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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 67-year-old woman presents to her General Practitioner complaining of chronic, unrelenting, dull...

    Incorrect

    • A 67-year-old woman presents to her General Practitioner complaining of chronic, unrelenting, dull epigastric pain radiating to her back. It is relieved when sitting forwards.
      On examination, her body mass index is normal, but she says that she is losing weight; her clothes have become baggy on her. She explains that she doesn't feel like eating with the pain she is suffering.
      Investigations reveal a haemoglobin level of 102 g/l (normal range: 115–165 g/l) while her alkaline phosphatase level is elevated.
      What is the most appropriate initial investigation?

      Your Answer: Check her CA 19-9 level

      Correct Answer: Arrange an abdominal computed tomography (CT) scan

      Explanation:

      Initial Management for Suspected Pancreatic Cancer: Abdominal CT Scan

      When a patient over 60 years old presents with weight loss and abdominal pain, an urgent direct-access CT scan should be considered to assess for pancreatic cancer. Other symptoms that may indicate pancreatic cancer include diarrhea, back pain, nausea, vomiting, constipation, and new-onset diabetes. Patients with pancreatic cancer typically report anorexia, malaise, fatigue, mid-epigastric or back pain, and weight loss. The pain may be unrelenting and worse when lying flat.

      The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice. Migratory thrombophlebitis and venous thrombosis also occur with higher frequency in patients with pancreatic cancer and may be the first presentation.

      While the CA 19-9 antigen is elevated in 75-80% of patients with pancreatic carcinoma, it is not recommended for screening. An abdominal ultrasound scan may reveal a pancreatic malignancy, but a CT scan is the preferred imaging that should be carried out urgently.

      Direct-access upper GI endoscopy may be appropriate for patients over 55 years old with weight loss and upper abdominal pain, reflux, or dyspepsia. However, in this case, an urgent CT scan is the most appropriate initial investigation due to the elevated alkaline phosphatase suggesting biliary obstruction. Checking ferritin levels may not be helpful in ruling in or out pancreatic cancer.

      Initial Management for Suspected Pancreatic Cancer: Abdominal CT Scan

    • This question is part of the following fields:

      • Gastroenterology
      30.2
      Seconds
  • Question 3 - A 42-year-old woman with no past medical history has been struggling to lose...

    Incorrect

    • A 42-year-old woman with no past medical history has been struggling to lose weight. She has been attending supervised weight loss sessions and gym classes, but has not been successful in her efforts. She was prescribed orlistat 120 mg, to be taken after each meal, 10 weeks ago when she weighed 100 kg (BMI 37 kg/m2). After 10 weeks of taking orlistat, she now weighs 97.5 kg. What would be the most appropriate management in this situation?

      Your Answer:

      Correct Answer: Discontinue orlistat

      Explanation:

      Options for Managing Inadequate Weight Loss with Orlistat

      Orlistat is a medication used to aid weight loss by reducing the absorption of dietary fat. However, if a patient fails to lose at least 5% of their body weight after 12 weeks of treatment, orlistat should be discontinued. Here are some options for managing inadequate weight loss with orlistat:

      1. Discontinue orlistat: If a patient has not lost at least 5% of their starting weight, orlistat should be discontinued. A lower weight loss target may be considered for patients with type II diabetes.

      2. Increase activity levels: Increasing physical activity can help with weight loss. However, it is important to address any underlying issues that may be hindering weight loss.

      3. Refer for bariatric surgery: Bariatric surgery may be an option for patients with a BMI of 40 kg/m2 or more, or 35–40 kg/m2 with significant comorbidity that could be improved with weight loss. Non-surgical methods of weight loss should be attempted prior to referral.

      4. Increase the dose to 180 mg with meals: The maximum dose of orlistat is 120 mg up to three times a day. A 60 mg preparation is available over the counter. However, increasing the dose beyond the recommended maximum is not advised.

      It is important to regularly review progress and adjust treatment accordingly to ensure the best outcomes for patients.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - A 70-year-old woman has observed abdominal swelling for a few months, along with...

    Incorrect

    • A 70-year-old woman has observed abdominal swelling for a few months, along with some abdominal tenderness. She has normochromic, normocytic anaemia, a decreased serum albumin level, and an elevated creatinine level of 180 μmol/l (normal 60–110 μmol/l). Her cancer antigen-125 level is elevated.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Ovarian carcinoma

      Explanation:

      Differential Diagnosis for Abdominal Distension and Elevated Creatinine Level

      Abdominal distension and elevated creatinine level can be indicative of various medical conditions. In the following vignette, ovarian carcinoma is the most likely diagnosis due to the presence of ascites, abnormal urea and electrolytes, elevated cancer antigen-125, normochromic, normocytic anaemia, and low albumin level. However, other conditions such as cirrhosis of the liver, diverticulitis, subacute intestinal obstruction, and uterine fibroids should also be considered and ruled out through further diagnostic testing and evaluation.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 70-year-old woman visits the General Practitioner after being discharged from the hospital...

