PASTEST Flashcards
A 45-year-old man is admitted with right-sided abdominal pain and his investigations include an abdominal ultrasound scan. The ultrasound reveals right-sided hydronephrosis with a dilated right ureter.
Which of the following inflammatory processes might impinge upon the right ureter and cause obstruction?
1) Acute appendicitis
2) A perforated caecal carcinoma
3) Crohn’s disease affecting the terminal ileum
4) All of the above
5) None of the above
All of the above
As stated, given the ultrasound findings, it is important to consider acute appendicitis, Crohn’s disease and a perforated caeceal carcinoma as a possible cause of his symptoms, due to their close proximity anatomically to the right distal ureter.
Acute appendicitis
The appendix lies anterior to the right ureter. As such, acute appendicitis and associated inflammatory processes can cause hydronephrosis and a hydroureter.
A perforated caecal carcinoma
Inflammatory processes, including local and generalised peritonitis, could cause obstruction, as the caecum lies anterior to the right ureter. This question refers specifically to inflammatory processes causing obstruction. However, tumour bulk could also cause obstruction of the right ureter.
Crohn’s disease affecting the terminal ileum
Again, the terminal ileum is found just anterior to the right ureter, and inflammation of Crohn’s disease affecting the terminal ileum could cause obstruction.
None of the above
Although a calculus in the distal right ureter would be included in the differential diagnosis for this patient, local anatomy and associated pathologies must be considered, given the ultrasound findings. Anteriorly, the right ureter is related to the terminal ileum, caecum, appendix, and ascending colon and their mesenteries.
A 17-year-old male presents with fever, malaise and severe anorectal pain with swelling. This is on a background of six month history of diarrhoea and weight loss.
What is the most likely diagnosis?
1) Intersphincteric abscess
2) Ischiorectal abscess
3) Necrotising fasciitis
4) Perianal abscess
5) Supralevator abscess
Explanation
Perianal abscess
The most common type of anorectal sepsis is a perianal abscess (60%), and it is more commonly seen in men than women. Crohn’s disease is associated with an increased incidence of anorectal sepsis.
Intersphincteric abscess
Intersphincteric abscesses only account for a small number (around 5%) of anorectal abscesses.
Ischiorectal abscess
Ischiorectal abscesses account for around 20% of anorectal abscesses. Therefore, a perianal abscess is more likely, given the clinical scenario.
Necrotising fasciitis
If untreated, perianal sepsis can lead to necrotising fasciitis, so prompt incision and drainage of abscesses is required. However, there are no features of necrotising fasciitis described in the question stem. Necrotising fasciitis is a surgical emergency caused by bacterial infection of the fascia and subsequent necrosis of the subcutaneous tissues. It requires emergency debridement of affected areas with wide margins and intravenous antibiotics. Even with prompt treatment, mortality is still approximately 25–35%.
Supralevator abscess
Supralevator abscesses can develop from abdominopelvic pathology and can produce lower abdominal or rectal pain.
A 3-week-old boy presents with vomiting, jaundice and dehydration. Investigations reveal hypokalaemia and metabolic alkalosis.
What is the most appropriate initial management?
1) Correction of metabolic derangements
2) Feeding jejunostomy
3) Ramstedt’s pyloromyotomy
4) Total parenteral nutrition
5) Upper GI endoscopy
Explanation
Correction of metabolic derangements
The classical electrolyte abnormality of infantile pyloric stenosis (IHPS) is hypokalaemic hypochloraemic alkalosis. Surgery should be undertaken only after careful correction of the abnormalities, with the consult of an experienced paediatrician and anaesthetist.
Feeding jejunostomy
This would not be appropriate initial management of IHPS. Furthermore, pyloromyotomy is required as a curative procedure.
Ramstedt’s pyloromyotomy
This is the definitive surgical procedure required. However, correction of electrolytes before surgery is paramount. Of note, the umbilicus should be excluded from the operative field because of the risk of Staphylococcus aureus infection.
Total parenteral nutrition
Correction of electrolyte abnormalities is required as initial management. Given the significant electrolyte derangements, total parenteral nutrition would be challenging and ill-advised.
Upper GI endoscopy
The tumour is most commonly diagnosed clinically as a palpable tumour on test feed, alongside a history of projectile vomiting and hungry feeding, with no bile in the vomitus. This prevents the need for a diagnostic endoscopy, while correction of electrolyte abnormalities should be the first priority.
The incidence of IHPS is 3–4/1000 (1 in 300–900) live births. It is more common in males and has a slightly higher incidence in first borns. If the mother had IHPS, the risk is 20%, and if the father had IHPS, the risk is 5%. The pylorus is increased in length and diameter with hypertrophy of the circular muscle layer and autonomic nerves. There may be jaundice in 5–10% of cases due to a reduction of glucuronyl transferase.
A 60-year-old gentleman with a past history of atrial fibrillation attends the Emergency Department, complaining of a 3-day history of progressively worsening generalised abdominal pain and bloody diarrhoea. He has had intermittent colicky postprandial abdominal pain for the last 6 months. There are no exacerbating factors, and his weight has gradually declined, presumably due to reduced oral intake from apprehension to eat. Clinical examination reveals sinus tachycardia and hypotension. He has severe generalised abdominal pain and distension, but no specific tenderness. What is the most likely diagnosis?
1) Acute diverticulitis
2) Gastrointestinal ischaemia
3) Perforated viscus
4) Ruptured abdominal aortic aneurysm
5) Ulcerative colitis
Explanation
Gastrointestinal ischaemia
The history suggests a gastrointestinal cause, for which the most likely answer is gastrointestinal ischaemia, mostly likely ischaemic colitis. It frequently presents as severe abdominal pain that is out of proportion to the clinical signs, bloody diarrhoea and a significantly raised serum lactate level that is poorly responsive to fluid resuscitation. The concurrent atrial fibrillation is also a potential thromboembolic source that may trigger such acute ischaemia.
Acute diverticulitis
If the causative pathology were acute diverticulitis, signs of sepsis would be expected. Additionally, diverticulitis presents with localised abdominal pain, usually the left iliac fossa, as diverticular disease most commonly affects the sigmoid colon.
Perforated viscus
A perforated viscus is merely likely to present with localisable signs and symptoms. For example, a perforated gastric ulcer would produce localised tenderness and guarding within the upper abdomen. Moreover, the history of colicky postprandial pain and atrial fibrillation is suggestive of abdominal ischaemia.
Ruptured abdominal aortic aneurysm
A ruptured abdominal aortic aneurysm is unlikely, as this patient has no risk factors suggesting the diagnosis.
Ulcerative colitis
Although ulcerative colitis is a possible cause, in the acute setting, it is more likely in a younger individual.
A 70-year-old gentleman undergoes a difficult laparoscopic cholecystectomy where the cystic duct is found to be wide. Before this procedure, he had undergone an endoscopic retrograde cholangiopancreatography (ERCP) and a sphincterotomy for common bile duct stones. In the post-operative period, he develops a subdiaphragmatic collection which is drained. The fluid is bile, and so a stent is placed within the common bile duct by ERCP. Within 24 hours, he becomes tachycardic and hypotensive, passes black stools and develops severe abdominal pain.
What is the most likely diagnosis?
1) Acute pancreatitis
2) Enterocutaneous fistula
3) Gastrointestinal haemorrhage
4) Small bowel obstruction
5) Small bowel perforation
Gastrointestinal haemorrhage
Division of the sphincter of Oddi with sphincterotomy may cause pancreatitis, duodenal perforation or bleeding. The black stools suggest the passage of melaena, and therefore upper gastrointestinal bleeding post-ERCP.
Acute pancreatitis
Pancreatitis is one of the most common complications post-ERCP, with an incidence of around 20%, and can also present with severe abdominal pain (localised to the epigastric region, with radiation to the back), hypotension and tachycardia. However, black stools are not consistent with acute pancreatitis.
Enterocutaneous fistula
An enterocutaneous fistula would not cause the passage of black stools.
Small bowel obstruction
Gallstone ileus as a form of small bowel obstruction post-ERCP is rare. Again, passage of black stools is more indicative of upper gastrointestinal bleeding which would not be present in small bowel obstruction.
Small bowel perforation
Perforation of the duodenum (usually periampullary or ductal perforation due to sphincterotomy or guidewire manipulation) is a recognised complication of ERCP. However, it is rare, with a reported rate of 0.6%. Therefore, gastrointestinal haemorrhage would be more likely.
A 46-year-old male presents with an acutely painful left groin. He is tender over the affected area and you notice that his swelling originates inferior and lateral to the pubic tubercle.
What is the most likely diagnosis?
1) Direct inguinal hernia
2) Femoral hernia
3) Indirect inguinal hernia
4) Obturator hernia
5) Spigelian hernia
Explanation
Femoral hernia
Femoral hernias always arise inferior and lateral to the pubic tubercle.
Direct inguinal hernia
Inguinal hernias originate superior and medial to the pubic tubercle, not inferior and lateral. Although clinical assessment can classify inguinal hernias as direct (through weakness in the abdominal wall) or indirect (through the inguinal canal), inguinal hernias can only be truly classified into ‘direct’ or ‘indirect’ at operation, when their relation to the inferior epigastric artery can be observed (direct – medial, indirect – lateral).
Indirect inguinal hernia
As above, inguinal hernias originate superior and medial to the pubic tubercle. Obturator hernia
Obturator hernias are rare and usually found in women.
Spigelian hernia
Spigelian hernias originate at the linea semilunaris of the abdominal wall.
A 54-year-old woman presents to the Emergency Department with severe upper abdominal pain which is constant and localised to the right upper quadrant. She is tachycardic and pyrexial, with a positive Murphy’s sign. A diagnosis of cholecystitis is made. She is treated with antibiotics and is offered a ‘hot’ cholecystectomy.
Concerning this diagnosis and its treatment, which of the following statements is correct?
1) Boas’ sign is pain in the right upper quadrant which radiates to the right iliac fossa as inflammatory fluid tracks down the right pericolic gutter
2) Hartmann’s pouch may be found at the junction of the cystic duct and common hepatic duct
3) The cystic duct is a boundary of the cystohepatic triangle
4) The bile duct lies in the free edge of the greater omentum
5) Ultrasound is more sensitive than computerised tomography (CT) in the diagnosis of cholecystitis
Explanation
The cystic duct is a boundary of the cystohepatic triangle
The boundaries of the cystohepatic triangle (Calot’s) are the cystic duct, the common hepatic duct and the inferior surface of the liver. The triangle’s contents include the right hepatic artery, cystic artery, cystic lymph node, connective tissue and lymphatics.
Boas’ sign is pain in the right upper quadrant which radiates to the right iliac fossa as inflammatory fluid tracks down the right pericolic gutter
Boas’ sign is hypersensitivity below the right scapula and can also be caused by phrenic irritation.
Hartmann’s pouch may be found at the junction of the cystic duct and common hepatic duct
Hartmann’s pouch is found at the junction of the gall bladder neck and the cystic duct. It is a pathological variant where a stone may become impacted.
The bile duct lies in the free edge of the greater omentum
The common hepatic duct is anterior to the portal vein, and the bile duct runs in the free edge of the lesser omentum.
Ultrasound is more sensitive than computerised tomography (CT) in the diagnosis of cholecystitis
Although CT scanning has a higher sensitivity and specificity, when compared with ultrasound scanning, it is more expensive and cannot visualise non-calcified gallstones. Additionally, the patient is not exposed to ionising radiation.
A patient undergoes intramedullary nailing for a mid-shaft fracture of the tibia three hours ago. The ward nurses are concerned as he is in a lot of pain. On examination, he has no neurovascular deficit. He complains of excruciating pain on passive plantar flexion of the big toe, but not on passive dorsiflexion.
What is the likely diagnosis?
1) Compartment syndrome of the deep posterior compartment of the leg
2) Compartment syndrome of the superficial posterior compartment of the leg
3) Compartment syndrome of the anterior compartment of the leg
4) Compartment syndrome of the lateral compartment of the leg
5) Compartment syndrome of the medial compartment of the leg
Explanation
Compartment syndrome of the anterior compartment of the leg
In compartment syndrome, pain is worsened by passive stretching (ie extension) of the affected compartment. In this case, the muscle being stretched is the extensor hallucis longus. This muscle is in the anterior compartment which also contains the tibialis anterior, the extensor digitorum longus and the peroneus tertius. This is a surgical emergency, as increasing pressure within the compartment exceeds perfusion pressure, causing hypoxia and ischaemia. It requires urgent fasciotomy, in which all osseofascial compartments are opened.
Compartment syndrome of the deep posterior compartment of the leg
The deep posterior compartment of the leg contains the flexor hallucis longus, along with the flexor digitorum longus and the tibialis posterior.
Compartment syndrome of the superficial posterior compartment of the leg
The superficial posterior compartment contains the gastrocnemius, the plantaris and the soleus.
Compartment syndrome of the lateral compartment of the leg The lateral compartment contains the peroneus longus and brevis. Compartment syndrome of the medial compartment of the leg There is no medial compartment of the leg.
A 45-year-old man has been sent to the accident and emergency department by his general practitioner who suspects that he is suffering from cauda equina syndrome. There is no history of spinal surgery in the patient.
Which of the following clinical findings supports this diagnosis?
1) Magnetic resonance imaging (MRI) of the spine which reveals a disc prolapse at T11
2) There is a positive Babinski sign
3) The patient’s chief complaint is of a shooting pain radiating down the back of his legs
4) The patient is in urinary retention, with reduced anal tone and bilateral lower limb weakness
5) The patient has purely sensory loss in all of the lumbar dermatomes
The patient is in urinary retention, with reduced anal tone and bilateral lower limb weakness As above, the signs of cauda equina syndrome can include urinary retention, reduced anal tone and bilateral lower limb weakness. Following clinical assessment, investigation with an MRI spine would be appropriate and surgical decompression may be required.
Magnetic resonance imaging (MRI) of the spine which reveals a disc prolapse at T11
Cauda equina syndrome affects the cauda equina which is situated below the level of the termination of the cord, at around the L1/2 disc space. As such, the disc prolapse at T11 would cause compression of the spinal cord.
There is a positive Babinski sign
A positive Babinski sign represents an upper motor neurone defect.
The patient’s chief complaint is of a shooting pain radiating down the back of his legs
Below the conus medullaris, the spinal canal contains the cauda equina which branches off the lower end of the spinal cord and contains the nerve roots from L1 to 5 and S1 to 5. These roots from L4 to S4 join in the sacral plexus. Compression to this area results in cauda equina syndrome. Signs include weakness of the muscles of the lower extremities, detrusor weaknesses causing urinary retention and post-void residual incontinence. There may be decreased anal tone and faecal incontinence, saddle anaesthesia, bilateral leg pain and weakness and bilateral absence of ankle reflexes. Pain may be absent.
The patient has purely sensory loss in all of the lumbar dermatomes
Sensory loss can be present in cauda equina syndrome, but primarily in the sacral dermatomes (S4–5) affecting the perianal region.
A 56-year-old man presents to the Accident and Emergency Department with severe vomiting and chest discomfort. His chest X-ray shows air in the mediastinum.
Which one of the following disease processes may cause this appearance?
1) Aortic rupture
2) Aortic dissection
3) Cardiac tamponade
4) Oesophageal perforation
5) Pericarditis
Explanation
Oesophageal perforation
Pneumomediastinum is the presence of air in the mediastinal tissues and can be readily seen on a chest radiograph. It is a hallmark of oesophageal perforation and large airway (trachea or bronchus) injury, and therefore must be taken seriously.
Aortic rupture
Isolated aortic rupture may cause mediastinal widening on the chest radiograph, but will not present as pneumomediastinum. Additionally, a patient with aortic rupture will likely present in extremis due to sudden circulatory collapse.
Aortic dissection
An aortic dissection occurs when there is an intimal tear of the aortic endothelium creating a false lumen. This can cause mediastinal widening on the chest radiograph, however there will be no air within the mediastinum.
Cardiac tamponade
Cardiac tamponade causes compression of the heart due to the accumulation of fluid, usually blood, impairing diastolic filling and so cardiac output. This may cause an enlarged cardiac shadow on the chest radiograph but no air would be visible within the mediastinum.
Pericarditis
Pericarditis is inflammation of the pericardium and has a number of aetiologies but it will not cause pneumomediastinum.
Acute limb compartment syndrome is characterised by increased pressure within an unyielding osteo-fascial compartment, resulting in local tissue hypoxia. Urgent surgery to decompress with responsible compartment(s) is necessary to reduce longer term morbidity and mortality.
Of the following symptoms, which one is a late sign of compartment syndrome and indicates the poorest prognosis?
1) Anaesthesia
2) Paraesthesia within distribution of sensory nerves
3) Pulses present
4) Severe pain on passive muscle stretch
5) Swollen limb
Anaesthesia
Complete anaesthesia is a late sign due to myoneural necrosis and indicates a poor prognosis.
Compartment syndrome is the term used to describe the condition in which the tissue pressure in an enclosed fascial compartment rises above the capillary pressure, so reducing blood flow to the distal tissues. Although direct measurement of compartmental pressures can be made, the condition should be treated on clinical grounds with removal of any occlusive dressings and elevation followed by fasciotomy if needed.
Paraesthesia within distribution of sensory nerves
Paraesthesia is a relatively late sign, however, progression to complete anaesthesia indicates a worse prognosis.
Pulses present
Distal pulses and capillary refill may be present even in the presence of significant increases in compartmental pressure.
Severe pain on passive muscle stretch
The earliest sign is pain out of proportion with the injury, particularly severe pain on passive muscle stretch. Other early signs are pink shiny skin and a feeling of pressure.
Swollen limb
This is an early sign of compartment syndrome and if diagnosis and treatment at this stage are swift then the prognosis would be good.
A 54-year-old man presents as an emergency to casualty following a crush injury to his left femur sustained on a building site. On examination a diagnosis of compartment syndrome is suspected.
Which one of the following early signs might be expected on examination of this man’s left lower limb to support this presumptive diagnosis?
1) Absent dorsalispedis pulse
2) Motor loss before sensory loss
3) Severe pain on passive stretch of the affected group of muscles
4) Greatly prolonged capillary refill
5) Blue or grey extremities
Explanation
Severe pain on passive stretch of the affected group of muscles
Severe pain in response to passive stretch of the ischaemic muscles is by far the most dramatic and reliable clinical sign.
Compartment syndrome is defined as an increase in the interstitial fluid pressure within an osteofascial compartment of sufficient magnitude to cause microcirculatory compromise and later myoneural necrosis. The limb becomes tense and swollen, and if not treated, the muscle weakness progresses to paralysis. Alternatively, areas of muscle may infarct, giving rise to rhabdomyolysis, hyperkalaemia, hyperphosphataemia, high uric acid levels and metabolic acidosis. It is a devastating early complication seen after long-bone fractures and crush injuries. It can also be caused by deep thermal burns, electrical injuries, restricting tourniquets and fluid extravasation (eg caused by iv regional anaesthesia).
Classically, compartment pressures are measured using a slit-catheter device. The normal resting pressure within the compartment tissues is approximately 3–4 mmHg. Compartment pressures in excess of 30–35 mmHg in a normally perfused patient have previously been taken to indicate the need for open-compartment fasciotomy. Recent evidence, however, suggests that fasciotomy should be undertaken if the difference between the diastolic pressure and the measured compartment pressure is < 30 mmHg.
Absent dorsalispedis pulse
Early in its development, the peripheral pulses are normal, as are fingertip/toe colour, temperature and capillary refill, as it is the microvasculature that is initially affected. Loss of peripheral pulses is usually a late sign and the diagnosis should be made before this progression of signs.
Motor loss before sensory loss
Thin cutaneous nerve fibres are more susceptible to ischaemia than the motor fibres, and distal paraesthesias occurs before motor loss.
Greatly prolonged capillary refill
Capillary refill may be normal in the early stages, so waiting until capillary refill time is prolonged is not appropriate as this will lead to a poor outcome for the patient. As such, prolonged capillary refill should not be used to support the presumptive diagnosis as ideally treatment would have taken place before this sign developing.
Blue or grey extremities
This would indicate significant disruption to the vasculature of the limb and ideally the diagnosis and subsequent treatment should have occurred before colour changes in the affected limb.
You are completing your paediatric surgical rotation and discussing with your consultant the indications for urgent surgery in an infant. Certain presentations must be dealt with swiftly to reduce future morbidity and mortality.
For which one of the following would a 4-month-old infant need urgent treatment?
1) A 6 cm strawberry naevus over the sacrum
2) Bat ears
3) Bilateral hydroceles
4) Metatarsus varus
5) Redcurrant coloured stool
Explanation
Redcurrant coloured stool
Redcurrant coloured stool is a late presentation suggesting a severe intussusception, and urgent treatment is required with a surgical opinion as soon as possible. Intussusception occurs when one section of the intestines invaginates another, the most common form is ileocolic. Surgical treatment is aimed at reducing the intussusception manually, usually an air enema or, if severe, resection of the affected bowel.
A 6 cm strawberry naevus over the sacrum
Strawberry naevus only requires treatment if the lesion is impairing sight, as failure to develop stereoscopic vision is a possibility. As this naevus is located on the sacrum, no treatment is required.
Bat ears
This is primarily a cosmetic concern for parents and is not an indication for urgent surgery.
Bilateral hydroceles
Bilateral hydroceles do not require urgent treatment as usually they resolve spontaneously.
Metatarsus varus
Metatarsus varus may correct with physiotherapy in due course and is not urgent.
You admit an elderly man through the Emergency Department with a 10-day history of abdominal distension, crampy abdominal pain and absolute constipation for the past 24 h. He has also been vomiting large amounts of faeculant material.
Which one of the following is the most common cause of colonic obstruction?
1) Endometriosis
2) Gallstone ileus
3) Irritable bowel syndrome
4) Sigmoid volvulus
5) Solitary rectal ulcer
Explanation
Sigmoid volvulus
The most common causes of colonic obstruction include carcinoma of the colon (approximately 65% incidence), diverticulitis (10% incidence), volvulus (approximately 5% incidence), others including pseudo-obstruction, radiational and inflammatory stricture, external hernias and ischaemic hernias approximately 20% incidence. A sigmoid volvulus may be resolved simply by passing a flatus tube rectally, if unsuccessful the patient will require surgery and manual reduction or resection of the volvulus.
Endometriosis
Endometriosis is a condition in which functioning endometrial tissue is found outside of the uterus, most commonly in the abdominal or pelvic cavity. If endometrial tissue is found on the bowel wall it can cause a stenosis and subsequent obstruction, however it is uncommon.
Gallstone ileus
Gallstone ileus is a rare form of bowel obstruction and occurs when a gallstone becomes lodged in the terminal ileum. It is a rare, but recognised complication of endoscopic retrograde cholangio-pancreatography (ERCP).
Irritable bowel syndrome
Irritable bowel syndrome does not cause bowel obstruction but may cause functional constipation.
Solitary rectal ulcer
Solitary rectal ulcers can cause obstruction if severe due to pain, however it is uncommon.
A 45-year-old man presents to the Acute Surgical Admissions Unit with a 1-day history of worsening epigastric pain, radiating through to the back, and vomiting. He is not able to find any comfortable position and analgesia is not helpful. Clinical examination reveals generalised abdominal guarding and rigidity.
What is the most definitive investigation to confirm diagnosis?
1) Amylase of 450 international units is suggestive of acute pancreatitis
2) Computed tomography (CT) scan of the abdomen
3) Ultrasound scan
4) Normal serum amylase excludes acute pancreatitis
5) The modified Glasgow score
Explanation
Computed tomography (CT) scan of the abdomen
In this context, a CT scan of the abdomen is the best investigative modality in confirming acute pancreatitis. It is also useful when the diagnosis is not clear and other conditions such as perforation and peritonitis are being considered.
Amylase of 450 international units is suggestive of acute pancreatitis
Amylase is often used to confirm the diagnosis of acute pancreatitis in conjunction with clinical symptoms and signs. However, the use of arbitrary values (eg >1000 or 3–4 times the upper limit of normal) are dependent upon the half-life of amylase. When available, plasma lipase has more accuracy than amylase. Lipase is produced by the pancreas alone and persists for longer than amylase. It is therefore more sensitive and specific in the diagnosis of acute pancreatitis.
Ultrasound scan
The pancreas is poorly visualised by ultrasonography but is useful to assess the aetiology (eg gallstones) or to detect other pathologies (eg abdominal aortic aneurysm). Normal serum amylase excludes acute pancreatitis
Amylase level gradually returns to normal over 3–4 days and delay in performing the test can lead to a false-negative result. A raised amylase can also occur in upper gastrointestinal (GI) perforation, mesenteric infarction, small bowel obstruction, tubo- ovarian disease, renal failure, or macroamylasaemia.
The modified Glasgow score
This is clinical severity and prognosis score, is not an investigation for acute pancreatitis.
A 55-year-old man with severe epigastric pain radiating through to the back presents with the following results:
Amylase (urine test): 500 IU, Total bilirubin: 50 mmol/l, Total bilirubin: 50 mmol/l, Alkaline phosphatase: 250 mmol/l, Aspartate transaminase: 50 mmol/l, Alanine transaminase: 95 mmol/l
Severity can be predicted with which one of the following?
1) APACHE I score
2) C-reactive protein
3) Glasgow Score
4) White-cell count
5) Serum amylase
Explanation
Glasgow Score
The Glasgow score can be used to predict severity and takes into consideration a number of parameters including; age, white-cell count, p (O ), serum glucose, calcium, albumin, LDH and urea. The British Society of Gastroenterology recommends that the Glasgow score be used to predict severity within 48 h following admission. It is only applicable when the presumed cause is either alcohol or gallstones. Computed tomography (CT) scan can also be used to assess prognosis by grading the extent of pancreatic necrosis (Balthazar score). Other CT features such as necrosis of the head of pancreas, mesenteric oedema and intraperitoneal fluid are also associated with a poorer outcome.
APACHE I score
The APACHE II score, not APACHE I, is a general severity of disease tool and mortality predictor used for the acutely unwell patient admitted to intensive care. It is not specific to pancreatitis. An APACHE II score > 8 could be used to be predictive of severe acute pancreatitis. It takes into consideration the physiological state of the patient, including oxygenation, haemodynamic stability, biochemical abnormalities, and neurological status.
C-reactive protein
C-reactive protein (CRP), an acute phase reactant, can be used in isolation as a predictor of severity. A CRP > 150 mg/l more than 48 h after the onset of symptoms is predictive of severe acute pancreatitis, however, there are more reliable indicators and scoring systems as CRP can be raised with any inflammatory process.
White-cell count
White-cell count is one of the parameters included in the Glasgow score, which can be used to predict severity, however in isolation it is not useful.
Serum amylase
Levels of serum amylase and lipase are not predictive of severity.
A 6-year-old boy is brought to the Accident and Emergency department with a 12-h history of vomiting, severe abdominal pain and being generally unwell. His parents say that he also had two episodes of convulsions during this period. On examination, he appears pale and dehydrated. The abdomen is rigid and tender, and his pain is worse over the right iliac fossa. His temperature is 40.2°C, blood pressure 82/64 mmHg, and pulse rate 172 beats/min. There is no discoloration over the anterior abdominal wall. Bowel sounds are absent.
From the options below choose the one that you think is the most likely pathological process in this child.
1) Necrotising enterocolitis
2) Uncomplicated acute appendicitis
3) Volvulus neonatorum
4) Meckel’s diverticulitis
5) Bacterial Peritonitis
Explanation
Bacterial Peritonitis
The signs and symptoms in this child are suggestive of spreading/established infection in the peritoneal cavity. Bacterial peritonitis in children may occur as a result of a ruptured viscus such as ruptured appendicitis or ruptured Meckel’s diverticulitis, or as a complication of abdominal surgery. The child may present with classical signs of peritonitis such as abdominal pain, pyrexia, nausea, vomiting, tachycardia, low blood pressure and decreased urine output. High pyrexia may result in febrile convulsions. Abdominal examination may reveal a board-like rigidity, guarding and rebound tenderness. Bowel sounds are absent if the peritonitis becomes established. Plain abdominal X-rays should be performed in both supine and upright positions to identify the presence of free gas beneath the diaphragm, which suggests perforation of a viscus. The common organisms responsible for bacterial peritonitis in children
include Escherichia coli, Klebsiella pneumoniae and Pseudomonas species.
Necrotising enterocolitis
This condition is primarily seen in premature neonates in which the bowel necroses and is a common cause of morbidity. As the child described in the case history is 6 years old, this answer is unlikely.
Uncomplicated acute appendicitis
Acute appendicitis would result in many of the signs and symptoms described in the case history, however, given the child is in extremis, it would suggest bacterial peritonitis. A ruptured appendix as a sequelae of appendicitis would cause bacterial peritonitis but this answer does not specify that the appendicitis has progressed to rupture.
Volvulus neonatorum This is a condition seen in newborns and would present in the neonatal period, therefore this child is too old to present with volvulus neonatorum. Additionally, the high grade fever, febrile convulsions and cardiac instability are suggestive of an extensive infective process which would not be seen with volvulus neonatorum.
Meckel’s diverticulitis
Merkel’s diverticulum is a congenital diverticulum most commonly found in the distal ileum, if bowel contents become trapped then diverticulitis can occur producing infective symptoms. As above however, only if there was perforation of a viscus would the severity of symptoms described in the case history be seen.
A 54-year-old man presents to the Accident and Emergency department with a 6 h history of gradual onset severe epigastric and central abdominal pain radiating through to his back. The pain reduces when he sits forward. He has also had three episodes of vomiting, mostly bilious.
He admits to drinking up to 40–50 units of alcohol per week. He has experienced similar episodes in the past but less severe. On examination, his pulse rate is 94 beats/min and respiratory rate is 18 breaths/min. Abdominal examination reveals that he is very tender over the epigastric region with moderate degree of guarding. Plain radiographs of the chest (erect) and abdomen (supine) are unremarkable.
From the options below choose the one that you think is the most likely diagnosis in this patient.
1) Intestinal obstruction
2) Mesenteric ischaemia
3) Acute pancreatitis
4) Perforated peptic ulcer
5) Ruptured abdominal aortic aneurysm
Explanation
Acute pancreatitis
The signs and symptoms in this patient are very suggestive of acute pancreatitis, with the most common causes being alcohol and gallstones. Pancreatitis is thought to result from early activation of pancreatic enzymes, producing auto-digestion of the pancreas and surrounding tissues. The severity of acute pancreatitis is validated using various prognostic scoring systems. Currently in the UK, the Glasgow–Imrie (modified Glasgow score) scoring system is widely used for assessing the severity, while the APACHE II is useful predicating the prognosis in acute pancreatitis. Serum C-reactive protein concentration, although not part of the Glasgow criteria, has an independent prognostic value if the peak level is >210 mg/litre in the first 4 days of the attack. Serum amylase is a useful indicator to diagnose acute pancreatitis; a diagnosis of acute pancreatitis is likely if the level is three times the upper limit of normal although this may vary between laboratories depending on the hospital policy/guidelines. An ultrasound of the abdomen is indicated in all patients with acute pancreatitis to determine the presence/absence of biliary calculi. A computed tomography (CT) scan of the abdomen should be performed on all patients with severe acute pancreatitis between the third and tenth days following the onset of symptoms to rule out pancreatic necrosis, in addition to use of the Balthazar score, which examines the radiographic features of acute pancreatitis.
Intestinal obstruction
Intestinal obstruction would more commonly present with generalised abdominal pain and distension, vomiting and absolute constipation. If intestinal obstruction was the causative pathology in this case history abnormalities would likely be seen on the abdominal X-ray, such as dilated loops of bowel.
Mesenteric ischaemia Intermittent, colicky, generalised abdominal pain, worse in the post prandial period, is the most common presentation of mesenteric ischaemia. A history of atrial fibrillation is a common co-morbidity. Furthermore, mesenteric ischaemia usually has a chronic, progressive history with the avoidance of food (due to pain) and weight loss.
Perforated peptic ulcer
This presentation could also be consistent with a perforated abdominal viscus. However, it is slightly less likely than pancreatitis in this scenario given that chest radiograph excluded free air. This patient has an unremarkable chest radiograph. It should be noted that air is not always seen under the diaphragm in hollow viscus rupture, but given that this patient has also had previous less severe episodes and drinks alcohol heavily, pancreatitis is more likely. It is also more likely given the gradual onset – patients with a perforated viscus often describe sudden onset abdominal pain. Guarding itself may indicate peritoneal irritation.
Ruptured abdominal aortic aneurysm
A ruptured abdominal aortic aneurysm is likely to result in a haemodynamically unstable patient due to circulatory collapse. Given that neither the patient’s heart rate or respiratory rate are raised, this diagnosis is less likely. Furthermore, the history is often of sudden onset pain, not of a gradual course over 6 h.
A 47-year-old barmaid presents to the Accident and Emergency department with a 12 h history of right upper quadrant pain and vomiting. She says that the pain is radiating to her right scapula and is exacerbated by breathing. She appears pale but not jaundiced. On examination, her pulse rate is 98 beats/min, blood pressure is 126/84 mmHg and temperature is 37.6°C. Abdominal examination reveals tenderness over the right hypochondrium but no mass is palpable. Plain radiographs of the abdomen (supine) and chest (erect) are unremarkable.
From the options below choose the one that you think is the most likely diagnosis in this patient.
1) Perforated peptic ulcer
2) Acute pancreatitis
3) Acute biliary cholangitis
4) Acute cholecystitis
5) Infective hepatitis
Explanation
Acute cholecystitis
The history, signs and symptoms in this patient are suggestive of acute cholecystitis. Acute cholecystitis is more common in women over the age of 40 and with high body mass index (BMI). Gallstones are the commonest cause for acute cholecystitis. Obstruction of the common bile duct due to stones leads to accumulation of bile and inflammation, resulting in an acutely inflamed gall bladder. Other risk factors for acute cholecystitis include alcohol abuse and tumours of the gall bladder. The signs and symptoms of acute cholecystitis include: severe right hypochondrial pain exacerbated by respiration, nausea and vomiting, and increase in temperature. The rise in temperature is frequently mild to moderate; a very high temperature with or without chills and rigours may point to a diagnosis of acute cholangitis. A tender, inflamed gall bladder may be palpable in some patients. Likewise, jaundice may or may not be present.
Perforated peptic ulcer
A perforated abdominal viscus would be likely to be identified on an erect chest radiograph with the presence of free air under the diaphragm, and cause more centralised pain. This patient has an unremarkable chest radiograph.
Acute pancreatitis
Pancreatitis more commonly presents with epigastric pain radiating through to the back.
Acute biliary cholangitis
Ascending infection of the biliary tree and ducts requires urgent treatment, but it generally presents with high grade fever, rigours and jaundice. Charcot’s triad of jaundice, fever (often with rigours) and right upper quadrant pain is often used to diagnose cholangitis.
Infective hepatitis Hepatitis broadly refers to the inflammation of the liver, and infective causes most commonly include the hepatitis viruses (A, B, C, D, E). Infective hepatitis is not often an acute presentation as described in the case history.
A 51-year-old woman presents to the Surgical Emergency Assessment Unit with a 12 h history of central colicky abdominal pain and vomiting. She has undergone a subtotal colectomy and formation of an end ileostomy for ulcerative colitis 7 years ago. Her ileostomy has not functioned for 2 days. On examination, she is tender over the upper abdomen and the abdomen is mildly distended. Plain abdominal radiograph reveals a number of small loops in the centre of the abdomen.
From the options below choose the one that you think is the most likely diagnosis in this patient.
1) Acute colonic pseudo-obstruction
2) Incarcerated incisional hernia
3) Bacterial peritonitis
4) Adhesional small bowel obstruction
5) Sigmoid volvulus
Explanation
Adhesional small bowel obstruction
The cardinal features of small bowel obstruction are pain, vomiting and abdominal distension; untreated, this leads to constipation with reduction in flatus which then becomes absolute. The pain is usually colicky due to excessive peristalsis, but may become continuous if strangulation or perforation occurs. Vomiting is early in high small bowel obstruction, late in low small bowel obstruction and delayed or absent in large bowel obstruction. The management involves appropriate resuscitation of the patient and surgical exploration of the abdomen to relieve the obstruction. Small bowel obstructions make up the majority of intestinal obstructions. Of these, adhesions following laparotomy and/or surgery to the bowel is the leading cause of small bowel obstruction. It can occur as a sequelae of ‘minor’ abdominal surgeries such as appendicectomies or ‘major’ surgeries such as resection of large sections of the bowel. In women, gynaecological procedures are an important cause. In addition, pelvic inflammatory disease can also lead to adhesions even in the absence of a surgical intervention in the abdomen.
Acute colonic pseudo-obstruction
This is obstruction and massive dilation of the colon in the absence of a mechanical blockage. As this patient has undergone a subtotal colectomy, this is not a possibility.
Incarcerated incisional hernia
Obstruction in a patient with known hernia can occur when a section of bowel becomes incarcerated within a hernial orifice. Abdominal examination would reveal localised tenderness over the incisional hernia, and there is not suggestion of a hernia in the case history.
Bacterial peritonitis
Bacterial peritonitis can occur as a result of a perforated abdominal viscus with infection of the peritoneal cavity. The patient may present with classical signs of peritonitis such as abdominal pain, pyrexia, nausea, vomiting, tachycardia, low blood pressure and decreased urine output. Abdominal examination may reveal a board-like rigidity, guarding and rebound tenderness.
Sigmoid volvulus This patient has previously undergone a subtotal colectomy with formation of an end ileostomy in which the sigmoid colon would have been resected.
A 75-year-old woman is admitted with small bowel obstruction and
pain radiating down the medial aspect of the right thigh to the knee. There is no palpable abnormality in the groin but the inner aspect of the groin is tender.
Which one of the following is the most likely diagnosis?
1) Femoral hernia
2) Gluteal hernia
3) Lumbar hernia
4) Obturator hernia
5) Sciatic hernia
Explanation
Obturator hernia
An obturator hernia is six times more common in women and twice as common on the right side. It particularly affects elderly women who have had recent rapid weight loss. The hernial sac protrudes through the obturator canal potentially compressing the geniculate branch of the obturator nerve causing referred pain.
Femoral hernia
Strangulated femoral hernias are generally palpable within the groin, lateral and inferior to the pubic tubercle.
Gluteal hernia
Gluteal hernias are very rare and are suggested by the presence of a painful swelling in the buttock or pain.
Lumbar hernia
Lumbar hernias are associated with paralysed muscles especially by poliomyelitis or spina bifida.
Sciatic hernia
Again, sciatic hernias are very rare but would be suggested by pain in the distribution of the sciatic nerve.
As a CT2 surgical trainee you are asked to perform a tracheostomy on a 52-year-old man currently on the Intensive Care Unit (ITU). The supervising consultant asks you where on the trachea would you normally perform the tracheostomy.
Selecting from the following, how would you answer?
1) Cricoid cartilage
2) Crycothyroid membrane
3) First tracheal cartilage
4) Second tracheal cartilage
5) Thyroid isthmus
In a typical surgical tracheostomy, the preferred site is usually between the second and third tracheal cartilages. Based on the given options, the most appropriate answer would be:
4) Second tracheal cartilage
Explanation:
• Cricoid cartilage (1): A tracheostomy is not performed at this level because it is part of the larynx and performing the procedure here can damage the larynx. • Cricothyroid membrane (2): This is the site for an emergency cricothyrotomy, not a tracheostomy. A cricothyrotomy is usually performed in acute situations where airway access is needed immediately. • First tracheal cartilage (3): This is too high and close to the cricoid cartilage, posing a risk of laryngeal damage. • Second tracheal cartilage (4): This is the most common site for a surgical tracheostomy, as it allows for secure placement of the tracheostomy tube while minimizing risks to the laryngeal structures. • Thyroid isthmus (5): The thyroid isthmus often lies over the second and third tracheal rings, and while the tracheostomy may involve moving or dividing the isthmus, the actual tracheal opening is made in the second or third tracheal cartilage.
Conclusion:
The most appropriate site for performing a tracheostomy is at the level of the second tracheal cartilage.
A 56-year-old woman with known metastatic breast cancer presents to the Emergency Department with a calcium concentration of 3.22 mmol/l (normal corrected Ca2+ 2.20– 2.60 mmol/l).
Which one of the following is the most appropriate initial management?
1) Intravenous hydrocortisone
2) Intravenous infusion of 0.9% sodium chloride
3) Intravenous infusion of sodium phosphate
4) Oral bisphosphonate
5) Oral thiazide diuretic
Explanation
Intravenous infusion of 0.9% sodium chloride
The priority in symptomatic hypercalcaemia is to rehydrate the patient and establish diuresis; 0.9% sodium chloride is the fluid of choice, and patients often require around 4–6 litres over a 24 h period.
Intravenous hydrocortisone
Corticosteroids may occasionally be helpful but are not first-line treatment. Intravenous infusion of sodium phosphate
Sodium phosphate infusion is dangerous: it lowers the calcium concentration rapidly, but risks causing metastatic calcification.
Oral bisphosphonate
Bisphosphonates are effective, but must be given intravenously to have a rapid effect. Oral thiazide diuretic
Diuretics are only helpful for management of fluid overload in patients receiving rehydration therapy, and so copious volumes of intravenous fluids. However, they are not useful for reducing serum calcium levels. Loop diuretics would be the diuretic of choice, not thiazide diuretics.
A 71-year-old man is taken to theatre as an emergency following perforation of his colon resulting in generalised peritonitis. A subtotal colectomy and end ileostomy is performed.
What is the most common cause of peritonitis?
1) Acute appendicitis
2) Acute cholecystitis
3) Perforated peptic ulcer
4) Post-operative complications
5) Secondary to an initial infection Explanation
Explanation
Post-operative complications
The most common cause of peritonitis is post-operative complications, accounting for approximately 30% of cases. Peritonitis is inflammation of the peritoneum that may be localised (peritonism) or generalised. It is classified according to the causative agent, examples including bacterial, chemical or biliary.
Acute appendicitis
Acute appendicitis accounts for around 20% of cases.
Acute cholecystitis
Acute cholecystitis rarely leads to biliary peritonitis because the inflamed gall-bladder rarely becomes gangrenous or perforates.
Perforated peptic ulcer
Perforated peptic ulcers account for around 20% of cases of peritonitis. Secondary to an initial infection
If an infection is severe causing a bacteraemia then peritonitis can occur as a consequence of the initial infection, however this is uncommon.
An 81-year-old woman is admitted with bowel obstruction, pain and dehydration. An abdominal radiograph is performed by the admitting doctor with features suggesting volvulus of the large bowel.
What is the commonest form of volvulus in the elderly?
1) Caecal
2) Sigmoid
3) Small bowel
4) Stomach
5) Transverse colon
Explanation
Sigmoid
Volvulus occurs when a segment of bowel twists on its mesentery. Sigmoid volvulus is the commonest form of volvulus in the elderly and occurs in an anticlockwise direction. It is seen in approximately 5% of cases of large bowel obstruction in developed countries. The characteristic radiological appearance is known as a ‘coffee bean’ which arises from the left iliac fossa. The volvulus may be resolved by passing a flatus tube and, if unsuccessful, more aggressive surgical management.
Caecal
Caecal volvulus is less common than volvulus of the sigmoid colon.
Small bowel
A small bowel volvulus is rare; more commonly obstruction of the small bowel is due to adhesions from previous surgery.
Stomach
Gastric volvulus is uncommon and can occur at any age but a higher incidence is seen in the elderly.
Transverse colon
Again, this is an uncommon form of volvulus.
A 55-year-old obese man with known diabetes is admitted to an acute medical ward with cellulitis of the lower limb. Over the next few hours he becomes unwell and complains of increased pain. His cellulitis spreads, he becomes
haemodynamically unstable and he requires inotropic support to maintain his blood pressure (BP). You do an arterial blood gas.
Which one of the following would you most expect to find?
1) Metabolic acidosis
2) Metabolic alkalosis
3) Mixed metabolic alkalosis with respiratory compromise
4) Respiratory acidosis
5) Respiratory alkalosis
Explanation
Metabolic acidosis
Metabolic acidosis can be due to impaired hydrogen excretion, increased hydrogen ion production or ingestion, or loss of bicarbonate. In this patient, the rapidly spreading cellulitis coupled with significant cardiovascular compromise could indicate necrotising fasciitis and should be suspected. The acidosis is likely due to a diabetic ketoacidosis; diabetes is also a risk factor for necrotising fasciitis. Other causes of metabolic acidosis include renal disease, lactic acidosis, salicylate poisoning and chronic diarrhoea and intestinal fistulas.
Metabolic alkalosis
Given the severe infection and diabetes a metabolic acidosis, not alkalosis, is likely. Mixed metabolic alkalosis with respiratory compromise
Metabolic alkalosis with respiratory compensation would be unlikely. Respiratory compensation would be through hypoventilation, and given this patient is haemodynamically unstable and septic it is likely he would be tachypneic. Additionally, sepsis causes a metabolic acidosis due to anaerobic respiration.
Respiratory acidosis
A respiratory acidosis would occur in the presence of hypoventilation. This patient is likely to have a high respiratory rate due to sepsis.
Respiratory alkalosis
This occurs during hyperventilation as more carbon dioxide is ‘blown off’ causing a reduction in hydrogen ions. Carbonic anhydrase in erythrocytes facilitates a reaction between carbon dioxide and water that results in hydrogen ions. As such, a reduction in carbon dioxide, through hyperventilation, will reduce the number of hydrogen ions and so acidity. The primary issues for this patient however is a metabolic acidosis due to sepsis.
A patient awaiting surgery for a parathyroid adenoma is admitted with confusion and drowsiness. The diagnosis of hypercalcaemic crisis is made.
What should be the initial treatment?
1) Intravenous magnesium
2) Intravenous fluids
3) Steroids
4) Calcitonin
5) Intravenous phosphate
Explanation
Intravenous fluids
Hypercalcaemic crisis occurs when a patient with mild hypercalcaemia has a rapid rise in plasma calcium. This is associated with rapid deterioration in the patient’s condition, in the form of confusion, drowsiness, vomiting and dehydration. The first-line treatment of hypercalcaemia is intravenous fluid replacement with 0.9% saline. Crises may be precipitated by intercurrent illness, operation or infection.
Intravenous magnesium
This has no role in the treatment of a hypercalcaemic crisis.
Steroids
Hypercalcaemic crises due to hyperparathyroidism do not respond to treatment with steroids. Even in hypercalcaemia of different aetiologies, corticosteroids are considered second-line treatment.
Calcitonin
The condition may be controlled pre-operatively by the careful use of calcitonin or mithramycin but these would not be initial treatment.
Intravenous phosphate
Sodium phosphate infusion is dangerous; it lowers the calcium concentration rapidly, but risks causing metastatic calcification.
A patient is admitted with diverticulitis. On assessment they are found to have a high fever, are tachycardic and have localised peritonism in the left iliac fossa.
Which one of the following statements fulfils the criteria for the correct definition of sepsis?
1) The presence of bacteria in the bloodstream
2) The presence of micro-organisms within a normally sterile viscus
3) Hypotension refractory to resuscitation in the presence of demonstrable infection
4) Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection.
5) Low blood pressure, signs of fluid overload and the presence of a proven source of infection.
Explanation
Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection.
Sepsis is a life-threatening condition associated with significant morbidity and mortality, yet with early recognition and management these can be improved greatly. As such, in recent years there has been a concerted effort to improve the recognition and management of sepsis which includes increasing public awareness and producing a clear definition of sepsis. Recent National Institute of Clinical Excellence (NICE) Guidance was released in 2016 in response to a UK Parliamentary inquiry examining sepsis. The ‘Time to Act’ report found failures in the recognition, diagnosis, and early management of those who died from sepsis. Part of this guidance was clarifying the definition of sepsis as previously there was a confusing mix of terminology being used to describe the disease process, including; septicaemia, sepsis, septic shock and systemic inflammatory response syndrome (SIRS). Efforts are now being made to improve the recognition, diagnosis and management of sepsis throughout the UK.
The presence of bacteria in the bloodstream
This simply describes a bacteraemia that may or may not be related to sepsis depending if there is organ dysfunction or a dysregulated host response to infection.
The presence of micro-organisms within a normally sterile viscus
Sepsis is a systemic dysregulated response to infection and is not limited to a viscus. Hypotension refractory to resuscitation in the presence of demonstrable infection
In the past this would have been referred to as septic shock. A universal definition of sepsis is now in use and terminology such as septic shock should be avoided and replaced simply with sepsis.
Low blood pressure, signs of fluid overload and the presence of a proven source of infection. This is not the universally agreed definition of sepsis.
A 69-year-old immunosuppressed man presents to the medical ward with cellulitis of the leg. Over the next 24 h he becomes systemically unwell. He is anuric and develops acute renal failure. His systolic blood pressure does not respond to fluids and he requires noradrenaline support. He has radiological signs of acute respiratory distress syndrome (ARDS) on his chest X-ray.
Which one of the following is true of multi-organ dysfunction syndrome?
1) Jaundice is usually due to gallstones
2) Mortality rates are low
3) Sepsis is a well recognised cause
4) There is a decreasing alveolar–arterial oxygen gradient
5) There is increased lung compliance
Explanation
Sepsis is a well recognised cause
There are several causes of multi-organ dysfunction syndrome, however infections (resulting in sepsis) and injuries (either trauma or surgery) are the most common causes. If sepsis is left untreated, or unrecognised, then this can progress to septic shock and multi-organ dysfunction syndrome.
Jaundice is usually due to gallstones
Intrahepatic cholestasis and hepatocyte necrosis is the usual cause of jaundice in these patients.
Mortality rates are low
Multi-organ dysfunction syndrome unsurprisingly is associated with a high mortality rate, approximately 30–100%.
There is a decreasing alveolar–arterial oxygen gradient
A decreasing alveolar–arterial (A–a) gradient implies there is a reduced diffusion barrier to Ocrossing from the alveolus to 2 blood and would enhance gas transfer. In ARDS the A–a gradient increases due to alveolar–capillary membrane thickening caused by endothelial leakage and accumulation of interstitial fluid.
There is increased lung compliance
Increased lung compliance means the lung is more distensible so that a smaller fall of intrapleural pressure would be required for a given tidal volume during inspiration and respiratory work would decrease (in emphysema this is a problem as expiratory recoil is reduced). In ARDS lung compliance is reduced. In multiple organ dysfunction syndrome there is an uncontrolled inflammatory response and mal-distribution of blood flow, as a result of microembolic phenomenon, excessive release of various vasoactive compounds (vasoconstrictors, vasodilators and those that increase capillary permeability) which leads to interstitial oedema and a mismatch between supply and demand for oxygen within the microcirculation. Other hypotheses include inappropriate and uncontrolled release of cytotoxic mediators from bacteria.
A 40-year-old woman with acute onset abdominal pain and fever is found to be tachycardic and hypotensive with localised guarding and tenderness in the epigastric region. Despite initiating therapy for her pancreatitis, she develops refractory hypoxaemia secondary to acute respiratory distress syndrome (ARDS).
Which one of the following is the most appropriate initial management considering her current clinical state?
1) Close monitoring within a level 1 care facility
2) Computed tomography (CT) scan
3) Dopamine therapy to support renal function
4) Early endoscopic retrograde cholangiopancreatography (ERCP)
5) Initiate nursing in a prone position
Explanation
Initiate nursing in a prone position
Nursing in a prone or seated position has been shown to improve refractory
hypoxaemia caused by ARDS.
Close monitoring within a level 1 care facility
Patients should be managed in a level 2 or level 3 facility, which refers to an acute district hospital (level 2) or level 3 which is a tertiary referral centre (usually a teaching hospital). A level 1 care facility refers to a community hospital.
Computed tomography (CT) scan
This patient is critically unwell and a CT scan is unlikely to change current management; she primary requires treatment for ARDS and pancreatitis. Furthermore, transfer to the radiology department carries inherent risk for limited benefit.
Dopamine therapy to support renal function
Dopamine is not recommended as it has been shown to cause arrhythmias, so should be avoided.
Early endoscopic retrograde cholangiopancreatography (ERCP)
This patient is critically unwell and in their current condition ERCP is extremely risky. Early ERCP is only recommended for patients with co-existing cholangitis or biliary obstruction.
A 19-year-old girl is admitted to the Emergency Department with a severe anaphylaxisreaction following a bee sting. She becomes severely hypotensive and her airway may be threatened.
Which one of the following management options would you be most appropriate?
1) Intramuscular adrenaline
2) Nebulised bronchocdilators
3) Beta blockers
4) Intravenous nitrates
5) Intravenous morphine
Explanation
Intramuscular adrenaline
The principles of management of severe anaphylactic shock include: airway maintenance and oxygen; intravenous fluids to provide circulatory support; and subcutaneous or intramuscular adrenaline (adrenaline). The dose for an adult is 0.5 mg adrenaline, repeated after 5 min as required. Subsequent treatment is with an anti- histamine (chlorphenamine 4 mg) and corticosteroid (hydrocortisone 100 mg), however, adrenaline should be given first as this is the life-saving treatment.
Nebulised bronchocdilators
Nebulised bronchodilators can help counteract the bronchospasm, however, intramuscular adrenaline is the primary treatment.
Beta blockers
Beta blockers are contraindicated as they lower blood pressure and may cause bronchoconstriction, so have no role in the treatment of anaphylaxis.
Intravenous nitrates
Intravenous nitrates cause vasodilation and have no role in the treatment of anaphylaxis.
Intravenous morphine
Intravenous is primarily reserved for severe pain management, therefore would not be indicated in the treatment of anaphylaxis.
A 25-year-old woman exhibiting features of septic shock is brought to your
attention. She has been admitted with acute appendicitis, unfortunately there has been a delay with CEPOD and she has deteriorated.
Which one of the following is correct?
1) Tissue uptake of oxygen by cells is normal
2) Peripheral vasoconstriction is seen
3) Blood cultures are commonly positive
4) Endotoxins act as a negative inotrope
5) Gram-negative organisms are the most common cause
Explanation
Endotoxins act as a negative inotrope
Endotoxins act as a negative inotrope and can initiate both ARDS and disseminated intravascular coagulation (DIC).
Tissue uptake of oxygen by cells is normal
Tissue uptake of oxygen by cells is reduced, contributing to the metabolic acidosis of sepsis due to anaerobic respiration and so increased lactic acid production.
Peripheral vasoconstriction is seen
Peripheral vasodilation is seen throughout the systemic circulation causing reduced tissue perfusion and organ dysfunction if not treated.
Blood cultures are commonly positive
Blood cultures are rarely positive, however, if the causative bacteria is grown from blood cultures then this significantly aids treatment as targeted antimicrobial therapy is possible.
Gram-negative organisms are the most common cause
Septicaemic shock is most commonly due to Gram-positive organisms. While Gram- negative bacteria were previously considered the most common cause of septic shock, recent epidemiological studies revealed approximately 200 000 cases of Gram-positive sepsis annually, compared with 150 000 cases of Gram-negative sepsis in recent years.
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348:1546–54.
A 68-year-old woman is admitted to the Intensive Care Unit (ITU) having sustained 40% burns in a house fire. Over the next 3 days she develops increasing respiratory needs , wheeze and reduced pa (O2 ) level . You suspect she has developed ARDS.
Which one of the following statements regarding ARDS is correct?
1) It has an increased pa (O2 ) (in mmHg) to FI O 2 ratio
2) It has < 20% mortality in established cases
3) It is caused due to collapse of the alveoli
4) It is characterised by decreased lung compliance
5) It usually develops in the first 24 h after injury
Explanation
It is characterised by decreased lung compliance. Pulmonary fibrosis in the later stages of the disease leads to a decrease in the functional residual capacity, further decrease in lung compliance, and an increase in the shunt effect. It has an increased pa (O2 ) (in mmHg) to FI O 2 ratio. ARDS is characterised by refractory hypoxemia (pa (O2 ) < 8 kPa at FI O 2 > 0.4), alveolar
inflammation and oedema, reduced total compliance (< 30 ml/cmH2 O) and a pa (O2 ) (in mmHg) to FI O 2 ratio of < 200 (normal is approximately 500). It has < 20% mortality in established cases. The mortality of this condition is as high as 50–70%.
It is caused due to collapse of the alveoli. Indirect or direct lung injury initiates abnormal behaviour and movement of neutrophils, platelets and macrophages. Neutrophils and platelets attach to capillary endothelium causing capillary leak. This leads to oedema of lung tissue and movement of neutrophils and erythrocytes into the lung parenchyma. Lung lymph flow is increased and there is thickening of the alveolar–capillary membrane. This results in impaired oxygen diffusion and reduced lung compliance as the alveolus is surrounded by fluid. In addition, some of the fluid in the pulmonary parenchyma may leak into the alveoli, giving the characteristic appearance of a hyaline membrane.
It usually develops in the first 24 h after injury. ARDS can present as soon as 2 h following injury. ARDS is an acute, diffuse inflammatory process resulting from direct or indirect pulmonary injury. It is most commonly seen in sepsis but can also occur after trauma, burns, inhalation injuries, shock and pancreatitis. In post-operative surgical patients, abdominal sepsis or central- line sepsis should be considered. Pulmonary signs are often minimal or non-specific, the patient simply being breathless, progressively tachypneic, hypoxic and then cyanotic.
Chest X-ray may be normal in the early stages but later shows bilateral diffuse pulmonary infiltration. Treatment, in addition to eliminating the precipitating cause, involves ventilating the patient in an Intensive Care Unit. Patients are usually nursed in
the prone position. The tidal volume should be kept low (approximately 6 ml/kg) and so should the pulmonary capillary wedge pressure (high pressures exacerbate pulmonary oedema).
You are treating a patient who underwent emergency laparotomy for faecal peritonitis 2 days ago. The patient is tachycardic and hypotensive and has developed acute respiratory distress syndrome (ARDS). What is the most likely cause of this?
1) Abdominal sepsis
2) Fat embolism
3) Pancreatitis
4) Pulmonary fibrosis
5) Trauma
Explanation
Abdominal sepsis
ARDS is an acute diffuse inflammatory process resulting from direct or indirect
pulmonary injury. It is most commonly seen in sepsis but can also occur after trauma,
burns, inhalation injuries, shock and pancreatitis. In post-operative surgical patients,
abdominal sepsis or central-line sepsis should be considered. Pulmonary signs are often
minimal or non-specific in the early stages, the patient simply being breathless, but, if
untreated, they could soon become hypoxic and cyanotic. Chest X-ray may be normal in
the early stages but later shows bilateral diffuse pulmonary infiltration. The mortality of
this condition is as high as 50–70%.
Fat embolism
Fat embolism is a recognised complication of long bone fractures which are associated
with major trauma. As described above, major trauma can cause ARDS, however, given
this patient has been treated for peritonitis, abdominal sepsis is the most likely cause.
Pancreatitis
Pancreatitis is a recognised cause of ARDS, however abdominal sepsis is more likely
given the case history.
Pulmonary fibrosis
Pulmonary fibrosis occurs as a result of ARDS. Fibrosis in the later stages of the disease
leads to a decrease in the functional residual capacity, further decrease in lung
compliance and an increase in the shunt effect.
Trauma
As mentioned, major trauma is a recognised cause of ARDS, however, abdominal sepsis
is the likely cause in this patient. ARDS is characterised by refractory hypoxaemia
(pa (O2 ) < 8 kPa at Fi O2 > 0.4), alveolar inflammation and oedema, reduced total
compliance (< 30 ml/cm water) and a pa (O2 ) (in mm Hg):Fi O 2 ratio of < 200 (normal is
approximately 500). Indirect or direct lung injury initiates abnormal behaviour and
movement of neutrophils, platelets and macrophages. Neutrophils and platelets attach
to capillary endothelium causing capillary leakage. This leads to oedema of lung tissue
and movement of neutrophils and erythrocytes into the lung parenchyma. Lung lymph
flow is increased with thickening of the alveolar–capillary membrane. This results in
impaired oxygen diffusion and reduced lung compliance as the alveolus is surrounded
by fluid. In addition, some of the fluid in the pulmonary parenchyma may leak into the alveoli, giving the characteristic appearance of a hyaline membrane. Treatment, in
addition to eliminating the precipitating aetiology, involves ventilating the patient in
intensive care. Patients are usually nursed in the prone position. The tidal volume
should be kept low (approximately 6 ml/kg), as should the pulmonary capillary wedge
pressure (high exacerbates pulmonary oedema).
You review a patient who underwent emergency laparotomy for abdominal sepsis 36 h
ago. The patient clearly has acute respiratory distress syndrome (ARDS).
Which one of the following would you expect in ARDS?
1) Focal infiltration on chest X-ray
2) Leakage of protein rich oedema fluid into the lung tissue
3) Only late occurrence of tachypnoea and tachycardia
4) Steroids promote recovery in the late phase
5) Thinning of the alveolar membrane
Explanation
Leakage of protein rich oedema fluid into the lung tissue
The underlying pathological process is leakage of cells and fluid through the capillary
walls of the alveoli. The alveolar membrane thickens and ultimately fibroses.
Focal infiltration on chest X-ray
Typically the chest X-ray shows diffuse infiltration.
Only late occurrence of tachypnoea and tachycardia
In the early stages, tachycardia and tachypnoea may be the only features. Later there is
cyanosis and worsening dyspnoea.
Steroids promote recovery in the late phase
Steroids have been used in the treatment of ARDS but there is no good evidence to
support their use. The cornerstones of treatment are support of the circulation,
respiratory support by ventilation and the use of appropriate antibiotics.
Thinning of the alveolar membrane
As mentioned thickening of the alveolar membrane occurs, and in the later stages of the
disease, fibrosis occurs.
Acute respiratory distress syndrome (ARDS) is a well recognised complication of sepsis,
trauma and other pulmonary insults, both direct and indirect. The commonest clinical
signs are tachypnoea, tachycardia, cyanosis and high-pitched coarse crepitations on
auscultation. The alveolar membrane becomes thickened. Differential diagnoses include
left ventricular failure, bronchitis, pneumonia and asthma.
Systemic Inflammatory Response Syndrome (SIRS) is an uncontrolled immune reaction, and can be classified by aetiology as either infectious or non-infectious SIRS has a
defined criteria for diagnosis. Recognition is essential as early intervention is more likely to prevent severe morbidity and mortality associated with pathologies such as sepsis.
Which one of the following would meet the requirements for SIRS?
1) Temperature of 37.5°C, a leucocyte count of 11 000/mm 3 , heart rate 150 beats/min
2) Temperature of 38°C, a leucocyte count of 5x10 9 /l, respiratory rate 15 breaths/min
3) Temperature of 35.5°C, a leucocyte count of 8x10 9 /l, pa (CO2 ) 50 mmHg
4) Temperature of 38.0°C, a leucocyte count of 2x10 9 /l, respiratory rate 30 breaths/min
5) Temperature of 37.5°C, a leucocyte count of 11x10 9 /l, heart rate 100 beats/min
Temperature of 38.0°C, a leucocyte count of 2x10 9 /l, respiratory rate 30 breaths/min
Pyrexia, leucopenia and tachypnoea are all consistent with SIRS. A patient is said to have SIRS if they satisfy two or more of the following criteria:
*temperature > 38°C or < 36°C
*heart rate > 90 beats/min
*respiratory rate > 20/min (or pa (CO2 ) < 32 mmHg)
*leucocyte count > 12 000/mm 3 or < 4000/mm 3 [or > 10% immature (band) cells].
*Temperature of 37.5°C, a leucocyte count of 11 000/mm 3 , heart rate 150 beats/min
This patient is normothermic, has a leucocyte count in the higher range of normal, and a significant tachycardia, as such they do not fit the criteria for SIRS.
Temperature of 38°C, a leucocyte count of 5x10 9 /l, respiratory rate 15 breaths/min
These parameters do not fill the criteria for SIRS.
Temperature of 35.5°C, a leucocyte count of 8x10 9 /l, pa (CO2 ) 50 mmHg
The low temperature fulfils the criteria, however, the leucocyte count is within the normal range (leucocyte count: 4–11 × 10 9 /l), and the pa (CO2 ) is satisfactory.
Temperature of 37.5°C, a leucocyte count of 11x10 9 /l, heart rate 100 beats/min Only the tachycardia would satisfy the SIRS criteria.
15-year-old post-splenectomy patient is admitted to hospital with sepsis. Since becoming a teenager she has been inconsistent in taking her prophylactic antibiotics.
Which one of the following is a sign indicative of septic shock ?
1) Confirmed or suspected infection
2) Core temperature < 36°C or > 38.3°C
3) Heart rate higher than 90 beats per min
4) Respiratory rate higher than 20 breaths per min
5) Urine output < 0.5ml/kg/h for more than 2 h
Explanation
Urine output < 0.5ml/kg/h for more than 2 h
Decreased urine output is an indicator of reduced renal perfusion, which can be used as a surrogate marker for reduced generalised tissue perfusion. This is therefore maybe a sign of septic shock as it represents renal dysfunction which occurs in severe circulatory abnormalities or circulatory collapse. Post-splenectomy sepsis can present 20 years after splenectomy and carries a high mortality. It is prevented by penicillin prophylaxis.
The micro-organisms most likely to lead to infection include pneumococcus and meningococcus species and H. influenzae. Other infections include those due to Escherichia coli and Plasmodium (malaria). The Surviving Sepsis Campaign has published international guidelines on the recognition and management of severe sepsis in an attempt to decrease the high mortality rates. Although NICE guidance lists ‘red- flags’ for sepsis (see below), the National Early Warning System (NEWS) introduced by the Royal College of Physicians is an alternative.
Red-flags for sepsis according to NICE Guidelines:
*systolic blood pressure <90 mmHg (or >40 mmHg fall from baseline)
*heart rate >130 beats per min
*oxygen saturations <91%
*respiratory rate >25 breaths per min
*responds only to voice or pain/unresponsive
*lactate >2.0 mmol.
Confirmed or suspected infection
A patient can have an ongoing infection but may not have sepsis which is defined as ‘life-threatening organ dysfunction due to a dysregulated host response to infection’.
Core temperature < 36°C or > 38.3°C
Although temperature is commonly used as an indicator of infection, it is not a helpful indicator of either severe sepsis or septic shock. Septic shock is defined as ‘a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality’ – The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). It indicates a patient who is septic with refractory hypotension when given an intravenous fluid challenge/bolus.
While sepsis is referred to as life-threatening organ dysfunction due to a dysregulated host response to infection, so a patient may have an infection causing pyrexia but may not have sepsis.
Heart rate higher than 90 beats per min
Heart rate can be used as a ‘red-flag’ sign for sepsis according to NICE guidance, however, it suggests a tachycardia above 130 beats per min.
Respiratory rate higher than 20 breaths per min
Again, NICE guidance suggests a ‘red-flag’ sign for sepsis is a respiratory rate above 25 breaths per min.
A 76-year-old patient is admitted to the acute admission unit with septic shock. Pulse is 106 beats per minute and blood pressure 90/40 mmHg. Urinary catheterisation produces 75 ml of concentrated urine (normal 800–2000 ml in 24 h).
Which one of the following principles applies to the choice of an appropriate intravenous fluid for resuscitation?
1) Certain intravenous solutions, which would be hypo-osmolar, have dextrose added to ensure they are iso-osmolar
2) Hartmann’s solution contains sodium, potassium, chloride, calcium and bicarbonate
3) An advantage of crystalloid solutions is that relatively small volumes have to be infused to restore an intravascular volume deficit
4) The normal colloid oncotic pressure is 70 mmHg
5) Albumin is indicated
The most appropriate principle regarding the choice of intravenous fluid for resuscitation in a patient with septic shock is:
1) Certain intravenous solutions, which would be hypo-osmolar, have dextrose added to ensure they are iso-osmolar
Explanation:
In the context of intravenous fluid resuscitation for septic shock, the principles involve understanding the properties and functions of different types of fluids. Here’s a breakdown of the options:
1. Certain intravenous solutions, which would be hypo-osmolar, have dextrose added to ensure they are iso-osmolar: This is correct. Solutions like 5% dextrose are isotonic and provide free water once dextrose is metabolized, helping to ensure fluids remain iso-osmolar to avoid causing cellular dehydration or overhydration. 2. Hartmann’s solution contains sodium, potassium, chloride, calcium, and bicarbonate: This is incorrect. Hartmann’s solution (or Ringer’s lactate) contains sodium, potassium, chloride, calcium, and lactate (which is metabolized to bicarbonate), but not bicarbonate directly. 3. An advantage of crystalloid solutions is that relatively small volumes have to be infused to restore an intravascular volume deficit: This is incorrect. Crystalloids generally require larger volumes compared to colloids to achieve the same intravascular volume expansion due to their distribution across the extracellular space. 4. The normal colloid oncotic pressure is 70 mmHg: This is incorrect. Normal colloid oncotic pressure (oncotic pressure) is around 25-30 mmHg, not 70 mmHg. 5. Albumin is indicated: This is incorrect as a blanket statement. Albumin is a colloid and can be used in specific situations, but it is not the first-line treatment for fluid resuscitation in septic shock due to its cost and lack of evidence showing superiority over crystalloids.
Correct Answer: 1) Certain intravenous solutions, which would be hypo-osmolar, have dextrose added to ensure they are iso-osmolar
You are treating a 48-year-old man with acute severe pancreatitis. He has been in hospital for 48 h and you are assessing his modified Glasgow score. His modified Glasgow score is 5.
What is his mortality risk?
1) 2%
2) 15%
3) 30%
4) 40%
5) 100%
Explanation
40%
The mortality risk for a patient scoring 5 on the modified Glasgow score is 40%. The following criteria are used to calculate the score.
2%
This would represent the mortality risk for a patient with a modified Glasgow score of
0–2.
15%
This would represent the mortality risk for a patient with a modified Glasgow score of
3–4.
30%
The mortality risk for a patient scoring 5 on the modified Glasgow score is greater than
30%.
100%
Mortality risk reaches 100% when the patient scores between 7 and 8 on the modified
Glasgow score. Pancreatitis is a common presentation in the UK, of which gallstones and alcohol are the two primary aetiologies. Gallstones account for up to 50% of pancreatitis
in the UK, while alcohol accounts for 20–25%. The modified Glasgow score takes into account a number of parameter taken within the first 48 h following admission which can then be used to assess mortality risk These criteria are as follows; pa (O2 ) < 60 mmHg; age > 55 years; neutrophils > 15 × 10 9 /l; calcium < 2 mmol/l; raised urea > 16 mmol/l; enzyme (LDH) > 600 units/l; albumin, 32 g/l; sugar (glucose) > 10 mmol/l.
A 42-year-old man with type 1 diabetes mellitus, which was diagnosed 23 years ago, is admitted to hospital with diabetic ketoacidosis (DKA). He is complaining of epigastric abdominal pain and vomiting.
Which one of the following findings on admission would most specifically suggest the precipitating cause of this illness?
1) Serum amylase activity of 1244 U/l (upper limit of normal, 150 U/l)
2) Serum creatinine concentration 140 µmol/l (normal value creatinine: 50–120 µmol/l)
3) Serum lactate concentration 4.3 mmol/l (normal value lactate: 0.5–2.2 mmol/l)
4) Serum triglyceride concentration 12.2 mmol/l (normal value triglycerides: 0–1.5 mmol/l)
5) White cell count of 15 × 10 9 /l (normal value WCC: 4–11 × 10 9 /l)
Explanation
Serum amylase activity of 1244 U/l (upper limit of normal, 150 U/l)
Patients in DKA often have elevated serum amylase activities as a result of decreased renal excretion of the enzyme, however, a level this high is very suggestive of pancreatitis and coupled with the epigastric pain, pancreatitis is the likely precipitant cause of his DKA.
Serum creatinine concentration 140 µmol/l (normal value creatinine: 50–120 µmol/l)
Serum creatinine concentration is often slightly raised in patients with DKA (even in the absence of diabetic nephropathy) as a result of dehydration and subsequently a
decreased glomerular filtration rate.
Serum lactate concentration 4.3 mmol/l (normal value lactate: 0.5–2.2 mmol/l)
Decreased tissue perfusion as a result of dehydration often leads to an element of lactic acidosis secondary to anaerobic respiration, in addition to the ketoacidosis.
Serum triglyceride concentration 12.2 mmol/l (normal value triglycerides: 0–1.5 mmol/l)
Hypertriglyceridaemia is common in uncontrolled diabetes.
White cell count of 15 × 10 9 /l (normal value WCC: 4–11 × 10 9 /l)
An increased white cell count can occur in any acute illness and does not specifically indicate infection.
Two hours after sustaining major trauma in a road traffic accident, a 22-year-old man, not known to have diabetes, is found to have a high blood glucose concentration. They have sustained significant injuries
Increased secretion of which one of the following substances is most likely to be responsible?
1) Adrenaline (epinephrine)
2) Cortisol
3) C-reactive protein
4) Growth hormone
5) Insulin
Explanation
Adrenaline (epinephrine)
During the metabolic response to trauma, there is increased secretion of catecholamines (such as adrenaline), cortisol, glucagon and growth hormone. Adrenaline acts most rapidly through stimulation of glycogenolysis causing blood glucose concentration to rise
Cortisol
Increased secretion of cortisol following trauma will increase blood glucose concentration, however, this occurs more slowly through the stimulation of gluconeogenesis.
C-reactive protein
C-reactive protein is an acute phase reactant and a marker of inflammation, but does not affect glucose homeostasis.
Growth hormone
Growth hormone is also released in response to major trauma. It can increase blood glucose concentration indirectly as it appears to potentiate the action of cortisol and opposes the action of insulin.
Insulin
Insulin is a hypoglycaemic hormone, therefore would lower blood glucose concentration.
An 18-year-old man presents to Accident and Emergency after vomiting blood following a night out for his birthday. On further questioning he admits to consuming a large amount of alcohol and then vomiting heavily. After vomiting around 12 times he noticed streaks of blood in his vomit.
What is the most likely diagnosis?
1) Aortic-enteric fistula
2) Boerhaave syndrome
3) Mallory-Weiss tear
4) Oesophageal varices
5) Peptic ulcer disease
Explanation
Mallory-Weiss tear
A Mallory–Weiss tea is a tear in the mucosal lining of the oesophagus that classically occurs after heavily vomiting (often following an alcohol binge as described in the case
history). Most cases of bleeding from this are self-limiting and usually minor.
Aortic-enteric fistula
Aortic-enteric fistulae occur mostly following abdominal aortic aneurysm (AAA) repair in which communication has developed between the aorta and the small bowel. They
result in very heavy blood loss into the small bowel and are often fatal.
Boerhaave syndrome
Boerhaave syndrome is perforation of the oesophagus secondary to vomiting. It is associated with a high morbidity and mortality, and would present with severe chest pain, fever and shock. The patient described in the case is not significantly unwell.
Oesophageal varices
Oesophageal varices are the result of portal hypertension as blood is shunted through arteriovenous anastomosis due to increased vascular resistance within the liver, most commonly as a result of cirrhosis secondary to alcohol. It would be rare for an 18-year- old to have significant liver cirrhosis to cause varices. Furthermore, variceal bleeding
would be profuse, and unlikely to present with just streaks of blood in the vomit.
Peptic ulcer disease
A peptic ulcer can cause upper gastrointestinal bleeding, however, it would be unlikely in a young adult, and does not fit with the case history.
An 82-year-old man is recovering in the Intensive Care Unit
seven days after an emergency repair of a difficult juxta-renal leaking abdominal aortic aneurysm. The nurse bleeps you because he has become tachycardic and his blood pressure has dropped to 80/50 mmHg. On assessment he is very pale and the nurse reports he has just had a large, fresh per rectal (PR) bleed.
What is the most likely cause for this?
1) Angiodysplasia
2) Aortic-enteric fistula
3) Diverticular disease
4) Gastric Cancer
5) Peptic ulcer disease
Explanation
Aortic-enteric fistula
Aortic-enteric fistulae occur mostly following abdominal aortic aneurysm (AAA) repair in which a communication has developed between the aorta and the small bowel. They result in very heavy blood loss into the small bowel and are often fatal.
Angiodysplasia
Angiodysplasia is the most common vascular lesion of the gut. Lesions are often multiple and presentation insidious, and may simply present as anaemia.
Diverticular disease
Diverticular disease may present with small amount of fresh PR bleeding, but given the proximity to surgery, an aortic-enteric fistula is more likely.
Gastric Cancer
Gastric cancer is likely to have a more insidious presentation. Again, as the bleeding would be upper gastrointestinal in nature, it would present as melaena not fresh blood.
Peptic ulcer disease
Peptic ulcer can cause bleeding, however this is likely to present as upper gastrointestinal bleeding. Occasionally, they can present as lower gastrointestinal bleeding but this will present as melena as opposed to fresh PR blood.
A 35-year-old male with known ulcerative colitis (UC) reports generalised itching, fatigue and abdominal pain. On examination, he is found to be jaundiced and his blood tests show a markedly raised bilirubin and alkaline phosphatase. A magnetic resonance cholangiopancreatography (MRCP) test shows multiple strictures in the biliary tree.
What is the most likely diagnosis?
1) Cholangitis
2) Cholecystitis
3) Primary biliary cirrhosis
4) Primary sclerosing cholangitis
5) Wilson’s disease
Explanation
Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is a condition in which inflammation, fibrosis and Strictures of the intrahepatic and extra-hepatic bile ducts occur. MRCP shows multiple strictures in the biliary tree and a characteristic ‘beaded’ appearance. Around 80% of patients with PSC will have a diagnosis of UC.
Cholangitis
Cholangitis is an ascending infection of the biliary tree, given this patient has no signs of infection this is unlikely. Furthermore, strictures would not be seen in cholangitis.
Cholecystitis
This refers to inflammation of the gallbladder, most common caused by gallstones. If the gallstones become lodged in the common bile duct then obstructive jaundice may be seen, however, the finding of strictures on MRCP is more suggestive of primary sclerosing cholangitis.
Primary biliary cirrhosis
Primary biliary cholangitis is an autoimmune disorder causing destruction of the small interlobular bile ducts, subsequent intrahepatic cholestasis causes fibrosis and
ultimately cirrhosis of the liver. The patient has a history of UC, so primary sclerosing cholangitis is a more likely, furthermore, strictures in the biliary tree would not be seen
on MRCP.
Wilson’s disease
Wilson’s disease is a rare inherited disorder of copper metabolism leading to a pathological accumulation of copper within various organ, particularly affecting the liver and brain. Presentation is usually in teenager years with either neuropsychiatric conditions due to accumulation of copper in the brain, or with coagulopathy and hepatic encephalopathy from accumulation in the liver. As such, this does not fit with the case history given.
An 18-year-old A-level student is referred from his GP with
right iliac fossa (RIF) pain and nausea. On examination, she has guarding and tenderness in the RIF. On deep palpation in the left iliac fossa (LIF) she still complains of pain in the RIF.
What is this sign called?
1) Aaron’s sign
2) Dunphy’s sign
3) Murphy’s sign
4) Rigler’s sign
5) Rovsing’s sign
Explanation
Rovsing’s sign
Rovsing’s sign describes pain in the RIF more than the LIF when the LIF is pressed, and is a sign of appendicitis.
Aaron’s sign
Aaron’s sign is pain referred to the epigastrium upon continuous firm pressure over
McBurney’s point and is indicative of appendicitis.
Dunphy’s sign
Dunphy’s sign is a medical sign in which increased abdominal pain occurs with coughing and is often present in appendicitis.
Murphy’s sign
Murphy’s sign occurs when pressing over the right upper quadrant (RUQ) with two fingers and asking the patient to breathe in, causes pain and arrest of inspiration as the
inflamed gall-bladder impinges on the examiner’s fingers. It is only positive if repeating the test on the left does not result in a similar pain.
Rigler’s sign
Rigler’s sign is a radiological sign in which air is seen on an abdominal X-ray on both sides of the intestine.
A previously well 83-year-old woman is brought into Accident and Emergency with abdominal pain and vomiting. On examination, she has a distended abdomen, and denies any previous surgery. On assessment of her groin, a tenderlump
is palpable on the left. It is below and lateral to the pubic tubercle.
What is the most likely cause of her symptoms?
1) Epigastric hernia
2) Femoral hernia
3) Direct inguinal hernia
4) Indirect inguinal hernia
5) Obturator hernia
Explanation
Femoral hernia
Femoral hernias classically emerge below and lateral to the pubic tubercle, and are
more common in women due to the wider pelvis. As the neck for femoral hernias is
relatively narrow and stiff, they are more likely to obstruct and strangulate.
Epigastric hernia
Given the patient has a lump in their groin, an epigastric hernia would be unlikely.
Direct inguinal hernia
Inguinal hernias emerge from above and medial to the pubic tubercle. Direct inguinal
hernias pass through Hasselbach’s triangle directly through a defect in the anterior
abdominal wall.
Indirect inguinal hernia
Again, inguinal hernias emerge from above and medial to the pubic tubercle, however,
indirect inguinal hernias pass through the inguinal canal.
