GI incorrects

Question 1

30 YO woman. diagnosed with iron deficiency. been taken iron supplements. some looseness of her stools and

low hemoglobin, low mcv, low ferritin

Answer 1

anti-ttg

coeliac disease most likely 30

pernicious anemia would cause macrocytic anemia! and iron deficiency anemia

Question 2

A 38 year old woman has abdominal pain 7 days after a laparoscopic sleeve gastrectomy for weight loss.Her temperature is 36.5°C, pulse rate 110 bpm, BP 120/72 mmHg and oxygen saturation 96% breathing oxygen 4 L/min via nasal prongs. She has reduced breath sounds in both bases. She has abdominal tenderness with guarding and reduced bowel sounds.
Which is the most appropriate diagnostic investigation?
A. Abdominal X-ray
B. Barium enema
C. CT of abdomen
D. Erect chest X-ray
E. Point-of-care FAST scan

Answer 2

Correct Answer(s): C
Justification for correct answer(s): The question aims to assess investigation of an acute abdomen following abdominal surgery. A CT scan (usually with intravenous contrast) is most likely to provide diagnostic information to plan further management. None of the other investigations are likely to be useful in

The question is DIAGNOSTIC investigation not first investigation. Gold standard in bowel obstruction = CT

Question 3

A 53 year old woman has 6 days of worsening abdominal pain. She has also had recent constipation. There is no rectal bleeding.Her temperature is 37.8°C, pulse rate 105 bpm and BP 140/85 mmHg. She has tenderness in the left iliac fossa with some guarding. Bowel sounds are normal. Rectal examination shows hard stools only.
Which is the most likely diagnosis?
A. Ischaemic colitis
B. Meckel’s diverticulitis
C. Proctocolitis
D. Rectal carcinoma
E. Sigmoid diverticulitis

UKMLA ppq

Answer 3

Diverticulitis s

Question 4

A 65 year old woman has had bloody diarrhoea six times each day for the past 4 weeks and is feeling unwell. She has noticed urgency to pass stool and has to get up in the night to pass stool. Her left eye has been red, but not painful.Her temperature is 38.5°C, pulse rate 109 bpm, BP 110/70 mmHg and respiratory rate 22 breaths per minute.Investigations:
Stool culture: negative
Which is the most likely diagnosis?
A. Adenocarcinoma of the colon
B. Crohn’s disease
C. Irritable bowel syndrome
D. Microscopic colitis
E. Ulcerative colitis

UKMLA ppq

Answer 4

Ulcerative colitis!

Question 5

1. A 48 year old man has 1 day of severe right upper quadrant pain. He has vomited five times. He smokes 10 cigarettes per day and drinks 31 units of alcohol per week.His temperature is 37.8°C, pulse rate 90 bpm and BP 140/84 mmHg. He is tender in the epigastrium and right upper quadrant, and there is voluntary guarding.Investigations:White cell count 15 × 109/L (3.8– 10.0)ALT 41 IU/L (10–50)
   Alkaline phosphatase 125 IU/L (25–115) Bilirubin 14 μmol/L (<17)Amylase 222U/L (<220) CRP 42 mg/L (<5)

UKMLA question!!

Answer 5

History and investigations fit with acute cholecystitis. amylase not high enough for acute pancreatitis. would expect higher bilirubin with cholangitis. biliary colic would not have inflammatory Response. LFTS do not fit with hepatitis

Question 6

Patient with hepatomegaly and T2DM. 16 units of alcohol a week. Alt is raised all other LFTs normal. Ferritin very raised. Most appropriate next investigation?

management?

Answer 6

Transferrin saturation to investigate hemochromatosis

venesection
desferroxiamine second line

Question 7

A 53 year old man has increasing abdominal swelling over several weeks,
with severe abdominal pain developing over the past 12 hours. He drinks one
to two bottles of vodka per day.
He has jaundice. His temperature is 37.6°C. He has spider naevi and
prominent veins on his abdominal wall. His abdomen is diffusely tender.

Investigations:
Haemoglobin 136 g/L (130–175)
White cell count 9.6 × 109
/L (3.8–10.0)
Platelets 160 × 109
/L (150–400)
INR 1.2 (1.0)
ALT 350 IU/L (10–50)
ALP 140 IU/L (25–115)
Bilirubin 78 μmol/L (<17)
Ultrasound scan of abdomen shows ascites with mild hepatosplenomegaly.

what is the most appropriate next step?

Answer 7

ascitic tap!!! - would reveal wbcs with neutrophil predominance

Spontaneous bacterial peritonitis (SBP) should
be suspected in patients with ascites due to cirrhosis who develop symptoms
such as fever, abdominal pain or tenderness, and confusion.

