GIS Important Questions Flashcards by 888 😉

[PP]
Which branch of the abdominal aorta supplies the spleen? (1 mark)

Coeliac trunk

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[PP]
Which organ is bordered superiorly by the spleen and supplied by the splenic artery? (1 mark)

Pancreas

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[PP]
Which peritoneal ligament transmits the splenic artery? (1 mark)

Splenorenal / Lienorenal ligament

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[PP]
A 33-year-old man involved in a car accident arrived at the hospital with a distended abdomen and pain in his left shoulder. Further examination revealed a haemoperitoneum and a laceration of the diaphragmatic surface of the spleen. Where would the blood accumulate in the greater sac if the patient remained seated? (1 mark)

Left paracolic gutter OR Rectovesical pouch

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[PP]
A 33-year-old man involved in a car accident arrived at the hospital with a distended abdomen and pain in his left shoulder. Further examination revealed a haemoperitoneum and a laceration of the diaphragmatic surface of the spleen. Which nerve transmitted the nociceptive signals for the referred shoulder pain? (1 mark)

Phrenic nerve

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[PP]
Name the MOST COMMON histological subtype of primary pancreatic cancer. (1 mark)

Adenocarcinoma

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[PP]
Name the cell type from which pancreatic adenocarcinoma is derived from. (1 mark)

Ductal epithelium

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[PP]
Name the anatomical part in which pancreatic cancer MOST COMMONLY occurs. (1 mark)

Head of pancreas

Head: 60%
Body: 15%
Tail: 5%
Diffuse: 20%

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[PP]
Name two symptoms associated with pancreatic cancer. (2 marks)

(Back) Pain
Obstructive jaundice (head)
Weight loss, malaise, anorexia
Symptoms of gastric outlet obstruction

Migratory thrombophlebitis (10%)
Late presentation (esp. body & tail)

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[PP]
Name two IMPORTANT aetiological factors leading to hepatocellular carcinoma. (2 marks)

Chronic HBV infection (80%)
Chronic HCV infection
Chronic alcoholism (via cirrhosis)
Cirrhosis (irrespective of causes)
Non-alcoholic steatohepatitis (NASH)
Metabolic disease
Aflatoxin

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[PP]
Name one histological feature of hepatocellular carcinoma. (1 mark)

Trabecular pattern: cords of tumour cells separated by sinusoids lined by endothelial cells (simulating normal liver architecture)
Bile pigment production: focal production by carcinoma cells (evidence of hepatocytic differentiation)
Clear cell change (uncommon)
Tumour cells: central nuclei with eosinophilic cytoplasm (simulating hepatocytes)

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[PP]
What is the MOST COMMON mode of spread of hepatocellular carcinoma? (1 mark)

Venous invasion

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[PP]
Name one blood tumour marker specific for hepatocellular carcinoma. (1 mark)

Serum alpha-fetoprotein

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[PP]
What is the purpose of faecal microbiota transplantation (FMT)? (1 mark)

Restore normal gut microbiota

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[PP]
Which disease has FMT been used as an experimental therapy? (1 mark)

Recurrent C. difficile infection

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[PP]
Which modulator is the MOST COMMON therapy for bacterial infections? (1 mark)

Antibiotics

4 types of modulators: antibiotics, prebiotics, probiotics, FMT

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[PP]
Inulin (a dietary fibre ingredient) is classified as which modulator? (1 mark)

Prebiotics

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[PP]
Which health condition has been shown to be improved in animal experiments via FMT from animals to humans? (1 mark)

Malnutrition / Kwashiorkor / Obesity

Malawian kwashiorkor twin pair -> sterile mice -> lost more weight

Obese humans (higher ratio of Firmicutes to Bacteroides -> better harvest energy from diet) -> sterile mice -> gained more weight

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[PP]
Disability-adjusted life year (DALY) is a summary measure of population disease burden.
DALY can be calculated as the sum of which two parameters? (2 marks)

Years of Life Lost due to Premature Mortality (YLL)
Years of Life Lost due to Disability (YLD)

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[PP]
How has the following changed over the last two decades? (3 marks)
1. contribution of communicable diseases to global DALY
2. contribution of NCDs to global DALY
3. contribution of NCDs to DALY in low-income countries

decreasing
increasing
increasing

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[PP]
Name the blood supply to the liver. (2 marks)

Hepatic portal vein
Hepatic artery

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[PP]
Describe the liver appearance of cirrhotic liver on computed tomography. (1 mark)

Irregular surface / outline
Small liver

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[PP]
Name two of the portosystemic collateral pathways developed with portal hypertension. (2 marks)

Recanalized umbilical vein
Gastroesophageal collaterals
Gastroepiploic collaterals
Splenorenal collateral
Pancreatico-duodenal collaterals
Haemorrhoidal collaterals

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[PP]
Define “diverticulum”. (1 mark)

Outpouching of intestinal wall

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[PP] Name two potential complications of diverticular disease. (2 marks)

1. Diverticulitis 2. Diverticular abscess 3. Acute peritonitis

[PP] Give one possible cause for diverticulum. (1 mark)

Low fibre diet, chronic constipation, hard stool

[PP] Barrett’s oesophagus is a pathological condition typically in which part?

Lower oesophagus

[PP] Name the histological hallmark for the diagnosis of Barrett’s oesophagus. (2 marks)

Intestinal metaplasia

[PP] Name the major risk factor of Barrett’s oesophagus. (1 mark)

Prolonged reflux oesophagitis

[PP] Name the major complication of Barrett’s oesophagus. (2 marks)

Adenocarcinoma (Lower 1/3 of oesophagus)

[PP] Explain what is faecal microbiota transplantation. (2 marks)

Therapy by infusing a solution of healthy donor faeces through a nasoduodenal tube / enema / nasogastric tube / capsule form to the patient’s gastrointestinal tract Upper GI: NG tube, gastroscopy Lower GI: enema, colonoscopy

[PP] Suggest a possible reason why antibiotic treatment failed. (2 marks)

Most probably antibiotic resistance developed in the pathogenic Clostridium difficile strain Previous antibiotic treatment disrupted the normal microbiota, allowing the outgrowth of Clostridium difficile

[PP] Suggest one hypothesis why faecal microbiota transplantation is effective in recurrent Clostridium difficile infection. (1 mark)

Restore normal gut microbiota in the patient => rebalance the immunity and suppress growth of C. difficile

[PP - Formative] A 45-year old man has moderately raised liver enzymes (transaminases) and is suspected of hepatitis. He mentions that he has previous episodes of such. Which of the following is the most likely cause of hepatitis in this man? A: Epstein Barr virus B: Hepatitis C virus C: Hepatitis D virus D: Human immunodeficiency virus

[PP - Formative] A 35-year old man is diagnosed with having hepatitis C viral (HCV) infection. His HCV RNA level in the blood is high and his liver enzymes are raised. His disease is different from hepatitis B viral (HBV) infection in which of the following: A: He is more prone to develop hepatocellular carcinoma than those with HBV infection B: His HCV infection can be eradicated with anti-viral drug while HBV infection cannot C: His HCV infection could have been prevented with anti-HCV vaccine D: His disease is less likely to develop cirrhosis than HBV infection

B X A: HBV has a higher oncogenic potential (DNA virus) B: Curative anti-viral drug for HCV but not HBV, only suppressive anti-viral for HBV X C: Vaccine for HBV but not HCV Note: 1. Maternal transmission for HBV but not HCV 2. Both: hepatitis, carrier state, end-stage liver disease, HCC

[PP] A 45-year-old man has moderately raised liver enzymes (transaminases) and is suspected of having hepatitis. Which of the following is the MOST LIKELY cause of hepatitis in this man? A. Alcoholism B. Biliary stones C. Clonorchiasis D. Pancreatitis

A Chronic alcoholism directly damages the liver hepatocytes and causes hepatitis, while the other diseases may cause damage to the bile ducts and not directly on the hepatocytes.

[PP] A 32-year-old woman is admitted with fulminant hepatitis. She is in the third trimester of pregnancy. She returned from Pakistan 4 weeks ago. What is the MOST LIKELY viral cause of her hepatitis?

Hepatitis E

[PP] In adults, there are several vestigial remnants of anatomical structures which are found in the foetus. The round ligament of liver is a remnant of which embryological structure?

Umbilical vein (carry oxygenated blood from placenta to foetus)

[PP] The peritoneum lines the abdominal cavity. Which of the following organs is retroperitoneal? A. ileum B. liver C. pancreas D. transverse colon

C Secondarily retroperitoneal

[PP] A 56-year-old man with acute severe abdominal pain suffered from ischaemic necrosis of the rectosigmoid junction. Where is the artery supplying the affected region of the colon? A. Inside the mesentery B. Inside the transverse mesocolon C. Posterior to the left inframesocolic compartment D. Posterior to the right paramesenteric compartment

C Rectosigmoid junction is supplied by branches of IMA (sigmoid a. & sup. rectal a.) Posterior to right inframesocolic compartment: colic & ileocolic arteries of SMA

[PP] Which structure forms from the common bile duct and pancreatic duct at the level of the duodenum?

Ampulla of Vater

[PP] Name the folds in different parts of the GI tract.

Stomach: rugae (longitudinal) Small intestine: plicae circulares (circular folds, transverse) Large intestine: semilunar folds, haustra (transverse)

[PP] A patient arrived at the Accident and Emergency Department complaining about severe right upper quadrant pain. Laceration of the liver was diagnosed. Which structure was clamped to stop the internal bleeding during the Pringle manoeuvre?

Hepatoduodenal ligament

[PP] During early foregut development, the stomach, liver, and spleen are held in place by a mesentery that is connected to both the dorsal and ventral body walls. Which structure is formed from the mesentery located between the liver and the ventral wall of the embryo?

Falciform ligament

[PP] Which vascular structure is used to divide the right from left hepatic lobe?

Middle hepatic vein

[PP] Which structure is formed by the right and left hepatic duct?

Common hepatic duct

[PP] The pancreas first appears at approximately 5 weeks of gestation. Which germ layer gives rise to the pancreas? (1 mark)

Endoderm

[PP] Which part of the gut tube gives rise to the pancreas? (1 mark)

Duodenum / Foregut

[PP] Which two parts of the pancreas are derived from the ventral pancreatic bud? (2 marks)

1. Caudal head 2. Uncinate process

[PP] Name a developmental defect caused by failure of fusion of the dorsal and ventral pancreatic ducts. (1 mark)

Pancreatic divisum

[PP] Name five consecutive layers of the anterolateral abdominal wall between skin and abdominal cavity. (5 marks)

1. Superficial fascia: Camper’s fascia & Scarpa’s fascia 2. Muscles: external oblique, internal oblique, transversus abdominis 3. Transversalis fascia 4. Extraperitoneal fat: might be missing 5. Peritoneum

[PP] Name the procedure for removal of the gallbladder.

Laparoscopic cholecystectomy

[PP] Which type of neuronal fibres are contained in superior mesenteric plexus? A. Postganglionic parasympathetic B. Preganglionic parasympathetic C. Preganglionic sympathetic D. Somatic motor

[PP] The embryonic midgut undergoes rotation and physiological umbilical herniation during development. Which two regions of the intestine originate from the cranial limb of the midgut? (2 marks)

1. Jejunum 2. Ileum

[PP] What causes physiological umbilical herniation? (2 marks)

The growth of midgut is faster than the abdominal cavity.

[PP] Name one congenital disorder that results from failure of the herniated gut to return to the abdominal cavity. (1 mark)

Omphalocele

[PP] A 63-year-old man was diagnosed with a pancreatic head cancer and presented with jaundice and abdominal pain. Explain the anatomical basis of his jaundice. (1 mark)

Compression of biliary tract -> conjugated bilirubin enters blood (bile cannot enter duodenum) -> hyperbilirubinaemia

[PP] List the structures that convey the pain impulse from the head of the pancreas to the spinal cord. (4 marks)

1. celiac ganglion and plexus 2. (greater and lesser) splanchnic nerves 3. sympathetic chain and white rami communicantes 4. dorsal root ganglion

[Self-assessment] A 28-year-old woman is admitted to the obstetric service for caesarean section delivery of a fetus that is in the breech position. The patient elects to have a transverse, suprapubic (Pfannenstiel or “bikini”) incision. Which nerve is most likely injured during this procedure? A. Genitofemoral B. Iliohypogastric C. Ilioinguinal D. Pudendal E. T10 intercostal (thoracoabdominal) nerve

B A. Genitofemoral nerve (L1-L2) - sensory innervation in females - from skin over mons pubis & labium majus - & anteromedial thigh B. Iliohypogastric nerve (L1) - sensory innervation from suprapubic skin C. Ilioinguinal nerve (L1) - sensory innervation from skin over mons pubis & labium majus - & proximal medial thigh D. Pudendal nerve (S2-S4) - sensory innervation from skin of perineum E. T10 intercostal (thoracoabdominal) nerve - sensory innervation from skin around umbilicus

[PP] Which aetiology accounts for high incidence of HCC in Europe?

Chronic alcoholism

[PP] A patient presents with haemoperitoneum and is found to have HCC. Which feature of the tumour does the surgeon find during operation?

Tumour is highly vascular

[PP] Inflammatory bowel disease can be further subclassified with reference to clinical and pathological features. By histology full-thickness inflammation and which of the following are classically seen in Crohn’s disease? A. Eosinophilic abscess B. Foreign body giant cell reaction C. Granulomas D. Vasculitis

[PP] Idiopathic inflammatory bowel disease with continuous involvement of bowel segment and toxic megacolon as a potential complication. Which pathological entity?

Ulcerative colitis

[PP] Idiopathic inflammatory bowel disease with transmural inflammation and granulomas. Which pathological entity?

Crohn’s disease

[PP] Outpouching of mucosa and submucosa through defects in bowel wall. Which pathological entity?

Diverticulum / Diverticulosis

[PP] Cessation of peristalsis resulting in intestinal obstruction. Which pathological entity?

Paralytic ileus

[PP] Intestinal wall twists around itself. Which pathological entity?

Volvulus

[PP] Intestinal wall gets caught in the peristaltic wave and gets carried along. Which pathological entity?

Intussusception

[PP] Acute pancreatitis refers to inflammation of the pancreas. What is the COMMONEST etiology for acute pancreatitis in Hong Kong? A. Alcoholism B. Biliary stones C. Cystic fibrosis D. Drug-induced

[PP] A 50-year-old male has an isolated increase in plasma alanine transaminase (ALT) concentration. Which of the following is a cause of the biochemical abnormality? A. Carcinoma of pancreas B. Carcinoma of the common bile duct C. Cirrhosis D. Fatty liver

[Old PP] Which of the following infections is transmitted by sharing of needles among intravenous drug abusers in Hong Kong? A. Hepatitis A B. Hepatitis C C. Hepatitis E D. Herpes simplex type 2 E. Influenza

B HCV: Contact with blood and body fluids (needles, sex, medical equipment)

[Old PP] What is the nature of the viral genome of HBV?

Double-stranded DNA

[Old PP] Most common cause(s) of post-transfusion hepatitis

HBV, HCV

[Old PP] Which hepatotropic viruses are transmitted by fecal-oral route?

HAV, HEV

[Old PP] Which hepatitic viruses can give rise to chronic liver disease?

HBV, HCV, HDV

[PP] A proportion of patients with chronic viral hepatitis will progress to cirrhosis. Name four complications / clinical manifestations of cirrhosis / portal hypertension (severe blockage of blood return from hepatic portal vein.)

1. Esophageal (and other) varices 2. Ascites, caput medusae 3. Splenomegaly 4. Hepatic encephalopathy 5. Haemorrhoids

[Old PP] Which hepatitic viruses cause infection by parental transmission?

HBV, HCV, HDV

[Old PP] Apart from HK, which parts of the world also have a high prevalence of HBV infection?

Sub-Saharan Africa, Southeast Asia, China

[Old PP] Incidence of which viral hepatitis is higher in Japan than Southeast Asia and Hong Kong?

Hepatitis C (also prevalent in Epygt and Pakistan)

[Old PP] HDV is a defective virus and it requires presence of another hepatitis virus to be infective. What is this virus?

HBV

[PP] Name the peritoneal formation that connects the transverse colon to the posterior abdominal wall.

Transverse mesocolon

[PP] Name the double-layered fold of peritoneum that connects the jejunum and ileum to the posterior abdominal wall.

Mesentery

[PP] Name the first peritoneal formation usually encountered in a midline laparotomy.

Greater omentum

[PP] Name a peritoneal formation derived from the ventral mesentery.

Falciform ligament

[PP] Name the peritoneal formation that extends from the lesser curvature of the stomach and the first part of duodenum to the inferior surface of liver.

Lesser omentum

[PP] Which two veins form the hepatic portal v.?

Sup. mesenteric v. & Splenic v. Some blood from inf. mesenteric v. and pancreatic v. drains into splenic v.

[PP] Explain what the ‘portal system’ means. (1 mark)

Blood passing through 2 intermittent capillary beds between an artery and a vein. Heart -> artery -> 1st capillary network in abdominal viscera -> hepatic portal v. -> 2nd capillary network in liver -> hepatic v. -> inf. vena cava -> heart

[PP] The superior mesenteric, inferior mesenteric and internal iliac arteries are the major blood supplying arteries to different parts of the colon. What is the watershed area that is the MOST SUSCEPTIBLE to ischemic injury?

Splenic flexure

[PP] Typhoid fever can be diagnosed by different laboratory tests. Which of the following tests is MOST SPECIFIC for the diagnosis of typhoid fever? A. A positive blood culture B. A positive Weil-Felix test in a single blood sample C. A positive Widal’s test in a single blood sample D. Acid-fast stain of stool showed acid-fast bacilli E. Gram smear of stool showed Gram negative bacilli

A Positive culture = always most SPECIFIC in bacteriology B & D: X for typhoid fever C: not very specific, need paired sera for a four-fold rise E: stool contains a huge variety of Gram -ve bacilli BASU 1st week: blood culture 2nd week: Agglutination (Widal’s test, commercial antigen detection tests) 3rd week: stool culture, rectal swab 4th week: Urine culture (low +ve rate) Bone marrow culture: high +ve rate but invasive

[PP] A 25-year-old lady presented with high fever and abdominal pain for 1 week. She had had mild diarrhoea which spontaneously subsided. A faint rash is noted over her abdomen. She had recently returned to Hong Kong after visiting relatives in India. What is the MOST LIKELY causative agent?

Salmonella typhi => typhoid fever Prodrome: constipation, diarrhoea Untreated: up to 4 weeks Abdominal pain, headache, relative bradycardia -> Rose spots (at the end of first week) (<1/3 of patients), splenomegaly, hepatomegaly, leukopenia Complications: intestinal hemorrhage, intestinal perforation, toxaemia Less severe: paratyphoid fever (Salmonella paratyphi A, B, C)

[PP] A 78-year-old woman was hospitalised for community-acquired pneumonia and treated with intravenous meropenem. After 10 days of treatment, she developed diarrhoea. Antibiotic-associated diarrhoea was suspected. Which of the following is the MOST LIKELY cause of her antibiotic-associated diarrhoea?

