GIL Quiz and BOFs

Question 1

Answer 1

The correct answer is: Identify the structures indicated by 1 → Columnar epithelium, Identify the structures indicated by 2 → Lamina propria, Identify the structures indicated by 3 → Muscularis mucosae, Identify the structures indicated by 4 → Sub mucosa, Identify the structures indicated by 5 → Circular muscle, Identify the structures indicated by 6 → Myenteric plexus, Identify the structures indicated by 7 → Longitudinal muscle, Identify the structures indicated by 8 → Serosa, Of the structures labelled which play a role in the regulation of GIT functions? → Myenteric plexus, Which structure is responsible for mucus secretion? → Columnar epithelium

9. Gastrointestinal tract function is regulated by the enteric nervous system. This system is contained within the myenteric and submucosal plexus. The myenteric plexus exists between the longitudinal and circular smooth muscle layers. The submucosal plexus is not shown on the cartoon above and exists between the circular muscle layer and the submucosa.
10. The intestinal mucus secretions are produced by the goblet cells within the columnar epithelium.

Question 2

Answer 2

The correct answer is: 1 → Non-rotation of the gut, 2 → Reverse rotation of the gut, 3 → Tracheoesophageal fistula

Question 3

Answer 3

The image demonstrates the normal appearance of the oesophageus during swallowing. In this image the narrowing (labelled A) depicts the region where the smooth muscle is contracted. Below that the oesophageus is enlarged where the bolus of food is located and the smooth muscle of the oesophageal wall is relaxed.

The correct answer is: Peristaltic contraction

Question 4

Answer 4

The antidepressant that this patient has been prescribed is a tricyclic antidepressant. This agent has antimuscarinic side effects including dry mouth, blurred vision and constipation. The symptoms the patient is describing are due to a lack of saliva. This makes swallowing difficult due to the lack of lubrication and the dental problems ensure because of the overgrowth of oral bacteria that would usually be controlled by the antibacterial agents in the saliva.

The correct answer is: Salivary gland

Question 5

Answer 5

The co-ordinated relaxation of the lower oesophageal sphincter as the peristaltic wave from the oesophageus delivers food to the opening is controlled by the activity of the enteric nervous system. The enteric nervous system mediators responsible for relaxation are nitric oxide or vasoactive intestinal peptide. The only other mediator in the list that could cause relaxation is norepinephrine. However norepinephrine is released from the postganglionic fibres of the sympathetic nervous system which are not responsible for these reflexes occurring in the gastrointestinal tract.

The correct answer is: Nitric oxide

Question 6

Answer 6

The failure of the lower oesophageal sphincter to relax is termed achalasia – an explanation of which is in the motility GOAL.

The correct answer is: Achalasia

Question 7

Answer 7

Cholecystokinin (CCK) is the endocrine hormone responsible for stimulating emptying of the gall bladder.

The correct answer is: Cholecystokinin

Question 8

Answer 8

Cholecystokinin is stimulated by the presence of proteins/ amino acids and fats in the lumen of the duodenum.

The correct answer is: Proteins, amino acids and fats

Question 9

Answer 9

The barium swallow will allow visualization of the swallowing process and will identify any motility problems or strictures.

The correct answer is: Barium swallow

Question 10

Answer 10

1. The history of significant weight loss, short history, epigastric discomfort and dysphagia, along with his age is most likely to be oesophagus carcinoma until proven otherwise
2. The regurgitation of fluids, the presence of a double swallow ( drinking a glass of water and examining the patient you will often see a double swallow – the first is the majority of the liquid but some may fill the pharyngeal pouch which is emptied by the second swallow and may be visible/ palpable on examining the neck) are key features for a pharyngeal pouch
3. The course of steroids and caused a temporary immunosuppression and consequently there is a candidial infection

The correct answer is: 1. A 62 year old man presents with a two month history of epigastric discomfort, weight loss and he has lost a stone in weight over the same period. He has noticed that he now has problems swallowing, particularly solids, especially meat and feels it gets ‘stuck’. → Oesophageal carcinoma, 2. A 74 year old lady presents with a history of difficulty swallowing. After swallowing liquids she has noticed that if she coughs she brings back some of the fluid. There are no other symptoms. Examination of the neck reveals a double swallow when drinking a glass of water and also a swelling in the neck → Pharyngeal pouch, 3. A 36 year old man presents with retrosternal discomfort and pain on swallowing food and liquids. He also complains of a sore throat. He has recently had a course of prednisilone for an acute exacerbation of asthma in addition to his long term preventative inhaler. → Oesophageal candidiasis

Question 11

Answer 11

The third pharmacological agent is a proton pump inhibitor. Increased proton pump activity is the final step in the pathways of all three chemicals (Ach, gastrin and histamine) that stimulate H+ secretion by parietal cells. Thus a proton pump inhibitor blocks the final common site of action in gastric acid secretion

The correct answer is: blocks the final common pathway in gastric acid secretion.

Question 12

Answer 12

Parietal cells secrete HCl and intrinsic factor into the stomach. HCl makes the stomach contents very acidic, which activates and enables optimal activity of pepsin, a protein digesting enzyme. Parietal cells do also secrete intrinsic factor, which is necessary for absorption of Vitamin B12 but the actual absorption is not a function of the parietal cells; this occurs in the ileum.
The correct answer is: HCl; activation of pepsin

Question 13

Answer 13

In GIT smooth muscle slow waves occur 3 to 12 times per minute. The membrane potential of the smooth muscle cell within the GIT varies with time as the slow waves pass across the cell. These slow waves lead to small changes in the resting membrane potential which make the membrane potential more positive so that the ion channels are more easily opened and an action potential can be initiated. These action potentials that are related to contraction of smooth muscle and the generation of tension within the muscle.