    Incorrect

    • A 70-year-old woman visits the General Practitioner after being discharged from the hospital three days ago. She underwent a cholecystectomy but had to stay longer due to a chest infection that required treatment. She is now experiencing watery diarrhoea, abdominal cramping pain, and mild lower abdominal tenderness.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Clostridioides difficile-associated colitis

      Explanation:

      Clostridioides difficile-Associated Colitis: Symptoms, Risk Factors, and Treatment Options

      Clostridioides difficile-associated colitis is a condition that should be suspected in patients with diarrhoea who have received antibiotics within the previous three months, have recently been in hospital, and/or have an occurrence of diarrhoea 48 hours or more after discharge from the hospital. Although cases can also occur in the community without a history of hospitalisation, the primary risk factor is a disturbance of the normal bacterial flora of the colon by exposure to antibiotics. The release of toxins causes mucosal inflammation and damage, leading to diarrhoea. While most patients develop diarrhoea during or shortly after starting antibiotics, some may not become symptomatic for up to ten weeks after antibiotics.

      Therapy for non-severe infection consists of oral vancomycin or fidaxomcyin as a second-line option. Ceasing the causative antibiotic (if possible) will result in resolution in approximately three days in about 20% of patients. However, more severe diseases will require hospitalisation.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - A 29-year-old man with a history of ulcerative colitis presents to his primary...

    Incorrect

    • A 29-year-old man with a history of ulcerative colitis presents to his primary care physician complaining of loose non-bloody stools and abdominal discomfort for the past 6 days. He has not been taking any regular medication and his disease has been quiescent for many years. A colonoscopy performed 5 years ago showed proctitis. On examination, his vital signs are within normal limits and his abdomen is diffusely soft with no peritonism. A stool culture is negative. What is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Mesalazine suppository

      Explanation:

      For a patient experiencing mild-to-moderate symptoms of distal ulcerative colitis, the recommended first-line treatment is topical (rectal) aminosalicylates, such as mesalazine suppositories. This is particularly effective for patients with left-sided disease, such as proctitis or proctosigmoiditis. While budesonide foam enema is sometimes used as an additional treatment for mild-to-moderate disease, it is generally less effective at inducing remission. Oral azathioprine is not recommended for inducing remission, but may be used to maintain remission in patients who have had multiple inflammatory exacerbations or if remission is not maintained by aminosalicylates alone. Oral mesalazine is less effective than topical mesalazine for mild or moderate proctitis, but may be offered as an additional treatment if symptoms persist after 4 weeks of topical mesalazine. For patients with pancolitis or extensive disease, oral mesalazine may be offered as a first-line treatment.

      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 7 - A 65-year-old White woman presents to her General Practitioner with right upper quadrant...

    Incorrect

    • A 65-year-old White woman presents to her General Practitioner with right upper quadrant pain, a liver mass, weight loss and anaemia. She describes no symptoms prior to this episode and is not on any regular medications.
      She drinks around ten units of alcohol per week and was previously an intravenous (IV) drug user, although she has not done this for many years. She has no significant family history.
      She is diagnosed with hepatocellular carcinoma (HCC).
      What is the most likely predisposing factor for this diagnosis in this patient?

      Your Answer:

      Correct Answer: Hepatitis C

      Explanation:

      Understanding the Possible Causes of Hepatocellular Carcinoma (HCC)

      Hepatocellular carcinoma (HCC) is a type of liver cancer that can be caused by various factors. In this case, the patient’s history of intravenous (IV) drug use puts her at risk of hepatitis B and C, which are the most common causes of HCC in Europe. Chronic hepatitis B or C infection can increase the risk of developing HCC by 3-5% per year, and having both infections can further increase the risk.

      Alcohol abuse is also a risk factor for HCC, but in this patient’s case, her drinking is not excessive. Hereditary hemochromatosis, a condition that causes the body to absorb too much iron, can also increase the risk of HCC, but it is less common than chronic hepatitis. However, this patient’s lack of previous symptoms and family history make it unlikely that hemochromatosis is the underlying cause of her HCC.

      Another possible predisposing factor for HCC is primary biliary cholangitis (PBC), an autoimmune disease that affects the liver’s bile ducts. PBC is more common in women and may present with fatigue and pruritus, but this patient’s symptoms do not fit this clinical picture.

      In summary, understanding the possible causes of HCC can help in identifying the underlying factors and developing appropriate treatment plans. In this patient’s case, chronic hepatitis B or C infection is the most likely cause of her HCC.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - A 25-year-old woman has been diagnosed as having coeliac disease. She has started...

