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  • Question 1 - A patient presents to the GP with swelling in the groin, on the...

    Correct

    • A patient presents to the GP with swelling in the groin, on the right. It does not have a cough impulse. The GP suspects a femoral hernia.

      What is the most common risk factor for femoral hernias in elderly patients?

      Your Answer: Female gender

      Explanation:

      Femoral hernias are more common in women, with female gender and pregnancy being identified as risk factors. A femoral hernia occurs when abdominal viscera or omentum protrudes through the femoral ring and into the femoral canal, with the neck of the hernia located below and lateral to the pubic tubercle. Although males can also develop femoral hernias, the condition is more prevalent in females with a ratio of 3:1.

      Understanding Femoral Hernias

      Femoral hernias occur when a part of the bowel or other abdominal organs pass through the femoral canal, which is a potential space in the anterior thigh. This can result in a lump in the groin area that is mildly painful and typically non-reducible. It is important to differentiate femoral hernias from inguinal hernias, which are located in a different area. Femoral hernias are less common than inguinal hernias and are more prevalent in women, especially those who have had multiple pregnancies.

      Diagnosis of femoral hernias is usually clinical, but ultrasound can also be used. It is important to rule out other possible causes of a lump in the groin area, such as lymphadenopathy, abscess, or aneurysm. Complications of femoral hernias include incarceration, strangulation, bowel obstruction, and bowel ischaemia, which can lead to significant morbidity and mortality.

      Surgical repair is necessary for femoral hernias, as the risk of strangulation is high. This can be done laparoscopically or via a laparotomy. Hernia support belts or trusses should not be used for femoral hernias due to the risk of strangulation. In emergency situations, a laparotomy may be the only option. Understanding the features, epidemiology, diagnosis, complications, and management of femoral hernias is crucial for healthcare professionals to provide appropriate care for their patients.

    • This question is part of the following fields:

      • Gastrointestinal System
      9.9
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  • Question 2 - Which of the following genes is not involved in the adenoma-carcinoma sequence of...

    Incorrect

    • Which of the following genes is not involved in the adenoma-carcinoma sequence of colorectal cancer?

      Your Answer: c-myc

      Correct Answer: src

      Explanation:

      Additional genes implicated include MCC, DCC, c-yes, and bcl-2.

      Colorectal cancer is a prevalent type of cancer in the UK, ranking third in terms of frequency and second in terms of cancer-related deaths. Every year, approximately 150,000 new cases are diagnosed, and 50,000 people die from the disease. The cancer can occur in different parts of the colon, with the rectum being the most common location, accounting for 40% of cases. The sigmoid colon follows closely, with 30% of cases, while the descending colon has only 5%. The transverse colon has 10% of cases, and the ascending colon and caecum have 15%.

    • This question is part of the following fields:

      • Gastrointestinal System
      7.7
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  • Question 3 - A 29-year-old man is diagnosed with pleomorphic adenoma and requires surgical resection. During...

    Incorrect

    • 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: Zygomatic branch of the facial nerve

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
      10.8
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  • Question 4 - A 25-year-old male patient reports experiencing mild jaundice following periods of fasting or...

    Incorrect

    • A 25-year-old male patient reports experiencing mild jaundice following periods of fasting or exercise. Upon examination, his complete blood count and liver function tests appear normal. What is the recommended course of treatment for this individual?

      Your Answer: Rifampicin

      Correct Answer: No treatment required

      Explanation:

      Gilbert Syndrome

      Gilbert syndrome is a common genetic condition that causes mild unconjugated hyperbilirubinemia, resulting in intermittent jaundice without any underlying liver disease or hemolysis. The bilirubin levels are usually less than 6 mg/dL, but most patients exhibit levels of less than 3 mg/dL. The condition is characterized by daily and seasonal variations, and occasionally, bilirubin levels may be normal in some patients. Gilbert syndrome can be triggered by dehydration, fasting, menstrual periods, or stress, such as an intercurrent illness or vigorous exercise. Patients may experience vague abdominal discomfort and fatigue, but these episodes resolve spontaneously, and no treatment is required except supportive care.

      In recent years, Gilbert syndrome is believed to be inherited in an autosomal recessive manner, although there are reports of autosomal dominant inheritance. Despite the mild symptoms, it is essential to understand the condition’s triggers and symptoms to avoid unnecessary medical interventions. Patients with Gilbert syndrome can lead a normal life with proper care and management.

    • This question is part of the following fields:

      • Gastrointestinal System
      21.3
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  • Question 5 - A 50-year-old man visits his doctor with complaints of abdominal pain, weight loss,...

    Incorrect

    • A 50-year-old man visits his doctor with complaints of abdominal pain, weight loss, and persistent diarrhoea for the past 5 months. During a colonoscopy, a suspicious growth is detected in his colon, which is later confirmed as adenocarcinoma. The patient reveals that his father was diagnosed with colon cancer at the age of 55.

      Based on this information, which genetic mutations are likely to be present in this patient?

      Your Answer: APC

      Correct Answer: MSH2/MLH1

      Explanation:

      Colorectal cancer can be classified into three types: sporadic, hereditary non-polyposis colorectal carcinoma (HNPCC), and familial adenomatous polyposis (FAP). Sporadic colon cancer is believed to be caused by a series of genetic mutations, including allelic loss of the APC gene, activation of the K-ras oncogene, and deletion of p53 and DCC tumor suppressor genes. HNPCC, which is an autosomal dominant condition, is the most common form of inherited colon cancer. It is caused by mutations in genes involved in DNA mismatch repair, leading to microsatellite instability. The most common genes affected are MSH2 and MLH1. Patients with HNPCC are also at a higher risk of other cancers, such as endometrial cancer. The Amsterdam criteria are sometimes used to aid diagnosis of HNPCC. FAP is a rare autosomal dominant condition that leads to the formation of hundreds of polyps by the age of 30-40 years. It is caused by a mutation in the APC gene. Patients with FAP are also at risk of duodenal tumors. A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma, and epidermoid cysts on the skin. Genetic testing can be done to diagnose HNPCC and FAP, and patients with FAP generally have a total colectomy with ileo-anal pouch formation in their twenties.

