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Question 1
Incorrect
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A 50-year-old woman is known to have diverticular disease. She has experienced pain in the left iliac fossa intermittently in the past put now the pain is more persistent and more severe. She is tender in the left iliac fossa but there is no guarding or rebound tenderness and a mass is not felt. Her temperature is 38oC.
Select from the list the single most useful drug in these circumstances.Your Answer: Ispaghula husk
Correct Answer: Co-amoxiclav
Explanation:Management of Diverticulitis in Primary Care
Diverticulitis is a common condition that can be managed in primary care, provided there are no complications. If the patient is not dehydrated, experiencing severe bleeding, or showing signs of perforation, abscess or fistula formation, or significant comorbidity, they can be treated at home.
The first step in treatment is to prescribe broad-spectrum antibiotics that cover anaerobes and Gram-negative rods. Co-amoxiclav or a combination of ciprofloxacin and metronidazole (if allergic to penicillin) are good options. The course of antibiotics should last for at least 7 days.
If the patient’s symptoms worsen or persist beyond 48 hours, hospital admission may be necessary. However, with proper management and monitoring, most cases of diverticulitis can be successfully treated in primary care.
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This question is part of the following fields:
- Gastroenterology
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Question 2
Correct
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A 62-year old male presents with dysphagia. His symptoms were first noticed a few months ago and have steadily worsened.
Initially he found difficulty swallowing solids but over recent weeks has also been having difficulty swallowing liquids. In addition to his swallowing problems he has lost over a stone in weight.
On examination, he looks thin and slightly pale.
What is the most likely diagnosis?Your Answer: Oesophageal cancer
Explanation:Possible Diagnosis for Dysphagia in a 60-Year-Old Patient
There are several factors that may suggest a diagnosis of oesophageal cancer in a patient in their 60s who presents with dysphagia. The gradual difficulty in swallowing solids and then liquids is a common symptom as the cancer grows and obstructs the oesophagus. Weight loss and pallor are also frequently observed due to cachexia and anaemia.
Achalasia, on the other hand, is a condition characterized by abnormal peristalsis and lack of lower oesophageal sphincter relaxation. It is most common in the third to fifth decades and presents with intermittent dysphagia, which is more pronounced for solids than liquids. Oesophageal cancer, however, tends to cause a more rapid and progressive dysphagia.
Chagas’ disease, caused by Trypanosoma cruzi spread by reduviid bugs, is not commonly seen in the United Kingdom but can cause a clinical picture similar to achalasia when it affects the oesophagus. GORD can also result in oesophageal stricture and dysphagia, but this is usually due to chronic reflux, and the history is relatively short. Finally, a pharyngeal pouch typically presents with dysphagia, halitosis, a neck lump, and regurgitation of undigested food.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 45-year-old man with a history of GORD symptoms presents to the clinic after a three month trial of omeprazole 20 mg. Further investigations have revealed that he has a hiatus hernia. The decision is made to continue his omeprazole treatment and he is advised to lose weight as his BMI is 32.
Despite losing 5 kg over the past six months, he has visited the clinic twice for antibiotics due to lower respiratory tract infections. He has also been experiencing a nocturnal cough and possible asthma symptoms. What is the best course of action for managing his condition?Your Answer: Advise him to prop up the head of the bed at night
Correct Answer: Increase his omeprazole to 40 mg
Explanation:Indications for Surgical Repair of Hiatus Hernia
Indications for surgical repair of hiatus hernia include recurrent respiratory tract infection due to reflux. It is also considered in patients who have a para-oesophageal hernia because of the risk of strangulation.
Given this patient’s young age and the fact that he has attended twice in six months with symptoms of respiratory tract infection, surgical referral for laparoscopic fundoplication is advised. This procedure can help alleviate symptoms of reflux and prevent further respiratory tract infections. It is important to consider surgical intervention in cases where conservative management has failed or when there is a risk of complications such as strangulation. Proper evaluation and management of hiatus hernia can improve the quality of life for patients and prevent potential complications.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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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: <10%
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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This question is part of the following fields:
- Gastroenterology
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Question 5
Incorrect
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A 56-year-old Polish waitress has come to see you for review. She has visited the surgery on several occasions over the preceding 12 months complaining of abdominal pain. She was initially treated with PPI, but on her most recent review one of your colleagues felt that she had IBS and gave her an antispasmodic.
Unfortunately, her pain persists and is continuous. Her appetite is poor since starting the antispasmodic and she is complaining that she is putting on weight because she is having difficulty doing up her skirt. On further questioning, she has been slightly constipated in recent months and passing urine more frequently.
Her mother and sister died of breast cancer aged 52 and 43 respectively and many family members have had renal calculi.
On examination, she appears anxious but there is no clinical evidence of anaemia or jaundice. She weighs 66 kg but there are no previous recordings for comparison. Her abdomen is soft and there are no masses. There is tenderness in the left iliac fossa and suprapubic area. Rectal examination is normal.
How would you manage this patient?Your Answer: Perform a pelvic examination and blood test for CA125
Correct Answer: Dipstick her urine and refer for renal ultrasound if positive for blood
Explanation:Detecting Ovarian Cancer: A Challenging Diagnosis
Detecting ovarian cancer can be a challenging diagnosis as the symptoms are often vague, especially in the early stages of the disease. However, there are certain risk factors and cardinal symptoms that can help in identifying the disease. Women with a family history of breast cancer, carriers of the BRCA1 and BRCA2 gene, and Polish women are at an increased risk of ovarian cancer. Patients presenting with persistent bloating, abdominal or pelvic pain, and difficulty in eating or fullness after eating small quantities of food should be evaluated for ovarian cancer.
NICE recommends that women over the age of 50 who have one or more symptoms associated with ovarian cancer occurring more than 12 times a month or for more than a month should be offered CA125 testing. If the CA125 is 35 IU/mL or greater, an urgent ultrasound scan of the pelvis should be arranged. Therefore, performing a pelvic examination and arranging testing for CA125 is the most appropriate way forward for patients with symptoms suggestive of ovarian cancer. Early detection and prompt treatment can improve the prognosis of ovarian cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Correct
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A 58-year-old woman comes to her General Practitioner with complaints of diarrhoea without any associated bleeding. She has also experienced weight loss and has abdominal pain with malaise and fever. During the examination, she has oral ulcers, sore red eyes and tender nodules on her shins. There is tenderness in the right iliac fossa and a vague right iliac fossa mass. What is the most probable diagnosis?
Your Answer: Crohn's disease
Explanation:Possible Diagnoses for a Patient with Gastrointestinal Symptoms and Other Complications
Crohn’s Disease, Appendicular Abscess, Ileocaecal Tuberculosis, Ovarian Cyst, and Ulcerative Colitis are possible diagnoses for a patient presenting with gastrointestinal symptoms and other complications. In women over 60 years of age, Crohn’s disease may even be the most likely diagnosis. This condition can cause episcleritis, uveitis, erythema nodosum, pyoderma gangrenosum, vasculitis, gallstones, kidney stones, or abnormal liver function tests. The predominantly right-sided symptoms suggest terminal ileitis, which is more common in Crohn’s disease than ulcerative colitis. Fever can occur in Crohn’s disease due to the inflammatory process, ranging from high fever during acute flare-ups to persistent low-grade fever. Appendicular abscess is a complication of acute appendicitis, causing a palpable mass in the right iliac fossa and fever. Ileocaecal tuberculosis can present with a palpable mass in the right lower quadrant and complications of obstruction, perforation, or malabsorption, especially in the presence of stricture. A large ovarian cyst may be palpable on abdominal examination, but it is unlikely to cause oral ulcers, sore eyes, or erythema nodosum. Ulcerative colitis, which has similar clinical features to Crohn’s disease, is usually diagnosed from the biopsy result following a sigmoidoscopy or colonoscopy. However, rectal bleeding is more common in ulcerative colitis, while fever is more common in Crohn’s disease. A right lower quadrant mass may be seen in Crohn’s disease but not in ulcerative colitis unless complicated by bowel cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Incorrect
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A 48-year-old woman presents to her General Practitioner with a 3-week history of intermittent rectal bleeding. She says she doesn't usually look but has noticed blood within her stools on several occasions over the past few weeks. She is a non-smoker and is normally fit and well, with no significant family history or past medical history. A diagnosis of colonic carcinoma is suspected.
Which of the following presenting symptoms would most support this diagnosis?
Your Answer: Macrocytic anaemia
Correct Answer: Abdominal pain
Explanation:Symptoms and Possible Underlying Pathologies: A Case Study
Abdominal pain, abdominal bloating, alternating diarrhea and constipation, macrocytic anemia, and mucous per rectum are all symptoms that can indicate different underlying pathologies. In the case of a patient under 50 years old presenting with rectal bleeding, abdominal pain may suggest a more serious underlying pathology, such as colorectal cancer. According to NICE guidance, a suspected cancer pathway referral should be considered in such cases. Abdominal bloating, on the other hand, is more likely to be a symptom of irritable bowel disease. Alternating diarrhea and constipation, as well as mucous per rectum, are indicators of functional bowel disorders, such as irritable bowel syndrome. Finally, macrocytic anemia, while not associated with colorectal cancer, may warrant further investigation if found. Understanding the different symptoms and their possible underlying pathologies is crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 8
Incorrect
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You are evaluating a 45-year-old woman with a 20-year history of Crohn's disease. She has been experiencing frequent flares and is currently troubled by loose, bloody stools, abdominal pain, and weight loss. Perianal symptoms are particularly bothersome, with severe pain during bowel movements due to nasty anal fissures. Additionally, she has multiple aphthous ulcers in her mouth, making eating and drinking painful. She is a smoker and has a past medical history of osteoporosis and psoriasis.
What is a correct statement regarding Crohn's disease in this patient?Your Answer: Smoking is not a risk factor for Crohn's disease
Correct Answer: Patients with perianal disease have a worse prognosis
Explanation:Psoriasis is an extraintestinal manifestation that is not associated with the activity of the disease.
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.
To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.
Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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A 35-year-old man with a known diagnosis of ulcerative colitis presents with a 5 day history of worsening symptoms. He has been having six episodes of uncomfortable bloody stools per day which is an increase compared to his regular bowel habits. Observations in clinic are stable but he is concerned that oral mesalazine is not controlling his disease.
What would be an appropriate medication to add in order to gain better control of his symptoms?Your Answer:
Correct Answer: Oral prednisolone
Explanation:If a patient with mild-moderate ulcerative colitis doesn’t respond to topical or oral aminosalicylates, the next step is to add oral corticosteroids. In this case, the patient is experiencing 5 bloody stools per day and is already taking mesalazine. Therefore, oral steroids are recommended for flare-ups, but they are not used for maintaining remission.
Anti-motility drugs like loperamide should not be used as they may increase the risk of toxic megacolon. Metronidazole is not necessary as there is no indication of an infection.
Intravenous hydrocortisone is not needed as the patient’s condition is stable and hospitalization is not required at this time. Severe exacerbation is typically defined as passing more than 6-8 episodes of bloody stools per day.
Although it is important to manage the patient’s discomfort, oral NSAIDs should be avoided as they can worsen colitis symptoms. Paracetamol is the preferred 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.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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You see an obese 40-year-old gentleman who was incidentally found to have fatty infiltration in his liver while being investigated for a slightly raised ALT. His other blood tests were unremarkable. He is known to have type 2 diabetes and is on metformin 500 mg OD. He doesn't drink alcohol. He is otherwise well in himself.
What would be the next most appropriate management step?Your Answer:
Correct Answer: Refer to hepatology
Explanation:Management of Non-Alcoholic Fatty Liver Disease
Patients with non-alcoholic fatty liver disease (NAFLD) should be assessed for the risk of advanced liver fibrosis using a non-invasive scoring system such as the Fibrosis (FIB)-4 Score, according to NICE guidelines. While obesity and metformin use may contribute to NAFLD, changes to glycaemic control should not be made without knowing the patient’s current status. Referral to hepatology is indicated if there is evidence of advanced liver disease or high risk of advanced liver fibrosis based on scoring. Hepatology can perform specialist investigations such as transient elastography and liver biopsy. Additional blood tests, including a liver screen, may be helpful, but an isolated repeat LFT would not be the next most important step in management.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 12
Incorrect
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 65-year-old lady came in with complaints of heartburn. She has a history of osteoporosis and has been on alendronate for several years.
What is the probable reason for her symptoms?Your Answer:
Correct Answer: Ischaemic heart disease
Explanation:Side Effects of Oral Bisphosphonates
Oral bisphosphonates can cause serious side effects in some patients, including esophagitis, gastritis, and diarrhea. However, when used as directed, these complications are rare. Patients with pre-existing esophageal conditions, such as achalasia, stricture, Barrett’s esophagus, severe reflux, and scleroderma, should avoid taking oral bisphosphonates.
Interestingly, if patients experience gastrointestinal side effects while taking bisphosphonates, treatment with proton pump inhibitors (PPIs) is often ineffective. The only way to alleviate these symptoms is by discontinuing the use of bisphosphonates. It is important for patients to discuss any concerns or pre-existing conditions with their healthcare provider before starting treatment with oral bisphosphonates.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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You come across a 30-year-old accountant who has been diagnosed with Crohn's disease after experiencing abdominal pain, loose stools and a microcytic anaemia. The individual is seeking further information on the condition.
