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  • Question 1 - An 80-year-old man comes to the emergency department complaining of sudden onset abdominal...

    Correct

    • An 80-year-old man comes to the emergency department complaining of sudden onset abdominal pain. He rates the pain as 8/10 in severity, spread throughout his abdomen and persistent. He reports having one instance of loose stools since the pain started. Despite mild abdominal distension, physical examination shows minimal findings.

      What sign would the physician anticipate discovering upon further examination that is most consistent with the clinical picture?

      Your Answer: An irregularly irregular pulse

      Explanation:

      Atrial fibrillation increases the risk of acute mesenteric ischaemia, which is characterized by sudden onset of abdominal pain that is disproportionate to physical examination findings. Diarrhoea may also be present. The presence of an irregularly irregular pulse is indicative of atrial fibrillation, which is a common cause of embolism and therefore the correct answer. Stridor is a sign of upper airway narrowing, bi-basal lung crepitations suggest fluid accumulation from heart failure or fluid overload, and bradycardia does not indicate a clot source.

      Acute mesenteric ischaemia is a condition that is commonly caused by an embolism that blocks the artery supplying the small bowel, such as the superior mesenteric artery. Patients with this condition usually have a history of atrial fibrillation. The abdominal pain associated with acute mesenteric ischaemia is sudden, severe, and does not match the physical exam findings.

      Immediate laparotomy is typically required for patients with acute mesenteric ischaemia, especially if there are signs of advanced ischemia, such as peritonitis or sepsis. Delaying surgery can lead to a poor prognosis for the patient.

    • This question is part of the following fields:

      • Gastrointestinal System
      20.5
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  • Question 2 - A 35-year-old male is undergoing investigation for oral thrush. During the examination, which...

    Incorrect

    • A 35-year-old male is undergoing investigation for oral thrush. During the examination, which two primary regions of the oral cavity are evaluated?

      Your Answer: Oral cavity proper and oral cavity minor

      Correct Answer: Vestibule and oral cavity proper

      Explanation:

      The gastrointestinal system is accessed through the mouth, which serves as the entrance for food. The act of chewing and swallowing is initiated voluntarily. Once swallowed, the process becomes automatic. The oral cavity is divided into two main regions: the vestibule, which is located between the mucosa of the lips and cheeks and the teeth, and the oral cavity proper. These two regions are connected to each other at the back of the second molar tooth.

      Understanding Oesophageal Candidiasis

      Oesophageal candidiasis is a medical condition that is identified by the presence of white spots in the oropharynx, which can extend into the oesophagus. This condition is commonly associated with the use of broad-spectrum antibiotics, immunosuppression, and immunological disorders. Patients with oesophageal candidiasis may experience oropharyngeal symptoms, odynophagia, and dysphagia.

      The treatment for oesophageal candidiasis involves addressing the underlying cause, which should be investigated by a medical professional. Additionally, oral antifungal agents are prescribed to manage the symptoms of the condition.

    • This question is part of the following fields:

      • Gastrointestinal System
      10.4
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  • Question 3 - A 39-year-old patient visits the doctor with complaints of occasional pain in the...

    Incorrect

    • A 39-year-old patient visits the doctor with complaints of occasional pain in the upper right quadrant of the abdomen. The patient reports that the pain worsens after meals, particularly after a heavy dinner. There are no other accompanying symptoms, and all vital signs are within normal limits.

      What is the most probable diagnosis?

      Your Answer: Ascending cholangitis

      Correct Answer: Biliary colic

      Explanation:

      Biliary colic can cause pain after eating a meal.

      Biliary colic occurs when the gallbladder contracts to release bile after a meal, but the presence of gallstones in the gallbladder causes pain during this process. The pain is typically worse after a fatty meal compared to a low-fat meal, as bile is needed to break down fat.

      In contrast, duodenal ulcers cause pain that is worse on an empty stomach and relieved by eating, as food acts as a buffer between the ulcer and stomach acid. The pain from an ulcer is typically described as a burning sensation, while biliary colic causes a sharp pain.

      Autoimmune hepatitis pain is unlikely to fluctuate as the patient described.

      Appendicitis pain typically starts in the center of the abdomen and then moves to the lower right quadrant, known as McBurney’s point.

      Ascending cholangitis is characterized by a triad of fever, pain, and jaundice, known as Charcot’s triad.

