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Question 1
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: Loperamide for symptom relief
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 2
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: Arrange an urgent upper GI endoscopy
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 3
Incorrect
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A 50 year old woman presents to the GP clinic with complaints of increasing dyspepsia, dysphagia, and fatigue. She reports a prolonged history of dark brown stools, but no recent occurrence of fresh blood. She denies any significant weight loss and has a past surgical history of peptic ulcer disease. Upon investigation, she is found to have H. pylori infection.
What should be the subsequent course of action?Your Answer: Routine referral to endoscopy
Correct Answer: 2 week referral to endoscopy
Explanation: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 4
Correct
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A 60-year-old man with liver cirrhosis of unknown origin is being evaluated in the clinic. What factor is most likely to indicate a poor prognosis?
Your Answer: Ascites
Explanation:Scoring Systems for Liver Cirrhosis
Liver cirrhosis is a serious condition that can lead to liver failure and death. To assess the severity of the disease, doctors use scoring systems such as the Child-Pugh classification and the Model for End-Stage Liver Disease (MELD). The Child-Pugh classification takes into account five factors: bilirubin levels, albumin levels, prothrombin time, encephalopathy, and ascites. Each factor is assigned a score of 1 to 3, depending on its severity, and the scores are added up to give a total score. The total score is then used to grade the severity of the disease as A, B, or C.
The MELD system uses a formula that takes into account a patient’s bilirubin, creatinine, and international normalized ratio (INR) to predict their survival. The formula calculates a score that ranges from 6 to 40, with higher scores indicating a higher risk of mortality. The MELD score is particularly useful for patients who are on a liver transplant waiting list, as it helps to prioritize patients based on their risk of mortality. Overall, both the Child-Pugh classification and the MELD system are important tools for assessing the severity of liver cirrhosis and determining the best course of treatment for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Correct
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You see a 38-year-old lady who has come to you for help reducing her weight. Her BMI is 32 kg/m2. She has tried joining a local dieting group and increasing her physical activity but is still finding it difficult to lose weight. After discussion, it is decided to start her on orlistat. She manages to lose 2Kg after 3 months treatment. She wants to know how much longer she is allowed to be on this medication.
Following an initial weight loss at 3 months, what is the restriction on how long orlistat should be prescribed?Your Answer: 3 months
Explanation:Orlistat Prescription Guidelines
Orlistat is a medication that inhibits pancreatic lipase and is prescribed to patients with a BMI of 30 kg/m2 or more (or 28 kg/m2 with an associated risk factor). Patients are expected to lose 5% of their initial body weight at 3 months for the prescription to be continued. However, for patients with diabetes, a 3% loss of body weight at 3 months is recommended.
Beyond the initial weight loss at 3 months, there is no restriction on how long orlistat should be prescribed. The decision to continue treatment should be made on an individual basis, taking into account the benefits, risks, and cost of treatment. Regular reviews should be undertaken to assess the benefits, risks, and costs of treatment. According to NICE, For people who have lost the recommended amount of weight, there is no restriction on how long orlistat may be prescribed. This should be reviewed at regular intervals.
In summary, orlistat is a medication that can be prescribed for an extended period of time, but the decision to continue treatment should be made on an individual basis, taking into account the benefits, risks, and cost of treatment. Regular reviews should be conducted to ensure that the medication is still appropriate for the patient.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Correct
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A 65-year-old man presents to the General Practice Surgery with jaundice.
On examination, he has an enlarged, nodular liver. He is referred to hospital where a computed tomography (CT) scan of his abdomen reveals a cirrhotic liver with a large mass. A CT-guided biopsy of the mass demonstrates a malignant tumour derived from hepatic parenchymal cells.
What is the most likely causative agent in this patient?Your Answer: Hepatitis B virus
Explanation:Viral Causes of Cancer: A Comparison
There are several viruses that have been linked to the development of cancer in humans. Among these, hepatitis B virus is one of the most significant causes of cancer in many parts of the world, particularly in China where liver cancer accounts for about 20% of all cancer deaths. Infant vaccination against the virus is now being introduced to protect the new generation, but it doesn’t provide retrospective protection. On the other hand, hepatitis C is a more common cause of liver cancer in Europe and the United States.