Obturator hernia
An obturator hernia is rare but is more common in women and twice as common on the
right side. It particularly affects elderly women who have had recent rapid weight loss.
The hernial sac protrudes through the obturator canal potentially compressing the
geniculate branch of the obturator nerve causing referred pain. Given their anatomical
location they are difficult to diagnose clinically and does not present as a lump in the
groin.
A 17-year-old girl is brought in with a history of abdominal and left-sided chest pain. She gives a history of excessive vomiting earlier after a large meal, followed by sudden
onset of the pain. On examination she looks very unwell, is febrile and has a chest X-ray that shows a left pleural effusion. She is peripherally shutdown, hypotensive and
tachycardic. Her only past medical history of note is eating disorders for which she is known to the adolescent psychiatry team.
What is the most likely diagnosis?
1) Achalasia
2) Hiatus hernia
3) Mallory–Weiss tear
4) Oesophageal cancer
5) Oesophageal rupture
Explanation
Oesophageal rupture
Oesophageal rupture (Boerhaave syndrome) occurs mostly either secondary to trauma eg during endoscopy or due to forceful vomiting. Excessive vomiting may be due to
alcohol or in patients with a history of excessive eating and forced vomiting eg due to bulimia as suggested in this case. Perforation of the oesophagus causes a mediastinitis and an early diagnosis is crucial. Patients will deteriorate rapidly with systemic inflammatory response syndrome, unless the perforation is minimal. In patients with a significant perforation, resuscitation with surgery to debride the mediastinum and place a T-tube within the oesophagus is needed in most cases.
Achalasia
This refers to oesophageal dysmotility secondary to failure of smooth muscle of the lower oesophageal sphincter to relax during swallowing. It causes progressive dysphagia and regurgitation. The acute history of excessive vomiting is more suggestive of oesophageal rupture, achalasia would likely present with a longer history.
Hiatus hernia
The cardia protrudes into the thoracic cavity through the phrenoesophageal membrane into the thoracic cavity in a hiatus hernia. The most common is a sliding hiatus hernia,
which causes symptoms of reflux. It is unlikely to present with a patient in extremis.
Mallory–Weiss tear
A Mallory–Weiss tear is a tear in the mucosal lining of the oesophagus that classically occurs after heavily vomiting (often following an alcohol binge as described in the case
history). Given the patient is in extremis, this is not likely to be the cause as most cases of bleeding from this are self-limiting and usually minor.
Oesophageal cancer
Oesophageal cancer in a young patient would be rare.
A 24-year-old man is taken to the Emergency Department by his friends as they are concerned regarding blood in his vomit. The patient is very inebriated and a collateral history from them reveals he has been on a stag night and drinking heavily. After arriving home he had been vomiting excessively and recent vomitus has shown streaks of blood. He is haemodynamically stable, with unremarkable blood results, no past medical history and no change in bowel habits with normal stool.
Which one of the following conditions is most likely?
1) Achalasia
2) Diffuse oesophageal spasm
3) Mallory–Weiss tear
4) Para-oesophageal hernia
5) Oesophageal Ca
Explanation
Mallory–Weiss tear
A Mallory–Weiss tear occurs after excessive vomiting, often secondary to alcohol and involves a mucosal tear in the mucosa and submucosa. In most cases the bleeding is minor and self-limiting, and no intervention is required.
Achalasia
Achalasia refers to oesophageal dysmotility secondary to failure of smooth muscle of the lower oesophageal sphincter to relax during swallowing. It causes progressive dysphagia and regurgitation. The acute history of excessive vomiting and alcohol binge is more suggestive of a Mallory–Weiss tear, achalasia would likely present with a longer history.
Diffuse oesophageal spasm
This is a disorder of oesophageal dysmotility causing uncoordinated contractions of the oesophagus. Diagnosis can be difficult but it usually presents with intermittent non-
cardiac retrosternal pain and dysphagia.
Para-oesophageal hernia
The acute history given would not support the diagnosis of a para-oesophageal hernia as this tends to present with reflux symptoms and dysphagia.
Oesophageal Ca
This would present with weight loss and dysphagia for which the patient has no history. Additionally, oesophageal cancer in a 24-year-old would be rare.
An overweight 41-year-old woman presents to the Emergency department with central abdominal pain which is colicky in nature, and vomiting. On further questioning it
emerges she has not opened her bowels for 4 days, and on examination her abdomen is distendedand tender centrally. A plain abdominal radiograph shows dilated loops of small bowel, however, no air is seen in the large bowel or rectum. The radiograph also suggests evidence of pneumobilia.
What is most likely the cause of her symptoms?
1) Caecal volvulus
2) Crohn’s disease
3) Diverticular stricture
4) Gallstone ileus
5) Sigmoid volvulus
Explanation
Gallstone ileus
It is unusual for a gallstone to cause problems outside of the biliary tree, but sometimes a gallstone can pass into the small bowel and cause an obstruction known as a gallstone
ileus. This occurs after formation of a cholecystoduodenal fistula between the gall-bladder and duodenum. This causes the presence of air in the biliary tree, (ie pneumobilia), which can be seen on imaging.
Caecal volvulus
A caecal volvulus would cause dilated loops of small bowel, however, it would not cause pneumobilia, which is presence of air in the biliary tree, and is more indicative of gallstone ileus.
Crohn’s disease
Crohn’s disease is an inflammatory bowel disease and can affect the entire length of the gastrointestinal tract with transmural inflammation noted and although Crohn’s disease can cause obstruction, pneumobilia is unlikely. Additionally, the history is more indicative of cholecystitis secondary to gallstones.
Diverticular stricture
The lack of air in the rectum suggests an obstructive picture and the absence of dilated large bowel loops goes against the diagnosis of large bowel obstruction caused by a diverticular stricture.
Sigmoid volvulus
A sigmoid volvulus causes a classic coffee-bean sign on abdominal X-ray.
A 20-year-old man is admitted as an emergency with suspected appendicitis. This is the most common emergency surgical operation and approximately 80 000 people a year
are admitted with this diagnosis in the UK. How may the symptoms present?
1) Colicky central abdominal pain shifting to right iliac fossa
2) Dysuria, frequency of micturition and fever
3) Nausea and vomiting
4) Sharp localised pain, worse on movement and found at McBurney’s point
5) All of the above
Explanation
All of the above
The possibilities of presentation of appendicitis are numerous; good knowledge of the
signs and symptoms of appendicitis is paramount as it is often a clinical diagnosis,
supported with evidence of inflammation in the blood results, and occasionally with
imaging, primarily ultrasound or in older patients computed tomography (CT) scan.
Colicky central abdominal pain shifting to right iliac fossa
The usual presenting history is of colicky and vague central abdominal pain shifting to
the right iliac fossa after 24 h and becoming constant with associated nausea and
pyrexia.
Dysuria, frequency of micturition and fever
History may mimic urinary tract infection with dysuria, frequency and fever. This
generally occurs when the appendix lies on or adjacent to the bladder.
Nausea and vomiting
Nausea and vomiting are common associated symptoms of appendicitis, and are usually
seen as the condition progresses.
Sharp localised pain, worse on movement and found at McBurney’s point
The classical area of maximal tenderness is one-third of the distance from the anterior
superior iliac spine (ASIS) to the umbilicus. This is McBurney’s point. Specific signs on
abdominal examination are as follows:
Psoas stretch sign – passive extension or hyperextension of the hip increases abdominal
pain due to the psoas muscle being in contact with the inflamed appendix.
Rovsing’s sign – Palpation in the left iliac fossa may produce pain at the site of
tenderness in the right iliac fossa due to movement of the inflamed parietal peritoneum.
A 64-year-old woman presents with severe abdominal pain
and a history of vomiting initially that has now settled, although she continues to retch. On assessment she has widespread abdominal tenderness and looks unwell. A blood gas confirms a metabolic acidosis and the nursing staff report they are unable to pass a nasogastric (NG) tube.
What is the likely diagnosis?
1) Gastric volvulus
2) Oesophageal perforation
3) Perforated duodenal ulcer
4) Sigmoid volvulus
5) Small bowel obstruction
Explanation
Gastric volvulus
Gastric volvulus classically involves Borchardt’s triad; epigastric pain, retching without
vomiting and the inability to pass an NG tube. The twisting can occur in two ways: along
the long axis of the stomach (organoaxial) or around the axis perpendicular to the
stomach (mesenteroaxial).
Oesophageal perforation
Oesophageal rupture or perforation occurs mostly either secondary to trauma eg during
endoscopy or due to prolonged forceful vomiting. It is likely to also cause retrosternal
pain and would not prevent passage of an NG tube.
Perforated duodenal ulcer
A perforated ulcer will cause epigastric abdominal pain with peritonitis and possibly
guarding depending on the extent of the perforation. Additionally, it would not obstruct
the passage of a nasogastric tube.
Sigmoid volvulus
Sigmoid volvulus is more likely to present with abdominal pain and complete
constipation. If vomiting were to occur, it would be faeculent in nature.
Small bowel obstruction
This would not prevent the passage of an NG tube.
A 3-year-old boy presents to the Emergency Department with a severe sore throat, temperature of 38.7 °C and noisy breathing. The child is sat forwards and drooling.
What is the most important first step to perform in the management of this child?
1) Examination of the oropharynx
2) Flexible laryngoscopy
3) IV access and blood cultures
4) IV antibiotics
5) Urgently call the paediatric anaesthetist
Explanation
Urgently call the paediatric anaesthetist
The child has acute epiglottitis. Acute epiglottitis tends to present with a rapidly
progressive sore throat and in the late stages, may be associated with inspiratory
stridor. The child will be toxic with a raised temperature and tends to sit forwards and
drool. The loose connective tissue swelling in the epiglottis can occlude the airway and
care must be taken to avoid this. Any attempts to examine the child, including simple
cannulation can precipitate laryngospasm and airway occlusion. Therefore the most
important step in managing this patient is to get the help of someone with experience in
managing paediatric airways.
Examination of the oropharynx
Any attempts to examine the child, including examination of the oropharynx can
precipitate laryngospasm and airway occlusion, and therefore is ill advised and should
be avoided.
Flexible laryngoscopy
As mentioned, any attempt to examine this child may trigger life-threatening airway
occlusion and so should be avoided.
IV access and blood cultures
While this child is likely to be septic given the history, no attempt to cannulate the
patient should be undertaken as this may cause airway obstruction.
IV antibiotics
This would require cannulation, which should not be undertaken.
A 22-year-old woman student presents with epistaxis. This
fails to improve with pressure. Which one of the following methods would be attempted next?
1) Embolisation
2) External carotid artery ligation
3) Sphenopalatine artery ligation
4) Trans-sphenoidal ligation
5) Use of silver nitrate
Explanation
Use of silver nitrate
Application of sustained pressure for epistaxis is the primary first aid measure. If
unsuccessful, silver nitrate or chemical cautery can be utilised and can be very effective
in stemming epistaxis. However, in higher risk patients (particularly the elderly on
anticoagulation), nasal packing, both anterior and posterior, may be required.
Progression to surgery and artery ligation would then be the next management method.
Embolisation
Maxillary artery embolisation is becoming a more frequently used alternative to artery
ligation, however, this is reserved for specialist interventional radiology centres, and
would only be indicated for refractory bleeding despite cautery and nasal packing.
External carotid artery ligation
Ligation of the external carotid artery is reserved for life-threatening epistaxis, other
measures should be trialled to stem bleeding before artery ligation.
Sphenopalatine artery ligation
Ligation of local arteries, such as the sphenopalatine, may be required and are not
uncommon, however, more conservative measures should be
trialled before progression to surgical ligation.
Trans-sphenoidal ligation
This is not indicated for epistaxis.
An 18-year-old gap-year student presents to the Accident and Emergency Department (A&E) with right-sided abdominal pain and rigours. On examination, he is clammy to touch, febrile and tender in the right upper quadrant. His only medical history of note is dysentery while on a backpacking trip to Mexico 2 months ago. What is the most likely diagnosis?
1) Amoebic liver abscess
2) Cholangiocarcinoma
3) Gallstones
4) Hydatid disease
5) Pancreatitis
Explanation
Amoebic liver abscess
Amoebic liver abscesses often occur secondary to Entamoeba histolytica infection in the
gut entering the portal circulation and spreading to the liver. The condition occurs
mostly in endemic areas and affects travellers visiting them. Clinical features include
abdominal pain (most commonly in the right upper quadrant), fever, rigours and
nausea/vomiting. Some patients will report a history of dysentery recently. Imaging
with ultrasound scan or computed tomography (CT) is useful in the diagnosis, and can
be combined with aspiration which produces a thick fluid resembling anchovy sauce.
Treatment mostly consists of metronidazole sometimes with percutaneous drainage.
Cholangiocarcinoma
Cholangiocarcinoma would be rare in an 18-year-old adult.
Gallstones
Gallstones presents with colicky, right upper quadrant abdominal pain. It may be
associated with pyrexia if there is cholecystitis. It would be uncommon in young men,
more often presenting in overweight, middle-aged women. As such, the case history
does not fit with this diagnosis.
Hydatid disease
Hydatid disease is caused by parasitic Echinococcus tapeworms, it causes the formation
of slow growing cysts, usually in the liver or lungs, containing hydatid fluid. Patients can
often be asymptomatic. Intermediate hosts are grazing animals, with dog and cats often
acting as definitive hosts. Humans are only accidental hosts. Given this patient has a
history of dysentery while travelling, this supports the diagnosis of amoebic abscess
formation, as opposed to hydatid disease.
Pancreatitis
This commonly presents with epigastric abdominal pain radiating through to the back.
The most common aetiology in the UK are gallstones or alcohol, both of which would be
unlikely in a young adult.
A 75-year-old man who has had a prolonged intensive care unit admission following an emergency abdominal aortic aneurysm repair is referred to the surgical team because of
increased abdominal pain and discomfort noted when he is moved. His bloods and urine show normal amylase and lipase levels respectively. A computed tomography (CT) scan showed no leak from the anastomosis, but an ultrasound scan showed a dilated gall-bladder with oedema in the wall. However, no gallstones were noted. What is the most likely diagnosis?
1) Aorta-enteric fistulae
2) Biliary colic
3) Cholecystitis
4) Ileus
5) Pancreatitis
Explanation
Cholecystitis
Acalculous cholecystitis is rare, but can occur in critically ill patients often
on the intensive care unit. The mechanism for this is thought to involve gall-
bladder stasis due to analgesia or parenteral nutrition. Imaging includes
ultrasound, which can show a dilated gall-bladder with oedema in the wall.
Aorta-enteric fistulae
Aortic-enteric fistulae occur mostly following abdominal aortic aneurysm (AAA) repair
in which a communication has developed between the aorta and the small bowel. They
result in very heavy blood loss into the small bowel and are often fatal.
Biliary colic
Biliary colic secondary to gallstones is common and presents as colicky abdominal pain.
Given that no gallstones were identified on ultrasound and the prolonged stay in
intensive care, this is less likely than acalculous cholecystitis.
Ileus
Ileus is common in patients who have undergone major abdominal surgery and is often
due to handling of the bowel during the operation. It usually resolves after a few days
and ‘bowel rest’. The findings of a distended gall-bladder suggest a more likely
pathology.
Pancreatitis
Pancreatitis usually presents with epigastric pain, and the most common causes are
gallstones or alcohol. Given no gallstones were identified on ultrasound but the gall-
bladderis distended and oedematous, acalculous cholecystitis must be considered.
Moreover, this patient has normal lipase and amylase levels.
A 57-year-old woman is admitted under the general surgical team with severe epigastric pain radiating to her back. She has a history of profuse vomiting and a serum amylase comes back as 1200 U/ml. She is started on treatment for acute pancreatitis and further tests are done.
Result Normal
Serum amylase
1200 U/l
<200 U/l
White-cell count
12 × 10 9 /l
4–11 × 10 9 /l
Calcium
1.9 mml/l
2.20–2.60 mmol/l
Urea
17 mmol/l
2.5–6.5 mmol/l
LDH
672 IU/l
100–190 IU/l
Albumin
31 g/l
35–55 g/l
Blood glucose
11 mmol/l
3.5–5.5 mmol/l
Arterial blood gas pa (O2 )
13.1 kPa
10.5–13.5 kPa
How severe is her pancreatitis using the modified Glasgow criteria?
1) Mild
2) Moderate
3) Severe
4) Haemorrhagic
5) Necrotic
Explanation
Severe
The modified Glasgow criteria can be used to assess the severity of acute pancreatitis by
using parameters taken within the first 48 h following admission. The most common
aetiologies in the UK are either gallstones or alcohol. This patient has significantly
deranged physiological and biochemical markers, increasing their Glasgow score,
indicating a severe pancreatitis.
Mild = 1 positive factor, moderate = 2 factors, severe = 3 positive factor.
Mild
The patient has significant derangements of the physiological and biochemical markers
used to assess severity of pancreatitis, increasing the Glasgow score above the mild
category.
Moderate
As above, the patient has significant derangements in the parameters used to calculate
the Glasgow score, causing the severity to be categorised as severe.
Haemorrhagic
The terms haemorrhagic and necrotic describe the computed tomography
(CT) scan appearance of the pancreas, and influence the Balthazar score.
Necrotic
Again, this term is reserved for describing the appearance of the pancreas on CT.
A 45-year-old woman with known gallstones is admitted with epigastric pain and vomiting. Her serum amylase is 1194 U/1ml. An abdominal ultrasound shows gallstones in the common bile duct (CBD) with a dilated CBD and it is thought she has acute gallstone pancreatitis. Chest X-ray (CXR) and abdominal X-ray (AXR) are unremarkable and her other test results are as follows:
Result Normal
White-cell count. 9 × 10 9 /l. 4–11 × 10 9 /l
Calcium. 2.3 mml/l. 2.20–2.60 mmol/l
Urea. 9 mmol/l. 2.5–6.5 mmol/l
LDH. 352 IU/l. 100–190 IU/l
Albumin. 35 g/l. 35–55 g/l
Blood glucose. 7 mmol/l. 3.5–5.5 mmol/l
Arterial blood gas pa (O2 ) 12 kPa. 10.5–13.5 kPa
With this information, which scoring system can be best used to assess the
severity of her pancreatitis?
1) APACHE
2) Balthazar
3) Glasgow
4) Hinchey
5) Ranson
Explanation
Glasgow
The modified Glasgow criteria can be used to assess the severity of acute pancreatitis by
using parameters taken within the first 48 h following admission.
APACHE
The APACHE score requires additional information to those provided eg blood pressure,
urine output and is used to assess mortality risk for patients admitted to intensive care
regardless of causative pathology. Balthazar
The Balthazar grade is based on the computed tomography (CT) scan appearance of the
pancreas.
Hinchey
The Hinchey classification grades diverticulitis not pancreatitis.
Ranson
Ranson’s criteria are valid for alcohol-induced pancreatitis and can only be applied after
48 h.
The severity of acute pancreatitis is typically classified based on various criteria, including clinical, biochemical, and radiological parameters. Here are some commonly used criteria:
1. Ranson’s Criteria: Developed by Dr. John Ranson in the 1970s, this system includes 11 criteria—5 assessed at admission and 6 during the first 48 hours. The presence of 3 or more of these criteria indicates severe pancreatitis and a poorer prognosis. 2. APACHE II Score (Acute Physiology and Chronic Health Evaluation II): This scoring system evaluates physiological parameters within the first 24 hours of admission. A higher score indicates a more severe condition and a worse prognosis. 3. Balthazar Score: This system assesses the severity of pancreatitis based on CT imaging findings. It uses a grading system from A to E, with E indicating the most severe form of pancreatitis. 4. Imrie Score: Similar to Ranson’s criteria, the Imrie scoring system evaluates clinical and laboratory parameters to predict the severity of pancreatitis. A score of 3 or more indicates severe pancreatitis. 5. CT Severity Index (CTSI): This index evaluates the extent of pancreatic and peripancreatic inflammation on CT imaging. It helps in predicting the severity of pancreatitis and guiding management decisions. 6. Bedside Index for Severity in Acute Pancreatitis (BISAP): This simplified scoring system assesses five parameters at admission—blood urea nitrogen, impaired mental status, systemic inflammatory response syndrome, age, and pleural effusion—to predict the severity of acute pancreatitis. 7. CRP (C-reactive protein): Elevated levels of CRP have been associated with severe acute pancreatitis and can be used as a marker for assessing severity. 8. Modified Glasgow Criteria: Similar to Glasgow Coma Scale, this criteria assesses various clinical parameters and organ dysfunction to predict the severity of pancreatitis.
These criteria help clinicians in assessing the severity of acute pancreatitis, guiding treatment decisions, and predicting patient outcomes.
Sources:
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734411/ • https://www.ncbi.nlm.nih.gov/books/NBK482291/
A 38-year-old woman with a 1-year history of intermittent epigastric pain presents with vomiting and abdominal distension. A plain abdominal radiograph reveals dilated loops of small bowel and pneumobilia. What is the most appropriate management?
1) Emergency laparotomy
2) Endoscopic retrograde cholangiopancreatography (ERCP)
3) Laparoscopic cholecystectomy
4) Percutaneous drainage of the gall bladder
5) Surgical closure of a cholecystoduodenal fistula
Explanation
Emergency laparotomy
This patient has a small bowel obstruction secondary to gallstone ileus. This is a surgical
emergency requiring urgent laparotomy. The gallstone usually impacts proximal to the
ileocaecal valve, and so it should be massaged through into the large intestine or
extracted via an enterotomy, so relieving the obstruction.
Endoscopic retrograde cholangiopancreatography (ERCP)
This intervention is used for the diagnosis and treatment of gallstones located in the
common bile duct. Again, this will not solve the small bowel obstruction which requires
emergency intervention.
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy is indicated for those with recurrent cholecystitis with
evidence of gallstones. This does not, however, address the small bowel obstruction
which is a surgical emergency requiring laparotomy.
Percutaneous drainage of the gall bladder
Small bowel obstruction is a surgical emergency and requires intervention.
Percutaneous drainage of the gall bladder will not resolve the bowel obstruction and
therefore would be inappropriate.
Surgical closure of a cholecystoduodenal fistula
The gallstone will have passed into the small bowel through a biliary-enteric fistula, but
this does not usually require surgical repair. Such fistulae often lead to pneumobilia,
which can be seen on plain abdominal radiographs.
A previously fit and well 54-year-old man attends the General Practice Surgery, as his family have told him he is ‘looking yellow’. On examination, he is aundiced, but his abdomen is soft and non-tender. In the right upper quadrant (RUQ), his
gall bladder is palpable. A triple-phase computerised tomography (CT) reveals a tumour at the head of
the pancreas.
Which of the following phenomena is demonstrated?
1) Cope sign
2) Courvoisier’s law
3) Murphy’s sign
4) Psoas sign
5) Rovsing’s sign
Explanation
Courvoisier’s law
Courvoisier’s law states that in the event of painless jaundice and a palpable gall
bladder, the cause is unlikely to be gallstones. This is because the presence of gallstones
tends to make the gall bladder fibrosed, and therefore it is unlikely to become distended
in the event of an obstruction of the biliary tree.
Cope sign
Cope sign involves flexion and internal rotation of the right hip, causing pain if the
appendix is lying in close relation to the obturator internus.
Murphy’s sign
Murphy’s sign occurs when, upon pressing over the RUQ with two fingers, asking the
patient to breathe in causes pain and arrest of inspiration, as the inflamed gall bladder
impinges on the examiner’s fingers.
Psoas sign
Psoas sign involves extension of the hip, causing pain if there is a retrocaecal appendix.
Rovsing’s sign
Rovsing’s sign describes pain in the right iliac fossa more than in the left iliac fossa
when the left iliac fossa is pressed.
A 37-year-old woman presents to the acute surgical take. She is
postpartum and on the oral contraceptive pill, she complains of right upper quadrant pain, nausea and vomiting. On examination she has
hepatosplenomegaly and ascites.
What is the most likely cause for this?
1) Alcoholic cirrhosis
2) Budd–Chiari syndrome
3) Pylephlebitis after acute appendicitis
4) Splenectomy
5) Tricuspid valve incompetence
Explanation
Budd–Chiari syndrome
Portal hypertension with a pressure of over 20 mmHg is commonly caused by pre-hepatic problems such as portal vein thrombosis, hepatic disease such as cirrhosis and post-hepatic problems such as tricuspid valve incompetence and Budd–Chiari syndrome of hepatic vein thrombosis. Budd–Chiari syndrome commonly results in
hepatosplenomegaly and ascites. It is associated with pregnancy and being postpartum.
Use of the oral contraceptive pill can also increase the risk for venous thromboembolic disease.
Alcoholic cirrhosis
There is no history of alcohol excess in the history given, so alcoholic cirrhosis would be unlikely.
Pylephlebitis after acute appendicitis
Pylephlebitis is an uncommon thrombophlebitis of the portal vein, caused by an infection such as appendicitis. The case history given, however, is not consistent with appendicitis, which commonly presents with vague, centralised abdominal pain, localising to the right iliac fossa over 24 hours.
Splenectomy
Palpable splenomegaly is noted on examination; therefore, splenectomy cannot be the cause.
Tricuspid valve incompetence
Although tricuspid valve incompetence can cause portal hypertension, and subsequently hepatosplenomegaly, as described in the case history, as the patient is postpartum, Budd–Chiari syndrome is the more likely diagnosis.
An elderly, confused man presents with a
grossly distended tympanic abdomen
and absolute constipation. A plain abdominal radiograph reveals a grossly
dilated large intestine , but no evidence of pneumoperitoneum. What is the most appropriate initial management?
1) Computerised tomographic scan of the abdomen and pelvis
2) Laparotomy and sigmoid colectomy
3) Laxatives
4) Sigmoidoscopy
5) Trephine ileostomy
Explanation
Computerised tomographic scan of the abdomen and pelvis
For this scenario, the differential diagnosis is pseudo-obstruction, sigmoid volvulus and carcinoma of the distal colon/rectum. Computerised tomography of the abdomen and pelvis is the best option, as it permits the diagnosis to be obtained and the correct treatment instituted. Pseudo-obstruction may be associated with an underlying precipitating condition such as renal failure, electrolyte abnormalities, myxoedema, stroke, myocardial infarction, chest infection and retroperitoneal malignancy (pseudo- obstruction in the presence of retroperitoneal malignancy is known as Ogilvie syndrome). Medical management comprises correction of electrolyte abnormalities, treatment of the underlying cause and use of the anticholinergic neostigmine (with heart monitor surveillance).
Laparotomy and sigmoid colectomy
At present, the diagnosis is not clear and further imaging is required, so the most
appropriate treatment can be initiated. Sigmoid colectomy is indicated in an elective setting for recurrent sigmoid volvulus. Sigmoid volvulus often has the characteristic ‘coffee bean’ sign on plain abdominal radiograph. Obstructed colon caused by a distal neoplasm is open to several surgical options following adequate resuscitation. These include stenting, defunctioning stoma, primary resection and anastomosis following on-
table colonic lavage or Hartmann’s procedure. Note if the patient was too unstable for the computerised tomography scanner, then exploratory laparotomy may indeed be indicated first.
Laxatives
Initiating treatment before identifying the causative pathology could cause further harm to the patient. For example, if the obstruction is caused by a carcinoma of the sigmoid colon, use of laxatives could precipitate a perforation.
Sigmoidoscopy
Sigmoidoscopy may be beneficial in decompressing the colon with a flatus tube when a sigmoid volvulus is the causative pathology. However, the diagnosis is not clear in this case, so further imaging is required before intervention. Fixation procedures for
recurrent sigmoid volvulus, such as sigmoidopexy, have been performed but are associated with high recurrence rates.
Trephine ileostomy
This is an operative technique to create a permanent end-colostomy without undergoing a laparotomy. Again, this would not be indicated until the diagnosis is clarified with further imaging.
An 82-year-old man presents with intermittent abdominal pain and vomiting. On further questioning, it is noted he has
not opened his bowels for 5 days and not passed wind for 2 days. On examination, he looks uncomfortable and his abdomen is grossly distended. His only past medical history of note is an open repair of an
abdominal aortic aneurysm (AAA) 4 months ago, from which he recovered well.
What is the most likely cause of his symptoms?
1) Adhesional small bowel obstruction
2) Aorto-enteric fistula
3) Incisional hernia
4) Diverticular disease
5) Sigmoid tumour
Explanation
Adhesional small bowel obstruction
This patient has a number of characteristic features of small bowel obstruction:
vomiting, constipation and abdominal distension. Adhesions are the most common
cause of small bowel obstruction in the developed world and can occur following any
form of abdominal surgery.
Aorto-enteric fistula
Aortic-enteric fistulae occur mostly following AAA repair, in which a communication has
developed between the aorta and the small bowel. They result in very heavy blood loss
into the small bowel, causing rectal bleeding, and are often fatal.
Incisional hernia
There is nothing in the history of the case to suggest the patient has an incisional hernia
which could be causing obstruction.
Diverticular disease
There are no features in the case history that suggest diverticular disease as the cause
for obstruction.
Sigmoid tumour
Carcinoma of the colon, particularly the sigmoid colon, is a common cause for large
bowel obstruction. However, there are no features in the history that point to a sigmoid
tumour as the cause for obstruction, and given this gentleman has had previous major
abdominal surgery, adhesional bowel obstruction is more likely.
An 88-year-old woman, who has a past medical history of dementia and is bed-bound in a nursing home, presents with a history of constipation for the last 7 days. Her carers have noted her abdomen has become grossly distended and is tender to touch. An abdominal X-ray demonstrates the coffee bean sign.
What would be an appropriate treatment option to manage this patient initially ?
1) Antibiotics
2) Computerised tomography (CT) scan
3) Exploratory laparotomy
4) Insertion of flatus tube
5) Sigmoid colectomy
Explanation
Insertion of flatus tube
The coffee bean sign and clinical history are highly suggestive of sigmoid volvulus,
which commonly occurs in elderly patients who have a chronic history of constipation.
Insertion of a flatus tube represents a relatively low-risk procedure that could
potentially resolve the patient’s symptoms and therefore would be a good first-line
option. If this fails, the next step would be flexible sigmoidoscopy.
Antibiotics
Antibiotics are not indicated, as there are no features in the case history suggestive of
infection.
Computerised tomography (CT) scan
A CT scan would confirm the diagnosis but offers no therapeutic benefit to the patient.
Exploratory laparotomy
Given the patient’s pre-morbid status of being a bed-bound nursing home patient, the
risks of any major surgery, eg laparotomy, would be great. Depending on the severity of
the patient’s dementia, they may also lack capacity to consent to surgery, and it is likely
to be against the patient’s best interests to undergo major surgery.
Sigmoid colectomy
Again, major surgery for this patient would be ill-advised.
An 85-year-old man is recovering 2 days after a hemiarthroplasty for a fractured neck of femur. The nurses call you as he has started vomiting profusely and his
abdomen is distended. He has not opened his bowels for 3 days and on examination, he has a distended, tender abdomen. He has never undergone any abdominal surgery and has no palpable herniae. His rectum is empty. His blood tests show a potassium level of 2.6 and a creatinine level of 144.
What is the most likely diagnosis?
1) Adhesional small bowel obstruction
2) Constipation secondary to opioids
3) Incisional hernia
4) Obstruction hernia
5) Pseudo-obstruction
Explanation
Pseudo-obstruction
The history of vomiting, constipation and a distended abdomen is suggestive of an
obstruction. In this case, this gentleman has developed pseudo-obstruction, which often
resembles bowel obstruction and can occur in any post-operative patients and can also
be triggered by deranged electrolytes, eg hypokalaemia. It is best managed
conservatively through correcting the underlying causes.
Adhesional small bowel obstruction
The most common cause for small bowel obstruction, namely adhesions, is unlikely in
this case, given the patient has never had abdominal surgery.
Constipation secondary to opioids
Although the patient is likely to have been prescribed opioid-based medication before
and following the hemi-arthroplasty, his empty rectum points away from constipation.
Incisional hernia
No hernias are palpable on examination and he has not previously undergone
abdominal surgery; as such, this is incorrect.
Obstruction hernia
This is unlikely, as there are no palpable hernias on examination and no history of
previous abdominal surgery.
A frail 87-year-old woman is brought in by her concerned family as she has started vomiting and not opened her bowels or passed wind for 3 days. On examination, she looks unwell with a distended abdomen, but no previous incisions, and on further questioning, she reports the pain radiates along the right upper medial thigh. Vaginal examination reveals a swelling in the right side wall of the vagina.
What is the most likely diagnosis?
1) Adhesional small bowel obstruction
2) Epigastric hernia
3) Para-umbilical hernia
4) Obturator hernia
5) Sigmoid volvulus
Explanation
Obturator hernia
Pain which radiates to the thigh is suggestive of pressure on the obturator nerve which supplies sensation to the medial thigh. This can be present in around 50% of patients with an obturator hernia. Obturator hernias occur most commonly in frail old women and often there are no signs. If pressure is present over the obturator nerve, patients often hold the leg flexed to reduce pain. Rectal, and more often vaginal, examination can reveal a swelling in the region of the obturator foramen.
Adhesional small bowel obstruction
Although the most common cause of small bowel obstruction is adhesions in the developed world, the lack of previous surgery makes this very unlikely.
Epigastric hernia
An epigastric hernia would not cause pain in the medial thigh and vaginal examination would be unremarkable. Furthermore, an epigastric hernia was not identified on examination of the abdomen.
Para-umbilical hernia
There were no hernias identified on abdominal examination, and a lack of previous abdominal surgery makes this diagnosis unlikely.
Sigmoid volvulus
Sigmoid volvulus is a common cause for bowel obstruction, particularly in the elderly.
However, it would not produce pain in the medial thigh and vaginal examination would be unremarkable.
A 32-year-old man develops an acutely painful arm after having been immobilised in a plaster cast, following a closed fracture of his distal radius 8 hours previously.
What is the most likely underlying diagnosis?
1) Compartment syndrome
2) Deep vein thrombosis
3) Early infection
4) Inadequate analgesia
5) Necrotising fascitis
Explanation
Compartment syndrome
Compartment syndrome is characterised by increased pressure within an unyielding osseofascial compartment, resulting in local tissue hypoxia. The earliest sign is pain out of proportion with the injury, particularly severe pain on passive muscle stretch. Pallor, paraesthesiae and pulselessness occur in late stages. Diagnosis is on clinical grounds, although compartment pressures can be measured. Raised creatine kinase (CK) levels are indicative of muscle necrosis. Fasciotomies to release the deep and superficial compartments should be performed early. Although more common in the lower limb, it is possible in the upper limb as well.
Deep vein thrombosis
While venous thromboembolic disease should be considered in those with prolonged immobilisation of a limb, development of a deep vein thrombosis within 8 hours is
improbable.
Early infection
Infection of the limb may be painful. However, there are no other signs of infection in the case history. Moreover, compartment syndrome should always be considered in an
acutely painful limb which has recently been immobilised in a plaster cast.
Inadequate analgesia
Adequate analgesia is important. However, effective immobilisation should provide sufficient pain relief. The history described is highly suggestive of compartment syndrome.
Necrotising fascitis
Necrotising fasciitis is a surgical emergency caused by bacterial infection of the fascia and subsequent necrosis of the subcutaneous tissues. It requires emergency debridement of affected areas with wide margins and intravenous antibiotics. In the case history, there is no suggestion of sepsis with haemodynamic compromise, which
would be seen with necrotising fasciitis.
A 2-year-old child is admitted to the Paediatric Emergency Department with malaise, rash, vomiting and fever. Mum reports that she has been off her food for the preceding 24 hours and has been running a low-grade temperature. She also points to a partial-thickness burn over her arm that has been de-roofed and treated with dressings by her general practitioner.
What is the likely diagnosis?
Select one answer only.
1) Anaphylaxis
2) Haemophilus influenza
3) Meningococcal septicaemia
4) Salmonella
5) Toxic shock syndrome
Explanation
Toxic shock syndrome
An unwell child with an unhealed burn must be treated for toxic shock syndrome until proven otherwise. Treatment will require management in the Intensive Care Department, with input from a paediatric consultant and the plastic surgery team. Circulatory support with cryoprecipitate may be necessary.
Anaphylaxis
This is a paediatric airway emergency which requires emergency administration of intramuscular adrenaline to prevent airway occlusion from a hypersensitivity reaction.
The history described is not consistent with anaphylaxis, which presents rapidly with lip and tongue swelling, airway compromise and difficulty breathing.
Haemophilus influenzae
There is no suggestion of respiratory signs or symptoms in the case history, so this is unlikely, despite being a common paediatric presentation.
Meningococcal septicaemia
Meningococcal meningitis leading to septicaemia is life-threatening and should always be considered in an acutely unwell child. However, given the unhealed burn, toxic shock
syndrome is more probable.
Salmonella
Salmonella infection would present with gastrointestinal symptoms and signs, of which there are none in the case history, other than anorexia which is a common and non-
specific symptom for an unwell child.
A 17-year-old man presents with right-sided abdominal pain, which is worse on movement, and anorexia. He is listed for an open appendicectomy which reveals a normal appendix. Further exploration intra-operatively reveals a normal caecum, and a terminal ileum with no obvious inflammation. However, an outpouching is noted on the terminal ileum around 60 cm from the ileocaecal valve.
What is the most likely diagnosis?
1) Abdominal tuberculosis (TB)
2) Appendicitis
3) Caecal carcinoma
4) Crohn’s disease
5) Meckel’s diverticulum
Explanation
Meckel’s diverticulum
The description of an outpouching in this location on the antimesenteric border is consistent with a Meckel’s diverticulum. These are embryological remnants of the vitello-intestinal duct and are a free diverticulum of the terminal ileum. They occur in 2% of the population, are commonly 2 feet (60 cm) from the ileocaecal valve, often 2
inches (5 cm) in length and twice as common in men than women. Acute inflammation may mimic appendicitis and it is important when performing an appendicectomy to search for a Meckel’s diverticulum if the appendix is normal.
Abdominal tuberculosis (TB)
The case history is not consistent with abdominal TB and no risk factor for TB is described.
Appendicitis
The normal appendix goes against a diagnosis of acute appendicitis.
Caecal carcinoma
The normal caecum makes a caecal tumour causes the symptoms very unlikely, furthermore, a caecal carcinoma in a 17-year-old adolescent would be rare.
Crohn’s disease
The lack of inflammation in the terminal ileum makes Crohn’s unlikely.
An 89-year-old woman is seen on the post-take ward round following CT scanning. She presented with tenderness in the left iliac fossa for 7 days. She has localised tenderness but feels better than on admission yesterday. Past medical history reveals a cerebrovascular accident (CVA) 5 years ago which has left her bed bound with chronic obstructive pulmonary disease (COPD), requiring multiple admissions. Her CT scan shows diverticulitis with a localised perforation. Blood results show a white-cell count of 18 × 10 9 /l (normal 4–11 × 10 9 /l) and C-reactive protein 160 mg/l (normal 0–10
mg/l).
What is the best initial management?
1) Discharge
2) Intravenous antibiotics and close monitoring
3) Laparotomy and primary anastomosis
4) Laparoscopic resection
5) Laxatives
Explanation
Intravenous antibiotics and close monitoring This elderly patient has a localised diverticular perforation with absence of peritonitis and is showing signs of improvement. She has significant past medical history that would make her a high risk candidate for surgery, therefore conservative management with IV antibiotics and close monitoring for signs of deterioration is the best management path.
Discharge
Discharge is obviously not appropriate at this point.
Laparotomy and primary anastomosis
A primary anastomosis would not be advisable in an acute case with potential contamination leading to a higher chance of anastomotic leak. An anastomotic leak could be disastrous in this patient and so a colostomy would be best surgical practice if she were to be taken to theatre.
Laparoscopic resection
If surgical intervention were required, laparoscopy may be difficult due to her COPD, particularly as carbon dioxide insufflation of the abdominal cavity will splint the diaphragm, making ventilation more difficult.
Laxatives
Laxatives are not the primary concern in this patient’s acute management.
A 78-year-old nursing home resident is admitted with severe diarrhoea and left iliac fossa pain. At flexible sigmoidoscopy diffuse pseudomembranes are seen. Biopsy is neutrophil rich.
What is the most likely diagnosis?
1) Crohn’s disease
2) Melanosis Coli
3) Malignancy
4) Pseudomembranous colitis
5) Ulcerative Colitis
Explanation
Pseudomembranous colitis
The appearance of pseudomembranes are typical for pseudomembranous colitis caused by Clostridium difficile. This pathogen is more common in nursing home or hospitalised patients, and is often associated with antibiotic use. High risk antibiotics include; fluoroquinolones, cephalosporins and clindamycin. Prevention of the spread of C. difficileinvolves isolation of infected patients, judicious hand hygiene and measured antibiotic use.
Crohn’s disease
Crohn’s disease is an inflammatory bowel condition affecting the entire length of the gastrointestinal tract. Biopsy would demonstrate transmural inflammation and presentation of Crohn’s disease is usually in early 20s.
Melanosis Coli
This is a benign condition identified on colonoscopy in which there is a disorder of pigmentation of the endothelium of the colon. As the condition is benign, it would not produce the symptoms described in the case history.
Malignancy
Malignancy can present with a change in bowel habit, although it is usually less dramatic than severe diarrhoea, while malignancies are usually painless until complications such as perforation or obstruction occur.
Ulcerative Colitis
Ulcerative colitis is an inflammatory bowel disease in which inflammation is limited to the colon. It presents in the early 20s, so a diagnosis of ulcerative colitis in the elderly is uncommon.
A 22-year-old right-hand-dominant woman is referred to the hand surgery unit with pain and swelling of her right index finger. She thinks she has sustained a small puncture wound
to the finger while helping her dad with gardening 2 days ago. On examination the finger is diffusely swollen, erythematous and held in a slightly flexed position. It is exquisitely painful to passively extend the finger , and most tender on the volar aspect.
What is the most likely diagnosis?
1) Cellulitis
2) Flexor tendon sheath infection
3) Foreign body
4) Mallet finger
5) Paronychia
Explanation
Flexor tendon sheath infection
A flexor tendon sheath infection is an infection of the sheath that forms the lubricating surface around the flexor tendons to the hand. This constitutes an emergency as severe infection can destroy these surfaces resulting in a painful and stiff finger. In most cases there will be a history of penetrating trauma before the infection.
There are four main signs of a flexor tendon sheath infection:
*diffuse swelling of the digit
*the digit will be partially flexed
*tenderness along the flexor tendon sheath
*pain on passive extension of the digit.
Cellulitis
Cellulitis would certainly be included in the differential diagnosis given the case history, however, cellulitis would not cause severe pain on passive extension of the finger.
Foreign body
This will likely produce localised inflammation and swelling around the site of the foreign body. Additionally, pain on passively extending the finger suggests tendon sheath infection.
Mallet finger
Mallet finger describes the deformity of disruption of the extensor digitorum tendon at the distal interphalangeal joint with blunt force trauma being the causative injury. The deformity is not described and the patient has not suffered blunt force trauma in the case history.
Paronychia
Paronychia is a local infection around a fingernail that often begins as a cellulitis before developing into an abscess which requires drainage. This is not described in the case history above.
Question:
A 60-year-old woman who had undergone a successful left renal transplant 1 week earlier presents with fever, oliguria, and rising serum creatinine. She has been referred back to the transplant team for ongoing care. Which is the best management option in such a scenario?
Options:
1. It is a picture of acute rejection characterized by preformed antibodies to donor human leukocyte antigen (HLA) and should be treated with intravenous hydrocortisone 2. Tacrolimus should be the first-line treatment 3. The woman has chronic graft rejection 4. Treatment is with prednisolone 5. Urinary obstruction, infection, reduced blood supply and drug toxicity should be considered before treating for acute graft rejection
Correct Answer:
5. Urinary obstruction, infection, reduced blood supply and drug toxicity should be considered before treating for acute graft rejection
Explanation:
In the immediate post-transplant period, a rise in serum creatinine accompanied by fever and oliguria can be due to several potential causes. While acute rejection is a possibility, it is crucial to first rule out other common causes such as:
• Urinary obstruction: Check for any blockages in the urinary tract. • Infection: Infections can cause fever and impact kidney function, and must be treated appropriately. • Reduced blood supply: Ensure that the transplanted kidney is receiving adequate blood flow. • Drug toxicity: Medications used post-transplant can sometimes be nephrotoxic.
It is important to conduct a thorough evaluation to rule out these causes before initiating treatment for acute graft rejection. This approach helps to avoid unnecessary immunosuppressive therapy and addresses any reversible causes of graft dysfunction. Therefore, the correct management strategy in this scenario is to consider and investigate other potential causes of the symptoms before treating for acute graft rejection.
Question:
A 71-year-old diabetic man presents with cellulitis of his lower limb and pyrexia. He has pain on flexion of his ankle and it is tender to palpation. He develops a metabolic acidosis, and his blood pressure and urine output decline steadily throughout the day. Further examination reveals a reddish-bronze discoloration of the skin and decreased sensation, with the margin of infection advancing rapidly along the fascial planes. What is the diagnosis?
Options:
1. Cellulitis 2. Compartment syndrome 3. Myositis 4. Necrotising fasciitis 5. Rhabdomyolysis
Correct Answer:
4. Necrotising fasciitis
Explanation:
Necrotising fasciitis is a severe, rapidly progressing soft tissue infection characterized by widespread necrosis of the fascia and subcutaneous tissue. The key features in this case that point towards necrotising fasciitis include:
• Rapid progression of infection: The infection is advancing rapidly along the fascial planes. • Severe systemic signs: The patient has metabolic acidosis, declining blood pressure, and urine output, indicating severe sepsis or septic shock. • Characteristic skin changes: The reddish-bronze discoloration and decreased sensation are typical signs of necrotising fasciitis. • Tenderness and pain: Severe pain and tenderness beyond what is expected for cellulitis.
These findings distinguish necrotising fasciitis from other conditions such as cellulitis, compartment syndrome, myositis, and rhabdomyolysis, which do not typically present with such rapid progression and systemic deterioration. Immediate surgical intervention and broad-spectrum antibiotics are critical in the management of necrotising fasciitis to prevent further tissue destruction and systemic complications.
Explanation
Necrotising fasciitis
The progressive symptoms and signs with progressive haemodynamic compromise is
highly suggestive of necrotising fasciitis. It is a surgical emergency requiring
debridement with wide margins and treatment with high dose intravenous antibiotics.
Necrotising fasciitis often involves an initial focus such as a puncture wound, insect bite,
or scratch, and usually begins like cellulitis with hot, red and tender skin. However,
there may be an initial dissemination in the deeper tissue planes in the absence of
surface changes. At the leading edge of infection, there is reddish or
bronze discoloration of the skin and decreased sensation. The margin of infection
advances rapidly along fascial planes with thrombosis of perforating vessels, oedema,
necrosis and sloughing of the skin occur. Haemorrhagic bullae are relatively common.
Clinical features can be divided into early findings, which include pain, cellulitis, pyrexia,
tachycardia, swelling, induration and skin anaesthesia. Late findings may include severe
pain, purple or black skin discoloration, blistering, haemorrhagic bullae, crepitus,
discharge of ‘dishwater’ fluid, severe sepsis or systemic inflammatory response
syndrome and multiorgan failure.
Cellulitis
The condition has progressed from a simple cellulitis to necrotising fasciitis given the
worsening condition of the patient and clinical signs of a rapidly spreading fascial
infection.
Compartment syndrome
Compartment syndrome is characterised by increased pressure within an unyielding
osseofascial compartment, resulting in local tissue hypoxia. It is often an early
complication of long bone fractures. The case history given is not consistent with
compartment syndrome.
Myositis
Myositis is a broad term used to describe inflammation of the muscles, of which there
can be many causes including infection, medications, trauma or be immune mediated. It would not be associated with rapidly advancing skin changes or significant
haemodynamic compromise.
Rhabdomyolysis
This is condition causing skeletal muscle to break down rapidly following either direct
or indirect injury, and is a common pathology following a crush injury. A rapid
accumulation of myoglobin can cause significant renal failure. Again, rhabdomyolysis
would not produce skin changes and the history is consistent with necrotising fasciitis.
Question:
A 22-year-old man presents with altered behaviour, fever, and sore throat. His GP started him on a course of amoxicillin. His condition worsened and he was admitted to the Emergency Department with reduced consciousness and a rash over his torso that spread to his limbs together with neck stiffness. What is his likely diagnosis?
Options:
1. Disseminating intravascular coagulopathy (DIC) 2. HIV seroconversion 3. Meningococcal sepsis 4. Staphylococcus scalded skin syndrome 5. Viral infection
Correct Answer:
3. Meningococcal sepsis
Explanation:
The patient’s presentation is highly suggestive of meningococcal sepsis, which is a life-threatening condition caused by the bacterium Neisseria meningitidis. The key features pointing towards this diagnosis include:
• Altered behaviour and reduced consciousness: Suggest central nervous system involvement. • Fever and sore throat: Common initial symptoms of an infection. • Rash: The rash described, which spreads from the torso to the limbs, is characteristic of the petechial or purpuric rash seen in meningococcal sepsis. • Neck stiffness: A sign of meningitis, which often accompanies meningococcal infection.
Other Options:
1. Disseminating intravascular coagulopathy (DIC): A serious condition that involves widespread blood clotting and bleeding, but it does not typically present with the combination of symptoms described. 2. HIV seroconversion: Can present with fever and rash, but the acute presentation of reduced consciousness and neck stiffness is not typical. 3. Staphylococcus scalded skin syndrome: Characterized by widespread redness and skin peeling, typically without the severe systemic symptoms described. 4. Viral infection: While it can present with fever and rash, the severity of symptoms and rapid progression is more indicative of a bacterial cause such as meningococcal sepsis.
Given the critical nature of meningococcal sepsis and the need for urgent treatment, this is the most likely diagnosis.
Question:
An 83-year-old woman is admitted to the hospital with bloody diarrhea, painful abdominal cramps, fever, and leucocytosis. She has recently been discharged from the hospital having been treated for community-acquired pneumonia. What is her likely diagnosis?
Options:
1. Bowel cancer 2. C. difficile 3. Campylobacter jejuni 4. Inflammatory bowel disease 5. Peptic ulcer
Correct Answer:
2. C. difficile
Explanation:
The patient’s presentation is highly suggestive of a Clostridium difficile (C. difficile) infection, which is a common cause of antibiotic-associated colitis. The key features include:
• Recent antibiotic use: She was recently treated for pneumonia, likely with antibiotics, which is a major risk factor for developing C. difficile infection. • Bloody diarrhea and abdominal cramps: These are classic symptoms of C. difficile colitis. • Fever and leucocytosis: Indicate an infectious process, commonly seen in severe C. difficile infection.
Other Options:
1. Bowel cancer: While it can cause changes in bowel habits and bleeding, the acute presentation with fever and leukocytosis is more indicative of an infectious cause. 2. Campylobacter jejuni: Typically causes gastroenteritis with diarrhea, but the association with recent antibiotic use makes C. difficile more likely. 3. Inflammatory bowel disease (IBD): Can present with bloody diarrhea and abdominal pain, but the acute onset after antibiotic use and presence of fever and leukocytosis point more towards an infectious etiology. 4. Peptic ulcer: Usually presents with upper abdominal pain and possibly bleeding, but not with bloody diarrhea and systemic symptoms like fever and leukocytosis.
Given the patient’s history of recent hospitalization and antibiotic treatment, C. difficile infection is the most likely diagnosis.
Question:
A 45-year-old previously well man presents with a 3-day history of constant right groin pain and nausea. He has been limping for 2 days. Physical examination is unremarkable other than slight tenderness in the right groin on palpation. Urine dipstick is positive for blood and his white cells are raised. What is the likely diagnosis?
Options:
1. Cystitis 2. Incarcerated femoral hernia 3. Psoas abscess 4. Pyelonephritis 5. Renal calculi
Correct Answer:
3. Psoas abscess
Explanation:
While renal calculi can present with many of these symptoms, the correct diagnosis in this context is a psoas abscess. The key features supporting this diagnosis include:
• Constant right groin pain and limping: The psoas muscle, located in the retroperitoneal space, can cause referred pain to the groin and hip, leading to limping. • Nausea: Can occur due to systemic infection and inflammation. • Tenderness in the right groin: Psoas abscess often presents with pain that can be elicited on palpation or during movements that stretch the psoas muscle, such as hip flexion. • Raised white cells: Indicative of an infection. • Positive urine dipstick for blood: Can occur due to adjacent structures being affected or due to irritation/inflammation from the abscess.
Other Options:
1. Cystitis: Typically presents with urinary symptoms like dysuria, frequency, and urgency, which are not highlighted in this case. 2. Incarcerated femoral hernia: Would likely present with a palpable mass and more acute, localized symptoms. 3. Pyelonephritis: Usually presents with systemic symptoms like fever, flank pain, and dysuria, and less commonly with significant groin pain and limping. 4. Renal calculi: Although possible, the presence of limping and the specific description of the groin pain suggests a muscular or soft tissue source, such as a psoas abscess.
Given the clinical presentation, a psoas abscess is the most appropriate diagnosis.
A 68-year-old male diabetic patient presents with foot pain. He has long-standing peripheral neuropathy and has been gardening wearing sandals. He reports 3 days of increasing pain and swelling of his calf. His legs are covered in blackened sores.
Which one of the following causes gas gangrene?
1) Clostridium perfringens
2) Staphylococcus aureus
3) Clostridium botulinum
4) Staphylococcus haemolyticus
5) Pseudomonas aeruginosa
Explanation
Clostridium perfringens
Gas gangrene can cause myonecrosis, gas production, and sepsis. It may progress to toxic shock rapidly. Features are large, blackened sores and crepitus caused by gas escaping the necrotic tissue. Clostridia are saprophytes; they live in soil and require a spore to protect them from dehydration. Clostridium perfringens, formerly C. welchii, can cause gas gangrene. There is gas production due to the proteolytic enzymes released by the organism. It also causes food poisoning at about 12–18 h after ingestion. This is caused by exotoxin production.
Staphylococcus aureus
Staphylococcus aureus is the commonest causative pathogen for cellulitis, however the case does not describe a simple cellulitis and another cause should be sought.
Clostridium botulinum
Also a member of the Clostridium genus, C. botulinum produces the exotoxin botulinum,which causes a flaccid paralysis as opposed to gas gangrene.
Staphylococcus haemolyticus
This bacteria is part of normal commensal skin flora, and is often the causative organism in opportunistic infections following a breach in the natural barrier of the skin, such as following cannulation.
Pseudomonas aeruginosa
Pseudomonas is an important pathogen with regard to hospital-acquired infections, multi-drug resistance and infections in immunocompromised patients. Diabetic patients with lower limb ulcers can often become colonised with Pseudomonas causing chronic non-healing ulcers, which are troublesome to treat. It does not however produce gas
gangrene.
A 35-year-old man presents to the Emergency department with a 24-h history of severevthrobbing pain in the finger tip
of his right index finger. He injured his hand while gardening 3 days before and thinks he cut his hand on a rose thorn. The fingertip is erythematous and swollen up to the distal interphalangeal joint (DIP) joint, but not proximal to it.
What is the most likely diagnosis?
1) Apical infection
2) Felon
3) Herpetic whitlow
4) Paronychia
5) Flexor tendon sheath infection
Explanation
Felon
A felon is an abscess in the compartments of the pulp. This is usually more painful than
a paronychia. The swelling does not extend proximal to the distal interphalangeal joint.
The infection often follows a penetrating trauma and is most common in the thumb and
index finger.
Apical infection
An apical infection involves the apical space, ie between the distal part of the nail and
the bone of the distal phalanx, infections of this space may occur when a splinter runs
under the nail. Tenderness is greatest at or just under the free edge of the nail.
Herpetic whitlow
Herpetic whitlow is caused by the herpes simplex virus and small clear vesicles would
be seen.
Paronychia
Paronychia is an infection beside or proximal to the nail, it usually begins as a simple
cellulitis before progressing into a definite abscess which requires incision and
drainage.
Flexor tendon sheath infection
Flexor tendon sheath infection is a surgical emergency with a sausage-shaped digit,
flexed position, tenderness over the flexor tendon sheath and pain on passive extension.
A 10-month-old boy presents with colicky abdominal pain, vomiting and redcurrant stools. On examination there is a
sausage-shaped mass palpable within an otherwise soft abdomen.
What is the most appropriate initial management?
1) Emergency laparotomy
2) Air enema
3) Lower gastrointestinal (GI) endoscopy
4) Rigid sigmoidoscopy
5) Stool softeners
Explanation
Air enema
The clinical picture is of intussusception which occurs in 0.4% of children. It is more common in boys, usually younger than 1 year old. Intussusception occurs when one section of the bowel invaginates into another, the most common form is ileocolic. Blood and mucus or ‘redcurrant jelly’ stool may be passed after the first 24 h as a late manifestation. Sausage-shaped mass may be felt in upper abdomen. Rectal examination is very important as occasionally the apex of intussusception is palpable. The majority of cases are successfully treated conservatively with an air enema.
Emergency laparotomy
Emergency operative management is only indicated in established peritonitis, perforation or failure of enema reduction.
Lower gastrointestinal (GI) endoscopy
Lower GI endoscopy would not be indicated given the clinical scenario, the initial management of choice would be an air enema.
Rigid sigmoidoscopy
Again, rigid sigmoidoscopy is not indicated.
Stool softeners
Stool softeners have no role in the treatment of intussusception.
You are examining an 18-month-old infant who is day 1 post-operation. The infant has a pulse of 150 beats/min, respiratory rate 30 breaths/min, urine output 1.6 ml/kg/h,
haemoglobin 11 g/dl and white-cell count 12 × 10 9 /l.
Which one of these options is abnormal for an infant of this age?
1) Haemoglobin
2) Pulse rate
3) Respiratory rate
4) Urine output
5) White-cell count
Explanation
Pulse rate
The normal ranges for physiological variables and blood test results vary with age in children. The normal value for pulse rate in a infant aged between 1–2 is 100–120 beats per minute, therefore, this infant is tachycardic, which warrants further investigation.
Haemoglobin
The normal range for haemoglobin is 10.5–13.5 g/dl.
Respiratory rate
A normal respiratory rate for an infant aged 1–2 years old is 25–35. This will reduce with age.
Urine output
Normal urine output would be more than 1.5 ml/kg/h.
White-cell count
A normal white-cell count will range from 6–15 × 10 9 /l.
A 1-day-old newborn girl has a distended abdomen and bilious vomiting. Per rectal (PR) examination reveals an empty rectum, and meconium has not been passed.
What is the most likely underlying associated condition that the patient may have?
1) Cerebral palsy
2) Cystic fibrosis
3) Down syndrome
4) Spina bifida
5) Turner’s syndrome
Explanation
Cystic fibrosis
The newborn has meconium ileus. Signs of this include a distended abdomen, bilious
vomiting and an empty rectum. The commonest association is with cystic fibrosis, and
15% of children with cystic fibrosis have meconium ileus.
Cerebral palsy
Cerebral palsy is a broad diagnosis covering a number of neurodevelopmental
conditions affecting movement and coordination. It is not associated with meconium
ileus.
Down syndrome
Down syndrome is a genetic disorder resulting from trisomy of chromosome 21. It is
associated with a number of conditions including congenital heart disease, epilepsy,
hypothyroidism and leukaemia.
Spina bifida
This is a birth defect resulting in failure of closure of the meninges. While there may be
bladder and bowel pathology due to failure of closure of the spinal cord, cystic fibrosis
has the commonest associated with meconium ileus.
Turner’s syndrome
This is a genetic disorder seen in women in which there complete, or partial loss, of the
X chromosome. It is not associated with meconium ileus.
An 8-year-old child presents with vague central abdominal pain and nausea. He is pyrexial (38.7 °C), and has a headache. On examination he has shifting abdominal tenderness and cervical lymphadenopathy.
What is the most likely diagnosis?
1) Acute appendicitis
2) Constipation
3) Crohn’s disease
4) Meckel’s diverticulum
5) Mesenteric adenitis
Explanation
Mesenteric adenitis
Mesenteric adenitis is an inflammation of the mesenteric lymph node accompanied by a
mild peritoneal reaction. It is most common between ages 5–10 years and often
follows/accompanies an URTI.
Acute appendicitis
Acute appendicitis can be distinguished from mesenteric adenitis by lack of cervical
lymphadenopathy, headache, mild abdominal pain, shifting tenderness and pyrexia
greater than 38 °C.
Constipation
Constipation would not cause pyrexia or cervical lymphadenopathy. There are a
number of causes of constipation in children including hypothyroidism, hypercalcaemia,
and Hirschsprung’s disease.
Crohn’s disease
The incidence of Crohn’s disease in children is increasing, presentation is similar to
adults, but children more commonly have extra-gastro-intestinal symptoms, none of
which has been described in the case history.
Meckel’s diverticulum
Meckel’s diverticulum can present with similar symptoms to appendicitis, or with
bleeding, perforation, intussusception, volvulus or obstruction.
A 9-month-old baby boy is brought to the Paediatric Surgical Emergency unit by his parents with a 24-hour history of intermittent episodes of crying, vomiting, and refusal to feed. The parents have noticed that the baby’s stools are mixed with blood. On examination, a ‘sausage-shaped’ mass is palpable over the right side of the abdomen. A per rectal examination reveals an empty rectum, but blood is noticed on the examining glove.
From the options below choose the one which you think is the most likely diagnosis in this patient:
1) Intussusception
2) Infantile hypertrophic pyloric stenosis
3) Duodenal atresia
4) Meconium ileus
5) Hirschsprung’s disease
The most likely diagnosis for this patient is:
Intussusception
Explanation:
1. Intussusception: This is a condition where a part of the intestine telescopes into an adjacent part, causing a blockage. It typically presents with intermittent abdominal pain, vomiting, bloody stools (often described as “currant jelly” stools), and a palpable sausage-shaped mass in the abdomen. The presence of blood on rectal examination supports this diagnosis. 2. Infantile Hypertrophic Pyloric Stenosis: This condition presents with projectile vomiting in infants but does not typically cause bloody stools or a palpable abdominal mass. 3. Duodenal Atresia: This congenital condition causes bilious vomiting in newborns and is usually diagnosed shortly after birth. It does not typically present with bloody stools or a palpable mass. 4. Meconium Ileus: Often associated with cystic fibrosis, this condition presents with bowel obstruction in newborns and meconium impaction but not with the acute symptoms described in this case. 5. Hirschsprung’s Disease: This condition involves a lack of nerve cells in parts of the colon, leading to severe constipation and abdominal distension. It does not typically present with acute episodes of crying, vomiting, or bloody stools.
Given the clinical presentation, intussusception is the most likely diagnosis.
A mother presents her 1-year-old son to the hospital with a history of absence of faeces production for 48 hours. The infant has a distended abdomen with a palpable sausage-shaped mass. His mother thinks he is constipated. What is the most common cause of obstruction in the first 2 years of life?
1) Hirschsprung’s disease
2) Hyperthyroidism
3) Coeliac disease
4) Intussusception
5) Hypercalcaemi
The most common cause of obstruction in the first 2 years of life is:
Intussusception
Explanation:
1. Intussusception: This is the most common cause of intestinal obstruction in young children, particularly between the ages of 6 months and 2 years. It occurs when a part of the intestine telescopes into an adjacent segment, leading to obstruction, reduced blood flow, and potentially severe complications. The classic presentation includes episodic crying, abdominal pain, vomiting, and the passage of “currant jelly” stools. A palpable sausage-shaped mass is a key clinical finding. 2. Hirschsprung’s Disease: While this condition can cause chronic constipation and abdominal distension due to a lack of ganglion cells in the colon, it is not the most common cause of acute intestinal obstruction in this age group. 3. Hyperthyroidism: This condition is rare in infants and does not typically present with acute intestinal obstruction. 4. Coeliac Disease: This autoimmune disorder affects the small intestine due to gluten sensitivity and can cause chronic symptoms such as diarrhea, malabsorption, and failure to thrive, but it is not typically associated with acute intestinal obstruction in infants. 5. Hypercalcaemia: Elevated calcium levels can lead to constipation but are not a common cause of intestinal obstruction in infants.
Given the clinical presentation of a distended abdomen, absence of stool production, and a palpable sausage-shaped mass, intussusception is the most likely diagnosis.
An 80-year-old man is referred to the Emergency Department with abdominal pain and vomiting. His pain
radiates to his back and slightly improves on leaning forwards. Examination reveals a soft abdomen with a very tender epigastrium . His past medical history consists of hypertension for which he takes bendroflumethiazide. Systolic blood pressure is 110 mmHg on both arms. X-rays are unremarkable apart from a prominent central loop.
What is the most likely diagnosis?
1) Aortic dissection
2) Biliary Colic
3) Pancreatitis
4) Renal Colic
5) Ruptured aortic aneurysm
Explanation
Pancreatitis
This patient is most likely to have pancreatitis possibly caused by thiazide diuretic use.
However, the most common cause is alcohol and gallstones in the UK and evidence of this must be sought on history and ultrasound scan. A significantly raised amylase should be apparent on the blood results, >1000 U/l (normal <200 U/l) is virtually diagnostic but beware that peritonitis and perforated duodenal ulcer for example can give similar appearances and a raised. Some units now use serum lipase which can be more sensitive. Pancreatitis can lead to vomiting but the X-ray appearance alludes to a sentinel loop – a paralytic ileus of duodenal or jejunal small bowel caused by local inflammation of the pancreas.
Aortic dissection
Of course in this age group, ruptured abdominal aortic aneurysm (AAA) and aortic dissection must be a consideration and vitally ruled out. Look for evidence of a pulsatile epigastric mass and difference in blood pressure in both arms. Computed tomography (CT) aortogram is suggested if there is any doubt, to rule out these other diagnoses.
Biliary Colic
Biliary colic more commonly presents with intermittent, colicky pain in the right upper quadrant and does not radiate through to the back.
Renal Colic
In renal colic, patients usually cannot get comfortable due to the spasmodic nature of the pain and urine dip may show blood.
Ruptured aortic aneurysm
As above, this is an important diagnosis to exclude, however, the case history is more consistent with acute pancreatitis.
At the request of the nursing staff, you agree to assess a patient who is being treated for a post-operative chest infection. You diagnose septic shock as per recent NICE guidance. On what parameters would you make that diagnosis?
1. Temperature 37°C, pulse rate 110/min, 25 mmHg improvement in systolic blood pressure following fluid bolus 2. Temperature greater than 38.3°C, pulse rate 100/min, blood pressure 134/82 mmHg without intravenous fluids 3. Temperature greater than 38°C and urine output less than 30 ml/h 4. Temperature 37.3°C and pulse rate 80/min 5. Temperature 38.4°C, urine output less than 30 ml/h, no improvement in blood pressure despite fluid challenge
To diagnose septic shock according to the recent NICE guidelines, you should look for the following key parameters:
1. Persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg despite adequate fluid resuscitation. 2. Serum lactate level > 2 mmol/L despite adequate fluid resuscitation.
Given these criteria, the correct answer is:
5. Temperature 38.4°C, urine output less than 30 ml/h, no improvement in blood pressure despite fluid challenge
Explanation:
• A temperature of 38.4°C indicates a fever, which is often present in septic patients. • Urine output less than 30 ml/h indicates significant hypoperfusion, a common feature in septic shock. • No improvement in blood pressure despite a fluid challenge suggests persistent hypotension, which is critical for diagnosing septic shock.
This scenario matches the definition of septic shock as outlined by NICE guidelines, involving persistent hypotension and evidence of organ dysfunction despite fluid resuscitation.
Sepsis is a potentially life-threatening emergency that requires early recognition and management. Prompt intervention subsequently reduces future morbidity and
mortality. According to National Institute of Clinical Excellence (NICE) Guidance, which of the following is a ‘red flag’ for sepsis?
1) Systolic blood pressure <100 mmHg
2) Heart rate >100 beats/min
3) Respiratory rate >25 breaths/min
4) Lactate of 1.9 mmol
5) White blood-cell count of >12 × 10 9 /l
Explanation
Respiratory rate >25 breaths/min
A raised respiratory rate is one of the first parameters to change in the presence of physiological stress. As such, the National Institute of Clinical Excellence (NICE) guidance identifies a raised respiratory rate as an important red flag for sepsis. Recent National Institute of Clinical Excellence (NICE) Guidance was released in 2016 in response to a UK Parliamentary inquiry examining sepsis. The ‘Time to Act’ report found failures in the recognition, diagnosis, and early management of those who died from sepsis. Efforts are now being made to improve the recognition and diagnosis of
sepsis, and close monitoring and identification of abnormal physiological parameters is an important aspect of this.
Systolic blood pressure <100 mmHg
Systolic blood pressure <90 mmHg is identified as a red flag for sepsis. Consideration of baseline blood pressure is also an important factor and therefore a >40 mmHg fall from
patient’s baseline should also be considered as a red flag in the context of sepsis.
Heart rate >100 beats/min
Tachycardia is an important indicator of physiological stress, however, the National Institute of Clinical Excellence (NICE) states that a heart rate >130 beats/min is a red flag for sepsis.
Lactate of 1.9 mmol
An elevated lactate is an indicator of reduce tissue perfusion as a result of anaerobic respiration. A measured lactate of >2.0 mmol is a ‘red flag’ for sepsis.
White blood-cell count of >12 × 10 9 /l
Although this would form part of a detailed review of a patient with suspected sepsis, the red flags refer specifically to physiological parameters. If abnormal, these should then trigger an in-depth review including investigations such as full blood count, blood cultures, radiological imaging as required.
You are sitting in the endocrine surgery clinic and a patient sees you with moon facies, central obesity and peripheral muscle wasting. You suspect Cushing syndrome. Which one of the following options is true of Cushing syndrome?
1) The commonest cause of Cushing syndrome is iatrogenic
2) Cushing syndrome is due to an excess of aldosterone
3) True Cushing syndrome is due to an adrenal adenoma
4) Removal of a pituitary adenoma carries a high risk of Nelson syndrome
5) Cushing syndrome is seen more in men than in women
The correct option is:
1) The commonest cause of Cushing syndrome is iatrogenic
Explanation:
• Iatrogenic Cushing syndrome is the most common cause of Cushing syndrome, resulting from the prolonged use of corticosteroid medications. These medications are often prescribed for conditions such as asthma, rheumatoid arthritis, and lupus. • Cushing syndrome is due to an excess of aldosterone: This statement is incorrect. Cushing syndrome is caused by an excess of cortisol, not aldosterone. Aldosterone excess is related to conditions such as Conn’s syndrome (primary hyperaldosteronism). • True Cushing syndrome is due to an adrenal adenoma: This statement is partially correct but not comprehensive. True Cushing syndrome can result from various sources, including pituitary adenomas (Cushing’s disease), ectopic ACTH production, or adrenal tumors (adenomas or carcinomas). However, adrenal adenomas are not the most common cause. • Removal of a pituitary adenoma carries a high risk of Nelson syndrome: This statement is incorrect. Nelson syndrome is a potential complication after bilateral adrenalectomy for Cushing’s disease, not after removal of a pituitary adenoma. • Cushing syndrome is seen more in men than in women: This statement is incorrect. Cushing syndrome is more commonly seen in women than in men, particularly in cases of Cushing’s disease (pituitary adenoma).
Thus, the most accurate statement regarding Cushing syndrome is that the commonest cause is iatrogenic, primarily due to the use of exogenous corticosteroids.
A 49-year-old man presented in the orthopaedic outpatient clinic with an X-ray that showed a compressed fracture at T10. He complained of increasing weakness over the past few months. Clinical examination revealed a blood pressure of 165/110 mmHg. Laboratory findings included a serum glucose of 8.6 mmol/l. He was mildly obese and had purplish striae on his thighs and abdomen. Which one of the following pathological lesions is most likely to explain these findings?
1. Adrenal cortical carcinoma 2. Anaplastic thyroid carcinoma 3. Multinodular goiter 4. Parathyroid adenoma 5. Phaeochromocytoma
The patient’s presentation is consistent with Cushing’s syndrome, which is characterized by a combination of features including central obesity, hypertension, glucose intolerance (as indicated by elevated serum glucose), and purplish striae. The clinical scenario provided points towards an underlying pathological lesion that can cause Cushing’s syndrome.
Among the options listed, the most likely cause is:
1. Adrenal cortical carcinoma
Explanation:
Adrenal cortical carcinoma can cause Cushing’s syndrome by producing excess cortisol. The symptoms described, such as obesity, hypertension, purplish striae, and glucose intolerance, align with Cushing’s syndrome. Other options, such as anaplastic thyroid carcinoma, multinodular goiter, parathyroid adenoma, and phaeochromocytoma, do not typically present with this specific combination of symptoms.
Thus, the correct answer is:
1. Adrenal cortical carcinoma
Adrenal cortical carcinoma is a rare cancer carrying a poor prognosis, with most cancers metastatic at diagnosis. The female to male ratio is 2–3:1, and there is a bimodal distribution, with peak incidence in the first decade of life and a second peak in the 4th–5th decade. Metastasis is most commonly to periadrenal tissue, regional lymph nodes, bone, liver, and lungs.
These are functioning tumors producing excess amounts of cortisol that are not under the control of pituitary adrenocorticotropic hormone (ACTH). Patients present with red flag symptoms such as fever, weight loss, back pain, and abdominal fullness, but also with symptoms relating to Cushing’s syndrome, as demonstrated in this scenario, and virilization syndromes.
Treatment is with adrenalectomy if the tumor is confined to the adrenal gland, or chemotherapy (mostly mitotane) and/or radiotherapy if there is extensive disease. If the tumor is confined to the adrenal gland and is treated, 5-year survival is 65%. This drops to 44% for tumors with local invasion to surrounding tissues and 7% for tumors with distant metastases at diagnosis.
Cushing’s syndrome involves chronic glucocorticoid excess, of which 90% are adrenocorticotropic hormone (ACTH)-dependent and 10% ACTH-independent. Causes of Cushing’s syndrome include Cushing’s disease and iatrogenic causes such as steroids. Signs of Cushing’s syndrome include:
Head and neck:
• Frontal balding • Moon face • Acne • Gynaecomastia in males • Plethoric complexion
Trunk:
• Kyphosis • Buffalo hump • Central obesity (due to altered fat distribution) • Purple striae on abdomen, breasts, and thighs • Thin, fragile skin • Predisposition to infection
Limbs:
• Proximal myopathy • Pathological fractures • Ankle edema (salt and water retention due to excess cortisol) • Hirsutism • Hair growth on the forearms in particular
Anaplastic carcinoma of the thyroid is a rare entity, accounting for 1–2% of all thyroid cancers, a very aggressive cancer with poor prognosis. It is not known to cause symptoms relating to Cushing’s syndrome.
A multinodular goiter is associated with hyperthyroidism but not Cushing’s syndrome. A parathyroid adenoma causes excessive secretion of parathyroid hormone (PTH) and results in symptoms relating to hypercalcemia and hypophosphatemia but not Cushing’s syndrome.
Phaeochromocytoma is a rare tumor arising most commonly in the chromaffin cells of the adrenal medulla and resulting in increased secretion of catecholamines. Patients tend to present with severe hypertension (often resistant to multiple therapeutic agents), excessive sweating, anxiety/panic attacks, headaches, and pallor.
You were asked to do the endocrine surgery in the outpatient clinic by your consultant. On that particular day you only saw patients with endocrine malignancies. Based on your knowledge about the natural history of various endocrine malignancies, which one of the following neoplasms has the best prognosis?
1) Adrenal cortical carcinoma
2) Anaplastic carcinoma of the thyroid
3) Follicular carcinoma of the thyroid
4) Papillary carcinoma of the thyroid
5) Parathyroid carcinoma
Explanation
Papillary carcinoma of the thyroid
Papillary carcinoma of the thyroid is the most common form of thyroid cancer accounting for 80% of cases, and of the examples in these answers, is the most common.
It is a well differentiated tumour, most commonly presenting in wom en (female to male ratio of 3:1), aged 35–40. It is slow growing and arises from T4 and thyroglobulin- producing follicular cells. It can metastasise via lymphatics and can be multifocal at diagnosis. It can metastasise to the lungs. It most commonly presents as a solitary thyroid nodule.
Histologically it shows stalks of epithelial cells (papillae) and in 50% of cases psammomabodies, representing calcific collections, are present. Additionally, cells show a characteristic pattern of nuclear inclusions called ‘orphan Annie eye’.
Radiologically it appears as a single mass with irregular borders, found in the subscapular region. Treatment is with thyroidectomy and radioactive iodine administration for positive lymph nodes.
If the tumour is confined to the thyroid gland on diagnosis, it has an excellent prognosis and a 5 year survival rate of 95%.
Adrenal cortical carcinoma
Adrenal cortical carcinoma is a rare cancer and prognosis depends on the extent of tumour spread at diagnosis. If the tumour is confined to the adrenal gland and is treated 5-year survival is 65%. This number drops to 44% for tumours with local invasion to surrounding tissues and 7% for tumour with distant metastases at diagnosis.
Anaplastic carcinoma of the thyroid
Anaplastic carcinoma of the thyroid is a rare entity, accounting for 1–2% of all thyroid cancers. It is however the most aggressive tumour and carries the worst prognosis. It
most commonly affects women and patients tend to present at an older age than with other thyroid cancers, ie in the 6th–7th decade of life. Patients present with a rapidly enlarging, firm, fixed thyroid mass and symptoms of local invasion such as hoarse voice and dyspnoea or stridor. Median patient survival is 8.1 months, as anaplastic carcinoma is poorly responsive to treatment.
Follicular carcinoma of the thyroid
Follicular carcinoma of the thyroid is the second most common malignancy of the thyroid accounting for about 10% of all thyroid cancers. It is a well differentiated cancer, typically presenting in women aged 40–60. These tumours arise from the follicular cells of the thyroid. 5-year survival rate is over 80% for non-invasive disease.
Parathyroid carcinoma
Parathyroid carcinoma is a very rare malignancy, occurring equally in men and women, with men having a worse prognosis. It usually occurs after the age of 30. Disease confined to the parathyroid glands at diagnosis has a 5 -year survival rate of 88.5%.
A 25-year-old woman was seen in the Emergency Department complaining of vague abdominal pain and some pain in her extremities. On further enquiry she revealed that she had been feeling depressed for several months. Physical examination revealed no major findings. A chest X-ray was normal. Serum biochemistry revealed the following:
Calcium: 3.47 mmol/l (2.20–2.60 mmol/l)
Serum albumin: 38 g/l (35–55 g/l)
Phosphate: 0.64 mmol/l (0.70–1.40 mmol/l)
What is the most likely diagnosis in this patient?
1) Chronic renal failure
2) Metastatic carcinoma
3) Parathyroid adenoma
4) Pituitary adenoma
5) Thyroid carcinoma
Explanation
Parathyroid adenoma
The patient has hypercalcaemia and hypophosphataemia, pointing towards the diagnosis of primary parathyroid disease. This patient most likely has primary hyperparathyroidism, the most common cause of which is a single parathyroid adenoma (85%). Other causes include: parathyroid gland hyperplasia affecting all four parathyroid glands (10–15%), multiple parathyroid adenomas (3–5%) or a
parathyroid carcinoma (1%).
The adenoma produces an excess of parathyroid hormone leading to: excessive calcium resorption from bone, increased renal calcium reabsorption, increased renal phosphate excretion and increased production of 1,25-dihydroxyvitamin D3 .
Therefore, blood tests reveal: a raised PTH, hypercalcaemia, hypophosphataemia and a raised vitamin D3 .
Treatment of a parathyroid adenoma is by surgical removal of the parathyroid glands.
For patients not fit/suitable for parathyroidectomy options for treatment include:
-preventing vitamin D deficiency, bisphosphonates to protect the bones, calcimimetics to control hypercalcaemia if required.
Chronic renal failure
Chronic kidney failure leads to secondary hyperparathyroidism. The diseased kidney fails to convert an adequate level of vitamin D to its active form, which reduces the amount of calcium absorbed from the intestines, and fails to excrete phosphate leading to formation of calcium phosphate compounds in the circulation and a reduction in free circulating calcium. Therefore, in secondary hyperparathyroidism there is a low serum concentration of calcium and vitamin D, a high serum concentration of parathyroid hormone and a high serum phosphate.
Metastatic carcinoma
The two most common causes of hypercalcaemia are primary hy perparathyroidism and hypercalcaemia of malignancy. The two are generally quite difficult to differentiate. In both calcium is raised (with hypercalcaemia of malignancy causing a more dramatic hypercalcaemia) and phosphate is low. parathyroid hormone (PTH) in primary
hyperparathyroidism is raised whereas in hypercalcaemia of malignancy it can be low/normal/raised depending on the mechanism involved.
Given the patient’s age and the fact that the symptoms have been ongoing for several months make parathyroid adenoma a far more likely diagnosis than metastatic carcinoma. The most common cancers associated with hypercalcaemia are: breast, lung and myeloma.