    • This question is part of the following fields:

      • Gastrointestinal System
      10.8
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  • Question 6 - A 2-year-old child is evaluated for inability to pass stool. After further testing,...

    Incorrect

    • A 2-year-old child is evaluated for inability to pass stool. After further testing, a rectal biopsy confirms a diagnosis of Hirschsprung's disease.

      Can you explain the pathophysiology behind this condition?

      Your Answer: Failure of the fusion of the anal tubercles and external invagination

      Correct Answer: Failure of the development of the parasympathetic plexuses

      Explanation:

      Hirschsprung’s disease is caused by a failure in the development of the parasympathetic plexuses, which are responsible for allowing the distal part of the large intestine to relax. Without these plexuses, the colon remains tightly sealed, preventing the passage of stool and leading to symptoms such as failure to pass meconium and constipation.

      Understanding Hirschsprung’s Disease

      Hirschsprung’s disease is a rare condition that affects 1 in 5,000 births. It is caused by a developmental failure of the parasympathetic Auerbach and Meissner plexuses, resulting in an aganglionic segment of bowel. This leads to uncoordinated peristalsis and functional obstruction, which can present as constipation and abdominal distension in older children or failure to pass meconium in the neonatal period.

      Hirschsprung’s disease is three times more common in males and is associated with Down’s syndrome. Diagnosis is made through a rectal biopsy, which is considered the gold standard. Treatment involves initial rectal washouts or bowel irrigation, followed by surgery to remove the affected segment of the colon.

      In summary, Hirschsprung’s disease is a rare but important differential diagnosis in childhood constipation. Understanding its pathophysiology, associations, possible presentations, and management is crucial for healthcare professionals to provide appropriate care for affected individuals.

    • This question is part of the following fields:

      • Gastrointestinal System
      12.7
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  • Question 7 - A 49-year-old woman comes to the Emergency Department complaining of colicky abdominal pain....

    Incorrect

    • A 49-year-old woman comes to the Emergency Department complaining of colicky abdominal pain. She states that she has been having on-and-off pain in the upper right quadrant for the past few months, especially after consuming fatty foods.

      Which cells are accountable for generating the hormone linked to this presentation?

      Your Answer: S cells

      Correct Answer: I cells

      Explanation:

      The correct answer is I cells, which are located in the upper small intestine. This patient’s symptoms are consistent with biliary colic, which occurs when the gallbladder contracts against an obstruction, typically a gallstone. Fatty foods stimulate the production of cholecystokinin (CCK) from the I cells in the duodenum, which promotes gallbladder contractility and the release of bile into the small intestine to aid in lipid emulsification.

      B cells are not involved in promoting gallbladder contractility and are instead part of the adaptive immune response. D cells release somatostatin, which decreases insulin production, and are found in the stomach, small intestine, and pancreas. G cells are located in the stomach and secrete gastrin to promote acid secretion by the parietal cells of the stomach.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
      9.5
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  • Question 8 - A 30-year-old male is diagnosed with carcinoid syndrome. What hormone is secreted by...

    Incorrect

    • A 30-year-old male is diagnosed with carcinoid syndrome. What hormone is secreted by carcinoids?

      Your Answer: Aldosterone

      Correct Answer: Serotonin

      Explanation:

      The rule of thirds for carcinoids is that one-third of cases involve multiple tumors, one-third affect the small bowel, and one-third result in metastasis or the development of a second tumor. It is important to note that carcinoids secrete serotonin, and carcinoid syndrome only occurs when there are liver metastases present, as the liver typically metabolizes the hormone released from primary lesions.

      Carcinoid tumours are a type of cancer that can cause a condition called carcinoid syndrome. This syndrome typically occurs when the cancer has spread to the liver and releases serotonin into the bloodstream. In some cases, it can also occur with lung carcinoid tumours, as the mediators are not cleared by the liver. The earliest symptom of carcinoid syndrome is often flushing, but it can also cause diarrhoea, bronchospasm, hypotension, and right heart valvular stenosis (or left heart involvement in bronchial carcinoid). Additionally, other molecules such as ACTH and GHRH may be secreted, leading to conditions like Cushing’s syndrome. Pellagra, a rare condition caused by a deficiency in niacin, can also develop as the tumour diverts dietary tryptophan to serotonin.

      To investigate carcinoid syndrome, doctors may perform a urinary 5-HIAA test or a plasma chromogranin A test. Treatment for the condition typically involves somatostatin analogues like octreotide, which can help manage symptoms like diarrhoea. Cyproheptadine may also be used to alleviate diarrhoea. Overall, early detection and treatment of carcinoid tumours can help prevent the development of carcinoid syndrome and improve outcomes for patients.

    • This question is part of the following fields:

      • Gastrointestinal System
      6.4
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  • Question 9 - A 61-year-old man arrives at the ED less than an hour after experiencing...

    Incorrect

    • A 61-year-old man arrives at the ED less than an hour after experiencing central chest pain that spreads to his left arm. His ECG reveals ST-elevation in the anterior leads, and he is set to undergo urgent PCI. The cardiologist plans to access the femoral artery. What is the accurate surface landmark for identifying the femoral artery?

