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  • Question 1 - A 50-year-old man comes to the Emergency Department complaining of right upper quadrant...

    Correct

    • A 50-year-old man comes to the Emergency Department complaining of right upper quadrant pain, dark urine, and pale stools that have been present for the past 24 hours. He reports being a part-time teacher and smoking 10 cigarettes daily. He has no significant medical history and is not taking any medications. Upon examination, his sclera are yellow, and his BMI is 29 kg/m². What investigation would be the most useful in this case?

      Your Answer: Ultrasound of abdomen

      Explanation:

      Gallstones: Symptoms, Diagnosis, and Treatment

      Gallstones 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 involves abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm the presence of stones in the bile duct. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and early ERCP or surgical exploration for stones in the bile duct. Intraoperative cholangiography or laparoscopic ultrasound may be used to confirm anatomy or exclude CBD stones during surgery. ERCP carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      16.9
      Seconds
  • Question 2 - A 48 year old man presents to the emergency department with acute abdominal...

    Incorrect

    • A 48 year old man presents to the emergency department with acute abdominal pain and feeling unwell. He is typically in good health and enjoys long distance running. His medical history includes a previous finger injury from playing cricket and gallstones that have not caused any issues. During examination, his sclera is noted to be icteric. His heart rate is 106 bpm and his blood pressure is 125/85 mmHg. He has a temperature of 38.1ºC. There is significant rebound tenderness and guarding in the right upper quadrant, and his bowel sounds are quiet. What is the most probable diagnosis?

      Your Answer: Acute cholecystitis

      Correct Answer: Ascending cholangitis

      Explanation:

      The man in this scenario is experiencing Charcot’s triad, which includes right upper quadrant pain, fever, and jaundice. These symptoms suggest that he may have ascending cholangitis, which is caused by a bacterial infection in the biliary tree due to obstruction from biliary stasis (likely caused by his gallstones). Treatment involves resuscitation, IV antibiotics, and biliary drainage.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      75.9
      Seconds
  • Question 3 - A 56-year-old male patient presents to the emergency department with a 3-day history...

    Incorrect

    • A 56-year-old male patient presents to the emergency department with a 3-day history of severe right upper quadrant pain preceded by a 2-month history of intermittent ache in the right upper quadrant. His basic observations include heart rate 115 beats/minute, respiratory rate 28 breaths/minute, blood pressure 90/55 mmHg, temperature 38.9°C, oxygen saturation 93% on air. His past medical history includes hypertension and type 2 diabetes mellitus.

      WCC 14 x 109cells/L
      Bilirubin 80 mg/dL
      Alkaline phosphatase 377 IU/L
      Alanine aminotransferase 70 U/L
      Amylase 300 U/L

      What is the most likely diagnosis?

      Your Answer: Pancreatitis

      Correct Answer: Ascending cholangitis

      Explanation:

      The three main symptoms of Charcot’s cholangitis are fever, jaundice, and pain in the upper right quadrant. This type of cholangitis is known for causing these three symptoms, which are collectively referred to as Charcot’s triad. When there is inflammation in the gastrointestinal tract, amylase levels may be slightly elevated. While cholecystitis can lead to jaundice, it is usually not severe. On the other hand, pancreatitis typically does not cause jaundice, and amylase levels are typically much higher.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      49.8
      Seconds
  • Question 4 - A 25-year-old woman presents with complaints of intermittent diarrhoea and constipation. She experiences...

    Correct

    • A 25-year-old woman presents with complaints of intermittent diarrhoea and constipation. She experiences bloating that is relieved by defecation and finds relief with hyoscine butylbromide (Buscopan). She denies any weight loss and has no relevant family history. Coeliac disease screening was negative and both full blood count and CRP were normal. Despite being diagnosed with irritable bowel syndrome and given dietary advice and antispasmodics, she disagrees with the diagnosis and requests further investigations. What is the most appropriate course of action?

      Your Answer: Reassure that further tests are not required at this stage

      Explanation:

      It is not recommended to use faecal occult blood testing for colorectal cancer screening in symptomatic patients who are under the age of 60. This woman is displaying symptoms of irritable bowel syndrome and has normal blood results, without any red flag symptoms. Repeating the full blood count is unlikely to provide any additional information. The use of steroids and azathioprine is not appropriate for treating irritable bowel syndrome, as they are typically used for ulcerative colitis, which is not likely in this case.

      Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

      Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

      Faecal Immunochemical Test (FIT) Screening:
      The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      16.2
      Seconds
  • Question 5 - A 50-year-old man who takes omeprazole 20 mg for gastroesophageal reflux disease has...

    Incorrect

    • A 50-year-old man who takes omeprazole 20 mg for gastroesophageal reflux disease has reported a recent worsening of his indigestion and an unintentional weight loss of 5kg over the past 2 months. He has been referred for a 2-week wait and scheduled for an endoscopy in 3 weeks. What guidance should he receive regarding his omeprazole usage?

      Your Answer: Continue taking omeprazole 20mg until day of gastroscopy

      Correct Answer: Stop taking omeprazole 2 weeks before endoscopy

      Explanation:

      To avoid the possibility of masking serious underlying pathology like gastric cancer, patients who are taking proton pump inhibitors or H2 receptor blockers should discontinue their use at least two weeks before undergoing an endoscopy.

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      45
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  • Question 6 - A 28-year-old female patient complains of symptoms that suggest coeliac disease. What is...

    Correct

    • A 28-year-old female patient complains of symptoms that suggest coeliac disease. What is the primary test that should be employed for screening individuals with coeliac disease?