    Incorrect

    • A 25-year-old woman has been diagnosed as having coeliac disease. She has started on a gluten-free diet.
      Select from the list the single most correct statement about her management.

      Your Answer:

      Correct Answer: IgA anti-tissue transglutaminase antibodies and endomysial antibodies disappear if the diet is maintained

      Explanation:

      Managing Coeliac Disease with a Gluten-Free Diet

      Coeliac disease is a condition where the immune system reacts to gluten, a protein found in wheat, barley, and rye. The resulting damage to the intestinal mucosa can cause a range of symptoms, including abdominal pain, bloating, and diarrhoea. However, starting a gluten-free diet can lead to rapid improvement.

      The diet involves avoiding all foods containing wheat, barley, or rye, such as bread, cake, and pies. Oats can be consumed in moderate quantities if they are free from other contaminating cereals, as they do not damage the intestinal mucosa in most coeliac patients. Rice, maize, potatoes, soya, jam, syrup, sugar, and treacle are all allowed. Gluten-free flour, bread, biscuits, and pasta can be prescribed on the NHS, and Coeliac UK provides a list of prescribable products.

      To monitor the response to the diet, serial tTGA or EMA antibodies can be used. If these antibodies continue to be present in the blood, it suggests dietary lapses.

      Supplements of calcium, vitamin D, iron, and folic acid are only necessary if dietary intake is inadequate, which is often the case, particularly in elderly patients. Most patients with coeliac disease have some degree of hyposplenism, which warrants immunisation against influenza, pneumococcus, and H. influenza type B. However, lifelong prophylactic antibiotics are not needed.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - A 55-year-old man presents with indigestion that has been troubling him for the...

    Incorrect

    • A 55-year-old man presents with indigestion that has been troubling him for the past two months. He reports no prior history of these symptoms and states that he has been able to eat and drink normally. However, he has noticed a recent weight loss. He denies any abdominal pain or changes in bowel habits. On examination, his abdomen appears normal. Laboratory tests, including a full blood count, renal function, liver function, and C-reactive protein, are all within normal limits. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Abdominal and erect x ray today

      Explanation:

      Urgent Upper Gastrointestinal Endoscopy for Stomach Cancer Assessment

      Urgent upper gastrointestinal endoscopy is necessary within two weeks for individuals experiencing dysphagia to assess for stomach cancer. Additionally, patients aged 55 or over with weight loss and upper abdominal pain, reflux, or dyspepsia should also undergo this procedure. A directed admission is not required, and x-rays are unnecessary as the patient doesn’t have an acute abdomen. The National Institute for Health and Care Excellence (NICE) recommends endoscopy over an ultrasound scan. This history necessitates an urgent investigation, and a routine referral to gastroenterology would not be appropriate. It is important to note that knowledge of the patient’s H Pylori status would not alter the need for urgent OGD, and referral should not be delayed for this reason.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - Benjamin, who has been struggling with bowel issues, has been diagnosed with irritable...

    Incorrect

    • Benjamin, who has been struggling with bowel issues, has been diagnosed with irritable bowel syndrome based on routine blood tests and his medical history. He experiences loose stool and abdominal discomfort, which is relieved after bowel movements, but there is no presence of blood in his stool. Despite increasing his fiber intake with brown rice, high bran cereals, and grains, as well as consuming three portions of fresh fruit daily for the past 18 months, his symptoms persist. What dietary recommendations would be suitable for him?

      Your Answer:

      Correct Answer: Reduce insoluble fibre intake

      Explanation:

      Loose stool and bloating have been linked to the consumption of insoluble fibre found in foods like brown rice, bran cereals, and grains. As a result, it is recommended to decrease the intake of insoluble fibre.

      To maintain a healthy digestive system, it is suggested to limit the consumption of fresh fruit to a maximum of three portions per day. There is currently no scientific evidence to support the use of aloe vera or prebiotics.

      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 11 - A 58-year-old woman comes to her General Practitioner with complaints of abdominal pain,...

    Incorrect

    • A 58-year-old woman comes to her General Practitioner with complaints of abdominal pain, nausea and weight loss for the past four months. She describes the pain as dull, piercing and it radiates to her back. She has a history of anorexia. On physical examination, there is mild tenderness in the epigastric region but no palpable masses. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Carcinoma of the pancreas

      Explanation:

      Differential Diagnosis of Abdominal Pain: A Case Study

      The patient presents with abdominal pain, and a differential diagnosis must be considered. The symptoms suggest carcinoma of the body or tail of the pancreas, as obstructive jaundice is not present. The pain is located in the epigastric region and radiates to the back, indicating retroperitoneal invasion of the splanchnic nerve plexus by the tumour.

