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Question 1
Incorrect
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A 42-year-old woman presents with a history of diarrhoea for the past eight weeks and fresh rectal bleeding for the past few weeks. She has a past medical history of irritable bowel syndrome and frequently experiences bloating, which has worsened in recent weeks. She started a new job two months ago, which has been stressful. On examination, there is abdominal tenderness but no other abnormal signs.
What would be the most appropriate next step in management?Your Answer: Refer for an urgent outpatient appointment
Correct Answer: Prescribe GTN ointment and review in a month
Explanation:Urgent Referral for Rectal Bleeding and Diarrhoea
This woman is experiencing persistent diarrhoea and rectal bleeding, which cannot be attributed to irritable bowel syndrome. According to NICE guidelines, she requires urgent referral for suspected cancer pathway referral within two weeks. This is because she is under 50 years of age and has rectal bleeding with unexplained symptoms such as abdominal pain, weight loss, and iron-deficiency anaemia.
Prescribing GTN ointment or loperamide would not be appropriate in this case as they would only delay diagnosis and not address the underlying issue. Carcinoembryonic antigen testing is useful for assessing prognosis and monitoring treatment in colorectal cancer patients, but it should only be ordered after malignancy has been confirmed. Similarly, TTG testing for coeliac disease is good practice for patients with IBS-like symptoms, but it would not be appropriate in the presence of rectal bleeding of unknown origin.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Correct
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A 50-year-old woman presents with jaundice and itching.
Which of the following results would most strongly support the diagnosis of primary biliary cholangitis?
Your Answer: Antimitochondrial antibodies
Explanation:Understanding Primary Biliary Cholangitis: Diagnostic Tests and Markers
Primary biliary cholangitis is an autoimmune disease that affects the biliary system, causing intrahepatic cholestasis and leading to cell damage, fibrosis, and cirrhosis. While there is no single definitive test for this condition, several markers can help diagnose and monitor it.
Antimitochondrial antibodies are present in 90-95% of individuals with primary biliary cholangitis, but are only found in 0.5% of normal controls. Anti-smooth muscle antibodies are also nonspecific, as they can be positive in connective tissue disease and chronic infections. Similarly, around 35% of patients with primary biliary cholangitis have positive antinuclear antibodies, but this is not specific to the condition.
Elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are common in primary biliary cholangitis, but significant elevations of alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (GGT) are usually more prominent. Additionally, a polyclonal increase in IgM (sometimes associated with elevated IgG) is typical but not specific to this condition.
Overall, a combination of these diagnostic tests and markers can help identify and monitor primary biliary cholangitis.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Correct
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A 60-year-old man comes to your clinic with a three-month history of dysphagia for solids. He reports weight loss and loss of appetite. He has a history of indigestion and heartburn for the past five years. He takes Gaviscon and Rennie tablets regularly. He is a heavy smoker and drinks regularly. During an endoscopy, a small tumour is found at the lower end of his oesophagus. What is the most probable cause of the tumour?
Your Answer: Barrett's oesophagus
Explanation:Gastro-oesophageal Reflux and its Potential Consequences
The patient’s medical history indicates a prolonged period of gastro-oesophageal reflux, which can lead to the development of Barrett’s oesophagus. This condition occurs when the normal squamous epithelium of the oesophageal lining is replaced by columnar epithelium, which is a precursor to cancer. To monitor for the presence of metaplasia, surveillance endoscopies are recommended every two to five years, depending on the length of the Barrett’s segment. If dysplasia is detected, more frequent surveillance or treatment may be necessary.
The onset of dysphagia for solids and weight loss is concerning, as it may indicate the presence of oesophageal carcinoma.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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You see a child who you are investigating for coeliac disease. Their serology test result is positive.
What would be the next step in your management?Your Answer: Repeat the serology test in 4 weeks
Correct Answer: No intervention
Explanation:Diagnosis of Coeliac Disease
Patients who are suspected of having coeliac disease and have positive serology test results should be referred to a gastroenterologist for further investigation. The gastroenterologist will perform an endoscopy and intestinal biopsy to confirm or exclude the diagnosis of coeliac disease. It is important for patients to continue eating gluten-containing foods until the biopsy is performed to ensure accurate results.
While dietary advice may be helpful if coeliac disease is confirmed, it is more appropriate to first seek a referral to a gastroenterologist. There is no need to repeat the serology test if it is positive. For more information on how to interpret coeliac serology results, refer to the link provided below. Proper diagnosis and management of coeliac disease can greatly improve a patient’s quality of life.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Correct
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A 25-year-old woman presents to her General Practitioner in her 28th week of pregnancy. After an uneventful first and second trimester to date, she has developed widespread itching over the last three weeks and she now has mild jaundice. Her bilirubin is 80 μmol/l (normal <21 μmol/l), alanine aminotransferase (ALT) at 82 IU/l (normal <40 IU/l), and the alkaline phosphatase is markedly raised.
Which of the following is the diagnosis that fits best with this clinical picture?
Your Answer: Intrahepatic cholestasis of pregnancy
Explanation:Liver Disorders in Pregnancy: Differential Diagnosis
During pregnancy, various liver disorders can occur, leading to abnormal liver function tests. Intrahepatic cholestasis of pregnancy is the most common pregnancy-related liver disorder, affecting 0.1-1.5% of pregnancies. It typically presents in the late second or early third trimester with generalized itching, starting on the palms and soles. An elevated alanine aminotransferase (ALT) is a more sensitive marker than aspartate aminotransferase (AST), and a fasting serum bile acid concentration of greater than 10 mmol/l is the key diagnostic test. Primary biliary cholangitis and acute fatty liver of pregnancy are less likely diagnoses, while cholelithiasis and hyperemesis gravidarum have different clinical presentations. Early diagnosis and management of liver disorders in pregnancy are crucial to prevent adverse outcomes such as prematurity and stillbirth.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Correct
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A 65-year-old White woman presents to her General Practitioner with right upper quadrant pain, a liver mass, weight loss and anaemia. She describes no symptoms prior to this episode and is not on any regular medications.
She drinks around ten units of alcohol per week and was previously an intravenous (IV) drug user, although she has not done this for many years. She has no significant family history.
She is diagnosed with hepatocellular carcinoma (HCC).
What is the most likely predisposing factor for this diagnosis in this patient?Your Answer: Hepatitis C
Explanation:Understanding the Possible Causes of Hepatocellular Carcinoma (HCC)
Hepatocellular carcinoma (HCC) is a type of liver cancer that can be caused by various factors. In this case, the patient’s history of intravenous (IV) drug use puts her at risk of hepatitis B and C, which are the most common causes of HCC in Europe. Chronic hepatitis B or C infection can increase the risk of developing HCC by 3-5% per year, and having both infections can further increase the risk.
Alcohol abuse is also a risk factor for HCC, but in this patient’s case, her drinking is not excessive. Hereditary hemochromatosis, a condition that causes the body to absorb too much iron, can also increase the risk of HCC, but it is less common than chronic hepatitis. However, this patient’s lack of previous symptoms and family history make it unlikely that hemochromatosis is the underlying cause of her HCC.
Another possible predisposing factor for HCC is primary biliary cholangitis (PBC), an autoimmune disease that affects the liver’s bile ducts. PBC is more common in women and may present with fatigue and pruritus, but this patient’s symptoms do not fit this clinical picture.
In summary, understanding the possible causes of HCC can help in identifying the underlying factors and developing appropriate treatment plans. In this patient’s case, chronic hepatitis B or C infection is the most likely cause of her HCC.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Incorrect
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Which of the following is not a known complication of coeliac disease in children?
Your Answer: Oesophageal cancer
Correct Answer: Hypersplenism
Explanation:Coeliac disease is associated with hypo-, rather than hypersplenism.
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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This question is part of the following fields:
- Gastroenterology
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Question 8
Correct
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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: 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.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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A 25-year-old woman presents to you with concerns about her risk for familial adenomatous polyposis (FAP). Her father and older brother have been diagnosed with the condition, and she previously declined testing but is now reconsidering. Her mother's side of the family has no history of illness. What is the probability that she has FAP? Select ONE answer.
Your Answer: 25%
Correct Answer: 50%
Explanation:Understanding the Inheritance Probability of Autosomal-Dominant Traits
Autosomal-dominant traits are genetic conditions that only require one affected gene to be inherited in order for the trait to be displayed. In the case of a patient whose father has Familial Adenomatous Polyposis (FAP), a rare autosomal-dominant condition, there is a 50% chance that she has inherited the affected gene from her father. This is because her father has one affected gene and one unaffected gene, and there is an equal chance of either gene being passed down to his offspring.
It is important to note that there is no 100% chance of being affected by an autosomal-dominant condition unless the parent is homozygous, meaning they carry two affected genes and no unaffected genes. This is unlikely in the case of FAP.
On the other hand, a 25% chance of being affected is associated with autosomal-recessive conditions, but only if both parents are carriers of the affected gene. In the case of autosomal-dominant traits, there is always some risk of inheriting the condition if one parent is affected.
To determine a more specific probability of inheritance, a Punnett square can be used to calculate the possible outcomes. In the case of FAP, the patient has a 50% chance of inheriting the affected gene from her father. Therefore, understanding the inheritance probability of autosomal-dominant traits is crucial in predicting the likelihood of passing on the condition to future generations.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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A 55-year-old man has recently been diagnosed with a duodenal ulcer at endoscopy. He is not taking any medication that might have caused this. Testing for Helicobacter pylori (H. pylori) returns positive.
What is the most appropriate initial treatment regimen?Your Answer: H2-receptor antagonist, amoxicillin, clarithromycin
Correct Answer: PPI, clarithromycin, metronidazole
Explanation:Comparison of Treatment Options for H. Pylori Infection
When treating a patient with a positive H. Pylori test, it is important to choose the appropriate eradication therapy. The National Institute for Health and Care Excellence (NICE) recommends a 7-day course of PPI twice daily, amoxicillin 1 g twice daily, and either clarithromycin 500 mg twice daily or metronidazole 400 mg twice daily. If the patient is allergic to penicillin, then a PPI with clarithromycin and metronidazole should be prescribed. If the infection is associated with NSAID use, two months of PPI should be prescribed before eradication therapy.
It is important to note that H2-receptor antagonists should not be used as first-line treatment for H. Pylori. Instead, a PPI should be used. The recommended PPIs are lansoprazole, omeprazole, esomeprazole, pantoprazole, or rabeprazole.
While antacids and dietary advice can be helpful in managing dyspepsia, they are not sufficient for treating H. Pylori. Eradication therapy with appropriate antibiotics is necessary.
If the patient has an ulcer associated with NSAID use and a positive H. Pylori test, NICE recommends using a full-dose PPI for two months before prescribing eradication therapy. However, if the patient is not taking any medication, this step is not necessary.
Sucralfate can protect the mucosa from acid, but it is not part of NICE guidance for H. Pylori treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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A 40-year-old male presents to the GP with a 7-day history of fever, sore throat and muscle aches. On examination, he is visibly jaundiced, his blood pressure 130/80 mmHg, heart rate 80/min, respiratory rate 13/min, HS I + II + 0, breath sounds are vesicular and abdomen is soft but tender in the right upper quadrant with hepatomegaly. The GP orders blood tests which show:
Hb 140 g/L Male: (135-180)
Female: (115 - 160)
Platelets 220 * 109/L (150 - 400)
WBC 11.5 * 109/L (4.0 - 11.0)
Na+ 142 mmol/L (135 - 145)
K+ 4.0 mmol/L (3.5 - 5.0)
Urea 6.4 mmol/L (2.0 - 7.0)
Creatinine 100 µmol/L (55 - 120)
CRP 50 mg/L (< 5)
Bilirubin 80 µmol/L (3 - 17)
ALP 100 u/L (30 - 100)
ALT 500 u/L (3 - 40)
γGT 150 u/L (8 - 60)
Albumin 45 g/L (35 - 50)
What is the most likely diagnosis?Your Answer: Acute cholecystitis
Correct Answer: Hepatitis A
Explanation:The symptoms exhibited by the patient suggest acute hepatitis, with fever and jaundice being prominent. Autoimmune hepatitis is typically observed in young females, making it less likely in this male patient. Hence, hepatitis A is a more probable diagnosis, given his presentation of myalgia, sore throat, fever, and jaundice.
Understanding Hepatitis A: Symptoms, Transmission, and Prevention
Hepatitis A is a viral infection that affects the liver. It is usually a mild illness that resolves on its own, with serious complications being rare. The virus is transmitted through the faecal-oral route, often in institutions. The incubation period is typically 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests.
While complications are rare, there is no increased risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates).
It is important to note that the vaccine requires a booster dose 6-12 months after the initial dose. By understanding the symptoms, transmission, and prevention of hepatitis A, individuals can take steps to protect themselves and others from this viral infection.
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This question is part of the following fields:
- Gastroenterology
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Question 12
Incorrect
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A 57-year-old man presents with a long-standing history of alternating episodes of diarrhoea and normal bowel habit. During his episodes, he experiences severe left-sided abdominal pain which usually resolves over a few days. He has always had to monitor his diet to avoid constipation but has not experienced any weight loss. On examination, there is tenderness in the left lower quadrant of his abdomen with no palpable masses. What is the most probable diagnosis?
Your Answer: Irritable bowel syndrome
Correct Answer: Diverticulitis
Explanation:Understanding Diverticulosis and Diverticulitis: Symptoms and Management
Diverticulosis is a condition where small pouches called diverticula form in the lining of the colon. About 75% of people with diverticula have no symptoms. However, those with uncomplicated diverticulosis may experience lower abdominal pain, bloating, constipation, or rectal bleeding. These symptoms may be exacerbated by eating and relieved by defecation or flatus. Left lower quadrant tenderness and fullness may also be present, which can be mistaken for irritable bowel syndrome.
On the other hand, diverticulitis is a more serious condition where the diverticula become inflamed or infected. Patients with diverticulitis may experience intermittent or constant left lower quadrant pain, accompanied by a change in bowel habits. Pyrexia and tachycardia are common, and examination usually reveals localised tenderness and sometimes a palpable mass. Mild cases of diverticulitis can be managed at home with paracetamol, clear fluids, and oral antibiotics. However, one third of patients may develop further complications such as perforation, abscess, fistula, or stricture/obstruction.
It is important to differentiate diverticulitis from other conditions such as colonic cancer, Crohn’s disease, and ulcerative colitis. Colonic cancer may present with weight loss and a more definite change in bowel habit, while Crohn’s disease and ulcerative colitis usually present with diarrhoea at a younger age than diverticulitis. Barium enema or colonoscopy may be needed to confirm the diagnosis.
In summary, understanding the symptoms and management of diverticulosis and diverticulitis is crucial for early detection and treatment. Patients with mild diverticulitis can be managed at home, but those with severe symptoms or complications require hospitalisation and possibly surgery. Regular screening and follow-up are recommended for those with diverticulosis to prevent complications.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 25-year-old woman has been diagnosed as having coeliac disease. She has started on a gluten-free diet.
Select from the list the single most correct statement about her management.Your Answer: Iron and folate supplements should be routinely prescribed
Correct Answer: IgA anti-tissue transglutaminase antibodies and endomysial antibodies disappear if the diet is maintained
Explanation:Managing Coeliac Disease with a Gluten-Free Diet
Coeliac disease is a condition where the immune system reacts to gluten, a protein found in wheat, barley, and rye. The resulting damage to the intestinal mucosa can cause a range of symptoms, including abdominal pain, bloating, and diarrhoea. However, starting a gluten-free diet can lead to rapid improvement.
The diet involves avoiding all foods containing wheat, barley, or rye, such as bread, cake, and pies. Oats can be consumed in moderate quantities if they are free from other contaminating cereals, as they do not damage the intestinal mucosa in most coeliac patients. Rice, maize, potatoes, soya, jam, syrup, sugar, and treacle are all allowed. Gluten-free flour, bread, biscuits, and pasta can be prescribed on the NHS, and Coeliac UK provides a list of prescribable products.
To monitor the response to the diet, serial tTGA or EMA antibodies can be used. If these antibodies continue to be present in the blood, it suggests dietary lapses.
