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  • Question 1 - A 72-year-old man comes to his General Practitioner complaining of jaundice and weight...

    Correct

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

      Your Answer: Pancreatic adenocarcinoma

      Explanation:

      Diagnosing Pancreatic Adenocarcinoma: Understanding the Symptoms and Differential Diagnosis

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 2 - A 35-year-old woman with hepatitis C visits your clinic as she is considering...

    Incorrect

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

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

      Your Answer: <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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 3 - A 72-year-old man presents to his General Practice Surgery, as he has developed...

    Correct

    • A 72-year-old man presents to his General Practice Surgery, as he has developed difficulty swallowing. He has a long history of ‘heartburn’, which he manages with over-the-counter antacids. He is a smoker with a 50-pack-year history and drinks around 15 units of alcohol per week. He thinks he has lost 4 kg of weight in the last few months.
      Endoscopy reveals a lesion in the lower third of the oesophagus.
      What is the most likely diagnosis?

      Your Answer: Adenocarcinoma of the oesophagus

      Explanation:

      Understanding Oesophageal Cancer and Related Conditions

      Oesophageal cancer is a serious condition that can be caused by various factors. Adenocarcinoma of the oesophagus is the most common type in the UK and is associated with chronic gastro-oesophageal reflux disease and Barrett’s oesophagus. Squamous carcinoma, on the other hand, is more likely to occur in the upper two thirds of the oesophagus. Both types of cancer are often asymptomatic until late in the disease, making early detection difficult.

      Barrett’s oesophagus is a condition caused by chronic GORD that can increase the risk of developing adenocarcinomas in the distal third of the oesophagus. GORD, which is the reflux of stomach acid into the oesophagus, can cause burning chest pain after eating. However, it doesn’t explain dysphagia or the presence of a lesion seen on endoscopy.

      An oesophageal stricture, which is a narrowing of the oesophagus, can also cause dysphagia and may be associated with chronic GORD. However, if weight loss, smoking, and alcohol consumption are present, and a lesion is seen on endoscopy, oesophageal cancer is more likely.

      In summary, understanding the risk factors and symptoms of oesophageal cancer and related conditions can aid in early detection and treatment. Regular check-ups and screenings are recommended for those at higher risk.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - Many elderly patients with colorectal cancer present with advanced disease. Early diagnosis is...

    Incorrect

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

      Your Answer: A 70-year-old man who has been constipated for 2 weeks with anal discomfort and blood on the toilet paper

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

      Explanation:

      Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis

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

      Rectal Bleeding in a Multiparous Woman

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

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

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

      Constipation in an 80-Year-Old Woman

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

      Anal Fissure in a 70-Year-Old Man

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

      Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 32-year-old male with type 1 diabetes attends for diabetic annual review. He...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - A 55-year-old man visits his General Practitioner, worried about potential hepatitis C infection....

    Correct

    • A 55-year-old man visits his General Practitioner, worried about potential hepatitis C infection. He has received multiple tattoos, all of which were done in the United Kingdom (UK). He has previously been vaccinated against hepatitis B. Upon examination, there are no indications of liver disease. What is the most suitable management advice to give this patient?

      Your Answer: He should be tested for anti-hepatitis C virus (anti-HCV)

      Explanation:

      Screening and Testing for Hepatitis C Infection

      Hepatitis C is a viral infection that can cause liver damage and other serious health problems. It is important to screen and test for hepatitis C in certain individuals, particularly those with unexplained abnormal liver function tests or who have undergone procedures with unsterilized equipment.

      Testing for anti-hepatitis C virus (anti-HCV) serology is recommended for those suspected of having HCV infection, although false negatives can occur in the acute stage of infection. A liver ultrasound (US) may be used to look for evidence of cirrhosis, but is not a diagnostic tool for hepatitis C.

      Screening for hepatitis C is necessary for those who have undergone tattooing, ear piercing, body piercing, or acupuncture with unsterile equipment, as these procedures can put a person at risk of acquiring the infection.

      Testing for HCV deoxyribonucleic acid (DNA) is necessary to confirm ongoing hepatitis C infection in those with positive serology. Chronic hepatitis C is considered in those in whom HCV RNA persists, which occurs in approximately 80% of cases. Normal liver function tests do not exclude hepatitis C infection, and deranged LFTs should be a reason to consider screening for the virus.

      In summary, screening and testing for hepatitis C is important for those at risk of infection or with unexplained abnormal liver function tests. Testing for HCV DNA is necessary to confirm ongoing infection, and normal LFTs do not exclude the possibility of hepatitis C.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - A 60-year-old woman presents with increasing epigastric pain after eating for the past...

    Incorrect

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

      Your Answer: Refer urgently for upper GI endoscopy

      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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - Whilst reviewing a middle-aged patient in a GP practice, you note the following...

    Incorrect

    • Whilst reviewing a middle-aged patient in a GP practice, you note the following blood test results:

      Hb 90 g/L Male: (135-180)
      Female: (115 - 160)
      Mean Cell Volume (MCV) 75 fL (80 - 96)
      Platelets 350 * 109/L (150 - 400)
      WBC 9.0 * 109/L (4.0 - 11.0)
      Na+ 137 mmol/L (135 - 145)
      K+ 3.7 mmol/L (3.5 - 5.0)
      Urea 14.0 mmol/L (2.0 - 7.0)
      Creatinine 74 µmol/L (55 - 120)
      CRP 2.3 mg/L (< 5)

      What is the most likely diagnosis for this middle-aged patient?

      Your Answer: Lower gastrointestinal bleed

      Correct Answer: Upper gastrointestinal bleed

      Explanation:

      Elevated urea levels may suggest an upper GI bleed rather than a lower GI bleed. Iron deficiency anemia or anemia of chronic disease do not account for the increased urea. Chronic kidney disease would result in a corresponding increase in creatinine, in addition to the elevated urea. The raised urea is caused by the digestion of the substantial protein meal of blood in the upper GI tract, which would not occur in a lower GI bleed.

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The main symptoms include haematemesis (vomiting of blood), melena (passage of altered blood per rectum), and a raised urea level due to the protein meal of the blood. The diagnosis can be determined by identifying the specific features associated with a particular condition, such as stigmata of chronic liver disease for oesophageal varices or abdominal pain for peptic ulcer disease.

      The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes. Oesophageal varices may present with a large volume of fresh blood, while gastric ulcers may cause low volume bleeds that present as iron deficiency anaemia. Duodenal ulcers are usually posteriorly sited and may erode the gastroduodenal artery. Aorto-enteric fistula is a rare but important cause of major haemorrhage associated with high mortality in patients with previous abdominal aortic aneurysm surgery.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation involves ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours. Treatment options include repeat endoscopy, interventional radiology, and surgery for non-variceal bleeding, while terlipressin and prophylactic antibiotics should be given to patients with variceal bleeding. Band ligation should be used for oesophageal varices, and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - A 63-year-old man presents with abdominal discomfort, loss of appetite, and weight loss....

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - You assess a 24 year old female with irritable bowel syndrome who expresses...

    Correct

    • You assess a 24 year old female with irritable bowel syndrome who expresses frustration with the lack of relief from loperamide and antispasmodic medication. After re-evaluating her history and conducting a thorough examination, you find no new developments or concerning symptoms. What course of action do you suggest for further treatment?

      Your Answer: Tricyclic antidepressant

      Explanation:

      According to the National Institute for Health and Care Excellence (NICE) guidelines on the diagnosis and management of irritable bowel syndrome (IBS) in primary care, tricyclic antidepressants (TCAs) should be considered as a second-line treatment for individuals with IBS if laxatives, antispasmodics, or loperamide have not been effective. The decision to prescribe medication should be based on the severity and nature of symptoms, and the choice of medication or combination of medications should be determined by the predominant symptom(s). Antispasmodic agents should be considered for individuals with IBS, along with dietary and lifestyle advice. Laxatives may be used for constipation, but lactulose should be avoided. Linaclotide may be considered for individuals with constipation who have not responded to other laxatives, and loperamide is the first choice for diarrhea. Individuals with IBS should be advised on how to adjust their medication doses to achieve a soft, well-formed stool. TCAs may be considered if other medications have not been effective, and selective serotonin reuptake inhibitors (SSRIs) may be considered if TCAs are not effective. Healthcare professionals should monitor individuals taking TCAs or SSRIs for side effects and adjust the dosage as necessary.

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - You are evaluating a 45-year-old woman with a 20-year history of Crohn's disease....

    Incorrect

    • 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: Osteoporosis occurs in 10% of patients with inflammatory bowel 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - A 79-year-old man comes to the clinic with bilateral angular stomatitis. He wears...

    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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 13 - A 28-year-old man visits his doctor with worries about a slight yellowing of...

    Incorrect

    • A 28-year-old man visits his doctor with worries about a slight yellowing of his sclera. During the examination, he displays mild jaundice and reports experiencing occasional jaundice in the past. Blood tests are conducted, revealing an elevated total bilirubin level of 48 µmol/l (normal <21 µmol/l) and no other irregularities. Which of the following supplementary discoveries would strongly suggest that Gilbert syndrome is the underlying cause?

      Your Answer:

      Correct Answer: Unconjugated hyperbilirubinaemia

      Explanation:

      Understanding Gilbert Syndrome: Symptoms and Diagnosis

      Gilbert syndrome is a genetic condition that affects 5-10% of the population. It is usually asymptomatic, but can cause mild jaundice during physical stressors such as fasting, infection, or lack of sleep. This is due to an abnormality in the liver enzyme responsible for conjugating bilirubin, resulting in unconjugated hyperbilirubinaemia. However, symptoms such as fatigue, loss of appetite, nausea, and abdominal pain are rare and may reflect the underlying stressor rather than the condition itself. Diagnosis is often made through routine liver function tests or the appearance of jaundice without other signs. Clay-coloured stools would suggest an alternative diagnosis such as biliary obstruction, while concomitant diabetes mellitus is not linked to Gilbert syndrome. Fasting can trigger an episode of jaundice, so resolution of symptoms during fasting would go against the diagnosis.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 14 - A 66-year-old man presents with a change in bowel habit. He has noticed...

    Incorrect

    • A 66-year-old man presents with a change in bowel habit. He has noticed that over the last three to four weeks he is passing looser, more frequent stools on a daily basis. Prior to the last three to four weeks he has not had any persistent problems with his bowels. He denies any rectal bleeding. He has no significant past history of any bowel problems.

      On examination his abdomen feels normal and his rectal examination is normal. You weigh him and his weight is the same as six months ago.

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Refer him urgently to a lower gastrointestinal specialist

      Explanation:

      NICE Guidelines for Urgent Referral and Faecal Occult Blood Testing in Patients with Change in Bowel Habit

      In accordance with NICE guidelines, patients aged 60 years and older with a change in bowel habit towards looser and more frequent stools (without rectal bleeding) should be urgently referred. This applies to our 68-year-old male patient. While faecal occult blood testing is not necessary in this case, NICE offers guidance on whom to test for colorectal cancer using this method.