      Understanding Biliary Colic and Gallstone-Related Disease

      Biliary colic is a condition that occurs when gallstones pass through the biliary tree. It is more common in women, especially those who are obese, fertile, or over the age of 40. Other risk factors include diabetes, Crohn’s disease, rapid weight loss, and certain medications. Biliary colic is caused by an increase in cholesterol, a decrease in bile salts, and biliary stasis. The pain is due to the gallbladder contracting against a stone lodged in the cystic duct. Symptoms include colicky right upper quadrant abdominal pain, nausea, and vomiting. Unlike other gallstone-related conditions, there is no fever or abnormal liver function tests.

      Ultrasound is the preferred diagnostic tool for biliary colic. Elective laparoscopic cholecystectomy is the recommended treatment. However, around 15% of patients may have gallstones in the common bile duct at the time of surgery, which can lead to obstructive jaundice. Other complications of gallstone-related disease include acute cholecystitis, ascending cholangitis, acute pancreatitis, gallstone ileus, and gallbladder cancer. It is important to understand the risk factors, pathophysiology, and management of biliary colic and gallstone-related disease to ensure prompt diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Gastrointestinal System
      15.6
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  • Question 4 - Which hormone is primarily responsible for sodium-potassium exchange in the salivary ducts? ...

    Incorrect

    • Which hormone is primarily responsible for sodium-potassium exchange in the salivary ducts?

      Your Answer: Angiotensin I

      Correct Answer: Aldosterone

      Explanation:

      The regulation of ion exchange in salivary glands is attributed to aldosterone. This hormone targets a pump that facilitates the exchange of sodium and potassium ions. Aldosterone is classified as a mineralocorticoid hormone and is produced in the zona glomerulosa of the adrenal gland.

      The parotid gland is located in front of and below the ear, overlying the mandibular ramus. Its salivary duct crosses the masseter muscle, pierces the buccinator muscle, and drains adjacent to the second upper molar tooth. The gland is traversed by several structures, including the facial nerve, external carotid artery, retromandibular vein, and auriculotemporal nerve. The gland is related to the masseter muscle, medial pterygoid muscle, superficial temporal and maxillary artery, facial nerve, stylomandibular ligament, posterior belly of the digastric muscle, sternocleidomastoid muscle, stylohyoid muscle, internal carotid artery, mastoid process, and styloid process. The gland is supplied by branches of the external carotid artery and drained by the retromandibular vein. Its lymphatic drainage is to the deep cervical nodes. The gland is innervated by the parasympathetic-secretomotor, sympathetic-superior cervical ganglion, and sensory-greater auricular nerve. Parasympathetic stimulation produces a water-rich, serous saliva, while sympathetic stimulation leads to the production of a low volume, enzyme-rich saliva.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 5 - A 65-year-old man is scheduled for a splenectomy. What is the most posteriorly...

    Incorrect

    • A 65-year-old man is scheduled for a splenectomy. What is the most posteriorly located structure of the spleen?

      Your Answer: Splenic vein

      Correct Answer: Lienorenal ligament

      Explanation:

      The phrenicocolic ligament provides the antero-lateral connection, while the gastro splenic ligament is located anteriorly to the lienorenal ligament. These ligaments converge around the vessels at the splenic hilum, with the lienorenal ligament being the most posterior.

      Understanding the Anatomy of the Spleen

      The spleen is a vital organ in the human body, serving as the largest lymphoid organ. It is located below the 9th-12th ribs and has a clenched fist shape. The spleen is an intraperitoneal organ, and its peritoneal attachments condense at the hilum, where the vessels enter the spleen. The blood supply of the spleen is from the splenic artery, which is derived from the coeliac axis, and the splenic vein, which is joined by the IMV and unites with the SMV.

      The spleen is derived from mesenchymal tissue during embryology. It weighs between 75-150g and has several relations with other organs. The diaphragm is superior to the spleen, while the gastric impression is anterior, the kidney is posterior, and the colon is inferior. The hilum of the spleen is formed by the tail of the pancreas and splenic vessels. The spleen also forms the apex of the lesser sac, which contains short gastric vessels.

      In conclusion, understanding the anatomy of the spleen is crucial in comprehending its functions and the role it plays in the human body. The spleen’s location, weight, and relations with other organs are essential in diagnosing and treating spleen-related conditions.

