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  • Question 1 - A 57-year-old man presents to his general practitioner (GP) with a 2-month history...

    Incorrect

    • A 57-year-old man presents to his general practitioner (GP) with a 2-month history of pain and difficulty swallowing when eating solid foods and now also has trouble swallowing liquids. He states that his trousers now feel looser around his waist and he no longer looks forward to his meals. His past medical history is significant for reflux disease for which he takes over-the-counter Gaviscon. He has a 20-pack-year history of smoking and drinks approximately 15 pints of beer per week. His family medical history is unremarkable.
      His observations are shown below:
      Temperature 36.4°C
      Blood pressure 155/69 mmHg
      Heart rate 66 beats per minute
      Respiratory rate 13 breaths per minute
      Sp(O2) 99% (room air)
      Physical examination is normal.
      Which of the following is the best next step in management?

      Your Answer: Proton-pump inhibitor (PPI) therapy

      Correct Answer: Immediate referral to upper gastrointestinal surgeon

      Explanation:

      Appropriate Management for a Patient with Dysphagia and ‘Alarm’ Symptoms

      When a patient presents with dysphagia and ‘alarm’ symptoms such as weight loss, anorexia, and swallowing difficulties, prompt referral for an urgent endoscopy is necessary. In the case of a patient with a significant smoking history, male sex, and alcohol intake, there is a high suspicion for oesophageal cancer, and an immediate referral to an upper gastrointestinal surgeon is required under the 2-week-wait rule.

      Continuing treatment with over-the-counter medications like Gaviscon would be inappropriate in this case, as would histamine-2 receptor antagonist therapy. Oesophageal manometry would only be indicated if the patient had an oesophageal motility disorder. Proton-pump inhibitor (PPI) therapy can be initiated in patients with gastroesophageal reflux disease, but it would not be appropriate as a sole treatment option for a patient with clinical manifestations concerning for oesophageal carcinoma.

      In summary, prompt referral for an urgent endoscopy is crucial for patients with dysphagia and ‘alarm’ symptoms, and appropriate management should be tailored to the individual patient’s clinical presentation.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 2 - A 40-year-old woman has been visiting her doctor frequently over the past year...

    Correct

    • A 40-year-old woman has been visiting her doctor frequently over the past year due to recurring episodes of abdominal cramps and diarrhoea. She is concerned about the possibility of bowel cancer, as her father passed away from it at the age of 86. She has no other relevant family history. She also mentions that she needs a refill for her salbutamol inhaler, which she takes for her recently diagnosed asthma. Additionally, she has noticed an increase in hot flashes and wonders if she is experiencing early menopause. She has lost some weight, which she attributes to her healthy diet. What is the most probable diagnosis?

      Your Answer: Gastrointestinal neuroendocrine tumour (NET)

      Explanation:

      Diagnosis and Management of Gastrointestinal Neuroendocrine Tumour (NET)

      A patient presenting with symptoms of diarrhoea, wheezing, and flushing may have a gastrointestinal neuroendocrine tumour (NET), also known as carcinoid syndrome. It is important to consider NET in the differential diagnosis, even in relatively young patients, as the average delay in diagnosis is 2-3 years.

      Appropriate investigations include routine blood tests, gut hormone measurement, 24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA) measurement, cross-sectional imaging, and gastrointestinal endoscopy. Management options include somatostatin analogues, peptide receptor radiotargeted therapy (PRRT), and molecularly targeted treatments such as sunitinib or everolimus.

      Health/illness-related anxiety, or hypochondriasis, should be a diagnosis of exclusion, and physical causes should be addressed first. Irritable bowel syndrome may cause similar symptoms, but without hot flashes or asthma. Colorectal or gastric adenocarcinoma may also be considered, but the symptoms are more consistent with a NET.

      Most gastrointestinal NETs are low grade, and even in metastatic disease, the median overall survival is around 10 years. Early diagnosis and appropriate management can improve outcomes for patients with NET.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 3 - A 26-year-old man has recently been diagnosed with ulcerative colitis. Investigation has revealed...

    Incorrect

    • A 26-year-old man has recently been diagnosed with ulcerative colitis. Investigation has revealed that he has distal disease only. He has a moderate exacerbation of his disease with an average of 4–5 episodes of bloody diarrhoea per day. There is no anaemia. His pulse rate is 80 bpm. He has no fever. His erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are normal.
      Which is the most appropriate medication to use in the first instance in this exacerbation?