Which of the following statements is accurate regarding Crohn's disease?Your Answer:
Correct Answer: Osteoporosis occurs in up to 30% of patients with inflammatory bowel disease
Explanation:Upon diagnosis, approximately 66% of individuals with inflammatory bowel disease exhibit anaemia. Crohn’s disease is typically diagnosed at a median age of 30 years. The global incidence and prevalence of Crohn’s disease are on the rise.
Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.
If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Incorrect
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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A 45-year-old woman is discharged from hospital following a haematemesis with a diagnosis of NSAID-induced gastric ulcer. She has taken ibuprofen regularly for pain relief and has found it effective, while finding paracetamol has been ineffective. She is taking 10 mg esomeprazole a day. She has a history of osteoarthritis and hypertension.
What is the most appropriate analgesia to prescribe this patient?Your Answer:
Correct Answer: Tramadol
Explanation:Choosing the Right Pain Medication for a Patient with Rheumatoid Arthritis and a History of Myocardial Infarction
When selecting a pain medication for a patient with rheumatoid arthritis and a history of myocardial infarction, it is important to consider the potential cardiovascular and gastrointestinal risks associated with each option. Tramadol is often the drug of choice due to its lower risk of cardiovascular and gastrointestinal problems, but it may still cause toxicity in some patients. Celecoxib, a cyclo-oxygenase-2 selective inhibitor, carries a lower risk of gastrointestinal side-effects but should be avoided in patients with a history of thrombotic events. Diclofenac and misoprostol carry an intermediate risk of gastrointestinal side-effects and increase the risk of thrombotic events. Ibuprofen and naproxen have lower gastrointestinal risks, but their use may be problematic in patients taking antiplatelet medication. Ultimately, the choice of pain medication should be made on a case-by-case basis, taking into account the patient’s individual medical history and risk factors.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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A 70-year-old woman comes to the clinic complaining of upper abdominal bloating and discomfort after meals that has been going on for three months. She reports feeling nauseated at times but denies vomiting. She has lost more than 1 stone in weight. She has not experienced any changes in bowel habits and has not passed any blood in her stools. She has no significant medical history.
During the physical examination, there is no evidence of jaundice or anemia, but she has diffuse upper abdominal tenderness, and her gallbladder is palpable on inspiration. A previous abdominal ultrasound scan conducted ten years ago revealed the presence of an incidental gallstone, but she did not undergo surgery as she was asymptomatic at the time. There is a strong family history of gallstones.
What is the most appropriate course of action?Your Answer:
Correct Answer: Routine referral for consideration of cholecystectomy
Explanation:Understanding Gallbladder Cancer and its Risk Factors
Gallbladder cancer is a rare form of cancer that often goes undiagnosed until it has reached an advanced stage. It is more common in women, especially those with a history of gallstones, and those who have a family history of the disease. Other risk factors include smoking, obesity, and diabetes. Native Americans, black, and Hispanic populations are also at a higher risk of developing Gallbladder cancer.
Symptoms of Gallbladder cancer can be vague and mimic benign disease, making it difficult to diagnose. However, unintentional weight loss is a red flag and should be taken seriously. Most Gallbladder tumors are adenocarcinomas and can spread to the liver and lungs. By the time symptoms appear, the cancer has often metastasized, and more than half of patients present with jaundice.
It is important to have a high index of suspicion for Gallbladder cancer, especially in patients with risk factors. Even if the abdominal examination is normal, significant weight loss should prompt urgent referral for investigation under the two week wait system. By understanding the risk factors and symptoms of Gallbladder cancer, healthcare professionals can help ensure early detection and treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Incorrect
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A 65-year-old man with coronary artery disease visits his General Practitioner after an abdominal ultrasound reveals an easily felt epigastric pulsation. The ultrasound shows a normal calibre abdominal aorta without aneurysm, but incidentally finds gallstones. The patient has never experienced biliary colic or jaundice and has a normal body mass index with no history of abdominal surgery.
What is the most appropriate treatment for this patient?Your Answer:
Correct Answer: No treatment
Explanation:Treatment Options for Asymptomatic Cholelithiasis
Asymptomatic cholelithiasis, or gallstones without any symptoms, doesn’t require therapeutic intervention. In fact, up to 70% of patients with gallstones are asymptomatic at the time of diagnosis. The risk of prophylactic cholecystectomy, or removal of the gallbladder, is greater than the benefit likely to be gained by removal. However, in a partially calcified ‘porcelain’ gallbladder, removal may be recommended to prevent pancreatitis or cholangitis.
Open cholecystectomy, a surgical procedure with a longer recovery time and higher risk of complications, is often reserved for patients where laparoscopy is a higher risk. Endoscopic removal of stones is not suitable for asymptomatic cholelithiasis as it doesn’t remove the gallbladder or stones within it.
If the patient becomes symptomatic, laparoscopic cholecystectomy would be the treatment of choice. However, for asymptomatic patients, the risks of a procedure outweigh the potential benefits of preventing future complications. Lithotripsy, a procedure that breaks up gallstones, is not routinely recommended for the treatment of any gallstones due to the risk of complications.
Treatment Options for Asymptomatic Cholelithiasis
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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A 40-year-old patient with epilepsy that is currently managed with phenytoin presents to his General Practitioner. He has recently been taking oral flucloxacillin for a leg injury that was precipitated by a recent fit. The patient occasionally drinks alcohol and has been taking paracetamol for pain relief after his leg injury. Clinical examination reveals jaundice; however, his abdomen is non-tender. Liver function tests are shown below.
Investigation Result Normal value
Bilirubin 280 μmol/l 1–22 μmol/l
Alkaline phosphatase (ALP) 440 U/l 45–105 U/l
Gamma-glutamyltransferase (GGT) 320 U/l 11–50 U/l
Alanine aminotransferase (ALT) 46 U/l < 35 U/l
What is the most likely cause of this patient’s jaundice?Your Answer:
Correct Answer: Flucloxacillin
Explanation:Causes of Jaundice: Identifying the Culprit in a Clinical Case
In this clinical case, a patient presents with jaundice and abnormal liver function tests. The following potential causes are considered:
Flucloxacillin: The patient’s presentation is consistent with cholestatic jaundice, which can be caused by flucloxacillin. Other drugs that can cause a similar picture include chlorpromazine, azathioprine, captopril, ciclosporin, penicillamine, erythromycin, and the combined oral contraceptive.
Ethanol: Although the patient reports occasional alcohol use, ethanol is an unlikely cause of cholestatic jaundice. Ethanol more commonly causes a hepatitic picture with elevated transaminase levels.
Gallstones: Cholecystitis typically doesn’t cause jaundice. If gallstones were the cause, right upper quadrant pain and tenderness would be expected.
Paracetamol: The patient is taking paracetamol, but there is no information about excessive use. Paracetamol overdose typically causes a hepatitic picture rather than cholestatic jaundice.
Phenytoin: Phenytoin typically causes a hepatitic picture with larger elevations in transaminase levels and a smaller rise in ALP levels.
In conclusion, flucloxacillin is the most likely cause of this patient’s cholestatic jaundice.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 32-year-old male with type 1 diabetes attends for diabetic annual review. He complains of feeling tired all the time stretching back several months.
Blood tests performed prior to the review appointment show normal renal, liver, and thyroid function; testosterone levels are normal. Full blood count reveals a modest anaemia with:
Haemoglobin 109 g/L (130-180)
MCV 79 fL (80-96)
HbA1c 50 mmol/mol (20-42)
Urine dipstick testing is normal with no ketones. Review of fingerprick blood sugars shows blood sugars consistently in single figures.
Clinical examination is unremarkable.
On further enquiry the patient denies any gastrointestinal symptoms. He is opening his bowels regularly with no change in bowel habit. There is no history of PR blood or mucous. His weight is stable. He denies abdominal pain or bloating. He follows a 'normal' diet. There is no known family history of gastrointestinal pathology or malignancy.
You request some further blood tests which confirm iron deficiency anaemia.
Which of the following is the most appropriate next approach?Your Answer:
Correct Answer: Perform serological testing for coeliac disease
Explanation:Serological Testing for Coeliac Disease
Serological testing for coeliac disease should be considered for individuals presenting with certain symptoms such as chronic diarrhoea, unexplained weight loss, and persistent fatigue. Additionally, those with autoimmune thyroid disease, irritable bowel syndrome, and type 1 diabetes should also be offered testing as they are at increased risk for coeliac disease. NICE guidance recommends testing for individuals with unexplained abdominal symptoms, mouth ulcers, and vitamin deficiencies, as well as first-degree relatives of those with coeliac disease. Coeliac disease is associated with a variety of conditions, including depression, epilepsy, and reduced bone mineral density, among others. In the case of a man with type 1 diabetes and iron deficiency anaemia, serological testing for coeliac disease would be the next appropriate step.
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This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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A 32-year-old woman presents to her General Practitioner three weeks after an Eastern Mediterranean holiday with her family, during which they ate out a lot. She complains of malaise, lack of appetite, jaundice and dark urine. She thinks she was febrile at the start, but the fever subsided once the jaundice appeared. On examination, she has a palpable liver and is tender in the right upper quadrant.
Investigations:
Investigation Result Normal value
Bilirubin 132 µmol /l < 21 µmol/l
Alanine aminotransferase (ALT) 4104 IU/l < 40 IU/l
Aspartate aminotransferase (AST) 3476 U/l < 33 U/l
Alkaline phosphatase (ALP) 184 IU/l 40–129 IU/l
What is the single most likely diagnosis?
Your Answer:
Correct Answer: Hepatitis A
Explanation:Differential Diagnosis for a Patient with Flu-like Symptoms and Jaundice
Hepatitis A is a vaccine-preventable infection commonly acquired during travel. It spreads through contaminated food and presents with flu-like symptoms followed by jaundice and dark urine. Biliary colic may cause right upper quadrant pain but is unlikely to cause fever or significantly raised liver transaminase levels. Hepatitis B is transmitted through sexual contact, needle sharing, blood transfusions, organ transplantation, or from mother to child during delivery. Pancreatic carcinoma presents with weight loss, obstructive jaundice, mid-epigastric or back pain, and disproportionately raised alkaline phosphatases levels. Salmonella enteritidis causes food poisoning with diarrhea, fever, and colicky abdominal pain.
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This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 32-year-old stock-market trader presents with an 8 week history of upper abdominal pain that comes on in the evening and also wakes him up in the early hours of the morning. His symptoms are relieved by food and milk.
Select the single most likely diagnosis from the list below.Your Answer:
Correct Answer: Peptic ulcer disease
Explanation:Common Gastrointestinal Disorders and their Symptoms
Peptic ulcer disease, chronic pancreatitis, cirrhosis, gallstones, and reflux oesophagitis are some of the most common gastrointestinal disorders. Peptic ulcers are often caused by non-steroidal anti-inflammatory drugs, alcohol, tobacco consumption, and Helicobacter pylori. The main symptom is epigastric pain, which is characterised by a gnawing or burning sensation and occurs after meals. Relief by food and alkalis is typical of duodenal ulcers, while food and alkalis provide only minimal relief in gastric ulcers.
Chronic pancreatitis causes intermittent attacks of severe pain, often in the mid-abdomen or left upper abdomen, and may be accompanied by diarrhoea and weight loss. Cirrhosis is often asymptomatic until there are obvious complications of liver disease, such as coagulopathy, ascites, variceal bleeding, or hepatic encephalopathy. Gallstones cause biliary colic, which is characterised by sporadic and unpredictable episodes of pain localised to the epigastrium or right upper quadrant. Obstructive jaundice may occur, and localising signs may be absent unless cholecystitis complicates the situation.
Reflux oesophagitis typically presents with heartburn, upper abdominal discomfort, regurgitation, and chest pain. There is no clear evidence to suggest that the stress of modern life or a steady diet of fast food causes ulcers. It is important to seek medical attention if any of these symptoms persist or worsen.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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A 40-year-old woman is experiencing fatigue and frequent bowel movements. Upon testing, it is found that she has positive anti-endomysial antibodies. Which of the following food items should she avoid, except for one?
Your Answer:
Correct Answer: Maize
Explanation: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.
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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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A 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21 μmol/l). He has suffered from episodic jaundice in the past but is otherwise fit and well. His diagnosis is Gilbert syndrome.
Which of the following is associated with Gilbert syndrome?
Your Answer:
Correct Answer: γ-glutamyltransferase in the normal range
Explanation:Understanding Gilbert Syndrome: Symptoms, Risks, and Diagnosis
Gilbert syndrome is a common, benign condition that causes mild unconjugated hyperbilirubinaemia. It is familial and occurs in 5-10% of adults in Western Europe. While some patients may experience symptoms such as fatigue, nausea, and abdominal pain, many are asymptomatic. Jaundice is usually mild and can worsen with physical exertion, fasting, or dehydration. However, liver function tests, including γ-glutamyltransferase, should be normal.
Unlike other liver conditions, Gilbert syndrome doesn’t cause abnormal liver histology or conjugated hyperbilirubinaemia. It is also not a risk factor for kernicterus at birth.
Diagnosis of Gilbert syndrome is based on clinical presentation and elevated unconjugated bilirubin levels. Fasting can actually increase bilirubin levels in this condition. Therefore, it is important to rule out other liver disorders if abnormal liver function tests or histology are present.