Human T-lymphocyte virus, Epstein–Barr virus, and human herpesvirus type 8 are also known to cause cancer in humans, but not liver cancer. Human T-lymphocyte viruses can cause adult T-cell leukaemia/lymphoma, while Epstein–Barr virus has been linked with Hodgkin’s lymphoma, Burkitt’s lymphoma, nasopharyngeal cancer, and gastric cancer. Human herpesvirus type 8 is associated with Kaposi’s sarcoma, which is most often found in men who have sex with men but can also occur in heterosexuals.
Human papillomavirus (HPV) is another virus that has been linked to cancer, but not liver cancer. HPV types 6 and 11 cause anogenital warts, while HPV16 and HPV18 are responsible for more than two thirds of all cervical cancers globally. HPV infection is also associated with anogenital cancer and some nasopharyngeal cancers.
In summary, while several viruses have been linked to the development of cancer in humans, their specific associations vary. It is important to understand these associations in order to develop effective prevention and treatment strategies.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Correct
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A 42-year-old male presents with jaundice and pruritus. He has a history of ulcerative colitis and is currently taking sulfasalazine. He reports feeling increasingly tired and has noticed a yellow tint to his eyes. On examination, he has scratch marks on his skin, hepatomegaly, and his blood pressure is 136/88 mmHg with a pulse rate of 74. Blood tests reveal elevated levels of bilirubin, ALT, and ALP. What is the most likely underlying diagnosis?
Your Answer: Gallstones
Explanation:Primary Sclerosing Cholangitis in Patients with Ulcerative Colitis
Patients with elevated ALP levels may be incidentally picked up and require further investigation. However, those who are symptomatic may present with jaundice, pruritus, fatigue, and abdominal pain. Clinically, patients may also have hepatomegaly and be jaundiced.
In the case of a patient with ulcerative colitis, the likelihood of primary sclerosing cholangitis (PSC) is significantly increased. Approximately 3% of UC sufferers have PSC, and 80% of those with PSC have UC. While gallstones in the common bile duct and liver cysts of hydatid disease can present with similar symptoms, the history of UC makes PSC a more likely diagnosis. Haemolytic anaemia and osteomalacia can cause elevated ALP levels, but they would not account for the cholestatic liver function and hepatomegaly seen in PSC.
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This question is part of the following fields:
- Gastroenterology
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Question 8
Correct
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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: 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 9
Correct
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A 42-year-old woman with no past medical history has been struggling to lose weight. She has been attending supervised weight loss sessions and gym classes, but has not been successful in her efforts. She was prescribed orlistat 120 mg, to be taken after each meal, 10 weeks ago when she weighed 100 kg (BMI 37 kg/m2). After 10 weeks of taking orlistat, she now weighs 97.5 kg. What would be the most appropriate management in this situation?
Your Answer: Discontinue orlistat
Explanation:Options for Managing Inadequate Weight Loss with Orlistat
Orlistat is a medication used to aid weight loss by reducing the absorption of dietary fat. However, if a patient fails to lose at least 5% of their body weight after 12 weeks of treatment, orlistat should be discontinued. Here are some options for managing inadequate weight loss with orlistat:
1. Discontinue orlistat: If a patient has not lost at least 5% of their starting weight, orlistat should be discontinued. A lower weight loss target may be considered for patients with type II diabetes.
2. Increase activity levels: Increasing physical activity can help with weight loss. However, it is important to address any underlying issues that may be hindering weight loss.
3. Refer for bariatric surgery: Bariatric surgery may be an option for patients with a BMI of 40 kg/m2 or more, or 35–40 kg/m2 with significant comorbidity that could be improved with weight loss. Non-surgical methods of weight loss should be attempted prior to referral.
4. Increase the dose to 180 mg with meals: The maximum dose of orlistat is 120 mg up to three times a day. A 60 mg preparation is available over the counter. However, increasing the dose beyond the recommended maximum is not advised.
It is important to regularly review progress and adjust treatment accordingly to ensure the best outcomes for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Correct
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A 65-year-old man visits the GP clinic complaining of rectal bleeding that has been ongoing for two days. He has experienced eight episodes of diarrhoea in the past 24 hours, with visible blood mixed with stool. He also reports feeling nauseous and having abdominal pain. The patient has a medical history of ulcerative colitis, hypertension, and type 2 diabetes, and is currently taking mesalazine enteric coated 800 mg twice daily, amlodipine 10 mg once daily, and metformin 500mg twice daily.
