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  • Question 1 - Which one of the following is not a result of cholecystokinin? ...

    Incorrect

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

      Your Answer: It causes gallbladder contraction

      Correct 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
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  • Question 2 - An 80-year-old man presents to the emergency department with acute and severe abdominal...

    Incorrect

    • An 80-year-old man presents to the emergency department with acute and severe abdominal pain, vomiting, and bloody stools. He has a medical history of atrial fibrillation and ischaemic heart disease. Upon examination, his heart rate is 140 beats per minute, blood pressure is 98/58mmHg, respiratory rate is 24 breaths per minute, oxygen saturations are 98% on air, and temperature is 38.8ºC. A CT scan with contrast of the abdomen reveals air in the intestinal wall. During surgery, it is discovered that the distal third of the colon to the superior part of the rectum is necrotic.

      Which artery is responsible for supplying blood to this portion of the bowel?

      Your Answer:

      Correct Answer: Inferior mesenteric artery

      Explanation:

      The correct artery supplying the affected area in this patient is the inferior mesenteric artery. This artery branches off the abdominal aorta and supplies the hindgut, which includes the distal third of the colon and the rectum superior to the pectinate line. It’s important to note that the anal canal is divided into two parts by the pectinate line, with the upper half supplied by the superior rectal artery branch of the inferior mesenteric artery, and the lower half supplied by the inferior rectal artery branch of the internal pudendal artery. Ischaemic heart disease and atrial fibrillation are risk factors for acute mesenteric ischaemia in this patient, which presents with severe, poorly-localised abdominal pain and tenderness. The coeliac trunk, which supplies the foregut, is not involved in this case. The internal pudendal artery supplies the inferior part of the anal canal, perineum, and genitalia, while the right colic artery, a branch of the superior mesenteric artery, supplies the ascending colon, which is not affected in this patient.

      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 3 - A 56-year-old woman presents with profuse diarrhoea one week after undergoing a cholecystectomy....

    Incorrect

    • A 56-year-old woman presents with profuse diarrhoea one week after undergoing a cholecystectomy. The surgery was uncomplicated, except for a minor bile spillage during gallbladder removal. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Clostridium difficile infection

      Explanation:

      Broad spectrum antibiotics are only given during a cholecystectomy if there is intraoperative bile spillage. It is not standard practice to administer antibiotics for an uncomplicated procedure. Surgeons typically address any bile spills during the operation, which greatly reduces the risk of delayed pelvic abscesses. As a result, such abscesses are very uncommon.

      Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

      To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 4 - A 50-year-old man is admitted to the general medical ward with complaints of...

    Incorrect

    • A 50-year-old man is admitted to the general medical ward with complaints of abdominal crampy pain and diarrhoea. He has had five loose stools in the past 24 hours. The patient was diagnosed with a lung abscess three days ago and is currently being treated with cefaclor in the ward. His blood pressure is 120/70 mmHg, pulse rate is 98 beats per minute, and temperature is 38.2 ºC. Blood investigations reveal Hb of 135 g/L, platelets of 280 * 109/L, and WBC of 13.4 * 109/L. A stool sample is sent for testing, and the results show the presence of gram-positive bacteria. The consultant prescribes metronidazole along with bezlotoxumab that binds to the toxin B of this bacterium. What is the most likely organism responsible for this patient's condition?

      Your Answer:

      Correct Answer: Clostridium difficile

      Explanation:

      Bezlotoxumab targets the Clostridium difficile toxin B, making it a monoclonal antibody used for treatment. Clostridium difficile is a gram-positive rod that can cause diarrhoea and abdominal pain when normal gut flora is suppressed by broad-spectrum antibiotics. Bacillus cereus, Campylobacter jejuni, and Escherichia coli are incorrect answers as they are either associated with different symptoms or are gram-negative, making bezlotoxumab ineffective for their treatment.

      Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

      To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 5 - An 80-year-old man who frequently drinks alcohol presents to his doctor with symptoms...

    Incorrect

    • An 80-year-old man who frequently drinks alcohol presents to his doctor with symptoms of productive cough, fever, and chills. Upon examination, a chest x-ray reveals a distinct cavity in the right lower lobe with an air-fluid level. The patient's sputum is sent for culture and sensitivity, and he is prescribed clindamycin.

      After ten days, the patient reports experiencing watery diarrhea 3-4 times a day and abdominal pain. He has not experienced any fever or weight loss, and his vital signs are normal. What is the initial medication recommended for his condition?

      Your Answer:

      Correct Answer: Vancomycin

      Explanation:

      The preferred antibiotic for treating C. difficile infection is oral vancomycin. However, in the case of a patient with clinical features and radiological findings indicative of a lung abscess, who also has a history of alcohol consumption that increases the risk of aspiration and lung abscesses, clindamycin was used as a treatment. Unfortunately, this led to the development of a C. difficile infection, which can be confusing when considering the antibiotics involved in causing and treating the infection.

      Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

      To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 6 - A 22-year-old university student with a history of primary sclerosing cholangitis presents to...

    Incorrect

    • A 22-year-old university student with a history of primary sclerosing cholangitis presents to the gastroenterologists with symptoms suggestive of ulcerative colitis. She has been experiencing bloody diarrhoea and fatigue for the past three months, with an average of seven bowel movements per day. Her medical history includes a childhood hepatitis A infection and an uncomplicated appendicectomy three years ago. She also has a family history of hepatocellular carcinoma.

