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Question 1
Incorrect
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A 40-year-old woman presented to the gastroenterology clinic with intermittent biliary type pain, fever, and jaundice requiring recurrent hospital admissions. During her last admission, she underwent laparoscopic cholecystectomy. She has a history of ulcerative colitis for the past 15 years.
Investigations revealed elevated serum alanine aminotransferase (100 U/L), serum alkaline phosphatase (383 U/L), and serum total bilirubin (45 μmol/L). However, her serum IgG, IgA, and IgM levels were normal, and serology for hepatitis B and C was negative. Ultrasound of the abdomen showed dilated intrahepatic ducts and a common bile duct of 6 mm.
What is the most likely diagnosis?Your Answer: Viral hepatitis
Correct Answer: Primary sclerosing cholangitis
Explanation:Cholangitis, PSC, and Other Related Conditions
Cholangitis is a medical condition that is characterized by the presence of biliary pain, fever, and jaundice. On the other hand, primary sclerosing cholangitis (PSC) is a progressive disease that affects the bile ducts, either intrahepatic or extrahepatic, or both. The cause of PSC is unknown, but it is characterized by a disproportionate elevation of serum alkaline phosphatase. Patients with PSC are prone to repeated episodes of acute cholangitis, which require hospitalization. Up to 90% of patients with PSC have underlying inflammatory bowel disease, usually ulcerative colitis. Imaging studies, such as MRCP, typically show multifocal strictures in the intrahepatic and extrahepatic bile ducts. The later course of PSC is characterized by secondary biliary cirrhosis, portal hypertension, and liver failure. Patients with PSC are also at higher risk of developing cholangiocarcinoma.
Autoimmune hepatitis, on the other hand, is characterized by a marked elevation in transaminitis, the presence of autoantibodies, and elevated serum IgG. Choledocholithiasis, another related condition, is usually diagnosed by an ultrasound scan of the abdomen, which shows a dilated common bile duct (larger than 6 mm) and stones in the bile duct. Meanwhile, primary biliary cholangitis (PBC) is unlikely to cause recurrent episodes of cholangitis. Unlike PSC, PBC does not affect extrahepatic bile ducts. Finally, viral hepatitis is unlikely in the absence of positive serology. these conditions and their characteristics is crucial in providing proper diagnosis and treatment to patients.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Incorrect
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A 45-year-old alcoholic presents to the Emergency Department with retrosternal chest pain, shortness of breath and pain on swallowing after a heavy drinking session the night before. He reports having vomited several times this morning, after which the pain started. He denies any blood in the vomit and has no melaena. On examination, he is febrile and tachypnoeic and has a heart rate of 110 bpm. A chest X-ray reveals a left-sided pneumothorax and air within the mediastinum.
Given the likely diagnosis, what is the most appropriate management to treat the underlying cause of his symptoms?Your Answer:
Correct Answer: Urgent surgery
Explanation:Management of Suspected Oesophageal Rupture
Suspected oesophageal rupture is a medical emergency that requires urgent intervention. This condition is more common in patients with a history of alcohol excess and can be associated with a triad of vomiting, chest pain, and subcutaneous emphysema. Symptoms include retrosternal chest/epigastric pain, tachypnoea, fever, pain on swallowing, and shock. A chest X-ray reveals gas within soft tissue spaces, pneumomediastinum, left pleural effusion, and left-sided pneumothorax. Without rapid treatment, the condition can be fatal.
Antibiotics are necessary to treat the infection that may result from oesophageal rupture. However, they will not address the underlying cause of the infection.
Chest drain insertion is not the correct management for pneumothorax secondary to oesophageal rupture. A chest drain would not resolve the underlying cause, and air would continue to enter the pleural cavity via the oesophagus.
Proton pump inhibitors (PPIs) are not appropriate for suspected oesophageal rupture. PPIs would be the correct management for a suspected perforated ulcer. However, the history of acute-onset pain following vomiting is more in keeping with oesophageal rupture.
Urgent endoscopy is not appropriate for suspected oesophageal rupture. Endoscopy risks further oesophageal perforation, and there is no report of haematemesis or melaena, making this a less likely cause of the patient’s symptoms.
Management of Suspected Oesophageal Rupture: Antibiotics, Chest Drain Insertion, PPIs, and Endoscopy
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 67-year-old man visits his GP complaining of a mass on his tongue. He has a history of HIV that is not well-controlled, and he does not follow his medication regimen. During the examination, the doctor observes shaggy, poorly-defined, hardened, slightly raised, and rough plaques on the side of the tongue. The plaques cannot be removed with a tongue blade. What is the most probable diagnosis?
Your Answer:
Correct Answer: Oral hairy leukoplakia
Explanation:Oral Lesions: Differential Diagnosis and Characteristics
Oral lesions can present in a variety of forms and have different characteristics. In this case, a patient with a history of immunosuppression presents with a white mass on the lateral aspect of the tongue that cannot be scraped off with a tongue blade. This is most consistent with oral hairy leukoplakia, a non-premalignant Epstein-Barr virus-mediated mucocutaneous manifestation that often presents in immunosuppressed patients. Treatment involves antivirals.
Other possible oral lesions include oral discoid lupus erythematosus, which is the oral manifestation of systemic lupus erythematosus and typically presents as punched-out lesions with surrounding erythema. Aphthous ulcers are round or oval-shaped lesions with surrounding erythema that typically occur on the inside of the mouth and can be treated with topical steroids. Oral candidiasis can be scraped off with a tongue blade, making it an unlikely diagnosis in this case. Oral lichen planus is a chronic inflammatory condition that can present as white, lacy patches or erosions on the gingival margin.
In summary, a thorough examination and consideration of the patient’s medical history are necessary to accurately diagnose and treat oral lesions.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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You have a geriatric patient who presents with massive haematemesis. He is agitated with a pulse of 110 bpm and a blood pressure of 130/90 mmHg. He is a known alcoholic.
