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Question 1
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: He is no longer eligible for bowel cancer screening within the NHS screening program
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 2
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 3
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: Nitrate
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 4
Incorrect
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A 60-year-old woman presents with increasing epigastric pain after eating for the past month. She has a history of intermittent heartburn and epigastric burning for over a year, which was previously managed with regular alginate. Three months ago, she reported no weight loss or vomiting, and her H. pylori status was checked. On her return visit, it was found that she is H. pylori positive and has experienced a reduced appetite, mild nausea, and some weight loss. What is the most appropriate course of action?
Your Answer: Refer routinely to a specialist in upper GI cancer
Correct Answer: Prescribe a PPI such as omeprazole 20 mg/day and review in two weeks
Explanation:Urgent Referral for Upper GI Cancer in H. pylori Positive Patient
This patient is showing red flag symptoms and signs that suggest upper GI cancer, including weight loss and poor appetite. Despite being Helicobacter pylori positive, urgent referral for upper GI endoscopy or to a specialist in upper GI cancer should not be delayed. An ultrasound scan is unlikely to be helpful, and prescribing a PPI should be avoided as it can mask underlying disease. It is important to prioritize urgent referral over prescribing eradication therapy for H. pylori, as the latter may delay the diagnosis of underlying pathology. By promptly referring the patient for further evaluation, healthcare providers can ensure timely diagnosis and treatment of potential upper GI cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Incorrect
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A 32-year-old man presents to his General Practitioner with a long history of intermittent abdominal discomfort and diarrhoea. He has noticed that his symptoms are particularly linked to gluten-containing foods and brings a food diary to support this theory. On examination, he has a body mass index of 19 kg/m2 and is clinically anaemic. Coeliac disease is suspected.
Which of the following investigations will most reliably diagnose this condition?
Your Answer: Xylose absorption test
Correct Answer: Microscopic examination of a small bowel biopsy specimen
Explanation:Diagnostic Tests for Coeliac Disease
Coeliac disease is an autoimmune disorder of the small bowel induced by gluten. The gold standard for diagnosis is the detection of subtotal villous atrophy on a small-bowel biopsy. However, the detection of tissue transglutaminase IgA antibodies is a widely used screening test with high specificity and sensitivity. Total immunoglobulin A (IgA) should also be measured in case of IgA deficiency. Antibodies become undetectable after 6-12 months of a gluten-free diet, making them useful for monitoring the disease. The xylose absorption test is not appropriate for this patient, while the detection of anti-gliadin antibodies and anti-endomysial antibodies can aid diagnosis but are not preferred methods. Serology for anti-tissue transglutaminase antibodies is the first-line screening test and aids referral to gastroenterology.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Incorrect
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A 35-year-old man with newly diagnosed ulcerative colitis (UC) comes to you with deteriorating symptoms. You believe he is experiencing a UC flare-up but doesn't need to be hospitalized based on clinical indications. He is presently taking suboptimal oral mesalazine once a day. He has no IBD care plan in place but has been diagnosed with severe disease.
What is the best course of action for managing his UC flare-up?Your Answer: Start oral mercaptopurine
Correct Answer: Start oral budesonide
Explanation:Treatment Options for Ulcerative Colitis Flares
Oral or rectal mesalazine (or rectal steroids) are the recommended first-line treatment for ulcerative colitis (UC) flares. The dose of oral mesalazine can be increased up to 4.8g daily for the treatment of flares. It is important to review the patient’s response to treatment after 2 weeks, or sooner if deterioration occurs.
While oral steroids are a potential treatment for UC flare-ups, they are not considered first-line treatments. Alternatives to oral steroids are preferred where possible. Immunosuppressants such as azathioprine and mercaptopurine may be considered by secondary care.
If a patient requires more than 2 courses of steroids in 12 months or is unable to reduce their oral steroid use below 15 mg prednisolone per day, escalation of IBD therapy may be necessary. It is important to inform the patient’s IBD team that a flare has occurred.
The IBD toolkit developed with the RCGP provides helpful advice on flare management. To ensure effective treatment of UC flares, it is important to follow these guidelines and work closely with the patient’s healthcare team.
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This question is part of the following fields:
- Gastroenterology
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Question 7
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: Acute gastritis
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 8
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: Baked beans
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 9
Incorrect
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A 54-year-old woman has a 3-week history of increasing jaundice and dark urine. In the past 4 months she has noticed intermittent loose, pale stools and has lost 6 kg in weight. On examination she is thin and jaundiced, with epigastric tenderness and a palpable gallbladder. Urine dipstick shows glucose +++, bilirubin +++ and urobilinogen +.
Select from the list the single most likely diagnosis.Your Answer: Malignant lymphadenopathy at the porta hepatis
Correct Answer: Carcinoma of the head of the pancreas
Explanation:Courvoisier’s Law and Obstructive Jaundice in Diagnosing Pancreatic Carcinoma
Courvoisier’s law is a crucial factor in diagnosing the cause of jaundice. If a palpable gallbladder is present in the presence of jaundice, it is unlikely to be due to gallstones. This is because gallstones cause a fibrotic gallbladder that will not distend in the presence of obstruction of the common bile duct. However, absence of Courvoisier’s sign doesn’t rule out malignancy.
In cases of obstructive jaundice, haemochromatosis can be excluded as a cause. The initial symptoms of haemochromatosis are usually vague and nonspecific, such as fatigue, weakness, arthropathy, and nonspecific abdominal problems.
Of the three obstructive neoplastic processes that remain, carcinoma of the head of the pancreas is the only one that will cause glycosuria. Therefore, the development of diabetes in anyone who is non-obese and over 50 years old without definite risk factors should raise suspicion of pancreatic carcinoma.
In conclusion, understanding Courvoisier’s law and the exclusions of other potential causes of obstructive jaundice is crucial in diagnosing pancreatic carcinoma.
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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 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: Oesophageal carcinoma
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 11
Correct
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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: 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 12
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: Pyloric stenosis
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 13
Incorrect
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A 45-year-old man underwent a right hemicolectomy for a Dukes' B colorectal carcinoma. What is the most suitable tumour marker to be monitored during his regular check-ups?
Your Answer: AFP
Correct Answer: CEA
Explanation:Tumor Markers: Identifying Cancer through Blood Tests
Tumor markers are substances produced by cancer cells or normal cells in response to cancer. These markers can be detected in blood, urine, or tissue samples and can help in the diagnosis, monitoring, and treatment of cancer. Here are some commonly used tumor markers and their significance:
Carcinoembryonic antigen (CEA) is a glycoprotein involved in cell adhesion. It is usually present only at very low levels in the blood of healthy adults but is raised in some cancers, including colorectal, stomach, pancreatic, lung, breast, and medullary thyroid cancers. While it lacks specificity and sensitivity to establish a diagnosis of colorectal cancer, it is used to help identify recurrences after surgical resection.
CA 19-9 (carbohydrate antigen 19-9) is secreted by some pancreatic tumors and is also elevated in gastric and hepato-biliary cancer. Its levels should fall when the tumor is treated, and rise again if the disease recurs.
PSA (prostate-specific antigen) is a marker for prostate cancer, while urinary 5HIAA (5-hydroxyindoleacetic acid) is elevated in carcinoid tumors and AFP (alpha-fetoprotein) is elevated in non-seminomatous germ cell tumors and hepatocellular cancer.
In conclusion, tumor markers play a crucial role in the diagnosis and management of cancer. However, it is important to note that elevated levels of these markers do not always indicate the presence of cancer and further testing is often required for confirmation.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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Each one of the following is a recognised complication of gastro-oesophageal reflux disease, except:
Your Answer: Oesophageal carcinoma
Correct Answer: Achalasia
Explanation:Managing Gastro-Oesophageal Reflux Disease
Gastro-oesophageal reflux disease (GORD) is a condition where gastric contents cause symptoms of oesophagitis. If GORD has not been investigated with endoscopy, it should be treated according to dyspepsia guidelines. However, if oesophagitis is confirmed through endoscopy, full dose proton pump inhibitors (PPIs) should be given for 1-2 months. If there is a positive response, low dose treatment may be given as required. If there is no response, double-dose PPIs should be given for 1 month.
For endoscopically negative reflux disease, full dose PPIs should be given for 1 month. If there is a positive response, low dose treatment may be given on an as-required basis with a limited number of repeat prescriptions. If there is no response, H2RA or prokinetic should be given for one month.
Complications of GORD include oesophagitis, ulcers, anaemia, benign strictures, Barrett’s oesophagus, and oesophageal carcinoma. It is important to manage GORD effectively to prevent these complications.
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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 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: 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 16
Incorrect
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What is the most accurate statement regarding gastrointestinal bleeding in patients who are using non-steroidal anti-inflammatory drugs (NSAIDs)?
Your Answer: It occurs when the patient complains of severe dyspepsia
Correct Answer: It is due to depletion of mucosal prostaglandin E (PGE) levels
Explanation:NSAIDs and Gastrointestinal Bleeds: Risk Factors and Mechanisms
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain relief and inflammation management. However, their use is associated with an increased risk of gastrointestinal bleeds, particularly in patients with pre-existing gastric or duodenal ulcers. Even those without a history of ulcers are at risk, with the relative risk varying among different NSAID preparations. NSAIDs directly damage the gastric mucosal barrier by depleting mucosal PGE levels, which decreases the gastroduodenal defence mechanisms and cytoprotective effect of PGE, resulting in mucosal injury, erosions and ulceration.
Several factors increase the risk of ulceration in the setting of NSAID use, including previous peptic ulcer disease, advanced age, female sex, high doses or combinations of NSAIDs, long-term NSAID use, concomitant use of anticoagulants, and severe comorbid illnesses. Even low-dose aspirin, with increasing use, is a major cause of upper gastrointestinal problems, particularly bleeding. It is important to note that NSAIDs may have adverse effects in all parts of the gastrointestinal tract, not only the stomach or duodenum; the oesophagus, small intestine and colon may also be affected. Endoscopic evidence of peptic ulceration is found in 20% of NSAID users even in the absence of symptoms.
In conclusion, while NSAIDs are effective in managing pain and inflammation, their use is associated with an increased risk of gastrointestinal bleeds. Patients with pre-existing gastric or duodenal ulcers are particularly at risk, but other factors such as advanced age, high doses or combinations of NSAIDs, and concomitant use of anticoagulants also increase the risk. It is important to weigh the benefits and risks of NSAID use and consider alternative pain management strategies in high-risk patients.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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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: Gentamicin
Correct 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 65-year-old woman presents for follow up after being prescribed trimethoprim for a suspected urinary tract infection by an out-of-hours doctor two weeks ago. She reports experiencing lower abdominal pains and bloating for the past six months, which have become increasingly severe and often wake her from sleep. She denies vomiting or diarrhea but notes increased frequency of urination. She has a poor appetite and has lost no weight. On examination, there is no clinical evidence of anemia or jaundice, and PR examination is normal. Which investigation is most likely to reveal the cause of this patient's symptoms?
Your Answer: Colposcopy
Explanation:Diagnosing Ovarian Cancer: Symptoms, Risk Factors, and Tumour Markers
Patients with ovarian cancer often present with vague abdominal symptoms that may have been wrongly attributed to other conditions such as urinary tract infection or irritable bowel syndrome. The key to establishing a diagnosis is to first think of ovarian cancer as a possibility and then, as always, to obtain a thorough history.
It helps to think of risk factors as well, because we know that certain factors are associated with an increased risk of ovarian cancer. These include obesity, late menopause, nulliparity, diabetes, and endometriosis. In terms of symptoms, patients may experience vague abdominal pains, early satiety, and urinary frequency/urgency.
Tumour markers can be a useful tool in certain clinical contexts. CA125 is a tumour marker associated with ovarian cancer and is a valuable test in the diagnosis of ovarian cancer with regard to initial primary care investigations. NICE recommends that women over the age of 50 who have one or more symptoms associated with ovarian cancer that occur more than 12 times a month or for more than a month are offered CA125 testing.
