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Flashcards in GI V Deck (40):
1

A 48-year-old woman with chronic pancreatitis due to gallstones is noted to have a macrocytic anaemia.
What is the most likely cause of the anaemia?
(Please select 1 option)
Bone marrow dysfunction
Folate deficiency
Hyposplenism
Hypothyroidism
Vitamin B12 deficiency

Vitamin B12 deficiency This is the correct answerThis is the correct answer
Chronic pancreatitis and the resultant pancreatic insufficiency results in the failure of splitting of dietary B12 from R-binders,a reaction that requires trypsin.

This inhibits the binding of intrinsic factor to the vitamin B12 so it is not absorbed.

2

A 64-year-old female treated with penicillin for a sore throat has presented with profuse diarrhoea. On sigmoidoscopy the mucosa appears a grey white-colour.

Pseudomembranous enterocolitis

Pseudomembranous enterocolitis (antibiotic-associated colitis) is an acute disorder of bacterial overgrowth (usually Clostridium difficle) due to short or long term antibiotic usage.

The condition is commoner after oral rather than intravenous antibiotics.

The hallmark of the condition is the appearance of a grey-white pseudomembrane between inflamed parts of the mucosa. Treatment is with oral metronidazole or vancomycin.

3

A 38-year-old female has presented with diarrhoea following a recent laparoscopic Nissen’s fundiplication for persistent gastro-oesophageal reflux.

Post-vagotomy

In the past diarrhoea was common following intentional vagotomy for peptic ulcer disease. With the introduction of proton-pump inhibitors this surgery is now rarely performed. Most post-vagotomy diarrhoea results from iatrogenic injury to the vagus during surgery on the stomach or the oesophagus.

The diarrhoea typically fades away over the first few post-operative months and is generally non-capacitating.

4

A 72-year-old female 10 days post total knee replacement on the orthopaedic ward has started to pass liquid stool having not passed stool for seven days.

Overflow

Spurious (overflow) diarrhoea is a trickling down of liquid faeces through channels in an impacted solid collection in the rectum. The condition is more common in the elderly and in bedridden patients. Unless the condition responds to conservative measures, manual evacuation under anaesthetic is usually required.

5

A 69-year-old male is seen in outpatients. He reports weight loss of 1 stone over three months but his history is otherwise unremarkable.
On examination his abdomen is soft with no palpable masses. A PR examination is normal.
His blood tests show:
Haemoglobin 8.0 g/dL (12-16)
MCV 70 fL (80-96)
Which of the following is the most appropriate investigation for this patient?
(Please select 1 option)
Abdominal x ray and colonoscopy
CT scan of the abdomen and upper GI endoscopy
Sigmoidoscopy and upper GI endoscopy
Ultrasound scan of abdomen and colonoscopy
Upper GI endoscopy and colonoscopy

Upper GI endoscopy and colonoscopy This is the correct answerThis is the correct answer
This man has weight loss and an unexplained microcytic anaemia.

The likely site of blood loss is from the GI tract in absence of an alternative explanation.

This may be due to an occult GI malignancy and therefore the initial investigations of choice are upper and lower GI endoscopy.

6

A 56-year-old male presents with generalised fatigue and upper abdominal discomfort with some weight loss over the last six months. He has otherwise been well but admits to consuming 10 units of alcohol per day.
On examination you note 2 cm hepatomegaly.
Liver function tests show:
ALT 140 IU/L (5-35)
AST 150 IU/L (1-31)
Alkaline Phosphatase 250 IU/L (45-105)
MCV 110 fL (80-96)
Which of the following is the most likely cause of his presentation?
(Please select 1 option)
Alcoholic hepatitis
Chronic active hepatitis
Hepatoma
Metastatic liver disease
Viral hepatitis

Alcoholic hepatitis is a syndrome of progressive inflammatory liver injury associated with long term heavy intake of ethanol.

Patients who are severely affected present with

Subacute onset of fever
Hepatomegaly
Leukocytosis
Marked impairment of liver function.
The liver exhibits

Characteristic centrilobular ballooning necrosis of hepatocytes
Neutrophilic infiltration
Large mitochondria
Mallory hyaline inclusions.
Steatosis (fatty liver) and cirrhosis frequently accompany alcoholic hepatitis.