      Cholangiocarcinoma, a malignancy of the biliary duct system, is unlikely as jaundice is not present. Pain in the right upper quadrant may occur in advanced disease. Early gastric carcinoma often presents with symptoms of uncomplicated dyspepsia, while advanced disease presents with weight loss, vomiting, anorexia, upper abdominal pain, and anaemia.

      Peptic ulcer disease is a possibility, with epigastric pain being the most common symptom. Duodenal ulcer pain often awakens the patient at night, and pain with radiation to the back can occur with posterior penetrating gastric ulcer complicated by pancreatitis. However, the presence of weight loss makes pancreatic carcinoma more likely.

      Zollinger-Ellison syndrome, caused by a non-beta-islet-cell, gastrin-secreting tumour of the pancreas, is also a possibility. Epigastric pain due to ulceration is a common symptom, particularly in sporadic cases and in men. Diarrhoea is the most common symptom in patients with multiple endocrine neoplasia type 1, as well as in female patients.

      In conclusion, the differential diagnosis of abdominal pain in this case includes carcinoma of the pancreas, peptic ulcer disease, and Zollinger-Ellison syndrome. Further diagnostic tests are necessary to confirm the diagnosis and determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - Rahul, a young adult, has been experiencing symptoms of irritable bowel syndrome and...

    Incorrect

    • Rahul, a young adult, has been experiencing symptoms of irritable bowel syndrome and seeks advice from his doctor regarding dietary changes that could alleviate his bloating and constipation. What diet would be beneficial for young adults dealing with irritable bowel syndrome?

      Your Answer:

      Correct Answer: Low FODMAP diet

      Explanation:

      Monash University in Australia has recently introduced a low-FODMAP diet for managing irritable bowel syndrome (IBS). FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine, leading to water intake and diarrhea or fermentation by bacteria causing bloating in the large bowel. A low-FODMAP diet has been found to reduce IBS symptoms such as bloating, abdominal pain, and irregular bowel habits. However, it is a challenging diet to follow as it excludes many foods containing Oligo-, Di-, Mono-saccharides and Polyols, including wheat, dairy, pulses, excess fructose, and some vegetables. Therefore, it is recommended to seek the advice of a dietician.

      The LOFFLEX diet, which stands for low fat/fibre exclusion diet, has been developed for individuals with Crohn’s disease. It is often used after the elemental diet to maintain remission by avoiding high-fiber and high-fat foods that can trigger Crohn’s. The ketogenic diet has been shown to improve seizure control in people with epilepsy, particularly in children who are under the supervision of a pediatric dietician and have drug-resistant epilepsy. The specific carbohydrate and paleo diets are popular new diet trends that GPs may encounter, both of which significantly limit carbohydrate intake in the diet.

      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 13 - A 63-year-old woman complains of abdominal discomfort, bloating, and a change in bowel...

    Incorrect

    • A 63-year-old woman complains of abdominal discomfort, bloating, and a change in bowel habit with looser, more frequent stools. She has been experiencing these symptoms since her husband passed away 3 months ago. Her daughter believes she may have irritable bowel syndrome and is seeking treatment. What is the recommended course of action for managing her symptoms?

      Your Answer:

      Correct Answer: 2 week referral to secondary care

      Explanation:

      This woman has exhibited a concerning symptom of experiencing loose stools for over 6 weeks, which is a red flag indicator. Given her age of over 60 years, it is important to discuss the potential of an underlying cancer and refer her to secondary care for further testing within 2 weeks to rule out the possibility of bowel cancer.

      Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.

      An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.

      The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.

      The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 14 - A 50-year-old man who you have treated for obesity comes for review. Despite...

    Incorrect

    • A 50-year-old man who you have treated for obesity comes for review. Despite ongoing lifestyle interventions and trials of orlistat and sibutramine he has failed to lose a significant amount of weight. He is currently taking lisinopril for hypertension but a recent fasting glucose was normal. For this patient, what is the cut-off body mass index (BMI) that would trigger a referral for consideration of bariatric surgery?

      Your Answer:

      Correct Answer: BMI > 35 kg/m^2

      Explanation:

      Bariatric Surgery for Obesity Management

      Bariatric surgery has become a significant option in managing obesity over the past decade. For obese patients who fail to lose weight with lifestyle and drug interventions, the risks and expenses of long-term obesity outweigh those of surgery. The NICE guidelines recommend that very obese patients with a BMI of 40-50 kg/m^2 or higher, particularly those with other conditions such as type 2 diabetes mellitus and hypertension, should be referred early for bariatric surgery rather than it being a last resort.

