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  • Question 1 - A 72-year-old woman with a previous history of surgery for a ruptured ovarian...

    Correct

    • A 72-year-old woman with a previous history of surgery for a ruptured ovarian cyst as a teenager presents with colicky central abdominal pain of 24 hours’ duration. She has now started to vomit and on further questioning admits to constipation for the last 12 hours. There is nothing else significant in her medical history.
      Select the single most correct option.

      Your Answer: She should be thoroughly examined for a strangulated hernia

      Explanation:

      Understanding Bowel Obstruction and Ischaemic Bowel

      Bowel obstruction can occur as a result of adhesions, which are commonly caused by previous abdominal surgery. Symptoms such as abdominal pain, bloating, and vomiting may indicate a small bowel obstruction. It is important to rule out a strangulated hernia, especially a small femoral hernia.

      Ischaemic bowel, on the other hand, is typically seen in patients with pre-existing cardiovascular disease and risk factors. This condition often presents acutely and is caused by an arterial occlusion. Symptoms include severe abdominal pain, fever, nausea, and diarrhoea, which may be bloody. It is important to suspect ischaemic bowel in patients with acute abdominal pain that is out of proportion to clinical findings.

      In summary, understanding the differences between bowel obstruction and ischaemic bowel can help healthcare professionals make accurate diagnoses and provide appropriate treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 2 - A 56-year-old man comes to the clinic, having just returned from living in...

    Incorrect

    • A 56-year-old man comes to the clinic, having just returned from living in Canada. He tells you he had a colonoscopy six months earlier; a polyp in the ascending colon was removed and this was classified as a Dukes' B tumour. He wonders if he needs further checks according to current guidance for surveillance after resection of colorectal cancer. What would you advise him?

      Your Answer:

      Correct Answer: Serial carcinoembryonic antigen (CEA) monitoring

      Explanation:

      Post-Treatment Surveillance Strategies for Colorectal Cancer: The Role of CEA Monitoring, Colonoscopy, and CT Scans

      Carcinoembryonic antigen (CEA) is a protein that is elevated in the serum of patients with colorectal cancer. While not suitable for screening, CEA levels can be used to monitor disease burden and predict prognosis in patients with established disease. Additionally, elevated preoperative CEA levels should return to baseline after complete resection, and failure to do so may indicate residual disease. Serial CEA testing can also aid in the early detection of recurrences, which can increase the likelihood of a complete resection.

      The National Institute for Health and Care Excellence recommends regular serum CEA tests (at least every six months in the first three years) and a minimum of two CT scans of the chest, abdomen, and pelvis in the first three years after treatment. Surveillance colonoscopy should be performed one year after initial treatment, and if normal, another colonoscopy should be performed at five years. The timing of colonoscopy after adenoma should be determined by the risk status of the adenoma.

      While periodic colonoscopy is beneficial for detecting metachronous cancers and preventing further cancers via removal of adenomatous polyps, trials have failed to show a survival benefit from annual or shorter intervals compared to less frequent intervals (three or five years) for detecting anastomotic recurrences. Routine fecal occult blood testing is not recommended in post-treatment surveillance guidelines.

      In summary, post-treatment surveillance strategies for colorectal cancer should include serial CEA monitoring, CT scans, and colonoscopy at recommended intervals. These strategies can aid in the early detection of recurrences and improve the likelihood of a complete resection.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 3 - A 32-year-old woman with a history of migraine experiences inadequate relief from the...

    Incorrect

    • A 32-year-old woman with a history of migraine experiences inadequate relief from the recommended dose of paracetamol during acute attacks. She consumes 10 units of alcohol per week and smokes 12 cigarettes per day.

      What could be a contributing factor to this issue?

      Your Answer:

      Correct Answer: Delayed gastric emptying

      Explanation:

      During acute migraine attacks, patients often experience delayed gastric emptying. Therefore, prokinetic agents like metoclopramide are commonly added to analgesics. Changes in P450 enzyme activity, such as those caused by smoking or drinking, are unlikely to have a significant impact on the metabolism of paracetamol.

      Managing Migraines: Guidelines and Treatment Options

      Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.

      For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.

      Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.

      For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.

      It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - A very sensible parent brings her 9-year-old into the surgery for review. She...

    Incorrect

    • A very sensible parent brings her 9-year-old into the surgery for review. She is concerned as her child is complaining of recurrent episodes of dull abdominal pain and missing significant days off school. Your physical examination is entirely normal.
      What would count most against a diagnosis of functional recurrent abdominal pain in this case?

      Your Answer:

      Correct Answer: Above average intellectual ability

      Explanation:

      Recurrent Abdominal Pain in Children

      Recurrent abdominal pain is a common complaint among children over the age of five, with approximately 10% experiencing it. It is crucial to determine the nature of the pain, its impact on the child’s daily life, and how the child and their family cope with it. Organic causes, such as gastrointestinal, urological, haematological, and miscellaneous causes, must be ruled out. Non-organic pain is suggested by peri-umbilical pain, and vomiting may be present, but weight loss is rare. Other important questions to ask include the timing of the pain, associated symptoms, family history, and social history. Physical examination is often unhelpful, and investigations are unlikely to provide a diagnosis when non-organic pain is suspected.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 14-month old infant presents with episodes of severe colic, associated with pallor...

