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Question 1
Incorrect
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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: Drug induced
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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This question is part of the following fields:
- Gastroenterology
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Question 2
Incorrect
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A 28-year-old man known to have diffuse ulcerative colitis for which he takes mesalazine 1.5g daily has an exacerbation. He is passing up to 10 loose stools per day with blood. He is feeling unwell, appears mildly dehydrated and anaemic.
Select from the list the single most appropriate initial management option.Your Answer: Increase the mesalazine dose to 4g daily
Correct Answer: Admit to hospital
Explanation:Treatment Options for Inflammatory Bowel Disease Exacerbations
Inflammatory bowel disease (IBD) can cause severe exacerbations that require hospitalization for fluid and electrolyte replacement, transfusion, and possibly intravenous corticosteroids. However, for less severe exacerbations of diffuse disease, there are other treatment options available.
One option is to increase the dose of mesalazine, which is an anti-inflammatory medication commonly used to treat IBD. Another option is to take oral prednisolone, which is a steroid medication that can help reduce inflammation in the gut.
For those with proctitis or distal disease, prednisolone enemas may be used as a treatment option. These enemas are administered directly into the rectum and can help reduce inflammation in the lower part of the colon.
Overall, the treatment options for IBD exacerbations depend on the severity and location of the disease. It is important to work closely with a healthcare provider to determine the best course of treatment for each individual case.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 35-year-old woman has been diagnosed with ulcerative colitis after an acute admission to the hospital with bleeding per rectum, fever and abdominal pain. At the time of diagnosis, she was initiated on mesalazine. Her bowel symptoms are now much improved and she is awaiting routine follow-up in the clinic.
Which of the following side effects should patients be specifically informed of and cautioned about when commencing mesalazine?Your Answer: Corneal deposits
Correct Answer: Pancytopenia
Explanation:Adverse Effects of Aminosalicylates: What to Watch Out For
Aminosalicylates, such as mesalazine and sulfasalazine, are drugs used to treat bowel inflammation. While they are generally safe, there are some potential adverse effects to be aware of. Common side effects include headache, nausea, rash, and abdominal pain. Patients may also become more sensitive to sunlight.
However, aminosalicylates can also rarely cause more serious issues such as blood disorders like agranulocytosis and aplastic anemia. Patients should be advised to report any unexplained bleeding, bruising, sore throat, fever, or malaise, and a full blood count should be performed if these symptoms occur. Nephrotoxicity is another potential adverse effect of mesalazine.
It’s important to note that mesalazine is not associated with skin pigmentation, corneal deposits, gum hypertrophy, or Parkinsonian features, which are side effects of other drugs. If patients experience any concerning symptoms while taking aminosalicylates, they should speak with their healthcare provider immediately.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Correct
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Correct
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A 14-year-old girl comes to the clinic with her parents who are worried about her experiencing recurrent episodes of abdominal pain, loss of appetite, and nausea for the past two months. Upon further inquiry, the pain is severe, occurs in the mornings, is intermittent, and can happen during vacations. Her weight is at the 50th percentile, and there are no abnormalities found during the examination. What is the probable diagnosis?
Your Answer: Abdominal migraine
Explanation:Abdominal Migraine: Recurrent Episodes of Midline Abdominal Pain in Children
Abdominal migraine is a disorder that mainly affects children and is characterized by recurrent episodes of midline abdominal pain. The pain can last from 1-72 hours and is of moderate to severe intensity. During the attacks, patients may experience anorexia, nausea, and vomiting. Marked pallor is commonly noted, and some patients may appear flushed. The pain is severe enough to interfere with normal daily activities, and many children describe their mood during the attack as one of intense misery. However, patients are completely symptom-free between attacks.
Abdominal migraine is an idiopathic disorder, meaning that the cause is unknown. It is unlikely to be school avoidance as the symptoms are episodic and can occur outside of school times.
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This question is part of the following fields:
- Gastroenterology
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Question 6
Incorrect
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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: Clindamycin
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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This question is part of the following fields:
- Gastroenterology
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Question 7
Correct
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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: 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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This question is part of the following fields:
- Gastroenterology
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Question 8
Incorrect
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A 60-year-old woman presents with increasing epigastric pain after eating for the past month. She has a history of intermittent heartburn and epigastric burning for over a year, which was previously managed with regular alginate. Three months ago, she reported no weight loss or vomiting, and her H. pylori status was checked. On her return visit, it was found that she is H. pylori positive and has experienced a reduced appetite, mild nausea, and some weight loss. What is the most appropriate course of action?
Your Answer: Refer urgently for upper GI endoscopy
Correct Answer: Prescribe a PPI such as omeprazole 20 mg/day and review in two weeks
Explanation:Urgent Referral for Upper GI Cancer in H. pylori Positive Patient
This patient is showing red flag symptoms and signs that suggest upper GI cancer, including weight loss and poor appetite. Despite being Helicobacter pylori positive, urgent referral for upper GI endoscopy or to a specialist in upper GI cancer should not be delayed. An ultrasound scan is unlikely to be helpful, and prescribing a PPI should be avoided as it can mask underlying disease. It is important to prioritize urgent referral over prescribing eradication therapy for H. pylori, as the latter may delay the diagnosis of underlying pathology. By promptly referring the patient for further evaluation, healthcare providers can ensure timely diagnosis and treatment of potential upper GI cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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Emma, aged 23 years, has been experiencing symptoms of irritable bowel syndrome (IBS) for the past 2 months, which she believes is due to the stress of her new job. She often feels bloated and has irregular bowel movements. Emma is hesitant to take medications and seeks advice from her GP, Dr. Patel, who recommends the low-FODMAP diet and refers her to a registered dietitian. What are some examples of safe low-FODMAP foods that can be included in Emma's diet to manage her IBS symptoms?
Your Answer: Baked beans
Correct Answer: Salmon
Explanation:Monash University in Australia has developed a low-FODMAP diet to manage irritable bowel syndrome (IBS). FODMAPs are short-chain carbohydrates found in many foods that are poorly absorbed in the small intestine. They can cause diarrhoea by encouraging water intake into the small intestine or bloating by fermenting in the large bowel. A low-FODMAP diet has been shown to reduce symptoms of IBS such as bloating, abdominal pain, and irregular bowel habits. However, this diet is challenging to follow as it excludes many foods that contain oligo-, di-, mono-saccharides, and polyols, including various vegetables, fruits, and grains. Therefore, it is recommended to seek the advice of a dietician rather than initiating the diet without guidance. High-FODMAP foods to avoid include wheat, most dairy products (except aged cheeses), pulses, beans, onion, garlic, and excess fructose. The diet mainly consists of unprocessed meat/fish and low FODMAP vegetables and grains.
Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Correct
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You encounter a 35-year-old male patient with ulcerative colitis. His previous colonoscopies have revealed widespread disease affecting his entire colon. He reports passing approximately 5 bloody stools per day for the past 3 days.
Upon examination, his heart rate is 82 beats per minute, blood pressure is 129/62 mmHg, and temperature is 36.9ºC. His abdomen is soft and non-tender.
What would be the most suitable course of action for this patient?Your Answer: Rectal mesalazine and oral sulfasalazine
Explanation:When a patient experiences a mild-moderate flare of ulcerative colitis that extends beyond the left-sided colon, it is recommended to add oral aminosalicylates to rectal aminosalicylates. This is because enemas can only reach a certain point and the addition of an oral medication ensures proper treatment. In this case, the patient’s colonoscopy showed extensive disease, making the use of an oral aminosalicylate necessary. Therefore, this is the correct option and using rectal mesalazine alone is not sufficient.
Using oral steroids like prednisolone and dexamethasone as a first-line treatment is not recommended.
Metronidazole is used to treat bacterial infections, but there is no indication of such an infection in this case.
Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.
To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.
In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.
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This question is part of the following fields:
- Gastroenterology
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Question 11
Incorrect
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A 54-year-old woman is admitted to your intermediate care unit with a significant medical history of chronic alcoholism. She sustained a brain injury six weeks ago after falling down the stairs at home and is currently bedridden. She was transferred for further rehabilitation and is being fed through a percutaneous gastrostomy, which was inserted three days ago after an initial period of nasogastric tube feeding. The nursing staff reports that she has become increasingly unwell over the past 24 hours, with lethargy and confusion. Upon examination, she appears to be short of breath, and there is evidence of peripheral and pulmonary edema. What is the most likely underlying diagnosis?
Your Answer: Korsakoff's syndrome
Correct Answer: Aspiration pneumonia
Explanation:Refeeding Syndrome in Malnourished Patients
Refeeding malnourished patients through enteral feeding requires careful monitoring of electrolytes and minerals. This is because refeeding can trigger a significant anabolic response that affects the levels of electrolytes and minerals essential to cellular function. Unfortunately, refeeding syndrome is often under-recognized and under-diagnosed. The metabolic changes that occur during refeeding can lead to marked hypophosphatemia and shifts in potassium, magnesium, glucose, and thiamine levels.
Refeeding syndrome is primarily caused by hypophosphatemia and can result in severe cardiorespiratory failure, edema, confusion, convulsions, coma, and even death. Therefore, it is crucial to closely monitor patients undergoing refeeding to prevent and manage refeeding syndrome.
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This question is part of the following fields:
- Gastroenterology
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Question 12
Incorrect
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A 50-year-old man with a history of ulcerative colitis (UC) is found to have sigmoid adenocarcinoma on surveillance colonoscopy. He was diagnosed with UC at the age of 14, with the disease mostly confined to the sigmoid colon and rectum. Although his symptoms have generally been well controlled on mesalazine, he has had relapses associated with poor compliance every 1–2 years.
Which single factor is this patient’s history most associated with the risk of developing colonic cancer?
Your Answer: Left-sided colitis
Correct Answer: Onset of disease in childhood
Explanation:Understanding the Risk Factors for Colonic Adenocarcinoma in Ulcerative Colitis Patients
Colonic adenocarcinoma is a serious complication that can develop in 3-5% of patients with ulcerative colitis (UC). The cancer tends to be multicentric and atypical in appearance, and it can rapidly metastasize. To prevent this, it is important to understand the risk factors associated with the onset of the disease in childhood.
One of the main risk factors for colon cancer in colitis is the early age of onset, which is before the age of 15 years. Other risk factors include extensive disease (pancolitis), duration (more than ten years), and unremitting disease. Colonoscopic surveillance is recommended for all patients, starting about ten years after the onset of symptoms.
It is important to note that annual relapses are not a risk factor for colonic carcinoma since there is remittance in between episodes. Chronic active inflammation and unremitting disease are the main risk factors.
Left-sided colitis is also a risk factor, but extensive disease and pancolitis carry a higher risk of developing colon cancer. Poor compliance with therapy is not a risk factor in itself, but unremitting disease is a risk factor for colon cancer in UC.
Finally, patients with proctitis alone do not need colonoscopy surveillance, as they are not at increased risk of developing colon cancer compared to the general population. Understanding these risk factors can help prevent the onset of colonic adenocarcinoma in UC patients.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 32-year-old woman comes to her General Practitioner complaining of constipation that has persisted since her last pregnancy two years ago. She has been using laxatives for the past few months. She reports no abdominal pain or diarrhoea and has not noticed any triggers or alleviating factors. Her weight is stable and she has not observed any blood in her stools. She is in good health otherwise.
What is the most probable diagnosis?Your Answer:
Correct Answer: Idiopathic constipation
Explanation:Possible Causes of Chronic Constipation: A Differential Diagnosis
Chronic constipation is a common condition affecting approximately 14% of the global population. While most cases do not require investigation, it is important to consider potential underlying causes in certain patients. Here are some possible diagnoses to consider:
1. Idiopathic constipation: This is the most common cause of chronic constipation, especially in young patients. A high-fiber diet and physical activity can help alleviate symptoms.
2. Diverticular disease: This condition is characterized by abdominal pain and diarrhea, but it usually presents later in life and chronic constipation is a risk factor.
3. Colon cancer: While chronic constipation can be a symptom of colon cancer, other factors such as weight loss and rectal bleeding are usually present. This diagnosis is unlikely in younger patients.
4. Hypothyroidism: Constipation can be a symptom of an underactive thyroid, but other symptoms such as weight gain and fatigue are usually present.
5. Irritable bowel syndrome (IBS): IBS can cause constipation and/or diarrhea, but it is usually associated with abdominal pain and bloating.
In summary, chronic constipation can have various underlying causes, and a careful history and physical examination can help determine the appropriate diagnostic approach.
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This question is part of the following fields:
- Gastroenterology
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Question 14
Incorrect
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A 50-year-old woman with type-2 diabetes complains of blood stained diarrhoea and cramping abdominal pain of several months’ duration. She underwent a hysterectomy and radiotherapy 2 years ago for endometrial carcinoma.
Select from the list the single most likely diagnosis.Your Answer:
Correct Answer: Chronic radiation enteropathy
Explanation:Chronic Radiation Enteropathy: Symptoms, Diagnosis, and Differential Diagnosis
Chronic radiation enteropathy is a progressive disease that can occur months or even years after radiation therapy. It is characterized by transmural bowel damage, obliterative endarteritis, and altered intestinal transit, leading to symptoms such as abdominal pain, diarrhea (which may be blood-stained), malabsorption, and dysmotility. Patients with a history of pelvic or abdominal radiation therapy are at risk for developing chronic radiation enteropathy, which can lead to intestinal obstruction, fistula formation, or perforation. Corrective surgery is associated with high morbidity and mortality, and long-term symptoms are common.
Diagnosis of chronic radiation enteropathy is based on the persistence of symptoms for three or more months following irradiation. Differential diagnosis includes irritable bowel syndrome, lymphoma, pseudomembranous colitis, and ulcerative colitis. However, the history of pelvic radiation is a key factor in distinguishing chronic radiation enteropathy from other conditions. While irritable bowel syndrome may cause diarrhea, blood in the stool is not a typical symptom. Lymphoma and ulcerative colitis may also present with bloody diarrhea and abdominal pain, but the history of radiation therapy makes chronic radiation enteropathy more likely. Pseudomembranous colitis is caused by infection with Clostridium difficile and is not typically associated with bloody stools.
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This question is part of the following fields:
- Gastroenterology
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Question 15
Incorrect
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A 56-year-old man presents with a sudden onset of acute severe pain in his upper abdomen, which radiates to his back. He experiences severe nausea and vomiting and finds that sitting forwards is the only way to alleviate the pain. His medical history includes hypertension and gallstones, which were incidentally discovered during an ultrasound scan. What is the MOST PROBABLE diagnosis?
Your Answer:
Correct Answer: Acute pancreatitis
Explanation:Differential Diagnosis of Acute Upper Abdominal Pain
Acute upper abdominal pain can have various causes, and it is important to differentiate between them to provide appropriate treatment. Here are some possible diagnoses based on the given symptoms:
1. Acute pancreatitis: This condition is often caused by gallstones or alcohol consumption and presents with severe upper abdominal pain. Blood tests show elevated amylase levels, and immediate hospital admission is necessary.
2. Budd-Chiari syndrome: This rare condition involves the blockage of the hepatic vein and can cause right upper abdominal pain, hepatomegaly, and ascites.
