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  • Question 1 - Which of the following statements about coeliac disease is accurate? ...

    Incorrect

    • Which of the following statements about coeliac disease is accurate?

      Your Answer: Antigliaden antibody is the gold standard in making the diagnosis

      Correct Answer: All coeliacs are intolerant to oats

      Explanation:

      Coeliac Disease: Diagnosis and Risks

      Coeliac disease is a condition where the immune system reacts to gluten, causing damage to the small intestine. Failure to adhere to a gluten-free diet can increase the risk of gastrointestinal cancers and gut lymphoma. However, after three to five years on a gluten-free diet, the risk of cancer decreases to that of a person without coeliac disease. The prevalence of coeliac disease varies in different countries, with rates as low as 1:300 in Italy and Spain to 1:18 in the Sahara. Two types of antibodies are tested for in the patient’s serology: Endomysial antibodies (EMA) and Tissue transglutaminase antibodies (tTGA). A small bowel biopsy is still considered the gold standard for diagnosis, and a referral to a gastroenterologist is necessary for patients with positive antibodies or those with negative antibodies but suspected CD. The suitability of oats for coeliacs is uncertain due to contamination by wheat.

      To summarize, coeliac disease diagnosis involves testing for antibodies and a small bowel biopsy. Adherence to a gluten-free diet is crucial to reduce the risk of cancer. The prevalence of coeliac disease varies globally, and the suitability of oats for coeliacs is uncertain.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 2 - A 26-year-old man is being discharged from the hospital after a flare-up of...

    Correct

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

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

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

      Your Answer: Daily rectal +/- oral mesalazine

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 3 - A 60-year-old man presents with persistent fatigue, poor appetite, occasional sweats and a...

    Incorrect

    • A 60-year-old man presents with persistent fatigue, poor appetite, occasional sweats and a feeling of upper abdominal discomfort. He smokes 15 cigarettes per day, drinks up to 10 units of alcohol a week. He has no change in bowel habit. His records show that he injected heroin for a short period of time in his twenties.

      He had an urgent ultrasound scan which shows a mass in his liver which has now been biopsied and reported as hepatocellular cancer of the liver.

      What is the greatest risk factor for hepatocellular primary liver cancer in this 60-year-old man?

      Your Answer: Hepatitis C infection

      Correct Answer: Hepatitis A infection

      Explanation:

      Hepatitis C and Liver Cancer

      Hepatitis C is a viral infection that often goes undiagnosed for up to 20 years, making it a significant risk for those who engage in needle sharing and drug use. This infection can lead to cirrhosis of the liver, which increases the risk of developing primary liver cancer. In fact, around 80% of hepatocellular carcinoma cases are caused by viral infections with either hepatitis C or hepatitis B.

      While gallstones and caffeine intake are not associated with an increased risk of liver cancer, previous cholecystectomy and chronic infection with hepatitis B can increase the risk. Statin use and hepatitis A infection, on the other hand, are not associated with an increased risk.

      It is crucial to consider hepatitis C testing for at-risk populations and to maintain a low index of suspicion for liver cancer in those with a hepatitis C diagnosis. Early detection and treatment can significantly improve outcomes for those with liver cancer.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 4 - You see a 60-year-old man with gastro-oesophageal reflux symptoms. He has a previous...

    Incorrect

    • You see a 60-year-old man with gastro-oesophageal reflux symptoms. He has a previous diagnosis of Barrett's oesophagus. The old notes show he was previously under regular follow up with the local gastroenterology department but he has not been seen for over three years.

      Over the last four months his gastro-oesophageal reflux symptoms have become significantly worse. He experiences daily retrosternal burning after meals which is severe and he has been vomiting at least once a week. His swallow is reportedly normal. There is no history of haematemesis or melaena. You weigh him and he has not lost any significant weight.

      On examination his abdomen is soft, non-tender and with no palpable masses. He takes omeprazole 20 mg once daily which he has done for many years. Since his symptoms have deteriorated he has increased this himself up to 20 mg twice daily. This has not provided any significant symptomatic benefit.

      You refer him urgently for an upper GI endoscopy.

      What advice would you give to the patient while waiting for the endoscopy?

      Your Answer: Stop the omeprazole (and any other acid suppression medication) for a minimum of two weeks prior to the endoscopy

      Correct Answer: Add in domperidone to the current dose of omeprazole to try and improve symptom control whilst further investigation is awaited

      Explanation:

      Importance of Stopping Acid Suppression Medication Prior to Endoscopy

      Acid suppression medication should be discontinued for at least two weeks before undergoing endoscopy. This is crucial because acid suppression medication can conceal serious underlying conditions. It is also essential to consider the patient’s medical history, especially if there is an unexplained deterioration of dyspepsia. This is particularly important for patients with Barrett’s oesophagus, known dysplasia, atrophic gastritis or intestinal metaplasia, or those who have undergone peptic ulcer surgery more than two decades ago. By taking these precautions, doctors can ensure that endoscopy results are accurate and reliable.

      Spacing:

      Acid suppression medication should be discontinued for at least two weeks before undergoing endoscopy. This is crucial because acid suppression medication can conceal serious underlying conditions.

      It is also essential to consider the patient’s medical history, especially if there is an unexplained deterioration of dyspepsia. This is particularly important for patients with Barrett’s oesophagus, known dysplasia, atrophic gastritis or intestinal metaplasia, or those who have undergone peptic ulcer surgery more than two decades ago.

      By taking these precautions, doctors can ensure that endoscopy results are accurate and reliable.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 47-year-old man presents to his General Practitioner with a deterioration in his...

    Correct

    • A 47-year-old man presents to his General Practitioner with a deterioration in his long-standing knee pain. His knee examination is normal but he is noted to have a body mass index of 39 kg/m2 (morbidly obese). He states that he has a sedentary job, but considers himself quite active, as he is a keen gardener and has an acre of land which he maintains at home. He has gained a lot of weight since quitting smoking in his early twenties. He mentions that everyone in his family is overweight.
      What is the single most important causative factor in the development of obesity in the majority of patients?

      Your Answer: Energy intake in excess of expenditure

      Explanation:

      Understanding the Complex Causes of Obesity

      Obesity is a complex condition that cannot be solely attributed to excessive food intake and lack of physical activity. While these factors do play a role, other factors such as genetic predisposition, insulin resistance, and intrauterine malnutrition also contribute to the development of obesity. A diet high in sugar and fat, excess alcohol consumption, and a sedentary lifestyle are all contributing factors. However, genetic factors, underlying medical conditions, sleep deprivation, and socioeconomic status also impact weight gain. It is recommended to maintain an active lifestyle by incorporating 150 minutes of moderate or 75 minutes of intense exercise per week. While smoking may suppress appetite, the impact of smoking cessation on weight gain is smaller than the balance of energy in versus out. While obese parents are more likely to have obese offspring, the causes of obesity are multifactorial and not solely attributed to genetics. Insulin resistance is more likely to be a consequence of obesity rather than a cause. Low birth weight and intrauterine growth restriction have also been associated with the development of obesity in later life. Overall, understanding the complex causes of obesity is crucial in developing effective prevention and treatment strategies.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 6 - You are evaluating a patient who has come back to see you for...

    Incorrect

    • You are evaluating a patient who has come back to see you for the results of some recent blood tests. Three months ago, she had a liver function test that revealed a bilirubin of 42 µmol/L (normal range 3-20). A repeat liver function test conducted last week has shown the same outcome. The rest of her liver profile is within normal limits.

      She is otherwise healthy and not taking any regular medication. She is not overweight, drinks alcohol only occasionally, and clinical examination is normal with no signs of liver disease. She is asymptomatic. Full blood count, renal function, thyroid function, fasting glucose, and fasting lipids are all within normal limits.

      What is the most appropriate next step in her management?

      Your Answer:

      Correct Answer: No further action needed. Reassure the patient as the result is stable and the other tests are normal.

      Explanation:

      Management of Isolated Slightly Raised Bilirubin Level

      When a patient presents with an isolated slightly raised bilirubin level and is asymptomatic, the next step is to confirm the proportion of unconjugated bilirubin to guide further investigation. If the unconjugated bilirubin is greater than 70%, the patient probably has Gilbert’s syndrome. However, if the bilirubin level is almost twice the upper limit of normal, confirmed on interval testing, further investigation is necessary.

      If the bilirubin level remains stable on repeat testing, no further action is needed unless there is clinical suspicion of haemolysis. However, if the bilirubin level rises on retesting, haemolysis must be considered and should be investigated with a blood film, reticulocyte count, lactate dehydrogenase, and haptoglobin. It is important to monitor the bilirubin level and investigate further if necessary to ensure proper management of the patient’s condition.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 7 - A 48-year-old intravenous drug user presents to the clinic with abnormal liver function...

    Incorrect

    • A 48-year-old intravenous drug user presents to the clinic with abnormal liver function tests (LFTs) detected during routine screening. He is asymptomatic and shows no signs of liver disease upon examination. Further blood tests reveal a positive hepatitis B envelope-antigen (HBeAg) result.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Current active hepatitis B infection

      Explanation:

      Understanding Hepatitis B and Related Tests

      Hepatitis B is a viral infection that affects the liver. There are different stages of the disease, and various tests can help diagnose and monitor it.

      Active Hepatitis B Infection:
      The presence of HBeAg in the blood indicates ongoing viral replication and is associated with large quantities of HBV DNA. Patients who have not developed anti-HBeAb are highly infectious and at greater risk of progressing to chronic liver disease.

      Chronic Hepatitis B in an Inactive State:
      Patients in the inactive carrier state have cleared HBeAg and have low levels of HBV DNA. However, they will still test positive for surface antigen.

      Cirrhosis of the Liver:
      Hepatitis B patients are at risk of developing cirrhosis, which is diagnosed clinically, on ultrasound, and with liver biopsy.

      Hepatitis E:
      Hepatitis E is a different viral infection spread via the faecal-oral route and is tested for with hepatitis E antibodies.

      Previous Hepatitis B Vaccination:
      Patients who have been vaccinated against hepatitis B will show antibodies to the surface antibody (anti-HBsAb) only. This doesn’t account for deranged LFTs.

