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  • Question 1 - A 25-year-old female presents to her GP with a 3-month history of bloating....

    Incorrect

    • A 25-year-old female presents to her GP with a 3-month history of bloating. She has tried excluding nightshades from her diet which provided some relief but her symptoms persist. Upon further questioning, she reports a lifelong feeling of incomplete bowel emptying after defecation. This symptom was previously investigated with endoscopy and biopsies, but no definitive diagnosis was made.

      Additionally, she reports the presence of mucus in her stool and intermittent abdominal pain. She has no significant medical history or regular medications, but does have a peanut allergy. Her mother has coeliac disease and her father has type 2 diabetes which is managed with insulin.

      What is the most likely diagnosis for this patient?

      Your Answer: Inflammatory bowel disease

      Correct Answer: Irritable bowel syndrome

      Explanation:

      Diagnosis and Management of Irritable Bowel Syndrome

      Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects many people. To diagnose IBS, a patient must have experienced abdominal pain, bloating, or a change in bowel habit for at least six months. A positive diagnosis of IBS is made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to two of the following four symptoms: altered stool passage, abdominal bloating, symptoms made worse by eating, and passage of mucus. Other features such as lethargy, nausea, backache, and bladder symptoms may also support the diagnosis.

      It is important to enquire about red flag features such as rectal bleeding, unexplained/unintentional weight loss, family history of bowel or ovarian cancer, and onset after 60 years of age. Primary care investigations such as a full blood count, ESR/CRP, and coeliac disease screen (tissue transglutaminase antibodies) are suggested. The National Institute for Health and Care Excellence (NICE) published clinical guidelines on the diagnosis and management of IBS in 2008 to help healthcare professionals provide the best care for patients with this condition.

    • This question is part of the following fields:

      • Gastrointestinal System
      60.4
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  • Question 2 - A 12-year-old boy presents to the emergency department with complaints of central abdominal...

    Correct

    • A 12-year-old boy presents to the emergency department with complaints of central abdominal pain that has shifted to the right iliac fossa. Upon examination, there are no indications of rebound tenderness or guarding.

      What is the most probable diagnosis, and how would you describe the pathophysiology of the condition?

      Your Answer: Obstruction of the appendiceal lumen due to lymphoid hyperplasia or faecolith

      Explanation:

      The pathophysiology of appendicitis involves obstruction of the appendiceal lumen, which is commonly caused by lymphoid hyperplasia or a faecolith. This condition is most prevalent in young individuals aged 10-20 years and is the most common acute abdominal condition requiring surgery. Blood clots are not a typical cause of appendiceal obstruction, but foreign bodies and worms can also contribute to this condition.

      Pancreatitis can lead to autodigestion in the pancreas, while autoimmune destruction of the pancreas is responsible for type 1 diabetes. Symptoms of type 1 diabetes, which typically develops at a younger age than type 2 diabetes, include polydipsia and polyuria.

      Acute appendicitis is a common condition that requires surgery and can occur at any age, but is most prevalent in young people aged 10-20 years. The pathogenesis of acute appendicitis involves lymphoid hyperplasia or a faecolith, which leads to obstruction of the appendiceal lumen. This obstruction causes gut organisms to invade the appendix wall, resulting in oedema, ischaemia, and possibly perforation.

      The most common symptom of acute appendicitis is abdominal pain, which is typically peri-umbilical and radiates to the right iliac fossa due to localised peritoneal inflammation. Other symptoms include mild pyrexia, anorexia, and nausea. Examination may reveal generalised or localised peritonism, rebound and percussion tenderness, guarding and rigidity, and classical signs such as Rovsing’s sign and psoas sign.

      Diagnosis of acute appendicitis is typically based on raised inflammatory markers and compatible history and examination findings. Imaging may be used in certain cases, such as ultrasound in females where pelvic organ pathology is suspected. Management of acute appendicitis involves appendicectomy, which can be performed via an open or laparoscopic approach. Patients with perforated appendicitis require copious abdominal lavage, while those without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy. Intravenous antibiotics alone have been trialled as a treatment for appendicitis, but evidence suggests that this is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

    • This question is part of the following fields:

      • Gastrointestinal System
      62.7
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  • Question 3 - Lila, a 7-year-old girl, undergoes surgery to correct an inguinal hernia. During the...

    Correct

    • Lila, a 7-year-old girl, undergoes surgery to correct an inguinal hernia. During the operation, how can the surgeon confirm that Lila has an indirect hernia?

      Your Answer: Indirect hernia is lateral to the epigastric vessels

      Explanation:

      An indirect inguinal hernia is situated on the lateral side of the epigastric vessels. This type of hernia occurs when the processus vaginalis fails to close properly, causing a protrusion through the deep inguinal ring and into the inguinal canal. In males, the hernia may extend into the scrotum, while in females, it may extend into the labia. On the other hand, a direct inguinal hernia is caused by weakened abdominal muscles, typically occurring in older individuals. The protrusion enters the inguinal canal through the posterior wall, which is located on the medial side of the epigastric vessels. It may then exit through the superficial inguinal ring.

      Understanding Inguinal Hernias

      Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main symptom is a lump in the groin area, which disappears when pressure is applied or when the patient lies down. Discomfort and aching are also common, especially during physical activity. However, severe pain is rare, and strangulation is even rarer.

