GI End of Block Mock - RareaWare PDF

GI END OF BLOCK MOCK - RAREAWARE Ethan Lowden – [email protected] Q1.) A 53 year old man attends clinic with dysphagia, regurgitation and retrosternal pain. He undergoes several investigations, including high resolution manometry, this is show below: Q1.) What does his HRM trace...

GI END OF BLOCK MOCK - RAREAWARE Ethan Lowden – [email protected] Q1.) A 53 year old man attends clinic with dysphagia, regurgitation and retrosternal pain. He undergoes several investigations, including high resolution manometry, this is show below: Q1.) What does his HRM trace show? a) Hiatus hernia b) Achalasia c) Scleroderma d) Jackhammer oesophagus e) Diffuse oesophageal spasm Q1 ANSWER a) Hiatus hernia b) Achalasia c) Scleroderma d) Jackhammer oesophagus e) Diffuse oesophageal spasm Q1 EXPLANATION: Q2.) Which of the following drugs decreases colonic motility? a) Loperamide b) Stimulant laxatives c) Prucalopride d) Linaclotide e) Cholinergics Q2 ANSWER a) Loperamide b) Stimulant laxatives c) Prucalopride d) Linaclotide e) Cholinergics Q2 EXPLANTION: a) Loperamide Gut selective opiate Mu receptor agonist – decreases tone and activity of myenteric plexus which slows colonic transit b) Stimulant laxatives Act on the intestinal wall to encourage contractions to increase gut motility c) Prucalopride Gut selective 5HT4 receptor agonist thus promoting ACh release which stimulates colonic longitudinal smooth muscle contractions and increases colonic motility d) Linaclotide Minimally absorbed guanylate C receptor agonist which increases secretion of Cl- and HCO3- into lumen which increases intestinal fluid volume to speed colonic transit e) Cholinergics Enhances colonic motor activity and thus colonic transit Trick answer – ANTI-CHOLINERGICS reduces colonic transit Q3.) Which of the following stimulates gastric acid secretion? a) Cholecystokinin b) Gastric inhibitory peptide c) Secretin O d) e) Histamine Somatostatin Q3 ANSWER a) Cholecystokinin b) Gastric inhibitory peptide c) Secretin d) Histamine e) Somatostatin Q3 EXPLANATION: a) Cholecystokinin From mucosal cells in duodenum and jejunum produced in response to fatty acids – inhibits acid secretion from parietal cells b) Gastric inhibitory peptide Produced in response to fatty acids to inhibit gastrin release and acid secretion from parietal cells c) Secretin Produced from mucosal cells in duodenum and jejunum – inhibits gastrin release and acid secretion from parietal cells d) Histamine Produced from ECL cell in response to gastrin release from G cell and acts on H2 receptors of parietal cells to increase gastric acid secretion e) Somatostatin Produced from D cells in mucosa of duodenum and jejunum in response to ACh – inhibits gastric acid, stimulates bile and pancreatic juice production Q4.) A 45 year old female attends hospital with a H.pylori infection. After taking a clinical history you become aware she is allergic to penicillin. What is the most appropriate first line treatment? a) Omeprazole, metronidazole and amoxycillin b) Omeprazole, clarithromycin and amoxycillin c) Omeprazole, metronidazole, clarithromycin d) Lansoprazole, metronidazole and amoxycillin e) Lansoprazole, clarithromycin and amoxycillin Q4 ANSWER: a) Omeprazole, metronidazole and amoxycillin b) Omeprazole, clarithromycin and amoxycillin c) Omeprazole, metronidazole, clarithromycin d) Lansoprazole, metronidazole and amoxycillin e) Lansoprazole, clarithromycin and amoxycillin Q4 EXPLANATION: First line treatment of H.pylori infection: Omeprazole, metronidazole and amoxycillin Second line treatment of H.pylori infection: Omeprazole, clarithromycin and amoxycillin First line treatment of H.pylori infection if allergic to penicillin: Omeprazole, metronidazole and clarithromycin Q5.) Which phase of the metastatic cascade is shown