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  • Question 1 - A 50-year-old obese woman presents to the Emergency Department (ED) with increasing shortness...

    Incorrect

    • A 50-year-old obese woman presents to the Emergency Department (ED) with increasing shortness of breath and right-sided chest pain over the past few days. She appears unwell and has a temperature of 38.9°C. On room air, her oxygen saturations are 85%, and her blood pressure is 70/40 mmHg with a heart rate of 130 beats per minute in sinus rhythm. A chest X-ray (CXR) reveals consolidation in the right lower lobe, and her blood tests show bilirubin levels of 120 µmol/litre and ALP levels of 300 IU/litre. She also experiences tenderness in the right upper quadrant.

      What additional investigation would you perform to confirm the diagnosis?

      Your Answer: Blood cultures

      Correct Answer: Ultrasound scan abdomen

      Explanation:

      Diagnostic Tests for Suspected Biliary Problem in a Patient with Pneumonia

      When a patient presents with symptoms of pneumonia, it is important to consider other potential underlying conditions. In this case, the patient’s blood tests suggest the possibility of cholecystitis or cholangitis, indicating a potential biliary problem. To confirm or exclude this diagnosis, an ultrasound scan of the abdomen is necessary. If the ultrasound rules out a biliary problem, the pneumonia remains the primary concern. A CT scan of the chest is not necessary at this point since the pneumonia has already been diagnosed. Blood cultures and sputum samples can help identify the organism causing the infection, but they do not confirm the overall diagnosis. Additionally, serum haptoglobin is not a reliable test for confirming haemolysis caused by mycoplasma pneumonia. Overall, a thorough diagnostic approach is necessary to accurately identify and treat the underlying condition in a patient with suspected pneumonia and potential biliary problems.

    • This question is part of the following fields:

      • Gastroenterology
      77.5
      Seconds
  • Question 2 - A 56-year-old diabetic woman presents with malaise to her general practitioner (GP). Her...

    Incorrect

    • A 56-year-old diabetic woman presents with malaise to her general practitioner (GP). Her GP takes liver function tests (LFTs): bilirubin 41 μmol/l, AST 46 iu/l, ALT 56 iu/l, GGT 241 iu/l, ALP 198 iu/l. On examination, her abdomen is soft and non-tender, and there are no palpable masses or organomegaly. What is the next best investigation?

      Your Answer: Endoscopic retrograde cholangiopancreatography (ERCP)

      Correct Answer: Ultrasound scan of the abdomen

      Explanation:

      Investigations for Obstructive Jaundice

      Obstructive jaundice can be caused by various conditions, including gallstones, pancreatic cancer, and autoimmune liver diseases like PSC or PBC. An obstructive/cholestatic picture is indicated by raised ALP and GGT levels compared to AST or ALT. The first-line investigation for obstruction is an ultrasound of the abdomen, which is cheap, simple, non-invasive, and readily available. It can detect intra- or extrahepatic duct dilation, liver size, shape, consistency, gallstones, and neoplasia in the pancreas. An autoantibody screen may help narrow down potential diagnoses, but an ultrasound provides more information. A CT scan may be requested after ultrasound to provide a more detailed anatomical picture. ERCP is a diagnostic and therapeutic procedure for biliary obstruction, but it has complications and risks associated with sedation. The PABA test is used to diagnose pancreatic insufficiency, which can cause weight loss, steatorrhoea, or diabetes mellitus.

      Investigating Obstructive Jaundice

    • This question is part of the following fields:

      • Gastroenterology
      70.2
      Seconds
  • Question 3 - A 32-year-old woman presents to the Emergency Department with severe epigastric pain and...

    Incorrect

    • A 32-year-old woman presents to the Emergency Department with severe epigastric pain and vomiting. The pain radiates through to her back and began 2 hours ago while she was out with her friends in a restaurant. She has a past medical history of gallstones and asthma.
      Which test should be used to confirm this woman’s diagnosis?

      Your Answer: Blood glucose

      Correct Answer: Serum lipase

      Explanation:

      Diagnostic Tests for Acute Pancreatitis

      Acute pancreatitis is a condition that is commonly caused by gallstones and alcohol consumption. Its symptoms include upper abdominal pain, nausea, and vomiting. While serum amylase is widely used for diagnosis, serum lipase is preferred where available. Serum lactate is a useful marker for organ perfusion and can indicate the severity of the inflammatory response. A raised white cell count, particularly neutrophilia, is associated with a poorer prognosis. Serum calcium levels may also be affected, but this is not a specific test for pancreatitis. Blood glucose levels may be abnormal, with hyperglycemia being common, but this is not diagnostic of acute pancreatitis.

    • This question is part of the following fields:

      • Gastroenterology
      63
      Seconds
  • Question 4 - A 86-year-old patient arrives at the Emergency Department complaining of epigastric pain and...

    Incorrect

    • A 86-year-old patient arrives at the Emergency Department complaining of epigastric pain and difficulty breathing. Upon examination, there is decreased airflow in the left base. A chest X-ray shows an air-fluid level located behind the mediastinum. What is the probable diagnosis?

      Your Answer: Early cholangitis

      Correct Answer: Diaphragmatic hiatal hernia

      Explanation:

      Diaphragmatic Hiatal Hernia

      Diaphragmatic hiatal hernia is a condition where the fundus or gastro-oesophageal junction of the stomach herniates upwards in the chest due to an abnormal defect in the diaphragm. A chest X-ray may reveal gastric air and fluid behind the mediastinum, and reduced air entry at the lung bases due to compression of the lung lobes. Immediate management involves stabilizing the patient with ABCDE and seeking an urgent surgical review for a possible Nissen fundoplication.

      Other conditions such as early cholangitis, aspiration pneumonia of the left lower lobe of the lung, ruptured left ventricle, or ruptured right ventricle may present with different symptoms and would not cause the air and fluid level behind the mediastinum seen in diaphragmatic hiatal hernia.

    • This question is part of the following fields:

      • Gastroenterology
      88
      Seconds
  • Question 5 - A 70-year-old man presents to his general practitioner (GP) with complaints of difficulty...

    Incorrect

    • A 70-year-old man presents to his general practitioner (GP) with complaints of difficulty swallowing. He mentions that solid food like meat often gets stuck in his throat. He is also beginning to lose weight and have difficulty swallowing thick liquids like soups. There is some pain on swallowing. His past medical history is significant for hypertension and depression. His current medications include amlodipine and sertraline. He has no drug allergies. He has a 30-pack-year history of smoking and drinks approximately 3–4 pints of beer per day. He is unsure of his family medical history, as he was adopted.
      Physical examination is normal, and his observations are shown below:
      Temperature 37.1°C
      Blood pressure 145/81 mmHg
      Heart rate 71 bpm
      Respiratory rate 14 breaths/min
      Oxygen saturation (SpO2) 97% (room air)
      Which of the following is the most appropriate investigation for this patient?

      Your Answer: Oesophageal manometry

      Correct Answer: Upper gastrointestinal (GI) endoscopy

      Explanation:

      Diagnostic Tests for Oesophageal Pathology: Indications and Limitations

      Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test for patients with progressive dysphagia and odynophagia, especially those with risk factors for oesophageal malignancy. Abdominal plain film and ultrasound are rarely diagnostic and should be used sparingly, with specific indications such as inflammatory bowel disease or bowel obstruction. Chest plain film may be useful in detecting free gas in the mediastinum, but is not necessary for stable patients. Oesophageal manometry is indicated for diffuse oesophageal spasm, which presents differently from the progressive dysphagia seen in the patient described above.

    • This question is part of the following fields:

      • Gastroenterology
      96
      Seconds
  • Question 6 - A 56-year-old woman presents with abnormal liver function tests and symptoms of fatigue...

    Incorrect

    • A 56-year-old woman presents with abnormal liver function tests and symptoms of fatigue and itching for the past three months. She reports drinking 5 units of alcohol per week and denies any intravenous recreational drug use. She has no significant medical history and has a body mass index of 24 kg/m2. On examination, she has hepatomegaly but no jaundice. Ultrasound of the liver is normal. Laboratory investigations reveal a serum albumin of 38 g/L, serum alanine aminotransferase of 40 U/L, serum alkaline phosphatase of 286 U/L, and serum total bilirubin of 27 μmol/L. What is the most likely diagnosis?

      Your Answer: Primary sclerosing cholangitis

      Correct Answer: Primary biliary cirrhosis

      Explanation:

      Primary Biliary Cirrhosis: A Breakdown of Immune Tolerance

      Primary biliary cirrhosis (PBC) is an autoimmune condition that affects middle-aged women. It is characterized by the breakdown of immune tolerance to mitochondrial antigens, leading to T cell-mediated destruction of the intrahepatic bile ducts. This process results in ductopenia, bile duct injury, and cholestasis, which eventually lead to liver injury and fibrosis, culminating in the development of cirrhosis.

      Most patients with PBC are asymptomatic at diagnosis, but eventually develop symptoms such as itching and fatigue. Antimitochondrial antibodies (AMAs) are found in 95% of patients with PBC, making it a useful diagnostic marker.

      While primary sclerosing cholangitis (PSC) is a possibility, it is more common in men and is usually accompanied by evidence of strictures or dilation on abdominal ultrasound scan. PSC also has a strong association with inflammatory bowel disease colitis. Alcoholic liver disease and autoimmune hepatitis are unlikely diagnoses in this case, as there is no history of excess alcohol consumption and the transaminitis (raised ALT and/or AST) commonly seen in autoimmune hepatitis is not present.

      On the other hand, non-alcoholic fatty liver disease (NAFLD) is more likely to be seen in overweight or obese individuals with other metabolic risk factors such as diabetes mellitus and hyperlipidaemia. It is often incidentally detected through abnormal liver function tests in asymptomatic individuals.

    • This question is part of the following fields:

      • Gastroenterology
      22.2
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  • Question 7 - A 45-year-old man with dyspepsia and a history of recurrent peptic ulcer disease...

    Incorrect

    • A 45-year-old man with dyspepsia and a history of recurrent peptic ulcer disease presents with intractable watery diarrhoea and weight loss. He has multiple gastric and duodenal peptic ulcers, which are poorly responding to medications such as antacids and omeprazole. Gastric acid output and serum gastrin level are elevated. Serum gastrin level fails to decrease following a test meal. On abdominal computerised tomography (CT) scan, no masses are found in the pancreas or duodenum.
      Which one of the following drugs is useful for this patient?

      Your Answer: Leuprolide

      Correct Answer: Octreotide

      Explanation:

      Treatment Options for Gastrinoma: Octreotide, Somatostatin Antagonist, Bromocriptine, Pergolide, and Leuprolide

      Gastrinoma is a rare condition characterized by multiple, recurrent, and refractory peptic ulcer disease, along with watery diarrhea and weight loss. The diagnosis is supported by an elevated serum gastrin level that is not suppressed by the test meal. While neoplastic masses of gastrinoma may or may not be localized by abdominal imaging, treatment options are available.

      Octreotide, a synthetic somatostatin, is useful in the treatment of gastrinoma, acromegaly, carcinoid tumor, and glucagonoma. Somatostatin is an inhibitory hormone in several endocrine systems, and a somatostatin antagonist would increase gastrin, growth hormone, and glucagon secretion. However, it has no role in the treatment of gastrinoma.

      Bromocriptine, a dopamine agonist, is used in the treatment of Parkinson’s disease, hyperprolactinemia, and pituitary tumors. Pergolide, another dopamine receptor agonist, was formerly used in the treatment of Parkinson’s disease but is no longer administered due to its association with valvular heart disease. Neither medication has a role in the treatment of gastrinoma.

      Leuprolide, a gonadotropin-releasing hormone (GnRH) receptor agonist, is used in the treatment of sex hormone-sensitive tumors such as prostate or breast cancer. It also has no role in the treatment of gastrinoma. Overall, octreotide remains the primary treatment option for gastrinoma.

    • This question is part of the following fields:

      • Gastroenterology
      9.4
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  • Question 8 - A 60-year-old woman presents to the Emergency Department with a sudden onset of...

    Incorrect

    • A 60-year-old woman presents to the Emergency Department with a sudden onset of severe abdominal pain. She suffers with osteoarthritis in both her knees and often takes codeine and ibuprofen. She admits that she often consumes an excessive amount of alcohol. On examination, she appears unwell and is tachycardic. Abdominal examination reveals diffuse tenderness with guarding and reduced bowel sounds. The computerised tomography (CT) scan of her abdomen is shown below.
      Which of the following is the most likely diagnosis, given the clinical scenario?

      Your Answer: Acute cholecystitis

      Correct Answer: Perforated peptic ulcer

      Explanation:

      Differential Diagnosis for Acute Abdominal Pain: Perforated Peptic Ulcer vs Other Conditions

      Acute abdominal pain is a common presentation in medical practice, and it can be caused by a variety of conditions. One of the most likely diagnoses in a patient with sudden onset of severe abdominal pain, diffuse tenderness, and guarding is a perforated peptic ulcer. This is especially true if the patient has a history of regular ibuprofen use and excess alcohol consumption without gastric protection. However, it is important to consider other potential causes of acute abdominal pain and rule them out through a thorough differential diagnosis.

      Some of the other conditions that may present with acute abdominal pain include acute appendicitis, gastritis, acute cholecystitis, and small bowel obstruction with strangulation. Each of these conditions has its own characteristic symptoms and signs that can help differentiate it from a perforated peptic ulcer. For example, acute appendicitis typically presents with a gradual onset of dull umbilical pain that shifts to the right iliac fossa, while acute cholecystitis presents with right upper quadrant pain and Murphy’s sign. Gastritis may cause severe pain, but the abdomen is usually soft, and bowel sounds are not reduced. Small bowel obstruction typically presents with colicky pain, vomiting, and distension, and may be associated with a history of abdominal surgery or hernias.

      In summary, while a perforated peptic ulcer is a likely diagnosis in a patient with sudden onset of severe abdominal pain, it is important to consider other potential causes and perform a thorough differential diagnosis to ensure appropriate management.

    • This question is part of the following fields:

      • Gastroenterology
      10.3
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  • Question 9 - An 80-year-old woman presents with a history of melaena on three separate occasions...

    Incorrect

    • An 80-year-old woman presents with a history of melaena on three separate occasions in the past three years. She reports having had many tests, including barium enemas, flexible sigmoidoscopies, and oesophagogastroduodenoscopies, which were all normal.

      One year ago she required two units of blood to raise her haematocrit from 24% to 30%. She has been taking iron, 300 mg orally BD, since then.

      The patient has hypertension, coronary artery disease, and heart failure treated with digoxin, enalapril, furosemide, and metoprolol. She does not have chest pain or dyspnoea.

      Her body mass index is 32, her pulse is 88 per minute, and blood pressure is 120/80 mm Hg supine and 118/82 mm Hg standing. The conjunctivae are pale. A ventricular gallop is heard. There are bruits over both femoral arteries.

