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Question 1
Correct
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A 78-year-old man is brought to the emergency department after a fall and is diagnosed with self-neglect. He reports experiencing fatigue, paraesthesia in his lower limbs, and overall muscle weakness that is more pronounced in his legs for the past 3 months. He has been finding it difficult to carry out his daily activities, especially cooking, due to his inability to stand for long periods of time.
What vitamin deficiency is most likely causing his symptoms?Your Answer: Vitamin B12
Explanation:Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.
Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.
Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Incorrect
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A 44-year-old female presents to her GP with persistent gastro-oesophageal reflux disease and complains of a burning pain in her chest. She is referred to a gastroenterologist who performs an endoscopy with biopsy, leading to a diagnosis of Barrett's oesophagus. Explain the metaplasia that occurs in Barrett's oesophagus and its association with an increased risk of oesophageal cancer.
Barrett's oesophagus is characterized by the metaplasia of the lower oesophageal epithelium from stratified squamous to simple columnar epithelium. This change from the normal stratified squamous epithelium increases the risk of oesophageal cancer by 30-fold and is often caused by gastro-oesophageal reflux disease.Your Answer: Simple columnar to stratified squamous
Correct Answer: Stratified squamous epithelium to simple columnar
Explanation:Barrett’s oesophagus is characterized by the transformation of the lower oesophageal epithelial cells from stratified squamous to simple columnar epithelium. This change from the normal stratified squamous epithelium increases the risk of oesophageal cancer by 30 times and is often associated with gastro-oesophageal reflux disease.
Metaplasia is a reversible process where differentiated cells transform into another cell type. This change may occur as an adaptive response to stress, where cells sensitive to adverse conditions are replaced by more resilient cell types. Metaplasia can be a normal physiological response, such as the transformation of cartilage into bone. The most common type of epithelial metaplasia involves the conversion of columnar cells to squamous cells, which can be caused by smoking or Schistosomiasis. In contrast, metaplasia from squamous to columnar cells occurs in Barrett’s esophagus. If the metaplastic stimulus is removed, the cells will revert to their original differentiation pattern. However, if the stimulus persists, dysplasia may develop. Although metaplasia is not directly carcinogenic, factors that predispose to metaplasia may induce malignant transformation. The pathogenesis of metaplasia involves the reprogramming of stem cells or undifferentiated mesenchymal cells present in connective tissue, which differentiate along a new pathway.
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This question is part of the following fields:
- Gastrointestinal System
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Question 3
Incorrect
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A 42-year-old man undergoes a partial thyroidectomy and experiences hoarseness upon returning to the ward. As a healthcare professional, you know that this is a common complication of thyroid surgery. Which nerve is most likely responsible for the patient's symptoms?
Your Answer: Internal branch of the superior laryngeal nerve
Correct Answer: Recurrent laryngeal nerve
Explanation:The recurrent laryngeal nerve is a branch of the vagus nerve (CN X) that provides motor supply to all but one of the laryngeal muscles and sensory supply to the larynx below the vocal cords. The left nerve loops under the arch of the aorta and passes deep to the inferior constrictor muscle of the pharynx, while the right nerve usually loops under the right subclavian artery. Both nerves pass close to or through the thyroid ligament, making them susceptible to injury during thyroid surgery. Dysfunction of either nerve can result in a hoarse voice.
The internal branch of the superior laryngeal nerve is the only other nerve among the given options that innervates the larynx. It carries sensory supply to the larynx above the vocal cords, while the external branch supplies the cricothyroid muscle. Dysfunction of the external branch can cause a hoarse voice, but dysfunction of the internal branch will not.
The greater auricular nerve and transverse cervical nerve are superficial cutaneous nerves that arise from the cervical plexus and supply the skin overlying the mandible, ear auricle, and neck. The phrenic nerve, also arising from the cervical plexus, provides motor innervation to the diaphragm and sensation to the parietal pericardium and pleura adjacent to the mediastinum.
During surgical procedures, there is a risk of nerve injury caused by the surgery itself. This is not only important for the patient’s well-being but also from a legal perspective. There are various operations that carry the risk of nerve damage, such as posterior triangle lymph node biopsy, Lloyd Davies stirrups, thyroidectomy, anterior resection of rectum, axillary node clearance, inguinal hernia surgery, varicose vein surgery, posterior approach to the hip, and carotid endarterectomy. Surgeons must have a good understanding of the anatomy of the area they are operating on to minimize the incidence of nerve lesions. Blind placement of haemostats is not recommended as it can also cause nerve damage.
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Incorrect
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A 65-year-old patient arrives at the emergency department with persistent watery diarrhea. Upon examination, the patient's blood work reveals hypokalemia and an increased level of serum vasoactive intestinal peptide (VIP). The physician informs the patient that the elevated VIP levels in their blood may be the cause of their diarrhea. As a medical student, the patient asks you about the functions of VIP. Can you identify one of its functions?
Your Answer: Promotes acid secretion by inhibiting parietal cells directly
Correct Answer: Inhibits acid secretion by stimulating somatostatin production
Explanation:VIPoma, also known as Verner-Morrison syndrome, can be diagnosed based on symptoms such as prolonged diarrhea, hypokalemia, dehydration, and elevated levels of VIP. VIP is produced by the small intestines and pancreas and works by stimulating the release of somatostatin, which in turn inhibits acid secretion. On the other hand, gastrin promotes the release of acid from parietal cells. The other answers provided are incorrect.
Overview of Gastrointestinal Hormones
Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.
One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.
Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.
Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.
In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
Incorrect
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A 30-year-old male presents with massive haematemesis and is diagnosed with splenomegaly. What is the probable origin of the bleeding?
Your Answer: Gastric ulcer
Correct Answer: Oesophageal varices
Explanation:Portal Hypertension and its Manifestations
Portal hypertension is a condition that often leads to splenomegaly and upper gastrointestinal (GI) bleeding. The primary cause of bleeding is oesophageal varices, which are dilated veins in the oesophagus. In addition to these symptoms, portal hypertension can also cause ascites, a buildup of fluid in the abdomen, and acute or chronic hepatic encephalopathy, a neurological disorder that affects the brain. Another common manifestation of portal hypertension is splenomegaly with hypersplenism, which occurs when the spleen becomes enlarged and overactive, leading to a decrease in the number of blood cells in circulation. the various symptoms of portal hypertension is crucial for early diagnosis and effective management of the condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Incorrect
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A 50-year-old man with dyspepsia is scheduled for an upper GI endoscopy. During the procedure, an irregular erythematous area is observed protruding proximally from the gastro-oesophageal junction. To confirm a diagnosis of Barrett's esophagus, which of the following cell types must be present in addition to specialised intestinal metaplasia?
Your Answer: Neutrophil
Correct Answer: Goblet cell
Explanation:The presence of goblet cells is a requirement for the diagnosis of Barrett’s esophagus.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 20-year-old woman currently completing her exams presents to her GP with fatigue and generalised weakness. She has also noted that her skin and the whites of her eyes appear yellow. The GP suspects the patient may have Gilbert’s syndrome and orders liver function tests to determine the patient’s baseline liver function. The GP advises the patient that no treatment is necessary for this condition.
Reference range
Bilirubin 3 - 17 µmol/L
ALP 30 - 100 u/L
ALT 3 - 40 u/L
γGT 8 - 60 u/L
Albumin 35 - 50 g/L
LDH 100 - 190 U/L
What set of results would be expected from this patient?Your Answer: Bilirubin 40 umol/l, ALT 15 U/L, LDH 160 U/L, GGT 25 U/L
Explanation:Jaundice becomes visible when bilirubin levels exceed 35 umol/l. Therefore, the correct option is the one with a bilirubin level of 40 umol/l, as this is typically the range where jaundice becomes visible. Furthermore, all other liver function values in this option are within the normal range. The other options are incorrect because they have bilirubin levels that are too low to cause visible jaundice, and the liver function results are usually normal in cases of Gilbert’s syndrome.
Understanding Bilirubin and Its Role in Jaundice
Bilirubin is a chemical by-product that is produced when red blood cells break down heme, a component found in these cells. This chemical is also found in other hepatic heme-containing proteins like myoglobin. The heme is processed within macrophages and oxidized to form biliverdin and iron. Biliverdin is then reduced to form unconjugated bilirubin, which is released into the bloodstream.
