One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.
Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.
Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.
In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.
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This question is part of the following fields:
- Gastrointestinal System
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Question 14
Correct
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A 4-day old neonate with Down's syndrome is experiencing excessive vomiting during their stay in the ward. The mother had an uncomplicated full-term pregnancy. The baby has not yet had their first bowel movement, causing increased concern for the parents. Upon examination, there is slight abdominal distension. Where is the site of pathology within the colon?
Your Answer: Muscularis propria externa
Explanation:The myenteric nerve plexus, also known as Auerbach’s plexus, is located within the muscularis externa, which is one of the four layers of the bowel. In neonates with Hirschsprung disease, there is a lack of ganglion cells in the myenteric plexus, resulting in a lack of peristalsis and symptoms such as nausea, vomiting, bloating, and delayed passage of meconium. This condition is more common in males and children with Down’s syndrome.
The four layers of the bowel, from deep to superficial, are the mucosa, submucosa, muscularis propria (externa), and serosa. The muscularis externa contains two layers of smooth muscle, the inner circular layer and the outer longitudinal layer, with the myenteric plexus located between them. The mucosa also contains a thin layer of connective tissue called the lamina propria.
Layers of the Gastrointestinal Tract and Their Functions
The gastrointestinal (GI) tract is composed of four layers, each with its own unique function. The innermost layer is the mucosa, which can be further divided into three sublayers: the epithelium, lamina propria, and muscularis mucosae. The epithelium is responsible for absorbing nutrients and secreting mucus, while the lamina propria contains blood vessels and immune cells. The muscularis mucosae helps to move food along the GI tract.
The submucosa is the layer that lies beneath the mucosa and contains Meissner’s plexus, which is responsible for regulating secretion and blood flow. The muscularis externa is the layer that lies beneath the submucosa and contains Auerbach’s plexus, which controls the motility of GI smooth muscle. Finally, the outermost layer of the GI tract is either the serosa or adventitia, depending on whether the organ is intraperitoneal or retroperitoneal. The serosa is responsible for secreting fluid to lubricate the organs, while the adventitia provides support and protection. Understanding the functions of each layer is important for understanding the overall function of the GI tract.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Incorrect
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During a sigmoid colectomy for colonic cancer in a 56-year-old man, which structure is most vulnerable to damage?
Your Answer: Superior mesenteric artery
Correct Answer: Left ureter
Explanation:The left ureter is the structure that is most commonly encountered and at the highest risk of damage by a careless surgeon, although all of these structures are at risk.
The colon begins with the caecum, which is the most dilated segment of the colon and is marked by the convergence of taenia coli. The ascending colon follows, which is retroperitoneal on its posterior aspect. The transverse colon comes after passing the hepatic flexure and becomes wholly intraperitoneal again. The splenic flexure marks the point where the transverse colon makes an oblique inferior turn to the left upper quadrant. The descending colon becomes wholly intraperitoneal at the level of L4 and becomes the sigmoid colon. The sigmoid colon is wholly intraperitoneal, but there are usually attachments laterally between the sigmoid and the lateral pelvic sidewall. At its distal end, the sigmoid becomes the upper rectum, which passes through the peritoneum and becomes extraperitoneal.
The arterial supply of the colon comes from the superior mesenteric artery and inferior mesenteric artery, which are linked by the marginal artery. The ascending colon is supplied by the ileocolic and right colic arteries, while the transverse colon is supplied by the middle colic artery. The descending and sigmoid colon are supplied by the inferior mesenteric artery. The venous drainage comes from regional veins that accompany arteries to the superior and inferior mesenteric vein. The lymphatic drainage initially follows nodal chains that accompany supplying arteries, then para-aortic nodes.
The colon has both intraperitoneal and extraperitoneal segments. The right and left colon are part intraperitoneal and part extraperitoneal, while the sigmoid and transverse colon are generally wholly intraperitoneal. The colon has various relations with other organs, such as the right ureter and gonadal vessels for the caecum/right colon, the gallbladder for the hepatic flexure, the spleen and tail of pancreas for the splenic flexure, the left ureter for the distal sigmoid/upper rectum, and the ureters, autonomic nerves, seminal vesicles, prostate, and urethra for the rectum.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Incorrect
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Liam, who is also suffering from chronic pancreatitis, undergoes a distal pancreatectomy. During a post-surgery consultation, he expresses his concern to the doctor about the possibility of experiencing poor food digestion after the operation, as he has read about others who have had the same issue. What measures can the doctor take to prevent this from happening to Liam?