Supplements of calcium, vitamin D, iron, and folic acid are only necessary if dietary intake is inadequate, which is often the case, particularly in elderly patients. Most patients with coeliac disease have some degree of hyposplenism, which warrants immunisation against influenza, pneumococcus, and H. influenza type B. However, lifelong prophylactic antibiotics are not needed.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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A 66-year-old woman presents to you for a medication review. She underwent H. pylori eradication treatment a year ago, but her symptoms of epigastric burning returned within a few months. She has been taking omeprazole 20 mg/day since then. She reports that her symptoms are worsening again and asks if further treatment for Helicobacter pylori would be beneficial. She has lost more than 7 lbs in weight. You urgently refer her for an upper GI endoscopy.
What advice would you give her while waiting for the investigation?Your Answer: Stop the omeprazole (and any other acid suppression medication) for a minimum of two weeks prior to the endoscopy
Correct Answer: Increase her omeprazole to 40 mg daily
Explanation:Importance of Stopping Acid Suppression Medication Prior to Endoscopy
In urgent cases where endoscopy is required, it is recommended to stop acid suppression medication for at least two weeks before the procedure. This is because acid suppression medication can hide serious underlying conditions that need to be addressed. However, there may be situations where stopping the medication is difficult due to symptoms, and clinical judgement must be used.
For instance, if a patient experiences unintentional weight loss, it is a red flag symptom for upper GI malignancy, and urgent referral for endoscopy is necessary. In such cases, the benefits of stopping acid suppression medication should be weighed against the potential risks of continuing it. Ultimately, the decision should be made based on the patient’s individual circumstances and the urgency of the situation. Proper evaluation and management can help ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Correct
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A 50-year-old woman presents to her General Practitioner with complaints of flushing, right-sided abdominal discomfort, diarrhoea and palpitations. She has been experiencing weight loss and there is a palpable mass in her right lower abdomen.
What is the most probable diagnosis?Your Answer: Carcinoid syndrome
Explanation:Differential Diagnosis for a Patient with Flushing and Right-Sided Abdominal Mass
Carcinoid Syndrome and Other Differential Diagnoses
Carcinoid tumours are rare neuroendocrine tumours that can secrete various bioactive compounds, including serotonin and bradykinin, leading to a distinct clinical syndrome called carcinoid syndrome. The symptoms of carcinoid syndrome include flushing, bronchospasm, diarrhoea, and right-sided valvular heart lesions, such as tricuspid regurgitation. However, classical carcinoid syndrome occurs in less than 10% of patients with carcinoid tumours, and the diagnosis requires histological confirmation.
Other possible causes of flushing and right-sided abdominal mass in this patient include appendiceal abscess, caecal carcinoma, menopausal symptoms, and ovarian tumour. An appendiceal abscess usually results from acute appendicitis and presents with pain and fever. Caecal carcinoma can cause similar symptoms as carcinoid tumours, but it is more common and has a worse prognosis. Menopausal symptoms may cause flushing, but they do not explain the other symptoms or the mass. Ovarian tumours may cause abdominal distension and pain, but they are often asymptomatic in the early stages.
Therefore, a thorough evaluation of this patient’s medical history, physical examination, laboratory tests, and imaging studies is necessary to establish the correct diagnosis and guide the appropriate treatment. Depending on the suspected diagnosis, the management may involve surgery, chemotherapy, hormone therapy, or supportive care.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Correct
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A 56-year-old man presents to his GP with symptoms of acid reflux. Upon testing positive for Helicobacter pylori, he undergoes triple therapy with amoxicillin, clarithromycin, and omeprazole. He is also taking ramipril and amlodipine for his hypertension. After completing the course of amoxicillin and clarithromycin, he continues on omeprazole.
Several months later, he returns to his GP with complaints of muscle aches. His blood test results are as follows:
- Hb: 150 g/L (normal range for males: 135-180)
- Platelets: 215 * 109/L (normal range: 150-400)
- WBC: 5 * 109/L (normal range: 4.0-11.0)
- Na+: 142 mmol/L (normal range: 135-145)
- K+: 3.9 mmol/L (normal range: 3.5-5.0)
- Bicarbonate: 24 mmol/L (normal range: 22-29)
- Urea: 4 mmol/L (normal range: 2.0-7.0)
- Creatinine: 75 µmol/L (normal range: 55-120)
- Calcium: 2.4 mmol/L (normal range: 2.1-2.6)
- Phosphate: 1.2 mmol/L (normal range: 0.8-1.4)
- Magnesium: 0.53 mmol/L (normal range: 0.7-1.0)
- Creatine kinase: 51 U/L (normal range: 35-250)
Which medication is most likely responsible for the patient's muscle aches?Your Answer: Omeprazole
Explanation:Hypomagnesaemia, a condition that can lead to muscle weakness, is a potential side effect of long-term use of proton pump inhibitors. Although rare, this effect may occur after 3 months or more commonly after 1 year of therapy. However, clarithromycin, ramipril, amlodipine, and amoxicillin are not associated with hypomagnesaemia.
Understanding Proton Pump Inhibitors
Proton pump inhibitors (PPIs) are medications that work by blocking the H+/K+ ATPase in the stomach parietal cells. This action is irreversible and helps to reduce the amount of acid produced in the stomach. Examples of PPIs include omeprazole and lansoprazole.
Despite their effectiveness in treating conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers, PPIs can have adverse effects. These include hyponatremia and hypomagnesemia, which are low levels of sodium and magnesium in the blood, respectively. Prolonged use of PPIs can also increase the risk of osteoporosis, leading to an increased risk of fractures. Additionally, there is a potential for microscopic colitis and an increased risk of C. difficile infections.
It is important to weigh the benefits and risks of PPIs with your healthcare provider and to use them only as directed. Regular monitoring of electrolyte levels and bone density may also be necessary for those on long-term PPI therapy.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Correct
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A 75-year-old man admitted to the care of the elderly ward is experiencing diarrhoea and has been isolated in a side room with barrier nursing due to the isolation of Clostridium difficile in his stool samples. What medication is most likely causing his diarrhoea?
Your Answer: Clindamycin
Explanation:The use of clindamycin as a treatment is strongly associated with an increased risk of developing C. difficile infection. This is because broad spectrum antibiotics, including clindamycin, can disrupt the normal gut flora and allow for the overgrowth of C. difficile. Other antibiotics commonly used to treat C. difficile include vancomycin and metronidazole, which are administered orally to ensure high concentrations in the colon. Additionally, proton pump inhibitors like omeprazole and lansoprazole are also believed to contribute to the development of C. difficile infection.
Clostridioides 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.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Correct
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Correct
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Benjamin, who has been struggling with bowel issues, has been diagnosed with irritable bowel syndrome based on routine blood tests and his medical history. He experiences loose stool and abdominal discomfort, which is relieved after bowel movements, but there is no presence of blood in his stool. Despite increasing his fiber intake with brown rice, high bran cereals, and grains, as well as consuming three portions of fresh fruit daily for the past 18 months, his symptoms persist. What dietary recommendations would be suitable for him?
Your Answer: Reduce insoluble fibre intake
Explanation:Loose stool and bloating have been linked to the consumption of insoluble fibre found in foods like brown rice, bran cereals, and grains. As a result, it is recommended to decrease the intake of insoluble fibre.
To maintain a healthy digestive system, it is suggested to limit the consumption of fresh fruit to a maximum of three portions per day. There is currently no scientific evidence to support the use of aloe vera or prebiotics.
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.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 42-year-old woman visits her GP with concerns about her bowel habits and a family history of colorectal cancer. She has a known diagnosis of irritable bowel syndrome (IBS) and has previously been investigated for changeable bowel symptoms. Her father, who recently underwent surgery for colon cancer, suggested she get her carcinoembryonic antigen (CEA) levels checked. After undergoing tests, she is diagnosed with bowel cancer. What is the most appropriate use of monitoring CEA levels in managing her condition?
Your Answer:
Correct Answer: For postoperative follow-up
Explanation:The Role of Carcinoembryonic Antigen (CEA) in Cancer Management
Carcinoembryonic antigen (CEA) is a glycoprotein that is primarily produced by cells in the gastrointestinal tract during embryonic development. While its levels are low in adults, CEA is a useful tumour marker for colorectal cancers. In this article, we explore the different ways in which CEA is used in cancer management.
Postoperative Follow-up
CEA levels are expected to fall to normal following successful removal of colorectal cancer. A rising CEA level thereafter may indicate possible progression or recurrence of the cancer. However, temporary rises can occur during chemotherapy and radiotherapy, so changes during treatment may not necessarily indicate cancer progression.Staging
CEA levels are not used in staging as there are many variables that can affect the levels. More reliable investigations are used for staging.Indicator for Operability
While a CEA level at diagnosis higher than 100 ng/ml usually indicates metastatic disease, other investigations are used in the initial assessment of a newly diagnosed cancer to determine suitability for operative management.Screening Method
CEA is not sensitive or specific enough to use for diagnosis or screening. Cancers of the pancreas, stomach, breast, lung, medullary carcinoma of the thyroid, and ovarian cancer may also elevate CEA. Some non-malignant conditions such as cirrhosis, pancreatitis, and inflammatory bowel disease also cause blood levels to rise.Detection of Early Stage
CEA is not used for the diagnosis of colorectal cancers as it is not sufficiently sensitive or specific. Early tumours may not cause significant blood elevations, nor may some advanced tumours. -
This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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A 65-year-old man presents with persistent reflux, nausea and retrosternal burning pain after eating over the last six weeks. There has been no change in bowel habit and has not noticed any melaena but he has lost a little weight.
On examination there is no abnormality in the abdomen. His weight is 76 kg.
He has a ten year history of dyspepsia which he has been treating with over-the-counter antacids. He had triple therapy nine years ago having had positive serology to Helicobacter pylori. He drinks around 16-20 units of alcohol per week and is an ex-smoker.
He was seen at the out of hours centre five weeks ago and prescribed prochlorperazine, but this has made no difference to his symptoms.
What is the most appropriate management strategy?Your Answer:
Correct Answer: Prescribe a daily H2 receptor antagonist (for example, ranitidine) for four weeks then review
Explanation:Managing Gastro-Oesophageal Reflux Disease (GORD) with Alarm Symptoms
When managing someone with symptoms of gastro-oesophageal reflux disease (GORD), it is crucial to look for alarm features such as unintentional weight loss, dysphagia, GI bleeding, persistent vomiting, and signs of anaemia. Patients may report weight loss, which should be recorded periodically for comparisons. In the presence of alarm symptoms, it is important to refer urgently for upper GI endoscopy, especially for patients aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia. According to NICE guidelines, the referral should be made under the two-week wait. The positive serology to Helicobacter pylori nine years ago would not alter the management given the current presentation.
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This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 46-year-old gentleman presents with lower gastrointestinal symptoms. He has a history of irritable bowel syndrome and has suffered with infrequent bouts of abdominal bloating and loose stools on and off for years. These are usually managed with mebeverine and loperamide. The diagnosis of irritable bowel syndrome was a clinical one and the only investigation he has had in the past were blood tests.
Over the last four weeks he has noticed that this has changed and that his bowels have been persistently loose and significantly more frequent than usual. He has no family history of bowel problems.
On examination he is systemically well with no fever. His abdomen is soft and non-tender with no palpable masses. Rectal examination reveals nothing focal. His weight is stable.
Which of the following investigations should you offer your patient?Your Answer:
Correct Answer: Faecal occult blood
Explanation:Investigating Acute Bowel Symptoms in a Patient with Irritable Bowel Syndrome
When a patient with a history of irritable bowel syndrome presents with acute bowel symptoms, it is important to investigate the underlying cause. However, certain investigations may not be appropriate in this context. For example, an abdominal ultrasound scan is not helpful in investigating bowel symptoms. Similarly, CEA tumour marker testing is a specialist investigation and not suitable for primary care. Ca125 is a marker for ovarian cancer and not relevant in this scenario.
According to NICE guidelines, testing for occult blood in faeces should be offered to assess for colorectal cancer in adults aged 50 and over with unexplained abdominal pain or weight loss, or in those under 60 with changes in their bowel habit or iron-deficiency anaemia. Stool mc+s may be requested, but it would not be helpful in risk stratifying the patient for urgent referral for colorectal cancer if an infective aetiology is not suspected. Therefore, it is important to choose appropriate investigations based on the patient’s symptoms and medical history.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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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:
Correct 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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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Incorrect
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A 28-year-old woman who is morbidly obese comes to the clinic as she wishes to lose weight. She asks about the calorie content of common foods.
Which of the following foods contains the highest number of calories?
Your Answer:
Correct Answer: Cheddar cheese 100g
Explanation:Caloric and Fat Content of Selected Foods
When it comes to watching our calorie and fat intake, it’s important to be mindful of the foods we consume. Here’s a breakdown of the caloric and fat content of some common foods:
Cheddar Cheese 100g
This amount of cheddar cheese contains a whopping 413 kcal and 34g of fat, making it the highest in both categories compared to the other foods listed.Banana 100g
A 100g banana contains 95 kcal and is a great source of potassium and fiber.Cornflakes 30g
A 30g serving of cornflakes with 125 ml of semi-skimmed milk contains 173 kcal and 2.5g of fat.Orange Juice Unsweetened 140ml
140 ml of unsweetened orange juice contains roughly 50 kcal. While it’s important to be mindful of sugar intake, consuming a small glass of fruit juice each day can count towards our recommended daily intake of fruits and vegetables.Plain Scone 48g
A plain scone weighing 48g contains around 173 kcal and 7g of fat. It’s important to enjoy treats in moderation and balance them with healthier options. -
This question is part of the following fields:
- Gastroenterology
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Question 27
Incorrect
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A 45-year-old man comes to you complaining of severe, intermittent pain in his right flank. Upon urine dipstick examination, you find blood and suspect ureteric colic. Hospitalization is not necessary at this time, so you prescribe oral naproxen and schedule a non-contrast CT scan. What type of medication could also be helpful in this situation?
Your Answer:
Correct Answer: Alpha-adrenergic blocker
Explanation:Calcium channel blockers may be utilized to assist in the natural passage of the stone.
Management and Prevention of Renal Stones
Renal stones, also known as kidney stones, can cause severe pain and discomfort. The British Association of Urological Surgeons (BAUS) has published guidelines on the management of acute ureteric/renal colic. Initial management includes the use of NSAIDs as the analgesia of choice for renal colic, with caution taken when prescribing certain NSAIDs due to increased risk of cardiovascular events. Alpha-adrenergic blockers are no longer routinely recommended, but may be beneficial for patients amenable to conservative management. Initial investigations include urine dipstick and culture, serum creatinine and electrolytes, FBC/CRP, and calcium/urate levels. Non-contrast CT KUB is now recommended as the first-line imaging for all patients, with ultrasound having a limited role.
Most renal stones measuring less than 5 mm in maximum diameter will pass spontaneously within 4 weeks. However, more intensive and urgent treatment is indicated in the presence of ureteral obstruction, renal developmental abnormality, and previous renal transplant. Treatment options include lithotripsy, nephrolithotomy, ureteroscopy, and open surgery. Shockwave lithotripsy involves generating a shock wave externally to the patient, while ureteroscopy involves passing a ureteroscope retrograde through the ureter and into the renal pelvis. Percutaneous nephrolithotomy involves gaining access to the renal collecting system and performing intracorporeal lithotripsy or stone fragmentation. The preferred treatment option depends on the size and complexity of the stone.
Prevention of renal stones involves lifestyle modifications such as high fluid intake, low animal protein and salt diet, and thiazide diuretics to increase distal tubular calcium resorption. Calcium stones may also be due to hypercalciuria, which can be managed with thiazide diuretics. Oxalate stones can be managed with cholestyramine and pyridoxine, while uric acid stones can be managed with allopurinol and urinary alkalinization with oral bicarbonate.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A 16-month-old boy recently treated for constipation is seen for review.
Six weeks ago, his parents brought him in and he was diagnosed with constipation. He was prescribed Movicol® Paediatric Plain sachets and given dietary advice. Following this, the child was able to open his bowels regularly with soft, well-formed stools.
Two weeks ago, the parents stopped the laxative and the child has once again developed problems. On further questioning, he is opening his bowels maximum twice a week and the stools are described as hard balls.