The correct answer is: oscillating resting membrane potentials.

Question 14

Answer 14

Peristalsis is a co-ordinated contraction of smooth muscle behind the bolus of food and relaxation of the smooth muscle in front of the bolus of food. Peristalsis moves food along the length of the GIT and is controlled by the enteric nervous system. Peristalsis requires the co-ordinated functioning of the sensory afferent nerves, the interneurons and the inhibitory and excitatory motor nerves. Peristalsis usually takes place after the food bolus has been mixed with the digestive enzymes within the lumen. This mixing occurs due to segmentation contractions.

The correct answer is: involves contraction of smooth muscle behind and relaxation of smooth muscle in front of the food bolus.

Question 15

Answer 15

Zollinger-Ellison syndrome is a tumour of the non-b-cell pancreas. The tumour is a gastroma secreting gastrin which then circulates to the gastric parietal cells to increase acid secretion leading to peptic ulcers and parietal cell growth. Because the tumour does not involve the pancreatic b-cells insulin production should not be affected. Absorption of lipids is decreased because increased acid secretion decreases the pH of the intestinal lumen which inactivates the pancreatic lipases.

The correct answer is: Increased serum gastrin levels

Question 16

Answer 16

The parietal cells of the stomach produce intrinsic factor, a glycoprotein that binds vitamin B12 in the lumen of the stomach and facilitates its absorption in the terminal ileum. Patients without a stomach and those with pernicious anemia (autoimmune destruction of parietal cells) will require B12 replacement therapy. Recall that B12 deficiency will lead to megaloblastic anemia. Note that parietal cells also synthesize and secrete HCl.

The correct answer is: Parietal cells

Question 17

Answer 17

Pepsin is secreted (in an inactive or zymogen form as pepsinogen) by the chief cells of the stomach. Pepsinogen is activated by contact with stomach acid. Although protein digestion usually begins with the actions of hydrochloric acid and pepsin, pancreatic enzymes complete the job as the food passes into the small intestine.
The correct answer is: Pepsin

Question 18

Answer 18

Omeprazole is a proton pump inhibitor (PPI) therefore it blocks the terminal step in gastric acid secretion by binding to the H+/K+ ATPase and preventing its pumping action (i.e. at a point which is after the effects of histamine, ACh, and gastrin).

The correct answer is: Omeprazole

Question 19

Answer 19

Clostridium difficile is usually present in the large intestine in small numbers. However, antibiotics can lead to the death of the normal GIT flora that Clostridium difficile would compete with and allow overgrowth of Clostridium difficile. This species can produce a toxin and cause pseudomembranous colitis which is characterized by diarrhoea, fever, and abdominal pain.
The correct answer is: Clostridium difficile

Question 20

Answer 20

Streptococcus mutans is an anaerobic bacteria. Therefore it ferments carbohydrates leading to the production of lactic acid. The acid produced attacks dental enamel and leads to caries and further tooth decay.
The correct answer is: Streptococcus mutans

Question 21

Answer 21

Question 22

Answer 22

Dysplastic intestinal metaplasia is a step on the path to invasive carcinoma, which is most likely to be glandular because it is arising from a glandular epithelium.

The correct answer is: Adenocarcinoma

Question 23

Answer 23

The correct answer is: Both the liver and the spleen descend towards the right iliac fossa on inspiration

Question 24

Answer 24

The correct answer is: There is an association between certain gastrointestinal conditions (e.g. Inflammatory Bowel Disease and Haemochromatosis) and peripheral arthropathy

Question 25

Answer 25

Acetylcholine is released from the postganglionic fibres of the vagus nerve which is part of the parasympathetic nervous system. The correct answer is: Acetylcholine

Question 26

Answer 26

Conjugation by UDP glucuronyl transferase results in a much more polar (hydrophilic or less hydrophobic) molecule which is more water soluble and therefore more easily excreted. The correct answer is: decrease the hydrophobicity of bilirubin.

Question 27

Answer 27

a. Correct answer b. The production NADH is enhanced, NOT NADPH c. Cholesterol synthesis is not considerably affected d. Lactate dehydrogenase is activated under this condition e. Oxaloacetate is an intermediate of gluconeogenesis, which is inhibited under alcohol, since alcohol removes the substrates for this pathway The correct answer is: Depletion of glucose stores leading to hypoglycaemia

Question 28

Answer 28

Question 29

Answer 29

Multiple small branches of the splenic artery supply the neck, body and tail of the pancreas. The head of the pancreas is supplied by the superior and inferior pancreaticoduodenal arteries. The correct answer is: The splenic artery

Question 30

Answer 30

This woman has a risk profile (female, fat, forties) and symptomatology consistent with gallstones (cholelithiasis). As would be expected, contraction of the gallbladder following a fatty meal often exacerbates the pain caused by gallstones. Cholecystokinin (CCK), the release of which is stimulated by dietary fat, is the hormone responsible for stimulation of gallbladder contraction. It is produced in I cells of the duodenum and jejunum. In addition to gallbladder contraction, CCK also stimulates pancreatic enzyme secretion and decreases the rate of gastric emptying. The correct answer is: Cholecystokinin

Question 31

Answer 31

The correct answer is: May be a consequence of altered oestrogen levels in patients with liver disease

Question 32

Answer 32

The lymphatic aggregates of the small intestina are called Peyer’s patches. Other regions of the GIT have large numbers of lymphocytes which can be aggregated into lymphatic nodules but only in the small intestine have these been called Peyer’s patches. The correct answer is: small intestine.

