eMedici - GenMed 1/3

Question 1

Presentation - Eva is a 46-year-old woman who attends her local health centre for review of a blood test. Her last blood test showed a corrected total calcium level of 2.45 mmol/L and she had not had hypercalcaemia prior to this. A previous routine blood examination six months earlier was normal. She had presented to the clinic last week for a check-up, with a two month history of feeling vaguely unwell and tired. On the basis on the calcium result, her blood tests were repeated and the results are now available. Which one of the following most accurately reflects her corrected total calcium?
- 1.38 mmol/L
- 2.28 mmol/L
- 2.42 mmol/L
- 2.68 mmol/L
- 3.0 mmol/L

Answer 1

= 2.68 mmol/L

Question 2

Which one of the following is the most likely cause for the hypercalcaemia?
- Sarcoidosis
- Vitamin D toxicity
- Primary hyperparathyroidism
- Spurious result
- Multiple myeloma

Answer 2

Primary hyperparathyroidism

Question 3

Investigations - Primary hyperparathyroidism and malignancy account for >90% of hypercalcaemia cases. In patients with known malignancy, it is important to assess for disease progression and possible metastases. Multiple myeloma should be suspected in patients with hypercalcaemia and a history of acute renal failure, anaemia or pathological fracture. Urinary Bence-Jones protein and a serum paraprotein screen should be done in these cases. Vitamin D toxicity is uncommon in healthy patients, but should be considered when there is underlying renal impairment. Drugs such as lithium and thiazide diuretics may also contribute to hypercalcaemia. Eva’s only clinical complaint is a one month history of fatigue. A blood sample is sent for PTH level and vitamin D metabolites estimation. Eva’s PTH level is 9.9 pmol/L (N: 1.0-7.0) and her vitamin D level is normal.

Answer 3

DEXA scan & Urinary calcium/creatinine clearance ratio

Question 4

Aetiology - Both primary hyperparathyroidism and familial hypocalciuric hypercalcaemia (FHH) will result in a high or inappropriately normal PTH level despite hypercalcaemia. PTH, which stimulates osteoclastic activity and works to increase serum calcium, should normally decrease in response to a high total calcium level. FHH is a rare autosomal dominant condition linked to mutations in the calcium sensing receptor gene (CASR). Patients with FHH are typically asymptomatic with a mild, longstanding hypercalcaemia and usually require no treatment. The underlying pathophysiology in FHH may be due to increased calcium reabsorption in renal tubules. Eva’s calcium/creatinine clearance ratio is 1.2 and a diagnosis of primary hyperparathyroidism is made.

Answer 4

= Parathyroid adenoma, Parathyroid hyperplasia, & Parathyroid carcinoma

Question 5

Management - Primary hyperparathyroidism is most commonly due to an adenoma in one or two parathyroid glands (85%). Parathyroid hyperplasia is the next most common cause, and parathyroid carcinoma is more rarely implicated. A history of radiation to the head or neck, multiple endocrine neoplasia 1 (MEN-1) and older age are risk factors for developing primary hyperparathyroidism. Eva undergoes a DEXA scan that shows a bone mineral density (BMD) T-score of -1.4 at AP spine and -0.9 at total Hip. She has no fractures and her eGFR is >60 ml/min.

Answer 5

= Sestamibi scan and neck ultrasound

Question 6

Which one of the following is the most appropriate next step in management?
- Intravenous rehydration
- Cinacalcet
- Calcitonin
- Pamidronate
- Parathyroidectomy
- Denosumab

Answer 6

= Intravenous rehydration

Question 7

Risks - Eva’s hypercalcaemia responds well to intravenous rehydration and her total calcium level drops to 2.7 mmol/L. Her pancreatitis is managed conservatively and her abdominal pain resolves over the next couple of days. The option of parathyroidectomy is discussed once again and Eva is now keen to have the surgery. She is counselled on the risks associated with the procedure. Which of the following risks are specifically associated with parathyroidectomy?

Answer 7

= Vocal cord paralysis & Hypocalcaemia

Question 8

What are the Clinical complications of hypercalcaemia?

Answer 8

Question 9

What 4 things should you consider in the assessment of a patient with hypercalcaemia?

Answer 9

Question 10

What is Jay’s Glasgow Coma Scale score?

Answer 10

= 13 - Jay’s opens his eyes to verbal commands (3), and is confused (4) but obeys motor commands (6) even though it takes several times to prompt him (6). A score of 15 would be the highest score and indicates normal neurological function.

Question 11

Investigations - After being reassured that Jay’s airway is patent and protected you assess his breathing. He is breathing deeply, has a tachypnoea and the breath sounds and expansion are normal and equal over both lung fields. You also note a sweet smell on his breath and Jay’s mucous membranes are dry. The rest of his physical examination is unremarkable. With help from the nurse you both insert two large bore cannulae into Jay’s antecubital fossae and take some baseline bloods. Which of the following laboratory investigations would be appropriate at this stage?

Answer 11

= Full blood count, Serum biochemistry, Blood sugar level, Liver function tests, Arterial blood gas analysis, Blood and urine ketones, Urinary drug screen, Blood cultures.

Question 12

Which of the following are potential explanations for these biochemical findings?
- Alcoholic ketoacidosis
- Anion gap acidosis
- Diabetic ketoacidosis
- Ethylene glycol toxicity
- Cocaine toxicity

Answer 12

= All except Cocaine toxicity

Question 13

Fluid balance - Further results are obtained:
- Blood sugar *40mmol/L
- Ketones * 5.2mmol/L
confirming a diagnosis of diabetic ketoacidosis. Jay’s condition appears to be worsening. In addition to the Kussmaul respiration, he is dehydrated and lapsing in and out of consciousness. He needs prompt resuscitation.

Which one of the following combinations is required at this stage?

Answer 13

Intravenous fluids and insulin

Question 14

Which of the following may have precipitated the diabetic ketoacidosis?
- Infection?
- Cocaine drug use?
- Non-compliance with medication?
- Insulin Overdose?

Answer 14

= Infection, Cocaine drug use, Non-compliance with medication.

Question 15

Which of the following investigations are likely to be of value in determining the cause of his diabetic ketoacidosis?
- Urine culture
- Chest X-ray
- Glycosylated haemoglobin (HbA1c)
- Upper abdominal ultrasound

Answer 15

= Chest X-ray

Question 16

Management - Jay is now transferred to the high dependency unit for close monitoring. Three hours after admission he has been given three litres of Hartmann’s and 20 units of actrapid insulin. A further litre of Hartmann’s is planned for the next two hours and the insulin infusion will continue at 5 units per hour. If on retesting it was found that his pH was now 7.1 and his blood glucose was 14 mmol/L what management plans would need to be instituted?

Answer 16

Add potassium to the intravenous fluid replacement regimen & Change the intravenous fluid regimen to include dextrose 5%

Question 17

Which of the following diagnoses must be considered?
- Inflammatory bowel disease
- Carcinoma of the colon
- Infectious colitis
- Diverticulitis
- Irritable bowel syndrome
- Mesenteric ischaemia

Answer 17

Question 18

History - With these possible diagnoses to consider, it is important to ask further questions to try and clarify the clinical picture. Select all the other questions that should be asked.