Unconjugated bilirubin is bound to albumin in the blood and then taken up by hepatocytes, where it is conjugated to make it water-soluble. From there, it is excreted into bile and enters the intestines to be broken down by intestinal bacteria. Bacterial proteases produce urobilinogen from bilirubin within the intestinal lumen, which is further processed by intestinal bacteria to form urobilin and stercobilin and excreted via the faeces. A small amount of bilirubin re-enters the portal circulation to be finally excreted via the kidneys in urine.
Jaundice occurs when bilirubin levels exceed 35 umol/l. Raised levels of unconjugated bilirubin may occur due to haemolysis, while hepatocyte defects, such as a compromised hepatocyte uptake of unconjugated bilirubin and/or defective conjugation, may occur in liver disease or deficiency of glucuronyl transferase. Raised levels of conjugated bilirubin can result from defective excretion of bilirubin, for example, Dubin-Johnson Syndrome, or cholestasis.
Cholestasis can result from a wide range of pathologies, which can be largely divided into physical causes, for example, gallstones, pancreatic and cholangiocarcinoma, or functional causes, for example, drug-induced, pregnancy-related and postoperative cholestasis. Understanding bilirubin and its role in jaundice is important in diagnosing and treating various liver and blood disorders.
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Incorrect
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Which of the following is more frequently observed in individuals with Crohn's disease compared to those with ulcerative colitis?
Your Answer: Goblet cell depletion on biopsy
Correct Answer: Fat wrapping of the terminal ileum
Explanation:Smoking has been found to exacerbate Crohn’s disease, and it also increases the risk of disease recurrence after resection. Patients with ileal disease, which is the most common site of the disease, often exhibit fat wrapping of the terminal ileum. The mesenteric fat in patients with inflammatory bowel disease (IBD) is typically dense, hard, and prone to significant bleeding during surgery. During endoscopy, the mucosa in Crohn’s disease patients is described as resembling cobblestones, while ulcerative colitis patients often exhibit mucosal islands (pseudopolyps).
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Incorrect
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A 63-year-old male presents to his GP with a complaint of blood in his stools. The blood is bright red and occurs during defecation, but it is not painful. He has been feeling more tired lately, but he has not experienced night sweats, weight loss, loss of appetite, or changes in bowel habits.
The patient has a history of liver cirrhosis and underwent an oesophageal endoscopy two years ago, but he cannot recall the results. He is a known alcoholic and attends AA.
Upon examination, the patient appears pale with conjunctival pallor, and ascites is present.
What is the most likely diagnosis?Your Answer: Colorectal carcinoma
Correct Answer: Haemorrhoids
Explanation:Haemorrhoids in Portal Hypertension
A likely diagnosis for a patient with a history of portal hypertension, ascites, endoscopy, and cirrhotic liver is haemorrhoids. Portal hypertension causes pressure to be passed on to the middle and inferior rectal veins, leading to their dilation and the development of haemorrhoids. While haemorrhoids are common in the general population, significant blood loss is rare. However, in patients with established cirrhosis, large amounts of blood can be lost through these varices.
An anal fissure is unlikely in this case, as there is no history of straining or a low-fibre diet, and they are typically painful. While colorectal carcinoma is an important diagnosis to consider, painless bright fresh blood is more likely to be caused by haemorrhoids in patients with a strong history of portal hypertension. In malignancy, fresh blood is less common, and a change in bowel habit is often a prominent feature.
A perianal haematoma is a thrombosed haemorrhoid that typically presents with severe pain, making it an unlikely diagnosis in this case. The patient’s presentation of painless bleeding further supports the diagnosis of haemorrhoids in the context of portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Incorrect
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A case of ischaemic left colon is diagnosed in a patient. Which artery, originating from the aorta at approximately the level of L3, is the most probable cause of this condition?
Your Answer: Superior rectal artery
Correct Answer: Inferior mesenteric artery
Explanation:The left side of the colon is most likely to be affected by the IMA, which typically originates at L3.
The Inferior Mesenteric Artery: Supplying the Hindgut
The inferior mesenteric artery (IMA) is responsible for supplying the embryonic hindgut with blood. It originates just above the aortic bifurcation, at the level of L3, and passes across the front of the aorta before settling on its left side. At the point where the left common iliac artery is located, the IMA becomes the superior rectal artery.
The hindgut, which includes the distal third of the colon and the rectum above the pectinate line, is supplied by the IMA. The left colic artery is one of the branches that emerges from the IMA near its origin. Up to three sigmoid arteries may also exit the IMA to supply the sigmoid colon further down the line.
Overall, the IMA plays a crucial role in ensuring that the hindgut receives the blood supply it needs to function properly. Its branches help to ensure that the colon and rectum are well-nourished and able to carry out their important digestive functions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Correct
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A 56-year-old accountant presents to the hospital with severe abdominal pain that has been ongoing for more than 3 hours. The pain is sharp and extends to his back, and he rates it as 8/10 on the pain scale. The pain subsides when he sits up. During the examination, he appears restless, cold, and clammy, with a pulse rate of 124 bpm and a blood pressure of 102/65. You notice some purple discoloration in his right flank, and his bowel sounds are normal. According to his social history, he has a history of excessive alcohol consumption. What is the most probable diagnosis?
Your Answer: Acute pancreatitis
Explanation:Pancreatitis is the most probable diagnosis due to several reasons. Firstly, the patient’s history indicates that he is an alcoholic, which is a risk factor for pancreatitis. Secondly, the severe and radiating pain to the back is a typical symptom of pancreatitis. Additionally, the patient shows signs of jaundice and circulation collapse, with a purple discoloration known as Grey Turner’s sign caused by retroperitoneal hemorrhage. On the other hand, appendicitis pain is usually colicky, localized in the lower right quadrant, and moves up centrally. Although circulation collapse may indicate intestinal obstruction, the absence of vomiting/nausea makes it less likely. Chronic kidney disease can be ruled out as it presents with symptoms such as weight loss, tiredness, bone pain, and itchy skin, which are not present in this acute presentation. Lastly, if there was a significant history of recent surgery, ileus and obstruction would be more likely, and the absence of bowel sounds would support this diagnosis.
Acute pancreatitis is a condition that is primarily caused by gallstones and alcohol consumption in the UK. However, there are other factors that can contribute to the development of this condition. A popular mnemonic used to remember these factors is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine. CT scans can show diffuse parenchymal enlargement with oedema and indistinct margins in patients with acute pancreatitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Incorrect
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A 28-year-old patient presents with sudden onset of fever and complains of a painful mouth. The patient has a history of inflammatory bowel disease and has recently started taking sulphasalazine. There is no history of recent travel or any other relevant medical history.
What urgent investigation should be performed in this case?Your Answer: C-reactive protein (CRP)
Correct Answer: Full blood count
Explanation:Aminosalicylates can cause various haematological adverse effects, including agranulocytosis, which can be detected through FBC testing. In this case, the patient’s recent exposure to sulphasalazine and symptoms of fever and mouth ulcers suggest bone marrow suppression with an infection. While an acute flare of IBD is a possible differential diagnosis, it is not strongly supported by the clinical signs. Amylase testing is not likely to be helpful in this case, as the presentation points more towards agranulocytosis than pancreatitis. CRP testing may be performed to monitor inflammation, but it is not likely to provide a specific diagnosis. Total bilirubin testing is included as a reminder of the potential haematological side-effects of aminosalicylates, such as haemolytic anaemia, but it is not a key investigation in this case. FBC testing is the most clinically urgent investigation to support the diagnosis of agranulocytosis.
Aminosalicylate Drugs for Inflammatory Bowel Disease
Aminosalicylate drugs are commonly used to treat inflammatory bowel disease (IBD). These drugs work by releasing 5-aminosalicyclic acid (5-ASA) in the colon, which acts as an anti-inflammatory agent. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis.
Sulphasalazine is a combination of sulphapyridine and 5-ASA. However, many of the side effects associated with this drug are due to the sulphapyridine component, such as rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Mesalazine is a delayed release form of 5-ASA that avoids the sulphapyridine side effects seen in patients taking sulphasalazine. However, it is still associated with side effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis.
Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken down by colonic bacteria. It is important to note that aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis. Therefore, a full blood count is a key investigation in an unwell patient taking these drugs. Pancreatitis is also more common in patients taking mesalazine compared to sulfasalazine.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Correct
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A 47-year-old man has a nasogastric tube inserted. The nurse takes a small aspirate of the fluid from the stomach and tests the pH of the aspirate. What is the typical intragastric pH?