Question 33

Answer 33

γ-(gamma) globulins, also called immunoglobulins, are produced by the plasma cells of the reticuloendothelial system The correct answer is: γ-globulins

Question 34

Answer 34

Even though there was a difference in the percentage of symptomatic infections (4.4% vs 3.3%); the confidence interval passes through 1, so the difference is not significant. The correct answer is: People who received immune globulin as post-exposure prophylaxis were equally likely to develop Hepatitis A than people who received Hepatitis A vaccine as post-exposure prophylaxis.

Question 35

Answer 35

Correct answer A) Because it is the only instance where p \< 0.05 in all other instances the p value is \> 0.05 The correct answers are: had significantly higher peak alanine aminotransferase levels than the immunoglobulin. recipients, waited significantly longer for their immunization from the time of exposure to the hepatitis A virus than the immunoglobulin recipients.

Question 36

Answer 36

1. Stellate cells normally produce matrix materials. In inflammatory conditions such as alcoholic liver disease they transform into myofibroblasts and produce excessive amounts of matrix, leading to fibrosis and cirrhosis. 2. Kupffer cells are the fixed macrophages of the liver. They are found in the sinusoids. Like all macrophages, they are produced in the bone marrow and circulate as monocytes before entering the tissues. 3. Mallory bodies (Mallory hyaline) are deposits of altered cytoskeletal filaments in damaged hepatocytes. They are common in alcoholic steatohepatitis. The correct answer is: 1. The principal source of collagen deposition in the space of Disse. → Stellate cells, 2. Derived from blood monocytes. → Kupffer cells, 3. Contain Mallory bodies in alcoholic liver disease. → Hepatocytes

Question 37

Answer 37

Intrinsic factor is released from the gastric parietal cells along with hydrochloric acid. This factor is essential for the absorption of vitamin B12. Lack of vitamin B12 leads to Pernicious anemia. This is a form of megaloblastic anaemia where the lack of Vitamin B12 inhibits DNA synthesis in red blood cells resulting in the formation of large, fragile erythrocytes. The correct answer is: Intrinsic factor

Question 38

Answer 38

1. Ultrasound investigation during pregnancy is useful in early detection of neural tube defects and spina bifida in the developing foetus. With which of the vitamins is food often fortified in order to reduce the risk of spina bifida caused by dietary deficiency? 2. Significant production of Vitamin K is via intestinal flora, and vitamin K is essential for proper clotting mechanisms. The newborn are particularly susceptible to deficiency. Antibiotics would destroy the beneficial as well as pathogenic bacteria. [Vitamin B12 is also produced by gut bacteria but is not usable because it cannot be absorbed without intrinsic factor, which is only produced in the stomach.] 3. Classic symptoms of beriberi (meaning “I can’t”); a deficiency of thiamine commonly seen in populations relying on white rice as their staple diet. Thiamine is present in the bran component which is eliminated during white rice processing. Alcohol reduces thiamine absorption in the gut and increases its excretion from the kidneys. Coffee contains a “thiaminase” which breaks down thiamine in the gut. So Rosemary had a “triple whammy”. Poor diet leading to insufficient thiamine intake (and other vitamins), plus alcohol and coffee which would both limit the absorption of what little thiamine she was consuming and exacerbate the deficiency. The correct answer is: 1. Ultrasound investigation during pregnancy is useful in early detection of neural tube defects and spina bifida in the developing foetus. With which of the vitamins is food often fortified in order to reduce the risk of spina bifida caused by dietary deficiency? → Vitamin B9 (folate), 2. Which of the vitamins (involved in the synthesis of blood clotting) would be specifically given as a dietary supplement in association with her antibiotic treament? → Vitamin K, 3. When she presented with depression, irritability, headache, lethargy, fatigue and weakness in her early twenties she was diagnosed with a specific deficiency of which principle vitamin? → Vitamin B1 (thiamin)

Question 39

Answer 39

Hepatitis A is spread by the faecal-oral transmission and children are frequent asymptomatic carriers. Hepatitis A is also a transient infection. The correct answer is: Hepatitis A

Question 40

Answer 40

A = C max (maximum concentration) B = minimum effective concentration for adverse effect C = therapeutic window E = T max (time at maximum concentration) The correct answer is: D

Question 41

Answer 41

1. Hirschprung disease is aganglionosis of the rectum and variable amounts of colon. 2. Virtually all non-neoplastic ulcers of the duodenum are peptic ulcers associated with infection by Helicobacter. 3. Mallory-Weiss syndrome: increased pressure by forceful vomiting causes the rupture. The correct answer is: 1. Failure of migration of ganglion cells. → Hirschprung disease, 2. Helicobacter pylori infection. → Chronic duodenal ulcer, 3. A problem caused by forceful vomiting → Mallory-Weiss syndrome

Question 42

Answer 42

Cytochrome P450 enzymes are involved in phase one reactions which are mostly oxidation reactions, not phase 2 conjugation reactions. All other statements are correct. The correct answer is: Isoforms metabolise many xenobiotics in conjugation reactions

Question 43

Answer 43

With high rectal administration all of the absorbed drug would end up in the portal vein draining into the liver. With all the other routes of administration the drug reaches the systemic circulation before the portal circulation. The correct answer is: High rectal

Question 44

Answer 44

Breakdown of drug X is increased leading to lower plasma concentrations so that toxicity is unlikely, but lack of effect may occur. In all other statements the total (B, E, D) or free drug concentration (A) of drug X in plasma is increased with possible opposite effects. The correct answer is: Drug Y induces metabolism of drug X

Question 45

Answer 45

While it is important to hear the parent’s concerns about their child’s health, the child is the patient so must be the focus of the consult. It is important to put the child first in the communication and each aspect of the consultation process. The correct answer is: discuss the assessment procedure with the child first then their parent.