Pituitary adenoma
A pituitary adenoma causes visual symptoms (bitemporal hemianopia), headaches and symptoms relating to the cellular origin of the adenoma. It does not commonly cause
hypercalcaemia.
Thyroid carcinoma
Thyroid carcinoma can lead to hypercalcaemia, but this is usually seen with advanced disease.
A 48-year-old man smoker presented to his GP complaining of a chronic dry cough and backache. The GP noticed truncal obesity, muscular weakness, hypertension, purplish abdominal striae and tenderness in the region of the lower thoracic spine. The patient was taking no medications.
Which one of the following diseases is most likely to be the cause for these findings?
1) 21-Hydroxylase enzyme deficiency
2) Extra-adrenal paraganglioma
3) Multiple endocrine neoplasia, type I
4) Small-cell anaplastic (oat cell) carcinoma
5) Tuberculosis
Explanation
Small-cell anaplastic (oat cell) carcinoma
The presenting signs in this scenario point to Cushing’s syndrome, secondary to excess circulating cortisol. Given that the patient is a smoker presenting with a dry cough and
lower back pain, it is most likely that the patient has small-cell lung cancer (also known as oat cell lung cancer) that has metastasised to the bones, and also secretes ectopic ACTH causing Cushing’s syndrome, as part of a paraneoplastic syndrome. This is very common with bronchogenic carcinoma.
Small-cell lung cancer is strongly associated with smoking and is a neuroendocrine tumour arising in the bronchial mucosa. It is fast growing, highly metastatic, rarely operable at diagnosis and associated with a 5-year survival of less than 20%.
CUSHing’s is where Cortisol is GUSHing.
Cushing’s syndrome: chronic glucocorticoid excess of which 90% are ACTH-dependent and 10% ACTH-independent. Causes of Cushing’s syndrome include Cushing’s disease
and iatrogenic causes such as steroids.
Signs of Cushing’s:
Head and neck
Trunk
Limbs
Frontal balding
Kyphosis
Proximal myopathy
Moon face
Buffalo hump
Pathological fractures
Acne
Gynaecomastia in males
Ankle oedema (salt and water rententiondue to excess cortisol) Plethoric complexion
Central obesity (due to altered fat distribution)
Hirsutism
Purple striae on abdomen, breasts and thigs
Thin, fragile skin
Hair growth of the foreaems in particular
Predisposition to infection
21-Hydroxylase enzyme deficiency
21-Hydroxylase enzyme deficiency, also known as congenital adrenal hyperplasia, is a condition commonly presenting at birth or early childhood with ambiguous genitalia.
Extra-adrenal paraganglioma
An extra-adrenal paraganglioma, also known as extra-adrenal phaeochromocytoma, are tumours producing catecholamines, such as adrenaline. The signs the patient presents with in this scenario relate to extra circulating cortisol and not catecholamines.
Multiple endocrine neoplasia, type I
Multiple endocrine neoplasia type I is a combination of parathyroid neoplasia, a pancreatic islet tumour and pituitary tumours. Presentation is most commonly with
symptoms associated with hypercalcaemia.
Other symptoms include: diarrhoea and abdominal pain in gastrinoma, hypoglycaemia
in insulinomas. Depending on the place of the pituitary tumour it can present with
Cushing’s disease due to over secretion of ACTH stimulating cortisol secretion.
MEN 1 is however an autosomal-dominant familial disorder, therefore there must be
some family history, presents usually in teenagers or patients in the 4th decade, but
does not tend to present with a cough.
MEN type I = Primary = pathology beginning with P
Parathyroid neoplasia
Pancreatic islet cell tumour (Zollinger–Ellison syndrome (50%), insulinoma (20%))
Pituitary tumours
Tuberculosis Tuberculosis can present with a cough and back pain but it is not known to cause a
Cushing’s syndrome.
A 37-year-old woman presents to your Endocrine Clinic with symptoms of anxiety, panic attacks and frequent headaches. Subsequent investigations have revealed her to have a
phaeochromocytoma. Regarding this condition, what is the
first-line diagnostic test?
1) Clonidine suppression test
2) Metaiodobenzylguanidine (MIBG) scintigraphy
3) Magnetic resonance imaging (MRI) scan
4) Plasma noradrenaline
5) 24-hour urinary vanillylmandelic acid (VMA)/homovanillic (HVA) secretion
Explanation
24-hour urinary vanillylmandelic acid (VMA)/homovanillic (HVA) secretion
Phaeochromocytomas are rare neuroendocrine tumours arising in the chromaffin cells
most commonly found in the adrenal medulla. They are associated with increased
catecholamine production and tend to present with severe hypertension (often
resistant to multiple therapeutic agents), excessive sweating, anxiety/panic
attacks, headaches andpallor. They are usually curable if detected and treated early. If,
however, they remain undiagnosed, they can lead to severe complications including
death.
First-line investigation for phaeochromocytoma includes a 24 h urine collection and
quantification of urinary vanillylmandelic and homovanillic acids. These are byproducts
of catecholamine production and are present at a low concentration in the urine of
unaffected individuals. In phaeochromocytoma, however, the concentration of these
molecules in the urine is significantly raised, indicating an increased production of
catecholamines.
Phaeochromocytomas are associated with conditions such as: multiple endocrine
neoplasias 2A and 2B, von Hippel–Lindau syndrome, neurofibromatosis.
Clonidine suppression test
Clonidine suppression test forms the second line test in the diagnosis of
phaeochromocytoma in cases where there is a high clinical suspicion but there was
borderline elevation in the catecholamines, not enough to qualify for a definitive
diagnosis.
The test relies on the fact that clonidine is a suppressor of physiological catecholamine
secretion, but has no effect over autonomous catecholamine
secretion, as in phaeochromocytoma. There should be collection of urine from 21:00 on
day 1 to 7:00 on day 2 occurs and catecholamines quantified. Then, on day 2, clonidine
is administered and collection of urine follows from 21:00 to 7:00 of day 3.
Catecholamines are quantified. In a normal individual the urine catecholamines from
the second collection, ie following clonidine administration, should be greatly reduced
when compared with the original collection. In patients with a
phaeochromocytoma, however, clonidine is unable to suppress catecholamine release,
and these remain in high concentrations in the urine. Metaiodobenzylguanidine (MIBG) scintigraphy
MIBG scintigraphy is a very specific test for detecting phaeochromocytoma.
Radioactive iodine-131-metaiodobenzylguanidine is administered to the patient. In a
normal patient, the adrenal medulla appears to uniformly uptake the radioactive
solution and its intensity is less than that of the liver uptake. For a patient with a
phaeochromocytoma there is a focal area in the ad renal medulla where there is very
strong and prolonged uptake of the solution. MIBG scintigraphy is not considered the
first-line investigation to detect phaeochromocytoma. MIBG is useful in detecting extra -
adrenal tumours or disease recurrence.
Magnetic resonance imaging (MRI) scan
Computed tomography (CT) and MRI scans are both sensitive in detecting
phaeochromocytomas, with MRI being superior to CT scans, but are not considered the
first-line investigation. These imaging modalities are used to localise t he tumour once
elevated urine catecholamines are detected.
Plasma noradrenaline
Elevated plasma noradrenaline is a sensitive test in detecting phaeochromocytoma. This
test has a high sensitivity of 96%, but a relatively low specificity of 85%, as plasma
noradrenaline can be elevated in other cases such as in patients
taking amitriptyline and some antipsychotic medication.
A 19-year-old woman presents to her GP with anxiety, sweating, heat intolerance,
weight loss and a tremor. Blood tests reveal Graves’ disease.
Which one of the following options concerning Graves’ disease is correct?
1) Carbimazole is drug of choice for treatment throughout pregnancy
2) Has equal sex incidence
3) In children has a high relapse rate when treated with antithyroid drugs
4) Is due to immunoglobulin M (IgM) thyroid-stimulating antibodies
5) Is a form of toxic multinodular goitre
Explanation
In children has a high relapse rate when treated with antithyroid drugs
About half of the children with Graves’ disease treated with antithyroid drug therapy
have a complete remission, but up to 1 in 3 children suffer a relapse. Features that
increase the risk of relapse include a large goitre, a high radioactive iodine uptake and a
high thyroid-stimulating immunoglobulin titre.
Graves’ disease: also known as Graves’ ophthalmopathy, thyroid-associated
ophthalmopathy, dysthyroid eye disease and infiltrative eye disease. In Graves’
disease the thyroid-stimulating auto-immunoglobulins are of the IgG class.
Carbimazole is drug of choice for treatment throughout pregnancy
Hyperthyroidism in pregnancy affects about 0.2% of the pregnant population (0.1 –
0.4%). The vast majority of these cases is caused by Grave’s disease. Carbimazole is the
medication used as first line in the treatment of Graves’ disease. It has however, been
reported to cause severe congenital defects if used during pregnancy. Therefore,
propylthiouracil is the medication of choice to treat Graves’ disease during the first
trimester of pregnancy. Following the first trimester, carbimazole use can resume for
the remainder of the pregnancy, as propylthiouracil is associated with hepatotoxicity.
Propylthiouracil inhibits the production of thyroid hormones by inhibiting the enzyme
thyroperoxidase.
Has equal sex incidence
Hyperthyroidism caused by Graves’ disease is more common in women, with an female
to male ratio of 7–8:1.
Is due to immunoglobulin M (IgM) thyroid-stimulating antibodies
Graves’ disease is the most common cause of hyperthyroidism and is an autoimmune
condition mediated by IgG thyroid-stimulating antibodies, which bind the thyroid-
stimulating hormone receptor, mimic the function of thyroid-stimulating hormone
leading to thyroid hyperplasia and an overproduction of thyroid hormones.
Is a form of toxic multinodular goitre In Graves’ disease the antibodies stimulating the thyroid -stimulating hormone receptor
lead to hyperplasia of the thyroid follicular cells of the thyroid gland leading to a toxic
diffuse goitre.
A 63-year-old woman is seen with an enlarging mass in her thyroid and difficulty
swallowing. She is later diagnosed with follicular carcinoma of the thyroid.
Which one of the statements is correct regarding follicular carcinoma of the
thyroid?
1) It can be diagnosed by fine-needle aspiration cytology (FNAC)
2) It can be monitored for recurrence by calcitonin levels
3) The most common presentation is a hoarse voice
4) It has a higher incidence in iodine-deficient regions of the world
5) It is most common at puberty
Explanation
It has a higher incidence in iodine-deficient regions of the world
Follicular carcinoma occurs more commonly in the Caucasian population, with an
incidence higher in areas of work where there is a higher incidenc e of iodine deficiency.
It can be diagnosed by fine-needle aspiration cytology (FNAC)
FNAC cannot differentiate between follicular carcinoma and follicular adenoma.
Therefore, histological diagnosis follows a thyroid lobectomy. If follicular carcinoma is
confirmed, a completion thyroidectomy should be performed.
It can be monitored for recurrence by calcitonin levels
In follicular carcinoma, up to 30% of patients may suffer a recurrence, which can occur
decades after the primary disease. Thyroglobulin seru m levels are tested every 6–12
months to detect recurrence. A rise in thyroglobulin levels indicates recurrence.
Calcitonin levels are used to monitor recurrence of medullary carcinoma.
The most common presentation is a hoarse voice
The most common presentation of a follicular carcinoma is a single, unilateral nodule or
a thyroid mass felt on palpation of the neck. Other patients present with symptoms of
difficulty swallowing, a hoarse voice or dyspnoea.
It is most common at puberty
Follicular carcinoma is common in all age groups, with cases reported from age 15 to
- It is, however, more common in adults aged 40 –60.
A 25-year-old woman presents to her general practitioner with a history of episodes of severe headaches and palpitations. On examination, it is noted she has a blood pressure of 180/100 mmHg, and further questioning reveals a family history of multiple endocrine neoplasia (MEN) 2a.
Which of the following conditions is found in MEN 2a?
1) Pancreatic tumour
2) Parathyroid hyperplasia
3) Pituitary tumour
4) Renal cell carcinoma
5) Small cell lung carcinoma
Explanation
Parathyroid hyperplasia
MEN is a group of conditions affecting the endocrine organs and presenting with tumours in multiple endocrine organs simultaneously. MEN 2 affects 1 in 35 000 people and, of the two subtypes, the most common is MEN 2a. It is inherited in an autosomal dominant pattern, and therefore, patients have family members who are affected.
MEN 2a is the association of medullary thyroid carcinoma, phaeochromocytoma and parathyroid hyperplasia. MEN 2b is the association of medullary thyroid carcinoma, mucosal neuroma and phaeochromocytoma.
Pancreatic tumour
Pancreatic islet tumours are seen in patients with MEN type 1. Pituitary tumour
A pituitary tumour forms part of MEN syndrome type 1.
Renal cell carcinoma
Renal cell carcinomas are not part of the tumours seen in patients with MEN syndromes.
MEN syndromes are characterised by the formation of tumours in multiple endocrine organs. Though non-endocrine tumours can coexist, they are not part of the description of the syndrome.
Small cell lung carcinoma
Small cell lung carcinoma is not part of the tumours seen in patients with MEN syndromes. MEN syndromes are characterised by the formation of tumours in multiple endocrine organs. Though tumours in non-endocrine organs can coexist, they are not part of the syndrome.
A 54-year-old woman presents with severe epigastric pain and vomiting. Blood tests show an elevated amylase level, and prior blood tests showed she has had hypercalcaemia which is thought may have precipitated acute pancreatitis.
Investigation of the hypercalcaemia shows she has primary hyperparathyroidism caused by a parathyroid adenoma.
What proportion of cases of primary hyperparathyroidism are caused by adenomas?
1) 1%
2) 10%
3) 30%
4) 5%
5) 85%
Explanation
85%
A single parathyroid adenoma is the cause of primary hyperparathyroidism in about 85% of cases.
Less common causes of primary hyperparathyroidism include: parathyroid gland hyperplasia involving all four glands or parathyroid carcinoma.
Excess parathyroid hormone causes hypercalcaemia.
1%
A parathyroid carcinoma can be the cause of primary hyperparathyroidism in about 1% of cases.
10%
In 10–15% of cases of primary hyperparathyroidism, the abnormalities are caused by parathyroid hyperplasia, involving all four parathyroid glands.
30%
Only 30% of patients with primary hyperparathyroidism are symptomatic. The remaining majority are usually asymptomatic, and the abnormalities associated with hyperparathyroidism are detected incidentally.
5%
Three to 5% of cases of primary hyperparathyroidism are due to a double adenoma.
A farmer presents with his wife as he has noted a lump in his lower neck which has increased in size substantially over the last few months. On further questioning, he admits to some difficulty swallowing and his wife thinks his voice has become hoarser. Investigations reveal anaplastic thyroid carcinoma.
In which of the following age groups is this most common?
1) 10-20
2) 30-40
3) 40-50
4) 60-70
5) 80-90
Explanation
60-70
Anaplastic thyroid carcinoma is rare (1–2% of thyroid malignancies) and the most aggressive form of primary thyroid cancer. Peak incidence is seen in adults aged 60–70
and carries a very bad prognosis, with only about 5% survival at 5 years. It is more common in women and is associated with iodine deficiency and a history of a multinodular goitre.
It can metastasise to the bone, brain and lung. Patients present with a rapidly growing neck mass, usually with symptoms of compression such as dyspnoea and dysphagia.
Treatment is usually palliative with doxorubicin and cisplatin but does not affect survival.
10-20
Thyroid cancer is rare in children. The rate of presentation peaks around the ages of
35–39. However, a significant amount of cases have been reported in the literature where a diagnosis of thyroid cancer is made in early adulthood.
30-40
Papillary thyroid carcinoma, which is the most common form of thyroid carcinoma, accounting for about 70% of cases, presents usually in patients aged 35 –40, with a female gender predilection.
40-50
Thyroid lymphomas most commonly affect women aged over 50 and there is an association of these cancers with Hashimoto’s thyroiditis.
80-90
Hurtle cell carcinoma, a rare form of thyroid carcinoma, has been reported in patients from the age of 20–85 years.
A 37-year-old woman presents with a 2-month history of progressively worsening hypothyroid symptoms. On examination, there is diffuse enlargement of her thyroid
gland, and after testing, she is diagnosed with Hashimoto’s thyroiditis.
In addition to anti-thyroglobulin antibodies, which other autoantibodies would be commonly found in Hashimoto’s thyroiditis?
1) Anti-centromere antibodies
2) Anti-microsomal antibodies
3) Anti-mitochondrial antibodiesc
4) ANCA (cytoplasmic Anti-Neutophil Cystoplasmic antibody)
5) pANCA (perinuclear ANCA)
Explanation
Anti-microsomal antibodies
Hashimoto’s thyroiditis is an autoimmune thyroid condition where the presence of
autoantibodies leads to cell destruction in the thyroid, reduced hormone output
and hypothyroidism.
It is the most common cause of hypothyroidism in areas where there is adequate iodine
intake. It is ten times more common in women and tends to present at ages of 30 –50;
however, it can present at any point during a patient’s lifetime.
The most common form of autoantibodies detected in Hashimoto’s thyroiditis is
antibodies against thyroid peroxidase. This is a microsomal component, an essential
enzyme involved in the production of thyroid hormones, and therefore these antibodies
are also referred to as anti-microsomal antibodies. Another group of commonly
detected autoantibodies is anti-thyroglobulin antibodies.
Hashimoto’s thyroiditis is associated with other autoimmune conditions such as
pernicious anaemia and coeliac disease. It also increases the risk for developing
lymphoma of the thyroid at a later stage in life.
Patients tend to present with symptoms (see mnemonic) of insidious onset, gradually
worsening, and with the presence of a diffuse goitre.
Treatment is usually with thyroid hormo ne supplementation. Surgery is not usually
required, unless there are compression symptoms from the goitre. Administration of
steroids can assist in shrinking of the goitre.
Anti-centromere antibodies
Anti-centromere antibodies are found in limited sclerod erma disease (CREST
syndrome).
Anti-mitochondrial antibodies
Anti-mitochondrial antibodies are associated with primary biliary sclerosis, an
autoimmune condition causing liver scarring.
cANCA (cytoplasmic Anti-Neutophil Cystoplasmic antibody)
c-ANCA is an autoantibody directed against proteinase 3 and is found in Wegener’s
granulomatosis. pANCA (perinuclear ANCA)
p-ANCA is an autoantibody directed against myeloperoxidase and is associated with
Churg–Strauss syndrome.
A 33-year-old woman has been listed for a laparoscopic adrenalectomy after being diagnosed with phaeochromocytoma due to episodic palpitations, hyperhidrosis and hypertension. During preoperative investigations, it is discovered she has multiple endocrine neoplasia 2a, and further investigation shows a medullary thyroid carcinoma.
What proportion of medullary thyroid carcinoma is familial ?
1) 1%
2) 5%
3) 20%
4) 50%
5) 75%
Explanation
20%
Medullary thyroid carcinoma is a malignancy of parafollicular C cells, of neural ectodermal origin, accounting for about 5% of total primary thyroid malignancies.
Medullary thyroid carcinoma is sporadic in 80% of the cases and familial in 20%. The familial form usually presents as part of the multiple endocrine neoplasia 2 syndrome (both a and b). The tumour is usually found in the upper two -thirds of the thyroid gland and can produce a variety of hormones such as calcitonin, prostaglandins and adrenocorticotrophic hormone (ACTH). Treatment is with thyroidectomy, with lymph node clearance as required.
The patient in this scenario has medullary carcinoma of the thyroid, presenting as part of multiple endocrine neoplasia type 2a.
1%
Medullary thyroid carcinoma can present with a thyroid nodule and local lymphadenopathy. It is important to note that metastatic medullary thyroid carcinoma presents with diarrhoea and flushes.
5%
Medullary thyroid carcinoma, a malignancy arising from parafollicular C cells , accounts for 5–8% of total primary thyroid malignancy cases.
50%
If a patient presents with metastatic medullary thyroid carcinoma that has spread to other parts of the body, the 10-year survival rate is < 50%, more specifically 20–40%.
75%
Up to 75% of medullary thyroid carcinoma are sporadic and therefore occur in patients with no family history.
A 54-year-old woman has undergone some blood tests, as part of an employment health screen. She reports she is in good health and, being very health-conscious, takes regular
vitamin and mineral supplements. She is taking bendroflumethiazide 2.5 mg for hypertension, and her blood pressure is 132/82 mmHg. The only abnormality is a serum calcium concentration of 2.94 mmol/l (normal 2.20–2.60 mmol/l).
Which of the following is the most likely cause?
1) Diuretic treatment
2) High dietary calcium intake
3) High dietary vitamin D intake
4) Occult malignancy
5) Primary hyperparathyroidism
Explanation
Primary hyperparathyroidism
Given the fact that the patient is asymptomatic, the most likely diagnosis is hypercalcaemia secondary to primary hyperparathyroidism. Primary hyperparathyroidism is, in the majority of cases (85%), the result of a single parathyroid adenoma. Other causes include: parathyroid gland hyperplasia affecting all four parathyroid glands (10–15%), multiple parathyroid adenomas (3–5%) or a parathyroid carcinoma (1%).
The adenoma produces an excess of parathyroid hormone, leading to: excessive calcium resorption from bone, increased renal calcium reabsorption, increased renal phosphate excretion and increased production of 1,25-dihydroxyvitamin D3 .
Therefore, blood tests reveal: a raised parathyroid hormone level, hypercalcaemia, hypophosphataemia and a raised vitamin D 3 level.
Treatment of a parathyroid adenoma is by surgical removal of the parathyroid glands.
For patients not fit/suitable for parathyroidectomy, options for treatment include: preventing vitamin D deficiency, bisphosphonates to protect the bones and calcimimetics to control hypercalcaemia if required.
Diuretic treatment
Thiazide diuretics, such as bendroflumethiazide mentioned in the above scenario, block the thiazide-sensitive Na + /Cl – cotransporter found on the apical membrane of the distal
convoluted tubules and therefore inhibit sodium and chloride reabsorption.
Common side-effects of thiazide diuretics include: hyponatraemia, hypokalaemia, hypercalcaemia, hyperglycaemia, hyperuricaemia, gout, postural hypotension and hypochloraemic alkalosis.
Hypercalcaemia caused by thiazide diuretics, however, is usually mild, and therefore unlikely to be the cause of the raised calcium concentration in this scenario.
High dietary calcium intake
Calcium absorption in the bowel is tightly regulated, and an increased dietary intake of calcium is not thought to be a cause of hypercalcaemia. High dietary vitamin D intake
Hypervitaminosis D, ie excess vitamin D intake, can lead to hypercalcaemia. It is usually the result of taking a large amount of vitamin D supplements. In this case , the patient is
only taking bendroflumethiazide and standard vitamin supplementation.
Occult malignancy
The two most common causes of hypercalcaemia are primary hyperparathyroidism and malignancy. Given the patient in this scenario is asymptomatic, it is more likely that the hypercalcaemia is the result of primary hyperparathyroidism.
A 42-year-old man with a past history of parathyroid adenoma presents with a mass in the neck and enlarged cervical lymph nodes. Fine-needle aspiration cytology confirms a diagnosis of medullary carcinoma of the thyroid.
Which one of the following forms of familial endocrine disease is this most likely to represent?
1) Cowden syndrome
2) Familial medullary carcinoma of the thyroid
3) Multiple endocrine neoplasia type 1
4) Multiple endocrine neoplasia type 2a
5) Multiple endocrine neoplasia type 2b
Explanation
Multiple endocrine neoplasia type 2a
This patient with a history of parathyroid adenoma presents with a medullary carcinoma of the thyroid. This represents an example of multiple endocrine neoplasia type 2a. This is described as the combination of: medullary thyroid carcinoma, phaeochromocytoma and hyperparathyroidism.
Cowden syndrome
Cowden syndrome is a very rare autosomal dominant condition, also referred to as multiple hamartoma syndrome, associated with the presence of multiple non -cancerous
growths called hamartomas. It increases the susceptibility of individuals affected to develop some forms of cancers such as thyroid, endometrial, colorectal and renal cancers and melanoma.
Familial medullary carcinoma of the thyroid
Familial medullary carcinoma of the thyroid is a subtype of multiple endocrine neoplasia type 2 where patients dev elop medullary carcinoma of the thyroid but have a lower probability of having a parathyroid adenoma or a phaeochromocytoma. This accounts for 10–20% of all multiple endocrine neoplasia type 2 cases.
Multiple endocrine neoplasia type 1
Multiple endocrine neoplasia type I describes the combination of parathyroid hyperplasia, pancreatic islet cell tumours and pituitary tumours.
Multiple endocrine neoplasia type 2b
Multiple endocrine neoplasia type 2b describes the combination of a medullary thyroid carcinoma, mucosal neuromas, phaeochromocytoma and marfanoid body habitus.
A woman patient presents with a moderately enlarged thyroid enlargement is symmetrical with a rubbery texture. She is euthyroid middle-aged woman gland. The Anti-thyroglobulin and anti-thyroid peroxidase/anti-microsomal antibodies are raised.
Which one of the following is the most likely diagnosis?
1) Acute suppurative thyroiditis
2) Autoimmune thyroiditis (Hashimoto’s thyroiditis)
3) Graves’ disease
4) Riedel’s thyroiditis
5) Subacute thyroiditis (De Quervain’s thyroiditis)
Explanation
Autoimmune thyroiditis (Hashimoto’s thyroiditis)
Hashimoto’s thyroiditis is an autoimmune thyroid condition where the presence of autoantibodies leads to cell destruction in the thyroid, reduced hormone output and hypothyroidism. It is the most common cause of hypothyroidism in areas where there is adequate iodine intake. It is ten times more common in women and tends to
present at ages 30–50; however, it can present at any point during a patient’s lifetime.
The most common form of autoantibodies detected in Hashimoto’s thyroiditis is antibodies against thyroid peroxidase. This is a microsomal component, an essential
enzyme involved in the production of thyroid hormones, and therefore these antibodies are also referred to as anti-microsomal antibodies. Another group of commonly detected autoantibodies is anti-thyroglobulin antibodies. Patients tend to present with symptoms of insidious onset, gradually worsening, and with the presence of a goitre. It
is a lymphocytic infiltration of the gland, with subsequent fibrosis, leading to diffuse enlargement. The goitre associated with Hashimoto’s thyroiditis is symmetrical,
rubbery in texture and painless. Hashimoto’s thyroiditis is associated with other autoimmune conditions such as pernicious anaemia and coeliac disease. It also increases the risk for developing lymphoma of the thyroid at a later stage in life.
Treatment is usually with thyroid hormone supplementation. Surgery is not usually required, unless there are compression symptoms from the goitre. Administration of steroids can assist in shrinking of the goitre.
Acute suppurative thyroiditis
Acute suppurative thyroiditis is a rare condition caused by bacterial infection of the thyroid gland that tends to affect patients with anatomical defects or concurrent thyroid
disease.
Graves’ disease
Graves’ disease presents with a toxic, diffuse goitre and is associated with thyroid - stimulating antibodies that bind to the thyroid -stimulating hormone receptors.
Riedel’s thyroiditis Riedel’s thyroiditis is a rare condition. It describes the chronic fibrosis of the thyroid gland, resulting in a rapidly growing, painful, hard and fixed thyroid mass. Fibrosis can extend outside the thyroid gland to surrounding structures.
Subacute thyroiditis (De Quervain’s thyroiditis)
De Quervain’s thyroiditis (or subacute thyroiditis) is usually viral in origin, and patients report a preceding viral illness such as mumps, measles, influenza, etc.
A 56-year-old woman presents with abdominal pain and constipation. She has no past medical history. Her blood tests show the following.
Result
Hb 15.3 g/dl. 11.5–15.5 g/dl
MCV. 95 fl. 76–98 fl
WCC. 10.3 x 10 9 /l. 4–11 x 10 9 /l
Serum corrected calcium. 2.95 mmol/l. 2.20–2.60 mmol/l
Serum phosphate. 0.7 mmol/l. 0.7–1.4 mmol/l
Serum alkaline phosphatase. 150 iu/l. 30–130 iu/l
What is the underlying diagnosis?
1) Primary hyperparathyroidism
2) Secondary hyperparathyroidism
3) Tertiary hyperparathyroidism
4) Osteoporosis
5) Paget’s disease
Explanation
Primary hyperparathyroidism
The most common causes of hypercalcaemia are primary hyperparathyroidism and malignancy. In this case, given the patient has mild hypercalcaemia, it is more likely that this is due to primary hyperparathyroidism.
Most primary hyperparathyroidism (85%) is caused by the presence of a single parathyroid adenoma. The adenoma produces an excess of parathyroid hormone (PTH), leading to: excessive calcium resorption from bone, increased renal calcium reabsorption, increased renal phosphate excretion and increased production of 1,25-dihydroxyvitamin D3 .
Therefore, blood tests reveal: a raised PTH level, hypercalcaemia, hypophosphataemia and a raised vitamin D 3 level. A mildly raised alkaline phosphatase level is also seen in primary hyperparathyroidism.
Treatment of a parathyroid adenoma is by surgical removal of the parathyroid glands. For patients not fit/suitable for parathyroidectomy, options for treatment include:
preventing vitamin D deficiency, bisphosphonates to protect the bones and calcimimetics to control hypercalcaemia if required.
Secondary hyperparathyroidism
In chronic renal disease, there is a reduction in the secretion of phosphate, with reduced estimated glomerular filtration rate (eGFR). The resulting hyperphosphataemia
stimulates PTH secretion and causes formation of calcium and phosphate crystals, leading to hypocalcaemia.
Therefore, in secondary hyperparathyroidism, biochemical findings include: raised PTH, low calcium, raised phosphate and raised alkaline phosphatase levels.
Tertiary hyperparathyroidism
Following a long-standing period of secondary hyperparathyroidism or following a renal transplant, tertiary hyperparathyroidism can arise. Following a period of
parathyroid gland stimulation, the parathyroid glands continue to secrete PTH autonomously and result in: raised PTH levels, hypercalcaemia and hyperphosphataemia.
Osteoporosis
Osteoporosis leaves calcium, phosphate and PTH levels unaffected. Alkaline phosphatase is normal.
Paget’s disease
Paget’s disease of the bone is associated with excessive bone breakdown and formation, with subsequent disorganised bone remodelling. This results in weakened bones
associated with pain and fractures.
In Paget’s disease, calcium, phosphate and PTH levels remain unaffected. Alkaline phosphatase level is markedly raised in Paget’s disease.
You are in the General Surgery Clinic and the general practitioner has referred a man with a breast lump. You examine the man and find he has gynaecomastia, with no
palpable mass of any concern.
Which of the following is a cause for this?
1) Liver cirrhosis
2) Low-dose, occasional cimetidine
3) Oral corticosteroids
4) Parathyroid gland tumours
5) Regular bromocriptine therapy
Explanation
Liver cirrhosis
Gynaecomastia, defined as ‘benign proliferation of male breast tissue’, is caused by a disruption in the oestrogen:testosterone ratio, in favour of oestrogen. It can be secondary to some medication therapy, most commonly spironolactone.
In liver disease, there is an increased activity of aromatase enzyme, leading to conversion of androgens to oestrogens. Additionally, the resulting high oestrogenic state increases the production of sex hormone-binding globulin (SHBG) in the liver, leading to a further decrease in serum free testosterone levels.
This tip in the balance in favour of oestrogen leads to gynaecomastia, as the oestrogens induce ductal hyperplasia and proliferation of breast tissue. Patients with alcoholic liver disease are at a higher risk for gynaecomastia because
phyto-oestrogens found in alcohol are direct inhibitors of testosterone.
Low-dose, occasional cimetidine
Cimetidine is a histamine receptor blocker used in the treatment of gastro-oesophageal reflux disease and in the prevention of gastric ulcers. Common side-effects of cimetidine include dizziness, drowsiness, diarrhoea and headache. It can rarely cause gynaecomastia or a breast lump, as it affects the cytochrome P450system in the liver and leads to raised serum oestrogens. This can lead to
gynaecomastia but is dose-dependent and seen in high doses and prolonged treatment.
Oral corticosteroids
Oral corticosteroids can lead to fat redistribution but are not known to cause gynaecomastia.
Parathyroid gland tumours
Parathyroid gland tumours present with signs relating to hypercalcaemia such as polyuria, polydipsia, renal stones, constipation and mental disturbances (depression).
Regular bromocriptine therapy Bromocriptine is an ergot derivative and a potent dopamine receptor agonist. It is used
in the treatment of Parkinson’s disease and also to suppress lactation in the treatment of galactorrhoea or in women following an intrauterine fetal death, by inhibiting secretion of prolactin. Known side-effects include: nausea, vomiting, constipation, hypotension, confusion and lethargy. It is not known to cause gynaecomastia.
A 42-year-old woman is referred to the Endocrine Clinic, as she was noted by the general practitioner to have a persistently raised blood pressure which has not responded to medication. She complains of heat intolerance, sweating and palpitations. She also reports a family history of phaeochromocytoma.
Which of the following options would be a good first-line investigation for phaeochromocytoma?
1) Clonidine suppression test
2) MIBG scintigraphy
3) Magnetic resonance imaging (MRI)
4) Plasma noradrenaline
5) 24-hour urinary vanillylmandelic acid (VMA)/homovanillic acid (HVA) secretion
Explanation
24-hour urinary vanillylmandelic acid (VMA)/homovanillic acid (HVA) secretion
Phaeochromocytomas are rare neuroendocrine tumours arising in the chromaffin cells,
most commonly found in the adrenal medulla. They are associated with increased
catecholamine production and tend to present with severe hypertension (often
resistant to multiple therapeutic agents), excessive sweating, anxiety/panic attacks,
headaches and pallor. They are usually curable if detected and treated appropriately. If,
however, they remain undiagnosed, they can lead to severe complications, including
death.
The first-line investigation for phaeochromocytomas includes a 24 -hour urine collection
and quantification of urinary VMA and HVA. These are by-products of catecholamine
production and are present in low concentrations in the urine of unaffected individuals.
In phaeochromocytoma, however, the concentration of these molecules in the urine is
raised, indicating an increased production of catecholam ines.
Phaeochromocytomas are associated with conditions such as multiple endocrine
neoplasia types 2a and 2b, von Hippel–Lindau syndrome and neurofibromatosis.
Clonidine suppression test
The clonidine suppression test forms the second -line test in the diagnosis of
phaeochromocytoma in cases where there is a high clinical suspicion but there is
borderline elevation in the catecholamines, not enough to qualify for a definitive
diagnosis.
The test relies on the fact that clonidine is a suppressor of physiologi cal catecholamine
secretion but has no effect over autonomous catecholamine secretion, like in the case of
phaeochromocytoma.
Collection of urine from 2100 h on day 1 to 0700 h on day 2 occurs and catecholamines
quantified. Then, on day 2, clonidine is administered and collection of urine follows
from 2100 h to 0700 h on day 3. Catecholamines are quantified. In a normal individual,
the urine catecholamines from the second collection, ie following clonidine
administration, should be greatly reduced when comp ared to the original collection. In patients with phaeochromocytoma, however, clonidine is unable to suppress
catecholamine release, and these remain in high concentrations in the urine.
MIBG scintigraphy
MIBG scintigraphy is a very specific test for detecting phaeochromocytoma. Radioactive
iodine-131-metaiodobenzylguanidine is administered to the patient. In a normal
patient, the adrenal medulla appears to uniformly uptake the radioactive solution and
its intensity is less than that of liver uptake. In the case of a patient with
phaeochromocytoma, there is a focal area in the adrenal medulla where there is very
strong and prolonged uptake of the solution. MIBG scintigraphy is not considered the
first-line investigation to detect phaeochromocytoma. MIBG is u seful in detecting extra-
adrenal tumours or disease recurrence.
Magnetic resonance imaging (MRI)
Computerised tomography (CT) and MRI scans are both sensitive in detecting
phaeochromocytomas, with MRI being superior to CT, but are not considered the first -
line investigation. These imaging modalities are used to localise the tumour once
elevated urine catecholamines are detected.
Plasma noradrenaline
Elevated plasma noradrenaline is a sensitive test in detecting phaeochromocytoma. This
test has a high sensitivity of 96%, but a relatively low specificity of 85%, as plasma
noradrenaline can be elevated in other cases such as in patients taking amitriptyline
and some antipsychotic medication.
A 60-year-old man is 2 weeks post-renal transplant, complaining of polyuria and polydypsia. His blood tests show the following:
Result
Hb. 10.1 g/dl. (13-18 g/dl)
MCV. 80 fl. (76–98 fl)
Ca. 2.95 mmol/l. (2.20–2.60 mmol/l)
Phosphate. 1.8 mmol/l. (0.7–1.4 mmol/l)
Alkaline phosphatase (ALP). 150 iu/l. (30–130 iu/l)
What is the underlying problem?
1) Primary hyperparathyroidism
2) Secondary hyperparathyroidism
3) Tertiary hyperparathyroidism
4) Osteoporosis
5) Paget’s disease
Explanation
Tertiary hyperparathyroidism
The patient presents with symptoms relating to hypercalcaemia that is caused by
tertiary hyperparathyroidism. Following a long -standing period of secondary
hyperparathyroidism, such as that occurring during renal failure, tertiary
hyperparathyroidism can arise. This is commonly seen following renal transplantation
to treat renal failure. Due to the prolonged stimulation that has occurred in the
parathyroid glands, in response to the relative serum hypocalcaemia caused by renal
failure, the glands continue to secrete PTH autonomously and inappropriately, even
after the correction of hypocalcaemia. As in the above scenario, this results in: raised
PTH levels, hypercalcaemia and hyperphosphataemia. Alkaline phosphatase level is
mildly raised in all forms of hyperparathyroidism but can also be normal.
Primary hyperparathyroidism
Primary hyperparathyroidism is most commonly due to a parathyroid adenoma and
results in raised parathyroid hormone (PTH) levels, hypercalcaemia (usually mild to
moderate), hypophosphataemia and raised vitamin D 3 levels. A mildly raised alkaline
phosphatase level is also seen in primary hyperparathyroidism. Secondary hyperparathyroidism
In chronic renal disease, there is a reduction in the secretion of phosphate, with reduced
estimated glomerular filtration rate (eGFR). The resulting hyperphosphataemia
stimulates PTH secretion and causes the formation of calcium and phosphate crystals,
leading to hypocalcaemia.
Therefore, in secondary hyperparathyroidism, biochemical findings include: raised PTH,
low calcium, raised phosphate and raised alkaline phosphatase levels.
Osteoporosis
Osteoporosis leaves calcium, phosphate and PTH levels unaffected. Alkaline
phosphatase level is normal.
Paget’s disease
Paget’s disease of the bone is associated with excessive bone breakdown and formation,
with subsequent disorganised bone remodelling. This results in weakened bones
associated with pain and fractures.
In Paget’s disease, calcium, phosphate and PTH levels remain unaffected. Alkaline
phosphatase level is markedly raised in Paget’s disease.
A patient is admitted to A&E with deranged biochemistry. Which of the following malignancies could be responsible for hypercalcaemia and low serum phosphate levels?
1. Osteoclastoma 2. Squamous cell carcinoma of the lung 3. Prostate cancer 4. Transitional cell carcinoma of the bladder 5. Basal cell carcinoma
Squamous cell carcinoma of the lung is responsible for hypercalcaemia and low serum phosphate levels. Ten percent of all lung cancers produce hormones or peptides involved in paraneoplastic syndromes.
One of the most commonly encountered paraneoplastic syndromes is humoral hypercalcaemia of malignancy, seen with squamous cell carcinoma of the lung. This cancer produces parathyroid hormone-related peptide, which mimics the action of parathyroid hormone.
Consequently, it causes hypercalcaemia and hypophosphataemia, as parathyroid hormone stimulates calcium resorption from bone, renal calcium reabsorption, renal phosphate excretion, and increased production of 1,25-dihydroxyvitamin D3.
Osteoclastoma is normally a benign primary bone tumor and does not typically cause hypercalcaemia and hypophosphataemia.
Prostate cancer can metastasize to the bones and lead to the release of calcium and phosphate into the bloodstream, resulting in hypercalcaemia and hyperphosphataemia.
Transitional cell carcinoma of the bladder may metastasize to the bones. Metastatic cancerous bone lesions can result in the release of mineralized calcium and phosphate into the bloodstream, leading to hypercalcaemia and hyperphosphataemia.
Basal cell carcinoma rarely associates with hypercalcaemia. Hypercalcaemia is more commonly associated with squamous cell carcinoma of the skin and melanoma, but not with basal cell carcinoma.
A 70-year-old man complains of constantly feeling cold and lethargic. He presents to the outpatient clinic referred by the GP as possible malignancy. What is the most likely hormonal deficiency to account for this?
1. Somatostatin 2. Cholecystokinin 3. Testosterone 4. Thyroxine 5. Insulin
Thyroxine deficiency, or hypothyroidism, is most likely to be affecting the patient in this scenario. It can be either primary (due to the thyroid gland not producing enough thyroxine) or secondary (where the thyroid gland is normal but does not receive enough TSH for stimulation of hormone production, suggesting a pituitary problem). Thyroxine is involved in the stimulation of cell metabolism and thermoregulation. Deficiency presents with a variety of symptoms relating to metabolic and mental slowness. If hypothyroidism is confirmed, it is treated with hormone replacement with a synthetic T4 molecule and monitored by regular TSH serum levels.
Somatostatin is a peptide hormone produced in the delta cells of the islets of Langerhans in the pancreas and the ventromedial nucleus of the hypothalamus. It inhibits the production of glucagon and insulin in the pancreas and the secretion of gastric acid, gastrin, and secretin. In the pituitary, it inhibits the secretion of multiple hormones such as growth hormone and thyroid-stimulating hormone (TSH). Somatostatin overproduction can result in diabetes, gallstones, fat intolerance in the diet, steatorrhea, and diarrhea. Somatostatin deficiency is very rare; only a few cases have been reported in the literature. However, decreased cerebrospinal fluid levels of somatostatin have been documented in patients with Alzheimer’s disease.
Cholecystokinin is a hormone produced by the I cells of the duodenum, which has multiple functions. It is released in response to the presence of fat in the duodenum and inhibits gastric emptying, promotes pancreatic hormone secretion, and promotes contraction of the gall bladder and relaxation of the sphincter of Oddi. Deficiency of cholecystokinin is extremely rare and usually manifests as part of a polyglandular syndrome, resulting in malabsorption.
Testosterone deficiency presents with loss of libido, erectile dysfunction, low semen volume, fatigue, hair loss, decrease in bone and muscle mass, with a corresponding increase in body fat, as well as mood changes.
Insulin deficiency presents with features of diabetes mellitus such as polyuria, polydipsia, increased thirst, and loss of weight.
Remember, hypothyroidism is ten times more common in women than men and occurs mainly in middle life.
A 41-year-old woman presents with renal colic. Biochemistry results reveal a plasma calcium level of 3.3 mmol/l (2.20–2.60 mmol/l), with an albumin level of 45 g/l (35 –55 g/l). Her medical history includes dyspepsia and depression.
What is the most likely underlying diagnosis?
1) Actinomycosis infection
2) Ectopic parathyroid hormone
3) Hyperparathyroidism
4) Hypoparathyroidism
5) Vitamin D deficiency
Explanation
Hyperparathyroidism
The patient presents symptomatic of hypercalcaemia with a renal stone, dyspepsia and depression. Given the patient is young and fit, the most likely cause of the hypercalcaemia seen in this scenario is primary hyperparathyroidism. However, as hypercalcaemia is commonly due to malignancy, this needs to be excluded.
Primary hyperparathyroidism is, in the majority of cases (85%), the result of a single parathyroid adenoma. Other causes include: parathyroid gland hyperplasia affecting all
four parathyroid glands (10–15%), multiple parathyroid adenomas (3–5%) or a parathyroid carcinoma (1%).
The adenoma produces an excess of parathyroid hormone, leading to excessive calcium resorption from bone, increased renal calcium reabsorption, increased renal phosphate
excretion and increased production of 1,25-dihydroxyvitamin D3 .
Therefore, blood tests reveal: a raised parathyroid hormone level, hypercalcaemia, hypophosphataemia and a raised vitamin D 3 level.
Treatment of a parathyroid adenoma is by surgical removal of the parathyroid glands (parathyroidectomy). For patients not fit/suitable for parathyroidectomy, options for treatment include: preventing vitamin D deficiency, bisphosphonates to protect the bones and calcimimetics to control hypercalcaemia if required.
Actinomycosis infection
Actinomycosis infection is a bacterial infection characterised by a suppurative granulomatous inflammation and formation of multiple abscesses, discharging sulfur - containing granules. It commonly affects the thorax, abdomen or face and neck (cervicofacial). Abdominal actinomycosis presents with sensation of a mass, fever,
weight loss, fatigue, nausea and vomiting. Blood biochemistry is usually normal, with the exception of a raised alkaline phosphatase level in the case of hepatic actinomycosis.
Ectopic parathyroid hormone
Ectopic parathyroid hormone secretion is usually secondary to malignancy as part of a paraneoplastic syndrome. Even though hypercalcaemia of malign ancy is a common cause of hypercalcaemia and needs to be excluded in this case, given the patient is young and fit, the most likely cause of the biochemical picture seen is primary hyperparathyroidism. Hypoparathyroidism
Hypoparathyroidism results in parathyroid hormone deficiency and subsequently in hypocalcaemia.
Vitamin D deficiency
Vitamin D deficiency would result in hypocalcaemia, as vitamin D is essential for the absorption of dietary calcium in the gastrointestinal system.
A patient is seen in the clinic with exopthalmous.
Which of the following thyroid function tests (TFTs) is suggestive of Graves’
disease?
1) Raised thyroid-stimulating hormone (TSH), raised free T4, raised free T3
2) Normal TSH, raised free T4, decreased T3
3) Decreased TSH, raised free T4, raised free T3
4) Decreased TSH, decreased free T4, decreased free T3
5) Raised TSH, normal free T4, normal free T3
Explanation
Decreased TSH, raised free T4, raised free T3
Graves’ disease is an autoimmune condition leading to a diffuse enlargement of the
thyroid, hyperstimulation and increased production of thyroid hormones. In Graves’
disease, there are thyrotropin receptor antibodies (immunoglobulin G (IgG) antibodies)
circulating in the blood, stimulating the TSH receptor and promoting the production of
thyroid hormones.
There is therefore increased free T3 and T4; this acts as a negative feedback on the
pituitary, suppressing the production of endogenous TSH, which is why, in Graves’
disease, TSH is low.
Raised thyroid-stimulating hormone (TSH), raised free T4, raised free T3
This can be seen in the presence of a TSH-secreting pituitary tumour, amiodarone
therapy or acute psychiatric illness.
Normal TSH, raised free T4, decreased T3
Beta blocker therapy interferes with the conversion of T4 to T3 and can therefore cause
the above picture.
Decreased TSH, decreased free T4, decreased free T3
This clinical scenario describes patients who have recently been treated for
hyperthyroidism or patients with congenital TSH or thyrotropin-releasing hormone
deficiency.
Raised TSH, normal free T4, normal free T3
This is the presentation of subclinical hypothyroidism.
A 49-year-old woman presents to the Outpatient Clinic with a corrected calcium level of 1.9 mmol/l. Clinical examination is unremarkable.
What is the most likely cause for her clinical problem?
1) Acute renal failure
2) Multiple endocrine neoplasia type 1 (MEN 1)
3) Parathyroid adenoma
4) Pregnancy
5) Vitamin D deficiency
Explanation
Vitamin D deficiency
Vitamin D is essential for the absorption of calcium in the gastrointestinal tract.
Therefore, a deficiency in vitamin D can cause reduced absorbed calcium from the diet and lead to hypocalcaemia.
Secondary hyperparathyroidism is a condition that results in stimulation of PTH secretion due to a reduction in serum calcium concentration. It is most commonly seen in chronic renal failure where there is reduced vitamin D activation and reduced phosphate excretion. The result is a reduction in calcium absorption from the gastrointestinal tract, but also binding of the free calcium to phosphate, causing the
formation of calcium phosphate compounds. These both lead to hypocalcaemia and stimulation of the parathyroid glands to produce PTH, in an effort to increase calcium
concentration in the serum.
Acute renal failure
Hypocalcaemia is often seen with chronic renal failure, as part of secondary hyperparathyroidism.
Multiple endocrine neoplasia type 1 (MEN 1)
MEN 1 is associated with a parathyroid adenoma, leading to hypercalcaemia through the mechanism of primary hyperparathyroidism, a pancreatic islet cell tumour and a
pituitary tumour.
Parathyroid adenoma
A parathyroid adenoma leads to primary hyperparathyroidism, through excess
secretion of parathyroid hormone (PTH) from the adenoma. Biochemical features of
primary hyperparathyroidism include: hypercalcaemia, hypophosphataemia, raised
PTH level and raised vitamin D 3 level. There is sometimes raised alkaline phosphatase
level as well.
Pregnancy
Pregnancy is a cause of primary hyperparathyroidism, resulting from hyperplasia of the
parathyroid glands.
A 23-year-old woman is commenced on
long-term
prednisolone for adrenal
insufficiency. She is currently otherwise fairly fit and well
On which of the side-effects should you counsel her?
1) Avascular necrosis of bone
2) Hepatotoxicity
3) Hyperkalaemia
4) Bone marrow suppression
5) Hypotension
Explanation
Avascular necrosis of bone
Avascular necrosis of bone and osteoporosis are well -recognised side-effects of long-
term corticosteroid therapy, irrespective of its mode of administration.
This is a multifactorial process, characterised by interruption of the vascular supply to
the bone, leading to marrow, medullary bone and cortex necrosis. Most commonly,
affected bones are those with a terminal blood supply, and necrosis occurs in the
epiphysis. These include the femur, humerus, carpals and talus.
Factors that increase the risk include: female gender, high daily dose and prolonged
therapy. It is thought that concurrent autoimmune disease also increases the risk of
developing avascular necrosis with corticosteroid therapy.
Hepatotoxicity
Glucocorticoid therapy is not known to have toxic effects on the liver.
Hyperkalaemia
Glucocorticoids exert several effects on the kidneys. They increase water diuresis and
glomerular filtration rate, while causing hypernatraemia and hypokalaemia, due to an
increase in sodium retention and potassium secretion.
Bone marrow suppression
Initiating corticosteroid therapy can cause a refl ex leukocytosis, predominantly
affecting polymorphonuclear leukocytes, ie neutrophils.
Prolonged therapy can lead to suppression of the immune system and increase the risk
for infection. Steroid therapy is not, however, a common cause of bone marrow
suppression, with common causes being cytotoxic chemotherapy or
immunosuppressants such as azathioprine.
Hypotension
Glucocorticoid therapy is associated with hypertension, and not hypotension. Steroids
stimulate the mineralocorticoid receptor in the kidney, resulting in sodium and water
resorption, increase in intravascular volume and therefore increase in blood pressure.
A 44-year-old woman is seen in the pre-assessment clinic before inguinal hernia repair. Her chest radiograph is normal and her blood results are as follows:
Ca. 3.0 mmol/l. 2.20–2.60 mmol/l
Na. 136 mmol/l. 135–145 mmol/l
K. 3.7 mmol/l. 3.5–5.0 mmol/l
Urea. 5.5 mmol/l. 2.5–6.5 mmol/l
Cr. 50 μmol/l. 50–120 μmol/l
What is the most likely cause of the hypercalcaemia?
1) Addison’s disease
2) Chronic renal failure
3) Diabetes mellitus
4) Sarcoidosis
5) Thyrotoxicosis
Explanation
Thyrotoxicosis
Thyrotoxicosis is associated with hypercalcaemia. Thyroid hormones directly stimulate bone resorption leading to decalcification and demineralisation leading to an increase in
serum calcium. This mechanism is not associated with hyperparathyroidism. However, there is a significant proportion of patients with hyperthyroidism that have concomitant primary hyperparathyroidism, leading to hypercalcaemia.
It is estimated that hypercalcaemia is seen in 25% of patients with proven hyperthyroidism. The patient will need other tests such as: thyroid-stimulating hormone (TSH), parathyroid hormone (PTH) as well as free T4 / T 3 to confirm the diagnosis. Toxic goitres tend to most commonly present around the 4 th -5 th decade of life, fitting with the age of the patient in this scenario.
Addison’s disease
Addison’s disease is a known cause of hypercalcaemia. It is due to adrenocortical insufficiency leading to glucocorticoid and mineralocorticoid deficiency. As a result of the mineralocorticoid (aldosterone) deficiency there is sodium loss in the kidneys and potassium retention.
Therefore Addison’s disease is associated with hyponatraemia an hyperkalaemia. With a normal sodium and potassium in this scenario the cause of the hypercalcaemia is not Addison’s disease.
Chronic renal failure
In this scenario the patient’s renal function is completely normal, with a normal urea and creatinine, ruling out chronic renal failure. Chronic renal failure is a common cause of secondary hyperparathyroidism presenting with a raised parathyro id hormone, hypocalcaemia and hyperphosphataemia. This is because in chronic renal disease there is a reduction in the excretion of phosphate and a low glomerular filtration rate. The retained phosphate creates phosphate–calcium compounds in the blood leading to a low free serum calcium.
Diabetes mellitus
Patients with diabetes mellitus are more likely to develop hypocalcaemia, as a result of diabetic renal disease, rather than hypercalcaemia. However, in some cases there is co -
existence of hyperparathyroidism and diabetes mellitus.
Sarcoidosis
Even though sarcoidosis is a cause of hypercalcaemia, it is unlikely in this scenario given the mention of a normal chest radiograph. Sarcoidosis presents with hilar and mediastinal node enlargement as well as parench ymal lung disease, both evident on chest radiography.
A 53-year-old woman undergoes
total thyroidectomy
for a benign multinodular goitre.
Her post-operative calcium is
1.8 mmol/l
and she complains of
tingling
in her fingers.
What is the most likely diagnosis?
1) Hypercalcaemia and overall reduced osteoclast activity
2) Hypocalcaemia and overall increased bone resorption and reduced parathyroid
hormone secretion
3) Hypocalcaemia and reduced conversion of vitamin D to 1,25-
dihydroxycholecalciferol
4) Hypocalcaemia and reduced renal reabsorption of calcium through the action of
1,25-dihdroxycholecalciferol
5) Hypocalcaemia and increased bone resorption
Explanation
Hypocalcaemia and reduced conversion of vitamin D to 1,25-dihydroxycholecalciferol
Post-operative hypocalcaemia is the most common complication encountered following
a thyroidectomy. This is caused by acute parathyroid insufficiency from the reduction in
the parathyroid parenchymal tissue, as often some or all of the parathyroid glands are
removed during a total thyroidectomy. This results in a reduced level of synthesis of
parathyroid hormone and leads to a reduction in bone resorption, reduced conversion
of vitamin D to 1,25-dihydroxycholecalciferol in the kidney are a
resulting hypocalcaemia due to a reduced absorption of dietary calcium in the
gastrointestinal tract. The resulting hypocalcaemia presents with paraesthesia in the
extremities and peri-orally (circumoral), abdominal cramps, tetany and posi tive
Chvostek’s and Trousseau’s signs.
Hypercalcaemia and overall reduced osteoclast activity
The patient presents with hypocalcaemia.
Hypocalcaemia and overall increased bone resorption and reduced parathyroid
hormone secretion
Increased bone resorption is the result of increased action of the parathyroid hormone
(PTH) and leads to hypercalcaemia. In hypoparathyroidism, there is a reduced level of
parathyroid hormone, with an overall decrease in bone resorption and hypocalcaemia.
Hypocalcaemia and reduced renal reabsorption of calcium through the action of 1,25 -
dihdroxycholecalciferol
Absorption of calcium through the action of 1,25 -dihydroxycholecalciferol occurs in the
gastrointestinal tract and not in the renal tract.
Hypocalcaemia and increased bone resorption Increased bone resorption is the result of increased action of parathyroid hormone
(PTH) and leads to hypercalcaemia and not hypocalcaemia.
You review a 75-year-old woman in fracture clinic who has a left distal radial fracture,
following a low energy injury. She has previously had a fractured neck of femur and two
vertebral wedge fractures. You discuss osteoporosis with the patient. They ask you what
can cause poor bone calcification.
Which one of the following is a cause of poor bone calcification?
1) Hypothyroidism
2) Bisphosphonates
3) Calcitonin
4) Hormone replacement therapy (HRT)
5) 1,25-Dihydroxyvitamin D deficiency
Explanation
1,25-Dihydroxyvitamin D deficiency
This patient presents with fragility fractures secondary to osteoporosis. Osteoporosis, is
a disease characterised by reduced bone strength leading to increased risk of fractures
and it most commonly occurs in post-menopausal women due to a variety of causes that
favour bone catabolism rather than bone mass increases and build up. Osteoporosis
presents with unusual fractures at low impact eg vertebral, neck of femur and Colles’
fractures. Vitamin D deficiency is one of the common causes leading to osteoporosis and
fragility fractures. Inadequate 1,25-dihydroxyvitamin D (1,25-dihydroxycholecalciferol)
can result either from inadequate exposure to sunlight, inadequate intake of vitamin D.
Vitamin D deficiency in children results in rickets, and in adults in osteomalacia, both of
which are characterised by a reduced mineral density of the bones making bones brittle
and fragile. Additionally, in the absence of vitamin D causes a reduced absorption of
calcium from the gastrointestinal system, leading to serum hypocalcaemia which is
detected by the parathyroid glands that stimulate production of parathyroid hormone.
The latter leads to an increase in bone resorption. Bones therefore lose their calcium
and become demineralised and brittle. Management of osteoporosis is multifaceted. It
includes lifestyle changes such as adequate calcium and vitamin D intake, smoking
cessation, introduction of exercise in daily activities, reduction in alcohol consumption
and falls prevention strategies. Pharmacological treatments include calcium and vitamin
D supplementation, bisphosphonates and calcitonin.
Hypothyroidism
In hyperthyroidism, the excess circulating thyroxine, increases the rate of bone
metabolism and resorption. Hypothyroidism however does not have a similar effect.
Bisphosphonates
Bisphosphonates are used in the treatment of osteoporosis as they act by promoting
osteoclast apoptosis and slowing bone resorption. They reduce the risk of fragility
fractures in post-menopausal women with osteoporosis. The most commonly used
bisphosphonate is alendronic acid.
Calcitonin Calcitonin, a hormone produced by the C-cells of the thyroid gland, in response to
hypercalcaemia reduces the serum calcium level and opposes the effect of parathyroid
hormone. It inhibits the resorption of bone by inhibiting osteoclast activity. Therefore, it
helps in maintaining adequate bone calcification and is being used as a treatment for
patients with osteoporosis.
Hormone replacement therapy (HRT)
Hormone replacement therapy, in the form of oestrogen only or oestrogen –
progesterone, slows bone metabolism and increases bone mineral density and reduces
the risk of a bone fragility fracture. However, once HRT is discontinued, there is
accelerated bone metabolism with a rapid decrease in bone mineral density and the
protective function of HRT that has preceded is lost. Osteoporosis is more common in
post-menopausal women due to the loss of the oestrogenic protective factors.
You are treating a patient pre-operatively who is going to undergo resection of a phaeochromocytoma. The patient is exhibiting features of high levels of circulating adrenaline.
What signs and symptoms would you expect to see?
1) Decreased sweat production, paroxysmal hypertension and decreased metabolic rate
2) Sweating, paroxysmal hypertension and decreased metabolic rate
3) Sweating, paroxysmal hypertension and increased metabolic rate
4) Sweating, paroxysmal hypotension and decreased metabolic rate
5) Sweating, paroxysmal hypotension and increased metabolic rate
Explanation
Sweating, paroxysmal hypertension and increased metabolic rate
Phaeochromocytomas are rare tumours, most commonly arising in the chromaffin cells of the adrenal medulla and resulting in increased secretion of catecholamines (adrenaline, noradrenaline, dopamine, occasionally). Adrenaline is a potent stimulator of the sympathetic system and increases the metabolic rate causing sweating. It binds to a- and b-adrenoceptors. Binding to a-adrenergic receptors brings about effects such as vasoconstriction, elevation in blood pressure, glycogenolysis and gluconeogenesis.
Binding to b-adrenergic receptors brings about tachycardia and increased contractility of the heart. Phaeochromocytoma is treated by adrenalectomy, however, adequate a- and b-adrenoceptor blockage is necessary before surgery. Alpha-receptor blockage controlsblood pressure and prevents a hypertensive crisis, whereas b -receptor blockage controls the heart rate. Adequate a-adrenoceptor blockage is necessary first, as unopposed alpha adrenergic activity that can occur during b-blockade may precipitate a hypertensive crisis.
Decreased sweat production, paroxysmal hypertension and decreased metabolic rate
Phaeochromocytoma is associated with increased sweat production, paroxysmal hypertension and increased metabolic rate.
Sweating, paroxysmal hypertension and decreased metabolic rate
Although phaeochromocytomas can occur in any age their peak incidence has been reported in patients between the age of 30–50.
Sweating, paroxysmal hypotension and decreased metabolic rate
Occasionally patients with phaeochromocytoma can have postural hypotension during an episode due to the high volume of fluid lost from excessive sweating.
Sweating, paroxysmal hypotension and increased metabolic rate Phaeochromocytomas typically present with a tetrad of headaches, palpitations, severe hypertension and excessive sweating. It is important to note that the symptoms are not
constant and are episodic, varying in frequency and duration over the course of the day.
As the tumour size increases, episodes become more frequent and prolonged.
An elderly man with a history of prostatism presents with acute retention of urine. His serum creatinine concentration is 520 μmol/l (50–120 μmol/l).
Which one of the following additional abnormal serum biochemistry test results is most suggestive of a chronic component to his renal failure?
1) Hyperkalaemia
2) Hyperuricaemia
3) Hypocalcaemia
4) Hyponatraemia
5) Low serum bicarbonate concentration
Explanation
Hypocalcaemia
Hypocalcaemia suggests that there is at least in part a longstanding element to the renal failure seen in this patient. This is due to two mechanisms: firstly there is reduced renal
synthesis of 1,25-dihydrocholecalciferol, the active form of vitamin D, necessary in the absorption of dietary calcium in the gastrointestinal system. Secondly, as the glomerular
filtration rate (GFR) drops, and the filtering ability of the kidney deteriorates, less phosphate is excreted in the urine. The circulating phosphate forms calcium-phosphate
compounds, reducing the amount of free circulating calcium. These two mechanisms lead to hypocalcaemia.
Hyperkalaemia
Hyperkalaemia can be the result of both acute and chronic renal failure and occurs due to reduced excretion of potassium and accumulation in the body.
Hyperuricaemia
Hyperuricaemia is the result of both acute and chronic renal failure and occurs secondary to the reduced ability of the kidney to filter and excrete waste products from the blood, leading to accumulation of these in the blood.
Hyponatraemia
Hyponatraemia can be a feature of both acute and chronic renal failure and occurs mainly due to a continued fluid intake while there has been a reduced ability to excrete
this fluid.
Low serum bicarbonate concentration
Low serum bicarbonate is a feature of metabolic acidosis that can precipitate both acute and chronic renal failure.
A patient is seen in the surgical endocrine clinic. They have developed systemic signs
and symptoms.
Which one of the following hormones is secreted by the
anterior
pituitary?
1) Testosterone
2) Oxytocin
3) TSH
4) CRH
5) ADH
Explanation
TSH
Thyroid-stimulating hormone (TSH) is produced by the thyrotrope cells in the anterior
pituitary. The anterior pituitary gland produces six hormones.
Testosterone
Testosterone is produced in the Leydig cells of the testicles, under the influence of
luteinising hormone (LH) and follicle-stimulating hormone (FSH) produced from the
anterior pituitary gland.
Oxytocin
Oxytocin is produced by the posterior pituitary gland and causes uterine contraction,
milk ejection and labour.
CRH
Corticotrophin releasing hormone (CRH) is produced by cells in the paraventricular
nucleus of the hypothalamus and stimulates corticotropes in the anterior pituitary to
produce ACTH.
ADH
Antidiuretic hormone (ADH), also known as vasopressin, is secreted form the posterior
pituitary gland and increases water permeability of the renal collecting ducts and distal
convoluted tubules leading to increased water reabsorption in the kidneys.
A patient presents with failure to tolerate cold and lethargy. Following thyroid function tests a diagnosis of hypothyroidism of the thyroid gland is made. Hypothyroidism is associated with increased plasma level of which one of the following?
1) Cholesterol
2) Albumin
3) rT3
4) Iodide
5) Thyroid stimulating immunoglobin
Explanation
Cholesterol
Hypothyroidism is the second most common cause of hypercholesterolaemia after diet. Thyroid hormones are inducers of HMG –CoA reductase enzyme, the first step in cholesterol synthesis, but also T 3 upregulates low-density lipoprotein (LDL) receptors in
the liver, where LDL-cholesterol binds and catabolism occurs.
Therefore, in hypothyroidism, even though there is a reduction in cholesterol synthesis there is also a downregulation of LDL receptors and catabolism of cholesterol in the liver, leading to an overall increase in the serum level of cholesterol. Hypothyroid patients are at an increased risk of developing cardiovascular disease and their lipid profile should be carefully monitored.
Albumin
Thyroid hormones promote albumin catabolism, while some of the circulating thyroid molecules travel in the blood bound to albumin. Therefore in hypothyroidism, there is decreased albumin catabolism, leading to more albumin available for glycosylation. It is the glycated albumin level that is raised in hypothyroid patients. Similarly in
hyperthyroidism, the glycated albumin levels are reduced as albumin catabolism is induced.
rT3
rT3 , is reverse tri-iodothyronine and is an inactive molecule formed by the deiodination of thyroxine. It differs from tri-iodothyronine in the positions that the iodine atoms are attached to the aromatic rings. The concentration of rT 3 in the serum tends to follow that of T4 . It is therefore reduced in hypothyroidism and raised in hyperthyroidism.
Iodide
Iodide is reduced in hypothyroid disease.
Thyroid stimulating immunoglobin
Thyroid-stimulating immunoglobulin is an antibody that binds the thyrotropin (TSH) receptor on the thyroid gland, stimulating thyroid hormone production. These are diagnostic of Grave’s disease, a form of hyperthyroidism.
A patient presents to the A&E with pneumonia. Incidentally, significant biochemical
abnormalities are found.
A parathyroid adenoma will be most likely to cause which one of the following?
1) Decreased osteoclastic activity
2) Decreased urinary phosphate excretion
3) Hypocalcaemia
4) Increased osteoblastic activity
5) Increased osteoclastic activity
Explanation
Increased osteoclastic activity
A parathyroid adenoma leads to increased production of parathyroid hormone (PTH)
the actions of which aim to increase serum calcium. This is done by acting on the bone,
gastrointestinal system and the kidney. In the bone PTH stimulates the activity of
osteoclasts in the bone leading to increased bone resorption. In the kidney it promotes
the conversion of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active
form of vitamin D, necessary to absorb dietary calcium from the gut. In the kidney PTH
also promotes excretion of phosphate in the urine at the renal proximal convoluted
tubule and calcium reabsorption in the distal convoluted tubule.
Decreased osteoclastic activity
A parathyroid adenoma produces parathyroid hormone (PTH) that stimulates
osteoclastic activity.
Decreased urinary phosphate excretion
A parathyroid adenoma producing parathyroid hormone (PTH) causes increased
urinary phosphate excretion in the proximal convoluted tubule.
Hypocalcaemia
A parathyroid adenoma produces parathyroid hormone (PTH) that causes
hypercalcaemia, hyperchloraemia and hypophosphataemia.
Increased osteoblastic activity
A parathyroid adenoma produces parathyroid hormone (PTH) that promotes the action
of osteoclasts, leading to bone resorption.
A 38-year-old woman presents with a plasma thyroid -stimulating hormone (TSH)
of
12.5 μ/L
(normal 0.17–3.2 μ/l) and a T 3 resin uptake of
19% (normal 25–35%).
Which one of the following clinical symptoms and signs would you expect in this
patient?
1) Anxiety
2) Increased body temperature
3) Palpitations
4) Periorbital swelling and lethargy
5) Tachycardia
Explanation
Periorbital swelling and lethargy
A raised TSH combined with a low T 3 resin uptake, and a low T4 , are characteristics of
hypothyroidism. Hypothyroidism is associated with a dull facial expression, periorbital
swelling secondary to mucopolysaccharide infiltration, decreased adrenergic drive –
causing bradycardia/cold intolerance/lethargy, as well as reduced basal metabolic rate
leading to decreased appetite and weight gain. Patients also experience mental
slowness, depression and forgetfulness. Periorbital swelling in hypothyroidism needs to
be distinguished to exophthalmos in Grave’s disease which is proptosis due to increased
retro-orbital tissue.
Anxiety
Anxiety is seen in hyperthyroid patients. The results of the thyroid function tests above
indicate that the patient is in a hypothyroid state.
Increased body temperature
Increased body temperature is a sign seen in hyperthyroid patients. The results of the
thyroid function tests above indicate that the patient is in a hypothyroid state.
Palpitations
Palpitations are experienced by hyperthyroid patients. The results of the thyroid
function tests above indicate that the patient is in a hypothyroid state.
Tachycardia
Tachycardia is a sign associated with hyperthyroidism. The results of
the thyroid function tests above indicate that the patient is in a hypothyroid state.
A 13-year-old girl develops
exophthalmos
, nervousness, diarrhoea and weight loss
following the death of her mother. Her blood pressure is
170/90 mmHg
(normal value
<120/80 mmHg).
What is the most likely diagnosis?
1) Multiple endocrine neoplasia 2 (MEN type 2)
2) Phaeochromocytoma
3) Graves’ disease
4) Retro-orbital pseudotumour
5) Acute appendicitis
Explanation
Graves’ disease
Graves’ disease is the most common cause of hyperthyroidism and is an autoimmune
condition mediated by thyroid-stimulating hormone antibodies. These bind the thyroid-
stimulating hormone receptor and mimic the action of endogenous TSH, leading to
hyperplasia of the follicular cells of the thyroid and excess hormone production. It can
present with a toxic diffuse goitre. It is m ore common in women, with a female-to-male
ratio of 7–8:1. The typical age range of presentation is 20 –40, but there have been
reports in teenage patients. The patient in this scenario presents symptomatic of
hyperthyroidism: nervousness, hypertension, diarrhoea and weight loss. Other
symptoms include: sweating, heat intolerance, tachycardia, an increased appetite and
emotional lability.
This patient also exhibits signs of Graves’ ophthalmopathy with exophthalmos and
proptosis from increased retro-orbital tissue. It is also associated with upper eyelid
retraction and lid lag. Treatment of Graves’ disease involves antithyroid drugs such as
carbimazole and propylthiouracil. Given the patient’s age propylthiouracil should be
avoided due to the high risk of hepatotoxicity especially in the paediatric population.
Other treatments involve radioactive iodine and thyroidectomy.
Multiple endocrine neoplasia 2 (MEN type 2)
Multiple endocrine neoplasia type 2 is associated with tumours of the endocrine system
and typically involves phaeochromocytoma and medullary thyroid cancer. Type 2A also
involves hyperparathyroidism, while those with type 2B may demonstrate a Marfanoid
body habitus. Even though the patient exhibits some signs associated with
phaeochromocytoma, it is very unlikely in this age group. Additionally, exophthalmos is
mostly associated with Graves’ disease, making hyperthyroidism a more likely
diagnosis.
Phaeochromocytoma
Even though the patient exhibits some signs associated with phaeochromocytoma
(hypertension, weight loss, diarrhoea, anxiety), it is an unlikely diagnosis in this age group. Additionally, exophthalmos is mostly associated with Graves’ disease, making
hyperthyroidism a more likely diagnosis.
Retro-orbital pseudotumour
A retro-orbital pseudotumour is an inflammatory condition involving the extraocular
muscles that presents with painful unilateral exophthalmos and diplopia. It is not
associated with diarrhoea or weight loss.
Acute appendicitis
Even though acute appendicitis can present with diarrhoea as well as hypertension and
anxiety relating to pain, it is not associated with exophthalmos or weight loss as in the
scenario above.
A patient is referred with refractory hypertension. Despite basic medical treatment their blood pressure remains 180/110mmHg. Which one of the following is correct regarding adrenals and surgical hypertension?
1) Renovascular disease is a rare cause of secondary hypertension
2) A phaeochromocytoma can be shown by metaiodobenzylguanidine (MIBG) scintigraphy
3) Most adrenal incidentalomas are hormone secreting
4) A raised midnight cortisol is diagnostic of Cushing’s syndrome
5) 30% of phaeochromocytomas are extra-adrenal
Explanation
A phaeochromocytoma can be shown by metaiodobenzylguanidine (MIBG) scintigraphy MIBG scintigraphy is a very specific test for detecting phaeochromocytoma. Radioactive iodine-131-metaiodobenzylguanidine is administered to the patient and localises to adrenergic tissue. In the case of a patient with a phaeochromocytoma there is a focal area in the adrenal medulla where there is very strong and prolonged uptake of the solution. MIBG scintigraphy is not considered the first line investigation to detect phaeochromocytoma. MIBG is useful in detecting extra-adrenal tumours or disease recurrence.
Renovascular disease is a rare cause of secondary hypertension
Secondary hypertension accounts for 5–10% of hypertensive patients. Renovascular disease is the most common cause of secondary hypertension, occu rring due to narrowing of the renal artery (renal artery stenosis). It typically presents in young
women (<30 years) and older men (>50 years). Other causes of secondary hypertension include: Conn syndrome, Cushing syndrome, phaeochromocytoma, hyperthyroid ism, congenital adrenal hyperplasia, use of oral contraceptives, and pregnancy.
Most adrenal incidentalomas are hormone secreting Adrenal incidentalomas are described as adrenal masses found incidentally. Of these, 85% are non-functional, ie do not secrete any hormones and the remaining 15% are either hormone-secreting or malignant.
A raised midnight cortisol is diagnostic of Cushing’s syndrome
Cortisol levels are secreted in a diurnal rhythm. They peak in the morning between 0700–0900 h and then gradually reduce throughout the day, reaching a nadir at around midnight. In Cushing syndrome there is loss of the diurnal rhythm and a raised midnight cortisol is thought to be the earliest sign of Cushing syndrome with a very high sensitivity. However, other factors can cause a midnight cortisol surge such as stress resulting from physical illness, being awake at midnight to perform the test and depression. As a result, for the diagnosis of Cushing syndrome the dexamethasone suppression test is used.
30% of phaeochromocytomas are extra-adrenal
About 10% of phaechromocytomas are extra-adrenal. It is important to remember that phaeochromocytoma follows the rule of 10s: 10% are malignant, 10% are bilateral, 10% are found in children, 10% of patients have multiple tumours, 10% are extra -adrenal (found in the thorax, neck, bladder, kidney, scrotum) and 10% are familial (von Hippel –Lindau syndrome).
You are treating a patient with hyperthyroidism. They want to know what the options
for ongoing management are.
Which one of the following statements is correct?
1) With antithyroid drugs patients have a high recurrence rate when therapy is
discontinued
2) Surgery is the most rapid method of permanent control and results in
euthyroidism in about 50% of cases at 5 years
3) Surgery has no permanent complications
4) Radio-iodine therapy gives permanent control and h as a low rate of
hypothyroidism
5) All other treatments, except surgery, are contraindicated in pregnancy
Explanation
With antithyroid drugs patients have a high recurrence rate when therapy is
discontinued
Antithyroid drugs do not offer permanent control as seen with surgery or radio-iodine.
If the patients discontinue their antithyroid medication, hyperthyroidism recurs in the
vast majority of cases. Antithyroid medication such as propylthiouracil and carbimazole
work as hormone antagonists therefore following cessation the disease can recur.
Combining antithyroid medication and radio -iodine therapy increases the rate of
achieving permanent control.
Surgery is the most rapid method of permanent control and results in euthyroidism in
about 50% of cases at 5 years
Thyroid surgery can lead to hypothyroidism, and occurs in 90% of patients post -
operatively at 5 years and this rises to almost 100% in 20 years.
Surgery has no permanent complications
Thyroid surgery is not without complications. These are grouped in to immediate, early
and late complications.
Radio-iodine therapy gives permanent control and has a low rate of hypothyroidism
Radio-iodine therapy yields good results and generally has a lower rate of recurrence of
hyperthyroidism when compared to medical therapy only. Return to a euthyroid state
takes about 2 months following treatment. Hypothyroidism is however a common
complication following radio-iodine therapy, affecting patients at a rate of up to 90% in
the first year.
All other treatments, except surgery, are contraindicated in pregnancy
Hyperthyroidism in pregnancy affects about 0.2% of pregnancies with Graves’ disease
being the most common cause, followed by gestational hyperthyroidism. During
pregnancy, the treatment options for hyperthyroidism ar e limited to antithyroid
medication and surgery. Radioactive iodine is contraindicated during pregnancy. During early pregnancy, propylthiouracil should be used, as carbimazole has a risk of
teratogenic effects. After the first trimester, the use of carbim azole can resume for the
remainder of the pregnancy, as propylthiouracil is associated with hepatotoxicity.
Surgery in pregnancy is reserved for cases of malignant disease where there is
uncontrolled hyperthyroidism or airway compromise. Otherwise, it is g enerally advised
for the operation to be postponed until after delivery due to the risk of general
anaesthesia on the fetus.
A 34-year-old woman has her blood pressure checked by her GP and it is found to be
180/100 mmHg (normal value <120/80 mmHg). She is diagnosed with a
phaeochromocytoma causing secondary hypertension.
Which one of the following is most likely regarding this patient’s
phaeochromocytoma?
1) It is usually bilateral
2) It is usually extra-adrenal
3) It is usually malignant
4) It may be screened for by urinary catecholamines
5) It is best treated medically
Explanation
It may be screened for by urinary catecholamines
Phaeochromocytoma is a rare neuroendocrine tumour, arising in the adre nals in 90% of
the cases, producing an excess amount of catecholamines. In patients where a
phaeochromocytoma is suspected, quantifying urinary total catecholamines
and metanephrines in a 24-hour urine sample collection, has the highest sensitivity and
specificity. Assessing the level of vanillylmandelic acid in a 24 -hour urine sample is not
as accurate.
It is usually bilateral
Phaeochromocytoma follows the rule of 10s. Only 10% of cases are bilateral.
It is usually extra-adrenal
Phaeochromocytoma follows the rule of 10s. Only 10% of cases are extra-adrenal and
have been described in the thorax, neck, bladder, kidney and scrotum.
It is usually malignant
Phaeochromocytoma follows the rule of 10s. Only 10% of cases are malignant.
It is best treated medically
There is no effective medical treatment for phaeochromocytoma. The patient is
adequately prepared pre-operatively with a-blockers and then b-blockers before
surgical removal of the phaeochromocytoma.
A 45-year-old man is being screened for secondary hypertension. He complains of muscle weakness and his blood results show hypernatraemia, hypokalaemia and
metabolic
alkalosis.
What is the most likely diagnosis?
1) Addison’s disease
2) Coarctation of the aorta
3) Conn syndrome
4) Incidental findings in patient with essential hypertension
5) Phaeochromocytoma
Explanation
Conn syndrome
The patient shows signs of Conn syndrome, with secondary hypertension,
hypernatraemia, hypokalaemia and a metabolic alkalosis. Conn syndrome is
primary hyperaldosteronism, ie excess secretion of aldosterone. Aldosterone is
produced in the zona glomerulosa of the cortex of the adrenals. It is a mineralocorticoid
hormone that acts on the mineralocorticoid receptors, found mainly in the distal
convoluted tubule and collecting ducts of the nephron, activating the basolateral
Na + /K + ion channels to reabsorb sodium and water and excrete potassium. It increases
the permeability of the collecting duct to sodium and stimulates the secretion of H + ions
into the urine. Through conservation of sodium and water, aldosterone increases blood
pressure. In hyperaldosteronism, there is excessive release of aldosterone, typically
from either adrenal hyperplasia or an adenoma. Conn syndrome most commonly affects
women, with a female to male ratio of 2:1, aged 30–50. Presenting features of Conn
syndrome include: hypertension, abdominal distension, weakness, ileus or features
related to complications of hypertension such as headaches, proteinuria. Treatment
incudes spironolactone (an aldosterone antagonist) or surgery with adrenalectomy.
Addison’s disease
Addison’s disease is the result of adrenocortical insufficiency and may present with
hypotension. It is associated with biochemical disturbances which include
hyponatraemia, hyperkalaemia and hypercalcaemia.
Coarctation of the aorta
Coarctation of the aorta is a known cause of secondary hypertension but does not lead
to the biochemical disturbances evident in the above scenario.
Incidental findings in patient with essential hypertension
Essential hypertension does not have a known cause and should not be associated with
biochemical abnormalities of hypernatraemia, hypokalaemia and metabolic alkalosis.
Phaeochromocytoma Phaeochromocytoma is a known cause of secondary hypertension, but does not lead to
the biochemical abnormalities evident in the scenario.