Your Answer: Refer her to a dietitian for advice regarding her diet
Correct Answer: Prescribe pancreatic enzymes (e.g. Creon)
Explanation:To aid digestion of food in patients with chronic pancreatitis, the management plan includes the replacement of pancreatic enzymes such as Creon. Inadequacy of pancreatic enzymes due to pancreatic surgery can also lead to poor digestion of food, which can be prevented by providing patients with pancreatic enzyme supplements like Creon. However, proton pump inhibitors or probiotics are not effective in replacing pancreatic enzymes. Fiona does not require a low fibre diet.
Understanding Chronic Pancreatitis
Chronic pancreatitis is a condition characterized by inflammation that can affect both the exocrine and endocrine functions of the pancreas. While alcohol excess is the leading cause of this condition, up to 20% of cases are unexplained. Other causes include genetic factors such as cystic fibrosis and haemochromatosis, as well as ductal obstruction due to tumors, stones, and structural abnormalities.
Symptoms of chronic pancreatitis include pain that worsens 15 to 30 minutes after a meal, steatorrhoea, and diabetes mellitus. Abdominal x-rays and CT scans are used to detect pancreatic calcification, which is present in around 30% of cases. Functional tests such as faecal elastase may also be used to assess exocrine function if imaging is inconclusive.
Management of chronic pancreatitis involves pancreatic enzyme supplements, analgesia, and antioxidants. While there is limited evidence to support the use of antioxidants, one study suggests that they may be beneficial in early stages of the disease. Overall, understanding the causes and symptoms of chronic pancreatitis is crucial for effective management and treatment.
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This question is part of the following fields:
- Gastrointestinal System
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Question 17
Incorrect
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A 68-year-old male presents with sudden and severe abdominal pain. He has a medical history of ischaemic heart disease and takes nitrates, atenolol and amlodipine for it. Upon examination, his pulse is irregularly irregular and measures 115 bpm, his blood pressure is 104/72 mmHg, and his temperature is 37.4°C. The abdomen is diffusely tender and bowel sounds are absent. What is the probable diagnosis?
Your Answer: Small bowel obstruction
Correct Answer: Mesenteric ischaemia
Explanation:Narrowing Down the Differential Diagnosis for Acute Abdomen
When presented with a patient experiencing an acute abdomen, the differential diagnosis can be extensive. However, by taking note of the key points in the patient’s history and conducting a thorough examination, one can narrow down the potential causes. In the case of a man with absent bowel sounds, atrial fibrillation, and a history of ischemic heart disease, the most likely cause of his presentation is mesenteric ischemia. This is due to the fact that he is not obstructed and has vascular disease. For further information on acute mesenteric ischemia, Medscape provides a helpful resource. By utilizing these tools and resources, healthcare professionals can more accurately diagnose and treat patients with acute abdominal symptoms.
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This question is part of the following fields:
- Gastrointestinal System
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Question 18
Correct
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As a GP, you are evaluating a 35-year-old female patient who has been experiencing a persistent burning sensation in her epigastrium that is temporarily relieved by eating meals. Your initial suspicion of H. pylori infection was ruled out by a negative serology test, and a two-week trial of full-dose proton pump inhibitor and triple eradication therapy failed to alleviate her symptoms. An endoscopy revealed multiple duodenal ulcers, and upon further questioning, the patient disclosed that her mother has a pituitary tumor. Which hormone is most likely to be elevated in this patient?
Your Answer: Gastrin
Explanation:Zollinger-Ellison Syndrome and Gastrinoma
Zollinger-Ellison syndrome is a familial condition that predisposes individuals to benign or malignant tumors of the pituitary and pancreas with parathyroid hyperplasia causing hyperparathyroidism. This autosomal dominant inherited syndrome should be considered in patients who present with unusual endocrine tumors, especially if they are relatively young at diagnosis or have a relevant family history.