Your Answer: 2
Explanation:Typically, the pH level in the stomach is 2, but the use of proton pump inhibitors can effectively eliminate acidity.
Understanding Gastric Secretions for Surgical Procedures
A basic understanding of gastric secretions is crucial for surgeons, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Gastric acid, produced by the parietal cells in the stomach, has a pH of around 2 and is maintained by the H+/K+ ATPase pump. Sodium and chloride ions are actively secreted from the parietal cell into the canaliculus, creating a negative potential across the membrane. Carbonic anhydrase forms carbonic acid, which dissociates, and the hydrogen ions formed by dissociation leave the cell via the H+/K+ antiporter pump. This leaves hydrogen and chloride ions in the canaliculus, which mix and are secreted into the lumen of the oxyntic gland.
There are three phases of gastric secretion: the cephalic phase, gastric phase, and intestinal phase. The cephalic phase is stimulated by the smell or taste of food and causes 30% of acid production. The gastric phase, which is caused by stomach distension, low H+, or peptides, causes 60% of acid production. The intestinal phase, which is caused by high acidity, distension, or hypertonic solutions in the duodenum, inhibits gastric acid secretion via enterogastrones and neural reflexes.
The regulation of gastric acid production involves various factors that increase or decrease production. Factors that increase production include vagal nerve stimulation, gastrin release, and histamine release. Factors that decrease production include somatostatin, cholecystokinin, and secretin. Understanding these factors and their associated pharmacology is essential for surgeons.
In summary, a working knowledge of gastric secretions is crucial for surgical procedures, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Understanding the phases of gastric secretion and the regulation of gastric acid production is essential for successful surgical outcomes.
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This question is part of the following fields:
- Gastrointestinal System
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Question 14
Incorrect
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During an Ivor Lewis Oesophagectomy for carcinoma of the upper third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Your Answer: Phrenic nerve
Correct Answer: Azygos vein
Explanation:The azygos vein is divided during oesophagectomy to allow mobilisation. It inserts into the SVC on the right side.
Treatment Options for Oesophageal Cancer
Oesophageal cancer is typically treated through surgical resection, with neoadjuvant chemotherapy given prior to the procedure. In situ disease may be managed through endoscopic mucosal resection, while unresectable disease may benefit from local ablative procedures, palliative chemotherapy, or stent insertion. However, resections are not typically offered to patients with distant metastasis or N2 disease, and local nodal involvement is not a contraindication to resection.
For lower and middle third oesophageal tumours, an Ivor-Lewis procedure is commonly performed. This involves a combined laparotomy and right thoracotomy, with the stomach mobilized through a rooftop incision and the oesophagus removed through a thoracotomy. The chest is then closed with underwater seal drainage and tube drains to the abdominal cavity. Postoperatively, patients will typically recover in the intensive care unit and may experience complications such as atelectasis, anastomotic leakage, and delayed gastric emptying.
Overall, treatment options for oesophageal cancer depend on the extent of the disease and the patient’s individual circumstances. While surgical resection is the mainstay of treatment, other options such as chemotherapy and local ablative procedures may be considered for unresectable disease.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Incorrect
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A 23-year-old woman presents to the gastroenterology clinic with a 6-month history of cramping abdominal pain and weight loss. She reports looser bowel motions and opening her bowels 2-4 times per day. There is no history of fever or vomiting. During the examination, the physician observes 4 oral mucosal ulcers. Mild tenderness is noted in the right iliac fossa. An endoscopy is ordered.
What are the expected endoscopy findings for this patient's most likely diagnosis?Your Answer: Villous atrophy
Correct Answer: Cobble-stoned appearance
Explanation:This patient has been diagnosed with Crohn’s disease, which is characterized by a long history of abdominal pain, weight loss, and diarrhea. Unlike ulcerative colitis, which only affects the colon, Crohn’s disease can affect any part of the gastrointestinal tract. In this case, oral mucosal ulceration is also present. The classic cobblestone appearance on endoscopy is due to deep ulceration in the gut mucosa with skip lesions in between.
On the other hand, loss of haustra is a finding seen in chronic ulcerative colitis on fluoroscopy. The chronic inflammatory process in the mucosal and submucosal layers of the colon can cause luminal narrowing, resulting in a drainpipe colon that is shortened and narrowed. In UC, shallow ulceration occurs in the mucosa, with spared mucosa giving rise to the appearance of polyps, also known as pseudopolyps. These can cause bloody diarrhea.
Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Incorrect
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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: Obturator 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 17
Correct
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A 17-year-old girl comes to the emergency department complaining of nausea and vomiting. A medical trainee, who has recently started her emergency rotation, prescribes metoclopramide to alleviate her symptoms before ordering some tests.
The nurse cautions the doctor that metoclopramide is not recommended for young female patients and suggests switching to cyclizine.
What is the reason for metoclopramide being unsuitable for this patient?Your Answer: Risk of oculogyric crisis
Explanation:Metoclopramide use in children and young adults can lead to oculogyric crisis, which is a dystonic reaction that causes the eyes to involuntarily gaze upwards for an extended period. Opioids can cause respiratory depression, while cyclizine may result in restlessness and urinary retention. Amiodarone use may cause slate-grey skin discoloration. Additionally, metoclopramide can increase urinary frequency.
Understanding the Mechanism and Uses of Metoclopramide
Metoclopramide is a medication primarily used to manage nausea, but it also has other uses such as treating gastro-oesophageal reflux disease and gastroparesis secondary to diabetic neuropathy. It is often combined with analgesics for the treatment of migraines. However, it is important to note that metoclopramide has adverse effects such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. It should also be avoided in bowel obstruction but may be helpful in paralytic ileus.
The mechanism of action of metoclopramide is quite complicated. It is primarily a D2 receptor antagonist, but it also has mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Its antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone, and at higher doses, the 5-HT3 receptor antagonist also has an effect. The gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity.
In summary, metoclopramide is a medication with multiple uses, but it also has adverse effects that should be considered. Its mechanism of action is complex, involving both D2 receptor antagonist and 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Understanding the uses and mechanism of action of metoclopramide is important for its safe and effective use.
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This question is part of the following fields:
- Gastrointestinal System
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Question 18
Incorrect
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A 54-year-old African American male is being consented for an endoscopic retrograde cholangiopancreatography (ERCP). He is very anxious about the procedure and requests for more information about the common complications of ERCP. He is concerned about peritonitis, which usually occurs secondary to a perforation of the bowel - a rare complication of ERCP. You reassure him that perforation of the bowel, although a very serious complication, is uncommon. However, they are other more common complications of ERCP that he should be aware of.
What is the most common complication of ERCP?Your Answer: Infection
Correct Answer: Acute pancreatitis
Explanation:The most frequent complication of ERCP is acute pancreatitis, which occurs when the X-ray contrast material or cannula irritates the pancreatic duct. While other complications may arise from ERCP, they are not as prevalent as acute pancreatitis.
Acute pancreatitis is a condition that is primarily caused by gallstones and alcohol consumption in the UK. However, there are other factors that can contribute to the development of this condition. A popular mnemonic used to remember these factors is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine. CT scans can show diffuse parenchymal enlargement with oedema and indistinct margins in patients with acute pancreatitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Correct
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A 65-year-old woman visits her GP complaining of altered bowel habit for the past 2 months. She denies experiencing melaena or fresh rectal blood. The patient has a medical history of type 2 diabetes mellitus and breast cancer, which has been in remission for 2 years. She consumes 14 units of alcohol per week.
During abdominal palpation, the liver edge is palpable and nodular, descending below the right costal margin. There is no presence of shifting dullness.
What is the probable cause of the patient's examination findings?Your Answer: Liver metastases
Explanation:If a patient has hepatomegaly and a history of malignancy, it is likely that they have liver metastases. The nodular edge of the liver, along with the patient’s history of breast cancer, is a cause for concern regarding cancer recurrence. Acute alcoholic hepatitis, Budd-Chiari syndrome, and non-alcoholic steatohepatitis are less likely causes in this scenario.
Understanding Hepatomegaly and Its Common Causes
Hepatomegaly refers to an enlarged liver, which can be caused by various factors. One of the most common causes is cirrhosis, which can lead to a decrease in liver size in later stages. In this case, the liver is non-tender and firm. Malignancy, such as metastatic spread or primary hepatoma, can also cause hepatomegaly. In this case, the liver edge is hard and irregular. Right heart failure can also lead to an enlarged liver, which is firm, smooth, and tender. It may even be pulsatile.