What is the most appropriate management plan?Your Answer:
Correct Answer: Restart the Movicol® Paediatric Plain but continue treatment for a longer period before slowly tapering
Explanation:Importance of Continuing Laxative Treatment for Children with Constipation
Early and abrupt cessation of treatment is the most common cause of relapse in children with constipation. Once a regular pattern of bowel habit is established, maintenance laxative should be continued for several weeks and gradually tapered off over a period of months based on stool consistency and frequency. It may take up to six months of maintenance treatment to retrain the bowel, and some children may require laxative treatment for several years.
The use of Movicol® Paediatric Plain sachets has been effective in establishing regular soft stools, but discontinuing the treatment has caused the problem to resurface. It is not recommended to switch to an alternative laxative or combine Movicol® Paediatric Plain with a stimulant laxative. The best approach is to restart the same laxative and continue its use for a longer period before tapering cautiously.
At this point, there is no need for referral to a pediatrician or blood tests. However, it is important to emphasize the importance of continuing laxative treatment as prescribed to prevent relapse and maintain regular bowel habits in children with constipation.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 56-year-old male presents two weeks following a knee replacement with severe diarrhea. What is the probable diagnosis?
Your Answer:
Correct Answer: Clostridium difficile
Explanation:The probable reason for the patient’s condition is Clostridium difficile, which could have been caused by the administration of broad-spectrum antibiotics during the operation. According to NICE guidelines, patients undergoing clean surgery with prosthesis or implant placement, clean-contaminated surgery, contaminated surgery, or surgery on a dirty or infected wound should receive antibiotics to prevent surgical site infections. In cases of contaminated or infected wounds, prophylaxis should be accompanied by antibiotic treatment.
Clostridioides 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.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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A 54-year-old woman is admitted to your intermediate care unit with a significant medical history of chronic alcoholism. She sustained a brain injury six weeks ago after falling down the stairs at home and is currently bedridden. She was transferred for further rehabilitation and is being fed through a percutaneous gastrostomy, which was inserted three days ago after an initial period of nasogastric tube feeding. The nursing staff reports that she has become increasingly unwell over the past 24 hours, with lethargy and confusion. Upon examination, she appears to be short of breath, and there is evidence of peripheral and pulmonary edema. What is the most likely underlying diagnosis?
Your Answer:
Correct Answer: Aspiration pneumonia
Explanation:Refeeding Syndrome in Malnourished Patients
Refeeding malnourished patients through enteral feeding requires careful monitoring of electrolytes and minerals. This is because refeeding can trigger a significant anabolic response that affects the levels of electrolytes and minerals essential to cellular function. Unfortunately, refeeding syndrome is often under-recognized and under-diagnosed. The metabolic changes that occur during refeeding can lead to marked hypophosphatemia and shifts in potassium, magnesium, glucose, and thiamine levels.
Refeeding syndrome is primarily caused by hypophosphatemia and can result in severe cardiorespiratory failure, edema, confusion, convulsions, coma, and even death. Therefore, it is crucial to closely monitor patients undergoing refeeding to prevent and manage refeeding syndrome.
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This question is part of the following fields:
- Gastroenterology
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Question 31
Incorrect
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Which statement about the epidemiology of colorectal cancer is accurate?
Your Answer:
Correct Answer: A quarter of patients diagnosed with bowel cancer will survive for at least 10 years
Explanation:Understanding the Epidemiology of Colorectal Cancer
A basic understanding of the epidemiology of colorectal cancer is important for general practitioners to consider when treating their patients. It is worth noting that 95% of colorectal cancer cases occur in individuals over the age of 50.
In terms of incorrect answer options, it is important to note that bowel cancer incidence rates have not increased by 6% over the last 10 years. Additionally, bowel cancer is not the second most common cause of cancer death in the UK overall, but rather in men alone it is second to prostate cancer and in women alone it is second to breast cancer.
Finally, while almost 42,000 people were diagnosed with bowel cancer in the UK in 2011, it is not accurate to say that half of patients diagnosed with colorectal cancer will survive their disease for 10 years or more. It is important for general practitioners to have accurate information about colorectal cancer in order to provide the best care for their patients.
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This question is part of the following fields:
- Gastroenterology
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Question 32
Incorrect
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A 30-year-old female who is being investigated for secondary amenorrhoea comes in with yellowing of the eyes. During the examination, spider naevi are observed, and the liver is tender and enlarged. The following blood tests are conducted:
- Hemoglobin (Hb): 11.6 g/dl
- Platelets (Plt): 145 * 109/l
- White blood cell count (WCC): 6.4 * 109/l
- Albumin: 33 g/l
- Bilirubin: 78 µmol/l
- Alanine transaminase (ALT): 245 iu/l
What is the most probable diagnosis?Your Answer:
Correct Answer: Autoimmune hepatitis
Explanation:When a young female experiences both abnormal liver function tests and a lack of menstrual periods, it is highly indicative of autoimmune hepatitis.
Autoimmune hepatitis is a condition that affects young females and has an unknown cause. It is often associated with other autoimmune disorders, hypergammaglobulinaemia, and HLA B8, DR3. There are three types of autoimmune hepatitis, which are classified based on the types of circulating antibodies present. Type I affects both adults and children and is characterized by the presence of Antinuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA). Type II affects children only and is characterized by the presence of anti-liver/kidney microsomal type 1 antibodies (LKM1). Type III affects adults in middle-age and is characterized by the presence of soluble liver-kidney antigen.
The symptoms of autoimmune hepatitis may include signs of chronic liver disease, acute hepatitis (which only 25% of patients present with), amenorrhoea (which is common), the presence of ANA/SMA/LKM1 antibodies, raised IgG levels, and liver biopsy showing inflammation extending beyond the limiting plate ‘piecemeal necrosis’ and bridging necrosis. The management of autoimmune hepatitis involves the use of steroids and other immunosuppressants such as azathioprine. In severe cases, liver transplantation may be necessary.
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This question is part of the following fields:
- Gastroenterology
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Question 33
Incorrect
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A 28-year-old woman developed sudden-onset severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. She has diminished bowel sounds exquisite tenderness in the mid-epigastrium with rebound tenderness and guarding. Her pulse is 110 and BP 130/75. She reports taking ibuprofen for dysmenorrhoea but last took it the day before the pain began.
Select from the list the single most likely diagnosis.Your Answer:
Correct Answer: Perforated peptic ulcer
Explanation:NSAIDs and Peptic Ulceration: Risks and Symptoms
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common cause of gastric and duodenal ulceration, second only to Helicobacter pylori. The inhibition of cyclooxygenase (COX) by NSAIDs reduces the production of gastric mucosal prostaglandins, leading to decreased cytoprotection. This can result in peptic ulceration, with at least one-third to one-half of ulcer perforations being associated with NSAIDs.
Patients at high risk of NSAID-induced peptic ulceration include the elderly, those with a history of peptic ulcer disease, and those with serious co-morbidities such as cardiovascular disease, diabetes, renal or hepatic impairment. The risk varies between individual NSAIDs and is also dose-related.
Symptoms of acute complications of NSAID-induced peptic ulceration can include peritonitis, which requires urgent surgical referral. Acute pancreatitis may present with similar symptoms, but tenderness may be less and there may be a history of Gallbladder disease or alcohol abuse. Gastritis typically doesn’t involve altered bowel sounds or signs of peritoneal irritation, while cholecystitis and appendicitis present with tenderness in the right upper quadrant and right iliac fossa, respectively.
In summary, NSAIDs can pose a significant risk for peptic ulceration, particularly in high-risk patients. It is important to be aware of the symptoms of acute complications and to promptly refer patients for appropriate management.
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This question is part of the following fields:
- Gastroenterology
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Question 34
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 35
Incorrect
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A 63-year-old woman complains of abdominal discomfort, bloating, and a change in bowel habit with looser, more frequent stools. She has been experiencing these symptoms since her husband passed away 3 months ago. Her daughter believes she may have irritable bowel syndrome and is seeking treatment. What is the recommended course of action for managing her symptoms?
Your Answer:
Correct Answer: 2 week referral to secondary care
Explanation:This woman has exhibited a concerning symptom of experiencing loose stools for over 6 weeks, which is a red flag indicator. Given her age of over 60 years, it is important to discuss the potential of an underlying cancer and refer her to secondary care for further testing within 2 weeks to rule out the possibility of bowel cancer.
Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.
An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.
The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.
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This question is part of the following fields:
- Gastroenterology
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Question 36
Incorrect
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A 72-year-old man comes to his General Practitioner complaining of jaundice and weight loss. He reports having pale coloured stool and dark urine. He denies experiencing any abdominal pain or fever. He has no significant medical or family history.
What is the most probable diagnosis?Your Answer:
Correct Answer: Pancreatic adenocarcinoma
Explanation:Diagnosing Pancreatic Adenocarcinoma: Understanding the Symptoms and Differential Diagnosis
Pancreatic adenocarcinoma is a serious condition that requires prompt diagnosis and treatment. One of the key symptoms of this condition is painless jaundice, which is often accompanied by weight loss. This is due to the obstructive jaundice that occurs when the tumor is located at the head of the pancreas. Other symptoms may include pale stools and dark urine.
It is important to note that patients may present with these symptoms before experiencing abdominal pain. This is why it is crucial to refer any patient aged 40 years and over with jaundice for suspected pancreatic cancer, according to National Institute for Health and Care Excellence (NICE) guidance.
When considering a differential diagnosis, gallstone obstruction and cholecystitis can be ruled out due to the absence of severe abdominal pain. Chronic pancreatitis is also unlikely due to the lack of abdominal pain and the rarity of jaundice as a symptom. Hepatitis A may present with similar symptoms, but abdominal pain occurs in only 40% of patients.
In conclusion, understanding the symptoms and differential diagnosis of pancreatic adenocarcinoma is crucial for prompt diagnosis and treatment. Any patient with jaundice should be referred for suspected pancreatic cancer, regardless of other symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 37
Incorrect
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A 72-year-old man presents to his General Practitioner with progressive dysphagia and weight loss. He is a smoker with a 45-pack-year history. He is fast-tracked for investigation of suspected oesophageal adenocarcinoma. It is noted that he has a past medical history relevant to the referral.
What is the most likely condition to warrant consideration in this patient’s referral?
Your Answer:
Correct Answer: Barrett's oesophagus
Explanation:Gastrointestinal Conditions and Their Associated Cancer Risks
Barrett’s Oesophagus, Duodenal Ulceration, Crohn’s Disease, Partial Gastrectomy, and Ulcerative Colitis are all gastrointestinal conditions that have been linked to an increased risk of cancer.
Barrett’s Oesophagus is a condition where the normal lining of the oesophagus is replaced by metaplastic columnar epithelium, which can lead to dysplasia and invasive adenocarcinoma. Risk factors for progression to adenocarcinoma include male sex, increasing age, extended segment disease, and family history. Smoking and alcohol are also strong risk factors.
Duodenal Ulceration is caused by Helicobacter pylori infection and has been linked to an increased risk of non-cardia gastric cancer.
Crohn’s Disease increases the risk of colon cancer, particularly if the entire colon is involved. The risk of small-intestinal malignancy is also increased.
Partial Gastrectomy is not associated with an increased risk of oesophageal adenocarcinoma, but gastric-stump cancer is a risk after partial gastrectomy, typically occurring ten years or longer after the procedure.
Ulcerative Colitis carries a significantly increased risk of colon cancer, with the extent and duration of the disease being important factors.
Overall, it is important for individuals with these gastrointestinal conditions to be aware of their increased cancer risk and to undergo regular screenings and surveillance to detect any potential malignancies early.
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This question is part of the following fields:
- Gastroenterology
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Question 38
Incorrect
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A 58-year-old woman presents with fatigue and shortness of breath on exertion. She has a hiatus hernia diagnosed on upper gastrointestinal endoscopy 3 months ago and takes omeprazole. She has had no respiratory symptoms, no change in bowel habit, no dysphagia or indigestion. On examination she is pale and tachycardic with a pulse rate of 100/min. Abdominal examination is normal. Blood tests reveal the following results:
Haemoglobin 72 g/l
White cell count 5.5 x109/l
Platelets 536 x109/l
ESR 36 mm/h
(hypochromic microcytic red blood cells)
Select from the list the single most likely diagnosis.Your Answer:
Correct Answer: Right-sided colonic carcinoma
Explanation:Causes of Iron Deficiency Anaemia and the Importance of Gastrointestinal Tract Investigation
Iron deficiency anaemia is a common condition that can be caused by various factors. In older patients, it is important to investigate the gastrointestinal tract as a potential source of bleeding. Right-sided colonic carcinomas often do not cause any changes in bowel habit, leading to late diagnosis or incidental discovery during investigations for anaemia. On the other hand, rectal carcinomas usually result in a change in bowel habit. Oesophageal carcinoma can cause dysphagia and should have been detected during recent endoscopy. Hiatus hernia is unlikely to cause severe anaemia, especially if the patient is taking omeprazole. Poor diet is also an unlikely explanation for new-onset iron deficiency anaemia in older patients. Therefore, routine assessment of iron deficiency anaemia should include investigation of the upper and lower gastrointestinal tract, with particular attention to visualising the caecum.
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This question is part of the following fields:
- Gastroenterology
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Question 39
Incorrect
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A 45-year-old patient complains of gastrointestinal symptoms. What feature in the history would be the least indicative of a diagnosis of irritable bowel syndrome?
Your Answer:
Correct Answer: 62-year-old female
Explanation:The new NICE guidelines identify onset after the age of 60 as a warning sign.
Diagnosis and Management of Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects many people. To diagnose IBS, a patient must have experienced abdominal pain, bloating, or a change in bowel habit for at least six months. A positive diagnosis of IBS is made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to two of the following four symptoms: altered stool passage, abdominal bloating, symptoms made worse by eating, and passage of mucous. Other features such as lethargy, nausea, backache, and bladder symptoms may also support the diagnosis.
It is important to enquire about red flag features such as rectal bleeding, unexplained/unintentional weight loss, family history of bowel or ovarian cancer, and onset after 60 years of age. Primary care investigations such as a full blood count, ESR/CRP, and coeliac disease screen (tissue transglutaminase antibodies) are suggested. The National Institute for Health and Care Excellence (NICE) published clinical guidelines on the diagnosis and management of IBS in 2008 to help healthcare professionals provide the best care for patients with this condition.
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This question is part of the following fields:
- Gastroenterology
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Question 40
Incorrect
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You have a consultation scheduled with Mr. Smith, a 74-year-old man who is interested in participating in the NHS bowel cancer screening program. He has never submitted the home test kits before and wants to know if he is eligible for screening.
Your Answer:
Correct Answer: He can self-refer for home test kit
Explanation:Patients who are over the age of 74 are no longer eligible for bowel cancer screening within the NHS screening program. However, they can still receive a home test kit every 2 years by self-referral (helpline number on NHS website). It is important to note that if a patient develops symptoms of bowel cancer, they should be formally investigated according to NICE suspected cancer guidelines. Additionally, in areas where bowel scope screening has been rolled out, patients can self-refer up to the age of 60 for one-off bowel scope screening.
Colorectal Cancer Screening with FIT Test
Overview:
Colorectal cancer is often developed from adenomatous polyps. Screening for this cancer has been proven to reduce mortality by 16%. The NHS provides home-based screening for older adults through the Faecal Immunochemical Test (FIT). Although a one-off flexible sigmoidoscopy was trialled in England, it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was further exacerbated by the COVID-19 pandemic. However, the trial showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used in future bowel screening programmes.Faecal Immunochemical Test (FIT) Screening:
The NHS offers a national screening programme every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests as it only detects human haemoglobin, not animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. Although a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy.Colonoscopy:
Approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer. -
This question is part of the following fields:
- Gastroenterology
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Question 41
Incorrect
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A 58-year-old woman comes to her General Practitioner with complaints of diarrhoea without any associated bleeding. She has also experienced weight loss and has abdominal pain with malaise and fever. During the examination, she has oral ulcers, sore red eyes and tender nodules on her shins. There is tenderness in the right iliac fossa and a vague right iliac fossa mass. What is the most probable diagnosis?