7

Which of the following statements regarding jejunal biopsy is correct?
(Please select 1 option)
Electron microscopy is necessary to confirm the presence of villous atrophy
In tropical countries apparently healthy people have a mucosal structure which would be regarded as abnormal in Europe
It can be used to diagnose Whipple's disease
It is contraindicated over the age of 70 years
Sub-total villous atrophy is diagnostic of gluten-sensitive enteropathy and is not found in other conditions

It can be used to diagnose Whipple's disease

The villous atrophy may be seen with a magnifying glass.

Apparently healthy people with a mucosal structure that would be regarded as abnormal in Europe would not be 'healthy'.

There is a group of patients who present with coeliac disease in older age - sometimes in their 90s. They present with iron deficiency anaemia, osteoporosis or weight loss.

Subtotal villous atrophy is seen in a number of conditions other than coeliac disease such as:

Severe tropical sprue
Cow's milk/soya sensitivity in children
Gastroenteritis
Whipple's disease
Hypogammaglobulinaemia
Neomycin therapy
Laxative abuse
Norwalk agent.

8

Normal ranges
Bilirubin 0-18
AST 5-45
ALT 5-40
Alkaline phosphatase 30-110
Gamma GT 10-50

A 54-year-old male presents with acute vomiting and upper abdominal pain. He drinks approximately 30 units of alcohol daily. On examination he has a few spider naevi and appears slightly jaundiced. He has two finger breadth hepatomegaly.
Results show:
Bilirubin 72 µmol/L
AST 98 IU/L
ALT 120 IU/L
Alkaline phosphatase 358 IU/L
Gamma GT 450 IU/L

Alcoholic cirrhosis

9

Normal ranges
Bilirubin 0-18
AST 5-45
ALT 5-40
Alkaline phosphatase 30-110
Gamma GT 10-50

A 55-year-old male attends with a three day history of flu-like symptoms and nausea. On examination he has a stuffy nose but is otherwise well.
Investigations show:
Bilirubin 28 µmol/L
AST 22 IU/L
ALT 30 IU/L
Alkaline phosphatase 75 IU/L
Gamma GT 45 IU/L

Gilbert's syndrome
Liver Function tests (LFTs) are among the most commonly used investigations in clinical medicine. A sound understanding of why they become abnormal and a rational, cost effective approach to their investigation is essential.

Marked elevations of aspartate transminase (AST) and alanine transaminase (ALT) with only modest rises of alkaline phosphatase and gamma glutamyl transferase (GT) suggest hepatitis whereas markedly raised alkaline phosphatase and gamma GT reflect a cholestatic picture.

Gilbert's disease is an autosomal recessive disorder in most subjects (although autosomal dominant inheritance has been reported). It is associated with benign, mildly symptomatic, non-haemolytic, unconjugated hyperbilirubinaemia. No treatment is required and the typical feature is the isolated elevation of bilirubin often found found completely co-incidentally. The bilirubin may rise in illness or starvation.

The greater than 10-fold elevation of transaminases in the middle aged female suggests a hepatitis and does not appear to be related to alcohol where elevation of alkaline phosphatase and gamma GT would be more pronounced.

The middle aged male with heavy alcohol use has examination and biochemical features which suggest an acute alcoholic hepatitis associated with cirrhosis.

10

Usually presents with chronic liver disease often in association with neurological features.

Wilson's disease
This case describes a child with Wilson's disease also known as hepatolenticular degeneration. It is an autosomal recessive condition characterised by cirrhosis of the liver, degenerative changes of the brain and Kayser-Fleischer rings on the cornea. It is as a result of low caeruloplasmin and high copper excretion.

11

A 9-month-old baby presents with a sudden onset of abdominal pain and loose stools which have the appearance of red currant jelly.

Intussusception
Intussusception is an invagination of the bowel in to an adjacent segment. It presents as paroxysmal pain occasionally with vomiting and palpation may reveal a sausage shaped mass in the right upper abdomen. A delay in diagnosis results in the child passing blood stained mucus rectally some times known as red currant jelly. Intussusception can sometimes be reduced hydro-statically, if unsuccessful surgery is required.

