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  • Question 1 - You are examining the blood results of a 31-year-old woman who visited you...

    Correct

    • You are examining the blood results of a 31-year-old woman who visited you last week complaining of abdominal pain, weight loss, fatigue, loose stools, mouth ulcers, and episcleritis. You suspected that she might have inflammatory bowel disease due to her positive family history. Her blood tests reveal a microcytic anaemia and an elevated CRP level.

      Which of the following statements is accurate?

      Your Answer: About two-thirds of people with inflammatory bowel disease have anaemia at diagnosis

      Explanation:

      Inflammatory bowel disease can have an impact on the fertility of both men and women. For instance, Crohn’s disease can lower fertility rates due to the presence of active disease. Additionally, women who have undergone abdominal surgery or experienced abdominal sepsis are at a higher risk of developing adhesions that can negatively affect the function of their fallopian tubes.

      Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 2 - An 83-year-old woman comes to her doctor with a recent weight loss of...

    Incorrect

    • An 83-year-old woman comes to her doctor with a recent weight loss of 6 kg over the past three months, without any significant pain. During the examination, she appears drawn and emaciated, with deep yellow sclera. She has experienced jaundice twice before, once in her teens, and her sister has also had it. She typically enjoys a glass or two of wine on weekends and smokes 10 cigarettes per day. What is the probable reason for her jaundice?

      Your Answer: Gilbert's syndrome

      Correct Answer: Infective hepatitis

      Explanation:

      Causes of Jaundice and their Characteristics

      Jaundice can be caused by various conditions, each with their own unique characteristics. Cancer of the pancreas, particularly in the head, can cause painless jaundice. On the other hand, cancer in the body or tail of the pancreas can present with dull, unremitting central abdominal pain or back pain. Smoking is a known risk factor for pancreatic cancer.

      Gilbert’s syndrome, a familial condition, can also cause jaundice. However, the jaundice in this case is pale yellow and the patient typically feels well. While Gilbert’s syndrome is not uncommon, it is important to consider other potential causes of jaundice, especially if the patient has significant weight loss. As a wise surgeon once said, People with IBS get Ca bowel too – never forget that.

      Hepatitis A is more commonly seen in adolescents and young adults. Primary biliary cirrhosis, on the other hand, has its peak incidence in the fifth decade of life and often presents with generalized pruritus or asymptomatic hepatomegaly. Understanding the characteristics of different causes of jaundice can help in making an accurate diagnosis and providing appropriate treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 3 - You are the GP trainee doing your morning clinic. You see a 35-year-old...

    Correct

    • You are the GP trainee doing your morning clinic. You see a 35-year-old woman with coeliac disease.

      Which of the following is indicated as part of her management?

      Your Answer: Administration of the pneumococcal vaccine

      Explanation:

      To prevent overwhelming pneumococcal sepsis due to hyposplenism, Coeliac UK advises that individuals with coeliac disease receive a pneumococcal infection vaccine and a booster every five years. Pertussis vaccines beyond those in the vaccination schedule are unnecessary. According to NICE CKS guidelines, annual blood tests for FBC, ferritin, thyroid function tests, liver function tests, B12, and folate are recommended. Calprotectin is utilized to assess gut inflammation, often as part of the diagnostic process for inflammatory bowel disease. Faecal occult blood testing is typically conducted if there are concerns about bowel cancer.

      Managing Coeliac Disease with a Gluten-Free Diet

      Coeliac disease is a condition that requires the management of a gluten-free diet. Gluten-containing cereals such as wheat, barley, rye, and oats must be avoided. However, some patients with coeliac disease can tolerate oats. Gluten-free foods include rice, potatoes, and corn. Compliance with a gluten-free diet can be checked by testing for tissue transglutaminase antibodies.

      Patients with coeliac disease often have functional hyposplenism, which is why they are offered the pneumococcal vaccine. Coeliac UK recommends that patients with coeliac disease receive the pneumococcal vaccine and have a booster every five years. influenza vaccine is given on an individual basis according to current guidelines.

      Overall, managing coeliac disease requires strict adherence to a gluten-free diet and regular immunisation to prevent infections.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - A 50-year-old man has abnormal liver function tests. He tests positive for anti-HCV...