Clostridioides (Clostridium) difficile

[PP] An 80-year-old man was hospitalised for intra-abdominal abscesses and ventilator-associated pneumonia. He developed bloody diarrhoea after 3 consecutive weeks of intravenous meropenem. What is the most likely causative agent?

C. difficile

[Old PP] Which of the following requires anaerobic culture from stool? A. Bacillus cereus B. Clostridium difficile C. Salmonella typhimurium D. Vibrio parahaemolyticus

[Old PP] Which of the following bacteria has to be grown in anaerobic culture? A. Bacillus cereus B. Clostridium difficile C. Campylobacter jejuni D. Salmonella typhimurium E. Vibrio cholerae

[Self-assessment] Regarding antibiotic-associated diarrhoea, A. Intravenous vancomycin is an effective treatment for C. difficile colitis. B. Toxic megacolon is a potentially life-threatening complication of Clostridioides (Clostridium) difficile. C. C. difficile is a non-spore forming, anaerobic Gram-positive bacillus.

B First-line treatment: - Oral vancomycin - Oral fidaxomicin (X HK) Overgrowth of C. difficile (produce toxins) -> watery diarrhoea, pseudomembranous colitis

[PP] A 38-year-old man presented with acute fever, abdominal pain, and bloody diarrhoea. Stool culture yielded a curved Gram-negative bacillus under microaerophilic conditions. What is the most likely causative agent?

Campylobacter e.g. C. jejuni

[PP] Mrs Lee, a 38-year-old woman, presented with a 5-day history of cramping abdominal pain and bloody diarrhoea. She had opened her bowels over 13 times in the preceding 24 hours. There was fresh red blood mixed in with her stool. She felt feverish. She had returned from a family holiday with her husband and two children 3 days before the onset. Her laboratory report indicated the presence of Campylobacter jejuni in her stool. What is the MOST APPROPRIATE antibiotic to be given in the management of Campylobacter enteritis? A. Azithromycin B. Doxycycline C. Metronidazole D. Trimethroprim-sulfamethoxazole

A Macrolides (e.g. erythromycin)

[PP] What is the MOST LIKELY explanation for the result of HBsAg negative, anti-HBs positive (>10 mIU/mL), and anti-HBc negative? (2 marks)

Prior HBV vaccination

[PP] If HBsAg is positive, which ANTIGEN test can help determine the phase of chronic hepatitis B infection? (2 marks)

HBeAg

[PP] If anti-HCV antibody is reactive, what is the follow-up test to determine whether there is current infection? (1 mark)

HCV RNA RT-PCR

[PP] A 40-year-old man with HBsAg +ve Anti-HBc +ve Anti-HBc IgM +ve Anti-HBs -ve Anti-HAV IgG +ve Anti-HAV IgM -ve What is the MOST LIKELY serological diagnosis?

Recent / Acute hepatitis B infection HBsAg ++ HBeAg + HBV DNA + Anti-HBc IgG + / - Anti-HBc IgM + Anti-HBe - Anti-HBs -

[PP] A 60-year-old woman with: HBsAg - Anti-HBc + Anti-HBc IgM - Anti-HBs + Anti-HAV IgG + Anti-HAV IgM - What is the most likely serological diagnosis?

Recovered from past hepatitis B infection HBsAg - HBeAg - HBV DNA - Anti-HBc + Anti-HBc IgM - Anti-HBe +/- Anti-HBs +

[PP] A 28-year-old health care worker with: HBsAg - Anti-HBc - Anti-HBs + Anti-HAV IgG - Anti-HAV IgM - What is the most likely serological diagnosis?

Hepatitis B vaccinated HBsAg - HBeAg - HBV DNA - Anti-HBc - Anti-HBc IgM - Anti-HBe - Anti-HBs +

[PP] A 35-year-old man with: HBsAg + Anti-HBc + Anti-HBc IgM - Anti-HAV IgG + Anti-HAV IgM + What is the most likely serological diagnosis?

Acute hepatitis A infection in a chronic hepatitis B carrier HBsAg + HBV DNA + Anti-HBc + Anti-HBc IgM - Anti-HBs - e-seroconverted (awakening of immune system, seroconversion may be marked by severe hepatitis, usually low level viral replication) HBeAg - Anti-HBe +

[PP] A 16-year-old male recently returned from Thailand with: HBsAg - Anti-HBc - Anti-HBs + Anti-HAV IgG + Anti-HAV IgM + What is the most likely serological diagnosis?

Acute hepatitis A infection in a person vaccinated against hepatitis B

[Old PP] What is the immunogen used in hepatitis B vaccine?

HBsAg

[Old P] Which serological marker can confirm a recent infection by HBV?

Anti-HBc IgM

[PP, Formative] What is the definition of chronic hepatitis B infection? (1 mark)

Carriage of HBsAg for >6 months

[PP, Formative] What is the significance of HBsAg? (2 marks)

Marker of hepatitis B infection

[PP, Formative] What is the significance of anti-HBc IgM? (2 marks)

Marker of acute hepatitis B infection

[PP, Formative] A 69-year-old woman is admitted with jaundice and loss of appetite. She reports frequent intake of pig liver congee. Which of the following is the MOST LIKELY cause of acute hepatitis in this scenario?

Hepatitis E

[PP, Formative] Helicobacter pylori infection is a major cause of gastric ulcer. Which of the following is a characteristic of Helicobacter pylori to cause infection in the stomach? A. Ability to grow in anaerobic environment B. Bipolar flagella C. Survival in alkaline environment D. Urease positive

Motility: unipolar flagella and spiral shape, urease (reduce mucus layer viscosity) Survival within mucus gel & low O2 environment: microaerophilic (5% O2) Survival in acidic environment: urease (urea -> ammonia)

[Old PP] Name an ulcer healing drug with gynecomastia as the potential side effect.

Cimetidine (-) dihydrotestosterone -> androgen R. => impotence, gynecomastia

[PP] Inhibition of gastric acid secretion and promotion of mucosal defense are two strategies for treating peptic ulcer. Anti-ulcer agents are effective but they have various adverse effects. Which of the following anti-ulcer agents is contraindicated during pregnancy? A. Bismuth B. Misoprostol C. Omeprazole D. Ranitidine E. Sucralfate

B Misoprostol (prostaglandin analogue) Stimulate uterine contraction => miscarriage (PGE2 receptor also in uterus)

[PP] Mr. Au is a 50-year-old businessman. He suffers from epigastric pain and the urea breath test is positive. He is allergic to penicillin. Which of the following new regimens is suitable for treating Mr. Au? A. Clarithromycin + metronidazole + amoxicillin + omeprazole B. Clarithromycin + metronidazole + bismuth + omeprazole C. Tetracycline + metronidazole + bismuth + sucralfate D. Tetracycline + metronidazole + sucralfate + famotidine

[PP] Mr. Chan is a 65-year-old retired businessman who has recently been diagnosed with gastro-oesophageal reflux disease (GERD). He is on long-term treatment with metoprolol and theophylline for his problem of hypertension and respiratory disease, respectively. Besides, he has constipation quite often so he sometimes takes methylcellulose. Which of the following gastric acid inhibitors is the MOST SUITABLE for the treatment of his GERD? A. Aluminium hydroxide B. Cimetidine C. Omeprazole D. Sodium bicarbonate

C X Aluminium hydroxide (constipation) X Cimetidine (inhibit metabolism of theophylline => drug toxicity) X Sodium bicarbonate (short-acting + sodium => hypertension)

[PP] Both active and passive uptake of glucose are performed by epithelial cells in the intestinal brush border. What drives the active transport of glucose? A. Cl- gradient B. H+ gradient C. K+ gradient D. Na+ gradient

D 1. Na+ dependent facilitated transport (active) - Glucose taken up via Na+-glucose symporter SGLT1 across the Na+ gradient (driving force) across the brush border - 2 Na+ => 1 glucose molecule 2. Facilitated diffusion - GLUT2 on apical / luminal surface Same for galactose

[PP] Sugars are transported across enterocytes via Na+-dependent facilitated transport and/or facilitated diffusion. Which sugar is transported SOLELY by facilitated diffusion? A. Fructose B. Galactose C. Glucose D. Sucrose

A In: GLUT5 Out: GLUT2

[PP] Which of the following features may Helicobacter pylori be recognised in gastric biopsy samples? A. Gram-positive cocci in clusters on the surface of gastric epithelium B. Intracellular Gram-negative cocci C. Spiral-shaped bacteria in the muscularis externa layer D. Spiral-shaped bacteria on the surface of gastric epithelium

[PP] Goblet cells are commonly present in the gastrointestinal tract. Which region of the gastrointestinal tract has the HIGHEST density of goblet cells? A. Colon B. Jejunum C. Oesophagus D. Stomach

A Goblet cells: secrete mucus Large intestine: faecal lubrication

[PP] A 29-year-old female was diagnosed with anaemia due to vitamin B12 deficiency. Which cell type within the stomach is MOST LIKELY affected? A. Chief cells B. Enteroendocrine cells C. Goblet cells D. Parietal cells

D Parietal cells secrete intrinsic factor which is essential for absorption of vitamin B12 in the terminal ileum

[PP] John is a 14-year-old boy with Gilbert syndrome. Which of the following value(s) is (are) MOST LIKELY to be elevated in his liver function test? A. Direct bilirubin B. Direct bilirubin and total bilirubin C. Indirect bilirubin and direct bilirubin D. Indirect bilirubin and total bilirubin

D Gilbert syndrome - unconjugated hyperbilirubinaemia Direct bilirubin = conjugated bilirubin Indirect bilirubin = unconjugated bilirubin Total = direct + indirect

[PP] Cystic fibrosis is caused by gene mutations that disrupt the ion channel cystic fibrosis transmembrane conductance regulator (CFTR) and is associated with impaired digestion. What is the primary cause of digestion problem in cystic fibrosis? A. Impaired acid secretion from parietal cells B. Impaired bicarbonate secretion from pancreatic duct cells C. Impaired pancreatic enzyme secretion from acinar cells D. Impaired synthesis of bile acid from liver

[PP] Polyps are commonly present colonoscopic findings. Histological examination would help to classify the subtypes. Which of the following types of polyps manifests as proliferation of glandular component accompanied by dysplasia in the epithelium but without stromal invasion? A. Adenomatous polyp B. Hamartomatous polyp C. Hyperplastic polyp D. Juvenile polyp

A Presence of dysplasia defines colonic adenomas

[PP] A 17-year-old man presented with Parkinson-like features and has a strong family history of Wilson disease. Which serum protein binaries will you check for this patient? A. Alpha-1 anti-trypsin B. C-reactive protein C. Ceruloplasmin D. Ferritin

[PP] Prevention includes a wide range of activities aiming at reducing risks or threats to health. Prevention activities are typically categorised in three levels. What is the aim of tertiary prevention? A. To reduce complications of disease B. To reduce incidence of disease C. To reduce overdiagnosis D. To reduce prevalence of disease

A B: primary prevention C: secondary prevention, reduce progression of disease D: prevalence (total number of cases) is reduced due to cure or death (can happen at secondary / tertiary levels)

[PP] Composite measures quantify the disease burden. Which composite measure is calculated as the number of years of healthy life that is foregone due to death or suffering? A. Disability-Adjusted Life Expectancy (DALE) B. Disability-Adjusted Life Year (DALY) C. Healthy Life Year (HeaLY) D. Quality-Adjusted Life Year (QALY)

B DALY = YLLs + YLDs YLLs = years of healthy life foregone due to premature mortality YLDs = years of life lost due to disability / time lived in states of less than full health Disability-Adjusted Life Expectancy (DALE) = no. of years that a newborn can live free of disease Healthy Life Years (HLY) = no. of remaining years that a person is expected to live at a certain age without the disability Quality-Adjusted Life Year (QALY) = value of health outcomes to the people who experience them - combine the two different benefits of treatment-length of life and quality of life

[Self-assessment] A 65-year-old woman is referred to a pain clinic with lancinating (“stabbing”) pain and a rash on the left side of her abdomen. A superficial abdominal reflex at the transverse level of the umbilicus is absent on her left side, which leads to a diagnosis of segmental abdominal herpes zoster infection. Which of the following nerves is most likely being assessed? A. T7 thoracoabdominal spinal nerve B. Ilioinguinal nerve C. Iliohypogastric nerve D. Subcostal nerve E. T10 thoracoabdominal nerve

E Superficial abdominal reflex: assess T8-T12 spinal cord levels 4 superficial cutaneous reflexes: 1. Abdominal 2. Cremasteric 3. Plantar 4. Anocutaneous A. Iliohypogastric (L1) B. Ilioinguinal (L1) C. Subcostal (T12) T7-T9: between xiphoid process (T6) & umbilicus (T10)

[PP, Formative] A 65-year-old male presents with a noticeable bulge in the right groin that enlarges during coughing and protrudes to the scrotum. Physical examination reveals that the bulge becomes more prominent with increased intra-abdominal pressure. Based on the presentation, what type of hernia is MOST LIKELY visible in this patient?

Indirect inguinal hernia - descend into scrotum - Coughing in standing position: impulse on index finger (deep inguinal ring) - more common than direct hernia - congenital, persistence of processus vaginalis - right side in men - covered by: peritoneum, coverings of spermatic cord

[PP, Formative] What are the anatomical distinctions between direct and indirect inguinal hernias? (2 marks)

1. Indirect hernia (usually congenital) - Protrude through deep (internal) inguinal ring (+inguinal canal, superficial inguinal ring) - Lateral to inferior epigastric vessels 2. Direct hernia (usually acquired) - Protrude through a weakness in transversalis fascia (posterior wall of inguinal canal) within Hesselbach’s triangle (inguinal triangle) & lateral to edge of conjoint tendon (falx inguinalis) - Protrude forward to (rarely through) superficial inguinal ring - Medial to inferior epigastric vessels

[PP, Formative] List two nerves that traverse the superficial inguinal ring.

1. Ilioinguinal nerve 2. Genital branch of genitofemoral nerve Pass through deep inguinal ring + inguinal canal: - Spermatic cord OR Round ligament of uterus - Genital branch of genitofemoral nerve (L1-L2) Pass through part of inguinal canal + superficial inguinal ring: - Ilioinguinal nerve (L1): enter through conjoint tendon (IO + TA), exit through superficial ring

[Old PP] A 70-year-old man presented with right groin mass passes through deep ring medial to pubic tubercle. During physical examination, mass does not appear from pressing over deep inguinal ring as he coughs. What is the position of hernia in relation to inguinal ligament and inferior epigastric artery?

Superior to inguinal ligament Lateral to inferior epigastric artery Hernia manually reduced by compression => Press over deep inguinal ring: - mass reappears: direct hernia - mass does not reappear: indirect hernia Superior to inguinal ligament: inguinal hernia Inferior to inguinal ligament: femoral hernia

[Old PP] A 70-year-old man is presented with groin mass. Mass disappears when patient lies in supine position, and reappears when he coughs forcefully. Mass can be prevented by applying pressure over deep inguinal ring. What is the position of the hernia in relation to inguinal ligament and inferior epigastric artery?

Superior to inguinal ligament Lateral to inferior epigastric artery

[Old PP] Which structure passes through superficial inguinal ring but not deep ring? A. Cremasteric artery B. Iliohypogastric nerve C. Ilioinguinal nerve D. Testicular vein E. Vas deferens

[Old PP] Which of the following will pass through the entire inguinal canal (i.e. from deep to superficial inguinal ring)? A. Ilioinguinal nerve B. Iliohypogastric nerve C. Inferior epigastric artery D. Superior epigastric artery E. Vas deferens

[Old PP] Which of the following is NOT TRUE concerning the anterior abdominal wall? A. Membranous layer of the superficial layer (Scarpa’s fascia) is continuous with Colles’ fascia B. Continuous of intercostal nerves run in plane between external oblique and internal oblique muscles C. Anterior layer of rectus sheath is, on most of its extent, contributed by aponeurosis of external and internal obliques D. Deep inguinal ring is an opening in fascia transversalis E. Deep inguinal ring is lateral to inferior epigastric vessels

B Anterior layer of rectus sheath: - Aponeurosis of EO + 1/2 of IO Posterior layer of rectus sheath: - Aponeurosis of 1/2 of IO + TA

[Old PP] Which of the following statements about anterior abdominal wall is FALSE? A. It allows flexion of trunk B. It is largely supplied by lower intercostal nerves C. It may contract during expiration D. It protects against hernia E. Muscles within it can flex thigh at hip joint

E Flexion of trunk: rectus abdominis, psoas major Forceful expiration: rectus abdominis, EO, IO, TA, internal intercostal m. Flexors of hip joint: iliacus, psoas major, rectus femoris

[Old PP] Which gastrointestinal structure is LEAST LIKELY to be found in left hypochondriac region? A. Spleen B. Left colic flexure C. Tail of pancreas D. Head of pancreas E. Left kidney

[Old PP] A 55-year-old male was diagnosed with irreducible indirect inguinal hernia. Surgical hernial repair using wire mesh method was carried out. List four important anatomical structures derived from abdominal wall that form inguinal canal.

1. Anterior wall - Aponeurosis of EO 2. Posterior wall - Medial: conjoint tendon (falx inguinalis) - Lateral: transversalis fascia 3. Roof / Superior wall - Arching fibres of IO + TA 4. Floor / Inferior wall - Inguinal & Lacunar ligaments

[Old PP] List two functions of inguinal canal.

Transmit 1. Male: spermatic cord containing BV, nerves, lymphatics and remnants of processus vaginalis / pathway for testes to descend from abdominal cavity into scrotum during embryonic development 2. Female: round ligament of uterus to maintain uterus position 3. All: genital branch of genitofemoral nerve (entire canal) + ilioinguinal nerve (partly)

[Self-assessment] A 61-year-old man undergoes surgical repair for a direct inguinal hernia. The surgeon confirms the patient’s hernia passes inferior to the conjoint tendon. Which aponeurotic layers contribute to this tendon?

Aponeurosis of IO & TA Conjoint tendon: - Deep side of superficial inguinal ring - Common for direct inguinal hernia to protrude to superficial inguinal ring by passing inferior to lower (free) border of conjoint tendon

[Self-assessment] A 47-year-old woman is prepared for a laparoscopic cholecystectomy (gallbladder removal). The paraumbilical region is anesthesized. Which dermatome is involved in the area of anesthesia?