      According to the guidelines, faecal occult blood testing should be offered to adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss. Additionally, those aged under 60 with changes in bowel habit or iron-deficiency anaemia should also be tested. For patients aged 60 and over, testing should be offered if they have anaemia even in the absence of iron deficiency.

      It is important to follow these guidelines to ensure timely and appropriate management of patients with potential colorectal cancer.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 15 - A 68-year-old man presents with a history of epigastric pain typical of dyspepsia...

    Incorrect

    • A 68-year-old man presents with a history of epigastric pain typical of dyspepsia which had been present for three months, together with weight loss of 2 stone over the same period.

      He had been treated with a proton pump inhibitor but had not benefited from this therapy. More recently he had noticed a difficulty when trying to eat solids and frequently vomited after meals.

      On examination he had a palpable mass in the epigastrium and his full blood count revealed a haemoglobin of 85 g/L (130-180).

      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Carcinoma of stomach

      Explanation:

      Alarm Symptoms of Foregut Malignancy

      The presence of alarm symptoms in patients over 55 years old, such as weight loss, bleeding, dysphagia, vomiting, blood loss, and a mass, are indicative of a malignancy of the foregut. It is crucial to refer these patients for urgent endoscopy, especially if dysphagia is a new onset symptom.

      However, it is unfortunate that patients with alarm symptoms are often treated with PPIs instead of being referred for further evaluation. Although PPIs may provide temporary relief, they only delay the diagnosis of the underlying tumor. Therefore, it is important to recognize the significance of alarm symptoms and promptly refer patients for appropriate diagnostic testing.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 50-year-old man presents to the clinic complaining of diarrhoea that has been...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - A 30-year old with newly diagnosed ulcerative colitis is initiated on mesalazine following...

    Incorrect

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

      Your Answer:

      Correct Answer: Acute pancreatitis

      Explanation:

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

      Aminosalicylate Drugs for Inflammatory Bowel Disease

      Aminosalicylate drugs are commonly used to treat inflammatory bowel disease (IBD). These drugs work by releasing 5-aminosalicyclic acid (5-ASA) in the colon, which acts as an anti-inflammatory agent. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis.

      Sulphasalazine is a combination of sulphapyridine and 5-ASA. However, many of the side effects associated with this drug are due to the sulphapyridine component, such as rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Mesalazine is a delayed release form of 5-ASA that avoids the sulphapyridine side effects seen in patients taking sulphasalazine. However, it is still associated with side effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis.

      Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken down by colonic bacteria. It is important to note that aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis. Therefore, a full blood count is a key investigation in an unwell patient taking these drugs. Pancreatitis is also more common in patients taking mesalazine compared to sulfasalazine.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - A 30-year-old man presents to his General Practitioner with cramping abdominal pain and...

    Incorrect

    • A 30-year-old man presents to his General Practitioner with cramping abdominal pain and profuse diarrhoea, which is sometimes bloody. He thinks it may be related to some chicken he ate 3 days ago before returning from a holiday in South East Asia. He has no other comorbidities and works in the local pub.
      On examination, his temperature is 38.0 °C. There is mild tenderness in the left iliac fossa. His observations are normal. A stool sample is positive for campylobacter.
      Which of the following is the most appropriate management?

      Your Answer:

      Correct Answer: Prescribe an antibiotic

      Explanation:

      Managing Campylobacter Infection: Antibiotics, Hydration, and Work Restrictions

      Campylobacter is a common bacterial cause of infectious intestinal disease, often contracted through undercooked meat, contaminated water, or contact with infected animals. When a patient presents with symptoms such as fever, bloody diarrhea, and abdominal pain, a stool culture should be performed to confirm the diagnosis. According to NICE guidelines, antibiotic treatment is recommended for patients with positive stool cultures and severe symptoms. Erythromycin is the first-line choice, with alternatives including azithromycin, clarithromycin, and ciprofloxacin.

      Patients should not return to work for at least 48 hours after the last episode of diarrhea or vomiting, and longer if they work with food or in other specific settings. Hospital admission is only necessary for severe symptoms or systemic illness. Antimotility drugs are not recommended for patients with possible Shiga toxin-producing Escherichia coli infection, but may be useful for travelers’ diarrhea. Oral rehydration salts are important for managing symptoms and preventing dehydration. With appropriate treatment and management, most cases of Campylobacter infection will resolve within a week.

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      • Gastroenterology
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  • Question 19 - A 72-year-old woman presents with painless pitting oedema of the right lower leg....

    Incorrect

    • A 72-year-old woman presents with painless pitting oedema of the right lower leg. It has been present for 2 months. She has noticed some abdominal bloating and has lost a little weight. There is no calf tenderness, or erythema. She has well-controlled hypertension and takes amlodipine and bendroflumethiazide.
      Select from the list the single most appropriate action.

      Your Answer:

      Correct Answer: Pelvic examination

      Explanation:

      Diagnosis and Causes of Leg Swelling: Importance of History and Examination

      Leg swelling can be caused by a variety of factors, and a proper diagnosis is crucial for effective treatment. Bilateral swelling is often linked to systemic conditions, while unilateral swelling is more commonly due to local causes. In cases of unilateral swelling, a pelvic mass should be considered as a potential cause. While a recent deep vein thrombosis is unlikely in this patient, a careful history and examination, along with appropriate tests, are necessary to determine the underlying cause. Symptomatic treatments should not be used without a definitive diagnosis.

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      • Gastroenterology
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  • Question 20 - A 50-year-old man presents with long-standing bowel symptoms that go back several years....

    Incorrect

    • A 50-year-old man presents with long-standing bowel symptoms that go back several years. He recently joined the practice and reports experiencing bouts of abdominal pain and diarrhea that can last up to a few weeks at a time. His previous GP diagnosed him with irritable bowel syndrome. He also has a history of ankylosing spondylitis, which was diagnosed in his early 20s, and recurrent mouth ulcers. He takes ibuprofen as needed to manage spinal pain from his ankylosing spondylitis.

      He is now presenting because he has had abdominal pain and profuse diarrhea for the past two weeks. He is having bowel movements 3-4 times a day, which is similar to previous attacks, but he is more concerned this time because he has noticed fresh blood mixed in with his stools. He has not traveled abroad and has had no contact with sick individuals. He denies any weight loss. He saw the Out of Hours GP service a few days ago, and they submitted a stool sample for testing, which showed no evidence of an infectious cause.

      On examination, he is hydrated and afebrile. His blood pressure is 138/90 mmHg, his pulse rate is 88 bpm, and he is not systemically unwell. His abdomen is tender around the umbilicus and across the lower abdomen. He has no guarding or acute surgical findings, and there are no masses or organomegaly. Due to the rectal blood loss, you perform a rectal examination, which reveals several perianal skin tags but nothing focal in the rectum.

      What is the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: In view of the ongoing loose stools and rectal bleeding refer him urgently to a lower gastrointestinal specialist as a suspected cancer

      Explanation:

      Possible Crohn’s Disease Diagnosis

      This patient’s symptoms suggest a possible diagnosis of Crohn’s disease, which has been previously misdiagnosed as irritable bowel syndrome. The recent discovery of blood in his stools is not consistent with IBS and indicates an alternative cause. Additionally, the presence of ankylosing spondylitis, mouth ulcers, and skin tags are all associated with Crohn’s disease.

      To confirm the diagnosis, the patient should undergo faecal calprotectin and blood tests, including FBC, U&Es, albumin, CRP, and ESR. These tests can be performed in primary care. However, the patient should also be referred to a lower GI specialist for further evaluation and confirmation of the diagnosis.

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  • Question 21 - A 76-year-old man presents to his General Practitioner for a routine check-up and...

    Incorrect

    • A 76-year-old man presents to his General Practitioner for a routine check-up and medication review. His history includes congestive cardiac failure, hypertension, rheumatoid arthritis and dementia. He is allergic to penicillin. He was admitted to the hospital one month ago suffering from acute exacerbation of congestive cardiac failure. During his admission, his medications were adjusted.
      Two weeks following discharge, he attended an out-of-hours clinic and was treated for a sore throat. He says he has been well overall since then other than having pains in his knees, which he has been treating with over-the-counter painkillers. The treating doctor decides to take some routine bloods.
      Investigation Result Normal value
      Bilirubin 54 µmol/l < 21 µmol/l
      Alanine aminotransferase (ALT) 43 IU/l < 40 IU/l
      Alkaline phosphatase (ALP) 323 IU/l 40–129 IU/l
      Gamma-glutamyl transferase (GGT) 299 IU/l 7–33 IU/l
      Albumin 32 g/l 35–55 g/l
      Which of the following medications is most likely to have caused the abnormalities in this patient’s liver function tests?

      Your Answer:

      Correct Answer: Erythromycin

      Explanation:

      Differential Diagnosis of Abnormal Liver Function Tests

      Abnormal liver function tests can be caused by a variety of factors, including medication use. In this case, the patient displays a cholestatic picture with a rise in alkaline phosphatase and gamma-glutamyl transferase levels exceeding the rise in alanine aminotransferase levels. Here is a differential diagnosis of potential causes:

      Erythromycin: This medication can cause cholestatic hepatotoxicity, which may have been used to treat the patient’s sore throat.

      Digoxin: While digoxin is a potentially toxic drug, it doesn’t typically cause hepatotoxicity. Symptoms of digoxin toxicity may include arrhythmias, gastrointestinal disturbance, confusion, or yellow vision.

      Methotrexate: Hepatotoxicity is a well-known side effect of methotrexate use, but it would be expected to see higher ALT levels in this case.

      Paracetamol: Overdosing on paracetamol can cause hepatotoxicity, but it would typically present as hepatocellular damage with a predominant rise in transaminases.

      Rosuvastatin: Statins may cause abnormalities in liver function tests, but cholestatic hepatotoxicity is rare and would not typically present with a disproportionate rise in transaminases.

      In conclusion, the patient’s abnormal liver function tests may be attributed to erythromycin use, but further investigation is necessary to confirm the diagnosis.

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  • Question 22 - A 35-year-old woman has chronic pancreatitis. She has lost weight and has diarrhoea...

    Incorrect

    • 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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  • Question 23 - A 50-year-old woman visited her doctor with complaints of intense pain in the...

    Incorrect

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

      What is the probable reason for her symptoms?

      Your Answer:

      Correct Answer: Thrombosed haemorrhoid

      Explanation:

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

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  • Question 24 - A 63-year-old man initially reported experiencing itching on his back. Subsequently, he began...

    Incorrect

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

      Your Answer:

      Correct Answer: Urgent CT scan

      Explanation:

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

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

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  • Question 25 - Benjamin, who has been struggling with bowel issues, has been diagnosed with irritable...

    Incorrect

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

      Your Answer:

      Correct Answer: Reduce insoluble fibre intake

      Explanation:

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

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

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

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  • Question 26 - You are evaluating a 37-year-old man who presented with an anal fissure caused...