      There are three types of bariatric surgery: primarily restrictive operations, primarily malabsorptive operations, and mixed operations. Laparoscopic-adjustable gastric banding (LAGB) is the first-line intervention for patients with a BMI of 30-39 kg/m^2. It produces less weight loss than malabsorptive or mixed procedures but has fewer complications. Sleeve gastrectomy reduces the stomach to about 15% of its original size, while the intragastric balloon can be left in the stomach for a maximum of six months. Biliopancreatic diversion with duodenal switch is usually reserved for very obese patients with a BMI of over 60 kg/m^2. Roux-en-Y gastric bypass surgery is both restrictive and malabsorptive in action.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 15 - A 35-year-old man with newly diagnosed ulcerative colitis (UC) comes to you with...

    Incorrect

    • A 35-year-old man with newly diagnosed ulcerative colitis (UC) comes to you with deteriorating symptoms. You believe he is experiencing a UC flare-up but doesn't need to be hospitalized based on clinical indications. He is presently taking suboptimal oral mesalazine once a day. He has no IBD care plan in place but has been diagnosed with severe disease.
      What is the best course of action for managing his UC flare-up?

      Your Answer:

      Correct Answer: Start oral budesonide

      Explanation:

      Treatment Options for Ulcerative Colitis Flares

      Oral or rectal mesalazine (or rectal steroids) are the recommended first-line treatment for ulcerative colitis (UC) flares. The dose of oral mesalazine can be increased up to 4.8g daily for the treatment of flares. It is important to review the patient’s response to treatment after 2 weeks, or sooner if deterioration occurs.

      While oral steroids are a potential treatment for UC flare-ups, they are not considered first-line treatments. Alternatives to oral steroids are preferred where possible. Immunosuppressants such as azathioprine and mercaptopurine may be considered by secondary care.

      If a patient requires more than 2 courses of steroids in 12 months or is unable to reduce their oral steroid use below 15 mg prednisolone per day, escalation of IBD therapy may be necessary. It is important to inform the patient’s IBD team that a flare has occurred.

      The IBD toolkit developed with the RCGP provides helpful advice on flare management. To ensure effective treatment of UC flares, it is important to follow these guidelines and work closely with the patient’s healthcare team.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 50-year-old woman visited her doctor with complaints of intense pain in the...

    Incorrect

    • A 50-year-old woman visited her doctor with complaints of intense pain in the anal area. She reported that the pain began after she strained to have a bowel movement. She had been experiencing constipation for the past 4 days and had been using over-the-counter laxatives. During the examination, the doctor observed a painful, firm, bluish-black lump at the edge of the anus.

      What is the probable reason for her symptoms?

      Your Answer:

      Correct Answer: Thrombosed haemorrhoid

      Explanation:

      Thrombosed haemorrhoids are characterized by severe pain and the presence of a tender lump. Upon examination, a purplish, swollen, and tender subcutaneous perianal mass can be observed. If the patient seeks medical attention within 72 hours of onset, referral for excision may be necessary. However, if the condition has progressed beyond this timeframe, patients can typically manage their symptoms with stool softeners, ice packs, and pain relief medication. Symptoms usually subside within 10 days.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - A 65-year-old patient who has been experiencing fatigue has a positive IgA tissue...

    Incorrect

    • A 65-year-old patient who has been experiencing fatigue has a positive IgA tissue transglutaminase (tTG) result. What is the initial management plan for this patient in regards to the test result?

      Your Answer:

      Correct Answer: Refer to gastroenterology

      Explanation:

      As part of a coeliac screen, IgA tissue transglutaminase (tTG) is one of the blood tests conducted along with total IgA and possibly anti-endomysial antibodies. According to the 2015 NICE guidance on Coeliac Disease, patients who test positive for this should be referred to gastroenterology for an intestinal endoscopy and biopsy to confirm the condition. Only after confirmation should the patient start a gluten-free diet under the guidance of a dietician.

      Managing Coeliac Disease with a Gluten-Free Diet

      Coeliac disease is a condition that requires the management of a gluten-free diet. Gluten-containing cereals such as wheat, barley, rye, and oats must be avoided. However, some patients with coeliac disease can tolerate oats. Gluten-free foods include rice, potatoes, and corn. Compliance with a gluten-free diet can be checked by testing for tissue transglutaminase antibodies.

      Patients with coeliac disease often have functional hyposplenism, which is why they are offered the pneumococcal vaccine. Coeliac UK recommends that patients with coeliac disease receive the pneumococcal vaccine and have a booster every five years. influenza vaccine is given on an individual basis according to current guidelines.

      Overall, managing coeliac disease requires strict adherence to a gluten-free diet and regular immunisation to prevent infections.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - Which of the following is not a known complication of coeliac disease in...

    Incorrect

    • Which of the following is not a known complication of coeliac disease in children?