      Your Answer: Tissue transglutaminase antibodies

      Explanation:

      According to NICE, the initial serological test for coeliac disease should be tissue transglutaminase antibodies.

      Investigating Coeliac Disease

      Coeliac disease is a condition caused by sensitivity to gluten, which can lead to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis of coeliac disease is made through a combination of serology and endoscopic intestinal biopsy. The gold standard for diagnosis is the biopsy, which should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis. The biopsy traditionally takes place in the duodenum, but jejunal biopsies are also sometimes performed. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Serology tests for coeliac disease include tissue transglutaminase antibodies and endomyseal antibodies, while anti-gliadin antibodies are not recommended. Patients who are already on a gluten-free diet should reintroduce gluten for at least six weeks prior to testing. Rectal gluten challenge is not widely used. A gluten-free diet can reverse villous atrophy and immunology in patients with coeliac disease.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      12.1
      Seconds
  • Question 7 - A 58-year-old man is recuperating on the ward after an emergency laparotomy and...

    Correct

    • A 58-year-old man is recuperating on the ward after an emergency laparotomy and ileocolic resection for Crohn's disease. The nursing staff has raised concerns about his abdominal wound on the fifth day post-operation. Upon review, you observe a clear wound dehiscence in the central area of his laparotomy incision, with a small portion of the bowel visible.

      What are the initial steps that should be taken in this situation?

      Your Answer: Cover the wound with sterile saline-soaked gauze and administer antibiotics while awaiting a senior review

      Explanation:

      When an abdominal wound reopens after surgery, it is called wound dehiscence. This can happen for various reasons, including infection, poor surgical technique, and malnutrition. As a junior doctor, it is important to know how to manage this emergency situation. The initial steps involve administering broad-spectrum antibiotics intravenously, covering the wound with sterile gauze soaked in sterile saline to prevent the abdominal contents from drying out, and arranging for the patient to undergo wound repair in the operating theatre. It is not advisable to attempt to close the wound on the ward, as this can be unsafe and increase the risk of infection or bowel injury. A nasogastric tube is not necessary, and simply redressing the wound without moist gauze can lead to fluid loss from the abdominal contents. It is also not necessary to arrange a CT scan, as the problem is evident and requires immediate management. While antibiotics and surgery are necessary, leaving the wound open and uncovered can lead to fluid loss and infection.

      Abdominal wound dehiscence is a serious issue that surgeons who perform abdominal surgery frequently encounter. It occurs when all layers of an abdominal mass closure fail, resulting in the protrusion of the viscera externally. This condition is associated with a 30% mortality rate and can be classified as either superficial or complete, depending on the extent of the wound failure.

      Several factors increase the risk of abdominal wound dehiscence, including malnutrition, vitamin deficiencies, jaundice, steroid use, major wound contamination (such as faecal peritonitis), and poor surgical technique. To prevent this condition, the preferred method is the mass closure technique, also known as the Jenkins Rule.

      When sudden full dehiscence occurs, the wound should be covered with saline impregnated gauze, and the patient should receive IV broad-spectrum antibiotics, analgesia, and IV fluids. Arrangements should also be made for a return to the operating theatre.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      34.3
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  • Question 8 - A 45-year-old man visits his GP with a 7-month history of abdominal bloating,...

    Incorrect

    • A 45-year-old man visits his GP with a 7-month history of abdominal bloating, pain and urgency to defecate in the morning. He has no history of nausea/vomiting, per rectum bleeding, mucus on stools or weight loss. He says that his symptoms become much worse, with worsening constipation, when he is stressed. Physical examination is unremarkable.
      Which of the following is the best initial treatment for his symptoms?

      Your Answer: Lactulose

      Correct Answer: Mebeverine

      Explanation:

      Understanding and Managing Irritable Bowel Syndrome (IBS)

      Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects 10-20% of the population, with women being more likely to develop it than men. It is characterized by abdominal pain, bloating, and altered bowel habits without any specific organic pathology.

      Diagnosis of IBS is based on the presence of symptoms such as abdominal pain or discomfort, bloating, and change in bowel habit for at least 6 months. Physical examination and further investigations are necessary to exclude other differential diagnoses.

      Management of IBS primarily involves psychological support and dietary measures such as fiber supplementation, low FODMAP diets, increased water intake, and avoiding trigger foods. Pharmacological treatment is adjunctive and should be directed at symptoms. Anti-spasmodics, anti-diarrheals, and antidepressants may have a positive effect on symptoms.

      It is important to note that symptoms not consistent with IBS, such as rectal bleeding, anorexia/weight loss, nocturnal symptoms, or fecal incontinence, should alert the clinician to the possibility of an organic pathology. Referral for psychological therapies should be considered for patients who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      60.1
      Seconds
  • Question 9 - A 14-year-old girl presents to a gastroenterology clinic with a history of diarrhoea,...

    Incorrect

    • A 14-year-old girl presents to a gastroenterology clinic with a history of diarrhoea, bloating, and severe abdominal pain for the past 8 months. Her full blood count results are as follows:
      Hb 118 g/L Male: (135-180)
      Female: (115 - 160)
      Platelets 190 * 109/L (150 - 400)
      WBC 7.5 * 109/L (4.0 - 11.0)

      What would be the most appropriate next investigation?