Aside from these common causes, hepatomegaly can also be caused by viral hepatitis, glandular fever, malaria, abscess (pyogenic or amoebic), hydatid disease, haematological malignancies, haemochromatosis, primary biliary cirrhosis, sarcoidosis, and amyloidosis.
Understanding the causes of hepatomegaly is important in diagnosing and treating the underlying condition. Proper diagnosis and treatment can help prevent further complications and improve overall health.
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This question is part of the following fields:
- Gastrointestinal System
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Question 20
Incorrect
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A 16-year-old presents to the Emergency Department with her father, who has noticed a yellowish tint to her eyes. Upon further inquiry, she reports having a flu-like illness a few days ago, which has since resolved. She has no medical history and is not taking any medications. On examination, scleral icterus is the only significant finding. The following are her blood test results:
Hb 130 g/L Male: (135-180) Female: (115 - 160)
Platelets 320 * 109/L (150 - 400)
WBC 6.0 * 109/L (4.0 - 11.0)
Bilirubin 80 µmol/L (3 - 17)
ALP 42 u/L (30 - 100)
ALT 30 u/L (3 - 40)
γGT 50 u/L (8 - 60)
Albumin 45 g/L (35 - 50)
What is the most probable cause of her symptoms?Your Answer: Gallstones
Correct Answer: Gilbert's syndrome
Explanation:Gilbert’s syndrome is characterized by an inherited deficiency of an enzyme used to conjugate bilirubin, resulting in elevated levels of unconjugated bilirubin in the blood. This can lead to isolated jaundice of the sclera or mouth during times of physiological stress.
Crigler Najjar syndrome, on the other hand, is a rare genetic disorder that causes an inability to convert and clear bilirubin from the body, resulting in jaundice shortly after birth.
Gallstones, which can be asymptomatic or present with right upper quadrant pain following a meal, are associated with risk factors such as being overweight, over 40 years old, female, or fertile.
Primary sclerosing cholangitis (PSC) is characterized by scarring and fibrosis of the bile ducts inside and outside the liver, and may occur alone or in combination with inflammatory diseases such as ulcerative colitis. Symptoms of PSC include jaundice, right upper quadrant pain, itching, fatigue, and weight loss.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastrointestinal System
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Question 21
Incorrect
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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: Unconjugated hyperbilirubinaemia
Correct 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Incorrect
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A 65-year-old obese male presents with recurrent episodes of colicky pain and bloating in the left iliac fossa. The patient has no significant medical history but has been a smoker for 25 years and does not consume alcohol. He works at a fast-food restaurant and usually eats his meals there.
Upon examination, the patient's vital signs are stable with a temperature of 37ºC, respiratory rate of 14 breaths per minute, oxygen saturations of 99% on air, heart rate of 60 beats per minute, and blood pressure of 125/70 mmHg. Abdominal and digital rectal examination reveal no significant findings. A colonoscopy was subsequently performed, which revealed multiple diverticula along the sigmoid colon.
What is the most appropriate course of management for this patient?Your Answer: Encourage smoking cessation
Correct Answer: Encourage high-fibre diet
Explanation:The development of intestinal diverticula is strongly linked to a low fibre diet, making it a major risk factor. To manage mild symptoms, patients are advised to modify their diet by gradually increasing fibre intake over several weeks and staying hydrated.
IV antibiotics and fluids are not necessary for diverticular disease, as it is not the same as diverticulitis.
Surgery is not recommended for uncomplicated diverticular disease.
While encouraging smoking cessation is important, dietary modification is the most suitable option for this patient.
Diverticulosis is a common condition where multiple outpouchings occur in the bowel wall, typically in the sigmoid colon. It is more accurate to use the term diverticulosis when referring to the presence of diverticula, while diverticular disease is reserved for symptomatic patients. Risk factors for this condition include a low-fibre diet and increasing age. Symptoms of diverticulosis can include altered bowel habits and colicky left-sided abdominal pain. A high-fibre diet is often recommended to alleviate these symptoms.
Diverticulitis is a complication of diverticulosis where one of the diverticula becomes infected. The typical presentation includes left iliac fossa pain and tenderness, anorexia, nausea, vomiting, diarrhea, and signs of infection such as pyrexia, raised WBC, and CRP. Mild attacks can be treated with oral antibiotics, while more severe episodes require hospitalization. Treatment involves nil by mouth, intravenous fluids, and intravenous antibiotics such as a cephalosporin and metronidazole. Complications of diverticulitis include abscess formation, peritonitis, obstruction, and perforation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Incorrect
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Sarah is a 65-year-old patient with decompensated liver cirrhosis. Two years ago she had variceal bleed, for which she has been taking propranolol and received endoscopic variceal ligation. Sarah presents to the emergency department with haematemesis and a recurrent oesophageal variceal bleed is suspected.
What emergency surgery is necessary in this case?Your Answer: No surgery required
Correct Answer: Transjugular intrahepatic portosystemic shunt (TIPS) procedure
Explanation:To address recurrent variceal haemorrhage despite optimal medical therapy, a TIPS procedure may be performed. This involves linking the hepatic vein to the portal vein, which helps to alleviate the complications associated with portal hypertension.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 24
Correct
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A 29-year-old woman reports experiencing watery stools and fecal urgency after undergoing gastrointestinal surgery to treat chronic bowel inflammation. While she suspects she may have developed irritable bowel syndrome, further investigation suggests that she may be suffering from bile acid malabsorption as a result of her surgery.
Where is the most likely site of this patient's surgery?Your Answer: Terminal ileum
Explanation:The primary role of the large intestine is to absorb water and create solid waste.
Bile is a liquid that is produced in the liver at a rate of 500ml to 1500mL per day. It is made up of bile salts, bicarbonate, cholesterol, steroids, and water. The flow of bile is regulated by three factors: hepatic secretion, gallbladder contraction, and sphincter of oddi resistance. Bile salts are absorbed in the terminal ileum and are recycled up to six times a day, with over 90% of all bile salts being recycled.
There are two types of bile salts: primary and secondary. Primary bile salts include cholate and chenodeoxycholate, while secondary bile salts are formed by bacterial action on primary bile salts and include deoxycholate and lithocholate. Deoxycholate is reabsorbed, while lithocholate is insoluble and excreted.
Gallstones can form when there is an excess of cholesterol in the bile. Bile salts have a detergent action and form micelles, which have a lipid center that transports fats. However, excessive amounts of cholesterol cannot be transported in this way and will precipitate, resulting in the formation of cholesterol-rich gallstones.
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This question is part of the following fields:
- Gastrointestinal System
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Question 25
Incorrect
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A 72-year-old female presents to her local physician complaining of general fatigue and tiredness. She reports no fever, night sweats, or weight loss. She maintains an active lifestyle and attends fitness classes weekly. Her medical history includes hypertension, type II diabetes mellitus, constipation, and depression.
The physician orders blood tests, and the results are as follows:
- Hb: 113 g/l
- Platelets: 239 * 109/l
- WBC: 6 * 109/l
- Neuts: 2 * 109/l
- Lymphs: 2 * 109/l
- Eosin: 0.3 * 109/l
- Na+: 142 mmol/l
- K+: 3.2 mmol/l
- Bilirubin: 12 µmol/l
- ALP: 23 u/l
- ALT: 10 u/l
- γGT: 23 u/l
- Urea: 4 mmol/l
- Creatinine: 50 µmol/l
- Albumin: 30 g/l
Which medication is most likely causing her symptoms?Your Answer: Heparin
Correct Answer: Senna
Explanation:Prolonged use of senna increases the risk of hypokalemia, which is evident in the patient’s blood results. The symptoms of mild hypokalemia are non-specific and include fatigue, muscle weakness, constipation, and rhabdomyolysis. Given the patient’s medical history of constipation, it is likely that she has been taking a laxative, which could be either osmotic or a stimulant. Both types of laxatives are known to cause hypokalemia, and in this case, senna is the likely culprit.
Heparin can cause hyperkalemia, especially when used in conjunction with spironolactone, ACE inhibitors, non-steroidal anti-inflammatory drugs, and trimethoprim. Heparin inhibits aldosterone synthesis, leading to increased potassium retention and sodium excretion. This effect is more pronounced in elderly individuals, diabetics, and those with renal failure. The risk of hyperkalemia increases with higher doses, prolonged use, and unfractionated heparin therapy.
