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Question 1
Correct
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A woman in her 40s is undergoing investigation for bowel cancer. During a colonoscopy, numerous small growths are found throughout her bowel, indicating the presence of an autosomal dominant familial condition that the clinician had suspected.
Which gene mutation is commonly associated with this diagnosis?Your Answer: APC
Explanation:While a majority of human cancers are linked to p53 malfunction, it should be noted that the APC gene is specifically associated with FAP and not p53.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
Correct
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Which one of the following does not result in the relaxation of the lower esophageal sphincter?
Your Answer: Metoclopramide
Explanation:Metoclopramide directly causes contraction of the smooth muscle of the LOS.
Peristalsis: The Movement of Food Through the Digestive System
Peristalsis is the process by which food is moved through the digestive system. Circular smooth muscle contracts behind the food bolus, while longitudinal smooth muscle propels the food through the oesophagus. Primary peristalsis spontaneously moves the food from the oesophagus into the stomach, taking about 9 seconds. Secondary peristalsis occurs when food does not enter the stomach, and stretch receptors are stimulated to cause peristalsis.
In the small intestine, peristalsis waves slow to a few seconds and cause a mixture of chyme. In the colon, three main types of peristaltic activity are recognised. Segmentation contractions are localised contractions in which the bolus is subjected to local forces to maximise mucosal absorption. Antiperistaltic contractions towards the ileum are localised reverse peristaltic waves to slow entry into the colon and maximise absorption. Mass movements are migratory peristaltic waves along the entire colon to empty the organ prior to the next ingestion of a food bolus.
Overall, peristalsis is a crucial process in the digestive system that ensures food is moved efficiently through the body.
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This question is part of the following fields:
- Gastrointestinal System
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Question 3
Incorrect
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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: Hepatogastric ligament
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 4
Correct
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A 28-year-old patient presents with sudden onset of fever and complains of a painful mouth. The patient has a history of inflammatory bowel disease and has recently started taking sulphasalazine. There is no history of recent travel or any other relevant medical history.
What urgent investigation should be performed in this case?Your Answer: Full blood count
Explanation:Aminosalicylates can cause various haematological adverse effects, including agranulocytosis, which can be detected through FBC testing. In this case, the patient’s recent exposure to sulphasalazine and symptoms of fever and mouth ulcers suggest bone marrow suppression with an infection. While an acute flare of IBD is a possible differential diagnosis, it is not strongly supported by the clinical signs. Amylase testing is not likely to be helpful in this case, as the presentation points more towards agranulocytosis than pancreatitis. CRP testing may be performed to monitor inflammation, but it is not likely to provide a specific diagnosis. Total bilirubin testing is included as a reminder of the potential haematological side-effects of aminosalicylates, such as haemolytic anaemia, but it is not a key investigation in this case. FBC testing is the most clinically urgent investigation to support the diagnosis of agranulocytosis.
Aminosalicylate Drugs for Inflammatory Bowel Disease
Aminosalicylate drugs are commonly used to treat inflammatory bowel disease (IBD). These drugs work by releasing 5-aminosalicyclic acid (5-ASA) in the colon, which acts as an anti-inflammatory agent. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis.
Sulphasalazine is a combination of sulphapyridine and 5-ASA. However, many of the side effects associated with this drug are due to the sulphapyridine component, such as rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Mesalazine is a delayed release form of 5-ASA that avoids the sulphapyridine side effects seen in patients taking sulphasalazine. However, it is still associated with side effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis.
Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken down by colonic bacteria. It is important to note that aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis. Therefore, a full blood count is a key investigation in an unwell patient taking these drugs. Pancreatitis is also more common in patients taking mesalazine compared to sulfasalazine.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
Correct
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A 55-year-old obese woman presents with a 4-hour history of right upper quadrant abdominal pain that started after a meal. Upon physical examination, tenderness was noted upon palpation of the right upper quadrant. An abdominal ultrasound revealed the presence of gallstones in the gallbladder. The surgeon opted for a cholecystectomy to remove the gallbladder. During the surgery, the surgeon identified the cystic duct and the inferior surface of the liver to locate the hepatobiliary triangle. What is the third border of the hepatobiliary triangle?
Your Answer: Common hepatic duct
Explanation:The area known as the hepatobiliary triangle is defined by three borders: the common hepatic duct on the medial side, the cystic duct on the inferior side, and the inferior edge of the liver on the superior side. This space is particularly important during laparoscopic cholecystectomy, as it allows for safe ligation and division of the cystic duct and cystic artery. It’s worth noting that the common bile duct is formed by the joining of the common hepatic duct and the cystic duct, but it is not considered one of the borders of the hepatobiliary triangle. The cystic artery, on the other hand, is located within this anatomical space. Finally, while the gastroduodenal artery does arise from the common hepatic artery, it is not one of the borders of the hepatobiliary triangle.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Incorrect
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A 57-year-old-male presents to the clinic with a complaint of a lump in his stomach. During the examination, a lump is observed on coughing and is located within Hesselbach's triangle. Can you identify the structures that form the borders of this region?
Your Answer: Inguinal ligament inferiorly, ASIS laterally, pubic tubercle medially
Correct Answer: Inguinal ligament inferiorly, inferior epigastric vessels laterally, lateral border of rectus sheath medially
Explanation:A possible exam question could be related to a patient displaying symptoms indicative of a hernia. Hesselbach’s triangle is the area where a direct inguinal hernia may manifest. Direct hernias are caused by deficiencies or vulnerabilities in the posterior abdominal wall, whereas indirect hernias protrude through the inguinal canal.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Correct
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A 26-year-old male presents with yellow discoloration of his skin. He reports having had the flu for the past week but is otherwise in good health. He vaguely remembers his uncle experiencing similar episodes of yellow skin. What is the probable diagnosis and what is the mode of inheritance for this condition?
Your Answer: Autosomal recessive
Explanation:Gilbert’s Syndrome is inherited in an autosomal recessive manner. It causes unconjugated hyperbilirubinaemia during periods of stress, such as fasting or infection.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastrointestinal System
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Question 8
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Correct
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A 50-year-old man returns from a trip to Asia where he indulged in the local seafood. He now presents with severe 'rice water' diarrhoea, reduced appetite, and low oral intake. Despite this, there is no change in the amount of diarrhoea. He also experiences low-grade fevers, vomiting, and watery diarrhoea for two weeks. He is admitted to the infectious diseases department of his local hospital for further evaluation. The stool osmolar gap is normal, and there are no detectable fat, white blood cells (WBCs), or red blood cells (RBCs) in the faeces. What type of diarrhoea is most likely affecting this patient?
Your Answer: Secretory diarrhoea
Explanation:Secretory diarrhoea is characterized by a change in the gut from an absorptive state to a secretory state, often caused by toxins or secretagogues. Chronic diarrhoea is usually caused by an underlying condition and can be classified into three subtypes: secretory, osmotic, and inflammatory. Secretory diarrhoea is characterized by large daily stool volumes and can occur even during fasting or sleep due to disrupted ion channels in the gastrointestinal tract. Osmotic diarrhoea is caused by something in the gut forcing water back into the lumen, often seen in malabsorption. Inflammatory diarrhoea is caused by inflammation of the bowel wall, either from medical disease or invasive organisms. Acute infectious diarrhoea can be invasive or enterotoxic/non-invasive, with the former presenting with bloody stool, leukocytosis, and fever, and the latter presenting with a watery stool and lacking systemic symptoms. In either case, WBCs can be detected in the stool.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Incorrect
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A 65-year-old male with an indirect inguinal hernia is scheduled for laparoscopic inguinal hernia repair. While performing the laparoscopy, the surgeon comes across various structures surrounding the inguinal canal. What is the structure that creates the anterior boundaries of the inguinal canal?
Your Answer: Inguinal ligament
Correct Answer: Aponeurosis of external oblique
Explanation:The aponeurosis of the external oblique forms the anterior boundaries of the inguinal canal. In males, the inguinal canal serves as the pathway for the testes to descend from the abdominal wall into the scrotum.
To remember the boundaries of the inguinal canal, the mnemonic MALT: 2Ms, 2As, 2Ls, 2Ts can be used. Starting from superior and moving around in order to posterior, the order can be remembered using the mnemonic SALT (superior, anterior, lower (floor), posterior).
The superior wall (roof) is formed by the internal oblique muscle and transverse abdominis muscle. The anterior wall is formed by the aponeurosis of the external oblique and aponeurosis of the internal oblique. The lower wall (floor) is formed by the inguinal ligament and lacunar ligament. The posterior wall is formed by the transversalis fascia and conjoint tendon.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Correct
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A 29-year-old man contacts his primary care physician with concerns about his skin turning yellow. He reports that this change has been occurring gradually over the past few days and is not accompanied by any pain or other symptoms. Upon further inquiry, the patient discloses that he was recently discharged from the hospital after receiving treatment for pyelonephritis. He denies any recent travel outside of his local area.
The patient's liver function tests reveal the following results:
- Bilirubin: 32 ”mol/L (normal range: 3 - 17)
- ALP: 41 u/L (normal range: 30 - 100)
- ALT: 19 u/L (normal range: 3 - 40)
- ÎłGT: 26 u/L (normal range: 8 - 60)
- Albumin: 43 g/L (normal range: 35 - 50)
What is the most likely diagnosis?Your Answer: Gilbert's syndrome
Explanation:The patient’s presentation is consistent with Gilbert’s syndrome, which is characterized by an increase in serum bilirubin during times of physiological stress due to a deficiency in the liver’s ability to process bilirubin. This can be triggered by illness, exercise, or fasting.
Autoimmune hepatitis, on the other hand, typically results in severely abnormal liver function tests with significantly elevated liver enzymes, which is not the case for this patient.
Hepatitis A is often associated with recent foreign travel and is accompanied by symptoms such as abdominal pain and diarrhea.
Mirizzi syndrome is a rare condition in which a gallstone becomes lodged in the biliary tree, causing a blockage of the bile duct. It typically presents with upper right quadrant pain and signs of obstructive jaundice.
While painless jaundice can be a symptom of pancreatic cancer, it is highly unlikely in a 27-year-old patient and is therefore an unlikely diagnosis in this case.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Correct
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A 23-year-old woman presents to the gastroenterology clinic with a 6-month history of cramping abdominal pain and weight loss. She reports looser bowel motions and opening her bowels 2-4 times per day. There is no history of fever or vomiting. During the examination, the physician observes 4 oral mucosal ulcers. Mild tenderness is noted in the right iliac fossa. An endoscopy is ordered.
What are the expected endoscopy findings for this patient's most likely diagnosis?Your Answer: Cobble-stoned appearance
Explanation:This patient has been diagnosed with Crohn’s disease, which is characterized by a long history of abdominal pain, weight loss, and diarrhea. Unlike ulcerative colitis, which only affects the colon, Crohn’s disease can affect any part of the gastrointestinal tract. In this case, oral mucosal ulceration is also present. The classic cobblestone appearance on endoscopy is due to deep ulceration in the gut mucosa with skip lesions in between.
On the other hand, loss of haustra is a finding seen in chronic ulcerative colitis on fluoroscopy. The chronic inflammatory process in the mucosal and submucosal layers of the colon can cause luminal narrowing, resulting in a drainpipe colon that is shortened and narrowed. In UC, shallow ulceration occurs in the mucosa, with spared mucosa giving rise to the appearance of polyps, also known as pseudopolyps. These can cause bloody diarrhea.
Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Incorrect
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A 65-year-old man is admitted to the surgical ward following an open surgical repair of a ruptured aortic aneurysm. During examination, he presents with a positive Grey Turner's sign, indicating retroperitoneal haemorrhage and resulting in blue discolouration of the flanks. Retroperitoneal haemorrhage can occur due to trauma to retroperitoneal structures. Can you identify which of the following structures is not retroperitoneal?
Your Answer: Head of the pancreas
Correct Answer: Tail of the pancreas
Explanation:The tail of the pancreas is the only intraperitoneal structure mentioned, while all the others are retroperitoneal. Retroperitoneal haemorrhage can be caused by various factors, including ruptured aneurysms and acute pancreatitis. A helpful mnemonic to remember retroperitoneal structures is SAD PUCKER.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 14
Correct
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An 80-year-old man presents to the emergency department with severe abdominal pain and haematochezia. The patient localises the pain to the umbilical region. He has a past medical history of atrial fibrillation, stroke and is currently being treated for multiple myeloma.
His observations show a heart rate of 122/min, a respiratory rate of 29/min, a blood pressure of 119/93 mmHg, an O2 saturation of 97%, and a temperature of 38.2 ÂșC. His chest is clear. Abdominal examination identify some mild tenderness with no guarding. An abdominal bruit is heard on auscultation.
Which segment of the gastrointestinal tract is commonly affected in this condition?Your Answer: Splenic flexure
Explanation:Ischaemic colitis most frequently affects the splenic flexure.
Understanding Ischaemic Colitis
Ischaemic colitis is a condition that occurs when there is a temporary reduction in blood flow to the large bowel. This can cause inflammation, ulcers, and bleeding. The condition is more likely to occur in areas of the bowel that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries, such as the splenic flexure.
When investigating ischaemic colitis, doctors may look for a sign called thumbprinting on an abdominal x-ray. This occurs due to mucosal edema and hemorrhage. It is important to diagnose and treat ischaemic colitis promptly to prevent complications and ensure a full recovery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Correct
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A 16-year-old boy presents to his GP with a 5-month history of passing frequent watery diarrhoea, up to 6 times a day. He reports occasional passage of mucus mixed with his stool and has experienced a weight loss of around 9kg. An endoscopy and biopsy are performed, revealing evidence of granuloma formation.
What is the probable diagnosis?Your Answer: Crohnâs disease
Explanation:The presence of granulomas in the gastrointestinal tract is a key feature of Crohn’s disease, which is a chronic inflammatory condition that can affect any part of the digestive system. The combination of granulomas and clinical history is highly indicative of this condition.
Coeliac disease, on the other hand, is an autoimmune disorder triggered by gluten consumption that causes villous atrophy and malabsorption. However, it does not involve the formation of granulomas.
Colonic tuberculosis, caused by Mycobacterium tuberculosis, is another granulomatous condition that affects the ileocaecal valve. However, the granulomas in this case are caseating with necrosis, and colonic tuberculosis is much less common than Crohn’s disease.
Endoscopy and biopsy are not necessary for diagnosing irritable bowel syndrome, as they are primarily used to rule out other conditions. Biopsies in irritable bowel syndrome would not reveal granuloma formation.
Ulcerative colitis, another inflammatory bowel disease, is characterized by crypt abscesses, pseudopolyps, and mucosal ulceration that can cause rectal bleeding. However, granulomas are not present in this condition.
Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.
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This question is part of the following fields:
- Gastrointestinal System
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Question 16
Incorrect
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Parasympathetic fibers innervating the parotid gland originate from where?
Your Answer: Submandibular 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 17
Correct
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A 45-year-old female with known type 1 diabetes and Graves' disease presents to the GP with worsening fatigue. She describes a history of headaches, shortness of breath and palpitations. Blood tests are taken and the results are displayed below.
Haemoglobin 79 g/dl
MCV 103 fl
White cell count 4.2 mmol/l
Platelets 220 mmol/l
What is the most likely vitamin or mineral deficiency in this patient?Your Answer: B12
Explanation:Anaemia is characterized by classic symptoms such as headaches, shortness of breath, and palpitations. The primary nutritional factors that can cause anaemia are deficiencies in B12, Folate, and Iron.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 18
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Incorrect
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In a patient with a carcinoma of the proximal sigmoid colon, what is the most probable origin of its vascular supply?
Your Answer: Internal iliac artery
Correct Answer: Inferior mesenteric artery
Explanation:When performing a high anterior resection for these types of tumors, it is necessary to ligate the inferior mesenteric artery. However, it is important to note that the internal iliac artery’s branches, particularly the middle rectal branch, play a crucial role in preserving blood flow to the rectal stump and ensuring the anastomoses’ integrity.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 20
Correct
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Surgical occlusion of which of these structures will cause the most significant decrease in hepatic blood flow?
Your Answer: Portal vein
Explanation:The contents of the portal vein consist of digested products. Sinusoids distribute arterial and venous blood to the central veins of the liver lobules, which then empty into the hepatic veins and ultimately into the IVC. Unlike other hepatic veins, the caudate lobe directly drains into the IVC.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 21
Correct
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A 20-year-old male is having surgery to remove his appendix due to appendicitis. Where is the appendix typically located in the body?
Your Answer: Retrocaecal
Explanation:The majority of appendixes are located in the retrocaecal position. In cases where removal of a retrocaecal appendix proves challenging, mobilizing the right colon can greatly enhance accessibility.
Appendix Anatomy and Location
The appendix is a small, finger-like projection located at the base of the caecum. It can be up to 10cm long and is mainly composed of lymphoid tissue, which can sometimes lead to confusion with mesenteric adenitis. The caecal taenia coli converge at the base of the appendix, forming a longitudinal muscle cover over it. This convergence can aid in identifying the appendix during surgery, especially if it is retrocaecal and difficult to locate. The arterial supply to the appendix comes from the appendicular artery, which is a branch of the ileocolic artery. It is important to note that the appendix is intra-peritoneal.
McBurney’s Point and Appendix Positions
McBurney’s point is a landmark used to locate the appendix during physical examination. It is located one-third of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus. The appendix can be found in six different positions, with the retrocaecal position being the most common at 74%. Other positions include pelvic, postileal, subcaecal, paracaecal, and preileal. It is important to be aware of these positions as they can affect the presentation of symptoms and the difficulty of locating the appendix during surgery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Correct
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A 65-year-old man presents to the emergency department with left-sided abdominal pain and rectal bleeding. He has a past medical history of atrial fibrillation and is on apixaban. He does not smoke cigarettes or drink alcohol.
His observations are heart rate 111 beats per minute, blood pressure 101/58 mmHg, respiratory rate 18/minute, oxygen saturation 96% on room air and temperature 37.8ÂșC.
Abdominal examination reveals tenderness in the left lower quadrant. Bowel sounds are sluggish. Rectal examination demonstrates a small amount of fresh red blood but no mass lesions, haemorrhoids or fissures. His pulse is irregular. Chest auscultation is normal.
An ECG demonstrates atrial fibrillation.
Blood tests:
Hb 133 g/L Male: (135-180)
Female: (115 - 160)
Platelets 444 * 109/L (150 - 400)
WBC 18.1 * 109/L (4.0 - 11.0)
Na+ 131 mmol/L (135 - 145)
K+ 4.6 mmol/L (3.5 - 5.0)
Urea 8.2 mmol/L (2.0 - 7.0)
Creatinine 130 ”mol/L (55 - 120)
CRP 32 mg/L (< 5)
Lactate 2.6 mmol/L (0.0-2.0)
Based on the presumed diagnosis, what is the likely location of the pathology?Your Answer: Splenic flexure
Explanation:Ischaemic colitis most frequently affects the splenic flexure.
Understanding Ischaemic Colitis
Ischaemic colitis is a condition that occurs when there is a temporary reduction in blood flow to the large bowel. This can cause inflammation, ulcers, and bleeding. The condition is more likely to occur in areas of the bowel that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries, such as the splenic flexure.
When investigating ischaemic colitis, doctors may look for a sign called thumbprinting on an abdominal x-ray. This occurs due to mucosal edema and hemorrhage. It is important to diagnose and treat ischaemic colitis promptly to prevent complications and ensure a full recovery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 24
Correct
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A 25-year-old male with Gilbert's syndrome (GS) visits his doctor worried about a recent change in skin tone. During the examination, his skin appears to be normal, but he insists that it was yellow earlier today.
What is true about Gilbert's syndrome?Your Answer: Transient jaundice after physiological stress such as exercise and fasting is seen in Gilbertâs syndrome
Explanation:Gilbert’s syndrome is a harmless liver condition that is characterized by increased levels of bilirubin in the blood. While some individuals may not experience any symptoms, others may develop temporary jaundice following physical stressors such as fasting or exercise. Treatment and regular monitoring are not necessary for this condition. It is important to reassure patients that Gilbert’s syndrome does not progress to chronic liver disease. The condition is caused by a mutation in the UGT1A1 gene, which leads to reduced activity of the UGT1A1 enzyme. Gilbert’s syndrome is more prevalent in males.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastrointestinal System
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Question 25
Incorrect
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A 15-year-old girl comes to the clinic with her father. She has lost 10kg in the last 2 months. Recently, her father found her vomiting in the bathroom. The girl admits to struggling with her self-esteem and body image, and has been inducing vomiting after meals. She feels anxious in social situations. During the examination, you observe swelling above the angle of the mandible, indicating parotid gland enlargement. Which nerve supplies the parasympathetic fibers to the parotid gland?
Your Answer: Mandibular nerve
Correct Answer: Glossopharyngeal nerve
Explanation:The correct answer is the glossopharyngeal nerve, which is the ninth cranial nerve. It provides parasympathetic innervation to the parotid gland and carries taste and sensation from the posterior third of the tongue, pharyngeal wall, tonsils, middle ear, external auditory canal, and auricle. It also supplies baroreceptors and chemoreceptors of the carotid sinus.
The facial nerve, the seventh cranial nerve, supplies the muscles of facial expression, taste from the anterior two-thirds of the tongue, and sensation from parts of the external acoustic meatus, auricle, and retro-auricular area. It also provides parasympathetic fibers to the submandibular gland, sublingual gland, nasal glands, and lacrimal glands.
The hypoglossal nerve, the twelfth cranial nerve, supplies the intrinsic muscles of the tongue and all but one of the extrinsic muscles of the tongue.
The greater auricular nerve is a superficial cutaneous branch of the cervical plexus that supplies sensation to the capsule of the parotid gland, skin overlying the gland, and skin over the mastoid process and outer ear.
The mandibular nerve, the third division of the trigeminal nerve, carries sensory and motor fibers. It carries sensation from the lower lip, lower teeth and gingivae, chin, and jaw. It also supplies motor innervation to the muscles of mastication, mylohyoid, the anterior belly of digastric, tensor veli palatini, and tensor tympani.
The patient in the question has sialadenosis, a benign, non-inflammatory enlargement of a salivary gland, in the parotid glands, which can be caused by bulimia nervosa.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 26
Correct
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A 4-year-old girl is rushed to the emergency department with complaints of abdominal pain. The child is crying and mentions that she feels pain in her tummy that comes and goes in 10-minute intervals. Additionally, the mother reports that her daughter has vomited twice and that she has noticed thick blood in her stool.
During the examination, a mass is detected in the center of the abdomen.
A bowel ultrasound is conducted, which shows that the bowel has a doughnut-like appearance.
Which part of the bowel is most likely affected by this condition?Your Answer: Ileocolic
Explanation:Intussusception, a condition that causes bowel obstruction by the invagination of proximal bowel into a more distal part, is most commonly found in infants. The ileocolic type is the most frequent, although different studies may show varying degrees of frequency for the different types. The pathogenesis of intussusception is still not fully understood, but theories include involvement of lymphoid tissue, abnormalities in inhibitory neurotransmitters, and electrolyte disturbances affecting gastric motility. Ultrasound is an effective diagnostic tool, which may reveal a target, doughnut, or pseudokidney sign. Ileoileocolic and colocolic types are less common.
Understanding Intussusception
Intussusception is a medical condition where one part of the bowel folds into the lumen of the adjacent bowel, usually around the ileocecal region. This condition is most common in infants between 6-18 months old, with boys being affected twice as often as girls. Symptoms of intussusception include severe, crampy abdominal pain, inconsolable crying, vomiting, and bloodstained stool, which is a late sign. During a paroxysm, the infant will draw their knees up and turn pale, and a sausage-shaped mass may be felt in the right upper quadrant.