      Rectal examination reveals dark brown stool that is positive for occult blood. Other findings of the physical examination are normal.

      Barium enema shows a few diverticula scattered throughout the descending and transverse colon.

      Colonoscopy shows angiodysplasia of the caecum but no bleeding is seen.

      Technetium (99mTc) red cell scan of the colon is negative.

      Haemoglobin is 105 g/L (115-165) and her haematocrit is 30% (36-47).

      What would be the most appropriate course of action at this time?

      Your Answer: Mesenteric angiography

      Correct Answer: Continued observation

      Explanation:

      Angiodysplasia

      Angiodysplasia is a condition where previously healthy blood vessels degenerate, commonly found in the caecum and proximal ascending colon. The majority of angiodysplasias, around 77%, are located in these areas. Symptoms of angiodysplasia include maroon-coloured stool, melaena, haematochezia, and haematemesis. Bleeding is usually low-grade, but in some cases, around 15%, it can be massive. However, bleeding stops spontaneously in over 90% of cases.

      Radionuclide scanning using technetium Tc99 labelled red blood cells can help detect and locate active bleeding from angiodysplasia, even at low rates of 0.1 ml/min. However, the intermittent nature of bleeding in angiodysplasia limits the usefulness of this method. For patients who are haemodynamically stable, a conservative approach is recommended as most bleeding angiodysplasias will stop on their own. Treatment is usually not necessary for asymptomatic patients who incidentally discover they have angiodysplasias.

      Overall, angiodysplasia and its symptoms is important for early detection and management.

    • This question is part of the following fields:

      • Gastroenterology
      3.1
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  • Question 10 - A 30-year-old woman presents with intermittent, crampy abdominal pain over the past three...

    Incorrect

    • A 30-year-old woman presents with intermittent, crampy abdominal pain over the past three months. She has noted frequent loose stools containing blood and mucous. She has also had a recent unintentional weight loss of 15 pounds. Past medical history of note includes treatment for a perianal fistula and anal fissures. The patient is investigated with imaging studies and endoscopy; histological examination of the intestinal biopsy specimens confirms a diagnosis of Crohn’s disease.
      Antibodies to which of the following organisms is most likely to be found in this patient’s serum?

      Your Answer: Giardia lamblia

      Correct Answer: Saccharomyces cerevisiae

      Explanation:

      Comparison of Microorganisms and Antibodies Associated with Crohn’s Disease

      Crohn’s disease is a chronic inflammatory bowel disease that can be difficult to diagnose. However, the presence of certain microorganisms and antibodies can aid in the diagnosis and classification of the disease.

      One such microorganism is Saccharomyces cerevisiae, a yeast that can trigger the formation of anti-Saccharomyces cerevisiae antibodies (ASCA’s) in some Crohn’s disease patients. On the other hand, perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are associated with ulcerative colitis.

      Yersinia enterocolitica is another microorganism that can mimic the symptoms of Crohn’s disease, particularly in the distal ileum. However, the presence of perianal fistula, anal fissure, and intermittent abdominal pain is more consistent with Crohn’s disease, which is often associated with ASCA’s.

      Entamoeba histolytica can cause colitis and dysentery, but it is not typically associated with Crohn’s disease. Similarly, Giardia lamblia can cause protracted steatorrhea but is not linked to Crohn’s disease.

      Finally, Cryptosporidium parvum can cause watery diarrhea, but it is not associated with Crohn’s disease or the formation of specific antibodies.

      In summary, the presence of certain microorganisms and antibodies can aid in the diagnosis and classification of Crohn’s disease, but it is important to consider the patient’s symptoms and medical history as well.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - A 42-year-old mechanic visits his GP complaining of intermittent jaundice that has been...

    Correct

    • A 42-year-old mechanic visits his GP complaining of intermittent jaundice that has been occurring for the past 5 months. He has been feeling fatigued lately and occasionally experiences mild itching on his arms. He denies any pain or weight loss. The patient has a history of ulcerative colitis, which was diagnosed 13 years ago and has been managed with mesalazine, anti-diarrhoeals, and steroids. The GP orders liver function tests, which reveal the following results:
      total bilirubin 38 mmol/l
      aspartate aminotransferase (AST) 32 iu/l
      alanine aminotransferase (ALT) 34 iu/l
      alkaline phosphatase 310 u/l.
      What is the most probable diagnosis?

      Your Answer: Primary sclerosing cholangitis (PSC)

      Explanation:

      Differential Diagnosis for Cholestatic Jaundice in a Patient with UC

      Primary sclerosing cholangitis (PSC) is a condition that should be considered in a patient with UC who presents with a raised alkaline phosphatase level. This is because approximately two-thirds of patients with PSC also have coexisting UC, and between 3% and 8% of UC sufferers will develop PSC. Chronic cholecystitis would present with pain, which is not present in this patient, making PSC the more likely diagnosis. Acute cholecystitis would present with right upper quadrant pain and obstructive liver function tests, which are not present in this case. Primary biliary cholangitis is more likely to affect women aged 30-60, and given the patient’s history of UC, PSC is more likely. Pancreatic carcinoma would be associated with weight loss and obstructive liver function tests. Therefore, in a patient with UC presenting with cholestatic jaundice, PSC should be considered as a possible diagnosis.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - A 26-year old woman has been asked to come in for a consultation...

    Incorrect

    • A 26-year old woman has been asked to come in for a consultation at her GP's office after her blood test results showed an elevated level of anti-tissue transglutaminase antibody. What condition is linked to this antibody?

      Your Answer: Systemic lupus erythematosus

      Correct Answer: Coeliac disease

      Explanation:

      Autoimmune Diseases: Causes and Symptoms

      Autoimmune diseases are conditions where the body’s immune system attacks its own tissues and organs. Here are some examples of autoimmune diseases and their causes and symptoms:

      Coeliac Disease
      Coeliac disease is caused by an autoimmune reaction to gluten, a protein found in wheat. Symptoms include chronic diarrhoea, weight loss, and fatigue.

      Graves’ Disease
      This autoimmune disease affects the thyroid gland, resulting in hyperthyroidism. It is associated with anti-thyroid-stimulating hormone (TSH) receptor antibodies.

      Pemphigus Vulgaris
      This rare autoimmune disease causes blistering of the skin and mucosal surfaces due to autoantibodies against desmoglein.

      Systemic Lupus Erythematosus
      This multisystem autoimmune disease is associated with a wide range of autoantibodies, including anti-nuclear antibody (ANA) and anti-double-stranded (ds) DNA. Symptoms can include joint pain, fatigue, and skin rashes.

      Type 1 Diabetes Mellitus
      This autoimmune disease results in the destruction of islet cells in the pancreas. Islet cell autoantibodies and antibodies to insulin have been described as causes. Symptoms include increased thirst and urination, weight loss, and fatigue.

      In summary, autoimmune diseases can affect various organs and tissues in the body, and their symptoms can range from mild to severe. Understanding their causes and symptoms is crucial for early diagnosis and effective treatment.

    • This question is part of the following fields:

      • Gastroenterology
      82.8
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  • Question 13 - A 25-year-old man presents with bilateral tremor of his hands and abdominal pain....

    Incorrect

    • A 25-year-old man presents with bilateral tremor of his hands and abdominal pain. He is a recent graduate of engineering from the local university, and has been having increasing difficulty using tools. The abdominal pain has been constant over the last 3 weeks. Over the last 8 months his family have noticed a significant change in his behaviour, with several episodes of depression interspersed with episodes of excessive drinking – both of which are very unusual for him. On examination he has resting tremor bilateral, is slightly hypertonic and has bradykinesia. The examining physician has noted brownish iris of both eyes. The patient has not noticed any change in his colouring. His liver function tests are as follows:
      serum bilirubin: 18.9 µmol/l (normal 3–17 µmol/l)
      serum ALT: 176 IU/l (normal 3–40 IU/l)
      serum AST: 254 IU/l (normal 3–30 IU/l)
      serum ALP: 259 µmol/l (normal 30–100 µmol/l)
      γ-glutamyl transferase (GT): 49 IU/l (normal 8–60 IU/l).
      What is the most likely diagnosis?

      Your Answer: Atypical depression

      Correct Answer: Wilson’s disease

      Explanation:

      Medical Conditions and Their Differential Diagnosis

      When presented with a patient exhibiting certain symptoms, it is important for medical professionals to consider a range of potential conditions in order to make an accurate diagnosis. In this case, the patient is exhibiting neurological symptoms and behavioural changes, as well as deranged liver function.

      One potential condition to consider is Wilson’s disease, which results from a mutation of copper transportation and can lead to copper accumulation in the liver and other organs. Another possibility is early onset Parkinson’s disease, which tends to occur in those aged 40-50 and does not present with liver dysfunction or behavioural changes.

      Hereditary haemochromatosis is another inherited disorder that can result in abnormal iron metabolism, while alpha-1 antitrypsin deficiency can lead to hepatitis and lung changes. However, neither of these conditions would explain the neurological symptoms and behavioural changes seen in this case.

      Finally, atypical depression is unlikely to result in deranged liver function or focal neurological symptoms. By considering these potential conditions and ruling out those that do not fit the patient’s presentation, medical professionals can arrive at a more accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Gastroenterology
      107.3
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  • Question 14 - A 28-year-old male returns from a backpacking trip in Eastern Europe with symptoms...

    Incorrect

    • A 28-year-old male returns from a backpacking trip in Eastern Europe with symptoms of diarrhea. He has been experiencing profuse watery diarrhea and colicky abdominal pain for the past week. He has been going to the toilet approximately 10 times a day and occasionally feels nauseated, but has not vomited. He has lost around 5 kg in weight due to this illness. On examination, he has a temperature of 37.7°C and appears slightly dehydrated. There is some slight tenderness on abdominal examination, but no specific abnormalities are detected. PR examination reveals watery, brown feces. What investigation would be the most appropriate for this patient?

      Your Answer: Blood culture

      Correct Answer: Stool microscopy and culture

      Explanation:

      Diagnosis and Treatment of Giardiasis in Traveller’s Diarrhoea

      Traveller’s diarrhoea is a common condition that can occur when travelling to different parts of the world. In this case, the patient is likely suffering from giardiasis, which is caused by a parasite that can be found in contaminated water or food. The best way to diagnose giardiasis is through microscopic examination of the faeces, where cysts may be seen. However, in some cases, chronic disease may occur, and cysts may not be found in the faeces. In such cases, a duodenal aspirate or biopsy may be required to confirm the diagnosis.

      The treatment for giardiasis is metronidazole, which is an antibiotic that is effective against the parasite.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 15 - A middle-aged woman presented to her General Practitioner (GP) with a 3-month history...

    Correct

    • A middle-aged woman presented to her General Practitioner (GP) with a 3-month history of epigastric pain and weight loss. She mentions that she tried over-the-counter antacids which provided some relief initially, but the pain has got worse. She decided to see her GP after realising she had lost about 5 kg. She denies any vomiting or loose stools. She has never had problems with her stomach before and she has no significant family history. Endoscopy and biopsy are performed; histology shows active inflammation.
      What is the most likely diagnosis?

      Your Answer: Helicobacter pylori gastritis

      Explanation:

      Helicobacter pylori gastritis is a common condition that can cause gastritis and peptic ulcers in some individuals. It is caused by a Gram-negative bacterium and can increase the risk of gastric adenocarcinoma. Treatment with antibiotics is necessary to eradicate the infection. Invasive carcinoma is unlikely in this patient as they do not have other symptoms associated with it. A duodenal ulcer is possible but not confirmed by the upper GI endoscopy. Crohn’s disease is unlikely as it presents with different symptoms. A gastrointestinal stromal tumour would have been detected during the endoscopy.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 23-year-old woman developed sudden-onset, severe epigastric pain 12 hours ago. She subsequently...

    Incorrect

    • A 23-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. The pain now feels more generalised, and even slight movement makes it worse. She has diminished bowel sounds and exquisite tenderness in the mid-epigastrium with rebound tenderness and board-like rigidity. Her pulse is 110 bpm and blood pressure 130/75. She reports taking ibuprofen for dysmenorrhoea. She had last taken ibuprofen the day before the pain began.
      What is the most likely diagnosis?

      Your Answer: Acute gastritis

      Correct Answer: Perforated peptic ulcer

      Explanation:

      Differential Diagnosis for Abdominal Pain: Perforated Peptic Ulcer

      Abdominal pain can have various causes, and it is important to consider the differential diagnosis to determine the appropriate treatment. In this case, the patient’s use of non-steroidal anti-inflammatory drugs (NSAIDs) suggests a possible perforated peptic ulcer as the cause of her symptoms.

      Perforated peptic ulcer is a serious complication of peptic ulcer disease that can result from the use of NSAIDs. The patient’s symptoms, including increasing generalised abdominal pain that is worse on moving, rebound tenderness, and board-like rigidity, are classic signs of generalised peritonitis. These symptoms suggest urgent surgical review and definitive surgical management.

      Other possible causes of abdominal pain, such as acute gastritis, acute pancreatitis, appendicitis, and cholecystitis, have been considered but are less likely based on the patient’s symptoms. It is important to consider the differential diagnosis carefully to ensure appropriate treatment and avoid potential complications.

    • This question is part of the following fields:

      • Gastroenterology
      8
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  • Question 17 - A 76-year-old woman comes to the Emergency Department complaining of worsening epigastric pain...

    Incorrect

    • A 76-year-old woman comes to the Emergency Department complaining of worsening epigastric pain over the past two weeks. She describes a deep pain in the central part of her abdomen that tends to improve after eating and worsens approximately two hours after the meal. The pain does not radiate. The patient has a medical history of rheumatoid arthritis and takes methotrexate and anti-inflammatory medications. She is also a heavy smoker. Her vital signs are within normal limits. On examination, there is tenderness in the epigastric region without guarding or rigidity. Bowel sounds are present. What is the most likely diagnosis for this patient?

      Your Answer: Appendicitis

      Correct Answer: Peptic ulcer disease (PUD)

      Explanation:

      Differential Diagnosis for Epigastric Pain: Peptic Ulcer Disease, Appendicitis, Chronic Mesenteric Ischaemia, Diverticulitis, and Pancreatitis

      Epigastric pain can be caused by various conditions, and it is important to consider the differential diagnosis to provide appropriate treatment. In this case, the patient’s risk factors for non-steroidal anti-inflammatory use and heavy smoking make peptic ulcer disease (PUD) in the duodenum the most likely diagnosis. Other potential causes of epigastric pain include appendicitis, chronic mesenteric ischaemia, diverticulitis, and pancreatitis. However, the patient’s symptoms and clinical signs do not align with these conditions. It is important to consider the patient’s medical history and risk factors when determining the most likely diagnosis and appropriate treatment plan.

    • This question is part of the following fields:

      • Gastroenterology
      62.4
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  • Question 18 - A 55-year-old obese woman, who recently returned from a trip to Japan, presents...