Overall, understanding the symptoms, risks, and diagnosis of Gilbert syndrome can help healthcare providers provide appropriate care and management for patients with this condition.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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A 14-month old infant presents with episodes of severe colic, associated with pallor and drawing of the legs upwards. This has been going on for several weeks.
The mother has brought the child to see you because she noticed that there seemed to be blood and mucous in the stool yesterday.
On examination there is a sausage-shaped mass palpable on the right side of the abdomen.
What is the diagnosis?Your Answer:
Correct Answer: Hirschsprung's disease
Explanation:Intussusception: A Common Cause of Intestinal Obstruction in Infants
Intussusception is a condition where a section of the bowel folds into itself, causing an obstruction. It is most commonly seen in infants over one month old, with the typical age of presentation being between two months to two years. The most common site of intussusception is the ileum passing into the caecum/colon through the ileocaecal valve.
Symptoms of intussusception include severe colic, pallor, and drawing of legs upwards during episodes of pain. A sausage-shaped mass may be palpable in the abdomen, and parents may notice the passage of a redcurrant jelly stool (blood-stained mucous). In severe cases, children may present with abdominal distention and shock.
The cause of intussusception is not always clear, but viral infections causing enlargement of Peyer’s patches have been implicated in forming a lead point for the development of intussusception. In children over the age of two, a specific lead point (such as a Meckel’s diverticulum or polyp) is more likely.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Incorrect
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A 35-year-old woman has chronic pancreatitis. She has lost weight and has diarrhoea that has become troublesome.
Select from the list the single most suitable preparation to relieve her diarrhoea.Your Answer:
Correct Answer: Pancreatin
Explanation:Gastrointestinal Medications: Pancreatin, Cholestyramine, Loperamide, Co-Phenotrope, and Ispaghula Husk
Pancreatin is a combination of digestive enzymes produced by the pancreas that aid in the breakdown of protein, fat, and starch. It is commonly used to treat conditions where the pancreas is not producing enough enzymes, such as pancreatitis, cystic fibrosis, or after surgical removal of the pancreas. Pancreatin should be taken with food or with medications that reduce stomach acid.
Cholestyramine is a medication that binds to bile in the gut, preventing its reabsorption. It is primarily used to treat itching in patients with advanced liver disease and to prevent diarrhea in individuals with Crohn’s disease who have had a portion of their small intestine removed.
Loperamide and co-phenotrope are anti-motility drugs that can be used to treat uncomplicated acute diarrhea in adults. These medications slow down the movement of the gut, allowing for more water to be absorbed and reducing the frequency of bowel movements.
Ispaghula husk is a bulk-forming laxative that absorbs water in the gut, increasing the bulk of stool and promoting regular bowel movements. It is commonly used to treat constipation and other bowel irregularities.
Overall, these medications can be effective in treating a variety of gastrointestinal conditions and symptoms. However, it is important to consult with a healthcare provider before starting any new medication.
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This question is part of the following fields:
- Gastroenterology
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Question 27
Incorrect
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A 28-year-old man known to have diffuse ulcerative colitis for which he takes mesalazine 1.5g daily has an exacerbation. He is passing up to 10 loose stools per day with blood. He is feeling unwell, appears mildly dehydrated and anaemic.
Select from the list the single most appropriate initial management option.Your Answer:
Correct Answer: Admit to hospital
Explanation:Treatment Options for Inflammatory Bowel Disease Exacerbations
Inflammatory bowel disease (IBD) can cause severe exacerbations that require hospitalization for fluid and electrolyte replacement, transfusion, and possibly intravenous corticosteroids. However, for less severe exacerbations of diffuse disease, there are other treatment options available.
One option is to increase the dose of mesalazine, which is an anti-inflammatory medication commonly used to treat IBD. Another option is to take oral prednisolone, which is a steroid medication that can help reduce inflammation in the gut.
For those with proctitis or distal disease, prednisolone enemas may be used as a treatment option. These enemas are administered directly into the rectum and can help reduce inflammation in the lower part of the colon.
Overall, the treatment options for IBD exacerbations depend on the severity and location of the disease. It is important to work closely with a healthcare provider to determine the best course of treatment for each individual case.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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You receive a positive faecal immunochemical test (FIT) result following investigation of an elderly patient's unexplained abdominal pain.
What would be the most appropriate next step in your management?Your Answer:
Correct Answer: Refer using a suspected lower gastrointestinal cancer pathway
Explanation:Faecal Occult Blood Tests for Colorectal Cancer
Faecal occult blood tests are recommended by NICE for patients who show symptoms that may suggest colorectal cancer but are unlikely to have the disease. If the test result is positive, patients should be referred through the suspected cancer pathway. However, a positive result may also indicate other conditions such as colorectal polyps or inflammatory bowel disease.
It is important to note that there is no need to repeat the FIT or order further investigations before referral. This test is a simple and effective way to detect early signs of colorectal cancer and can help healthcare professionals make informed decisions about patient care.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 32-year-old woman comes to her General Practitioner complaining of constipation that has persisted since her last pregnancy two years ago. She has been using laxatives for the past few months. She reports no abdominal pain or diarrhoea and has not noticed any triggers or alleviating factors. Her weight is stable and she has not observed any blood in her stools. She is in good health otherwise.
What is the most probable diagnosis?Your Answer:
Correct Answer: Idiopathic constipation
Explanation:Possible Causes of Chronic Constipation: A Differential Diagnosis
Chronic constipation is a common condition affecting approximately 14% of the global population. While most cases do not require investigation, it is important to consider potential underlying causes in certain patients. Here are some possible diagnoses to consider:
1. Idiopathic constipation: This is the most common cause of chronic constipation, especially in young patients. A high-fiber diet and physical activity can help alleviate symptoms.
2. Diverticular disease: This condition is characterized by abdominal pain and diarrhea, but it usually presents later in life and chronic constipation is a risk factor.
3. Colon cancer: While chronic constipation can be a symptom of colon cancer, other factors such as weight loss and rectal bleeding are usually present. This diagnosis is unlikely in younger patients.
4. Hypothyroidism: Constipation can be a symptom of an underactive thyroid, but other symptoms such as weight gain and fatigue are usually present.
5. Irritable bowel syndrome (IBS): IBS can cause constipation and/or diarrhea, but it is usually associated with abdominal pain and bloating.
In summary, chronic constipation can have various underlying causes, and a careful history and physical examination can help determine the appropriate diagnostic approach.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 31
Incorrect
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You see a 32-year-old man who has recently been diagnosed with Crohn's disease. He presented with frequent and loose stools, with occasional blood and mucous. He is otherwise fit and well. His only other past medical history is appendicitis as a 16-year-old.
He has been reviewed by a gastroenterologist and is on a reducing dose of corticosteroid.
Can you provide him with more information about Crohn's disease?Your Answer:
Correct Answer: The risk of Crohn's disease increases early after an appendicectomy
Explanation:Smoking increases the likelihood of developing Crohn’s disease.
Experiencing infectious gastroenteritis raises the risk of developing Crohn’s disease by four times, especially within the first year.
The chances of developing Crohn’s disease are higher in the early stages after having an appendicectomy.
Crohn’s disease affects both genders equally, with no significant difference in occurrence rates.
Understanding Crohn’s Disease
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.
Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include nonspecific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.
To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.
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This question is part of the following fields:
- Gastroenterology
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Question 32
Incorrect
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A 50-year-old man with type 2 diabetes presents for review. He reports feeling well and having recently undergone foot and optometrist checks. He enjoys drinking alcohol on the weekends, limiting himself to 4-5 standard drinks each Saturday. His HbA1c remains stable at 48 mmol/L while taking metformin. However, his liver function tests reveal the following results:
Bilirubin: 18 µmol/L (3 - 17)
ALP: 95 u/L (30 - 100)
ALT: 157 u/L (3 - 40)
γGT: 40 u/L (8 - 60)
AST: 74 u/L (3 - 40)
Albumin: 37 g/L (35 - 50)
What is the most likely cause of these findings?Your Answer:
Correct Answer: Non-alcoholic fatty liver disease
Explanation:Non-alcoholic fatty liver disease is the most common cause of abnormal liver function tests (LFT) in patients with type 2 diabetes. This condition is prevalent in developed countries and should be assessed through a reassessment of the patient’s LFTs and an ultrasound if necessary. The patient’s weekend drinking habits are not significant enough to suggest alcoholic liver disease as the cause of the LFT derangement. Drug-induced liver injuries (DILI) are not predictable and can present with various LFT changes, including cholestatic and mixed patterns. Gallstone disease is more common in overweight fertile females and presents with a cholestatic pattern of LFT derangement. Viral hepatitis is a possible cause but not the most likely answer in this case. A liver screen may be necessary if the LFT derangement persists without explanation from an ultrasound.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 33
Incorrect
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A very sensible parent brings her 9-year-old into the surgery for review. She is concerned as her child is complaining of recurrent episodes of dull abdominal pain and missing significant days off school. Your physical examination is entirely normal.
What would count most against a diagnosis of functional recurrent abdominal pain in this case?Your Answer:
Correct Answer: Above average intellectual ability
Explanation:Recurrent Abdominal Pain in Children
Recurrent abdominal pain is a common complaint among children over the age of five, with approximately 10% experiencing it. It is crucial to determine the nature of the pain, its impact on the child’s daily life, and how the child and their family cope with it. Organic causes, such as gastrointestinal, urological, haematological, and miscellaneous causes, must be ruled out. Non-organic pain is suggested by peri-umbilical pain, and vomiting may be present, but weight loss is rare. Other important questions to ask include the timing of the pain, associated symptoms, family history, and social history. Physical examination is often unhelpful, and investigations are unlikely to provide a diagnosis when non-organic pain is suspected.
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This question is part of the following fields:
- Gastroenterology
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Question 34
Incorrect
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A 48-year-old man visits his doctor, reporting an increase in breast size over the past few years. He has alcoholic cirrhosis and continues to consume one bottle of vodka daily. He is prescribed furosemide for oedema but takes no other medications.
What is the probable reason for this patient's gynaecomastia?Your Answer:
Correct Answer: Altered oestrogen metabolism
Explanation:Understanding the Causes of Gynaecomastia in Cirrhosis
Gynaecomastia in cirrhosis is a complex condition with various potential causes. One of the most likely culprits is the disordered metabolism of sex steroids, which can result in excess levels of oestrogens. As liver function decreases, plasma testosterone concentrations also decrease, often leading to associated symptoms such as testicular atrophy and loss of body hair.
While furosemide is not typically associated with gynaecomastia, spironolactone therapy used in cirrhosis treatment can be a contributing factor. Excess energy intake from alcohol is also a common issue in alcohol-related cirrhosis, as patients may substitute alcohol for food and suffer from nutritional deficiencies.
Although bodybuilders taking anabolic steroids may report gynaecomastia, there is no indication in the patient’s history to suggest this as a cause. Additionally, it is important to note that low testosterone levels, rather than excess levels, are typically associated with gynaecomastia. By understanding the various potential causes of this condition, healthcare professionals can better diagnose and treat gynaecomastia in cirrhosis patients.
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This question is part of the following fields:
- Gastroenterology
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Question 35
Incorrect
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Each one of the following is a recognised complication of gastro-oesophageal reflux disease, except:
Your Answer:
Correct Answer: Achalasia
Explanation:Managing Gastro-Oesophageal Reflux Disease
Gastro-oesophageal reflux disease (GORD) is a condition where gastric contents cause symptoms of oesophagitis. If GORD has not been investigated with endoscopy, it should be treated according to dyspepsia guidelines. However, if oesophagitis is confirmed through endoscopy, full dose proton pump inhibitors (PPIs) should be given for 1-2 months. If there is a positive response, low dose treatment may be given as required. If there is no response, double-dose PPIs should be given for 1 month.
For endoscopically negative reflux disease, full dose PPIs should be given for 1 month. If there is a positive response, low dose treatment may be given on an as-required basis with a limited number of repeat prescriptions. If there is no response, H2RA or prokinetic should be given for one month.
Complications of GORD include oesophagitis, ulcers, anaemia, benign strictures, Barrett’s oesophagus, and oesophageal carcinoma. It is important to manage GORD effectively to prevent these complications.
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This question is part of the following fields:
- Gastroenterology
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Question 36
Incorrect
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A 32-year-old woman presents to her General Practitioner complaining of long-standing intermittent abdominal distension and bloating, which changes with her menstrual cycle, and is interspersed with bouts of loose motions. She works as a teacher in a busy school and finds work stressful. She has previously taken a course of fluoxetine for depression or anxiety. Examination of the abdomen is normal.
What is the single most likely diagnosis?Your Answer:
Correct Answer: Irritable bowel syndrome
Explanation:Understanding Common Gastrointestinal Disorders: Differential Diagnosis
Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder affecting 10-20% of the UK population, with a higher incidence in females and those with underlying anxiety. Symptoms include abdominal pain or discomfort, bloating, and change in bowel habit lasting for at least six months. Defecation may provide relief, while eating can exacerbate symptoms. Other common symptoms include lethargy, nausea, backache, and bladder problems. Diagnosis is based on clinical presentation, as examination and investigations are typically normal.
Ulcerative colitis is a potential differential diagnosis if the patient presents with pain or blood in their stool. However, the long history of symptoms without significant systemic illness, normal examination, and links to stress/menstruation in this case suggest IBS. Normal inflammatory markers would support this diagnosis.
Chronic pancreatitis is characterized by persistent inflammation or damage, often linked to alcohol excess. The primary symptom is significant pain, which is not present in this case.