      During examination, stage 1 haemorrhoids and a scar over McBurney's point are noted. Given her medical history, which condition warrants annual colonoscopy in this patient?

      Your Answer:

      Correct Answer: Primary sclerosing cholangitis

      Explanation:

      Annual colonoscopy is recommended for individuals who have both ulcerative colitis and PSC.

      Colorectal Cancer Risk in Ulcerative Colitis Patients

      Ulcerative colitis patients have a significantly higher risk of developing colorectal cancer compared to the general population. The risk is mainly related to chronic inflammation, and studies report varying rates. Unfortunately, patients with ulcerative colitis often experience delayed diagnosis, leading to a worse prognosis. Lesions may also be multifocal, further increasing the risk of cancer.

      Several factors increase the risk of colorectal cancer in ulcerative colitis patients, including disease duration of more than 10 years, pancolitis, onset before 15 years old, unremitting disease, and poor compliance to treatment. To manage this risk, colonoscopy surveillance is recommended, and the frequency of surveillance depends on the patient’s risk stratification.

      Patients with lower risk require a colonoscopy every five years, while those with intermediate risk require a colonoscopy every three years. Patients with higher risk require a colonoscopy every year. The risk stratification is based on factors such as the extent of colitis, the severity of active endoscopic/histological inflammation, the presence of post-inflammatory polyps, and family history of colorectal cancer. Primary sclerosing cholangitis or a family history of colorectal cancer in first-degree relatives aged less than 50 years also increase the risk of cancer. By following these guidelines, ulcerative colitis patients can receive appropriate surveillance and management to reduce their risk of developing colorectal cancer.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 7 - In individuals with an annular pancreas, what is the most probable location of...

    Incorrect

    • In individuals with an annular pancreas, what is the most probable location of blockage?

      Your Answer:

      Correct Answer: The second part of the duodenum

      Explanation:

      The pancreas is formed from two outgrowths of the foregut, namely the ventral and dorsal buds. As the rotation process takes place, the ventral bud merges with the gallbladder and bile duct, which are located nearby. However, if the pancreas fails to rotate properly, it may exert pressure on the duodenum, leading to obstruction. This condition is often caused by an abnormality in the development of the duodenum, and the most commonly affected area is the second part of the duodenum.

      Anatomy of the Pancreas

      The pancreas is located behind the stomach and is a retroperitoneal organ. It can be accessed surgically by dividing the peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head is situated in the curvature of the duodenum, while its tail is close to the hilum of the spleen. The pancreas has various relations with other organs, such as the inferior vena cava, common bile duct, renal veins, superior mesenteric vein and artery, crus of diaphragm, psoas muscle, adrenal gland, kidney, aorta, pylorus, gastroduodenal artery, and splenic hilum.

      The arterial supply of the pancreas is through the pancreaticoduodenal artery for the head and the splenic artery for the rest of the organ. The venous drainage for the head is through the superior mesenteric vein, while the body and tail are drained by the splenic vein. The ampulla of Vater is an important landmark that marks the transition from foregut to midgut and is located halfway along the second part of the duodenum. Overall, understanding the anatomy of the pancreas is crucial for surgical procedures and diagnosing pancreatic diseases.

    • 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...

    Incorrect

    • 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:

      Correct 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 case of ischaemic left colon is diagnosed in a patient. Which artery,...

    Incorrect

    • A case of ischaemic left colon is diagnosed in a patient. Which artery, originating from the aorta at approximately the level of L3, is the most probable cause of this condition?

      Your Answer:

      Correct Answer: Inferior mesenteric artery

      Explanation:

      The left side of the colon is most likely to be affected by the IMA, which typically originates at L3.

      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 10 - An 83-year-old woman comes to your clinic with a painful red swelling on...

    Incorrect

    • An 83-year-old woman comes to your clinic with a painful red swelling on her cheek that she noticed this morning. She has been feeling fatigued for a few days. The patient lives alone and has a history of pressure ulcers due to limited mobility. During the examination, you observe an erythematous swelling above the right angle of the mandible that is warm and tender to the touch. You suspect that the patient has a parotid gland infection. What is the nerve that provides sensation to the parotid gland capsule?

      Your Answer:

      Correct Answer: Greater auricular nerve

      Explanation:

      The greater auricular nerve (GAN) supplies sensation to the parotid gland, skin overlying the gland, mastoid process, and outer ear. The facial nerve supplies muscles of facial expression, taste from the anterior two-thirds of the tongue, and sensation from parts of the external acoustic meatus, auricle, and retro-auricular area. The mandibular nerve carries sensory and motor fibers, supplying sensation to the lower lip, lower teeth and gingivae, chin, and jaw, and motor innervation to muscles of mastication. The lingual nerve supplies sensation to the tongue and travels with taste fibers from the chorda tympani of the facial nerve. The glossopharyngeal nerve carries taste and sensation from the posterior third of the tongue, sensation from the pharyngeal wall and tonsils, the middle ear, external auditory canal, and auricle, and parasympathetic fibers that supply the parotid gland. Infective parotitis is uncommon and has increased risk in dehydrated or intubated elderly patients.

      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
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