    Incorrect

    • A 55-year-old obese woman, who recently returned from a trip to Japan, presents with chronic diarrhoea, fatigue, and greasy, bulky stools. She is a non-smoker and non-drinker who consumes meat. Stool examination confirms steatorrhoea, and blood tests reveal elevated folic acid levels and reduced vitamin B12 levels. The only abnormal finding on a CT scan of the abdomen is multiple diverticula in the jejunum. What is the most likely cause of this patient's macrocytic anaemia?

      Your Answer: Dietary deficiency of vitamin B12

      Correct Answer: Increased utilisation of vitamin B12 by bacteria

      Explanation:

      Causes of Vitamin B12 Deficiency: An Overview

      Vitamin B12 deficiency can be caused by various factors, including bacterial overgrowth syndrome, acquired deficiency of intrinsic factor, chronic pancreatic insufficiency, dietary deficiency, and fish tapeworm infestation.

      Bacterial Overgrowth Syndrome: This disorder is characterized by the proliferation of colonic bacteria in the small bowel, resulting in diarrhea, steatorrhea, and macrocytic anemia. The bacteria involved are usually Escherichia coli or Bacteroides, which can convert conjugated bile acids to unconjugated bile acids, leading to impaired micelle formation and steatorrhea. The bacteria also utilize vitamin B12, causing macrocytic anemia.

      Acquired Deficiency of Intrinsic Factor: This condition is seen in pernicious anemia, which does not have diarrhea or steatorrhea.

      Chronic Pancreatic Insufficiency: This is most commonly associated with chronic pancreatitis caused by high alcohol intake or cystic fibrosis. However, in this case, the patient has no history of alcohol intake or CF, and blood tests do not reveal hyperglycemia. CT abdomen can detect calcification of the pancreas, characteristic of chronic pancreatitis.

      Dietary Deficiency of Vitamin B12: This is unlikely in non-vegetarians like the patient in this case.

      Fish Tapeworm Infestation: This infestation can cause vitamin B12 deficiency, but it is more common in countries where people commonly eat raw freshwater fish. In this case, the presence of diarrhea, steatorrhea, and CT abdomen findings suggestive of jejunal diverticula make bacterial overgrowth syndrome more likely.

      In conclusion, vitamin B12 deficiency can have various causes, and a thorough evaluation is necessary to determine the underlying condition.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 19 - A 28-year-old woman presents with complaints of intermittent abdominal distension and bloating. She...

    Incorrect

    • A 28-year-old woman presents with complaints of intermittent abdominal distension and bloating. She experiences bouts of loose motions that provide relief from the symptoms. There is no history of rectal bleeding or weight loss. The patient works as a manager in a busy office and finds work to be stressful. She has previously taken a course of fluoxetine for depression/anxiety. Abdominal examination is unremarkable.
      What is the probable diagnosis?

      Your Answer: Ulcerative colitis

      Correct Answer: Irritable bowel syndrome (IBS)

      Explanation:

      IBS is a chronic condition that affects bowel function, but its cause is unknown. To diagnose IBS, patients must have experienced abdominal pain or discomfort for at least 3 months, along with two or more of the following symptoms: relief after defecation, changes in stool frequency or appearance, and abdominal bloating. Other symptoms may include altered stool passage, mucorrhoea, and headaches. Blood tests are recommended to rule out other conditions, and further investigation is not necessary unless symptoms of organic disease are present. Diverticulitis, anxiety disorder, Crohn’s disease, and ulcerative colitis are all conditions that can be ruled out based on the absence of certain symptoms.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 20 - A 70-year-old man presents to his GP with a complaint of difficulty swallowing...

    Incorrect

    • A 70-year-old man presents to his GP with a complaint of difficulty swallowing that has been occurring for the past four weeks. He reports that solid foods are particularly problematic and feel as though they are getting stuck. The patient has a medical history of hypertension and osteoarthritis of the knees, for which he takes amlodipine 5 mg OD and paracetamol 1 g as required respectively. He has a 20-pack year smoking history but does not consume alcohol. On examination, the patient appears well at rest and has a normal body habitus. Abdominal examination is largely unremarkable, except for some mild epigastric discomfort. What is the most appropriate next step in management?

      Your Answer: Acute specialist care of the elderly clinic referral

      Correct Answer: Refer to gastroenterology for OGD (oesophago-gastro-duodenoscopy) under the 2-week wait criteria

      Explanation:

      Recognizing Red Flags for Oesophageal Cancer: Referring for OGD under the 2-Week Wait Criteria

      When a patient presents with subacute and first-onset dysphagia limited to solids, it suggests a new mass obstructing the oesophagus. This symptom is a red flag for oesophageal cancer, and a 2-week wait referral for OGD is necessary to prevent a delay in diagnosis. If abnormal tissue is found during the OGD, biopsies will be taken for histological analysis to confirm the diagnosis.

      PPI therapy and review in a month is not appropriate for dysphagia, as it may delay a potential cancer diagnosis. Emergency hospital admission is unnecessary, as the patient is not acutely unstable. Routine outpatient gastrointestinal appointment is appropriate, but it must be performed within two weeks in accordance with the UK’s referral guidelines for potential cancer diagnoses. Acute specialist care of the elderly clinic referral is not necessary, as the patient’s age alone does not indicate a need for geriatric care.

      It is important to explain to the patient that while cancer is a possibility, there may be other explanations as well. Encouraging a step-by-step approach and informing the patient that the specialist who conducts the OGD will explain things in more detail when consenting them for the procedure is appropriate. The full criteria for a 2-week wait referral for OGD includes new-onset dysphagia at any age, and additional criteria for patients over 55 years old with weight loss, epigastric abdominal pain, dyspepsia, reflux, or a history of Barrett’s oesophagus.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 21 - A 50-year-old male patient presents with dyspepsia of 4 weeks’ duration. Other than...

    Correct

    • A 50-year-old male patient presents with dyspepsia of 4 weeks’ duration. Other than a 15-pack year history of smoking, he has no other medical history and reports no prescribed or over-the-counter medications. Endoscopy reveals features of gastritis and a solitary gastric ulcer in the pyloric antrum. A rapid urease test turned red, revealing a positive result.
      What would be a suitable treatment for this patient?

      Your Answer: Amoxicillin, clarithromycin and omeprazole

      Explanation:

      Diagnosis and Treatment of Helicobacter pylori Infection

      Helicobacter pylori is a Gram-negative bacillus that causes chronic gastritis and can lead to ulceration if left untreated. Diagnosis of H. pylori infection can be done through a rapid urease test, which detects the presence of the enzyme urease produced by the bacterium. Treatment for H. pylori infection involves a 7-day course of two antibiotics and a proton pump inhibitor (PPI). Fluconazole, prednisolone and azathioprine, and quinine and clindamycin are not appropriate treatments for H. pylori infection. Combination drug therapy is common to reduce the risk of resistance in chronic infections. Repeat testing should be done after treatment to ensure clearance of the infection.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 22 - A 32-year-old man presents with upper abdominal pain and is diagnosed with Helicobacter...

    Correct

    • A 32-year-old man presents with upper abdominal pain and is diagnosed with Helicobacter pylori infection. He is treated with appropriate eradication therapy and advised to follow up with his general practitioner for testing of eradication.
      What would be the most suitable method for testing eradication in this patient?

      Your Answer: The 13C urea breath test

      Explanation:

      Methods for Detecting and Confirming Eradication of H. pylori Infection

      There are several methods available for detecting and confirming eradication of H. pylori infection. Serologic testing for antibodies to H. pylori in the blood or saliva is a cheap and simple initial detection method with high sensitivity and specificity. However, it is not useful for follow-up as patients may continue to have antibodies for several months after eradication therapy. Stool sample analysis may also be used for initial detection, but the 13C urea breath test is currently the only recommended method for confirming eradication following treatment. Histological examination of tissue biopsy samples is an invasive procedure and not recommended for eradication testing. The CLO test, which is carried out on biopsied tissue at endoscopy, can provide immediate results but is also an invasive procedure and not appropriate for confirming eradication. Overall, the 13C urea breath test is the most reliable method for confirming eradication of H. pylori infection.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 23 - A 47-year-old man presents to the Hepatology Clinic with mild elevations in levels...

    Incorrect

    • A 47-year-old man presents to the Hepatology Clinic with mild elevations in levels of alkaline phosphatase (ALP) and aminotransferases. He has a history of type 2 diabetes mellitus and obesity, but denies alcohol use and past drug use. On physical examination, he is found to be obese with hepatomegaly. Laboratory studies show negative results for hepatitis and autoimmune liver disease. His aminotransferase, ALP, and autoimmune liver results are provided. What is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Weight loss

      Explanation:

      Understanding Non-Alcoholic Fatty Liver Disease and Treatment Options

      Non-Alcoholic Fatty Liver Disease (NAFLD) is a condition characterized by hepatic steatosis in the absence of alcohol or drug misuse. Patients with NAFLD often have other metabolic conditions such as obesity, hypertension, and dyslipidemia. Diagnosis involves ruling out other causes of hepatomegaly and demonstrating hepatic steatosis through liver biopsy or radiology. Conservative management with weight loss and control of cardiovascular risk factors is the mainstay of treatment, as there are currently no recommended medications for NAFLD.

      Azathioprine is an immunosuppressive medication used in the management of autoimmune hepatitis. Before starting a patient on azathioprine, TPMT activity should be tested for, as those with low TPMT activity have an increased risk of azathioprine-induced myelosuppression. Liver transplant is indicated for patients with declining hepatic function or liver cirrhosis, which this patient does not have.

      Naltrexone can be used for symptomatic relief of pruritus in patients with primary biliary cholangitis (PBC), but this patient has negative antibodies for autoimmune liver disease. Oral steroids are indicated in patients with autoimmune liver disease, which this patient does not have. Overall, understanding the diagnosis and treatment options for NAFLD is crucial for managing this condition effectively.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 24 - A 33-year-old former intravenous (iv) drug abuser presents to outpatient clinic with abnormal...

    Incorrect

    • A 33-year-old former intravenous (iv) drug abuser presents to outpatient clinic with abnormal liver function tests (LFTs) at the recommendation of his general practitioner. Although he is not experiencing any symptoms, a physical examination reveals hepatomegaly measuring 4 cm. Further blood tests confirm that he is positive for hepatitis C, with a significantly elevated viral load of hepatitis C RNA. What would be the most crucial investigation to determine the appropriate management of his hepatitis C?

      Your Answer:

      Correct Answer: Hepatitis C genotype

      Explanation:

      Hepatitis C Management and Testing

      Hepatitis C is a viral infection that can be acquired through blood or sexual contact, including shared needles during intravenous drug use and contaminated blood products. While some patients may be asymptomatic, the virus can cause progressive damage to the liver and may lead to liver failure requiring transplantation if left untreated.

      Before starting treatment for chronic hepatitis C, it is important to determine the patient’s hepatitis C genotype, as this guides the length and type of treatment and predicts the likelihood of response. Dual therapy with interferon α and ribavirin is traditionally the most effective treatment, but newer oral medications like sofosbuvir, boceprevir, and telaprevir are now used in combination with PEG-interferon and ribavirin for genotype 1 hepatitis C.

      Screening for HIV is also important, as HIV infection often coexists with hepatitis C, but the result does not influence hepatitis C management. An ultrasound of the abdomen can determine the structure of the liver and the presence of cirrhosis, but it does not alter hepatitis C management. A chest X-ray is not necessary in this patient, and ongoing intravenous drug use does not affect hepatitis C management.

      Overall, proper testing and management of hepatitis C can prevent further liver damage and improve patient outcomes.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 25 - A 55-year-old man presents to the Emergency Department after vomiting bright red blood...

    Incorrect

    • A 55-year-old man presents to the Emergency Department after vomiting bright red blood multiple times over the past four hours. He has a history of alcohol abuse and has been diagnosed with spontaneous bacterial peritonitis in the past. He currently consumes 4-5 pints of beer daily and has a poor compliance with his medication regimen, resulting in missed appointments and discharge from outpatient follow-up. On examination, he has dry mucous membranes, palmar erythema, and hepatomegaly. His vital signs are as follows: temperature 36.6°C, blood pressure 113/67 mmHg, respiratory rate 21 breaths per minute, heart rate 100 beats per minute, and SpO2 99% on room air. The patient is resuscitated with aggressive intravenous fluids, and the gastroenterology team is consulted. They suspect bleeding oesophageal varices and perform an upper gastrointestinal endoscopy, which confirms the diagnosis. The varices are banded, and bleeding is significantly reduced.

      Which medication is most likely to prevent further episodes of oesophageal varices in this 55-year-old patient?

      Your Answer:

      Correct Answer: Propranolol

      Explanation:

      Medications for Secondary Prevention of Variceal Hemorrhage

      Variceal hemorrhage is a serious complication of portal hypertension, which can be prevented by using certain medications. Non-selective beta-blockers like nadolol or propranolol are commonly used for secondary prevention of variceal hemorrhage. They work by blocking dilatory tone of the mesenteric arterioles, resulting in unopposed vasoconstriction and therefore a decrease in portal inflow. Selective beta-blockers are not effective in reducing portal hypertension. The dose of the non-selective beta-blocker should be titrated to achieve a resting heart rate of between 55 and 60 beats per minute. Ciprofloxacin is another medication used in prophylaxis of spontaneous bacterial peritonitis in high-risk patients. However, it is not effective in preventing variceal bleeding. Proton-pump inhibitors (PPIs) like omeprazole are used in the treatment of gastric reflux and peptic ulcer disease, but they have little impact on portal hypertension and are not indicated in the prophylaxis of variceal bleeding. Similarly, ranitidine, a histamine-2 receptor antagonist, is not likely to help prevent further episodes of variceal bleeding.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 26 - A 65-year-old man was admitted to hospital for a work-up of a suspected...

    Incorrect

    • A 65-year-old man was admitted to hospital for a work-up of a suspected cholangiocarcinoma. He underwent a magnetic resonance cholangiopancreatography (MRCP). After this, he complains of chills, nausea, vomiting and upper-right abdominal pain. He has also spiked a fever of 38.9 °C.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Liver abscess

      Explanation:

      Differential Diagnosis for a Patient with Abdominal Pain and Infective Symptoms

      A liver abscess is the most probable diagnosis for a patient presenting with fever, abdominal pain, chills, nausea, and vomiting after undergoing an MRCP. Disseminated intravascular coagulation (DIC) is unlikely as the patient does not exhibit characteristic symptoms such as multiorgan failure, shock, widespread bleeding, or clots. Fatty-liver disease could cause similar symptoms but would not have an acute onset or infective symptoms. Hepatitis is a possibility but would typically present with additional symptoms such as dark urine and pale stools. Liver metastases are unlikely to have a sudden onset and infective symptoms. While it is a possibility, a liver abscess is the most likely diagnosis, especially given the patient’s recent MRCP and suspected cholangiocarcinoma.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 27 - A 11-month-old boy is admitted to hospital with an episode of rectal bleeding...