    Incorrect

    • You are evaluating a 37-year-old man who presented with an anal fissure caused by constipation and straining. He reports no systemic symptoms and is generally in good health. Despite using lidocaine ointment as prescribed, he continues to experience severe rectal pain during bowel movements and passes bright red blood with every stool. His stools have become softer due to modifications in his diet and regular lactulose use. What is the next step in managing this patient's condition?

      Your Answer:

      Correct Answer: Prescribe topical GTN ointment for 6-8 weeks and review if still not healed

      Explanation:

      To alleviate pain and promote healing, suggest using an ointment (if there are no contraindications) twice a day for 6-8 weeks. Referral to colorectal surgeons is not necessary at this time since there are no indications of a severe underlying condition. If the GTN treatment is ineffective after 6-8 weeks, referral to the surgeons may be considered. Topical diltiazem may be prescribed under specialist guidance, but hydrocortisone ointment is not a recommended treatment for anal fissures.

      Understanding Anal Fissures: Causes, Symptoms, and Treatment

      Anal fissures are tears in the lining of the anal canal that can cause pain and rectal bleeding. They can be acute or chronic, depending on how long they have been present. Risk factors for developing anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.

      Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, other underlying causes such as Crohn’s disease should be considered.

      Management of acute anal fissures involves softening stool, dietary advice, and the use of bulk-forming laxatives or lubricants before defecation. Topical anaesthetics and analgesia can also be used to manage pain.

      For chronic anal fissures, the same techniques should be continued, but topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after 8 weeks, surgery (sphincterotomy) or botulinum toxin may be considered and a referral to secondary care may be necessary.

      Understanding the causes, symptoms, and treatment options for anal fissures can help individuals manage their condition and seek appropriate medical care when necessary.

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  • Question 27 - Which of the following patients is most likely to require screening for hepatocellular...

    Incorrect

    • Which of the following patients is most likely to require screening for hepatocellular carcinoma?

      Your Answer:

      Correct Answer: A 45-year-old man with liver cirrhosis secondary to hepatitis C

      Explanation:

      Hepatocellular carcinoma (HCC) is a type of cancer that ranks third in terms of prevalence worldwide. The most common cause of HCC globally is chronic hepatitis B, while chronic hepatitis C is the leading cause in Europe. The primary risk factor for developing HCC is liver cirrhosis, which can result from various factors such as hepatitis B & C, alcohol, haemochromatosis, and primary biliary cirrhosis. Other risk factors include alpha-1 antitrypsin deficiency, hereditary tyrosinosis, glycogen storage disease, aflatoxin, certain drugs, porphyria cutanea tarda, male sex, diabetes mellitus, and metabolic syndrome.

      HCC often presents late and may exhibit features of liver cirrhosis or failure such as jaundice, ascites, RUQ pain, hepatomegaly, pruritus, and splenomegaly. In some cases, it may manifest as decompensation in patients with chronic liver disease. Elevated levels of alpha-fetoprotein (AFP) are also common. High-risk groups such as patients with liver cirrhosis secondary to hepatitis B & C or haemochromatosis, and men with liver cirrhosis secondary to alcohol should undergo screening with ultrasound (+/- AFP).

      Management options for early-stage HCC include surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolisation, and sorafenib, a multikinase inhibitor. Proper management and early detection are crucial in improving the prognosis of HCC.

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  • Question 28 - A 67-year-old male presents with problems with constipation.

    He has a history of...

    Incorrect

    • A 67-year-old male presents with problems with constipation.

      He has a history of ischaemic heart disease for which he is receiving medication.

      Which of the following agents is most likely to be responsible for his presentation?

      Your Answer:

      Correct Answer: Aspirin

      Explanation:

      Verapamil and its Side Effects

      Verapamil is a medication that is commonly known to cause constipation. In addition to this, it is also associated with other side effects such as oedema and headaches. Oedema is the swelling of body tissues, usually in the legs and feet, while headaches can range from mild to severe. It is important to be aware of these potential side effects when taking verapamil and to speak with a healthcare provider if they become bothersome or persistent. Proper monitoring and management can help to alleviate these symptoms and ensure the safe and effective use of verapamil.

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  • Question 29 - A 42-year-old male presents with jaundice and pruritus. He has a history of...

    Incorrect

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

      Your Answer:

      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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  • Question 30 - A 25-year-old male medical student who has been feeling unwell for several days...

    Incorrect

    • A 25-year-old male medical student who has been feeling unwell for several days is noticed to have slightly icteric sclerae by his girlfriend and has liver function tests performed. The results of these are normal apart from a serum bilirubin concentration of 44 µmol/l (normal < 21 μmol/L). His urine doesn't contain bilirubin.
      Select from the list the single most likely diagnosis.

      Your Answer:

      Correct Answer: Gilbert syndrome

      Explanation:

      Possible Causes of Jaundice: A Differential Diagnosis

      Jaundice is a common clinical manifestation of various diseases. In this case, the patient presents with jaundice, and the differential diagnosis includes several inherited disorders of bilirubin metabolism, chronic haemolytic disorders, and infectious diseases.

      Gilbert Syndrome: This is a relatively mild inherited disorder caused by a deficiency of glucuronosyl transferase, resulting in an accumulation of unconjugated bilirubin. The jaundice usually subsides in a few days and may be more obvious during an intercurrent illness.

      Dubin–Johnson Syndrome: This is another inherited disorder of bilirubin metabolism, but in this case, there is a defect in the secretion of bilirubin from the liver. The bilirubin that accumulates in the plasma is conjugated, water-soluble, and excreted in the urine. Onset of jaundice may commonly first occur during puberty or early adulthood and can be precipitated by alcohol, infection, pregnancy, or contraceptive pill use.

      Hereditary Spherocytosis: This is a chronic haemolytic disorder due to a defect in the red cell membrane, most frequently in spectrin, a structural protein. It can present with a wide range of severity, from jaundice at birth to asymptomatic anaemia or jaundice in adults.

      Infectious Mononucleosis: This viral infection can cause hepatitis and jaundice, but elevated transaminase activity would be expected.

      Rotor Syndrome: This is a possible differential diagnosis, but this condition would cause a mixed hyperbilirubinaemia. Therefore, Gilbert’s disease is the more likely diagnosis in this scenario.

      In conclusion, the differential diagnosis of jaundice includes several inherited disorders of bilirubin metabolism, chronic haemolytic disorders, and infectious diseases. A thorough evaluation of the patient’s medical history, physical examination, and laboratory tests is necessary to establish the correct diagnosis and provide appropriate treatment.

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  • Question 31 - A 45-year-old woman is discharged from hospital following a haematemesis with a diagnosis...

    Incorrect

    • 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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  • Question 32 - A 70-year-old woman has observed abdominal swelling for a few months, along with...

    Incorrect

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

      Your Answer:

      Correct Answer: Ovarian carcinoma

      Explanation:

      Differential Diagnosis for Abdominal Distension and Elevated Creatinine Level

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

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  • Question 33 - A 68-year-old man presents to the clinic with complaints of fatigue and lack...

    Incorrect

    • A 68-year-old man presents to the clinic with complaints of fatigue and lack of energy. His recent blood test showed macrocytosis and a low haemoglobin level, indicating a folic acid deficiency. He requests dietary recommendations from the physician to address this issue.
      What is the most suitable food item to suggest?

      Your Answer:

      Correct Answer: Spinach

      Explanation:

      Folate Content in Common Foods

      Folate, also known as vitamin B9, is an essential nutrient that is important for cell growth and development. While it is found naturally in many foods, it is also added to processed foods and supplements in the form of folic acid. Here is a breakdown of the folate content in some common foods:

      Spinach: With 194 μg of folic acid per 100g, spinach is the richest source of folate on this list.

      Egg: While eggs contain 47 μg of folic acid per 100g, they only provide around a quarter of the folate per 100g that is found in spinach.

      Carrot: Carrots contain about 21 μg of folic acid per 100g, less than half the amount of folate found in eggs and only around 11% of the amount provided by spinach.

      Milk: Cow’s milk contains 5-7 μg of folic acid per 100g, making it the second-lowest source of folate in this range of options.

      Apple: Apples provide the lowest source of folate in this range of options, with only about 3 μg of folic acid per 100g.

      It is important to note that women who are pregnant or breastfeeding require more folate and should take a daily supplement of 400 micrograms. While many food manufacturers fortify their products with folic acid, wholegrain products already contain natural folate. Folate deficiency can occur due to poor intake, excessive alcohol consumption, or malnutrition.

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  • Question 34 - A 20-year-old man with a history of ulcerative colitis presents with a 3-day...

    Incorrect

    • A 20-year-old man with a history of ulcerative colitis presents with a 3-day history of abdominal pain and bloody diarrhoea, passing around 8 stools per day. He denies any recent travel or exposure to unwell individuals.

      During examination, his heart rate is 95 beats per minute, blood pressure is 110/70 mmHg, and temperature is 37.8 ºC. His abdomen is soft but mildly tender throughout.

      What is the best course of action for managing this patient's symptoms?

      Your Answer:

      Correct Answer: Admit to hospital

      Explanation:

      Hospitalization and IV corticosteroids are necessary for the treatment of a severe flare of ulcerative colitis, as seen in this patient with over 6 bloody stools per day and systemic symptoms like tachycardia and fever. Mild to moderate cases can be managed with aminosalicylates and oral steroids. Simple analgesia, increased fluid intake, and oral antibiotics are not effective in managing severe flares of ulcerative colitis.

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

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

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

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  • Question 35 - A 54-year-old woman is admitted to your intermediate care unit with a significant...

    Incorrect

    • A 54-year-old woman is admitted to your intermediate care unit with a significant medical history of chronic alcoholism. She sustained a brain injury six weeks ago after falling down the stairs at home and is currently bedridden. She was transferred for further rehabilitation and is being fed through a percutaneous gastrostomy, which was inserted three days ago after an initial period of nasogastric tube feeding. The nursing staff reports that she has become increasingly unwell over the past 24 hours, with lethargy and confusion. Upon examination, she appears to be short of breath, and there is evidence of peripheral and pulmonary edema. What is the most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Aspiration pneumonia

      Explanation:

      Refeeding Syndrome in Malnourished Patients

      Refeeding malnourished patients through enteral feeding requires careful monitoring of electrolytes and minerals. This is because refeeding can trigger a significant anabolic response that affects the levels of electrolytes and minerals essential to cellular function. Unfortunately, refeeding syndrome is often under-recognized and under-diagnosed. The metabolic changes that occur during refeeding can lead to marked hypophosphatemia and shifts in potassium, magnesium, glucose, and thiamine levels.

      Refeeding syndrome is primarily caused by hypophosphatemia and can result in severe cardiorespiratory failure, edema, confusion, convulsions, coma, and even death. Therefore, it is crucial to closely monitor patients undergoing refeeding to prevent and manage refeeding syndrome.

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  • Question 36 - A 46-year-old man is a frequent visitor to surgery complaining of pruritus ani.