One manifestation of Zollinger-Ellison syndrome is the development of a pancreatic tumor called a gastrinoma, which secretes the hormone gastrin. Gastrin stimulates the release of hydrochloric acid from parietal cells in the stomach, which optimizes conditions for protein digesting enzymes. However, excessive production of gastrin can occur in gastrinomas, leading to excessive HCL production that can denature the mucosa and submosa of the gastrointestinal tract, causing symptoms, ulceration, and even perforation of the duodenum.
While other pancreatic tumors can also produce hormones such as insulin or glucagon, the symptoms and clinical findings in this case suggest a diagnosis of gastrinoma. Cholecystokinin and somatostatin are hormones that have inhibitory effects on HCL secretion and do not fit with the clinical picture. Cholecystokinin also produces the feeling of satiety.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Correct
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During a left hemicolectomy the sigmoid colon is mobilised. As the bowel is retracted medially a vessel is injured, anterior to the colon. Which one of the following is the most likely vessel?
Your Answer: Gonadal vessels
Explanation:During a right hemicolectomy, the gonadal vessels and ureter are crucial structures located at the posterior aspect that may be vulnerable to injury.
The Caecum: Location, Relations, and Functions
The caecum is a part of the colon located in the proximal right colon below the ileocaecal valve. It is an intraperitoneal structure that has posterior relations with the psoas, iliacus, femoral nerve, genitofemoral nerve, and gonadal vessels. Its anterior relations include the greater omentum. The caecum is supplied by the ileocolic artery and its lymphatic drainage is through the mesenteric nodes that accompany the venous drainage.
The caecum is known for its distensibility, making it the most distensible part of the colon. However, in cases of complete large bowel obstruction with a competent ileocaecal valve, the caecum is the most likely site of eventual perforation. Despite this potential complication, the caecum plays an important role in the digestive system. It is responsible for the absorption of fluids and electrolytes, as well as the fermentation of indigestible carbohydrates. Additionally, the caecum is a site for the growth and proliferation of beneficial bacteria that aid in digestion and immune function.
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This question is part of the following fields:
- Gastrointestinal System
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Question 20
Correct
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A patient with gastric ulcers has been diagnosed with significantly low levels of somatostatin. The medical consultant suspects that a particular type of cell found in both the pancreas and stomach is affected, leading to the disruption of somatostatin release.
Which type of cell is impacted in this case?Your Answer: D cells
Explanation:Somatostatin is released by D cells found in both the pancreas and stomach. These cells release somatostatin to inhibit the hormone gastrin and reduce gastric secretions. The patient’s low levels of somatostatin may have led to an increase in gastrin secretion and stomach acid, potentially causing gastric ulcers. G cells secrete gastrin, while parietal cells secrete gastric acid. Pancreatic cells is too general of a term and does not specify the specific type of cell responsible for somatostatin production.
Overview of Gastrointestinal Hormones
Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.
One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.
Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.
Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.
In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.
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This question is part of the following fields:
- Gastrointestinal System
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Question 21
Correct
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A 65-year-old man presents to the clinic with a complaint of losing 1 stone in weight over the past three months. Apart from this, he has no significant medical history. During the physical examination, his abdomen is soft, and no palpable masses are detected. A normal PR examination is also observed. The patient's blood tests reveal a haemoglobin level of 80 g/L (120-160) and an MCV of 70 fL (80-96). What is the most appropriate initial investigation for this patient?
Your Answer: Upper GI endoscopy and colonoscopy
Explanation:Possible GI Malignancy in a Man with Weight Loss and Microcytic Anaemia
This man is experiencing weight loss and has an unexplained microcytic anaemia. The most probable cause of his blood loss is from the gastrointestinal (GI) tract, as there is no other apparent explanation. This could be due to an occult GI malignancy, which is why the recommended initial investigations are upper and lower GI endoscopy. These tests will help to identify any potential sources of bleeding in the GI tract and determine if there is an underlying malignancy. It is important to diagnose and treat any potential malignancy as early as possible to improve the patient’s prognosis. Therefore, prompt investigation and management are crucial in this case.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Incorrect
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Samantha, a 52-year-old female, visits her doctor with a lump in her groin that becomes more prominent when she coughs. The lump is not painful, but the doctor notes that it is located inferior and lateral to the pubic tubercle during the examination. This leads to a diagnosis of a femoral hernia, where a portion of the bowel has entered the femoral canal and caused a bulge in the femoral triangle, an area in the upper thigh.
