Gasteroenterology

151. A 45-year-old man is admitted with acute upper gastrointestinal bleeding. What is the most common cause for this condition? Oesophageal varices Chronic peptic ulceration NSAID therapy Gastro-oesophageal reflux disease MalloryWeiss syndrome

Your answer

Chronic peptic ulceration still accounts for approximately half of all cases of upper gastrointestinal (GI) haemorrhage. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) can cause haemorrhagic gastropathy that accounts for 1520% of upper GI bleeds. Oesophageal varices are responsible for another 1520% of cases. MalloryWeiss syndrome (510%) and gastro-oesophageal reflux disease (25%) are other causes of this condition.

152. You review a 32-year-old woman who is morbidly obese. You are advising her about the calorie content of commonly used foods. Which of the following foods contains the greatest number of calories? 1 scone (70 g) 1 bowl of cornflakes (not including milk) (45 g) 300 g of chicken korma A sausage and egg triple sandwich pack (256 g) 50 g of salted peanuts

Your answer

A typical supermarket sausage and egg sandwich pack contains significant levels of fat (around 53 g per 256 g serving). This is even more than in a chicken korma (around 30 g of fat per serving). In general the level of fat, contributing 9 calories per g of energy value, is the food component, which adds significantly to the total number of calories in the food item. This is the rationale for following a low fat diet.

153. Which one of the following conditions is expected to be associated with normal urinary D-xylose test? Coeliac disease

Chronic pancreatitis Your answer Blind loop syndrome Chronic renal failure Liver cirrhosis with ascites

This test distinguishes between malabsorption due to small intestinal diseases and that due to pancreatic exocrine insufficiency. A five hour urinary excretion of 5g or greater is normal following the oral administration of 25 g of D-xylose to a well hydrated subject. Decreased xylose absorption and excretion are found in patients with damage to the proximal small intestine and in bacterial overgrowth in the small intestine (the bacteria catabolises the xylose). Patients with pancreatic steatorrhoea usually have normal xylose absorption. Abnormal results may be encountered in renal failure, the elderly and patients with ascites due to an excretion defect rather than malabsorption.

154. A 32-year-old man was referred with gastro-oesophageal reflux disease and commenced on a proton-pump inhibitor. Which of the following is true of the gastric K+/H+-ATPase proton pump? It is made up of alpha-, beta- and gamma-subunits It is an acute antigen in pernicious anaemia Omeprazole binds irreversibly Is situated in chief cells It also occurs in other tissues

Your answer

The proton pump is only contained in the tubovesicles of the parietal cell. The alphasubunit catalyses the enzymatic activity and forms a covalent complex with omeprazole. This is irreversible. However, as the half-life of the pump is 2436 hours, the duration of the effect of proton-pump inhibitors is limited by the degradation of these pumps.

155. A 56-year-old man presents to his GP complaining of lethargy. Routine blood testing reveals hypochromic microcytic anaemia with low ferritin. He has had no symptoms of indigestion or change in bowel habit and there is no medication use of note. Which of the following would be the most appropriate investigation in this patient?

Upper gastrointestinal (GI) endoscopy Rigid sigmoidoscopy Computed tomography (CT) scan abdomen Barium enema Flexible colonoscopy Your answer Case series indicate that, where there are no symptoms, investigation for iron deficiency anaemia is more likely to yield significant lower GI pathology, which is often malignant. For this reason colonoscopy is recommended as the best choice investigation from the above options. While dual pathology with abnormalities such as oesophagitis, duodenitis or gastritis is often found, the incidence of upper GI malignancy is much lower. Degree of anaemia or presence or absence of upper or lower GI symptoms appears not to improve the chances of predicting whether upper or lower GI endoscopy will yield a diagnosis.

156. A 79-year-old woman is admitted with a two-day history of abdominal pain, vomiting and diarrhoea. Past medical history includes myocardial infarction ten years previously. Her bowel habit was usually regular. On examination her temperature is 37.5 C, blood pressure 120/80 mmHg, pulse 120/min irregularly irregular. Abdominal examination reveals a soft abdomen but with tenderness in the left iliac fossa and suprapubic area. Bowel sounds are present and of normal pitch. Rectal examination is normal. Investigations: Hb 13.7 g/dl Na 139 mmol/l

WCC 15 x 109/l K 5.1 mmol/l 9 Platelets 452 x 10 /l Urea 8.2 mmol/l Plain abdominal X-ray is unremarkable. What is the most likely diagnosis? Inferior myocardial infarction Sigmoid volvulus Diverticulitis Inferior mesenteric artery occlusion Your answer Ulcerative proctitis

The presence of atrial fibrillation and lack of pre-existing bowel symptoms would suggest an acute mesenteric vascular occlusion as the cause of her illness rather than diverticulitis which would be the next most likely diagnosis.