    Incorrect

    • A 11-month-old boy is admitted to hospital with an episode of rectal bleeding - the mother noticed that the child had been difficult to settle in the day, on changing the child's nappy she noted a substance which looked like redcurrant jelly in the nappy contents. A diagnosis of Meckel's diverticulum is suspected.
      With regard to Meckel’s diverticulum, which one of the following statements is correct?

      Your Answer:

      Correct Answer: It may contain ectopic tissue

      Explanation:

      Understanding Meckel’s Diverticulum: A Congenital Abnormality of the Gastrointestinal Tract

      Meckel’s diverticulum is a common congenital abnormality of the gastrointestinal tract that affects around 2-4% of the population. It is an anatomical remnant of the vitello-intestinal duct, which connects the primitive midgut to the yolk sac during fetal development. Meckel’s diverticulum can contain various types of tissue, including gastric mucosa, liver tissue, carcinoid, or lymphoid tissue. It is usually located around 2 feet from the ileocaecal valve and is commonly found adjacent to the vermiform appendix.

      Symptoms of Meckel’s diverticulum can closely mimic appendicitis, and it can be a cause of bowel obstruction, perforation, and gastrointestinal bleeding. Bleeding is the most common cause of clinical presentations, and the presence of gastric mucosa is important as it can ulcerate and cause bleeding. If a normal-looking appendix is found during laparoscopy, it is important to exclude Meckel’s diverticulum as a potential cause of the patient’s symptoms. The mortality rate in untreated cases is estimated to be 2.5-15%.

      Advances in imaging have made it easier to detect Meckel’s diverticulum. It can be picked up on barium imaging, computed tomography enterography, and radionuclide technetium scanning (Meckel’s scan). Selective mesenteric arteriography may also be useful in patients with negative imaging results.

      In conclusion, understanding Meckel’s diverticulum is important for clinicians as it is a common congenital abnormality that can cause significant morbidity and mortality if left untreated.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 28 - A 35-year-old stockbroker has been experiencing difficulty swallowing solids for the past few...

    Incorrect

    • A 35-year-old stockbroker has been experiencing difficulty swallowing solids for the past few months, while having no trouble swallowing liquids. He does not smoke and denies any alcohol consumption. His medical history is unremarkable except for the fact that he has been using antacids and H2-receptor blockers for gastro-oesophageal reflux disease for the past 5 years, with little relief from symptoms. Upon examination, there are no notable findings.
      What is the probable reason for this man's dysphagia?

      Your Answer:

      Correct Answer: Benign oesophageal stricture

      Explanation:

      Causes of dysphagia: differential diagnosis based on patient history

      Dysphagia, or difficulty swallowing, can have various causes, including structural abnormalities, functional disorders, and neoplastic conditions. Based on the patient’s history, several possibilities can be considered. For example, a benign oesophageal stricture may develop in patients with acid gastro-oesophageal reflux disease and can be treated with endoscopic dilation and reflux management. Diffuse oesophageal spasm, on the other hand, may cause dysphagia for both solids and liquids and be accompanied by chest pain. A lower oesophageal web can produce episodic dysphagia when food gets stuck in the distal oesophagus. Oesophageal squamous carcinoma is less likely in a young non-smoking patient, but should not be ruled out entirely. Scleroderma, a connective tissue disorder, may also cause dysphagia along with Raynaud’s phenomenon and skin changes. Therefore, a thorough evaluation and appropriate diagnostic tests are necessary to determine the underlying cause of dysphagia and guide the treatment plan.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 29 - A 32-year-old man presents for a general check-up. He is well in himself...

    Incorrect

    • A 32-year-old man presents for a general check-up. He is well in himself and reports no symptoms.
      On examination, he has a body mass index (BMI) of 33 kg/m2 and there are some thickened folds of skin in his axilla and the nape of his neck. His blood pressure is 140/90 mmHg. He is a non-smoker and does not drink.
      A set of blood work is ordered. He demonstrated impaired fasting glucose in addition to the results below.
      Investigation Result Normal value
      Haemoglobin (Hb) 140 g/l 135–175 g/l
      Cholesterol 5.8 mmol/l < 5.2 mmol/l
      Triglyceride 3.9 mmol/l 0–1.5 mmol/l
      Alanine aminotransferase (ALT) 60 IU/l 5–30 IU/l
      Aspartate aminotransferase (AST) 30 IU/l 10–40 IU/l
      Gamma-glutamyl transferase (GGT) 30 IU/l 5–30 IU/l
      What is the next best investigation?

      Your Answer:

      Correct Answer: Ultrasound liver

      Explanation:

      Choosing the Best Investigation: A Case Study

      In this case study, a patient presents with non-alcoholic fatty liver disease (NAFLD), raised ALT, impaired glucose regulation, acanthosis nigricans, and a high BMI. The question is, what investigation should be done next?

      Ultrasound liver is the best investigation in this case. It is quick, inexpensive, and can provide enough information to guide management at initial stages. Weight management and dietary modification can help abate symptoms.

      Screening for hereditary haemochromatosis is not appropriate in this case, as the patient does not complain of arthritis, diabetes, or changes to the skin.

      Haematinics are not necessary, as the Hb is normal.

      A CT scan of the abdomen would be useful, but it is costly and would result in the patient receiving radiation. It should not be the next best investigation.

      Serum ceruloplasmin is not necessary, as there is nothing in the history to suggest Wilson’s disease.

      In conclusion, choosing the best investigation requires careful consideration of the patient’s history and symptoms. In this case, ultrasound liver is the most appropriate next step.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 30 - A 49-year-old woman visits her GP complaining of fatigue and wondering if she...

    Incorrect

    • A 49-year-old woman visits her GP complaining of fatigue and wondering if she has entered menopause. Upon conducting a blood test, the results show a Hb of 101 g/l, MCV 108.2 fl, and a B12 level of 46 ng/l. She also reports experiencing occasional changes in bowel movements. What test would be most effective in differentiating pernicious anemia from other malabsorption causes as the reason for her low B12 levels?

      Your Answer:

      Correct Answer: Intrinsic factor antibodies

      Explanation:

      Understanding Pernicious Anaemia: Diagnosis and Treatment

      Pernicious anaemia is a type of macrocytic anaemia caused by a deficiency of vitamin B12. This deficiency is often due to antibodies that target either intrinsic factor or the gastric parietal cells. To diagnose pernicious anaemia, blood tests for intrinsic factor antibodies and gastric parietal cell-antibodies are necessary.

      Other tests, such as the PABA test, folic acid level, serum gastrin level, and C14 breath test, are not useful in identifying pernicious anaemia. Vitamin B12 is normally absorbed in the terminal ileum, but a problem in any part of this chain may result in vitamin B12 deficiency.

      Patients with pernicious anaemia require lifelong vitamin B12 injections, typically six injections over the first two weeks from diagnosis and then one every three months to maintain adequate levels. Understanding the diagnosis and treatment of pernicious anaemia is crucial for managing this condition effectively.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 31 - A 42-year-old man with end-stage liver disease is admitted with a painful, distended...

    Incorrect

    • A 42-year-old man with end-stage liver disease is admitted with a painful, distended abdomen. Examination findings: generalised abdominal tenderness and ascites. Temperature 37.5 °C.
      Which intervention should be undertaken first?

      Your Answer:

      Correct Answer: Diagnostic ascitic tap

      Explanation:

      Management of Ascites: Importance of Prompt Investigation and Treatment of Spontaneous Bacterial Peritonitis

      Ascites is a common complication in patients with end-stage liver disease and poor synthetic function. Spontaneous bacterial peritonitis (SBP) is a serious complication that can occur in these patients, leading to a high mortality rate. Prompt investigation and treatment are crucial in managing ascites and preventing SBP.

      Diagnostic paracentesis tap should be performed promptly in any patient presenting with ascites, regardless of the time of day. A broad-spectrum antibiotic should be given immediately if there is a raised cell count consistent with SBP. Once SBP has been excluded or treated, therapeutic paracentesis may be considered for patients with large, tense, or resistant ascites.

      During a diagnostic tap, various investigations should be performed, including cell count, microscopy, culture and sensitivity, cytology, protein and albumin, lactate dehydrogenase, glucose, and amylase. Additional investigations may be indicated based on the patient’s condition.

      The most common cause of SBP is Escherichia coli, and oral ciprofloxacin or co-amoxiclav are recommended as first-line agents. Intravenous cephalosporins may be used if the patient is unwell. However, a diagnosis of SBP should be confirmed before starting treatment.

      First-line medical management of ascites is spironolactone, which achieves better clinical results than furosemide. Furosemide may be used in conjunction with spironolactone in resistant ascites or where potassium rises due to spironolactone.

      In summary, prompt investigation and treatment of ascites are crucial in managing SBP and preventing complications. A diagnostic paracentesis tap should be performed promptly, and appropriate investigations and treatment should be initiated based on the patient’s condition.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 32 - A 21-year-old student presents to the University Health Service with jaundice. He had...

    Incorrect

    • A 21-year-old student presents to the University Health Service with jaundice. He had been to a party three nights earlier and since then has been laid up in bed with flu-like symptoms. On examination, he has mild jaundice, but otherwise the examination is normal.
      Bloods:
      Investigation Result Normal value
      Bilirubin 62 μmol/l 2–17 µmol/l
      Alanine aminotransferase (ALT) 21 IU/l 5–30 IU/l
      Aspartate aminotransferase (AST) 15 IU/l 10–40 IU/l
      Haemoglobin 131 g/l 135–175 g/l
      White cell count (WCC) 4.2 × 109/l 4–11 × 109/l
      Platelets 320 × 109/l 150–400 × 109/l
      Which of the following is the most likely diagnosis in this case?

      Your Answer:

      Correct Answer: Gilbert's syndrome

      Explanation:

      Understanding Gilbert’s Syndrome and Its Differential Diagnosis

      Gilbert’s syndrome is a genetic condition that affects the conjugation of bilirubin due to a defect in the bilirubin-uridine diphosphate (UDP) glucuronyl transferase enzyme. This results in an isolated rise in bilirubin levels during times of stress, fatigue, or viral illness. A 48-hour fast can confirm the diagnosis if it is unclear. The condition is benign and does not require specific treatment.

      Crigler-Najjar syndrome is another condition that affects UDP glucuronyl transferase, but it presents with jaundice and typically results in death during the neonatal period.

      Cholecystitis causes right upper quadrant abdominal pain and fever but does not typically result in jaundice. Acute ethanol poisoning can lead to alcoholic hepatitis, but the mild jaundice and overall well-being of the patient are more consistent with Gilbert’s syndrome.

      Viral hepatitis can also cause jaundice, but the clinical picture is more in line with Gilbert’s syndrome. Understanding the differential diagnosis is crucial in determining the appropriate treatment and management for patients.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 33 - A 50-year-old man presents with sudden onset of upper abdominal pain and vomiting....

    Incorrect

    • A 50-year-old man presents with sudden onset of upper abdominal pain and vomiting. His vital signs are stable upon triage.
      During the physical examination, he appears to be in significant distress and has a tense abdomen upon palpation.
      What initial test should be performed to confirm a perforation?

      Your Answer:

      Correct Answer: Erect chest X-ray

      Explanation:

      The Importance of an Erect Chest X-Ray in Diagnosing Perforated Abdominal Viscus

      When a patient presents with acute abdominal pain, it is crucial to consider the possibility of a perforated abdominal viscus, which requires immediate surgical intervention. The first-line investigation for this condition is an erect chest X-ray, which can detect the presence of free air under the diaphragm (pneumoperitoneum). To ensure accuracy, the patient should be in a seated position for 10-15 minutes before the X-ray is taken. If the patient cannot sit up due to hypotension, a lateral decubitus abdominal film may be used instead. However, in most cases, a CT scan of the abdomen and pelvis will be requested by the surgical team.

      Other diagnostic methods, such as a urine dipstick, liver function tests, and bedside ultrasound, are not effective in detecting a perforation. While plain abdominal films may show signs of perforation, they are not the preferred method of diagnosis. In cases of perforation, the presence of free abdominal air can make the opposite side of the bowel wall appear clearer, which is known as the Rigler’s signs or the double wall sign.

      In conclusion, an erect chest X-ray is a crucial diagnostic tool in identifying a perforated abdominal viscus. Early detection and intervention can prevent serious complications and improve patient outcomes.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 34 - A 5-year old child has been admitted to the hospital after experiencing fever,...

    Incorrect

    • A 5-year old child has been admitted to the hospital after experiencing fever, feeling unwell, and developing bloody diarrhea for the past two days. What is the probable cause of these symptoms?

      Your Answer:

      Correct Answer: Escherichia coli 0157

      Explanation:

      Causes of Acute Diarrhoea and Haemolytic Uraemic Syndrome

      Enterohaemorrhagic verocytotoxin-producing E coli 0157:H7 is the most probable cause of acute diarrhoea and haemolytic uraemic syndrome. This type of E coli is known to produce toxins that can damage the lining of the intestine and cause bloody diarrhoea. In severe cases, it can lead to haemolytic uraemic syndrome, a condition that affects the kidneys and can cause kidney failure.

      Crohn’s disease is an inflammatory bowel disease that can cause chronic diarrhoea, but it would be unusual for it to present acutely as in this case. Polio and giardiasis are other possible causes of diarrhoea, but they typically present as non-bloody diarrhoea. It is important to identify the underlying cause of acute diarrhoea and haemolytic uraemic syndrome to provide appropriate treatment and prevent complications.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 35 - A 67-year-old man presents with a complaint of passing small amounts of fresh...

    Incorrect

    • A 67-year-old man presents with a complaint of passing small amounts of fresh red blood with his stool. He also reports a small amount of mucous discharge with his stool and feeling pruritic and sore around his anus for the past couple of days. The patient denies any pain but has been more constipated than usual over the past few months. He denies any recent weight loss and has a BMI of approximately 35. The patient has a history of hypercholesterolaemia and chronic obstructive pulmonary disease. He recently completed a 7-day course of amoxicillin for a lower respiratory tract infection 5 days ago. What is the most likely cause of his rectal bleeding?

      Your Answer:

      Correct Answer: Haemorrhoids

      Explanation:

      Differential Diagnosis for Rectal Bleeding: Haemorrhoids, Colon Cancer, Diverticulitis, Anal Fissure, and Ulcerative Colitis

      Rectal bleeding can be a concerning symptom for patients and healthcare providers alike. In this case, the patient has multiple risk factors for haemorrhoids, which are the most likely cause of his symptoms. However, it is important to consider other potential diagnoses, such as colon cancer, diverticulitis, anal fissure, and ulcerative colitis.