To diagnose intussusception, ultrasound is now the preferred method of investigation, which may show a target-like mass. Treatment for intussusception involves reducing the bowel by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema. If this method fails, or the child has signs of peritonitis, surgery is performed. Understanding the symptoms and treatment options for intussusception is crucial for parents and healthcare professionals to ensure prompt and effective management of this condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 27
Correct
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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: 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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This question is part of the following fields:
- Gastrointestinal System
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Question 28
Correct
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A 50-year-old man arrives at the emergency department complaining of haematemesis. He appears unkempt and emits a strong odour of alcohol. During the examination, the physician notes the presence of palmar erythema, spider naevi, and jaundiced sclera. The patient's vital signs indicate tachycardia and tachypnea, with a blood pressure of 90/55 mmHg. What is the probable reason for the patient's haematemesis?
Your Answer: Oesophageal varices
Explanation:The patient is exhibiting signs of shock, possibly due to hypovolemia caused by significant blood loss from variceal bleeding. The patient’s physical examination reveals indications of chronic liver disease, making oesophageal varices the most probable cause of the bleeding. Mallory-Weiss tear, which causes painful episodes of haematemesis, usually occurs after repeated forceful vomiting, but there is no evidence of vomiting in this patient. Peptic ulcers typically affect older patients with abdominal pain and those taking non-steroidal anti-inflammatory drugs.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Incorrect
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Which one of the following forms the medial wall of the femoral canal?
Your Answer: Sartorius
Correct Answer: Lacunar ligament
Explanation:It is important to differentiate between the femoral canal and the femoral triangle, particularly during exams when time is limited.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 30
Correct
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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: 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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This question is part of the following fields:
- Gastrointestinal System
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Question 31
Correct
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A 67-year-old man has been admitted to the surgical ward with abdominal pain and rectal bleeding. According to the notes, he has not had a bowel movement in five days. Additionally, he has begun vomiting and his abdomen is swollen.
What is the probable diagnosis?Your Answer: Large bowel obstruction
Explanation:Large bowel obstruction is the most likely diagnosis based on the pattern of symptoms, which include abdominal distension, absence of passing flatus or stool, and late onset or no vomiting.
Large bowel obstruction occurs when there is a blockage in the passage of food, fluids, and gas through the large intestines. The most common cause of this condition is a tumor, accounting for 60% of cases. Colonic malignancy is often the initial presenting complaint in approximately 30% of cases, especially in more distal colonic and rectal tumors due to their smaller lumen diameter. Other causes include volvulus and diverticular disease.
Clinical features of large bowel obstruction include abdominal pain, distention, and absence of passing flatus or stool. Nausea and vomiting may suggest a more proximal lesion, while peritonism may be present if there is associated bowel perforation. It is important to consider the underlying causes, such as recent symptoms suggestive of colorectal cancer.
Abdominal x-ray is still commonly used as a first-line investigation, with a diameter greater than the normal limits of 10-12 cm for the caecum, 8 cm for the ascending colon, and 6.5 cm for recto-sigmoid being diagnostic of obstruction. CT scan is highly sensitive and specific for identifying obstruction and its underlying cause.
Initial management of large bowel obstruction includes NBM, IV fluids, and nasogastric tube with free drainage. Conservative management for up to 72 hours can be trialed if the cause of obstruction does not require surgery, after which further management may be required if there is no resolution. Around 75% of cases will eventually require surgery. IV antibiotics are given if perforation is suspected or surgery is planned. Emergency surgery is necessary if there is any overt peritonitis or evidence of bowel perforation, involving irrigation of the abdominal cavity, resection of perforated segment and ischaemic bowel, and addressing the underlying cause of the obstruction.
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This question is part of the following fields:
- Gastrointestinal System
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Question 32
Correct
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A 50-year-old male is brought to your clinic by his wife due to concerns of his 'skin and eyes looking yellow' and has worsened since it started 3 months ago. On systematic examination, you noticed jaundice and cachexia but it is otherwise unremarkable. On further questioning the man himself reports that his urine has been getting darker as well as stools becoming paler. You order an urgent CT scan which showed a mass lesion at the head of the pancreas. What is the direct explanation for the change in color of his stools?
Your Answer: Decrease in stercobilin
Explanation:The presentation of symptoms related to the conjugation of bilirubin varies depending on where the process is disrupted, such as pre-hepatic, hepatic, or post-hepatic. In this case, a mass in the pancreatic head has caused an obstruction of the common bile duct, which is post-hepatic. This obstruction results in less conjugated bilirubin reaching the intestinal tract and more being absorbed into the systemic circulation. As a result, there is a decrease in stercobilin production, leading to paler stools.
Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. The majority of pancreatic tumors are adenocarcinomas and are typically found in the head of the pancreas. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and mutations in the BRCA2 and KRAS genes.
Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, and pruritus. Courvoisier’s law states that a palpable gallbladder is unlikely to be due to gallstones in the presence of painless obstructive jaundice. However, patients often present with non-specific symptoms such as anorexia, weight loss, and epigastric pain. Loss of exocrine and endocrine function can also occur, leading to steatorrhea and diabetes mellitus. Atypical back pain and migratory thrombophlebitis (Trousseau sign) are also common.
Ultrasound has a sensitivity of around 60-90% for detecting pancreatic cancer, but high-resolution CT scanning is the preferred diagnostic tool. The ‘double duct’ sign, which is the simultaneous dilatation of the common bile and pancreatic ducts, may be seen on imaging.
Less than 20% of patients with pancreatic cancer are suitable for surgery at the time of diagnosis. A Whipple’s resection (pancreaticoduodenectomy) may be performed for resectable lesions in the head of the pancreas, but side-effects such as dumping syndrome and peptic ulcer disease can occur. Adjuvant chemotherapy is typically given following surgery, and ERCP with stenting may be used for palliation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 33
Correct
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A 56-year-old woman presents with profuse diarrhoea one week after undergoing a cholecystectomy. The surgery was uncomplicated, except for a minor bile spillage during gallbladder removal. What is the probable diagnosis?
Your Answer: Clostridium difficile infection
Explanation:Broad spectrum antibiotics are only given during a cholecystectomy if there is intraoperative bile spillage. It is not standard practice to administer antibiotics for an uncomplicated procedure. Surgeons typically address any bile spills during the operation, which greatly reduces the risk of delayed pelvic abscesses. As a result, such abscesses are very uncommon.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 34
Correct
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A 50-year-old man visits his doctor with complaints of abdominal pain, weight loss, and persistent diarrhoea for the past 5 months. During a colonoscopy, a suspicious growth is detected in his colon, which is later confirmed as adenocarcinoma. The patient reveals that his father was diagnosed with colon cancer at the age of 55.
Based on this information, which genetic mutations are likely to be present in this patient?Your Answer: MSH2/MLH1
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 35
Correct
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A 32-year-old alcoholic woman presents with visible jaundice and confusion and is admitted to the gastroenterology ward. Upon examination, she has a distended tender abdomen with hepatomegaly and shifting dullness. All her observations are within normal limits. The following blood test results are obtained:
- Hb: 121 g/L (normal range for females: 115-160 g/L)
- MCV: 103 g/L (normal range: 82-100 g/L)
- Bilirubin: 78 ”mol/L (normal range: 3-17 ”mol/L)
- ALP: 112 u/L (normal range: 30-100 u/L)
- ALT: 276 u/L (normal range: 3-40 u/L)
- AST: 552 u/L (normal range: 3-30 u/L)
- ÎłGT: 161 u/L (normal range: 8-60 u/L)
An aspirate of fluid is taken and shows a serum-ascites albumin gradient (SAAG) of 14 g/L. What is the most likely diagnosis that explains the SAAG value in this patient?Your Answer: Portal hypertension
Explanation:Ascites can be diagnosed by measuring the SAAG value, with a high SAAG gradient (>11g/L) indicating the presence of portal hypertension. In the case of a SAAG value of >11g/L, the ascites is considered a transudate and is likely caused by portal hypertension. This is consistent with the patient’s symptoms, which suggest ascites due to alcoholic liver disease leading to liver cirrhosis and portal hypertension. Other potential causes of ascites would result in an exudative picture with a SAAG value of <11g/L. Biliary ascites is a rare consequence of biliary procedures or trauma, and would present with abdominal distension but not hepatomegaly. While bile is sterile, peritonitis is likely to occur, leading to septic symptoms. However, the SAAG value and the patient’s symptoms make biliary ascites less likely. Bowel obstruction is not consistent with the patient’s symptoms, as it would not explain the presence of jaundice. While a distended abdomen may be present, other features of delirium would also be expected. Additionally, a patient with bowel obstruction would report a history of not passing flatus or bowel movements. Nephrotic syndrome would present with oedema, proteinuria, and hypoalbuminaemia, which are not described in the patient’s symptoms. The raised liver enzymes and macrocytic anaemia are more consistent with liver pathology. Ascites is a medical condition characterized by the accumulation of abnormal amounts of fluid in the abdominal cavity. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. If the SAAG level is greater than 11g/L, it indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. Other causes of portal hypertension include cardiac conditions like right heart failure and constrictive pericarditis, as well as infections like tuberculous peritonitis. On the other hand, if the SAAG level is less than 11g/L, ascites may be caused by hypoalbuminaemia, malignancy, pancreatitis, bowel obstruction, and other conditions. The management of ascites involves reducing dietary sodium and sometimes fluid restriction if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone are often prescribed, and loop diuretics may be added if necessary. Therapeutic abdominal paracentesis may be performed for tense ascites, and large-volume paracentesis requires albumin cover to reduce the risk of complications. Prophylactic antibiotics may also be given to prevent spontaneous bacterial peritonitis. In some cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.
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This question is part of the following fields:
- Gastrointestinal System
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Question 36
Correct
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An 80-year-old woman comes to the clinic complaining of fatigue, indigestion, and weight loss that has been going on for 3 months. During the examination, the doctor notices jaundice in the conjunctival sclera and mild tenderness in the right upper quadrant upon palpation. After conducting scans and biopsy, the results suggest gallbladder cancer.
What is the most likely lymph node to be the first site of metastasis for the cancer cells?Your Answer: Lund's node (cystic lymph node)
Explanation:Lund’s node serves as the first lymph node to be affected by cancer cells draining from the gallbladder, making it the sentinel lymph node for this organ. This suggests that Lund’s node is the primary target for metastasis in gallbladder cancer.
Cloquet’s node is classified as one of the deep inguinal nodes, while Virchow’s node is a sentinel lymph node located on the left supraclavicular region. Virchow’s node is associated with certain abdominal cancers, such as gastric cancer.
Peyer’s patches are clusters of lymphoid follicles that can be found throughout the ileum.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 37
Correct
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A 53-year-old man visits his doctor complaining of heartburn. It occurs after meals and is not related to physical activity. He is a heavy drinker, consuming around 20 units of alcohol per week, and has been smoking 2 packs of cigarettes per day since he was 20 years old. He denies experiencing weight loss, melaena, haematemesis, or dysphagia.
The doctor prescribes ranitidine as an alternative to omeprazole. What is a true statement about ranitidine?Your Answer: Is a competitive antagonist of H2 receptors on gastric parietal cells
Explanation:Ranitidine competes with histamine for binding to H2 receptors on gastric parietal cells, acting as an antagonist. It is not associated with sexual disinhibition, but can cause sexual dysfunction such as decreased libido and impotence. When the stomach pH drops too low, somatostatin secretion is stimulated, which inhibits acid secretion by parietal cells and also suppresses the release of positive regulators like histamine and gastrin. Ranitidine enhances the function of somatostatin rather than inhibiting it. As a result, it suppresses both normal and meal-stimulated acid secretion by parietal cells, making the third and fourth options incorrect.
Histamine-2 Receptor Antagonists and their Withdrawal from the Market
Histamine-2 (H2) receptor antagonists are medications used to treat dyspepsia, which includes conditions such as gastritis and gastro-oesophageal reflux disease. They were previously considered a first-line treatment option, but have since been replaced by more effective proton pump inhibitors. One example of an H2 receptor antagonist is ranitidine.
However, in 2020, ranitidine was withdrawn from the market due to the discovery of small amounts of the carcinogen N-nitrosodimethylamine (NDMA) in products from multiple manufacturers. This led to concerns about the safety of the medication and its potential to cause cancer. As a result, patients who were taking ranitidine were advised to speak with their healthcare provider about alternative treatment options.
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This question is part of the following fields:
- Gastrointestinal System
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Question 38
Correct
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Which of the following illnesses is not regarded as a risk factor for stomach cancer?
Your 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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This question is part of the following fields:
- Gastrointestinal System
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Question 39
Correct
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You are present during the colonoscopy of a middle-aged patient who is being investigated by gastroenterology due to experiencing severe abdominal pain and passing bloody stools multiple times a day for several weeks. Although the symptoms have subsided, the patient also complains of significant joint pain and has had episodes of painful, red left eye with blurry vision. The consultant suspects ulcerative colitis as the probable diagnosis and performs a biopsy during the procedure to confirm it. What feature would most likely confirm the consultant's suspicions?
Your Answer: Crypt abscesses
Explanation:Ulcerative colitis is a chronic inflammatory bowel disease that can cause various symptoms, including ocular manifestations such as anterior uveitis. A biopsy of affected tissue is crucial in diagnosing ulcerative colitis and distinguishing it from other similar conditions, particularly Crohn’s disease. The characteristic microscopic features of ulcerative colitis include crypt abscesses and pseudopolyps. Partial villous atrophy is not typically associated with ulcerative colitis but may be seen in tropical sprue. Crypt hyperplasia and complete villous atrophy are more commonly seen in coeliac disease. Non-caseating granulomas and transmural inflammation are typical histological features of Crohn’s disease, which is the primary differential diagnosis for ulcerative colitis.
Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.
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This question is part of the following fields:
- Gastrointestinal System
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Question 40
Incorrect
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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: Femoral 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 41
Incorrect
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During a liver resection, what structure will be located posterior to the epiploic foramen at this level when a surgeon performs a pringles manoeuvre?
Your Answer: Cystic duct
Correct Answer: Inferior vena cava
Explanation:To manage bleeding caused by liver injury or a challenging cholecystectomy, a vascular clamp can be utilized at the epiploic foramen. This opening is defined by the following borders: the bile duct on the right, the portal vein at the back, and the hepatic artery on the left, all of which are located in the free edge of the lesser omentum.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 42
Correct
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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: 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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This question is part of the following fields:
- Gastrointestinal System
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Question 43
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 44
Correct
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A 27-year-old man visits his doctor reporting persistent fatigue, weight loss, and intermittent non-bloody diarrhea. He also has a blistering skin rash on his abdomen. His recent blood tests reveal low hemoglobin levels, high mean corpuscular volume, and low vitamin B12 levels. The doctor inquires about the man's diet and finds it to be sufficient, leading to a suspicion of malabsorption. What is the probable cause of the malabsorption?
Your Answer: Villous atrophy
Explanation:Malabsorption is a common consequence of coeliac disease, which is caused by the destruction of epithelial cells on the villi of the small intestine due to an immune response to gluten. This results in villous atrophy, reducing the surface area of the gastrointestinal tract and impairing absorption. Coeliac disease often leads to B12 deficiency, particularly in the terminal ileum where villous damage is most severe. While decreased gut motility can cause constipation, it does not contribute to malabsorption in coeliac disease. Similarly, down-regulation of brush-border enzymes is not responsible for malabsorption in this condition, although it can occur in response to other immune responses or infections. Although increased gut motility can lead to malabsorption, it is not a mechanism of malnutrition in coeliac disease. Finally, it is important to note that coeliac disease reduces surface area rather than increasing it, which would actually enhance nutrient absorption.
Understanding Coeliac Disease
Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.
To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.
Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.
The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.
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This question is part of the following fields:
- Gastrointestinal System
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Question 45
Incorrect
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On examining the caecum, what structure is most likely to be detected at the point where all the tenia coli converge?
Your Answer: Appendix tip
Correct Answer: Appendix base
Explanation:The tenia coli come together at the bottom of the appendix.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 46
Incorrect
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A 42-year-old man undergoes a partial thyroidectomy and experiences hoarseness upon returning to the ward. As a healthcare professional, you know that this is a common complication of thyroid surgery. Which nerve is most likely responsible for the patient's symptoms?
Your Answer: Internal branch of the superior laryngeal nerve
Correct Answer: Recurrent laryngeal nerve
Explanation:The recurrent laryngeal nerve is a branch of the vagus nerve (CN X) that provides motor supply to all but one of the laryngeal muscles and sensory supply to the larynx below the vocal cords. The left nerve loops under the arch of the aorta and passes deep to the inferior constrictor muscle of the pharynx, while the right nerve usually loops under the right subclavian artery. Both nerves pass close to or through the thyroid ligament, making them susceptible to injury during thyroid surgery. Dysfunction of either nerve can result in a hoarse voice.
The internal branch of the superior laryngeal nerve is the only other nerve among the given options that innervates the larynx. It carries sensory supply to the larynx above the vocal cords, while the external branch supplies the cricothyroid muscle. Dysfunction of the external branch can cause a hoarse voice, but dysfunction of the internal branch will not.
The greater auricular nerve and transverse cervical nerve are superficial cutaneous nerves that arise from the cervical plexus and supply the skin overlying the mandible, ear auricle, and neck. The phrenic nerve, also arising from the cervical plexus, provides motor innervation to the diaphragm and sensation to the parietal pericardium and pleura adjacent to the mediastinum.
During surgical procedures, there is a risk of nerve injury caused by the surgery itself. This is not only important for the patient’s well-being but also from a legal perspective. There are various operations that carry the risk of nerve damage, such as posterior triangle lymph node biopsy, Lloyd Davies stirrups, thyroidectomy, anterior resection of rectum, axillary node clearance, inguinal hernia surgery, varicose vein surgery, posterior approach to the hip, and carotid endarterectomy. Surgeons must have a good understanding of the anatomy of the area they are operating on to minimize the incidence of nerve lesions. Blind placement of haemostats is not recommended as it can also cause nerve damage.
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This question is part of the following fields:
- Gastrointestinal System
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Question 47
Incorrect
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A 50-year-old man has been diagnosed with a gastrointestinal stromal tumour in his stomach. What is the typical cell type that gives rise to these tumours?
Your Answer: Primitive stem cells of the gut wall
Correct Answer: Interstitial cells of Cajal
Explanation:Gastrointestinal stromal tumors (GISTs) originate from Cajal’s interstitial pacemaker cells, which are typically found outside the mucosal layer and cause minimal damage to it.
Gastrointestinal Stromal Tumours: Characteristics and Treatment Options
Gastrointestinal stromal tumours (GISTs) are rare tumours that originate from the interstitial pacemaker cells of Cajal. These tumours are primarily found in the stomach (70%), with the remainder occurring in the small intestine (20%) and colon/rectum (5%). Most GISTs are solitary lesions and are sporadic in nature. The majority of GISTs express CD117, a transmembrane tyrosine kinase receptor, and have a mutation of the c-KIT gene.
The main goal of surgery for GISTs is to resect the tumour with a 1-2 cm margin of normal tissue. Extensive resections are not usually required. However, there is a high local recurrence rate, which is related to the site of the tumour, incomplete resections, and high mitotic count. Salvage surgery for recurrent disease is associated with a median survival of 15 months.
In high-risk patients, the use of imatinib has greatly improved prognosis. In the ACOSOG trial, imatinib reduced relapse rates from 17% to 2%. In the UK, imatinib is recommended by NICE for use in patients with metastatic disease or locally unresectable disease.
Overall, GISTs are rare tumours that require careful management. Surgery with a margin of normal tissue is the mainstay of treatment, but the risk of recurrence is high. Imatinib has shown promise in improving prognosis for high-risk patients.
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This question is part of the following fields:
- Gastrointestinal System
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Question 48
Correct
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 49
Correct
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A 29-year-old woman is currently under investigation by her GP for chronic diarrhoea due to repeated occurrences of loose, bloody stools. As per the WHO guidelines, what is the definition of chronic diarrhoea?
Your Answer: Diarrhoea for >14 days
Explanation:Chronic diarrhoea is defined by the WHO as lasting for more than 14 days. The leading causes of this condition are irritable bowel syndrome, ulcerative colitis and Crohn’s disease, coeliac disease, hyperthyroidism, and infection. The remaining options provided are incorrect and do not align with the WHO’s definition.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 50
Correct
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A 68-year-old man is having his left kidney and ureter removed. During the surgery, the surgeons remove the ureter. What provides the blood supply to the upper part of the ureter?
Your Answer: Branches of the renal artery
Explanation:The renal artery provides branches that supply the proximal ureter, while other feeding vessels are described in the following.
Anatomy of the Ureter
The ureter is a muscular tube that measures 25-35 cm in length and is lined by transitional epithelium. It is surrounded by a thick muscular coat that becomes three muscular layers as it crosses the bony pelvis. This retroperitoneal structure overlies the transverse processes L2-L5 and lies anterior to the bifurcation of iliac vessels. The blood supply to the ureter is segmental and includes the renal artery, aortic branches, gonadal branches, common iliac, and internal iliac. It is important to note that the ureter lies beneath the uterine artery.
In summary, the ureter is a vital structure in the urinary system that plays a crucial role in transporting urine from the kidneys to the bladder. Its unique anatomy and blood supply make it a complex structure that requires careful consideration in any surgical or medical intervention.
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This question is part of the following fields:
- Gastrointestinal System
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Question 51
Correct
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A 33-year-old woman presents to the emergency department with acute illness. Her vital signs are as follows.
Heart rate 96 BPM (60-80)
Respiratory rate 30 per minute (12-20)
Temperature 39.2 ÂșC (35.5-37.5)
Blood pressure 112/84 mmHg (100-140/60-90)
An infection is suspected, but the source is unknown. Further investigation with a CT scan of the chest and abdomen reveals a retroperitoneal collection, likely caused by leakage from a damaged retroperitoneal structure.
Which of the following structures is most likely affected?Your Answer: Ureter
Explanation:The ureters are located in the retroperitoneal space and damage to them can result in the accumulation of fluid in this area. This retroperitoneal collection may be caused by leaked fluid from the damaged ureter. It is important to note that the ureter is the only retroperitoneal structure among the provided options, making it the most likely cause of the fluid accumulation in this patient.
To remember the retroperitoneal structures, a helpful mnemonic is SAD PUCKER, which stands for Suprarenal (adrenal) glands, Aorta/inferior vena cava, Duodenum (2nd and 3rd parts), Pancreas (except tail), Ureters, Colon (ascending and descending), Kidneys, Esophagus, and Rectum.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 52
Incorrect
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During liver mobilisation for a pediatric liver transplant, the hepatic ligaments will need to be mobilized. Which of the following statements regarding these structures is false?
Your Answer: The falciform ligament divides into the left triangular ligament and coronary ligament
Correct Answer: The right triangular ligament is an early branch of the left triangular ligament
Explanation:The coronary ligament continues as the right triangular ligament.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 53
Correct
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A 55-year-old man visits his GP complaining of worsening acid reflux, despite receiving aggressive treatment. He reports feeling like he has lost weight and has a medical history of duodenal ulcers. During his last endoscopy, Barrett's oesophagus was detected. Which type of cancer is most commonly linked to this condition?
Your Answer: Oesophageal adenocarcinoma
Explanation:The most significant risk factor for developing oesophageal adenocarcinoma, one of the two types of oesophageal carcinomas in the UK, is Barrett’s oesophagus. This condition occurs when chronic acid exposure causes a metaplastic change from squamous epithelium to gastric columnar epithelium in the lower end of the oesophagus, increasing the risk of developing adenocarcinoma.
Duodenal adenocarcinoma, a relatively rare cancer of the gastrointestinal tract, is often caused by genetic conditions such as HNCCP/Lynch syndrome and familial adenomatous polyposis (FAP), as well as Crohn’s disease. Patients with this type of cancer typically experience abdominal pain, reflux, and weight loss due to the malignancy obstructing the flow of digested chyme from the stomach to the jejunum.