In summary, a high index of suspicion is needed when considering ovarian cancer as a possibility. It is important to take into account risk factors and symptoms, and to consider the use of tumour markers such as CA125 in certain clinical contexts. By being aware of these factors, healthcare professionals can help to ensure timely and accurate diagnosis of ovarian cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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Barbara is a 64-year-old woman who presents to your clinic with a one-month history of difficulty swallowing both liquids and solids. She also reports pain while swallowing. Barbara is otherwise feeling well. She has a past medical history of hypertension and is a non-smoker.
Upon examination, Barbara's throat appears normal, and there are no other abnormalities detected on neurological and abdominal examination.
What is the most suitable course of action for managing Barbara's condition?Your Answer: Referral to speech and language therapy
Correct Answer: Urgent direct access upper gastrointestinal endoscopy within 2 weeks
Explanation:Odynophagia is a worrying symptom that can be indicative of oesophageal cancer. According to NICE guidelines, individuals with dysphagia or those aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia should be urgently referred for direct access upper gastrointestinal endoscopy within 2 weeks to assess for oesophageal cancer.
In Albert’s case, as he is presenting with dysphagia and odynophagia, urgent upper GI endoscopy within 2 weeks is the appropriate course of action. While blood tests such as FBC and CRP may provide some clues towards a cancer diagnosis, the priority is to rule out malignancy through endoscopy.
Referral to speech and language therapy would not be appropriate at this stage, as the focus is on diagnosing or ruling out cancer. Prescribing analgesia may provide some relief for odynophagia, but it would not address the underlying issue of dysphagia or the need to investigate for malignancy.
While a barium swallow may be useful in investigating dysphagia and odynophagia, urgent upper GI endoscopy is the most appropriate investigation to assess for oesophageal cancer.
Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment
Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus. The most common presenting symptom is dysphagia, followed by anorexia and weight loss, vomiting, and other possible features such as odynophagia, hoarseness, melaena, and cough.
To diagnose oesophageal cancer, upper GI endoscopy with biopsy is used, and endoscopic ultrasound is preferred for locoregional staging. CT scanning of the chest, abdomen, and pelvis is used for initial staging, and FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans. Laparoscopy is sometimes performed to detect occult peritoneal disease.
Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. In addition to surgical resection, many patients will be treated with adjuvant chemotherapy.
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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 47-year-old man presents to his General Practitioner with a deterioration in his long-standing knee pain. His knee examination is normal but he is noted to have a body mass index of 39 kg/m2 (morbidly obese). He states that he has a sedentary job, but considers himself quite active, as he is a keen gardener and has an acre of land which he maintains at home. He has gained a lot of weight since quitting smoking in his early twenties. He mentions that everyone in his family is overweight.
What is the single most important causative factor in the development of obesity in the majority of patients?Your Answer: Intrauterine malnutrition
Correct Answer: Energy intake in excess of expenditure
Explanation:Understanding the Complex Causes of Obesity
Obesity is a complex condition that cannot be solely attributed to excessive food intake and lack of physical activity. While these factors do play a role, other factors such as genetic predisposition, insulin resistance, and intrauterine malnutrition also contribute to the development of obesity. A diet high in sugar and fat, excess alcohol consumption, and a sedentary lifestyle are all contributing factors. However, genetic factors, underlying medical conditions, sleep deprivation, and socioeconomic status also impact weight gain. It is recommended to maintain an active lifestyle by incorporating 150 minutes of moderate or 75 minutes of intense exercise per week. While smoking may suppress appetite, the impact of smoking cessation on weight gain is smaller than the balance of energy in versus out. While obese parents are more likely to have obese offspring, the causes of obesity are multifactorial and not solely attributed to genetics. Insulin resistance is more likely to be a consequence of obesity rather than a cause. Low birth weight and intrauterine growth restriction have also been associated with the development of obesity in later life. Overall, understanding the complex causes of obesity is crucial in developing effective prevention and treatment strategies.
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This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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A 45-year-old man comes in for a routine check-up and reports experiencing persistent fatigue and indigestion. He has been belching excessively at night and is bothered by constant bloating. He denies any alterations in his bowel movements and has not noticed any rectal bleeding. During the physical examination, you observe mild conjunctival pallor and a slightly distended abdomen. A rectal exam reveals no abnormalities.
What is the most frequent underlying condition that could explain these symptoms?Your Answer: Myelodysplastic syndrome
Correct Answer: Coeliac disease
Explanation:Coeliac disease is the most likely underlying diagnosis as it can present with nonspecific gastrointestinal symptoms and fatigue. Bowel cancer should also be considered and appropriate screening carried out if there is clinical suspicion or red flag symptoms. Gastro-oesophageal reflux is unlikely to cause fatigue or anaemia, while inflammatory bowel disease is less common than irritable bowel and there are no signs of it in the stem.
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 22
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: Specific hepatitis C tests are only necessary if liver function is abnormal
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 23
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 24
Correct
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A 55-year-old woman presents to the clinic with abnormal liver function tests (LFTs). She reports drinking no more than 3 units of alcohol per week and has no significant medical history. Her dentist prescribed amoxicillin for a dental infection 2 weeks ago. On physical examination, she is overweight with a BMI of 30 kg/m2. Her LFTs reveal:
ALT 120 U/L (5-40)
AST 130 U/L (10-40)
Alkaline phosphatase 200 U/L (45-105)
What is the most likely cause of her abnormal LFTs?Your Answer: Non-alcoholic fatty liver disease
Explanation:Non-Alcoholic Fatty Liver Disease (NAFLD) and its Causes
Non-alcoholic fatty liver disease (NAFLD) is a common condition caused by the accumulation of fat in the liver, leading to inflammation. It is often associated with obesity, hypertension, dyslipidaemia, and insulin resistance. NAFLD is the most likely cause of liver enzyme abnormalities in patients with these conditions. However, other causes of hepatitis should be excluded before making this diagnosis.
Patients who are obese and diabetic are advised to lose weight and control their diabetes. A low-fat, low-calorie diet is usually recommended alongside treatment to lower HbA1c. Patients with NAFLD should avoid alcohol or other substances that could be harmful to the liver. It is important to note that deranged liver enzymes are not listed as side effects for amoxicillin in the British National Formulary.
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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 50-year-old overweight woman presents to her General Practitioner with right upper-quadrant pain after eating. She drinks around 13 units of alcohol per week.
She undergoes some blood tests:
Investigation Result Normal value
γ-glutamyl transferase (GGT) 90 IU/l 11–50 IU/l
Aspartate aminotransferase (AST) 48 IU/l 4–45 IU/l
Alanine aminotransferase (ALT) 48 IU/l < 40 IU/l
Alkaline phosphatase (ALP) 240 IU/l 25–130 IU/l
Bilirubin 23 µmol/l < 21 µmol/l
Albumin 40 g/l 38–50 g/l
Prothrombin time (PT) 12 s 12–14.8 s
What is the most likely diagnosis?Your Answer: Pancreatitis
Correct Answer: Gallstones
Explanation:Interpreting Liver Enzyme Results: Differential Diagnosis
When interpreting liver enzyme results, it is important to consider the pattern of elevation and accompanying symptoms to arrive at a differential diagnosis. Here are some possible diagnoses for a patient with elevated alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) levels:
Gallstones: A cholestatic picture with a more significant rise in ALP and GGT over alanine transaminase (ALT) and aspartate transaminase (AST) suggests an obstructive or cholestatic condition. Accompanied by right upper-quadrant pain after eating, gallstones are the most likely diagnosis.
Alcohol abuse: Disproportionate elevation of GGT compared to other liver enzymes may indicate alcohol abuse or alcoholic liver disease. In this case, the ALP is also elevated to the same extent as the GGT, but the patient drinks below the recommended alcohol intake per week.
Paget’s disease: Paget’s disease may cause bone pain and elevated ALP levels. However, the accompanying rise in GGT provides a sensitive indicator of hepatobiliary disease, which is not associated with skeletal disease.
Pancreatitis: Although raised GGT levels have been reported in pancreatic disease, the accompanying derangement of other liver enzymes suggests a liver or biliary cause.
Viral hepatitis: A cholestatic picture with more significant rises in ALP and GGT over ALT and AST is not typical of acute hepatitis, which presents with a hepatocellular picture.
In summary, interpreting liver enzyme results requires careful consideration of the pattern of elevation and accompanying symptoms to arrive at a differential diagnosis.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Correct
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A 31-year-old female with a history of ulcerative colitis presents with an increase in stool frequency and passing around 4 bloody stools per day. Previous colonoscopies have shown rectal disease. On examination, her heart rate is 62 beats per minute, blood pressure is 110/70 mmHg, and temperature is 36.8ºC. Her abdomen is soft and non-tender. What is the best course of action for management?
Your Answer: Rectal mesalazine
Explanation:For a mild-moderate flare of distal ulcerative colitis, the recommended initial treatment is rectal aminosalicylates. This patient is experiencing a moderate flare with four bloody stools per day and no systemic symptoms, indicating the use of topical aminosalicylates.
While oral aminosalicylates, topical corticosteroids, and corticosteroids are also options for managing mild to moderate ulcerative colitis flares, rectal aminosalicylates are the first-line treatment.
Severe flares of ulcerative colitis may require hospitalization for intravenous steroids, but this is not necessary for this patient who is passing less than six bloody stools per day and has no systemic symptoms.
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 27
Incorrect
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An 80-year-old man comes to his general practice clinic with a 3-month history of alternating constipation and diarrhea, along with gradual weight loss. During the examination, he looks cachectic and has nodular hepatomegaly. He doesn't have jaundice, and his liver function tests are normal. What is the most probable diagnosis? Choose ONE answer only.
Your Answer: Cirrhosis
Correct Answer: Liver metastases
Explanation:Differential diagnosis of nodular hepatomegaly
Nodular hepatomegaly, or an enlarged liver with palpable nodules, can have various causes. Among them, liver metastases and cirrhosis are common, while hepatocellular carcinoma, lymphoma, and myelofibrosis are less frequent but still possible differential diagnoses.
Liver metastases often originate from the bowel or breast and may not affect liver function until they involve over half of the liver or obstruct the biliary tract. Cirrhosis, on the other hand, results from chronic liver disease and typically raises the serum alanine aminotransferase level, but this patient’s liver function tests are normal.
Hepatocellular carcinoma, a type of liver cancer, shares some features with liver metastases but is less common and may be associated with hepatitis B or C. Lymphoma, a cancer of the lymphatic system, is even rarer than hepatocellular carcinoma as a cause of nodular hepatomegaly, but it may involve other sites besides the liver.
Myelofibrosis is a bone marrow disorder that can lead to fibrosis in the liver and spleen, among other organs. It may not cause symptoms in the early stages but can manifest as leukoerythroblastic anaemia, malaise, weight loss, and night sweats later on. While myelofibrosis is not a common cause of nodular hepatomegaly, it should be considered in the differential diagnosis, especially if other features suggest a myeloproliferative neoplasm.
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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 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: Short duration of disease
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 29
Incorrect
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A 46-year-old man is a frequent visitor to surgery complaining of pruritus ani.
You have examined him previously and excluded organic causes. He has a love of Indian cuisine. In an attempt to help him cope with the problem, you offer advice.
Which of the following is true?Your Answer: Capsaicin on prescription may be helpful
Correct Answer: Briefs are preferable to boxer shorts
Explanation:Tips for Managing Pruritus Ani
Pruritus ani, or anal itching, can be a bothersome and embarrassing condition. However, there are several ways to manage it. First, it is recommended to wear cotton underwear and looser clothing to prevent irritation. Topical capsaicin in very dilute form has shown to be beneficial, but more concentrated creams may worsen the situation. Certain foods such as tomatoes, citrus fruit, and spicy foods may also exacerbate the condition. Keeping the area dry is crucial, and using a hair dryer can be an efficient way to do so. It is important to note that medication can cause a more generalized pruritus, but products such as colchicine and evening primrose oil have been linked to pruritus ani. By following these tips, individuals can better manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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Which of the following is not a known complication of coeliac disease in children?
Your Answer: Subfertility
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 31
Incorrect
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A 56-year-old man comes to the clinic, having just returned from living in Canada. He tells you he had a colonoscopy six months earlier; a polyp in the ascending colon was removed and this was classified as a Dukes' B tumour. He wonders if he needs further checks according to current guidance for surveillance after resection of colorectal cancer. What would you advise him?