3. Acute cholecystitis: This condition is characterized by localized pain in the upper right abdomen and a positive Murphy’s sign (pain worsened by deep breathing).
4. Perforated duodenal ulcer: This condition can cause sudden upper abdominal pain, but it is usually associated with a history of dyspepsia or NSAID use.
5. Renal colic: This condition causes severe pain in the loin-to-groin area and is often accompanied by urinary symptoms and hematuria.
In conclusion, a thorough evaluation of the patient’s symptoms and medical history is necessary to determine the underlying cause of acute upper abdominal pain.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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A 32-year-old woman visits her doctor with complaints of abdominal cramps, bloating and diarrhoea. She has recently returned from a trip to Asia, where she consumed food from various street vendors. Upon examination, her temperature is normal. Analysis of three stool samples reveals cysts, and she responds well to a course of metronidazole. What is the most probable diagnosis?
Your Answer:
Correct Answer: Giardiasis
Explanation:Possible Causes of a Patient’s Abdominal Symptoms: A Differential Diagnosis
The patient presents with abdominal symptoms including cramps, bloating, and diarrhea. The following are possible causes of these symptoms:
1. Giardiasis: Caused by the protozoan parasite Giardia lamblia, transmitted by poor hygiene, and often associated with travel to areas with poor sanitation. Symptoms include diarrhea, flatulence, cramps, bloating, and nausea. Treatment is with metronidazole.
2. Typhoid fever: Caused by Salmonella typhi, often associated with travel to India, Pakistan, and Bangladesh. Symptoms include fever, but not present in this case.
3. Cryptosporidiosis: A parasite infection often causing sudden onset of watery diarrhea, abdominal cramps, and fever. Can be foodborne, waterborne, or transmitted through direct contact with livestock or infected people. Self-limiting, but may require treatment with metronidazole.
4. Salmonella enteritidis infection: The most common cause of salmonella gastroenteritis, often associated with contaminated food or poor hygiene. Symptoms include fever, which is not reported in this case.
5. Tapeworm infection: Caused by ingestion of uncooked or undercooked meat/fish containing tapeworm larvae. Symptoms vary depending on the type of tapeworm and may include abdominal discomfort, weight loss, and abnormal LFTs. Eggs may be found on stool examination, not cysts as in this case.
Overall, giardiasis and cryptosporidiosis are the most likely diagnoses given the patient’s symptoms and travel history. However, further testing and evaluation may be necessary to confirm the diagnosis and determine the appropriate treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 17
Incorrect
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A 27 year old woman presents with intermittent abdominal bloating, pain and diarrhea for the past 3 months. She denies any rectal bleeding, weight loss or family history of bowel disease. On examination, her abdomen appears normal. Along with a full blood count (FBC), urea & electrolytes (U&E), coeliac screen, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), what initial investigation would be most helpful in differentiating between irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) in a primary care setting?
Your Answer:
Correct Answer: Faecal calprotectin
Explanation:NICE recommends the use of faecal calprotectin in primary care to distinguish between IBS and IBD. This protein is released in the bowel during inflammation and can be detected in a stool sample. Its use can reduce the need for invasive diagnostic testing and referral of patients with typical IBS symptoms. However, a positive result doesn’t confirm IBD and patients should be referred to secondary care for further investigation.
NICE has also provided guidance on the diagnostic criteria for IBS and the necessary investigations. They suggest conducting FBC, ESR, CRP, and coeliac screen (TTG). However, they advise against performing ultrasound, sigmoidoscopy or colonoscopy, barium study, thyroid function test, stool microscopy and culture, and faecal occult blood and hydrogen breath test.
Understanding Diarrhoea: Causes and Characteristics
Diarrhoea is defined as having more than three loose or watery stools per day. It can be classified as acute if it lasts for less than 14 days and chronic if it persists for more than 14 days. Gastroenteritis, diverticulitis, and antibiotic therapy are common causes of acute diarrhoea. On the other hand, irritable bowel syndrome, ulcerative colitis, Crohn’s disease, colorectal cancer, and coeliac disease are some of the conditions that can cause chronic diarrhoea.
Symptoms of gastroenteritis may include abdominal pain, nausea, and vomiting. Diverticulitis is characterized by left lower quadrant pain, diarrhoea, and fever. Antibiotic therapy, especially with broad-spectrum antibiotics, can also cause diarrhoea, including Clostridioides difficile infection. Chronic diarrhoea may be caused by irritable bowel syndrome, which is characterized by abdominal pain, bloating, and changes in bowel habits. Ulcerative colitis may cause bloody diarrhoea, crampy abdominal pain, and weight loss. Crohn’s disease may cause crampy abdominal pain, diarrhoea, and malabsorption. Colorectal cancer may cause diarrhoea, rectal bleeding, anaemia, and weight loss. Coeliac disease may cause diarrhoea, abdominal distension, lethargy, and weight loss.
Other conditions associated with diarrhoea include thyrotoxicosis, laxative abuse, appendicitis, and radiation enteritis. It is important to seek medical attention if diarrhoea persists for more than a few days or is accompanied by other symptoms such as fever, severe abdominal pain, or blood in the stool.
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This question is part of the following fields:
- Gastroenterology
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Question 18
Incorrect
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A 32-year-old woman presents to her General Practitioner with complaints of intermittent central abdominal pain and bloating, which is often relieved when she opens her bowels. She also experiences loose stools and occasional urgency to pass a stool. These symptoms have been occurring on and off for about six months, and she has not experienced any weight loss or bleeding. On examination, her abdomen appears normal. The patient has recently been promoted to a more responsible position at work. What is the most appropriate intervention to relieve this patient's symptoms?
Your Answer:
Correct Answer: Mebeverine
Explanation:Appropriate Medications for Irritable Bowel Syndrome: A Case Study
A patient presents with symptoms consistent with irritable bowel syndrome (IBS), including abdominal pain relieved by defecation and the absence of red-flag symptoms. The likely cause of her flare-up is increased stress following a job promotion. Antispasmodics such as mebeverine are appropriate for symptomatic relief of abdominal pain in IBS, while omeprazole is not indicated for this patient. Domperidone is not necessary for the relief of nausea and vomiting, and lactulose is not recommended due to potential bloating. Linaclotide is not appropriate for this patient as her symptoms have only been present for six months and there is no evidence that other laxatives have failed. Overall, mebeverine and lifestyle changes are the recommended interventions for this patient with IBS.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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Rahul, a young adult, has been experiencing symptoms of irritable bowel syndrome and seeks advice from his doctor regarding dietary changes that could alleviate his bloating and constipation. What diet would be beneficial for young adults dealing with irritable bowel syndrome?
Your Answer:
Correct Answer: Low FODMAP diet
Explanation:Monash University in Australia has recently introduced a low-FODMAP diet for managing irritable bowel syndrome (IBS). FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine, leading to water intake and diarrhea or fermentation by bacteria causing bloating in the large bowel. A low-FODMAP diet has been found to reduce IBS symptoms such as bloating, abdominal pain, and irregular bowel habits. However, it is a challenging diet to follow as it excludes many foods containing Oligo-, Di-, Mono-saccharides and Polyols, including wheat, dairy, pulses, excess fructose, and some vegetables. Therefore, it is recommended to seek the advice of a dietician.
The LOFFLEX diet, which stands for low fat/fibre exclusion diet, has been developed for individuals with Crohn’s disease. It is often used after the elemental diet to maintain remission by avoiding high-fiber and high-fat foods that can trigger Crohn’s. The ketogenic diet has been shown to improve seizure control in people with epilepsy, particularly in children who are under the supervision of a pediatric dietician and have drug-resistant epilepsy. The specific carbohydrate and paleo diets are popular new diet trends that GPs may encounter, both of which significantly limit carbohydrate intake in the diet.
Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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Which of the following is not a characteristic of non-alcoholic steatohepatitis?
Your Answer:
Correct Answer: Type 1 diabetes mellitus
Explanation:Non-alcoholic fatty liver disease may be considered as a potential cause of abnormal liver function tests in patients with type 2 diabetes mellitus.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 21
Incorrect
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A concerned man visits your clinic as he participated in the routine bowel cancer screening program and received a positive faecal occult blood test (FOBt) result. He inquires if this indicates that he has bowel cancer. What is the estimated percentage of patients with a positive FOBt result who are subsequently diagnosed with bowel cancer during colonoscopy?
Your Answer:
Correct Answer: 10%
Explanation:Colorectal Cancer Screening with FIT Test
Overview:
Colorectal cancer is often developed from adenomatous polyps. Screening for this cancer has been proven to reduce mortality by 16%. The NHS provides home-based screening for older adults through the Faecal Immunochemical Test (FIT). Although a one-off flexible sigmoidoscopy was trialled in England, it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was further exacerbated by the COVID-19 pandemic. However, the trial showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used in future bowel screening programmes.Faecal Immunochemical Test (FIT) Screening:
The NHS offers a national screening programme every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests as it only detects human haemoglobin, not animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. Although a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy.Colonoscopy:
Approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer. -
This question is part of the following fields:
- Gastroenterology
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Question 22
Incorrect
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A 28-year-old man visits his General Practitioner with complaints of dysphagia. He believes it has been present for around 18 months, but it is getting worse. He also reports experiencing chest discomfort, coughing at night, and waking up with undigested food on his pillow in the morning.
During the examination, his throat, neck, chest, and abdomen appear normal.
What is the most probable diagnosis?Your Answer:
Correct Answer: Achalasia
Explanation:The patient’s symptoms suggest a diagnosis of achalasia, which is characterized by the failure of the lower oesophageal sphincter to relax, leading to a functional stricture. This can cause substernal cramps, regurgitation, and pulmonary aspiration due to the retention of food and saliva in the oesophagus, resulting in a nocturnal cough. Diagnosis is made using a barium swallow, and treatment involves endoscopic balloon dilation or cardiomyotomy. Barrett’s oesophagus, motor neurone disease, oesophageal carcinoma, and pharyngeal pouch are less likely diagnoses based on the patient’s age, symptoms, and medical history.
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This question is part of the following fields:
- Gastroenterology
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Question 23
Incorrect
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A 70-year-old woman comes to the clinic complaining of upper abdominal bloating and discomfort after meals that has been going on for three months. She reports feeling nauseated at times but denies vomiting. She has lost more than 1 stone in weight. She has not experienced any changes in bowel habits and has not passed any blood in her stools. She has no significant medical history.
During the physical examination, there is no evidence of jaundice or anemia, but she has diffuse upper abdominal tenderness, and her gallbladder is palpable on inspiration. A previous abdominal ultrasound scan conducted ten years ago revealed the presence of an incidental gallstone, but she did not undergo surgery as she was asymptomatic at the time. There is a strong family history of gallstones.
What is the most appropriate course of action?Your Answer:
Correct Answer: Routine referral for consideration of cholecystectomy
Explanation:Understanding Gallbladder Cancer and its Risk Factors
Gallbladder cancer is a rare form of cancer that often goes undiagnosed until it has reached an advanced stage. It is more common in women, especially those with a history of gallstones, and those who have a family history of the disease. Other risk factors include smoking, obesity, and diabetes. Native Americans, black, and Hispanic populations are also at a higher risk of developing Gallbladder cancer.
Symptoms of Gallbladder cancer can be vague and mimic benign disease, making it difficult to diagnose. However, unintentional weight loss is a red flag and should be taken seriously. Most Gallbladder tumors are adenocarcinomas and can spread to the liver and lungs. By the time symptoms appear, the cancer has often metastasized, and more than half of patients present with jaundice.
It is important to have a high index of suspicion for Gallbladder cancer, especially in patients with risk factors. Even if the abdominal examination is normal, significant weight loss should prompt urgent referral for investigation under the two week wait system. By understanding the risk factors and symptoms of Gallbladder cancer, healthcare professionals can help ensure early detection and treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 24
Incorrect
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A 50-year-old man presents to his General Practitioner concerned that he may have cirrhosis of the liver. He has regularly drunk more than 30 units of alcohol every week for many years. Over the last three months, he has lost 2 kg in weight. He attributes this to a poor appetite.
On examination, there are no obvious features.
What is the most appropriate advice you can provide this patient?
Your Answer:
Correct Answer: The presence of chronic hepatitis C infection makes a diagnosis of liver cirrhosis more likely
Explanation:Diagnosing Liver Cirrhosis in Patients with Chronic Hepatitis C Infection
Liver cirrhosis is a common complication of chronic hepatitis C infection and can be caused by other factors such as alcohol consumption. Patients with chronic hepatitis C infection who are over 55 years old, male, and consume moderate amounts of alcohol are at higher risk of developing cirrhosis. However, cirrhosis can be asymptomatic until complications arise. An ultrasound scan can detect cirrhosis and its complications, but a liver biopsy is the gold standard for diagnosis. Abnormal liver function tests may indicate liver damage, but they are not always conclusive. The absence of signs doesn’t exclude a diagnosis of liver cirrhosis. Further investigation is necessary before considering a liver biopsy.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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A 56-year-old woman comes to the clinic with jaundice soon after being released from the hospital. Her liver function tests show the following results:
- Albumin: 49 g/l
- Bilirubin: 89 µmol/l
- Alanine transferase (ALT): 66 iu/l
- Alkaline phosphatase (ALP): 245 µmol/l
- Gamma glutamyl transferase (yGT): 529 u/l
Which antibiotic is most likely responsible for her condition?Your Answer:
Correct Answer: Flucloxacillin
Explanation:Cholestasis is a commonly known adverse effect of Flucloxacillin.
Drug-induced liver disease can be categorized into three types: hepatocellular, cholestatic, or mixed. However, there can be some overlap between these categories, as some drugs can cause a range of liver changes. Certain drugs tend to cause a hepatocellular picture, such as paracetamol, sodium valproate, and statins. On the other hand, drugs like the combined oral contraceptive pill, flucloxacillin, and anabolic steroids tend to cause cholestasis with or without hepatitis. Methotrexate, methyldopa, and amiodarone are known to cause liver cirrhosis. It is important to note that there are rare reported causes of drug-induced liver disease, such as nifedipine.
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This question is part of the following fields:
- Gastroenterology
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Question 26
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 27
Incorrect
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A 40-year-old patient with epilepsy that is currently managed with phenytoin presents to his General Practitioner. He has recently been taking oral flucloxacillin for a leg injury that was precipitated by a recent fit. The patient occasionally drinks alcohol and has been taking paracetamol for pain relief after his leg injury. Clinical examination reveals jaundice; however, his abdomen is non-tender. Liver function tests are shown below.
Investigation Result Normal value
Bilirubin 280 μmol/l 1–22 μmol/l
Alkaline phosphatase (ALP) 440 U/l 45–105 U/l
Gamma-glutamyltransferase (GGT) 320 U/l 11–50 U/l
Alanine aminotransferase (ALT) 46 U/l < 35 U/l
What is the most likely cause of this patient’s jaundice?Your Answer:
Correct Answer: Flucloxacillin
Explanation:Causes of Jaundice: Identifying the Culprit in a Clinical Case
In this clinical case, a patient presents with jaundice and abnormal liver function tests. The following potential causes are considered:
Flucloxacillin: The patient’s presentation is consistent with cholestatic jaundice, which can be caused by flucloxacillin. Other drugs that can cause a similar picture include chlorpromazine, azathioprine, captopril, ciclosporin, penicillamine, erythromycin, and the combined oral contraceptive.