157. A 56-year-old woman with established hepatic cirrhosis was admitted confused and drowsy. What is the most important immediate investigation? Blood culture CT scan brain Red-cell folate Blood glucose Upper GI endoscopy

Your answer

This is a Keep it simple question. The test that will give you key information on a rapidly reversible and potentially life-threatening complication is the blood glucose: hepatic gluconeogenesis can be significantly down-regulated both by the cirrhosis and further alcohol consumption. A CT of the head (to rule out a subdural haematoma) is important but takes longer. The other tests have little impact on the acute management of the patient.

158. A 23-year-old woman complains of intermittent diarrhoea containing blood and mucus, tiredness and anorexia. Cultures of stool samples are negative. Examination is unremarkable. What is the most appropriate investigation? Upper GI endoscopy with jejunal biopsy Barium enema Hydrogen breath test Colonoscopy and biopsies Plain X-ray of the abdomen

Your answer

This lady has ulcerative colitis. She should undergo colonoscopy as this will show the extent of disease and will allow biopsies to be taken.

159. A 57-year-old publican is referred by his GP with chronic left-sided/central upper abdominal pain. He admits to enjoying three or four pints of beer during an evening in the pub. Over the past 18 months he has lost about 12.5 kg (2 stone) in weight, and his wife says he prefers alcohol to food. He has intermittent diarrhoea, which he reports as being oily and difficult to flush away on occasions. Examination reveals a slim man with some tenderness to deep palpation in the epigastrium. Blood testing reveals a mild normochromic normocytic anaemia and a raised ALT level to twice the upper limit of normal. Amylase and antigliadin antibodies are normal. Upper abdominal ultrasound is performed and there is diffuse pancreatic calcification but nothing else of note. Which diagnosis fits best with this clinical picture? Acute pancreatitis Chronic pancreatitis Your answer Coeliac disease Pancreatic carcinoma Recurrent cholecystitis

There is a history of excess alcohol consumption and chronic upper abdominal pain. The diarrhoea suggests a deficiency of pancreatic enzymes. These findings coupled with diffuse pancreatic calcification are highly suggestive of chronic pancreatitis. Alcohol accounts for 6080% of chronic pancreatitis cases in the developed world. Other causes include cystic fibrosis, and an autosomal-dominant familial pancreatitis syndrome has been identified. Alcohol is thought to alter the balance of trypsinogen in the pancreas and this may be one factor involved in the association with alcohol. Where the diagnosis is unclear, magnetic resonance cholangiopancreatography (MRCP) or spiral CT may be useful. Treatment includes pain relief and pancreatic enzyme replacement, with withdrawal of alcohol.

160. A 56-year-old man with polycythaemia vera is admitted with acute abdominal pain, nausea, vomiting and abdominal distension. He is apyrexial with tender hepatomegaly and ascites; an ascitic tap reveals a high protein content and no organisms. What is the most likely diagnosis? Spontaneous bacterial peritonitis BuddChiari syndrome Veno-occlusive disease Malignant liver disease Haemochromatosis

Your answer

BuddChiari syndrome occurs following obstruction to the venous outflow of the liver due to occlusion of the hepatic vein. In one-third of the patients the cause is unknown. Patients with hypercoagulable states, such as polycythaemia vera or leukaemia, and women on the contraceptive pill are at risk. The acute form presents with abdominal pain, nausea, vomiting, tender hepatomegaly and ascites. Liver histology shows centrilobular congestion with hepatocyte atrophy. The chronic form presents with hepatomegaly, mild jaundice, ascites and splenomegaly with portal hypertension.

161. A 79-year-old woman has been seen twice by her GP during the past 8 months complaining of dull abdominal pain radiating through to her back. The GP diagnosed wear and tear on the spine and prescribed analgesics. The pain is partially relieved by sitting forward. Her daughter, who says she has not been

eating for weeks, has brought her to casualty. Examination reveals a cachectic woman, she has a normochromic normocytic anaemia and liver function tests reveal mildly elevated transaminases and a grossly elevated bilirubin and alkaline phosphatase. Ultrasound scan reveals bile duct obstruction with suspicion of a mass in the epigastrum. Which diagnosis fits best with this clinical picture? Pancreatic carcinoma Your answer Hepatocellular carcinoma Cholecystitis GIlymphoma with bile duct obstruction Gastric carcinoma with local spread Pancreatic carcinoma has an incidence of 9 per 100,000, with the peak incidence occurring above 60 years of age. There is a 3:2 male preponderance. Symptoms include epigastric pain radiating to the back, which is partially relieved by sitting forward, and jaundice (occurring late and often the presenting feature). Pancreatic carcinoma may also be associated with thrombophlebitis migrans, and patients may present with thromboembolic phenomena. Spiral CT, magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde CP (ERCP) may be useful adjuncts to investigations where the diagnosis is unclear. The CA 19.9 tumour marker may also be helpful. Unfortunately, the majority of tumours are unsuitable for resection and because of this, the survival rate at 5 years is only 2%. Some 20% of patients may actually have a technically respectable tumour, but surgical resection may be impossible due to comorbidities.