    Incorrect

    • A 50-year-old man has abnormal liver function tests. He tests positive for anti-HCV and HCV RNA.
      Select from the list the single correct statement about hepatitis C.

      Your Answer: Asymptomatic disease is uncommon

      Correct Answer: Co-infection with HIV results in more rapid progression of liver disease

      Explanation:

      Hepatitis C: A Silent Threat to Liver Health

      Hepatitis C is a viral infection that often goes unnoticed in its acute phase, with only a minority of patients presenting with symptoms such as jaundice or abnormal liver enzymes. Unfortunately, the majority of patients do not clear the infection and go on to develop chronic disease, which can remain undetected for decades. The primary mode of transmission is through intravenous drug use and sharing needles, although sexual transmission is possible, especially in those co-infected with HIV. Needle-stick injuries and exposure to infected blood also pose a risk of transmission. Unfortunately, there is no post-exposure vaccine or effective preventative treatment. Factors that increase the risk of rapid progression of liver disease include male sex, age over 40, alcohol consumption, and co-infection with HIV or hepatitis B. With the increased survival of HIV patients, end-stage liver disease due to HCV infection has become a significant problem.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 62-year-old woman presents with a history of anorexia, weight loss, and abdominal...

    Incorrect

    • A 62-year-old woman presents with a history of anorexia, weight loss, and abdominal discomfort for the past five weeks. On examination, she appears pale and cachectic with no significant abdominal findings. However, there is palpable adenopathy in the left supraclavicular fossa.
      What is the most probable diagnosis?

      Your Answer: Hypertrophic pyloric stenosis

      Correct Answer: Carcinoma of the stomach

      Explanation:

      Metastatic Lymph Nodes in the Neck: Causes and Symptoms

      Metastatic lymph nodes in the neck, particularly at the root of the neck, are often indicative of cancer in the abdomen, specifically gastric or pancreatic tumors. These types of cancers can remain asymptomatic while spreading to the lymph nodes, making early detection difficult. Virchow’s node is a term used to describe an enlarged left supraclavicular node, which can also be caused by lymphoma, breast cancer, or arm infection. On the other hand, an enlarged right supraclavicular lymph node is typically associated with thoracic malignancies such as lung and esophageal cancer, as well as Hodgkin’s lymphoma. It’s important to note that none of the other options are malignant disorders. If you notice any unusual swelling or lumps in your neck, it’s important to seek medical attention promptly.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - A 70-year-old man presents with complaints of lower abdominal pain. He has been...

    Incorrect

    • A 70-year-old man presents with complaints of lower abdominal pain. He has been experiencing the pain for the past two months and has come in for an emergency appointment today because he has not had a bowel movement in a week. He cannot recall the last time he passed gas.

      He mentions that his stools have been significantly looser over the past few months and that he has noticed blood in his feces on occasion. Upon examination, it is discovered that he has lost over two stone in weight since his last visit to the practice six months ago. Palpation of the abdomen reveals a soft but distended abdomen with a mass in the left lower quadrant. A rectal examination shows an empty rectum with no abnormalities.

      What is the most probable underlying diagnosis?

      Your Answer: Ulcerative colitis

      Correct Answer: Colonic carcinoma

      Explanation:

      Likely Diagnosis for a 69-Year-Old with Weight Loss and Constipation

      A 69-year-old man with a history of weight loss, blood in his stool, and a palpable abdominal mass is likely suffering from bowel carcinoma. His symptoms have now progressed to absolute constipation due to an obstructing tumor. Other potential diagnoses, such as diverticular abscess, faecal impaction, and inflammatory bowel disease, are less likely based on his history and examination.

      A diverticular abscess typically presents with a tender mass and fever, while faecal impaction may cause a palpable mass but doesn’t typically result in weight loss or blood in the stool. Inflammatory bowel disease is rare in patients of this age and would not typically cause such significant weight loss. Overall, the patient’s symptoms are most consistent with a diagnosis of bowel carcinoma.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - A 45-year-old man with a history of GORD symptoms presents to the clinic...

