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Question 1
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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: 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.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Correct
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A 50-year-old man presents to the Acute Medical Unit with complaints of mucous and bloody diarrhoea. He has experienced milder episodes intermittently over the past five years but has never sought medical attention. The patient reports left lower abdominal pain and occasional right hip pain. On examination, there is tenderness in the lower left abdominal region without radiation. The patient has not traveled outside the UK and has not been in contact with anyone with similar symptoms. There is no significant family history. What is the most probable diagnosis?
Your Answer: Ulcerative colitis
Explanation:Understanding Gastrointestinal Conditions: A Comparison of Ulcerative Colitis, Colon Carcinoma, Acute Diverticulitis, Crohn’s Disease, and Irritable Bowel Syndrome
Gastrointestinal conditions can be challenging to differentiate due to their overlapping symptoms. This article aims to provide a comparison of five common gastrointestinal conditions: ulcerative colitis, colon carcinoma, acute diverticulitis, Crohn’s disease, and irritable bowel syndrome.
Ulcerative colitis is a type of inflammatory bowel disease (IBD) that presents with bloody diarrhea as its main feature. Hip pain is also a common extra-intestinal manifestation in this condition.
Colon carcinoma, on the other hand, has an insidious onset and is characterized by weight loss, iron-deficiency anemia, and altered bowel habits. It is usually detected through screening tests such as FOBT, FIT, or flexible sigmoidoscopy.
Acute diverticulitis is a condition that affects older people and is caused by chronic pressure from constipation due to low dietary fiber consumption. It presents with abdominal pain and blood in the stool, but mucous is not a common feature.
Crohn’s disease is another type of IBD that presents with abdominal pain and diarrhea. However, bloody diarrhea is not common. Patients may also experience weight loss, fatigue, and extra-intestinal manifestations such as oral ulcers and perianal involvement.
Irritable bowel syndrome (IBS) is a gastrointestinal condition characterized by episodes of diarrhea and constipation, as well as flatulence and bloating. Abdominal pain is relieved upon opening the bowels and passing loose stools. IBS is different from IBD and is often associated with psychological factors such as depression and anxiety disorders.
In conclusion, understanding the differences between these gastrointestinal conditions is crucial for accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 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: Vitamin B5
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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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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A 50-year-old man presents to the upper gastrointestinal surgeon with a 9-month history of difficulty swallowing both liquids and solid foods. He also complains of regurgitating food. He has been eating smaller and smaller meals given the above symptoms. He has a past medical history of depression for which he takes citalopram. He has never smoked or drank alcohol. He has trialled over-the-counter proton-pump inhibitor (PPI) medication without any symptom relief.
Physical examination is normal. A recent chest radiograph also appears to be normal. His electrocardiogram (ECG) is also normal.
His observations are shown below:
Temperature 36.8 °C
Blood pressure 127/79 mmHg
Heart rate 75 beats per minute
Respiratory rate 16 breaths per minute
Sp(O2) 98% (room air)
A diagnosis of achalasia is likely.
Which of the following is the most appropriate definitive management for this condition?Your Answer: Botulinum toxin A injections
Correct Answer: Pneumatic dilation
Explanation:Achalasia is a condition where the lower esophageal sphincter fails to relax, causing difficulty in swallowing and regurgitation. Pneumatic dilation is a treatment option that involves using a balloon to stretch the sphincter and reduce pressure in the esophagus. However, this procedure carries a risk of perforation and is only recommended for patients who are good surgical candidates. Botulinum toxin A injections can also be used to inhibit the neurons that increase sphincter tone, but may require repeat treatments. Gastrostomy, or creating an artificial opening into the stomach, is reserved for severe cases where other treatments have failed and the patient is not a surgical candidate. Sublingual isosorbide dinitrate and nifedipine are pharmacological options that can temporarily relax the sphincter and may be used as a bridge while waiting for definitive treatment or for patients who cannot tolerate invasive procedures.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Incorrect
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A 32-year-old woman who was diagnosed with ulcerative colitis (UC) five years ago is seeking advice on the frequency of colonoscopy in UC. Her UC is currently under control, and she has no family history of malignancy. She had a routine colonoscopy about 18 months ago. When should she schedule her next colonoscopy appointment?
Your Answer: Colonoscopy is only indicated if the patient’s symptoms deteriorate
Correct Answer: In four years' time
Explanation:Colonoscopy Surveillance for Patients with Ulcerative Colitis
Explanation:
Patients with ulcerative colitis (UC) are at an increased risk for colonic malignancy. The frequency of colonoscopy surveillance depends on the activity of the disease and the family history of colorectal cancer. Patients with well-controlled UC are considered to be at low risk and should have a surveillance colonoscopy every five years, according to the National Institute for Health and Care Excellence (NICE) guidelines. Patients at intermediate risk should have a surveillance colonoscopy every three years, while patients in the high-risk group should have annual screening. It is important to ask about the patient’s family history of colorectal cancer to determine their risk stratification. Colonoscopy is not only indicated if the patient’s symptoms deteriorate, but also for routine surveillance to detect any potential malignancy. -
This question is part of the following fields:
- Gastroenterology
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Question 6
Correct
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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: 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.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Correct
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A 32-year-old white man presents to his doctor with concerns about fatigue and changes to his tongue. He reports no other symptoms.
The patient has been following a strict vegan diet for the past six years and has a history of Crohn's disease. He is currently receiving immunomodulation therapy for his condition. His vital signs are within normal limits.
Upon examination of his mouth, a beefy-red tongue is observed. His neurological exam is unremarkable.
What is the most suitable course of treatment for this patient?Your Answer: Vitamin B12 supplementation
Explanation:Supplementation Options for Nutrient Deficiencies: A Clinical Overview
Vitamin B12 Supplementation for Deficiency
Vitamin B12 is a crucial nutrient involved in the production of red blood cells. Its deficiency can cause various clinical presentations, including glossitis, jaundice, depression, psychosis, and neurological findings like subacute combined degeneration of the spinal cord. The deficiency is commonly seen in strict vegans and patients with diseases affecting the terminal ileum. Management depends on the cause, and oral supplementation is recommended for dietary causes, while intramuscular injections are indicated for malabsorption.
Folate Supplementation for Deficiency
Folate deficiency is typically seen in patients with alcoholism and those taking anti-folate medications. However, the clinical findings of folate deficiency are different from those of vitamin B12 deficiency. Patients with folate deficiency may present with fatigue, weakness, and pallor.
Magnesium Supplementation for Hypomagnesaemia
Hypomagnesaemia is commonly seen in patients with severe diarrhoea, diuretic use, alcoholism, or long-term proton pump inhibitor use. The clinical presentation of hypomagnesaemia is variable but classically involves ataxia, paraesthesia, seizures, and tetany. Management involves magnesium replacement.
Oral Steroids for Acute Exacerbations of Crohn’s Disease
Oral steroids are indicated in patients suffering from acute exacerbations of Crohn’s disease, which typically presents with abdominal pain, diarrhoea, fatigue, and fevers.
Vitamin D Supplementation for Deficiency
Vitamin D deficiency is typically seen in patients with dark skin, fatigue, bone pain, weakness, and osteoporosis. Supplementation is recommended for patients with vitamin D deficiency.
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This question is part of the following fields:
- Gastroenterology
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Question 8
Correct
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A 42-year-old female patient complains of a slow onset of difficulty swallowing both solids and liquids. An upper GI endoscopy shows no abnormalities, and there is no visible swelling in the neck. A preliminary psychiatric evaluation reveals no issues. The on-call junior doctor suspects a psychological or functional cause. What signs would indicate an organic origin for the dysphagia?