Amiloride is a potassium-sparing diuretic that works by inhibiting sodium reabsorption in the kidneys. It promotes the loss of sodium and water from the body without depleting potassium. Amiloride causes hyperkalemia by inhibiting sodium reabsorption at various points in the kidneys, which reduces potassium and hydrogen secretion and subsequent excretion.
Losartan is an angiotensin II receptor blocker that is known to cause hyperkalemia and is therefore not the cause of the patient’s hypokalemia.
Understanding Laxatives
Laxatives are frequently prescribed medications in clinical practice, with constipation being a common issue among patients. While constipation may be a symptom of underlying pathology, many patients experience simple idiopathic constipation. The British National Formulary (BNF) categorizes laxatives into four groups: osmotic, stimulant, bulk-forming, and faecal softeners.
Osmotic laxatives, such as lactulose, macrogols, and rectal phosphates, work by drawing water into the bowel to soften stools and promote bowel movements. Stimulant laxatives, including senna, docusate, bisacodyl, and glycerol, stimulate the muscles in the bowel to contract and move stool along. Co-danthramer, a combination of a stimulant and a bulk-forming laxative, should only be prescribed to palliative patients due to its potential carcinogenic effects.
Bulk-forming laxatives, such as ispaghula husk and methylcellulose, work by increasing the bulk of stool and promoting regular bowel movements. Faecal softeners, such as arachis oil enemas, are not commonly prescribed but can be used to soften stool and ease bowel movements.
In summary, understanding the different types of laxatives and their mechanisms of action can help healthcare professionals prescribe the most appropriate treatment for patients experiencing constipation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Incorrect
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On examining the caecum, what structure is most likely to be detected at the point where all the tenia coli converge?
Your Answer: Appendix tip
Correct Answer: Appendix base
Explanation:The tenia coli come together at the bottom of the appendix.
The Caecum: Location, Relations, and Functions
The caecum is a part of the colon located in the proximal right colon below the ileocaecal valve. It is an intraperitoneal structure that has posterior relations with the psoas, iliacus, femoral nerve, genitofemoral nerve, and gonadal vessels. Its anterior relations include the greater omentum. The caecum is supplied by the ileocolic artery and its lymphatic drainage is through the mesenteric nodes that accompany the venous drainage.
The caecum is known for its distensibility, making it the most distensible part of the colon. However, in cases of complete large bowel obstruction with a competent ileocaecal valve, the caecum is the most likely site of eventual perforation. Despite this potential complication, the caecum plays an important role in the digestive system. It is responsible for the absorption of fluids and electrolytes, as well as the fermentation of indigestible carbohydrates. Additionally, the caecum is a site for the growth and proliferation of beneficial bacteria that aid in digestion and immune function.
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This question is part of the following fields:
- Gastrointestinal System
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Question 27
Incorrect
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A 48-year-old man is under your care after being diagnosed with pneumonia. On the day before his expected discharge, he experiences severe diarrhea without blood and needs intravenous fluids. A request for stool culture is made.
What would the microbiology report likely indicate as the responsible microbe?Your Answer: Gram-negative coccus
Correct Answer: Gram-positive bacillus
Explanation:Clostridium difficile is a type of gram-positive bacillus that can cause pseudomembranous colitis, particularly after the use of broad-spectrum antibiotics.
Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Correct
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A 70-year-old male presents with two episodes of haemetemesis. He has a medical history of ischaemic heart disease (IHD) and is currently on medication. What is the probable reason for his condition?
Your Answer: Peptic ulceration
Explanation:The effects of different medications on renal tubular acidosis (RTA) are significant. RTA is a condition that affects the kidneys’ ability to regulate acid-base balance in the body. Various medications can cause RTA through different mechanisms.
Spironolactone, for instance, is a direct antagonist of aldosterone, a hormone that regulates sodium and potassium levels in the body. By blocking aldosterone, spironolactone can lead to hyperkalemia (high potassium levels) and a reduction in serum bicarbonate, which is a type of RTA known as type 4.
Type 4 RTA can also occur in people with diabetes mellitus due to scarring associated with diabetic nephropathy. Metformin, a medication commonly used to treat diabetes, can cause lactic acidosis, a condition where there is an excess of lactic acid in the blood. Pioglitazone, another diabetes medication, can cause salt and water retention and may also be associated with bladder tumors.
Ramipril, a medication used to treat high blood pressure and heart failure, can also cause hyperkalemia, but this is not related to direct aldosterone antagonism. Healthcare providers must be aware of the effects of different medications on RTA to ensure proper management and treatment of this condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Incorrect
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A 56-year-old woman presents with profuse diarrhoea one week after undergoing a cholecystectomy. The surgery was uncomplicated, except for a minor bile spillage during gallbladder removal. What is the probable diagnosis?
Your Answer: Campylobacter infection
Correct Answer: Clostridium difficile infection
Explanation:Broad spectrum antibiotics are only given during a cholecystectomy if there is intraoperative bile spillage. It is not standard practice to administer antibiotics for an uncomplicated procedure. Surgeons typically address any bile spills during the operation, which greatly reduces the risk of delayed pelvic abscesses. As a result, such abscesses are very uncommon.
Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Correct
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A 35-year-old man has arrived at the emergency department following a car crash. He is experiencing tachycardia and his blood pressure is rapidly decreasing from 90/60mmHg. He is feeling dizzy and disoriented, and is experiencing pain in his left upper quadrant and left shoulder. Which organ is most likely to have sustained damage?
Your Answer: Spleen
Explanation:The patient’s tachycardia and low blood pressure indicate internal bleeding due to trauma. Although he experiences pain in his upper left abdominal quadrant, it does not rule out the possibility of internal bleeding. However, it makes heart and lung injuries less likely as he would have also complained of chest pain. The pain in his left shoulder suggests that the left phrenic nerve has been affected, which indicates damage to the spleen rather than the liver, as it would have been on the right side. The spleen is commonly damaged in trauma and could explain the rapid drop in blood pressure.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 31
Incorrect
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A 63-year-old female patient arrives at the emergency department complaining of severe, sudden-onset abdominal pain that has been ongoing for an hour. She describes the pain as intense and cramping, with a severity rating of 9/10.
The patient has a medical history of hypertension, type 2 diabetes, and atrial fibrillation.
After undergoing a contrast CT scan, a thrombus is discovered in the inferior mesenteric artery, and the patient is immediately scheduled for an urgent laparotomy.
What structures are likely to be affected based on this diagnosis?Your Answer: Caecum, ileum and appendix
Correct Answer: Distal third of colon and the rectum superior to pectinate line
Explanation:The inferior mesenteric artery is responsible for supplying blood to the hindgut, which includes the distal third of the colon and the rectum superior to the pectinate line. In this case, the patient’s sudden onset of severe abdominal pain and history of atrial fibrillation suggest acute mesenteric ischemia, with the affected artery being the inferior mesenteric artery. Therefore, if a thrombus were to block this artery, the distal third of the colon and superior rectum would experience ischaemic changes. It is important to note that the ascending colon, caecum, ileum, appendix, greater omentum, and stomach are supplied by different arteries and would not be affected by a thrombus in the inferior mesenteric artery.
The Inferior Mesenteric Artery: Supplying the Hindgut
The inferior mesenteric artery (IMA) is responsible for supplying the embryonic hindgut with blood. It originates just above the aortic bifurcation, at the level of L3, and passes across the front of the aorta before settling on its left side. At the point where the left common iliac artery is located, the IMA becomes the superior rectal artery.
The hindgut, which includes the distal third of the colon and the rectum above the pectinate line, is supplied by the IMA. The left colic artery is one of the branches that emerges from the IMA near its origin. Up to three sigmoid arteries may also exit the IMA to supply the sigmoid colon further down the line.
Overall, the IMA plays a crucial role in ensuring that the hindgut receives the blood supply it needs to function properly. Its branches help to ensure that the colon and rectum are well-nourished and able to carry out their important digestive functions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 32
Incorrect
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A 65-year-old man presents to the clinic with a complaint of losing 1 stone in weight over the past three months. Apart from this, he has no significant medical history. During the physical examination, his abdomen is soft, and no palpable masses are detected. A normal PR examination is also observed. The patient's blood tests reveal a haemoglobin level of 80 g/L (120-160) and an MCV of 70 fL (80-96). What is the most appropriate initial investigation for this patient?