Question 8

A 53 year old woman has 6 months of worsening tiredness.
She has jaundice, xanthelasma and 7 cm non-tender hepatomegaly.
Investigations:
INR 1.2 (1.0)
ALT 60 IU/L (10–50)
ALP 302 IU/L (25–115)
Bilirubin 50 µmol/L (<17)
Antinuclear antibodies 1:40 (negative at 1:20)
Antimitochondrial antibodies 1:320 (negative at 1:20)
Ultrasound scan of abdomen hepatosplenomegaly, no biliary dilatation

diagnosis?

most appropriate treatment?

Answer 8

primary billiary cirrhosis!!! -> raised ALP, AMA positive, no evidence of obstruction!!!

ursodeoxycholic acid!!!

Question 9

which type of inflammatory bowel disease involves presence of crypts abscesses!! and depletion of goblet cells?

Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)

Answer 9

ulcerative colitis

vs deep ulcers in chrons disease

Question 10

A 57-year-old woman presents to the Emergency Department with a two-day history of abdominal pain and fever. She has a significant medical history of severe alcoholism, consuming at least 65 units of alcohol per week for the past 10 years. On examination, she appears to be in pain, exhibits a distended abdomen without shifting dullness, and has a jaundiced sclera.

raised lfts

most likely diagnosis?
managment?

Answer 10

alcoholic hepatitis!!

glucocorticoids!! eg prednisolone!!!!

this is not alcohol withrdawal!
this is not hepatic encephalopathy as there is no confusion, if it was, you would use rifaximin

Question 11

First episode of C difficile treatment?

A recurrent episode of C. difficile within 12 weeks of symptom resolution should be treated wit

treatment for life threatening c difficile infection and criteria?

Answer 11

oral vancomycin aloneee for 10 days.
second line = oral fidoxmycin. must stop oral vancomycin first!!
still doesnt clear up = oral vancomycin + iv metro

oral!! fidaxomicin!!

Oral vancomycin and IV metronidazole. hypotension, ileus, or toxic megacolon.

Question 12

name the types of surgery based on the location of the colon cancer

Answer 12

Sigmoid colon = High anterior resection

Upper rectum = Anterior resection

Low rectum = Anterior resection

Anal verge = Abdomino-perineal excision of rectum

the colon itself = hemicolectomy

Question 13

A 55-year-old man presents to the emergency department with progressive abdominal swelling and no significant past medical history. On examination, his abdomen is distended and shifting dullness is present. Fluid aspiration from his abdomen and subsequent blood tests reveal the following results:

Serum albumin 31 g/L
Ascites albumin 11 g/L

What is the most likely cause of his presentation?

Answer 13

a high SAAG gradient (> 11g/L) indicates portal hypertension!!

Liver disorders are the most common cause
cirrhosis/alcoholic liver disease
acute liver failure
liver metastases

Cardiac
right heart failure
constrictive pericarditis

Other causes
Budd-Chiari syndrome
portal vein thrombosis
veno-occlusive disease
myxoedema

low saag indicates a peritoneal cause of ascites, including tuberculous peritonitis and peritoneal mesothelioma or nephrotic syndrome

Question 14

Patients aged ≥ 60 years with anaemia (even in the absence of iron deficiency) should have a FIT test first to determine need for urgent colorectal cancer pathway referral

Question 15

If a mild-moderate flare of distal ulcerative colitis doesn’t respond to topical (rectal) aminosalicylates then oral aminosalicylates should be added. still no response, oral corticosteroids.

how should a severe flare be treated?

signs of a severe flare?

Answer 15

admission and iv steroids

Features of severe disease include
>6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers/ an ESR >30mm/hour.

Question 16

A 64-year-old man presents to the emergency department with abdominal pain that ‘comes and goes’ over the course of the past day. He is vomiting and hasn’t been able to eat. On examination, he has scleral icterus. There is guarding in the right upper quadrant. His heart rate is 110bpm, respiratory rate 25/min, temperature 37.9ºC, BP 100/60 mmHg.

What is the most likely diagnosis?

Answer 16

acute cholangitis!!!

note acute cholecystitis does not cause jaundice. lfts may be normal in acute cholecystitis and amylase may be slightly raised vs 3x upper limit criteria in pancreatitis

similarly fever in cholecystitis and not in biliary colic

Question 17

ascites secondary to liver cirrhosis treatment?

Answer 17

spirinolactone

Question 18

how should a colonic tumour with signs of perforation be managed?
(extraluminal air and a paracolic fluid collection). signs and symptoms of perforation (shallow breathing, abdominal distension, hypotension and tachycardia).

Answer 18

end colostomy/ end stoma

Question 19

hemorrhoids grading system

Answer 19

Grade I Do not prolapse out of the anal canal
Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced

Question 20

Ulcerative colitis inducing remission?

Chrons disease inducing remission?

maintaining remission in these conditions?

Answer 20

ulcerative colitis
mild to moderate
= salisciliates (topical/rectal first then oral), then ORAL glucocorticoids

(note you dont stop one, you just add on the next if not enough)

Severe
= IV glucocorticoids. if still not resolving consider IV ciclosporin or surgery

Features of severe disease include
>6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers/ an ESR >30mm/hour.