      The traditional classification of inguinal hernias into indirect and direct types is no longer relevant in clinical management. Instead, the current consensus is to treat medically fit patients, even if they are asymptomatic. A hernia truss may be an option for those who are not fit for surgery, but it has limited use in other patients. Mesh repair is the preferred method, as it has the lowest recurrence rate. Unilateral hernias are usually repaired through an open approach, while bilateral and recurrent hernias are repaired laparoscopically.

      After surgery, patients are advised to return to non-manual work after 2-3 weeks for open repair and 1-2 weeks for laparoscopic repair. Complications may include early bruising and wound infection, as well as late chronic pain and recurrence. It is important to seek medical attention if any of these symptoms occur.

    • This question is part of the following fields:

      • Gastrointestinal System
      47.5
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  • Question 4 - A 50-year-old man arrives at the emergency department with complaints of a high...

    Incorrect

    • A 50-year-old man arrives at the emergency department with complaints of a high fever and flank pain. He reports experiencing mild burning during urination for the past 5 days, but his urine output has decreased since the onset of fever yesterday. The patient has a history of poorly controlled type II diabetes mellitus.

      Based on the probable diagnosis, which structure is at the highest risk of co-infection?

      Your Answer: Liver

      Correct Answer: Psoas muscle

      Explanation:

      The woman in the scenario is likely suffering from pyelonephritis, which is a result of a UTI. Her poorly controlled blood sugar levels due to diabetes make her more susceptible to recurrent UTIs. Since the kidneys are retroperitoneal organs, the infection can spread to other organs within that space. The psoas muscle, located at the back, can become co-infected with pyelonephritis, leading to the formation of an abscess. The symptoms of a psoas abscess may be minimal, and an MRI abdopelvis is the best imaging technique to detect it. Peritoneal structures are less likely to become infected, and peritonitis is usually caused by infected ascitic fluid, leading to Spontaneous Bacterial Peritonitis (SBP).

      The retroperitoneal structures are those that are located behind the peritoneum, which is the membrane that lines the abdominal cavity. These structures include the duodenum (2nd, 3rd, and 4th parts), ascending and descending colon, kidneys, ureters, aorta, and inferior vena cava. They are situated in the back of the abdominal cavity, close to the spine. In contrast, intraperitoneal structures are those that are located within the peritoneal cavity, such as the stomach, duodenum (1st part), jejunum, ileum, transverse colon, and sigmoid colon. It is important to note that the retroperitoneal structures are not well demonstrated in the diagram as the posterior aspect has been removed, but they are still significant in terms of their location and function.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 5 - Which one of the following is not a result of cholecystokinin? ...

    Correct

    • Which one of the following is not a result of cholecystokinin?

      Your Answer: It increases the rate of gastric emptying

      Explanation:

      The rate of gastric emptying is reduced.

      Understanding Gastric Secretions for Surgical Procedures

      A basic understanding of gastric secretions is crucial for surgeons, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Gastric acid, produced by the parietal cells in the stomach, has a pH of around 2 and is maintained by the H+/K+ ATPase pump. Sodium and chloride ions are actively secreted from the parietal cell into the canaliculus, creating a negative potential across the membrane. Carbonic anhydrase forms carbonic acid, which dissociates, and the hydrogen ions formed by dissociation leave the cell via the H+/K+ antiporter pump. This leaves hydrogen and chloride ions in the canaliculus, which mix and are secreted into the lumen of the oxyntic gland.

      There are three phases of gastric secretion: the cephalic phase, gastric phase, and intestinal phase. The cephalic phase is stimulated by the smell or taste of food and causes 30% of acid production. The gastric phase, which is caused by stomach distension, low H+, or peptides, causes 60% of acid production. The intestinal phase, which is caused by high acidity, distension, or hypertonic solutions in the duodenum, inhibits gastric acid secretion via enterogastrones and neural reflexes.

      The regulation of gastric acid production involves various factors that increase or decrease production. Factors that increase production include vagal nerve stimulation, gastrin release, and histamine release. Factors that decrease production include somatostatin, cholecystokinin, and secretin. Understanding these factors and their associated pharmacology is essential for surgeons.

      In summary, a working knowledge of gastric secretions is crucial for surgical procedures, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Understanding the phases of gastric secretion and the regulation of gastric acid production is essential for successful surgical outcomes.

    • This question is part of the following fields:

      • Gastrointestinal System
      57
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  • Question 6 - A 70-year-old male presents with abdominal pain.

    He has a past medical history...

    Incorrect

    • A 70-year-old male presents with abdominal pain.

      He has a past medical history of stroke and myocardial infarction. During examination, there was noticeable distension of the abdomen and the stools were maroon in color. The lactate level was found to be 5 mmol/L, which is above the normal range of <2.2 mmol/L.

      What is the most probable diagnosis for this patient?

      Your Answer: Ulcerative colitis

      Correct Answer: Acute mesenteric ischaemia

      Explanation:

      Acute Mesenteric Ischaemia

      Acute mesenteric ischaemia is a condition that occurs when there is a disruption in blood flow to the small intestine or right colon. This can be caused by arterial or venous disease, with arterial disease further classified as non-occlusive or occlusive. The classic triad of symptoms associated with acute mesenteric ischaemia includes gastrointestinal emptying, abdominal pain, and underlying cardiac disease.

      The hallmark symptom of mesenteric ischaemia is severe abdominal pain, which may be accompanied by other symptoms such as nausea, vomiting, abdominal distention, ileus, peritonitis, blood in the stool, and shock. Advanced ischaemia is characterized by the presence of these symptoms.