During the examination, the patient appears pale and has a temperature of 38ºC. His heart rate is 108/min, and his blood pressure is 112/74 mmHg. The abdominal exam reveals generalised tenderness and guarding, but no rebound tenderness.
What is the appropriate course of action for managing this patient's condition?Your Answer: Urgent hospital admission
Explanation:The appropriate course of action for a severe flare-up of ulcerative colitis is urgent hospital admission for IV corticosteroids. This is based on the Truelove and Witts’ severity index, which indicates that the patient is experiencing a severe flare-up due to symptoms such as opening their bowels more than 6 times per day and systemic upset (e.g. fever and tachycardia). NICE guidelines recommend immediate hospital admission for assessment and treatment with IV corticosteroids. It should be noted that a short course of oral steroids or rectal mesalazine may be used for mild to moderate flare-ups, while loperamide and dose increases of mesalazine are not appropriate for managing severe flare-ups.
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 11
Correct
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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: 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 12
Incorrect
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A 62-year-old woman presents with long-standing gastrointestinal symptoms. She was diagnosed with irritable bowel syndrome as a young adult and currently takes hyoscine butylbromide 10-20 mg QDS PRN and loperamide 2 mg PRN for her symptoms. She also has a history of type 1 diabetes diagnosed at the age of 10.
She has been experiencing intermittent abdominal pains and bloating, as well as periodic bouts of diarrhea for years. Her latest blood tests, which were done as part of her diabetic annual review, show a modest anemia (hemoglobin 105 g/L). Her liver function tests show a slight persistent elevation of ALT and ALP, which has been the case for the last six to seven years and has not significantly deteriorated. Her thyroid function, bone profile, and ESR are all within normal limits. Her HbA1c is satisfactory at 50 mmol/mol.
There has been no significant change in her gastrointestinal symptoms recently. She has never had any rectal bleeding or mucous passed per rectum. Her weight is stable. She reports no acute illness but does feel more tired than usual over the last few months. She follows a 'normal' diet. Clinical examination reveals no focal abnormalities. She denies any obvious source of blood loss with no reported gastro-oesophageal reflux, haematemesis, haemoptysis, or haematuria. Urine dipstick testing shows no blood.
She has no family history of bowel cancer, but her mother and one of her maternal aunts both suffered from irritable bowel syndrome. Follow-up blood tests show low ferritin and folate levels.
What is the most appropriate next step in managing this 62-year-old woman's symptoms?Your Answer: Refer her urgently to a lower gastrointestinal specialist
Correct Answer: Reassure her that no further investigation or treatment is needed as her symptoms are chronic
Explanation:Coeliac Disease and Iron Deficiency Anaemia
Note the low folate levels and anaemia in a type 1 diabetic with chronic gastrointestinal symptoms and liver function test abnormalities. These features suggest coeliac disease, which is often misdiagnosed as irritable bowel syndrome. It is recommended by NICE to routinely test for coeliac disease when diagnosing IBS. Family members with IBS should also be investigated for coeliac disease if the diagnosis is confirmed.
Patients with untreated coeliac disease often have mild liver function test abnormalities and are at increased risk for osteoporosis and hypothyroidism. The low folate levels suggest malabsorption as a possible cause. NICE CKS recommends screening all people with iron deficiency anaemia for coeliac disease using coeliac serology.
For iron deficiency anaemia without dyspepsia, consider the possibility of gastrointestinal cancer and urgently refer for further investigations. For women who are not menstruating, with unexplained iron deficiency anaemia and a haemoglobin level of 10 g/100 mL or below, refer urgently within 2 weeks for upper and lower gastrointestinal investigations.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Correct
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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: 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 14
Incorrect
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A 56-year-old man presents with dyspepsia and is found to have a gastric ulcer and H. pylori infection on endoscopy. He undergoes H. pylori eradication therapy but continues to experience symptoms six weeks later. What is the best test to confirm eradication of H. pylori?
Your Answer: Hydrogen breath test
Correct Answer: Urea breath test
Explanation:The sole recommended test for H. pylori after eradication therapy is the urea breath test. It should be noted that H. pylori serology will still show positive results even after eradication. A stool antigen test, rather than culture, may be a suitable substitute.
Tests for Helicobacter pylori
There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which determines the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.