    You...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 37 - A 68-year-old woman is discharged home after undergoing a loop ileostomy following an...

    Incorrect

    • A 68-year-old woman is discharged home after undergoing a loop ileostomy following an anterior resection of a rectal carcinoma. She has recovered well over the last week. She is not taking anticoagulants and is being careful to drink at least one litre of extra water a day.
      What is the most likely early complication she may experience following this procedure?

      Your Answer:

      Correct Answer: Irritant dermatitis

      Explanation:

      Complications of Ileostomy: Understanding the Risks

      Ileostomy is a surgical procedure that involves creating an opening in the abdomen to allow waste to pass out of the body. While the procedure can be life-changing for patients with certain medical conditions, it is not without its risks. Here are some of the potential complications of ileostomy:

      Irritant Dermatitis: The skin around the stoma can become irritated and inflamed, either due to contact with stoma equipment or leakage of feces. Hypoallergenic products and corticosteroid lotions can help manage this condition.

      Parastomal Hernia: This occurs when a bulge or protrusion develops around the stoma site. While conservative management is often possible, surgery may be necessary in some cases.

      Dehydration: High output from the ileostomy can lead to dehydration, making it important for patients to maintain a good fluid intake.

      Pernicious Anemia: As vitamin B12 is absorbed in the terminal ileum, patients may develop pernicious anemia over time. Supplements can help manage this condition.

      Severe Stomal Hemorrhage: While some bleeding is common after bag changes, severe bleeding is more likely in patients taking antiplatelet drugs.

      Understanding these potential complications can help patients and healthcare providers monitor for early signs and manage them effectively.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 38 - You are the GP trainee doing your morning clinic. You see a 35-year-old...

    Incorrect

    • You are the GP trainee doing your morning clinic. You see a 35-year-old woman with coeliac disease.

      Which of the following is indicated as part of her management?

      Your Answer:

      Correct Answer: Administration of the pneumococcal vaccine

      Explanation:

      To prevent overwhelming pneumococcal sepsis due to hyposplenism, Coeliac UK advises that individuals with coeliac disease receive a pneumococcal infection vaccine and a booster every five years. Pertussis vaccines beyond those in the vaccination schedule are unnecessary. According to NICE CKS guidelines, annual blood tests for FBC, ferritin, thyroid function tests, liver function tests, B12, and folate are recommended. Calprotectin is utilized to assess gut inflammation, often as part of the diagnostic process for inflammatory bowel disease. Faecal occult blood testing is typically conducted if there are concerns about bowel cancer.

      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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      • Gastroenterology
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  • Question 39 - A 58-year-old woman comes to her General Practitioner with complaints of abdominal pain,...

    Incorrect

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

      Your Answer:

      Correct Answer: Carcinoma of the pancreas

      Explanation:

      Differential Diagnosis of Abdominal Pain: A Case Study

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

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

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

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

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

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      • Gastroenterology
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  • Question 40 - A 48-year-old woman complains of fatigue and itching. She denies any alcohol abuse...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 41 - A 55-year-old woman presents to the clinic with abnormal liver function tests (LFTs)....

    Incorrect

    • A 55-year-old woman presents to the clinic with abnormal liver function tests (LFTs). She reports drinking no more than 3 units of alcohol per week and has no significant medical history. Her dentist prescribed amoxicillin for a dental infection 2 weeks ago. On physical examination, she is overweight with a BMI of 30 kg/m2. Her LFTs reveal:
      ALT 120 U/L (5-40)
      AST 130 U/L (10-40)
      Alkaline phosphatase 200 U/L (45-105)
      What is the most likely cause of her abnormal LFTs?

      Your Answer:

      Correct Answer: Non-alcoholic fatty liver disease

      Explanation:

      Non-Alcoholic Fatty Liver Disease (NAFLD) and its Causes

      Non-alcoholic fatty liver disease (NAFLD) is a common condition caused by the accumulation of fat in the liver, leading to inflammation. It is often associated with obesity, hypertension, dyslipidaemia, and insulin resistance. NAFLD is the most likely cause of liver enzyme abnormalities in patients with these conditions. However, other causes of hepatitis should be excluded before making this diagnosis.

      Patients who are obese and diabetic are advised to lose weight and control their diabetes. A low-fat, low-calorie diet is usually recommended alongside treatment to lower HbA1c. Patients with NAFLD should avoid alcohol or other substances that could be harmful to the liver. It is important to note that deranged liver enzymes are not listed as side effects for amoxicillin in the British National Formulary.

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      • Gastroenterology
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  • Question 42 - A 35-year-old man with a known diagnosis of ulcerative colitis presents with a...

    Incorrect

    • 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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  • Question 43 - A 31-year-old female with a history of ulcerative colitis presents with an increase...

    Incorrect

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

      Your Answer:

      Correct Answer: Rectal mesalazine

      Explanation:

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

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

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

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

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

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

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      • Gastroenterology
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  • Question 44 - A 62-year-old Chinese man comes to the General Practice Surgery complaining of weight...

    Incorrect

    • A 62-year-old Chinese man comes to the General Practice Surgery complaining of weight loss, jaundice and right upper quadrant pain that has been going on for 3 months. He is a non-smoker and only drinks alcohol occasionally.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Hepatocellular carcinoma (HCC)

      Explanation:

      Comparison of Liver Cancer Types and Symptoms

      Hepatocellular carcinoma (HCC) is a primary liver cancer that originates from hepatocytes and is commonly caused by alcohol abuse, viral hepatitis, and metabolic liver disease. It is more prevalent in Asia and Africa due to the high incidence of hepatitis B, hepatitis C, and aflatoxin exposure. Symptoms of HCC include right upper quadrant pain, jaundice, and weight loss.

      Oesophageal cancer, cholangiocarcinoma, pancreatic carcinoma, and stomach cancer can also present with similar symptoms to HCC, but each has its own unique risk factors and prevalence. Oesophageal cancer is mainly caused by alcohol and tobacco use, while cholangiocarcinoma is a rare cancer of the bile ducts. Pancreatic carcinoma is more common in older individuals or those with chronic pancreatitis. Stomach cancer may cause similar symptoms if it metastasizes to the liver, but it is less common than HCC.

      In summary, while these cancers may present similarly, the patient’s ethnicity, age, and risk factors can help determine the most likely type of liver cancer.

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  • Question 45 - A 56-year-old man with a history of ulcerative colitis presents to his GP...

    Incorrect

    • A 56-year-old man with a history of ulcerative colitis presents to his GP for a follow-up appointment after experiencing a recent exacerbation that required oral corticosteroids for remission. He reports feeling well with no abdominal symptoms, but has had four exacerbations in the past year that required treatment with oral corticosteroids. His current medications include paracetamol and mesalazine. On examination, his vital signs are within normal limits and his abdominal exam is unremarkable. His recent blood test results show no significant abnormalities. According to NICE guidelines, what is the recommended next step in managing his ulcerative colitis?

      Your Answer:

      Correct Answer: Oral thiopurines (azathioprine or mercaptopurine)

      Explanation:

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

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

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

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      • Gastroenterology
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  • Question 46 - A 32-year-old man presents to his General Practitioner with a long history of...

    Incorrect

    • A 32-year-old man presents to his General Practitioner with a long history of intermittent abdominal discomfort and diarrhoea. He has noticed that his symptoms are particularly linked to gluten-containing foods and brings a food diary to support this theory. On examination, he has a body mass index of 19 kg/m2 and is clinically anaemic. Coeliac disease is suspected.
      Which of the following investigations will most reliably diagnose this condition?

      Your Answer:

      Correct Answer: Microscopic examination of a small bowel biopsy specimen

      Explanation:

      Diagnostic Tests for Coeliac Disease

      Coeliac disease is an autoimmune disorder of the small bowel induced by gluten. The gold standard for diagnosis is the detection of subtotal villous atrophy on a small-bowel biopsy. However, the detection of tissue transglutaminase IgA antibodies is a widely used screening test with high specificity and sensitivity. Total immunoglobulin A (IgA) should also be measured in case of IgA deficiency. Antibodies become undetectable after 6-12 months of a gluten-free diet, making them useful for monitoring the disease. The xylose absorption test is not appropriate for this patient, while the detection of anti-gliadin antibodies and anti-endomysial antibodies can aid diagnosis but are not preferred methods. Serology for anti-tissue transglutaminase antibodies is the first-line screening test and aids referral to gastroenterology.

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      • Gastroenterology
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  • Question 47 - A 32-year-old man visits his General Practitioner to discuss his recent diagnosis of...

    Incorrect

    • A 32-year-old man visits his General Practitioner to discuss his recent diagnosis of Crohn's disease. He presented eight months ago with weight loss and a change in bowel habit, and was referred to the Gastroenterology Department. The diagnosis was confirmed and he was successfully treated as an inpatient. At the time, he declined maintenance therapy but has since become very worried about this decision and would like to start the treatment. What is the most suitable agent to maintain remission in this patient?

      Your Answer:

      Correct Answer: Azathioprine

      Explanation:

      Medications for Maintaining Remission in Crohn’s Disease

      Crohn’s disease is a chronic inflammatory condition that affects the digestive tract. While some patients may choose not to take medication to maintain remission, others may opt for drug therapy. The two main options are azathioprine and mercaptopurine, but it is important to measure thiopurine methyltransferase (TPMT) activity before using these drugs. Sulfasalazine is effective in maintaining remission for ulcerative colitis but has limited efficacy for Crohn’s disease. Methotrexate may be considered if other drugs fail or are not tolerated. Metronidazole is used for perianal disease but not for maintaining remission. Conventional corticosteroids like prednisolone or budesonide should not be used for long-term maintenance due to the risks associated with prolonged steroid use. Preventative treatment may be particularly appropriate for those with adverse prognostic factors such as early age of onset, perianal disease, corticosteroid use at presentation, and severe illness at presentation.

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  • Question 48 - A 29-year-old man with a history of ulcerative colitis presents to his primary...

    Incorrect

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

      Your Answer:

      Correct Answer: Mesalazine suppository

      Explanation:

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

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

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

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

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      • Gastroenterology
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  • Question 49 - An overweight 35-year-old woman presents with a short history of right upper-quadrant pain,...

    Incorrect

    • An overweight 35-year-old woman presents with a short history of right upper-quadrant pain, fever, and jaundice. There is no previous history of illness and, apart from the jaundice, she has no signs of chronic liver disease.
      Initial investigations are as follows:
      Investigation Result Normal Values
      Haemoglobin (Hb) 115 g/l 115–155 g/l
      Mean corpuscular volume (MCV) 105 fl 80–100fl
      Bilirubin 162 µmol/l 5-26 µmol/l
      Aspartate transaminase (AST) 145 U/l 5–34 U/l
      Alanine transaminase (ALT) 40 U/l < 55 U/l
      Alkaline phosphatase (ALP) 126 U/l 30–130 U/l
      Gamma glutamyl transferase (GGT) 200 U/l 7–33 U/l
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Alcoholic hepatitis

      Explanation:

      Possible Causes of Acute Right Upper-Quadrant Pain, Fever, and Jaundice: A Differential Diagnosis

      When a patient presents with acute right upper-quadrant pain, fever, and jaundice, several conditions may be responsible. A differential diagnosis can help narrow down the possible causes based on the patient’s symptoms and laboratory results. Here are some potential conditions to consider:

      Alcoholic Hepatitis
      If the patient has a raised ALT or AST, alcoholic hepatitis may be the cause. An AST:ALT ratio >2 is typical of alcoholic liver disease or cirrhosis, and a macrocytosis and raised GGT further support this diagnosis.