Question 46

Answer 46

1. This patient has the core features of encepathaolpathic delirium in that the patient demonstrates aggression, swift mood change and brief concentration. 2. Marys memory difficulties suggest that she has brain insult. When this is considered alongside the liver tests it indicates a profile consistent with a chronic liver dysfunction. Portal hypertension is indicated by the haematemesis occurring due to rupture of oesophageal varices. 3. Peter has picked up Hepatitis C in his travels. This commonly presents between 2 weeks and 6 months after infection and is endemic in parts of Asia. The correct answer is: 1. Jonathan is a patient who presents with jaundice. In taking their history you ask about drinking behaviours and the previously docile patient swears at you and then gazes without apparent focus out the window. → Portalsystemic encepathalpathy, 2. Mary is 63 years old who lives alone since her husband died about 10 years ago. She seems vague and uncertain when she comes to see you and explains that she is worried because had coughed up bright red blood this morning after she had eaten her toast for breakfast. → Chronic liver dysfunction with portal hypertension, 3. Peter is a 18 year old who finished school and then spent the next 5 months travelling around India and Pakistan where he enjoyed the local cuisine. He has now been home for about a month and has noticed that he hasn’t been hungry and presents with malaise, nausea, fatigue and temperature. → Acute viral hepatitis

Question 47

Answer 47

Failure of the detoxification function of the liver allows toxic substances to accumulate in the blood, causing encephalopathy. The vascular shunts in cirrhosis let blood bypass the hepatocytes, and are an important cause of this phenomenon. The other major cause is failure of hepatocyte function, which in cirrhosis is largely due to capillarisation of sinusoids. Deposition of bile salts does occur in cirrhotic patients with cholestasis, but the main symptom is itching. The correct answer is: Vascular shunts bypassing hepatocytes

Question 48

Answer 48

The portal triad is surrounded by the hepatoduodenal ligament. The portal triad is the hepatic artery, portal vein and bile duct The correct answers are: Left hepatic duct, left hepatic artery, left portal vein, Portal vein, bile duct, hepatic artery

Question 49

Answer 49

Enteropeptidase, formerly called enterokinase, activates trypsinogen by limited proteolytic digestion to give trypsin. Trypsin is itself capable of activating trypsinogen, which produces a positive feedback effect. Trypsin also activates chymotrypsinogen (and several other proteolytic enzymes), so deficiency of enteropeptidase results in a severe deficiency of enzymes that digest protein. The correct answer is: Trypsin

Question 50

Answer 50

Vitamin D is essential for uptake of calcium, and regulation of calcium metabolism and bone mineralisation. Vitamin D deficiency is the classic cause of Rickets. However, with adequate provision of vitamin D similar deficiency symptoms will occur with lack of calcium itself. The correct answer is: Calcium

Question 51

Answer 51

The correct answer is: Superior mesenteric

Question 52

Answer 52

The correct answer is: Omphalocele

Question 53

Answer 53

Bilirubin is a degradative product of haemoglobin metabolism. Bilirubin (pigment) stones are specifically associated with excessive bilirubin production in haemolytic anaemias, including sickle cell anaemia. Bilirubin stones can also be seen in hepatic cirrhosis and liver fluke infestation. Calcium oxalate stones (choice B) and cystine stones (choice E) are found in the kidney, rather than the gallbladder. Pure cholesterol stones (choice C) are less common than mixed gallstones, but have the same risk factors, including obesity and multiple pregnancies. Mixed stones (choice D) are the common "garden variety" gallstones, found especially in obese, middle aged patients, with a female predominance. The correct answer is: Calcium bilirubinate

Question 54

Answer 54

The correct answer is: 90 degrees clockwise

Question 55

Answer 55

The principal route of metabolism of ethanol is via alcohol dehydrogenase, which uses hydrogen from ethanol to form NADH from NAD+, markedly increasing the ratio of NADH to NAD+. The relative excess of NADH has a number of effects, including inhibiting, rather than stimulating fatty acid oxidation (choice A); inhibiting gluconeogenesis rather than stimulating it (choice B); inhibiting, rather than stimulating (choice C) glycerophosphate dehydrogenase; and favouring the formation of lactate rather than pyruvate from glycolysis (thereby increasing, rather than decreasing the lactate/pyruvate ratio; choice D). The correct answer is: The ratio of NADH to NAD+ is increased

Question 56

Answer 56

1. This infection is caused by ingestion of trematodes that are on food plants that grow in water. The treated that migrates to the liver and releases eggs into the bile duct. 2. Hepatitis A is transmitted via the faecal–oral route and is more common in younger children and their contacts – parents, teachers etc. The clinical pattern is one of pale stools, deep jaundice with a prodromal flu like illness. 3. Patients with infectious mononucleosis or glandular fever present with many symptoms – fever, malaise, night sweats, heavy exudates on their fauces/tonsils and may have an associated hepatitis secondary to the EBV. The correct answer is: 1. A 19 year old student presents to his GP with pain in the right upper quadrant and tells you they have come back from an overseas trip to Europe where he spent some time helping out on a relatives sheep farm. Examination him and he appears to have a tender liver and he has eosinophilia and there are eggs in his faecal sample. → Fasciola hepatica, 2. A nursery teacher presents with malaise and flu like symptoms. Initially there is little to find on examination however within 3-4 days her stools become pale, her urine dark and she is deeply jaundiced. She has no history of illicit drug use → Hepatitis A, 3. A 37 year old single man presents with pain in the right upper quadrant, a sore throat and heavy sweats. Exanimation reveals his fauces are erythematous and covered in exudates. → Infectious mononucleosis (EBV)