Your Answer: CT scan of the abdomen and upper GI endoscopy
Correct Answer: Upper GI endoscopy and colonoscopy
Explanation:Possible GI Malignancy in a Man with Weight Loss and Microcytic Anaemia
This man is experiencing weight loss and has an unexplained microcytic anaemia. The most probable cause of his blood loss is from the gastrointestinal (GI) tract, as there is no other apparent explanation. This could be due to an occult GI malignancy, which is why the recommended initial investigations are upper and lower GI endoscopy. These tests will help to identify any potential sources of bleeding in the GI tract and determine if there is an underlying malignancy. It is important to diagnose and treat any potential malignancy as early as possible to improve the patient’s prognosis. Therefore, prompt investigation and management are crucial in this case.
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This question is part of the following fields:
- Gastrointestinal System
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Question 33
Incorrect
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A 32-year-old man comes to you complaining of persistent diarrhoea for the past 10 days. He describes his diarrhoea as watery and foul-smelling, but denies any blood. He feels exhausted and asks for a prescription for an antidiarrhoeal medication. He has no notable medical history.
The stool cultures come back negative, and you contemplate starting the patient on diphenoxylate. Can you explain the mechanism of action of this drug?Your Answer: Inhibits peristalsis by acting on kappa-opioid in the GI tract
Correct Answer: Inhibits peristalsis by acting on μ-opioid in the GI tract
Explanation:Diphenoxylate slows down peristalsis in the GI tract by acting on μ-opioid receptors.
Increased gut motility can be achieved through the positive cholinergic effect of muscarinic receptor activation.
All other options are inaccurate.
Antidiarrhoeal Agents: Opioid Agonists
Antidiarrhoeal agents are medications used to treat diarrhoea. Opioid agonists are a type of antidiarrhoeal agent that work by slowing down the movement of the intestines, which reduces the frequency and urgency of bowel movements. Two common opioid agonists used for this purpose are loperamide and diphenoxylate.
Loperamide is available over-the-counter and is often used to treat acute diarrhoea. It works by binding to opioid receptors in the intestines, which reduces the contractions of the muscles in the intestinal wall. This slows down the movement of food and waste through the intestines, allowing more time for water to be absorbed and resulting in firmer stools.
Diphenoxylate is a prescription medication that is often used to treat chronic diarrhoea. It works in a similar way to loperamide, but is often combined with atropine to discourage abuse and overdose.
Overall, opioid agonists are effective at treating diarrhoea, but should be used with caution and under the guidance of a healthcare professional. They can cause side effects such as constipation, dizziness, and nausea, and may interact with other medications.
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This question is part of the following fields:
- Gastrointestinal System
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Question 34
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 35
Correct
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 36
Incorrect
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A surgeon is scheduled to perform a laparotomy for a perforated duodenal ulcer on a pediatric patient. An upper midline incision will be made. Which structure is most likely to be divided by the incision?
Your Answer: None of the above
Correct Answer: Linea alba
Explanation:When performing upper midline abdominal incisions, the linea alba is typically divided. It is not common to divide muscles in this approach, as it does not typically enhance access and encountering them is not a routine occurrence.
Abdominal Incisions: Types and Techniques
Abdominal incisions are surgical procedures that involve making an opening in the abdominal wall to access the organs inside. The most common approach is the midline incision, which involves dividing the linea alba, transversalis fascia, extraperitoneal fat, and peritoneum. Another type is the paramedian incision, which is parallel to the midline and involves dividing the anterior rectus sheath, rectus, posterior rectus sheath, transversalis fascia, extraperitoneal fat, and peritoneum. The battle incision is similar to the paramedian but involves displacing the rectus medially.
Other types of abdominal incisions include Kocher’s incision under the right subcostal margin for cholecystectomy, Lanz incision in the right iliac fossa for appendicectomy, gridiron oblique incision centered over McBurney’s point for appendicectomy, Pfannenstiel’s transverse supra-pubic incision primarily used to access pelvic organs, McEvedy’s groin incision for emergency repair of a strangulated femoral hernia, and Rutherford Morrison extraperitoneal approach to the left or right lower quadrants for access to iliac vessels and renal transplantation.
Each type of incision has its own advantages and disadvantages, and the choice of incision depends on the specific surgical procedure and the surgeon’s preference. Proper closure of the incision is crucial to prevent complications such as infection and hernia formation. Overall, abdominal incisions are important techniques in surgical practice that allow for safe and effective access to the abdominal organs.
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This question is part of the following fields:
- Gastrointestinal System
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Question 37
Incorrect
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What is the anatomical distribution of ulcerative colitis?
Your Answer: Starts at ileocaecal valve + never spreads beyond sigmoid colon + skip lesions
Correct Answer: Starts at rectum + rarely spreads beyond ileocaecal valve + continuous
Explanation:Understanding Ulcerative Colitis
Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation in the rectum and spreads continuously without going beyond the ileocaecal valve. It is most commonly seen in people aged 15-25 years and 55-65 years. The symptoms of ulcerative colitis are insidious and intermittent, including bloody diarrhea, urgency, tenesmus, abdominal pain, and extra-intestinal features. Diagnosis is done through colonoscopy and biopsy, but in severe cases, a flexible sigmoidoscopy is preferred to avoid the risk of perforation. The typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa, and inflammatory cell infiltrate in lamina propria. Extra-intestinal features of inflammatory bowel disease include arthritis, erythema nodosum, episcleritis, osteoporosis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis. Ulcerative colitis is linked with sacroiliitis, and a barium enema can show the whole colon affected by an irregular mucosa with loss of normal haustral markings.
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This question is part of the following fields:
- Gastrointestinal System
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Question 38
Incorrect
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A 50-year-old man with persistent constipation visits his doctor seeking a laxative prescription. Despite having a good appetite and hydration, he has no notable medical history except for constipation. He is a non-alcoholic but occasionally smokes when socializing with friends.
The doctor intends to prescribe a laxative to alleviate the patient's constipation, but like any other medication, laxatives have side effects that must be taken into account before prescribing.
What is the laxative that has been demonstrated to have carcinogenic properties?Your Answer: Lactulose
Correct Answer: Co-danthramer
Explanation:Co-danthramer is a genotoxic laxative that should only be prescribed to patients receiving palliative care due to its potential to cause cancer. Other laxatives should be considered first for patients with constipation. However, if constipation is not improved by other laxatives, co-danthramer may be prescribed to palliative patients. It is important to note that a high-fibre diet, adequate fluid intake, and exercise are recommended for all patients with constipation. Fruits and vegetables high in fibre and sorbitol, as well as fruit juices high in sorbitol, can also be helpful in preventing and treating constipation.
Understanding Laxatives
Laxatives are frequently prescribed medications in clinical practice, with constipation being a common issue among patients. While constipation may be a symptom of underlying pathology, many patients experience simple idiopathic constipation. The British National Formulary (BNF) categorizes laxatives into four groups: osmotic, stimulant, bulk-forming, and faecal softeners.
Osmotic laxatives, such as lactulose, macrogols, and rectal phosphates, work by drawing water into the bowel to soften stools and promote bowel movements. Stimulant laxatives, including senna, docusate, bisacodyl, and glycerol, stimulate the muscles in the bowel to contract and move stool along. Co-danthramer, a combination of a stimulant and a bulk-forming laxative, should only be prescribed to palliative patients due to its potential carcinogenic effects.
Bulk-forming laxatives, such as ispaghula husk and methylcellulose, work by increasing the bulk of stool and promoting regular bowel movements. Faecal softeners, such as arachis oil enemas, are not commonly prescribed but can be used to soften stool and ease bowel movements.
In summary, understanding the different types of laxatives and their mechanisms of action can help healthcare professionals prescribe the most appropriate treatment for patients experiencing constipation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 39
Correct
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As an observer in the colorectal surgical department, you spend a morning watching a colonoscopy list. A number of patients who arrive during the morning are individuals with Hereditary Non-Polyposis Colorectal Cancer (HNPCC), who are being screened to detect any early signs of colorectal cancer. What is the lifetime risk of developing colorectal cancer for individuals with this condition?
Your Answer: 90%
Explanation:Colorectal cancer can be classified into three types: sporadic, hereditary non-polyposis colorectal carcinoma (HNPCC), and familial adenomatous polyposis (FAP). Sporadic colon cancer is believed to be caused by a series of genetic mutations, including allelic loss of the APC gene, activation of the K-ras oncogene, and deletion of p53 and DCC tumor suppressor genes. HNPCC, which is an autosomal dominant condition, is the most common form of inherited colon cancer. It is caused by mutations in genes involved in DNA mismatch repair, leading to microsatellite instability. The most common genes affected are MSH2 and MLH1. Patients with HNPCC are also at a higher risk of other cancers, such as endometrial cancer. The Amsterdam criteria are sometimes used to aid diagnosis of HNPCC. FAP is a rare autosomal dominant condition that leads to the formation of hundreds of polyps by the age of 30-40 years. It is caused by a mutation in the APC gene. Patients with FAP are also at risk of duodenal tumors. A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma, and epidermoid cysts on the skin. Genetic testing can be done to diagnose HNPCC and FAP, and patients with FAP generally have a total colectomy with ileo-anal pouch formation in their twenties.