Your Answer: Raynaud's phenomenon
Explanation:The relationship between Raynaud’s phenomenon and dysphagia is important in identifying potential underlying systemic diseases such as scleroderma. Raynaud’s phenomenon is a common symptom found in scleroderma, a systemic disease that can cause dysphagia and oesophageal dysmotility. While Raynaud’s phenomenon may be the only early manifestation of scleroderma, gastrointestinal involvement can also occur in the early stages. Therefore, the combination of Raynaud’s phenomenon with oesophageal symptoms should prompt further investigation for scleroderma.
Arthritis is not a specific cause of dysphagia-related illness, although it may occur in a variety of diseases. In scleroderma, arthralgia is more common than arthritis. Globus pharyngeus, the sensation of having something stuck in the throat, can cause severe distress, but despite extensive investigation, there is no known cause. Malar rash, found in systemic lupus erythematosus (SLE), is not associated with dysphagia. Weakness is a non-specific symptom that may be a manifestation of psychiatric illness or malnutrition as a consequence of dysphagia, and cannot guide further management.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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A 5-year-old girl with confirmed coeliac disease needs a 1-month prescription for gluten-free staple foods.
What would be the most suitable prescription for gluten-free staple foods?Your Answer: 2 kg bread + 1000g pasta + 2 kg oats = 18 units
Correct Answer: 1 kg bread + 750 g pasta + 1 kg oats = 10 units
Explanation:Determining the Correct Gluten Prescription for a Patient
When prescribing gluten for a patient, it is important to follow the National Prescribing Guidelines to ensure the correct amount is given. For example, a combination of 1 kg bread, 750 g pasta, and 1 kg oats would result in 10 units of gluten, which is the recommended amount for a 3-year-old patient. However, it is important to note that regional restrictions may apply, such as in England where only bread/flour mixes can be prescribed.
Other combinations, such as 2 kg bread, 1500 g pasta, and 2 kg oats, would result in double the recommended amount of gluten for a 3-year-old patient. It is also important to consider the patient’s age range, as the recommended amount of gluten varies for different age groups.
In summary, determining the correct gluten prescription for a patient involves following the National Prescribing Guidelines, considering regional restrictions, and taking into account the patient’s age range.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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A 30-year-old man has arrived at the Emergency Department complaining of fever, jaundice and malaise over the last three days. His initial lab results indicate elevated liver enzymes and a decreased platelet count. He has not traveled recently. The possibility of autoimmune hepatitis is being evaluated. What antibodies are the most specific for this condition?
Your Answer: Anti-nuclear antibody
Correct Answer: Anti-smooth muscle antibodies
Explanation:Differentiating Autoimmune Liver Disease: Antibody Tests
When a patient presents with abnormal liver function tests and a young age, autoimmune liver disease is a possible diagnosis. To confirm this, the most specific antibody test is for anti-smooth muscle antibodies, which are positive in about 80% of patients with autoimmune liver disease.
On the other hand, anti-mitochondrial antibodies are the hallmark of primary biliary cholangitis, with over 95% of patients being subtype M2 positive. Hepatitis A IgM antibodies are elevated in patients with acute hepatitis A infection, but not in autoimmune liver disease.
While raised anti-nuclear antibodies (ANAs) are seen in many autoimmune conditions, they are not very specific for autoimmune hepatitis. Positive ANAs are also seen in other diseases like systemic sclerosis, rheumatoid arthritis, and Sjögren syndrome. Similarly, anti-Smith antibodies are seen in about 20% of patients with systemic lupus erythematosus but are not specific for autoimmune liver disease.
In conclusion, antibody tests play a crucial role in differentiating autoimmune liver disease from other liver conditions.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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A 56-year-old patient with a history of alcoholism is admitted to the emergency department after experiencing acute haematemesis. During emergency endoscopy, bleeding oesophageal varices are discovered and treated with banding. The patient's hospital stay is uneventful, and they are ready for discharge after 10 days. What medication would be the most appropriate prophylactic agent to prevent the patient from experiencing further variceal bleeding?
Your Answer: Nifedipine
Correct Answer: Propranolol
Explanation:Portal Hypertension and Varices in Alcoholic Cirrhosis
The portal vein is responsible for carrying blood from the gut and spleen to the liver. In cases of alcoholic cirrhosis, this flow can become obstructed, leading to increased pressure and the need for blood to find alternative routes. This often results in the development of porto-systemic collaterals, with the gastro-oesophageal junction being the most common site. As a result, patients with alcoholic cirrhosis often present with varices, which are superficial and prone to rupture, causing acute and massive haematemesis.
To prevent rebleeding and reduce portal pressures, beta blockers such as propranolol have been found to be the most effective treatment for portal hypertension. Propranolol is licensed for this purpose and can help manage the complications associated with varices in alcoholic cirrhosis.
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This question is part of the following fields:
- Gastroenterology
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Question 12
Incorrect
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A 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: Aphthous ulcer
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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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 38-year-old man presents to the clinic after an insurance medical. He was noted to have an abnormal alanine aminotransferase (ALT). Past history includes obesity, hypertension and hypercholesterolaemia, which he manages with diet control. He denies any significant alcohol intake. He has a body mass index (BMI) of 31.
Investigations:
Investigation Result Normal value
Haemoglobin 139 g/l 135–175 g/l
White cell count (WCC) 4.1 × 109/l 4–11 × 109/l
Platelets 394 × 109/l 150–400 × 109/l
Sodium (Na+) 143 mmo/l 135–145 mmol/l
Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
Creatinine 85 μmol/l 50–120 µmol/l
Alanine aminotransferase (ALT) 150 IU/l 5–30 IU/l
Alkaline phosphatase 95 IU/l 30–130 IU/l
Bilirubin 28 μmol/l 2–17 µmol/l
Total cholesterol 6.8 mmol/l < 5.2 mmol/l
Triglycerides 3.8 mmol/l 0–1.5 mmol/l
Ultrasound of liver Increase in echogenicity
Which of the following is the most likely diagnosis?Your Answer: Viral hepatitis
Correct Answer: Non-alcoholic fatty liver disease (NAFLD)
Explanation:Understanding Liver Diseases: NAFLD, Viral Hepatitis, Alcohol-related Cirrhosis, Wilson’s Disease, and Haemochromatosis
Liver diseases can have various causes and presentations. One of the most common is non-alcoholic fatty liver disease (NAFLD), which is closely associated with obesity, hypertension, diabetes, and dyslipidaemia. NAFLD is often asymptomatic, but some patients may experience tiredness or epigastric fullness. Weight loss is the primary treatment, although glitazones have shown promising results in improving liver function.
Viral hepatitis is another common liver disease, but there are no indicators of it in this patient’s history. Alcohol-related cirrhosis is often caused by excessive alcohol intake, but this patient denies alcohol consumption, making NAFLD a more likely diagnosis.
Wilson’s disease typically presents with neuropsychiatric symptoms or signs, and the presence of Kayser-Fleischer rings is a key diagnostic feature. Haemochromatosis, on the other hand, results from iron overload and is often associated with diabetes mellitus and bronzing of the skin.
Understanding the different types of liver diseases and their presentations is crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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A 35-year-old General Practice manager is referred to the Gastroenterology Clinic with a 2-year history of gastroenterological complaints. The patient reports abdominal bloating, especially after meals and in the evenings, and alternating symptoms of diarrhoea and constipation. She also has a history of anxiety and is currently very busy at work – she feels this is also having an impact on her symptoms, as her symptoms tend to settle when she is on leave.