Ethanol: Although the patient reports occasional alcohol use, ethanol is an unlikely cause of cholestatic jaundice. Ethanol more commonly causes a hepatitic picture with elevated transaminase levels.
Gallstones: Cholecystitis typically doesn’t cause jaundice. If gallstones were the cause, right upper quadrant pain and tenderness would be expected.
Paracetamol: The patient is taking paracetamol, but there is no information about excessive use. Paracetamol overdose typically causes a hepatitic picture rather than cholestatic jaundice.
Phenytoin: Phenytoin typically causes a hepatitic picture with larger elevations in transaminase levels and a smaller rise in ALP levels.
In conclusion, flucloxacillin is the most likely cause of this patient’s cholestatic jaundice.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 48-year-old alcoholic patient visits the General Practitioner (GP) for a check-up. He has recently been released from the hospital after experiencing an upper gastrointestinal bleed caused by oesophageal varices. He informs you that he has quit drinking and inquires about the likelihood of experiencing another bleeding episode.
What is the accurate statement regarding the risk of future bleeding from oesophageal varices?Your Answer:
Correct Answer: The risk of re-bleeding is greater than 60% within a year
Explanation:Understanding Variceal Haemorrhage: Causes, Complications, and Prognosis
Variceal haemorrhage is a common complication of portal hypertension, with almost 90% of cirrhosis patients developing varices and 30% experiencing bleeding. The mortality rate for the first episode is high, ranging from 30-50%. The severity of liver disease and associated systemic disorders worsen the prognosis, increasing the likelihood of a bleed. Patients who have had one episode of bleeding have a high chance of recurrence within a year, with one-third of further episodes being fatal. While abstaining from alcohol can slow the progression of liver disease, it cannot reverse portal hypertension. Understanding the causes, complications, and prognosis of variceal haemorrhage is crucial for effective management and prevention.
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This question is part of the following fields:
- Gastroenterology
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Question 30
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 31
Incorrect
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A 55-year-old man reports that he has noticed black tarry stools over the last 2 weeks. He has vomited a small amount of blood.
Your Answer:
Correct Answer: Melaena can result from oesophageal varices
Explanation:Understanding Melaena: Causes, Symptoms, and Treatment
Melaena is a medical condition characterized by black tarry stools, which is often caused by an acute upper gastrointestinal bleed. The bleeding can occur in the oesophagus, stomach, duodenum, small bowel, or right side of the colon, with peptic ulcer disease being the most common cause. In some cases, melaena may be the only symptom of bleeding from oesophageal varices, which are associated with portal hypertension.
Acute upper gastrointestinal bleeding is a medical emergency that requires immediate attention, as it can be life-threatening. Patients who are haemodynamically unstable should undergo endoscopy within 2 hours after resuscitation, while other patients should have endoscopy within 24 hours. It is important to note that proton pump inhibitors should not be given before endoscopy.
Patients who are at higher risk of complications include those aged over 60 years and those with co-morbidities. The mortality rate for patients with acute upper gastrointestinal bleeding in hospital is around 10%. Therefore, it is crucial to seek medical attention promptly if you experience symptoms of melena or haematemesis.
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This question is part of the following fields:
- Gastroenterology
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Question 32
Incorrect
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A 65-year-old White woman presents to her General Practitioner with right upper quadrant pain, a liver mass, weight loss and anaemia. She describes no symptoms prior to this episode and is not on any regular medications.
She drinks around ten units of alcohol per week and was previously an intravenous (IV) drug user, although she has not done this for many years. She has no significant family history.
She is diagnosed with hepatocellular carcinoma (HCC).
What is the most likely predisposing factor for this diagnosis in this patient?Your Answer:
Correct Answer: Hepatitis C
Explanation:Understanding the Possible Causes of Hepatocellular Carcinoma (HCC)
Hepatocellular carcinoma (HCC) is a type of liver cancer that can be caused by various factors. In this case, the patient’s history of intravenous (IV) drug use puts her at risk of hepatitis B and C, which are the most common causes of HCC in Europe. Chronic hepatitis B or C infection can increase the risk of developing HCC by 3-5% per year, and having both infections can further increase the risk.
Alcohol abuse is also a risk factor for HCC, but in this patient’s case, her drinking is not excessive. Hereditary hemochromatosis, a condition that causes the body to absorb too much iron, can also increase the risk of HCC, but it is less common than chronic hepatitis. However, this patient’s lack of previous symptoms and family history make it unlikely that hemochromatosis is the underlying cause of her HCC.
Another possible predisposing factor for HCC is primary biliary cholangitis (PBC), an autoimmune disease that affects the liver’s bile ducts. PBC is more common in women and may present with fatigue and pruritus, but this patient’s symptoms do not fit this clinical picture.
In summary, understanding the possible causes of HCC can help in identifying the underlying factors and developing appropriate treatment plans. In this patient’s case, chronic hepatitis B or C infection is the most likely cause of her HCC.
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This question is part of the following fields:
- Gastroenterology
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Question 33
Incorrect
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A 16-month-old boy recently treated for constipation is seen for review.
Six weeks ago, his parents brought him in and he was diagnosed with constipation. He was prescribed Movicol® Paediatric Plain sachets and given dietary advice. Following this, the child was able to open his bowels regularly with soft, well-formed stools.
Two weeks ago, the parents stopped the laxative and the child has once again developed problems. On further questioning, he is opening his bowels maximum twice a week and the stools are described as hard balls.
What is the most appropriate management plan?Your Answer:
Correct Answer: Restart the Movicol® Paediatric Plain but continue treatment for a longer period before slowly tapering
Explanation:Importance of Continuing Laxative Treatment for Children with Constipation
Early and abrupt cessation of treatment is the most common cause of relapse in children with constipation. Once a regular pattern of bowel habit is established, maintenance laxative should be continued for several weeks and gradually tapered off over a period of months based on stool consistency and frequency. It may take up to six months of maintenance treatment to retrain the bowel, and some children may require laxative treatment for several years.
The use of Movicol® Paediatric Plain sachets has been effective in establishing regular soft stools, but discontinuing the treatment has caused the problem to resurface. It is not recommended to switch to an alternative laxative or combine Movicol® Paediatric Plain with a stimulant laxative. The best approach is to restart the same laxative and continue its use for a longer period before tapering cautiously.
At this point, there is no need for referral to a pediatrician or blood tests. However, it is important to emphasize the importance of continuing laxative treatment as prescribed to prevent relapse and maintain regular bowel habits in children with constipation.
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This question is part of the following fields:
- Gastroenterology
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Question 34
Incorrect
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A 22-year-old man presents to his General Practitioner with profound tiredness and a lack of appetite which have been present for about a week. He has just returned from a gap-year trip to Thailand and noticed he was jaundiced just before coming home. He also experienced a fever, but this subsided once his jaundice appeared. He has no sexual history, doesn't abuse intravenous (IV) drugs and did not receive a blood transfusion or get a tattoo or piercing during his trip.
Investigations:
Investigation Result Normal value
Haemoglobin (Hb) 140 g/l 135–175 g/l
White cell count (WCC) 9.0 × 109/l 4.0–11.0 × 109/l
Alanine aminotransferase (ALT) 950 IU/l < 40 IU/l
Alkaline phosphatase (ALP) 150 IU/l 25–130 IU/l
Bilirubin 240 µmol/l < 21 µmol/l
Albumin 40 g/l 38–50 g/l
Prothrombin time (PT) 12.0 s 12.0–14.8 s
What is the most likely diagnosis?Your Answer:
Correct Answer: Hepatitis A (Hep A)
Explanation:Based on the patient’s symptoms and history, the most likely diagnosis is Hepatitis A. The initial fever, anorexia, and malaise followed by jaundice and elevated liver enzymes are typical of Hep A. A confirmation test for anti-Hep A immunoglobulin M can be done. Hep A is not common in the UK but is more prevalent in areas with poor sanitation, especially among travelers. Cytomegalovirus infection can also cause a mononucleosis-like syndrome with fever, splenomegaly, and mild liver enzyme increases, but rises in ALP and bilirubin are less common. Hep B and C are unlikely as there are no risk factors in the patient’s history. Leptospirosis, which is associated with exposure to rat-infected water and conjunctival suffusion, is less likely than Hep A.
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This question is part of the following fields:
- Gastroenterology
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Question 35
Incorrect
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A 56-year-old man presents to his primary care physician with a complaint of altered bowel habits. He reports experiencing constipation for the past 3 months, followed by occasional episodes of loose stools. He denies any associated pain, rectal bleeding, or unexplained weight loss. The patient is in good health, has a regular diet, and takes no medications. On physical examination, the abdomen is soft and non-tender with no palpable masses.
What would be the most suitable course of action for this patient?Your Answer:
Correct Answer: Faecal immunochemical testing (FIT)
Explanation:For patients who show new symptoms of colorectal cancer but do not meet the 2-week referral criteria, it is recommended to undergo the FIT test. In this case, as the patient is under 60 years old, an urgent referral is not necessary. However, if the change in bowel habit persists, it is important to consider a referral to a lower gastrointestinal specialist. It is not appropriate to request a faecal calprotectin test as it is mainly used for suspected IBD cases. A full blood count is necessary, but it should not be the only test performed. The most crucial step in management is to request a FIT test, which can trigger a 2-week wait if the result is positive. While providing reassurance to the patient is important, it should not be done without any investigation as it may lead to missing a potential colorectal cancer.
Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.
An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.
The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.
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This question is part of the following fields:
- Gastroenterology
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Question 36
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 37
Incorrect
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Coeliac disease screening should be conducted for all patients diagnosed with?
Your Answer:
Correct Answer: Graves' disease
Explanation: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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This question is part of the following fields:
- Gastroenterology
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Question 38
Incorrect
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You see a 49-year-old gentleman with a change in bowel habit. He has had routine blood tests which were all normal. He reports no rectal bleeding. On examination, his abdomen is soft, non-tender and the rectal examination was normal.
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 Screening
Faecal occult blood tests are recommended by NICE for patients who exhibit symptoms that may indicate colorectal cancer but are unlikely to have the disease. These tests are also used for routine screening. However, it is crucial to consider the criteria for suspected lower GI cancer referrals when deciding to use this test. For instance, if a patient is 60 years or older and has experienced a change in bowel habit, they should be referred using a suspected lower GI cancer pathway instead of undergoing a faecal occult blood test. Proper screening and referral protocols can help ensure timely and accurate diagnosis and treatment of colorectal cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 39
Incorrect
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A 50-year-old man has a 25-year history of ulcerative colitis. He has had courses of prednisolone for exacerbations in the past but has never persisted with prophylactic medication. He has not had a hospital review for many years. He has now had a change in bowel habit for six months, with increasing diarrhoea.
Which of the following is the single most important management step for this patient?Your Answer:
Correct Answer: Urgent colonoscopy
Explanation:Management of a Patient with Subacute Change in Bowel Habit and Ulcerative Colitis
Patients with ulcerative colitis have an increased risk of developing colonic adenocarcinoma, which starts 8-10 years after the onset of the disease. Surveillance colonoscopy is recommended every 1-2 years to assess for dysplasia. In a patient with a long-standing disease and a new change in bowel habit, there should be a high index of suspicion for malignancy, especially if routine surveillance has been missed.
An abdominal plain X-ray may be useful in acute presentations of ulcerative colitis, but it is not the best choice for subacute changes in bowel habit. Oral mesalazine may reduce the risk of developing colorectal cancer, but it doesn’t address the red flags in this case.
Oral prednisolone may be prescribed to see if there is any resolution of symptoms, but the priority is an urgent colonoscopy to rule out a new diagnosis of colorectal cancer.
Stool microscopy and culture are unlikely to be helpful in this case, as there is no acute-onset diarrhea or recent foreign travel.
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This question is part of the following fields:
- Gastroenterology
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Question 40
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 41
Incorrect
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A 72-year-old man comes to his General Practitioner complaining of jaundice and weight loss. He reports having pale coloured stool and dark urine. He denies experiencing any abdominal pain or fever. He has no significant medical or family history.
What is the most probable diagnosis?Your Answer:
Correct Answer: Pancreatic adenocarcinoma
Explanation:Diagnosing Pancreatic Adenocarcinoma: Understanding the Symptoms and Differential Diagnosis
Pancreatic adenocarcinoma is a serious condition that requires prompt diagnosis and treatment. One of the key symptoms of this condition is painless jaundice, which is often accompanied by weight loss. This is due to the obstructive jaundice that occurs when the tumor is located at the head of the pancreas. Other symptoms may include pale stools and dark urine.
It is important to note that patients may present with these symptoms before experiencing abdominal pain. This is why it is crucial to refer any patient aged 40 years and over with jaundice for suspected pancreatic cancer, according to National Institute for Health and Care Excellence (NICE) guidance.
When considering a differential diagnosis, gallstone obstruction and cholecystitis can be ruled out due to the absence of severe abdominal pain. Chronic pancreatitis is also unlikely due to the lack of abdominal pain and the rarity of jaundice as a symptom. Hepatitis A may present with similar symptoms, but abdominal pain occurs in only 40% of patients.
In conclusion, understanding the symptoms and differential diagnosis of pancreatic adenocarcinoma is crucial for prompt diagnosis and treatment. Any patient with jaundice should be referred for suspected pancreatic cancer, regardless of other symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 42
Incorrect
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A 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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This question is part of the following fields:
- Gastroenterology
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Question 43
Incorrect
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A 38-year-old man is seen for follow up regarding his dyspepsia.
He was found to be positive for Helicobacter pylori on serological testing and received eradication therapy. He also underwent an upper GI endoscopy last year which did not reveal any focal pathology. Despite this, he still experiences reflux symptoms, and you decide to retest him for Helicobacter pylori.
What is the most appropriate method of retesting?Your Answer:
Correct Answer: Saliva assay
Explanation:Retesting for Helicobacter pylori after Eradication Therapy
The NICE guidelines on Dyspepsia (CG184) provide recommendations for retesting patients who have received eradication therapy for Helicobacter pylori. The first-line tests for detecting H. pylori are the stool antigen test and the urea breath test, while serological testing can be used if locally validated. However, serology is not appropriate for retesting as it remains positive due to past exposure. Saliva assays are inconsistent in accuracy, and gastric biopsy is invasive and costly.
If a patient tests positive for H. pylori and receives eradication therapy, retesting may be necessary. Currently, there is insufficient evidence to recommend stool antigen testing as a test of eradication. Therefore, NICE recommends retesting via the urea breath test.
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This question is part of the following fields:
- Gastroenterology
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Question 44
Incorrect
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A 54-year-old woman has a 3-week history of increasing jaundice and dark urine. In the past 4 months she has noticed intermittent loose, pale stools and has lost 6 kg in weight. On examination she is thin and jaundiced, with epigastric tenderness and a palpable gallbladder. Urine dipstick shows glucose +++, bilirubin +++ and urobilinogen +.