      Your Answer:

      Correct Answer: Hypersplenism

      Explanation:

      Coeliac disease is associated with hypo-, rather than hypersplenism.

      Understanding Coeliac Disease

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

      To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.

      Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.

      The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.

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      • Gastroenterology
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  • Question 19 - Many elderly patients with colorectal cancer present with advanced disease. Early diagnosis is...

    Incorrect

    • Many elderly patients with colorectal cancer present with advanced disease. Early diagnosis is essential.
      Select from the list the single elderly patient who satisfies the criteria for urgent referral (2-week rule).

      Your Answer:

      Correct Answer: A 65-year-old man who has had loose stools for 6 weeks but no rectal bleeding

      Explanation:

      Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis

      Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. According to the National Institute for Health and Care Excellence (NICE), patients over 50 years old with unexplained rectal bleeding or over 60 years old with a change in bowel habit should be referred for an appointment within 2 weeks for suspected colorectal cancer. However, other conditions can also cause similar symptoms, and differential diagnosis is important to ensure appropriate management.

      Rectal Bleeding in a Multiparous Woman

      Rectal bleeding is a common symptom that can be caused by various conditions, including haemorrhoids. In a 40-year-old multiparous woman, routine referral would be appropriate if piles could not be identified.

      Change in Bowel Habit in a 60-Year-Old Man

      A change in bowel habit in a 60-year-old man is more likely to be caused by an acute infection, such as enterohaemorrhagic E. coli or Shigella. Investigations should be directed to finding the cause.

      Constipation in an 80-Year-Old Woman

      Constipation is a common symptom in the elderly, and dietary factors may play a role. In an 80-year-old woman with intermittent constipation and no teeth, the symptom is likely to be longstanding and not indicative of colorectal cancer.

      Anal Fissure in a 70-Year-Old Man

      Anal fissure is a possible cause of rectal bleeding in a 70-year-old man. Further investigation is needed to confirm the diagnosis and rule out other conditions.

      Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis

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      • Gastroenterology
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  • Question 20 - A 66-year-old woman presents to you for a medication review. She underwent H....

    Incorrect

    • A 66-year-old woman presents to you for a medication review. She underwent H. pylori eradication treatment a year ago, but her symptoms of epigastric burning returned within a few months. She has been taking omeprazole 20 mg/day since then. She reports that her symptoms are worsening again and asks if further treatment for Helicobacter pylori would be beneficial. She has lost more than 7 lbs in weight. You urgently refer her for an upper GI endoscopy.

      What advice would you give her while waiting for the investigation?

      Your Answer:

      Correct Answer: Increase her omeprazole to 40 mg daily

      Explanation:

      Importance of Stopping Acid Suppression Medication Prior to Endoscopy

      In urgent cases where endoscopy is required, it is recommended to stop acid suppression medication for at least two weeks before the procedure. This is because acid suppression medication can hide serious underlying conditions that need to be addressed. However, there may be situations where stopping the medication is difficult due to symptoms, and clinical judgement must be used.

      For instance, if a patient experiences unintentional weight loss, it is a red flag symptom for upper GI malignancy, and urgent referral for endoscopy is necessary. In such cases, the benefits of stopping acid suppression medication should be weighed against the potential risks of continuing it. Ultimately, the decision should be made based on the patient’s individual circumstances and the urgency of the situation. Proper evaluation and management can help ensure the best possible outcome for the patient.

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      • Gastroenterology
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  • Question 21 - A 25-year-old woman is diagnosed with coeliac disease.

    Which of the following foods should...

    Incorrect

    • A 25-year-old woman is diagnosed with coeliac disease.

      Which of the following foods should she avoid?

      Your Answer:

      Correct Answer: Barley

      Explanation:

      Safe and Unsafe Grains for a Gluten-Free Diet

      Following a gluten-free diet can be challenging, especially when it comes to grains. If you have celiac disease or gluten intolerance, it’s important to avoid wheat, rye, and barley as they contain gluten. However, there are still plenty of safe grains to choose from. Maize, rice, millet, and potatoes are all gluten-free and can be enjoyed without worry. By making simple substitutions and being mindful of ingredients, you can still enjoy a varied and delicious diet while avoiding gluten.

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      • Gastroenterology
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  • Question 22 - A 28-year-old woman comes in for evaluation. She reports having 'IBS' and experiencing...

    Incorrect

    • A 28-year-old woman comes in for evaluation. She reports having 'IBS' and experiencing occasional episodes of abdominal pain, bloating, and loose stools for the past two years. However, her symptoms have significantly worsened over the past two weeks. She is now having 3-4 watery, grey, 'frothy' stools per day, along with increased abdominal bloating, cramps, and flatulence. She also feels that she has lost weight based on the fit of her clothes. The following blood tests are ordered:

      Hb 10.9 g/dl
      Platelets 199 * 109/l
      WBC 7.2 * 109/l
      Ferritin 15 ng/ml
      Vitamin B12 225 ng/l
      Folate 2.1 nmol/l

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Coeliac disease

      Explanation:

      The key indicators in this case suggest that the patient may have coeliac disease, as evidenced by her anaemia and low levels of ferritin and folate. While her description of diarrhoea is typical, some patients may have more visibly fatty stools.