*note -> if lesion extends past the left-sided colon, oral aminosalicylates should be added to rectal aminosalicylates as first line, as enemas only reach so far

chrons disease
= glucocorticoids immediately to induce remission!! oral topical or iV. eg prednisolone.

maintaining remission
topical mesalazine is used in UC as first line!!! azathioprine and mercaptopurine are reserved for severe or repeated relapses (>/= 2 admissions in last year). think of it as uc is not as extensive as chrons so start with something weaker first = topical mesalazine!!!!!

chrons = azathiprine, mercaptopurine!!!! are first line. can also try methotrexate

Question 21

He has just returned from a week in Morocco.

Starting on the last day of his holiday, he described watery diarrhoea 4-5 times per day. He describes some mild cramping pains in his abdomen and nausea, but no vomiting. There is no blood in the stool.

He is afebrile and his observations are all normal.

most likely causative organism?

Answer 21

ecoli = travellers diarrhea

not cholera as no signs of dehydration or systemic upset

Question 22

A 45-year-old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?

Answer 22

pseudocyst!!!
typically occurs 4 weeks or more after an attack of acute pancreatitis
Most are retrogastric

contrast pancreatic abscess which typically occur as a result of infected psuedocyst

Question 23

A 22-year-old nurse is being screened for immunity to communicable diseases prior to commencing employment. The following results are found:

HBsAg negative
anti-HBs positive
anti-HBc (IgG) positive

Based on these results, what is the patient’s hepatitis B status?

Answer 23

previous infection not a carrier/resolved

due to hbc

meanwhile Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies chronic HBV infection

if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent

must distinguish chronic from acte infection

Question 24

Patients must eat gluten for at least 6 weeks before they are tested for coeliac disease

Question 25

woman with lynch sydrome
Other than colorectal cancer, what malignancy is this woman most at risk of developing?

Answer 25

endometrial cancer!!!

more common than ovarian!!

Question 26

investigation and management of perianal fistula in chrons disease?

management of perianal abscess? how would this present differently?

Answer 26

mri pelvis!!! and oral metronidazole. symptoms of fistula = pain, drainage

incisicion and drainage. abscess
= tender lump next to her anus. On examination, it is warm, tender to touch, and somewhat fluctuant.

Question 27

diverticular disease diagnosis?

Answer 27

CT abdomen and pelvis
colonoscopy

Question 28

Which one of the following antibiotics is most likely to cause pseudomembranous colitis?

Answer 28

ceftriaxone!

Cephalosporins, eg cefaclor! and ceftriaxone not just clindamycin, are strongly linked to C.difficile

Question 29

A 51-year-old woman presents to her general practitioner complaining of lethargy, pallor and dyspnoea. She has a past medical history of coeliac disease, currently managed with a gluten-free diet and hypothyroidism, managed with levothyroxine. The doctor ordered blood tests which show the following:

Hb 98 g/L (115 - 160)
Platelets 190 * 10 9/L (150 - 400)
WBC 5.6 * 10 9/L (4.0 - 11.0)
Reticulocytes 1.2 % (0.5 - 1.5)
MCV 98 fl (76 - 95 fl)
Ferritin 210 ng/mL (20 - 230)
Total iron binding capacity 330 µg/dL (250 - 450)

What is the most likely cause of her presentation?

Answer 29

pernicious anemia!

linked to autoimmune diseases eg thyroid disease

Question 30

what condition is associated with the development of gallstones?

Answer 30

chrons disease

Question 31

High quality evidence suggests that epidural analgesia helps to accelerate the return of normal bowel function after abdominal surgery

Question 32

name some indicators of severe pancreatitis

Answer 32

age > 55 years
hypocalcaemia!!!!
hyperglycaemia!!! - must check blood sugars
hypoxia
neutrophilia
elevated LDH and AST

prognostic factors in pancreatitis
P - PaO2 <8kPa

A - Age >55-years-old

N - Neutrophilia: WCC >15x10(9)/L

C - Calcium <2 mmol/L

R - Renal function: Urea >16 mmol/L

E - Enzymes: LDH >600iu/L; AST >200iu/L

A - Albumin <32g/L (serum)

S - Sugar: blood glucose >10 mmol/L

Question 33

acute anal fissure treatment?

chronic anal fissure treatment?

Answer 33

dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line
lidocaine

Chronic = topical GTN!±

still not resolved = surgery (sphincterotomy) or botulinum toxin

Question 34

first line treatment of acute pancreatitis?

scoring system for acute pancreatitis?

Answer 34

IV fluid resuscitation + IV opioids!!!

patients dont need to be NBM unless vomiting, patients dont need antibiotics unless evidence of necrosis

glasgow score

Question 35

which GI condition is associated with secondary osteoarthritis (with hook-like osteophytes at the 2nd and 3rd digits at the metacarpophalangeal joints being pathognomonic) and a slate-grey appearance of the skin.