Select from the list the single most likely diagnosis.Your Answer:
Correct Answer: Carcinoma of the head of the pancreas
Explanation:Courvoisier’s Law and Obstructive Jaundice in Diagnosing Pancreatic Carcinoma
Courvoisier’s law is a crucial factor in diagnosing the cause of jaundice. If a palpable gallbladder is present in the presence of jaundice, it is unlikely to be due to gallstones. This is because gallstones cause a fibrotic gallbladder that will not distend in the presence of obstruction of the common bile duct. However, absence of Courvoisier’s sign doesn’t rule out malignancy.
In cases of obstructive jaundice, haemochromatosis can be excluded as a cause. The initial symptoms of haemochromatosis are usually vague and nonspecific, such as fatigue, weakness, arthropathy, and nonspecific abdominal problems.
Of the three obstructive neoplastic processes that remain, carcinoma of the head of the pancreas is the only one that will cause glycosuria. Therefore, the development of diabetes in anyone who is non-obese and over 50 years old without definite risk factors should raise suspicion of pancreatic carcinoma.
In conclusion, understanding Courvoisier’s law and the exclusions of other potential causes of obstructive jaundice is crucial in diagnosing pancreatic carcinoma.
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This question is part of the following fields:
- Gastroenterology
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Question 45
Incorrect
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A 70-year-old woman with squamous cell lung cancer presents with confusion.
Her family reports that she has become slowly more confused over the last two weeks. She is also complaining of generalised aches and pains, lethargy and thirst. Further enquiry reveals that she has been having increasing problems with constipation.
What is the underlying cause of this presentation?Your Answer:
Correct Answer: Ectopic parathyroid hormone production
Explanation:Paraneoplastic Syndromes Associated with Lung Cancer
Lung cancer can be associated with various paraneoplastic syndromes, which are caused by substances produced by the tumor that affect other parts of the body. One such syndrome is hypercalcemia, which can cause confusion, lethargy, aches and pains, thirst, and constipation. Squamous cell lung carcinoma is particularly associated with ectopic parathyroid hormone production, leading to increased calcium levels.
Other paraneoplastic syndromes associated with lung cancer include Cushing’s syndrome, which can occur with small cell lung cancer due to ectopic ACTH production; Horner’s syndrome, which can occur with apical lung tumors that invade sympathetic nerve fibers, causing ptosis, miosis, and anhydrosis; and Lambert-Eaton syndrome, an autoimmune process associated with small cell lung cancer that causes muscle weakness and hyporeflexia.
Another condition associated with lung cancer is SIADH, which causes hyponatremia and can lead to confusion, seizures, cardiac failure, edema, and muscle weakness. Causes of SIADH include small cell lung cancer, as well as other malignancies, stroke, subarachnoid hemorrhage, vasculitis, TB, and certain drugs like opiates. Understanding these paraneoplastic syndromes can help clinicians identify and manage symptoms in patients with lung cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 46
Incorrect
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A 30-year-old man presents to his General Practitioner with cramping abdominal pain and profuse diarrhoea, which is sometimes bloody. He thinks it may be related to some chicken he ate 3 days ago before returning from a holiday in South East Asia. He has no other comorbidities and works in the local pub.
On examination, his temperature is 38.0 °C. There is mild tenderness in the left iliac fossa. His observations are normal. A stool sample is positive for campylobacter.
Which of the following is the most appropriate management?Your Answer:
Correct Answer: Prescribe an antibiotic
Explanation:Managing Campylobacter Infection: Antibiotics, Hydration, and Work Restrictions
Campylobacter is a common bacterial cause of infectious intestinal disease, often contracted through undercooked meat, contaminated water, or contact with infected animals. When a patient presents with symptoms such as fever, bloody diarrhea, and abdominal pain, a stool culture should be performed to confirm the diagnosis. According to NICE guidelines, antibiotic treatment is recommended for patients with positive stool cultures and severe symptoms. Erythromycin is the first-line choice, with alternatives including azithromycin, clarithromycin, and ciprofloxacin.
Patients should not return to work for at least 48 hours after the last episode of diarrhea or vomiting, and longer if they work with food or in other specific settings. Hospital admission is only necessary for severe symptoms or systemic illness. Antimotility drugs are not recommended for patients with possible Shiga toxin-producing Escherichia coli infection, but may be useful for travelers’ diarrhea. Oral rehydration salts are important for managing symptoms and preventing dehydration. With appropriate treatment and management, most cases of Campylobacter infection will resolve within a week.
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This question is part of the following fields:
- Gastroenterology
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Question 47
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 48
Incorrect
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A 25-year-old woman has been diagnosed as having coeliac disease. She has started on a gluten-free diet.
Select from the list the single most correct statement about her management.Your Answer:
Correct Answer: IgA anti-tissue transglutaminase antibodies and endomysial antibodies disappear if the diet is maintained
Explanation:Managing Coeliac Disease with a Gluten-Free Diet
Coeliac disease is a condition where the immune system reacts to gluten, a protein found in wheat, barley, and rye. The resulting damage to the intestinal mucosa can cause a range of symptoms, including abdominal pain, bloating, and diarrhoea. However, starting a gluten-free diet can lead to rapid improvement.
The diet involves avoiding all foods containing wheat, barley, or rye, such as bread, cake, and pies. Oats can be consumed in moderate quantities if they are free from other contaminating cereals, as they do not damage the intestinal mucosa in most coeliac patients. Rice, maize, potatoes, soya, jam, syrup, sugar, and treacle are all allowed. Gluten-free flour, bread, biscuits, and pasta can be prescribed on the NHS, and Coeliac UK provides a list of prescribable products.
To monitor the response to the diet, serial tTGA or EMA antibodies can be used. If these antibodies continue to be present in the blood, it suggests dietary lapses.
Supplements of calcium, vitamin D, iron, and folic acid are only necessary if dietary intake is inadequate, which is often the case, particularly in elderly patients. Most patients with coeliac disease have some degree of hyposplenism, which warrants immunisation against influenza, pneumococcus, and H. influenza type B. However, lifelong prophylactic antibiotics are not needed.
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This question is part of the following fields:
- Gastroenterology
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Question 49
Incorrect
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A 27 year old male with a history of ulcerative colitis presents with rectal symptoms and bloody diarrhoea. Upon examination, he appears comfortable and well hydrated. His vital signs include a regular pulse of 88 beats per minute, a temperature of 37.5ºC, and a blood pressure of 120/80 mmHg. There is mild tenderness in the left iliac fossa, but no palpable masses or rebound tenderness. Rectal examination reveals tenderness and blood in the rectum. What is the most appropriate initial treatment for this patient's mild/moderate proctitis flare?
Your Answer:
Correct Answer: Rectal mesalazine
Explanation:When experiencing a mild-moderate flare of distal ulcerative colitis, the initial treatment option is the use of topical (rectal) aminosalicylates. It is recommended to start with local treatment for rectal symptoms. Topical aminosalicylates are more effective than steroids, but a combination of both can be used if monotherapy is not effective. If the disease is diffuse or if symptoms do not respond to topical treatments, oral aminosalicylates can be used. In cases of severe disease, oral steroids can be considered.
Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.
To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.
In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.
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This question is part of the following fields:
- Gastroenterology
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Question 50
Incorrect
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A 65-year-old man with coronary artery disease visits his General Practitioner after an abdominal ultrasound reveals an easily felt epigastric pulsation. The ultrasound shows a normal calibre abdominal aorta without aneurysm, but incidentally finds gallstones. The patient has never experienced biliary colic or jaundice and has a normal body mass index with no history of abdominal surgery.
What is the most appropriate treatment for this patient?Your Answer:
Correct Answer: No treatment
Explanation:Treatment Options for Asymptomatic Cholelithiasis
Asymptomatic cholelithiasis, or gallstones without any symptoms, doesn’t require therapeutic intervention. In fact, up to 70% of patients with gallstones are asymptomatic at the time of diagnosis. The risk of prophylactic cholecystectomy, or removal of the gallbladder, is greater than the benefit likely to be gained by removal. However, in a partially calcified ‘porcelain’ gallbladder, removal may be recommended to prevent pancreatitis or cholangitis.
Open cholecystectomy, a surgical procedure with a longer recovery time and higher risk of complications, is often reserved for patients where laparoscopy is a higher risk. Endoscopic removal of stones is not suitable for asymptomatic cholelithiasis as it doesn’t remove the gallbladder or stones within it.
If the patient becomes symptomatic, laparoscopic cholecystectomy would be the treatment of choice. However, for asymptomatic patients, the risks of a procedure outweigh the potential benefits of preventing future complications. Lithotripsy, a procedure that breaks up gallstones, is not routinely recommended for the treatment of any gallstones due to the risk of complications.
Treatment Options for Asymptomatic Cholelithiasis
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This question is part of the following fields:
- Gastroenterology
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Question 51
Incorrect
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A 56-year-old male presents two weeks following a knee replacement with severe diarrhea. What is the probable diagnosis?
Your Answer:
Correct Answer: Clostridium difficile
Explanation:The probable reason for the patient’s condition is Clostridium difficile, which could have been caused by the administration of broad-spectrum antibiotics during the operation. According to NICE guidelines, patients undergoing clean surgery with prosthesis or implant placement, clean-contaminated surgery, contaminated surgery, or surgery on a dirty or infected wound should receive antibiotics to prevent surgical site infections. In cases of contaminated or infected wounds, prophylaxis should be accompanied by antibiotic treatment.
Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Gastroenterology
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Question 52
Incorrect
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A 57-year-old woman visits her GP complaining of experiencing indigestion for the past two months. She is in good health, has never had a similar episode before, and is not taking any regular medication. Notably, she has not experienced any recent weight loss or vomiting, and her abdominal examination is normal. What is the best initial course of action?
Your Answer:
Correct Answer: Lifestyle advice + one month course of a full-dose proton pump inhibitor
Explanation:As per the revised NICE guidelines of 2015, there is no need for an immediate endoscopy referral for her. However, if she fails to respond to treatment, a non-urgent referral would be advisable.
Management of Dyspepsia and Referral Criteria for Suspected Cancer
Dyspepsia is a common condition that can be managed through a stepwise approach. The first step is to review medications that may be causing dyspepsia and provide lifestyle advice. If symptoms persist, a full-dose proton pump inhibitor or a ‘test and treat’ approach for H. pylori can be tried for one month. If symptoms still persist, the alternative approach should be attempted.
For patients who meet referral criteria for suspected cancer, urgent referral for an endoscopy within two weeks is necessary. This includes patients with dysphagia, an upper abdominal mass consistent with stomach cancer, and patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent referral is recommended for patients with haematemesis and patients aged 55 years or older with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with symptoms such as nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.
Testing for H. pylori infection can be done through a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms have resolved following a ‘test and treat’ approach, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.
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This question is part of the following fields:
- Gastroenterology
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Question 53
Incorrect
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A 67-year-old woman presents to her General Practitioner complaining of chronic, unrelenting, dull epigastric pain radiating to her back. It is relieved when sitting forwards.
On examination, her body mass index is normal, but she says that she is losing weight; her clothes have become baggy on her. She explains that she doesn't feel like eating with the pain she is suffering.
Investigations reveal a haemoglobin level of 102 g/l (normal range: 115–165 g/l) while her alkaline phosphatase level is elevated.
What is the most appropriate initial investigation?
Your Answer:
Correct Answer: Arrange an abdominal computed tomography (CT) scan
Explanation:Initial Management for Suspected Pancreatic Cancer: Abdominal CT Scan
When a patient over 60 years old presents with weight loss and abdominal pain, an urgent direct-access CT scan should be considered to assess for pancreatic cancer. Other symptoms that may indicate pancreatic cancer include diarrhea, back pain, nausea, vomiting, constipation, and new-onset diabetes. Patients with pancreatic cancer typically report anorexia, malaise, fatigue, mid-epigastric or back pain, and weight loss. The pain may be unrelenting and worse when lying flat.
The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice. Migratory thrombophlebitis and venous thrombosis also occur with higher frequency in patients with pancreatic cancer and may be the first presentation.
While the CA 19-9 antigen is elevated in 75-80% of patients with pancreatic carcinoma, it is not recommended for screening. An abdominal ultrasound scan may reveal a pancreatic malignancy, but a CT scan is the preferred imaging that should be carried out urgently.
Direct-access upper GI endoscopy may be appropriate for patients over 55 years old with weight loss and upper abdominal pain, reflux, or dyspepsia. However, in this case, an urgent CT scan is the most appropriate initial investigation due to the elevated alkaline phosphatase suggesting biliary obstruction. Checking ferritin levels may not be helpful in ruling in or out pancreatic cancer.
Initial Management for Suspected Pancreatic Cancer: Abdominal CT Scan
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This question is part of the following fields:
- Gastroenterology
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Question 54
Incorrect
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A 60-year-old woman visits her General Practitioner for a consultation. She recently underwent bowel cancer screening and had to have a colonoscopy, which revealed the presence of four small benign polyps (< 10mm) that were completely removed. Her discharge letter mentions that she will be seen again, and she is curious if she will require another colonoscopy. What is the most suitable level of routine surveillance for this patient?
Your Answer:
Correct Answer: Colonoscopy at 3 years
Explanation:Stratification of Colorectal Cancer Risk Based on Adenoma Findings
Colorectal cancer risk can be categorized based on the findings of adenomas at baseline and subsequent surveillance examinations. Low risk individuals have one or two adenomas less than 10mm and require no follow-up or a colonoscopy every five years until one is negative. Intermediate risk individuals have three or four adenomas, or one or two adenomas with one larger than 10mm, and require a colonoscopy every three years until two consecutive colonoscopies are negative. High risk individuals have five or more adenomas, or three or four adenomas with one larger than 10mm, and require a colonoscopy at 12 months before returning to three-yearly surveillance.
It is widely accepted that most colorectal cancers arise from adenomas, which have a prevalence of 30-40% at 60 years. However, the lifetime cumulative incidence of colorectal cancer is only 5.5%, indicating that many adenomas do not progress. The risk of malignancy increases with adenoma size, with flat or depressed adenomas progressing more rapidly than polypoid adenomas. While there is no direct evidence, observational studies suggest that polypectomy can reduce cancer mortality. However, there is no evidence that further colonoscopies provide greater benefit than the initial clearance.
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This question is part of the following fields:
- Gastroenterology
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Question 55
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 56
Incorrect
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A 50-year-old woman presents to her General Practitioner with complaints of flushing, right-sided abdominal discomfort, diarrhoea and palpitations. She has been experiencing weight loss and there is a palpable mass in her right lower abdomen.
What is the most probable diagnosis?Your Answer:
Correct Answer: Carcinoid syndrome
Explanation:Differential Diagnosis for a Patient with Flushing and Right-Sided Abdominal Mass
Carcinoid Syndrome and Other Differential Diagnoses
Carcinoid tumours are rare neuroendocrine tumours that can secrete various bioactive compounds, including serotonin and bradykinin, leading to a distinct clinical syndrome called carcinoid syndrome. The symptoms of carcinoid syndrome include flushing, bronchospasm, diarrhoea, and right-sided valvular heart lesions, such as tricuspid regurgitation. However, classical carcinoid syndrome occurs in less than 10% of patients with carcinoid tumours, and the diagnosis requires histological confirmation.