12

A 4-day-old infant presents with severe abdominal distension and feculent vomiting

Hirschsprung's disease
Hirschsprung's disease is absence of ganglia cells in part or all of the wall of the colon. The child presents with bilious or faeculent vomiting, constipation and distension.

13

A 5-week-old breast fed baby is admitted with a two week history of vomiting and dehydration. On examination an olive sized mass is palpable.

Pyloric stenosis
Pyloric stenosis is most prevalent amongst first born male and age of onset is usually between 3-6 weeks of age. Babies present with projectile vomiting and examination may reveal visible peristaltic waves and an olive sized mass may be palpable in the upper epigastrium.

14

A 3-month-old baby boy is admitted with episodic screaming. On examination he is mottled and has a delayed capillary refill time. Palpation of the abdomen reveals a sausage shaped mass.

Intussusception
Intussusception - a segment of bowel becomes telescoped in to an adjacent of bowel often in areas where the bowel is aperistaltic, for example Peyer's patches, Meckel's diverticulum, tumour or an area of oedema secondary to Henoch-Schönlein purpura. The child presents with pain, vomiting and signs of shock. A mass may be palpable in the right upper quadrant.

15

A baby with cystic fibrosis develops vomiting and abdominal distension. A ground glass appearance is seen on plain x ray of abdomen.

Meconium plug syndrome
Meconium plug syndrome is the commonest form of small bowel obstruction and the infant presents with distension, vomiting and constipation. A plain film x ray of abdomen may reveal a ground glass appearance.

16

A 62-year-old male with a one year history of Type 2 diabetes, presents with weight loss, anorexia and jaundice. On examination he is jaundiced with a palpable gall bladder.

Ca 19-9

Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumour markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumour markers do not have sufficient sensitivity or specificity for use in screening.

Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses.

Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer.

PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluate specific syndromes of adenocarcinoma of unknown primary.

17

A 34-year-old female presents with lower abdominal pain and weight loss. On examination she has ascites and a palpable 10 cm mass extends from the pelvis.

Ca 125

CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy.

Alpha-fetoprotein (AFP), a marker for hepatocellular carcinoma, sometimes is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy.

Testing for the beta subunit of human chorionic gonadotropin (b-hCG) is an integral part of the diagnosis and management of gestational trophoblastic disease.

Combined AFP and b-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumours, and in monitoring the response to therapy.

AFP and b-hCG also may be useful in evaluating potential origins of poorly differentiated metastatic cancer.

18

A 40-year-old businessman returns from a visit to India with right hypochondrial pain, mucous diarrhoea, fever and tender hepatomegaly. Examination reveals right upper abdominal tenderness without jaundice.

Amoebic hepatitis

The businessman returning from India with a diarrhoeal illness with blood and pus, associated with hepatitis is likely to have amoebiasis. This is due to Entamoeba histolytica, often causes a hepatitis which can be mistaken for viral hepatitis, although the absence of jaundice in this case would argue against the latter. Treatment is with metronidazole.

19

A 35-year-old man presents with recurrent lower abdominal pain. Skin tags are noted around anus. Barium follow through picture shows marked narrowing of a small intestine segment.

Crohn's disease
The young male with abdominal pain and a stricture in the small intestine suggests Crohn's disease.

20

A 55-year-old male presents with a six weeks history of upper abdominal pain, which may wake him during the night, is relieved by eating but recurs two to three hours later. Examination reveals that he is pale with no other abnormalities on examination.

Duodenal ulcer

The 55-year-old male has typical symptoms of a duodenal ulcer with relief on eating which tends to recur two to three hours later. In contrast, a gastric ulcer is associated with pain precipitated by foods. Anaemia may be associated with both.

21

Normal ranges:
Bilirubin 0-18
AST 5-45
ALT 5-40
Alkaline phosphatase 30-110
GammaGT 10-50

A 42-year-old female presents with a two month history of fatigue and weight loss. She admits to drinking approximately two cans of lager nightly since her divorce one year ago. On examination she has a few spider naevi and palpable hepatomegaly. Investigations show
Bilirubin 28 µmol/l
AST 550 iu/l
ALT 476 iu/l
Alkaline phosphatase 210 iu/l
gammaGT 200 iu/l

Autoimmune chronic hepatitis

Liver function tests (LFTs) are among the most commonly used investigations in clinical medicine.