    • This question is part of the following fields:

      • Gastrointestinal System
      4.3
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  • Question 6 - Lila, a 7-year-old girl, undergoes surgery to correct an inguinal hernia. During the...

    Incorrect

    • Lila, a 7-year-old girl, undergoes surgery to correct an inguinal hernia. During the operation, how can the surgeon confirm that Lila has an indirect hernia?

      Your Answer: Indirect hernia is superior to the epigastric vessels

      Correct Answer: Indirect hernia is lateral to the epigastric vessels

      Explanation:

      An indirect inguinal hernia is situated on the lateral side of the epigastric vessels. This type of hernia occurs when the processus vaginalis fails to close properly, causing a protrusion through the deep inguinal ring and into the inguinal canal. In males, the hernia may extend into the scrotum, while in females, it may extend into the labia. On the other hand, a direct inguinal hernia is caused by weakened abdominal muscles, typically occurring in older individuals. The protrusion enters the inguinal canal through the posterior wall, which is located on the medial side of the epigastric vessels. It may then exit through the superficial inguinal ring.

      Understanding Inguinal Hernias

      Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main symptom is a lump in the groin area, which disappears when pressure is applied or when the patient lies down. Discomfort and aching are also common, especially during physical activity. However, severe pain is rare, and strangulation is even rarer.

      The traditional classification of inguinal hernias into indirect and direct types is no longer relevant in clinical management. Instead, the current consensus is to treat medically fit patients, even if they are asymptomatic. A hernia truss may be an option for those who are not fit for surgery, but it has limited use in other patients. Mesh repair is the preferred method, as it has the lowest recurrence rate. Unilateral hernias are usually repaired through an open approach, while bilateral and recurrent hernias are repaired laparoscopically.

      After surgery, patients are advised to return to non-manual work after 2-3 weeks for open repair and 1-2 weeks for laparoscopic repair. Complications may include early bruising and wound infection, as well as late chronic pain and recurrence. It is important to seek medical attention if any of these symptoms occur.

    • This question is part of the following fields:

      • Gastrointestinal System
      5.2
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  • Question 7 - A 63-year-old man with a history of alcohol abuse presents with recurrent epigastric...

    Incorrect

    • A 63-year-old man with a history of alcohol abuse presents with recurrent epigastric pain. An OGD reveals the presence of varices in the lower esophagus. To prevent variceal bleeding, which medication would be the most suitable prophylactic option?

      Your Answer: Omeprazole

      Correct Answer: Propranolol

      Explanation:

      A non-cardioselective β blocker (NSBB) is the appropriate medication for prophylaxis against oesophageal bleeding in patients with varices. NSBBs work by causing splanchnic vasoconstriction, which reduces portal blood flow. Omeprazole, warfarin, and unfractionated heparin are not suitable options for this purpose.

      Variceal haemorrhage is a serious condition that requires prompt and effective management. The initial treatment involves resuscitation of the patient, correction of clotting abnormalities, and administration 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 for controlling bleeding, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. However, TIPSS can lead to exacerbation of hepatic encephalopathy, which is a common complication.

      To prevent variceal haemorrhage, prophylactic measures such as propranolol and endoscopic variceal band ligation (EVL) are recommended. Propranolol has been shown to reduce rebleeding and mortality compared to placebo. EVL is superior to endoscopic sclerotherapy and should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. NICE guidelines recommend offering endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.

    • This question is part of the following fields:

      • Gastrointestinal System
      14.3
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  • Question 8 - A 16-year-old boy is diagnosed with Meckel's diverticulum. What embryological structure does it...

    Incorrect

    • A 16-year-old boy is diagnosed with Meckel's diverticulum. What embryological structure does it originate from?

      Your Answer: Cloaca

      Correct Answer: Vitello-intestinal duct

      Explanation:

      The Meckel’s diverticulum is a condition where the vitello-intestinal duct persists, and it is characterized by being 2 inches (5cm) long, located 2 feet (60 cm) from the ileocaecal valve, 2 times more common in men, and involving 2 tissue types.

