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  • Question 1 - A 72-year-old male came to his doctor complaining of loose stool during the...

    Incorrect

    • A 72-year-old male came to his doctor complaining of loose stool during the night for the past 2 months. He has a medical history of uncontrolled diabetes, chronic kidney disease, retinopathy, osteoarthritis, and coeliac disease. He denied experiencing abdominal pain, bloating, weight loss, or vomiting. Upon examination, his abdomen appeared normal, and his vital signs were stable. His blood glucose level was 18.7mmol/L.

      What is the most probable diagnosis?

      Your Answer: Overflow diarrhoea

      Correct Answer: Autonomic neuropathy

      Explanation:

      Autonomic neuropathy is a possible cause of night time diarrhoea in diabetics with poor control of their condition. Other potential diagnoses, such as irritable bowel syndrome, microscopic colitis, Crohn’s disease, and chronic constipation, should be considered and ruled out before making a definitive diagnosis. However, given the patient’s age and medical history, autonomic neuropathy is a likely explanation for her symptoms.

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

      Gastrointestinal autonomic neuropathy is another complication of diabetes that can cause symptoms such as gastroparesis, erratic blood glucose control, bloating, and vomiting. This can be managed with medications such as metoclopramide, domperidone, or erythromycin, which are prokinetic agents. Chronic diarrhea is another common issue that often occurs at night. Gastroesophageal reflux disease is also a complication of diabetes that is caused by decreased lower esophageal sphincter pressure.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 2 - A 32-year-old woman visits her doctor with complaints of abdominal cramps, bloating and...

    Incorrect

    • A 32-year-old woman visits her doctor with complaints of abdominal cramps, bloating and diarrhoea. She has recently returned from a trip to Asia, where she consumed food from various street vendors. Upon examination, her temperature is normal. Analysis of three stool samples reveals cysts, and she responds well to a course of metronidazole. What is the most probable diagnosis?

      Your Answer: Cryptosporidiosis

      Correct Answer: Giardiasis

      Explanation:

      Possible Causes of a Patient’s Abdominal Symptoms: A Differential Diagnosis

      The patient presents with abdominal symptoms including cramps, bloating, and diarrhea. The following are possible causes of these symptoms:

      1. Giardiasis: Caused by the protozoan parasite Giardia lamblia, transmitted by poor hygiene, and often associated with travel to areas with poor sanitation. Symptoms include diarrhea, flatulence, cramps, bloating, and nausea. Treatment is with metronidazole.

      2. Typhoid fever: Caused by Salmonella typhi, often associated with travel to India, Pakistan, and Bangladesh. Symptoms include fever, but not present in this case.

      3. Cryptosporidiosis: A parasite infection often causing sudden onset of watery diarrhea, abdominal cramps, and fever. Can be foodborne, waterborne, or transmitted through direct contact with livestock or infected people. Self-limiting, but may require treatment with metronidazole.

      4. Salmonella enteritidis infection: The most common cause of salmonella gastroenteritis, often associated with contaminated food or poor hygiene. Symptoms include fever, which is not reported in this case.

      5. Tapeworm infection: Caused by ingestion of uncooked or undercooked meat/fish containing tapeworm larvae. Symptoms vary depending on the type of tapeworm and may include abdominal discomfort, weight loss, and abnormal LFTs. Eggs may be found on stool examination, not cysts as in this case.

      Overall, giardiasis and cryptosporidiosis are the most likely diagnoses given the patient’s symptoms and travel history. However, further testing and evaluation may be necessary to confirm the diagnosis and determine the appropriate treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 3 - A 50-year-old woman presents to her General Practitioner following an Occupational Health screen.
    Investigations...

    Correct

    • A 50-year-old woman presents to her General Practitioner following an Occupational Health screen.
      Investigations have shown the following hepatitis B (HBV) serology:
      Test Result
      HBsAg
      (Hepatitis B surface antigen)
      Positive
      HBeAg
      (Hepatitis B e-antigen)
      Positive
      Anti-HBs
      (Antibody to HBsAg)
      Negative
      Anti-HBe
      (Antibody to HBeAg)
      Negative
      Anti-HBc IgG
      (Antibody to hepatitis B core-antigen immunoglobulin G)
      Positive
      Which of the following most accurately reflects this patient’s HBV status?

      Your Answer: Persistent carrier, high infectivity

      Explanation:

      Understanding Hepatitis B Test Results

      Hepatitis B is a viral infection that affects the liver. Understanding the results of hepatitis B tests is important for proper diagnosis and treatment. Here, we will discuss the different test results and what they mean.

      Persistent Carrier with High Infectivity:
      If a patient is positive for surface antigen, e-antigen, and core antibody, and negative for surface antibodies and e-antibodies, it suggests chronic carrier status. The presence of e-antigen confers high infectivity, indicating active viral replication. Core antibodies are a marker of past infection and will not be found in vaccinated individuals who have never been infected.