      Haemorrhoids are caused by increased pressure in the blood vessels around the anus, which can be exacerbated by obesity, chronic constipation, and coughing. Symptoms include fresh red blood and mucous after passing stool, a pruritic anus, and soreness around the anus.

      Colon cancer is less likely in this case, as it typically presents with a change in bowel habit and blood in the stool, but not with a pruritic, sore anus. However, if there is no evidence of haemorrhoids on examination, colonoscopy may be recommended to rule out cancer.

      Diverticulitis is characterised by passing fresh, red blood per rectum, as well as nausea and vomiting, pyrexia, and abdominal pain.

      Anal fissure also involves the passage of small amounts of fresh red blood with stools, but is associated with sharp anal pain when stools are passed.

      Ulcerative colitis can be associated with passage of blood and mucous with stools, as well as weight loss, diarrhoea, anaemia, and fatigue. The patient has some risk factors for ulcerative colitis, which has two peak ages for diagnosis: 15-35 and 50-70 years old.

      In summary, while haemorrhoids are the most likely cause of this patient’s symptoms, it is important to consider other potential diagnoses and perform appropriate testing to rule out more serious conditions.

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      • Gastroenterology
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  • Question 36 - What is the most likely diagnosis for a 45-year-old woman who has had...

    Incorrect

    • What is the most likely diagnosis for a 45-year-old woman who has had severe itching for three weeks and presents to your clinic with abnormal liver function tests and a positive anti-TPO antibody?

      Your Answer:

      Correct Answer: Primary biliary cholangitis

      Explanation:

      Autoimmune Diseases and Hepatic Disorders: A Comparison of Symptoms and Diagnostic Findings

      Primary biliary cholangitis is characterized by severe itching, mild jaundice, and elevated levels of alkaline phosphatase, ALT, and AST. Anti-mitochondrial antibody is positive, and LDL and TG may be mildly elevated. Patients may also exhibit microcytic anemia and elevated anti-TPO levels, as seen in Hashimoto’s thyroiditis. In contrast, primary sclerosing cholangitis affects men and is associated with colitis due to inflammatory bowel disease. Anti-mitochondrial antibody is often negative, and p-ANCA is often positive. Addison’s disease is characterized by fatigue, weakness, weight loss, hypoglycemia, and hyperkalemia, and may coexist with other autoimmune diseases. Autoimmune hepatitis is characterized by elevated levels of ANA, anti-smooth muscle antibody, anti-mitochondrial antibody, and anti-LKM antibody, with normal or slightly elevated levels of alkaline phosphatase. Chronic viral hepatitis is indicated by elevated levels of HBs antigen and anti-HBC antibody, with anti-HBs antibody indicating a history of prior infection or vaccination.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 37 - A 49-year-old man is admitted with chronic alcoholic liver disease. He gives little...

    Incorrect

    • A 49-year-old man is admitted with chronic alcoholic liver disease. He gives little history himself. On examination, he has grade 1 encephalopathy, a liver enlarged by 4 cm and clinically significant ascites.
      Which one of the following combinations is most reflective of synthetic liver function?

      Your Answer:

      Correct Answer: Prothrombin time and albumin

      Explanation:

      Understanding Liver Function Tests: Indicators of Synthetic and Parenchymal Function

      Liver function tests are crucial in determining the nature of any liver impairment. The liver is responsible for producing vitamin K and albumin, and any dysfunction can lead to an increase in prothrombin time, indicating acute synthetic function. Albumin, on the other hand, provides an indication of synthetic liver function over a longer period due to its half-life of 20 days in serum.

      While prothrombin time is a reliable indicator, alkaline phosphatase (ALP) would be raised in obstructive (cholestatic) disease. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) represent liver parenchymal function, rather than synthetic function. It’s important to note that both can be normal despite significantly decreased synthetic function of the liver.

      While albumin does give an indication of liver function, it can be influenced by many other factors. ALP, on the other hand, would be raised in cholestatic disease. It’s important to consider all these factors when interpreting liver function tests, as neither ALT nor ALP would indicate synthetic function of the liver.

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      • Gastroenterology
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  • Question 38 - A 50-year-old man patient who has a history of type 2 diabetes mellitus...

    Incorrect

    • A 50-year-old man patient who has a history of type 2 diabetes mellitus presents to his general practitioner with complaints of white lesions in his mouth.
      On examination, the white lesions inside the patient’s mouth can easily be scraped off with minimal bleeding. The patient does not have cervical lymph node enlargement and is otherwise well.
      Which of the following options is the most appropriate step in the management of this patient?

      Your Answer:

      Correct Answer: Nystatin

      Explanation:

      Management of Oral Candidiasis: Understanding the Treatment Options and Indications for Referral

      Oral candidiasis is a common fungal infection that can affect individuals of all ages, particularly infants, older patients who wear dentures, diabetics, and immunosuppressed patients. The infection is caused by the yeast Candida albicans and typically presents as white lesions in the mouth that can be easily scraped off with a tongue blade.

      The first-line treatment for localised disease involves topical treatment with nystatin suspension, which is swished and swallowed in the mouth three to four times a day. However, immunosuppressed patients may suffer from widespread C. albicans infections, such as oesophageal candidiasis and candidaemia, which require more aggressive treatment with intravenous antifungal medications like amphotericin B.

      It is important to note that testing for Epstein-Barr virus (EBV) is not required in patients with isolated oral thrush. However, immediate specialist referral would be necessary if oropharyngeal cancer was being considered in the differential diagnosis. The two-week wait referral is also indicated for unexplained oral ulceration lasting more than three weeks and persistent, unexplained cervical lymph node enlargement.

      In conclusion, understanding the appropriate treatment options and indications for referral is crucial in managing oral candidiasis effectively. Topical treatment with nystatin suspension is the first-line therapy for localised disease, while more aggressive treatment with intravenous antifungal medications is necessary for disseminated fungal infections. Referral to a specialist is necessary in cases where oropharyngeal cancer is suspected or when there is unexplained oral ulceration or persistent cervical lymph node enlargement.

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      • Gastroenterology
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  • Question 39 - A 61-year-old man comes to the Emergency Department complaining of sudden and severe...

    Incorrect

    • A 61-year-old man comes to the Emergency Department complaining of sudden and severe abdominal pain that started an hour ago and worsens with movement. He has no significant medical or surgical history except for a recent prescription for rheumatoid arthritis. Upon examination, the patient is lying still, has a rapid heart rate, and an increased respiratory rate. The abdomen is extremely tender, and there is intense guarding.
      What investigation is most suitable for this patient?

      Your Answer:

      Correct Answer: Erect chest X-ray

      Explanation:

      When a patient presents to the Emergency Department with an acute abdomen, an erect chest X-ray is urgently required. This inexpensive and non-invasive investigation can quickly provide important information, such as the presence of air under the diaphragm which may indicate a perforation requiring surgical intervention. However, if there is no air under the right hemidiaphragm but the history and examination suggest perforation, a CT scan of the abdomen may be necessary. NSAIDs, which are commonly used but can cause gastric and duodenal ulcers, should be given with a proton pump inhibitor if used for an extended period. Colonoscopy is generally used to investigate PR bleeding, change of bowel habit, or weight loss. An abdominal X-ray is not useful in this scenario, while an amylase level should be sent to assess for pancreatitis. Abdominal ultrasound is generally used to assess the biliary tree and gallbladder in acute cholecystitis or to assess trauma in a FAST scan.

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      • Gastroenterology
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  • Question 40 - A 25-year-old man presents with mild jaundice following a flu-like illness. During a...

    Incorrect

    • A 25-year-old man presents with mild jaundice following a flu-like illness. During a review by a gastroenterologist, he has been told that a diagnosis of Gilbert’s syndrome is probable.
      Which of the following test results most suggests this diagnosis?

      Your Answer:

      Correct Answer: Absence of bilirubin in the urine

      Explanation:

      Understanding Gilbert’s Syndrome: Absence of Bilirubin in Urine and Other Characteristics

      Gilbert’s syndrome is a genetic condition that affects 5-10% of the population in Western Europe. It is characterized by intermittent raised unconjugated bilirubin levels due to a defective enzyme involved in bilirubin conjugation. Despite this, patients with Gilbert’s syndrome have normal liver function, no evidence of liver disease, and no haemolysis. Attacks are usually triggered by various insults to the body.

      One notable characteristic of Gilbert’s syndrome is the absence of bilirubin in the urine. This is because unconjugated bilirubin is non-water-soluble and cannot be excreted in the urine. In unaffected individuals, conjugated bilirubin is released into the bile and excreted in the faeces or reabsorbed in the circulation and excreted in the urine as urobilinogen.

      Other characteristics that are not expected in Gilbert’s syndrome include decreased serum haptoglobin concentration, elevated aspartate aminotransferase (AST) activity, and increased reticulocyte count. Haptoglobin is an acute phase protein that is decreased in haemolysis, which is not associated with Gilbert’s syndrome. AST activity is associated with normal liver function, which is also a characteristic of Gilbert’s syndrome. A raised reticulocyte count is observed in haemolytic anaemia, which is not present in Gilbert’s syndrome.

      Increased urinary urobilinogen excretion is also not expected in Gilbert’s syndrome as it is associated with haemolytic anaemia. Understanding the characteristics of Gilbert’s syndrome can aid in its diagnosis and management, which typically does not require treatment.

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      • Gastroenterology
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  • Question 41 - A 70-year-old female complains of abdominal pain and melaena. She has a medical...

    Incorrect

    • A 70-year-old female complains of abdominal pain and melaena. She has a medical history of hypertension, type 2 diabetes, and right knee osteoarthritis. Which medication could be causing her symptoms?

      Your Answer:

      Correct Answer: Diclofenac

      Explanation:

      Causes of Peptic Ulceration and the Role of Medications

      Peptic ulceration is a condition that can cause acute gastrointestinal (GI) blood loss. One of the common causes of peptic ulceration is the reduction in the production of protective mucous in the stomach, which exposes the stomach epithelium to acid. This can be a consequence of using non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac, which is commonly used in the treatment of osteoarthritis. Steroids are also known to contribute to peptic ulceration.

      On the other hand, tramadol, an opiate, does not increase the risk of GI ulceration. It is important to be aware of the potential side effects of medications and to discuss any concerns with a healthcare provider. By doing so, patients can receive appropriate treatment while minimizing the risk of adverse effects.

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      • Gastroenterology
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  • Question 42 - A 59-year-old librarian is brought to the Emergency Department after experiencing haematemesis. The...

    Incorrect

    • A 59-year-old librarian is brought to the Emergency Department after experiencing haematemesis. The patient has been complaining of epigastric discomfort for the past few weeks and has been self-medicating with over-the-counter antacids. This morning, the patient continued to experience the discomfort and suddenly vomited about a cup of fresh blood. The patient is a non-smoker but consumes approximately 15 units of alcohol per week. He is currently taking atorvastatin for high cholesterol but has no other significant medical history. Upon further questioning, the patient reveals that he takes 75 mg aspirin daily, as he once read in the newspaper that it would be beneficial for his long-term cardiac health. What is the mechanism by which aspirin damages the gastric mucosa?

      Your Answer:

      Correct Answer: Reduced surface mucous secretion

      Explanation:

      Effects of Aspirin on Gastric Mucosal Lining

      Aspirin is a commonly used medication for pain relief and anti-inflammatory purposes. However, it can have adverse effects on the gastric mucosal lining. One of the effects of aspirin is the reduction of surface mucous secretion, which normally protects the gastric mucosal lining. This is due to the inhibition of PGE2 production. To prevent gastrointestinal bleeding and peptic ulceration, patients taking aspirin should consider taking a proton pump inhibitor alongside it.

      Aspirin has no effect on gastric motility, but it causes a reduction in PGI2, resulting in reduced blood flow to the gastric lining and mucosal ischaemia. This prevents the elimination of acid that has diffused into the submucosa. Aspirin also causes decreased surface bicarbonate secretion and increased acid production from gastric parietal cells, as prostaglandins normally inhibit acid secretion.

      It is important to note that the risk factors for aspirin and non-steroidal anti-inflammatory drug (NSAID)-induced injury include advanced age, history of peptic ulcer disease, concomitant use of glucocorticoids, high dose of NSAIDs, multiple NSAIDs, and concomitant use of clopidogrel or anticoagulants. Therefore, patients should be cautious when taking aspirin and consult with their healthcare provider if they have any concerns.

      The Adverse Effects of Aspirin on Gastric Mucosal Lining

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      • Gastroenterology
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  • Question 43 - A 45-year-old man who lives in a local hostel for the homeless is...

    Incorrect

    • A 45-year-old man who lives in a local hostel for the homeless is added onto the medical take following a seizure. He last consumed alcohol 32 h previously and, when assessed, he is tremulous and anxious, wishing to self-discharge. His nutritional status and personal hygiene are poor.
      Which one of the following is the most essential to be carefully monitored while an inpatient?

      Your Answer:

      Correct Answer: Phosphate

      Explanation:

      Monitoring Electrolytes in Alcohol Withdrawal: Importance of Serum Phosphate

      Alcohol dependency can lead to poor personal hygiene, nutritional deficiencies, and alcohol withdrawal. During withdrawal, electrolyte imbalances may occur, including magnesium, potassium, and serum phosphate. Of these, serum phosphate levels require close monitoring, especially during refeeding, as they may plummet dangerously low and require prompt replacement with intravenous phosphate. Gamma glutamyl transferase (GGT) may also be elevated but is not useful in this situation. Sodium levels should be monitored to avoid hyponatraemia, but serum phosphate levels are more likely to change rapidly and must be monitored closely to prevent refeeding syndrome. Haemoglobin levels are not the most appropriate answer in this case unless there is an acute change or bleeding risk.

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      • Gastroenterology
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  • Question 44 - A 65-year-old man presents with symptoms of early satiety, nausea and abdominal fullness....

    Incorrect

    • A 65-year-old man presents with symptoms of early satiety, nausea and abdominal fullness. He has lost 6 kg in weight over the past 3 months. There is no other past medical history of note. On examination, he looks very thin and there is a palpable epigastric mass.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 101 g/l 135–175 g/l
      White cell count (WCC) 5.9 × 109/l 4–11 × 109/l
      Platelets 140 × 109/l 150–400 × 109/l
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 4.3 mmol/l 3.5–5.0 mmol/l
      Creatinine 170 μmol/l 50–120 µmol/l
      Alanine aminotransferase (ALT) 35 IU/l 5–30 IU/l
      Alkaline phosphatase 68 IU/l 30–130 IU/l
      Upper gastrointestinal endoscopy reveals a smooth mass in the body of the stomach with normal-looking mucosa overlying it. Multiple biopsies: spindle cell tissue, cells undergoing multiple mitoses.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Gastrointestinal stromal tumour (GIST)

      Explanation:

      Gastrointestinal Stromal Tumours (GISTs) vs Other Gastric Conditions

      Gastrointestinal stromal tumours (GISTs) are the most common tumours of mesenchymal origin in the gastrointestinal tract, with approximately 50-70% occurring in the stomach. They are histologically characterized by spindle cells, epithelioid-like cells, or mixed spindle-epithelioid cells. GISTs tend to occur in individuals above the age of 40 and are equally common in men and women. Biopsy specimens are stained with DOG1 for identification, and surgical resection is the preferred treatment option. Systemic chemotherapy with imatinib is an alternative for patients who cannot undergo complete surgical resection. Disease survival rates at the 5-year stage range from 30-60%.