      Your Answer: Faecal calprotectin

      Correct Answer: Serum immunoglobulin IgA tissue transglutaminase antibody (tTGA) and total IgA

      Explanation:

      Investigating Coeliac Disease

      Coeliac disease is a condition caused by sensitivity to gluten, which can lead to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis of coeliac disease is made through a combination of serology and endoscopic intestinal biopsy. The gold standard for diagnosis is the biopsy, which should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis. The biopsy traditionally takes place in the duodenum, but jejunal biopsies are also sometimes performed. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Serology tests for coeliac disease include tissue transglutaminase antibodies and endomyseal antibodies, while anti-gliadin antibodies are not recommended. Patients who are already on a gluten-free diet should reintroduce gluten for at least six weeks prior to testing. Rectal gluten challenge is not widely used. A gluten-free diet can reverse villous atrophy and immunology in patients with coeliac disease.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      113.4
      Seconds
  • Question 10 - A 56-year-old woman presents to the emergency department complaining of right upper quadrant...

    Correct

    • A 56-year-old woman presents to the emergency department complaining of right upper quadrant pain and rigors that have been ongoing for 2 days. She had previously seen her GP 6 months ago for biliary colic and was referred for an elective cholecystectomy. Upon examination, her blood work reveals elevated levels of WCC, CRP, and bilirubin. Based on these findings, what is the most probable diagnosis?

      Your Answer: Ascending cholangitis

      Explanation:

      If a patient with a history of gallstones experiences RUQ pain along with elevated inflammatory markers, it is more likely to be acute cholecystitis or cholangitis rather than biliary colic. The presence of fever and abnormal LFTs suggests ascending cholangitis, as opposed to cholecystitis, which is indicated by Charcot’s triad of RUQ pain, fever, and jaundice. Acute pancreatitis is unlikely if amylase levels are normal, and the sudden onset of symptoms makes malignancy, particularly cholangiocarcinoma, less probable.

      Understanding Ascending Cholangitis

      Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

      To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

      Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      11.1
      Seconds
  • Question 11 - A 32-year-old woman with a 9-month history of weight loss, intermittent bloody mucus...

    Correct

    • A 32-year-old woman with a 9-month history of weight loss, intermittent bloody mucus stools and abdominal pain undergoes a colonoscopy, which shows a mucosal ‘cobblestone’ pattern and skip lesions. She drinks approximately four units of alcohol a week and has a smoking history of five pack years.
      Which of the following is the most appropriate lifestyle advice for this patient?

      Your Answer: Stop smoking

      Explanation:

      Lifestyle Advice for Patients with Inflammatory Bowel Disease

      Inflammatory bowel disease (IBD) is a chronic inflammatory process that can affect any part of the gastrointestinal tract. Patients with IBD may experience symptoms such as diarrhoea, abdominal pain, and bleeding. Here are some lifestyle advice for patients with IBD:

      Stop smoking: Research suggests that smoking can make Crohn’s disease worse. Smokers with Crohn’s disease have more severe symptoms and complications, require more medication, and are more likely to need surgery.

      Eat a balanced diet: Patients with IBD may need to be careful about the amount and type of fibre in their diet. During flare-ups, it may be helpful to reduce the amount of insoluble fibre consumed, but, once the flare-up is over, it is important to increase fibre intake again.

      Avoid alcohol: Although there is no evidence that alcohol consumption worsens IBD symptoms, alcohol can affect the lining of the gastrointestinal tract and interact with certain medications.

      Quit smoking: Although smoking may delay or even prevent ulcerative colitis, the health risks of smoking outweigh any benefits seen in UC, and strongly discourage smoking in everyone, whether or not they have IBD.

      Consider probiotics: The role of probiotics in IBD is not fully understood, but their use can be discussed with a General Practitioner or dietitian. More research is needed on their general effectiveness.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      206.8
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  • Question 12 - You are evaluating a patient with Crohn's disease. Which of the following non-intestinal...

    Incorrect

    • You are evaluating a patient with Crohn's disease. Which of the following non-intestinal symptoms of Crohn's disease is associated with disease activity?

      Your Answer: Pyoderma gangrenosum

      Correct Answer: Erythema nodosum

      Explanation:

      Understanding Crohn’s Disease

      Crohn’s disease is a type of inflammatory bowel disease that affects various parts of the digestive tract, from the mouth to the anus. Although the exact cause of Crohn’s disease is unknown, there is a strong genetic susceptibility. The disease is characterized by inflammation in all layers of the digestive tract, 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 may include non-specific symptoms such as weight loss and lethargy, 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 is important to note that Crohn’s disease shares some extra-intestinal features with ulcerative colitis, another type of inflammatory bowel disease. Arthritis is the most common extra-intestinal feature in both Crohn’s disease and ulcerative colitis, while primary sclerosing cholangitis is much more common in ulcerative colitis. Understanding the symptoms and features of Crohn’s disease can help with early diagnosis and management of the disease.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      7
      Seconds
  • Question 13 - A 42-year-old woman presents to her General Practitioner with a diagnosis of primary...

    Correct

    • A 42-year-old woman presents to her General Practitioner with a diagnosis of primary biliary cholangitis (PBC). She initially complained of abdominal pain and itching, but is now asymptomatic except for significant fatigue. What medication should be prescribed for this patient? Choose the most likely option.

      Your Answer: Ursodeoxycholic acid (UDCA)

      Explanation:

      Treatment Options for Primary Biliary Cholangitis

      Primary biliary cholangitis (PBC) is a liver disease that can lead to cirrhosis if left untreated. Ursodeoxycholic acid (UDCA) is the main treatment for PBC, as it can prevent or delay the development of cirrhosis. UDCA increases bile flow, inhibits toxic bile acid production, prevents hepatocyte apoptosis, and reduces the liver’s immune response. However, UDCA may cause side effects such as diarrhea, nausea, and thinning hair.