Which one of the following features in the clinical history would point towards a likely organic cause of abdominal pain (ie non-functional) diagnosis?Your Answer: mucous per rectum
Correct Answer: Unexplained weight loss
Explanation:Understanding Irritable Bowel Syndrome Symptoms and Red Flags
Irritable bowel syndrome (IBS) is a complex condition that can manifest in various ways. Some common symptoms include tenesmus, abdominal bloating, mucous per rectum, relief of symptoms on defecation, lethargy, backache, and generalised symptoms. However, it’s important to note that these symptoms alone do not necessarily indicate an organic cause of abdominal pain.
On the other hand, there are red flag symptoms that may suggest an underlying condition other than IBS. These include unintentional and unexplained weight loss, rectal bleeding, a family history of bowel or ovarian cancer, and a change in bowel habit lasting for more than six weeks, especially in people over 60 years old.
It’s crucial to understand the difference between IBS symptoms and red flag symptoms to ensure proper diagnosis and treatment. If you experience any of the red flag symptoms, it’s essential to seek medical attention promptly.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Correct
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A 50-year-old woman presents with difficult-to-manage diabetes mellitus. She was diagnosed with gallstones a year earlier. She also complains of steatorrhoea and diarrhoea. There has been some weight loss over the past 6 months.
Investigations:
Investigation Result Normal value
Haemoglobin 119 g/l 115–155 g/l
White cell count (WCC) 4.7 × 109/l 4–11 × 109/l
Platelets 179 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
Creatinine 120 μmol/l 50–120 µmol/l
Glucose 9.8 mmol/l 3.5–5.5 mmol/l
Somatostatin 105 pg/ml 10–22 pg/ml
T1-weighted gadolinium-enhanced magnetic resonance imaging (MRI): 4-cm pancreatic tumour
Which of the following is the most likely diagnosis?Your Answer: Somatostatinoma
Explanation:Overview of APUD Cell Tumours and their Presentations
APUD cell tumours are rare and can affect various organs in the body. Some of the most common types include somatostatinoma, glucagonoma, insulinoma, gastrinoma, and VIPoma. These tumours can present with a range of symptoms, such as gallstones, weight loss, diarrhoea, diabetes mellitus, necrolytic migratory erythema, sweating, light-headedness, and peptic ulceration. Diagnosis can be challenging, but imaging techniques and hormone measurements can aid in identifying the tumour. Treatment options include surgery, chemotherapy, and hormone therapy. It is important to note that some of these tumours may be associated with genetic syndromes, such as MEN 1 syndrome.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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A 50-year-old woman comes to see her GP complaining of persistent abdominal cramping, bloating, and diarrhoea that has been going on for 5 months. She reports no blood in her stools, no unexplained weight loss, and no fatigue. Her medical history includes obesity, but there is no family history of any relevant conditions.
Upon examination, her heart rate is 80 bpm, her blood pressure is 130/75 mmHg, and she has no fever. Both her abdominal and pelvic exams are unremarkable, and there is no pallor or jaundice.
What is the most appropriate next step in managing this patient's symptoms?Your Answer: Measure anti-TTG antibodies
Correct Answer: Measure serum CA-125
Explanation:If a woman aged 50 or older presents with persistent symptoms of irritable bowel syndrome (IBS), such as cramping, bloating, and diarrhoea, ovarian cancer should be suspected even without other symptoms like unexplained weight loss or fatigue. This is because ovarian cancer often presents with non-specific symptoms similar to IBS and rarely occurs for the first time in patients aged 50 or older. It is important to measure serum CA-125 to help diagnose ovarian cancer. An abdominal and pelvic examination should also be carried out, but if this is normal, measuring CA-125 is the next step. Ultrasound scans of the abdomen and pelvis are recommended once CA-125 has been measured, and if these suggest malignancy, other ultrasounds may be considered under specialist guidance. Measuring anti-TTG antibodies is not necessary in this case, as IBS rarely presents for the first time in patients aged 50 or older. Urgent referral to gastroenterology is not appropriate unless the patient has features of inflammatory bowel disease.
Ovarian cancer is a common malignancy in women, ranking fifth in frequency. It is most commonly diagnosed in women over the age of 60 and has a poor prognosis due to late detection. The majority of ovarian cancers, around 90%, are of epithelial origin, with serous carcinomas accounting for 70-80% of cases. Interestingly, recent research suggests that many ovarian cancers may actually originate in the distal end of the fallopian tube. Risk factors for ovarian cancer include a family history of BRCA1 or BRCA2 gene mutations, early menarche, late menopause, and nulliparity.
Clinical features of ovarian cancer are often vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms such as urgency, early satiety, and diarrhea. The initial diagnostic test recommended by NICE is a CA125 blood test, although this can also be elevated in other conditions such as endometriosis and benign ovarian cysts. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 test should not be used for screening asymptomatic women. Diagnosis of ovarian cancer is difficult and usually requires a diagnostic laparotomy.
Management of ovarian cancer typically involves a combination of surgery and platinum-based chemotherapy. Unfortunately, 80% of women have advanced disease at the time of diagnosis, leading to a 5-year survival rate of only 46%. It was previously thought that infertility treatment increased the risk of ovarian cancer due to increased ovulation, but recent evidence suggests that this is not a significant factor. In fact, the combined oral contraceptive pill and multiple pregnancies have been shown to reduce the risk of ovarian cancer by reducing the number of ovulations.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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A 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: Urgent endoscopy
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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This question is part of the following fields:
- Gastroenterology
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Question 18
Incorrect
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A 30-year-old Caucasian woman complains of weight loss, steatorrhoea and diarrhoea. Anaemia and metabolic bone disease are detected during investigations. A small intestine biopsy reveals severe villous atrophy, particularly in the proximal segments. The patient responds well to a gluten-free diet for one year, but her symptoms return despite maintaining the diet. A repeat biopsy shows changes similar to the previous one. What condition should be suspected in this patient?
Your Answer: Tropical sprue
Correct Answer: T-cell intestinal lymphoma
Explanation:Considerations for Non-Responsive Coeliac Disease
Coeliac disease, also known as gluten-sensitive enteropathy, is associated with specific human leukocyte antigen subtypes. The hallmark of this disease is the disappearance of clinical features and intestinal histologic findings upon discontinuing gluten in the diet. However, in cases where patients who were previously responding well to a gluten-free diet stop responding, the possibility of intestinal T-cell lymphoma, a complication of coeliac disease, should be strongly considered.
Other conditions, such as tropical sprue, dermatitis herpetiformis, collagenous sprue, and refractory sprue, may also present with similar symptoms but have different responses to gluten restriction. Tropical sprue does not respond to gluten restriction, while dermatitis herpetiformis is a skin disease associated with coeliac disease and does not cause failure of response to a gluten-free diet. Collagenous sprue is characterized by the presence of a collagen layer beneath the basement membrane and does not respond to a gluten-free diet. Refractory sprue, on the other hand, is a subset of coeliac disease where patients do not respond to gluten restriction and may require glucocorticoids or restriction of soy products.
In conclusion, when a patient with coeliac disease stops responding to a gluten-free diet, it is important to consider the possibility of intestinal T-cell lymphoma and differentiate it from other conditions that may present with similar symptoms but have different responses to gluten restriction.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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A 50-year-old man presents to the Emergency Department (ED) with epigastric pain and small volume coffee-ground vomiting. He has a history of peptic ulcers, and another ulcer is suspected. What initial first-line investigation is most appropriate to check if the ulcer might have perforated?
Your Answer: Ultrasound abdomen
Correct Answer: Erect chest X-ray
Explanation:Investigating Perforated Peptic Ulcers: Imaging Modalities
When investigating a possible perforated peptic ulcer, there are several imaging modalities available. However, not all of them are equally effective. The most appropriate first-line investigation is an erect chest X-ray, which can quickly and cost-effectively show air under the diaphragm if a perforation has occurred.