Diverticulitis is an acute presentation, with left iliac fossa pain, change in bowel habit, bleeding per rectum, and systemic illness. The chronic course, combination of symptoms, and normal examination make this diagnosis unlikely.
Peptic ulcer disease is also unlikely, as it typically causes pain linked to eating, nausea or vomiting, and is acute or progressive in nature. While stress can be a trigger, it is not the primary cause of this disorder.
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This question is part of the following fields:
- Gastroenterology
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Question 37
Incorrect
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A 56-year-old man comes to the clinic, having just returned from living in Canada. He tells you he had a colonoscopy six months earlier; a polyp in the ascending colon was removed and this was classified as a Dukes' B tumour. He wonders if he needs further checks according to current guidance for surveillance after resection of colorectal cancer. What would you advise him?
Your Answer:
Correct Answer: Serial carcinoembryonic antigen (CEA) monitoring
Explanation:Post-Treatment Surveillance Strategies for Colorectal Cancer: The Role of CEA Monitoring, Colonoscopy, and CT Scans
Carcinoembryonic antigen (CEA) is a protein that is elevated in the serum of patients with colorectal cancer. While not suitable for screening, CEA levels can be used to monitor disease burden and predict prognosis in patients with established disease. Additionally, elevated preoperative CEA levels should return to baseline after complete resection, and failure to do so may indicate residual disease. Serial CEA testing can also aid in the early detection of recurrences, which can increase the likelihood of a complete resection.
The National Institute for Health and Care Excellence recommends regular serum CEA tests (at least every six months in the first three years) and a minimum of two CT scans of the chest, abdomen, and pelvis in the first three years after treatment. Surveillance colonoscopy should be performed one year after initial treatment, and if normal, another colonoscopy should be performed at five years. The timing of colonoscopy after adenoma should be determined by the risk status of the adenoma.
While periodic colonoscopy is beneficial for detecting metachronous cancers and preventing further cancers via removal of adenomatous polyps, trials have failed to show a survival benefit from annual or shorter intervals compared to less frequent intervals (three or five years) for detecting anastomotic recurrences. Routine fecal occult blood testing is not recommended in post-treatment surveillance guidelines.
In summary, post-treatment surveillance strategies for colorectal cancer should include serial CEA monitoring, CT scans, and colonoscopy at recommended intervals. These strategies can aid in the early detection of recurrences and improve the likelihood of a complete resection.
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This question is part of the following fields:
- Gastroenterology
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Question 38
Incorrect
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 39
Incorrect
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A 50-year-old woman presents with anaemia on a routine blood test. Her haemoglobin is 96 g/L (115-165) and her MCV is 72 fL (80-96). Further blood tests reveal a ferritin of 8 µg/L (15-300) and negative coeliac serology. Haemoglobin electrophoresis is normal.
She denies any gastrointestinal symptoms, rectal bleeding, weight loss, haematuria or haemoptysis. Her menstrual cycle is regular with periods every 28 days. She reports heavy bleeding for five days followed by lighter bleeding for three days, which has been the case for several years. She doesn't consider her periods to be problematic.
Physical examination, including urine dipstick testing, is unremarkable.
What is the most appropriate next step?Your Answer:
Correct Answer: Start oral iron replacement
Explanation:Investigating Anaemia: Identifying and Treating Iron Deficiency
A new diagnosis of anaemia should prompt further investigation. A low mean corpuscular volume (MCV) suggests iron deficiency anaemia, which can be confirmed with a ferritin level test. However, it is important to note that ferritin levels may be falsely normal in the presence of an acute phase response. In such cases, iron studies may be useful. Once iron deficiency is confirmed, the underlying cause should be identified.
Patients with upper gastrointestinal symptoms or unexplained low haemoglobin levels require urgent referral for endoscopic gastrointestinal assessment. Coeliac serology and haemoglobin electrophoresis should also be considered to rule out coeliac disease and hereditary causes of microcytic anaemia, respectively.
In patients who do not require urgent referral, non-gastrointestinal blood loss and poor diet should be considered. Menstrual blood loss is a common cause of iron deficiency anaemia in menstruating women. In such cases, iron replacement therapy should be initiated, and haemoglobin levels should be monitored for improvement. If heavy menstrual bleeding is the cause, it should be treated, and if the patient doesn’t respond to iron supplementation, gastroenterology referral is appropriate.
In summary, identifying and treating iron deficiency anaemia requires a thorough investigation of the underlying cause. Prompt referral is necessary in certain cases, while others may require iron replacement therapy and monitoring.
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This question is part of the following fields:
- Gastroenterology
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Question 40
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 41
Incorrect
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A 30-year-old man who is typically healthy visits his GP complaining of indigestion that has persisted for 2 months. He has not experienced any weight changes or difficulty swallowing. Upon examination, there are no notable findings in the abdomen. What is the most appropriate initial course of action from the following choices?
Your Answer:
Correct Answer: One month course of a full-dose proton pump inhibitor
Explanation:The management of dyspepsia according to NICE guidelines doesn’t recommend a specific first-line approach between a one month course of a PPI or ‘test and treat’ strategy. However, testing for H pylori is preferred by some clinicians before initiating acid-suppression therapy as false-negative results may occur if done within 2 weeks. Therefore, only the answer that aligns with current NICE guidelines should be chosen.
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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This question is part of the following fields:
- Gastroenterology
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Question 42
Incorrect
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A 55-year-old man presents with persistent epigastric discomfort for the past 2 months. The discomfort worsens after meals and occasionally causes reflux symptoms when he lies down. Despite attempting to modify his diet, he has only experienced limited relief and has lost some weight, although he is unsure of the exact amount. He denies any difficulty swallowing or vomiting blood. He has tried over-the-counter gaviscon with little effect and is seeking further relief. Physical examination is unremarkable, with no evidence of an abdominal mass.
What is the most appropriate course of treatment for this patient?Your Answer:
Correct Answer: Urgent referral for endoscopy
Explanation:Weight loss with dyspepsia is a concerning symptom in individuals over 55 years old and warrants urgent referral for an endoscopy to identify any underlying pathology. Helicobacter pylori testing may not be the most appropriate option in this case. Symptomatic relief can be provided with proton-pump inhibitors or ranitidine, but they do not rule out any underlying pathology.
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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This question is part of the following fields:
- Gastroenterology
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Question 43
Incorrect
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A 30-year-old man with a history of chronic constipation presents with acute perianal pain. The pain has been present for a week and is exacerbated during defecation. He also notes a small amount of bright red blood on the paper when he wipes himself.
Abdominal examination is unremarkable but rectal examination is not possible due to pain.
What is the likely diagnosis?Your Answer:
Correct Answer: Fissure
Explanation:Understanding Fissures: Symptoms and Treatment
Perianal pain that worsens during defecation and is accompanied by fresh bleeding is a common symptom of fissures. However, due to the pain associated with rectal examination, visualizing the fissure is often not possible. Most fissures are located in the midline posteriorly and can be treated with GTN cream during the acute phase, providing relief in two-thirds of cases. Understanding the symptoms and treatment options for fissures can help individuals seek appropriate medical attention and manage their condition effectively.
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This question is part of the following fields:
- Gastroenterology
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Question 44
Incorrect
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A 42-year-old man undergoes occupational health screening blood tests. His anti-Hepatitis C virus (anti-HCV) test returns positive. On examination, he is feeling well with no signs of liver disease. He has no other comorbidities.
What is the most important next test to perform for this patient?
Your Answer:
Correct Answer: Hepatitis C (HCV) ribonucleic acid (RNA)
Explanation:Common Tests for Hepatitis C and Co-Infections
Hepatitis C (HCV) is a viral infection that affects the liver. There are several tests available to diagnose and monitor HCV, as well as to screen for co-infections with other viruses. Here are some of the most common tests used:
1. HCV RNA: This test detects the presence of HCV ribonucleic acid in the blood, which is the most sensitive way to diagnose HCV infection. It can detect the virus within 1-2 weeks after infection and can confirm ongoing infection if antibodies are positive.
2. HBV DNA: This test measures the amount of hepatitis B virus deoxyribonucleic acid in the blood, which can help monitor the viral load of hepatitis B. Since HBV and HCV can coexist, it’s important to screen for both viruses.
3. Anti-HIV antibodies: HIV and HCV share many of the same risk factors, so patients with HCV should be screened for HIV. However, it’s important to first confirm the diagnosis of HCV before testing for HIV.
4. AST and ALT: These enzymes are released into the bloodstream when the liver is damaged, which can indicate HCV infection. However, they are nonspecific and cannot confirm a diagnosis on their own.
5. IgM anti-HAV: This test detects recent infection with hepatitis A, which can coexist with HCV. However, confirming the diagnosis of HCV is the first priority.
Overall, these tests can help diagnose and monitor HCV, as well as screen for co-infections with other viruses. It’s important to work with a healthcare provider to determine the best testing strategy for each individual case.
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This question is part of the following fields:
- Gastroenterology
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Question 45
Incorrect
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A 56-year-old man visits his General Practitioner with a complaint of burning retrosternal pain. He has had this issue before and has treated it with over-the-counter remedies. He sometimes experiences food sticking. He smokes 20 cigarettes daily. During the examination, there is some epigastric tenderness, but only upon deep palpation. What is the best course of action for managing this patient?
Your Answer:
Correct Answer: Upper gastrointestinal (GI) endoscopy
Explanation:Management of Gastroesophageal Reflux Disease with Red-Flag Symptom
Gastroesophageal reflux disease (GORD) is a common condition that can be managed with lifestyle advice and medication. However, when red-flag symptoms such as dysphagia are present, urgent investigation is necessary to rule out oesophageal cancer.
The National Institute for Health and Care Excellence (NICE) recommends urgent direct-access upper gastrointestinal endoscopy within two weeks for people with dysphagia. Long-term reflux disease may lead to Barrett’s oesophagus, which requires surveillance endoscopy every two years.
Lifestyle advice is a key element in managing GORD, including weight loss, alcohol and smoking cessation, small regular meals, avoiding food and hot drinks before bedtime, and raising the head of the bed at night. Antacids are available over the counter but are not sufficient for red-flag symptoms. H2-antagonists are not the first-line treatment for reflux disease, and proton-pump inhibitors (PPIs) are more effective in relieving heartburn.
For a new episode of reflux disease, a full dose of PPI is given for a month, and the dose is stepped down or a low-dose PPI is used for recurrent symptoms as required. PPIs are highly effective in symptom relief, but urgent endoscopy is necessary for red-flag symptoms such as dysphagia.
In summary, the management of GORD involves lifestyle advice and medication, but red-flag symptoms require urgent investigation to rule out oesophageal cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 46
Incorrect
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A 46-year-old gentleman presents with lower gastrointestinal symptoms. He has a history of irritable bowel syndrome and has suffered with infrequent bouts of abdominal bloating and loose stools on and off for years. These are usually managed with mebeverine and loperamide. The diagnosis of irritable bowel syndrome was a clinical one and the only investigation he has had in the past were blood tests.
Over the last four weeks he has noticed that this has changed and that his bowels have been persistently loose and significantly more frequent than usual. He has no family history of bowel problems.
On examination he is systemically well with no fever. His abdomen is soft and non-tender with no palpable masses. Rectal examination reveals nothing focal. His weight is stable.
Which of the following investigations should you offer your patient?Your Answer:
Correct Answer: Faecal occult blood
Explanation:Investigating Acute Bowel Symptoms in a Patient with Irritable Bowel Syndrome
When a patient with a history of irritable bowel syndrome presents with acute bowel symptoms, it is important to investigate the underlying cause. However, certain investigations may not be appropriate in this context. For example, an abdominal ultrasound scan is not helpful in investigating bowel symptoms. Similarly, CEA tumour marker testing is a specialist investigation and not suitable for primary care. Ca125 is a marker for ovarian cancer and not relevant in this scenario.
According to NICE guidelines, testing for occult blood in faeces should be offered to assess for colorectal cancer in adults aged 50 and over with unexplained abdominal pain or weight loss, or in those under 60 with changes in their bowel habit or iron-deficiency anaemia. Stool mc+s may be requested, but it would not be helpful in risk stratifying the patient for urgent referral for colorectal cancer if an infective aetiology is not suspected. Therefore, it is important to choose appropriate investigations based on the patient’s symptoms and medical history.
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This question is part of the following fields:
- Gastroenterology
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Question 47
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 48
Incorrect
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A 28-year-old woman developed sudden-onset severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. She has diminished bowel sounds exquisite tenderness in the mid-epigastrium with rebound tenderness and guarding. Her pulse is 110 and BP 130/75. She reports taking ibuprofen for dysmenorrhoea but last took it the day before the pain began.
Select from the list the single most likely diagnosis.Your Answer:
Correct Answer: Perforated peptic ulcer
Explanation:NSAIDs and Peptic Ulceration: Risks and Symptoms
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common cause of gastric and duodenal ulceration, second only to Helicobacter pylori. The inhibition of cyclooxygenase (COX) by NSAIDs reduces the production of gastric mucosal prostaglandins, leading to decreased cytoprotection. This can result in peptic ulceration, with at least one-third to one-half of ulcer perforations being associated with NSAIDs.
Patients at high risk of NSAID-induced peptic ulceration include the elderly, those with a history of peptic ulcer disease, and those with serious co-morbidities such as cardiovascular disease, diabetes, renal or hepatic impairment. The risk varies between individual NSAIDs and is also dose-related.