      Spironolactone is a diuretic that can be useful for end-stage liver disease with ascites, but it is not indicated for treating fatigue in PBC patients. Aspirin and ibuprofen should be avoided by PBC patients, as they can worsen liver disease. Cholestyramine is used for cholestatic itching, but it should not be taken with UDCA as it can prevent UDCA absorption.

      In summary, UDCA is the primary treatment for PBC, and other medications should be used with caution and only for specific symptoms or complications.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      4.9
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  • Question 14 - Which of the following is a common feature of ulcerative colitis? ...

    Incorrect

    • Which of the following is a common feature of ulcerative colitis?

      Your Answer: Skip lesions

      Correct Answer: Pseudopolyps

      Explanation:

      Pseudopolyps observed during endoscopy are indicative of ulcerative colitis.

      Crohn’s disease and ulcerative colitis are the two main types of inflammatory bowel disease with many similarities in symptoms and management options. However, there are key differences such as non-bloody diarrhea and upper gastrointestinal symptoms being more common in Crohn’s disease, while bloody diarrhea and abdominal pain in the left lower quadrant are more common in ulcerative colitis. Complications and pathology also differ between the two diseases.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      4.7
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  • Question 15 - A 50-year-old male comes to the emergency department complaining of malaise, yellowing sclera,...

    Correct

    • A 50-year-old male comes to the emergency department complaining of malaise, yellowing sclera, and increasing abdominal girth. He admits to drinking 80 cl of whisky daily and has had several unsuccessful attempts at community detoxification. The patient has a medical history of liver cirrhosis. During the examination, a significantly distended abdomen with a shifting dullness and an enlarged mass in the right upper quadrant are observed.

      What is the most suitable medication to prescribe for this patient?

      Your Answer: Spironolactone

      Explanation:

      For patients with ascites caused by liver cirrhosis, it is recommended to prescribe an aldosterone antagonist, such as spironolactone, as the preferred diuretic to combat sodium retention. A low-salt diet should also be implemented. While furosemide can be useful in combination with spironolactone, it is not effective in blocking aldosterone and should not be used as a single agent. Nephrotoxic medications, including naproxen, should be avoided. ACE inhibitors, like ramipril, can induce renal failure and should be used with caution and careful monitoring of blood pressure and renal function. Restricting high sodium concentration fluids will not be beneficial, but a low sodium diet is recommended to prevent water retention.

      Understanding Ascites: Causes and Management

      Ascites is a medical condition characterized by the accumulation of abnormal fluid in the abdomen. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. A SAAG level greater than 11g/L indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. On the other hand, a SAAG level less than 11g/L is caused by hypoalbuminaemia, malignancy, infections, and other factors such as bowel obstruction and biliary ascites.

      The management of ascites involves reducing dietary sodium and fluid restriction, especially if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone and loop diuretics are often prescribed to patients. In some cases, drainage through therapeutic abdominal paracentesis is necessary. Large-volume paracentesis requires albumin cover to reduce the risk of paracentesis-induced circulatory dysfunction and mortality. Prophylactic antibiotics are also recommended to prevent spontaneous bacterial peritonitis. In severe cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.

      Understanding the causes and management of ascites is crucial in providing appropriate medical care to patients. Proper diagnosis and treatment can help alleviate symptoms and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      1.4
      Seconds
  • Question 16 - A 50-year-old man visits the Gastroenterology Clinic with concerns about his tongue. He...

    Incorrect

    • A 50-year-old man visits the Gastroenterology Clinic with concerns about his tongue. He has noticed unusual patterns on his tongue that have been present for a while, but he is worried about tongue cancer as he has been a heavy smoker for the past 20 years. What is the most suitable initial management option for this patient?

      Your Answer: Surgical correction

      Correct Answer: None

      Explanation:

      Geographic Tongue: A Benign Condition Requiring No Medical Intervention

      Geographic tongue, also known as benign migratory glossitis, is a common condition that affects up to 3% of the general population. While some patients may experience a burning sensation when consuming hot or spicy foods, most are asymptomatic. The diagnosis of geographic tongue can usually be confirmed from history and physical examination alone, and no medical intervention is required.

      Surgical correction is not warranted for geographic tongue, as it is a benign condition of no clinical significance. Aspiration for cytology is also not appropriate, as the diagnosis can be made without further investigation. Excision biopsy may actually cause harm, as histological findings are identical to those seen in pustular psoriasis.

      A full blood count is not necessary for the diagnosis of geographic tongue. Instead, the condition can be identified through the elongation of rete ridges, hyperparakeratosis and acanthosis at the periphery, loss of filiform papillae, and migration and clustering of neutrophils within the epithelium towards the centre of the lesions. The predominant inflammatory infiltrates in the lamina propria is neutrophils with an admixture of chronic inflammatory cells.

      In summary, geographic tongue is a benign condition that requires no medical intervention. Diagnosis can be made through history and physical examination alone, and further investigation may cause harm.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      16.8
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  • Question 17 - A 50-year-old man presents to the emergency department with right upper quadrant pain,...

    Incorrect

    • A 50-year-old man presents to the emergency department with right upper quadrant pain, fatigue, and anorexia that has been going on for a few weeks and is getting gradually worse. His past medical history includes heavy alcohol intake, gastroesophageal reflux disease (GORD) and a hiatus hernia. He only takes omeprazole and has no known allergies.