A supine chest X-ray is not effective for this purpose, as lying down changes the direction of gravitational effect and will not show the air under the diaphragm. Similarly, an ultrasound of the abdomen is not useful for identifying a perforated ulcer, as it is better suited for visualizing soft tissue structures and blood flow.
While a CT scan of the abdomen and pelvis can be useful for investigating perforation, an erect chest X-ray is still the preferred first-line investigation due to its simplicity and speed. An X-ray of the abdomen may be appropriate in some cases, but if the patient has vomited coffee-ground liquid, an erect chest X-ray is necessary to investigate possible upper gastrointestinal bleeding.
In summary, an erect chest X-ray is the most appropriate first-line investigation for a possible perforated peptic ulcer, as it is quick, cost-effective, and can show air under the diaphragm. Other imaging modalities may be useful in certain cases, but should not be relied upon as the primary investigation.
Investigating Perforated Peptic Ulcers: Imaging Modalities
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 45-year-old woman presents with sudden onset of constant abdominal pain. She tells you she has a history of peptic ulcers. The pain is worse with inspiration and movement.
On examination, there is rebound tenderness and guarding. There are absent bowel sounds. A chest X-ray shows free air under the diaphragm.
What clinical sign tells you that the peritonitis involves the whole abdomen and is not localised?Your Answer: Constant abdominal pain
Correct Answer: Absent bowel sounds
Explanation:Understanding the Signs and Symptoms of Peritonitis
Peritonitis is a condition characterized by inflammation of the peritoneum, the membrane lining the abdominal and pelvic cavity. It can be caused by various factors, including organ inflammation, viscus perforation, and bowel obstruction. Here are some of the common signs and symptoms of peritonitis:
Absent Bowel Sounds: This is the most indicative sign of generalised peritonitis, but it can also be present in paralytic ileus or complete bowel obstruction.
Guarding: This is the tensing of muscles of the abdominal wall, detected when palpating the abdomen, which protects an inflamed organ. It is present in localised and generalised peritonitis.
Pain Worse on Inspiration: Pain on inspiration can be a sign of either local or generalised peritonitis – the pain associated with peritonitis can be aggravated by any type of movement, including inspiration or coughing.
Rebound Tenderness: This is a clinical sign where pain is elicited upon removal of pressure from the abdomen, rather than on application of pressure. It is indicative of localised or generalised peritonitis.
Constant Abdominal Pain: This can have various causes, including bowel obstruction, necrotising enterocolitis, colonic infection, peritoneal dialysis, post-laparotomy or laparoscopy, and many more.
Understanding these signs and symptoms can help in the early detection and treatment of peritonitis. If you experience any of these symptoms, it is important to seek medical attention immediately.
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This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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During a cholecystectomy, the consultant ligates the cystic artery. Which vessel is the cystic artery typically a branch of, supplying the gallbladder?
Your Answer: Hepatic proper artery
Correct Answer: Right hepatic artery
Explanation:The Hepatic Arteries and Their Branches
The liver is a vital organ that requires a constant supply of oxygen and nutrients. This is provided by the hepatic arteries and their branches. Here are some important branches of the hepatic arteries:
1. Right Hepatic Artery: This artery supplies the right side of the liver and is the main branch of the hepatic artery proper. It usually gives rise to the cystic artery, which supplies the gallbladder.
2. Gastroduodenal Artery: This artery is a branch of the common hepatic artery and supplies the pylorus of the stomach and the proximal duodenum.
3. Right Gastric Artery: This artery is a branch of the hepatic artery proper and supplies the lesser curvature of the stomach.
4. Hepatic Proper Artery: This artery is a branch of the common hepatic artery and divides into the right and left hepatic arteries. These arteries supply the right and left sides of the liver, respectively.
5. Left Hepatic Artery: This artery is a branch of the hepatic artery proper and supplies the left side of the liver.
In summary, the hepatic arteries and their branches play a crucial role in maintaining the health and function of the liver.
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This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 43-year-old man presents with painless jaundice 2 months after returning from a trip to Thailand. He has no known history of liver disease. Laboratory results reveal bilirubin levels of 210 µmol/l, ALT levels of 1206 iu/l, ALP levels of 405 iu/l, PT of 10 s, and albumin levels of 41 g/dl. What is the most probable diagnosis?
Your Answer: Non-alcoholic steatohepatitis (NASH)
Correct Answer: Acute hepatitis B
Explanation:Differential Diagnosis for Acute Hepatitis with Jaundice
Acute hepatitis with jaundice can have various causes, and a differential diagnosis is necessary to determine the underlying condition. In this case, the blood tests indicate significant hepatocellular damage as the cause of the patient’s jaundice, making viral hepatitis the most likely option.
Acute hepatitis B is a common cause of jaundice, especially in endemic regions like Asia. The patient may have acquired the infection through sexual contact or needle-sharing. The acute infection usually lasts for 1-3 months, and most patients make a full recovery.
Acute hepatitis C is less likely as it is usually asymptomatic in adults, and only a small percentage develops symptoms. Primary biliary cholangitis, on the other hand, presents with an insidious onset of pruritus and lethargy, followed by jaundice, and causes a cholestatic picture. Acute alcoholic hepatitis rarely causes an ALT >500 and should be suspected if another cause or concomitant cause is present. Non-alcoholic steatohepatitis (NASH) is chronic and usually leads to mildly abnormal liver function tests in patients with risk factors for the metabolic syndrome.
In conclusion, a thorough differential diagnosis is necessary to determine the underlying cause of acute hepatitis with jaundice, and in this case, viral hepatitis is the most likely option.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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A 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: It is most commonly situated immediately adjacent to the vermiform appendix
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.
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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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A 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: Chronic cholecystitis
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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A 42-year-old man, who had recently undergone treatment for an inflamed appendix, presented with fever, abdominal pain and diarrhoea. He is diagnosed with Clostridium difficile infection and started on oral vancomycin. However, after 3 days, his diarrhoea continues and his total white cell count (WCC) is 22.7 (4–11 × 109/l). He remembers having a similar illness 2 years ago, after gallbladder surgery which seemed to come back subsequently.
Which of the following treatment options may be tried in his case?Your Answer: IV clindamycin
Correct Answer: Faecal transplant
Explanation:Faecal Transplant: A New Treatment Option for Severe and Recurrent C. difficile Infection
Severe and treatment-resistant C. difficile infection can be a challenging condition to manage. In cases where intravenous metronidazole is not an option, faecal microbiota transplantation (FMT) has emerged as a promising treatment option. FMT involves transferring bacterial flora from a healthy donor to the patient’s gut, which can effectively cure the current infection and prevent recurrence.
A randomized study published in the New England Journal of Medicine reported a 94% cure rate of pseudomembranous colitis caused by C. difficile with FMT, compared to just 31% with vancomycin. While FMT is recommended by the National Institute for Health and Care Excellence (NICE) in recurrent cases that are resistant to antibiotic therapy, it is still a relatively new treatment option that requires further validation.
Other treatment options, such as IV clindamycin and intravenous ciprofloxacin, are not suitable for this condition. Oral metronidazole is a second-line treatment for mild or moderate cases, but it is unlikely to be effective in severe cases that are resistant to oral vancomycin. Total colectomy may be necessary in cases of colonic perforation or toxic megacolon with systemic symptoms, but it is not a good choice for this patient.
