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  • Question 1 - A 50-year-old man arrives at the emergency department with complaints of a high...

    Correct

    • A 50-year-old man arrives at the emergency department with complaints of a high fever and flank pain. He reports experiencing mild burning during urination for the past 5 days, but his urine output has decreased since the onset of fever yesterday. The patient has a history of poorly controlled type II diabetes mellitus.

      Based on the probable diagnosis, which structure is at the highest risk of co-infection?

      Your Answer: Psoas muscle

      Explanation:

      The woman in the scenario is likely suffering from pyelonephritis, which is a result of a UTI. Her poorly controlled blood sugar levels due to diabetes make her more susceptible to recurrent UTIs. Since the kidneys are retroperitoneal organs, the infection can spread to other organs within that space. The psoas muscle, located at the back, can become co-infected with pyelonephritis, leading to the formation of an abscess. The symptoms of a psoas abscess may be minimal, and an MRI abdopelvis is the best imaging technique to detect it. Peritoneal structures are less likely to become infected, and peritonitis is usually caused by infected ascitic fluid, leading to Spontaneous Bacterial Peritonitis (SBP).

      The retroperitoneal structures are those that are located behind the peritoneum, which is the membrane that lines the abdominal cavity. These structures include the duodenum (2nd, 3rd, and 4th parts), ascending and descending colon, kidneys, ureters, aorta, and inferior vena cava. They are situated in the back of the abdominal cavity, close to the spine. In contrast, intraperitoneal structures are those that are located within the peritoneal cavity, such as the stomach, duodenum (1st part), jejunum, ileum, transverse colon, and sigmoid colon. It is important to note that the retroperitoneal structures are not well demonstrated in the diagram as the posterior aspect has been removed, but they are still significant in terms of their location and function.

    • This question is part of the following fields:

      • Gastrointestinal System
      13.6
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  • Question 2 - A 29-year-old woman reports experiencing watery stools and fecal urgency after undergoing gastrointestinal...

    Incorrect

    • A 29-year-old woman reports experiencing watery stools and fecal urgency after undergoing gastrointestinal surgery to treat chronic bowel inflammation. While she suspects she may have developed irritable bowel syndrome, further investigation suggests that she may be suffering from bile acid malabsorption as a result of her surgery.

      Where is the most likely site of this patient's surgery?

      Your Answer: Descending colon

      Correct Answer: Terminal ileum

      Explanation:

      The primary role of the large intestine is to absorb water and create solid waste.

      Bile is a liquid that is produced in the liver at a rate of 500ml to 1500mL per day. It is made up of bile salts, bicarbonate, cholesterol, steroids, and water. The flow of bile is regulated by three factors: hepatic secretion, gallbladder contraction, and sphincter of oddi resistance. Bile salts are absorbed in the terminal ileum and are recycled up to six times a day, with over 90% of all bile salts being recycled.

      There are two types of bile salts: primary and secondary. Primary bile salts include cholate and chenodeoxycholate, while secondary bile salts are formed by bacterial action on primary bile salts and include deoxycholate and lithocholate. Deoxycholate is reabsorbed, while lithocholate is insoluble and excreted.

      Gallstones can form when there is an excess of cholesterol in the bile. Bile salts have a detergent action and form micelles, which have a lipid center that transports fats. However, excessive amounts of cholesterol cannot be transported in this way and will precipitate, resulting in the formation of cholesterol-rich gallstones.

    • This question is part of the following fields:

      • Gastrointestinal System
      20.8
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  • Question 3 - The antenatal ultrasound (US) performed on a baby small for gestational age, reveals...

    Incorrect

    • The antenatal ultrasound (US) performed on a baby small for gestational age, reveals a midline abdominal wall defect with a membranous sac enclosing the protruding intestinal contents. Is it advantageous to offer amniocentesis for additional genetic investigations, despite the potential risks involved?

      Your Answer: To definitely diagnose an omphalocoele

      Correct Answer: Early diagnosis of any genetic conditions associated with this defect

      Explanation:

      BWS can also cause gigantism, which may explain the macrosomia observed in this case. Genetic and chromosomal abnormalities are commonly associated with omphalocoele, and genetic studies are conducted to detect any such abnormalities early on, not just Down’s syndrome.

      The US findings indicate the presence of an omphalocoele, not a gastroschisis, which is an abdominal wall defect without a membranous sac covering, usually located to the right of a normal umbilical cord insertion site. As such, genetic studies are not used to diagnose either defect, and this option is incorrect.

      Omphalocoele can be diagnosed without genetic studies, but if the membranous sac ruptures in utero, there may be some uncertainty in the diagnosis. In such cases, genetic studies can help confirm the diagnosis, given the high incidence of associated genetic abnormalities with omphalocoele.

      While foetuses with omphalocoele are more likely to have associated structural defects, genetic studies are not useful in identifying these. An echocardiogram would be a more effective means of detecting any other structural defects.

      Gastroschisis and Exomphalos: Congenital Visceral Malformations

      Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis is a condition where there is a defect in the anterior abdominal wall, located just beside the umbilical cord. On the other hand, exomphalos, also known as omphalocoele, is a condition where the abdominal contents protrude through the anterior abdominal wall, but are covered by an amniotic sac formed by amniotic membrane and peritoneum.

      In terms of management, vaginal delivery may be attempted for gastroschisis, and newborns should be taken to the operating room as soon as possible after delivery, ideally within four hours. For exomphalos, a caesarean section is indicated to reduce the risk of sac rupture. A staged repair may be undertaken as primary closure may be difficult due to lack of space or high intra-abdominal pressure. If this occurs, the sac is allowed to granulate and epithelialize over the coming weeks or months, forming a shell. As the infant grows, a point will be reached when the sac contents can fit within the abdominal cavity. At this point, the shell will be removed, and the abdomen closed.

      Overall, both gastroschisis and exomphalos require careful management and monitoring to ensure the best possible outcomes for the newborn.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 4 - A 27-year-old female patient presents to her GP with a concern about experiencing...

    Incorrect

    • A 27-year-old female patient presents to her GP with a concern about experiencing bloody vomit on multiple occasions over the past 48 hours. She reports that the vomiting is causing her pain. During the examination, the GP observes that the patient's voice is hoarse, and she is wearing loose, baggy clothing despite the warm weather. Upon further inquiry, the patient reveals that she has been inducing vomiting for some time, but this is the first instance of bleeding. What is the most probable cause of the patient's haematemesis?

      Your Answer: Oesophageal varices

      Correct Answer: Mallory-Weiss tear

      Explanation:

      The patient’s condition is caused by a mallory-weiss tear, which is likely due to their history of bulimia nervosa. Forceful vomiting can lead to this tear, resulting in painful episodes of vomiting blood.

      Peptic ulcers are more commonly seen in older patients or those experiencing abdominal pain and taking NSAIDs.

      Oesophageal varices are typically found in patients with a history of alcohol abuse and may present with signs of chronic liver disease.

      Gastric carcinoma is more likely to occur in high-risk patients, such as men over 55 who smoke, and may be accompanied by weight loss.

      Hereditary telangiectasia is characterized by a positive family history and the presence of telangiectasia around the lips, tongue, or mucus membranes. Epistaxis is a common symptom of this vascular malformation.

      Less Common Oesophageal Disorders

      Plummer-Vinson syndrome is a condition characterized by a triad of dysphagia, glossitis, and iron-deficiency anaemia. Dysphagia is caused by oesophageal webs, which are thin membranes that form in the oesophagus. Treatment for this condition includes iron supplementation and dilation of the webs.

      Mallory-Weiss syndrome is a disorder that occurs when severe vomiting leads to painful mucosal lacerations at the gastroesophageal junction, resulting in haematemesis. This condition is common in alcoholics.

      Boerhaave syndrome is a severe disorder that occurs when severe vomiting leads to oesophageal rupture. This condition requires immediate medical attention.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 5 - During a radical gastrectomy for carcinoma of the stomach, if the patient is...

    Incorrect

    • During a radical gastrectomy for carcinoma of the stomach, if the patient is elderly, would the surgeons still remove the omentum? What is the main source of its blood supply?

      Your Answer: Middle colic artery

      Correct Answer: Gastroepiploic artery

      Explanation:

      The omental branches of the right and left gastro-epiploic arteries provide the blood supply to the omentum, while the colonic vessels do not play a role in this. The left gastro-epiploic artery originates from the splenic artery, and the right gastro-epiploic artery is the final branch of the gastroduodenal artery.

      The Omentum: A Protective Structure in the Abdomen

      The omentum is a structure in the abdomen that invests the stomach and is divided into two parts: the greater and lesser omentum. The greater omentum is attached to the lower lateral border of the stomach and contains the gastro-epiploic arteries. It varies in size and is less developed in children. However, it plays an important role in protecting against visceral perforation, such as in cases of appendicitis.

      The lesser omentum is located between the omentum and transverse colon, providing a potential entry point into the lesser sac. Malignant processes can affect the omentum, with ovarian cancer being the most notable. Overall, the omentum is a crucial structure in the abdomen that serves as a protective barrier against potential injuries and diseases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 6 - Secretions from which of the following will contain the highest levels of potassium?...

    Correct

    • Secretions from which of the following will contain the highest levels of potassium?

      Your Answer: Rectum

      Explanation:

      The rectum can produce potassium-rich secretions, which is why resins are given to treat hyperkalemia and why patients with villous adenoma of the rectum may experience hypokalemia.

      Potassium Secretions in the GI Tract

      Potassium is secreted in various parts of the gastrointestinal (GI) tract. The salivary glands can secrete up to 60mmol/L of potassium, while the stomach secretes only 10 mmol/L. The bile, pancreas, and small bowel also secrete potassium, with average figures of 5 mmol/L, 4-5 mmol/L, and 10 mmol/L, respectively. The rectum has the highest potassium secretion, with an average of 30 mmol/L. However, the exact composition of potassium secretions varies depending on factors such as disease, serum aldosterone levels, and serum pH.

      It is important to note that gastric potassium secretions are low, and hypokalaemia (low potassium levels) may occur in vomiting. However, this is usually due to renal wasting of potassium rather than potassium loss in vomit. Understanding the different levels of potassium secretion in the GI tract can be helpful in diagnosing and treating potassium-related disorders.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 7 - A 48-year-old woman complains of fatigue. She has experienced occasional bouts of diarrhea...

    Incorrect

    • A 48-year-old woman complains of fatigue. She has experienced occasional bouts of diarrhea for several years and has recurrent abdominal pain and bloating.

      During the abdominal examination, no abnormalities were found, but a blood test revealed anemia due to folate deficiency. The patient tested positive for immunoglobulin A-tissue transglutaminase (IgA-tTG), and an intestinal biopsy showed villous atrophy.

      Which serotype is most strongly linked to this condition?

      Your Answer: HLA-B51

      Correct Answer: HLA-DQ2

      Explanation:

      The incorrect HLA serotypes are HLA-A3, HLA-B27, and HLA-B51. HLA-A3 is associated with haemochromatosis, which can be asymptomatic in early stages and present with non-specific symptoms such as lethargy and arthralgia. HLA-B27 is associated with ankylosing spondylitis, reactive arthritis, and anterior uveitis. Ankylosing spondylitis presents with lower back pain and stiffness that worsens in the morning and improves with exercise. Reactive arthritis is characterized by arthritis following an infection, along with possible symptoms of urethritis and conjunctivitis. Anterior uveitis is inflammation of the iris and ciliary body and is a differential diagnosis for red eye. HLA-B51 is associated with Behçet’s disease, which involves oral and genital ulcers and anterior uveitis.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 8 - A 50-year-old woman presents with an unknown cause of jaundice. She noticed the...

    Incorrect

    • A 50-year-old woman presents with an unknown cause of jaundice. She noticed the yellowing of her skin and eyes in the mirror that morning. Upon examination, a palpable mass is found in the right upper quadrant of her abdomen. Her lab results show a total bilirubin level of 124 umol/L and high levels of conjugated bilirubin in her urine. What is the most probable diagnosis?

      Your Answer: Ascending cholangitis

      Correct Answer: Cholangiocarcinoma

      Explanation:

      To correctly diagnose this patient, knowledge of Courvoisier’s sign is necessary. This sign indicates that a palpable gallbladder in the presence of painless jaundice is unlikely to be caused by gallstones. Therefore, biliary colic is an incorrect answer as it is a painful condition. Haemolytic anaemia is also an incorrect answer as the blood test results would differ from this patient’s results. The correct answer is cholangiocarcinoma, which is a cancer of the biliary tree that can cause painless obstructive jaundice. Gilbert’s syndrome is not the most appropriate answer as it only presents with a raised bilirubin and does not cause an increase in ALP.

      Understanding Cholangiocarcinoma

      Cholangiocarcinoma, also known as bile duct cancer, is a serious medical condition that can be caused by primary sclerosing cholangitis. This disease is characterized by persistent biliary colic symptoms, which can be accompanied by anorexia, jaundice, and weight loss. In some cases, a palpable mass in the right upper quadrant may be present, which is known as the Courvoisier sign. Additionally, periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen.

      One of the main risk factors for cholangiocarcinoma is primary sclerosing cholangitis. This condition can cause inflammation and scarring of the bile ducts, which can lead to the development of cancer over time. To detect cholangiocarcinoma in patients with primary sclerosing cholangitis, doctors often use a blood test to measure CA 19-9 levels.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 9 - A 12-year-old boy presents to the emergency department with complaints of central abdominal...

    Correct

    • A 12-year-old boy presents to the emergency department with complaints of central abdominal pain that has shifted to the right iliac fossa. Upon examination, there are no indications of rebound tenderness or guarding.

      What is the most probable diagnosis, and how would you describe the pathophysiology of the condition?

      Your Answer: Obstruction of the appendiceal lumen due to lymphoid hyperplasia or faecolith

      Explanation:

      The pathophysiology of appendicitis involves obstruction of the appendiceal lumen, which is commonly caused by lymphoid hyperplasia or a faecolith. This condition is most prevalent in young individuals aged 10-20 years and is the most common acute abdominal condition requiring surgery. Blood clots are not a typical cause of appendiceal obstruction, but foreign bodies and worms can also contribute to this condition.

      Pancreatitis can lead to autodigestion in the pancreas, while autoimmune destruction of the pancreas is responsible for type 1 diabetes. Symptoms of type 1 diabetes, which typically develops at a younger age than type 2 diabetes, include polydipsia and polyuria.

      Acute appendicitis is a common condition that requires surgery and can occur at any age, but is most prevalent in young people aged 10-20 years. The pathogenesis of acute appendicitis involves lymphoid hyperplasia or a faecolith, which leads to obstruction of the appendiceal lumen. This obstruction causes gut organisms to invade the appendix wall, resulting in oedema, ischaemia, and possibly perforation.

      The most common symptom of acute appendicitis is abdominal pain, which is typically peri-umbilical and radiates to the right iliac fossa due to localised peritoneal inflammation. Other symptoms include mild pyrexia, anorexia, and nausea. Examination may reveal generalised or localised peritonism, rebound and percussion tenderness, guarding and rigidity, and classical signs such as Rovsing’s sign and psoas sign.

      Diagnosis of acute appendicitis is typically based on raised inflammatory markers and compatible history and examination findings. Imaging may be used in certain cases, such as ultrasound in females where pelvic organ pathology is suspected. Management of acute appendicitis involves appendicectomy, which can be performed via an open or laparoscopic approach. Patients with perforated appendicitis require copious abdominal lavage, while those without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy. Intravenous antibiotics alone have been trialled as a treatment for appendicitis, but evidence suggests that this is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 10 - A patient in her 50s has been diagnosed with duodenal ulcers caused by...

    Correct

    • A patient in her 50s has been diagnosed with duodenal ulcers caused by excessive gastric acid secretion. Upon reviewing her pancreatic function, the consultant found that her S cells are not functioning properly, resulting in decreased secretion of secretin. How will this impact her treatment plan?

      Your Answer: Secretion of bicarbonate-rich fluid

      Explanation:

      The secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells is increased by secretin.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 11 - A 30-year-old patient comes to see his doctor complaining of feeling fatigued, sluggish...

    Incorrect

    • A 30-year-old patient comes to see his doctor complaining of feeling fatigued, sluggish and having difficulty concentrating at work lately. He appears pale and his hands feel cool to the touch. He reports being a non-smoker, drinking very little and adopting a vegan diet last year. What could be the reason for this patient's development of anaemia?

      Your Answer: The body is unable to absorb non-haem iron

      Correct Answer: Fe3+ is insoluble and must be converted into Fe2+ before it is absorbed

      Explanation:

      Iron is absorbed from food in two forms: haem iron (found in meat) and non-haem iron (found in green vegetables). Haem iron is easier to absorb than non-haem iron. Non-haem iron is mostly in the form of insoluble ferric (Fe3+) iron, which needs to be converted to soluble ferrous (Fe2+) iron before it can be absorbed by the body. However, the amount of iron absorbed this way is often not enough to meet the body’s needs. Vegetarians and vegans are at higher risk of iron deficiency anaemia (IDA) because they consume less haem iron.

      The patient’s symptoms suggest IDA caused by a change in diet, rather than anaemia of chronic disease. Ferritin is a marker of iron stores and is reduced in IDA. Hepcidin is a hormone that regulates iron storage in the body. Low serum hepcidin levels are seen in IDA, but this is not a reliable marker of the condition. Transferrin is a protein that binds to iron in the blood. In IDA, transferrin levels are high and ferritin levels are low. Transferrin saturation is low in IDA and anaemia of chronic disease, but high in haemochromatosis. Total iron-binding capacity (TIBC) is normal or high in IDA, but low in anaemia of chronic disease due to increased iron storage in cells and limited release into the blood.

      Understanding Ferritin Levels in the Body

      Ferritin is a protein found inside cells that binds to iron and stores it for later use. When ferritin levels are increased, it is usually defined as being above 300 µg/L in men and postmenopausal women, and above 200 µg/L in premenopausal women. However, it is important to note that ferritin is an acute phase protein, meaning that it can be synthesized in larger quantities during times of inflammation. This can lead to falsely elevated results, which must be interpreted in the context of the patient’s clinical picture and other blood test results.

      There are two main categories of causes for increased ferritin levels: those without iron overload (which account for around 90% of patients) and those with iron overload (which account for around 10% of patients). Causes of increased ferritin levels without iron overload include inflammation, alcohol excess, liver disease, chronic kidney disease, and malignancy. Causes of increased ferritin levels with iron overload include primary iron overload (hereditary hemochromatosis) and secondary iron overload (which can occur after repeated transfusions).

      On the other hand, reduced ferritin levels can be an indication of iron deficiency anemia. Since iron and ferritin are bound together, a decrease in ferritin levels can suggest a decrease in iron levels as well. Measuring serum ferritin levels can be helpful in determining whether a low hemoglobin level and microcytosis are truly caused by an iron deficiency state. It is important to note that the best test for determining iron overload is transferrin saturation, with normal values being less than 45% in females and less than 50% in males.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 12 - A 57-year-old man is having a pancreatectomy for cancer. While removing the gland,...

    Incorrect

    • A 57-year-old man is having a pancreatectomy for cancer. While removing the gland, which structure will the surgeon not come across behind the pancreas?

      Your Answer: Common bile duct

      Correct Answer: Gastroduodenal artery

      Explanation:

      At the superior part of the pancreas, the gastroduodenal artery splits into the pancreaticoduodenal and gastro-epiploic arteries.

      Anatomy of the Pancreas

      The pancreas is located behind the stomach and is a retroperitoneal organ. It can be accessed surgically by dividing the peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head is situated in the curvature of the duodenum, while its tail is close to the hilum of the spleen. The pancreas has various relations with other organs, such as the inferior vena cava, common bile duct, renal veins, superior mesenteric vein and artery, crus of diaphragm, psoas muscle, adrenal gland, kidney, aorta, pylorus, gastroduodenal artery, and splenic hilum.