Your Answer: Faecal occult blood tests
Correct Answer: Serial carcinoembryonic antigen (CEA) monitoring
Explanation:Post-Treatment Surveillance Strategies for Colorectal Cancer: The Role of CEA Monitoring, Colonoscopy, and CT Scans
Carcinoembryonic antigen (CEA) is a protein that is elevated in the serum of patients with colorectal cancer. While not suitable for screening, CEA levels can be used to monitor disease burden and predict prognosis in patients with established disease. Additionally, elevated preoperative CEA levels should return to baseline after complete resection, and failure to do so may indicate residual disease. Serial CEA testing can also aid in the early detection of recurrences, which can increase the likelihood of a complete resection.
The National Institute for Health and Care Excellence recommends regular serum CEA tests (at least every six months in the first three years) and a minimum of two CT scans of the chest, abdomen, and pelvis in the first three years after treatment. Surveillance colonoscopy should be performed one year after initial treatment, and if normal, another colonoscopy should be performed at five years. The timing of colonoscopy after adenoma should be determined by the risk status of the adenoma.
While periodic colonoscopy is beneficial for detecting metachronous cancers and preventing further cancers via removal of adenomatous polyps, trials have failed to show a survival benefit from annual or shorter intervals compared to less frequent intervals (three or five years) for detecting anastomotic recurrences. Routine fecal occult blood testing is not recommended in post-treatment surveillance guidelines.
In summary, post-treatment surveillance strategies for colorectal cancer should include serial CEA monitoring, CT scans, and colonoscopy at recommended intervals. These strategies can aid in the early detection of recurrences and improve the likelihood of a complete resection.
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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 28-year-old man presented having recently returned from Bangladesh. He reported jaundice and itching. His viral hepatitis serology shows active hepatitis E infection.
Select from the list the single true statement concerning hepatitis E.Your Answer: He should be treated with γ globulin
Correct Answer: Chronic hepatitis doesn't occur in immunocompetent patients
Explanation:Hepatitis E and D: A Comparison
Hepatitis E is a self-limiting illness that follows a similar course to hepatitis A. However, fulminant disease can occur in a small percentage of cases. This type of hepatitis is most commonly found in developing countries and is transmitted through contaminated drinking water. While person-to-person contact transmission is rare, maternal-neonatal transmission can occur, with pregnant women being at the highest risk of developing fulminant hepatitis. Management of hepatitis E is supportive, and there are no chronic cases except in immunocompromised individuals.
On the other hand, hepatitis D requires co-infection with hepatitis B to cause inflammation. Co-infection with hepatitis D increases the likelihood of hepatitis B progressing to chronic disease and cirrhosis. Hepatitis D is most commonly found in Mediterranean countries, parts of Eastern Europe, the Middle East, Africa, and South America.
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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 50-year-old woman with type-2 diabetes complains of blood stained diarrhoea and cramping abdominal pain of several months’ duration. She underwent a hysterectomy and radiotherapy 2 years ago for endometrial carcinoma.
Select from the list the single most likely diagnosis.Your Answer: Irritable bowel syndrome
Correct Answer: Chronic radiation enteropathy
Explanation:Chronic Radiation Enteropathy: Symptoms, Diagnosis, and Differential Diagnosis
Chronic radiation enteropathy is a progressive disease that can occur months or even years after radiation therapy. It is characterized by transmural bowel damage, obliterative endarteritis, and altered intestinal transit, leading to symptoms such as abdominal pain, diarrhea (which may be blood-stained), malabsorption, and dysmotility. Patients with a history of pelvic or abdominal radiation therapy are at risk for developing chronic radiation enteropathy, which can lead to intestinal obstruction, fistula formation, or perforation. Corrective surgery is associated with high morbidity and mortality, and long-term symptoms are common.
Diagnosis of chronic radiation enteropathy is based on the persistence of symptoms for three or more months following irradiation. Differential diagnosis includes irritable bowel syndrome, lymphoma, pseudomembranous colitis, and ulcerative colitis. However, the history of pelvic radiation is a key factor in distinguishing chronic radiation enteropathy from other conditions. While irritable bowel syndrome may cause diarrhea, blood in the stool is not a typical symptom. Lymphoma and ulcerative colitis may also present with bloody diarrhea and abdominal pain, but the history of radiation therapy makes chronic radiation enteropathy more likely. Pseudomembranous colitis is caused by infection with Clostridium difficile and is not typically associated with bloody stools.
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This question is part of the following fields:
- Gastroenterology
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Question 34
Incorrect
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Coeliac disease screening should be conducted for all patients diagnosed with?
Your Answer: Splenomegaly
Correct Answer: Graves' disease
Explanation: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 35
Incorrect
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A 55-year-old man presents with persistent epigastric discomfort for the past 2 months. The discomfort worsens after meals and occasionally causes reflux symptoms when he lies down. Despite attempting to modify his diet, he has only experienced limited relief and has lost some weight, although he is unsure of the exact amount. He denies any difficulty swallowing or vomiting blood. He has tried over-the-counter gaviscon with little effect and is seeking further relief. Physical examination is unremarkable, with no evidence of an abdominal mass.
What is the most appropriate course of treatment for this patient?Your Answer: Helicobacter pylori testing
Correct Answer: Urgent referral for endoscopy
Explanation:Weight loss with dyspepsia is a concerning symptom in individuals over 55 years old and warrants urgent referral for an endoscopy to identify any underlying pathology. Helicobacter pylori testing may not be the most appropriate option in this case. Symptomatic relief can be provided with proton-pump inhibitors or ranitidine, but they do not rule out any underlying pathology.
Management of Dyspepsia and Referral Criteria for Suspected Cancer
Dyspepsia is a common condition that can be managed through a stepwise approach. The first step is to review medications that may be causing dyspepsia and provide lifestyle advice. If symptoms persist, a full-dose proton pump inhibitor or a ‘test and treat’ approach for H. pylori can be tried for one month. If symptoms still persist, the alternative approach should be attempted.
For patients who meet referral criteria for suspected cancer, urgent referral for an endoscopy within two weeks is necessary. This includes patients with dysphagia, an upper abdominal mass consistent with stomach cancer, and patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent referral is recommended for patients with haematemesis and patients aged 55 years or older with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with symptoms such as nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.
Testing for H. pylori infection can be done through a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms have resolved following a ‘test and treat’ approach, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.
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This question is part of the following fields:
- Gastroenterology
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Question 36
Correct
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A 32-year-old woman of African ethnic origin frequently experiences abdominal tenderness and bloating and intermittently suffers from diarrhoea. She has been dealing with these symptoms for a few years and knows that some of her family members have had similar issues. Her condition has worsened since she arrived in the UK 2 years ago, but she denies any problems with adjusting to life here. On physical examination, there are no abnormalities detected.
What is the most suitable initial management step for this patient?Your Answer: Trial of dairy-free diet
Explanation:Lactose intolerance is a common condition among people of Far-Eastern and African origin, affecting up to 85% and over 60% of these populations, respectively. This is due to a deficiency of the enzyme lactase, which breaks down lactose. In contrast, people from northern Europe are less likely to experience lactose intolerance as they have a higher lactose intake and are more likely to inherit the ability to digest lactose. Lactose intolerance can cause symptoms similar to irritable bowel syndrome, such as bloating and diarrhea, as undigested lactose is broken down by gut bacteria. Diagnosis can be confirmed through the lactose breath hydrogen test or by trialing a dairy-free diet. While a small intestinal mucosal biopsy can directly assay lactase activity, it is usually too invasive for a mild condition. Women with lactose intolerance should seek alternative sources of dietary calcium.
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This question is part of the following fields:
- Gastroenterology
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Question 37
Correct
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A 28-year-old woman presents to her General Practitioner (GP) with a history of weight loss of 8 kg, frothy stools and general malaise. Her haemoglobin level is 102 g/l, with a mean corpuscular volume (MCV) of 98 fl. The GP is considering a diagnosis of coeliac disease.
What is the single feature that best supports this diagnosis?
Your Answer: Dermatitis herpetiformis
Explanation:Dermatitis herpetiformis is a skin disease that causes blisters and is linked to coeliac disease. Both conditions are thought to be caused by autoantibodies that attack transglutaminase enzymes. DH is often seen in patients with coeliac disease, with around 80% of DH patients also showing signs of coeliac disease on small intestine biopsy. A rectal biopsy showing neutrophil infiltration would not be enough to diagnose coeliac disease, as a biopsy from the small intestine is needed to confirm the condition. Coeliac disease is a genetic disorder, and if one family member has it, there is a chance that their first-degree relatives may also be affected. Metronidazole would not help with coeliac disease symptoms, but may be used to treat other gastrointestinal conditions. Hydrogen breath testing is used to diagnose bacterial overgrowth and carbohydrate malabsorption, as bacteria in the intestine produce hydrogen during carbohydrate breakdown.
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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 30-year-old woman presents with jaundiced sclera that developed over a period of 2 days. She had been fasting for religious reasons during this time and has no past medical history of jaundice. The patient is asymptomatic and her abdominal examination is unremarkable. Upon blood testing, her FBC and reticulocyte count are normal, as well as her blood film. She has predominantly unconjugated bilirubin levels of 50 µmol/L (normal range 3 - 17) and otherwise normal LFTs. What is the most appropriate management for this patient?
Your Answer: 2 week wait upper gastroenterology referral
Correct Answer: Reassure
Explanation:If a person has an increased serum bilirubin concentration with normal liver function tests, it may indicate Gilbert’s syndrome. This condition is characterized by a rise in bilirubin in response to physiological stress and may cause mild jaundice during fasting. However, it doesn’t require treatment or monitoring and cannot progress to chronic liver disease. Therefore, reassurance is the most appropriate option, and hospital admission or ultrasound scanning is unnecessary. Additionally, as Gilbert’s syndrome is not associated with upper GI malignancies, a 2-week wait clinic is not required. Repeating liver function tests in 48 hours would not change the management plan for this condition.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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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 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: Pain around the umbilicus
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 40
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: Campylobacter infection
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 41
Incorrect
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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:
Correct Answer: Colonic carcinoma
Explanation:Likely Diagnosis for a 69-Year-Old with Weight Loss and Constipation
A 69-year-old man with a history of weight loss, blood in his stool, and a palpable abdominal mass is likely suffering from bowel carcinoma. His symptoms have now progressed to absolute constipation due to an obstructing tumor. Other potential diagnoses, such as diverticular abscess, faecal impaction, and inflammatory bowel disease, are less likely based on his history and examination.
A diverticular abscess typically presents with a tender mass and fever, while faecal impaction may cause a palpable mass but doesn’t typically result in weight loss or blood in the stool. Inflammatory bowel disease is rare in patients of this age and would not typically cause such significant weight loss. Overall, the patient’s symptoms are most consistent with a diagnosis of bowel carcinoma.
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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 25-year-old traveler comes back from a year of backpacking in a remote area of India. He has been experiencing diarrhea for two weeks and the laboratory confirms that he has giardiasis.
What is true about giardiasis?Your Answer:
Correct Answer: Diagnosis is made by culture of stool
Explanation:Giardiasis: Causes, Symptoms, and Diagnosis
Giardiasis is a parasitic infection caused by Giardia lamblia. The incubation period for this infection is typically 1-2 weeks. Symptoms include diarrhea, but it is not bloody like in dysentery. The organism attaches to the small bowel but doesn’t invade it. Metronidazole and tinidazole are commonly used in treatment.
To diagnose giardiasis, stool samples are examined microscopically for cysts, not cultures. It may be necessary to collect several samples to confirm the diagnosis as cysts may not be present in every stool. Infection can be contracted from any contaminated water, whether it is still or running. It is important to practice good hygiene and avoid drinking untreated water to prevent giardiasis.
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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 28-year-old woman presents as an emergency to her GP with acute vomiting which began some 3-4 h after attending an afternoon meeting. Cream cakes were served during the coffee break.
Select from the list the most likely causative organism of this acute attack of vomiting.Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Understanding Bacterial Food Poisoning: Causes and Symptoms
Bacterial food poisoning is a common problem that can result from consuming contaminated food or water. Among the different types of bacteria that can cause food poisoning, Staphylococcus aureus, Bacillus cereus, Yersinia, Campylobacter, and Salmonella are the most common. Each of these bacteria has its own unique characteristics and symptoms.