      On examination, he looks jaundiced.

      A liver function test is done which shows:

      Bilirubin 50 µmol/L (3 - 17)
      ALT 150 u/L (3 - 40)
      AST 300 u/L (8 - 33)
      Albumin 35 g/L (35 - 50)

      What is the most likely diagnosis?

      Your Answer: Hepatitis A

      Correct Answer: Alcoholic hepatitis

      Explanation:

      Understanding Alcoholic Liver Disease and its Management

      Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. One of the characteristic findings in this disease is an elevated gamma-GT level. Additionally, a ratio of AST:ALT greater than 2, and especially greater than 3, strongly suggests acute alcoholic hepatitis.

      When it comes to managing alcoholic hepatitis, glucocorticoids such as prednisolone are often used during acute episodes. The Maddrey’s discriminant function (DF) is used to determine who would benefit from glucocorticoid therapy. This function is calculated using prothrombin time and bilirubin concentration. Pentoxyphylline is also sometimes used as a treatment option.

      A study called STOPAH compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednisolone. The study showed that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes. Understanding the different types of alcoholic liver disease and their management options is crucial for healthcare professionals in providing effective care for patients.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 18 - You are assessing a 50-year-old man who has been diagnosed with Barrett's oesophagus...

    Incorrect

    • You are assessing a 50-year-old man who has been diagnosed with Barrett's oesophagus following difficult to control symptoms. Biopsies did not reveal any dysplasia. What is the most strongly linked risk factor modification for the development of Barrett's oesophagus?

      Your Answer: Alcohol

      Correct Answer: Gastro-oesophageal reflux disease

      Explanation:

      Barrett’s oesophagus is most strongly associated with the presence of GORD as a risk factor.

      Understanding Barrett’s Oesophagus

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, increasing the risk of oesophageal adenocarcinoma by 50-100 fold. It is typically identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia. The length of the affected segment correlates strongly with the chances of identifying metaplasia, with the overall prevalence estimated to be around 1 in 20. Risk factors include gastro-oesophageal reflux disease (GORD), male gender, smoking, and central obesity. Interestingly, alcohol does not seem to be an independent risk factor for Barrett’s. Management includes high-dose proton pump inhibitors and endoscopic surveillance with biopsies every 3-5 years for patients with metaplasia. If dysplasia of any grade is identified, endoscopic intervention such as radiofrequency ablation or endoscopic mucosal resection is offered.

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, increasing the risk of oesophageal adenocarcinoma. It is typically identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia. The length of the affected segment correlates strongly with the chances of identifying metaplasia, with the overall prevalence estimated to be around 1 in 20. Risk factors include GORD, male gender, smoking, and central obesity. Interestingly, alcohol does not seem to be an independent risk factor for Barrett’s. Management includes high-dose proton pump inhibitors and endoscopic surveillance with biopsies every 3-5 years for patients with metaplasia. If dysplasia of any grade is identified, endoscopic intervention such as radiofrequency ablation or endoscopic mucosal resection is offered.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 19 - A 35-year-old female complains of abdominal discomfort accompanied by alternating episodes of constipation...

    Incorrect

    • A 35-year-old female complains of abdominal discomfort accompanied by alternating episodes of constipation and diarrhea. What symptom is the least indicative of irritable bowel syndrome?

      Your Answer: Feeling of incomplete stool evacuation

      Correct Answer: Waking at night due to the pain

      Explanation:

      It is not typical for irritable bowel syndrome to cause pain that disrupts a patient’s sleep.

      Diagnosis and Management of Irritable Bowel Syndrome

      Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects many people. In 2008, the National Institute for Health and Care Excellence (NICE) published clinical guidelines on the diagnosis and management of IBS. According to these guidelines, a positive diagnosis of IBS should be considered if the patient has had abdominal pain, bloating, or a change in bowel habit for at least six months. Additionally, a positive diagnosis should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to two of the following four symptoms: altered stool passage, abdominal bloating, symptoms made worse by eating, and passage of mucus. Other features such as lethargy, nausea, backache, and bladder symptoms may also support the diagnosis.

      It is important to note that red flag features should be enquired about, including rectal bleeding, unexplained/unintentional weight loss, family history of bowel or ovarian cancer, and onset after 60 years of age. Primary care investigations such as a full blood count, ESR/CRP, and coeliac disease screen (tissue transglutaminase antibodies) are suggested. By following these guidelines, healthcare professionals can effectively diagnose and manage IBS in their patients.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 20 - You are asked to review an 80-year-old woman in the clinic who has...

    Correct

    • You are asked to review an 80-year-old woman in the clinic who has been referred by her GP due to weight loss, early satiety and increasing anorexia. On examination, the GP notes a palpable left supraclavicular node and an epigastric mass, but no jaundice. There is microcytic anaemia, with normal liver enzymes. Her past history includes excess consumption of alcohol and a 30-pack-year smoking history.
      Which of the following is the most likely diagnosis?

      Your Answer: Gastric carcinoma

      Explanation:

      Gastric carcinoma is the most common type of gastric malignancy, with adenocarcinoma accounting for 90-95% of cases. Risk factors include smoking and excessive alcohol consumption. Early gastric cancer may not present with any symptoms, while advanced disease may cause indigestion, anorexia, weight loss, early postprandial fullness, and a palpable enlarged stomach with succussion splash. Troisier’s sign, the presence of a hard and enlarged left-sided supraclavicular lymph node, suggests metastatic abdominal malignancy.