      Understanding Hepatitis B and Related Tests

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 8 - A 70-year-old woman has observed abdominal swelling for a few months, along with...

    Incorrect

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

      Your Answer:

      Correct Answer: Ovarian carcinoma

      Explanation:

      Differential Diagnosis for Abdominal Distension and Elevated Creatinine Level

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 9 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - A 63-year-old man presents with abdominal discomfort, loss of appetite, and weight loss....

    Incorrect

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

      Your Answer:

      Correct Answer: Urgent ultrasound scan

      Explanation:

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

      An urgent direct access CT scan is recommended within two weeks for individuals aged 60 and above who have experienced weight loss and any of the following symptoms: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes. CT scan is preferred over ultrasound, unless CT is not available. Endoscopy is not necessary as the symptoms do not suggest stomach or oesophageal cancer, which would present with more dysphagia and dyspepsia.

      While a gastroenterology opinion may be necessary, it should not be requested routinely as the patient’s symptoms are considered red flags and require a more urgent approach. Although the patient is currently medically stable, an immediate referral to the medical assessment unit is not warranted. This approach ensures timely and appropriate management for elderly patients with potential pancreatic cancer.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 11 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 12 - You are examining the blood results of a 31-year-old woman who visited you...

    Incorrect

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

      Which of the following statements is accurate?

      Your Answer:

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

      Explanation:

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

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 13 - A 65-year-old man with coronary artery disease visits his General Practitioner after an...

    Incorrect

    • A 65-year-old man with coronary artery disease visits his General Practitioner after an abdominal ultrasound reveals an easily felt epigastric pulsation. The ultrasound shows a normal calibre abdominal aorta without aneurysm, but incidentally finds gallstones. The patient has never experienced biliary colic or jaundice and has a normal body mass index with no history of abdominal surgery.
      What is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: No treatment

      Explanation:

      Treatment Options for Asymptomatic Cholelithiasis

      Asymptomatic cholelithiasis, or gallstones without any symptoms, doesn’t require therapeutic intervention. In fact, up to 70% of patients with gallstones are asymptomatic at the time of diagnosis. The risk of prophylactic cholecystectomy, or removal of the gallbladder, is greater than the benefit likely to be gained by removal. However, in a partially calcified ‘porcelain’ gallbladder, removal may be recommended to prevent pancreatitis or cholangitis.

      Open cholecystectomy, a surgical procedure with a longer recovery time and higher risk of complications, is often reserved for patients where laparoscopy is a higher risk. Endoscopic removal of stones is not suitable for asymptomatic cholelithiasis as it doesn’t remove the gallbladder or stones within it.

      If the patient becomes symptomatic, laparoscopic cholecystectomy would be the treatment of choice. However, for asymptomatic patients, the risks of a procedure outweigh the potential benefits of preventing future complications. Lithotripsy, a procedure that breaks up gallstones, is not routinely recommended for the treatment of any gallstones due to the risk of complications.

      Treatment Options for Asymptomatic Cholelithiasis

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 14 - A 28-year-old woman with chronic left iliac fossa pain and alternating bowel habit...

    Incorrect

    • A 28-year-old woman with chronic left iliac fossa pain and alternating bowel habit is diagnosed with irritable bowel syndrome. She has been treated with a combination of antispasmodics, laxatives and anti-motility agents for 6 months but there has been no significant improvement in her symptoms. What is the most appropriate next step according to recent NICE guidelines?

      Your Answer:

      Correct Answer: Low-dose tricyclic antidepressant

      Explanation:

      NICE suggests that psychological interventions should be taken into account after a period of 12 months. Tricyclic antidepressants are recommended over selective serotonin reuptake inhibitors.

      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 15 - A 35-year-old man has previously been diagnosed with distal colitis and proctitis. He...

    Incorrect

    • A 35-year-old man has previously been diagnosed with distal colitis and proctitis. He is not currently taking any medication. He has been symptom-free but now reports a recurrence of his diarrhea.
      What is the most appropriate course of action for managing his condition?

      Your Answer:

      Correct Answer: Mesalazine foam enema

      Explanation:

      Treatment Options for Mild-to-Moderate Ulcerative Colitis

      Ulcerative colitis is a chronic inflammatory bowel disease that affects the colon and rectum. In mild-to-moderate cases, the recommended initial treatment is local application of an aminosalicylate, such as mesalazine foam enema. Corticosteroid enema or suppositories are alternatives but are less effective.

      If there is no response to local treatment, oral mesalazine can be added. However, oral therapy alone with mesalazine is less effective than topical treatment for milder acute exacerbations of inflammatory bowel disease (proctitis). More severe exacerbations require oral steroids.

      For adults with a mild to moderate first presentation or inflammatory exacerbation of left-sided or extensive ulcerative colitis, oral mesalazine is the first line choice to induce remission. Topical mesalazine or oral beclomethasone dipropionate may also be considered.

      Managing Mild-to-Moderate Ulcerative Colitis: Treatment Options and Recommendations

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - A 57-year-old male presents with generalised fatigue and upper abdominal discomfort with some...

    Incorrect

    • A 57-year-old male presents with generalised fatigue and upper abdominal discomfort with some weight loss over the last six months.

      He has otherwise been well but admits to consuming 10 units of alcohol per day.

      On examination you note 2 cm hepatomegaly.

      Liver function tests show an:
      ALT 100 IU/L (5-35)
      AST 210 IU/L (1-31)
      Alkaline Phosphatase 250 IU/L (45-105)
      MCV 110 fL (80-96)

      Which of the following is the most likely cause of his presentation?

      Your Answer:

      Correct Answer: Viral hepatitis

      Explanation:

      Understanding Alcoholic Hepatitis

      Alcoholic hepatitis is a condition that occurs due to prolonged and heavy consumption of alcohol, leading to progressive liver inflammation. The symptoms of this condition include a subacute onset of fever, hepatomegaly, leukocytosis, and marked impairment of liver function. The liver exhibits characteristic centrilobular ballooning necrosis of hepatocytes, neutrophilic infiltration, large mitochondria, and Mallory hyaline inclusions. In addition, steatosis (fatty liver) and cirrhosis are common in patients with alcoholic hepatitis.Proper management and cessation of alcohol consumption can help improve the prognosis of patients with alcoholic hepatitis.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 18 - A 50-year-old woman visited her doctor with complaints of intense pain in the...

    Incorrect

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

      What is the probable reason for her symptoms?

      Your Answer:

      Correct Answer: Thrombosed haemorrhoid

      Explanation:

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 19 - 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 20 - 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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  • Question 21 - 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 22 - A 29-year-old woman has been diagnosed with irritable bowel syndrome (IBS). She experiences...

    Incorrect

    • A 29-year-old woman has been diagnosed with irritable bowel syndrome (IBS). She experiences spasms of pain in the left iliac fossa and has alternating periods of constipation and loose stools. As her healthcare provider, you are contemplating drug therapy to alleviate her symptoms.

      What is the medication that NICE advises against using in patients with IBS?

      Your Answer:

      Correct Answer: Lactulose

      Explanation:

      NICE advises against the use of lactulose for the treatment of IBS.

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

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  • Question 23 - A 40-year-old woman has chronic diarrhoea and is suspected to have irritable bowel...

    Incorrect

    • A 40-year-old woman has chronic diarrhoea and is suspected to have irritable bowel syndrome. What is the most suitable test to diagnose bile acid malabsorption?

      Your Answer:

      Correct Answer: SeHCAT (tauroselcholic [75 selenium] acid) test

      Explanation:

      Diagnostic Tests for Bile Acid Malabsorption and Coeliac Disease

      Bile acids play a crucial role in the absorption of lipids, and their malabsorption can lead to gastrointestinal symptoms such as diarrhoea, bloating, and faecal incontinence. Bile acid malabsorption can be classified into three types, with primary idiopathic malabsorption being particularly common in patients with irritable bowel syndrome. Crohn’s disease and certain surgeries or diseases can also cause bile acid malabsorption.

      The SeHCAT test is a diagnostic tool that tracks the retention and loss of bile acids through the enterohepatic circulation. A capsule containing radiolabeled 75 SeHCAT is ingested, and the percentage retention of SeHCAT at seven days is calculated. A value less than 15% indicates excessive bile acid loss and suggests bile acid malabsorption.

      Faecal fat estimation is a standard test for malabsorption, but it is not specific for bile acids. Anti-transglutaminase antibodies are found in coeliac disease, and higher levels of these antibodies suggest a diagnosis of that condition. Small bowel biopsy is performed to confirm a diagnosis of coeliac disease. The urea breath test is a rapid diagnostic procedure used in retesting for infections by Helicobacter pylori, which requires the triple-therapy regimen for treatment.

      In summary, the SeHCAT test, faecal fat estimation, anti-transglutaminase antibodies, small bowel biopsy, and urea breath test are all diagnostic tools that can aid in the diagnosis of bile acid malabsorption and coeliac disease.

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  • Question 24 - A 32-year-old woman of African ethnic origin frequently experiences abdominal tenderness and bloating...

    Incorrect

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

      Your Answer:

      Correct Answer: Trial of dairy-free diet

      Explanation:

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

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  • Question 25 - Which of the following is not a characteristic of non-alcoholic steatohepatitis? ...

    Incorrect

    • Which of the following is not a characteristic of non-alcoholic steatohepatitis?

      Your Answer:

      Correct Answer: Type 1 diabetes mellitus

      Explanation:

      Non-alcoholic fatty liver disease may be considered as a potential cause of abnormal liver function tests in patients with type 2 diabetes mellitus.

      Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management

      Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.

      NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.

      The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.

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  • Question 26 - A 32-year-old woman presents to the General Practitioner with concerns about coeliac disease....

    Incorrect

    • A 32-year-old woman presents to the General Practitioner with concerns about coeliac disease. She reports feeling uncomfortable after consuming wheat, but doesn't experience diarrhoea. What is the most suitable initial course of action?