In conclusion, FMT is a promising new treatment option for severe and recurrent C. difficile infection that is resistant to antibiotic therapy. Further research is needed to fully understand its effectiveness and potential risks.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Correct
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A 65-year-old man presents to Gastroenterology with haematemesis and is found to have oesophageal varices on endoscopy. He denies any history of alcohol consumption. On examination, he has a small liver with splenomegaly. His blood pressure is 130/90 mmHg and heart rate is 88 beats per minute. Laboratory investigations reveal low albumin levels, elevated bilirubin, ALT, AST, and ALP levels, and high ferritin levels. What is the most likely diagnosis?
Your Answer: Haemochromatosis
Explanation:Liver Diseases and Their Differentiating Factors
Liver diseases can lead to cirrhosis and eventually portal hypertension and oesophageal varices. However, differentiating factors can help identify the specific condition.
Haemochromatosis is an autosomal recessive condition that results in abnormal iron metabolism and deposition of iron in body tissues. Elevated ferritin levels and bronze skin coloration are common indicators.
Primary biliary cholangitis can also lead to cirrhosis and portal hypertension, but the ALP would be raised, and the patient would more likely be a woman.
Wilson’s disease is a genetically inherited condition that results in abnormal copper metabolism and deposition of copper in the tissues. Kayser–Fleischer rings in the eyes, psychiatric symptoms, and cognitive impairment are common indicators.
Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome and high-fat diets. Ferritin levels would not be expected to be raised.
Chronic viral hepatitis caused by hepatitis B or C can result in cirrhosis and portal hypertension. A history of injection drug use is a common indicator, and ferritin levels would not be raised.
In conclusion, identifying differentiating factors can help diagnose specific liver diseases and provide appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 27
Correct
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A 30-year-old patient presents with complaints of recurrent bloody diarrhoea and symptoms of iritis. On examination, there is a painful nodular erythematosus eruption on the shin and anal tags are observed. What diagnostic test would you recommend to confirm the diagnosis?
Your Answer: Colonoscopy
Explanation:Inflammatory Bowel Disease with Crohn’s Disease Suggestion
The patient’s symptoms and physical examination suggest inflammatory bowel disease, with anal skin tags indicating a possible diagnosis of Crohn’s disease. Other symptoms consistent with this diagnosis include iritis and a skin rash that may be erythema nodosum. To confirm the diagnosis, a colonoscopy with biopsies would be the initial investigation. While serum ACE levels can aid in diagnosis, they are often elevated in conditions other than sarcoidosis.
Overall, the patient’s symptoms and physical examination point towards inflammatory bowel disease, with Crohn’s disease as a possible subtype. Further testing is necessary to confirm the diagnosis and rule out other conditions.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A 45-year-old man with a history of intravenous (iv) drug abuse 16 years ago is referred by his doctor with abnormal liver function tests. He has significantly raised alanine aminotransferase (ALT). He tests positive for hepatitis C RNA and genotyping reveals genotype 1 hepatitis C. Liver biopsy reveals lymphocytic infiltration with some evidence of early hepatic fibrosis with associated necrosis.
Which of the following is the most appropriate therapy for this man?Your Answer: Ribavirin
Correct Answer: Direct acting antivirals (DAAs)
Explanation:Treatment Options for Hepatitis C: Direct Acting Antivirals and Combination Therapies
Hepatitis C is a viral infection that can lead to serious long-term health complications such as cirrhosis and liver cancer. Interferon-based treatments are no longer recommended as first-line therapy for hepatitis C, as direct acting antivirals (DAAs) have proven to be more effective. DAAs target different stages of the hepatitis C virus lifecycle and have a success rate of over 90%. Treatment typically involves a once-daily oral tablet regimen for 8-12 weeks and is most effective when given before cirrhosis develops.
While ribavirin alone is not as effective, combination therapies such as PEG-interferon α and ribavirin have been used in the past. However, for patients with genotype 1 disease (which has a worse prognosis), the addition of a protease inhibitor to the treatment regimen is recommended for better outcomes.
It is important to note that blood-borne infection rates for hepatitis C are high and can occur after just one or two instances of sharing needles during recreational drug use. Testing for hepatitis C involves antibody testing, followed by RNA and genotyping to guide the appropriate combination and length of treatment.
Overall, the combination of PEG-interferon, ribavirin, and a protease inhibitor is no longer used in the treatment of hepatitis C, as newer and more effective therapies have been developed.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 22-year-old gang member was brought to the Emergency Department with a knife still in his abdomen after being stabbed in the left upper quadrant. A CT scan revealed that the tip of the knife had punctured the superior border of the greater omentum at the junction of the body and pyloric antrum of the stomach.
What is the most likely direct branch artery that has been severed by the knife?Your Answer: Hepatic artery proper
Correct Answer: Gastroduodenal artery
Explanation:The knife likely cut the right gastro-omental artery, which is a branch of the gastroduodenal artery. This artery runs along the greater curvature of the stomach within the superior border of the greater omentum and anastomoses with the left gastro-omental artery, a branch of the splenic artery. The coeliac trunk, which supplies blood to the foregut, is not related to the greater omentum but to the lesser omentum. The hepatic artery proper, one of the terminal branches of the common hepatic artery, courses towards the liver in the free edge of the lesser omentum. The splenic artery, a tortuous branch of the coeliac trunk, supplies blood to the spleen and gives off the left gastro-omental artery. The short gastric artery, on the other hand, supplies blood to the fundus of the stomach and branches off the splenic artery.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Correct
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A 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: 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.
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This question is part of the following fields:
- Gastroenterology
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Question 31
Incorrect
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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: Irritable bowel syndrome
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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This question is part of the following fields:
- Gastroenterology
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Question 32
Incorrect
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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: Histamine-2 receptor antagonist therapy
Correct Answer: Immediate referral to upper gastrointestinal surgeon
Explanation:Appropriate Management for a Patient with Dysphagia and ‘Alarm’ Symptoms
When a patient presents with dysphagia and ‘alarm’ symptoms such as weight loss, anorexia, and swallowing difficulties, prompt referral for an urgent endoscopy is necessary. In the case of a patient with a significant smoking history, male sex, and alcohol intake, there is a high suspicion for oesophageal cancer, and an immediate referral to an upper gastrointestinal surgeon is required under the 2-week-wait rule.
Continuing treatment with over-the-counter medications like Gaviscon would be inappropriate in this case, as would histamine-2 receptor antagonist therapy. Oesophageal manometry would only be indicated if the patient had an oesophageal motility disorder. Proton-pump inhibitor (PPI) therapy can be initiated in patients with gastroesophageal reflux disease, but it would not be appropriate as a sole treatment option for a patient with clinical manifestations concerning for oesophageal carcinoma.
In summary, prompt referral for an urgent endoscopy is crucial for patients with dysphagia and ‘alarm’ symptoms, and appropriate management should be tailored to the individual patient’s clinical presentation.
