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  • Question 1 - A 32-year-old man visits the general surgery practice with a 2-year history of...

    Correct

    • A 32-year-old man visits the general surgery practice with a 2-year history of occasional abdominal discomfort, bloating and change in bowel habit, which alternates between loose stools and constipation. He reports that these episodes are most intense during his work-related stress and after consuming spicy food. There is no history of weight loss or presence of blood or mucus in the stool. Physical examination, including digital rectal examination, is unremarkable. Bloods, including full blood count, liver function test, thyroid function test and coeliac screen are all normal.
      Which of the following is the most likely diagnosis?

      Your Answer: Irritable bowel syndrome (IBS)

      Explanation:

      Differential Diagnosis for Abdominal Symptoms: Irritable Bowel Syndrome, Ulcerative Colitis, Colorectal Cancer, Polycystic Ovarian Syndrome, and Ovarian Cancer

      Abdominal symptoms can be caused by a variety of conditions, making differential diagnosis crucial. Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder characterized by abdominal pain, bloating, and altered bowel habits. It is more prevalent in women and can be associated with stress. Diagnosis is made by excluding other differential diagnoses, and management includes psychological support and dietary measures, with pharmacological treatment as adjunctive therapy.

      Ulcerative colitis (UC) presents with rectal bleeding, frequent stools, and mucus discharge from the rectum. Physical examination may reveal proctitis and left-sided abdominal tenderness. UC is associated with extracolonic manifestations, but this patient’s symptoms are not consistent with a diagnosis of UC.

      Colorectal cancer typically presents with rectal bleeding, change in bowel habits, abdominal pain, weight loss, and malaise. However, this patient’s age, clinical history, and normal examination findings make this diagnosis unlikely.

      Polycystic ovarian syndrome (PCOS) presents with hyperandrogenism symptoms such as oligomenorrhea, hirsutism, and acne. Abdominal pain, bloating, and change in bowel habits are not features of PCOS.

      Ovarian cancer may present with minimal or non-specific symptoms, but persistent abdominal distension and/or pain, early satiety, or lethargy may be present. However, this patient’s young age makes this diagnosis less likely.

      The National Institute for Health and Care Excellence recommends that any woman aged over 50 years who presents with new IBS-like symptoms within the past year should have ovarian cancer excluded with a serum CA125 measurement.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 2 - A 28-year-old woman presents with bloody diarrhoea that has been ongoing for six...

    Incorrect

    • A 28-year-old woman presents with bloody diarrhoea that has been ongoing for six weeks. She reports passing 3-4 loose stools per day with small amounts of blood. She feels lethargic but has no fever or significant abdominal pain. A colonoscopy reveals inflammatory changes in the ascending, transverse, and descending colon consistent with ulcerative colitis. Her blood work shows Hb of 142 g/L, platelets of 323 * 109/L, WBC of 8.1 * 109/L, and CRP of 22 mg/L. What is the most appropriate first-line medication for inducing remission?

      Your Answer: Oral prednisolone

      Correct Answer: Oral aminosalicylate + rectal aminosalicylate

      Explanation:

      For a patient experiencing a mild to moderate flare-up of ulcerative colitis that extends beyond the left-sided colon, it is recommended to supplement rectal aminosalicylates with oral aminosalicylates. This is because enemas have limited reach and may not effectively treat the disease outside of their range.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools and presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Extensive disease may require a high-dose oral aminosalicylate and topical treatment. Severe colitis should be treated in a hospital with intravenous steroids or ciclosporin. Maintaining remission can involve using a low maintenance dose of an oral aminosalicylate or oral azathioprine/mercaptopurine. Methotrexate is not recommended, but probiotics may prevent relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 3 - A 50 year old woman arrives at the Emergency Department complaining of cramp-like...

    Incorrect

    • A 50 year old woman arrives at the Emergency Department complaining of cramp-like abdominal pain, nausea, and vomiting that started 4 hours ago. She describes the pain as intermittent and has experienced similar pain before, but not as severe as this time. The patient has a history of chronic obstructive pulmonary disease, which is well-controlled with inhalers, and has been a smoker for 25 pack years.

      Her vital signs are heart rate 110/min, respiratory rate 20/min, blood pressure 130/84 mmHg, temperature 38.6ºC, and oxygen saturation of 99% on room air. Upon examination, the patient appears very ill and sweaty, with some yellowing of the eyes. Palpation of the abdomen reveals tenderness in the right upper quadrant.

      What is the most likely cause of this woman's symptoms?

      Your Answer: Cholecystitis

      Correct Answer: Ascending cholangitis

      Explanation:

      Cholangitis can occur even in the absence of stones, although they are commonly associated with the condition. ERCP can be used to drain the biliary tree, but surgical exploration of the common bile duct may be necessary in certain cases.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 4 - A 42-year-old woman with diagnosed irritable bowel syndrome (IBS) is currently taking loperamide,...

    Correct

    • A 42-year-old woman with diagnosed irritable bowel syndrome (IBS) is currently taking loperamide, movicol and hyoscine butylbromide (Buscopan) for management. However, she is still experiencing bloating and abdominal pain.
      What would be the next treatment option from the list below?

      Your Answer: Tricyclic antidepressant (eg amitriptyline)

      Explanation:

      Understanding and Managing Irritable Bowel Syndrome (IBS)

      Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects 10-20% of the population, with women being more susceptible than men. It is characterized by abdominal pain, bloating, and altered bowel habits without any specific organic pathology. Diagnosis is based on the presence of symptoms for at least 6 months, and physical examination and investigations are used to exclude other differential diagnoses.

      Management of IBS involves psychological support and dietary measures, such as fibre supplementation, low FODMAP diets, increased water intake, and avoiding trigger foods. Pharmacological treatment is adjunctive and should be directed at symptoms. Antispasmodics, antidiarrhoeals, and antidepressants may have a positive effect on symptoms. However, the choice of medication should be based on the nature and severity of symptoms, with the option of single or combination medication determined by the predominant symptom(s).

      It is important to note that certain medications, such as aspirin and NSAIDs, can worsen IBS symptoms, and laxatives like lactulose should be discouraged. Patients should be made aware of these potential risks and advised accordingly. Overall, a multidisciplinary approach involving healthcare professionals and patients is essential for the effective management of IBS.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 5 - A 42-year-old-woman, who rarely visits the clinic, complains of heartburn and acid reflux...

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    • A 42-year-old-woman, who rarely visits the clinic, complains of heartburn and acid reflux for the past 3 weeks. She comes back after taking a PPI for 1 week with some relief. Her BMI is 27 kg/m2. What is the most suitable next step in her treatment?

      Your Answer: Continue the PPI and review in 2 weeks

      Explanation:

      Management of New-Onset Dyspepsia in a Middle-Aged Patient

      When a middle-aged patient presents with new-onset dyspepsia, it is important to take a thorough clinical history to rule out more serious conditions such as malignancy. A 4-week course of full-dose PPI is typically recommended, although there is no clear evidence on whether this or Helicobacter pylori testing should be done first. If PPIs are used, a 2-week washout period is necessary before testing for H. pylori to avoid false-negative results.

      While alginate preparations like Gaviscon® can be used to inhibit gastric acid reflux, it may be more appropriate to increase the PPI dose if the patient has already experienced some improvement with this medication. However, if the patient exhibits ‘red flag’ symptoms like gastrointestinal bleeding, anorexia, weight loss, dysphagia, or the presence of an epigastric mass, urgent endoscopy is necessary. Endoscopy is also recommended for patients over 55 with persistent, unexplained dyspepsia that has not responded well to PPIs.

      Finally, while this patient’s BMI is on the higher end of the healthy range, referral to a dietician is unlikely to be necessary unless there are specific concerns about weight loss measures. Overall, a comprehensive approach to managing new-onset dyspepsia in middle-aged patients involves careful consideration of symptoms, medication options, and potential underlying conditions.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 6 - A 60-year-old man who was recently diagnosed with chronic pancreatitis presents to his...

    Correct

    • A 60-year-old man who was recently diagnosed with chronic pancreatitis presents to his General Practitioner due to persistent central abdominal pain. This has been present ever since he was admitted to the hospital and diagnosed with chronic pancreatitis; however, he feels that the medication he was prescribed is losing its effects.
      The patient is currently on amlodipine, amitriptyline, perindopril and pancreatic enzyme replacement.
      Which of the following management options is the best next step to control the patient’s pain?
      Select the SINGLE best management plan from the list below.
      Select ONE option only.

      Your Answer: Stop amitriptyline, start duloxetine

      Explanation:

      Managing Neuropathic Pain: Choosing the Right Medication

      Neuropathic pain can be a challenging condition to manage, especially when standard analgesia such as non-steroidal anti-inflammatory drugs and paracetamol prove ineffective. According to the National Institute for Health and Care Excellence (NICE) guidelines, the first-line management of neuropathic pain involves starting the patient on amitriptyline, duloxetine, gabapentin or pregabalin. However, if the first-line drug treatment does not work, one of the other drugs can be tried.

      It is important to note that drugs for neuropathic pain are typically used as monotherapy rather than in combinations. Therefore, if a drug does not achieve the desired clinical effect, it should be replaced by another drug rather than adding a new drug to it. Duloxetine is a good next option, but it should replace the amitriptyline rather than be added to it.

      Further management of neuropathic pain includes pain management clinics and tramadol as rescue therapy for exacerbations of neuropathic pain. By choosing the right medication and following appropriate management strategies, patients with neuropathic pain can achieve better pain control and improved quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 7 - A 75-year-old man presents to the emergency department with acute upper gastrointestinal bleeding...

    Correct

    • A 75-year-old man presents to the emergency department with acute upper gastrointestinal bleeding due to alcoholic liver cirrhosis. The medical team performs an ABCDE assessment and administers terlipressin. An urgent endoscopy is requested. What medication should be administered to the patient prior to the endoscopy?

      Your Answer: Antibiotic therapy

      Explanation:

      Antibiotic therapy is the appropriate course of action to reduce mortality in cirrhotic patients experiencing gastrointestinal bleeding. Prophylactic antibiotics, particularly quinolones, should be administered alongside terlipressin for individuals suspected of having variceal bleeding. The use of cimetidine is not recommended for acute treatment before endoscopy, but it may be used as a preventative measure for mild acid reflux symptoms. Octreotide is sometimes used as an alternative to terlipressin, but studies indicate that it is less effective in reducing mortality. Propranolol is utilized as a prophylactic measure to decrease the incidence of variceal bleeding.

      Variceal haemorrhage is a serious condition that requires prompt management. The initial treatment involves resuscitation of the patient before endoscopy. Correcting clotting with FFP and vitamin K is important, as is the use of vasoactive agents such as terlipressin or octreotide. Prophylactic IV antibiotics are also recommended to reduce mortality in patients with liver cirrhosis. Endoscopic variceal band ligation is the preferred method of treatment, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. Propranolol and EVL are effective in preventing rebleeding and mortality, and are recommended by NICE guidelines. Proton pump inhibitor cover is given to prevent EVL-induced ulceration.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 8 - A 28-year-old man comes to your clinic seeking advice on how to improve...

    Correct

    • A 28-year-old man comes to your clinic seeking advice on how to improve his health after his uncle passed away from a heart attack at the age of 50. He mentions that he has already begun going to the gym three times a week and has increased his consumption of fruits and vegetables. However, he works in finance and is finding it difficult to reduce his alcohol consumption. What is the highest recommended weekly alcohol limit for men in the UK?

      Your Answer: 14 units

      Explanation:

      The latest recommendations state that individuals should limit their alcohol consumption to no more than 14 units per week, regardless of gender. Additionally, it is suggested that individuals should spread out their drinking over a minimum of three days if they regularly consume 14 units per week.

      Alcohol consumption guidelines were revised in 2016 by the Chief Medical Officer, based on recommendations from an expert group report. The most significant change was a reduction in the recommended maximum number of units of alcohol for men from 21 to 14, aligning with the guidelines for women. The government now advises that both men and women should not exceed 14 units of alcohol per week, and if they do, it is best to spread it evenly over three or more days. Pregnant women are advised not to drink alcohol at all, as it can cause long-term harm to the baby. One unit of alcohol is equivalent to 10 mL of pure ethanol, and the strength of a drink is determined by its alcohol by volume (ABV). Examples of one unit of alcohol include a 25ml single measure of spirits with an ABV of 40%, a third of a pint of beer with an ABV of 5-6%, and half a 175ml standard glass of red wine with an ABV of 12%. To calculate the number of units in a drink, multiply the number of millilitres by the ABV and divide by 1,000.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 9 - A 42-year-old construction worker is referred by his family doctor with chronic upper...

    Incorrect

    • A 42-year-old construction worker is referred by his family doctor with chronic upper abdominal pain on the right side. He admits to drinking a six-pack of beer every night after work. Over the past year, he has lost about 9 kg (1.5 stone) in weight, and his wife says that he often skips meals in favor of alcohol. He has occasional diarrhea, which he describes as greasy and difficult to flush away. Physical examination reveals a lean man with tenderness upon deep palpation in the right upper quadrant. Blood testing reveals mild normochromic/normocytic anaemia and alanine aminotransferase (ALT) level raised to twice the upper limit of normal. Amylase and anti-gliadin antibodies are normal. Upper abdominal ultrasound is performed and there is diffuse pancreatic calcification, but nothing else of note.
      Which diagnosis best fits this clinical picture?

      Your Answer: Pancreatic carcinoma

      Correct Answer: Chronic pancreatitis

      Explanation:

      Chronic pancreatitis is a condition where the pancreas undergoes ongoing inflammation, resulting in irreversible changes. The most common symptom is recurring abdominal pain, often in the mid or upper left abdomen, accompanied by weight loss and diarrhea. Imaging tests can reveal inflammation or calcium deposits in the pancreas, and pancreatic calcifications are considered a telltale sign of chronic pancreatitis. Excessive alcohol consumption is the leading cause of this condition, as it can cause blockages in the pancreatic ducts and stimulate inflammation.

      Pancreatic carcinoma is a type of cancer that typically affects individuals over the age of 50. Symptoms are often vague and non-specific, such as fatigue, nausea, and mid-epigastric or back pain. Obstructive jaundice is a common symptom, with elevated levels of bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase. Ultrasound is often used for diagnosis, but it may not reveal the extent of the cancer.

      Acute pancreatitis is characterized by sudden, severe abdominal pain, nausea, vomiting, and diarrhea. Fever, tachycardia, and abdominal muscle guarding are also common symptoms. Serum amylase and lipase levels are typically elevated, and leukocytosis may be present.

      Coeliac disease is a chronic digestive disorder that results in an inability to tolerate gliadin, a component of gluten. Laboratory tests may reveal electrolyte imbalances, malnutrition, and anemia. The most reliable antibodies for confirming coeliac disease are tissue transglutaminase immunoglobulin A, endomysial IgA, and reticulin IgA.

      Recurrent cholecystitis is a condition where the gallbladder becomes inflamed due to gallstones blocking the cystic duct. Symptoms include recurring episodes of biliary colic, but a palpable mass is not always present. Ultrasound may reveal a thickened gallbladder wall, gallstones, or calcification.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 10 - A 72-year-old male presents to the emergency department with complaints of new-onset pain...

    Incorrect

    • A 72-year-old male presents to the emergency department with complaints of new-onset pain in his left groin. Upon examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle is observed, accompanied by erythema of the overlying skin. The patient reports vomiting twice and passing stools with blood mixed in them once. He appears to be in pain and is sweating profusely. His medical history includes peptic ulcer disease, which is managed with omeprazole. What is the most likely diagnosis?

      Your Answer: Strangulated inguinal hernia

      Correct Answer: Strangulated femoral hernia

      Explanation:

      A femoral hernia can lead to the serious complication of strangulation. In this case, the patient has a non-reducible mass located below the pubic tubercle, which is typical of a femoral hernia. However, the accompanying symptoms of vomiting, bloody stools, and a toxic appearance suggest that the hernia has become strangulated, meaning that the blood supply to the herniated tissue has been compromised and may lead to tissue death.

      An incarcerated femoral hernia would also present as a non-reducible mass below the pubic tubercle, but without the symptoms of strangulation.

      In contrast, an incarcerated inguinal hernia would present as a non-reducible mass above and towards the middle of the pubic tubercle, and would not cause symptoms of strangulation.

      A perforated peptic ulcer would cause pain in the upper abdomen, syncope, and possibly vomiting blood, which is different from the patient’s symptoms.

      Similarly, a strangulated inguinal hernia would cause similar symptoms, but the mass would be located above and towards the middle of the pubic tubercle, rather than below it.

      Understanding Femoral Hernias

      Femoral hernias occur when a part of the bowel or other abdominal organs pass through the femoral canal, which is a potential space in the anterior thigh. This can result in a lump in the groin area that is mildly painful and typically non-reducible. Femoral hernias are less common than inguinal hernias, accounting for only 5% of abdominal hernias, and are more prevalent in women, especially those who have had multiple pregnancies. Diagnosis is usually clinical, but ultrasound may be used to confirm the presence of a femoral hernia and exclude other possible causes of a lump in the groin area.

      Complications of femoral hernias include incarceration, where the herniated tissue cannot be reduced, and strangulation, which is a surgical emergency. The risk of strangulation is higher with femoral hernias than with inguinal hernias and increases over time. Bowel obstruction and bowel ischaemia may also occur, leading to significant morbidity and mortality for the patient.

      Surgical repair is necessary for femoral hernias, and it can be done laparoscopically or via a laparotomy. Hernia support belts or trusses should not be used for femoral hernias due to the risk of strangulation. In an emergency situation, a laparotomy may be the only option. It is essential to distinguish femoral hernias from inguinal hernias, as they have different locations and require different management approaches.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 11 - A 42-year-old woman presents with a persistent history of acid reflux. She has...

    Correct

    • A 42-year-old woman presents with a persistent history of acid reflux. She has visited her primary care physician multiple times. A trial of low-dose proton pump inhibitor (PPI) and lifestyle changes has not improved her symptoms. She has been tested for Helicobacter pylori, and the results were negative. Her screening blood tests are normal.
      What is the best course of action for management?

      Your Answer: Do an upper gastrointestinal (GI) endoscopy

      Explanation:

      Approaches to Managing Dyspepsia in Patients with Gastro-Oesophageal Reflux Disease

      Patients with chronic gastro-oesophageal reflux disease (GORD) are at risk of developing Barrett’s oesophagus and oesophageal cancer. Therefore, patients aged 50 years or older with a history of chronic GORD should undergo at least one upper gastrointestinal (GI) endoscopy to screen for these conditions. In younger patients, long-term low-dose proton pump inhibitor (PPI) therapy may be considered, with dose adjustment if necessary. However, ongoing dyspepsia in a patient over 50 years old warrants further investigation to exclude serious pathology. Intermittent high-dose PPI therapy is currently only used in hospital for specific indications. Counselling with false reassurance should be avoided in patients with concerning symptoms.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 12 - A 65-year-old man presents to your clinic with a chief complaint of progressive...