    Incorrect

    • A 14-month old infant presents with episodes of severe colic, associated with pallor and drawing of the legs upwards. This has been going on for several weeks.

      The mother has brought the child to see you because she noticed that there seemed to be blood and mucous in the stool yesterday.

      On examination there is a sausage-shaped mass palpable on the right side of the abdomen.

      What is the diagnosis?

      Your Answer:

      Correct Answer: Hirschsprung's disease

      Explanation:

      Intussusception: A Common Cause of Intestinal Obstruction in Infants

      Intussusception is a condition where a section of the bowel folds into itself, causing an obstruction. It is most commonly seen in infants over one month old, with the typical age of presentation being between two months to two years. The most common site of intussusception is the ileum passing into the caecum/colon through the ileocaecal valve.

      Symptoms of intussusception include severe colic, pallor, and drawing of legs upwards during episodes of pain. A sausage-shaped mass may be palpable in the abdomen, and parents may notice the passage of a redcurrant jelly stool (blood-stained mucous). In severe cases, children may present with abdominal distention and shock.

      The cause of intussusception is not always clear, but viral infections causing enlargement of Peyer’s patches have been implicated in forming a lead point for the development of intussusception. In children over the age of two, a specific lead point (such as a Meckel’s diverticulum or polyp) is more likely.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - A 56-year-old man presents to the GP with a 3-week history of nausea,...

    Incorrect

    • A 56-year-old man presents to the GP with a 3-week history of nausea, particularly worse after eating. He has not experienced any weight loss, upper abdominal pain or reflux. His past medical history includes a fractured right ankle in his twenties. He has no relevant family history. He is a social smoker and drinks around 2 pints with his friends at the weekend. The GP orders bloods which show:

      Hb 140 g/L Male: (135-180)
      Female: (115 - 160)
      Platelets 550 * 109/L (150 - 400)
      WBC 9.5 * 109/L (4.0 - 11.0)
      Na+ 142 mmol/L (135 - 145)
      K+ 4.1 mmol/L (3.5 - 5.0)
      Urea 5.5 mmol/L (2.0 - 7.0)
      Creatinine 75 µmol/L (55 - 120)
      CRP 3 mg/L (< 5)

      What would be the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: Non urgent referral for endoscopy

      Explanation:

      A non-urgent referral to GI is necessary for patients who have both raised platelet count and nausea due to dyspepsia. In this case, the patient, who is 58 years old, meets the criteria for such referral.

      While ondansetron is effective for chemically mediated nausea, metoclopramide or domperidone may be more appropriate for patients with reduced gastric motility.

      PPI trial is typically used as a second line management for dyspepsia patients who do not require endoscopy referral.

      Reassurance should not be given to patients who meet the criteria for non-urgent endoscopy referral, such as this man with dyspepsia symptoms and abnormal blood results.

      Urgent endoscopy referral is not necessary for patients who only present with nausea.

      Management of Dyspepsia and Referral Criteria for Suspected Cancer

      Dyspepsia is a common condition that can be managed through a stepwise approach. The first step is to review medications that may be causing dyspepsia and provide lifestyle advice. If symptoms persist, a full-dose proton pump inhibitor or a ‘test and treat’ approach for H. pylori can be tried for one month. If symptoms still persist, the alternative approach should be attempted.

      For patients who meet referral criteria for suspected cancer, urgent referral for an endoscopy within two weeks is necessary. This includes patients with dysphagia, an upper abdominal mass consistent with stomach cancer, and patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent referral is recommended for patients with haematemesis and patients aged 55 years or older with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with symptoms such as nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.

      Testing for H. pylori infection can be done through a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms have resolved following a ‘test and treat’ approach, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - Primary sclerosing cholangitis is most commonly associated with which of the following conditions?...

    Incorrect

    • Primary sclerosing cholangitis is most commonly associated with which of the following conditions?

      Your Answer:

      Correct Answer: Ulcerative colitis

      Explanation:

      Understanding Primary Sclerosing Cholangitis

      Primary sclerosing cholangitis is a condition that affects the bile ducts, causing inflammation and fibrosis. The cause of this disease is unknown, but it is often associated with ulcerative colitis, with 4% of UC patients having PSC and 80% of PSC patients having UC. Crohn’s disease and HIV are also less common associations.

      Symptoms of PSC include cholestasis, jaundice, pruritus, raised bilirubin and ALP levels, right upper quadrant pain, and fatigue. To diagnose PSC, doctors typically use endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), which show multiple biliary strictures giving a ‘beaded’ appearance. A positive p-ANCA test may also be indicative of PSC.

      Liver biopsy may show fibrous, obliterative cholangitis, often described as ‘onion skin’, but it has a limited role in diagnosis. Complications of PSC include an increased risk of cholangiocarcinoma (in 10% of cases) and colorectal cancer.

      Overall, understanding the symptoms, associations, and diagnostic methods for PSC is crucial for early detection and management of this condition.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - You assess a 32-year-old male with a 15-year history of ulcerative colitis. He...