      Your Answer:

      Correct Answer: Blood test for immunoglobulin A (IgA) anti-tissue transglutaminase (tTG)

      Explanation:

      First-line Testing for Coeliac Disease

      The National Institute for Health and Care Excellence recommends that the first-line testing for coeliac disease should be for immunoglobulin A (IgA) anti-tissue transglutaminase, replacing IgA endomysial antibodies (EMA) as the most appropriate initial test. Total IgA is also typically measured. However, false negatives may occur if there is an IgA deficiency. In such cases, positive testing should prompt referral for biopsy. False-negative results may also occur in patients who have abstained from gluten for some time. Antigliadin antibodies are no longer used routinely due to their low specificity and sensitivity. Faecal fat is a nonspecific sign of malabsorption and can be positive in many other conditions, such as chronic pancreatitis, cystic fibrosis, and following gastrectomy.

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  • Question 27 - 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 28 - A 28-year-old man presented having recently returned from Bangladesh. He reported jaundice and...

    Incorrect

    • A 28-year-old man presented having recently returned from Bangladesh. He reported jaundice and itching. His viral hepatitis serology shows active hepatitis E infection.
      Select from the list the single true statement concerning hepatitis E.

      Your Answer:

      Correct Answer: Chronic hepatitis doesn't occur in immunocompetent patients

      Explanation:

      Hepatitis E and D: A Comparison

      Hepatitis E is a self-limiting illness that follows a similar course to hepatitis A. However, fulminant disease can occur in a small percentage of cases. This type of hepatitis is most commonly found in developing countries and is transmitted through contaminated drinking water. While person-to-person contact transmission is rare, maternal-neonatal transmission can occur, with pregnant women being at the highest risk of developing fulminant hepatitis. Management of hepatitis E is supportive, and there are no chronic cases except in immunocompromised individuals.

      On the other hand, hepatitis D requires co-infection with hepatitis B to cause inflammation. Co-infection with hepatitis D increases the likelihood of hepatitis B progressing to chronic disease and cirrhosis. Hepatitis D is most commonly found in Mediterranean countries, parts of Eastern Europe, the Middle East, Africa, and South America.

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  • Question 29 - A 28-year-old woman developed sudden-onset severe epigastric pain 12 hours ago. She subsequently...

    Incorrect

    • A 28-year-old woman developed sudden-onset severe epigastric pain 12 hours ago. She subsequently began having episodes of nausea and vomiting, especially after trying to eat or drink. She has diminished bowel sounds exquisite tenderness in the mid-epigastrium with rebound tenderness and guarding. Her pulse is 110 and BP 130/75. She reports taking ibuprofen for dysmenorrhoea but last took it the day before the pain began.
      Select from the list the single most likely diagnosis.

      Your Answer:

      Correct Answer: Perforated peptic ulcer

      Explanation:

      NSAIDs and Peptic Ulceration: Risks and Symptoms

      Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common cause of gastric and duodenal ulceration, second only to Helicobacter pylori. The inhibition of cyclooxygenase (COX) by NSAIDs reduces the production of gastric mucosal prostaglandins, leading to decreased cytoprotection. This can result in peptic ulceration, with at least one-third to one-half of ulcer perforations being associated with NSAIDs.

      Patients at high risk of NSAID-induced peptic ulceration include the elderly, those with a history of peptic ulcer disease, and those with serious co-morbidities such as cardiovascular disease, diabetes, renal or hepatic impairment. The risk varies between individual NSAIDs and is also dose-related.

      Symptoms of acute complications of NSAID-induced peptic ulceration can include peritonitis, which requires urgent surgical referral. Acute pancreatitis may present with similar symptoms, but tenderness may be less and there may be a history of Gallbladder disease or alcohol abuse. Gastritis typically doesn’t involve altered bowel sounds or signs of peritoneal irritation, while cholecystitis and appendicitis present with tenderness in the right upper quadrant and right iliac fossa, respectively.

      In summary, NSAIDs can pose a significant risk for peptic ulceration, particularly in high-risk patients. It is important to be aware of the symptoms of acute complications and to promptly refer patients for appropriate management.

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  • Question 30 - 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 31 - You are requested to visit a 38-year-old man with motor neurone disease at...

    Incorrect

    • You are requested to visit a 38-year-old man with motor neurone disease at his residence. He was hospitalized for urosepsis and has just returned home. During his hospital stay, he underwent percutaneous endoscopic gastrostomy to facilitate enteral nutrition at home. What is the most probable complication of enteral feeding that he may experience?

      Your Answer:

      Correct Answer: Aspiration pneumonia

      Explanation:

      Common Problems with Enteral Feeding

      Enteral feeding, or tube feeding, can cause various gastrointestinal problems. Nausea is a common issue that can be caused by administering the feed too quickly or altered gastric emptying. Abdominal bloating and cramps can also occur for similar reasons. Constipation may be a problem, but it is unlikely that the lack of fiber in enteral feeds is the underlying cause. Diarrhea is the most common complication of enteral tube feeding, affecting up to 30% of patients on general medical and surgical wards and 68% of those on ITU. Diarrhea can be unpleasant for the patient and can worsen pressure sores and contribute to fluid and electrolyte imbalances.

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  • Question 32 - A 65-year-old woman presents for follow up after being prescribed trimethoprim for a...

    Incorrect

    • A 65-year-old woman presents for follow up after being prescribed trimethoprim for a suspected urinary tract infection by an out-of-hours doctor two weeks ago. She reports experiencing lower abdominal pains and bloating for the past six months, which have become increasingly severe and often wake her from sleep. She denies vomiting or diarrhea but notes increased frequency of urination. She has a poor appetite and has lost no weight. On examination, there is no clinical evidence of anemia or jaundice, and PR examination is normal. Which investigation is most likely to reveal the cause of this patient's symptoms?

      Your Answer:

      Correct Answer: Colposcopy

      Explanation:

      Diagnosing Ovarian Cancer: Symptoms, Risk Factors, and Tumour Markers

      Patients with ovarian cancer often present with vague abdominal symptoms that may have been wrongly attributed to other conditions such as urinary tract infection or irritable bowel syndrome. The key to establishing a diagnosis is to first think of ovarian cancer as a possibility and then, as always, to obtain a thorough history.

      It helps to think of risk factors as well, because we know that certain factors are associated with an increased risk of ovarian cancer. These include obesity, late menopause, nulliparity, diabetes, and endometriosis. In terms of symptoms, patients may experience vague abdominal pains, early satiety, and urinary frequency/urgency.

      Tumour markers can be a useful tool in certain clinical contexts. CA125 is a tumour marker associated with ovarian cancer and is a valuable test in the diagnosis of ovarian cancer with regard to initial primary care investigations. NICE recommends that women over the age of 50 who have one or more symptoms associated with ovarian cancer that occur more than 12 times a month or for more than a month are offered CA125 testing.

      In summary, a high index of suspicion is needed when considering ovarian cancer as a possibility. It is important to take into account risk factors and symptoms, and to consider the use of tumour markers such as CA125 in certain clinical contexts. By being aware of these factors, healthcare professionals can help to ensure timely and accurate diagnosis of ovarian cancer.

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  • Question 33 - A 32-year-old woman presents to her General Practitioner three weeks after an Eastern...

    Incorrect

    • A 32-year-old woman presents to her General Practitioner three weeks after an Eastern Mediterranean holiday with her family, during which they ate out a lot. She complains of malaise, lack of appetite, jaundice and dark urine. She thinks she was febrile at the start, but the fever subsided once the jaundice appeared. On examination, she has a palpable liver and is tender in the right upper quadrant.
      Investigations:
      Investigation Result Normal value
      Bilirubin 132 µmol /l < 21 µmol/l
      Alanine aminotransferase (ALT) 4104 IU/l < 40 IU/l
      Aspartate aminotransferase (AST) 3476 U/l < 33 U/l
      Alkaline phosphatase (ALP) 184 IU/l 40–129 IU/l
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Hepatitis A

      Explanation:

      Differential Diagnosis for a Patient with Flu-like Symptoms and Jaundice

      Hepatitis A is a vaccine-preventable infection commonly acquired during travel. It spreads through contaminated food and presents with flu-like symptoms followed by jaundice and dark urine. Biliary colic may cause right upper quadrant pain but is unlikely to cause fever or significantly raised liver transaminase levels. Hepatitis B is transmitted through sexual contact, needle sharing, blood transfusions, organ transplantation, or from mother to child during delivery. Pancreatic carcinoma presents with weight loss, obstructive jaundice, mid-epigastric or back pain, and disproportionately raised alkaline phosphatases levels. Salmonella enteritidis causes food poisoning with diarrhea, fever, and colicky abdominal pain.

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  • Question 34 - A 50-year-old man presents to his General Practitioner for a routine review. He...

    Incorrect

    • A 50-year-old man presents to his General Practitioner for a routine review. He denies alcohol excess and has a body mass index of 36 kg/m2. He is also noted to be a diet-controlled type II diabetic and smokes 10 cigarettes per day.
      Investigations Results Normal value
      Cholesterol 7.7 mmol/l <5 mmol/l
      Fasting triglyceride 2.5 mmol/l <1.7 mmol/l
      Alanine aminotransferase (ALT) 150 IU/l <40 IU/l
      Which of the following is the single most likely explanation regarding the significance of his raised liver enzyme?

      Your Answer:

      Correct Answer: Probably has non alcoholic steatohepatitis, which can include fibrosis

      Explanation:

      Understanding Liver Function Test Results in a Patient with Metabolic Risk Factors

      Liver function tests are an important tool for assessing liver health. In a patient with metabolic risk factors such as obesity, dyslipidaemia, and abnormal glucose tolerance, elevated liver transaminases may indicate non-alcoholic steatohepatitis (NASH), a condition that can lead to fibrosis and eventually cirrhosis if left untreated. Weight loss and control of comorbidities are the mainstay of management for NASH. While autoimmune hepatitis is a rarer possibility, it may be considered if the patient has a history of other autoimmune disorders and a normal body mass index and lipid profile. Regardless of the specific diagnosis, abnormal liver function test results in a patient with metabolic risk factors require further investigation and management.

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  • Question 35 - A 56-year-old man presents to his primary care physician with a complaint of...

    Incorrect

    • A 56-year-old man presents to his primary care physician with a complaint of altered bowel habits. He reports experiencing constipation for the past 3 months, followed by occasional episodes of loose stools. He denies any associated pain, rectal bleeding, or unexplained weight loss. The patient is in good health, has a regular diet, and takes no medications. On physical examination, the abdomen is soft and non-tender with no palpable masses.