A sound understanding of why they become abnormal and a rational, cost effective approach to their investigation is essential.

Marked elevations of aspartate transaminase (AST) and alanine transaminase (ALT) with only modest rises of alkaline phosphatase and gamma guanine thymine (GT) suggest hepatitis, whereas markedly raised alkaline phosphatase and gamma GT reflect a cholestatic picture.

22

In which of the following is flattening of the mucosa of the small intestine not recognised?
(Please select 1 option)
Crohn's disease
Giardiasis
Gluten-sensitive enteropathy (coeliac disease)
Milk-sensitive enteropathy
Severe malnutrition

Crohns

Flattening of the mucosa of the small intestine is not recognised in Crohn's disease. Typical features are granulomas and giant cells.

It is recognsied in milk-sensitive enteropathy, notably in young children and also gastroentertis.

In some individuals it is recognised in giardiasis1.

Other notable causes include:

Tropical sprue
Soy protein intolerance
Eosinophilic gastroenteropathy
Immune deficiency syndromes
Severe malnutrition
Ischaemia
Drugs, and
Irradiation.

23

In postgastrectomy syndromes which of the following is true?
(Please select 1 option)
Anaemia is more common after gastroduodenostomy than gastrojejunostomy
Anaemia is seen in all cases
Early dumping is associated with abdominal pain
Early dumping is due to rebound hypoglycaemia
Folate deficiency is common

Early dumping is associated with abdominal pain

Features include early and late 'dumping'.

Early dumping seen in most patients in convalescence but persists in 5-12% and is associated with epigastric fullness, abdominal colic, sensation of warmth, sweating, tachycardia, vomiting or diarrhoea and commences immediately after meal.

Late dumping is associated with an insulin surge and hypoglycaemia.

Anaemia may be megaloblastic (vitamin B12 deficiency) or iron deficient.

Hypocalcaemia is well described causing (late) osteomalacia with backache and weakness.

Folate deficiency would be perishingly rare.

24

Which of the following is true regarding bile acids?
(Please select 1 option)
Are about 50% reabsorbed from the intestinal lumen
Are conjugated with taurine and glycine before excretion into bile
Are formed in the distal ileum
Are synthesised at up to 10 mg/day in normal individuals
Cannot be metabolised by intestinal bacteria

Are conjugated with taurine and glycine before excretion into bile

Bile acids are synthesised from cholesterol by the liver (300-500 mg/day), stored in the gallbladder and undergo enterohepatic reabsorption, where approximately 96% is reabsorbed.

Intestinal metabolism by excessive gut flora may result in malabsorption and diarrhoea.

25

Which of the following is correct regarding benign gastric ulcers?
(Please select 1 option)
Are associated with increased acid secretion, especially at night
Are more common in women than men
Are usually multiple
Are usually situated on the greater curvature
Occur more frequently in patients receiving steroids

Occur more frequently in patients receiving steroids This is the correct answerThis is the correct answer
Benign ulcers

Are more likely to occur on the lesser curve
Are precipitated by drugs
Occur in men
Are more likely to be single.
Greater curve ulcers are more likely to be malignant.

26

Recurrent abdominal pain is an unusual symptom in which of the following?
(Please select 1 option)
Abdominal aortic aneurysm
Acute intermittent porphyria
Atheroma of the superior mesenteric artery (SMA)
Chronic lead poisoning
Sickle cell anaemia

Abdominal aortic aneurysm

Abdominal aortic aneurysms are usually asymptomatic and are usually an incidental finding. Pain is associated with impending or actual rupture of the aneurysm and is therefore not a recurrent symptom.

The most common presenting symptom in acute intermittent porphyria is abdominal pain. Severe RPF can cause ureteric obstruction.

Lead poisoning usually produces the classic 'lead colic'.

SMA atheroma classically causes pain following food (abdominal angina).