Answer 18

Quantitative and qualitative information on bowel motions, Family history of IBD, Constitutional Symptoms: weightloss, malaise, anorexia, Recent travel, Current medication.

Question 19

Which initial investigations would be appropriate?

Answer 19

Question 20

Colonoscopy - Lars is reviewed in the clinic after some investigation have been performed. He has a mild normocytic anaemia with an elevated white cells count, elevated ESR 30 mm/hr and C-reactive protein (CRP) 50 mg/ dL. Stool analysis is negative for common pathogens. Faecal calprotectin is raised. His liver function test and metabolic profile are unremarkable. A decision is made to refer Lars for a gastroenterological opinion. The gastroenterologist agrees that the likely diagnosis is ulcerative colitis and decides to perform an urgent colonoscopy the following week. Which of the following are the macroscopic features the gastroenterologist will look for to confirm this diagnosis?

Answer 20

= Backwash ileitis, Pseudopolyps, Broad-based ulcers, Inflammation that starts in the rectum and extends proximally.

Question 21

Choose the first line treatment for ulcerative colitis.

Answer 21

= Oral and rectal 5-ASA (mesalazine)

Question 22

Drug side effects - Lars is started on sulfasalazine (5-ASA) 2g twice daily and mesalazine enema 1g each night. He is monitored over the next 10 - 14 days, but despite complying with therapy, fails to achieve resolution of his rectal bleeding or improvement in diarrhoea. Lars is now commenced on oral prednisolone 40mg daily with the aim to reassess response to therapy again in the next 2-4 weeks. Prednisolone up to 1mg/kg/daily can be used in a tapering fashion usually over a 6-8 week period. Lars is warned about the potential side effects of this drug. Which of the following are recognised side effects of prednisolone?

Answer 22

Question 23

Which of the following management options would be appropriate?
- Commence antibiotic therapy
- Intravenous fluid therapy
- Antidiarrhoeal agents
- Intravenous hydrocortisone 100mg 6 hourly
- Prophylactic anticoagulation
- Opioid analgesia
- Methotrexate
- Consider infliximab if the patient fails to respond to intravenous corticosteroid therapy

Answer 23

Question 24

What additional conditions need to be excluded with this acute presentation?

Answer 24

Clostridium difficile colitis & CMV colitis - In an acute flare up of ulcerative colitis in a patient that has achieved substantial remission, other potential infections with cytomegalovirus (CMV) and Clostridium difficile need to be considered.

Question 25

Surgery - Lars is admitted to hospital for treatment of an acute severe flare of his ulcerative colitis. The cause of this flare is not clear. During this admission his case is discussed with the surgeons with a view to colectomy. What are the indications for surgical management in ulcerative colitis?

Answer 25

Acute severe colitis that fails to respond to medical therapy Toxic dilatation of the colon (toxic megacolon) Refractory haemorrhage Perforation of the colon Failure of medical therapy to achieve sustained clinical remission Colorectal cancer risk in chronic colitis. Lars is reviewed by a surgeon to discuss the option of colectomy. Despite best practice medical management and regular infliximab infusions, Lars fails to achieve reduction of his inflammatory markers and improvement of his symptoms. Due to the patient's inability to achieve substantial remission he elects to undergo a colectomy.

Question 26

Which of the following are risk factors or diseases that could result in Franz's jaundice? - Haemolysis - Intravenous drug use - Recent antibiotic use - Recent travel to South-East Asia - Hydatid disease - Heavy alcohol consumption - Gall stones - Inflammatory bowel disease - Haemochromatosis

Answer 26

= Haemolysis, Intravenous drug use, Recent antibiotic use, Recent travel to South-East Asia, Heavy alcohol consumption, Gall stones, & Haemochromatosis.

Question 27

History - Franz reports that his symptoms started ten days ago with dark, tea-coloured urine and his stools becoming paler in colour. More information needs to be obtained from the history. Which of the following pieces of information are likely to be of diagnostic value?

Answer 27

Important points on the patient’s medical history (and family history) that should be asked include: - History of gallstones - History of pancreatitis - Known liver disease: cirrhosis, non-alcoholic fatty liver disease - Known malignancy: either primary hepatic or biliary carcinoma, or known metastatic disease - Autoimmune conditions: primary biliary cirrhosis, sclerosing cholangitis, autoimmune hepatitis, any other autoimmune conditions (inflammatory bowel disease, diabetes, thyroid disease, etc) - Storage disorders: haemochromatosis, Wilson’s disease, a1-antitryptsin deficiency - Haemolytic anaemias such as sickle cell anaemia. - History of adverse drug reactions

Question 28

Which of the following are stigmata of chronic liver disease? - Spider naevi/angiomas - Janeway lesions - Gynaecomastia - Head titubation - Palmar erythema - Chvostek sign - Clubbing of the fingernails - Testicular atrophy - Koilonychia - Ascites

Answer 28

Question 29

Which of the diagnoses should be considered? - Cholangitis - Viral hepatitis - Carcinoma of the head of the pancreas - Drug-induced cholestasis - Alcoholic liver disease

Answer 29

= Cholangitis & Drug-induced cholestasis

Question 30

Investigations - From the information gained so far, it is quite likely that some intra-hepatic and post-hepatic causes should be considered. Some investigations will be needed to help determine the cause of Franz's jaundice. Which of the following initial investigations should be undertaken?

Answer 30

A CT scan would not be a first-line investigation. Franz does not have risk factors for cancer and so cancer markers would be an inappropriate first-line investigation. In addition, cancer markers, such as alpha-feto protein and CA 19-9, have poor sensitivity and specificity and are more appropriately used for prognostication in patients with known disease.

Question 31

Physiology - Blood samples are collected and arrangements are made for an ultrasound scan. The pathophysiology of jaundice will be considered. Bilirubin is the breakdown product of which blood component? - Platelets - Lymphocytes - Globin - Haem

Answer 31

**= Haem** Erythrocytes are broken down by Kupffer cells in the liver and reticulo-endothelial system. Iron and globin are recycled. Haem is converted to biliverdin via haem oxygenase, and biliverdin is then reduced to bilirubin via bilirubin reductase.

Question 32

Physiology - Which enzyme is responsible for bilirubin conjugation in the liver? - Lactate dehydrogenase - UDP-glucuronyltransferase - Bilirubin transferase - Beta-glucuronidase

Answer 32

**= UDP-glucuronyltransferase**

Question 33

Physiology - Where does the majority of bile acid reabsorption occur? - Distal colon - Proximal colon - Terminal ileum - Duodenum

Answer 33

**Terminal Ileum** - About 95% of bile acids are reabsorbed in the terminal ileum. Conjugated bilirubin enters the gut then is reduced to urobilinogen which is absorbed by intestinal epithelium and returned to the liver via the enterohepatic circulation. Excess circulating urobilinogen is excreted by the kidneys, giving urine its straw colour.

Question 34

Physiology - Pre-hepatic jaundice results in which combination of stool, urine and urinalysis findings (UA).

Answer 34

= Normal colour urine, no bilirubin on UA, positive urobilinogen on UA, normal stool.