below: Q5.) Which phase of the metastatic cascade is shown below: a) Intravasation b) Extravasation c) Metastatic colonisation d) Local invasion and neovascularisation e) Arrest at a distant organ site Q5 ANSWER: a) Intravasation b) Extravasation c) Metastatic colonisation d) Local invasion and neovascularisation e) Arrest at a distant organ site Q5 EXPLANATION Q5 EXPLANATION: Intravasation = the entry of tumour cells into the circulation Extravasation = the exit of tumour cells from the circulation Q6.) Which of the following is not a sign of upper gastrointestinal bleeding: a) Haematemesis b) Coffee ground vomiting c) Melaena d) Overt faecal bleeding e) Iron deficiency anaemia Q6 ANSWER a) Haematemesis b) Coffee ground vomiting c) Melaena d) Overt faecal bleeding e) Iron deficiency anaemia Q6 EXPLANATION: The signs of an upper gastrointestinal bleed includes: Haematemesis (vomiting blood) Coffee ground vomiting Melaena (black, tarry stools due to break down of blood through GI tract) Fall in haemoglobin on a full blood count The signs of a lower gastrointestinal bleed includes: Overt faecal bleeding - bright red apparent bleeding Occult bleed Q7.) Which of the following is not a common cause of acute pancreatitis: a) Gallstones b) Alcohol c) Scorpion stings d) Hypocalcaemia e) Endoscopic retrograde cholangiopancreatography (ERCP) Q7 ANSWER a) Gallstones b) Alcohol c) Scorpion stings d) Hypocalcaemia e) Endoscopic retrograde cholangiopancreatography (ERCP) Q7 EXPLANATION: A way of remembering the causes of acute pancreatitis is the mnemonic: I GET SMASHED Q8.) A 24 year old female presents in the emergency department with abdominal pain. She undergoes pancreatic function tests, with her results shown below: Pancreatic function test: Patient’s levels: Normal range: Serum amylase 1000U/L 200ug/g Q8.) What is the most likely diagnosis based on her results? a) Chronic pancreatitis b) Ruptured ectopic pregnancy c) Acute pancreatitis d) Pancreatic insufficiency e) Macroamylase Q8 ANSWER: a) Chronic pancreatitis b) Ruptured ectopic pregnancy c) Acute pancreatitis d) Pancreatic insufficiency e) Macroamylase Q8 EXPLANATION: Pancreatic tests are divided into: Tests of pancreatic damage Serum amylase Urine amylase Serum lipase Tests of pancreatic function Direct and indirect function tests Faecal chymotrypsin Faecal elastase Q8 EXPLANATION: Serum amylase In acute pancreatitis rises within 5-8 hours of onset of symptoms, normalises by day 4 In acute pancreatitis rises to 4-6 times ULN Low specificity to pancreas – causes of hyperamylasaemia (DKA, opiates, macroamylase) Urine amylase Used to differentiate between amylase isoenzymes; S and P Serum lipase In acute pancreatitis rises within 4-8 hours of onset of symptoms, peaks at 24 hours and then normalises within 8-14 days >3x ULN in acute pancreatitis Higher clinical sensitivity and specificity than amylase Faecal elastase Marker of choice to detect pancreatic insufficiency – will be decreased Useful in determining amount of pancreatic replacement therapy required Q8 EXPLANATION: Condition: Serum amylase: Urine amylase: Serum lipase: Faecal elastase: Acute pancreatitis ↑↑↑ ↑↑↑ ↑↑↑ Normal Chronic pancreatitis ↑ Normal ↑ ↓ Pancreatic Normal Normal Normal ↓ insufficiency Ruptured ectopic ↑ ↑ Normal Normal pregnancy Macroamylase ↑ Normal Normal Normal Q9.) A 15 year old boy is admitted to hospital with suspected appendicitis due to tenderness at McBurneys point. Where is this located? a) 1/3rd laterally along the line between the umbilicus and ASIS on the right side b) Halfway between the umbilicus and ASIS on the right side c) 2/3rds laterally along the line between umbilicus and ASIS on the right side d) 1/3rd laterally along the line between the umbilicus and ASIS on the left side e) 2/3rd laterally along the line between the