162. A 45-year-old woman with ulcerative colitis is admitted with a history of jaundice, pruritus and intermittent abdominal pain. Examination shows hepatosplenomegaly and mild ascites. Blood tests confirm an obstructive jaundice, and mitochondrial antibodies are not detected. What is the most likely diagnosis? Liver cirrhosis Chronic active hepatitis Sclerosing cholangitis Metastatic carcinoma Pancreatic carcinoma

Your answer

This patient has inflammatory bowel disease and is at risk of developing sclerosing cholangitis. This results from inflammation and fibrosis of the bile ducts leading to multiple areas of narrowing throughout the biliary system. Patients with AIDS also develop sclerosing cholangitis. Patients may be asymptomatic or may present as above. The alkaline phosphatase level is high and the mitochondrial antibody is not detected. Liver biopsy will show fibrous obliterative cholangitis with loss of interlobular and adjacent septal bile ducts. An ERCP will demonstrate the multiple strictures. Treatment is unsatisfactory methotrexate has been used, but liver transplantation may be needed.

163. A junior doctor is being investigated following a needle-stick injury while taking a blood sample from a patient infected with hepatitis B virus. Which test will provide the earliest diagnosis of hepatitis B infection in this case? HBeAg IgM anti-HBc Anti-HBeAg HBsAg IgG anti-HBc

Your answer

Following hepatitis B infection, the first virological marker detectable in the serum is HBsAg. IgM anti-HBc would confirm the diagnosis of an acute infection. HBeAg and antiHBeAg appear later in the serum. IgG anti-HBc indicates past exposure to hepatitis B (HBsAg-negative).

164. A patient with colon cancer presents with weight loss. What is the most likely factor responsible for this?

Depression Anorexia Your answer Problems with taste High levels of tumour necrosis factor High levels of IL-6

All contribute the most important is anorexia.

165. A 34-year-old man presents with symptoms of reflux oesophagitis. You elect to start lansoprazole as he has already made changes to his lifestyle without complete resolution of the reflux symptoms. Which of the following statements best describes the mode of action of lansoprazole? It binds to the histamine H1 receptor It binds to the histamine H2 receptor It inhibits the hydrogensodium-ATP proton pump It inhibits the hydrogenpotassium-ATP proton pump It inhibits the hydrogencalcium-ATP proton pump

Your answer

Lansoprazole is a proton-pump inhibitor. There are a number of other drugs in the class, including omeprazole, and they work by blocking the hydrogenpotassium-ATP pump that allows the gastric parietal cells to secrete acid. The drugs are indicated for the treatment of peptic ulceration, oesophagitis and for helicobacter eradication as part of a triple-therapy regime. Histamine H2-receptor blocking drugs, such as ranitidine, have a lesser effect on gastric acid reduction and many are now sold over the counter in pharmacies.

166. A 67-year-old man has presented to the Emergency department with epigastric and left upper quadrant pain for the third time in a year. He has suffered from diarrhoea for around 18 months in total, and claims that his weight has decreased by 12.7 kg (2 stone). The ambulance team who visited his accommodation noticed empty whisky bottles by the

rubbish bin. Amylase is within the normal range. What diagnosis fits best with this clinical picture? Cirrhosis Acute pancreatitis Chronic pancreatitis Your answer Peptic ulcer disease Coeliac disease Symptoms include left upper quadrant and epigastric pain, significant weight loss, bulky foul-smelling fatty stools, epigastric mass (in 10% of patients) and jaundice in 510% of patients. Aetiology includes chronic alcoholism, duct obstruction, malnutrition, hyperparathyroidism and cystic fibrosis. The male to female ratio of cases is 5:1. Serum amylase and lipase may be elevated, but amylase may also be normal in some cases. Abnormal glucose tolerance or diabetes may also be feature. A 72-h collection of faeces for faecal fat estimation is useful in the evaluation of malabsorption and steatorrhoea. Imaging studies include plain radiography (may reveal calcification), ultrasound, computed tomography (CT) scan or endoscopic retrograde cholangiopancreatography (ERCP). Important in management is the avoidance of alcohol and switching to smaller, more frequent, low-fat meals. Pancreatic enzyme supplements are useful for malabsorption, and octreotide may be useful in cases of resistant pancreatic pain. The long-term prognosis is poor, with 50% of patients expected to die with 10 years due to further pancreatitis or malignancy.