Question 35

Treatment - Whilst awaiting the results of the investigations, Franz wonders if there is something that he can use to help him with the itching. You have just finished revising the pathophysiology of jaundice when the nurse comes to tell you that Mr Ali is complaining about his itchy skin. The nurse would like you to prescribe some medication for his pruritus. Which of the following medications would be appropriate? - Promethazine - Cholestyramine - Naloxone

Answer 35

= Any of these three medications could be considered.

Question 36

Pathology - The results of the blood tests are now available. Which pathological process are they most consistent with? is suspected based on the pattern of LFTs? - Pre-hepatic pathology - Hepatocellular pathology - Cholestatic pathology - Isolated elevated bilirubin

Answer 36

**= Cholestatic pathology** A hepatocellular disease pattern will result in a disproportionate elevation in the serum aminotransferases compared with the alkaline phosphatase, with or without elevation of serum bilirubin, and abnormal tests of synthetic function (albumin, prothrombin time). Common hepatocellular diseases associated with an elevated bilirubin and jaundice include viral and toxic hepatitis (including drugs, herbal therapies, and alcohol) and end-stage cirrhosis from any cause. A cholestatic disease pattern will have a disproportionate elevation in alkaline phosphatase compared with the serum aminotransferases, with or without elevation of serum bilirubin (Image 1), and abnormal tests of synthetic function. The ALP must be twice the upper limit of normal combined with a significant elevation in GGT to be classified as cholestatic injury (Image 2). Cholestasis can be caused by either intra-hepatic or extra-hepatic pathologies. Common causes include partial bile duct obstruction, biliary cirrhosis (primary or secondary), sclerosing cholangitis (primary or secondary), and certain drugs. Franz's biochemical picture on his liver function tests suggests a cholestatic pathology. There is a significant rise in the alkaline phosphatase (ALP) and γ- glutamyl transpeptidase (GGT) which indicates either a post-hepatic obstructive cause (such as cholelithiasis) or intra-hepatic cholestasis (Image 3). Cholestatic injury is defined as an elevation of serum alkaline phosphatase (ALP) to greater than twice the upper limit of normal combined with a major elevation of γ-glutamyl transpeptidase (GGT) with minimal elevation of alanine transaminase (ALT) value. Alternatively, cholestasis is thought to be present when there is an increase in both ALT and ALP, but with an ALT:ALP ratio of < 2. With a pre-hepatic pathology the conjugated bilirubin is significantly elevated indicating a hepatic or post-hepatic cause. In pre-hepatic pathologies, there would be an elevated unconjugated bilirubin with a normal conjugated bilirubin. A hepatocellular pathology is unlikely as there is only a minor rise in alanine aminotransferase (ALT) comparative to alkaline phosphatase (ALP) and γ- glutamyl transpeptidase (GGT). The liver function test shows derangement of liver enzymes as well as elevated bilirubin (Image 4) and therefore the pattern of Isolated elevated bilirubin is not present. Gilbert's syndrome may give an isolated elevation of bilirubin.

Question 37

Which one of the following combinations shows the common patterns of drug-induced liver injury? - Hepatocellular, cirrhotic, obstructive - Obstructive, inflammatory, mixed - Hepatocellular, cholestatic, mixed-picture

Answer 37

= Hepatocellular, cholestatic, mixed-picture

Question 38

Franz is reviewed the following day. Repeat liver function tests show bilirubin has risen, but his other liver enzymes are fairly stable. The other tests that were ordered all come back normal. This included a lipid profile, iron studies, thyroid function test, caeruloplasmin, and autoimmune antibodies (anti-nuclear antibody, anti-neutrophil cytoplasmic antibody, anti-mitochondrial antibody). With gastroenterological input, a (MRCP) is arranged to confidently exclude bile duct obstruction. It confirms no structural biliary or hepatic pathology. It is very likely that celecoxib is the culprit. What investigation could be ordered to confirm the diagnosis of drug-induced cholestasis? - Fibroscan - Fine-slice CT scan - Magnetic resonance cholangiopancreatography (MRCP) - Ultrasound-guided liver biopsy - Antimitochondrial antibodies and IgG4 levels

Answer 38

= Ultrasound-guided liver biopsy

Question 39

Which drugs can cause Drug-induced cholestasis?

Answer 39

Question 40

Presentation - A 82-year-old man presents to his general practitioner with a three week history of increasing tiredness and fatigue. Ken has been off his food during this time and with a decreased appetite has become constipated. He thinks he might have lost a little weight over this time. In the last few days he has developed some discomfort in the right upper quadrant of his abdomen. Ken is normally in good health for his age and the only medications he takes 'are tablets for my blood pressure and something for the cholesterol...' He stopped smoking 15 years ago, with a 25 pack-year history. He enjoys a glass of wine most evenings. The only other illness of note is an episode of diverticulitis two years ago, which required a stay in hospital. He is a retired sheep farmer from Hamilton, Victoria. The doctor does not find anything abnormal on physical examination and thinks a CT scan would be appropriate. Several images from the study are shown. This shows two prominent filling defects in the liver. No other abnormalities are seen on the scan. In which of the liver segments are these lesions located?

Answer 40

The lesions are in segments IV and VI of the liver.

Question 41

Aetiology The Couinaud system of classification divides the liver into eight functional segments, each with its own arterial and portal venous inflow, venous outflow and bile drainage. Two lesions are clearly visible. Thought must be given to possible explanations for these lesions. Which of the following diagnoses need to be considered? - Abscess formation - Haemangioma - Hydatid cysts - Hepatocellular carcinoma - Focal nodular hyperplasia - Metastatic disease - Hepatic cysts

Answer 41

= Metastatic disease

Question 42

Aetiology The Couinaud system of classification divides the liver into eight functional segments, each with its own arterial and portal venous inflow, venous outflow and bile drainage. Two lesions are clearly visible. Thought must be given to possible explanations for these lesions. Which of the following diagnoses need to be considered? - Abscess formation - Haemangioma - Hydatid cysts - Hepatocellular carcinoma - Focal nodular hyperplasia - Metastatic disease - Hepatic cysts

Answer 42

= Metastatic disease

Question 43

Investigations - The appearances are most suggestive of metastatic disease. The General Practitioner had also arranged some laboratory investigations. Which one of the following would be the most appropriate next step in management? - Endoscopic retrograde cholangiopancreatography (ERCP) - Fine needle aspiration biopsy - Tumour markers - Endoscopy and colonoscopy - Magnetic resonance cholangiopancreatography (MRCP) - Positron emission tomography (PET scan)

Answer 43

= Endoscopy and colonoscopy

Question 44

Presentation - Mr. Finchurch is a 23-year-old indigenous man from outback South Australia who presents with 6 weeks of progressive dysphagia. Initially, solid foods such as sandwiches and pies were "sticking in his throat" and after two weeks he started to regurgitate his food. Mr Finchurch is now unable to swallow liquids and is concerned because he has lost 15kg of weight over the 6 weeks despite having a normal appetite. For the past three months, Mr. Finchurch has been weak and easily fatigued and has noticed a mild retrosternal burning pain. He has had no hoarseness of the voice, no cough and no haemoptysis. His past medical and surgical history is unremarkable and he takes no regular medications. He has no known allergies and no family history of atopy. Likely causes of this patient’s dysphagia include which of the following?