      What would be the most suitable course of action for this patient?

      Your Answer:

      Correct Answer: Faecal immunochemical testing (FIT)

      Explanation:

      For patients who show new symptoms of colorectal cancer but do not meet the 2-week referral criteria, it is recommended to undergo the FIT test. In this case, as the patient is under 60 years old, an urgent referral is not necessary. However, if the change in bowel habit persists, it is important to consider a referral to a lower gastrointestinal specialist. It is not appropriate to request a faecal calprotectin test as it is mainly used for suspected IBD cases. A full blood count is necessary, but it should not be the only test performed. The most crucial step in management is to request a FIT test, which can trigger a 2-week wait if the result is positive. While providing reassurance to the patient is important, it should not be done without any investigation as it may lead to missing a potential colorectal cancer.

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

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

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

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

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  • Question 36 - 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 37 - A 42-year-old woman with type 1 diabetes comes in for her diabetic annual...

    Incorrect

    • A 42-year-old woman with type 1 diabetes comes in for her diabetic annual review. She reports feeling constantly fatigued for the past few months. Her blood work shows normal thyroid, liver, and renal function. However, her full blood count indicates a mild anemia with a hemoglobin level of 105 g/L and MCV of 80 fL. Her HbA1c is 52 mmol/mol, and her urine dipstick test is negative for ketones. Upon examination, there are no notable findings. The patient denies any gastrointestinal symptoms, has regular bowel movements, and has not experienced any rectal bleeding or mucous. Her weight is stable, and she doesn't experience abdominal pain or bloating. There is no known family history of gastrointestinal pathology or malignancy. Further blood tests confirm iron deficiency anemia. The patient follows a regular gluten-containing diet. What is the most appropriate initial serological test to perform for coeliac disease in this patient?

      Your Answer:

      Correct Answer: IgA endomysial antibody (EMA) testing

      Explanation:

      Serological testing for coeliac disease is used to determine if further investigation is necessary. The preferred first choice test is IgA transglutaminase, with IgA endomysial antibodies used if the result is equivocal. False negative results can occur in those with IgA deficiency, so this should be ruled out. HLA testing may be considered in specific situations but is not necessary for initial testing. If there is significant clinical suspicion of coeliac disease despite negative serological testing, referral to a specialist should still be offered. Accuracy of testing depends on following a gluten-containing diet for at least six weeks prior to testing. A clinical response to a gluten-free diet is not diagnostic of coeliac disease.

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      • Gastroenterology
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  • Question 38 - 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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      • Gastroenterology
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  • Question 39 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 40 - You suspect a patient you have seen on a home visit who is...

    Incorrect

    • You suspect a patient you have seen on a home visit who is elderly and was previously treated with antibiotics has now developed Clostridium difficile (C. difficile) infection.

      Which of the following is most likely to have caused this infection?

      Your Answer:

      Correct Answer: Clarithromycin

      Explanation:

      Antibiotics and C. difficile Infection

      Antibiotics are known to increase the risk of patients developing C. difficile infection. However, certain antibiotics are more frequently associated with this infection than others. These include clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins.

      If a patient does develop C. difficile infection, there are treatments available. Metronidazole and vancomycin are commonly used to treat this infection. It is important for healthcare providers to be aware of the risks associated with antibiotics and to use them judiciously to prevent the development of C. difficile infection. By doing so, patients can receive the necessary treatment without experiencing unnecessary complications.

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      • Gastroenterology
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  • Question 41 - A 68-year-old gentleman presents with a change in bowel habit. He reports that...

    Incorrect

    • A 68-year-old gentleman presents with a change in bowel habit. He reports that over the last two to three months he is opening his bowels four to five times a day and the consistency of his stools has become very loose. He has noticed small amounts of blood in his faeces but put this down to 'piles'.

      Previously, he used to open his bowels on average once a day and has no personal history of any gastrointestinal problems. There is no family history of bowel problems, he has not lost any weight and he denies any rectal blood loss. Stool mc&s is normal as are his recent blood tests which show that he is not anaemic. Abdominal and rectal examinations are normal.

      He tells you that he is not overly concerned about the symptoms as about two months ago he submitted his bowel screening samples and recently had a letter saying that his screening tests were negative. What is the most appropriate next approach in this instance?

      Your Answer:

      Correct Answer: Refer him urgently to a specialist for investigation of his lower gastrointestinal tract

      Explanation:

      Importance of Urgent Referral for Patients with Bowel Symptoms

      Screening tests are designed for asymptomatic individuals in an at-risk population. However, it is not uncommon for patients with bowel symptoms to mention that they are not worried as they have done their bowel screening and it was negative.

      In the case of a 66-year-old man with persistent changes in bowel habit towards looser stools with some rectal bleeding, urgent referral for further investigation is necessary. It is important to note that relying on recent bowel screening results may falsely reassure patients and delay necessary medical attention.

      Therefore, it is crucial for healthcare professionals to prioritize the patient’s current symptoms and promptly refer them for further evaluation, regardless of their previous screening results. Early detection and treatment can significantly improve outcomes for patients with bowel symptoms.

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      • Gastroenterology
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  • Question 42 - Oliver is a 25-year-old man, who was diagnosed with coeliac disease when he...

    Incorrect

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

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

      Which one of the following drinks can he safely ingest?

      Your Answer:

      Correct Answer: Whiskey

      Explanation:

      Coeliac Disease and Gluten-Free Alcohol

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

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

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      • Gastroenterology
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  • Question 43 - A 55-year-old man presents with persistent epigastric discomfort for the past 2 months....

    Incorrect

    • A 55-year-old man presents with persistent epigastric discomfort for the past 2 months. The discomfort worsens after meals and occasionally causes reflux symptoms when he lies down. Despite attempting to modify his diet, he has only experienced limited relief and has lost some weight, although he is unsure of the exact amount. He denies any difficulty swallowing or vomiting blood. He has tried over-the-counter gaviscon with little effect and is seeking further relief. Physical examination is unremarkable, with no evidence of an abdominal mass.

      What is the most appropriate course of treatment for this patient?

      Your Answer:

      Correct Answer: Urgent referral for endoscopy

      Explanation:

      Weight loss with dyspepsia is a concerning symptom in individuals over 55 years old and warrants urgent referral for an endoscopy to identify any underlying pathology. Helicobacter pylori testing may not be the most appropriate option in this case. Symptomatic relief can be provided with proton-pump inhibitors or ranitidine, but they do not rule out any underlying pathology.

      Management of Dyspepsia and Referral Criteria for Suspected Cancer

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

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

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

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      • Gastroenterology
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  • Question 44 - A 70-year-old woman comes to the clinic complaining of upper abdominal bloating and...

    Incorrect

    • A 70-year-old woman comes to the clinic complaining of upper abdominal bloating and discomfort after meals that has been going on for three months. She reports feeling nauseated at times but denies vomiting. She has lost more than 1 stone in weight. She has not experienced any changes in bowel habits and has not passed any blood in her stools. She has no significant medical history.

      During the physical examination, there is no evidence of jaundice or anemia, but she has diffuse upper abdominal tenderness, and her gallbladder is palpable on inspiration. A previous abdominal ultrasound scan conducted ten years ago revealed the presence of an incidental gallstone, but she did not undergo surgery as she was asymptomatic at the time. There is a strong family history of gallstones.

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Routine referral for consideration of cholecystectomy

      Explanation:

      Understanding Gallbladder Cancer and its Risk Factors

      Gallbladder cancer is a rare form of cancer that often goes undiagnosed until it has reached an advanced stage. It is more common in women, especially those with a history of gallstones, and those who have a family history of the disease. Other risk factors include smoking, obesity, and diabetes. Native Americans, black, and Hispanic populations are also at a higher risk of developing Gallbladder cancer.

      Symptoms of Gallbladder cancer can be vague and mimic benign disease, making it difficult to diagnose. However, unintentional weight loss is a red flag and should be taken seriously. Most Gallbladder tumors are adenocarcinomas and can spread to the liver and lungs. By the time symptoms appear, the cancer has often metastasized, and more than half of patients present with jaundice.

      It is important to have a high index of suspicion for Gallbladder cancer, especially in patients with risk factors. Even if the abdominal examination is normal, significant weight loss should prompt urgent referral for investigation under the two week wait system. By understanding the risk factors and symptoms of Gallbladder cancer, healthcare professionals can help ensure early detection and treatment.

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      • Gastroenterology
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  • Question 45 - A 14-month old infant presents with episodes of severe colic, associated with pallor...

    Incorrect

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

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

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

      What is the diagnosis?

      Your Answer:

      Correct Answer: Hirschsprung's disease

      Explanation:

      Intussusception: A Common Cause of Intestinal Obstruction in Infants

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

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

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

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      • Gastroenterology
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  • Question 46 - A 65-year-old man residing in assisted living is brought in by his caregiver...

    Incorrect

    • A 65-year-old man residing in assisted living is brought in by his caregiver for a routine health check-up. His recent blood tests, including liver function tests, have all returned normal. The results are as follows:

      - Bilirubin: 10 umol/l (normal range: 3 - 17 umol/l)
      - Alanine transferase (ALT): 35 iu/l (normal range: 3 - 40 iu/l)
      - Aspartate transaminase (AST): 25 iu/l (normal range: 3 - 30 iu/l)
      - Alkaline phosphatase (ALP): 90 umol/l (normal range: 30 - 100 umol/l)
      - Gamma glutamyl transferase (yGT): 50 u/l (normal range: 8 - 60 u/l)
      - Total protein: 70 g/l (normal range: 60 - 80 g/l)

      During the consultation, the patient reveals that he consumes 62 units of alcohol per week. You discuss the possibility of referring him for alcohol dependence treatment and community detoxification.

      What would be the most appropriate course of action now?

      Your Answer:

      Correct Answer: Refer the patient for a FibroScan (transient elastography)

      Explanation:

      Patients who consume more than 50 units of alcohol per week (males) or more than 35 units per week (females) should be referred for an ELF test or FibroScan, even if their liver function tests are normal, according to current NICE CKS guidance. This is because patients may have significant cirrhosis despite normal liver function tests, and FibroScan is the most accurate method for screening for cirrhosis.