    Correct

    • A 45-year-old man with a history of GORD symptoms presents to the clinic after a three month trial of omeprazole 20 mg. Further investigations have revealed that he has a hiatus hernia. The decision is made to continue his omeprazole treatment and he is advised to lose weight as his BMI is 32.

      Despite losing 5 kg over the past six months, he has visited the clinic twice for antibiotics due to lower respiratory tract infections. He has also been experiencing a nocturnal cough and possible asthma symptoms. What is the best course of action for managing his condition?

      Your Answer: Increase his omeprazole to 40 mg

      Explanation:

      Indications for Surgical Repair of Hiatus Hernia

      Indications for surgical repair of hiatus hernia include recurrent respiratory tract infection due to reflux. It is also considered in patients who have a para-oesophageal hernia because of the risk of strangulation.

      Given this patient’s young age and the fact that he has attended twice in six months with symptoms of respiratory tract infection, surgical referral for laparoscopic fundoplication is advised. This procedure can help alleviate symptoms of reflux and prevent further respiratory tract infections. It is important to consider surgical intervention in cases where conservative management has failed or when there is a risk of complications such as strangulation. Proper evaluation and management of hiatus hernia can improve the quality of life for patients and prevent potential complications.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - A 55-year-old man presents to his General Practitioner concerned that he may be...

    Correct

    • A 55-year-old man presents to his General Practitioner concerned that he may be at an increased risk of developing colon cancer. His father died at the age of 56 from a sigmoid colon adenocarcinoma. His brother, aged 61, has just undergone a colectomy for a caecal carcinoma.
      What is the most appropriate management for this patient?

      Your Answer: Refer for one-off colonoscopy aged 55

      Explanation:

      Screening Recommendations for Patients with Family History of Colorectal Cancer

      Patients with a family history of colorectal cancer may be at an increased risk of developing the disease. The British Society of Gastroenterology and the Association of Coloproctology for Great Britain and Ireland have produced screening guidelines for patients with family history profiles that place them in a moderate-risk category.

      Colonoscopy is recommended for patients with a family history of two first-degree relatives with a mean age of less than 60 years with colorectal cancer, starting at the age of 55. Abdominal ultrasound examination doesn’t have a role in screening for or diagnosing colorectal cancer.

      Patients with an increased risk should not be advised that they have no increased risk. Instead, they should be screened appropriately. Faecal immunochemical tests (FIT) are used to detect blood in the stool and are used in the national bowel cancer screening programme. However, patients with a higher risk, given their family history, should be offered earlier screening with colonoscopy rather than waiting until they are eligible for the national screening programme. False positives and negatives are possible with FIT, making colonoscopy a more reliable screening option for high-risk patients.

      Therefore, it is important for patients with a family history of colorectal cancer to be aware of the screening recommendations and to discuss their individual risk and screening options with their healthcare provider.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - A 40-year-old woman is experiencing fatigue and frequent bowel movements. Upon testing, it...

    Incorrect

    • A 40-year-old woman is experiencing fatigue and frequent bowel movements. Upon testing, it is found that she has positive anti-endomysial antibodies. Which of the following food items should she avoid, except for one?

      Your Answer: Rye

      Correct Answer: Maize

      Explanation:

      Managing Coeliac Disease with a Gluten-Free Diet

      Coeliac disease is a condition that requires the management of a gluten-free diet. Gluten-containing cereals such as wheat, barley, rye, and oats must be avoided. However, some patients with coeliac disease can tolerate oats. Gluten-free foods include rice, potatoes, and corn. Compliance with a gluten-free diet can be checked by testing for tissue transglutaminase antibodies.

      Patients with coeliac disease often have functional hyposplenism, which is why they are offered the pneumococcal vaccine. Coeliac UK recommends that patients with coeliac disease receive the pneumococcal vaccine and have a booster every five years. influenza vaccine is given on an individual basis according to current guidelines.

      Overall, managing coeliac disease requires strict adherence to a gluten-free diet and regular immunisation to prevent infections.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - A 67-year-old woman presents with a change in bowel habit. She has noticed...