Sickle cell disease results in pain due to occlusion of the small mesenteric vessels.

27

With which of the following is carcinoma of the oesophagus positively associated?
(Please select 1 option)
Barrett's oesophagus
Blood group A
Colonic carcinoma
Crohn's disease
Oesophagitis

Barrett's oesophagus

In the United Kingdom, oesophageal cancer is the eighth most common malignancy with a 3:1 male:female ratio. Approximately two thirds are adenocarcinomas and one third squamous cell carcinomas.

If reflux disease results in Barrett's oesophagus, then there is an increased risk of malignant change. Up to 1% of the population may have Barrett's epithelium. This is defined as endoscopically visible columnar epithelium, of any length, that shows intestinal metaplasia on histological examination.

The rate of malignant change is estimated at 1% per annum which gives a lifetime risk of 25% if the condition is diagnosed in middle age.

Other factors in the development of oesophageal malignancy are

Obesity
High fat intake
Cigarette smoking
High alcohol intake.
Specific risk factors for squamous cell carcinoma include

Achalasia
Coeliac disease
Caustic stricture.

28

A technetium-99m labelled white cell scan of the abdomen is helpful for detecting which of the following?
(Please select 1 option)
Colonic carcinoma
Intra-abdominal masses
Splenomegaly
Strictures in the intestines
Terminal ileitis in Crohn's disease

Terminal ileitis in Crohn's disease This is the correct answerThis is the correct answer
Radionuclide scanning using Tc-99m may be useful in identifying or localising inflammatory process.

29

Which of the following is true of pancreatitis?
(Please select 1 option)
Can be differentiated from ruptured ectopic pregnancy when the serum amylase is greater than three times its normal value
Has a 1% mortality when associated with an Imrie score of 3 on admission
Is an absolute contraindication to ERCP
Treated with octreotide has been shown to reduce mortality
With a serum amylase above 1000 iu/l is a poor prognostic factor

Can be differentiated from ruptured ectopic pregnancy when the serum amylase is greater than three times its normal value

A serum amylase of greater than three times its normal value is virtually diagnostic of acute pancreatitis. Levels below this may also be caused by

Mumps
Ruptured pancreatic cyst
Perforated peptic ulcer
Cholecystitis
Mesenteric infarction.
The importance of serum amylase is that it is a diagnostic tool and the level is no indication of severity.

On the other hand

Glucose
White cell count
Lactate dehydrogenase (LDH) and
Aspartate transaminase (AST)
on initial assessment are used in the Imrie criteria to score severity, giving an indication to prognosis and likelihood of requiring admission to intensive care.

An Imrie score of 3 is associated with 10% mortality of 10-20%, and with an Imrie score of above 5, mortality is of the order of 50%.

The majority of cases of pancreatitis require supportive treatment and careful monitoring only. Medical management may include the use of antibiotics in selected cases and ERCP may be therapeutic in gallstone pancreatitis.

Octreotide, a somatostatin analogue, lacks evidence in reducing mortality and is therefore not used.

30

Which of the following is correct regarding the normal liver?
(Please select 1 option)
A portal tract contains a branch of the portal vein, hepatic arteriole and bile duct
After feeding, the portal vein provides 35-40% of total liver blood flow
Hepatocytes only make up 20-30% of the total liver cell mass
The hepatic veins drain directly into the portal vein
There are no reticulo-endothelial cells

A portal tract contains a branch of the portal vein, hepatic arteriole and bile duct

The liver has classically been divided into 1-2 mm diameter hexagonal lobules with a terminal tributary of the hepatic vein at the centre of each lobule. At each corner of the hexagonal lobule is a branch of the hepatic artery, portal vein, and biliary tree known as a portal tract or portal triad.

Normal hepatic blood flow is 1,500 ml/min (30-40% from the hepatic artery and 60-70% from the portal vein).

About two thirds of the liver mass are hepatocytes. The remaining mass is accounted for by the:

Extracellular matrix
Cells which line the sinusoids (endothelial cells, Kupffer cells, stellate cells, and pit cells)
Bile ducts (biliary epithelial cells)
Blood vessels (vascular endothelial cells).
There are usually three main hepatic veins (left, right and middle), all of which drain directly into the inferior vena cava (IVC). Several additional veins drain directly in to the IVC, including those from the caudate lobe. The veins from the caudate lobe often remain patent in Budd-Chiari syndrome, allowing the caudate lobe to undergo compensatory hyperplasia.