      Your Answer: Midway between the ASIS and the pubic tubercle

      Correct Answer: Midway between the ASIS and the pubic symphysis

      Explanation:

      The mid-inguinal point, which is the surface landmark for the femoral artery, is located at the midpoint between the ASIS and pubic symphysis. It should not be confused with the midpoint of the inguinal ligament, which is where the deep inguinal ring is located and runs from the ASIS to the pubic tubercle. While the other three options are not specific surface landmarks, it is worth noting that the superficial inguinal ring, which is the exit of the inguinal canal, is typically located superolateral to the pubic tubercle within a range of 1-2 cm.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
      8.2
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  • Question 10 - A 63-year-old female patient arrives at the emergency department complaining of severe, sudden-onset...

    Incorrect

    • A 63-year-old female patient arrives at the emergency department complaining of severe, sudden-onset abdominal pain that has been ongoing for an hour. She describes the pain as intense and cramping, with a severity rating of 9/10.

      The patient has a medical history of hypertension, type 2 diabetes, and atrial fibrillation.

      After undergoing a contrast CT scan, a thrombus is discovered in the inferior mesenteric artery, and the patient is immediately scheduled for an urgent laparotomy.

      What structures are likely to be affected based on this diagnosis?

      Your Answer:

      Correct Answer: Distal third of colon and the rectum superior to pectinate line

      Explanation:

      The inferior mesenteric artery is responsible for supplying blood to the hindgut, which includes the distal third of the colon and the rectum superior to the pectinate line. In this case, the patient’s sudden onset of severe abdominal pain and history of atrial fibrillation suggest acute mesenteric ischemia, with the affected artery being the inferior mesenteric artery. Therefore, if a thrombus were to block this artery, the distal third of the colon and superior rectum would experience ischaemic changes. It is important to note that the ascending colon, caecum, ileum, appendix, greater omentum, and stomach are supplied by different arteries and would not be affected by a thrombus in the inferior mesenteric artery.

      The Inferior Mesenteric Artery: Supplying the Hindgut

      The inferior mesenteric artery (IMA) is responsible for supplying the embryonic hindgut with blood. It originates just above the aortic bifurcation, at the level of L3, and passes across the front of the aorta before settling on its left side. At the point where the left common iliac artery is located, the IMA becomes the superior rectal artery.

      The hindgut, which includes the distal third of the colon and the rectum above the pectinate line, is supplied by the IMA. The left colic artery is one of the branches that emerges from the IMA near its origin. Up to three sigmoid arteries may also exit the IMA to supply the sigmoid colon further down the line.

      Overall, the IMA plays a crucial role in ensuring that the hindgut receives the blood supply it needs to function properly. Its branches help to ensure that the colon and rectum are well-nourished and able to carry out their important digestive functions.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 11 - Which symptom is the least common in individuals with pancreatic cancer? ...

    Incorrect

    • Which symptom is the least common in individuals with pancreatic cancer?

      Your Answer:

      Correct Answer: Hyperamylasaemia

      Explanation:

      Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. The majority of pancreatic tumors are adenocarcinomas and are typically found in the head of the pancreas. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and mutations in the BRCA2 and KRAS genes.

      Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, and pruritus. Courvoisier’s law states that a palpable gallbladder is unlikely to be due to gallstones in the presence of painless obstructive jaundice. However, patients often present with non-specific symptoms such as anorexia, weight loss, and epigastric pain. Loss of exocrine and endocrine function can also occur, leading to steatorrhea and diabetes mellitus. Atypical back pain and migratory thrombophlebitis (Trousseau sign) are also common.

      Ultrasound has a sensitivity of around 60-90% for detecting pancreatic cancer, but high-resolution CT scanning is the preferred diagnostic tool. The ‘double duct’ sign, which is the simultaneous dilatation of the common bile and pancreatic ducts, may be seen on imaging.

      Less than 20% of patients with pancreatic cancer are suitable for surgery at the time of diagnosis. A Whipple’s resection (pancreaticoduodenectomy) may be performed for resectable lesions in the head of the pancreas, but side-effects such as dumping syndrome and peptic ulcer disease can occur. Adjuvant chemotherapy is typically given following surgery, and ERCP with stenting may be used for palliation.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 12 - A 67-year-old woman visits her GP after discovering a lump in her groin...

    Incorrect

    • A 67-year-old woman visits her GP after discovering a lump in her groin subsequent to relocating. The patient reports that she can push the lump back in, but it returns when she coughs. During the examination, the GP identifies the lump located superior and medial to the pubic tubercle. The GP reduces the lump, applies pressure to the midpoint of the inguinal ligament, and instructs the patient to cough. The lump reappears, leading the GP to tentatively diagnose the patient with a direct inguinal hernia. Through which anatomical structures will the hernia pass?

      Your Answer:

      Correct Answer: Transversalis fascia and superficial inguinal ring

      Explanation:

      The correct structures for a direct inguinal hernia to pass through are the transversalis fascia (which forms the posterior wall of the inguinal canal) and the superficial ring. If the hernia were to pass through other structures, such as the deep inguinal ring, it would reappear upon increased intra-abdominal pressure. In contrast, an indirect inguinal hernia enters the canal through the deep inguinal ring and exits at the superficial ring, so it would not reappear if the deep inguinal ring were blocked.