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This question is part of the following fields:
- Gastroenterology
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Question 33
Incorrect
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A 50-year-old man presents to the Emergency Department with a 3-week history of tiredness, epigastric discomfort and an episode of passing black stools. His past medical history includes a 4-year history of rheumatoid arthritis for which he takes regular methotrexate, folic acid and naproxen. He recently received a course of oral corticosteroids for a flare of his rheumatoid arthritis. He denies alcohol consumption and is a non-smoker. On systemic enquiry he reports a good appetite and denies any weight loss. The examination reveals conjunctival pallor and a soft abdomen with tenderness in the epigastrium. His temperature is 36.7°C, blood pressure is 112/68 mmHg, pulse is 81 beats per minute and oxygen saturations are 96% on room air. A full blood count is taken which reveals the following:
Investigation Result Normal Value
Haemoglobin 76 g/l 135–175 g/l
Mean corpuscular volume (MCV) 68 fl 76–98 fl
White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
Platelets 380 × 109/l 150–400 × 109/l
Which of the following is the most likely diagnosis?Your Answer: Oesophageal varices
Correct Answer: Peptic ulcer
Explanation:Gastrointestinal Conditions: Peptic Ulcer, Atrophic Gastritis, Barrett’s Oesophagus, Gastric Cancer, and Oesophageal Varices
Peptic Ulcer:
Peptic ulceration is commonly caused by NSAID use or Helicobacter pylori infection. Symptoms include dyspepsia, upper gastrointestinal bleeding, and iron deficiency anaemia. Treatment involves admission to a gastrointestinal ward for resuscitation, proton pump inhibitor initiation, and urgent endoscopy. If caused by H. pylori, triple therapy is initiated.Atrophic Gastritis:
Atrophic gastritis is a chronic inflammatory change of the gastric mucosa, resulting in malabsorption and anaemia. However, it is unlikely to account for melaena or epigastric discomfort.Barrett’s Oesophagus:
Barrett’s oesophagus is a histological diagnosis resulting from chronic acid reflux. It is unlikely to cause the patient’s symptoms as there is no history of reflux.Gastric Cancer:
Gastric cancer is less likely due to the lack of risk factors and additional ‘red flag’ symptoms such as weight loss and appetite change. Biopsies of peptic ulcers are taken at endoscopy to check for an underlying malignant process.Oesophageal Varices:
Oesophageal varices are caused by chronic liver disease and can result in severe bleeding and haematemesis. However, this diagnosis is unlikely as there is little history to suggest chronic liver disease. -
This question is part of the following fields:
- Gastroenterology
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Question 34
Incorrect
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A 42-year-old man presents to A&E with sudden onset of severe epigastric pain and bright red blood in his vomit. He has a long history of heavy alcohol consumption. On examination, he has guarding over the epigastric region and cool extremities. He also has a distended abdomen with ascites and spider naevi on his neck and cheek. The patient is unstable hemodynamically, and fluid resuscitation is initiated. What is the most crucial medication to begin given the probable diagnosis?
Your Answer: Propranolol
Correct Answer: Terlipressin
Explanation:Medications for Oesophageal Variceal Bleeds
Oesophageal variceal bleeds are a serious medical emergency that require prompt treatment. The most important medication to administer in this situation is terlipressin, which reduces bleeding by constricting the mesenteric arterial circulation and decreasing portal venous inflow. Clopidogrel, an antiplatelet medication, should not be used as it may worsen bleeding. Propranolol, a beta-blocker, can be used prophylactically to prevent variceal bleeding but is not the most important medication to start in an acute setting. Omeprazole, a proton pump inhibitor, is not recommended before endoscopy in the latest guidelines but is often used in hospital protocols. Tranexamic acid can aid in the treatment of acute bleeding but is not indicated for oesophageal variceal bleeds. Following terlipressin administration, band ligation should be performed, and if bleeding persists, TIPS should be considered.
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This question is part of the following fields:
- Gastroenterology
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Question 35
Incorrect
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A 38-year-old traveller returns from a long period of travelling in Indonesia. He complains of persistent fever and night sweats, has lost weight and now feels a dull right upper quadrant pain. On further questioning, he admits to having lived very cheaply during his trip and to eating meat from street vendors that may have been undercooked. On examination, he is mildly jaundiced.
Bloods:
Investigation Result Normal value
Bilirubin 98 μmol/l 2–17 µmol/l
Alanine aminotransferase (ALT) 57 IU/l 5–30 IU/l
Alkaline phosphatase 186 IU/l 30–130 IU/l
Haemoglobin 112g/l 135–175 g/l
White cell count (WCC) 12.1 × 109/l 4–11 × 109/l
Platelets 165 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 55 mm/hour 0–10mm in the 1st hour
An abdominal ultrasound scan shows a cystic mass within the right lobe of the liver.
Which of the following represents the most effective treatment for this man?Your Answer: Metronidazole orally (po)
Correct Answer: Drainage and albendazole po
Explanation:Treatment Options for Liver Cysts: Hydatid Disease and Amoebic Liver Abscess
Hydatid disease is a parasitic infection that can occur from consuming undercooked meat sold by street vendors. The majority of cysts occur in the liver, with the remaining cysts isolated to other areas of the body. The preferred treatment is drainage, either surgically or radiologically, along with the use of albendazole to reduce the risk of recurrence. Amoebic liver abscess is a potential differential diagnosis, but ultrasound findings can differentiate between the two. Metronidazole is used to manage amoebic liver cysts, while cefuroxime is used for pyogenic bacterial liver abscess. Definitive management for hydatid disease requires drainage of fluid. For amoebic liver abscess, metronidazole with or without drainage under ultrasound is the preferred treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 36
Incorrect
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A 43-year-old man presents to his General Practitioner (GP) with four months of difficulty swallowing both liquids and solid food. He also complains of regurgitation of undigested food and retrosternal chest pain when this happens. He no longer looks forward to his meals and thinks he may be starting to lose weight. He has no other medical problems. He has never smoked or drank alcohol and denies drug use. He presented two months ago with similar symptoms and a different GP treated the patient with a proton-pump inhibitor (PPI), which his symptoms did not respond to.
Physical examination is normal. A recent chest radiograph appears to be normal. His electrocardiogram (ECG) does not show any ischaemic changes.
His observations and blood tests results are shown below:
Temperature 36.9 °C
Blood pressure 125/59 mmHg
Heart rate 65 beats per minute
Respiratory rate 14 breaths per minute
Sp(O2) 96% (room air)
Which of the following is the most likely diagnosis?Your Answer: Acute coronary syndrome
Correct Answer: Achalasia
Explanation:Differential Diagnosis for Dysphagia: Achalasia, Acute Coronary Syndrome, Diffuse Oesophageal Spasm, Oesophageal Carcinoma, and Pill-Induced Oesophagitis
Dysphagia, or difficulty swallowing, can be caused by various conditions. Among the possible diagnoses, achalasia is the most suitable response for a patient who presents with dysphagia to both solids and liquids with regurgitation of food. Achalasia is a rare motility disorder that affects the oesophagus, resulting in the failure of the lower oesophageal sphincter to relax. The patient may also have a normal ECG and no atherosclerotic risk factors, ruling out acute coronary syndrome. Diffuse oesophageal spasm, which causes intermittent and poorly coordinated contractions of the distal oesophagus, is less likely as the patient has continuous symptoms. Oesophageal carcinoma, which typically presents with progressive dysphagia from solids to liquids, is also unlikely as the patient lacks risk factors for the disease. Pill-induced oesophagitis, on the other hand, should be suspected in patients with heartburn or dysphagia and a history of ingestion of medications known to cause oesophageal injury. In summary, the differential diagnosis for dysphagia includes achalasia, acute coronary syndrome, diffuse oesophageal spasm, oesophageal carcinoma, and pill-induced oesophagitis.
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This question is part of the following fields:
- Gastroenterology
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Question 37
Correct
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A 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: 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.