    Incorrect

    • You assess a 32-year-old male with a 15-year history of ulcerative colitis. He reports passing three bloody stools per day for the past week, but denies any abdominal pain and has maintained a good appetite. Upon examination, there are no notable findings in the abdomen. What is the most probable explanation for this current episode?

      Your Answer:

      Correct Answer: Mild exacerbation of ulcerative colitis

      Explanation:

      Ulcerative colitis flares can occur without any identifiable trigger, but there are several factors that are often associated with them. These include stress, certain medications such as NSAIDs and antibiotics, and cessation of smoking. Flares are typically categorized as mild, moderate, or severe based on the number of stools a person has per day, the presence of blood in the stools, and the level of systemic disturbance. Mild flares involve fewer than four stools daily with or without blood and no systemic disturbance. Moderate flares involve four to six stools a day with minimal systemic disturbance. Severe flares involve more than six stools a day with blood and evidence of systemic disturbance such as fever, tachycardia, abdominal tenderness, distension, reduced bowel sounds, anemia, or hypoalbuminemia. Patients with severe disease should be admitted to the hospital.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - You see a 44-year-old lady whose brother and nephew both died of pancreatic...

    Incorrect

    • You see a 44-year-old lady whose brother and nephew both died of pancreatic cancer. The lady was diagnosed with diabetes from a range of tests. In addition, she noticed that her skin started to have a yellow tinge and she complained of itching over her body.

      Which is the best management option?

      Your Answer:

      Correct Answer: Arrange an MRI of the pancreas

      Explanation:

      Urgent Referral for Suspected Pancreatic Cancer

      With a strong family history of pancreatic cancer, it is important to have a low threshold for investigating any concerning symptoms. In addition, if a patient aged 60 or over presents with weight loss and any of the following symptoms – diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes – a CT scan should be carried out urgently.

      In this case, the patient has also been diagnosed with diabetes and jaundice, which further warrants an urgent referral for suspected cancer. It is important to note that an MRI should not be arranged in primary care, and the decision can be left with the specialist. Additionally, an ultrasound is not the preferred investigation in this instance.

      A routine referral would be inappropriate due to the red flags highlighted in the patient’s history. With such a strong family history, it is crucial to investigate this patient further and take appropriate action.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - A 31-year-old female with a history of ulcerative colitis presents with an increase...

    Incorrect

    • A 31-year-old female with a history of ulcerative colitis presents with an increase in stool frequency and passing around 4 bloody stools per day. Previous colonoscopies have shown rectal disease. On examination, her heart rate is 62 beats per minute, blood pressure is 110/70 mmHg, and temperature is 36.8ºC. Her abdomen is soft and non-tender. What is the best course of action for management?

      Your Answer:

      Correct Answer: Rectal mesalazine

      Explanation:

      For a mild-moderate flare of distal ulcerative colitis, the recommended initial treatment is rectal aminosalicylates. This patient is experiencing a moderate flare with four bloody stools per day and no systemic symptoms, indicating the use of topical aminosalicylates.

      While oral aminosalicylates, topical corticosteroids, and corticosteroids are also options for managing mild to moderate ulcerative colitis flares, rectal aminosalicylates are the first-line treatment.

      Severe flares of ulcerative colitis may require hospitalization for intravenous steroids, but this is not necessary for this patient who is passing less than six bloody stools per day and has no systemic symptoms.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - A 68-year-old woman presents with a two month history of mild nausea and...

    Incorrect

    • A 68-year-old woman presents with a two month history of mild nausea and upper abdominal discomfort after eating. You suspect gallstones so arrange an ultrasound scan of the abdomen along with a full blood count and liver function tests. Her BMI is 36.

      The ultrasound scan doesn't show any stones in the Gallbladder and her liver function tests are normal. Her haemoglobin level is 95 g/L with a microcytic picture. When it was checked 18 months ago her haemoglobin level was 120 g/L. She has no history of vaginal bleeding or melaena. Her BMI is now 32.

      What is the most appropriate management?

      Your Answer:

      Correct Answer: Arrange a routine barium meal and swallow

      Explanation:

      Urgent Referral for Upper GI Endoscopy in a Woman with Recent Onset Anemia and Weight Loss

      This woman, aged over 55, has recently developed anemia and has also experienced weight loss. According to the latest NICE guidelines, urgent referral for upper GI endoscopy is necessary in such cases. Routine referrals for CT scan and barium meal are not appropriate. Treating with iron without referral is not recommended as it may delay diagnosis.

      The loss of blood from the gastrointestinal tract is a common cause of anemia, and the symptoms experienced by this woman suggest an upper GI cause. Therefore, it is important to refer her for an upper GI endoscopy as soon as possible to identify the underlying cause of her symptoms and provide appropriate treatment. Proper diagnosis and treatment can help prevent further complications and improve the woman’s overall health and well-being.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - A 32-year-old woman has been experiencing abdominal pain and intermittent bloody diarrhoea for...