      There are several risk factors associated with acute mesenteric ischaemia, including congestive heart failure, cardiac arrhythmias (especially atrial fibrillation), recent myocardial infarction, atherosclerosis, hypercoagulable states, and hypovolaemia. It is important to be aware of these risk factors and to seek medical attention promptly if any symptoms of acute mesenteric ischaemia are present.

    • This question is part of the following fields:

      • Gastrointestinal System
      61
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  • Question 7 - A 63-year-old man arrives at the emergency department complaining of dizziness and haematemesis...

    Incorrect

    • A 63-year-old man arrives at the emergency department complaining of dizziness and haematemesis that started 2 hours ago. He has a medical history of hypertension and type 2 diabetes mellitus.

      The patient is stabilized after receiving 2 litres of normal saline for fluid resuscitation. The next day, a gastroscopy is performed, revealing a peptic ulcer that is no longer actively bleeding. The CLO test is positive, indicating the presence of the likely organism.

      What is the name of the enzyme secreted by this organism to aid its survival in the stomach?

      Your Answer: Beta-lactamase

      Correct Answer: Urease

      Explanation:

      Helicobacter pylori uses urease to survive in the stomach by neutralizing gastric acid. This enzyme produces ammonia, which creates a more suitable environment for bacterial growth. The patient’s CLO positive peptic ulcer is consistent with a Helicobacter pylori infection. It is important to note that Helicobacter pylori does not use arginase, beta-lactamase, protease, or trypsin to neutralize stomach acid.

      Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems

      Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.

      The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.

      The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 8 - A patient with gastric ulcers has been diagnosed with significantly low levels of...

    Correct

    • A patient with gastric ulcers has been diagnosed with significantly low levels of somatostatin. The medical consultant suspects that a particular type of cell found in both the pancreas and stomach is affected, leading to the disruption of somatostatin release.

      Which type of cell is impacted in this case?

      Your Answer: D cells

      Explanation:

      Somatostatin is released by D cells found in both the pancreas and stomach. These cells release somatostatin to inhibit the hormone gastrin and reduce gastric secretions. The patient’s low levels of somatostatin may have led to an increase in gastrin secretion and stomach acid, potentially causing gastric ulcers. G cells secrete gastrin, while parietal cells secrete gastric acid. Pancreatic cells is too general of a term and does not specify the specific type of cell responsible for somatostatin production.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 9 - A 25-year-old female has received a pan proctocolectomy and ileoanal pouch due to...

    Correct

    • A 25-year-old female has received a pan proctocolectomy and ileoanal pouch due to familial adenomatous polyposis coli. What is the most frequent non-colonic manifestation of this condition?

      Your Answer: Duodenal polyps

      Explanation:

      Polyposis syndromes are a group of genetic disorders that cause the development of multiple polyps in the colon and other parts of the gastrointestinal tract. These polyps can increase the risk of developing cancer, and therefore, early detection and management are crucial. There are several types of polyposis syndromes, each with its own genetic defect, features, and associated disorders.

      Familial adenomatous polyposis (FAP) is caused by a mutation in the APC gene and is characterized by the development of over 100 colonic adenomas, with a 100% risk of cancer. Screening and management involve regular colonoscopies and resectional surgery if polyps are found. FAP is also associated with gastric and duodenal polyps and abdominal desmoid tumors.

      MYH-associated polyposis is caused by a biallelic mutation of the MYH gene and is associated with multiple colonic polyps and an increased risk of right-sided cancers. Attenuated phenotype can be managed with regular colonoscopies, while resection and ileoanal pouch reconstruction are recommended for those with multiple polyps.

      Peutz-Jeghers syndrome is caused by a mutation in the STK11 gene and is characterized by multiple benign intestinal hamartomas, episodic obstruction, and an increased risk of GI cancers. Screening involves annual examinations and pan-intestinal endoscopy every 2-3 years.

      Cowden disease is caused by a mutation in the PTEN gene and is characterized by macrocephaly, multiple intestinal hamartomas, and an increased risk of cancer at any site. Targeted individualized screening is recommended, with extra surveillance for breast, thyroid, and uterine cancers.

      HNPCC (Lynch syndrome) is caused by germline mutations of DNA mismatch repair genes and is associated with an increased risk of colorectal, endometrial, and gastric cancers. Colonoscopies every 1-2 years from age 25 and consideration of prophylactic surgery are recommended, along with extra colonic surveillance.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 10 - What is not considered a risk factor for the development of oesophageal cancer?...

    Correct

    • What is not considered a risk factor for the development of oesophageal cancer?

      Your Answer: Blood group O

      Explanation:

      Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment

      Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus. The most common presenting symptom is dysphagia, followed by anorexia and weight loss, vomiting, and other possible features such as odynophagia, hoarseness, melaena, and cough.

      To diagnose oesophageal cancer, upper GI endoscopy with biopsy is used, and endoscopic ultrasound is preferred for locoregional staging. CT scanning of the chest, abdomen, and pelvis is used for initial staging, and FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans. Laparoscopy is sometimes performed to detect occult peritoneal disease.

      Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. In addition to surgical resection, many patients will be treated with adjuvant chemotherapy.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 11 - A 35-year-old patient with consistent PR bleeding is diagnosed with Crohn's disease. What...