Another test is the rapid urease test, also known as the CLO test. This test involves mixing a biopsy sample with urea and pH indicator, and a color change indicates H. pylori urease activity. Serum antibody tests remain positive even after eradication, and the sensitivity and specificity are 85% and 80%, respectively. Culture of gastric biopsy provides information on antibiotic sensitivity, with a sensitivity of 70% and specificity of 100%. Gastric biopsy with histological evaluation alone has a sensitivity and specificity of 95-99%. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.
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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 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: 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 16
Correct
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A 50-year-old woman presents with jaundice and itching.
Which of the following results would most strongly support the diagnosis of primary biliary cholangitis?
Your Answer: Antimitochondrial antibodies
Explanation:Understanding Primary Biliary Cholangitis: Diagnostic Tests and Markers
Primary biliary cholangitis is an autoimmune disease that affects the biliary system, causing intrahepatic cholestasis and leading to cell damage, fibrosis, and cirrhosis. While there is no single definitive test for this condition, several markers can help diagnose and monitor it.
Antimitochondrial antibodies are present in 90-95% of individuals with primary biliary cholangitis, but are only found in 0.5% of normal controls. Anti-smooth muscle antibodies are also nonspecific, as they can be positive in connective tissue disease and chronic infections. Similarly, around 35% of patients with primary biliary cholangitis have positive antinuclear antibodies, but this is not specific to the condition.
Elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are common in primary biliary cholangitis, but significant elevations of alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (GGT) are usually more prominent. Additionally, a polyclonal increase in IgM (sometimes associated with elevated IgG) is typical but not specific to this condition.
Overall, a combination of these diagnostic tests and markers can help identify and monitor primary biliary cholangitis.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Correct
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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 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 18
Correct
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A 66-year-old woman presents to you for a medication review. She underwent H. pylori eradication treatment a year ago, but her symptoms of epigastric burning returned within a few months. She has been taking omeprazole 20 mg/day since then. She reports that her symptoms are worsening again and asks if further treatment for Helicobacter pylori would be beneficial. She has lost more than 7 lbs in weight. You urgently refer her for an upper GI endoscopy.
What advice would you give her while waiting for the investigation?Your Answer: Increase her omeprazole to 40 mg daily
Explanation:Importance of Stopping Acid Suppression Medication Prior to Endoscopy
In urgent cases where endoscopy is required, it is recommended to stop acid suppression medication for at least two weeks before the procedure. This is because acid suppression medication can hide serious underlying conditions that need to be addressed. However, there may be situations where stopping the medication is difficult due to symptoms, and clinical judgement must be used.
For instance, if a patient experiences unintentional weight loss, it is a red flag symptom for upper GI malignancy, and urgent referral for endoscopy is necessary. In such cases, the benefits of stopping acid suppression medication should be weighed against the potential risks of continuing it. Ultimately, the decision should be made based on the patient’s individual circumstances and the urgency of the situation. Proper evaluation and management can help ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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Primary sclerosing cholangitis is most commonly associated with which of the following conditions?
Your Answer: Crohn's disease
Correct Answer: Ulcerative colitis
Explanation:Understanding Primary Sclerosing Cholangitis
Primary sclerosing cholangitis is a condition that affects the bile ducts, causing inflammation and fibrosis. The cause of this disease is unknown, but it is often associated with ulcerative colitis, with 4% of UC patients having PSC and 80% of PSC patients having UC. Crohn’s disease and HIV are also less common associations.
Symptoms of PSC include cholestasis, jaundice, pruritus, raised bilirubin and ALP levels, right upper quadrant pain, and fatigue. To diagnose PSC, doctors typically use endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), which show multiple biliary strictures giving a ‘beaded’ appearance. A positive p-ANCA test may also be indicative of PSC.
Liver biopsy may show fibrous, obliterative cholangitis, often described as ‘onion skin’, but it has a limited role in diagnosis. Complications of PSC include an increased risk of cholangiocarcinoma (in 10% of cases) and colorectal cancer.
Overall, understanding the symptoms, associations, and diagnostic methods for PSC is crucial for early detection and management of this condition.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Correct
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A 47-year-old man has been diagnosed with a duodenal ulcer and CLO testing during gastroscopy confirms the presence of Helicobacter pylori. What is the best course of action for eradicating Helicobacter pylori?
Your Answer: Lansoprazole + amoxicillin + clarithromycin
Explanation:Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems
Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.
The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.
The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.
