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Question 1
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A kidney, ureter, and bladder (KUB) ultrasound for a hypertensive man with a BP of 160/90 mmHg and proteinuria++ revealed a decrease in size of the kidneys with smooth borders and normal pelvicalyceal system. What is the cause of hypertension in the patient?
Your Answer: Chronic glomerulonephritis
Explanation:Causes of hypertension in bilateral renal artery stenosis are as follows: 90% probable cause is atherosclerosis with manifestations of CAD, TIA or stroke. The other less common cause is fibromuscular dysplasia that includes carotid and vertebral artery with manifestations of headache, TIA, and stroke.
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This question is part of the following fields:
- Gastrointestinal System
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Question 2
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A 44-year-old woman was admitted with dull retrosternal chest pain. History reveals the pain has been present for two weeks. Clinical examination and ECG, however, show nothing interesting. CXR shows an air-fluid level behind the heart. Which hernia would explain this presentation?
Your Answer: Hiatal
Explanation:A hiatal hernia may be asymptomatic, however classically it presents on CXR with a very characteristic air-fluid level behind the heart. If pain is present, PPIs can be administered. If pain is persistent, surgical intervention should be considered to ameliorate the risk of strangulation. There are two types of hiatal hernias; sliding or Para oesophageal.
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This question is part of the following fields:
- Gastrointestinal System
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Question 3
Correct
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A 25-year-old male had an emergency appendicectomy. His doctor prescribed him prophylactic antibiotics to avoid infection after the surgery. Which of the following antibiotics is the best choice for post abdominal surgery?
Your Answer: Cefuroxime
Explanation:Cefuroxime is the best choice in the case of gut surgery as it is very effective in preventing infections against gut anaerobes, enterococci and coliforms.
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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 26-year-old office worker presents with a 3 year history of epigastric pain, especially 30 minutes after eating. This is associated with nausea and belching. She also describes constipation with occasional explosive diarrhoea. The stools are normally hard with mucus and she needs to strain with every motion. Abdominal pain is relieved after defecation but abdominal bloating persists. She wakes up an hour earlier each morning to finish her breakfast in order to prevent vomiting. She has missed work on a few occasions and feels that her weight has fluctuated. Past medical history includes scarlet fever. She is not on any regular medications except intermittent laxatives over the counter. Abdominal examination is normal. Rectal examination reveals an anal fissure.
Investigation results:
Haemoglobin (Hb 13.1 g/dl
White blood count (WBC) 6.0 × 109/l
Platelets 180× 109/l
Mean cell volume (MCV) 87 fL
International normalised ratio (INR) 1.0
Na+ 136 mmol/l
K+ 3.9 mmol/l
Urea 3.7 mmol/l
Creatinine 70 μmol/l
Albumin 39 glL
Liver function test normal
Anti-endomysial antibody negative
Thyroid function test normal
Gastroscopy normal
Flexible sigmoidoscopy and biopsy normal
Abdominal and pelvic ultrasound scans are normal
What is the most likely diagnosis to account for her symptoms?Your Answer: Overlap irritable bowel syndrome and functional dyspepsia
Explanation:This is most likely describing irritable bowel syndrome (IBS). Symptoms are either diarrhoea, constipation, or both, abdominal pain, bloating, of varying duration. It is a functional, not an organic problem, as far as research shows at this point. It is essentially a diagnosis of exclusion. Treatment is a high fibre diet with fluids. Caffeine should be avoided as this can worsen symptoms.
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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 27-year-old patient presents to the OPD with a history of longstanding constipation, blood on the side of stool and extremely painful defecation. Digital rectal examination also results in pain. What is the most likely diagnosis?
Your Answer: Anal fissure
Explanation:An anal fissure is a longitudinal tear of the perianal skin distal to the dentate line, often due to increased anal sphincter tone. Anal fissures are classified according to aetiology (e.g., trauma or underlying disease) or duration of disease (e.g., acute or chronic). They are typically very painful and may present with bright red blood per rectum (haematochezia). Anal fissures are a clinical diagnosis based on history and examination findings. Management is primarily conservative, and includes stool softeners, analgesia, and possible local muscle relaxation; because of the risk of incontinence, surgical intervention is a last resort.