What is the best step in the management for this elderly patient?Your Answer:
Correct Answer: Endoscopy
Explanation:Management of Upper Gastrointestinal Bleeding: Endoscopy, Laparotomy, Sengstaken-Blakemore Tube, and IV Antibiotics
In cases of upper gastrointestinal bleeding, prompt and appropriate management is crucial. For patients with severe haematemesis and haemodynamic instability, immediate resuscitation and endoscopy are recommended by the National Institute for Health and Care Excellence (NICE) guidelines. Crossmatching blood for potential transfusion is also necessary. Urgent endoscopy within 24 hours of admission is advised for patients with smaller haematemesis who are haemodynamically stable.
Laparotomy is not necessary unless the bleeding is life-threatening and cannot be contained despite resuscitation or transfusion, medical or endoscopic therapy fails, or the patient has a high Rockall score or re-bleeding. The insertion of a Sengstaken-Blakemore tube may be considered for haematemesis from oesophageal varices, but endoscopy remains the primary diagnostic and therapeutic tool.
Prophylactic antibiotics are recommended for patients with suspected or confirmed variceal bleeding at endoscopy. However, arranging for a psychiatric consult is not appropriate in the acute phase of management, as the patient requires immediate treatment and resuscitation.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Incorrect
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A 5-year-old girl with confirmed coeliac disease needs a 1-month prescription for gluten-free staple foods.
What would be the most suitable prescription for gluten-free staple foods?Your Answer:
Correct Answer: 1 kg bread + 750 g pasta + 1 kg oats = 10 units
Explanation:Determining the Correct Gluten Prescription for a Patient
When prescribing gluten for a patient, it is important to follow the National Prescribing Guidelines to ensure the correct amount is given. For example, a combination of 1 kg bread, 750 g pasta, and 1 kg oats would result in 10 units of gluten, which is the recommended amount for a 3-year-old patient. However, it is important to note that regional restrictions may apply, such as in England where only bread/flour mixes can be prescribed.
Other combinations, such as 2 kg bread, 1500 g pasta, and 2 kg oats, would result in double the recommended amount of gluten for a 3-year-old patient. It is also important to consider the patient’s age range, as the recommended amount of gluten varies for different age groups.
In summary, determining the correct gluten prescription for a patient involves following the National Prescribing Guidelines, considering regional restrictions, and taking into account the patient’s age range.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Incorrect
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A 58-year-old woman presents to the Emergency Department with abdominal pain, fever and two episodes of vomiting. She states that she has had previous episodes of right upper-quadrant pain with radiation to the right shoulder blade but has never sought medical attention for this.
Her past medical history is significant for obesity and hypertension.
Examination reveals an obese abdomen with tenderness in the right upper quadrant and epigastric region. No jaundice is evident.
Observations are as follows:
Temperature 38.5°C
Heart rate 87 beats per minute
Respiratory rate 19 breaths per minute
SpO2 98% (room air)
Blood pressure 145/86 mmHg
Laboratory results reveal an elevated white cell count and C-reactive protein. An abdominal ultrasound reveals multiple gallstones in the body of the gallbladder. The gallbladder is thickened, with the largest stone measuring 17 mm.
Which of the following is the most appropriate next step in management?Your Answer:
Correct Answer: Laparoscopic cholecystectomy
Explanation:Differentiating between surgical interventions for gallbladder disease
Gallbladder disease can present in various ways, and the appropriate surgical intervention depends on the specific clinical scenario. In the case of acute cholecystitis, which is characterized by right upper quadrant pain, fever, and an elevated white cell count, immediate surgical input is necessary. Laparoscopic cholecystectomy is the recommended course of action, but it is important to wait for the settling of acute symptoms before proceeding with surgery.
Exploratory laparotomy, on the other hand, is indicated in patients who are haemodynamically unstable and have a rigid, peritonitic abdomen on examination. If the patient has a soft abdomen without haemodynamic instability, exploratory laparotomy is not necessary.
Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in patients who have common bile duct stones. However, if the patient has gallstones in the body of the gallbladder, ERCP is not the appropriate intervention.
Intravenous (IV) proton pump inhibitors, such as pantoprazole, are indicated in patients suffering from severe peptic ulcer disease, which typically presents with deep epigastric pain in a patient with risk factors for peptic ulcers, such as non-steroidal anti-inflammatory use or Helicobacter pylori infection.
Finally, percutaneous cholecystostomy is mainly reserved for patients who are critically unwell or are poor surgical candidates. This procedure involves the image-guided placement of a drainage catheter into the gallbladder lumen with the aim of stabilizing the patient so that a more measured surgical approach can be taken in the future.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Incorrect
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A 38-year-old woman has chronic pancreatitis. She has lost weight and has troublesome diarrhoea. She reports that she has had diarrhoea daily and it has a strong, malodorous smell. The unintentional weight loss is 7 kg over the last year and she has had a general decrease in energy.
Which preparation would be most suitable to decrease her diarrhoea?Your Answer:
Correct Answer: Pancreatin
Explanation:Common Gastrointestinal Medications and Their Uses
Pancreatin is a mixture of digestive enzymes that aid in the digestion of carbohydrates, lipids, and proteins. It is used in conditions where there is a lack of pancreatic enzyme production, such as cystic fibrosis and chronic pancreatitis. Pancreatin should be taken with meals and may cause side-effects such as nausea and hypersensitivity.
Co-phenotrope is a combination drug that controls the consistency of faeces following ileostomy or colostomy formation and in acute diarrhoea. It is composed of diphenoxylate and atropine and may cause side-effects such as abdominal pain and lethargy.
Cholestyramine binds bile in the gastrointestinal tract, preventing its reabsorption. It is used in conditions such as hypercholesterolaemia and primary biliary cholangitis. Side-effects may include constipation and nausea.
Loperamide is an antimotility agent used in acute diarrhoea. It may cause side-effects such as constipation and nausea.