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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 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: Viral hepatitis
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 22
Correct
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A 25-year-old woman developed nausea, vomiting, and abdominal cramps 4 hours after consuming a salad and a hamburger at a nearby restaurant. She subsequently experienced watery diarrhea a few hours later. Which single organism is most likely responsible for her illness?
Your Answer: Staphylococcus aureus
Explanation:Common Types of Food Poisoning and Their Symptoms
Food poisoning can be caused by various bacteria and toxins that contaminate food. Here are some common types of food poisoning and their symptoms:
1. Staphylococcal food poisoning: This type of food poisoning is caused by preformed enterotoxins produced by Staphylococcus aureus. Symptoms include profuse vomiting and watery diarrhea, which can occur 1-6 hours after eating contaminated food.
2. Yersinia infection: This type of food poisoning is usually associated with improperly cooked meat. Symptoms may appear 3-10 days after ingestion of contaminated food.
3. Listeria monocytogenes infection: This type of food poisoning can develop from 2 to 70 days after eating contaminated food. Symptoms include mild flu-like symptoms with diarrhea and vomiting, but the elderly, pregnant women, newborns, and immunosuppressed individuals are at risk of more serious consequences.
4. Vibrio vulnificus-associated food poisoning: This type of food poisoning is caused by contaminated seafood, particularly oysters or undercooked shellfish. Symptoms usually appear 1-7 days after ingestion.
5. Clostridium perfringens infection: This type of food poisoning is caused by spores that can grow into new cells if cooked food is not promptly served or refrigerated. Symptoms include diarrhea and abdominal pain, but not fever or vomiting. Outbreaks are often linked to institutions or events with catered food.
It is important to handle and cook food properly to prevent food poisoning. If you experience symptoms of food poisoning, seek medical attention immediately.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Correct
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You suspect a patient you have seen on a home visit who is elderly and was previously treated with antibiotics has now developed Clostridium difficile (C. difficile) infection.
Which of the following is most likely to have caused this infection?Your Answer: Clarithromycin
Explanation:Antibiotics and C. difficile Infection
Antibiotics are known to increase the risk of patients developing C. difficile infection. However, certain antibiotics are more frequently associated with this infection than others. These include clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins.
If a patient does develop C. difficile infection, there are treatments available. Metronidazole and vancomycin are commonly used to treat this infection. It is important for healthcare providers to be aware of the risks associated with antibiotics and to use them judiciously to prevent the development of C. difficile infection. By doing so, patients can receive the necessary treatment without experiencing unnecessary 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 man presents to his General Practitioner concerned that he may be at an increased risk of developing colon cancer. His father died at the age of 56 from a sigmoid colon adenocarcinoma. His brother, aged 61, has just undergone a colectomy for a caecal carcinoma.
What is the most appropriate management for this patient?Your Answer: Refer for one-off colonoscopy aged 55
Explanation:Screening Recommendations for Patients with Family History of Colorectal Cancer
Patients with a family history of colorectal cancer may be at an increased risk of developing the disease. The British Society of Gastroenterology and the Association of Coloproctology for Great Britain and Ireland have produced screening guidelines for patients with family history profiles that place them in a moderate-risk category.
Colonoscopy is recommended for patients with a family history of two first-degree relatives with a mean age of less than 60 years with colorectal cancer, starting at the age of 55. Abdominal ultrasound examination doesn’t have a role in screening for or diagnosing colorectal cancer.
Patients with an increased risk should not be advised that they have no increased risk. Instead, they should be screened appropriately. Faecal immunochemical tests (FIT) are used to detect blood in the stool and are used in the national bowel cancer screening programme. However, patients with a higher risk, given their family history, should be offered earlier screening with colonoscopy rather than waiting until they are eligible for the national screening programme. False positives and negatives are possible with FIT, making colonoscopy a more reliable screening option for high-risk patients.
Therefore, it is important for patients with a family history of colorectal cancer to be aware of the screening recommendations and to discuss their individual risk and screening options with their healthcare provider.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Correct
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A 26-year-old woman presents to her GP complaining of yellowing of her eyes and generalized itching for the past 5 days. She denies any fever, myalgia, or abdominal pain. She reports that her urine has become darker and her stools have become paler. She has been in good health otherwise.
The patient had visited the clinic 3 weeks ago for a sore throat and was prescribed antibiotics. She has been taking the combined oral contraceptive pill for the past 6 months.