    Correct

    • A 65-year-old man presents to your clinic with a chief complaint of progressive difficulty in swallowing over the past 4 months. Upon further inquiry, he reports a weight loss of approximately 2.5 kilograms, which he attributes to a decreased appetite. He denies any pain with swallowing or regurgitation of food. During the interview, you observe a change in his voice quality. What is the probable diagnosis?

      Your Answer: Oesophageal carcinoma

      Explanation:

      When a patient experiences progressive dysphagia along with weight loss, it is important to investigate for possible oesophageal carcinoma as this is a common characteristic. Laryngeal nerve damage can also cause hoarseness in patients with this type of cancer. Although achalasia may present with similar symptoms, patients typically have difficulty swallowing both solids and liquids equally and may experience intermittent regurgitation of food. On the other hand, patients with oesophageal spasm usually experience pain when swallowing.

      Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment

      Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus.

      Risk factors for adenocarcinoma include GORD, Barrett’s oesophagus, smoking, achalasia, and obesity. Squamous cell cancer is more common in the developing world and is associated with smoking, alcohol, achalasia, Plummer-Vinson syndrome, and diets rich in nitrosamines.

      The most common presenting symptom for both types of oesophageal cancer is dysphagia, followed by anorexia and weight loss. Other possible features include odynophagia, hoarseness, melaena, vomiting, and cough.

      Diagnosis is done through upper GI endoscopy with biopsy, endoscopic ultrasound for locoregional staging, CT scanning for initial staging, and FDG-PET CT for detecting occult metastases. Laparoscopy may also be performed to detect occult peritoneal disease.

      Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. Adjuvant chemotherapy may also be used in many patients.

      Overall, oesophageal cancer is a serious condition that requires prompt diagnosis and treatment. Understanding the types, risk factors, features, diagnosis, and treatment options can help patients and healthcare providers make informed decisions about managing this disease.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 13 - A General Practice is conducting an audit on the number of elderly patients...

    Correct

    • A General Practice is conducting an audit on the number of elderly patients with gastrointestinal symptoms who were referred for endoscopy without a clear clinical indication.
      Which of the following intestinal diseases necessitates blood tests and small intestinal biopsy for a precise diagnosis?

      Your Answer: Coeliac disease

      Explanation:

      Diagnosing Gastrointestinal Conditions through Biopsy Findings

      Biopsy findings play a crucial role in diagnosing various gastrointestinal conditions. However, some conditions require additional proof to confirm the diagnosis. Here are some examples:

      Coeliac disease: Biopsy findings may show changes in the small intestine, but they are non-specific. Positive serology for anti-endomysial or anti-gliadin antibodies is needed for confirmation.

      Abetalipoproteinemia: This condition can be diagnosed on biopsy findings alone. Clear enterocytes due to lipid accumulation are characteristic.

      Intestinal lymphangiectasia: Biopsy findings alone can diagnose primary intestinal lymphangiectasia, which is evidenced by the dilatation of lymphatics of the intestinal mucosa without any evidence of inflammation.

      Mycobacterium avium (M avium) infection: Foamy macrophages containing numerous acid-fast bacilli are characteristic of M avium infection and can be diagnosed through biopsy findings alone.

      Whipple’s disease: Biopsy findings alone can diagnose Whipple’s disease, which is characterised by swollen macrophages containing numerous periodic acid Schiff (PAS) positive granules due to the glycogen content of bacterial cell walls.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 14 - A 49-year-old woman with poorly controlled type 1 diabetes mellitus presents with complaints...

    Correct

    • A 49-year-old woman with poorly controlled type 1 diabetes mellitus presents with complaints of bloating and vomiting after meals. She reports that her blood glucose levels have been fluctuating more frequently lately. Which medication is most likely to provide relief for her symptoms?

      Your Answer: Metoclopramide

      Explanation:

      Gastric emptying dysfunction can cause upper gastrointestinal symptoms and disrupt glucose control. Metoclopramide, a pro-kinetic medication, can help improve gastric emptying and alleviate these issues.

      Diabetes can cause peripheral neuropathy, which typically results in sensory loss rather than motor loss. This often affects the lower legs first due to the length of the sensory neurons supplying this area, resulting in a glove and stocking distribution. Painful diabetic neuropathy is a common issue that can be managed with drugs such as amitriptyline, duloxetine, gabapentin, or pregabalin. If these drugs do not work, tramadol may be used as a rescue therapy, and topical capsaicin may be used for localized neuropathic pain. Pain management clinics may also be helpful for patients with resistant problems.

      Gastrointestinal autonomic neuropathy can cause gastroparesis, which can lead to erratic blood glucose control, bloating, and vomiting. This can be managed with prokinetic agents such as metoclopramide, domperidone, or erythromycin. Chronic diarrhea, which often occurs at night, is another potential complication of diabetic neuropathy. Gastroesophageal reflux disease can also occur due to decreased lower esophageal sphincter pressure.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 15 - As a foundation year two doctor on the surgical admissions unit, you encounter...

    Correct

    • As a foundation year two doctor on the surgical admissions unit, you encounter a thirty-year-old patient complaining of right upper abdominal pain and anorexia. Upon examination, you find an overweight Caucasian female with a soft abdomen that is tender in the right upper quadrant. Her observations indicate fever and mild tachycardia. Blood tests reveal a significantly elevated bilirubin level (87 umol/L). What is the probable diagnosis?

      Your Answer: Ascending cholangitis

      Explanation:

      The presence of fever, jaundice and right upper quadrant pain is known as Charcot’s cholangitis triad, which indicates an infection of the bile ducts. This patient is likely suffering from ascending cholangitis. Cholecystitis, which is inflammation of the gallbladder, can also cause right upper quadrant pain and may precede ascending cholangitis. While gallstones are a common cause of cholangitis, they can be asymptomatic and are not a diagnosis on their own. Pregnancy is not a likely cause of right upper quadrant pain. Gilbert’s syndrome typically causes mild jaundice only during times of stress and is usually asymptomatic.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 16 - A 62-year-old woman comes to the Emergency Department with acute abdominal pain. She...

    Correct

    • A 62-year-old woman comes to the Emergency Department with acute abdominal pain. She is experiencing severe pain in the epigastric region that radiates to her back and is vomiting excessively. When questioned, she confesses to having had too many drinks at a bachelorette party the night before. Her serum amylase level is 1190 u/l. What is the most suitable initial management step?

      Your Answer: Fluid resuscitation

      Explanation:

      Treatment and Diagnosis of Acute Pancreatitis

      Acute pancreatitis can lead to systemic inflammatory response syndrome and multiple organ dysfunction syndromes. The mainstay of treatment is supportive measures such as fluid resuscitation and oxygen supplementation. Abdominal ultrasound can be useful to identify gallstones as the cause of pancreatitis, but fluid resuscitation takes priority. IV antibiotics are not indicated unless complications occur. Enteral feeding is preferred over nil by mouth, and parenteral feeding should be considered if enteral feeding is not tolerated. Urgent CT of the abdomen is not necessary in the acute stage unless complications are suspected. However, for severe pancreatitis, contrast-enhanced CT may be indicated four days after initial symptoms to assess for complications.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 17 - A 50-year-old man with a history of gallstone disease comes to the clinic...

    Correct

    • A 50-year-old man with a history of gallstone disease comes to the clinic complaining of pain in the right upper quadrant for the past two days. He reports feeling like he has the flu and his wife mentions that he has had a fever for the past day. During the examination, his temperature is recorded as 38.1ºC, blood pressure at 100/60 mmHg, and pulse at 102/min. He experiences tenderness in the right upper quadrant and his sclera have a yellowish tint. What is the most probable diagnosis?

      Your Answer: Ascending cholangitis

      Explanation:

      The presence of fever, jaundice, and pain in the right upper quadrant indicates Charcot’s cholangitis triad, which is commonly associated with ascending cholangitis. This combination of symptoms is not typically seen in cases of acute cholecystitis.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 18 - A 50-year-old male comes to the emergency department complaining of malaise, yellowing sclera,...

    Incorrect

    • A 50-year-old male comes to the emergency department complaining of malaise, yellowing sclera, and increasing abdominal girth. He admits to drinking 80 cl of whisky daily and has had several unsuccessful attempts at community detoxification. The patient has a medical history of liver cirrhosis. During the examination, a significantly distended abdomen with a shifting dullness and an enlarged mass in the right upper quadrant are observed.

      What is the most suitable medication to prescribe for this patient?

      Your Answer: Furosemide

      Correct Answer: Spironolactone

      Explanation:

      For patients with ascites caused by liver cirrhosis, it is recommended to prescribe an aldosterone antagonist, such as spironolactone, as the preferred diuretic to combat sodium retention. A low-salt diet should also be implemented. While furosemide can be useful in combination with spironolactone, it is not effective in blocking aldosterone and should not be used as a single agent. Nephrotoxic medications, including naproxen, should be avoided. ACE inhibitors, like ramipril, can induce renal failure and should be used with caution and careful monitoring of blood pressure and renal function. Restricting high sodium concentration fluids will not be beneficial, but a low sodium diet is recommended to prevent water retention.

      Understanding Ascites: Causes and Management

      Ascites is a medical condition characterized by the accumulation of abnormal fluid in the abdomen. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. A SAAG level greater than 11g/L indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. On the other hand, a SAAG level less than 11g/L is caused by hypoalbuminaemia, malignancy, infections, and other factors such as bowel obstruction and biliary ascites.

      The management of ascites involves reducing dietary sodium and fluid restriction, especially if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone and loop diuretics are often prescribed to patients. In some cases, drainage through therapeutic abdominal paracentesis is necessary. Large-volume paracentesis requires albumin cover to reduce the risk of paracentesis-induced circulatory dysfunction and mortality. Prophylactic antibiotics are also recommended to prevent spontaneous bacterial peritonitis. In severe cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.

      Understanding the causes and management of ascites is crucial in providing appropriate medical care to patients. Proper diagnosis and treatment can help alleviate symptoms and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 19 - Crohn's disease is characterized by which of the following features? Please select the...

    Correct

    • Crohn's disease is characterized by which of the following features? Please select the ONE most characteristic feature from the list provided.

      Your Answer: Skip lesions

      Explanation:

      Comparison of Crohn’s Disease and Ulcerative Colitis

      Crohn’s disease and ulcerative colitis are two types of inflammatory bowel disease that affect the gastrointestinal tract. Crohn’s disease can occur anywhere along the GI tract, while ulcerative colitis typically only affects the large intestine.

      One characteristic of Crohn’s disease is the presence of skip lesions, or areas of inflammation discontinuity. The colon wall may also appear thickened and have a cobblestone appearance. In contrast, ulcerative colitis shows continuous inflammation in affected areas, with a thinner colon wall and ulcers limited to the mucous lining of the large intestine.

      Both diseases can cause rectal bleeding, but it is more common in ulcerative colitis. Other symptoms of ulcerative colitis include frequent stools and mucus discharge from the rectum, while Crohn’s disease often presents with prolonged diarrhea and abdominal pain.

      Pseudopolyps, or benign lesions originating from the mucosa, can occur in both diseases but are more prevalent in ulcerative colitis. Crypt abscess formation, characterized by intense infiltration of the mucosa and submucosa with neutrophils and crypt abscesses, is a hallmark of ulcerative colitis.

      Management of these diseases includes medical therapy, endoscopy, and surgery for complications such as bleeding or obstruction. Understanding the differences between Crohn’s disease and ulcerative colitis is crucial for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 20 - A 25-year-old student presents to his General Practitioner with symptoms of a flu-like...

    Incorrect

    • A 25-year-old student presents to his General Practitioner with symptoms of a flu-like illness. He reports not having eaten for the past 48 hours. During examination, mild jaundice is observed, but no other significant physical findings are noted. The patient's total serum bilirubin level is elevated at 60 μmol/l (reference range < 20 μmol/l), while the other liver function tests (LFTs) are normal. Full blood count (FBC), urea and electrolytes, and haptoglobins are within normal limits. What is the most likely diagnosis for this clinical presentation?

      Your Answer: Hepatitis A

      Correct Answer: Gilbert syndrome

      Explanation:

      Differential Diagnosis: Jaundice and Abdominal Symptoms

      Gilbert Syndrome:
      Gilbert syndrome is an inherited condition that can manifest as jaundice on clinical examination. Patients may also experience non-specific symptoms such as abdominal cramps, fatigue, and malaise. Fasting, febrile illness, alcohol, or exercise can exacerbate jaundice in patients with Gilbert syndrome. Diagnosis is based on a thorough history and physical examination, as well as blood tests that show unconjugated hyperbilirubinaemia.

      Haemolytic Anaemia:
      Haemolysis is the premature destruction of erythrocytes, which can lead to anaemia if bone marrow activity cannot compensate for erythrocyte loss. Mild haemolysis can be asymptomatic, while severe haemolysis can cause life-threatening symptoms such as angina and cardiopulmonary decompensation. Changes in lactate dehydrogenase and serum haptoglobin levels are the most sensitive general tests for haemolytic anaemia.

      Hepatitis A:
      Hepatitis A is a viral infection that results almost exclusively from ingestion, typically through faecal-oral transmission. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for immunoglobulin M (IgM) antibody to HAV.

      Hepatitis B:
      Hepatitis B is a viral infection that is transmitted haematogenously and sexually. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for hepatitis B surface antigen (HBsAg).

      Cholecystitis:
      Cholecystitis is inflammation of the gall bladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gall bladder. Symptoms include upper abdominal pain, nausea, vomiting, and fever. Signs of peritoneal irritation may also be present.

      Conclusion:
      In summary, the differential diagnosis of jaundice and abdominal symptoms includes Gilbert syndrome, haemolytic anaemia, hepatitis A, hepatitis B, and cholecystitis. Diagnosis is based on a thorough history and physical examination, as well as blood tests and serologic testing as appropriate. Treatment

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 21 - A 68-year-old man presents with persistent dyspepsia that is alleviated by omeprazole. He...

    Incorrect

    • A 68-year-old man presents with persistent dyspepsia that is alleviated by omeprazole. He has been taking omeprazole 20 mg daily for the past 2 years. What is a drawback of using a proton-pump inhibitor (PPI) for an extended period of time?

      Your Answer: Increased risk of liver impairment

      Correct Answer: Increased risk of fractures

      Explanation:

      According to the BNF, PPIs should be taken in the lowest effective dose for the shortest possible time, and their long-term use should be regularly evaluated. Prolonged use of PPIs can conceal the signs of stomach cancer and heighten the likelihood of osteoporosis and fractures by hindering the absorption of calcium and magnesium.

      Understanding Proton Pump Inhibitors and Their Adverse Effects

      Proton pump inhibitors (PPIs) are medications that block the H+/K+ ATPase of the gastric parietal cell, leading to irreversible effects. Common examples of PPIs include omeprazole and lansoprazole. While these medications are effective in treating conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers, they can also have adverse effects on the body.

      One of the potential adverse effects of PPIs is hyponatremia, which is a condition characterized by low levels of sodium in the blood. PPIs can also lead to hypomagnesemia, which is a deficiency of magnesium in the blood. Additionally, long-term use of PPIs has been linked to an increased risk of osteoporosis and fractures. Another potential adverse effect is microscopic colitis, which is inflammation of the colon that can cause diarrhea and abdominal pain. Finally, PPIs have been associated with an increased risk of C. difficile infections, which can cause severe diarrhea and other gastrointestinal symptoms.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 22 - A 60-year-old woman has been diagnosed with Parkinson's disease and is currently taking...

    Incorrect

    • A 60-year-old woman has been diagnosed with Parkinson's disease and is currently taking Sinemet (co-careldopa) prescribed by her neurologist. However, she is experiencing severe nausea as a side effect. What is the best anti-emetic medication to recommend?

      Your Answer: Cyclizine

      Correct Answer: Domperidone

      Explanation:

      Understanding Parkinsonism and Its Causes

      Parkinsonism is a term used to describe a group of neurological disorders that share similar symptoms with Parkinson’s disease. The causes of Parkinsonism can vary, with some cases being drug-induced, such as the use of antipsychotics or metoclopramide. Other causes include progressive supranuclear palsy, multiple system atrophy, Wilson’s disease, post-encephalitis, and dementia pugilistica, which is often seen in individuals who have suffered from chronic head trauma, such as boxers. Additionally, exposure to toxins like carbon monoxide or MPTP can also lead to Parkinsonism.

      It is important to note that not all medications that cause extra-pyramidal side-effects will lead to Parkinsonism. For example, domperidone does not cross the blood-brain barrier and therefore does not cause these side-effects. Understanding the various causes of Parkinsonism can help with early diagnosis and treatment, as well as prevention in some cases. By identifying the underlying cause, healthcare professionals can tailor treatment plans to address the specific needs of each patient.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 23 - A 24-year-old woman presents to the emergency department with a 3-day history of...

    Incorrect

    • A 24-year-old woman presents to the emergency department with a 3-day history of vomiting. She is unable to take any fluids orally and complains of feeling dizzy and lethargic. There is no past medical history of note and she takes no regular medications. She is 12 weeks pregnant.

      On examination, she has a temperature of 36.5ºC with a heart rate of 110 beats/min and a blood pressure of 100/60 mmHg. She has dry mucous membranes. Her abdomen is soft and nontender.

      What is the most appropriate initial anti-emetic for this patient, given the likely diagnosis?

      Your Answer: Metoclopramide

      Correct Answer: Cyclizine

      Explanation:

      Antihistamines, specifically cyclizine, are the recommended first-line treatment for nausea and vomiting in pregnancy, including hyperemesis gravidarum. Dexamethasone is not typically used for hyperemesis gravidarum, as it is more commonly used for post-operative and chemotherapy-induced nausea and vomiting. Domperidone is not commonly used for hyperemesis gravidarum, as it is primarily used to treat nausea in patients with Parkinson’s disease. Metoclopramide is a second-line treatment option for hyperemesis gravidarum, but is not the first-line choice.

      Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 24 - A 28-year-old woman comes in for a check-up. She has a history of...

    Correct

    • A 28-year-old woman comes in for a check-up. She has a history of perianal abscess, but no other significant medical issues. Over the past few months, she has visited the Emergency Department twice due to persistent abdominal pain. She has also experienced occasional episodes of bloody diarrhea. Blood tests reveal microcytic anemia and mild hypokalemia. Her albumin levels are low, but her liver function tests are normal. Barium imaging shows a small bowel stricture with evidence of mucosal ulceration, as well as normal-looking mucosa and skip pattern lesions. Based on these symptoms, what is the most likely diagnosis?

      Your Answer: Crohn's disease

      Explanation:

      Differential Diagnosis of Chronic Diarrhoea with Abdominal Pain and Weight Loss

      Chronic diarrhoea with abdominal pain and weight loss can be indicative of various gastrointestinal disorders. A thorough differential diagnosis is necessary to determine the underlying cause.

      Crohn’s Disease: This inflammatory bowel disease can affect any part of the gastrointestinal tract and is characterized by prolonged diarrhoea with abdominal pain, weight loss, and fatigue. Diarrhoea is usually not bloody, but if the colon is involved, patients may report diffuse abdominal pain accompanied by mucus, blood, and pus in the stool. Serologic tests such as ASCA and p-ANCA can help differentiate Crohn’s disease from other conditions.