Gastric malignancy, the most common type of which is adenocarcinoma, is not associated with Barrett’s oesophagus. Symptoms of gastric cancer include heartburn, abdominal pain, loss of appetite, and early satiety, and the most significant risk factor is H. pylori infection.
Oesophageal leiomyoma, a benign tumour, is not linked to Barrett’s oesophagus. Patients may experience reflux if the mass enlarges, but the most common symptoms are retrosternal discomfort and difficulty swallowing.
Squamous cell carcinoma, the other type of oesophageal malignancy, is associated with smoking and alcohol and tends to occur in the upper oesophagus. Unlike adenocarcinoma, weight loss is usually an early symptom of this type of cancer.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 54
Correct
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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: 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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This question is part of the following fields:
- Gastrointestinal System
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Question 55
Correct
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A 16-year-old girl complains of pain in her right iliac fossa and is diagnosed with acute appendicitis. You bring her to the operating room for a laparoscopic appendectomy. While performing the procedure, you are distracted by the scrub nurse and accidentally tear the appendicular artery, causing significant bleeding. Which vessel is likely to be the primary source of the hemorrhage?
Your Answer: Ileo-colic artery
Explanation:The ileocolic artery gives rise to the appendicular artery.
Appendix Anatomy and Location
The appendix is a small, finger-like projection located at the base of the caecum. It can be up to 10cm long and is mainly composed of lymphoid tissue, which can sometimes lead to confusion with mesenteric adenitis. The caecal taenia coli converge at the base of the appendix, forming a longitudinal muscle cover over it. This convergence can aid in identifying the appendix during surgery, especially if it is retrocaecal and difficult to locate. The arterial supply to the appendix comes from the appendicular artery, which is a branch of the ileocolic artery. It is important to note that the appendix is intra-peritoneal.
McBurney’s Point and Appendix Positions
McBurney’s point is a landmark used to locate the appendix during physical examination. It is located one-third of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus. The appendix can be found in six different positions, with the retrocaecal position being the most common at 74%. Other positions include pelvic, postileal, subcaecal, paracaecal, and preileal. It is important to be aware of these positions as they can affect the presentation of symptoms and the difficulty of locating the appendix during surgery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 56
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 57
Correct
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A 26-year-old male presented with weight loss, cramping abdominal pain, and bloody diarrhea. During colonoscopy, a diffusely red and friable mucosa was observed in the rectum and sigmoid colon, while the mucosa was normal in the proximal region. Over time, the disease progressed to involve most of the colon, except for the ileum. After several years, a colonic biopsy revealed high grade epithelial dysplasia. What was the probable initial diagnosis?
Your Answer: Ulcerative colitis
Explanation:Ulcerative colitis advances from the distal to proximal regions in a progressive manner, leading to dysplastic changes over time. These endoscopic observations necessitate frequent endoscopic monitoring, and if a colonic mass is present, a pancproctocolectomy is typically recommended.
Understanding Ulcerative Colitis
Ulcerative colitis is a type of inflammatory bowel disease that causes inflammation in the rectum and spreads continuously without going beyond the ileocaecal valve. It is most commonly seen in people aged 15-25 years and 55-65 years. The symptoms of ulcerative colitis are insidious and intermittent, including bloody diarrhea, urgency, tenesmus, abdominal pain, and extra-intestinal features. Diagnosis is done through colonoscopy and biopsy, but in severe cases, a flexible sigmoidoscopy is preferred to avoid the risk of perforation. The typical findings include red, raw mucosa that bleeds easily, widespread ulceration with preservation of adjacent mucosa, and inflammatory cell infiltrate in lamina propria. Extra-intestinal features of inflammatory bowel disease include arthritis, erythema nodosum, episcleritis, osteoporosis, uveitis, pyoderma gangrenosum, clubbing, and primary sclerosing cholangitis. Ulcerative colitis is linked with sacroiliitis, and a barium enema can show the whole colon affected by an irregular mucosa with loss of normal haustral markings.
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This question is part of the following fields:
- Gastrointestinal System
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Question 58
Incorrect
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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: Sartorius
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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This question is part of the following fields:
- Gastrointestinal System
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Question 59
Correct
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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: 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 60
Incorrect
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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: Antagonist of Ό-opioid receptors in the myenteric plexus of the large intestine
Correct Answer: Agonist of Ό-opioid receptors in the myenteric plexus of the large intestine
Explanation:The myenteric plexus of the large intestine’s ÎŒ-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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This question is part of the following fields:
- Gastrointestinal System
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Question 61
Correct
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A 15-year-old boy, with a family history of Gilbert's syndrome, is showing symptoms of hepatic dysfunction. Upon conducting liver function tests, it is found that he has elevated levels of unconjugated bilirubin. After genetic testing, it is confirmed that he has Gilbert's syndrome. What is the reason behind the increased levels of unconjugated bilirubin in Gilbert's syndrome?
Your Answer: Reduced levels of UDP-glucuronosyl transferase-1
Explanation:Gilbert’s syndrome is characterized by a decrease in UDP glucuronosyltransferase levels.
Enhanced drug effects can occur due to reduced warfarin metabolism caused by CYP2C9 deficiency.
Elevated GGT levels are often caused by pancreatic disease, cholestasis, excessive alcohol consumption, and certain medications.
Dubin-Johnson syndrome is associated with defective hepatocyte excretion of conjugated bilirubin.
Disordered metabolism of clopidogrel and other drugs, including proton-pump inhibitors, anticonvulsants, and sedatives, can result from reduced CYP2C19 levels.Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastrointestinal System
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Question 62
Correct
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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-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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 63
Correct
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As a GP, you are evaluating a 35-year-old female patient who has been experiencing a persistent burning sensation in her epigastrium that is temporarily relieved by eating meals. Your initial suspicion of H. pylori infection was ruled out by a negative serology test, and a two-week trial of full-dose proton pump inhibitor and triple eradication therapy failed to alleviate her symptoms. An endoscopy revealed multiple duodenal ulcers, and upon further questioning, the patient disclosed that her mother has a pituitary tumor. Which hormone is most likely to be elevated in this patient?
Your Answer: Gastrin
Explanation:Zollinger-Ellison Syndrome and Gastrinoma
Zollinger-Ellison syndrome is a familial condition that predisposes individuals to benign or malignant tumors of the pituitary and pancreas with parathyroid hyperplasia causing hyperparathyroidism. This autosomal dominant inherited syndrome should be considered in patients who present with unusual endocrine tumors, especially if they are relatively young at diagnosis or have a relevant family history.
One manifestation of Zollinger-Ellison syndrome is the development of a pancreatic tumor called a gastrinoma, which secretes the hormone gastrin. Gastrin stimulates the release of hydrochloric acid from parietal cells in the stomach, which optimizes conditions for protein digesting enzymes. However, excessive production of gastrin can occur in gastrinomas, leading to excessive HCL production that can denature the mucosa and submosa of the gastrointestinal tract, causing symptoms, ulceration, and even perforation of the duodenum.
While other pancreatic tumors can also produce hormones such as insulin or glucagon, the symptoms and clinical findings in this case suggest a diagnosis of gastrinoma. Cholecystokinin and somatostatin are hormones that have inhibitory effects on HCL secretion and do not fit with the clinical picture. Cholecystokinin also produces the feeling of satiety.
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This question is part of the following fields:
- Gastrointestinal System
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Question 64
Correct
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A 57-year-old male presents to his GP with a three-month history of abdominal discomfort. He reports feeling bloated all the time, with increased flatulence. He occasionally experiences more severe symptoms, such as profuse malodorous diarrhoea and vomiting.
Upon examination, the GP notes aphthous ulceration and conjunctival pallor. The patient undergoes several blood tests and is referred for a duodenal biopsy.
The following test results are returned:
Hb 110 g/L Male: (135-180)
Female: (115 - 160)
MCV 92 fl (80-100)
Platelets 320 * 109/L (150 - 400)
WBC 7.5 * 109/L (4.0 - 11.0)
Ferritin 12 ng/mL (20 - 230)
Vitamin B12 200 ng/L (200 - 900)
Folate 2.5 nmol/L (> 3.0)
Transglutaminase IgA antibody 280 u/ml (<100)
Ca125 18 u/ml (<35)
Based on the likely diagnosis, what would be the expected finding on biopsy?Your Answer: Villous atrophy
Explanation:Coeliac disease is characterized by villous atrophy, which leads to malabsorption. This patient’s symptoms are typical of coeliac disease, which can affect both males and females in their 50s. Patients often experience non-specific abdominal discomfort for several months, similar to irritable bowel syndrome, and may not notice correlations between symptoms and specific dietary components like gluten.
Aphthous ulceration is a common sign of coeliac disease, and patients may also experience nutritional deficiencies such as iron and folate deficiency due to malabsorption. Histology will reveal villous atrophy and crypt hyperplasia. Iron and folate deficiency can lead to a normocytic anaemia and conjunctival pallor. Positive anti-transglutaminase antibodies are specific for coeliac disease.
Ulcerative colitis is characterized by crypt abscess and mucosal ulcers, while Crohn’s disease is associated with non-caseating granulomas and full-thickness inflammation. These inflammatory bowel diseases typically present in patients in their 20s and may have systemic and extraintestinal features. Anti-tTG will not be positive in IBD. Ovarian cancer is an important differential diagnosis for females over 40 with symptoms similar to irritable bowel syndrome.
Understanding Coeliac Disease
Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.
To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.
Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.
The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.
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This question is part of the following fields:
- Gastrointestinal System
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Question 65
Correct
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Which one of the following triggers the production of stomach acid?
Your Answer: Histamine
Explanation:Gastrin is produced by G cells and stimulates the production of gastric acid. Pepsin is responsible for digesting protein and is secreted simultaneously with gastrin. Secretin, produced by mucosal cells in the duodenum and jejunum, inhibits gastric acid production and stimulates the production of bile and pancreatic juice. Gastric inhibitory peptide, produced in response to fatty acids, inhibits the release of gastrin and acid secretion from parietal cells. Cholecystokinin, also produced by mucosal cells in the duodenum and jejunum in response to fatty acids, inhibits acid secretion from parietal cells and causes the gallbladder to contract while relaxing the sphincter of Oddi.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 66
Correct
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A 75-year-old man is scheduled for a sub total oesophagectomy with anastomosis of the stomach to the cervical oesophagus. What is the primary vessel responsible for supplying arterial blood to the oesophageal portion of the anastomosis?
Your Answer: Inferior thyroid artery
Explanation:The inferior thyroid artery supplies the cervical oesophagus, while direct branches from the thoracic aorta supply the thoracic oesophagus (which has been removed in this case).
Anatomy of the Oesophagus
The oesophagus is a muscular tube that is approximately 25 cm long and starts at the C6 vertebrae, pierces the diaphragm at T10, and ends at T11. It is lined with non-keratinized stratified squamous epithelium and has constrictions at various distances from the incisors, including the cricoid cartilage at 15cm, the arch of the aorta at 22.5cm, the left principal bronchus at 27cm, and the diaphragmatic hiatus at 40cm.
The oesophagus is surrounded by various structures, including the trachea to T4, the recurrent laryngeal nerve, the left bronchus and left atrium, and the diaphragm anteriorly. Posteriorly, it is related to the thoracic duct to the left at T5, the hemiazygos to the left at T8, the descending aorta, and the first two intercostal branches of the aorta. The arterial, venous, and lymphatic drainage of the oesophagus varies depending on the location, with the upper third being supplied by the inferior thyroid artery and drained by the deep cervical lymphatics, the mid-third being supplied by aortic branches and drained by azygos branches and mediastinal lymphatics, and the lower third being supplied by the left gastric artery and drained by posterior mediastinal and coeliac veins and gastric lymphatics.
The nerve supply of the oesophagus also varies, with the upper half being supplied by the recurrent laryngeal nerve and the lower half being supplied by the oesophageal plexus of the vagus nerve. The muscularis externa of the oesophagus is composed of both smooth and striated muscle, with the composition varying depending on the location.
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This question is part of the following fields:
- Gastrointestinal System
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Question 67
Incorrect
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A 67-year-old woman is currently admitted to the female orthopedic ward following a left total hip replacement after a femoral neck fracture. The surgery was uncomplicated, and the patient is expected to be discharged in four days. However, in the evening, the patient complains of feeling unwell and experiencing pain in the left hip area. The nurse records her vital signs, which include a pulse rate of 94 beats per minute, a respiratory rate of 20 breaths per minute, a blood pressure of 105/63 mmHg, and a temperature of 38.1ÂșC (100.6 degrees Fahrenheit). The ward doctor suspects a bone infection around the hip prosthesis and initiates treatment with clindamycin while awaiting review by the orthopedic surgeon. The patient's pain and suspected bone infection eventually subside, but after two days, the patient develops severe abdominal pain and diarrhea. What is the most likely causative organism responsible for this patient's condition?
Your Answer: Gram-negative, oxidase-positive comma-shaped rods
Correct Answer: Gram-positive anaerobic bacilli
Explanation:Pseudomembranous colitis is caused by the gram-positive bacillus Clostridium difficile, which can overgrow in the intestine following broad-spectrum antibiotic use. A patient recovering from a total hip replacement who develops signs of infection and is treated with clindamycin may develop severe abdominal pain and diarrhea, indicating a diagnosis of pseudomembranous colitis. Treatment options include metronidazole or oral vancomycin for more severe cases. Staphylococcus bacteria are gram-positive, catalase-positive cocci that can be differentiated based on coagulase positivity and novobiocin sensitivity. Listeria, Bacillus, and Corynebacterium are gram-positive aerobic bacilli, while Campylobacter jejuni, Vibrio cholerae, and Helicobacter pylori are gram-negative, oxidase-positive comma-shaped rods with specific growth characteristics.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 68
Incorrect
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A 50-year-old man with dyspepsia is scheduled for an upper GI endoscopy. During the procedure, an irregular erythematous area is observed protruding proximally from the gastro-oesophageal junction. To confirm a diagnosis of Barrett's esophagus, which of the following cell types must be present in addition to specialised intestinal metaplasia?
Your Answer: Macrophages
Correct Answer: Goblet cell
Explanation:The presence of goblet cells is a requirement for the diagnosis of Barrett’s esophagus.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 69
Correct
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A 28-year-old woman presents with fatigue, low energy, and lethargy. She has a medical history of migraine, ulcerative colitis, depression, and generalized anxiety disorder.
During the physical examination, slight pallor is noted in her eyes, but otherwise, everything appears normal.
The results of her blood test from this morning are as follows:
- Hemoglobin (Hb): 98 g/l
- Platelets: 300 * 109/l
- White blood cells (WBC): 6 * 109/l
- Mean corpuscular volume (MCV): 112
- C-reactive protein (CRP): 5 mg/L
- Erythrocyte sedimentation rate (ESR): 5 mm/hr
- Thyroid function test (TFT): normal
Based on these findings, what is the most likely cause of her symptoms and abnormal blood results?Your Answer: Long-term use of sulfasalazine
Explanation:Sulphasalazine is the likely cause of megaloblastic anaemia in this patient, as her blood results indicate macrocytic anaemia and she has a history of ulcerative colitis for which she is taking the medication. Microcytic anaemia is commonly caused by poor iron intake, while sickle cell anaemia causes microcytic anaemia. Long-term use of sumatriptan is not associated with macrocytic anaemia. Although hypothyroidism can cause macrocytic anaemia, this option is incorrect as the patient’s thyroid function tests are normal.
Aminosalicylate Drugs for Inflammatory Bowel Disease
Aminosalicylate drugs are commonly used to treat inflammatory bowel disease (IBD). These drugs work by releasing 5-aminosalicyclic acid (5-ASA) in the colon, which acts as an anti-inflammatory agent. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis.
Sulphasalazine is a combination of sulphapyridine and 5-ASA. However, many of the side effects associated with this drug are due to the sulphapyridine component, such as rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Mesalazine is a delayed release form of 5-ASA that avoids the sulphapyridine side effects seen in patients taking sulphasalazine. However, it is still associated with side effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis.
Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken down by colonic bacteria. It is important to note that aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis. Therefore, a full blood count is a key investigation in an unwell patient taking these drugs. Pancreatitis is also more common in patients taking mesalazine compared to sulfasalazine.
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This question is part of the following fields:
- Gastrointestinal System
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Question 70
Incorrect
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Mobilization of the left lobe of the liver will aid in accessing which surgical area?
Your Answer: Pylorus of stomach
Correct Answer: Abdominal oesophagus
Explanation:The posterior fundus of the stomach is located while the inferolateral position is occupied by the pylorus. In order to access the proximal stomach and abdominal esophagus during a total gastrectomy, it is helpful to divide the ligaments that hold the left lobe of the liver. However, this maneuver is not usually necessary during a distal gastrectomy.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 71
Incorrect
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A 57-year-old woman is scheduled for a left hemicolectomy to treat splenic flexure carcinoma. The surgical team plans to perform a high ligation of the inferior mesenteric vein. Typically, what does this structure drain into?
Your Answer:
Correct Answer: Splenic vein
Explanation:Colonic surgery carries the risk of ureteric injury, which should be taken into consideration.
Ileus can be caused during surgery when the inferior mesenteric vein joins the splenic vein near the duodenum, which is a known complication.
Anatomy of the Left Colon
The left colon is a part of the large intestine that passes inferiorly and becomes extraperitoneal in its posterior aspect. It is closely related to the ureter and gonadal vessels, which may be affected by disease processes. At a certain level, the left colon becomes the sigmoid colon, which is wholly intraperitoneal once again. The sigmoid colon is highly mobile and may even be found on the right side of the abdomen. As it passes towards the midline, the taenia blend marks the transition between the sigmoid colon and upper rectum.
The blood supply of the left colon comes from the inferior mesenteric artery. However, the marginal artery, which comes from the right colon, also contributes significantly. This contribution becomes clinically significant when the inferior mesenteric artery is divided surgically, such as during an abdominal aortic aneurysm repair. Understanding the anatomy of the left colon is important for diagnosing and treating diseases that affect this part of the large intestine.
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This question is part of the following fields:
- Gastrointestinal System
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Question 72
Incorrect
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A 56-year-old accountant presents to the hospital with severe abdominal pain that has been ongoing for more than 3 hours. The pain is sharp and extends to his back, and he rates it as 8/10 on the pain scale. The pain subsides when he sits up. During the examination, he appears restless, cold, and clammy, with a pulse rate of 124 bpm and a blood pressure of 102/65. You notice some purple discoloration in his right flank, and his bowel sounds are normal. According to his social history, he has a history of excessive alcohol consumption. What is the most probable diagnosis?
Your Answer:
Correct Answer: Acute pancreatitis
Explanation:Pancreatitis is the most probable diagnosis due to several reasons. Firstly, the patient’s history indicates that he is an alcoholic, which is a risk factor for pancreatitis. Secondly, the severe and radiating pain to the back is a typical symptom of pancreatitis. Additionally, the patient shows signs of jaundice and circulation collapse, with a purple discoloration known as Grey Turner’s sign caused by retroperitoneal hemorrhage. On the other hand, appendicitis pain is usually colicky, localized in the lower right quadrant, and moves up centrally. Although circulation collapse may indicate intestinal obstruction, the absence of vomiting/nausea makes it less likely. Chronic kidney disease can be ruled out as it presents with symptoms such as weight loss, tiredness, bone pain, and itchy skin, which are not present in this acute presentation. Lastly, if there was a significant history of recent surgery, ileus and obstruction would be more likely, and the absence of bowel sounds would support this diagnosis.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 73
Incorrect
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A 60-year-old man comes to the hospital complaining of intense upper abdominal pain, fever, and vomiting. After diagnosis, he is found to have acute pancreatitis. Among the liver function tests, which one is significantly elevated in cases of pancreatitis?
Your Answer:
Correct Answer: Amylase
Explanation:Acute pancreatitis is a condition that is primarily caused by gallstones and alcohol consumption in the UK. However, there are other factors that can contribute to the development of this condition. A popular mnemonic used to remember these factors is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine. CT scans can show diffuse parenchymal enlargement with oedema and indistinct margins in patients with acute pancreatitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 74
Incorrect
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A 58-year-old man is having a superficial parotidectomy for a pleomorphic adenoma. What is the most superficially located structure encountered during the dissection of the parotid?
Your Answer:
Correct Answer: Facial nerve
Explanation:The facial nerve is situated at the surface of the parotid gland, followed by the retromandibular vein at a slightly deeper level, and the arterial layer at the deepest level.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 75
Incorrect
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A 50-year-old obese woman presents with right upper quadrant abdominal pain, nausea and vomiting. She has a family history of gallstone disease. Upon physical examination, a positive Murphy's sign is observed. An abdominal ultrasound reveals gallstones in the thickened gallbladder. The surgeon opts for a laparoscopic cholecystectomy to remove the gallbladder. During the procedure, the surgeon identifies and dissects the hepatobiliary triangle to safely ligate and divide two structures.
What are the two structures being referred to in the above scenario?Your Answer:
Correct Answer: Cystic duct and cystic artery
Explanation:During laparoscopic cholecystectomy, the hepatobiliary triangle plays a crucial role in ensuring the safe ligation and division of the cystic duct and cystic artery. Surgeons must carefully dissect this area to identify these structures and avoid any potential biliary complications.
The hepatobiliary triangle is bordered by the common hepatic duct, which is formed by the union of the common bile duct and cystic duct. The cystic artery branches off from the right hepatic artery, while Lund’s node serves as the sentinel lymph node of the gallbladder.
The accessory duct is considered auxiliary to the biliary tree, and the left and right hepatic ducts merge into the common hepatic duct. The gastroduodenal artery arises from the common hepatic artery, and the cystic vein helps distinguish between the cystic and common hepatic ducts during surgery, but is not ligated.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 76
Incorrect
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A 65-year-old man has been diagnosed with colorectal cancer. He underwent an open right hemicolectomy to remove the tumor. The pathology report indicates that the cancer has invaded the muscularis propria of the bowel wall but has not reached the serosal layer. Out of the 20 lymph nodes removed, 3 were positive for metastatic disease. A PET scan revealed no distant metastases. What is the TNM clinical classification of this patient's colorectal cancer?
Your Answer:
Correct Answer: T2 N1 M0
Explanation:The TNM classification system for colon cancer includes assessment of the primary tumor (T), regional lymph nodes (N), and distant metastasis (M). The T category ranges from TX (primary tumor cannot be assessed) to T4b (tumor directly invades or adheres to other organs or structures). The N category ranges from NX (regional lymph nodes cannot be assessed) to N2b (metastasis in 7 or more regional lymph nodes). The M category ranges from M0 (no distant metastasis) to M1b (metastases in more than 1 organ/site or the peritoneum).
Colorectal cancer referral guidelines were updated by NICE in 2015. Patients who are 40 years or older with unexplained weight loss and abdominal pain, those who are 50 years or older with unexplained rectal bleeding, and those who are 60 years or older with iron deficiency anaemia or a change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients with positive results for occult blood in their faeces should also be referred urgently.
An urgent referral should be considered if there is a rectal or abdominal mass, an unexplained anal mass or anal ulceration, or if patients under 50 years old have rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anaemia.
The NHS offers a national screening programme for colorectal cancer every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post. FIT is a type of faecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, those under 60 years old with changes in their bowel habit or iron deficiency anaemia, and those who are 60 years or older who have anaemia even in the absence of iron deficiency.
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This question is part of the following fields:
- Gastrointestinal System
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Question 77
Incorrect
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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 manâs 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 patientâs 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 78
Incorrect
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A 67-year-old male is receiving treatment for his colorectal cancer from the oncology team at his nearby hospital. What type of colorectal carcinoma is most frequently encountered?
Your Answer:
Correct Answer: Adenocarcinoma
Explanation:The most common type of colorectal cancer is adenocarcinoma, which originates from the mucosal lining of the colon. Initially, it develops as a benign adenoma from glandular cells of the mucosa, which later transforms into a malignant form.