      It is unlikely that the patient has irritable bowel syndrome, as her blood test results would not be consistent with this diagnosis. While menorrhagia may explain her anaemia and low ferritin levels, it would not account for the low folate.

      Coeliac disease is much more common than Crohn’s disease, and exams typically provide more clues to suggest a diagnosis of Crohn’s (such as mouth ulcers).

      Understanding Coeliac Disease

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

      To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.

      Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.

      The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 23 - A 27-year-old woman with a history of Crohn's disease is seeking advice regarding...

    Incorrect

    • A 27-year-old woman with a history of Crohn's disease is seeking advice regarding her desire to start a family with her partner. She is currently taking methotrexate and wants to know if it is safe to conceive.

      What would be the best course of action to recommend?

      Your Answer:

      Correct Answer: He should wait at least 6 months after stopping treatment

      Explanation:

      Men and women who are undergoing methotrexate treatment must use reliable contraception throughout the duration of the treatment and for a minimum of 6 months after it has ended.

      Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

      Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

      It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

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      • Gastroenterology
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  • Question 24 - Oliver is a 25-year-old man, who was diagnosed with coeliac disease when he...

    Incorrect

    • Oliver is a 25-year-old man, who was diagnosed with coeliac disease when he was aged five having been referred to the paediatricians with failure to thrive and anaemia.

      He is very aware of foods that may cause problems, but wants to know if there are any drinks that should be avoided when he goes out clubbing with friends.

      Which one of the following drinks can he safely ingest?

      Your Answer:

      Correct Answer: Whiskey

      Explanation:

      Coeliac Disease and Gluten-Free Alcohol

      Patients with coeliac disease must avoid consuming foodstuffs that contain gluten. This means that anything made with wheat, barley, and oats (in some cases) should be avoided. When it comes to alcohol, beers, lagers, stouts, and real ales, whether alcoholic or not, must be avoided due to their gluten content. However, there are now several gluten-free beers and lagers available in the market.

      On the other hand, wine, champagne, port, sherry, ciders, liqueurs, and spirits, including whiskey, are all gluten-free. Although whiskey is initially made from barley, the distilling process involved in its production removes the gluten, making it safe for coeliacs to consume. It is essential for individuals with coeliac disease to be mindful of their alcohol intake and to choose gluten-free options to avoid any adverse reactions.

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      • Gastroenterology
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  • Question 25 - You have a consultation scheduled with Mr. Smith, a 74-year-old man who is...

    Incorrect

    • You have a consultation scheduled with Mr. Smith, a 74-year-old man who is interested in participating in the NHS bowel cancer screening program. He has never submitted the home test kits before and wants to know if he is eligible for screening.

      Your Answer:

      Correct Answer: He can self-refer for home test kit

      Explanation:

      Patients who are over the age of 74 are no longer eligible for bowel cancer screening within the NHS screening program. However, they can still receive a home test kit every 2 years by self-referral (helpline number on NHS website). It is important to note that if a patient develops symptoms of bowel cancer, they should be formally investigated according to NICE suspected cancer guidelines. Additionally, in areas where bowel scope screening has been rolled out, patients can self-refer up to the age of 60 for one-off bowel scope screening.

      Colorectal Cancer Screening with FIT Test

      Overview:
      Colorectal cancer is often developed from adenomatous polyps. Screening for this cancer has been proven to reduce mortality by 16%. The NHS provides home-based screening for older adults through the Faecal Immunochemical Test (FIT). Although a one-off flexible sigmoidoscopy was trialled in England, it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was further exacerbated by the COVID-19 pandemic. However, the trial showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used in future bowel screening programmes.

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

      Colonoscopy:
      Approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

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      • Gastroenterology
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  • Question 26 - A 58-year-old woman has acute pancreatitis.

    Which one of the following is the most...

    Incorrect

    • A 58-year-old woman has acute pancreatitis.

      Which one of the following is the most likely cause?

      Your Answer:

      Correct Answer: Mumps

      Explanation:

      Causes of Pancreatitis: Gallstones and Alcohol

      Pancreatitis is commonly caused by gallstones and alcohol. Gallstones are the most frequent cause, while alcohol is the second most common. Other causes of pancreatitis are less common.

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      • Gastroenterology
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  • Question 27 - A 49-year-old woman presents with lethargy and pruritus. She reports having a normal...