    Correct

    • A 35-year-old patient with consistent PR bleeding is diagnosed with Crohn's disease. What is the primary medication used to induce remission of this condition?

      Your Answer: Prednisolone

      Explanation:

      To induce remission of Crohn’s disease, glucocorticoids (whether oral, topical or intravenous) are typically the first line of treatment. 5-ASA drugs are considered a second option for inducing remission of IBD. Azathioprine is more commonly used for maintaining remission. Steroids are specifically used to induce remission of Crohn’s disease. Infliximab is particularly effective for treating refractory disease and fistulating Crohn’s.

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.

      To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.

      Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 12 - A 65-year-old male patient is referred to the upper GI clinic under the...

    Correct

    • A 65-year-old male patient is referred to the upper GI clinic under the two-week rule. His daughter first noticed that his skin and eyes are becoming yellow. His past medical history includes neurofibromatosis type 1. He was recently diagnosed with Type 2 diabetes mellitus however the blood glucose has been very poorly controlled despite maximum therapy of metformin and gliclazide. On examination, he is jaundiced. There is mild discomfort in the epigastric region and the right upper quadrant. An urgent abdominal CT scan shows a mass arising from the head of the pancreas and dilated common bile duct. A subsequent endoscopic retrograde cholangiopancreatography (ERCP) and biopsy confirms a pancreatic somatostatinoma.

      From which cells in the pancreas is this tumour originating?

      Your Answer: D cells

      Explanation:

      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
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  • Question 13 - Mrs. Smith is a 75-year-old woman who has been admitted with pneumonia. She...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 14 - 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: Superior mesenteric artery

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 15 - A 42-year-old female patient arrives at the emergency department complaining of intense abdominal...

    Incorrect

    • A 42-year-old female patient arrives at the emergency department complaining of intense abdominal pain on the right side. Upon further inquiry, she describes the pain as crampy, intermittent, and spreading to her right shoulder. She has no fever. The patient notes that the pain worsens after meals.

      Which hormone is accountable for the fluctuation in pain?

      Your Answer: Insulin

      Correct Answer: Cholecystokinin

      Explanation:

      The hormone that increases gallbladder contraction is Cholecystokinin (CCK). It is secreted by I cells in the upper small intestine, particularly in response to a high-fat meal. Although it has many functions, its role in increasing gallbladder contraction may exacerbate biliary colic caused by gallstones in the patient described.

      Gastrin, insulin, and secretin are also hormones that can be released in response to food intake, but they do not have any known effect on gallbladder contraction. Therefore, CCK is the most appropriate answer.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 16 - A 55-year-old man visits his doctor for the third time complaining of general...

    Correct

    • A 55-year-old man visits his doctor for the third time complaining of general fatigue and feeling mentally cloudy. Upon conducting another blood test, the doctor discovers that the patient has extremely low levels of vitamin B12. The diagnosis is pernicious anemia caused by antibodies against intrinsic factor. What are the cells in the gastrointestinal tract responsible for secreting intrinsic factor?

      Your Answer: Parietal cells

      Explanation:

      The cause of pernicious anaemia is an autoimmune response that targets intrinsic factor and possibly gastric parietal cells, leading to their destruction. These cells are responsible for producing intrinsic factor, which is necessary for the absorption of vitamin B12 in the small intestine.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 17 - A 65-year-old man presents to the emergency department with a two-day history of...

    Correct

    • A 65-year-old man presents to the emergency department with a two-day history of rectal bleeding. He has had diarrhoea eight times in the past 24 hours with visible blood mixed with stool. He also complains of nausea and abdominal pain. His past medical history includes ulcerative colitis, hypertension and type 2 diabetes. He is currently taking mesalazine enteric coated 800 mg twice daily, amlodipine 10mg once daily and metformin 500mg twice daily.

      Upon examination, he appears pale and has a temperature of 38ÂșC. His heart rate is 108/min with a blood pressure of 112/74mmHg. Abdominal exam shows generalised tenderness and guarding, but no rebound tenderness. His blood results are as follows:

      - Hb 137 g/L Male: (135-180)
      - Platelets 550 * 109/L (150 - 400)
      - WBC 14.1 * 109/L (4.0 - 11.0)
      - Na+ 144 mmol/L (135 - 145)
      - K+ 3.4 mmol/L (3.5 - 5.0)
      - Urea 8.4 mmol/L (2.0 - 7.0)
      - Creatinine 134 ”mol/L (55 - 120)
      - CRP 110 mg/L (< 5)
      - ESR 45 mm/hr Men: < (age / 2)

      What is the most appropriate next step in managing this patient?

      Your Answer: Urgent hospital admission

      Explanation:

      A severe flare-up of ulcerative colitis necessitates urgent hospital admission for IV corticosteroids. This is the correct answer as the patient’s symptoms indicate a severe flare-up according to Truelove and Witts’ severity index. The patient is experiencing more than 6 bowel movements per day with systemic upset (fever and tachycardia) and an ESR of over 30. NICE recommends urgent hospital admission for assessment and treatment with IV corticosteroids.

      If the exacerbation is mild or moderate, oral corticosteroids may be appropriate. Therefore, send home with a course of oral corticosteroids is an incorrect answer.

      Gastroenteritis requires oral rehydration therapy, but this patient’s symptoms suggest an exacerbation of ulcerative colitis. Therefore, oral rehydration therapy is an incorrect answer.