Symptoms of acute complications of NSAID-induced peptic ulceration can include peritonitis, which requires urgent surgical referral. Acute pancreatitis may present with similar symptoms, but tenderness may be less and there may be a history of Gallbladder disease or alcohol abuse. Gastritis typically doesn’t involve altered bowel sounds or signs of peritoneal irritation, while cholecystitis and appendicitis present with tenderness in the right upper quadrant and right iliac fossa, respectively.
In summary, NSAIDs can pose a significant risk for peptic ulceration, particularly in high-risk patients. It is important to be aware of the symptoms of acute complications and to promptly refer patients for appropriate management.
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This question is part of the following fields:
- Gastroenterology
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Question 49
Incorrect
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A 50-year-old man presents to the clinic complaining of diarrhoea that has been ongoing for the past eight weeks. He has also experienced fresh rectal bleeding on multiple occasions during this time. The patient has a history of irritable bowel syndrome and haemorrhoids. On examination, his abdomen is soft with no palpable masses, and a normal rectal exam is noted.
What would be the next appropriate step in managing this patient?Your Answer:
Correct Answer: Prescribe loperamide and review in three to four weeks
Explanation:NICE Guidelines for Referral of Suspected Colorectal Cancer
According to the National Institute for Health and Care Excellence (NICE) guidelines, individuals under the age of 50 who experience a change in bowel habit to looser and/or more frequent stools, along with rectal bleeding, should be urgently referred for suspected colorectal cancer.
In addition, NICE recommends considering a suspected cancer pathway referral for adults under 50 with rectal bleeding and unexplained symptoms such as abdominal pain, weight loss, and iron-deficiency anemia. These referrals should result in an appointment within two weeks to ensure prompt diagnosis and treatment.
It is important to follow these guidelines to ensure early detection and treatment of colorectal cancer, which can significantly improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 50
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 51
Incorrect
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What is the most accurate statement regarding gastrointestinal bleeding in patients who are using non-steroidal anti-inflammatory drugs (NSAIDs)?
Your Answer:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 52
Incorrect
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A 25-year-old male blood donor presents with the following blood results:
Bilirubin 41 µmol/L
ALP 84 U/L
ALT 23 U/L
Albumin 41 g/L
His medical history reveals recent complaints of coryzal symptoms and a non-productive cough. Based on these findings, what is the most probable diagnosis?Your Answer:
Correct Answer: Gilbert's syndrome
Explanation:Gilbert’s syndrome is typically characterized by a rise in bilirubin levels in response to physiological stress. Therefore, it is likely that a 22-year-old male with isolated hyperbilirubinemia has Gilbert’s syndrome. Dubin-Johnson and Rotor syndrome, which both result in conjugated bilirubinemia, can be ruled out based on a normal dipstick urinalysis. Viral infections are often responsible for triggering a bilirubin increase in individuals with Gilbert’s syndrome.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastroenterology
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Question 53
Incorrect
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You encounter a client who is worried about having coeliac disease. They have recently reintroduced gluten in their diet. How long should the client be consuming gluten before NICE suggests testing for coeliac disease?
Your Answer:
Correct Answer: 4 weeks
Explanation:NICE Guidelines for Coeliac Disease Testing
According to the National Institute for Health and Care Excellence (NICE), individuals who are being tested for coeliac disease should have consumed gluten-containing foods equivalent to at least 4 slices of bread over the previous 6 weeks. Additionally, they should be consuming these foods at least twice per day during this time. This is important because consuming gluten is necessary to trigger the immune response that leads to the production of antibodies, which are used to diagnose coeliac disease. Therefore, it is essential that individuals do not follow a gluten-free diet before being tested for coeliac disease. Following these guidelines can help ensure accurate diagnosis and appropriate treatment for individuals with coeliac disease.
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This question is part of the following fields:
- Gastroenterology
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Question 54
Incorrect
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When managing women of any age and non-menstruating men who present with unexplained iron deficiency anaemia, what is the threshold haemoglobin level that should prompt urgent referral?
Your Answer:
Correct Answer: 120 g/L for men and women
Explanation:Iron Deficiency Anaemia and its Possible Causes
Iron deficiency anaemia is a condition that can be diagnosed through a low serum ferritin, red cell microcytosis, and hypochromia. It is often caused by gastrointestinal issues such as colonic cancer, gastric cancer, and coeliac disease. To determine the underlying cause, patients should undergo a PR examination, urine testing, and coeliac screen.
In some cases, unexplained iron deficiency anaemia can be an early indication of an underlying malignancy. Menorrhagia may also cause iron deficiency in women of childbearing age, but a detailed history should be taken to rule out other possible causes. Any man or non-menstruating woman presenting with anaemia should be referred for urgent investigation. It is important to understand the appropriate referral thresholds and look out for additional red flags that may warrant referral.
It is important to note that while occult bleeding from the gastrointestinal tract is a common cause of iron deficiency anaemia, blood loss may also occur through other means, such as urological cancers. Therefore, it is crucial to consider all possible causes and conduct thorough investigations to determine the underlying issue.
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This question is part of the following fields:
- Gastroenterology
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Question 55
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 56
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 57
Incorrect
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A concerned man visits your clinic as he participated in the routine bowel cancer screening program and received a positive faecal occult blood test (FOBt) result. He inquires if this indicates that he has bowel cancer. What is the estimated percentage of patients with a positive FOBt result who are subsequently diagnosed with bowel cancer during colonoscopy?
Your Answer:
Correct Answer: 10%
Explanation: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. -
This question is part of the following fields:
- Gastroenterology
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Question 58
Incorrect
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A 56-year-old man presents with dyspepsia and is found to have a gastric ulcer and H. pylori infection on endoscopy. He undergoes H. pylori eradication therapy but continues to experience symptoms six weeks later. What is the best test to confirm eradication of H. pylori?
Your Answer:
Correct Answer: Urea breath test
Explanation:The sole recommended test for H. pylori after eradication therapy is the urea breath test. It should be noted that H. pylori serology will still show positive results even after eradication. A stool antigen test, rather than culture, may be a suitable substitute.
Tests for Helicobacter pylori
There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which determines the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.
Another test is the rapid urease test, also known as the CLO test. This test involves mixing a biopsy sample with urea and pH indicator, and a color change indicates H. pylori urease activity. Serum antibody tests remain positive even after eradication, and the sensitivity and specificity are 85% and 80%, respectively. Culture of gastric biopsy provides information on antibiotic sensitivity, with a sensitivity of 70% and specificity of 100%. Gastric biopsy with histological evaluation alone has a sensitivity and specificity of 95-99%. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.
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This question is part of the following fields:
- Gastroenterology
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Question 59
Incorrect
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A 29-year-old woman who initially complained of abdominal discomfort and irregular bowel movements is diagnosed with irritable bowel syndrome. What dietary advice should be avoided in this case?
Your Answer:
Correct Answer: Increase the intake of fibre such as bran and wholemeal bread
Explanation:IBS patients should steer clear of insoluble sources of fiber like bran and wholemeal.
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.
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This question is part of the following fields:
- Gastroenterology
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Question 60
Incorrect
-
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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 61
Incorrect
-
A 47-year-old man presents to his General Practitioner with a deterioration in his long-standing knee pain. His knee examination is normal but he is noted to have a body mass index of 39 kg/m2 (morbidly obese). He states that he has a sedentary job, but considers himself quite active, as he is a keen gardener and has an acre of land which he maintains at home. He has gained a lot of weight since quitting smoking in his early twenties. He mentions that everyone in his family is overweight.
What is the single most important causative factor in the development of obesity in the majority of patients?Your Answer:
Correct Answer: Energy intake in excess of expenditure
Explanation:Understanding the Complex Causes of Obesity
Obesity is a complex condition that cannot be solely attributed to excessive food intake and lack of physical activity. While these factors do play a role, other factors such as genetic predisposition, insulin resistance, and intrauterine malnutrition also contribute to the development of obesity. A diet high in sugar and fat, excess alcohol consumption, and a sedentary lifestyle are all contributing factors. However, genetic factors, underlying medical conditions, sleep deprivation, and socioeconomic status also impact weight gain. It is recommended to maintain an active lifestyle by incorporating 150 minutes of moderate or 75 minutes of intense exercise per week. While smoking may suppress appetite, the impact of smoking cessation on weight gain is smaller than the balance of energy in versus out. While obese parents are more likely to have obese offspring, the causes of obesity are multifactorial and not solely attributed to genetics. Insulin resistance is more likely to be a consequence of obesity rather than a cause. Low birth weight and intrauterine growth restriction have also been associated with the development of obesity in later life. Overall, understanding the complex causes of obesity is crucial in developing effective prevention and treatment strategies.
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This question is part of the following fields:
- Gastroenterology
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Question 62
Incorrect
-
A 48-year-old alcoholic patient visits the General Practitioner (GP) for a check-up. He has recently been released from the hospital after experiencing an upper gastrointestinal bleed caused by oesophageal varices. He informs you that he has quit drinking and inquires about the likelihood of experiencing another bleeding episode.
What is the accurate statement regarding the risk of future bleeding from oesophageal varices?Your Answer:
Correct Answer: The risk of re-bleeding is greater than 60% within a year
Explanation:Understanding Variceal Haemorrhage: Causes, Complications, and Prognosis
Variceal haemorrhage is a common complication of portal hypertension, with almost 90% of cirrhosis patients developing varices and 30% experiencing bleeding. The mortality rate for the first episode is high, ranging from 30-50%. The severity of liver disease and associated systemic disorders worsen the prognosis, increasing the likelihood of a bleed. Patients who have had one episode of bleeding have a high chance of recurrence within a year, with one-third of further episodes being fatal. While abstaining from alcohol can slow the progression of liver disease, it cannot reverse portal hypertension. Understanding the causes, complications, and prognosis of variceal haemorrhage is crucial for effective management and prevention.
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This question is part of the following fields:
- Gastroenterology
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Question 63
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.
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This question is part of the following fields:
- Gastroenterology
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Question 64
Incorrect
-
A 56-year-old man presents to his primary care physician with a complaint of altered bowel habits. He reports experiencing constipation for the past 3 months, followed by occasional episodes of loose stools. He denies any associated pain, rectal bleeding, or unexplained weight loss. The patient is in good health, has a regular diet, and takes no medications. On physical examination, the abdomen is soft and non-tender with no palpable masses.
What would be the most suitable course of action for this patient?Your Answer:
Correct Answer: Faecal immunochemical testing (FIT)
Explanation:For patients who show new symptoms of colorectal cancer but do not meet the 2-week referral criteria, it is recommended to undergo the FIT test. In this case, as the patient is under 60 years old, an urgent referral is not necessary. However, if the change in bowel habit persists, it is important to consider a referral to a lower gastrointestinal specialist. It is not appropriate to request a faecal calprotectin test as it is mainly used for suspected IBD cases. A full blood count is necessary, but it should not be the only test performed. The most crucial step in management is to request a FIT test, which can trigger a 2-week wait if the result is positive. While providing reassurance to the patient is important, it should not be done without any investigation as it may lead to missing a potential colorectal 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.
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This question is part of the following fields:
- Gastroenterology
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Question 65
Incorrect
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A 62-year-old man presents to his GP with fatigue, nausea and abdominal distension. He admits to consuming 10-15 units of alcohol daily for many years. On examination, he displays spider naevi on his chest wall, jaundice and shifting dullness. He has a body mass index of 34 (obese). Blood tests reveal an AST:ALT ratio of 3:1 and an elevated serum ferritin. What is the most probable diagnosis?
Your Answer:
Correct Answer: Alcoholic Cirrhosis
Explanation:Understanding Alcoholic Cirrhosis: Causes, Symptoms, and Diagnosis
Alcoholic liver disease (ALD) is a leading cause of cirrhosis in developed countries, typically resulting from high levels of alcohol intake over an extended period. ALD progresses through fatty liver disease, alcoholic hepatitis, and ultimately cirrhosis, which presents with clinical signs such as jaundice, ascites, easy bruising, fatigue, abdominal pain, and nausea. Unfortunately, ALD is also responsible for 30% of global liver cancer deaths.
Alcoholic fatty infiltration is a reversible stage of ALD, but if clinical signs and blood results suggest progression to cirrhosis, the damage may be irreversible. Alcoholic active hepatitis is also reversible, but if the patient shows signs of cirrhosis, alcohol is likely the cause.
While transferrin saturation and serum ferritin levels may be increased in ALD, they do not necessarily indicate concomitant haemochromatosis, especially with a history of alcohol abuse.
It’s worth noting that most causes of liver disease, including non-alcoholic fatty liver disease, are associated with an AST to ALT ratio of <1. However, alcoholic liver disease often produces an AST:ALT ratio of 2:1 or higher. In summary, understanding the causes, symptoms, and diagnosis of alcoholic cirrhosis is crucial for early detection and treatment. Reducing alcohol intake and seeking medical attention can help prevent irreversible liver damage and improve overall health outcomes.
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This question is part of the following fields:
- Gastroenterology
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Question 66
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.
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This question is part of the following fields:
- Gastroenterology
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Question 67
Incorrect
-
A 65-year-old man presents to the General Practice Surgery with jaundice.