What are the contents of this anatomical region from lateral to medial?Your Answer: Femoral artery, femoral vein, femoral nerve, empty space, lymphatics
Correct Answer: Femoral nerve, femoral artery, femoral vein, empty space, lymphatics
Explanation:To remember the contents of the femoral triangle from lateral to medial, use the acronym NAVEL: femoral NERVE, femoral ARTERY, femoral VEIN, EMPTY space, and LYMPHATICS. The femoral triangle is located in the anterior thigh and is bordered by the inguinal ligament superiorly, the medial border of the sartorius muscle laterally, and the medial border of the adductor longus muscle medially. A femoral hernia occurs when bowel enters the femoral ring and canal, which are located beneath the inguinal ligament, causing a bulge in the femoral triangle. The femoral nerve is located more laterally than the femoral artery and vein, while the femoral artery is more lateral than the femoral vein.
Understanding the Anatomy of the Femoral Triangle
The femoral triangle is an important anatomical region located in the upper thigh. It is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. The floor of the femoral triangle is made up of the iliacus, psoas major, adductor longus, and pectineus muscles, while the roof is formed by the fascia lata and superficial fascia. The superficial inguinal lymph nodes and the long saphenous vein are also found in this region.
The femoral triangle contains several important structures, including the femoral vein, femoral artery, femoral nerve, deep and superficial inguinal lymph nodes, lateral cutaneous nerve, great saphenous vein, and femoral branch of the genitofemoral nerve. The femoral artery can be palpated at the mid inguinal point, making it an important landmark for medical professionals.
Understanding the anatomy of the femoral triangle is important for medical professionals, as it is a common site for procedures such as venipuncture, arterial puncture, and nerve blocks. It is also important for identifying and treating conditions that affect the structures within this region, such as femoral hernias and lymphadenopathy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Correct
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Which of the following is not an extraintestinal manifestation of Crohn's disease?
Your Answer: Erythema multiforme
Explanation:Understanding Crohn’s Disease
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.
Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include non-specific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.
To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.
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This question is part of the following fields:
- Gastrointestinal System
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Question 24
Incorrect
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A 58-year-old woman presents to her GP with an incidental finding of megaloblastic anaemia and low vitamin B12 levels. She has a history of type 1 diabetes mellitus. What could be the probable cause of her decreased vitamin levels?
Your Answer: Malabsorption
Correct Answer: Pernicious anaemia
Explanation:Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.
Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.
Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 25
Incorrect
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Sophie, a 19-year-old girl with type 1 diabetes mellitus, arrives at the emergency department with confusion, vomiting, and abdominal pain. Upon examination, she displays tachycardia and tachypnea. The medical team orders various tests, including an arterial blood gas.
The results are as follows:
pH 7.29 mmol/l
K+ 6.0 mmol/l
Glucose 15mmol/l
The doctors initiate treatment for diabetic ketoacidosis.
What ECG abnormality can be observed in relation to Sophie's potassium level?Your Answer: Tall tented T waves and tall P waves
Correct Answer: Tall tented T waves and flattened P waves
Explanation:When a person has hyperkalaemia, their blood has an excess of potassium which can lead to cardiac arrhythmias. One of the common ECG abnormalities seen in hyperkalaemia is tall tented T waves. Other possible ECG changes include wide QRS complexes and flattened P waves. In contrast, hypokalaemia can cause T wave depression, U waves, and tall P waves on an ECG. Delta waves are typically seen in patients with Wolfe-Parkinson-White syndrome.
ECG Findings in Hyperkalaemia
Hyperkalaemia is a condition characterized by high levels of potassium in the blood. This condition can have serious consequences on the heart, leading to abnormal ECG findings. The ECG findings in hyperkalaemia include peaked or ‘tall-tented’ T waves, loss of P waves, broad QRS complexes, sinusoidal wave pattern, and ventricular fibrillation.
The first ECG finding in hyperkalaemia is the appearance of peaked or ‘tall-tented’ T waves. This is followed by the loss of P waves, which are the small waves that represent atrial depolarization. The QRS complexes, which represent ventricular depolarization, become broad and prolonged. The sinusoidal wave pattern is a characteristic finding in severe hyperkalaemia, where the ECG tracing appears as a series of undulating waves. Finally, ventricular fibrillation, a life-threatening arrhythmia, can occur in severe hyperkalaemia.