T10

[Self-assessment] Following resection of the large intestine, an ileostomy is performed on a 51-year-old woman. While making the incision in the lower right quadrant of the anterior abdominal wall, the surgeon notes that the muscle fibres of one of the layers being incised are oriented in an inferomedial direction. Which of the following muscles has the surgeon observed? A. External oblique B. Transversus abdominis C. Latissimus dorsi D. Quadratus lumborum E. Internal oblique

A EO: inferomedial IO: superomedial IO & EO fibres: near-right angles to each other => provide strength to anterolateral abdominal wall TA: nearly horizontal

[Self-assessment] A 23-year-old man presents with pain in the right inguinal region when he bends over (forwards) or lifts heavy items. Physical examination in the area of pain detects a bulge that extends into the scrotum. The patient’s age and physical examination result in a diagnosis of an indirect inguinal hernia on the right side. The patient is scheduled for herniorrhaphy (surgical repair of the hernia). At which of the following locations will the surgeon locate the extraperitoneal fat layer? A. Between the internal and external oblique muscles B. Deep to transversalis fascia C. Deep to parietal peritoneum D. Superficial to Camper’s fascia E. Superficial to Scarpa’s fascia

B Extraperitoneal fat: between transversalis fascia & extraperitoneal fat Most superficial = Camper’s fascia (fat)

[PP] The blood supplies of the different parts of the intestine are indicative of their embryological origins. Which artery is the blood supply to the jejunum? A. Coeliac trunk B. Inferior mesenteric artery C. Internal pudendal artery D. Superior mesenteric artery E. Superior rectal artery

[NPT] Name the 3 major branches of the celiac trunk.

1. Left gastric artery 2. Splenic artery 3. Common hepatic artery

[NPT] Name the 5 major branches of the superior mesenteric artery.

1. Inferior pancreaticoduodenal artery 2. Middle colic artery 3. Right colic artery 4. Ileocolic artery 5. Intestinal arteries (jejunal / ileal)

[NPT] Name the 3 major branches of the inferior mesenteric artery.

1. Left colic artery 2. Sigmoid arteries 3. Superior rectal artery

[NPT] Name the artery that connects the superior and inferior mesenteric arteries to provide an anastomosis at the splenic flexure.

Marginal artery (of Drummond)

[NPT] Describe the arterial supply at the rectosigmoid junction.

1. Sigmoid branches of IMA 2. Superior rectal artery

[Old PP] A patient has a peptic ulcer in pylorus which penetrates along antrum through greater curvature of stomach, resulting in bleeding. Which artery is involved? A. Left gastric artery B. Right gastric artery C. Left gastroepiploic artery D. Right gastroepiploic artery E. Short gastric artery

D A: from celiac trunk -> superior portion of lesser curvature B: from common hepatic artery of celiac trunk -> inferior portion of lesser curvature C: from splenic artery of celiac trunk -> superior portion of greater curvature D: from gastroduodenal artery -> inferior portion of greater curvature E: from splenic artery -> fundus

[Old PP] Gastrointestinal tract is supplied by three main trunks branching from abdominal aorta. What is blood supply to duodenum? A. Coeliac trunk + Inferior mesenteric artery B. Superior mesenteric artery + coeliac trunk C. Coeliac trunk only D. Superior mesenteric artery + inferior mesenteric artery E. Superior mesenteric artery only

[Old PP] Superior mesenteric artery forms acute angle with abdominal aorta. This will compress on which structure? A. Left renal vein B. Right renal vein C. Left renal artery D. Right renal artery

[Old PP] A 58-year-old businessman is diagnosed with gastric cancer, and partial gastronomy was recommended, involving body and fundus, excluding pyloric antrum. Which are main branches of arteries that need to be ligated during surgery? A. Hepatic artery and right colic artery B. Left gastric artery and splenic artery C. Middle colic artery and lumbar artery D. Right gastric artery and gastroduodenal artery E. Short gastric artery and left colic artery

[Old PP] A 50-year-old businessman was diagnosed of gastric cancer. A partial gastrectomy involving body and fundus of stomach excluding pyloric antrum was recommended. Which branches of main arteries were to be ligated during the surgery? A. Hepatic artery, splenic artery, left and right gastric arteries B. Left and right gastric arteries, left and right gastroepiploic arteries, short gastric artery C. Left gastric artery, right gastric artery, left gastroepiploic artery D. Left gastric artery, right gastric artery, pancreaticoduodenal artery E. Short gastric artery, right gastric artery, left gastroepiploic artery

[Old PP] Which of the following is NOT supplied by branches of celiac trunk? A. Stomach B. Lesser omentum C. Liver D. Spleen E. Right colic flexure

[NPT] Explain how cirrhosis leads to portal hypertension in relation to the blood supply to the liver.

The liver receives blood supply from the hepatic artery proper (25%) which has a high BP, and hepatic portal vein (75%) which has a low BP There is a loss of architecture in cirrhotic livers This allows blood from hepatic artery proper to directly shunt into hepatic portal vein, leading to portal hypertension

[PP] A person feels pain in the stomach. Where is the cell body of the first-order sensory neuron located?

Dorsal root ganglion

[NPT] Name 4 sites of portosystemic anastomosis.

1. Lower esophagus 2. Umbilicus 3. Upper anal canal 4. Retroperitoneal

[NPT] Describe the portosystemic anastomosis at lower esophagus and name an associated clinical manifestation.

Esophageal branches of left gastric vein (portal) -> azygous vein (systemic) Esophageal varices

[NPT] Describe the portosystemic anastomosis at umbilicus and name an associated clinical manifestation.

Paraumbilical veins (portal) -> Periumbilical veins (systemic) which drain into superior & inferior epigastric veins Caput medusae

[NPT] Describe the portosystemic anastomosis at upper anal canal and name an associated clinical manifestation.

Superior rectal vein (portal) -> middle & inferior rectal veins (systemic) Hemorrhoids

[NPT] Describe the portosystemic anastomosis at retroperitoneal space.

Colic veins (portal) -> colic veins (systemic) which drain into ascending lumbar vein

[PP] The arrector pili muscles on the anterior abdominal wall at the level of umbilicus receive sympathetic innervation. Trace the sympathetic pathway by listing five anatomical structures, from proximal to distal, that accommodate the sympathetic fibres from ventral root of the spinal nerve to the target. (5 marks)

1. T10 Spinal nerve 2. White ramus communicans (1 mark) 3. Sympathetic chain ganglia at sympathetic trunk (paravertebral ganglia) (T10) (1 mark) 4. Grey ramus communicans (1 mark) 5. Ventral ramus of spinal nerve (T10) (1 mark) 6. T10 intercostal nerve (1 mark)

[PP] List four gross anatomical structures that transmit the pain impulse from the receptors in the wall of the stomach to the spinal cord.

1. Celiac ganglion and plexus 2. Greater splanchnic nerve 3. Sympathetic trunk 4. White ramus communicans

[NPT] Name the location of the following regarding the sympathetic interaction of the foregut. 1. Preganglionic cell bodies 2. Preganglionic axons 3. Postganglionic cell bodies 4. Postganglionic axons

1. Lateral horn (T5-T9) 2. Greater splanchnic nerve 3. Celiac ganglia 4. Celiac plexus

[NPT] Explain why a patient with gastritis feels pain in his epigastric region.

1st order neurons from stomach and epigastric region converge to the same 2nd order neuron

[PP] A. Celiac ganglion B. Inferior hypogastric plexus C. Inferior mesenteric ganglion D. Lumbar splanchnic nerves E. Pelvic splanchnic nerves F. Sacral splanchnic nerves G. Superior mesenteric ganglion H. Sympathetic trunk I. Thoracic splanchnic nerves J. Vagus nerve Which of the above supplies parasympathetic innervation to the sigmoid colon?

[PP] A. Celiac ganglion B. Inferior hypogastric plexus C. Inferior mesenteric ganglion D. Lumbar splanchnic nerves E. Pelvic splanchnic nerves F. Sacral splanchnic nerves G. Superior mesenteric ganglion H. Sympathetic trunk I. Thoracic splanchnic nerves J. Vagus nerve Which of the above is the location of sympathetic postganglionic neurons which supplies ascending colon?

[PP] What is the commonest histological subtype of colon cancer?

Adenocarcinoma

[PP] Name three risk factors for colon cancer.

1. Diet and lifestyle: low intake of fibre, consumption of red meat and refined carbohydrate (sugar), sedentary lifestyle, obesity, smoking 2. Gastrointestinal diseases: Crohn’s disease, ulcerative colitis 3. Genetics: positive family history of colorectal cancer, hereditary colorectal carcinoma syndromes

[PP] Name one commonly mutated gene in colon cancer.

APC, K-RAS, TP53, LOH, SMAD

[NPT] State the mode of inheritance of Lynch syndrome.

Autosomal dominant - same as familial adenomatous polyposis (FAP) Lynch syndrome = Hereditary non-polyposis colorectal cancer (HNPCC)

[NPT] Name 2 genes mutated in Lynch syndrome.

MSH2, MLH1 - DNA mismatch repair genes VS FAP: APC/WNT pathway (APC -> KRAS -> WNT)

[NPT] Name 2 extra-intestinal manifestations of Lynch syndrome.

1. Endometrial carcinoma 2. Ovarian carcinoma 3. Ureter and renal pelvis carcinoma 4. Biliary tract carcinoma (GI: colon / gastric CA) VS FAP 1. Skin and bone tumours 2. Brain tumours (GI: >=100 adenomatous polyps in colon, >90% chance of colon CA by 50 y/o)

[Old PP] Lymphatic spread is a common route of colon cancer. Name 4 lymph nodes immediately draining from colon.

Left colic, middle colic, right colic, ileocolic lymph nodes immediately draining

[Old PP] In addition to spreading through lymphatics, list three other routes of spread of colon cancer in abdomen.

1. Direct spread 2. Haematogenous spread 3. Transcoelomic / peritoneal spread (spreading through peritoneum) 4. Perineural invasion 5. Implantation (in body cavities)

[Self-assessment] Which of the following types of colon polyps is a well-recognised precursor lesion for colon adenocarcinoma? A. Hamartomatous polyp B. Tubular adenoma C. Inflammatory pseudopolyp

B Via adenoma-carcinoma sequence 4 major types of colonic polyps: 1. Hyperplastic polyps 2. Adenomas 3. Inflammatory polyps 4. Hamartomatous polyps (proliferation of both epithelial & stromal cells, can be hereditary)

[PP] Polyps are common colonoscopic findings. Histological examination would help to classify the subtypes. Which of the following types of polyps manifests as proliferation of glandular component accompanied by dysplasia in the epithelium but without stromal invasion? A. Adenomatous polyp B. Hamartomatous polyp C. Hyperplastic polyp D. Juvenile polyp

A Epithelial dysplasia = defining feature of colonic adenomas

[PP] A. Amikacin B. Amoxicillin C. Bismuth compound D. Clarithromycin E. Penicillin G F. Potassium-competitive acid blocker G. Proton pump inhibitor H. Ranitidine bismuth citrate I. Rifabutin J. Tetracycline Which of the agents listed above is best described by the following statements with regard to the treatment of Helicobacter pylori infection? The MOST COMMONLY used agent for reducing gastric acid secretion in Hong Kong

[PP] A. Amikacin B. Amoxicillin C. Bismuth compound D. Clarithromycin E. Penicillin G F. Potassium-competitive acid blocker G. Proton pump inhibitor H. Ranitidine bismuth citrate I. Rifabutin J. Tetracycline Which of the agents listed above is best described by the following statements with regard to the treatment of Helicobacter pylori infection? A first-line antibiotic whose efficacy in recent years have been compromised by growing antibiotic resistance in many countries

D Clarithromycin (macrolide)

[PP] A. Amikacin B. Amoxicillin C. Bismuth compound D. Clarithromycin E. Penicillin G F. Potassium-competitive acid blocker G. Proton pump inhibitor H. Ranitidine bismuth citrate I. Rifabutin J. Tetracycline Which of the agents listed above is best described by the following statements with regard to the treatment of Helicobacter pylori infection? An antibiotic that is contraindicated during pregnancy

[PP] A. Amikacin B. Amoxicillin C. Bismuth compound D. Clarithromycin E. Penicillin G F. Potassium-competitive acid blocker G. Proton pump inhibitor H. Ranitidine bismuth citrate I. Rifabutin J. Tetracycline Which of the agents listed above is best described by the following statements with regard to the treatment of Helicobacter pylori infection? A beta-lactam antibiotic that still retains good activity against Helicobacter pylori

[PP] A. Amikacin B. Amoxicillin C. Bismuth compound D. Clarithromycin E. Penicillin G F. Potassium-competitive acid blocker G. Proton pump inhibitor H. Ranitidine bismuth citrate I. Rifabutin J. Tetracycline Which of the agents listed above is best described by the following statements with regard to the treatment of Helicobacter pylori infection? An antibiotic that may be used in salvage therapy against multi-resistant Helicobacter pylori strains

[PP] A gram-negative, spiral-shaped bacterium occurring in the stomach is frequently found in the local people in Hong Kong. What is the MOST characteristic feature of this organism? A. It can lead to cholangiocarcinoma of the liver B. It inhabits within the layer of mucin produced by gastric epithelial cells C. It is a World Health Organization class II carcinogen D. It is most frequently found in the body of the stomach

B Class I carcinogen

[PP] A 47-year-old woman with duodenal ulcer was diagnosed with Helicobacter pylori infection. Which of the following treatment regimens is the MOST APPROPRIATE for her H. pylori-related peptic ulcer disease? A. Amoxicillin and clarithromycin for 4 weeks B. Amoxicillin monotherapy for 6 weeks C. Amoxicillin, clarithromycin and a proton pump inhibitor for 2 weeks D. Amoxicillin, clarithromycin and metronidazole for 2 weeks

[PP] Diagnosis of Helicobacter pylori infection can be achieved by a variety of laboratory investigations. Name the single most appropriate approach for each of the following scenarios. A 32-year-old with suspected peptic ulcer disease and Helicobacter pylori infection who refused esophagogastroduodenoscopy.

Urea breath test or stool antigen detection

[PP] Diagnosis of Helicobacter pylori infection can be achieved by a variety of laboratory investigations. Name the single most appropriate approach for each of the following scenarios. A patient who has received 2 previous courses of eradication therapy for Helicobacter pylori infection but still has persistent infection.

Esophagoduodenoscopy + biopsy and antibiotic susceptibility testing

[PP] Diagnosis of Helicobacter pylori infection can be achieved by a variety of laboratory investigations. Name the single most appropriate approach for each of the following scenarios. A community-wide survey on the prevalence of Helicobacter pylori infection.

Serology (antibody detection)

[PP] A 38-year-old man underwent esophagogastroduodenoscopy for abdominal discomfort. Culture of the biopsied gastric tissue yielded a curved Gram-negative bacillus under microaerophilic condition which was strongly urease positive. Name the MOST LIKELY causative organism of his condition.

Helicobacter pylori

[PP] Name two chronic non-malignant complications associated with infection with this organism.

Chronic gastritis, peptic ulcer disease (PUD), non-ulcer dyspepsia

[PP] Name one type of gastric lymphoma associated with infection with Helicobacter pylori.

Gastric mucosa-associated lymphoid tissue lymphoma (MALToma) (low-grade B-cell lymphoma)

[PP] Name one antibiotic used in combination therapy for Helicobacter pylori.

Amoxicillin, clarithromycin, metronidazole, tetracycline Non-antibiotics: 1. proton pump inhibitor (e.g. omeprazole) 2. bismuth

[PP] A 20-year-old female presents to the hospital for a 3-day history of watery diarrhoea. She has consumed undercooked chicken 2 days prior to the onset of her diarrhoea. Stool has been sent to the microbiology laboratory for bacterial culture. Name three common bacterial pathogens that can cause diarrhoea with this presentation.

1. Vibrio parahaemolyticus 2. Non-typhoidal Salmonella 3. Campylobacter jejuni 4. Enterotoxigenic Escherichia coli (Rotavirus, Norovirus, Giardia, Cryptosporidium) Gastroenteritis (incubation period of a few days) VS Food poisoning (consumption of pre-formed toxins, rapid onset within hours)

[PP] A 20-year-old female presents to the hospital for a 3-day history of watery diarrhoea. She has consumed undercooked chicken 2 days prior to the onset of her diarrhoea. Stool has been sent to the microbiology laboratory for bacterial culture. Name two bacterial culture media which are used for the isolation of bacterial pathogens.

MacConkey agar Xylose-lysine-deoxycholate (XLD) agar Thiosulphate-citrate-bile salts-sucrose (TCBS) agar Sorbitol MacConkey agar

[PP] A 40-year-old man complained of abdominal pain. His serum liver function test revealed the following results: Gamma-glutamyl transferase (GGT): 440 U/L (Normal: <60 U/L) Alkaline phosphatase (ALP): 280 U/L (Normal: 30-110 U/L) Alanine aminotransferase (ALT): 45 U/L (Normal: <55 U/L) Aspartate aminotransferase (AST): 43 U/L (Normal: <45 U/L) What does U/L stand for?

Unit per litre

Alanine aminotransferase (ALT) Aspartate aminotransferase (AST)

Biliary tract obstruction e.g. gallstones, cholangitis, cholangiocarcinoma, carcinoma of head of pancreas Cholestatic pattern: - predominant increase in ductal enzymes (ALP, GGT) Normal ALT, AST (parenchymal enzymes) => no or limited hepatocellilar injury

[PP] A 56-year-old man complained of abdominal distension, weight loss of 10kg and loss of appetite over the past three months. He was admitted via the Accident and Emergency Department to the medical ward. Two days before admission, he also complained of passage of melaena. He was noted to be slightly jaundiced by the medical officer during admission. Hypothesise two pathological mechanisms / processes that may explain his problem of jaundice, abdominal distension, weight loss and melaena. (4 marks)

1. Liver cirrhosis with complications of hepatocellular carcinoma and portal hypertension leading to esophageal variceal bleeding and ascites 2. Cholangiocarcinoma or pancreatic carcinoma with peritoneal metastasis, leading to obstructive jaundice and peptic ulcer bleeding secondary to stress

[PP] A 56-year-old man complained of abdominal distension, weight loss of 10kg and loss of appetite over the past three months. He was admitted via the Accident and Emergency Department to the medical ward. Two days before admission, he also complained of passage of melaena. He was noted to be slightly jaundiced by the medical officer during admission. It was found that his serum alpha-fetoprotein (AFP) was high. Name one non-cancer medical condition associated with his high serum alpha-fetoprotein (AFP).

Active hepatitis / cirrhosis

[PP, formative] Which nerve supplies the anterior and posterior walls of the stomach?

Vagus nerve

[PP, formative] What is the degree of stomach rotation around its longitudinal axis?

The stomach rotates 90°

[PP, formative] What is the direction of stomach rotation around its longitudinal axis

Clockwise

[PP, formative] Which organ develops between the two leaves of the dorsal mesogastrium?