Squamous cell carcinoma arises from squamous cells, which are not present in the colon. Ductal carcinoma is a breast cancer that originates from ductal cells. Basal cell carcinoma is a type of skin cancer, while mesothelioma is a malignancy that affects the mesothelium, commonly found in the lining of the chest wall.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 79
Incorrect
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A 40-year-old male presents with a six-month history of frequent diarrhoea. He describes up to ten episodes a day of bloody stool. The patient denies any night sweats, fever, or weight loss, explains that he has not changed his diet recently.
On examination he has;
Normal vital signs
No ulcerations in his mouth
Mild lower abdominal tenderness
Pain and blood noted on rectal examination
What is the most probable finding on colonoscopy or biopsy?Your Answer:
Correct Answer: Crypt abscesses
Explanation:ASCA, also known as anti-Saccharomyces cerevisiae antibodies, can be abbreviated as 6.
Inflammatory bowel disease (IBD) is a condition that includes two main types: Crohn’s disease and ulcerative colitis. Although they share many similarities in terms of symptoms, diagnosis, and treatment, there are some key differences between the two. Crohn’s disease is characterized by non-bloody diarrhea, weight loss, upper gastrointestinal symptoms, mouth ulcers, perianal disease, and a palpable abdominal mass in the right iliac fossa. On the other hand, ulcerative colitis is characterized by bloody diarrhea, abdominal pain in the left lower quadrant, tenesmus, gallstones, and primary sclerosing cholangitis. Complications of Crohn’s disease include obstruction, fistula, and colorectal cancer, while ulcerative colitis has a higher risk of colorectal cancer than Crohn’s disease. Pathologically, Crohn’s disease lesions can be seen anywhere from the mouth to anus, while ulcerative colitis inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. Endoscopy and radiology can help diagnose and differentiate between the two types of IBD.
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This question is part of the following fields:
- Gastrointestinal System
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Question 80
Incorrect
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A 67-year-old man comes to the emergency department complaining of abrupt abdominal pain. He reports the pain as cramping, with a severity of 6/10, and spread throughout his abdomen. The patient has a medical history of hypertension and type 2 diabetes mellitus. He used to smoke and has a smoking history of 40 pack years.
What is the most probable part of the colon affected in this patient?Your Answer:
Correct Answer: Splenic flexure
Explanation:Ischaemic colitis frequently affects the splenic flexure, which is a vulnerable area due to its location at the border of regions supplied by different arteries. Symptoms such as cramping and generalised abdominal pain, along with a history of smoking and hypertension, suggest a diagnosis of ischaemic colitis. While the rectosigmoid junction is also a watershed area, it is less commonly affected than the splenic flexure. Other regions of the large bowel are less susceptible to ischaemic colitis.
Understanding Ischaemic Colitis
Ischaemic colitis is a condition that occurs when there is a temporary reduction in blood flow to the large bowel. This can cause inflammation, ulcers, and bleeding. The condition is more likely to occur in areas of the bowel that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries, such as the splenic flexure.
When investigating ischaemic colitis, doctors may look for a sign called thumbprinting on an abdominal x-ray. This occurs due to mucosal edema and hemorrhage. It is important to diagnose and treat ischaemic colitis promptly to prevent complications and ensure a full recovery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 81
Incorrect
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A 25-year-old male with a history of Crohn's disease visits his gastroenterologist for a routine checkup. During the appointment, he inquires about the underlying cause of his condition. Which gene variations have been associated with Crohn's disease?
Your Answer:
Correct Answer: NOD-2
Explanation:The development of Crohn’s disease is connected to a genetic abnormality in the NOD-2 gene.
Phenylketonuria is linked to the PKU mutation.
Cystic fibrosis is associated with the CFTR mutation.
Ehlers-Danlos syndrome is connected to the COL1A1 mutation.
Understanding Crohn’s Disease
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus. The exact cause of Crohn’s disease is unknown, but there is a strong genetic component. Inflammation occurs in all layers of the affected area, which can lead to complications such as strictures, fistulas, and adhesions.
Symptoms of Crohn’s disease typically appear in late adolescence or early adulthood and can include non-specific symptoms such as weight loss and lethargy, as well as more specific symptoms like diarrhea, abdominal pain, and perianal disease. Extra-intestinal features, such as arthritis, erythema nodosum, and osteoporosis, are also common in patients with Crohn’s disease.
To diagnose Crohn’s disease, doctors may look for raised inflammatory markers, increased faecal calprotectin, anemia, and low levels of vitamin B12 and vitamin D. It’s important to note that Crohn’s disease shares some features with ulcerative colitis, another type of inflammatory bowel disease, but there are also important differences between the two conditions. Understanding the symptoms and diagnostic criteria for Crohn’s disease can help patients and healthcare providers manage this chronic condition more effectively.
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This question is part of the following fields:
- Gastrointestinal System
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Question 82
Incorrect
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A 16-year-old boy presents to the hospital with suspected appendicitis. Upon examination, he exhibits maximum tenderness at McBurney's point. Can you identify the location of McBurney's point?
Your Answer:
Correct Answer: 2/3rds laterally along the line between the umbilicus and the anterior superior iliac spine
Explanation:To locate McBurney’s point, one should draw an imaginary line from the umbilicus to the anterior superior iliac spine on the right-hand side and then find the point that is 2/3rds of the way along this line. The other choices do not provide the correct location for this anatomical landmark.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 83
Incorrect
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A 50-year-old woman arrives at the emergency department complaining of abrupt abdominal pain. She has a 35-pack-year smoking history and has been managing polycythemia vera for 10 years with intermittent phlebotomy. Upon initial evaluation, she appears alert and has a distended abdomen with shifting dullness and tender hepatomegaly. What is the probable diagnosis based on these observations?
Your Answer:
Correct Answer: Budd-Chiari syndrome
Explanation:Budd-Chiari syndrome is the correct diagnosis for this patient, as it is caused by hepatic vein thrombosis. The patient has significant risk factors for thrombophilia and is presenting with the classic triad of right upper quadrant abdominal pain, ascites (as evidenced by shifting dullness on examination), and hepatomegaly.
While decompensated cirrhosis can also cause ascites and hepatomegaly, it is unlikely to cause an acute abdomen and is more likely to present with associated jaundice and encephalopathy. Therefore, this option is incorrect.
Right-sided heart failure can also lead to ascites due to raised portosystemic pressure, but this option is incorrect as the patient does not have risk factors for heart failure apart from smoking and does not have other typical findings of heart failure such as dyspnea and peripheral edema.
Nephrotic syndrome can also cause ascites due to hypoalbuminemia-related fluid retention, but there is no mention of proteinuria or hypoalbuminemia, which typically causes peri-orbital edema. Therefore, this option is also incorrect.
Understanding Budd-Chiari Syndrome
Budd-Chiari syndrome, also known as hepatic vein thrombosis, is a condition that is often associated with an underlying hematological disease or another procoagulant condition. The causes of this syndrome include polycythemia rubra vera, thrombophilia, pregnancy, and the use of combined oral contraceptive pills. The symptoms of Budd-Chiari syndrome typically include sudden onset and severe abdominal pain, ascites leading to abdominal distension, and tender hepatomegaly.
To diagnose Budd-Chiari syndrome, an ultrasound with Doppler flow studies is usually the initial radiological investigation. This test is highly sensitive and can help identify the presence of the condition. It is important to diagnose and treat Budd-Chiari syndrome promptly to prevent complications such as liver failure and portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 84
Incorrect
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A 55-year-old man presents with odynophagia and undergoes an upper GI endoscopy. During the procedure, a reddish area is observed protruding into the esophagus from the gastroesophageal junction. What is the most probable pathological cause for this phenomenon?
Your Answer:
Correct Answer: Metaplasia
Explanation:Metaplasia is the most probable diagnosis for this condition, indicating Barretts oesophagus. However, biopsies are necessary to rule out dysplasia.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 85
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 86
Incorrect
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A 42-year-old female patient arrives at the emergency department complaining of intense abdominal pain on the right side. Upon further inquiry, she describes the pain as crampy, intermittent, and spreading to her right shoulder. She has no fever. The patient notes that the pain worsens after meals.
Which hormone is accountable for the fluctuation in pain?Your Answer:
Correct Answer: Cholecystokinin
Explanation:The hormone that increases gallbladder contraction is Cholecystokinin (CCK). It is secreted by I cells in the upper small intestine, particularly in response to a high-fat meal. Although it has many functions, its role in increasing gallbladder contraction may exacerbate biliary colic caused by gallstones in the patient described.
Gastrin, insulin, and secretin are also hormones that can be released in response to food intake, but they do not have any known effect on gallbladder contraction. Therefore, CCK is the most appropriate answer.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 87
Incorrect
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As a busy surgical trainee on the colorectal unit, you have been tasked with reviewing the histopathology results for colonic polyps. Which type of polyp described below poses the highest risk of malignant transformation? Please note that this question is specifically for a trainee who is slightly older and more experienced.
Your Answer:
Correct Answer: Villous adenoma
Explanation:The risk of malignant transformation is highest in villous adenomas, while hyperplastic polyps pose little risk. Hamartomatous polyp syndromes may increase the risk of malignancy in patients, but the polyps themselves have low malignant potential.
Understanding Colonic Polyps and Follow-Up Procedures
Colonic polyps can occur in isolation or as part of polyposis syndromes, with greater than 100 polyps typically present in FAP. The risk of malignancy is related to size, with a 10% risk in a 1 cm adenoma. While isolated adenomas seldom cause symptoms, distally sited villous lesions may produce mucous and electrolyte disturbances if very large.
Follow-up procedures for colonic polyps depend on the number and size of the polyps. Low-risk cases with 1 or 2 adenomas less than 1 cm require no follow-up or re-colonoscopy for 5 years. Moderate-risk cases with 3 or 4 small adenomas or 1 adenoma greater than 1 cm require a re-scope at 3 years. High-risk cases with more than 5 small adenomas or more than 3 with 1 of them greater than 1 cm require a re-scope at 1 year.
Segmental resection or complete colectomy may be necessary in cases of incomplete excision of malignant polyps, malignant sessile polyps, malignant pedunculated polyps with submucosal invasion, polyps with poorly differentiated carcinoma, or familial polyposis coli. Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy is recommended. Rectal polypoidal lesions may be treated with trans anal endoscopic microsurgery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 88
Incorrect
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A 35-year-old woman came in with a 7-month history of upper abdominal pain and nausea. She reported no weight loss. An upper GI endoscopy showed mild gastritis, but her symptoms persisted even after a 3-month course of proton pump inhibitors. A CT scan was done and revealed a probable gastrinoma. Which type of cell does the hormone produced by this tumor target to stimulate acid secretion?
Your Answer:
Correct Answer: Parietal cell
Explanation:The secretion of H+ by gastric parietal cells is increased by gastrin.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 89
Incorrect
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A 30-year-old male presents to his general practitioner complaining of jaundice and fatigue that has been present for the past 2 days. He mentions that he has experienced similar symptoms in the past but has never sought medical attention until now. He reports having a severe case of the flu recently. The patient has no significant medical history and leads a healthy lifestyle, abstaining from alcohol and smoking.
What enzyme deficiency is likely responsible for this condition?Your Answer:
Correct Answer: UDP glucuronosyltransferase
Explanation:Individuals with Gilbert’s syndrome exhibit a decrease in the amount of UDP glucuronosyltransferase, an enzyme responsible for conjugating bilirubin in the liver. This deficiency leads to an accumulation of unconjugated bilirubin, which cannot be eliminated through urine, resulting in jaundice. Although symptoms may arise during periods of stress, the condition is generally not clinically significant.
HMG-CoA reductase is an enzyme involved in cholesterol synthesis, while lipoprotein lipase plays a central role in lipid metabolism and is associated with various conditions such as hypertriglyceridemia. G6PD deficiency, on the other hand, affects the pentose phosphate pathway by reducing the production of NADPH.
Gilbert’s syndrome is a genetic disorder that affects the way bilirubin is processed in the body. It is caused by a deficiency of UDP glucuronosyltransferase, which leads to unconjugated hyperbilirubinemia. This means that bilirubin is not properly broken down and eliminated from the body, resulting in jaundice. However, jaundice may only be visible during certain conditions such as fasting, exercise, or illness. The prevalence of Gilbert’s syndrome is around 1-2% in the general population.
To diagnose Gilbert’s syndrome, doctors may look for a rise in bilirubin levels after prolonged fasting or the administration of IV nicotinic acid. However, treatment is not necessary for this condition. While the exact mode of inheritance is still debated, it is known to be an autosomal recessive disorder.
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This question is part of the following fields:
- Gastrointestinal System
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Question 90
Incorrect
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A 55-year-old man with a carcinoma of the lower third of the oesophagus is having an oesophagogastrectomy. During the mobilization of the lower part of the oesophagus, where is the thoracic duct most likely to be encountered by the surgeons?
Your Answer:
Correct Answer: Posterior to the oesophagus
Explanation:The thoracic duct is situated at the back of the oesophagus and takes a leftward course at the Angle of Louis. It joins the aorta at T12 as it enters the thorax.
The Thoracic Duct: Anatomy and Clinical Significance
The thoracic duct is a continuation of the cisterna chyli located in the abdomen. It enters the thorax at the level of T12 and runs posterior to the esophagus for most of its intrathoracic course. At T5, it passes to the left side of the body. Lymphatics from the left side of the head and neck join the thoracic duct before it empties into the left brachiocephalic vein. In contrast, lymphatics from the right side of the head and neck drain into the right lymphatic duct, which eventually empties into the right brachiocephalic vein via the mediastinal trunk.
The thoracic duct’s location in the thorax makes it vulnerable to injury during oesophageal surgery. To avoid damaging the duct, some surgeons apply cream to patients before oesophagectomy to help identify the cut ends of the duct. Understanding the anatomy and clinical significance of the thoracic duct is essential for healthcare professionals involved in thoracic surgery and lymphatic drainage disorders.
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This question is part of the following fields:
- Gastrointestinal System
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Question 91
Incorrect
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A 28-year-old man comes to you with a lump in his testicle. As you take his history, you wonder which of the following factors poses the greatest risk for testicular cancer?
Your Answer:
Correct Answer: Cryptorchidism
Explanation:Testicular cancer is more likely to occur in men who have had undescended testis, with a 40-fold increase in risk. Other risk factors include being of white ethnicity, being between the ages of 15-35, and not having had testicular trauma.
Cryptorchidism: Undescended Testis in Boys
Cryptorchidism is a congenital condition where one or both testes fail to descend into the scrotum by the age of 3 months. Although the cause of this condition is mostly unknown, it may be associated with other congenital defects such as abnormal epididymis, cerebral palsy, mental retardation, Wilms tumour, and abdominal wall defects. Retractile testes and intersex conditions should be considered in the differential diagnosis.
Correcting cryptorchidism is important to reduce the risk of infertility, examine the testes for testicular cancer, avoid testicular torsion, and improve cosmetic appearance. Males with undescended testis are at a higher risk of developing testicular cancer, especially if the testis is intra-abdominal.
The treatment for cryptorchidism is orchidopexy, which is usually performed between 6 to 18 months of age. The procedure involves exploring the inguinal area, mobilizing the testis, and implanting it into a dartos pouch. In cases where the testis is intra-abdominal, laparoscopic evaluation and mobilization may be necessary. If left untreated, the Sertoli cells will degrade after the age of 2 years, and orchidectomy may be a better option for those presenting late in their teenage years.
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This question is part of the following fields:
- Gastrointestinal System
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Question 92
Incorrect
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A 72-year-old man is receiving an angiogram to investigate gastrointestinal bleeding. During the procedure, the radiologist inserts the catheter into the coeliac axis. What is the usual spinal level where this vessel originates from the aorta?
Your Answer:
Correct Answer: T12
Explanation:The coeliac axis is positioned at T12 and branches off the aorta at an almost horizontal angle. It comprises three significant branches.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 93
Incorrect
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A 56-year-old female patient who underwent tubal ligation presents to her general practitioner with complaints of abdominal pain, flank pain, visible blood in her urine, and involuntary urinary leakage. She has a history of lithotripsy for renal calculi one year ago. A CT scan of her abdomen and pelvis reveals an intra-abdominal fluid collection. What is the most probable diagnosis?
Your Answer:
Correct Answer: Ureter injury
Explanation:The patient’s symptoms and CT findings suggest that they may have suffered iatrogenic damage to their ureters, which are retroperitoneal organs. This can lead to fluid accumulation in the retroperitoneal space, causing haematuria, abdominal/flank pain, and incontinence. While calculi and lithotripsy can damage the ureter mucosal lining, they are unlikely to have caused fluid accumulation in the intra-abdominal cavity, especially since the lithotripsy was performed a year ago. Pelvic inflammatory disease and urinary tract infections can cause similar symptoms, but their CT findings would be different.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 94
Incorrect
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A 27-year-old man is stabbed in the groin and the area within the femoral triangle needs to be examined. What forms the lateral wall of the femoral triangle?
Your Answer:
Correct Answer: Sartorius
Explanation:Understanding the Anatomy of the Femoral Triangle
The femoral triangle is an important anatomical region located in the upper thigh. It is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. The floor of the femoral triangle is made up of the iliacus, psoas major, adductor longus, and pectineus muscles, while the roof is formed by the fascia lata and superficial fascia. The superficial inguinal lymph nodes and the long saphenous vein are also found in this region.
The femoral triangle contains several important structures, including the femoral vein, femoral artery, femoral nerve, deep and superficial inguinal lymph nodes, lateral cutaneous nerve, great saphenous vein, and femoral branch of the genitofemoral nerve. The femoral artery can be palpated at the mid inguinal point, making it an important landmark for medical professionals.
Understanding the anatomy of the femoral triangle is important for medical professionals, as it is a common site for procedures such as venipuncture, arterial puncture, and nerve blocks. It is also important for identifying and treating conditions that affect the structures within this region, such as femoral hernias and lymphadenopathy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 95
Incorrect
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A 72-year-old man presents to his physician with a gradual yellowing of his skin. During the examination, the physician observes jaundiced sclerae and palpates a round mass under the right costal margin, measuring approximately 4 cm in diameter. The patient's abdomen is soft, non-tender, and not distended.
The physician orders a blood test, which reveals the following results:
- Bilirubin: 180 ”mol/L (3 - 17)
- ALP: 98 u/L (30 - 100)
- ALT: 36 u/L (3 - 40)
- ÎłGT: 71 u/L (8 - 60)
- Albumin: 43 g/L (35 - 50)
What clinical sign is evident, and what is the probable diagnosis?Your Answer:
Correct Answer: Courvoisier's sign indicating biliary tract cancer
Explanation:If a patient has painless jaundice and a palpable gallbladder in the right upper quadrant, it is unlikely to be caused by gallstones and more likely to be a malignancy. This is known as Courvoisier’s sign, and the most common cancers associated with it are cholangiocarcinoma and adenocarcinoma of the pancreatic head.
Rovsing’s sign is a sign of acute appendicitis, where palpation of the left lower quadrant causes pain in the right lower quadrant.
Virchow’s sign is the presence of a palpable left supraclavicular lymph node, which is a sign of metastatic gastric cancer.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 96
Incorrect
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A 65-year-old man comes to the emergency department with a significant swelling in his abdomen. He confesses to consuming more alcohol since losing his job five years ago, but he has no other significant medical history.
During the examination, the doctor observes shifting dullness. To confirm the suspicion of portal hypertension, the doctor orders liver function tests and an ascitic tap (paracentesis).
What result from the tests would provide the strongest indication of portal hypertension?Your Answer:
Correct Answer: Serum-ascites albumin gradient (SAAG) of 13.1 g/L
Explanation:Ascites is a medical condition characterized by the accumulation of abnormal amounts of fluid in the abdominal cavity. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. If the SAAG level is greater than 11g/L, it indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. Other causes of portal hypertension include cardiac conditions like right heart failure and constrictive pericarditis, as well as infections like tuberculous peritonitis. On the other hand, if the SAAG level is less than 11g/L, ascites may be caused by hypoalbuminaemia, malignancy, pancreatitis, bowel obstruction, and other conditions.
The management of ascites involves reducing dietary sodium and sometimes fluid restriction if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone are often prescribed, and loop diuretics may be added if necessary. Therapeutic abdominal paracentesis may be performed for tense ascites, and large-volume paracentesis requires albumin cover to reduce the risk of complications. Prophylactic antibiotics may also be given to prevent spontaneous bacterial peritonitis. In some cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.
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This question is part of the following fields:
- Gastrointestinal System
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Question 97
Incorrect
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A woman undergoes a high anterior resection for carcinoma of the upper rectum. Which one of the following vessels will require ligation?
Your Answer:
Correct Answer: Inferior mesenteric artery
Explanation:Anterior resection typically involves dividing the IMA, which is necessary for oncological reasons and also allows for adequate mobilization of the colon for anastomosis.
The colon begins with the caecum, which is the most dilated segment of the colon and is marked by the convergence of taenia coli. The ascending colon follows, which is retroperitoneal on its posterior aspect. The transverse colon comes after passing the hepatic flexure and becomes wholly intraperitoneal again. The splenic flexure marks the point where the transverse colon makes an oblique inferior turn to the left upper quadrant. The descending colon becomes wholly intraperitoneal at the level of L4 and becomes the sigmoid colon. The sigmoid colon is wholly intraperitoneal, but there are usually attachments laterally between the sigmoid and the lateral pelvic sidewall. At its distal end, the sigmoid becomes the upper rectum, which passes through the peritoneum and becomes extraperitoneal.
The arterial supply of the colon comes from the superior mesenteric artery and inferior mesenteric artery, which are linked by the marginal artery. The ascending colon is supplied by the ileocolic and right colic arteries, while the transverse colon is supplied by the middle colic artery. The descending and sigmoid colon are supplied by the inferior mesenteric artery. The venous drainage comes from regional veins that accompany arteries to the superior and inferior mesenteric vein. The lymphatic drainage initially follows nodal chains that accompany supplying arteries, then para-aortic nodes.
The colon has both intraperitoneal and extraperitoneal segments. The right and left colon are part intraperitoneal and part extraperitoneal, while the sigmoid and transverse colon are generally wholly intraperitoneal. The colon has various relations with other organs, such as the right ureter and gonadal vessels for the caecum/right colon, the gallbladder for the hepatic flexure, the spleen and tail of pancreas for the splenic flexure, the left ureter for the distal sigmoid/upper rectum, and the ureters, autonomic nerves, seminal vesicles, prostate, and urethra for the rectum.
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This question is part of the following fields:
- Gastrointestinal System
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Question 98
Incorrect
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A 4-day old neonate with Down's syndrome is experiencing excessive vomiting during their stay in the ward. The mother had an uncomplicated full-term pregnancy. The baby has not yet had their first bowel movement, causing increased concern for the parents. Upon examination, there is slight abdominal distension. Where is the site of pathology within the colon?
Your Answer:
Correct Answer: Muscularis propria externa
Explanation:The myenteric nerve plexus, also known as Auerbach’s plexus, is located within the muscularis externa, which is one of the four layers of the bowel. In neonates with Hirschsprung disease, there is a lack of ganglion cells in the myenteric plexus, resulting in a lack of peristalsis and symptoms such as nausea, vomiting, bloating, and delayed passage of meconium. This condition is more common in males and children with Down’s syndrome.
The four layers of the bowel, from deep to superficial, are the mucosa, submucosa, muscularis propria (externa), and serosa. The muscularis externa contains two layers of smooth muscle, the inner circular layer and the outer longitudinal layer, with the myenteric plexus located between them. The mucosa also contains a thin layer of connective tissue called the lamina propria.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 99
Incorrect
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A 55-year-old man comes to the emergency department complaining of sudden abdominal pain in the epigastric region. He has a history of heavy alcohol consumption, but this is his first visit to the department. Upon examination, he is sweating profusely and has a fever. His heart rate is 130 beats per minute, and his blood pressure is 90/60 mmHg. You diagnose him with acute pancreatitis and are concerned about potential complications.