      Other gastric conditions, such as gastric carcinoma, Helicobacter pylori gastritis, gastric leiomyosarcoma, and gastric lipoma, may present with similar symptoms but have different endoscopic and histological findings. Gastric carcinomas are most often adenocarcinomas, while Helicobacter pylori gastritis is the most common cause of gastritis worldwide. Gastric leiomyosarcoma is a differential diagnosis for GISTs, but GISTs are more common. Gastric lipomas would not present with the same combination of findings seen in GISTs.

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  • Question 45 - You are working at a General Practice surgery, and a 30-year-old office worker...

    Incorrect

    • You are working at a General Practice surgery, and a 30-year-old office worker presents with abdominal discomfort and frequent episodes of diarrhoea with blood and mucous mixed in. He reports feeling as though he needs to empty his bowels, even after he has just done so. Symptoms have worsened over the past 2 months. He has no nausea or vomiting and has not been abroad in the last year. He has not lost weight. His only recent medications are paracetamol and loperamide. On examination, his abdomen is soft, but there is mild tenderness in the left lower quadrant. There is blood on the glove after digital rectal examination.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Ulcerative colitis

      Explanation:

      Differential diagnosis for a young patient with bloody diarrhoea and left lower quadrant pain

      Explanation:

      A young patient presents with frequent episodes of bloody diarrhoea, tenesmus, and left lower quadrant tenderness. The differential diagnosis includes several conditions that affect the large bowel, such as inflammatory bowel disease (ulcerative colitis or Crohn’s disease), Clostridium difficile infection, colorectal cancer, diverticulitis, and irritable bowel syndrome.

      To confirm the diagnosis and distinguish between ulcerative colitis and Crohn’s disease, sigmoidoscopy or colonoscopy with biopsies will be needed. C. difficile infection is unlikely in this case, as the patient does not have risk factors such as recent antibiotic use, older age, recent hospital stay, or proton pump inhibitor use.

      Colorectal cancer is also unlikely given the patient’s age, but inflammatory bowel disease, especially ulcerative colitis, increases the risk for colorectal cancer later in life. Therefore, it is important to ask about a family history of cancer and perform appropriate investigations.

      Diverticulitis is another possible cause of left lower quadrant pain, but it is uncommon in young people, and symptomatic diverticula are rare below the age of 40. Most people have diverticula by the age of 50, but they are often asymptomatic unless they become inflamed, causing fever and tachycardia.

      Finally, irritable bowel syndrome may cause bleeding from trauma to the perianal area, but the bleeding is usually small in volume and not mixed in with the stool. Therefore, this condition is less likely to explain the patient’s symptoms of bloody diarrhoea and left lower quadrant pain.

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      • Gastroenterology
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  • Question 46 - A 50-year-old woman presents with a few months history of abdominal pain and...

    Incorrect

    • A 50-year-old woman presents with a few months history of abdominal pain and diarrhoea. Further questioning reveals increasing episodes of facial flushing and occasional wheeze. Clinical examination reveals irregular, craggy hepatomegaly. Abdominal CT is performed which revealed nonspecific thickening of a terminal small bowel loop, a large calcified lesion in the small bowel mesentery and innumerable lesions in the liver.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Carcinoid syndrome

      Explanation:

      Understanding Carcinoid Syndrome and Differential Diagnosis

      Carcinoid syndrome is a rare neuroendocrine tumor that secretes serotonin and is commonly found in the terminal ileum. While the primary tumor is often asymptomatic, metastasis can lead to symptoms such as diarrhea, facial flushing, and bronchospasm. Abdominal pain may also be present due to liver and mesenteric metastases. Diagnosis is made through biopsy or finding elevated levels of 5-HIAA in urine. Treatment options include surgery, chemotherapy, and somatostatin analogues like octreotide.

      Whipple’s disease presents with diarrhea, weight loss, and migratory arthritis, typically affecting the duodenum. Yersinia ileitis and tuberculosis both affect the terminal ileum and cause diarrhea and thickening of small bowel loops on CT, but do not match the symptoms and imaging findings described in the case of carcinoid syndrome. Normal menopause is also not a likely diagnosis based on the patient’s history and imaging results. A thorough differential diagnosis is important in accurately identifying and treating carcinoid syndrome.

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      • Gastroenterology
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  • Question 47 - A 49-year-old man is brought to the Emergency Department by ambulance after a...

    Incorrect

    • A 49-year-old man is brought to the Emergency Department by ambulance after a witnessed fall. He struck his head on the pavement. He is known to the nursing staff, having been brought in on numerous occasions for the management of alcohol intoxication. On examination, his vital signs are within normal limits, but he is minimally responsive to verbal commands and has slurred speech. He has an elevated serum alcohol level. A computed tomography (CT) brain is reported as normal. He is admitted for overnight observation, hydrated with intravenous dextrose and given acetaminophen for pain relief.
      By day 2 of his admission, he remains confused and inappropriate. He appears at times indifferent and does not pay attention to questioning. When he does respond, his answers are tangential and he does not appear to know his own name. On morning ward rounds, you notice that he has a bilateral rectus palsy which was not present at the time of admission. A repeat CT of his brain is normal.
      To which one of the following vitamin deficiencies is this presentation is most likely due?

      Your Answer:

      Correct Answer: Vitamin B1

      Explanation:

      The Importance of B Vitamins in Neurological Health

      B vitamins play a crucial role in neurological health, and deficiencies can lead to a range of symptoms and conditions. Wernicke’s encephalopathy, characterized by encephalopathy, oculomotor dysfunction, and gait ataxia, is caused by a deficiency in vitamin B1 and is commonly seen in chronic alcohol users and those with anorexia nervosa or hyperemesis gravidarum. Vitamin B3 deficiency can cause neurologic symptoms, photosensitivity dermatitis, and GI upset, while vitamin B2 deficiency can lead to normochromic, normocytic anemia, pharyngitis, cheilitis, glossitis, and stomatitis. Vitamin B5 deficiency is rare but can cause paraesthesiae of the extremities and GI upset. Vitamin B12 deficiency has multi-system effects, including neurologic syndromes, haematologic syndrome, and skeletal changes. It is crucial to address any potential deficiencies in B vitamins to prevent these neurological complications.

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      • Gastroenterology
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  • Question 48 - A 50-year-old man presents with painless bleeding per rectum for two days. The...

    Incorrect

    • A 50-year-old man presents with painless bleeding per rectum for two days. The blood was mixed with stool every time. There was no pain or tenesmus. There has been no loss of weight.

      He has never experienced these symptoms before, although he has suffered from constipation over the past three years. At the clinic, he complained of mild fever, although on examination, his temperature was normal.

      He has recently returned from a trip to India where he took part in a mountain expedition to Kedarnath. He takes no drugs, with the exception of thyroxine which he has taken for the past two years.

      What is the immediate management?

      Your Answer:

      Correct Answer: Stool microscopy & culture

      Explanation:

      Rectal Bleeding in a Patient with a Recent Mountain Expedition

      This patient has recently returned from a mountain expedition in a tropical country, where his diet and water intake may have been irregular. As a result, he is at risk of food and water-borne infections such as amoebiasis, which can cause bloody stools. To determine the cause of the bleeding, stool tests and microscopy should be conducted before treatment is initiated.

      It is important to note that laxatives should not be used until the cause of the bloody stool is identified. In cases of colonic cancer, laxatives can cause intestinal obstruction, while in conditions such as inflammatory bowel disease, they can irritate the bowel walls and worsen the condition. The patient’s history of constipation is likely due to hypothyroidism, which is being treated.

      While chronic liver disease can cause rectal bleeding, there is no indication of such a condition in this patient. When bleeding is caused by piles, blood is typically found on the toilet paper and not mixed with stools. Lower GI endoscopy may be necessary if the bleeding persists, but invasive tests should only be conducted when fully justified.

      Observation is not an appropriate course of action in this case. In older patients, rectal bleeding should always be taken seriously and thoroughly investigated to determine the underlying cause.

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      • Gastroenterology
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  • Question 49 - A 67-year-old man had a gastric endoscopy to investigate possible gastritis. During the...

    Incorrect

    • A 67-year-old man had a gastric endoscopy to investigate possible gastritis. During the procedure, the endoscope passed through the oesophagogastric junction and entered the stomach.
      Which part of the stomach is situated closest to this junction?

      Your Answer:

      Correct Answer: Cardia

      Explanation:

      Anatomy of the Stomach: Regions and Parts

      The stomach is a muscular organ located in the upper abdomen that plays a crucial role in digestion. It is divided into several regions and parts, each with its own unique function. Here is a breakdown of the anatomy of the stomach:

      Cardia: This region surrounds the opening of the oesophagus into the stomach and is adjacent to the fundus. It is in continuity with the body of the stomach.

      Fundus: The fundus is the uppermost region of the stomach that is in contact with the inferior surface of the diaphragm. It is located above the level of the cardial orifice.

      Body: The body is the largest region of the stomach and is located between the fundus and pyloric antrum. It has a greater and lesser curvature.

      Pyloric antrum: This region is the proximal part of the pylorus, which is the distal part of the stomach. It lies between the body of the stomach and the first part of the duodenum.

      Pyloric canal: The pyloric canal is the distal part of the pylorus that leads to the muscular pyloric sphincter.

      Understanding the different regions and parts of the stomach is important for diagnosing and treating various digestive disorders.

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      • Gastroenterology
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  • Question 50 - A 61-year-old man presents to the Emergency Department with acute-onset severe epigastric pain...

    Incorrect

    • A 61-year-old man presents to the Emergency Department with acute-onset severe epigastric pain for the last eight hours. The pain radiates to the back and has been poorly controlled with paracetamol. The patient has not had this type of pain before. He also has associated nausea and five episodes of non-bloody, non-bilious vomiting. He last moved his bowels this morning. His past medical history is significant for alcoholism, epilepsy and depression, for which he is not compliant with treatment. The patient has been drinking approximately 25 pints of beer per week for the last 15 years. He has had no previous surgeries.
      His observations and blood tests results are shown below. Examination reveals tenderness in the epigastrium, without rigidity.
      Investigation Result Normal value
      Temperature 37.0 °C
      Blood pressure 151/81 mmHg
      Heart rate 81 bpm
      Respiratory rate 19 breaths/min
      Oxygen saturation (SpO2) 99% (room air)
      C-reactive protein 102 mg/l 0–10 mg/l
      White cell count 18.5 × 109/l 4–11 × 109/l
      Amylase 992 U/l < 200 U/l
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute pancreatitis

      Explanation:

      The patient’s symptoms and lab results suggest that they have acute pancreatitis, which is commonly seen in individuals with alcoholism or gallstone disease. This condition is characterized by severe epigastric pain that may radiate to the back, and an increase in pancreatic enzymes like amylase within 6-12 hours of onset. Lipase levels can also aid in diagnosis, as they rise earlier and last longer than amylase levels. Acute mesenteric ischemia, perforated peptic ulcer, pyelonephritis, and small bowel obstruction are less likely diagnoses based on the patient’s symptoms and medical history.

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  • Question 51 - A 22-year-old woman presents with unintentional weight loss and blood stained diarrhoea. The...

    Incorrect

    • A 22-year-old woman presents with unintentional weight loss and blood stained diarrhoea. The blood is fresh, and mucous is often present in the stool. On examination, she has oral ulcers, erythema nodosum and conjunctivitis. The mucosa looks abnormal and multiple biopsies are taken. Ulcerative colitis is suspected.
      Which of the following findings would support a diagnosis of ulcerative colitis over Crohn’s disease?

      Your Answer:

      Correct Answer: Crypt abscesses

      Explanation:

      When differentiating between ulcerative colitis and Crohn’s disease, it is important to note that crypt abscesses are typical for ulcerative colitis, while other options are more commonly found in Crohn’s disease. Ulcerative colitis is the most common form of inflammatory bowel disease, with inflammation starting in the rectum and spreading upwards in a contiguous fashion. Patients typically experience left-sided abdominal pain, cramping, bloody diarrhea with mucous, and unintentional weight loss. Extra-intestinal manifestations may include seronegative arthropathy and pyoderma gangrenosum. Barium enema and colonoscopy are used to diagnose ulcerative colitis, with the latter revealing diffuse and contiguous ulceration and inflammatory infiltrates affecting the mucosa and submucosa only. Complications of long-term ulcerative colitis include large bowel adenocarcinoma, toxic megacolon, and primary sclerosing cholangitis. In contrast, Crohn’s disease usually presents with right-sided abdominal pain, watery diarrhea, and weight loss. Barium enema and colonoscopy reveal multiple ulcers and bowel wall thickening, with the microscopic appearance showing a mixed acute and chronic transmural inflammatory infiltrate with non-caseating granulomas. Terminal ileum involvement is typical for Crohn’s disease, while stricturing and fistula formation are common complications due to its transmural inflammatory nature. Overall, while both ulcerative colitis and Crohn’s disease are systemic illnesses, they have distinct differences in their clinical presentation and diagnostic features.

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  • Question 52 - A 45-year-old accountant presents with right upper quadrant pain and abnormal liver function...

    Incorrect

    • A 45-year-old accountant presents with right upper quadrant pain and abnormal liver function tests. An ultrasound scan reveals a dilated common bile duct. The patient undergoes an endoscopic retrograde cholangiopancreatography (ERCP) procedure. During the procedure, the consultant asks you to identify the location of the Ampulla of Vater, which is cannulated. Can you tell me where the Ampulla of Vater enters the bowel?

      Your Answer:

      Correct Answer: Descending (second part) duodenum

      Explanation:

      The Parts of the Duodenum: A Brief Overview

      The duodenum is the first part of the small intestine and is divided into four parts. Each part has its own unique characteristics and functions.

      Superior (first part) duodenum: This is the first part of the duodenum that connects the stomach to the small intestine.

      Descending (second part) duodenum: The ampulla of Vater, where the common bile duct and pancreatic duct enter the duodenum, is located in this part. It is cannulated during ERCP to access the biliary tree.

      Inferior (third part) duodenum: The ampulla of Vater does not join this part, but rather the second part.

      Ascending (fourth part) duodenum: This is the last part of the duodenum that joins the jejunum, the second part of the small intestine.

      Understanding the different parts of the duodenum is important for diagnosing and treating gastrointestinal disorders.