On examination, the patient appears jaundiced in both her skin and sclera. She has no rash but has multiple scratches on her arms due to itching. There is no palpable hepatosplenomegaly, and she has no abdominal tenderness.
Laboratory tests reveal:
- Bilirubin 110 µmol/L (3 - 17)
- ALP 200 u/L (30 - 100)
- ALT 60 u/L (3 - 40)
- γGT 120 u/L (8 - 60)
- Albumin 40 g/L (35 - 50)
What is the most likely cause of her symptoms?Your Answer: Combined oral contraceptive pill
Explanation:The patient is presenting with cholestatic jaundice, likely caused by the oral contraceptive pill. This results in intrahepatic jaundice, dark urine, and pale stools. Paracetamol overdose and viral hepatitis would cause hepatocellular jaundice, while Gilbert’s syndrome is an unconjugated hyperbilirubinaemia. Choledocholithiasis could also cause obstructive cholestasis. It is appropriate to stop the pill and consider alternative contraception methods, and additional imaging may be necessary if jaundice doesn’t resolve.
Drug-induced liver disease can be categorized into three types: hepatocellular, cholestatic, or mixed. However, there can be some overlap between these categories, as some drugs can cause a range of liver changes. Certain drugs tend to cause a hepatocellular picture, such as paracetamol, sodium valproate, and statins. On the other hand, drugs like the combined oral contraceptive pill, flucloxacillin, and anabolic steroids tend to cause cholestasis with or without hepatitis. Methotrexate, methyldopa, and amiodarone are known to cause liver cirrhosis. It is important to note that there are rare reported causes of drug-induced liver disease, such as nifedipine.
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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 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: 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 27
Correct
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A 56-year-old man visits his General Practitioner with a complaint of burning retrosternal pain. He has had this issue before and has treated it with over-the-counter remedies. He sometimes experiences food sticking. He smokes 20 cigarettes daily. During the examination, there is some epigastric tenderness, but only upon deep palpation. What is the best course of action for managing this patient?
Your Answer: Upper gastrointestinal (GI) endoscopy
Explanation:Management of Gastroesophageal Reflux Disease with Red-Flag Symptom
Gastroesophageal reflux disease (GORD) is a common condition that can be managed with lifestyle advice and medication. However, when red-flag symptoms such as dysphagia are present, urgent investigation is necessary to rule out oesophageal cancer.
The National Institute for Health and Care Excellence (NICE) recommends urgent direct-access upper gastrointestinal endoscopy within two weeks for people with dysphagia. Long-term reflux disease may lead to Barrett’s oesophagus, which requires surveillance endoscopy every two years.
Lifestyle advice is a key element in managing GORD, including weight loss, alcohol and smoking cessation, small regular meals, avoiding food and hot drinks before bedtime, and raising the head of the bed at night. Antacids are available over the counter but are not sufficient for red-flag symptoms. H2-antagonists are not the first-line treatment for reflux disease, and proton-pump inhibitors (PPIs) are more effective in relieving heartburn.
For a new episode of reflux disease, a full dose of PPI is given for a month, and the dose is stepped down or a low-dose PPI is used for recurrent symptoms as required. PPIs are highly effective in symptom relief, but urgent endoscopy is necessary for red-flag symptoms such as dysphagia.
In summary, the management of GORD involves lifestyle advice and medication, but red-flag symptoms require urgent investigation to rule out oesophageal cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Correct
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Which statement about the epidemiology of colorectal cancer is accurate?
Your Answer: A quarter of patients diagnosed with bowel cancer will survive for at least 10 years
Explanation:Understanding the Epidemiology of Colorectal Cancer
A basic understanding of the epidemiology of colorectal cancer is important for general practitioners to consider when treating their patients. It is worth noting that 95% of colorectal cancer cases occur in individuals over the age of 50.
In terms of incorrect answer options, it is important to note that bowel cancer incidence rates have not increased by 6% over the last 10 years. Additionally, bowel cancer is not the second most common cause of cancer death in the UK overall, but rather in men alone it is second to prostate cancer and in women alone it is second to breast cancer.
Finally, while almost 42,000 people were diagnosed with bowel cancer in the UK in 2011, it is not accurate to say that half of patients diagnosed with colorectal cancer will survive their disease for 10 years or more. It is important for general practitioners to have accurate information about colorectal cancer in order to provide the best care for their patients.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Correct
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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: 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 30
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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