A 68-year-old man presents to his GP with weight gain, bruising and generalised weakness and is diagnosed with Cushing syndrome. He is found to be hyperglycaemic and serum adrenocorticotropic hormone (ACTH) levels are very high Overnight high-dose dexamethasone suppression test shows a raised morning cortisol level.
Which one of the following is most likely to be found?
1) Adrenocortical adenoma
2) Adrenocortical carcinoma
3) Basophil pituitary adenoma
4) Small-cell bronchial carcinoma
5) Bronchial carcinoid
Explanation
Small-cell bronchial carcinoma
The patient presents with signs relating to Cushing syndrome, characterised by the excess production of cortisol in the body. The raised ACTH excludes an adrenal cause. The high-dose overnight dexamethasone suppression test is used to differentiate ACTH -dependent causes of Cushing syndrome. If the cause is a pituitar y adenoma then high-dose dexamethasone suppresses the production of ACTH from the adenoma cells and therefore causes a low morning cortisol.
As the cortisol level remained unaffected, the source of ACTH is not the pituitary and is therefore an ectopic sour ce. From the options available, small-cell bronchial carcinoma, accounting for 15% of all primary lung tumours, is the most common cause of ectopic ACTH production. This is a paraneoplastic syndrome that can occur with the following tumours: small -cell lung tumours, bronchial carcinoid tumours, islet-cell tumours of the pancreas, medullary carcinoma of the thyroid and thymic tumours. Signs of Cushing syndrome are summarised in the table below:
Head and neck
Trunk
Limbs
Frontal balding
Kyphosis
Proximal myopathy
Moon face
Buffalo hump
Pathological fractures
Acne
Gynaecomastia in men
Ankle oedema (salt and water retention due to excess cortisol)
Plethoric complexion
Central obesity (due to altered fat distribution) Hirsutism
Purple striae on abdomen, breasts, thighs
Pigmentation in ACTH-dependent cases, in areas exposed to sunlight
Thin skin
Hair growth of forearms in particular
Tissue wasting
Predisposition to infection
Bad wound healing
Adrenocortical adenoma
When Cushing syndrome is the result of an adrenal cause, such as an adrenocortical adenoma or an adrenocortical carcinoma, the excess circulating cortisol suppresses the hypothalamus–pituitary axis and leads to a low corticotrophin releasing hormone (CRH) and ACTH. In this scenario ACTH is high as is morning cortisol.
Adrenocortical carcinoma
Where Cushing syndrome is the result of an adrenal cause, such as an adrenocortical adenoma or an adrenocortical carcinoma, the excess circulating cortisol suppresses the hypothalamus–pituitary axis and leads to a low CRH and ACTH. In this scenario ACTH is high as is morning cortisol.
Basophil pituitary adenoma
Cushing’s disease is caused by a pituitary adenoma, arising in either the basophil or chromophobe cells. However, in this scenario the cause of the patient’s presentation is not a pituitary adenoma. In the case of a pituitary adenoma, cortisol level should be suppressed, following a high-dose overnight dexamethasone suppression test.
Bronchial carcinoid
Both bronchial carcinoid and small-cell bronchial carcinoma can produce a Cushing syndrome by ectopic secretion of ACTH. Small -cell bronchial carcinoma is more common that bronchial carcinoid. Bronchial carcinoid is a rare entity, accounting for 1–6% of primary lung tumours and tends to present between the 4th and 5th decade of life.
A 43-year-old woman has a history of medullary thyroid carcinoma and parathyroid hyperplasia. She is concerned about symptoms to be aware of in her children. Which other condition would be associated with multiple endocrine neoplasia type 2A (MEN2A)?
1) Pituitary adenoma
2) Gastrinoma
3) Marfanoid habitus
4) Neurofibromatosis
5) Phaeochromocytoma
Explanation
Phaeochromocytoma
Phaeochromocytoma is found in patients with both MEN2A and MEN2B syndromes. Patients with MEN2A have the following combination of conditions: medullary thyroid carcinoma, phaeochromocytoma and hyperparathyroidism (parathyroid hyperplasia).
MEN2 is an autosomal-dominant condition associated with the RET proto-oncogene. There is also a third variation of MEN2 called familial MEN2, presenting with a medullary thyroid carcinoma and no other manifestations. MEN2A (Sipple syndrome):
type 2 = secondary = Sipple.
Pituitary adenoma
Pituitary adenomas are associated with multiple endocrine neoplasia type 1. This condition is described as the combination of: parathyroid hyperplasia, pancreatic islet - cell tumours and a pituitary adenoma.
Gastrinoma
A gastrinoma is a gastrin-secreting tumour most commonly found in the duodenum or pancreas and can lead to Zollinger–Ellison syndrome – peptic ulceration because of excess. Up to 50% of patients with Zollinger–Ellison syndrome are found to have MEN1.
Marfanoid habitus
Marfanoid habitus is seen in patients with multiple endocrine neoplasia type 2B. This condition describes the combination of medullary thyroid carcinoma, phaeochromocytoma, mucosal neuromas and Marfanoid body habitus.
Neurofibromatosis
Neurofibromatosis is not part of multiple endocrine neoplasia.
A 26-year-old woman presents to the pre-assessment clinic with elevated serum calcium levels. She tells you she has familial hypocalciuric hypercalcaemia. Which one of the following statements is correct regarding familial hypocalciuric hypercalcaemia?
1) Hypermagnesaemia may be seen
2) It is autosomal-recessive
3) It is associated with increased urinary calcium excretion – more than 200 mg per 24 h
4) It is associated with low parathyroid hormone (PTH) levels
5) The condition responds to parathyroidectomy
Explanation
Hypermagnesaemia may be seen
Familial hypocalciuric hypercalcaemia (FHH) is a rare autosomal -dominant condition with high penetrance, associated with loss-of-function mutations in the calcium sensing receptor (CaSR), a G-coupled protein receptor which is found in the kidney and parathyroid tissue. In the parathyroid gland its function is to sense serum calcium levels and regulate parathyroid hormone (PTH) release, whereas in the kidney it inhibits reabsorption of calcium. In FHH, there is loss of the negative feedback system on PTH release when serum calcium is elevated due to a reduction in the receptor’s sensitivity, leading to sustained mild hypercalcaemia. In the kidney there is reduced excretion leading to hypocalciuria. In most cases there is also hypermagn esaemia. Patients are usually asymptomatic. FHH is confirmed with genetic testing.
It is autosomal-recessive
Familial hypocalciuric hypercalcaemia is inherited in an autosomal -dominant fashion with a high penetrance.
It is associated with increased urinary calcium excretion – more than 200 mg per 24 h Familial hypocalciuric hypercalcaemia is characterised by raised serum calcium levels, low urinary calcium levels, normal or slightly elevated parathyroid hormone level and commonly associated with hypermagnesaemia.
It is associated with low parathyroid hormone (PTH) levels Familial hypocalciuric hypercalcaemia is characterised by normal or slightly raised levels of parathyroid hormone.
The condition responds to parathyroidectomy
In patients that are asymptomatic, treatment is not necessary. Familial hypocalciuric hypercalcaemia should not be treated with parathyroidectomy and does not respond to diuretic or bisphosphonate treatment. Calcimimetics have been used for symptomatic cases as well as pamidronate. Parathyroidectomy is reserved for patients with recurrent pancreatitis.
A 52-year-old woman with longstanding rheumatoid arthritis is seen in a pre-assessment clinic before a planned left total knee replacement. On examination, she is noted to be
overweight and struggles to rise from a chair. She is noted to be on long-term steroids
for rheumatoid arthritis and is found to have a high blood pressure ,raised fasting plasma glucose and striae seen in her skin.
Which one of the following conditions is she most likely to have developed secondary to her medication?
1) Addison’s disease
2) Congenital adrenal hyperplasia
3) Conn syndrome
4) Cushing syndrome
5) Phaeochromocytoma
Explanation
Cushing syndrome
Cushing syndrome is a condition related to excess cortisol. The commonest cause is
iatrogenic, resulting from exogenous administration of glucocorticoid medication for
chronic conditions such as asthma, chronic obstructive pulmonary disease (COPD),
arthritis etc. Endogenous causes of Cushing inclu de: a pituitary adenoma producing an
excess of adrenocorticotropic hormone (ACTH), adrenocortical adenoma or carcinoma
and a functional tumour producing ectopic adrenocorticotropic hormone (ACTH) such
as an oat-cell lung carcinoma. Cushing syndrome relates to a collection of signs and
symptoms that occur as the result of excess cortisol. These are summarised in the table
below:
Head and neck
Trunk
Limbs
Frontal balding
Kyphosis
Proximal myopathy
Moon face
Buffalo hump
Pathological features
Acne
Gynaecomastia in men
Ankle oedema (salt and water retention due to excess cortisol)
Plethoric complexion
Central obesity (due to altered fat distribution)
Hirsutism
Purple striae on abdomen, breasts, thighs
Pigmentation in ACTH-dependent cases, in areas exposed to sunlight
Thin skin
Hair growth of forearms in particular
Tissue wasting
Predisposition to infection
Bad wound healing
Addison’s disease
Addison’s disease is the result of adrenocortical insufficiency and can present with hypotension. It is associated with biochemical disturbances as well: hyponatraemia,
hyperkalaemia and hypercalcaemia.
Congenital adrenal hyperplasia
Congenital adrenal hyperplasia is an autosomal-recessive condition associated with
deficiency in the enzyme 21α-hydroxylase, involved in the synthesis of cortisol and
aldosterone. It tends to present at birth or early infancy.
Conn syndrome
Conn syndrome is a condition associated with hyperaldosteronism. It is mineralocorticoid and not glucocorticoid excess. Even though patients with Conn syndrome present with hypertension, the remaining signs described in the scenario above relate to glucocorticoid excess. Patients with Conn syndrome present with hypernatraemia and hypokalaemia.
Phaeochromocytoma
Phaeochromocytoma is a rare neuroendocrine tumour, arising in the chromaffin cells of
the adrenals in 90% of the cases, producing an excess amount of catecholamines. Even
though it is associated with hypertension, the remaining signs described in the scenario
relate to corticosteroid excess. Patients with phaeochromocytoma present with severe
hypertension associated with headaches, palpitations and diaphoresis.
A 35-year-old woman is found at her preoperative assessment to be
tachycardic
, with a
heart rate of 120 beats/min, extremely
anxious
and to have a smoothly
enlarged
goitre
in her neck. A diagnosis of
Graves’ disease
is confirmed.
What are her blood tests likely to show?
1) Low thyroxine; which regulates carbohydrate metabolism
2) Raised thyroxine; secreted by the colloid cells of the thyroid gland
3) Raised thyroxine level; mostly bound to albumin in the blood
4) Raised thyroxine-stimulating hormone (TSH) from the posterior pituitary
5) Thyroid-stimulating hormone receptor immunoglobulins
Explanation
Thyroid-stimulating hormone receptor immunoglobulins
Graves’ disease is a form of hyperthyroidism of autoimmune origin. It is associated with
the presence of circulating TSH receptor immunoglobulins (antibodies), that bind to the
TSH receptor in the thyroid. These antibodies mimic the function of TSH, leading to
stimulation of the thyroid gland to produce more triiodothyronine (T3) and thyroxine
(T4). The elevated serum-circulating hormones activate the negative feedback
mechanism and suppress release of TSH from the anterior pituitary gland.
Low thyroxine; which regulates carbohydrate metabolism
Thyroxine (T4) is the hormone produced from the thyroid gland. Graves’ disease is a
state of hyperthyroidism. Therefore, serum thyroxine level s would be
raised. Thyroxine stimulates lipid and carbohydrate metabolism.
Raised thyroxine; secreted by the colloid cells of the thyroid gland
Raised thyroxine is found in patients with Graves’ disease as this is a form of
hyperthyroidism, however thyroxine is secreted by the follicular and not the colloid
cells of the thyroid gland.
Raised thyroxine level; mostly bound to albumin in the blood
In overt hyperthyroidism there is a raised free (unbound) thyroxine level (free T4).
Raised thyroxine-stimulating hormone (TSH) from the posterior pituitary
TSH is secreted from the anterior pituitary. However, the cause of Graves’ disease is not
raised TSH but the presence of TSH receptor immunoglobulins, that mimic the function
of TSH by binding to the TSH receptor and stimulating the thyroid gland to release
hormone molecules. TSH is suppressed via a negative feedback mechanism and is
therefore low in patients with Graves’ disease.
A 45-year-old woman presents with generalised weakness and fatigue. She has a history of renal colic. Her calcium is found to be raised at 3.1. An inferior parathyroid adenoma
is suspected.
Which one of the following statements is most likely to be true?
1) This parathyroid gland would have developed fro m the second branchial pouch
2) This would be an unusual case, as the majority of primary hyperparathyroidism
is due to diffuse hypertrophy of the parathyroids
3) The adenoma could be localised by a combination of ultrasound and sestamibi
radionucleotide scan
4) This woman’s weakness and fatigue are incidental to the hypercalcaemia
5) Parathyroid tissue cannot be implanted elsewhere in the body after total
parathyroid excision
Explanation
The adenoma could be localised by a combination of ultrasound and sestamibi
radionucleotide scan
Pre-operative parathyroid adenoma localisation can be done by either ultrasound,
sestamibi (methoxyisobutylisonitrile (MIBI), uses technetium) radionucleotide scan or
technetium/thallium scan. The inferior parathyroids are much more variable in their
position.
This parathyroid gland would have developed from the second branchial pouch
The superior and inferior parathyroids develop from the fourth and third branchial
pouches, respectively.
This would be an unusual case, as the majority o f primary hyperparathyroidism is due
to diffuse hypertrophy of the parathyroids
Primary hyperparathyroidism is usually due to a solitary secreting parathyroid
adenoma. Hyperparathyroidism presents as:
‘bones’ (arthralgia and osteoporosis)
‘stones’ (renal)
abdominal ‘groans’ (pancreatitis, peptic ulcers and constipation)
‘moans’ (depression, fatigue and weakness).
This woman’s weakness and fatigue are incidental to the hypercalcaemia
This woman’s weakness and fatigue are almost definitely as a result of her
hypercalcaemia. Parathyroid tissue cannot be implanted elsewhere in the body after total parathyroid
excision
Tertiary hyperparathyroidism occurs in renal failure, in which the parathyroids
function autonomously. In such cases, subcutaneous reimplantation of half a
parathyroid in the forearm allows easy access if further resection is required.
A 55-year-old woman with
poorly-controlled
polymyalgia rheumatica (PMR) complains
of weight gain, muscle weakness and easy bruising. She is found to have increased
abdominal girth, striae, bruising and raised serum glucose levels. A diagnosis of
Cushing’s syndrome is made.
What is most likely to be the cause of her Cushing syndrome?
1) Iatrogenic steroids
2) Medullary carcinoma of the thyroid
3) Pituitary tumour
4) Lung tumour secreting adrenocorticotropic hormone (ACTH)
5) Polymyalgia rheumatica
Explanation
Iatrogenic steroids
This woman has Cushing syndrome and the commonest cause of this is iatrogenic
through the administration of steroids. In this case, this woman has poorly controlled
polymyalgia rheumatica (PMR) and is likely to have been on prolonged steroid
treatment. Endogenous cases are caused by primar y pituitary disease ie pituitary
adenoma (70%, referred to as Cushing’s disease), primary adrenal tumours (15%) and
ectopic adrenocorticotropic hormone (ACTH)-secreting tumours (15%).
The diagnosis of Cushing syndrome depends on the loss of normal circadia n rhythm as
well as persistent elevation of cortisol. It is necessary to take at least three serum
samples to demonstrate the loss of rhythm. The mean 24 -h cortisol levels can be
estimated by collecting and measuring the 24-h urinary free cortisol, which gives an
integrated measure of cortisol production. As a screening test it has 95% specificity.
Medullary carcinoma of the thyroid
Medullary carcinomas of the thyroid can rarely produce ectopic adrenocorticotropic
hormone (ACTH), however iatrogenic administration of steroids is more likely in this
case given the history of PMR.
Pituitary tumour
Pituitary tumours can produce adrenocorticotropic hormone (ACTH), however, the
history of polymyalgia rheumatica (PMR) means iatrogenic steroid administration is
more likely.
Lung tumour secreting adrenocorticotropic hormone (ACTH)
ACTH secreting tumours, of which bronchial carcinoma is the most common, can cause
Cushing syndrome, however there is no history indicative of lung cancer.
Polymyalgia rheumatica
Administration of steroids to treat polymyalgia rheumatica (PMR), not PMR per se,
causes Cushing syndrome.
A 65-year old man is diagnosed with a parathyroid
adenoma
. He attends the
Outpatient’s Clinic for advice on management options.
What is the best option for treatment?
1) Only surgery is curative
2) Bisphosphonates and calcitonin result in good long -term control
3) Octreotide results in good control of parathyroid hormone (PTH) levels
4) Surgery is reserved for those not improving on bisphosphonate treatment
5) Reducing dietary calcium intake can be curative
Explanation
Only surgery is curative
Parathyroidectomy is the only curative treatment for primary hyperparathyroidism
caused by a parathyroid adenoma.
Bisphosphonates and calcitonin result in good long-term control
Bisphosphonates, calcitonin and octreotide do not have a role in treatment.
Octreotide results in good control of parathyroid hormone (PTH) levels
Octreotide is used in nuclear imaging. Parathyroid tumours expressing somato statin
may show octreotide uptake, which may indicate a possibility for the use of
somatostatin analogues for medical treatment when surgery is not possible. Octreotide
does not have a role in the treatment of primary hyperparathyroidism.
Surgery is reserved for those not improving on bisphosphonate treatment
Surgery is the only curative treatment of primary hyperparathyroidism secondary to a
parathyroid adenoma. Bisphosphonates do not have a role in treatment of primary
hyperparathyroidism.
Reducing dietary calcium intake can be curative
Low calcium intake stimulates the parathyroids and high intake accentuates
hypercalcaemia, so the recommendation is moderate intake followed up with curative
surgery by removal of the parathyroid glands.
A 48-year old woman is found to have incidental deranged biochemistry. She is
subsequently diagnosed with
primary hyperparathyroidism
.
Which one of the following is likely to be correct?
1) She will also have diabetes mellitus
2) She will probably be asymptomatic
3) She will have reduced parathyroid hormone (PTH) levels
4) She will have a raised phosphate
5) She will have MEN2b syndrome
Explanation
She will probably be asymptomatic
Asymptomatic primary hyperparathyroidism is found in greater than 50 % of patients.
In 85% of cases, it is caused by a single parathyroid adenoma, but can be due to multiple
gland adenomas/hyperplasia and rarely even parathyroid carcinoma.
She will also have diabetes mellitus
Patients with primary hyperparathyroidism are very slightly more likely to also have
diabetes and vice versa. It is not certain therefore that this patient would have diabetes.
She will have reduced parathyroid hormone (PTH) levels
Patients will have a raised serum calcium and parathyroid hormone and a reduced
phosphate (secondary to renal excretion, causing phosphaturia).
She will have a raised phosphate
As mentioned, the patient will have a low phosphate due to renal excretion of phosphate
in response to raised serum calcium and parathyroid hormone.
She will have MEN2b syndrome
Hyperparathyroidism is found in MEN 1 and MEN 2a syndromes, but not in MEN 2b.
A 40-year-old fit and well Polish woman presents to the Ear, Nose and Throat (ENT)
clinic with a
solitary
thyroid nodule. She is
asymptomatic
.
What is the most useful first line investigation?
1) Computed tomography (CT) scan
2) MRI scan
3) Fine-needle aspiration cytology
4) Technetium radio-isotope scan
5) Core biopsy
Explanation
Fine-needle aspiration cytology
Thyroid nodules are common, and the majority are within multinodular goitres. The
most useful initial investigations are ultrasound and fine-needle aspiration cytology of
any dominant nodules.
Thyroid function tests in patients with multinodular goitre or a solitary thyroid nodule
are usually normal. These are therefore usually only necessary if you suspect a hot
nodule in a symptomatic patient. Only around 10 –20% of cold nodules in adults and
50% in children are malignant.
Computed tomography (CT) scan
Further imaging is only necessary if you suspect a very large goitre causing tracheal
compression or retrosternal extension. In such cases, CT scan of the neck and thorax is
useful.
MRI scan
MRI scanning does not have a role in the investigation of a simple thyroid nodule.
Technetium radio-isotope scan
Technetium radio-isotope scan is useful for the assessment of parathyroid adenomas
and the myocardium, but is not used in the assessment of thyroid nodules.
Core biopsy
Fine-needle aspiration, not core biopsy, is sufficient in gaining samples from nodules for
histological examination. Furthermore, fine-needle aspiration is less invasive than core
biopsy.
A 54-year-old man presents to his GP with a 2-week history of sweating, headache,
constipation and itchy lesions over his back. On examination his blood pressure is
162/94 mmHg and his pulse rate is 102/min. Twenty-four hour urinary
catecholamines, metanephrines and vanillylmandelic acid are fo und to be elevated. A
computed tomography (CT) and a 131I-meta-iodo-benzyl-guanidine scan confirms
a
phaeochromocytoma
. He is subsequently found to have a
medullary carcinoma
of the
thyroid.
Which one of the following do you think is the most likely diagnosis in this
patient?
1) Multiple Endocrine Neoplasia (MEN) I
2) Secondary hyperparathyroidism
3) Multiple Endocrine Neoplasia IIB
4) Carcinoid tumour
5) Multiple Endocrine Neoplasia IIA
Explanation
Multiple Endocrine Neoplasia IIA
Multiple Endocrine Neoplasia II (MEN II) is an autosomal-dominant disorder caused by
mutations in the RET proto-oncogene. MEN II has three distinct subtypes – MEN
IIA, MEN IIB, and familial medullary thyroid carcinoma only. MEN IIA describes the
association of medullary thyroid carcinoma, phaeochromocytomas and parathyroid
tumours. Patients with pheochromocytomas may present with hypertension,
tachycardia, sweating and headaches. Cutaneous lichen amyloidosis in patients with
MEN IIA manifests as multiple pruritic scaly skin lesions in the scapular area of the
back.
Multiple Endocrine Neoplasia (MEN) I
MEN I is characterised by carcinomas of the pituitary, pancreas and parathyroid. This
patient has symptoms of a phaeochromocytoma, which is then confirmed on
investigation. Phaeochromocytomas are not present in MEN I.
Secondary hyperparathyroidism
This is most commonly seen in patients with chronic kidney disease causing
hypocalcaemia and hyperphosphataemia which then stimulates the parathyroid glands.
Multiple Endocrine Neoplasia IIB
MEN IIB can be distinguished from MEN IIA due to the presence of marfanoid features
and mucosal neuromas, neither of which are described in the case history. In MEN IIB,
the medullary cancer is very aggressive with most patients dying before developing
either a phaeochromocytoma or hyperparathyroidism.
Carcinoid tumour Carcinoid tumours most commonly secrete ectopic serotonin, excess levels of which
would not produce the clinical picture described in the case history. Instead they are
likely to present with flushing, diarrhoea, abdominal cramps and wheezing.
A 30-year-old woman presents with a lump in the non-tender and has rapidly increased in size. Her right lobe of lymph nodes the thyroid. It is hard , are enlarged. She has previously had radiotherapy to her neck. Histology shows Orphan Annie nuclei.
The most likely tumour is?
1) Follicular adenoma
2) Anaplastic carcinoma
3) Medullary carcinoma
4) Papillary carcinoma
5) Follicular carcinoma
Explanation
Papillary carcinoma
Papillary carcinoma is the commonest malignant thyroid tumour. This is more common
in younger patients, women and those with a past history of head and neck irradiation.
It often spreads to local lymph nodes. Orphan Annie nuclei are characteristic,
psammoma bodies may also be seen. It is extremely responsive to treatment and
prognosis is excellent.
Follicular adenoma
Follicular adenomas of the thyroid are benign and therefore would not metastasise to
the regional lymph nodes as described in the case history.
Anaplastic carcinoma
Anaplastic carcinoma is an extremely aggressive thyroid cancer and is usually
unresponsive to treatment. It more commonly presents in elderly patients.
Medullary carcinoma
Medullary carcinoma only accounts for around 3% of thyroid cancer and therefore it is
more likely the patient described has a papillary carcinoma.
Follicular carcinoma
Follicular carcinoma more commonly presents in women over the age of 50, accounts
for around 15% of all thyroid cancer, and has a good prognosis.
A 22-year-
hormone (
old woman has puffy eyes TSH) concentration is low
and
but
hoarse voice. Her plasma thyroid -stimulating increases markedly when she is given
thyrotrophin-releasing hormone (
TRH).
She probably has which one of the following conditions?
1) Hyperthyroidism due to a thyroid tumour
2) Hyperthyroidism due to a primary abnormality in the hypothalamus
3) Hypothyroidism due to a primary abnormality in the hypothalamus
4) Hypothyroidism due to a primary abnormality in the pituitary gland
5) Hypothyroidism due to a primary abnormality in the thyroid gland
Explanation
Hypothyroidism due to a primary abnormality in the hypothalamus
Tertiary hypothyroidism, also called hypothalamic -pituitary axis hypothyroidism,
results when the hypothalamus fails to instruct the pituitary to produce sufficient TSH.
This young woman’s hypothyroidism improves with TRH administration, confirming
the diagnosis of tertiary hypothyroidism.
Hyperthyroidism due to a thyroid tumour
The patient has no signs or symptoms of thyroid malignancy, which often presents with
a firm mass noticed by the patient which arises from the thyroid.
Hyperthyroidism due to a primary abnormality in the hypothalamus
The patient has symptoms of hypothyroidism, not hyperthyroidism. Hyperthyroidism
can present with palpitations, tremor, weight loss (despite increased appetite), fatigue,
hair loss and heat intolerance.
Hypothyroidism due to a primary abnormality in the pituitary gland
As her TSH level increases in response to TRH, this suggests there is no abnormality in
the pituitary gland.
Hypothyroidism due to a primary abnormality in the thyroid gland
The administration of TRH and subsequent increase in TSH suggests that the primary
abnormality is due to an abnormality with the hypothalamus.
A young patient undergoes OGD and they are found to have multiple ulcers in the stomachand duodenum. They are promptly started on PPI and undergo further
investigations.
What is the cause of gastric hypersecretion in Zollinger–Ellison (ZE) syndrome?
1) Histamine antagonism
2) Increased gastrin secretion
3) Somatostatin secretion
4) Vagal inhibition
5) Vagal stimulation
Explanation
Increased gastrin secretion
Zollinger–Ellison syndrome is a result of an endocrine tumour of the pancreatic G -cells
(gastrinoma) and results in gastrin hypersecretion with resultant severe gastric
ulceration. The normal physiological stimulation of gastric secretion has three phases:
cephalic
gastric
intestinal.
The cephalic phase is vagally mediated and stimulated by the sight and smell of food.
The parasympathetic input causes gastrin release from antral G -cells, which causes acid
and pepsin secretion. Vagal input also directly stimulates gastric glands and rel eases
histamine from mast cells which activated parietal cells to produce acid. The gastric
phase begins with food entering the stomach, distending it, causing vagal stimulation.
This accounts for ~60% of gastric acid secretion.
The intestinal phase only accounts for ~5% of secretion and gastrin secretion is
mediated by the presence of food in the duodenum.
Histamine antagonism
Histamine agonism, not antagonism, would result in gastric hypersecretion.
Somatostatin secretion
Somatostatin is an inhibitory hormone and acts directly on parietal cells to reduce acid
secretion.
Vagal inhibition
Vagal inhibition would reduce gastric secretion while ZE is characterised by severe
gastric ulceration secondary to increased gastric secretion.
Vagal stimulation
The vagal nerve does play a role in the normal physiological stimulation of gastric
secretion, most notably due to food entering the stomach causing vagal stimulation and
subsequently gastric secretion. However, in ZE syndrome, excessive gastric secretion is
due to increased gastrin secretion.
A 67-year old man presents with diarrhoea and abdominal pain. He is found to
have raised levels of urinary 5-HIAA.
Which one of the following symptoms or signs, in addition to his presentation, is
most likely to go with a diagnosis of carcinoid syndrome?
1) Alternating constipation
2) Dysmenorrhoea
3) Flushing
4) Mitral regurgitation
5) Nausea
Explanation
Flushing
Carcinoid syndrome occurs secondary to carcinoid tumours which are neuroendocrine
neoplasia. These tumours often secrete serotonin and can produce the following
symptoms;
flushing
telangiectasia
diarrhoea
bronchospasm
right heart valve lesions (tricuspid regurgitation and stenosis, pulmonary stenosis)
pellagra (rarely).
Alternating constipation
Diarrhoea, not constipation, is associated with carcinoid syndrome.
Dysmenorrhoea
Dysmenorrhoea refers to pain during menstruation, and as the patient is male this is
very unlikely indeed!
Mitral regurgitation
The tricuspid valve is more likely to be affected in carcinoid syndrome, and flushing is
more likely than either of these.
Nausea
Nausea is a very non-specific symptom and is present in many conditions. Flushing is
far more characteristic of carcinoid syndrome.
A 43-year-old man presents with abdominal pain and is found on
oesophagogastroduodenoscopy (OGD) to have a duodenal ulcer. He is treated with a
proton pump inhibitor and Helicobacter pylori eradication treatment, but the
ulcer is
persistent
.
Gastrin levels
are checked and found to be
raised
.
What syndrome does this man have?
1) Multiple endocrine neoplasia type I
2) Multiple endocrine neoplasia type IIa
3) Multiple endocrine neoplasia type IIb
4) Zollinger–Ellison syndrome
5) None of the above
Explanation
Zollinger–Ellison syndrome
Zollinger–Ellison syndrome results from a gastrin-secreting tumour of the islet cells of
the pancreas or rarely of the duodenum or gastric antrum. This causes an increase in
the levels of circulating gastrin. It often presents as intractable duodenal ulceration
with a high incidence of bleeding and perforation. If the ulcer perforates, the patient
may present with the classical signs and symptoms of peritonitis.
Approximately 25% of patients with Zollinger –Ellison syndrome are associated with
multiple endocrine neoplasia type 1, with an associated adenoma of the parathyroid in
approximately 25% of patients and hyperplasia of the adrenal and thyroid in 10% of
patients. Proton pump inhibitors that suppress acid production and promote healing
comprise first-line treatment. H-2 antagonists may also be used, but are less effective
than proton pump inhibitors in reducing acid production. Surgery to remove the
tumour is only undertaken if the ulcers are resistant to the above medical treatment
options.
Multiple endocrine neoplasia type I
MEN I can be associated with Zollinger–Ellison syndrome in around 25% of patients,
however there are no other features of MEN I, for example, hyperparathyroidism.
Multiple endocrine neoplasia type IIa
MEN II is characterised by parathyroid hyperplasia, medullary thyroid carcinoma
and phaeochromocytoma. This condition would not cause raised gastrin levels or
persistent gastric ulceration.
Multiple endocrine neoplasia type IIb
Again, MEN II would not cause persistent ulceration. MEN IIb is differentiat ed from
MEN IIa by the presence of mucosal neuromas. None of the above
The patient’s ulceration has not improved despite appropriate therapy,
and he has been subsequently found to have raised gastrin levels, which is indicative of
Zollinger–Ellison syndrome.
Acute hypokalaemia can lead to muscle weakness and direct renal tubular cell injury.
The causes can be classified according to the presence or absence of hypertension with
reference also to the plasma renin activity and urinary potassium excretion.
Which one of the following is a cause of hypokalaemia
without hypertension
but
with high plasma renin activity?
1) Liddle syndrome
2) Cushing’s syndrome
3) Liquorice excess
4) Renovascular disease
5) Gitelman’s syndrome
Explanation
Gitelman’s syndrome
Gitelman’s syndrome can be either autosomal recessive or dominant and is
characterised by hypokalaemic metabolic alkalosis and with hypocalciuria and
hypomagnesaemia. Blood pressure is low or normal.
Liddle syndrome
Causes of hypokalaemia with hypertension (potassium excretion usually
> 30 mmol/day) and low plasma renin activity include Liddle’s syndrome, which is
an autosomal-dominantsyndrome of hypertension and variable degrees of
hypokalaemic metabolic alkalosis.
Cushing’s syndrome
In Cushing’s syndrome (sustained overproduction of cortisol) patients will exhibit
hypertension and low plasma renin activity.
Liquorice excess
With liquorice excess, 11-β-hydroxysteroid dehydrogenase metabolises co rtisol and
prevents it from binding to the mineralocorticoid receptor. Acquired or congenital
conditions in which this enzyme is inhibited have a Conn’s phenotype and this includes
patients taking liquorice in excess and renovascular disease.
Renovascular disease
As mentioned, patients with acquired or congenital conditions in which 11-β-
hydroxysteroid dehydrogenase is inhibited have a Conn’s phenotype and this includes
patients taking liquorice in excess and with renovascular disease.
A patient admitted under your care with appendicitis underwent successful surgery and
is ready for discharge. You notice their blood glucose has been high throughout their
admission.
The 2011 WHO criterion for diagnosis of diabetes mellitus is whi ch of the
following?
1) Fasting plasma glucose >6.0 mmol/l
2) Random plasma glucose >12.0 mmol/l
3) Plasma glucose <7.8 mmol/l at 2 h after glucose-tolerance test
4) Plasma HbA1c >6.5%
5) Glucose-tolerance test is required for confirmation of diagnosis
Explanation
Plasma HbA1c >6.5%
The 2011 WHO recommendations for diagnosis of type II diabetes mellitus suggests
that Hb A 1c can be used as a diagnostic test for diabetes providing that stringent quality
assurance tests are in place and assays are standardised to criteria al igned to the
international reference values, and there are no conditions present that preclude its
accurate measurement.
An Hb A 1c of 48 mmol/mol (6.5%) is recommended as the cut point for diagnosing
diabetes. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed
using glucose tests.
Situations when Hb A 1c is not appropriate for diagnosis of diabetes include:
children and young people
patients suspected of having type 1 diabetes
pregnancy
patients with symptoms of diabetes for less tha n 2 months
patients at high diabetes risk who are acutely ill
patients taking medication that may cause rapid glucose rise, eg steroids,
antipsychotics
patients with acute pancreatic damage, including pancreatic surgery
presence of other factors that influence HbA 1c and its measurement (such as
haemoglobinopathies, haemolytic disorders, alcohol excess or chronic kidney
disease).
Fasting plasma glucose >6.0 mmol/l
Diabetes may be diagnosed with a fasting plasma glucose >7.0 mmol/l and associated
diabetic symptoms such as increased thirst/urination, recurrent infections or weight loss. It must be remembered, however, that compliance with the fasting period is often
poor.
Random plasma glucose >12.0 mmol/l
A random plasma glucose of >11.1 mmol/l is sufficient for the diagnosis of diabetes.
Again, symptoms of diabetes must be present.
Plasma glucose <7.8 mmol/l at 2 h after glucose-tolerance test
The glucose-tolerance test can be used to diagnose diabetes. Here, 75 g of glucose is
administered to the patient and if their venous glucose is > 11.1 mmol/l at 2 h following
administration then diabetes can be diagnosed.
Glucose-tolerance test is required for confirmation of diagnosis
The glucose-tolerance test is only one of the several available diagnostic tests that can
be utilised.
A 55-year-old woman presents with features consistent with Cushing’s syndrome. She is taking no medication. Her basal cortisol and plasma adrenocorticotrophic hormone (ACTH )levels are significantly raised. A high-dose dexamethasone suppression test
results in no decrease in morning cortisol serum concentration.
What is the most likely diagnosis?
1) Adrenal tumour
2) Carney syndrome
3) Cushing’s disease
4) Depression
5) Ectopic ACTH-secreting tumour
Explanation
Ectopic ACTH-secreting tumour
A raised ACTH level with a raised cortisol implies that the problem is caused by excess
ACTH production, otherwise negative feedback would suppress ACTH. Although failure
of cortisol suppression after low-dose dexamethasone may be seen with both pituitary
tumours (ieCushing’s disease) and ectopic ACTH-secreting tumours, high-dose
dexamethasone often results in cortisol suppression for pituitary tumours, as they
retain a degree of negative feedback. A persistently raised cortisol level after high-dose
dexamethasone suppression therefore implies that an ectopic ACTH-secreting tumour is
the most likely pathology.
Adrenal tumour
An adrenal adenoma can produce excess cortisol, however this would have the effect of
suppressing ACTH production due to a negative feedback loop.
Carney syndrome
Carney syndrome comprises atrial myxoma and freckles with high cortisol leve ls
independent of ACTH.
Cushing’s disease
Cushing’s disease refers to a pituitary adenoma that secretes excess ACTH.
Given that the morning cortisol level remains high despite the high-dose
dexamethasone suppression test suggests there is ectopic ACTH production, as even
pituitary tumours retain some negative feedback.
Depression
Depression does not result in persistently raised cortisol and ACTH levels.
A patient with known cancer is noted to have high concentrations of calcium in their
blood. Hypercalcaemia can be present in malignant disease secondary to the secretion
of
parathyroid hormone-related peptide
by a tumour.
It is most frequently associated with which one of the following?
1) Carcinoid tumours
2) Lymphoma
3) Multiple myeloma
4) Small-cell carcinoma of the bronchus
5) Squamous-cell carcinoma of the bronchus
Explanation
Squamous-cell carcinoma of the bronchus
Hypercalcaemia is a frequent complication of cancer, and is most usually the result of
the secretion of parathyroid hormone-related peptide (paraneoplastic syndrome).
Squamous-cell carcinomas are particularly frequently responsible, but hypercalcaemia
is uncommon with other bronchogenic cancers.
Carcinoid tumours
Carcinoid tumours sometimes secrete vasopressin or adrenocorticotrophic hormone
(ACTH), but rarely cause hypercalcaemia.
Lymphoma
In lymphomas, unregulated extrarenal production of calcitriol can be responsible.
Multiple myeloma
In myeloma, the secretion of osteoclast-activating cytokines is the usual cause of
hypercalcaemia.
Small-cell carcinoma of the bronchus
Small-cell carcinoma of the bronchus is more commonly associated with ectopic ACTH
and antidiuretic hormone (ADH) secretion [the latter leading to syndrome of
inappropriate antidiuretic hormone secretion (SIADH)], as well as Lambert–Eaton
myasthenic syndrome.
A 72-year-old
Afro-Caribbean
woman is found to have a serum calcium concentration
of
3.12 mmol/l
. They undergo investigations to delineate the cause.
Which one of the following clinical features, if present, would most direct you
towards a specific cause?
1) Bone pain
2) Hilar lymphadenopathy
3) Polyuria
4) Short QT interval
5) Ureteric colic
Explanation
Hilar lymphadenopathy
The presence of hilar lymphadenopathy in a patient (especially an Afro-Caribbean
patient) with hypercalcaemia should raise a suspicion that the latter is due to sarcoid
(in which the granulomas secrete calcitriol, 1,25 -dihydroxycholecalciferol).
Bone pain
Bone pain can occur with hypercalcaemia secondary t o malignancy or
hyperparathyroidism.
Polyuria
Polyuria is a feature of severe hypercalcaemia, irrespective of the cause.
Short QT interval
A short QT interval is also a non-specific feature of hypercalcaemia.
Ureteric colic
Ureteric colic is particularly associated with primary hyperparathyroidism, but is not
specific to this cause.
A 16-year-old boy presents with delayed puberty. On examination, he has a pre-adolescent body habitus and no evidence of development of secondary sexual characteristics. Serum testosterone, luteinising hormone (LH), and follicle-stimulating hormone (FSH) concentrations are all in the prepubertal range. The LH and FSH concentrations increase only slightly following a single injection of gonadotrophin-releasing hormone (GnRH), but a normal response is elicited after GnRH is given daily for 7 consecutive days.
Which one of the following is most likely to be the cause of his delayed puberty?
1) A hypothalamic disorder
2) A pituitary disorder
3) Klinefelter’s syndrome
4) Mumps orchitis in childhood
5) Seminiferous tubular dysfunction
Correct Answer:
1) A hypothalamic disorder
Explanation:
- The patient has hypogonadotropic hypogonadism (low LH, FSH, and testosterone), which suggests a problem with the hypothalamus or pituitary gland.
- The subnormal response to a single GnRH injection but normal response after 7 days of GnRH stimulation indicates that the pituitary gland is intact but not receiving sufficient GnRH from the hypothalamus. This pattern is characteristic of a hypothalamic disorder, such as Kallmann syndrome (a congenital GnRH deficiency).
- A pituitary disorder would typically show no response to GnRH stimulation, even after repeated doses.
- Klinefelter’s syndrome, mumps orchitis, and seminiferous tubular dysfunction are associated with primary hypogonadism (high LH and FSH with low testosterone), which is not seen in this case.
This question tests the candidate’s ability to interpret endocrine test results and understand the pathophysiology of delayed puberty.
A 64-year-old woman presents with a painless lump she has noticed on the front
neck which moves on swallowing. On examination, she is noted to have a
thyroid
of her
nodule
and cervical
lymphadenopathy
. A fine-needle aspiration (FNA) of the thyroid
nodule reveals
psammoma bodies
.
What is the most likely diagnosis?
1) Anaplastic thyroid carcinoma
2) Follicular thyroid carcinoma
3) Lymphoma
4) Medullary thyroid carcinoma
5) Papillary thyroid carcinoma
Explanation
Papillary thyroid carcinoma
Papillary carcinoma of the thyroid gland accounts for around two-thirds of thyroid
malignancies. The tumour spreads via the lymphatics and at presentation over half of
patients will have cervical lymph node involvement. Histologically psammoma bodies
are typical.
Anaplastic thyroid carcinoma
Anaplastic carcinoma is a very aggressive tumour type that is most commonly found in
the elderly. It has a very poor prognosis with few patients surviving beyond 1 year.
Follicular thyroid carcinoma
Follicular thyroid carcinoma accounts for 20% of thyroid tumours and classically
spreads via the bloodstream. Therefore lymph node involvement at presentation is very
uncommon.
Lymphoma
Thyroid lymphoma is very rare affecting predominantly women over the age of 70
years, many of whom have a diagnosis of Hashimoto’s thyroiditis.
Medullary thyroid carcinoma
Medullary thyroid carcinoma occurs in 5 –10% of thyroid malignancies. It is derived
from C-cells and therefore produces calcitonin, which can be measured in the blood.
A 42-year-old man is referred to his GP because of problems in his workplace linked to his mood swings. On taking a detailed history he reports episodes of light-headedness,
disorientation
with an associated
aggressive
temper. These
resolve
following
the
consumption of food
. He has previously been investigated and was found to have a
blood sugar of
1.8
mm/l during an attack.
What is the most likely diagnosis?
1) Gastrinoma
2) Glucagonoma
3) Insulinoma
4) Phaeochromocytoma
5) Zollinger-Ellison syndrome
Explanation
Insulinoma
Insulinomas are not common and occur in around 1 in a million of the population. They
arise from β islet cells and are mostly benign. They often cause symptoms relating to
hypoglycaemia, eg light-headedness, mood swings and in some cases unconsciousness.
The diagnosis should be suspected when Whipple’s triad is present – attacks brought on
by fasting, hypoglycaemia (<2.0 mmol/l) during an episode and symptoms then
improving with glucose administration.
Gastrinoma
A gastronome is a tumour found in the pancreas or duodenum that secretes gastrin. It is
the most common cause of Zollinger–Ellison syndrome.
Glucagonoma
A glucagonoma is a rare tumour of the alpha cells within the pancreas causing excess
levels of glucagon resulting in a high plasma glucose.
Phaeochromocytoma
Phaeochromocytoma is a neuroendocrine tumour of the adrenal gland that secretes
excess catecholamines.
Zollinger-Ellison syndrome
Zollinger–Ellison syndrome is characterised by severe gastric ulceration secondary to
tumour secreting gastrin.
A 55-year-old woman is referred to a general surgery clinic after a dermatologist has diagnosed a migratory necrolytic erythema. The patient also has a history of diabetes
mellitus and weight loss.
What is the most likely diagnosis?
1) Cushing’s syndrome
2) Gastrinoma
3) Glucagonoma
4) Insulinoma
5) Phaeochromocytoma
Explanation
Glucagonoma
Glucagonomas are very rare tumours with an incidence of around 1 in 20 million. There
are often metastases present when the patient presents. Classic features of
glucagonomas are migratory necrolytic erythema (bright red, papular and blister-type
rash that can affect any part of the body, especially around the mouth), diabetes mellitus
and weight loss (somewhat paradoxical). The rash is very characteristic and may be
sufficient evidence to raise the concern itself. It is secondary to a zinc deficiency in the
skin.
Cushing’s syndrome
Cushing’s syndrome refers to prolonged exposure to cortisol and has several
aetiologies, including iatrogenic steroid administration and pituitary tumours. Weight
gain, not weight loss, is associated with Cushing’s syndrome. Skin changes, such as
abdominal striae, may be apparent.
Gastrinoma
A gastrinoma is a tumour found in the pancreas or duodenum that secretes gastrin. It is
the most common cause of Zollinger–Ellison syndrome.
Insulinoma
Insulinomas are not common and occur in around 1 in a million of the population. They
arise from β islet cells and are mostly benign. They often cause symptoms relating to
hypoglycaemia, eg light-headedness, mood swings and in some cases unconsciousness.
The diagnosis should be suspected when Whipple’s triad is present – attacks brought on
by fasting, hypoglycaemia (<2.0 mmol/l) during an episode and symptoms then
improving with glucose administration.
Phaeochromocytoma
Phaeochromocytoma is a neuroendocrine tumour of the adrenal gland that secretes
excess catecholamines.
A 35-year-old woman
it emerges that this is
is referred by her GP with hyperhidrosis. On intermittent in nature and is precipitated by
further questioning exercise and
overeating
. In addition to this she reports severe headaches and
palpitations. On a
previous, occasion her blood pressure was measured and was found to be
190/110
mmHg
.
What is the most likely diagnosis?
1) Cushing syndrome
2) Gastrinoma
3) Neuroblastoma
4) Phaeochromocytoma
5) Zollinger-Ellison syndrome
Explanation
Phaeochromocytoma
Phaeochromocytomas are rare catecholamine-producing tumours that arise from
sympathetic paraganglia cells that are collections of adrenaline-secreting chromaffin
cells. They occur in around one in a million people and are the underlying cause for less
than 1% of hypertension. Around 10% are bilateral, 10% are malignant, 10% are
familial and 10% are extra-adrenal (the ‘rule of 10s’). The most common extra-adrenal
site is the organ of Zuckerkandl, which is by the aortic bifurcation. The most common
symptom is sweating, and other symptoms include paroxysmal headaches,
palpitations and precordial pain. Pre-operative management with Alpha- and Beta-
blockers is crucial before anaesthetic induction to minimise morbidity and mortality.
Cushing syndrome
Cushing syndrome refers to prolonged exposure to cortisol and has several aetiologies,
including iatrogenic steroid administration and pituitary tumours. While it cause
hypertension, headaches, palpitations and hyperhidrosis are not recognised symptoms
of Cushing syndrome.
Gastrinoma
A gastrinoma is a tumour found in the pancreas or duodenum that secretes gastrin. It is
the most common cause of Zollinger–Ellison syndrome.
Neuroblastoma
Neuroblastoma is a malignant tumour of nerve cells and can commonly arise in the
adrenal glands, spinal cord and brain, however it would not account for the symptoms
and signs described in the case history.
Zollinger-Ellison syndrome
Zollinger–Ellison syndrome is characterised by severe or recurrent peptic
ulcerationsecondary to a gastrin-secreting tumour
A 27-year-old man is referred to an endocrine clinic as he has been complaining of excessive thirst and polyuria. Random and fasting plasma glucose levels are normal
,
and his urine is noted to have a
low specific gravity
and osmolality.
Which of the following is the most likely cause?
1) Diabetes insipidus
2) Glucagonoma
3) Insulinoma
4) Type 1 diabetes mellitus
5) Type 2 diabetes mellitus
Explanation
Diabetes insipidus
Diabetes insipidus (DI) is an uncommon condition with excessive production of urine
and thirst. It is classified according to the source of the problem as cranial DI [deficiency
in antidiuretic hormone (ADH) production] or nephrogenic DI (renal tubules
unresponsive to ADH). The urine has a low specific gravity and osmolality.
Glucagonoma
A glucagonoma is a rare tumour of the alpha cells within the pancreas, causing excess
levels of glucagon resulting in a high plasma glucose.
Insulinoma
Insulinomas are not common and occur in around one in a million of the population.
They arise from β islet cells and are mostly benign. They often cause symptoms relating
to hypoglycaemia, eg light-headedness, mood swings and in some cases
unconsciousness.
Type 1 diabetes mellitus
As the random and fasting glucose levels are within the normal range, this makes a
diagnosis of diabetes mellitus (DM) less likely Furthermore, type 1 DM is often
diagnosed at an earlier age than this patient.
Type 2 diabetes mellitus
Again, as the plasma glucose levels are normal, this makes a diagnosis of diabetes
mellitus less likely.
A 39-year-old man is admitted to the intensive care unit (ICU) following a road traffic
accident for which he has sustained multiple injuries. One of these is a skull base
fracture and he is being investigated for possible pituitary dysfunction.
Which one of the following hormones is secreted by the
posterior
pituitary gland?
1) Follicle-stimulating hormone (FSH)
2) Growth hormone
3) Prolactin
4) Thyroid-stimulating hormone
5) Vasopressin
Explanation
Vasopressin
The pituitary gland is divided into two parts - the anterior pituitary gland
(adenohypophysis) and posterior (neurohypophysis). These have different
embryological origins and different functions. The neurohypophysis (posterior
pituitary) secretes oxytocin and vasopressin (ADH).
Follicle-stimulating hormone (FSH)
The adenohypophysis produces gonadotrophins (LH and FSH), growth hormone,
prolactin, thyroid-stimulating hormone and adrenocorticotrophic hormone (ACTH).
Growth hormone
The anterior pituitary produces growth hormone.
Prolactin
Prolactin is produced by the anterior pituitary.
Thyroid-stimulating hormone
The anterior pituitary produces thyroid -stimulating hormone (TSH).
A final-year medical student is on his elective in
South America
and is intrigued to find a
series of patients with very large goitres who are otherwise well. Blood tests reveal
these patients are euthyroid.
What is the most likely cause for the goitres?
1) Autoimmune hypothyroidism
2) Hashimoto’s thyroiditis
3) Iodine deficiency
4) Myxoedema coma
5) Toxic multinodular goitre
Explanation
Iodine deficiency
Iodine deficiency can cause a goitre and is still found in mountainous areas, for example
the Alps, Himalayas, and Andes. The thyroid function may be euthyroid or hypothyroid
depending on the severity of the iodine deficiency. Iodine deficiency causes a
generalised hyperplasia of the thyroid gland resulting in a large goitre (the so-called
endemic goitre).
Autoimmune hypothyroidism
Autoimmune thyroiditis can present with a goitre and the patient may be either hyper -
or hypothyroid. There is a familial element to autoimmune hypothyroidism, and it can
also occur in the context of high iodine consumption.
Hashimoto’s thyroiditis
Hashimoto’s thyroiditis is an autoimmune condition that leads to gradual destruction of
the thyroid gland resulting in hypothyroidism and a large painless goitre.
Myxoedema coma
This occurs in the context of severe hypothyroidism – the patients in this case history
are euthyroid.
Toxic multinodular goitre
A toxic multinodular goitre is a common cause of hyperthyroidism, second only to
Grave’s disease.
A 47-year-old man is referred to an
Endocrine Clinic
for further investigation as he has
been complaining of a headache, sweating and his GP thinks his appearance
has
changed
since his last appointment 10 years ago. On examination he has
a
prominent
supraorbital ridge,
prognathism
and
interdental separation
.
Which one of the following tests are of most diagnostic value in confirming
acromegaly?
1) Growth hormone (GH) levels
2) Insulin-like growth factor-1 (IGF-1) levels
3) Oral glucose-tolerance test with GH levels
4) Prolactin levels
5) Visual field testing
Explanation
Oral glucose-tolerance test with GH levels
In normal subjects an oral glucose-tolerance test will suppress GH to <2 mU/l, in
patients with acromegaly, it is not suppressed, and increases in 50%.
Growth hormone (GH) levels
Serum GH levels are often elevated, but levels can fluctuate and a normal level
does notexclude a diagnosis.
Insulin-like growth factor-1 (IGF-1) levels
IGF-1 levels are often raised with acromegaly.
Prolactin levels
Prolactin levels are raised in 30% of patients, but again does not confirm the diagnosis.
Visual field testing
Although visual field defects are common, this does not confirm the diagnosis.
A 57-year-old woman is referred to an Endocrine Clinic with an increase in proximal myopathy and thin skin. She is thought to have Cushing syndrome weight, after a low-
dose dexamethasone suppression test shows that the serum cortisol concentration
remains high . A further high-dose dexamethasone suppression test shows the serum cortisol level does decrease after 48 h of dexamethasone.
What is the most likely source for her Cushing’s syndrome?
1) Adrenal adenoma
2) Adrenal carcinoma
3) Ectopic ACTH
4) Iatrogenic cause
5) Pituitary disease
Explanation
Pituitary disease
Most patients with pituitary-dependent Cushing’s syndrome, ie Cushing’s disease will
suppress plasma cortisol following a high -dose dexamethasone test as illustrated in this
case.
Adrenal adenoma
Adrenal adenomas may produce cortisol, however this would result in suppression
of adrenocorticotrophic hormone (ACTH) due to the negative feedback loop to the
pituitary.
Adrenal carcinoma
Adrenal carcinoma are extremely rare and may produce cortisol, although again this
would result in suppression of ACTH.
Ectopic ACTH
A failure to suppress ACTH would suggest an ectopic source of ACTH or an adrenal
tumour.
Iatrogenic cause
Although the most common cause for Cushing’s syndrome is exogenous steroid
administration, this would have been excluded in the history for this patient.
A patient who is being followed up for a bilateral
adrenalectomy
for Cushing syndrome
is noted to have increased pigmentation and complains of headaches in his follow-up
appointment. Visual field testing also demonstrates
bitemporal hemianopia
which was
not present pre-operatively.
What complication has the patient developed?
1) Acromegaly
2) Addison’s disease
3) Diabetes insipidus
4) Nelson’s syndrome
5) Waterhouse–Friderichsen syndrome
Explanation
Nelson’s syndrome
Nelson’s syndrome involves a combination of skin hyperpigmentation and an expanding
pituitary tumour. It mostly occurs following an adrenalectomy for Cushing’s disease and
is caused by the reduction in circulating cortisol causing reduced negative feedback on
the pituitary gland, and therefore and increased ACTH production. This increase in
ACTH levels causes hyperpigmentation as it is physically related to and
resembles melanocyte-stimulating hormone (MSH).
Acromegaly
Acromegaly is a disorder, often of the pituitary gland, resulting in excess production of
growth hormone. It can present with visual field defects, however, given the history of
the adrenalectomy, Nelson syndrome is more likely.
Addison’s disease
Addison’s disease is an autoimmune disorder resulting in primary adrenal insufficiency.
Diabetes insipidus
Diabetes insipidus is a condition whereby either the kidneys are not responsive
to antidiuretic hormone (ADH) or there is a deficiency in production of ADH. This
patient does not have excess thirst and micturition. Furthermore, visual field defects
would not be expected.
Waterhouse–Friderichsen syndrome
This syndrome refers to haemorrhage within the adrenal glands, most commonly
secondary to Neisseria meningitidis infection. These patients are often desperately
unwell with overwhelming sepsis, for example as seen with meningitis.
The paediatric surgical team are asked to review a neonate with ambiguous external
genitalia. Further testing reveals a female genotype and it is thought she
has pseudohermaphroditism due to congenital adrenal hyperplasia (CAH).
What is the most common enzyme deficiency in patients with CAH?
1) 3ß-hydroxysteroid dehydrogenase
2) 11β-Hydroxylase
3) 11α-Hydroxylase
4) 17-Hydroxylase
5) 21-Hydroxylase
Explanation
21-Hydroxylase
The most common cause for CAH is an enzyme deficiency of 21 -hydroxylase (in 90% of
cases). This is essential in cortisol synthesis, and reduced cortisol levels cause an
increase in ACTH which results in increased precursors of cortisol which are instead
switched to testosterone production. In women this can manifest
as pseudohermaphroditism and in males as precocious sexual maturity.
3ß-hydroxysteroid dehydrogenase
This enzyme has a role in the production of progesterone and therefore is not
implicated in CAH.
11β-Hydroxylase
This enzyme is involved in the final steps of synthesis of cortisol. Deficiencies can cause
CAH, however it is less common than 21-hydroxylase.
11α-Hydroxylase
This enzyme is involved in the hydroxylation of steroids such as cortisol and does not
result in CAH.
17-Hydroxylase
Deficiency in this hormone can result in CAH, however it is uncommon.
A 54-year-old woman presents to the GP with palpitations and heat intolerance. Further
questioning reveals an increased appetite, weight loss and persistent diarrhoea. It is
thought she may have thyrotoxicosis.
What is the most common cause of thyrotoxicosis?
1) Congenital
2) Graves’ disease
3) Multinodular toxic goiter
4) Riedel’s thyroiditis
5) Toxic solitary nodule
Explanation
Graves’ disease
Thyrotoxicosis affects almost 2% of the population and in 95% of cases is the result of
one of three causes: Graves’ disease, multinodular toxic goitre and a toxic solitary
nodule. The commonest of these is Graves’ disease, which is most common in women
between 20 and 40 years. Grave’s disease is also associated with eye changes
(exophthalmos, ophthalmoplegia) and pretibial myxoedema, in addition to the other
signs and symptoms of hyperthyroidism.
Congenital
Congenital abnormalities can affect the thyroid gland, however this is more commonly
hypothyroidism and would present at birth or shortly after.
Multinodular toxic goitre
Multinodular toxic goitre can cause thyrotoxicosis, however Graves’ disease is a more
common cause.
Riedel’s thyroiditis
Riedel’s thyroiditis (woody hard thyroid) is rare and results in painless, chronic fibrosis
of the thyroid gland. Some patients can become hypothyroid, however, very few become
hyperthyroid.
Toxic solitary nodule
Again, a toxic solitary nodule may cause thyrotoxicosis, however it is much less common
than either Graves’ disease or multi nodular toxic goitre.
A 33-year-old woman is noted to have a raised serum calcium when being investigated
following renal calculi. Further investigation reveals raised serum parathyroid hormone
(PTH) levels and she is diagnosed with primary hyperparathyroidism.
Approximately what proportion of primary hyperparathyroidism is caused by a
parathyroid
carcinoma
?
1) 1%
2) 5%
3) 10%
4) 30%
5) 50%
Explanation
1%
Primary hyperparathyroidism is caused by a solitary adenoma in 85 –90% of patients,
hyperplasia in around 15–10% and a carcinoma in less than 1%. It may be diagnosed
through routine blood tests on asymptomatic patients who are noted to have
hypercalcaemia, or patients may develop symptoms. These symptoms mostly affect the
kidneys and bone, and include nephrocalcinosis and renal calculi, and demineralisation
of bone.
5%
Parathyroid carcinoma is rare and causes primary hyperparathyroidism and is the
underlying pathology in less than 1% of cases. Typically, the serum PTH concentration
is extremely high, unlike for a parathyroid adenoma or hyperplasia, in
which the PTH concentration is increased, but not massively.
10%
Parathyroid carcinomas are rare, accounting for less than 1% of cases of primary
hyperparathyroidism. Parathyroid gland hyperplasia, however, accounts for 10–15% of
cases of hypercalcaemia with raised PTH levels.
30%
Parathyroid carcinomas are rare, accounting for less than 1% of cases of primary
hyperparathyroidism.
50%
Parathyroid adenomas are the most common cause for primary hyperparathyroid ism.
Parathyroid carcinomas are rare.
A 42-year-
successful
old man is noted to have raised plasma calcium levels 6 months after a renal transplantation for end-stage renal failure secondary to polycystic
kidney disease. He has had no problems with his graft and no longer requires dialysis.
Further blood tests reveal
raised parathyroid hormone (PTH)
levels.
What is the most likely diagnosis in this patient?
1) Hypoparathyroidism
2) Primary hyperparathyroidism
3) Pseudohypoparathyroidism
4) Secondary hyperparathyroidism
5) Tertiary hyperparathyroidism
Explanation
Tertiary hyperparathyroidism
Tertiary hyperparathyroidism develops when the excessive PTH secretion in secondary
hyperparathyroidism (eg due to chronic hypocalcaemia in renal failure) becomes
autonomous. This often occurs when the underlying cause for chronic hypocalcaemia is
corrected, eg following a renal transplant. Management options for tertiary
hyperparathyroidism include total parathyroidectomy, subtotal parathyroidectom y or
autotransplantation of parathyroid tissue into an arm muscle (where it can be easily
located if problems persist). Patients require calcium and vitamin D replacement to
correct bone disease and reduce the risk of recurrence.
Hypoparathyroidism
Hypoparathyroidism would present with low levels of PTH.
Primary hyperparathyroidism
Primary hyperparathyroidism is usually as a result of parathyroid adenomas. Given the
history of chronic kidney disease and subsequent hyperparathyroidism, tertiary
hyperparathyroidism is the likely cause.
Pseudohypoparathyroidism
This is an extremely rare condition in which there is resistance to PTH, resulting in
hypocalcaemia and appropriately high PTH levels. Given the history of renal transplant
and rarity of pseudohypoparathyroidism, tertiary hyperparathyroidism is more likely.
Secondary hyperparathyroidism
Secondary hyperparathyroidism occurs in the context of chronic kidney disease
resulting in hypocalcaemia, this stimulates the parathyroid glands to increase
production of PTH.
You are assisting your consultant in the ENT clinic. You see a patient in clinic with a
malignant thyroid swelling.
Which one of the following is correct regarding the types of thyroid cancer?
1) Anaplastic cancer has a good prognosis
2) Anaplastic cancer is commoner in younger patients
3) Follicular carcinoma cannot be diagnosed on fine-needle aspiration (FNA)
4) Follicular carcinoma is the most common type
5) Medullary cancer only occurs in patients with multiple endocrine neoplasia type
II (MEN II)
Explanation
Follicular carcinoma cannot be diagnosed on fine-needle aspiration (FNA)
Follicular carcinoma cannot be differentiated from follicular adenoma by FNA.
Anaplastic cancer has a good prognosis
Anaplastic cancer has a very poor prognosis, and is usually seen in older patients.
Anaplastic cancer is commoner in younger patients
As mentioned, it is more commonly in the elderly, particularly women over the age of 70
years.
Follicular carcinoma is the most common type
Papillary adenocarcinoma is the commonest type (70%). Female to male ratio for
thyroid cancer is 3:1.
Medullary cancer only occurs in patients with multiple endocrine neoplasia type II
(MEN II)
Medullary cancer of the thyroid is associated with the MEN II syndrome but most
patients who have medullary cancer will not have MEN.
A 55-year-old man with a history of
secondary to alcohol is being managed conservatively as an outpatient. It is decided to assess the exocrine function
chronic pancreatitis
of
his pancreas before nutritional interventions.
Which one of the following is the optimal technique for assessing the exocrine
status of the pancreas?
1) Albumin levels
2) Barium meal
3) CT
4) Lundh meal
5) Ultrasound
Explanation
Lundh meal
The Lundh meal is a combination of skimmed milk powder mixed with corn oil and
dextrose used to assess exocrine pancreatic function. Following administration, serum
lipase measurements can provide a good indicator of exocrine pancreatic status.
The faecal elastase test is increasingly used for detecting exocrine insufficiency and is
more acceptable to patients.
Albumin levels
Serum albumin level may be decreased for many reasons eg inadequate diet, sepsis,
nephrotic syndrome. It is more commonly used to assess the synthetic function of the
liver.
Barium meal
A barium meal will not provide a functional assessment of the exocrine status of the
pancreas.
CT
While CT can be very good for imaging the pancreas and assessing anatomical
abnormalities and gland atrophy, it does not provide any information about the
exocrine status of the pancreas.
Ultrasound
Again, ultrasound imaging will not provide a function assessment of the exocrine
function of the pancreas.
A 20-year-old medical student presents with a history of epigastric pain and family
history of multiple endocrine neoplasia (
MEN) syndrome. He undergoes endoscopy
which shows
gastric erosions
. He is a non-smoker.
Which one of the following statements is most likely to be correct?
1) Blood tests show a high serum gastrin level
2) Family history is unlikely to be relevant
3) No further tests are required
4) Proton pump inhibitors are the mainstay of management
5) The aetiology is likely to be alcohol related
Explanation
Blood tests show a high serum gastrin level
This patient has Zollinger–Ellison syndrome. This syndrome is rare and can be linked
with MEN type 1. It is characterised by high serum gastrin levels as a result of a gastrin -
secreting neuroendocrine tumour usually situated in the pancreas. Treatment involves
proton pump inhibitors and surgical excision of tumour or chemotherapy.
Family history is unlikely to be relevant
Family history is important when considering MEN syndrome, which is associated with
Zollinger–Ellison syndrome.
No further tests are required
The patient has gastric erosions at a young age and warrants further investigation,
particularly in light of the family history of MEN syndrome.
Proton pump inhibitors are the mainstay of management
Proton pump inhibitors are an important aspect of treatment in Zollinger–
Ellison syndrome, however, the patient is likely to require surgical excision of the
tumour or chemotherapy.
The aetiology is likely to be alcohol related
Alcohol can increase the risk of gastritis and associated erosions, and while medical
students often have a high alcohol consumption there is no mention of excessive alcohol
intake in this case history.
A 27-year-old woman presents with
pain in the front of her neck which radiates to her jaw and ears. She reports she has been generally run down and lethargic for a few days.
On examination she has a slight swelling in the anterior neck which elevates on swallowing and which exacerbates her pain. Blood tests show slightly elevated T4 and T3 levels.
What is the most likely diagnosis?
1) De Quervain’s thyroiditis
2) Graves’ disease
3) Hashimoto’s thyroiditis
4) Post-partum thyroiditis
5) Riedel’s thyroiditis
The most likely diagnosis for the 27-year-old woman presenting with these symptoms is 1) De Quervain’s thyroiditis.
Here are the key points supporting this diagnosis:
- Neck Pain and Radiating Symptoms: The patient reports pain in the front of her neck that radiates to her jaw and ears, which is characteristic of De Quervain’s thyroiditis.
- General Malaise and Lethargy: She has been feeling run down and lethargic, which aligns with the systemic symptoms often associated with De Quervain’s thyroiditis, such as myalgia, malaise, and fatigue.
- Thyroid Swelling and Pain: The slight swelling in the anterior neck that exacerbates her pain on swallowing is consistent with De Quervain’s thyroiditis, which typically presents with a tender and swollen thyroid gland.
- Elevated T4 and T3 Levels: The blood tests showing slightly elevated T4 and T3 levels are indicative of the initial hyperthyroid phase seen in De Quervain’s thyroiditis.
These features collectively point towards De Quervain’s thyroiditis as the most likely diagnosis.
A patient presents with tiredness. High titres of antithyroid microsomal and
antithyroglobulin
antibodies
are found.
Which one of the following diagnoses is suggested?
1) Hashimoto’s thyroiditis
2) Reidel’s thyroiditis
3) Grave’s disease
4) Hypoparathyroidism
5) Idiopathic hypothyroidism
Explanation
Hashimoto’s thyroiditis
The condition associated with antithyroid microsomal antibodies (antithyroid
peroxidase antibodies) and antithyroglobulin antibodies, presenting with a complaint of
tiredness is Hashimoto’s thyroiditis. Hashimoto’s thyroiditis is an autoimmune thyroid
condition, in which the presence of autoantibodies leads to cell d estruction in the
thyroid, reduced hormone output and hypothyroidism. It is the most common cause
of hypothyroidism in areas where there is adequate iodine intake. It is 10 times more
common in women and tends to present in the ages of 30 –50, however it can present at
any point during a patient’s lifetime. Hashimoto’s thyroiditis is associated with other
autoimmune conditions such as pernicious anaemia and coeliac disease. It also
increases the risk of developing lymphoma of the thyroid at a later stage in life. Patients
tend to present with symptoms as described in the mnemonic below, of insidious onset,
gradually worsening and the presence of a diffuse goitre. Treatment is with thyroid
hormone supplementation. Surgery is not usually required unless there a re
compression symptoms from the goitre. Administration of steroids can assist in the
shrinking of the goitre pre-operatively. Hypothyroidism is 10 times more common in
women than men and occurs mainly in middle life.
Reidel’s thyroiditis
Riedel’s thyroiditis is a rare condition. It describes the chronic fibrosis of the thyroid
gland resulting in a rapidly growing, painful, hard and fixed thyroid mass. Fibrosis can
extend outside the thyroid gland to surrounding structures.
Grave’s disease
Grave’s disease presents is a form of hyperthyroidism, commonly presenting with a
toxic goitre. It is associated with the presence of IgG thyroid -stimulating
immunoglobulins, that bind to the thyroid-stimulating hormone receptors and stimulate
the production of thyroid hormones.
Hypoparathyroidism
Hypoparathyroidism is most commonly secondary to total thyroidectomy. It can also be
idiopathic or due to inability of the bones or kidneys to respond to parathyroid
hormone. In any case, it is not characterised by the presence of autoantibodies. Patients
present with symptoms relating to hypocalcaemia such as paraesthesia in the
extremities and peri-orally (circumoral), abdominal cramps and tetany. Idiopathic hypothyroidism
The term idiopathic is used to describe disease where the cause is unknown therefore it
does not apply in this case.
A 35-year-old woman presents with a neck lump which is hard and, on examination,
moves up with swallowing, and palpable cervical lymphadenopathy is present. Her only
other history of note is that she is from the Ukraine and grew up
near Chernobyl
and
informs you her older sister had a similar problem.
Which of the following thyroid tumours are
associated with radiation exposure
?
1) Anaplastic
2) Follicular
3) Lymphoma
4) Medullary
5) Papillary
Explanation
Papillary
Papillary carcinoma is the most common thyroid carcinoma, accounting for about 80%
of thyroid malignancies. It is a well-differentiated tumour, most commonly presenting in
women aged 35–40. It can be familial and is associated with exposure to radiation, most
significantly if this occurred in childhood.
It most commonly presents as a solitary thyroid nodule that radiologically appears as a
mass with irregular borders and is non-capsulated. It metastasises to the cervical lymph
nodes and rarely to the lungs.
Treatment is with surgical thyroidectomy ± regional lymph node clearance and
radioactive iodine administration for positive lymph nodes.
If the tumour is confined to the thyroid gland on diagnosis, it has an excellent prognosis
and a 5-year survival rate of 95%.
Anaplastic
Anaplastic thyroid carcinoma is rare (1% of all thyroid malignancies), is highly
malignant and has a very poor prognosis.
Follicular
Follicular carcinoma is the second most common type of thyroid malignancies and is
more common in areas where there is a higher incidence of iodine deficiency.
Lymphoma
Primary thyroid lymphoma is a non-Hodgkin’s B-cell lymphoma associated with
Hashimoto’s thyroiditis.
Medullary
Medullary thyroid carcinoma accounts for about 5% of all thyroid malignancies an d is
associated with multiple endocrine neoplasia type 2.
A
25-year-old
woman was seen in the Emergency Department complaining
of
vagueabdominal pain and some pain in her extremities. On further enquiry she
revealed that she had been feeling
depressed
for several months. Physical examination
revealed no major findings. A chest X-ray was normal. Serum biochemistry revealed the
following:
Result
Normal
Calcium
3.47 mmol/l
2.20–2.60 mmol/l
Serum albumin
38 g/l
35–55 g/l
Phosphate
0.64 mmol/l
0.70–1.40 mmol/l
What is the most likely diagnosis in this patient?
1) Chronic renal failure
2) Metastatic carcinoma
3) Parathyroid adenoma
4) Pituitary adenoma
5) Thyroid carcinoma
Explanation
Parathyroid adenoma
The patient has hypercalcaemia and hypophosphataemia, pointing towards the
diagnosis of primary parathyroid disease. This patient most likely has primary
hyperparathyroidism, the most common cause of which is a single parathyroid
adenoma (85%). Other causes include: parathyroid gland hyper plasia affecting
all four parathyroid glands (10–15%), multiple parathyroid adenomas (3–5%) or a
parathyroid carcinoma (1%).
The adenoma produces an excess of parathyroid hormone leading to: excessive calcium
resorption from bone, increased renal calcium reabsorption, increased renal phosphate
excretion and increased production of 1,25-dihydroxyvitamin D3 .
Therefore, blood tests reveal: a raised PTH, hypercalcaemia, hypophosphataemia and a
raised vitamin D3 .
Treatment of a parathyroid adenoma is by surgical removal of the parathyroid glands.
For patients not fit/suitable for parathyroidectomy options for treatment include:
preventing vitamin D deficiency, bisphosphonates to protect the bones, calcimimetics to
control hypercalcaemia if required.
Chronic renal failure Chronic kidney failure leads to secondary hyperparathyroidism. The diseased kidney
fails to convert an adequate level of vitamin D to its active form, which reduces the
amount of calcium absorbed from the intestines, and fails to excrete phosphate leading
to formation of calcium phosphate compounds in the circulation and a reduction in free
circulating calcium. Therefore, in secondary hyperparathyroidism there is a low serum
concentration of calcium and vitamin D, a high serum concentration of para thyroid
hormone and a high serum phosphate.
Metastatic carcinoma
The two most common causes of hypercalcaemia are primary hyperparathyroidism and
hypercalcaemia of malignancy. The two are generally quite difficult to differentiate. In
both calcium is raised (with hypercalcaemia of malignancy causing a more dramatic
hypercalcaemia) and phosphate is low. parathyroid hormone (PTH) in primary
hyperparathyroidism is raised whereas in hypercalcaemia of malignancy it can be
low/normal/raised depending on the mechanism involved.
Given the patient’s age and the fact that the symptoms have been ongoing for several
months make parathyroid adenoma a far more likely diagnosis than metastatic
carcinoma. The most common cancers associated with hypercalcaemia are: breast, l ung
and myeloma.
Pituitary adenoma
A pituitary adenoma causes visual symptoms (bitemporal hemianopia), headaches and
symptoms relating to the cellular origin of the adenoma. It does not commonly cause
hypercalcaemia.
Thyroid carcinoma
Thyroid carcinoma can lead to hypercalcaemia, but this is usually seen with advanced
disease.
A 3-week -old boy presents with non-bilious vomiting, hypochloraemic metabolic alkalosis , hypokalaemia. On examination there is an epigastric mass. What is the most likely diagnosis?
1) Bacterial gastroenteritis
2) Gastro-oesophageal reflux disease
3) Obstructed umbilical hernia
4) Pyloric stenosis
5) Wilms’ tumour
Diagnosis of the 3-Week-Old Boy with Symptoms
To determine the most likely diagnosis for the 3-week-old boy presenting with non-bilious vomiting, hypochloraemic metabolic alkalosis, hypokalaemia, and an epigastric mass, we need to analyze each symptom and correlate it with the potential diagnoses provided.
Symptom Analysis
Non-bilious vomiting: This type of vomiting is often associated with conditions affecting gastric outflow. In infants, this can indicate a blockage or narrowing in the pylorus (the opening from the stomach to the small intestine).
Hypochloraemic metabolic alkalosis: This condition arises when there is a loss of hydrochloric acid (HCl) from the stomach due to persistent vomiting. The loss of chloride leads to low levels of potassium (hypokalaemia) as well.
Hypokalaemia: Low potassium levels are commonly seen in cases of prolonged vomiting or conditions that lead to significant fluid loss.
Epigastric mass: The presence of a palpable mass in the epigastric region is particularly indicative. In infants, this could suggest hypertrophy of the pyloric muscle, which is characteristic of pyloric stenosis.
Differential Diagnosis Evaluation
Now let’s evaluate each option:
Bacterial gastroenteritis: Typically presents with diarrhea rather than isolated vomiting and would not usually cause an epigastric mass.
Gastro-oesophageal reflux disease (GERD): While it can cause vomiting in infants, it does not typically present with an epigastric mass or significant electrolyte imbalances like hypochloraemic metabolic alkalosis.
Obstructed umbilical hernia: This condition may cause vomiting but would more likely present with signs of bowel obstruction and pain rather than a specific epigastric mass.
Pyloric stenosis: This condition is characterized by non-bilious projectile vomiting due to gastric outlet obstruction caused by hypertrophy of the pyloric sphincter muscle. The classic presentation includes electrolyte imbalances such as hypochloraemic metabolic alkalosis and hypokalaemia, along with a palpable “olive-like” mass in the right upper quadrant or epigastric area.
Wilms’ tumour: Although it can present as an abdominal mass in children, it typically does not cause non-bilious vomiting or significant electrolyte disturbances like those described here.
Conclusion
Given all these considerations, the symptoms presented by this infant—non-bilious vomiting, hypochloraemic metabolic alkalosis, hypokalaemia, and an epigastric mass—are most consistent with:
Pyloric stenosis
A 3-week-old boy presents with non-bilious vomiting, hypokalaemia and hypochloraemic
alkalosis. On examination he has an epigastric mass. He is diagnosed with
pyloric stenosis
and is
taken to theatre to undergo
Ramstedt’s pyloromyotomy.
To which level should the incision be made?
1) Circular muscle layer
2) Longitudinal muscle layer
3) Mucosa
4) Serosa
5) Submucosa
Explanation
Mucosa
For Ramstedt’s procedure to be effective, a longitudinal incision is made through the
hypertrophied muscle as far as the mucosa; the mucosa is left intact and is seen bulging into the
incision. If the mucosa is split during the procedure then it should be re-sutured.
Circular muscle layer
The incision is a sero -muscular incision as deep as the mucosa. An incomplete incision will
result in continued gastric outflow obstruction.
Longitudinal muscle layer
The incision is a sero -muscular incision as deep as the mucosa.
Serosa
The incision is a sero -muscular incision as deep as the mucosa.
Submucosa
The incision is a sero -muscular incision as deep as the mucosa.
A 56-year-old nervous,
obese
woman presents to the Emergency Department with
mild
upper
abdominal pain and symptoms of an acidic taste in the mouth occurring several times per day
over the past 2 years. She states her pain is worse after eating. She is
haemodynamically
stable
and has normal observations.
Which one of the following most accurately describes this woman’s probable condition?
1) It is usually treated by highly selective vagotomy in cases where trials of medication have
failed
2) It is usually worsened by smoking which acts to contract the lower oesophageal sphincter
and increase oesophageal acidity
3) In cases such as this lifestyle modifying advice often has the desired effect
4) Prokinetic drugs such as metoclopramide should be used as the treatment of choice in this
condition
5) It leads to the development of Barrett’s metaplasia in 30% of cases
Explanation
In cases such as this lifestyle modifying advice often has the desired effect
In patients with mild symptoms, the first option should be lifestyle modifications like losing
weight, giving up smoking, not eating within 2 h of lying flat and raising the head of the bed by
6–8 inches.
It is usually treated by highly selective vagotomy in cases where trials of medication have failed
If surgical intervention is needed then the treatment of choice is a Nissen’s fundoplication.
Vagotomy has largely been superseded by proton pump inhibitors.
It is usually worsened by smoking which acts to contract the lower oesophageal sphincter and
increase oesophageal acidity
Insufficient clearance of acid can contribute to the symptoms of gastro -oesophageal reflux
disease (GORD), but this is not the most common problem which is incompetence of the lower
oesophageal sphincter plus failure of the anatomical valve at the angle of His. It is worsened by
smoking, the main action of which is to relax the lower oesophageal sphincter allowing stomach
acid to enter the oesophagus. Other risk factors include obesity and alcohol, which also result in
decreased competency of the lower oesophageal sphincter.
Prokinetic drugs such as metoclopramide should be used as the treatment of choice in this
condition
If simple lifestyle modifications do not work then proton pump inhibitors and H 2 blockers should
be tried before prokinetics.
It leads to the development of Barrett’s metaplasia in 30% of cases
Barrett’s oesophagus is seen in approximately 10% of patients undergoing endoscopy for
investigation of GORD.
A 63-year-old obese man has been referred to your clinic with symptoms of acid reflux, upper
abdominal pain and a new onset nocturnal cough. He has tried maximum dose proton pump
inhibitor treatment for 6 months with little relief. Which one of the following statements seems the most appropriate?
1) The oesophagus is a muscular tube approximately 25 cm long comprised of an inner
longitudinal muscle and an outer circular muscle coat which overlap in the middle part.
2) The lower oesophageal sphincter is a distinct anatomical condensation of muscle which
together with the angle of His acts to present reflu x of gastric acid back into the distal
oesophagus.
3) The best way of investigating gastro -oesophageal reflux disease is ambulatory pH
monitoring in which a probe is placed within the oesophagus itself and provides a
continuous reading of the level of oesophageal acidity
4) Barrett’s oesophagus is diagnosed on the anatomical endoscopic appearance of the Z line.