      Your Answer: Cyclosporine

      Correct Answer: Mesalazine

      Explanation:

      Treatment Options for Moderate Exacerbation of Distal Ulcerative Colitis

      Distal ulcerative colitis can cause moderate exacerbation, which is characterized by 4-6 bowel movements per day, pulse rate <90 bpm, no anemia, and ESR 30 or below. The first-line therapy for this condition includes topical or oral aminosalicylate, with mesalazine or sulfasalazine being the most commonly used options. However, these medications can cause side-effects such as diarrhea, vomiting, abdominal pain, and hypersensitivity. In rare cases, they may also lead to peripheral neuropathy and blood disorders. Codeine phosphate is not used in the management of ulcerative colitis, while ciclosporin is reserved for acute severe flare-ups that do not respond to corticosteroids. Infliximab, a monoclonal antibody against tumour necrosis α, is used for patients who are intolerant to steroids or have not responded to corticosteroid therapy. However, it can cause hepatitis and interstitial lung disease, and may reactivate tuberculosis and hepatitis B. Steroids such as prednisolone can be used as second-line treatment if the patient cannot tolerate or declines aminosalicylates or if aminosalicylates are contraindicated. Topical corticosteroids are usually preferred, but oral prednisolone can also be considered.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - Olivia is a 15-year-old girl presenting with abdominal pains. The abdominal pain was...

    Incorrect

    • Olivia is a 15-year-old girl presenting with abdominal pains. The abdominal pain was around her lower abdomen and is crampy in nature and occasionally radiates to her back. Her pain normally comes on approximately before the onset of her period. She also feels increasingly fatigued during this period. No abdominal pains were noted outside of this menstrual  period. Olivia has no significant medical history. She denies any recent changes in her diet or bowel habits. She has not experienced any recent weight loss or rectal bleeding. She denies any family history of inflammatory bowel disease or colon cancer. Given the likely diagnosis, what is the likely 1st line treatment?

      Your Answer:

      Correct Answer: Mefenamic acid

      Explanation:

      Primary dysmenorrhoea is likely the cause of the patient’s abdominal pain, as it occurs around the time of her menstrual cycle and there are no other accompanying symptoms. Since the patient is not sexually active and has no risk factors, a pelvic ultrasound may not be necessary to diagnose primary dysmenorrhoea. The first line of treatment for this condition is NSAIDs, such as mefenamic acid, ibuprofen, or naproxen, which work by reducing the amount of prostaglandins in the body and thereby reducing the severity of pain.

      Dysmenorrhoea is a condition where women experience excessive pain during their menstrual period. There are two types of dysmenorrhoea: primary and secondary. Primary dysmenorrhoea affects up to 50% of menstruating women and is not caused by any underlying pelvic pathology. It usually appears within 1-2 years of the menarche and is thought to be partially caused by excessive endometrial prostaglandin production. Symptoms include suprapubic cramping pains that may radiate to the back or down the thigh, and pain typically starts just before or within a few hours of the period starting. NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women, and combined oral contraceptive pills are used second line for management.

      Secondary dysmenorrhoea, on the other hand, typically develops many years after the menarche and is caused by an underlying pathology. The pain usually starts 3-4 days before the onset of the period. Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices, and fibroids. Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation. It is important to note that the intrauterine system (Mirena) may help dysmenorrhoea, but this only applies to normal copper coils.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 55-year-old woman presents with acute abdominal pain and a temperature of 38.5...

    Incorrect

    • A 55-year-old woman presents with acute abdominal pain and a temperature of 38.5 °C, pulse 130 bpm and blood pressure 100/70 mmHg. She does not allow any attending doctor to touch her abdomen, as she is in severe pain.
      Past records reveal that she was suffering from ulcerative colitis, for which she was on oral mesalazine and azathioprine. She has recently had diarrhoea for which she has taken loperamide.
      What is the next appropriate diagnostic test?

      Your Answer:

      Correct Answer: Erect X-ray of the abdomen

      Explanation:

      Diagnostic Tests for Suspected Toxic Megacolon in a Patient with Ulcerative Colitis

      When a patient with ulcerative colitis (UC) presents with fever and severe abdominal pain after taking anti-diarrhoeal agents, toxic megacolon should be considered as a potential complication. This rare but life-threatening condition can be precipitated by electrolyte disturbances, antimotility agents, opiates, barium enema studies, and colonoscopies during acute UC episodes. To diagnose toxic megacolon, a straight X-ray of the abdomen is necessary to show colonic dilation with a diameter greater than 6 cm and loss of haustrations, which is typically found in the transverse colon. Perforation and peritonitis are also possible complications, which can be detected by an erect chest X-ray. Regular clinical examination is crucial since patients with toxic megacolon may not exhibit signs of peritonitis after perforation due to steroid use. While blood tests for serum electrolytes, C-reactive protein (CRP), and antineutrophil cytoplasmic antibodies (ANCA) may be useful in diagnosing UC, they are not specific to toxic megacolon. Azathioprine toxicity is also unlikely in this case, as it typically presents with bone marrow suppression and is only a concern when used concurrently with allopurinol or in patients lacking TPMT activity.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - An obese 60-year-old man presents to his General Practitioner (GP) with ongoing vague...