Psyllium, also known as ispaghula, is a bulk-forming laxative that aids in normal bowel elimination. It is mainly used as a laxative but may also be used to treat mild diarrhoea.
Understanding Common Gastrointestinal Medications
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This question is part of the following fields:
- Gastroenterology
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Question 8
Incorrect
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A 55-year-old man with a long history of ulcerative colitis (UC) presents to the clinic for evaluation. Although his inflammatory bowel disease is currently under control, he reports experiencing increased lethargy and itching. During the physical examination, his blood pressure is 118/72 mmHg, and his pulse is 68 bpm. The patient displays mildly jaundiced sclerae and evidence of scratch marks on his skin.
Lab Results:
Test Result Normal Range
Hemoglobin 112g/L 135–175 g/L
White blood cell count (WBC) 8.9 × 109/L 4–11 × 109/L
Platelets 189 × 109/L 150–400 × 109/L
Sodium (Na+) 140 mmol/L 135–145 mmol/L
Potassium (K+) 4.2 mmol/L 3.5–5.0 mmol/L
Creatinine 115 μmol/L 50–120 µmol/L
Alkaline phosphatase 380 U/L 30–130 IU/L
Alanine aminotransferase (ALT) 205 U/L 5–30 IU/L
Bilirubin 80 μmol/L 2–17 µmol/L
Ultrasound Evidence of bile duct dilation
What is the most probable diagnosis?Your Answer:
Correct Answer: Primary sclerosing cholangitis (PSC)
Explanation:Differentiating Primary Sclerosing Cholangitis from Other Liver Conditions
Primary sclerosing cholangitis (PSC) is a condition that affects the liver and bile ducts, causing autoimmune sclerosis and irregularities in the biliary diameter. Patients with PSC may present with deranged liver function tests, jaundice, itching, and chronic fatigue. PSC is more common in men, and up to 50% of patients with PSC also have ulcerative colitis (UC). Ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP) can show intrahepatic biliary duct stricture and dilation, often with extrahepatic duct involvement. Cholangiocarcinoma is a long-term risk in cases of PSC.
Alcoholic-related cirrhosis is a possibility, but it is unlikely in the absence of a history of alcohol excess. Primary biliary cholangitis (PBC) is an autoimmune condition that causes destruction of the intrahepatic bile ducts, resulting in a cholestatic pattern of jaundice. PBC mostly affects middle-aged women and does not cause bile duct dilation on ultrasound. Ascending cholangitis is a medical emergency that presents with a triad of jaundice, fever, and right upper quadrant tenderness. Autoimmune hepatitis most often occurs in middle-aged women presenting with general malaise, anorexia, and weight loss of insidious onset, with abnormal liver function tests. It normally causes hepatitis, rather than cholestasis.
In summary, differentiating PSC from other liver conditions requires a thorough evaluation of the patient’s medical history, symptoms, and diagnostic tests.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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A 32-year-old, malnourished patient needs to have a nasogastric tube (NGT) inserted for enteral feeding. What is the most important measure to take before beginning the feeding plan?
Your Answer:
Correct Answer: Chest radiograph
Explanation:Confirming Nasogastric Tube Placement: The Role of Chest Radiograph
Confirming the placement of a nasogastric tube (NGT) is crucial to prevent potential harm to the patient. While pH testing was previously used, chest radiograph has become the preferred method due to its increasing availability and negligible radiation exposure. The NGT has two main indications: enteral feeding/medication administration and stomach decompression. A chest radiograph should confirm that the NGT is passed down the midline, past the carina, past the level of the diaphragm, deviates to the left, and the tip is seen in the stomach. Respiratory distress absence is a reliable indicator of correct placement, while aspirating or auscultating the tube is unreliable. Abdominal radiographs are not recommended due to their inability to visualize the entire length of the NGT and the unnecessary radiation risk to the patient.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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A 20-year old man presents to the Surgical Assessment Unit complaining of sudden onset abdominal pain. What physical examination finding is most indicative of a possible diagnosis of appendicitis?
Your Answer:
Correct Answer: Tenderness over McBurney’s point
Explanation:Common Abdominal Exam Findings and Their Significance
Abdominal exams are an important part of diagnosing various medical conditions. Here are some common findings and their significance:
Tenderness over McBurney’s point: This is a sign of possible appendicitis. McBurney’s point is located a third of the way from the right anterior superior iliac spine to the umbilicus.
Grey–Turner’s sign: Flank bruising is a sign of retroperitoneal hemorrhage, which is commonly associated with acute pancreatitis.
Murphy’s sign: This suggests cholecystitis. The examiner places their hand below the right costal margin and the tender gallbladder moves inferiorly on inhalation, causing the patient to catch their breath.
Tinkling bowel sounds: High-pitched, ‘tinkling’ bowel sounds are typically associated with mechanical bowel obstruction.
Absent bowel sounds: This is suggestive of paralytic ileus, which most commonly occurs after abdominal surgery.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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A 45-year-old man is admitted to Emergency Department (ED) with haematemesis of bright red blood. He is an alcoholic. He has cool extremities, guarding over the epigastric region, he is ascitic, and has eight spider naevi on his neck and chest. An ABCD management is begun along with fluid resuscitation.
Given the likely diagnosis, what medication is it most important to start?Your Answer:
Correct Answer: Terlipressin
Explanation:In cases of suspected variceal bleeding, the priority medication to administer is terlipressin. This drug causes constriction of the mesenteric arterial circulation, leading to a decrease in portal venous inflow and subsequent reduction in portal pressure, which can help to control bleeding. Band ligation should be performed after administering terlipressin, and if bleeding persists, a transjugular intrahepatic portosystemic shunt (TIPS) may be necessary. Antibiotics may also be given prophylactically, but they do not directly affect bleeding. Clopidogrel should be avoided as it can worsen bleeding, while omeprazole may be used according to hospital guidelines. Tranexamic acid is not indicated for oesophageal variceal bleeds.