Answer 35

hemachromatosis!!!

Question 36

A 22-year-old man presents with 4 episodes of non-bloody diarrhoea in a 24-hour period. He has a past medical history of ulcerative colitis. Observations are within normal limits. He is started on rectal aminosalicylates however there is no improvement.

Blood results are as follows:

Hb 145 g/L Male: (135-180)
Female: (115 - 160)
WBC 8.2 * 109/L (4.0 - 11.0)
Na+ 138 mmol/L (135 - 145)
K+ 4.4 mmol/L (3.5 - 5.0)
Urea 6.2 mmol/L (2.0 - 7.0)
Creatinine 74 µmol/L (55 - 120)
CRP 8 mg/L (< 5)
ESR 12 mm/hr Men: < (age / 2)
Women: < ((age + 10) / 2)

A colonoscopy is performed:

Colonoscopy Diffuse superficial ulceration from the rectum to the hepatic flexure

what treatment is indicated?

Answer 36

oral aminosalicylates as this is a mild to moderate flare!!

Question 37

A 29-year-old man who is known to have ulcerative colitis is admitted to hospital with a flare of his disease. For the past three days he has been passing up to five bloody stools per day. Over the past 24 hours he has also developed abdominal pain and a low grade pyrexia. Bloods show the following:

Hb 13.9 g/dl
Platelets 422 * 109/l
WBC 10.1 * 109/l
ESR 88 mm/hr
CRP 198 mg/l

What is the most important next investigation to perform?

Answer 37

abdominal xray!!

to rule out toxic megacolon

Question 38

management of acute diverticulitis?

management of recurrent acute diverticulitis requiring hospitalisation?

Answer 38

Mild attacks of diverticulitis may be managed conservatively with antibiotics.

Peri colonic abscesses should be drained either surgically or radiologically.

Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.

Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.

Question 39

A 40-year-old man with known diverticular disease diagnosed on colonoscopy 1 year previously is admitted with acute abdominal pain. His abdomen is maximally tender in the left iliac fossa and he describes pneumaturia. His GP has been giving him metronidazole for 2 days.

next step in management?

Answer 39

CT! to rule out fistula

pneumaturia = gas from bowel in urine/bubbles

Question 40

An 83-year-old lady with known diverticular disease is admitted with a brisk PR bleed. On assessment the bleeding is settling and her abdomen is soft. Hb 10.2, other blood tests are normal

next step in management

Answer 40

active observation!!

Diverticular bleeds often settle spontaneously. Acute colonoscopy is rarely helpful. Isolated diverticular bleeds without evidence of infection do not necessarily require antibiotics.

Question 41

A 72-year-old man is admitted with large bowel obstruction and CT scan suggests diverticular stricture in the sigmoid colon.

Answer 41

laparotomy

Question 42

sliding hiatus hernia first line management?

Answer 42

Lifestyle advice weight loss and omeprazole

surgery not indicated unless complications e.g. upper GI haemorrhage or necrosis.

Question 43

most common site affected by chrons disease?

Answer 43

ileum

Question 44

A 54-year-old builder presents to his general practitioner with a lump in his groin. He has a past medical history of chronic obstructive pulmonary disease and no other past medical or surgical history. He reports the lump appeared three weeks ago, is mildly painful and has not grown in size. On examination, there is a reducible soft, single lump on the left side which lies superior to the pubic tubercle with no overlying skin changes. You suspect this is an indirect inguinal hernia.

what type of hernia does patient have? examination finding?

Answer 44

indirect inguinal hernia

No reappearance during coughing when covering the deep inguinal ring

Question 45

Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.

Features
ascites
abdominal pain
fever

Diagnosis?

the most common organism found on ascitic fluid culture?

Management?

Answer 45

paracentesis: neutrophil count > 250 cells/ul

ecoli

IV cefotaxime

Question 46

A 67-year-old male presents to the emergency department complaining of new-onset pain in his left groin. On examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle can be observed. It is accompanied by erythema of the overlying skin. When asked, he admits to vomiting twice and passing stools with blood mixed in them once. He looks in pain and sweaty. He has a past medical history of peptic ulcer disease, managed with omeprazole.

Which one of the following is the most likely diagnosis?

Answer 46

Strangulated femoral hernia

A strangulated inguinal hernia would present with similar symptoms such as systemic upset, pain, erythema, vomiting, and bloody stools. But the mass would be superior and medial !!! to the pubic tubercle rather than inferolateral!!!

Question 47

gold standard investigation for coeliac disease?

Answer 47

small bowel biopsy!! - jejunal!! specifically not ileal

TTG is first line but not gold standard

Question 48

name an organism causing diarrhea with a very short incubation period

longest incubation period?