      Abdominal aortic aneurysm (AAA) presents with a pulsatile epigastric mass, but not an enlarged supraclavicular node. Patients are usually asymptomatic unless there is an aneurysm leak, which causes abdominal and/or back pain and rapid deterioration.

      Cholangiocarcinoma, a malignant tumor of the bile duct, typically presents with jaundice, weight loss, and abdominal pain. Normal liver function tests make this diagnosis unlikely.

      Benign gastric ulcers cause epigastric pain, usually a burning sensation postprandially. This patient’s symptoms, including weight loss, anorexia, and lymphadenopathy, suggest malignant pathology.

      Crohn’s disease, a chronic inflammatory bowel disease, can affect any part of the gastrointestinal tract. Gastroduodenal Crohn’s disease presents with vague symptoms such as weight loss, anorexia, dyspepsia, nausea, and vomiting. However, the examination findings in this patient make a malignant diagnosis more likely.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 21 - Which one of the following statements regarding pancreatic cancer is true? ...

    Correct

    • Which one of the following statements regarding pancreatic cancer is true?

      Your Answer: High-resolution CT scanning is the diagnostic investigation of choice

      Explanation:

      Pancreatic cancer is best diagnosed through high-resolution CT scanning. Although chronic pancreatitis increases the risk, neither alcohol nor gallstone disease are significant independent risk factors. Radiotherapy is not effective for surgical resection. Unfortunately, most patients are diagnosed with unresectable lesions.

      Understanding Pancreatic Cancer: Risk Factors, Symptoms, and Management

      Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. Adenocarcinomas, which occur at the head of the pancreas, make up over 80% of pancreatic tumors. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and genetic mutations such as BRCA2 and KRAS.

      Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, pruritus, anorexia, weight loss, epigastric pain, loss of exocrine and endocrine function, and atypical back pain. Migratory thrombophlebitis, also known as Trousseau sign, is more common in pancreatic cancer than in other cancers.

      Diagnosis of pancreatic cancer can be made through ultrasound or high-resolution CT scanning, which may show the double duct sign – simultaneous dilatation of the common bile and pancreatic ducts. However, less than 20% of patients are suitable for surgery at diagnosis. A Whipple’s resection, or pancreaticoduodenectomy, may be performed for resectable lesions in the head of the pancreas. Adjuvant chemotherapy is usually given following surgery, and ERCP with stenting may be used for palliation.

      In summary, pancreatic cancer is a serious disease with non-specific symptoms that can be difficult to diagnose. Understanding the risk factors and symptoms can help with early detection and management.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 22 - A 44-year-old woman presents to the emergency department with sudden onset abdominal pain...

    Correct

    • A 44-year-old woman presents to the emergency department with sudden onset abdominal pain and vomiting for the past 5 days. She feels nauseated and cannot tolerate any food and only minimal liquid. She denies diarrhoea and has not had a bowel movement for 4 days.

      Her past medical history includes chronic lower back pain for which she takes regular co-codamol. The last time she was in hospital was for her cesarean section 10 years ago.

      Upon examination, she appears clammy and dehydrated. Her abdomen is distended and tender throughout. Bowel sounds are inaudible.

      What is the most probable underlying cause of this patient's presentation?

      Your Answer: Adhesions

      Explanation:

      The most common cause of small bowel obstruction is adhesions. This patient is experiencing symptoms such as abdominal pain, distention, and constipation, which are similar to those of large bowel obstruction. However, the onset of nausea and vomiting is an early sign of small bowel obstruction, indicating a proximal lesion. Adhesions are scar tissue that can form due to inflammation or manipulation of the abdominal contents during surgery, and they are often present in patients who are asymptomatic for years before experiencing symptoms. Given the patient’s history of a previous cesarean section, adhesional small bowel obstruction is a likely diagnosis.

      Large bowel obstruction is most commonly caused by colorectal cancer, and symptoms include abdominal pain, distention, and constipation. However, nausea and vomiting are later signs compared to small bowel obstruction.

      Gallstone ileus is a rare complication of cholecystitis where a gallstone passes through a fistula between the gallstone and small bowel before becoming impacted, leading to small bowel obstruction.

      Inguinal hernias can also cause small bowel obstruction, as they involve a protrusion of abdominal contents through a defect in the abdominal wall. However, the patient’s history of previous abdominal surgery makes adhesions a more likely cause.

      While regular opioid use can lead to constipation, it is not a cause of obstruction. In this case, the patient’s bilious vomiting and positive findings of abdominal tenderness and distension suggest intestinal obstruction rather than simple constipation.

      Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common cause of this condition is adhesions, which can develop after previous surgeries, followed by hernias. Symptoms of small bowel obstruction 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-line imaging for suspected small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early obstruction. Management involves initial steps such as NBM, IV fluids, and nasogastric tube with free drainage. Some patients may respond to conservative management, but others may require surgery.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 23 - A 42-year-old man with a 4-week history of a diagnosed anal fissure returns...

    Correct

    • A 42-year-old man with a 4-week history of a diagnosed anal fissure returns to the general practice surgery for review. He has been regularly using stool softeners along with eating a healthy diet and drinking adequate water. He is still experiencing bleeding and pain on opening his bowels. Examination reveals an anal fissure with no alarming signs.
      Which of the following would be the most appropriate management at this stage?