Question 57

Answer 57

Secretory IgA • Is anti-inflammatory, Can inhibit phagocytosis and chemotaxis of neutrophils and macrophages, Can down regulate synthesis of TNFα and IL-6 (inflammatory cytokines), Can inhibit microbial adherence, neutralise microbial enzymes, Neutralises viruses and toxins • IgA is a dimer of immunoglobulin molecule, first line of defence in protecting the intestinal epithelium from enteric toxins and pathogenic microorganisms. Acts as Immune exclusion = SIgA blocks the access of dietary antigens and pathogens to epithelial receptors, traps them in mucous, and helps get rid of them by peristalsis The correct answer is: Inhibits microbial adherence

Question 58

Answer 58

1. The hypoglossal nerve is the motor innervation to the majority of the intrinsic and extrinsic muscles of the tongue. So if there is a problem with the hypoglossal nerve that is bilateral the tongue won’t project forward, if it projects forward but to one side then the problem if unilateral and the tongue will point in the direction of the damage. In this case there is left hypoglossal nerve that is damaged. 2. The taste sensation is on the anterior 2/3rds if the tongue. This is the oral part of the tongue and is innervated by the facial nerve. 3. All the muscles of the soft palate are innervated by the vagus nerve except for tensor veli palatine which is fed by the mandibular nerve. Hence the ability to tense is independent of the other functions. The correct answer is: 1. A young football player is taken to emergency after breaking his jaw during a match. The doctor asks him to stick out his tongue and notices that the tip of the tongue points to the left → Hypoglossal nerve, 2. An elderly man presents to his doctor complaining that he has lost taste on the anterior 2/3rds of his tongue. → Facial nerve, 3. Dorothy complains to her doctor about difficult in swallowing. Investigations identify problems with her soft palate. The doctor notices that she can tense the soft palate but cannot elevate or depress it, nor can she move the uvula or elevate the back of the tongue → Vagus nerve

Question 59

Answer 59

a) it is the switching on of the proto-oncogenes that will initiate the disease process b) It is non-functioning in the development of colorectal cancer c) Often hyperplastic but benign and not sufficient for tumorigenesis. As exemplified with the case of colorectal cancer, several ‘events’ are required to lead to complete tumorigenesis. d) Wnt signalling is not related to MMR enzymes which are caretakers. e) Correct. The correct answer is: When mutated the APC glycoprotein is non-functioning and so and β-catenin builds up in the cytoplasm

Question 60

Answer 60

a) Correct answer b) p53 is a transcription factor, NOT a protein kinase that would be able to phosphorylate another protein. c) p53 as a transcription factor activates the synthesis of the small Cdk inhibitor protein p21 (also called WAF). d) p53 induces the exit from the cell cycle (upon DNA damage) and the induction of apoptosis. e) p53 does NOT activate cyclin D1 expression, but the expression of p21 (see C). The correct answer is: inducing cell cycle arrest in response to DNA damage.

Question 61

Answer 61

The symptom is tenesmus and is characteristic of an anal or rectal mass The correct answer is: low rectum.

Question 62

Answer 62

The patient has familial adenomatous polyposis, which is due to an inherited mutation in APC. The correct answer is: APC

Question 63

Answer 63

1. Enterokinase is a brush border enzyme that activates the digestive enzymes secreted by the pancreas. 2. The pancreatic enzyme Lipase is responsible for lipid digestion. Absence of this enzyme results in excretion of fat in the stools. 3. The change in pancreatic structure with chronic inflammation associated with pancreatitis results in pancreatic enzymes being present in the blood supply. The correct answer is: 1. Which enzyme is not secreted by the pancreas? → Enterokinase, 2. Loss of this enzyme is associated with foul smelling stools that tend to float. → Lipase, 3. This pancreatic enzyme contributes to digestion of starch and is measured in the blood stream in pancreatits. → Amylase

Question 64

Answer 64

1. This is an example of a vomiting gastroenteritis, it is commonly caused by Stapylococcus aureus, Bacillus cereus or viruses. The organisms are localised to the stomach and small intestine. 2. This is an example of a watery diarrhoea. The organisms are localised to the small intestines. It is commonly caused by Rotavirus, Norovirus, Giardia Lamblia, Cryptosporidium parvum, Vibrio cholerae and ETEC. 3. This is an example of inflammatory or exudative diarrhoea. It is most commonly caused by Campylobacter jejuni, Salmonella spp, Yersinia enterocolitica infection of the both the small and large intestine or Shigella spp, EHEC, Clostridium difficile or Entamoeba histolytica infection of the large intestine. Campylobacter jejuni is the most common bacterial cause of diarrhoea in Australia. 4. Gentamicin is an aminoglycoside antibiotic that is poorly absorbed form the gastrointestinal tract. The use of this antibiotic has alteration of normal intestinal flora allowing proliferation of antibiotic resistant toxin-producing C. difficile which is responsible for the diarrhoea. The correct answer is: 1. Your patient presents with severe sudden onset vomiting but no diarrhoea or fever. → Staphylococcus aureus, 2. Your patient complains of having had a large volume or watery diarrhoea for the last 9 days although they have had no fever. You send a stool sample off to the laboratory for testing and they report that there are no blood or leucocytes present in the stool. → Giardia Lamblia, 3. Your patient presents diarrhoea for the last 3 days along with abdominal pain on the lower left abdominal. They mention passing some blood and on questioning remember that they had a temperature and chills before the diarrhoea started. → Campylobacter jejuni, 4. Your patient has just finished two courses of oral gentamicin. They now complain of abdominal pain and diarrhoea. → Clostridium difficile

Question 65

Answer 65

a) Macromolecular glycogen is never transported out of the cell b) does not occur during fasting c) correct answer d) Muscle glycogen does not produce glucose for the blood e) Muscle does not have glucose-6-phosphatase The correct answer is: serves as a source of fuel for ATP synthesis within that tissue.