Other possible causes of flushing and right-sided abdominal mass in this patient include appendiceal abscess, caecal carcinoma, menopausal symptoms, and ovarian tumour. An appendiceal abscess usually results from acute appendicitis and presents with pain and fever. Caecal carcinoma can cause similar symptoms as carcinoid tumours, but it is more common and has a worse prognosis. Menopausal symptoms may cause flushing, but they do not explain the other symptoms or the mass. Ovarian tumours may cause abdominal distension and pain, but they are often asymptomatic in the early stages.
Therefore, a thorough evaluation of this patient’s medical history, physical examination, laboratory tests, and imaging studies is necessary to establish the correct diagnosis and guide the appropriate treatment. Depending on the suspected diagnosis, the management may involve surgery, chemotherapy, hormone therapy, or supportive care.
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This question is part of the following fields:
- Gastroenterology
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Question 57
Incorrect
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A 32-year-old woman presents to her General Practitioner three weeks after an Eastern Mediterranean holiday with her family, during which they ate out a lot. She complains of malaise, lack of appetite, jaundice and dark urine. She thinks she was febrile at the start, but the fever subsided once the jaundice appeared. On examination, she has a palpable liver and is tender in the right upper quadrant.
Investigations:
Investigation Result Normal value
Bilirubin 132 µmol /l < 21 µmol/l
Alanine aminotransferase (ALT) 4104 IU/l < 40 IU/l
Aspartate aminotransferase (AST) 3476 U/l < 33 U/l
Alkaline phosphatase (ALP) 184 IU/l 40–129 IU/l
What is the single most likely diagnosis?
Your Answer:
Correct Answer: Hepatitis A
Explanation:Differential Diagnosis for a Patient with Flu-like Symptoms and Jaundice
Hepatitis A is a vaccine-preventable infection commonly acquired during travel. It spreads through contaminated food and presents with flu-like symptoms followed by jaundice and dark urine. Biliary colic may cause right upper quadrant pain but is unlikely to cause fever or significantly raised liver transaminase levels. Hepatitis B is transmitted through sexual contact, needle sharing, blood transfusions, organ transplantation, or from mother to child during delivery. Pancreatic carcinoma presents with weight loss, obstructive jaundice, mid-epigastric or back pain, and disproportionately raised alkaline phosphatases levels. Salmonella enteritidis causes food poisoning with diarrhea, fever, and colicky abdominal pain.
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This question is part of the following fields:
- Gastroenterology
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Question 58
Incorrect
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A 25-year-old woman presents to her General Practitioner in her 28th week of pregnancy. After an uneventful first and second trimester to date, she has developed widespread itching over the last three weeks and she now has mild jaundice. Her bilirubin is 80 μmol/l (normal <21 μmol/l), alanine aminotransferase (ALT) at 82 IU/l (normal <40 IU/l), and the alkaline phosphatase is markedly raised.
Which of the following is the diagnosis that fits best with this clinical picture?
Your Answer:
Correct Answer: Intrahepatic cholestasis of pregnancy
Explanation:Liver Disorders in Pregnancy: Differential Diagnosis
During pregnancy, various liver disorders can occur, leading to abnormal liver function tests. Intrahepatic cholestasis of pregnancy is the most common pregnancy-related liver disorder, affecting 0.1-1.5% of pregnancies. It typically presents in the late second or early third trimester with generalized itching, starting on the palms and soles. An elevated alanine aminotransferase (ALT) is a more sensitive marker than aspartate aminotransferase (AST), and a fasting serum bile acid concentration of greater than 10 mmol/l is the key diagnostic test. Primary biliary cholangitis and acute fatty liver of pregnancy are less likely diagnoses, while cholelithiasis and hyperemesis gravidarum have different clinical presentations. Early diagnosis and management of liver disorders in pregnancy are crucial to prevent adverse outcomes such as prematurity and stillbirth.
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This question is part of the following fields:
- Gastroenterology
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Question 59
Incorrect
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A 35-year-old lady visited the GP for the treatment of her haemorrhoids and was prescribed a topical treatment containing corticosteroids and local anesthetic. She was not given any instructions on how long to use this treatment for and has now come to seek advice on the duration of treatment.
What is the SINGLE MOST suitable advice to give her?Your Answer:
Correct Answer: Corticosteroid preparations can only be used for 2 days, but local anaesthetic use can continue for 2 weeks
Explanation:Initial Management of Anal Fissures
Corticosteroid-containing preparations should not be used for more than 7 days as prolonged use can result in skin atrophy, contact dermatitis, and skin sensitisation. Similarly, anaesthetic-containing preparations should only be used for a few days as they can lead to sensitisation of anal skin.
Aside from topical treatments, there are other crucial initial management steps that should be taken. These include ensuring that stools are soft and easy to pass, optimising anal hygiene and toileting practices, such as avoiding straining during bowel movements.
If conservative treatment fails or if symptoms recur, referral to secondary care should be considered.
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This question is part of the following fields:
- Gastroenterology
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Question 60
Incorrect
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A 62-year-old man presents to his GP with fatigue, nausea and abdominal distension. He admits to consuming 10-15 units of alcohol daily for many years. On examination, he displays spider naevi on his chest wall, jaundice and shifting dullness. He has a body mass index of 34 (obese). Blood tests reveal an AST:ALT ratio of 3:1 and an elevated serum ferritin. What is the most probable diagnosis?
Your Answer:
Correct Answer: Alcoholic Cirrhosis
Explanation:Understanding Alcoholic Cirrhosis: Causes, Symptoms, and Diagnosis
Alcoholic liver disease (ALD) is a leading cause of cirrhosis in developed countries, typically resulting from high levels of alcohol intake over an extended period. ALD progresses through fatty liver disease, alcoholic hepatitis, and ultimately cirrhosis, which presents with clinical signs such as jaundice, ascites, easy bruising, fatigue, abdominal pain, and nausea. Unfortunately, ALD is also responsible for 30% of global liver cancer deaths.
Alcoholic fatty infiltration is a reversible stage of ALD, but if clinical signs and blood results suggest progression to cirrhosis, the damage may be irreversible. Alcoholic active hepatitis is also reversible, but if the patient shows signs of cirrhosis, alcohol is likely the cause.
While transferrin saturation and serum ferritin levels may be increased in ALD, they do not necessarily indicate concomitant haemochromatosis, especially with a history of alcohol abuse.
It’s worth noting that most causes of liver disease, including non-alcoholic fatty liver disease, are associated with an AST to ALT ratio of <1. However, alcoholic liver disease often produces an AST:ALT ratio of 2:1 or higher. In summary, understanding the causes, symptoms, and diagnosis of alcoholic cirrhosis is crucial for early detection and treatment. Reducing alcohol intake and seeking medical attention can help prevent irreversible liver damage and improve overall health outcomes.
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This question is part of the following fields:
- Gastroenterology
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Question 61
Incorrect
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A 48-year-old woman is being investigated for jaundice. She first noticed this symptom 2 months ago, but for 4 months previously, had been experiencing generalised pruritus. The results of liver function tests are as follows:
Investigations:
Investigations Results Normal value
Serum bilirubin 325 µmol/l < 21 µmol/l
Aspartate aminotransaminase 55 U/l 15–42 U/l
Alkaline phosphatase 436 U/l 80–150 U/l
Y-glutamyltransferase 82 U/l 11–51 U/
Albumin 36 g/l 30-50 g/l
Total protein 82 g/l 60-80 g/l
Select from the list the single MOST LIKELY diagnosis.Your Answer:
Correct Answer: Primary biliary cholangitis
Explanation:Possible Causes of Elevated Alkaline Phosphatase Concentration
The elevated alkaline phosphatase concentration in a patient suggests cholestatic jaundice. However, the underlying cause of this condition may vary. Alcoholic cirrhosis is a common cause, but it is unlikely in this case due to the only slightly elevated γ-glutamyltransferase. Cholangiocarcinoma is a rare tumor that can cause obstructive cholestasis. Carcinoma of the head of the pancreas is another possible cause, which often presents with weight loss. Autoimmune liver disease is also a possibility, indicated by a high globulin concentration. Primary sclerosing cholangitis is a potential diagnosis, but it is more common in men and often associated with inflammatory bowel disease. On the other hand, primary biliary cholangitis is more common in women. Therefore, a thorough evaluation is necessary to determine the underlying cause of the elevated alkaline phosphatase concentration.
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This question is part of the following fields:
- Gastroenterology
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Question 62
Incorrect
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A 30-year-old man typically takes his medication without water. He reports experiencing pain in his lower sternum when swallowing.
Which medication is the most probable cause of this symptom?Your Answer:
Correct Answer: Doxycycline
Explanation:Doxycycline-Induced Oesophagal Ulcer: Symptoms, Treatment, and Prevention
Doxycycline-induced oesophagal ulcer is a condition that affects mostly young people with no history of oesophagal dysfunction. The most common symptoms include heartburn, midsternal pain, and dysphagia. Fortunately, the symptoms usually resolve within a few days of stopping doxycycline. However, in severe cases, complete recovery may take longer than two weeks.
To minimize the risk of oesophagitis, it is best to take doxycycline with a meal. Alternatively, it can be taken with a large glass of water or other fluid, and the patient should then remain upright for at least 30 minutes. It is also worth noting that doxycycline can be taken with food with minimal effect on absorption.
It is important to be aware that other drugs can cause oesophagitis, including other tetracyclines, clindamycin, potassium chloride, bisphosphonates, and non-steroidal anti-inflammatory drugs. Therefore, it is crucial to consult a healthcare professional before taking any medication and to follow their instructions carefully.
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This question is part of the following fields:
- Gastroenterology
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Question 63
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 64
Incorrect
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A 61-year-old woman presents to your clinic with a bowel issue. She has a history of irritable bowel syndrome and has experienced occasional abdominal bloating and changes in stool consistency for many years. However, over the past four weeks, she has noticed a significant increase in symptoms, including daily loose and frequent stools. She denies any rectal bleeding and cannot recall experiencing loose stools for this extended period before.
Upon examination, she appears well, with a soft and non-tender abdomen and no palpable masses. Rectal examination is normal, and her weight is comparable to her last visit a year ago.
Which of the following tests would you suggest for this patient?Your Answer:
Correct Answer: Abdominal x ray
Explanation:Investigating Bowel Symptoms in Patients with Irritable Bowel Syndrome
A patient with a history of irritable bowel syndrome (IBS) presenting with acute bowel symptoms is a common scenario. However, if their symptoms have undergone a marked change and become more persistent than usual, it is important to consider the possibility of colorectal cancer. In this context, an abdominal X-ray or ultrasound is not appropriate, and testing for inflammatory markers such as ESR doesn’t provide specific information that would aid referral. Tumour marker testing is also not an appropriate primary care investigation.
According to NICE guidelines, quantitative faecal immunochemical tests should be offered to assess for colorectal cancer in adults without rectal bleeding who are aged 50 and over with unexplained abdominal pain or weight loss, or aged under 60 with changes in their bowel habit or iron-deficiency anaemia. It is important to follow these guidelines to ensure appropriate investigation and referral for patients with IBS and changing bowel symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 65
Incorrect
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You see a 44-year-old lady whose brother and nephew both died of pancreatic cancer. The lady was diagnosed with diabetes from a range of tests. In addition, she noticed that her skin started to have a yellow tinge and she complained of itching over her body.
Which is the best management option?Your Answer:
Correct Answer: Arrange an MRI of the pancreas
Explanation:Urgent Referral for Suspected Pancreatic Cancer
With a strong family history of pancreatic cancer, it is important to have a low threshold for investigating any concerning symptoms. In addition, if a patient aged 60 or over presents with weight loss and any of the following symptoms – diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes – a CT scan should be carried out urgently.
In this case, the patient has also been diagnosed with diabetes and jaundice, which further warrants an urgent referral for suspected cancer. It is important to note that an MRI should not be arranged in primary care, and the decision can be left with the specialist. Additionally, an ultrasound is not the preferred investigation in this instance.
A routine referral would be inappropriate due to the red flags highlighted in the patient’s history. With such a strong family history, it is crucial to investigate this patient further and take appropriate action.
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This question is part of the following fields:
- Gastroenterology
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Question 66
Incorrect
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A client is administered ondansetron for chemotherapy-induced vomiting. What is the most probable adverse effect?
Your Answer:
Correct Answer: Constipation
Explanation:Understanding 5-HT3 Antagonists
5-HT3 antagonists are a type of medication used to treat nausea, particularly in patients undergoing chemotherapy. These drugs work by targeting the chemoreceptor trigger zone in the medulla oblongata, which is responsible for triggering nausea and vomiting. Examples of 5-HT3 antagonists include ondansetron and palonosetron, with the latter being a second-generation drug that has the advantage of having a reduced effect on the QT interval.
While 5-HT3 antagonists are generally well-tolerated, they can have some adverse effects. One of the most significant concerns is the potential for a prolonged QT interval, which can increase the risk of arrhythmias and other cardiac complications. Additionally, constipation is a common side effect of these medications. Overall, 5-HT3 antagonists are an important tool in the management of chemotherapy-induced nausea, but their use should be carefully monitored to minimize the risk of adverse effects.
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This question is part of the following fields:
- Gastroenterology
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Question 67
Incorrect
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At what age is ulcerative colitis commonly diagnosed?
Your Answer:
Correct Answer: Bimodal: 15-25 years + 55-65 years
Explanation:Understanding Ulcerative Colitis
Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation in the rectum and spreads continuously without going beyond the ileocaecal valve. It is most commonly seen in people aged 15-25 years and 55-65 years. The symptoms of ulcerative colitis are insidious and intermittent, including bloody diarrhea, urgency, tenesmus, abdominal pain, and extra-intestinal features. Diagnosis is done through colonoscopy and biopsy, but in severe cases, a flexible sigmoidoscopy is preferred to avoid the risk of perforation. The typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa, and inflammatory cell infiltrate in lamina propria. Extra-intestinal features of inflammatory bowel disease include arthritis, erythema nodosum, episcleritis, osteoporosis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis. Ulcerative colitis is linked with sacroiliitis, and a barium enema can show the whole colon affected by an irregular mucosa with loss of normal haustral markings.
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This question is part of the following fields:
- Gastroenterology
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Question 68
Incorrect
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A 56-year-old man presents to the GP with a 3-week history of nausea, particularly worse after eating. He has not experienced any weight loss, upper abdominal pain or reflux. His past medical history includes a fractured right ankle in his twenties. He has no relevant family history. He is a social smoker and drinks around 2 pints with his friends at the weekend. The GP orders bloods which show:
Hb 140 g/L Male: (135-180)
Female: (115 - 160)
Platelets 550 * 109/L (150 - 400)
WBC 9.5 * 109/L (4.0 - 11.0)
Na+ 142 mmol/L (135 - 145)
K+ 4.1 mmol/L (3.5 - 5.0)
Urea 5.5 mmol/L (2.0 - 7.0)
Creatinine 75 µmol/L (55 - 120)
CRP 3 mg/L (< 5)
What would be the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Non urgent referral for endoscopy
Explanation:A non-urgent referral to GI is necessary for patients who have both raised platelet count and nausea due to dyspepsia. In this case, the patient, who is 58 years old, meets the criteria for such referral.