      Ulcerative Colitis: Unlike Crohn’s disease, UC involves only the large bowel and is characterized by rectal bleeding, frequent stools, and mucus discharge from the rectum. Sigmoidoscopy can confirm the diagnosis.

      Small Bowel Lymphoma: MALTomas can occur in various gastrointestinal sites, but most patients have no physical findings.

      Coeliac Disease: This chronic disorder results in an inability to tolerate gliadin and is characterized by electrolyte imbalances, evidence of malnutrition, and anaemia. Diarrhoea is the most common symptom, with characteristic foul-smelling stools.

      Tropical Sprue: This syndrome is characterized by acute or chronic diarrhoea, weight loss, and nutrient malabsorption and occurs in residents or visitors to the tropics and subtropics. However, it is not suggestive in the absence of a history of foreign travel.

      In conclusion, a thorough evaluation of symptoms and diagnostic tests is necessary to differentiate between these gastrointestinal disorders and determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 25 - A 56-year-old woman presents with dyspepsia and an endoscopy reveals a gastric ulcer....

    Incorrect

    • A 56-year-old woman presents with dyspepsia and an endoscopy reveals a gastric ulcer. A CLO test confirms H. pylori infection and she is treated with eradication therapy. However, at her follow-up appointment six weeks later, her symptoms persist. What is the best test to confirm H. pylori eradication?

      Your Answer: Culture of gastric biopsy

      Correct Answer: Urea breath test

      Explanation:

      The sole recommended test for H. pylori after eradication therapy is the urea breath test. It should be noted that H. pylori serology will still show positive results even after eradication. In such cases, a stool antigen test, rather than culture, may be a suitable alternative.

      Tests for Helicobacter pylori

      There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.

      Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.

      Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 26 - Which of the following is most commonly linked to elevated levels of CA...

    Correct

    • Which of the following is most commonly linked to elevated levels of CA 19-9?

      Your Answer: Pancreatic cancer

      Explanation:

      CA 19-9 and Pancreatic Cancer

      Understanding Tumour Markers

      Tumour markers are substances that can be found in the blood, urine, or tissues of people with cancer. They are often used to help diagnose and monitor cancer, as well as to determine the effectiveness of treatment. Tumour markers can be divided into different categories, including monoclonal antibodies against carbohydrate or glycoprotein tumour antigens, tumour antigens, enzymes, and hormones.

      Monoclonal antibodies are used to target specific tumour antigens, which are proteins or other molecules that are found on the surface of cancer cells. Some common tumour markers include CA 125 for ovarian cancer, CA 19-9 for pancreatic cancer, and CA 15-3 for breast cancer. However, it is important to note that tumour markers usually have a low specificity, meaning that they can also be found in people without cancer.

      Tumour antigens are proteins that are produced by cancer cells and can be detected in the blood or tissues of people with cancer. Some examples of tumour antigens include prostate specific antigen (PSA) for prostatic carcinoma, alpha-feto protein (AFP) for hepatocellular carcinoma and teratoma, and carcinoembryonic antigen (CEA) for colorectal cancer.

      Enzymes and hormones can also be used as tumour markers. For example, alkaline phosphatase and neurone specific enolase are enzymes that can be elevated in people with cancer, while hormones such as calcitonin and ADH can be used to detect certain types of cancer.

      In summary, tumour markers are an important tool in the diagnosis and monitoring of cancer. However, they should be used in conjunction with other diagnostic tests and imaging studies, as they are not always specific to cancer and can also be elevated in people without cancer.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 27 - A 29-year-old man comes in for follow-up. He was diagnosed with an anal...

    Correct

    • A 29-year-old man comes in for follow-up. He was diagnosed with an anal fissure approximately 8 weeks ago and has attempted dietary changes, laxatives, and topical anesthetics with minimal improvement. What would be the most suitable course of action to take next?

      Your Answer: Topical glyceryl trinitrate

      Explanation:

      Topical glyceryl trinitrate is used to treat chronic anal fissure.

      Understanding Anal Fissures: Causes, Symptoms, and Treatment

      Anal fissures are tears in the lining of the distal anal canal that can be either acute or chronic. Acute fissures last for less than six weeks, while chronic fissures persist for more than six weeks. The most common risk factors for anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.

      Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, underlying causes such as Crohn’s disease should be considered.

      Management of acute anal fissures involves softening stool, dietary advice, bulk-forming laxatives, lubricants, topical anaesthetics, and analgesia. For chronic anal fissures, the same techniques should be continued, and topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after eight weeks, surgery (sphincterotomy) or botulinum toxin may be considered, and referral to secondary care is recommended.

      In summary, anal fissures can be a painful and uncomfortable condition, but with proper management, they can be effectively treated. It is important to identify and address underlying risk factors to prevent the development of chronic fissures.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 28 - Which of the following characteristics is more prevalent in Crohn's disease compared to...

    Correct

    • Which of the following characteristics is more prevalent in Crohn's disease compared to ulcerative colitis?

      Your Answer: Abdominal mass palpable in the right iliac fossa

      Explanation:

      Crohn’s disease and ulcerative colitis are the two main types of inflammatory bowel disease with many similarities in symptoms and management options. However, there are key differences such as non-bloody diarrhea and upper gastrointestinal symptoms being more common in Crohn’s disease, while bloody diarrhea and abdominal pain in the left lower quadrant are more common in ulcerative colitis. Complications and pathology also differ between the two diseases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 29 - A 32-year-old man presents with a recent change in bowel habit and is...

    Correct

    • A 32-year-old man presents with a recent change in bowel habit and is scheduled for outpatient sigmoidoscopy. He reports passing 3 stools daily with some mucus but no blood. The patient is in good overall health, with stable vital signs and normal blood test results. He has no known allergies and is not taking any medications at present.

      During the sigmoidoscopy, the patient is found to have localised proctitis, with no inflammation detected further up the gastrointestinal tract. Based on these findings, the patient is diagnosed with ulcerative colitis and receives appropriate counselling.

      What would be the most effective drug management approach for this patient's current symptoms?

      Your Answer: Rectal aminosalicylates

      Explanation:

      For a mild-moderate flare of distal ulcerative colitis, the recommended first-line treatment is rectal aminosalicylates. This is particularly effective if the inflammation is limited to the rectum. If rectal aminosalicylates are not effective, oral aminosalicylates may be used in combination with or instead of the topical treatment. However, if the patient has contraindications or intolerances to aminosalicylates, topical or oral steroids may be preferred. Intravenous steroids are typically reserved for severe flares of colitis with symptoms such as frequent bloody stools, systemic upset, anemia, or elevated inflammatory markers.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools and presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Extensive disease may require a high-dose oral aminosalicylate and topical treatment. Severe colitis should be treated in a hospital with intravenous steroids or ciclosporin. Maintaining remission can involve using a low maintenance dose of an oral aminosalicylate or oral azathioprine/mercaptopurine. Methotrexate is not recommended, but probiotics may prevent relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 30 - A 50-year-old woman was urgently referred for investigation (2-week wait) via the cancer...

    Correct

    • A 50-year-old woman was urgently referred for investigation (2-week wait) via the cancer referral pathway by her General Practitioner after presenting with a 2-month history of weight loss and fatigue. Blood tests reveal a carcinoembryonic antigen (CEA) level of 300 μg/l (Normal range: 2.5–5.0 μg/l).
      Which of the following is the most probable diagnosis?

      Your Answer: Colorectal cancer

      Explanation:

      Overview of Common Cancers and Tumor Markers

      Colorectal Cancer, Hepatocellular Cancer, Lung Cancer, Prostate Cancer, and Testicular Cancer are some of the most common types of cancer. Each type presents with different symptoms and may require different diagnostic tests. Tumor markers, such as carcinoembryonic antigen (CEA) for colorectal cancer, alpha-fetoprotein for hepatocellular and testicular cancer, and bombesin for lung cancer, can be used to screen high-risk groups, assess prognosis, detect recurrence, and monitor treatment. Digital rectal examination (DRE) is often used in conjunction with prostate-specific antigen (PSA) as a screening test for prostate cancer. Early detection and treatment can improve outcomes for patients with cancer.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 31 - A 44-year-old woman presents to the emergency department with sudden onset abdominal pain...

    Incorrect

    • A 44-year-old woman presents to the emergency department with sudden onset abdominal pain and vomiting for the past 5 days. She feels nauseated and cannot tolerate any food and only minimal liquid. She denies diarrhoea and has not had a bowel movement for 4 days.

      Her past medical history includes chronic lower back pain for which she takes regular co-codamol. The last time she was in hospital was for her cesarean section 10 years ago.

      Upon examination, she appears clammy and dehydrated. Her abdomen is distended and tender throughout. Bowel sounds are inaudible.

      What is the most probable underlying cause of this patient's presentation?

      Your Answer: Opioid prescription

      Correct Answer: Adhesions

      Explanation:

      The most common cause of small bowel obstruction is adhesions. This patient is experiencing symptoms such as abdominal pain, distention, and constipation, which are similar to those of large bowel obstruction. However, the onset of nausea and vomiting is an early sign of small bowel obstruction, indicating a proximal lesion. Adhesions are scar tissue that can form due to inflammation or manipulation of the abdominal contents during surgery, and they are often present in patients who are asymptomatic for years before experiencing symptoms. Given the patient’s history of a previous cesarean section, adhesional small bowel obstruction is a likely diagnosis.

      Large bowel obstruction is most commonly caused by colorectal cancer, and symptoms include abdominal pain, distention, and constipation. However, nausea and vomiting are later signs compared to small bowel obstruction.

      Gallstone ileus is a rare complication of cholecystitis where a gallstone passes through a fistula between the gallstone and small bowel before becoming impacted, leading to small bowel obstruction.

      Inguinal hernias can also cause small bowel obstruction, as they involve a protrusion of abdominal contents through a defect in the abdominal wall. However, the patient’s history of previous abdominal surgery makes adhesions a more likely cause.

      While regular opioid use can lead to constipation, it is not a cause of obstruction. In this case, the patient’s bilious vomiting and positive findings of abdominal tenderness and distension suggest intestinal obstruction rather than simple constipation.

      Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common cause of this condition is adhesions, which can develop after previous surgeries, followed by hernias. Symptoms of small bowel obstruction include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first-line imaging for suspected small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early obstruction. Management involves initial steps such as NBM, IV fluids, and nasogastric tube with free drainage. Some patients may respond to conservative management, but others may require surgery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 32 - A 57-year-old patient visits the GP clinic complaining of painful burning sensations in...

    Correct

    • A 57-year-old patient visits the GP clinic complaining of painful burning sensations in her chest for the past week, particularly after eating. She also mentions feeling bloated, which is a new experience for her. During the examination, the GP observes some abdominal tenderness and decides to order an upper GI endoscopy. The patient is currently taking aspirin, metformin, and omeprazole. What guidance should the GP offer her regarding the procedure?

      Your Answer: Stop the omeprazole two weeks before the procedure

      Explanation:

      To ensure proper identification of any pathology during the upper GI endoscopy, it is recommended that the patient discontinues the use of proton pump inhibitors, such as omeprazole, at least two weeks prior to the procedure.

      Investigating Gastro-Oesophageal Reflux Disease

      Gastro-oesophageal reflux disease (GORD) can be difficult to diagnose as there is often a poor correlation between symptoms and the appearance of the oesophagus during endoscopy. However, there are certain indications for upper GI endoscopy, including age over 55 years, symptoms lasting more than four weeks or persistent symptoms despite treatment, dysphagia, relapsing symptoms, and weight loss. If endoscopy is negative, further investigation may be necessary. The gold standard test for diagnosis is 24-hour oesophageal pH monitoring. It is important to consider these investigations in order to accurately diagnose and treat GORD.

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      • Gastroenterology/Nutrition
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  • Question 33 - A 64-year-old man is scheduled for a follow-up after a positive faecal occult...

    Correct

    • A 64-year-old man is scheduled for a follow-up after a positive faecal occult blood test as part of the national screening programme. While discussing colonoscopy, he inquires about the percentage of patients with a positive faecal occult blood test who have colorectal cancer. What is the most precise response?

      Your Answer: 5 - 15%

      Explanation:

      The likelihood of having an adenoma increases with a positive result on a faecal occult blood test.

      Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

      Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

      Faecal Immunochemical Test (FIT) Screening:
      The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 34 - A 62-year-old woman presents to her General Practitioner complaining of a 3-day history...

    Correct

    • A 62-year-old woman presents to her General Practitioner complaining of a 3-day history of acute left-sided abdominal pain, diarrhoea and fever. She has a history of chronic constipation. On examination she is tachycardic and there is localised peritonism in the left iliac fossa.
      What would be the next most appropriate step in this patient’s management?

      Your Answer: Admit to hospital under the surgical team for investigation and management

      Explanation:

      Differentiating Appropriate Management Strategies for Diverticulitis: A Guide for Healthcare Professionals

      Diverticulitis is a common condition that can lead to serious complications if not managed appropriately. As a healthcare professional, it is important to understand the different management strategies available and when they are appropriate. Here are some scenarios and the recommended management strategies:

      1. Admit to hospital under the surgical team for investigation and management: This is the recommended management strategy for a patient with peritonitis secondary to diverticulitis. The surgical team may choose to use imaging investigations first or proceed straight to surgery for operative management.

      2. Admit to hospital for urgent magnetic resonance imaging (MRI) enterography: MRI enterography is not usually used in diverticular disease. A CT scan would be quicker and would provide the required information needed to evaluate whether or not the patient needs emergency surgery.

      3. Analgesia and fluids and review in 24 hours: This management strategy is not appropriate for a patient with severe diverticulitis and peritonism. Urgent intravenous antibiotics and fluid management in the hospital are needed.

      4. Arrange a stool sample and commence antibiotics in the community: A stool sample is unlikely to provide any additional information in this scenario. Urgent admission to the hospital for further management is needed.

      5. Admit to hospital for urgent colonoscopy: Performing a colonoscopy on an inflamed bowel would be inappropriate since the risk of perforation would be high. A colonoscopy is sometimes used to evaluate the patient after the diverticulitis is present, to exclude other intramural pathology.

      In conclusion, appropriate management strategies for diverticulitis depend on the severity of the condition and the presence of complications. Healthcare professionals should be aware of the different options available and choose the most appropriate one for each patient.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 35 - A 50-year-old obese man with a history of type 2 diabetes mellitus presents...

    Incorrect

    • A 50-year-old obese man with a history of type 2 diabetes mellitus presents at the clinic for a review. He is currently asymptomatic but his recent annual blood tests have shown slightly abnormal liver function tests. The results are as follows:
      - Bilirubin: 20 µmol/L (3 - 17)
      - ALP: 104 u/L (30 - 100)
      - ALT: 53 u/L (3 - 40)
      - γGT: 58 u/L (8 - 60)
      - Albumin: 38 g/L (35 - 50)

      A liver ultrasound was conducted and reported fatty changes. All other standard liver screen bloods, including viral serology, are normal. The patient's alcoholic intake is within recommended limits. What is the most appropriate next test to perform?

      Your Answer: Repeat liver ultrasound after calorific restricted diet for 1 month

      Correct Answer: Enhanced liver fibrosis blood test

      Explanation:

      For patients with non-alcoholic fatty liver disease who exhibit characteristics such as obesity and type 2 diabetes mellitus, it is recommended to conduct an enhanced liver fibrosis (ELF) test to aid in the diagnosis of liver fibrosis. According to NICE guidelines, if NAFLD is discovered incidentally, an ELF blood test should be conducted to evaluate for the presence of more advanced liver disease.

      Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management

      Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.

      NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.

      The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 36 - A 58-year-old man undergoes routine screening tests as part of his NHS health...

    Incorrect

    • A 58-year-old man undergoes routine screening tests as part of his NHS health check. His results show an HbA1C level of 52 mmol/mol (<42), eGFR of >90 ml/min (>90), blood pressure of 130/84 mmHg, and a QRISK-3 score of 24.3%. After a repeat measurement, he is diagnosed with type 2 diabetes mellitus (T2DM) and decides to make lifestyle changes and take medication. However, he experiences significant gastrointestinal side effects with metformin, even after switching to a modified-release preparation.

      What would be the most appropriate class of drug to switch to?

      Your Answer: Sulfonylurea

      Correct Answer: SGLT-2 inhibitor

      Explanation:

      A suitable medication would have been a DDP-4 inhibitor, glitazone, or sulfonylurea. The use of GLP-1 receptor agonists is not appropriate, as it is only recommended when triple therapy with metformin and two other oral drugs has failed.

      NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 37 - A 62-year-old male presents to the liver clinic with persistently abnormal liver function...

    Incorrect

    • A 62-year-old male presents to the liver clinic with persistently abnormal liver function tests over the past 2 months. He recently completed a course of co-amoxiclav for a respiratory tract infection. The patient has a history of intravenous drug use, hypertension, and type two diabetes mellitus. His BMI is 31 kg/m², and he consumes 15 units of alcohol per week. A liver ultrasound showed increased hepatic echogenicity. The following liver function tests and virology report were obtained:

      - Bilirubin: 22 µmol/L (3 - 17)
      - ALP: 118 u/L (30 - 100)
      - ALT: 170 u/L (5 - 30)
      - AST: 63 u/L (10 - 40)
      - γGT: 52 u/L (8 - 60)
      - Albumin: 32 g/L (35 - 50)
      - HBsAg: Negative
      - Anti-HBs: Positive
      - Anti-HBc: Negative
      - Anti-HCV: Negative
      - HCV PCR: Negative

      What is the most likely cause of this patient's abnormal liver function tests?

      Your Answer: Hepatitis B

      Correct Answer: Non-alcoholic fatty liver disease

      Explanation:

      Abnormal liver function tests in the context of obesity may suggest the presence of non-alcoholic fatty liver disease.

      Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management

      Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.

      NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.

      The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 38 - What advice should you give a young adult (who is NOT pregnant) if...

    Correct

    • What advice should you give a young adult (who is NOT pregnant) if they ask what is the recommended amount of alcohol they can consume?

      Your Answer: No more than 14 units of alcohol per week. If you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more

      Explanation:

      Alcohol consumption guidelines were revised in 2016 by the Chief Medical Officer, based on recommendations from an expert group report. The most significant change was a reduction in the recommended maximum number of units of alcohol for men from 21 to 14, aligning with the guidelines for women. The government now advises that both men and women should not exceed 14 units of alcohol per week, and if they do, it is best to spread it evenly over three or more days. Pregnant women are advised not to drink alcohol at all, as it can cause long-term harm to the baby. One unit of alcohol is equivalent to 10 mL of pure ethanol, and the strength of a drink is determined by its alcohol by volume (ABV). Examples of one unit of alcohol include a 25ml single measure of spirits with an ABV of 40%, a third of a pint of beer with an ABV of 5-6%, and half a 175ml standard glass of red wine with an ABV of 12%. To calculate the number of units in a drink, multiply the number of millilitres by the ABV and divide by 1,000.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 39 - A 45-year-old woman, with a history of gallstones, arrives at the emergency department...