Your Answer:
Correct Answer: Crohn's disease
Explanation:Possible Diagnoses for a Patient with Gastrointestinal Symptoms and Other Complications
Crohn’s Disease, Appendicular Abscess, Ileocaecal Tuberculosis, Ovarian Cyst, and Ulcerative Colitis are possible diagnoses for a patient presenting with gastrointestinal symptoms and other complications. In women over 60 years of age, Crohn’s disease may even be the most likely diagnosis. This condition can cause episcleritis, uveitis, erythema nodosum, pyoderma gangrenosum, vasculitis, gallstones, kidney stones, or abnormal liver function tests. The predominantly right-sided symptoms suggest terminal ileitis, which is more common in Crohn’s disease than ulcerative colitis. Fever can occur in Crohn’s disease due to the inflammatory process, ranging from high fever during acute flare-ups to persistent low-grade fever. Appendicular abscess is a complication of acute appendicitis, causing a palpable mass in the right iliac fossa and fever. Ileocaecal tuberculosis can present with a palpable mass in the right lower quadrant and complications of obstruction, perforation, or malabsorption, especially in the presence of stricture. A large ovarian cyst may be palpable on abdominal examination, but it is unlikely to cause oral ulcers, sore eyes, or erythema nodosum. Ulcerative colitis, which has similar clinical features to Crohn’s disease, is usually diagnosed from the biopsy result following a sigmoidoscopy or colonoscopy. However, rectal bleeding is more common in ulcerative colitis, while fever is more common in Crohn’s disease. A right lower quadrant mass may be seen in Crohn’s disease but not in ulcerative colitis unless complicated by bowel cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 42
Incorrect
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A 60-year-old man comes to his General Practitioner complaining of swelling in his ankles and fluid-filled blisters around his feet that burst easily. He has a history of Crohn's disease that has been bothering him for a long time. Upon examination, he appears normal except for a urinalysis that shows 2+ protein. What is the most probable diagnosis? Choose only ONE option.
Your Answer:
Correct Answer: Amyloidosis
Explanation:Medical Conditions Associated with Crohn’s Disease
Crohn’s disease is a chronic inflammatory bowel disease that can lead to various medical conditions. One of these conditions is amyloidosis, which occurs when extracellular protein deposits disrupt normal organ function. This can result in nephrotic syndrome, characterized by protein in the urine and edema. While cardiac disease is uncommon in Crohn’s disease, it can occur and may present as congestive heart failure. Cirrhosis of the liver is also a potential complication, particularly in cases of primary sclerosing cholangitis. However, there is no indication of liver failure in the presented case. Nephritic syndrome, which involves protein and blood in the urine, is not the likely cause of the patient’s symptoms. While cutaneous manifestations such as blisters can occur in Crohn’s disease, pemphigus is a rare association and is not the likely cause of the patient’s edema and proteinuria.
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This question is part of the following fields:
- Gastroenterology
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Question 43
Incorrect
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A 50-year-old woman visited her doctor with complaints of intense pain in the anal area. She reported that the pain began after she strained to have a bowel movement. She had been experiencing constipation for the past 4 days and had been using over-the-counter laxatives. During the examination, the doctor observed a painful, firm, bluish-black lump at the edge of the anus.
What is the probable reason for her symptoms?Your Answer:
Correct Answer: Thrombosed haemorrhoid
Explanation:Thrombosed haemorrhoids are characterized by severe pain and the presence of a tender lump. Upon examination, a purplish, swollen, and tender subcutaneous perianal mass can be observed. If the patient seeks medical attention within 72 hours of onset, referral for excision may be necessary. However, if the condition has progressed beyond this timeframe, patients can typically manage their symptoms with stool softeners, ice packs, and pain relief medication. Symptoms usually subside within 10 days.
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This question is part of the following fields:
- Gastroenterology
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Question 44
Incorrect
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A 62-year-old man presents with a three month history of epigastric pain after eating and intermittent heartburn between meals. He reports weight loss but denies any nausea or vomiting. There is no change in bowel habit and no history of passing blood or melaena stools. He has no significant past medical history, drinks up to 10 units of alcohol a week, and quit smoking five years ago. What is the optimal course of action for managing his symptoms?
Your Answer:
Correct Answer: Treat with an oral proton pump inhibitor (for example, omeprazole 20 mg daily) and review in two weeks
Explanation:NICE Guidelines for Suspected Oesophageal Cancer
According to NICE guidelines, urgent direct access upper gastrointestinal endoscopy should be offered to assess for oesophageal cancer in individuals with dysphagia or those aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia. A routine ultrasound scan is unlikely to be helpful, and even if Helicobacter pylori is positive, referral should not be delayed. It is advised to be free from acid suppression therapy for at least two weeks before endoscopy in case treatment masks underlying pathology. Therefore, proton pump inhibitors should not be prescribed when referring urgently for endoscopy. These guidelines aim to improve the recognition and referral of suspected oesophageal cancer for prompt diagnosis and treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 45
Incorrect
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A 68-year-old gentleman presents with a change in bowel habit. He reports that over the last two to three months he is opening his bowels four to five times a day and the consistency of his stools has become very loose. He has noticed small amounts of blood in his faeces but put this down to 'piles'.
Previously, he used to open his bowels on average once a day and has no personal history of any gastrointestinal problems. There is no family history of bowel problems, he has not lost any weight and he denies any rectal blood loss. Stool mc&s is normal as are his recent blood tests which show that he is not anaemic. Abdominal and rectal examinations are normal.
He tells you that he is not overly concerned about the symptoms as about two months ago he submitted his bowel screening samples and recently had a letter saying that his screening tests were negative. What is the most appropriate next approach in this instance?Your Answer:
Correct Answer: Refer him urgently to a specialist for investigation of his lower gastrointestinal tract
Explanation:Importance of Urgent Referral for Patients with Bowel Symptoms
Screening tests are designed for asymptomatic individuals in an at-risk population. However, it is not uncommon for patients with bowel symptoms to mention that they are not worried as they have done their bowel screening and it was negative.
In the case of a 66-year-old man with persistent changes in bowel habit towards looser stools with some rectal bleeding, urgent referral for further investigation is necessary. It is important to note that relying on recent bowel screening results may falsely reassure patients and delay necessary medical attention.
Therefore, it is crucial for healthcare professionals to prioritize the patient’s current symptoms and promptly refer them for further evaluation, regardless of their previous screening results. Early detection and treatment can significantly improve outcomes for patients with bowel symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 46
Incorrect
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A 50-year-old man has had intermittent heartburn and acid regurgitation over the past 10 years. He has previously had an H2 receptor antagonist and a proton pump inhibitor with good effect. He occasionally has bought preparations from the pharmacy with good effect. His body mass index (BMI) is 29 kg/m2 and he smokes 15 cigarettes per day. His symptoms have been worse recently and are waking him at night.
Select from the list the single management option that is likely to be most effective in bringing about a QUICK resolution of his symptoms.Your Answer:
Correct Answer: Proton pump inhibitor (PPI)
Explanation:Management of Gastro-Oesophageal Reflux Disease-Like Symptoms
Explanation:
When a patient presents with symptoms suggestive of gastro-oesophageal reflux disease (GORD), it is recommended to manage it as uninvestigated dyspepsia, according to NICE guidelines. This is because an endoscopy has not been carried out, and there are no red flag symptoms that require immediate referral for endoscopy.
The first step in managing GORD-like symptoms is to advise the patient on lifestyle modifications such as weight loss, dietary changes, smoking cessation, and alcohol reduction. These changes may lead to a reduction in symptoms.
In the short term, a full dose of a proton pump inhibitor (PPI) for one month is the most effective treatment to bring about a quick resolution of symptoms. If the patient has responded well to PPI in the past, it is likely to be effective again. Testing for H. pylori may also be an option if it has not been done previously.
After the initial treatment, a low-dose PPI as required may be appropriate for the patient. Other drugs such as H2 receptor antagonists, antacids, and prokinetics can also be used in the management of uninvestigated dyspepsia. However, they are not the first choice according to the guidelines and are less likely to be as effective as a PPI.
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This question is part of the following fields:
- Gastroenterology
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Question 47
Incorrect
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A 63-year-old man initially reported experiencing itching on his back. Subsequently, he began to experience abdominal discomfort, loss of appetite, weight loss, and fatigue. An x-ray was performed, which showed no abnormalities. What would be the gold standard management option?
Your Answer:
Correct Answer: Urgent CT scan
Explanation:Urgent CT Scan for Pancreatic Cancer in Elderly Patients with Red Flag Symptoms
An urgent direct access CT scan is recommended within two weeks for patients aged 60 and over who have experienced weight loss and any of the following symptoms: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes. CT scan is preferred over ultrasound unless CT is not available. Endoscopy is not necessary as the symptoms do not suggest stomach or oesophageal cancer, which would present with more dysphagia and dyspepsia. While a gastroenterology opinion may be required, it should not be requested routinely as the patient’s red flag symptoms warrant a more urgent approach. Although the patient is currently medically stable, an immediate referral to the medical assessment unit is not necessary.
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This question is part of the following fields:
- Gastroenterology
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Question 48
Incorrect
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You are evaluating a 45-year-old woman with a 20-year history of Crohn's disease. She has been experiencing frequent flares and is currently troubled by loose, bloody stools, abdominal pain, and weight loss. Perianal symptoms are particularly bothersome, with severe pain during bowel movements due to nasty anal fissures. Additionally, she has multiple aphthous ulcers in her mouth, making eating and drinking painful. She is a smoker and has a past medical history of osteoporosis and psoriasis.
What is a correct statement regarding Crohn's disease in this patient?Your Answer:
Correct Answer: Patients with perianal disease have a worse prognosis
Explanation:Psoriasis is an extraintestinal manifestation that is not associated with the activity of the disease.
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.
To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.
Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.
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This question is part of the following fields:
- Gastroenterology
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Question 49
Incorrect
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A 49-year-old man with a history of alcohol abuse and liver cirrhosis presents with worsening abdominal distension and ankle swelling. Upon examination, there is mild tenderness in the suprapubic area, but the abdomen is soft with no masses or rebound tenderness. The abdomen appears slightly distended with shifting dullness, and there is pitting edema up to mid-shin level. The patient is stable hemodynamically and shows no signs of jaundice or encephalopathy.
What medication would be most beneficial for this patient?Your Answer:
Correct Answer: Spironolactone
Explanation:Spironolactone is the recommended diuretic for managing ascites, which is suggested by the patient’s history of cirrhosis and increasing abdominal distension. While bendroflumethiazide can be used for hypertension and edema, it is not licensed for ascites. Codeine should be avoided as it can cause constipation, which could increase the risk of encephalopathy. Furosemide is not licensed for ascites, but is used for heart failure and resistant hypertension. Ramipril is primarily used for hypertension, heart failure, chronic kidney disease, and post-myocardial infarction, but is not indicated for ascites management.
Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200 mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. In addition, spironolactone has been shown to reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor, according to the RALES study.
However, spironolactone can cause adverse effects such as hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone. It is important to monitor potassium levels in patients taking spironolactone to prevent hyperkalaemia, which can lead to serious complications such as cardiac arrhythmias. Overall, spironolactone is a useful medication for treating various conditions, but its potential adverse effects should be carefully considered and monitored.
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This question is part of the following fields:
- Gastroenterology
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Question 50
Incorrect
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A 50-year-old man presents having recently noticed a lump in his right groin which disappears when he is recumbent. It is accompanied by some discomfort.
He has a chronic cough due to smoking. He has had an appendicectomy previously.
What is the most likely diagnosis?Your Answer:
Correct Answer: Femoral hernia
Explanation:Inguinal Hernia: A Likely Cause of a Lump in the Groin
Inguinal hernia is the most probable reason for a lump in the right groin of a patient in this age group. This type of hernia occurs when a part of the intestine protrudes through the external inguinal ring. It may go unnoticed for a while, cause discomfort or pain, and resolve when lying flat. Femoral hernias are more common in females, while an epigastric hernia or an incisional hernia following appendicectomy would be unlikely in this anatomical site.
This patient’s persistent cough due to smoking puts him at a higher risk of developing hernias.
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This question is part of the following fields:
- Gastroenterology
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Question 51
Incorrect
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A 30-year old with newly diagnosed ulcerative colitis is initiated on mesalazine following a recent weaning off of high dose steroids. After two weeks, he experiences intense discomfort in his epigastrium and upper right quadrant. What is the probable diagnosis?
Your Answer:
Correct Answer: Acute pancreatitis
Explanation:When it comes to the risk of pancreatitis, mesalazine is more likely to cause it than sulfasalazine. Although oral aminosalicylates can cause gastric side-effects such as diarrhoea, nausea, vomiting, and colitis exacerbation, acute pancreatitis is a rare but possible complication.
Aminosalicylate Drugs for Inflammatory Bowel Disease
Aminosalicylate drugs are commonly used to treat inflammatory bowel disease (IBD). These drugs work by releasing 5-aminosalicyclic acid (5-ASA) in the colon, which acts as an anti-inflammatory agent. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis.
Sulphasalazine is a combination of sulphapyridine and 5-ASA. However, many of the side effects associated with this drug are due to the sulphapyridine component, such as rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Mesalazine is a delayed release form of 5-ASA that avoids the sulphapyridine side effects seen in patients taking sulphasalazine. However, it is still associated with side effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis.
Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken down by colonic bacteria. It is important to note that aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis. Therefore, a full blood count is a key investigation in an unwell patient taking these drugs. Pancreatitis is also more common in patients taking mesalazine compared to sulfasalazine.
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This question is part of the following fields:
- Gastroenterology
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Question 52
Incorrect
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You see a 60-year-old man with gastro-oesophageal reflux symptoms. He has a previous diagnosis of Barrett's oesophagus. The old notes show he was previously under regular follow up with the local gastroenterology department but he has not been seen for over three years.
Over the last four months his gastro-oesophageal reflux symptoms have become significantly worse. He experiences daily retrosternal burning after meals which is severe and he has been vomiting at least once a week. His swallow is reportedly normal. There is no history of haematemesis or melaena. You weigh him and he has not lost any significant weight.
On examination his abdomen is soft, non-tender and with no palpable masses. He takes omeprazole 20 mg once daily which he has done for many years. Since his symptoms have deteriorated he has increased this himself up to 20 mg twice daily. This has not provided any significant symptomatic benefit.
You refer him urgently for an upper GI endoscopy.
What advice would you give to the patient while waiting for the endoscopy?Your Answer:
Correct Answer: Add in domperidone to the current dose of omeprazole to try and improve symptom control whilst further investigation is awaited
Explanation:Importance of Stopping Acid Suppression Medication Prior to Endoscopy
Acid suppression medication should be discontinued for at least two weeks before undergoing endoscopy. This is crucial because acid suppression medication can conceal serious underlying conditions. It is also essential to consider the patient’s medical history, especially if there is an unexplained deterioration of dyspepsia. This is particularly important for patients with Barrett’s oesophagus, known dysplasia, atrophic gastritis or intestinal metaplasia, or those who have undergone peptic ulcer surgery more than two decades ago. By taking these precautions, doctors can ensure that endoscopy results are accurate and reliable.
Spacing:
Acid suppression medication should be discontinued for at least two weeks before undergoing endoscopy. This is crucial because acid suppression medication can conceal serious underlying conditions.
It is also essential to consider the patient’s medical history, especially if there is an unexplained deterioration of dyspepsia. This is particularly important for patients with Barrett’s oesophagus, known dysplasia, atrophic gastritis or intestinal metaplasia, or those who have undergone peptic ulcer surgery more than two decades ago.
By taking these precautions, doctors can ensure that endoscopy results are accurate and reliable.
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This question is part of the following fields:
- Gastroenterology
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Question 53
Incorrect
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A 45-year-old teacher has recently been diagnosed with hepatitis C infection, following a referral to the local gastroenterologist.
You have not yet received their clinic letter but the patient says that they explained to him that he will be starting treatment soon and wanted to ask you a few questions about the likely success.
Which of the following factors is associated with a good response to interferon alpha in patients with hepatitis C?Your Answer:
Correct Answer: Presence of cirrhosis
Explanation:Factors Affecting Response to Interferon Alpha in Hepatitis C Treatment
A high viral load, obesity, old age, cirrhosis, continued alcohol use, immune deficiency, poor adherence to treatment, and significant steatosis on liver biopsy are all factors that can affect the response rate to interferon alpha in hepatitis C treatment. Patients with genotype 1 infection and a high viral load are particularly at risk for a poor response to interferon alpha. On the other hand, patients with genotypes 2 or 3 infection and a short duration of disease have a better chance of responding well to treatment. The recommended duration of therapy also varies depending on the genotype. It is important to address these factors when considering treatment options for hepatitis C patients.