      Persistent Carrier with Low Infectivity:
      If a patient is positive for surface antigen and core antibody, but negative for e-antigen and e-antibodies, it suggests a moderately high viral load and elevated ALT levels. This is caused by a hepatitis B virus that has certain mutations (pre-core mutation) that allow the virus to replicate even when the e-antigen is absent.

      Previous Vaccination against Hepatitis B:
      If a patient has surface antibodies but not core antibodies, it indicates previous vaccination against hepatitis B.

      Spontaneously Cleared Infection:
      If a patient has lost surface antigen and developed surface antibodies, it marks seroconversion and indicates immunity. If IgM antibodies to core antigen (anti-HBc IgM) are present, it indicates recent infection.

      In conclusion, understanding hepatitis B test results is crucial for proper diagnosis and treatment. Consultation with a healthcare provider is recommended for interpretation of test results and appropriate management.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - You are reviewing a 60-year-old patient who has returned to see you for...

    Correct

    • You are reviewing a 60-year-old patient who has returned to see you for the results of some recent blood tests.

      Two months previously she had a liver function test that showed a bilirubin of 39 µmol/L (normal range 3-20 µmol/L). A repeat liver function test performed last week has shown the same result. The remainder of her liver profile is within normal limits.

      She is otherwise well and not on any regular medication. She is not overweight, drinks alcohol only occasionally and clinical examination is normal with no stigmata of liver disease. She is asymptomatic.

      Full blood count, renal function, thyroid function, fasting glucose and fasting lipids are all within normal limits.

      What is the most appropriate next step in her management?

      Your Answer: Request a GGT blood test

      Explanation:

      Management of Isolated Slightly Raised Bilirubin Levels

      When a patient presents with an isolated slightly raised bilirubin level and is asymptomatic, the next step is to confirm the proportion of unconjugated bilirubin to guide further investigation. If the unconjugated bilirubin is greater than 70%, the patient probably has Gilbert’s syndrome. In this case, if the bilirubin level remains stable on repeat testing, no further action is needed unless there is clinical suspicion of haemolysis. However, if the bilirubin level rises on retesting, haemolysis must be considered and should be investigated with a blood film, reticulocyte count, lactate dehydrogenase, and haptoglobin. It is important to note that the bilirubin level is almost twice the upper limit of normal, which was confirmed on interval testing. Therefore, it is crucial to monitor the patient’s bilirubin levels and investigate further if necessary.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 32-year-old woman of African ethnic origin frequently experiences abdominal tenderness and bloating...

    Incorrect

    • A 32-year-old woman of African ethnic origin frequently experiences abdominal tenderness and bloating and intermittently suffers from diarrhoea. She has been dealing with these symptoms for a few years and knows that some of her family members have had similar issues. Her condition has worsened since she arrived in the UK 2 years ago, but she denies any problems with adjusting to life here. On physical examination, there are no abnormalities detected.
      What is the most suitable initial management step for this patient?

      Your Answer: Reassurance

      Correct Answer: Trial of dairy-free diet

      Explanation:

      Lactose intolerance is a common condition among people of Far-Eastern and African origin, affecting up to 85% and over 60% of these populations, respectively. This is due to a deficiency of the enzyme lactase, which breaks down lactose. In contrast, people from northern Europe are less likely to experience lactose intolerance as they have a higher lactose intake and are more likely to inherit the ability to digest lactose. Lactose intolerance can cause symptoms similar to irritable bowel syndrome, such as bloating and diarrhea, as undigested lactose is broken down by gut bacteria. Diagnosis can be confirmed through the lactose breath hydrogen test or by trialing a dairy-free diet. While a small intestinal mucosal biopsy can directly assay lactase activity, it is usually too invasive for a mild condition. Women with lactose intolerance should seek alternative sources of dietary calcium.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - You are examining the blood results of a 31-year-old woman who visited you...

    Incorrect

    • You are examining the blood results of a 31-year-old woman who visited you last week complaining of abdominal pain, weight loss, fatigue, loose stools, mouth ulcers, and episcleritis. You suspected that she might have inflammatory bowel disease due to her positive family history. Her blood tests reveal a microcytic anaemia and an elevated CRP level.

      Which of the following statements is accurate?

      Your Answer: Erythema nodosum is an extra-intestinal manifestation not related to disease activity

      Correct Answer: About two-thirds of people with inflammatory bowel disease have anaemia at diagnosis

      Explanation:

      Inflammatory bowel disease can have an impact on the fertility of both men and women. For instance, Crohn’s disease can lower fertility rates due to the presence of active disease. Additionally, women who have undergone abdominal surgery or experienced abdominal sepsis are at a higher risk of developing adhesions that can negatively affect the function of their fallopian tubes.

      Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - What is the most accurate statement regarding gastrointestinal bleeding in patients who are...

    Correct

    • What is the most accurate statement regarding gastrointestinal bleeding in patients who are using non-steroidal anti-inflammatory drugs (NSAIDs)?