    Correct

    • A 45-year-old woman, with a history of gallstones, arrives at the emergency department complaining of central abdominal pain that radiates to her back. Upon conducting blood tests, you observe the following result:
      Amylase 480 U/L (30 - 110). The patient is diagnosed with acute pancreatitis and inquires about the severity of her condition. What is the primary factor in determining the clinical severity of acute pancreatitis?

      Your Answer: Presence of any systemic or local complications

      Explanation:

      When determining the severity of pancreatitis, the presence of systemic or local complications is the most important factor to consider. Mild acute pancreatitis is characterized by the absence of both organ failure and local complications. Local complications in severe cases may include peripancreatic fluid collections, pancreatic or peripancreatic necrosis, pseudocysts, and walled-off areas of necrosis. The Atlanta classification system categorizes acute pancreatitis as mild, moderate, or severe. Mild cases have no organ failure, local or systemic complications, and typically resolve within a week. Pain level and initial CRP levels are not used to classify severity, but a high white blood cell count may indicate an increased risk of severe pancreatitis. Serum amylase levels and pancreatic calcification on CT scans are also not reliable indicators of severity.

      Managing Acute Pancreatitis in a Hospital Setting

      Acute pancreatitis is a serious condition that requires management in a hospital setting. The severity of the condition can be stratified based on the presence of organ failure and local complications. Key aspects of care include fluid resuscitation, aggressive early hydration with crystalloids, and adequate pain management with intravenous opioids. Patients should not be made ‘nil-by-mouth’ unless there is a clear reason, and enteral nutrition should be offered within 72 hours of presentation. Antibiotics should not be used prophylactically, but may be indicated in cases of infected pancreatic necrosis. Surgery may be necessary for patients with acute pancreatitis due to gallstones or obstructed biliary systems, and those with infected necrosis may require radiological drainage or surgical necrosectomy.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 40 - A 65-year-old male with a history of COPD and hypertension complains of pain...

    Correct

    • A 65-year-old male with a history of COPD and hypertension complains of pain while swallowing. The patient is currently taking a salbutamol and beclomethasone inhaler, bendroflumethiazide, and amlodipine. What could be the possible reason for this symptom?

      Your Answer: Oesophageal candidiasis

      Explanation:

      Oesophageal candidiasis, a known complication of inhaled steroid therapy, often presents with pain while swallowing (odynophagia).

      Understanding Dysphagia and its Causes

      Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the esophagus, such as oesophageal cancer, oesophagitis, oesophageal candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, and myasthenia gravis. Each condition has its own characteristic features, which can help in identifying the underlying cause of dysphagia. For instance, dysphagia associated with weight loss, anorexia, or vomiting during eating may indicate oesophageal cancer, while dysphagia of both liquids and solids from the start may suggest achalasia.

      To determine the cause of dysphagia, patients usually undergo an upper GI endoscopy, which allows doctors to examine the esophagus and detect any abnormalities. Fluoroscopic swallowing studies may also be done to evaluate motility disorders. Additionally, a full blood count and ambulatory oesophageal pH and manometry studies may be required for certain conditions.

      It’s important to note that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. Therefore, understanding the different causes of dysphagia and their characteristic features can aid in prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 41 - An 80-year-old male has been diagnosed with upper rectal cancer. The cancer is...

    Incorrect

    • An 80-year-old male has been diagnosed with upper rectal cancer. The cancer is confined to the area and the medical team has decided to perform an anterior resection to remove it. The surgeon believes that to achieve the best long-term outcome, it is necessary to temporarily divert the colon to safeguard the colorectal anastomosis. What type of stoma would be most suitable?

      Your Answer: End ileostomy

      Correct Answer: Loop ileostomy

      Explanation:

      A loop ileostomy is the appropriate procedure for defunctioning the colon to protect an anastomosis. This involves taking a loop of ileum, making a horizontal incision, and bringing it up to the skin. It is commonly used after rectal cancer surgery and can be reversed at a later time.

      An end colostomy is performed when an anastomosis is not possible or desirable, and the colon needs to be diverted or resected. The distal part of the colon is brought up to the skin in this procedure.

      An end ileostomy is typically done after the complete removal of the colon or when an ileocolic anastomosis is not planned. While it can be used to defunction the colon, it is more challenging to reverse.

      A gastrostomy is used for gastric decompression or feeding.

      A loop jejunostomy is used as a high-output stoma and may be performed after an emergency laparotomy with planned early closure.

      Abdominal stomas are created during various abdominal procedures to bring the lumen or contents of organs onto the skin. Typically, this involves the bowel, but other organs may also be diverted if necessary. The type and method of construction of the stoma will depend on the contents of the bowel. Small bowel stomas should be spouted to prevent irritant contents from coming into contact with the skin, while colonic stomas do not require spouting. Proper siting of the stoma is crucial to reduce the risk of leakage and subsequent maceration of the surrounding skin. The type and location of the stoma will vary depending on the purpose, such as defunctioning the colon or providing feeding access. Overall, abdominal stomas are a necessary medical intervention that requires careful consideration and planning.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 42 - A 28-year-old woman is in week 32 of her pregnancy. She has been...

    Correct

    • A 28-year-old woman is in week 32 of her pregnancy. She has been experiencing itching for two weeks and is worried. She now has mild jaundice. Her total bilirubin level is elevated at around 85 μmol/l (reference range <20 μmol/), and her alanine aminotransferase (ALT) level is elevated at 78 iu/l (reference range 20–60 iu/l); her alkaline phosphatase (ALP) level is significantly elevated. What is the most appropriate diagnosis for this clinical presentation?

      Your Answer: Intrahepatic cholestasis of pregnancy

      Explanation:

      Differential Diagnosis of Liver Disorders in Pregnancy

      Intrahepatic cholestasis of pregnancy (ICP), hyperemesis gravidarum, cholecystitis, acute fatty liver of pregnancy (AFLP), and HELLP syndrome are all potential liver disorders that can occur during pregnancy.

      ICP is the most common pregnancy-related liver disorder and is characterised by generalised itching, jaundice, and elevated total serum bile acid levels. Maternal outcomes are good, but fetal outcomes can be devastating.

      Hyperemesis gravidarum is characterised by persistent nausea and vomiting associated with ketosis and weight loss. Elevated transaminase levels may occur, but significantly elevated liver enzymes would suggest an alternative aetiology.

      Cholecystitis is inflammation of the gall bladder that occurs most commonly due to gallstones. The most common presenting symptom is upper abdominal pain, which localises to the right upper quadrant.

      AFLP is characterised by microvesicular steatosis in the liver and can present with malaise, nausea and vomiting, right upper quadrant and epigastric pain, and acute renal failure. Both AST and ALT levels can be elevated, and hypoglycaemia is common.

      HELLP syndrome is a life-threatening condition that can potentially complicate pregnancy and is characterised by haemolysis, elevated liver enzyme levels, and low platelet levels. Symptoms are non-specific and include malaise, nausea and vomiting, and weight gain. A normal platelet count and no evidence of haemolysis are not consistent with a diagnosis of HELLP syndrome.

      Early recognition, treatment, and timely delivery are imperative for all of these liver disorders in pregnancy.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 43 - A 28-year-old female comes to the gastroenterology clinic for a follow-up on her...

    Incorrect

    • A 28-year-old female comes to the gastroenterology clinic for a follow-up on her Crohn's disease. She has been on budesonide for 3 months to induce remission and reports feeling well. She did not experience any acute episodes during treatment and her bowel habits are regular. The physician determines that she requires maintenance therapy. What is the most suitable medication to prescribe?

      Your Answer: Mesalazine

      Correct Answer: Azathioprine

      Explanation:

      Bone marrow suppression, which can be fatal, is a potential risk associated with the use of azathioprine as a second-line treatment for Crohn’s disease. Budesonide, a corticosteroid medication primarily used for asthma prevention, may be considered as a second-line option for inducing remission in Crohn’s patients. Mesalazine, which acts locally on the colon’s mucous membrane and has various anti-inflammatory effects, is less effective than glucocorticoids but can be used as a second-line option to induce remission. Methotrexate, a folate derivative that inhibits enzymes responsible for nucleotide synthesis, is the second-line medication used to maintain remission in Crohn’s patients. However, in this case, there is no indication to use second-line management instead of first-line treatment.

      Managing Crohn’s Disease: Guidelines and Treatment Options

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.

      To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.

      To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 44 - A 72-year-old man with atrial fibrillation (AF) experiences colicky abdominal pain after eating...

    Correct

    • A 72-year-old man with atrial fibrillation (AF) experiences colicky abdominal pain after eating a large meal; this has been happening consistently for the past 3 weeks, causing him to develop a fear of eating.
      What is the most probable diagnosis?

      Your Answer: Chronic mesenteric ischaemia (CMI)

      Explanation:

      Differential Diagnosis for Abdominal Pain: Chronic Mesenteric Ischaemia, Chronic Pancreatitis, Diverticulitis, Gastric Cancer, and Acute Mesenteric Ischaemic Embolism

      Abdominal pain is a common presenting symptom in clinical practice, and it can be caused by a variety of conditions. In this article, we will discuss the differential diagnosis for abdominal pain, including chronic mesenteric ischaemia (CMI), chronic pancreatitis, diverticulitis, gastric cancer, and acute mesenteric ischaemic embolism.

      CMI usually results from atherosclerotic disease of two or more mesenteric vessels, while chronic pancreatitis is characterised by a continuing, chronic, inflammatory process of the pancreas. Diverticulitis is an inflammation of one or more diverticula, while gastric cancer is the third most common cause of cancer-related death in the world. Acute mesenteric ischaemic embolism is characterised by pain that is disproportionate to physical examination findings.

      Each condition has its own unique set of symptoms and clinical presentation. By understanding the differential diagnosis for abdominal pain, clinicians can make an accurate diagnosis and provide appropriate treatment for their patients.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 45 - A 38-year-old woman complains of itching and yellowing of the skin.
    Blood tests reveal:
    Bilirubin...

    Correct

    • A 38-year-old woman complains of itching and yellowing of the skin.
      Blood tests reveal:
      Bilirubin 45 µmol/L (3 - 17)
      ALP 326 u/L (30 - 100)
      ALT 72 u/L (3 - 40)
      Positive anti-mitochondrial antibodies.
      What is the probable diagnosis?

      Your Answer: Primary biliary cholangitis

      Explanation:

      Primary biliary cholangitis is a likely diagnosis for a middle-aged female patient with an obstructive liver injury picture and positive anti-mitochondrial antibodies, M2 subtype. This differential is important to consider, as alcohol abuse may not always be obvious and gallstones could produce a similar result on liver function tests. However, the absence of pain and positive anti-mitochondrial antibodies make these less likely. Paracetamol overdose is also a potential differential, but the liver function profile in this case is more consistent with an obstructive picture, with a higher ALP and bilirubin and a modest increase in ALT. Additionally, anti-mitochondrial antibodies are not associated with paracetamol overdose.

      Primary Biliary Cholangitis: A Chronic Liver Disorder

      Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.

      This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.

      The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 46 - Primary biliary cholangitis is most commonly associated with middle-aged women and which specific...

    Correct

    • Primary biliary cholangitis is most commonly associated with middle-aged women and which specific antibodies?

      Your Answer: Anti-mitochondrial antibodies

      Explanation:

      The M rule for primary biliary cholangitis includes the presence of IgM and anti-Mitochondrial antibodies, specifically the M2 subtype, in middle-aged women.

      Primary Biliary Cholangitis: A Chronic Liver Disorder

      Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.

      This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.

      The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 47 - A 16-year-old girl comes to the clinic complaining of upper abdominal pain. She...

    Correct

    • A 16-year-old girl comes to the clinic complaining of upper abdominal pain. She is typically healthy and takes a combined oral contraceptive pill. Her mother has a history of hereditary spherocytosis and is with her during the visit. The pain is intermittent but has intensified today. There have been no alterations to her bowel movements, and she has not experienced any nausea or vomiting. What is the probable diagnosis?

      Your Answer: Biliary colic

      Explanation:

      Chronic haemolysis and gallstone formation are present in this patient with hereditary spherocytosis. It is crucial to consider splenic rupture as a potential differential diagnosis in a patient with hereditary spherocytosis who is unwell.

      Understanding Hereditary Spherocytosis

      Hereditary spherocytosis is the most common hereditary haemolytic anaemia in people of northern European descent. It is an autosomal dominant defect of the red blood cell cytoskeleton, which replaces the normal biconcave disc shape with a sphere-shaped red blood cell. This condition reduces the red blood cell survival as they are destroyed by the spleen. Patients with hereditary spherocytosis may present with failure to thrive, jaundice, gallstones, splenomegaly, and aplastic crisis precipitated by parvovirus infection. The degree of haemolysis is variable, and the mean corpuscular haemoglobin concentration (MCHC) is elevated.

      The diagnosis of hereditary spherocytosis is based on a family history of the condition, typical clinical features, and laboratory investigations such as spherocytes, raised MCHC, and an increase in reticulocytes. The osmotic fragility test was previously the recommended investigation of choice, but it is now deemed unreliable and is no longer recommended. If the diagnosis is equivocal, the EMA binding test and the cryohaemolysis test are recommended. For atypical presentations, electrophoresis analysis of erythrocyte membranes is the method of choice.

      The management of hereditary spherocytosis involves supportive treatment during acute haemolytic crisis, including transfusion if necessary. Longer-term treatment includes folate replacement and splenectomy. It is important to note that hereditary spherocytosis differs from G6PD deficiency, which is an X-linked recessive condition that affects males of African and Mediterranean descent. The diagnostic test for G6PD deficiency involves measuring enzyme activity, while the EMA binding test is used for hereditary spherocytosis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 48 - Each one of the following is a recognised complication of gastro-oesophageal reflux disease,...

    Incorrect

    • Each one of the following is a recognised complication of gastro-oesophageal reflux disease, except:

      Your Answer: Oesophageal carcinoma

      Correct Answer: Achalasia

      Explanation:

      Managing Gastro-Oesophageal Reflux Disease

      Gastro-oesophageal reflux disease (GORD) is a condition where gastric contents cause symptoms of oesophagitis. If GORD has not been investigated with endoscopy, it should be treated according to dyspepsia guidelines. However, if oesophagitis is confirmed through endoscopy, a full dose proton pump inhibitor (PPI) should be given for 1-2 months. If there is a positive response, low dose treatment may be given as required. If there is no response, double-dose PPI should be given for 1 month.

      On the other hand, if endoscopy shows negative reflux disease, a full dose PPI should be given for 1 month. If there is a positive response, low dose treatment may be given on an as-required basis with a limited number of repeat prescriptions. If there is no response, H2RA or prokinetic should be given for one month.

      Complications of GORD include oesophagitis, ulcers, anaemia, benign strictures, Barrett’s oesophagus, and oesophageal carcinoma. Therefore, it is important to manage GORD effectively to prevent these complications.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 49 - Which of the following causes of gastroenteritis has the lengthiest incubation period? ...

    Correct

    • Which of the following causes of gastroenteritis has the lengthiest incubation period?

      Your Answer: Giardiasis

      Explanation:

      Gastroenteritis can occur either at home or while traveling, known as travelers’ diarrhea. This condition is characterized by at least three loose to watery stools in 24 hours, accompanied by abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of travelers’ diarrhea is Escherichia coli. Acute food poisoning is another pattern of illness that results in sudden onset of nausea, vomiting, and diarrhea after ingesting a toxin. Staphylococcus aureus, Bacillus cereus, or Clostridium perfringens are typically responsible for acute food poisoning.

      There are several types of infections that can cause gastroenteritis, each with its own typical presentation. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea, while cholera causes profuse, watery diarrhea and severe dehydration leading to weight loss. Shigella causes bloody diarrhea, vomiting, and abdominal pain, while Staphylococcus aureus results in severe vomiting with a short incubation period. Campylobacter typically starts with a flu-like prodrome and progresses to crampy abdominal pains, fever, and diarrhea, which may be bloody and mimic appendicitis. Bacillus cereus can cause two types of illness, vomiting within six hours, typically due to rice, or diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.

      The incubation period for gastroenteritis varies depending on the type of infection. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 50 - Samantha, 72, has a confirmed sigmoid colon tumor graded as T3N0M0. Surgery was...

    Correct

    • Samantha, 72, has a confirmed sigmoid colon tumor graded as T3N0M0. Surgery was recommended as the primary treatment and scheduled for next week. However, she was rushed to the emergency department with severe abdominal pain, which was diagnosed as a perforation. What is the most suitable surgical procedure for Samantha?

      Your Answer: Hartmann's procedure

      Explanation:

      The most suitable surgery for the patient in this case would be a Hartmann’s procedure. To determine the appropriate surgery, it is essential to consider the urgency of the operation and the location of the malignancy. As the patient has an emergency perforation resulting from the malignancy, the surgery needs to be appropriate for an emergency situation. Under normal circumstances, the patient would undergo surgery that involves resection of the relevant section of bowel and anastomosis of the two ends. However, in emergency situations, anastomosis is not the preferred surgical option.

      A Hartmann’s procedure involves resection of the relevant portion of bowel and the formation of an end colostomy/ileostomy. In the future, patients can undergo a reversal of Hartmann’s procedure, where the end colostomy is closed following the formation of a colorectal anastomosis, restoring continuity of the bowels. This makes it the ideal surgical procedure for emergency situations. Additionally, this operation involves resection of the sigmoid colon, where the patient’s tumor is located.

      Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.

      For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.

      Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.

      Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

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      • Gastroenterology/Nutrition
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  • Question 51 - At a practice meeting, you are discussing strategies to increase the rate of...

    Correct

    • At a practice meeting, you are discussing strategies to increase the rate of early cancer detection. Which of the following patients is most likely to need screening for hepatocellular carcinoma, given that they are 50 years old?

      Your Answer: A 45-year-old man with liver cirrhosis secondary to hepatitis C

      Explanation:

      Hepatocellular carcinoma (HCC) is a type of cancer that ranks as the third most common cause of cancer worldwide. The leading cause of HCC globally is chronic hepatitis B, while chronic hepatitis C is the most common cause in Europe. The primary risk factor for developing HCC is liver cirrhosis, which can result from various factors such as hepatitis B and C, alcohol, haemochromatosis, and primary biliary cirrhosis. Other risk factors include alpha-1 antitrypsin deficiency, hereditary tyrosinosis, glycogen storage disease, aflatoxin, certain drugs, porphyria cutanea tarda, male sex, diabetes mellitus, and metabolic syndrome.

      HCC tends to present late, and patients may exhibit features of liver cirrhosis or failure such as jaundice, ascites, RUQ pain, hepatomegaly, pruritus, and splenomegaly. In some cases, decompensation may occur in patients with chronic liver disease. Raised AFP levels are also common. Screening with ultrasound and alpha-fetoprotein may be necessary for high-risk groups, including patients with liver cirrhosis secondary to hepatitis B and C or haemochromatosis, and men with liver cirrhosis secondary to alcohol.