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This question is part of the following fields:
- Gastroenterology
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Question 54
Incorrect
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A 45-year-old woman is discharged from hospital following a haematemesis with a diagnosis of NSAID-induced gastric ulcer. She has taken ibuprofen regularly for pain relief and has found it effective, while finding paracetamol has been ineffective. She is taking 10 mg esomeprazole a day. She has a history of osteoarthritis and hypertension.
What is the most appropriate analgesia to prescribe this patient?Your Answer:
Correct Answer: Tramadol
Explanation:Choosing the Right Pain Medication for a Patient with Rheumatoid Arthritis and a History of Myocardial Infarction
When selecting a pain medication for a patient with rheumatoid arthritis and a history of myocardial infarction, it is important to consider the potential cardiovascular and gastrointestinal risks associated with each option. Tramadol is often the drug of choice due to its lower risk of cardiovascular and gastrointestinal problems, but it may still cause toxicity in some patients. Celecoxib, a cyclo-oxygenase-2 selective inhibitor, carries a lower risk of gastrointestinal side-effects but should be avoided in patients with a history of thrombotic events. Diclofenac and misoprostol carry an intermediate risk of gastrointestinal side-effects and increase the risk of thrombotic events. Ibuprofen and naproxen have lower gastrointestinal risks, but their use may be problematic in patients taking antiplatelet medication. Ultimately, the choice of pain medication should be made on a case-by-case basis, taking into account the patient’s individual medical history and risk factors.
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This question is part of the following fields:
- Gastroenterology
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Question 55
Incorrect
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A 28-year-old man visits his General Practitioner with complaints of dysphagia. He believes it has been present for around 18 months, but it is getting worse. He also reports experiencing chest discomfort, coughing at night, and waking up with undigested food on his pillow in the morning.
During the examination, his throat, neck, chest, and abdomen appear normal.
What is the most probable diagnosis?Your Answer:
Correct Answer: Achalasia
Explanation:The patient’s symptoms suggest a diagnosis of achalasia, which is characterized by the failure of the lower oesophageal sphincter to relax, leading to a functional stricture. This can cause substernal cramps, regurgitation, and pulmonary aspiration due to the retention of food and saliva in the oesophagus, resulting in a nocturnal cough. Diagnosis is made using a barium swallow, and treatment involves endoscopic balloon dilation or cardiomyotomy. Barrett’s oesophagus, motor neurone disease, oesophageal carcinoma, and pharyngeal pouch are less likely diagnoses based on the patient’s age, symptoms, and medical history.
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This question is part of the following fields:
- Gastroenterology
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Question 56
Incorrect
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A 48-year-old man visits his doctor, reporting an increase in breast size over the past few years. He has alcoholic cirrhosis and continues to consume one bottle of vodka daily. He is prescribed furosemide for oedema but takes no other medications.
What is the probable reason for this patient's gynaecomastia?Your Answer:
Correct Answer: Altered oestrogen metabolism
Explanation:Understanding the Causes of Gynaecomastia in Cirrhosis
Gynaecomastia in cirrhosis is a complex condition with various potential causes. One of the most likely culprits is the disordered metabolism of sex steroids, which can result in excess levels of oestrogens. As liver function decreases, plasma testosterone concentrations also decrease, often leading to associated symptoms such as testicular atrophy and loss of body hair.
While furosemide is not typically associated with gynaecomastia, spironolactone therapy used in cirrhosis treatment can be a contributing factor. Excess energy intake from alcohol is also a common issue in alcohol-related cirrhosis, as patients may substitute alcohol for food and suffer from nutritional deficiencies.
Although bodybuilders taking anabolic steroids may report gynaecomastia, there is no indication in the patient’s history to suggest this as a cause. Additionally, it is important to note that low testosterone levels, rather than excess levels, are typically associated with gynaecomastia. By understanding the various potential causes of this condition, healthcare professionals can better diagnose and treat gynaecomastia in cirrhosis patients.
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This question is part of the following fields:
- Gastroenterology
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Question 57
Incorrect
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A 14-month old infant presents with episodes of severe colic, associated with pallor and drawing of the legs upwards. This has been going on for several weeks.
The mother has brought the child to see you because she noticed that there seemed to be blood and mucous in the stool yesterday.
On examination there is a sausage-shaped mass palpable on the right side of the abdomen.
What is the diagnosis?Your Answer:
Correct Answer: Hirschsprung's disease
Explanation:Intussusception: A Common Cause of Intestinal Obstruction in Infants
Intussusception is a condition where a section of the bowel folds into itself, causing an obstruction. It is most commonly seen in infants over one month old, with the typical age of presentation being between two months to two years. The most common site of intussusception is the ileum passing into the caecum/colon through the ileocaecal valve.
Symptoms of intussusception include severe colic, pallor, and drawing of legs upwards during episodes of pain. A sausage-shaped mass may be palpable in the abdomen, and parents may notice the passage of a redcurrant jelly stool (blood-stained mucous). In severe cases, children may present with abdominal distention and shock.
The cause of intussusception is not always clear, but viral infections causing enlargement of Peyer’s patches have been implicated in forming a lead point for the development of intussusception. In children over the age of two, a specific lead point (such as a Meckel’s diverticulum or polyp) is more likely.
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This question is part of the following fields:
- Gastroenterology
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Question 58
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 59
Incorrect
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A 42-year-old man undergoes occupational health screening blood tests. His anti-Hepatitis C virus (anti-HCV) test returns positive. On examination, he is feeling well with no signs of liver disease. He has no other comorbidities.
What is the most important next test to perform for this patient?
Your Answer:
Correct Answer: Hepatitis C (HCV) ribonucleic acid (RNA)
Explanation:Common Tests for Hepatitis C and Co-Infections
Hepatitis C (HCV) is a viral infection that affects the liver. There are several tests available to diagnose and monitor HCV, as well as to screen for co-infections with other viruses. Here are some of the most common tests used:
1. HCV RNA: This test detects the presence of HCV ribonucleic acid in the blood, which is the most sensitive way to diagnose HCV infection. It can detect the virus within 1-2 weeks after infection and can confirm ongoing infection if antibodies are positive.
2. HBV DNA: This test measures the amount of hepatitis B virus deoxyribonucleic acid in the blood, which can help monitor the viral load of hepatitis B. Since HBV and HCV can coexist, it’s important to screen for both viruses.
3. Anti-HIV antibodies: HIV and HCV share many of the same risk factors, so patients with HCV should be screened for HIV. However, it’s important to first confirm the diagnosis of HCV before testing for HIV.
4. AST and ALT: These enzymes are released into the bloodstream when the liver is damaged, which can indicate HCV infection. However, they are nonspecific and cannot confirm a diagnosis on their own.
5. IgM anti-HAV: This test detects recent infection with hepatitis A, which can coexist with HCV. However, confirming the diagnosis of HCV is the first priority.
Overall, these tests can help diagnose and monitor HCV, as well as screen for co-infections with other viruses. It’s important to work with a healthcare provider to determine the best testing strategy for each individual case.
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This question is part of the following fields:
- Gastroenterology
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Question 60
Incorrect
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You see a 49-year-old gentleman with a change in bowel habit. He has had routine blood tests which were all normal. He reports no rectal bleeding. On examination, his abdomen is soft, non-tender and the rectal examination was normal.
What would be the most appropriate next step in your management?Your Answer:
Correct Answer: Refer using a suspected lower gastrointestinal cancer pathway
Explanation:Faecal Occult Blood Tests for Colorectal Cancer Screening
Faecal occult blood tests are recommended by NICE for patients who exhibit symptoms that may indicate colorectal cancer but are unlikely to have the disease. These tests are also used for routine screening. However, it is crucial to consider the criteria for suspected lower GI cancer referrals when deciding to use this test. For instance, if a patient is 60 years or older and has experienced a change in bowel habit, they should be referred using a suspected lower GI cancer pathway instead of undergoing a faecal occult blood test. Proper screening and referral protocols can help ensure timely and accurate diagnosis and treatment of colorectal cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 61
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 62
Incorrect
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You see a 32-year-old man who has recently been diagnosed with Crohn's disease. He presented with frequent and loose stools, with occasional blood and mucous. He is otherwise fit and well. His only other past medical history is appendicitis as a 16-year-old.
He has been reviewed by a gastroenterologist and is on a reducing dose of corticosteroid.
Can you provide him with more information about Crohn's disease?Your Answer:
Correct Answer: The risk of Crohn's disease increases early after an appendicectomy
Explanation:Smoking increases the likelihood of developing Crohn’s disease.
Experiencing infectious gastroenteritis raises the risk of developing Crohn’s disease by four times, especially within the first year.
The chances of developing Crohn’s disease are higher in the early stages after having an appendicectomy.
Crohn’s disease affects both genders equally, with no significant difference in occurrence rates.
Understanding Crohn’s Disease
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.
Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include nonspecific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.
To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.
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This question is part of the following fields:
- Gastroenterology
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Question 63
Incorrect
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A 50-year-old woman presents with anaemia on a routine blood test. Her haemoglobin is 96 g/L (115-165) and her MCV is 72 fL (80-96). Further blood tests reveal a ferritin of 8 µg/L (15-300) and negative coeliac serology. Haemoglobin electrophoresis is normal.
She denies any gastrointestinal symptoms, rectal bleeding, weight loss, haematuria or haemoptysis. Her menstrual cycle is regular with periods every 28 days. She reports heavy bleeding for five days followed by lighter bleeding for three days, which has been the case for several years. She doesn't consider her periods to be problematic.
Physical examination, including urine dipstick testing, is unremarkable.
What is the most appropriate next step?Your Answer:
Correct Answer: Start oral iron replacement
Explanation:Investigating Anaemia: Identifying and Treating Iron Deficiency
A new diagnosis of anaemia should prompt further investigation. A low mean corpuscular volume (MCV) suggests iron deficiency anaemia, which can be confirmed with a ferritin level test. However, it is important to note that ferritin levels may be falsely normal in the presence of an acute phase response. In such cases, iron studies may be useful. Once iron deficiency is confirmed, the underlying cause should be identified.
Patients with upper gastrointestinal symptoms or unexplained low haemoglobin levels require urgent referral for endoscopic gastrointestinal assessment. Coeliac serology and haemoglobin electrophoresis should also be considered to rule out coeliac disease and hereditary causes of microcytic anaemia, respectively.
In patients who do not require urgent referral, non-gastrointestinal blood loss and poor diet should be considered. Menstrual blood loss is a common cause of iron deficiency anaemia in menstruating women. In such cases, iron replacement therapy should be initiated, and haemoglobin levels should be monitored for improvement. If heavy menstrual bleeding is the cause, it should be treated, and if the patient doesn’t respond to iron supplementation, gastroenterology referral is appropriate.
In summary, identifying and treating iron deficiency anaemia requires a thorough investigation of the underlying cause. Prompt referral is necessary in certain cases, while others may require iron replacement therapy and monitoring.
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This question is part of the following fields:
- Gastroenterology
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Question 64
Incorrect
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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:
Correct 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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This question is part of the following fields:
- Gastroenterology
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Question 65
Incorrect
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A 60-year-old man with liver cirrhosis of unknown origin is being evaluated in the clinic. What factor is most likely to indicate a poor prognosis?
Your Answer:
Correct Answer: Ascites
Explanation:Scoring Systems for Liver Cirrhosis
Liver cirrhosis is a serious condition that can lead to liver failure and death. To assess the severity of the disease, doctors use scoring systems such as the Child-Pugh classification and the Model for End-Stage Liver Disease (MELD). The Child-Pugh classification takes into account five factors: bilirubin levels, albumin levels, prothrombin time, encephalopathy, and ascites. Each factor is assigned a score of 1 to 3, depending on its severity, and the scores are added up to give a total score. The total score is then used to grade the severity of the disease as A, B, or C.
The MELD system uses a formula that takes into account a patient’s bilirubin, creatinine, and international normalized ratio (INR) to predict their survival. The formula calculates a score that ranges from 6 to 40, with higher scores indicating a higher risk of mortality. The MELD score is particularly useful for patients who are on a liver transplant waiting list, as it helps to prioritize patients based on their risk of mortality. Overall, both the Child-Pugh classification and the MELD system are important tools for assessing the severity of liver cirrhosis and determining the best course of treatment for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 66
Incorrect
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A 62-year-old woman presents with long-standing gastrointestinal symptoms. She was diagnosed with irritable bowel syndrome as a young adult and currently takes hyoscine butylbromide 10-20 mg QDS PRN and loperamide 2 mg PRN for her symptoms. She also has a history of type 1 diabetes diagnosed at the age of 10.
She has been experiencing intermittent abdominal pains and bloating, as well as periodic bouts of diarrhea for years. Her latest blood tests, which were done as part of her diabetic annual review, show a modest anemia (hemoglobin 105 g/L). Her liver function tests show a slight persistent elevation of ALT and ALP, which has been the case for the last six to seven years and has not significantly deteriorated. Her thyroid function, bone profile, and ESR are all within normal limits. Her HbA1c is satisfactory at 50 mmol/mol.
There has been no significant change in her gastrointestinal symptoms recently. She has never had any rectal bleeding or mucous passed per rectum. Her weight is stable. She reports no acute illness but does feel more tired than usual over the last few months. She follows a 'normal' diet. Clinical examination reveals no focal abnormalities. She denies any obvious source of blood loss with no reported gastro-oesophageal reflux, haematemesis, haemoptysis, or haematuria. Urine dipstick testing shows no blood.
She has no family history of bowel cancer, but her mother and one of her maternal aunts both suffered from irritable bowel syndrome. Follow-up blood tests show low ferritin and folate levels.
What is the most appropriate next step in managing this 62-year-old woman's symptoms?Your Answer:
Correct Answer: Reassure her that no further investigation or treatment is needed as her symptoms are chronic
Explanation:Coeliac Disease and Iron Deficiency Anaemia
Note the low folate levels and anaemia in a type 1 diabetic with chronic gastrointestinal symptoms and liver function test abnormalities. These features suggest coeliac disease, which is often misdiagnosed as irritable bowel syndrome. It is recommended by NICE to routinely test for coeliac disease when diagnosing IBS. Family members with IBS should also be investigated for coeliac disease if the diagnosis is confirmed.
Patients with untreated coeliac disease often have mild liver function test abnormalities and are at increased risk for osteoporosis and hypothyroidism. The low folate levels suggest malabsorption as a possible cause. NICE CKS recommends screening all people with iron deficiency anaemia for coeliac disease using coeliac serology.
For iron deficiency anaemia without dyspepsia, consider the possibility of gastrointestinal cancer and urgently refer for further investigations. For women who are not menstruating, with unexplained iron deficiency anaemia and a haemoglobin level of 10 g/100 mL or below, refer urgently within 2 weeks for upper and lower gastrointestinal investigations.
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This question is part of the following fields:
- Gastroenterology
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Question 67
Incorrect
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A 50-year-old man presents with long-standing bowel symptoms that go back several years. He recently joined the practice and reports experiencing bouts of abdominal pain and diarrhea that can last up to a few weeks at a time. His previous GP diagnosed him with irritable bowel syndrome. He also has a history of ankylosing spondylitis, which was diagnosed in his early 20s, and recurrent mouth ulcers. He takes ibuprofen as needed to manage spinal pain from his ankylosing spondylitis.
He is now presenting because he has had abdominal pain and profuse diarrhea for the past two weeks. He is having bowel movements 3-4 times a day, which is similar to previous attacks, but he is more concerned this time because he has noticed fresh blood mixed in with his stools. He has not traveled abroad and has had no contact with sick individuals. He denies any weight loss. He saw the Out of Hours GP service a few days ago, and they submitted a stool sample for testing, which showed no evidence of an infectious cause.