Answer 48

bacillus cereus

longest = shigella

Question 49

coeliac disease can cause chronic or intermittent diarrhea, joint pains (due to vitamin d deficiency and osteomalacia

Question 50

Patient >= 60 years old with new iron-deficiency anaemia management?

Answer 50

→ urgent colorectal cancer pathway referral

Question 51

Distal transverse or descending colon cancer → left hemicolectomy

transverse hemicolectomy reserved for tumours in central transverse colon

Question 52

repair approach for strangulated inguinal hernias??

Answer 52

open repair!!! (lchtenstein technique)

NOT laparoscopic repair

Question 53

large volume paracentesis with an ascitic drain is planned as ascitic fluid is >5L

What must be prescribed when performing this procedure to reduce mortality risk?

Answer 53

IV human albumin solution

to avoid paracentesis-induced circulatory dysfunction (PICD). PICD leads to faster accumulation of ascites, hyponatraemia, and renal impairment.

Question 54

Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved to reduce risk of SBP

Question 55

The mother of a 2-month-old boy comes to surgery as she has noticed a soft lump in his right groin area. There is no antenatal or postnatal history of note. He is breast feeding well and is opening his bowels regularly. On examination you note a 1 cm swelling in the right inguinal region which is reducible and disappears on laying him flat. Scrotal examination is normal. What is the most appropriate action?

Answer 55

Refer to paediatric surgery
Congenital inguinal hernias have a high rate of complications and should be repaired promptly once identified.

Question 56

management of ascending cholangitis that has not resolved with antibiotics?

Answer 56

ERCP after 24-48 hours to relieve any obstruction

Question 57

A 52-year-old woman presents with sepsis secondary to ascending cholangitis. Blood cultures grew Escherichia coli sensitive to gentamicin. She has received 2 days of treatment with gentamicin. The gentamicin levels have been in normal range. She remains febrile with rigors, a rising white cell count and tenderness in the right upper quadrant.

What is the most likely explanation?

Answer 57

Abscess or deep seated infection

eg gallbladder empyema requiring drainage

Question 58

A 30-year-old unkempt female of no fixed abode presents to the emergency department with severe right upper quadrant pain, decreased consciousness levels and vomiting. She is confused and combative, so a further history is difficult to obtain. On examination she appears thin, jaundiced and has large bruises on her arms and legs. Needle track marks are noted in her anterior cubital fossa. Abdominal exam reveals tenderness in the right upper quadrant but nil else of note.

Hb 102 g/L ALT 375 U/L
MCV 101 fL AST 790 U/L
WBC 12.0 x 109 /L ALP 170 U/L
INR 2.5 GGT 425 U/L
Bilirubin 89 µmol/L Amylase 350 U/L

Which of the following is the most likely diagnosis in this patient?

Answer 58

alcoholic hepatitis

While the needle track marks do suggest a history of IVDU, a risk factor for hepatitis B virus infection, this would not explain the macrocytic anaemia or the fact that the GGT is raised more than the ALP.

Question 59

for anal fissures, you would not expect a ‘palpable, bulging nodule’ as seen in hemorrhoids but a split in the anal mucosa.

Question 60

A negative pressure room is commonly reserved for airborne communicable diseases such as tuberculosis but is not warranted for a patient with C. difficile infection; a standard side room will suffice.

Question 61

36-year-old patient attends for a routine gastroenterology review. He has a background of ulcerative colitis, which was diagnosed several years prior. In the past 12 months, he has had 3 flares of his disease, all of which have required the use of oral corticosteroids to settle. His gastroenterologist is now deciding on which medication should be given to maintain remission.

What is the most appropriate choice of medication?

Answer 61

oral azathioprine

Question 62

B12 deficiency management?

Answer 62

Vitamin B12 deficiency is typically managed intramuscular B12 replacement, a loading regime followed by 2-3 monthly injections

Vitamin B12 1mg IM three times/week then 1mg IM every 3 months
53%

nottt oral b12 supplements

Question 63

A 40-year-old woman has been admitted to the hospital with a severe flare of her ulcerative colitis. She has experienced several episodes of abdominal pain and bloody diarrhoea during the last 2 weeks.

What is the most appropriate investigation to assess disease activity and therapeutic response at this stage?

Answer 63

sigmoidoscopy!!!

In patients with severe colitis,
colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred

Question 64

An 8-year-old boy attends the emergency department with his mother. She is concerned that he has not been eating for the last 24 hours due to abdominal pain. He denies vomiting and diarrhoea and there is no history of recent illness. He is usually a healthy child with no past medical history of note.

His observations are as follows:
Temperature 38.1ºC
Heart rate 155bpm
Blood pressure 110/60mmHg
Respiratory rate 25 breaths/min
Oxygen saturations 99% on air

On examination, he appears pale with cool peripheries. Chest sounds are clear and heart sounds are normal. There is central guarding on abdominal palpation with no obvious organomegaly.

Urinalysis: + leucocytes.

What is the most likely diagnosis?