    Incorrect

    • A 32-year-old woman has been experiencing abdominal pain and intermittent bloody diarrhoea for the past 4 months. She has a history of perianal abscess. Her blood test shows hypochromic, microcytic anaemia and mild hypokalaemia. Although her liver function tests are normal, her albumin is reduced. Barium imaging reveals a small bowel stricture with evidence of mucosal ulceration extending into the colon, interspersed with normal looking mucosa ‘skipping’. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Crohn's disease

      Explanation:

      Understanding Crohn’s Disease: Symptoms, Diagnosis, and Differential Diagnosis

      Crohn’s disease is a chronic inflammatory condition that can affect any part of the gastrointestinal tract. The most commonly affected sites are the ileocecal region and the colon. Patients with Crohn’s disease experience relapses and remissions, with symptoms including low-grade fever, prolonged diarrhea, right lower quadrant or periumbilical pain, weight loss, and fatigue. Perianal disease may also occur, with symptoms such as perirectal pain, malodorous discharge, and fistula formation. Extra-intestinal manifestations may include arthritis, erythema nodosum, and primary sclerosing cholangitis.

      To establish a diagnosis of Crohn’s disease, ileocolonoscopy and biopsies from affected areas are first-line procedures. A cobblestone-like appearance is often seen, representing areas of ulceration separated by narrow areas of healthy tissue. Barium follow-through examination is useful for looking for inflammation and narrowing of the small bowel.

      Differential diagnosis for Crohn’s disease include coeliac disease, small bowel lymphoma, tropical sprue, and ulcerative colitis. Coeliac disease presents as a malabsorption syndrome with weight loss and steatorrhoea, while small bowel lymphoma is rare and presents with nonspecific symptoms such as abdominal pain and weight loss. Tropical sprue is a post-infectious malabsorption syndrome that occurs in tropical areas, and ulcerative colitis may be clinically indistinguishable from colonic Crohn’s disease but lacks the small bowel involvement and skip lesions seen in Crohn’s disease.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 13 - A patient in their 50s with irritable bowel syndrome (IBS) is still experiencing...

    Incorrect

    • A patient in their 50s with irritable bowel syndrome (IBS) is still experiencing constipation and abdominal discomfort despite trying various laxatives. According to NICE guidelines, linaclotide should be considered as a new medication for patients with IBS with constipation who have not responded to different laxatives. What is the primary mechanism of action of linaclotide?

      Your Answer:

      Correct Answer: Increases amount of fluid in the intestinal lumen

      Explanation:

      Anxiety-reducing (alleviates symptoms of distress)

      Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 14 - A 65-year-old man visits the GP clinic complaining of rectal bleeding that has...

    Incorrect

    • A 65-year-old man visits the GP clinic complaining of rectal bleeding that has been ongoing for two days. He has experienced eight episodes of diarrhoea in the past 24 hours, with visible blood mixed with stool. He also reports feeling nauseous and having abdominal pain. The patient has a medical history of ulcerative colitis, hypertension, and type 2 diabetes, and is currently taking mesalazine enteric coated 800 mg twice daily, amlodipine 10 mg once daily, and metformin 500mg twice daily.

      During the examination, the patient appears pale and has a temperature of 38ºC. His heart rate is 108/min, and his blood pressure is 112/74 mmHg. The abdominal exam reveals generalised tenderness and guarding, but no rebound tenderness.

      What is the appropriate course of action for managing this patient's condition?

      Your Answer:

      Correct Answer: Urgent hospital admission

      Explanation:

      The appropriate course of action for a severe flare-up of ulcerative colitis is urgent hospital admission for IV corticosteroids. This is based on the Truelove and Witts’ severity index, which indicates that the patient is experiencing a severe flare-up due to symptoms such as opening their bowels more than 6 times per day and systemic upset (e.g. fever and tachycardia). NICE guidelines recommend immediate hospital admission for assessment and treatment with IV corticosteroids. It should be noted that a short course of oral steroids or rectal mesalazine may be used for mild to moderate flare-ups, while loperamide and dose increases of mesalazine are not appropriate for managing severe flare-ups.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 15 - A 68-year-old woman presents to your clinic with a complaint of looser stools...

    Incorrect

    • A 68-year-old woman presents to your clinic with a complaint of looser stools than usual. She reports having three bowel movements per day for the past three months, whereas previously she had only one per day. On physical examination, her abdomen is soft and there are no palpable masses or tenderness. A digital rectal examination is unremarkable. The patient reports that she recently underwent bowel screening tests, which came back negative. What is the most appropriate next step in managing this patient's symptoms?

      Your Answer:

      Correct Answer: Refer routinely to a lower gastrointestinal specialist

      Explanation:

      Importance of Urgent Referral for Persistent Change in Bowel Habit

      Screening tests are designed for asymptomatic individuals in an at-risk population. However, it is not uncommon for patients with bowel symptoms to rely on negative screening results and dismiss their symptoms. In the case of a 72-year-old man with a persistent change in bowel habit towards looser stools, urgent referral for further investigation is necessary.

      It is important to note that relying solely on recent negative bowel screening results can be inadequate and should not falsely reassure patients. Therefore, healthcare providers should prioritize investigating any persistent changes in bowel habits to ensure timely diagnosis and treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 50-year-old man complains of frequent palpitations. These usually occur when he eats...