      Management options for early-stage HCC include surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolisation, and sorafenib, a multikinase inhibitor. It is important to note that Wilson’s disease is an exception to the typical causes of liver cirrhosis and HCC.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 52 - A 32-year-old woman presents to her General Practitioner complaining of occasional abdominal distension...

    Correct

    • A 32-year-old woman presents to her General Practitioner complaining of occasional abdominal distension and bloating, which varies with her menstrual cycle and is accompanied by episodes of constipation. She works as a teacher and finds work stressful; she has previously taken a course of sertraline for depression/anxiety. On examination, bloods and colonoscopy are normal.
      Which of the following is the most probable diagnosis?

      Your Answer: Irritable bowel syndrome (IBS)

      Explanation:

      Irritable bowel syndrome (IBS) is a gastrointestinal disorder that causes abdominal pain, bloating, and changes in bowel habits without any identifiable organic pathology. It is more common in women and can be worsened by stress and the perimenstrual period. Diagnosis is made by ruling out other potential causes of symptoms. Management includes dietary changes, such as increasing fiber intake and avoiding trigger foods, as well as psychological support. Medications may also be used to alleviate symptoms. This patient’s symptoms are not consistent with chronic pancreatitis, ulcerative colitis, peptic ulcer disease, or diverticulitis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 53 - A 35-year-old man with ulcerative colitis is seen for his follow-up appointment. He...

    Incorrect

    • A 35-year-old man with ulcerative colitis is seen for his follow-up appointment. He had a moderate flare-up of his condition two months ago, which was treated with oral steroids and resolved. He has not had any other flare-ups in the past year and his most recent colonoscopy showed left-sided disease. He is currently asymptomatic, with normal observations and bowel movements of 2-3 times per day. What is the best medical treatment to maintain remission for this patient?

      Your Answer: Oral azathioprine

      Correct Answer: Oral mesalazine

      Explanation:

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools and presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Extensive disease may require a high-dose oral aminosalicylate and topical treatment. Severe colitis should be treated in a hospital with intravenous steroids or ciclosporin. Maintaining remission can involve using a low maintenance dose of an oral aminosalicylate or oral azathioprine/mercaptopurine. Methotrexate is not recommended, but probiotics may prevent relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 54 - You are asked to review an 80-year-old woman in the clinic who has...

    Correct

    • You are asked to review an 80-year-old woman in the clinic who has been referred by her GP due to weight loss, early satiety and increasing anorexia. On examination, the GP notes a palpable left supraclavicular node and an epigastric mass, but no jaundice. There is microcytic anaemia, with normal liver enzymes. Her past history includes excess consumption of alcohol and a 30-pack-year smoking history.
      Which of the following is the most likely diagnosis?

      Your Answer: Gastric carcinoma

      Explanation:

      Gastric carcinoma is the most common type of gastric malignancy, with adenocarcinoma accounting for 90-95% of cases. Risk factors include smoking and excessive alcohol consumption. Early gastric cancer may not present with any symptoms, while advanced disease may cause indigestion, anorexia, weight loss, early postprandial fullness, and a palpable enlarged stomach with succussion splash. Troisier’s sign, the presence of a hard and enlarged left-sided supraclavicular lymph node, suggests metastatic abdominal malignancy.

      Abdominal aortic aneurysm (AAA) presents with a pulsatile epigastric mass, but not an enlarged supraclavicular node. Patients are usually asymptomatic unless there is an aneurysm leak, which causes abdominal and/or back pain and rapid deterioration.

      Cholangiocarcinoma, a malignant tumor of the bile duct, typically presents with jaundice, weight loss, and abdominal pain. Normal liver function tests make this diagnosis unlikely.

      Benign gastric ulcers cause epigastric pain, usually a burning sensation postprandially. This patient’s symptoms, including weight loss, anorexia, and lymphadenopathy, suggest malignant pathology.

      Crohn’s disease, a chronic inflammatory bowel disease, can affect any part of the gastrointestinal tract. Gastroduodenal Crohn’s disease presents with vague symptoms such as weight loss, anorexia, dyspepsia, nausea, and vomiting. However, the examination findings in this patient make a malignant diagnosis more likely.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 55 - What is an accurate statement about alcoholic liver disease (ALD)? ...

    Incorrect

    • What is an accurate statement about alcoholic liver disease (ALD)?

      Your Answer: Men are more susceptible than women

      Correct Answer: In alcoholic hepatitis the AST : ALT ratio is at least 2 : 1

      Explanation:

      Alcoholic Liver Disease: Facts and Myths

      Alcoholic liver disease (ALD) is a common liver disease caused by overconsumption of alcohol. Here are some facts and myths about ALD:

      Myth: In alcoholic hepatitis, the AST:ALT ratio is less than 2:1.
      Fact: Unlike most other liver diseases, including viral hepatitis, alcoholic hepatitis exhibits at least a 2:1 AST:ALT ratio.

      Myth: Hepatic iron overload is not indicative of concomitant heterozygote haemochromatosis.
      Fact: Evidence of iron overload, such as elevated levels of transferrin saturation and serum ferritin, is common in ALD and may indicate concomitant heterozygote haemochromatosis.

      Myth: Women are less susceptible to ALD than men.
      Fact: Women are actually twice as susceptible to ALD than men, even when consumption is corrected for body weight, and may develop ALD with shorter durations and doses of chronic consumption.

      Myth: Alcoholic fatty infiltration is irreversible once established.
      Fact: Although steatosis (fatty infiltration) will develop in any individual who consumes a large quantity of alcohol over a long period of time, this process is usually transient and reversible. Alcoholic hepatitis and alcoholic fatty infiltration are reversible with abstinence and adequate nutrition.

      Myth: Alcoholic cirrhosis does not progress to hepatocellular carcinoma.
      Fact: Like other causes of liver cirrhosis, alcoholic cirrhosis can also progress to hepatocellular carcinoma.

      In conclusion, ALD is a serious liver disease that can have irreversible consequences if not addressed in a timely manner. It is important to understand the facts and myths surrounding this disease to ensure proper diagnosis and treatment.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 56 - A 42-year-old woman presents to the Emergency Department with retrosternal chest pain. She...

    Correct

    • A 42-year-old woman presents to the Emergency Department with retrosternal chest pain. She is admitted and all cardiac investigations are normal. She is diagnosed with gastro-oesophageal reflux disease.
      Which of the following symptoms would most commonly require an urgent inpatient upper gastrointestinal (GI) endoscopy before being discharged?

      Your Answer: Melaena

      Explanation:

      Melaena is a serious symptom of upper GI bleeding that requires emergency treatment. The patient must be stabilized and resuscitated before undergoing an upper GI endoscopy within 24 hours of admission. Dysphagia is a red-flag symptom that may indicate oesophageal or gastric cancer and requires urgent investigation with an upper GI endoscopy within two weeks. Epigastric pain without red-flag symptoms should be treated with PPIs for 4-8 weeks before any investigation is necessary. Vomiting with high platelet count, weight loss, reflux, dyspepsia, or upper-abdominal pain requires a non-urgent OGD. Weight loss in patients over 55 years with reflux symptoms requires a 2-week wait referral for suspected cancer, but not an urgent inpatient endoscopy.

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      • Gastroenterology/Nutrition
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  • Question 57 - What is the most commonly associated condition with primary sclerosing cholangitis? ...

    Correct

    • What is the most commonly associated condition with primary sclerosing cholangitis?

      Your Answer: Ulcerative colitis

      Explanation:

      Understanding Primary Sclerosing Cholangitis

      Primary sclerosing cholangitis is a condition that affects the bile ducts, causing inflammation and fibrosis. The cause of this disease is unknown, but it is often associated with ulcerative colitis, with 4% of UC patients having PSC and 80% of PSC patients having UC. Crohn’s disease and HIV are also less common associations. Symptoms of PSC include cholestasis, jaundice, pruritus, right upper quadrant pain, and fatigue. Diagnosis is typically made through endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), which show multiple biliary strictures giving a ‘beaded’ appearance. A liver biopsy may also be performed, but it has a limited role in diagnosis. Complications of PSC include cholangiocarcinoma in 10% of cases and an increased risk of colorectal cancer.

      Overall, understanding primary sclerosing cholangitis is important for early diagnosis and management of the disease. With proper treatment and monitoring, patients can manage their symptoms and reduce the risk of complications.

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      • Gastroenterology/Nutrition
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  • Question 58 - A 62-year-old man with a history of hypertension presents to the emergency department...

    Correct

    • A 62-year-old man with a history of hypertension presents to the emergency department with sudden onset of abdominal pain, vomiting and diarrhoea. On examination, his abdomen is distended and tender, with generalised guarding. Vital signs show heart rate 110 beats/min, BP 120/80 mmHg. Bloods show lactate 3.5 mmol/l, urea 10 mmol/l, creatinine 150 µmol/l and bicarbonate 14 mmol/l.
      Blood test
      Reference range
      Lactate
      <2 mmol/l
      Urea
      2.5–7.1 mmol/l
      Creatinine
      44–97 µmol/l
      Bicarbonate
      22–29 mmol/l.
      Based on the history, what is the most likely diagnosis?
      Choose the SINGLE most likely diagnosis from the options below.

      Your Answer: Mesenteric ischaemia

      Explanation:

      Acute mesenteric ischaemia (AMI) is a rare but potentially life-threatening condition caused by inadequate blood flow through the mesenteric vessels, leading to ischaemia and gangrene of the bowel wall. It can be classified as either arterial or venous, with embolic phenomena being the most common cause. Symptoms include sudden and severe abdominal pain, vomiting, and diarrhoea, with physical signs developing late in the disease process. Early and aggressive diagnosis and treatment are crucial to reduce mortality, but once bowel wall infarction has occurred, the mortality rate may be as high as 90%. Appendicitis, diverticulitis, pseudomembranous colitis, and ruptured AAA are important differential diagnoses to consider.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 59 - An 82-year-old man arrives at the emergency department with haematemesis that began 45...

    Correct

    • An 82-year-old man arrives at the emergency department with haematemesis that began 45 minutes ago. He has a history of chronic back pain and takes ibuprofen, as well as warfarin for his atrial fibrillation. The medical team initiates resuscitation and places two large-bore cannulas. What is the appropriate management for this patient in an acute setting?

      Your Answer: IV prothrombin complex concentrate

      Explanation:

      There is insufficient evidence to support the use of PPIs in stopping bleeding, as in most cases, bleeding ceases without their administration. Administering IV proton pump inhibitors and fresh frozen plasma prior to endoscopy is incorrect, as PPIs should not be given and fresh frozen plasma should only be given to patients with specific blood clotting abnormalities.

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The clinical features of this condition include haematemesis, melena, and a raised urea level due to the protein meal of the blood. The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation is also necessary, including ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours.

      For non-variceal bleeding, proton pump inhibitors (PPIs) should not be given before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. However, PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy. If further bleeding occurs, options include repeat endoscopy, interventional radiology, and surgery. For variceal bleeding, terlipressin and prophylactic antibiotics should be given to patients at presentation, and band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 60 - A 57-year-old accountant has presented to her GP with a 5-day history of...

    Correct

    • A 57-year-old accountant has presented to her GP with a 5-day history of heartburn, nausea and a metallic taste in her mouth. She has a good appetite and has lost 2kg in the last month. She has a past medical history of hypertension, gastro-oesophageal reflux disease and osteoporosis. She takes amlodipine 5mg OD, risedronate 35 mg OD and lansoprazole 30 mg OD.

      On examination, her abdomen is soft and nontender and there are no palpable masses. Her observations are normal.

      What is the most appropriate management for this patient from the following options?

      Your Answer: Urgent upper gastrointestinal endoscopy

      Explanation:

      An urgent referral is warranted when weight loss is a prominent symptom in dyspepsia.

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 61 - A 72-year-old man is being investigated for unexplained weight loss. He reports experiencing...

    Correct

    • A 72-year-old man is being investigated for unexplained weight loss. He reports experiencing abdominal pain, dyspepsia, and nausea. He has a history of pernicious anaemia. What is the probable diagnosis based on these symptoms?

      Your Answer: Stomach cancer

      Explanation:

      Dyspepsia, abdominal pain, nausea, and anorexia are among the early signs of stomach cancer. This type of cancer is uncommon and is more likely to occur in individuals over the age of 50, particularly those with pernicious anemia. Pancreatic cancer is linked to the onset of diabetes. Bone pain is a typical symptom of myeloma. Recurrent infections, bleeding, and bruising are common symptoms of acute leukemia.

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 62 - A 50-year-old woman visits your clinic to inquire about the safety of taking...

    Correct

    • A 50-year-old woman visits your clinic to inquire about the safety of taking multivitamin supplements. She confesses that she has been consuming high doses of vitamin B6 supplements, believing that it would alleviate her anemia and boost her energy levels. She seeks your advice on whether she should continue taking the supplements.
      What is a potential adverse effect of excessive intake of vitamin B6 (pyridoxine)?

      Your Answer: Peripheral neuropathy

      Explanation:

      Pyridoxine, also known as vitamin B6, is essential for the formation of haemoglobin and can be obtained from various food sources such as chicken, fish, vegetables, eggs, peanuts, milk, and potatoes. The recommended daily intake of vitamin B6 is 1.4mg for men and 1.2mg for women, which can be easily met through a balanced diet. However, prolonged consumption of over 200mg of vitamin B6 per day can result in peripheral neuropathy.

      Understanding Peripheral Neuropathy: Causes and Symptoms

      Peripheral neuropathy is a condition that affects the nerves outside of the brain and spinal cord. It can be categorized into two types based on the predominant symptoms: motor loss and sensory loss. Motor loss conditions include Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies (such as Charcot-Marie-Tooth), chronic inflammatory demyelinating polyneuropathy (CIDP), and diphtheria. On the other hand, sensory loss conditions include diabetes, uremia, leprosy, alcoholism, vitamin B12 deficiency, and amyloidosis.

      Alcoholic neuropathy is a type of peripheral neuropathy that is caused by both direct toxic effects and reduced absorption of B vitamins. It typically presents with sensory symptoms before motor symptoms. Vitamin B12 deficiency can also lead to peripheral neuropathy, specifically subacute combined degeneration of the spinal cord. In this case, the dorsal column is usually affected first, causing joint position and vibration issues before distal paraesthesia.

      Understanding the causes and symptoms of peripheral neuropathy is crucial in diagnosing and treating the condition. Proper management can help alleviate symptoms and improve quality of life for those affected.

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      • Gastroenterology/Nutrition
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  • Question 63 - A 40-year-old woman with amyotrophic lateral sclerosis is in a meeting with her...

    Correct

    • A 40-year-old woman with amyotrophic lateral sclerosis is in a meeting with her clinical team to discuss her ongoing care. The team notes that she has been experiencing weight loss and increased fatigue. The patient reports struggling with chewing and swallowing food, even when it has been mashed or pureed. What is the most suitable long-term management plan for this patient?

      Your Answer: Insert a percutaneous gastrostomy tube

      Explanation:

      The most appropriate way to provide nutritional support for patients with motor neuron disease is through the insertion of a percutaneous gastrostomy (PEG) tube. If a patient is struggling to feed themselves, they may initially benefit from smaller, more liquid-like meals, but if this is not sufficient, a PEG tube is a definitive long-term management option. Continuing with their current diet regimen is not recommended as it may lead to poor nutrition and a risk of aspiration. Total parenteral nutrition is only used as a last resort when there is impaired nutrient absorption. Inserting a nasogastric tube is not a suitable option as it must be removed after a few weeks to avoid adverse effects. A percutaneous jejunostomy tube is also not recommended as it is less commonly used and harder to maintain than a PEG tube.

      Managing Motor Neuron Disease

      Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It typically presents after the age of 40 and can manifest in different patterns, such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The cause of the disease is unknown.

      One medication used in the management of motor neuron disease is riluzole, which works by preventing the stimulation of glutamate receptors. It is mainly used in cases of amyotrophic lateral sclerosis and has been shown to prolong life by approximately three months.

      Respiratory care is also an important aspect of managing motor neuron disease. Non-invasive ventilation, usually in the form of BIPAP, is used at night and has been associated with a survival benefit of around seven months.

      Nutrition support is also crucial in managing motor neuron disease. The preferred method is percutaneous gastrostomy tube (PEG), which has been linked to prolonged survival.

      Unfortunately, the prognosis for motor neuron disease is poor, with 50% of patients dying within three years.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 64 - Which one of the following statements regarding pancreatic cancer is true? ...

    Correct

    • Which one of the following statements regarding pancreatic cancer is true?

      Your Answer: High-resolution CT scanning is the diagnostic investigation of choice

      Explanation:

      Pancreatic cancer is best diagnosed through high-resolution CT scanning. Although chronic pancreatitis increases the risk, neither alcohol nor gallstone disease are significant independent risk factors. Radiotherapy is not effective for surgical resection. Unfortunately, most patients are diagnosed with unresectable lesions.

      Understanding Pancreatic Cancer: Risk Factors, Symptoms, and Management

      Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. Adenocarcinomas, which occur at the head of the pancreas, make up over 80% of pancreatic tumors. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and genetic mutations such as BRCA2 and KRAS.

      Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, pruritus, anorexia, weight loss, epigastric pain, loss of exocrine and endocrine function, and atypical back pain. Migratory thrombophlebitis, also known as Trousseau sign, is more common in pancreatic cancer than in other cancers.

      Diagnosis of pancreatic cancer can be made through ultrasound or high-resolution CT scanning, which may show the double duct sign – simultaneous dilatation of the common bile and pancreatic ducts. However, less than 20% of patients are suitable for surgery at diagnosis. A Whipple’s resection, or pancreaticoduodenectomy, may be performed for resectable lesions in the head of the pancreas. Adjuvant chemotherapy is usually given following surgery, and ERCP with stenting may be used for palliation.

      In summary, pancreatic cancer is a serious disease with non-specific symptoms that can be difficult to diagnose. Understanding the risk factors and symptoms can help with early detection and management.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 65 - A 28-year-old pregnant woman presents to the GP with jaundice and itchy skin...

    Correct

    • A 28-year-old pregnant woman presents to the GP with jaundice and itchy skin for the past 2 weeks. She claims that is a lot worse during this pregnancy compared to her last one. History reveals that she is currently 30 weeks pregnant with no complications up until presentation.

      On examination, the only notable findings are mild jaundice seen in the sclerae, as well as excoriations around the umbilicus and flanks. She denies any tenderness in her abdomen during the examination. Blood tests show the following:

      ALT 206 U/L
      AST 159 U/L
      ALP 796 umol/l
      GGT 397 U/L
      Bilirubin (direct) 56 umol/L
      Bile salts 34 umol/L
      Bile salts reference range 0 - 14 umol/L

      What is the most likely diagnosis?

      Your Answer: Obstetric cholestasis

      Explanation:

      Obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy, is a condition that occurs when the flow of bile is impaired, resulting in a buildup of bile salts in the skin and placenta. The cause of this condition is believed to be a combination of hormonal, genetic, and environmental factors. While the pruritic symptoms can be distressing for the mother, the buildup of bile salts can also harm the fetus. The fetus’s immature liver may struggle to break down the excessive levels of bile salts, and the vasoconstricting effect of bile salts on human placental chorionic veins may lead to sudden asphyxial events in the fetus, resulting in anoxia and death.