      Your Answer: It is due to depletion of mucosal prostaglandin E (PGE) levels

      Explanation:

      NSAIDs and Gastrointestinal Bleeds: Risk Factors and Mechanisms

      Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain relief and inflammation management. However, their use is associated with an increased risk of gastrointestinal bleeds, particularly in patients with pre-existing gastric or duodenal ulcers. Even those without a history of ulcers are at risk, with the relative risk varying among different NSAID preparations. NSAIDs directly damage the gastric mucosal barrier by depleting mucosal PGE levels, which decreases the gastroduodenal defence mechanisms and cytoprotective effect of PGE, resulting in mucosal injury, erosions and ulceration.

      Several factors increase the risk of ulceration in the setting of NSAID use, including previous peptic ulcer disease, advanced age, female sex, high doses or combinations of NSAIDs, long-term NSAID use, concomitant use of anticoagulants, and severe comorbid illnesses. Even low-dose aspirin, with increasing use, is a major cause of upper gastrointestinal problems, particularly bleeding. It is important to note that NSAIDs may have adverse effects in all parts of the gastrointestinal tract, not only the stomach or duodenum; the oesophagus, small intestine and colon may also be affected. Endoscopic evidence of peptic ulceration is found in 20% of NSAID users even in the absence of symptoms.

      In conclusion, while NSAIDs are effective in managing pain and inflammation, their use is associated with an increased risk of gastrointestinal bleeds. Patients with pre-existing gastric or duodenal ulcers are particularly at risk, but other factors such as advanced age, high doses or combinations of NSAIDs, and concomitant use of anticoagulants also increase the risk. It is important to weigh the benefits and risks of NSAID use and consider alternative pain management strategies in high-risk patients.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - A 47-year-old man has been diagnosed with a duodenal ulcer and CLO testing...

    Correct

    • A 47-year-old man has been diagnosed with a duodenal ulcer and CLO testing during gastroscopy confirms the presence of Helicobacter pylori. What is the best course of action for eradicating Helicobacter pylori?

      Your Answer: Lansoprazole + amoxicillin + clarithromycin

      Explanation:

      Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems

      Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.

      The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.

      The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - A 25-year-old woman comes to her doctor with jaundice, anorexia, nausea, and mild...

    Incorrect

    • A 25-year-old woman comes to her doctor with jaundice, anorexia, nausea, and mild tenderness in the right upper abdomen. She is currently 16 weeks pregnant and feeling ill. What is the probable reason for her jaundice?

      Your Answer: Intrahepatic cholestasis of pregnancy

      Correct Answer: Viral hepatitis

      Explanation:

      Liver Disorders During Pregnancy: Causes and Consequences

      During pregnancy, the liver can be affected by various disorders that can have serious consequences for both the mother and the fetus. Here are some of the most common liver disorders that can occur during pregnancy:

      1. Viral Hepatitis: Hepatitis B is the most common cause of jaundice in pregnancy, especially in developing countries. While most viral hepatitis infections are not affected by pregnancy, hepatitis E can be fatal for pregnant women.

      2. Acute Fatty Liver of Pregnancy: This rare disorder can progress to liver failure and usually occurs late in pregnancy. Early delivery can lead to complete recovery.

      3. Gallstones: This is the second most common abdominal emergency in pregnant women and can cause severe pain in the right upper quadrant.

      4. Intrahepatic Cholestasis of Pregnancy: This disorder is characterized by itching and elevated serum bile acids and can lead to serious complications for the fetus, including stillbirth.

      5. Pre-eclamptic Liver Disease and HELLP Syndrome: Jaundice may occur in 3-10% of pre-eclamptic pregnancies, and prompt delivery is the most effective treatment for HELLP syndrome.

      It is important for pregnant women to be aware of these liver disorders and to seek medical attention if they experience any symptoms. Early diagnosis and treatment can help prevent serious complications for both the mother and the fetus.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - A 42-year-old male presents with jaundice and pruritus. He has a history of...

    Incorrect

    • A 42-year-old male presents with jaundice and pruritus. He has a history of ulcerative colitis and is currently taking sulfasalazine. He reports feeling increasingly tired and has noticed a yellow tint to his eyes. On examination, he has scratch marks on his skin, hepatomegaly, and his blood pressure is 136/88 mmHg with a pulse rate of 74. Blood tests reveal elevated levels of bilirubin, ALT, and ALP. What is the most likely underlying diagnosis?

      Your Answer: Primary sclerosing cholangitis (PSC)

      Correct Answer: Gallstones

      Explanation:

      Primary Sclerosing Cholangitis in Patients with Ulcerative Colitis

      Patients with elevated ALP levels may be incidentally picked up and require further investigation. However, those who are symptomatic may present with jaundice, pruritus, fatigue, and abdominal pain. Clinically, patients may also have hepatomegaly and be jaundiced.

