gastroentrology PT 1 2016 modif

8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 298 A 26-year-old woman presents to her GP complaining of intermittent abdominal distension and bloating, which changes with her menstrual cycle, and is interspersed with bouts of loose motions She works as a trader in a busy office and finds work stressful: she has previously taken a course of Prozac® for depression/anxiety Examination, bloods and sigmoidoscopy were all normal What is the best-fit diagnosis? A Chronic pancreatitis B Ulcerative colitis C Peptic ulcer disease D Diverticulitis E Irritable bowel syndrome Explanation Irritable bowel syndrome Irritable bowel syndrome has a female to male preponderance of 2:1 and frequently occurs in patients with underlying problems of anxiety Examination and investigations are invariably normal Any history of weight loss, bleeding, onset > 40 years of age or faecal incontinence would not fit with this picture, however, and these features should trigger other investigations if the basic examination/investigations are unremarkable Management Management is with antispasmodics such as peppermint oil (eg Colpermin®), a high-fibre diet and avoidance of trigger foods (a significant proportion of patients report improvement when cutting out dairy foods) In many cases, serotonin-reuptake inhibitors such as Prozac® also have positive effects on symptoms 1406 Next Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/22/2016 MyPastest Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 298 A 48-year-old publican presents with acute-onset confusion and a mild fever On examination he has signs of chronic liver disease and ascites and is generally tender over his abdomen Blood tests reveal mildly raised aspartate aminotrasferase (AST) and alanine aminotransferase (ALT) levels and a bilirubin of 186 μmol/l His creatinine is 145 μmol/l His international normalised ratio (INR) is and he has a mixed-picture anaemia with a haemoglobin of 9.8 g/dl, low platelets and an elevated neutrophil count Ascitic tap reveals fluid with a polymorphonuclear cell count of > 250/mm3 What is the most likely diagnosis? A Spontaneous bacterial peritonitis B Perforated duodenal ulcer C Cholangitis D Cholecystitis E Acute pancreatitis Explanation Spontaneous bacterial peritonitis This man clearly has alcoholic cirrhosis, which is decompensated with ascites The ascites has become infected and spontaneous bacterial peritonitis has developed Diagnosis is made on the basis of a white count of > 250 cells/mm3, the presence of bacteria on Gram staining and a positive ascitic fluid culture Pathogens are usually Gram negative, and include Escherichia coli, Klebsiella pneumoniae and enterococci The treatment of choice includes piperacillin/tazobactam for severe disease, although ciprofloxacin or ofloxacin might be used in selected patients 1407 Next Question Previous Question Tag Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893 Feedback End Review 1/2 8/22/2016 MyPastest Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 298 An 82-year-old woman is admitted from a nursing home with profuse diarrhoea She was discharged weeks earlier from the orthopaedic ward, where she was treated for a fractured hip There was some evidence of osteomyelitis during that admission and she was treated with clindamycin and discharged on tablets On examination she is drowsy and dehydrated, with lower abdominal tenderness She soils the bed with watery diarrhoea during the examination Blood tests confirm pre-renal failure What is the most likely diagnosis? A Salmonellosis B Ulcerative colitis C Enteric parasitic infection D Pseudomembranous colitis E Colonic malignancy Explanation Pseudomembranous colitis Pseudomembranous colitis can occur in up to 10% of patients who have received a course of clindamycin In addition, it is thought that many nursing-home residents show chronic carriage of Clostridium difficile (the causative pathogen) Sigmoidoscopy will usually reveal raised, white-yellow exudative plaques adherent to the colonic mucosa (the pseudomembrane) The diagnosis is made by the presence of clostridium toxin in the stool Treatment is with oral metronidazole or vancomycin for 10–14 days, accompanied by appropriate rehydration therapy The mortality rate is as high as 10% in the elderly Salmonellosis would not be impossible here but the osteomyelitis associated with this tends to affect the long bones and typically occurs in patients with sickle cell disease 1408 Next Question Previous Question Tag Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893 Feedback End Review 1/2 8/22/2016 MyPastest Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 298 Which one of the following statements best describes a feature of irritable bowel syndrome? A Characterised by nocturnal diarrhoea B If there is nausea and vomiting the diagnosis should be reconsidered C Weight loss becomes more evident as the disease runs a chronic course D Sigmoidoscopy findings are often diagnostic E A diet high in soluble fibre is often prescribed for the treatment of the syndrome Explanation Irritable bowel syndrome Irritable bowel syndrome is a functional disorder of the alimentary tract that is characterised by altered bowel function, constipation and diarrhoea, with or without abdominal pain, nausea and vomiting, with no significant physical, laboratory or histological findings Anaemia, occult