While ondansetron is effective for chemically mediated nausea, metoclopramide or domperidone may be more appropriate for patients with reduced gastric motility.
PPI trial is typically used as a second line management for dyspepsia patients who do not require endoscopy referral.
Reassurance should not be given to patients who meet the criteria for non-urgent endoscopy referral, such as this man with dyspepsia symptoms and abnormal blood results.
Urgent endoscopy referral is not necessary for patients who only present with nausea.
Management of Dyspepsia and Referral Criteria for Suspected Cancer
Dyspepsia is a common condition that can be managed through a stepwise approach. The first step is to review medications that may be causing dyspepsia and provide lifestyle advice. If symptoms persist, a full-dose proton pump inhibitor or a ‘test and treat’ approach for H. pylori can be tried for one month. If symptoms still persist, the alternative approach should be attempted.
For patients who meet referral criteria for suspected cancer, urgent referral for an endoscopy within two weeks is necessary. This includes patients with dysphagia, an upper abdominal mass consistent with stomach cancer, and patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent referral is recommended for patients with haematemesis and patients aged 55 years or older with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with symptoms such as nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.
Testing for H. pylori infection can be done through a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms have resolved following a ‘test and treat’ approach, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.
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This question is part of the following fields:
- Gastroenterology
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Question 69
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 70
Incorrect
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A 68-year-old woman is discharged home after undergoing a loop ileostomy following an anterior resection of a rectal carcinoma. She has recovered well over the last week. She is not taking anticoagulants and is being careful to drink at least one litre of extra water a day.
What is the most likely early complication she may experience following this procedure?
Your Answer:
Correct Answer: Irritant dermatitis
Explanation:Complications of Ileostomy: Understanding the Risks
Ileostomy is a surgical procedure that involves creating an opening in the abdomen to allow waste to pass out of the body. While the procedure can be life-changing for patients with certain medical conditions, it is not without its risks. Here are some of the potential complications of ileostomy:
Irritant Dermatitis: The skin around the stoma can become irritated and inflamed, either due to contact with stoma equipment or leakage of feces. Hypoallergenic products and corticosteroid lotions can help manage this condition.
Parastomal Hernia: This occurs when a bulge or protrusion develops around the stoma site. While conservative management is often possible, surgery may be necessary in some cases.
Dehydration: High output from the ileostomy can lead to dehydration, making it important for patients to maintain a good fluid intake.
Pernicious Anemia: As vitamin B12 is absorbed in the terminal ileum, patients may develop pernicious anemia over time. Supplements can help manage this condition.
Severe Stomal Hemorrhage: While some bleeding is common after bag changes, severe bleeding is more likely in patients taking antiplatelet drugs.
Understanding these potential complications can help patients and healthcare providers monitor for early signs and manage them effectively.
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This question is part of the following fields:
- Gastroenterology
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Question 71
Incorrect
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A 54-year-old man has recently attended a well-man clinic. He is in good health and reports no symptoms. His body mass index is 22 kg/m2. He takes no regular medication. He is a non-smoker and drinks approximately 3 units of alcohol per week. He presents to you for review of his blood tests, as shown below:
- eGFR 92 mL/min/1.73m2
- HBA1c 38 mmol/mol
- Bilirubin 12 umol/l (3 - 17 umol/l)
- Alanine transferase (ALT) 70 iu/l (3 - 40 iu/l)
- Aspartate transaminase (AST) 30 iu/l (3 - 30 iu/l)
- Alkaline phosphatase (ALP) 95 umol/l (30 - 100 umol/l)
- Gamma glutamyl transferase (yGT) 55 u/l (8 - 60 u/l)
- Total protein 72 g/l (60 - 80 g/l)
What would be the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Arrange a liver screen including a liver ultrasound and blood tests, and review the patient with the results
Explanation:It is common for incidental raised liver function tests to persist even after a month, and normalised liver function tests do not necessarily indicate the absence or resolution of chronic liver diseases. Standard liver screen blood tests include Antinuclear antibody, anti-smooth muscle antibody, serum immunoglobulins, anti-mitochondrial antibody, ferritin, transferrin saturation, and a viral hepatitis screen.
Given that the patient is currently well, there is no need for immediate hepatology review. Urgent hepatology referral within two weeks is also unnecessary as the patient is not exhibiting any concerning symptoms.
Since the patient is consuming alcohol within recommended limits, there is no need for a referral for FibroScan (transient elastography).
According to current guidelines, repeating liver function tests after an initial abnormal result is not recommended as they are unlikely to normalise unless an acute cause has been identified. Waiting for 12 months to repeat the bloods is also inappropriate.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 72
Incorrect
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A 72-year-old man presents to his GP clinic complaining of persistent diarrhoea. He has a medical history of gastro-oesophageal reflux disease.
He was recently hospitalized for pneumonia and received IV antibiotics. While in the hospital, he developed watery diarrhoea, nausea, and abdominal discomfort. After a stool sample, he was prescribed a 10-day course of oral vancomycin and discharged home. However, his diarrhoea has not improved.
Upon examination, he appears alert, his vital signs are normal, and his abdomen is non-tender.
What would be the next course of treatment to consider?Your Answer:
Correct Answer: Fidaxomicin
Explanation:If initial treatment with vancomycin is ineffective against Clostridium difficile, the next recommended option is oral fidaxomicin, unless the infection is life-threatening.
Based on the patient’s symptoms and medical history, it is likely that he has contracted Clostridium difficile infection due to his recent antibiotic use and possible use of proton-pump inhibitors. Therefore, oral fidaxomicin would be the appropriate second-line treatment option.
Continuing with vancomycin would not be the best course of action, as fidaxomicin is recommended as the next step if vancomycin is ineffective.
Using loperamide for symptom relief is not recommended in cases of suspected Clostridium difficile infection, as it may slow down the clearance of toxins produced by the bacteria.
Piperacillin-tazobactam is not a suitable treatment option for Clostridium difficile infection, as it is a broad-spectrum antibiotic that can increase the risk of developing the infection.
Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Gastroenterology
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Question 73
Incorrect
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A 50-year-old male undergoes an endoscopy after being referred by his GP with recurrent indigestion.
The endoscopy reveals a small duodenal ulcer and Helicobacter pylori is demonstrated to be present. He has not been given eradication treatment before and is allergic to penicillin.
You consider a seven day, twice daily course of eradication therapy.
How would you treat this patient?Your Answer:
Correct Answer: Esomeprazole 10 mg, Metronidazole, Tetracycline
Explanation:Helicobacter Infection and Treatment
Helicobacter infection is common in patients with duodenal and peptic ulceration. The recommended therapy includes acid suppression and eradication of Helicobacter. Triple therapy with a proton pump inhibitor (PPI) such as omeprazole, along with two antibiotics (amoxicillin/clarithromycin plus metronidazole), has been found to be highly effective.
It is important to note that patients who are allergic to penicillin require a different treatment regimen. The lowest cost treatment option should be chosen, taking into account previous exposure to clarithromycin or metronidazole. In cases where the patient is allergic to penicillin and has had previous exposure to clarithromycin, bismuth and tetracycline should be added to the treatment regimen.
The recommended PPI doses for Helicobacter pylori eradication therapy are esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20-40 mg, pantoprazole 40 mg, and rabeprazole 20 mg. It is important to follow these guidelines to ensure effective treatment of Helicobacter infection.
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This question is part of the following fields:
- Gastroenterology
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Question 74
Incorrect
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A 25-year-old man has a bilirubin concentration of 55 μmol/l (normal value <21 μmol/l). He has suffered from episodic jaundice in the past but is otherwise fit and well. His diagnosis is Gilbert syndrome.
Which of the following is associated with Gilbert syndrome?
Your Answer:
Correct Answer: γ-glutamyltransferase in the normal range
Explanation:Understanding Gilbert Syndrome: Symptoms, Risks, and Diagnosis
Gilbert syndrome is a common, benign condition that causes mild unconjugated hyperbilirubinaemia. It is familial and occurs in 5-10% of adults in Western Europe. While some patients may experience symptoms such as fatigue, nausea, and abdominal pain, many are asymptomatic. Jaundice is usually mild and can worsen with physical exertion, fasting, or dehydration. However, liver function tests, including γ-glutamyltransferase, should be normal.
Unlike other liver conditions, Gilbert syndrome doesn’t cause abnormal liver histology or conjugated hyperbilirubinaemia. It is also not a risk factor for kernicterus at birth.
Diagnosis of Gilbert syndrome is based on clinical presentation and elevated unconjugated bilirubin levels. Fasting can actually increase bilirubin levels in this condition. Therefore, it is important to rule out other liver disorders if abnormal liver function tests or histology are present.
Overall, understanding the symptoms, risks, and diagnosis of Gilbert syndrome can help healthcare providers provide appropriate care and management for patients with this condition.
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This question is part of the following fields:
- Gastroenterology
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Question 75
Incorrect
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A 27-year-old woman with a history of Crohn's disease is seeking advice regarding her desire to start a family with her partner. She is currently taking methotrexate and wants to know if it is safe to conceive.
What would be the best course of action to recommend?Your Answer:
Correct Answer: He should wait at least 6 months after stopping treatment
Explanation:Men and women who are undergoing methotrexate treatment must use reliable contraception throughout the duration of the treatment and for a minimum of 6 months after it has ended.
Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.
Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.
It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.
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This question is part of the following fields:
- Gastroenterology
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Question 76
Incorrect
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Each one of the following is a recognised complication of gastro-oesophageal reflux disease, except:
Your Answer:
Correct Answer: Achalasia
Explanation:Managing Gastro-Oesophageal Reflux Disease
Gastro-oesophageal reflux disease (GORD) is a condition where gastric contents cause symptoms of oesophagitis. If GORD has not been investigated with endoscopy, it should be treated according to dyspepsia guidelines. However, if oesophagitis is confirmed through endoscopy, full dose proton pump inhibitors (PPIs) should be given for 1-2 months. If there is a positive response, low dose treatment may be given as required. If there is no response, double-dose PPIs should be given for 1 month.
For endoscopically negative reflux disease, full dose PPIs should be given for 1 month. If there is a positive response, low dose treatment may be given on an as-required basis with a limited number of repeat prescriptions. If there is no response, H2RA or prokinetic should be given for one month.
Complications of GORD include oesophagitis, ulcers, anaemia, benign strictures, Barrett’s oesophagus, and oesophageal carcinoma. It is important to manage GORD effectively to prevent these complications.
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This question is part of the following fields:
- Gastroenterology
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Question 77
Incorrect
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A 79-year-old man comes to the clinic with bilateral angular stomatitis. He wears dentures that have become a bit loose and his diet is not varied.
In the process of advising and treating his angular stomatitis, which of the following is correct?Your Answer:
Correct Answer: May be due to chronic constipation
Explanation:Stomatitis: Causes and Associated Factors
Stomatitis is a condition that can be caused by ill-fitting dentures and slack facial muscles, which can lead to Candida overgrowth. It is not associated with reactive arthritis, but it may be seen in Behçet’s disease. While it is not directly linked to constipation, it can be associated with inflammatory bowel disease.
Iron deficiency is a possible factor in the development of stomatitis, as are deficiencies in riboflavin, niacin, pyridoxine, folic acid, and cyanocobalamin. Vitamin C deficiency can also cause stomatitis, as well as scurvy.
It is important to address the underlying causes of stomatitis in order to effectively treat the condition. Proper dental care and nutrition can help prevent stomatitis from developing or recurrent.
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This question is part of the following fields:
- Gastroenterology
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Question 78
Incorrect
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A 14-month old infant presents with episodes of severe colic, associated with pallor and drawing of the legs upwards. This has been going on for several weeks.
The mother has brought the child to see you because she noticed that there seemed to be blood and mucous in the stool yesterday.
On examination there is a sausage-shaped mass palpable on the right side of the abdomen.
What is the diagnosis?Your Answer:
Correct Answer: Hirschsprung's disease
Explanation:Intussusception: A Common Cause of Intestinal Obstruction in Infants
Intussusception is a condition where a section of the bowel folds into itself, causing an obstruction. It is most commonly seen in infants over one month old, with the typical age of presentation being between two months to two years. The most common site of intussusception is the ileum passing into the caecum/colon through the ileocaecal valve.
Symptoms of intussusception include severe colic, pallor, and drawing of legs upwards during episodes of pain. A sausage-shaped mass may be palpable in the abdomen, and parents may notice the passage of a redcurrant jelly stool (blood-stained mucous). In severe cases, children may present with abdominal distention and shock.
The cause of intussusception is not always clear, but viral infections causing enlargement of Peyer’s patches have been implicated in forming a lead point for the development of intussusception. In children over the age of two, a specific lead point (such as a Meckel’s diverticulum or polyp) is more likely.
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This question is part of the following fields:
- Gastroenterology
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Question 79
Incorrect
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A 55-year-old man presents with long-standing gastrointestinal symptoms. His medical history includes a diagnosis of irritable bowel syndrome in his early adulthood. He currently takes mebeverine 135 mg TDS and loperamide 2 mg PRN for symptom relief. He reports intermittent abdominal pain, bloating, and periodic bouts of diarrhea. His latest blood tests, done as part of his diabetic annual review, show a mild microcytic anemia and a slight persistent elevation of ALT and ALP. He has no new symptoms and follows a normal diet. On examination, there are no focal abnormalities. He is interested in trying a gluten-free diet as his mother found it helpful for her IBS. What advice should be given regarding testing for coeliac disease?
Your Answer:
Correct Answer: Serological testing can be carried out appropriately at any time regardless of a person's dietary intake of gluten
Explanation:Testing for Coeliac Disease
Accuracy of testing for coeliac disease is dependent on the person following a gluten-containing diet. For at least six weeks prior to testing, a person should follow a normal diet containing gluten in more than one meal a day. This is the case for both serological and histological testing. If a diagnosis of coeliac disease is suspected and the person is reluctant to include or reintroduce gluten in their diet prior to any testing, then they should be referred to a gastrointestinal specialist.
Serological testing for coeliac disease is used to indicate whether further investigation is needed. A positive test should prompt referral to a gastrointestinal specialist for intestinal biopsy to confirm or exclude the diagnosis. When serology is requested, the preferred first choice test is currently IgA transglutaminase (tTGA). If the result is equivocal, IgA endomysial antibodies (EMA) testing can be used.
IgA deficiency can lead to false negative results, so IgA deficiency should be ruled out if serology is negative. IgG tTGA and/or IgG EMA serology can be used in those with confirmed IgA deficiency. Human leucocyte antigen (HLA) DQ2/DQ8 testing may be considered by gastrointestinal specialists in specific clinical situations; however, it doesn’t have a role in the initial testing for coeliac disease.