    Incorrect

    • A 67-year-old woman presents with a change in bowel habit. She has noticed that over the past four to six weeks she has been opening her bowels two to three times a day with very loose stools. On a few occasions there have been small amounts of fresh blood in the stools. She has attributed this fresh blood to haemorrhoids which she has had in the past. Prior to this recent four to six week period she had typically opened her bowels once a day with well-formed stools.

      There is no reported family history of bowel problems. A stool sample was sent to the laboratory two to three weeks after the looser stools started and stool microscopy was normal, as are her recent blood tests which show she is not anaemic. Clinical examination is unremarkable with normal abdominal and rectal examinations. Her weight is stable.

      She tells you that she is not overly concerned about the symptoms as about a month ago she submitted her bowel screening samples and recently had a letter saying that her screening tests were negative.

      What is the most appropriate next approach in this instance?

      Your Answer: Refer her urgently to a specialist for investigation of her lower gastrointestinal tract

      Correct Answer: Reassure the patient that in view of the negative bowel screening she doesn't require any further investigation but should continue to participate in screening every two years

      Explanation:

      Importance of Urgent Referral for Patients with Bowel Symptoms

      Screening tests are designed for asymptomatic individuals in at-risk populations. However, it is not uncommon for patients with bowel symptoms to falsely reassure themselves with negative screening results. In the case of a 68-year-old woman with persistent changes in bowel habit and rectal bleeding, urgent referral for further investigation is necessary.

      It is important to note that relying on recent negative screening results can be inadequate and should not delay necessary medical attention.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - A 35-year-old man has had dysphagia for three weeks. He thinks it is...

    Incorrect

    • A 35-year-old man has had dysphagia for three weeks. He thinks it is getting worse. He has lost a small amount of weight.

      What is the best course of action?

      Your Answer: Refer urgently for endoscopy

      Correct Answer: Check an FBC and then consider referral

      Explanation:

      Urgent Referral for Endoscopy in Suspected Oesophageal Cancer

      This man requires an urgent referral for endoscopy as he may have cancer of the oesophagus. As a medical professional, it is important to identify alarm symptoms and understand referral guidelines that may apply. In this case, the patient’s dysphagia and weight loss are concerning and require urgent attention. An urgent referral is defined as one where the patient should be seen within two weeks.

      It is crucial to get this question right, as nearly 20% of respondents did not refer this patient urgently. If you answered incorrectly, take a moment to review the latest NICE guidance to update your knowledge. Practice questions like these can highlight areas of knowledge deficiency and stimulate further learning. By remembering this scenario, you will be better equipped to handle similar situations in the future.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - A mother brings her 9-year-old son who has been vomiting for the last...

    Correct

    • A mother brings her 9-year-old son who has been vomiting for the last day. He reports that since he was 4 years old he has had vomiting episodes 6 to 10 times a year every 4 to 8 weeks. The episodes last for around a day and no clear trigger has been found. He is a well and happy child who is able to eat, drink and gain weight appropriately between these episodes.

      He has been thoroughly investigated previously and he has been diagnosed with cyclical vomiting syndrome (CVS).

      He has now developed a new symptom associated with his attacks where he complains of abdominal pain, headache, and a sensitivity to light and noise.

      What is the most likely cause of this new set of symptoms?

      Your Answer: Migraine

      Explanation:

      Patients who have cyclical vomiting syndrome have a high probability of developing migraines. The diagnosis of cyclical vomiting syndrome, along with the presence of migraine symptoms such as abdominal pain (which can occur in children), makes migraine the most likely diagnosis. Meningitis is unlikely due to normal examination findings, and meningioma is rare in children and less common than migraine. Gastroenteritis cannot explain the headache or sensitivity to light and noise. There is no indication in the patient’s history of drug overdose.

      Understanding Cyclical Vomiting Syndrome

      Cyclical vomiting syndrome is a rare condition that is more commonly seen in children than adults. Females are slightly more affected than males. The exact cause of this condition is unknown, but it has been observed that 80% of children and 25% of adults who develop CVS also have migraines.

      The symptoms of CVS include severe nausea and sudden vomiting that can last for hours to days. Patients may also experience intense sweating and nausea before an episode. However, they may feel well in between episodes. Other symptoms that may be present include weight loss, reduced appetite, abdominal pain, diarrhea, dizziness, photophobia, and headache.