      The arterial supply of the pancreas is through the pancreaticoduodenal artery for the head and the splenic artery for the rest of the organ. The venous drainage for the head is through the superior mesenteric vein, while the body and tail are drained by the splenic vein. The ampulla of Vater is an important landmark that marks the transition from foregut to midgut and is located halfway along the second part of the duodenum. Overall, understanding the anatomy of the pancreas is crucial for surgical procedures and diagnosing pancreatic diseases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 13 - A 45-year-old man presents to the surgical team with abdominal pain, bloating, and...

    Incorrect

    • A 45-year-old man presents to the surgical team with abdominal pain, bloating, and vomiting. Based on an abdominal x-ray, there is suspicion of a malignancy causing intestinal obstruction. Which of the following antiemetics should be avoided for managing the patient's vomiting?

      Your Answer: Ondansetron

      Correct Answer: Metoclopramide

      Explanation:

      It is not recommended to use metoclopramide as an antiemetic in cases of bowel obstruction. This is because metoclopramide works by blocking dopamine receptors and stimulating peripheral 5HT3 receptors, which promote gastric emptying. However, in cases of intestinal obstruction, gastric emptying is not possible and this effect can be harmful. The choice of antiemetic should be based on the patient’s individual needs and the underlying cause of their nausea.

      Understanding the Mechanism and Uses of Metoclopramide

      Metoclopramide is a medication primarily used to manage nausea, but it also has other uses such as treating gastro-oesophageal reflux disease and gastroparesis secondary to diabetic neuropathy. It is often combined with analgesics for the treatment of migraines. However, it is important to note that metoclopramide has adverse effects such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. It should also be avoided in bowel obstruction but may be helpful in paralytic ileus.

      The mechanism of action of metoclopramide is quite complicated. It is primarily a D2 receptor antagonist, but it also has mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Its antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone, and at higher doses, the 5-HT3 receptor antagonist also has an effect. The gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity.

      In summary, metoclopramide is a medication with multiple uses, but it also has adverse effects that should be considered. Its mechanism of action is complex, involving both D2 receptor antagonist and 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Understanding the uses and mechanism of action of metoclopramide is important for its safe and effective use.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 14 - A 23-year-old man presents to his GP with complaints of persistent diarrhoea, abdominal...

    Incorrect

    • A 23-year-old man presents to his GP with complaints of persistent diarrhoea, abdominal pain, and weight loss. He reports experiencing generalised pain and feeling extremely fatigued. The patient denies any blood in his stool and has a past medical history of type 1 diabetes mellitus.

      Upon investigation, the patient's tissue transglutaminase IgA (tTG-IgA) levels are found to be elevated. What is the most probable finding on duodenal biopsy for this likely diagnosis?

      Your Answer: Crypt hypoplasia

      Correct Answer: Villous atrophy

      Explanation:

      Malabsorption occurs in coeliac disease due to villous atrophy, which is caused by an immune response to gluten in the gastrointestinal tract. This can lead to nutritional deficiencies in affected individuals. While coeliac disease is associated with a slightly increased risk of small bowel carcinoma, it is unlikely to occur in a young patient. Crypt hyperplasia, not hypoplasia, is a common finding in coeliac disease. Coeliac disease is associated with a decreased number of goblet cells, not an increased number. Non-caseating granulomas are typically seen in Crohn’s disease, not coeliac disease.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 15 - Parasympathetic fibers innervating the parotid gland originate from where? ...

    Incorrect

    • Parasympathetic fibers innervating the parotid gland originate from where?

      Your Answer: Pterygopalatine ganglion

      Correct Answer: Otic ganglion

      Explanation:

      The inferior salivatory nucleus is responsible for regulating the secretion of saliva from the parotid gland through postsynaptic parasympathetic fibers. These fibers exit the brain via the glossopharyngeal nerve’s tympanic branch and pass through the tympanic plexus in the middle ear before forming the lesser petrosal nerve. The otic ganglion is where the fibers synapse before continuing on as part of the mandibular nerve’s auriculotemporal branch to reach the parotid gland.

      The parotid gland is located in front of and below the ear, overlying the mandibular ramus. Its salivary duct crosses the masseter muscle, pierces the buccinator muscle, and drains adjacent to the second upper molar tooth. The gland is traversed by several structures, including the facial nerve, external carotid artery, retromandibular vein, and auriculotemporal nerve. The gland is related to the masseter muscle, medial pterygoid muscle, superficial temporal and maxillary artery, facial nerve, stylomandibular ligament, posterior belly of the digastric muscle, sternocleidomastoid muscle, stylohyoid muscle, internal carotid artery, mastoid process, and styloid process. The gland is supplied by branches of the external carotid artery and drained by the retromandibular vein. Its lymphatic drainage is to the deep cervical nodes. The gland is innervated by the parasympathetic-secretomotor, sympathetic-superior cervical ganglion, and sensory-greater auricular nerve. Parasympathetic stimulation produces a water-rich, serous saliva, while sympathetic stimulation leads to the production of a low volume, enzyme-rich saliva.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 16 - A 48-year-old female patient complains of pain in the right hypochondrium. Upon palpation...

    Incorrect

    • A 48-year-old female patient complains of pain in the right hypochondrium. Upon palpation of the abdomen, she experiences tenderness in the right upper quadrant and reports that the pain worsens during inspiration. Based on the history and examination, the probable diagnosis is cholecystitis caused by a gallstone. If the gallstone were to move out of the gallbladder, which of the ducts would it enter first?

      Your Answer: Accessory duct

      Correct Answer: Cystic duct

      Explanation:

      The biliary tree is composed of various ducts, including the cystic duct that transports bile from the gallbladder. The right and left hepatic ducts in the liver merge to form the common hepatic duct, which then combines with the cystic duct to create the common bile duct. The pancreatic duct from the pancreas also connects to the common bile duct, and they both empty into the duodenum through the hepatopancreatic ampulla (of Vater). The accessory duct, which may or may not exist, is a small supplementary duct(s) to the biliary tree.

      The gallbladder is a sac made of fibromuscular tissue that can hold up to 50 ml of fluid. Its lining is made up of columnar epithelium. The gallbladder is located in close proximity to various organs, including the liver, transverse colon, and the first part of the duodenum. It is covered by peritoneum and is situated between the right lobe and quadrate lobe of the liver. The gallbladder receives its arterial supply from the cystic artery, which is a branch of the right hepatic artery. Its venous drainage is directly to the liver, and its lymphatic drainage is through Lund’s node. The gallbladder is innervated by both sympathetic and parasympathetic nerves. The common bile duct originates from the confluence of the cystic and common hepatic ducts and is located in the hepatobiliary triangle, which is bordered by the common hepatic duct, cystic duct, and the inferior edge of the liver. The cystic artery is also found within this triangle.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 17 - A 48-year-old woman arrives at the Emergency Department complaining of persistent, dull discomfort...

    Incorrect

    • A 48-year-old woman arrives at the Emergency Department complaining of persistent, dull discomfort in the upper right quadrant of her abdomen. Upon examination, an ultrasound reveals the presence of a mass in her gallbladder. Subsequent biopsy results confirm the diagnosis of adenocarcinoma, a cancerous tumour that originates from the epithelial cells of the gallbladder.

      How would you characterize these epithelial cells?

      Your Answer: Simple cuboidal

      Correct Answer: Simple columnar

      Explanation:

      The lining of the gallbladder is composed of simple columnar epithelium, which is also found in other parts of the gastrointestinal tract such as the small intestine, stomach, and large intestine. Simple cuboidal epithelium is rare and is mainly found in the renal tubules and on the surface of the ovaries. Simple squamous epithelium is present in areas where rapid diffusion of small molecules is necessary, such as in alveoli and capillaries, as well as in glomeruli where ultra-filtration occurs. Pseudostratified columnar epithelium is primarily found in the upper respiratory tract.

      The gallbladder is a sac made of fibromuscular tissue that can hold up to 50 ml of fluid. Its lining is made up of columnar epithelium. The gallbladder is located in close proximity to various organs, including the liver, transverse colon, and the first part of the duodenum. It is covered by peritoneum and is situated between the right lobe and quadrate lobe of the liver. The gallbladder receives its arterial supply from the cystic artery, which is a branch of the right hepatic artery. Its venous drainage is directly to the liver, and its lymphatic drainage is through Lund’s node. The gallbladder is innervated by both sympathetic and parasympathetic nerves. The common bile duct originates from the confluence of the cystic and common hepatic ducts and is located in the hepatobiliary triangle, which is bordered by the common hepatic duct, cystic duct, and the inferior edge of the liver. The cystic artery is also found within this triangle.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 18 - A 25-year-old male patient complains of mucous passage and diarrhea, leading to a...

    Incorrect

    • A 25-year-old male patient complains of mucous passage and diarrhea, leading to a suspicion of ulcerative colitis. Which of the following is not commonly associated with this disease?

      Your Answer: Significant risk of dysplasia in long standing disease

      Correct Answer: Episodes of large bowel obstruction during acute attacks

      Explanation:

      Crohn’s disease is associated with a higher risk of colorectal cancer compared to the general population, particularly if the disease has been present for over 20 years. Granulomas are a common feature of Crohn’s disease. The disease typically affects the rectum and can spread upwards, and contact bleeding may occur. In cases of longstanding ulcerative colitis, there may be crypt atrophy and metaplasia/dysplasia.

      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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 19 - A 25-year-old male patient visits his general practitioner complaining of abdominal pain, diarrhea,...

    Correct

    • A 25-year-old male patient visits his general practitioner complaining of abdominal pain, diarrhea, and painful aphthous ulcers that have been bothering him for the last four weeks. He has also observed that his clothes have become loose lately.

      What is the typical disease pattern associated with his condition?

      Your Answer: Inflammation anywhere from the mouth to anus

      Explanation:

      Crohn’s disease is characterized by inflammation that can occur anywhere from the mouth to the anus. This patient’s symptoms, including weight loss, abdominal pain, and diarrhea, suggest inflammatory bowel disease (IBD). The presence of mouth ulcers indicates Crohn’s disease, as it is known for causing discontinuous inflammation throughout the gastrointestinal tract. Ulcerative colitis, on the other hand, does not cause mouth ulcers and typically involves continuous inflammation that extends from the rectum. While colorectal polyposis can be a complication of IBD, it alone does not explain the patient’s symptoms. Ulcerative colitis is characterized by continuous inflammation that is limited to the submucosa and originates in the rectum, which is not the case for this patient.

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

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 20 - A 72-year-old man comes to the clinic with a left groin swelling and...

    Incorrect

    • A 72-year-old man comes to the clinic with a left groin swelling and reports experiencing moderate pain and discomfort. The diagnosis is an inguinal hernia, and he is scheduled for elective surgery to repair the defect. During the procedure, which nerve running through the inguinal canal is at risk of being damaged?

      Your Answer: Sciatic nerve

      Correct Answer: Ilioinguinal nerve

      Explanation:

      The inguinal canal is a crucial anatomical structure that houses the spermatic cord in males and the ilioinguinal nerve in both genders. The ilioinguinal and iliohypogastric nerves stem from the L1 nerve root and run through the canal. The ilioinguinal nerve enters the canal via the abdominal muscles and exits through the external inguinal ring. It is primarily a sensory nerve that provides sensation to the upper medial thigh. If the nerve is damaged during hernia repair, patients may experience numbness in this area after surgery.

      Other nerves that pass through the pelvis include the femoral nerve, which descends behind the inguinal canal, the obturator nerve, which travels through the obturator foramen, and the sciatic nerve, which exits the pelvis through the greater sciatic foramen and runs posteriorly.

      The inguinal canal is located above the inguinal ligament and measures 4 cm in length. Its superficial ring is situated in front of the pubic tubercle, while the deep ring is found about 1.5-2 cm above the halfway point between the anterior superior iliac spine and the pubic tubercle. The canal is bounded by the external oblique aponeurosis, inguinal ligament, lacunar ligament, internal oblique, transversus abdominis, external ring, and conjoint tendon. In males, the canal contains the spermatic cord and ilioinguinal nerve, while in females, it houses the round ligament of the uterus and ilioinguinal nerve.

      The boundaries of Hesselbach’s triangle, which are frequently tested, are located in the inguinal region. Additionally, the inguinal canal is closely related to the vessels of the lower limb, which should be taken into account when repairing hernial defects in this area.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 21 - A 40-year-old male presents with mild intermittent diarrhoea over the last 3 months....

    Incorrect

    • A 40-year-old male presents with mild intermittent diarrhoea over the last 3 months. He has also noticed 4kg of unintentional weight loss over this time. On further review, he has not noticed any night sweats or fever, and he has not changed his diet recently. There is no blood in his stools, and he is otherwise well, with no past medical conditions.

      On examination he has;
      Normal vital signs
      Ulcerations in his mouth
      Pain on rectal examination

      What is the most likely finding on endoscopy?

      Your Answer: Normal intestinal mucosa

      Correct Answer: cobblestone appearance

      Explanation:

      The patient is likely suffering from Crohn’s disease as indicated by the presence of skip lesions/mouth ulcerations, weight loss, and non-bloody diarrhea. The cobblestone appearance observed on endoscopy is a typical feature of Crohn’s disease. Pseudopolyps, on the other hand, are commonly seen in patients with ulcerative colitis. Additionally, pANCA is more frequently found in ulcerative colitis, while ASCA is present in Crohn’s disease. Ulcerative colitis is characterized by continuous inflammation of the mucosa.

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

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 22 - A 55-year-old Caucasian man visits his primary care physician complaining of heartburn that...

    Incorrect

    • A 55-year-old Caucasian man visits his primary care physician complaining of heartburn that has been bothering him for the past 3 months. He reports experiencing gnawing pain in his upper abdomen that worsens between meals but improves after eating. The pain does not spread to other areas and is relieved by taking antacids that can be purchased over-the-counter.

      The patient undergoes a gastroscopy, which reveals a bleeding ulcer measuring 2x3cm in the first part of his duodenum.

      What is the probable cause of this patient's ulcer?

      Your Answer: Adenocarcinoma

      Correct Answer: Helicobacter pylori infection

      Explanation:

      The most likely cause of the patient’s duodenal ulcer is Helicobacter pylori infection, which is responsible for the majority of cases. Diagnosis can be made through serology, microbiology, histology, or CLO testing. The patient’s symptoms of gnawing epigastric pain and improvement with food are consistent with a duodenal ulcer. Adenocarcinoma is an unlikely cause as duodenal ulcers are typically benign. Alcohol excess and NSAIDs are not the most common causes of duodenal ulcers, with Helicobacter pylori being the primary culprit.

      Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems

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

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

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

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 23 - At which of the following sites is the development of diverticulosis least likely...

    Incorrect

    • At which of the following sites is the development of diverticulosis least likely in individuals over 60 years of age?

      Your Answer: Sigmoid colon

      Correct Answer: Rectum

      Explanation:

      It is extremely rare for diverticular disease to affect the rectum due to the circular muscle coat present in this area, which is a result of the blending of the tenia at the recto-sigmoid junction. While left-sided colonic diverticular disease is more common, right-sided colonic diverticular disease is also acknowledged.

      Understanding Diverticular Disease

      Diverticular disease is a common condition that involves the protrusion of the colon’s mucosa through its muscular wall. This typically occurs between the taenia coli, where vessels penetrate the muscle to supply the mucosa. Symptoms of diverticular disease include altered bowel habits, rectal bleeding, and abdominal pain. Complications can arise, such as diverticulitis, haemorrhage, fistula development, perforation and faecal peritonitis, abscess formation, and diverticular phlegmon.

      To diagnose diverticular disease, patients may undergo a colonoscopy, CT cologram, or barium enema. However, it can be challenging to rule out cancer, especially in diverticular strictures. Acutely unwell surgical patients require a systematic investigation, including plain abdominal films and an erect chest x-ray to identify perforation. An abdominal CT scan with oral and intravenous contrast can help identify acute inflammation and local complications.

      Treatment for diverticular disease includes increasing dietary fibre intake and managing mild attacks with antibiotics. Peri colonic abscesses require drainage, either surgically or radiologically. Recurrent episodes of acute diverticulitis requiring hospitalisation may indicate a segmental resection. Hinchey IV perforations, which involve generalised faecal peritonitis, require a resection and usually a stoma. This group has a high risk of postoperative complications and typically requires HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 24 - A 39-year-old man presents to his family physician with a persistent abdominal pain...

    Incorrect

    • A 39-year-old man presents to his family physician with a persistent abdominal pain that has been bothering him for the past three months. He reports that the pain usually occurs after eating and has not been relieved with over-the-counter antacids and omeprazole. The patient denies any recent weight loss or difficulty swallowing. Upon examination, the abdomen is soft and non-tender. The physician orders a urea breath test, which comes back positive. What is the organism responsible for this patient's symptoms?

      Your Answer: Gram-negative, oxidase positive, non-lactose fermenting bacilli

      Correct Answer: Gram-negative, oxidase positive, catalase positive comma-shaped rods

      Explanation:

      The patient has peptic ulcer disease caused by Helicobacter pylori, which can also increase the risk of gastric adenocarcinoma. Triple therapy with two antibiotics and one proton-pump inhibitor is the standard treatment. Pseudomonas aeruginosa, Neisseria meningitidis, Vibrio cholerae, and Staphylococcus epidermidis are other bacteria with different types of infections they can cause.

      Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems

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

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

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

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 25 - A 78-year-old woman is diagnosed with a femoral hernia and requires surgery. What...

    Incorrect

    • A 78-year-old woman is diagnosed with a femoral hernia and requires surgery. What structure forms the posterior wall of the femoral canal?

      Your Answer: Lacunar ligament

      Correct Answer: Pectineal ligament

      Explanation:

      Understanding the Femoral Canal

      The femoral canal is a fascial tunnel located at the medial aspect of the femoral sheath. It contains both the femoral artery and femoral vein, with the canal lying medial to the vein. The borders of the femoral canal include the femoral vein laterally, the lacunar ligament medially, the inguinal ligament anteriorly, and the pectineal ligament posteriorly.

      The femoral canal plays a significant role in allowing the femoral vein to expand, which facilitates increased venous return to the lower limbs. However, it can also be a site of femoral hernias, which occur when abdominal contents protrude through the femoral canal. The relatively tight neck of the femoral canal places these hernias at high risk of strangulation, making it important to understand the anatomy and function of this structure. Overall, understanding the femoral canal is crucial for medical professionals in diagnosing and treating potential issues related to this area.

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      • Gastrointestinal System
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  • Question 26 - A 25-year-old man is stabbed in the chest about 10cm below the left...

    Incorrect

    • A 25-year-old man is stabbed in the chest about 10cm below the left nipple. Upon arrival at the emergency department, an abdominal ultrasound scan reveals a significant amount of intraperitoneal bleeding. Which of the following statements regarding the probable location of the injury is false?

      Your Answer: Part of its posterior surface is devoid of peritoneum.

      Correct Answer: The quadrate lobe is contained within the functional right lobe.

      Explanation:

      The most probable location of injury in the liver is the right lobe. Hence, option B is the correct answer as the quadrate lobe is considered as a functional part of the left lobe. The liver is mostly covered by peritoneum, except for the bare area at the back. The right lobe of the liver has the largest bare area and is also bigger than the left lobe.

      Structure and Relations of the Liver

      The liver is divided into four lobes: the right lobe, left lobe, quadrate lobe, and caudate lobe. The right lobe is supplied by the right hepatic artery and contains Couinaud segments V to VIII, while the left lobe is supplied by the left hepatic artery and contains Couinaud segments II to IV. The quadrate lobe is part of the right lobe anatomically but functionally is part of the left, and the caudate lobe is supplied by both right and left hepatic arteries and lies behind the plane of the porta hepatis. The liver lobules are separated by portal canals that contain the portal triad: the hepatic artery, portal vein, and tributary of bile duct.

      The liver has various relations with other organs in the body. Anteriorly, it is related to the diaphragm, esophagus, xiphoid process, stomach, duodenum, hepatic flexure of colon, right kidney, gallbladder, and inferior vena cava. The porta hepatis is located on the postero-inferior surface of the liver and transmits the common hepatic duct, hepatic artery, portal vein, sympathetic and parasympathetic nerve fibers, and lymphatic drainage of the liver and nodes.