      Meckel’s diverticulum is a congenital diverticulum of the small intestine that is a remnant of the omphalomesenteric duct. It occurs in 2% of the population, is 2 feet from the ileocaecal valve, and is 2 inches long. It is usually asymptomatic but can present with abdominal pain, rectal bleeding, or intestinal obstruction. Investigation includes a Meckel’s scan or mesenteric arteriography. Management involves removal if narrow neck or symptomatic, with options between wedge excision or formal small bowel resection and anastomosis. Meckel’s diverticulum is typically lined by ileal mucosa but ectopic gastric, pancreatic, and jejunal mucosa can also occur.

    • This question is part of the following fields:

      • Gastrointestinal System
      3
      Seconds
  • Question 9 - A 56-year-old female patient who underwent tubal ligation presents to her general practitioner...

    Incorrect

    • A 56-year-old female patient who underwent tubal ligation presents to her general practitioner with complaints of abdominal pain, flank pain, visible blood in her urine, and involuntary urinary leakage. She has a history of lithotripsy for renal calculi one year ago. A CT scan of her abdomen and pelvis reveals an intra-abdominal fluid collection. What is the most probable diagnosis?

      Your Answer: Pelvic inflammatory disease

      Correct Answer: Ureter injury

      Explanation:

      The patient’s symptoms and CT findings suggest that they may have suffered iatrogenic damage to their ureters, which are retroperitoneal organs. This can lead to fluid accumulation in the retroperitoneal space, causing haematuria, abdominal/flank pain, and incontinence. While calculi and lithotripsy can damage the ureter mucosal lining, they are unlikely to have caused fluid accumulation in the intra-abdominal cavity, especially since the lithotripsy was performed a year ago. Pelvic inflammatory disease and urinary tract infections can cause similar symptoms, but their CT findings would be different.

      The retroperitoneal structures are those that are located behind the peritoneum, which is the membrane that lines the abdominal cavity. These structures include the duodenum (2nd, 3rd, and 4th parts), ascending and descending colon, kidneys, ureters, aorta, and inferior vena cava. They are situated in the back of the abdominal cavity, close to the spine. In contrast, intraperitoneal structures are those that are located within the peritoneal cavity, such as the stomach, duodenum (1st part), jejunum, ileum, transverse colon, and sigmoid colon. It is important to note that the retroperitoneal structures are not well demonstrated in the diagram as the posterior aspect has been removed, but they are still significant in terms of their location and function.

    • This question is part of the following fields:

      • Gastrointestinal System
      15
      Seconds
  • Question 10 - A 30-year-old man presents with an inguinal hernia. What structure needs to be...

    Incorrect

    • A 30-year-old man presents with an inguinal hernia. What structure needs to be divided during open surgery to access the inguinal canal?

      Your Answer: Inferior epigastric artery

      Correct Answer: External oblique aponeurosis

      Explanation:

      What forms the front wall of the inguinal canal? The external oblique aponeurosis forms the front wall. To access the canal and perform a hernia repair, the aponeurosis is divided. The posterior wall is made up of the transversalis fascia and conjoint tendons, which are not typically cut to gain entry to the inguinal canal.

      The External Oblique Muscle: Anatomy and Function

      The external oblique muscle is one of the three muscles that make up the anterolateral aspect of the abdominal wall. It is the outermost muscle and plays an important role in supporting the abdominal viscera. The muscle originates from the outer surfaces of the lowest eight ribs and inserts into the anterior two-thirds of the outer lip of the iliac crest. The remaining portion of the muscle becomes the aponeurosis, which fuses with the linea alba in the midline.

      The external oblique muscle is innervated by the ventral rami of the lower six thoracic nerves. Its main function is to contain the abdominal viscera and raise intra-abdominal pressure. Additionally, it can move the trunk to one side. The aponeurosis of the external oblique muscle also forms the anterior wall of the inguinal canal, which is an important anatomical landmark in the groin region.

      Overall, the external oblique muscle is a crucial component of the abdominal wall and plays an important role in maintaining the integrity of the abdominal cavity. Its unique anatomy and function make it an important muscle for both movement and protection of the internal organs.

    • This question is part of the following fields:

      • Gastrointestinal System
      8
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  • Question 11 - A 32-year-old man has come in for a follow-up appointment after being diagnosed...

    Correct

    • A 32-year-old man has come in for a follow-up appointment after being diagnosed with irritable bowel syndrome. However, his faecal calprotectin was slightly elevated, but not high enough to raise suspicion of inflammatory bowel disease.