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This question is part of the following fields:
- Gastrointestinal System
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Question 6
Correct
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Which of the following statements is true concerning gastrin?
Your Answer: Release is triggered by GI luminal peptides
Explanation:Gastrin is released by G cells in the antrum of the stomach. It stimulates secretion of gastric acid (HCl) by the parietal cells of the stomach and also aids in gastric motility. It is released in response to the following stimuli: vagal stimulation, antrum distention, hypercalcemia. It is inhibited by the following: presence of acid in stomach, SST, secretion, GIP, VIP, glucagon, calcitonin.
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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 34 year-old gentleman presented with 3 months history of abdominal pain, intermittent diarrhoea, melena and loss of weight. The most likely diagnosis will be?
Your Answer: Inflammatory bowel disease
Explanation:Inflammatory bowel disease (IBD) is characterized by abdominal and pelvic pain, intermittent diarrhoea, loss of weight and tenesmus. Irritable bowel disease is associated either with diarrhoea or constipation and occurs in stressful conditions for the individual. A UTI is characterised by dysuria, fever and lumbar pain. Adenomyosis is characterised by heavy menstrual bleeding and chronic pelvic pain.
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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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A 20-year-old girl is presented to the OPD with her mother. Her mother reports that she eats very large portions of food most of the time, but takes diet pills and remains depressed because she thinks she is overweight. However, on general physical examination, she appears to be very thin and her blood pressure is lower than normal. Investigations reveal that she has hypokalaemia. What is this girl most likely suffering from?
Your Answer: Bulimia nervosa
Explanation:Bulimia nervosa is a condition in which a person is involved in binge eating and then purging in an attempt to stay thin despite eating a lot of food. Frequent vomiting can cause electrolyte imbalance that manifests as hyperkalaemia and may lead to hypotension.
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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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Conjugated bilirubin is converted and metabolised into urobilinogen before excretion. This metabolism takes place in which part of the body?
Your Answer: Large intestine
Explanation:Unconjugated bilirubin is conjugated to glucuronic acid in the hepatocyte. Conjugated bilirubin passes into the enterohepatic circulation and the bilirubin which evades this system is metabolised by bacteria, primarily in the large intestine, to urobilinogen, then stercobilinogen and eventually oxidised to stercobilin. Stercobilin gives faeces its brown colour.
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This question is part of the following fields:
- Gastrointestinal System
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Question 10
Correct
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A 55-year-old man attends follow-up for liver cirrhosis, which reveals a large dominant nodule in the right lobe of liver on CT Scan. Which tumour marker would most likely be elevated?
Your Answer: Alpha feto-protein (AFP)
Explanation:A considerably increased serum AFP is characteristic of hepatocellular cancer. A distinct nodule for cirrhotic patients should be investigated to rule out hepatocellular cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 11
Incorrect
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A 51-year-old man was brought to the Emergency department for loose stools. He was dehydrated, weak and in shock. He had previously been complaining of large stool volumes for a one month period. Stool colour was normal. There was no history of laxative abuse and no significant past medical history.
What is the most likely diagnosis?Your Answer: Carcinoid syndrome
Correct Answer: VIPoma
Explanation:Given that the patient has had large amount, high volume watery diarrhoea in an acute period of time, from the answer choices given, this narrows the diagnosis down to VIPoma or carcinoid syndrome. You would expect with carcinoid syndrome for there to be periodic episodes of diarrhoea, though, with a description of flushing, additionally, associated with these episodes. Thus, VIPoma is the most likely answer here. VIPomas are known to cause hypokalaemia from this large amount of watery diarrhoea. Stool volume should be > 700 ml/day.
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This question is part of the following fields:
- Gastrointestinal System
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Question 12
Incorrect
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A patient was admitted due to vomiting for further investigations. He noticed blood in his vomit and the physicians decided to perform an esophagogastroduodenoscopy which revealed haemorrhage in the lesser curvature of the stomach. Which artery is responsible for the bleeding?