      The liver is supported by ligaments, including the falciform ligament, which is a two-layer fold of peritoneum from the umbilicus to the anterior liver surface and contains the ligamentum teres (remnant of the umbilical vein). The ligamentum venosum is a remnant of the ductus venosus. The liver is supplied by the hepatic artery and drained by the hepatic veins and portal vein. Its nervous supply comes from the sympathetic and parasympathetic trunks of the coeliac plexus.

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      • Gastrointestinal System
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  • Question 27 - A 65-year-old man arrives at the Emergency Department after collapsing at home. According...

    Correct

    • A 65-year-old man arrives at the Emergency Department after collapsing at home. According to his wife, he had complained of sudden lower back pain just before the collapse. Upon examination, he appears pale and hypotensive, leading you to suspect a ruptured abdominal aortic aneurysm. Can you determine at which level the affected structure terminates?

      Your Answer: L4

      Explanation:

      The section of the aorta that runs through the abdomen, known as the abdominal aorta, extends from the T12 vertebrae to the L4 vertebrae. This area is particularly susceptible to developing an aneurysm, which is most commonly seen in men over the age of 65. Risk factors for abdominal aortic aneurysms include smoking, diabetes, high blood pressure, and high cholesterol levels. Symptoms are often absent until the aneurysm ruptures, causing sudden and severe pain in the lower back or abdomen, as well as a drop in blood pressure and consciousness. To detect potential aneurysms, the NHS offers a one-time ultrasound screening for men over the age of 65 who have not previously been screened.

      The abdominal aorta is a major blood vessel that originates from the 12th thoracic vertebrae and terminates at the fourth lumbar vertebrae. It is located in the abdomen and is surrounded by various organs and structures. The posterior relations of the abdominal aorta include the vertebral bodies of the first to fourth lumbar vertebrae. The anterior relations include the lesser omentum, liver, left renal vein, inferior mesenteric vein, third part of the duodenum, pancreas, parietal peritoneum, and peritoneal cavity. The right lateral relations include the right crus of the diaphragm, cisterna chyli, azygos vein, and inferior vena cava (which becomes posterior distally). The left lateral relations include the fourth part of the duodenum, duodenal-jejunal flexure, and left sympathetic trunk. Overall, the abdominal aorta is an important blood vessel that supplies oxygenated blood to various organs in the abdomen.

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      • Gastrointestinal System
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  • Question 28 - A 55-year-old man is having a distal pancreatectomy due to trauma. What vessel...

    Correct

    • A 55-year-old man is having a distal pancreatectomy due to trauma. What vessel is responsible for supplying the tail of the pancreas with arterial blood?

      Your Answer: Splenic artery

      Explanation:

      The pancreaticoduodenal artery supplies the pancreatic head, while branches of the splenic artery supply the pancreatic tail. There is an arterial watershed between the two regions.

      Anatomy of the Pancreas

      The pancreas is located behind the stomach and is a retroperitoneal organ. It can be accessed surgically by dividing the peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head is situated in the curvature of the duodenum, while its tail is close to the hilum of the spleen. The pancreas has various relations with other organs, such as the inferior vena cava, common bile duct, renal veins, superior mesenteric vein and artery, crus of diaphragm, psoas muscle, adrenal gland, kidney, aorta, pylorus, gastroduodenal artery, and splenic hilum.

      The arterial supply of the pancreas is through the pancreaticoduodenal artery for the head and the splenic artery for the rest of the organ. The venous drainage for the head is through the superior mesenteric vein, while the body and tail are drained by the splenic vein. The ampulla of Vater is an important landmark that marks the transition from foregut to midgut and is located halfway along the second part of the duodenum. Overall, understanding the anatomy of the pancreas is crucial for surgical procedures and diagnosing pancreatic diseases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 29 - A 23-year-old male complains of crampy abdominal pain, bloating, and diarrhea. He recently...

    Correct

    • A 23-year-old male complains of crampy abdominal pain, bloating, and diarrhea. He recently came back from a trip to Egypt where he swam in the local pool a few days ago. He reports having 5 bowel movements per day, and his stool floats in the toilet water without any blood. What is the probable cause of his symptoms?

      Your Answer: Giardia lamblia

      Explanation:

      Giardia can lead to the occurrence of greasy stool due to its ability to cause fat malabsorption. Additionally, it is important to note that Giardia is resistant to chlorination, which increases the risk of transmission in swimming pools.

      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 Clostridium 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.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 30 - A scan is being done on a foetus which is 34 weeks gestation....

    Incorrect

    • A scan is being done on a foetus which is 34 weeks gestation. The pancreas and its associated ducts are identified.

      What does the pancreatic duct in the foetus become in the adult?

      Your Answer:

      Correct Answer: Ligamentum teres

      Explanation:

      The ligamentum teres in the adult is derived from the umbilical vein in the foetus.

      The Three Embryological Layers and their Corresponding Gastrointestinal Structures and Blood Supply

      The gastrointestinal system is a complex network of organs responsible for the digestion and absorption of nutrients. During embryonic development, the gastrointestinal system is formed from three distinct layers: the foregut, midgut, and hindgut. Each layer gives rise to specific structures and is supplied by a corresponding blood vessel.

      The foregut extends from the mouth to the proximal half of the duodenum and is supplied by the coeliac trunk. The midgut encompasses the distal half of the duodenum to the splenic flexure of the colon and is supplied by the superior mesenteric artery. Lastly, the hindgut includes the descending colon to the rectum and is supplied by the inferior mesenteric artery.

      Understanding the embryological origin and blood supply of the gastrointestinal system is crucial in diagnosing and treating gastrointestinal disorders. By identifying the specific structures and blood vessels involved, healthcare professionals can better target their interventions and improve patient outcomes.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 31 - A 65-year-old patient arrives at the emergency department with persistent watery diarrhea. Upon...

    Incorrect

    • A 65-year-old patient arrives at the emergency department with persistent watery diarrhea. Upon examination, the patient's blood work reveals hypokalemia and an increased level of serum vasoactive intestinal peptide (VIP). The physician informs the patient that the elevated VIP levels in their blood may be the cause of their diarrhea. As a medical student, the patient asks you about the functions of VIP. Can you identify one of its functions?

      Your Answer:

      Correct Answer: Inhibits acid secretion by stimulating somatostatin production

      Explanation:

      VIPoma, also known as Verner-Morrison syndrome, can be diagnosed based on symptoms such as prolonged diarrhea, hypokalemia, dehydration, and elevated levels of VIP. VIP is produced by the small intestines and pancreas and works by stimulating the release of somatostatin, which in turn inhibits acid secretion. On the other hand, gastrin promotes the release of acid from parietal cells. The other answers provided are incorrect.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 32 - A 78-year-old man reports experiencing discomfort behind his breastbone and occasional backflow of...

    Incorrect

    • A 78-year-old man reports experiencing discomfort behind his breastbone and occasional backflow of stomach acid into his mouth, especially after meals and at bedtime, causing sleep disturbance. What is a potential risk factor for GORD?

      Your Answer:

      Correct Answer: Smoking

      Explanation:

      Gastro-Oesophageal Reflux Disease (GORD)

      Gastro-oesophageal reflux disease (GORD) is a chronic condition where stomach acid flows back up into the oesophagus, causing discomfort and increasing the risk of oesophageal cancer. Obesity is a known risk factor for GORD, as excess weight around the abdomen increases pressure in the stomach. Hiatus hernia, which also results from increased intra-abdominal pressure, is also associated with GORD. This is because the widening of the diaphragmatic hiatus in hiatus hernia reduces the effectiveness of the lower oesophageal sphincter in preventing acid reflux.

      Smoking is another risk factor for GORD, although the exact mechanism by which it weakens the lower oesophageal sphincter is not fully understood. Interestingly, male sex does not appear to be associated with GORD. Overall, the risk factors for GORD can help individuals take steps to prevent or manage this chronic condition.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 33 - A 2-year-old boy with no significant medical history is brought to the ER...

    Incorrect

    • A 2-year-old boy with no significant medical history is brought to the ER by his mother due to a week-long crying spell and passing bright red stools. The patient cries loudly upon palpation of the right lower quadrant. Meckel's diverticulum is confirmed through a positive technetium-99m scan. What is the embryological source of this abnormality?

      Your Answer:

      Correct Answer: Omphalomesenteric duct

      Explanation:

      The correct answer is omphalomesenteric duct, which is the precursor to Meckel’s diverticulum. Meckel’s diverticulum is a true diverticulum that forms due to the persistence of this duct and may contain gastric or pancreatic tissue. It is the most common congenital anomaly of the GI tract and can present with various symptoms.

      Auerbach plexus is an incorrect answer. Its absence is associated with Hirschsprung disease or achalasia.

      Fetal umbilical vein is also incorrect. It becomes the ligamentum teres hepatis within the falciform ligament of the liver.

      Pleuroperitoneal membrane is another incorrect answer. A congenital defect in this structure can lead to a left-sided diaphragmatic hernia in infants.

      Meckel’s diverticulum is a congenital diverticulum of the small intestine that is a remnant of the omphalomesenteric duct. It occurs in 2% of the population, is 2 feet from the ileocaecal valve, and is 2 inches long. It is usually asymptomatic but can present with abdominal pain, rectal bleeding, or intestinal obstruction. Investigation includes a Meckel’s scan or mesenteric arteriography. Management involves removal if narrow neck or symptomatic, with options between wedge excision or formal small bowel resection and anastomosis. Meckel’s diverticulum is typically lined by ileal mucosa but ectopic gastric, pancreatic, and jejunal mucosa can also occur.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 34 - A 50-year-old man comes to the clinic with bilateral inguinal hernias. The surgical...

    Incorrect

    • A 50-year-old man comes to the clinic with bilateral inguinal hernias. The surgical team plans to perform a laparoscopic extraperitoneal repair. During the procedure, the surgeons make an infraumbilical incision and move the inferior part of the rectus abdominis muscle forward to insert a prosthetic mesh for hernia repair. What anatomical structure will be located behind the mesh?

      Your Answer:

      Correct Answer: Peritoneum

      Explanation:

      In a TEP repair of inguinal hernia, the peritoneum is the only structure located behind the mesh. The query specifically pertains to the structure situated behind the rectus abdominis muscle. As this area is situated below the arcuate line, the transversalis fascia and peritoneum are positioned behind it.

      The rectus sheath is a structure formed by the aponeuroses of the lateral abdominal wall muscles. Its composition varies depending on the anatomical level. Above the costal margin, the anterior sheath is made up of the external oblique aponeurosis, with the costal cartilages located behind it. From the costal margin to the arcuate line, the anterior rectus sheath is composed of the external oblique aponeurosis and the anterior part of the internal oblique aponeurosis. The posterior rectus sheath is formed by the posterior part of the internal oblique aponeurosis and transversus abdominis. Below the arcuate line, all the abdominal muscle aponeuroses are located in the anterior aspect of the rectus sheath, while the transversalis fascia and peritoneum are located posteriorly. The arcuate line is the point where the inferior epigastric vessels enter the rectus sheath.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 35 - A 36-year-old man who is overweight visits his GP with complaints of heartburn...

    Incorrect

    • A 36-year-old man who is overweight visits his GP with complaints of heartburn and regurgitation that worsen when lying flat. The GP suspects gastroesophageal reflux caused by a hiatus hernia and recommends lifestyle changes to promote weight loss, as well as antacids.

      Where is the opening through which this problem occurs located in the diaphragm?

      Your Answer:

      Correct Answer: T10

      Explanation:

      The level at which the oesophagus passes through the diaphragm is T10, which is also where the oesophageal hiatus is located. When the stomach protrudes through this opening, it is referred to as a hiatus hernia.

      Understanding Diaphragm Apertures

      The diaphragm is a muscle that separates the chest cavity from the abdominal cavity and plays a crucial role in respiration. Diaphragm apertures are openings within this muscle that allow specific structures to pass from the thoracic cavity to the abdominal cavity. The three main apertures are the aortic hiatus at T12, the oesophageal hiatus at T10, and the vena cava foramen at T8. To remember the vertebral levels of these apertures, a useful mnemonic involves counting the total number of letters in the spellings of vena cava (8), oesophagus (10), and aortic hiatus (12).

      In addition to these main apertures, smaller openings in the diaphragm exist in the form of lesser diaphragmatic apertures. These allow much smaller structures to pass through the thoracic cavity into the abdomen across the diaphragm. Examples of lesser diaphragmatic apertures include the left phrenic nerve, small veins, superior epigastric artery, intercostal nerves and vessels, subcostal nerves and vessels, splanchnic nerves, and the sympathetic trunk. Understanding the diaphragm and its apertures is important in the diagnosis and treatment of various medical conditions.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 36 - A 36-year-old male with a history of prolonged NSAID use and gastroesophageal reflux...

    Incorrect

    • A 36-year-old male with a history of prolonged NSAID use and gastroesophageal reflux disease presents to the acute surgical unit complaining of abdominal pain and hematemesis. During an endoscopy to investigate a suspected upper gastrointestinal bleed, a gastric ulcer is discovered on the posterior aspect of the stomach body that has eroded through an artery. Which specific artery is most likely to have been affected?

      Your Answer:

      Correct Answer: Splenic artery

      Explanation:

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

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

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

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      • Gastrointestinal System
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  • Question 37 - A 42-year-old woman experiences repeated episodes of biliary colic. How much bile enters...

    Incorrect

    • A 42-year-old woman experiences repeated episodes of biliary colic. How much bile enters the duodenum in a day, approximately?

      Your Answer:

      Correct Answer: 500 mL

      Explanation:

      The small bowel receives a daily supply of bile ranging from 500 mL to 1.5 L, with the majority of bile salts being reused through the enterohepatic circulation. The contraction of the gallbladder results in a lumenal pressure of around 25 cm water, which can cause severe pain in cases of biliary colic.

      Bile is a liquid that is produced in the liver at a rate of 500ml to 1500mL per day. It is made up of bile salts, bicarbonate, cholesterol, steroids, and water. The flow of bile is regulated by three factors: hepatic secretion, gallbladder contraction, and sphincter of oddi resistance. Bile salts are absorbed in the terminal ileum and are recycled up to six times a day, with over 90% of all bile salts being recycled.

      There are two types of bile salts: primary and secondary. Primary bile salts include cholate and chenodeoxycholate, while secondary bile salts are formed by bacterial action on primary bile salts and include deoxycholate and lithocholate. Deoxycholate is reabsorbed, while lithocholate is insoluble and excreted.

      Gallstones can form when there is an excess of cholesterol in the bile. Bile salts have a detergent action and form micelles, which have a lipid center that transports fats. However, excessive amounts of cholesterol cannot be transported in this way and will precipitate, resulting in the formation of cholesterol-rich gallstones.

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      • Gastrointestinal System
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  • Question 38 - A different patient undergoes a femoral hernia repair and during the operation, the...

    Incorrect

    • A different patient undergoes a femoral hernia repair and during the operation, the surgeon decides to enter the abdominal cavity to resect small bowel. A transverse incision is made two thirds of the way between the umbilicus and the symphysis pubis. Which of the structures listed below will remain intact?

      Your Answer:

      Correct Answer: Posterior lamina of the rectus sheath

      Explanation:

      At this level, the incision is situated beneath the arcuate line and there is a lack of posterior wall in the rectus sheath.

      The rectus sheath is a structure formed by the aponeuroses of the lateral abdominal wall muscles. Its composition varies depending on the anatomical level. Above the costal margin, the anterior sheath is made up of the external oblique aponeurosis, with the costal cartilages located behind it. From the costal margin to the arcuate line, the anterior rectus sheath is composed of the external oblique aponeurosis and the anterior part of the internal oblique aponeurosis. The posterior rectus sheath is formed by the posterior part of the internal oblique aponeurosis and transversus abdominis. Below the arcuate line, all the abdominal muscle aponeuroses are located in the anterior aspect of the rectus sheath, while the transversalis fascia and peritoneum are located posteriorly. The arcuate line is the point where the inferior epigastric vessels enter the rectus sheath.

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      • Gastrointestinal System
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  • Question 39 - A 67-year-old man is brought to the emergency department after a fall and...

    Incorrect

    • A 67-year-old man is brought to the emergency department after a fall and head injury he sustained while walking home. He has a history of multiple similar admissions related to alcohol excess. During his hospital stay, his blood sugar levels remain consistently high and he appears disheveled. There is no significant past medical history.

      What could be the probable reason for the patient's elevated blood glucose levels?

      Your Answer:

      Correct Answer: Destruction of islets of Langerhans cells

      Explanation:

      Chronic pancreatitis can cause diabetes as it destroys the islet of Langerhans cells in the pancreas. This patient has a history of recurrent admissions due to alcohol-related falls, indicating excessive alcohol intake, which is the most common risk factor for chronic pancreatitis. A high sugar diet alone should not consistently elevated blood sugar levels if normal insulin control mechanisms are functioning properly. Gastrointestinal bleeding and the stress response to injury would not immediately raise blood sugar levels. In this case, the patient’s alcohol intake suggests chronic pancreatitis as the cause of elevated blood sugar levels rather than type 2 diabetes mellitus.

      Understanding Chronic Pancreatitis

      Chronic pancreatitis is a condition characterized by inflammation that can affect both the exocrine and endocrine functions of the pancreas. While alcohol excess is the leading cause of this condition, up to 20% of cases are unexplained. Other causes include genetic factors such as cystic fibrosis and haemochromatosis, as well as ductal obstruction due to tumors, stones, and structural abnormalities.

      Symptoms of chronic pancreatitis include pain that worsens 15 to 30 minutes after a meal, steatorrhoea, and diabetes mellitus. Abdominal x-rays and CT scans are used to detect pancreatic calcification, which is present in around 30% of cases. Functional tests such as faecal elastase may also be used to assess exocrine function if imaging is inconclusive.

      Management of chronic pancreatitis involves pancreatic enzyme supplements, analgesia, and antioxidants. While there is limited evidence to support the use of antioxidants, one study suggests that they may be beneficial in early stages of the disease. Overall, understanding the causes and symptoms of chronic pancreatitis is crucial for effective management and treatment.

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      • Gastrointestinal System
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  • Question 40 - A man in his 50s is diagnosed with pernicious anaemia. What is the...

    Incorrect

    • A man in his 50s is diagnosed with pernicious anaemia. What is the probable cause for this condition?

      Your Answer:

      Correct Answer: Autoimmune antibodies to parietal cells

      Explanation:

      The destruction of gastric parietal cells, often due to autoimmune factors, is a primary cause of pernicious anaemia. In some cases, mixed patterns may be present and further diagnostic assessment may be necessary, particularly in instances of bacterial overgrowth.

      Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.

      Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.

      Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.

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      • Gastrointestinal System
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  • Question 41 - A patient with gastric ulcers has been diagnosed with significantly low levels of...

    Incorrect

    • A patient with gastric ulcers has been diagnosed with significantly low levels of somatostatin. The medical consultant suspects that a particular type of cell found in both the pancreas and stomach is affected, leading to the disruption of somatostatin release.

      Which type of cell is impacted in this case?

      Your Answer:

      Correct Answer: D cells

      Explanation:

      Somatostatin is released by D cells found in both the pancreas and stomach. These cells release somatostatin to inhibit the hormone gastrin and reduce gastric secretions. The patient’s low levels of somatostatin may have led to an increase in gastrin secretion and stomach acid, potentially causing gastric ulcers. G cells secrete gastrin, while parietal cells secrete gastric acid. Pancreatic cells is too general of a term and does not specify the specific type of cell responsible for somatostatin production.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 42 - During a left hemicolectomy the sigmoid colon is mobilised. As the bowel is...

    Incorrect

    • During a left hemicolectomy the sigmoid colon is mobilised. As the bowel is retracted medially a vessel is injured, anterior to the colon. Which one of the following is the most likely vessel?

      Your Answer:

      Correct Answer: Gonadal vessels

      Explanation:

      During a right hemicolectomy, the gonadal vessels and ureter are crucial structures located at the posterior aspect that may be vulnerable to injury.

      The Caecum: Location, Relations, and Functions

      The caecum is a part of the colon located in the proximal right colon below the ileocaecal valve. It is an intraperitoneal structure that has posterior relations with the psoas, iliacus, femoral nerve, genitofemoral nerve, and gonadal vessels. Its anterior relations include the greater omentum. The caecum is supplied by the ileocolic artery and its lymphatic drainage is through the mesenteric nodes that accompany the venous drainage.