5) There are three predictable sites of oesophageal constriction which relate to the
cricopharyngeal sphincter (15 cm from incisors), where it is crossed by the aortic arch
(22 cm) and where it passes through the diaphragm (38 cm)
Explanation
The best way of investigating gastro -oesophageal reflux disease is ambulatory pH monitoring in
which a probe is placed within the oesophagus itself and provides a continu ous reading of the
level of oesophageal acidity
Twenty-four hour ambulatory monitoring was introduced in 1969 and has become the best way
for monitoring the pattern of exposure of acid in the oesophagus, and the gold standard for
gastro-oesophageal reflux disease. The monitor is placed so that the pH probe lies 5 cm above
the oesophageal sphincter, therefore being able to record the presence of acid within the
oesophagus itself.
The oesophagus is a muscular tube approximately 25 cm long comprised of an inne r longitudinal
muscle and an outer circular muscle coat which overlap in the middle part.
The oesophagus is approximately 25 cm long, but comprises an inner circular muscle coat and an
outer longitudinal coat, which is striated muscle in the upper part and smooth muscle in the
lower part with considerable overlap in the middle.
The lower oesophageal sphincter is a distinct anatomical condensation of muscle which together
with the angle of His acts to present reflux of gastric acid back into the distal oesophagus.
The lower oesophageal sphincter is a physiological rather than an anatomical sphincter and there
is no distinct condensation of muscle here.
Barrett’s oesophagus is diagnosed on the anatomical endoscopic appearance of the Z line.
Barrett’s oesophagus needs to be diagnosed by endoscopy, with multiple biopsies to show
metaplasia of the normal oesophageal squamous epithelium to columnar epithelium with goblet
cells – it cannot be diagnosed from pH monitoring or the position of the Z line alone.
There are three predictable sites of oesophageal constriction which relate to the cricopharyngeal
sphincter (15 cm from incisors), where it is crossed by the aortic arch (22 cm) and where it
passes through the diaphragm (38 cm) In addition to the three levels of constriction described there is a fourth which lies at 27 cm from
the incisors and corresponds to the left principle bronchus.
A 67-year-old man presents with a long history of vague upper gastrointestinal symptoms
including dysphagia and heartburn. An oesophago -gastro-duodenoscopy (OGD) reveals the
presence of a para-oesophageal hernia.
Which one of these statements most accurately describes this condition?
1) Can cause palpitations due to a relative increase in pressure on the underside of the
thoracic diaphragm
2) Are more common than sliding herniae
3) Occurs in a younger age group than sliding herniae 4) Occurs when a part of the stomach herniates through the oesophageal hiatus with
subsequent herniation of the gastro oesophageal junction
5) Occurs more commonly in female patients
Explanation
Occurs more commonly in female patients
Para-oesophageal hiatus herniae have an established preponderance of women affected.
Can cause palpitations due to a relat ive increase in pressure on the underside of the thoracic
diaphragm
Palpitations can occur but this is though pressure on the vagus nerve. Symptoms usually relate to
the mechanical effects of additional compression on the lower oesophagus, and patients
commonly complain of dysphagia. Gastric volvulus is a recognised complication, but because of
the elderly age group, surgery may be high risk.
Are more common than sliding herniae
Sliding hiatus herniae are the commonest type (95%).
Occurs in a younger age group than sliding herniae
Para-oesophageal hernias occur when a part of the stomach herniates through the oesophageal
hiatus to lie next to the oesophago -gastric (OG) junction without herniation of the junction. The
more common sliding hiatus hernia occur when the oesophagogastric junction herniates through
the hiatus.
Occurs when a part of the stomach herniates through the oesophageal hiatus with subsequent
herniation of the gastro oesophageal junction
Para-oesophageal hernias occur when a part of the stoma ch herniates through the oesophageal
hiatus to lie next to the oesophago -gastric (OG) junction without herniation of the junction. The
more common sliding hiatus hernia occur when the oesophagogastric junction herniates through
the hiatus.
An elderly woman presents to the Emergency Department with severe dysphagia. Her symptoms
have been progressing and there is a vague suggestion of a gastric bubble above the diaphragm
on the chest radiograph, raising the possibility of a hiatus hernia.
Which one of the following is correct regarding hiatus herniae?
1) The majority of patients with hiatus herniae are symptomatic, and usually experience acid
reflux
2) As with gastro-oesophageal reflux disease, the most appropriate initial diagnostic
modality is ambulatory pH monitoring 3) When GORD is associated with a proven sliding hiatus hernia, surgical management in
the form of a Nissen fundoplication is the treatment of choice
4) Despite the high fibre diet, paradoxically hiatus herniae are found more commonly in
rural African communities
5) Sliding herniae are primarily associated with symptoms of GORD, whilst rolling herniae
can cause gastric strangulation and necrosis and gangrene
Explanation
Sliding herniae are primarily associated with symptoms of GORD, whilst rolling herniae can
cause gastric strangulation and necrosis and gangrene
Complications include incarceration, gangrene and gastric volvulus. Oesophagitis is more
commonly associated with sliding hiatus hernias.
The majority of patients with hiatus herniae are symptomatic, and usually experience acid reflux
The majority of hiatus herniae are sliding or axial in nature, are usually asymptomatic but can be
associated with oesophagitis, stricture formation, dysphagia, chronic anaemia and inhal ational
pneumonitis. Rolling herniae or para-oesophageal hiatal herniae usually affect elderly patients
who present with intermittent dysphagia, pain after eating due to distension of the intrathoracic
part of the stomach, cardiac symptoms such as palpitat ions due to pressure effects on the vagus
nerve, and hiccups due to phrenic nerve irritation.
As with gastro-oesophageal reflux disease, the most appropriate initial diagnostic modality is
ambulatory pH monitoring
Ambulatory pH monitoring is the gold standard for diagnosis of GORD, however, it is not
usually necessary. The most appropriate investigation is more frequently upper GI endoscopy,
upper GI contrast series or upper GI manometry to disprove other possible diagnoses (eg peptic
ulcer disease), and to monitor chronic patients for signs of Barrett’s oesophagus.
When GORD is associated with a proven sliding hiatus hernia, surgical management in the form
of a Nissen fundoplication is the treatment of choice
In severe cases of hiatus herniae, a Nissen fundoplication may be necessary but in the vast
majority of patients symptoms can be managed by lifestyle modification and medications such as
proton pump inhibitors and H 2 blockers.
Despite the high fibre diet, paradoxically hiatus herniae are found more commonly in rural
African communities
The low fibre diet of westernised society, and also the prolonged sitting position for defecation,
results in a higher incidence of hiatus herniae.
A 76-year-old woman presents to the Emergency Department with profuse fresh rectal bleeding with clots. She has a pulse rate of 90 beats per min (bpm) and a blood pressure (BP) of 140/86.
She had a similar episode 2 years ago, has not lost any weight and has normal bowel habits. She is also on omeprazole for long standing gastro -oesophageal reflux disease.
Which one of the following statements best describes this clinical scenario?
1) The commonest cause of massive rectal bleeding is diverticulitis and this is usually
painless
2) The passage of bright red blood is never due to duodenal ulcer
3) It is usually controlled by catheter-directed infusion of vasopressin
4) Following resuscitation an urgent OGD is a diagnostic option
5) It may be localised by angiography if <0.5 ml/ min
Explanation
Following resuscitation an urgent OGD is a diagnostic option
In a stable patient an urgent OGD is a relatively simple diagnostic test that can also be
therapeutic if a bleeding source is identified. However, usually a computed tomography (C T)
angiogram and selective embolization if the bleeding point can be identified would be indicated
in this patient.
The commonest cause of massive rectal bleeding is diverticulitis and this is usually painless
Diverticular disease with erosion of small vessels in the bowel wall is the most common form of
significant lower gastrointestinal haemorrhage and is usually painless. Diverticulitis however
often presents with left iliac fossa (LIF) pain and pyrexia but is rarely associated with bleeding.
The passage of bright red blood is never due to duodenal ulcer
Fresh per rectal (PR) bleeding is usually from the lower GI tract, however, if bleeding is brisk, it
may come from as high up as a peptic or duodenal ulcer, with the presence of blood promoting a
fast transit time.
It is usually controlled by catheter-directed infusion of vasopressin
Vasopressin has little role in the management of this scenario – if they do not settle
conservatively, then patients will need surgery.
It may be localised by angiography if <0.5 ml/min
Angiographic techniques can pick up bleeding at the rate of >0.5 ml/min in experienced hands.
A 32-year-old man is referred to your general surgical clinic complaining of a 3 -month history of dysphagia starting to both solids and liquids. In addition he complains of retrosternal chest pain and 1 stone of weight loss over the last 3 months. He is a moderate drinker and has a 20 pack -year smoking history.
Which one of the following statements best represents this man’s likely condition?
1) The most likely differential diagnosis in this man is oesophageal carcinoma
2) In oesophageal carcinoma, dysphagia is progressive like achalasia
3) Oesophageal achalasia which can be treated by dilating the lower oesophagus and associated sphincter
4) Achalasia which is characterised by incomplete lower oesophageal sphincter relaxation, decreased LOS tone and increased peristalsis of the oesophagus
5) Although achalasia can be primary (affecting 1/100,000 individuals per year) it is much more commonly associated with other conditions
Explanation Oesophageal achalasia which can be treated by dilating the lower oesophagus and associated
sphincter
Treatment of achalasia should initially be by lifestyle modification and medications to reduce
lower oesophageal sphincter (LOS) pressure (eg nifedipine). Invasive treatments include balloon
dilatation and also Heller’s cardiomyotomy together with a partial fundoplication to prevent
excessive reflux.
The most likely differential diagnosis in this man is oesophageal carcinoma
In carcino ma, difficulties begin with swallowing solids and progress to include liquids. Normally
this dysphagia is painless.
In oesophageal carcinoma, dysphagia is progressive like achalasia
While in carcinoma, difficulties begin with swallowing solids and progress to include liquids, in
achalasia patients have equal difficulty in swallowing both liquids and solids.
Achalasia which is characterised by incomplete lower oesophageal sphincter relaxation,
decreased LOS tone and increased peristalsis of the oesophagus
It is characterised by incomplete LOS relaxation, increased LOS tone and lack of oesophageal
peristalsis. This results in dysphagia to both liquids and solids, chest pain that can be worse after
eating, and unintentional weight loss.
Although achalasia can be primary (affecting 1/100,000 individuals per year) it is much more
commonly associated with other conditions
Achalasia is a condition caused by failure of development of the lower oesophageal inhibitory
neurons and involves the smooth muscle layers of the oesophagus and LOS. The most common
form is primary achalasia but it also occurs associated with other conditions such as cancer or
Chagas’ disease but much more infrequently.
A 56-year-old woman has been referred to your surgical clinic with symptoms of waterbrash and
a new onset night cough. She has tried maximal medical management with her GP and a
diagnosis of reflux oesophagitis has been made on oesophago -gastro-duodenoscopy (OGD).
Which one of the following statements is true regarding th is condition?
1) Does not require more than alteration of lifestyle to treat
2) If untreated may cause stricturing of the oesophagus
3) Is always present with hiatus hernia
4) Is preferably treated with surgery
5) Is treated surgically principally by attempting to narrow the gastro-oesophageal junction
Explanation
If untreated may cause stricturing of the oesophagus
If GORD goes untreated then a common eventual complication is oesophageal stricture. Does not require more than alteration of lifestyle to treat
Often lifestyle alterations are successful, but should they not be medical management with
proton pump inhibitor (PPI) or H 2 antagonists are frequently required. Further steps in
management include gastric motility agents, then surgery.
Is always present with hiatus hernia
The majority of hiatus herniae are asymptomatic.
Is preferably treated with surgery
The initial management of mild cases is with lifestyle changes – these include weight loss,
reducing smoking and alcohol intake, and avoiding food in the 2 h before be d. Should these fail
or symptoms be more severe medical management with PPI or H 2 antagonists can be tried,
followed by gastric motility agents. Surgery is only usually considered if symptoms remain
following failure of lifestyle and medical management.
Is treated surgically principally by attempting to narrow the gastro -oesophageal junction
Surgical management is with a Nissen’s fundoplication in which the fundus is wrapped around
the distal oesophagus with plication of the oesophageal hiatus. The gastro-oesophageal
junction (GOJ) itself is not touched. This procedure can be performed open or laparoscopically.
A 78-year-old woman presents to the Emergency Department 3 years following a Hartmann’s
procedure for perforated diverticular disease. She has never wanted a reversal of her stoma but
has recently noticed a tender lump adjacent to the stoma. A diagnosis of a parastomal hernia has
been made.
Which one of the following statements best reflects this condition?
1) Parastomal herniae are commonly asymptomatic
2) Is more common when the stoma is brought through the rectus muscle
3) Occurs in 30% of colostomies
4) Should always be repaired
5) Should be repaired using a mesh
Explanation
Parastomal herniae are commonly asymptomatic
Parastomal herniae are usually asymptomatic.
Is more common when the stoma is brought through the rectus muscle
Parastomal herniae occur in approximately 10% of colostomies and are usually asymptomatic.
They rarely lead to complications and therefore usually do not need treating surgically. Factors that may increase the risk of developing a parasternal hernia include obesity, increasing age, post
operative infection, malnutrition, and site of the stoma (stoma being placed outside of the rectus
abdominus). Approximately 80 percent of patients with parastomal hernia remain asymptomatic
and do not need further intervention.
Occurs in 30% of colostomies
Parastomal herniae occur in 10% of colostomies.
Should always be repaired
Since parastomal herniae are usually asymptomatic and rarely lead to complications treatment is
not usually necessary.
Should be repaired using a mesh
Mesh repair can be undertaken, but the presence of foreign material around a stoma site leads to
a high risk of infection, so this procedure is rarely carried out.
A 26-year-old woman presents to the Emergency Department with
right iliac fossa peritonism,
pyrexia and vomiting
. A diagnostic laparoscopy reveals appendicitis which is duly resected.
Regarding the Alvarado score, which one of the following is correct?
1) Appendicitis is associated with a right shift in the neutrophil profile
2) Appendicitis is associated with migratory right iliac fossa pain
3) Appendicitis is unlikely with a score over 5
4) Does not count rebound tenderness in the marking scheme
5) Is associated with a higher mortality if the score is over 13
Explanation
Appendicitis is associated with migratory right iliac fossa pain
This feature of the history is part of the scoring process.
Appendicitis is associated with a right shift in the neutrophil profile
A left shift in the neutrophil profile is part of the scoring process, a right shift is not.
Appendicitis is unlikely with a score over 5
If the score is less than 5 then appendicitis is unlikely, 5 –6 is equivocal, 7 or greater is likely.
Does not count rebound tenderness in the marking scheme
Rebound tenderness is an important part of the scoring process. Is associated with a higher mortality if the score is over 13
The score dose not predict mortalit y.
Acute appendicitis has an associated mortality of 0.25% and a morbidity of 7.7%. It classically
presents with periumbilical pain that then localises to the right iliac fossa, anorexia, nausea and
vomiting. The patient will likely be tender in the right iliac fossa (RIF) and have signs of
localised peritonism. The presentation is, however, variable because of the variability in position
of the appendix and a high retrocaecal appendix may mimic cholecystitis, and appendicitis itself
may be caused by a caecal carcinoma which occludes the appendix lumen. The peak incidence is
towards 30 years of age with a second peak at 70 years. It has an overall incidence of 10% of the
population. It is marginally more common in men (1.6 times).
The Alvarado score is a clinical and laboratory based scoring system marked out of 10 which
assesses the likelihood of the diagnosis of appendicitis:
if <5 appendicitis is unlikely
5–6 is equivocal and may require scanning
> 7 is strongly predictive.
Points are awarded as below:
Migratory RIF pain (1 point), anorexia (1 point), nausea and vomiting (1point), RIF tenderness
(2 points), rebound tenderness (1 point), fever (1 point), leucocytosis (2 points), left shift in
neutrophils (1 point).
You are sitting in on a general surgical clinic and your consultant is discussing rarer causes of
small bowl obstruction. The next patient previously had an intussuscepted bowel.
Intussusception is most common in which one of the following?
1) Women in the summer months
2) Women in the winter months
3) Women regardless of the time of year
4) Men in the summer months
5) Men in the winter months
Explanation
Men in the winter months
It is more common in the winter months and in men. Children with this condition other have flu-
like symptoms, and this effect, together with the predisposition to winter months, suggests virus
involvement in the development of the condition.
Women in the summer months
Intussusception is less common in women and the summer months.
Women in the winter months
Intussusception is more common in men than in women, but is indeed more common in the
winter months. Women regardless of the time of year
Intussusception is more common in men than women.
Men in the summer months
While intussusception is more common in men, it is still more common in winter than in
summer.
Intussusception is the telescoping of one part of the intestine into the other and is most common
in infants aged 4 months to 1 year, with peak incidence between 6 –9 months. Presenting features
are abdominal pain, fever, ‘redcurrant jelly’ stool, and obstruction. Other risk factors include
previous intussusception, or family history of the condition, and intestinal malrotation. An
ultrasound scan (USS) or a barium or a ir enema may detect the point of intussusception. The
enema may also relieve the intussusception, otherwise surgery may be required.
A 23-year-old man presents with severe perianal discomfort and fever. A magnetic resonance
imaging scan of the pelvis is performed and the radiologist reports a collection of pus
inferior
and lateral to levator ani.
What is the most likely diagnosis?
1) Horseshoe abscess
2) Intersphincteric abscess
3) Ischiorectal abscess
4) Perianal abscess
5) Supralevator abscess
Explanation
Ischiorectal abscess
The ischiorectal (or ischioanal) fossae are prism-shaped fascia-lined potential spaces adjacent to
the rectum. They are bordered by the levator ani muscle (superiorly and medially), the anal canal
(medially), the perineal skin (inferiorly), and the ischial tuberosity (laterally). Ischiorectal
abscesses are the second most common type of anorectal sepsis.
Horseshoe abscess
This option is an ischiorectal abscess that extends to both sides of the anal canal so forming a
horseshoe shape.
Intersphincteric abscess
Intersphincteric abscesses sit between the internal and external sphincters. They may not be
visible as they can be completely contained within the anal canal. In this instance either digital
rectal examination or examination under anaesthetic (EUA) is required for diagnosis.
Perianal abscess These are most common. They are superficial, do not transverse the external sphincter but sit just
under the skin.
Supralevator abscess
These are the least common, they form from an upward extension of an intersphincteric abscess
into the supralevator space. They may also form from an intra -abdominal inflammation (eg
appendicitis) tracking down.
A 70-year-old woman attends the clinic with a history of right upper quadrant pain. She has an
ultrasound scan of the abdomen that reveals a normal liver, a common bile duct diameter of 5
mm and
multiple gallstones
within a contracted
thick-walled gall-bladder
.
Which one of the following statements is true regarding this patient?
1) A laparoscopic cholecystectomy should be recommended
2) Gallbladder carcinoma can be excluded
3) She has acute cholecystitis
4) She has Mirizzi’s syndrome which is a gallstone that is eroding through the gallbladder
wall into the ileum
5) The common bile duct is dilated
Explanation
A laparoscopic cholecystectomy should be recommended
Given the patient’s ongoing symptoms and thick-walled appearance to the gall-bladder,
cholecystectomy should be considered. Differentials for a thic k-walled gall-bladder include the
normal physiological state after food, cholecystitis (acute and chronic), infiltrative gall -bladder
cancer, and liver conditions such as cirrhosis.
Gallbladder carcinoma can be excluded
This condition cannot be fully excluded without biopsy.
She has acute cholecystitis
Acute cholecystitis presents with right upper quadrant pain, fever and raised inflammatory
markers. Murphy’s sign is usually positive (a positive Murphy’s sign is when pressure under the
right costal margin o n inspiration results in pain and the patient ‘catching’ their breath). There
can be fluid surrounding the gall-bladder as part of the inflammatory process.
She has Mirizzi’s syndrome which is a gallstone that is eroding through the gallbladder wall into
the ileum Mirizzi’s syndrome is obstructive jaundice caused by a large gallstone in Hartmann’s pouch
compressing the common bile duct. Mirizzi’s syndrome is one of the indications to convert from
laparoscopic cholecystectomy to an open procedure, often leav ing Hartmann’s pouch behind to
fibrose.
The common bile duct is dilated
Six millimetres is the upper limit of normal for common bile duct diameter, and allowances of a
few millimetres more may be made in elderly patients.
A 30-year-old man with
ulcerative colitis
attends the coloproctology clinic following a
Gastroenterology referral for restorative proctocolectomy.
Which one of the following is most accurate regarding restorative proctocolectomy?
1) Patients with both ulcerative colitis and primary sclerosing cholangitis are at higher risk
of requiring proctocolectomy than patients with ulcerative colitis alone
2) Pouch surveillance is mandatory in all cases of ulcerative colitis
3) Pouchitis is common with restorative procotocolectomy
4) Restorative proctolcolectomy is a three-stage procedure
5) Restorative proctocolectomy is contra-indicated in patients who have an internal anal
sphincter defect
Explanation
Patients with both ulcerative colitis and primary sclerosing cholang itis are at higher risk of
requiring proctocolectomy than patients with ulcerative colitis alone
Indications for proctocolectomy in ulcerative colitis (UC) include (non-exhaustive list):
Acute/emergency – toxic mega-colon, fulminant UC uncontrolled by medical treatment,
perforation, uncontrolled bleeding.
Elective – chronic steroid dependency or systemic side-effects from treatment, dysplasia or
adenocarcinoma on biopsy, refractory disease despite medical management.
PSC, in particular, is associated with an increased risk of developing colorectal cancer so, in
line with the above indications, is more likely to require restorative proctocolectomy.
Pouch surveillance is mandatory in all cases of ulcerative colitis Pouch surveillance is recommended for tho se who have colonic dysplasia or neoplasm, as there
are rare case reports of neoplasm developing within the pouch. It is not mandatory in all cases of
UC.
Pouchitis is common with restorative procotocolectomy
After 10 years around 50% of patients will have had their first episode of pouchitis. The
incidence of pouch failure is 5–15% per year and reasons include pelvic sepsis, poor function
and pouchitis.
Restorative proctolcolectomy is a three-stage procedure
Reoperative pelvic surgery (RPC) should be a one stage or two stage operation (if a
defunctioning stoma is employed). Further descriptive evidence may be found via the links
below.
Restorative proctocolectomy is contra-indicated in patients who have an internal anal sphincter
defect
Contraindications fo r restorative proctocolectomy pouch formation include small bowel disease
involvement (eg in Crohns) and anal disease involvement (eg in Crohns, or low rectal cancers).
Ulcerative colitis starts as a proctitis and ascends in a continuous fashion affecting up to the
entire colon, but typically not the small bowel. However, incompetent ileocaecal valves are not
uncommon and can lead to a ‘backwash’ ileitis, making distinction from Crohn’s or a mixed
colitis difficult. UC has many extra-intestinal manifestations, such as uveitis, arthritis, primary
sclerosing cholangitis and erythema nodosum. It is associated to the HLA-B27 phenotype.
Restorative proctocolectomy is a procedure by which a pouch from terminal ileum is fashioned
and anastomosed to the anus, 1–2 cm above the dentate line. The pouch is usually J in shape and
measures 15 cm in length. RPC is most commonly recommended in ulcerative colitis and
familial adenomatous polyposis where the colon needs to be removed to eliminate the risk of
colon cancer. Ideal pouch function is approximately 4–6 times per day and two times at night.
The benefit of the pouch is to eliminate urgency from a simple ileo -anal anastomosis, and avoid
a permanent ileostomy.
A 70-year-old woman presents to
the clinic with a lump in
the groin. The lump is reducible and
has a cough impulse. It is located
above
and
medial to the
pubic tubercle
.
Which one of the following is true about this type of hernia?
1) In women a direct hernia is more likely than an indirect one
2) Open repair requires fixation of mesh to the reflected edge of the Inguinal ligament
3) Repair requires preservation of the round ligament
4) The diagnosis is that of an femoral hernia which is more common than an inguinal hern ia
in women
5) The hernia can be repaired with a local anaesthetic block to L2 and L3
Explanation
Open repair requires fixation of mesh to the reflected edge of the Inguinal ligament
An inguinal hernia emerges above and medial to the pubic tubercle, so in this patient we suspect
an inguinal hernia. The inguinal canal in women contains the round ligament of the uterus and a
remnant of the processus vaginalis. A persistent processus vaginalis in women forms the canal of
Nuck. The floor of the inguinal canal is formed by the reflected edge of the inguinal ligament. As
part of the Lichtenstein procedure the lower part of the mesh is fixed to this reflected edge of the
inguinal ligament with the mesh above this positioned to reinforce the posterior wall of the canal.
In women a direct hernia is more likely than an indirect one
Direct hernias are rare in women (man to woman ratio 10:1), they result from an acquired
weakness of the wall of the inguinal canal formed by the transversalis fascia. Indirect hernias
occur through the internal inguinal ring where there is an inherent weakness. Direct hernias
occur usually in the elderly population, whereas indirect hernias can occur at any age and can be
congenital.
Repair requires preservation of the round ligament
During repair the round ligament can be divided.
The diagnosis is that of an femoral hernia which is more common than an inguinal hernia in
women
Femoral hernia accounts for 20% of hernias in women and 5% of hernias in men. The man to
woman ratio of inguinal hernia is 10 to 1. The hernia can be repaired with a local anaesthetic block to L2 and L3
Inguinal hernia can be repaired by a local anaesthetic block that requires infiltration of the
iliohypogastric and ilioinguinal nerves (T12 and L1), 2 cm medial from the ant erior superior iliac
spine, the genitofemoral nerve (L1 and L2), 1–2 cm lateral to the pubic tubercle and local
infiltration of the subcutaneous tissues along the line of incision.
A 55-year old man with
cirrhosis
of the liver due to chronic alcohol use presents to the acute
surgical take. He has had fresh per rectum
(PR) bleeding
and is found to have a
mass
in the low
rectum on PR.
What would be the next step in his management?
1) Computerized tomography scan of the abdomen and pelvis
2) Capsule endoscopy
3) Colonoscopy
4) Low anterior resection
5) Magnetic resonance imaging (MRI) of the pelvis
Explanation
Colonoscopy
The differential here is rectal neoplasm, polyp and varices. The best investigation would be an
endoluminal one, ie colonoscopy. Biopsies should only be considered if the mass is not of a
vascular nature as attempting to biopsy a varices would likely lead to heavy bleeding. In patients
that are unfit for colonoscopy axial imaging may be considered.
Computerized tomography scan of the abdomen and pelvis
This is not the best initial diagnostic investigation.
Capsule endoscopy
Capsule endoscopy is a useful investigation to image the small intestines, however for a low
colonic mass a different endoluminal investigation would be far more useful.
Low anterior resection
This may be the treatment of choice, for example if a malignancy is diagnosed. It is not,
however, a diagnostic investigation.
Magnetic resonance imaging (MRI) of the pelvis
This is part of the imaging required for the local staging of rectal cancers, it is not the best initial
diagnostic investigation. Along with the differentials of rectal neoplasm or polyp, this patient’s history of cirrhosis means
that varices must also be considered on the differential list. Common sites for varices are as
follows:
In the gastro-oesophageal region, the oesophageal tributaries of the left gastric vein
anastomose with the oesophageal veins, which empty into the azygos vein.
In the paraumbilical region the paraumbilical veins in the falciform ligament anastomose
with the subcutaneous veins in the anterior abdominal wall.
In the anorectal region the superior rectal vein anastomoses with the middle and inferior
rectal veins, which are anastomoses of the internal iliac and internal pudendal veins.
A 2-week-old boy presents with projectile vomiting, palpable epigastric mass and failure to thrive. He is diagnosed with hypertrophic pyloric stenosis and undergoes Ramstedt’s
pyloromyotomy.
Which one is the deepest layer of the pyloric wall to be divided?
1) Circular muscle
2) Longitudinal muscle
3) Mucosa
4) Parietal peritnoneum
5) Serosal surface
Explanation
Circular muscle
The circular muscle is the last layer to be divided.
Longitudinal muscle
The longitudinal muscle sits outside the circular muscle.
Mucosa
The mucosa is left intact.
Parietal peritnoneum
The peritoneum is divided to gain access to the greater curvature of the stomach.
Serosal surface
The serosa is cut through before the muscular layers being divided. Ramstedt’s pyloromyotomy is indicated in hypertrophic pyloric stenosis. An incision is made
along the length of the hypertrophic muscle, and the layers of longitudinal and circular muscle are divided until the mucosa is exposed.
A 25-year-old woman attends the Coloproctology Clinic with a 4-month history of
intermittent,
painful, fresh per rectum (PR) bleeding. She is found to have anal
spasm
and a
chronic
anal fissure
.
What will be the most appropriate first line management?
1) Advancement flap
2) Examination under anaesthesia and Botulinum A toxin
3) Flexible sigmoidoscopy and high fibre diet
4) Lateral sphincterotomy
5) 2% Diltiazem ointment
Explanation
2% Diltiazem ointment
The accepted treatment protocol for anal fissures is firstly topical 0.2% glyceryl trinitrate(GTN)
or 2% Diltiazem followed by Botox and then lateral sphincterotomy or advancement flap. The
latter is considered in women with low pressure anal fissure. Anterior anal fissures are
commoner in women due to the lack of support to the anal canal anteriorly, bu t posterior fissures
are most common overall.
Advancement flap
An advancement flap is considered in low pressure anal fissure, but is not first -line treatment.
Examination under anaesthesia and Botulinum A toxin
Examination under anaesthesia is not usually indicated for primary anal fissure – it may,
however, be necessary in elderly patients or other groups in whom a secondary cause is
suspected. Additionally, in the paediatric group if abuse is considered, a possible cause
examination under anaesthesia (EUA) may be indicated. Botulinum toxin is a useful treatment
causing relaxation of the sphincter, improving blood flow and therefore healing time, but is
usually considered after other topical treatments have failed.
Flexible sigmoidoscopy and high fibre diet
Whilst a high fibre diet is important in both prevention and treatment of primary anal fissure it is
not thought to offer much benefit in the treatment of chronic anal fissures. Additionally a flexible
sigmoidoscopy is not usually a first -line measure in young patients when primary anal fissure is
suspected. However, in elderly patients, secondary causes such as anal or rectal cancer are more
likely and further investigation may be indicated.
Lateral sphincterotomy Lateral sphincterotomy can be considered should topical treatments or Botox management not
prove successful. The aim is to reduce the pressure of the sphincter, which aids blood flow to the
area and therefore healing.
A 56-year -old woman presents to casualty with severe upper abdominal pain. On questioning she admits to several similar episodes of upper abdominal pain radiating to her back over the past 4 years that have all required admission. On examination she is in in severe pain and looks thin and unkempt. A diagnosis of chronic pancreatitis is made.
Which one of the following statements is the most likely aetiology in this woman?
1) Alcohol
2) Cholelithiasis
3) Hypocalcaemia
4) Hypothermia
5) Mumps
Explanation
Alcohol
The most common cause of chronic pancreatitis is chronic excess alcohol.
Cholelithiasis
Cholelithiasis (gallstones) and choledocholithiasis (gallstones in the common bile duct) are common causes of acute pancreatitis, which with alcohol accounts for approximately 80% of cases.
Hypocalcaemia
Hypocalcaemia is a complication of acute pancreatitis, as opposed to hypercalcaemia which is a cause.
Hypothermia
Hypothermia is a recognised cause of acute pancreatitis but alcohol is the most likely cause in this scenario.
Mumps
Viral infections such as mumps are also well recognised causes of acute pancreatitis, but alcohol is the most likely cause in this scenario.
A 36-year-old woman presents to casualty with
profuse hematemesis
. She is a heavy drinker and
has been for several years. On examination she appears confused and has obvious ascites.
Which one of the following procedures should be completed first in her management?
1) Administration of vasoactive drugs such as somatostatin or octreotide
2) Balloon tamponade using a Sengstaken–Blakemore tube
3) Performing TIPS procedure as an emergency
4) Performing an urgent oesophago -gastroduodenoscopy (OGD) and endoscopic band
ligation
5) Securing IV access
Explanation
Securing IV access
The clinical vignette suggests a patient with decompensated liver disease (ascites, confusion) as a
result of heavy drinking. The suspicion must therefore be that this patient has presented with a
variceal haemorrhage. Oesophageal varices may present with profuse haematemesis and this
patient should be initially approached with an AB CDE assessment. As part of this, IV access
should be secured and bloods sent including an urgent crossmatch.
Administration of vasoactive drugs such as somatostatin or octreotide
If urgent endoscopy is available then this should occur as soon as possible in a patient with
active variceal bleeding. If not, then vasoactive drugs such as somatostatin, octreotide or
Glypressin should be considered. These would require an IV line to be placed to be administered.
Balloon tamponade using a Sengstaken–Blakemore tube
Balloon tamponade is considered normally only if band ligation or sclerotherapy fails to
adequately control the patient’s variceal haemorrhage, or in an emergency setting when
endoscopy is not available.
Performing TIPS procedure as an emergency
Transjugular intrahepatic portosystemic shunt (TIPS) procedure can be used to reduce portal
pressure by diverting portal blood flow into the hepatic vein and may be used if other methods
firstly cannot control bleeding.
Performing an urgent oesophago -gastroduodenoscopy (OGD) and endoscopic band ligation In patients with variceal bleeding this procedure is the most important immediate definitive
management, however it does not supersede a basic ABCDE (Airway maintenance with cervical
spine protection, Breathing and ventilation, Circulation with haemorrhage control, Disability:
neurological status, Exposure/environmental control) assessment and resuscitation of the patient.
You are seeing a
patient in clinic with
complete
rectal prolapse, and she asks about the potential
complications of
conservative treatment
of this condition. Which one of the following statements would you tell her is the commonest?
1) Incarceration
2) Incontinence
3) Rectal carcinoma
4) Strangulation
5) Ulceration
Explanation
Incontinence
The commonest of the correct options listed here is faecal incontinence (75%), which may
actually be the patient’s presenting symptom. Alternatively constipation can very commonly be
either the presenting symptom or a complication. Rectal prolapse is a condition that most
commonly affects older women, but can occur in any age. Partial rectal prolapse (prolapse of the
mucosal layer only) occurs more commonly in children while complete rectal prolapse (prolapse
of all layers of the rectum) is typical in elderly women. Patients may present because they have
felt/noticed the prolapse, often while straining to pass stool. Additionally they may present with
symptoms such as incontinence, constipation, per rectal (PR) ble eding or pain. Diagnosis may be
simple with the prolapse visualised either at rest or on straining/performing the Valsalva
manoeuvre. Imaging may be required in some patients, for example an evacuating proctogram.
Incarceration
Incarceration is a complicat ion of rectal prolapse, however, it is not the commonest of the correct
options listed here.
Rectal carcinoma
Occasionally a prolapse can be a presenting feature of rectal carcinoma.
Strangulation
This is a complication of rectal prolapse that requires emergency surgery. It presents with a
painful non-reducible prolapse. It is not the most common of the options listed.
Ulceration
Ulceration and necrosis of the rectal wall are common complications, albeit not the most
common listed option.
An 18-month-old child is brought to see you in clinic as his mother has noted mucus and blood
staining on
nappies, and has seen a bright red mass intermittently protruding from his anus. You
diagnose a
partial
rectal prolapse.
Which one of the following statements is true regarding partial rectal prolapses? 1) It involves all layers of the rectal wall
2) It is associated with a significant increased risk of rectal carcinoma
3) It is more common in adults than children
4) It should be treated with Delorme’s procedure
5) The majority resolves with conservative treatment
Explanation
The majority resolves with conservative treatment
Most cases of partial rectal prolapse in children resolve with conservative treatment.
It involves all layers of the rectal wall
Complete rectal prolapse involves all layers of the rectal wall and is more commonly seen in
elderly women. Partial rectal prolapse is more common in children and involves the mucosal
layer only.
It is associated with a significant increased risk of r ectal carcinoma
There is an associated risk of rectal carcinoma in adults with complete rectal prolapse, but this
risk has not been reported in children with partial rectal prolapse; it may be more commonly
associated with cystic fibrosis, Ehlers–Danlos or Hirschsprung’s disease.
It is more common in adults than children
In adults complete rectal prolapse is more common, in children partial rectal prolapse is more
common.
It should be treated with Delorme’s procedure
Delorme’s procedure is excision of the mucosal component of a prolapse with plication of the
muscle from below, and is generally used in adults.
A 25-year
-old man from Uganda presents with a high
perianal fistula. He is a non-smoker who
has had a
chronic cough
for 3 months and has noticed
weight loss
of 2 stone in 6 months.
What is the most likely associated condition leading to this high anal fistula?
1) Carcinoma
2) Crohn’s disease 3) Diverticular disease
4) Tuberculosis
5) Ulcerative colitis
Explanation
Tuberculosis
The patient’s country of origin, Uganda, where tuberculosis (TB) is endemic, along with the
history of chronic cough and weight loss are highly suspicious for tuberculosis infection. Low
and high fistula are defined by the level at which they pass through the anal sphincters. A low
fistula’s internal orifice is below puborectalis. A high fistula’s orifice begins above this. The
former are common, relatively easy to manage and do not usually threaten the patient’s
sphincteric muscle function (and therefore continence). High fistulae are infrequent, complex to
manage and can lead to incontinence.
Carcinoma
This option is a possibility, and should certainly be considered given the weight loss red flag. It
is unlikely in a patient of this age, and does not explain h is cough and therefore is not the most
likely option.
Crohn’s disease
All the options listed are possible causes of high fistula. Crohn’s disease is a recognised cause in
this age group and the weight loss would fit with this diagnosis. Crohn’s disease is, however,
more common in smokers and this option does not explain the chronic cough.
Diverticular disease
All the options listed are possible causes of high fistula. Diverticular disease is possible, but
uncommon in younger patients.
Ulcerative colitis
Ulcerative colitis is a recognised cause in this age group and the weight loss would fit with this
diagnosis, however, this option also does not explain the chronic cough from which the patient
has been suffering.
An
88-year-old
woman presents to the Emergency Department with
recurrent
painless abdominal
distension and vomiting. She has not opened her bowels for 5 days. Examination reveals a
distended, soft, mildly tender abdomen with reduced bowel sounds. Plain radiog raphs
demonstrate distended loops of large bowel that appear
unchanged
from those on previous
admissions for similar presentations. A diagnosis of colonic pseudo -obstruction is made.
Which one of the following statements is true? 1) A barium enema is likely to demonstrate a mechanical cause
2) The condition is not commonly associated with physical trauma
3) The condition is rarely associated with electrolyte disturbances
4) Institutionalised and immobile elderly patients are at increased risk
5) The condition may successfully be treated by gastroscopy
Explanation
Institutionalised and immobile elderly patients are at increased risk
This is correct, other risk factors include cerebral palsy, Parkinson’s disease or other
neurological disorders; chronic renal, pulmonary or cardiac disease; prolonged immobility; and
prolonged use of narcotic drugs and other anticholinergic drugs that reduce bowel motility.
Chronic colonic pseudo-obstruction is characterised by symptoms of recurrent bowel
obstruction, abdominal bloating and/or pain, evidence of bowel obstruction on radiographic
imaging, and no evidence of anatomic/structural abnormality. Possible complica tions include
diarrhoea (and associated electrolyte disturbances), intestinal perforation, nutritional deficiencies
and weight loss.
A barium enema is likely to demonstrate a mechanical cause
Pseudo-obstruction is not caused by a mechanical obstruction, instead it is a result of ineffective
peristalsis of the intestine.
The condition is not commonly associated with physical trauma
Physical trauma is a common cause of pseudo -obstruction.
The condition is rarely associated with electrolyte disturbances
Weight loss and electrolyte disturbances are common occurring as a result of loss of appetite,
frequent vomiting and poor nutritional intake. Additionally, the causative conditions in
secondary pseudo-obstruction (eg Parkinson’s disease, cerebral palsy, immobility, or chronic
renal failure) may impair the patient’s ability to take on adequate/appropriate nutrition or may
directly lead to electrolyte disturbances themselves.
The condition may successfully be treated by gastroscopy
Colonoscopy is often successful in decompressing the colon, although symptomatic relief from
this is often temporary.
A 47-year-old man with a
long history of alcohol abuse
is admitted to hospital with acute
abdominal pain and is diagnosed clinically as having acute pancreatitis. This is confirmed by
finding a high serum amylase activity and by the results of an ultrasound scan. He has not had a
similar illness before. His serum is seen to be
lipaemic: serum triglyceride concentration is 26
mmol/l (normal <1.7 mmol/l)
Which one of the following statements is the most likely cause of the
hypertriglyceridaemia?
1) Decreased pancreatic lipase secretion
2) Deficiency of apolipoprotein C-II 3) Deficiency of LDL (low-density lipoprotein) receptors
4) Deficiency of lipoprotein lipase
5) Increased synthesis of VLDL (very-low-density lipoprotein)
Explanation
Increased synthesis of VLDL (very-low-density lipoprotein)
Hypertriglyceridaemia occurs frequently in association with a high alcohol intak e, and is due to
the increased synthesis of triglyceride for incorporation into VLDL in the liver. This is thought to
be as a result of the altered redox state as a consequence of alcohol metabolism, which favours
fat synthesis
Decreased pancreatic lipase secretion
Pancreatic lipase is normally secreted into the gut and higher plasma levels are found
in pancreatitis
Deficiency of apolipoprotein C-II
Apolipoprotein C-II activates lipoprotein lipase, which is responsible for the clearance of very-
low-density lipoprotein (VLDL) and chylomicrons from the plasma. Both lipase deficiency and
apolipoprotein C-II deficiency are rare, inherited causes of severe hypertriglyceridaemia, which
usually present in childhood.
Deficiency of LDL (low-density lipoprotein) recep tors
LDL receptors are involved in the transport of cholesterol from the plasma to the interior of cells:
deficiency is the cause of familial hypercholesterolaemia.
Deficiency of lipoprotein lipase
Lipoprotein lipase deficiency is a rare inherited cause of severe hypertriglyceridaemia. The
condition usually presents in childhood. Lipoprotein lipase is responsible for the clearance of
very-low-density lipoprotein (VLDL) and chylomicrons from the plasma.
An infant should pass meconium at or soon after bir th. It results from materials ingested by the
neonate whilst it remains in utero.
The commonest underlying cause for meconium ileus in a newborn is?
1) Hirschsprung’s disease
2) Intussusceptions
3) Duodenal atresia
4) Imperforate anus
5) Cystic fibrosis
Explanation
Cystic fibrosis
Most newborn babies with meconium ileus have cystic fibrosis. Cystic fibrosis (CF) is an
autosomal-recessive disorder associated with the production of abnormal mucous with high salt
content. The Guthrie tests done in the first days of life include a spot test for CF, however, a
sweat chloride test is used to confirm the diagnosis. Meconium ileus occurs in CF as a result of
the following: the pancreas undergoes dysplasia, so with the loss of pancreatic enzymes and
presence of abnormal mucous, thick meconium forms. This is thick enough to causes
intraluminal intestinal obstruction usually at the level of the terminal ileum. Affected bowel will
be dilated and filled with heavy meconium making it prone to volvulus.
Hirschsprung’s disease
Hirschsprung’s disease results from abnormal development of the intrinsic nerves of the colon
and results in megacolon, rather than meconium ileus.
Intussusceptions
Intussusception is a common paediatric cause of obstruction, classically presenting with passing
of a ‘red currant jelly’ stool and signs of obstruction. It results from part of the bowel ‘folding’
into an adjacent section of bowel such that it becomes trapped within the lumen of the adjacent
section.
Duodenal atresia
This condition is the congenital a bsence of the duodenal lumen. It may be detected antenatally as
it is a cause of polyhydramnios, in newborns it will present with features of intestinal
obstruction.
Imperforate anus
This is a congenital absence or obstruction of the anal passage, which wi ll be quickly detected as
part of the routine newborn screening examination.
Oesophageal cancer is a severe diagnosis requiring risky surgery where oncological success is
not always assured. Benign lesions are rare.
The commonest benign tumour of the oesophagus is?
1) Fibroma
2) Pseudopolyps
3) Adenoma
4) Leiomyoma
5) Fibrous polyps
Leiomyoma
Leiomyoma is the commonest benign tumour that occurs commonly in the lower part of the
oesophagus, although it is still a relatively rare growth. Overall benign tumours of the
oesophagus make up approximately 1% of all oesophageal tumours, and leiomyomas are around
two-thirds of this, or 0.6% of all oesophageal tumours. The majority of these are asymptomatic.
The commonest symptomatic presentation is dysphagia. The tumours are well encapsulated.
Endoscopic resection for small pedunculated lesions and localised resection for larger lesions is
the treatment if symptomatic.
Fibroma
Fibromas do occur, but are very rare and certainly not as common as leiomyomas.
Pseudopolyps
Pseudopolyps can occur, these are typically inflammatory in nature as a result of repetitive
inflammation/ulceration followed by deposition of granular tissue/regrowth of norma l tissue.
Adenoma
Adenomas do occur, but are very rare and certainly not as common as leiomyomas.
Fibrous polyps
The second commonest benign tumours are fibrous or fibrovascular polyps that occur commonly
in the upper third of the oesophagus.
Most of the tumours of the oesophagus are malignant and symptomatic benign tumours account
for less than 1% of oesophageal tumours.
Crohn’s disease has distinct pathological features. This differentiates from other gastrointestinal
pathologies
Which one of the following is not a pathological characteristic of Crohn’s disease?
1) There are abnormal areas intervening between normal mucosa ‘skip lesions’
2) Usually limited to mucosa
3) Ulceration in the bowel is usually deep
4) Non-caseating granuloma
5) May affect any part of the alimentary tract
Explanation
Usually limited to mucosa Crohn’s is typically a transmural inflammatory process
There are abnormal areas intervening between normal mucosa ‘skip lesions’
In Crohn’s disease there are often abnormal areas intervening between normal mucosa, these are
called ‘skip lesions’.
Ulceration in the bowel is usually deep
The inflammation is transmural and ulceration are typically deep. This situation leads to a
predisposition to fistulae formation, perforations, abs cesses and strictures.
Non-caseating granuloma
Granuloma are a histological feature of Crohn’s disease.
May affect any part of the alimentary tract
In ulcerative colitis the rectum is always affected, however in Crohn’s disease any part of the
alimentary tract may be affected. Perianal disease is common in Crohn’s disease presenting with
features such as fissures, abscesses and fistulae. Mouth ulcers can also be a presenting feature.
Crohn’s disease is an inflammatory bowel disease that affects any part of the alimentary tract.
Patients are typically diagnosed before the age of 30, and it affects any ethnic group, but mostly
white patients and Ashkenazi Jews. Family history of the disease is a risk factor, and current
cigarette smoking is a very strong risk factor and also associated with more severe disease and an
increased likelihood of needing surgery. Presenting symptoms of gastrointestinal disease (ie not
extra-intestinal manifestations) frequently include weight loss, loss of appetite, abdominal pain,
diarrhoea with blood in stool. Additionally, mouth ulcers and perianal disease are common in
Crohn’s presenting with features such as fissures, abscesses and fistulae. The inflammation is
transmural affecting the whole thickness of the affected bowel and no n-caveating granulomas are
typically found. The terminal ileum is affected in nearly 75% of the cases. As the inflammation
is transmural and the ulcers associated with the disease are deep, fistulae formation, perforations,
abscesses and strictures are not unusual. Inflammatory bowel diseases are associated with extra -
intestinal manifestations that affect the skin (pyoderma gangrenosum, erythema nodosum), eyes
(iritis), joints (sacroiliitis, ankylosing spondylitis), biliary tree (sclerosing cholangitis, chr onic
active hepatitis).
Blockage of biliary outflow from the liver results in dilated intrahepatic ducts. There is
interruption of the enterohepatic circulation and concentration of bilirubin increases in the blood.
For a patient with obstructive jaundice, which one of the following statements is true?
1) Clinically detectable jaundice does not occur until the bilirubin is above 60 µmol
2) Bile salt deposition in the skin can cause intense itching
3) Most biliary strictures are due to inflammatory scarring after cholecystitis
4) Cholangiocarcinoma is the commonest neoplasm causing obstructive jaundice
5) Primary sclerosing cholangitis (PSC) is more commonly seen in Crohn’s disease than in
Ulcerative colitis
Explanation
Bile salt deposition in the skin can cause intense itching
Biliary obstruction leads to accumulation of bile salts with backflow into the liver and systemic
circulation, raising their blood concentration and leading to skin deposition and pruritus. Clinically detectable jaundice does not occur until the bilirubin is above 60 µmol
Clinically detectable jaundice occurs above 30 µmol/l, at 60 µmol/l the jaundice should be
obvious.
Most biliary strictures are due to inflammatory scarring after chole cystitis
Most biliary strictures are iatrogenic after surgery, only small numbers are post inflammatory
disease.
Cholangiocarcinoma is the commonest neoplasm causing obstructive jaundice
Adenocarcinoma of the head of the pancreas is the commonest neoplasm leading to obstructive
jaundice. Ninety per cent of pancreatic carcinomas are adenocarcinomas derived from the ductal
cells of the exocrine pancreas; these have only a 5% 5 -year survival rate.
Cholangiocarcinoma is a rare tumour arising from biliary epithe lium. Unlike adenocarcinoma of
the pancreas these tumours are slow growing and often metastasise late so that complete
resection is often possible – nevertheless they have a poor prognosis.
Primary sclerosing cholangitis (PSC) is more commonly seen in Croh n’s disease than in
Ulcerative colitis
Primary sclerosing cholangitis is a rare condition thought to be of autoimmune origin; it results
in progressive fibrosis of the biliary system. PSC may arise spontaneously but is usually in
association with long-standing UC, rather than Crohn’s disease. Areas of short localised disease
can be treated with an indwelling stent.
A senior house officer (SHO) working in a surgical ward
developed hepatitis, which resolved in
2 weeks. His blood tests showed that he had hepatitis A.
Six months after
this episode a liver
biopsy is performed for this SHO.
What is the biopsy most likely to show?
1) Central necrosis
2) Chronic septal fibrosis
3) Lobular fibrosis
4) Normal architecture
5) Periportal fibrosis
Explanation
Normal architecture
Hepatitis A virus has no known chronic carrier state and does not lead to chronic hepatitis or
cirrhosis. If a liver biopsy is performed after the patient has completely recovered from this
infection it will therefore show normal architecture.
Central necrosis
Central necrosis is a finding of acute hepatitis. Chronic septal fibrosis
This option a part of the histological findings of chronic hepatitis.
Lobular fibrosis
This option is a part of the histological findings of chronic hepatitis.
Periportal fibrosis
This option is a part of the histological findings of chronic hepatitis. It is also found in
schistosomiasis.
Hepatitis A virus is a single-stranded RNA picornavirus. This virus is the most common cause of
acute viral hepatitis and is particularly commo n in children and young adults. In some countries
more than 75% of adults have been exposed. Hepatitis A virus spreads primarily by faecal–oral
contact and so can occur in areas of poor hygiene. Water -borne and food-borne epidemics occur,
especially in underdeveloped countries. Eating contaminated raw shellfish is sometimes
responsible. Sporadic cases are also common, usually as a result of person-to-person contact.
Faecal shedding of the virus occurs before symptoms develop and usually ceases a few days after
symptoms begin. This means that infectivity often has already ceased when the hepatitis
becomes clinically evident. Hepatitis A virus has no known chronic carrier state and does not
lead to chronic hepatitis or cirrhosis. If a liver biopsy is performed after the patient has
completely recovered from this infection it will therefore show normal architecture.
A
25-year-old
man with jaundice had laboratory investigations performed which showed: total
bilirubin
7.0 mg/dL
, (normal 0.3 to 1.0 mg/dL), direct (conjugated) bilirubin
0.5 mg/dl
(normal <
0.2 mg/dL) and
anaemia
.
What is the most likely cause of his jaundice?
1) Fibrosis of the common bile duct
2) Haemolysis
3) Hepatitis
4) Sclerosing cholangitis
5) Schistosomiasis
Explanation
Haemolysis
Haemolysis results in the destruction of red cells therefore anaemia. Destruction of red cells also
leads to the increased production of unconjugated bilirubin.
Fibrosis of the common bile duct
This option would cause an obstructive pattern of jaundice, the patient’s direct (conjugated)
bilirubin would be expected to be significantly more elevated than here.
Hepatitis Hepatitis typically causes a non-obstructive pattern of jaundice, as this patient’s blood tests
suggest. However, it does not explain the anaemia.
Sclerosing cholangitis
This option would cause an obstructive pattern of jaundice, the patient’s direct (conjugated)
bilirubin would be expected to be significantly more elevated than here.
Schistosomiasis
Schistosomiasis typically causes a non-obstructive pattern of jaundice, as this patient’s blood
tests suggest. However, it does not explain the anaemia.
Hyperbilirubinaemia results from increased bilirubin production, decreased liver uptake or
conjugation, or decreased biliary excretion. Total bilirubin normally is mostly unconjugated,
with values of <1.2 mg/dl ( <20 μmol/l). Fractionation can measure the proportion of bilirubin
that is conjugated (or direct, ie measured directly). Fractionation is r equired only in neonatal
jaundice or if the bilirubin is elevated, but the other liver test results are normal, suggesting that
hepatobiliary disease is not the cause. Unconjugated hyperbilirubinaemia (indirect bilirubin
fraction > 85%) reflects increased bilirubin production (for example when haemolysis is the case,
as in this scenario) or defective liver uptake or conjugation (eg in hepatitis, or Gilbert’s
syndrome). Such increases in unconjugated bilirubin are generally less than five -fold ( <6 mg/dl
or <100 μmol/l) unless there is concurrent liver disease. Conjugated hyperbilirubinaemia
typically suggests decreased biliary excretion, also known as obstructive jaundice. Common
causes of this condition include gall stones, cancers (such as head of pancreas tumours), chronic
inflammatory diseases such as primary sclerosis cholangitis, and iatrogenically following
procedures such as ERCP.
A 43-year-old man has developed
sclerosing cholangitis
and iron deficiency anaemia secondary
to
chronic bloody diarrhoea
. They undergo colonoscopy as an outpatient.
A colonic biopsy would be most likely to show which one of the following?
1) Colonic adenocarcinoma
2) Diverticulitis
3) Granulomatous inflammation
4) Pseudopolyps
5) Villous adenoma
Explanation
Pseudopolyps
Pseudopolyps are a classic finding of ulcerative colitis. This diagnosis is suggested by presence
of sclerosing cholangitis (an extra-intestinal manifestation) along with the bloody diarrhoea in
the scenario above.
Colonic adenocarcinoma
This answer is not correct, it does not explain the sclerosis cholangitis.
Diverticulitis
Diverticulitis is not usually a chronic complaint, it is an acute inflammation of diverticula
typically in the distal colon. It presents typically with left iliac fossa tenderness, bloody
diarrhoea, and fever. Granulomatous inflammation
Granulomatous inflammation suggests Crohn’s disease, however, Crohn’s is not classically
associated with sclerosing cholangitis.
Villous adenoma
A villous adenoma is a non-malignant polyp that is most commonly found within the colon.
They can result in diarrhoea, typically not bloody diarrhoea though. They have considerable
potential to develop into malignant adenocarcinoma.
Ulcerative colitis affects the mucosa and submucosa of the rectum and colon, with a sharp border
between normal and affected tissue. Only in severe disease is the muscularis layer involved. In
early cases, the mucous membrane is erythaematous, finely granular and friable, with loss of the
normal vascular pattern and often with scattered haemorrhagic areas. Large mucosal ulcers with
copious purulent exudate are characteristic of severe disease. Islands of relatively normal or
hyperplastic inflammatory mucosa project above areas of ulcerated mucosa – these are name
pseudopolyps. Fistulas and abscesses do not occur, unlike in Crohn’s disease.
A 38-year-old man with ulcerative colitis develops pruritus and fatigue. His alkaline phosphatase is elevated. The biliary tree appears to have a ‘beaded’ appearance on barium radiography.
Which one of the following is the most likely diagnosis?
1) Acute cholecystitis
2) Chronic cholelithiasis
3) Cholesterosis
4) Gallstone ileus
5) Sclerosing cholangitis
Explanation
Sclerosing cholangitis
Primary sclerosing cholangitis is a chronic cholestatic syndrome characterised by patchy
inflammation, fibrosis and strictures of the intrahepatic and extrahepatic bile ducts. These patchy
affects are what led to the classic ‘beaded’ appearance mentioned in the scenario above. Around
80% of patients with PSC have inflammatory bowel disease, often ulcerative colitis. Symptoms
of fatigue and pruritus develop late. The diagnosis is based on contrast cholangiography (with
endoscopic retrograde cholangiopancreatography) or magnetic resonance
cholangiopancreatography. The disease leads to eventual obliteration of the bile ducts, with
cirrhosis, hepatic failure and sometimes cholangiocarcinoma.
Acute cholecystitis
Cholecystitis presents with Murphy’s positive right upper quadrant pain and signs of infection.
On imaging the gall-bladder may appear thick-walled and with some surrounding fluid.
Chronic cholelithiasis
Chronic cholelithiasis may well be asymptomatic, or may present with symptoms of biliary colic.
Imaging will reveal gallstones within the gall-bladder. Cholesterosis
Otherwise known as ‘strawberry gall-bladder’, this condition gives the wall of the gall-bladder a
strawberry-like colour and visual texture as a result of hig h cholesterol.
Gallstone ileus
Gallstone ileus is mechanical obstruction of the bowel due to a gallstone.
You are asked to examine a 42-yearof pain in the upper central abdomen
old man in the surgical out -patient clinic who gives a history that occurs 2–3 h after meals. He also tells you that he
often
wakes
up during the night with a similar pain.
Based on this history, what do you feel is the most likely cause of the pain?
1) Duodenal ulcer
2) Gastritis
3) Gastric ulcer
4) Pyloric stenosis
5) Zollinger-Ellison syndrome
Explanation
Duodenal ulcer
Duodenal ulcers tend to be associated with a fairly consistent pattern of pain. Pain is absent when
the patient awakens but appears mid-morning, is relieved by food, but recurs 2–3 h after a meal.
Pain that awakens a patient at night is common and is highly suggestive of duodenal ulcer.
Duodenal ulcers are more common than gastric ulcers.
Gastritis
Gastritis pain is usually intermittent and described as indigestion or ‘burning’ pain, it is typically
worsened shortly after eating food.
Gastric ulcer
Gastric ulcer pain also tends to be relieved by food, and come back a few hours later. Pain at
night being common. They are not, however, as common as duodenal ulcers.
Pyloric stenosis
Pyloric stenosis is extremely rare in adults. It presents with vomiting after meals and weight loss
as patients are not usually able to adequately nourish themselves. Zollinger-Ellison syndrome
This is a rare condition. Gastrinomas within either the pancreas or duodenum secret the hormone
gastrin, this hormone results in increased acid production within the stomach uncontrolled by
normal feedback loops. Excessive acid production then results in large numbers of gastric and
duodenal ulcers.
A 67-year-old woman presenting with symptoms of severe gastro-oesophageal reflux
disease has recently had an upper gastrointestinal (GI) endoscopy. She has now been given a diagnosis of Barrett’s oesophagus.
Which one of the following statements most accurately describes this condition?
1) Occurs in approximately 40% of patients with gastro-oesophageal reflux disease (GORD)
in the long term
2) Is caused by chronic reflux of gastric acid into the lower oesophagus causing metaplasia of the normal squamous epithelium of the lower oesophagus to columnar and goblet cell epithelium.
3) Presents with malignancy in one-third of cases
4) Is diagnosed by the position of the z line which rises from its normal position
5) Histamine H2 blockers are the treatment of choice
Explanation
Is caused by chronic reflux of gastric acid into the lower oesophagus causing metaplasia of the
normal squamous epithelium of the lower oesophagus to columnar and goblet cell epithelium.
The chronic reflux of gastric acid into the lower oesophagus causes chronic inflammation. As a
result of this inflammation there is metaplasia of the affected oesophageal epithelium from
squamous epithelium to columnar epithelium with goblet cells. Later dysplasia can occur and
eventually this can develop into malignancy.
Occurs in approximately 40% of patients with gastro-oesophageal reflux disease (GORD) in the
long term
Around 5–15% of patients with gastro -oesophageal reflux disease (GORD) will develop
Barrett’s oesophagus (metaplasia), which in turn is associated with an increased risk of
oesophageal malignancy (neoplasia).
Presents with malignancy in one-third of cases
The risk of developing oesophageal cancer in people with Barrett’s is 0.13 %. About 1 in 860
patients with Barrett’s go on to develop cancer (Cancer Research UK).
Is diagnosed by the position of the z line which rises from its normal position The histological changes (from squamous to columnar epithelium with goblet cells) together
with elevation of the Z line on oesophago -gastro-duodenoscopy (OGD) is diagnostic. The Z line
usually lies 3 cm from the lower oesophageal sphincter and is identified by a change in colour
from salmon pink to a deeper red.
Histamine H2 blockers are the treatment of choice
The treatment of choice is with proton pump inhibitors and close follow up.
A 56-year-old man presents to the acute surgical team with tenderness and pain in the left lower
quadrant, fever, nausea, diarrhoea and an increase white cell count. You suspect colonic
diverticular disease.
Which one of the following is correct regarding colonic diverticular disease?
1) It is frequently associated with electrolyte disturbances
2) It is a premalignant disease
3) It is usually an inherited condition
4) It may cause a vesicovaginal fistula
5) It may present with large bowel obstruction
Explanation
It may present with large bowel obstruction
Obstruction is unusual but well recognised. Often this is a result of fibrous tissue development
and stricturing following an episode, or several episodes, of diverticulitis. Diverticular
perforation is a common and important complication of diverticular disease and can be managed
medically or surgically depending on the Hinchey Classification. Fistulae to bladder, skin,
vagina and other loops of bowel are also common complications.
It is frequently associated with electrolyte d isturbances
Diverticulae are very common and often asymptomatic. Presenting features can include
persistent pain, irregular bowel habit including diarrhoea or constipation (or alternating).
Complications are also common presenting features, most commonly diverticulitis.
It is a premalignant disease
Colonic diverticular disease is not related to colon cancer but shares common dietary factors with
colorectal carcinoma.
It is usually an inherited condition
Colonic diverticular disease is not inherited. The biggest risk factor is lack of dietary fibre and it
usually occurs in older patients.
It may cause a vesicovaginal fistula
Fistula to bladder, skin, vagina and other loops of bowel are common but not vesicovaginal
fistulae.
A 78-year-old woman presents with weight loss, nausea, vomiting and jaundice and is diagnosed
with carcinoma of the gall-bladder. She has a history of gallstones.
Which one of the following would suggest a better prognosis in this patient?
1) Age
2) Female
3) Presence of gallstones
4) TNM stage I disease
5) TNM of T4, any N, M0
Explanation
TNM stage I disease
While most gall-bladder carcinoma presents at a late stage and has a poor survival, if detected
early prognosis is much better. At stage 1A (T1, N0, M0) – simple cholecystectomy, should be
curative. At stage IB (T2, N0, M0) extended cholecystectomy is performed conveying a 5 -year
survival rate of 70–90%. The tumour is usually an adenocarcinoma, although in 10% of patients
squamous cell carcinoma may occur. Adenocar cinoma, particularly papillary adenocarcinoma, is
associated with the best prognosis.
Age
Age is a recognised risk factor for carcinoma of the gall-bladder, with the incidence rising with
age. It is most commonly diagnosed in those greater than 65 years of age.
Female
Female gender is a recognised risk factor for carcinoma of the gall-bladder, with a 2:1 female to
male ratio. This may be due to the increased frequency of cholelithiasis in women.
Presence of gallstones
Over 75% of patients with gall-bladder cancer have cholelithiasis. Other important predisposing
conditions include chronic cholecystitis, porcelain gall-bladder, gall-bladder polyps and
choledochal cysts.
TNM of T4, any N, M0
Gall-bladder carcinoma usually presents at a late stage and stage III disease (T4, any N, M0) is
generally not surgically curable (a 1-year survival rate for advanced gall-bladder cancer is less
than 5% with a median survival of 2–4 months).
A 55-year-old man presents with
jaundice
, abdominal
ascites
, loss of weight and abdominal pain.
You suspect hepatocellular carcinoma.
Which one of the following would you expect in hepatocellular carcinoma?
1) Women are affected more than men
2) In hepatitis B virus endemic areas it usually presents above the age of 50
3) It is associated with HIV
4) It is associated with alcoholic liver disease
5) Serum a-fetoprotein levels (AFP) are normal
Explanation
It is associated with alcoholic liver disease
Alcoholic liver disease is strongly associated with hepatocellular carcinoma. I t is considered a
causative factor in up to 45% of hepatocellular carcinoma cases (in American and Italian studies.
Alcohol is causative through two possible mechanisms – direct genotoxicity and because
excessive chronic alcohol consumption leads to cirrho sis.
Women are affected more than men
Men are more commonly affected than women. Worldwide this ratio varies between 2:1 and 4:1.
In hepatitis B virus endemic areas it usually presents above the age of 50
In the UK the average age of presentation is 66, in countries with endemic hepatitis B there are
peaks in the age distribution at 45 and 65.
It is associated with HIV
Common viral risk factors include hepatitis B and C viruses (HBV and HCV). In Europe and
North America anti-HCV antibodies are present in around 70% of patients with hepatocellular
carcinoma (HCC). In countries with endemic hepatitis B, 90% of patients with HCC are positive
for hepatitis B. HIV is not an independent risk factor for HCC although co -infection with HCV
and HIV may lead to more rapid progression to HCC.
Serum a-fetoprotein levels (AFP) are normal
AFP levels are usually raised. Patients with cirrhosis due to HBV, HCV, alcohol, primary biliary
cirrhosis or haemochromatosis should be offered a 6 -monthly abdominal ultrasound scan and
serum AFP test as screening for hepatocellular carcinoma.
Clinical features of hepatocellular carcinoma include weight loss, anorexia, fever, a right upper
quadrant pain and ascites. Chemotherapy and radiotherapy are generally unhelpful. Survival,
except in very selected groups, is seldom more than 6 months.
A 64-year-old man presents with a large mass in his anus, which is ulcerated and bleeds easily.
He is concerned and seeking your advice about treatment options.
Which one of the following statements regarding squamous cell carcinoma (SCC) of the
anal canal is correct?
1) It characteristically presents with faecal incontinence
2) It does not metastasise
3) It is relatively radioresistant
4) It is related to increased dietary fat intake
5) It is associated with human papillomavirus infection
Explanation
It is associated with human papillomavirus infection
The human papillomavirus (usually type 16) may cause intraepithelial neoplasia, which with
time progresses to anal carcinoma. This virus is found in approximately 70% of patients. Other
risk factors for anal carcinoma include a history of cervical or vaginal cancer, history of sexually
transmitted disease and immunosuppression following solid organ transplantation.
It characteristically presents with faecal incontinence
Rectal bleeding is the most common initial symptom (45% of cases); 30% of patients complain
of pain or a sensation of a mass.
It does not metastasise
Anal cancer can metastasize. The nodal metastatic locations depend on the lymphat ic drainage,
which is dependent on where the anal cancer originates: above the dentate line, flows to the
perirectal and paravertebral nodes; below the dentate line, drainage is through the inguinal and
femoral nodes. The most common site of distal metasta sis is the liver.
It is relatively radioresistant
Anal carcinoma is relatively radiosensitive. Presently, combination radiotherapy and
chemotherapy [fluorouracil (5-FU) ± mitomycin or 5-FU + cisplatin] is used as initial standard
first-line treatment. Abdo minoperineal (AP) resection is reserved for recurrent or resistant
tumours.
It is related to increased dietary fat intake
Increased dietary fat intake is thought to be a risk factor for colorectal cancer, not for anal
cancer.
A 58-year-old man presents with ongoing indigestion, abdominal pain and loss of appetite. An
oesophago-gastroduodenoscopy (OGD) reveals gastric cancer.
Which one of the following statements regarding incidence of gastric cancer is correct?
1) Incidence is increasing in Europe
2) Incidence is lower in people with H. pylori infection
3) Incidence shows no preference for diets high or low in fresh fruit
4) Incidence is higher in those with blood group B or O
5) Incidence is higher in patients with pernicious anaemia
Explanation
Incidence is higher in patients with pernicious anaemia
Risk factors for developing gastric cancer include the presence of H. pylori, blood group A,
pernicious anaemia, previous gastric surgery and the presence of gastric polyps.
Incidence is increasing in Europe
The incidence of gastric cancer is decreasing in Europe.
Incidence is lower in people with H. pylori infection
Risk factors for developing gastric cancer include the presence of H. pylori, blood group A,
pernicious anaemia, previous gastric surgery and the presence of gastric polyps.
Incidence shows no preference for diets high or low in fresh fruit
Fresh fruit and vitamin C may be protective, but there is no consistent evidence to support it.
Incidence is higher in those with blood group B o r O
Blood group A may be associated with higher incidence, not groups B or O.
Gastric cancer in Western Europe often presents in patients over 55 years of age with new -onset
dyspepsia/reflux and upper abdominal pain. Other red flags include upper abdominal mass and
dysphagia, – these patients should be considered for urgent gastroscopy. Patients may also have
nausea, vomiting, anaemia, treatment -resistant dyspepsia or weight loss.
A 21-year-old man presents with multiple colorectal polyps. He has a family history of familial
adenomatous polyposis (FAP). At colonoscopy he has multiple colorectal polyps.
Which one of the following statements is correct? 1) FAP is inherited as an autosomal recessive trait
2) FAP has an approximate 60% risk of progression to adenocarcinoma
3) FAP is diagnosed by computed tomography (CT) scan
4) FAP can present with other extra-colonic connective tissue abnormalities
5) The APC gene is an oncogene
Explanation
FAP can present with other extra-colonic connective tissue abnormalities
Gardner’s syndrome is a variant of FAP and can present with extra-colonic abnormalities
including multiple osteomas, epidermal cysts, desmoid tumours, lipomas and other connective
tissue abnormalities. Additionally it is associated with small bowel cancer, thyroid cancer,
pancreatic cancer, biliary cancer and hepatoblastoma.
FAP is inherited as an autosomal recessive trait
FAP is an inherited disease transmitted as an autosomal dominant trait.
FAP has an approximate 60% risk of progression to adenocarcinoma
In FAP, the risk of progression of an adenomatous polyp to adenocarcinoma is virtually 100%.
FAP is diagnosed by computed tomography (CT) scan
FAP is normally diagnosed at colonoscopy when a patient is found to have more than 100 polyps
alongside a strong family history and genetic testing.
The APC gene is an oncogene
An oncogene is a gene that is causative in cancer – either through activation or higher expression
levels. APC is a tumour suppressor gene – mutation results in inactivation. It is responsible for
the production of adenomatous polyposis coli.
FAP is an autosomal dominant inherited disease resulting in multiple adenomatous polyps within
the colon and a near 100% chance of progression to adenocarcinoma. It is estimated to have an
incidence at between 1:7000 to 1:22 000. Less than 1% of colorectal ca ncers is due to FAP.
Patients with known FAP should have yearly endoscopic screening at a minimum and will
usually require a colectomy at some point in their disease progression (as the number of polyps
increases, the risk of cancer increases). Even after colectomy, surveillance is still required at
between 6-monthly and 4-yearly testing depending on how much rectal tissue is left.
A 57-year-old woman presents with hypergastrinaemia, duodenal ulcers and diarrhoea. She is
subsequently diagnosed with a gastrinoma neuroendocrine tumour.
Which one of the following statements concerning gastrinoma is correct?
1) They are malignant in 10% of cases
2) They occur at extrapancreatic sites in 30% of cases
3) They originate from H cells
4) They are associated with multiple endocrine neoplasia (MEN)
5) They secrete hydrochloric acid
Explanation
They are associated with multiple endocrine neoplasia (MEN)
Gastrinoma may occur as one of the MEN syndromes (ie typically MEN 1):
MEN type
Features
MEN1
Parathyroid
Pancreas
Pituitary
MEN2a
Parathyroid
Phaeochromocytoma
Medullary thyroid cancer
MEN2b
Marfanoid/mucosal neuroma
Phaeochromocytoma
Medullary thyroid cancer
They are malignant in 10% of cases
Around 60% of cases are malignant.
They occur at extrapancreatic sites in 30% of cases
Although gastrin is usually produced by gastric antral G cells, tumours of G cells most
commonly originate in the pancreas. Around 10% occur in extrapancreatic sites, eg in the
duodenum.
They originate from H cells
They originate from G cells.
They secrete hydrochloric acid
G cells secrete gastrin. Gastrin is responsible for stimulating hydrochloric acid secretion from the
parietal cells of the stomach. Excess gastrin production results in Zollinger–Ellison syndrome,
resulting in widespread peptic ulceration.
You are discussing a patient in the
colorectal
multi-disciplinary team (
MDT
). This young man
has presented with profuse bloody diarrhoea and progr essive weight loss. Colonic biopsies are
suggestive of inflammatory bowel disease.
Which one of the following is more suggestive of ulcerative colitis than Crohn’s disease?
1) Cancer
2) Fistula formation
3) Obstruction
4) Perianal involvement
5) Stricture formation
Explanation
Cancer
The risk of developing cancer is higher in ulcerative colitis (UC) than in Crohn’s disease – the
main associated risks are duration of disease and extent of disease (ie total colitis is greater than
partial colitis). After 10 years of total colitis the risk of cancer is approximately 4–5%.
Fistula formation
Fistula formation, as well as intra-abdominal or peri-anal abscesses, are a frequent complication
of Crohn’s disease.
Obstruction
Obstruction is a frequent complication of Crohn’s disease.
Perianal involvement
Perianal problems (fissures, fistulae, skin tags) are much more commonly seen in Crohn’s
disease than in UC.
Stricture formation
Strictures are a frequent complication of Crohn’s disease.
Crohn’s disease is a granulomatous inflammatory disorder involving the whole thickness of the
bowel wall (any part of the gastrointestinal tract from mouth to anus). Ulcerative colitis is a non -
granuloma process that only involves the mucosa. This difference may explain the higher
incidence of stricture, obstruction and fistula formation in Crohn’s disease. Perianal problems
(fissures, fistulae, skin tags) are much more commonly seen in Crohn’s disease than in UC. UC
invariably involves the rectum and extends proximally towards the caecum, and can sometimes
cause a ‘backwash ileitis’.
Crohn’s disease
Ulcerative colitis
Segments affected
Any part of the alimentary tract from mouth to anus, most commonly the terminal ileum
Affects the rectum, extending contiguously proximally a variable amount but limited to the colon
Pattern of disease
Skip lesions
Continuous
Macroscopic findings
Cobblestones, aphthous and linear ulcers, abscesses, luminal narrowing
Pseudopolyps, very friable mucosa, toxic megacolon
Microscopic
Transmural inflammation, granulomas
Submucosal or mucosal findings
inflammation, crypt abscesses
Common symptoms
Abdominal pain, diarrhoea, weight loss, mouth ulcers, perianal disease
Bloody diarrhoea, weight loss, abdominal pain
Extraintestinal features
Perianal disease (fissures, fist ulae, tags, abscesses), mouth ulcers, oral aphthous ulcers, erythema nodosum, arthritis and spondyloarthropathies, uveitis, episcleritis
PSC, arthritis and spondyloarthropathies, uveitis, episcleritis
You are performing a laparoscopic appendicectomy and notice an inflamed structure
approximately 60 cm from the terminal ileum. The appendix appears normal. You diagnose an
inflamed Meckel’s diverticulum.
Which one of the following statements is true of a Meckel’s’ diverticulum?
1) It is a common cause of malabsorption
2) It is found in over 20% of the general population
3) It is invariably found in the jejunum
4) It may lead to macrocytic anaemia
5) It may present with rectal bleeding
Explanation
It may present with rectal bleeding
Some cases of Meckel’s diverticulum are asymptomatic, but 1 in 2 contain either heterotopic
gastric or pancreatic mucosa. Most symptomatic cases will present before the age of 2 years.
Complications of Meckel’s diverticulum include diverticulitis, intussusception, ulceration and gastrointestinal bleeding, intestinal obstruction and perforation. Meckel’s diverticulum, the rule
of 2s:
occurs in 2% of the population
2:1 male:female ratio
approximately 2 inches long
found 2 feet from the ileocaecal junction
1 in 2 will contain ectopic tissue (gastric or pancreatic)
only 2% are symptomatic
important cause of rectal bleeding in the under 2s.
It is a common cause of malabsorption
Most cases of Meckel’s diverticulum are asymptomatic, but 20% contain heterotopic gastric or
pancreatic mucosa. Complications of Meckel’s diverticulum include infection/inflammation,
intussusception, ulceration and gastrointestinal bleeding, intestinal obstruction and perforation.
It is found in over 20% of the general population
Meckel’s diverticulum occurs in 2% of the population and affects men twice as often as women.
It is invariably found in the jejunum
It is classically found in the distal ileum, 60 cm from the ileocaecal valve on the antimesenteric
border of the small intestine and is approximately 5 cm long.
It may lead to macrocytic anaemia
The common causes of macrocytic anaemia include vitamin B12 or folate deficiency, alcohol,
liver disease or reticulocytosis – Meckel’s diverticulum does not cause a macrocytic anaemia.
Meckel’s diverticulum is a true diverticulum with a mucous membrane and a muscular coat and
may be connected to the umbilicus by either a fibrous band or a complete fistula – remnants of
the vitellointestinal duct. If a Meckel’s diverticulum is found incidentally, it should be left alone,
especially if it is non-inflamed with a wide neck.
You are assessing a middle-aged woman in your clinic. She initially presented to you via
casualty with progressive weight loss and abdominal pain together with intermittent diarrhoea
and constipation. Her computed tomography (CT) scan reveals a stenosing lesion in the sigmoid
colon.
Which one of the following statements is true regarding colorectal carcinoma?
1) Irritable bowel syndrome is associated with an increased incidence of colorectal
carcinoma
2) Left sided colonic tumours usually present with anaemia
3) More than 80% of colonic carcinomas arise within adenomatous polyps
4) Left-sided colonic tumours tend to be exophytic
5) The commonest genetic abnormality in colonic carcinoma is p53
Explanation
More than 80% of colonic carcinomas arise within adenomatous polyps
More than 80% of colorectal cancers arise from pre-existing polyps, which makes the disease
suitable for screening. The initial screening test used in the UK is the faecal occult blood test,
given to 60–74-year-olds every 2 years. In patients with a positive test or symptoms suggestive
of colorectal cancer, endoscopy with colonoscopy or flexible sigmoidoscopy and biopsy is the
diagnostic investigation of choice. Irritable bowel syndrome is associated with an increased incidence of colorectal carcinoma
Colorectal carcinoma is associated with inflammatory bowel disease, especially ulcerative
colitis, rather than irritable bowel syndrome.
Left sided colonic tumours usually present with anaemia
Right-sided colonic tumours tend to be exophytic and often present with anaemia as the caecum
is of a large calibre so rarely obstructs. In contrast, left-sided cancers tend to be stenotic.
Left-sided colonic tumours tend to be exophytic
Right-sided colonic tumours tend to be exophytic and often present with anaemia as the caecum
is of a large calibre so rarely obstructs. In contrast, left -sided cancers tend to be stenotic.
The commonest genetic abnormality in colonic carcinoma is p53
The commonest genetic abnormality is in the APC gene – it is a tumour suppressor gene.
Mutations in the TP53 gene, which codes for the p53 protein – another tumour suppressor gene –
are also common. There are also several syndromes that have a strong association with this
cancer [Gardener’s syndrome, hereditary nonpolyposis colorectal cancer (HNPCC) and FAP].
You are admitting a young man who has presented with 1 week of se vere abdominal pain
following a binge drinking session on holiday. A diagnosis of acute pancreatitis is made.
Which one of the following are correct regarding complications of acute pancreatitis?
1) Gastrointestinal haemorrhage with resultant haematemesis and melaena is usually the
result of rupture of the posterior duodenal artery due to stress
2) Hypocalcaemia is relatively common and is caused by fat saponification
3) Pancreatic pseudocysts are formed in the greater sac of the abdomen
4) Relative hypoxia in acute pancreatitis is due to multiple sub-clinical pulmonary emboli
due to hypercoagulability
5) Splenic rupture is a common complication
Explanation
Hypocalcaemia is relatively common and is caused by fat saponification
Acute pancreatitis is an inflammatory process that is caused by the release of pancreatic enzymes
from the pancreatic acini. This causes both localised and systemic damage. The release of
pancreatic enzymes into the body’s circulation results in fat necrosis and saponification – the free
fatty acids released by this process bind calcium and result in systemic hypocalcaemia.