      Intrahepatic Cholestasis of Pregnancy: Symptoms and Management

      Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

      The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

      It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 66 - A 54-year-old man with a history of alcoholic liver disease and cirrhosis is...

    Correct

    • A 54-year-old man with a history of alcoholic liver disease and cirrhosis is scheduled for an oesophago-gastro-duodenoscopy (OGD) to screen for oesophageal varices. The OGD reveals several high-risk varices, and medical prophylaxis is advised. What medication would be the best choice?

      Your Answer: Propranolol

      Explanation:

      Propranolol, a non-selective beta-blocker, is utilized for the prevention of oesophageal bleeding. Bisoprolol and metoprolol, both cardio-selective beta-blockers, are not as effective as propranolol for the extended management of varices. Terlipressin, a vasopressin analogue, is recommended for the immediate treatment of variceal bleeding.

      Variceal haemorrhage is a serious condition that requires prompt management. The initial treatment involves resuscitation of the patient before endoscopy. Correcting clotting with FFP and vitamin K is important, as is the use of vasoactive agents such as terlipressin or octreotide. Prophylactic IV antibiotics are also recommended to reduce mortality in patients with liver cirrhosis. Endoscopic variceal band ligation is the preferred method of treatment, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. Propranolol and EVL are effective in preventing rebleeding and mortality, and are recommended by NICE guidelines. Proton pump inhibitor cover is given to prevent EVL-induced ulceration.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 67 - An 80-year-old man presents to the Emergency Department with a history of vomiting...

    Correct

    • An 80-year-old man presents to the Emergency Department with a history of vomiting blood earlier in the day. What is the most significant factor indicating an upper gastrointestinal bleed?

      Your Answer: Urea = 15.4 mmol/l on a background of normal renal function

      Explanation:

      A temporary and disproportionate increase in blood urea can be caused by an upper gastrointestinal bleed, which can function as a source of protein.

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The clinical features of this condition include haematemesis, melena, and a raised urea level due to the protein meal of the blood. The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation is also necessary, including ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours.

      For non-variceal bleeding, proton pump inhibitors (PPIs) should not be given before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. However, PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy. If further bleeding occurs, options include repeat endoscopy, interventional radiology, and surgery. For variceal bleeding, terlipressin and prophylactic antibiotics should be given to patients at presentation, and band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 68 - A 56-year-old man is admitted to the Emergency Department. His wife reports that...

    Correct

    • A 56-year-old man is admitted to the Emergency Department. His wife reports that he has been experiencing worsening confusion for approximately one week. Upon examination, there are evident indications of chronic liver disease, along with nystagmus and cerebellar ataxia. The patient appears highly confused. His liver function tests (LFTs) are normal except for elevated gamma-glutamyl transferase (GGT), a full blood count reveals macrocytosis, and blood glucose levels are normal. What is the most appropriate diagnosis for this clinical presentation?

      Your Answer: Wernicke encephalopathy (WE)

      Explanation:

      Differential Diagnosis for Confusion in a Patient with Alcohol Misuse

      Wernicke Encephalopathy (WE), caused by thiamine deficiency and commonly associated with chronic alcoholism, is a serious neurological disorder that presents with a classic triad of ocular findings, cerebellar dysfunction, and confusion. Rapid correction of brain thiamine deficiency is crucial, and treatment is initially administered parenterally. Neurological dysfunction, especially memory and learning impairment, can persist even after treatment, leading to Korsakoff syndrome.

      Subdural hematoma, more common in individuals who misuse alcohol, is an important differential diagnosis in cases of acute confusion. However, a history of head injury, even minor, and a headache with or without vomiting are typically present. Acute hematomas present soon after the injury, while chronic hematomas may not present until 2-3 weeks after the trauma.

      Acute alcohol poisoning is unlikely in a patient with worsening confusion over the past week. Sudden onset of confusion following an alcohol binge that improves with abstinence is expected.

      Hepatic encephalopathy, a spectrum that develops in patients with advanced liver disease, may present with a change in personality, short-term memory loss, or reduced level of consciousness. However, cerebellar signs such as nystagmus and ataxia are not associated with this condition.

      Delirium tremens, a rapid onset of confusion as a result of alcohol withdrawal, typically appears three days after abstinence from alcohol and may include visual hallucinations, acute confusion, and tremor. If untreated, seizures may occur. However, the presence of nystagmus and ataxia in this case makes WE the more likely diagnosis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 69 - A 65-year-old man with a history of type 2 diabetes, angina, and erectile...

    Correct

    • A 65-year-old man with a history of type 2 diabetes, angina, and erectile dysfunction presents with complaints of rectal pain. During a per rectum examination, the patient experiences discomfort and an anal ulceration is discovered. What is the most probable cause of this man's symptoms?

      Your Answer: Nicorandil

      Explanation:

      Nicorandil, a medication used for angina, can lead to anal ulceration as a potential adverse effect. GTN spray may cause headaches, dizziness, and low blood pressure. Gastric discomfort is a possible side effect of both metformin and ibuprofen. Excessive use of paracetamol can result in liver damage.

      Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved by stimulating guanylyl cyclase, which increases the levels of cGMP in the body. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers in the skin, mucous membranes, and eyes. Additionally, nicorandil can cause gastrointestinal ulcers, including anal ulceration. It is important to note that nicorandil should not be used in patients with left ventricular failure.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 70 - A 25-year-old woman presents with complaints of intermittent diarrhoea and constipation. She experiences...

    Incorrect

    • A 25-year-old woman presents with complaints of intermittent diarrhoea and constipation. She experiences bloating that is relieved by defecation and finds relief with hyoscine butylbromide (Buscopan). She denies any weight loss and has no relevant family history. Coeliac disease screening was negative and both full blood count and CRP were normal. Despite being diagnosed with irritable bowel syndrome and given dietary advice and antispasmodics, she disagrees with the diagnosis and requests further investigations. What is the most appropriate course of action?

      Your Answer: Faecal occult blood test

      Correct Answer: Reassure that further tests are not required at this stage

      Explanation:

      It is not recommended to use faecal occult blood testing for colorectal cancer screening in symptomatic patients who are under the age of 60. This woman is displaying symptoms of irritable bowel syndrome and has normal blood results, without any red flag symptoms. Repeating the full blood count is unlikely to provide any additional information. The use of steroids and azathioprine is not appropriate for treating irritable bowel syndrome, as they are typically used for ulcerative colitis, which is not likely in this case.

      Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

      Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

      Faecal Immunochemical Test (FIT) Screening:
      The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 71 - A 49 year old man complains of experiencing dyspepsia on and off for...

    Correct

    • A 49 year old man complains of experiencing dyspepsia on and off for the past few months. He reports no signs of bleeding, dysphagia or weight loss, abstains from alcohol and is generally healthy. He is not taking any regular medication and has been using over-the-counter antacids which provide some relief. Physical examination reveals no abnormalities. What is your recommended plan for continued management?

      Your Answer: Proton pump inhibitor

      Explanation:

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 72 - A 6-year-old girl is brought to see her GP by her mother. She...

    Correct

    • A 6-year-old girl is brought to see her GP by her mother. She is noted to be on the 4th centile for weight. Her mother notes that for the past few months her daughter has been tired and passes greasy foul-smelling stools three times a day. Blood tests reveal mild anaemia, positive serum IgA anti-endomysial antibody (EMA-IgA) and very elevated tissue transglutaminase (tTG) levels.
      Which of the following is the most likely cause of her symptoms?
      Select the SINGLE most likely cause from the list below. Select ONE option only.

      Your Answer: Coeliac disease

      Explanation:

      Understanding Coeliac Disease: Symptoms, Diagnosis, and Treatment

      Coeliac disease (CD) is a common autoimmune disorder that affects almost 1% of individuals in developed countries. It is triggered by gluten and related prolamins present in wheat, rye, and barley, and primarily affects the small intestine, leading to flattening of the small intestinal mucosa. CD can present in various ways, including typical GI symptoms, atypical symptoms, or no symptoms at all. Diagnosis is made through serology tests for specific autoimmune markers, and treatment involves a lifelong avoidance of gluten ingestion.

      Other potential diagnoses, such as travellers’ diarrhoea, growth hormone deficiency, hypothyroidism, and severe combined immunodeficiency, have different clinical presentations and are not consistent with this patient’s symptoms. Understanding the symptoms, diagnosis, and treatment of CD is crucial for proper management and improved quality of life for affected individuals.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 73 - A 48 year old man presents to the emergency department with acute abdominal...

    Correct

    • A 48 year old man presents to the emergency department with acute abdominal pain and feeling unwell. He is typically in good health and enjoys long distance running. His medical history includes a previous finger injury from playing cricket and gallstones that have not caused any issues. During examination, his sclera is noted to be icteric. His heart rate is 106 bpm and his blood pressure is 125/85 mmHg. He has a temperature of 38.1ºC. There is significant rebound tenderness and guarding in the right upper quadrant, and his bowel sounds are quiet. What is the most probable diagnosis?

      Your Answer: Ascending cholangitis

      Explanation:

      The man in this scenario is experiencing Charcot’s triad, which includes right upper quadrant pain, fever, and jaundice. These symptoms suggest that he may have ascending cholangitis, which is caused by a bacterial infection in the biliary tree due to obstruction from biliary stasis (likely caused by his gallstones). Treatment involves resuscitation, IV antibiotics, and biliary drainage.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 74 - Samantha, 74, visits her doctor complaining of jaundice. She is also a heavy...

    Correct

    • Samantha, 74, visits her doctor complaining of jaundice. She is also a heavy drinker, consuming around 30-35 units per week. During the examination, a palpable gallbladder is detected, but there is no history of abdominal pain. The doctor orders blood tests, and the results are as follows:
      - Albumin: 28 g/L
      - Alk Phos: 320 U/L
      - ALT: 90 U/L
      - Bilirubin: 100 umol/L
      - INR: 1.5
      - GGT: 120 U/L

      What is the most likely diagnosis for Samantha?

      Your Answer: Pancreatic cancer

      Explanation:

      Pancreatic cancer is the correct answer for this question, as indicated by Courvoisier’s sign. This sign suggests that a painless, enlarged gallbladder and mild jaundice are unlikely to be caused by gallstones, but rather by a malignancy of the pancreas or biliary tree. While alcoholic hepatitis and primary biliary cirrhosis are possible differentials, the presence of a painless, enlarged gallbladder makes them less likely. Paracetamol overdose is not a likely cause, as it would not result in a painless, palpable gallbladder and jaundice is not typically associated with this type of overdose.

      Understanding Pancreatic Cancer: Risk Factors, Symptoms, and Management

      Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. Adenocarcinomas, which occur at the head of the pancreas, make up over 80% of pancreatic tumors. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and genetic mutations such as BRCA2 and KRAS.

      Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, pruritus, anorexia, weight loss, epigastric pain, loss of exocrine and endocrine function, and atypical back pain. Migratory thrombophlebitis, also known as Trousseau sign, is more common in pancreatic cancer than in other cancers.

      Diagnosis of pancreatic cancer can be made through ultrasound or high-resolution CT scanning, which may show the double duct sign – simultaneous dilatation of the common bile and pancreatic ducts. However, less than 20% of patients are suitable for surgery at diagnosis. A Whipple’s resection, or pancreaticoduodenectomy, may be performed for resectable lesions in the head of the pancreas. Adjuvant chemotherapy is usually given following surgery, and ERCP with stenting may be used for palliation.

      In summary, pancreatic cancer is a serious disease with non-specific symptoms that can be difficult to diagnose. Understanding the risk factors and symptoms can help with early detection and management.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 75 - A 56-year-old male patient presents to the emergency department with a 3-day history...

    Correct

    • A 56-year-old male patient presents to the emergency department with a 3-day history of severe right upper quadrant pain preceded by a 2-month history of intermittent ache in the right upper quadrant. His basic observations include heart rate 115 beats/minute, respiratory rate 28 breaths/minute, blood pressure 90/55 mmHg, temperature 38.9°C, oxygen saturation 93% on air. His past medical history includes hypertension and type 2 diabetes mellitus.

      WCC 14 x 109cells/L
      Bilirubin 80 mg/dL
      Alkaline phosphatase 377 IU/L
      Alanine aminotransferase 70 U/L
      Amylase 300 U/L

      What is the most likely diagnosis?

      Your Answer: Ascending cholangitis

      Explanation:

      The three main symptoms of Charcot’s cholangitis are fever, jaundice, and pain in the upper right quadrant. This type of cholangitis is known for causing these three symptoms, which are collectively referred to as Charcot’s triad. When there is inflammation in the gastrointestinal tract, amylase levels may be slightly elevated. While cholecystitis can lead to jaundice, it is usually not severe. On the other hand, pancreatitis typically does not cause jaundice, and amylase levels are typically much higher.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 76 - A 50-year-old man visits the Gastroenterology Clinic with concerns about his tongue. He...

    Correct

    • A 50-year-old man visits the Gastroenterology Clinic with concerns about his tongue. He has noticed unusual patterns on his tongue that have been present for a while, but he is worried about tongue cancer as he has been a heavy smoker for the past 20 years. What is the most suitable initial management option for this patient?

      Your Answer: None

      Explanation:

      Geographic Tongue: A Benign Condition Requiring No Medical Intervention

      Geographic tongue, also known as benign migratory glossitis, is a common condition that affects up to 3% of the general population. While some patients may experience a burning sensation when consuming hot or spicy foods, most are asymptomatic. The diagnosis of geographic tongue can usually be confirmed from history and physical examination alone, and no medical intervention is required.

      Surgical correction is not warranted for geographic tongue, as it is a benign condition of no clinical significance. Aspiration for cytology is also not appropriate, as the diagnosis can be made without further investigation. Excision biopsy may actually cause harm, as histological findings are identical to those seen in pustular psoriasis.

      A full blood count is not necessary for the diagnosis of geographic tongue. Instead, the condition can be identified through the elongation of rete ridges, hyperparakeratosis and acanthosis at the periphery, loss of filiform papillae, and migration and clustering of neutrophils within the epithelium towards the centre of the lesions. The predominant inflammatory infiltrates in the lamina propria is neutrophils with an admixture of chronic inflammatory cells.

      In summary, geographic tongue is a benign condition that requires no medical intervention. Diagnosis can be made through history and physical examination alone, and further investigation may cause harm.

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      • Gastroenterology/Nutrition
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  • Question 77 - Which one of the following pathological changes favours ulcerative colitis (UC) over Crohn...

    Correct

    • Which one of the following pathological changes favours ulcerative colitis (UC) over Crohn disease in elderly patients?

      Your Answer: Crypt abscesses

      Explanation:

      Differences between Crohn’s Disease and Ulcerative Colitis

      Crohn’s disease and ulcerative colitis are both types of inflammatory bowel disease, but they differ in several aspects. One of the main differences is the presence of granulomas. While a lack of granulomas does not rule out Crohn’s disease, it is a far more likely option if they are present. Granulomas are not present in ulcerative colitis.

      Another difference is the layers of the bowel affected. Crohn’s disease affects all layers of the bowel, known as transmural disease, whereas ulcerative colitis is confined to the mucosa with occasional submucosa inflammation. Only Crohn’s disease has muscularis and serosa involvement. Additionally, Crohn’s disease can affect anything from the mouth to the anus, whereas ulcerative colitis is limited to colonic lesions.

      Skip lesions, or areas of discontinuity of the inflammatory process, are characteristic of Crohn’s disease. When skip lesions are present, this is suggestive of Crohn’s disease. Ulcerative colitis is a continuous disease, whereas Crohn’s disease can be present in multiple areas of the bowel with sharply demarcated areas.

      In terms of histology, both diseases show intense infiltration of the mucosa and submucosa with neutrophils and lymphoid aggregates. However, in fulminant cases of ulcerative colitis, the muscularis propria may be affected. On the other hand, the histologic characteristic pattern of inflammation in Crohn’s disease is transmural involvement of the bowel wall by lymphoid infiltrates that contain non-caseating granulomas.

      Therefore, it is important to differentiate between Crohn’s disease and ulcerative colitis to provide appropriate treatment. Endoscopy must be performed if ulcerative colitis is suspected.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 78 - A 32-year-old woman with a 9-month history of weight loss, intermittent bloody mucus...

    Correct

    • A 32-year-old woman with a 9-month history of weight loss, intermittent bloody mucus stools and abdominal pain undergoes a colonoscopy, which shows a mucosal ‘cobblestone’ pattern and skip lesions. She drinks approximately four units of alcohol a week and has a smoking history of five pack years.
      Which of the following is the most appropriate lifestyle advice for this patient?

      Your Answer: Stop smoking

      Explanation:

      Lifestyle Advice for Patients with Inflammatory Bowel Disease

      Inflammatory bowel disease (IBD) is a chronic inflammatory process that can affect any part of the gastrointestinal tract. Patients with IBD may experience symptoms such as diarrhoea, abdominal pain, and bleeding. Here are some lifestyle advice for patients with IBD:

      Stop smoking: Research suggests that smoking can make Crohn’s disease worse. Smokers with Crohn’s disease have more severe symptoms and complications, require more medication, and are more likely to need surgery.

      Eat a balanced diet: Patients with IBD may need to be careful about the amount and type of fibre in their diet. During flare-ups, it may be helpful to reduce the amount of insoluble fibre consumed, but, once the flare-up is over, it is important to increase fibre intake again.

      Avoid alcohol: Although there is no evidence that alcohol consumption worsens IBD symptoms, alcohol can affect the lining of the gastrointestinal tract and interact with certain medications.

      Quit smoking: Although smoking may delay or even prevent ulcerative colitis, the health risks of smoking outweigh any benefits seen in UC, and strongly discourage smoking in everyone, whether or not they have IBD.

      Consider probiotics: The role of probiotics in IBD is not fully understood, but their use can be discussed with a General Practitioner or dietitian. More research is needed on their general effectiveness.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 79 - A 54 year old woman presents to the General Practice clinic with complaints...

    Correct

    • A 54 year old woman presents to the General Practice clinic with complaints of increasing dyspepsia, dysphagia, and fatigue. She reports a prolonged history of dark brown stools, but denies any recent episodes of fresh blood. She has not experienced any unexplained weight loss and underwent surgery for a peptic ulcer a decade ago. Upon investigation, she is found to have H. pylori. What should be the subsequent course of action?

      Your Answer: 2 week referral to endoscopy

      Explanation:

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 80 - A 35-year-old woman presents to the hospital with diarrhea and abdominal pain. She...

    Correct

    • A 35-year-old woman presents to the hospital with diarrhea and abdominal pain. She has a history of depression and takes citalopram, smokes 20 cigarettes per day, and drinks 20 units of alcohol per week. During ileocolonoscopy, Crohn's disease is diagnosed, and she is treated with glucocorticoid therapy. What is the most crucial step to decrease the likelihood of future episodes?

      Your Answer: Stop smoking

      Explanation:

      Managing Crohn’s Disease: Guidelines and Treatment Options

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.

      To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.