167. A 32-year-old man presented with abdominal pain, bloating and nausea after meals. He reported he has lost 10 kg in weight over the previous three months and also had some non-blood stained diarrhoea. He smokes 30 cigarettes per day but does not drink alcohol. His plain abdominal X-ray demonstrated dilated loops of small bowel. What is the most likely diagnosis? Coeliac disease Crohns disease Your answer Giardiasis

Pancreatic insufficiency Small-bowel adenocarcinoma The symptoms described suggest a small-bowel stricture. This, together with the diarrhoea, supports a diagnosis of an inflammatory bowel disease and Crohns disease affects the small bowel. It is also more common and more severe in smokers (in contrast to ulcerative colitis, which is less common in smokers). Small-bowel adenocarcinoma would be the other option but is becoming rarer. Uncomplicated coeliac disease does not cause strictures; however, it can be associated with ulcerating jejunitis and small-bowel lymphoma, which could present in this way. Giardiasis causes diarrhoea, some weight loss and sometimes bloating or pain, but rarely nausea. Chronic pancreatitis and pancreatic insufficiency could also present like this, but they would be unusual in a nondrinker without a good history of recurrent gallstone pancreatitis.

168. A 21-year-old woman was admitted following a paracetamol overdose. Which of the following is true? A normal bilirubin at 48 hours indicates successful treatment Chronic alcohol use reduces the risk of hepatits Glutathione conjugation is the first phase of liver metabolism N-acetylcysteine is contraindicated 48 hours after the overdose The prothrombin time is a good indicator of prognosis Your answer The risk of severity of a paracetamol overdose increases with old age, alcohol consumption, HIV or AIDS or in the very young. Any paracetamol level above the treatment line should be treated with N-acetylcysteine, irrespective of the time since the overdose, and should be continued if liver failure develops. The INR at 48 hours is the best early indicator, and a doubling of the INR in a 24-hour period should lead to referral to a specialist unit.

The hepatic metabolism of paracetamol is to a quinonimine (the toxic metabolite) then glutathione conjugation. Once the glutathione stores are depleted, the quinonimine binds to sulphydryl groups on the hepatocyte membrane causing necrosis. N-acetylcysteine frees glutathione groups, increasing their availability.

169. A 32-year-old woman was referred for endoscopy and found to have a duodenal ulcer and a positive urease test. She was given lansoprazole, amoxicillin and clarithromycin for 7 days. Which of the following is the most appropriate way of determining the successful eradication of H. pylori? [13C]urea breath test Your answer Blood serology testing Endoscopy and antral histology Endoscopy and CLO test Faecal antigen testing Serological testing for Helicobacter pylori remains positive for 612 months after successful eradication of the infection. Endoscopy and either histology or urease testing is invasive and unnecessary. It also has a high risk of giving false-negative results after eradication therapy. Faecal antigen testing is useful in children but less so in adults. It is rarely used in the UK.As long as the patient has been off the proton-pump inhibitor for two weeks, the [13C]urea breath test remains the most sensitive for detecting infection. It is based on the presence of H. pylori urease converting labelled urea to ammonium, ultimately releasing labelled CO2, which is then expired and measured.

170. A 45-year-old bar owner from Tenerife presents for review. Although he has been in the UK for 3 months during the winter season, he still looks deeply tanned. He is tired and feels 'washed out', attending with his girlfriend who is concerned he is impotent and has lost interest in sex. He has a past history of joint pains and mild arthritis, particularly affecting his knees. There is a family

history of autoimmune disease, with type-1 diabetes in one first-degree relative, and hypothyroidism in another. On examination he is deeply pigmented, there is loss of body hair and testicular atrophy. His fasting blood glucose concentration is 8.4 mmol/l, and alkaline phosphatase and transaminases levels are raised. Which diagnosis fits best with this clinical picture? Alcoholic cirrhosis Diabetes mellitus Primary adrenal failure Haemochromatosis Your answer Wilsons disease Haemochromatosis generally presents in the fifth decade in men, but presentation is later in women since the menses act as a natural form of venesection. The incidence is around 1 in 300 in Caucasians. So-called bronze diabetes it is associated with arthropathy, diabetes mellitus, impotence and eventual cirrhosis of the liver. The cause is excess iron deposition in the liver due to increased iron absorption despite excessive iron stores; this results in the accumulation of iron, particularly in the liver. It has an autosomal-recessive pattern of inheritance, and the commonest gene mutation can now be screened for. Phlebotomy is the treatment of choice, generally aiming to reduce the haematocrit to below 40%. Prognosis is good if treatment is commenced before the development of advanced cirrhosis.

171. Which one of the following statements BEST describes a person with irritable bowel syndrome (IBS)? Characterised by nocturnal diarrhoea If there is nausea and vomiting the diagnosis should be reconsidered

Weight loss becomes more evident as the disease runs a chronic course Sigmoidoscopy findings are often diagnostic High fibre diet is often prescribed for the treatment of the syndrome

Your answer

Irritable bowel syndrome is a functional disorder of the alimentary tract characterised by altered bowel function, constipation and diarrhoea with or without abdominal pain, nausea and vomiting, with the absence of significant physical, laboratory and 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 may be of use for some patients, others may gain benefit from dairy exclusion.