      Loperamide may be used in the management of ulcerative colitis, but urgent hospital assessment is necessary due to the patient’s hemodynamic compromise. Therefore, send home with loperamide and send home with safety net advice alone are incorrect answers.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 18 - A 32-year-old woman undergoes a colonoscopy and a biopsy reveals a malignant tumour...

    Incorrect

    • A 32-year-old woman undergoes a colonoscopy and a biopsy reveals a malignant tumour in her sigmoid colon. Her grandmother died of colorectal cancer at 30-years-old and her father developed endometrial cancer at 40-years-old. Which gene is suspected to be responsible for this condition?

      Your Answer: PTEN gene

      Correct Answer: Mismatch repair genes

      Explanation:

      The patient’s familial background indicates the possibility of Lynch syndrome, given that several of his close relatives developed cancer at a young age. This is supported by the fact that his family has a history of both colorectal cancer, which may indicate a defect in the APC gene, and endometrial cancer, which is also linked to Lynch syndrome. Lynch syndrome is associated with mutations in mismatch repair genes such as MSH2, MLH1, PMS2, and GTBP, which are responsible for identifying and repairing errors that occur during DNA replication, such as insertions and deletions of bases. Mutations in these genes can increase the risk of developing cancers such as colorectal, endometrial, and renal cancer.

      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
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  • Question 19 - A 42-year-old woman has a laparoscopic cholecystectomy as a daycase, but the surgery...

    Correct

    • A 42-year-old woman has a laparoscopic cholecystectomy as a daycase, but the surgery proves to be more challenging than expected. As a result, the surgeon inserts a drain to the liver bed. During recovery, 1.5 litres of blood is observed to enter the drain. What is the initial substance to be released in this scenario?

      Your Answer: Renin

      Explanation:

      Renin secretion is triggered by the juxtaglomerular cells in the kidney sensing a decrease in blood pressure.

      Shock is a condition where there is not enough blood flow to the tissues. There are five main types of shock: septic, haemorrhagic, neurogenic, cardiogenic, and anaphylactic. Septic shock is caused by an infection that triggers a particular response in the body. Haemorrhagic shock is caused by blood loss, and there are four classes of haemorrhagic shock based on the amount of blood loss and associated symptoms. Neurogenic shock occurs when there is a disruption in the autonomic nervous system, leading to decreased vascular resistance and decreased cardiac output. Cardiogenic shock is caused by heart disease or direct myocardial trauma. Anaphylactic shock is a severe, life-threatening allergic reaction. Adrenaline is the most important drug in treating anaphylaxis and should be given as soon as possible.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 20 - A 32-year-old alcoholic woman presents with visible jaundice and confusion and is admitted...

    Incorrect

    • A 32-year-old alcoholic woman presents with visible jaundice and confusion and is admitted to the gastroenterology ward. Upon examination, she has a distended tender abdomen with hepatomegaly and shifting dullness. All her observations are within normal limits. The following blood test results are obtained:

      - Hb: 121 g/L (normal range for females: 115-160 g/L)
      - MCV: 103 g/L (normal range: 82-100 g/L)
      - Bilirubin: 78 ”mol/L (normal range: 3-17 ”mol/L)
      - ALP: 112 u/L (normal range: 30-100 u/L)
      - ALT: 276 u/L (normal range: 3-40 u/L)
      - AST: 552 u/L (normal range: 3-30 u/L)
      - ÎłGT: 161 u/L (normal range: 8-60 u/L)

      An aspirate of fluid is taken and shows a serum-ascites albumin gradient (SAAG) of 14 g/L. What is the most likely diagnosis that explains the SAAG value in this patient?

      Your Answer:

      Correct Answer: Portal hypertension

      Explanation:

      Ascites can be diagnosed by measuring the SAAG value, with a high SAAG gradient (>11g/L) indicating the presence of portal hypertension. In the case of a SAAG value of >11g/L, the ascites is considered a transudate and is likely caused by portal hypertension. This is consistent with the patient’s symptoms, which suggest ascites due to alcoholic liver disease leading to liver cirrhosis and portal hypertension. Other potential causes of ascites would result in an exudative picture with a SAAG value of <11g/L. Biliary ascites is a rare consequence of biliary procedures or trauma, and would present with abdominal distension but not hepatomegaly. While bile is sterile, peritonitis is likely to occur, leading to septic symptoms. However, the SAAG value and the patient’s symptoms make biliary ascites less likely. Bowel obstruction is not consistent with the patient’s symptoms, as it would not explain the presence of jaundice. While a distended abdomen may be present, other features of delirium would also be expected. Additionally, a patient with bowel obstruction would report a history of not passing flatus or bowel movements. Nephrotic syndrome would present with oedema, proteinuria, and hypoalbuminaemia, which are not described in the patient’s symptoms. The raised liver enzymes and macrocytic anaemia are more consistent with liver pathology. Ascites is a medical condition characterized by the accumulation of abnormal amounts of fluid in the abdominal cavity. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. If the SAAG level is greater than 11g/L, it indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. Other causes of portal hypertension include cardiac conditions like right heart failure and constrictive pericarditis, as well as infections like tuberculous peritonitis. On the other hand, if the SAAG level is less than 11g/L, ascites may be caused by hypoalbuminaemia, malignancy, pancreatitis, bowel obstruction, and other conditions. The management of ascites involves reducing dietary sodium and sometimes fluid restriction if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone are often prescribed, and loop diuretics may be added if necessary. Therapeutic abdominal paracentesis may be performed for tense ascites, and large-volume paracentesis requires albumin cover to reduce the risk of complications. Prophylactic antibiotics may also be given to prevent spontaneous bacterial peritonitis. In some cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 21 - A 32-year-old woman is being evaluated for an abdominal mass. She delivered her...