      While monitoring liver function is important, the next appropriate step would be to assess using a FibroScan, as patients can have advanced cirrhosis with normal liver function tests. Waiting 2 or 4 years to repeat liver function tests is too long, as the disease may progress significantly in the meantime.

      Liver ultrasound may be helpful, but it is not sufficient for detecting cirrhosis in all cases. Ultrasound screening for liver cirrhosis alone is not recommended, as patients may have cirrhosis without evidence on liver ultrasound.

      Taking no further action is not appropriate, given the potential for liver disease despite normal liver function tests.

      Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. When investigating this disease, gamma-GT levels are typically elevated, and a ratio of AST:ALT greater than 3 strongly suggests acute alcoholic hepatitis. In terms of management, glucocorticoids like prednisolone are often used during acute episodes of alcoholic hepatitis. Maddrey’s discriminant function is used to determine who would benefit from glucocorticoid therapy, and pentoxyphylline may also be used. The STOPAH study compared the effectiveness of pentoxyphylline and prednisolone and found that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes.

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      • Gastroenterology
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  • Question 47 - A 65-year-old man visits the GP clinic complaining of rectal bleeding that has...

    Incorrect

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

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

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

      Your Answer:

      Correct Answer: Urgent hospital admission

      Explanation:

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

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

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

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

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      • Gastroenterology
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  • Question 48 - 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 49 - Sarah is a 36-year-old woman who has been experiencing dyspepsia symptoms for a...

    Incorrect

    • Sarah is a 36-year-old woman who has been experiencing dyspepsia symptoms for a few months. Her GP prescribed omeprazole 20 mg once daily, which has provided some relief. However, her symptoms return once she stops taking the medication. What would be the most appropriate next step in Sarah's treatment plan?

      Your Answer:

      Correct Answer: Request a stool test for H. pylori

      Explanation:

      According to NICE guidelines, patients with dyspepsia should be assessed for red flag symptoms and offered lifestyle advice before trying either a PPI or ‘test and treat’ approach. If one approach fails, the other can be attempted. In this scenario, as the patient has not been tested for H. pylori, a stool test should be performed before considering other options. An endoscopy may be necessary if symptoms persist despite optimal management in primary care. An FBC may be performed if there is concern for malignancy. Changing from omeprazole to lansoprazole is unlikely to be effective as they have the same mechanism of action. Before prescribing 40 mg omeprazole, H. pylori should be excluded.

      Management of Dyspepsia and Referral Criteria for Suspected Cancer

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

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

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

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      • Gastroenterology
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  • Question 50 - You are reviewing a 75-year-old man who has come to see you for...

    Incorrect

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

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

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

      Your Answer:

      Correct Answer: Inflammatory colitis

      Explanation:

      Melanosis Coli: A Benign Condition Caused by Laxative Use

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

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

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

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

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  • Question 51 - A 60-year-old man with liver cirrhosis of unknown origin is being evaluated in...

    Incorrect

    • A 60-year-old man with liver cirrhosis of unknown origin is being evaluated in the clinic. What factor is most likely to indicate a poor prognosis?

      Your Answer:

      Correct Answer: Ascites

      Explanation:

      Scoring Systems for Liver Cirrhosis

      Liver cirrhosis is a serious condition that can lead to liver failure and death. To assess the severity of the disease, doctors use scoring systems such as the Child-Pugh classification and the Model for End-Stage Liver Disease (MELD). The Child-Pugh classification takes into account five factors: bilirubin levels, albumin levels, prothrombin time, encephalopathy, and ascites. Each factor is assigned a score of 1 to 3, depending on its severity, and the scores are added up to give a total score. The total score is then used to grade the severity of the disease as A, B, or C.

      The MELD system uses a formula that takes into account a patient’s bilirubin, creatinine, and international normalized ratio (INR) to predict their survival. The formula calculates a score that ranges from 6 to 40, with higher scores indicating a higher risk of mortality. The MELD score is particularly useful for patients who are on a liver transplant waiting list, as it helps to prioritize patients based on their risk of mortality. Overall, both the Child-Pugh classification and the MELD system are important tools for assessing the severity of liver cirrhosis and determining the best course of treatment for patients.

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  • Question 52 - A 65-year-old gentleman presents with complaints of 'chest pains'. Upon further discussion, he...

    Incorrect

    • A 65-year-old gentleman presents with complaints of 'chest pains'. Upon further discussion, he reports experiencing postprandial retrosternal burning for the past six months. The symptom has been persistent and occurring daily over that time. He has been using an over-the-counter alginate antacid at least once a day for the last four months, but it has not provided significant relief. A colleague prescribed a 3-month course of PPIs, which he has completed without any cessation of his symptoms.

      The patient is typically healthy with no significant medical history. He has been a smoker of 20 cigarettes a day since the age of 18 and drinks alcohol occasionally. He reports no dysphagia or odynophagia and his weight is stable. He has experienced occasional vomiting when symptomatic but no persistent vomiting. He denies any haematemesis and his bowel habit is stable with no rectal bleeding or black stools.

      Upon examination, he has some angular stomatitis and mild glossitis. His abdomen is soft and non-tender with no palpable masses. What is the most appropriate management strategy?

      Your Answer:

      Correct Answer: Advise he takes the alginate preparation after meals TDS and also at night

      Explanation:

      NICE Guidelines for Upper GI Endoscopy and GORD Treatment

      According to the latest NICE guidance NG12 (updated in October 2015), patients with certain symptoms should be referred for upper gastrointestinal (GI) endoscopy. Urgent direct access upper GI endoscopy should be offered to those with dysphagia or aged 55 and over with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent direct access upper GI endoscopy should be considered for those with haematemesis, treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, raised platelet count with certain symptoms, or nausea/vomiting with certain symptoms.

      For mild gastro-oesophageal reflux disease (GORD) symptoms occurring less than once a week, antacids can be used as needed. For more frequent symptoms, a proton pump inhibitor (PPI) is recommended. Initial treatment is a high dose PPI for four weeks, taken once daily 30-60 minutes before the first meal of the day. If symptoms persist after one month, offer another month at full dose. Doubling the dose of PPI can be considered for severe symptoms. If there is no response to PPI treatment, reconsider the diagnosis and consider specialist referral. A H2 receptor antagonist can be added to a PPI for patients with a partial response to PPI treatment.

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      • Gastroenterology
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  • Question 53 - Sarah is a 44-year-old woman who presented to you last month with a...

    Incorrect

    • Sarah is a 44-year-old woman who presented to you last month with a 6 week history of upper abdominal pain, heartburn and occasional reflux. Her medical history is unremarkable and you agreed on a plan for a 1 month trial of omeprazole 20 mg daily.

      Sarah returns for a follow-up appointment after completing a month of omeprazole. Her symptoms have only slightly improved and they are still bothering her.

      What would be the most suitable course of action?

      Your Answer:

      Correct Answer: Test for Helicobacter pylori infection in 2 weeks and treat if positive

      Explanation:

      If initial treatment for dyspepsia with either a PPI or ‘test and treat’ approach fails, the alternative strategy should be tried next. In Mark’s case, he has completed 1 month of a full-dose PPI and should now be tested for H. pylori infection. Referral for routine upper gastrointestinal endoscopy is not necessary at this stage.

      Management of Dyspepsia and Referral Criteria for Suspected Cancer

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

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

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

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      • Gastroenterology
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  • Question 54 - 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 55 - 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.

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      • Gastroenterology
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  • Question 56 - 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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  • Question 57 - 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 58 - 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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  • Question 59 - A 55-year-old man has recently been diagnosed with a duodenal ulcer at endoscopy....

    Incorrect

    • A 55-year-old man has recently been diagnosed with a duodenal ulcer at endoscopy. He is not taking any medication that might have caused this. Testing for Helicobacter pylori (H. pylori) returns positive.
      What is the most appropriate initial treatment regimen?

      Your Answer:

      Correct Answer: PPI, clarithromycin, metronidazole

      Explanation:

      Comparison of Treatment Options for H. Pylori Infection

      When treating a patient with a positive H. Pylori test, it is important to choose the appropriate eradication therapy. The National Institute for Health and Care Excellence (NICE) recommends a 7-day course of PPI twice daily, amoxicillin 1 g twice daily, and either clarithromycin 500 mg twice daily or metronidazole 400 mg twice daily. If the patient is allergic to penicillin, then a PPI with clarithromycin and metronidazole should be prescribed. If the infection is associated with NSAID use, two months of PPI should be prescribed before eradication therapy.

      It is important to note that H2-receptor antagonists should not be used as first-line treatment for H. Pylori. Instead, a PPI should be used. The recommended PPIs are lansoprazole, omeprazole, esomeprazole, pantoprazole, or rabeprazole.

      While antacids and dietary advice can be helpful in managing dyspepsia, they are not sufficient for treating H. Pylori. Eradication therapy with appropriate antibiotics is necessary.

      If the patient has an ulcer associated with NSAID use and a positive H. Pylori test, NICE recommends using a full-dose PPI for two months before prescribing eradication therapy. However, if the patient is not taking any medication, this step is not necessary.

      Sucralfate can protect the mucosa from acid, but it is not part of NICE guidance for H. Pylori treatment.

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  • Question 60 - A 30-year-old man who is typically healthy visits his GP complaining of indigestion...

    Incorrect

    • A 30-year-old man who is typically healthy visits his GP complaining of indigestion that has persisted for 2 months. He has not experienced any weight changes or difficulty swallowing. Upon examination, there are no notable findings in the abdomen. What is the most appropriate initial course of action from the following choices?

      Your Answer:

      Correct Answer: One month course of a full-dose proton pump inhibitor

      Explanation:

      The management of dyspepsia according to NICE guidelines doesn’t recommend a specific first-line approach between a one month course of a PPI or ‘test and treat’ strategy. However, testing for H pylori is preferred by some clinicians before initiating acid-suppression therapy as false-negative results may occur if done within 2 weeks. Therefore, only the answer that aligns with current NICE guidelines should be chosen.

      Management of Dyspepsia and Referral Criteria for Suspected Cancer

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

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

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

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  • Question 61 - 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.

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  • Question 62 - A 55-year-old man visits his General Practitioner, worried about potential hepatitis C infection....