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This question is part of the following fields:
- Gastroenterology
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Question 38
Correct
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A 58-year-old-man visits his General Practitioner with concerns of constipation and rectal bleeding. He reports a recent loss of appetite and occasional abdominal pain over the past few months. The patient's blood test results are as follows:
Investigation Result Normal value
Haemoglobin 98 g/l 130 – 180 g/l
Mean corpuscular value (MCV) 93 fl 80 –100 fl
What is the most suitable test to conduct for the diagnosis of this patient?Your Answer: Colonoscopy
Explanation:The patient in this scenario presents with symptoms that suggest a blockage in their bowel and potential signs of cancer, such as a loss of appetite and anemia. Therefore, the most important initial investigation is a colonoscopy. A colonic transit study is not appropriate as it is used for slow colonic transit and this patient has symptoms of obstruction. An abdominal X-ray can be used to investigate faecal impaction and rectal masses, but a colonoscopy should be used first-line for detailed information about colonic masses. While a CT abdomen may be needed, a colonoscopy should be performed as the initial investigation for intestinal luminal obstruction and potential malignancy. Checking thyroid function may be useful if there is suspicion of a secondary cause of constipation, but in this case, the patient’s symptoms suggest colonic obstruction and cancer, making a thyroid function test an inappropriate initial investigation.
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This question is part of the following fields:
- Gastroenterology
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Question 39
Incorrect
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A 40-year-old woman from Vietnam presents with abdominal swelling. She has no history of blood transfusion or jaundice in the past and is in a stable relationship with two children. Upon admission, she was found to be icteric. During the investigation, she experienced a bout of haematemesis and was admitted to the High Dependency Unit.
What is the most probable cause of her symptoms?Your Answer: Haemochromatosis
Correct Answer: Hepatitis B infection
Explanation:The patient is likely suffering from chronic liver disease and portal hypertension, possibly caused by a hepatitis B infection. This is common in regions such as sub-Saharan Africa and East Asia, where up to 10% of adults may be chronically infected. Acute paracetamol overdose can also cause liver failure, but it does not typically present with haematemesis. Mushroom poisoning can be deadly and cause liver damage, but it is not a cause of chronic liver disease. Hepatitis C is another cause of liver cirrhosis, but it is more common in other regions such as Egypt. Haemochromatosis is a rare autosomal recessive disease that can present with cirrhosis and other symptoms, but it is less likely in this case.
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This question is part of the following fields:
- Gastroenterology
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Question 40
Incorrect
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A 31-year-old woman presents to your Surgical Clinic referred by her General Practitioner (GP) with complaints of heartburn and indigestion that have been worsening at night. She denies any other gastrointestinal (GI) symptoms. She has a normal diet but smokes 20 cigarettes a day. On examination, you note that she is a large woman with a body mass index (BMI) of 37. Abdominal examination is unremarkable. An endoscopy is ordered, and the report is as follows:
Endoscopy – oesophagogastroduodenoscopy (OGD)
The OGD was performed with xylocaine throat spray, and intubation was uncomplicated. The oesophagus appears normal. A 5-cm hiatus hernia is observed and confirmed on J-manoeuvre. The stomach and duodenum up to D2 appear to be normal. CLO test was negative. Z-line at 45 cm.
What would be your next best step in managing this patient?Your Answer: Refer for oesophageal manometry studies
Correct Answer: Conservative therapy with weight loss, smoking cessation and dietary advice, and proton pump inhibitor (PPI) therapy
Explanation:Treatment Options for Gastroesophageal Reflux Disease (GERD)
GERD is a common condition that affects the digestive system. It occurs when stomach acid flows back into the esophagus, causing discomfort and other symptoms. There are several treatment options available for GERD, depending on the severity of the condition.
Conservative Therapy
Conservative therapy is the first line of treatment for GERD. This includes weight loss, smoking cessation, dietary advice, and proton pump inhibitor (PPI) therapy. PPIs are effective at reducing acid volume and can provide relief from symptoms. Patients should be encouraged to make lifestyle changes to improve their overall health and reduce the risk of complications.
Fundoplication
Fundoplication may be necessary for patients with severe GERD who do not respond to conservative measures. This surgical procedure involves wrapping the upper part of the stomach around the lower esophageal sphincter to strengthen it and prevent acid reflux.
Oesophageal Manometry Studies
Oesophageal manometry studies may be recommended if conservative measures and fundoplication fail. This test measures the strength and coordination of the muscles in the esophagus and can help identify any underlying issues.
24-Hour pH Studies
24-hour pH studies may also be recommended if conservative measures and fundoplication fail. This test measures the amount of acid in the esophagus over a 24-hour period and can help determine the severity of GERD.
Triple Therapy for Helicobacter Pylori
Triple therapy may be necessary if the CLO test for Helicobacter pylori is positive. This treatment involves a combination of antibiotics and PPIs to eradicate the bacteria and reduce acid production.
In conclusion, there are several treatment options available for GERD, ranging from conservative measures to surgical intervention. Patients should work closely with their healthcare provider to determine the best course of action based on their individual needs and symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 41
Correct
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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: 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.
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This question is part of the following fields:
- Gastroenterology
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Question 42
Incorrect
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A 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: Whipple’s disease
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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This question is part of the following fields:
- Gastroenterology
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Question 43
Incorrect
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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: Amylase levels
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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This question is part of the following fields:
- Gastroenterology
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Question 44
Incorrect
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A 7-year-old child is brought to the paediatrician by his parents for a follow-up examination after diagnosis of a genetically inherited disease. During the examination, the paediatrician observes a yellow-brown discoloration around the iris.
Which type of renal dysfunction is typically treated as the first-line approach for this child's condition?Your Answer: Type II membranoproliferative glomerulonephritis
Correct Answer: Membranous nephropathy
Explanation:Common Glomerular Diseases and Their Associations
Glomerular diseases are a group of conditions that affect the glomeruli, the tiny blood vessels in the kidneys that filter waste and excess fluids from the blood. Here are some common glomerular diseases and their associations:
1. Membranous nephropathy: This disease is associated with Wilson’s disease, an inherited disorder of copper metabolism. Treatment involves the use of penicillamine, which is associated with membranous nephropathy.
2. Focal segmental glomerulosclerosis: This disease is associated with intravenous drug abuse, HIV, being of African origin, and obesity.
3. Minimal change disease: This nephrotic syndrome is associated with Hodgkin’s lymphoma and recent upper respiratory tract infection or routine immunisation.
4. Type II membranoproliferative glomerulonephritis: This disease is associated with C3 nephritic factor, an antibody that stabilises C3 convertase and causes alternative complement activation.
5. Diffuse proliferative glomerulonephritis: This nephritic syndrome is associated with systemic lupus erythematosus (SLE).
Understanding the associations between glomerular diseases and their underlying causes can help in the diagnosis and management of these conditions.
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This question is part of the following fields:
- Gastroenterology
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Question 45
Incorrect
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A 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: Viral hepatitis
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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This question is part of the following fields:
- Gastroenterology
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Question 46
Incorrect
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A 29-year-old man was involved in a motorcycle race accident where a rod pierced his abdomen. He underwent emergency surgery and survived. After a year, he complains of abdominal pain and frequent stools, and is diagnosed with anemia. His blood tests show a vitamin B12 level of 41 (160–900 pmol/l) and serum folate of 35 ug/l (4.20 - 18.70 ug/l). He denies any dietary intolerance or rectal bleeding. What is the gold standard test for diagnosing this condition?
Your Answer: Blood IgA–tTG level
Correct Answer: Culture of small intestinal fluid
Explanation:Diagnosis and Management of Small Intestinal Bacterial Overgrowth (SIBO)
Small intestinal bacterial overgrowth (SIBO) is a condition that can cause malabsorption, steatorrhoea, and megaloblastic anaemia. It is often seen in patients who have had abdominal surgery and is characterized by an overgrowth of bacteria in the small intestine. The gold standard for diagnosis of SIBO is culture of small intestinal fluid aspirate, with a duodenal aspirate showing >105 CFU/ml considered a sensitive marker for SIBO.