    Incorrect

    • A 32-year-old woman is being evaluated for an abdominal mass. She delivered her first child vaginally and without any issues. Biopsy results indicate the presence of differentiated fibroblasts in sheets, which is indicative of a desmoid tumor. What is a potential risk factor for this type of tumor?

      Your Answer:

      Correct Answer: APC mutations

      Explanation:

      Desmoid tumours are more likely to occur in individuals with APC mutations.

      Pancreatic and hepatic cancer have been linked to CA-199.

      Breast cancer is strongly linked to BRCA1 and BRCA2 mutations.

      Burkitt’s lymphoma, a high-grade B-cell neoplasm, is associated with translocation of the C-myc gene.

      Desmoid tumours are growths that arise from musculoaponeurotic structures and are made up of clonal proliferations of myofibroblasts. They are typically firm and have a tendency to infiltrate surrounding tissue. These tumours are often seen in patients with familial adenomatous polyposis coli, and are most commonly found in women after childbirth in the rectus abdominis muscle. Bi allelic APC mutations are usually present in desmoid tumours.

      The preferred treatment for desmoid tumours is radical surgical resection, although radiotherapy and chemotherapy may be considered in some cases. Non-surgical therapy is generally less effective than surgical resection. In certain cases of abdominal desmoids, observation may be preferred as some tumours may spontaneously regress. However, desmoids have a high likelihood of local recurrence. These tumours consist of sheets of differentiated fibroblasts.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 22 - A patient with moderate gastro-oesophageal reflux disease undergoes upper gastrointestinal endoscopy and biopsy....

    Incorrect

    • A patient with moderate gastro-oesophageal reflux disease undergoes upper gastrointestinal endoscopy and biopsy. Upon examination of the biopsy specimen, the pathologist observes that the original epithelium of the oesophagus (A) has been substituted by a distinct type of epithelium (B) that is typically present in the intestine.

      What is the epithelium (B) that the pathologist is most likely to have identified?

      Your Answer:

      Correct Answer: Columnar epithelium

      Explanation:

      Barrett’s oesophagus is characterized by the replacement of the original stratified squamous epithelium with columnar epithelium, which is typically found lining the intestines. Simple cuboidal epithelium is present in small gland ducts, kidney tubules, and secretory portions. Pseudostratified columnar epithelium is found in the upper respiratory tract and trachea, while stratified squamous epithelium lines areas that experience tension, such as the mouth, oesophagus, and vagina.

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, which increases the risk of oesophageal adenocarcinoma by 50-100 fold. It is usually identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia, as there are no screening programs for it. The length of the affected segment determines the chances of identifying metaplasia, with short (<3 cm) and long (>3 cm) subtypes. The prevalence of Barrett’s oesophagus is estimated to be around 1 in 20, and it is identified in up to 12% of those undergoing endoscopy for reflux.

      The columnar epithelium in Barrett’s oesophagus may resemble that of the cardiac region of the stomach or that of the small intestine, with goblet cells and brush border. The single strongest risk factor for Barrett’s oesophagus is gastro-oesophageal reflux disease (GORD), followed by male gender, smoking, and central obesity. Alcohol is not an independent risk factor for Barrett’s, but it is associated with both GORD and oesophageal cancer. Patients with Barrett’s oesophagus often have coexistent GORD symptoms.

      The management of Barrett’s oesophagus involves high-dose proton pump inhibitor, although the evidence base for its effectiveness in reducing the progression to dysplasia or inducing regression of the lesion is limited. Endoscopic surveillance with biopsies is recommended every 3-5 years for patients with metaplasia but not dysplasia. If dysplasia of any grade is identified, endoscopic intervention is offered, such as radiofrequency ablation, which is the preferred first-line treatment, particularly for low-grade dysplasia, or endoscopic mucosal resection.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 23 - Surgical occlusion of which of these structures will cause the most significant decrease...

    Incorrect

    • Surgical occlusion of which of these structures will cause the most significant decrease in hepatic blood flow?

      Your Answer:

      Correct Answer: Portal vein

      Explanation:

      The contents of the portal vein consist of digested products. Sinusoids distribute arterial and venous blood to the central veins of the liver lobules, which then empty into the hepatic veins and ultimately into the IVC. Unlike other hepatic veins, the caudate lobe directly drains into the IVC.

      Structure and Relations of the Liver

      The liver is divided into four lobes: the right lobe, left lobe, quadrate lobe, and caudate lobe. The right lobe is supplied by the right hepatic artery and contains Couinaud segments V to VIII, while the left lobe is supplied by the left hepatic artery and contains Couinaud segments II to IV. The quadrate lobe is part of the right lobe anatomically but functionally is part of the left, and the caudate lobe is supplied by both right and left hepatic arteries and lies behind the plane of the porta hepatis. The liver lobules are separated by portal canals that contain the portal triad: the hepatic artery, portal vein, and tributary of bile duct.