      Autoimmune Hepatitis
      A short history of right upper-quadrant pain, fever, and jaundice may suggest autoimmune hepatitis. However, a raised AST:ALT ratio makes alcoholic liver disease more likely.

      Carcinoma of the Head of the Pancreas
      Painless obstructive jaundice, dark urine, and pale stools are typical of carcinoma of the head of the pancreas. As the tumor grows, it may cause epigastric pain that radiates to the back. However, this condition should not present with a fever.

      Cholecystitis
      Cholecystitis can cause similar symptoms, but LFTs would show a different pattern, typically with a raised ALP and GGT and raised bilirubin if the patient is jaundiced. A normal ALP makes cholecystitis less likely.

      Hepatitis A Infection
      Hepatitis A infection can also cause acute right upper-quadrant pain, fever, and jaundice. However, significantly raised ALT and AST levels are typical of this condition because the virus replicates within hepatocytes.

      In summary, a differential diagnosis can help identify the possible causes of acute right upper-quadrant pain, fever, and jaundice. Laboratory results, such as AST:ALT ratio, macrocytosis, and GGT levels, can provide additional clues to narrow down the diagnosis.

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  • Question 50 - A 58-year-old woman presents with fatigue and shortness of breath on exertion. She...

    Incorrect

    • A 58-year-old woman presents with fatigue and shortness of breath on exertion. She has a hiatus hernia diagnosed on upper gastrointestinal endoscopy 3 months ago and takes omeprazole. She has had no respiratory symptoms, no change in bowel habit, no dysphagia or indigestion. On examination she is pale and tachycardic with a pulse rate of 100/min. Abdominal examination is normal. Blood tests reveal the following results:
      Haemoglobin 72 g/l
      White cell count 5.5 x109/l
      Platelets 536 x109/l
      ESR 36 mm/h
      (hypochromic microcytic red blood cells)
      Select from the list the single most likely diagnosis.

      Your Answer:

      Correct Answer: Right-sided colonic carcinoma

      Explanation:

      Causes of Iron Deficiency Anaemia and the Importance of Gastrointestinal Tract Investigation

      Iron deficiency anaemia is a common condition that can be caused by various factors. In older patients, it is important to investigate the gastrointestinal tract as a potential source of bleeding. Right-sided colonic carcinomas often do not cause any changes in bowel habit, leading to late diagnosis or incidental discovery during investigations for anaemia. On the other hand, rectal carcinomas usually result in a change in bowel habit. Oesophageal carcinoma can cause dysphagia and should have been detected during recent endoscopy. Hiatus hernia is unlikely to cause severe anaemia, especially if the patient is taking omeprazole. Poor diet is also an unlikely explanation for new-onset iron deficiency anaemia in older patients. Therefore, routine assessment of iron deficiency anaemia should include investigation of the upper and lower gastrointestinal tract, with particular attention to visualising the caecum.

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      • Gastroenterology
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  • Question 51 - A 62-year old male presents with dysphagia. His symptoms were first noticed a...

    Incorrect

    • 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:

      Correct 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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      • Gastroenterology
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  • Question 52 - A 50-year-old man presents having recently noticed a lump in his right groin...

    Incorrect

    • A 50-year-old man presents having recently noticed a lump in his right groin which disappears when he is recumbent. It is accompanied by some discomfort. He has a chronic cough due to smoking and has had an appendicectomy previously. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Inguinal hernia

      Explanation:

      Inguinal hernia is the most probable reason for a lump in the right groin of a patient in this age group. This type of hernia occurs when a part of the intestine protrudes through the external inguinal ring. It may go unnoticed for a while, cause discomfort or pain, and resolve when lying flat. Femoral hernias are more common in females, while an epigastric hernia or an incisional hernia following appendicectomy would be unlikely in this anatomical site.

      This patient’s persistent cough due to smoking puts him at a higher risk of developing hernias.

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      • Gastroenterology
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  • Question 53 - A 40-year-old woman visits her doctor with a complaint of recurrent central abdominal...

    Incorrect

    • A 40-year-old woman visits her doctor with a complaint of recurrent central abdominal pain that she has been experiencing for a long time. The pain usually subsides when she has a bowel movement. She has an irregular bowel pattern, with instances of both constipation and diarrhea. She has never observed any blood in her feces, and her weight has remained constant.
      Which of the following symptoms is most indicative of the probable diagnosis? Choose ONE option only.

      Your Answer:

      Correct Answer: Central abdominal pain

      Explanation:

      Understanding Irritable Bowel Syndrome: Symptoms and Red Flags

      Irritable bowel syndrome (IBS) is a group of symptoms that affect the intestinal motility, causing central or lower abdominal pain, bloating, alternating constipation and diarrhea, rectal mucous, and tenesmus. However, it is important to note that IBS doesn’t cause rectal bleeding or unintentional weight loss.

      While a high-fiber diet may not necessarily relieve symptoms of IBS, nocturnal diarrhea may indicate an underlying organic disease and should prompt further investigation. It is crucial to recognize these red flag symptoms and seek medical attention to determine the underlying cause.

      Understanding the symptoms and red flags of IBS can help individuals manage their condition and seek appropriate medical care when necessary.

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      • Gastroenterology
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  • Question 54 - A 65-year-old man presents with new onset bilateral gynaecomastia.
    He has been diagnosed with...

    Incorrect

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

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

      Your Answer:

      Correct Answer: Rabeprazole sodium

      Explanation:

      Drugs that can cause gynaecomastia

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

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

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

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      • Gastroenterology
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  • Question 55 - A 25-year-old male blood donor presents with the following blood results:

    Bilirubin 41 µmol/L
    ALP...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 56 - A 29-year-old woman who initially complained of abdominal discomfort and irregular bowel movements...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 57 - Which statement about the epidemiology of colorectal cancer is accurate? ...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 58 - A 32-year-old male presents with central abdominal pain that radiates to the back...

    Incorrect

    • A 32-year-old male presents with central abdominal pain that radiates to the back and vomiting. His amylase level is 1,245 u/dl. Which medication is the most probable cause of his symptoms?

      Your Answer:

      Correct Answer: Sodium valproate

      Explanation:

      Acute pancreatitis is a condition that is primarily caused by gallstones and alcohol consumption in the UK. However, there are other factors that can contribute to the development of this condition. A popular mnemonic used to remember these factors is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine. CT scans can show diffuse parenchymal enlargement with oedema and indistinct margins in patients with acute pancreatitis.

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      • Gastroenterology
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  • Question 59 - A 54-year-old man has recently attended a well-man clinic. He is in good...

    Incorrect

    • A 54-year-old man has recently attended a well-man clinic. He is in good health and reports no symptoms. His body mass index is 22 kg/m2. He takes no regular medication. He is a non-smoker and drinks approximately 3 units of alcohol per week. He presents to you for review of his blood tests, as shown below:

      - eGFR 92 mL/min/1.73m2
      - HBA1c 38 mmol/mol
      - Bilirubin 12 umol/l (3 - 17 umol/l)
      - Alanine transferase (ALT) 70 iu/l (3 - 40 iu/l)
      - Aspartate transaminase (AST) 30 iu/l (3 - 30 iu/l)
      - Alkaline phosphatase (ALP) 95 umol/l (30 - 100 umol/l)
      - Gamma glutamyl transferase (yGT) 55 u/l (8 - 60 u/l)
      - Total protein 72 g/l (60 - 80 g/l)

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

      Your Answer:

      Correct Answer: Arrange a liver screen including a liver ultrasound and blood tests, and review the patient with the results

      Explanation:

      It is common for incidental raised liver function tests to persist even after a month, and normalised liver function tests do not necessarily indicate the absence or resolution of chronic liver diseases. Standard liver screen blood tests include Antinuclear antibody, anti-smooth muscle antibody, serum immunoglobulins, anti-mitochondrial antibody, ferritin, transferrin saturation, and a viral hepatitis screen.

      Given that the patient is currently well, there is no need for immediate hepatology review. Urgent hepatology referral within two weeks is also unnecessary as the patient is not exhibiting any concerning symptoms.

      Since the patient is consuming alcohol within recommended limits, there is no need for a referral for FibroScan (transient elastography).

      According to current guidelines, repeating liver function tests after an initial abnormal result is not recommended as they are unlikely to normalise unless an acute cause has been identified. Waiting for 12 months to repeat the bloods is also inappropriate.

      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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  • Question 60 - A 48-year-old alcoholic patient visits the General Practitioner (GP) for a check-up. He...

    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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      • Gastroenterology
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  • Question 61 - A 42-year-old man comes to the General Practitioner complaining of painful swelling on...

    Incorrect

    • A 42-year-old man comes to the General Practitioner complaining of painful swelling on the side of his anus that has been present for 10 days. Upon perianal examination, there is an inflamed, tender swelling that extends 12 cm lateral to the anus. Due to pain, a digital rectal examination was not performed. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Ischiorectal abscess

      Explanation:

      Differentiating Anorectal Conditions: Ischiorectal Abscess, Rectocele, Inflamed Anal Skin Tag, Perianal Abscess, and Pilonidal Abscess

      An ischiorectal abscess is a deeper and larger abscess that is further from the anus. It presents as a deep, tender swelling and may not have external signs until late. When it discharges, it does so through an external opening that is typically more than 5 cm from the anus.

      A rectocele is a prolapse of the wall between the rectum and the vagina and is not usually painful. It is not present in male patients.

      An anal skin tag is a fibro-epithelial polyp that hangs off the skin around the outside of the anus. It may become infected and inflamed, but it would not extend 12 cm from the anus.

      A perianal abscess is a simple anorectal abscess that arises from glandular crypts in the anus or rectum. It presents as a red, tender swelling close to the anus.

      A pilonidal abscess presents as a painful, tender lump in the natal cleft, which may be fluctuant and have a purulent discharge. It may also have accompanying cellulitis. However, the location described here is not consistent with a pilonidal abscess.

      In summary, understanding the characteristics and locations of different anorectal conditions can aid in their differentiation and appropriate management.

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      • Gastroenterology
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  • Question 62 - What is the most accurate statement regarding gastrointestinal bleeding in patients who are...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 63 - A 50-year-old man presents to his General Practitioner concerned that he may have...