172. A 47-year-old patient with maturity-onset diabetes is being advised regarding his diet. Which of the following foods should he be most careful to avoid as far as possible? Banana Peanuts Carrots Cornflakes Yoghurt

Your answer

Cornflakes have the highest glycaemic index (84) in this list. The glycaemic index is a measure of a foods ability to raise blood sugar levels. The indexing is achieved by comparing a foods digestion rate to that of glucose (which has a glycaemic index of 100). The higher the glycaemic index, the faster the food will enter the bloodstream and raise the blood glucose level. Banana (50), carrot (49), yoghurt (33) and peanuts (14) have lower glycaemic indices.

173. A 17-year-old Caucasian woman presents with lethargy and chronic nausea. She has been unable to complete her AS levels and her mother is worried she may be depressed. On examination, there are signs of chronic liver disease and a gold-yellow ring at the periphery of the iris in both eyes. Her serum copper level is low. What is the most likely diagnosis? Haemochromatosis Wilsons disease Alcoholic cirrhosis Acute autoimmune hepatitis Hepatitis C

Your answer

The clue here is the low serum copper, and the diagnosis is Wilsons disease. This is a disorder of copper transport characterised by inadequate biliary copper excretion leading to accumulation in the liver, brain, kidneys and corneas. The defect is in the incorporation of copper into ceruloplasmin. There may be acute presentation or a chronic hepatitic picture. Laboratory findings include raised aspartate transaminase (AST), low ceruloplasmin, low serum copper, raised urinary copper excretion and low serum uric acid. Biopsy reveals evidence of steatosis, focal necrosis, inflammation and, later, cirrhosis. Chronic treatment is with penicillamine as a copper chelator, and prognosis with early intervention is good.

174. A 34-year-old man returns from India with abdominal pain, a fever, nausea and sweats. Examination reveals an enlarged tender liver. Several abscesses are visualised on ultrasound. Which of the following is the most likely cause? Clostridium perfringens Klebsiella histiolytica Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pneumoniae

Your answer

The commonest causes of a pyogenic abscess are: enterococci; Staph. aureus; and E. coli. Patients with pyogenic abscesses present with pain, fever, shock and weight loss. Management is by ultrasound-guided drainage and antibiotics targeted towards the cultured organism. Assessment of other gastrointestinal pathology may reveal an underlying cause for loss of the normal bowel-wall barrier to infections.Amoebic abscesses tend to present later, unless they burst. Again, aspiration and appropriate antibiotics are used. Hydatid liver abscesses have a typical ultrasound appearance and should not be aspirated due to the risk of seeding and peritoneal spread.

175. A 46-year-old woman was referred with profuse watery diarrhoea and dehydration. Investigations showed an average daily stool weight of 4,353 g/24 h and a serum VIP level of > 400 pg/ml (< 20 pg/ml). What is the most likely mechanism of her diarrhoea? Infective due to small-bowel overgrowth Inflammatory due to intercurrent malignancy Malabsorptive due to pancreatic insufficiency Osmotic secondary to high oral water intake Secretory due to enterocyte stimulation Your answer The diagnosis is that of VIPoma, a gut hormone-secreting tumour found in the pancreas or small bowel. (VIPoma, vasoactive intestinal polypeptide-secreting tumour.) The diarrhoea is secretory due to general cellular secretion, resulting in a massive watery diarrhoea. The normal daily stool weight is 250300 g. There are various causes of diarrhoea: osmotic (osmotically active substance in the bowel lumen, laxatives, malabsorption); inflammatory (inflammatory bowel disease, infective (eg Shigella spp.)); and secretory (VIPoma, cholera toxin, bilesalt malabsorption, tubulovillous adenoma).

176. A patient with hepatic encephalopathy is given lactulose. Which of the following statements about lactulose is true? It is absorbed from the gut It causes hypermagnesaemia It is contraindicated in diabetes It reduces proliferation of ammonia producing bacteria It reduces absorption of spironolactone Your answer

Lactulose is a disaccharide, there is no disaccharidase on the microvillus membrane of enterocytes that hydrolyses lactulose. Its metabolism by colonic bacteria leads to production of lactic acid and other organic acids, a fall in colonic pH, and increased ionisation of nitrogenous compounds. These changes may lead to a decrease in the absorption of nitrogenous compounds, including ammonia. Lactulose is a cathartic and is widely believed to be efficacious in the management of hepatic encephalopathy.

177. A 23-year-old woman is in her 29th week of pregnancy. She has suffered from itching for 3 weeks and is concerned. She now has mild jaundice. Her bilirubin is raised at around 80 mol/l and her ALT is raised at 82 U/l, alkaline phosphatase is markedly raised. Which diagnosis fits best with this clinical picture? Cholecystitis Acute fatty liver of pregnancy Hyperemesis gravidorum Intrahepatic cholestasis of pregnancy Your answer HELLP syndrome Intrahepatic cholestasis of pregnancy occurs in around 0.10.2% of pregnancies. The commonest symptom is itching, and jaundice appears some 14 weeks after the itching. Both ALT and bilirubin levels are raised. The disease is associated with increased rates of stillbirth, prematurity and a fetal mortality rate of around 3.5%. Treatment is symptomatic, using ursodeoxycholic acid. Liver biopsy is not indicated, but the underlying pathology would show centrilobular cholestasis. There is a tendency for the cholestasis to recur in subsequent pregnancies or after using the oral contraceptive pill.