Your Answer: Pancreaticoduodenal artery
Correct Answer: Right gastric artery
Explanation:The right gastric artery arises from the hepatic artery or the left hepatic artery and supplies the pylorus, traveling along the lesser curvature of the stomach anastomosing with the left gastric artery.
The pancreaticoduodenal artery supplies mainly the upper and lower duodenum and the head of the pancreas.
The gastro-omental arteries supply the greater curvature of the stomach. -
This question is part of the following fields:
- Gastrointestinal System
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Question 13
Incorrect
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A 72-year-old male presents complaining of having intermittent trouble with swallowing. He has also been regurgitating stale food material. He sometimes wakes up in the middle of the night feeling like he is suffocating. Choose the most likely diagnosis.
Your Answer: Oesophageal spasm
Correct Answer: Pharyngeal pouch
Explanation:In benign stricture, oesophageal carcinoma, and systemic sclerosis, there is persistent dysphagia (rather than intermittent). In oesophageal spasm, there is no regurgitation of stale food material. The symptoms described are consistent with pharyngeal pouch.
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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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A 36-year-old man is being investigated for recurrent gastric and duodenal ulceration diagnosed at endoscopy. He has suffered from bouts of abdominal pain and intermittent diarrhoea although his weight is stable.
Some of his investigations are outlined below.
Basal acid secretion 20 mEq/h (1-5)
Fasting gastrin 200 pg/ml (<100)
Secretin test:
Basal gastrin 200 pg/ml
Post-secretin 500 pg/ml
Which of the following are responsible for the elevated gastrin levels?Your Answer: Gastrinoma
Explanation:This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. The secretin test is a test that can differentiate gastrinoma from other causes of high gastrin levels. Gastrin will rise after secretin injection if the patient has a gastrinoma.
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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 patient presents with occasionally severe retrosternal chest pain and dysphagia for both solids and liquids. What would be the best management option if the barium swallow showed a dilated oesophagus which tapers to a fine distal end?
Your Answer: Dilatation of the LES
Explanation:Dysphagia for both solids and liquids indicates either obstruction or impaired oesophageal peristalsis which is usually due to neuromuscular causes such as achalasia. Achalasia is the failure of smooth muscle fibres to relax, which can cause the lower oesophageal sphincter to remain closed. The lower part of the oesophagus is more narrow than normal and presents as a birds beak appearance on barium swallow. If dysphagia was present only on solid food consumption, a benign or malignant tumour must be suspected.
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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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A 55-year-old female presents with complaints of retrosternal chest pain and dysphagia (which is intermittent and unpredictable in nature). When she swallows, food very suddenly 'sticks' in her chest. She is able to clear it when she drinks water, and then can finish the meal without any further incidence. A barium meal shows she has a corkscrew oesophagus. What is the most likely type of dysphagia here?
Your Answer: Plummer-Vinson syndrome
Correct Answer: Oesophageal spasm
Explanation:All of the symptoms observed in this patient are typical of uncoordinated irregular oesophageal peristalsis – this is characteristic of oesophageal spasm. The cork-screw oesophagus is also diagnostic of the condition.
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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 32-year-old lady is found to be hepatitis B surface antigen positive. This positive result has persisted for more than six months. Hepatitis B envelope antigen (HBeAg) is negative. HBV DNA is negative. Her liver function tests are all entirely normal.
Which of the following options would be the best for further management?Your Answer: No antiviral therapy but monitor serology
Explanation:Again, remember the Hepatitis B serologies: In chronic hepatitis B infection, you have +HBsAg, +anti-HBc, (-)IgM antiHBc, and (-) anti-HBs. In acute hepatitis B infection, you have +HBsAg, + anti-HBc, + IgM anti-HBc, and negative anti-HBs. In immunity due to natural infection, you have negative HBsAg, + anti-HBc, and + anti-HBs. In immunity due to vaccination, you have negative HBsAg, negative anti-HBc, and positive anti-HBs. IN THIS CASE, the person is HBsAg+ for 6 months and everything else is negative, normal transaminase. They do not need antiviral therapy, but their serology should be monitored serially. There would be no reason to do a liver biopsy.