      The caecum is known for its distensibility, making it the most distensible part of the colon. However, in cases of complete large bowel obstruction with a competent ileocaecal valve, the caecum is the most likely site of eventual perforation. Despite this potential complication, the caecum plays an important role in the digestive system. It is responsible for the absorption of fluids and electrolytes, as well as the fermentation of indigestible carbohydrates. Additionally, the caecum is a site for the growth and proliferation of beneficial bacteria that aid in digestion and immune function.

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      • Gastrointestinal System
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  • Question 43 - A 50-year-old man has metastatic adenocarcinoma of the colon that has spread throughout...

    Incorrect

    • A 50-year-old man has metastatic adenocarcinoma of the colon that has spread throughout his body. Which of the following tumor markers is expected to be elevated?

      Your Answer:

      Correct Answer: Carcinoembryonic antigen

      Explanation:

      Using CEA as a screening tool for colonic cancer is not justifiable. While it is true that CEA levels are elevated in colonic cancer, this is also the case in non-malignant conditions such as cirrhosis and colitis. Additionally, the highest levels of CEA are typically seen in cases of metastatic disease. Therefore, CEA should not be used to monitor colitis patients for the development of colonic cancer. This information is supported by a study published in the BMJ in 2009.

      Diagnosis and Staging of Colorectal Cancer

      Diagnosis of colorectal cancer is typically done through a colonoscopy, which is considered the gold standard as long as it is complete and provides good mucosal visualization. Other options for diagnosis include double-contrast barium enema and CT colonography. Once a malignant diagnosis is made, patients will undergo staging using chest, abdomen, and pelvic CT scans. Patients with rectal cancer will also undergo evaluation of the mesorectum with pelvic MRI scanning. For examination purposes, the Dukes and TNM systems are preferred.

      Tumour Markers in Colorectal Cancer

      Carcinoembryonic antigen (CEA) is the main tumour marker in colorectal cancer. While not all tumours secrete CEA, it is still used as a marker for disease burden and is once again being used routinely in follow-up. However, it is important to note that CEA levels may also be raised in conditions such as IBD.

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      • Gastrointestinal System
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  • Question 44 - A 65-year-old woman presents with microcytic anaemia on routine blood tests. She reports...

    Incorrect

    • A 65-year-old woman presents with microcytic anaemia on routine blood tests. She reports feeling fatigued and experiencing occasional episodes of fresh red blood in her stool. Despite passing stool less frequently, she expresses no concern to her physician. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Rectal cancer

      Explanation:

      Rectal cancer is characterized by symptoms such as passing fresh blood, which distinguishes it from duodenal cancer that presents with upper gastrointestinal bleeding. Inflammatory bowel disease typically includes abdominal pain, fever, and passing bloody stools, and may have more severe presentations, but microcytic anemia is not a common feature. Irritable bowel syndrome does not involve passing bloody stools and is associated with vague symptoms like bloating, backache, and urinary problems. Gastroenteritis is unlikely as it is accompanied by vomiting, diarrhea, and fever, which the patient has not reported.

      Colorectal cancer is a prevalent type of cancer in the UK, ranking third in terms of frequency and second in terms of cancer-related deaths. Every year, approximately 150,000 new cases are diagnosed, and 50,000 people die from the disease. The cancer can occur in different parts of the colon, with the rectum being the most common location, accounting for 40% of cases. The sigmoid colon follows closely, with 30% of cases, while the descending colon has only 5%. The transverse colon has 10% of cases, and the ascending colon and caecum have 15%.

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      • Gastrointestinal System
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  • Question 45 - A 36-year-old male patient visits the surgical clinic with a suspected direct inguinal...

    Incorrect

    • A 36-year-old male patient visits the surgical clinic with a suspected direct inguinal hernia that is likely to pass through Hesselbach's triangle. What structure forms the medial edge of this triangle?

      Your Answer:

      Correct Answer: Rectus abdominis muscle

      Explanation:

      Although of minimal clinical significance, Hesselbach’s triangle is the pathway for direct inguinal hernias, with the rectus muscle serving as its medial boundary.

      Hesselbach’s Triangle and Direct Hernias

      Hesselbach’s triangle is an anatomical region located in the lower abdomen. It is bordered by the epigastric vessels on the superolateral side, the lateral edge of the rectus muscle medially, and the inguinal ligament inferiorly. This triangle is important in the diagnosis and treatment of direct hernias, which pass through this region.

      To better understand the location of direct hernias, it is essential to know the boundaries of Hesselbach’s triangle. The epigastric vessels are located on the upper and outer side of the triangle, while the lateral edge of the rectus muscle is on the inner side. The inguinal ligament forms the lower boundary of the triangle.

      In medical exams, it is common to test the knowledge of Hesselbach’s triangle and its boundaries. Understanding this region is crucial for identifying and treating direct hernias, which can cause discomfort and other complications. By knowing the location of Hesselbach’s triangle, medical professionals can better diagnose and treat patients with direct hernias.

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  • Question 46 - A 50-year-old man with chronic abdominal pain and a known alcohol dependency visits...

    Incorrect

    • A 50-year-old man with chronic abdominal pain and a known alcohol dependency visits his gastroenterologist with a recent onset of diarrhoea. The gastroenterologist plans to conduct an abdominal MRI to assess the functionality of the responsible organ. Before the MRI, a hormone is administered.

      What is the purpose of this hormone?

      Your Answer:

      Correct Answer: Increased pancreatic secretion of bicarbonate

      Explanation:

      The patient in question is likely suffering from chronic pancreatitis due to excessive alcohol consumption. This can lead to poor exocrine pancreatic function and result in diarrhea due to insufficient production of digestive enzymes. To assess pancreatic exocrine function, the patient is undergoing testing with secretin, a hormone that stimulates the secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells, as seen on abdominal MRI.

      Somatostatin, on the other hand, is a hormone that decreases the secretion of endogenous hormones from the pancreas and also reduces the exogenous production of bicarbonate. Therefore, it is not useful in testing pancreatic function.

      Somatostatin also inhibits the secretion of hydrochloric acid from gastric parietal cells and is released from delta cells in the stomach when the pH is low.

      Increased intestinal secretion of bicarbonate is not the primary mechanism for neutralizing gastric acid. It is only supplementary to the pancreatic release of bicarbonate and is stimulated by gastric contents in the duodenum, not by secretin.

      There is no specific hormone that increases pancreatic secretion of insulin and glucagon, but somatostatin can decrease the secretion of both hormones.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 47 - A 75-year-old woman comes to the clinic with a painful lump in her...

    Incorrect

    • A 75-year-old woman comes to the clinic with a painful lump in her right groin. Upon examination, a tender swelling is found below and to the side of the pubic tubercle. It exhibits a cough impulse. What is the probable underlying diagnosis?

      Your Answer:

      Correct Answer: Femoral hernia

      Explanation:

      Although a saphena varix thrombophlebitis can result in a sensitive bulge in the affected area, it typically does not produce a cough impulse.

      Understanding the Femoral Canal

      The femoral canal is a fascial tunnel located at the medial aspect of the femoral sheath. It contains both the femoral artery and femoral vein, with the canal lying medial to the vein. The borders of the femoral canal include the femoral vein laterally, the lacunar ligament medially, the inguinal ligament anteriorly, and the pectineal ligament posteriorly.

      The femoral canal plays a significant role in allowing the femoral vein to expand, which facilitates increased venous return to the lower limbs. However, it can also be a site of femoral hernias, which occur when abdominal contents protrude through the femoral canal. The relatively tight neck of the femoral canal places these hernias at high risk of strangulation, making it important to understand the anatomy and function of this structure. Overall, understanding the femoral canal is crucial for medical professionals in diagnosing and treating potential issues related to this area.

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      • Gastrointestinal System
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  • Question 48 - A 50-year-old man presents with a sudden exacerbation of arthralgia affecting his hands...

    Incorrect

    • A 50-year-old man presents with a sudden exacerbation of arthralgia affecting his hands and wrists. He also complains of feeling excessively fatigued lately. The patient has a medical history of hypertension and type 2 diabetes mellitus. Upon examination, his BMI is found to be 35 kg/m2. Laboratory tests reveal:

      - Na+ 140 mmol/l
      - K+ 4.2 mmol/l
      - Urea 3.8 mmol/l
      - Creatinine 100 µmol/l
      - Plasma glucose 11.8 mmol/l
      - ALT 150 u/l
      - Serum ferritin 2000 ng/ml

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Haemochromatosis

      Explanation:

      Hereditary haemochromatosis is a genetic disorder that affects how the body processes iron. It is inherited in an autosomal recessive pattern. The symptoms in the early stages can be vague and non-specific, such as feeling tired and experiencing joint pain. As the condition progresses, it can lead to chronic liver disease and a condition known as bronze diabetes, which is characterized by iron buildup in the pancreas causing diabetes, and a bronze or grey pigmentation of the skin. Based on the patient’s symptoms of joint pain, elevated ALT levels, and significantly high ferritin levels, it is highly likely that they have haemochromatosis.

      Understanding Haemochromatosis: Symptoms and Complications

      Haemochromatosis is a genetic disorder that affects iron absorption and metabolism, leading to iron accumulation in the body. It is caused by mutations in the HFE gene on both copies of chromosome 6. This disorder is prevalent in people of European descent, with 1 in 10 carrying a mutation in the genes affecting iron metabolism. Early symptoms of haemochromatosis are often non-specific, such as lethargy and arthralgia, and may go unnoticed. However, as the disease progresses, patients may experience fatigue, erectile dysfunction, and skin pigmentation.

      Other complications of haemochromatosis include diabetes mellitus, liver disease, cardiac failure, hypogonadism, and arthritis. While some symptoms are reversible with treatment, such as cardiomyopathy, skin pigmentation, diabetes mellitus, hypogonadotrophic hypogonadism, and arthropathy, liver cirrhosis is irreversible.

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  • Question 49 - You are an FY2 on the gastroenterology ward. A 35-year-old patient being treated...

    Incorrect

    • You are an FY2 on the gastroenterology ward. A 35-year-old patient being treated for Crohn's disease complains of nausea. After considering various anti-emetics, your consultant instructs you to initiate metoclopramide as he believes it will be beneficial in this case due to its distinct mechanism of action.

      What is the unique mechanism of action of metoclopramide as an anti-emetic?

      Your Answer:

      Correct Answer: Blocks dopamine receptors at the CTZ and acts on 5-HT receptors

      Explanation:

      Anti-emetics have different mechanisms of action and are used based on the cause of the patient’s nausea and vomiting. Metoclopramide works by blocking dopamine receptors in the CTZ and acting on 5-HT receptors in the GI tract. On the other hand, 5-HT antagonists like ondansetron block 5-HT3 serotonin receptors in the GI tract, solitary tract nucleus, and CTZ to prevent nausea and vomiting. NK-1 receptor antagonists such as aprepitant reduce substance P to prevent emesis. Somatostatin analogues like octreotide relieve nausea and vomiting caused by bowel obstruction. Vasodilators can produce nitric oxide, which activates guanylyl cyclase and leads to protein kinase G production and subsequent vasodilation.

      Understanding the Mechanism and Uses of Metoclopramide

      Metoclopramide is a medication primarily used to manage nausea, but it also has other uses such as treating gastro-oesophageal reflux disease and gastroparesis secondary to diabetic neuropathy. It is often combined with analgesics for the treatment of migraines. However, it is important to note that metoclopramide has adverse effects such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. It should also be avoided in bowel obstruction but may be helpful in paralytic ileus.

      The mechanism of action of metoclopramide is quite complicated. It is primarily a D2 receptor antagonist, but it also has mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Its antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone, and at higher doses, the 5-HT3 receptor antagonist also has an effect. The gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity.

      In summary, metoclopramide is a medication with multiple uses, but it also has adverse effects that should be considered. Its mechanism of action is complex, involving both D2 receptor antagonist and 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Understanding the uses and mechanism of action of metoclopramide is important for its safe and effective use.

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  • Question 50 - A three-week-old infant is brought to the paediatrician with jaundice that started in...

    Incorrect

    • A three-week-old infant is brought to the paediatrician with jaundice that started in the first week of life. The mother reports that the baby has undergone a week of phototherapy, but there has been no improvement in the yellowing. Additionally, the mother has observed that the baby's urine is dark and stools are pale.

      The baby was born via normal vaginal delivery at 39 weeks' gestation without any complications or injuries noted during birth.

      On examination, the baby appears well and alert, with normal limb movements. Scleral icterus is present, but there is no associated conjunctival pallor. The head examination is unremarkable, and the anterior fontanelle is normotensive.

      An abdominal ultrasound reveals an atretic gallbladder with irregular contours and an indistinct wall, associated with the lack of smooth echogenic mucosal lining.

      What additional findings are likely to be discovered in this infant upon further investigation?

      Your Answer:

      Correct Answer: Conjugated hyperbilirubinaemia

      Explanation:

      The elevated level of conjugated bilirubin in the baby suggests biliary atresia, which is characterized by prolonged neonatal jaundice and obstructive jaundice. The ultrasound scan also shows the gallbladder ghost triad, which is highly specific for biliary atresia. This condition causes post-hepatic obstruction of the biliary tree, resulting in conjugated hyperbilirubinaemia.

      Unconjugated hyperbilirubinaemia may be caused by prehepatic factors such as haemolysis. However, ABO or Rhesus incompatibility between mother and child typically presents within the first few days of life and resolves with phototherapy. The absence of injury and infection in the child makes these causes unlikely.

      A positive direct Coombs test indicates haemolysis, but this is unlikely as the child did not present with conjunctival pallor and other symptoms of haemolytic disease of the newborn. Raised lactate dehydrogenase is also not found in this baby, which further supports the absence of haemolysis.

      Understanding Biliary Atresia in Neonatal Children

      Biliary atresia is a condition that affects neonatal children, causing an obstruction in the flow of bile due to either obliteration or discontinuity within the extrahepatic biliary system. The cause of this condition is not fully understood, but it is believed that infectious agents, congenital malformations, and retained toxins within the bile may contribute to its development. Biliary atresia occurs in 1 in every 10,000-15,000 live births and is more common in females than males.

      There are three types of biliary atresia, with type 3 being the most common, affecting over 90% of cases. Symptoms of biliary atresia typically present in the first few weeks of life and include jaundice, dark urine, pale stools, and appetite and growth disturbance. Diagnosis is made through various tests, including serum bilirubin, liver function tests, and ultrasound of the biliary tree and liver.

      Surgical intervention is the only definitive treatment for biliary atresia, with medical intervention including antibiotic coverage and bile acid enhancers following surgery. Complications of biliary atresia include unsuccessful anastomosis formation, progressive liver disease, cirrhosis, and eventual hepatocellular carcinoma. Prognosis is good if surgery is successful, but in cases where surgery fails, liver transplantation may be required in the first two years of life.

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  • Question 51 - You are working on a general surgical receiving ward when a 70-year-old woman...

    Incorrect

    • You are working on a general surgical receiving ward when a 70-year-old woman is admitted from the emergency department with sudden and severe abdominal pain that radiates to her back. The patient reports that she is normally healthy, but has been struggling with rheumatoid arthritis for the past few years, which is improving with treatment. She does not consume alcohol and has had an open cholecystectomy in the past, although she cannot recall when it occurred.

      Blood tests were conducted in the emergency department:

      - Hb 140 g/L (Male: 135-180, Female: 115-160)
      - Platelets 350 * 109/L (150-400)
      - WBC 12.9 * 109/L (4.0-11.0)
      - Amylase 1200 U/L (70-300)

      Based on the likely diagnosis, what is the most probable cause of this patient's presentation?

      Your Answer:

      Correct Answer: Azathioprine

      Explanation:

      Acute pancreatitis can be caused by azathioprine.

      It is important to note that the symptoms and blood tests suggest acute pancreatitis. The most common causes of this condition are gallstones and alcohol, but these have been ruled out through patient history. Although there is a possibility of retained stones in the common bile duct after cholecystectomy, it is unlikely given the time since the operation.

      Other less common causes include trauma (which is not present in this case) and sodium valproate (which the patient has not been taking).

      Therefore, the most likely cause of acute pancreatitis in this case is azathioprine, an immunosuppressive medication used to treat rheumatoid arthritis, which is known to have a side effect of acute pancreatitis.

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

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      • Gastrointestinal System
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  • Question 52 - A 25-year-old man is suspected of having an inflamed Meckel's diverticulum. Where is...

    Incorrect

    • A 25-year-old man is suspected of having an inflamed Meckel's diverticulum. Where is it most likely to be located?

      Your Answer:

      Correct Answer: Approximately 60 cm proximal to the ileocaecal valve

      Explanation:

      The length of these growths is 2 inches (5cm), and they are twice as common in men. They involve two types of tissue and are located approximately 2 feet (60cm) from the ileocaecal valve.

      Meckel’s diverticulum is a congenital diverticulum of the small intestine that is a remnant of the omphalomesenteric duct. It occurs in 2% of the population, is 2 feet from the ileocaecal valve, and is 2 inches long. It is usually asymptomatic but can present with abdominal pain, rectal bleeding, or intestinal obstruction. Investigation includes a Meckel’s scan or mesenteric arteriography. Management involves removal if narrow neck or symptomatic, with options between wedge excision or formal small bowel resection and anastomosis. Meckel’s diverticulum is typically lined by ileal mucosa but ectopic gastric, pancreatic, and jejunal mucosa can also occur.

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  • Question 53 - A 47-year-old man has a nasogastric tube inserted. The nurse takes a small...

    Incorrect

    • A 47-year-old man has a nasogastric tube inserted. The nurse takes a small aspirate of the fluid from the stomach and tests the pH of the aspirate. What is the typical intragastric pH?

      Your Answer:

      Correct Answer: 2

      Explanation:

      Typically, the pH level in the stomach is 2, but the use of proton pump inhibitors can effectively eliminate acidity.

      Understanding Gastric Secretions for Surgical Procedures

      A basic understanding of gastric secretions is crucial for surgeons, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Gastric acid, produced by the parietal cells in the stomach, has a pH of around 2 and is maintained by the H+/K+ ATPase pump. Sodium and chloride ions are actively secreted from the parietal cell into the canaliculus, creating a negative potential across the membrane. Carbonic anhydrase forms carbonic acid, which dissociates, and the hydrogen ions formed by dissociation leave the cell via the H+/K+ antiporter pump. This leaves hydrogen and chloride ions in the canaliculus, which mix and are secreted into the lumen of the oxyntic gland.

      There are three phases of gastric secretion: the cephalic phase, gastric phase, and intestinal phase. The cephalic phase is stimulated by the smell or taste of food and causes 30% of acid production. The gastric phase, which is caused by stomach distension, low H+, or peptides, causes 60% of acid production. The intestinal phase, which is caused by high acidity, distension, or hypertonic solutions in the duodenum, inhibits gastric acid secretion via enterogastrones and neural reflexes.

      The regulation of gastric acid production involves various factors that increase or decrease production. Factors that increase production include vagal nerve stimulation, gastrin release, and histamine release. Factors that decrease production include somatostatin, cholecystokinin, and secretin. Understanding these factors and their associated pharmacology is essential for surgeons.

      In summary, a working knowledge of gastric secretions is crucial for surgical procedures, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Understanding the phases of gastric secretion and the regulation of gastric acid production is essential for successful surgical outcomes.

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  • Question 54 - A 32-year-old woman presents with a 14-day history of profuse, watery diarrhoea. She...

    Incorrect

    • A 32-year-old woman presents with a 14-day history of profuse, watery diarrhoea. She denies the presence of blood. There is no history of recent travel. The diarrhoea is stopping her from going to work, and so she has been forced to take unpaid leave. She wants to return to work as she is the sole breadwinner for the family.

      On examination, she is apyrexial but looks clinically dehydrated.

      After ruling out infection and inflammatory bowel disease, you prescribe a short course of loperamide to help slow down her bowel movements.