    Incorrect

    • 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:

      Correct 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.

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  • Question 63 - You see a 38-year-old lady who has come to you for help reducing...

    Incorrect

    • You see a 38-year-old lady who has come to you for help reducing her weight. Her BMI is 32 kg/m2. She has tried joining a local dieting group and increasing her physical activity but is still finding it difficult to lose weight. After discussion, it is decided to start her on orlistat. She manages to lose 2Kg after 3 months treatment. She wants to know how much longer she is allowed to be on this medication.

      Following an initial weight loss at 3 months, what is the restriction on how long orlistat should be prescribed?

      Your Answer:

      Correct Answer: 3 months

      Explanation:

      Orlistat Prescription Guidelines

      Orlistat is a medication that inhibits pancreatic lipase and is prescribed to patients with a BMI of 30 kg/m2 or more (or 28 kg/m2 with an associated risk factor). Patients are expected to lose 5% of their initial body weight at 3 months for the prescription to be continued. However, for patients with diabetes, a 3% loss of body weight at 3 months is recommended.

      Beyond the initial weight loss at 3 months, there is no restriction on how long orlistat should be prescribed. The decision to continue treatment should be made on an individual basis, taking into account the benefits, risks, and cost of treatment. Regular reviews should be undertaken to assess the benefits, risks, and costs of treatment. According to NICE, For people who have lost the recommended amount of weight, there is no restriction on how long orlistat may be prescribed. This should be reviewed at regular intervals.

      In summary, orlistat is a medication that can be prescribed for an extended period of time, but the decision to continue treatment should be made on an individual basis, taking into account the benefits, risks, and cost of treatment. Regular reviews should be conducted to ensure that the medication is still appropriate for the patient.

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  • Question 64 - A 40-year-old patient with epilepsy that is currently managed with phenytoin presents to...

    Incorrect

    • A 40-year-old patient with epilepsy that is currently managed with phenytoin presents to his General Practitioner. He has recently been taking oral flucloxacillin for a leg injury that was precipitated by a recent fit. The patient occasionally drinks alcohol and has been taking paracetamol for pain relief after his leg injury. Clinical examination reveals jaundice; however, his abdomen is non-tender. Liver function tests are shown below.
      Investigation Result Normal value
      Bilirubin 280 μmol/l 1–22 μmol/l
      Alkaline phosphatase (ALP) 440 U/l 45–105 U/l
      Gamma-glutamyltransferase (GGT) 320 U/l 11–50 U/l
      Alanine aminotransferase (ALT) 46 U/l < 35 U/l
      What is the most likely cause of this patient’s jaundice?

      Your Answer:

      Correct Answer: Flucloxacillin

      Explanation:

      Causes of Jaundice: Identifying the Culprit in a Clinical Case

      In this clinical case, a patient presents with jaundice and abnormal liver function tests. The following potential causes are considered:

      Flucloxacillin: The patient’s presentation is consistent with cholestatic jaundice, which can be caused by flucloxacillin. Other drugs that can cause a similar picture include chlorpromazine, azathioprine, captopril, ciclosporin, penicillamine, erythromycin, and the combined oral contraceptive.

      Ethanol: Although the patient reports occasional alcohol use, ethanol is an unlikely cause of cholestatic jaundice. Ethanol more commonly causes a hepatitic picture with elevated transaminase levels.

      Gallstones: Cholecystitis typically doesn’t cause jaundice. If gallstones were the cause, right upper quadrant pain and tenderness would be expected.

      Paracetamol: The patient is taking paracetamol, but there is no information about excessive use. Paracetamol overdose typically causes a hepatitic picture rather than cholestatic jaundice.

      Phenytoin: Phenytoin typically causes a hepatitic picture with larger elevations in transaminase levels and a smaller rise in ALP levels.

      In conclusion, flucloxacillin is the most likely cause of this patient’s cholestatic jaundice.

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

    Incorrect

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

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

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

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

      What is the most appropriate management strategy?

      Your Answer:

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

      Explanation:

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

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

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  • Question 66 - A 60-year-old woman presents with increasing epigastric pain after eating for the past...

    Incorrect

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

      Your Answer:

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

      Explanation:

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

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

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  • Question 67 - 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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  • Question 68 - A 25-year-old woman developed nausea, vomiting, and abdominal cramps 4 hours after consuming...

    Incorrect

    • A 25-year-old woman developed nausea, vomiting, and abdominal cramps 4 hours after consuming a salad and a hamburger at a nearby restaurant. She subsequently experienced watery diarrhea a few hours later. Which single organism is most likely responsible for her illness?

      Your Answer:

      Correct Answer: Staphylococcus aureus

      Explanation:

      Common Types of Food Poisoning and Their Symptoms

      Food poisoning can be caused by various bacteria and toxins that contaminate food. Here are some common types of food poisoning and their symptoms:

      1. Staphylococcal food poisoning: This type of food poisoning is caused by preformed enterotoxins produced by Staphylococcus aureus. Symptoms include profuse vomiting and watery diarrhea, which can occur 1-6 hours after eating contaminated food.

      2. Yersinia infection: This type of food poisoning is usually associated with improperly cooked meat. Symptoms may appear 3-10 days after ingestion of contaminated food.

      3. Listeria monocytogenes infection: This type of food poisoning can develop from 2 to 70 days after eating contaminated food. Symptoms include mild flu-like symptoms with diarrhea and vomiting, but the elderly, pregnant women, newborns, and immunosuppressed individuals are at risk of more serious consequences.

      4. Vibrio vulnificus-associated food poisoning: This type of food poisoning is caused by contaminated seafood, particularly oysters or undercooked shellfish. Symptoms usually appear 1-7 days after ingestion.

      5. Clostridium perfringens infection: This type of food poisoning is caused by spores that can grow into new cells if cooked food is not promptly served or refrigerated. Symptoms include diarrhea and abdominal pain, but not fever or vomiting. Outbreaks are often linked to institutions or events with catered food.

      It is important to handle and cook food properly to prevent food poisoning. If you experience symptoms of food poisoning, seek medical attention immediately.

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  • Question 69 - You see a 30-year-old lady with a rash on her arm. It started...

    Incorrect

    • You see a 30-year-old lady with a rash on her arm. It started as a small red pimple on her right forearm but has grown into a painful deep ulcer. She has Crohn's disease but is currently not on any treatment for it. She takes the combined contraceptive pill and occasional ibuprofen for headaches.

      You suspect she has pyoderma gangrenosum.

      Your Answer:

      Correct Answer: Extra-intestinal manifestations are common affecting up to 35% of people with Crohn's disease

      Explanation:

      Pyoderma gangrenosum, which is not linked to disease activity, can occur as a manifestation of Crohn’s disease outside of the intestines.

      The use of oral contraceptive drugs may elevate the likelihood of developing inflammatory bowel disease in women.

      Inflammatory bowel disease relapse or exacerbation may be heightened by the use of NSAIDs.

      Following an episode of infectious gastroenteritis, the risk of developing Crohn’s disease is increased by four times, particularly within the first year.

      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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      • Gastroenterology
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  • Question 70 - 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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      • Gastroenterology
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  • Question 71 - A 50-year-old woman who is currently 4 weeks into a course of postoperative...

    Incorrect

    • A 50-year-old woman who is currently 4 weeks into a course of postoperative radiotherapy for locally advanced cervical carcinoma has abdominal pain and diarrhoea.
      Select the single most likely cause.

      Your Answer:

      Correct Answer: Radiation enteritis

      Explanation:

      Radiation Enteritis: Understanding the Inflammation of the Bowel

      Radiation enteritis is a condition that occurs as a result of radiation-induced inflammation of the bowel. The severity of the condition is dependent on the volume of bowel that has been irradiated and the radiation dose. During therapy, patients may experience acute radiation enteritis, which manifests as ileitis, colitis, or proctitis, with symptoms such as abdominal pain and diarrhea.

      In virtually all patients undergoing radiation therapy, acute radiation-induced injury to the GI mucosa occurs when the bowel is irradiated. Delayed effects may occur after three months or more, and they are due to mucosal atrophy, vascular sclerosis, and intestinal wall fibrosis. These effects can lead to malabsorption or dysmotility, causing further complications.

      It is important to note that the clinical picture of radiation enteritis is unlikely to be due to a surgical complication, given the time frame. Additionally, it is less suggestive of bowel obstruction or perforation. Local malignant infiltration into the bowel is most likely to present with obstruction. Understanding the symptoms and causes of radiation enteritis can help healthcare professionals provide appropriate treatment and management for patients.

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      • Gastroenterology
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  • Question 72 - A very sensible parent brings her 9-year-old into the surgery for review. She...

    Incorrect

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

      Your Answer:

      Correct Answer: Above average intellectual ability

      Explanation:

      Recurrent Abdominal Pain in Children

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

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      • Gastroenterology
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  • Question 73 - A 27 year old male with a history of ulcerative colitis presents with...

    Incorrect

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

      Your Answer:

      Correct Answer: Rectal mesalazine

      Explanation:

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

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

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

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

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      • Gastroenterology
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  • Question 74 - 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.

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  • Question 75 - Which of the following is not a known complication of coeliac disease in...

    Incorrect

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

      Your Answer:

      Correct Answer: Hypersplenism

      Explanation:

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

      Understanding Coeliac Disease

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

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

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

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

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      • Gastroenterology
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  • Question 76 - A 50-year-old woman presents with anaemia on a routine blood test. Her haemoglobin...

    Incorrect

    • A 50-year-old woman presents with anaemia on a routine blood test. Her haemoglobin is 96 g/L (115-165) and her MCV is 72 fL (80-96). Further blood tests reveal a ferritin of 8 µg/L (15-300) and negative coeliac serology. Haemoglobin electrophoresis is normal.

      She denies any gastrointestinal symptoms, rectal bleeding, weight loss, haematuria or haemoptysis. Her menstrual cycle is regular with periods every 28 days. She reports heavy bleeding for five days followed by lighter bleeding for three days, which has been the case for several years. She doesn't consider her periods to be problematic.

      Physical examination, including urine dipstick testing, is unremarkable.

      What is the most appropriate next step?