      In the case of a patient with ulcerative colitis, the likelihood of primary sclerosing cholangitis (PSC) is significantly increased. Approximately 3% of UC sufferers have PSC, and 80% of those with PSC have UC. While gallstones in the common bile duct and liver cysts of hydatid disease can present with similar symptoms, the history of UC makes PSC a more likely diagnosis. Haemolytic anaemia and osteomalacia can cause elevated ALP levels, but they would not account for the cholestatic liver function and hepatomegaly seen in PSC.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - A 38-year-old female with ulcerative colitis is discovered to have anti-smooth muscle antibodies.

    What...

    Incorrect

    • A 38-year-old female with ulcerative colitis is discovered to have anti-smooth muscle antibodies.

      What is the most suitable subsequent test for this patient?

      Your Answer: Liver function test

      Correct Answer: Order an urgent endoscopy

      Explanation:

      Next Investigation for Women with Suspected Autoimmune Hepatitis

      The most appropriate next investigation for this woman is to conduct liver function tests (LFTs) to assess if there are any features of autoimmune hepatitis. This includes checking for raised levels of bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase. If any of these levels are elevated, further diagnostic imaging or a liver biopsy may be required to confirm the diagnosis.

      Autoimmune hepatitis is often seen in individuals with other autoimmune disorders such as ulcerative colitis. Therefore, it is important to conduct these tests to determine the underlying cause of the woman’s symptoms and provide appropriate treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - A 26-year-old woman presents to her GP complaining of yellowing of her eyes...

    Incorrect

    • A 26-year-old woman presents to her GP complaining of yellowing of her eyes and generalized itching for the past 5 days. She denies any fever, myalgia, or abdominal pain. She reports that her urine has become darker and her stools have become paler. She has been in good health otherwise.

      The patient had visited the clinic 3 weeks ago for a sore throat and was prescribed antibiotics. She has been taking the combined oral contraceptive pill for the past 6 months.

      On examination, the patient appears jaundiced in both her skin and sclera. She has no rash but has multiple scratches on her arms due to itching. There is no palpable hepatosplenomegaly, and she has no abdominal tenderness.

      Laboratory tests reveal:

      - Bilirubin 110 µmol/L (3 - 17)
      - ALP 200 u/L (30 - 100)
      - ALT 60 u/L (3 - 40)
      - γGT 120 u/L (8 - 60)
      - Albumin 40 g/L (35 - 50)

      What is the most likely cause of her symptoms?

      Your Answer: Viral hepatitis

      Correct Answer: Combined oral contraceptive pill

      Explanation:

      The patient is presenting with cholestatic jaundice, likely caused by the oral contraceptive pill. This results in intrahepatic jaundice, dark urine, and pale stools. Paracetamol overdose and viral hepatitis would cause hepatocellular jaundice, while Gilbert’s syndrome is an unconjugated hyperbilirubinaemia. Choledocholithiasis could also cause obstructive cholestasis. It is appropriate to stop the pill and consider alternative contraception methods, and additional imaging may be necessary if jaundice doesn’t resolve.

      Drug-induced liver disease can be categorized into three types: hepatocellular, cholestatic, or mixed. However, there can be some overlap between these categories, as some drugs can cause a range of liver changes. Certain drugs tend to cause a hepatocellular picture, such as paracetamol, sodium valproate, and statins. On the other hand, drugs like the combined oral contraceptive pill, flucloxacillin, and anabolic steroids tend to cause cholestasis with or without hepatitis. Methotrexate, methyldopa, and amiodarone are known to cause liver cirrhosis. It is important to note that there are rare reported causes of drug-induced liver disease, such as nifedipine.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 13 - A 65-year-old man presents with persistent reflux, nausea and retrosternal burning pain after...

    Incorrect

    • A 65-year-old man presents with persistent reflux, nausea and retrosternal burning pain after eating over the last six weeks. There has been no change in bowel habit and has not noticed any melaena but he has lost a little weight.

      On examination there is no abnormality in the abdomen. His weight is 76 kg.

      He has a ten year history of dyspepsia which he has been treating with over-the-counter antacids. He had triple therapy nine years ago having had positive serology to Helicobacter pylori. He drinks around 16-20 units of alcohol per week and is an ex-smoker.

      He was seen at the out of hours centre five weeks ago and prescribed prochlorperazine, but this has made no difference to his symptoms.

      What is the most appropriate management strategy?

      Your Answer: Refer urgently for upper GI endoscopy under the two week wait referral system

      Correct Answer: Prescribe a daily H2 receptor antagonist (for example, ranitidine) for four weeks then review

      Explanation:

      Managing Gastro-Oesophageal Reflux Disease (GORD) with Alarm Symptoms

      When managing someone with symptoms of gastro-oesophageal reflux disease (GORD), it is crucial to look for alarm features such as unintentional weight loss, dysphagia, GI bleeding, persistent vomiting, and signs of anaemia. Patients may report weight loss, which should be recorded periodically for comparisons. In the presence of alarm symptoms, it is important to refer urgently for upper GI endoscopy, especially for patients aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia. According to NICE guidelines, the referral should be made under the two-week wait. The positive serology to Helicobacter pylori nine years ago would not alter the management given the current presentation.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 14 - A 16-month-old boy recently treated for constipation is seen for review.