Staphylococcus aureus is known to multiply rapidly in foods that are rich in carbohydrates and salt, such as dairy products, ice cream, cold meats, or mayonnaise. It produces a heat-stable endotoxin that causes nausea, vomiting, and diarrhea within 1-6 hours of ingestion.
Bacillus cereus infection is associated with slow-cooked food and reheated rice. The bacterium produces an emetic toxin that leads to vomiting within 1-5 hours. It can be difficult to distinguish from other short-term bacterial foodborne intoxications such as by Staphylococcus aureus.
Yersinia infection results in diarrhea some 3-10 days after contact and presents with bloody diarrhea, abdominal pain, and fever. The organism is acquired usually by insufficiently cooked pork or contaminated water, meat, or milk.
Campylobacter infection has an incubation period of 2-5 days and results in flu-like symptoms, abdominal pain, and diarrhea. It is the most common bacterium that causes food poisoning in the UK.
Salmonella infection normally leads to a picture of acute gastroenteritis with fever, abdominal cramps, and diarrhea between 12-36 hours after the ingestion of infected food. Infection occurs from a wide variety of infected foods that usually look and smell normal.
It is important for registered medical practitioners to notify the “proper officer” at their local council or local health protection team of suspected cases of food poisoning. By understanding the causes and symptoms of bacterial food poisoning, individuals can take steps to prevent infection and seek prompt medical attention if necessary.
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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 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 45
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 46
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 47
Incorrect
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A 67-year-old male presents with problems with constipation.
He has a history of ischaemic heart disease for which he is receiving medication.
Which of the following agents is most likely to be responsible for his presentation?Your Answer:
Correct Answer: Aspirin
Explanation:Verapamil and its Side Effects
Verapamil is a medication that is commonly known to cause constipation. In addition to this, it is also associated with other side effects such as oedema and headaches. Oedema is the swelling of body tissues, usually in the legs and feet, while headaches can range from mild to severe. It is important to be aware of these potential side effects when taking verapamil and to speak with a healthcare provider if they become bothersome or persistent. Proper monitoring and management can help to alleviate these symptoms and ensure the safe and effective use of verapamil.
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This question is part of the following fields:
- Gastroenterology
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Question 48
Incorrect
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A 55-year-old man reports that he has noticed black tarry stools over the last 2 weeks. He has vomited a small amount of blood.
Your Answer:
Correct Answer: Melaena can result from oesophageal varices
Explanation:Understanding Melaena: Causes, Symptoms, and Treatment
Melaena is a medical condition characterized by black tarry stools, which is often caused by an acute upper gastrointestinal bleed. The bleeding can occur in the oesophagus, stomach, duodenum, small bowel, or right side of the colon, with peptic ulcer disease being the most common cause. In some cases, melaena may be the only symptom of bleeding from oesophageal varices, which are associated with portal hypertension.
Acute upper gastrointestinal bleeding is a medical emergency that requires immediate attention, as it can be life-threatening. Patients who are haemodynamically unstable should undergo endoscopy within 2 hours after resuscitation, while other patients should have endoscopy within 24 hours. It is important to note that proton pump inhibitors should not be given before endoscopy.
Patients who are at higher risk of complications include those aged over 60 years and those with co-morbidities. The mortality rate for patients with acute upper gastrointestinal bleeding in hospital is around 10%. Therefore, it is crucial to seek medical attention promptly if you experience symptoms of melena or haematemesis.
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This question is part of the following fields:
- Gastroenterology
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Question 49
Incorrect
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You are reviewing a 75-year-old man who has come to see you for the result of his recent colonoscopy. The report states:
Good bowel preparation, optimal views, no intraluminal mass seen appearances consistent with melanosis coli and confirmed on biopsy.
What is the cause of this gentleman's colonoscopy findings?Your Answer:
Correct Answer: Inflammatory colitis
Explanation:Melanosis Coli: A Benign Condition Caused by Laxative Use
Many gastroenterology departments now offer rapid access for endoscopy directly from primary care. Consequently, GPs increasingly have endoscopy reports sent back to them for patients who can be managed in primary care and do not need any further hospital input.
In this case, the endoscopy report identified melanosis coli, a benign condition that causes pigmentation of the colon wall. This condition is typically caused by long-term use of anthraquinone laxatives such as senna. The lesions are not due to melanin but rather a brown pigment called lipofuscin, which is deposited in macrophages in the colonic mucosa.
It is important to note that melanosis coli is not a feature of inflammatory colitis or diverticular disease. Colonic lesions are often biopsied, and as in this case, the biopsy confirms the clinical diagnosis and doesn’t suggest the presence of carcinoma.
Peutz-Jegher syndrome is an autosomal dominant condition that causes gastrointestinal polyps. Patients with this condition can display mucocutaneous pigmentation and perioral freckling. Polyps may undergo malignant transformation, and sufferers of this condition have a 12-fold increased risk of carcinoma.
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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 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 51
Incorrect
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A 32-year-old male presents with central abdominal pain that radiates to the back and vomiting. His amylase level is 1,245 u/dl. Which medication is the most probable cause of his symptoms?
Your Answer:
Correct Answer: Sodium valproate
Explanation:Acute pancreatitis is a condition that is primarily caused by gallstones and alcohol consumption in the UK. However, there are other factors that can contribute to the development of this condition. A popular mnemonic used to remember these factors is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine. CT scans can show diffuse parenchymal enlargement with oedema and indistinct margins in patients with acute pancreatitis.
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This question is part of the following fields:
- Gastroenterology
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Question 52
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:
Correct Answer: It carries an increased risk of subsequent hepatocellular carcinoma
Explanation:Understanding Chronic Hepatitis B Infection
Chronic hepatitis B infection occurs in up to 10% of adults who contract the virus. This means that the virus remains in the body long-term, with the surface antigen (HBsAg) persisting in the serum. However, up to two-thirds of people in the chronic phase remain well and do not experience any liver damage or other issues. This is known as the carrier state or chronic inactive hepatitis B, where HBeAg is absent, anti-HBe is present, and HBV DNA levels are low or undetectable. While carriers can still transmit the virus, their infectivity is lower than those with chronic active hepatitis.
Around 20% of carriers will eventually clear the virus naturally, but this can take several years. However, some carriers may experience spontaneous reactivation of hepatitis B due to the emergence of the HBeAg-negative strain of the virus. The remaining individuals with chronic hepatitis B experience persistent liver inflammation, also known as chronic active hepatitis B. Symptoms can include muscle aches, fatigue, nausea, lack of appetite, intolerance to alcohol, liver pain, jaundice, and depression. HBeAg is usually still present, and the virus is still replicating, with raised HBV DNA levels and high infectivity. Transaminase levels may be elevated, but not always significantly.
If left untreated, chronic active hepatitis B can lead to cirrhosis and even hepatocellular carcinoma. It’s important to note that hepatitis D is a separate virus that only infects individuals who are already infected with hepatitis B. Understanding the different phases and potential outcomes of chronic hepatitis B infection is crucial for proper management and treatment.
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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 35-year-old woman with hepatitis C visits your clinic as she is considering starting a family. She has no other medical issues. She inquires about the likelihood of her baby contracting hepatitis C.
What is the probability of the virus being passed from mother to child?Your Answer:
Correct Answer: 75-100%
Explanation:Transmission Rates of Hepatitis B and C from Mother to Child
The transmission rate of hepatitis B virus from mother to child can be as high as 90%, while the transmission rate of hepatitis C virus is only about 6%. This is because the neonatal immune system is not yet mature enough to fight off the hepatitis B virus, but it is able to fight off the hepatitis C virus to some extent. However, if the mother is also HIV positive, the transmission rate of hepatitis C virus can be higher. It is important to take time to understand this information before making any decisions.
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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 32-year-old woman comes to her General Practitioner, reporting increased fatigue over the past few weeks. She has no other symptoms and no signs of liver disease upon examination. She was diagnosed with hepatitis B infection ten years ago and is concerned that the infection may still be active. What is the most suitable test for this patient?
Your Answer:
Correct Answer: Hepatitis B virus (HBV) deoxyribonucleic acid (DNA)
Explanation:Understanding Hepatitis B Markers
Hepatitis B virus (HBV) can be detected through various markers in the blood. The most sensitive indicator of viral replication is the presence of HBV DNA, which is found in high concentrations in both acute and chronic infections. A high level of HBV DNA is associated with an increased risk of liver damage and cancer. Effective antiviral treatment can lower the HBV DNA level.
Anti-HBAb levels indicate decreased viral replication and infectivity in chronic carriers. These patients will only exhibit low levels of HBV DNA.
HBeAg testing is indicated in the follow-up of chronic infection. In those with chronic (active) infection, it remains positive. However, hepatitis B virus DNA can be found without e antigen in hepatitis due to mutant strains of the virus.
Anti-HBsAb is a marker of immunity to hepatitis B. Patients who are immune to the disease as a result of previous infection will also be positive for anti-HBeAg, but they will have cleared HBsAg and will not exhibit detectable HBV DNA. Patients who have been vaccinated for hepatitis B will also be positive for anti-HBsAb, without having any other positive markers.
The presence of IgM anti-HBc indicates acute hepatitis, but doesn’t provide detail on the likelihood that the condition has become chronic. Understanding these markers can help in the diagnosis and management of hepatitis B.
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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 62-year-old Chinese man comes to the General Practice Surgery complaining of weight loss, jaundice and right upper quadrant pain that has been going on for 3 months. He is a non-smoker and only drinks alcohol occasionally.
What is the most probable diagnosis?Your Answer:
Correct Answer: Hepatocellular carcinoma (HCC)
Explanation:Comparison of Liver Cancer Types and Symptoms
Hepatocellular carcinoma (HCC) is a primary liver cancer that originates from hepatocytes and is commonly caused by alcohol abuse, viral hepatitis, and metabolic liver disease. It is more prevalent in Asia and Africa due to the high incidence of hepatitis B, hepatitis C, and aflatoxin exposure. Symptoms of HCC include right upper quadrant pain, jaundice, and weight loss.
Oesophageal cancer, cholangiocarcinoma, pancreatic carcinoma, and stomach cancer can also present with similar symptoms to HCC, but each has its own unique risk factors and prevalence. Oesophageal cancer is mainly caused by alcohol and tobacco use, while cholangiocarcinoma is a rare cancer of the bile ducts. Pancreatic carcinoma is more common in older individuals or those with chronic pancreatitis. Stomach cancer may cause similar symptoms if it metastasizes to the liver, but it is less common than HCC.
In summary, while these cancers may present similarly, the patient’s ethnicity, age, and risk factors can help determine the most likely type of liver cancer.
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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 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21 μmol/l). He has suffered from episodic jaundice in the past but is otherwise fit and well. His diagnosis is Gilbert syndrome.
Which of the following is associated with Gilbert syndrome?
Your Answer:
Correct Answer: γ-glutamyltransferase in the normal range
Explanation:Understanding Gilbert Syndrome: Symptoms, Risks, and Diagnosis
Gilbert syndrome is a common, benign condition that causes mild unconjugated hyperbilirubinaemia. It is familial and occurs in 5-10% of adults in Western Europe. While some patients may experience symptoms such as fatigue, nausea, and abdominal pain, many are asymptomatic. Jaundice is usually mild and can worsen with physical exertion, fasting, or dehydration. However, liver function tests, including γ-glutamyltransferase, should be normal.
Unlike other liver conditions, Gilbert syndrome doesn’t cause abnormal liver histology or conjugated hyperbilirubinaemia. It is also not a risk factor for kernicterus at birth.
Diagnosis of Gilbert syndrome is based on clinical presentation and elevated unconjugated bilirubin levels. Fasting can actually increase bilirubin levels in this condition. Therefore, it is important to rule out other liver disorders if abnormal liver function tests or histology are present.
Overall, understanding the symptoms, risks, and diagnosis of Gilbert syndrome can help healthcare providers provide appropriate care and management for patients with this condition.