      He had initially presented with abdominal pain and diarrhoea, along with feelings of discomfort and bloating that were relieved upon defecation. He denied any presence of blood in his stool. You prescribed psyllium husk and scheduled a review in four weeks. He has a medical history of low back pain, migraine, and depression.

      Today, his faecal calprotectin has returned to normal levels. What is the most likely cause of the initial abnormal test result?

      Your Answer: Use of NSAIDs

      Explanation:

      Mallory-Weiss syndrome (MWS) is characterized by a rupture in the mucous membrane at the junction of the stomach and oesophagus.

      Faecal Calprotectin: A Screening Tool for Intestinal Inflammation

      Faecal calprotectin is a recommended screening tool for inflammatory bowel disease (IBD) by NICE. It is a test that detects intestinal inflammation and can also be used to monitor the response to treatment in IBD patients. The test has a high sensitivity of 93% and specificity of 96% for IBD in adults. However, in children, the specificity falls to around 75%.

      Apart from IBD, other conditions that can cause a raised faecal calprotectin include bowel malignancy, coeliac disease, infectious colitis, and the use of NSAIDs. Therefore, faecal calprotectin is a useful diagnostic tool for detecting intestinal inflammation and can aid in the diagnosis and management of various gastrointestinal conditions.

    • This question is part of the following fields:

      • Gastrointestinal System
      43.3
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  • Question 12 - A 25-year-old male with a history of Crohn's disease visits his gastroenterologist for...

    Incorrect

    • A 25-year-old male with a history of Crohn's disease visits his gastroenterologist for a routine checkup. During the appointment, he inquires about the underlying cause of his condition. Which gene variations have been associated with Crohn's disease?

      Your Answer: COL1A1

      Correct Answer: NOD-2

      Explanation:

      The development of Crohn’s disease is connected to a genetic abnormality in the NOD-2 gene.

      Phenylketonuria is linked to the PKU mutation.

      Cystic fibrosis is associated with the CFTR mutation.

      Ehlers-Danlos syndrome is connected to the COL1A1 mutation.

      Understanding Crohn’s Disease

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.

      Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include non-specific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.

      To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.

    • This question is part of the following fields:

      • Gastrointestinal System
      4.2
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  • Question 13 - A 72-year-old retired fisherman presents with a sudden episode of rectal bleeding. The...

    Correct

    • A 72-year-old retired fisherman presents with a sudden episode of rectal bleeding. The bleeding was significant and included clots. He feels dizzy and has collapsed.

      He reports experiencing heartburn regularly and takes lisinopril and bendroflumethiazide for hypertension, as well as aspirin and ibuprofen for hangovers. He drinks six large whisky measures and smokes 10 cigarettes daily.

      During examination, he is apyrexial, his heart rate is 106 bpm, blood pressure is 108/74 mmHg, and his respiratory rate is 18. He appears pale and has epigastric tenderness.

      What is the immediate action that should be taken?

      Your Answer: Give 1litre 0.9% NaCl over one hour

      Explanation:

      Urgent Resuscitation Needed for Patient in Hypovolaemic Shock

      A patient is experiencing hypovolaemic shock and requires immediate infusion of colloid or crystalloid. Waiting for eight hours is not an option, and dextrose is not recommended as it quickly moves out of the intravascular space. The patient will undergo endoscopy, but only after initial resuscitation. While regular omeprazole may help prevent recurrence, it is not urgent.

    • This question is part of the following fields:

      • Gastrointestinal System
      41.8
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  • Question 14 - A 52-year-old man presents with a dry cough at night that has been...

    Incorrect

    • A 52-year-old man presents with a dry cough at night that has been bothering him for the past 2 years. He also reports several incidences of heartburn and regurgitation. He has tried multiple over-the-counter antitussives but there has been no improvement in his symptoms. He smokes one pack of cigarettes a day. Vitals are unremarkable and body mass index is 35 kg/m2. Upper endoscopy is performed which shows salmon-coloured mucosa at the lower third oesophagus. A biopsy is taken for histopathology which shows intestinal-type columnar epithelium.

      What oesophageal complication is the patient at high risk for due to his microscopic findings?