      To diagnose CVS, doctors may perform routine blood tests to exclude any underlying conditions. A pregnancy test may also be considered in women. Treatment for CVS involves avoiding triggers and using prophylactic medications such as amitriptyline, propranolol, and topiramate. During acute episodes, medications such as ondansetron, prochlorperazine, and triptans may be used.

      In summary, cyclical vomiting syndrome is a rare condition that can be challenging to diagnose and manage. However, with proper treatment and avoidance of triggers, patients can experience relief from their symptoms.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 13 - A 20-year-old man with a history of ulcerative colitis presents with a 3-day...

    Correct

    • A 20-year-old man with a history of ulcerative colitis presents with a 3-day history of abdominal pain and bloody diarrhoea, passing around 8 stools per day. He denies any recent travel or exposure to unwell individuals.

      During examination, his heart rate is 95 beats per minute, blood pressure is 110/70 mmHg, and temperature is 37.8 ºC. His abdomen is soft but mildly tender throughout.

      What is the best course of action for managing this patient's symptoms?

      Your Answer: Admit to hospital

      Explanation:

      Hospitalization and IV corticosteroids are necessary for the treatment of a severe flare of ulcerative colitis, as seen in this patient with over 6 bloody stools per day and systemic symptoms like tachycardia and fever. Mild to moderate cases can be managed with aminosalicylates and oral steroids. Simple analgesia, increased fluid intake, and oral antibiotics are not effective in managing severe flares of ulcerative colitis.

      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:

      • Gastroenterology
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  • Question 14 - A 28-year-old woman comes in for evaluation. She reports having 'IBS' and experiencing...

    Correct

    • A 28-year-old woman comes in for evaluation. She reports having 'IBS' and experiencing occasional episodes of abdominal pain, bloating, and loose stools for the past two years. However, her symptoms have significantly worsened over the past two weeks. She is now having 3-4 watery, grey, 'frothy' stools per day, along with increased abdominal bloating, cramps, and flatulence. She also feels that she has lost weight based on the fit of her clothes. The following blood tests are ordered:

      Hb 10.9 g/dl
      Platelets 199 * 109/l
      WBC 7.2 * 109/l
      Ferritin 15 ng/ml
      Vitamin B12 225 ng/l
      Folate 2.1 nmol/l

      What is the most probable diagnosis?

      Your Answer: Coeliac disease

      Explanation:

      The key indicators in this case suggest that the patient may have coeliac disease, as evidenced by her anaemia and low levels of ferritin and folate. While her description of diarrhoea is typical, some patients may have more visibly fatty stools.

      It is unlikely that the patient has irritable bowel syndrome, as her blood test results would not be consistent with this diagnosis. While menorrhagia may explain her anaemia and low ferritin levels, it would not account for the low folate.

      Coeliac disease is much more common than Crohn’s disease, and exams typically provide more clues to suggest a diagnosis of Crohn’s (such as mouth ulcers).

      Understanding Coeliac Disease

      Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.

      To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.

      Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.

      The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.

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      • Gastroenterology
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  • Question 15 - A 29-year-old woman who initially complained of abdominal discomfort and irregular bowel movements...

    Incorrect

    • A 29-year-old woman who initially complained of abdominal discomfort and irregular bowel movements is diagnosed with irritable bowel syndrome. What dietary advice should be avoided in this case?

      Your Answer: Drink at least 8 cups of fluid per day

      Correct Answer: Increase the intake of fibre such as bran and wholemeal bread

      Explanation:

      IBS patients should steer clear of insoluble sources of fiber like bran and wholemeal.

      Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 50-year-old woman is known to have diverticular disease. She has experienced pain...

    Correct

    • A 50-year-old woman is known to have diverticular disease. She has experienced pain in the left iliac fossa intermittently in the past put now the pain is more persistent and more severe. She is tender in the left iliac fossa but there is no guarding or rebound tenderness and a mass is not felt. Her temperature is 38oC.
      Select from the list the single most useful drug in these circumstances.