The Kupffer cells are the reticulo-endothelial cells of the liver, which are a major functional component of the reticulo-endothelial system.

31

Which one of the following may present with angular stomatitis?
(Please select 1 option)
Aortic aneurysm
B12 deficiency
Coeliac disease
Patterson Brown-Kelly syndrome (Plummer-Vinson)
Peutz-Jegher's syndrome

Patterson Brown-Kelly syndrome (Plummer-Vinson)

Angular stomatitis is seen in iron deficiency anaemia, and is associated with

• Plummer-Vinson (cricoid web and iron deficiency anaemia)
• Crohn's disease
• Diverticular disease (with iron deficiency).

It is not a typical feature of Peutz-Jegher's syndrome.

32

Which of the following is true regarding duodenal ulcers (DU)?
(Please select 1 option)
Become less common with increasing age
Smoking is associated with lower relapse rates
The healing rate on placebo therapy is 30%
The healing rate with colloidal bismuth is superior to ranitidine
The relapse rate after treatment is 80% at one ye

The healing rate on placebo therapy is 30%

This is a difficult question, as prior to eradication of H. pylori therapy and with H2 blockers, the relapse rate of duodenal ulcers was 75-80%. However with H. pylori eradication the relapse rate is as low as 5%.

Other factors associated with DU include

Age
Blood group O.

33

Which one of the following is not associated with hepatocellular damage?
(Please select 1 option)
Causes raised levels of transaminases in the plasma
Is a recognised cause of gynaecomastia
Is associated with elevated acid phosphatase levels
Is associated with haemochromatosis
May be due to an auto-immune process

Is associated with elevated acid phosphatase levels

Hepatocellular damage may arise from autoimmune disease (primary biliary cirrhosis, chronic active hepatitis), infections such as HBV.

Hepatocellular damage is manifest as raised transaminases (AST/ALT) and to a lesser extent raised alkaline phosphatase and gamma GT.

Acid phosphatase is a marker of prostate.

Drugs such as rifampicin, penicillins, alcohol and metabolic conditions such as haemochromatosis, Wilson's disease, etc, are associated.

It, like digoxin therapy, antiprostatic therapy, testicular cancer and bronchogenic carcinoma can produce gynaecomastia.

34

Which of the following is true of the Zollinger-Ellison (ZE) syndrome?
(Please select 1 option)
Is associated with excessive gastrin secretion after calcium infusion
Is associated with hypothyroidism
Is diagnosed by the demonstration of raised gastrin levels and achlorydia
More commonly results from primary antral G cell hyperplasia than a pancreatic adenoma
Results in gastric mucosal atrophy

Is associated with excessive gastrin secretion after calcium infusion

ZE syndrome is associated with hypergastrinaemia and is usually due to a neuroendocrine tumour of the pancreas.

It often manifests as recurrent peptic ulceration which endoscopically may extend to the jejunum.

It is associated with hyperparathyroidism as part of the MEN type 1 syndrome.

Approximately 10% are malignant.

35

Which of the following is true of the ulnar nerve?
(Please select 1 option)
Originates from the lateral cord of the brachial plexus
Has no branches below the elbow
Innervates the abductor pollicis longus
Innervates the lateral half of the flexor digitorum profundus
Innervates the medial two lumbricals

Innervates the medial two lumbricals This is the correct answerThis is the correct answer
Ulnar nerve origins:

C7, C8, T1 originates from medial and lateral cords of brachial plexus and

Passes through intermuscular septum in mid-arm
Behind medial epicondyle
Between two heads of flexor carpi ulnaris
Lies anterior to flexor digitorum profundus.
Muscles supplied: flexor carpi ulnaris; medial (ulnar) side of flexor digitorum profundus; adductor pollicis; flexor pollicis brevis; abductor/opponens/flexor digiti minimi; all interossei; third and fourth lumbricals.