      Your Answer:

      Correct Answer: Start oral iron replacement

      Explanation:

      Investigating Anaemia: Identifying and Treating Iron Deficiency

      A new diagnosis of anaemia should prompt further investigation. A low mean corpuscular volume (MCV) suggests iron deficiency anaemia, which can be confirmed with a ferritin level test. However, it is important to note that ferritin levels may be falsely normal in the presence of an acute phase response. In such cases, iron studies may be useful. Once iron deficiency is confirmed, the underlying cause should be identified.

      Patients with upper gastrointestinal symptoms or unexplained low haemoglobin levels require urgent referral for endoscopic gastrointestinal assessment. Coeliac serology and haemoglobin electrophoresis should also be considered to rule out coeliac disease and hereditary causes of microcytic anaemia, respectively.

      In patients who do not require urgent referral, non-gastrointestinal blood loss and poor diet should be considered. Menstrual blood loss is a common cause of iron deficiency anaemia in menstruating women. In such cases, iron replacement therapy should be initiated, and haemoglobin levels should be monitored for improvement. If heavy menstrual bleeding is the cause, it should be treated, and if the patient doesn’t respond to iron supplementation, gastroenterology referral is appropriate.

      In summary, identifying and treating iron deficiency anaemia requires a thorough investigation of the underlying cause. Prompt referral is necessary in certain cases, while others may require iron replacement therapy and monitoring.

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  • Question 77 - A 62-year-old lady presents to you with complaints of progressive bloating and feeling...

    Incorrect

    • A 62-year-old lady presents to you with complaints of progressive bloating and feeling full for the past two months. She requests a prescription for Colpermin, as her sister found it helpful for her IBS. Additionally, she reports experiencing urinary frequency for several weeks and suspects a UTI. On examination, her abdomen appears non-specifically bloated, and a urine dip reveals trace protein but no blood, glucose, or leukocytes. She went through menopause at 54, is nulliparous, and has a family history of psoriasis. There are no known allergies. What would be the most appropriate course of action?

      Your Answer:

      Correct Answer: Arrange abdominal ultrasound scan

      Explanation:

      Consideration of Ovarian Cancer in New Onset IBS after 50

      This patient presenting with new onset IBS after the age of 50 should prompt consideration of ovarian cancer. According to NICE guidelines, symptoms such as bloating, early satiety, pelvic/abdominal pain, and urinary frequency/urgency should raise suspicion of ovarian cancer. CA 125 is the test of choice if ovarian cancer is being considered.

      Risk factors for ovarian cancer include nulliparity and late menopause. Symptoms that should raise suspicion of ovarian cancer include progressive bloating, early satiety, and urinary frequency. A vaginal examination should be performed if ovarian cancer is suspected since abdominal examination alone can miss an ovarian mass. The family history of psoriasis is not relevant in this case.

      Prescribing Colpermin is not necessarily incorrect, but IBS is a diagnosis of exclusion that should be given once serious and common alternatives have been ruled out. Prescribing an antibiotic is inappropriate because there is no evidence of infection here.

      An abdominopelvic scan would be an alternative to arranging CA 125, but an abdominal scan by itself is usually not sufficient to fully examine the ovaries. If a CA 125 was high, an ultrasound scan would be arranged to assess the ovaries in more detail, and the results of the two would be combined in an RMI score to assess the risk of malignancy.

      In summary, it is important to consider ovarian cancer in cases of new onset IBS after 50, especially if symptoms such as bloating, early satiety, pelvic/abdominal pain, and urinary frequency/urgency are present. A thorough examination and appropriate tests should be performed to rule out this serious condition.

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  • Question 78 - A patient with irritable bowel syndrome (IBS) and a tendency towards loose stools...

    Incorrect

    • A patient with irritable bowel syndrome (IBS) and a tendency towards loose stools has not responded well to loperamide and antispasmodics. According to NICE, what is the recommended second-line medication class for this condition?

      Your Answer:

      Correct Answer: Tricyclic antidepressant

      Explanation:

      The initial medication prescribed for individuals with irritable bowel syndrome typically includes antispasmodics, as well as loperamide for diarrhea or laxatives for constipation. If these treatments prove ineffective, low-dose tricyclic antidepressants such as amitriptyline (5-10 mg at night) may be considered as a secondary option to alleviate abdominal pain and discomfort, according to NICE guidelines. Linaclotide may also be an option for those experiencing constipation. Selective serotonin reuptake inhibitors may be used as a tertiary treatment.

      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 79 - A 25-year-old woman presents to you with concerns about her risk for familial...

    Incorrect

    • A 25-year-old woman presents to you with concerns about her risk for familial adenomatous polyposis (FAP). Her father and older brother have been diagnosed with the condition, and she previously declined testing but is now reconsidering. Her mother's side of the family has no history of illness. What is the probability that she has FAP? Select ONE answer.

      Your Answer:

      Correct Answer: 50%

      Explanation:

      Understanding the Inheritance Probability of Autosomal-Dominant Traits

      Autosomal-dominant traits are genetic conditions that only require one affected gene to be inherited in order for the trait to be displayed. In the case of a patient whose father has Familial Adenomatous Polyposis (FAP), a rare autosomal-dominant condition, there is a 50% chance that she has inherited the affected gene from her father. This is because her father has one affected gene and one unaffected gene, and there is an equal chance of either gene being passed down to his offspring.

      It is important to note that there is no 100% chance of being affected by an autosomal-dominant condition unless the parent is homozygous, meaning they carry two affected genes and no unaffected genes. This is unlikely in the case of FAP.

      On the other hand, a 25% chance of being affected is associated with autosomal-recessive conditions, but only if both parents are carriers of the affected gene. In the case of autosomal-dominant traits, there is always some risk of inheriting the condition if one parent is affected.

      To determine a more specific probability of inheritance, a Punnett square can be used to calculate the possible outcomes. In the case of FAP, the patient has a 50% chance of inheriting the affected gene from her father. Therefore, understanding the inheritance probability of autosomal-dominant traits is crucial in predicting the likelihood of passing on the condition to future generations.

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      • Gastroenterology
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  • Question 80 - You assess a 23-year-old woman who has been newly diagnosed with ulcerative colitis...

    Incorrect

    • You assess a 23-year-old woman who has been newly diagnosed with ulcerative colitis on the left side. The gastroenterologists prescribed high-dose oral mesalazine five days ago, but there has been no improvement in her bowel movements, which consist of passing 3-4 loose stools per day with small amounts of blood. She is still in good health, and her abdominal examination is normal. What is the recommended duration of the initial mesalazine treatment before determining its effectiveness?

      Your Answer:

      Correct Answer: 4 weeks

      Explanation:

      Patients with mild-moderate flares of ulcerative colitis are usually evaluated for treatment response over a period of 4 weeks.

      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 81 - A 35-year-old man with newly diagnosed ulcerative colitis (UC) comes to you with...

    Incorrect

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

      Your Answer:

      Correct Answer: Start oral budesonide

      Explanation:

      Treatment Options for Ulcerative Colitis Flares

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

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

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

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

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  • Question 82 - 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 83 - A 68-year-old woman presents with a two month history of mild nausea and...

    Incorrect

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

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

      What is the most appropriate management?

      Your Answer:

      Correct Answer: Arrange a routine barium meal and swallow

      Explanation:

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

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

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

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  • Question 84 - 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 85 - You see a 32-year-old man who has recently been diagnosed with Crohn's disease....

    Incorrect

    • You see a 32-year-old man who has recently been diagnosed with Crohn's disease. He presented with frequent and loose stools, with occasional blood and mucous. He is otherwise fit and well. His only other past medical history is appendicitis as a 16-year-old.

      He has been reviewed by a gastroenterologist and is on a reducing dose of corticosteroid.

      Can you provide him with more information about Crohn's disease?

      Your Answer:

      Correct Answer: The risk of Crohn's disease increases early after an appendicectomy

      Explanation:

      Smoking increases the likelihood of developing Crohn’s disease.

      Experiencing infectious gastroenteritis raises the risk of developing Crohn’s disease by four times, especially within the first year.

      The chances of developing Crohn’s disease are higher in the early stages after having an appendicectomy.

      Crohn’s disease affects both genders equally, with no significant difference in occurrence rates.

      Understanding Crohn’s Disease

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.

      Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include nonspecific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.

      To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.

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  • Question 86 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 87 - What is one of the most common symptoms observed in individuals with Cow's...

    Incorrect

    • What is one of the most common symptoms observed in individuals with Cow's milk protein intolerance?

      Your Answer:

      Correct Answer: Stridor

      Explanation:

      Cow’s Milk and Soy Intolerance in Infants

      Cow’s milk intolerance in infants can lead to anaphylactic responses, but it is more commonly associated with gastrointestinal effects and malabsorption, resulting in diarrhea. One of the most common symptoms of cow’s milk protein allergy (CMPA) is bloody stool. On the other hand, adverse reactions to soy have been reported in 10-35% of infants with CMPA. Soy may be considered as an alternative for infants over 6 months who refuse to drink extensively hydrolyzed formula and/or amino acid formula. However, soy formulations contain high concentrations of phytate, aluminum, and phytoestrogens (isoflavones), which may have undesired effects. Therefore, it is important to monitor infants for any adverse reactions when introducing soy-based formulas.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 88 - Benjamin, who has been struggling with bowel issues, has been diagnosed with irritable...

    Incorrect

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

      Your Answer:

      Correct Answer: Reduce insoluble fibre intake

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 89 - A 32-year-old woman has been experiencing abdominal pain and intermittent bloody diarrhoea for...

    Incorrect

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

      Your Answer:

      Correct Answer: Crohn's disease

      Explanation:

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

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

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

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

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      • Gastroenterology
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  • Question 90 - You see an obese 40-year-old gentleman who was incidentally found to have fatty...

    Incorrect

    • You see an obese 40-year-old gentleman who was incidentally found to have fatty infiltration in his liver while being investigated for a slightly raised ALT. His other blood tests were unremarkable. He is known to have type 2 diabetes and is on metformin 500 mg OD. He doesn't drink alcohol. He is otherwise well in himself.

      What would be the next most appropriate management step?