    Incorrect

    • A 50-year-old man complains of frequent palpitations. These usually occur when he eats and subside abruptly after he finishes eating. They are not accompanied by chest pain, but, on occasion, he also feels lightheaded. He has no reflux symptoms or dyspepsia. He is otherwise well and on presentation his blood pressure is 136/84 mmHg, his pulse is in sinus rhythm, and examination of his heart and abdomen are normal. His electrocardiogram (ECG) is normal.
      What is the most appropriate investigation?

      Your Answer:

      Correct Answer: 24 hour portable electrocardiogram (ECG)

      Explanation:

      The Most Appropriate Investigation for Palpitations and Dizziness: A Cardiac Investigation

      When a patient presents with palpitations and dizziness, a cardiac cause is often suspected. While the association with food may be a red herring, the combination of symptoms suggests a need for further investigation. An ECG or examination of the pulse may not reveal an underlying cause unless the patient is experiencing symptoms at that exact moment. Therefore, a 24 hour portable ECG is often recommended to assess the cardiac rhythm over a longer period of time.

      A chest X-ray is unlikely to be helpful in the absence of chest pain or respiratory symptoms. Similarly, an endoscopy may be indicated for dyspeptic symptoms, but the history of palpitations and dizziness suggests a cardiac cause. H. pylori testing is only relevant for dyspeptic symptoms, and thyroid function tests are important for anyone experiencing palpitations, as hyperthyroidism can be a cause.

      In summary, when a patient presents with palpitations and dizziness, a cardiac investigation is the most appropriate first step. A 24 hour portable ECG can provide valuable information about the cardiac rhythm over a longer period of time.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - You come across a 30-year-old accountant who has been diagnosed with Crohn's disease...

    Incorrect

    • You come across a 30-year-old accountant who has been diagnosed with Crohn's disease after experiencing abdominal pain, loose stools and a microcytic anaemia. The individual is seeking further information on the condition.

      Which of the following statements is accurate regarding Crohn's disease?

      Your Answer:

      Correct Answer: Osteoporosis occurs in up to 30% of patients with inflammatory bowel disease

      Explanation:

      Upon diagnosis, approximately 66% of individuals with inflammatory bowel disease exhibit anaemia. Crohn’s disease is typically diagnosed at a median age of 30 years. The global incidence and prevalence of Crohn’s disease are on the rise.

      Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.

      If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - A 30-year old with newly diagnosed ulcerative colitis is initiated on mesalazine following...

    Incorrect

    • A 30-year old with newly diagnosed ulcerative colitis is initiated on mesalazine following a recent weaning off of high dose steroids. After two weeks, he experiences intense discomfort in his epigastrium and upper right quadrant. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Acute pancreatitis

      Explanation:

      When it comes to the risk of pancreatitis, mesalazine is more likely to cause it than sulfasalazine. Although oral aminosalicylates can cause gastric side-effects such as diarrhoea, nausea, vomiting, and colitis exacerbation, acute pancreatitis is a rare but possible complication.

      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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      • Gastroenterology
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  • Question 19 - A 60-year-old woman presents with increasing epigastric pain after eating for the past...

    Incorrect

    • A 60-year-old woman presents with increasing epigastric pain after eating for the past month. She has a history of intermittent heartburn and epigastric burning for over a year, which was previously managed with regular alginate. Three months ago, she reported no weight loss or vomiting, and her H. pylori status was checked. On her return visit, it was found that she is H. pylori positive and has experienced a reduced appetite, mild nausea, and some weight loss. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Prescribe a PPI such as omeprazole 20 mg/day and review in two weeks

      Explanation:

      Urgent Referral for Upper GI Cancer in H. pylori Positive Patient

      This patient is showing red flag symptoms and signs that suggest upper GI cancer, including weight loss and poor appetite. Despite being Helicobacter pylori positive, urgent referral for upper GI endoscopy or to a specialist in upper GI cancer should not be delayed. An ultrasound scan is unlikely to be helpful, and prescribing a PPI should be avoided as it can mask underlying disease. It is important to prioritize urgent referral over prescribing eradication therapy for H. pylori, as the latter may delay the diagnosis of underlying pathology. By promptly referring the patient for further evaluation, healthcare providers can ensure timely diagnosis and treatment of potential upper GI cancer.

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      • Gastroenterology
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  • Question 20 - A 42-year-old woman visits her GP with concerns about her bowel habits and...

    Incorrect

    • A 42-year-old woman visits her GP with concerns about her bowel habits and a family history of colorectal cancer. She has a known diagnosis of irritable bowel syndrome (IBS) and has previously been investigated for changeable bowel symptoms. Her father, who recently underwent surgery for colon cancer, suggested she get her carcinoembryonic antigen (CEA) levels checked. After undergoing tests, she is diagnosed with bowel cancer. What is the most appropriate use of monitoring CEA levels in managing her condition?

      Your Answer:

      Correct Answer: For postoperative follow-up

      Explanation:

      The Role of Carcinoembryonic Antigen (CEA) in Cancer Management

      Carcinoembryonic antigen (CEA) is a glycoprotein that is primarily produced by cells in the gastrointestinal tract during embryonic development. While its levels are low in adults, CEA is a useful tumour marker for colorectal cancers. In this article, we explore the different ways in which CEA is used in cancer management.