On examination, he is hydrated and afebrile. His blood pressure is 138/90 mmHg, his pulse rate is 88 bpm, and he is not systemically unwell. His abdomen is tender around the umbilicus and across the lower abdomen. He has no guarding or acute surgical findings, and there are no masses or organomegaly. Due to the rectal blood loss, you perform a rectal examination, which reveals several perianal skin tags but nothing focal in the rectum.
What is the most appropriate next step in managing this patient?Your Answer:
Correct Answer: In view of the ongoing loose stools and rectal bleeding refer him urgently to a lower gastrointestinal specialist as a suspected cancer
Explanation:Possible Crohn’s Disease Diagnosis
This patient’s symptoms suggest a possible diagnosis of Crohn’s disease, which has been previously misdiagnosed as irritable bowel syndrome. The recent discovery of blood in his stools is not consistent with IBS and indicates an alternative cause. Additionally, the presence of ankylosing spondylitis, mouth ulcers, and skin tags are all associated with Crohn’s disease.
To confirm the diagnosis, the patient should undergo faecal calprotectin and blood tests, including FBC, U&Es, albumin, CRP, and ESR. These tests can be performed in primary care. However, the patient should also be referred to a lower GI specialist for further evaluation and confirmation of the diagnosis.
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This question is part of the following fields:
- Gastroenterology
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Question 68
Incorrect
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Emma, aged 23 years, has been experiencing symptoms of irritable bowel syndrome (IBS) for the past 2 months, which she believes is due to the stress of her new job. She often feels bloated and has irregular bowel movements. Emma is hesitant to take medications and seeks advice from her GP, Dr. Patel, who recommends the low-FODMAP diet and refers her to a registered dietitian. What are some examples of safe low-FODMAP foods that can be included in Emma's diet to manage her IBS symptoms?
Your Answer:
Correct Answer: Salmon
Explanation:Monash University in Australia has developed a low-FODMAP diet to manage irritable bowel syndrome (IBS). FODMAPs are short-chain carbohydrates found in many foods that are poorly absorbed in the small intestine. They can cause diarrhoea by encouraging water intake into the small intestine or bloating by fermenting in the large bowel. A low-FODMAP diet has been shown to reduce symptoms of IBS such as bloating, abdominal pain, and irregular bowel habits. However, this diet is challenging to follow as it excludes many foods that contain oligo-, di-, mono-saccharides, and polyols, including various vegetables, fruits, and grains. Therefore, it is recommended to seek the advice of a dietician rather than initiating the diet without guidance. High-FODMAP foods to avoid include wheat, most dairy products (except aged cheeses), pulses, beans, onion, garlic, and excess fructose. The diet mainly consists of unprocessed meat/fish and low FODMAP vegetables and grains.
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.
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This question is part of the following fields:
- Gastroenterology
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Question 69
Incorrect
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A 32-year-old woman presents to her General Practitioner with complaints of intermittent central abdominal pain and bloating, which is often relieved when she opens her bowels. She also experiences loose stools and occasional urgency to pass a stool. These symptoms have been occurring on and off for about six months, and she has not experienced any weight loss or bleeding. On examination, her abdomen appears normal. The patient has recently been promoted to a more responsible position at work. What is the most appropriate intervention to relieve this patient's symptoms?
Your Answer:
Correct Answer: Mebeverine
Explanation:Appropriate Medications for Irritable Bowel Syndrome: A Case Study
A patient presents with symptoms consistent with irritable bowel syndrome (IBS), including abdominal pain relieved by defecation and the absence of red-flag symptoms. The likely cause of her flare-up is increased stress following a job promotion. Antispasmodics such as mebeverine are appropriate for symptomatic relief of abdominal pain in IBS, while omeprazole is not indicated for this patient. Domperidone is not necessary for the relief of nausea and vomiting, and lactulose is not recommended due to potential bloating. Linaclotide is not appropriate for this patient as her symptoms have only been present for six months and there is no evidence that other laxatives have failed. Overall, mebeverine and lifestyle changes are the recommended interventions for this patient with IBS.
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This question is part of the following fields:
- Gastroenterology
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Question 70
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 71
Incorrect
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A 56-year-old man presents to his primary care physician with a complaint of altered bowel habits. He reports experiencing constipation for the past 3 months, followed by occasional episodes of loose stools. He denies any associated pain, rectal bleeding, or unexplained weight loss. The patient is in good health, has a regular diet, and takes no medications. On physical examination, the abdomen is soft and non-tender with no palpable masses.
What would be the most suitable course of action for this patient?Your Answer:
Correct Answer: Faecal immunochemical testing (FIT)
Explanation:For patients who show new symptoms of colorectal cancer but do not meet the 2-week referral criteria, it is recommended to undergo the FIT test. In this case, as the patient is under 60 years old, an urgent referral is not necessary. However, if the change in bowel habit persists, it is important to consider a referral to a lower gastrointestinal specialist. It is not appropriate to request a faecal calprotectin test as it is mainly used for suspected IBD cases. A full blood count is necessary, but it should not be the only test performed. The most crucial step in management is to request a FIT test, which can trigger a 2-week wait if the result is positive. While providing reassurance to the patient is important, it should not be done without any investigation as it may lead to missing a potential colorectal cancer.
Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.
An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.
The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.
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This question is part of the following fields:
- Gastroenterology
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Question 72
Incorrect
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A 28-year-old man visits his General Practitioner with complaints of abdominal pain, bloating and nausea after meals. He has also experienced a weight loss of around 10 kg in the past three months, along with some non-bloody diarrhoea. He is a heavy smoker, consuming 30 cigarettes per day, but doesn't consume alcohol. A previous plain abdominal X-ray revealed dilated loops of the small bowel. What is the most probable diagnosis?
Your Answer:
Correct Answer: Crohn's disease
Explanation:Possible Diagnoses for a 32-Year-Old Man with Abdominal Pain and Diarrhoea
A 32-year-old man presents with abdominal pain, bloating, nausea after meals, and diarrhoea. The most likely diagnosis is Crohn’s disease, an inflammatory bowel disease that affects the small bowel and is more common and severe in smokers. Small-bowel adenocarcinoma is a rare possibility, but less likely in this case. Coeliac disease can be associated with ulcerative jejunitis and small-bowel lymphoma, but doesn’t cause strictures. Giardiasis rarely causes nausea and doesn’t show X-ray changes, and would often be associated with a history of foreign travel. Chronic pancreatitis and pancreatic insufficiency could also present with these symptoms, but would be unusual in a non-drinker without a history of recurrent gallstone pancreatitis. A plain abdominal X-ray might show pancreatic calcification.
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This question is part of the following fields:
- Gastroenterology
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Question 73
Incorrect
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A 35 year old woman has been diagnosed with irritable bowel syndrome (IBS). She has previously visited the gastroenterology clinic and all tests, including colonoscopy, were normal. Her main concerns are abdominal pain, bloating, and constipation. Despite taking antispasmodics, regular movicol, and following a dietician advice, she still experiences symptoms. She has tried other laxatives before, but with little improvement. What would be the most suitable next step?
Your Answer:
Correct Answer: Linaclotide
Explanation:The diagnosis and management of IBS have been addressed by NICE in their guidance. The first line of pharmacological treatment includes antispasmodics such as Hyoscine or mebeverine, loperamide for diarrhea, and laxatives for constipation. Lactulose should be avoided. If the above treatments have not helped, second-line options include tricyclic antidepressants such as up to 30 mg amitriptyline. Third-line options include serotonin selective reuptake inhibitors. Linaclotide can be considered if the patient has had constipation for at least 12 months and has not benefited from different laxatives. Other management options include dietary advice and psychological treatments. However, acupuncture and reflexology are not recommended for managing IBS.
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.
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This question is part of the following fields:
- Gastroenterology
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Question 74
Incorrect
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A 55-year-old man presents with long-standing gastrointestinal symptoms. His medical history includes a diagnosis of irritable bowel syndrome in his early adulthood. He currently takes mebeverine 135 mg TDS and loperamide 2 mg PRN for symptom relief. He reports intermittent abdominal pain, bloating, and periodic bouts of diarrhea. His latest blood tests, done as part of his diabetic annual review, show a mild microcytic anemia and a slight persistent elevation of ALT and ALP. He has no new symptoms and follows a normal diet. On examination, there are no focal abnormalities. He is interested in trying a gluten-free diet as his mother found it helpful for her IBS. What advice should be given regarding testing for coeliac disease?
Your Answer:
Correct Answer: Serological testing can be carried out appropriately at any time regardless of a person's dietary intake of gluten
Explanation:Testing for Coeliac Disease
Accuracy of testing for coeliac disease is dependent on the person following a gluten-containing diet. For at least six weeks prior to testing, a person should follow a normal diet containing gluten in more than one meal a day. This is the case for both serological and histological testing. If a diagnosis of coeliac disease is suspected and the person is reluctant to include or reintroduce gluten in their diet prior to any testing, then they should be referred to a gastrointestinal specialist.
Serological testing for coeliac disease is used to indicate whether further investigation is needed. A positive test should prompt referral to a gastrointestinal specialist for intestinal biopsy to confirm or exclude the diagnosis. When serology is requested, the preferred first choice test is currently IgA transglutaminase (tTGA). If the result is equivocal, IgA endomysial antibodies (EMA) testing can be used.
IgA deficiency can lead to false negative results, so IgA deficiency should be ruled out if serology is negative. IgG tTGA and/or IgG EMA serology can be used in those with confirmed IgA deficiency. Human leucocyte antigen (HLA) DQ2/DQ8 testing may be considered by gastrointestinal specialists in specific clinical situations; however, it doesn’t have a role in the initial testing for coeliac disease.
It should be borne in mind that if serological testing is negative but there is significant clinical suspicion of coeliac disease, then referral to a gastrointestinal specialist should be offered as serological tests are not 100% accurate. A clinical response to gluten-free diet is not diagnostic of coeliac disease. For example, some patients with irritable bowel syndrome may be gluten sensitive but not have coeliac disease. Implications of a positive test should be discussed prior to serological testing being performed, including the nature of the further investigations needed and the implications for other family members should the test be positive.
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This question is part of the following fields:
- Gastroenterology
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Question 75
Incorrect
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A 48-year-old woman presents to her General Practitioner with a 3-week history of intermittent rectal bleeding. She says she doesn't usually look but has noticed blood within her stools on several occasions over the past few weeks. She is a non-smoker and is normally fit and well, with no significant family history or past medical history. A diagnosis of colonic carcinoma is suspected.
Which of the following presenting symptoms would most support this diagnosis?
Your Answer:
Correct Answer: Abdominal pain
Explanation:Symptoms and Possible Underlying Pathologies: A Case Study
Abdominal pain, abdominal bloating, alternating diarrhea and constipation, macrocytic anemia, and mucous per rectum are all symptoms that can indicate different underlying pathologies. In the case of a patient under 50 years old presenting with rectal bleeding, abdominal pain may suggest a more serious underlying pathology, such as colorectal cancer. According to NICE guidance, a suspected cancer pathway referral should be considered in such cases. Abdominal bloating, on the other hand, is more likely to be a symptom of irritable bowel disease. Alternating diarrhea and constipation, as well as mucous per rectum, are indicators of functional bowel disorders, such as irritable bowel syndrome. Finally, macrocytic anemia, while not associated with colorectal cancer, may warrant further investigation if found. Understanding the different symptoms and their possible underlying pathologies is crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 76
Incorrect
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A 56-year-old man presents with a sudden onset of acute severe pain in his upper abdomen, which radiates to his back. He experiences severe nausea and vomiting and finds that sitting forwards is the only way to alleviate the pain. His medical history includes hypertension and gallstones, which were incidentally discovered during an ultrasound scan. What is the MOST PROBABLE diagnosis?
Your Answer:
Correct Answer: Acute pancreatitis
Explanation:Differential Diagnosis of Acute Upper Abdominal Pain
Acute upper abdominal pain can have various causes, and it is important to differentiate between them to provide appropriate treatment. Here are some possible diagnoses based on the given symptoms:
1. Acute pancreatitis: This condition is often caused by gallstones or alcohol consumption and presents with severe upper abdominal pain. Blood tests show elevated amylase levels, and immediate hospital admission is necessary.
2. Budd-Chiari syndrome: This rare condition involves the blockage of the hepatic vein and can cause right upper abdominal pain, hepatomegaly, and ascites.
3. Acute cholecystitis: This condition is characterized by localized pain in the upper right abdomen and a positive Murphy’s sign (pain worsened by deep breathing).
4. Perforated duodenal ulcer: This condition can cause sudden upper abdominal pain, but it is usually associated with a history of dyspepsia or NSAID use.
5. Renal colic: This condition causes severe pain in the loin-to-groin area and is often accompanied by urinary symptoms and hematuria.
In conclusion, a thorough evaluation of the patient’s symptoms and medical history is necessary to determine the underlying cause of acute upper abdominal pain.
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This question is part of the following fields:
- Gastroenterology
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Question 77
Incorrect
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A 50-year-old woman who is currently 4 weeks into a course of postoperative radiotherapy for locally advanced cervical carcinoma has abdominal pain and diarrhoea.
Select the single most likely cause.Your Answer:
Correct Answer: Radiation enteritis
Explanation:Radiation Enteritis: Understanding the Inflammation of the Bowel
Radiation enteritis is a condition that occurs as a result of radiation-induced inflammation of the bowel. The severity of the condition is dependent on the volume of bowel that has been irradiated and the radiation dose. During therapy, patients may experience acute radiation enteritis, which manifests as ileitis, colitis, or proctitis, with symptoms such as abdominal pain and diarrhea.
In virtually all patients undergoing radiation therapy, acute radiation-induced injury to the GI mucosa occurs when the bowel is irradiated. Delayed effects may occur after three months or more, and they are due to mucosal atrophy, vascular sclerosis, and intestinal wall fibrosis. These effects can lead to malabsorption or dysmotility, causing further complications.
It is important to note that the clinical picture of radiation enteritis is unlikely to be due to a surgical complication, given the time frame. Additionally, it is less suggestive of bowel obstruction or perforation. Local malignant infiltration into the bowel is most likely to present with obstruction. Understanding the symptoms and causes of radiation enteritis can help healthcare professionals provide appropriate treatment and management for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 78
Incorrect
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A 66-year-old man presents with a change in bowel habit. He has noticed that over the last three to four weeks he is passing looser, more frequent stools on a daily basis. Prior to the last three to four weeks he has not had any persistent problems with his bowels. He denies any rectal bleeding. He has no significant past history of any bowel problems.
On examination his abdomen feels normal and his rectal examination is normal. You weigh him and his weight is the same as six months ago.
What is the most appropriate course of action?Your Answer:
Correct Answer: Refer him urgently to a lower gastrointestinal specialist
Explanation:NICE Guidelines for Urgent Referral and Faecal Occult Blood Testing in Patients with Change in Bowel Habit
In accordance with NICE guidelines, patients aged 60 years and older with a change in bowel habit towards looser and more frequent stools (without rectal bleeding) should be urgently referred. This applies to our 68-year-old male patient. While faecal occult blood testing is not necessary in this case, NICE offers guidance on whom to test for colorectal cancer using this method.
According to the guidelines, faecal occult blood testing should be offered to adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss. Additionally, those aged under 60 with changes in bowel habit or iron-deficiency anaemia should also be tested. For patients aged 60 and over, testing should be offered if they have anaemia even in the absence of iron deficiency.
It is important to follow these guidelines to ensure timely and appropriate management of patients with potential colorectal cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 79
Incorrect
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A 25-year-old man visits his General Practitioner with mild jaundice after experiencing flu-like symptoms. He has no prior medical conditions and is in good health. After being evaluated by a Gastroenterologist, it is suspected that he may have Gilbert syndrome. What test result would be most suitable for confirming this diagnosis?
Your Answer:
Correct Answer: Absence of bilirubin in the urine
Explanation:Distinguishing Gilbert Syndrome from Haemolysis: Key Indicators
Gilbert syndrome is a genetic condition that causes unconjugated hyperbilirubinaemia without any signs of liver disease or haemolysis. One key indicator is the absence of bilirubin in the urine, as excess bilirubin is unconjugated and doesn’t appear in the urine. Additionally, there should be no signs of liver function abnormality, despite a slight increase in serum aspartate aminotransferase (AST) activity that may occur in haemolysis. Another distinguishing factor is the maintenance of normal urinary urobilinogen excretion, as opposed to an increase in haemolytic jaundice. Finally, an increased reticulocyte count, which is elevated in haemolysis, should prompt investigation for an alternative diagnosis in Gilbert syndrome. Overall, understanding these key indicators can aid in distinguishing Gilbert syndrome from haemolysis.