      Your Answer:

      Correct Answer: Refer to hepatology

      Explanation:

      Management of Non-Alcoholic Fatty Liver Disease

      Patients with non-alcoholic fatty liver disease (NAFLD) should be assessed for the risk of advanced liver fibrosis using a non-invasive scoring system such as the Fibrosis (FIB)-4 Score, according to NICE guidelines. While obesity and metformin use may contribute to NAFLD, changes to glycaemic control should not be made without knowing the patient’s current status. Referral to hepatology is indicated if there is evidence of advanced liver disease or high risk of advanced liver fibrosis based on scoring. Hepatology can perform specialist investigations such as transient elastography and liver biopsy. Additional blood tests, including a liver screen, may be helpful, but an isolated repeat LFT would not be the next most important step in management.

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      • Gastroenterology
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  • Question 91 - 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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      • Gastroenterology
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  • Question 92 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 93 - 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 94 - 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 95 - 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 96 - A 40-year-old male presents to the GP with a 7-day history of fever,...

    Incorrect

    • A 40-year-old male presents to the GP with a 7-day history of fever, sore throat and muscle aches. On examination, he is visibly jaundiced, his blood pressure 130/80 mmHg, heart rate 80/min, respiratory rate 13/min, HS I + II + 0, breath sounds are vesicular and abdomen is soft but tender in the right upper quadrant with hepatomegaly. The GP orders blood tests which show:

      Hb 140 g/L Male: (135-180)
      Female: (115 - 160)
      Platelets 220 * 109/L (150 - 400)
      WBC 11.5 * 109/L (4.0 - 11.0)
      Na+ 142 mmol/L (135 - 145)
      K+ 4.0 mmol/L (3.5 - 5.0)
      Urea 6.4 mmol/L (2.0 - 7.0)
      Creatinine 100 µmol/L (55 - 120)
      CRP 50 mg/L (< 5)
      Bilirubin 80 µmol/L (3 - 17)
      ALP 100 u/L (30 - 100)
      ALT 500 u/L (3 - 40)
      γGT 150 u/L (8 - 60)
      Albumin 45 g/L (35 - 50)

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Hepatitis A

      Explanation:

      The symptoms exhibited by the patient suggest acute hepatitis, with fever and jaundice being prominent. Autoimmune hepatitis is typically observed in young females, making it less likely in this male patient. Hence, hepatitis A is a more probable diagnosis, given his presentation of myalgia, sore throat, fever, and jaundice.

      Understanding Hepatitis A: Symptoms, Transmission, and Prevention

      Hepatitis A is a viral infection that affects the liver. It is usually a mild illness that resolves on its own, with serious complications being rare. The virus is transmitted through the faecal-oral route, often in institutions. The incubation period is typically 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests.

      While complications are rare, there is no increased risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates).

      It is important to note that the vaccine requires a booster dose 6-12 months after the initial dose. By understanding the symptoms, transmission, and prevention of hepatitis A, individuals can take steps to protect themselves and others from this viral infection.

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      • Gastroenterology
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  • Question 97 - A 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21...

    Incorrect

    • A 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21 μmol/l). He has suffered from episodic jaundice in the past but is otherwise fit and well. His diagnosis is Gilbert syndrome.
      Which of the following is associated with Gilbert syndrome?

      Your Answer:

      Correct Answer: γ-glutamyltransferase in the normal range

      Explanation:

      Understanding Gilbert Syndrome: Symptoms, Risks, and Diagnosis

      Gilbert syndrome is a common, benign condition that causes mild unconjugated hyperbilirubinaemia. It is familial and occurs in 5-10% of adults in Western Europe. While some patients may experience symptoms such as fatigue, nausea, and abdominal pain, many are asymptomatic. Jaundice is usually mild and can worsen with physical exertion, fasting, or dehydration. However, liver function tests, including γ-glutamyltransferase, should be normal.

      Unlike other liver conditions, Gilbert syndrome doesn’t cause abnormal liver histology or conjugated hyperbilirubinaemia. It is also not a risk factor for kernicterus at birth.

      Diagnosis of Gilbert syndrome is based on clinical presentation and elevated unconjugated bilirubin levels. Fasting can actually increase bilirubin levels in this condition. Therefore, it is important to rule out other liver disorders if abnormal liver function tests or histology are present.

      Overall, understanding the symptoms, risks, and diagnosis of Gilbert syndrome can help healthcare providers provide appropriate care and management for patients with this condition.

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      • Gastroenterology
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  • Question 98 - 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 99 - A 72-year-old man presents to his General Practitioner with progressive dysphagia and weight...

    Incorrect

    • A 72-year-old man presents to his General Practitioner with progressive dysphagia and weight loss. He is a smoker with a 45-pack-year history. He is fast-tracked for investigation of suspected oesophageal adenocarcinoma. It is noted that he has a past medical history relevant to the referral.
      What is the most likely condition to warrant consideration in this patient’s referral?

      Your Answer:

      Correct Answer: Barrett's oesophagus

      Explanation:

      Gastrointestinal Conditions and Their Associated Cancer Risks

      Barrett’s Oesophagus, Duodenal Ulceration, Crohn’s Disease, Partial Gastrectomy, and Ulcerative Colitis are all gastrointestinal conditions that have been linked to an increased risk of cancer.

      Barrett’s Oesophagus is a condition where the normal lining of the oesophagus is replaced by metaplastic columnar epithelium, which can lead to dysplasia and invasive adenocarcinoma. Risk factors for progression to adenocarcinoma include male sex, increasing age, extended segment disease, and family history. Smoking and alcohol are also strong risk factors.

      Duodenal Ulceration is caused by Helicobacter pylori infection and has been linked to an increased risk of non-cardia gastric cancer.

      Crohn’s Disease increases the risk of colon cancer, particularly if the entire colon is involved. The risk of small-intestinal malignancy is also increased.

      Partial Gastrectomy is not associated with an increased risk of oesophageal adenocarcinoma, but gastric-stump cancer is a risk after partial gastrectomy, typically occurring ten years or longer after the procedure.

      Ulcerative Colitis carries a significantly increased risk of colon cancer, with the extent and duration of the disease being important factors.

      Overall, it is important for individuals with these gastrointestinal conditions to be aware of their increased cancer risk and to undergo regular screenings and surveillance to detect any potential malignancies early.

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      • Gastroenterology
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  • Question 100 - 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 101 - A 35-year-old woman has been diagnosed with ulcerative colitis after an acute admission...

    Incorrect

    • A 35-year-old woman has been diagnosed with ulcerative colitis after an acute admission to the hospital with bleeding per rectum, fever and abdominal pain. At the time of diagnosis, she was initiated on mesalazine. Her bowel symptoms are now much improved and she is awaiting routine follow-up in the clinic.
      Which of the following side effects should patients be specifically informed of and cautioned about when commencing mesalazine?

      Your Answer:

      Correct Answer: Pancytopenia

      Explanation:

      Adverse Effects of Aminosalicylates: What to Watch Out For

      Aminosalicylates, such as mesalazine and sulfasalazine, are drugs used to treat bowel inflammation. While they are generally safe, there are some potential adverse effects to be aware of. Common side effects include headache, nausea, rash, and abdominal pain. Patients may also become more sensitive to sunlight.

      However, aminosalicylates can also rarely cause more serious issues such as blood disorders like agranulocytosis and aplastic anemia. Patients should be advised to report any unexplained bleeding, bruising, sore throat, fever, or malaise, and a full blood count should be performed if these symptoms occur. Nephrotoxicity is another potential adverse effect of mesalazine.

      It’s important to note that mesalazine is not associated with skin pigmentation, corneal deposits, gum hypertrophy, or Parkinsonian features, which are side effects of other drugs. If patients experience any concerning symptoms while taking aminosalicylates, they should speak with their healthcare provider immediately.

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      • Gastroenterology
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  • Question 102 - A 49-year-old woman presents with lethargy and pruritus. She reports having a normal...

    Incorrect

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

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

      What additional test is most likely to provide a diagnosis?

      Your Answer:

      Correct Answer: Anti-mitochondrial antibodies

      Explanation:

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

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      • Gastroenterology
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  • Question 103 - 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 104 - A 57-year-old man presents with a long-standing history of alternating episodes of diarrhoea...

    Incorrect

    • A 57-year-old man presents with a long-standing history of alternating episodes of diarrhoea and normal bowel habit. During his episodes, he experiences severe left-sided abdominal pain which usually resolves over a few days. He has always had to monitor his diet to avoid constipation but has not experienced any weight loss. On examination, there is tenderness in the left lower quadrant of his abdomen with no palpable masses. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Diverticulitis

      Explanation:

      Understanding Diverticulosis and Diverticulitis: Symptoms and Management

      Diverticulosis is a condition where small pouches called diverticula form in the lining of the colon. About 75% of people with diverticula have no symptoms. However, those with uncomplicated diverticulosis may experience lower abdominal pain, bloating, constipation, or rectal bleeding. These symptoms may be exacerbated by eating and relieved by defecation or flatus. Left lower quadrant tenderness and fullness may also be present, which can be mistaken for irritable bowel syndrome.

      On the other hand, diverticulitis is a more serious condition where the diverticula become inflamed or infected. Patients with diverticulitis may experience intermittent or constant left lower quadrant pain, accompanied by a change in bowel habits. Pyrexia and tachycardia are common, and examination usually reveals localised tenderness and sometimes a palpable mass. Mild cases of diverticulitis can be managed at home with paracetamol, clear fluids, and oral antibiotics. However, one third of patients may develop further complications such as perforation, abscess, fistula, or stricture/obstruction.

      It is important to differentiate diverticulitis from other conditions such as colonic cancer, Crohn’s disease, and ulcerative colitis. Colonic cancer may present with weight loss and a more definite change in bowel habit, while Crohn’s disease and ulcerative colitis usually present with diarrhoea at a younger age than diverticulitis. Barium enema or colonoscopy may be needed to confirm the diagnosis.

      In summary, understanding the symptoms and management of diverticulosis and diverticulitis is crucial for early detection and treatment. Patients with mild diverticulitis can be managed at home, but those with severe symptoms or complications require hospitalisation and possibly surgery. Regular screening and follow-up are recommended for those with diverticulosis to prevent complications.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 105 - 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.

    • This question is part of the following fields:

      • Gastroenterology
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