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Question 1
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A 74-year-old man presents with left-sided lower abdominal pain. He is obese and admits to a dislike of high fibre foods. The pain has been grumbling for the past couple of weeks and is partially relieved by defecation. He has suffered intermittent diarrhoea.
Blood testing reveals a neutrophilia, and there is also a microcytic anaemia. Barium enema shows multiple diverticula, more marked on the left-hand side of the colon.
Which diagnosis fits best with this clinical picture?Your Answer: Diverticular disease
Explanation:Given that he has diverticula in the clinical scenario combined with his presenting symptoms, it is likely that he has diverticular disease. A low fibre diet would support this diagnosis. Acute diverticulitis would require treatment with antibiotics. Depending on the severity (Hinchey classification) would determine if he needs oral or IV antibiotics, hospital admission or outpatient treatment. Sometimes abscesses or micro perforations occur, which typical require drainage and possibly surgical intervention. Diverticular disease is clearly a better answer than other possible answer choices, simply based on the symptoms presented in the prompt (and mention of low fibre).
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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 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 3
Correct
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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: 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 4
Incorrect
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Which of the following stimulates bicarbonate secretion from the pancreas and liver?
Your Answer: Cholecystokinin
Correct Answer: Secretin
Explanation:Secretin stimulates bicarbonate secretion from the pancreas and liver. VIP induces relaxation of the stomach and gallbladder, secretion of water into pancreatic juice/ bile, and inhibits gastric acid secretion/absorption. CCK classically stimulates gallbladder contraction and relaxation of the sphincter of Oddi. Gastrin stimulates the secretion of HCl by parietal cells in the stomach. Motilin, as the name suggests, increases motility.
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This question is part of the following fields:
- Gastrointestinal System
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Question 5
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A 20-year-old female has been referred for investigation of an iron deficiency anaemia. Her mother passed away at age 28, due to colonic carcinoma complicating Peutz-Jegher syndrome. Choose the mode of inheritance of Peutz-Jegher syndrome which is most likely.
Your Answer: Autosomal dominant
Explanation:Peutz-Jegher syndrome is an autosomal dominant condition which is characterised by perioral pigmentation and hamartomas of the bowel. It was initially assumed that these did not predispose to malignancy, but due to recent studies, the opposite is now believed to be true.
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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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A 50-year-old female known with diabetes visited the OPD with a tender lump near her anal opening. She says she also has fever. Which of the following management options should be recommended to the patient in this case?
Your Answer: Incision and drainage and antibiotics
Explanation:The lump near the anal opening is an anal abscess that should be treated via incising and draining it in order to cure the fever the patient has. Antibiotics will then be given in order to prevent any further infections.
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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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The tumour suppressor gene is associated with multiple colonic polyps in which of the following autosomal dominant disorders?
Your Answer: Familial adenomatous polyposis (FAP)
Explanation:Familial adenomatous polyposis (FAP) is an inherited disorder where patients present with malignancy in their middle age. APC tumour suppressor gene is responsible for this disorder. Other disorders mentioned in the above options do not involve the tumour suppressor gene and are not autosomal dominant disorders.
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This question is part of the following fields:
- Gastrointestinal System
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Question 9
Correct
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A 62-year-old female with a history of COPD and hypertension presents with pain on swallowing. Current medication includes a salbutamol and becotide inhaler, bendrofluazide and amlodipine. What is the most likely cause of the presentation?
Your Answer: Oesophageal candidiasis
Explanation:The history gives you a woman who is on inhaled steroid therapy. It is always a good idea for patients to rinse their mouths well after using inhaled steroids. Odynophagia (pain on swallowing) is a symptom of oesophageal candidiasis, which is the most likely answer given the steroids. Typically, you might see this in someone who is immunocompromised (classically, in HIV+ patients).
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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 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 11
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A 3-year-old boy has been brought to the hospital by his mother with pallor, lethargy and abdominal enlargement. His mother said she only noticed these symptoms two weeks ago but further questioning reveals that they have been progressively worsening over a longer period of time. The boy was born naturally following an uncomplicated pregnancy. Past and family histories are not significant and the family hasn't been on any vacations recently. However, the mother mentions a metabolic disorder present in the family history but couldn't remember the exact name. Clinical examination reveals generalised pallor, abdominal enlargement, massive splenomegaly and hepatomegaly. The spleen is firm but not tender and there is no icterus or lymphadenopathy. What is the most probable diagnosis?