      Your Answer: Topical glyceryl trinitrate (GTN)

      Explanation:

      Management of Primary Anal Fissure: Treatment Options and Referral Guidelines

      Primary anal fissure is a common condition that can cause significant pain and discomfort. The National Institute for Health and Care Excellence (NICE) provides guidelines for the management of this condition, which include prescribing rectal topical glyceryl trinitrate (GTN) 0.4% ointment for 6-8 weeks to relieve pain and aid healing. Referral to a colorectal surgeon is warranted if the fissure does not heal after this period. Botulinum toxin injections can be considered in secondary care settings for chronic and recurrent cases, but only after a trial of topical GTN. Taking no action is not recommended, as it can lead to chronic non-healing ulcers. Trying different laxatives, such as senna, is also unlikely to help and should not be the first-line treatment for anal fissure. Overall, early intervention with topical GTN and appropriate referral can improve outcomes for patients with primary anal fissure.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 24 - A 26-year-old male complains of epigastric pain and reflux that worsens after eating....

    Correct

    • A 26-year-old male complains of epigastric pain and reflux that worsens after eating. He underwent first-line triple-therapy eradication treatment for a positive Helicobacter pylori stool antigen test 3 months ago, which initially relieved his symptoms. However, they have now returned, and he wishes to undergo re-testing. What is the most suitable test to arrange?

      Your Answer: Urea breath test

      Explanation:

      Tests for Helicobacter pylori

      There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.

      Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.

      Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 25 - A 60-year-old woman presents to her General Practitioner with mild central abdominal discomfort....

    Correct

    • A 60-year-old woman presents to her General Practitioner with mild central abdominal discomfort. She also reports unintentional weight loss over the past four months. However, she denies any rectal bleeding or fatigue and has no significant family history.
      What is the most appropriate course of action for management?

      Your Answer: 2-week wait referral to the colorectal services

      Explanation:

      Referral for Investigation of Colorectal Cancer with a 2-Week Wait

      According to the National Institute for Health and Care Excellence (NICE) guidelines, patients aged 40 or over who present with unexplained weight loss and abdominal pain should be referred for investigation of colorectal cancer with a 2-week wait. Other criteria for a 2-week wait referral include patients with unexplained rectal bleeding, iron-deficiency anaemia, change in bowel habit, positive faecal occult blood tests, rectal or abdominal mass, unexplained anal mass or anal ulceration, and patients under 50 years with rectal bleeding and any of the following unexplained symptoms or findings: abdominal pain, change in bowel habit, weight loss or iron-deficiency anaemia.

      Doing nothing and just following up with the patient, prescribing analgesia and following up in one month, referring the patient routinely, or taking urgent bloods and following up in two weeks would not be appropriate in the presence of red-flag symptoms and can create a serious delay in diagnosis and treatment. Therefore, referral for investigation of colorectal cancer with a 2-week wait is the recommended course of action. However, taking urgent bloods and following up the patient in two weeks can still be done while the patient is waiting for the referral appointment.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 26 - A 42-year-old woman presents with a persistent history of acid reflux. She has...

    Incorrect

    • A 42-year-old woman presents with a persistent history of acid reflux. She has visited her primary care physician multiple times. A trial of low-dose proton pump inhibitor (PPI) and lifestyle changes has not improved her symptoms. She has been tested for Helicobacter pylori, and the results were negative. Her screening blood tests are normal.
      What is the best course of action for management?

      Your Answer: Ask the GP to discontinue PPI and advise lifestyle measures

      Correct Answer: Do an upper gastrointestinal (GI) endoscopy

      Explanation:

      Approaches to Managing Dyspepsia in Patients with Gastro-Oesophageal Reflux Disease

      Patients with chronic gastro-oesophageal reflux disease (GORD) are at risk of developing Barrett’s oesophagus and oesophageal cancer. Therefore, patients aged 50 years or older with a history of chronic GORD should undergo at least one upper gastrointestinal (GI) endoscopy to screen for these conditions. In younger patients, long-term low-dose proton pump inhibitor (PPI) therapy may be considered, with dose adjustment if necessary. However, ongoing dyspepsia in a patient over 50 years old warrants further investigation to exclude serious pathology. Intermittent high-dose PPI therapy is currently only used in hospital for specific indications. Counselling with false reassurance should be avoided in patients with concerning symptoms.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      28.5
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  • Question 27 - A 68-year-old male presents with a 2-day history of feeling unwell and abdominal...

    Incorrect

    • A 68-year-old male presents with a 2-day history of feeling unwell and abdominal pain. Upon examination, you note a distended abdomen with guarding and absent bowel sounds. The patient's blood pressure is 88/42 mmHg, and heart rate is 120 bpm. A CT scan reveals a perforation of the sigmoid colon due to a large lesion causing bowel obstruction. The patient undergoes emergency laparotomy. What surgical procedure is most likely to have been performed?

      Your Answer: Ileocolic anastomosis

      Correct Answer: End colostomy

      Explanation:

      When dealing with an emergency situation where a colonic tumour has caused perforation, it is riskier to perform a colon-colon anastomosis. This is because it could result in an anastomotic leak, which would release bowel contents into the abdomen. Therefore, it is safer to perform an end colostomy, which can be reversed at a later time. Ileostomy, both end and loop, is not suitable for this patient as the perforation is located in the distal colon. Ileocolic anastomoses are generally safe in emergency situations and do not require de-functioning. However, in this case, an ileocolic anastomosis would not be appropriate as the obstructing lesion is in the distal colon rather than the proximal colon.

      Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.

      For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.

      Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.

      Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 28 - A 28-year-old woman is in week 32 of her pregnancy. She has been...