What symptom is most likely to be present in this patient?Your Answer:
Correct Answer: Blue discolouration of the flank regions
Explanation:The patient is experiencing acute pancreatitis, possibly due to excessive alcohol consumption. As this is his first visit to the emergency department, it is unlikely to be a sudden attack on top of chronic pancreatitis. The presence of tachycardia and hypotension suggests that he is also experiencing blood loss. The correct answer should identify an acute condition associated with blood loss.
a. Bulky, greasy stools are a long-term complication of chronic pancreatitis, indicating that the pancreas has lost its exocrine function and is unable to properly digest food.
b. Grey Turner’s sign is a sign of blood pooling in the retroperitoneal space, which can occur due to inflammation of the retroperitoneal pancreas.
c. This is a complication of long-term diabetes or chronic pancreatitis.
d. Ascites is not typically associated with an acute first-time presentation of pancreatitis, although it can have many causes.
e. This description is typical of an abdominal obstruction, which may cause nausea and vomiting.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 100
Incorrect
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A 22-year-old university student with a history of primary sclerosing cholangitis presents to the gastroenterologists with symptoms suggestive of ulcerative colitis. She has been experiencing bloody diarrhoea and fatigue for the past three months, with an average of seven bowel movements per day. Her medical history includes a childhood hepatitis A infection and an uncomplicated appendicectomy three years ago. She also has a family history of hepatocellular carcinoma.
During examination, stage 1 haemorrhoids and a scar over McBurney's point are noted. Given her medical history, which condition warrants annual colonoscopy in this patient?Your Answer:
Correct Answer: Primary sclerosing cholangitis
Explanation:Annual colonoscopy is recommended for individuals who have both ulcerative colitis and PSC.
Colorectal Cancer Risk in Ulcerative Colitis Patients
Ulcerative colitis patients have a significantly higher risk of developing colorectal cancer compared to the general population. The risk is mainly related to chronic inflammation, and studies report varying rates. Unfortunately, patients with ulcerative colitis often experience delayed diagnosis, leading to a worse prognosis. Lesions may also be multifocal, further increasing the risk of cancer.
Several factors increase the risk of colorectal cancer in ulcerative colitis patients, including disease duration of more than 10 years, pancolitis, onset before 15 years old, unremitting disease, and poor compliance to treatment. To manage this risk, colonoscopy surveillance is recommended, and the frequency of surveillance depends on the patient’s risk stratification.
Patients with lower risk require a colonoscopy every five years, while those with intermediate risk require a colonoscopy every three years. Patients with higher risk require a colonoscopy every year. The risk stratification is based on factors such as the extent of colitis, the severity of active endoscopic/histological inflammation, the presence of post-inflammatory polyps, and family history of colorectal cancer. Primary sclerosing cholangitis or a family history of colorectal cancer in first-degree relatives aged less than 50 years also increase the risk of cancer. By following these guidelines, ulcerative colitis patients can receive appropriate surveillance and management to reduce their risk of developing colorectal cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 101
Incorrect
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A 3-year-old girl is brought to the emergency department due to severe abdominal pain. She has tenderness throughout her abdomen, but it is especially painful in the right iliac fossa. Her parents are concerned because they noticed blood in her stool earlier today.
The patient is admitted and receives appropriate treatment. Further investigations reveal the presence of ectopic ileal mucosa.
What is the probable underlying condition?Your Answer:
Correct Answer: Meckel's diverticulum
Explanation:Meckel’s diverticulum is the most likely diagnosis for this child’s symptoms. It is a congenital condition that affects about 2% of the population and typically presents with symptoms around the age of 2. Some children with Meckel’s diverticulum may develop diverticulitis, which can be mistaken for appendicitis. The presence of ectopic ileal mucosa is a key factor in diagnosing Meckel’s diverticulum.
Appendicitis is an unlikely diagnosis as it would not explain the presence of ectopic ileal mucosa. Duodenal atresia is also unlikely as it typically presents in newborns and is associated with Down’s syndrome. Necrotising enterocolitis is another unlikely diagnosis as it primarily affects premature infants and would not explain the ectopic ileal mucosa.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 102
Incorrect
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A 65-year-old patient is scheduled for a right hemicolectomy to treat a caecum carcinoma. Which of the following vessels will need to be high ligated for optimal oncological control?
Your Answer:
Correct Answer: Ileo-colic artery
Explanation:During a right hemicolectomy, the caecum is supplied by the ileo-colic artery which requires high ligation. It is generally recommended to preserve the middle colic artery when resecting a caecal lesion. It should be noted that the SMA does not directly supply the caecum.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 103
Incorrect
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A 72-year-old woman visits her doctor complaining of painful legs, particularly in her thighs, which occur after walking and subside on rest. She occasionally takes paracetamol to alleviate the pain. Her medical history includes hyperlipidaemia, type II diabetes mellitus, hypertension, and depression. The physician suspects that her pain may be due to claudication of the femoral artery, which is a continuation of the external iliac artery. Can you correctly identify the anatomical landmark where the external iliac artery becomes the femoral artery?
Your Answer:
Correct Answer: Inguinal ligament
Explanation:After passing the inguinal ligament, the external iliac artery transforms into the femoral artery. This means that the other options provided are not accurate. Here is a brief explanation of their anatomical importance:
– The medial edge of the sartorius muscle creates the lateral wall of the femoral triangle.
– The medial edge of the adductor longus muscle creates the medial wall of the femoral triangle.
– The femoral vein creates the lateral border of the femoral canal.
– The pectineus muscle creates the posterior border of the femoral canal.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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 104
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 105
Incorrect
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A 63-year-old man with a history of alcohol abuse presents with recurrent epigastric pain. An OGD reveals the presence of varices in the lower esophagus. To prevent variceal bleeding, which medication would be the most suitable prophylactic option?
Your Answer:
Correct Answer: Propranolol
Explanation:A non-cardioselective ÎČ blocker (NSBB) is the appropriate medication for prophylaxis against oesophageal bleeding in patients with varices. NSBBs work by causing splanchnic vasoconstriction, which reduces portal blood flow. Omeprazole, warfarin, and unfractionated heparin are not suitable options for this purpose.
Variceal haemorrhage is a serious condition that requires prompt and effective management. The initial treatment involves resuscitation of the patient, correction of clotting abnormalities, and administration of vasoactive agents such as terlipressin or octreotide. Prophylactic IV antibiotics are also recommended to reduce mortality in patients with liver cirrhosis. Endoscopic variceal band ligation is the preferred method for controlling bleeding, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. However, TIPSS can lead to exacerbation of hepatic encephalopathy, which is a common complication.
To prevent variceal haemorrhage, prophylactic measures such as propranolol and endoscopic variceal band ligation (EVL) are recommended. Propranolol has been shown to reduce rebleeding and mortality compared to placebo. EVL is superior to endoscopic sclerotherapy and should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. NICE guidelines recommend offering endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.
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This question is part of the following fields:
- Gastrointestinal System
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Question 106
Incorrect
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A 52-year-old woman comes to the clinic complaining of distension and pain on the right side of her abdomen. She has a BMI of 30 kg/mÂČ and has been diagnosed with type-2 diabetes mellitus. Upon conducting liver function tests, it was found that her Alanine Transaminase (ALT) levels were elevated. To investigate further, a liver ultrasound was ordered to examine the blood flow in and out of the liver. Which of the following blood vessels provides approximately one-third of the liver's blood supply?
Your Answer:
Correct Answer: Hepatic artery proper
Explanation: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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This question is part of the following fields:
- Gastrointestinal System
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Question 107
Incorrect
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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 37ÂșC, 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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This question is part of the following fields:
- Gastrointestinal System
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Question 108
Incorrect
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A 75-year-old woman with caecal carcinoma is having a right hemicolectomy done via a transverse incision. During the procedure, the incision is extended medially by dividing the rectus sheath, and a brisk arterial hemorrhage occurs. What vessel is the source of the damage?
Your Answer:
Correct Answer: External iliac artery
Explanation:The damaged vessel is the epigastric artery, which has its origin in the external iliac artery (as shown below).
The Inferior Epigastric Artery: Origin and Pathway
The inferior epigastric artery is a blood vessel that originates from the external iliac artery just above the inguinal ligament. It runs along the medial edge of the deep inguinal ring and then continues upwards to lie behind the rectus abdominis muscle. This artery is responsible for supplying blood to the lower abdominal wall and pelvic region. Its pathway is illustrated in the image below.
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This question is part of the following fields:
- Gastrointestinal System
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Question 109
Incorrect
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Which one of the following is not well absorbed after a gastrectomy?
Your Answer:
Correct Answer: Vitamin B12
Explanation:The absorption of Vitamin B12 is affected by post gastrectomy syndrome, while the absorption of other vitamins remains unaffected. This syndrome is characterized by the rapid emptying of food from the stomach into the duodenum, leading to symptoms such as abdominal pain, diarrhoea, and hypoglycaemia. Complications of this syndrome include malabsorption of Vitamin B12 and iron, as well as osteoporosis. Treatment involves following a diet that is high in protein and low in carbohydrates, and replacing any deficiencies in Vitamin B12, iron, and calcium.
Understanding Gastric Emptying and Its Controlling Factors
The stomach plays a crucial role in both mechanical and immunological functions. It retains solid and liquid materials, which undergo peristaltic activity against a closed pyloric sphincter, leading to fragmentation of food bolus material. Gastric acid helps neutralize any pathogens present. The time material spends in the stomach depends on its composition and volume, with amino acids and fat delaying gastric emptying.
Gastric emptying is controlled by neuronal stimulation mediated via the vagus and the parasympathetic nervous system, which favors an increase in gastric motility. Hormonal factors such as gastric inhibitory peptide, cholecystokinin, and enteroglucagon also play a role in delaying or increasing gastric emptying.
Diseases affecting gastric emptying can lead to bacterial overgrowth, retained food, and the formation of bezoars that may occlude the pylorus and worsen gastric emptying. Gastric surgery can also have profound effects on gastric emptying, with vagal disruption causing delayed emptying.
Diabetic gastroparesis is predominantly due to neuropathy affecting the vagus nerve, leading to poor stomach emptying and repeated vomiting. Malignancies such as distal gastric cancer and pancreatic cancer may also obstruct the pylorus and delay emptying. Congenital hypertrophic pyloric stenosis is a disease of infancy that presents with projectile non-bile stained vomiting and is treated with pyloromyotomy.
In summary, understanding gastric emptying and its controlling factors is crucial in diagnosing and treating various diseases that affect the stomach’s function.
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This question is part of the following fields:
- Gastrointestinal System
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Question 110
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 111
Incorrect
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A 2-year-old girl is brought to the emergency department with acute abdominal pain that is generalised across her abdomen. Her parents report that the pain comes and goes and that she has been pulling her legs up to her chest when she screams, which is unusual for her. They also mention that she has been off her feeds and that her stools appear redder. During the examination, a mass is felt in the abdomen in the right lower quadrant. The girl's vital signs are as follows: blood pressure- 50/40mmHg, pulse- 176bpm, respiratory rate-30 breaths per minute, 02 saturations- 99%. What is the most likely diagnosis?
Your Answer:
Correct Answer: Intussusception
Explanation:The infant in this scenario is displaying symptoms of intussusception, including red current jelly stools and shock. Malrotation, which typically causes obstruction, can be ruled out as there is evidence of the passage of red stools. Meckel’s diverticulitis does not cause the infant to draw their knees up and is not typically associated with shock. Pyloric stenosis is characterized by projectile vomiting and not bloody stools. Acute appendicitis is not a likely diagnosis based on this presentation.
Understanding Intussusception
Intussusception is a medical condition where one part of the bowel folds into the lumen of the adjacent bowel, usually around the ileocecal region. This condition is most common in infants between 6-18 months old, with boys being affected twice as often as girls. Symptoms of intussusception include severe, crampy abdominal pain, inconsolable crying, vomiting, and bloodstained stool, which is a late sign. During a paroxysm, the infant will draw their knees up and turn pale, and a sausage-shaped mass may be felt in the right upper quadrant.
To diagnose intussusception, ultrasound is now the preferred method of investigation, which may show a target-like mass. Treatment for intussusception involves reducing the bowel by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema. If this method fails, or the child has signs of peritonitis, surgery is performed. Understanding the symptoms and treatment options for intussusception is crucial for parents and healthcare professionals to ensure prompt and effective management of this condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 112
Incorrect
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A 52-year-old woman visits her primary care physician after her spouse noticed a gradual yellowing of her eyes over the past three days. The patient reports experiencing fatigue and excessive sleepiness for several years, along with occasional bouts of intense itching. She has no significant medical history. Lab tests reveal elevated levels of alkaline phosphatase, IgM antibodies, and anti-mitochondrial antibodies. What is the underlying pathology of this patient's condition?
Your Answer:
Correct Answer: Interlobular bile duct granulomatous destruction with dense lymphocytic infiltrate
Explanation:The patient’s symptoms and laboratory findings suggest a cholestatic disease, specifically primary biliary cholangitis, which is an autoimmune condition of the biliary tract. This disease is more common in middle-aged women and can present with symptoms such as fatigue and pruritus. Non-alcoholic steatohepatitis is a metabolic syndrome-related condition characterized by triglyceride accumulation and myofibroblast proliferation, while primary sclerosing cholangitis is characterized by bile duct inflammation and sclerosis. Alcoholic hepatitis is caused by long-term alcohol misuse and is characterized by macrovesicular fatty change, spotty necrosis, and fibrosis.
Primary biliary cholangitis is a chronic liver disorder that affects middle-aged women. It is thought to be an autoimmune condition that damages interlobular bile ducts, causing progressive cholestasis and potentially leading to cirrhosis. The classic presentation is itching in a middle-aged woman. It is associated with Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Diagnosis involves immunology and imaging tests. Management includes ursodeoxycholic acid, cholestyramine for pruritus, and liver transplantation in severe cases. Complications include cirrhosis, osteomalacia and osteoporosis, and an increased risk of hepatocellular carcinoma.
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This question is part of the following fields:
- Gastrointestinal System
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Question 113
Incorrect
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A 58-year-old woman presents to the colorectal clinic with complaints of pruritus ani. During the examination, a polypoidal mass is discovered below the dentate line. A biopsy confirms the presence of squamous cell carcinoma. Which lymph node groups are at risk of metastasis from this lesion?
Your Answer:
Correct Answer: Inguinal
Explanation:If there are any injuries or abnormalities located beyond the dentate line, they will be drained towards the inguinal nodes. In some cases, this may require a block dissection of the groin.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 114
Incorrect
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A man in his early 50s arrives at the Emergency Department complaining of abdominal pain and haematemesis. Upon diagnosis, he is found to have a peptic ulcer. During his treatment, he reveals that he has been taking ibuprofen for several years. His physician informs him that this may have caused the bleeding and recommends taking omeprazole, a gastroprotective medication, in addition to his ibuprofen to lower his chances of recurrence. What is the mechanism of action of omeprazole?
Your Answer:
Correct Answer: Gastric parietal cell H+/K+-ATPase inhibition
Explanation:The irreversible blockade of H+/K+ ATPase is caused by PPIs.
Parietal cells contain H+/K+-ATPase, which is inhibited by omeprazole, a proton pump inhibitor. Therefore, any answer indicating chief cells or H+/K+-ATPase stimulation is incorrect and potentially harmful.
Ranitidine is an example of a different class of gastroprotective drugs that inhibits H2 receptors.
Understanding Proton Pump Inhibitors
Proton pump inhibitors (PPIs) are medications that work by blocking the H+/K+ ATPase in the stomach’s parietal cells. This action is irreversible and helps to reduce the amount of acid produced in the stomach. Examples of PPIs include omeprazole and lansoprazole.
Despite their effectiveness in treating conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers, PPIs can have adverse effects. These include hyponatremia and hypomagnesemia, which are low levels of sodium and magnesium in the blood, respectively. Prolonged use of PPIs can also increase the risk of osteoporosis, leading to an increased risk of fractures. Additionally, there is a potential for microscopic colitis and an increased risk of C. difficile infections.
It is important to weigh the benefits and risks of PPIs with your healthcare provider and to use them only as directed. Regular monitoring of electrolyte levels and bone density may also be necessary for those on long-term PPI therapy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 115
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 116
Incorrect
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A 9-month-old baby girl is brought to the clinic by her parents who recently moved from the Philippines. The baby has a noticeable mass in her abdomen, resembling a sausage shape. During questioning, the father mentions that the baby had vomited green substance a few hours ago. The baby is immediately referred to the hospital. What is the probable diagnosis?
Your Answer:
Correct Answer: Intussusception
Explanation:Understanding Intussusception
Intussusception is a medical condition where one part of the bowel folds into the lumen of the adjacent bowel, usually around the ileocecal region. This condition is most common in infants between 6-18 months old, with boys being affected twice as often as girls. Symptoms of intussusception include severe, crampy abdominal pain, inconsolable crying, vomiting, and bloodstained stool, which is a late sign. During a paroxysm, the infant will draw their knees up and turn pale, and a sausage-shaped mass may be felt in the right upper quadrant.
To diagnose intussusception, ultrasound is now the preferred method of investigation, which may show a target-like mass. Treatment for intussusception involves reducing the bowel by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema. If this method fails, or the child has signs of peritonitis, surgery is performed. Understanding the symptoms and treatment options for intussusception is crucial for parents and healthcare professionals to ensure prompt and effective management of this condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 117
Incorrect
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A 55-year-old inpatient needs to undergo a magnetic resonance cholangiopancreatography (MRCP) to investigate possible gallstones. However, it was discovered that the patient had consumed a fatty meal in the morning, and the medical team wants to postpone the procedure. The reason being that the patient's gallbladder would be harder to visualize due to the release of cholecystokinin (CCK) in response to the meal.
What type of cells in the intestine are responsible for secreting CCK?Your Answer:
Correct Answer: I cells
Explanation:The I cells located in the upper small intestine release cholecystokinin, a hormone that triggers the contraction of the gallbladder when fats, proteins, and amino acids are ingested. Additionally, cholecystokinin stimulates the exocrine pancreas, slows down gastric emptying by relaxing the stomach, and induces a feeling of fullness through vagal stimulation.
K and L cells secrete gastric inhibitory peptide (GIP) and glucagon-like peptide-1 (GLP-1), respectively. These incretins increase in response to glucose and regulate metabolism. GLP-1 agonists, also known as incretin mimetics, are medications that enhance the effects of these hormones.
ECL cells, found in the stomach, secrete histamine, which increases acid secretion to aid in digestion.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 118
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 119
Incorrect
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A 49-year-old woman presents to the emergency department with severe abdominal pain that started an hour ago. She reports feeling unwell recently, but this is the first time she has experienced this type of pain, which is mainly located in the right upper quadrant. During the examination, the physician notes hepatomegaly and ascites, and the patient's eyes have a slight yellow tint. An ultrasound scan reveals reduced blood flow in the hepatic veins, and there is no history of recent travel, drug use, or needlestick injury. The patient has not experienced recent weight loss, and her last menstrual period was two weeks ago. She is not taking any regular or over-the-counter medications. What condition could potentially be causing this patient's symptoms?
Your Answer:
Correct Answer: Protein C deficiency
Explanation:Budd-Chiari syndrome, which is characterized by abdominal pain, ascites, hepatomegaly, and jaundice, can be caused by hypercoagulable states such as protein C and S deficiencies. In this case, the patient’s protein C deficiency increased their risk of developing a thrombus in the hepatic veins, leading to Budd-Chiari syndrome. Other risk factors for thrombus formation include pregnancy and hepatocellular carcinoma. The use of oral contraceptives would also increase the risk of thrombus formation, while warfarin treatment would decrease it. Atrial fibrillation, on the other hand, would predispose a patient to systemic embolism, which can cause ischaemic symptoms in various arterial circulations.
Understanding Budd-Chiari Syndrome
Budd-Chiari syndrome, also known as hepatic vein thrombosis, is a condition that is often associated with an underlying hematological disease or another procoagulant condition. The causes of this syndrome include polycythemia rubra vera, thrombophilia, pregnancy, and the use of combined oral contraceptive pills. The symptoms of Budd-Chiari syndrome typically include sudden onset and severe abdominal pain, ascites leading to abdominal distension, and tender hepatomegaly.
To diagnose Budd-Chiari syndrome, an ultrasound with Doppler flow studies is usually the initial radiological investigation. This test is highly sensitive and can help identify the presence of the condition. It is important to diagnose and treat Budd-Chiari syndrome promptly to prevent complications such as liver failure and portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 120
Incorrect
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A 54-year-old man presents to the emergency department with pleuritic chest pain and shortness of breath. He is a construction worker who has a history of smoking. After diagnosis and treatment, the consultant recommends placement of a filter to reduce the risk of future incidents. A needle is inserted into the femoral vein and advanced up into the abdomen, where a filter is placed.
Based on the likely location of the filter, which of the following statements is true regarding the organ?
- It is attached to the posterior wall via a mesentery
- It is located posteriorly to the peritoneum
- It is attached to the liver via multiple ligaments
- It is wrapped in a double fold of peritoneal fat
- It is attached to the liver via an omentum
Additionally, it is important to note that the inferior vena cava is a retroperitoneal organ, and damage to it can result in a collection of blood in the retroperitoneal space.Your Answer:
Correct Answer: It is located posteriorly to the peritoneum
Explanation:The IVC is situated in the retroperitoneal space and any damage to it can result in the accumulation of blood in this area. The woman’s symptoms suggest that she may have a pulmonary embolism, which is a common complication of frequent travel. To prevent future occurrences, a filter can be inserted into the IVC. This is done by inserting a needle into the femoral vein and advancing the filter up to the level of the retroperitoneal IVC.
In contrast, intraperitoneal organs such as the small bowel are connected to the posterior wall through a mesentery. The liver is attached to both the diaphragm and the posterior abdominal wall by ligaments. The term double fold of peritoneal fat pertains to intraperitoneal organs. Finally, the lesser omentum serves as the attachment between the stomach and the liver.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 121
Incorrect
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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 ”mol/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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 122
Incorrect
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A 44-year-old female presents to her GP with persistent gastro-oesophageal reflux disease and complains of a burning pain in her chest. She is referred to a gastroenterologist who performs an endoscopy with biopsy, leading to a diagnosis of Barrett's oesophagus. Explain the metaplasia that occurs in Barrett's oesophagus and its association with an increased risk of oesophageal cancer.
Barrett's oesophagus is characterized by the metaplasia of the lower oesophageal epithelium from stratified squamous to simple columnar epithelium. This change from the normal stratified squamous epithelium increases the risk of oesophageal cancer by 30-fold and is often caused by gastro-oesophageal reflux disease.Your Answer:
Correct Answer: Stratified squamous epithelium to simple columnar
Explanation:Barrett’s oesophagus is characterized by the transformation of the lower oesophageal epithelial cells from stratified squamous to simple columnar epithelium. This change from the normal stratified squamous epithelium increases the risk of oesophageal cancer by 30 times and is often associated with gastro-oesophageal reflux disease.
Metaplasia is a reversible process where differentiated cells transform into another cell type. This change may occur as an adaptive response to stress, where cells sensitive to adverse conditions are replaced by more resilient cell types. Metaplasia can be a normal physiological response, such as the transformation of cartilage into bone. The most common type of epithelial metaplasia involves the conversion of columnar cells to squamous cells, which can be caused by smoking or Schistosomiasis. In contrast, metaplasia from squamous to columnar cells occurs in Barrett’s esophagus. If the metaplastic stimulus is removed, the cells will revert to their original differentiation pattern. However, if the stimulus persists, dysplasia may develop. Although metaplasia is not directly carcinogenic, factors that predispose to metaplasia may induce malignant transformation. The pathogenesis of metaplasia involves the reprogramming of stem cells or undifferentiated mesenchymal cells present in connective tissue, which differentiate along a new pathway.