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This question is part of the following fields:
- Gastroenterology
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Question 12
Incorrect
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A 42-year-old female patient complains of a slow onset of difficulty swallowing both solids and liquids. An upper GI endoscopy shows no abnormalities, and there is no visible swelling in the neck. A preliminary psychiatric evaluation reveals no issues. The on-call junior doctor suspects a psychological or functional cause. What signs would indicate an organic origin for the dysphagia?
Your Answer:
Correct Answer: Raynaud's phenomenon
Explanation:The relationship between Raynaud’s phenomenon and dysphagia is important in identifying potential underlying systemic diseases such as scleroderma. Raynaud’s phenomenon is a common symptom found in scleroderma, a systemic disease that can cause dysphagia and oesophageal dysmotility. While Raynaud’s phenomenon may be the only early manifestation of scleroderma, gastrointestinal involvement can also occur in the early stages. Therefore, the combination of Raynaud’s phenomenon with oesophageal symptoms should prompt further investigation for scleroderma.
Arthritis is not a specific cause of dysphagia-related illness, although it may occur in a variety of diseases. In scleroderma, arthralgia is more common than arthritis. Globus pharyngeus, the sensation of having something stuck in the throat, can cause severe distress, but despite extensive investigation, there is no known cause. Malar rash, found in systemic lupus erythematosus (SLE), is not associated with dysphagia. Weakness is a non-specific symptom that may be a manifestation of psychiatric illness or malnutrition as a consequence of dysphagia, and cannot guide further management.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 22-year-old man presents to the Student Health Service after a ‘flu like’ illness. He has noticed that his eyes have become yellow over the past two days and he has been off his food. On examination, there are no significant abnormal findings.
Investigations:
Investigation Result Normal value
Haemoglobin 140 g/l 135–175 g/l
White cell count (WCC) 6.4 × 109/l 4–11 × 109/l
Platelets 230 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
Creatinine 80 μmol/l 50–120 µmol/l
Alanine aminotransferase (ALT) 25 IU/l 5–30 IU/l
Bilirubin 67 μmol/l 2–17 µmol/l
Lactate Dehydrogenase (LDH) 105 IU/l 100–190 IU/l
Urine bile salts +
Hepatic ultrasound scan – Normal
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Gilbert syndrome
Explanation:Differential Diagnosis for a Patient with Elevated Bilirubin Levels
One possible cause of elevated bilirubin levels is Gilbert syndrome, an autosomal recessive condition that results in a deficiency of glucuronyl transferase activity. This condition leads to an increase in unconjugated bilirubin levels, which can become more pronounced during periods of fasting or illness. Treatment for Gilbert syndrome is not necessary, and the prognosis is excellent without significant long-term effects.
Hepatitis A is another possible cause of elevated bilirubin levels, particularly in individuals who have traveled to areas where the virus is common or who have occupational exposure to contaminated materials. Symptoms of hepatitis A include flu-like symptoms, anorexia, nausea, vomiting, and malaise, followed by acute hepatitis with jaundice, pale stools, and dark urine. However, the absence of risk factors and normal alanine aminotransferase levels make hepatitis A unlikely.
Infectious mononucleosis, caused by the Epstein-Barr virus, can also cause elevated bilirubin levels. Symptoms typically include acute tonsillitis and flu-like symptoms, as well as viral hepatitis. However, the absence of upper respiratory tract infection symptoms, normal ALT levels, and the lack of lymphocytosis make this diagnosis unlikely.
Autoimmune hemolysis is another possible cause of elevated bilirubin levels, but normal hemoglobin and lactate dehydrogenase levels make this diagnosis unlikely.
Hepatitis B is a viral infection that is primarily transmitted through sexual contact and intravenous drug use. Symptoms include acute hepatitis with jaundice, and chronic infection can develop in some cases. However, normal ALT levels and the absence of risk factors make this diagnosis unlikely.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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A 36-year-old man presents with abnormal liver function tests. He has no history of alcohol consumption and no known risk factors for liver disease. However, his grandfather passed away from liver cancer. Upon investigation, his serum albumin is 38 g/L (37-49), serum total bilirubin is 41 μmol/L (1-22), serum alanine aminotransferase is 105 U/L (5-35), serum alkaline phosphatase is 135 U/L (45-105), serum ferritin is 1360 mcg/L, and serum iron saturation is 84%. A liver biopsy reveals Perls' Prussian blue positive deposits in the liver. What is the most appropriate first-line treatment?
Your Answer:
Correct Answer: Venesection
Explanation:Venesection is the primary treatment for haemochromatosis, with a target serum ferritin of less than 50 mcg/L achieved within three to six months. Azathioprine and prednisolone are not used in treatment, while iron chelators such as desferrioxamine are reserved for certain cases. Ursodeoxycholic acid is used in treating primary biliary cirrhosis.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Incorrect
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A 39-year-old man presents to Accident and Emergency with sudden onset vomiting and severe upper abdominal pain. On examination, he appears unwell, with a high heart and respiratory rate, and a temperature of 38.0°C. His blood pressure is 112/74 mmHg. He localises the pain to his upper abdomen, with some radiation to the back. His abdomen is generally tender, with bowel sounds present. There is no blood in his vomit. He is unable to provide further history due to the pain and nausea, but he is known to Accident and Emergency due to many previous admissions with alcohol intoxication. He has previously been normotensive, is a non-smoker and has not been treated for any other conditions.
Based on the information provided, what is the most likely diagnosis?Your Answer:
Correct Answer: Acute pancreatitis
Explanation:Differential Diagnosis for Acute Upper Abdominal Pain: Considerations and Exclusions
Acute upper abdominal pain can be caused by a variety of conditions, and a thorough differential diagnosis is necessary to determine the underlying cause. In this case, the patient’s history of alcohol abuse is a significant risk factor for acute pancreatitis, which is consistent with the presentation of quick-onset, severe upper abdominal pain with vomiting. Mild pyrexia is also common in acute pancreatitis. However, other conditions must be considered and excluded.