Spleen

[PP] Name one foregut derivative that lies against the posterior body wall following stomach rotation.

Duodenum or pancreas

[PP] Name the hollow space that is located behind the stomach after rotation.

Omental bursa / Lesser sac

[PP] Name two organs that are derived from the ventral portion of the foregut.

Liver, gallbladder, trachea, lung buds

[PP] To what extent and in which direction does the developing stomach rotate?

90° clockwise around its longitudinal axis

[PP] What is the duct at the apex of the midgut loop?

Vitelline duct / yolk stalk

[PP] Midgut development occurs between 6-8th weeks of gestation. What is the artery supplying the midgut?

Superior mesenteric artery

[PP] A tsunami tidal wave hits the coastline of Thailand and the people living there are forced to drink unclean water. Within the next several days, a large number of people develop severe diarrhoea. Vibrio cholerae is found in the sample of their drinking water. What specific transport process is affected by Vibrio cholerae? Which cell expresses that channel?

Secretion (active transport) of Cl- via CFTR (cystic fibrosis transmembrane conductance regulator) Crypt cells in small and large intestine

[PP] A tsunami tidal wave hits the coastline of Thailand and the people living there are forced to drink unclean water. Within the next several days, a large number of people develop severe diarrhoea. Vibrio cholerae is found in the sample of their drinking water. Briefly explain how the affected channel can lead to diarrhoea. (2 marks)

Increased secretion of Cl- into intestinal lumen via CFTR on apical membrane -> intracellular [Cl-] decreases -> electrochemical gradient => 1. NKCC1 on basolateral membrane pumps Na+, K+, Cl- into crypt cells 2. Na+ enters intestinal lumen via paracellular pathway 3. Water flows along osmotic gradient into intestinal lumen by osmosis (secretion > absorption) => loss of water and electrolytes in watery diarrhoea

[PP] Most of the sodium ion in the intestinal fluid is reabsorbed. Sodium ion reabsorption in the large intestine depends on which mechanism? A. Co-transport with amino acids B. Co-transport with chloride ions C. Co-transport with glucose D. Counter transport with potassium ions E. Diffusion through water-filled channels

E Distal large intestine: - diffusion via ENaC - stimulated by aldosterone in colon - bowel inflammation: decreased expression of ENaC Proximal large intestine: 1. Co-transport with SCFA 2. NHE-3 3. HCO3-/Cl- exchanger

[Old PP] Which of the following is mechanism of transport of sodium in large intestine? A. Countertransport with H+ and K+ B. Co-transport with amino acids C. Co-transport with Cl- D. Co-transport with glucose E. Diffusion down concentration gradient

E Others: small intestine Na+ extruded by Na+/K+ pump at basolateral membrane

[Old PP] Which of the following conditions can result in secretory diarrhoea? A. Amoeba infection B. Cholera C. Fat indigestion D. Intestinal hurry E. Lactose intolerance

B Amoeba infection (Entamoeba histolytica) -> diarrhoea with blood and mucus (dysentery) Intestinal hurry: - increased motility -> rapid transit -> less absorption e.g. irritable bowel syndrome Lactose intolerance - lactase deficiency => osmotic diarrhoea (due to un-reabsorbed solutes) Secretory diarrhoea - inflammation caused by infection (enteritis) - enterotoxins (Vibrio cholerae / E. coli) - increased secretion of Cl- by activation of CFTR

[Old PP] Following arterial blood gas results were obtained from a 71-year-old woman who had been vomiting for past week. pH: 7.54 (7.35-7.45) pCO2: 6.0 kPa (4.7-6.0) pO2: 11.0 kPa (10.0-13.0) HCO3-: 39 mmol/L (20-28) What type of acid-base imbalance is most likely for this patient? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis E. Mixed acid-base imbalance

B Consequences of diarrhoea: - dehydration => kidney failure, shock - hyponatremia - hypochloremia - metabolic alkalosis - loss of bicarbonate - metabolic acidosis - malnutrition

[Old PP] A 5-year-old pre-schooler presents in the morning with severe abdominal pain, vomiting, fever and copious watery diarrhoea. Diarrhoea started yesterday after lunch with large-volume watery diarrhoea but child now has small-volume, frequent stools with mucus and blood. In which anatomical location does small intestinal secretion occur? A. Villi B. Crypts C. Brush border D. Lacteals E. Enteroendocrine cells

B Absorption: villi Secretion: crypts

[Old PP] Which condition would most likely cause hypokalaemia? A. Metabolic acidosis B. Diarrhoea C. Adrenal insufficiency D. Hypovolemia E. Hyperosmotic extracellular fluid

[Old PP] Absorption of water from digestive tract A. Is completed during transit through small intestine B. Occurs primarily from proximal colon C. Is dependent primarily on active transport of Ca2+ D. Occurs secondarily to ions E. Is completed and no water is left in faeces

[Old PP] Diarrhoea A. Can cause hyperchloraemic alkalosis B. Can cause hyperkalaemia C. Can cause hypervolaemia D. Can cause hyperchloraemic acidosis E. Is a consequence of higher than normal fluid intake

D Due to loss of bicarbonate => metabolic acidosis => retention of Cl- by kidneys

[PP] Short-chain and long-chain fatty acids enter enterocytes via different mechanisms. Give TWO reasons why short-chain fatty acids can enter enterocytes by simple diffusion.

1. Small in size 2. Relatively water-soluble

[PP] Name the structure made of bile salts that packages long-chain fatty acids for approaching the luminal cell surface of enterocytes.

Micelles

[PP] Name TWO membrane proteins that facilitate transport of long-chain fatty acids into enterocytes.

1. Fatty acid translocase (FAT or CD36) 2. Fatty acid-binding proteins (FABP_pm) 3. Fatty acid transport proteins (FATPs)

[PP] M/64, low-grade fever, malaise, nausea, diarrhoea, abdominal discomfort Blood test: ALT, AST >3000 U/L Return from Cambodia No recent surgery, no sexual contact, no IV drug injection List 2 viruses that lead to this clinical scenario.

HAV, HEV

[PP] Name 1 serology and 1 molecular test for either HAV and HEV.

HAV: Anti-HAV IgM HEV: HEV RNA PCR

[PP] Name one vaccine for HAV, HEV. (1 mark)

Hepatitis A vaccine Hepatitis E vaccine (Hecolin): mainland China only

[PP] Dietary L-carnitine, which is abundant in red meat, might be linked with chronic diseases, perhaps via the gut microbiota-dependent metabolism. Which chronic disease has been suggested to be linked with dietary L-carnitine? A. Atopic disease B. Cardiovascular disease C. Depression D. Diabetes mellitus

B Dietary L-carnitine / phosphatidylcholine -> choline carnitine -> trimethyl amine (TMA) (produced by gut microbiota) -> trimethyl amine N-oxide -> atherosclerosis

[PP] A plant-based diet is associated with with a lower risk of developing obesity. One possible mechanism is promoting the growth of beneficial gut microbiota. What function of the gut microbiome might be related to obesity? A. Differentiation B. Metabolism C. Reproduction D. Respiration

[PP] Faecal microbiota transplantation is a modulator of gut microbiota. For which disease is faecal microbiota transplantation used as a regulated experimental drug? A. C. difficile infection B. Colorectal cancer C. E. coli infection D. Obesity

[Old PP] What is used to characterise human gut microbiome? A. Cultures dependent B. Culture-independent molecular assays C. Enzyme-linked immunosorbent assays D. Probiotics E. Prebiotics

B Metagenomics (e.g. 16S rRNA sequencing) + Metatranscriptomics + Metaproteomics

[Self-assessment] What molecular assaying below allows researchers to most directly identify and classify microbiota? A. Metaproteomics B. Metagenomics C. Metabolomics

B Generate microbial genome sequencing (e.g. 16S rRNA sequencing)

[Self-assessment] Which type of the microbes below is likely the most abundant in the healthy colon? A. Facultative anaerobes B. Obligate anaerobes C. Obligate aerobes

B Ferment / respire anaerobically -> adapt to low O2 in distal GI tract Main microbial phyla in adult gut microbiome: - Firmicutes (Gram +ve, Lactobacillus, Clostridium) & Bacteroidetes (Gram -ve, mainly Bacteroides + Prevotella, more antibiotic-resistant due to outer membrane, LPS, exo/endotoxins) - Others: Actinobacteria (+ve), Proteobacteria, Fusobacteria (-ve) - Mainly obligate & facultative anaerobes

[Self-assessment] Infants on which mode of early feeding have a higher diversity of Bifidobacterium? A. Breast feeding B. Formula feeding C. Mixed feeding

A Formula-fed: more Bacteroides, Clostridium

[Self-assessment] Which modulator of microbiota eliminates both pathogenic and beneficial bacteria? A. Prebiotics B. Antibiotics C. Probiotics

B Prebiotics 益生元 - Promote growth of beneficial microbiota - Inulin, trans-galacto-oligosaccharides (dairy products, beans, root vegetables) Probiotics 益生菌 - Live beneficial microbiota - Lactobacilli, Bifidobacteria

[Self-assessment] Which disease has faecal microbiota transplantation (FMT) been used as an experimental therapy in humans? A. Recurrent C. difficile infection B. Kwashiorkor malnutrition C. Cardiovascular disease

[Self-assessment] Which microbe was observed to be more abundant in Europeans with type 2 diabetes than in normal individuals? A. Lactobacillus species B. Escherichia coli C. Clostridium species

A Chinese: - more Clostridium, E. coli - less butyrate-producing bacteria

[PP] 3 hours after buffet, several people experienced nausea and vomiting but without diarrhoea. Which of the following is most likely causative agent? A. Vibrio parahaemolyticus B. Shigella dysenteriae C. Staphylococcus aureus D. Clostridium difficile

C S. aureus (contaminated by food handlers), B. cereus (inappropriate storage temperature e.g. reheated fried rice) => non-inflammatory diarrhoea (short incubation period, vomiting) Vibrio, non-typhoidal Salmonella, Campylobacter, E. coli, viruses => non-inflammatory diarrhoea (watery diarrhoea +/- abdominal / systemic symptoms) Shigella -> bacillary dysentery Entamoeba histolytica -> amoebic dysentery Other dysentery: Non-typhoidal Salmonella, Campylobacter Clostridium difficile -> antibiotic-associated diarrhoea

[PP] The incubation period of gastrointestinal pathogens may provide clues to the identity of the most likely enteric pathogens in foodborne outbreaks. Which of the following pathogens is typically associated with a short incubation period of less than 6 hours? A. Clostridium perfringens B. Salmonella enterica serotype Typhi C. Staphylococcus aureus D. Vibrio parahaemolyticus

C Also Bacillus cereus

[PP] A 70-year-old man underwent right hemicolectomy due to perforation of a colonic carcinoma. Postoperatively he developed infection of the surgical wound. What are the MOST LIKELY pathogens involved in causing the surgical wound infection? A. Escherichia coli + Bacteroides fragilis B. Haemophilus influenzae + Viridans streptococci C. Neisseria gonorrhoeae + Streptococcus pyogenes D. Treponema pallidum + Pseudomonas aeruginosa

A Common colonic flora E. coli: facultative anaerobe Bacteroides: obligate anaerobe

[PP] Norovirus is one of the commonest causes of viral gastroenteritis. What is the test of choice in routine laboratory diagnosis of norovirus infections? A. Detection of anti-norovirus antibody in serum B. Electron microscopy using vomitus samples C. Nucleic acid amplification tests on stool samples D. Tissue culture for viruses using stool samples E. Viral antigen detection using stool samples

C RT-PCR

[PP] A 1-year-old girl is admitted with severe diarrhoea. Rotavirus gastroenteritis is suspected. Which of the following methods can detect rotavirus in faecal samples? A. Electron microscopy B. Fluorescent microscopy C. Stool rotavirus IgA assay D. Thiosulfate-citrate-bile salts-sucrose (TCBS) agar

A Test of choice: 1. Antigen detection assays (ELISA / immunochromatographic assays) 2. RT-PCR of faecal samples

[PP] A 25-year-old medical student went to Haiti for volunteer work. During her stay, she developed severe watery diarrhoea with “rice water stool” and dehydration requiring hospitalisation. Culture of her stool sample yielded a motile Gram-negative bacillus which grows as yellow colonies in thiosulfate-citrate-bile salts-sucrose (TCBS) agar. Which of the following is the MOST LIKELY causative organism of her condition? A. Campylobacter jejuni B. Clostridium difficile C. Shigella dysenteriae D. Vibrio cholerae

D TCBS agar - Sucrose fermenter (yellow): Vibrio cholerae - Sucrose non-fermenter (green): Vibrio parahaemolyticus

[PP] Gastrointestinal microbiology and infection A. Bacillus cereus B. Campylobacter jejuni C. Clostridioides difficile D. Clostridium perfringens E. Entamoeba histolytica F. Helicobacter pylori G. Salmonella enterica serotype Typhimurium H. Shigella dysenteriae I. Vibrio cholerae J. Vibrio parahaemolyticus Select the MOST LIKELY causative organism. A 42-year-old woman was newly diagnosed with gastric mucosa-associated lymphoid tissue lymphoma.

[PP] Gastrointestinal microbiology and infection A. Bacillus cereus B. Campylobacter jejuni C. Clostridioides difficile D. Clostridium perfringens E. Entamoeba histolytica F. Helicobacter pylori G. Salmonella enterica serotype Typhimurium H. Shigella dysenteriae I. Vibrio cholerae J. Vibrio parahaemolyticus Select the MOST LIKELY causative organism. A 28-year-old woman presented with acute fever, abdominal pain, diarrhoea, blood and mucus in stool, and tenesmus. Stool culture yielded a Gram-negative non-lactose-fermenting bacillus in MacConkey agar incubated at 35°C at room air.

H Bloody diarrhoea with mucus in stool -> dysentery Gram -ve non-lactose-fermenting bacillus in MacConkey agar -> Shigella / Salmonella (yellow colonies VS commensals e.g. E. coli: lactose fermenters -> pink)

[PP] A patient complains of loss of appetite, heartburn and malaise. On examination, well-defined gastric epithelium extends beyond diaphragm level, what is the most likely cause? A. Stomach mobility disorders B. Oesophagitis C. Hiatal hernia D. Stomach ulcer

C Upper part of stomach protrudes through diaphragm into thoracic cavity Causes: 1. Increased intra-abdominal pressure - obesity - heavy lifting - frequent or hard coughing 2. Loss of diaphragmatic muscular tone with ageing HIA Heavy person, heavy lifting Increased coughing Abdominal pressure increase, Ageing

[NPT] Which of the following separates the quadrate lobe from the right lobe of the liver? A. Falciform ligament B. Inferior vena cava C. Ligamentum teres hepatis D. Ligamentum venosum

B Better: gallbladder Ligamentum teres hepatis (round ligament): separate quadrate lobe & left lobe Ligamentum venosum: separate caudate lobe & left lobe Porta hepatis: separate caudate lobe & quadrate lobe

[NPT] Which of the following is NOT a foregut derivative? A. Esophagus B. Lungs C. Stomach D. Spleen

[NPT] Which of the following best describes the parotid gland A. Predominantly mixed acini B. Predominantly mucous acini C. Predominantly serous acini D. Predominantly serous demilune

C Parotid: predominantly serous Submandibular: mixed (mucous + serous) Sublingual: predominantly mucous Go posteriorly -> become more serous

[NPT] Which of the following has the highest Hounsfield unit? A. Air B. Fat C. Water D. Soft tissue

D Describe radiointensity (~brightness) 1. Bone / iodine 2. Soft tissue 3. Water 4. Fat 5. Air

[NPT] A female patient has been diagnosed with hypervascular hepatocellular carcinoma (HCC). Name one toxin that is associated with HCC (1 mark)

Aflatoxin

[PP] A female patient has been diagnosed with hypervascular hepatocellular carcinoma (HCC). Explain why the tumor is soft in biopsy (1 mark)

High vascularity and minimal supportive stroma

[NPT] Name the most common cause of acute pancreatitis in Hong Kong. (1 mark)

Gallstones

[NPT] Which of the following is not known to be a virulence factor of H. pylori? A. Flagella B. Vacuolating cytotoxin C. Cytotoxin-associated gene A D. Exotoxin A

[NPT] Name the most common microorganism responsible for enteric fever.

Salmonella Typhi

[NPT] Suggest a type of vaccine that could protect patients in Hong Kong from Salmonella Typhi.

Vi capsular polysaccharide vaccine

[NPT] Which of the following is observed when Shigella dysenteriae is cultured on XLD agar? A. Red colonies with black center B. Red colonies without black center C. Yellow colonies with black center D. Yellow colonies without black center

B Xylose-lysine-deoxycholate (XLD) agar Salmonella: red colonies + black centre Shigella: red colonies E. coli: yellow colonies

[PP] A child with pale skin, diarrhea and vomiting a few days ago. - CBC: - Hb: ↓ - WBC :↓ - Platelet: ↓ - Urinary sediment analysis: Dysmorphic red cells - RFT: ↑ Creatinine What's the causative agent? A. Campylobacter jejuni B. Entamoeba histolytica C. Shiga-toxin producing E. coli D. Shigella dysentriae

C Haemolytic Uremic Syndrome (HUS): a type of MAHA - O157:H7 EHEC (Shiga-like toxin) - Shigella (Shiga toxin) Anemia, leukopenia, thrombocytopenia RBC trauma Renal impairment

[PP] Pringle manoeuvre is used to control liver haemorrhage. Name the specific part of the lesser omentum that covers the structures of the portal triad. (1 mark)

Hepatoduodenal ligament Portal triad = hepatic artery (proper) + hepatic portal vein + common bile duct

[PP] Which two vessels are clamped in a Pringle manoeuvre? (2 marks)

Hepatic artery Hepatic portal vein

[PP] Which two structures unite to form the common bile duct? (2 marks)

Common hepatic duct + cystic duct

[NPT] A. Falciform ligament B. Ligamentum teres hepatis C. Hepatoduodenal ligament D. Hepatogastric ligament E. Hepatoesophageal ligament F. Gastrocolic ligament G. Gastrosplenic ligament H. Lienorenal ligament Match the following structures to the ligaments that contains it. Hepatic artery proper

[NPT] Where are the preganglionic cell bodies providing parasympathetic Innervation to the foregut located?