    Incorrect

    • An obese 60-year-old man presents to his General Practitioner (GP) with ongoing vague abdominal pain and fatigue for the last three months. His past medical history is significant for type 2 diabetes mellitus and hypertension.
      Physical examination suggests hepatomegaly. Laboratory studies reveal a negative hepatitis panel and normal iron studies. Antibodies for autoimmune liver disease are also normal.
      A diagnosis of non-alcoholic fatty liver disease (NAFLD) is likely.
      Which of the following is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Weight loss

      Explanation:

      Management of Hepatomegaly and Non-Alcoholic Fatty Liver Disease (NAFLD)

      Hepatomegaly and non-alcoholic fatty liver disease (NAFLD) are common conditions that require appropriate management to prevent progression to liver cirrhosis and other complications. The following are important considerations in the management of these conditions:

      Diagnosis: Diagnosis of NAFLD involves ruling out other causes of hepatomegaly and demonstrating hepatic steatosis through liver biopsy or radiology.

      Conservative management: Most patients with NAFLD can be managed conservatively with maximized control of cardiovascular risk factors, weight loss, immunizations to hepatitis A and B viruses, and alcohol abstinence. Weight loss in a controlled manner is recommended, with a 10% reduction in body weight over a 6-month period being an appropriate recommendation to patients. Rapid weight loss should be avoided, as it can worsen liver inflammation and fibrosis. Unfortunately, no medications are currently licensed for the management of NAFLD.

      Liver transplant: Patients with NAFLD do not require a liver transplant at this stage. Conservative management with weight loss and controlling cardiovascular risk factors is the recommended approach.

      Oral steroids: Oral steroids are indicated in patients with autoimmune hepatitis. Patients with autoimmune hepatitis typically present with other immune-mediated conditions like pernicious anemia and ulcerative colitis.

      Penicillamine: Penicillamine is the treatment for patients with Wilson’s disease, a rare disorder of copper excretion that leads to excess copper deposition in the liver and brain. Patients typically present with neurological signs like tremor, ataxia, clumsiness, or abdominal signs like fulminant liver failure.

      Ursodeoxycholic acid: Ursodeoxycholic acid is used in the management of primary biliary cholangitis (PBC), a condition more common in women. Given this patient’s normal autoimmune screen, PBC is an unlikely diagnosis.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - A 55-year-old man, with a 25-pack-year history of smoking, presents to his General...

    Incorrect

    • A 55-year-old man, with a 25-pack-year history of smoking, presents to his General Practitioner with a 3-month history of epigastric pain. He has been unable to mow his lawn since the pain began and is often woken up at night. He finds that the pain is relieved by taking antacids. He has also had to cut back on his spicy food intake.
      What is the most probable reason for this man's epigastric pain?

      Your Answer:

      Correct Answer: Duodenal ulcer

      Explanation:

      Common Gastrointestinal Conditions and Their Symptoms

      Gastrointestinal conditions can cause a range of symptoms, from mild discomfort to severe pain. Here are some of the most common conditions and their symptoms:

      Duodenal Ulcer: These are breaks in the lining of the duodenum, which is part of the small intestine. They are more common than gastric ulcers and are often caused by an overproduction of gastric acid. Symptoms include epigastric pain that is relieved by eating or drinking milk.

      Gastric Ulcer: These are less common than duodenal ulcers and tend to occur in patients with normal or low levels of gastric acid. Risk factors are similar to those of duodenal ulcers. Symptoms include epigastric pain.

      Oesophagitis: This condition occurs when stomach acid flows back into the oesophagus, causing inflammation. Treatment is aimed at reducing reflux symptoms. Patients may need to be assessed for Barrett’s oesophagus.

      Pancreatitis: This condition is characterized by inflammation of the pancreas and typically presents with epigastric pain that radiates to the back.

      Gallstones: These are hard deposits that form in the gallbladder and can cause right upper quadrant pain. Symptoms may be aggravated by eating fatty foods. While historically more common in females in their forties, the condition is becoming increasingly common in younger age groups.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - A 38-year-old man is referred by his general practitioner due to experiencing epigastric...