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  • Question 53 - A 65-year-old man (with known metastatic pancreatic cancer) presented with severe obstructive jaundice...

    Incorrect

    • A 65-year-old man (with known metastatic pancreatic cancer) presented with severe obstructive jaundice and signs of hepatic encephalopathy. He was treated with a biliary stent (percutaneous transhepatic cholangiography (PTC)) and discharged when his jaundice, confusion and pruritus had started to improve. He re-presented shortly after discharge with rigors, pyrexia and feeling generally unwell. His blood cultures showed Gram-negative rods.
      What is the most likely cause of his current presentation?

      Your Answer:

      Correct Answer: Ascending cholangitis

      Explanation:

      Possible Causes of Fever and Rigors in a Patient with a Biliary Stent

      Introduction:
      A patient with a biliary stent inserted via endoscopic retrograde cholangiopancreatography (ERCP) presents with fever and rigors. This article discusses the possible causes of these symptoms.

      Possible Causes:
      1. Ascending Cholangitis: This is the most likely option as the patient’s biliary stent and the ERCP procedure are both well-known risk factors for acute cholangitis. The obstruction caused by the stent can lead to recurrent biliary sepsis, which can be life-threatening and requires prompt treatment with broad-spectrum antibiotics and IV fluids.

      2. Lower Respiratory Tract Infection: Sedation and endoscopy increase the risk of pulmonary infection, particularly aspiration. However, the biliary stent itself is the biggest risk factor, and the patient’s symptoms point towards ascending cholangitis.

      3. Hepatitis: This is an unlikely cause of fever and rigors as there are no risk factors for common causes of acute hepatitis, and Gram-negative rods are not a common cause of hepatitis.

      4. Metastatic Pancreatic Cancer: While this condition can increase the risk of infection due to immunocompromised, it does not fully explain the patient’s presentation as it would not cause frank fever and rigors.

      5. Pyelonephritis: This bacterial infection of the kidney can cause pyrexia, rigors, and malaise, with Gram-negative rods, especially E. coli, as common causes. However, the recent biliary stent insertion puts this patient at high risk of ascending cholangitis.

      Conclusion:
      In conclusion, the most likely cause of fever and rigors in a patient with a biliary stent is ascending cholangitis. However, other possible causes should also be considered and ruled out through appropriate diagnostic tests.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 54 - A 68-year-old man presents with jaundice and a 4-month history of progressive weight...

    Incorrect

    • A 68-year-old man presents with jaundice and a 4-month history of progressive weight loss. He denies any abdominal pain or fever. He reports pale-coloured stool and dark urine.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Pancreatic carcinoma

      Explanation:

      Pancreatic carcinoma is characterized by painless jaundice and weight loss, particularly in the head of the pancreas where a growing mass can compress or infiltrate the common bile duct. This can cause pale stools and dark urine, as well as malaise and anorexia. Acute cholecystitis, on the other hand, presents with sudden right upper quadrant pain and fevers, with tenderness and a positive Murphy’s sign. Chronic pancreatitis often causes weight loss, steatorrhea, and diabetes symptoms, as well as chronic or acute-on-chronic epigastric pain. Gallstone obstruction results in acute colicky RUQ pain, with or without jaundice depending on the location of the stone. Hepatitis A typically presents with a flu-like illness followed by jaundice, fevers, and RUQ pain, with risk factors for acquiring the condition and no pale stools or dark urine.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 55 - A 45-year-old alcoholic presents to the Emergency Department with retrosternal chest pain, shortness...

    Incorrect

    • A 45-year-old alcoholic presents to the Emergency Department with retrosternal chest pain, shortness of breath and pain on swallowing after a heavy drinking session the night before. He reports having vomited several times this morning, after which the pain started. He denies any blood in the vomit and has no melaena. On examination, he is febrile and tachypnoeic and has a heart rate of 110 bpm. A chest X-ray reveals a left-sided pneumothorax and air within the mediastinum.
      Given the likely diagnosis, what is the most appropriate management to treat the underlying cause of his symptoms?

      Your Answer:

      Correct Answer: Urgent surgery

      Explanation:

      Management of Suspected Oesophageal Rupture

      Suspected oesophageal rupture is a medical emergency that requires urgent intervention. This condition is more common in patients with a history of alcohol excess and can be associated with a triad of vomiting, chest pain, and subcutaneous emphysema. Symptoms include retrosternal chest/epigastric pain, tachypnoea, fever, pain on swallowing, and shock. A chest X-ray reveals gas within soft tissue spaces, pneumomediastinum, left pleural effusion, and left-sided pneumothorax. Without rapid treatment, the condition can be fatal.

      Antibiotics are necessary to treat the infection that may result from oesophageal rupture. However, they will not address the underlying cause of the infection.

      Chest drain insertion is not the correct management for pneumothorax secondary to oesophageal rupture. A chest drain would not resolve the underlying cause, and air would continue to enter the pleural cavity via the oesophagus.

      Proton pump inhibitors (PPIs) are not appropriate for suspected oesophageal rupture. PPIs would be the correct management for a suspected perforated ulcer. However, the history of acute-onset pain following vomiting is more in keeping with oesophageal rupture.

      Urgent endoscopy is not appropriate for suspected oesophageal rupture. Endoscopy risks further oesophageal perforation, and there is no report of haematemesis or melaena, making this a less likely cause of the patient’s symptoms.

      Management of Suspected Oesophageal Rupture: Antibiotics, Chest Drain Insertion, PPIs, and Endoscopy

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      • Gastroenterology
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  • Question 56 - A 28-year-old woman is admitted after a paracetamol overdose. She took 25 500-mg...

    Incorrect

    • A 28-year-old woman is admitted after a paracetamol overdose. She took 25 500-mg tablets 6 hours ago. This is her first overdose. She has a history of anorexia nervosa and is severely malnourished, weighing only 42 kg. She has a past medical history of asthma, for which she uses a long-acting corticosteroid inhaler. She also takes citalopram 20 mg once daily for depression. What factor increases her risk of hepatotoxicity after a paracetamol overdose?

      Your Answer:

      Correct Answer: Her history of anorexia nervosa

      Explanation:

      Factors affecting liver injury following paracetamol overdose

      Paracetamol overdose can lead to liver injury due to the formation of a reactive metabolite called N-acetyl-p-benzoquinone imine (NAPQI), which depletes the liver’s natural antioxidant glutathione and damages liver cells. Certain risk factors increase the likelihood of liver injury following paracetamol overdose. These include malnourishment, eating disorders (such as anorexia or bulimia), failure to thrive or cystic fibrosis in children, acquired immune deficiency syndrome (AIDS), cachexia, alcoholism, enzyme-inducing drugs, and regular alcohol consumption. The use of inhaled corticosteroids for asthma or selective serotonin reuptake inhibitors (SSRIs) does not increase the risk of hepatotoxicity. However, the antidote for paracetamol poisoning, acetylcysteine, acts as a precursor for glutathione and replenishes the body’s stores to prevent further liver damage. Overall, age does not significantly affect the risk of liver injury following paracetamol overdose.

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      • Gastroenterology
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  • Question 57 - An unknown middle-aged man was brought to the Emergency Department. He was found...

    Incorrect

    • An unknown middle-aged man was brought to the Emergency Department. He was found wandering aimlessly in the street and his gait was unsteady, suggestive of alcoholism. However, he did not smell of alcohol. He could not answer questions as to his whereabouts and there seemed to be decreased comprehension. He had cheilosis and glossitis. As he was asked to walk along a line to check for tandem gait, he bumped into a stool and it became evident that he could not see clearly. After admission, the next day, the ward nurse reported that the patient had passed stool five times last night and the other patients were complaining of the very foul smell. His blood tests reveal:
      Calcium 1.90 (2.20–2.60 mmol/l)
      Albumin 40 (35–55 g/l)
      PO43− 0.40 (0.70–1.40 mmol/l)
      Which of the following treatments is given in this condition?

      Your Answer:

      Correct Answer: Megadose vitamin E

      Explanation:

      The patient is exhibiting symptoms of abetalipoproteinaemia, a rare genetic disorder that results in defective lipoprotein synthesis and fat malabsorption. This leads to deficiencies in fat-soluble vitamins, including vitamin E, which is responsible for the neurological symptoms and visual problems. Vitamin A deficiency may also contribute to visual problems, while vitamin D deficiency can cause low calcium and phosphate levels and metabolic bone disease. Fomepizole is used to treat methanol poisoning, which presents with neurological symptoms and metabolic acidosis. However, this does not explain the patient’s cheilosis or glossitis. IV thiamine is used to treat Wernicke’s encephalopathy, a result of vitamin B deficiency commonly seen in malnourished patients with a history of alcohol abuse. Pancreatic enzyme supplements are used in chronic pancreatitis with exocrine insufficiency, while oral zinc therapy is used in Wilson’s disease, an autosomal recessive condition that causes excessive copper accumulation and can present with extrapyramidal features or neuropsychiatric manifestations.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 58 - A 45-year-old woman with a known tumour in the superior (first) part of...

    Incorrect

    • A 45-year-old woman with a known tumour in the superior (first) part of the duodenum complains of right upper quadrant pain and jaundice. A CT scan of the abdomen reveals that the tumour is causing obstruction of the biliary tree by pressing against it. Which segment of the biliary tree is most likely to be impacted?

      Your Answer:

      Correct Answer: Common bile duct

      Explanation:

      Anatomy of the Biliary Tree: Location and Function of the Common Bile Duct, Common Hepatic Duct, Left Hepatic Duct, Cystic Duct, and Right Hepatic Duct

      The biliary tree is a network of ducts that transport bile from the liver and gallbladder to the small intestine. Understanding the anatomy of the biliary tree is important for diagnosing and treating conditions that affect the liver, gallbladder, and pancreas. Here is a breakdown of the location and function of the common bile duct, common hepatic duct, left hepatic duct, cystic duct, and right hepatic duct:

      Common Bile Duct: The common bile duct is the most likely to be occluded in cases of biliary obstruction. It descends posteriorly to the superior part of the duodenum before meeting the pancreatic duct at the ampulla of Vater in the descending part of the duodenum. The gastroduodenal artery, portal vein, and inferior vena cava are also located in this area.

      Common Hepatic Duct: The common hepatic duct is formed by the junction of the left and right main hepatic ducts and is located in the free margin of the lesser omentum. It is found at a further superior location than the duodenum.

      Left Hepatic Duct: The left hepatic duct drains the left lobe of the liver and is found above the superior part of the duodenum.

      Cystic Duct: The cystic duct extends from the gallbladder to the common hepatic duct, which it joins to form the common bile duct. It lies further superior than the superior part of the duodenum.

      Right Hepatic Duct: The right hepatic duct drains the right functional lobe of the liver. It joins the left hepatic duct to form the common hepatic duct. It is found superior to the level of the superior part of the duodenum.

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      • Gastroenterology
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  • Question 59 - A 67-year-old man visits his GP complaining of a mass on his tongue....

    Incorrect

    • A 67-year-old man visits his GP complaining of a mass on his tongue. He has a history of HIV that is not well-controlled, and he does not follow his medication regimen. During the examination, the doctor observes shaggy, poorly-defined, hardened, slightly raised, and rough plaques on the side of the tongue. The plaques cannot be removed with a tongue blade. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Oral hairy leukoplakia

      Explanation:

      Oral Lesions: Differential Diagnosis and Characteristics

      Oral lesions can present in a variety of forms and have different characteristics. In this case, a patient with a history of immunosuppression presents with a white mass on the lateral aspect of the tongue that cannot be scraped off with a tongue blade. This is most consistent with oral hairy leukoplakia, a non-premalignant Epstein-Barr virus-mediated mucocutaneous manifestation that often presents in immunosuppressed patients. Treatment involves antivirals.

      Other possible oral lesions include oral discoid lupus erythematosus, which is the oral manifestation of systemic lupus erythematosus and typically presents as punched-out lesions with surrounding erythema. Aphthous ulcers are round or oval-shaped lesions with surrounding erythema that typically occur on the inside of the mouth and can be treated with topical steroids. Oral candidiasis can be scraped off with a tongue blade, making it an unlikely diagnosis in this case. Oral lichen planus is a chronic inflammatory condition that can present as white, lacy patches or erosions on the gingival margin.

      In summary, a thorough examination and consideration of the patient’s medical history are necessary to accurately diagnose and treat oral lesions.

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      • Gastroenterology
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  • Question 60 - A 52-year-old male taxi driver presented with altered consciousness. He was discovered on...

    Incorrect

    • A 52-year-old male taxi driver presented with altered consciousness. He was discovered on the roadside in this state and brought to the Emergency Department. He had a strong smell of alcohol and was also found to be icteric. Ascites and gynaecomastia were clinically present. The following morning during examination, he was lying still in bed without interest in his surroundings. He was able to report his name and occupation promptly but continued to insist that it was midnight. He was cooperative during physical examination, but once the attending doctor pressed his abdomen, he swore loudly, despite being known as a generally gentle person. What is the grading of hepatic encephalopathy for this patient?

      Your Answer:

      Correct Answer: 2

      Explanation:

      Understanding the West Haven Criteria for Hepatic Encephalopathy

      The West Haven Criteria is a scoring system used to assess the severity of hepatic encephalopathy, a condition where the liver is unable to remove toxins from the blood, leading to brain dysfunction. The criteria range from 0 to 4, with higher scores indicating more severe symptoms.

      A score of 0 indicates normal mental status with minimal changes in memory, concentration, intellectual function, and coordination. This is also known as minimal hepatic encephalopathy.

      A score of 1 indicates mild confusion, euphoria or depression, decreased attention, slowing of mental tasks, irritability, and sleep pattern disorders such as an inverted sleep cycle.

      A score of 2 indicates drowsiness, lethargy, gross deficits in mental tasks, personality changes, inappropriate behavior, and intermittent disorientation.

      A score of 3 presents with somnolence but rousability, inability to perform mental tasks, disorientation to time and place, marked confusion, amnesia, occasional fits of rage, and speech that is present but incomprehensible.

      A score of 4 indicates coma with or without response to painful stimuli.

      Understanding the West Haven Criteria is important in diagnosing and managing hepatic encephalopathy, as it helps healthcare professionals determine the severity of the condition and develop appropriate treatment plans.

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      • Gastroenterology
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  • Question 61 - A 36-year-old man presents with abnormal liver function tests. He has no history...

    Incorrect

    • A 36-year-old man presents with abnormal liver function tests. He has no history of alcohol consumption and no known risk factors for liver disease. However, his grandfather passed away from liver cancer. Upon investigation, his serum albumin is 38 g/L (37-49), serum total bilirubin is 41 μmol/L (1-22), serum alanine aminotransferase is 105 U/L (5-35), serum alkaline phosphatase is 135 U/L (45-105), serum ferritin is 1360 mcg/L, and serum iron saturation is 84%. A liver biopsy reveals Perls' Prussian blue positive deposits in the liver. What is the most appropriate first-line treatment?