Answer 44

Eosinophilic oesophagitis, Achalasia, & Corrosive injury

Question 45

Risk factors - Mr. Finchurch has a 5 pack-year tobacco smoking history, drinks approximately 70g of alcoholic spirits per day and smokes 20 cones of marijuana per day. His father died of oesophageal cancer at the age of 60 and his diet consists of mostly take-away food, with little in terms of fruit and vegetables. Despite his young age, it is important to think about the risk factors for oesophageal cancer. Which of the following are risk factors for squamous cell carcinoma of the oesophagus?

Answer 45

- Male sex - Cigarette smoking - Achalasia - Alcohol consumption - Tylosis

Question 46

Which of the following are risk factors for squamous cell carcinoma of the oesophagus?

Answer 46

Male sex, Cigarette smoking, Achalasia, Alcohol consumption, & Tylosis

Question 47

Investigations - Apart from heavy consumption of cigarettes and alcohol the patient does not appear to have any other risk factors for oesophageal malignancy. On examination the patient is thin and weighs only 49kg. He has pallor of the conjunctiva, is mildly tachycardic and there is a palpable right sided jugulo-digastric lymph node, which is firm, mobile and non-tender. There is no inflammation or pus on the tonsils and no peri-tonsillar abscess. The liver edge is smooth and there is no hepatomegaly. What investigations are indicated at this stage?

Answer 47

= Complete blood examination, Endoscopy ± biopsy, & Serum biochemistry

Question 48

Image interpretation - An endoscopy is arranged to determine the underlying cause of the patient's dysphagia. The following view is obtained in the upper oesophagus. WHat is the most likely diagnosis? - Food bolus impaction - Schatski’s ring - Eosinophilic oesophagitis - Ulcerative oesophagitis - Pharyngeal pouch - Tumour

Answer 48

= Tumour

Question 49

Pathology - Endoscopy demonstrated a proximal 8cm circumferential lesion extending from the upper oesophageal sphincter to 23 cm distal to the incisors (the cardia is measured as 40 cm from the incisors). There was no dilatation of the distal oesophagus, no evidence of Barrett’s epithelium and no mucosal ulceration. A biopsy of the lesion demonstrated masses of atypical eosinophilic keratinising cells surrounded by desmoplastic stroma. A photograph of the haematoxylin and eosin stained tissue is shown. What is the pathological diagnosis? - Non-invasive squamous cell carcinoma - Eosinophilic oesophagitis - Adenocarcinoma of the oesophagus - Gastro-oesophageal reflux disease (GORD) - Invasive squamous cell carcinoma - Leiomyoma

Answer 49

= Invasive squamous cell carcinoma

Question 50

Treatment - With the diagnosis of squamous cell carcinoma confirmed the disease is staged. A CT scan of the neck, chest and abdomen is performed. The primary tumour is identified and there is no evidence of local extension, nodal disease or distant spread. The oesophageal lumen is too narrow to allow passage of the endoscopic ultrasound. This investigation is useful for determining T-staging and identifying local nodal involvement. A staging PET study was also performed. (Image 1) This shows increased uptake within the soft tissue in the upper oesophagus and low grade increased uptake within the right jugulo-digastric lymph node. Apart from some residual tracer at the site of injection in the left arm, the rest of the study shows physiological activity. This patient has a stage III squamous cell carcinoma of the upper oesophagus. What is the most appropriate treatment option? - Palliative care - Surgical resection - Chemotherapy - Radiotherapy - Mesh stent - Multimodal therapy

Answer 50

= Multimodal therapy

Question 51

**Squamous cell carcinoma of the oesophagus** - Risk Factors? - Clinical Presentation?

Answer 51

Question 52

**Squamous cell carcinoma of the oesophagus** - Investigations? - Staging? - Prognosis?

Answer 52

Question 53

Which of the following conditions should be considered in the differential diagnosis? - Bacterial gastroenteritis/colitis - Viral gastroenteritis - Ulcerative colitis - Crohn's disease - Diverticulitis - Colorectal cancer - Irritable bowel syndrome - Ischaemic colitis

Answer 53

= Bacterial gastroenteritis/colitis & Ulcerative colitis

Question 54

Based on the clinical and laboratory findings, which one of the following is the most approximate estimate of Marc’s free body water deficit? - 1L - 1.5L - 2L - 2.5L - 3L - 5L

Answer 54

= 2.5L

Question 55

Which one of the following is the most likely diagnosis? (Also see image on answer) - Crohn's disease - Ulcerative colitis - Infective colitis

Answer 55

**= Ulcerative colitis** The assessment at this stage is a 25-year-old man with acute onset of severe acute colitis manifesting with significant bloody diarrhoea and raised inflammatory markers in the absence of identifiable infection. A flexible sigmoidoscopy crucially shows a continuous and circumferential pattern to the inflammation with almost confluent areas of ulceration, which is typical of ulcerative colitis. In comparison, Crohn’s disease is more likely to be associated with ‘skip lesions’, where there are areas of ulceration with spaces of relatively unaffected tissue in between. There is no proven infection, so infectious colitis would be less likely.

Question 56

Assessment - Marc is showing evidence of an acute colitis, which can be associated with high morbidity and mortality if not promptly recognised and adequately managed. The Truelove and Witts criteria are often used to grade the severity of acute colitis. Which of the following fulfil the Truelove and Witts criteria for severe acute colitis?

Answer 56

1. 6+ bowel movements per day 2. Bloody stools 3. Fever 4. Heart rate >90 beats per minute 5. Anaemia 6. ESR >30mm/hr

Question 57

Assessment - Ulcerative colitis is a type of inflammatory bowel disease, as is Crohn's disease. Which one of the following is more common with ulcerative colitis than Crohn’s disease?

Answer 57

= Potentially curable with colectomy

Question 58

Side effects - Marc is diagnosed with acute severe ulcerative colitis, and commenced on hydrocortisone 100mg IV qid. His disease is thought to predominantly affect the left side of the colon. He is given mesalazine enemas and suppositories, but these are soon ceased due to frequent ongoing diarrhoea. As Marc is on high-dose steroids, he should be aware of their potential side-effects. Which of the following are potential side effects of steroids that the patient should be aware of?

Answer 58

Insomnia and mood changes are well recognised potential side effects of steroid therapy. In some cases, overt mania and psychosis can even occur. Fluid retention, weight gain and hypertension are well recognised side effects, as is hyperglycaemia. While steroids can certainly contribute to a Cushingoid state, there is actually a higher risk of hypocortisolism following cessation of therapy due to HPA axis suppression, particularly if steroids are abruptly discontinued after a prolonged course (generally >2 weeks).

Question 59

Management - It is now three days into Marc’s admission and he is still has ongoing bloody diarrhoea, opening his bowels up to nine times a day. He is also requiring regular intravenous fluids, including potassium supplementation, to maintain his fluid and electrolyte balance. His abdominal X-ray and C-RP are largely unchanged compared to those done on admission. Which one of the following would be the most appropriate plan of ongoing management?