      Postoperative Follow-up
      CEA levels are expected to fall to normal following successful removal of colorectal cancer. A rising CEA level thereafter may indicate possible progression or recurrence of the cancer. However, temporary rises can occur during chemotherapy and radiotherapy, so changes during treatment may not necessarily indicate cancer progression.

      Staging
      CEA levels are not used in staging as there are many variables that can affect the levels. More reliable investigations are used for staging.

      Indicator for Operability
      While a CEA level at diagnosis higher than 100 ng/ml usually indicates metastatic disease, other investigations are used in the initial assessment of a newly diagnosed cancer to determine suitability for operative management.

      Screening Method
      CEA is not sensitive or specific enough to use for diagnosis or screening. Cancers of the pancreas, stomach, breast, lung, medullary carcinoma of the thyroid, and ovarian cancer may also elevate CEA. Some non-malignant conditions such as cirrhosis, pancreatitis, and inflammatory bowel disease also cause blood levels to rise.

      Detection of Early Stage
      CEA is not used for the diagnosis of colorectal cancers as it is not sufficiently sensitive or specific. Early tumours may not cause significant blood elevations, nor may some advanced tumours.

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  • Question 21 - A 27 year old male with a history of ulcerative colitis presents with...

    Incorrect

    • A 27 year old male with a history of ulcerative colitis presents with rectal symptoms and bloody diarrhoea. Upon examination, he appears comfortable and well hydrated. His vital signs include a regular pulse of 88 beats per minute, a temperature of 37.5ºC, and a blood pressure of 120/80 mmHg. There is mild tenderness in the left iliac fossa, but no palpable masses or rebound tenderness. Rectal examination reveals tenderness and blood in the rectum. What is the most appropriate initial treatment for this patient's mild/moderate proctitis flare?

      Your Answer:

      Correct Answer: Rectal mesalazine

      Explanation:

      When experiencing a mild-moderate flare of distal ulcerative colitis, the initial treatment option is the use of topical (rectal) aminosalicylates. It is recommended to start with local treatment for rectal symptoms. Topical aminosalicylates are more effective than steroids, but a combination of both can be used if monotherapy is not effective. If the disease is diffuse or if symptoms do not respond to topical treatments, oral aminosalicylates can be used. In cases of severe disease, oral steroids can be considered.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

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      • Gastroenterology
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  • Question 22 - What is the most suitable approach to prevent variceal bleeding in a 45-year-old...

    Incorrect

    • What is the most suitable approach to prevent variceal bleeding in a 45-year-old man with a history of alcohol abuse who has been diagnosed with grade 3 oesophageal varices during an outpatient endoscopy?

      Your Answer:

      Correct Answer: Propranolol

      Explanation:

      The prophylaxis of oesophageal bleeding can be achieved using a non-cardioselective B-blocker (NSBB), while endoscopic sclerotherapy is no longer considered effective in preventing variceal haemorrhage.

      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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      • Gastroenterology
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  • Question 23 - A 79-year-old man comes in for the results of his recent blood tests....

    Incorrect

    • A 79-year-old man comes in for the results of his recent blood tests. He had visited the clinic yesterday due to jaundice and urgent blood tests were conducted. He denies any abdominal discomfort and feels fine. His heart rate is 82 beats per minute and he has a slight fever of 37.5 oC. The results of his liver function tests are as follows:

      - Bilirubin 150 µmol/L (3 - 17)
      - ALP 110 u/L (30 - 100)
      - ALT 20 u/L (3 - 40)
      - γGT 15 u/L (8 - 60)
      - Albumin 40 g/L (35 - 50)

      As per the current NICE CKS guidelines, what would be the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: Arrange same day admission to secondary care

      Explanation:

      The patient with jaundice and a bilirubin level exceeding 100 micromol/L requires same day admission. Additionally, the patient is feverish, which further supports the need for immediate hospitalization.

      Hepatobiliary disease and related disorders can present with a variety of symptoms and exam findings. Viral hepatitis may cause nausea, vomiting, anorexia, myalgia, lethargy, and RUQ pain, and risk factors such as foreign travel or intravenous drug use may be highlighted in exam questions. Congestive hepatomegaly can occur as a result of congestive heart failure and may cause pain due to liver stretching. Biliary colic is characterized by intermittent RUQ pain that often occurs after eating, and attacks may be accompanied by nausea. Acute cholecystitis presents with severe and persistent pain that may radiate to the back or right shoulder, and the patient may be pyrexial and have a positive Murphy’s sign. Ascending cholangitis is an infection of the bile ducts that presents with fever, RUQ pain, and jaundice. Gallstone ileus can cause small bowel obstruction and is associated with abdominal pain, distension, and vomiting. Cholangiocarcinoma may cause persistent biliary colic symptoms, anorexia, jaundice, weight loss, and exam findings such as a palpable mass in the RUQ and lymphadenopathy. Acute pancreatitis may be due to alcohol or gallstones and presents with severe epigastric pain, vomiting, tenderness, ileus, and low-grade fever. Pancreatic cancer may present with painless jaundice, anorexia, weight loss, and pain. Amoebic liver abscess may cause malaise, anorexia, weight loss, and mild RUQ pain, but jaundice is uncommon.