      Your Answer: Squamous cell carcinoma

      Correct Answer: Adenocarcinoma

      Explanation:

      Barrett’s oesophagus poses the greatest risk for the development of adenocarcinoma of the oesophagus. The patient’s symptoms of heartburn, regurgitation, and nocturnal dry cough suggest the presence of gastroesophageal reflux disease (GORD), which is characterized by the reflux of gastric acid into the oesophagus. The normal oesophageal mucosa is not well-equipped to withstand the corrosive effects of gastric acid, and thus, it undergoes metaplasia to intestinal-type columnar epithelium, resulting in Barrett’s oesophagus. This condition is highly susceptible to dysplasia and progression to adenocarcinoma, and can be identified by its salmon-colored appearance during upper endoscopy.

      Achalasia, on the other hand, is a motility disorder of the oesophagus that is not associated with GORD or Barrett’s oesophagus. However, it may increase the risk of squamous cell carcinoma of the oesophagus, rather than adenocarcinoma.

      Mallory-Weiss syndrome (MWS) is characterized by a mucosal tear in the oesophagus, which is typically caused by severe vomiting. It is not associated with regurgitation due to GORD.

      Oesophageal perforation is usually associated with endoscopy or severe vomiting. Although the patient is at risk of oesophageal perforation due to the previous endoscopy, the question specifically pertains to the risk associated with microscopic findings.

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, which increases the risk of oesophageal adenocarcinoma by 50-100 fold. It is usually identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia, as there are no screening programs for it. The length of the affected segment determines the chances of identifying metaplasia, with short (<3 cm) and long (>3 cm) subtypes. The prevalence of Barrett’s oesophagus is estimated to be around 1 in 20, and it is identified in up to 12% of those undergoing endoscopy for reflux.

      The columnar epithelium in Barrett’s oesophagus may resemble that of the cardiac region of the stomach or that of the small intestine, with goblet cells and brush border. The single strongest risk factor for Barrett’s oesophagus is gastro-oesophageal reflux disease (GORD), followed by male gender, smoking, and central obesity. Alcohol is not an independent risk factor for Barrett’s, but it is associated with both GORD and oesophageal cancer. Patients with Barrett’s oesophagus often have coexistent GORD symptoms.

      The management of Barrett’s oesophagus involves high-dose proton pump inhibitor, although the evidence base for its effectiveness in reducing the progression to dysplasia or inducing regression of the lesion is limited. Endoscopic surveillance with biopsies is recommended every 3-5 years for patients with metaplasia but not dysplasia. If dysplasia of any grade is identified, endoscopic intervention is offered, such as radiofrequency ablation, which is the preferred first-line treatment, particularly for low-grade dysplasia, or endoscopic mucosal resection.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 15 - What is the most frequent type of tumor found in the colon? ...

    Incorrect

    • What is the most frequent type of tumor found in the colon?

      Your Answer: Squamous cell carcinoma

      Correct Answer: Adenocarcinoma

      Explanation:

      Adenocarcinomas are frequently occurring and usually develop due to the sequence of adenoma leading to carcinoma.

      Colorectal cancer is a prevalent type of cancer in the UK, ranking third in terms of frequency and second in terms of cancer-related deaths. Every year, approximately 150,000 new cases are diagnosed, and 50,000 people die from the disease. The cancer can occur in different parts of the colon, with the rectum being the most common location, accounting for 40% of cases. The sigmoid colon follows closely, with 30% of cases, while the descending colon has only 5%. The transverse colon has 10% of cases, and the ascending colon and caecum have 15%.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 16 - A 72-year-old man comes to the clinic with a left groin swelling and...

    Incorrect

    • A 72-year-old man comes to the clinic with a left groin swelling and reports experiencing moderate pain and discomfort. The diagnosis is an inguinal hernia, and he is scheduled for elective surgery to repair the defect. During the procedure, which nerve running through the inguinal canal is at risk of being damaged?

      Your Answer: Sciatic nerve

      Correct Answer: Ilioinguinal nerve

      Explanation:

      The inguinal canal is a crucial anatomical structure that houses the spermatic cord in males and the ilioinguinal nerve in both genders. The ilioinguinal and iliohypogastric nerves stem from the L1 nerve root and run through the canal. The ilioinguinal nerve enters the canal via the abdominal muscles and exits through the external inguinal ring. It is primarily a sensory nerve that provides sensation to the upper medial thigh. If the nerve is damaged during hernia repair, patients may experience numbness in this area after surgery.