Answer 59

**= Switch to infliximab** As Marc’s acute severe colitis has failed to improve after 72 hours of high-dose intravenous steroids he will require a change in treatment. Anti-TNF-⍺ agents such as infliximab are commonly used as ‘rescue agents’ for patients with acute severe colitis that has failed to respond to steroids. Less commonly used alternatives include cyclosporine. Switching to prednisolone is unlikely to improve the situation as Marc has already shown his disease is not currently responsive to steroids. Furthermore, gastrointestinal absorption may be impaired due to his ongoing diarrhoea. Transitioning to oral prednisolone may be an option as part of an ongoing weaning regimen after there has been an adequate response to intravenous steroids (generally after five days).

Question 60

Which one of the following is this serological pattern most consistent with? - No previous exposure to Hepatitis B - Previous vaccination to Hepatitis B - Previous cleared Hepatitis B infection - Chronic infection with Hepatitis B

Answer 60

= Previous vaccination to Hepatitis B

Question 61

Assuming he is able to achieve remission and consequently reasonable control of his disease with appropriate therapy, which one of the following pieces of advice would be most appropriate? - Annual colonoscopy from 8 years post-diagnosis - Colonoscopy every 2-3 years from 8 years post-diagnosis - Colonoscopy every 5 years from the year of diagnosis - Regular national bowel cancer screening program but from 40 years of age rather than 50 - Regular faecal occult blood test every 2 years from 50-74 years of age as per baseline national bowel cancer screening program.

Answer 61

Colonoscopy every 2-3 years from 8 years post-diagnosis

Question 62

Presentation - A 72-year-old man presents to the Emergency Department with fever, chills, malaise, nausea and anorexia. These symptoms have been present for six weeks but over the last two days have increased in severity and Mr Grassi thought he should seek medical help (Image). For the past week he has also noticed a vague right upper quadrant pain that relapses and remits throughout the day. Since these symptoms started he has lost about two kilograms in weight. Which questions are relevant to Mr Grassi's history?

Answer 62

The initial focus should be on getting as much information as possible about his presenting symptoms. Further definition of the character, severity and frequency of the pain will help differentiate various pathologies. For example a basal pneumonia would likely be a sharp pleuritic pain that worsens on inspiration, whereas hepatitis would be more dull and diffuse. The photograph of the patient does give a strong clue as to where questions should be focused. In this case of right upper quadrant pain, the timing and onset of the pain will, for example, help differentiate between the transient pain of biliary colic and the sustained pain of cholangitis. Questions on changes in skin colour yellowing of his scera might be relevant - if he has jaundice then this will help narrow down the differential diagnoses and suggest either a hepatic or biliary origin. Many drugs, especially antibiotics, can be hepatotoxic or cause jaundice, but it is unlikely this would explain his weight loss. It would be helpful to find out if he had noticed any changes in the colour of his urine and stools. but only relevant if he complains of jaundice. It is then useful in determining whether it is obstructive jaundice.

Question 63

Which one of the following is the most likely diagnoses? - Acute cholecystitis - Right lower lobe pneumonia - Liver abscess - Choledocholithiasis - Viral hepatits

Answer 63

= Liver abscess

Question 64

Which of the following initial investigations would be likely to help with establishing the diagnosis? - Chest X-ray - Ultrasound - MRI - CT - MRCP - ERCP

Answer 64

= Ultrasound & CT

Question 65

Aetiology An ultrasound is performed (Images 1, 2). This shows showed several hypoechoic fluid density lesions. They are heterogenous in nature and with distinct margins, but there is no obvious wall. None of the lesions are located at the peripheries of the liver. Lobulations are not present and there are no daughter cysts. No intra- or extra-hepatic duct dilatation was noted. A follow up CT abdomen is performed (Images 3, 4). This shows several heterogenous lesions in the liver. Venous phase of contrast highlights significant rim enhancement and distinct margins on all the lesions (Image 5). No septae or lobulations are visible. The findings are consistent with liver abscess formation. There are several types of liver abscess. Based on the radiology, which one of the following types is most likely? - Pyogenic - Amoebic - Hydatid - Fungal - Mycobacterial

Answer 65

= Pyogenic

Question 66

Management - The radiological appearances are highly suggestive of pyogenic abscess formation and Mr Grassi is started on empirical antibiotic therapy (amoxicillin, gentamicin, and metronidazole). A longer term management plan must be considered. Which one of the following would be the most appropriate plan of management?

Answer 66

= Percutaneous drainage and antibiotics

Question 67

Aetiology - Mrs Grassi's condition is stabilised with intravenous fluids and broad spectrum antibiotics are started. The underlying cause of the abscess must be determined. There are a number of different ways in which a pyogenic liver abscess can become established. Which one of the following is the most likely cause in this case?

Answer 67

= Portal pyaemia

Question 68

Aetiology - The source of Mr Grassi's liver abscess formation is most likely the gastrointestinal tract. Which one of the following is the most likely underlying problem?

Answer 68

= Diverticular disease

Question 69

What are the 3 major forms of liver abscess? Causes?

Answer 69

The liver abscess is the most common form of visceral abscess worldwide. There are three major forms of liver abscess: 1. Pyogenic abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases developed countries. 2. Amoebic abscess due to Entamoeba histolytica (10% of cases) 3. Hydatid disease, caused by the parasite Echinococcus (less than 10% of cases)

Question 70

Answer 70

Question 71

Which of the following changes are evident in the image? - A solitary gallstone - Multiple gallstones - Thin walled gallbladder - Thick walled gallbladder - Echogenic shadows - Emphysematous cholecystitis

Answer 71

Numerous gallstones can be seen on the inferior aspect of the gallbladder. The gallbladder is thin-walled and several echogenic shadows beyond the gallstones are apparent.

Question 72

With which of the following problems might the patient (Image 5) have presented? - Obstructive jaundice - Acute pancreatitis - Steatorrhoea - Cholangitis - Anaemia - Biliary colic

Answer 72

**= Obstructive jaundice, Acute pancreatitis, Cholangitis & Biliary colic** The patient has a stone in the common bile duct. Whilst stones in this site (or passing through) could remain asymptomatic, they may present with: - obstructive jaundice - acute pancreatitis - cholangitis - biliary colic

Question 73

Presentation - A 65-year-old man is brought into the Emergency Department of a small rural hospital by his wife. She states that George has been 'out of sorts' over the last three days and was unable to get out of bed this morning. He has been confused at times and irritable, which is out of character. She provide information about his history and George was diagnosed with hepatitis C virus (HCV) at the age of 35 after a “rough couple of years experimenting with drugs”. George regularly sees his general practitioner and a specialist in Adelaide about his hepatitis C. His wife is unsure of the specifics but knows that the liver is 'not too good'. She hands over a copy of his last blood tests. Which one of the following is correct regarding the expected laboratory findings in a patient with chronic HCV?