umbilicus and ASIS on the left side Q9 ANSWER: a) 1/3rd laterally along the line between the umbilicus and ASIS on the right side b) Halfway between the umbilicus and ASIS on the right side c) 2/3rds laterally along the line between umbilicus and ASIS on the right side d) 1/3rd laterally along the line between the umbilicus and ASIS on the left side e) 2/3rd laterally along the line between the umbilicus and ASIS on the left side Q9 EXPLANATION: Q10.) Which of the following is the most correct definition of cirrhosis: a) Global process with necrosis and nodular formation b) Global process with fibrosis and cyst formation c) Diffuse process with necrosis and nodular formation d) Diffuse process with necrosis and cyst formation e) Diffuse process with fibrosis and nodular formation Q10 ANSWER: a) Global process with necrosis and nodular formation b) Global process with fibrosis and c) Diffuse process with necrosis and nodular formation d) Diffuse process with necrosis and e) Diffuse process with fibrosis and nodular formation Q11.) A 73-year-old man presents to the hospital with portal hypertension as a result of liver failure. Which of the following signs would unlikely be due to this? a) Caput medusae b) Splenomegaly c) Ascites d) Palmar erythema e) Thrombocytopenia Q11 ANSWER: a) Caput medusae b) Splenomegaly c) Ascites d) Palmar erythema e) Thrombocytopenia Q11 EXPLANATION: Liver cirrhosis increases the resistance to blood flow through the liver, as a result there is increased back pressure on the portal system – this is called portal hypertension Back pressure on the portal system results in swollen and tortuous vessels at sites between the portal and systemic venous systems – these sites are known as collaterals These collaterals can occur at: Distal oesophagus – causes oesophageal varices Anterior abdominal wall - causes caput medusae Q11 EXPLANATION: The different signs of portal hypertension includes: Splenomegaly – back pressure into where the systemic circulation drains causes reduced blood flow through your spleen causing it to swell with excess blood and create new blood vessels to accommodate the increased blood flow Thrombocytopenia – enlarged spleen causes platelets to become trapped within the liver and thus lowers platelet levels Ascites – fluid from enlarged collateral veins leaks into the abdomen inside the peritoneal cavity Caput medusae – disteneded paraumbilical veins due to portal hypertension Q12.) You are an FY2 and performing an abdominal examination on a patient. During palpation of the abdomen you discover a positive Murphy’s sign. Where is Murphy’s point located? a) Between lateral border of rectus abdominus muscles and costal margin – 9th costal cartilage on right side b) Between lateral border of rectus abdominus muscles and costal margin – 9th costal cartilage on left side c) Between lateral border of rectus abdominus muscles and costal margin – 8th costal cartilage on left side d) Between medial border of rectus abdominus muscle and costal margin – 8th costal cartilage on right side e) Between medial border of rectus abdominus muscle and costal margin – 8th costal cartilage on left side Q12 ANSWER a) Between lateral border of rectus abdominus muscles and costal margin – 9th costal cartilage on right side b) Between lateral border of rectus abdominus muscles and costal margin – 9th costal cartilage on left side c) Between lateral border of rectus abdominus muscles and costal margin – 8th costal cartilage on left side d) Between medial border of rectus abdominus muscle and costal margin – 8th costal cartilage on right side e) Between medial border of rectus abdominus muscle and costal margin – 8th costal cartilage on left side Q12 EXPLANATION: Murphy’s sign = extreme tenderness over the gallbladder fundus elicited by palpating fingers up towards