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      • Gastroenterology
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  • Question 24 - A 14-year-old girl comes to the clinic with her parents who are worried...

    Incorrect

    • A 14-year-old girl comes to the clinic with her parents who are worried about her experiencing recurrent episodes of abdominal pain, loss of appetite, and nausea for the past two months. Upon further inquiry, the pain is severe, occurs in the mornings, is intermittent, and can happen during vacations. Her weight is at the 50th percentile, and there are no abnormalities found during the examination. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Abdominal migraine

      Explanation:

      Abdominal Migraine: Recurrent Episodes of Midline Abdominal Pain in Children

      Abdominal migraine is a disorder that mainly affects children and is characterized by recurrent episodes of midline abdominal pain. The pain can last from 1-72 hours and is of moderate to severe intensity. During the attacks, patients may experience anorexia, nausea, and vomiting. Marked pallor is commonly noted, and some patients may appear flushed. The pain is severe enough to interfere with normal daily activities, and many children describe their mood during the attack as one of intense misery. However, patients are completely symptom-free between attacks.

      Abdominal migraine is an idiopathic disorder, meaning that the cause is unknown. It is unlikely to be school avoidance as the symptoms are episodic and can occur outside of school times.

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      • Gastroenterology
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  • Question 25 - A 28-year-old man known to have diffuse ulcerative colitis for which he takes...

    Incorrect

    • A 28-year-old man known to have diffuse ulcerative colitis for which he takes mesalazine 1.5g daily has an exacerbation. He is passing up to 10 loose stools per day with blood. He is feeling unwell, appears mildly dehydrated and anaemic.
      Select from the list the single most appropriate initial management option.

      Your Answer:

      Correct Answer: Admit to hospital

      Explanation:

      Treatment Options for Inflammatory Bowel Disease Exacerbations

      Inflammatory bowel disease (IBD) can cause severe exacerbations that require hospitalization for fluid and electrolyte replacement, transfusion, and possibly intravenous corticosteroids. However, for less severe exacerbations of diffuse disease, there are other treatment options available.

      One option is to increase the dose of mesalazine, which is an anti-inflammatory medication commonly used to treat IBD. Another option is to take oral prednisolone, which is a steroid medication that can help reduce inflammation in the gut.

      For those with proctitis or distal disease, prednisolone enemas may be used as a treatment option. These enemas are administered directly into the rectum and can help reduce inflammation in the lower part of the colon.

      Overall, the treatment options for IBD exacerbations depend on the severity and location of the disease. It is important to work closely with a healthcare provider to determine the best course of treatment for each individual case.

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      • Gastroenterology
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  • Question 26 - A 55-year-old woman visits her General Practitioner with complaints of haemorrhoids that she...

    Incorrect

    • A 55-year-old woman visits her General Practitioner with complaints of haemorrhoids that she has been experiencing for several years. She frequently experiences itchiness and pain. She has a daily bowel movement with soft stool. Upon examination, there is no indication of a rash or fissure. What is the most suitable medication to prescribe for this patient?

      Your Answer:

      Correct Answer: Cinchocaine (dibucaine) hydrochloride 0.5%, hydrocortisone 0.5% ointment

      Explanation:

      Topical Treatments for Haemorrhoids: Options and Considerations

      Haemorrhoids are a common condition that can cause discomfort and itching. Topical treatments are often used to alleviate symptoms, and there are several options available. However, it is important to choose the appropriate treatment based on the patient’s symptoms and medical history. Here are some considerations for different topical treatments:

      – Cinchocaine (dibucaine) hydrochloride 0.5%, hydrocortisone 0.5% ointment: This preparation contains a local anaesthetic and corticosteroid, which can provide short-term relief. It is suitable for occasional use.
      – Hydrocortisone 1%, miconazole nitrate 2% cream: This cream contains an anti-candida agent and is appropriate for intertrigo. However, if the patient doesn’t have a rash or signs of fungal infection, this may not be the best option.
      – Clobetasol propionate cream: This potent topical steroid is used for vulval and anal lichen sclerosus. It is not recommended if the patient doesn’t have a rash.
      – Glyceryl trinitrate ointment: This unlicensed preparation is used for anal fissure, which is characterized by painful bowel movements and rectal bleeding. If the patient doesn’t have these symptoms, this treatment is not appropriate.
      – Lactulose solution: Constipation can contribute to haemorrhoids, and lactulose can help manage this. However, if the patient doesn’t have constipation, this treatment may not be necessary.

      In summary, choosing the right topical treatment for haemorrhoids requires careful consideration of the patient’s symptoms and medical history. Consultation with a healthcare professional is recommended to determine the best course of action.

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      • Gastroenterology
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  • Question 27 - A 72-year-old man comes to his General Practitioner complaining of jaundice and weight...