    Incorrect

    • A 50-year-old man presents to his General Practitioner concerned that he may have cirrhosis of the liver. He has regularly drunk more than 30 units of alcohol every week for many years. Over the last three months, he has lost 2 kg in weight. He attributes this to a poor appetite.
      On examination, there are no obvious features.
      What is the most appropriate advice you can provide this patient?

      Your Answer:

      Correct Answer: The presence of chronic hepatitis C infection makes a diagnosis of liver cirrhosis more likely

      Explanation:

      Diagnosing Liver Cirrhosis in Patients with Chronic Hepatitis C Infection

      Liver cirrhosis is a common complication of chronic hepatitis C infection and can be caused by other factors such as alcohol consumption. Patients with chronic hepatitis C infection who are over 55 years old, male, and consume moderate amounts of alcohol are at higher risk of developing cirrhosis. However, cirrhosis can be asymptomatic until complications arise. An ultrasound scan can detect cirrhosis and its complications, but a liver biopsy is the gold standard for diagnosis. Abnormal liver function tests may indicate liver damage, but they are not always conclusive. The absence of signs doesn’t exclude a diagnosis of liver cirrhosis. Further investigation is necessary before considering a liver biopsy.

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      • Gastroenterology
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  • Question 64 - A 56-year-old man complains of fatigue and unexplained weight loss during the past...

    Incorrect

    • A 56-year-old man complains of fatigue and unexplained weight loss during the past few months. He has been suffering from ulcerative colitis since his early 30s. His liver function tests show abnormalities.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Biliary tract carcinoma

      Explanation:

      Differential Diagnosis for a Patient with Ulcerative Colitis and Deranged Liver Function

      Ulcerative colitis (UC) is associated with various conditions, including primary sclerosing cholangitis (PSC), which confers a high risk for cholangiocarcinoma. Therefore, a patient with UC and deranged liver function is likely to have cancer, specifically cholangiocarcinoma. Gallstones, chronic pancreatitis, and small bowel lymphoma are less likely diagnoses due to their lack of association with UC and/or absence of relevant symptoms. Primary biliary cholangitis is a possibility, but its incidence is not increased in patients with UC. Overall, cholangiocarcinoma should be considered as a potential diagnosis in a patient with UC and deranged liver function.

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      • Gastroenterology
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  • Question 65 - A 54-year-old woman has a 3-week history of increasing jaundice and dark urine....

    Incorrect

    • A 54-year-old woman has a 3-week history of increasing jaundice and dark urine. In the past 4 months she has noticed intermittent loose, pale stools and has lost 6 kg in weight. On examination she is thin and jaundiced, with epigastric tenderness and a palpable gallbladder. Urine dipstick shows glucose +++, bilirubin +++ and urobilinogen +.
      Select from the list the single most likely diagnosis.

      Your Answer:

      Correct Answer: Carcinoma of the head of the pancreas

      Explanation:

      Courvoisier’s Law and Obstructive Jaundice in Diagnosing Pancreatic Carcinoma

      Courvoisier’s law is a crucial factor in diagnosing the cause of jaundice. If a palpable gallbladder is present in the presence of jaundice, it is unlikely to be due to gallstones. This is because gallstones cause a fibrotic gallbladder that will not distend in the presence of obstruction of the common bile duct. However, absence of Courvoisier’s sign doesn’t rule out malignancy.

      In cases of obstructive jaundice, haemochromatosis can be excluded as a cause. The initial symptoms of haemochromatosis are usually vague and nonspecific, such as fatigue, weakness, arthropathy, and nonspecific abdominal problems.

      Of the three obstructive neoplastic processes that remain, carcinoma of the head of the pancreas is the only one that will cause glycosuria. Therefore, the development of diabetes in anyone who is non-obese and over 50 years old without definite risk factors should raise suspicion of pancreatic carcinoma.

      In conclusion, understanding Courvoisier’s law and the exclusions of other potential causes of obstructive jaundice is crucial in diagnosing pancreatic carcinoma.

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      • Gastroenterology
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  • Question 66 - A 50-year-old woman presents with jaundice and itching.
    Which of the following results would...

    Incorrect

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

      Your Answer:

      Correct Answer: Antimitochondrial antibodies

      Explanation:

      Understanding Primary Biliary Cholangitis: Diagnostic Tests and Markers

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

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

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

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

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      • Gastroenterology
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  • Question 67 - A 45-year-old man returns after he was found to have abnormal liver biochemistry....

    Incorrect

    • A 45-year-old man returns after he was found to have abnormal liver biochemistry. Investigations showed he had an alanine aminotransferase (ALT) of 98 iu/l and was Hep B surface-antigen positive.
      Select from the list the single statement that is true of chronic hepatitis due to the hepatitis B virus.

      Your Answer:

      Correct Answer: It carries an increased risk of subsequent hepatocellular carcinoma

      Explanation:

      Understanding Chronic Hepatitis B Infection

      Chronic hepatitis B infection occurs in up to 10% of adults who contract the virus. This means that the virus remains in the body long-term, with the surface antigen (HBsAg) persisting in the serum. However, up to two-thirds of people in the chronic phase remain well and do not experience any liver damage or other issues. This is known as the carrier state or chronic inactive hepatitis B, where HBeAg is absent, anti-HBe is present, and HBV DNA levels are low or undetectable. While carriers can still transmit the virus, their infectivity is lower than those with chronic active hepatitis.

      Around 20% of carriers will eventually clear the virus naturally, but this can take several years. However, some carriers may experience spontaneous reactivation of hepatitis B due to the emergence of the HBeAg-negative strain of the virus. The remaining individuals with chronic hepatitis B experience persistent liver inflammation, also known as chronic active hepatitis B. Symptoms can include muscle aches, fatigue, nausea, lack of appetite, intolerance to alcohol, liver pain, jaundice, and depression. HBeAg is usually still present, and the virus is still replicating, with raised HBV DNA levels and high infectivity. Transaminase levels may be elevated, but not always significantly.

      If left untreated, chronic active hepatitis B can lead to cirrhosis and even hepatocellular carcinoma. It’s important to note that hepatitis D is a separate virus that only infects individuals who are already infected with hepatitis B. Understanding the different phases and potential outcomes of chronic hepatitis B infection is crucial for proper management and treatment.

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      • Gastroenterology
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  • Question 68 - You see a child who you are investigating for coeliac disease. Their serology...

    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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      • Gastroenterology
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  • Question 69 - A 56-year-old man comes to the clinic, having just returned from living in...

    Incorrect

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

      Your Answer:

      Correct Answer: Serial carcinoembryonic antigen (CEA) monitoring

      Explanation:

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

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

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

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

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

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      • Gastroenterology
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  • Question 70 - A 25-year-old woman comes to her doctor with jaundice, anorexia, nausea, and mild...

    Incorrect

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

      Your Answer:

      Correct Answer: Viral hepatitis

      Explanation:

      Liver Disorders During Pregnancy: Causes and Consequences

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

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

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

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

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

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

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

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      • Gastroenterology
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  • Question 71 - A 58-year-old woman has acute pancreatitis.

    Which one of the following is the most...

    Incorrect

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

      Which one of the following is the most likely cause?

      Your Answer:

      Correct Answer: Mumps

      Explanation:

      Causes of Pancreatitis: Gallstones and Alcohol

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

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      • Gastroenterology
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  • Question 72 - You receive a positive faecal immunochemical test (FIT) result following investigation of an...

    Incorrect

    • 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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  • Question 73 - A 25-year-old woman presents to her General Practitioner in her 28th week of...

    Incorrect

    • 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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  • Question 74 - A 32-year-old woman presents to her General Practitioner complaining of long-standing intermittent abdominal...

    Incorrect

    • 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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  • Question 75 - A 50-year-old woman presents to her General Practitioner following an Occupational Health screen.
    Investigations...

    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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  • Question 76 - A 45-year-old man comes in for a routine check-up and reports experiencing persistent...

    Incorrect

    • A 45-year-old man comes in for a routine check-up and reports experiencing persistent fatigue and indigestion. He has been belching excessively at night and is bothered by constant bloating. He denies any alterations in his bowel movements and has not noticed any rectal bleeding. During the physical examination, you observe mild conjunctival pallor and a slightly distended abdomen. A rectal exam reveals no abnormalities.

      What is the most frequent underlying condition that could explain these symptoms?

      Your Answer:

      Correct Answer: Coeliac disease

      Explanation:

      Coeliac disease is the most likely underlying diagnosis as it can present with nonspecific gastrointestinal symptoms and fatigue. Bowel cancer should also be considered and appropriate screening carried out if there is clinical suspicion or red flag symptoms. Gastro-oesophageal reflux is unlikely to cause fatigue or anaemia, while inflammatory bowel disease is less common than irritable bowel and there are no signs of it in the stem.

      Understanding Coeliac Disease

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

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

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

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

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  • Question 77 - You see a 36-year-old lady with weight loss, abdominal pain, loose stools and...

    Incorrect

    • 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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  • Question 78 - A 44-year-old woman presents with complaints of lethargy. Routine blood testing reveals hypochromic...

    Incorrect

    • A 44-year-old woman presents with complaints of lethargy. Routine blood testing reveals hypochromic microcytic anaemia with a low ferritin. Her haemoglobin level is 100 g/l. She has had no symptoms of abnormal bleeding, indigestion or change in bowel habit and there is no medication use of note. She is still menstruating and regards her menstrual loss as normal. She has a normal diet and there have been no recent foreign trips. Faecal occult blood tests are negative. There is no family history of colorectal cancer. Abdominal examination is normal.
      What is most appropriate for this stage in her management?

      Your Answer:

      Correct Answer: Measure tissue transglutaminase antibody

      Explanation:

      Recommended Actions for Patients with Iron Deficiency Anaemia

      Iron deficiency anaemia is a common condition that requires prompt diagnosis and treatment. Here are some recommended actions for patients with this condition:

      Screen for Coeliac Disease: All patients with iron deficiency anaemia should be screened for coeliac disease using coeliac serology, which involves measuring the presence of anti-endomysial antibody or tissue transglutaminase antibody.

      Refer for Gastrointestinal Investigations: Men of any age with unexplained iron deficiency anaemia and a haemoglobin level of 110 g/l or below, as well as women who are not menstruating with a haemoglobin level of 100 g/l or below, should be urgently referred for upper and lower gastrointestinal investigations. For other patients, referral for gastrointestinal investigation will depend on the haemoglobin level and clinical findings.

      Prescribe Iron Supplements: Treatment for iron deficiency anaemia should begin with oral ferrous sulphate 200 mg tablets two or three times a day. Doctors should not wait for investigations to be carried out before prescribing iron supplements.

      Check Vitamin B12 and Folate Levels: Vitamin B12 and folate levels should be checked if the anaemia is normocytic with a low or normal ferritin level, there is an inadequate response to iron supplements, vitamin B12 or folate deficiency is suspected, or the patient is in an older age bracket.

      Avoid Inappropriate Tests: Pelvic ultrasound examination is not necessary for patients with iron deficiency anaemia unless they have gynaecological symptoms.