      The inguinal canal is located above the inguinal ligament and measures 4 cm in length. Its superficial ring is situated in front of the pubic tubercle, while the deep ring is found about 1.5-2 cm above the halfway point between the anterior superior iliac spine and the pubic tubercle. The canal is bounded by the external oblique aponeurosis, inguinal ligament, lacunar ligament, internal oblique, transversus abdominis, external ring, and conjoint tendon. In males, the canal contains the spermatic cord and ilioinguinal nerve, while in females, it houses the round ligament of the uterus and ilioinguinal nerve.

      The boundaries of Hesselbach’s triangle, which are frequently tested, are located in the inguinal region. Additionally, the inguinal canal is closely related to the vessels of the lower limb, which should be taken into account when repairing hernial defects in this area.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 13 - Sophie presents acutely to the hospital with severe epigastric pain that is radiating...

    Incorrect

    • Sophie presents acutely to the hospital with severe epigastric pain that is radiating to the back, nausea and vomiting. Upon questioning, she has suffered from several episodes of biliary colic in the past. A blood test reveals a lipase level of 1000U/L.

      What is the underlying pathophysiology of Sophie's condition?

      Your Answer:

      Correct Answer: Pancreatic enzymes released as a result of inflammation autodigest the pancreatic tissue

      Explanation:

      The cause of acute pancreatitis is the autodigestion of pancreatic tissue by pancreatic enzymes, which results in tissue necrosis. The patient is experiencing typical symptoms of acute pancreatitis, including epigastric pain that radiates to the back, nausea, and vomiting. The presence of elevated lipase levels, which are more than three times the upper limit of normal, is also indicative of acute pancreatitis. The patient’s history of biliary colic suggests that gallstones may be the underlying cause of this condition.

      During acute pancreatitis, inflammation of the pancreas triggers the release and activation of pancreatic enzymes, which then begin to digest the pancreatic tissue. This process is known as autodigestion. Autodigestion of fat can lead to tissue necrosis, while autodigestion of blood vessels can cause retroperitoneal hemorrhage, which can be identified by the presence of Grey Turner’s sign and Cullen’s sign.

      Understanding Acute Pancreatitis

      Acute pancreatitis is a condition that is commonly caused by alcohol or gallstones. It occurs when the pancreatic enzymes start to digest the pancreatic tissue, leading to necrosis. The most common symptom of acute pancreatitis is severe epigastric pain that may radiate through to the back. Vomiting is also common, and examination may reveal epigastric tenderness, ileus, and low-grade fever. Although rare, periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) may also be present.

      To diagnose acute pancreatitis, doctors typically measure the levels of serum amylase and lipase in the blood. While amylase is raised in 75% of patients, it does not correlate with disease severity. Lipase, on the other hand, is more sensitive and specific than amylase and has a longer half-life, making it useful for late presentations. Imaging, such as ultrasound or contrast-enhanced CT, may also be necessary to assess the aetiology of the condition.

      Scoring systems, such as the Ranson score, Glasgow score, and APACHE II, are used to identify cases of severe pancreatitis that may require intensive care management. Factors indicating severe pancreatitis include age over 55 years, hypocalcaemia, hyperglycaemia, hypoxia, neutrophilia, and elevated LDH and AST. However, the actual amylase level is not of prognostic value.

      In summary, acute pancreatitis is a condition that can cause severe pain and discomfort. It is important to diagnose and manage it promptly to prevent complications.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 14 - A healthy 56-year-old woman attends her flexible sigmoidoscopy as part of the UK's...

    Incorrect

    • A healthy 56-year-old woman attends her flexible sigmoidoscopy as part of the UK's national screening program. While performing the procedure, the surgeon observes and biopsies several polyps for further analysis. Additionally, the patient has multiple hyperpigmented macules on her lips.

      During her follow-up visit, the patient is informed that the type of polyp found in her bowel increases her risk of developing cancers in other parts of her body.

      What is the name of the benign colorectal tumor that the patient has?

      Your Answer:

      Correct Answer: Peutz-Jeghers polyps

      Explanation:

      Understanding Peutz-Jeghers Syndrome

      Peutz-Jeghers syndrome is a genetic condition that is inherited in an autosomal dominant manner. It is characterized by the presence of numerous hamartomatous polyps in the gastrointestinal tract, particularly in the small bowel. In addition, patients with this syndrome may also have pigmented freckles on their lips, face, palms, and soles.

      While the polyps themselves are not cancerous, individuals with Peutz-Jeghers syndrome have an increased risk of developing other types of gastrointestinal tract cancers. In fact, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.

      Common symptoms of Peutz-Jeghers syndrome include small bowel obstruction, which is often due to intussusception, as well as gastrointestinal bleeding. Management of this condition is typically conservative unless complications develop. It is important for individuals with Peutz-Jeghers syndrome to undergo regular screening and surveillance to detect any potential cancerous growths early on.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 15 - A 45-year-old man presents to the surgical team with abdominal pain, bloating, and...

    Incorrect

    • A 45-year-old man presents to the surgical team with abdominal pain, bloating, and vomiting. Based on an abdominal x-ray, there is suspicion of a malignancy causing intestinal obstruction. Which of the following antiemetics should be avoided for managing the patient's vomiting?

      Your Answer:

      Correct Answer: Metoclopramide

      Explanation:

      It is not recommended to use metoclopramide as an antiemetic in cases of bowel obstruction. This is because metoclopramide works by blocking dopamine receptors and stimulating peripheral 5HT3 receptors, which promote gastric emptying. However, in cases of intestinal obstruction, gastric emptying is not possible and this effect can be harmful. The choice of antiemetic should be based on the patient’s individual needs and the underlying cause of their nausea.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 16 - A 47-year-old woman presents to the out of hours GP service with abdominal...