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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 25-year-old woman comes to her General Practitioner with symptoms of intermittent diarrhoea containing blood and mucous, tiredness and anorexia that have been present for 6 months. Stool samples have been negative for any cultures. The abdomen and rectum examination is normal.
What is the most suitable course of action for primary care management?
Your Answer:
Correct Answer: Refer urgently to gastroenterology
Explanation:Management of a Patient with Suspected Inflammatory Bowel Disease
If a young person presents with rectal bleeding, diarrhea, and anorexia without an infective cause, inflammatory bowel disease (IBD) should be suspected. IBD includes Crohn’s disease and ulcerative colitis, and a definitive diagnosis is necessary for proper management. Colonoscopy and intestinal biopsies are required for diagnosis, while blood tests and fecal calprotectin may aid in the diagnosis but cannot differentiate between the two types of IBD. Urgent referral to gastroenterology is necessary for diagnostic investigations.
An abdominal X-ray is only indicated if acute bowel obstruction is suspected, which is unlikely in this patient’s case. Blood tests may be appropriate in primary care, including FBC, inflammatory markers, renal profile, TFTs, coeliac screen, and LFTs. However, loperamide should not be prescribed in undiagnosed IBD as it can increase the risk of toxic megacolon.
Once a confirmed diagnosis is made, referral to a dietician may be beneficial for dietary advice. A 2-week-wait referral to gastroenterology is not necessary in this patient’s case, as she is a young adult and malignancy is less likely to be the cause of her symptoms. Clinical judgement should be used, and the presence of a suspicious rectal or abdominal mass would warrant referral at any age.
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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 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 59
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 60
Incorrect
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A 50-year-old male undergoes an endoscopy after being referred by his GP with recurrent indigestion.
The endoscopy reveals a small duodenal ulcer and Helicobacter pylori is demonstrated to be present. He has not been given eradication treatment before and is allergic to penicillin.
You consider a seven day, twice daily course of eradication therapy.
How would you treat this patient?Your Answer:
Correct Answer: Esomeprazole 10 mg, Metronidazole, Tetracycline
Explanation:Helicobacter Infection and Treatment
Helicobacter infection is common in patients with duodenal and peptic ulceration. The recommended therapy includes acid suppression and eradication of Helicobacter. Triple therapy with a proton pump inhibitor (PPI) such as omeprazole, along with two antibiotics (amoxicillin/clarithromycin plus metronidazole), has been found to be highly effective.
It is important to note that patients who are allergic to penicillin require a different treatment regimen. The lowest cost treatment option should be chosen, taking into account previous exposure to clarithromycin or metronidazole. In cases where the patient is allergic to penicillin and has had previous exposure to clarithromycin, bismuth and tetracycline should be added to the treatment regimen.
The recommended PPI doses for Helicobacter pylori eradication therapy are esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20-40 mg, pantoprazole 40 mg, and rabeprazole 20 mg. It is important to follow these guidelines to ensure effective treatment of Helicobacter infection.
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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 70-year-old woman with squamous cell lung cancer presents with confusion.
Her family reports that she has become slowly more confused over the last two weeks. She is also complaining of generalised aches and pains, lethargy and thirst. Further enquiry reveals that she has been having increasing problems with constipation.
What is the underlying cause of this presentation?Your Answer:
Correct Answer: Ectopic parathyroid hormone production
Explanation:Paraneoplastic Syndromes Associated with Lung Cancer
Lung cancer can be associated with various paraneoplastic syndromes, which are caused by substances produced by the tumor that affect other parts of the body. One such syndrome is hypercalcemia, which can cause confusion, lethargy, aches and pains, thirst, and constipation. Squamous cell lung carcinoma is particularly associated with ectopic parathyroid hormone production, leading to increased calcium levels.
Other paraneoplastic syndromes associated with lung cancer include Cushing’s syndrome, which can occur with small cell lung cancer due to ectopic ACTH production; Horner’s syndrome, which can occur with apical lung tumors that invade sympathetic nerve fibers, causing ptosis, miosis, and anhydrosis; and Lambert-Eaton syndrome, an autoimmune process associated with small cell lung cancer that causes muscle weakness and hyporeflexia.
Another condition associated with lung cancer is SIADH, which causes hyponatremia and can lead to confusion, seizures, cardiac failure, edema, and muscle weakness. Causes of SIADH include small cell lung cancer, as well as other malignancies, stroke, subarachnoid hemorrhage, vasculitis, TB, and certain drugs like opiates. Understanding these paraneoplastic syndromes can help clinicians identify and manage symptoms in patients with lung cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 62
Incorrect
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A 72-year-old man presents to his GP clinic complaining of persistent diarrhoea. He has a medical history of gastro-oesophageal reflux disease.
He was recently hospitalized for pneumonia and received IV antibiotics. While in the hospital, he developed watery diarrhoea, nausea, and abdominal discomfort. After a stool sample, he was prescribed a 10-day course of oral vancomycin and discharged home. However, his diarrhoea has not improved.
Upon examination, he appears alert, his vital signs are normal, and his abdomen is non-tender.
What would be the next course of treatment to consider?Your Answer:
Correct Answer: Fidaxomicin
Explanation:If initial treatment with vancomycin is ineffective against Clostridium difficile, the next recommended option is oral fidaxomicin, unless the infection is life-threatening.
Based on the patient’s symptoms and medical history, it is likely that he has contracted Clostridium difficile infection due to his recent antibiotic use and possible use of proton-pump inhibitors. Therefore, oral fidaxomicin would be the appropriate second-line treatment option.
Continuing with vancomycin would not be the best course of action, as fidaxomicin is recommended as the next step if vancomycin is ineffective.
Using loperamide for symptom relief is not recommended in cases of suspected Clostridium difficile infection, as it may slow down the clearance of toxins produced by the bacteria.
Piperacillin-tazobactam is not a suitable treatment option for Clostridium difficile infection, as it is a broad-spectrum antibiotic that can increase the risk of developing the 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 63
Incorrect
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A 50-year-old man presents to his General Practitioner for a routine review. He denies alcohol excess and has a body mass index of 36 kg/m2. He is also noted to be a diet-controlled type II diabetic and smokes 10 cigarettes per day.
Investigations Results Normal value
Cholesterol 7.7 mmol/l <5 mmol/l
Fasting triglyceride 2.5 mmol/l <1.7 mmol/l
Alanine aminotransferase (ALT) 150 IU/l <40 IU/l
Which of the following is the single most likely explanation regarding the significance of his raised liver enzyme?
Your Answer:
Correct Answer: Probably has non alcoholic steatohepatitis, which can include fibrosis
Explanation:Understanding Liver Function Test Results in a Patient with Metabolic Risk Factors
Liver function tests are an important tool for assessing liver health. In a patient with metabolic risk factors such as obesity, dyslipidaemia, and abnormal glucose tolerance, elevated liver transaminases may indicate non-alcoholic steatohepatitis (NASH), a condition that can lead to fibrosis and eventually cirrhosis if left untreated. Weight loss and control of comorbidities are the mainstay of management for NASH. While autoimmune hepatitis is a rarer possibility, it may be considered if the patient has a history of other autoimmune disorders and a normal body mass index and lipid profile. Regardless of the specific diagnosis, abnormal liver function test results in a patient with metabolic risk factors require further investigation and management.
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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 25-year-old woman comes to her doctor with jaundice, anorexia, nausea, and mild tenderness in the right upper abdomen. She is currently 16 weeks pregnant and feeling ill. What is the probable reason for her jaundice?
Your Answer:
Correct Answer: Viral hepatitis
Explanation:Liver Disorders During Pregnancy: Causes and Consequences
During pregnancy, the liver can be affected by various disorders that can have serious consequences for both the mother and the fetus. Here are some of the most common liver disorders that can occur during pregnancy:
1. Viral Hepatitis: Hepatitis B is the most common cause of jaundice in pregnancy, especially in developing countries. While most viral hepatitis infections are not affected by pregnancy, hepatitis E can be fatal for pregnant women.
2. Acute Fatty Liver of Pregnancy: This rare disorder can progress to liver failure and usually occurs late in pregnancy. Early delivery can lead to complete recovery.
3. Gallstones: This is the second most common abdominal emergency in pregnant women and can cause severe pain in the right upper quadrant.
4. Intrahepatic Cholestasis of Pregnancy: This disorder is characterized by itching and elevated serum bile acids and can lead to serious complications for the fetus, including stillbirth.
5. Pre-eclamptic Liver Disease and HELLP Syndrome: Jaundice may occur in 3-10% of pre-eclamptic pregnancies, and prompt delivery is the most effective treatment for HELLP syndrome.
It is important for pregnant women to be aware of these liver disorders and to seek medical attention if they experience any symptoms. Early diagnosis and treatment can help prevent serious complications for both the mother and the fetus.
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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 58-year-old man presents with a six week history of persistent loose stools. Prior to this he opened his bowels once a day most days and his stools were easily passed and 'soft'. Over the last six weeks he complains of loose 'watery' stools and is opening his bowels four to five times a day. This pattern has been occurring every day for the last six weeks.
He denies any weight loss, abdominal pain, rectal bleeding or passage of rectal mucous. There is no family history of note. He feels well with no fever or systemic symptoms.
Abdominal and rectal examinations are normal.
You refer the patient urgently to a lower GI specialist.
What additional investigation should be arranged at this stage?Your Answer:
Correct Answer: Request tumour markers including CEA
Explanation:Urgent Referral for Patient with Change in Bowel Habit
This patient requires urgent referral as he is over 60 years old and has experienced a change in bowel habit. According to NICE guidelines, the only test that may be helpful in this case is a full blood count, which can be performed alongside the referral. This will ensure that the result is available for the specialist in clinic.
NICE guidelines recommend testing for occult blood in faeces to assess for colorectal cancer in adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss, or are aged 60 and over and have anaemia even in the absence of iron deficiency. However, in this case, there has been no history of weight loss or abdominal pain, and the patient is not known to be anaemic. Therefore, other tests or investigations are not recommended as they will only serve to delay the process.
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This question is part of the following fields:
- Gastroenterology
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Question 66
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 67
Incorrect
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A 35-year-old woman has chronic pancreatitis. She has lost weight and has diarrhoea that has become troublesome.
Select from the list the single most suitable preparation to relieve her diarrhoea.Your Answer:
Correct Answer: Pancreatin
Explanation:Gastrointestinal Medications: Pancreatin, Cholestyramine, Loperamide, Co-Phenotrope, and Ispaghula Husk
Pancreatin is a combination of digestive enzymes produced by the pancreas that aid in the breakdown of protein, fat, and starch. It is commonly used to treat conditions where the pancreas is not producing enough enzymes, such as pancreatitis, cystic fibrosis, or after surgical removal of the pancreas. Pancreatin should be taken with food or with medications that reduce stomach acid.
Cholestyramine is a medication that binds to bile in the gut, preventing its reabsorption. It is primarily used to treat itching in patients with advanced liver disease and to prevent diarrhea in individuals with Crohn’s disease who have had a portion of their small intestine removed.
Loperamide and co-phenotrope are anti-motility drugs that can be used to treat uncomplicated acute diarrhea in adults. These medications slow down the movement of the gut, allowing for more water to be absorbed and reducing the frequency of bowel movements.
Ispaghula husk is a bulk-forming laxative that absorbs water in the gut, increasing the bulk of stool and promoting regular bowel movements. It is commonly used to treat constipation and other bowel irregularities.
Overall, these medications can be effective in treating a variety of gastrointestinal conditions and symptoms. However, it is important to consult with a healthcare provider before starting any new medication.
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This question is part of the following fields:
- Gastroenterology
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Question 68
Incorrect
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A 65-year-old man residing in assisted living is brought in by his caregiver for a routine health check-up. His recent blood tests, including liver function tests, have all returned normal. The results are as follows:
- Bilirubin: 10 umol/l (normal range: 3 - 17 umol/l)
- Alanine transferase (ALT): 35 iu/l (normal range: 3 - 40 iu/l)
- Aspartate transaminase (AST): 25 iu/l (normal range: 3 - 30 iu/l)
- Alkaline phosphatase (ALP): 90 umol/l (normal range: 30 - 100 umol/l)
- Gamma glutamyl transferase (yGT): 50 u/l (normal range: 8 - 60 u/l)
- Total protein: 70 g/l (normal range: 60 - 80 g/l)
During the consultation, the patient reveals that he consumes 62 units of alcohol per week. You discuss the possibility of referring him for alcohol dependence treatment and community detoxification.