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This question is part of the following fields:
- Gastrointestinal System
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Question 123
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 124
Incorrect
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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:
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 125
Incorrect
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A 30-year-old man is about to undergo a surgical procedure and is being catheterised. What changes will occur as the catheter enters his prostatic urethra?
Your Answer:
Correct Answer: Resistance will decrease
Explanation:The membranous urethra is narrower than the prostatic urethra, resulting in increased resistance. The prostatic urethra is angled vertically.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 126
Incorrect
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A 54-year-old man undergoes an abdomino-perineal excision of the colon and rectum and is now experiencing impotence. What is the probable cause?
Your Answer:
Correct Answer: Damage to the hypogastric plexus during mobilisation of the inferior mesenteric artery
Explanation:The most frequent cause is injury to the autonomic nerves.
During surgical procedures, there is a risk of nerve injury caused by the surgery itself. This is not only important for the patient’s well-being but also from a legal perspective. There are various operations that carry the risk of nerve damage, such as posterior triangle lymph node biopsy, Lloyd Davies stirrups, thyroidectomy, anterior resection of rectum, axillary node clearance, inguinal hernia surgery, varicose vein surgery, posterior approach to the hip, and carotid endarterectomy. Surgeons must have a good understanding of the anatomy of the area they are operating on to minimize the incidence of nerve lesions. Blind placement of haemostats is not recommended as it can also cause nerve damage.
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This question is part of the following fields:
- Gastrointestinal System
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Question 127
Incorrect
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A 56-year-old woman arrives at the emergency department complaining of abdominal pain that has been ongoing for two days. The pain is diffuse, sudden in onset, and not radiating. She has a medical history of antiphospholipid syndrome but no cirrhosis.
Upon examination, the patient is visibly jaundiced and her abdomen is noticeably distended. There is painful hepatomegaly and shifting dullness. Abdominal ultrasonography confirms the presence of ascites and venous outflow obstruction.
Which vessel is the most likely culprit for the occlusion?Your Answer:
Correct Answer: Hepatic vein
Explanation:Budd-Chiari syndrome is caused by thrombosis of the hepatic vein, resulting in symptoms such as painful hepatomegaly, jaundice, and ascites. This patient’s antiphospholipid syndrome increases their risk of thrombosis, making Budd-Chiari syndrome more likely than hepatic portal vein thrombosis. Inferior mesenteric vein thrombosis is an unlikely cause of the patient’s symptoms, while inferior vena cava thrombosis would present differently and is associated with lung malignancy.
Understanding Budd-Chiari Syndrome
Budd-Chiari syndrome, also known as hepatic vein thrombosis, is a condition that is often associated with an underlying hematological disease or another procoagulant condition. The causes of this syndrome include polycythemia rubra vera, thrombophilia, pregnancy, and the use of combined oral contraceptive pills. The symptoms of Budd-Chiari syndrome typically include sudden onset and severe abdominal pain, ascites leading to abdominal distension, and tender hepatomegaly.
To diagnose Budd-Chiari syndrome, an ultrasound with Doppler flow studies is usually the initial radiological investigation. This test is highly sensitive and can help identify the presence of the condition. It is important to diagnose and treat Budd-Chiari syndrome promptly to prevent complications such as liver failure and portal hypertension.
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This question is part of the following fields:
- Gastrointestinal System
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Question 128
Incorrect
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A 6-year-old boy complains of pain in the right iliac fossa and there is a suspicion of appendicitis. What is the embryological origin of the appendix?
Your Answer:
Correct Answer: Midgut
Explanation:Periumbilical pain may be a symptom of early appendicitis due to the fact that the appendix originates from the midgut.
Appendix Anatomy and Location
The appendix is a small, finger-like projection located at the base of the caecum. It can be up to 10cm long and is mainly composed of lymphoid tissue, which can sometimes lead to confusion with mesenteric adenitis. The caecal taenia coli converge at the base of the appendix, forming a longitudinal muscle cover over it. This convergence can aid in identifying the appendix during surgery, especially if it is retrocaecal and difficult to locate. The arterial supply to the appendix comes from the appendicular artery, which is a branch of the ileocolic artery. It is important to note that the appendix is intra-peritoneal.
McBurney’s Point and Appendix Positions
McBurney’s point is a landmark used to locate the appendix during physical examination. It is located one-third of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus. The appendix can be found in six different positions, with the retrocaecal position being the most common at 74%. Other positions include pelvic, postileal, subcaecal, paracaecal, and preileal. It is important to be aware of these positions as they can affect the presentation of symptoms and the difficulty of locating the appendix during surgery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 129
Incorrect
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A 35-year-old female patient visits the gastroenterology clinic complaining of abdominal discomfort, bloating, flatulence, and diarrhea that have persisted for 8 months. She reports that her symptoms worsen after consuming meals, particularly those high in carbohydrates. During the examination, the gastroenterologist observes no significant abdominal findings but notices rashes on her elbows and knees. As part of her diagnostic workup, the gastroenterologist is contemplating endoscopy and small bowel biopsy. What is the probable biopsy result?
Your Answer:
Correct Answer: Villous atrophy
Explanation:Coeliac disease can be diagnosed through a biopsy that shows villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia. This condition is likely the cause of the patient’s chronic symptoms, which are triggered by meals containing gluten. Fortunately, adhering to a strict gluten-free diet can reverse the villous atrophy. In some cases, coeliac disease may also present with a vesicular rash called dermatitis herpetiformis. Other pathological findings, such as mucosal defects, irregular gland-like structures, or transmural inflammation with granulomas and lymphoid aggregates, suggest different diseases.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 130
Incorrect
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As an observer in the colorectal surgical department, you spend a morning watching a colonoscopy list. A number of patients who arrive during the morning are individuals with Hereditary Non-Polyposis Colorectal Cancer (HNPCC), who are being screened to detect any early signs of colorectal cancer. What is the lifetime risk of developing colorectal cancer for individuals with this condition?
Your Answer:
Correct Answer: 90%
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 131
Incorrect
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An 73-year-old man with chronic obstructive airway disease (COPD) is admitted to your ward. He presents with dyspnea and inability to lie flat. What physical examination findings would indicate a possible diagnosis of cor pulmonale, or right-sided heart failure secondary to COPD?
Your Answer:
Correct Answer: Smooth hepatomegaly
Explanation: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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This question is part of the following fields:
- Gastrointestinal System
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Question 132
Incorrect
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A 35-year-old male presents to his general practitioner complaining of severe left flank pain that comes and goes. The doctor suspects a kidney stone and refers him for a CT scan. However, before the scan, the stone ruptures through the organ wall and urine starts to leak. Which of the following organs is most likely to come into contact with the leaked urine?
Your Answer:
Correct Answer: Inferior vena cava
Explanation:The ureters are situated behind the peritoneum and any damage to them can result in the accumulation of fluid in the retroperitoneal space.
Kidney stones are most likely to get stuck in the ureter, specifically at the uretopelvic junction, pelvic brim, or vesicoureteric junction. Since the entire ureter is located behind the peritoneum, any rupture could cause urine to leak into the retroperitoneal space. This space is connected to other organs behind the peritoneum, such as the inferior vena cava.
All the other organs mentioned are located within the peritoneum.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 133
Incorrect
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Which one of the following is not true of gastric cancer?
Your Answer:
Correct Answer: Individuals with histological evidence of signet ring cells have a lower incidence of lymph node metastasis
Explanation:Poorly differentiated gastric cancer is characterized by the presence of signet ring cells, which is linked to a higher likelihood of metastasis.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 134
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 135
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 136
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 137
Incorrect
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A 65-year-old man visits his GP complaining of watery diarrhoea that has persisted for a month. He denies any alterations to his diet or recent international travel. The patient's weight has remained stable.
During an abdominal ultrasound, a pancreatic nodule is discovered. Upon biopsy, it is determined that the nodule originates from pancreatic S cells.
What hormone is expected to be secreted by the pancreatic nodule?Your Answer:
Correct Answer: Secretin
Explanation:The correct answer is Secretin. S cells in the upper small intestine secrete this gastrointestinal hormone, which promotes the secretion of bicarbonate-rich fluid from the pancreas. Pancreatic secretinomas, a rare type of gastrointestinal neuroendocrine tumor, can cause watery diarrhea.
Cholecystokinin is another gastrointestinal hormone that promotes the contraction of the gallbladder and the secretion of bile at the ampulla of Vater. However, it does not promote the secretion of bicarbonate-rich fluid from the pancreas.
Gastrin is a gastrointestinal hormone that promotes gastric motility and the secretion of hydrochloric acid by parietal cells. It is released by the G cells of the gastric antrum.
Motilin is a gastrointestinal hormone secreted by M cells within Peyer’s patches of the small intestine, which promotes gastrointestinal motility.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 138
Incorrect
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A 45-year-old woman with a family history of multiple endocrine neoplasia type 1 visits her GP complaining of upper abdominal pain. She reports experiencing worsening dyspepsia after meals for the past three months. Upon further questioning, she discloses that she has had loose stools and unintentionally lost approximately one stone in weight during this time.
What is the typical physiological function of the hormone that is accountable for this patient's symptoms?Your Answer:
Correct Answer: Increase H+ secretion by gastric parietal cells
Explanation:The correct answer is that gastrin increases the secretion of H+ by gastric parietal cells. This patient is suffering from Zollinger-Ellison syndrome due to a gastrinoma, which results in excessive production of gastrin and an overly acidic environment in the duodenum. This leads to symptoms such as dyspepsia, diarrhoea, and weight loss, as the intestinal pH is no longer optimal for digestion. The patient’s family history of multiple endocrine neoplasia type 1 is also a clue, as this condition is associated with around 25% of gastrinomas. Gastrin’s normal function is to increase the secretion of H+ by gastric parietal cells to aid in digestion.
The options delay gastric emptying, increase H+ secretion by gastric chief cells, and stimulate pancreatic bicarbonate secretion are incorrect. Gastrin’s role is to promote digestion and increase gastric emptying, not delay it. Gastric chief cells secrete pepsinogen and gastric lipase to aid in protein and fat digestion, not H+. Finally, pancreatic bicarbonate secretion is stimulated by secretin, which is produced by duodenal S-cells, not gastrin.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 139
Incorrect
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A 65-year-old male is undergoing a Whipples procedure for adenocarcinoma of the pancreas. During the mobilisation of the pancreatic head, the surgeons come across a large vessel passing over the anterior aspect of the uncinate process. What is the probable identity of this vessel?
Your Answer:
Correct Answer: Superior mesenteric artery
Explanation:The origin of the superior mesenteric artery is the aorta, and it travels in front of the lower section of the pancreas. If this area is invaded, it is not recommended to undergo resectional surgery.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 140
Incorrect
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A 67-year-old man presents to the emergency department with vomiting blood. The medical team suspects bleeding oesophageal varices and prescribes terlipressin. The patient has a history of alcohol abuse and examination reveals ascites.
Why was terlipressin prescribed in this case?Your Answer:
Correct Answer: Vasoconstriction of splanchnic vessels
Explanation:Terlipressin works by constricting the splanchnic vessels, which increases systemic vascular resistance and promotes renal fluid reabsorption. This leads to an increase in arterial pressure and helps to treat hypovolaemic hypotension. Terlipressin also has a sympathetic stimulating effect and is an analogue of vasopressin.
Variceal haemorrhage is a serious condition that requires prompt and effective management. The initial treatment involves resuscitation of the patient, correction of clotting abnormalities, and administration of vasoactive agents such as terlipressin or octreotide. Prophylactic IV antibiotics are also recommended to reduce mortality in patients with liver cirrhosis. Endoscopic variceal band ligation is the preferred method for controlling bleeding, and the use of a Sengstaken-Blakemore tube or Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be necessary if bleeding cannot be controlled. However, TIPSS can lead to exacerbation of hepatic encephalopathy, which is a common complication.
To prevent variceal haemorrhage, prophylactic measures such as propranolol and endoscopic variceal band ligation (EVL) are recommended. Propranolol has been shown to reduce rebleeding and mortality compared to placebo. EVL is superior to endoscopic sclerotherapy and should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. NICE guidelines recommend offering endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.
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This question is part of the following fields:
- Gastrointestinal System
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Question 141
Incorrect
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A 75-year-old woman comes in with a femoral hernia. What structure makes up the lateral boundary of the femoral canal?
Your Answer:
Correct Answer: Femoral vein
Explanation:The purpose of the canal is to facilitate the natural expansion of the femoral vein located on its side.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 142
Incorrect
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A 65-year-old female patient presents to the gastroenterology clinic complaining of recurrent epigastric pain and acid reflux that has not responded to antacids or proton-pump inhibitors. Upon gastroscopy, an ulcer is discovered in the descending duodenum and a tumor is found in the antrum of the stomach. What type of cell is the origin of this tumor?
Your Answer:
Correct Answer: G cells
Explanation:Gastrin is synthesized by the G cells located in the antrum of the stomach.
Based on the symptoms presented, it is probable that the patient has a gastrinoma. This type of tumor produces an excess of gastrin, which stimulates the production of hydrochloric acid, leading to the development of peptic ulcers. Normally, gastrin is secreted by the G cells located in the antrum of the stomach.
Other cells found in the stomach include S cells, which produce secretin, I cells, which produce CCK, and D cells, which produce somatostatin. However, there is no such cell as an H cell in the stomach.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 143
Incorrect
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Mr Stent is a 56-year-old man who has been scheduled for a laparoscopic right hemicolectomy. However, he has several comorbidities that were discovered during the anaesthetic clinic. These include constipation, a latex allergy, coronary artery disease, moderately raised intracranial pressure due to a benign space occupying brain tumour, and a protein C deficiency. Considering his medical history, which of the following is an absolute contraindication to laparoscopic surgery?
Your Answer:
Correct Answer: Raised intracranial pressure
Explanation:Laparoscopic surgery should not be performed in patients with significantly raised intracranial pressure. It is important to understand the indications, complications, and contraindications of both laparoscopic and open surgery. Thrombophilia can be managed with anticoagulation, constipation is not a contraindication but may increase the risk of bowel perforation, a patient with a latex allergy should have all latex equipment removed and the theatre cleaned, and a patient with coronary artery disease may be at higher risk during anaesthesia but this will be assessed before surgery in the anaesthetics clinic.
Risks and Complications of Laparoscopy
Laparoscopy is a minimally invasive surgical procedure that involves the insertion of a small camera and instruments through small incisions in the abdomen. While it is generally considered safe, there are some risks and complications associated with the procedure.
One of the general risks of laparoscopy is the use of anaesthetic, which can cause complications such as allergic reactions or breathing difficulties. Additionally, some patients may experience a vasovagal reaction, which is a sudden drop in blood pressure and heart rate in response to abdominal distension.
Another potential complication of laparoscopy is extra-peritoneal gas insufflation, which can cause surgical emphysema. This occurs when gas used to inflate the abdomen during the procedure leaks into the surrounding tissues, causing swelling and discomfort.
Injuries to the gastro-intestinal tract and blood vessels are also possible complications of laparoscopy. These can include damage to the common iliacs or deep inferior epigastric artery, which can cause bleeding and other serious complications.
Overall, while laparoscopy is generally considered safe, it is important for patients to be aware of the potential risks and complications associated with the procedure. Patients should discuss these risks with their healthcare provider before undergoing laparoscopy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 144
Incorrect
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A patient with a history of diverticular disease presents to the surgical assessment unit with abdominal pain and a fever. Her white blood cell count is elevated, but she is otherwise stable. The diagnosis is diverticulitis. What is the best course of action for managing this condition?
Your Answer:
Correct Answer: Antibiotics, a liquid diet and analgesia
Explanation:The initial management approach for mild diverticulitis typically involves a combination of oral antibiotics, a liquid diet, and analgesia.
Understanding Diverticulitis
Diverticulitis is a condition where an out-pouching of the intestinal mucosa becomes infected. This out-pouching is called a diverticulum and the presence of these pouches is known as diverticulosis. Diverticula are common and are thought to be caused by increased pressure in the colon. They usually occur in the sigmoid colon and are more prevalent in Westerners over the age of 60. While only a quarter of people with diverticulosis experience symptoms, 75% of those who do will have an episode of diverticulitis.
Risk factors for diverticulitis include age, lack of dietary fiber, obesity (especially in younger patients), and a sedentary lifestyle. Patients with diverticular disease may experience intermittent abdominal pain, bloating, and changes in bowel habits. Those with acute diverticulitis may experience severe abdominal pain, nausea and vomiting, changes in bowel habits, and urinary symptoms. Complications may include colovesical or colovaginal fistulas.
Signs of diverticulitis include low-grade fever, tachycardia, tender lower left quadrant of the abdomen, and possibly a palpable mass. Imaging tests such as an erect chest X-ray, abdominal X-ray, and CT scan may be used to diagnose diverticulitis. Treatment may involve oral antibiotics, a liquid diet, and analgesia for mild cases. More severe cases may require hospitalization for intravenous antibiotics. Colonoscopy should be avoided initially due to the risk of perforation.
In summary, diverticulitis is a common condition that can cause significant discomfort and complications. Understanding the risk factors, symptoms, and signs of diverticulitis can help with early diagnosis and treatment.
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This question is part of the following fields:
- Gastrointestinal System
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Question 145
Incorrect
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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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 146
Incorrect
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A 55-year-old man visits his doctor for the third time complaining of general fatigue and feeling mentally cloudy. Upon conducting another blood test, the doctor discovers that the patient has extremely low levels of vitamin B12. The diagnosis is pernicious anemia caused by antibodies against intrinsic factor. What are the cells in the gastrointestinal tract responsible for secreting intrinsic factor?
Your Answer:
Correct Answer: Parietal cells
Explanation:The cause of pernicious anaemia is an autoimmune response that targets intrinsic factor and possibly gastric parietal cells, leading to their destruction. These cells are responsible for producing intrinsic factor, which is necessary for the absorption of vitamin B12 in the small intestine.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 147
Incorrect
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A 48-year-old man is under your care after being diagnosed with pneumonia. On the day before his expected discharge, he experiences severe diarrhea without blood and needs intravenous fluids. A request for stool culture is made.
What would the microbiology report likely indicate as the responsible microbe?Your Answer:
Correct Answer: Gram-positive bacillus
Explanation:Clostridium difficile is a type of gram-positive bacillus that can cause pseudomembranous colitis, particularly after the use of broad-spectrum antibiotics.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 148
Incorrect
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A 50-year-old construction worker presents with a haematemesis.
His wife provides a history that he has consumed approximately six cans of beer per day together with liberal quantities of whiskey for many years. He has attempted to quit drinking in the past but was unsuccessful.
Upon examination, he appears distressed and disoriented. His pulse is 110 beats per minute and blood pressure is 112/80 mmHg. He has several spider naevi over his chest. Abdominal examination reveals a distended abdomen with ascites.
What would be your next course of action for this patient?Your Answer:
Correct Answer: Endoscopy
Explanation:Possible Causes of Haematemesis in a Patient with Alcohol Abuse
When a patient with a history of alcohol abuse presents with symptoms of chronic liver disease and sudden haematemesis, the possibility of bleeding oesophageal varices should be considered as the primary diagnosis. However, other potential causes such as peptic ulceration or haemorrhagic gastritis should also be taken into account. To determine the exact cause of the bleeding, an urgent endoscopy should be requested. This procedure will allow for a thorough examination of the gastrointestinal tract and enable the medical team to identify the source of the bleeding. Prompt diagnosis and treatment are crucial in managing this potentially life-threatening condition.
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This question is part of the following fields:
- Gastrointestinal System
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Question 149
Incorrect
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A 16-year-old boy is diagnosed with Meckel's diverticulum. What embryological structure does it originate from?
Your Answer:
Correct Answer: Vitello-intestinal duct
Explanation:The Meckel’s diverticulum is a condition where the vitello-intestinal duct persists, and it is characterized by being 2 inches (5cm) long, located 2 feet (60 cm) from the ileocaecal valve, 2 times more common in men, and involving 2 tissue types.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 150
Incorrect
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What is the nerve root value of the external urethral sphincter?
Your Answer:
Correct Answer: S2, S3, S4
Explanation:The pudendal nerve branches provide innervation to the external urethral sphincter, indicating that the root values are S2, S3, S4.
Urethral Anatomy: Differences Between Male and Female
The anatomy of the urethra differs between males and females. In females, the urethra is shorter and more angled than in males. It is located outside of the peritoneum and is surrounded by the endopelvic fascia. The neck of the bladder is subject to intra-abdominal pressure, and any weakness in this area can lead to stress urinary incontinence. The female urethra is surrounded by the external urethral sphincter, which is innervated by the pudendal nerve. It is located in front of the vaginal opening.
In males, the urethra is much longer and is divided into four parts. The pre-prostatic urethra is very short and lies between the bladder and prostate gland. The prostatic urethra is wider than the membranous urethra and contains several openings for the transmission of semen. The membranous urethra is the narrowest part of the urethra and is surrounded by the external sphincter. The penile urethra travels through the corpus spongiosum on the underside of the penis and is the longest segment of the urethra. The bulbo-urethral glands open into the spongiose section of the urethra.
The urothelium, which lines the inside of the urethra, is transitional near the bladder and becomes squamous further down the urethra. Understanding the differences in urethral anatomy between males and females is important for diagnosing and treating urological conditions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 151
Incorrect
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A 70-year-old woman visits her doctor as she has discovered a lump in her groin. She reports feeling well otherwise and has not experienced any changes in bowel movements or abdominal discomfort. The patient mentions that the lump tends to increase in size throughout the day, particularly when she is busy looking after her grandchildren. She has never undergone abdominal surgery. The doctor suspects a hernia and upon examination, identifies that it can be reduced and locates the hernia's neck, which is situated inferiorly and laterally to the pubic tubercle. What is the probable cause of the patient's groin lump?
Your Answer:
Correct Answer: Femoral hernia
Explanation:Femoral hernias are more prevalent in women than men, and their location at the neck of the hernia, which is inferior and lateral to the pubic tubercle, is indicative of a femoral hernia. On the other hand, an inguinal hernia would have its neck located superior and medial to the pubic tubercle, while both direct and indirect inguinal hernias share this characteristic. Since the patient has no surgical history, this cannot be an incisional hernia. A spigelian hernia, on the other hand, occurs when there is a herniation through the spigelian fascia, which is located along the semilunar line.
Understanding Inguinal Hernias
Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main symptom is a lump in the groin area, which disappears when pressure is applied or when the patient lies down. Discomfort and aching are also common, especially during physical activity. However, severe pain is rare, and strangulation is even rarer.
The traditional classification of inguinal hernias into indirect and direct types is no longer relevant in clinical management. Instead, the current consensus is to treat medically fit patients, even if they are asymptomatic. A hernia truss may be an option for those who are not fit for surgery, but it has limited use in other patients. Mesh repair is the preferred method, as it has the lowest recurrence rate. Unilateral hernias are usually repaired through an open approach, while bilateral and recurrent hernias are repaired laparoscopically.
After surgery, patients are advised to return to non-manual work after 2-3 weeks for open repair and 1-2 weeks for laparoscopic repair. Complications may include early bruising and wound infection, as well as late chronic pain and recurrence. It is important to seek medical attention if any of these symptoms occur.
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This question is part of the following fields:
- Gastrointestinal System
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Question 152
Incorrect
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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:
Correct 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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This question is part of the following fields:
- Gastrointestinal System
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Question 153
Incorrect
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A 56-year-old man presents to the emergency department with profuse haematemesis. Upon admission, his vital signs include a temperature of 36.9ÂșC, oxygen saturation of 94% on air, heart rate of 124 beats per minute, respiratory rate of 26 breaths per minute, and blood pressure of 82/58 mmHg. An urgent endoscopy was performed to achieve haemostasis, revealing an ulcer on the posterior wall of the duodenum. Which artery is the most likely source of the gastrointestinal bleed?