Brainstem (dorsal motor nucleus X) Foregut: DMX (brainstem) -> CN X -> esophageal plexus, celiac plexus -> wall organ Midgut: DMX (brainstem) -> vagal trunk -> superior mesenteric plexus -> wall of organ Hindgut: lateral horn (S2-S4) -> pelvic splanchnic nerve -> wall of organ

[Old PP] Describe orientation of 3rd part of duodenum. A. Inferior and anterior B. Inferior and posterior C. Posterior and superior D. Transverse and anterior E. Transverse and posterior

D Superior -> descending -> transverse -> ascending

[Old PP] A patient is found to have part of intestine herniated into epiploic foramen; now surgeon needs to know what is directly anterior to herniated intestine in epiploic foramen in order not to injure that structure during surgery. Which structure is that? A. Caudate process of liver B. IVC C. Superior pole of left kidney D. Portal vein E. First part of duodenum

D Hepatoduodenal ligament (containing portal triad) is anterior to epiploic foramen of Winslow (which separates greater sac & lesser sac / omental bursa)

[Old PP] Which of following structure(s) is/are considered to be retroperitoneal? A. Transverse colon B. Appendix C. Sigmoid colon D. Jejunum E. None of above is correct

[Old PP] Which duct when blocked will result in pain but no jaundice? A. Cystic duct B. Common hepatic duct C. Common bile duct D. None of the above

[Old PP] Which of the following organs is retroperitoneal? A. Liver B. Right kidney C. Spleen D. Stomach E. Transverse colon

[Old PP] Which of following is NOT TRUE regarding duodenum? A. Bile duct enters second portion of duodenum. B. Its lymph is drained into celiac and superior mesenteric nodes. C. Its greater part is intraperitoneal. D. Its blood supply is derived from branches of celiac and superior mesenteric arteries. E. Pancreas is related to the medial side of second (vertical) portion of C-loop of duodenum.

C Only 1st part is intraperitoneal 2nd-4th parts: retroperitoneal

[Old PP] A 60-year-old male was diagnosed with cancer of gastric antrum. Cancer has spread to regional lymph nodes. Which group of regional lymph nodes is most likely to be affected? A. Celiac lymph nodes B. Common iliac lymph nodes C. Inferior mesenteric lymph nodes D. Paraaortic lymph nodes E. Superior mesenteric lymph nodes

[Old PP] A 70 y/o presented with dysphagia and diagnosed with oesophageal carcinoma by endoscopy. In radiographical findings, where will the tumour be seen? A. Anterior mediastinum B. Inferior mediastinum C. Middle mediastinum D. Posterior mediastinum E. Superior mediastinum

D Common site for oesophageal carcinoma: middle oesophagus Lower boundary of superior mediastinum: T4/T5 (angle of Louis) Oesophagus: C6 → T10 (oesophageal opening) → End at ~2cm below diaphragm => middle oesophagus is approximately lower than T5 which is lower than angle of Louis => not superior mediastinum

[Old PP] A patient needs a liver transplant and he/she has a donor who will donate his/her left lobe. Knowing anatomy of liver is very important for operation. Which of anatomical landmarks divide left and right lobes of liver on visceral surface? A. Fissure of ligamentum teres and falciform ligament B. Fissure of ligamentum teres and ligamentum venosum C. Fissure of falciform ligament and ligamentum venosum D. Oblique fissure E. Horizontal fissure and

[Old PP] A catheter that monitors pressure at its tip is inserted through nose and passed an unknown distance. Catheter records a pressure between swallows that is sub-atmospheric and that decreases during inspiration and increases during expiration. Where is catheter tip most likely inserted? A. Orad region of stomach B. Upper oesophageal sphincter C. Oesophageal body above diaphragm D. Oesophageal body below diaphragm E. Lower oesophageal sphincter

C A: in abdominal cavity B: high-pressure, prevent air entry into esophagus E: high-pressure, prevent reflux

[Old PP] Amy Foster is a 16-year-old girl who presents to you, her general practitioner, with vague symptoms. She gives a history of poor dietary intake and feels she is overweight. She has clinical evidence of weight loss. You suspect that she may have an eating disorder. In relation to small intestine A. Small intestine comprises duodenum, jejunum, ileum and caecum B. All parts of small intestine are retroperitoneal C. Jejunum receives bile from bile duct D. Duodenum is shortest part of small intestine E. Small intestine is characterised by presence of taeniae coli on its walls

D Taeniae coli: colon Jejunum, ileum: suspended from posterior abdominal wall by mesentery -> intraperitoneal

[NPT] Define hernia.

An abnormal exit of a tissue / organ (through muscle / surrounding tissue) E.g. hiatal hernia, inguinal hernia, femoral hernia

[NPT] Describe how you can locate the deep inguinal ring.

Mid-point of inguinal ligament = mid-point between ASIS and pubic tubercle VS Mid-inguinal point = mid-point between ASIS and pubic symphysis - femoral artery - more medial and superior

[NPT] Name the lateral border of the inguinal triangle.

Inferior epigastric vessels Boundaries of inguinal (Hesselbach’s) triangle - Lateral: inferior epigastric vessels - Medial: rectus abdominis - Inferior: inguinal ligament

[NPT] Describe the structures forming the walls of inguinal canal.

1. Roof: arching fibres of IO + TA, conjoint tendon 2. Floor: inguinal ligament (ASIS -> pubic tubercle), lacunar ligament (medial + inferior to inguinal ligament) 3. Anterior: Aponeurosis of EO (superficial ring) + IO (deep ring) 4. Posterior: Transversalis fascia (lateral, weak), reinforced by conjoint tendon (medial, strong) 5. Lateral: deep inguinal ring (Transversalis fascia), mid-pt of ASIS and pubic tubercle 6. Medial: superficial inguinal ring (EO aponeurosis), superior to pubic tubercle

[Practical] During the physical examination of a newborn male, a pediatrician noted a scrotal mass on the left side. The soft, nontender, reducible bulge can be palpated at the location of inguinal canal and extend into the scrotum. What is the most likely diagnosis? A. Indirect inguinal hernia B. Direct inguinal hernia C. Hydrocele D. Femoral hernia

A Femoral hernia: - project through femoral canal - more in females (wider pelvis) Hydrocele: - accumulated serous fluid in spermatic cord - painless swollen testis like a water balloon

[Practical] The abdominal wall has a unique segmental sensory innervation pattern. Choose the correct spinal nerve segment that innervates the following: the level of the xiphoid process of the sternum, the level of the umbilicus, and just above the pubic symphysis.

T6 T10 L1

[Practical] Name the two layers of the supericial fascia of anterior abdominal wall.

1. Camper’s fascia (superficial fatty layer) 2. Scarpa’s fascia (deeper membranous layer)

[Practical] Name the demarcated landmarks that separate the anterior abdominal wall into nine regions.

1. Superior horizontal plane - subcostal plane (inferior to costal margin) OR - transpyloric plane (midway between inferior end of body of sternum & umbilicus) 2. Inferior horizontal plane - transtubercular plane (between tubercles of iliac crests) 3. Vertical planes - L & R mid-clavicular planes

[Practical] Name the demarcated landmarks that separate the anterior abdominal wall into four quadrants.

Horizontal transumbilical plane Vertical median plane

[PP] Toxin production is a common pathogenic mechanism by foodborne pathogens. Which of the following organisms typically produces a neurotoxin as the main pathogenic mechanism? A. Clostridium botulinum B. Enterotoxigenic Escherichia coli C. Salmonella typhi D. Shigella flexneri E. Vibrio cholerae

A Neurotoxins: S. aureus, C. botulinum, B. cereus

[NPT] A. Bacillus cereus B. Campylobacter jejuni C. Campylobacter fetus D. Clonorchis sinensis E. Clostridium botulinum F. Clostridium difficile G. Clostridium perfringens H. Entamoeba histolytica I. Enteroinvasive E.coli J. Enterotoxigenic E. coli K. Enteropathogenic E. coli L. Hookworms M. Helicobacter pylori N. Norovirus O. Rotavirus P. Salmonella enterica Q. Salmonella typhi R. Salmonella paratyphi A S. Salmonella paratyphi B T. Salmonella paratyphi C U. Shigella dysentriae V. Staphylococcus aureus W. Taenia solium X. Verocytotoxigenic E. coli Y. Vibrio cholerae Z. Vibrio parahaemolyticus A 35-year-old male presented with muscle paralysis and dyspnea. He had caned beef stew for dinner last night and he started vomiting around midnight.

E Muscle paralysis -> C. botulinum (neurotoxin) Canned food -> C. botulinum Vomiting, acute onset -> non-inflammatory

[NPT] A. Bacillus cereus B. Campylobacter jejuni C. Campylobacter fetus D. Clonorchis sinensis E. Clostridium botulinum F. Clostridium difficile G. Clostridium perfringens H. Entamoeba histolytica I. Enteroinvasive E.coli J. Enterotoxigenic E. coli K. Enteropathogenic E. coli L. Hookworms M. Helicobacter pylori N. Norovirus O. Rotavirus P. Salmonella enterica Q. Salmonella typhi R. Salmonella paratyphi A S. Salmonella paratyphi B T. Salmonella paratyphi C U. Shigella dysentriae V. Staphylococcus aureus W. Taenia solium X. Verocytotoxigenic / Verotoxigenic E. coli Y. Vibrio cholerae Z. Vibrio parahaemolyticus A 55-year-old female presented with hematuria and anemia. Culture on MacConkey agar showed pink colonies, while culture on Sorbitol MacConkey agar showed yellow colonies.

X Hematuria, anemia -> blood loss via urine MacConkey agar: Pink -> lactose fermenters -> commensals (e.g. E. coli, Klebsiella) Yellow -> lactose non-fermenters -> Salmonella, Shigella, etc. Sorbitol MacConkey agar: Pink -> sorbitol fermenters -> commensals Yellow -> sorbitol non-fermenters -> O157:H7 E. coli (EHEC = STEC + VTEC)

[NPT] A. Bacillus cereus B. Campylobacter jejuni C. Campylobacter fetus D. Clonorchis sinensis E. Clostridium botulinum F. Clostridium difficile G. Clostridium perfringens H. Entamoeba histolytica I. Enteroinvasive E.coli J. Enterotoxigenic E. coli K. Enteropathogenic E. coli L. Hookworms M. Helicobacter pylori N. Norovirus O. Rotavirus P. Salmonella enterica Q. Salmonella typhi R. Salmonella paratyphi A S. Salmonella paratyphi B T. Salmonella paratyphi C U. Shigella dysentriae V. Staphylococcus aureus W. Taenia solium X. Verocytotoxigenic / Verotoxigenic E. coli Y. Vibrio cholerae Z. Vibrio parahaemolyticus A 65-year-old male presented with watery diarrhea. He worked as a fishmonger. Culture on TCBS agar showed green colonies.

Z Sucrose non-fermenter

[NPT] A. Bacillus cereus B. Campylobacter jejuni C. Campylobacter fetus D. Clonorchis sinensis E. Clostridium botulinum F. Clostridium difficile G. Clostridium perfringens H. Entamoeba histolytica I. Enteroinvasive E.coli J. Enterotoxigenic E. coli K. Enteropathogenic E. coli L. Hookworms M. Helicobacter pylori N. Norovirus O. Rotavirus P. Salmonella enterica Q. Salmonella typhi R. Salmonella paratyphi A S. Salmonella paratyphi B T. Salmonella paratyphi C U. Shigella dysentriae V. Staphylococcus aureus W. Taenia solium X. Verocytotoxigenic / Verotoxigenic E. coli Y. Vibrio cholerae Z. Vibrio parahaemolyticus A 70-year-old patient complained of diarrhea with blood and mucus in his stool. Trichrome stain showed erythrophagocytosis.

H Dysentery (amoebic VS bacillary: Shigella, EIEC) Erythrophagocytosis on trichrome stain -> Entamoeba histolytica

[NPT] A. Bacillus cereus B. Campylobacter jejuni C. Campylobacter fetus D. Clonorchis sinensis E. Clostridium botulinum F. Clostridium difficile G. Clostridium perfringens H. Entamoeba histolytica I. Enteroinvasive E.coli J. Enterotoxigenic E. coli K. Enteropathogenic E. coli L. Hookworms M. Helicobacter pylori N. Norovirus O. Rotavirus P. Salmonella enterica Q. Salmonella typhi R. Salmonella paratyphi A S. Salmonella paratyphi B T. Salmonella paratyphi C U. Shigella dysentriae V. Staphylococcus aureus W. Taenia solium X. Verocytotoxigenic / Verotoxigenic E. coli Y. Vibrio cholerae Z. Vibrio parahaemolyticus A 26-year-old male presented with complaints of fatigue, weight loss and painless jaundice. He regularly consumes raw fish.

D Jaundice: Pain (gallstones) VS painless (malignancy) Raw fish: - Clonorchis sinensis - (Vibrio) Biliary inflammation -> obstruction / large duct iCCA / HCC / cirrhosis

[PP] Name a dermatological manifestation in enteric fever. (1 mark)

Rose spots (faint rash over chest and abdomen)

[NPT] Explain the steps by which Salmonella Typhi may lead to central nervous system dissemination. (2 marks)

- After ingestion, Salmonella Typhi multiplies in Peyer’s patches in ileum - Dissemination to the reticuloendothelial system

[PP] Mucous secretory glands are commonly located in the mucosal layer along the alimentary canal. Which part of the alimentary canal has mucous secretory glands in the submucosal layer? A. Colon B. Ileum C. Oesophagus D. Stomach

C Submucosal glands: 1. Esophageal glands 2. Brunner’s glands @ duodenum

[PP] Acute pancreatitis involves autodigestion of the parenchyma by inappropriately activated enzymes. Fat necrosis is one of the complications.. Which of the following is the key deregulated enzyme? A. Amylase B. Lipase C. Elastase D. Protease

B Elastase digests blood vessels -> retroperitoneal haemorrhage Lipase digests fat -> fatty acid => Fat necrosis (yellow, chalky) Opaque patches = free fatty acid + calcium

[PP] The diagram below shows the muscularis externa of oesophagus under high magnification (haematoxylin and eosin (H&E) staining). It shows some muscle cells with peripheral nuclei, and some with long spindle-shaped nuclei. (Source: Virtual Image Aperio System, HKU) Which level of oesophagus is shown in the diagram? A. Beginning of oesophagus B. Lower third of oesophagus C. Middle third of oesophagus D. Oesophagogastric junction

C Upper 1/3: skeletal Middle 1/3: mixed Lower 1/3: smooth

[PP] H&E stained section of the gastric gland (Source: Virtual , Image Aperio System, HKU) What is the main product of chief (zymogenic) cell? A. Gastric intrinsic factor B. Gastrin C. Hydrochloric acid D. Pepsinogen

D Parietal (oxyntic) cell: HCL, intrinsic factor (enhance vit. B12 absorption) Chief (zymogenic) cell: pepsinogen Enteroendocrine cell: hormones, neurotransmitters

[PP] The classic hepatic lobule is the basic structural unit of the liver. What is the key histological structure located at its centre? A. Bile duct B. Hepatic artery C. Hepatic portal vein D. Hepatic vein E. Portal triad

D 1. Classic lobule - 6 portal triads <-> 1 central vein - Venous drainage 2. Portal lobule - 3 central veins <-> 1 portal triad - Bile drainage 3. Hepatic acinus - 2 central veins <-> 2 portal triads - Arterial O2 drainage

[PP] Liver is the site of vitamin A storage. In which cell in the liver is vitamin A stored? A. Hepatocyte B. Kupffer cell C. Pit cell D. Stellate cell

D Ito cells (hepatic stellate cells) - in space of Disse / perisinusoidal space - store vitamin A - synthesise ECM & collagen Kupffer cells - resident macrophages - break down RBCs

[PP] The liver is arranged into cords of liver cells with sinusoidal space between them. What flows in the perisinusoidal space in the liver? A. Bile B. Blood C. Lymph D. Plasma

[PP] DIGESTIVE SYSTEM A. Appendix B. Colon C. Duodenum D. Ileum E. Jejunum F. Liver G. Oesophagus H. Oral cavity I. Pancreas J. Stomach Parietal cells

[PP] DIGESTIVE SYSTEM A. Appendix B. Colon C. Duodenum D. Ileum E. Jejunum F. Liver G. Oesophagus H. Oral cavity I. Pancreas J. Stomach Peyer’s patches

[PP] DIGESTIVE SYSTEM A. Appendix B. Colon C. Duodenum D. Ileum E. Jejunum F. Liver G. Oesophagus H. Oral cavity I. Pancreas J. Stomach Striated muscles

[PP] DIGESTIVE SYSTEM A. Appendix B. Colon C. Duodenum D. Ileum E. Jejunum F. Liver G. Oesophagus H. Oral cavity I. Pancreas J. Stomach Brunner’s glands

[PP] DIGESTIVE SYSTEM A. Appendix B. Colon C. Duodenum D. Ileum E. Jejunum F. Liver G. Oesophagus H. Oral cavity I. Pancreas J. Stomach Centroacinar cells

[PP] Sinusoid is a special type of blood vessel in liver. Name three types of cells lining the liver sinusoid. (3 marks)

1. Kupffer cells 2. Ito cells (hepatic stellate cells) 3. Endothelial cells

[PP] Sinusoid is a special type of blood vessel in liver. Briefly describe the functions of any two types of cells lining the liver sinusoid (2 marks)

1. Kupffer cells: resident liver macrophages, breakdown of red blood cells 2. Ito cells (hepatic stellate cells): storage of vitamin A, production of extracellular matrix and collagen 3. Endothelial cells forming a thin, continuous layer: facilitate substance exchange

[ALW] Topographically, describe how to locate the McBurney’s point.

1/3 from ASIS to umbilicus

[ALW] Define dermatome.

An area of skin mainly supplied by a single spinal nerve

[ALW] Define referred pain.

- Pain is perceived at a location other than the site of painful stimulus - Spinal nerves from different body parts converge on the same 2nd order neuron in spinal cord => brain misinterprets source of pain

[ALW] Explain why a patient with inflammation of the appendix initially feels pain around the umbilicus.

1st order neurons from appendix and umbilicus converge onto same 2nd order neuron at T10 level of spinal cord

[ALW] Why is cholera potentially fatal?

Large amounts of rice-water stool -> rapid dehydration -> hypovolemic shock, metabolic acidosis

[ALW] What treatment is recommended for cholera?

- Oral / IV rehydration solution - Severely ill (Low BP, rapid HR) -> antibiotics 1. Tetracyclines (e.g. doxycycline) 2. Macrolides (e.g. azithromycin) 3. Fluoroquinolones (e.g. ciprofloxacin)

[ALW] Name 3 treatments for gastroenteritis.

1. Oral rehydration solution 2. Loperamide, bismuth subsalicyclate 3. Antibiotics for high risk groups

[ALW] State a difference between clinical presentation of cholera and food poisoning syndrome.

Cholera: vomiting without nausea / distress Food poisoning: vomiting with distress + diarrhoea

[ALW] Describe the molecular basis of oral rehydration therapy.