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This question is part of the following fields:
- Gastrointestinal System
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Question 40
Correct
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A 45-year-old taxi driver presents with a six-month history of constipation and colicky suprapubic pain that varies in intensity without any apparent pattern. He has experienced occasional episodes of diarrhoea and fever. Although he drinks little alcohol and does not smoke, he consumes large amounts of coffee. On examination, there is mild tenderness in the suprapubic region, but no other abnormalities are detected. What is the probable diagnosis?
Your Answer: Diverticular disease
Explanation:Differential Diagnosis for Rectal Bleeding
Rectal bleeding can be a concerning symptom for patients and healthcare providers alike. While neoplasia may be a possible cause, diverticular disease is more common. To confirm the presence of diverticula, a barium enema should be performed, and a sigmoidoscopy should be done to rule out a tumor. Cystitis is rare in men and would present with symptoms such as urinary frequency, urgency, nocturia, and dysuria. Inflammatory bowel disease can affect any part of the gastrointestinal tract and often presents with weight loss, fever, malaise, and potentially arthralgia. However, the lack of systemic symptoms suggests an alternative diagnosis. Ulcerative colitis often causes rectal bleeding, while Crohn’s disease can cause rectal bleeding and inflammation from the mouth to anus. It is more commonly diagnosed in patients before the age of 30. It is important to consider these differential diagnoses when evaluating a patient with rectal bleeding to ensure appropriate management and treatment.
Further Reading:
Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ. 2006;332:271-5. -
This question is part of the following fields:
- Gastrointestinal System
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Question 41
Incorrect
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A 40-year-old female comes to the clinic complaining of difficulty swallowing both solid and liquid foods for the past 3 months. She denies any hoarseness of voice but reports having had pneumonia a month ago, which resolved with antibiotics. Upon examination, oesophageal manometry reveals absent peristalsis, increased lower sphincter tone, and incomplete relaxation of the lower sphincter during swallowing.
What is the most probable diagnosis for this patient?Your Answer: Oesophageal carcinoma
Correct Answer: Achalasia
Explanation:The classic triad for achalasia includes loss of peristalsis, increased lower sphincter tone, and inadequate relaxation of the lower sphincter, which is evident on manometry. Dysphagia for both solid and liquid is also a common symptom of achalasia.
Unlike achalasia, Barrett’s esophagus does not show any changes on manometry. However, it can be identified through the presence of intestinal metaplasia on endoscopy.
Diffuse esophageal spasm is a motility disorder that does not affect lower esophageal sphincter pressure and relaxation during swallowing. Instead, manometry reveals repetitive high amplitude contractions.
Hiatus hernia is typically associated with gastroesophageal reflux disease and does not show any abnormal findings on manometry.
Understanding Dysphagia and its Causes
Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the oesophagus, including cancer, oesophagitis, candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, myasthenia gravis, and globus hystericus. These conditions have distinct features that can help in their diagnosis, such as weight loss and anorexia in oesophageal cancer, heartburn in oesophagitis, dysphagia of both liquids and solids in achalasia, and anxiety in globus hystericus. Dysphagia can also be classified as extrinsic, intrinsic, or neurological, depending on the underlying cause.
To diagnose dysphagia, patients usually undergo an upper GI endoscopy, a full blood count, and fluoroscopic swallowing studies. Additional tests, such as ambulatory oesophageal pH and manometry studies, may be needed for specific 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. By understanding the causes and features of dysphagia, healthcare professionals can provide timely and appropriate management for their patients.
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This question is part of the following fields:
- Gastrointestinal System
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Question 42
Correct
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A 78-year-old woman is diagnosed with a femoral hernia and requires surgery. What structure forms the posterior wall of the femoral canal?
Your Answer: Pectineal ligament
Explanation:Understanding the Femoral Canal
The femoral canal is a fascial tunnel located at the medial aspect of the femoral sheath. It contains both the femoral artery and femoral vein, with the canal lying medial to the vein. The borders of the femoral canal include the femoral vein laterally, the lacunar ligament medially, the inguinal ligament anteriorly, and the pectineal ligament posteriorly.
The femoral canal plays a significant role in allowing the femoral vein to expand, which facilitates increased venous return to the lower limbs. However, it can also be a site of femoral hernias, which occur when abdominal contents protrude through the femoral canal. The relatively tight neck of the femoral canal places these hernias at high risk of strangulation, making it important to understand the anatomy and function of this structure. Overall, understanding the femoral canal is crucial for medical professionals in diagnosing and treating potential issues related to this area.
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This question is part of the following fields:
- Gastrointestinal System
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Question 43
Incorrect
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A 67-year-old man has been admitted to the surgical ward with abdominal pain and rectal bleeding. According to the notes, he has not had a bowel movement in five days. Additionally, he has begun vomiting and his abdomen is swollen.
What is the probable diagnosis?Your Answer: Constipation
Correct Answer: Large bowel obstruction
Explanation:Large bowel obstruction is the most likely diagnosis based on the pattern of symptoms, which include abdominal distension, absence of passing flatus or stool, and late onset or no vomiting.
Large bowel obstruction occurs when there is a blockage in the passage of food, fluids, and gas through the large intestines. The most common cause of this condition is a tumor, accounting for 60% of cases. Colonic malignancy is often the initial presenting complaint in approximately 30% of cases, especially in more distal colonic and rectal tumors due to their smaller lumen diameter. Other causes include volvulus and diverticular disease.
Clinical features of large bowel obstruction include abdominal pain, distention, and absence of passing flatus or stool. Nausea and vomiting may suggest a more proximal lesion, while peritonism may be present if there is associated bowel perforation. It is important to consider the underlying causes, such as recent symptoms suggestive of colorectal cancer.
Abdominal x-ray is still commonly used as a first-line investigation, with a diameter greater than the normal limits of 10-12 cm for the caecum, 8 cm for the ascending colon, and 6.5 cm for recto-sigmoid being diagnostic of obstruction. CT scan is highly sensitive and specific for identifying obstruction and its underlying cause.
Initial management of large bowel obstruction includes NBM, IV fluids, and nasogastric tube with free drainage. Conservative management for up to 72 hours can be trialed if the cause of obstruction does not require surgery, after which further management may be required if there is no resolution. Around 75% of cases will eventually require surgery. IV antibiotics are given if perforation is suspected or surgery is planned. Emergency surgery is necessary if there is any overt peritonitis or evidence of bowel perforation, involving irrigation of the abdominal cavity, resection of perforated segment and ischaemic bowel, and addressing the underlying cause of the obstruction.
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This question is part of the following fields:
- Gastrointestinal System
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Question 44
Incorrect
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A 50-year-old male has been diagnosed with carcinoma of the head of the pancreas. He has reported that his stool is sticking to the toilet bowl and not flushing away. Which enzyme deficiency is most likely causing this issue?
Your Answer: Amylase
Correct Answer: Lipase
Explanation:Steatorrhoea, characterized by pale and malodorous stools that are hard to flush, is primarily caused by a deficiency in lipase.
Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. The majority of pancreatic tumors are adenocarcinomas and are typically found in the head of the pancreas. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and mutations in the BRCA2 and KRAS genes.
Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, and pruritus. Courvoisier’s law states that a palpable gallbladder is unlikely to be due to gallstones in the presence of painless obstructive jaundice. However, patients often present with non-specific symptoms such as anorexia, weight loss, and epigastric pain. Loss of exocrine and endocrine function can also occur, leading to steatorrhea and diabetes mellitus. Atypical back pain and migratory thrombophlebitis (Trousseau sign) are also common.
Ultrasound has a sensitivity of around 60-90% for detecting pancreatic cancer, but high-resolution CT scanning is the preferred diagnostic tool. The ‘double duct’ sign, which is the simultaneous dilatation of the common bile and pancreatic ducts, may be seen on imaging.