Pulmonary embolism can cause acute pain, but it is typically pleuritic and associated with shortness of breath rather than nausea and vomiting. Aortic dissection is another potential cause of sudden-onset upper abdominal pain, but it is rare under the age of 40 and typically associated with a history of hypertension and smoking. Myocardial infarction should also be on the differential diagnosis, but the location of the pain and radiation to the back, along with the lack of a history of cardiac disease or hypertension, suggest other diagnoses. Nevertheless, an electrocardiogram (ECG) should be performed to exclude myocardial infarction.
Bleeding oesophageal varices can develop as a consequence of portal hypertension, which is usually due to cirrhosis. Although the patient is not known to have liver disease, his history of alcohol abuse is a significant risk factor for cirrhosis. However, bleeding oesophageal varices would present with haematemesis, which the patient does not have.
In conclusion, a thorough differential diagnosis is necessary to determine the underlying cause of acute upper abdominal pain. In this case, acute pancreatitis is the most likely diagnosis, but other conditions must be considered and excluded.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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A 33-year-old university teacher returned to the United Kingdom after spending 2 years in India on a spiritual journey. During his time there, he stayed in various ashrams and ate local food with the local disciples. Unfortunately, he contracted malaria twice, suffered from diarrhoea once, and had a urinary tract infection. Upon returning to the UK, he complained of chronic diarrhoea and abdominal pain, which worsened after consuming milk. Blood tests showed a low haemoglobin level of 92 g/l (normal range: 135-175 g/l), a high mean corpuscular volume (MCV) of 109 fl (normal range: 76-98 fl), and a white cell count (WCC) of 8 × 109/l (normal range: 4-11 × 109/l). Stool samples and blood tests for IgA Ttg and HIV antibodies were negative. What test would be most helpful in diagnosing this patient?
Your Answer:
Correct Answer: Small intestinal biopsy
Explanation:Diagnostic Tests for Chronic Diarrhoea: A Comparison
Chronic diarrhoea can have various causes, including intestinal parasitic infection and malabsorption syndromes like tropical sprue. Here, we compare different diagnostic tests that can help in identifying the underlying cause of chronic diarrhoea.
Small Intestinal Biopsy: This test can diagnose parasites like Giardia or Cryptosporidium, which may be missed in stool tests. It can also diagnose villous atrophy, suggestive of tropical sprue.
Colonoscopy: While colonoscopy can show amoebic ulcers or other intestinal parasites, it is unlikely to be of use in investigating malabsorption.
Lactose Breath Test: This test diagnoses lactase deficiency only and does not tell us about the aetiology of chronic diarrhoea.
Serum Vitamin B12 Level: This test diagnoses a deficiency of the vitamin, but it will not tell about the aetiology, eg dietary insufficiency or malabsorption.
Small Intestinal Aspirate Culture: This test is done if bacterial overgrowth is suspected, which occurs in cases with a previous intestinal surgery or in motility disorders like scleroderma. However, there is no mention of this history in the case presented here.
In conclusion, the choice of diagnostic test depends on the suspected underlying cause of chronic diarrhoea. A small intestinal biopsy is a useful test for diagnosing both parasitic infections and malabsorption syndromes like tropical sprue.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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A 50-year-old man was admitted for an endoscopic retrograde cholangio-pancreatography (ERCP) due to biliary colic. He had an uneventful procedure, but was re-admitted the same night with severe abdominal pain. He is tachycardic, short of breath, and has a pleural effusion on his chest X-ray (CXR). His blood tests show C-reactive protein (CRP) 200 mg/litre, white cell count (WCC) 16 × 109/litre, creatine 150 µmol/litre, urea 8 mmol/litre, phosphate 1.1 mmol/litre, calcium 0.7 mmol/litre.
What is his most likely diagnosis?Your Answer:
Correct Answer: Pancreatitis
Explanation:Diagnosing and Managing Complications of ERCP: A Case Study
A patient presents with abdominal pain, hypocalcaemia, and a pleural effusion several hours after undergoing an ERCP. The most likely diagnosis is pancreatitis, a known complication of the procedure. Immediate management includes confirming the diagnosis and severity of pancreatitis, aggressive intravenous fluid resuscitation, oxygen, and adequate analgesia. Severe cases may require transfer to intensive care. Intestinal and biliary perforation are unlikely causes, as they would have presented with immediate post-operative pain. A reaction to contrast would have occurred during the procedure. Another possible complication is ascending cholangitis, which presents with fever, jaundice, and abdominal pain, but is unlikely to cause hypocalcaemia or a pleural effusion. It is important to promptly diagnose and manage complications of ERCP to prevent severe complications and improve patient outcomes.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Incorrect
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A 68-year-old man has come in with jaundice and no pain. His doctor has noted a possible palpable gallbladder. Where is the fundus of the gallbladder most likely to be palpable based on these symptoms?
Your Answer:
Correct Answer: Lateral edge of right rectus abdominis muscle and the costal margin
Explanation:Anatomical Landmarks and their Surface Markings in the Abdomen
The human abdomen is a complex region with various structures and organs that are important for digestion and metabolism. In this article, we will discuss some of the anatomical landmarks and their surface markings in the abdomen.
Surface Marking: Lateral edge of right rectus abdominis muscle and the costal margin
Anatomical Landmark: Fundus of the gallbladderThe fundus of the gallbladder is located closest to the anterior abdominal wall. Its surface marking is the point where the lateral edge of the right rectus abdominis muscle meets the costal margin, which is also in the transpyloric plane. It is important to note that Courvoisier’s law exists in surgery, which states that a palpable, enlarged gallbladder accompanied by painless jaundice is unlikely to be caused by gallstone disease.
Surface Marking: Anterior axillary line and the transpyloric plane
Anatomical Landmark: Hilum of the spleenThe transpyloric plane is an imaginary line that runs axially approximately at the L1 vertebral body. The hilum of the spleen can be found at the intersection of the anterior axillary line and the transpyloric plane.