What would be the most appropriate course of action now?Your Answer:
Correct Answer: Refer the patient for a FibroScan (transient elastography)
Explanation:Patients who consume more than 50 units of alcohol per week (males) or more than 35 units per week (females) should be referred for an ELF test or FibroScan, even if their liver function tests are normal, according to current NICE CKS guidance. This is because patients may have significant cirrhosis despite normal liver function tests, and FibroScan is the most accurate method for screening for cirrhosis.
While monitoring liver function is important, the next appropriate step would be to assess using a FibroScan, as patients can have advanced cirrhosis with normal liver function tests. Waiting 2 or 4 years to repeat liver function tests is too long, as the disease may progress significantly in the meantime.
Liver ultrasound may be helpful, but it is not sufficient for detecting cirrhosis in all cases. Ultrasound screening for liver cirrhosis alone is not recommended, as patients may have cirrhosis without evidence on liver ultrasound.
Taking no further action is not appropriate, given the potential for liver disease despite normal liver function tests.
Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. When investigating this disease, gamma-GT levels are typically elevated, and a ratio of AST:ALT greater than 3 strongly suggests acute alcoholic hepatitis. In terms of management, glucocorticoids like prednisolone are often used during acute episodes of alcoholic hepatitis. Maddrey’s discriminant function is used to determine who would benefit from glucocorticoid therapy, and pentoxyphylline may also be used. The STOPAH study compared the effectiveness of pentoxyphylline and prednisolone and found that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes.
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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 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 70
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 71
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 72
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 73
Incorrect
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A concerned man visits your clinic as he participated in the routine bowel cancer screening program and received a positive faecal occult blood test (FOBt) result. He inquires if this indicates that he has bowel cancer. What is the estimated percentage of patients with a positive FOBt result who are subsequently diagnosed with bowel cancer during colonoscopy?
Your Answer:
Correct Answer: 10%
Explanation: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 74
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 75
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 76
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 77
Incorrect
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You receive a positive faecal immunochemical test (FIT) result following investigation of an elderly patient's unexplained abdominal pain.
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
Faecal occult blood tests are recommended by NICE for patients who show symptoms that may suggest colorectal cancer but are unlikely to have the disease. If the test result is positive, patients should be referred through the suspected cancer pathway. However, a positive result may also indicate other conditions such as colorectal polyps or inflammatory bowel disease.
It is important to note that there is no need to repeat the FIT or order further investigations before referral. This test is a simple and effective way to detect early signs of colorectal cancer and can help healthcare professionals make informed decisions about patient care.
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This question is part of the following fields:
- Gastroenterology
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Question 78
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 79
Incorrect
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Sarah is a 36-year-old woman who has been experiencing dyspepsia symptoms for a few months. Her GP prescribed omeprazole 20 mg once daily, which has provided some relief. However, her symptoms return once she stops taking the medication. What would be the most appropriate next step in Sarah's treatment plan?
Your Answer:
Correct Answer: Request a stool test for H. pylori
Explanation:According to NICE guidelines, patients with dyspepsia should be assessed for red flag symptoms and offered lifestyle advice before trying either a PPI or ‘test and treat’ approach. If one approach fails, the other can be attempted. In this scenario, as the patient has not been tested for H. pylori, a stool test should be performed before considering other options. An endoscopy may be necessary if symptoms persist despite optimal management in primary care. An FBC may be performed if there is concern for malignancy. Changing from omeprazole to lansoprazole is unlikely to be effective as they have the same mechanism of action. Before prescribing 40 mg omeprazole, H. pylori should be excluded.
Management of Dyspepsia and Referral Criteria for Suspected Cancer
Dyspepsia is a common condition that can be managed through a stepwise approach. The first step is to review medications that may be causing dyspepsia and provide lifestyle advice. If symptoms persist, a full-dose proton pump inhibitor or a ‘test and treat’ approach for H. pylori can be tried for one month. If symptoms still persist, the alternative approach should be attempted.
For patients who meet referral criteria for suspected cancer, urgent referral for an endoscopy within two weeks is necessary. This includes patients with dysphagia, an upper abdominal mass consistent with stomach cancer, and patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent referral is recommended for patients with haematemesis and patients aged 55 years or older with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with symptoms such as nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.
Testing for H. pylori infection can be done through a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms have resolved following a ‘test and treat’ approach, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.
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This question is part of the following fields:
- Gastroenterology
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Question 80
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 81
Incorrect
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A 42-year-old man presents with recurrent epigastric pain that is relieved by vomiting and has noticed some weight loss. He denies anorexia but admits to a fear of food bringing on the pain. On examination, he is tender in the epigastrium with no palpable masses. He also reports having dark stools, but attributes it to his love for red wine. What is the most probable diagnosis?
Your Answer:
Correct Answer: Gastric ulcer
Explanation:Understanding Gastric Ulcers and Their Symptoms
Gastric ulcers are a common condition that can cause a range of symptoms. One of the most typical symptoms is abdominal pain, which can be described as a burning or gnawing sensation. Other symptoms may include nausea, vomiting, and loss of appetite.
It’s important to note that the symptoms of a gastric ulcer can be similar to those of other conditions, such as duodenal ulcers, gallstones, gastric carcinoma, and hiatus hernia. However, there are some key differences to look out for.
In duodenal ulcers, for example, the pain is usually delayed after eating and can be relieved by food. Gallstones, on the other hand, typically cause pain in the right upper quadrant and do not usually result in melaena (dark, tarry stools).
Gastric carcinoma should be considered in anyone with abdominal pain and weight loss, but gastric ulcer is more likely in younger patients without anorexia. Hiatus hernia, meanwhile, is often associated with heartburn and reflux.
If you are experiencing symptoms of a gastric ulcer, it’s important to seek medical attention. Your doctor can perform tests to determine the cause of your symptoms and recommend appropriate treatment.
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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 32-year-old woman presents to her General Practitioner complaining of long-standing intermittent abdominal distension and bloating, which changes with her menstrual cycle, and is interspersed with bouts of loose motions. She works as a teacher in a busy school and finds work stressful. She has previously taken a course of fluoxetine for depression or anxiety. Examination of the abdomen is normal.
What is the single most likely diagnosis?Your Answer:
Correct Answer: Irritable bowel syndrome
Explanation:Understanding Common Gastrointestinal Disorders: Differential Diagnosis
Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder affecting 10-20% of the UK population, with a higher incidence in females and those with underlying anxiety. Symptoms include abdominal pain or discomfort, bloating, and change in bowel habit lasting for at least six months. Defecation may provide relief, while eating can exacerbate symptoms. Other common symptoms include lethargy, nausea, backache, and bladder problems. Diagnosis is based on clinical presentation, as examination and investigations are typically normal.
Ulcerative colitis is a potential differential diagnosis if the patient presents with pain or blood in their stool. However, the long history of symptoms without significant systemic illness, normal examination, and links to stress/menstruation in this case suggest IBS. Normal inflammatory markers would support this diagnosis.
Chronic pancreatitis is characterized by persistent inflammation or damage, often linked to alcohol excess. The primary symptom is significant pain, which is not present in this case.
Diverticulitis is an acute presentation, with left iliac fossa pain, change in bowel habit, bleeding per rectum, and systemic illness. The chronic course, combination of symptoms, and normal examination make this diagnosis unlikely.
Peptic ulcer disease is also unlikely, as it typically causes pain linked to eating, nausea or vomiting, and is acute or progressive in nature. While stress can be a trigger, it is not the primary cause of this disorder.
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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 72-year-old male came to his doctor complaining of loose stool during the night for the past 2 months. He has a medical history of uncontrolled diabetes, chronic kidney disease, retinopathy, osteoarthritis, and coeliac disease. He denied experiencing abdominal pain, bloating, weight loss, or vomiting. Upon examination, his abdomen appeared normal, and his vital signs were stable. His blood glucose level was 18.7mmol/L.
What is the most probable diagnosis?Your Answer:
Correct Answer: Autonomic neuropathy
Explanation:Autonomic neuropathy is a possible cause of night time diarrhoea in diabetics with poor control of their condition. Other potential diagnoses, such as irritable bowel syndrome, microscopic colitis, Crohn’s disease, and chronic constipation, should be considered and ruled out before making a definitive diagnosis. However, given the patient’s age and medical history, autonomic neuropathy is a likely explanation for her symptoms.
Diabetes can cause peripheral neuropathy, which typically results in sensory loss rather than motor loss. This can lead to a glove and stocking distribution of symptoms, with the lower legs being affected first. Painful diabetic neuropathy is a common issue that can be managed with medications such as amitriptyline, duloxetine, gabapentin, or pregabalin. If these drugs do not work, tramadol may be used as a rescue therapy for exacerbations of neuropathic pain. Topical capsaicin may also be used for localized neuropathic pain. Pain management clinics may be helpful for patients with resistant problems.
Gastrointestinal autonomic neuropathy is another complication of diabetes that can cause symptoms such as gastroparesis, erratic blood glucose control, bloating, and vomiting. This can be managed with medications such as metoclopramide, domperidone, or erythromycin, which are prokinetic agents. Chronic diarrhea is another common issue that often occurs at night. Gastroesophageal reflux disease is also a complication of diabetes that is caused by decreased lower esophageal sphincter pressure.
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This question is part of the following fields:
- Gastroenterology
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Question 84
Incorrect
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A 65-year-old man with coronary artery disease visits his General Practitioner after an abdominal ultrasound reveals an easily felt epigastric pulsation. The ultrasound shows a normal calibre abdominal aorta without aneurysm, but incidentally finds gallstones. The patient has never experienced biliary colic or jaundice and has a normal body mass index with no history of abdominal surgery.
What is the most appropriate treatment for this patient?Your Answer:
Correct Answer: No treatment
Explanation:Treatment Options for Asymptomatic Cholelithiasis
Asymptomatic cholelithiasis, or gallstones without any symptoms, doesn’t require therapeutic intervention. In fact, up to 70% of patients with gallstones are asymptomatic at the time of diagnosis. The risk of prophylactic cholecystectomy, or removal of the gallbladder, is greater than the benefit likely to be gained by removal. However, in a partially calcified ‘porcelain’ gallbladder, removal may be recommended to prevent pancreatitis or cholangitis.
Open cholecystectomy, a surgical procedure with a longer recovery time and higher risk of complications, is often reserved for patients where laparoscopy is a higher risk. Endoscopic removal of stones is not suitable for asymptomatic cholelithiasis as it doesn’t remove the gallbladder or stones within it.
If the patient becomes symptomatic, laparoscopic cholecystectomy would be the treatment of choice. However, for asymptomatic patients, the risks of a procedure outweigh the potential benefits of preventing future complications. Lithotripsy, a procedure that breaks up gallstones, is not routinely recommended for the treatment of any gallstones due to the risk of complications.
Treatment Options for Asymptomatic Cholelithiasis
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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 35-year-old man has previously been diagnosed with distal colitis and proctitis. He is not currently taking any medication. He has been symptom-free but now reports a recurrence of his diarrhea.
What is the most appropriate course of action for managing his condition?Your Answer:
Correct Answer: Mesalazine foam enema
Explanation:Treatment Options for Mild-to-Moderate Ulcerative Colitis
Ulcerative colitis is a chronic inflammatory bowel disease that affects the colon and rectum. In mild-to-moderate cases, the recommended initial treatment is local application of an aminosalicylate, such as mesalazine foam enema. Corticosteroid enema or suppositories are alternatives but are less effective.
If there is no response to local treatment, oral mesalazine can be added. However, oral therapy alone with mesalazine is less effective than topical treatment for milder acute exacerbations of inflammatory bowel disease (proctitis). More severe exacerbations require oral steroids.
For adults with a mild to moderate first presentation or inflammatory exacerbation of left-sided or extensive ulcerative colitis, oral mesalazine is the first line choice to induce remission. Topical mesalazine or oral beclomethasone dipropionate may also be considered.