On examination, he has an enlarged, nodular liver. He is referred to hospital where a computed tomography (CT) scan of his abdomen reveals a cirrhotic liver with a large mass. A CT-guided biopsy of the mass demonstrates a malignant tumour derived from hepatic parenchymal cells.
What is the most likely causative agent in this patient?Your Answer:
Correct Answer: Hepatitis B virus
Explanation:Viral Causes of Cancer: A Comparison
There are several viruses that have been linked to the development of cancer in humans. Among these, hepatitis B virus is one of the most significant causes of cancer in many parts of the world, particularly in China where liver cancer accounts for about 20% of all cancer deaths. Infant vaccination against the virus is now being introduced to protect the new generation, but it doesn’t provide retrospective protection. On the other hand, hepatitis C is a more common cause of liver cancer in Europe and the United States.
Human T-lymphocyte virus, Epstein–Barr virus, and human herpesvirus type 8 are also known to cause cancer in humans, but not liver cancer. Human T-lymphocyte viruses can cause adult T-cell leukaemia/lymphoma, while Epstein–Barr virus has been linked with Hodgkin’s lymphoma, Burkitt’s lymphoma, nasopharyngeal cancer, and gastric cancer. Human herpesvirus type 8 is associated with Kaposi’s sarcoma, which is most often found in men who have sex with men but can also occur in heterosexuals.
Human papillomavirus (HPV) is another virus that has been linked to cancer, but not liver cancer. HPV types 6 and 11 cause anogenital warts, while HPV16 and HPV18 are responsible for more than two thirds of all cervical cancers globally. HPV infection is also associated with anogenital cancer and some nasopharyngeal cancers.
In summary, while several viruses have been linked to the development of cancer in humans, their specific associations vary. It is important to understand these associations in order to develop effective prevention and treatment strategies.
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This question is part of the following fields:
- Gastroenterology
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Question 68
Incorrect
-
You see a child who you are investigating for coeliac disease. Their serology test result is positive.
What would be the next step in your management?Your Answer:
Correct Answer: No intervention
Explanation:Diagnosis of Coeliac Disease
Patients who are suspected of having coeliac disease and have positive serology test results should be referred to a gastroenterologist for further investigation. The gastroenterologist will perform an endoscopy and intestinal biopsy to confirm or exclude the diagnosis of coeliac disease. It is important for patients to continue eating gluten-containing foods until the biopsy is performed to ensure accurate results.
While dietary advice may be helpful if coeliac disease is confirmed, it is more appropriate to first seek a referral to a gastroenterologist. There is no need to repeat the serology test if it is positive. For more information on how to interpret coeliac serology results, refer to the link provided below. Proper diagnosis and management of coeliac disease can greatly improve a patient’s quality of life.
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This question is part of the following fields:
- Gastroenterology
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Question 69
Incorrect
-
A 56-year-old man presents with a sudden onset of acute severe pain in his upper abdomen, which radiates to his back. He experiences severe nausea and vomiting and finds that sitting forwards is the only way to alleviate the pain. His medical history includes hypertension and gallstones, which were incidentally discovered during an ultrasound scan. What is the MOST PROBABLE diagnosis?
Your Answer:
Correct Answer: Acute pancreatitis
Explanation:Differential Diagnosis of Acute Upper Abdominal Pain
Acute upper abdominal pain can have various causes, and it is important to differentiate between them to provide appropriate treatment. Here are some possible diagnoses based on the given symptoms:
1. Acute pancreatitis: This condition is often caused by gallstones or alcohol consumption and presents with severe upper abdominal pain. Blood tests show elevated amylase levels, and immediate hospital admission is necessary.
2. Budd-Chiari syndrome: This rare condition involves the blockage of the hepatic vein and can cause right upper abdominal pain, hepatomegaly, and ascites.
3. Acute cholecystitis: This condition is characterized by localized pain in the upper right abdomen and a positive Murphy’s sign (pain worsened by deep breathing).
4. Perforated duodenal ulcer: This condition can cause sudden upper abdominal pain, but it is usually associated with a history of dyspepsia or NSAID use.
5. Renal colic: This condition causes severe pain in the loin-to-groin area and is often accompanied by urinary symptoms and hematuria.
In conclusion, a thorough evaluation of the patient’s symptoms and medical history is necessary to determine the underlying cause of acute upper abdominal pain.
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This question is part of the following fields:
- Gastroenterology
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Question 70
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.
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This question is part of the following fields:
- Gastroenterology
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Question 71
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.
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This question is part of the following fields:
- Gastroenterology
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Question 72
Incorrect
-
A 79-year-old man comes to the clinic with bilateral angular stomatitis. He wears dentures that have become a bit loose and his diet is not varied.
In the process of advising and treating his angular stomatitis, which of the following is correct?Your Answer:
Correct Answer: May be due to chronic constipation
Explanation:Stomatitis: Causes and Associated Factors
Stomatitis is a condition that can be caused by ill-fitting dentures and slack facial muscles, which can lead to Candida overgrowth. It is not associated with reactive arthritis, but it may be seen in Behçet’s disease. While it is not directly linked to constipation, it can be associated with inflammatory bowel disease.
Iron deficiency is a possible factor in the development of stomatitis, as are deficiencies in riboflavin, niacin, pyridoxine, folic acid, and cyanocobalamin. Vitamin C deficiency can also cause stomatitis, as well as scurvy.
It is important to address the underlying causes of stomatitis in order to effectively treat the condition. Proper dental care and nutrition can help prevent stomatitis from developing or recurrent.
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This question is part of the following fields:
- Gastroenterology
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Question 73
Incorrect
-
A 32-year-old woman presents to her General Practitioner with complaints of intermittent central abdominal pain and bloating, which is often relieved when she opens her bowels. She also experiences loose stools and occasional urgency to pass a stool. These symptoms have been occurring on and off for about six months, and she has not experienced any weight loss or bleeding. On examination, her abdomen appears normal. The patient has recently been promoted to a more responsible position at work. What is the most appropriate intervention to relieve this patient's symptoms?
Your Answer:
Correct Answer: Mebeverine
Explanation:Appropriate Medications for Irritable Bowel Syndrome: A Case Study
A patient presents with symptoms consistent with irritable bowel syndrome (IBS), including abdominal pain relieved by defecation and the absence of red-flag symptoms. The likely cause of her flare-up is increased stress following a job promotion. Antispasmodics such as mebeverine are appropriate for symptomatic relief of abdominal pain in IBS, while omeprazole is not indicated for this patient. Domperidone is not necessary for the relief of nausea and vomiting, and lactulose is not recommended due to potential bloating. Linaclotide is not appropriate for this patient as her symptoms have only been present for six months and there is no evidence that other laxatives have failed. Overall, mebeverine and lifestyle changes are the recommended interventions for this patient with IBS.
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This question is part of the following fields:
- Gastroenterology
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Question 74
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 75
Incorrect
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You see a 36-year-old lady with weight loss, abdominal pain, loose stools and bloody diarrhoea. She has been having these symptoms for 6 weeks. She smokes 10 cigarettes a day. She drinks minimal alcohol. She had an appendicectomy 3 years ago while on holiday in Morocco. She also suffers from anal fissures and mouth ulcers.
You suspect she has Crohn's disease and you refer her to the local gastroenterology team.
Which statement below is correct?Your Answer:
Correct Answer: The median age of diagnosis for Crohn's disease is approximately 30 years old
Explanation:Crohn’s disease is typically diagnosed around the age of 30, with the median age at diagnosis being 30 years.
After an appendicectomy, the risk of Crohn’s disease increases initially but returns to the same level as the general population after approximately 5 years.
The global incidence and prevalence of Crohn’s disease are on the rise.
In contrast to ulcerative colitis, smoking is a risk factor for developing Crohn’s disease.
The use of oral contraceptive drugs may elevate the risk of inflammatory bowel disease in women.
Understanding Crohn’s Disease
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.
Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include nonspecific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.
To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.
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This question is part of the following fields:
- Gastroenterology
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Question 76
Incorrect
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A 27 year old male with a history of ulcerative colitis presents with rectal symptoms and bloody diarrhoea. Upon examination, he appears comfortable and well hydrated. His vital signs include a regular pulse of 88 beats per minute, a temperature of 37.5ºC, and a blood pressure of 120/80 mmHg. There is mild tenderness in the left iliac fossa, but no palpable masses or rebound tenderness. Rectal examination reveals tenderness and blood in the rectum. What is the most appropriate initial treatment for this patient's mild/moderate proctitis flare?
Your Answer:
Correct Answer: Rectal mesalazine
Explanation:When experiencing a mild-moderate flare of distal ulcerative colitis, the initial treatment option is the use of topical (rectal) aminosalicylates. It is recommended to start with local treatment for rectal symptoms. Topical aminosalicylates are more effective than steroids, but a combination of both can be used if monotherapy is not effective. If the disease is diffuse or if symptoms do not respond to topical treatments, oral aminosalicylates can be used. In cases of severe disease, oral steroids can be considered.
Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.
To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.
In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.
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This question is part of the following fields:
- Gastroenterology
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Question 77
Incorrect
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 78
Incorrect
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A 60-year-old woman presents with increasing epigastric pain after eating for the past month. She has a history of intermittent heartburn and epigastric burning for over a year, which was previously managed with regular alginate. Three months ago, she reported no weight loss or vomiting, and her H. pylori status was checked. On her return visit, it was found that she is H. pylori positive and has experienced a reduced appetite, mild nausea, and some weight loss. What is the most appropriate course of action?
Your Answer:
Correct Answer: Prescribe a PPI such as omeprazole 20 mg/day and review in two weeks
Explanation:Urgent Referral for Upper GI Cancer in H. pylori Positive Patient
This patient is showing red flag symptoms and signs that suggest upper GI cancer, including weight loss and poor appetite. Despite being Helicobacter pylori positive, urgent referral for upper GI endoscopy or to a specialist in upper GI cancer should not be delayed. An ultrasound scan is unlikely to be helpful, and prescribing a PPI should be avoided as it can mask underlying disease. It is important to prioritize urgent referral over prescribing eradication therapy for H. pylori, as the latter may delay the diagnosis of underlying pathology. By promptly referring the patient for further evaluation, healthcare providers can ensure timely diagnosis and treatment of potential upper GI cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 79
Incorrect
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You encounter a 35-year-old male patient with ulcerative colitis. His previous colonoscopies have revealed widespread disease affecting his entire colon. He reports passing approximately 5 bloody stools per day for the past 3 days.
Upon examination, his heart rate is 82 beats per minute, blood pressure is 129/62 mmHg, and temperature is 36.9ºC. His abdomen is soft and non-tender.
What would be the most suitable course of action for this patient?Your Answer:
Correct Answer: Rectal mesalazine and oral sulfasalazine
Explanation:When a patient experiences a mild-moderate flare of ulcerative colitis that extends beyond the left-sided colon, it is recommended to add oral aminosalicylates to rectal aminosalicylates. This is because enemas can only reach a certain point and the addition of an oral medication ensures proper treatment. In this case, the patient’s colonoscopy showed extensive disease, making the use of an oral aminosalicylate necessary. Therefore, this is the correct option and using rectal mesalazine alone is not sufficient.
Using oral steroids like prednisolone and dexamethasone as a first-line treatment is not recommended.
Metronidazole is used to treat bacterial infections, but there is no indication of such an infection in this case.
Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.
To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.
In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.
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This question is part of the following fields:
- Gastroenterology
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Question 80
Incorrect
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A 50-year-old obese man with a history of type 2 diabetes mellitus presents to the clinic for a review. He reports feeling well and asymptomatic. However, his recent annual blood tests have shown slightly abnormal liver function tests:
- Bilirubin 20 µmol/L (3 - 17)
- ALP 104 u/L (30 - 100)
- ALT 53 u/L (3 - 40)
- γGT 58 u/L (8 - 60)
- Albumin 38 g/L (35 - 50)
A liver ultrasound performed during his follow-up visit reveals fatty changes. All other standard liver screen bloods, including viral serology, are normal. The patient's alcoholic intake is within recommended limits.
What would be the most appropriate next test to perform?Your Answer:
Correct Answer: Enhanced liver fibrosis blood test
Explanation:For patients with non-alcoholic fatty liver disease, it is advised to undergo enhanced liver fibrosis (ELF) testing to assist in the detection of liver fibrosis. A typical patient with this condition is someone who is overweight and has type 2 diabetes mellitus. According to NICE guidelines, if NAFLD is discovered by chance, an ELF blood test should be conducted to evaluate for the presence of advanced liver disease.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 81
Incorrect
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A 63-year-old man initially reported experiencing itching on his back. Subsequently, he began to experience abdominal discomfort, loss of appetite, weight loss, and fatigue. An x-ray was performed, which showed no abnormalities. What would be the gold standard management option?
Your Answer:
Correct Answer: Urgent CT scan
Explanation:Urgent CT Scan for Pancreatic Cancer in Elderly Patients with Red Flag Symptoms
An urgent direct access CT scan is recommended within two weeks for patients aged 60 and over who have experienced weight loss and any of the following symptoms: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes. CT scan is preferred over ultrasound unless CT is not available. Endoscopy is not necessary as the symptoms do not suggest stomach or oesophageal cancer, which would present with more dysphagia and dyspepsia. While a gastroenterology opinion may be required, it should not be requested routinely as the patient’s red flag symptoms warrant a more urgent approach. Although the patient is currently medically stable, an immediate referral to the medical assessment unit is not necessary.