      Your Answer: Co-amoxiclav

      Explanation:

      Management of Diverticulitis in Primary Care

      Diverticulitis is a common condition that can be managed in primary care, provided there are no complications. If the patient is not dehydrated, experiencing severe bleeding, or showing signs of perforation, abscess or fistula formation, or significant comorbidity, they can be treated at home.

      The first step in treatment is to prescribe broad-spectrum antibiotics that cover anaerobes and Gram-negative rods. Co-amoxiclav or a combination of ciprofloxacin and metronidazole (if allergic to penicillin) are good options. The course of antibiotics should last for at least 7 days.

      If the patient’s symptoms worsen or persist beyond 48 hours, hospital admission may be necessary. However, with proper management and monitoring, most cases of diverticulitis can be successfully treated in primary care.

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      • Gastroenterology
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  • Question 17 - An 80-year-old woman presents to your clinic with complaints of constipation. She reports...

    Incorrect

    • An 80-year-old woman presents to your clinic with complaints of constipation. She reports a four week history of reduced stool frequency with firmer stool consistency. She currently has a bowel movement every other day, whereas prior to the last four weeks she had a bowel movement once a day. She denies any rectal bleeding or diarrhea and has no anal symptoms or incontinence. On examination, her abdomen is soft and non-tender without masses. Rectal examination is also normal. She has been taking codeine phosphate 30 mg qds for her arthritic knee, which was prescribed by a colleague one month ago. Recent blood tests show normal full blood count, ESR, thyroid function, and calcium. What is the most appropriate management for this patient?

      Your Answer: Refer urgently to a lower gastrointestinal specialist

      Correct Answer: Provide advice regarding the constipation and reassure

      Explanation:

      Managing Constipation in a Patient on Analgesia

      The patient’s constipation is not a mystery as it coincides with the prescription of codeine phosphate, which slows down bowel transit. There are no other concerning symptoms in the patient’s history or examination that would warrant an urgent referral to a lower gastrointestinal specialist for suspected cancer.

      To manage the patient’s constipation, the healthcare provider should provide advice on diet and lifestyle, review the patient’s medication to identify any contributing factors, and counsel the patient on red flags. The patient has already undergone blood tests to investigate secondary causes of constipation, such as hypothyroidism or hypercalcaemia. The healthcare provider can also discuss the use of laxatives with the patient.

      Overall, managing constipation in a patient on analgesia involves identifying contributing factors, providing lifestyle advice, and discussing treatment options with the patient.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - A 62-year-old woman presents to her General Practitioner with complaints of epigastric pain...

    Incorrect

    • A 62-year-old woman presents to her General Practitioner with complaints of epigastric pain and waterbrash that have lasted for four months. It is not worsening, but neither is it resolving. She has been taking alendronic acid tablets for osteoporosis over a similar timeframe. There is no history of dysphagia or weight loss and an examination of her abdomen is normal. Full blood count, inflammatory markers, urea and electrolytes, and liver function tests are all normal.
      Which of the following is the single most likely diagnosis?

      Your Answer: Pancreatic carcinoma

      Correct Answer: Oesophagitis

      Explanation:

      Possible Causes of Epigastric Pain: A Case Study

      Epigastric pain is a common complaint among adults, with up to 60% experiencing heartburn and using over-the-counter products to relieve indigestion. However, it can also be a symptom of more serious conditions such as oesophagitis, gastric carcinoma, pancreatic carcinoma, peptic ulcer disease, and oesophageal carcinoma.

      In a case study, a patient presented with stable epigastric pain for four months, accompanied by waterbrash and a history of alendronate use. While gastric and pancreatic carcinomas were deemed unlikely due to the absence of red flag symptoms and deterioration in clinical condition, oesophagitis was considered the most likely diagnosis. Contributing factors such as alcohol, NSAIDs, bisphosphonates, and smoking were identified, and treatment involved eliminating these factors and using proton pump inhibitors like omeprazole.

      Overall, it is important to consider various possible causes of epigastric pain and conduct a thorough evaluation to determine the appropriate diagnosis and treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 19 - A 27 year old woman presents with intermittent abdominal bloating, pain and diarrhea...