In summary, hyperkalaemia can have serious consequences on the heart, leading to abnormal ECG findings. These findings include peaked or ‘tall-tented’ T waves, loss of P waves, broad QRS complexes, sinusoidal wave pattern, and ventricular fibrillation. It is important to recognize these ECG findings in hyperkalaemia as they can guide appropriate management and prevent life-threatening complications.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Incorrect
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A 17-year-old girl comes to the emergency department complaining of nausea and vomiting. A medical trainee, who has recently started her emergency rotation, prescribes metoclopramide to alleviate her symptoms before ordering some tests.
The nurse cautions the doctor that metoclopramide is not recommended for young female patients and suggests switching to cyclizine.
What is the reason for metoclopramide being unsuitable for this patient?Your Answer: Risk of urinary retention
Correct Answer: Risk of oculogyric crisis
Explanation:Metoclopramide use in children and young adults can lead to oculogyric crisis, which is a dystonic reaction that causes the eyes to involuntarily gaze upwards for an extended period. Opioids can cause respiratory depression, while cyclizine may result in restlessness and urinary retention. Amiodarone use may cause slate-grey skin discoloration. Additionally, metoclopramide can increase urinary frequency.
Understanding the Mechanism and Uses of Metoclopramide
Metoclopramide is a medication primarily used to manage nausea, but it also has other uses such as treating gastro-oesophageal reflux disease and gastroparesis secondary to diabetic neuropathy. It is often combined with analgesics for the treatment of migraines. However, it is important to note that metoclopramide has adverse effects such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. It should also be avoided in bowel obstruction but may be helpful in paralytic ileus.
The mechanism of action of metoclopramide is quite complicated. It is primarily a D2 receptor antagonist, but it also has mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Its antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone, and at higher doses, the 5-HT3 receptor antagonist also has an effect. The gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity.
In summary, metoclopramide is a medication with multiple uses, but it also has adverse effects that should be considered. Its mechanism of action is complex, involving both D2 receptor antagonist and 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Understanding the uses and mechanism of action of metoclopramide is important for its safe and effective use.
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This question is part of the following fields:
- Gastrointestinal System
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Question 27
Incorrect
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A 29-year-old man is diagnosed with pleomorphic adenoma and requires surgical resection. During the procedure, which of the following structures is least likely to be encountered in the resection of the parotid gland?
Your Answer: External carotid artery
Correct Answer: Mandibular nerve
Explanation:The parotid gland is traversed by several important structures, including the facial nerve and its branches, the external carotid artery and its branches (such as the maxillary and superficial temporal arteries), the retromandibular vein, and the auriculotemporal nerve. However, the mandibular nerve is located at a safe distance from the gland. The maxillary vein joins with the superficial temporal vein to form the retromandibular vein, which passes through the parotid gland. Damage to the auriculotemporal nerve during a parotidectomy can result in regrowth that attaches to sweat glands, leading to gustatory sweating (Freys Syndrome). The marginal mandibular branch of the facial nerve is also associated with the parotid gland.
The parotid gland is located in front of and below the ear, overlying the mandibular ramus. Its salivary duct crosses the masseter muscle, pierces the buccinator muscle, and drains adjacent to the second upper molar tooth. The gland is traversed by several structures, including the facial nerve, external carotid artery, retromandibular vein, and auriculotemporal nerve. The gland is related to the masseter muscle, medial pterygoid muscle, superficial temporal and maxillary artery, facial nerve, stylomandibular ligament, posterior belly of the digastric muscle, sternocleidomastoid muscle, stylohyoid muscle, internal carotid artery, mastoid process, and styloid process. The gland is supplied by branches of the external carotid artery and drained by the retromandibular vein. Its lymphatic drainage is to the deep cervical nodes. The gland is innervated by the parasympathetic-secretomotor, sympathetic-superior cervical ganglion, and sensory-greater auricular nerve. Parasympathetic stimulation produces a water-rich, serous saliva, while sympathetic stimulation leads to the production of a low volume, enzyme-rich saliva.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Correct
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A 36-year-old man who is overweight visits his GP with complaints of heartburn and regurgitation that worsen when lying flat. The GP suspects gastroesophageal reflux caused by a hiatus hernia and recommends lifestyle changes to promote weight loss, as well as antacids.