Sensory - The ulnar nerve innervates the skin over hypothenar muscles; 11/2 digits (little and ring) but can be 21/2 fingers. An autonomous zone is the tip of little finger.

36

Which of the following is true concerning intussusception in childhood?
(Please select 1 option)
Has, as the earliest sign, the passage of redcurrant jelly stools
Has a peak incidence in the first two months of life
Is accompanied by enlargement of mesenteric lymph nodes
Is characterised by lethargy
May be caused by a Rotavirus infection

Is accompanied by enlargement of mesenteric lymph nodes

Intussusception is a condition associated with the prolapse of one part of the bowel into an adjacent region.

It is most common in children 3 - 12 months, more frequently in males (3:1) and although most cases are idiopathic, conditions such as intestinal lymphadenopathy (adenovirus) may predispose.

Symptoms include

Paroxysms of abdominal pain with pallor
Vomiting and
Initially, loose watery stools.
Later, redcurrant jelly stools occur.

37

Acute pancreatitis carries a worse prognosis when associated with which of the following?
(Please select 1 option)
A blood urea greater than 9 mmol/L
A PaO2 less than 8 kPa
A serum calcium less than 2.30 mmol/L
A serum glucose greater than 8 mmol/L
A white cell count greater than 5 ×109/L

A PaO2 less than 8 kPa

Indicators of poor prognosis (modified Imrie criteria) are outlined below:

If a patient has two or more of the following parameters with a serum amylase more than four times the normal they are suffering with severe acute pancreatitis and require admission to the high dependency unit.

PaO2 55
WCC 15 ×109/L
Calcium 2.0 mmol/L
Urea 16 mmol/L
LDH 600 IU/L
Albumin

38

Which one of the following drugs reduces gastric acid secretion?
(Please select 1 option)
Aluminium hydroxide
Erythromycin
Metoclopramide
Misoprostol
Prednisolone

Misoprostol

Simple antacid (for example, aluminium hydroxide) neutralises acid but does not reduce production of acid.

Proton pump inhibitor and H2-antagonist are powerful acid suppressants.

Misoprostol is a prostaglandin 1E analogue. It acts on parietal cells (acid producing) to reduce acid secretion by inhibition of adenyl cyclase. It is mainly used in the elderly who have to continue with NSAIDs.

Prednisolone decreases mucosal protection. Whether it increases gastric acid secretion still appears uncertain.

Metoclopramide and erythromycin increase gastric emptying.

39

Which of the following features is not associated with carcinoid syndrome?
(Please select 1 option)
Bronchoconstriction
Cyproheptadine is effective in controlling diarrhoea
Death usually occurs within three months of onset
Right sided cardiac valvular fibrosis occurs most commonly
The primary lesion is most often located in the ileocaecal region

Death usually occurs within three months of onset

Carcinoid syndrome is usually a consequence of a primary lesion within the appendix/ileocaecal region.

The symptoms are often a result of the release of synthesised products and include bronchoconstriction, flushing and diarrhoea. These products are metabolised by the lungs and so valvular fibrosis is usually confined to the right. The prognosis is excellent with long term survival (above 10 years) a feature.

Treatment is with somatostatin.

Cyproheptadine may help with diarrhoea as well as flushes.

40

Which of the following is correct in suspected acute pulmonary embolism (PE)?
(Please select 1 option)
A normal chest x ray excludes the diagnosis
A normal plasma D-dimer excludes the diagnosis
A normal V/Q scan has a high negative predictive value
CT of the lungs is a sensitive tool for the diagnosis of emboliin proximal pulmonary veins
Pulmonary angiography is an unreliable investigation for both proximal and distal emboli

A normal V/Q scan has a high negative predictive value

A normal VQ scan makes any but the smallest embolism unlikely.

CXRs are almost always normal in small acute PE.

There is about 2% chance of missing a PE with plasma D-dimers. It has very high sensitivity (good for detection) but poor specificity (poor at exclusion as a number of conditions cause raised D-dimers).

CT is poor at detecting small emboli in distal segmental arteries.

Pulmonary angiography is the gold standard of investigation but mortality in 0.5% cases, major complications in 1% and minor complications in 0.5%.