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This question is part of the following fields:
- Gastroenterology
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Question 82
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 83
Incorrect
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A 60-year-old man presents to his General Practitioner complaining of dysphagia for both solids and liquids. He is experiencing no associated nausea or abdominal pain. His weight is stable and he is a lifelong non-smoker.
What is the most likely diagnosis?Your Answer:
Correct Answer: Achalasia
Explanation:Differential Diagnosis for Dysphagia: Achalasia, Benign Oesophageal Stricture, Barrett’s Oesophagus, Carcinoma of the Oesophagus, and Schatzki’s Rings
Dysphagia, or difficulty swallowing, can be caused by various oesophageal disorders. One such disorder is achalasia, which is characterized by dysphagia for both solids and liquids. It occurs in adults aged 25-60 years and is diagnosed by a barium swallow that reveals a dilated oesophagus. Other symptoms include regurgitation of food, chest pain, heartburn, and nocturnal cough. Benign oesophageal stricture is less likely as it only causes dysphagia for solids. Barrett’s oesophagus, a change in cell type of the epithelium in the distal portion of the oesophagus due to prolonged frequent acid exposure, primarily causes heartburn and acid regurgitation. Carcinoma of the oesophagus should be considered, but it usually causes dysphagia of solids and weight loss. Schatzki’s rings, rings of mucosa or muscle in the lower oesophagus, cause intermittent and non-progressive dysphagia for solids, usually after a patient eats a meal in a hurried fashion. Daily dysphagia is not usually a feature.
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This question is part of the following fields:
- Gastroenterology
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Question 84
Incorrect
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What is the most typical trait of a patient with vitamin C deficiency?
Your Answer:
Correct Answer: Paraesthesia and ataxia
Explanation:Understanding Vitamin C Deficiency and Scurvy
Vitamin C is an essential nutrient that is primarily found in fruits and vegetables. A deficiency of ascorbic acid can lead to scurvy, a condition characterized by inflamed and bleeding gums, impaired wound healing, and other symptoms. Cutaneous findings of scurvy include follicular hyperkeratosis, perifollicular haemorrhages, ecchymoses, xerosis, leg oedema, poor wound healing, and bent or coiled body hairs.
It is important to note that cheilosis and red tongue are more indicative of vitamin B12 or iron deficiency, while diarrhoea and delusions suggest vitamin B deficiency (pellagra). Ocular muscle palsy and dementia are more likely to be associated with thiamine deficiency or Wernicke’s encephalopathy.
Vitamin C deficiency is not uncommon in the elderly population, and it is crucial to be aware of the signs and symptoms to make a proper diagnosis. Measuring vitamin C concentrations in the white cell can confirm the diagnosis of scurvy.
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This question is part of the following fields:
- Gastroenterology
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Question 85
Incorrect
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A 28-year-old woman presents as an emergency to her GP with acute vomiting which began some 3-4 h after attending an afternoon meeting. Cream cakes were served during the coffee break.
Select from the list the most likely causative organism of this acute attack of vomiting.Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Understanding Bacterial Food Poisoning: Causes and Symptoms
Bacterial food poisoning is a common problem that can result from consuming contaminated food or water. Among the different types of bacteria that can cause food poisoning, Staphylococcus aureus, Bacillus cereus, Yersinia, Campylobacter, and Salmonella are the most common. Each of these bacteria has its own unique characteristics and symptoms.
Staphylococcus aureus is known to multiply rapidly in foods that are rich in carbohydrates and salt, such as dairy products, ice cream, cold meats, or mayonnaise. It produces a heat-stable endotoxin that causes nausea, vomiting, and diarrhea within 1-6 hours of ingestion.
Bacillus cereus infection is associated with slow-cooked food and reheated rice. The bacterium produces an emetic toxin that leads to vomiting within 1-5 hours. It can be difficult to distinguish from other short-term bacterial foodborne intoxications such as by Staphylococcus aureus.
Yersinia infection results in diarrhea some 3-10 days after contact and presents with bloody diarrhea, abdominal pain, and fever. The organism is acquired usually by insufficiently cooked pork or contaminated water, meat, or milk.
Campylobacter infection has an incubation period of 2-5 days and results in flu-like symptoms, abdominal pain, and diarrhea. It is the most common bacterium that causes food poisoning in the UK.
Salmonella infection normally leads to a picture of acute gastroenteritis with fever, abdominal cramps, and diarrhea between 12-36 hours after the ingestion of infected food. Infection occurs from a wide variety of infected foods that usually look and smell normal.
It is important for registered medical practitioners to notify the “proper officer” at their local council or local health protection team of suspected cases of food poisoning. By understanding the causes and symptoms of bacterial food poisoning, individuals can take steps to prevent infection and seek prompt medical attention if necessary.
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This question is part of the following fields:
- Gastroenterology
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Question 86
Incorrect
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A 55-year-old woman visits her General Practitioner with complaints of haemorrhoids that she has been experiencing for several years. She frequently experiences itchiness and pain. She has a daily bowel movement with soft stool. Upon examination, there is no indication of a rash or fissure. What is the most suitable medication to prescribe for this patient?
Your Answer:
Correct Answer: Cinchocaine (dibucaine) hydrochloride 0.5%, hydrocortisone 0.5% ointment
Explanation:Topical Treatments for Haemorrhoids: Options and Considerations
Haemorrhoids are a common condition that can cause discomfort and itching. Topical treatments are often used to alleviate symptoms, and there are several options available. However, it is important to choose the appropriate treatment based on the patient’s symptoms and medical history. Here are some considerations for different topical treatments:
– Cinchocaine (dibucaine) hydrochloride 0.5%, hydrocortisone 0.5% ointment: This preparation contains a local anaesthetic and corticosteroid, which can provide short-term relief. It is suitable for occasional use.
– Hydrocortisone 1%, miconazole nitrate 2% cream: This cream contains an anti-candida agent and is appropriate for intertrigo. However, if the patient doesn’t have a rash or signs of fungal infection, this may not be the best option.
– Clobetasol propionate cream: This potent topical steroid is used for vulval and anal lichen sclerosus. It is not recommended if the patient doesn’t have a rash.
– Glyceryl trinitrate ointment: This unlicensed preparation is used for anal fissure, which is characterized by painful bowel movements and rectal bleeding. If the patient doesn’t have these symptoms, this treatment is not appropriate.
– Lactulose solution: Constipation can contribute to haemorrhoids, and lactulose can help manage this. However, if the patient doesn’t have constipation, this treatment may not be necessary.In summary, choosing the right topical treatment for haemorrhoids requires careful consideration of the patient’s symptoms and medical history. Consultation with a healthcare professional is recommended to determine the best course of action.
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This question is part of the following fields:
- Gastroenterology
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Question 87
Incorrect
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A 60-year-old man with liver cirrhosis of unknown origin is being evaluated in the clinic. What factor is most likely to indicate a poor prognosis?
Your Answer:
Correct Answer: Ascites
Explanation:Scoring Systems for Liver Cirrhosis
Liver cirrhosis is a serious condition that can lead to liver failure and death. To assess the severity of the disease, doctors use scoring systems such as the Child-Pugh classification and the Model for End-Stage Liver Disease (MELD). The Child-Pugh classification takes into account five factors: bilirubin levels, albumin levels, prothrombin time, encephalopathy, and ascites. Each factor is assigned a score of 1 to 3, depending on its severity, and the scores are added up to give a total score. The total score is then used to grade the severity of the disease as A, B, or C.
The MELD system uses a formula that takes into account a patient’s bilirubin, creatinine, and international normalized ratio (INR) to predict their survival. The formula calculates a score that ranges from 6 to 40, with higher scores indicating a higher risk of mortality. The MELD score is particularly useful for patients who are on a liver transplant waiting list, as it helps to prioritize patients based on their risk of mortality. Overall, both the Child-Pugh classification and the MELD system are important tools for assessing the severity of liver cirrhosis and determining the best course of treatment for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 88
Incorrect
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A 50-year-old man complains of frequent palpitations. These usually occur when he eats and subside abruptly after he finishes eating. They are not accompanied by chest pain, but, on occasion, he also feels lightheaded. He has no reflux symptoms or dyspepsia. He is otherwise well and on presentation his blood pressure is 136/84 mmHg, his pulse is in sinus rhythm, and examination of his heart and abdomen are normal. His electrocardiogram (ECG) is normal.
What is the most appropriate investigation?Your Answer:
Correct Answer: 24 hour portable electrocardiogram (ECG)
Explanation:The Most Appropriate Investigation for Palpitations and Dizziness: A Cardiac Investigation
When a patient presents with palpitations and dizziness, a cardiac cause is often suspected. While the association with food may be a red herring, the combination of symptoms suggests a need for further investigation. An ECG or examination of the pulse may not reveal an underlying cause unless the patient is experiencing symptoms at that exact moment. Therefore, a 24 hour portable ECG is often recommended to assess the cardiac rhythm over a longer period of time.
A chest X-ray is unlikely to be helpful in the absence of chest pain or respiratory symptoms. Similarly, an endoscopy may be indicated for dyspeptic symptoms, but the history of palpitations and dizziness suggests a cardiac cause. H. pylori testing is only relevant for dyspeptic symptoms, and thyroid function tests are important for anyone experiencing palpitations, as hyperthyroidism can be a cause.
In summary, when a patient presents with palpitations and dizziness, a cardiac investigation is the most appropriate first step. A 24 hour portable ECG can provide valuable information about the cardiac rhythm over a longer period of time.
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This question is part of the following fields:
- Gastroenterology
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Question 89
Incorrect
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A 65-year-old man visits the GP clinic complaining of rectal bleeding that has been ongoing for two days. He has experienced eight episodes of diarrhoea in the past 24 hours, with visible blood mixed with stool. He also reports feeling nauseous and having abdominal pain. The patient has a medical history of ulcerative colitis, hypertension, and type 2 diabetes, and is currently taking mesalazine enteric coated 800 mg twice daily, amlodipine 10 mg once daily, and metformin 500mg twice daily.
During the examination, the patient appears pale and has a temperature of 38ºC. His heart rate is 108/min, and his blood pressure is 112/74 mmHg. The abdominal exam reveals generalised tenderness and guarding, but no rebound tenderness.
What is the appropriate course of action for managing this patient's condition?Your Answer:
Correct Answer: Urgent hospital admission
Explanation:The appropriate course of action for a severe flare-up of ulcerative colitis is urgent hospital admission for IV corticosteroids. This is based on the Truelove and Witts’ severity index, which indicates that the patient is experiencing a severe flare-up due to symptoms such as opening their bowels more than 6 times per day and systemic upset (e.g. fever and tachycardia). NICE guidelines recommend immediate hospital admission for assessment and treatment with IV corticosteroids. It should be noted that a short course of oral steroids or rectal mesalazine may be used for mild to moderate flare-ups, while loperamide and dose increases of mesalazine are not appropriate for managing severe flare-ups.
Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.
To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.
In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.
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This question is part of the following fields:
- Gastroenterology
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Question 90
Incorrect
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You observe a 35-year-old librarian who has been living with Crohn's disease for 18 years. She has been in remission for the past six years, but has been experiencing abdominal pain and passing bloody stools for the past week. She is seeking treatment.
She is generally healthy and takes the combined contraceptive pill and ibuprofen as needed for back pain. She smokes five cigarettes daily but doesn't consume alcohol.
What is the accurate statement regarding her condition?Your Answer:
Correct Answer: Smoking increases the risk of Crohn's disease relapse
Explanation:Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.
To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.
Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.
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This question is part of the following fields:
- Gastroenterology
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Question 91
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 92
Incorrect
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A 50-year-old male undergoes an endoscopy after being referred by his GP with recurrent indigestion.
The endoscopy reveals a small duodenal ulcer and Helicobacter pylori is demonstrated to be present. He has not been given eradication treatment before and is allergic to penicillin.
You consider a seven day, twice daily course of eradication therapy.
How would you treat this patient?Your Answer:
Correct Answer: Esomeprazole 10 mg, Metronidazole, Tetracycline
Explanation:Helicobacter Infection and Treatment
Helicobacter infection is common in patients with duodenal and peptic ulceration. The recommended therapy includes acid suppression and eradication of Helicobacter. Triple therapy with a proton pump inhibitor (PPI) such as omeprazole, along with two antibiotics (amoxicillin/clarithromycin plus metronidazole), has been found to be highly effective.
It is important to note that patients who are allergic to penicillin require a different treatment regimen. The lowest cost treatment option should be chosen, taking into account previous exposure to clarithromycin or metronidazole. In cases where the patient is allergic to penicillin and has had previous exposure to clarithromycin, bismuth and tetracycline should be added to the treatment regimen.
The recommended PPI doses for Helicobacter pylori eradication therapy are esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20-40 mg, pantoprazole 40 mg, and rabeprazole 20 mg. It is important to follow these guidelines to ensure effective treatment of Helicobacter infection.
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This question is part of the following fields:
- Gastroenterology
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Question 93
Incorrect
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A 46-year-old man is a frequent visitor to surgery complaining of pruritus ani.
You have examined him previously and excluded organic causes. He has a love of Indian cuisine. In an attempt to help him cope with the problem, you offer advice.