Where is the opening through which this problem occurs located in the diaphragm?Your Answer: T10
Explanation:The level at which the oesophagus passes through the diaphragm is T10, which is also where the oesophageal hiatus is located. When the stomach protrudes through this opening, it is referred to as a hiatus hernia.
Understanding Diaphragm Apertures
The diaphragm is a muscle that separates the chest cavity from the abdominal cavity and plays a crucial role in respiration. Diaphragm apertures are openings within this muscle that allow specific structures to pass from the thoracic cavity to the abdominal cavity. The three main apertures are the aortic hiatus at T12, the oesophageal hiatus at T10, and the vena cava foramen at T8. To remember the vertebral levels of these apertures, a useful mnemonic involves counting the total number of letters in the spellings of vena cava (8), oesophagus (10), and aortic hiatus (12).
In addition to these main apertures, smaller openings in the diaphragm exist in the form of lesser diaphragmatic apertures. These allow much smaller structures to pass through the thoracic cavity into the abdomen across the diaphragm. Examples of lesser diaphragmatic apertures include the left phrenic nerve, small veins, superior epigastric artery, intercostal nerves and vessels, subcostal nerves and vessels, splanchnic nerves, and the sympathetic trunk. Understanding the diaphragm and its apertures is important in the diagnosis and treatment of various medical conditions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Correct
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A 25-year-old man comes to the emergency department complaining of abdominal pain and vomiting. He reports not having a bowel movement for the past five days.
His medical history includes a ruptured appendix three years ago. There is no significant medical or family history.
During the examination, you observe abdominal distension and tinkling bowel sounds.
An abdominal X-ray shows dilated loops of small bowel.
What is the leading cause of the probable diagnosis in this scenario?Your Answer: Adhesions
Explanation:The leading cause of small bowel obstruction is adhesions, which can occur due to previous abdominal surgery and cause internal surfaces to stick together. An abdominal X-ray showing dilated small bowel loops is a common indicator of this condition. While a hernia can also cause small bowel obstruction, it is less likely in this case due to the patient’s surgical history. Intussusception is rare in adults and more commonly seen in young children. Malignancy is a less common cause of small bowel obstruction, especially in patients without risk factors or demographic factors that suggest a higher likelihood of cancer.
Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common causes of this condition are adhesions resulting from previous surgeries and hernias. Symptoms include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first imaging test used to diagnose small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early stages of obstruction. Management involves NBM, IV fluids, and a nasogastric tube with free drainage. Conservative management may be effective for some patients, but surgery is often necessary.
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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Correct
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A 7-year-old girl with Down Syndrome is brought to the pediatrician by her father. She has been complaining of intermittent abdominal pain for the past few months. During the physical examination, the doctor finds a soft, non-tender abdomen. Additionally, the girl has been experiencing episodes of diarrhea and has a vesicular rash on her leg.
Hemoglobin: 120 g/L (normal range for females: 115-160 g/L)
Mean Corpuscular Volume (MCV): 75 fL (normal range: 78-100 fL)
Platelet count: 320 * 109/L (normal range: 150-400 * 109/L)
White Blood Cell count (WBC): 9.8 * 109/L (normal range: 4.0-11.0 * 109/L)
Based on the likely diagnosis, what is the underlying pathophysiological cause of this girl's anemia?Your Answer: Villous atrophy affecting the distal duodenum
Explanation:Coeliac disease leads to malabsorption as a result of villous atrophy in the distal duodenum. This case exhibits typical symptoms of coeliac disease, including iron deficiency anaemia, abdominal pain, and diarrhoea. The presence of a vesicular rash on the skin indicates dermatitis herpetiformis, a skin manifestation of coeliac disease. The patient’s Down syndrome also increases the risk of developing this condition. Macrophages invading the intestinal wall is an incorrect answer as lymphocytic infiltration is involved in the pathogenesis of coeliac disease. Pancreatic insufficiency is also an unlikely diagnosis as it typically causes malabsorption of fat-soluble vitamins and Vitamin B12, which is not evident in this case. Villous atrophy affecting the proximal colon is also incorrect as the small intestine is responsible for nutrient absorption in the body.
Understanding Coeliac Disease
Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.
To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.
Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.
The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.
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This question is part of the following fields:
- Gastrointestinal System
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