      What is the mechanism of action of the prescribed anti-diarrhoeal medication?

      Your Answer:

      Correct Answer: Agonist of μ-opioid receptors in the myenteric plexus of the large intestine

      Explanation:

      The myenteric plexus of the large intestine’s μ-opioid receptors are targeted by loperamide.

      Antidiarrhoeal Agents: Opioid Agonists

      Antidiarrhoeal agents are medications used to treat diarrhoea. Opioid agonists are a type of antidiarrhoeal agent that work by slowing down the movement of the intestines, which reduces the frequency and urgency of bowel movements. Two common opioid agonists used for this purpose are loperamide and diphenoxylate.

      Loperamide is available over-the-counter and is often used to treat acute diarrhoea. It works by binding to opioid receptors in the intestines, which reduces the contractions of the muscles in the intestinal wall. This slows down the movement of food and waste through the intestines, allowing more time for water to be absorbed and resulting in firmer stools.

      Diphenoxylate is a prescription medication that is often used to treat chronic diarrhoea. It works in a similar way to loperamide, but is often combined with atropine to discourage abuse and overdose.

      Overall, opioid agonists are effective at treating diarrhoea, but should be used with caution and under the guidance of a healthcare professional. They can cause side effects such as constipation, dizziness, and nausea, and may interact with other medications.

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  • Question 55 - A patient with common bile duct obstruction is undergoing an endoscopic retrograde cholangiopancreatography...

    Incorrect

    • A patient with common bile duct obstruction is undergoing an endoscopic retrograde cholangiopancreatography (ERCP). During the procedure, the Ampulla of Vater, a structure that marks the anatomical transition from the foregut to midgut is encountered.

      What two structures combine to form the Ampulla of Vater in a different patient?

      Your Answer:

      Correct Answer: Pancreatic duct and common bile duct

      Explanation:

      The correct anatomy of the biliary and pancreatic ducts is as follows: the common hepatic duct and cystic duct merge to form the common bile duct, which then joins with the pancreatic duct to form the Ampulla of Vater. This structure, also known as the hepatopancreatic duct, enters the second part of the duodenum. The flow of pancreatic enzymes and bile into the duodenum is controlled by the Sphincter of Oddi, a muscular valve also known as Glisson’s sphincter.

      Anatomy of the Pancreas

      The pancreas is located behind the stomach and is a retroperitoneal organ. It can be accessed surgically by dividing the peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head is situated in the curvature of the duodenum, while its tail is close to the hilum of the spleen. The pancreas has various relations with other organs, such as the inferior vena cava, common bile duct, renal veins, superior mesenteric vein and artery, crus of diaphragm, psoas muscle, adrenal gland, kidney, aorta, pylorus, gastroduodenal artery, and splenic hilum.

      The arterial supply of the pancreas is through the pancreaticoduodenal artery for the head and the splenic artery for the rest of the organ. The venous drainage for the head is through the superior mesenteric vein, while the body and tail are drained by the splenic vein. The ampulla of Vater is an important landmark that marks the transition from foregut to midgut and is located halfway along the second part of the duodenum. Overall, understanding the anatomy of the pancreas is crucial for surgical procedures and diagnosing pancreatic diseases.

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  • Question 56 - A patient with moderate gastro-oesophageal reflux disease undergoes upper gastrointestinal endoscopy and biopsy....

    Incorrect

    • A patient with moderate gastro-oesophageal reflux disease undergoes upper gastrointestinal endoscopy and biopsy. Upon examination of the biopsy specimen, the pathologist observes that the original epithelium of the oesophagus (A) has been substituted by a distinct type of epithelium (B) that is typically present in the intestine.

      What is the epithelium (B) that the pathologist is most likely to have identified?

      Your Answer:

      Correct Answer: Columnar epithelium

      Explanation:

      Barrett’s oesophagus is characterized by the replacement of the original stratified squamous epithelium with columnar epithelium, which is typically found lining the intestines. Simple cuboidal epithelium is present in small gland ducts, kidney tubules, and secretory portions. Pseudostratified columnar epithelium is found in the upper respiratory tract and trachea, while stratified squamous epithelium lines areas that experience tension, such as the mouth, oesophagus, and vagina.

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, which increases the risk of oesophageal adenocarcinoma by 50-100 fold. It is usually identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia, as there are no screening programs for it. The length of the affected segment determines the chances of identifying metaplasia, with short (<3 cm) and long (>3 cm) subtypes. The prevalence of Barrett’s oesophagus is estimated to be around 1 in 20, and it is identified in up to 12% of those undergoing endoscopy for reflux.

      The columnar epithelium in Barrett’s oesophagus may resemble that of the cardiac region of the stomach or that of the small intestine, with goblet cells and brush border. The single strongest risk factor for Barrett’s oesophagus is gastro-oesophageal reflux disease (GORD), followed by male gender, smoking, and central obesity. Alcohol is not an independent risk factor for Barrett’s, but it is associated with both GORD and oesophageal cancer. Patients with Barrett’s oesophagus often have coexistent GORD symptoms.

      The management of Barrett’s oesophagus involves high-dose proton pump inhibitor, although the evidence base for its effectiveness in reducing the progression to dysplasia or inducing regression of the lesion is limited. Endoscopic surveillance with biopsies is recommended every 3-5 years for patients with metaplasia but not dysplasia. If dysplasia of any grade is identified, endoscopic intervention is offered, such as radiofrequency ablation, which is the preferred first-line treatment, particularly for low-grade dysplasia, or endoscopic mucosal resection.

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  • Question 57 - A 4-year-old boy is brought to the GP by his mother due to...

    Incorrect

    • A 4-year-old boy is brought to the GP by his mother due to concerns about his growth and weight gain. The mother has noticed that her son is smaller than other children his age and has difficulty putting on weight. Additionally, she has observed that his stools have become pale and greasy, and he frequently experiences bloating. Upon examination, the boy appears underweight and pale, with abdominal distension and muscle wasting in the buttocks. Based on this history and examination, what is the most likely diagnosis?

      Your Answer:

      Correct Answer: Coeliac disease

      Explanation:

      Coeliac disease typically presents in children around the age when they start consuming wheat and cereal, but some individuals may not show symptoms until later in life. It is crucial for healthcare professionals to be able to identify this condition, both in clinical settings and for exams.

      Coeliac Disease in Children: Causes, Symptoms, and Diagnosis

      Coeliac disease is a condition that affects children and is caused by sensitivity to gluten, a protein found in cereals. This sensitivity leads to villous atrophy, which causes malabsorption. Children usually present with symptoms before the age of 3, coinciding with the introduction of cereals into their diet. The incidence of coeliac disease is around 1 in 100, and it is strongly associated with HLA-DQ2 and HLA-DQ8. Symptoms of coeliac disease include failure to thrive, diarrhoea, abdominal distension, and anaemia in older children. However, many cases are not diagnosed until adulthood.

      Diagnosis of coeliac disease involves a jejunal biopsy showing subtotal villous atrophy, as well as screening tests for anti-endomysial and anti-gliadin antibodies. The biopsy shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, as well as dense mixed inflammatory infiltrate in the lamina propria. Another biopsy may show flat mucosa with hyperplastic crypts and dense cellular infiltrate in the lamina propria, as well as an increased number of intraepithelial lymphocytes and vacuolated superficial epithelial cells. Overall, coeliac disease is a serious condition that requires early diagnosis and management to prevent long-term complications.

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  • Question 58 - A 54-year-old male presents to the emergency department with frank haematemesis. He is...

    Incorrect

    • A 54-year-old male presents to the emergency department with frank haematemesis. He is urgently resuscitated and undergoes an urgent oesophagogastroduodenoscopy (OGD), which reveals an active bleed in the distal part of the lesser curvature of the stomach. The bleed is successfully controlled with endoclips and adrenaline. The patient has a history of gastric ulcers. What is the most probable artery responsible for the bleeding?

      Your Answer:

      Correct Answer: Right gastric artery

      Explanation:

      The distal lesser curvature of the stomach is supplied by the right gastric artery, while the proximal lesser curvature is supplied by the left gastric artery. The proximal greater curvature is supplied by the left gastroepiploic artery, and the distal greater curvature is supplied by the right gastroepiploic artery.

      The Gastroduodenal Artery: Supply and Path

      The gastroduodenal artery is responsible for supplying blood to the pylorus, proximal part of the duodenum, and indirectly to the pancreatic head through the anterior and posterior superior pancreaticoduodenal arteries. It commonly arises from the common hepatic artery of the coeliac trunk and terminates by bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery.

      To better understand the relationship of the gastroduodenal artery to the first part of the duodenum, the stomach is reflected superiorly in an image sourced from Wikipedia. This artery plays a crucial role in providing oxygenated blood to the digestive system, ensuring proper functioning and health.

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  • Question 59 - A 30-year-old male pedestrian is struck by a van while on a busy...

    Incorrect

    • A 30-year-old male pedestrian is struck by a van while on a busy road and is transported to the Emergency Department via ambulance. Despite receiving high flow 100% oxygen, he remains dyspneic and hypoxic. His blood pressure is 110/70 mmHg and his pulse rate is 115 bpm. Upon examination, the right side of his chest is hyper-resonant on percussion and has decreased breath sounds. Additionally, the trachea is deviated to the left. What is the most probable underlying diagnosis?

      Your Answer:

      Correct Answer: Tension pneumothorax

      Explanation:

      A flap-like defect on the lung surface caused by chest trauma, whether blunt or penetrating, can lead to a tension pneumothorax. Symptoms may include difficulty breathing, worsening oxygen levels, a hollow sound upon tapping the chest, and the trachea being pushed to one side. The recommended course of action is to perform needle decompression and insert a chest tube.

      Thoracic Trauma: Types and Management

      Thoracic trauma refers to injuries that affect the chest area, including the lungs, heart, and blood vessels. There are several types of thoracic trauma, each with its own set of symptoms and management strategies. Tension pneumothorax, for example, occurs when pressure builds up in the thorax due to a laceration in the lung parenchyma. This condition is often caused by mechanical ventilation in patients with pleural injury. Flail chest, on the other hand, occurs when the chest wall disconnects from the thoracic cage due to multiple rib fractures. This condition is associated with pulmonary contusion and abnormal chest motion.

      Other types of thoracic trauma include pneumothorax, haemothorax, cardiac tamponade, pulmonary contusion, blunt cardiac injury, aorta disruption, diaphragm disruption, and mediastinal traversing wounds. Each of these conditions has its own set of symptoms and management strategies. For example, patients with traumatic pneumothorax should never be mechanically ventilated until a chest drain is inserted. Haemothoraces large enough to appear on CXR are treated with a large bore chest drain, and surgical exploration is warranted if >1500ml blood is drained immediately. In cases of cardiac tamponade, Beck’s triad (elevated venous pressure, reduced arterial pressure, reduced heart sounds) and pulsus paradoxus may be present. Early intubation within an hour is recommended for patients with significant hypoxia due to pulmonary contusion. Overall, prompt and appropriate management of thoracic trauma is crucial for improving patient outcomes.

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  • Question 60 - A 50-year-old female with a history of sickle cell disease arrives at the...

    Incorrect

    • A 50-year-old female with a history of sickle cell disease arrives at the emergency department complaining of severe epigastric pain that extends to her back. The patient displays clinical signs of jaundice. She reports drinking only one small glass of red wine per week and no other alcohol intake. What is the probable reason for acute pancreatitis in this patient?

      Your Answer:

      Correct Answer: Gallstones

      Explanation:

      The leading causes of pancreatitis are gallstones and heavy alcohol use. However, in the case of this patient with sickle cell disease, pigment gallstones are the most probable cause of their acute pancreatitis. Although autoimmune diseases like polyarteritis nodosa can also lead to pancreatitis, it is less common than gallstones. Additionally, the patient’s alcohol consumption is not significant enough to be a likely cause of their condition.

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

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  • Question 61 - A previously healthy woman of 23 years-old presented with acute epigastric pain. On...

    Incorrect

    • A previously healthy woman of 23 years-old presented with acute epigastric pain. On investigations, a largely elevated lipase was discovered with a normal amylase level, and a diagnosis of chronic pancreatitis was made. This patient rarely drinks alcohol, and ultrasonography of the abdomen ruled out gallstones. The results of tests for autoimmune pancreatitis were negative. Twenty days later, imaging tests using magnetic resonance cholangiopancreatography (MRCP) revealed the cause of the chronic pancreatitis.

      What was the most probable reason behind the chronic pancreatitis in this 23-year-old woman?

      Your Answer:

      Correct Answer: Pancreas divisum

      Explanation:

      Pancreas divisum is a condition where the dorsal and ventral buds of the pancreas fail to fuse in a portion of the population. This can lead to chronic pancreatitis due to insufficient drainage of pancreatic secretions through the minor papilla instead of the major papilla. Other causes of chronic pancreatitis include autoimmune pancreatitis and cystic fibrosis, but these have been ruled out in this case as the patient is a previously healthy individual with negative autoimmune antibodies. Acute pancreatitis can be caused by mumps or a Trinidadian scorpion bite.

      Understanding Chronic Pancreatitis

      Chronic pancreatitis is a condition characterized by inflammation that can affect both the exocrine and endocrine functions of the pancreas. While alcohol excess is the leading cause of this condition, up to 20% of cases are unexplained. Other causes include genetic factors such as cystic fibrosis and haemochromatosis, as well as ductal obstruction due to tumors, stones, and structural abnormalities.

      Symptoms of chronic pancreatitis include pain that worsens 15 to 30 minutes after a meal, steatorrhoea, and diabetes mellitus. Abdominal x-rays and CT scans are used to detect pancreatic calcification, which is present in around 30% of cases. Functional tests such as faecal elastase may also be used to assess exocrine function if imaging is inconclusive.

      Management of chronic pancreatitis involves pancreatic enzyme supplements, analgesia, and antioxidants. While there is limited evidence to support the use of antioxidants, one study suggests that they may be beneficial in early stages of the disease. Overall, understanding the causes and symptoms of chronic pancreatitis is crucial for effective management and treatment.

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  • Question 62 - A 45-year-old African American male presents to his physician with complaints of epigastric...

    Incorrect

    • A 45-year-old African American male presents to his physician with complaints of epigastric pain occurring a few hours after eating. He reports experiencing this for several months but denies any weight loss, loss of appetite, or night sweats. He does not smoke or drink alcohol and maintains a healthy diet. He denies excessive use of non-steroidal anti-inflammatory drugs. A Helicobacter pylori stool antigen test comes back negative, and he is prescribed a proton pump inhibitor. After three months, he reports no relief of symptoms and has been experiencing severe diarrhea.

      The patient's special laboratory investigations reveal negative stool ova and parasites, with normal levels of sodium, potassium, bicarbonate, and urea. His creatinine levels are within the normal range, but his fasting serum gastrin levels are significantly elevated at 1200 pg/mL (normal range: 0-125). Additionally, his gastric pH is measured at 1.2, which is lower than the normal range of >2.

      What is the most likely diagnosis for this patient?

      Your Answer:

      Correct Answer: Zollinger- Ellison syndrome

      Explanation:

      Zollinger-Ellison syndrome (ZES) is the most likely diagnosis for the patient due to their persistent epigastric pain, diarrhea, and high levels of serum gastrin, which cannot be explained by peptic ulcer disease alone. ZES is caused by a gastrin-secreting tumor in the pancreas or duodenum, and is often associated with MEN 1. Diagnosis is confirmed by elevated serum gastrin levels at least 10 times the upper limit of normal, reduced gastric pH, and a secretin stimulation test if necessary.

      Carcinoid syndrome is an incorrect diagnosis as it presents with different symptoms such as diarrhea, wheezing, flushing, and valvular lesions due to serotonin secretion.

      Although celiac disease can cause epigastric pain and diarrhea, the elevated gastrin levels make ZES a more likely diagnosis. Celiac disease is diagnosed by measuring levels of anti-TTG and anti-endomysial IgA.

      Gastric carcinoma is unlikely as there are no risk factors, constitutional symptoms, or elevated fasting gastrin levels.

      H. pylori infection has been ruled out by a negative stool antigen test.

      Understanding Zollinger-Ellison Syndrome

      Zollinger-Ellison syndrome is a medical condition that is caused by the overproduction of gastrin, which is usually due to a tumor in the pancreas or duodenum. This condition is often associated with MEN type I syndrome, which affects around 30% of cases. The symptoms of Zollinger-Ellison syndrome include multiple gastroduodenal ulcers, diarrhea, and malabsorption.

      To diagnose Zollinger-Ellison syndrome, doctors typically perform a fasting gastrin level test, which is considered the best screening test. Additionally, a secretin stimulation test may also be performed to confirm the diagnosis. With early diagnosis and treatment, the symptoms of Zollinger-Ellison syndrome can be managed effectively.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 63 - A 32-year-old man visits his GP reporting a recent onset tremor, along with...

    Incorrect

    • A 32-year-old man visits his GP reporting a recent onset tremor, along with difficulties in coordination, slurred speech, and deteriorating handwriting. The patient denies experiencing any weakness, visual impairment, or dizziness. Following a battery of blood tests, the diagnosis of Wilson's disease is confirmed.

      Which region of the brain is typically impacted in this disorder?

      Your Answer:

      Correct Answer: Basal ganglia

      Explanation:

      Wilson’s disease causes elevated copper levels in the body, leading to deposits in various organs, with the basal ganglia in the brain being the most commonly affected. Damage to this structure results in symptoms. Broca’s area in the frontal lobe is involved in language production and is commonly affected in stroke. The midbrain is involved in consciousness and movement, while the motor cortex is involved in planning and executing movement. The ventricles are fluid-filled spaces involved in cerebrospinal fluid movement and formation.

      Understanding Wilson’s Disease

      Wilson’s disease is a genetic disorder that causes excessive copper accumulation in the tissues due to metabolic abnormalities. It is an autosomal recessive disorder caused by a defect in the ATP7B gene located on chromosome 13. Symptoms usually appear between the ages of 10 to 25 years, with children presenting with liver disease and young adults with neurological disease.

      The disease is characterised by excessive copper deposition in the tissues, particularly in the brain, liver, and cornea. This can lead to a range of symptoms, including hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioural problems, asterixis, chorea, dementia, parkinsonism, Kayser-Fleischer rings, renal tubular acidosis, haemolysis, and blue nails.

      To diagnose Wilson’s disease, doctors may perform a slit lamp examination for Kayser-Fleischer rings, measure serum ceruloplasmin and total serum copper (which is often reduced), and check for increased 24-hour urinary copper excretion. Genetic analysis of the ATP7B gene can confirm the diagnosis.

      Treatment for Wilson’s disease typically involves chelating agents such as penicillamine or trientine hydrochloride, which help to remove excess copper from the body. Tetrathiomolybdate is a newer agent that is currently under investigation. With proper management, individuals with Wilson’s disease can lead normal lives.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 64 - A woman in her 50s presents to the emergency department with an upper...

    Incorrect

    • A woman in her 50s presents to the emergency department with an upper gastrointestinal bleed. The coeliac trunk supplies the arterial blood to the upper gastrointestinal tract. However, which gastrointestinal structure receives its primary blood supply from the superior mesenteric artery instead of the coeliac trunk?

      Your Answer:

      Correct Answer: Proximal jejunum

      Explanation:

      The coeliac trunk provides blood supply to the foregut, which includes all structures from the gastro-oesophageal junction to the duodenal-jejunal flexure. However, the superior mesenteric artery’s jejunal branches supply blood to the entire jejunum.

      Branches of the Abdominal Aorta

      The abdominal aorta is a major blood vessel that supplies oxygenated blood to the abdominal organs and lower extremities. It gives rise to several branches that supply blood to various organs and tissues. These branches can be classified into two types: parietal and visceral.

      The parietal branches supply blood to the walls of the abdominal cavity, while the visceral branches supply blood to the abdominal organs. The branches of the abdominal aorta include the inferior phrenic, coeliac, superior mesenteric, middle suprarenal, renal, gonadal, lumbar, inferior mesenteric, median sacral, and common iliac arteries.