    Incorrect

    • A 47-year-old woman presents to the out of hours GP service with abdominal pain. She has suffered from 'heartburn' for many years but for the last 6 months she has started getting a different kind of pain, which she describes as 'stabbing'. When asked where she feels it, the patient points to below her right breast. The pain has been occurring more frequently and with greater severity over the last 3 weeks, and tonight it is unbearable. It tends to come on shortly after she has eaten, and lasts up to 3 hours. She denies constipation, diarrhoea and vomiting, although she feels nauseated. She reports 'a couple of pounds' weight loss over the last few weeks because she has been eating less to avoid the pain.

      On examination her abdomen is soft but very tender in the right upper quadrant, with a positive Murphy's sign. She is afebrile and normotensive.

      What is the most likely cause of the patient's presentation?

      Your Answer:

      Correct Answer: Biliary colic

      Explanation:

      Biliary colic can be characterized by pain that occurs after eating, especially after consuming high-fat meals. The patient’s symptoms are consistent with this type of pain. However, if the patient were experiencing ascending cholangitis, they would likely be more acutely ill and have a fever. Duodenal ulcers can also cause upper abdominal pain, but the pain tends to be constant, gnawing, and centralized, and may differ with eating. If the ulcer bleeds, the patient may experience haematemesis or melaena. Although the patient reports experiencing heartburn, their current presentation is more indicative of biliary colic than gastro-oesophageal reflux disease.

      Understanding Biliary Colic and Gallstone-Related Disease

      Biliary colic is a condition that occurs when gallstones pass through the biliary tree. It is more common in women, especially those who are obese, fertile, or over the age of 40. Other risk factors include diabetes, Crohn’s disease, rapid weight loss, and certain medications. Biliary colic is caused by an increase in cholesterol, a decrease in bile salts, and biliary stasis. The pain is due to the gallbladder contracting against a stone lodged in the cystic duct. Symptoms include colicky right upper quadrant abdominal pain, nausea, and vomiting. Unlike other gallstone-related conditions, there is no fever or abnormal liver function tests.

      Ultrasound is the preferred diagnostic tool for biliary colic. Elective laparoscopic cholecystectomy is the recommended treatment. However, around 15% of patients may have gallstones in the common bile duct at the time of surgery, which can lead to obstructive jaundice. Other complications of gallstone-related disease include acute cholecystitis, ascending cholangitis, acute pancreatitis, gallstone ileus, and gallbladder cancer. It is important to understand the risk factors, pathophysiology, and management of biliary colic and gallstone-related disease to ensure prompt diagnosis and appropriate treatment.

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      • Gastrointestinal System
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  • Question 17 - A 78-year-old man is brought to the emergency department after a fall and...

    Incorrect

    • A 78-year-old man is brought to the emergency department after a fall and is diagnosed with self-neglect. He reports experiencing fatigue, paraesthesia in his lower limbs, and overall muscle weakness that is more pronounced in his legs for the past 3 months. He has been finding it difficult to carry out his daily activities, especially cooking, due to his inability to stand for long periods of time.

      What vitamin deficiency is most likely causing his symptoms?

      Your Answer:

      Correct Answer: Vitamin B12

      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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      • Gastrointestinal System
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  • Question 18 - A 75-year-old man has been experiencing abdominal discomfort and distension for the past...

    Incorrect

    • A 75-year-old man has been experiencing abdominal discomfort and distension for the past two days. He has not had a bowel movement in a week and has not passed gas in two days. He seems sluggish and has a temperature of 35.5°C. His pulse is 56 BPM, and his abdomen is not tender. An X-ray of his abdomen reveals enlarged loops of both small and large bowel. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Pseudo-obstruction

      Explanation:

      Pseudo-Obstruction and its Causes

      Pseudo-obstruction is a condition that can be caused by various factors, including hypothyroidism, hypokalaemia, diabetes, uraemia, and hypocalcaemia. In the case of hypothyroidism, the slowness and hypothermia of the patient suggest that this may be the underlying cause of the pseudo-obstruction. However, other factors should also be considered.

      It is important to note that pseudo-obstruction is a condition that affects the digestive system, specifically the intestines. It is characterized by symptoms that mimic those of a bowel obstruction, such as abdominal pain, bloating, and constipation. However, unlike a true bowel obstruction, there is no physical blockage in the intestines.

      To diagnose pseudo-obstruction, doctors may perform various tests, including X-rays, CT scans, and blood tests. Treatment options may include medications to stimulate the intestines, changes in diet, and surgery in severe cases.

      Overall, it is important to identify the underlying cause of pseudo-obstruction in order to provide appropriate treatment and management of the condition.

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      • Gastrointestinal System
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  • Question 19 - Which of the following hepatobiliary conditions is commonly linked with ulcerative colitis, typically...

    Incorrect

    • Which of the following hepatobiliary conditions is commonly linked with ulcerative colitis, typically seen in adult patients?

      Your Answer:

      Correct Answer: Primary sclerosing cholangitis

      Explanation:

      The risk of developing liver cancer is higher in patients with primary sclerosing cholangitis (PSC) and ulcerative colitis. However, the risk of malignant transformation is not increased in patients with Crohn’s disease. Impaired entero-hepatic circulation in Crohn’s disease is linked to the development of gallstones. Unlike PSC, ulcerative colitis does not elevate the risk of other liver lesions.