      The liver has various relations with other organs in the body. Anteriorly, it is related to the diaphragm, esophagus, xiphoid process, stomach, duodenum, hepatic flexure of colon, right kidney, gallbladder, and inferior vena cava. The porta hepatis is located on the postero-inferior surface of the liver and transmits the common hepatic duct, hepatic artery, portal vein, sympathetic and parasympathetic nerve fibers, and lymphatic drainage of the liver and nodes.

      The liver is supported by ligaments, including the falciform ligament, which is a two-layer fold of peritoneum from the umbilicus to the anterior liver surface and contains the ligamentum teres (remnant of the umbilical vein). The ligamentum venosum is a remnant of the ductus venosus. The liver is supplied by the hepatic artery and drained by the hepatic veins and portal vein. Its nervous supply comes from the sympathetic and parasympathetic trunks of the coeliac plexus.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 24 - A 35-year-old female patient visits the gastroenterology clinic complaining of abdominal discomfort, bloating,...

    Incorrect

    • A 35-year-old female patient visits the gastroenterology clinic complaining of abdominal discomfort, bloating, flatulence, and diarrhea that have persisted for 8 months. She reports that her symptoms worsen after consuming meals, particularly those high in carbohydrates. During the examination, the gastroenterologist observes no significant abdominal findings but notices rashes on her elbows and knees. As part of her diagnostic workup, the gastroenterologist is contemplating endoscopy and small bowel biopsy. What is the probable biopsy result?

      Your Answer:

      Correct Answer: Villous atrophy

      Explanation:

      Coeliac disease can be diagnosed through a biopsy that shows villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia. This condition is likely the cause of the patient’s chronic symptoms, which are triggered by meals containing gluten. Fortunately, adhering to a strict gluten-free diet can reverse the villous atrophy. In some cases, coeliac disease may also present with a vesicular rash called dermatitis herpetiformis. Other pathological findings, such as mucosal defects, irregular gland-like structures, or transmural inflammation with granulomas and lymphoid aggregates, suggest different diseases.

      Investigating Coeliac Disease

      Coeliac disease is a condition caused by sensitivity to gluten, which leads to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis is made through a combination of serology and endoscopic intestinal biopsy, with villous atrophy and immunology typically reversing on a gluten-free diet.

      To investigate coeliac disease, NICE guidelines recommend using tissue transglutaminase (TTG) antibodies (IgA) as the first-choice serology test, along with endomyseal antibody (IgA) and testing for selective IgA deficiency. Anti-gliadin antibody (IgA or IgG) tests are not recommended. The ‘gold standard’ for diagnosis is an endoscopic intestinal biopsy, which should be performed in all suspected cases to confirm or exclude the diagnosis. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Rectal gluten challenge is a less commonly used method.

      In summary, investigating coeliac disease involves a combination of serology and endoscopic intestinal biopsy, with NICE guidelines recommending specific tests and the ‘gold standard’ being an intestinal biopsy. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, and lymphocyte infiltration.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 25 - A woman in her 40s is undergoing investigation for bowel cancer. During a...

    Incorrect

    • A woman in her 40s is undergoing investigation for bowel cancer. During a colonoscopy, numerous small growths are found throughout her bowel, indicating the presence of an autosomal dominant familial condition that the clinician had suspected.

      Which gene mutation is commonly associated with this diagnosis?

      Your Answer:

      Correct Answer: APC

      Explanation:

      While a majority of human cancers are linked to p53 malfunction, it should be noted that the APC gene is specifically associated with FAP and not p53.

      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
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  • Question 26 - A 67-year-old male is receiving treatment for his colorectal cancer from the oncology...

    Incorrect

    • A 67-year-old male is receiving treatment for his colorectal cancer from the oncology team at his nearby hospital. What type of colorectal carcinoma is most frequently encountered?

      Your Answer:

      Correct Answer: Adenocarcinoma

      Explanation:

      The most common type of colorectal cancer is adenocarcinoma, which originates from the mucosal lining of the colon. Initially, it develops as a benign adenoma from glandular cells of the mucosa, which later transforms into a malignant form.

      Squamous cell carcinoma arises from squamous cells, which are not present in the colon. Ductal carcinoma is a breast cancer that originates from ductal cells. Basal cell carcinoma is a type of skin cancer, while mesothelioma is a malignancy that affects the mesothelium, commonly found in the lining of the chest wall.

      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
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  • Question 27 - A 32-year-old female undergoes an emergency caesarean section due to failed induction of...

    Incorrect

    • A 32-year-old female undergoes an emergency caesarean section due to failed induction of labor and a macrosomic baby. After delivery, she is transferred to the postnatal ward. However, prior to discharge, she complains of abdominal pain, has a fever of 39ÂșC, and a tachycardia of 106 bpm. A CT scan reveals the presence of fluid accumulation in the retroperitoneal space. What is the probable cause of these CT findings?

      Your Answer:

      Correct Answer: Ureteral injury during caesarean section

      Explanation:

      If the ureters are damaged during a caesarean section, it can cause fluid to accumulate in the retroperitoneal area. This can lead to pain and inflammation, which may present as fever and a rapid heartbeat. Ovarian thrombus is a rare complication that can occur after a caesarean section. CT scans can show filling defects and an increased diameter in the affected vein. The pyloric antrum is located near the bottom of the stomach, close to the pyloric sphincter. Since the stomach is an intraperitoneal organ in the left upper quadrant, it is unlikely to be lacerated during a caesarean section. Any damage to the stomach would not result in retroperitoneal fluid accumulation.