    Correct

    • A 27 year old woman presents with intermittent abdominal bloating, pain and diarrhea for the past 3 months. She denies any rectal bleeding, weight loss or family history of bowel disease. On examination, her abdomen appears normal. Along with a full blood count (FBC), urea & electrolytes (U&E), coeliac screen, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), what initial investigation would be most helpful in differentiating between irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) in a primary care setting?

      Your Answer: Faecal calprotectin

      Explanation:

      NICE recommends the use of faecal calprotectin in primary care to distinguish between IBS and IBD. This protein is released in the bowel during inflammation and can be detected in a stool sample. Its use can reduce the need for invasive diagnostic testing and referral of patients with typical IBS symptoms. However, a positive result doesn’t confirm IBD and patients should be referred to secondary care for further investigation.

      NICE has also provided guidance on the diagnostic criteria for IBS and the necessary investigations. They suggest conducting FBC, ESR, CRP, and coeliac screen (TTG). However, they advise against performing ultrasound, sigmoidoscopy or colonoscopy, barium study, thyroid function test, stool microscopy and culture, and faecal occult blood and hydrogen breath test.

      Understanding Diarrhoea: Causes and Characteristics

      Diarrhoea is defined as having more than three loose or watery stools per day. It can be classified as acute if it lasts for less than 14 days and chronic if it persists for more than 14 days. Gastroenteritis, diverticulitis, and antibiotic therapy are common causes of acute diarrhoea. On the other hand, irritable bowel syndrome, ulcerative colitis, Crohn’s disease, colorectal cancer, and coeliac disease are some of the conditions that can cause chronic diarrhoea.

      Symptoms of gastroenteritis may include abdominal pain, nausea, and vomiting. Diverticulitis is characterized by left lower quadrant pain, diarrhoea, and fever. Antibiotic therapy, especially with broad-spectrum antibiotics, can also cause diarrhoea, including Clostridioides difficile infection. Chronic diarrhoea may be caused by irritable bowel syndrome, which is characterized by abdominal pain, bloating, and changes in bowel habits. Ulcerative colitis may cause bloody diarrhoea, crampy abdominal pain, and weight loss. Crohn’s disease may cause crampy abdominal pain, diarrhoea, and malabsorption. Colorectal cancer may cause diarrhoea, rectal bleeding, anaemia, and weight loss. Coeliac disease may cause diarrhoea, abdominal distension, lethargy, and weight loss.

      Other conditions associated with diarrhoea include thyrotoxicosis, laxative abuse, appendicitis, and radiation enteritis. It is important to seek medical attention if diarrhoea persists for more than a few days or is accompanied by other symptoms such as fever, severe abdominal pain, or blood in the stool.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 20 - A 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21...

    Correct

    • A 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21 μmol/l). He has suffered from episodic jaundice in the past but is otherwise fit and well. His diagnosis is Gilbert syndrome.
      Which of the following is associated with Gilbert syndrome?

      Your Answer: γ-glutamyltransferase in the normal range

      Explanation:

      Understanding Gilbert Syndrome: Symptoms, Risks, and Diagnosis

      Gilbert syndrome is a common, benign condition that causes mild unconjugated hyperbilirubinaemia. It is familial and occurs in 5-10% of adults in Western Europe. While some patients may experience symptoms such as fatigue, nausea, and abdominal pain, many are asymptomatic. Jaundice is usually mild and can worsen with physical exertion, fasting, or dehydration. However, liver function tests, including γ-glutamyltransferase, should be normal.

      Unlike other liver conditions, Gilbert syndrome doesn’t cause abnormal liver histology or conjugated hyperbilirubinaemia. It is also not a risk factor for kernicterus at birth.

      Diagnosis of Gilbert syndrome is based on clinical presentation and elevated unconjugated bilirubin levels. Fasting can actually increase bilirubin levels in this condition. Therefore, it is important to rule out other liver disorders if abnormal liver function tests or histology are present.

      Overall, understanding the symptoms, risks, and diagnosis of Gilbert syndrome can help healthcare providers provide appropriate care and management for patients with this condition.

    • This question is part of the following fields:

      • Gastroenterology
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