- Each sugar molecule cotransported with 2 Na+ via SGLT1 -> 260 water molecules co-transported into enterocytes => 5L/day water absorbed Apical: SGLT1 Basal: Na+/K+ ATPase (maintain low intracellular [Na+]), GLUT2

[ALW] What is the use of sodium and potassium in oral rehydration solution?

Diarrhoea -> loss of electrolytes Replace the loss to prevent hyponatremia / hypokalemia (via SGLT1 / passive absorption)

[ALW] What is the use of bicarbonate in oral rehydration solution?

Prevent / Correct metabolic acidosis Alternative: citrate

[ALW] Name two extraintestinal complications of Campylobacter infection.

1. Guillain-Barré syndrome (2-3 weeks after diarrhoea) 2. Reactive arthritis + bacteraemia

[ALW] Name one inflammatory condition in rectum which can be associated with acute GI infections and is common in individuals with inflammatory bowel disease.

Proctitis syndrome

[ALW] Name three clinical presentations of dysentery.

1. Bloody diarrhoea (small volume) 2. Tenesmus (feeling of incomplete emptying) 2. Fever

[PP] Ms. Chan, a 41-year-old teacher with good health, has become critically ill after returning from a holiday in Sri Lanka. During the past 7 days, she has suffered from high fever (often up to 39°C - 40°C) despite taking paracetamol, headaches, diarrhoea, stomach cramps and poor appetite. Diagnosis of typhoid fever has been made and she was given ceftriaxone. What class/group of antibiotics does ceftriaxone belong to?

Third generation cephalosporins

Intravenous

[PP] Ms. Chan, a 41-year-old teacher with good health, has become critically ill after returning from a holiday in Sri Lanka. During the past 7 days, she has suffered from high fever (often up to 39°C - 40°C) despite taking paracetamol, headaches, diarrhoea, stomach cramps and poor appetite. Diagnosis of typhoid fever has been made and she was given ceftriaxone. What is the mechanism of action for ceftriaxone? (2 marks)

- Bactericidal - Mimic D-Ala-D-Ala and bind covalently to active site of penicillin-binding protein (PBP) -> Inhibit transpeptidase in cell wall peptidoglycan synthesis -> Inhibit bacterial cell wall synthesis -> Cell lysis due to osmotic pressure / activation of autolysins to destroy cell wall

[PP] Ms. Chan, a 41-year-old teacher with good health, has become critically ill after returning from a holiday in Sri Lanka. During the past 7 days, she has suffered from high fever (often up to 39°C - 40°C) despite taking paracetamol, headaches, diarrhoea, stomach cramps and poor appetite. Diagnosis of typhoid fever has been made and she was given ceftriaxone. State one common adverse effect of ceftriaxone. (1 mark)

Allergy

[PP] A 35-year-old human immunodeficiency virus (HIV)-infected patient, returned from a trip to Thailand. He presented to the Accident and Emergency Department with profuse watery diarrhoea per day for the past 3 days, along with severe abdominal cramps, nausea, vomiting. Upon physical examination, he was feverish (39°C). He stated that he is allergic to beta-lactam antibiotics. If faecal leukocytes are present, Which group of antibiotics the patient should most likely be empirically given? Name one example of the group of antibiotics. (2 marks)

Macrolides Azithromycin

- Bacterostatic - Bind irreversibly to a site on 50S ribosome - Inhibit translocation of polypeptide from A site -> P site catalysed by peptidyltransferase - Incoming tRNA cannot bind to still occupied acceptor site - Inhibit protein synthesis

[PP] Interferon can be used to treat both hepatitis B and C infections, On the other hand, entecavir can only treat hepatitis B. Explain why in terms of their mechanisms of action.

Interferon - inhibits spread of viruses by 1. Alerting our cells that there is a virus around 2. Direct the immune system to produce antiviral protein -> block viral reproduction Entecavir (NRTI - nucleoside reverse transcriptase inhibitor) 1. Competitive inhibitor of HBV reverse transcriptase 2. Chain terminator when NRTI is incorporated into DNA -> stop DNA elongation - cannot target HCV (RNA virus, no reverse transcription as it is not retrovirus like HBV) -> no viral replication

[PP] List two common malignancy caused by chronic gastritis.

Gastric adenocarcinoma Gastric mucosa-associated lymphoid tissue lymphoma (Gastric MALToma)

[Self-assessment] Which of the following is the characteristic of pegylated interferon alpha 2b? A. Its dosage must be adjusted by body weight B. The polyethylene glycol in pegylated interferon alpha 2b is a branched molecule C. Its absorption is slower than that of pegylated interferon alpha 2a

A Widely distributed in the body -> higher dose for heavier patients to compensate for dilution effect Pegylated interferon alpha 2a: - fixed dose - larger thus slower absorption Polyethylene glycol in pegylated interferon 2b is small and linear

[Self-assessment] Which of the following drugs should be used for the treatment of hepatitis B patients with failing liver? A. Pegylated interferon B. Interferon C. Nucleos(t)ide reverse transcriptase inhibitor

[Self-assessment] What is the disadvantage of nucleos(t)ide reverse transcriptase inhibitor when compared with pegylated interferon? A. Drug resistance is easily developed B. Its adverse effect is flu-like symptoms C. Its duration of treatment is longer

C >1 year VS 6 months - 1 year Resistance: lamivudine, telbivudine, adefovir

[Self-assessment] Which of the following enzymes in hepatitis C virus is inhibited by ribavirin? A. DNA polymerase B. RNA-dependent RNA polymerase C. Reverse transcriptase

B Guanosine nucleoside analogue 1. Inhibit RNA-dependent RNA polymerase (RDRP) -> X RNA replication 2. Inhibit inosine monophosphate dehydrogenase (IMPDH) -> deplete GTP -> X RNA replication 3. Induce TH1-favoured immune response 4. Increase mutation rate of HCV -> dysfunction of certain viral protein

[Self-assessment] Simeprevir is a NS3/4A inhibitor. What is the function of NS3/4A in hepatitis C virus? A. It is a RNA-dependent RNA polymerase. B. It is responsible for the cleavage of hepatitis C polyprotein into functional proteins. C. It is responsible for the viral replication and assembly.

B NS3/4A: protease to cleave RNA polyprotein into functional peptide for release NS5A: viral replication and assembly NS5B: RNA-dependent RNA polymerase -> RNA replication

[Self-assessment] Which of the following is the characteristic of NS5B-nucleoside inhibitor in treating hepatitis C? A. It has a low barrier of developing drug resistance B. It has a narrow genotypic coverage C. It can shorten the duration of treatment of interferon

C Shortened to 12 weeks High barrier of developing drug resistance Pan genotypic coverage (Sofosbuvir - genotypes 1, 4, 2, 3)

[Self-assessment] Which of the following is the characteristic of chloroquine? A. It inhibits heme polymerase B. It is used to kill intestinal but not extraintestinal amoeba C. It is able to destroy the cysts of amoeba

A Chloroquine inhibits heme polymerase -> prevent conversion of heme to hemezoin -> accumulation of heme kills extraintestinal amoeba Cysts of amoeba are highly resistant

[Self-assessment] How cam metronidazole be converted to active form? A. It is oxidized by the heme polymerase B. It is hydrolysed by the gut bacteria C. It is reduced by pyruvate-ferredoxin oxidoreducatase

C Converted to active form by pyruvate-ferredoxin oxidoreductase (PFOR) -> disrupt DNA helical structure -> X DNA replication

[Self-assessment] Which of the following drug act as a depolarizing neuromuscular blocker on the parasitic worms? A. Ivermectin B. Mebendazole C. Pyrantel

C Pyrantel: - depolarising neuromuscular blocker - occupy and desensitise nicotinic receptor in NMJ of worms Ivermectin: - non-depolarising neuromuscular blocker - act on glutamate-gated chloride channels Mebendazole: - inhibit worm’s ability to absorb glucose

[NPT] Name a non-pathogenic commensal amoeba. (1 mark)

Entamoeba dispar

[NPT] What drug combination may you use to treat invasive amebiasis? (2 marks)

Metronidazole + luminal agent (e.g. iodoquinol) Intestinal: iodoquinol Extraintestinal: chloroquine Both, metronidazole

[NPT] Anthelmintics may work by causing membrane depolarization or hyperpolarization. Give one example of an anthelmintic for each mechanism. (2 marks)

Depolarising: Pyrantel - persistently occupy and desensitise nicotinic receptor in neuromuscular junction -> paralysis Non-depolarising: Ivermectin - bind to glutamate-gated chloride channel -> increase chloride permeability -> hyperpolarisation -> paralysis

[Self-assessment] Which of the following anti-ulcer agents should not be used by pregnant women? A. Sucralfate B. Misoprostol C. Ranitidine

B Prostaglandin analogue -> uterine contraction Sucralfate is not absorbed in GI tract so it does not go to foetus

[Self-assessment] Which of the following combinations can be used as the triple therapy for Helicobacter pylori-associated peptic ulcer? A. Clarithromycin + Amoxicillin + Omeprazole B. Clarithromycin + Amoxicillin + Sucralfate C. Clarithromycin + Proton pump inhibitor + Sucralfate

A Proton pump inhibitor + (clarithromycin + amoxicillin + metronidazole) (2 out of 3)

[Self-assessment] Which of the following is the side effect of sucralfate in treating peptic ulcer? A. Constipation B. Darkening of teeth C. Uterine contraction

A Sucralfate = sucrose sulphate + aluminium hydroxide (causing constipation) Darkening of teeth: bismuth Uterine contraction: misoprostol

[PP] A doctor prescribes sucralfate to treat a patient's peptic ulcer. The patient is reminded not to take antacids before or simultaneously with sucralfate. Explain what will happen when antacids are taken before or simultaneously with sucralfate based on their mechanisms of action. (5 marks)

Sucralfate releases Al in the presence of acid - remaining compound acquires strong -ve charge and binds to +ve charged group in mucoprotein - making the mucus thick and viscous to protect the gastric mucosa including area of ulceration from acid and pepsin If antacids are taken before or simultaneously with sucralfate, antacids neutralise gastric acids -> prevent activation of sucralfate

[NPT] Explain why H2 antagonist can be used to treat patients with peptic ulcer.

Inhibit H2 receptors in parietal cells -> reduce cAMP -> reduce PKA action -> inhibit H+/K+ ATPase proton pump -> decrease gastric acid secretion

[NPT] Give an example of H2 antagonist that can be used be peptic ulcer but should be avoided in male patients (1 mark) and explain why (1 mark).

Cimetidine May lead to impotence and gynecomastia As it inhibits binding of dihydrotestosterone to androgen receptors

[NPT] Explain how cimetidine may affect patients taking warfarin.

Inhibit CYP450 metabolism of warfarin -> toxicity

[NPT] Suggest one use of histamine antagonists other than the treatment of peptic ulcers.

H1 antagonist: sedatives, antiemetics, antiallergic drugs

[PP] GASTROINTESTINAL TRACT INFECTIONS A. Associated with consumption of freshwater crabs B. Association with consumption of raw oysters C. Development of muscle paralysis D. Dysentery E. Guillain-Barré syndrome F. Haemorrhagic colitis G. Profuse watery diarrhoea leading to hypotension H. Recent antibiotic use I. Rose spots, hepatosplenomegaly J. Short incubation period (2-6 hours) For each of the following gastrointestinal pathogens, what is the MOST CHARACTERISTIC clinical or epidemiological feature? The option may be used once, more than once, or not at all. Clostridioides difficile

C Guillain-Barré syndrome, reactive arthritis: extraintestinal manifestations of campylobacteriosis

F Enterohaemorrhagic / Verocytotoxigenic / Shiga-toxin producing (EHEC / VTEC / STEC): haemorrhagic colitis, haemolytic uremic syndrome, thrombotic thrombocytopenic purpura

[PP] ENTERIC PARASITES A. Ascaris lumbricoides B. Clonorchis sinensis C. Cryptosporidium hominis D. Cyclospora cayatanensis E. Entamoeba histolytica F. Enterobius vermicularis G. Giardia duodenalis H. Hookworms I. Taenia solium J. Trichuris trichiura For each of the following clinical or parasitological features, choose one enteric parasite above that BEST fits the description. The option may be used once, more than once, or not at all. Typically causes acute colitis, but may be complicated by liver abscess.

[PP] ENTERIC PARASITES A. Ascaris lumbricoides B. Clonorchis sinensis C. Cryptosporidium hominis D. Cyclospora cayatanensis E. Entamoeba histolytica F. Enterobius vermicularis G. Giardia duodenalis H. Hookworms I. Taenia solium J. Trichuris trichiura For each of the following clinical or parasitological features, choose one enteric parasite above that BEST fits the description. The option may be used once, more than once, or not at all. One of the intermediate hosts involves a freshwater snail.

[PP] Describe the function of pancreatic acini.

Secrete digestive enzyme precursors

[PP] A 25-year-old man has an acute onset of right upper quadrant abdominal pain. Abdominal ultrasound reveals a dilated gallbladder with thickened wall and filled with calculi. Laparoscopic cholecystectomy is performed and the gallbladder is opened to reveal ten multifaceted 0.5 to 1 cm diameter dark black gallstones. Which of the following condition is this man MOST LIKELY suffering from? A. Hypercholesterolemia B. Hyperparathyroidism C. Laron syndrome D. Sickle cell anaemia

D Hemolysis -> black pigment stones

[PP] A 75-year-old man presented to the Accident and Emergency Department with vomiting and abdominal distension. An abdominal radiography was performed which showed some dilated bowel loops. What features are supportive of dilated large bowels rather than small bowels on the radiograph? A. Centrally located bowel loops B. Lack of faeces in the dilated bowel loops C. Presence of haustra D. Presence of valvulae conniventes

C Small intestine: central, no faeces, valvulae conniventes

[PP] Mr. Yan is a 61-year-old man who received oesophagectomy for his oesophageal cancer 10 days ago. He has been complaining of chest tightness and a chest radiograph was performed which revealed abnormal shadow in left lower zone of this lung, left pleural effusion and pneumomediastinum. You suspect an anastomotic leak. What imaging investigation would you request to confirm? A. Barium meal B. Erect and supine X-ray of the abdomen C. Ultrasound of the chest D. Water soluble contrast of upper gastrointestinal swallow

D Barium meal is contraindicated in suspected leaks / perforations due to risk of peritonitis

[PP] [2019 M23 2nd Summative Q7] A 61-year-old man who had an oesophagectomy for oesophageal cancer 10 days ago. His post op recovery had been hampered by continuous low grade fever and dysphagia. He had also been complaining of chest tightness. Chest radiograph was performed which revealed a moderate left-sided hydropneumothorax and pneumomediastinum. You suspect an anastomotic leak. What imaging investigation would you request to confirm the diagnosis? A. Barium meal B. Barium swallow C. Erect and supine X-ray of the abdomen D. Ultrasound of the chest E. Water soluble contrast swallow

[Self-assessment] The splenic vein and the SMV join to form the? A. Main portal vein B. IMV C. Middle hepatic vein

[Self-assessment] The neck of the pancreas lies just anterior to the? A. Porta hepatis B. IVC and aorta C. SMA and SMV

C Mesenteric vessels can be invaded in pancreatic cancer and affects tumour resectability / staging

[Self-assessment] What is in the fissure for the ligamentum teres? A. Cystic duct B. Umbilical vein remnant C. Aberrant right hepatic artery

B May be recanalised in portal hypertension -> caput medusae

[PP] Regarding chlorea, A. Vibrio cholerae O1 and O139 have epidemic potential. B. V. cholera and V. parahaemolyticus are Gram negative, oxidase-negative, curved, facultatively anaerobic bacteria. C. Endemic cholera is usually caused by Vibrio parahaemolyticus.

A Gram-negative, oxidase-positive, curved, facultative anaerobic bacilli

[PP] Regarding infectious diarrhoea and gastrointestinal pathogens, A. Oral rehydration solution is not effective in the presence of diarrhoea. B. Campylobacter jejuni is a Gram negative, spiral, motile bacterium which can cause intestinal and extraintestinal infections. C. Norovirus has an incubation period of 5-7 days.

B Contraindications for ORS: severe vomiting, impaired consciousness Norovirus: incubation period of 12-48 hours

[Self-assessment] Nutrients are absorbed mainly by Select one: A. The small intestines B. The colon C. Both the colon and small intestines

[Self-assessment] What is the function of SGLT1 in enterocytes? Select one: A. Transport of glucose from the enterocyte to blood B. Transport of glucose from the lumen to the enterocyte C. Transport of Na + ions out into the blood

B SGLT1 cotransports 2 Na+ with each sugar molecule

[PP, formative] A 30-year-old man contracted amoebiasis after his trip to India. The amoeba infection was confined to his intestine and did not spread to other parts of his body. After taking medication to treat his amoebiasis, he experienced numbness in his fingers and a metallic taste in his mouth. Which of the following drugs did he take for treating the amoebiasis? A. Amoxicillin B. Chloroquine C. Levofloxacin D. Metronidazole

[PP, formative] Absorption of nutrients in the Gastrointestinal tract involves different types of transport mechanism. Which of the following BEST DESCRIBES the mechanism used for fructose absorption? A. Endocytosis B. Facilitated diffusion C. Simple diffusion D. Sodium-dependent facilitated transport

[PP, formative] A male patient aged 65-year-old has recurrent gout and is prescribed with allopurinol to prevent gouty attack. What is the biological effect of allopurinol? A. Inducing the metabolism of uric acid B. Inhibiting the formation of uric acid C. Reducing the reabsorption of uric acid D. Stimulating the excretion of uric acid

[PP, formative] A patient arrived at the Accident & Emergency Department complaining about severe abdominal pain. Internal bleeding is suspected. Which organ supplied by all three branches of the celiac trunk is the likely source of bleeding? A. Gallbladder B. Spleen C. Stomach D. Transverse colon

[PP, formative] Osteogenesis imperfecta is a genetic disorder with brittle bones that can be treated with bisphosphonates to increase the overall bone mass. This treatment alters the balance between which pair of skeletal cells in bone remodelling? A. Chondrocytes and hypertrophic chondrocytes B. Chondrocytes and osteoblasts C. Osteoblasts and osteoclasts D. Osteoblasts and osteocytes

[PP, formative] A 75-year-old man with a past history of osteoarthritis in the left knee presents with a 1-week history of acute pain in the right knee without fever. Joint aspiration is performed and the pathology report says "the fluid contains neutrophils and birefringent needle crystals". What is the MOST LIKELY diagnosis? A. Acute septic arthritis B. Ankylosing spondylitis C. Calcium pyrophosphate deposition disease D. Gout

[PP, formative] Ultraviolet light plays an important role in photoaging, and malignancies. What absorb(s) photons in the dermis? A. Apocrine glands B. Langerhan cells C. Melanin D. Stratum lucidum

[Old PP] Name three aetiologies of oesophageal carcinoma. (3 marks)

1. Diet (restricted diet of cornmeal & pickled vegetable, carcinogenic nitrosamine, trace elements deficiency, fungal contaminants 2. Chronic alcoholism (SCC) and tobacco smoking (SCC, adenocarcinoma) 3. Barrett’s esophagus (adenocarinoma) 4. Esophageal disorder: achalasia (SCC) 5. Genetic predisposition

[Old PP] What is most frequent histological subtype of esophageal cancer locally? (2 marks)

Squamous cell carcinoma

[Old PP] What is most common site in oesophagus for esophageal SCC? (2 marks)

Middle part of esophagus

[Old PP] What is type of spread of esophageal cancer? (2 marks)

1. Lymphatic (regional LNs) 2. Direct invasion -> lungs, aorta 3. Submucosal spread -> multiple nodules 4. Hematogenous -> liver, brain (least common)

[Old PP] Name two countries / cities which have a high incidence of this cancer. (2 marks)

China, India, Japan UK, Around Caspian Sea, South and East Africa

[Old PP] What is most important factor leading to esophageal cancer? (2 marks)

Diet

[Old PP] What is achalasia? (1 mark)

Failure of relaxation of lower esophageal sphincter during swallowing -> aperistalsis

[Old PP] Name three causes of infective oesophagitis. (3 marks)

Fungal in immunocompromised: Candida, Aspergillus, Mucor Viral: HSV, Cytomegalovirus

[Old PP] What are predisposing factors for gastroesophageal reflux disease (GERD)? (3 marks)

1. Hiatal hernia 2. Increased intra-abdominal pressure 3. Abnormal upper GI motility (e.g. lowered LES tone, delayed gastric emptying)

[Old PP] Name two symptoms associated with GERD.