    Six weeks ago,...

    Incorrect

    • A 16-month-old boy recently treated for constipation is seen for review.

      Six weeks ago, his parents brought him in and he was diagnosed with constipation. He was prescribed Movicol® Paediatric Plain sachets and given dietary advice. Following this, the child was able to open his bowels regularly with soft, well-formed stools.

      Two weeks ago, the parents stopped the laxative and the child has once again developed problems. On further questioning, he is opening his bowels maximum twice a week and the stools are described as hard balls.

      What is the most appropriate management plan?

      Your Answer:

      Correct Answer: Restart the Movicol® Paediatric Plain but continue treatment for a longer period before slowly tapering

      Explanation:

      Importance of Continuing Laxative Treatment for Children with Constipation

      Early and abrupt cessation of treatment is the most common cause of relapse in children with constipation. Once a regular pattern of bowel habit is established, maintenance laxative should be continued for several weeks and gradually tapered off over a period of months based on stool consistency and frequency. It may take up to six months of maintenance treatment to retrain the bowel, and some children may require laxative treatment for several years.

      The use of Movicol® Paediatric Plain sachets has been effective in establishing regular soft stools, but discontinuing the treatment has caused the problem to resurface. It is not recommended to switch to an alternative laxative or combine Movicol® Paediatric Plain with a stimulant laxative. The best approach is to restart the same laxative and continue its use for a longer period before tapering cautiously.

      At this point, there is no need for referral to a pediatrician or blood tests. However, it is important to emphasize the importance of continuing laxative treatment as prescribed to prevent relapse and maintain regular bowel habits in children with constipation.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 15 - A 40-year-old police officer attends his General Practitioner to request screening for hepatitis...

    Incorrect

    • A 40-year-old police officer attends his General Practitioner to request screening for hepatitis B. He was exposed to blood from a person possibly infected with hepatitis B virus around three weeks ago. He has never been vaccinated against this and requests blood screening. He feels well and has no comorbidities.
      What is the most important test to perform at this stage?

      Your Answer:

      Correct Answer: Hepatitis B surface antigen (HBsAg)

      Explanation:

      Hepatitis B Markers: Understanding the Different Types

      Hepatitis B is a viral infection that affects the liver. It is important to detect and monitor the different markers associated with the disease to determine the stage of infection and the appropriate treatment. Here are the different types of hepatitis B markers and their significance:

      1. Hepatitis B surface antigen (HBsAg) – This is the first marker to appear in the serum after infection. It indicates the presence of the viral envelope and can be detected between one to nine weeks after infection. Its persistence indicates chronic hepatitis B.

      2. Anti-hepatitis B envelope antigen (anti-HBeAg) – This antibody appears after the clearance of the e antigen, signifying the resolution of the acute phase.

      3. Hepatitis B envelope antigen (HBeAg) – This marker develops during the early phases of the acute infection and can persist in chronic infections. It is associated with high levels of viral replication and infectivity.

      4. Immunoglobulin G (IgG) anti-hepatitis B core antigen (anti-HBc) – This antibody stays positive for life following infection with hepatitis B, even once cleared.

      5. Immunoglobulin M (IgM) anti-hepatitis B core antigen (anti-HBc) – This antibody confirms the diagnosis of acute infection but is detectable later than HBsAg.

      Understanding these markers is crucial in the diagnosis and management of hepatitis B. Regular monitoring of these markers can help determine the progression of the disease and the effectiveness of treatment.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 32-year-old woman comes to her General Practitioner, reporting increased fatigue over the...

    Incorrect

    • A 32-year-old woman comes to her General Practitioner, reporting increased fatigue over the past few weeks. She has no other symptoms and no signs of liver disease upon examination. She was diagnosed with hepatitis B infection ten years ago and is concerned that the infection may still be active. What is the most suitable test for this patient?

      Your Answer:

      Correct Answer: Hepatitis B virus (HBV) deoxyribonucleic acid (DNA)

      Explanation:

      Understanding Hepatitis B Markers

      Hepatitis B virus (HBV) can be detected through various markers in the blood. The most sensitive indicator of viral replication is the presence of HBV DNA, which is found in high concentrations in both acute and chronic infections. A high level of HBV DNA is associated with an increased risk of liver damage and cancer. Effective antiviral treatment can lower the HBV DNA level.

      Anti-HBAb levels indicate decreased viral replication and infectivity in chronic carriers. These patients will only exhibit low levels of HBV DNA.

      HBeAg testing is indicated in the follow-up of chronic infection. In those with chronic (active) infection, it remains positive. However, hepatitis B virus DNA can be found without e antigen in hepatitis due to mutant strains of the virus.