Answer 64

Anorexia is a common feature of appendicitis

lack of previous viral infection makes mesenteric adenitis less likely

constipation does not cause anorexia or guarding on examination. Furthermore, the presence of fever and leucocytes in the urine suggest an infective process, further ruling out constipation as a diagnosis.

Question 65

Hepatitis A presents with flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs, bilirubin doesnt have to be sky high

Question 66

A 61-year-old man presents with persistent diarrhoea and abdominal pain. During the last week, he had several days of reduced bowel movements. On further questioning, he admits to having occasional blood in his stools.

On examination, he has a heart rate of 86bpm and a temperature of 37.9ºC. There is lower left quadrant tenderness. He is admitted and treated.

A CT chest, abdomen, and pelvis shows mural thickening of the colon and the presence of pericolic fat stranding in the sigmoid colon.

What lifestyle advice can help manage the likely diagnosis?

Answer 66

Increase fruit and vegetables in his diet

CT scan typical of diverticulitis

Question 67

Maddrey’s discriminant function (DF) is often used during acute episodes of alcoholic hepatitis to determine who would benefit from glucocorticoid therapy

it is calculated by a formula using?

Answer 67

prothrombin time and bilirubin concentration

Question 68

what feature is used to determine the severity of c difficile infection?

Answer 68

white cell count?

Question 69

name an extra-intestinal manifestations of inflammatory bowel disease that is much more common in ulcerative colitis than in Crohn’s disease?

Answer 69

PSC

Question 70

Campylobacter infection is often self-limiting but if severe then treatment with?

Answer 70

clarithromycin

Question 71

A 54-year-old homeless man is found unconscious on the street. He is brought into the emergency department and a set of bloods is taken. The following abnormality is found. He is sent for an ultrasound which shows no dilation of the biliary tree.

Amylase 1100 U/l

What is the most likely cause of this mans presentation?

Answer 71

hypothermia

Question 72

what gene mutations are associated with hereditary non-polyposis colorectal carcinoma/

Answer 72

MSH2/MLH1 gene mutations
46%

Question 73

most common symptom of chrons disease in children?

Answer 73

abdominal pain in children. The pain is typically crampy and often located in the right lower quadrant, reflecting ileal involvement.

Question 74

Charcot’s triad in ascending cholangitis plus hypotension and confusion is known as?

Answer 74

reynolds pentad

Question 75

A 23-year-old man presents with a three-day history of continuous throbbing anal pain. He feels pain worse near his anus that is exacerbated by moving and defecating. He has noticed blood whilst wiping, and on one occasion, some pus was mixed with stool. He has a past medical history of Crohn’s disease, managed with oral prednisolone.

On examination, you can see some redness and swelling to the perineum. During a rectal exam, you can feel a deep, palpable, tender fixed mass at the 6 o’clock position. The natal cleft is unremarkable. His temperature is 37.9ºC.

What is the most likely diagnosis?

Answer 75

perianal abscess!

fever and purulent discharge points away from hemorrhoids

Question 76

analingus/ ano oral sex has the highest risk of which sti?

Answer 76

hep A

Question 77

Acute cholecystitis treatment: intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis

Question 78

name some drugs causing acute pancreatitis

Answer 78

azathioprine, mesalazine!!!*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

sodium valproate!!! = common in young people
IBD drugs as well!!

Question 79

Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every five years, as there is a potential for people with coeliac disease to develop overwhelming pneumococcal sepsis due to hyposplenism

Question 80

notable foods which are gluten-free in coeliac disease include: rice, potatoes and corn (maize)

Question 81

if a barium enema and axr shows whole colon affected (total white-out) without skip lesions, most likely diagnosis?

Answer 81

UC

Question 82

key investigation for a suspected perforated peptic ulcer

Answer 82

erect chest x ray!!

Question 83

Whilst this patient does have new right iliac fossa pain with anorexia and a mildly raised white cell count, there is no history of migration of pain, she does not have nausea or vomiting, there is no rebound tenderness and she is apyrexic. In this case, the suspicion of appendicitis is not high enough to take the patient straight to the theatre and other causes of right iliac fossa pain should be considered. -> ultrasound abdomen

Question 84

NICE now recommend doing Faecal Immunochemical Test (FIT) testing before deciding whether to refer people of the urgent suspected colorectal cancer pathway for a colonoscopy.

Question 85

A 30-year-old man attends his friend’s stag do where they go to eat at an ‘all you can eat’ buffet. Seven plates in, he finally feels satiated and they eventually head over to the local casino.

Two hours after finishing the meal, he is at a poker tournament. He suddenly feels unwell and begins to profusely vomit all over the table.

He goes home and through the night the vomiting subsides. The next day he is feeling better, grateful he did not have diarrhoea.

What is the most likely causative organism?