Surface Marking: Linea alba and the transpyloric plane
Anatomical Landmark: Origin of the superior mesenteric arteryThe origin of the superior mesenteric artery can be found at the intersection of the linea alba and the transpyloric plane.
Surface Marking: Mid-clavicular line and the transpyloric plane
Anatomical Landmark: Hepatic flexure of the colon on the right and splenic flexure of the colon on the leftAt the intersection of the mid-clavicular line and the transpyloric plane, the hepatic flexure of the colon can be found on the right and the splenic flexure of the colon on the left.
Surface Marking: Mid-clavicular line and a horizontal line through the umbilicus
Anatomical Landmark: Ascending colon on the right and descending colon on the leftAt the intersection of the mid-clavicular line and a horizontal line through the umbilicus, the ascending colon is found on the right and the descending colon on the left. If the liver or spleen are enlarged, their tips can also
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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A 50-year-old man arrived at the Emergency Department with massive haematemesis. An emergency endoscopy revealed a bleeding gastric ulcer located on the lesser curvature of the stomach. Which vessel is most likely affected?
Your Answer:
Correct Answer: The left gastric artery
Explanation:Arteries that supply the stomach: A brief overview
The stomach is a vital organ that requires a constant supply of blood to function properly. There are several arteries that supply blood to different parts of the stomach. Here is a brief overview of these arteries:
1. Left gastric artery: This artery supplies the lesser curvature of the stomach along with the right gastric artery. Bleeding at the lesser curvature of the stomach is most likely to be caused by these two arteries. The left gastric artery is one of the three branches that arise from the coeliac trunk.
2. Right gastroepiploic artery: This artery, along with the left gastroepiploic artery, supplies the greater curvature of the stomach.
3. Left gastroepiploic artery: This artery, along with the right gastroepiploic artery, supplies the greater curvature of the stomach.
4. Gastroduodenal artery: This artery is a branch off the common hepatic artery that supplies the duodenum, head of the pancreas, and greater curvature of the stomach.
5. Short gastric arteries: These are four or five small arteries from the splenic artery that supply the fundus of the stomach.
Understanding the different arteries that supply the stomach is important for diagnosing and treating various medical conditions related to the stomach.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 23-year-old woman developed sudden-onset, severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. The pain now feels more generalised, and even slight movement makes it worse. She has diminished bowel sounds and exquisite tenderness in the mid-epigastrium with rebound tenderness and board-like rigidity. Her pulse is 110 bpm and blood pressure 130/75. She reports taking ibuprofen for dysmenorrhoea. She had last taken ibuprofen the day before the pain began.
What is the most likely diagnosis?Your Answer:
Correct Answer: Perforated peptic ulcer
Explanation:Differential Diagnosis for Abdominal Pain: Perforated Peptic Ulcer
Abdominal pain can have various causes, and it is important to consider the differential diagnosis to determine the appropriate treatment. In this case, the patient’s use of non-steroidal anti-inflammatory drugs (NSAIDs) suggests a possible perforated peptic ulcer as the cause of her symptoms.
Perforated peptic ulcer is a serious complication of peptic ulcer disease that can result from the use of NSAIDs. The patient’s symptoms, including increasing generalised abdominal pain that is worse on moving, rebound tenderness, and board-like rigidity, are classic signs of generalised peritonitis. These symptoms suggest urgent surgical review and definitive surgical management.
Other possible causes of abdominal pain, such as acute gastritis, acute pancreatitis, appendicitis, and cholecystitis, have been considered but are less likely based on the patient’s symptoms. It is important to consider the differential diagnosis carefully to ensure appropriate treatment and avoid potential complications.
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This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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A 50-year-old woman presents with difficult-to-manage diabetes mellitus. She was diagnosed with gallstones a year earlier. She also complains of steatorrhoea and diarrhoea. There has been some weight loss over the past 6 months.
Investigations:
Investigation Result Normal value
Haemoglobin 119 g/l 115–155 g/l
White cell count (WCC) 4.7 × 109/l 4–11 × 109/l
Platelets 179 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
Creatinine 120 μmol/l 50–120 µmol/l
Glucose 9.8 mmol/l 3.5–5.5 mmol/l
Somatostatin 105 pg/ml 10–22 pg/ml
T1-weighted gadolinium-enhanced magnetic resonance imaging (MRI): 4-cm pancreatic tumour
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Somatostatinoma
Explanation:Overview of APUD Cell Tumours and their Presentations
APUD cell tumours are rare and can affect various organs in the body. Some of the most common types include somatostatinoma, glucagonoma, insulinoma, gastrinoma, and VIPoma. These tumours can present with a range of symptoms, such as gallstones, weight loss, diarrhoea, diabetes mellitus, necrolytic migratory erythema, sweating, light-headedness, and peptic ulceration. Diagnosis can be challenging, but imaging techniques and hormone measurements can aid in identifying the tumour. Treatment options include surgery, chemotherapy, and hormone therapy. It is important to note that some of these tumours may be associated with genetic syndromes, such as MEN 1 syndrome.
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This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 21-year-old woman is brought to the Emergency Department by her flatmates who claim that she has vomited up blood. Apparently she had consumed far too much alcohol over the course of the night, had vomited on multiple occasions, and then began to dry-retch. After a period of retching, she vomited a minimal amount of bright red blood. On examination, she is intoxicated and has marked epigastric tenderness; her blood pressure is 135/75 mmHg, with a heart rate of 70 bpm, regular.