costal margin as patient takes deep inhalation Q13.) A positive Murphy’s sign is indicative of acute cholecystitis which is a potential complication of gallstones. Which of the following is not a known risk factor for gallstones? a) Female sex b) White race c) Fertile d) >50 years of age e) BMI >30 Q13 ANSWER a) Female sex b) White race c) Fertile d) >50 years of age e) BMI >30 Q13 EXPLANATION: The risk factors for gallstones can be remembered by the “5Fs”: Female Fair Forty Fertile Fat Q14.) Which of the following is a cause of extrinsic biliary compression? a) Cholangiosarcoma b) Primary sclerosing cholangitis c) IgG4 disease d) Mirizzi syndrome e) Common bile duct stones Q14 ANSWER: a) Cholangiosarcoma b) Primary sclerosing cholangitis c) IgG4 disease d) Mirizzi syndrome e) Common bile duct stones Q14 EXPLANATION: Biliary obstruction can either be caused by: Extrinsic compression Intramural causes Intraluminal causes Q14 EXPLANATION Causes of extrinsic compression: Tumours – most commonly pancreatic Cancer of the head of the pancreas can compress the common bile duct as it passes through pancreatic tissue Often presents late with painless jaundice – typically incurable disease Inflammation – pancreatitis Gallstone passes through the ampulla of Vater and causes pressure build up and stasis of exocrine secretions within the pancreatic duct – results in autodigestion of the pancreas Mirizzi syndrome Gallstone stuck in the gallbladder neck or cystic duct and obstructs the common hepatic duct – this results in inflammation and ulceration which gradual erodes the common hepatic duct wall and allows the stone to pass into the duct and obstruct the lumen Q14 EXPLANATION: Intramural causes: Tumours – cholangiosarcoma Cholangiosarcoma = adenocarcinoma of epithelial lining of the bile ducts Most common type are extrahepatic tumours which involve the hepatic duct bifurcation – also known as hilar cholangiosarcomas or Klatskin tumours Inflammation – primary sclerosing cholangitis (PSC) and IgG4 disease PSC – inflammatory disorder which causes scarring within the bile ducts which hardens and narrows the bile ducts IgG4 disease – fibroinflammatory disorder which causes thickening of the bile ducts and thus narrowing of the lumen Scarring/ fibrosis – post-inflammatory or post-surgical Q14 EXPLANATION: Causes of intraluminal obstruction: Stones – most common Sludge Polyps Q15.) Which of the following is the correct description of the fissure for ligamentum teres: a) Lies between the quadrate lobe and the left liver lobe; remnant of the umbilical vein b) Lies between the quadrate lobe and the left liver lobe; remnant of the ductus venosum c) Lies between the quadrate lobe and the left liver lobe; remnant of the foramen ovale d) Lies between the caudate lobe and the left liver lobe; remnant of the umbilical vein e) Lies between the caudate lobe and the left liver lobe; remnant of the ductus venosum Q15 ANSWER: a) Lies between the quadrate lobe and the left liver lobe; remnant of the umbilical vein b) Lies between the quadrate lobe and the left liver lobe; remnant of the ductus venosum c) Lies between the quadrate lobe and the left liver lobe; remnant of the foramen ovale d) Lies between the caudate lobe and the left liver lobe; remnant of the umbilical vein e) Lies between the caudate lobe and the left liver lobe; remnant of the ductus venosum Q15 EXPLANATION: Fissure for ligamentum teres = separates quadrate and left lobe and is a remnant of the umbilical vein Fissure for ligamentum venosum = separates caudate and left lobe and is remnant of ductus venosum Q16.) A 34-year-old male attends the hospital due to gradual yellowing of the sclera. LFTs are performed and his results are shown below: Liver function tests: Patients levels: Normal range: Total bilirubin 40 0-17umol/L AST 35