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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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Which one of the following is most associated with the development of acute pancreatitis?
Your Answer: Hyperchylomicronaemia
Explanation:Hyperchylomicronaemia is an increase (markedly) in chylomicrons, and this can cause acute pancreatitis, as well as xanthomas. It can be seen in familial lipoprotein lipase (LPL) deficiency, primary type V hyperlipoproteinemia, idiopathic hyperchylomicronaemia, and familial apolipoprotein CII deficiency. Treatment is dietary fat restriction in order to avoid pancreatitis attacks.
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This question is part of the following fields:
- Gastrointestinal System
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Question 19
Correct
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A 40-year-old lady who underwent a recent subtotal gastrectomy for peptic ulcer disease has now developed anaemia with a haemoglobin of 6.4, tiredness, fatigue and loss of vibration sensation in both legs. What is the underlying cause of her symptoms?
Your Answer: B12 deficiency
Explanation:Vit B12 needs intrinsic factor to be absorbed, which is secreted in the stomach. Its deficiency is characterised by macrocytic anaemia with peripheral neuropathy.
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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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A 76-year-old woman is admitted with a productive cough and pyrexia. Chest x-ray shows a pneumonia and she is commenced on intravenous ceftriaxone. Following admission a stool sample is sent because of diarrhoea. This confirms the suspected diagnosis of Clostridium difficile diarrhoea and a 10-day course of oral metronidazole is started. After 10 days her diarrhoea is ongoing but she remains clinically stable. What is the most appropriate treatment?
Your Answer: Oral vancomycin for 14 days
Explanation:When a patient fails treatment with metronidazole (Flagyl) treatment, the next course of action is to change to oral vancomycin, which is shown to be effective in the treatment of c diff colitis. Oral rifampicin is not a treatment for c diff. Oral metronidazole is not resolving her symptoms so is not the correct answer. clindamycin is a cause of c diff colitis, not a treatment. IV Vanc is not active in the gut so is not the treatment; oral is active in the gut.
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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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Which of the following options is true regarding H. pylori bacteria?
Your Answer: It is the cause of >60% of gastric ulceration
Explanation:It is the cause of gastric ulcers in more than 60% of the cases. It is a gram negative bacteria and does not cause oesophageal carcinoma.
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This question is part of the following fields:
- Gastrointestinal System
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Question 22
Incorrect
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A 35-year-old gentleman with a history of alcohol excess presents to hospital with progressive abdominal distension. He now complains of early satiety and abdominal discomfort as a result of the distension. Examination reveals a significantly distended abdomen with shifting dullness. A diagnostic ascitic tap is performed and the fluid sent for analysis.
What is the most appropriate first line treatment for his ascites?Your Answer: Spironolactone
Correct Answer: Paracentesis
Explanation:The first line treatment for ascites that is symptomatic is paracentesis. If it is not symptomatic, treatment could be with salt and fluid restriction as well as spironolactone. If spironolactone maximum dosage is reached, you can use furosemide additionally. Amiloride is not a diuretic that is recommended in this case.
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This question is part of the following fields:
- Gastrointestinal System
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Question 23
Incorrect
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A 53-year-old male underwent a partial gastrectomy 15 years ago for a complicated peptic ulcer. Which of the following elements may be deficient in this man?
Your Answer: Folate
Correct Answer: Iron
Explanation:The proper gastric acidity is required to transform iron from ferric to ferrous state in order to be absorbable. Even partial gastrectomy may cause dumping syndrome. Malabsorption is rare.
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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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The digital rectal examination and flexible sigmoidoscopy of a 30-year-old woman are normal. However, she still complains of recurrent and brief episodes of severe rectal pain. What is the most likely diagnosis?
Your Answer: Proctalgia fugax
Explanation:The digital rectal examination and sigmoidoscopy are normal, a fact that excludes all the other possible diagnoses. Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain that are self-limiting. The diagnosis of proctalgia fugax requires exclusion of other causes of rectal or anal pain.