Investigations:
Investigation
Result
Normal value
Haemoglobin 145 g/l 115–155 g/l
White cell count (WCC) 5.4 × 109/l 4–11 × 109/l
Platelets 301 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Creatinine 75 μmol/l 50–120 µmol/l
Which of the following is the most appropriate treatment for her?Your Answer:
Correct Answer: Discharge in the morning if stable
Explanation:Management of Mallory-Weiss Tear: A Case Study
A Mallory-Weiss tear is a longitudinal mucosal laceration at the gastro-oesophageal junction or cardia caused by repeated retching. In a stable patient with a Hb of 145 g/l, significant blood loss is unlikely. Observation overnight is recommended, and if stable, the patient can be discharged the following morning. Further endoscopic investigation is not necessary in this case. Intravenous pantoprazole is not indicated for a Mallory-Weiss tear, and antacid treatment is unnecessary as the tear will heal spontaneously. Urgent endoscopic investigation is not required if the patient remains clinically stable and improves.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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A 39-year-old male with a history of alcoholism was admitted to the hospital with jaundice and altered consciousness. He had been previously admitted for ascites and jaundice. Upon investigation, his bilirubin levels were found to be 44 µmol/L (5.1-22), serum albumin levels were 28 g/L (40-50), and his prothrombin time was 21 seconds (13 seconds). The patient had a fluid thrill in his abdomen and exhibited asterixis. Although he was awake, he was unable to distinguish between day and night. What is the patient's Child-Pugh score (CTP)?
Your Answer:
Correct Answer: 12
Explanation:The Child-Turcotte-Pugh score (CTP) is used to assess disease severity in cirrhosis of liver. It consists of five clinical measures, each scored from 1 to 3 according to severity. The minimum score is 5 and maximum score is 15. Once a score has been calculated, the patient is graded A, B, or C for severity. The CTP score is primarily used to decide the need for liver transplantation. However, some criticisms of this scoring system highlight the fact that each of the five categories is given equal weighting, which is not always appropriate. Additionally, in two specific diseases, primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin cut-off levels in the table are markedly different.
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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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A 55-year-old man presents with epigastric pain which radiates to the back. He feels nauseous and has been vomiting since arriving at the Emergency Department (ED). On questioning, the man tells you that he takes no regular medication. He was last in hospital three years ago after he fell from his bicycle when cycling under the influence of alcohol. He was not admitted. He travelled to Nigeria to visit relatives three months ago.
On examination, the man’s abdomen is tender in the epigastrium. He is jaundiced. He is also tachycardic and pyrexial. Some of his investigation results are as follows:
Investigation Result Normal value
Alkaline phosphatase (ALP) 320 IU/l 30–130 IU/l
Alanine aminotransferase (ALT) 70 IU/l 5–30 IU/l
Bilirubin 45 µmol/l 2–17 µmol/l
What is the best initial treatment for this man?Your Answer:
Correct Answer: Admission, iv fluids, analgesia, keep nil by mouth and place a nasogastric tube
Explanation:Appropriate Treatment for Pancreatitis and Cholecystitis: Differentiating Symptoms and Initial Management
Pancreatitis and cholecystitis are two conditions that can present with similar symptoms, such as epigastric pain and nausea. However, the nature of the pain and other clinical indicators can help differentiate between the two and guide appropriate initial treatment.
For a patient with pancreatitis, initial treatment would involve admission, IV fluids, analgesia, and keeping them nil by mouth. A nasogastric tube may also be placed to help with vomiting and facilitate healing. Antibiotics and surgical intervention are not typically indicated unless there are complications such as necrosis or abscess.
In contrast, a patient with cholecystitis would receive broad-spectrum antibiotics and analgesia as initial management. Laparoscopic cholecystectomy would only be considered after further investigations such as abdominal ultrasound or MRCP.
It’s important to note that other factors, such as a recent history of travel, may also need to be considered in determining appropriate treatment. However, careful evaluation of symptoms and clinical indicators can help guide initial management and ensure the best possible outcomes for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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A 32-year-old woman presents to the Emergency Department with severe epigastric pain and vomiting. The pain radiates through to her back and began 2 hours ago while she was out with her friends in a restaurant. She has a past medical history of gallstones and asthma.
Which test should be used to confirm this woman’s diagnosis?Your Answer:
Correct Answer: Serum lipase
Explanation:Diagnostic Tests for Acute Pancreatitis
Acute pancreatitis is a condition that is commonly caused by gallstones and alcohol consumption. Its symptoms include upper abdominal pain, nausea, and vomiting. While serum amylase is widely used for diagnosis, serum lipase is preferred where available. Serum lactate is a useful marker for organ perfusion and can indicate the severity of the inflammatory response. A raised white cell count, particularly neutrophilia, is associated with a poorer prognosis. Serum calcium levels may also be affected, but this is not a specific test for pancreatitis. Blood glucose levels may be abnormal, with hyperglycemia being common, but this is not diagnostic of acute pancreatitis.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Incorrect
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A 50-year-old man presents to his general practitioner (GP) with several months of difficulty swallowing both liquids and solid foods. He states he also often regurgitates undigested food. He no longer looks forward to his meals and is beginning to lose weight. He denies chest pain.
Physical examination is normal. An electrocardiogram (ECG) and chest X-ray are also normal. Blood tests reveal normal inflammatory markers and normal renal function. He has had a trial of proton pump inhibitor (PPI) therapy, without relief of his symptoms. An upper gastrointestinal endoscopy is performed by the Gastroenterology team, which is also normal.
Which of the following is the most appropriate investigation for this patient?Your Answer:
Correct Answer: Oesophageal manometry
Explanation:The recommended first-line investigation for a patient with dysphagia to both solid foods and liquids, regurgitation, and weight loss, who has failed PPI therapy and has a normal upper endoscopy, is oesophageal manometry. This test can diagnose achalasia, a rare disorder characterized by impaired relaxation of the lower oesophageal sphincter due to neuronal degeneration of the myenteric plexus. Amylase levels are indicated in patients suspected of having acute pancreatitis, which presents with severe epigastric pain and is often associated with alcoholism or gallstone disease. Barium swallow is useful for detecting obstructions, reflux, or strictures in the oesophagus, but oesophageal manometry is preferred for diagnosing abnormal peristalsis in patients with suspected achalasia. A CT scan of the chest is indicated for lung cancer staging or chest trauma, while lateral cervical spine radiographs are used to diagnose dysphagia caused by large cervical osteophytes, which is unlikely in a relatively young patient.
