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questions
1. A term baby is born with a vitelline duct still present. Her
baby check was normal and she was discharged 2 days
after birth. She remains well until she attends university
at 19 years of age, when she develops colicky
abdominal pain. What is the likely cause?
a. Appendicitis
b. Meckels diverticulum
c. Exomphalos
d. Gastroschisis
e. Atresia
2. A 56-year-old man presents to the GP complaining of
weight loss of 2 kg over 3 months and lethargy. On
further question he reveals that his stools are paler than
normal, and his urine dark in colour. He denies being in
any pain. On examination his sclerae look yellow. What
is the most likely diagnosis?
a. Gallstones
b. Acute pancreatitis
c. Autoimmune hepatitis
d. Pancreatic cancer
e. Hepatocellular carcinoma
3. A 78-year-old female is admitted to the surgical
assessment unit with severe, sudden onset, abdominal
pain for the past 3 days along with bloody diarrhoea for
the past 24 hours. She has a past medical history of atrial
fibrillation. Bloods are unremarkable apart from an
elevated lactate. What is the most likely diagnosis?
a. Ulcerative colitis
b. Colorectal carcinoma
c. Angiodysplasia
d. Crohns disease
e. Ischaemic bowel
4. A 40-year-old gentleman has been suffering from
reflux symptoms for 1 year. He drinks approximately
40 units of alcohol a week, and has recently managed
to give up smoking. His GP send him for an upper GI
endoscopy for further investigation. This looked
suspicious for Barretts Oesophagus so a biopsy
was taken. What would you expect the histology
to show?
a. Columnar cells
b. Squamous cells
c. Glandular cells
d. Transitional cells
e. Connective tissue cells
5. A 52-year-old female attended her local walk-in centre
complaining of tiredness. On further questioning she
had pruritus. A full panel of blood tests were sent off,
and she was informed later in the week that one of the
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180
Hepatocellular carcinoma
Cholangiocarcinoma
Ampullary adenoma
Colorectal cancer
Pancreatic cancer
181
U&Es
Serum amylase
Abdominal X-ray
CT abdomen
182
Iron-deficiency anaemia
Anaemia of chronic disease
Pernicious anaemia
Haemolytic anaemia
Thalassaemia
1. Diarrhoea
F. Rotavirus infection
A. Ulcerative colitis
H. Acute pancreatitis
B. Colon cancer
C. Gastroenteritis
D. Giardiasis
E. Crohns disease
F. Coeliac disease
G. Pseudomembranous colitis
H. Thyrotoxicosis
I. Irritable bowel syndrome
1. A 25-year-old male gives a history of diarrhoea for
1 week. He has no associated abdominal pain, vomiting
or rectal bleeding. Past medical history reveals he was
treated with antibiotics by his GP 2 weeks ago for a skin
infection. Standard stool culture is negative.
2. A 72-year-old gentleman visits the GP complaining of
weight loss, and opening his bowels more frequently, up
to four times a day. He has no abdominal pain or PR
bleeding, but on examination he is noted to look pale.
3. A 23-year-old woman has been seen by the GP on
two occasions over the last 5 years complaining of
loose stool, with intermittent lower abdominal pain,
which she describes as cramps. She stopped smoking
3 months ago, and feels that her symptoms are getting
worse, and has also noticed some blood mixed in with
her stools.
4. A 24-year-old woman gives a 10-year history of
intermittent lower abdominal pain and loose stools. She
denies any PR bleeding, although suggests that her
symptoms often correspond to when she feels under
stress at work.
5. A 67-year-old woman visits the GP having had
diarrhoea for 3 months. She denies any abdominal pain
but admits to loosing 1 stone in weight recently
although denies eating any less than usual. She is
concerned as her brother has been recently diagnosed
with bowel cancer. On examination it is noted that her
pulse is irregular.
2. Vomiting
D. Acute pancreatitis
E. Crohns disease
A. Gastric cancer
F. Ectopic pregnancy
B. Acute gastritis
G. Bowel Obstruction
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5. Dysphagia
A. Oesophageal candidiasis
B. Barretts oesophagus
C. Achalasia
D. Oesophageal web
E. Oesophageal carcinoma
F. Oesophageal stricture
G. Scleroderma
H. Oesophageal dysmotility
I. Presence of a foreign body
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6. Jaundice
A. Alpha-1-antitrypsin deficiency
B. Primary biliary cirrhosis
C. Gallstones
185
SBA answers
1. b. Meckels diverticulum
Meckels diverticulum is the remnant of the
vitelline duct present in embryonic life. It connects the developing embryo with the yolk sac.
It is often asymptomatic, however acute
inflammation of the diverticulum may occur,
mimicking acute appendicitis. The mucosa at
the mouth of the diverticulum may become
inflamed and lead to intussusceptions and
obstruction, or the diverticulum may perforate
and cause peritonitis.