      Anti-HBsAb is a marker of immunity to hepatitis B. Patients who are immune to the disease as a result of previous infection will also be positive for anti-HBeAg, but they will have cleared HBsAg and will not exhibit detectable HBV DNA. Patients who have been vaccinated for hepatitis B will also be positive for anti-HBsAb, without having any other positive markers.

      The presence of IgM anti-HBc indicates acute hepatitis, but doesn’t provide detail on the likelihood that the condition has become chronic. Understanding these markers can help in the diagnosis and management of hepatitis B.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - You are reviewing a 75-year-old man who has come to see you for...

    Incorrect

    • You are reviewing a 75-year-old man who has come to see you for the result of his recent colonoscopy. The report states:

      Good bowel preparation, optimal views, no intraluminal mass seen appearances consistent with melanosis coli and confirmed on biopsy.

      What is the cause of this gentleman's colonoscopy findings?

      Your Answer:

      Correct Answer: Inflammatory colitis

      Explanation:

      Melanosis Coli: A Benign Condition Caused by Laxative Use

      Many gastroenterology departments now offer rapid access for endoscopy directly from primary care. Consequently, GPs increasingly have endoscopy reports sent back to them for patients who can be managed in primary care and do not need any further hospital input.

      In this case, the endoscopy report identified melanosis coli, a benign condition that causes pigmentation of the colon wall. This condition is typically caused by long-term use of anthraquinone laxatives such as senna. The lesions are not due to melanin but rather a brown pigment called lipofuscin, which is deposited in macrophages in the colonic mucosa.

      It is important to note that melanosis coli is not a feature of inflammatory colitis or diverticular disease. Colonic lesions are often biopsied, and as in this case, the biopsy confirms the clinical diagnosis and doesn’t suggest the presence of carcinoma.

      Peutz-Jegher syndrome is an autosomal dominant condition that causes gastrointestinal polyps. Patients with this condition can display mucocutaneous pigmentation and perioral freckling. Polyps may undergo malignant transformation, and sufferers of this condition have a 12-fold increased risk of carcinoma.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - A 32-year-old woman visits her doctor complaining of excessive morning sickness during her...

    Incorrect

    • A 32-year-old woman visits her doctor complaining of excessive morning sickness during her third month of pregnancy. Her routine blood tests show an ALT level of 64 IU (normal range: < 40 IU/l) and a bilirubin of 55 µmol/l (normal range: < 21 µmol/l). What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Hyperemesis gravidarum (HG)

      Explanation:

      Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting that occurs during pregnancy and can lead to fluid and electrolyte imbalances, ketosis, and weight loss. It often affects the liver, with abnormal ALT levels in about half of patients. Jaundice may also occur in severe cases. While HG typically resolves by the end of the third trimester, it can persist throughout pregnancy in some cases.

      Acute fatty liver of pregnancy (AFLP) is a rare condition that occurs in about 5 out of 100,000 pregnancies. It often presents in the third trimester with symptoms such as nausea, vomiting, abdominal pain, fever, headache, and pruritus. Jaundice may also occur and can become severe. AFLP is typically managed by prompt delivery and supportive care, but it is unlikely to be the diagnosis for a patient in the first trimester.

      HELLP syndrome is a condition that can occur in patients with severe pre-eclampsia, with symptoms including abnormal pain and elevated AST levels. It is most likely to occur close to delivery, but it can occur as early as 20 weeks. However, this patient is only 13 weeks pregnant, making HELLP syndrome an unlikely diagnosis.

      Intrahepatic cholestasis of pregnancy (ICP) is a common condition that should be considered in cases of abnormal liver function tests in the second trimester. It is characterized by itching, and severe cases may lead to jaundice. Affected pregnancies are at an increased risk of prematurity and stillbirth, so early delivery may be necessary.

      Pre-eclampsia is a condition that typically occurs in the second half of pregnancy and is characterized by high blood pressure and proteinuria. It may also cause peripheral edema, abdominal pain, headache, and visual problems. Treatment involves delivery.

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      • Gastroenterology
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  • Question 19 - A 50-year-old woman presents with jaundice and itching.
    Which of the following results would...

    Incorrect

    • A 50-year-old woman presents with jaundice and itching.
      Which of the following results would most strongly support the diagnosis of primary biliary cholangitis?

      Your Answer:

      Correct Answer: Antimitochondrial antibodies

      Explanation:

      Understanding Primary Biliary Cholangitis: Diagnostic Tests and Markers

      Primary biliary cholangitis is an autoimmune disease that affects the biliary system, causing intrahepatic cholestasis and leading to cell damage, fibrosis, and cirrhosis. While there is no single definitive test for this condition, several markers can help diagnose and monitor it.

      Antimitochondrial antibodies are present in 90-95% of individuals with primary biliary cholangitis, but are only found in 0.5% of normal controls. Anti-smooth muscle antibodies are also nonspecific, as they can be positive in connective tissue disease and chronic infections. Similarly, around 35% of patients with primary biliary cholangitis have positive antinuclear antibodies, but this is not specific to the condition.

      Elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are common in primary biliary cholangitis, but significant elevations of alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (GGT) are usually more prominent. Additionally, a polyclonal increase in IgM (sometimes associated with elevated IgG) is typical but not specific to this condition.

      Overall, a combination of these diagnostic tests and markers can help identify and monitor primary biliary cholangitis.

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      • Gastroenterology
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  • Question 20 - 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 21 - A 35-year-old woman with hepatitis C visits your clinic as she is considering...

    Incorrect

    • A 35-year-old woman with hepatitis C visits your clinic as she is considering starting a family. She has no other medical issues. She inquires about the likelihood of her baby contracting hepatitis C.

      What is the probability of the virus being passed from mother to child?

      Your Answer:

      Correct Answer: 75-100%

      Explanation:

      Transmission Rates of Hepatitis B and C from Mother to Child

      The transmission rate of hepatitis B virus from mother to child can be as high as 90%, while the transmission rate of hepatitis C virus is only about 6%. This is because the neonatal immune system is not yet mature enough to fight off the hepatitis B virus, but it is able to fight off the hepatitis C virus to some extent. However, if the mother is also HIV positive, the transmission rate of hepatitis C virus can be higher. It is important to take time to understand this information before making any decisions.

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      • Gastroenterology
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  • Question 22 - A 63-year-old man presents with abdominal discomfort, loss of appetite, and weight loss....

    Incorrect

    • A 63-year-old man presents with abdominal discomfort, loss of appetite, and weight loss. He reports feeling fatigued and experiencing itching on his back. A recent abdominal x-ray showed no abnormalities. What would be considered the gold standard for managing his symptoms?

      Your Answer:

      Correct Answer: Urgent ultrasound 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 individuals aged 60 and above 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 necessary, it should not be requested routinely as the patient’s symptoms are considered red flags and require a more urgent approach. Although the patient is currently medically stable, an immediate referral to the medical assessment unit is not warranted. This approach ensures timely and appropriate management for elderly patients with potential pancreatic cancer.

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      • Gastroenterology
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  • Question 23 - 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.

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      • Gastroenterology
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  • Question 24 - A 75-year-old man admitted to the care of the elderly ward is experiencing...

    Incorrect

    • A 75-year-old man admitted to the care of the elderly ward is experiencing diarrhoea and has been isolated in a side room with barrier nursing due to the isolation of Clostridium difficile in his stool samples. What medication is most likely causing his diarrhoea?

      Your Answer:

      Correct Answer: Clindamycin

      Explanation:

      The use of clindamycin as a treatment is strongly associated with an increased risk of developing C. difficile infection. This is because broad spectrum antibiotics, including clindamycin, can disrupt the normal gut flora and allow for the overgrowth of C. difficile. Other antibiotics commonly used to treat C. difficile include vancomycin and metronidazole, which are administered orally to ensure high concentrations in the colon. Additionally, proton pump inhibitors like omeprazole and lansoprazole are also believed to contribute to the development of C. difficile infection.

      Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

      To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

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      • Gastroenterology
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  • Question 25 - 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 26 - A client is administered ondansetron for chemotherapy-induced vomiting. What is the most probable...

    Incorrect

    • A client is administered ondansetron for chemotherapy-induced vomiting. What is the most probable adverse effect?

      Your Answer:

      Correct Answer: Constipation

      Explanation:

      Understanding 5-HT3 Antagonists

      5-HT3 antagonists are a type of medication used to treat nausea, particularly in patients undergoing chemotherapy. These drugs work by targeting the chemoreceptor trigger zone in the medulla oblongata, which is responsible for triggering nausea and vomiting. Examples of 5-HT3 antagonists include ondansetron and palonosetron, with the latter being a second-generation drug that has the advantage of having a reduced effect on the QT interval.

      While 5-HT3 antagonists are generally well-tolerated, they can have some adverse effects. One of the most significant concerns is the potential for a prolonged QT interval, which can increase the risk of arrhythmias and other cardiac complications. Additionally, constipation is a common side effect of these medications. Overall, 5-HT3 antagonists are an important tool in the management of chemotherapy-induced nausea, but their use should be carefully monitored to minimize the risk of adverse effects.

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      • Gastroenterology
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  • Question 27 - A 28-year-old man visits his General Practitioner with complaints of abdominal pain, bloating...

    Incorrect

    • A 28-year-old man visits his General Practitioner with complaints of abdominal pain, bloating and nausea after meals. He has also experienced a weight loss of around 10 kg in the past three months, along with some non-bloody diarrhoea. He is a heavy smoker, consuming 30 cigarettes per day, but doesn't consume alcohol. A previous plain abdominal X-ray revealed dilated loops of the small bowel. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Crohn's disease

      Explanation:

      Possible Diagnoses for a 32-Year-Old Man with Abdominal Pain and Diarrhoea

      A 32-year-old man presents with abdominal pain, bloating, nausea after meals, and diarrhoea. The most likely diagnosis is Crohn’s disease, an inflammatory bowel disease that affects the small bowel and is more common and severe in smokers. Small-bowel adenocarcinoma is a rare possibility, but less likely in this case. Coeliac disease can be associated with ulcerative jejunitis and small-bowel lymphoma, but doesn’t cause strictures. Giardiasis rarely causes nausea and doesn’t show X-ray changes, and would often be associated with a history of foreign travel. Chronic pancreatitis and pancreatic insufficiency could also present with these symptoms, but would be unusual in a non-drinker without a history of recurrent gallstone pancreatitis. A plain abdominal X-ray might show pancreatic calcification.