Gastrointestinal haemorrhage with resultant haematemesis and melaena is usually the result of
rupture of the posterior duodenal artery due to stress
Stress-induced gastric erosions frequently occur – these can result in haemorrhage and resultant
haematemesis and melaena. This is the most common cause of haemorrhage. Proton pump inhibitors (PPIs) or H 2 antagonists are prophylactically used to prevent stress-induced gastric
erosions.
Pancreatic pseudocysts are formed in the greater sac of the abdomen
Pancreatic pseudocysts are enzyme rich collections, which are formed in the lesser sac of the
abdomen following acute and/or chronic pancreatitis.
Relative hypoxia in acute pancreatitis is due to multiple sub-clinical pulmonary emboli due to
hypercoagulability
Hypoxia is usually due to hypo -ventilation due to pain, however, ARDS can also occur due to
release of inflammatory mediators.
Splenic rupture is a common complication
Splenic rupture is a very rare complication of acute pancreatitis. Common complications include:
pancreatic pseudocysts, pancreatic abscess, stress-induced gastric erosions with haematemesis or
melaena, acute renal failure, toxic psychosis, multiple organ failure, hypocalcaemia and chronic
pancreatitis.
You are trying to give the family of a young woman who has endoscopic retrograde
cholangiopancreatography (ERCP)-related pancreatitis, some indication of her disease severity.
You decide to perform additional tests so that you can determine the modified Glasgow score
(Imrie criteria).
Which one of the following thresholds scores a point in the modified Glasgow criteria
(Imrie criteria) for acute pancreatitis?
1) Age >40
2) Alkaline phosphatase (ALP) > 200 IU/l
3) Corrected calcium < 2 mmol/l
4) Haematocrit <.45
5) Pa (O2 ) < 10
Explanation
Corrected calcium < 2 mmol/l
Prognosis of pancreatitis (Ranson’s criteria)
One point is given for each criterion present, severe pancreatitis = three or more points.
Age >40
Age > 55 would score a point.
Alkaline phosphatase (ALP) > 200 IU/l
ALP is not part of the scoring system. Haematocrit <.45
A haematocrit count is not part of the scoring system.
Pa (O2 ) < 10
Pa (O2 ) < 8 would score a point.
The modified Glasgow criteria enable early diagnosis of severe acute pancreatitis. The following
parameters are part of the scoring system:
age > 55
blood glucose > 10 mmol/l – no history of diabetes
white cell count (WCC) > 15.5 × 10 9 /l
lactate dehydrogenase (LDH) > 600 IU/l
aspartate aminotransferase (AST) > 200 U/l
corrected calcium < 2 mmol/l
urea > 16 mmol/l
Pa (O2 ) < 8 kPa (60 mmHg)
albumin < 32 g/l.
The mortality per positive criterion:
0–2 < 5% mortality
3–4 20% mortality
5–6 40% mortality
7–8 100% mortality.
The modified Glasgow criteria does not include serum amylase, haematocrit or pH.
You are examining a
63-year-old
man with abdominal pain, ascites and jaundice. An abdominal
ultrasound scan (USS) shows signs suspicious of a hepatocellular carcinoma.
Which one of the following is correct regarding hepatocellular carcinoma (HCC)?
1) Women are affected more than men
2) It is associated with hepatitis A viruses
3) It is associated with type 1 diabetes
4) Serum a-fetoprotein (AFP) levels are in the normal range
5) Usually presents above the age of 50
Explanation
Usually presents above the age of 50
Liver cancer incidence is strongly related to age, with the highest incidence rates being in older
males and females. In the UK in 2012-2014, on average each year more than 4 in 10 (44%) cases
were diagnosed in people aged 75 and over.
Women are affected more than men
Men are more commonly affected than women, world-wide this varies between 2:1 and 4:1.
It is associated with hepatitis A viruses
Common viral risk factors include hepatitis B and C viruses (HBV and HCV). In Europe and
North America anti-HCV antibodies are present in around 70% of patients with hepatocellular
carcinoma. While in countries with endemic hepatitis B 90% of patients with HC C are positive for hepatitis B. Alone, HIV is not a risk factor for HCC although co -infection with HCV and
HIV may lead to more rapid progression to HCC.
It is associated with type 1 diabetes
Type 2 diabetes with poor insulin control may be associated with hepatocellular carcinoma.
Serum a-fetoprotein (AFP) levels are in the normal range
Serum a-fetoprotein (AFP) levels are usually raised. Patients with cirrhosis due to HBV, HCV,
alcohol, primary biliary cirrhosis or haemochromatosis should be offered a 6 -monthly abdominal
ultrasound scan and serum AFP test as screening for hepatocellular carcinoma.
Clinical features include weight loss, anorexia, fever, a right upper quadrant pain, and ascites.
Serum a-fetoprotein is usually raised. Surgical resection is occasionally possible. Chemotherapy
and radiotherapy are unhelpful. Survival, except in very selected groups, is seldom more than 6
months.
You are assisting your consultant with a laparoscopic cholecystectomy. During the operation he
asks you questions to test your knowledge.
Which one of the following statements is correct regarding biliary pathology?
1) Pigment stones area the commonest type of gallstones
2) Sickle-cell disease causes largely acalculous cholecystitis
3) 80% of gallstones are symptomatic
4) Murphy’s sign is right upper quadrant (RUQ) pain on palpation, causing sudden cessation
of inspiration and forcing the patient to catch breath
5) A common infecting agent in cholecystitis is Salmonella
Explanation
Murphy’s sign is right upper quadrant (RUQ) pain on palpation, causing sudden cessation of
inspiration and forcing the patient to catch breath
Murphy’s sign is an indication of acute cholecystitis. The patient catches breath due to pain on
inspiration while the right hypochondrium is deeply palpated, but not when the left
hypochondrium is deeply palpated, due to downward movement of the inflamed gall-bladder
onto the examining hand during inspiration.
Pigment stones area the commonest type of gallstones
Cholesterol gallstones are the most common but with haemolytic conditions, such as sickle -cell
anaemia, pigment stones are also common.
Sickle-cell disease causes largely acalculous cholecystitis
Sickle-cell disease results in increased red-cell haemolysis and turnover, leading to a
preponderance to develop pigment stones.
80% of gallstones are symptomatic
Approximately 70% of gallstones are thought to be asymptomatic and are found on routine
ultrasound examination. A common infecting agent in cholecystitis is Salmonella
Secondary infection within stagnant bile converts cholelithiasis to cholecystitis. Common
organisms are E. coli, Klebsiella, Enterococcus faecalis and Bacteroides.
You are seeing an elderly man in the Emergency Department with gross abdominal distension and prominent superficial abdominal veins. He has shifting dullness and you diagnose ascites secondary to chronic liver disease.
Which one of the following statements is correct regarding ascites?
1) Malignancy causing ascites is a transudate
2) When associated with oedema this is usually non-pitting
3) A high serum-ascites albumin gradient (>1.1) indicates a transudate such as pancreatitis
4) A low serum-ascites albumin gradient (<1.1) indicates an exudate such as hereditary
angioedema
5) Spontaneous bacterial peritonitis is due to the introduction of sepsis following an ascitic
tap
Understanding Ascites and Its Causes
Ascites is the accumulation of fluid in the peritoneal cavity, often associated with liver disease, malignancy, heart failure, or infections. The nature of the fluid can be classified into transudate and exudate based on the serum-ascites albumin gradient (SAAG). This classification helps determine the underlying cause of ascites.
- Malignancy causing ascites is a transudate
This statement is incorrect. Malignant ascites typically presents as an exudate due to increased capillary permeability associated with tumor involvement in the peritoneum. Therefore, malignancy-related ascites usually has a low serum-ascites albumin gradient (<1.1).
- When associated with oedema this is usually non-pitting
This statement is misleading. Edema associated with liver disease and ascites can be either pitting or non-pitting depending on various factors such as the duration and severity of fluid retention. In cases of significant liver dysfunction leading to hypoalbuminemia, edema may present as pitting.
- A high serum-ascites albumin gradient (>1.1) indicates a transudate such as pancreatitis
This statement is incorrect. A high SAAG (>1.1) indicates that the ascitic fluid is likely a transudate, which is commonly seen in conditions like cirrhosis or heart failure rather than pancreatitis specifically, which can lead to exudative ascites.
- A low serum-ascites albumin gradient (<1.1) indicates an exudate such as hereditary angioedema
This statement is also incorrect in its association; while a low SAAG (<1.1) does indicate an exudative process, hereditary angioedema does not typically cause ascites. Exudative causes are more commonly linked to infections (like tuberculosis), malignancies, or inflammatory processes.
- Spontaneous bacterial peritonitis is due to the introduction of sepsis following an ascitic tap
This statement contains some truth but lacks clarity regarding spontaneous bacterial peritonitis (SBP). SBP occurs without any identifiable source of infection and is primarily due to bacterial translocation from the gut flora into the ascitic fluid rather than being directly caused by an invasive procedure like an ascitic tap.
Given these evaluations:
The correct answer regarding ascites from the options provided would be none of them are entirely accurate, but if we were to select one that aligns closest with common clinical understanding regarding SBP’s pathophysiology without misinterpretation, it would be option 5 concerning SBP’s association with infection risk post-tap.
However, since none of these statements accurately reflect established medical knowledge about ascites comprehensively:
Answer: None of the statements are correct regarding ascites in their entirety; however, option 5 has elements related to SBP risk post-tap but misrepresents its primary causation mechanism.
A patient with cirrhosis requires a laparotomy. The surgical team are making a decision on the
risks and benefits of surgical vs conservative treatment.
The Child–Pugh classification of the severity of
the following?
chronic liver disease
includes which one of
1) Ascites
2) Aspartate transaminase
3) Bleeding varices
4) Cholesterol
5) Clotting time
Explanation
Ascites
See overall explanation for tables showing the full scoring system and prognosis depending on
score.
Aspartate transaminase
See overall explanation for tables showing the full scoring system and prognosis depending on
score.
Bleeding varices
See overall explanation for tables showing the full scoring system and prognosis depending on
score.
Cholesterol
See overall explanation for tables showing the full scoring system and prognosis depending on
score.
Clotting time
See overall explanation for tables showing the full scoring system and prognosis depending on
score.
The Child-Pugh classification takes into account bilirubin level, albumin level, ascites,
encephalopathy, and prothrombin time.
A
B
C Bilirubin
<34
34-51
> 51
Albumin
> 35
28-35
<28
Ascites
None
Controlled
Refractory
Encephalopathy
None
Minimal
Advanced
Prothombin
<4
4-6
> 6
8
A 28-year-old man presents with severe right -sided abdominal pain together with peritonism in
the right iliac fossa. His clinical picture and haematological profile are consistent with
appendicitis but at operation an inflamed Meckel’s diverticulum is identified.
Which one of the following statements is true regarding Meckel’s diverticulum?
1) It is a partial persistence of the median umbilical ligament
2) It arises on the mesenteric border of the small bowel
3) It typically lies about 60 cm from the ileocaecal valve
4) It is present in 0.2% of individuals
5) It contains heterotopic pancreatic tissue in 40% of cases
Explanation
It typically lies about 60 cm from the ileocaecal valve
It is classically found in the distal ileum, within 100 cm (typically 60 cm) from the ileocaecal
valve on the antimesenteric border of the small intestine and is approximately 5 cm long.
Meckel’s diverticulum is a true diverticulum with a mucous membrane and a muscular coat and
may be connected to the umbilicus by either a fibrous band or a complete fistula – remnants of
the vitellointestinal duct. If a Meckel’s diverticulum is found incidentally, it should be left alone,
especially if it is non-inflamed with a wide neck. Meckel’s diverticulum, the rule of 2s:
occurs in 2% of the population
2:1 male:female ratio
approximately 2 inches long
found 2 feet from the ileocaecal junction
1 in 2 will contain ectopic tissue (gastric or pancreatic)
only 2% are symptomatic
important cause of rectal bleeding in the under 2s.
It is a partial persistence of the median umbilical ligament
A Meckel’s diverticulum is a partial persistence of the vitellointestinal duct and there may be a
fibrous connection to the umbilicus. The median umbilical ligament or ‘urachus ’ is a connection
between the umbilicus and the bladder.
It arises on the mesenteric border of the small bowel
Meckel’s diverticulum arises on the antimesenteric border of the small bowel. It is present in 0.2% of individuals
It is present in 2% of individuals and affects men twice as often as women.
It contains heterotopic pancreatic tissue in 40% of cases
Some cases of Meckel’s diverticulum are asymptomatic, but 50% contain heterotopic gastric or
pancreatic mucosa. Complications of Meckel’s diverticulum include intussusception, ulceration
and gastrointestinal bleeding, intestinal obstruction and perforation.
An elderly man presents with progressive dysphagia and weight loss. He is a lifetime heavy smoker and his GP is concerned. Which one of the following statements best represents his diagnosis of oesophageal carcinoma?
1) It has wide geographical variation in incidence rates and is increasing in frequency in the UK
2) Squamous-cell carcinomas of the oesophagus usually occur in the upper two -thirds of the oesophagus and are associated with GORD
3) The development of a hoarse or husky voice is a concerning feature likely to be due to
direct invasion of the aryepiglottic folds
4) Palliation of symptoms is seldom necessary as most patients die soon after developing
dysphagia
5) Diagnosis is usually established by a barium swallow alone
Explanation
It has wide geographical variation in incidence rates and is increasing in frequency in the UK
Oesophageal carcinoma in the UK is increasing in incidence. There is a great deal of
geographical variation in the incidence, with the highest risk areas being central Asia and
South/East Africa. Common risk factors include smoking, alcohol, ingestion of caustic agent s
(including very hot drinks), age, obesity and previous radiotherapy.
Squamous-cell carcinomas of the oesophagus usually occur in the upper two -thirds of the
oesophagus and are associated with GORD
If found in the lower one-third of the oesophagus, it is usually of the adenocarcinoma type and
associated with gastro -oesophageal reflux disease (GORD). If found in the upper two -thirds of
the oesophagus is of similar origin as head and neck cancers and is of squamous -cell origin. This
type, however, is usually associated with smoking not GORD as the above answer states.
The development of a hoarse or husky voice is a concerning feature likely to be due to direct
invasion of the aryepiglottic folds
A hoarse voice is a worrying feature but is usually due to involvement of the recurrent laryngeal
nerve.
Palliation of symptoms is seldom necessary as most patients die soon after developing dysphagia
Palliation is an important aim of all treatment for oesophageal cancers when cure is not possible.
Overall survival for oesophageal cancer is 40% at 1 year, 15% at 5 years (cancer research UK
statistics). However, survival varies by type (squamous-cell carcinoma or adenocarcinoma) and
by stage of presentation. Early cancers may be fully resectable with oesophagectomy or
endoscopic mucosal resection for very early cancer. Adjuvant and neoadjuvant radiotherapy and
chemotherapy are also used in oesophageal cancer.
Diagnosis is usually established by a barium swallow alone Diagnosis may be suggested by a barium swallow but definitive diagnosis requires histology
obtained via an oesophago -gastro- duodenoscopy (OGD).
A 68-year-old woman presents with symptoms of gastro -oesophageal reflux disease. She has
tested positive for Helicobacter pylori infection and been started on proton pump inhibitor (PPI)
and eradication therapy.
Which one of the following tests, in common usage, has the highest combined sensitivity
and specificity when used to detect Helicobacter pylori infection?
1) Culture of biopsy material
2) McNemar’s test
3) The biopsy urease test
4) The urea breath test
5) Serology/stool testing
Explanation
The urea breath test
The urea breath test detects radiolabelled carbon dioxide in the breath after ingesting
radiolabelled urea (sensitivity 95%, specificity 96%).
Culture of biopsy material
Culture of biopsies may yield the presence of H. pylori, but this is not routinely used
McNemar’s test
McNemar’s test is a non-parametrical statistical test and nothing to do with H. pylori.
The biopsy urease test
Biopsy of the stomach wall is the basis of the urease test (‘Clo -test’), which takes up to 30 min to
get a result and depends on the presence of urease in the bacterium to alter the substrate from
orange to pink. Sensitivity is the highest of the presented options (98%), but it is not highly
specific (82%).
Serology/stool testing
Serology testing is used, but serological testing (sensitivity 92%, specificity 83%) performs less
well when compared with breath testing, which is the most sensitive and specific (sensitivity
95%, specificity 96%) and stool testing (sensitivity 95%, specificity 94%)
A 76-year-old lifelong smoker presented to the Emergency Department with haematemesis.
Following stabilisation, an oesophago -gastro- duodenoscopy (OGD) was performed with the
presumed diagnosis of a gastric ulcer. A large polypoid mass was found in the distal oesophagus
adjacent to the gastro -oesophageal junction with evidence of a co -existent hiatus hernia. Biopsy
confirmed the diagnosis of
oesophageal adenocarcinoma
.
Which one of the following confers the highest relative risk of developing this condition?
1) Barrett’s oesophagus
2) Human papillomavirus (HPV) infection
3) Alcohol
4) Gastro-oesophageal reflux disease
5) Helicobacter pylori infection
Explanation
Barrett’s oesophagus
Barrett’s oesophagus is considered a pre-malignant lesion associated with a risk of 6–14% of
developing oesophageal adenocarcinoma and requires regular endoscopic surveillance. T he
relative risk of oesophageal cancer is approximately 11.
Human papillomavirus (HPV) infection
The relative risk of oesophageal squamous-cell carcinoma is between 2.4 and 3.6 in human
papillomavirus (HPV) infected patients.
Alcohol
Alcohol is a recognised risk factor for squamous carcinoma, the risk increases with volume
drunk with relative risk of between 1.8–7.4.
Gastro-oesophageal reflux disease
The relative risk of adenocarcinoma is between 4.9 for patients who have weekly symptoms, to
7.4 for patient s who have daily symptoms.
Helicobacter pylori infection
This infection is associated with gastric cancer rather than oesophageal cancer.
The most common presenting symptom of oesophageal cancer is dysphagia, usually this will
progressively worsening and symptoms will start with dysphagia to food and progress on to
dysphagia for liquids. Cancer in the distal third of the oesophagus is most frequently
adenocarcinoma, which is most commonly associated with gastro -oesophageal reflux disease and
especially Barrett’s oesophagus. Cancers of the upper two -thirds of the oesophagus are
classically squamous-cell carcinomas.
884 Intussusception is much more common in the paediatric population. Often a lesion in the bowel
will cause the pathological process to take place.
Which one of the following is the most common pathological lead point in intussusception?
1) Dance’s sign
2) Intraluminal haematoma
3) Meckel’s diverticulum
4) Hypertrophic Peyer’s patch
5) Polyps
Explanation
Hypertrophic Peyer’s patch
Peyer’s patches in the ileum are the pathological lead patch in up to 90% of cases.
Dance’s sign
Dance’s sign, (a feeling of emptiness on palpation), with viscera absent in the right lower
quadrant on abdominal X-ray is seen in 15% of cases. It is not, however, a ‘lead point’ in
intussusception.
Intraluminal haematoma
An intraluminal haematoma in Henoch–Schönlein purpura may trigger intussusception.
Meckel’s diverticulum
Meckel’s diverticulum and polyps are identified as a pathological lead point in 10% of cases.
Polyps
Meckel’s diverticulum and polyps are identified as a pathological lead point in 10% of cases.
Intussusception is a condition where a part of the bowel, normally small bowel, telescopes inside
an adjacent part of the bowel. It is most common in infants aged 4 months to 1 year, with peak
incidence between 6–9 months. Risk factors, aside from age, include previous intussusception, or
family history of the condition, and intestinal malrotation. It presents with abdominal pain,
‘redcurrant jelly’ stool and signs of obstruction and sepsis. Diagnosis can be made on ultrasound
scan (USS) or on air or contrast enema. The enema can serve a dual purpose to also decompress
the intussuscepted segment. If this fails surgery may be required. Pathologically the theory is th at
a ‘lead point’ is usually to blame that instigates the telescoping – it is thought that up to 90% of
cases are as a result of Peyer’s patches.
You are reviewing a 1-day-old with abdominal distension and bile stained vomiting . He has not yet passed meconium. You suspect Hirschsprung’s disease.
Which one of the following is true?
1) There is a congenital ganglion absence in the rectum
2) There will be dilation of the affected segment
3) This affects both sexes equally
4) This is diagnosed by cold-cup rectal biopsy
5) This usually presents in patients greater than 10-years of age
Explanation
There is a congenital ganglion absence in the rectum
In Hirschsprung’s disease there is a defective neural crest -cell migration resulting in a congenital absence of the ganglia that normally make up Auerbach (myenteric) plexus and Meissner (submucosal) plexus to part of the colon. The result of this absence is increased tone in the affected part of the colon, and an absence of appropriate peristalsis that causes a functional (rather than mechanical) obstruction.
There will be dilation of the affected segment
Dilatation occurs proximal to the affected segment. The affected segment is hypertonic and therefore stenotic so faeces accumulate proximal to this.
This affects both sexes equally
Hirschsprung’s disease occurs in 1 in 5000 births and has an M:F ratio of 5:1.
This is diagnosed by cold-cup rectal biopsy
Suction biopsy of the narrowed segment is first line, this is examined for absence of Auerbach and Meissner plexus. Full-thickness rectal biopsy is required if suction biopsy is inconclusive.
This usually presents in patients greater than 10-years of age
Most commonly Hirschsprung’s disease is diagnosed shortly after birth because of failure to pass meconium within 48 h of deliver y. Other symptoms can include signs of obstruction such as abdominal distension and vomiting. Additionally diagnosis can be delayed, presenting later in childhood with chronic constipation.
A patient presents
with jaundice. On closer examination
the presence of Kayser–Fleischer rings
is noted.
This is pathognomonic of which one of the following?
1) Autoimmune hepatitis 2) Sclerosing cholangitis
3) Primary biliary cirrhosis (PBC)
4) Haemochromatosis
5) Wilson’s disease
Explanation
Wilson’s disease
In Wilson’s disease, the presence of Kayser –Fleischer rings indicates neurological impairment. It
consists of copper deposition in the cornea and may be seen as a greenish or golden brown ring
around the cornea on slit lamp examination. Symptoms mostly relate to deposition of copper in
the liver (causing liver disease) and brain (causing neuropsychiatric symptoms, such as
parkinsonism due to deposition in the basal ganglia).
Autoimmune hepatitis
Autoimmune hepatitis has no specific associat ed eye signs, it can present as an acute or chronic
hepatitis.
Sclerosing cholangitis
This condition is frequently associated with inflammatory bowel disease, especially ulcerative
colitis. It may present before or after diagnosis of inflammatory bowel disease. Symptoms are
mostly related to liver disease, there are no specific eye signs.
Primary biliary cirrhosis (PBC)
Patients with PBC frequently develop xerostomia and dry eyes. It typically presents in middle -
aged women with intense itching and signs of liver disease such as jaundice.
Haemochromatosis
There are no specific eye signs associated with this condition. Presentation can include liver
disease, cardiac failure, arthritis, diabetes, tray-bronze skin and other endocrine complaints.
A 32-year-old woman who had undergone an appendicectomy 2 weeks ago presents to her General Practitioner with a 24 h history of right upper quadrant abdominal pain, fever with chills
and rigors, and shortness of breath. She says that the pain is radiating to her right
shoulder
tip
.
On examination, her temperature is 38.9°C, pulse rate is 106/min and she is acutely
tender
over
the right hypochondric region. Chest X-ray reveals a right -sided basal
atelectasis
and
mild
pleural effusion
. From the options below choose the one option that you think is the most likely diagnosis in
this patient.
1) Emphysema of right lung
2) Acute pancreatitis
3) Sclerosing cholangitis
4) Subphrenic abscess
5) Pyonephrosis
Explanation
Subphrenic abscess
Subphrenic abscess usually arises 3 to 6 weeks following abdominal surgery, mainly to the
biliary tract, duodenum or stomach, or following a perforated viscus or anastomotic leakage.
The subphrenic space is in direct contact with the para-colic gutter thereby allowing peritoneal
contamination such as bile, blood or bowel contents to spread. Subphrenic abscess is right -sided
in about 50%, left -sided in 25% and bilateral in 25% of patients. Clinical features
include pyrexia with chills and rigors, anorexia, loss of appetite and loss of weight.
Diaphragmatic irritation may affect the lung, resulting in chest pain, dyspnoea and non -
productive cough. Basal atelectasis, pneumonia and pleural effusion are recognised
complications of this condition. Additionally, diaphragmatic irritation can cause referred pain to
the shoulder because the phrenic nerve (which innervates the diaphragm) shares nerve roots with
the dermatomes overlying the shoulder (ie roots C3 –5). Ultrasound scan is the investigation of
choice to diagnose subphrenic abscess, and, if an abscess is identified, ultrasound guided
percutaneous drainage catheter may be placed at the same time.
Emphysema of right lung
Pulmonary emphysema is a chronic lung condition that, along with chronic bronchitis, is now
more commonly known clinically as chronic obstructive pulmonary disease (COPD). In
emphysema there is dilation of the airways distal to the terminal bronchioles due to destruction
of elastase within the supporting connective tissue of the distal airways, most commonly it is
associated with smoking although a less predisposing factor is alpha 1 -antitrypsin deficiency.
Patients with chronic obstructive pulmonary disease (COPD) are predisposed to lower
respiratory tract infections which would explain the shortness of breath, fevers and c hest X-ray
changes, but would not normally cause RUQ tenderness with pain radiating to the shoulder.
Acute pancreatitis
Acute pancreatitis is an important differential of the acute abdomen, however, this patient’s
recent surgery and confirmed appendicitis, combined with atypical signs for pancreatitis (ie RUQ
pain) means this diagnosis is not the most likely. It rarely presents with rigors.
Sclerosing cholangitis
Sclerosing cholangitis is a chronic inflammatory condition, usually found in the presence of
inflammatory bowel disease. It can lead to chronic liver disease through obstruction of the biliary
ducts. It is not a likely diagnosis in this acute scenario especially without evidence of liver
disease (eg jaundice). Pyonephrosis
Pyonephrosis is a collection within the renal pelvis. It is a recognised complication of
pyelonephritis, renal stones or hydronephrosis but can also occur as a primary condition. You
would expect the patient’s pain to be over the renal angle more that the right hypochondrium,
urinary symptoms may be present, and chest signs would not be typical.
An 87-year-old woman who lives in residential care is brought to the Accident and Emergency
Department with a 24 h history
of abdominal pain of
sudden onset
. On examination, she is pale,
cold and appears to be in
shock
. Her blood
and
mildly tender
pressure is 102/68 mmHg and her pulse is 92/min and
irregular. Abdomen is soft
over the umbilical
region. Bowel sounds are
absent
.
She was noticed to pass a few episodes of passing dark (
bloody) coloured motions during the
day. Analysis of arterial blood gas reveals:
Result
Normal
pH
7.24
7.35–7.45 Bicarbonate
20 mmol
22–26 mmol
Base excess
−10 mmol
−2 to +2 mmol
Which of the following is the most likely diagnosis in this patient?
1) Sigmoid volvulus
2) Acute small bowel obstruction
3) Toxic megacolon
4) Leaking abdominal aortic aneurysm
5) Mesenteric infarction (Ischaemic bowel disease)
Explanation
Mesenteric infarction (Ischaemic bowel disease)
The history, signs and symptoms are classical of mesenteric infarction, which is part of the
spectrum of ischaemic bowel disease. While ischaemic bowel disease is a spectrum of acute and
chronic conditions resulting in inadequate blood flow to the bowel (either large or small),
mesenteric infarction specifically implies an obstruction to blood flow of the small bowel (which
is supplied by the mesenteric vessels) that has resulted in cell death. The risk factors include age,
atrial fibrillation, previous myocardial infarction, heart failure and thrombophilia – the ischaemia
then caused by an embolic event. Mesenteric infarction typically presents with persistent and
generalised abdominal pain. Vomiting may or may not be present. Some patients may pre sent
with shock, with the shock being out of proportion to the clinical symptoms. The infarcted bowel
may shed the ‘non-viable mucosa’, which mixed with mucus, results in dark-coloured (also
known as plum-coloured) stools. The inflammatory markers such as the white cell count and C-
reactive protein may be elevated. Arterial blood gas analysis is a very useful investigation, which
may reveal a metabolic acidosis. This condition is a surgical emergency as the patient rapidly
become septic and may die from septic shock unless the infarcted bowel (‘dead gut’) is removed.
Sigmoid volvulus
This condition typically presents with abdominal distension and failure to pass stool or flatus
(absolute constipation), lower abdominal pain is also a frequent symptom. Their a bdomen will be
clinically distended but may not be tender. Complications include ischaemia of the section
affected, perforation and peritonitis. Risk factors include being elderly, chronic constipation and
male gender.
Acute small bowel obstruction
Acute small bowel obstruction normally presents with colicky abdominal pain, nausea and
vomiting failure to pass stool/flatus occurring after this as the obstruction may be relatively
proximal. Mostly commonly it is secondary to adhesions, hernias or malignancy. Other causes of
small bowel obstruction include Crohn’s disease, volvulus, and foreign bodies (including
gallstone ileus and swallowed foreign bodies). Toxic megacolon
Toxic megacolon presents as a complication to conditions such as inflammatory bowel dise ase
or Clostridium difficile infection most commonly. It presents with severe abdominal pain,
distention and signs of sepsis. With no antecedent history of a causative condition this option is
not the most likely.
Leaking abdominal aortic aneurysm
A leaking abdominal aortic aneurysm may present acutely with haemorrhagic shock, or
subacutely less commonly. Additionally the rupture may be contained within the retroperitoneum
or uncontained – the latter allowing for much greater and faster blood loss. Classic signs include
abdominal pain, back pain, hypotension and a palpable expansile mass in the abdomen. This
diagnosis could account for the patient’s relatively shocked state, but does not explain the fever
or dark stool.
A
74-year-old man
presents to his General
Practitioner
with a 4-month history of
vague
lower
abdominal pain, abdominal distension and
constipation. On further questioning he says that he
has noticed a
change in his bowel habits
, a sense of
incomplete
evacuation
of the bowel and his
stools to be mixed with
blood
. He has
lost
more than a stone in
weight
during this period. On
examination, the abdomen is soft but a
mass
is felt over the left iliac fossa. Plain abdominal X-
ray reveals a markedly
dilated colon.
From the options below choose the one that you think is the most likely diagnosis in this
patient.
1) Toxic megacolon
2) Acute colonic pseudo-obstruction
3) Sigmoid volvulus
4) Colonic carcinoma
5) Diverticular disease
Colonic carcinoma Elderly patients with per rectal bleeding, change in bowel habit, and weight loss should be
considered to have colonic cancer unless proven otherwise.
Toxic megacolon
Toxic megacolon normally presents secondary to a predisposing condition, such as ulcerative
colitis or C. difficile infection. It is an acute presentation, with abdominal pain and distension and
signs of sepsis.
Acute colonic pseudo-obstruction
The chronicity of the history makes acute colonic pseudo -obstruction unlikely.
Sigmoid volvulus
Sigmoid volvulus usually presents with a rapid onset abdominal distension and absolute
constipation. The chronic history to this presentation makes a sigmoid volvulus unlikely, it
would also not explain the per rectum (PR) bleeding nor the weight loss.
Diverticular disease
While diverticular disease can explain the patient’s change in bowel habit and PR bleeding, it
does not explain the patient’s weight loss.
The clinical presentation of patients with colonic malignancy depends on the site of the tumour.
Right-sided colonic carcinoma commonly presents with anaemia, tiredness, malaise, pallor and
loss of weight, while the left -sided colonic carcinoma presents with change in the bowel habits,
bleeding per rectum and intestinal obstruction. Rectal carcinoma, in addition to the features seen
in left-sided colonic carcinoma, is associated with a sense of incomplete evacuation of the bowel
(tenesmus). Increase in age is a risk factor for developing colonic cancer. The other risk factors,
among others, include a family history of colon cancer, familial adenomatous polyposis, diet rich
in red meat and long standing ulcerative colitis or Crohn’s disease. The investigation of choice
for suspected colonic malignancy is a colonoscopy with biopsy of suspicious lesions. If this is
not possible, usually due to patient’s lack of fitness for the examination, then flexible
sigmoidoscopy or computed tomography (CT) colonoscopy is usually the next
line. Carcinoembryonic antigen (CEA) is the commonly used tumour marker to diagnose colonic
malignancy and subsequently to assess the progress, including recurrence.
Obviously, in a case of acute obstruction due to suspected malignancy a different initial set of
investigations will be required, likely to include basic bloods and plain abd ominal X-ray (AXR),
with CT scan likely required acutely if surgery is contemplated. Dukes’ classification for
colorectal cancers is useful to be aware of, however, in clinical practice the TNM classification is
now more frequently used.
Classification
Disease extent
Duke A
Limited to muscular propria
Duke B
Extending beyond muscularis propria Duke C
Lymph node involvement
Duke D
Distant Metastatic spread
A 33-year-old company executive presents to his General Practitioner with a 6-week history
of
upper
abdominal pain and diarrhoea. He also says that he has had a few episodes of
‘dark-
coloured’ vomitus
during this period. General examination is unremarkable. Endoscopic
examination
of his upper gastrointestinal region reveals
multiple ulcers
in the
stomach
and
duodenum.
From the options below choose the ONE that you think is the most likely diagnosis in this
patient
1) Carcinoid tumour
2) Gastrinoma
3) Somatostatinoma
4) Vasoactive intestinal peptide tumour
5) ACTH secreting tumour
Explanation
Gastrinoma
Gastrinomas, which occur primarily in the pancreas and duodenum, are malignant in nearly two -
thirds of cases. The patients may present with upper abdominal/epigastric pain and vomiting; the
vomitus may be ‘coffee-ground’ due to bleeding from the ulcers. Ninety per cent of patients with gastrinomas develop peptic ulceration due to excess gastrin release by the tumour – gastrin
stimulates gastric acid hypersection, which causes ulceration. Gastrinomas may eit her arise
sporadically or as part of Zollinger–Ellison syndrome (peptic ulceration, gastric acid
hypersecretion and islet -cell tumour of the pancreas). Sporadic Zollinger –Ellison occurs most
frequently in the fifth decade of life. Approximately 20% of patients with Zollinger–Ellison
syndrome have MEN type I syndrome. An elevated basal gastric acid output >15 mEq/h and a
serum gastrin >1000 pg/ml are suggestive of a gastrinoma. If it is difficult to make a diagnosis, a
secretin stimulation test may be indicated. Lesions are localised by somatostatin-receptor
scintography. A CT scan may be indicated to exclude metastases. The treatment of this condition
is either conservative (high dose proton pump inhibitors) or surgical. Surgical resection may be
aided by intra-operative ultrasound and/or intra-operative endoscopy.
Carcinoid tumour
This is a neuroendocrine tumour most commonly found in the small bowel. It can cause local
symptoms (eg in the bowel it can cause bowel obstruction, bleeding or diarrhoea), and sym ptoms
as a result of release of hormones such as serotonin into the bloodstream (carcinoid syndrome –
diarrhoea, abdominal pain, flushing, tachycardia, wheeze). They can be sporadic, but are also
part of MEN-1. Diagnosis is by 24-h urinary collection to detect unusually high levels of urinary
carcinoid breakdown products.
Somatostatinoma
This is a tumour of the delta cells (the cells responsible for production of somatostatin) of the
pancreas. The clinical result of this is a result of the inhibitory actions of somatostatin on various
pancreatic and gastrointestinal hormones: suppression of insulin – diabetes, suppression of CCK
and secretin – steatorrhoea and gallstones, suppression of gastrin – hypochlorhydria.
Vasoactive intestinal peptide tumour
VIPomas develop from pancreatic islet cells. Release of VIP results in sometimes profound
watery diarrhoea, hypokalaemia and associated symptoms, abdominal pain, weight loss.
ACTH secreting tumour
ACTH tumours are normally pituitary tumours, however, exogenous ACT H production can
result from other tumours (notably certain lung cancers). Excess ACTH production results in
excess stimulation of cortisol production in the adrenals and therefore Cushing’s syndrome.
A 28-year-old hair stylist presents to her General Practitioner with a 3-month history of crampy lower abdominal pain, diarrhoea (12–15 times/day), mouth ulcers and loss of appetite. She reckons that she has lost nearly a stone in weight during this period. She smokes 20 cigarettes/day.
Abdominal examination reveals a mildly tender mass over her right iliac fossa. A few abscesses with sinus formation are noticed in the perianal region.
Which of the following is the most likely diagnosis in this patient?
1) Pelvic inflammatory disease (PID)
2) Pseudomembranous colitis
3) Ulcerative colitis
4) Crohn’s disease
5) Carcinoma of the colon
Step-by-Step Analysis of the Symptoms and Diagnosis
Patient Presentation: The patient is a 28-year-old female hair stylist presenting with a 3-month history of:
Crampy lower abdominal pain
Diarrhoea (12–15 times/day)
Mouth ulcers
Loss of appetite
Significant weight loss (nearly a stone)
Physical Examination Findings:
Mildly tender mass over the right iliac fossa
Presence of abscesses with sinus formation in the perianal region
Differential Diagnosis Consideration:
Pelvic Inflammatory Disease (PID):
Typically presents with lower abdominal pain, fever, and abnormal vaginal discharge.
Less likely due to the absence of fever and specific gastrointestinal symptoms.
Pseudomembranous Colitis:
Often caused by Clostridium difficile infection, leading to diarrhea and abdominal pain.
Usually associated with recent antibiotic use, which is not mentioned in this case.
Ulcerative Colitis:
A form of inflammatory bowel disease (IBD) characterized by continuous inflammation of the colon.
Symptoms include bloody diarrhea, abdominal pain, and urgency but does not typically present with perianal abscesses or sinus formation.
Crohn’s Disease:
Another type of IBD that can affect any part of the gastrointestinal tract.
Commonly presents with abdominal pain, diarrhea (which may be bloody), weight loss, and complications such as strictures or fistulas.
The presence of perianal abscesses is particularly indicative of Crohn’s disease.
Carcinoma of the Colon:
Generally presents later in life with changes in bowel habits, weight loss, and possibly obstruction.
Less likely given the patient’s age and symptom profile.
Conclusion: Considering all symptoms presented—particularly the combination of crampy abdominal pain, frequent diarrhea, mouth ulcers, significant weight loss, and especially the presence of perianal abscesses—the most fitting diagnosis for this patient is Crohn’s disease. This condition aligns well with her clinical presentation and physical examination findings.
Thus, based on this thorough analysis:
Answer: Crohn’s disease
A 44-year-old woman presents to the Surgical Emergency Assessment Unit with a 72 h history of abdominal pain, vomiting and being generally unwell. She has also noticed pale stools and
dark urine
. On examination, she is
jaundiced
and is tender over the
right upper quadrant
. An
ultrasound reveals a
dilated
proximal common bile duct with intra-hepatic duct
dilatation. A
magnetic resonance (MR) cholangiopancreatogram confirms a
fistula
between the gall-bladder
and the common bile duct, and a
large calculus
is found in the
common bile duct
just distal to the
fistula.
From the options below choose the one that you think is the most likely diagnosis in this
patient.
1) Carcinoma of the head of the pancreas
2) Cholangiocarcinoma
3) Mirizzi’s syndrome
4) Hepatocellular carcinoma
5) Carcinoma of the ampulla of Vater
cholecystocholedochal fistula formation due to direct pressure necrosis of adjacent duct
walls from large impacted stones.
Patients may present with pain over the right upper quadrant of the abdomen, vomiting, fever,
recurrent cholangitis, cholecystitis or pancreatitis. Pale stools and dark urine result from
obstruction of the flow of bile into the intestine. Treatment of this condition is exploration of the
common bile duct by either open or laparoscopic cholecystectomy and placement of a T-tube.
Carcinoma of the head of the pancreas
This is the commonest malignant cause of obstructive jaundice classically causing ‘painless
jaundice’ and presenting late. The acute history and tenderness is not typical for this
presentation, additionally the imaging findings are not in keeping with this diagnosis.
Cholangiocarcinoma
This is a relatively uncommon malignant cause of obstructive jaundice. The acute history and
tenderness is not typical for this presentation, additionally the imag ing findings are not in
keeping with this diagnosis.
Hepatocellular carcinoma
Hepatocellular carcinoma (HCC) does not typically cause obstructive jaundice. In the UK it is
normally found in patient’s with underlying liver disease or cirrhosis, for example due to
hepatitis B, C or alcohol. Aflatoxin ingestion is a notable cause in South-East Asia and sub-
Saharan Africa – this is a toxin produced by fungal growth in certain grains. Presentation of
HCC may be on routine screening of patients with known liver d isease, with local physical
symptoms such as right upper quadrant pain, or with signs of liver failure – either due to
decompensation of underlying liver disease or massive infiltration of the liver by the carcinoma
cells.
Carcinoma of the ampulla of Vater
This is a rare cancer arising from the ampulla of Vater. It most commonly presents with
obstructive jaundice, however, the acute history and tenderness is not typical for this
presentation, additionally the imaging findings are not in keeping with this diagnosis.
A 56-year-old man, who drinks about
60–70 units
of alcohol per week, presents to the
Emergency Department with severe abdominal pain and 2 –3 episodes of
vomiting blood
. On
examination, he appears pale with a pulse rate of 110/min. Abdominal examination
reveals
dilated veins in the anterior abdominal wall
, mild
ascites, a
large
spleen and a
small
nodular liver
.
Which of the following is the most likely diagnosis in this patient?
1) Chronic pancreatitis
2) Hepatocellular carcinoma (HCC)
3) Amoebic hepatitis
4) Alcoholic liver cirrhosis
5) Myeloproliferative disorder
Explanation
Alcoholic liver cirrhosis
Alcoholic liver cirrhosis can cause portal hypertension; which causes the stigmata this patient
presents with. Portal hypertension is defined as an increase in the portal vein pressure of more
than 10 mmHg (the normal portal vein pressure is in the range of 5 –10 mmHg). Among other
causes, cirrhosis of the liver is one of the important causes of portal hyperte nsion and currently
accounts for up to 90% of cases in the UK. As a result of the portal hypertension collateral
channels develop between the portal system and systemic circulation – common sites for this
include the lower end of oesophagus (resulting in o esophageal varices), distal rectum, and
anterior abdominal wall (resulting in dilated tortuous veins in the anterior abdominal wall known
as caput medusae). Bleeding from varies can be profuse and life-threatening – bleeding from
oesophageal varies is part icularly common particularly oesophageal varices leading to
haematemesis and/or melaena. Treatment requires urgent resuscitation, definitive management is
usually endoscopic. Some of the signs and symptoms of portal hypertension include abdominal pain, ascites, jaundice, splenomegaly and signs of cirrhosis (such as spider naevi, gynaecomastia,
palmar erythema and testicular atrophy).
Chronic pancreatitis
Chronic pancreatitis can present either due to chronic insufficiency of it is exocrine function
(causing steatorrhoea, fat-soluble vitamin deficiency and weight loss), endocrine function (most
notably causing insulin-dependent diabetes mellitus) or due to distinct episodes of acute -on-
chronic inflammation presenting with severe epigastric abdominal pain and often vomiting.
Alcohol is the commonest cause of this condition in the UK.
Hepatocellular carcinoma (HCC)
In the UK this condition is normally found in patient’s with underlying liver disease or cirrhosis,
for example due to hepatitis B, C or alcohol. Aflatoxin ingestion is a notable cause in South-East
Asia and sub-Saharan Africa – this is a toxin produced by fungal growth in certain grains.
Presentation of HCC may be on routine screening of patients with known liver disease, with
local physical symptoms such as right upper quadrant pain, or with signs of liver failure – either
due to decompensation of underlying liver disease or massive infiltration of the liver by the
carcinoma cells.
Amoebic hepatitis
Entamoeba histolytica can cause localised abscesses or a diffuse hepatitis. Presentation normally
includes right upper quadrant tenderness and hepatomegaly, fever, and possibly jaundice. Bloods
will show evidence of hepatitis. Liver infection will normally follow an episode of intestinal
amebiasis/amoebic d ysentery. Risk factors for this condition include old age, recent tropical
travel and immunosuppression (including chronic alcohol use, steroids, HIV, etc.).
Myeloproliferative disorder
Myeloproliferative disorders encompass chronic myeloid leukaemia (CML) , essential
thrombocythaemia, polycythaemia (rubra) vera and myelofibrosis. They can all cause
hepatosplenomegaly and portal hypertension (which explains this patient’s presentation) –
however, in a patient drinking as much alcohol as this portal hypertens ion caused by liver
cirrhosis is the most likely cause.
Gallbladder pathology commonly presents on the acute general surgical take. A spectrum of
diseases exist.
Which one of the following clinical conditions is most likely to be associated with
identification of Aschoff–Rokitansky sinuses?
1) Acute cholecystitis
2) Cholesterosis of the gall-bladder (strawberry gall-bladder)
3) Chronic cholecystitis
4) Mucocele of the gall-bladder
5) Xanthogranulomatous cholecystit is
Explanation
Chronic cholecystitis
Chronic cholecystitis is associated with a fibrotic thick walled gall-bladder. Within the thickened
wall are Aschoff–Rokitansky sinuses, mucosal herniations often containing inspissated bile.
Acute cholecystitis
Acute cholecystitis is associated with increased vascular permeability and infiltration with acute
inflammatory cells.
Cholesterosis of the gall-bladder (strawberry gall-bladder)
Cholesterol-laden macrophages in the lamina propria of the gall-bladder mucosa are a feature of
cholesterosis.
Mucocele of the gall-bladder
Mucocele of the gall-bladder normally occurs in a thin walled non-inflamed gall-bladder.
Xanthogranulomatous cholecystitis
Xanthogranulomatous cholecystitis is a rare form of chronic cholecystitis characterised by huge
numbers of lipid-laden macrophages and giant -cells. Xanthogranulomatous cholecystitis can
easily be mistaken for carcinoma.
Inflammatory bowel diseases are systemic conditions. The significance o f other signs and
symptoms can point more clearly to the underlying disease process.
Which one of the following associated extra-alimentary conditions is far more suggestive of
ulcerative colitis than Crohn’s disease?
1) Ankylosing spondylitis
2) Arthropathy
3) Erythema nodosum
4) Primary sclerosing cholangitis
5) Pyoderma gangrenosum
Explanation
Primary sclerosing cholangitis
Primary sclerosing cholangitis is far more common in ulcerative colitis than in Crohn’sdisease. It
is characterised by a progressive fibrous inf lammatory reaction within the biliary tree leading to
irregularity with multiple stenosis and biliary obstruction. There is no apparent relationship
between the duration or severity of ulcerative colitis and ultimate progression to liver failure.
Ankylosing spondylitis
Arthropathy and ankylosing spondylitis are both features of ulcerative colitis and Crohn’s
disease. Ankylosing spondylitis is slightly more common in ulcerative colitis.
Arthropathy
Arthropathy and ankylosing spondylitis are both features of ulcerative colitis and Crohn’s
disease.
Erythema nodosum
Erythema nodosum is the commonest cutaneous manifestation of inflammatory bowel disease
and occurs slightly more commonly in Crohn’s disease.
Pyoderma gangrenosum
Pyoderma gangrenosum is slightly more prevalent in ulcerative colitis than Crohn’s disease,
however, primary sclerosing cholangitis is far more common still in ulcerative colitis.
The following table summarises several key differences between ulcerative colitis and Crohn’s
disease. Crohn’s disease
Ulcerative colitis
Segments affected
Any part of the alimentary tract from mouth to anus, most commonly the terminal ileum
Affects the rectum, extending contiguously proximally a variable amount but limited to the colon
Pattern of disease
Skip lesions
Continuous
Macroscopic findings
Cobblestones, aphthous and linear ulcers, abscesses, luminal narrowing
Pseudopolyps, very friable mucosa, toxic megacolon
Microscopic findings
Transmural inflammation, granulomas
Submucosal or mucosal inflammation, crypt abscesses
Common symptoms
Abdominal pain, diarrhoea, weight loss, mouth ulcers, perianal disease
Bloody diarrhoea, weight loss, abdominal pain
Extraintestinal features
Perianal disease (fissures, fistulae, tags, abscesses), mouth ulcers, oral aphthous ulcers, erythema nodosum, arthritis and spondyloarthropathies, uveitis, episcleritis
PSC, pyoderma gangrenosum, arthritis and spondyloarthropathies, uveitis, episcleritis
A 52-year-old woman with chronic abdominal pain was noticed to be pale at the time of
assessment
in the surgical out -patient clinic. Investigations showed that
she had a
decreased
serum iron
and
total iron-binding capacity (TIBC) in association with a
normal serum ferritin
.
These findings are most indicative of which one of the following?
1) Anaemia of chronic disease
2) Autoimmune haemolytic anaemia
3) Chronic blood loss
4) Malabsorption
5) Vitamin B 12 deficiency
Explanation
Anaemia of chronic disease
The serum iron, iron-binding capacity and saturation are all low, but there is plenty of storage
iron that is not being utilised so ferritin is normal. These symptoms are typical of anaemia of
chronic disease – you would also expect to find a normal mean corpuscular volume (MCV)
(normocytic).
Autoimmune haemolytic anaemia
In haemolytic anaemia the haemolysed cells release haemoglobin that is usually not lost from the
body and is recycled, so the iron studies are usually normal. The patient’s MCV will normally be
increased due to reticulocytosis (macrocytic), while LDH and bilirubin will be increased and
haptoglobin decreased.
Chronic blood loss
Chronic blood loss can lead to iron deficiency because of the loss of iron, with a low serum iron,
high TIBC and low ferritin. The MCV is typically decreased (microcytic).
Malabsorption
Malabsorption, particularly in disease processes involving the duodenum, can occasionally
explain iron deficiency anaemia, which has a high TIBC and low ferritin. Malabsorption
involving the distal ileum can produce a megalobla stic anaemia through malabsorption of
vitamin B 12 (macrocytic).
Vitamin B 12 deficiency Vitamin B 12 and folate deficiencies lead to a megaloblastic anaemia that is not associated with
abnormalities in iron metabolism. The bone marrow contains megaloblastic cells, while
peripheral blood contains large red blood cells (macrocytosis) and hypersegmented neutrophils.
The following table explains the expected results of iron studies in several conditions:
Iron
TIBC
TIBC saturation
Ferritin
MCV
Iron deficiency
Low
High
Low
Low
Decreased
Anaemia of chronic disease
Low
Low
Low
Normal
Normal
Acute phase response
Low
Low
Low
High
Normal
Haemochromatosis/iron overload
High
Low
High
High
Normal
A 38-
year-old woman has been diagnosed with atrophic gastritis. You are reviewing her
OGD
report
.
Which one of the following findings is most likely in this patient?
1) Decreased mean corpuscular volume in the red blood cells
2) Decreased serum ferritin
3) Decreased serum folate
4) Increased neutrophil segmentation
5) Increased reticulocyte count
Explanation
Increased neutrophil segmentation
This is a sign of megaloblastic anaemia, known as hypersegmented neutrophils, which is a
symptom of atrophic gastritis due to vitamin B-12 deficiency. Other signs include macrocytosis
(high MCV), and megaloblasts within the bone marrow.
Decreased mean corpuscular volume in the red blood cells
Decreased microcytosis (MCV) is classic of iron deficiency anaemia, as well as thalassaemia and
sideroblastic anaemia.
Decreased serum ferritin
Decreased serum ferritin represents a lack of iron stores in the body, for example in iron
deficiency anaemia.
Decreased serum folate
Folate deficiency leads to a megaloblastic anaemia. Its absorption is not affected by atrophic
gastritis.
Increased reticulocyte count
Increased reticulocyte count is a classic sign of haemolytic anaemia.
A
40-year-old
man is diagnosed with right -sided
synchronous
colonic tumours,
which
are
mucinous
and
poorly differentiated
. His mother had died at an
early age of
ovarian cancer
and
his maternal grandfather had died aged approximately 40 years of
advanced caecal carcinoma
.
From the following list of inherited syndromes which one is most likely to be preval ent in
this family?
1) Cowden’s syndrome
2) Familial adenomatous polyposis
3) Hereditary non-polyposis colorectal cancer
4) Juvenile polyposis
5) Peutz-Jeghers syndrome
Explanation
Hereditary non-polyposis colorectal cancer
Hereditary non-polyposis colorectal cancer (HNPCC) is an inherited condition – there are
various genes that may be involved but they are all characteristically involved in DNA mismatch
repair. Colonic tumours associated with HNPCC tend to have certain distinguishing pathological
features. They occur on average 20 years before the peak incidence of sporadic tumours and are
frequently synchronous and metachronous with a predilection for the proximal colon. They tend
to be mucinous, poorly differentiated and ‘signet -ring’ in appearance. Ovarian cancer is
associated with HNPCC along with cancers of the endometrium and stomach.
Cowden’s syndrome
This is an autosomal-dominant condition associated with multiple hamartomas (especially in the
breast and thyroid tissue, skin and mucosal membranes), and an incr eased incidence of certain
cancers (breast and endometrial in women, as well as thyroid and renal cancers).
Familial adenomatous polyposis
This condition is inherited, resulting in the development of 100s of polyps in the large bowel,
with an associated increased risk of colorectal cancer. Additionally, patients are at increased risk
of other cancers including pancreatic and stomach, and have other characteristic findings such as
osteomata, sebaceous cysts and fibromas. A specific collection of signs/sympto ms in familial
adenomatous polyposis (FAP) is known as Gardner syndrome.
Juvenile polyposis
Juvenile polyposis is a genetic condition in which multiple hamartomas develop within the
gastro intestinal tract (GI) tract with an associated increased risk in ca ncer of the GI tract (from
the stomach to rectum).
Peutz-Jeghers syndrome
This autosomal-dominant condition is characterised by multiple patches of hyperpigmentation on
the lips/oral mucosa and hands and feet, and hamartomas within the GI tract. Patients a re also at
increased risk of cancer in the pancreas, liver and lung, in men also in the testicles and in women
the breast, uterus and ovaries.
A 26-year-old woman presents
with right upper quadrant discomfort and elevated serum
transaminases. A diagnosis of
hepatitis C virus infection
is made following detection of
antihepatitis C virus antibodies.
Which one of the following represents the most likely subsequent event?
1) Complete recover y 2) Development of chronic hepatitis C
3) End stage liver disease
4) Transmission to her monogamous partner
5) Vertical transmission to potential children
Explanation
Development of chronic hepatitis C
In total, 50–80% of those with acute hepatitis C will develop a chronic infection.
Complete recovery
In total, 25–50% of patients with acute hepatitis C will completely clear the virus and therefore
make a complete recovery.
End stage liver disease
In total, 20% of those individuals affected by chronic hepatitis C will develop progressive
cirrhosis and resultant end-stage liver failure. Additionally, hepatocellular carcinoma occurs in
1–4% of those with associated cirrhosis per year.
Transmission to her monogamous partner
Transmission to monogamous partners and vertical transmission is uncommon and accounts for
the minority of new cases of hepatitis C virus infection. Hepatitis C virus is transmitted by
parenteral or per mucosal exposure to infected blood or body fluids. Many patients have a history
of intravenous drug abuse or transmission of blood products before the implementation of
antihepatitis C virus screening of blood donors in 1992.
Vertical transmission to potential children
Transmission to monogamous partners and vertical transmission is uncommon and accounts for
the minority of new cases of hepatitis C virus infection. Hepatitis C virus is transmitted by
parenteral or per mucosal exposure to infected blood or body fluids. Many patients have a history
of intravenous drug abuse or transmission of blood products before the implementation of
antihepatitis C virus screening of blood donors in 1992.
Hepatitis C virus has risk factors for infection in the UK patient population including intravenous
drug use with sharing of paraphernalia, blood product transfusion (before screening for HCV in
1992), tattoos or piercings, while sexual and vertical transmission are also routes they are less
common. Acute hepatitis C is defined as being the first 6 months of infection after the incubation
period, while chronic hepatitis C is an infection longer than this period. Most patients are
asymptomatic during this period – however, testing for hepatitis C should be considered in
patients with clinical features of hepatitis (RUQ pain, jaundice, flu -like symptoms, diarrhoea and
vomiting), risk factors, or deranged liver function tests. The presence of HCV antibodies show
whether a patient has ever been infected with HCV, while the presence of HCV RNA shows an
active infection.
You are in the general surgical clinic seeing a patient with histology results after biopsy of a
lesion at the anal verge. The tissue sample is in keeping with a diagnosis of anal cancer.
Which one of the following statements is correct regardi ng anal cancer?
1) First-line treatment is by radical surgery
2) It accounts for 50% of anorectal malignancies
3) Most anal malignancies are squamous cell carcinomas
4) Perianal papilloma is not related to the development of anal cancer 5) Tumours above the dentate line spread to the para-aortic lymph nodes
Explanation
Most anal malignancies are squamous cell carcinomas
Of anal cancers, 80% of them are squamous-cell carcinomas. Rectal bleeding is the most
common initial symptom (45% of cases); 30% of patients complain of pain or sensation of a
mass.
First-line treatment is by radical surgery
Anal carcinoma is relatively radiosensitive. Presently, combination radiotherapy and
chemotherapy [fluorouracil (5-FU) ± mitomycin or 5-FU + cisplatin] is used as initial standard
first-line treatment. Abdominoperineal (AP) resection is reserved for recurrent or resistant
tumours or in combination with neoadjuvant chemo -radiotherapy.
It accounts for 50% of anorectal malignancies
Anal cancers account for approximately 10% of anorectal ma lignancies.
Perianal papilloma is not related to the development of anal cancer
Perianal papillomas have been shown to predispose to the development of anal cancer. The
human papillomavirus (usually type 16) may cause papillomas/intraepithelial neoplasia, which
with time progresses to anal carcinoma. This virus is found in approximately 70% of patients.
Other risk factors for anal carcinoma include a history of cervical or vaginal cancer, history of
sexually transmitted disease and immunosuppression following solid organ transplantation.
Tumours above the dentate line spread to the para-aortic lymph nodes
The nodal metastatic locations depend on the lymphatic drainage, which is dependent on where
the anal cancer originates: above the dentate line, flows to t he perirectal and internal iliac nodes;
below the dentate line, drainage is through the inguinal and femoral nodes. The most common
site of distal metastasis is the liver.
You
are in the general surgery clinic reviewing a 27-year-old patient referred with an
abdominal
mass
and you suspect colorectal carcinoma. They are subsequently referred for urgent
colonoscopy.
Which one of the following statements is correct regarding colorectal carcinoma?
1) It is associated with a high fibre, low fat diet
2) It is associated primarily with Krukenberg’s tumours
3) It is best treated by abdominal-perineal resection if the tumour is up to 15 cm from the
anal canal 4) It has a palpable mass on digital rectal examination in over 60% of cases of r ectal
tumours
5) It is found in the rectum in 10% of cases
Explanation
It has a palpable mass on digital rectal examination in over 60% of cases of rectal tumours
Colorectal cancer presents as a palpable rectal mass in 60% of cases of rectal tumours. Other
common symptoms of a rectal cancer include peri-rectal (PR) bleeding, change in bowel habit,
tenesmus, or abdominal discomfort.
It is associated with a high fibre, low fat diet
The opposite is true, a high fat and low fibre diet predisposes to colorectal c arcinoma. Other risk
factors include diet high in red/processed meat, obesity, increasing age, alcohol and tobacco use.
Additionally other conditions such as inflammatory bowel disease, and inherited conditions such
as familial adenomatous polyposis syndro me and hereditary non-polyposis colorectal cancer
(HNPCC) syndrome are significant risk factors.
It is associated primarily with Krukenberg’s tumours
Krukenberg’s tumours are malignant metastases within the ovaries – their primary site is
normally gastrointestinal (GI), primarily it is associated with stomach carcinomas spreading to
ovaries.
It is best treated by abdominal-perineal resection if the tumour is up to 15 cm from the anal canal
Abdominal–perineal resections are used for low rectal tumours, where tumours are within 8 cm
from the anal canal. Left -sided tumours above this point may undergo left hemi-colectomy,
while transverse and right -sided hemi-colectomies may be used in these respective areas. Right -
sided hemi-colectomy is also the operation of choice for caecal tumours. Radiotherapy is
frequently used in rectal cancers too – either as neoadjuvant or adjuvant therapy, but not
commonly in other cancers of the colon. Chemotherapy may be used in all sites of colorectal
cancer, depending on type/stage.
It is found in the rectum in 10% of cases
Approximately 45% of colorectal tumours are found in the rectum.
It is useful to be aware of the Dukes’ staging system for colorectal cancer (although this system
has largely been replaced by the TNM staging system clinically it is a frequent exam question!).
Please see the following link for a comprehensive description of colorectal cancer staging by the
American Joint Committee on Cancer (AJCC, 7th edition). Modified Astler –Coller staging
system:
Stage A: Limited to mucosa
Stage B1: Extending into the muscularis propria but not penetrating through it; nodes are
not involved.
Stage B2: Penetrating through the muscularis propria; nodes are not involved.
Stage C1: Extending into the muscularis propria but not penet rating through it. Nodes are
involved.
Stage C2: Penetrating through the muscularis propria. Nodes are involved.
Stage D: Distant metastatic spread.
You are reviewing the results of a colonoscopy with a patient in the general clinic. They are
concerned about their future risk of significant disease.
Which one of these conditions puts the patient at increased risk of colorectal cancer?
1) Haemorrhoids
2) Hamartoma
3) Angiodysplasia
4) Solitary polyp
5) Ulcerative colitis
Explanation
Ulcerative colitis
There is malignant potential in ulcerative colitis – after 10 years the risk is around 2%, then 8%
at 20 years and 18% at 30 years. Those individuals with ulcerative colitis for 10 years or longer
are offered surveillance at between 1–5-yearly intervals depending on whether they are deemed
low, intermediate or high risk of developing colorectal cancer.
Haemorrhoids
Haemorrhoids are swollen or inflamed vascular structures within the anal canal. They can
present with pain, itching and per rectal (PR) bleeding – the major risk factor for these is
constipation or straining at stool, as well as being common in pregnancy. They do not increase
the risk of colorectal cancer.
Hamartoma
Hamartomas are benign focal growths within an organ comprised of cells/tissue that normal ly
arise from that organ but have developed into an abnormally structured growth. They resemble
neoplasms but are do not have malignant potential. There are, however, syndromes in which
multiple hamartomas are present that can result in increased risk of malignancy. Cowden’s
syndrome is characterized by multiple hamartomas throughout the gastrointestinal (GI) tract,
skin, thyroid and other organs, and while the hamartomas themselves are benign, the patient has
an increased risk of malignancy due to mutations in the PTEN tumour suppressor gene.
Angiodysplasia
Angiodysplasia are arteriovenous malformations within the gastrointestinal tract which may be
single or multiple. They are usually asymptomatic but can present with acute episodes of
painless bleeding or malena (depending on their position within the GI tract). Chronic bleeding
may lead to anaemia. Solitary polyp
Solitary juvenile polyps are benign hamartomatous polyps, most commonly found in the rectum
and occurring before the age of 20 (although they can occur at any age). The term juvenile
describes the polyp, not the age of the patient. They may present with rectal bleeding, but do not
predispose to cancer. This is in contrast to juvenile polyposis syndrome where multiple mostly
hamartomatous polyps are found either within the rectum and colon, or throughout the GI tract –
with an increased risk of adenocarcinoma.
A 74-year-old
Asian man
presents with a 6-month history of weight loss and epigastric pain. An
oesophago-gastro-duodenoscopy (OGD) shows an ulceration lesion in the fundus of the stomach.
Which one of the following is true regarding the incidence of gastric carcinoma?
1) It is decreased in patients with chronic atrophic gastritis
2) It is higher among women
3) It is highest in India
4) It is reduced in patients with blood group A
5) The incidence is declining world-wide
Explanation The incidence is declining world-wide
This statement is correct, the incidence of gastric cancer is declining world-wide. The incidence
of gastric cancer in the UK is between 6500–7000 cases a year and is also declining, the highest
risk age group being 85–90-year-olds.
It is decreased in patients with chronic atrophic gastritis
Chronic atrophic gastritis is a condition where chronic inflammation of the gastric mucosa leads
to a gastric glandular atrophy and loss of parietal cells (therefore a decrease in production of
peptic acid and intrinsic factor), replaced by intestinal metaplasia and fibrous tissue deposition.
This condition can present with chronic stomach pain, nausea, vomiting and weight loss, and
with a megaloblastic anaemia due to lack of vitamin B 12 absorption. The commonest predisposing
conditions are H. pylori infection and autoimmune gastritis. Chronic atrophic gastritis and
resultant intestinal metaplasia both lead to increased gastric cancer risk.
It is higher among women
The male to female ratio is approximately 2:1.
It is highest in India
The highest rates of gastric cancer occur in Japan, Mongolia and Korea, while most cases world -
wide are in developing countries.
It is reduced in patients with blood group A
The incidence of stomach cancer has been shown to be 20% higher in those with blood group A
compared to those with blood group O.
A
6-month
-old male infant presents with fresh
rectal bleeding (resembling
redcurrant jelly
),
vomiting, abdominal pain and a
palpable mass
. The parents want to know whether or not their
son will need an operation
What is the most likely cause?
1) Anal fissure
2) Hamartomatous polyp
3) Inflammatory bowel disease
4) Intussusception
5) Rectal ulceration
Explanation
Intussusception Intussusception is a condition in which a portion of the bowel telescopes within an adjacent
segment of bowel. Most commonly this is the ileum entering the caecum. Sometimes an
anatomical lead point is identified as causing the intussusception – this may be a Meckel’s
diverticulum, polyp or a hyper plastic Peyer’s patch (ie from a rece nt viral infection). It
classically presents with the triad of rectal bleeding, vomiting and abdominal pain. The rectal
bleeding is often described as like red currant jelly. An abdominal mass (the intussuscepted
segment) may be palpable.
Ultrasound is the investigation of choice initially, and treatment is with either barium or water -
soluble enema (which will usually both visualise and reduce the intussusception). If this fails
surgical reduction may be required.
Anal fissure
Anal fissures present with pain and fresh per rectal (PR) bleeding on passing stool, often noticed
most on wiping rather than in the stool itself. The main risk factor is constipation. The pain is felt
at the site of the fissure rather than intra-abdominally (although this may be difficult to determine
in a 6-month-old infant. This condition would not explain the vomiting, ‘redcurrant jelly’ or the
abdominal mass.
Hamartomatous polyp
Hamartomas are benign focal growths within an organ comprised of cells/tissue that normally
arise from that organ but have developed into an abnormally structured growth. They resemble
neoplasms but do not have malignant potential. Within the gastrointestinal (GI) tract they may
present with GI bleeding, but the description of ‘red currant jelly stool’ is classical for
intussusception.
Inflammatory bowel disease
Inflammatory bowel disease (IBD) could explain this patient’s symptoms (Crohn’s disease, for
example, can present with an inflammatory right iliac fossa mass), however, it would be unusual
to present in such a young child and usually presents between the ages of 15 –25. It is by no
means the most likely diagnosis offered here.
Rectal ulceration
This option is a rare, benign condition in childhood that usually presents with per rectal (PR)
bleeding and mucous, lower abdominal and perineal pain, and constipation. It would not explain
the patient’s abdominal mass or vomiting. The most likely diagnosis in this scenario is
intussusception.
Other causes of rectal bleeding in children not considered above inclu de Meckel’s diverticulum,
vascular malformations, and Henoch–Schönlein purpura.
A 20-year-old diabetic man presents to the surgical take with anal pain, pruritus ani and
discharge. He has had repeat admissions for anal abscesses and is awaiting an examination under
anaesthesia (EUA) for anal fistula.
Of the following statements regarding anal fistula, which one is correct?
1) They always start from an abscess
2) They are always associated with Crohn’s disease
3) They are initially managed with antibiotics
4) In the case of complex fistulae the investigation of choice is a contrast CT
5) When following Goodsall’s rule, in the case of an anterior fistula, the internal opening follows a
direct path
Explanation
When following Goodsall’s rule, in the case of an anterior fistula, the internal opening follows a direct
path Goodsall’s rule states that an external opening lying anterior to Goodsall’s line (the transverse
anal line) is usually associated with a straight tr act, whereas an external opening lying posterior
to it may follow a curving tract.
They always start from an abscess
A fistula is an abnormal communication between two epithelialized surfaces. Up to 80% of anal
fistulas are due to an anorectal abscesses. Other causes include post-surgical complications,
trauma, penetrating injury, tuberculosis (TB) infection or Crohn’s disease.
They are always associated with Crohn’s disease
They can be caused by Crohn’s disease. Most, however, start from an abscess, while others
develop insidiously or from causes such as haemorrhoidectomy, trauma, penetrating injury, TB
infection or tumours
They are initially managed with antibiotics
Antibiotics are used in cases complicated by cellulitis or sepsis, or if the patient is
immunocompromised. The treatment of the fistula itself in simple cases is with fistulotomy,
while in other cases other techniques may be required/indicated such as the Ligation of the
Intersphincteric Fistula Tract (LIFT) procedure or Seton sutures.
In the case of complex fistulae the investigation of choice is a contrast CT
Complex fistulae are best imaged by a magnetic resonance imaging (MRI) scan.
A 22-year-old
diabetic
man presents to the surgical take with
anal pain, pruritus ani and
discharge. He is awaiting an EUA for
anal fistula
.
When looking back through his medical history what are you most likely to see of
particular note?
1) Carcinoma
2) Ulcerative colitis
3) Recurrent abscess
4) Trauma
5) Tuberculosis
Explanation
Recurrent abscess A fistula is an abnormal communication between two epithelialized surfaces. Up to 80% of anal
fistulas are due to an anorectal abscesses. Other causes include post -surgical complications,
trauma, penetrating injury, tuberculosis (TB) infection or Crohn’s disease.
Carcinoma
This option is a cause, but not the most common.
Ulcerative colitis
Fistula are common in Crohn’s disease, however, because inflammation in ulcerative colitis is
confined to the mucosa and submucosa (rather than being transmural as in Crohn’s) fistula are
not classically seen in ulcerative colitis.
Trauma
This option is a cause, but not the most common.
Tuberculosis
This option is a cause, but not the most common.
A 24-year-old
woman
presents with a recurrent cyst over her natal cleft. She has had multiple
previous incisions and drainage and has exc essive scarring as a result. She is obese and hirsute.
With reference to the description of the patient above, what is most unusual given her
diagnosis of pilonidal sinus?
1) Age of patient
2) Hirsutism
3) Female sex
4) Recurrence of condition following surgery
5) Obesity
Explanation
Female sex Men are affected three to four times more often than women.
Age of patient
Pilonidal sinus is a condition predominantly affecting young adults between the ages of 20 and
40 years.
Hirsutism
Risk factors include hirsutism, obesity, prolonged sitting as part of normal daily routine, family
history, male sex, and deep natal cleft.
Recurrence of condition following surgery
If an abscess forms then treatment is incision and drainage, while chronic discharging sinuses or
recurrent abscesses may require removal of the tract or laying it open and allowing it to heal by
secondary intention. Reported recurrence rates vary but may be up to 50%.
Obesity
Patients may frequently be described as hairy and may also be obese.
A pilonidal sinus is usually found in the midline in the natal cleft. The cause is unclear although
a loose hair piercing the skin is thought to be attributable. These may be asymptomatic, or
present acutely with abscess formation, or chronically with ongoing discharge.
A patient is listed on the day case endoscopy list for surveillance colonoscopy for familial
adenomatous polyposis (FAP). Your consultant quizzes you on this disease.
How is FAP most usually diagnosed in children of affected individu als?
1) DNA screening - gene present on short arm of chromosome 15
2) Male children only of known FAP patients need will be screened
3) Ophthalmoscopy or DNA screening
4) Sigmoidoscopy and biopsy after adenomas become symptomatic
5) Such children are most likely to present with carcinoma of the colon or rectum
Explanation
Ophthalmoscopy or DNA screening
DNA screening is 95% predictive. In addition, it is important to note that many patients with
FAP are found to have bilateral lesions of congenital hypertrophy of the retinal pigment
epithelium (CHRPE) on ophthalmoscopy.
DNA screening - gene present on short arm of chromosome 15 The gene is present on the short arm of chromosome 5.
Male children only of known FAP patients need will be screened
FAP, due to mutation of t he APC gene, is an autosomal-dominant condition that affects men and
women equally.
Sigmoidoscopy and biopsy after adenomas become symptomatic
Diagnosis in new patients with new mutations and no family history is usually by sigmoidoscopy
and biopsy after t he adenomas become symptomatic. If 100 or more adenomas are present, FAP
is presumed.
Such children are most likely to present with carcinoma of the colon or rectum
The risk of malignancy in FAP is almost 100%. However, this risk increases with age, and
children rarely present with carcinoma. Polyps may be visible from age 7, but the risk of cancer
is 7% at 21, rising to almost 100% by age 50.
A 79-year-old patient who tested positive on faecal occult blood test, presents for
sigmoidoscopy. A colonic polyp is noted.
Which one of the following statements concerning colonic polyp is correct?
1) Hamartomatous polyps are made up of smooth muscle cells
2) Over 25% of the population over 45 years of age may have asymptomatic adenomas
3) They usually bleed on contact
4) Their malignant potential is indirectly related to the size of the lesion
5) Pseudopolyps can be inflammatory
Explanation
Pseudopolyps can be inflammatory
An inflammatory polyp is an island of inflamed mucosa surrounded by ulcerated tissue, a classic
example of this is in ulcerative colitis – called pseudopolyps.
Hamartomatous polyps are made up of smooth muscle cells
Hamartomas are benign focal growths within an organ comp rised of cells/tissue that normally
arise from that organ but have developed into an abnormally structured growth – they resemble
neoplasms but do not have malignant potential. Over 25% of the population over 45 years of age may have asymptomatic adenomas
Approximately 25% of men and 15% of women over the age of 50 years may have an adenoma
identified at colonoscopy.
They usually bleed on contact
Benign adenomas do not usually bleed on contact, bleeding is more common if the polyp is
malignant.
Their malignant potential is indirectly related to the size of the lesion
The guidelines from NICE recommend ongoing screening for all patients with polyps found on
colonoscopy at 5-yearly intervals. However, if any of the polyps found are ³10mm in diameter
then this screening should be at 3- or 1-yearly intervals, depending on the number of polyps.
A 58-year-old man presents to clinic with pain on defecation and point bleeding on toilet paper.
You examine him and find haemorrhoids.
What is the best conservative treatment you would advise for
first-degree haemorrhoids
?
1) Bedrest and analgesia
2) Elevated legs and an ice pack
3) No treatment should be given
4) Surgery
5) Reassurance and advice on eating an increased fibre diet
Explanation
Reassurance and advice on eating an increased fibre diet
First-degree haemorrhoids may respond to increasing fibre in the diet or to bulking agents.
Reassurance that symptoms are due only to haemorrhoids is important.
Bedrest and analgesia
Thrombosed strangulated haemorrhoids may be treated conservatively with analgesia, bedrest,
elevated legs and an icepack or by surgery. Elevated legs and an ice pack
Thrombosed strangulated haemorrhoids may be treated conservatively with analgesia, bedrest,
elevated legs and an icepack or by surgery.
No treatment should be given
Asymptomatic haemorrhoids should not be treated but reassurance and advice regarding a high -
fibre diet is important.
Surgery
Thrombosed strangulated haemorrhoids may be treated conservatively with analgesia, bedrest,
elevated legs or an icepack. Symptomatic first - and second-degree haemorrhoids that have
persisted despite medical intervention can be treated with rubber band ligation or injection
sclerotherapy, whereas third-degree haemorrhoids are ideally managed by formal
haemorrhoidectomy.
Haemorrhoids are swollen vascular cushions that affect approximately 40% of patients at some
point. The most common presenting symptoms are noticeable prolapse and fresh rectal bleeding,
they may also cause pruritus or pain. Risk factors include constipation and straining at stool,
increasing age, or increased intra-abdominal pressure (eg pregnancy, pelvic masses).
Haemorrhoids can be internal or external, external arising below the dentate line. If internal they
can then be described as first - through to fourth-degree:
1st – Haemorrhoids within lumen of the anal canal, no prolapse.
2nd – Haemorrhoids prolapse on straining but spontaneously reduce when straining is stopped.
3rd – Haemorrhoids prolapse but are fully reducible with manual pressure.
4th – Haemorrhoids are irreducibly prolapsed.
A 74-year-old man is brought into the Accident and Emergency resuscitation unit acutely unwell
with severe abdominal pain. On examination he looks poorly, has a weak pulse and is
hypotensive and tachycardic. He has a diffusely tender abdomen with widespread guarding and
an erect chest X-ray confirms air under the diaphragm. He is taken for a laparotomy and this
shows a perforated diverticulum.
Which one of the following sites does diverticular disease most commonly affect?
1) Ascending colon
2) Caecum
3) Rectum
4) Sigmoid colon
5) Transverse colon
Explanation
Sigmoid colon
Almost 50% of cases affect the sigmoid alone while a further nearly 25% of cases affect the
sigmoid and descending colon. In total the sigmoid colon is involved in over 80% of cases.
Ascending colon
Right-sided diverticula are present in fewer than 20% of cases in the Western population.
However, in the Asian population, right -sided diverticula are more common, although this is
changing with the adoption of a Western diet.
Caecum Right-sided diverticula are present in fewer than 20% of cases in the Western population.
However, in the Asian population, right -sided diverticula are more common, although this is
changing with the adoption of a Western diet.
Rectum
Rectal diverticula are extremely rare, presenting in less than 1% of cases
Transverse colon
The most common site for diverticula is the sigmoid colon.
Diverticulosis descr ibes the presence of pouches of protruding mucosa through the colonic wall.
They primarily occur in the large bowel where the longitudinal outer layer of muscle is arranged
as distinct bands called ‘taenia coli’ that give rise to sites of relative weakness in-between the
bands. Presence of diverticula increases with age – it affects approximately 50% by 50 years of
age and 70% by 80 years of age. It is most common in the descending and sigmoid colon in the
Western population, but can occur throughout the co lon. The most important modifiable risk
factor appears to be lack of dietary fibre and resultant constipation.
Diverticular disease is the term used to refer to symptomatic diverticulosis – the most common
symptoms being altered bowel habit (often alternat ing between constipation and diarrhoea) and
lower abdominal pain. It is not a premalignant condition but can co -exist with colorectal cancers.
Diverticulitis is an acute inflammatory exacerbation of pre-existing diverticulosis. This usually
presents with left iliac fossa pain, fever and can also present with per rectal (PR) bleeding.
A 51-year-old alcoholic is admitted with severe epigastric pain radiating to the back, fevers,
dehydration and jaundice. He undergoes scoring and it is deemed that he should be admitted
directly to HDU.
Which one of the following is a
poor prognostic factor
in pancreatitis according to
Ranson’s criteria?
1) Amylase 2600 IU/l
2) Arterial pa (O2 ) of 7 kPa
3) Corrected serum calcium of 2.6 mmol/l
4) Leukocyte count of 5 × 10 9 /l
5) Rise in packed-cell volume by more than 10%
Explanation
Arterial pa (O2 ) of 7 kPa
This is correct – arterial partial pressure of oxygen of < 8 (< 60 mmHg) is one of Ranson’s
criteria. Ranson’s criteria are used to predict severe pancreatitis and a prognosis of approximate
mortality. It was initially described for alcoholic (ie non-gallstone) pancreatitis. Several factors
are assessed at presentation and again at 48 h to give the full score. 1 point is given for each
criterion present, and this allows the following prognosis:
0–2 points = 1% mortality from this episode
3–4 points = 15% mortality
5–6 points = 40% mortality
7 or more points = 100% mortality
Amylase 2600 IU/l Amylase (normal value < 200 U/l) is a useful diagno stic investigation for pancreatitis. It is not,
however, prognostically useful.
Corrected serum calcium of 2.6 mmol/l
Corrected serum calcium of < 2.0 mmol/l scores a point in Ranson’s criteria and would therefore
indicate poor prognosis.
Leukocyte count of 5 × 10 9 /l
A white-cell count greater than 16 × 10 9 /l scores a point in Ranson’s criteria and would therefore
indicate poor prognosis.
Rise in packed-cell volume by more than 10%
Packed-cell volume indicates the volume of red cells circulating as a perce ntage of total blood
volume. It is raised most commonly in dehydration or in excess production of red cells – it is not
part of Ranson’s criteria. A fall in haematocrit at 48 h by > 10% from admission does score,
however.
A 63-year-old woman presenting with colorectal cancer asks about risk factors for the disease.
She is due to undergo colonoscopy for change in bowel habit.
Which of the following is associated with the greatest attributable burden of disease
incolorectal cancer?
1) Familial adenomatous polyposis (FAP)
2) Hereditary nonpolyposis colorectal cancer (HNPCC)
3) Other familial colon cancer syndrome (excluding FAP/HNPCC)
4) Pre-existing inflammatory bowel disease (IBD)
5) Sporadic factor
Explanation
Sporadic factor
Around 65% of colorectal cancers are thought to be sporadic – ie the genetic mutations present
within these cancers are not inherited. Important risk factors in developing sporadic colorectal
cancer include age, diet rich in red meat and lo w in fibre, smoking and obesity.