178. A resident doctor who was infected with hepatitis B a year ago now presents with jaundice, weight loss and malaise. His IgM anti-HBc titre is not elevated but his serum IgM anti-delta is raised along with IgG anti-HBc. What is the most likely diagnosis? Hepatitis B Hepatitis C Hepatitis D Hepatitis A Hepatitis E

Your answer

Hepatitis D viral infection can occur either as a co-infection with HBV or as a superinfection in an HBsAg-positive patient. Superinfection results in an acute flare-up of a

previously quiescent chronic HBV infection. Diagnosis is by finding serum IgM anti-delta at the same time as IgG anti-HBc. Patients are usually negative for IgM anti-HBc.

179. A 58-year-old man presents with progressively worsening indigestion and weight loss. His GP can feel an epigastric mass and arranges upper gastrointestinal (GI) endoscopy. Biopsy of a suspicious lesion in the stomach reveals numerous signet ring cells. Which of the following is the most likely underlying diagnosis? Gastric lymphoma Oesophageal carcinoma Gastric adenocarcinoma Gastric leiomyoma Gastrinoma

Your answer

Gastric adenocarcinoma cells may show a number of different morphologies, each of which may be associated with a better or worse prognosis. Classification is based on the most unfavourable microscopic element seen, these are, in order of increasingly poor prognosis, tubular, papillary, mucinous or signet-ring cells, undifferentiated lesions are associated with the worst outcome. Tumours are also characterised according to macroscopic appearance, ulcerative, polypoid, scirrhous, superficial spreading or multicentric.

180. A 60-year-old man presents with alternating constipation and diarrhoea, anorexia and weight loss. Colonoscopy reveals a mass in the sigmoid colon, a biopsy from which confirms colorectal cancer. Which investigative finding would be most helpful in assessing the tendency of this neoplasm to metastasise? Size of the tumour Carcinoembryonic antigen levels Depth of penetration of bowel wall Proportion of bowel circumference involved Location of tumour in the colon

Your answer

Carcinoembryonic antigen (CEA) is a tumour marker for colorectal cancer. The CEA assay is 70% accurate in predicting the development of liver metastases within 1 year. Raised CEA levels have a high correlation with tumour recurrence and the presence of metastases. The depth of tumour penetration is related to the prognosis, as is the size of the tumour and extent of involvement of the bowel.

181. A 48-year-old man undergoes flexible colonoscopy for iron deficiency anaemia. Unfortunately three dysplastic polyps are identified and removed, the sizes of which are 0.9 cm, 1.4 cm and 1.8 cm. Which of the following represents the most appropriate time period before follow-up colonoscopy?

6 months 1 year 3 years Your answer 4 years 5 years The British Society of Gastroenterology (BSG) published guidelines on the followup period for dysplastic colonic polyps in 2002. (Ref. Gut 2002:51 suppl V6V9). For low-risk patients, (one to two adenomas that are both small, <1 cm) a 5-year period is recommended. For medium-risk patients (three to four adenomas or at least one adenoma bigger than or equal to 1 cm), 3-year follow up is recommended. For high-risk patients (five or more small adenomas or more than three with at least one at or above 1 cm in size), the recommended follow-up period is 1 year. Where patients have a family history of polyps, unless they have one of the dominant polyposis syndromes, eg familial adenomatous polyposis (FAP), the follow-up period should be the same as above.

182. A 24-year-old man presents with malaise, mild fever, loss of weight and anorexia. On examination, his scleras appear yellow. Serum bilirubin is elevated at 85 mol/l (normal 1 22 mol/l). ELISA for IgG anti-HEV is positive and HEV RNA is detectable in serum by PCR. What would be the characteristic finding on liver biopsy in this case? Ground-glass hepatocytes

Marked cholestasis Lymphoid aggregates Microvesicular steatosis Marked increase in the activation of sinusoidal lining cells

Your answer

Marked cholestasis is the hallmark histological finding in hepatitis E virus infection. Ground-glass hepatocytes are large hepatocytes containing surface antigen. They are seen in chronic hepatitis. Lymphoid aggregates and a marked increase in the activation of sinusoidal lining cells are seen in hepatitis C infection. Microvesicular steatosis occurs in hepatitis D.

