GIL Written Exam Qs

Question 1

Gabe is a 24-year-old male medical student who visits you because he has been feeling tired and has noticed that his urine has recently become very dark. As Gabe walks into the consulting room you notice that his skin has a definite yellow colour and you immediately start thinking about the causes of jaundice.

a) Describe the following steps involved in bilirubin metabolism and excretion. (7 marks)

• Release
• Plasma transport
• Hepatic metabolism
• Excretion

Answer 1

Release: bilirubin is released from red blood cells when they are broken down
Plasma transport: unconjugated bilirubin is transported through the plasma bound to albumin
Hepatic metabolism: in the liver the bilirubin is conjugated to glucuronide which makes it water soluble, conjugated bilirubin is excreted into the bile and passes into the intestines
Excretion: In the intestines the intestinal bacteria metabolise the conjugated bilirubin to produce urobilinogen. Urobilinogen is further metabolised to stercobilin which is excreted then
in the faeces. some urobilinogen is absorbed into the blood stream and excreted in the urine

Question 2

b) Give one (1) possible cause for each of the three different types of jaundice. (3 marks)

• Pre-hepatic jaundice
• Intra-hepatic jaundice
• Post-hepatic jaundice

Answer 2

Pre-hepatic jaundice: examples include haemolysis, autoimmune haemolysis

Intra-hepatic jaundice: examples include viral hepatitis, drugs, chronic alcoholic hepatitis, cirrhosis, cholestasis

Post-hepatic jaundice: examples include common duct stones, carcinoma of the bile duct, carcinoma of the pancreas, billary stricture, pancreatitis

Question 3

Gabe is a 24-year-old male medical student who visits you because he has been feeling tired and has noticed that his urine has recently become very dark. As Gabe walks into the consulting room you notice that his skin has a definite yellow colour and you immediately start thinking about the causes of jaundice.

c) List three (3) questions you would ask when taking a history from Gabe that would help you to determine the cause of his jaundice. (3 marks)

Answer 3

Alcohol history, abdominal pain, blood transfusions, sexual activity, iv drug use, weight loss, fever, stools, travel history, experiences sharing needles,

Question 4

Gabe is a 24-year-old male medical student who visits you because he has been feeling tired and has noticed that his urine has recently become very dark. As Gabe walks into the consulting room you notice that his skin has a definite yellow colour and you immediately start thinking about the causes of jaundice.

d) Based on the results from the blood tests what type of jaundice do you suspect Gabe is experiencing? (1 mark)

Due to the elevated lymphocytes you suspect that Gabe has contracted viral hepatitis.

e) Explain why, based on the results from the liver function test results. (2 marks)

Answer 4

d) intrahepatic jaundice or hepatitis
e) Intrahepatic damage is indicated by the elevation in the ALT and AST which are enzymes located within the hepatocytes. Decreased hepatocyte function is indicated by the reduced serum albumin.

Question 5

f) Describe two (2) distinguishing features relevant to hepatitis A and B. (4 marks)

Answer 5

Hepatitis A
mild, acute illness, often without jaundice, most common hepatitis virus infection, particularly common in children, spreads via faecal-oral contact

Hepatitis B
transmitted parenterally via contaminated blood or blood products, or via sexual contact, associated with a wide spectrum of liver disease, can develop into an asymptomatic carrier state, which is associated with hepatocellular carcinoma

Question 6

Peter is a 54-year-old male executive in a real estate management firm who was hospitalized with chest pain and vomiting.

a) List three (3) possible differential diagnoses that you would consider for this patient. (3 marks)

Answer 6

Any three of the following: Esophagitis, gastric ulcer, gastritis, duodenitis, duodenal ulcer myocardial infarction, pulmonary embolus,

Question 7

Peter is a 54-year-old male executive in a real estate management firm who was hospitalized with chest pain and vomiting.

On questioning, you discover that Peter’s pain is in his upper left abdomen and that he has had it for many years. He regularly experiences what he describes as periodic gnawing epigastric pain that tends to appear approximately 2 hours after a meal. Usually, his pain is temporarily relieved by antacid preparations.

b) What cell type in the mucosa of the stomach is responsible for gastric acid secretion? (1 mark)
c) In what anatomical region of the stomach are these cells located? (1 mark)
d) List three (3) factors that stimulate release of gastric acid. Include in your answer their target receptor and where they are released from. (6 marks)

Answer 7

b) Parietal cells
c) Body of the stomach

d) Factor: Acetylcholine
* *Target Receptor:** Muscarinic (M3)
* *Released from:** Vagus nerve

• *Factor:** Gastrin
• *Target Receptor:** CCK receptors
• *Released from:**Antral G cells
• *Factor:** Histamine
• *Target Receptor:** Histamine receptors (H2)
• *Released from:**Enterochromaffin like cells

Question 8

Peter is referred for an endoscopy where biopsies are collected from the stomach mucosa and sent for pathology. The pathologist reports “chronic gastritis with erosion of the gastric mucosa and the presence of the bacterium Helicobacter pylori.”

e) Describe how H. pylori are able to live in the acidic environment of the stomach and how this contributes to their ability to cause gastritis. (3 marks)
f) Describe the pathophysiological features of erosion of the gastric mucosa. (2 marks)
g) What pharmacological treatments are used to eradicate H. pylori? (3 marks)
h) If the patient remains untreated, what is one (1) long term complication that could occur? (1 mark)

Answer 8

e) H.pylori secretes large amounts of the enzyme urease. This breaks down urea to ammonia(NH3) and bicarbonate (HCO3-). The bicarbonate forms a basic cloud around the bacteria and protects it from the gastric acid but the ammonia is toxic to the gastric epithelial cells
f) Erosion indicates that the ulcer formed with the death of gastric epithelial cells is shallow and does not penetrate beyond the mucosa.

g) Triple therapy with the antibiotics and a proton pump inhibitor
antibiotics = Amoxicillin and Clarithromycin,
proton pump inhibitors = Omeprazole or Esomeprazole

h) Gastric adenocarcinoma or gastric lymphoma