2. d. Pancreatic cancer
The most likely diagnosis here is carcinoma of
the head of the pancreas. The tumour obstructs
the common bile duct causing jaundice and
dark urine because of conjugated hyperbilirubinaemia. The faeces are pale due to a lack of
stercobilinogen. Painless jaundice is typically
the presenting feature of carcinoma of the head
of the pancreas, along with weight loss.
3. e. Ischaemic bowel
Ischaemic bowel is difficult to diagnose and
commonly missed. It usually presents as abdominal pain out of proportion to clinical findings and investigations, and is often a diagnosis
of exclusion; however the presence of metabolic
acidosis helps. It rarely occurs in patients less
than 60 years old. CT angiogram is the investigation of choice.
4. a. Columnar cells
Barretts oesophagus is when prolonged injury
results in the normal squamous epithelium of
the lower oesophagus being replaced by columnar epithelium. This metaplastic change
may be followed by dysplastic change, which
predisposes to malignant transformation. The
majority of patients present with a long history
of reflux.
5. a. Primary biliary cirrhosis
Primary biliary cirrhosis (PBC) is an autoimmune disorder and predominantly affects
women, especially those 4050 years of age,
more than men. All patients with PBC have
antimitochondrial autoantibodies and this, together with raised serum alkaline phosphatase,
is diagnostic for the condition. Patients often
present with pruritus and fatigue, and jaundice
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SBA answers
10. a. Oesophageal varices
The examination findings here show evidence
of liver disease. This helps point to the diagnosis of oesophageal varices as the cause of the
upper gastrointestinal bleed. In patients with
cirrhosis of the liver and portal hypertension
the raised pressure in the portal system causes
the site of a connection between the systemic
and portal venous systems to open up and
enlarge. The enlarged veins protrude into the
lumen of the lower oesophagus and may burst,
resulting in haematemesis. A man with this
history could also be prone to a MalloryWeiss
tear without varices but usually there would
be a history of retching or vomiting before
blood appears. The diagnoses rarely cause large
volume haematemesis.
11. c. IV fluids
There is clinical evidence of shock with the
patient being tachycardic and hypotensive, so
the initial management should be resuscitation
with IV fluids. All of the other investigations are
relevant, and should be done once the patient
is haemodynamically stable.
12. e. Cholangitis
The triad of symptoms which includes fever,
abdominal pain and jaundice are typical in
cholangitis. Cholangitis occurs when gallstones become impacted in the bile duct; the
bile which is unable to escape becomes concentrated and infected, resulting in acute cholecystitis. This causes a rise in the LFTs, particularly
bilirubin and alkaline phosphatase. The other
diseases do not cause jaundice with pain.
13. b. Hepatic encephalopathy
Hepatic encephalopathy is a neurological disorder caused by metabolic failure of the hepatocytes and the shunting of blood around the
liver (due to cirrhosis or after portocaval anastomosis). It may occur in both chronic and
acute liver failure, and results in the exposure
of the brain to abnormal metabolites, causing
oedema and astrocyte changes. Symptoms include disturbances in consciousness (ranging
from confusion to coma and death), asterixis
(coarse flap of outstretched hand) and fluctuating neurological signs including seizures,
muscular rigidity and hyperreflexia.
14. c. Gilberts syndrome
The isolated rise in the bilirubin within the
liver function tests is suggestive of Gilberts
syndrome. This is a congenital disorder caused
by patients having a reduced amount of the
enzyme UDP-glucuronyl transferase (UGT-1),
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SBA answers
19. c. Iron tablets
The low haemoglobin and low MCV suggests
microcytic anaemia. In females of menstrual
age the most common cause of this is irondeficiency anaemia caused by menorrhagia,
sometimes on a background of an irondeficient diet. Patients should have further
bloods sent off for iron studies to confirm
the diagnosis, and then be started on iron
tablets such as ferrous sulphate if appropriate.
If patients had either vitamin B12 or folate
deficiency, then the MCV should be high.
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SBA answers
diagnosis. Crohns disease may affect any part
of the gastrointestinal tract from the mouth
to the anus. Endoscopy usually shows skip
lesions and deep ulcers and fissures in the
mucosa. Ulcerative colitis usually starts in the
rectum and it may extend proximally, although
never beyond the colon. Unlike Crohns, which
commonly shows skip lesions, ulcerative colitis is continuous. Areas of normal gut are not
found between lesions.
28. e. Cyclizine
Cyclizine is an antiemetic from the H1-receptor
antagonist class. These are effective against
motion sickness, as these receptors are found
in the vestibular nuclei, and against vomiting
caused by substances acting in the stomach
29. b. Direct inguinal hernia
A hernia is the protrusion of any organ or tissue
through its coverings and outside its normal
body cavity. If reducible, hernias can be pushed
back into the compartment from which they
came from. Inguinal hernias are the most
common site and may be direct (protruding
through the posterior wall of the inguinal
canal), or indirect (passing through the inguinal canal). Indirect hernias are much more
common, and lie lateral to the inferior epigastric vessels. Direct inguinal hernias are less
common and they lie medial to the inferior
epigastric vessels.