      By following these recommended actions, patients with iron deficiency anaemia can receive timely and appropriate care.

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  • Question 79 - You encounter a 35-year-old male patient with ulcerative colitis. His previous colonoscopies have...

    Incorrect

    • 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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  • Question 80 - The treatment room nurse requests your assistance in evaluating a 67-year-old male patient...

    Incorrect

    • The treatment room nurse requests your assistance in evaluating a 67-year-old male patient who has been experiencing a non-healing skin ulcer in his natal cleft. Despite various attempts, there has been no improvement in the condition. The patient has a medical history of angina, benign prostatic hypertrophy, and asthma. Which medication among his current prescriptions is the most probable cause of this non-healing ulcer?

      Your Answer:

      Correct Answer: Nicorandil

      Explanation:

      Nicorandil can lead to anal ulceration. This is because ulceration is a known side effect of nicorandil, which can cause ulcers in the skin, mucosa, and eyes. It can also cause gastrointestinal ulcers that may result in complications such as perforation, haemorrhage, fistula, or abscess. If ulceration occurs, nicorandil treatment should be discontinued, and alternative medication should be considered.

      Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved through the activation of guanylyl cyclase, which results in an increase in cGMP. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers on the skin, mucous membranes, and eyes. Additionally, gastrointestinal ulcers, including anal ulceration, may also occur. It is important to note that nicorandil should not be used in patients with left ventricular failure.

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  • Question 81 - A 45-year-old teacher has recently been diagnosed with hepatitis C infection, following a...

    Incorrect

    • A 45-year-old teacher has recently been diagnosed with hepatitis C infection, following a referral to the local gastroenterologist.

      You have not yet received their clinic letter but the patient says that they explained to him that he will be starting treatment soon and wanted to ask you a few questions about the likely success.

      Which of the following factors is associated with a good response to interferon alpha in patients with hepatitis C?

      Your Answer:

      Correct Answer: Presence of cirrhosis

      Explanation:

      Factors Affecting Response to Interferon Alpha in Hepatitis C Treatment

      A high viral load, obesity, old age, cirrhosis, continued alcohol use, immune deficiency, poor adherence to treatment, and significant steatosis on liver biopsy are all factors that can affect the response rate to interferon alpha in hepatitis C treatment. Patients with genotype 1 infection and a high viral load are particularly at risk for a poor response to interferon alpha. On the other hand, patients with genotypes 2 or 3 infection and a short duration of disease have a better chance of responding well to treatment. The recommended duration of therapy also varies depending on the genotype. It is important to address these factors when considering treatment options for hepatitis C patients.

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  • Question 82 - A 38-year-old female with ulcerative colitis is discovered to have anti-smooth muscle antibodies.

    What...

    Incorrect

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

      What is the most suitable subsequent test for this patient?

      Your Answer:

      Correct Answer: Order an urgent endoscopy

      Explanation:

      Next Investigation for Women with Suspected Autoimmune Hepatitis

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

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

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  • Question 83 - A 62-year-old woman presents with a history of anorexia, weight loss, and abdominal...

    Incorrect

    • 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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  • Question 84 - A 32-year-old woman with a history of migraine experiences inadequate relief from the...

    Incorrect

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

      What could be a contributing factor to this issue?

      Your Answer:

      Correct Answer: Delayed gastric emptying

      Explanation:

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

      Managing Migraines: Guidelines and Treatment Options

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

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

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

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

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

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  • Question 85 - A 32-year-old woman comes to her General Practitioner, reporting increased fatigue over the...

    Incorrect

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

      Your Answer:

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

      Explanation:

      Understanding Hepatitis B Markers

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

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

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

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

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

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  • Question 86 - A 42-year-old man undergoes occupational health screening blood tests. His anti-Hepatitis C virus...

    Incorrect

    • 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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  • Question 87 - A 50-year-old man with a history of ulcerative colitis (UC) is found to...

    Incorrect

    • A 50-year-old man with a history of ulcerative colitis (UC) is found to have sigmoid adenocarcinoma on surveillance colonoscopy. He was diagnosed with UC at the age of 14, with the disease mostly confined to the sigmoid colon and rectum. Although his symptoms have generally been well controlled on mesalazine, he has had relapses associated with poor compliance every 1–2 years.
      Which single factor is this patient’s history most associated with the risk of developing colonic cancer?

      Your Answer:

      Correct Answer: Onset of disease in childhood

      Explanation:

      Understanding the Risk Factors for Colonic Adenocarcinoma in Ulcerative Colitis Patients

      Colonic adenocarcinoma is a serious complication that can develop in 3-5% of patients with ulcerative colitis (UC). The cancer tends to be multicentric and atypical in appearance, and it can rapidly metastasize. To prevent this, it is important to understand the risk factors associated with the onset of the disease in childhood.

      One of the main risk factors for colon cancer in colitis is the early age of onset, which is before the age of 15 years. Other risk factors include extensive disease (pancolitis), duration (more than ten years), and unremitting disease. Colonoscopic surveillance is recommended for all patients, starting about ten years after the onset of symptoms.

      It is important to note that annual relapses are not a risk factor for colonic carcinoma since there is remittance in between episodes. Chronic active inflammation and unremitting disease are the main risk factors.

      Left-sided colitis is also a risk factor, but extensive disease and pancolitis carry a higher risk of developing colon cancer. Poor compliance with therapy is not a risk factor in itself, but unremitting disease is a risk factor for colon cancer in UC.

      Finally, patients with proctitis alone do not need colonoscopy surveillance, as they are not at increased risk of developing colon cancer compared to the general population. Understanding these risk factors can help prevent the onset of colonic adenocarcinoma in UC patients.

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  • Question 88 - Barbara is a 64-year-old woman who presents to your clinic with a one-month...

    Incorrect

    • Barbara is a 64-year-old woman who presents to your clinic with a one-month history of difficulty swallowing both liquids and solids. She also reports pain while swallowing. Barbara is otherwise feeling well. She has a past medical history of hypertension and is a non-smoker.

      Upon examination, Barbara's throat appears normal, and there are no other abnormalities detected on neurological and abdominal examination.

      What is the most suitable course of action for managing Barbara's condition?

      Your Answer:

      Correct Answer: Urgent direct access upper gastrointestinal endoscopy within 2 weeks

      Explanation:

      Odynophagia is a worrying symptom that can be indicative of oesophageal cancer. According to NICE guidelines, individuals with dysphagia or those aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia should be urgently referred for direct access upper gastrointestinal endoscopy within 2 weeks to assess for oesophageal cancer.

      In Albert’s case, as he is presenting with dysphagia and odynophagia, urgent upper GI endoscopy within 2 weeks is the appropriate course of action. While blood tests such as FBC and CRP may provide some clues towards a cancer diagnosis, the priority is to rule out malignancy through endoscopy.

      Referral to speech and language therapy would not be appropriate at this stage, as the focus is on diagnosing or ruling out cancer. Prescribing analgesia may provide some relief for odynophagia, but it would not address the underlying issue of dysphagia or the need to investigate for malignancy.

      While a barium swallow may be useful in investigating dysphagia and odynophagia, urgent upper GI endoscopy is the most appropriate investigation to assess for oesophageal cancer.

      Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment

      Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus. The most common presenting symptom is dysphagia, followed by anorexia and weight loss, vomiting, and other possible features such as odynophagia, hoarseness, melaena, and cough.

      To diagnose oesophageal cancer, upper GI endoscopy with biopsy is used, and endoscopic ultrasound is preferred for locoregional staging. CT scanning of the chest, abdomen, and pelvis is used for initial staging, and FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans. Laparoscopy is sometimes performed to detect occult peritoneal disease.

      Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. In addition to surgical resection, many patients will be treated with adjuvant chemotherapy.

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      • Gastroenterology
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  • Question 89 - You observe a 35-year-old librarian who has been living with Crohn's disease for...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 90 - A 50-year-old man has had intermittent heartburn and acid regurgitation over the past...

    Incorrect

    • A 50-year-old man has had intermittent heartburn and acid regurgitation over the past 10 years. He has previously had an H2 receptor antagonist and a proton pump inhibitor with good effect. He occasionally has bought preparations from the pharmacy with good effect. His body mass index (BMI) is 29 kg/m2 and he smokes 15 cigarettes per day. His symptoms have been worse recently and are waking him at night.
      Select from the list the single management option that is likely to be most effective in bringing about a QUICK resolution of his symptoms.

      Your Answer:

      Correct Answer: Proton pump inhibitor (PPI)

      Explanation:

      Management of Gastro-Oesophageal Reflux Disease-Like Symptoms

      Explanation:

      When a patient presents with symptoms suggestive of gastro-oesophageal reflux disease (GORD), it is recommended to manage it as uninvestigated dyspepsia, according to NICE guidelines. This is because an endoscopy has not been carried out, and there are no red flag symptoms that require immediate referral for endoscopy.

      The first step in managing GORD-like symptoms is to advise the patient on lifestyle modifications such as weight loss, dietary changes, smoking cessation, and alcohol reduction. These changes may lead to a reduction in symptoms.

      In the short term, a full dose of a proton pump inhibitor (PPI) for one month is the most effective treatment to bring about a quick resolution of symptoms. If the patient has responded well to PPI in the past, it is likely to be effective again. Testing for H. pylori may also be an option if it has not been done previously.

      After the initial treatment, a low-dose PPI as required may be appropriate for the patient. Other drugs such as H2 receptor antagonists, antacids, and prokinetics can also be used in the management of uninvestigated dyspepsia. However, they are not the first choice according to the guidelines and are less likely to be as effective as a PPI.

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      • Gastroenterology
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  • Question 91 - A 60-year-old woman visits her General Practitioner for a consultation. She recently underwent...

    Incorrect

    • A 60-year-old woman visits her General Practitioner for a consultation. She recently underwent bowel cancer screening and had to have a colonoscopy, which revealed the presence of four small benign polyps (< 10mm) that were completely removed. Her discharge letter mentions that she will be seen again, and she is curious if she will require another colonoscopy. What is the most suitable level of routine surveillance for this patient?

      Your Answer:

      Correct Answer: Colonoscopy at 3 years

      Explanation:

      Stratification of Colorectal Cancer Risk Based on Adenoma Findings

      Colorectal cancer risk can be categorized based on the findings of adenomas at baseline and subsequent surveillance examinations. Low risk individuals have one or two adenomas less than 10mm and require no follow-up or a colonoscopy every five years until one is negative. Intermediate risk individuals have three or four adenomas, or one or two adenomas with one larger than 10mm, and require a colonoscopy every three years until two consecutive colonoscopies are negative. High risk individuals have five or more adenomas, or three or four adenomas with one larger than 10mm, and require a colonoscopy at 12 months before returning to three-yearly surveillance.