    Incorrect

    • A 72-year-old man comes to his General Practitioner complaining of jaundice and weight loss. He reports having pale coloured stool and dark urine. He denies experiencing any abdominal pain or fever. He has no significant medical or family history.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Pancreatic adenocarcinoma

      Explanation:

      Diagnosing Pancreatic Adenocarcinoma: Understanding the Symptoms and Differential Diagnosis

      Pancreatic adenocarcinoma is a serious condition that requires prompt diagnosis and treatment. One of the key symptoms of this condition is painless jaundice, which is often accompanied by weight loss. This is due to the obstructive jaundice that occurs when the tumor is located at the head of the pancreas. Other symptoms may include pale stools and dark urine.

      It is important to note that patients may present with these symptoms before experiencing abdominal pain. This is why it is crucial to refer any patient aged 40 years and over with jaundice for suspected pancreatic cancer, according to National Institute for Health and Care Excellence (NICE) guidance.

      When considering a differential diagnosis, gallstone obstruction and cholecystitis can be ruled out due to the absence of severe abdominal pain. Chronic pancreatitis is also unlikely due to the lack of abdominal pain and the rarity of jaundice as a symptom. Hepatitis A may present with similar symptoms, but abdominal pain occurs in only 40% of patients.

      In conclusion, understanding the symptoms and differential diagnosis of pancreatic adenocarcinoma is crucial for prompt diagnosis and treatment. Any patient with jaundice should be referred for suspected pancreatic cancer, regardless of other symptoms.

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      • Gastroenterology
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  • Question 28 - A 45-year-old man with a history of GORD symptoms presents to the clinic...

    Incorrect

    • A 45-year-old man with a history of GORD symptoms presents to the clinic after a three month trial of omeprazole 20 mg. Further investigations have revealed that he has a hiatus hernia. The decision is made to continue his omeprazole treatment and he is advised to lose weight as his BMI is 32.

      Despite losing 5 kg over the past six months, he has visited the clinic twice for antibiotics due to lower respiratory tract infections. He has also been experiencing a nocturnal cough and possible asthma symptoms. What is the best course of action for managing his condition?

      Your Answer:

      Correct Answer: Increase his omeprazole to 40 mg

      Explanation:

      Indications for Surgical Repair of Hiatus Hernia

      Indications for surgical repair of hiatus hernia include recurrent respiratory tract infection due to reflux. It is also considered in patients who have a para-oesophageal hernia because of the risk of strangulation.

      Given this patient’s young age and the fact that he has attended twice in six months with symptoms of respiratory tract infection, surgical referral for laparoscopic fundoplication is advised. This procedure can help alleviate symptoms of reflux and prevent further respiratory tract infections. It is important to consider surgical intervention in cases where conservative management has failed or when there is a risk of complications such as strangulation. Proper evaluation and management of hiatus hernia can improve the quality of life for patients and prevent potential complications.

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      • Gastroenterology
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  • Question 29 - A 63-year-old man initially reported experiencing itching on his back. Subsequently, he began...

    Incorrect

    • A 63-year-old man initially reported experiencing itching on his back. Subsequently, he began to experience abdominal discomfort, loss of appetite, weight loss, and fatigue. An x-ray was performed, which showed no abnormalities. What would be the gold standard management option?

      Your Answer:

      Correct Answer: Urgent CT scan

      Explanation:

      Urgent CT Scan for Pancreatic Cancer in Elderly Patients with Red Flag Symptoms

      An urgent direct access CT scan is recommended within two weeks for patients aged 60 and over who have experienced weight loss and any of the following symptoms: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes. CT scan is preferred over ultrasound unless CT is not available. Endoscopy is not necessary as the symptoms do not suggest stomach or oesophageal cancer, which would present with more dysphagia and dyspepsia. While a gastroenterology opinion may be required, it should not be requested routinely as the patient’s red flag symptoms warrant a more urgent approach. Although the patient is currently medically stable, an immediate referral to the medical assessment unit is not necessary.

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      • Gastroenterology
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  • Question 30 - A 26-year-old man is being discharged from the hospital after a flare-up of...

    Incorrect

    • A 26-year-old man is being discharged from the hospital after a flare-up of ulcerative proctosigmoiditis. His symptoms improved after a 5-day course of intravenous corticosteroids, which had since been tapered down to oral prednisolone before discharge.

      He contacts you, concerned that he was not informed by the discharging team whether he should continue taking prednisolone to prevent a relapse or not. He is running out of medication soon and is unsure of what to do. You reach out to the on-call gastroenterologist for guidance.

      What would be the recommended first-line treatment for maintaining remission?

      Your Answer:

      Correct Answer: Daily rectal +/- oral mesalazine

      Explanation:

      The first-line treatment for maintaining remission in patients with ulcerative colitis who have proctitis or proctosigmoiditis is a daily rectal aminosalicylate, with the addition of an oral aminosalicylate if necessary. Topical and/or oral aminosalicylates are also the first-line treatment for inducing and maintaining remission in mild-moderate ulcerative colitis, with the route of administration depending on the location of the disease. If aminosalicylates fail to induce remission, a short-term course of oral or topical corticosteroids may be added. Severe colitis requires hospital admission and treatment with IV corticosteroids, with the addition of IV ciclosporin if necessary. Surgery is the last resort. Twice-weekly corticosteroid enemas, daily azathioprine, and daily low-dose oral prednisolone for 3 months are not correct treatments for maintaining remission in ulcerative colitis.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology
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