Question 66

Answer 66

The correct answer is: Tumour invades through the muscularis into the sub serosa or into the pericolic or perirectal tissues

Question 67

Answer 67

The correct answer is: is necessary for glucose to enter the blood from the liver cell.

Question 68

Answer 68

The correct answer is: Metastasis in 1 to 3 regional lymph nodes

Question 69

Answer 69

The correct answer is: No distant metastasis

Question 70

Answer 70

Higher true positive or lower false negative increases the proportion of false positives = higher positive predictive value. We can’t tell the differences of any of the other measures from this limited information, however, if the negative test results do not change, the sensitivity is likely to be higher; the specificity is likely to be higher; and the accuracy is likely to be higher in population A. The negative predictive value would be unchanged. The correct answer is: The positive predictive value is likely to be higher in population A

Question 71

Answer 71

Confidence intervals exclude 1 for both, indicating the relative risk is significantly greater than 1.0. The risk of HBV is greater in those who have ever shared needles is 1.38 but the confidence intervals do include 1.0, indicating the difference is not significant. The prevalence of (number of users with) HCV is greater suggesting an increased rather than a reduced risk. The correct answer is: The risk of both HBV and HCV is greater in those who have been injecting for more than 7.7 years.

Question 72

Answer 72

a) Think of the essential fatty acids! b) The liver can also synthesise fatty acids. c) Via acetyl-CoA production. The so-called ketogenic amino acids also contribute to acetyl-CoA production. d) ONLY the essential ones are not synthesised. e) ONLY the essential ones are not synthesised. The correct answer is: can be synthesized from excess dietary carbohydrates or proteins.

Question 73

Answer 73

The correct answer is: 1. A 5 year old by presents with a sore throat and fever. On inspection his tonsils appear enlarged and have white pustules on their surface. He is prescribed penicillin. What type of antibiotic is penicillin? → β-lactam, 2. An 37 year old woman develops an infection after having an operation in her local hospital. She is prescribed vancomycin. Vancomycin is an example of which type of antibiotics? → Glycopeptide, 3. A 50 year old woman presents with urinary urgency and frequency. She describes burning pain on urination. Urinalysys indicates that she is suffering form a urinary tract infection and you prescribe sulfurmethoxosol. What type of antibiotic is sulfurmethoxosol? → Sulfonamide, 4. A 5 year old girl presents with conjunctivitis. You prescribe eye drops containing chloramphenicol. Chloramphenicol is an example of which type of antibiotics? → Amphenicol

Question 74

Answer 74

Even though there was a difference in the percentage of symptomatic infections (4.4% vs 3.3%); the confidence interval passes through 1, so the difference is not significant. The correct answer is: People who received immune globulin as post-exposure prophylaxis were equally likely to develop Hepatitis A than people who received Hepatitis A vaccine as post-exposure prophylaxis.

Question 75

Answer 75

a) Think of the essential fatty acids! b) The liver can also synthesise fatty acids. c) Via acetyl-CoA production. The so-called ketogenic amino acids also contribute to acetyl-CoA production. d) ONLY the essential ones are not synthesised. e) ONLY the essential ones are not synthesised. The correct answer is: can be synthesized from excess dietary carbohydrates or proteins.

Question 76

Answer 76

1. Hirschprung disease is aganglionosis of the rectum and variable amounts of colon. 2. Virtually all non-neoplastic ulcers of the duodenum are peptic ulcers associated with infection by Helicobacter. 3. Trypanosoma cruzi causes Chagas disease; it results in achalasia when it involves the oesophagus. The correct answer is: 1. Failure of migration of ganglion cells. → Hirschprung disease, 2. Helicobacter pylori infection. → Chronic duodenal ulcer, 3. Trypanosomal infection. → Chagas disease

Question 77

Answer 77

The correct answer is: Posterior vagal trunk

Question 78

Answer 78

Episodes of haemolytic anaemia upon oxidative challenge, e.g. with certain drugs like chloroquine, are a typical feature of glucose 6-phosphate dehydrogenase deficiency. Haemoglobinopathies result in other symptoms, e.g. sickle cell anaemia. the other ones are way out. The correct answer is: Glucose 6-phosphate dehygrogenase deficiency

Question 79

Answer 79

1. The low BMI and the self induced vomiting suggest an eating disorder, the concurrent use of laxatives in attempting to lose weight is common. 2. The symptoms point to malabsorption, with the macrocytosis (larger red blood cells) due to B12 malabsorption and the intermittent diarrhoea and low protein again pointing to a malabsorption syndrome. 3. The change in bowel habit and slow progressive weight loss would suggest a tumour, which in this case would be a colorectal carcinoma that ould be encircling the lumen, which on a barium enema may show as an ‘apple core’ constriction. The correct answer is: 1. A 21 year old female student, who supports herself by part-time modelling, complains of diarrhoea. She is light for her height (1.78 m, 56 kg, BMI 17.7) and admits to self-induced vomiting. Her colonic mucosa is seen to be abnormally pigmented at colonoscopy. → Laxative abuse, 2. A 36 year old male complains of abdominal distension and intermittent diarrhoea. On examination he has a slightly distended abdomen and swollen ankles. Blood tests show that he has a large red blood cells, and low concentrations of calcium and albumin. → Malabsorption, 3. A 56 year old woman presents with a 6 month history of frequent colicky abdominal pains. When the pains are present she has noticed her abdomen swelling. Her bowel habit alternates between mild constipation and mild diarrhoea. There is no blood in her stools. She is loosing weight steadily. → Bowel obstruction