Heartburn Regurgitation

[Old PP] Name the most common histological subtype of oesophageal cancer associated with GERD.

Adenocarcinoma

[Old PP] Name three complications of achalasia.

Reflux esophagitis -> Barrett’s esophagus SCC in upper 2/3 of esophagus Aspiration pneumonia

[Old PP] What is most frequent histological subtype of gastric cancer in Hong Kong? (2 marks)

Adenocarcinoma

[Old PP] What is most common site in stomach for gastric cancer? (2 marks)

Pre-pyloric region

[Old PP] What is most common type of spread of gastric cancer? (2 marks)

Lymphatic (regional LN) Others: hematogenous, peritoneal, direct invasion

[Old PP] There is a peculiar type of spread of this cancer. What is it? (2 marks)

Peritoneal spread -> Krukenberg tumours in bilateral ovaries

[Old PP] Name two of most important factors leading to gastric cancer. (2 marks)

1. Helicobacter pylori (WHO Class I carcinogen) 2. Tobacco smoking 3. Diet (nitrosamines from smoked and salted fish, picked vegetables) 4. Pre-malignant conditions (gastric adenomas, autoimmune gastritis, pernicious anemia, dysplasia)

[Old PP] List three complications of peptic ulcer.

1. Haemorrhage: melena with black tarry stool, hematemesis with coffee ground material or fresh blood 2. Perforation: acute peritonitis (chemical -> bacterial) 3. Penetration into adjacent organs: acute pancreatitis 4. Fibrosis and stenosis (rare): pyloric stenosis / hour-glass appearance Ulcer-cancer is extremely uncommon (never for duodenal ulcer)

[Old PP] Name two etiological factors leading to chronic gastritis.

H. pylori Autoimmune

[Old PP] Name two etiological factors leading to acute gastritis.

NSAIDs Tobacco smoking Chronic alcoholism Severe stress (stroke: Cushing’s ulcer, burns: Curling’s ulcer)

[Old PP] A. Acute appendicitis B. Adenocarcinoma of lower oesophagus C. Cholelithiasis D. Colorectal cancer E. Diverticulosis F. Hepatocellular carcinoma G. Inflammatory bowel disease H. Small cell cancer of oesophagus I. Stomach cancer J. Traveller’s diarrhoea Following are risk factors of which of GI diseases above respectively? Pregnancy

C Female, fat, forty, fertile

[Old PP] Which of following is a foodborne parasite? A. Clonorchis sinensis B. Hookworm C. Plasmodium D. Schistosoma E. Trichomonas vaginalis

A Liver fluke from raw fish -> large duct iCCA (also Opisthorchis viverrini)

[Old PP] A female with pain was found to have a solitary stone in gall bladder. What is most likely composition of stone? A. Bile pigment B. Calcium bilirubinate C. Calcium carbonate D. Cholesterol E. Magnesium carbonate

D B, C, D: constituents of bile

[Old PP] A 75-year-old man shows symptoms of jaundice. CT scan shows a 4 cm tumour at head of pancreas, lymph node enlargement and lung nodules. What histological features would likely be observed? A. Amyloid deposition B. Atrophy of acini C. Lymphocytic infiltration of islets D. Malignant glands with fibrous stroma E. Necrosis and haemorrhage

[Old PP] 45y/o alcoholic, acute abdominal pain radiating to back. Serum amylase level 1500 IU/L (normal range given). What is most likely histological feature? A. Amyloid deposition B. Fibrosis of parenchyma C. Malignant gland formation D. Necrosis and haemorrhage E. Proliferation of islet cells

[Old PP] A 60-year-old man with a history of gallstones presents with a sudden onset of severe, constant epigastric pain, radiating to middle back. He is febrile, vomiting and discolouration around flank and umbilicus upon physical examination. There is an elevated level of serum amylase and lipase. What is most likely diagnosis? A. Acute appendicitis B. Acute cholangitis C. Acute cholecystitis D. Acute diverticulitis E. Acute pancreatitis

[Old PP] A patient with pancreatitis experienced abdominal distension after meal. Intake of which of following carbohydrates would be cause of abdominal distension? A. Cellulose B. Chitin C. Lactose D. Starch E. Sucrose

[Old PP] A 55-year-old chronic alcoholic man visits his family doctor for a health check. After doing CT scan his liver was found to be fibrotic and shows cirrhosis. He quits drinking after some time. He is still at risk in which of following diseases? A. Cholangiocarcinoma B. Cholelithiasis C. Clonorchiasis D. Hepatocellular adenoma E. Hepatocellular carcinoma

[PP] There are three pathological features of cirrhotic liver to make this diagnosis. State two. (2 marks)

1. Diffuse process affecting the entire liver 2. Regenerative nodules of hepatocytes 3. Fibrous connective tissue surrounding regenerative nodules -> fibrous septa / stroma

[PP] If a HCC patient develops hypoglycaemia, what would be the reason?

1. Replacement of liver with tumour -> reduce glycogen stored in remaining part without tumour 2. Clear cell type with excessive glycogen storage in tumour 3. Insulin-like peptide secretion

[PP] List two hereditary aetiologies leading to cirrhosis.

1. Wilson’s disease 2. Alpha-1 antitrypsin deficiency

[PP] List two aetiologies leading to cirrhosis.

HBV, HCV, HDV Alcohol / toxins / drugs Non-alcoholic steatohepatitis (NASH) Autoimmune hepatitis Primary biliary cirrhosis (autoimmune)

[PP] Outline the venous drainage of the duodenum and the pancreas. ● Pancreas → (1) _________ → (2) ___________ ● Pancreas + Duodenum → (3) __________ → (4) _________ (2) and (4) drains into (5) __________ → Liver

(1) pancreatic veins (2) splenic vein (3) pancreaticoduodenal veins (4) superior mesenteric vein (5) portal vein

[PP] [PP, formative] Lecithin-cholesterol acyltransferase (LCAT) activity may be decreased in liver dysfunction, such as cirrhosis. How does decreased LCAT activity affect composition of low-density lipoprotein? A. Decreased free cholesterol B. Decreased triacylglycerol C. Increased cholesterol ester D. Increased triacylglycerol

D Liver diseases Reduced LCAT -> reduced cholesterol ester, increased free cholesterol Reduced LPL, HTGL -> increased TAG Reduced LCAT, increased TAG -> LDL become TAG-rich & cholesterol ester-poor Impaired VLDL production: Plasma TAG is normal as LDL is TAG-rich Increased NEFA to meet fasting energy requirements of peripheral tissues (reduced hepatic glucose output)

[PP] Function of FABP. A. Act as a feedback signal for fatty acid transport B. Maintain inward drive for fatty acid C. Prevent formation of intracellular fat droplets D. Temporary storage site for fatty acid

D Temporarily bind and transport FA intracellularly

[PP] Raised ALP level can imply hepatic dysfunction or bone dysfunction. Content of which of the following enzymes is likely to rise together if it is hepatic origin? A. ALT B. CK C. Gamma-glutamyl transpeptidase D. Lactate dehydrogenase

[PP] Pancreas is important in fat digestion and absorption. Which vitamin may become deficient in pancreatic disorders? A. Folic acid B. Vitamin B6 C. Vitamin B12 D. Vitamin C E. Vitamin D

E Malabsorption of fat -> malabsorption of fat-soluble vitamins (A, D, E, K) Features related to pancreatic insufficiency: malabsorption, weight loss, steatorrhoea, hypoalbuminaemia, DM

[PP] Swallowing requires intricate control of the oral cavities, pharynx, larynx and oesophagus. Which brain area controls the movement of epiglottis during swallowing? A. Cerebral cortex B. Hypothalamus C. Medulla oblongata D. Pons

[PP] 19-year-old woman visited her doctor because of nausea, diarrhoea, and flatulence. The doctor administered 50 g oral lactose at time 0 and measured breath hydrogen every 30 minutes for 3 hours. The results show increased hydrogen ions. What is your diagnosis of this patient's condition? A. Decreased brush border isomaltase B. Decreased brush border lactase C. Decreased gastric pepsin D. Decreased pancreatic lactase

B Lactose intolerance -> undigested lactose is fermented by bacteria in colon

[PP] Secretin is a major hormone that regulates gastrointestinal secretion. Which process is stimulated by secretin? A. Decreases gastric acid secretion in an empty stomach B. Decreases gastric acid secretion when protein is digested in duodenum C. Increases gastric acid secretion when smelling the food D. Increases saliva secretion when seeing the food

B Intestinal phase - Initially stimulated by gastric - Later inhibited by enterogastric reflex, cholecystokinin (CCK), secretin and glucose dependent insulinotropic peptide (GIP)

[PP] Functional metabolism of vitamin B12 is essential to human health. Which metabolic pathway is affected when there is vitamin B12 deficiency? A. Carboxylation of pyruvate to oxaloacetate B. Decarboxylation of amino acids from amine C. Synthesis of methionine from homocysteine D. Synthesis of thymidine monophosphate

C 1. Methyltransferase: homocysteine -> methionine (for DNA methylation, myelin synthesis, DNA synthesis) 2. Methylmalonyl CoA mutase: methylmalonyl-CoA -> succinyl-CoA (for TCA cycle, myelin synthesis)

B Pancreatic ducts secrete bicarbonate to neutralise acidic chyme

[PP] Proteolytic enzymes are secreted as zymogens into the gastrointestinal tract and then activated for the digestion of dietary proteins. Which enzyme initiates on the pancreatic phase of protein digestion in the gastrointestinal tract? A. Chymotrypsin B. Enteropeptidase P C. Pepsinogen D. Proelastase E. Trypsin

E Enteropeptidase: trypsinogen -> trypsin

[PP] Omphalocele is a rare abdominal wall defect. Which developmental defect accounts for the omphalocele? A. Failure of elongation of the midgut B. Failure of herniation of the midgut into the umbilical cord C. Failure of the herniated gut to return to the abdominal cavity D. Failure of the herniated gut to rotate the first 90° anticlockwise

[PP] Malrotation of the mid-gut could obstruct blood supply leading to intestine ischaemia. Which of the following blood vessels is obstructed? A. Coeliac artery B. Inferior mesenteric artery C. Superior mesenteric artery D. Superior rectal artery

[PP] A 60-year-old man who came to your clinic for progressive dysphagia in the recent 2 months. He admitted that he had heartburn sensation 10 years ago and an upper endoscopy at that time revealed salmon pink mucosal patches at the gastro-oesophageal junction. Now another upper endoscopy showed a malignant-looking mass overlying the previously noted salmon pink patches at the gastro-oesophageal junction. What is the MOST LIKELY histology of this mass? A. Adenocarcinoma B. Large cell neuroendocrine tumour C. Small cell carcinoma D. Squamous cell carcinoma E. Undifferentiated carcinoma

A Malignant predisposition at lower 1/3 of oesophagus -> adenocarcinoma Lump formation -> dysphagia

[PP] A 60-year-old man presented with heartburn symptoms. Upper endoscopy showed salmon pink mucosal patches at the gastro-oesophageal junction and biopsy revealed intestinal metaplasia. He defaulted medical follow up. Ten years later he attended the gastrointestinal clinic for dysphagia, and this time endoscopy found a malignant-looking tumour at the gastro esophageal junction where the salmon-pink mucosa had been present. What is the MOST LIKELY histology of this tumour? A. Adenocarcinoma B. Large cell neuroendocrine tumour C. Small cell carcinoma D. Squamous cell carcinoma

[PP] Barrett's oesophagus is a risk factor for oesophageal cancer in the lower one-third of the oesophagus. What is the histological subtype associated with this condition? A. Adenocarcinoma B. Small cell carcinoma C. Squamous cell carcinoma D. Undifferentiated carcinoma

[PP] Barrett's oesophagus is related to protracted reflux oesophagitis. What is the diagnostic histological feature of Barrett's oesophagus? A. Glandular dysplasia B. Intestinal metaplasia C. Squamous hyperplasia D. Squamous metaplasia

[PP] A 50-year-old male complained of mild upper abdominal discomfort and had an upper endoscopic examination. A small area of the fundus showed some loss of rugal folds in the mucosa. A biopsy from this area revealed a well-differentiated adenocarcinoma which had invaded for just a short distance into the submucosa. The doctor told him this was an early gastric cancer. This lesion is BEST characterised by which of the following? A. Absence of lymph node metastasis B. Absence of ulceration C. Diffuse involvement of the mucosa of the whole stomach D. Excellent prognosis with a 5-year survival post-resection of >90% if no invasion into muscularis propria

D Regardless of lymph node metastasis

[PP] A gram-negative, spiral-shaped bacterium occurring in the stomach is frequently found in the local people in Hong Kong. Which of the following BEST describes this organism? A. It is a World Health Organization Class I carcinogen. B. It is most frequently found in the body of the stomach. C. It is stained up with Ziehl-Neelsen stain which facilitates identification. D. It produces enzymes such as matrix metalloproteinases which can digest fibrous tissue.

[PP] A 54-year-old man is hepatitis B surface antigen positive. He is found to have a firm, nodular liver. Which of the following is MOST LIKELY to be his liver pathology? A. Diffuse regenerative nodules surrounded by fibrous tissue B. Focal nodular hyperplasia with a central scar C. Portal vein thrombosis D. Severe fatty change of the liver

[PP] A 65-year-old man presented with a whitish solid tumour growing along the large bile ducts in the left lobe of the liver. He had no cirrhosis and was tested negative for hepatitis B virus. What is the MOST LIKELY predisposing factor for his tumour? A. Chronic alcoholism B. Chronic hepatitis C infection C. Recurrent pyogenic cholangitis D. Schistosomiasis

C Liver flukes - Clonorchis sinensis - Opisthorchis viverrini Large duct intrahepatic cholangiocarcinoma (iCCA)

[PP] Primary pancreatic adenocarcinoma is a highly aggressive cancer with a very poor prognosis. What is the cell of origin for pancreatic adenocarcinoma? A. Acinar cells B. Ductal epithelial cells C. Islet cells D. Pancreatic stellate cells

[PP] Acute pancreatitis could range from a self-limiting to a life-threatening condition. Macroscopically, deposition of chalky material can be seen on the pancreatic surface. Which pathological process does this represent? A. Amyloid deposition B. Fat necrosis C. Granulomatous inflammation D. Hyalinisation of blood vessels

[PP] A 45-year-old chronic alcoholic presented with acute abdominal pain that radiated to the back. Serum amylase level was over 1500 IU/L (normal range: 25-125 IU/L). Ultrasonography of the abdomen showed a swollen pancreas. What is the MOST LIKELY histology of the pancreas? A. Amyloid deposition B. Fibrosis of parenchyma C. Malignant glands among the fibrous stroma D. Necrosis and haemorrhage E. Proliferation of islet cells

D Necrotic pancreatic tissue Damage of vasculature -> haemorrhage Fat necrosis -> yellow chalky blobs

[PP] A 50-year-old male has an isolated increase in plasma alanine transaminase (ALT) concentration. Which of the following is a cause of the biochemical abnormality? A. Carcinoma of pancreas B. Carcinoma cf the common bile duct C. Cirrhosis D. Fatty liver

[PP] Site specific abnormalities in the liver may be reflected by collective abnormal values of more than one biomarker in a liver function test. In case of bile duct blockage, what biomarker is likely to be elevated together with gamma-glutamyl transferase? A. Alanine aminotransferase B. Alanine phosphatase C. Alkaline aminotransferase D. Alkaline phosphatase

[PP] A 25-year-old man underwent a routine health check with the following liver function test results (unconjugated hyperbilirubinaemia) He has a good past health and no symptoms. Physical examination was unremarkable. What is the MOST LIKELY diagnosis? A. Crigler-Najjar syndrome B. Dubin-Johnson syndrome C. Gilbert syndrome D. Rotor syndrome

C U Can Go C DR Unconjugated: Crigler-Najjar syndrome, Gilbert syndrome (good past health) Conjugated: Dubin-Johnson syndrome, Rotor syndrome

[PP] A 70-year-old man presented with low back pain was found to have an increased serum total protein concentration up to 100 g/L (Normal: 60 - 80 g/L). Which of the following tests will suggest monoclonal gammopathy as the cause for the hyperproteinemia? A. Liver function test B. Renal function test C. Serum immunoglobulins D. Serum protein electrophoresis

D Multiple myeloma Serum protein electrophoresis: show paraprotein / monoclonal band Serum Ig: cannot distinguish monoclonal / polyclonal gammopathy

[PP] A 47-year-old patient with a severe Methicillin-resistant Staphylococcus aureus (MRSA) infection was given a drug by intravenous infusion. Because the drug was administered too rapidly, the patient developed hypotension, as well as marked flushing and itching over the upper portion of his chest, neck and face. Which of the following antibiotics is the MOST LIKELY causative agent? A. Amoxicillin B. Cefuroxime C. Ciprofloxacin D. Doxycycline E. Vancomycin

E Slow infusion -> pain, thrombophlebitis (many blood clots in veins) Rapid infusion -> red man syndrome (flushing) Nephrotoxicity, ototoxicity -> dosage adjustment in renal failure