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This question is part of the following fields:
- Gastroenterology
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Question 80
Incorrect
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A 56-year-old man with a history of ulcerative colitis presents to his GP for a follow-up appointment after experiencing a recent exacerbation that required oral corticosteroids for remission. He reports feeling well with no abdominal symptoms, but has had four exacerbations in the past year that required treatment with oral corticosteroids. His current medications include paracetamol and mesalazine. On examination, his vital signs are within normal limits and his abdominal exam is unremarkable. His recent blood test results show no significant abnormalities. According to NICE guidelines, what is the recommended next step in managing his ulcerative colitis?
Your Answer:
Correct Answer: Oral thiopurines (azathioprine or mercaptopurine)
Explanation: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.
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This question is part of the following fields:
- Gastroenterology
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Question 81
Incorrect
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A 28-year-old nurse had a needlestick injury six months ago. She did not present immediately to Occupational Health but eventually came because she began to feel tired and lethargic. She has a raised alanine aminotransferase (ALT) level, anti-hepatitis B surface antibodies and anti-hepatitis C virus (HCV) antibodies. Low levels of HCV ribonucleic acid (RNA) are detected. A liver biopsy reveals early inflammatory changes.
What is the most likely diagnosis?Your Answer:
Correct Answer: Chronic hepatitis C infection
Explanation:Explanation of Hepatitis C Infection and Differential Diagnosis
Hepatitis C virus (HCV) ribonucleic acid (RNA) is detected in a patient, indicating active hepatitis C infection. The presence of anti-HCV antibodies and an 8-month history since exposure confirms that the infection is now chronic. Liver biopsy may show varying degrees of inflammation, fibrosis, and cirrhosis, with this patient exhibiting early inflammatory changes.
Autoimmune hepatitis, which is associated with antinuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA), is not consistent with the presence of anti-HCV antibodies and HCV RNA. Chronic hepatitis B infection is also ruled out, as the patient’s anti-hepatitis B antibodies are likely due to vaccination. Functional symptoms may cause tiredness and lethargy, but the patient’s deranged liver function tests and positive hepatitis C antibodies indicate an underlying diagnosis of hepatitis C.
Understanding Hepatitis C Infection and Differential Diagnosis
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This question is part of the following fields:
- Gastroenterology
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Question 82
Incorrect
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A 68-year-old man presents with a history of epigastric pain typical of dyspepsia which had been present for three months, together with weight loss of 2 stone over the same period.
He had been treated with a proton pump inhibitor but had not benefited from this therapy. More recently he had noticed a difficulty when trying to eat solids and frequently vomited after meals.
On examination he had a palpable mass in the epigastrium and his full blood count revealed a haemoglobin of 85 g/L (130-180).
What is the likely diagnosis?Your Answer:
Correct Answer: Carcinoma of stomach
Explanation:Alarm Symptoms of Foregut Malignancy
The presence of alarm symptoms in patients over 55 years old, such as weight loss, bleeding, dysphagia, vomiting, blood loss, and a mass, are indicative of a malignancy of the foregut. It is crucial to refer these patients for urgent endoscopy, especially if dysphagia is a new onset symptom.
However, it is unfortunate that patients with alarm symptoms are often treated with PPIs instead of being referred for further evaluation. Although PPIs may provide temporary relief, they only delay the diagnosis of the underlying tumor. Therefore, it is important to recognize the significance of alarm symptoms and promptly refer patients for appropriate diagnostic testing.
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This question is part of the following fields:
- Gastroenterology
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Question 83
Incorrect
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A 55-year-old man visits his General Practitioner, worried about potential hepatitis C infection. He has received multiple tattoos, all of which were done in the United Kingdom (UK). He has previously been vaccinated against hepatitis B. Upon examination, there are no indications of liver disease. What is the most suitable management advice to give this patient?
Your Answer:
Correct Answer: He should be tested for anti-hepatitis C virus (anti-HCV)
Explanation:Screening and Testing for Hepatitis C Infection
Hepatitis C is a viral infection that can cause liver damage and other serious health problems. It is important to screen and test for hepatitis C in certain individuals, particularly those with unexplained abnormal liver function tests or who have undergone procedures with unsterilized equipment.
Testing for anti-hepatitis C virus (anti-HCV) serology is recommended for those suspected of having HCV infection, although false negatives can occur in the acute stage of infection. A liver ultrasound (US) may be used to look for evidence of cirrhosis, but is not a diagnostic tool for hepatitis C.
Screening for hepatitis C is necessary for those who have undergone tattooing, ear piercing, body piercing, or acupuncture with unsterile equipment, as these procedures can put a person at risk of acquiring the infection.
Testing for HCV deoxyribonucleic acid (DNA) is necessary to confirm ongoing hepatitis C infection in those with positive serology. Chronic hepatitis C is considered in those in whom HCV RNA persists, which occurs in approximately 80% of cases. Normal liver function tests do not exclude hepatitis C infection, and deranged LFTs should be a reason to consider screening for the virus.
In summary, screening and testing for hepatitis C is important for those at risk of infection or with unexplained abnormal liver function tests. Testing for HCV DNA is necessary to confirm ongoing infection, and normal LFTs do not exclude the possibility of hepatitis C.
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This question is part of the following fields:
- Gastroenterology
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Question 84
Incorrect
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Which drug is listed as having a severe interaction with Cimetidine, considering that Ranitidine is unavailable due to a manufacturing problem and GP practices in the area are advised to prescribe Cimetidine as a potential cost-effective alternative?
Your Answer:
Correct Answer: Bendroflumethiazide
Explanation:Cimetidine and Nifedipine Interaction
Cimetidine and nifedipine have a severe interaction as cimetidine moderately increases the exposure to nifedipine. The manufacturer advises monitoring and adjusting the dose accordingly. It is important to note that the British National Formulary (BNF) categorizes interactions as severe (red) or moderate (amber). While the list of amber interactions for a drug can be extensive, it is crucial to focus on the most severe (red) ones, especially when it comes to exams or clinical practice.
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This question is part of the following fields:
- Gastroenterology
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Question 85
Incorrect
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A 40-year-old woman visits her doctor with a complaint of recurrent central abdominal pain that she has been experiencing for a long time. The pain usually subsides when she has a bowel movement. She has an irregular bowel pattern, with instances of both constipation and diarrhea. She has never observed any blood in her feces, and her weight has remained constant.
Which of the following symptoms is most indicative of the probable diagnosis? Choose ONE option only.Your Answer:
Correct Answer: Central abdominal pain
Explanation:Understanding Irritable Bowel Syndrome: Symptoms and Red Flags
Irritable bowel syndrome (IBS) is a group of symptoms that affect the intestinal motility, causing central or lower abdominal pain, bloating, alternating constipation and diarrhea, rectal mucous, and tenesmus. However, it is important to note that IBS doesn’t cause rectal bleeding or unintentional weight loss.
While a high-fiber diet may not necessarily relieve symptoms of IBS, nocturnal diarrhea may indicate an underlying organic disease and should prompt further investigation. It is crucial to recognize these red flag symptoms and seek medical attention to determine the underlying cause.
Understanding the symptoms and red flags of IBS can help individuals manage their condition and seek appropriate medical care when necessary.
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This question is part of the following fields:
- Gastroenterology
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Question 86
Incorrect
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Which of the following statements about coeliac disease is accurate?
Your Answer:
Correct Answer: All coeliacs are intolerant to oats
Explanation:Coeliac Disease: Diagnosis and Risks
Coeliac disease is a condition where the immune system reacts to gluten, causing damage to the small intestine. Failure to adhere to a gluten-free diet can increase the risk of gastrointestinal cancers and gut lymphoma. However, after three to five years on a gluten-free diet, the risk of cancer decreases to that of a person without coeliac disease. The prevalence of coeliac disease varies in different countries, with rates as low as 1:300 in Italy and Spain to 1:18 in the Sahara. Two types of antibodies are tested for in the patient’s serology: Endomysial antibodies (EMA) and Tissue transglutaminase antibodies (tTGA). A small bowel biopsy is still considered the gold standard for diagnosis, and a referral to a gastroenterologist is necessary for patients with positive antibodies or those with negative antibodies but suspected CD. The suitability of oats for coeliacs is uncertain due to contamination by wheat.
To summarize, coeliac disease diagnosis involves testing for antibodies and a small bowel biopsy. Adherence to a gluten-free diet is crucial to reduce the risk of cancer. The prevalence of coeliac disease varies globally, and the suitability of oats for coeliacs is uncertain.
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This question is part of the following fields:
- Gastroenterology
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Question 87
Incorrect
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Which of the following is not a characteristic of non-alcoholic steatohepatitis?
Your Answer:
Correct Answer: Type 1 diabetes mellitus
Explanation:Non-alcoholic fatty liver disease may be considered as a potential cause of abnormal liver function tests in patients with type 2 diabetes mellitus.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 88
Incorrect
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A 35-year-old lady visited the GP for the treatment of her haemorrhoids and was prescribed a topical treatment containing corticosteroids and local anesthetic. She was not given any instructions on how long to use this treatment for and has now come to seek advice on the duration of treatment.
What is the SINGLE MOST suitable advice to give her?Your Answer:
Correct Answer: Corticosteroid preparations can only be used for 2 days, but local anaesthetic use can continue for 2 weeks
Explanation:Initial Management of Anal Fissures
Corticosteroid-containing preparations should not be used for more than 7 days as prolonged use can result in skin atrophy, contact dermatitis, and skin sensitisation. Similarly, anaesthetic-containing preparations should only be used for a few days as they can lead to sensitisation of anal skin.
Aside from topical treatments, there are other crucial initial management steps that should be taken. These include ensuring that stools are soft and easy to pass, optimising anal hygiene and toileting practices, such as avoiding straining during bowel movements.
If conservative treatment fails or if symptoms recur, referral to secondary care should be considered.
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This question is part of the following fields:
- Gastroenterology
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Question 89
Incorrect
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A 62-year old male presents with dysphagia. His symptoms were first noticed a few months ago and have steadily worsened.
Initially he found difficulty swallowing solids but over recent weeks has also been having difficulty swallowing liquids. In addition to his swallowing problems he has lost over a stone in weight.
On examination, he looks thin and slightly pale.
What is the most likely diagnosis?Your Answer:
Correct Answer: Oesophageal cancer
Explanation:Possible Diagnosis for Dysphagia in a 60-Year-Old Patient
There are several factors that may suggest a diagnosis of oesophageal cancer in a patient in their 60s who presents with dysphagia. The gradual difficulty in swallowing solids and then liquids is a common symptom as the cancer grows and obstructs the oesophagus. Weight loss and pallor are also frequently observed due to cachexia and anaemia.
Achalasia, on the other hand, is a condition characterized by abnormal peristalsis and lack of lower oesophageal sphincter relaxation. It is most common in the third to fifth decades and presents with intermittent dysphagia, which is more pronounced for solids than liquids. Oesophageal cancer, however, tends to cause a more rapid and progressive dysphagia.
Chagas’ disease, caused by Trypanosoma cruzi spread by reduviid bugs, is not commonly seen in the United Kingdom but can cause a clinical picture similar to achalasia when it affects the oesophagus. GORD can also result in oesophageal stricture and dysphagia, but this is usually due to chronic reflux, and the history is relatively short. Finally, a pharyngeal pouch typically presents with dysphagia, halitosis, a neck lump, and regurgitation of undigested food.
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This question is part of the following fields:
- Gastroenterology
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Question 90
Incorrect
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A 64-year-old man complains of insomnia and lethargy. He denies any other systemic symptoms. During a routine clinical examination, a non-pulsatile mass is palpated in the right lower quadrant of his abdomen that doesn't move with respiration. What is the best course of action for management?
Your Answer:
Correct Answer: Urgent referral to local colorectal service
Explanation:Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.
An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.
The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.
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This question is part of the following fields:
- Gastroenterology
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Question 91
Incorrect
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A 27 year old male with a history of ulcerative colitis presents with rectal symptoms and bloody diarrhoea. Upon examination, he appears comfortable and well hydrated. His vital signs include a regular pulse of 88 beats per minute, a temperature of 37.5ºC, and a blood pressure of 120/80 mmHg. There is mild tenderness in the left iliac fossa, but no palpable masses or rebound tenderness. Rectal examination reveals tenderness and blood in the rectum. What is the most appropriate initial treatment for this patient's mild/moderate proctitis flare?
Your Answer:
Correct Answer: Rectal mesalazine
Explanation:When experiencing a mild-moderate flare of distal ulcerative colitis, the initial treatment option is the use of topical (rectal) aminosalicylates. It is recommended to start with local treatment for rectal symptoms. Topical aminosalicylates are more effective than steroids, but a combination of both can be used if monotherapy is not effective. If the disease is diffuse or if symptoms do not respond to topical treatments, oral aminosalicylates can be used. In cases of severe disease, oral steroids can be considered.
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.
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This question is part of the following fields:
- Gastroenterology
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Question 92
Incorrect
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A 30-year-old man presents to his General Practitioner with cramping abdominal pain and profuse diarrhoea, which is sometimes bloody. He thinks it may be related to some chicken he ate 3 days ago before returning from a holiday in South East Asia. He has no other comorbidities and works in the local pub.
On examination, his temperature is 38.0 °C. There is mild tenderness in the left iliac fossa. His observations are normal. A stool sample is positive for campylobacter.
Which of the following is the most appropriate management?Your Answer:
Correct Answer: Prescribe an antibiotic
Explanation:Managing Campylobacter Infection: Antibiotics, Hydration, and Work Restrictions
Campylobacter is a common bacterial cause of infectious intestinal disease, often contracted through undercooked meat, contaminated water, or contact with infected animals. When a patient presents with symptoms such as fever, bloody diarrhea, and abdominal pain, a stool culture should be performed to confirm the diagnosis. According to NICE guidelines, antibiotic treatment is recommended for patients with positive stool cultures and severe symptoms. Erythromycin is the first-line choice, with alternatives including azithromycin, clarithromycin, and ciprofloxacin.
Patients should not return to work for at least 48 hours after the last episode of diarrhea or vomiting, and longer if they work with food or in other specific settings. Hospital admission is only necessary for severe symptoms or systemic illness. Antimotility drugs are not recommended for patients with possible Shiga toxin-producing Escherichia coli infection, but may be useful for travelers’ diarrhea. Oral rehydration salts are important for managing symptoms and preventing dehydration. With appropriate treatment and management, most cases of Campylobacter infection will resolve within a week.
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This question is part of the following fields:
- Gastroenterology
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Question 93
Incorrect
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You are evaluating a 37-year-old man who presented with an anal fissure caused by constipation and straining. He reports no systemic symptoms and is generally in good health. Despite using lidocaine ointment as prescribed, he continues to experience severe rectal pain during bowel movements and passes bright red blood with every stool. His stools have become softer due to modifications in his diet and regular lactulose use. What is the next step in managing this patient's condition?
Your Answer:
Correct Answer: Prescribe topical GTN ointment for 6-8 weeks and review if still not healed
Explanation:To alleviate pain and promote healing, suggest using an ointment (if there are no contraindications) twice a day for 6-8 weeks. Referral to colorectal surgeons is not necessary at this time since there are no indications of a severe underlying condition. If the GTN treatment is ineffective after 6-8 weeks, referral to the surgeons may be considered. Topical diltiazem may be prescribed under specialist guidance, but hydrocortisone ointment is not a recommended treatment for anal fissures.
Understanding Anal Fissures: Causes, Symptoms, and Treatment
Anal fissures are tears in the lining of the anal canal that can cause pain and rectal bleeding. They can be acute or chronic, depending on how long they have been present. Risk factors for developing anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.
Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, other underlying causes such as Crohn’s disease should be considered.
Management of acute anal fissures involves softening stool, dietary advice, and the use of bulk-forming laxatives or lubricants before defecation. Topical anaesthetics and analgesia can also be used to manage pain.
For chronic anal fissures, the same techniques should be continued, but topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after 8 weeks, surgery (sphincterotomy) or botulinum toxin may be considered and a referral to secondary care may be necessary.