183. A 59-year-old otherwise fit man undergoes an annual endoscopic follow-up for Barretts disease of the oesophagus. His latest biopsy shows poorly differentiated cells. Which of the following is the best management option ? Give an increased dose of a proton-pump inhibitor and continue annual surveillance Refer for photodynamic therapy Continue the maintenance dose of a proton-pump inhibitor and follow up every three months with four quadrant biopsies Refer for oesophagectomy Repeat endoscopy and biopsies immediately. If repeat shows poor differentiation then refer for oesophagectomy, otherwise continue annual Your surveillance. This is because the presence of poorly differentiated cells raises answer the possibility that there may infact already be co-existing malignancy that has been missed on the first endoscopy. Repeat endoscopy and biopsies immediately. If repeat shows poor differentiation then refer for oesophagectomy, otherwise continue annual surveillance.

184. An 82-year-old woman is admitted from a nursing home with profuse diarrhoea. She was discharged 2 weeks earlier from the orthopaedic ward where she was treated for a fractured hip. Unfortunately at the time there was some evidence of osteomyelitis and she had been treated with clindamycin and sent home with 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?

Salmonellosis Ulcerative colitis Enteric parasitic infection Pseudomembranous colitis Your answer Colonic malignancy

Pseudomembranous colitis may occur in up to 10% of patients who have received a course of clindamycin. In addition, it is thought that many nursing-home residents may be responsible for the chronic carriage of Clostridium difficile (the causative pathogen). Sigmoidoscopy will usually reveal raised, whiteyellow exudative plaques adherent to the colonic mucosa (pseudomembrane). Diagnosis is made by the presence of clostridium toxin in the stool. Treatment is with oral metronidazole or vancomycin for 1014 days, accompanied by appropriate rehydration therapy. Unfortunately, the mortality rate may be up to 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 diease. 185. A 40 year-old woman with pernicious anaemia is admitted with jaundice. She drinks 10 units of alcohol per week. Examination shows bruises on her arms and legs, palmar erythema, spider naevi and hepatosplenomegaly. She also complains of joint pains and amenorrhoea of recent onset. Her bilirubin is raised at 89 mol/l (normal: <17 mol/l), her AST is 450 U/l (normal: 1040 U/l) and she has a mild normochromic, normocytic anaemia. She is on long-term nitrofurantoin for recurrent UTI. What is the most likely diagnosis? Primary biliary cirrhosis Alcohol liver disease Nitrofurantoin-induced chronic active hepatitis Idiopathic cirrhosis Viral hepatitis

Your answer

This woman has signs of chronic liver disease. She is also on long-term nitrofurantoin, which is known to cause chronic active hepatitis. Anti-liver/kidney microsomal antibodies will be positive. Improvement will follow the withdrawal of nitrofurantoin.

186. ou review a 24-year-old woman who is noted to be markedly underweight. You suspect that she may have a protein malabsorption syndrome and contemplate trying the patient on an elemental diet. When thinking about dietary protein, which of the following best describes the site of polypeptide absorption? The proximal stomach The distal stomach The small intestine The ascending colon The descending colon

Your answer

While dietary protein is digested into polypeptides by pepsin and by exposure to low pH in the stomach, it is not the site of polypeptide absorption. Polypeptides pass into the duodenum where they are further degraded by pancreatic proteases. Further digestion then occurs at the level of the intestinal brush border and most absorption occurs in the form of amino acids.

187. A 48-year-old man with haemochromatosis undergoes venesection. Which of the following features would be most likely to show improvement? Arthropathy Cardiomyopathy Diabetes mellitus Skin pigmentation Testicular atrophy

Your answer

There is good evidence that cardiac failure associated with haemochromatosis may improve in response to venesection, with improvement in symptoms and a reduced requirement for diuretic therapy. Arthropathy never shows a response to venesection and, where testicular atrophy is established, there is rarely any improvement in male sexual function. Diabetes mellitus related to haemochromatosis does not resolve, although requirements for insulin may be reduced. Liver biopsy is usually used to assess the degree of iron overload. Venesection is proven to have positive effects on life expectancy, but the risk of hepatocellular carcinoma is not diminished by venesection if cirrhosis is already established. Patients may be venesected up to twice weekly during the first 2 years of treatment.

188. A 31-year-old man presents with microcytic anaemia. He admits to a change in bowel habit some months earlier. His past history of note includes hyperpigmented retinal pigment epithelium, noted when he attended the optician. His father died at the age of 41 years from colonic carcinoma. The patient also had some teeth removed for overcrowding during his teenage years and has suffered from a number of troublesome lipomas. Colonoscopy reveals a number of dysplastic polyps and a right-sided colonic carcinoma. What is the most likely diagnosis? Juvenile polyposis Gardners syndrome Your answer Sporadic colon cancer PeutzJeghers syndrome Neurofibromatosis

Gardners syndrome has an autosomal-dominant mode of inheritance and is characterised by multiple adenomatous intestinal polyps, osteomas and soft tissue tumours, including lipomas, fibromas and epidermoid cysts. Congenital hypertrophy of the retinal pigment epithelium is also a feature. Polyps occur at a mean age of 16 years and may be found anywhere within the gastrointestinal tract. Cancer occurs in 7% of individuals by the age of 21, 50% by age 39 and 90% by age 45. The average age of presentation with colonic carcinoma in unscreened individuals is 35 years. The cause is a mutation on the adenomatous polyposis coli (APC) gene on chromosome 5q21. Total colectomy is the recommended treatment of choice after the appearance of colonic polyps.