      Understanding Ulcerative Colitis

      Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation in the rectum and spreads continuously without going beyond the ileocaecal valve. It is most commonly seen in people aged 15-25 years and 55-65 years. The symptoms of ulcerative colitis are insidious and intermittent, including bloody diarrhea, urgency, tenesmus, abdominal pain, and extra-intestinal features. Diagnosis is done through colonoscopy and biopsy, but in severe cases, a flexible sigmoidoscopy is preferred to avoid the risk of perforation. The typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa, and inflammatory cell infiltrate in lamina propria. Extra-intestinal features of inflammatory bowel disease include arthritis, erythema nodosum, episcleritis, osteoporosis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis. Ulcerative colitis is linked with sacroiliitis, and a barium enema can show the whole colon affected by an irregular mucosa with loss of normal haustral markings.

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      • Gastrointestinal System
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  • Question 20 - On examining the caecum, what structure is most likely to be detected at...

    Incorrect

    • On examining the caecum, what structure is most likely to be detected at the point where all the tenia coli converge?

      Your Answer:

      Correct Answer: Appendix base

      Explanation:

      The tenia coli come together at the bottom of the appendix.

      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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  • Question 21 - During a ward round on the gastroenterology ward, you assess a 75-year-old man...

    Incorrect

    • During a ward round on the gastroenterology ward, you assess a 75-year-old man with a history of hepatocellular carcinoma. He spent most of his life in Pakistan, where he consumed a diet high in grains and chicken. He has never contracted a hepatitis virus. Despite being a non-smoker, he has resided in a household where other inhabitants smoke indoors for the majority of his adult life.

      What is the potential risk factor for hepatocellular carcinoma that this patient may have been exposed to?

      Your Answer:

      Correct Answer: Aflatoxin

      Explanation:

      Hepatocellular carcinoma is commonly caused by chronic hepatitis B infection worldwide and chronic hepatitis C infection in Europe. However, there are other significant risk factors to consider, such as aflatoxins. These toxic carcinogens are produced by certain types of mold and can be found in improperly stored grains and seeds. While Caroli’s disease and primary sclerosing cholangitis are risk factors for cholangiocarcinoma, they are less significant for hepatocellular carcinoma.

      Hepatocellular carcinoma (HCC) is a type of cancer that ranks third in terms of prevalence worldwide. The most common cause of HCC globally is chronic hepatitis B, while chronic hepatitis C is the leading cause in Europe. The primary risk factor for developing HCC is liver cirrhosis, which can result from various factors such as hepatitis B & C, alcohol, haemochromatosis, and primary biliary cirrhosis. Other risk factors include alpha-1 antitrypsin deficiency, hereditary tyrosinosis, glycogen storage disease, aflatoxin, certain drugs, porphyria cutanea tarda, male sex, diabetes mellitus, and metabolic syndrome.

      HCC often presents late and may exhibit features of liver cirrhosis or failure such as jaundice, ascites, RUQ pain, hepatomegaly, pruritus, and splenomegaly. In some cases, it may manifest as decompensation in patients with chronic liver disease. Elevated levels of alpha-fetoprotein (AFP) are also common. High-risk groups such as patients with liver cirrhosis secondary to hepatitis B & C or haemochromatosis, and men with liver cirrhosis secondary to alcohol should undergo screening with ultrasound (+/- AFP).

      Management options for early-stage HCC include surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolisation, and sorafenib, a multikinase inhibitor. Proper management and early detection are crucial in improving the prognosis of HCC.

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  • Question 22 - Mrs. Smith is a 75-year-old woman who has been admitted with pneumonia. She...

    Incorrect

    • Mrs. Smith is a 75-year-old woman who has been admitted with pneumonia. She is frail and receiving antibiotics and fluids intravenously. She has no appetite and a Speech And Language Therapy (SALT) review concludes she is at risk of aspiration.

      Her past medical history includes hypertension and angina.

      What would be the most appropriate nutritional support option for Mrs. Smith?

      Your Answer:

      Correct Answer: Nasogastric tube (NG tube)

      Explanation:

      NICE Guidelines for Parenteral Nutrition

      Parenteral nutrition is a method of feeding that involves delivering nutrients directly into the bloodstream through a vein. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the use of parenteral nutrition in patients who are malnourished or at risk of malnutrition.

      To identify patients who are malnourished, healthcare professionals should look for a BMI of less than 18.5 kg/m2, unintentional weight loss of more than 10% over 3-6 months, or a BMI of less than 20 kg/m2 with unintentional weight loss of more than 5% over 3-6 months. Patients who have eaten little or nothing for more than 5 days, have poor absorptive capacity, high nutrient losses, or high metabolism are also at risk of malnutrition.

      If a patient has unsafe or inadequate oral intake or a non-functional gastrointestinal tract, perforation, or inaccessible GI tract, healthcare professionals should consider parenteral nutrition. For feeding periods of less than 14 days, feeding via a peripheral venous catheter is recommended. For feeding periods of more than 30 days, a tunneled subclavian line is recommended. Continuous administration is recommended for severely unwell patients, but if feed is needed for more than 2 weeks, healthcare professionals should consider changing from continuous to cyclical feeding. In the first 24-48 hours, no more than 50% of the daily regime should be given to unwell patients.

      For surgical patients who are malnourished with an unsafe swallow or non-functional GI tract, perforation, or inaccessible GI tract, perioperative parenteral feeding should be considered.

      Overall, these guidelines provide healthcare professionals with a framework for identifying patients who may benefit from parenteral nutrition and the appropriate methods for administering it.

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  • Question 23 - Which one of the following statements relating to the greater omentum is false?...

    Incorrect

    • Which one of the following statements relating to the greater omentum is false?

      Your Answer:

      Correct Answer: It has no relationship to the lesser sac.

      Explanation:

      This area is linked to the transverse colon and the lesser sac, and is often accessed during a colonic resection. It is also frequently affected by metastasis in various types of visceral cancers.