Managing Mild-to-Moderate Ulcerative Colitis: Treatment Options and Recommendations
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This question is part of the following fields:
- Gastroenterology
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Question 86
Incorrect
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A 62-year-old lady presents to you with complaints of progressive bloating and feeling full for the past two months. She requests a prescription for Colpermin, as her sister found it helpful for her IBS. Additionally, she reports experiencing urinary frequency for several weeks and suspects a UTI. On examination, her abdomen appears non-specifically bloated, and a urine dip reveals trace protein but no blood, glucose, or leukocytes. She went through menopause at 54, is nulliparous, and has a family history of psoriasis. There are no known allergies. What would be the most appropriate course of action?
Your Answer:
Correct Answer: Arrange abdominal ultrasound scan
Explanation:Consideration of Ovarian Cancer in New Onset IBS after 50
This patient presenting with new onset IBS after the age of 50 should prompt consideration of ovarian cancer. According to NICE guidelines, symptoms such as bloating, early satiety, pelvic/abdominal pain, and urinary frequency/urgency should raise suspicion of ovarian cancer. CA 125 is the test of choice if ovarian cancer is being considered.
Risk factors for ovarian cancer include nulliparity and late menopause. Symptoms that should raise suspicion of ovarian cancer include progressive bloating, early satiety, and urinary frequency. A vaginal examination should be performed if ovarian cancer is suspected since abdominal examination alone can miss an ovarian mass. The family history of psoriasis is not relevant in this case.
Prescribing Colpermin is not necessarily incorrect, but IBS is a diagnosis of exclusion that should be given once serious and common alternatives have been ruled out. Prescribing an antibiotic is inappropriate because there is no evidence of infection here.
An abdominopelvic scan would be an alternative to arranging CA 125, but an abdominal scan by itself is usually not sufficient to fully examine the ovaries. If a CA 125 was high, an ultrasound scan would be arranged to assess the ovaries in more detail, and the results of the two would be combined in an RMI score to assess the risk of malignancy.
In summary, it is important to consider ovarian cancer in cases of new onset IBS after 50, especially if symptoms such as bloating, early satiety, pelvic/abdominal pain, and urinary frequency/urgency are present. A thorough examination and appropriate tests should be performed to rule out this serious condition.
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This question is part of the following fields:
- Gastroenterology
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Question 87
Incorrect
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A 32-year-old male with type 1 diabetes attends for diabetic annual review. He complains of feeling tired all the time stretching back several months.
Blood tests performed prior to the review appointment show normal renal, liver, and thyroid function; testosterone levels are normal. Full blood count reveals a modest anaemia with:
Haemoglobin 109 g/L (130-180)
MCV 79 fL (80-96)
HbA1c 50 mmol/mol (20-42)
Urine dipstick testing is normal with no ketones. Review of fingerprick blood sugars shows blood sugars consistently in single figures.
Clinical examination is unremarkable.
On further enquiry the patient denies any gastrointestinal symptoms. He is opening his bowels regularly with no change in bowel habit. There is no history of PR blood or mucous. His weight is stable. He denies abdominal pain or bloating. He follows a 'normal' diet. There is no known family history of gastrointestinal pathology or malignancy.
You request some further blood tests which confirm iron deficiency anaemia.
Which of the following is the most appropriate next approach?Your Answer:
Correct Answer: Perform serological testing for coeliac disease
Explanation:Serological Testing for Coeliac Disease
Serological testing for coeliac disease should be considered for individuals presenting with certain symptoms such as chronic diarrhoea, unexplained weight loss, and persistent fatigue. Additionally, those with autoimmune thyroid disease, irritable bowel syndrome, and type 1 diabetes should also be offered testing as they are at increased risk for coeliac disease. NICE guidance recommends testing for individuals with unexplained abdominal symptoms, mouth ulcers, and vitamin deficiencies, as well as first-degree relatives of those with coeliac disease. Coeliac disease is associated with a variety of conditions, including depression, epilepsy, and reduced bone mineral density, among others. In the case of a man with type 1 diabetes and iron deficiency anaemia, serological testing for coeliac disease would be the next appropriate step.
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This question is part of the following fields:
- Gastroenterology
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Question 88
Incorrect
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You are the GP trainee doing your morning clinic. You see a 35-year-old woman with coeliac disease.
Which of the following is indicated as part of her management?Your Answer:
Correct Answer: Administration of the pneumococcal vaccine
Explanation:To prevent overwhelming pneumococcal sepsis due to hyposplenism, Coeliac UK advises that individuals with coeliac disease receive a pneumococcal infection vaccine and a booster every five years. Pertussis vaccines beyond those in the vaccination schedule are unnecessary. According to NICE CKS guidelines, annual blood tests for FBC, ferritin, thyroid function tests, liver function tests, B12, and folate are recommended. Calprotectin is utilized to assess gut inflammation, often as part of the diagnostic process for inflammatory bowel disease. Faecal occult blood testing is typically conducted if there are concerns about bowel cancer.
Managing Coeliac Disease with a Gluten-Free Diet
Coeliac disease is a condition that requires the management of a gluten-free diet. Gluten-containing cereals such as wheat, barley, rye, and oats must be avoided. However, some patients with coeliac disease can tolerate oats. Gluten-free foods include rice, potatoes, and corn. Compliance with a gluten-free diet can be checked by testing for tissue transglutaminase antibodies.
Patients with coeliac disease often have functional hyposplenism, which is why they are offered the pneumococcal vaccine. Coeliac UK recommends that patients with coeliac disease receive the pneumococcal vaccine and have a booster every five years. influenza vaccine is given on an individual basis according to current guidelines.
Overall, managing coeliac disease requires strict adherence to a gluten-free diet and regular immunisation to prevent infections.
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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 79-year-old man comes to the clinic with bilateral angular stomatitis. He wears dentures that have become a bit loose and his diet is not varied.
In the process of advising and treating his angular stomatitis, which of the following is correct?Your Answer:
Correct Answer: May be due to chronic constipation
Explanation:Stomatitis: Causes and Associated Factors
Stomatitis is a condition that can be caused by ill-fitting dentures and slack facial muscles, which can lead to Candida overgrowth. It is not associated with reactive arthritis, but it may be seen in Behçet’s disease. While it is not directly linked to constipation, it can be associated with inflammatory bowel disease.
Iron deficiency is a possible factor in the development of stomatitis, as are deficiencies in riboflavin, niacin, pyridoxine, folic acid, and cyanocobalamin. Vitamin C deficiency can also cause stomatitis, as well as scurvy.
It is important to address the underlying causes of stomatitis in order to effectively treat the condition. Proper dental care and nutrition can help prevent stomatitis from developing or recurrent.
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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 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:
Correct 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 91
Incorrect
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A 70-year-old man presents with faecal incontinence and diarrhoea, which he finds embarrassing. He has a history of irregular bowel movements but has never experienced this before. He was recently prescribed codeine for knee osteoarthritis. What is the most probable cause of his faecal incontinence?
Your Answer:
Correct Answer: Constipation with overflow
Explanation:Possible Causes of Faecal Incontinence
Faecal incontinence, or the inability to control bowel movements, can have various underlying causes. One of the strongest predictors of faecal incontinence is chronic diarrhoea, which can be caused by conditions such as irritable bowel syndrome, inflammatory bowel disease, lactose intolerance, and others. Another possible cause is constipation with overflow, where the patient is prone to constipation and may experience incontinence due to the addition of certain medications like codeine.
Laxative abuse, although it can lead to diarrhoea, is not necessarily a direct cause of faecal incontinence. Cerebrovascular disease may also contribute to incontinence, but there is no indication of this in the given scenario. Haemorrhoids, which can result from chronic constipation, typically cause rectal bleeding and pain but are not commonly associated with faecal incontinence. Prostatic disease may contribute to constipation but is less likely to cause faecal incontinence.
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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 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 93
Incorrect
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A 60-year-old man presents with persistent fatigue, poor appetite, occasional sweats and a feeling of upper abdominal discomfort. He smokes 15 cigarettes per day, drinks up to 10 units of alcohol a week. He has no change in bowel habit. His records show that he injected heroin for a short period of time in his twenties.
He had an urgent ultrasound scan which shows a mass in his liver which has now been biopsied and reported as hepatocellular cancer of the liver.
What is the greatest risk factor for hepatocellular primary liver cancer in this 60-year-old man?Your Answer:
Correct Answer: Hepatitis A infection
Explanation:Hepatitis C and Liver Cancer
Hepatitis C is a viral infection that often goes undiagnosed for up to 20 years, making it a significant risk for those who engage in needle sharing and drug use. This infection can lead to cirrhosis of the liver, which increases the risk of developing primary liver cancer. In fact, around 80% of hepatocellular carcinoma cases are caused by viral infections with either hepatitis C or hepatitis B.
While gallstones and caffeine intake are not associated with an increased risk of liver cancer, previous cholecystectomy and chronic infection with hepatitis B can increase the risk. Statin use and hepatitis A infection, on the other hand, are not associated with an increased risk.
It is crucial to consider hepatitis C testing for at-risk populations and to maintain a low index of suspicion for liver cancer in those with a hepatitis C diagnosis. Early detection and treatment can significantly improve outcomes for those with liver cancer.
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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 55-year-old man presents with a four week history of retrosternal burning particularly after large meals. He also complains of episodes of epigastric discomfort usually during the night. He has no nausea or vomiting, has had no black stools and his weight has been steady for the last few years.
He smokes five cigarettes per day and drinks up to 10 units of alcohol per week. On examination of the abdomen he has mild epigastric tenderness with no masses palpable. He has been buying antacid tablets which give short periods of relief of his symptoms only.
What is the most appropriate management strategy?Your Answer:
Correct Answer: Arrange a routine upper GI endoscopy
Explanation:Management of Dyspepsia in a Patient Under 55 Years Old
Until recently, the National Institute for Health and Care Excellence (NICE) recommended referral for all new onset dyspepsia in patients over 55 years old. However, current guidelines state that referral is only necessary if other symptoms are present. In the case of a patient under 55 years old with no alarm symptoms, treatment to relieve symptoms should be offered.
According to NICE guidance, a four-week course of a full dose proton pump inhibitor (PPI) such as omeprazole is recommended. It is also advisable to check the patient’s Helicobacter pylori status and haemoglobin level. If the patient is found to have iron deficiency anaemia, further investigation would be necessary.
In summary, the management of dyspepsia in a patient under 55 years old involves offering treatment to relieve symptoms and checking for Helicobacter pylori status and haemoglobin level. Referral is only necessary if other symptoms are present or if iron deficiency anaemia is detected.
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This question is part of the following fields:
- Gastroenterology
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Question 95
Incorrect
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A 65-year-old gentleman presents with complaints of 'chest pains'. Upon further discussion, he reports experiencing postprandial retrosternal burning for the past six months. The symptom has been persistent and occurring daily over that time. He has been using an over-the-counter alginate antacid at least once a day for the last four months, but it has not provided significant relief. A colleague prescribed a 3-month course of PPIs, which he has completed without any cessation of his symptoms.
The patient is typically healthy with no significant medical history. He has been a smoker of 20 cigarettes a day since the age of 18 and drinks alcohol occasionally. He reports no dysphagia or odynophagia and his weight is stable. He has experienced occasional vomiting when symptomatic but no persistent vomiting. He denies any haematemesis and his bowel habit is stable with no rectal bleeding or black stools.
Upon examination, he has some angular stomatitis and mild glossitis. His abdomen is soft and non-tender with no palpable masses. What is the most appropriate management strategy?Your Answer:
Correct Answer: Advise he takes the alginate preparation after meals TDS and also at night
Explanation:NICE Guidelines for Upper GI Endoscopy and GORD Treatment
According to the latest NICE guidance NG12 (updated in October 2015), patients with certain symptoms should be referred for upper gastrointestinal (GI) endoscopy. Urgent direct access upper GI endoscopy should be offered to those with dysphagia or aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent direct access upper GI endoscopy should be considered for those with haematemesis, treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, raised platelet count with certain symptoms, or nausea/vomiting with certain symptoms.