Your Answer: Gaucher's disease
Explanation:Gaucher’s disease is characterized by hepatosplenomegaly, cytopenia, sometimes severe bone involvement and, in certain forms, neurological impairment. The variability in the clinical presentations of GD may be explained by the continuum of phenotypes. However, three major phenotypic presentations can usually be distinguished. Type-1 GD is usually named non-neuronopathic GD; type-2 and type-3 are termed neuronopathic-GD. Gaucher disease (GD, ORPHA355) is a rare, autosomal recessive genetic disorder. It is caused by a deficiency of the lysosomal enzyme, glucocerebrosidase, which leads to an accumulation of its substrate, glucosylceramide, in macrophages.
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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 45-year-old female develops profuse watery diarrhoea with lower abdominal pain seven days after undergoing laparoscopic cholecystectomy. What is the most likely diagnosis?
Your Answer: Bile acid diarrhoea
Correct Answer: Pseudomembranous colitis
Explanation:Pseudomembranous colitis is caused by a C. difficile infection that causes membranes to form on the colon wall. It is caused most commonly by broad-spectrum antibiotics. This would include cephalosporins, broad-spectrum penicillin, and clindamycin. Macrolides and quinolones have also been reported as potential aetiologies, but much less commonly. This woman would have received antibiotics prophylactically before her surgery, predisposing her to a possible c difficile infection. This is a much better answer choice than pseudo obstruction, abdominal sepsis, bile acid diarrhoea, and campylobacter gastroenteritis simply based on history of present illness.
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This question is part of the following fields:
- Gastrointestinal System
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Question 13
Incorrect
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Conjugated bilirubin is converted and metabolised into urobilinogen before excretion. This metabolism takes place in which part of the body?
Your Answer: Hepatic sinusoids
Correct 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 14
Correct
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Which of the following does the inferior mesenteric artery supply?
Your Answer: From the splenic flexure to the first third of the rectum
Explanation:The coeliac axis supplies the liver and stomach and from the oesophagus to the first half of the duodenum.
The second half of the duodenum to the first two thirds of the transverse colon is supplied by the superior mesenteric artery.
The inferior mesenteric supplies the last third of the transverse colon (approximately from the splenic flexure) to the first third of the rectum.
The last two thirds of the rectum are supplied by the middle rectal artery.
The greater curvature of the stomach is supplied by branches of the splenic artery, which itself comes from the coeliac axis. -
This question is part of the following fields:
- Gastrointestinal System
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Question 15
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A 19-year-old male presents with a 1-year history of diarrhoea as well as abdominal discomfort. He has 10 episodes of loose stools per day and 3 episodes of loose stools per night. He reports weight loss in the past few months. On examination of the abdomen, tenderness was present in the right lower quadrant. Endoscopy revealed cobblestone mucosa in the ileum. Which of the following conditions is he most likely suffering from?
Your Answer: Crohn's Disease
Explanation:Cobblestone mucosa is characteristic of Crohn’s Disease. It is not a feature of any of the other options mentioned. Crohn’s disease is a condition of IBD (Inflammatory Bowel Disease).
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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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Cholecystokinin is secreted from:
Your Answer: D cells in the pancreas
Correct Answer: I cells in upper small intestine
Explanation:Cholecystokinin (CCK) was discovered in 1928 in jejunal extracts as a gallbladder contraction factor. It was later shown to be member of a peptide family, which are all ligands for the CCK1 and CCK2 receptors. CCK peptides are known to be synthetized in the small intestinal endocrine I-cells and cerebral neurons.
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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 24-year-old waiter applies for a job at a cafeteria. He gives a history of having had enteric fever 2 years ago. Which of the following investigations is most likely to indicate a chronic carrier status?
Your Answer: Culture of intestinal secretions
Explanation:The chronic asymptomatic carrier state is thought to be why there is continued appearance of the bacterium in human populations. As shedding of the organism is intermittent and sometimes at low levels, methods to detect it have been limited. The Salmonella typhi may be cultured from intestinal secretions, faeces or urine in chronic carriers and is recommended to confirm the diagnosis. Vi agglutination test can also be high in normal people in areas with typhoid endemic. Full blood count or blood culture would not be helpful to determine carrier status. Widal antigen test is unable to differentiate carriers from people with a hx of prior infection.
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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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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 19
Correct
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A 69-year-old man on the cardiology ward who is hypotensive, and tachycardic is having profuse melaena. He was commenced on dabigatran 150mg bd by the cardiologists 48 hours earlier for non-valvular atrial fibrillation. Following appropriate resuscitation which of the following treatments is most likely to improve his bleeding?
Your Answer: Idarucizumab (Praxbind)
Explanation:Idarucizumab (Praxbind) is a newer antidote for dabigatran, the first of its kind. It is a monoclonal antibody fragment that binds dabigatrin with a higher affinity than thrombin. It is very expensive.
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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 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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SESSION STATS - PERFORMANCE PER SPECIALTY