      The Omentum: A Protective Structure in the Abdomen

      The omentum is a structure in the abdomen that invests the stomach and is divided into two parts: the greater and lesser omentum. The greater omentum is attached to the lower lateral border of the stomach and contains the gastro-epiploic arteries. It varies in size and is less developed in children. However, it plays an important role in protecting against visceral perforation, such as in cases of appendicitis.

      The lesser omentum is located between the omentum and transverse colon, providing a potential entry point into the lesser sac. Malignant processes can affect the omentum, with ovarian cancer being the most notable. Overall, the omentum is a crucial structure in the abdomen that serves as a protective barrier against potential injuries and diseases.

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      • Gastrointestinal System
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  • Question 24 - A 56-year-old man presents to the emergency department with profuse haematemesis. Upon admission,...

    Incorrect

    • A 56-year-old man presents to the emergency department with profuse haematemesis. Upon admission, his vital signs include a temperature of 36.9ºC, oxygen saturation of 94% on air, heart rate of 124 beats per minute, respiratory rate of 26 breaths per minute, and blood pressure of 82/58 mmHg. An urgent endoscopy was performed to achieve haemostasis, revealing an ulcer on the posterior wall of the duodenum. Which artery is the most likely source of the gastrointestinal bleed?

      Your Answer:

      Correct Answer: Gastroduodenal artery

      Explanation:

      Duodenal ulcers on the posterior wall pose a risk to the gastroduodenal artery, which supplies blood to this area. The posterior wall is a common site for duodenal ulcers, and erosion of the ulcer through the duodenal wall can result in severe upper gastrointestinal bleeding. The inferior mesenteric artery, on the other hand, supplies blood to the hindgut (transverse colon, descending colon, and sigmoid colon) and does not include the duodenum. The inferior pancreaticoduodenal artery, which arises from the superior mesenteric artery, supplies the lower part of the duodenum but does not provide the majority of the blood supply to the posterior duodenal wall, which is mainly supplied by the gastroduodenal artery.

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The main symptoms include haematemesis (vomiting of blood), melena (passage of altered blood per rectum), and a raised urea level due to the protein meal of the blood. The diagnosis can be determined by identifying the specific features associated with a particular condition, such as stigmata of chronic liver disease for oesophageal varices or abdominal pain for peptic ulcer disease.

      The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes. Oesophageal varices may present with a large volume of fresh blood, while gastric ulcers may cause low volume bleeds that present as iron deficiency anaemia. Duodenal ulcers are usually posteriorly sited and may erode the gastroduodenal artery. Aorto-enteric fistula is a rare but important cause of major haemorrhage associated with high mortality in patients with previous abdominal aortic aneurysm surgery.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation involves ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours. Treatment options include repeat endoscopy, interventional radiology, and surgery for non-variceal bleeding, while terlipressin and prophylactic antibiotics should be given to patients with variceal bleeding. Band ligation should be used for oesophageal varices, and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

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  • Question 25 - A 57-year-old man with a history of hyperlipidemia, hypertension, and type II diabetes...

    Incorrect

    • A 57-year-old man with a history of hyperlipidemia, hypertension, and type II diabetes presents to the emergency department with dull chest pain accompanied by sweating and nausea. He is promptly administered oxygen, aspirin, morphine, metoclopramide, atenolol, and nitrates.

      Upon examination, angiography reveals significant blockage in all four coronary vessels. As a result, he is scheduled for an urgent coronary artery bypass graft, which will necessitate the removal of a vein from his lower limb.

      Which nerve is most frequently affected during a vein harvest for CABG?

      Your Answer:

      Correct Answer: Saphenous nerve

      Explanation:

      During a coronary artery bypass graft (CABG), the great saphenous vein is often harvested. However, this procedure can lead to damage of the saphenous nerve, which runs closely alongside the vein in the medial aspect of the leg. Saphenous neuralgia, characterized by numbness, heightened sensitivity, and pain in the saphenous nerve distribution area, can result from such injury. Other nerves are not typically affected during a vein harvest for CABG.

      During surgical procedures, there is a risk of nerve injury caused by the surgery itself. This is not only important for the patient’s well-being but also from a legal perspective. There are various operations that carry the risk of nerve damage, such as posterior triangle lymph node biopsy, Lloyd Davies stirrups, thyroidectomy, anterior resection of rectum, axillary node clearance, inguinal hernia surgery, varicose vein surgery, posterior approach to the hip, and carotid endarterectomy. Surgeons must have a good understanding of the anatomy of the area they are operating on to minimize the incidence of nerve lesions. Blind placement of haemostats is not recommended as it can also cause nerve damage.

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      • Gastrointestinal System
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  • Question 26 - A 30-year-old male presents to the emergency department after vomiting blood. He had...

    Incorrect

    • A 30-year-old male presents to the emergency department after vomiting blood. He had been out drinking heavily with friends and had vomited multiple times, with the last episode containing a significant amount of blood.

      Upon examination, the patient appeared intoxicated and had a pulse of 96 bpm and a blood pressure of 120/74 mmHg. Abdominal examination revealed no abnormalities.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Mallory-Weiss tear

      Explanation:

      Mallory Weiss Tear and Alcoholic Gastritis

      Repeated episodes of vomiting due to alcohol consumption can lead to a Mallory Weiss tear, which is a mucosal tear in the esophagus. This tear can cause hematemesis, which is vomiting of blood. This is a common occurrence in habitual drinkers who suffer from alcoholic gastritis. Along with upper abdominal pain, this condition can cause a rise in esophageal pressures, leading to mucosal tears. However, most patients only lose small amounts of blood, and symptoms can often be resolved with minimal intervention. It is important to seek medical attention if symptoms persist or worsen.