    Incorrect

    • A 38-year-old man is referred by his general practitioner due to experiencing epigastric pain. The pain occurs approximately 3 hours after eating a meal. Despite using both histamine 2 receptor blockers and proton pump inhibitors (PPIs), he has only experienced moderate relief and tests negative on a urease breath test. An endoscopy is performed, revealing multiple duodenal ulcers. The patient's gastrin level is tested and found to be above normal. A computed tomography (CT) scan is ordered, and the patient is diagnosed with Zollinger-Ellison syndrome. Which hormone typically inhibits gastrin secretion?

      Your Answer:

      Correct Answer: Somatostatin

      Explanation:

      Hormones and Enzymes: Their Effects on Gastrin Secretion

      Gastrin secretion is regulated by various hormones and enzymes in the body. One such hormone is somatostatin, which inhibits the release of gastrin. In the treatment of gastrinomas, somatostatin analogues like octreotide can be used instead of proton pump inhibitors (PPIs).

      Aldosterone, on the other hand, is a steroid hormone that is not related to gastrin and has no effect on its secretion. Similarly, glycogen synthase and hexokinase, which play regulatory roles in carbohydrate metabolism, do not affect gastrin secretion.

      Another steroid hormone, progesterone, also does not play a role in the regulation of gastrin secretion. Understanding the effects of hormones and enzymes on gastrin secretion can help in the development of targeted treatments for gastrointestinal disorders.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - A 35-year-old man presents with sudden onset abdominal pain that worsens when lying...

    Incorrect

    • A 35-year-old man presents with sudden onset abdominal pain that worsens when lying down. He reports feeling nauseous and has been vomiting. The nursing staff notes that he has a rapid heart rate and a fever of 38.1°C. Upon examination, his abdomen is tender and there is significant guarding. Bruising is present around his belly button. The patient admits to drinking six cans of strong beer daily and smoking two packs of cigarettes per day. He recalls being hospitalized two years ago for vomiting blood but cannot remember the treatment he received. He has no other significant medical history and does not take any regular medications. What is the most likely cause of the man's symptoms and presentation?

      Your Answer:

      Correct Answer: Pancreatitis with retroperitoneal haemorrhage

      Explanation:

      Differential diagnosis for a man with abdominal pain, nausea, and periumbilical bruising

      The man in question presents with classic symptoms of pancreatitis, including abdominal pain that radiates to the back and worsens on lying down. However, his periumbilical bruising suggests retroperitoneal haemorrhage, which can also cause flank bruising. Given his alcohol consumption, coagulopathy is a possible contributing factor. Hepatic cirrhosis could explain coagulopathy, but not the rapid onset of abdominal pain or the absence of ecchymosis elsewhere. A ruptured duodenal ulcer or bleeding oesophageal varices are less likely causes, as there is no evidence of upper gastrointestinal bleeding this time. A pancreatic abscess is a potential complication of pancreatitis, but would typically have a longer onset and more systemic symptoms. Therefore, the differential diagnosis includes pancreatitis with retroperitoneal haemorrhage, possibly related to coagulopathy from alcohol use.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - A General Practice is conducting an audit on the number of elderly patients...

    Incorrect

    • A General Practice is conducting an audit on the number of elderly patients with gastrointestinal symptoms who were referred for endoscopy without a clear clinical indication.
      Which of the following intestinal diseases necessitates blood tests and small intestinal biopsy for precise diagnosis?

      Your Answer:

      Correct Answer: Coeliac disease

      Explanation:

      Diagnostic Biopsy Findings for Various Intestinal Conditions

      When conducting a biopsy of the small intestine, various changes may be observed that can indicate the presence of certain conditions. However, it is important to note that these changes are not always specific to a particular disease and may be found in other conditions as well. Therefore, additional diagnostic tests may be necessary to confirm a diagnosis.

      Coeliac disease is one condition that can be suggested by biopsy findings, which may include infiltration by lymphocytes and plasma cells, villous atrophy, and crypt hyperplasia. However, positive serology for anti-endomysial or anti-gliadin antibodies is also needed to confirm gluten sensitivity.

      Abetalipoproteinemia, Mycobacterium avium infection, Whipple’s disease, and intestinal lymphangiectasia are other conditions that can be diagnosed based on biopsy findings alone. Abetalipoproteinemia is characterized by clear enterocytes due to lipid accumulation, while Mycobacterium avium infection is identified by the presence of foamy macrophages containing acid-fast bacilli. In Whipple’s disease, macrophages are swollen and contain PAS-positive granules due to the glycogen content of bacterial cell walls. Finally, primary intestinal lymphangiectasia is diagnosed by the dilation of lymphatics in the intestinal mucosa without any evidence of inflammation.

    • This question is part of the following fields:

      • Gastroenterology
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Gastroenterology (1/3) 33%
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