30. c. Serum amylase
Diagnosis of acute pancreatitis is by measurement of serum amylase. It is normally greatly
elevated (five times or more) in acute pancreatitis. The rest of the investigations are relevant
once acute pancreatitis has been diagnosed.
The U&Es and arterial blood gases should be
done in order to ascertain the severity of the disease, by using the Glasgow criteria. Abdominal
X-ray may show an absent psoas shadow and an
air-filled dilatation of the proximal jejunum. CT
is typically done after the acute event to assess
the degree of damage to the pancreas.
31. a. Duodenal ulcer
The positive C14 breath test is indicative of the
presence of H. pylori, which is closely associated
with peptic ulcer disease. The history given
means the diagnosis is most likely to be a duodenal ulcer. With duodenal ulcers, classically
the epigastric pain is said to be relieved by
food or antacids, and exacerbated by hunger.
The epigastric pain with gastric ulcers is characteristically associated with food.
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32. d. Mucosa
The gastrointestinal tract maintains the same
basic structure throughout its length. From
the innermost to the outermost, the layers
which comprise the basic structure are the mucosa (composed of the epithelial layer, lamina
propria and muscularis mucosae), submucosa,
two smooth layers (the inner is circular, and the
outer longitudinal) and finally the serosa.
33. c. Glossitis
Glossitis is inflammation of the tongue. It may
occur in anaemia and certain other deficiency
states, most notably vitamin B12 deficiency.
The most common symptoms are difficulty with
chewing and swallowing foods, tender tongue,
smooth tongue swelling, and a change in colour
(is paler if caused by pernicious anaemia).
34. b. IgA
The defences of the small intestine are in the
most part due to T and B lymphocytes. The
main type of antibody produced by intestinal
B cells is IgA, the major immunoglobulin of external secretions. IgA prevents microorganisms
from entering the gut lumen as it binds and
neutralizes them directly without the need for
other effector systems. A much smaller amount
of IgM is also secreted by the intestinal B cells.
35. a. Cefotaxime
Pseudomembranous colitis is caused by an overgrowth of Clostridium difficile, a bacillus which
is carried by 2% of the population, asymptomatically. It usually occurs post antibiotic therapy
which suppresses the normal colonic flora
allowing C. difficile to proliferate. Pseudomembranous colitis is associated mainly with broadspectrum antibiotics; however cephalosporins
areconsideredthehighest-risk group.Cefotaxime
is a third-generation cephalosporin antibiotic.
36. a. Tropical sprue
The symptoms of weight loss, diarrhoea and
steatorrhea are classic symptoms for malabsorption. The colonoscopy findings of villous
atrophy is suggestive initially of coeliac disease,
however you would expect the patients symptoms to improve with a gluten-free diet. Tropical sprue is a chronic, progressive malabsorption
in patients from the tropics (mainly the West
Indies and Asia) associated with abnormalities
of small intestinal structure and function. It is
thought to have an infective cause. Like coeliac
disease, there is villous atrophy, although obviously a gluten-free diet is of no help. Treatment
is with broad-spectrum antibiotics.
SBA answers
37. e. Colonoscopy
This history of a change in bowel habit for
greater than 6 weeks with PR bleeding is one
of the criteria of the NICE guidelines for an
urgent 2-week referral for patients of any age.
This should include an urgent colonoscopy
and review by a colorectal surgeon.
38. d. Squamous cell carcinoma
Achalasia is a known risk factor for the development of squamous cell carcinoma of the oesophagus. This is thought to be caused by chronic
inflammation and stasis within the oesophagus. Other risk factors for the development of
squamous cell carcinoma are smoking, alcohol,
tylosis and PlummerVinson Syndrome.
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EMQ answers
1 Diarrhoea
1. G.
2. B.
3. A.
4. I.
5. H.
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EMQ answers
5 Dysphagia
Oesophageal web is associated with Plummer
Vinson syndrome, which is associated with
dysphagia and iron-deficient anaemia, which is
suggested from the blood results.
2. F. Strictures are a complication of longstanding
reflux disease. This is due to gastric acid causing
damage to the mucosa. Surgical intervention is
required.
3. C. This is a typical history of achalasia. The chest
pain was caused by oesophageal spasms.
4. E. Oesophageal carcinoma needs to be excluded in
patients with progressive dysphagia and
significant weight loss.
5. A. This patient is immunosuppressed whilst having
chemotherapy, which puts patients at risk for
mucosal candidiasis.
1. D.
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6 Jaundice
1. H.