Your Answer:
Correct Answer: Gastroduodenal artery
Explanation:Duodenal ulcers on the posterior wall pose a risk to the gastroduodenal artery, which supplies blood to this area. The posterior wall is a common site for duodenal ulcers, and erosion of the ulcer through the duodenal wall can result in severe upper gastrointestinal bleeding. The inferior mesenteric artery, on the other hand, supplies blood to the hindgut (transverse colon, descending colon, and sigmoid colon) and does not include the duodenum. The inferior pancreaticoduodenal artery, which arises from the superior mesenteric artery, supplies the lower part of the duodenum but does not provide the majority of the blood supply to the posterior duodenal wall, which is mainly supplied by the gastroduodenal artery.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 154
Incorrect
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A 45-year-old man experiences a pelvic fracture with a complication involving the junction of the membranous urethra and bulbar urethra. What is the most probable direction for the leaked urine to flow?
Your Answer:
Correct Answer: Anteriorly into the connective tissues surrounding the scrotum
Explanation:The superficial perineal pouch is a compartment that is bordered superficially by the superficial perineal fascia, deep by the perineal membrane (which is the inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains various structures such as the crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males, and the greater vestibular glands in females. In cases of urethral rupture, the urine will tend to pass forward because the fascial condensations will prevent the urine from passing laterally and posteriorly.
The Urogenital Triangle and Superficial Perineal Pouch
The urogenital triangle is a structure formed by the ischiopubic inferior rami and ischial tuberosities, with a fascial sheet attached to its sides, creating the inferior fascia of the urogenital diaphragm. It serves as a pathway for the urethra in males and both the urethra and vagina in females. The membranous urethra is located deep to this structure and is surrounded by the external urethral sphincter.
In males, the superficial perineal pouch lies superficial to the urogenital diaphragm and contains the bulb of the penis, crura of the penis, superficial transverse perineal muscle, posterior scrotal arteries, and posterior scrotal nerves. Meanwhile, in females, the internal pudendal artery branches to become the posterior labial arteries in the superficial perineal pouch.
Understanding the anatomy of the urogenital triangle and superficial perineal pouch is crucial in diagnosing and treating urogenital disorders. Proper knowledge of these structures can aid in the identification of potential issues and the development of effective treatment plans.
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This question is part of the following fields:
- Gastrointestinal System
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Question 155
Incorrect
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A 50-year-old man is having a left hemicolectomy. During the procedure, the surgeons come across a tubular structure located at the inferior aspect of psoas major. What is the most probable identity of this structure?
Your Answer:
Correct Answer: Left ureter
Explanation:The left colon is positioned anterior to the left ureter. The iliac vessels are usually in closer proximity to the sigmoid colon and upper rectum, which are not typically located above the L4 vertebrae.
Anatomy of the Ureter
The ureter is a muscular tube that measures 25-35 cm in length and is lined by transitional epithelium. It is surrounded by a thick muscular coat that becomes three muscular layers as it crosses the bony pelvis. This retroperitoneal structure overlies the transverse processes L2-L5 and lies anterior to the bifurcation of iliac vessels. The blood supply to the ureter is segmental and includes the renal artery, aortic branches, gonadal branches, common iliac, and internal iliac. It is important to note that the ureter lies beneath the uterine artery.
In summary, the ureter is a vital structure in the urinary system that plays a crucial role in transporting urine from the kidneys to the bladder. Its unique anatomy and blood supply make it a complex structure that requires careful consideration in any surgical or medical intervention.
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This question is part of the following fields:
- Gastrointestinal System
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Question 156
Incorrect
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A 44-year-old man presents to the emergency department with haematemesis and is referred for urgent endoscopy, which reveals a 1.5cm ulcer in the first portion of the duodenum. He has a history of generalised anxiety disorder, but takes no prescription or over the counter medications and has no known drug allergies. Lately, he has been experiencing increased fatigue and bloating. On examination, his abdomen is soft and non-tender, and he has no fever. What is the most probable cause of this man's ulcer?
Your Answer:
Correct Answer: Helicobacter pylori
Explanation:Duodenal ulceration can be caused by various factors, including Helicobacter pylori infection, regular use of NSAIDs, and Crohn’s disease. However, in this particular case, the most likely cause of the patient’s duodenal ulcer is Helicobacter pylori infection. This bacterium produces enzymes that neutralize stomach acid, allowing it to survive in the stomach and weaken the protective barrier of the stomach and duodenum. Contrary to popular belief, a high-stress job or spicy foods are not the cause of peptic ulcer disease, although they may exacerbate the symptoms. Regular use of NSAIDs is a strong risk factor for peptic ulcer disease, but the patient does not have any of the risk factors for NSAID-induced peptic ulcer disease. Crohn’s disease may affect any part of the gastrointestinal tract, but it is less likely to be the cause of this man’s duodenal ulcer. Diagnosis of duodenal ulceration can be done through serology, microbiology, histology, or CLO testing.
Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems
Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.
The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.
The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.
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This question is part of the following fields:
- Gastrointestinal System
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Question 157
Incorrect
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A 47-year-old woman presents to the out of hours GP service with abdominal pain. She has suffered from 'heartburn' for many years but for the last 6 months she has started getting a different kind of pain, which she describes as 'stabbing'. When asked where she feels it, the patient points to below her right breast. The pain has been occurring more frequently and with greater severity over the last 3 weeks, and tonight it is unbearable. It tends to come on shortly after she has eaten, and lasts up to 3 hours. She denies constipation, diarrhoea and vomiting, although she feels nauseated. She reports 'a couple of pounds' weight loss over the last few weeks because she has been eating less to avoid the pain.
On examination her abdomen is soft but very tender in the right upper quadrant, with a positive Murphy's sign. She is afebrile and normotensive.
What is the most likely cause of the patient's presentation?Your Answer:
Correct Answer: Biliary colic
Explanation:Biliary colic can be characterized by pain that occurs after eating, especially after consuming high-fat meals. The patient’s symptoms are consistent with this type of pain. However, if the patient were experiencing ascending cholangitis, they would likely be more acutely ill and have a fever. Duodenal ulcers can also cause upper abdominal pain, but the pain tends to be constant, gnawing, and centralized, and may differ with eating. If the ulcer bleeds, the patient may experience haematemesis or melaena. Although the patient reports experiencing heartburn, their current presentation is more indicative of biliary colic than gastro-oesophageal reflux disease.
Understanding Biliary Colic and Gallstone-Related Disease
Biliary colic is a condition that occurs when gallstones pass through the biliary tree. It is more common in women, especially those who are obese, fertile, or over the age of 40. Other risk factors include diabetes, Crohn’s disease, rapid weight loss, and certain medications. Biliary colic is caused by an increase in cholesterol, a decrease in bile salts, and biliary stasis. The pain is due to the gallbladder contracting against a stone lodged in the cystic duct. Symptoms include colicky right upper quadrant abdominal pain, nausea, and vomiting. Unlike other gallstone-related conditions, there is no fever or abnormal liver function tests.
Ultrasound is the preferred diagnostic tool for biliary colic. Elective laparoscopic cholecystectomy is the recommended treatment. However, around 15% of patients may have gallstones in the common bile duct at the time of surgery, which can lead to obstructive jaundice. Other complications of gallstone-related disease include acute cholecystitis, ascending cholangitis, acute pancreatitis, gallstone ileus, and gallbladder cancer. It is important to understand the risk factors, pathophysiology, and management of biliary colic and gallstone-related disease to ensure prompt diagnosis and appropriate treatment.
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This question is part of the following fields:
- Gastrointestinal System
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Question 158
Incorrect
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A 63-year-old man arrives at the emergency department complaining of dizziness and haematemesis that started 2 hours ago. He has a medical history of hypertension and type 2 diabetes mellitus.
The patient is stabilized after receiving 2 litres of normal saline for fluid resuscitation. The next day, a gastroscopy is performed, revealing a peptic ulcer that is no longer actively bleeding. The CLO test is positive, indicating the presence of the likely organism.
What is the name of the enzyme secreted by this organism to aid its survival in the stomach?Your Answer:
Correct Answer: Urease
Explanation:Helicobacter pylori uses urease to survive in the stomach by neutralizing gastric acid. This enzyme produces ammonia, which creates a more suitable environment for bacterial growth. The patient’s CLO positive peptic ulcer is consistent with a Helicobacter pylori infection. It is important to note that Helicobacter pylori does not use arginase, beta-lactamase, protease, or trypsin to neutralize stomach acid.
Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems
Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.
The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.
The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.
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This question is part of the following fields:
- Gastrointestinal System
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Question 159
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 160
Incorrect
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An 80-year-old man presents to the emergency department with acute and severe abdominal pain, vomiting, and bloody stools. He has a medical history of atrial fibrillation and ischaemic heart disease. Upon examination, his heart rate is 140 beats per minute, blood pressure is 98/58mmHg, respiratory rate is 24 breaths per minute, oxygen saturations are 98% on air, and temperature is 38.8ÂșC. A CT scan with contrast of the abdomen reveals air in the intestinal wall. During surgery, it is discovered that the distal third of the colon to the superior part of the rectum is necrotic.
Which artery is responsible for supplying blood to this portion of the bowel?Your Answer:
Correct Answer: Inferior mesenteric artery
Explanation:The correct artery supplying the affected area in this patient is the inferior mesenteric artery. This artery branches off the abdominal aorta and supplies the hindgut, which includes the distal third of the colon and the rectum superior to the pectinate line. It’s important to note that the anal canal is divided into two parts by the pectinate line, with the upper half supplied by the superior rectal artery branch of the inferior mesenteric artery, and the lower half supplied by the inferior rectal artery branch of the internal pudendal artery. Ischaemic heart disease and atrial fibrillation are risk factors for acute mesenteric ischaemia in this patient, which presents with severe, poorly-localised abdominal pain and tenderness. The coeliac trunk, which supplies the foregut, is not involved in this case. The internal pudendal artery supplies the inferior part of the anal canal, perineum, and genitalia, while the right colic artery, a branch of the superior mesenteric artery, supplies the ascending colon, which is not affected in this patient.
The Inferior Mesenteric Artery: Supplying the Hindgut
The inferior mesenteric artery (IMA) is responsible for supplying the embryonic hindgut with blood. It originates just above the aortic bifurcation, at the level of L3, and passes across the front of the aorta before settling on its left side. At the point where the left common iliac artery is located, the IMA becomes the superior rectal artery.
The hindgut, which includes the distal third of the colon and the rectum above the pectinate line, is supplied by the IMA. The left colic artery is one of the branches that emerges from the IMA near its origin. Up to three sigmoid arteries may also exit the IMA to supply the sigmoid colon further down the line.
Overall, the IMA plays a crucial role in ensuring that the hindgut receives the blood supply it needs to function properly. Its branches help to ensure that the colon and rectum are well-nourished and able to carry out their important digestive functions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 161
Incorrect
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A 25-year-old male patient visits the surgical clinic with an inguinal hernia. During the examination, a small direct hernia is observed along with pigmented spots on his palms, soles, and around his mouth. The patient had undergone a reduction of an intussusception when he was 10 years old. If a colonoscopy is performed, which of the following lesions is most likely to be detected?
Your Answer:
Correct Answer: Hamartomas
Explanation:It is probable that he has Peutz-Jeghers syndrome, a condition that is linked to the presence of Hamartomas.
Understanding Peutz-Jeghers Syndrome
Peutz-Jeghers syndrome is a genetic condition that is inherited in an autosomal dominant manner. It is characterized by the presence of numerous hamartomatous polyps in the gastrointestinal tract, particularly in the small bowel. In addition, patients with this syndrome may also have pigmented freckles on their lips, face, palms, and soles.
While the polyps themselves are not cancerous, individuals with Peutz-Jeghers syndrome have an increased risk of developing other types of gastrointestinal tract cancers. In fact, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.
Common symptoms of Peutz-Jeghers syndrome include small bowel obstruction, which is often due to intussusception, as well as gastrointestinal bleeding. Management of this condition is typically conservative unless complications develop. It is important for individuals with Peutz-Jeghers syndrome to undergo regular screening and surveillance to detect any potential cancerous growths early on.
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This question is part of the following fields:
- Gastrointestinal System
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Question 162
Incorrect
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A 65-year-old woman visits her GP after discovering a lump in her groin that has been present for the past 2 weeks. The patient reports that she can push the lump back in, but it returns when she coughs. During the examination, the GP identifies the lump located superior and medial to the pubic tubercle. The GP successfully reduces the lump by applying pressure 2 cm above the midpoint of the inguinal ligament and asking the patient to cough. Based on the findings, the GP suspects an indirect inguinal hernia. What structures will the hernia pass through anatomically?
Your Answer:
Correct Answer: Deep inguinal ring and superficial inguinal ring
Explanation:The correct answer is that an indirect inguinal hernia enters the inguinal canal through the deep inguinal ring and exits at the superficial inguinal ring. This type of hernia is diagnosed by preventing re-herniation through pressure on the deep ring.
In contrast, a direct inguinal hernia enters the inguinal canal by passing through the posterior wall of the canal. This type of hernia would reappear upon increased intra-abdominal pressure, such as coughing.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 163
Incorrect
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A 28-year-old male patient is diagnosed with an inguinal hernia and is scheduled for open surgical repair. During the procedure, the surgeons opt to use a mesh to reinforce the posterior wall of the inguinal canal. What structures will be located behind the mesh?
Your Answer:
Correct Answer: Transversalis fascia
Explanation:The posterior wall of the inguinal canal is formed by the transversalis fascia, the conjoint tendon, and the deep inguinal ring located laterally. The superior wall (roof) is made up of the internal oblique and transversus abdominis muscles, while the anterior wall consists of the aponeurosis of the external oblique and internal oblique muscles. The lower wall (floor) is formed by the inguinal ligament and lacunar ligament.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 164
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 165
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 166
Incorrect
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Which of the following is not a branch of the abdominal aorta?
Your Answer:
Correct Answer: Superior phrenic artery
Explanation:To remember the order of branches, use the phrase ‘Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin’:
Phrenic [inferior]
Celiac
Superior mesenteric
Suprarenal [middle]
Renal
Testicular [‘in men’ only]
Lumbars
Inferior mesenteric
SacralNote that the superior phrenic artery branches from the aorta in the thorax.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 167
Incorrect
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A 29-year-old man is diagnosed with pleomorphic adenoma and requires surgical resection. During the procedure, which of the following structures is least likely to be encountered in the resection of the parotid gland?
Your Answer:
Correct Answer: Mandibular nerve
Explanation:The parotid gland is traversed by several important structures, including the facial nerve and its branches, the external carotid artery and its branches (such as the maxillary and superficial temporal arteries), the retromandibular vein, and the auriculotemporal nerve. However, the mandibular nerve is located at a safe distance from the gland. The maxillary vein joins with the superficial temporal vein to form the retromandibular vein, which passes through the parotid gland. Damage to the auriculotemporal nerve during a parotidectomy can result in regrowth that attaches to sweat glands, leading to gustatory sweating (Freys Syndrome). The marginal mandibular branch of the facial nerve is also associated with 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 168
Incorrect
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A 58-year-old man comes to the emergency department complaining of severe abdominal pain and profuse diarrhoea. He has been experiencing up to 10 bowel movements per day for the past 48 hours. The patient has a history of prostatitis and has recently finished a course of ciprofloxacin. He denies any recent travel but did consume a takeaway meal earlier in the week.
The following investigations were conducted:
Stool microscopy Gram-positive bacillus
What is the probable organism responsible for the patient's symptoms?Your Answer:
Correct Answer: Clostridium difficile
Explanation:Clostridium difficile is a gram-positive bacillus that is responsible for pseudomembranous colitis, which can occur after the use of broad-spectrum antibiotics. This is the correct answer for this patient’s condition. Ciprofloxacin, which the patient recently took, is a common antibiotic that can cause Clostridium difficile (C. diff) diarrhoea. Other antibiotics that can increase the risk of C. diff infection include clindamycin, co-amoxiclav, and cephalosporins.
Campylobacter jejuni is not the correct answer. This gram-negative bacillus is the most common cause of food poisoning in the UK and is also associated with Guillain-Barre syndrome. However, the patient’s stool culture results do not support a diagnosis of Campylobacter jejuni infection.
Escherichia coli is another possible cause of diarrhoea, but it is a gram-negative bacillus and is typically associated with travellers’ diarrhoea and food poisoning.
Shigella dysenteriae is also a gram-negative bacillus that can cause diarrhoea and dysentery, but it is not the correct answer for this patient’s condition.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 169
Incorrect
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A 32-year-old man has come in for a follow-up appointment after being diagnosed with irritable bowel syndrome. However, his faecal calprotectin was slightly elevated, but not high enough to raise suspicion of inflammatory bowel disease.
He had initially presented with abdominal pain and diarrhoea, along with feelings of discomfort and bloating that were relieved upon defecation. He denied any presence of blood in his stool. You prescribed psyllium husk and scheduled a review in four weeks. He has a medical history of low back pain, migraine, and depression.
Today, his faecal calprotectin has returned to normal levels. What is the most likely cause of the initial abnormal test result?Your Answer:
Correct Answer: Use of NSAIDs
Explanation:Mallory-Weiss syndrome (MWS) is characterized by a rupture in the mucous membrane at the junction of the stomach and oesophagus.
Faecal Calprotectin: A Screening Tool for Intestinal Inflammation
Faecal calprotectin is a recommended screening tool for inflammatory bowel disease (IBD) by NICE. It is a test that detects intestinal inflammation and can also be used to monitor the response to treatment in IBD patients. The test has a high sensitivity of 93% and specificity of 96% for IBD in adults. However, in children, the specificity falls to around 75%.
Apart from IBD, other conditions that can cause a raised faecal calprotectin include bowel malignancy, coeliac disease, infectious colitis, and the use of NSAIDs. Therefore, faecal calprotectin is a useful diagnostic tool for detecting intestinal inflammation and can aid in the diagnosis and management of various gastrointestinal conditions.
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This question is part of the following fields:
- Gastrointestinal System
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Question 170
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 171
Incorrect
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A 72-year-old female presents to her local physician complaining of general fatigue and tiredness. She reports no fever, night sweats, or weight loss. She maintains an active lifestyle and attends fitness classes weekly. Her medical history includes hypertension, type II diabetes mellitus, constipation, and depression.
The physician orders blood tests, and the results are as follows:
- Hb: 113 g/l
- Platelets: 239 * 109/l
- WBC: 6 * 109/l
- Neuts: 2 * 109/l
- Lymphs: 2 * 109/l
- Eosin: 0.3 * 109/l
- Na+: 142 mmol/l
- K+: 3.2 mmol/l
- Bilirubin: 12 ”mol/l
- ALP: 23 u/l
- ALT: 10 u/l
- ÎłGT: 23 u/l
- Urea: 4 mmol/l
- Creatinine: 50 ”mol/l
- Albumin: 30 g/l
Which medication is most likely causing her symptoms?Your Answer:
Correct Answer: Senna
Explanation:Prolonged use of senna increases the risk of hypokalemia, which is evident in the patient’s blood results. The symptoms of mild hypokalemia are non-specific and include fatigue, muscle weakness, constipation, and rhabdomyolysis. Given the patient’s medical history of constipation, it is likely that she has been taking a laxative, which could be either osmotic or a stimulant. Both types of laxatives are known to cause hypokalemia, and in this case, senna is the likely culprit.
Heparin can cause hyperkalemia, especially when used in conjunction with spironolactone, ACE inhibitors, non-steroidal anti-inflammatory drugs, and trimethoprim. Heparin inhibits aldosterone synthesis, leading to increased potassium retention and sodium excretion. This effect is more pronounced in elderly individuals, diabetics, and those with renal failure. The risk of hyperkalemia increases with higher doses, prolonged use, and unfractionated heparin therapy.
Amiloride is a potassium-sparing diuretic that works by inhibiting sodium reabsorption in the kidneys. It promotes the loss of sodium and water from the body without depleting potassium. Amiloride causes hyperkalemia by inhibiting sodium reabsorption at various points in the kidneys, which reduces potassium and hydrogen secretion and subsequent excretion.
Losartan is an angiotensin II receptor blocker that is known to cause hyperkalemia and is therefore not the cause of the patient’s hypokalemia.
Understanding Laxatives
Laxatives are frequently prescribed medications in clinical practice, with constipation being a common issue among patients. While constipation may be a symptom of underlying pathology, many patients experience simple idiopathic constipation. The British National Formulary (BNF) categorizes laxatives into four groups: osmotic, stimulant, bulk-forming, and faecal softeners.
Osmotic laxatives, such as lactulose, macrogols, and rectal phosphates, work by drawing water into the bowel to soften stools and promote bowel movements. Stimulant laxatives, including senna, docusate, bisacodyl, and glycerol, stimulate the muscles in the bowel to contract and move stool along. Co-danthramer, a combination of a stimulant and a bulk-forming laxative, should only be prescribed to palliative patients due to its potential carcinogenic effects.
Bulk-forming laxatives, such as ispaghula husk and methylcellulose, work by increasing the bulk of stool and promoting regular bowel movements. Faecal softeners, such as arachis oil enemas, are not commonly prescribed but can be used to soften stool and ease bowel movements.
In summary, understanding the different types of laxatives and their mechanisms of action can help healthcare professionals prescribe the most appropriate treatment for patients experiencing constipation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 172
Incorrect
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A pharmaceutical company is striving to develop a novel weight-loss drug that imitates the satiety-inducing effects of the endogenous peptide hormone cholecystokinin (CCK).
What are the cells that naturally synthesize and secrete this hormone?Your Answer:
Correct Answer: I cells in the upper small intestine
Explanation:CCK is a hormone produced by I cells in the upper small intestine that enhances the digestion of fats and proteins. When partially digested proteins and fats are detected, CCK is synthesized and released, resulting in various processes such as the secretion of digestive enzymes from the pancreas, contraction of the gallbladder, relaxation of the sphincter of Oddi, decreased gastric emptying, and a trophic effect on pancreatic acinar cells. These processes lead to the breakdown of fats and proteins and suppression of hunger.
B cells, on the other hand, are part of the immune system and produce antibodies as part of the B cell receptors. They are produced in the bone marrow and migrate to the spleen and lymphatic system, but they do not play a role in satiety.
Somatostatin is a hormone released from D cells in the pancreas and stomach that regulates peptide hormone release and gastric emptying. It is stimulated by the presence of fat, bile salt, and glucose in the intestines.
Gastrin is a hormone that increases acid release from parietal cells in the stomach and aids in gastric motility. It is released from G cells in the antrum of the stomach in response to distension of the stomach, stimulation of the vagus nerves, and the presence of peptides/amino acids in the lumen.
Secretin is a hormone that regulates enzyme secretion from the stomach, pancreas, and liver. It is released from the S cells in the duodenum in response to the presence of acid in the lumen.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 173
Incorrect
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A 54-year-old man with dyspepsia is diagnosed with a duodenal ulcer and a positive CLO test. Which statement about the probable causative organism is incorrect?
Your Answer:
Correct Answer: In patients who are colonised there is commonly evidence of fundal gastritis on endoscopy
Explanation:Duodenal ulceration cases can be caused by Helicobacter pylori infection, which can be diagnosed through serology, microbiology, histology, or CLO testing. Detecting the infection through endoscopy may not show any typical features, so the recommended approach is to take an antral biopsy for CLO testing during the endoscopy procedure.
Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems
Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.
The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.
The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.
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This question is part of the following fields:
- Gastrointestinal System
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Question 174
Incorrect
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A 25-year-old male presents to the emergency department with upper abdominal pain that radiates to the back. This started a few hours previously and has been accompanied by some nausea and vomiting. The patient denies any alcohol intake recently.
On examination, he has tenderness in the epigastric and right upper quadrant regions. He has a fever of 38.9°C. An ultrasound scan reveals no evidence of gallstones. The patient is given a preliminary diagnosis of acute pancreatitis and some blood tests are requested.