It should be borne in mind that if serological testing is negative but there is significant clinical suspicion of coeliac disease, then referral to a gastrointestinal specialist should be offered as serological tests are not 100% accurate. A clinical response to gluten-free diet is not diagnostic of coeliac disease. For example, some patients with irritable bowel syndrome may be gluten sensitive but not have coeliac disease. Implications of a positive test should be discussed prior to serological testing being performed, including the nature of the further investigations needed and the implications for other family members should the test be positive.
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This question is part of the following fields:
- Gastroenterology
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Question 80
Incorrect
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A 32-year-old woman with a history of migraine experiences inadequate relief from the recommended dose of paracetamol during acute attacks. She consumes 10 units of alcohol per week and smokes 12 cigarettes per day.
What could be a contributing factor to this issue?Your Answer:
Correct Answer: Delayed gastric emptying
Explanation:During acute migraine attacks, patients often experience delayed gastric emptying. Therefore, prokinetic agents like metoclopramide are commonly added to analgesics. Changes in P450 enzyme activity, such as those caused by smoking or drinking, are unlikely to have a significant impact on the metabolism of paracetamol.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.
For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.
Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.
For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.
It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.
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This question is part of the following fields:
- Gastroenterology
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Question 81
Incorrect
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What is the most typical trait of a patient with vitamin C deficiency?
Your Answer:
Correct Answer: Paraesthesia and ataxia
Explanation:Understanding Vitamin C Deficiency and Scurvy
Vitamin C is an essential nutrient that is primarily found in fruits and vegetables. A deficiency of ascorbic acid can lead to scurvy, a condition characterized by inflamed and bleeding gums, impaired wound healing, and other symptoms. Cutaneous findings of scurvy include follicular hyperkeratosis, perifollicular haemorrhages, ecchymoses, xerosis, leg oedema, poor wound healing, and bent or coiled body hairs.
It is important to note that cheilosis and red tongue are more indicative of vitamin B12 or iron deficiency, while diarrhoea and delusions suggest vitamin B deficiency (pellagra). Ocular muscle palsy and dementia are more likely to be associated with thiamine deficiency or Wernicke’s encephalopathy.
Vitamin C deficiency is not uncommon in the elderly population, and it is crucial to be aware of the signs and symptoms to make a proper diagnosis. Measuring vitamin C concentrations in the white cell can confirm the diagnosis of scurvy.
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This question is part of the following fields:
- Gastroenterology
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Question 82
Incorrect
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A 28-year-old man presents to his General Practitioner with a flare-up of symptoms, including diarrhoea which is occasionally bloody, up to four times a day. He has diffuse ulcerative colitis and has been in remission; he takes 1.5 g of mesalazine a day.
On examination, his blood pressure is 115/72 mmHg, while his pulse is 75 bpm. Abdominal examination is normal.
What is the most appropriate intervention for this patient?
Your Answer:
Correct Answer: Prednisolone tablets
Explanation:Treatment Options for Moderate Exacerbation of Ulcerative Colitis
When a patient experiences a moderate exacerbation of ulcerative colitis, there are several treatment options available. The most appropriate choice is a dose of 20-40 mg of oral prednisolone per day, which should be continued until the patient enters remission. If there is an inadequate response after 2-4 weeks, ciclosporin tablets can be added to the regimen to induce remission. However, these should only be prescribed by specialists in secondary care. Anti-motility drugs such as co-phenotrope should not be used as they may precipitate paralytic ileus and megacolon in active ulcerative colitis. Topical mesalazine is only effective for distal disease, so it is not appropriate for patients with diffuse disease. Topical corticosteroids in the form of prednisolone retention enemas can be used to induce remission in patients with proctitis, but for diffuse disease, oral corticosteroids are more effective.
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This question is part of the following fields:
- Gastroenterology
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Question 83
Incorrect
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A 68-year-old gentleman presents with a change in bowel habit. He reports that over the last two to three months he is opening his bowels four to five times a day and the consistency of his stools has become very loose. He has noticed small amounts of blood in his faeces but put this down to 'piles'.
Previously, he used to open his bowels on average once a day and has no personal history of any gastrointestinal problems. There is no family history of bowel problems, he has not lost any weight and he denies any rectal blood loss. Stool mc&s is normal as are his recent blood tests which show that he is not anaemic. Abdominal and rectal examinations are normal.
He tells you that he is not overly concerned about the symptoms as about two months ago he submitted his bowel screening samples and recently had a letter saying that his screening tests were negative. What is the most appropriate next approach in this instance?Your Answer:
Correct Answer: Refer him urgently to a specialist for investigation of his lower gastrointestinal tract
Explanation:Importance of Urgent Referral for Patients with Bowel Symptoms
Screening tests are designed for asymptomatic individuals in an at-risk population. However, it is not uncommon for patients with bowel symptoms to mention that they are not worried as they have done their bowel screening and it was negative.
In the case of a 66-year-old man with persistent changes in bowel habit towards looser stools with some rectal bleeding, urgent referral for further investigation is necessary. It is important to note that relying on recent bowel screening results may falsely reassure patients and delay necessary medical attention.
Therefore, it is crucial for healthcare professionals to prioritize the patient’s current symptoms and promptly refer them for further evaluation, regardless of their previous screening results. Early detection and treatment can significantly improve outcomes for patients with bowel symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 84
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 85
Incorrect
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Many elderly patients with colorectal cancer present with advanced disease. Early diagnosis is essential.
Select from the list the single elderly patient who satisfies the criteria for urgent referral (2-week rule).Your Answer:
Correct Answer: A 65-year-old man who has had loose stools for 6 weeks but no rectal bleeding
Explanation:Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis
Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. According to the National Institute for Health and Care Excellence (NICE), patients over 50 years old with unexplained rectal bleeding or over 60 years old with a change in bowel habit should be referred for an appointment within 2 weeks for suspected colorectal cancer. However, other conditions can also cause similar symptoms, and differential diagnosis is important to ensure appropriate management.
Rectal Bleeding in a Multiparous Woman
Rectal bleeding is a common symptom that can be caused by various conditions, including haemorrhoids. In a 40-year-old multiparous woman, routine referral would be appropriate if piles could not be identified.
Change in Bowel Habit in a 60-Year-Old Man
A change in bowel habit in a 60-year-old man is more likely to be caused by an acute infection, such as enterohaemorrhagic E. coli or Shigella. Investigations should be directed to finding the cause.
Constipation in an 80-Year-Old Woman
Constipation is a common symptom in the elderly, and dietary factors may play a role. In an 80-year-old woman with intermittent constipation and no teeth, the symptom is likely to be longstanding and not indicative of colorectal cancer.
Anal Fissure in a 70-Year-Old Man
Anal fissure is a possible cause of rectal bleeding in a 70-year-old man. Further investigation is needed to confirm the diagnosis and rule out other conditions.
Identifying Symptoms of Colorectal Cancer: Referral Recommendations and Differential Diagnosis
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This question is part of the following fields:
- Gastroenterology
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Question 86
Incorrect
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You see a 32-year-old man who has recently been diagnosed with Crohn's disease. He presented with frequent and loose stools, with occasional blood and mucous. He is otherwise fit and well. His only other past medical history is appendicitis as a 16-year-old.
He has been reviewed by a gastroenterologist and is on a reducing dose of corticosteroid.
Can you provide him with more information about Crohn's disease?Your Answer:
Correct Answer: The risk of Crohn's disease increases early after an appendicectomy
Explanation:Smoking increases the likelihood of developing Crohn’s disease.
Experiencing infectious gastroenteritis raises the risk of developing Crohn’s disease by four times, especially within the first year.
The chances of developing Crohn’s disease are higher in the early stages after having an appendicectomy.
Crohn’s disease affects both genders equally, with no significant difference in occurrence rates.
Understanding Crohn’s Disease
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.
Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include nonspecific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.
To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.
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This question is part of the following fields:
- Gastroenterology
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Question 87
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 88
Incorrect
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A 62-year old male presents with dysphagia. His symptoms were first noticed a few months ago and have steadily worsened.
Initially he found difficulty swallowing solids but over recent weeks has also been having difficulty swallowing liquids. In addition to his swallowing problems he has lost over a stone in weight.
On examination, he looks thin and slightly pale.
What is the most likely diagnosis?Your Answer:
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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This question is part of the following fields:
- Gastroenterology
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Question 89
Incorrect
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You get a call from the wife of a 60-year-old patient of yours who has been stented in the previous week for inoperable pancreatic carcinoma.
He was recovering well from his procedure, with resolving obstructive jaundice, but he has had rigors all night long, with a drenching fever, measured at 38.4°C. According to his wife his jaundice has got worse again.
You see him and he looks very unwell, pale with rigors and a cold sweat. He is tender in the epigastrium and the right upper quadrant.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Cholecystitis
Explanation:Antibiotic Treatment for Bacterial Infection after Stenting Procedure
After a stenting procedure, it is possible for bacteria to enter the body. The most common pathogens that cause infection in this case are Escherichia coli, Klebsiella, enterococcus, and Bacteroides. To treat this bacterial infection, an antibiotic with sufficient coverage for gram-negative bacteria and the ability to penetrate the bile duct is necessary. Ciprofloxacin is the recommended drug of choice for this type of infection.
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This question is part of the following fields:
- Gastroenterology
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Question 90
Incorrect
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A 50-year-old obese man with a history of type 2 diabetes mellitus presents to the clinic for a review. He reports feeling well and asymptomatic. However, his recent annual blood tests have shown slightly abnormal liver function tests:
- Bilirubin 20 µmol/L (3 - 17)
- ALP 104 u/L (30 - 100)
- ALT 53 u/L (3 - 40)
- γGT 58 u/L (8 - 60)
- Albumin 38 g/L (35 - 50)
A liver ultrasound performed during his follow-up visit reveals fatty changes. All other standard liver screen bloods, including viral serology, are normal. The patient's alcoholic intake is within recommended limits.
What would be the most appropriate next test to perform?Your Answer:
Correct Answer: Enhanced liver fibrosis blood test
Explanation:For patients with non-alcoholic fatty liver disease, it is advised to undergo enhanced liver fibrosis (ELF) testing to assist in the detection of liver fibrosis. A typical patient with this condition is someone who is overweight and has type 2 diabetes mellitus. According to NICE guidelines, if NAFLD is discovered by chance, an ELF blood test should be conducted to evaluate for the presence of advanced liver disease.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.
NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.
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This question is part of the following fields:
- Gastroenterology
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Question 91
Incorrect
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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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This question is part of the following fields:
- Gastroenterology
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Question 92
Incorrect
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A 72-year-old man presents to his General Practice Surgery, as he has developed difficulty swallowing. He has a long history of ‘heartburn’, which he manages with over-the-counter antacids. He is a smoker with a 50-pack-year history and drinks around 15 units of alcohol per week. He thinks he has lost 4 kg of weight in the last few months.
Endoscopy reveals a lesion in the lower third of the oesophagus.
What is the most likely diagnosis?Your Answer:
Correct Answer: Adenocarcinoma of the oesophagus
Explanation:Understanding Oesophageal Cancer and Related Conditions
Oesophageal cancer is a serious condition that can be caused by various factors. Adenocarcinoma of the oesophagus is the most common type in the UK and is associated with chronic gastro-oesophageal reflux disease and Barrett’s oesophagus. Squamous carcinoma, on the other hand, is more likely to occur in the upper two thirds of the oesophagus. Both types of cancer are often asymptomatic until late in the disease, making early detection difficult.
Barrett’s oesophagus is a condition caused by chronic GORD that can increase the risk of developing adenocarcinomas in the distal third of the oesophagus. GORD, which is the reflux of stomach acid into the oesophagus, can cause burning chest pain after eating. However, it doesn’t explain dysphagia or the presence of a lesion seen on endoscopy.
An oesophageal stricture, which is a narrowing of the oesophagus, can also cause dysphagia and may be associated with chronic GORD. However, if weight loss, smoking, and alcohol consumption are present, and a lesion is seen on endoscopy, oesophageal cancer is more likely.
In summary, understanding the risk factors and symptoms of oesophageal cancer and related conditions can aid in early detection and treatment. Regular check-ups and screenings are recommended for those at higher risk.
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This question is part of the following fields:
- Gastroenterology
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Question 93
Incorrect
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A 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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This question is part of the following fields:
- Gastroenterology
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Question 94
Incorrect
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A 29-year-old woman who initially complained of abdominal discomfort and irregular bowel movements is diagnosed with irritable bowel syndrome. What dietary advice should be avoided in this case?
Your Answer:
Correct Answer: Increase the intake of fibre such as bran and wholemeal bread
Explanation:IBS patients should steer clear of insoluble sources of fiber like bran and wholemeal.
Managing irritable bowel syndrome (IBS) can be challenging and varies from patient to patient. The National Institute for Health and Care Excellence (NICE) updated its guidelines in 2015 to provide recommendations for the management of IBS. The first-line pharmacological treatment depends on the predominant symptom, with antispasmodic agents recommended for pain, laxatives (excluding lactulose) for constipation, and loperamide for diarrhea. If conventional laxatives are not effective for constipation, linaclotide may be considered. Low-dose tricyclic antidepressants are the second-line pharmacological treatment of choice. For patients who do not respond to pharmacological treatments, psychological interventions such as cognitive behavioral therapy, hypnotherapy, or psychological therapy may be considered. Complementary and alternative medicines such as acupuncture or reflexology are not recommended. General dietary advice includes having regular meals, drinking at least 8 cups of fluid per day, limiting tea and coffee to 3 cups per day, reducing alcohol and fizzy drink intake, limiting high-fiber and resistant starch foods, and increasing intake of oats and linseeds for wind and bloating.
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This question is part of the following fields:
- Gastroenterology
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Question 95
Incorrect
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A 44-year-old woman presents with complaints of lethargy. Routine blood testing reveals hypochromic microcytic anaemia with a low ferritin. Her haemoglobin level is 100 g/l. She has had no symptoms of abnormal bleeding, indigestion or change in bowel habit and there is no medication use of note. She is still menstruating and regards her menstrual loss as normal. She has a normal diet and there have been no recent foreign trips. Faecal occult blood tests are negative. There is no family history of colorectal cancer. Abdominal examination is normal.
What is most appropriate for this stage in her management?Your Answer:
Correct Answer: Measure tissue transglutaminase antibody
Explanation:Recommended Actions for Patients with Iron Deficiency Anaemia
Iron deficiency anaemia is a common condition that requires prompt diagnosis and treatment. Here are some recommended actions for patients with this condition:
Screen for Coeliac Disease: All patients with iron deficiency anaemia should be screened for coeliac disease using coeliac serology, which involves measuring the presence of anti-endomysial antibody or tissue transglutaminase antibody.
Refer for Gastrointestinal Investigations: Men of any age with unexplained iron deficiency anaemia and a haemoglobin level of 110 g/l or below, as well as women who are not menstruating with a haemoglobin level of 100 g/l or below, should be urgently referred for upper and lower gastrointestinal investigations. For other patients, referral for gastrointestinal investigation will depend on the haemoglobin level and clinical findings.