      The retroperitoneal structures are those that are located behind the peritoneum, which is the membrane that lines the abdominal cavity. These structures include the duodenum (2nd, 3rd, and 4th parts), ascending and descending colon, kidneys, ureters, aorta, and inferior vena cava. They are situated in the back of the abdominal cavity, close to the spine. In contrast, intraperitoneal structures are those that are located within the peritoneal cavity, such as the stomach, duodenum (1st part), jejunum, ileum, transverse colon, and sigmoid colon. It is important to note that the retroperitoneal structures are not well demonstrated in the diagram as the posterior aspect has been removed, but they are still significant in terms of their location and function.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 28 - A 75-year-old man presents to the emergency department complaining of diffuse abdominal pain...

    Incorrect

    • A 75-year-old man presents to the emergency department complaining of diffuse abdominal pain that has been ongoing for several hours. He reports passing bloody stool during a recent bowel movement. Upon examination, you observe an irregular pulse and a tender abdomen. After conducting tests, you diagnose the patient with ischaemic colitis affecting the transverse colon.

      What other organ receives blood supply from the same branch of the aorta at the vertebral level L1?

      Your Answer:

      Correct Answer: 4th part of the duodenum

      Explanation:

      The splenic flexure of the colon marks the boundary between the midgut and the hindgut.

      When a blood clot travels to the abdominal arteries and blocks the blood supply to a section of the gut, it can lead to ischaemic colitis. This condition is more prevalent in older individuals, and those with atrial fibrillation (as indicated by the patient’s irregular pulse) are at a higher risk. The area most commonly affected is the watershed region of the colon, where blood supply transitions from one artery to another. This region is the junction between the midgut and the hindgut.

      The superior mesenteric artery supplies the midgut, which includes the proximal transverse colon.

      The foregut-derived organs, such as the 1st part of the duodenum, spleen, and liver, are supplied by the coeliac trunk.

      The hindgut includes the descending colon, which is supplied by the inferior mesenteric artery.

      The Three Embryological Layers and their Corresponding Gastrointestinal Structures and Blood Supply

      The gastrointestinal system is a complex network of organs responsible for the digestion and absorption of nutrients. During embryonic development, the gastrointestinal system is formed from three distinct layers: the foregut, midgut, and hindgut. Each layer gives rise to specific structures and is supplied by a corresponding blood vessel.

      The foregut extends from the mouth to the proximal half of the duodenum and is supplied by the coeliac trunk. The midgut encompasses the distal half of the duodenum to the splenic flexure of the colon and is supplied by the superior mesenteric artery. Lastly, the hindgut includes the descending colon to the rectum and is supplied by the inferior mesenteric artery.

      Understanding the embryological origin and blood supply of the gastrointestinal system is crucial in diagnosing and treating gastrointestinal disorders. By identifying the specific structures and blood vessels involved, healthcare professionals can better target their interventions and improve patient outcomes.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 29 - A 26-year-old male presents with yellow discoloration of his skin. He reports having...

    Incorrect

    • A 26-year-old male presents with yellow discoloration of his skin. He reports having had the flu for the past week but is otherwise in good health. He vaguely remembers his uncle experiencing similar episodes of yellow skin. What is the probable diagnosis and what is the mode of inheritance for this condition?

      Your Answer:

      Correct Answer: Autosomal recessive

      Explanation:

      Gilbert’s Syndrome is inherited in an autosomal recessive manner. It causes unconjugated hyperbilirubinaemia during periods of stress, such as fasting or infection.

      Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.

      To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 30 - A 50-year-old man with dyspepsia is scheduled for an upper GI endoscopy. During...

    Incorrect

    • A 50-year-old man with dyspepsia is scheduled for an upper GI endoscopy. During the procedure, an irregular erythematous area is observed protruding proximally from the gastro-oesophageal junction. To confirm a diagnosis of Barrett's esophagus, which of the following cell types must be present in addition to specialised intestinal metaplasia?

      Your Answer:

      Correct Answer: Goblet cell

      Explanation:

      The presence of goblet cells is a requirement for the diagnosis of Barrett’s esophagus.

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, which increases the risk of oesophageal adenocarcinoma by 50-100 fold. It is usually identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia, as there are no screening programs for it. The length of the affected segment determines the chances of identifying metaplasia, with short (<3 cm) and long (>3 cm) subtypes. The prevalence of Barrett’s oesophagus is estimated to be around 1 in 20, and it is identified in up to 12% of those undergoing endoscopy for reflux.

      The columnar epithelium in Barrett’s oesophagus may resemble that of the cardiac region of the stomach or that of the small intestine, with goblet cells and brush border. The single strongest risk factor for Barrett’s oesophagus is gastro-oesophageal reflux disease (GORD), followed by male gender, smoking, and central obesity. Alcohol is not an independent risk factor for Barrett’s, but it is associated with both GORD and oesophageal cancer. Patients with Barrett’s oesophagus often have coexistent GORD symptoms.

      The management of Barrett’s oesophagus involves high-dose proton pump inhibitor, although the evidence base for its effectiveness in reducing the progression to dysplasia or inducing regression of the lesion is limited. Endoscopic surveillance with biopsies is recommended every 3-5 years for patients with metaplasia but not dysplasia. If dysplasia of any grade is identified, endoscopic intervention is offered, such as radiofrequency ablation, which is the preferred first-line treatment, particularly for low-grade dysplasia, or endoscopic mucosal resection.

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      • Gastrointestinal System
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