Answer 73

= HCV antibody positive

Question 74

Diagnosis - George is disoriented and drowsy and cannot provide any history. His wife provides a medication list which includes peginterferon α-2a, 180mcg sub-cutaneously, once weekly, and 600mg of ribavirin twice daily. He has not had any previous operations and does not smoke or drink. On examination he is jaundiced and has obvious palmar erythema and Dupuytren's contractures bilaterally (Image 1). He has spider naevi across his chest and back (Image 2). His sclera are markedly icteric (Image 3). His lips and tongue are dry and his breath is offensively malodorous. He is afebrile and has a tachycardia at a regular rate of 110/min. His blood pressure is 120/55 mmHg. His heart sounds are dual with no murmurs. His JVP is not elevated. He has pitting oedema to the mid-calf bilaterally. His chest is clear with no added sounds. His abdomen is distended and there is shifting dullness on percussion. His abdomen is non-tender and no masses are palpable. His liver is not palpable. Neurological examination of the cranial nerves and upper and lower limbs is unremarkable. A urinary catheter is inserted and 5 mls of dark urine is all that is initially drained. Which one of the following is the most likely diagnosis? - Hepatorenal syndrome - Subacute bacterial peritonitis - Variceal haemorrhage - Hepatocellular carcinoma

Answer 74

= Hepatorenal syndrome

Question 75

Management - It is apparent that the most likely explanation for George's current predicament is hepatic and uraemic encephalopathy. He has evidence from the blood results of decompensated liver cirrhosis including hyperbilirubinaemia, mild hypoglycaemia, transaminitis, hypoalbuminaemia and an elevated INR. This has been complicated by acute renal failure, likely secondary to hepatorenal syndrome. Which one of the following would be the most appropriate management strategy for the next 24 hours.

Answer 75

= Arrange for immediate transfer to a tertiary level intensive care

Question 76

Complications - The medical retrieval team in Adelaide is contacted and they indicate that they will arrange prompt retrieval of the patient. In the meantime, intravenous access has been established, a fluid bolus given and maintenance therapy instituted. The hypoglycaemia is corrected. Whilst waiting for the retrieval team to arrive, some thought can be given to the potential complications of cirrhosis. Which of the following can be potential complications of cirrhosis?

Answer 76

Question 77

Treatment - The retrieval team arrive and the patient is moved to Adelaide by air ambulance. On arrival to intensive care unit in Adelaide the diagnosis of hepatorenal syndrome is confirmed. There are many different treatment options available for George. Which of the following treatments have proven benefits in the outcome of hepatorenal syndrome?

Answer 77

= Terlipressin (vasopressin analogue) with albumin & Liver transplant

Question 78

Contraindications - The patient's renal function slowly returns to normal over two weeks. George and his wife are now questioning about the chance of getting a liver transplant. There are certain circumstances which would rule the patient out of being a suitable candidate. Which of the following would be contra-indications for liver transplantation?

Answer 78

= Persisting alcohol abuse, The presence of widespread malignancy, & Inability to comply with medical treatment

Question 79

Which of the following are reasonable explanations for his current symptoms? - Duodenal ulcer - Mallory-Weiss syndrome - Aortoduodenal fistula - Small bowel carcinoid tumour - Carcinoma of the colon - Ulcerative colitis - Ischaemic colitis - Diverticular disease - Angiodysplasia - Haemorrhoids - Anal fissure

Answer 79

= Duodenal ulcer, Aortoduodenal fistula, Diverticular disease.

Question 80

Management - Blood is cross-matched and two units are given. The duty gastroenterological team is contacted and they now take over his management. Three hours after admission Mr Irwin's blood pressure is 120/70 mmHg and his pulse 100/min. A decision must be made as to the next step in his management. Which one of the following is the most appropriate next step in management?

Answer 80

= Gastroscopy

Question 81

What does the examination show? - A normal examination - Duodenal ulcer - A gastric ulcer - Aortoduodenal fistula

Answer 81

**= A normal examination** A good view is obtained from the oesophagus, through the stomach and down in to the second part of the duodenum. The examination is normal. Here is an example of a duodenal ulcer (Image 1). There is blood clot in the base - indicative of recent haemorrhage. A good view of the stomach has been obtained - and it is normal. Here is an example of a benign ulcer on the lesser curve of the stomach (Image 2). There is no evidence of fistula formation in the duodenum.

Question 82

Management - The endoscopy is normal and the gastroenterologists are confident that the source of the bleeding is almost certainly from the large bowel. Shortly after the gastroscopy Mr Irwin passes more fresh blood and clots. His blood pressure is 110/70 mmHg and his pulse 110/min. His abdomen is soft. The results of further laboratory investigations are now available. Which one of the following is the most appropriate next step in management? - Immediate colonoscopy - Lavage followed by colonoscopy - CT angiography - Visceral angiography - Red cell scan

Answer 82

= CT angiography

Question 83

Presentation - Dan Beddoe is a 42-year-old man who is brought into the Emergency Department after a large vomit of blood at home. Dan is accompanied by his wife and together they provide the story. At 3.00am this morning, Dan awoke with nausea and proceeded urgently to the bathroom. He vomited a large amount of blood and then began to feel the need to open his bowels. He passed a large volume of frank blood per rectum. He called out and alerted his wife but when he stood he felt dizzy and lost consciousness. Which of the following are likely anatomical sources of his blood loss?

Answer 83

= Oesophagus, Stomach, & First part of the duodenum

Question 84

Clinical assessment - Dan’s wife found her husband confused on the bathroom floor and immediately called an ambulance. When assessed in the Emergency Department, Dan is confused, sweating and pale. He appears cachectic and his abdomen is grossly distended, with prominent veins on his stomach and chest. Dozens of spider naevi cover his arms, praecordium and neck (Image). His blood pressure is 85/50 mmHg lying, heart rate 128/min, respiratory rate 30/min and the capillary refill time four seconds. The heart sounds are dual with no murmurs heard and his chest is clear throughout. His abdomen is tight but non-tender. His liver span is 7cm and shifting dullness is present. Based on his clinical presentation, approximately how much of his circulating volume has Dan lost? - 0-15% - 15-30% - 30-40% - >40%

Answer 84

**30-40%** - Dan has had a Class III haemorrhage, as suggested by his hypotension, tachycardia >120/min, respiratory rate >30/min, pallor, sweating, delayed capillary refill and his mental state of confusion

Question 85

Which of the following diagnoses need to be considered? - Acute gastritis - Depression - Epistaxis - Gastric cancer - Mallory-Weiss tear - Oesophageal cancer - Oesophageal varices - Peptic ulcer disease - Portal hypertensive gastropathy

Answer 85

= Depression, Oesophageal varices, & Peptic ulcer disease

Question 86

Based on the Child Pugh classification system, which one of the following best estimates the likely 1-year survival?

Answer 86

**= 45%** Dan’s one year survival is estimated at 45% as his clinical and biochemical data fulfil the criteria for Child Pugh Class C cirrhosis based on the scoring system below (Image). The cumulative total based on the criteria is 12 points (3 points for total bilirubin, 2 points for serum albumin, 2 points for INR, 3 points for Ascites and 2 points for hepatic encephalopathy.) The prognostic scores for each Child Pugh class are detailed in the table. For patients with unexpectedly low or high scores, consider comparing with the MELD (Model for End Stage Liver Disease) and MELD-Na score due to their better prognostic value.