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This question is part of the following fields:
- Gastroenterology
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Question 27
Incorrect
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A 25-year-old medical student is worried that she might have coeliac disease after learning about it during her gastroenterology rotation. She schedules an appointment with her GP to address her concerns, and the GP orders routine blood tests and coeliac serology as the initial investigation. What is the most frequently linked condition to coeliac disease?
Your Answer:
Correct Answer: Iron deficiency
Explanation:Coeliac Disease and Common Associated Conditions
Coeliac disease is an autoimmune disorder that causes the small intestine villi to atrophy upon exposure to gliadin, resulting in malabsorption syndrome and steatorrhoea. This condition often leads to deficiencies in iron, other minerals, nutrients, and fat-soluble vitamins. While the incidence of gastrointestinal malignancies is increased in people with coeliac disease, it is a relatively rare occurrence. Dermatitis herpetiformis, an itchy, vesicular rash, is commonly linked to coeliac disease and managed with a gluten-free diet. Osteoporosis is also common due to malabsorption of calcium and vitamin D. Infertility is not commonly associated with coeliac disease, especially in those on a gluten-free diet. However, untreated coeliac disease may have an impact on fertility, but results of studies are inconclusive. The most common associated condition with coeliac disease is iron deficiency anaemia.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A 28-year-old woman reports difficulty swallowing both solids and liquids, with occasional food getting stuck and needing to be washed down with a large drink. Achalasia of the oesophagus is suspected. Which nerve supplies the muscularis externa of the oesophagus?
Your Answer:
Correct Answer: Vagus nerves
Explanation:The vagus nerves are part of the tenth pair of cranial nerves and work with sympathetic nerves to form the oesophageal plexus. They have a parasympathetic function, stimulating peristalsis and supplying smooth muscle. The lower oesophageal sphincter, which relaxes to allow food into the stomach, is influenced by the vagus nerve. Oesophageal achalasia can occur when there is increased tone of the lower oesophageal sphincter, incomplete relaxation, and lack of peristalsis, leading to dysphagia and regurgitation.
The glossopharyngeal nerves are mixed cranial nerves that supply motor fibres to the stylopharyngeus muscle and parasympathetic fibres to the parotid gland. They also form the pharyngeal plexus with the vagus nerve, supplying the palate, larynx, and pharynx.
The greater splanchnic nerves contribute to the coeliac plexus, which supplies the enteric nervous system and the adrenals. The intercostal nerves arise from the anterior rami of the first 11 thoracic spinal nerves and supply various structures in their intercostal space. The phrenic nerves supply the diaphragm.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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An 80-year-old man presented with progressive dyspepsia and weight loss. Endoscopy revealed a stenosing lesion that bled easily. A biopsy and histopathological examination revealed adenocarcinoma of the oesophagus.
Which of the following is the most likely aetiological factor?Your Answer:
Correct Answer: Gastro-oesophageal reflux disease (GORD)
Explanation:Factors Contributing to Oesophageal Cancer
Oesophageal cancer is a common and aggressive tumour that can be caused by various factors. The two most common types of oesophageal cancer are squamous cell carcinoma and adenocarcinoma. In developed countries, adenocarcinoma is more prevalent, while squamous cell carcinoma is more common in the developing world.
Gastro-oesophageal reflux disease (GORD) is the most common predisposing factor for oesophageal adenocarcinoma. Acid reflux can cause irritation that progresses to metaplasia, dysplasia, and eventually adenocarcinoma. Approximately 10-15% of patients who undergo endoscopy for reflux symptoms have Barrett’s epithelium.
Cigarette smoking and chronic alcohol exposure are the most common aetiological factors for squamous cell carcinoma in Western cultures. However, no association has been found between alcohol and oesophageal adenocarcinoma. The risk of adenocarcinoma is also increased among smokers.
Achalasia, a condition that affects the oesophagus, increases the risk of both adeno and squamous cell carcinoma. However, dysphagia is not mentioned as a contributing factor.
Limited evidence suggests that excessive fruit and vegetable consumption may be protective against both types of cancer. Helicobacter pylori infection, which can cause stomach cancer, has not been associated with oesophageal cancer.
Factors Contributing to Oesophageal Cancer
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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A 50-year-old man, with a history of chronic alcohol abuse, presents to the Emergency Department with pain in the right and left upper quadrants. He has had bouts of abdominal pain in the past year. For the past month, he has had more frequent and worsening abdominal pain. Physical examination reveals right upper and left upper quadrant pain with guarding. An abdominal plain film radiograph reveals no free air, but there is an extensive peritoneal fluid collection, along with dilated loops of the small bowel. An abdominal computed tomography (CT) scan reveals a 6- to 7-cm cystic mass in the tail of the pancreas.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Pancreatic pseudocyst
Explanation:Differentiating Pancreatic Conditions: Pseudocysts, Adenocarcinoma, Islet Cell Adenoma, Acute Pancreatitis, and Metastatic Carcinoma
Pancreatic pseudocysts are collections of necrotic-haemorrhagic material that lack an epithelial lining and account for 75% of cysts in the pancreas. They often occur after an episode of acute pancreatitis or traumatic injury to the abdomen.
Pancreatic adenocarcinoma, on the other hand, is a solid mass that is not related to alcoholism. It usually develops in the head of the gland and is characterised by hard, stellate, poorly defined masses.
Islet cell adenomas, which are often non-functional, are not cystic and can be difficult to image due to their small size. However, some may secrete hormones such as insulin or gastrin.
Acute pancreatitis is a reversible inflammation of the pancreas that ranges in severity from oedema and fat necrosis to severe haemorrhage and parenchymal necrosis. It is a medical emergency characterised by sudden severe pain in the abdomen.
Finally, metastatic carcinoma is characterised by multiple solid masses.
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This question is part of the following fields:
- Gastroenterology
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