      To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 81 - A 30-year-old female who is being investigated for secondary amenorrhoea comes in with...

    Incorrect

    • A 30-year-old female who is being investigated for secondary amenorrhoea comes in with yellowing of the eyes. During the examination, spider naevi are observed, and the liver is tender and enlarged. The blood tests reveal the following results: Hb 11.6 g/dl, Plt 145 * 109/l, WCC 6.4 * 109/l, Albumin 33 g/l, Bilirubin 78 µmol/l, and ALT 245 iu/l. What is the most probable diagnosis?

      Your Answer: Primary biliary cirrhosis

      Correct Answer: Autoimmune hepatitis

      Explanation:

      When a young female experiences both abnormal liver function tests and a lack of menstrual periods, it is highly indicative of autoimmune hepatitis.

      Understanding Autoimmune Hepatitis

      Autoimmune hepatitis is a condition that affects mostly young females and has an unknown cause. It is often associated with other autoimmune disorders, hypergammaglobulinaemia, and HLA B8, DR3. There are three types of autoimmune hepatitis, which are classified based on the types of circulating antibodies present. Type I affects both adults and children and is characterized by the presence of anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA). Type II affects children only and is characterized by the presence of anti-liver/kidney microsomal type 1 antibodies (LKM1). Type III affects adults in middle-age and is characterized by the presence of soluble liver-kidney antigen.

      Autoimmune hepatitis may present with signs of chronic liver disease, and only 25% of cases present with acute hepatitis symptoms such as fever and jaundice. Amenorrhea is a common symptom. Diagnosis is made through the presence of ANA/SMA/LKM1 antibodies, raised IgG levels, and liver biopsy showing inflammation extending beyond the limiting plate, piecemeal necrosis, and bridging necrosis.

      Management of autoimmune hepatitis involves the use of steroids and other immunosuppressants such as azathioprine. In severe cases, liver transplantation may be necessary.

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      • Gastroenterology/Nutrition
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  • Question 82 - A 42-year-old woman presents to her General Practitioner with a diagnosis of primary...

    Incorrect

    • A 42-year-old woman presents to her General Practitioner with a diagnosis of primary biliary cholangitis (PBC). She initially complained of abdominal pain and itching, but is now asymptomatic except for significant fatigue. What medication should be prescribed for this patient? Choose the most likely option.

      Your Answer: Cholestyramine

      Correct Answer: Ursodeoxycholic acid (UDCA)

      Explanation:

      Treatment Options for Primary Biliary Cholangitis

      Primary biliary cholangitis (PBC) is a liver disease that can lead to cirrhosis if left untreated. Ursodeoxycholic acid (UDCA) is the main treatment for PBC, as it can prevent or delay the development of cirrhosis. UDCA increases bile flow, inhibits toxic bile acid production, prevents hepatocyte apoptosis, and reduces the liver’s immune response. However, UDCA may cause side effects such as diarrhea, nausea, and thinning hair.

      Spironolactone is a diuretic that can be useful for end-stage liver disease with ascites, but it is not indicated for treating fatigue in PBC patients. Aspirin and ibuprofen should be avoided by PBC patients, as they can worsen liver disease. Cholestyramine is used for cholestatic itching, but it should not be taken with UDCA as it can prevent UDCA absorption.

      In summary, UDCA is the primary treatment for PBC, and other medications should be used with caution and only for specific symptoms or complications.

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      • Gastroenterology/Nutrition
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  • Question 83 - A 49-year-old woman comes to see her doctor complaining of increasing fatigue, itchy...

    Correct

    • A 49-year-old woman comes to see her doctor complaining of increasing fatigue, itchy skin, and pain in the upper right side of her abdomen. She has a medical history of autoimmune disorders such as hypothyroidism and coeliac disease. The doctor suspects that she may have primary biliary cholangitis (PBC). What is the first test that should be ordered for this patient?

      Your Answer: Anti-mitochondrial autoantibodies

      Explanation:

      Understanding the Diagnostic Tests for Primary Biliary Cholangitis

      Primary biliary cholangitis (PBC) is a chronic autoimmune disease that affects the biliary system. It can lead to the destruction of small bile ducts and eventually cirrhosis. While it may be asymptomatic in the early stages, symptoms such as fatigue, abdominal pain, and dry eyes may develop over time. To diagnose PBC, a blood test for anti-mitochondrial antibodies is the most appropriate first step. If positive, a liver ultrasound scan and biopsy can confirm the diagnosis. Other tests, such as an MRI scan or tests for anti-La and anti-Ro antibodies, are not used in the diagnosis of PBC.

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      • Gastroenterology/Nutrition
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  • Question 84 - A 35-year-old female patient complains of indigestion for the past three months. She...

    Correct

    • A 35-year-old female patient complains of indigestion for the past three months. She denies any weight loss, anorexia, dysphagia, vomiting, or alteration in bowel habits. Her abdominal examination is normal. What factor could potentially reduce the reliability of a 13C-urea breath test?

      Your Answer: Course of amoxicillin stopping 3 weeks ago

      Explanation:

      To undergo a urea breath test, one must not have taken antibiotics within the last four weeks and must not have taken any antisecretory drugs, such as PPI, within the last two weeks.

      Tests for Helicobacter pylori

      There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.

      Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.

      Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.

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      • Gastroenterology/Nutrition
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  • Question 85 - A 30-year-old woman presents with chronic diarrhoea. She says that her stools float...

    Correct

    • A 30-year-old woman presents with chronic diarrhoea. She says that her stools float and are difficult to flush away.
      Investigations reveal the following:
      Investigation Result Normal value
      Potassium (K+) 3.1 mmol/l 3.5–5.0 mmol/l
      Corrected calcium (Ca2+) 2.08 mmol/l 2.20–2.60 mmol/l
      Albumin 29 g/l 35–55 g/l
      Haemoglobin (Hb) 91 g/l 115–155 g/l
      Mean corpuscular volume (MCV) 89 fl 76–98 fl
      Coeliac disease is suspected.
      Which of the following is the initial investigation of choice?

      Your Answer: Anti-tissue transglutaminase (anti-TTG)

      Explanation:

      Diagnosis and Investigation of Coeliac Disease

      Coeliac disease is a possible diagnosis in patients presenting with chronic diarrhoea and steatorrhoea. The initial investigation of choice is the anti-tissue transglutaminase (anti-TTG) test, which has a sensitivity of over 96%. However, it is important to check immunoglobulin A (IgA) levels concurrently, as anti-TTG is an IgA antibody and may not be raised in the presence of IgA deficiency.

      The treatment of choice for coeliac disease is a lifelong gluten-free diet, avoiding gluten-containing foods such as wheat, barley, rye, and oats. Patients with coeliac disease are at increased risk of small bowel lymphoma and oesophageal carcinoma over the long term.

      While faecal fat estimation may be useful in estimating steatorrhoea, small bowel biopsy is the gold standard investigation for coeliac disease. However, this would not be the initial investigation of choice as it is invasive. An anti-TTG test is more sensitive and specific than an anti-gliadin test in untreated coeliac disease. Magnesium (Mg2+) levels may be abnormal in coeliac disease, but this would not be diagnostic and therefore not the first investigation of choice.

      In summary, the diagnosis of coeliac disease requires a combination of clinical presentation, laboratory investigations, and small bowel biopsy if necessary. The anti-TTG test is the initial investigation of choice, and a gluten-free diet is the treatment of choice.

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      • Gastroenterology/Nutrition
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  • Question 86 - A 35-year-old woman comes back from a trip. During her final day overseas,...

    Correct

    • A 35-year-old woman comes back from a trip. During her final day overseas, she had lunch from an unlicensed street food vendor. After eight days of returning home, she encounters bloating, abdominal discomfort, and non-bloody diarrhea, and she observes that her stools are floating in the toilet bowl. The patient's symptoms persist for nine weeks. What is the probable pathogen responsible for the patient's symptoms?

      Your Answer: Giardia

      Explanation:

      Chronic Giardia infection can lead to malabsorption.

      Giardia is a type of protozoan that can be transmitted through the ingestion of contaminated fecal matter. While giardiasis typically resolves within a few weeks, if the infection persists for more than six weeks, it is considered chronic. Chronic Giardia infection can cause malabsorption of various nutrients, including vitamin A, B12, iron, zinc, and lipids. This malabsorption can result in steatorrhea, which is characterized by greasy, foul-smelling stools that float in the toilet bowl.

      It is important to note that other pathogens, such as Entamoeba histolytica, Escherichia coli, and Salmonella, do not commonly cause malabsorption. While they may cause diarrhea and other gastrointestinal symptoms, they do not typically result in the malabsorption of nutrients.

      Understanding Giardiasis

      Giardiasis is a condition caused by a type of protozoan called Giardia lamblia. It is transmitted through the faeco-oral route and can be contracted through various means such as foreign travel, drinking water from rivers or lakes, and even male-male sexual contact. While some individuals may not experience any symptoms, others may suffer from non-bloody diarrhea, bloating, abdominal pain, lethargy, flatulence, and weight loss. In severe cases, malabsorption and lactose intolerance may occur. Diagnosis can be made through stool microscopy, stool antigen detection assay, or PCR assays. Treatment typically involves the use of metronidazole.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 87 - A 25-year-old woman presents to the neurology clinic with a unilateral hand tremor....

    Correct

    • A 25-year-old woman presents to the neurology clinic with a unilateral hand tremor. Her family has noticed changes in her behavior, mood, and speech over the past year. During the examination, a resting tremor is observed in her right hand, along with bradykinesia and a lack of movement. Additionally, dark circular marks are visible around her iris. The patient mentions that her uncle passed away from liver cirrhosis at the age of 42. What is the probable diagnosis?

      Your Answer: Wilson's disease

      Explanation:

      Wilson’s disease is indicated by the presence of both liver and neurological conditions, as well as the presence of Kayser-Fleischer rings and a family history of liver disease.

      Wilson’s disease is a genetic disorder that causes excessive copper buildup in the body tissues due to increased copper absorption from the small intestine and decreased hepatic copper excretion. It is an autosomal recessive disorder caused by a defect in the ATP7B gene located on chromosome 13. Symptoms usually appear between the ages of 10 and 25, with children presenting with liver disease and young adults with neurological disease. The disease is characterised by excessive copper deposition in the brain, liver, and cornea, resulting in various symptoms such as hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioural problems, Kayser-Fleischer rings, renal tubular acidosis, haemolysis, and blue nails.

      To diagnose Wilson’s disease, a slit lamp examination is conducted to check for Kayser-Fleischer rings, and blood and urine tests are performed to measure copper levels. The diagnosis is confirmed by genetic analysis of the ATP7B gene. The traditional first-line treatment for Wilson’s disease is penicillamine, which chelates copper. However, trientine hydrochloride is an alternative chelating agent that may become first-line treatment in the future. Tetrathiomolybdate is a newer agent that is currently under investigation for the treatment of Wilson’s disease.

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      • Gastroenterology/Nutrition
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  • Question 88 - A 65-year-old man is admitted to the hospital with severe abdominal pain that...

    Incorrect

    • A 65-year-old man is admitted to the hospital with severe abdominal pain that is typically worst shortly after eating a meal. He admits to regularly drinking at least 30 units of alcohol per week for the last 35 years and has recently been diagnosed with type 2 diabetes mellitus by his GP. An abdominal CT scan shows calcification of his pancreas.
      What tests can be used to assess the exocrine function of the pancreas, given the likely diagnosis?

      Your Answer: Serum amylase

      Correct Answer: Faecal elastase

      Explanation:

      The most appropriate test to assess exocrine function in chronic pancreatitis is faecal elastase. This is particularly relevant for a patient who has a history of long-term alcohol consumption and has recently been diagnosed with diabetes, which are both common complications of chronic pancreatitis. Faecal calprotectin is not relevant in this context as it is used to diagnose inflammatory bowel diseases. Serum amylase may not be useful in chronic pancreatitis as patients may have normal levels despite loss of pancreatic function. Serum calcium is not used to assess pancreatic function in chronic pancreatitis, but is part of the Glasgow score for acute pancreatitis. Lipase is not typically used to assess exocrine function, but deficiency in this enzyme can lead to steatorrhoea in patients with chronic pancreatitis.

      Understanding Chronic Pancreatitis

      Chronic pancreatitis is a condition characterized by inflammation that can affect both the exocrine and endocrine functions of the pancreas. While alcohol excess is the leading cause of this condition, up to 20% of cases are unexplained. Other causes include genetic factors such as cystic fibrosis and haemochromatosis, as well as ductal obstruction due to tumors, stones, and structural abnormalities like pancreas divisum and annular pancreas.

      Symptoms of chronic pancreatitis include pain that worsens 15 to 30 minutes after a meal, steatorrhoea, and diabetes mellitus. Abdominal x-rays can show pancreatic calcification in 30% of cases, while CT scans are more sensitive at detecting calcification with a sensitivity of 80% and specificity of 85%. Functional tests like faecal elastase may be used to assess exocrine function if imaging is inconclusive.

      Management of chronic pancreatitis involves pancreatic enzyme supplements, analgesia, and antioxidants, although the evidence base for the latter is limited. It is important to understand the causes, symptoms, and management of chronic pancreatitis to effectively manage this condition.

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      • Gastroenterology/Nutrition
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  • Question 89 - A 32-year-old teacher presents with bloody diarrhoea; he says that he has been...

    Incorrect

    • A 32-year-old teacher presents with bloody diarrhoea; he says that he has been passing up to 10 motions a day for the past 3–4 weeks. He now presents to the Emergency Department, complaining of abdominal pain and bloating. On examination, he is dehydrated with a clearly distended, tender abdomen. There is anaemia with raised plasma viscosity; potassium level is mildly decreased at 3.3 mmol/l (reference range 3.5–5.1 mmol/l), and urea level is raised, in keeping with dehydration. Liver function testing reveals a decreased albumin level. Autoantibody screen is positive for c-ANCA (cytoplasmic anti-neutrophil cytoplasmic antibody). Colonoscopy shows friable mucosa with a uniform pattern of inflammation and loss of normal mucosa. Stool culture is negative.
      Which one of these diagnoses fits best with this clinical picture?

      Your Answer: Crohn's disease

      Correct Answer: Ulcerative colitis

      Explanation:

      Ulcerative colitis is a type of inflammatory bowel disease that affects only the large bowel. Symptoms include rectal bleeding, frequent stools, and mucus discharge from the rectum. Diagnosis is confirmed through sigmoidoscopy, which reveals continuous inflammation with loss of normal mucosa and intense infiltration of the mucosa and submucosa with various immune cells. The presence of p-ANCA is highly associated with UC. Crohn’s disease, coeliac disease, ischaemic colitis, and diverticulitis have different clinical presentations and diagnostic criteria, which do not match the symptoms and test results of this patient.

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      • Gastroenterology/Nutrition
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  • Question 90 - An 80-year-old man comes to the liver clinic for his regular check-up. He...

    Correct

    • An 80-year-old man comes to the liver clinic for his regular check-up. He has been a patient of the clinic for a while due to his liver cirrhosis caused by alcohol abuse. During the examination, he appears cachexic and jaundiced. Upon closer inspection of his abdomen, it is distended, and the shifting dullness test indicates the presence of free fluid in the abdomen. A sample of the fluid is collected, which shows 17g/l of fluid protein. What medication would be the most appropriate to prescribe?

      Your Answer: Spironolactone

      Explanation:

      The recommended treatment for ascites in this patient with liver cirrhosis is spironolactone. This medication is an aldosterone antagonist that helps counteract the fluid overload caused by secondary hyperaldosteronism in patients with hepatic cirrhosis. Azathioprine is not appropriate for this patient as it is used to treat autoimmune hepatitis. Ciprofloxacin may be prescribed for spontaneous ascites, but only if the ascitic protein is 15 g/litre or less, which is not the case for this patient. Prednisolone is used for acute liver failure, which is not the diagnosis for this patient with chronic liver disease.

      Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. However, it is important to note that spironolactone can cause hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone.

      One study, known as RALES, found that low dose spironolactone can reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor. It is important to consult with a healthcare professional before taking spironolactone to determine if it is the right medication for your specific condition and to monitor for any potential adverse effects.

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      • Gastroenterology/Nutrition
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  • Question 91 - Which of the following is not a risk factor for gastric cancer? ...

    Incorrect

    • Which of the following is not a risk factor for gastric cancer?

      Your Answer: H. pylori infection

      Correct Answer: History of duodenal ulceration

      Explanation:

      Gastric Cancer: Risk Factors, Features, Investigations, and Management

      Gastric cancer is a relatively uncommon cancer, accounting for only 2% of all cancer diagnoses in developed countries. It is more prevalent in older individuals, with half of patients being over 75 years old, and has a higher incidence in males. Risk factors for gastric cancer include Helicobacter pylori infection, atrophic gastritis, dietary factors such as salt and nitrate consumption, smoking, and blood group.

      Symptoms of gastric cancer can be vague and include abdominal pain, dyspepsia, weight loss, anorexia, nausea, vomiting, and dysphagia. Overt upper gastrointestinal bleeding is rare. If the cancer has spread to the lymph nodes, Virchow’s node and Sister Mary Joseph’s node may be affected.

      Diagnosis of gastric cancer is typically made through oesophago-gastro-duodenoscopy with biopsy. Signet ring cells may be present in gastric cancer, and a higher number of these cells is associated with a worse prognosis. Staging is done through CT scans.

      Management of gastric cancer depends on the extent and location of the cancer. Surgical options include endoscopic mucosal resection, partial gastrectomy, and total gastrectomy. Chemotherapy may also be used.

      Overall, gastric cancer is a relatively rare cancer with specific risk factors and symptoms. Early diagnosis and appropriate management are crucial for improving outcomes.

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      • Gastroenterology/Nutrition
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  • Question 92 - A 50-year-old woman with a history of alcoholic liver disease presents to the...

    Correct

    • A 50-year-old woman with a history of alcoholic liver disease presents to the clinic with advanced cirrhosis and ascites. A recent ascitic tap revealed a protein concentration of 12 g/L and no evidence of organisms. What is the best course of action to manage the risk of spontaneous bacterial peritonitis?

      Your Answer: Oral ciprofloxacin

      Explanation:

      To prevent spontaneous bacterial peritonitis, it is recommended to administer oral ciprofloxacin or norfloxacin as prophylaxis to patients with ascites and protein concentration of 15 g/L or less.

      Understanding Spontaneous Bacterial Peritonitis

      Spontaneous bacterial peritonitis (SBP) is a type of peritonitis that typically affects individuals with ascites caused by liver cirrhosis. The condition is characterized by symptoms such as abdominal pain, fever, and ascites. Diagnosis is usually made through paracentesis, which involves analyzing the ascitic fluid for a neutrophil count of over 250 cells/ul. The most common organism found on ascitic fluid culture is E. coli.

      Management of SBP typically involves the administration of intravenous cefotaxime. Antibiotic prophylaxis is also recommended for patients with ascites who have previously experienced an episode of SBP or have a fluid protein level of less than 15 g/l and a Child-Pugh score of at least 9 or hepatorenal syndrome. NICE recommends prophylactic oral ciprofloxacin or norfloxacin until the ascites has resolved.