Familial adenomatous polyposis (FAP)
Less than 1% of colorectal cancer is attributable to FAP.
Hereditary nonpolyposis colorectal cancer (HNPCC)
This accounts for approximately 2–4% of colorectal cancers.
Other familial colon cancer syndrome (excluding FAP/HNPCC)
Inheritance is a factor in up to one-third of colorectal cancer cases; however, only 5% of
colorectal cancers arise in the setting of an inherited colorectal cancer syndrome – this number
includes FAP and HNPCC, which are the most common. Pre-existing inflammatory bowel disease (IBD)
IBD-related colorectal cancer accounts for < 2% of all colorectal cancers.
A 21-year-old man presents with abdominal pain and diarrhoea, with episodes up to 12 times a
day. He is diagnosed with Crohn’s disease.
Which one of the following is true of both Crohn’s disease and ulcerative colitis?
1) They are more common in urban areas than rural areas
2) Any part of alimentary canal affected from mouth to anus
3) Small, shallow ulcers
4) In 30% of cases, only the ileum is affected
5) 60% of cases are confined to rectum and sigmoid
Explanation
They are more common in urban areas than rural areas
Both Crohn’s disease and ulcerative colitis are more common in those living in urba n areas
compared with rural areas. The following table summarises key aspects of Crohn’s disease and
ulcerative colitis.
Crohn’s disease
Ulcerative colitis
Prevalence
145 per 100 000
240 per 100 000
Segments affected
Any part of the alimentary tract from mouth to anus, most commonly the terminal ileum. Commonly spares the rectum
Affects the rectum, extending contiguously proximally a variable amount but limited to the colon
Pattern of disease
Skip lesions
Continuous
Macroscopic
Cobblestones, aphthous and linear ulcers, ‘rose-thorn’ ulcers, abscesses, luminal
Pseudopolyps, very friable mucosa, featureless colon, findings
narrowing or stricturing
decreased haustrae, shortened colon, toxic megacolon
Microscopic findings
Transmural inflammation, granulomas
Submucosal or mucosal inflammation, crypt abscesses
Common symptoms
Abdominal pain, diarrhoea, weight loss, mouth ulcers, perianal disease
Bloody diarrhoea, weight loss, abdominal pain
Extraintestinal features
Perianal disease (fissures, fist ulae, tags, abscesses), mouth ulcers, oral aphthous ulcers, erythema nodosum, arthritis and spondyloarthropathies, uveitis, episcleritis
Primary sclerosing cholangitis, arthritis and spondyloarthropathies, uveitis, episcleritis
Any part of alimentary cana l affected from mouth to anus
Crohn’s disease can affect any part of the alimentary canal, with mouth ulcers and perianal
disease common features. It classically produces skip lesions whereby different parts of the
bowel are affected in a discontinuous manner. Ulcerative colitis affects the rectum and a variable
but continuous amount of proximal large bowel. Backwash ileitis can occur, causing
inflammation of the terminal ileum but otherwise the small bowel is not affected.
Small, shallow ulcers
Small, shallow ulcers are typical of ulcerative colitis; those seen in Crohn’s disease tend to be
very deep.
In 30% of cases, only the ileum is affected
In Crohn’s disease, only the ileum is affected in 30% of cases. Ulcerative colitis will not affect
the ileum, except in some cases in which backwash ileitis can occur (less than 10%).
60% of cases are confined to rectum and sigmoid
In ulcerative colitis, 60% of cases are confined to the rectum and sigmoid colon. Crohn’s disease
classically causes skip lesions thro ughout the entire alimentary tract from mouth to anus, but the
rectum is commonly spared.
A 21-year-old man presents with abdominal pain, cramps and diarrhoea, and inflammatory
bowel disease is diagnosed. He has a had colonoscopy and is now having further investigations
with a barium enema.
Which one of the following findings would suggest
Crohn’s disease rather than ulcerative
colitis
(UC)?
1) Affects rectum and spreads proximally
2) Cobblestone appearance of mucosa
3) Featureless ‘lead pipe’ colon
4) Thumbprinting
5) Small ulcers
Any part of the alimentary tract from mouth to anus, most commonly the terminal ileum. Commonly spares the rectum
Skip lesions
Ulcerative colitis
Prevalence
Segments affected
Pattern of disease
240 per 100 000
Affects the rectum, extending contiguously proximally a variable amount but limited to the colon
Continuous
Macroscopic
Cobblestones, aphthous and linear ulcers,
Pseudopolyps, very friable findings
‘rose-thorn’ ulcers, abscesses, luminal narrowing or stricturing
mucosa, featureless colon, decreased haustrae, shortened colon, toxic megacolon
Microscopic findings
Transmural inflammation, granulomas
Submucosal or mucosal inflammation, crypt abscesses
Common symptoms
Abdominal pain, diarrhoea, weight loss, mouth ulcers, perianal disease
Bloody diarrhoea, weight loss, abdominal pain
Extraintestinal features
Perianal disease (fissures, fistulae, tags, abscesses), mouth ulcers, oral aphthous ulcers, erythema nodosum, arthritis and spondyloarthropathies, uveitis, episcleritis
Primary sclerosing cholangitis, arthritis and spondyloarthropathies, uveitis, episcleritis
Affects rectum and spreads proximally
Crohn’s disease can affect any part of the alimentary canal, with mouth ulcers and perianal
disease common features. It classically produces skip lesions whereby different parts of the
bowel are affected in a discontinuous manner. Ulcerative colitis usually affects the rectum and a
variable but continuous amount of proximal large bowel, backwash ileitis can occur causing
inflammation of the terminal ileum, but otherwise the small bowel is not affected.
Featureless ‘lead pipe’ colon
A featureless ‘lead pipe’ colon can occur in chronic ulcerative colitis in affected segments due to
the inflammation and oedema resulting in loss of haustrae.
Thumbprinting
Thumbprinting is a relatively non-specific sign suggesting colonic oedema, which ma y be
present in ulcerative colitis. It is, however, a feature of plain radiographs, not of barium enema.
Small ulcers
Ulcers in Crohn’s disease are typically deep because inflammation is transmural and the mucosa
has a cobblestoned appearance.
A 16-year-old girl presents with weight loss, abdominal pain and diarrhoea mixed with blood
and mucus.
Which one of the following statements regarding ulcerative colitis is correct?
1) It has a prevalence of approximately six cases per 100 000 of the population
2) It has a positive family history with those with a first degree relative affected having a
15% lifetime risk of developing the disease
3) It is always confined to the rectum
4) It is investigated by ultrasound as the investigation of choice
5) It is not a pre-malignant condition
Explanation
It has a positive family history with those with a first degree relative affected having a 15%
lifetime risk of developing the disease
Those with a first degree relative have up to a 15% lifetime chance of developing ulcerative
colitis.
It has a prevalence of approximately six cases per 100 000 of the population
The prevalence in the UK is around 240 per 100 000 population.
It is always confined to the rectum
Ulcerative colitis always affects the rectum w ith a variable involvement proximally in a
continuous manner. It is confined to the large bowel with the exception of occasional cases of
backwash ileitis, in which the terminal ileum is inflamed. Otherwise, it does not affect the small
bowel.
It is invest igated by ultrasound as the investigation of choice
Colonoscopy with biopsy is the gold standard investigation for diagnosis and sub-classification
of inflammatory bowel disease.
It is not a pre-malignant condition
There is malignant potential in ulcerative colitis – after ten years, the risk is around 2%, then 8%
at 20 years and 18% at 30 years. Those with ulcerative colitis for ten years or longer are offered
surveillance at between 1–5-yearly intervals depending on whether they are deemed low,
intermediate or high-risk of developing colorectal cancer.
An overweight 32-year-old woman presents with a short history of painless jaundice. There is no
previous history of illness and she has no other signs of chronic liver disease. Initial
investigations reveal:
Result
Normal
Haemoglobulin
12.7 g/dl
12–15.5 g/dl
MCV
105 fl
80–96 fl
Serum bilirubin
162 µmol/l
< 21 µmol/l
AST
175 U/l
5–45 U/l
ALP
224 U/l
25–110 U/l
g-Glutamyltransferase
200 U/l
< 65 U/l
Which one of the following is the most likely diagnosis?
1) Alcoholic liver disease
2) Autoimmune chronic hepatitis
3) Non-metastatic carcinoma of the head of the pancreas
4) Cholecystitis
5) Hepatitis A infection
Explanation
Alcoholic liver disease
Jaundice with an elevation of both AST and alkaline phosphatase suggests mixed hepatocellular
damage and cholestatic liver disease, typical of acute alcoholic hepatitis on a background of
chronic liver disease (and is not excluded by the lack of physical signs). The high g -
glutamyltransferase lends support to this as it is typically elevated in alcoholism (although it may
be increased in liver disease of any cause). A mild macrocytosis is typical of chronic excessive
alcohol intake and is not a feature of the other conditions. AST and alanine a minotransferase
(ALT) are enzymes released from hepatocytes when they are damaged; therefore, when
hepatocellular damage predominates, these enzymes will be raised. ALP is typically raised where
cholestasis is present.
Autoimmune chronic hepatitis Autoimmune chronic hepatitis typically causes a hepatocellular damage. You would therefore
expect AST to be raised with much lesser change in ALP.
Non-metastatic carcinoma of the head of the pancreas
In patients presenting with painless jaundice, a diagnosis of pa ncreatic cancer causing an
obstructive jaundice should be considered. The mixed picture of cholestasis and hepatocellular
damage, however, does not fit with pancreatic cancer which normally causes a cholestasis – the
ALP would be expected to be elevated with much lesser AST elevation.
Cholecystitis
Chronic cholecystitis can cause jaundice but it would be unusual for there to be no history of
acute episodes. Additionally, the cause of jaundice in these patients is normally due to
obstruction, either due to a common biliary duct stone or because of local inflammation putting
pressure on the biliary tree – an obstructive/cholestatic pattern would be more suggested by a
high ALP and normal or only mildly elevated AST.
Hepatitis A infection
In hepatitis A, a hepatocellular picture develops so AST is typically higher than alkaline
phosphatase. This infection causes hepatitis and results directly in hepatocellular damage.
A
65-year-old man
presents with retention. On examination he is found to have a large smooth
prostate.
Which one of the following statements about prostatic pathology is true?
1) Benign prostatic hyperplasia (BPH) affects 50% of men over 50
2) The severity of symptoms is related to the size of the prostate gland
3) Finasteride, a 5-alpha-reductase inhibitor, will decrease the size of the prostate gland
within a week and therefore allow a trial without a catheter
4) Benign prostatic hyperplasia will not increase prostate-specific antigen (PSA)
5) The aim of transurethral prostatectomy is to core out the whole prostate
Explanation
Benign prostatic hyperplasia (BPH) affects 50% of men over 50
The proportion of men affected increases with increasing age, and the prevalence of lower
urinary tract symptoms also increases with age. However, many of the 50% will have only mild
or moderate symptoms, which are acceptable to them without treatment.
The severity of symptoms is related to the size of the prostate gland
The severity of symptoms is not related to the size o f the gland but to the encroachment on the
prostatic urethra and the resulting obstruction to urinary flow.
Finasteride, a 5-alpha-reductase inhibitor, will decrease the size of the prostate gland within a
week and therefore allow a trial without a catheter
Finasteride is an alpha-reductase inhibitor, which blocks the conversion of testosterone to
dihydrotestosterone and reduces the size of the hyperplastic glands. A 6 -month trial of treatment
is required and symptoms may be reduced or delayed or even avoid surgery. Alpha-adrenergic
blockers can be used to relax bladder neck muscle fibres and fibres in the prostate gland, and
take effect within a week.
Benign prostatic hyperplasia will not increase prostate-specific antigen (PSA)
Normal levels increase with age. Benign prostatic hyperplasia (BPH) can cause a small rise in
PSA, but the higher the rise in PSA the more specific it is for prostate cancer: > 4.1 ng/ml =
9.1%, > 10 = 55.5%.
The aim of transurethral prostatectomy is to core out the whole prostate The aim of transurethral resection of the prostate (TURP) is to debulk the prostate gland
surrounding the urethra and leave the normal peripheral tissue.
A patient with an extensive family history of colorectal cancer is seen in the outpatient clinic.
They are concerned about passing on problems to their future children.
Which one of the following is true for a patient of familial adenomatous polyposis (FAP)?
1) If no mutation can be identified then family members should be screened for the
condition using colonoscopy or flexible sigmoidoscopy from 13–15 years of age
2) Desmoid tumours occurring as part of FAP are benign and do not cause any problems
3) Colonic cancer is the only malignancy associated with FAP
4) FAP affects 1 in 1000 people
5) The FAP adenomatous polyposis coli (APC) gene shows an autosomal-recessive form of
inheritance
Explanation
If no mutation can be identified then family members should be screened for the condition using
colonoscopy or flexible sigmoidoscopy from 13–15 years of age
The British Society of Gastroenterology guidelines suggest that relatives of the patient who have
a 50% risk of FAP should be offered yearly large bowel surveillance from the age of 13 –15 until
the age of 30. From then, 3–5-yearly screening until they are 60 is advised. As FAP is an
autosomal-dominant condition, the children of the patient will have a 50% risk of the condition,
so should be offered screening as above. A specific collection of signs/symptoms in FAP is
known as Gardner syndrome.
Desmoid tumours occurring as part of FAP are benign and do not cause any problems
Desmoid tumours, which are solid tumours of the connective tissues, particularly within the
abdomen, occur in up to 15% of people with FAP. Although they are not malignant, they can
cause major problems by aggressively invading surrounding tissues. Desmoid tumours account
for up to 11% of deaths in those with FAP.
Colonic cancer is the only malignancy associated with FAP
Individuals affected with FAP risk developing a duodenal malignancy, other small bowel
cancers, thyroid cancer, pancreatic cancer, adrenal cancer, and hepatoblastoma.
FAP affects 1 in 1000 people
FAP affects 1 in 10 000 people. Men and women are equally affected. The FAP adenomatous polyposis coli (APC) gene shows an autosomal-recessive form of
inheritance
FAP is autosomal-dominant. About 20–30% of cases seem to arise from new mutations.
Inflammatory bowel diseases cause significant morbidity. Specific variants have different
optimal management plans.
Which one of the following statements is true about the differences between Crohn’s
disease and ulcerative colitis?
1) Both Crohn’s disease and ulcerative colitis start then spread from the rectal mucosa
2) Crohn’s disease has a clear demarcation between involved and uninvolved mucosa,
whereas ulcerative colitis shows skip lesions with normal mucosa in-between
3) The incidence of gallstones and kidney stones is increased in Crohn’s disease but not in
ulcerative colitis
4) Weight loss is more commonly seen in ulcerative colitis than in Crohn’s disease
5) Fistulae are often seen in both diseases
narrowing or stricturing
decreased haustrae, shortened colon, toxic megacolon
Microscopic findings
Transmural inflammation, granulomas
Submucosal or mucosal inflammation, crypt abscesses
Common symptoms
Abdominal pain, diarrhoea, weight loss, mouth ulcers, perianal disease
Bloody diarrhoea, weight loss, abdominal pain
Extraintestinal features
Perianal disease (fissures, fist ulae, tags, abscesses), mouth ulcers, oral aphthous ulcers, erythema nodosum, arthritis and spondyloarthropathies, uveitis, episcleritis
Primary sclerosing cholangitis, arthritis and spondyloarthropathies, uveitis, episcleritis
Both Crohn’s disease and ulcerative colitis start then spread from the rectal mucosa
Ulcerative colitis always involves the rectum with disease then spreading proximally throughout
the colon. There can be backwash ileitis where there is some involvement of the terminal ileum,
but ulcerative colitis is really a colonic disease. Ulcerative colitis remains confined to the rectum
in approximately 25% of cases. In the remainder of cases, it spreads proximally and
contiguously. Pancolitis occurs in 10% of patients. Crohn’s disease, convers ely, consists of
segmental involvement by a non-specific granulomatous inflammatory process. The most
important pathological feature is involvement of all layers of the bowel, not just the mucosa, and
the submucosa as is characteristic of ulcerative colitis.
Crohn’s disease has a clear demarcation between involved and uninvolved mucosa, whereas
ulcerative colitis shows skip lesions with normal mucosa in-between
Crohn’s disease is discontinuous, with skip areas interspersed between one or more involved
areas. Late in the disease, the mucosa develops a cobblestone appearance, which results from
deep longitudinal ulcerations interlaced with intervening normal mucosa. The three major
patterns of involvement in Crohn’s disease are:
disease in the ileum and caecum, occurring in 40% of patients
disease confined to the small intestine, occurring in 30% of patients
disease confined to the colon, occurring in 25% of patients.
Weight loss is more commonly seen in ulcerative colitis than in Crohn’s disease
Weight loss is more commonly seen with Crohn’s disease due to the loss of absorptive capacity
in the small bowel. Ulcerative colitis is more likely to present with bloody diarrhoea and
symptoms suggestive of an inflamed rectum, such as tenesmus and urgency. Fistulae are often seen in both diseases
Fistulae are not usually seen in ulcerative colitis because there is only mucosal and submucosal
involvement in the large bowel. Crohn’s disease, however, has full-thickness involvement of the
bowel wall and can therefore form a fistula with nearby structures, eg recto -vaginal, recto-
vesical.
A patient with an acute abdomen is not responding to conservative treatment. A plain abdominal
X-ray demonstrates a
very distended large bowel.
Which one of the following is true of toxic megacolon?
1) Toxic megacolon is due to large bowel obstruction causing dilatation of the colon 2) Toxic megacolon does not occur in Crohn’s disease
3) On abdominal X-ray a transverse colonic diameter of 8cm is significant
4) Mortality rates in Toxic megacolon of any aetiology are 40%
5) First line treatment is surgical resection
Explanation
On abdominal X-ray a transverse colonic diameter of 8cm is significant
The transverse colon is often used as the point of reference for dilatation, its normal diameter =
5.5–6.5 cm. Loss of colonic haustra is also seen, and possible thumbprinting – a coarse, irregular,
mucosal pattern of the large bowel.
Toxic megacolon is due to large bowel obstruction causing dilat ation of the colon
The hallmarks of toxic megacolon, a potentially lethal condition, are non-obstructive colonic
dilatation larger than 6 cm and signs of systemic toxicity.
Toxic megacolon does not occur in Crohn’s disease
Toxic megacolon may complicate any number of colitides, including inflammatory bowel
disease – which is the most common aetiology (around 50%). Other causes include ischaemic,
infectious (Clostridium difficile), radiation, and pseudomembranous colitis. It is more common in
ulcerative colitis but can also occur in Crohn’s disease.
Mortality rates in Toxic megacolon of any aetiology are 40%
Mortality rates have been falling due to better care and earlier surgical involvement, and are now
quoted as being 5–20%. Once perforation has occurred mortality rates are thought to increase
five-fold.
First line treatment is surgical resection
Initial management is medical. During the initial resuscitation, fluid and electrolyte replacement,
and transfusion should be aggressive. Broad-spectrum intravenous antibiotics should be initiated.
All medications that may affect colonic motility must be stopped. These include narcotics,
antidiarrhoeals, and anticholinergic agents. The patient should be put on bowel rest, and a
nasogastric tube placed to assist with gastrointestinal (GI) decompression. If the patient has
underlying inflammatory bowel disease then this should be treated too. Should medical
management fail then surgical resection will be required.
You are looking after a young man on the Intensive Care Unit (ITU) with severe
pancreatitis. Initially when he was admitted he was fairly well, but continued to deteriorate after
48 hrs into his admission.
Which one of the following are correct regarding pancreatitis?
1) Feeding via the total parentral route is preferred as it prevents over stimulation of the pancreas
2) Serum amylase is a reliable marker of severity and progression of pancreatitis
3) The APACHE II scale is the most commonly used prognostic scale in acute pancreatitis
4) The BALTHAZAR scoring system assesses severity of pancreatis using serial ultrasound scans
5) If infected pancreatic necrosis develops the mortality rate is approximately 25%
Explanation
If infected pancreatic necrosis develops the mortality rate is approximately 25%
This is correct, this rate compares with that of mild acute pancreatitis, which has a mortality of
around 1%, and sterile pancreatic necrosis at 10%. About 20 –30% of patients with acute
pancreatitis develop complications of necrosis or organ failure. Due to the wide spectrum of the
disease, several systems have been developed in an attempt to provide reliable prognostic
classification for patients. The most frequently used of these is the modified Glasgow score.
Modified Glasgow score criteria:
pa (O2 ) < 7.9 kPa
age > 55 years
neutrophils (white blood cell (WBC) > 15)
calcium < 2 mmol/l
urea > 16 mmol/l
LDH > 600 IU/l
albumin < 32 g/L (serum)
blood glucose > 10 mmol/l
If three or more of these criteria are present in the first 48 h of admission then severe pancreatitis
is likely. Various scores can also be used to estimate mortality:
score 0 to 2: 2% mortality
score 3 to 4: 15% mortality
score 5–6: 40% mortality
score 7 to 8: 100% mortality.
Feeding via the total parentral route is preferred as it prevents over stimulation of the pancreas
Opinion has recently changed regarding feeding in pancreatitis. It is now best practice to feed by
the enteral route via a feeding tube placed past the pancreatic duct into the 3rd part of the
duodenum. For milder cases, patients can have oral intake as this is tolerated.
Serum amylase is a reliable marker of severity and progression of pancreatitis
Although amylase and lipase levels are useful in the diagnosis of pancreatitis they have no role i n
assessing severity – for example, neither is used in the Ranson scoring system used to
prognosticate acute pancreatitis. Lipase rises in 4–6 h and normalises in 7–14 days. Amylase
may be normal in 10% of cases. The APACHE II scale is the most commonly used prognostic scale in acute pancreatitis
The APACHE II is a scoring system designed to assess disease severity patients admitted to the
ITU. It has been well studied in acute pancreatitis, but by design is an admission score designed
to assess disease severity in all adult patients admitted to general ITU. It uses the patients age,
and various physiology and biochemical/laboratory values within the first 24 h of admission. A
higher score corresponds to a higher severity of disease and a higher risk of deat h from this
admission. The most frequently used prognostic classification for patients with acute pancreatitis
is the modified Glasgow score.
The BALTHAZAR scoring system assesses severity of pancreatis using serial ultrasound scans
The BALTHAZAR score is a computed tomography (CT) scan-based scoring system that is used
to grade the severity of pancreatitis.
A 55-year-old woman presents with jaundice due to
pancreatic cancer
. Her pain is minimal and
attended as her husband noticed she had gone yellow. She has lost a significant amount of weight
recently.
Which one of the following statements is true regarding her jaundice?
1) It is due to excess bile production
2) It is due to haemolytic anaemia
3) It is part of a paraneoplastic syndrome
4) It is post-hepatic jaundice
5) It is secondary to tumour lysis syndrome
Explanation
It is post-hepatic jaundice This is correct – neoplasms classically within the head of the pancreas can compress or invade
and obstruct the common bile duct. This leads to an obstructive or cholestatic jaundice. Bilirubin
is principally derived from the degradation of haemoglobin within the spleen and is carried to the
liver bound to albumin, as in its unconjugated form it is not water soluble. Within the liver,
bilirubin is conjugated by glucuronyltransferase, making it water soluble, and is secreted into the
duodenum. At the distal ileum the bilirubin is either converted to urobilinogen and excreted in
the faeces as stercobilinogen, or is re-absorbed and renally excreted. Jaundice becomes clinically
apparent at serum levels >35–40 µmol/l.
Jaundice may be classified as pre-hepatic, hepatic, or post -hepatic, depending on the site of the
obstruction or metabolic abnormality.
Pre-hepatic (haemolytic) jaundice: caused by disorders resulting in increased destruction of red
cells, eg autoimmune haemolytic anaemia or sickle cell disease which overwhelms the livers
ability to process the excess bilirubin. The excess bilirubin is unconjugated so no bilirubin is
detected in the urine. Hepatic (parenchymal) jaundice: caused by any condition affecting
hepatocyte function, eg acute hepatitis infection, alcoholic hepatitis, drug-induced hepatitis, or
cirrhosis of any cause.
Post-hepatic (cholestatic) jaundice: caused by physical obstruction of the biliary system eg
carcinoma of the head of pancreas or gallstones. Typically there is dark urine (the bilirubin is
water soluble, so is excreted in the urine) and pale stools (due to steatorrhoea from lack normal
biliary function in aiding fat absorption).
It is due to excess bile production
Jaundice is a result of excess bilirubin, while bilirubin is excreted in the bile excess bile
production would not be expected to result in jaundice.
It is due to haemolytic anaemia
Haemolytic anaemia is an example of pre-hepatic jaundice – it is not the correct answer in this
instance.
It is part of a paraneoplastic syndrome
Paraneoplastic syndromes are effects of malignancy not caused by the local effect of the cancer
itself – they are frequently hormo nal or immunological. Examples include Cushing syndrome in
small-cell lung cancer caused by ectopic adrenocorticotropic hormone (ACTH) production, or
Lambert–Eaton myasthenia syndrome caused by antibodies produced against small-cell lung
cancer that are active against pre-synaptic voltage gated calcium channels.
Paraneoplastic syndromes associated with pancreatic cancer include Cushing syndrome,
carcinoid syndrome and dermatomyositis.
It is secondary to tumour lysis syndrome Tumour lysis syndrome is a potential treatment complication of most commonly, haematological
cancers. Rapid lysis of leukaemia or lymphoma cells results in metabolic abnormalities including
hyperkalaemia, hyperphosphataemia, hypocalcaemia, lactic acidosis and hyperuricaemia. It is
potentially life-threatening – however, it does not usually result in jaundice.
A 52-year-old woman undergoes an investigation for jaundice. She first noticed
this symptom 2 months ago, but for 4 months previously she had been experiencing generalised pruritus. The
results of liver function tests are as follows:
Result
Normal
Serum bilirubin
325 mmol/l
0–22 µmol/l
Aspartate aminotransaminase
55 U/l
15–42 U/ mmol/l
Alkaline phosphatase
436 U/l
80–150 U/l γ-Glutamyltransferase
82 U/l
11–51 U/l
Albumin
36 g/l
30–50 g/l
Total protein
82 g/l
60–80 g/l
Which one of the following is the most likely diagnosis?
1) Alcoholic cirrhosis
2) Carcinoma of the head of the pancreas
3) Cholangiocarcinoma
4) Primary biliary cirrhosis
5) Primary sclerosing cholangitis
Explanation
Primary biliary cirrhosis
Primary biliary cirrhosis frequently presents first with progressive and insidious onset of pruritus
and general malaise/lethargy, jaundice occurring later in the disease process. It is more common
in women than men (ratio 9:1), classically presenting between 40 –60 years of age. It is an
autoimmune condition associated with antimitochondrial antibodies, and the presence of
excessive antibodies is suggested by the slight ele vation in total protein with low–normal
albumin (this suggests a high globulin concentration). The disease process results in progressive
destruction of the intrahepatic bile ducts, and therefore an obstructive/cholestatic jaundice
supported by the raised alkaline phosphatase (ALP), but relatively normal aspartate transaminase
(AST).
Alcoholic cirrhosis
Alcoholic cirrhosis is a common cause of the above picture but is unlikely (although not
excluded) by the absence of history of alcohol excess, and the only slightly elevated g-
glutamyltransferase (which is sensitive, although non-specific, for alcohol excess).
Carcinoma of the head of the pancreas
Carcinoma of the head of the pancreas frequently presents in this manner (although weight loss
is often present also), but the slight elevation in total protein with low –normal albumin suggests
a high globulin concentration, which suggests autoimmune liver disease.
Cholangiocarcinoma Cholangiocarcinoma is a rare tumour, although could present like this. As with carc inoma of the
head of the pancreas, weight loss is often present also, and the slight elevation in total protein
with low–normal albumin suggests a high globulin concentration, which suggests autoimmune
liver disease.
Primary sclerosing cholangitis
Primary sclerosing cholangitis is a possibility but is commoner in men than women (3:1), and in
75% of cases are associated with inflammatory bowel disease. In this case primary biliary
cirrhosis is more likely.
A 20-year-old man presents with mild jaundice following a flu-like illness. Following review by a gastroenterologist, he has been told that a diagnosis of Gilbert syndrome is probable.
Which laboratory test is most likely to confirm this diagnosis?
1) Absence of bilirubin in the urine
2) Decreased serum haptoglobin concentration
3) Elevated serum aspartate aminotransferase (transaminase, AST) activity
4) Increased reticulocyte count
5) Increased urinary urobilinogen excretion
Gilbert syndrome is an inherited, autosomal-recessive condition resulting in abnormal liver metabolism of bilirubin. It is relatively common affecting around 5% of the population.
The correct laboratory test to confirm a diagnosis of Gilbert syndrome is 1) Absence of bilirubin in the urine.
In Gilbert syndrome, there is an increase in unconjugated bilirubin, which is water-insoluble and does not appear in the urine. Diagnosis is typically supported by elevated serum unconjugated bilirubin with normal liver function tests and no evidence of hemolysis
Gilbert syndrome is normally asymptomatic, but mild jaundice may develop whe n there is physiological
stress (eg infection or fasting). In Gilbert syndrome, the excess bilirubin is unconjugated, and
does not appear in the urine. You would also not expect to find bilirubin the urine in other causes
of pre-hepatic jaundice, such as haemolytic disease.
Decreased serum haptoglobin concentration
Decreased serum haptoglobin concentration is a sign of haemolytic anaemia. Haptoglobin will
bind free haemoglobin released by lysed red cells and this complex is then removed by the
spleen.
Elevated serum aspartate aminotransferase (transaminase, AST) activity
Elevated AST is a non-specific sign of hepatocellular damage – the excess activity being
detected in the blood a result of the release of these enzymes from their normal intracellular site
within hepatocytes. This would be raised, for example, in alcoholic hepatitis, viral hepatitis, or
drug-induced liver damage. Haemolysis may also cause a slight increase in serum
aminotransferase (transaminase) activity as red blood cells also have a small amount of AST
within them. AST is also found in skeletal muscle among other cell types.
Increased reticulocyte count
This is a sign of excess haemolysis – the rapid destruction of red blood cells resulting in rapid
production of red blood cells and therefore an increased number of reticulates in the peripheral
blood count.
Increased urinary urobilinogen excretion
However, in haemolytic jaundice, urinary urobilinogen is increased (increased production of
bilirubin, and hence of urobilinogen), the reticulocyte count may be elevated and serum
haptoglobin concentration decreased. Bilirubin is principally derived from the degradation of
haemoglobin within the spleen and is carried to the liver bound to albumin, as in its
unconjugated form it is not water soluble. Within the liver bilirubin is conjugated by
glucuronyltransferase, making it water soluble, and is secreted into the duodenum. At the distal
ileum the bilirubin is either converted to urobilinogen and excreted in the faeces as
stercobilinogen, or is re-absorbed and renally excreted. Jaundice becomes clinically apparent at
serum levels >35–40 µmol/l. Jaundice may be classified as pre-hepatic, hepatic, or post -hepatic,
depending on the site of the obstruction or metabolic abnormality.
Pre-hepatic (haemolytic) jaundice: caused by disorders resulting in increased destruction of red
cells eg autoimmune haemolytic anaemia or sickle cell disease which overwhelms the livers
ability to process the excess bilirubin. The excess bilirubin is unconjugated so no bilirub in is
detected in the urine.
Hepatic (parenchymal) jaundice: caused by any condition affecting hepatocyte function eg acute
hepatitis infection, alcoholic hepatitis, drug-induced hepatitis, or cirrhosis of any cause.
Post-hepatic (cholestatic) jaundice: caused by physical obstruction of the biliary system eg
carcinoma of the head of pancreas or gallstones. Typically there is dark urine (the bilirubin is
water soluble, so is excreted in the urine) and pale stools (due to steatorrhoea from lack normal
biliary function in aiding fat absorption).
You are asked to see an
82-year-old
woman
under the medical team
with a lower respiratory
tract illness and
non-tender
abdominal distension. There are
dilated loops
on her abdominal film.
Blood tests reveal:
Result
Normal
Sodium
138 mmol/l
135–145 mmol/l
Potassium
3.1 mmol/l
3.5–5 mmol/l
Urea
10 mmol/l
2.5–6.5 mmol/l
Creatinine
118 µmol/l
50–120 µmol/l
White cell count
17/mm
3
<5/mm
3
C-reactive protein
11.5 mg/dl
<3 mg/dl
What is the most likely diagnosis?
1) Colorectal cancer
2) Constipation
3) Diverticulitis
4) Pseudo-obstruction
5) Small bowel obstruction
Explanation
Pseudo-obstruction
Pseudo-obstruction is an example of non-mechanical bowel obstruction. It can be acute or
chronic. Acute is also known as Ogilvie syndrome. In 80% of cases, colonic pseudo -obstruction
is associated with other clinical conditions. The most common are cardio -respiratory illness, post-trauma or pelvic surgery. It usually presents as this clinical vignette with abdominal
distension in the context of another acute condition, intermittent constipation and nausea or
vomiting are frequent symptoms, colicky abdominal pain may be present. Imaging will reveal
dilated bowel loops. Treatment should be based on correcting the associated cause such as the
respiratory illness or correcting electrolyte imbalances – usually potassium, magnesium or
phosphate. This may resolve the ‘obstruction’. Otherwise consider endoscopic decompression.
Neostigmine has also been used in some chronic cases.
Colorectal cancer
Colorectal cancer, particularly left -sided lesions, can cause and therefore present with
obstruction, which would give abdominal distension and dilated bowel loops. However,
mechanical obstruction is frequently painful. Usually colorectal cancer pres ents insidiously with
a change in bowel habit or PR bleeding, or with an otherwise unexplained microcytic anaemia.
Constipation
Constipation is a frequent complication for patients in hospital, both because of medication used
(for example opiates) and because many patients are relatively immobile. In patients with
constipation abdominal distension can occur. Frequently patients will have left iliac fossa pain.
Dilated loops would not be typical and faecal loading may be seen in the colon.
Diverticulitis
Diverticulitis refers to inflammation of diverticulae, which are most frequently found in the
sigmoid colon. It normally presents with left iliac fossa pain and fever, possibly with PR
bleeding. Inflammatory markers would be elevated, although in this instanc e these are more
likely to be explained by the already diagnosed lower respiratory tract infection.
Small bowel obstruction
Small bowel obstruction usually presents with vomiting, absolute constipation, and painful
abdominal distension. The commonest causes are intra-abdominal adhesions and hernias, other
causes include foreign bodies, gallstone ileus, volvulus, neoplasms and strictures (eg from
previous ischaemia or from Crohn’s disease). In small bowel obstruction you will usually see
dilated small bowel loops proximal to the point of obstruction.
A 62-year-old woman undergoes a
gastric bypass
. She attends the surgical assessment unit
feeling unwell, is seen by the consultant and told she has
dumping syndrome
. She is unsure what
this means and you have been asked to explain it to her.
What are the likely symptoms that she has been suffering?
1) Collapse and chest pain
2) Left upper quadrant pain, diarrhoea, chest pain
3) Pain before eating, dizziness and nausea
4) Postprandial pain, vomiting and dizziness
5) Shortness of breath and chest pain
Explanation
Postprandial pain, vomiting and dizziness
Dumping syndrome following gastrectomy is due to an absent gastric reservoir, abnormal
postoperative gastric motor function and hormonal secretion alteration. After eating, symptoms
are related to the rapid transit of hyperosmolar contents into the small bowel. It can be split into
early dumping syndrome, occurring within 10–30 min after a meal, and late dumping syndrome,
which occurs after 2–3 h. Early dumping syndrome results from rapid osmotic fluid shifts from
the blood into the intestine resulting in decreased total blood volume and intestinal distension.
Late dumping syndrome results from rapid absorption of sugar from the intestine followed by a
rapid increase in insulin levels and a subsequent hypoglycaemic episode. Early dumping
syndrome symptoms include abdominal pain, vomiting and nausea, diarrhoea, sweating and
flushing, and dizziness. Late dumping syndrome symptoms include sweating, weakness, flushing and dizziness. Treatment is largely through managing dietary intake with several small meals a
day (instead of large meals) and avoiding simple sugars. Additionally, liquids should be drunk in
between meals not alongside meals. A high fibre diet can also help. Octreotide and proton pump
inhibitors (PPIs) can also help to slow gastric emptying if conservative management fails.
Collapse and chest pain
This is not correct.
Left upper quadrant pain, diarrhoea, chest pain
This is not correct.
Pain before eating, dizziness and nausea
This is not correct, in particular symptoms occur after eating.
Shortness of breath and chest pain
This is not correct.
A patient is undergoing a right hemicolectomy for a caecal tumour. The ileocaecal valve and part
of the terminal ileum are resected before the anastomosis between ileum and transverse colon is
made.
Resection of the
terminal ileum
is most commonly associated with the malabsorption of
which one of the following components?
1) Bile salts
2) Calcium
3) Cholesterol
4) Folic acid
5) Sodium
Explanation
Bile salts
Bile salts are primarily re-absorbed in the terminal ileum – loss of bile salts in faeces has several
knock-on effects. Bile salts released in the bile are normally responsible for solubilising dietary
fat – so excess loss of bile salts results in fat malabsorption. One important effect of this is
malabsorption of the fat soluble vitamins A, D, E and K. Additionally the terminal ileum is the
primary site for absorption of vitamin B 12 – loss of which results in a macrocytic anaemia.
Calcium
Calcium and folic acid are mainly absorbed in the jejunum.
Cholesterol Dietary fat, including cholesterol, is primarily absorbed in the jejunum. However, excess loss of
bile salts, which are absorbed in the ileum, can lead to fat malabsorption in the jejunum.
Folic acid
Calcium and folic acid are mainly absorbed in the jejunum.
Sodium
Sodium is re-absorbed throughout the small bowel.
A 35-year-old man patient is admitted to the surgical assessment unit with severe
colicky right
upper quadrant pain
, he is not febrile and has no abdominal tenderness. His past medical history
consists of
Crohn’s disease
, previous laparotomy for
small bowel resection
and asthma.
What is the most likely risk factor responsible for his symptoms?
1) Age
2) Diet
3) Lack of bile salts
4) Increased haemosiderin
5) Sex
Explanation
Lack of bile salts
This patient has gallstones because of a lack of bile salts which are usually involved in fat
absorption. He has Crohn’s disease, which resulted in a small bowel resection. This is most
commonly in the terminal ileum where bile salts are most predominantly absorbed. Bile salts aid
with the absorption of fat by forming micelles. Without the presence of bile salts in bile,
cholesterol will more readily sediment out to form gallstones. Other risk factors include obesity,
female sex, increasing age, diabetes me llitus, and premenopausal status or use of HRT/oral
contraceptives.
Age
Increasing age is a risk factor for developing gallstones, classically they become more likely
especially above the age of 40.
Diet Dietary factors are not a major risk factor for deve loping gallstones.
Increased haemosiderin
Haemosiderin is a complex that stores ferritin; deposits are most commonly associated with iron
overload conditions, such as hereditary haemochromatosis. They are not a risk factor for
gallstones.
Sex
Gallstones are more common in women than in men.
A 61-year-old woman presents with persistent vomiting of largely undigested food. She has lost
a significant amount of weight,
in the A&E department she is now in extremis.
Prolonged
vomiting in
gastric
outflow obstruction is associated with which of the
following?
1) Decreased antidiuretic hormone (ADH) secretion
2) Hypochloraemic alkalosis
3) Metabolic acidosis
4) Respiratory alkalosis
5) Hyperkalaemia
Explanation
Hypochloraemic alkalosis
Prolonged vomiting causes a hypochloraemic metabolic alkalosis. The reason for this is that
H + and Cl – , from gastric secretions within the stomach, are lost and in addition the alkaline
pancreatic and duodenal secretions are retained. The loss of H + obviously directly leads to
alkalosis, however the loss of Cl – also results in retention of the other major anion in the body,
HCO 3 – (bicarbonate). All together this results in a hypochloraemic metabolic alkalosis. The loss
of fluid volume causes a physiological response that includes sympathetic stimulation, increase
in ADH secretion and activation of the renin–angiotensin–aldosterone system. In small bowel
obstruction, there is also loss of alkaline intestinal secretions, which prevents the development of
metabolic alkalosis.
Decreased antidiuretic hormone (ADH) secretion
Loss of fluid and inability to take in oral fluids will result in dehydration and loss of
intravascular fluid volume and therefore increased ADH secretion as the body tries to maintain
its intravascular fluid volume.
Metabolic acidosis The loss of H+ and Cl – from gastric secretions results in hypochloraemic metabolic alkalosis.
Respiratory alkalosis
Respiratory alkalosis results from hyperventilation and therefore excess removal of carbon
dioxide from the body, while the patient will be alkalotic this is not due to a respiratory cause.
Hyperkalaemia
The patient will most likely become hypokalaemic. A relatively small amount of potassium will
be directly lost in the vomit. However, more importantly, the pat ient will become alkalotic
(metabolic alkalosis) – alkalosis results in a transcellular exchange of potassium going into the
cells and hydrogen ions leaving the intracellular compartment, the increased reabsorption of
H + in the kidneys also results in increased exchange of potassium into the urine. Finally the
patient’s hypovolaemia and resultant increase in aldosterone production also results in loss of
potassium at the kidneys.
A 22-year-old man presents with a long history of intermittent abdominal discomfort and
diarrhoea. On examination, he has a body mass index of 19 kg/m 2 and is clinically anaemic.
Coeliac disease is suspected.
Which one of the following investigations will
most reliably
diagnose this condition?
1) Detection of antigliadin antibodies in serum
2) Detection of endomysial antibodies (EMA) in serum
3) Detection of tissue transglutaminase (TTG) antibodies in serum
4) Microscopic examination of a small bowel biopsy specimen
5) Xylose absorption test
Explanation
Microscopic examination of a small bowel biopsy specimen
The detection of the typical appearance of subtotal villous atrophy on a small bowel biopsy is
regarded as the ‘gold standard’ for the diagnosis of coeliac disease. Other changes include
increased numbers lymphocytes and crypt hyperplasia.
Detection of antigliadin antibodies in serum
Sensitivity and specificity among studies for this test is highly variable but generally less than
endomysial antibodies (EMA) and tissue transglutaminase (TTG) antibodies.
Detection of endomysial antibodies (EMA) in serum
Sensitivity and specificity are >95% making this a very good screening test, however, biopsy
remains the gold standard. Endomysial antibodies have been identified as binding to a spec ific
form of tissue transglutaminase within the endomysium.
Detection of tissue transglutaminase (TTG) antibodies in serum
Again sensitivity and specificity are >95% therefore this test is good for screening – but biopsy is
the gold standard.
Xylose absorption test The xylose absorption test is a non-specific test for intestinal malabsorption.
A 21-year-old male medical student who has been feeling non-specifically unwell for several days is noticed to have slightly icteric sclerae by his girlfriend and has liver function tests performed. The results of these are normal apart from a serum bilirubin concentration of 44 μmol/L (normal range 3–17 μmol/L). His urine does not contain bilirubin.
Which one of the following is the most likely diagnosis?
1) Dubin–Johnson syndrome
2) Gilbert syndrome
3) Hereditary spherocytosis
4) Infectious mononucleosis
5) Rotor syndrome
Explanation
Gilbert syndrome
Gilbert syndrome is a common (approximately 1:2 0) autosomal-recessive cause of mild unconjugated hyperbilirubinaemia. This occurs due to defective conjugation within the liver. Normally mild jaundice develops when affected patients develop concomitant infections, are fasting or have other physiological stressors. As the hyperbilirubinaemia is unconjugated it will
not be present in the urine.
Dubin–Johnson syndrome
Dubin–Johnson syndrome is an autosomal-recessive condition causing a conjugated hyperbilirubinaemia due to a defect in the secretion of bilir ubin from the liver. The bilirubin that then accumulates in the plasma is conjugated, water -soluble and so is excreted in the urine. One key difference between and Rotor syndrome is that in Rotor syndrome the liver is classically
pigmented black.
Hereditary spherocytosis
Hereditary spherocytosis is a chronic haemolytic disorder due to a defect in the red -cell membrane (most frequently in spectrin, a structural protein). It can present with a wide range of severity, from jaundice at birth to asymptomatic anaemia or jaundice in adults. It is pre-hepatic jaundice and will therefore be unconjugated with no bilirubin in the urine. However, it is much less common than Gilbert’s syndrome so less likely (approximately 1:5000 in Northern Europeans).
Infectious mononucleosis
Infectious mononucleosis (IM) can cause hepatitis and jaundice but an elevated transaminase activity would be expected. It normally presents with a tonsillitis, general malaise, and cervical lymphadenopathy – the absence of these makes IM unlikely.
Rotor syndrome
Rotor syndrome is an autosomal-recessive condition, causing a conjugated hyperbilirubinaemia due to defective transporter proteins from hepatocytes into the biliary tree. As the bilirubin that accumulates in the plasma is conjugated, water-soluble and therefore excreted in the urine.
A 62-year-old man presents to his GP as his family have noticed he has ‘gone yellow’. On further questioning he admits to generalised pruritus and around 2 stone of weight loss. He denies any abdominal or chest pain. On examination you note he has icteric sclera and widespread scratch marks.
What is the most likely diagnosis?
1) Biliary colic
2) Ascending cholangitis
3) Cholecystitis
4) Gallstone ileus
5) Pancreatic cancer
Explanation
Pancreatic cancer
Pancreatic cancer classically presents insidiously with painless jaundice, often with a history of weight loss as the cancer usually presents at late stage. These cancers tend to be cancers of the head of the pancreas as it is through this portion of the pancreas that the CBD traverses. As this is the only condition listed that typically causes painless jaundice it is the correct answer.
Obstructive jaundice classically produces dark urine and paler stools and it would be usefu l to know this from the history.
Biliary colic
This normally presents with sudden onset, colicky right upper quadrant pain. Often associated with recent ingestion of large/fatty meals. It is unusual for jaundice to develop unless a gallstone has entered to common bile duct, or occasionally a gallstone within the neck of the gall-bladder or Hartmann’s pouch can compress the common bile duct (CBD) and cause an obstructive jaundice (known as Mirizzi’s syndrome). The absence of pain and insidious onset strongly goes against this diagnosis.
Ascending cholangitis
Ascending cholangitis is a medical emergency that can be recognised by Charcot’s triad of fever, right upper quadrant abdominal pain and jaundice. This insidious presentation does not fit this diagnosis.
Cholecystitis
Cholecystitis normally presents with constant right upper quadrant pain and fever, classically the patient is Murphy’s positive in which deep inspiration while palpating the right upper quadrant (RUQ) results in the patient ‘catching their breath’ as the inflamed gall-bladder is lowered onto the palpating hand. Jaundice is uncommon unless a stone within the neck of the gall-bladder or Hartmann’s pouch is compressing the CBD and can cause an obstructive jaundice (known as Mirizzi’s syndrome), additionally the localised inflammation and swelling around the gall- bladder can result in compression of the CBD and therefore an obstructive jaundice.
Gallstone ileus
Gallstone ileus occurs when a gallstone enters the small bowel, usually through a fistula connecting the gall-bladder and small intestine. It can then cause a mechanical small bowel obstruction. It does not cause jaundice.
A 17-year-old man is being investigated for tremor and dysarthria. His GP has performed blood tests that show very deranged liver function tests (LFTs). On examination, he is noted to have a tremor, impaired memory and slit -lamp examination reveals Kayser–Fleischer rings.
What is the most likely diagnosis?
1) Alcoholic cirrhosis
2) Alpha-1 antitrypsin deficiency
3) Autoimmune hepatitis
4) Hepatitis B
5) Wilson’s disease
Explanation
Wilson’s disease
Wilson’s disease is an autosomal-recessive disorder that results in the toxic accumulation of
copper in the liver and central nervous system (CNS) (in particular the basal ganglia). Children
often present with liver disease, and adults with CNS features. Kayser –Fleischer rings are copper
deposits in the iris (Descemet’s membrane) that are pathognomic but not invariable and may
require a slit-lamp to be seen. Blood tests would possibly reveal low ceruloplasmin and high
serum copper, along with abnormal LFTs. First -line treatment is with d-penicillamine, a copper
chelating drug, along with dietary advice on avoidance of copper -containing foods.
Alcoholic cirrhosis
Alcohol is a very common cause of deranged liver function tests, and can also present with
confusion and ataxia as part of Wernicke’s syndrome. However, this patient is very young to
have developed this already, especially without any mention of a significant alcohol history, and
alcohol does not cause Kayser–Fleischer rings (which are pathognomonic of Wilson’s disease).
Alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin deficiency is an autosomal-recessive condition that predispo ses affected
patients to cirrhosis and chronic obstructive pulmonary disease (COPD) (due to a predisposition
to develop emphysematous changes in the lungs), it does not have neurological affects.
Autoimmune hepatitis Autoimmune hepatitis can present as an acute hepatitis or a chronic hepatitis and eventually
leads to cirrhosis. It is associated with autoantibodies, including antinuclear antibody (ANA) and
smooth muscle autoantibodies, it is most common in women and in those aged 40 –50 years.
Additionally, it does not cause neurological disease.
Hepatitis B
Hepatitis B is a viral hepatitis, which in the UK is normally acquired as an adult through needle -
sharing or sexual intercourse. In endemic countries the vertical transmission route is relatively
much more important. In the majority (approx 95%) of those infected as adults it causes an acute
infection that may be symptomatic or may cause hepatitis, but is eventually cleared successfully.
The risk of chronic infection if infected perinatally at birth is ar ound 90%. Those with a chronic
infection can also develop cirrhosis (approx 20%) or reactivation of the disease periodically
(approx 25%). These scenarios could account this patient’s deranged LFTs, however, hepatitis B
does not usually cause neurological effects and in the absence of stated risk factors hepatitis B
infection is unlikely.
A 57-year-old businessman from Thailand
presents to his GP with symptoms of malaise, weight loss and right upper quadrant pain. On examination he is noted to have hepatomegaly, which is irregular.A
bruit is also heard over the liver. His blood tests show very raised a- fetoprotein (AFP) levels.
What is the most likely diagnosis?
1) Cholangiocarcinoma
2) Fibrosarcoma of the liver
3) Gallstones
4) Hepatocellular carcinoma (HCC)
5) Liver haemangioma
Explanation
Hepatocellular carcinoma (HCC)
HCC is the commonest malignant tumour of hepatocytes accounting for 90% of primary liver
cancers. World-wide it is most commonly caused by chronic hepatitis B, followed by hepatitis C
infection, and its incidence is highest in Asia (such as Thailand where this patient is from) and
sub-Saharan Africa. In Europe, hepatitis C infection is the most common cause, however any
cause of cirrhosis puts patients at increased risk of HCC – so alcoholism, autoimmune conditions
such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), and genetic
conditions such as haemochromatosis PBC are all common causes. Another important cause in
Asia and sub-Saharan Africa is aflatoxins – these are toxins produced by fungi that contaminate
foodstuff such as peanuts and grains. In the UK the incidence of HCC is around 4.3 per 100 000
(Cancer Research UK). It commonly presents on the background of cirrhosis and associated
signs, possibly presenting due to a deterioration in the patient’s chronic liver disease. Other
symptoms suggestive of HCC include right upper quadrant pain, weight loss, and new onset
ascites/jaundice. On examination they may be palpable as an irregular hepatomegaly and
sometimes a bruit may be heard over them. The a-fetoprotein levels are raised in 80% of patients.
Patients at high risk of HCC should be screened every 6 –12 months with ultrasound liver and
serum AFP – these patients include cirrhotic patients due to HBV/HCV, PBC, haemochromatosis
and alcoholism.
Cholangiocarcinoma
Cholangiocarcinoma most commonly presents with jaundice and deranged liver function tests,
possibly with abdominal pain, all due to obstruction of the biliary tree , often on a background of
weight loss. It can also present acutely with fever, jaundice and abdominal pain due to it
predisposing towards ascending cholangitis. It is a rare cancer, affecting 3.58 per 100 000
population in England (National Cancer Intelligence Network statistics for rare and less common
cancers). In addition, it would be unusual for this cancer to present with a palpable mass without
having caused obstruction and resultant jaundice.
Fibrosarcoma of the liver Fibrosarcomas are tumours arising from fibroblasts. They are most common in the limbs, but
even then are uncommon. The literature regarding these tumours affecting the liver is confined to
only a few case reports in which they tend to present as large masses. The most common type of
sarcoma affecting the liver is the angiosarcoma, which makes up around 0.3% of all liver cancers
(Cancer Research UK statistics).
Gallstones
Gallstones normally present in the context of biliary colic – sudden onset, colicky right upper
quadrant pain. Often associated with recent ingestion of large/fatty meals. They would not
explain the bruit, or the palpable irregular hepatomegaly, nor the raised AFP or weight loss.
Liver haemangioma
These are the most common benign liver tumour, mostly they are incidental findings on imaging
for other indications, if they do present clinically it is normally with a right upper quadrant
(RUQ) ‘fullness’ or pain – they would not, however, cause this patient’s weight loss or raised
AFP.
A sigmoidoscopy reveals an inflamed mucosa and a rectal biopsy shows an inflammatory infiltrate with goblet-cell depletion and crypt abscesses.
What is the most likely diagnosis?
1) Coeliac disease
2) Crohn’s disease
3) Irritable bowel syndrome
4) Ulcerative colitis
5) Whipple’s disease
Answer: 4) Ulcerative colitis
Explanation:
The sigmoidoscopy findings of inflamed mucosa and the rectal biopsy showing goblet-cell depletion, crypt abscesses, and inflammatory infiltrate are classic histological features of ulcerative colitis (UC). UC is characterized by:
- Continuous mucosal inflammation starting in the rectum and extending proximally.
- Crypt abscesses (neutrophils infiltrating crypts).
- Goblet-cell depletion due to chronic mucosal damage.
- No granulomas or transmural inflammation (which would suggest Crohn’s disease).
Exclusion of Other Options:
1. Coeliac disease: Affects the small intestine (villous atrophy), not the rectum.
2. Crohn’s disease: Typically causes transmural inflammation, skip lesions, and granulomas; rectal involvement is less common.
3. Irritable bowel syndrome (IBS): A functional disorder without structural or inflammatory changes on biopsy.
5. Whipple’s disease: Rare systemic infection with PAS-positive macrophages in the small intestine, not the rectum.
Conclusion: The clinical, endoscopic, and histological findings strongly support ulcerative colitis as the diagnosis.
A 17-year-old A-level student presents with diarrhoea, abdominal pain and weight loss. On examination, she is tender in the
right iliac fossa (RIF) and on further questioning she had a perianal abscess drained 1 year ago. A barium enema shows cobblestoning in the RIF. What is the most likely diagnosis?
1) Coeliac disease
2) Crohn’s disease
3) Irritable bowel syndrome
4) Whipple’s disease
5) Ulcerative colitis
Explanation
Crohn’s disease
Crohn’s disease is a form of inflammatory bowel disease that has several features in common with ulcerative colitis and commonly presents between 10 –40 years of age. However, it is characterised by transmural granulomatous inflammation and can affect any part of the gut. It is most commonly found in the terminal ileum (and therefore may produce discomfort in the RIF), but can affect anywhere from mouth to anus causing discontinuous skip lesions. Other features seen include diarrhoea and weight loss. Perianal disease is also common and may manifest as abscesses and fistulae. Barium enemas will classically show cobblestoning and ‘rose -thorn’ ulcers. A magnetic resonance imaging (MRI) scan can also be used to assess the extent of pelvic disease. Endoscopy may reveal deep ulceration and a cobblestone appearance, fissures, abscesses and stenosis are frequent findings. Histologically there may be an inflammatory infiltrate, non - caseating granulomas and transmural inflammation.
Coeliac disease
Coeliac disease is a condition that affects the small bowel – chronic inflammation results from autoimmune reaction to gluten, with serum findings of antiendomysial, antitissue transglutaminase and antigliadin antibodies. It results in diarrhoea, normally without blood, abdominal pain and bloating, and malabsorption. Endoscopic findings in the small bowel include villous atrophy, increased numbers of lymphocytes and crypt hyperplasia.
Irritable bowel syndrome
Irritable bowel syndrome (IBS) presents with long -term altered bowel function, such as diarrhoea or constipation or alternation between the two, often with abdominal pain or bloating. It is a functional condition, by definition with no discernible metabolic or mechanical cause – signs or symptoms such as bloody diarrhoea, anaemia, weight loss, and evidence of malabsorption all point firmly away from this diagnosis.
Whipple’s disease
Whipple’s disease is caused by infection with Tropheryma whipplei, commonly it presents with diarrhoea (steatorrhoea) and weight loss as a result of malabsorption. Joint pain and arthritis are also common, usually a migratory non-deforming arthritis. Less common but recognised features also include skin pigmentation, endocarditis, uveitis and CNS involvement. Diagnosis is made by endoscopy of the duodenum, and biopsy showing PAS -positive macrophages and non-acid- fast Gram-positive bacilli.
Ulcerative colitis
Ulcerative colitis commonly presents between the ages of 15 and 30 years. It is characterised by diarrhoea often with mucus and blood. There may be a crampy abdominal pain, and the frequency of motions may be related to the severity of an attack. It may affect only the rectum (proctitis in approximately 50%), or spread proximally to involve part or the rest of the colon.
Barium enema reveals button-shaped ulcers and pseudopolyps, thickened bowel-wall and haustra, filiform polyps and, in cases of chronic inflammation, a ‘lead pipe’ colon can occur (featureless colon with no normal haustral markings). Sigmoidoscopy shows an inflamed and friable mucosa from the rectum and a variable but continuous amount proximally. Histologically there may be an inflammatory infiltrate, goblet -cell depletion, glandular distortion, mucosal ulcers and crypt abscesses.
A 56-year-old man presents with episodes of severe epigastric pain radiating through to his back for several weeks. He also reports he has noticed his stools have tended to float more recently and are very difficult to flush away. On examination erythema is noted over the epigastrium.
What is the most likely diagnosis?
1) Acute pancreatitis
2) Biliary colic
3) Coeliac disease
4) Chronic pancreatitis
5) Pancreatic Cancer
Explanation
Chronic pancreatitis
Chronic pancreatitis presents most commonly either with chronic epigastric pain, or multiple
episodes of acute epigastric pain, often radiating into the back. The pain may be relieved by
sitting forwards and is often made worse by eating. Patients may also report nausea and
vomiting, bloating and pale/difficult to flush/malodourous stools (steatorrhoea) with weight loss.
The later symptoms are a result of pancreatic exocrine insufficiency resulting in malabsorption.
The patient may also have signs/symptoms of endocrine insufficiency resulting in high body
mass (BM), with polyuria and polydipsia. The commonest cause of chronic pancreatitis is
alcohol excess, while gallstones is another common cause. It can also idiopathic, due to trauma,
autoimmune disease, cystic fibrosis or other genetic disorders. There are a number of features of
this case to suggest it is chronic pancreatitis rather than acute – its prolonged history and the
patient has symptoms suggestive of steatorrhoea from exocrine insufficiency. The presence of
erythema ab igne also fits with a chronic picture. This is a ‘rash’ consisting of reticular erythema
and hyperpigmentation most often caused by chronic use of a hot water bottle to relieve pain and
is often seen in the epigastrium or on the back.
Acute pancreatitis
Acute pancreatitis classically presents with sudden onset of severe epigastric pain radiating
through to the back, better on sitting forwards. Commonly patients will be nauseous and
vomiting, and have evidence of localised peritonitis (such as rebound tenderness and guarding in
the epigastrium). The most common causes are gallstones and excessive alcohol, other causes
can be remembered by the mnemonic below. While the description of the pain suffered by the
patient is certainly fitting with pancreatitis, there are several features that point towards chronic
rather than acute pancreatitis – including the multiple episodes over several weeks, and the
evidence of exocrine insufficiency causing steatorrhoea.
Biliary colic This normally presents with sudden onset, colicky right upper quadrant pain. Often associated
with recent ingestion of large/fatty meals. The site of the pain in this patient does not fit with this
description, and biliary colic would not explain his stools.
Coeliac disease
Coeliac disease is a condition that affects the small bowel – chronic inflammation results from
autoimmune reaction to gluten, with serum findings of anti-endomysial, anti-tissue
transglutaminase and anti-gliadin antibodies. It results in diarrhoea (normally without blood),
abdominal pain, bloating, weight loss, fatigue and mouth ulcers. In addition commonly
malabsorption is present which may manifest as iron-deficiency anaemia or vitamin B12 /folate
deficiency with macrocytic anaemia, or steatorrhoea (as in this patient). The severe pain,
radiating into the patient’s back and in multiple distinct episodes does not fit with coeliac disease
which tends to present with a milder colicky abdominal pain, or indigestion-type pain.
Pancreatic Cancer
Pancreatic cancer classically presents insidiously with painless jaundice. These cancers tend to
be cancers of the head of the pancreas as it is through this portion of the pancreas that the
common bile duct (CBD) traverses. Other symptoms of pancreat ic cancer (of any anatomical
position) are general malaise, poor appetite, significant weight loss, and epigastric abdominal
pain or lower thoracic back pain. Multiple severe episodes of epigastric pain without a history of
weight loss/malaise do not fit well with pancreatic cancer.
A 22-year-old woman presents to her GP with a history of vague abdominal pain and bloating.
On further questioning she reports weight loss and passing offensive stools which are
difficult to flush away. As part of her investigations a jejunal biopsy is performed. This shows crypt hyperplasia and subtotal
villous atrophy. What is the most likely diagnosis?
1) Bacterial overgrowth
2) Coeliac disease
3) Crohn’s disease
4) Ulcerative colitis
5) Tropical malabsorption
The most likely diagnosis for a 22-year-old woman with vague abdominal pain, bloating, weight loss, offensive stools that are difficult to flush (steatorrhea), and jejunal biopsy findings of crypt hyperplasia and subtotal villous atrophy is 2) Coeliac disease.
-
Clinical features:
- Weight loss, abdominal pain, bloating, and steatorrhea are classic symptoms of malabsorption.
- Offensive stools that are difficult to flush suggest fat malabsorption, which is common in coeliac disease due to damage to the small intestinal mucosa.
-
Jejunal biopsy findings:
- Crypt hyperplasia and subtotal villous atrophy are hallmark histological features of coeliac disease. These changes occur due to an immune-mediated reaction to gluten, leading to inflammation and flattening of the villi, which impairs nutrient absorption.
- Bacterial overgrowth: This can cause malabsorption and bloating but does not typically cause subtotal villous atrophy or crypt hyperplasia.
- Crohn’s disease: While Crohn’s disease can cause malabsorption and weight loss, it is more commonly associated with patchy inflammation, ulceration, and granulomas, not subtotal villous atrophy.
- Ulcerative colitis: This primarily affects the colon and does not cause small intestinal villous atrophy.
- Tropical malabsorption: This can cause villous atrophy but is more common in tropical regions and is associated with infectious causes (e.g., tropical sprue). Coeliac disease is more likely in this case given the clinical context.
The combination of symptoms, steatorrhea, and jejunal biopsy findings strongly points to coeliac disease as the most likely diagnosis. Confirmation can be made with serological testing (e.g., anti-tissue transglutaminase antibodies) and response to a gluten-free diet.
A 45-year-old woman is referred to an upper gastrointestinal (GI) clinic with a history of
dysphagia over the last month. She feels it has developed gradually and she is now struggling to swallow food. Her only past medical history of note is Raynaud’s phenomenon, and on examination it is noted she has radial furrowing of the lips and her fingers are tapered. She has no history of weight loss, change in bowel habit or family history of note.
What is the most likely diagnosis?
1) Achalasia
2) Myasthenia gravis
3) Oesophageal carcinoma
4) Scleroderma
5) Syringobulbia
The most likely diagnosis for this 45-year-old woman with dysphagia, Raynaud’s phenomenon, radial furrowing of the lips, and tapered fingers is 4) Scleroderma (specifically, systemic sclerosis).
-
Key Features:
- Dysphagia: A common symptom in systemic sclerosis due to esophageal involvement, where fibrosis and smooth muscle atrophy impair esophageal motility.
- Raynaud’s phenomenon: A hallmark of systemic sclerosis, caused by vascular dysfunction.
- Radial furrowing of the lips and tapered fingers: These are classic physical findings in systemic sclerosis, reflecting skin thickening and fibrosis.
-
Why Not Other Options:
- 1) Achalasia: Causes dysphagia but is not associated with Raynaud’s phenomenon or skin changes.
- 2) Myasthenia gravis: Can cause dysphagia due to muscle weakness but is not associated with Raynaud’s phenomenon or skin changes.
- 3) Oesophageal carcinoma: Typically presents with progressive dysphagia and weight loss, but there is no association with Raynaud’s phenomenon or skin changes.
- 5) Syringobulbia: A rare condition affecting the brainstem, which can cause dysphagia but is not associated with Raynaud’s phenomenon or skin changes.
The combination of dysphagia, Raynaud’s phenomenon, and characteristic skin changes (radial furrowing of the lips and tapered fingers) strongly suggests systemic sclerosis (scleroderma). Further evaluation, such as esophageal manometry or serological testing (e.g., anti-centromere or anti-Scl-70 antibodies), can confirm the diagnosis.
A 44-year-old woman is being investigated for intermittent right upper quadrant pain that occurs mostly after an incidental
eating. An ultrasound scan shows gallstones within the gall bladder and finding of a liver lesion, which presents as an echogenic spot. Further imaging with a contrast-enhanced computed tomography (CT) scan demonstrated distinctive puddling of
contrast in venous channels. It is thought the patient has a benign liver tumour.
Which one of the following is the commonest benign tumour of the liver?
1) Cholangiocarcinoma 2) Haemangioma
3) Haemangiosarcoma
4) Hepatocellular carcinoma
5) Hepatic adenoma
Explanation
Haemangioma
Haemangiomas are the commonest benign tumour of the liver and mostly remain asymptomatic.
If they are very large (>5 cm) there is a risk of abdominal pain and rupture with intra -abdominal
haemorrhage. Single-photon emission CT scan (SPECT) with 99 Tc m -labelled red blood cells will
demonstrate persistence of blood activity in the lesion.
Cholangiocarcinoma
Cholangiocarcinoma is a malignant lesion of the biliary tree, whereas this case describes the
lesion within the liver parenchyma.
Haemangiosarcoma
Haemangiosarcoma is a rare malignant lesion of the liver, more commonly seen in dogs than
humans.
Hepatocellular carcinoma
Hepatocellular carcinoma is a malignant lesion of the liver. It is the most common form of liver
cancer, has a strong association with chronic liver disease, and are often multifocal at diagnosis
so prognosis is guarded.
Hepatic adenoma
Hepatic adenomas are rare benign lesions of the liver and typically present in younger women,
often on the background of elevated levels of oestrogen for example from the combined oral
contraceptive pill.
A 78-year-old man presents to his GP with a strange feeling of food getting stuck when he
swallows. This has been present for around 3 months and initially was only noticed when eating solid foods such as bread or meat, but
now he has problems swallowing liquids. He also reports significant unintended weight loss.
Which one of the following is the most likely cause?
1) Achalasia
2) Barrett’s oesophagus
3) Hiatus hernia 4) Oesophageal carcinoma
5) Pharyngeal pouch
Explanation
Oesophageal carcinoma
Presenting features of oesophageal carcinoma are classically progressive dysphagia (initially
solids and then liquids), associated with significant weight loss. Retrosternal chest discomfort
may occur. The most common forms of oesophageal cancer are squamous and adenocarcinoma.
Adenocarcinoma now exceeds squamous carcinoma by a ratio of 2:1. The ratio was previously in
the reverse direction.
Achalasia
Achalasia is a motility disorder of the oesophagus in which relaxation of the lower oesophageal
sphincter fails preventing passage of food into the stomach. It presents with progressive
dysphagia and regurgitation of undigested food
Barrett’s oesophagus
Adenocarcinoma is predisposed to by a metaplastic change in the oesophageal mucosa from
squamous to columnar epithelium by chronic reflux (Barrett’s oesophagu s). However, in this
case there is no history of reflux disease.
Hiatus hernia
A hiatus hernia is likely to result in reflux symptoms and retrosternal pain, it would not cause
dysphagia and weight loss.
Pharyngeal pouch
A pharyngeal pouch is a diverticulum through Killian’s dehiscence. It presents with halitosis,
dysphagia and regurgitation. It is common in elderly men, however significant weight loss would
not necessarily be expected as described in the case above.
A 41-year-old woman is urgently re ferred because of
dysphagia
. On assessment you note the
patient is wearing gloves because she gets very
painful hands in the cold
. She describes a colour
change going from
white to blue to bright red. It is also noted she has very
tight skin around her
lips
and she reports limited mouth opening.
What disease process is likely to be present?
1) Achalasia
2) Diffuse oesophageal spasm 3) Myasthenia gravis
4) Oesophageal carcinoma
5) Scleroderma
Explanation
Scleroderma
The colour change describes the classic pattern in Raynaud’s syndrome. This may be idiopathic,
or associated with connective tissue disorders, vascular obstructive disorders or occupation. In
this case, the patient has scleroderma. Calcinosis cutis, Raynaud’s phenomenon, oesophophageal
dysfunction, sclerodactyly and telangiectasia syndrome (CREST) syndrome is a form of
scleroderma. Its five main features are associated with anticentromere antibodies.
Achalasia
Achalasia is a motility disorder of the oesophagus in which relaxation of the lower oesophageal
sphincter fails, preventing passage of food into the stomach. It presents with progressive
dysphagia and regurgitation of undigested food.
Diffuse oesophageal spasm
Diffuse oesophageal spasm causes intermittent chest pain upon eating food as the oesophagu s
spasms against a food bolus. It can be very painful but would not cause true dysphagia or lip
changes.
Myasthenia gravis
Myasthenia gravis is an autoimmune condition due to antibodies against the acetylcholine
receptors of the neuromuscular junction. It results in progressive muscle fatigue. There is no
association with Raynaud’s phenomenon and lip changes.
Oesophageal carcinoma
Oesophageal carcinoma classically presents with progressive dysphagia (initially solids and then
liquids). This is often associated with significant weight loss. Retrosternal chest discomfort may
also occur. The key features in this history to differentiate are skin colour changes and lip
changes.
A 57-year-old man presents to his GP with vague symptoms of a
bdominal pain and weight loss
.
On examination his abdomen is soft, but an
irregular hepatomegaly
is noted and on further
assessment a
hard
lymph node is palpable in the
left supraclavicular fossa
.
What is the most likely cause?
1) Duodenal ulcer
2) Gallstones
3) Gastric cancer
4) Gastro-oesophageal reflux disease (GORD)
5) Gastric ulcer
Gastric cancer
Gastric cancer often starts with very non-specific symptoms – anorexia, weight loss, features of
dyspepsia. Tumours of the antrum can cause gastric outlet obstruction and present with fullness,
nausea and vomiting. Features found on examination can include signs of metastases – ascites,
irregular hepatomegaly and Virchow’s node (a hard lymph node in the left supraclavicular
fossa).
Duodenal ulcer
While a duodenal ulcer may present with vague abdominal pain, there is unlikely to be
significant weight loss and irregular hepatomegaly would not be seen.
Gallstones
Gallstones will result in right upper quadrant abdominal pain that is wor se when consuming fatty
meals. Virchow’s node is indicative of an intra-abdominal malignancy.
Gastro-oesophageal reflux disease (GORD)
GORD would not present with weight loss or irregular hepatomegaly. It is a common condition
resulting in indigestion that is worse after food and upon lying down.
Gastric ulcer
An ulcer would not cause irregular hepatomegaly or significant weight loss.
A 17-year-old man with known mental health problems is admitted to a burns unit after self-immolation. On arrival his burns were
mostly full thickness and the surface area was 34%. He is moved to the Burns Intensive Care Unit (ICU) and is intubated and ventilated and requiring inotropic support. Six days later he develops an episode of
haematemesis.
What is likely to be the cause?
1) Curling’s ulcer
2) Cushing’s ulcer
3) Oesophageal burns
4) Mallory-Weiss tear
5) Zollinger-Ellison syndrome
The most likely cause of haematemesis in this 17-year-old man with extensive burns is 1) Curling’s ulcer.
-
Curling’s Ulcer:
- This is a stress ulcer that occurs in patients with severe burns, typically involving >30% of total body surface area.
- It is caused by hypovolaemic shock, reduced splanchnic blood flow, and increased gastric acid secretion following major burns.
- It usually presents 5–14 days after the burn injury, which aligns with the timeline in this case (6 days post-burn).
-
Why Not Other Options:
- 2) Cushing’s ulcer: This is a stress ulcer associated with head injury or raised intracranial pressure, not burns.
- 3) Oesophageal burns: These would present immediately after the injury, not 6 days later.
- 4) Mallory-Weiss tear: This is caused by forceful vomiting and retching, often in the context of alcohol abuse or bulimia, and is not specifically related to burns.
- 5) Zollinger-Ellison syndrome: This is a rare condition caused by a gastrin-secreting tumor, leading to severe peptic ulcer disease, but it is not associated with burns.
The development of haematemesis 6 days after extensive burns is most consistent with Curling’s ulcer. Management includes proton pump inhibitors (PPIs), endoscopic evaluation, and treatment of the underlying burn injury.
.
A 58-year-old man is referred to a dermatologist by his GP due to careful inspection it is noted he has a pigmented, rough thickening skin changes in his axillae. On of his skin in his axillae, with warty lesions.
What other important conditions must be considered in the case?
1) Rheumatoid arthritis
2) Coeliac disease
3) Crohn’s disease
4) Gastrointestinal cancer
5) Chronic pancreatitis
Explanation Gastrointestinal cancer
The skin changes described in this case is acanthosis nigricans and is associated with
gastrointestinal (eg stomach) cancer.
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune condition resulting in inflammation of the synovium
causing joint pain and swelling. Cutaneous manifestations include palmar erythema, skin
atrophy, and brittle nails.
Coeliac disease
Coeliac disease is associated with dermatitis herpetiformis in which itchy blisters develop over
the knees, elbows and scalp.
Crohn’s disease
Crohn’s disease is associated with several skin changes including pyoderma gangrenosum and
erythema nodosum.
Chronic pancreatitis
Cutaneous manifestations of chronic pancreatitis are uncommon and often examination is
unremarkable except for vague abdominal pain.
A 29-year-old woman with a body mass index (BMI) of more than 40 kg/m 2 undergoes a gastric bypass procedure. She rapidly begins to lose weight after the procedure.
Which one of the following is the most appropriate statement regarding this procedure?
1) Perioperative mortality associated with bariatric surgery is 3% and is an important
consideration that should be discussed with the patient before surgery
2) An adjustable gastric band forms an integral part of the procedure
3) Iron and vitamin B 12 deficiency are common
4) Jejuno-ileal bypass with cholecystectomy is the pref erred option
5) Weight loss from a biliopancreatic diversion with duodenal switch is less effective than
biliopancreatic diversion alone
Explanation Iron and vitamin B 12 deficiency are common Surgery for morbid obesity is considered in individuals who have a body mass index (BMI) more than 40 kg/m 2 . Obesity surgery for patients with a body mass index (BMI) between 35 –39 kg/m 2 may be justified if they have a co -morbid condition that will be improved by weight loss.
The decision to operate must be made within a dedicated multidisciplinary team comprising a bariatric surgeon, dietician, physician, anaesthetist, radiologist and clinical nurse specialist. the conditions that can be improved by weight loss include type II diabetes mellitus, hypertension and dyslipidaemia (the metabolic syndrome). Others include obstructive sleep apnoea, decreased mobility, osteoarthritis and hypertrophic cardiomyopathy and poor quality of life. Importantly, it must be remembered that gastric bypass surgery can result in iron and vitam in B 12 deficiencies.
Perioperative mortality associated with bariatric surgery is 3% and is an important consideration that should be discussed with the patient before surgery
Perioperative mortality for bariatric surgery is reported as less than 0.3% and is declining due to improved management in specialist bariatric centres with multidisciplinary care. Complications of surgery should always be discussed with the patient; in bariatric surgery patient expectations around weight loss following surgery can be unrealistic and must be managed.
An adjustable gastric band forms an integral part of the procedure
The surgery can be broadly classified into restrictive and malabsorptive. The former consists of
gastric banding or vertical banded gastroplasty which reduces the size of the stomach. The latter
is achieved by bypass procedures to alter the digestive tract so that less absorption occurs. Most
procedures are a combination of the two techniques.
Jejuno-ileal bypass with cholecystectomy is the preferred option
Jejuno-ileal bypass has fallen from favour as it has been associated with serious complications.
Weight loss from a biliopancreatic diversion with duodenal switch is less effective than
biliopancreatic diversion alone
A combined surgical approach of biliop ancreatic diversion with duodenal switch is associated
with greater weight loss.
A 51-year-old man presents with an upper gastrointestinal (GI) bleed. His systolic blood pressure is 118 mmHg and blood results show an haemoglobin (Hb) of 11 g/dl (normal 10.5 –13.5 g/dl).
Endoscopy reveals a duodenal ulcer with a
visible bleeding vessel which is successfully clipped and injected with adrenaline.
Which is the most significant factor in predicting re-bleeding in this case?
1) Age
2) Blood pressure
3) Ulcer size
4) Urea
5) Visible bleeding vessel at the time of endoscopy
bleeding. The Blatchford score, which has been shown to predict the risk of requiring
intervention (transfusion, endoscopic or surgical therapy) and the Rockall score, which predicts
the risk of re-bleeding and death. Below is a table showing the Rockall score. The scores are
summed, the higher the score the higher the risk of re-bleeding and the higher the risk of
mortality.
Admission scores
0 points
1 points
2 points
3 points
Age
<60
60–79
80+
–
Shock
SBP >100, pulse <100
SBP >100, pulse >100
SBP <100, pulse >100
–
Comorbidities
None
None
CCF, IHD or other major comorbidity
Renal or liver failure, disseminated malignancy
Postendoscopy
0 points
1 points
2 points
3 points
Diagnosis
Mallory–Weiss tear, no lesion
All other diagnoses
Malignancy of upper GI tract
–
Major stigmata
None or dark spot only
–
Blood, adherent clot, visible or bleeding vessel
–
As you can see from the scoring system – the most important factors in predicting re-bleeding
are: the presence of significant endoscopic stigmata of recent haemorrhage with a visible
bleeding vessel, haemodynamic instability or shock, malignancy of the up per GI tract, age over
60 years and certain comorbidities. The Blatchford score also includes systolic blood pressure
and pulse, hepatic disease and cardiac failure, and additionally includes admission haemoglobin,
urea, melaena, syncope.
Age
Age of 60 years or above does predict re-bleeding risk, however, this patient is <60 years old.
Blood pressure
This patient’s blood pressure is within the normal range – while a low blood pressure does
predict increased re-bleeding risk, a normal blood pressure does not. Ulcer size
Ulcer size does not influence re-bleeding risk according to the major guidelines and scoring
systems.
Urea
This option is part of the Blatchford scoring system that predicts the need for intervention, but
has not been shown to predict re-bleeding risk, we do not know this patient’s urea levels so
cannot comment any further on it.
A 48-year-old obese woman presents with right upper quadrant (RUQ) pain and nausea, she reports similar episodes in the past that have resolved spontaneously. On examination she is afebrile and has a soft abdomen which is tender in the RUQ and a plain X -ray shows radio-opaque round opacities in the RUQ. These are thought to represent gallstones.
What proportion of gallstones can be seen on a plain abdominal X-ray?
1) <1%
2) 15%
3) 30%
4) 50%
5) >75%
Explanation
15%
Around 10–15% of gallstones can be seen on plain imaging due to calcification of the stones.
These often appear as rings due to calcium deposition around a central organic core. In some
cases the gall-bladder may be calcified (‘porcelain gall-bladder’) and therefore visible. Porcelain
gall-bladder is a type of chronic cholecystitis, its presence increases the risk of developing gall-
bladder cancer and cholecystectomy is the usual treatment. The most common imaging modality
used to detect gallstones is abdominal ultrasound – this has a much higher sensitivity of 85%,
and specificity up to 100%.
<1%
The correct answer is 10–15%. 30%
Gallstones are not usually visualised with abdominal X-ray (AXR).
50%
As above, however renal stones tend to be more radio -opaque.
> 75%
This is an incorrect response.
A 41-year-old man is referred from his GP with a long history of epigastric pain
which is relieved by eating. He is otherwise well, and drinks alcohol only occasionally. The only other feature of note is a long-standing history of diarrhoea, which has not responded to several changes in diet. An oesophago-gastroduodenoscopy (OGD) reveals multiple small duodenal ulcers.
What is the most likely diagnosis?