      The inferior phrenic artery arises from the upper border of the abdominal aorta and supplies blood to the diaphragm. The coeliac artery supplies blood to the liver, stomach, spleen, and pancreas. The superior mesenteric artery supplies blood to the small intestine, cecum, and ascending colon. The middle suprarenal artery supplies blood to the adrenal gland. The renal arteries supply blood to the kidneys. The gonadal arteries supply blood to the testes or ovaries. The lumbar arteries supply blood to the muscles and skin of the back. The inferior mesenteric artery supplies blood to the descending colon, sigmoid colon, and rectum. The median sacral artery supplies blood to the sacrum and coccyx. The common iliac arteries are the terminal branches of the abdominal aorta and supply blood to the pelvis and lower extremities.

      Understanding the branches of the abdominal aorta is important for diagnosing and treating various medical conditions that affect the abdominal organs and lower extremities.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 65 - A 32-year-old woman undergoes a colonoscopy and a biopsy reveals a malignant tumour...

    Incorrect

    • A 32-year-old woman undergoes a colonoscopy and a biopsy reveals a malignant tumour in her sigmoid colon. Her grandmother died of colorectal cancer at 30-years-old and her father developed endometrial cancer at 40-years-old. Which gene is suspected to be responsible for this condition?

      Your Answer:

      Correct Answer: Mismatch repair genes

      Explanation:

      The patient’s familial background indicates the possibility of Lynch syndrome, given that several of his close relatives developed cancer at a young age. This is supported by the fact that his family has a history of both colorectal cancer, which may indicate a defect in the APC gene, and endometrial cancer, which is also linked to Lynch syndrome. Lynch syndrome is associated with mutations in mismatch repair genes such as MSH2, MLH1, PMS2, and GTBP, which are responsible for identifying and repairing errors that occur during DNA replication, such as insertions and deletions of bases. Mutations in these genes can increase the risk of developing cancers such as colorectal, endometrial, and renal cancer.

      Colorectal cancer can be classified into three types: sporadic, hereditary non-polyposis colorectal carcinoma (HNPCC), and familial adenomatous polyposis (FAP). Sporadic colon cancer is believed to be caused by a series of genetic mutations, including allelic loss of the APC gene, activation of the K-ras oncogene, and deletion of p53 and DCC tumor suppressor genes. HNPCC, which is an autosomal dominant condition, is the most common form of inherited colon cancer. It is caused by mutations in genes involved in DNA mismatch repair, leading to microsatellite instability. The most common genes affected are MSH2 and MLH1. Patients with HNPCC are also at a higher risk of other cancers, such as endometrial cancer. The Amsterdam criteria are sometimes used to aid diagnosis of HNPCC. FAP is a rare autosomal dominant condition that leads to the formation of hundreds of polyps by the age of 30-40 years. It is caused by a mutation in the APC gene. Patients with FAP are also at risk of duodenal tumors. A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma, and epidermoid cysts on the skin. Genetic testing can be done to diagnose HNPCC and FAP, and patients with FAP generally have a total colectomy with ileo-anal pouch formation in their twenties.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 66 - A 75-year-old man is scheduled for a radical prostatectomy to treat prostate gland...

    Incorrect

    • A 75-year-old man is scheduled for a radical prostatectomy to treat prostate gland carcinoma. Which lymph nodes will the tumour primarily drain into?

      Your Answer:

      Correct Answer: Internal iliac

      Explanation:

      The prostate lymphatic drainage goes mainly to the internal iliac nodes, with the sacral nodes also involved.

      Anatomy of the Prostate Gland

      The prostate gland is a small, walnut-shaped gland located below the bladder and separated from the rectum by Denonvilliers fascia. It receives its blood supply from the internal iliac vessels, specifically the inferior vesical artery. The gland has an internal sphincter at its apex, which can be damaged during surgery and result in retrograde ejaculation.

      The prostate gland has four lobes: the posterior lobe, median lobe, and two lateral lobes. It also has an isthmus and three zones: the peripheral zone, central zone, and transition zone. The peripheral zone, which is the subcapsular portion of the posterior prostate, is where most prostate cancers occur.

      The gland is surrounded by various structures, including the pubic symphysis, prostatic venous plexus, Denonvilliers fascia, rectum, ejaculatory ducts, lateral venous plexus, and levator ani. Its lymphatic drainage is to the internal iliac nodes, and its innervation comes from the inferior hypogastric plexus.

      In summary, the prostate gland is a small but important gland in the male reproductive system. Its anatomy includes lobes, zones, and various surrounding structures, and it plays a crucial role in ejaculation and prostate health.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 67 - A 15-year-old girl comes to the hospital complaining of severe right upper quadrant...

    Incorrect

    • A 15-year-old girl comes to the hospital complaining of severe right upper quadrant pain and vomiting that started 4 hours ago. She has a medical history of depression and anemia and is currently taking iron supplements and the combined oral contraceptive pill. Upon examination, she appears confused and has yellow-tinted sclera. Her prothrombin time is 50 seconds, and her blood results show a pH of 7.1, albumin levels of 18g/L, ALT levels of 150 iu/L, ALP levels of 40 umol/L, bilirubin levels of 76 µmol/L, and yGT levels of 115 u/L. Based on these findings, what is the most likely cause of her presentation?

      Your Answer:

      Correct Answer: Paracetamol overdose

      Explanation:

      The most common cause of liver failure in the UK is an overdose of paracetamol. This patient’s symptoms, including vomiting, severe pain in the upper right quadrant, jaundice, confusion, and prolonged prothrombin time, suggest acute liver failure. In this condition, ALT and bilirubin levels are significantly elevated, while yGT and ALP may be normal or elevated. Hypoalbuminemia is also a characteristic feature of acute liver failure.

      Given the patient’s history of depression, her risk of self-harm and suicide attempts is higher than that of the general population. However, acute fatty liver of pregnancy is unlikely to be the cause of her liver failure, as she takes the combined oral contraceptive pill, which reduces the chances of pregnancy.

      Alcohol is also an unlikely cause of her liver failure, as it takes many years of chronic alcohol abuse to develop alcohol-related liver failure, and this patient is very young.

      While testing for hepatitis B antibodies and antigens should be included in the liver screen, paracetamol overdose is a more likely cause of liver failure in the UK.

      Understanding Acute Liver Failure

      Acute liver failure is a condition characterized by the sudden onset of liver dysfunction, which can lead to various complications in the body. The causes of acute liver failure include paracetamol overdose, alcohol, viral hepatitis (usually A or B), and acute fatty liver of pregnancy. The symptoms of acute liver failure include jaundice, raised prothrombin time, hypoalbuminaemia, hepatic encephalopathy, and hepatorenal syndrome. It is important to note that liver function tests may not always accurately reflect the synthetic function of the liver, and it is best to assess the prothrombin time and albumin level to determine the severity of the condition. Understanding acute liver failure is crucial in managing and treating this potentially life-threatening condition.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 68 - A 27-year-old man presents with fatigue and joint pains for the past 8...

    Incorrect

    • A 27-year-old man presents with fatigue and joint pains for the past 8 months. He cannot recall any specific trigger for the symptoms and they have been persistent. During examination, you observe that his skin is quite tanned but no other significant findings are noted.

      The following are his blood test results:

      - Bilirubin: 10 umol/L
      - ALT: 120 IU/L
      - Albumin: 35 g/L
      - Ferritin: 450 mg/mL
      - Transferrin saturation: 70%
      - Random plasma glucose: 17.0 mmol/L

      Afterwards, a genetic test was conducted and returned with positive results. Based on the most probable diagnosis, what is the mode of inheritance for this disease?

      Your Answer:

      Correct Answer: Autosomal recessive

      Explanation:

      The probable condition affecting the patient is hereditary haemochromatosis, which is inherited in an autosomal recessive manner. The presence of iron overload and abnormal liver function tests are indicative of this diagnosis. Additionally, the patient’s elevated blood glucose levels and skin pigmentation changes may suggest the presence of bronze diabetes.

      Understanding Haemochromatosis: Symptoms and Complications

      Haemochromatosis is a genetic disorder that affects iron absorption and metabolism, leading to iron accumulation in the body. It is caused by mutations in the HFE gene on both copies of chromosome 6. This disorder is prevalent in people of European descent, with 1 in 10 carrying a mutation in the genes affecting iron metabolism. Early symptoms of haemochromatosis are often non-specific, such as lethargy and arthralgia, and may go unnoticed. However, as the disease progresses, patients may experience fatigue, erectile dysfunction, and skin pigmentation.

      Other complications of haemochromatosis include diabetes mellitus, liver disease, cardiac failure, hypogonadism, and arthritis. While some symptoms are reversible with treatment, such as cardiomyopathy, skin pigmentation, diabetes mellitus, hypogonadotrophic hypogonadism, and arthropathy, liver cirrhosis is irreversible.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 69 - A 58-year-old male patient visits the gastroenterology clinic complaining of abdominal pain, weight...

    Incorrect

    • A 58-year-old male patient visits the gastroenterology clinic complaining of abdominal pain, weight loss, and diarrhoea for the past 6 months. During gastroscopy, a gastrinoma is discovered in the antrum of his stomach. What is the purpose of the hormone produced by this tumor?

      Your Answer:

      Correct Answer: It increases HCL production and increases gastric motility

      Explanation:

      A tumor that secretes gastrin is known as a gastrinoma, which leads to an increase in both gastrointestinal motility and HCL production. It should be noted that while gastrin does increase gastric motility, it does not have an effect on the secretion of pancreatic fluid. This is instead regulated by hormones such as VIP, CCK, and secretin.

      Overview of Gastrointestinal Hormones

      Gastrointestinal hormones play a crucial role in the digestion and absorption of food. These hormones are secreted by various cells in the stomach and small intestine in response to different stimuli such as the presence of food, pH changes, and neural signals.

      One of the major hormones involved in food digestion is gastrin, which is secreted by G cells in the antrum of the stomach. Gastrin increases acid secretion by gastric parietal cells, stimulates the secretion of pepsinogen and intrinsic factor, and increases gastric motility. Another hormone, cholecystokinin (CCK), is secreted by I cells in the upper small intestine in response to partially digested proteins and triglycerides. CCK increases the secretion of enzyme-rich fluid from the pancreas, contraction of the gallbladder, and relaxation of the sphincter of Oddi. It also decreases gastric emptying and induces satiety.

      Secretin is another hormone secreted by S cells in the upper small intestine in response to acidic chyme and fatty acids. Secretin increases the secretion of bicarbonate-rich fluid from the pancreas and hepatic duct cells, decreases gastric acid secretion, and has a trophic effect on pancreatic acinar cells. Vasoactive intestinal peptide (VIP) is a neural hormone that stimulates secretion by the pancreas and intestines and inhibits acid secretion.

      Finally, somatostatin is secreted by D cells in the pancreas and stomach in response to fat, bile salts, and glucose in the intestinal lumen. Somatostatin decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, and decreases insulin and glucagon secretion. It also inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      In summary, gastrointestinal hormones play a crucial role in regulating the digestive process and maintaining homeostasis in the gastrointestinal tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 70 - A passionate surgical resident attempts his first independent splenectomy. The procedure proves to...

    Incorrect

    • A passionate surgical resident attempts his first independent splenectomy. The procedure proves to be more challenging than expected and the resident places a tube drain in the splenic bed at the conclusion of the surgery. Within the next 24 hours, around 500ml of clear fluid drains into the tube. What is the most probable result of biochemical testing on the fluid?

      Elevated creatinine
      28%
      Elevated triglycerides
      10%
      Elevated glucagon
      9%
      Elevated amylase
      25%
      None of the above
      29%

      During a splenectomy, the tail of the pancreas may be harmed, causing the pancreatic duct to drain into the splenic bed, resulting in an increase in amylase levels. Glucagon is not produced in the pancreatic duct.

      Your Answer:

      Correct Answer: Elevated amylase

      Explanation:

      If the tail of the pancreas is damaged during splenectomy, the pancreatic duct may end up draining into the splenic bed. This can result in an increase in amylase levels, but there will be no secretion of glucagon into the pancreatic duct.

      Understanding the Anatomy of the Spleen

      The spleen is a vital organ in the human body, serving as the largest lymphoid organ. It is located below the 9th-12th ribs and has a clenched fist shape. The spleen is an intraperitoneal organ, and its peritoneal attachments condense at the hilum, where the vessels enter the spleen. The blood supply of the spleen is from the splenic artery, which is derived from the coeliac axis, and the splenic vein, which is joined by the IMV and unites with the SMV.

      The spleen is derived from mesenchymal tissue during embryology. It weighs between 75-150g and has several relations with other organs. The diaphragm is superior to the spleen, while the gastric impression is anterior, the kidney is posterior, and the colon is inferior. The hilum of the spleen is formed by the tail of the pancreas and splenic vessels. The spleen also forms the apex of the lesser sac, which contains short gastric vessels.

      In conclusion, understanding the anatomy of the spleen is crucial in comprehending its functions and the role it plays in the human body. The spleen’s location, weight, and relations with other organs are essential in diagnosing and treating spleen-related conditions.

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      • Gastrointestinal System
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  • Question 71 - A 25-year-old male patient reports experiencing mild jaundice following periods of fasting or...

    Incorrect

    • A 25-year-old male patient reports experiencing mild jaundice following periods of fasting or exercise. Upon examination, his complete blood count and liver function tests appear normal. What is the recommended course of treatment for this individual?

      Your Answer:

      Correct Answer: No treatment required

      Explanation:

      Gilbert Syndrome

      Gilbert syndrome is a common genetic condition that causes mild unconjugated hyperbilirubinemia, resulting in intermittent jaundice without any underlying liver disease or hemolysis. The bilirubin levels are usually less than 6 mg/dL, but most patients exhibit levels of less than 3 mg/dL. The condition is characterized by daily and seasonal variations, and occasionally, bilirubin levels may be normal in some patients. Gilbert syndrome can be triggered by dehydration, fasting, menstrual periods, or stress, such as an intercurrent illness or vigorous exercise. Patients may experience vague abdominal discomfort and fatigue, but these episodes resolve spontaneously, and no treatment is required except supportive care.

      In recent years, Gilbert syndrome is believed to be inherited in an autosomal recessive manner, although there are reports of autosomal dominant inheritance. Despite the mild symptoms, it is essential to understand the condition’s triggers and symptoms to avoid unnecessary medical interventions. Patients with Gilbert syndrome can lead a normal life with proper care and management.

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      • Gastrointestinal System
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  • Question 72 - A 68-year-old man presents with a 6-day history of abdominal pain, nausea, severe...

    Incorrect

    • A 68-year-old man presents with a 6-day history of abdominal pain, nausea, severe diarrhoea, fever, and malaise. He had received treatment for community-acquired pneumonia with ceftriaxone 3 weeks ago which has since resolved. Upon examination, he displays a fever of 38.4°C and abdominal distension and tenderness. Blood tests reveal a raised white cell count, leading to suspicion of Clostridium difficile infection.

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

      Your Answer:

      Correct Answer: Prescribe oral vancomycin

      Explanation:

      The recommended treatment for Clostridium difficile infections is antibiotics, with oral vancomycin being the first line option. IV metronidazole is only used in severe cases and in combination with oral vancomycin. Bezlotoxumab, a monoclonal antibody, may be used to prevent recurrence but is not currently considered cost-effective. Oral clarithromycin is not the preferred antibiotic for this type of infection. Conservative treatment with IV fluids and antipyretics is not appropriate and antibiotics should be administered.

      Clostridium 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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      • Gastrointestinal System
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  • Question 73 - A 78-year-old man is brought to the emergency department after a fall and...

    Incorrect

    • A 78-year-old man is brought to the emergency department after a fall and is diagnosed with self-neglect. He reports experiencing fatigue, paraesthesia in his lower limbs, and overall muscle weakness that is more pronounced in his legs for the past 3 months. He has been finding it difficult to carry out his daily activities, especially cooking, due to his inability to stand for long periods of time.

      What vitamin deficiency is most likely causing his symptoms?

      Your Answer:

      Correct Answer: Vitamin B12

      Explanation:

      Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.

      Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.

      Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 74 - Which of the following suppresses the production of stomach acid? ...

    Incorrect

    • Which of the following suppresses the production of stomach acid?

      Your Answer:

      Correct Answer: Nausea

      Explanation:

      Gastric secretion is suppressed by nausea through the involvement of higher cerebral activity and sympathetic innervation.

      Understanding Gastric Secretions for Surgical Procedures

      A basic understanding of gastric secretions is crucial for surgeons, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Gastric acid, produced by the parietal cells in the stomach, has a pH of around 2 and is maintained by the H+/K+ ATPase pump. Sodium and chloride ions are actively secreted from the parietal cell into the canaliculus, creating a negative potential across the membrane. Carbonic anhydrase forms carbonic acid, which dissociates, and the hydrogen ions formed by dissociation leave the cell via the H+/K+ antiporter pump. This leaves hydrogen and chloride ions in the canaliculus, which mix and are secreted into the lumen of the oxyntic gland.

      There are three phases of gastric secretion: the cephalic phase, gastric phase, and intestinal phase. The cephalic phase is stimulated by the smell or taste of food and causes 30% of acid production. The gastric phase, which is caused by stomach distension, low H+, or peptides, causes 60% of acid production. The intestinal phase, which is caused by high acidity, distension, or hypertonic solutions in the duodenum, inhibits gastric acid secretion via enterogastrones and neural reflexes.

      The regulation of gastric acid production involves various factors that increase or decrease production. Factors that increase production include vagal nerve stimulation, gastrin release, and histamine release. Factors that decrease production include somatostatin, cholecystokinin, and secretin. Understanding these factors and their associated pharmacology is essential for surgeons.

      In summary, a working knowledge of gastric secretions is crucial for surgical procedures, especially when dealing with patients who have undergone acid-lowering procedures or are prescribed anti-secretory drugs. Understanding the phases of gastric secretion and the regulation of gastric acid production is essential for successful surgical outcomes.

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      • Gastrointestinal System
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  • Question 75 - A 40-year-old female comes to the clinic complaining of difficulty swallowing both solid...

    Incorrect

    • A 40-year-old female comes to the clinic complaining of difficulty swallowing both solid and liquid foods for the past 3 months. She denies any hoarseness of voice but reports having had pneumonia a month ago, which resolved with antibiotics. Upon examination, oesophageal manometry reveals absent peristalsis, increased lower sphincter tone, and incomplete relaxation of the lower sphincter during swallowing.

      What is the most probable diagnosis for this patient?

      Your Answer:

      Correct Answer: Achalasia

      Explanation:

      The classic triad for achalasia includes loss of peristalsis, increased lower sphincter tone, and inadequate relaxation of the lower sphincter, which is evident on manometry. Dysphagia for both solid and liquid is also a common symptom of achalasia.

      Unlike achalasia, Barrett’s esophagus does not show any changes on manometry. However, it can be identified through the presence of intestinal metaplasia on endoscopy.

      Diffuse esophageal spasm is a motility disorder that does not affect lower esophageal sphincter pressure and relaxation during swallowing. Instead, manometry reveals repetitive high amplitude contractions.

      Hiatus hernia is typically associated with gastroesophageal reflux disease and does not show any abnormal findings on manometry.

      Understanding Dysphagia and its Causes

      Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the oesophagus, including cancer, oesophagitis, candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, myasthenia gravis, and globus hystericus. These conditions have distinct features that can help in their diagnosis, such as weight loss and anorexia in oesophageal cancer, heartburn in oesophagitis, dysphagia of both liquids and solids in achalasia, and anxiety in globus hystericus. Dysphagia can also be classified as extrinsic, intrinsic, or neurological, depending on the underlying cause.

      To diagnose dysphagia, patients usually undergo an upper GI endoscopy, a full blood count, and fluoroscopic swallowing studies. Additional tests, such as ambulatory oesophageal pH and manometry studies, may be needed for specific conditions. It’s important to note that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. By understanding the causes and features of dysphagia, healthcare professionals can provide timely and appropriate management for their patients.

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      • Gastrointestinal System
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  • Question 76 - Is the presence of liver metastases necessary for the development of carcinoid syndrome?...

    Incorrect

    • Is the presence of liver metastases necessary for the development of carcinoid syndrome?