SIBO is thought to develop as a failure of normal mechanisms that control bacterial growth within the small gut, with decreased gastric acid secretion and factors that affect gut motility being important. Any structural defect can have an effect on gut motility, and intestinal surgery predisposes patients to diverticular formation or stricture formation, both of which will lead to an increased risk of SIBO.
Bacterial overgrowth responds to antibiotic therapy, with many antibiotics being effective in SIBO, including metronidazole, ciprofloxacin, co-amoxiclav, and rifaximin. A 2-week course of antibiotics may be tried initially, but in many patients, long-term antibiotic therapy may be needed.
Other diagnostic tests for SIBO include hydrogen breath tests, which can give quick results but may be confounded by factors such as intestinal transit time, diet, smoking, and methane-producing bacteria. Serum folate levels and blood IgA-tTG levels are not diagnostic of SIBO, but intestinal biopsy specimens (unwashed) may be sent for culture.
In conclusion, SIBO is a common cause of malabsorption in the Western world, particularly in conditions where there is intestinal stasis or formation of a blind loop. Diagnosis is made through culture of small intestinal fluid aspirate, and treatment involves antibiotic therapy.
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This question is part of the following fields:
- Gastroenterology
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Question 47
Incorrect
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A 55-year-old man presents to the clinic with abnormal liver function tests (LFTs). He reports drinking no more than 3 units of alcohol per week and has no significant medical history. The patient was prescribed amoxicillin by his primary care physician for a sinus infection two weeks ago.
During the physical examination, the patient's BMI is found to be 40 kg/m2, indicating obesity. The LFTs reveal:
- ALT 120 U/L (5-40)
- AST 130 U/L (10-40)
- Alkaline phosphatase 200 U/L (45-105)
What is the most likely cause of this liver function test derangement?Your Answer: Hypothyroidism
Correct Answer: Non-alcoholic fatty liver disease
Explanation:Non-Alcoholic Fatty Liver Disease (NAFLD) as a Cause of Liver Enzyme Abnormalities
Non-alcoholic fatty liver disease (NAFLD) is a common cause of liver enzyme abnormalities, characterized by the accumulation of fat in the liver leading to inflammation. It is often associated with obesity, hypertension, dyslipidemia, and insulin resistance, which are part of the metabolic syndrome. However, other causes of hepatitis should be ruled out before making a diagnosis of NAFLD.
Patients who are obese and diabetic are advised to lose weight and control their diabetes. A low-fat, low-calorie diet is usually recommended alongside treatment to lower HbA1c. Patients with NAFLD should avoid alcohol or other substances that could be harmful to the liver.
It is important to note that deranged liver enzymes are not listed as side effects for amoxicillin in the British National Formulary. Therefore, if a patient presents with liver enzyme abnormalities, NAFLD should be considered as a possible cause and appropriate investigations should be carried out to confirm the diagnosis.
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This question is part of the following fields:
- Gastroenterology
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Question 48
Incorrect
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A 32-year-old man presents with complaints of heartburn and epigastric pain that are affecting his daily routine. Upon endoscopy, a shallow ulcer is observed on the posterior aspect of the first part of the duodenum. Which artery is most likely to be eroded by the ulcer?
Your Answer: Short gastric artery
Correct Answer: Gastroduodenal artery
Explanation:Arteries of the Gastrointestinal Tract
The gastrointestinal tract is supplied by several arteries, each with its own unique function and potential for complications. Here are some of the main arteries and their roles:
1. Gastroduodenal artery: This artery is often the culprit of gastrointestinal bleeding from peptic ulcer disease. It is the first branch of the common hepatic artery and runs behind the first part of the duodenum.
2. Short gastric artery: A branch of the splenic artery, this artery supplies the cardia and superior part of the greater curvature of the stomach.
3. Splenic artery: One of the three main branches of the coeliac trunk, this artery supplies the pancreas body and tail. It is at high risk of bleeding in severe pancreatitis due to its close proximity to the supero-posterior border of the pancreas.
4. Left gastric artery: Another branch of the coeliac trunk, this artery supplies the lesser curvature of the stomach along with the right gastric artery.
5. Left gastroepiploic artery: This artery, also a branch of the splenic artery, supplies much of the greater curvature of the stomach.
Understanding the roles and potential complications of these arteries is crucial in the diagnosis and treatment of gastrointestinal disorders.
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This question is part of the following fields:
- Gastroenterology
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Question 49
Incorrect
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A 65-year-old man presents to the Emergency Department after several episodes of vomiting bright red blood. He has presented to the same hospital in the past for spontaneous bacterial peritonitis, alcohol intoxication and peptic ulcer disease (PUD). The gastroenterology team review the patient and perform an urgent gastroscopy, which reveals several oesophageal varices.
Which of the following medications should be prescribed to this patient to reduce his chance of future variceal bleeding?Your Answer: Atenolol
Correct Answer: Propranolol
Explanation:Medications for Alcoholic Liver Disease and Variceal Bleeding Prophylaxis
Secondary prophylaxis for variceal haemorrhage in patients with alcoholic liver disease involves the use of non-specific beta-blockers like nadolol and propranolol. These medications reduce portal inflow and prevent further episodes of variceal bleeding. However, it is important to initiate treatment at the lowest possible dose and monitor for complications such as bradycardia.
Omeprazole, a proton pump inhibitor commonly used for reflux and PUD, is not indicated for the management of variceal bleeding. Erythromycin, a macrolide antibiotic with prokinetic properties, has no role in secondary prophylaxis for variceal bleeding.
Atenolol, a cardioselective beta-blocker, is not the preferred choice for patients with oesophageal varices as it has limited effect on peripheral tissues. Instead, a non-selective beta-blocker is more appropriate.
H2 antagonists like ranitidine and cimetidine can be used as alternatives to proton pump inhibitors in some patients with reflux and PUD.
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This question is part of the following fields:
- Gastroenterology
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Question 50
Correct
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A 21-year-old anatomy student presents with diarrhoea and weight loss. The patient complains of increased frequency of loose motions associated with cramping abdominal pain for six weeks, with an accompanying 5 kg weight loss. He opens his bowels anywhere from three to six times daily, the stool frequently has mucous in it, but no blood. The patient has no recent history of foreign travel and has had no ill contacts. He is a non-smoker and does not drink alcohol. The patient is referred to Gastroenterology for further investigation. A colonoscopy and biopsy of an affected area of bowel reveals ulcerative colitis.
Which of the following is an extra-intestinal clinical feature associated with inflammatory bowel disease?Your Answer: Sacroiliitis
Explanation:Extraintestinal Clinical Features Associated with IBD
Inflammatory bowel disease (IBD) is often accompanied by joint pain and inflammation, with migratory polyarthritis and sacroiliitis being common arthritic conditions. Other extraintestinal clinical features associated with IBD include aphthous ulcers, anterior uveitis, conjunctivitis, episcleritis, pyoderma gangrenosum, erythema nodosum, erythema multiforme, finger clubbing, primary sclerosing cholangitis, and fissures. However, aortic aneurysm is not known to be associated with IBD, as it is commonly linked to Marfan syndrome, Ehlers-Danlos syndrome, and collagen-vascular diseases. While peripheral arthropathy of the hands is associated with IBD, it is typically asymmetrical and non-deforming. Deforming arthropathy of the hands is more commonly associated with psoriatic arthritis and rheumatoid arthritis. Heberden’s nodes and Bouchard’s nodes, bony distal and proximal interphalangeal joint nodes, are found in osteoarthritis and are not associated with IBD. Prostatitis, a bacterial infection of the prostate gland, is not associated with IBD and is typically caused by Chlamydia or gonorrhoeae in young, sexually active men, and Escherichia coli in older men.
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This question is part of the following fields:
- Gastroenterology
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