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  • Question 27 - A 49-year-old woman experiences jaundice and undergoes an ERCP. After 36 hours, she...

    Incorrect

    • A 49-year-old woman experiences jaundice and undergoes an ERCP. After 36 hours, she develops a fever and rigors. What organism is most likely to be cultured from her blood sample?

      Your Answer:

      Correct Answer: Escherichia coli

      Explanation:

      A surgical emergency is indicated when Charcot’s triad is present. Patients require biliary decompression and administration of broad-spectrum antibiotics. The most frequently identified organism in cholangitis infections is E. coli, with enterobacter being a less common finding.

      Ascending Cholangitis: A Bacterial Infection of the Biliary Tree

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. The primary risk factor for this condition is gallstones. Patients with ascending cholangitis may experience Charcot’s triad, which includes fever, jaundice, and right upper quadrant pain. However, this triad is only present in 20-50% of cases. Fever is the most common symptom, occurring in 90% of patients, followed by RUQ pain (70%) and jaundice (60%). In some cases, patients may also experience hypotension and confusion, which, when combined with the other three symptoms, makeup Reynolds’ pentad.

      In addition to the above symptoms, patients with ascending cholangitis may also have raised inflammatory markers. Ultrasound is typically the first-line investigation used to diagnose this condition. It is used to look for bile duct dilation and stones.

      The management of ascending cholangitis involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction. By understanding the symptoms and risk factors associated with ascending cholangitis, healthcare providers can diagnose and treat this condition promptly, reducing the risk of complications.

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  • Question 28 - An 80-year-old male with Parkinson's disease (PD) arrives at the emergency department with...

    Incorrect

    • An 80-year-old male with Parkinson's disease (PD) arrives at the emergency department with sudden chest pain, indicating a possible heart attack. What treatment should be avoided in the management of this patient?

      Your Answer:

      Correct Answer: Metoclopramide

      Explanation:

      Metoclopramide should not be given to patients with Parkinsonism due to its dopamine antagonist properties which can worsen the symptoms of the disease. However, it can be prescribed as an antiemetic when administering morphine to ACS patients who are not contraindicated. Oxygen is safe for PD patients, while clopidogrel is used for its antiplatelet effects.

      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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      • Gastrointestinal System
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  • Question 29 - A 55-year-old male has been diagnosed with a transverse colon carcinoma. What is...

    Incorrect

    • A 55-year-old male has been diagnosed with a transverse colon carcinoma. What is the recommended structure to ligate near its origin for optimal tumor clearance?

      Your Answer:

      Correct Answer: Middle colic artery

      Explanation:

      During cancer resections, the transverse colon is supplied by the middle colic artery, which is a branch of the superior mesenteric artery and requires ligation at a high level.

      The Transverse Colon: Anatomy and Relations

      The transverse colon is a part of the large intestine that begins at the hepatic flexure, where the right colon makes a sharp turn. At this point, it becomes intraperitoneal and is connected to the inferior border of the pancreas by the transverse mesocolon. The middle colic artery and vein are contained within the mesentery. The greater omentum is attached to the superior aspect of the transverse colon, which can be easily separated. The colon undergoes another sharp turn at the splenic flexure, where the greater omentum remains attached up to this point. The distal 1/3 of the transverse colon is supplied by the inferior mesenteric artery.

      The transverse colon is related to various structures. Superiorly, it is in contact with the liver, gallbladder, the greater curvature of the stomach, and the lower end of the spleen. Inferiorly, it is related to the small intestine. Anteriorly, it is in contact with the greater omentum, while posteriorly, it is in contact with the descending portion of the duodenum, the head of the pancreas, convolutions of the jejunum and ileum, and the spleen. Understanding the anatomy and relations of the transverse colon is important for medical professionals in diagnosing and treating various gastrointestinal conditions.

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  • Question 30 - A 32-year-old male has been diagnosed with a carcinoid tumor in his appendix....

    Incorrect

    • A 32-year-old male has been diagnosed with a carcinoid tumor in his appendix. Which of the substances listed below would be useful for monitoring during his follow-up?

      Your Answer:

      Correct Answer: Chromogranin A

      Explanation:

      Differentiating between blood and urine tests for carcinoid syndrome is crucial. Chromogranin A, neuron-specific enolase (NSE), substance P, and gastrin are typically measured in blood tests, while urine tests typically measure 5 HIAA, a serotonin metabolite. Occasionally, blood tests for serotonin (5 hydroxytryptamine) may also be conducted.

      Carcinoid tumours are a type of cancer that can cause a condition called carcinoid syndrome. This syndrome typically occurs when the cancer has spread to the liver and releases serotonin into the bloodstream. In some cases, it can also occur with lung carcinoid tumours, as the mediators are not cleared by the liver. The earliest symptom of carcinoid syndrome is often flushing, but it can also cause diarrhoea, bronchospasm, hypotension, and right heart valvular stenosis (or left heart involvement in bronchial carcinoid). Additionally, other molecules such as ACTH and GHRH may be secreted, leading to conditions like Cushing’s syndrome. Pellagra, a rare condition caused by a deficiency in niacin, can also develop as the tumour diverts dietary tryptophan to serotonin.

      To investigate carcinoid syndrome, doctors may perform a urinary 5-HIAA test or a plasma chromogranin A test. Treatment for the condition typically involves somatostatin analogues like octreotide, which can help manage symptoms like diarrhoea. Cyproheptadine may also be used to alleviate diarrhoea. Overall, early detection and treatment of carcinoid tumours can help prevent the development of carcinoid syndrome and improve outcomes for patients.

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