blood in the stool, weight loss or nocturnal symptoms cannot be attributed to irritable bowel syndrome A diet high in soluble fibre can be useful in some patients and others seem to gain benefit from excluding dairy foods 1609 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/22/2016 MyPastest Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 298 Which one of the following pathological changes favours a diagnosis of ulcerative colitis over Crohn’s disease? A Ileal involvement B Crypt abscesses C Transmural involvement D Granulomas E Skip lesions Explanation Inflammatory bowel diseases Crohn’s disease Crohn’s disease can involve any segment in the alimentary canal but distal ileum involvement is characteristic The inflammatory process involves all layers of the bowel with the formation of non-caseating granulomas, ulcers and fistulae Discontinuity of the inflammatory process across the bowel (skip lesions) is also characteristic Ulcerative colitis In ulcerative colitis there is diffuse, continuous involvement of the colon with proctitis as an early feature in 90% of cases The inflammation is confined to the mucosa and lamina propria with crypt abscess formation Ileal involvement is not a common feature of ulcerative colitis but the distal segment of the ileum can be involved in the inflammatory process from adjacent inflamed colonic segment (backwash ileitis) Table of pathological findings; Crohn's Disease Ulcerative colitis Transmural inflammation Mucosa and submucosa only involved Mucosal ulcers (in 30% only) Inflammatory cell infiltrate https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/22/2016 MyPastest Fissuring ulcers Crypt abscesses Lymphoid aggregates Neutrophil infiltrates 1610 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/22/2016 MyPastest imaging modalities The first-line treatment of choice is with antibiotics (which should cover Gram-negative organisms); sphincterotomy via ERCP is indicated where gallstones in the common bile duct have resulted in cholangitis Acute hepatitis (Option A) is incorrect Although acute hepatitis is associated with a raised bilirubin and abnormal liver enzymes, the abnormality is a rise in transaminases rather than alkaline phosphatase Furthermore, abdominal pain in acute hepatitis is almost always relatively mild Pancreatitis (Option C) is incorrect Since the amylase level is normal, pancreatitis is unlikely Peptic ulcer disease (Option D) is incorrect Peptic ulcer disease may present with acute severe abdominal pain, but this would not explain this woman’s abnormal blood test findings Right ureteric calculus (Option E) is incorrect Ureteric calculus may present with acute severe abdominal pain, but this would not explain this woman’s abnormal blood test findings 46429 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 293 of 298 A 75-year-old nun presented to her general practitioner with gradual-onset abdominal swelling over some months and generalised abdominal tenderness, perhaps worse in her right flank On examination, there was inguinal lymphadenopathy Blood tests revealed a normochromic, normocytic anaemia, decreased serum albumin level and an elevated creatinine of 180 μmol/l Her CA-125 level was raised What is the most likely diagnosis? A Cervical carcinoma B Cirrhosis of the liver C Haemochromatosis D Ovarian carcinoma E Wilson’s disease Explanation  The answer is Ovarian carcinoma – This scenario is very suggestive of ovarian carcinoma Ovarian carcinoma has an annual incidence of around 12.9–15.1/100 000 women per year, but the incidence rises with increasing age: the median age of presentation is 61, with the peak occurring between the ages of 75 and 79 years There is an increased genetic predisposition to the condition in carriers of the BRCA1 gene (breast–ovarian carcinoma syndrome) Low parity, delayed childbearing, obesity and subfertility all appear to be risk factors for the condition CA-125 has reasonable sensitivity and specificity for ovarian carcinoma, although levels may also be raised in certain benign gynaecological conditions (eg endometriosis), or non-gynaecological conditions (eg cirrhosis, ascites, breast cancer, and so on) Crosssectional imaging is helpful in confirming the diagnosis and staging the disease, with ultrasound, CT and MRI all being of use This woman’s creatinine may be raised because of urinary tract obstruction from the malignancy, either from the mass of the primary tumour, or because of spread of the cancer into the omentum It would be typical for people with ovarian carcinoma to have a normochromic, normocytic anaemia and a low albumin level (although any ascitic fluid is likely to be protein-rich) https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/3 8/22/2016 MyPastest The initial treatment of choice in this scenario would be to drain the ascites (to relieve symptoms), and to consider stenting of the ureters if they are being extrinsically compressed by tumour mass Chemotherapy (either with or without surgery) might be appropriate in younger patients, but many patients present with very advanced disease, which has a 5% 5-year survival rate Cervical carcinoma (Option A) is incorrect Cervical carcinoma tends to occur in younger women than this patient; furthermore, major risk factors include early onset of sexual activity, multiple sexual partners and sexually transmitted infections, which are all clearly