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This question is part of the following fields:
- Gastrointestinal System
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Question 25
Correct
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A 43-year-old man is reviewed in the gastroenterology clinic. He has had troublesome dyspepsia for the past six months which has not settled with proton pump inhibitor (PPI) therapy. During the review of his systems he also reports passing 6-7 watery stools per day. An OGD 3 weeks ago showed gastric erosions and ulcers.
Which one of the following investigations is most likely to be diagnostic?Your Answer: Fasting gastrin
Explanation:This case describes Zollinger-Ellison syndrome. It is characterized by refractory peptic ulcer disease, often multiple ulcers. This is typically caused by secretion of gastrin from a gastrinoma, a neuroendocrine tumour. The most common site of ulceration is the duodenum. A symptom of a pancreatic gastrinoma may be steatorrhea from the hypersecretion of gastrin. Serum gastrin levels > 1000 and a pH < 2 are diagnostic of pancreatic gastrinoma. None of the other answer choices are a better answer than this. CT abdomen may potentially show a tumour, but this is not diagnostic for type.
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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 37-year-old woman known with ulcerative colitis is referred with a microcytic anaemia. Blood tests reveal the following results:
Hb 88 g/L (120-160)
WCC 3.6 ×109/L (4-11)
Platelets 222 ×109/L (150-400)
MCV 70 fL (80-96)
Haptoglobins <0.04 g/L (0.13-1.63)
Lactate dehydrogenase 850 U/L (100-250)
Bilirubin 68 µmol/L (1-22)
Alkaline phosphatase 100 U/L (45-105)
ALT 23 U/L (5-40)
Which investigation would confirm the underlying diagnosis?Your Answer: Direct Coombs' test
Explanation:This a case of autoimmune haemolytic anaemia which is a rare complication of the less used treatment, salazopyrine, used for inflammatory bowel disease (IBD). A direct Coombs’ test looks for erythrocytes already coated with antibody, whereas the indirect test is used to detect potential red cell antibody interactions floating around in the blood.
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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 36-year-old man with diabetes is referred with abnormal liver biochemistry. Which of the following is in keeping with a diagnosis of haemochromatosis?
Your Answer: Transferrin saturation 78% (20-50)
Explanation:A high transferrin saturation is seen in hemochromatosis, as well as a high iron level (>30), a high ferritin level, and a LOW TIBC (<20). Think of it like the opposite findings of iron deficiency anaemia which is a low iron, low ferritin, high TIBC.
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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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While investigating a patient with hepatocellular carcinoma (HCC), blood tests reveal a raised level of serum ferritin. What would be the most probable cause for HCC in this patient?
Your Answer: Haemochromatosis
Explanation:Haemochromatosis is the excessive accumulation of iron in the body mainly involving the liver, pancreas, testes, skin etc. Serum ferritin is high indicating iron overload. Haemochromatosis is a known cause for chronic liver cell disease, cirrhosis and HCC.
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This question is part of the following fields:
- Gastrointestinal System
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Question 29
Correct
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A 24-year-old woman presents as an emergency to her GP with acute vomiting which began some 3-4 hours after attending an afternoon meeting. Cream cakes were served during the coffee break.
Which of the following organisms is the most likely cause of this acute attack of vomiting?Your Answer: Staphylococcus aureus
Explanation:Staph. aureus is the most likely cause. It is found in foods like dairy products, cold meats, or mayonnaise. It produces a heat-stable ENDOTOXIN (remember this) that causes nausea, vomiting, and diarrhoea 1-6 hours after ingestion of contaminated food. B. cereus is classically associated with fried rice being reheated. Salmonella is typical with raw eggs and undercooked poultry. Campylobacter which is most commonly associated with food poisoning, is seen with poultry 50% of the time. Yersinia enterocolitica is seen with raw or undercooked pork, and may be a case presenting with mesenteric adenitis.
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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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Which of the following is consistent with a diagnosis of insulinoma?
Your Answer: Low fasting glucose, high insulin, high C peptide
Explanation:Insulinoma is associated with LOW fasting glucose, HIGH insulin level, and HIGH C peptide. Insulin-abuse or overdose will cause HGH insulin levels and a LOW C peptide. If the C peptide is low, be suspicious.
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This question is part of the following fields:
- Gastrointestinal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