Understanding the causes, symptoms, and treatment options for anal fissures can help individuals manage their condition and seek appropriate medical care when necessary.
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This question is part of the following fields:
- Gastroenterology
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Question 94
Incorrect
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A 72-year-old woman with a previous history of surgery for a ruptured ovarian cyst as a teenager presents with colicky central abdominal pain of 24 hours’ duration. She has now started to vomit and on further questioning admits to constipation for the last 12 hours. There is nothing else significant in her medical history.
Select the single most correct option.Your Answer:
Correct Answer: She should be thoroughly examined for a strangulated hernia
Explanation:Understanding Bowel Obstruction and Ischaemic Bowel
Bowel obstruction can occur as a result of adhesions, which are commonly caused by previous abdominal surgery. Symptoms such as abdominal pain, bloating, and vomiting may indicate a small bowel obstruction. It is important to rule out a strangulated hernia, especially a small femoral hernia.
Ischaemic bowel, on the other hand, is typically seen in patients with pre-existing cardiovascular disease and risk factors. This condition often presents acutely and is caused by an arterial occlusion. Symptoms include severe abdominal pain, fever, nausea, and diarrhoea, which may be bloody. It is important to suspect ischaemic bowel in patients with acute abdominal pain that is out of proportion to clinical findings.
In summary, understanding the differences between bowel obstruction and ischaemic bowel can help healthcare professionals make accurate diagnoses and provide appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 95
Incorrect
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What is the most suitable approach to prevent variceal bleeding in a 45-year-old man with a history of alcohol abuse who has been diagnosed with grade 3 oesophageal varices during an outpatient endoscopy?
Your Answer:
Correct Answer: Propranolol
Explanation:The prophylaxis of oesophageal bleeding can be achieved using a non-cardioselective B-blocker (NSBB), while endoscopic sclerotherapy is no longer considered effective in preventing variceal haemorrhage.
Variceal haemorrhage is a serious condition that requires prompt and effective management. The initial treatment involves resuscitation of the patient, correction of clotting abnormalities, and administration of vasoactive agents such as terlipressin or octreotide. Prophylactic IV antibiotics are also recommended to reduce mortality in patients with liver cirrhosis. Endoscopic variceal band ligation is the preferred method for controlling bleeding, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. However, TIPSS can lead to exacerbation of hepatic encephalopathy, which is a common complication.
To prevent variceal haemorrhage, prophylactic measures such as propranolol and endoscopic variceal band ligation (EVL) are recommended. Propranolol has been shown to reduce rebleeding and mortality compared to placebo. EVL is superior to endoscopic sclerotherapy and should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. NICE guidelines recommend offering endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.
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This question is part of the following fields:
- Gastroenterology
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Question 96
Incorrect
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A 50-year-old man presents to the clinic complaining of diarrhoea that has been ongoing for the past eight weeks. He has also experienced fresh rectal bleeding on multiple occasions during this time. The patient has a history of irritable bowel syndrome and haemorrhoids. On examination, his abdomen is soft with no palpable masses, and a normal rectal exam is noted.
What would be the next appropriate step in managing this patient?Your Answer:
Correct Answer: Prescribe loperamide and review in three to four weeks
Explanation:NICE Guidelines for Referral of Suspected Colorectal Cancer
According to the National Institute for Health and Care Excellence (NICE) guidelines, individuals under the age of 50 who experience a change in bowel habit to looser and/or more frequent stools, along with rectal bleeding, should be urgently referred for suspected colorectal cancer.
In addition, NICE recommends considering a suspected cancer pathway referral for adults under 50 with rectal bleeding and unexplained symptoms such as abdominal pain, weight loss, and iron-deficiency anemia. These referrals should result in an appointment within two weeks to ensure prompt diagnosis and treatment.
It is important to follow these guidelines to ensure early detection and treatment of colorectal cancer, which can significantly improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 97
Incorrect
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A 70-year-old woman visits the General Practitioner after being discharged from the hospital three days ago. She underwent a cholecystectomy but had to stay longer due to a chest infection that required treatment. She is now experiencing watery diarrhoea, abdominal cramping pain, and mild lower abdominal tenderness.
What is the most probable diagnosis?Your Answer:
Correct Answer: Clostridioides difficile-associated colitis
Explanation:Clostridioides difficile-Associated Colitis: Symptoms, Risk Factors, and Treatment Options
Clostridioides difficile-associated colitis is a condition that should be suspected in patients with diarrhoea who have received antibiotics within the previous three months, have recently been in hospital, and/or have an occurrence of diarrhoea 48 hours or more after discharge from the hospital. Although cases can also occur in the community without a history of hospitalisation, the primary risk factor is a disturbance of the normal bacterial flora of the colon by exposure to antibiotics. The release of toxins causes mucosal inflammation and damage, leading to diarrhoea. While most patients develop diarrhoea during or shortly after starting antibiotics, some may not become symptomatic for up to ten weeks after antibiotics.
Therapy for non-severe infection consists of oral vancomycin or fidaxomcyin as a second-line option. Ceasing the causative antibiotic (if possible) will result in resolution in approximately three days in about 20% of patients. However, more severe diseases will require hospitalisation.
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This question is part of the following fields:
- Gastroenterology
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Question 98
Incorrect
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A 60-year-old man presents to his General Practitioner complaining of dysphagia for both solids and liquids. He is experiencing no associated nausea or abdominal pain. His weight is stable and he is a lifelong non-smoker.
What is the most likely diagnosis?Your Answer:
Correct Answer: Achalasia
Explanation:Differential Diagnosis for Dysphagia: Achalasia, Benign Oesophageal Stricture, Barrett’s Oesophagus, Carcinoma of the Oesophagus, and Schatzki’s Rings
Dysphagia, or difficulty swallowing, can be caused by various oesophageal disorders. One such disorder is achalasia, which is characterized by dysphagia for both solids and liquids. It occurs in adults aged 25-60 years and is diagnosed by a barium swallow that reveals a dilated oesophagus. Other symptoms include regurgitation of food, chest pain, heartburn, and nocturnal cough. Benign oesophageal stricture is less likely as it only causes dysphagia for solids. Barrett’s oesophagus, a change in cell type of the epithelium in the distal portion of the oesophagus due to prolonged frequent acid exposure, primarily causes heartburn and acid regurgitation. Carcinoma of the oesophagus should be considered, but it usually causes dysphagia of solids and weight loss. Schatzki’s rings, rings of mucosa or muscle in the lower oesophagus, cause intermittent and non-progressive dysphagia for solids, usually after a patient eats a meal in a hurried fashion. Daily dysphagia is not usually a feature.
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This question is part of the following fields:
- Gastroenterology
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Question 99
Incorrect
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You come across a 30-year-old accountant who has been diagnosed with Crohn's disease after experiencing abdominal pain, loose stools and a microcytic anaemia. The individual is seeking further information on the condition.
Which of the following statements is accurate regarding Crohn's disease?Your Answer:
Correct Answer: Osteoporosis occurs in up to 30% of patients with inflammatory bowel disease
Explanation:Upon diagnosis, approximately 66% of individuals with inflammatory bowel disease exhibit anaemia. Crohn’s disease is typically diagnosed at a median age of 30 years. The global incidence and prevalence of Crohn’s disease are on the rise.
Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.
If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 100
Incorrect
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You are evaluating a patient who has come back to see you for the results of some recent blood tests. Three months ago, she had a liver function test that revealed a bilirubin of 42 µmol/L (normal range 3-20). A repeat liver function test conducted last week has shown the same outcome. The rest of her liver profile is within normal limits.
She is otherwise healthy and not taking any regular medication. She is not overweight, drinks alcohol only occasionally, and clinical examination is normal with no signs of liver disease. She is asymptomatic. Full blood count, renal function, thyroid function, fasting glucose, and fasting lipids are all within normal limits.
What is the most appropriate next step in her management?Your Answer:
Correct Answer: No further action needed. Reassure the patient as the result is stable and the other tests are normal.
Explanation:Management of Isolated Slightly Raised Bilirubin Level
When a patient presents with an isolated slightly raised bilirubin level and is asymptomatic, the next step is to confirm the proportion of unconjugated bilirubin to guide further investigation. If the unconjugated bilirubin is greater than 70%, the patient probably has Gilbert’s syndrome. However, if the bilirubin level is almost twice the upper limit of normal, confirmed on interval testing, further investigation is necessary.
If the bilirubin level remains stable on repeat testing, no further action is needed unless there is clinical suspicion of haemolysis. However, if the bilirubin level rises on retesting, haemolysis must be considered and should be investigated with a blood film, reticulocyte count, lactate dehydrogenase, and haptoglobin. It is important to monitor the bilirubin level and investigate further if necessary to ensure proper management of the patient’s condition.
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This question is part of the following fields:
- Gastroenterology
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Question 101
Incorrect
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A 50-year-old woman presents to her General Practitioner following an Occupational Health screen.
Investigations have shown the following hepatitis B (HBV) serology:
Test Result
HBsAg
(Hepatitis B surface antigen)
Positive
HBeAg
(Hepatitis B e-antigen)
Positive
Anti-HBs
(Antibody to HBsAg)
Negative
Anti-HBe
(Antibody to HBeAg)
Negative
Anti-HBc IgG
(Antibody to hepatitis B core-antigen immunoglobulin G)
Positive
Which of the following most accurately reflects this patient’s HBV status?
Your Answer:
Correct Answer: Persistent carrier, high infectivity
Explanation:Understanding Hepatitis B Test Results
Hepatitis B is a viral infection that affects the liver. Understanding the results of hepatitis B tests is important for proper diagnosis and treatment. Here, we will discuss the different test results and what they mean.
Persistent Carrier with High Infectivity:
If a patient is positive for surface antigen, e-antigen, and core antibody, and negative for surface antibodies and e-antibodies, it suggests chronic carrier status. The presence of e-antigen confers high infectivity, indicating active viral replication. Core antibodies are a marker of past infection and will not be found in vaccinated individuals who have never been infected.Persistent Carrier with Low Infectivity:
If a patient is positive for surface antigen and core antibody, but negative for e-antigen and e-antibodies, it suggests a moderately high viral load and elevated ALT levels. This is caused by a hepatitis B virus that has certain mutations (pre-core mutation) that allow the virus to replicate even when the e-antigen is absent.Previous Vaccination against Hepatitis B:
If a patient has surface antibodies but not core antibodies, it indicates previous vaccination against hepatitis B.Spontaneously Cleared Infection:
If a patient has lost surface antigen and developed surface antibodies, it marks seroconversion and indicates immunity. If IgM antibodies to core antigen (anti-HBc IgM) are present, it indicates recent infection.In conclusion, understanding hepatitis B test results is crucial for proper diagnosis and treatment. Consultation with a healthcare provider is recommended for interpretation of test results and appropriate management.
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This question is part of the following fields:
- Gastroenterology
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Question 102
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 103
Incorrect
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A very sensible parent brings her 9-year-old into the surgery for review. She is concerned as her child is complaining of recurrent episodes of dull abdominal pain and missing significant days off school. Your physical examination is entirely normal.
What would count most against a diagnosis of functional recurrent abdominal pain in this case?Your Answer:
Correct Answer: Above average intellectual ability
Explanation:Recurrent Abdominal Pain in Children
Recurrent abdominal pain is a common complaint among children over the age of five, with approximately 10% experiencing it. It is crucial to determine the nature of the pain, its impact on the child’s daily life, and how the child and their family cope with it. Organic causes, such as gastrointestinal, urological, haematological, and miscellaneous causes, must be ruled out. Non-organic pain is suggested by peri-umbilical pain, and vomiting may be present, but weight loss is rare. Other important questions to ask include the timing of the pain, associated symptoms, family history, and social history. Physical examination is often unhelpful, and investigations are unlikely to provide a diagnosis when non-organic pain is suspected.
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This question is part of the following fields:
- Gastroenterology
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Question 104
Incorrect
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A 68-year-old man presents to the clinic with complaints of fatigue and lack of energy. His recent blood test showed macrocytosis and a low haemoglobin level, indicating a folic acid deficiency. He requests dietary recommendations from the physician to address this issue.
What is the most suitable food item to suggest?Your Answer:
Correct Answer: Spinach
Explanation:Folate Content in Common Foods
Folate, also known as vitamin B9, is an essential nutrient that is important for cell growth and development. While it is found naturally in many foods, it is also added to processed foods and supplements in the form of folic acid. Here is a breakdown of the folate content in some common foods:
Spinach: With 194 μg of folic acid per 100g, spinach is the richest source of folate on this list.
Egg: While eggs contain 47 μg of folic acid per 100g, they only provide around a quarter of the folate per 100g that is found in spinach.
Carrot: Carrots contain about 21 μg of folic acid per 100g, less than half the amount of folate found in eggs and only around 11% of the amount provided by spinach.
Milk: Cow’s milk contains 5-7 μg of folic acid per 100g, making it the second-lowest source of folate in this range of options.
Apple: Apples provide the lowest source of folate in this range of options, with only about 3 μg of folic acid per 100g.
It is important to note that women who are pregnant or breastfeeding require more folate and should take a daily supplement of 400 micrograms. While many food manufacturers fortify their products with folic acid, wholegrain products already contain natural folate. Folate deficiency can occur due to poor intake, excessive alcohol consumption, or malnutrition.
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This question is part of the following fields:
- Gastroenterology
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Question 105
Incorrect
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A 49-year-old woman presents with lethargy and pruritus. She reports having a normal appetite and no weight loss. Upon examination, there is no clinical jaundice or organomegaly. The following blood tests were obtained:
- Hemoglobin: 12.8 g/dL
- Platelets: 188 * 10^9/L
- White blood cells: 6.7 * 10^9/L
- Sodium: 140 mmol/L
- Potassium: 3.9 mmol/L
- Urea: 6.2 mmol/L
- Creatinine: 68 µmol/L
- Bilirubin: 30 µmol/L
- Alkaline phosphatase: 231 U/L
- Alanine transaminase: 38 U/L
- Gamma-glutamyl transferase: 367 U/L
- Albumin: 39 g/L
What additional test is most likely to provide a diagnosis?Your Answer:
Correct Answer: Anti-mitochondrial antibodies
Explanation:Primary biliary cholangitis is a chronic liver disorder that affects middle-aged women. It is thought to be an autoimmune condition that damages interlobular bile ducts, causing progressive cholestasis and potentially leading to cirrhosis. The classic presentation is itching in a middle-aged woman. It is associated with Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Diagnosis involves immunology and imaging tests. Management includes ursodeoxycholic acid, cholestyramine for pruritus, and liver transplantation in severe cases. Complications include cirrhosis, osteomalacia and osteoporosis, and an increased risk of hepatocellular carcinoma.
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This question is part of the following fields:
- Gastroenterology
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Question 106
Incorrect
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You assess a 32-year-old male with a 15-year history of ulcerative colitis. He reports passing three bloody stools per day for the past week, but denies any abdominal pain and has maintained a good appetite. Upon examination, there are no notable findings in the abdomen. What is the most probable explanation for this current episode?
Your Answer:
Correct Answer: Mild exacerbation of ulcerative colitis
Explanation:Ulcerative colitis flares can occur without any identifiable trigger, but there are several factors that are often associated with them. These include stress, certain medications such as NSAIDs and antibiotics, and cessation of smoking. Flares are typically categorized as mild, moderate, or severe based on the number of stools a person has per day, the presence of blood in the stools, and the level of systemic disturbance. Mild flares involve fewer than four stools daily with or without blood and no systemic disturbance. Moderate flares involve four to six stools a day with minimal systemic disturbance. Severe flares involve more than six stools a day with blood and evidence of systemic disturbance such as fever, tachycardia, abdominal tenderness, distension, reduced bowel sounds, anemia, or hypoalbuminemia. Patients with severe disease should be admitted to the hospital.
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This question is part of the following fields:
- Gastroenterology
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Question 107
Incorrect
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A 45-year-old man returns after he was found to have abnormal liver biochemistry. Investigations showed he had an alanine aminotransferase (ALT) of 98 iu/l and was Hep B surface-antigen positive.
Select from the list the single statement that is true of chronic hepatitis due to the hepatitis B virus.Your Answer:
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