    Incorrect

    • A 49-year-old woman presents with lethargy and pruritus. She reports having a normal appetite and no weight loss. Upon examination, there is no clinical jaundice or organomegaly. The following blood tests were obtained:

      - Hemoglobin: 12.8 g/dL
      - Platelets: 188 * 10^9/L
      - White blood cells: 6.7 * 10^9/L
      - Sodium: 140 mmol/L
      - Potassium: 3.9 mmol/L
      - Urea: 6.2 mmol/L
      - Creatinine: 68 µmol/L
      - Bilirubin: 30 µmol/L
      - Alkaline phosphatase: 231 U/L
      - Alanine transaminase: 38 U/L
      - Gamma-glutamyl transferase: 367 U/L
      - Albumin: 39 g/L

      What additional test is most likely to provide a diagnosis?

      Your Answer:

      Correct Answer: Anti-mitochondrial antibodies

      Explanation:

      Primary biliary cholangitis is a chronic liver disorder that affects middle-aged women. It is thought to be an autoimmune condition that damages interlobular bile ducts, causing progressive cholestasis and potentially leading to cirrhosis. The classic presentation is itching in a middle-aged woman. It is associated with Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Diagnosis involves immunology and imaging tests. Management includes ursodeoxycholic acid, cholestyramine for pruritus, and liver transplantation in severe cases. Complications include cirrhosis, osteomalacia and osteoporosis, and an increased risk of hepatocellular carcinoma.

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      • Gastroenterology
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  • Question 28 - A 50-year-old woman with type-2 diabetes complains of blood stained diarrhoea and cramping...

    Incorrect

    • A 50-year-old woman with type-2 diabetes complains of blood stained diarrhoea and cramping abdominal pain of several months’ duration. She underwent a hysterectomy and radiotherapy 2 years ago for endometrial carcinoma.
      Select from the list the single most likely diagnosis.

      Your Answer:

      Correct Answer: Chronic radiation enteropathy

      Explanation:

      Chronic Radiation Enteropathy: Symptoms, Diagnosis, and Differential Diagnosis

      Chronic radiation enteropathy is a progressive disease that can occur months or even years after radiation therapy. It is characterized by transmural bowel damage, obliterative endarteritis, and altered intestinal transit, leading to symptoms such as abdominal pain, diarrhea (which may be blood-stained), malabsorption, and dysmotility. Patients with a history of pelvic or abdominal radiation therapy are at risk for developing chronic radiation enteropathy, which can lead to intestinal obstruction, fistula formation, or perforation. Corrective surgery is associated with high morbidity and mortality, and long-term symptoms are common.

      Diagnosis of chronic radiation enteropathy is based on the persistence of symptoms for three or more months following irradiation. Differential diagnosis includes irritable bowel syndrome, lymphoma, pseudomembranous colitis, and ulcerative colitis. However, the history of pelvic radiation is a key factor in distinguishing chronic radiation enteropathy from other conditions. While irritable bowel syndrome may cause diarrhea, blood in the stool is not a typical symptom. Lymphoma and ulcerative colitis may also present with bloody diarrhea and abdominal pain, but the history of radiation therapy makes chronic radiation enteropathy more likely. Pseudomembranous colitis is caused by infection with Clostridium difficile and is not typically associated with bloody stools.

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      • Gastroenterology
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  • Question 29 - A 35-year-old woman presented with persistent dyspepsia and was referred for a gastroscopy....

    Incorrect

    • A 35-year-old woman presented with persistent dyspepsia and was referred for a gastroscopy. The test confirmed a duodenal ulcer and a positive urease test. After completing the H. pylori eradication regimen of lansoprazole, amoxicillin and clarithromycin for seven days, she returned to her GP with ongoing epigastric pain. What is the most appropriate way to determine the successful eradication of H. pylori?

      Your Answer:

      Correct Answer: [13C] urea breath test

      Explanation:

      Non-Invasive Tests for Confirming Eradication of H. pylori Infection

      After completing eradication therapy for H. pylori infection, routine retesting is not recommended unless there are persistent symptoms. In such cases, the [13C] urea breath test is a sensitive and non-invasive option for detecting the presence of H. pylori bacteria. This test involves administering a drink containing urea labelled with an uncommon isotope and detecting the presence of isotope-labelled carbon dioxide in exhaled breath after 30 minutes. Faecal antigen testing can also be used as a second-line option if the urea breath test is not available. Blood serology testing is not recommended as it remains positive for several months after successful eradication. Endoscopy and histology or CLO test are invasive and costly options that are not justified when accurate non-invasive tests are available. Testing should occur at least four weeks after stopping antibiotics and two weeks after stopping proton pump inhibitors.

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      • Gastroenterology
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  • Question 30 - 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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