Question 80

Answer 80

1. The dispersed rash in this case is dermatitis herpetiformis which can accompany coeliac disease. 2. The cause is radiation enteritis following radiotherapy to the paraaortic nodes. Symptoms usually improve after approximately 6 weeks. 3. The farmer has developed a parasitic infection, the commonest being giardiasis. The correct answer is: 1. A 32 year old lady presents with a history of abdominal pain, weight loss and altered bowel habit. Examination reveals a dispersed blistering type rash on her wrists and buttocks. → Coeliac disease, 2. A 32 year old man has received treatment for a testicular seminoma which included para-aortic node spread. Following treatment he has developed persistent diarrhoea and steatorrhoea. → Radiation enteritis, 3. A 34 year old cattle farmer presents with weight loss and steatorrhoea, in his history you note that he initially started with very profuse watery diarrhoea which seemed to settle after a few weeks but he has been increasingly unwell → Parasite infestation

Question 81

Answer 81

The fact the there are fat droplets within the epithelial cells and that there are no chylomicrons made indicates an insufficiency of these cells to make chylomicrons. Apolipoprotein synthesis in these cells is required for the production of chylomicrons. All other answers have nothing to do with it. The correct answer is: decreased synthesis of an apolipoprotein.

Question 82

Answer 82

All answers with ’glycolysis’ are wrong, since this breaks down glucose. Fatty acid synthesis would also use up glucose. This leaves only answer C as correct. The correct answer is: Glycogen breakdown and gluconeogenesis

Question 83

Answer 83

The correct answer is: 3-Hydroxybutyrate

Question 84

Answer 84

EAR provides 100% of needs for 50% of population: not 50% of needs for 100% of population. While RDI provides 100% of needs for 97% of population. The correct answer is: Estimated average requirement (EAR)

Question 85

Answer 85

The correct answer is: Greater splanchnic

Question 86

Answer 86

The correct answer is: Superior mesenteric artery

Question 87

Answer 87

The correct answers are: parasympathetic innervation to the anterior body and fundus of the stomach + parasympathetic innervation to the posterior body of the stomach and duodenum.

Question 88

Answer 88

The correct answer is: 1. Region A → left gastro-omental, 2. Region B → right gastric, 3. Region C → superior pancreaticoduodenals (ant + post)

Question 89

Answer 89

The correct answer is: Jejunum

Question 90

Answer 90

The statins such as atorvastatin act by inhibiting the rate limiting step in the metabolism production by competitively inhibiting the activity of HMG CoA reductase leading to a reduction of LDL cholesterol. The correct answers are: Acetate thiokinase, HMG-CoA reductase

Question 91

Answer 91

The child is not digesting fat and is suffering from steatorrhea. Because of the relatively limited supply of lipase fat absorption is usually the first affected by alterations in pancreatic output. The correct answer is: Lipase

Question 92

Answer 92

1. Pancreatic acinar cells have receptors for cholecystokinin (CCK) and muscarinic acetylcholine receptors. Cholecystokinin is an endocrine hormone released from the ‘I’ cells located in the duodenal mucosa. CCK is released in response to amino acids (particularly phenylalanine, methionine and tryptophan), small peptides and fatty acids in the intestinal lumen. CCK then acts on the acinar cells to stimulate enzyme secretion. 2. The release of bicarbonate-rich aqueous secretions from the pancreatic duct cells occurs in response to the endocrine hormone secretin. Secretin is released from S cells in the duodenal mucosa in response to acid in the intestinal lumen. Secretin promotes an increase release of aqueous bicarbonate-rich fluid from the pancreatic ducts. 3. Insulin is one of the endocrine hormones released from the pancreatic islets of Langerhans. Blood levels of this hormone are high after a meal when blood glucose is high. This hormone acts to facilitate lowering of blood glucose levels and storage of glucose. The correct answer is: 1. This hormone stimulates pancreatic acinar cells to increase release of pancreatic enzymes. Release of this hormone is stimulated by the presence of small peptides and fats in the lumen of the duodenum. → Cholecystokinin, 2. This hormone stimulates the pancreatic duct cells to release bicarbonate-rick aqueous solutions. This hormone is released from cells in the duodenum in response to acidic chyme entering the duodenum. → Secretin, 3. This hormone acts after a meal to reduce blood sugar levels. This hormone stimulates glucose absorption by hepatocytes and stimulates glycogenesis. → Insulin

Question 93

Answer 93

The digestion and absorption of fat occurs in the following order: The bile salts coat (emulsify) fat droplets allows the pancreatic lipase and colipase access to an increased surface area and facilitates the break down of the ingested fats. Once released the monoglycerides and fatty acids move out of micelles and are absorbed into the enterocytes. Cholesterol also is transported into cells and the absorbed cholesterol and other fat breakdown products are formed into chylomicrorons. These chylomicrons are then released from the enterocytes and pass into the lymphatic circulation. The correct answer is: 1, 6, 5, 2, 3, 4

Question 94

Answer 94

The correct answer is: Vitamin C

Question 95

Answer 95

The primary function of the small intestine is absorption of nutrients. This is reflected in the large numbers of absorptive cells in the epithelium lining the tube. The correct answer is: absorptive cells which transport nutrients from the lumen to the lamina propria.