Which of the following is true?Your Answer:
Correct Answer: Briefs are preferable to boxer shorts
Explanation:Tips for Managing Pruritus Ani
Pruritus ani, or anal itching, can be a bothersome and embarrassing condition. However, there are several ways to manage it. First, it is recommended to wear cotton underwear and looser clothing to prevent irritation. Topical capsaicin in very dilute form has shown to be beneficial, but more concentrated creams may worsen the situation. Certain foods such as tomatoes, citrus fruit, and spicy foods may also exacerbate the condition. Keeping the area dry is crucial, and using a hair dryer can be an efficient way to do so. It is important to note that medication can cause a more generalized pruritus, but products such as colchicine and evening primrose oil have been linked to pruritus ani. By following these tips, individuals can better manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Gastroenterology
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Question 94
Incorrect
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A 25-year-old female presents with a history of weight loss and diarrhoea. During a colonoscopy to investigate her symptoms, a biopsy is taken and the report indicates the presence of pigment-laden macrophages suggestive of melanosis coli. What is the probable diagnosis?
Your Answer:
Correct Answer: Laxative abuse
Explanation:Understanding Melanosis Coli: A Pigmentation Disorder of the Bowel Wall
Melanosis coli is a condition that affects the pigmentation of the bowel wall. This disorder is characterized by the presence of pigment-laden macrophages, which can be observed through histology. One of the primary causes of melanosis coli is laxative abuse, particularly the use of anthraquinone compounds like senna.
This condition is a result of the accumulation of melanin in the macrophages of the colon. The pigmentation can be seen as dark brown or black spots on the lining of the colon. While melanosis coli is not typically a serious condition, it can be a sign of underlying issues such as chronic constipation or other gastrointestinal disorders.
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This question is part of the following fields:
- Gastroenterology
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Question 95
Incorrect
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Sarah is a 44-year-old woman who presented to you last month with a 6 week history of upper abdominal pain, heartburn and occasional reflux. Her medical history is unremarkable and you agreed on a plan for a 1 month trial of omeprazole 20 mg daily.
Sarah returns for a follow-up appointment after completing a month of omeprazole. Her symptoms have only slightly improved and they are still bothering her.
What would be the most suitable course of action?Your Answer:
Correct Answer: Test for Helicobacter pylori infection in 2 weeks and treat if positive
Explanation:If initial treatment for dyspepsia with either a PPI or ‘test and treat’ approach fails, the alternative strategy should be tried next. In Mark’s case, he has completed 1 month of a full-dose PPI and should now be tested for H. pylori infection. Referral for routine upper gastrointestinal endoscopy is not necessary at this stage.
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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This question is part of the following fields:
- Gastroenterology
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Question 96
Incorrect
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A 25-year-old woman presents to her General Practitioner in her 28th week of pregnancy. After an uneventful first and second trimester to date, she has developed widespread itching over the last three weeks and she now has mild jaundice. Her bilirubin is 80 μmol/l (normal <21 μmol/l), alanine aminotransferase (ALT) at 82 IU/l (normal <40 IU/l), and the alkaline phosphatase is markedly raised.
Which of the following is the diagnosis that fits best with this clinical picture?
Your Answer:
Correct Answer: Intrahepatic cholestasis of pregnancy
Explanation:Liver Disorders in Pregnancy: Differential Diagnosis
During pregnancy, various liver disorders can occur, leading to abnormal liver function tests. Intrahepatic cholestasis of pregnancy is the most common pregnancy-related liver disorder, affecting 0.1-1.5% of pregnancies. It typically presents in the late second or early third trimester with generalized itching, starting on the palms and soles. An elevated alanine aminotransferase (ALT) is a more sensitive marker than aspartate aminotransferase (AST), and a fasting serum bile acid concentration of greater than 10 mmol/l is the key diagnostic test. Primary biliary cholangitis and acute fatty liver of pregnancy are less likely diagnoses, while cholelithiasis and hyperemesis gravidarum have different clinical presentations. Early diagnosis and management of liver disorders in pregnancy are crucial to prevent adverse outcomes such as prematurity and stillbirth.
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This question is part of the following fields:
- Gastroenterology
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Question 97
Incorrect
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A 45-year-old man underwent a right hemicolectomy for a Dukes' B colorectal carcinoma. What is the most suitable tumour marker to be monitored during his regular check-ups?
Your Answer:
Correct Answer: CEA
Explanation:Tumor Markers: Identifying Cancer through Blood Tests
Tumor markers are substances produced by cancer cells or normal cells in response to cancer. These markers can be detected in blood, urine, or tissue samples and can help in the diagnosis, monitoring, and treatment of cancer. Here are some commonly used tumor markers and their significance:
Carcinoembryonic antigen (CEA) is a glycoprotein involved in cell adhesion. It is usually present only at very low levels in the blood of healthy adults but is raised in some cancers, including colorectal, stomach, pancreatic, lung, breast, and medullary thyroid cancers. While it lacks specificity and sensitivity to establish a diagnosis of colorectal cancer, it is used to help identify recurrences after surgical resection.
CA 19-9 (carbohydrate antigen 19-9) is secreted by some pancreatic tumors and is also elevated in gastric and hepato-biliary cancer. Its levels should fall when the tumor is treated, and rise again if the disease recurs.
PSA (prostate-specific antigen) is a marker for prostate cancer, while urinary 5HIAA (5-hydroxyindoleacetic acid) is elevated in carcinoid tumors and AFP (alpha-fetoprotein) is elevated in non-seminomatous germ cell tumors and hepatocellular cancer.
In conclusion, tumor markers play a crucial role in the diagnosis and management of cancer. However, it is important to note that elevated levels of these markers do not always indicate the presence of cancer and further testing is often required for confirmation.
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This question is part of the following fields:
- Gastroenterology
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Question 98
Incorrect
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A 35-year-old man visits his General Practitioner with complaints of persistent symptoms despite adhering to a gluten-free diet. He is experiencing frequent episodes of abdominal discomfort and diarrhoea. He was diagnosed with coeliac disease a few years ago and has been managing it well otherwise.
What is the most probable diagnosis?Your Answer:
Correct Answer: Intestinal lymphoma
Explanation:Intestinal lymphoma is a rare but increased risk for individuals with coeliac disease, particularly those with refractory coeliac disease. Symptoms of enteropathy-associated T-cell lymphoma include persistent diarrhoea, stomach pain, and unexplained weight loss. Adhering to a gluten-free diet can decrease the risk of developing lymphoma, as well as other potential complications such as carcinoma of the small bowel or oesophagus. Intestinal lymphangiectasia, bacterial overgrowth of the small intestine, Crohn’s disease, and Giardia intestinalis infection are other possible causes of chronic diarrhoea and weight loss, but are less likely in this case.
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This question is part of the following fields:
- Gastroenterology
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Question 99
Incorrect
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Which statement about the epidemiology of colorectal cancer is accurate?
Your Answer:
Correct Answer: A quarter of patients diagnosed with bowel cancer will survive for at least 10 years
Explanation:Understanding the Epidemiology of Colorectal Cancer
A basic understanding of the epidemiology of colorectal cancer is important for general practitioners to consider when treating their patients. It is worth noting that 95% of colorectal cancer cases occur in individuals over the age of 50.
In terms of incorrect answer options, it is important to note that bowel cancer incidence rates have not increased by 6% over the last 10 years. Additionally, bowel cancer is not the second most common cause of cancer death in the UK overall, but rather in men alone it is second to prostate cancer and in women alone it is second to breast cancer.
Finally, while almost 42,000 people were diagnosed with bowel cancer in the UK in 2011, it is not accurate to say that half of patients diagnosed with colorectal cancer will survive their disease for 10 years or more. It is important for general practitioners to have accurate information about colorectal cancer in order to provide the best care for their patients.
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This question is part of the following fields:
- Gastroenterology
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Question 100
Incorrect
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A 62-year-old woman presents with a history of anorexia, weight loss, and abdominal discomfort for the past five weeks. On examination, she appears pale and cachectic with no significant abdominal findings. However, there is palpable adenopathy in the left supraclavicular fossa.
What is the most probable diagnosis?Your Answer:
Correct Answer: Carcinoma of the stomach
Explanation:Metastatic Lymph Nodes in the Neck: Causes and Symptoms
Metastatic lymph nodes in the neck, particularly at the root of the neck, are often indicative of cancer in the abdomen, specifically gastric or pancreatic tumors. These types of cancers can remain asymptomatic while spreading to the lymph nodes, making early detection difficult. Virchow’s node is a term used to describe an enlarged left supraclavicular node, which can also be caused by lymphoma, breast cancer, or arm infection. On the other hand, an enlarged right supraclavicular lymph node is typically associated with thoracic malignancies such as lung and esophageal cancer, as well as Hodgkin’s lymphoma. It’s important to note that none of the other options are malignant disorders. If you notice any unusual swelling or lumps in your neck, it’s important to seek medical attention promptly.
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This question is part of the following fields:
- Gastroenterology
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Question 101
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastroenterology
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Question 102
Incorrect
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Which of the following is not a characteristic of non-alcoholic steatohepatitis?
Your Answer:
Correct Answer: Type 1 diabetes mellitus
Explanation:Non-alcoholic fatty liver disease may be considered as a potential cause of abnormal liver function tests in patients with type 2 diabetes mellitus.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 103
Incorrect
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A 68-year-old gentleman presents with a change in bowel habit. He reports that over the last two to three months he is opening his bowels four to five times a day and the consistency of his stools has become very loose. He has noticed small amounts of blood in his faeces but put this down to 'piles'.
Previously, he used to open his bowels on average once a day and has no personal history of any gastrointestinal problems. There is no family history of bowel problems, he has not lost any weight and he denies any rectal blood loss. Stool mc&s is normal as are his recent blood tests which show that he is not anaemic. Abdominal and rectal examinations are normal.
He tells you that he is not overly concerned about the symptoms as about two months ago he submitted his bowel screening samples and recently had a letter saying that his screening tests were negative. What is the most appropriate next approach in this instance?Your Answer:
Correct Answer: Refer him urgently to a specialist for investigation of his lower gastrointestinal tract
Explanation:Importance of Urgent Referral for Patients with Bowel Symptoms
Screening tests are designed for asymptomatic individuals in an at-risk population. However, it is not uncommon for patients with bowel symptoms to mention that they are not worried as they have done their bowel screening and it was negative.
In the case of a 66-year-old man with persistent changes in bowel habit towards looser stools with some rectal bleeding, urgent referral for further investigation is necessary. It is important to note that relying on recent bowel screening results may falsely reassure patients and delay necessary medical attention.
Therefore, it is crucial for healthcare professionals to prioritize the patient’s current symptoms and promptly refer them for further evaluation, regardless of their previous screening results. Early detection and treatment can significantly improve outcomes for patients with bowel symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 104
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastroenterology
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Question 105
Incorrect
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A 48-year-old woman complains of fatigue and itching. She denies any alcohol abuse and is not on any medications. She has xanthelasmas and her alkaline phosphatase level is elevated.
What is the most probable diagnosis?Your Answer:
Correct Answer: Primary biliary cholangitis (PBC)
Explanation:Possible Diagnoses for a Patient with Pruritus and Xanthelasmas
The patient’s symptoms of pruritus and xanthelasmas suggest a possible diagnosis of primary biliary cholangitis (PBC), a chronic liver disease that primarily affects women between the ages of 30 and 65. Fatigue is often the first symptom, and pruritus is also common. Elevated alkaline phosphatase levels and increased lipid and cholesterol levels are typical of PBC. Xanthelasmas may be present in late-stage disease.
Familial hypercholesterolaemia may also cause xanthelasmas, but pruritus and elevated alkaline phosphatase levels would not be expected. Asteatotic eczema may cause pruritus, but it is more common in elderly patients and would not explain the elevated alkaline phosphatase levels. Carcinoma of the head of the pancreas may cause painless jaundice and pruritus, but it would not explain the xanthelasmas. Paget’s disease of bone may cause elevated alkaline phosphatase levels, but it would not explain the xanthelasmas or pruritus.
Overall, the combination of symptoms suggests PBC as the most likely diagnosis.
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This question is part of the following fields:
- Gastroenterology
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Question 106
Incorrect
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A 35-year-old woman has been diagnosed with ulcerative colitis after an acute admission to the hospital with bleeding per rectum, fever and abdominal pain. At the time of diagnosis, she was initiated on mesalazine. Her bowel symptoms are now much improved and she is awaiting routine follow-up in the clinic.
Which of the following side effects should patients be specifically informed of and cautioned about when commencing mesalazine?Your Answer:
Correct Answer: Pancytopenia
Explanation:Adverse Effects of Aminosalicylates: What to Watch Out For
Aminosalicylates, such as mesalazine and sulfasalazine, are drugs used to treat bowel inflammation. While they are generally safe, there are some potential adverse effects to be aware of. Common side effects include headache, nausea, rash, and abdominal pain. Patients may also become more sensitive to sunlight.
However, aminosalicylates can also rarely cause more serious issues such as blood disorders like agranulocytosis and aplastic anemia. Patients should be advised to report any unexplained bleeding, bruising, sore throat, fever, or malaise, and a full blood count should be performed if these symptoms occur. Nephrotoxicity is another potential adverse effect of mesalazine.
It’s important to note that mesalazine is not associated with skin pigmentation, corneal deposits, gum hypertrophy, or Parkinsonian features, which are side effects of other drugs. If patients experience any concerning symptoms while taking aminosalicylates, they should speak with their healthcare provider immediately.
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This question is part of the following fields:
- Gastroenterology
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