Answer 85

Staphylococcus aureus gastroenteritis is characterised by a short incubation period and severe vomiting

Question 86

acute pancreatitis

While awaiting transfer to the ward, she becomes increasingly short of breath and tachypnoeic. She develops central cyanosis.

What is the most likely cause of her deterioration?

Answer 86

acute respiratory distress syndrome!!

Question 87

A 75-year-old male presents with severe, sharp pain on defecation. He has suffered from constipation for several years but recently has had a few weeks of constant loose stools. He denies nausea or vomiting but does report intermittent blood in his stools and some possible weight loss over the past few months.

On examination, you see an anal fissure at the 3 o’clock position.

What would be the first step in the management plan?

Answer 87

refer to colorectal surgeons via 2 week pathway

Primary anal fissures are typically caused by constipation, with approximately 90% occurring posteriorly, and 10% anteriorly. A lateral anal fissure suggests a secondary cause and requires further investigation. The additional history of change in bowel habit, weight loss, and blood in the stools, in this particular age group, would require an urgent referral to secondary care.

Question 88

Hepatitis E is spread by the faecal-oral route and is most commonly spread by undercooked pork eg hog roast

Question 89

This image demonstrates the complete loss of haustral markings in the distal part of the bowel (‘lead pipe colon’), consistent with ulcerative colitis.

Question 90

A 43-year-old woman presents with a 4 month history of malaise, diarrhoea, stomach cramps and bloating. There has been no weight loss and the diarrhoea is not bloody, but looks pale. She has not noticed any other symptoms and there has been no recent travel. She has Grave’s disease but this has been treated with radioiodine ablation and thyroxine replacement therapy. Some blood tests are performed:

IgA tissue transglutaminase (TTG) 3.7 U/ml (<4)
Total IgA 47 mg/dL (82-453)

What is the most likely cause of her symptoms?

Answer 90

coeliac disease!!!

You cannot interpret TTG level in coeliac disease without looking at the IgA level

Her symptoms and age are consistent and coeliac disease is often associated with other autoimmune conditions (such as Grave’s disease). She has IgA deficiency so interpretation of a normal IgA tTG is impossible. To further investigate if this is the true cause, IgG tTG could me measured, but the definitive investigation would be a duodenal biopsy.

Question 91

umbilical hernia in 9 month old management?

Answer 91

Reassure the parents that the vast majority resolve by the age of 4-5 years

Question 92

patient is visibly jaundiced and her abdomen is distended.

On questioning, the patient describes feeling increasingly bloated over the past month and has found ‘small red dots’ appearing on her upper chest, these disappear when pressed on, and subsequently, refill from the centre. She is uncertain if she has lost weight but she does describe her clothes seeming baggier over the past few months.

She has a background of type 2 diabetes, hypertension, and liver cirrhosis secondary to chronic hepatitis B.

What is the most likely cause of the patient’s deterioration?

Answer 92

Hepatocellular carcinoma (HCC) is correct. The patient is presenting with decompensated liver disease. HCC is a known cause of this.

Further, hepatitis B is known to be a risk factor for hepatocellular carcinoma, and the patient’s history of probable weight loss, anorexia, fits this picture.

Hepatitis D infection is incorrect, as although it can cause a decompensated liver failure picture, there are no signs pointing to this in the clinical scenario. This would typically present with features of acute hepatitis such as fever, nausea and vomiting, abdominal pain, jaundice, dark urine and pale stools

Question 93

what points towards a severe flare in ulcerative colitis?

Answer 93

Temperature greater than 37.8°C
Heart rate greater than 90 beats per minute
Anaemia (Hb less than 105g/ L)
Erythrocyte sedimentation rate greater than 30 mm/hour - NOT CRP

Question 94

For a patient undergoing an elective splenectomy, when is the optimal time to give the pneumococcal vaccine?

Answer 94

2 weeks before surgery

Question 95

abnormal LFTS point more towards acute cholecystitis

Question 96

HBsAg positive, anti-HBs negative, IgM anti-HBc positive - acute infection

Question 97

A 23-year-old female calls 111 due to worsening diarrhoea. She has had 5 episodes of watery diarrhoea in the past 24 hours since flying back from Colombia. Her diarrhoea is associated with severe abdominal cramps, nausea and retching, and feeling faint. She denies any blood in her stool.

What is the most likely causative organism for her symptoms?

Answer 97

e coli

Question 98

A 65-year-old man presents to the emergency department with acute abdominal pain and vomiting. He points to his xiphisternum and states the pain started there, before becoming generalised. He noticed ground coffee-like material in his vomit but has not passed any bloody stools. His past medical history includes atrial fibrillation, peptic ulcer disease, and osteoarthritis.

His pulse is 112 bpm, his blood pressure is 134/75 mmHg, and his temperature is 37.8ºC. His abdomen is distended with generalised tenderness. Guarding and rebound tenderness are also present.

What is the most appropriate initial step?