      The following are true of carcinoid tumours except:

      - When present in the appendix tip and measure less than 2 cm have an excellent prognosis (33%)
      - Even when metastatic disease is present it tends to follow a protracted course (26%)
      - When present in the appendix body tend to present with carcinoid syndrome even when liver metastases are not present (17%)
      - May be imaged using 5 HIAA radionucleotide scanning (12%)
      - Advanced appendiceal carcinoids may require right hemicolectomy (12%)

      Rule of thirds:

      - 1/3 multiple
      - 1/3 small bowel
      - 1/3 metastasize
      - 1/3 second tumour

      Important for me:

      Less important:

      Your Answer:

      Correct Answer: When present in the appendix body tend to present with carcinoid syndrome even when liver metastases are not present

      Explanation:

      The presence of liver metastases is a requirement for the occurrence of carcinoid syndrome. The liver is divided into thirds, with one-third dedicated to multiple tumors, one-third to small bowel involvement, and one-third to metastasis or the development of a secondary tumor.

      Carcinoid tumours are a type of cancer that can cause a condition called carcinoid syndrome. This syndrome typically occurs when the cancer has spread to the liver and releases serotonin into the bloodstream. In some cases, it can also occur with lung carcinoid tumours, as the mediators are not cleared by the liver. The earliest symptom of carcinoid syndrome is often flushing, but it can also cause diarrhoea, bronchospasm, hypotension, and right heart valvular stenosis (or left heart involvement in bronchial carcinoid). Additionally, other molecules such as ACTH and GHRH may be secreted, leading to conditions like Cushing’s syndrome. Pellagra, a rare condition caused by a deficiency in niacin, can also develop as the tumour diverts dietary tryptophan to serotonin.

      To investigate carcinoid syndrome, doctors may perform a urinary 5-HIAA test or a plasma chromogranin A test. Treatment for the condition typically involves somatostatin analogues like octreotide, which can help manage symptoms like diarrhoea. Cyproheptadine may also be used to alleviate diarrhoea. Overall, early detection and treatment of carcinoid tumours can help prevent the development of carcinoid syndrome and improve outcomes for patients.

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      • Gastrointestinal System
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  • Question 77 - A 32-year-old female presents to her GP with complaints of chronic fatigue, bloating,...

    Incorrect

    • A 32-year-old female presents to her GP with complaints of chronic fatigue, bloating, and intermittent diarrhea. She denies any recent changes in her diet, rectal bleeding, or weight loss. Upon physical examination, no abnormalities are detected. Further investigations reveal the following results: Hb 95g/L (Female: 115-160), Platelets 200 * 109/L (150-400), WBC 6.2 * 109/L (4.0-11.0), and raised IgA-tTG serology. What additional test should the GP arrange to confirm the likely diagnosis?

      Your Answer:

      Correct Answer: Endoscopic intestinal biopsy

      Explanation:

      The preferred method for diagnosing coeliac disease is through an endoscopic intestinal biopsy, which is considered the gold standard. This should be performed if there is suspicion of the condition based on serology results. While endomysial antibody testing can be useful, it is more expensive and not as preferred as the biopsy. A stomach biopsy would not be helpful in diagnosing coeliac disease, as the condition affects the cells in the intestine. A skin biopsy would only be necessary if there were skin lesions indicative of dermatitis herpetiformis. Repeating the IgA-tTG serology test is not recommended for diagnosis.

      Investigating Coeliac Disease

      Coeliac disease is a condition caused by sensitivity to gluten, which leads to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis is made through a combination of serology and endoscopic intestinal biopsy, with villous atrophy and immunology typically reversing on a gluten-free diet.

      To investigate coeliac disease, NICE guidelines recommend using tissue transglutaminase (TTG) antibodies (IgA) as the first-choice serology test, along with endomyseal antibody (IgA) and testing for selective IgA deficiency. Anti-gliadin antibody (IgA or IgG) tests are not recommended. The ‘gold standard’ for diagnosis is an endoscopic intestinal biopsy, which should be performed in all suspected cases to confirm or exclude the diagnosis. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Rectal gluten challenge is a less commonly used method.

      In summary, investigating coeliac disease involves a combination of serology and endoscopic intestinal biopsy, with NICE guidelines recommending specific tests and the ‘gold standard’ being an intestinal biopsy. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, and lymphocyte infiltration.

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  • Question 78 - A 25-year-old man comes to the emergency department complaining of abdominal pain and...

    Incorrect

    • A 25-year-old man comes to the emergency department complaining of abdominal pain and vomiting. He reports not having a bowel movement for the past five days.

      His medical history includes a ruptured appendix three years ago. There is no significant medical or family history.

      During the examination, you observe abdominal distension and tinkling bowel sounds.

      An abdominal X-ray shows dilated loops of small bowel.

      What is the leading cause of the probable diagnosis in this scenario?

      Your Answer:

      Correct Answer: Adhesions

      Explanation:

      The leading cause of small bowel obstruction is adhesions, which can occur due to previous abdominal surgery and cause internal surfaces to stick together. An abdominal X-ray showing dilated small bowel loops is a common indicator of this condition. While a hernia can also cause small bowel obstruction, it is less likely in this case due to the patient’s surgical history. Intussusception is rare in adults and more commonly seen in young children. Malignancy is a less common cause of small bowel obstruction, especially in patients without risk factors or demographic factors that suggest a higher likelihood of cancer.

      Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common causes of this condition are adhesions resulting from previous surgeries and hernias. Symptoms include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first imaging test used to diagnose small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early stages of obstruction. Management involves NBM, IV fluids, and a nasogastric tube with free drainage. Conservative management may be effective for some patients, but surgery is often necessary.

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  • Question 79 - A 65-year-old woman visits her GP complaining of altered bowel habit for the...

    Incorrect

    • A 65-year-old woman visits her GP complaining of altered bowel habit for the past 2 months. She denies experiencing melaena or fresh rectal blood. The patient has a medical history of type 2 diabetes mellitus and breast cancer, which has been in remission for 2 years. She consumes 14 units of alcohol per week.

      During abdominal palpation, the liver edge is palpable and nodular, descending below the right costal margin. There is no presence of shifting dullness.

      What is the probable cause of the patient's examination findings?

      Your Answer:

      Correct Answer: Liver metastases

      Explanation:

      If a patient has hepatomegaly and a history of malignancy, it is likely that they have liver metastases. The nodular edge of the liver, along with the patient’s history of breast cancer, is a cause for concern regarding cancer recurrence. Acute alcoholic hepatitis, Budd-Chiari syndrome, and non-alcoholic steatohepatitis are less likely causes in this scenario.

      Understanding Hepatomegaly and Its Common Causes

      Hepatomegaly refers to an enlarged liver, which can be caused by various factors. One of the most common causes is cirrhosis, which can lead to a decrease in liver size in later stages. In this case, the liver is non-tender and firm. Malignancy, such as metastatic spread or primary hepatoma, can also cause hepatomegaly. In this case, the liver edge is hard and irregular. Right heart failure can also lead to an enlarged liver, which is firm, smooth, and tender. It may even be pulsatile.

      Aside from these common causes, hepatomegaly can also be caused by viral hepatitis, glandular fever, malaria, abscess (pyogenic or amoebic), hydatid disease, haematological malignancies, haemochromatosis, primary biliary cirrhosis, sarcoidosis, and amyloidosis.

      Understanding the causes of hepatomegaly is important in diagnosing and treating the underlying condition. Proper diagnosis and treatment can help prevent further complications and improve overall health.

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  • Question 80 - A 67-year-old female is hospitalized with acute pancreatitis. What factor would indicate a...

    Incorrect

    • A 67-year-old female is hospitalized with acute pancreatitis. What factor would indicate a poor prognosis?

      Your Answer:

      Correct Answer: Glucose 15.8mmol/l

      Explanation:

      The Glasgow Prognostic Score is a useful tool for assessing the severity of acute pancreatitis. If three or more of the following criteria are present within the first 48 hours, it is likely that the patient is experiencing severe pancreatitis and should be referred to the High Dependency Unit or Intensive Care Unit. Conversely, if the score is less than three, severe pancreatitis is unlikely. The criteria include: age over 55 years, white blood cell count over 15 x 109/L, urea over 16 mmol/L, glucose over 10 mmol/L, pO2 less than 8 kPa (60 mm Hg), albumin less than 32 g/L, calcium less than 2 mmol/L, LDH over 600 units/L, and AST/ALT over 200 units. Based on these criteria, the only option that meets the threshold for severe pancreatitis is a glucose level of 15.8 mmol/L.

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

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  • Question 81 - A 7-year-old girl with Down Syndrome is brought to the pediatrician by her...

    Incorrect

    • A 7-year-old girl with Down Syndrome is brought to the pediatrician by her father. She has been complaining of intermittent abdominal pain for the past few months. During the physical examination, the doctor finds a soft, non-tender abdomen. Additionally, the girl has been experiencing episodes of diarrhea and has a vesicular rash on her leg.

      Hemoglobin: 120 g/L (normal range for females: 115-160 g/L)
      Mean Corpuscular Volume (MCV): 75 fL (normal range: 78-100 fL)
      Platelet count: 320 * 109/L (normal range: 150-400 * 109/L)
      White Blood Cell count (WBC): 9.8 * 109/L (normal range: 4.0-11.0 * 109/L)

      Based on the likely diagnosis, what is the underlying pathophysiological cause of this girl's anemia?

      Your Answer:

      Correct Answer: Villous atrophy affecting the distal duodenum

      Explanation:

      Coeliac disease leads to malabsorption as a result of villous atrophy in the distal duodenum. This case exhibits typical symptoms of coeliac disease, including iron deficiency anaemia, abdominal pain, and diarrhoea. The presence of a vesicular rash on the skin indicates dermatitis herpetiformis, a skin manifestation of coeliac disease. The patient’s Down syndrome also increases the risk of developing this condition. Macrophages invading the intestinal wall is an incorrect answer as lymphocytic infiltration is involved in the pathogenesis of coeliac disease. Pancreatic insufficiency is also an unlikely diagnosis as it typically causes malabsorption of fat-soluble vitamins and Vitamin B12, which is not evident in this case. Villous atrophy affecting the proximal colon is also incorrect as the small intestine is responsible for nutrient absorption in the body.

      Understanding Coeliac Disease

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

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

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

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

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  • Question 82 - A 42-year-old woman has a laparoscopic cholecystectomy as a daycase, but the surgery...

    Incorrect

    • A 42-year-old woman has a laparoscopic cholecystectomy as a daycase, but the surgery proves to be more challenging than expected. As a result, the surgeon inserts a drain to the liver bed. During recovery, 1.5 litres of blood is observed to enter the drain. What is the initial substance to be released in this scenario?

      Your Answer:

      Correct Answer: Renin

      Explanation:

      Renin secretion is triggered by the juxtaglomerular cells in the kidney sensing a decrease in blood pressure.

      Shock is a condition where there is not enough blood flow to the tissues. There are five main types of shock: septic, haemorrhagic, neurogenic, cardiogenic, and anaphylactic. Septic shock is caused by an infection that triggers a particular response in the body. Haemorrhagic shock is caused by blood loss, and there are four classes of haemorrhagic shock based on the amount of blood loss and associated symptoms. Neurogenic shock occurs when there is a disruption in the autonomic nervous system, leading to decreased vascular resistance and decreased cardiac output. Cardiogenic shock is caused by heart disease or direct myocardial trauma. Anaphylactic shock is a severe, life-threatening allergic reaction. Adrenaline is the most important drug in treating anaphylaxis and should be given as soon as possible.

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  • Question 83 - A 65-year-old man is scheduled for a splenectomy. What is the most posteriorly...

    Incorrect

    • A 65-year-old man is scheduled for a splenectomy. What is the most posteriorly located structure of the spleen?

      Your Answer:

      Correct Answer: Lienorenal ligament

      Explanation:

      The phrenicocolic ligament provides the antero-lateral connection, while the gastro splenic ligament is located anteriorly to the lienorenal ligament. These ligaments converge around the vessels at the splenic hilum, with the lienorenal ligament being the most posterior.

      Understanding the Anatomy of the Spleen

      The spleen is a vital organ in the human body, serving as the largest lymphoid organ. It is located below the 9th-12th ribs and has a clenched fist shape. The spleen is an intraperitoneal organ, and its peritoneal attachments condense at the hilum, where the vessels enter the spleen. The blood supply of the spleen is from the splenic artery, which is derived from the coeliac axis, and the splenic vein, which is joined by the IMV and unites with the SMV.

      The spleen is derived from mesenchymal tissue during embryology. It weighs between 75-150g and has several relations with other organs. The diaphragm is superior to the spleen, while the gastric impression is anterior, the kidney is posterior, and the colon is inferior. The hilum of the spleen is formed by the tail of the pancreas and splenic vessels. The spleen also forms the apex of the lesser sac, which contains short gastric vessels.

      In conclusion, understanding the anatomy of the spleen is crucial in comprehending its functions and the role it plays in the human body. The spleen’s location, weight, and relations with other organs are essential in diagnosing and treating spleen-related conditions.

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  • Question 84 - A 35-year-old patient with consistent PR bleeding is diagnosed with Crohn's disease. What...

    Incorrect

    • A 35-year-old patient with consistent PR bleeding is diagnosed with Crohn's disease. What is the primary medication used to induce remission of this condition?

      Your Answer:

      Correct Answer: Prednisolone

      Explanation:

      To induce remission of Crohn’s disease, glucocorticoids (whether oral, topical or intravenous) are typically the first line of treatment. 5-ASA drugs are considered a second option for inducing remission of IBD. Azathioprine is more commonly used for maintaining remission. Steroids are specifically used to induce remission of Crohn’s disease. Infliximab is particularly effective for treating refractory disease and fistulating Crohn’s.

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.

      To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.

      Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.

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  • Question 85 - A 46-year-old male has presented with bruises on his legs. He also reports...

    Incorrect

    • A 46-year-old male has presented with bruises on his legs. He also reports that he bleeds excessively whenever he gets a cut on his limbs. He has a past medical history of familial hypercholesterolaemia. His body mass index is 31 kg/m2. He does not have a medical history of bleeding disorders and denies a family history of haemophilia.

      During his last visit, his lipid profile showed elevated total cholesterol, elevated LDL and low HDL. He was prescribed a medication to help lower his LDL cholesterol.

      What medication was he most likely prescribed?

      Your Answer:

      Correct Answer: Cholestyramine

      Explanation:

      Cholestyramine has the potential to decrease the absorption of fat-soluble vitamins, including vitamin A, D, E, and K. Vitamin K is particularly important for the production of clotting factors II, VII, IX, and X, and a deficiency in this vitamin can result in clotting abnormalities.

      Clomiphene is a medication used to stimulate ovulation in women with polycystic ovary syndrome (PCOS), and it is not linked to an elevated risk of bleeding.

      Psyllium husk is not known to cause any bleeding disorders.

      Cholestyramine: A Medication for Managing High Cholesterol

      Cholestyramine is a medication used to manage high levels of cholesterol in the body. It works by reducing the reabsorption of bile acid in the small intestine, which leads to an increase in the conversion of cholesterol to bile acid. This medication is particularly effective in reducing LDL cholesterol levels. In addition to its use in managing hyperlipidaemia, cholestyramine is also sometimes used to treat diarrhoea following bowel resection in patients with Crohn’s disease.

      However, cholestyramine is not without its adverse effects. Some patients may experience abdominal cramps and constipation while taking this medication. It can also decrease the absorption of fat-soluble vitamins, which can lead to deficiencies if not properly managed. Additionally, cholestyramine may increase the risk of developing cholesterol gallstones and raise the level of triglycerides in the blood. Therefore, it is important for patients to discuss the potential benefits and risks of cholestyramine with their healthcare provider before starting this medication.

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  • Question 86 - A 65-year-old obese male presents with recurrent episodes of colicky pain and bloating...

    Incorrect

    • A 65-year-old obese male presents with recurrent episodes of colicky pain and bloating in the left iliac fossa. The patient has no significant medical history but has been a smoker for 25 years and does not consume alcohol. He works at a fast-food restaurant and usually eats his meals there.

      Upon examination, the patient's vital signs are stable with a temperature of 37ºC, respiratory rate of 14 breaths per minute, oxygen saturations of 99% on air, heart rate of 60 beats per minute, and blood pressure of 125/70 mmHg. Abdominal and digital rectal examination reveal no significant findings. A colonoscopy was subsequently performed, which revealed multiple diverticula along the sigmoid colon.

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

      Your Answer:

      Correct Answer: Encourage high-fibre diet

      Explanation:

      The development of intestinal diverticula is strongly linked to a low fibre diet, making it a major risk factor. To manage mild symptoms, patients are advised to modify their diet by gradually increasing fibre intake over several weeks and staying hydrated.

      IV antibiotics and fluids are not necessary for diverticular disease, as it is not the same as diverticulitis.

      Surgery is not recommended for uncomplicated diverticular disease.

      While encouraging smoking cessation is important, dietary modification is the most suitable option for this patient.

      Diverticulosis is a common condition where multiple outpouchings occur in the bowel wall, typically in the sigmoid colon. It is more accurate to use the term diverticulosis when referring to the presence of diverticula, while diverticular disease is reserved for symptomatic patients. Risk factors for this condition include a low-fibre diet and increasing age. Symptoms of diverticulosis can include altered bowel habits and colicky left-sided abdominal pain. A high-fibre diet is often recommended to alleviate these symptoms.

      Diverticulitis is a complication of diverticulosis where one of the diverticula becomes infected. The typical presentation includes left iliac fossa pain and tenderness, anorexia, nausea, vomiting, diarrhea, and signs of infection such as pyrexia, raised WBC, and CRP. Mild attacks can be treated with oral antibiotics, while more severe episodes require hospitalization. Treatment involves nil by mouth, intravenous fluids, and intravenous antibiotics such as a cephalosporin and metronidazole. Complications of diverticulitis include abscess formation, peritonitis, obstruction, and perforation.

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  • Question 87 - A 54-year-old African American male is being consented for an endoscopic retrograde cholangiopancreatography...

    Incorrect

    • A 54-year-old African American male is being consented for an endoscopic retrograde cholangiopancreatography (ERCP). He is very anxious about the procedure and requests for more information about the common complications of ERCP. He is concerned about peritonitis, which usually occurs secondary to a perforation of the bowel - a rare complication of ERCP. You reassure him that perforation of the bowel, although a very serious complication, is uncommon. However, they are other more common complications of ERCP that he should be aware of.

      What is the most common complication of ERCP?

      Your Answer:

      Correct Answer: Acute pancreatitis

      Explanation:

      The most frequent complication of ERCP is acute pancreatitis, which occurs when the X-ray contrast material or cannula irritates the pancreatic duct. While other complications may arise from ERCP, they are not as prevalent as acute pancreatitis.

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

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      • Gastrointestinal System
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  • Question 88 - A 68-year-old male visits his doctor complaining of persistent fatigue over the past...

    Incorrect

    • A 68-year-old male visits his doctor complaining of persistent fatigue over the past few months. He mentions experiencing confusion and difficulty focusing on tasks that were once effortless. Additionally, he has noticed a tingling sensation in the toes of both feet.

      After conducting blood tests, the doctor discovers that the patient has macrocytic anemia. The doctor suspects that the patient may be suffering from pernicious anemia.

      What is the pathophysiology of this condition?

      Your Answer:

      Correct Answer: Autoimmune destruction of parietal cells in the stomach

      Explanation:

      Pernicious anaemia is a result of autoimmune destruction of parietal cells, which leads to the formation of autoantibodies against intrinsic factor. This results in decreased absorption of vitamin B12 and subsequently causes macrocytic anaemia. Coeliac disease, on the other hand, is caused by autoimmune destruction of the intestinal epithelium following gluten ingestion, leading to severe malabsorption and changes in bowel habits. Crohn’s disease involves autoimmune granulomatous inflammation of the intestinal epithelium, causing ulcer formation and malabsorption, but it does not cause pernicious anaemia. While GI blood loss may cause anaemia, it is more likely to result in normocytic or microcytic anaemia, such as iron deficient anaemia, and not pernicious anaemia.

      Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.

      Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.

      Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.

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  • Question 89 - Which of the following illnesses is not regarded as a risk factor for...

    Incorrect

    • Which of the following illnesses is not regarded as a risk factor for stomach cancer?

      Your Answer:

      Correct Answer: Long term therapy with H2 blockers

      Explanation:

      Currently, the use of H2 blockers does not appear to increase the risk of gastric cancer, unlike certain acid lowering procedures that do.

      Gastric cancer is a relatively uncommon type of cancer, accounting for only 2% of all cancer diagnoses in developed countries. It is more prevalent in older individuals, with half of patients being over the age of 75, and is more common in males than females. Several risk factors have been identified, including Helicobacter pylori infection, atrophic gastritis, certain dietary habits, smoking, and blood group. Symptoms of gastric cancer can include abdominal pain, weight loss, nausea, vomiting, and dysphagia. In some cases, lymphatic spread may result in the appearance of nodules in the left supraclavicular lymph node or periumbilical area. Diagnosis is typically made through oesophago-gastro-duodenoscopy with biopsy, and staging is done using CT. Treatment options depend on the extent and location of the cancer and may include endoscopic mucosal resection, partial or total gastrectomy, and chemotherapy.

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  • Question 90 - An older gentleman was discovered to have an asymptomatic midline abdominal mass. What...

    Incorrect

    • An older gentleman was discovered to have an asymptomatic midline abdominal mass. What physical feature during examination would suggest a diagnosis of an abdominal aortic aneurysm (AAA)?

      Your Answer:

      Correct Answer: Expansile

      Explanation:

      Abdominal Aortic Aneurysm:
      An abdominal aortic aneurysm (AAA) is frequently found incidentally in men, particularly in older age groups. As a result, ultrasound screening has been introduced in many areas to detect this condition. However, the diagnosis of AAA cannot be made based on pulsatility alone, as it is common for pulsations to be transmitted by the organs that lie over the aorta. Instead, an AAA is characterized by its expansile nature. If a tender, pulsatile swelling is present, it may indicate a perforated AAA, which is a medical emergency. Therefore, it is important for men to undergo regular screening for AAA to detect and manage this condition early.

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  • Question 91 - A 68-year-old man presents with an abdominal aortic aneurysm that causes displacement of...

    Incorrect

    • A 68-year-old man presents with an abdominal aortic aneurysm that causes displacement of the left renal vein. At this level, which branch of the aorta is most likely to be affected?

      Your Answer:

      Correct Answer: Superior mesenteric artery

      Explanation:

      The left renal vein is situated posterior to the SMA at its point of origin from the aorta. In cases of juxtarenal AAA, separation of the left renal vein may be necessary, but if the SMA is directly affected, a combination of surgical bypass and endovascular occlusion may be required.

      Branches of the Abdominal Aorta

      The abdominal aorta is a major blood vessel that supplies oxygenated blood to the abdominal organs and lower extremities. It gives rise to several branches that supply blood to various organs and tissues. These branches can be classified into two types: parietal and visceral.

      The parietal branches supply blood to the walls of the abdominal cavity, while the visceral branches supply blood to the abdominal organs. The branches of the abdominal aorta include the inferior phrenic, coeliac, superior mesenteric, middle suprarenal, renal, gonadal, lumbar, inferior mesenteric, median sacral, and common iliac arteries.

      The inferior phrenic artery arises from the upper border of the abdominal aorta and supplies blood to the diaphragm. The coeliac artery supplies blood to the liver, stomach, spleen, and pancreas. The superior mesenteric artery supplies blood to the small intestine, cecum, and ascending colon. The middle suprarenal artery supplies blood to the adrenal gland. The renal arteries supply blood to the kidneys. The gonadal arteries supply blood to the testes or ovaries. The lumbar arteries supply blood to the muscles and skin of the back. The inferior mesenteric artery supplies blood to the descending colon, sigmoid colon, and rectum. The median sacral artery supplies blood to the sacrum and coccyx. The common iliac arteries are the terminal branches of the abdominal aorta and supply blood to the pelvis and lower extremities.

      Understanding the branches of the abdominal aorta is important for diagnosing and treating various medical conditions that affect the abdominal organs and lower extremities.

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  • Question 92 - A 30-year-old man presents with an inguinal hernia. What structure needs to be...

    Incorrect

    • A 30-year-old man presents with an inguinal hernia. What structure needs to be divided during open surgery to access the inguinal canal?

      Your Answer:

      Correct Answer: External oblique aponeurosis

      Explanation:

      What forms the front wall of the inguinal canal? The external oblique aponeurosis forms the front wall. To access the canal and perform a hernia repair, the aponeurosis is divided. The posterior wall is made up of the transversalis fascia and conjoint tendons, which are not typically cut to gain entry to the inguinal canal.

      The External Oblique Muscle: Anatomy and Function

      The external oblique muscle is one of the three muscles that make up the anterolateral aspect of the abdominal wall. It is the outermost muscle and plays an important role in supporting the abdominal viscera. The muscle originates from the outer surfaces of the lowest eight ribs and inserts into the anterior two-thirds of the outer lip of the iliac crest. The remaining portion of the muscle becomes the aponeurosis, which fuses with the linea alba in the midline.

      The external oblique muscle is innervated by the ventral rami of the lower six thoracic nerves. Its main function is to contain the abdominal viscera and raise intra-abdominal pressure. Additionally, it can move the trunk to one side. The aponeurosis of the external oblique muscle also forms the anterior wall of the inguinal canal, which is an important anatomical landmark in the groin region.

      Overall, the external oblique muscle is a crucial component of the abdominal wall and plays an important role in maintaining the integrity of the abdominal cavity. Its unique anatomy and function make it an important muscle for both movement and protection of the internal organs.

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      • Gastrointestinal System
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  • Question 93 - As a fourth year medical student, you are observing a morning colonoscopy list...

    Incorrect

    • As a fourth year medical student, you are observing a morning colonoscopy list at the hospital. You come across patients who have been referred for imaging due to specific symptoms like rectal bleeding, as well as those who are undergoing routine annual colonoscopies. You are aware that most cases of colorectal cancer are sporadic, with no known genetic predisposition in patients. However, there are also certain genetic mutations that require patients to undergo colonoscopy screening for the development of colorectal cancer.

      Can you provide examples of such genetic mutations?

      Your Answer:

      Correct Answer: FAP and HNPCC

      Explanation:

      Colorectal cancer can be classified into three types: sporadic, hereditary non-polyposis colorectal carcinoma (HNPCC), and familial adenomatous polyposis (FAP). Sporadic colon cancer is believed to be caused by a series of genetic mutations, including allelic loss of the APC gene, activation of the K-ras oncogene, and deletion of p53 and DCC tumor suppressor genes. HNPCC, which is an autosomal dominant condition, is the most common form of inherited colon cancer. It is caused by mutations in genes involved in DNA mismatch repair, leading to microsatellite instability. The most common genes affected are MSH2 and MLH1. Patients with HNPCC are also at a higher risk of other cancers, such as endometrial cancer. The Amsterdam criteria are sometimes used to aid diagnosis of HNPCC. FAP is a rare autosomal dominant condition that leads to the formation of hundreds of polyps by the age of 30-40 years. It is caused by a mutation in the APC gene. Patients with FAP are also at risk of duodenal tumors. A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma, and epidermoid cysts on the skin. Genetic testing can be done to diagnose HNPCC and FAP, and patients with FAP generally have a total colectomy with ileo-anal pouch formation in their twenties.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 94 - An 80-year-old male with Parkinson's disease (PD) arrives at the emergency department with...

    Incorrect

    • An 80-year-old male with Parkinson's disease (PD) arrives at the emergency department with sudden chest pain, indicating a possible heart attack. What treatment should be avoided in the management of this patient?

      Your Answer:

      Correct Answer: Metoclopramide

      Explanation:

      Metoclopramide should not be given to patients with Parkinsonism due to its dopamine antagonist properties which can worsen the symptoms of the disease. However, it can be prescribed as an antiemetic when administering morphine to ACS patients who are not contraindicated. Oxygen is safe for PD patients, while clopidogrel is used for its antiplatelet effects.

      Understanding the Mechanism and Uses of Metoclopramide

      Metoclopramide is a medication primarily used to manage nausea, but it also has other uses such as treating gastro-oesophageal reflux disease and gastroparesis secondary to diabetic neuropathy. It is often combined with analgesics for the treatment of migraines. However, it is important to note that metoclopramide has adverse effects such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. It should also be avoided in bowel obstruction but may be helpful in paralytic ileus.

      The mechanism of action of metoclopramide is quite complicated. It is primarily a D2 receptor antagonist, but it also has mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Its antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone, and at higher doses, the 5-HT3 receptor antagonist also has an effect. The gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity.

      In summary, metoclopramide is a medication with multiple uses, but it also has adverse effects that should be considered. Its mechanism of action is complex, involving both D2 receptor antagonist and 5-HT3 receptor antagonist/5-HT4 receptor agonist activity. Understanding the uses and mechanism of action of metoclopramide is important for its safe and effective use.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 95 - A 58-year-old man with a history of multiple emergency department admissions for alcohol-related...

    Incorrect

    • A 58-year-old man with a history of multiple emergency department admissions for alcohol-related injuries and admissions under the general medical team for alcohol withdrawal is admitted after a twelve-day drinking binge. He presents with confusion, icterus, and hepatomegaly, with stigmata of chronic liver disease. Upon admission, his blood work shows thrombocytopenia, transaminitis with hyperbilirubinemia, and a severe coagulopathy. The diagnosis is severe acute alcoholic hepatitis. In liver disease-associated coagulopathy, which clotting factor is typically increased?

      Your Answer:

      Correct Answer: Factor VIII

      Explanation:

      Coagulopathy in Liver Disease: Paradoxical Supra-normal Factor VIII and Increased Thrombosis Risk

      In liver failure, the levels of all clotting factors decrease except for factor VIII, which paradoxically increases. This is because factor VIII is synthesized in endothelial cells throughout the body, unlike other clotting factors that are synthesized only in hepatic endothelial cells. Additionally, good hepatic function is required for the rapid clearance of activated factor VIII from the bloodstream, leading to further increases in circulating factor VIII. Despite conventional coagulation studies suggesting an increased risk of bleeding, patients with chronic liver disease are paradoxically at an increased risk of thrombosis formation. This is due to several factors, including reduced synthesis of natural anticoagulants such as protein C, protein S, and antithrombin, which are all decreased in chronic liver disease.

      Reference:
      Tripodi et al. An imbalance of pro- vs anticoagulation factors in plasma from patients with cirrhosis. Gastroenterology. 2009 Dec;137(6):2105-11.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 96 - A 58-year-old woman diagnosed with squamous cell carcinoma of the anus is preparing...

    Incorrect

    • A 58-year-old woman diagnosed with squamous cell carcinoma of the anus is preparing for an abdominoperineal resection (APR). This surgical procedure involves the complete removal of the distal colon, rectum, and anal sphincter complex through both anterior abdominal and perineal incisions, resulting in a permanent colostomy. During the process, several arteries are ligated, including the one that supplies the anal canal below the levator ani. Can you identify the name of this artery and its branching point?

      Your Answer:

      Correct Answer: Inferior rectal artery - a branches of internal pudendal artery

      Explanation:

      The internal pudendal artery gives rise to the inferior rectal artery, which supplies the muscle and skin of the anal and urogenital triangle. The superior rectal artery, on the other hand, supplies the sigmoid mesocolon and not the lower part of the anal canal. The middle rectal artery is a branch of the internal pudendal artery and not the deep external pudendal artery, making the fifth option incorrect.

      Anatomy of the Rectum

      The rectum is a capacitance organ that measures approximately 12 cm in length. It consists of both intra and extraperitoneal components, with the transition from the sigmoid colon marked by the disappearance of the tenia coli. The extra peritoneal rectum is surrounded by mesorectal fat that contains lymph nodes, which are removed during rectal cancer surgery. The fascial layers that surround the rectum are important clinical landmarks, with the fascia of Denonvilliers located anteriorly and Waldeyers fascia located posteriorly.

      In males, the rectum is adjacent to the rectovesical pouch, bladder, prostate, and seminal vesicles, while in females, it is adjacent to the recto-uterine pouch (Douglas), cervix, and vaginal wall. Posteriorly, the rectum is in contact with the sacrum, coccyx, and middle sacral artery, while laterally, it is adjacent to the levator ani and coccygeus muscles.

      The superior rectal artery supplies blood to the rectum, while the superior rectal vein drains it. Mesorectal lymph nodes located superior to the dentate line drain into the internal iliac and then para-aortic nodes, while those located inferior to the dentate line drain into the inguinal nodes. Understanding the anatomy of the rectum is crucial for surgical procedures and the diagnosis and treatment of rectal diseases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 97 - An elderly man, aged 72, visits his family doctor with complaints of a...

    Incorrect

    • An elderly man, aged 72, visits his family doctor with complaints of a vague abdominal pain that has been bothering him for the past few months. He is unable to pinpoint the exact location of the pain but mentions that it is more severe around the epigastric region. The pain worsens after meals and has resulted in a loss of appetite and recent weight loss. The man denies experiencing any nausea or vomiting and reports only mild constipation. He has a long-standing history of type 2 diabetes mellitus, hypertension, and dyslipidemia and is currently taking glipizide, insulin injections, atorvastatin, candesartan, and metoprolol as regular medications. Additionally, he is a current smoker with a 25 pack-year history. On examination, the abdomen is soft and non-tender. The man’s vital signs include a heart rate of 62 beats per minute, respiratory rate of 13 breaths per minute, and blood pressure of 147/91 mmHg. What is the most likely mechanism responsible for this patient’s symptoms?

      Your Answer:

      Correct Answer: Fatty accumulation, foam cell formation and fibrous plaque formation in the wall of blood vessels

      Explanation:

      The patient’s symptoms suggest that he may have chronic mesenteric ischemia, which is often caused by atherosclerosis in the arteries supplying the splanchnic circulatory vessels. There is no indication of recent abdominal surgery or an underlying inflammatory process. Constipation is a common issue in elderly individuals, but it is not typically associated with abdominal pain. Meckel diverticulum is a congenital defect that can cause symptoms such as melaena, acute appendicitis, and acute abdominal pain due to ectopic acid secretion. Diverticulitis is characterized by inflammation in the colon, often due to a lack of dietary fiber. Small bowel obstruction due to adhesions is a surgical emergency. Chronic mesenteric ischemia, also known as intestinal angina, is common in individuals with atherosclerotic diseases such as diabetics, smokers, hypertensive patients, and those with dyslipidemia. As the population ages and chronic diseases become more prevalent, the incidence and prevalence of chronic mesenteric ischemia are expected to increase.

      Ischaemia to the lower gastrointestinal tract can result in acute mesenteric ischaemia, chronic mesenteric ischaemia, and ischaemic colitis. Common predisposing factors include increasing age, atrial fibrillation, other causes of emboli, cardiovascular disease risk factors, and cocaine use. Common features include abdominal pain, rectal bleeding, diarrhea, fever, and elevated white blood cell count with lactic acidosis. CT is the investigation of choice. Acute mesenteric ischaemia is typically caused by an embolism and requires urgent surgery. Chronic mesenteric ischaemia presents with intermittent abdominal pain. Ischaemic colitis is an acute but transient compromise in blood flow to the large bowel and may require surgery in a minority of cases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 98 - A 10-year-old girl is undergoing investigation for coeliac disease and has recently undergone...

    Incorrect

    • A 10-year-old girl is undergoing investigation for coeliac disease and has recently undergone biopsies of both the small and large intestinal linings.

      What can be found in the lining of the small intestine but not in that of the large intestine during a normal biopsy?

      Your Answer:

      Correct Answer: Villi

      Explanation:

      The basic structure of the linings in the small and large intestines is similar, consisting of mucosa, submucosa, muscularis externa, and serosa. Both intestines have muscularis mucosae within the mucosa, myenteric nerve plexus innervating the muscularis externa, columnar epithelial cells lining the mucosa, and goblet cells that secrete mucins. However, each intestine has specialized functions. The small intestine is responsible for digesting and absorbing nutrients, which is facilitated by the presence of villi and microvilli on its epithelium, providing a large surface area. These structures are not present in the large intestine.

      Layers of the Gastrointestinal Tract and Their Functions

      The gastrointestinal (GI) tract is composed of four layers, each with its own unique function. The innermost layer is the mucosa, which can be further divided into three sublayers: the epithelium, lamina propria, and muscularis mucosae. The epithelium is responsible for absorbing nutrients and secreting mucus, while the lamina propria contains blood vessels and immune cells. The muscularis mucosae helps to move food along the GI tract.

      The submucosa is the layer that lies beneath the mucosa and contains Meissner’s plexus, which is responsible for regulating secretion and blood flow. The muscularis externa is the layer that lies beneath the submucosa and contains Auerbach’s plexus, which controls the motility of GI smooth muscle. Finally, the outermost layer of the GI tract is either the serosa or adventitia, depending on whether the organ is intraperitoneal or retroperitoneal. The serosa is responsible for secreting fluid to lubricate the organs, while the adventitia provides support and protection. Understanding the functions of each layer is important for understanding the overall function of the GI tract.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 99 - A 75-year-old male with a history of atrial fibrillation and diverticulitis presents to...

    Incorrect

    • A 75-year-old male with a history of atrial fibrillation and diverticulitis presents to the emergency department with severe abdominal pain. After thorough investigation, including mesenteric angiography, it was found that the left colic flexure was experiencing ischemia. Which artery provides direct supply to this region through its branches?

      Your Answer:

      Correct Answer: Inferior mesenteric artery (IMA)

      Explanation:

      The inferior mesenteric artery supplies the distal 1/3 of the transverse colon, while the proximal two thirds are supplied by the middle colic artery, a branch of the SMA. The left colic artery, a branch of the IMA, supplies the remaining distal portion. Although the left colic artery is the primary supplier, collateral flow from branches of the middle colic artery also contributes. The left colic flexure, located between the end of the SMA and the start of the IMA’s blood supply, is a watershed region that can be susceptible to ischemia due to atherosclerotic changes or hypotension.

      The splenic artery directly supplies the spleen and also has branches that supply the stomach and pancreas. There is no such thing as the AMA or PMA.

      The Transverse Colon: Anatomy and Relations

      The transverse colon is a part of the large intestine that begins at the hepatic flexure, where the right colon makes a sharp turn. At this point, it becomes intraperitoneal and is connected to the inferior border of the pancreas by the transverse mesocolon. The middle colic artery and vein are contained within the mesentery. The greater omentum is attached to the superior aspect of the transverse colon, which can be easily separated. The colon undergoes another sharp turn at the splenic flexure, where the greater omentum remains attached up to this point. The distal 1/3 of the transverse colon is supplied by the inferior mesenteric artery.

      The transverse colon is related to various structures. Superiorly, it is in contact with the liver, gallbladder, the greater curvature of the stomach, and the lower end of the spleen. Inferiorly, it is related to the small intestine. Anteriorly, it is in contact with the greater omentum, while posteriorly, it is in contact with the descending portion of the duodenum, the head of the pancreas, convolutions of the jejunum and ileum, and the spleen. Understanding the anatomy and relations of the transverse colon is important for medical professionals in diagnosing and treating various gastrointestinal conditions.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 100 - A 20-year-old man presents to the gastroenterology clinic with a 5-month history of...

    Incorrect

    • A 20-year-old man presents to the gastroenterology clinic with a 5-month history of abdominal pain and diarrhoea. He reports passing fresh red blood in his stool and having up to 7 bowel movements a day in the last month. He has lost 6kg in weight over the last 5 months.

      The patient is referred for various investigations.

      What finding would support the probable diagnosis?

      Your Answer:

      Correct Answer: Goblet cell depletion

      Explanation:

      Crohn’s disease has the potential to impact any section of the digestive system, including the oral mucosa and peri-anal region. It is common for there to be healthy areas of bowel in between the inflamed segments. The disease is characterized by deep ulceration in the gut mucosa, with skip lesions creating a distinctive cobblestone appearance during endoscopy.

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

    • This question is part of the following fields:

      • Gastrointestinal System
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