Less than 20% of patients with pancreatic cancer are suitable for surgery at the time of diagnosis. A Whipple’s resection (pancreaticoduodenectomy) may be performed for resectable lesions in the head of the pancreas, but side-effects such as dumping syndrome and peptic ulcer disease can occur. Adjuvant chemotherapy is typically given following surgery, and ERCP with stenting may be used for palliation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 45
Correct
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A 72-year-old man presents to his physician with a gradual yellowing of his skin. During the examination, the physician observes jaundiced sclerae and palpates a round mass under the right costal margin, measuring approximately 4 cm in diameter. The patient's abdomen is soft, non-tender, and not distended.
The physician orders a blood test, which reveals the following results:
- Bilirubin: 180 µmol/L (3 - 17)
- ALP: 98 u/L (30 - 100)
- ALT: 36 u/L (3 - 40)
- γGT: 71 u/L (8 - 60)
- Albumin: 43 g/L (35 - 50)
What clinical sign is evident, and what is the probable diagnosis?Your Answer: Courvoisier's sign indicating biliary tract cancer
Explanation:If a patient has painless jaundice and a palpable gallbladder in the right upper quadrant, it is unlikely to be caused by gallstones and more likely to be a malignancy. This is known as Courvoisier’s sign, and the most common cancers associated with it are cholangiocarcinoma and adenocarcinoma of the pancreatic head.
Rovsing’s sign is a sign of acute appendicitis, where palpation of the left lower quadrant causes pain in the right lower quadrant.
Virchow’s sign is the presence of a palpable left supraclavicular lymph node, which is a sign of metastatic gastric cancer.
Understanding Cholangiocarcinoma
Cholangiocarcinoma, also known as bile duct cancer, is a serious medical condition that can be caused by primary sclerosing cholangitis. This disease is characterized by persistent biliary colic symptoms, which can be accompanied by anorexia, jaundice, and weight loss. In some cases, a palpable mass in the right upper quadrant may be present, which is known as the Courvoisier sign. Additionally, periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen.
One of the main risk factors for cholangiocarcinoma is primary sclerosing cholangitis. This condition can cause inflammation and scarring of the bile ducts, which can lead to the development of cancer over time. To detect cholangiocarcinoma in patients with primary sclerosing cholangitis, doctors often use a blood test to measure CA 19-9 levels.
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This question is part of the following fields:
- Gastrointestinal System
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Question 46
Incorrect
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A 65-year-old man visits his GP complaining of a lump in his groin. He reports no other symptoms such as abdominal pain or changes in bowel habits. Upon examination, the GP notes that the lump is soft and can be reduced without causing discomfort to the patient. The GP suspects an inguinal hernia but is unsure if it is direct or indirect. To determine this, the GP reduces the lump and applies pressure to the anatomical landmark for the deep inguinal ring. What is this landmark?
Your Answer: Inferior and lateral to the pubic tubercle
Correct Answer: Superior to the midpoint of the inguinal ligament
Explanation: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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 47
Incorrect
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During a ward round on the gastroenterology ward, you assess a 75-year-old man with a history of hepatocellular carcinoma. He spent most of his life in Pakistan, where he consumed a diet high in grains and chicken. He has never contracted a hepatitis virus. Despite being a non-smoker, he has resided in a household where other inhabitants smoke indoors for the majority of his adult life.
What is the potential risk factor for hepatocellular carcinoma that this patient may have been exposed to?Your Answer: Caroli's disease
Correct Answer: Aflatoxin
Explanation:Hepatocellular carcinoma is commonly caused by chronic hepatitis B infection worldwide and chronic hepatitis C infection in Europe. However, there are other significant risk factors to consider, such as aflatoxins. These toxic carcinogens are produced by certain types of mold and can be found in improperly stored grains and seeds. While Caroli’s disease and primary sclerosing cholangitis are risk factors for cholangiocarcinoma, they are less significant for hepatocellular carcinoma.
Hepatocellular carcinoma (HCC) is a type of cancer that ranks third in terms of prevalence worldwide. The most common cause of HCC globally is chronic hepatitis B, while chronic hepatitis C is the leading cause in Europe. The primary risk factor for developing HCC is liver cirrhosis, which can result from various factors such as hepatitis B & 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 often presents late and may exhibit features of liver cirrhosis or failure such as jaundice, ascites, RUQ pain, hepatomegaly, pruritus, and splenomegaly. In some cases, it may manifest as decompensation in patients with chronic liver disease. Elevated levels of alpha-fetoprotein (AFP) are also common. High-risk groups such as patients with liver cirrhosis secondary to hepatitis B & C or haemochromatosis, and men with liver cirrhosis secondary to alcohol should undergo screening with ultrasound (+/- AFP).
Management options for early-stage HCC include surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolisation, and sorafenib, a multikinase inhibitor. Proper management and early detection are crucial in improving the prognosis of HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 48
Correct
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A 29-year-old man is diagnosed with pleomorphic adenoma and requires surgical resection. During the procedure, which of the following structures is least likely to be encountered in the resection of the parotid gland?
Your Answer: Mandibular nerve
Explanation:The parotid gland is traversed by several important structures, including the facial nerve and its branches, the external carotid artery and its branches (such as the maxillary and superficial temporal arteries), the retromandibular vein, and the auriculotemporal nerve. However, the mandibular nerve is located at a safe distance from the gland. The maxillary vein joins with the superficial temporal vein to form the retromandibular vein, which passes through the parotid gland. Damage to the auriculotemporal nerve during a parotidectomy can result in regrowth that attaches to sweat glands, leading to gustatory sweating (Freys Syndrome). The marginal mandibular branch of the facial nerve is also associated with the parotid 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 49
Incorrect
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Secretions from which of the following will contain the highest levels of potassium?
Your Answer: Gallbladder
Correct Answer: Rectum
Explanation:The rectum can produce potassium-rich secretions, which is why resins are given to treat hyperkalemia and why patients with villous adenoma of the rectum may experience hypokalemia.
Potassium Secretions in the GI Tract
Potassium is secreted in various parts of the gastrointestinal (GI) tract. The salivary glands can secrete up to 60mmol/L of potassium, while the stomach secretes only 10 mmol/L. The bile, pancreas, and small bowel also secrete potassium, with average figures of 5 mmol/L, 4-5 mmol/L, and 10 mmol/L, respectively. The rectum has the highest potassium secretion, with an average of 30 mmol/L. However, the exact composition of potassium secretions varies depending on factors such as disease, serum aldosterone levels, and serum pH.
It is important to note that gastric potassium secretions are low, and hypokalaemia (low potassium levels) may occur in vomiting. However, this is usually due to renal wasting of potassium rather than potassium loss in vomit. Understanding the different levels of potassium secretion in the GI tract can be helpful in diagnosing and treating potassium-related disorders.
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This question is part of the following fields:
- Gastrointestinal System
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Question 50
Correct
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As a busy surgical trainee on the colorectal unit, you have been tasked with reviewing the histopathology results for colonic polyps. Which type of polyp described below poses the highest risk of malignant transformation? Please note that this question is specifically for a trainee who is slightly older and more experienced.
Your Answer: Villous adenoma
Explanation:The risk of malignant transformation is highest in villous adenomas, while hyperplastic polyps pose little risk. Hamartomatous polyp syndromes may increase the risk of malignancy in patients, but the polyps themselves have low malignant potential.
Understanding Colonic Polyps and Follow-Up Procedures
Colonic polyps can occur in isolation or as part of polyposis syndromes, with greater than 100 polyps typically present in FAP. The risk of malignancy is related to size, with a 10% risk in a 1 cm adenoma. While isolated adenomas seldom cause symptoms, distally sited villous lesions may produce mucous and electrolyte disturbances if very large.
Follow-up procedures for colonic polyps depend on the number and size of the polyps. Low-risk cases with 1 or 2 adenomas less than 1 cm require no follow-up or re-colonoscopy for 5 years. Moderate-risk cases with 3 or 4 small adenomas or 1 adenoma greater than 1 cm require a re-scope at 3 years. High-risk cases with more than 5 small adenomas or more than 3 with 1 of them greater than 1 cm require a re-scope at 1 year.
Segmental resection or complete colectomy may be necessary in cases of incomplete excision of malignant polyps, malignant sessile polyps, malignant pedunculated polyps with submucosal invasion, polyps with poorly differentiated carcinoma, or familial polyposis coli. Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy is recommended. Rectal polypoidal lesions may be treated with trans anal endoscopic microsurgery.
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This question is part of the following fields:
- Gastrointestinal System
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