Question 87

Which of the following are contraindications for liver transplant in Australia? - Extra-hepatic manifestations of inborn error of metabolism - Inability to co-operate with lifelong medical supervision - Life-threatening non-hepatic illness - Life threatening acute or chronic liver disease not amenable to alternative therapy - Persisting alcohol or substance abuse - Severe neurologic or developmental impairment - The presence of significant malignancy

Answer 87

= Inability to co-operate with lifelong medical supervision, Life-threatening non-hepatic illness, & Persisting alcohol or substance abuse

Question 88

What is the the anatomical determinant for classifying upper versus lower gastrointestinal bleeding?

Answer 88

The ligament of Treitz which attaches from the left crus of the diaphragm to the gut at the duodenojejunal junction has classically been the anatomical determinant for classifying upper versus lower gastrointestinal bleeding. Bleeds proximal to this may present with haematemesis and melaena, whereas bleeds distal to this usually produce frank or partially digested blood. However, it is important to note that massive upper gastrointestinal blood loss or blood loss with exceptionally fast transit time may present before sufficient digestion to melaena has occurred. It is also possible that a lower gastrointestinal bleed may present resembling closer to melaena due to increased transit times allowing for greater digestion, however this is rarer.

Question 89

Presentation - A 56-year-old man presents to his General Practitioner with a two-month history of retrosternal burning pain, worse after meals. The pain starts in his epigastrium and radiates upwards. Initially he was getting good control of his symptoms with an antacid preparation, but his symptoms are now persistent despite regular use of the antacid. He wonders if he can have a prescription for something stronger. Mario's other health issues include type II diabetes and hypertension. He is on metformin and perindopril. He drinks at least two glasses of wine a day and smokes about 10 cigarettes a day. On examination Mario is considerably overweight, with a BMI of 33. His blood pressure is 130/90 mmHg and pulse 90/min. The rest of the physical examination is normal. Which one of the following is the most appropriate initial plan of management?

Answer 89

= Endoscopy Whilst dietetic advice, lifestyle management and a proton pump inhibitor should be part of his overall management, the focus of the management plan must be an endoscopy.

Question 90

History - The General Practitioner has decided that the priority in management must be to arrange an endoscopy for Mario. Why has the doctor made this decision? - The presence of a 'red flag' symptom - The investigation is required prior to prescription of a proton pump inhibitor - The endoscopy will set a baseline for future management

Answer 90

**= The presence of a 'red flag' symptom** Proton pump inhibitors can be purchased over-the-counter. i.e. a prescription is not required and the patient would no need any investigation prior to their use. Baseline endoscopy does not have a role in the standard management of patients with reflux symptoms. Mario has a 'red flag' symptom.

Question 91

Mario's symptoms are of relatively recent onset. Whilst they are almost certain benign in terms of their pathological origins, patients with dyspepsia and so-called 'red flag symptoms' warrant further attention. These are more than just reflux symptoms and include: 1. age 55+ with unexplained and 2. persistent dyspepsia 3. persistent vomiting 4. unintentional weight loss 5. dysphagia 6. epigastric mass 7. chronic gastrointestinal bleeding 8. iron deficiency anaemia Dyspeptic symptoms to consider include heartburn, early satiety, regurgitation and post-prandial fullness. The reason that any of these issues should make the practitioner take action is the possibility of underlying malignancy. With many upper gastrointestinal cancers now occurring in younger age groups, it might be more appropriate to take serious notice of any of these symptoms occurring for the first time in a patient from the age of 40 years onwards. Put in perspective, perhaps some 40% of the population will experience dyspeptic symptoms at some time or other and it is persistence of these symptoms that should be taken seriously. An endoscopy is arranged for Mario. One view is shown at 35 cm from the incisors. What does it show?

Answer 91

= Columnar-lined epithelium

Question 92

Management - The endoscopy has shown changes in the mucosal lining consistent with Barrett's oesophagus. This is a relatively short segment of Barrett's oesophagus, being only some 3 cm in length. In accordance with current management guidelines, 4-quadrant biopsies are taken at 2 cm intervals along the length of the Barrett's epithelium. A good view is obtained to the duodenum and no other abnormalities are seen. The biopsies confirm the diagnosis of Barrett's, showing only changes of intestinal metaplasia. Which one of the following is the most appropriate plan of management?

Answer 92

= Proton-pump inhibitor and endoscopic review in three years

Question 93

Management - Mario is started on a proton-pump inhibitor and arrangements are made for a repeat endoscopy in three years time. In addition he is given advice on lifestyle measures and arrangement made for him to be reviewed by his General Practitioner in three months. Mario heeds the advice, manages to lose some weight and reduces his alcohol and cigarette consumption. His heartburn symptoms improve. At repeat endoscopy at three years, the following view is obtained of his lower oesophagus (Image). Four-quadrant biopsies are taken at 2 cm intervals. The Barrett's oesophagus is now about 6 cm in length. Again, the changes of intestinal metaplasia are noted and in two of the biopsies there is evidence of low grade dysplasia. Which one of the following is the most appropriate plan of management?\ - Double the dose of the proton-pump inhibitor - Repeat the endoscopy and biopsies - pH and manometric studies - Anti-reflux surgery - Endoscopic eradication therapy

Answer 93

= Endoscopic eradication therapy

Question 94

An appropriate range of differential diagnoses would include which of the following? - Carcinoma of the colon - Coeliac disease - Diverticulitis - Infective gastroenteritis - Inflammatory bowel disease

Answer 94

= Coeliac disease, Infective gastroenteritis, & Inflammatory bowel disease

Question 95

Investigations - Given the patient's history and clinical examination, an appropriate range of differentials including bowel cancer, coeliac disease, infective gastroenteritis and inflammatory bowel disease are considered. The patient will require some investigations. Which of the following investigations would be most appropriate at this stage?

Answer 95

Question 96

Which of the further studies would be appropriate? - Abdominal CT - Abdominal X-ray - Colonoscopy with terminal ileum intubation - Endoscopy with duodenal biopsy

Answer 96

= Colonoscopy with terminal ileum intubation

Question 97

Data interpretation - After considering the clinical presentation and initial investigations, a working diagnosis of ulcerative colitis is made. A colonoscopy with ilieal intubation is performed. Biopsies will be taken of colonic tissue and - if feasible - the distal ileum. Macroscopic and histological features help to differentiate between ulcerative colitis and Crohn’s disease. Which of the following features would be consistent with ulcerative colitis?

Answer 97

= Continuous inflammation & Inflammation extending to sub-mucosal layer

Question 98

Diagnosis - Macroscopically, the colonoscopy shows a continuous pancolitis extending from the rectum through to the caecum (image). Some mild inflammatory changes are noted in the terminal ileum. No ulceration, skip lesions, cobblestoning or pseudo polyps are found. Perianal examination is normal. Biopsies are taken from the caecum and rectum as well as the ascending, descending and sigmoid colon. Histological analysis shows an active, severe colitis, consistent with inflammatory bowel disease of an unknown aetiology. The depth of inflammation is unable to be determined. Granuloma formation is not present. The biopsy sample from the terminal ileum shows no pathological or inflammatory changes. Based on all this information, which one of the following is the most likely diagnosis? - Crohn's disease - Infective colitis - Irritable bowel syndrome - Ulcerative colitis - Ischaemic colitis

Answer 98

= Ulcerative colitis

Question 99

Management - The working diagnosis of ulcerative colitis is made. Which one of the following would be the most appropriate initial management plan for Grace?