      Your Answer:

      Correct Answer: Venesection

      Explanation:

      Venesection is the primary treatment for haemochromatosis, with a target serum ferritin of less than 50 mcg/L achieved within three to six months. Azathioprine and prednisolone are not used in treatment, while iron chelators such as desferrioxamine are reserved for certain cases. Ursodeoxycholic acid is used in treating primary biliary cirrhosis.

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      • Gastroenterology
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  • Question 62 - A 75-year-old widower comes to the Emergency Department following a mechanical fall at...

    Incorrect

    • A 75-year-old widower comes to the Emergency Department following a mechanical fall at a nearby store. His orthopaedic examination is normal, but he is extremely thin and agitated, has halitosis and gingivitis, and perifollicular hemorrhages are visible.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Vitamin C deficiency

      Explanation:

      Differential diagnosis of a patient with muscle pain, fatigue, skin dots, bleeding gums, and weight loss

      Scurvy, a rare condition in the general population, is a relatively common nutritional finding in the elderly and socially disadvantaged groups. It results from a deficiency of vitamin C, which is needed to make collagen. Without vitamin C, collagen cannot be replaced and tissue breaks down, leading to symptoms such as muscle and joint pain, fatigue, red dots on the skin (perifollicular haemorrhages), bleeding and inflammation of the gums (gingivitis), decreased wound healing, and easy bruising. Treatment involves vitamin C supplementation and dietary changes.

      Lead poisoning, although not likely to cause the signs present in this patient, can cause abdominal pain, confusion, and headaches, and in severe cases, seizures, coma, and death. It is usually caused by exposure to lead in the environment, such as from contaminated water, soil, or paint.

      Vitamin K deficiency, although rare, can cause bleeding and easy bruising, but it is much less common than vitamin C deficiency. Vitamin K is needed for blood clotting and bone health, and it is found in green leafy vegetables, liver, and eggs.

      Hypothyroidism, a common endocrine disorder, is more likely to cause weight gain than weight loss, as it slows down the body’s metabolism. It can also cause dry, coarse skin, fatigue, and depression. Treatment involves thyroid hormone replacement therapy.

      Pellagra, a rare condition caused by a deficiency of niacin (vitamin B3), can cause diarrhoea, dermatitis, and dementia. It may also cause aggression and red skin lesions, but it is less common than vitamin C deficiency. Treatment involves niacin supplementation and dietary changes.

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      • Gastroenterology
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  • Question 63 - A 40-year-old woman presented to the gastroenterology clinic with intermittent biliary type pain,...

    Incorrect

    • A 40-year-old woman presented to the gastroenterology clinic with intermittent biliary type pain, fever, and jaundice requiring recurrent hospital admissions. During her last admission, she underwent laparoscopic cholecystectomy. She has a history of ulcerative colitis for the past 15 years.

      Investigations revealed elevated serum alanine aminotransferase (100 U/L), serum alkaline phosphatase (383 U/L), and serum total bilirubin (45 μmol/L). However, her serum IgG, IgA, and IgM levels were normal, and serology for hepatitis B and C was negative. Ultrasound of the abdomen showed dilated intrahepatic ducts and a common bile duct of 6 mm.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Primary sclerosing cholangitis

      Explanation:

      Cholangitis, PSC, and Other Related Conditions

      Cholangitis is a medical condition that is characterized by the presence of biliary pain, fever, and jaundice. On the other hand, primary sclerosing cholangitis (PSC) is a progressive disease that affects the bile ducts, either intrahepatic or extrahepatic, or both. The cause of PSC is unknown, but it is characterized by a disproportionate elevation of serum alkaline phosphatase. Patients with PSC are prone to repeated episodes of acute cholangitis, which require hospitalization. Up to 90% of patients with PSC have underlying inflammatory bowel disease, usually ulcerative colitis. Imaging studies, such as MRCP, typically show multifocal strictures in the intrahepatic and extrahepatic bile ducts. The later course of PSC is characterized by secondary biliary cirrhosis, portal hypertension, and liver failure. Patients with PSC are also at higher risk of developing cholangiocarcinoma.

      Autoimmune hepatitis, on the other hand, is characterized by a marked elevation in transaminitis, the presence of autoantibodies, and elevated serum IgG. Choledocholithiasis, another related condition, is usually diagnosed by an ultrasound scan of the abdomen, which shows a dilated common bile duct (larger than 6 mm) and stones in the bile duct. Meanwhile, primary biliary cholangitis (PBC) is unlikely to cause recurrent episodes of cholangitis. Unlike PSC, PBC does not affect extrahepatic bile ducts. Finally, viral hepatitis is unlikely in the absence of positive serology. these conditions and their characteristics is crucial in providing proper diagnosis and treatment to patients.

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      • Gastroenterology
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  • Question 64 - As the F1 on call, you have been summoned to attend to a...

    Incorrect

    • As the F1 on call, you have been summoned to attend to a 36-year-old man who has been admitted with decompensated alcoholic liver disease. Upon examination, you observe widespread stigmata of chronic liver disease with tense ascites and mild peripheral oedema. There is no indication of encephalopathy, and all vital signs are within acceptable limits. The most recent blood tests reveal a haemoglobin level of 115 g/L (120-140), a white cell count of 5.6 ×109/L (4.0-11.0), and a platelet count of 79 ×109/L (150-400), among other things. The patient is experiencing abdominal pain. What is the safest analgesic agent to prescribe to this patient?

      Your Answer:

      Correct Answer: Paracetamol

      Explanation:

      Special Considerations for Drug Prescribing in Patients with Advanced Liver Disease

      Patients with advanced liver disease require special attention when it comes to drug prescribing due to the altered pathophysiology of the liver. The liver’s poor synthetic function can lead to impaired enzyme formation, reducing the ability to excrete hepatically metabolized drugs. Concurrent use of enzyme-inducing drugs can lead to the accumulation of toxic metabolites. Additionally, reduced synthesis of blood clotting factors by a damaged liver means that these patients can often auto-anticoagulate, and drugs that interfere with the clotting process are best avoided.

      Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac should be avoided in liver disease patients. These drugs promote gastric irritation, increasing the likelihood of gastrointestinal bleeding, which is significantly increased if there are upper gastrointestinal varices present. NSAIDs can also promote fluid retention and worsen peripheral edema and ascites. Morphine sulfate and tramadol hydrochloride are both opioid analgesics that should only be considered in patients with advanced liver disease by hepatologists as they can promote the development of hepatic encephalopathy. Paracetamol is considered the safest analgesic to use in these patients, even in severe liver disease, as long as the doses are halved.

      In conclusion, patients with advanced liver disease require special care in drug prescribing due to the altered pathophysiology of the liver. It is important to avoid drugs that interfere with the clotting process, promote gastric irritation, and worsen peripheral edema and ascites. Opioid analgesics should only be considered by hepatologists, and paracetamol is considered the safest analgesic to use in these patients.

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      • Gastroenterology
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  • Question 65 - A 57-year-old man presents to his general practitioner (GP) with a 2-month history...

    Incorrect

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

      Your Answer:

      Correct Answer: Immediate referral to upper gastrointestinal surgeon

      Explanation:

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

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

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

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

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      • Gastroenterology
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  • Question 66 - A 23-year-old plumber is admitted to the Surgical Ward after undergoing an appendicectomy....

    Incorrect

    • A 23-year-old plumber is admitted to the Surgical Ward after undergoing an appendicectomy. A medical student conducts a thorough examination and takes a detailed medical history of the patient. The student observes that the patient is exhibiting jaundice but does not display any other symptoms of liver dysfunction. The liver function tests reveal the following results: total bilirubin of 52 mmol/l, aspartate aminotransferase (AST) 37 iu/l, alanine aminotransferase (ALT) 32 iu/l, and alkaline phosphatase 70 u/l. What is the likely condition affecting this patient?

      Your Answer:

      Correct Answer: Gilbert’s syndrome

      Explanation:

      Differentiating Causes of Jaundice: A Brief Overview

      Jaundice is a common clinical finding that can be caused by a variety of underlying conditions. One possible cause is Gilbert’s syndrome, a congenital defect in the liver’s ability to conjugate bilirubin. This results in mild unconjugated hyperbilirubinemia, which may occasionally lead to jaundice during fasting or concurrent illness. However, Gilbert’s syndrome is typically benign and requires no treatment.

      In contrast, Crigler-Najjar type I and type II are also defects in glucuronyl transferase activity, but they present with severe jaundice or death in the neonatal period. Wilson’s disease, a rare disorder of copper metabolism, can also cause jaundice, but it is unlikely to be the cause in this scenario.

      Another possible cause of jaundice is Caroli’s syndrome, a congenital dilation of the intrahepatic bile duct that presents with recurrent episodes of cholangitis. It is important to differentiate between these various causes of jaundice in order to provide appropriate management and treatment.

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      • Gastroenterology
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  • Question 67 - A 26-year-old man has recently been diagnosed with ulcerative colitis. Investigation has revealed...

    Incorrect

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

      Your Answer:

      Correct Answer: Mesalazine

      Explanation:

      Treatment Options for Moderate Exacerbation of Distal Ulcerative Colitis

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

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      • Gastroenterology
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  • Question 68 - A 56-year-old man comes to the Emergency Department with haematemesis. His friends report...

    Incorrect

    • A 56-year-old man comes to the Emergency Department with haematemesis. His friends report that he drank a large amount of alcohol earlier and had prolonged vomiting because he is not used to drinking so much. During the examination, his vital signs are: pulse 110 bpm, blood pressure 100/60 mmHg. There are no notable findings during systemic examination.
      What is the most likely cause of the haematemesis in this case?

      Your Answer:

      Correct Answer: Mallory-Weiss tear

      Explanation:

      Causes of haematemesis and their associated symptoms

      Haematemesis, or vomiting of blood, can be caused by various conditions affecting the upper gastrointestinal tract. Here we discuss some of the common causes and their associated symptoms.

      Mallory-Weiss tear
      This type of tear occurs at the junction between the oesophagus and the stomach, and is often due to severe vomiting or retching, especially in people with alcohol problems. The tear can cause internal bleeding and low blood pressure, and is usually accompanied by a history of recent vomiting.

      Peptic ulcer disease
      Peptic ulcers are sores in the lining of the stomach or duodenum, and can cause epigastric pain, especially after eating or when hungry. Bleeding from a peptic ulcer is usually associated with these symptoms, and may be mild or severe.

      Oesophageal varices
      Varices are enlarged veins in the oesophagus that can occur in people with chronic liver disease, especially due to alcohol abuse or viral hepatitis. Variceal bleeding can cause massive haematemesis and is a medical emergency.

      Barrett’s oesophagus
      This condition is a type of metaplasia, or abnormal tissue growth, in the lower oesophagus, often due to chronic acid reflux. Although Barrett’s mucosa can lead to cancer, bleeding is not a common symptom.

      Gastritis
      Gastritis is inflammation of the stomach lining, often due to NSAIDs or infection with Helicobacter pylori. It can cause epigastric pain, nausea, and vomiting, and may be associated with mild bleeding. Treatment usually involves acid suppression and eradication of H. pylori if present.

      In summary, haematemesis can be caused by various conditions affecting the upper digestive system, and the associated symptoms can help to narrow down the possible causes. Prompt medical attention is needed for severe or recurrent bleeding.

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      • Gastroenterology
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  • Question 69 - A 61-year-old man has been admitted to a General Surgical Ward, following an...

    Incorrect

    • A 61-year-old man has been admitted to a General Surgical Ward, following an endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. The procedure took place approximately two hours ago and went well, without complications. The patient is now complaining of central abdominal pain, radiating to the back.
      His observations are normal. Examination is significant for central abdominal pain. His blood tests are significant for an amylase level of 814 u/l. His pre-ERCP amylase level was 89 u/l.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute pancreatitis

      Explanation:

      Complications of ERCP: Post-ERCP Pancreatitis, Papillary Stenosis, Anaphylaxis, Duodenal Pneumostasis, and Oesophageal Perforation

      Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure used to examine the bile ducts and pancreatic ducts. However, like any medical procedure, ERCP is not without risks. Here are some of the possible complications of ERCP:

      Post-ERCP Pancreatitis: This is a common complication of ERCP, with an incidence of approximately 2-3%. It is characterized by abdominal pain that radiates to the back and a significant elevation in amylase levels. Treatment involves analgesia, hydration, and bowel rest.

      Papillary Stenosis: This is a late complication of ERCP that occurs in approximately 2-4% of patients. It is treated with endoscopic management, such as stenting or balloon dilation.

      Anaphylaxis: Although rare, anaphylactic reactions to contrast agents used during ERCP can occur. Symptoms include respiratory compromise and hypotension, and treatment involves adrenaline and airway support.

      Duodenal Pneumostasis: This complication refers to a collection of air in the duodenal wall and is typically recognized during the procedure. The procedure should be stopped to avoid bowel perforation.

      Oesophageal Perforation: This is a rare complication of ERCP that typically presents with chest pain, mediastinitis, and cardiovascular instability.

      In conclusion, while ERCP is a useful diagnostic and therapeutic tool, it is important to be aware of the potential complications and to take appropriate measures to prevent and manage them.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 70 - A 65-year-old man presents with increased satiety, dull abdominal pain and weight loss...

    Incorrect

    • A 65-year-old man presents with increased satiety, dull abdominal pain and weight loss over the past 6 months. He smokes 20 cigarettes per day and has suffered from indigestion symptoms for some years. On examination, his body mass index is 18 and he looks thin. He has epigastric tenderness and a suspicion of a mass on examination of the abdomen.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 101 g/l 135–175 g/l
      White cell count (WCC) 9.2 × 109/l 4–11 × 109/l
      Platelets 201 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 110 μmol/l 50–120 µmol/l
      Faecal occult blood (FOB) Positive
      Upper gastrointestinal endoscopy Yellowish coloured, ulcerating
      submucosal mass within the
      stomach
      Histology Extensive lymphocytes within the biopsy
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Gastric lymphoma

      Explanation:

      Histological Diagnoses of Gastric Conditions

      Gastric lymphoma is often caused by chronic infection with H. pylori, and eradicating the infection can be curative. If not, chemotherapy is the first-line treatment. Other risk factors include HIV infection and long-term immunosuppressive therapy. In contrast, H. pylori gastritis is diagnosed through histological examination, which reveals lymphocytes and may indicate gastric lymphoma. Gastric ulcers are characterized by inflammation, necrosis, fibrinoid tissue, or granulation tissue on histology. Gastric carcinoma is identified through adenocarcinoma of diffuse or intestinal type, with higher grades exhibiting poorly formed tubules, intracellular mucous, and signet ring cells. Finally, alcoholic gastritis is diagnosed through histology as neutrophils in the epithelium above the basement membrane.

    • This question is part of the following fields:

      • Gastroenterology
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