Question 96

Answer 96

Even though this range would be seen as higher than normal for the general population, for individuals over 65 years of age the extra body mass provides protection in case of illness. Also, accurate height measurement can be difficult to measure for this age group. The correct answer is: 22 - 27

Question 97

Answer 97

The correct answer is: **a)** This digestive enzyme is primarily responsible for the digestion of the pasta component of an Italian meal. → Amylase, **b)** This enzyme is produced by the action of an enzyme on the surface of intestinal epithelial cells on a proenzyme. → Trypsin, **c)** A 4-year-old boy is brought to the doctor because his mother is worried that his stools are foul-smelling and tend to float. He is subsequently diagnosed with pancreatic insufficiency. Lack of which of the above enzymes is causing his symptoms? → Lipase

Question 98

Answer 98

The correct answer is: **a)** A 24-year-old woman recently developed a urinary tract infection which was treated with antibiotics. She comes to you asking if a probiotic drink might help her condition and asks you which bacteria they most commonly contain. → Lactobacillus species, **b)** A patient complains of having nausea, abdominal discomfort and persistent watery diarrhoea for the last fourteen days although they have had no fever. You send a stool sample off to the laboratory for testing and they report the presence of a parasitic organism in the sample. → Giardia lamblia, **c)** A patient presents with diarrhoea for the last three days along with abdominal pain in the left lower quadrant. He mentions passing some blood and on questioning remembers that he had a temperature and chills before the diarrhoea started. → Campylobacter jejuni

Question 99

Answer 99

The correct answer is: **a)** A 2-year-old girl is brought to the doctor with a 4 month history of abdominal bloating with explosive diarrhoea. → Lactose intolerance, **b)** A 25-year-old woman presents with increasing tiredness to the point that getting to work is difficult. Blood tests reveal that she has low haemoglobin but a raised mean cell volume. The blood film shows macrocytosis. → Vitamin B12 deficiency, **c)** A 5-year-old boy is referred to a paediatrician due to ‘failure to thrive’. His parents have noticed that he has been losing weight and that his bowel movements have become loose. Blood tests revealed the presence of both anti-gliadin antibodies and endomysial antibodies. → Coeliac disease

Question 100

Answer 100

The correct answer is: **a)** A 55-year-old man complains of feeling like he constantly needs to pass stools, even though his bowels are empty. What is this symptom called? → Tenesmus, **b)** A 35-year-old woman presents to her doctor with a 6 month history of increasingly tiredness and lethargy. She has lost 5 kg in weight and has been suffering from fevers and peri-umbilical colicky pains that have been slowly getting worse. She has also had loose bowel motions that have progressed into diarrhea and recently noticed small amounts of blood and mucus on the toilet paper. What is the most likely cause of her symptoms? → Crohn’s disease, **c)** A 32-year-old woman who is 5 months pregnant notices bright red blood on the toilet paper and in the toilet bowel when she defecates. She otherwise feels well and hasn’t had any complications with her pregnancy except for mild constipation. You perform a rectal examination and have bright red blood on your glove and feel a small lump near the anus. What is your most likely diagnosis? → Haemorrhoids

Question 101

Answer 101

The correct answer is: Upregulation of the carnitine shuttle

Question 102

Answer 102

The correct answer is: H⁺/K⁺ATPase in the parietal cells

Question 103

Answer 103

The correct answer is: Alcoholic hepatitis

Question 104

Answer 104

The correct answer is: Glucose-6-phosphatase

Question 105

Answer 105

The correct answer is: Blood in the stool

Question 106

Answer 106

The correct answer is: Stelate cells

Question 107

Answer 107

The correct answer is: Secretin

Question 108

Answer 108

The correct answer is: Irritable bowel syndrome

Question 109

Answer 109

The correct answer is: p53

Question 110

Answer 110

The correct answer is: Small Pox

Question 111

Answer 111

The correct answer is: Alcohol

Question 112

Answer 112

The correct answer is: Campylobacter spp.

Question 113

Answer 113

The correct answer is: Unconjugated bilirubin

Question 114

Answer 114

Primary prevention is concerned with preventing the onset of disease; it aims to reduce the incidence of disease. It involves interventions that are applied before there is any evidence of disease or injury. The correct answer is: primary prevention.

Question 115

Answer 115

The goal of screening is to reduce morbidity or mortality from the disease by detecting diseases in their earliest stages, when treatment is usually more successful. The correct answer is: be able to detect disease at an early stage.

Question 116

Answer 116

The expenditure of resources on screening must be justifiable in terms of eliminating or decreasing adverse health consequences. The correct answer is: the cost of care of those affected.

Question 117

Answer 117

The correct answer is: Chloramphenicol (C)

Question 118

Answer 118

The correct answer is: Structure E

Question 119

A 65-year-old woman presents with difficulty swallowing both solid and liquid food. Based on the barium swallow shown below, what is the basis for her symptoms? ## Footnote **Select one:** Failure of coordinated peristaltic contractions Failure of reflex relaxation of the stomach Failure of the lower oesophageal sphincter to relax Failure of the upper oesophageal sphincter to relax Hiatus hernia leading to reflux of stomach contents

Answer 119

The correct answer is: Failure of the lower oesophageal sphincter to relax

Question 120

Answer 120

The correct answer is: Region A

Question 121

Answer 121

The correct answer is: Metabolic acidosis

Question 122

A patient with diarrhoea is investigated with a barium enema. What is the structure labelled "X" on the x-ray of the patient's abdomen below? **Select one:** Ascending colon Caecum Descending colon Sigmoid colon Transverse colon

Answer 122

The correct answers are: Ascending colon, Sigmoid colon

Question 123

Answer 123

The correct answers are: Enzyme D, Enzyme E

Question 124

Answer 124

The correct answers are: Region B, Region D

Question 125

Which of the labeled regions of the intestine is innervated by the pelvic splanchnic nerve?

Answer 125

The correct answers are: Region B, Region D

Question 126

What is the structure labeled X in the image of the stomach shown below? ## Footnote **Select one:** Blood vessel Circular muscle layer Intestinal epithelial tissue Longitudinal muscle layer Muscularis mucosa

Answer 126

The correct answer is: Muscularis mucosa