Answer 98

erect chest x ray!!!

perforated peptic ulcer

Question 99

A 68-year-old woman presents with a lump in her groin. She first noticed it around a week ago. She reports no pain or other symptoms and last opened her bowels this morning.

On examination, you are able to palpate the lump that the patient is describing. It is inferolateral to the pubic tubercle on the left side. The overlying skin is neither tender nor erythematous, and the patient feels well.

Given the most likely diagnosis, what is the most appropriate next step?

Answer 99

urgent surgical repair!!!

Femoral hernias need to be repaired, regardless of whether they are symptomatic, due to the risk of strangulation

elective surgical repair is more appropriate for inguinal hernias

Question 100

A 34-year-old lady presents to the GP with worsening nausea and fatigue over a 2 week period. On examination, there is a yellow tinge to the sclera of her eyes. She lives in a remote fishing village and consumes a diet high in seafood. She does not smoke or consume alcohol. She does not report any weight loss or other constitutional features. Her LFTs are as follows:

Bilirubin 20 µmol/l
ALP 160 u/l
ALT 550 u/l
γGT 30 u/l
Albumin 35 g/l

Other routine blood results are within normal limits.

What is the most likely cause of her symptoms?

Answer 100

hep E

also most likely cause of hepatitis in pregnant woman

Question 101

when should the surgery for acute cholecystitis take place?

Answer 101

within 1 WEEK

Question 102

inguinal hernia, no surgery. risk of strangulation over next 12 months

Answer 102

<5%

Question 103

A 64-year-old man presents to the GP with a new lump he has noticed on his abdomen. On examination, there is a single visible protrusion 5cm above the umbilicus in the midline. It appears pink and is painless with no signs of necrosis. There are bowel sounds present.

What is the most likely diagnosis?

Answer 103

epigastric hernia!!!

Para-umbilical hernia is incorrect - these are typically an asymmetrical bulge directly above or below the umbilicus.

Umbilical hernia is incorrect - these are typically a symmetrical bulge directly below the umbilicus.

Question 104

a hernia that is swollen and non reducible is called?

if it was also tender with systemic upset this would point to?

Answer 104

incarcerated

strangulated

Question 105

Richters hernia - firm mass over abdominal wall

Richter’s hernia is characterised by the absence of symptoms of obstruction even in the presence of strangulation, as the bowel lumen is patent while bowel wall is compromised. The VBG shows a low pH (acidotic) with a low pCO2 (due to partial respiratory compensation) and low bicarbonate (suggesting the cause of acidosis is metabolic) - metabolic acidosis which can occur due to the build-up of lactate.

Question 106

Harold, 75, has a known sigmoid colon tumour that was graded as T3N0M0. Surgeons recommended surgery as the first line treatment for this and it was scheduled for next week. However, he has just been brought to the emergency department with intense abdominal pain, which was found to be due to a perforation. Which of the following operations is most appropriate for Harold?

Answer 106

Hartmann’s procedure!!! -> it involves resection of the relevant portion of bowel and formation of an end colostomy/ileostomy.

Question 107

A diagnosis of biliary colic is expected. She is given analgesia and has blood taken.

What would be expected of her blood tests?

Answer 107

Normal ALP and γGT, normal AST and ALT, normal CRP
43%

Question 108

A 62-year-old woman presents to her General Practitioner with a two-week history of jaundice. She has observed that her stools are paler and her urine has become darker, although she experiences no pain. Her past medical history includes systemic lupus erythematosus and ulcerative colitis.

On examination, she is jaundiced and there is a palpable epigastric mass. The following blood test results are available:

Bilirubin 80 µmol/L (3 - 17)
ALP 245 u/L (30 - 100)
ALT 65 u/L (3 - 40)
γGT 66 u/L (8 - 60)
Albumin 40 g/L (35 - 50)

What investigation should be ordered to confirm the likely diagnosis?

Answer 108

Pancreatic protocol high-resolution CT scan!!!

used to diagnose pancreatic CANCER

VS ultrasound first line for acute pancreatitis

Question 109

unilateral inguinal repair method vs bilateral inguinal repair method

Answer 109

unilateral = open repair with mesh

bilateral = laparascopic repair with mesh

Question 110

management of pancreatic pseudocyst?

Answer 110

conservative management initially

Question 111

what should be measured before commencing azathioprine or mercaptopurine?

Answer 111

TPMT

Question 112

ascites presentation, next step in investigation? EFA q

Answer 112

ascitic tap!!!

not hepatitis serology!

Question 113

72 year old, difficulty swallowing solids, cancer of middle 3rd of oesophagus with hepatic mets.. most appropriate initial management of dysphagia?

EFA q

Answer 113

oesophageal stent

Question 114

patient with severe RUQ pain, vomited 5 times
drinks 31 units of alcohol each week

raised wcc and crp
amylase not high enough for acute pancreatitis,
LFTS dont fit with hepatitis

most likely diagnosis?

EFA q

Answer 114

acute cholecystitis