1) Curling’s ulcer
2) Cushing’s ulcer
3) Duodenal carcinoma
4) VIPoma
5) Zollinger-Ellison syndrome
Explanation
Zollinger-Ellison syndrome
Zollinger–Ellison syndrome is the constellation of multiple, usually severe, peptic ulcers
affecting the stomach and duodenum associated with a gastrinoma (a tumour of gastrin-secreting
‘G’ cells, usually in the pancreas but can also be in the stomach or duodenum). Excess gastrin
promotes excess gastric acid secretion – this acid leads to peptic ulceration, and diarrhoea is a
common symptom too. Patients complain of epigastric pain due to peptic ulceration which may
be better with food. Around one-third of patients have MEN-1syndrome.
Curling’s ulcer
A Curling’s ulcer is a stress ulcer within the stomach or duodenum that occurs acutely in
association with severe skin burns. They are usually multiple and shallow. Cushing’s ulcer
A Cushing’s ulcer is an ulcer within the stomach or duodenum associated with raised intracranial
pressure – raised intracranial pressure classically presents with headaches that are worse in the
morning and on lying down, associated with nausea and blurred vision.
Duodenal carcinoma
Duodenal carcinoma is uncommon [only 0.3% of gastrointestinal (GI) malignancies], it is
usually an adenocarcinoma and could present as an ulcerated lesion, commonly it presents with
abdominal pain, as well as weight loss, nausea and vomiting, or with bleeding. It is unlikely to
present as multiple small erosions as described here though, and most commonly presents in the
sixth decade of life.
VIPoma
This is a rare type of cancer of the pancreatic islets that results in secretion of vasoactive
intestinal peptide (VIP). It primarily presents with watery diarrhoea, that can result in
hypokalaemia and dehydration. It is sometimes associated with multiple endocrine neoplasia
type 1 (MEN1).
A 57-year-old man with known alcoholic liver disease, presents with confusion and is generally unwell. On examination he is noted to have a distended abdomen with shifting dullness. Imaging later confirms a mass in his liver that is thought to be malignant in origin.
What is the most likely nature of this mass?
1) Cholangiocarcinoma
2) Fibrolamellar carcinoma
3) Haemangioma
4) Hepatic angiosarcoma
5) Hepatocellular carcinoma (HCC)
Explanation
Hepatocellular carcinoma (HCC)
HCC is the commonest malignant tumour of hepatocytes accounting for 90% of primary liver
cancers. It usually occurs on a background of cirrhosis, world-wide it is most commonly caused
by chronic hepatitis B, followed by hepatitis C infection, and its incidence is highest in Asia and
sub-Saharan Africa. In Europe, hepatitis C infection is the most common cause, however, any
cause of cirrhosis puts patients at increased risk of HCC – so alcoholism, autoimmune conditions
such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), and genetic
conditions such as haemochromatosis are all common causes. Another important cause in Asia
and sub-Saharan Africa is Aflatoxins – these are toxins produced by fungi contaminating
foodstuff such as peanuts and grains. In the UK the incidence of HCC is around 4.3 per 100 000
(Cancer Research UK). It commonly presents on the background of cirrhosis and associated
signs, possibly presenting due to a deterioration in the patient’s chronic liver disease, for
example with encephalopathy, ascites and reduced synthetic function. Other symptoms
suggestive of HCC include right upper quadrant pain, weight lo ss, and new onset
ascites/jaundice. On examination they may be palpable as an irregular hepatomegaly and
sometimes a bruit may be heard over them. The a-fetoprotein levels are raised in 80% of patients.
Increasingly patients are also detected on screening in the UK. Patients at high risk of HCC should be screened every 6–12 months with ultrasound liver and serum AFP – these patients
include cirrhotic patients due to HBV/HCV, PBC, haemochromatosis and alcoholism (see BSG
Guidelines for more information).
Cholangiocarcinoma
Cholangiocarcinoma most commonly presents with jaundice and deranged liver function tests,
possibly with abdominal pain, all due to obstruction of the biliary tree, often on a background of
weight loss. It can also present acutely with fever, jaundice and abdominal pain due to it
predisposing towards ascending cholangitis. It is a rare cancer, affecting 3.58 per 100 000
population in England (National Cancer Intelligence Network statistics for rare and less common
cancers).
Fibrolamellar carcinoma
Fibrolamellar carcinoma is a rare variant of HCC, around 1:5 million population incidence,
affecting children and young adults without a history of background liver disease. Risk factors
remain poorly understood.
Haemangioma
These are the most common benign liver tumour, mostly they are incidental findings on imaging
for other indications, if they do present clinically it is normally with a RUQ ‘fullness’ or pain –
they would not, however, cause this patient’s signs of decompensated liver disease.
Hepatic angiosarcoma
This cancer makes up around 2% of primary liver cancers, originating from endothelial cells
within the liver. It usually presents with a mass and general signs such as weight loss and
malaise. It can also present with rupture and bleed ing. Risk factors include environmental toxins,
such as vinyl chloride or arsenic.
A 56-year-old woman attends her general practitioner seeking advice on a heavy dependence on alcohol. She is currently low of mood, unemployed and complains of upper abdominal pain, nausea, vomiting and retching.
Which one of the following symptoms are associated with chronic alcohol abuse?
1) Hightened libido
2) Menstrual disturbance
3) Microcytosis
4) Primary thrombocythemia
5) Sydenham’s chorea
The correct symptom associated with chronic alcohol abuse in this scenario is:
2) Menstrual disturbance
Chronic alcohol abuse can lead to a wide range of physical, psychological, and hormonal disturbances. Among the options provided:
- Menstrual disturbance: Chronic alcohol use can disrupt the hypothalamic-pituitary-gonadal axis, leading to hormonal imbalances. This can result in irregular menstrual cycles, amenorrhea (absence of menstruation), or other menstrual disturbances.
-
Other symptoms of chronic alcohol abuse (not listed in the options but relevant to the case):
- Upper abdominal pain: Often due to alcoholic hepatitis, pancreatitis, or gastritis.
- Nausea, vomiting, and retching: Common in alcohol withdrawal or due to gastritis.
- Low mood: Alcohol is a depressant and can exacerbate or cause depression.
- Liver damage: Leading to jaundice, ascites, or coagulopathy.
- Neuropathy: Peripheral nerve damage due to alcohol toxicity or vitamin deficiencies.
- Macrocytosis: Enlarged red blood cells due to folate or vitamin B12 deficiency (not microcytosis).
- Heightened libido: Chronic alcohol abuse is more likely to reduce libido due to hormonal imbalances and general health decline.
- Microcytosis: This is typically associated with iron deficiency anemia, not chronic alcohol abuse. Alcohol abuse is more likely to cause macrocytosis due to folate or vitamin B12 deficiency.
- Primary thrombocythemia: This is a myeloproliferative disorder unrelated to alcohol abuse.
- Sydenham’s chorea: This is a neurological disorder associated with rheumatic fever, not alcohol abuse.
The symptom most directly associated with chronic alcohol abuse in this list is menstrual disturbance.
A 78-year-old woman is taken to the Accident and Emergency department by her family
with
severe abdominal pain
and
fevers. On examination she appears unwell and is spiking
temperatures. You note she is
icteric
and on palpation is most
tender in the right upper
quadrant
(RUQ).
What is the most likely disease process in this patient?
1) Biliary colic
2) Cholangitis
3) Cholecystitis
4) Gallstone ileus
5) Renal colic
Explanation
Cholangitis
Ascending cholangitis is a medical emergency that can be recognised by Charcot’s triad of fever,
right upper quadrant abdominal pain and jaundice. It is caused commonly by biliary obstruction
that promotes biliary stasis and allows for infection to ascend from the duodenum. The
commonest risk factor is a gallstone but other causes include pancreatic head cancer or
cholangiocarcinoma, strictures, stents or recent endoscopic retrograde cholangiopancreatography
(ERCP). Patients can become very unwell with cholangitis and develop sepsis and subsequent
septic shock. Treatment involves intravenous (IV) antibiotics, fluid resuscitation and an ERCP to
relieve the biliary obstruction.
Biliary colic
This normally presents with sudden onset, colicky right upper quadrant pain. Often associated
with recent ingestion of large/fatty meals. It is unusual for jaundice to develop unless
a gallstone has entered to common bile duct, or occasionally a gallstone within the neck of the
gall-bladder or Hartmann’s pouch can compress the CBD and cause an obstructive jaundice
(known as Mirizzi’s syndrome). Additionally, patients are not usually tender in the RUQ
(although this is where the pain is lo cated) and they should not be febrile. Cholecystitis
Cholecystitis normally presents with constant right upper quadrant pain and fever, classically the
patient is Murphy’s positive where deep inspiration while palpating the RUQ results in the
patient ‘catching their breath’ as the inflamed gall-bladder is lowered onto the palpating hand.
Jaundice is uncommon unless a stone within the neck of the gall-bladder or Hartmann’s pouch is
compressing the common bile duct (CBD), which can cause an obstructive jaund ice (known as
Mirizzi’s syndrome), additionally the localised inflammation and swelling around the gall -
bladder can result in compression of the CBD and therefore an obstructive jaundice. Because
jaundice is unusual this is not the most likely cause of this presentation.
Gallstone ileus
Gallstone ileus occurs when a gallstone enters to small bowel, usually through a fistula
connecting the gall-bladder and small intestine. It can then cause a mechanical small bowel
obstruction. It does not cause jaundice or fevers, tenderness would not be localised to the RUQ.
Renal colic
Renal colic is caused by renal stones within the urinary tract – it presents with severe colicky
loin-to-groin pain, normally with blood on urine dipstick. Fevers do not occur except in
superadded infection. The patient may be tender in the renal angle, but should not be tender in
the RUQ. This certainly would not cause jaundice.
A 27-year-old woman presents with severe
pain during defecation. She also reports a small amount of blood on the toilet paper following defecation. Her only past medical history is constipation, which has become worse because of the pain.
What is the most likely diagnosis?
1) Anal fissure
2) Anal fistula
3) Haemorrhoids
4) Perianal abscess
5) Pilonidal sinus
Explanation
Anal fissure
The history in the case is quite classical for an anal fissure where pain is the dominant symptom.
Normally there is severe sharp anal pain on passing stool, with a burning pain afterwards. A
small amount of blood on wiping may then occur, though is not always present. Examination
should reveal an anal fissure, and exclude the other causes mentioned here. Common risk factors
are constipation and hard stools, and Crohn’s disease.
Anal fistula
An anal fistula is a connection between the anal canal and the perianal skin. Most commonly
they result secondary to perianal abscesses, though they can also be secondary to Crohn’s
disease, trauma, or cancer, among other causes. They can present with pain, itching, loc alised
swelling, or discharge of pus. The absence of preceding history, and the predominance of pain at
defecation makes anal fistula less likely diagnosis.
Haemorrhoids
These may be asymptomatic, or present with itching/irritation, bright painless bleedi ng per
rectum (PR), or a feeling of ‘fullness’. Pain is not common unless the haemorrhoids are
strangulated or thrombosed, in which case the pain will be severe and constant (not just when
passing stool).
Perianal abscess Perianal abscess presents normally with perianal pain and swelling, it may be worse when
passing stool but will normally be present at other times too. Bleeding is not a common
symptom. They are not related to constipation.
Pilonidal sinus
Pilonidal sinuses are normally present in the nat al cleft – they can be asymptomatic, or present as
a small non-tender pit or lump. They may also present as a painful and tender lump, possibly
with purulent discharge as an acute pilonidal abscess. Symptoms are not usually related to
passing stool, and bleeding is not a common symptom, the major risk factors include hirsutism
and poor personal hygiene.
A 35-year-old man presents after being referred from the GP with a painful, discharging swelling around his anus. He has had a similar problem twice in tender, erythematous swelling is noted in the natal cleft the past and on examination a very, but separate from the anal verge.
What is the most likely diagnosis?
1) Ischiorectal abscess
2) Hidradenitis suppurativa
3) Perianal abscess
4) Pilonidal abscess
5) Supralevator abscess
Explanation
Pilonidal abscess
The commonest site for pilonidal abscesses is the natal cleft and there may be a history of
recurrent episodes over months or years. Pilonidal means ‘hair’s nest’ in Latin and theories
regarding its aetiology involve shed hairs getting trapped in pits and becoming a nidus for local
infection. Clinically there may be openings in the midline or either side of it sometimes with
tufts of hair. There may be inflammation of the adjacent skin and pus may be expressed via the
openings. Management involves incision and drainage of the abscess and then other procedures
can be done electively to try and prevent recurrence. Antibiotics are indicated if systemic signs
of infection, or evidence of surrounding cellulitis is present.
Ischiorectal abscess
The ischiorectal (or ischioanal) fossae are prism-shaped fascia-lined potential spaces adjacent to
the rectum. They are bordered by the levator ani muscle (superiorly and medially), the anal canal
(medially), the perineal skin (inferiorly), and the ischial tuberosity (later ally). Ischiorectal
abscesses are the second most common type of anorectal sepsis (30% of anorectal abscesses),
after perianal abscess. Like other anorectal abscesses the pain is predominantly perianal, and
often worse just before/during bowel movements – the anatomical description of this patient’s
abscess does not fit with this diagnosis.
Hidradenitis suppurativa
This is a long-term condition with multiple abscesses caused by infections within sweat glands,
they are most commonly found under the arm pits, around the buttocks and groin. As well as
normally having multiple lesions, the chronicity of the condition normally means that there is
evidence of old abscesses, such as scarring of the skin. This is unlikely because of the single
lesion this patient suffers from. Perianal abscess
Perianal abscesses are the commonest form of anorectal abscess (60% of total – and present
normally with perianal pain and swelling), it may be worse when passing stool but will normally
be present at other times too. They are frequently recurrent, as in this patient, but the description
of its location fits better with pilonidal abscess.
Supralevator abscess
This describes an abscess that forms from an upward extension of an intersphincteric abscess
into the supralevator space. They may also form from an intra-abdominal inflammation (eg
appendicitis) tracking down. They are very uncommon making up only 4% on anorectal
abscesses. Like other anorectal abscesses the pain is predominantly perianal, and often worse just
before/during bowel movements – as well as being a very uncommon diagnosis, the anatomical
description of this patient’s abscess does not fit with this diagnosis.
An 18-year-old woman presents with intermittent abdominal pain and discomfort that is cramping in nature with a feeling of associated bloating. The discomfort is often relieved through opening her bowels, and she also reports intermittent episodes of diarrhoea, she denies any weight loss, rectal bleeding or mucous. A colonoscopy is
unremarkable. Blood tests reveal normal
full blood count (FBC), urea and electrolytes (U&Es) and C-reactive protein (CRP)/erythrocyte sedimentation rate (ESR).
What is the most likely cause of her symptoms?
1) Coeliac disease
2) Crohn’s disease
3) Irritable bowel syndrome
4) Hiatus hernia
5) Ulcerative colitis
Explanation
Irritable bowel syndrome
Irritable bowel syndrome (IBS) is one of the commonest causes of abdominal pain and is a
functional disorder with no discernible metabolic or mec hanical cause resulting in a mixture of
pain, discomfort, bloating and altered bowel habit. It does not cause per rectum (PR) bleeding or
mucus, or weight loss and these symptoms are suggestive of organic pathology and should be
investigated appropriately and not attributed to IBS. National Institute of Clinical Excellence
(NICE) recommend FBC, ESR and CRP and a coeliac screen, although other bloods and imaging
are unnecessary unless there are signs/symptoms concerning for organic disease. Certainly, a
colonoscopy done in a patient IBS will show a normal rectum and colon, and treatment focuses
on symptomatic relief through dietary measures, antispasmodics and psychological approaches.
Coeliac disease
Coeliac disease is an autoimmune inflammatory condition of the small bowel caused by ongoing
gluten exposure. Symptoms include abdominal bloating and pain, diarrhoea, weight loss and
signs of malabsorption – this may commonly include steatorrhoea or anaemia (iron deficiency, or
vitamin B 12 or folate deficiency). Colonoscopy would be normal, although small bowel biopsy
would reveal villous atrophy, crypt hyperplasia and increased numbers of lymphocytes. Bloods
tests typically show autoantibodies (anti-tTG, anti-gliadin and anti-endomysial), anaemia, and
possibly raised inflammatory markers – a coeliac screen is recommended by the National
Institute of Clinical Excellence (NICE) Guidance on inflammatory bowel disease (IBS) before
making the diagnosis of IBS.
Crohn’s disease
This classically presents with abdominal pain, often in the right iliac fossa (as the terminal ileum
is the most frequently affected segment of bowel) and non-bloody diarrhoea, weight loss and
general malaise are also likely. On examination the patient is likely to have abdominal tenderness. Colonoscopy may be normal, as Crohn’s can affect any site of the alimentary canal,
classically causing skip lesions. Perianal disease (fistulae, abscesses, fissures) and mouth ulcers
are also common. Bloods tests may reveal anaemia, in particular a macrocytic a naemia due to
vitamin B 12 malabsorption if the terminal ileum is involved – additionally, evidence of
inflammation is likely on the patient’s blood tests.
Hiatus hernia
Hiatus hernia describes herniation of the stomach through the diaphragm – it is normally
asymptomatic but can present with symptoms of gastro -oesophageal reflux disease (GORD)
(indigestion/heart burn, nocturnal cough, acid brash). Blood tests and colonoscopy would be
normal, but it would not usually cause the patient’s abdominal symptoms.
Ulcerative colitis
This classically presents with abdominal pain and tenderness with bloody diarrhoea, weight loss
and general malaise. Ulcerative colitis (UC) affects the rectum, and a variable but continuous
amount of colon proximal to this. Colonoscopy would therefore not be expected to be normal
with ongoing symptoms as in this case. Bloods tests would also likely be abnormal, revealing
raised inflammatory markers.
A 46-year-old man attends the colorectal clinic presenting with a 4-month history of a
change in bowel habit with blood mixed with stool. He has no relevant past medical history.
What is the most appropriate investigation?
1) Barium enema
2) Capsule endoscopy
3) Colonoscopy
4) Computed tomography (CT) scan
5) Oesphagoduodenoscopy
Explanation
Colonoscopy
This 46-year-old man requires a lower gastrointestinal (GI) endoscopy for his red flag symptoms
of change in bowel habit associated with per rectum (PR) bleeding. This test is the best
investigation as it allows inspection of the bowel mucosa, biopsy if required and is potentially
even therapeutic, for example, if a polyp is seen this can be removed by snare and sent for
histology. It is an invasive test, requiring bowel preparation before the procedure but he is
otherwise well and there are no contraindications in undertaking colonoscopy.
Barium enema
A barium enema, although it could be useful, is not the best test for this patient. It may give an
impression of a lesion in the bowel wall but does not give such a ccurate information as would
colonoscopy in this case. Furthermore he would still require an endoscopic biopsy if a lesion was
seen.
Capsule endoscopy
Capsule endoscopy is an expensive test and not readily available. It is useful for looking for a
source of gastrointestinal (GI) bleeding that occurs in the small bowel beyond the scope of the
oesophago-gastroduodenoscopy (OGD) and proximal to the caecum/terminal ileum which
cannot be accessed by colonoscopy.
Computed tomography (CT) scan
CT scans maybe usefu l for detecting gross bowel pathology and staging for cancers but would
not be as useful as colonoscopy.
Oesphagoduodenoscopy
Oesphagoduodenoscopy (OGD) is useful if an upper gastrointestinal (GI) source is suspected but
this patient has lower GI symptoms.
A 32-year-old woman with a history of chronic diarrhoea undergoes a flexible sigmoidoscopy. There is brownish discoloration on the wall of the sigmoid in a
moiré pattern. Biopsy reveals characteristic
pigment-laden macrophages within the mucosa on periodic acid–Schiff (PAS) staining. She works as a swimwear model
and is very concerned with her appearance.
What is the most likely diagnosis?
1) Crohn’s disease
2) Campylobacter infection
3) Diverticulitis
4) Melanosis coli
5) Ulcerative colitis
Explanation
Melanosis coli
Brownish discoloration on the wall of the sigmoid in a moiré pattern and characteristic pigment -
laden macrophages within the mucosa with PAS staining on mucosal biopsy are characteristic
features of melanosis coli and indicate la xative abuse. Although, colonoscopic appearance does
not have any negative sequelae, chronic diarrhoea requires advice on stopping laxative abuse.
Note her occupation as a model suggests she may feel pressurised to lose weight. Offer
psychological support if required.
Crohn’s disease
Colonoscopic findings of Crohn’s disease include cobblestone appearance, in which oedematous
islands of mucosa are separated by fissures. These can then extend through all layers of the
bowel. Transmural involvement can lead to stricture and fistulae formation. Skip lesions are
common where there is healthy bowel between diseased segments. Microscopically there can be
deep fissuring ulcers, oedema and inflammatory cell infiltrates with foci of lymphocytes and
non-caseating granulomas. Pigment -laden macrophages within the mucosa on PAS staining is
not a feature of Crohn’s disease.
Campylobacter infection
Diagnosis of Campylobacter infection is made on direct microscopy of faeces or isolation of the
organism. On sigmoidoscopy, the findings may be similar to those observed in
pseudomembranous colitis or inflammatory bowel disease. These include mucosal oedema,
hyperaemia, patchy petechiae and aphthoid ulceration. Pigment -laden macrophages within the
mucosa on PAS staining is not a feature of Campylobacter infection.
Diverticulitis
Diverticulitis may present with similar features as mentioned in the history. In the current era of
advanced imaging most of the complications of diverticulitis are diagnosed by computed
tomography (CT) scan. However lower gastrointestinal (GI) endoscopy is required to rule out malignancy once the acute phase is over. Sigmoidoscopy may show openings of diverticulae.
Pigment-laden macrophages within the mucosa on PAS staining is not a feature of diverticulitis .
Ulcerative colitis
On colonoscopy, inflammation is restricted to the mucosa and submucosa of the large bowel
with ulcerative colitis. Abscesses develop at the base of the colonic crypts and once burst can
lead to ulceration. Oedema of the intervening muc osa leads to pseudopolyp appearance.
Histologically, there is chronic inflammatory cell infiltrate, crypt architectural distortion and
goblet cell depletion. Granulomas are usually absent. Pigment -laden macrophages within the
mucosa on PAS staining is not a feature of ulcerative colitis.
A 65-year-old woman presents with a change in bowel habit. She
has had
fresh bloody
diarrhoea
for the
last 2 months. Flexible sigmoidoscopy revealed
inflamed and
ulcerated
mucosa
from the rectum to as high as the scope could extend in the
splenic flexure
.
Biopsy shows
superficial ulceration
and
diffuse mucosal inflammation
. What is the likely diagnosis?
1) Crohn’s disease
2) Ischaemic colitis
3) Diverticulitis
4) Salmonella infection
5) Ulcerative colitis
Explanation
Ulcerative colitis
This patient has ulcerative colitis as evident in history, endoscopy findings with confluent
inflammation, and histology results. This inflammatory disorder differs from Crohn’s disease as
granulomas are absent, fissures are rare and inflammation is superficial involving the mucosal
layer.
Crohn’s disease
Colonoscopic findings of Crohn’s disease include a cobblestone appearance, in which
oedematous islands of mucosa are separated by fissures. These can then extend through all layers
of the bowel. Transmural involvement can lead to stricture and fistulae formation. Skip lesions
are common where there is healthy bowel between diseased segments. Microscopically there can
be deep fissuring ulcers, oedema and inflammatory cell infiltrates with foci of lymphocytes and
non-caseating granulomas. Pigment -laden macrophages within the mucosa on periodic acid–
Schiff (PAS) staining is not a feature of Crohn’s disease.
Ischaemic colitis
Ischaemic colitis presents in a similar way to inflammatory bowel disease or infectious colitis.
Endoscopic findings that distinguish ischaemic colitis from inflammatory bowel disease are the
segmental distribution, rectum sparing and rapid resolution on serial examinations. Histological
changes in ischaemic colitis include oedema, distorted crypts, mucosal and submucosal
haemorrhage, and inflammatory infiltration into the lamina propria, granulation tissue,
intravascular platelet thrombi and necrosis.
Diverticulitis
Diverticulitis may present with similar features as mentioned in history. In the current era of
advanced imaging most of the complications of diverticulosis are diagnosed by computed
tomography (CT) scan. However lower gastrointestinal (GI) endoscopy is required to rule out
malignancy once acute phase is over. Sigmoidoscopy may show openings of diverticulae.
Salmonella infection Diagnosis of Salmonella infection is made clinically and with microbiological investigations.
Colonoscopy may be required in some cases where complications such as bleeding occurs
requiring endoscopic intervention. Colonoscopic findings include multiple variable -sized
punched-out ulcers with slightly elevated margins. Moreover, the most commonly involved area
is the terminal ileum, followed by the ileocecal valve and ascending/transverse colon. The left
colon is usually spared.
A 72-year-old patient presents with urinary retention.
He describes
pneumaturia and faeculent
debris
in his urine. He has had significant
two months. A contrast
enema shows an
weight loss and a change in bowel habit over the last obstructing lesion in the distal sigmoid colon. He
is
otherwise fit and well
.
What is the best definitive treatment in this case? 1) Catheterisation
2) Neostigmine
3) Stenting of the stricture
4) Surgical resection of colonic lesion
5) Neoadjuvant chemoradiotherapy
Explanation
Surgical resection of colonic lesion
Definitive management of colovesical fistulae is surgical. It may be with curative or palliative
intent depending upon the extent of local invasion. With curative intention it may include en bloc
resection with or without pelvic exenteration. With palliative intent it may be urinary and faecal
diversion leading to urostomy and colostomy respectively.
Catheterisation
This patient has developed a malignant colovesical fistula as a result of a sigmoid tumour. This
patient will initially need a catheter but it is not the ‘definitive’ treatment requested. A fistula
will not heal if there is distal obstruction – in this case an obstructing operative tumour.
Neostigmine
Neostigmine is an anticholinesterase agent that increases the effect of acetylcholine. It is helpful
in the management of patients with neurogenic bladder having urinary retention. It is not helpful
in patients having urinary retention due to a malignant colovesical fistula. Moreover, the
question is regarding definitive management, which will be en bloc resection with or without
pelvic exenteration; or faecal and urinary diversion in case of palliat ion.
Stenting of the stricture
Stenting may help in relieving colonic obstruction but it is not the definitive management of
malignant colovesical fistulae.
Neoadjuvant chemoradiotherapy
In case of rectal tumour, neoadjuvant chemoradiotherapy reduces the r isk of recurrence.
However, in the case of sigmoid tumours, neoadjuvant treatment is not recommended due to the
high position of the tumour that can put the small bowel at risk of radiation enteritis.
You are called to the delivery room with your registrar to see a baby who the midwife says has
‘no abdominal wall’. When you get there you find a baby with an
abdominal defect
with loops of
bowel outside the abdomen, and
no covering layers.
What is the most likely diagnosis?
1) Umbilical hernia 2) Gastroschisis
3) Omphalocoele major
4) Hernia of the umbilical cord
5) Omphalocoele minor
Explanation
Gastroschisis
In gastroschisis there is no peritoneal covering, and it is rarely associated with congenital defects
seen in patients with omphalocoele. However, sometimes it may be associated with intestinal
atresia. Management initially consists of covering the defect with cling film to prevent heat and
moisture loss, while establishing intravenous (IV) access for IV fluids.
Umbilical hernia
An umbilical hernia is covered by skin. The defect is herniation of the abdominal contents
through the umbilical fibromuscular ring. Umbilical hernias usually occur in infants and reach
their maximal size by the first month of life. Most hernias of this type close spontaneously by the
first year of life, with only a 2–10% incidence in children older than 1 year.
Omphalocoele major
An omphalocoele is a congenital defect of the anterior abdominal wall in which the abdominal
contents are covered by a sac. The sac has three layers: the perito neum, Wharton’s jelly, and the
amnion. The sac may contain intestinal loops, the bladder, and the liver. Unlike gastroschisis it is
often associated with other congenital anomalies. Contents in the case of omphalocoele protrude
through the central defect in the abdomen and there is no umbilicus. Depending on the size of the
defect it may be labelled as major or minor. A defect of more than 4 cm is designated major,
while less than 4 cm it is minor.
Hernia of the umbilical cord
In a hernia of the umbilical cord a cuff of skin is seen extending from the abdominal wall onto
the neck of the sac. The hernia sac comprises of the outer amnion and the inner peritoneal lining
and contains contents varying from loops of bowel to any mobile intraperitoneal organs.
Omphalocoele minor
Omphalocoele minor is a congenital defect of the anterior abdominal wall in which the
abdominal contents are covered by a sac and the defect is less than 4 cm.
A 9-month-old baby presents with excessive crying and
withdrawing of legs
for the last 12 h.
Between the attacks he looks
quite healthy. He has vomited a few times and has passed
mucous
mixed with
blood per rectum
shaped mass
in the upper
. A week ago he had a
viral illness. Examination reveals a
sausage-
abdomen.
What is the most likely diagnosis?
1) Pyloric stenosis
2) Intussusception
3) Gastroenteritis
4) Midgut volvulus
5) Necrotising enterocolitis
Explanation
Intussusception
Intussusception is the commonest gastrointestinal surgical emergency in children between 3
months and 2 years. The ileocecal junction is the commonest location. A part of the bowel
invaginates into the adjacent section, leading to obstruction. The patient usually presents with
intermittent colicky abdominal pain lasting 1–2 min which frequently recurs. It is associated with
vomiting. Blood is passed PR, often described as red-currant jelly in appearance. The
invaginated bowel segment may be palpable as a sausage-shaped mass.
Pyloric stenosis
Presentation with vomit ing may mimic pyloric stenosis, however pyloric stenosis usually
presents around the age of 4–6 weeks. Vomiting is projectile, bleeding per rectum is rare but an
olive-shaped mass may be palpable in epigastric region. Diagnosis is by ultrasound (US) scan o f
the abdomen. Electrolyte abnormalities include hypokalemia, hypochloraemic metabolic
alkalosis with paradoxical aciduria. Treatment is by open or laparoscopic pyloromyotomy.
Gastroenteritis
The presentation may mimic acute gastroenteritis, however a palp able sausage-shaped mass is
suggestive of intussusception.
Midgut volvulus
Midgut volvulus may present as a surgical emergency. With a 12 h history the abdomen is
distended and tender and the child is usually in a state of shock. Such patients require emer gency
laparotomy without any investigations.
Necrotising enterocolitis
Necrotising enterocolitis (NEC) is a condition that involves premature neonates. The usual
presentation is greenish aspirates in a premature neonate who is in the Neonatal Intensive Car e
Unit (NICU). The abdomen becomes shiny, tender and distended. An X -ray of the abdomen may
show pneumatosis intestinalis. Treatment is medical (with antibiotics) or surgical depending
upon the severity of the NEC.
You are treating a 4-week-old baby who has had
jaundice since birth
at full-term, weight 5 lb.
The child has developed palpable firm
hepatosplenomegaly, pale stools and dark urine
.
Ultrasound scan (USS) shows
no dilatation
of the biliary tree.
What is the most likely cause?
1) Biliary atresia
2) Choledochal cysts
3) Extrahepatic bile duct tumour
4) Ileal atresia
5) Spontaneous perforation of the bile duct
Explanation
Biliary atresia
There are numerous causes of jaundice in neonates including physiological, med ical and
surgical. Surgical causes include biliary atresia, choledochal cysts, spontaneous perforation of the bile duct, inspissated bowel within the common bile duct, and extrahepatic bile duct tumours.
In biliary atresia the bile ducts are destroyed by inflammation. Clinical signs include jaundice,
and the development of firm hepatosplenomegaly, pale stools and dark urine, which are not seen
at birth. Children usually go to full term, but with a low birthweight. No single test is diagnostic
of this condit ion.
Choledochal cysts
Choledochal cysts are congenital cystic dilatations of the biliary tree. Infants typically present
with jaundice, pale stools and right upper quadrant mass. USS would classically reveal dilatation
of the biliary tree.
Extrahepatic bile duct tumour
Bile duct tumours are uncommon and typically present with jaundice, affecting older patients
with the average age of 60–65 years.
Ileal atresia
This is a malformation of the ileum resulting in a complete luminal obstruction and would
typically be diagnosed within the first 24 h of birth if it had not been picked up on antenatal
scans. The infant is unlikely to have passed stool, will have a distended abdomen and may be
vomiting.
Spontaneous perforation of the bile duct
This is a rare conditio n affecting infants and children with the cause unknown. The infants can
present acutely with biliary peritonitis or later with jaundice, pale stools and abdominal
distension. An ultrasound would demonstrate ascites.
A 4-day-old full-term neonate has developed abdominal distension and
bilious
aspirates. He
passed meconium in the first 24 h. An abdominal X-ray shows
distended small bowel loops
and
fluid levels with
no air in the rectum.
What is the most likely cause?
1) Duodenal atresia
2) Hirschsprung’s disease
3) Meconium ileus
4) Oesophageal atresia
5) Small bowel atresia
Explanation
Small bowel atresia Small bowel atresia can be diagnosed antenatally. It presents with bilious vomiting, abdominal
distension, and failure to pass further stools following passage of meconium. Plain abdominal X-
ray shows distended loops of bowel with fluid levels.
Duodenal atresia
Duodenal atresia can be diagnosed antenatally. Abdominal distension is not marked as
obstruction is proximal. In duodenal atresia a double gas bubble would be expected on
abdominal X-ray.
Hirschsprung’s disease
In Hirschsprung’s disease there is failure in passage of meconium in the first 48 h in most cases.
The rest of the findings may match with the above description. Rectal stimulation and washouts
help in emptying the bowel unless the pathology involves whole of the colon.
Meconium ileus
In meconium ileus, passage of meconium fails to occur. X-ray findings may show a soap bubble
appearance. Meconium ileus may be managed by rectal washouts in certain selected cases. Work
up should include screening for cystic fibrosis.
Oesophageal atresia
With oesophageal atresia, excessive salivation and frothing occurs. A trial of passage of a
nasogastric tube (NG) tube fails and X-rays show NG tube coiling in the oesophagus.
A
4-week-old
full-term male baby is brought with history of
projectile,
non-bilious
vomiting.
Examination reveals a
severely dehydrated
baby with a scaphoid abdomen.
Which one of the following is the most likely diagnosis?
1) Duodenal Atresia
2) Hirschprung’s disease
3) Pyloric stenosis
4) Malrotation
5) Meconium Ileus
Explanation
Pyloric stenosis Typical presentation is around 4–6 weeks in the first male baby of the family. Vomiting is
projectile and non-bilious due to the high level of obstruction (the thickened pyloric muscle),
which is above the entrance of the common bile duct into the duodenum. Distension is not
usually a feature. Between the episodes the baby is eager to take feeds. Electrolyte disturbance s
include hypokalaemic, and hypochloraemic metabolic alkalosis.
Duodenal Atresia
Vomiting is bilious and presentation is earlier following birth.
Hirschprung’s disease
Prominent features are inability to open the bowels and abdominal distension. Vomiting is a late
feature and is bilious.
Malrotation
Presentation is with acute abdomen and bilious vomiting. If midgut volvulus has developed the
baby requires emergency laparotomy. No further investigations should be done. Bilious vomiting
in a newborn is a surgical emergency until proved otherwise. Malrotation is the diagnosis, which
needs exclusion with an upper gastrointestinal (GI) contrast to look at the layout of the intestine,
specifically whether the duodenal–jejunal flexure is on the correct side of the vertebrae – the left
is the correct side.
Meconium Ileus
Presentation is at birth with abdominal distension, failure to pass stool and bilious aspirates.
A 69-year-old man presents with a history of weight loss, altered bowel habit and feeling
generally unwell. Investigations reveal a caecal carcinoma. He undergoes a right hemicolectomy.
Histology reveals a large tumour that has
extended into the muscularis propria but spared the
lymph nodes.
What is the most likely Astler-Coller classification of Dukes’ staging for this tumour?
1) Dukes’ A
2) Dukes’ B1
3) Dukes’ C1
4) Dukes’ C2
5) Dukes’ D
According to the new Dukes’ staging it is B1 once the tumour has spread into the muscularis
propria but has not penetrated through it. If it has penetrated through he propria, it is staged as
B2.
The original staging system derived by Cuthbert Dukes was:
A – Invasion into but not through the bowel wall (90% 5-year survival)
B – Invasion through the bowel wall but not involving lymph nodes (70% 5-year survival)
C – Involvement of lymph nodes (30% 5-year survival)
D – Distant metastases.
This was revised by Astler–Coller in 1954:
A – Limited to mucosa
B1 – Into muscularis propria but not penetrating it. No nodes.
B2 – Penetrating muscularis propria. No nodes.
C1 – Metastasis to one to four regional lymph nodes
C2 – Metastasis to more than four lymph nodes.
D – Distant metastases.
Dukes’ A
If the tumour is limited to the mucosa it is classified as Dukes’ A.
Dukes’ C1
If the tumour has spread into regional lymph nodes (between one and four) it is staged as C1.
Dukes’ C2
Spread to lymph nodes beyond the regional lymph nodes (more than four) is classified as C2.
Dukes’ D
Distant metastasis is classified as stage D.
An elderly man presents to your clinic with progressive weight loss, dysphagia and several
episodes of hematemesis. An upper gastrointestinal endoscopy reveals a fungating growth in
his
distal oesophagus
. Biopsy has been taken for histopathology.
What would be the most likely histopathological finding?
1) Squamous cell carcinoma
2) Malignant melanoma
3) Adenocarcinoma of the intestinal type
4) Metaplastic columnar epithelium
5) Dysplastic columnar epithelium
Explanation
Adenocarcinoma of the intestinal type
The lower end of the oesophagus is prone to develop metaplastic changes in response to reflux
oesophagitis. Change of normal squamous epithelium to columnar type is called as Barrett’s
oesophagus. These changes are reversible. However, in longst anding cases, dysplasia may occur
that can lead to adenocarcinoma. As the mass in the summary is in the lower oesophagus then,
most probably, malignant adenocarcinoma is the most likely diagnosis. Squamous cell carcinoma
Squamous cell carcinoma occurs in t he upper part of the oesophagus.
Malignant melanoma
Primary and metastatic malignant melanoma may occur in some patients, but it is a very rare
problem. Moreover history and endoscopic findings are more suggestive of adenocarcinoma.
Metaplastic columnar epithelium
This is suggestive of Barrett’s oesophagus. Oesophageal squamous epithelium is replaced by
columnar epithelium of the intestinal type with goblet cells. Adenocarcinoma may develop in
longstanding cases of Barrett’s oesophagus.
Dysplastic columnar epithelium
This finding is suggestive of dysplasia in Barrett’s oesophagus. It is a premalignant condition
and can lead to adenocarcinoma of the lower end of the oesophagus and longstanding cases of
gastro-oesophageal reflux disease (GORD). Oesophageal carcinoma is divided into an
adenocarcinoma, which affects the distal one-third (50–80%) and squamous cell carcinomas (90–
95%), which affect the upper two -thirds. Squamous cell carcinomas are associated with tobacco
(as is adenocarcinoma) and also alcohol intake, whereas adenocarcinoma is closely linked to
GORD and Barrett’s oesophagus. Most oesophageal cancers present late and therefore are not
suitable for minimally invasive surgery. Sadly, palliation is often the only treatment available.
You see a 67-year-old woman in your clinic. She has been complaining for 2 months of anorexia,
abdominal bloating and 2 stones of weight loss. A computed tomography (CT) scan suggests
a
thickened stomach
without any definitive mass. Endoscopic biopsy reveals malignant
signet
ring
type cells with
intracytoplasmic mucin
.
Which one of the following is most likely diagnosis?
1) Metastatic tumours of the stomach
2) Gastrointestinal stromal tumour (GIST)
3) Gastric carcinoid
4) Gastric Lymphoma
5) Linitis plastica
Explanation
Linitis plastica
Gastric linitis plastica is a diffuse type of cancer. Malignant cells invade throughout the stomach,
resulting in the thickening and rigidity of the stomach wall. Most of the patients present late.
Endoscopically the stomach looks thick with reduced distensibility. Biopsy reveals invasion of
all the layers of the stomach in a diffuse pattern. Malignant cells look like a signet ring.
Prognosis is poor and treatment may include radical surgery or palliative chemotherapy.
Metastatic tumours of the stomach These tumours may present as ulcers or diffused stomach thickening, however biopsy will reveal
the site of origin of such metastasis.
Gastrointestinal stromal tumour (GIST)
Small gastric GISTs appear as serosal, submucosal or intramural nodules. They are usually
incidental findings during abdominal surgery or endoscopy. Histologically these are positive for
KIT tyrosine kinase receptors.
Gastric carcinoid
Histology shows enterochromaffin like (ECL) cells that are a distinctive type of neuroendocrine
cell in the gastric mucosa underlying the epithelium.
Gastric Lymphoma
Gastric lymphomas may be primary or secondary. Endoscopically, these are visible as enlarged
gastric folds, or ulcers in the case of low grade lesions and a mass in the case of high grade
lesions. Histology and immunohistochemistry may differentiate between different types of
lymphomas.
You see a 67-year-old woman in your clinic. She has been complaining of 2 months of anorexia,
abdominal bloating and 2 stones of weight loss. A computed tomography (CT) scan suggests a
thickened stomach and oesophago -gastroduodenoscopy (OGD) reveal linitis plastica.
Which one of the following statements is true of stomach cancer?
1) There is a strong association between heavy alcohol intake and stomach cancer
2) The majority of H.pylori infections result in stomach cancer
3) Gastric carcinoma is commoner in women than men
4) Linitis plastica tends to be associated with H.pylori infection
5) Gastrointestinal stromal tumours form the most common histological subtype of gastric cancer
Explanation
There is a strong association between heavy alcohol intake and stomach cancer
There is significant body of evidence suggesting that a heavy alcohol intake increases gastric
cancer risk. Smoking also increases the risk from 40% increased risk for current smokers to 82%
increased risk for heavy smokers. Other risk factors include autoimmune atrophic gastritis,
pernicious anaemia, Menetrier disease and intestinal metaplasia.
The majority of H.pylori infections result in stomach cancer
H. pylori infection is the main risk factor for 65–80% of gastric carcinomas but these only occur
in approximately 2% of infections.
Gastric carcinoma is commoner in women than men Men are affected more co mmonly than women.
Linitis plastica tends to be associated with H.pylori infection
Linitis plastica tends not to be associated with H. pylori and has a more genetic association.
Gastrointestinal stromal tumours form the most common histological subtype of gastric cancer
The most common subtype of gastric cancer is adenocarcinoma (90 –95%). Other histological
subtypes include: lymphoma (1–5%), gastrointestinal stromal tumours (2%), carcinoids (1%),
adenoacanthomas (1%) and squamous cell carcinoma (1%).
You review a 37-year-old woman in the Emergency department who presents with abdominal
pain and vomiting. On examination you note circumoral pigmentation and a distended abdomen.
A computed tomography (CT) scan shows ileo-ileal intussusception.
Which one of the following statements regarding Peutz–Jeghers syndrome is true?
1) It is an autosomal-recessive condition
2) It is characterised by polyps typically present in the small bowel
3) Pigmentation is limited to the circumoral skin and buccal mucosa
4) Histological examination of polyps adenomas
5) There is no increased risk of cancer with this condition
Explanation
It is characterised by polyps typically present in the small bowel
Polyps in Peutz–Jeghers are typically present in the small bowel but may affect the entire
gastrointestinal (GI) tract.
It is an autosomal-recessive condition
Peutz–Jeghers is an autosomal-dominant condition. It is associated with germ-line mutations in
the STK11 gene on chromosome 19.
Pigmentation is limited to the circumoral skin and buccal mucosa
Pigmentation can also affect the hands and genitalia.
Histological examination of polyps adenomas Polyps in Peutz–Jeghers in are hamartomas.
There is no increased risk of cancer with this condition
Hamartomas are usually benign; there is a very small risk of malignant transformation. However,
there is also an increased risk of pancreatic, breast, lung, ovarian and endometrial cancer
associated with Peutz–Jeghers syndrome.
You are examining a man with abdominal pain, ascites and jaundice. An abdominal ultrasound
scan (USS) shows signs suspicious of a hepatocellular carcinoma.
Which one of the following is correct regarding hepatocellular carcinoma (HCC)?
1) Women are affected more than men
2) It is mainly associated with hepatitis B and C viruses
3) It is associated with type 1 diabetes
4) Serum a-fetoprotein is normal
5) Usually presents below the age of 30
Explanation
It is mainly associated with hepatitis B and C viruses
Hepatitis B virus (HBV) and hepatitis C virus (HCV) are well known causes of HCC. HBV is a
major independent risk factor and, in countries where it is prevalent, 90% of patients with HCC
are positive for HBV. With HCV the HCC classically develops in the setting of cirrhosis.
Women are affected more than men
Men are more commonly affected than women (3:1).
It is associated with type 1 diabetes
Although not completely understood there is an increased risk of HCC in type 2 diabetes and
relates to poor glucose control and insulin levels.
Serum a-fetoprotein is normal Serum α-fetoprotein is a tumour marker and is usually raised in HCC. It is also raised in other
cancers such as testicular and ovarian tumours.
Usually presents below the age of 30
HCC usually presents later with the average age at diagnosis of 65 years.
A 59-year-old man presents with rectal bleeding and offensive stool. Investigations reveal a
Meckel’s diverticulum.
Which one of the following is true regarding Meckel’s diverticulum?
1) It involves two layers of the intestinal wall only
2) It is seen in 2% of people, usually presenting in patients over two years of age
3) It is 60 cm from the ileocaecal valve
4) It is usually found in the jejunum on the antimesenteric border and is approximately 5 cm
long
5) It occurs twice as frequently in women than in men
Explanation
It is 60 cm from the ileocaecal valve
It is classically found in the distal ileum, 60 cm (2 feet) from the ileocaecal valve on the
antimesenteric border of the ileum and is approximately 5 cm (2 inches) long.
It involves two layers of the intestinal wall only
A Meckel’s diverticulum is an example of a true diverticulum and contains all the layers of the
intestinal wall.
It is seen in 2% of people, usually presenting in patients over two years of a ge
While it is present in 2% of people, most symptomatic cases will present before the age of 2.
It is usually found in the jejunum on the antimesenteric border and is approximately 5 cm long It is classically found in the distal ileum, 60 cm from the ileo caecal valve on the antimesenteric
border and is approximately 5 cm long.
It occurs twice as frequently in women than in men
Meckel’s diverticulum occurs in 2% of the population and affects men twice as often as women.
An infant attends the paediatric surgical clinic with their parents as a follow up patient. They had
a staged repair of a congenital abdominal wall defect.
Which one of the following statements about exomphalos is true?
1) In the vast majority of cases in which exomphalos is present it is the only congenital
abnormality
2) Maternal smoking decreases the risk of developing it
3) It is associated with Edward syndrome
4) Its incidence is decreasing
5) It is associated with Potter syndrome
Explanation
It is associated with Edward syndrome
Associated syndromes include Beckwith–Wiedemann syndrome (features include macroglossia,
macrosomia, omphalocele/exomphalos, umbilical hernia, ear pits, neonatal hypoglycaemia,
hepatoblastoma), Edward syndrome (trisomy 18, features include heart defects, omphalocele,
oesophageal atresia, microcephaly, micrognathia, cleft lip/palate, widely spaced eyes, ptosis,
webbing of toes, undescended testicles) and Patau syndrome (trisomy 13, features include
microcephaly, structural eye defects, polydactyly, low-set ears, omphalocele, rocker-bottom feet,
abnormal genitalia and heart defects).
In the vast majority of cases in which exomphalos is present it is the only congenital abnormality
The incidence of associated abnormalities is between 40–70%, including chromosomal
(trisomies 13, 18 and 21), cardiac, genitourinary, gastrointestinal, craniofacial, and pulmonary
hypoplasia.
Maternal smoking decreases the risk of developing it
Both maternal alcohol use and heavy smoking are associated with an increased ris k. Its incidence is decreasing
Incidence is 1 in 5000 to 1 in 10 000 live births although the incidence seems to be increasing
worldwide.
It is associated with Potter syndrome
Potter syndrome or sequence relates to renal abnormalities, it is not associated with exomphalos.
Oligohydramnios as a result of renal abnormalities, urinary tract obstruction or amniotic fluid
leakage may lead to fetal compression with joint contractures (arthrogryposis), pulmonary
hypoplasia and squashed facies.
A surgical registrar is performing his third solo laparoscopic cholecystectomy in a 47 -year-old
woman. When attempting to
dissect out Calot’s triangle
to identify the cystic artery great
difficulty is experienced as the anatomy appears aberrant.
What proportion of patients have anomalies of the gall-bladder and biliary tree?
1) <1%
2) 25%
3) 50%
4) 75%
5) >90%
Explanation
50%
Calot’s triangle, also known as the cystohepatic or hepatobiliary triangle is an anatomic space
that is of great relevance when performing a laparoscopic cholecystectomy. It is bounded by the
common hepatic duct medially, cystic duct laterally and liver superiorly, and is used to locate the
cystic artery which runs within. Anomalies of the gall-bladder or biliary tree are found within
50% of subjects and are important during surgery. There are a vast array of different anomalies
that can occur, by way of example these anomalies include:
Anomalous ducts in around 12% – around 85% of which are found (and occasionally injured)
within Calot’s triangle.
Anomalous gall-bladder development – rarely agenesis of the gall-bladder (around 0.02%), more
commonly multiple gall bladders around (1 in 3800), or other anomalies such as the gall-bladder
opening directly into the side of the common bile duct ie the cystic duct is absent.
Variation in the blood vessel arrangement supplying the gall-bladder eg in 25% of people the
right hepatic artery crosses in front of the common hepatic duct instead of behind it. <1%
Difficult biliary anatomy is relatively common, often making what is usually a routine operation
very difficult.
25%
This answer is not correct, the correct answer is 50%.
75%
The variant anatomy encountered is less than this percentage.
> 90%
This estimate is not correct.
A
neonate
is noted to have persistent,
progressive jaundice
, pale stools and dark urine. On
examination there is
hepatosplenomegaly
. The gall-bladder is
absent
on ultrasonography.
What is the most likely cause of this?
1) Breast milk jaundice
2) Hepatocellular cholestasis
3) Haemolytic disease of the new-born
4) Paediatric biliary atresia
5) Choledochal cyst
Explanation
Paediatric biliary atresia
Biliary atresia is of unknown aetiology. The extra-hepatic bile ducts are destroyed by
inflammation. It present s with jaundice, pale stools and dark urine with hepatosplenomegaly. An
absent gall bladder is characteristic finding of extrahepatic biliary atresia as it is atretic.
Treatment requires a Kasai’s procedure, this involves removal of all the extrahepatic tr ee and
portoenterostomy. Outcome is poor if diagnosis is delayed.
Breast milk jaundice
Breast milk jaundice is a type of neonatal jaundice that is associated with breastfeeding. It is
characterized by indirect hyperbilirubinemia in an otherwise healthy breastfed neonate. Signs of
obstructive jaundice mentioned in the summary will be absent. Diagnosis is by exclusion.
Hepatocellular cholestasis
Hepatocellular cholestasis results from stasis of bile pigments within the liver. The underlying
aetiology can include any of viral hepatitis, Alpha1-antitrypsin deficiency, inborn errors of bile
acid synthesis, drug-induced cholestasis or total parenteral nutrition (TPN) associated
cholestasis. However, the clinical and biochemical picture differs as features of obstructive
jaundice will be absent.
Haemolytic disease of the new-born The jaundice is of non-obstructive variety. It results from rhesus incompatibility. Antibodies
against Rh +ve red blood cells cross the placenta and cause haemolysis. Depending upon seve rity
the disease may range from hydrops fetalis to neonatal jaundice at birth. Laboratory
investigations may show indirect hyperbilirubinemia.
Choledochal cyst
The presentation closely resembles that of extrahepatic biliary atresia. The differentiating poi nt is
presence of a gall-bladder. A choledochal cyst on ultrasound may also be visible.
A patient with Crohn’s has had multiple resections for stricturing disease. They are developing
further symptoms and attend the Emergency Department.
In a patient who has undergone an extensive ileocolic resection, which one of the following
biochemical abnormalities would be most expected?
1) A microcytic anaemia
2) Hyperparathyroidism
3) Vitamin K excess
4) Decreased parathyroid hormone (PTH)
5) Hypermagnesaemia
Explanation
Decreased parathyroid hormone (PTH)
The terminal ileum is an important site of bile salt re-absorption, excess loss of bile salts which
are responsible solubilising lipids in the jejunum. The excess loss of bile salts therefore leads to
fat malabsorption and excess fatty acids within the distal bowel – these can chelate magnesium
causing hypomagnesaemia (not hyper). Hypomagnesaemia has a suppressive effect on
parathyroid hormone (PTH) release resulting in acquired hypoparathyroidism.
A microcytic anaemia
The terminal ileum is the site of vitamin B 12 absorption – malabsorption leads to development of
a macrocytic anaemia.
Hyperparathyroidism
The terminal ileum is an important site of bile salt re-absorption. Excess loss of bile salts, which
are responsible solubilising lipids in the jejunum, can occur. The excess loss of bile salts leads to
fat malabsorption and excess fatty acids within the distal bowel – these fatty acids can chelate
magnesium causing hypomagnesaemia (not hypermagnesaemia). Hypomagnesaemia has a
suppressive effect on parathyroid hormone (PTH) release resulting in acquired
hypoparathyroidism.
Vitamin K excess
The terminal ileum is an important site of bile salt re-absorption, and therefo re loss results in fat
and fat soluble vitamin (vitamins A, D, E and K) malabsorption. Hypermagnesaemia
The terminal ileum is an important site of vitamin B 12 absorption as well as bile salt re-
absorption. Loss of bile salts results in fat malabsorption and excess fatty acids within the distal
bowel – these can chelate magnesium. This leads to hypomagnesaemia (not hypermagnesaemia).
You receive the tumour extends histology report from a specimen from a colonic resection. It reveals that the into, but not through the muscularis propria. There is one local lymph nodegroup involved.
What is the Dukes’ stage classification of the tumour according to the modified Astler–
Coller system?
1) D
2) C1
3) C2
4) B1
5) B2
The correct answer is C1.
Explanation:
The modified Astler–Coller staging system for colorectal cancer is as follows:
• Stage A: Limited to the mucosa.
• Stage B1: Extending into the muscularis propria but not penetrating through it; no lymph node involvement.
• Stage B2: Penetrating through the muscularis propria; no lymph node involvement.
• Stage C1: Extending into the muscularis propria but not penetrating through it; lymph nodes involved.
• Stage C2: Penetrating through the muscularis propria; lymph nodes involved.
• Stage D: Distant metastatic spread.
Since the histology report indicates that the tumour extends into but not through the muscularis propria and involves a local lymph node, it corresponds to Stage C1 .
While performing a radical mastectomy, the surgeon injured the long thoracic nerve. Which of the following muscles will be affected due to injury to the long thoracic nerve?
A Anterior scalene
B Middle scalene
C Serratus anterior
D Subscapularis
E Teres major
The muscle affected due to injury to the long thoracic nerve is the serratus anterior.
The long thoracic nerve innervates the serratus anterior muscle. Injury to this nerve can lead to a condition known as “winged scapula,” where the shoulder blade protrudes out abnormally. This can occur during surgeries such as a radical mastectomy, where the nerve may be damaged accidentally. The serratus anterior muscle plays a crucial role in the movement and stabilization of the scapula, particularly in protraction and upward rotation.
So, the correct answer is:
C. Serratus anterior
A motorcyclist involved in a hit-and-run accident was thrown from his motorcycle. He landed on the right side of his head and the tip of his shoulder, bending his head sharply to the left and stretching the right side of his neck. Subsequent neurological examination revealed that the roots of the fifth and sixth cervical nerves had been torn away from the spinal cord. What part of the upper limb will have diminished cutaneous sensations in this patient?
A The back of the shoulder
B. The top of the shoulder and the lateral side of the arm
C The pectoral region
D The medial side of the armand fore.rm
E The tip of the little finger
The roots of the fifth and sixth cervical nerves contribute significantly to the brachial plexus, particularly forming the upper trunk, which eventually gives rise to several nerves that innervate specific areas of the upper limb. When these nerve roots are torn, it typically affects the areas supplied by the nerves that arise from these roots.
In this scenario, the cutaneous areas most affected would be those innervated by the C5 and C6 dermatomes. These areas include:
• The top of the shoulder (innervated by the supraclavicular nerves, which are derived from C3 and C4 but can be affected indirectly due to proximity). • The lateral side of the arm (innervated by the axillary nerve from C5 and C6). • The lateral aspect of the forearm (innervated by the musculocutaneous nerve, which has contributions from C5, C6, and C7).
Given this information, the part of the upper limb that will have diminished cutaneous sensations in this patient is:
B. The top of the shoulder and the lateral side of the arm
A 75-year-old patient has an olecranon fracture. This injury will most likely disrupt the function of which of the following muscles?”
The options given are:
A. Brachialis
B. Flexor digitorum profundus
C. Flexor pollicis longus
D. Pronator teres
E. Triceps brachii
The muscle most likely to be affected by an olecranon fracture is the triceps brachii, as the tendon of the triceps inserts on the olecranon process of the ulna. An olecranon fracture can disrupt the triceps’ ability to extend the elbow.
So, the correct answer is:
E. Triceps brachii
A motorcyclist fell from his bike. On arrival in ASE it was noticed that extension of his right humerus was severely limited. He has sustained injury to the:
A Long thoracic nerve:
B Medial pectoral nerve
C Suprascapular nerve
D Thoracodorsal nerve
E Upper subscapular nerve
Extension of the humerus is primarily facilitated by muscles such as the latissimus dorsi and the long head of the triceps brachii. Among the nerves listed, the one that innervates the latissimus dorsi is the thoracodorsal nerve.
An injury to the thoracodorsal nerve would impair the function of the latissimus dorsi muscle, leading to a limitation in the extension of the humerus.
Therefore, the correct answer is:
D. Thoracodorsal nerve
A young boy fell from his skateboard, twisted his forearm and sprained his annular ligament. The annular ligament in the forearm:
A Encircles the head of the radius
B Encircles the head of the ulna
C Encircles the styloid process of the radius
• Goes from the olecranon fossa to the olecranon process
E. Spans the space between the ulna and radius
The annular ligament is an important structure in the elbow joint. It specifically stabilizes the proximal radioulnar joint by holding the head of the radius in place as it articulates with the ulna.
The correct description of the annular ligament is:
A. Encircles the head of the radius
Branches of the brachial artery contribute to the anastomotic circulation around the: -
A Acromioclavicular joint
B Elbow joint
C Glenohumeral joint
D Head of the humerus
E Scapula
The brachial artery provides several branches that contribute to the anastomotic circulation around the elbow joint, ensuring adequate blood supply to the area despite movements that might otherwise impede blood flow.
Therefore, the correct answer is:
B. Elbow joint
A rugby player sustained injury to his right supraspinatus muscle. Injury to the supraspinatus muscle will affect:
A Adduction of the humerus
B Abduction of the humerus above the horizontal plane
C Lateral rotation of the humerus
D Initiation of abduction of the humerus
E Superior rotation of the scapula
The supraspinatus muscle is primarily responsible for initiating the first 15 degrees of abduction of the humerus at the shoulder joint. Injury to this muscle would specifically impair this initial movement, though full abduction can still be carried out by the deltoid muscle after the first 15 degrees.
Therefore, the correct answer is:
D. Initiation of abduction of the humerus
While performing mastectomy, the surgeon injured the lateral thoracic artery. The lateral thoracic artery:
A Is a branch of the subclavian artery
B Is a branch of the brachial artery
C Accompanies the long thoracic nerve to the serratus anterior muscle
D Accompanies the thoracodorsal nerve to the serratus anterior muscle
E Emerges through the triangular space
The lateral thoracic artery is a branch of the axillary artery, specifically from its second part. This artery accompanies the long thoracic nerve and supplies blood to the serratus anterior muscle, among other structures.
Therefore, the correct answer is:
C. Accompanies the long thoracic nerve to the serratus anterior muscle
A young gymnast sustained injury to a muscle that acts to depress the glenoid fossa directly. Which of the following is a muscle that acts to depress the glenoid fossa directly?
A Pectoralis minor
B Serratus anterior
C Pectoralis major
D Latissimus dorsi
E Supraspinatus
The muscle that acts to depress the glenoid fossa directly is the pectoralis minor. This muscle attaches to the coracoid process of the scapula and, when contracted, it pulls the scapula forward and downward, which in turn depresses the glenoid fossa.
Therefore, the correct answer is:
A. Pectoralis minor
The common flexor tendon of the forearm was avulsed from its attachment. Which of the following muscles originates from the common flexor tendon of the forearm?
A Flexor digitorum superficialis
B Flexor digitorum profundus
C Flexor pollicis longus
D Pronator quadratus
E Extensor carpi ulnaris
The common flexor tendon of the forearm is the origin for several muscles located in the superficial and intermediate layers of the anterior (flexor) compartment of the forearm. One of the primary muscles that originates from this tendon is the flexor digitorum superficialis.
Therefore, the correct answer is:
A. Flexor digitorum superficialis
Which of the following muscle combinations will work together to abduct the wrist?
A’ Pronator teres and brachioradialis
B Palmaris longus and extensor digitorum
C Extensor carpi radialis brevis and flexor carpi radialis
D Extensor carpi radialis brevis and extensor carpi ulnaris
E Supinator and extensor pollicis longus
The correct answer is D) Extensor carpi radialis brevis and extensor carpi ulnaris.
The abduction of the wrist is the movement of the hand away from the midline of the body. This motion is primarily accomplished by the combined action of two muscles:
- Extensor carpi radialis brevis: This muscle originates from the lateral epicondyle of the humerus and inserts into the base of the third metacarpal bone. When contracted, it extends and abducts the wrist.
- Extensor carpi ulnaris: This muscle originates from the lateral epicondyle of the humerus and inserts into the base of the fifth metacarpal bone. When contracted, it extends and abducts the wrist.
The other muscle combinations mentioned in the options are involved in different movements of the wrist and forearm:
A) Pronator teres and brachioradialis are involved in pronation and flexion of the forearm, respectively.
B) Palmaris longus and extensor digitorum are involved in flexion of the wrist and extension of the digits, respectively.
C) Extensor carpi radialis brevis and flexor carpi radialis are involved in abduction and flexion of the wrist, respectively.
E) Supinator and extensor pollicis longus are involved in supination of the forearm and extension of the thumb, respectively.
Therefore, the correct combination of muscles responsible for abducting the wrist is extensor carpi radialis brevis and extensor carpi ulnaris.
Which of the following statements regarding adduction of the digits of the hand is CORRECT?
A The palmar interosseous muscles are the sole adductors
of the digits
B The lumbrical muscles produce adduction of the digits
C There are two muscles that produce adduction of the thumb
D All of the adductors of the digits take at least part of
their attachments from metacarpalbones
E Adduction of the digits will be affected by carpal tunnel syndrome
The correct statement regarding adduction of the digits of the hand is D) All of the adductors of the digits take at least part of their attachments from metacarpal bones.
Explanation:
A) Incorrect. The palmar interossei are not the sole adductors of the digits. The lumbrical muscles and the adductor pollicis also contribute to adduction.
B) Correct. The lumbrical muscles are responsible for adduction of the fingers at the metacarpophalangeal joints.
C) Incorrect. There is only one muscle specifically responsible for adduction of the thumb, which is the adductor pollicis.
D) Correct. All of the muscles responsible for adduction of the digits take at least part of their attachments from the metacarpal bones. The lumbrical muscles originate from the tendons of the flexor digitorum profundus and insert onto the radial side of the proximal phalanges and extensor expansions. The palmar interossei originate from the sides of the metacarpal bones and insert onto the bases of the proximal phalanges and extensor expansions. The adductor pollicis originates from the capitate bone and the bases of the 2nd and 3rd metacarpals and inserts onto the base of the proximal phalanx of the thumb.
E) Incorrect. Carpal tunnel syndrome primarily affects the median nerve, which does not directly innervate the muscles responsible for adduction of the digits. Carpal tunnel syndrome can affect the thenar and hypothenar muscle groups, which are responsible for abduction and opposition of the thumb and little finger, respectively.
Therefore, the correct statement is D) All of the adductors of the digits take at least part of their attachments from metacarpal bones.
A victim of a road traffic accident has a severed nerve in her right upper limb resulting in loss of adduction of all the digits of the right hand.
Which nerve controls adduction of all the digits of the hand?
A Ulnar nerve
B Median nerve
C Radial nerve
D Upper subscapular nerve
E Musculocutaneous nerve
The correct answer is A) Ulnar nerve. The ulnar nerve innervates the intrinsic muscles of the hand, which are responsible for various movements, including adduction of the digits. When the ulnar nerve is damaged, as in the case of a severed nerve in the right upper limb, it can result in the loss of adduction of the digits of the affected hand. This condition is known as ulnar nerve palsy.
Source:
• Nerve injuries of the hand: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5982572/
During surgery to remove a lump from the axilla, a nerve originating from the lateral cord of the brachial plexus was injured. Which of the following nerves originates from the lateral cord of the brachial plexus?
A Ulnar
B Medial pectoral
C Suprascapular
D Lateral pectoral
E Thoracodorsal
The correct answer is D) Lateral pectoral nerve.
The lateral cord of the brachial plexus gives rise to several nerves, one of which is the lateral pectoral nerve. This nerve innervates the pectoralis major muscle, assisting in its function.
Source:
• Brachial Plexus Anatomy: https://teachmeanatomy.info/upper-limb/nerves/brachial-plexus/
A rugby player sustained spinal cord injury at spinal level C8. What is likely to be seen in this patient?
A The brachialis muscle will be paralysed
B The muscles innervated by the radial nerve that would most likely be affected would be the most proximal ones
C The hypothenar muscles would be completely paralysed
D Innervation to the deltoid muscle would be affected
E The patient, would be unable to flex their humerus
A rugby player who sustained a spinal cord injury at the C8 level is likely to experience specific neurological deficits based on the functions innervated by the C8 nerve roots. Here is an analysis of the options provided:
- The brachialis muscle is primarily innervated by the musculocutaneous nerve, which originates from the C5 and C6 nerve roots. Therefore, a C8 spinal cord injury would not typically affect the brachialis muscle.
- The radial nerve innervates muscles in the posterior compartment of the arm and forearm, including the triceps brachii and the extensor muscles of the forearm. Since the radial nerve receives contributions from C5 to T1, a C8 injury would not selectively affect the most proximal muscles but could impact the muscles innervated by the C8 and T1 roots, which are more distal.
- The hypothenar muscles are innervated by the ulnar nerve, which receives fibers from the C8 and T1 nerve roots. A C8 spinal cord injury could indeed affect the hypothenar muscles, potentially leading to paralysis or significant weakness in these muscles[4][6].
- The deltoid muscle is innervated by the axillary nerve, which originates from the C5 and C6 nerve roots. Therefore, a C8 spinal cord injury would not affect the innervation to the deltoid muscle[3][5].
- Flexion of the humerus at the shoulder joint involves muscles such as the deltoid (anterior fibers) and the pectoralis major, which are innervated by nerves originating from the C5 and C6 nerve roots. Thus, a C8 spinal cord injury would not typically impair the ability to flex the humerus[5].
The most likely outcome for a patient with a C8 spinal cord injury is that the hypothenar muscles would be completely or significantly paralyzed due to the involvement of the ulnar nerve, which is innervated by the C8 and T1 nerve roots. Therefore, the correct answer is:
C. The hypothenar muscles would be completely paralysed
The intertubercular groove of the humerus contains the:
A Tendon of the pectoralis minor muscle
B Tendon of the long head of the triceps brachii muscle
C Tendon of the coracobrachialis muscle
D Tendon of the short head of the biceps brachii muscle
E Tendon of the long head of the biceps brachii muscle
The intertubercular groove of the humerus, also known as the bicipital groove, contains the tendon of the long head of the biceps brachii muscle. This groove is a deep indentation on the humerus that separates the greater tubercle from the lesser tubercle and allows for the passage of the long tendon of the biceps brachii muscle, which is enveloped in a synovial sheath[2][3][4][6].
Therefore, the correct answer is:
E. Tendon of the long head of the biceps brachii muscle
Sources
[1] Radiographic anatomy of the intertubercular groove of the humerus https://pubmed.ncbi.nlm.nih.gov/3996427/
[2] Intertubercular sulcus - AnatomyZone https://anatomyzone.com/articles/intertubercular-sulcus/
[3] Bicipital groove - Wikipedia https://en.wikipedia.org/wiki/Bicipital_groove
[4] The Humerus - Proximal - Shaft - Distal - TeachMeAnatomy https://teachmeanatomy.info/upper-limb/bones/humerus/
[5] Intertubercular Tendon Sheath | Complete Anatomy - Elsevier https://www.elsevier.com/resources/anatomy/connective-tissue/connective-tissue-of-upper-limb/intertubercular-tendon-sheath/21848
[6] Review of Bicipital Groove Morphology and Its Analysis in North … https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392950/
[7] Intertubercular Sulcus | Complete Anatomy - Elsevier https://www.elsevier.com/resources/anatomy/skeletal-system/appendicular-skeleton/intertubercular-sulcus/24211
[8] Humerus: Anatomy and clinical notes - Kenhub https://www.kenhub.com/en/library/anatomy/the-humerus
A young man presented in A&E following a street fight with profuse bleeding from the superior ulnar collateral artery. The superior ulnar collateral artery is a direct branch of which artery?
A Ulnar
B Radial
C Brachial
D Profunda brachii
E Axillary
Based on the information provided in the search results, the correct answer is C) Brachial artery.
The key evidence comes from the following excerpts:
“The superior ulnar collateral artery is a vessel arising from the brachial artery at the middle part of the arm.”
[2] “The superior ulnar collateral artery arises from the brachial artery.”
[3] “The superior ulnar collateral artery (inferior profunda artery), of small size, arises from the brachial artery a little below the middle of the arm.”
Multiple authoritative sources clearly state that the superior ulnar collateral artery originates as a branch from the brachial artery in the middle/upper arm region. Therefore, the brachial artery is the direct parent vessel that gives rise to the superior ulnar collateral artery. [2][3]
Sources
[1] Superior ulnar collateral artery | Radiology Reference Article https://radiopaedia.org/articles/superior-ulnar-collateral-artery?lang=gb
[2] Superior Ulnar Collateral Artery | Complete Anatomy - Elsevier https://www.elsevier.com/resources/anatomy/cardiovascular-system/arteries/superior-ulnar-collateral-artery/19414
[3] Superior ulnar collateral artery - Wikipedia https://en.wikipedia.org/wiki/Superior_ulnar_collateral_artery
[4] Superior Ulnar Collateral Artery Anatomy, Function & Diagram https://www.healthline.com/human-body-maps/superior-ulnar-collateral-artery/male
[5] Inferior ulnar collateral artery - Wikipedia https://en.wikipedia.org/wiki/Inferior_ulnar_collateral_artery
[6] Anterior ulnar recurrent artery - Wikipedia https://en.wikipedia.org/wiki/Anterior_ulnar_recurrent_artery
[7] Ulnar artery: Branches, definition, clinical notes - Kenhub https://www.kenhub.com/en/library/anatomy/the-ulnar-artery
[8] Posterior ulnar recurrent artery - Wikipedia https://en.wikipedia.org/wiki/Posterior_ulnar_recurrent_artery
[9] Brachial artery: Anatomy and branches - Kenhub https://www.kenhub.com/en/library/anatomy/brachial-artery
[10] Medial collateral artery - Wikipedia https://en.wikipedia.org/wiki/Medial_collateral_artery
[11] Radial collateral artery - Wikipedia https://en.wikipedia.org/wiki/Radial_collateral_artery
[12] Brachial artery - Wikipedia https://en.wikipedia.org/wiki/Brachial_artery
[13] Anatomy, Shoulder and Upper Limb, Profunda Brachii Artery - NCBI https://www.ncbi.nlm.nih.gov/books/NBK542225/
[14] Ulnar nerve - Wikipedia https://en.wikipedia.org/wiki/Ulnar_nerve
[15] Brachial artery | Radiology Reference Article | Radiopaedia.org https://radiopaedia.org/articles/brachial-artery?lang=gb
[16] Superior ulnar collateral artery - e-Anatomy - IMAIOS https://www.imaios.com/en/e-anatomy/anatomical-structure/superior-ulnar-collateral-artery-1553673144
[17] Posterior ulnar recurrent artery | Radiology Reference Article https://radiopaedia.org/articles/posterior-ulnar-recurrent-artery?lang=gb
The primary ventral rami of the brachial plexus muscles
A Emerge from between the middle and posterior scalene
B Are formed from spinal levels C7 to T3
C Do not give rise to any nerves directly
D Form the trunks of the brachial plexus
E: Combine to form the cords of the brachial plexus
The correct answer is D) Form the trunks of the brachial plexus.
The key evidence from the search results:
[2] “The brachial plexus consists of roots, trunks, divisions, cords and terminal branches as it travels from proximal to distal upper limb…Roots are formed between the scalenus anterior and scalenus medius muscles by the anterior rami of C5-C8 and T1 nerve roots…Trunks form from the roots as they pass between scalenus anterior and medius muscles.”
[3] “The ventral rami of C5 to T1 are referred to as the “roots” of the plexus…Shortly after emerging from the intervertebral foramina, the 5 roots (C5-T1) unite to form 3 trunks.”
[4] “The brachial plexus is formed by the anterior rami (divisions) of cervical spinal nerves C5, C6, C7 and C8, and the first thoracic spinal nerve, T1…The ‘roots’ refer the anterior rami of the spinal nerves that comprise the brachial plexus.”
[5] “The brachial plexus is formed by the anterior primary rami of C5 through T1…The 3 trunks continue from the posterior triangle into the axilla, with C5 and C6 roots forming the superior trunk, C8 and T1 roots forming the inferior trunk, and the C7 root continuing as the middle trunk.”
Multiple authoritative sources clearly state that the ventral/anterior rami of the spinal nerves C5-T1 form the roots of the brachial plexus, and these roots then combine to form the three trunks (superior, middle, inferior) of the brachial plexus. Therefore, the primary ventral rami directly give rise to and form the trunks of the brachial plexus. [2][3][4][5]
Sources
[1] Anatomy of the Ventral Rami, Upper Trunk, and Its Divisions and … https://www.sciencedirect.com/science/article/abs/pii/B9780124103900000408
[2] Brachial plexus | Radiology Reference Article | Radiopaedia.org https://radiopaedia.org/articles/brachial-plexus?lang=gb
[3] Overview, Gross Anatomy, Blood Supply of the Brachial Plexus https://emedicine.medscape.com/article/1877731-overview
[4] The Brachial Plexus - Sections - Branches - TeachMeAnatomy https://teachmeanatomy.info/upper-limb/nerves/brachial-plexus/
[5] Anatomy, Head and Neck: Brachial Plexus - StatPearls - NCBI https://www.ncbi.nlm.nih.gov/books/NBK531473/
The muscle producing the main movement of the proximal radioulnar joint was paralysed following a stab wound to the cubital fossa. Which of the following muscles produces the main movement Pronation
A Extensor carpi ulnaris
B Pronator teres
C Triceps brachii
D Brachioradialis
E Brachialis
Based on the information provided in the search results, the correct answer is B) Pronator teres.
The key evidence comes from the following excerpts:
[1] “The muscles that act on the proximal radioulnar joint to produce pronation are pronator quadratus and pronator teres. The force of the pronator teres is included in fast movements and movements against resistance.”
[2] “Pronation: Produced by the pronator quadratus and pronator teres.”
[3] “Rotatory movements of the head of the radius within the collar formed by the annular ligament and the radial notch, allowing…pronation (by the action of pronator teres and pronator quadratus muscles).”
Multiple authoritative sources clearly state that the pronator teres muscle is one of the primary muscles responsible for producing the pronation movement at the proximal radioulnar joint. The pronator teres is specifically mentioned as being involved in faster, more forceful pronation movements.
Therefore, if the muscle producing the main pronation movement at the proximal radioulnar joint was paralyzed following a stab wound to the cubital fossa (where the pronator teres passes through), the paralyzed muscle would be the pronator teres. [1][2][3]
Sources
[1] Proximal radioulnar joint: Anatomy, movements - Kenhub https://www.kenhub.com/en/library/anatomy/proximal-radioulnar-joint
[2] The Radioulnar Joints - TeachMeAnatomy https://teachmeanatomy.info/upper-limb/joints/radioulnar-joints/
[3] Proximal radioulnar joint | Radiology Reference Article - Radiopaedia https://radiopaedia.org/articles/proximal-radioulnar-joint-2?lang=gb
[4] elbow and radio-ulnar joints https://ouhsc.edu/bserdac/dthompso/web/namics/elbow.htm
[5] Elbow joint: Anatomy, ligaments, movements, blood supply | Kenhub https://www.kenhub.com/en/library/anatomy/elbow-joint
Which of the following statements is CORRECT regarding the extensor retinaculum of the wrist?
A It is a direct extension of the axillary fascia
B The median nerve runs deep to it
C The tendon of the brachioradialis muscle runs through
D It contains a compartment for the thenar muscles
E It prevents the tendons of the posterior compartment of the forearm from ‘bowstringing’ when the hand is extended at the wrist
E) It prevents the tendons of the posterior compartment of the forearm from ‘bowstringing’ when the hand is extended at the wrist.
This statement is correct based on the information provided in the search results:
[1] “The extensor retinaculum of the wrist holds the extensor tendons in position and prevents bowstringing of the tendons.”
[2] “Extensor Retinaculum helps to keep the extensor tendons in alignment and prevent bowstringing during movements.”
[3] “The extensor retinaculum is a thickened portion of the antebrachial fascia that holds the tendons of the extensor muscles in place…It is located on the back of the forearm, just proximal to the hand.”
[4] “The extensor retinaculum of the wrist is the broad ligamentous sheet located at the dorsal aspect of the wrist and functions to keep the extensor tendons in alignment and prevent bowstringing during movement.”
Multiple authoritative sources clearly state that the main function of the extensor retinaculum is to prevent the extensor tendons passing through the posterior compartment of the forearm from bowstringing or deviating away from the wrist when the hand is extended. [1][2][3][4]
The other options are incorrect based on the information given:
A) It is not an extension of the axillary fascia, but rather the antebrachial fascia.
B) The median nerve does not run deep to the extensor retinaculum.
C) The brachioradialis tendon does not pass through the extensor retinaculum compartments.
D) It does not contain a compartment for the thenar (intrinsic hand) muscles.
Sources
[1] Extensor Retinaculum of Wrist | Complete Anatomy - Elsevier https://www.elsevier.com/resources/anatomy/connective-tissue/fasciae/extensor-retinaculum-of-wrist/17913
[2] Extensor Retinaculum (Wrist) - Physiopedia https://www.physio-pedia.com/Extensor_Retinaculum_%28Wrist%29
[3] Extensor retinaculum of the hand - Wikipedia https://en.wikipedia.org/wiki/Extensor_retinaculum_of_the_hand
[4] Extensor retinaculum (wrist) | Radiology Reference Article https://radiopaedia.org/articles/extensor-retinaculum-wrist?lang=gb
[5] The extensor retinaculum of the wrist - PubMed https://pubmed.ncbi.nlm.nih.gov/6747233/
A 28-year-old woman undergoing ovarian stimulation for IVF presents with severe abdominal pain, ascites, and difficulty breathing. Laboratory results show elevated hematocrit and leukocytosis. What is the most appropriate initial management for severe ovarian hyperstimulation syndrome (OHSS)?
Options:
1. Immediate laparotomy 2. High-dose corticosteroids 3. Intravenous fluids and anticoagulation 4. Oral contraceptive pills 5. Watchful waiting
Correct Answer:
3. Intravenous fluids and anticoagulation
Explanation:
Severe ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation characterized by enlarged ovaries, fluid accumulation in the abdomen (ascites), and a risk of thromboembolism due to hemoconcentration. Management includes supportive care with intravenous fluids to maintain intravascular volume, anticoagulation to prevent thromboembolic events, and careful monitoring. Immediate laparotomy and high-dose corticosteroids are not indicated. Oral contraceptive pills are not useful in the acute management of OHSS. Watchful waiting is inappropriate due to the severity of the symptoms and the potential for rapid deterioration.
Explanation
It is important to ascribe a severity to cases of OHSS for audit purposes, and a classification of mild, moderate, severe or critical exists.
Features of severe OHSS include: Clinical ascites (± hydrothorax)
Oliguria (< 300 ml/day or < 30 ml/hour)
Haematocrit > 0.45
Hyponatraemia (sodium < 135 mmol/l)
Hypo-osmolality (osmolality < 282 mOsm/kg)
Hyperkalaemia (potassium > 5 mmol/l)
Hypoproteinaemia (serum albumin < 35 g/l)
Ovarian size usually > 12 cma
Reference:
Royal College of Obstetricians and Gynaecologists (RCOG) Ovarian Hyperstimulation Syndrome, Management (Green-top Guideline No. 5).