unlikely here In addition, the typical presenting symptom of cervical carcinoma is with heavy/irregular vaginal bleeding, which has not been described Cirrhosis of the liver (Option B) is incorrect Although this woman’s abdominal swelling may suggest ascites, the absence of any obvious risk factors for or clinical features of chronic liver disease make it very unlikely that the diagnosis is cirrhosis Haemochromatosis (Option C) is incorrect Although haemochromatosis may cause cirrhosis with subsequent ascites formation there is no specific information such as joint problems, diabetes and skin discoloration to suggest this diagnosis Wilson’s disease (Option E) is incorrect Although Wilson’s disease may cause cirrhosis with subsequent ascites formation there is no specific information such as neuropsychiatric disease to suggest this diagnosis 46430 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 0% 2/3 8/22/2016 MyPastest Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 3/3 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 294 of 298 A 21-year-old student was admitted to an airport medical centre with severe diarrhea; he had come directly off a flight from India He spent most of the flight in the aircraft toilet before collapsing just before the plane landed He described eating shellfish from roadside stalls a few days before travelling home He had experienced some vomiting days prior, but this had soon settled, and he had not had any abdominal pain Examination revealed him to be hypovolaemic; he soiled the bed during the examination with watery diarrhoea, without blood Blood test results were abnormal, with haemoglobin at the upper end of the normal range, a raised haematocrit, and markedly elevated urea, with a smaller rise in creatinine He also had borderline hypoglycaemia, with a random blood glucose level of 3.4 mmol/l What is the most likely diagnosis? A Cholera B Crohn’s disease C Salmonella enteritidis infection D Typhoid fever E Ulcerative colitis Explanation  The answer is Cholera – This scenario is very suggestive of cholera, caused by a strain of Vibrio cholerae, probably contained in shellfish bought from a roadside stall The illness is characterised by an abrupt onset of voluminous watery diarrhoea, which – in the absence of appropriate rehydration – is associated with a rapid descent into hypovolaemia, acidosis and death The diarrhoea is caused by the cholera toxin, which acts on intestinal epithelial cells, causing a massive secretion of fluid and electrolytes Although the mortality rate of adequately hydrated patients is less than 1%, it is much higher in the developing world, particularly in children under the age of years Treatment is with oral or intravenous rehydration, and with with doxycycline or co-trimoxazole https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/3 8/22/2016 MyPastest Crohn’s disease (Option B) is incorrect Given that this man has a very acute illness (without any suggestion of previous GI symptoms, weight loss or other constitutional features), then inflammatory bowel disease seems unlikely In particular, the absence of abdominal pain would be very unusual if this was a Crohn’s flare Salmonella enteritidis infection (Option C) is incorrect S enteritidis infection is typically associated with significant abdominal pain and often blood and mucus mixed in with the stool, so seems unlikely here Additionally, Salmonella is typically transmitted by poultry, meat, eggs or certain vegetables, rather than shellfish (as seems to be the source of transmission here) Typhoid fever (Option D) is incorrect Typhoid fever (also caused by Salmonella infection) is usually characterised by high fever but only modest GI symptoms, so also may be ruled out Additionally, Salmonella is typically transmitted by poultry, meat, eggs or certain vegetables, rather than shellfish (as seems to be the source of transmission here) Ulcerative colitis (Option E) is incorrect Given that this man has a very acute illness (without any suggestion of previous GI symptoms, weight loss or other constitutional features), then inflammatory bowel disease seems unlikely In particular, the absence of rectal bleeding makes ulcerative colitis very unlikely 46431 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 298 Responses Total: 298 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/3 8/22/2016 MyPastest © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 3/3 8/22/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 295 of 298 A 45-year-old man who was HIV-positive presented with diarrhoea He had lost 12 kg in weight during the past months and looked cachetic He was passing voluminous diarrhoea 6–10 times per day and during the night, but denied either abdominal pain or fever He was known to be only intermittently compliant with antiretroviral therapy He had not travelled abroad for over 10 years His CD4 count on admission was 80 What is the most likely causative organism? A A cryptosporidium B A microsporidium C Cytomegalovirus D Isospora belli E Mycobacterium avium intracellulare Explanation  The answer is A cryptosporidium – Cryptosporidium infection in HIV-positive patients is typically associated with moderate to severe diarrhoea, but there is often little or no abdominal pain and no fever Severe weight loss is also a common feature Cryptosporidium infection particularly occurs when the CD4 count is low (