Answer 99

Oral 5-aminosalicylate and rectal 5-aminosalicylate

Question 100

Presentation - A 68-year-old woman presents to the Emergency Department with a three day history of dyspnoea, productive cough and sharp, right-sided chest pain that is worse on deep inspiration and coughing. Mrs Walker has a 50 pack-year smoking history and takes pantoprazole for gastro-oesophageal reflux. On examination, her temperature is 38.9C, respiratory rate 20/min, pulse 85/min and blood pressure 110/70 mmHg. Her oxygen saturation on room air is 90%. On auscultation of the chest she has bronchial breath sounds in the right side of her chest. A chest X-ray is performed. What does the chest X-ray show?

Answer 100

**= Right middle lobe and lower consolidation** The upper zone on the right is clear and there is evidence of right middle and lower lobe consolidation.

Question 101

Investigations - Mrs Walker has a raised white cell count. Whilst awaiting results from sputum culture she is started on amoxycillin 2g IV tds, azithromycin 500mg orally daily and had a stat dose of intravenous gentamicin. In addition, she is given physiotherapy and breathing exercises. She is admitted to hospital for further treatment. Four days after admission, Mrs Walker's symptoms of dyspnoea, productive cough and chest pain have improved dramatically. Unfortunately she has now developed watery diarrhoea, passing 7-8 bowel motions per day. She also has crampy abdominal pain and loss of appetite. The concern is that with the use of the broad spectrum antibiotics, her gut flora has been altered and she might well have a Clostridioides difficile infection. Some investigations might be considered. Which one of the following would be most appropriate at this stage?

Answer 101

= Enzyme-linked immunosorbent assay (ELISA) for C. difficile toxin A and B

Question 102

Risk factors - Mrs Walker’s stool sample comes back positive for C. difficile toxin A and B and a stool culture is positive for C. difficile. Her current antibiotics are ceased and she is given supportive therapy and was started on metronidazole and vancomycin to treat the C. difficile colitis. There are a number of risk factors for C. difficile. Which one of the following is most strongly associated with C. difficile colitis?

Answer 102

= Antibiotic usage

Question 103

Which of the following investigations should be included in a faecal donor screening investigations? - Viral hepatitis and HIV serology - Stool screening for enteric pathogens, including C. difficile - Diabetes - CMV, EBV and toxoplasmosis - CBE and LFTs - Colonoscopy

Answer 103

- It is almost a self-evident truth that the donor should be screening for viral hepatitis and HIV serology and in the same way that potential blood donors are screened for infectious disease, any donor of any part of their body or products should be screened. - Stool should be screened for enteric pathogens - the donor maybe an asymptomatic carrier of C. difficile. - Basic laboratory investigations, including a full blood count and liver function tests should be performed. - All potentially infectious diseases such as CMV, EBV and toxoplasmosis must be excluded. - Whether or not the potential donor has diabetes is immaterial and the presence of diabetes does not infer any increased risk. A colonoscopy does not assist in screening for infective agents.

Question 104

Does this patient require admission?

Answer 104

Yes - Mr Unger requires admission as he scores a total of one on the Glasgow Blatchford bleeding score. This risk assessment tool is used for acute upper gastrointestinal bleeding and facilitates the decision-making with regard to whether a patient can be safely allowed to go home with the intent of early outpatient endoscopy rather than hospital admission. A score of zero defines the safety margin. The score is defined as seen in the attached image.

Question 105

Aetiology - Based on the observation that Mr Unger has melaena stool, the assumption is made that he has either had a recent bleed from his upper digestive tract - or is still bleeding. He is advised to come into hospital. An intravenous line is inserted and a blood sample has already been sent to the laboratory for Grouping. At this stage, some thought can be given to likely causes for his presumed bleed. Which of the following would be reasonable explanations for his acute bleed?

Answer 105

Bleeding peptic ulcer

Question 106

It is very likely that with his recent ingestion of a course of diclofenac that Mr Unger has developed a peptic ulcer. Instructions are given that he will only be given a blood transfusion if: - he is actively bleeding - he becomes haemodynamically unstable - the haemoglobin falls to <70g/L - the platelet count is <50 thousand/uL An endoscopy is arranged. Which one of the following is the most likely diagnosis? - Erosive oesophagitis - Mallory-Weiss tear - Bleeding oesophageal varices - Malignant gastric ulcer - Duodenal ulcer

Answer 106

**= Duodenal ulcer** The endoscopy shows a bleeding ulcer in the first part of the duodenum that is the likely cause of the patient’s melaena. The duodenum can be identified by the circular folds known as plicae circularis. Ulcerative oesophagitis a very different appearance and the following photograph shows patches of ulceration and slough at the lower end of the oesophagus (Image 1). Mallory-Weiss tears are seen as shallow mucosal lacerations at the cardio-oesophageal junction. The photograph shows some old clot overlying the mucosal tear and the squamous-columnar junction can be seen immediately blood the clot (Image 2). Oesophageal varices appear as long and tortuous blue columns in the oesophagus (Image 3). The dilated submucosal veins can be seen running up the oesophagus in several large channels. A malignant gastric ulcer will typically have raised, rolled edges, as shown (Image 4).

Question 107

Management - The endoscopist has identified a duodenal ulcer. There are a number of management options to consider at this stage. Which one of the following would be the most appropriate next step in management?

Answer 107

**= Adrenaline injection**

Question 108

Classification - When the endoscopist finds an ulcer in a patient who has been admitted with a suspected bleed from a peptic ulcer, the first question they will ask themselves is 'what is the risk of further bleeding?' The Forrest classification helps address this question. Ulcers that are actively bleeding or oozing are classified Forrest I demand some sort of endoscopic approach - and if that does not control blood loss, angiographic or surgical intervention may be required. The risk of rebleeding in Forrest I ulcers can be over 80% and around 50% for Forrest II. Thus Forrest II ulcers should also be actively treated. The risk of rebleeding for Forrest III ulcers is about 20% and is questionable as to where any endoscopic manoeuvres are required for this group. Information obtained from the endoscopy can be combined with the clinical data to calculate an overall risk - both in terms of rebleeding and mortality - the Rockall score. What is Mr Unger's Rockall score?

Answer 108

= 3

Question 109

Aetiology - Duodenal ulcers are an important cause of acute upper gastrointestinal haemorrhage. There are a number of different causes of ulceration. Select the three most important causes of peptic ulceration.

Answer 109

= Helicobacter pylori infection, Non-steroidal anti-inflammatory drugs, & Zollinger-Ellison syndrome

Question 110

Pathology - The pattern of treatment of peptic ulcer disease has changed dramatically over the last two decades. This is mainly due to the identification of Helicobacter pylori as the common causative agent. Which one of the following most accurately describes how H. pylori exerts its pathogenic effect?

Answer 110

= Destruction of the unstirred layer

Question 111

List 5 causes of upper gastrointestinal haemorrhage

Answer 111