Prescribe Iron Supplements: Treatment for iron deficiency anaemia should begin with oral ferrous sulphate 200 mg tablets two or three times a day. Doctors should not wait for investigations to be carried out before prescribing iron supplements.
Check Vitamin B12 and Folate Levels: Vitamin B12 and folate levels should be checked if the anaemia is normocytic with a low or normal ferritin level, there is an inadequate response to iron supplements, vitamin B12 or folate deficiency is suspected, or the patient is in an older age bracket.
Avoid Inappropriate Tests: Pelvic ultrasound examination is not necessary for patients with iron deficiency anaemia unless they have gynaecological symptoms.
By following these recommended actions, patients with iron deficiency anaemia can receive timely and appropriate care.
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This question is part of the following fields:
- Gastroenterology
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Question 96
Incorrect
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A mother brings her 9-year-old son who has been vomiting for the last day. He reports that since he was 4 years old he has had vomiting episodes 6 to 10 times a year every 4 to 8 weeks. The episodes last for around a day and no clear trigger has been found. He is a well and happy child who is able to eat, drink and gain weight appropriately between these episodes.
He has been thoroughly investigated previously and he has been diagnosed with cyclical vomiting syndrome (CVS).
He has now developed a new symptom associated with his attacks where he complains of abdominal pain, headache, and a sensitivity to light and noise.
What is the most likely cause of this new set of symptoms?Your Answer:
Correct Answer: Migraine
Explanation:Patients who have cyclical vomiting syndrome have a high probability of developing migraines. The diagnosis of cyclical vomiting syndrome, along with the presence of migraine symptoms such as abdominal pain (which can occur in children), makes migraine the most likely diagnosis. Meningitis is unlikely due to normal examination findings, and meningioma is rare in children and less common than migraine. Gastroenteritis cannot explain the headache or sensitivity to light and noise. There is no indication in the patient’s history of drug overdose.
Understanding Cyclical Vomiting Syndrome
Cyclical vomiting syndrome is a rare condition that is more commonly seen in children than adults. Females are slightly more affected than males. The exact cause of this condition is unknown, but it has been observed that 80% of children and 25% of adults who develop CVS also have migraines.
The symptoms of CVS include severe nausea and sudden vomiting that can last for hours to days. Patients may also experience intense sweating and nausea before an episode. However, they may feel well in between episodes. Other symptoms that may be present include weight loss, reduced appetite, abdominal pain, diarrhea, dizziness, photophobia, and headache.
To diagnose CVS, doctors may perform routine blood tests to exclude any underlying conditions. A pregnancy test may also be considered in women. Treatment for CVS involves avoiding triggers and using prophylactic medications such as amitriptyline, propranolol, and topiramate. During acute episodes, medications such as ondansetron, prochlorperazine, and triptans may be used.
In summary, cyclical vomiting syndrome is a rare condition that can be challenging to diagnose and manage. However, with proper treatment and avoidance of triggers, patients can experience relief from their symptoms.
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This question is part of the following fields:
- Gastroenterology
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Question 97
Incorrect
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A 63-year-old man presents with abdominal discomfort, loss of appetite, and weight loss. He reports feeling fatigued and experiencing itching on his back. A recent abdominal x-ray showed no abnormalities. What would be considered the gold standard for managing his symptoms?
Your Answer:
Correct Answer: Urgent ultrasound scan
Explanation:Urgent CT Scan for Pancreatic Cancer in Elderly Patients with Red Flag Symptoms
An urgent direct access CT scan is recommended within two weeks for individuals aged 60 and above who have experienced weight loss and any of the following symptoms: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes. CT scan is preferred over ultrasound, unless CT is not available. Endoscopy is not necessary as the symptoms do not suggest stomach or oesophageal cancer, which would present with more dysphagia and dyspepsia.
While a gastroenterology opinion may be necessary, it should not be requested routinely as the patient’s symptoms are considered red flags and require a more urgent approach. Although the patient is currently medically stable, an immediate referral to the medical assessment unit is not warranted. This approach ensures timely and appropriate management for elderly patients with potential pancreatic cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 98
Incorrect
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A 32-year-old male with type 1 diabetes attends for diabetic annual review. He complains of feeling tired all the time stretching back several months.
Blood tests performed prior to the review appointment show normal renal, liver, and thyroid function; testosterone levels are normal. Full blood count reveals a modest anaemia with:
Haemoglobin 109 g/L (130-180)
MCV 79 fL (80-96)
HbA1c 50 mmol/mol (20-42)
Urine dipstick testing is normal with no ketones. Review of fingerprick blood sugars shows blood sugars consistently in single figures.
Clinical examination is unremarkable.
On further enquiry the patient denies any gastrointestinal symptoms. He is opening his bowels regularly with no change in bowel habit. There is no history of PR blood or mucous. His weight is stable. He denies abdominal pain or bloating. He follows a 'normal' diet. There is no known family history of gastrointestinal pathology or malignancy.
You request some further blood tests which confirm iron deficiency anaemia.
Which of the following is the most appropriate next approach?Your Answer:
Correct Answer: Perform serological testing for coeliac disease
Explanation:Serological Testing for Coeliac Disease
Serological testing for coeliac disease should be considered for individuals presenting with certain symptoms such as chronic diarrhoea, unexplained weight loss, and persistent fatigue. Additionally, those with autoimmune thyroid disease, irritable bowel syndrome, and type 1 diabetes should also be offered testing as they are at increased risk for coeliac disease. NICE guidance recommends testing for individuals with unexplained abdominal symptoms, mouth ulcers, and vitamin deficiencies, as well as first-degree relatives of those with coeliac disease. Coeliac disease is associated with a variety of conditions, including depression, epilepsy, and reduced bone mineral density, among others. In the case of a man with type 1 diabetes and iron deficiency anaemia, serological testing for coeliac disease would be the next appropriate step.
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This question is part of the following fields:
- Gastroenterology
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Question 99
Incorrect
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A 35-year-old man has had dysphagia for three weeks. He thinks it is getting worse. He has lost a small amount of weight.
What is the best course of action?Your Answer:
Correct Answer: Check an FBC and then consider referral
Explanation:Urgent Referral for Endoscopy in Suspected Oesophageal Cancer
This man requires an urgent referral for endoscopy as he may have cancer of the oesophagus. As a medical professional, it is important to identify alarm symptoms and understand referral guidelines that may apply. In this case, the patient’s dysphagia and weight loss are concerning and require urgent attention. An urgent referral is defined as one where the patient should be seen within two weeks.
It is crucial to get this question right, as nearly 20% of respondents did not refer this patient urgently. If you answered incorrectly, take a moment to review the latest NICE guidance to update your knowledge. Practice questions like these can highlight areas of knowledge deficiency and stimulate further learning. By remembering this scenario, you will be better equipped to handle similar situations in the future.
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This question is part of the following fields:
- Gastroenterology
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Question 100
Incorrect
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Sarah is a 44-year-old woman who presented to you last month with a 6 week history of upper abdominal pain, heartburn and occasional reflux. Her medical history is unremarkable and you agreed on a plan for a 1 month trial of omeprazole 20 mg daily.
Sarah returns for a follow-up appointment after completing a month of omeprazole. Her symptoms have only slightly improved and they are still bothering her.
What would be the most suitable course of action?Your Answer:
Correct Answer: Test for Helicobacter pylori infection in 2 weeks and treat if positive
Explanation:If initial treatment for dyspepsia with either a PPI or ‘test and treat’ approach fails, the alternative strategy should be tried next. In Mark’s case, he has completed 1 month of a full-dose PPI and should now be tested for H. pylori infection. Referral for routine upper gastrointestinal endoscopy is not necessary at this stage.
Management of Dyspepsia and Referral Criteria for Suspected Cancer
Dyspepsia is a common condition that can be managed through a stepwise approach. The first step is to review medications that may be causing dyspepsia and provide lifestyle advice. If symptoms persist, a full-dose proton pump inhibitor or a ‘test and treat’ approach for H. pylori can be tried for one month. If symptoms still persist, the alternative approach should be attempted.
For patients who meet referral criteria for suspected cancer, urgent referral for an endoscopy within two weeks is necessary. This includes patients with dysphagia, an upper abdominal mass consistent with stomach cancer, and patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia. Non-urgent referral is recommended for patients with haematemesis and patients aged 55 years or older with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with symptoms such as nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.
Testing for H. pylori infection can be done through a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms have resolved following a ‘test and treat’ approach, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.
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This question is part of the following fields:
- Gastroenterology
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Question 101
Incorrect
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A 79-year-old man comes in for the results of his recent blood tests. He had visited the clinic yesterday due to jaundice and urgent blood tests were conducted. He denies any abdominal discomfort and feels fine. His heart rate is 82 beats per minute and he has a slight fever of 37.5 oC. The results of his liver function tests are as follows:
- Bilirubin 150 µmol/L (3 - 17)
- ALP 110 u/L (30 - 100)
- ALT 20 u/L (3 - 40)
- γGT 15 u/L (8 - 60)
- Albumin 40 g/L (35 - 50)
As per the current NICE CKS guidelines, what would be the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Arrange same day admission to secondary care
Explanation:The patient with jaundice and a bilirubin level exceeding 100 micromol/L requires same day admission. Additionally, the patient is feverish, which further supports the need for immediate hospitalization.
Hepatobiliary disease and related disorders can present with a variety of symptoms and exam findings. Viral hepatitis may cause nausea, vomiting, anorexia, myalgia, lethargy, and RUQ pain, and risk factors such as foreign travel or intravenous drug use may be highlighted in exam questions. Congestive hepatomegaly can occur as a result of congestive heart failure and may cause pain due to liver stretching. Biliary colic is characterized by intermittent RUQ pain that often occurs after eating, and attacks may be accompanied by nausea. Acute cholecystitis presents with severe and persistent pain that may radiate to the back or right shoulder, and the patient may be pyrexial and have a positive Murphy’s sign. Ascending cholangitis is an infection of the bile ducts that presents with fever, RUQ pain, and jaundice. Gallstone ileus can cause small bowel obstruction and is associated with abdominal pain, distension, and vomiting. Cholangiocarcinoma may cause persistent biliary colic symptoms, anorexia, jaundice, weight loss, and exam findings such as a palpable mass in the RUQ and lymphadenopathy. Acute pancreatitis may be due to alcohol or gallstones and presents with severe epigastric pain, vomiting, tenderness, ileus, and low-grade fever. Pancreatic cancer may present with painless jaundice, anorexia, weight loss, and pain. Amoebic liver abscess may cause malaise, anorexia, weight loss, and mild RUQ pain, but jaundice is uncommon.
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This question is part of the following fields:
- Gastroenterology
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Question 102
Incorrect
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A 55-year-old man presents to his General Practitioner concerned that he may be at an increased risk of developing colon cancer. His father died at the age of 56 from a sigmoid colon adenocarcinoma. His brother, aged 61, has just undergone a colectomy for a caecal carcinoma.
What is the most appropriate management for this patient?Your Answer:
Correct Answer: Refer for one-off colonoscopy aged 55
Explanation:Screening Recommendations for Patients with Family History of Colorectal Cancer
Patients with a family history of colorectal cancer may be at an increased risk of developing the disease. The British Society of Gastroenterology and the Association of Coloproctology for Great Britain and Ireland have produced screening guidelines for patients with family history profiles that place them in a moderate-risk category.
Colonoscopy is recommended for patients with a family history of two first-degree relatives with a mean age of less than 60 years with colorectal cancer, starting at the age of 55. Abdominal ultrasound examination doesn’t have a role in screening for or diagnosing colorectal cancer.
Patients with an increased risk should not be advised that they have no increased risk. Instead, they should be screened appropriately. Faecal immunochemical tests (FIT) are used to detect blood in the stool and are used in the national bowel cancer screening programme. However, patients with a higher risk, given their family history, should be offered earlier screening with colonoscopy rather than waiting until they are eligible for the national screening programme. False positives and negatives are possible with FIT, making colonoscopy a more reliable screening option for high-risk patients.
Therefore, it is important for patients with a family history of colorectal cancer to be aware of the screening recommendations and to discuss their individual risk and screening options with their healthcare provider.
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This question is part of the following fields:
- Gastroenterology
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Question 103
Incorrect
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A 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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This question is part of the following fields:
- Gastroenterology
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Question 104
Incorrect
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A 63-year-old woman complains of abdominal discomfort, bloating, and a change in bowel habit with looser, more frequent stools. She has been experiencing these symptoms since her husband passed away 3 months ago. Her daughter believes she may have irritable bowel syndrome and is seeking treatment. What is the recommended course of action for managing her symptoms?
Your Answer:
Correct Answer: 2 week referral to secondary care
Explanation:This woman has exhibited a concerning symptom of experiencing loose stools for over 6 weeks, which is a red flag indicator. Given her age of over 60 years, it is important to discuss the potential of an underlying cancer and refer her to secondary care for further testing within 2 weeks to rule out the possibility of bowel cancer.
Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.
An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.
The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.
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This question is part of the following fields:
- Gastroenterology
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Question 105
Incorrect
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A 65-year-old man presents to the General Practice Surgery with jaundice.
On examination, he has an enlarged, nodular liver. He is referred to hospital where a computed tomography (CT) scan of his abdomen reveals a cirrhotic liver with a large mass. A CT-guided biopsy of the mass demonstrates a malignant tumour derived from hepatic parenchymal cells.
What is the most likely causative agent in this patient?Your Answer:
Correct Answer: Hepatitis B virus
Explanation:Viral Causes of Cancer: A Comparison
There are several viruses that have been linked to the development of cancer in humans. Among these, hepatitis B virus is one of the most significant causes of cancer in many parts of the world, particularly in China where liver cancer accounts for about 20% of all cancer deaths. Infant vaccination against the virus is now being introduced to protect the new generation, but it doesn’t provide retrospective protection. On the other hand, hepatitis C is a more common cause of liver cancer in Europe and the United States.
Human T-lymphocyte virus, Epstein–Barr virus, and human herpesvirus type 8 are also known to cause cancer in humans, but not liver cancer. Human T-lymphocyte viruses can cause adult T-cell leukaemia/lymphoma, while Epstein–Barr virus has been linked with Hodgkin’s lymphoma, Burkitt’s lymphoma, nasopharyngeal cancer, and gastric cancer. Human herpesvirus type 8 is associated with Kaposi’s sarcoma, which is most often found in men who have sex with men but can also occur in heterosexuals.
Human papillomavirus (HPV) is another virus that has been linked to cancer, but not liver cancer. HPV types 6 and 11 cause anogenital warts, while HPV16 and HPV18 are responsible for more than two thirds of all cervical cancers globally. HPV infection is also associated with anogenital cancer and some nasopharyngeal cancers.
In summary, while several viruses have been linked to the development of cancer in humans, their specific associations vary. It is important to understand these associations in order to develop effective prevention and treatment strategies.
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This question is part of the following fields:
- Gastroenterology
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Question 106
Incorrect
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Which of the following statements about coeliac disease is accurate?
Your Answer:
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.
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This question is part of the following fields:
- Gastroenterology
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