      Alcoholic liver disease is a significant predictor of poor prognosis in SBP. Understanding the symptoms, diagnosis, and management of SBP is crucial for healthcare professionals to provide appropriate care and improve patient outcomes.

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      • Gastroenterology/Nutrition
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  • Question 93 - A 23-year-old man presents to his general practitioner (GP) with a nodular rash...

    Correct

    • A 23-year-old man presents to his general practitioner (GP) with a nodular rash over his shins, which was dusky blue in appearance at first but has now faded to a bruise-like appearance. His past history of note includes intermittent diarrhoea, occasionally with blood. There is no other past history of note. On examination, there is minor tenderness on the left side of his abdomen, and proctoscopy reveals moderate inflammation of the rectum. Blood testing reveals a raised C-reactive protein (CRP) level and normochromic/normocytic anaemia.
      Which diagnosis best fits this clinical picture?

      Your Answer: Ulcerative colitis (UC)

      Explanation:

      Erythema Nodosum and its Association with Various Diseases

      Erythema nodosum is a skin condition characterized by painful, red nodules on the legs. It can be associated with various underlying diseases. In patients with ulcerative colitis, erythema nodosum is a common extraintestinal manifestation, along with uveitis, primary sclerosing cholangitis, ankylosing spondylitis, and pyoderma gangrenosum. However, sarcoidosis, tuberculosis, and mycoplasma infection can also cause erythema nodosum. It is important to consider the patient’s clinical presentation and other symptoms to determine the underlying cause. In this case, the patient’s gastrointestinal symptoms suggest inflammatory bowel disease, specifically ulcerative colitis.

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      • Gastroenterology/Nutrition
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  • Question 94 - A 54-year-old diabetic patient visits your clinic with a complaint of painless difficulty...

    Correct

    • A 54-year-old diabetic patient visits your clinic with a complaint of painless difficulty in swallowing that has been ongoing for the past two months. The patient reports that the difficulty has been getting worse, but is unsure if there has been any weight loss. On examination, there are no notable findings.

      What would be your next course of action considering the possible diagnoses?

      Your Answer: Referral for gastroscopy

      Explanation:

      If a patient experiences new-onset dysphagia, urgent endoscopy is necessary regardless of age or other symptoms. In the case of progressive dysphagia, it is crucial to rule out oesophageal or stomach cancer with a two week wait referral for gastroscopy. Gastroparesis, a delay in gastric emptying associated with diabetes, can be treated with metoclopramide. Plummer-vinson syndrome, which is characterized by iron deficiency anaemia and oesophageal webs, can also cause dysphagia along with glossitis and stomatitis. Gaviscon is not a suitable treatment for dysphagia as it only helps with dyspepsia. While a stroke can cause difficulties in initiating swallowing, it is typically sudden onset rather than progressive.

      Understanding Dysphagia and its Causes

      Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the esophagus, such as oesophageal cancer, oesophagitis, oesophageal candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, and myasthenia gravis. Each condition has its own characteristic features, which can help in identifying the underlying cause of dysphagia. For instance, dysphagia associated with weight loss, anorexia, or vomiting during eating may indicate oesophageal cancer, while dysphagia of both liquids and solids from the start may suggest achalasia.

      To determine the cause of dysphagia, patients usually undergo an upper GI endoscopy, which allows doctors to examine the esophagus and detect any abnormalities. Fluoroscopic swallowing studies may also be done to evaluate motility disorders. Additionally, a full blood count and ambulatory oesophageal pH and manometry studies may be required for certain conditions.

      It’s important to note that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. Therefore, understanding the different causes of dysphagia and their characteristic features can aid in prompt diagnosis and treatment.

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      • Gastroenterology/Nutrition
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  • Question 95 - A 45-year-old woman presents to the Emergency Department with a 2-month history of...

    Incorrect

    • A 45-year-old woman presents to the Emergency Department with a 2-month history of dull abdominal pain. It is central and occasionally radiates to her back. However, this is not always present and it seems to get worse half an hour after a meal. She denies any vomiting or diarrhoea but confirms that painful episodes are accompanied by nausea.
      The patient does not have any past medical history but admits that she has been drinking a glass of wine every night for the past 15 years. An abdominal X-ray is done.
      Given the likely diagnosis, which of the following findings are most likely to be seen on the abdominal X-ray?
      Select the SINGLE most likely finding from the list below.

      Your Answer: Football sign

      Correct Answer: Pancreatic calcifications

      Explanation:

      The patient’s symptoms of dull, central abdominal pain that worsens after meals and radiates to the back, along with a history of regular alcohol consumption, suggest a diagnosis of chronic pancreatitis. Imaging studies, such as an abdominal X-ray or CT scan, may reveal pancreatic calcifications, which are a common finding in chronic pancreatitis. If imaging is inconclusive, a faecal elastase test may be used to assess pancreatic exocrine function. The presence of the football sign, air under the diaphragm, dilated loops of small bowel, or the Rigler sign on an abdominal X-ray would suggest other conditions such as gastrointestinal perforation or bowel obstruction, which do not fit the patient’s presentation.

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      • Gastroenterology/Nutrition
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  • Question 96 - You assess a 19-year-old female patient in the outpatient medical assessment unit. Over...

    Correct

    • You assess a 19-year-old female patient in the outpatient medical assessment unit. Over the course of the last four months, she has been experiencing repeated episodes of severe vomiting lasting a few hours, preceded by intense sweating and nausea. She has also noticed a decrease in appetite and a slight loosening of her clothes. She was hospitalized once in the past four months due to dehydration. Her medical history includes migraines, but no psychiatric history. Routine blood tests with her GP and during her previous admission were unremarkable. What is the most probable diagnosis?

      Your Answer: Cyclical vomiting syndrome

      Explanation:

      Cyclical Vomiting Syndrome is characterized by severe nausea and vomiting that occurs in distinct episodes lasting from a few hours to a few days. This condition is often associated with migraine and may also result in reduced appetite and weight loss. Unlike Crohn’s disease, which typically presents with diarrhea, abdominal pain, and weight loss, Cyclical Vomiting Syndrome does not involve these symptoms. While nausea and weight loss may be present in Pheochromocytoma, this condition does not typically involve discrete episodes of vomiting. Symptoms such as headaches, tremors, palpitations, and anxiety may also be present in Pheochromocytoma. The episodes of vomiting in Cyclical Vomiting Syndrome are not related to food consumption, making bulimia an unlikely diagnosis.

      Understanding Cyclical Vomiting Syndrome

      Cyclical vomiting syndrome is a rare condition that is more commonly seen in children than adults. It affects females slightly more than males, and its cause is unknown. However, 80% of children and 25% of adults who develop CVS also have migraines. The condition is characterized by severe nausea and sudden vomiting that can last for hours to days. Patients may experience intense sweating and nausea before an episode, but they are typically well in between episodes. Other symptoms that may be present include weight loss, reduced appetite, abdominal pain, diarrhea, dizziness, photophobia, and headache.

      To diagnose CVS, doctors typically perform routine blood tests to exclude any underlying conditions. A pregnancy test may also be considered in women. Treatment for CVS involves avoiding triggers and using prophylactic medications such as amitriptyline, propranolol, and topiramate. During acute episodes, ondansetron, prochlorperazine, and triptans may be used.

      Overall, understanding cyclical vomiting syndrome is important for patients and healthcare providers alike. By recognizing the symptoms and seeking appropriate treatment, patients can manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 97 - A 28-year-old woman comes in for a check-up. She reports having 'IBS' and...

    Correct

    • A 28-year-old woman comes in for a check-up. She reports having 'IBS' and experiencing occasional episodes of abdominal pain, bloating, and loose stools for the past two years. However, her symptoms have worsened significantly over the past two weeks. She is now having 3-4 watery, grey, 'frothy' stools per day, along with increased abdominal bloating, cramps, and flatulence. She also feels that she has lost weight based on the fit of her clothes. The following blood tests are ordered:
      Hb 10.9 g/dl
      Platelets 199 * 109/l
      WBC 7.2 * 109/l
      Ferritin 15 ng/ml
      Vitamin B12 225 ng/l
      Folate 2.1 nmol/l
      What is the most likely diagnosis?

      Your Answer: Coeliac disease

      Explanation:

      The key indicators in this case are the presence of anaemia and low levels of ferritin and folate, which are all typical of coeliac disease. The description of the diarrhoea also matches the usual symptoms, although some patients may have stools that are visibly fatty.

      While irritable bowel syndrome is a common condition, it is unlikely to be the cause in this case due to the abnormal blood test results. Low levels of ferritin and folate would not typically be associated with IBS or gastroenteritis. Even if the patient had menorrhagia, this would not explain the low folate levels, although it could account for the anaemia and low ferritin.

      Coeliac disease is much more common than Crohn’s disease, with a prevalence that is around 100 times higher. In an exam scenario, there would typically be more clues pointing towards a diagnosis of Crohn’s disease, such as the presence of mouth ulcers.

      Understanding Coeliac Disease

      Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.

      To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, unexplained gastrointestinal symptoms, sudden weight loss, and autoimmune thyroid disease. Other conditions associated with coeliac disease include irritable bowel syndrome, dermatitis herpetiformis, and type 1 diabetes. First-degree relatives of patients with coeliac disease should also be screened.

      Complications of coeliac disease include anemia, hyposplenism, osteoporosis, lactose intolerance, and enteropathy-associated T-cell lymphoma of the small intestine. In rare cases, coeliac disease may lead to esophageal cancer or other malignancies.

      Overall, understanding coeliac disease is crucial for early diagnosis and management of the condition. Screening for coeliac disease in patients with relevant symptoms and conditions can help prevent complications and improve quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 98 - A 32-year-old man presents with a burning sensation and unusual appearance to his...

    Correct

    • A 32-year-old man presents with a burning sensation and unusual appearance to his tongue. Upon examination, small bumps are observed on the surface of the tongue, along with red patches and white lines that resemble a map.
      What is the most probable cause?

      Your Answer: Geographic tongue

      Explanation:

      Understanding Geographic Tongue: Symptoms, Causes, and Treatment

      Geographic tongue, also known as benign migratory glossitis, is a common condition that affects the tongue. It is characterized by irregularly shaped, red, smooth, and swollen patches on the tongue, often with a white border, giving rise to a map-like appearance. The exact cause of geographic tongue is unknown, but it has been associated with fissured tongue and has an inverse association with cigarette smoking.

      Symptoms of geographic tongue include a burning sensation on the tongue, and eating acidic foods can worsen the pain. While the condition is usually self-limiting, symptomatic treatment can include topical anaesthetic preparations and/or soluble corticosteroids used as a ‘mouth rinse’.

      It is important to note that geographic tongue is not a pre-malignant condition and is not associated with an increased risk of oral cancer. However, it is important to seek medical attention if you experience any unusual symptoms or changes in your oral health.

      Overall, understanding the symptoms, causes, and treatment options for geographic tongue can help individuals manage their condition and maintain good oral health.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 99 - A 26-year-old man with a history of ulcerative colitis presents to the GP...

    Correct

    • A 26-year-old man with a history of ulcerative colitis presents to the GP with symptoms of feeling unwell. He has been experiencing up to 8 bowel movements a day for the past 3 days, with blood present in his stool each time. He denies having a fever. Urgent blood tests reveal the following results:

      Hb 110 g/L Male: (135-180) Female: (115 - 160)
      Platelets 384 * 109/L (150 - 400)
      WBC 16 * 109/L (4.0 - 11.0)
      Na+ 138 mmol/L (135 - 145)
      K+ 4.2 mmol/L (3.5 - 5.0)
      Urea 2.4 mmol/L (2.0 - 7.0)
      Creatinine 58 µmol/L (55 - 120)
      CRP 109 mg/L (< 5)

      What is the initial treatment plan for this patient, given the severity of his symptoms?

      Your Answer: Admit to hospital for IV steroids

      Explanation:

      When dealing with a severe flare of ulcerative colitis, it is important to evaluate the severity of the condition. In this case, the patient is experiencing more than six bloody stools per day, as well as systemic upset indicated by raised inflammatory markers and anaemia. This places him in the severe category. The first line of treatment would be IV corticosteroids, with IV ciclosporin as a second-line option if the steroids do not induce remission. Hospital admission for IV steroids is the appropriate course of action to induce remission, after which maintenance treatment can be assessed. For moderate extensive disease, oral aminosalicylate and oral steroids can be used. It would be inappropriate to send this patient home without any treatment, as he is clearly unwell and experiencing a flare of UC.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools and presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Extensive disease may require a high-dose oral aminosalicylate and topical treatment. Severe colitis should be treated in a hospital with intravenous steroids or ciclosporin. Maintaining remission can involve using a low maintenance dose of an oral aminosalicylate or oral azathioprine/mercaptopurine. Methotrexate is not recommended, but probiotics may prevent relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 100 - What is the most accurate description of a characteristic of irritable bowel syndrome...

    Correct

    • What is the most accurate description of a characteristic of irritable bowel syndrome (IBS)?

      Your Answer: A low FODMAP diet is often prescribed for treatment of the syndrome

      Explanation:

      Understanding Irritable Bowel Syndrome: Diagnosis and Management

      Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder that presents with abdominal pain, bloating, and altered bowel habits. While there is no specific organic pathology associated with IBS, it can significantly impact a patient’s quality of life. Management of IBS involves providing psychological support and recommending dietary measures such as fibre supplementation, increased water intake, and avoiding trigger foods. A low FODMAP diet, which involves avoiding consumption of garlic, onion, high fructose fruits, wheat, alcohol, and dairy, may also be helpful. Pharmacological treatment is adjunctive and should be directed at symptoms. However, if there are ‘red flag’ symptoms such as bleeding, anemia, chronic diarrhea, older age, history of colon polyps, cancer in the patient or first-degree relatives, or constitutional symptoms such as anorexia or weight loss, lower gastrointestinal endoscopy should be performed. Nocturnal symptoms are not consistent with IBS, and weight loss is a ‘red flag’ symptom that should alert the clinician to the possibility of an organic pathology.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 101 - Which of the following is a common feature of ulcerative colitis? ...

    Incorrect

    • Which of the following is a common feature of ulcerative colitis?

      Your Answer: Inflammation in all layers from mucosa to serosa

      Correct Answer: Pseudopolyps

      Explanation:

      Pseudopolyps observed during endoscopy are indicative of ulcerative colitis.

      Crohn’s disease and ulcerative colitis are the two main types of inflammatory bowel disease with many similarities in symptoms and management options. However, there are key differences such as non-bloody diarrhea and upper gastrointestinal symptoms being more common in Crohn’s disease, while bloody diarrhea and abdominal pain in the left lower quadrant are more common in ulcerative colitis. Complications and pathology also differ between the two diseases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 102 - A 35-year-old man presents to the Emergency Department with rapid onset abdominal pain,...

    Correct

    • A 35-year-old man presents to the Emergency Department with rapid onset abdominal pain, which is worse on lying. He feels nauseous and is vomiting.
      On examination, he is tachycardic and pyrexial at 38.1°C. His abdomen is tender with marked guarding. There is bruising around his umbilicus.
      The patient reports drinking six cans of strong lager per day. He also smokes two packets of cigarettes a day. He says he was last in hospital two years ago when he was vomiting blood. He cannot remember what treatment he was given. He has no other medical history of note. He does not take any medications regularly.
      What is the most likely cause for the man’s presentation and signs?

      Your Answer: Pancreatitis with retroperitoneal haemorrhage

      Explanation:

      Differential diagnosis for a man with abdominal pain and retroperitoneal haemorrhage

      The man in question presents with classic symptoms of pancreatitis, including abdominal pain that radiates to the back and worsens on lying down, as well as nausea. However, his periumbilical bruising suggests retroperitoneal haemorrhage, which can also manifest as flank bruising. This condition may be related to his alcohol consumption, which increases the risk of both pancreatitis and coagulopathy.

      While bleeding oesophageal varices are another potential consequence of alcohol abuse, they would not explain the absence of haematemesis or malanea on this admission, nor the retroperitoneal haemorrhage. Similarly, hepatic cirrhosis and consequent coagulopathy could contribute to bleeding but would not account for the sudden onset of abdominal pain or the lack of ecchymosis elsewhere. A pancreatic abscess, which can develop as a complication of pancreatitis, would typically present with a swinging fever and a longer history of symptoms.

      Finally, a ruptured duodenal ulcer could cause upper gastrointestinal bleeding, but there is no evidence of this in the current case. The absence of reflux also makes this diagnosis less likely. Overall, the differential diagnosis for this patient includes pancreatitis with retroperitoneal haemorrhage, which may be related to alcohol use, and other conditions that do not fully fit the clinical picture.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 103 - As a healthcare professional, you are providing dietary recommendations to a middle-aged patient...

    Correct

    • As a healthcare professional, you are providing dietary recommendations to a middle-aged patient who has been diagnosed with type 2 diabetes mellitus and is struggling with obesity. According to the latest NICE guidelines, which of the following should not be promoted?

      Your Answer: Food products specifically targeted at diabetics

      Explanation:

      According to NICE, it is not recommended to consume foods that are marketed exclusively for individuals with diabetes.

      NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 104 - A 26-year-old male complains of epigastric pain and reflux that worsens after eating....

    Correct

    • A 26-year-old male complains of epigastric pain and reflux that worsens after eating. He underwent first-line triple-therapy eradication treatment for a positive Helicobacter pylori stool antigen test 3 months ago, which initially relieved his symptoms. However, they have now returned, and he wishes to undergo re-testing. What is the most suitable test to arrange?

      Your Answer: Urea breath test

      Explanation:

      Tests for Helicobacter pylori

      There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.

      Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.

      Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 105 - A 35-year-old overweight man visits the clinic with concerns about abdominal discomfort he...

    Correct

    • A 35-year-old overweight man visits the clinic with concerns about abdominal discomfort he experienced over the weekend. He reports that the discomfort began in his upper abdomen shortly after eating a large pizza on Friday night. The discomfort then shifted to the left side of his abdomen. He also vomited a few times. Most of the symptoms subsided within 24 hours. During the examination, he is still slightly tender in the left upper quadrant and has no fever or jaundice.
      What is the most probable diagnosis?

      Your Answer: Biliary colic

      Explanation:

      Biliary colic is a common symptom of gallstones, occurring in 1-4% of patients with choledocholithiasis. The pain is intense and dull, usually resolving within 30-90 minutes, and often occurs after consuming fatty meals. This matches the patient’s symptoms and risk factors. If left untreated, biliary colic can progress to acute cholecystitis, which presents with upper abdominal pain, nausea, vomiting, and fever. However, since the patient’s symptoms resolved within 24 hours, acute cholecystitis is unlikely. Acute viral hepatitis is also an unlikely diagnosis, as the patient has no known exposure to the viruses and her symptoms resolved too quickly. Acute pancreatitis presents with severe abdominal pain, nausea, vomiting, and fever, which does not match the patient’s symptoms. Ascending cholangitis is also unlikely, as the patient is afebrile and not jaundiced, and her symptoms resolved within 24 hours.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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