For mild gastro-oesophageal reflux disease (GORD) symptoms occurring less than once a week, antacids can be used as needed. For more frequent symptoms, a proton pump inhibitor (PPI) is recommended. Initial treatment is a high dose PPI for four weeks, taken once daily 30-60 minutes before the first meal of the day. If symptoms persist after one month, offer another month at full dose. Doubling the dose of PPI can be considered for severe symptoms. If there is no response to PPI treatment, reconsider the diagnosis and consider specialist referral. A H2 receptor antagonist can be added to a PPI for patients with a partial response to PPI treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 96
Incorrect
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Samantha, 74, visits her doctor complaining of jaundice. She has a history of heavy alcohol consumption, drinking around 35-40 units per week. Samantha denies experiencing any abdominal pain, and her abdominal examination doesn't reveal any pain, but a palpable gallbladder is detected. Blood tests are conducted, and the results are as follows:
- Albumin: 30 g/L
- Alk Phos: 342 U/L
- ALT: 95 U/L
- Bilirubin: 102 mol/L
- INR: 1.4
- GGT: 123 U/L
What is the probable diagnosis?Your Answer:
Correct Answer: Pancreatic cancer
Explanation:Pancreatic cancer is the most likely cause based on Courvoisier’s sign, which indicates that a painless, enlarged gallbladder and mild jaundice are unlikely to be caused by gallstones and more likely to be caused by a malignancy of the pancreas or biliary tree. Alcoholic hepatitis and primary biliary cirrhosis are possible differentials, but the absence of pain and an enlarged gallbladder makes them less likely. Paracetamol overdose is not a probable cause as it doesn’t typically result in a painless, palpable gallbladder and jaundice.
Pancreatic cancer is a type of cancer that is often diagnosed late due to its nonspecific symptoms. The majority of pancreatic tumors are adenocarcinomas and are typically found in the head of the pancreas. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and mutations in the BRCA2 and KRAS genes.
Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, and pruritus. Courvoisier’s law states that a palpable gallbladder is unlikely to be due to gallstones in the presence of painless obstructive jaundice. However, patients often present with nonspecific symptoms such as anorexia, weight loss, and epigastric pain. Loss of exocrine and endocrine function can also occur, leading to steatorrhea and diabetes mellitus. Atypical back pain and migratory thrombophlebitis (Trousseau sign) are also common.
Ultrasound has a sensitivity of around 60-90% for detecting pancreatic cancer, but high-resolution CT scanning is the preferred diagnostic tool. The ‘double duct’ sign, which is the simultaneous dilatation of the common bile and pancreatic ducts, may be seen on imaging.
Less than 20% of patients with pancreatic cancer are suitable for surgery at the time of diagnosis. A Whipple’s resection (pancreaticoduodenectomy) may be performed for resectable lesions in the head of the pancreas, but side-effects such as dumping syndrome and peptic ulcer disease can occur. Adjuvant chemotherapy is typically given following surgery, and ERCP with stenting may be used for palliation.
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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 67-year-old woman presents to her General Practitioner complaining of chronic, unrelenting, dull epigastric pain radiating to her back. It is relieved when sitting forwards.
On examination, her body mass index is normal, but she says that she is losing weight; her clothes have become baggy on her. She explains that she doesn't feel like eating with the pain she is suffering.
Investigations reveal a haemoglobin level of 102 g/l (normal range: 115–165 g/l) while her alkaline phosphatase level is elevated.
What is the most appropriate initial investigation?
Your Answer:
Correct Answer: Arrange an abdominal computed tomography (CT) scan
Explanation:Initial Management for Suspected Pancreatic Cancer: Abdominal CT Scan
When a patient over 60 years old presents with weight loss and abdominal pain, an urgent direct-access CT scan should be considered to assess for pancreatic cancer. Other symptoms that may indicate pancreatic cancer include diarrhea, back pain, nausea, vomiting, constipation, and new-onset diabetes. Patients with pancreatic cancer typically report anorexia, malaise, fatigue, mid-epigastric or back pain, and weight loss. The pain may be unrelenting and worse when lying flat.
The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice. Migratory thrombophlebitis and venous thrombosis also occur with higher frequency in patients with pancreatic cancer and may be the first presentation.
While the CA 19-9 antigen is elevated in 75-80% of patients with pancreatic carcinoma, it is not recommended for screening. An abdominal ultrasound scan may reveal a pancreatic malignancy, but a CT scan is the preferred imaging that should be carried out urgently.
Direct-access upper GI endoscopy may be appropriate for patients over 55 years old with weight loss and upper abdominal pain, reflux, or dyspepsia. However, in this case, an urgent CT scan is the most appropriate initial investigation due to the elevated alkaline phosphatase suggesting biliary obstruction. Checking ferritin levels may not be helpful in ruling in or out pancreatic cancer.
Initial Management for Suspected Pancreatic Cancer: Abdominal CT Scan
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This question is part of the following fields:
- Gastroenterology
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Question 98
Incorrect
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The treatment room nurse requests your assistance in evaluating a 67-year-old male patient who has been experiencing a non-healing skin ulcer in his natal cleft. Despite various attempts, there has been no improvement in the condition. The patient has a medical history of angina, benign prostatic hypertrophy, and asthma. Which medication among his current prescriptions is the most probable cause of this non-healing ulcer?
Your Answer:
Correct Answer: Nicorandil
Explanation:Nicorandil can lead to anal ulceration. This is because ulceration is a known side effect of nicorandil, which can cause ulcers in the skin, mucosa, and eyes. It can also cause gastrointestinal ulcers that may result in complications such as perforation, haemorrhage, fistula, or abscess. If ulceration occurs, nicorandil treatment should be discontinued, and alternative medication should be considered.
Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved through the activation of guanylyl cyclase, which results in an increase in cGMP. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers on the skin, mucous membranes, and eyes. Additionally, gastrointestinal ulcers, including anal ulceration, may also occur. It is important to note that nicorandil should not be used in patients with left ventricular failure.
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This question is part of the following fields:
- Gastroenterology
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Question 99
Incorrect
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A 29-year-old man with a history of ulcerative colitis presents to his primary care physician complaining of loose non-bloody stools and abdominal discomfort for the past 6 days. He has not been taking any regular medication and his disease has been quiescent for many years. A colonoscopy performed 5 years ago showed proctitis. On examination, his vital signs are within normal limits and his abdomen is diffusely soft with no peritonism. A stool culture is negative. What is the most appropriate treatment for this patient?
Your Answer:
Correct Answer: Mesalazine suppository
Explanation:For a patient experiencing mild-to-moderate symptoms of distal ulcerative colitis, the recommended first-line treatment is topical (rectal) aminosalicylates, such as mesalazine suppositories. This is particularly effective for patients with left-sided disease, such as proctitis or proctosigmoiditis. While budesonide foam enema is sometimes used as an additional treatment for mild-to-moderate disease, it is generally less effective at inducing remission. Oral azathioprine is not recommended for inducing remission, but may be used to maintain remission in patients who have had multiple inflammatory exacerbations or if remission is not maintained by aminosalicylates alone. Oral mesalazine is less effective than topical mesalazine for mild or moderate proctitis, but may be offered as an additional treatment if symptoms persist after 4 weeks of topical mesalazine. For patients with pancolitis or extensive disease, oral mesalazine may be offered as a first-line treatment.
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 100
Incorrect
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A 35-year-old man visits his General Practitioner with complaints of persistent symptoms despite adhering to a gluten-free diet. He is experiencing frequent episodes of abdominal discomfort and diarrhoea. He was diagnosed with coeliac disease a few years ago and has been managing it well otherwise.
What is the most probable diagnosis?Your Answer:
Correct Answer: Intestinal lymphoma
Explanation:Intestinal lymphoma is a rare but increased risk for individuals with coeliac disease, particularly those with refractory coeliac disease. Symptoms of enteropathy-associated T-cell lymphoma include persistent diarrhoea, stomach pain, and unexplained weight loss. Adhering to a gluten-free diet can decrease the risk of developing lymphoma, as well as other potential complications such as carcinoma of the small bowel or oesophagus. Intestinal lymphangiectasia, bacterial overgrowth of the small intestine, Crohn’s disease, and Giardia intestinalis infection are other possible causes of chronic diarrhoea and weight loss, but are less likely in this case.
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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 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 102
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 103
Incorrect
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A 25-year-old male blood donor presents with the following blood results:
Bilirubin 41 µmol/L
ALP 84 U/L
ALT 23 U/L
Albumin 41 g/L
His medical history reveals recent complaints of coryzal symptoms and a non-productive cough. Based on these findings, what is the most probable diagnosis?Your Answer:
Correct Answer: Gilbert's syndrome
Explanation:Gilbert’s syndrome is typically characterized by a rise in bilirubin levels in response to physiological stress. Therefore, it is likely that a 22-year-old male with isolated hyperbilirubinemia has Gilbert’s syndrome. Dubin-Johnson and Rotor syndrome, which both result in conjugated bilirubinemia, can be ruled out based on a normal dipstick urinalysis. Viral infections are often responsible for triggering a bilirubin increase in individuals with Gilbert’s syndrome.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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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 40-year-old police officer attends his General Practitioner to request screening for hepatitis B. He was exposed to blood from a person possibly infected with hepatitis B virus around three weeks ago. He has never been vaccinated against this and requests blood screening. He feels well and has no comorbidities.
What is the most important test to perform at this stage?
Your Answer:
Correct Answer: Hepatitis B surface antigen (HBsAg)
Explanation:Hepatitis B Markers: Understanding the Different Types
Hepatitis B is a viral infection that affects the liver. It is important to detect and monitor the different markers associated with the disease to determine the stage of infection and the appropriate treatment. Here are the different types of hepatitis B markers and their significance:
1. Hepatitis B surface antigen (HBsAg) – This is the first marker to appear in the serum after infection. It indicates the presence of the viral envelope and can be detected between one to nine weeks after infection. Its persistence indicates chronic hepatitis B.
2. Anti-hepatitis B envelope antigen (anti-HBeAg) – This antibody appears after the clearance of the e antigen, signifying the resolution of the acute phase.
3. Hepatitis B envelope antigen (HBeAg) – This marker develops during the early phases of the acute infection and can persist in chronic infections. It is associated with high levels of viral replication and infectivity.
4. Immunoglobulin G (IgG) anti-hepatitis B core antigen (anti-HBc) – This antibody stays positive for life following infection with hepatitis B, even once cleared.
5. Immunoglobulin M (IgM) anti-hepatitis B core antigen (anti-HBc) – This antibody confirms the diagnosis of acute infection but is detectable later than HBsAg.
Understanding these markers is crucial in the diagnosis and management of hepatitis B. Regular monitoring of these markers can help determine the progression of the disease and the effectiveness of treatment.
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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 65-year-old man presents with new onset bilateral gynaecomastia.
He has been diagnosed with Zollinger-Ellison syndrome and heart failure in the last year. He underwent normal puberty at age 14.
Which of the following drugs would be most likely to cause gynaecomastia?Your Answer:
Correct Answer: Rabeprazole sodium
Explanation:Drugs that can cause gynaecomastia
Research has shown that the risk of developing gynaecomastia is almost insignificant when using other drugs as part of the treatment of Zollinger-Ellison syndrome. However, there are other drugs that can cause gynaecomastia, including spironolactone, digoxin, methyldopa, gonadotrophins, and cyproterone acetate.
Zollinger-Ellison syndrome is a condition where a gastrin-secreting pancreatic adenoma is associated with peptic ulcer, and 50-60% of cases are malignant. It is suspected in patients with multiple peptic ulcers that are resistant to drugs and occurs in approximately 0.1% of patients with duodenal ulcer disease.
A case study into male gynaecomastia has shown that spironolactone induced gynaecomastia by blocking androgen production, blocking androgens from binding to their receptors, and increasing both total and free oestrogen levels. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare professional.
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This question is part of the following fields:
- Gastroenterology
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Question 106
Incorrect
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A 32-year-old man visits his General Practitioner to discuss his recent diagnosis of Crohn's disease. He presented eight months ago with weight loss and a change in bowel habit, and was referred to the Gastroenterology Department. The diagnosis was confirmed and he was successfully treated as an inpatient. At the time, he declined maintenance therapy but has since become very worried about this decision and would like to start the treatment. What is the most suitable agent to maintain remission in this patient?
Your Answer:
Correct Answer:
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