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      • Gastroenterology
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  • Question 28 - A 65-year-old man presents with new onset bilateral gynaecomastia.
    He has been diagnosed with...

    Incorrect

    • A 65-year-old man presents with new onset bilateral gynaecomastia.
      He has been diagnosed with Zollinger-Ellison syndrome and heart failure in the last year. He underwent normal puberty at age 14.

      Which of the following drugs would be most likely to cause gynaecomastia?

      Your Answer:

      Correct Answer: Rabeprazole sodium

      Explanation:

      Drugs that can cause gynaecomastia

      Research has shown that the risk of developing gynaecomastia is almost insignificant when using other drugs as part of the treatment of Zollinger-Ellison syndrome. However, there are other drugs that can cause gynaecomastia, including spironolactone, digoxin, methyldopa, gonadotrophins, and cyproterone acetate.

      Zollinger-Ellison syndrome is a condition where a gastrin-secreting pancreatic adenoma is associated with peptic ulcer, and 50-60% of cases are malignant. It is suspected in patients with multiple peptic ulcers that are resistant to drugs and occurs in approximately 0.1% of patients with duodenal ulcer disease.

      A case study into male gynaecomastia has shown that spironolactone induced gynaecomastia by blocking androgen production, blocking androgens from binding to their receptors, and increasing both total and free oestrogen levels. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare professional.

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      • Gastroenterology
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  • Question 29 - A 28-year-old gentleman has come to discuss his recent blood test results.

    A few...

    Incorrect

    • A 28-year-old gentleman has come to discuss his recent blood test results.

      A few months previously he had a private health screening that showed an abnormality on his liver function tests. He was subsequently told to see his GP for further advice. You can see that a liver function test done at that time showed a bilirubin level of 41 µmol/L (normal 3-20) with the remainder of the liver function profile being within normal limits.

      Prior to seeing you today a colleague has repeated the liver function with a few other tests. The results show a normal full blood count, renal function and thyroid function.

      Repeat LFTs reveal:
      Bilirubin 40 µmol/L
      ALT 35 U/L
      ALP 104 U/L
      Conjugated bilirubin 7 μmol/L

      He is well in himself and has no significant past medical history. General systems examination is normal.

      What is the likely underlying diagnosis?

      Your Answer:

      Correct Answer: Haemolysis

      Explanation:

      Elevated Bilirubin Levels in Asymptomatic Patients

      This patient has an isolated slightly raised bilirubin level and is not experiencing any symptoms. The bilirubin level is twice the upper limit of normal, which has been confirmed on interval testing. The next step is to determine the proportion of unconjugated bilirubin to guide further investigation. If greater than 70% is unconjugated, as is the case here, the patient probably has Gilbert’s syndrome.

      If the bilirubin level remains stable on repeat testing, then no further action is needed unless there is clinical suspicion of haemolysis. However, if the bilirubin level rises on retesting, haemolysis must be considered and should be investigated with a blood film, reticulocyte count, lactate dehydrogenase, and haptoglobin. It is important to monitor bilirubin levels in asymptomatic patients to detect any potential underlying conditions.

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      • Gastroenterology
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  • Question 30 - A 35 year old woman has been diagnosed with irritable bowel syndrome (IBS)....

    Incorrect

    • A 35 year old woman has been diagnosed with irritable bowel syndrome (IBS). She has previously visited the gastroenterology clinic and all tests, including colonoscopy, were normal. Her main concerns are abdominal pain, bloating, and constipation. Despite taking antispasmodics, regular movicol, and following a dietician advice, she still experiences symptoms. She has tried other laxatives before, but with little improvement. What would be the most suitable next step?

      Your Answer:

      Correct Answer: Linaclotide

      Explanation:

      The diagnosis and management of IBS have been addressed by NICE in their guidance. The first line of pharmacological treatment includes antispasmodics such as Hyoscine or mebeverine, loperamide for diarrhea, and laxatives for constipation. Lactulose should be avoided. If the above treatments have not helped, second-line options include tricyclic antidepressants such as up to 30 mg amitriptyline. Third-line options include serotonin selective reuptake inhibitors. Linaclotide can be considered if the patient has had constipation for at least 12 months and has not benefited from different laxatives. Other management options include dietary advice and psychological treatments. However, acupuncture and reflexology are not recommended for managing IBS.

      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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Gastroenterology (4/13) 31%
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