      Other nerves that pass through the pelvis include the femoral nerve, which descends behind the inguinal canal, the obturator nerve, which travels through the obturator foramen, and the sciatic nerve, which exits the pelvis through the greater sciatic foramen and runs posteriorly.

      The inguinal canal is located above the inguinal ligament and measures 4 cm in length. Its superficial ring is situated in front of the pubic tubercle, while the deep ring is found about 1.5-2 cm above the halfway point between the anterior superior iliac spine and the pubic tubercle. The canal is bounded by the external oblique aponeurosis, inguinal ligament, lacunar ligament, internal oblique, transversus abdominis, external ring, and conjoint tendon. In males, the canal contains the spermatic cord and ilioinguinal nerve, while in females, it houses the round ligament of the uterus and ilioinguinal nerve.

      The boundaries of Hesselbach’s triangle, which are frequently tested, are located in the inguinal region. Additionally, the inguinal canal is closely related to the vessels of the lower limb, which should be taken into account when repairing hernial defects in this area.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 17 - A 25-year-old man is suspected of having an inflamed Meckel's diverticulum. Where is...

    Correct

    • A 25-year-old man is suspected of having an inflamed Meckel's diverticulum. Where is it most likely to be located?

      Your Answer: Approximately 60 cm proximal to the ileocaecal valve

      Explanation:

      The length of these growths is 2 inches (5cm), and they are twice as common in men. They involve two types of tissue and are located approximately 2 feet (60cm) from the ileocaecal valve.

      Meckel’s diverticulum is a congenital diverticulum of the small intestine that is a remnant of the omphalomesenteric duct. It occurs in 2% of the population, is 2 feet from the ileocaecal valve, and is 2 inches long. It is usually asymptomatic but can present with abdominal pain, rectal bleeding, or intestinal obstruction. Investigation includes a Meckel’s scan or mesenteric arteriography. Management involves removal if narrow neck or symptomatic, with options between wedge excision or formal small bowel resection and anastomosis. Meckel’s diverticulum is typically lined by ileal mucosa but ectopic gastric, pancreatic, and jejunal mucosa can also occur.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 18 - A 50-year-old man comes to the clinic with bilateral inguinal hernias. The surgical...

    Incorrect

    • A 50-year-old man comes to the clinic with bilateral inguinal hernias. The surgical team plans to perform a laparoscopic extraperitoneal repair. During the procedure, the surgeons make an infraumbilical incision and move the inferior part of the rectus abdominis muscle forward to insert a prosthetic mesh for hernia repair. What anatomical structure will be located behind the mesh?

      Your Answer: Bucks fascia

      Correct Answer: Peritoneum

      Explanation:

      In a TEP repair of inguinal hernia, the peritoneum is the only structure located behind the mesh. The query specifically pertains to the structure situated behind the rectus abdominis muscle. As this area is situated below the arcuate line, the transversalis fascia and peritoneum are positioned behind it.

      The rectus sheath is a structure formed by the aponeuroses of the lateral abdominal wall muscles. Its composition varies depending on the anatomical level. Above the costal margin, the anterior sheath is made up of the external oblique aponeurosis, with the costal cartilages located behind it. From the costal margin to the arcuate line, the anterior rectus sheath is composed of the external oblique aponeurosis and the anterior part of the internal oblique aponeurosis. The posterior rectus sheath is formed by the posterior part of the internal oblique aponeurosis and transversus abdominis. Below the arcuate line, all the abdominal muscle aponeuroses are located in the anterior aspect of the rectus sheath, while the transversalis fascia and peritoneum are located posteriorly. The arcuate line is the point where the inferior epigastric vessels enter the rectus sheath.

    • This question is part of the following fields:

      • Gastrointestinal System
      7.3
      Seconds
  • Question 19 - A 65-year-old man arrives at the Emergency Department after collapsing at home. According...

    Correct

    • A 65-year-old man arrives at the Emergency Department after collapsing at home. According to his wife, he had complained of sudden lower back pain just before the collapse. Upon examination, he appears pale and hypotensive, leading you to suspect a ruptured abdominal aortic aneurysm. Can you determine at which level the affected structure terminates?