What could be the cause of this patient's condition?Your Answer:
Correct Answer: Mumps
Explanation:Mumps is a known cause of acute pancreatitis, but it has become rare since the introduction of the MMR vaccine. In 2018, there were only 1088 cases of mumps in the UK, which statistically translates to around 54 cases of acute pancreatitis secondary to mumps. Inflammatory bowel disease may also lead to pancreatitis, but it is usually caused by gallstones or medication used to treat IBD. While influenzae and gastroenteritis are not commonly associated with pancreatitis, there have been a few reported cases linking influenzae A to acute pancreatitis, although these occurrences are extremely rare.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 175
Incorrect
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A 76-year-old man is undergoing a femoro-popliteal bypass graft. The surgery is not going smoothly, and the surgeon is having difficulty accessing the area. Which structure needs to be retracted to improve access to the femoral artery in the groin?
Your Answer:
Correct Answer: Sartorius
Explanation:To enhance accessibility, the sartorius muscle can be pulled back as the femoral artery passes beneath it at the lower boundary of the femoral triangle.
Understanding the Anatomy of the Femoral Triangle
The femoral triangle is an important anatomical region located in the upper thigh. It is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. The floor of the femoral triangle is made up of the iliacus, psoas major, adductor longus, and pectineus muscles, while the roof is formed by the fascia lata and superficial fascia. The superficial inguinal lymph nodes and the long saphenous vein are also found in this region.
The femoral triangle contains several important structures, including the femoral vein, femoral artery, femoral nerve, deep and superficial inguinal lymph nodes, lateral cutaneous nerve, great saphenous vein, and femoral branch of the genitofemoral nerve. The femoral artery can be palpated at the mid inguinal point, making it an important landmark for medical professionals.
Understanding the anatomy of the femoral triangle is important for medical professionals, as it is a common site for procedures such as venipuncture, arterial puncture, and nerve blocks. It is also important for identifying and treating conditions that affect the structures within this region, such as femoral hernias and lymphadenopathy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 176
Incorrect
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A 32-year-old female with a history of iron deficiency anemia presents to the hospital with pain in the right upper quadrant. After diagnosis, she is found to have acute cholecystitis. Which of the following is NOT a risk factor for the development of gallstones?
Your Answer:
Correct Answer: Iron deficiency anaemia
Explanation:The following factors increase the likelihood of developing gallstones and can be remembered as the ‘5 F’s’:
– Being overweight (having a body mass index greater than 30 kg/m2)
– Being female
– Being of reproductive age
– Being of fair complexion (Caucasian)
– Being 40 years of age or olderGallstones are a common condition, with up to 24% of women and 12% of men affected. Local infection and cholecystitis may develop in up to 30% of cases, and 12% of patients undergoing surgery will have stones in the common bile duct. The majority of gallstones are of mixed composition, with pure cholesterol stones accounting for 20% of cases. Symptoms typically include colicky right upper quadrant pain that worsens after fatty meals. Diagnosis is usually made through abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm suspected bile duct stones. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and surgical management for stones in the common bile duct. ERCP may be used to remove bile duct stones, but carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.
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This question is part of the following fields:
- Gastrointestinal System
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Question 177
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 178
Incorrect
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A 70-year-old male presents with abdominal pain.
He has a past medical history of stroke and myocardial infarction. During examination, there was noticeable distension of the abdomen and the stools were maroon in color. The lactate level was found to be 5 mmol/L, which is above the normal range of <2.2 mmol/L.
What is the most probable diagnosis for this patient?Your Answer:
Correct Answer: Acute mesenteric ischaemia
Explanation:Acute Mesenteric Ischaemia
Acute mesenteric ischaemia is a condition that occurs when there is a disruption in blood flow to the small intestine or right colon. This can be caused by arterial or venous disease, with arterial disease further classified as non-occlusive or occlusive. The classic triad of symptoms associated with acute mesenteric ischaemia includes gastrointestinal emptying, abdominal pain, and underlying cardiac disease.
The hallmark symptom of mesenteric ischaemia is severe abdominal pain, which may be accompanied by other symptoms such as nausea, vomiting, abdominal distention, ileus, peritonitis, blood in the stool, and shock. Advanced ischaemia is characterized by the presence of these symptoms.
There are several risk factors associated with acute mesenteric ischaemia, including congestive heart failure, cardiac arrhythmias (especially atrial fibrillation), recent myocardial infarction, atherosclerosis, hypercoagulable states, and hypovolaemia. It is important to be aware of these risk factors and to seek medical attention promptly if any symptoms of acute mesenteric ischaemia are present.
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This question is part of the following fields:
- Gastrointestinal System
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Question 179
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 180
Incorrect
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A 10-year-old girl presents to her doctor with a 2-month history of flatulence, foul-smelling diarrhoea, and a weight loss of 2kg. Her mother reports observing greasy, floating stools during this time.
During the examination, the patient appears to be in good health. There are no palpable masses or organomegaly during abdominal examination.
The child's serum anti-tissue transglutaminase antibodies are found to be elevated. What is the most probable HLA type for this child?Your Answer:
Correct Answer: HLA-DQ2
Explanation:The HLA most commonly associated with coeliac disease is HLA-DQ2. HLA, also known as human leukocyte antigen or major histocompatibility complex, is expressed on self-cells in the body and plays a role in presenting antigens to the immune system. The child’s symptoms of coeliac disease include fatty, floaty stools (steatorrhoea), weight loss, and positive tissue transglutaminase antibodies.
HLA-A01 is not commonly associated with autoimmune conditions, but has been linked to methotrexate-induced liver cirrhosis.
HLA-B27 is associated with psoriatic arthritis, reactive arthritis, ankylosing spondylitis, and inflammatory bowel disease.
HLA-B35 is not commonly associated with autoimmune conditions.
Understanding Coeliac Disease
Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.
To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, failure to thrive or faltering growth in children, persistent or unexplained gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden or unexpected weight loss, unexplained anemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.
Complications of coeliac disease include anemia, hyposplenism, osteoporosis, osteomalacia, lactose intolerance, enteropathy-associated T-cell lymphoma of the small intestine, subfertility, and unfavorable pregnancy outcomes. In rare cases, it can lead to esophageal cancer and other malignancies.
The diagnosis of coeliac disease is confirmed through a duodenal biopsy, which shows complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, intraepithelial lymphocytosis, and dense mixed inflammatory infiltrate in the lamina propria. Treatment involves a lifelong gluten-free diet.
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This question is part of the following fields:
- Gastrointestinal System
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Question 181
Incorrect
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Which one of the following options in relation to the liver is true for individuals?
Your Answer:
Correct Answer: The caudate lobe is superior to the porta hepatis
Explanation:The ligamentum venosum and caudate lobe are located on the same side as the posterior vena cava. Positioned behind the liver, the ligamentum venosum is situated in the portal triad, which includes the portal vein (not the hepatic vein). The coronary ligament layers create a bare area of the liver, leaving a void. Additionally, the porta hepatis contains both sympathetic and parasympathetic nerves.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 182
Incorrect
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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:
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 ”g/L in men and postmenopausal women, and above 200 ”g/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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 183
Incorrect
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An old woman on your ward is experiencing abdominal pain and has vomited twice today. She has not had a bowel movement for three days. During your examination, you notice that her abdomen is distended and her rectum is empty.
What is the most appropriate initial treatment?Your Answer:
Correct Answer: Give IV fluids and pass a nasogastric tube for decompression
Explanation:The initial management of small bowel obstruction involves administering IV fluids and performing gastric decompression through the use of a nasogastric tube, also known as ‘drip-and-suck’. Diagnostic laparoscopy is not necessary at this stage, unless there are signs of sepsis or peritonitis. Giving a laxative such as Senna is not recommended and requesting a surgical review is not necessary at this point.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 184
Incorrect
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A 32-year-old man comes to you complaining of persistent diarrhoea for the past 10 days. He describes his diarrhoea as watery and foul-smelling, but denies any blood. He feels exhausted and asks for a prescription for an antidiarrhoeal medication. He has no notable medical history.
The stool cultures come back negative, and you contemplate starting the patient on diphenoxylate. Can you explain the mechanism of action of this drug?Your Answer:
Correct Answer: Inhibits peristalsis by acting on Ό-opioid in the GI tract
Explanation:Diphenoxylate slows down peristalsis in the GI tract by acting on Ό-opioid receptors.
Increased gut motility can be achieved through the positive cholinergic effect of muscarinic receptor activation.
All other options are inaccurate.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 185
Incorrect
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What is the most frequent type of tumor found in the colon?
Your Answer:
Correct Answer: Adenocarcinoma
Explanation:Adenocarcinomas are frequently occurring and usually develop due to the sequence of adenoma leading to carcinoma.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 186
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 187
Incorrect
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During an abdominal aortic aneurysm repair, a 78-year-old man has two clamps placed on his aorta, with the inferior clamp positioned at the point of aortic bifurcation. Which vertebral body will be located posterior to the clamp at this level?
Your Answer:
Correct Answer: L4
Explanation:The point at which the aorta divides into two branches is known as the bifurcation, which is a crucial anatomical landmark that is frequently assessed. This bifurcation typically occurs at the level of the fourth lumbar vertebrae (L4).
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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This question is part of the following fields:
- Gastrointestinal System
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Question 188
Incorrect
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A 68-year-old male presents with sudden and severe abdominal pain. He has a medical history of ischaemic heart disease and takes nitrates, atenolol and amlodipine for it. Upon examination, his pulse is irregularly irregular and measures 115 bpm, his blood pressure is 104/72 mmHg, and his temperature is 37.4°C. The abdomen is diffusely tender and bowel sounds are absent. What is the probable diagnosis?
Your Answer:
Correct Answer: Mesenteric ischaemia
Explanation:Narrowing Down the Differential Diagnosis for Acute Abdomen
When presented with a patient experiencing an acute abdomen, the differential diagnosis can be extensive. However, by taking note of the key points in the patient’s history and conducting a thorough examination, one can narrow down the potential causes. In the case of a man with absent bowel sounds, atrial fibrillation, and a history of ischemic heart disease, the most likely cause of his presentation is mesenteric ischemia. This is due to the fact that he is not obstructed and has vascular disease. For further information on acute mesenteric ischemia, Medscape provides a helpful resource. By utilizing these tools and resources, healthcare professionals can more accurately diagnose and treat patients with acute abdominal symptoms.
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This question is part of the following fields:
- Gastrointestinal System
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Question 189
Incorrect
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Which symptom is the least common in individuals with pancreatic cancer?
Your Answer:
Correct Answer: Hyperamylasaemia
Explanation:Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. The majority of pancreatic tumors are adenocarcinomas and are typically found in the head of the pancreas. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and mutations in the BRCA2 and KRAS genes.
Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, and pruritus. Courvoisier’s law states that a palpable gallbladder is unlikely to be due to gallstones in the presence of painless obstructive jaundice. However, patients often present with non-specific symptoms such as anorexia, weight loss, and epigastric pain. Loss of exocrine and endocrine function can also occur, leading to steatorrhea and diabetes mellitus. Atypical back pain and migratory thrombophlebitis (Trousseau sign) are also common.
Ultrasound has a sensitivity of around 60-90% for detecting pancreatic cancer, but high-resolution CT scanning is the preferred diagnostic tool. The ‘double duct’ sign, which is the simultaneous dilatation of the common bile and pancreatic ducts, may be seen on imaging.
Less than 20% of patients with pancreatic cancer are suitable for surgery at the time of diagnosis. A Whipple’s resection (pancreaticoduodenectomy) may be performed for resectable lesions in the head of the pancreas, but side-effects such as dumping syndrome and peptic ulcer disease can occur. Adjuvant chemotherapy is typically given following surgery, and ERCP with stenting may be used for palliation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 190
Incorrect
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A 55-year-old woman presents to the emergency department complaining of vomiting and a severe headache that developed after experiencing blurred vision. The physician prescribes an antiemetic. Which of the following antiemetics aids in gastric emptying?
Your Answer:
Correct Answer: Metoclopramide
Explanation:The effectiveness of antiemetics depends on their ability to interact with different receptors to varying degrees. Therefore, the selection of an antiemetic will be based on the patient’s condition and the underlying cause of their nausea.
Metoclopramide functions as a dopamine antagonist, but it also has an agonistic impact on peripheral 5HT3 receptors and an antagonistic effect on muscarinic receptors, which helps to facilitate gastric emptying.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 191
Incorrect
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Sarah, a 70-year-old female, visits her doctor with a lump in her groin. Upon examination, the doctor observes that the lump becomes more prominent when the patient coughs. Considering Sarah's age and the location of the lump, the doctor diagnoses her with a direct inguinal hernia. What structure did Sarah's bowel pass through to be classified as a direct inguinal hernia?
Your Answer:
Correct Answer: Hesselbach's triangle
Explanation:Hesselbach’s triangle is a weak area in the anterior abdominal wall through which direct inguinal hernias can travel. Indirect inguinal hernias occur when the bowel passes through the inguinal canal via the deep inguinal ring. Femoral hernias occur when a portion of the bowel enters the femoral canal through the femoral ring. The failure of the processus vaginalis to close during embryonic development increases the risk of developing an indirect inguinal hernia.
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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This question is part of the following fields:
- Gastrointestinal System
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Question 192
Incorrect
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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 193
Incorrect
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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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This question is part of the following fields:
- Gastrointestinal System
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Question 194
Incorrect
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An 80-year-old male visits his GP with a complaint of blood in his stool and increased frequency of bowel movements. He has also experienced mild weight loss due to a change in appetite. Upon referral to secondary care, a mass is discovered in his ascending colon. If the mass were to perforate the bowel wall, where would bowel gas most likely accumulate?
Your Answer:
Correct Answer: Retroperitoneal space
Explanation:The patient’s symptoms suggest that he may have bowel cancer in his ascending colon. As the ascending colon is located behind the peritoneum, a rupture of the colon could lead to the accumulation of gas in the retroperitoneal space.
Pneumoperitoneum, which is the presence of gas in the peritoneum, is typically caused by a perforated peptic ulcer. On the other hand, subcutaneous emphysema is the trapping of air under the skin layer and is usually associated with chest wall trauma or pneumothorax.
Air in the intra-mural space refers to the presence of air within the bowel wall and is not likely to occur in cases of perforation. This condition is typically associated with intestinal ischaemia and infarction.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 195
Incorrect
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A 36-year-old female patient presents with persistent dyspepsia of 6 months duration. She failed multiple trials of conservative treatment by her GP, therefore, she was referred for the gastroenterologist for further review.
Investigations were done and her urea breath test was negative for Helicobacter pylori. Gastroscopy revealed multiple gastroduodenal ulcers. What type of cells are affected by the high levels of fasting gastrin detected?Your Answer:
Correct Answer: Gastric parietal cells
Explanation:The secretion of gastrin hormone from G cells in the antrum of the stomach is responsible for increasing the secretion of H+ by gastric parietal cells. Additionally, chief cells secrete pepsin, which is a proteolytic enzyme, while D cells in the pancreas and stomach secrete somatostatin hormone. Gastrin hormone is released in response to distension of the stomach and vagal stimulation.
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.
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This question is part of the following fields:
- Gastrointestinal System
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Question 196
Incorrect
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A 55-year-old man presents to the emergency department with haematemesis which he has never experienced before. He reports a 3 week history of intermittent dull pain in the upper left quadrant and, upon further inquiry, he mentions that he believes he has been losing weight but he doesn't weigh himself often as he has always been in good shape. Other than a badly sprained ankle 10 weeks ago, for which he admits he is still taking ibuprofen, he has no medical conditions and is not taking any regular medication. He is a non-smoker and only drinks alcohol occasionally. What is the most probable cause of the patient's haematemesis?
Your Answer:
Correct Answer: Peptic ulcer
Explanation:Peptic ulcer is a frequent cause of haematemesis in patients who have been using NSAIDs extensively, as seen in this patient’s case. Peptic ulcers can manifest with various symptoms such as haematemesis, abdominal pain, nausea, weight loss, and acid reflux. Typically, the pain subsides when the patient eats or drinks.
Although weight loss can be a sign of malignancy, this patient has few risk factors (over 55 years old, smoker, high alcohol consumption, and obesity).
Any instance of repeated forceful vomiting can lead to a mallory-weiss tear, which presents as painful episodes of haematemesis.
Oesophageal varices are expected in patients with a history of alcohol abuse and usually present with signs of chronic liver disease.
Hereditary telangiectasia usually presents with a positive family history and telangiectasia around the lips, tongue, or mucus membranes. Epistaxis is a common symptom of this vascular malformation.
Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems
Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.
The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.
The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.
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This question is part of the following fields:
- Gastrointestinal System
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Question 197
Incorrect
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A surgeon is scheduled to perform a laparotomy for a perforated duodenal ulcer on a pediatric patient. An upper midline incision will be made. Which structure is most likely to be divided by the incision?
Your Answer:
Correct Answer: Linea alba
Explanation:When performing upper midline abdominal incisions, the linea alba is typically divided. It is not common to divide muscles in this approach, as it does not typically enhance access and encountering them is not a routine occurrence.
Abdominal Incisions: Types and Techniques
Abdominal incisions are surgical procedures that involve making an opening in the abdominal wall to access the organs inside. The most common approach is the midline incision, which involves dividing the linea alba, transversalis fascia, extraperitoneal fat, and peritoneum. Another type is the paramedian incision, which is parallel to the midline and involves dividing the anterior rectus sheath, rectus, posterior rectus sheath, transversalis fascia, extraperitoneal fat, and peritoneum. The battle incision is similar to the paramedian but involves displacing the rectus medially.
Other types of abdominal incisions include Kocher’s incision under the right subcostal margin for cholecystectomy, Lanz incision in the right iliac fossa for appendicectomy, gridiron oblique incision centered over McBurney’s point for appendicectomy, Pfannenstiel’s transverse supra-pubic incision primarily used to access pelvic organs, McEvedy’s groin incision for emergency repair of a strangulated femoral hernia, and Rutherford Morrison extraperitoneal approach to the left or right lower quadrants for access to iliac vessels and renal transplantation.
Each type of incision has its own advantages and disadvantages, and the choice of incision depends on the specific surgical procedure and the surgeon’s preference. Proper closure of the incision is crucial to prevent complications such as infection and hernia formation. Overall, abdominal incisions are important techniques in surgical practice that allow for safe and effective access to the abdominal organs.
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This question is part of the following fields:
- Gastrointestinal System
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Question 198
Incorrect
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Which type of epithelium lines the lumenal surface of the typical esophagus?
Your Answer:
Correct Answer: Non keratinised stratified squamous epithelium
Explanation:The lining of the oesophagus is composed of stratified squamous epithelium that is not keratinised. Metaplastic processes in reflux can lead to the transformation of this epithelium into glandular type epithelium.
Anatomy of the Oesophagus
The oesophagus is a muscular tube that is approximately 25 cm long and starts at the C6 vertebrae, pierces the diaphragm at T10, and ends at T11. It is lined with non-keratinized stratified squamous epithelium and has constrictions at various distances from the incisors, including the cricoid cartilage at 15cm, the arch of the aorta at 22.5cm, the left principal bronchus at 27cm, and the diaphragmatic hiatus at 40cm.
The oesophagus is surrounded by various structures, including the trachea to T4, the recurrent laryngeal nerve, the left bronchus and left atrium, and the diaphragm anteriorly. Posteriorly, it is related to the thoracic duct to the left at T5, the hemiazygos to the left at T8, the descending aorta, and the first two intercostal branches of the aorta. The arterial, venous, and lymphatic drainage of the oesophagus varies depending on the location, with the upper third being supplied by the inferior thyroid artery and drained by the deep cervical lymphatics, the mid-third being supplied by aortic branches and drained by azygos branches and mediastinal lymphatics, and the lower third being supplied by the left gastric artery and drained by posterior mediastinal and coeliac veins and gastric lymphatics.
The nerve supply of the oesophagus also varies, with the upper half being supplied by the recurrent laryngeal nerve and the lower half being supplied by the oesophageal plexus of the vagus nerve. The muscularis externa of the oesophagus is composed of both smooth and striated muscle, with the composition varying depending on the location.
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This question is part of the following fields:
- Gastrointestinal System
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Question 199
Incorrect
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A 42-year-old female presents to the emergency department with severe generalised abdominal pain and haematemesis. The patient reports ongoing epigastric pain over the past few months which was worse after eating meals. She had a similar but milder episode about 4 years ago, which was treated with omeprazole. Past medical history includes osteoarthritis for which she takes ibuprofen.
Clinical observations reveal a heart rate of 120 beats per minute, blood pressure of 90/78 mmHg, respiratory rate of 25/min, oxygen saturations of 98% on air and a temperature of 37.5ÂșC. On examination, the patient has severe epigastric tenderness on palpation.
What is the first-line treatment for the likely diagnosis?Your Answer:
Correct Answer: Endoscopic intervention
Explanation:The most likely diagnosis for the patient is a perforated peptic ulcer, which may have been caused by their use of ibuprofen. The recommended first-line treatment according to NICE guidelines is endoscopic intervention, which can confirm the diagnosis and stop the bleeding. This involves injecting adrenaline into the bleeding site and using cautery and/or clip application. Helicobacter pylori eradication therapy is not appropriate in this case, as the patient’s symptoms suggest a perforated peptic ulcer rather than peptic ulcer disease caused by H. pylori. IV proton-pump inhibitor infusion may be considered later, but the patient requires immediate management with endoscopic intervention.
Managing Acute Bleeding in Peptic Ulcer Disease
Peptic ulcer disease is a condition that can lead to acute bleeding, which is the most common complication of the disease. In fact, bleeding accounts for about three-quarters of all problems associated with peptic ulcer disease. The gastroduodenal artery is often the source of significant gastrointestinal bleeding in patients with this condition. The most common symptom of acute bleeding in peptic ulcer disease is haematemesis, but patients may also experience melaena, hypotension, and tachycardia.
When managing acute bleeding in peptic ulcer disease, an ABC approach should be taken, as with any upper gastrointestinal haemorrhage. Intravenous proton pump inhibitors are the first-line treatment, and endoscopic intervention is typically the preferred approach. However, if endoscopic intervention fails (which occurs in approximately 10% of patients), urgent interventional angiography with transarterial embolization or surgery may be necessary. By following these management strategies, healthcare providers can effectively address acute bleeding in patients with peptic ulcer disease.
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This question is part of the following fields:
- Gastrointestinal System
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Question 200
Incorrect
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A 65-year-old male patient undergoes liver resection surgery and encounters uncontrolled hepatic bleeding. To interrupt the blood flow, the surgeon performs the 'Pringle manoeuvre' by clamping the hepatic artery, portal vein, and common bile duct, which form the anterior boundary of the epiploic foramen. What other vessel serves as a boundary in this area?
Your Answer:
Correct Answer: Inferior vena cava
Explanation:The inferior vena cava serves as the posterior boundary of the epiploic foramen. The anterior boundary is formed by the hepatoduodenal ligament, which contains the bile duct, portal vein, and hepatic artery. The first part of the duodenum forms the inferior boundary, while the caudate process of the liver forms the superior boundary.
The Epiploic Foramen and its Boundaries
The epiploic foramen is a small opening in the peritoneum that connects the greater and lesser sacs of the abdomen. It is located posterior to the liver and anterior to the inferior vena cava. The boundaries of the epiploic foramen include the bile duct to the right, the portal vein behind, and the hepatic artery to the left. The inferior boundary is the first part of the duodenum, while the superior boundary is the caudate process of the liver.
During liver surgery, bleeding can be controlled by performing a Pringles manoeuvre. This involves placing a vascular clamp across the anterior aspect of the epiploic foramen, which occludes the common bile duct, hepatic artery, and portal vein. This technique is useful in preventing excessive bleeding during liver surgery and can help to ensure a successful outcome.
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This question is part of the following fields:
- Gastrointestinal System
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