    Correct

    • A 28-year-old woman is in week 32 of her pregnancy. She has been experiencing itching for two weeks and is worried. She now has mild jaundice. Her total bilirubin level is elevated at around 85 μmol/l (reference range <20 μmol/), and her alanine aminotransferase (ALT) level is elevated at 78 iu/l (reference range 20–60 iu/l); her alkaline phosphatase (ALP) level is significantly elevated. What is the most appropriate diagnosis for this clinical presentation?

      Your Answer: Intrahepatic cholestasis of pregnancy

      Explanation:

      Differential Diagnosis of Liver Disorders in Pregnancy

      Intrahepatic cholestasis of pregnancy (ICP), hyperemesis gravidarum, cholecystitis, acute fatty liver of pregnancy (AFLP), and HELLP syndrome are all potential liver disorders that can occur during pregnancy.

      ICP is the most common pregnancy-related liver disorder and is characterised by generalised itching, jaundice, and elevated total serum bile acid levels. Maternal outcomes are good, but fetal outcomes can be devastating.

      Hyperemesis gravidarum is characterised by persistent nausea and vomiting associated with ketosis and weight loss. Elevated transaminase levels may occur, but significantly elevated liver enzymes would suggest an alternative aetiology.

      Cholecystitis is inflammation of the gall bladder that occurs most commonly due to gallstones. The most common presenting symptom is upper abdominal pain, which localises to the right upper quadrant.

      AFLP is characterised by microvesicular steatosis in the liver and can present with malaise, nausea and vomiting, right upper quadrant and epigastric pain, and acute renal failure. Both AST and ALT levels can be elevated, and hypoglycaemia is common.

      HELLP syndrome is a life-threatening condition that can potentially complicate pregnancy and is characterised by haemolysis, elevated liver enzyme levels, and low platelet levels. Symptoms are non-specific and include malaise, nausea and vomiting, and weight gain. A normal platelet count and no evidence of haemolysis are not consistent with a diagnosis of HELLP syndrome.

      Early recognition, treatment, and timely delivery are imperative for all of these liver disorders in pregnancy.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 29 - A 28-year-old man presents to the colorectal surgeons with recurrent episodes of bright...

    Incorrect

    • A 28-year-old man presents to the colorectal surgeons with recurrent episodes of bright red rectal bleeding over the past 5 months. During examination, a muco-epithelial defect is observed in the posterior midline of the anus. However, a complete digital rectal exam (DRE) could not be performed due to severe pain. Despite trying bulk-forming laxatives, lubricants, and topical glyceryl trinitrate (GTN), the patient has experienced little relief. What is the recommended next step in managing this likely diagnosis?

      Your Answer: High-fibre diet

      Correct Answer: Sphincterotomy

      Explanation:

      For cases of anal fissures that do not respond to conservative management, sphincterotomy may be considered as the next step. This is likely the case for the patient in question, who has not seen improvement with laxatives, lubricants, and topical GTN. While a high-fibre diet is important in managing anal fissures, it should be initiated alongside other conservative measures. If the patient had a perianal abscess, incision and drainage would be the appropriate treatment. For haemorrhoids, rubber band ligation would be the management, while anal fistulae would require seton insertion.

      Understanding Anal Fissures: Causes, Symptoms, and Treatment

      Anal fissures are tears in the lining of the distal anal canal that can be either acute or chronic. Acute fissures last for less than six weeks, while chronic fissures persist for more than six weeks. The most common risk factors for anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.

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

      Management of acute anal fissures involves softening stool, dietary advice, bulk-forming laxatives, lubricants, topical anaesthetics, and analgesia. For chronic anal fissures, the same techniques should be continued, and topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after eight weeks, surgery (sphincterotomy) or botulinum toxin may be considered, and referral to secondary care is recommended.

      In summary, anal fissures can be a painful and uncomfortable condition, but with proper management, they can be effectively treated. It is important to identify and address underlying risk factors to prevent the development of chronic fissures.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 30 - A 26-year-old woman has been asked to come in for a consultation at...

    Correct

    • A 26-year-old woman has been asked to come in for a consultation at her local medical practice after her blood test results showed an elevated level of anti-tissue transglutaminase antibody (anti-TGA). What condition is linked to anti-TGA?

      Your Answer: Coeliac disease

      Explanation:

      Autoimmune Diseases: Understanding the Causes and Symptoms

      Autoimmune diseases are conditions where the body’s immune system mistakenly attacks its own tissues. Here are some examples of autoimmune diseases and their causes and symptoms:

      Coeliac Disease: This disease is caused by gluten sensitivity and results in chronic diarrhoea, weight loss, and fatigue. It is caused by an autoimmune reaction to glutenin or gliadin, which are gluten proteins found in wheat.

      Pemphigus Vulgaris: This rare autoimmune disease causes blistering to the skin and mucosal surfaces. It is caused by autoantibodies against desmoglein.

      Graves’ Disease: This autoimmune disease of the thyroid results in hyperthyroidism. It is associated with anti-thyroid-stimulating hormone receptor antibodies.

      Systemic Lupus Erythematosus (SLE): SLE is a multisystem autoimmune disease associated with a wide number of autoantibodies, including anti-nuclear antibody (ANA), anti-double-stranded (ds) DNA, anti-Smith, anti-SSA, anti-ribosomal P, anti-RNP, and anti-histone antibodies.

      Type I Diabetes Mellitus (T1DM): T1DM is an autoimmune disease resulting in destruction of the islet cells. Islet cell autoantibodies and antibodies to insulin have been described.

      Understanding the causes and symptoms of autoimmune diseases can help with early diagnosis and treatment.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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