      Your Answer: L4

      Explanation:

      The section of the aorta that runs through the abdomen, known as the abdominal aorta, extends from the T12 vertebrae to the L4 vertebrae. This area is particularly susceptible to developing an aneurysm, which is most commonly seen in men over the age of 65. Risk factors for abdominal aortic aneurysms include smoking, diabetes, high blood pressure, and high cholesterol levels. Symptoms are often absent until the aneurysm ruptures, causing sudden and severe pain in the lower back or abdomen, as well as a drop in blood pressure and consciousness. To detect potential aneurysms, the NHS offers a one-time ultrasound screening for men over the age of 65 who have not previously been screened.

      The abdominal aorta is a major blood vessel that originates from the 12th thoracic vertebrae and terminates at the fourth lumbar vertebrae. It is located in the abdomen and is surrounded by various organs and structures. The posterior relations of the abdominal aorta include the vertebral bodies of the first to fourth lumbar vertebrae. The anterior relations include the lesser omentum, liver, left renal vein, inferior mesenteric vein, third part of the duodenum, pancreas, parietal peritoneum, and peritoneal cavity. The right lateral relations include the right crus of the diaphragm, cisterna chyli, azygos vein, and inferior vena cava (which becomes posterior distally). The left lateral relations include the fourth part of the duodenum, duodenal-jejunal flexure, and left sympathetic trunk. Overall, the abdominal aorta is an important blood vessel that supplies oxygenated blood to various organs in the abdomen.

    • This question is part of the following fields:

      • Gastrointestinal System
      7.2
      Seconds
  • Question 20 - A three-week-old infant is brought to the paediatrician with jaundice that started in...

    Correct

    • A three-week-old infant is brought to the paediatrician with jaundice that started in the first week of life. The mother reports that the baby has undergone a week of phototherapy, but there has been no improvement in the yellowing. Additionally, the mother has observed that the baby's urine is dark and stools are pale.

      The baby was born via normal vaginal delivery at 39 weeks' gestation without any complications or injuries noted during birth.

      On examination, the baby appears well and alert, with normal limb movements. Scleral icterus is present, but there is no associated conjunctival pallor. The head examination is unremarkable, and the anterior fontanelle is normotensive.

      An abdominal ultrasound reveals an atretic gallbladder with irregular contours and an indistinct wall, associated with the lack of smooth echogenic mucosal lining.

      What additional findings are likely to be discovered in this infant upon further investigation?

      Your Answer: Conjugated hyperbilirubinaemia

      Explanation:

      The elevated level of conjugated bilirubin in the baby suggests biliary atresia, which is characterized by prolonged neonatal jaundice and obstructive jaundice. The ultrasound scan also shows the gallbladder ghost triad, which is highly specific for biliary atresia. This condition causes post-hepatic obstruction of the biliary tree, resulting in conjugated hyperbilirubinaemia.

      Unconjugated hyperbilirubinaemia may be caused by prehepatic factors such as haemolysis. However, ABO or Rhesus incompatibility between mother and child typically presents within the first few days of life and resolves with phototherapy. The absence of injury and infection in the child makes these causes unlikely.

      A positive direct Coombs test indicates haemolysis, but this is unlikely as the child did not present with conjunctival pallor and other symptoms of haemolytic disease of the newborn. Raised lactate dehydrogenase is also not found in this baby, which further supports the absence of haemolysis.

      Understanding Biliary Atresia in Neonatal Children

      Biliary atresia is a condition that affects neonatal children, causing an obstruction in the flow of bile due to either obliteration or discontinuity within the extrahepatic biliary system. The cause of this condition is not fully understood, but it is believed that infectious agents, congenital malformations, and retained toxins within the bile may contribute to its development. Biliary atresia occurs in 1 in every 10,000-15,000 live births and is more common in females than males.

      There are three types of biliary atresia, with type 3 being the most common, affecting over 90% of cases. Symptoms of biliary atresia typically present in the first few weeks of life and include jaundice, dark urine, pale stools, and appetite and growth disturbance. Diagnosis is made through various tests, including serum bilirubin, liver function tests, and ultrasound of the biliary tree and liver.

      Surgical intervention is the only definitive treatment for biliary atresia, with medical intervention including antibiotic coverage and bile acid enhancers following surgery. Complications of biliary atresia include unsuccessful anastomosis formation, progressive liver disease, cirrhosis, and eventual hepatocellular carcinoma. Prognosis is good if surgery is successful, but in cases where surgery fails, liver transplantation may be required in the first two years of life.

    • This question is part of the following fields:

      • Gastrointestinal System
      17.9
      Seconds

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