      It is widely accepted that most colorectal cancers arise from adenomas, which have a prevalence of 30-40% at 60 years. However, the lifetime cumulative incidence of colorectal cancer is only 5.5%, indicating that many adenomas do not progress. The risk of malignancy increases with adenoma size, with flat or depressed adenomas progressing more rapidly than polypoid adenomas. While there is no direct evidence, observational studies suggest that polypectomy can reduce cancer mortality. However, there is no evidence that further colonoscopies provide greater benefit than the initial clearance.

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      • Gastroenterology
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  • Question 92 - A patient in their 50s with irritable bowel syndrome (IBS) is still experiencing...

    Incorrect

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

      Your Answer:

      Correct Answer: Increases amount of fluid in the intestinal lumen

      Explanation:

      Anxiety-reducing (alleviates symptoms of distress)

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

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  • Question 93 - A 32-year-old woman comes to her General Practitioner complaining of constipation that has...

    Incorrect

    • 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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      • Gastroenterology
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  • Question 94 - A 55-year-old man reports that he has noticed black tarry stools over the...

    Incorrect

    • A 55-year-old man reports that he has noticed black tarry stools over the last 2 weeks. He has vomited a small amount of blood.

      Your Answer:

      Correct Answer: Melaena can result from oesophageal varices

      Explanation:

      Understanding Melaena: Causes, Symptoms, and Treatment

      Melaena is a medical condition characterized by black tarry stools, which is often caused by an acute upper gastrointestinal bleed. The bleeding can occur in the oesophagus, stomach, duodenum, small bowel, or right side of the colon, with peptic ulcer disease being the most common cause. In some cases, melaena may be the only symptom of bleeding from oesophageal varices, which are associated with portal hypertension.

      Acute upper gastrointestinal bleeding is a medical emergency that requires immediate attention, as it can be life-threatening. Patients who are haemodynamically unstable should undergo endoscopy within 2 hours after resuscitation, while other patients should have endoscopy within 24 hours. It is important to note that proton pump inhibitors should not be given before endoscopy.

      Patients who are at higher risk of complications include those aged over 60 years and those with co-morbidities. The mortality rate for patients with acute upper gastrointestinal bleeding in hospital is around 10%. Therefore, it is crucial to seek medical attention promptly if you experience symptoms of melena or haematemesis.

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  • Question 95 - A concerned man visits your clinic as he participated in the routine bowel...

    Incorrect

    • 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.

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  • Question 96 - You come across a 30-year-old accountant who has been diagnosed with Crohn's disease...

    Incorrect

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

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

      Your Answer:

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

      Explanation:

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

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

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

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  • Question 97 - A 28-year-old man presents to his General Practitioner with a flare-up of symptoms,...

    Incorrect

    • A 28-year-old man presents to his General Practitioner with a flare-up of symptoms, including diarrhoea which is occasionally bloody, up to four times a day. He has diffuse ulcerative colitis and has been in remission; he takes 1.5 g of mesalazine a day.
      On examination, his blood pressure is 115/72 mmHg, while his pulse is 75 bpm. Abdominal examination is normal.
      What is the most appropriate intervention for this patient?

      Your Answer:

      Correct Answer: Prednisolone tablets

      Explanation:

      Treatment Options for Moderate Exacerbation of Ulcerative Colitis

      When a patient experiences a moderate exacerbation of ulcerative colitis, there are several treatment options available. The most appropriate choice is a dose of 20-40 mg of oral prednisolone per day, which should be continued until the patient enters remission. If there is an inadequate response after 2-4 weeks, ciclosporin tablets can be added to the regimen to induce remission. However, these should only be prescribed by specialists in secondary care. Anti-motility drugs such as co-phenotrope should not be used as they may precipitate paralytic ileus and megacolon in active ulcerative colitis. Topical mesalazine is only effective for distal disease, so it is not appropriate for patients with diffuse disease. Topical corticosteroids in the form of prednisolone retention enemas can be used to induce remission in patients with proctitis, but for diffuse disease, oral corticosteroids are more effective.

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  • Question 98 - Which of the following is not a known complication of coeliac disease in...

    Incorrect

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

      Your Answer:

      Correct Answer: Hypersplenism

      Explanation:

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

      Understanding Coeliac Disease

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

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

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

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

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  • Question 99 - A 35-year-old lady visited the GP for the treatment of her haemorrhoids and...

    Incorrect

    • A 35-year-old lady visited the GP for the treatment of her haemorrhoids and was prescribed a topical treatment containing corticosteroids and local anesthetic. She was not given any instructions on how long to use this treatment for and has now come to seek advice on the duration of treatment.

      What is the SINGLE MOST suitable advice to give her?

      Your Answer:

      Correct Answer: Corticosteroid preparations can only be used for 2 days, but local anaesthetic use can continue for 2 weeks

      Explanation:

      Initial Management of Anal Fissures

      Corticosteroid-containing preparations should not be used for more than 7 days as prolonged use can result in skin atrophy, contact dermatitis, and skin sensitisation. Similarly, anaesthetic-containing preparations should only be used for a few days as they can lead to sensitisation of anal skin.

      Aside from topical treatments, there are other crucial initial management steps that should be taken. These include ensuring that stools are soft and easy to pass, optimising anal hygiene and toileting practices, such as avoiding straining during bowel movements.

      If conservative treatment fails or if symptoms recur, referral to secondary care should be considered.

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  • Question 100 - A 55-year-old man presents with long-standing gastrointestinal symptoms. His medical history includes a...

    Incorrect

    • A 55-year-old man presents with long-standing gastrointestinal symptoms. His medical history includes a diagnosis of irritable bowel syndrome in his early adulthood. He currently takes mebeverine 135 mg TDS and loperamide 2 mg PRN for symptom relief. He reports intermittent abdominal pain, bloating, and periodic bouts of diarrhea. His latest blood tests, done as part of his diabetic annual review, show a mild microcytic anemia and a slight persistent elevation of ALT and ALP. He has no new symptoms and follows a normal diet. On examination, there are no focal abnormalities. He is interested in trying a gluten-free diet as his mother found it helpful for her IBS. What advice should be given regarding testing for coeliac disease?

      Your Answer:

      Correct Answer: Serological testing can be carried out appropriately at any time regardless of a person's dietary intake of gluten

      Explanation:

      Testing for Coeliac Disease

      Accuracy of testing for coeliac disease is dependent on the person following a gluten-containing diet. For at least six weeks prior to testing, a person should follow a normal diet containing gluten in more than one meal a day. This is the case for both serological and histological testing. If a diagnosis of coeliac disease is suspected and the person is reluctant to include or reintroduce gluten in their diet prior to any testing, then they should be referred to a gastrointestinal specialist.

      Serological testing for coeliac disease is used to indicate whether further investigation is needed. A positive test should prompt referral to a gastrointestinal specialist for intestinal biopsy to confirm or exclude the diagnosis. When serology is requested, the preferred first choice test is currently IgA transglutaminase (tTGA). If the result is equivocal, IgA endomysial antibodies (EMA) testing can be used.

      IgA deficiency can lead to false negative results, so IgA deficiency should be ruled out if serology is negative. IgG tTGA and/or IgG EMA serology can be used in those with confirmed IgA deficiency. Human leucocyte antigen (HLA) DQ2/DQ8 testing may be considered by gastrointestinal specialists in specific clinical situations; however, it doesn’t have a role in the initial testing for coeliac disease.

      It should be borne in mind that if serological testing is negative but there is significant clinical suspicion of coeliac disease, then referral to a gastrointestinal specialist should be offered as serological tests are not 100% accurate. A clinical response to gluten-free diet is not diagnostic of coeliac disease. For example, some patients with irritable bowel syndrome may be gluten sensitive but not have coeliac disease. Implications of a positive test should be discussed prior to serological testing being performed, including the nature of the further investigations needed and the implications for other family members should the test be positive.

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  • Question 101 - A 25-year-old woman is diagnosed with coeliac disease.

    Which of the following foods should...

    Incorrect

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

      Which of the following foods should she avoid?

      Your Answer:

      Correct Answer: Barley

      Explanation:

      Safe and Unsafe Grains for a Gluten-Free Diet

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

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      • Gastroenterology
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  • Question 102 - At what age is ulcerative colitis commonly diagnosed? ...

    Incorrect

    • At what age is ulcerative colitis commonly diagnosed?

      Your Answer:

      Correct Answer: Bimodal: 15-25 years + 55-65 years

      Explanation:

      Understanding Ulcerative Colitis

      Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation in the rectum and spreads continuously without going beyond the ileocaecal valve. It is most commonly seen in people aged 15-25 years and 55-65 years. The symptoms of ulcerative colitis are insidious and intermittent, including bloody diarrhea, urgency, tenesmus, abdominal pain, and extra-intestinal features. Diagnosis is done through colonoscopy and biopsy, but in severe cases, a flexible sigmoidoscopy is preferred to avoid the risk of perforation. The typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa, and inflammatory cell infiltrate in lamina propria. Extra-intestinal features of inflammatory bowel disease include arthritis, erythema nodosum, episcleritis, osteoporosis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis. Ulcerative colitis is linked with sacroiliitis, and a barium enema can show the whole colon affected by an irregular mucosa with loss of normal haustral markings.

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  • Question 103 - A 28-year-old gentleman has come to discuss his recent blood test results.

    A few...

    Incorrect

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

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

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

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

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

      What is the likely underlying diagnosis?

      Your Answer:

      Correct Answer: Haemolysis

      Explanation:

      Elevated Bilirubin Levels in Asymptomatic Patients

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

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

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  • Question 104 - A 56-year-old woman comes to the clinic with jaundice soon after being released...

    Incorrect

    • A 56-year-old woman comes to the clinic with jaundice soon after being released from the hospital. Her liver function tests show the following results:

      - Albumin: 49 g/l
      - Bilirubin: 89 µmol/l
      - Alanine transferase (ALT): 66 iu/l
      - Alkaline phosphatase (ALP): 245 µmol/l
      - Gamma glutamyl transferase (yGT): 529 u/l

      Which antibiotic is most likely responsible for her condition?

      Your Answer:

      Correct Answer: Flucloxacillin

      Explanation:

      Cholestasis is a commonly known adverse effect of Flucloxacillin.

      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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  • Question 105 - A 45-year-old man underwent a right hemicolectomy for a Dukes' B colorectal carcinoma....

    Incorrect

    • 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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  • Question 106 - Sarah is a 35-year-old woman who presented to her GP with abdominal pain....

    Incorrect

    • Sarah is a 35-year-old woman who presented to her GP with abdominal pain. The pain was burning in nature and was localised to her epigastric area. A stool test for Helicobacter pylori was done, which came back as positive. Accordingly, she was treated with eradication therapy for one week. Despite the treatment, her symptoms have continued. She would like to be tested to check the bacteria has been eradicated. She is not keen on being referred for an endoscopy.

      Which of the following investigations should she be referred for?

      Your Answer:

      Correct Answer: Urea breath test

      Explanation:

      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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      • Gastroenterology
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  • Question 107 - A 35-year-old woman has been diagnosed with ulcerative colitis after an acute admission...

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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 pati