[PP] Urea cycle takes place in the hepatocytes. Besides mitochondrial matrix, which of the following cellular compartments is also involved? A. Cytosol B. Golgi C. Mitochondrial inner membrane D. Mitochondrial outer membrane

[PP] Fuel molecules used to generate ATP can be produced endogenously in the body. Which of the following metabolites can only be generated in the liver? A. Alpha-keto acids B. Fatty acids C. Glucose D. Ketone bodies

[PP] As a result of protein turnover in skeletal muscle, the a-amino group of amino acids is delivered to the liver for conversion to urea. Which amino acid is responsible for vascular delivery of the a-amino group from skeletal muscle to the liver? A. Alanine B. Glutamate C. Glycine D. Phenylalanine

[PP] During fasting, liver production of ketone bodies is increased. The ketone bodies are delivered to extrahepatic tissues where mitochondrial oxidation of ketone bodies yields substrates for energy production. What limits hepatocyte mitochondria in the capacity to utilise ketone bodies for energy production? A. High activity of fatty acid oxidation B. High [NADH]/[NAD+] C. Low β-hydroxybutyrate dehydrogenase activity D. Low thiotransferase activity E. Spontaneous thiolase activity

[PP] A 17-year-old girl is diagnosed with acute appendicitis. How would one describe the MOST COMMON surface projection for the base/root of the infected organ? A. 2 cm inferior to the umbilicus on the midline B. One-half the distance between the umbilicus and the pubic tubercle C. One-third of the distance from the anterior superior iliac spine to the umbilicus D. Two-thirds of the distance from the anterior superior iliac spine to the umbilicus

[PP] A 43-year-old female is referred for gallbladder removal. The artery to be ligated during cholecystectomy is typically located in the triangle between the liver, cystic duct, and which other structure? A. Coeliac trunk B. Common hepatic duct C. Ligamentum venosum D. Median umbilical ligament

B Ligation of cystic artery in Calot’s triangle (bounded by inferior surface of liver, cystic duct, common hepatic duct)

[Old PP] A 56-year-old man, previous IV drug user, was referred from an outpatient clinic for abnormal blood tests. He lost nearly 5 kg in past 4 months and has lost his appetite. Further investigations show he has elevated alpha-fetoprotein. What is most likely diagnosis? A. Yolk sac tumour B. Choriocarcinoma C. Seminoma D. Teratoma E. Hepatocellular carcinoma

[NPT] Name an anatomical landmark in the intestines that could help the surgeon localize the appendix. (1 mark)

Taeniae coli (free taenia, omental taenia, mesocolic taenia)

[Old PP] Name nervous structure found in muscularis externa. (1 mark)

Myenteric / Auerbach’s plexus MYAM (Myenteric plexus - Muscularis externa) MESS (Meissner plexus - Submucosal)

[Old PP] Name one distinct histological feature for each of any two regions of small intestine. (2 marks)

Duodenum: Brunner’s glands (branched tubular mucous glands) in submucosa Ileum: Peyer’s patches in lamina propria of mucosa, M cells in epithelium

[Old PP] Describe any four common histological features of all three regions of small intestine. (4 marks)

Mucosa 1. Villi with simple columnar epithelium (enterocytes forming brush border of microvilli + goblet cells) 2. Intestinal glands (crypts of Lieberkuhn) (short tubular) open between villi 3. Lacteals in lamina propria Submucosa 4. Plicae circulares (circular folds) protrude towards lumen Muscularis externa Serosa / adventitia

[Old PP] A large part of gastrointestinal tract is lined by simple epithelium. Nave five cell types present in small intestine and briefly comment their functions. (10 marks)

1. Enterocytes: absorptive cells with brush border of microvilli 2. Goblet cells: secrete mucus -> protect and lubricate intestinal lining In intestinal glands only: 3. Paneth cells: secrete defensins (defensive functions, innate immunity) 4. Enteroendocrine cells: secrete local GI hormones -> regulate GI motility and secretion 5. Stem cells at base of crypt: divide and differentiate to form new cells

[Old PP] Name cell type in liver which produces bile. (1 mark)

Hepatocytes

[Old PP] Describe, in order, route by which bile flows in liver. (3 marks)

Bile is secreted by hepatocytes into bile canaliculi between 2 adjacent hepatocytes, sealed by tight junctions -> make their way through liver cords / plates -> merge to form canals of Hering -> drain into bile ducts in portal triad -> drain into L/R hepatic duct -> common hepatic duct

[Old PP] What is central component of a classical hepatic lobule? A. Hepatic artery B. Bile duct C. Hepatic portal vein D. Portal triad E. Hepatic vein

[Old PP] In what cells in liver is vitamin A stored? A. Ductal cell B. Fibroblasts C. Kupffer cell D. Parenchymal cell E. Stellate cell

[Old PP] What is type of epithelium lining liver? A. Pseudostratified ciliated columnar B. Simple columnar C. Simple cuboidal D. Simple squamous E. Stratified squamous

[Old PP] Which of following distinguishes pancreas from other exocrine glands in body? A. Presence of abundant rough endoplasmic reticulum in cell B. Presence of interlobular ducts C. Presence of centroacinar cells within secretory ducts D. Presence of intercalated ducts E. Presence of myoepithelial cells

[Old PP] In liver, blood flow through special structures called sinusoids. Which of following is most likely feature of sinusoids? A. RBC present in space of Disse B. Sinusoidal cells lined with well-developed basal lamina C. Sinusoids deliver blood to portal blood D. Sinusoids receive blood supply from hepatic artery and portal vein E. They open into lumen of bile canaliculi

D Space of Disse / Perisinusoidal space: - contains Ito cells - lined by discontinuous endothelial cells

[Old PP] Following are characteristics of pancreas EXCEPT A. Presence of islets of Langerhans B. Secretory cells with basal basophilia C. Many acini have centroacinar cells D. Absence of intercalated ducts E. Secrete large number of digestive enzymes

D Basal basophilia (rER) Apical eosinophilia (zymogen granules)

[Old PP] Diffuse lymphoid tissue, referred as gut-associated lymphoid tissue (GALT), is found entirely along GI tract. In which histological layer is GALT mainly found? A. Adventitia B. Mucosa C. Muscularis propria D. Submucosa E. Serosa

[Old PP] Gastrointestinal (GI) tract has distinctive histological layers, which supports regional functions of GI system. Where in GI tract has highest concentration of lymphatic nodules named Peyer's patches? A. Appendix B. Duodenum C. Ileum D. Rectum E. Stomach

Mucous glands are mainly found in mucosal layer in gastrointestinal system. In which of following part of gastrointestinal tract is mucous gland found in submucosal layer? A. Appendix B. Duodenum C. Ileum D. Jejunum E. Pylorus of stomach

B Brunner’s glands

[Old PP] Epithelium of digestive system is continually renewed by stem cells present along gastrointestinal tract. What is location of intestinal stem cells that differentiate into different kinds of cell types in intestinal epithelium? A. Base of intestinal crypt B. Junction between villi and intestinal crypt C. Neck of intestinal crypt D. Entire intestinal crypt E. Tip of intestinal crypt

[Old PP] Where are stem cells for gastric epithelium located? A. Base of gastric gland B. In gastric pit C. Junction between base of gastric pit and neck of gastric glands D. Junction between neck and base of gastric glands E. Surface epithelium

[Old PP] A student examines histology of intestine. What would be found only in small bowel but not in large bowel? A. Striated border at apical region of epithelium B. External longitudinal muscle in muscularis externa C. Goblet cells D. Lymphocytes in lamina propria E. Villi

[Old PP] With regard to enteric neurons of gastrointestinal system, which of following statements is correct? A. Numerous sensory neurons whose cell bodies are in myenteric and submucosal plexuses respond to mechanical and chemical stimuli B. Enteric neurons work dependently on autonomic nervous system in regulation of gastrointestinal functions C. Its submucosal nerves mainly control GI movements/contractions D. Its myenteric nerves mainly control GI secretion and local blood flow E. Number of neurons is much less than that in entire spinal cord

A B: ENS can work independent of ANS MESS: Meissner’s plexus in submucosa -> secretion of mucosal glands (and motility of Muscularis mucosae) MYAM: Myenteric / Auerbach’s plexus in Muscularis external -> motility by controlling contraction of Muscularis externa E: no. of neurons is comparable to that of spinal cord

[Old PP] All of following statements about rectal histology and anatomy are correct EXCEPT A. Epithelial lining is of simple columnar type. B. Epithelium contains numerous goblet cells. C. Wall contains numerous lymphatic nodules. D. Muscle layers display prominent taeniae coli

D C: MALT D: 3 longitudinal bands of outer longitudinal muscles forming taeniae coli in colon but not rectum

[Old PP] Mucous glands can be found in submucosa of following organ(s): A. Stomach B. Ascending colon C. Oesophagus D. Transverse colon E. Appendix

[Old PP] Which of following statements relating to small intestine is TRUE? A. Brunner's glands are located in lamina propria of duodenum. B. Goblet cells are present only in epithelium of duodenum. C. Lacteals are present only in ileum. D. Peyer's patches are present in ileum. E. Muscularis muscosae contains three layers of smooth muscle in duodenum.

[PP] What is the difference between conjugated and unconjugated bilirubin in terms of solubility?

Conjugated bilirubin is more water-soluble than unconjugated bilirubin (majority in normal subjects, tightly bound to albumin, water-insoluble)

[PP] What is haemolysis?

Destruction of RBCs

[PP] A 23-year-old male with known G6PD deficiency is diagnosed with haemolysis. His serum total bilirubin is 24.95 mg/dL (normal reference: 0.3-1.0 mg/dL), serum conjugated bilirubin is 3.43 mg/dL (normal reference: 0.1-0.3 mg/dL), and serum unconjugated bilirubin is 21.52 mg/dL (normal reference: 0.2-0.8 mg/dL). How do the observed differential elevations in serum bilirubin levels support the diagnosis of haemolysis? (2 marks)

Increase in unconjugated bilirubin is more significant than increase in conjugated bilirubin, suggesting a pre-hepatic cause (increased haemolysis to form unconjugated bilirubin in macrophages) Conjugation occurs in liver

[PP] A 23-year-old male with known G6PD deficiency is diagnosed with haemolysis. His serum total bilirubin is 24.95 mg/dL (normal reference: 0.3-1.0 mg/dL), serum conjugated bilirubin is 3.43 mg/dL (normal reference: 0.1-0.3 mg/dL), and serum unconjugated bilirubin is 21.52 mg/dL (normal reference: 0.2-0.8 mg/dL). Give one disorder which may cause a greater increase in conjugated bilirubin over unconjugated bilirubin levels in serum. (1 mark)

Biliary tract obstruction (e.g. gallstones)

[PP] Monitoring bilirubin levels is an important tool in assessing liver and overall health. Which form of bilirubin is typically elevated in cases of obstructive jaundice? A. Both conjugated and non-conjugated bilirubin B. Conjugated bilirubin C. Indirect bilirubin D. Unconjugated bilirubin

[PP] Transaminase reactions are frequently monitored in liver function tests. Which of the following molecules is used as amino group acceptor in transaminase reactions? A. Alpha-Ketoglutarate B. Malate C. Oxaloacetate D. Pyruvate

[PP] Which of the following BEST describes amino acid transport from the intestinal lumen into enterocytes? A. It is conducted by facilitated diffusion and is bidirectional. B. It is conducted by facilitated diffusion and is unidirectional. C. It is conducted by Na+-dependent transporters with overlapping specificity for different amino acids. D. It is conducted by Na+-dependent transporters with unique specificity for different amino acids.

[PP] Which of the following components of Helicobacter pylori is the key target for rapid diagnosis of the infection using breath test? A. Flagella B. Lipopolysaccharide C. Peptidoglycan D. Urease

[PP] A 56-year-old man who is a chronic drinker comes to your clinic. He is going on a 4- week business trip to India, and he wishes to know more about hepatitis vaccination. Which of the following is true regarding vaccination against viral hepatitis? A. Hepatitis A vaccine only provides short-term protection. B. Hepatitis B vaccine is a subunit vaccine. C. Hepatitis E vaccine is available in Hong Kong. D. Vaccination with hepatitis B vaccine produces anti-HBc antibody.

B Hepatitis E vaccine (Hecolin): mainland China only HBV vaccine -> Anti-HBs

[PP] According to the World Health Organization, viral hepatitis is the seventh leading cause of mortality worldwide and the only communicable disease where mortality is increasing. Which of the following is true regarding the epidemiology of viral hepatitis? A. Hepatitis A virus has caused outbreaks in men who have sex with men. B. Hepatitis D virus can cause superinfection in patients with chronic hepatitis C. C. In Hong Kong, 40-60% of people infected with human immunodeficiency virus (HIV) are also chronic hepatitis C carriers. D. Rat hepatitis E virus cannot infect humans.

[PP] A 70-year-old woman underwent laparotomy and right hemicolectomy for perforated carcinoma of colon. What is the optimal antibiotic regimen for empirical treatment of her secondary peritonitis? A. Ampicillin + amikacin B. Ceftriaxone + gentamicin C. Levofloxacin D. Piperacillin-tazobactam

[PP] Crohn's disease is a type of inflammatory bowel disease. It is characterised by skin lesions, serpentine ulcers and strictures. Which of the following is a characteristic histological feature of Crohn's disease? A. Amyloid deposition B . Caseating necrosis C. Granulomas D . Psammoma bodies

[PP] A 50-year-old man has vague upper abdominal discomfort for several months. A stool sample tests positive for occult blood. An upper gastrointestinal endoscopy reveals a solitary, 0.8 cm diameter ulceration of the stomach. The ulcer has sharp edges and a clean base. Which of the following diagnosis is MOST LIKELY? A. A fungal infection of the stomach B. A leiomyosarcoma arising from the muscle coat C. A peptic ulcer D. An adenocarcinoma

[PP] A 56-year-old man was admitted for fever and right upper quadrant abdominal pain. He had a fever of 38.4ºC on admission and the white blood cell count was elevated. Computed tomography (CT) of the abdomen revealed the presence of liver abscess. The patient had a longstanding history of gallstone disease. CT-guided aspiration of the liver abscess was performed. Bacterial culture of the liver abscess aspirate will MOST LIKELY yield: A. Escherichia coli + Enterococcus faecalis + Bacteroides fragilis B. Pseudomonas aeruginosa C. Staphylococcus aureus D. Streptococcus pneumoniae + Haemophilus influenzae

[PP] A patient has taken non-steroid anti-inflammatory drug to reduce her pain for many years. However, she suffered from peptic ulcer because of the drug. Her doctor would like to prescribe a drug called misoprostol to her. In what situation her doctor CANNOT prescribe misoprostol? A. She is a smoker. B. She is allergic to penicillin. C. She is infected by Helicobacter pylori. D. She is pregnant.

[PP] A 50-year-old woman suffers from chronic hepatitis B with decompensated cirrhosis. Which of the following drugs is the MOST SUITABLE for her? A. Interferon B. NS3/4A proteinase inhibitor C. NS5B polymerase inhibitor D. Nucleotide reverse transcriptase inhibitor

D Interferons and pegylated interferons cannot be used in px with decompensated cirrhosis NS3/4A proteinase inhibitors, NS5B polymerase inhibitor are for HCV

[PP] Liver function tests are valuable diagnostic tools for identifying hepatic dysfunction. Which of the following bilirubin levels would typically be elevated in patients with Gilbert syndrome? A. Direct bilirubin B. Direct bilirubin and total bilirubin C. Indirect bilirubin and direct bilirubin D. Indirect bilirubin and total bilirubin

[NPT] Explain how gallstones may lead to acute pancreatitis. (2 marks)

- Gallstones obstruct the pancreatic duct - Pancreatic enzymes are activated in the pancreatic duct, leading to autodigestion of parenchyma

[NPT] Suggest a serological test that may help you establish the diagnosis of acute pancreatitis. (1 mark)

- Serum amylase - Serum lipase - Related to likelihood (X severity)

[NPT] Pancreatic pseudocyst may arise as a complication of late stage acute pancreatitis. Explain why pancreatic pseudocysts are not true cysts. (1 mark)

- Pseudocysts are lined by granulation tissue, not epithelium

[PP, formative] During embryogenesis, the liver bud penetrates ventrally from the duodenum into the mesodermal septum transversum. Which of the following structure arises from the septum transversum? A. Central tendon of the diaphragm B. Dorsal mesentery of the oesophagus C. Greater omentum D. Pleuroperitoneal membrane

A + connective tissue in liver

[PP] Partitioning of cloaca A. Urorectal septum B. Allantois C. Septum transversum

A Into anterior primitive urogenital sinus & posterior rectum

[PP, formative] A female patient aged 65 years old went to the hospital because of an inflamed ankle caused by sprain after walking on an uneven surface. Medical history taking indicated that she has gastric ulcer and osteoporosis. Which oral anti-inflammatory drug is MOST APPROPRIATE to relieve her symptoms? A. Aspirin B. Celecoxib C. Indomethacin D. Prednisolone

B Celecoxib = selective COX-2 inhibitor (also NSAID) Aspirin (salicylate), indomethacin (acetic acid): both among tNSAIDs -> COX-1 selective => upper GI disturbances Prednisolone (synthetic glucocorticoids): contraindicated in peptic ulcer and osteoporosis

[PP, formative] Absorption of nutrients in the Gastrointestinal tract involve different types of transport mechanism. Which of the following BEST DESCRIBES the mechanism used in absorption of short-chain fatty acids into enterocytes? A. Endocytosis B. Facilitated diffusion C. Simple diffusion D. Sodium-dependent facilitated transport

[PP] Kelly Chan, a 27-year-old woman presents to the Accident & Emergency Department complaining of 10-12 episodes of nonbloody diarrhoea per day for the past 2 days, along with severe abdominal cramps, nausea, vomiting, and a low-grade fever. She states that she just returned from a vacation to Mexico. While in Mexico, she did not drink any of the local water and ate only cooked foods. If faecal leukocytes are present, what is the MOST APPROPRIATE empirical treatment for the patient? A. Acyclovir B. Ciprofloxacin C. Cycloserine D. Doxycycline

[PP] Afferent signals of the heart have different pathways. Which of the following ganglion give rise to visceral afferent signals for referred pain in ischemic heart disease? A. Inferior ganglion of vagus nerve B. lower cervical ganglion C. T1 dorsal root ganglion D. T4 sympathetic ganglion

[PP] What is the structure that divides right liver lobe to medial and lateral - IVC - common hepatic duct - main portal vein - right hepatic vein

Right hepatic vein Middle hepatic vein: separate left and right lobe Left hepatic vein: separate left lobe into medial and lateral

[PP] mechanism of transport of GLUT2 - Na-dependent facilitated transport - facilitated diffusion - simple diffusion

facilitated diffusion

GIS Important Questions Flashcards

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