189. A 25-year-old woman presented with weight loss, abdominal pain and diarrhoea. Her anti-endomysial antibody was positive and a duodenal biopsy confirmed subtotal villous atropy. Which of the following is a feature of coeliac disease?

Erythema nodosum Splenic atrophy Colonic ulceration Constipation Gastric atrophy

Your answer

Coeliac disease is linked to all upper GI malignancies and can cause iron and folate deficiencies. Hyposplenism is seen in up to 50% of cases and responds poorly to gluten withdrawal. Small-bowel ulceration is associated with ulcerating jejunitis, but not colonic or gastric ulcers. The commonest symptoms are diarrhoea and abdominal pain and bloating, with weight loss and oral ulcers. The commonest skin lesion is dermatitis herpetiformis, a vesicular itchy rash on the arms and buttocks. This responds well to dapsone.

190. Which of the following features best distinguishes Crohn's disease from ulcerative colitis? Uveitis Rectal bleeding Fatty liver Non-caseating granulomas Crypt abscesses

Your answer

Annual incidence of Crohns disease stands at around 56/100,000 for ulcerative colitis the incidence is higher at around 615/100,000 per year. There are various differences between the two conditions. Histological differences between Crohns and ulcerative colitis include the fact that inflammation is deep (transmural) and patchy in Crohns disease but tends to be mucosal and continuous in ulcerative colitis, non-caseating granulomas are typical of Crohns disease but not ulcerative colitis, goblet cells are present in normal numbers in Crohns but depleted in ulcerative colitis and crypt abscesses do occur in Crohns disease, but are more common in ulcerative colitis. Extra-gastrointestinal manifestations of inflammatory bowel disease are similar in prevalence for uveitis, episcleritis and conjunctivitis. Arthralgia and inflammatory back pain occur with slightly increased frequency in Crohns disease, as do erythaema nodosum and pyoderma gangrenosum. Sclerosing cholangitis is commoner in ulcerative colitis and nephrolithiasis and gallstones are both commoner in Crohns disease patients.

191. A 45-year-old woman was referred with itching and abnormal liver biochemistry. Which of the following is a feature of primary biliary cirrhosis?

Anti-mitochondrial antibodies Increased serum IgA Middle-aged male patients Increased serum copper level Histological piecemeal necrosis

Your answer

PBC usually affects middle-aged women, is associated with anti-mitochondrial (M2) antibodies and elevated serum IgM and an increased level of copper in the liver. Biopsy shows inflammatory duct destruction, patchy fibrosis and cirrhosis. The progression is variable and patients may eventually need a liver transplant if appropriate. Treatment with ursodeoxycholic acid improves liver biochemistry but probably does not improve the prognosis.

192. A 33-year-old man with ulcerative pancolitis was seen. His symptoms were worsening despite intravenous hydrocortisone. Which of the following is true? Ciclosporin is indicated to induce remission Your answer Cytomegalovirus is a common cause of non-responsive colitis Infliximab is indicated to induce remission NSAIDs are a useful adjunct to therapy Surgery is contraindicated Third-line therapy for severe ulcerative colitis is ciclosporin, azathioprine, 6mercaptopurine and possibly methotrexate. Infliximab is confined to the treatment of steroid-/azathioprine-resistant Crohns disease. It is a chimeric human/mouse antibody raised against tumour necrosis factor- (TNF) and is used in fistulating disease and resistant disease mainly to induce remission; however, it may be used as a maintenance therapy. It can induce a hypersensitivity reaction, and host antibodies may be raised against it so reducing its efficacy. Hydrocortisone given at the same time reduces the risk of both these complications. The other adverse effect is an increased risk of infection (notably TB) and therefore thorough investigation to rule out infection is required. NSAIDs cause flares of inflammatory bowel disease.

193. A 27-year-old woman attends for review. She has a past history of perianal abscess but nothing else of note. During the past few months she has twice presented to A&E complaining of grumbling abdominal pain. In addition, she has suffered intermittent episodes of bloody diarrhoea. Microcytic anaemia is found on blood testing and she has mild hypokalaemia. Albumin is reduced but other liver function tests are unremarkable. Barium imaging reveals a small bowel stricture with evidence of mucosal ulceration extending into the colon, interspersed with normal looking mucosa skipping. Given this clinical picture, which is the most likely diagnosis? Ulcerative colitis Small bowel lymphoma Coeliac disease Tropical sprue Crohns disease Your answer Crohns disease has a prevalence of around 1 in 1000, and is most commonly seen in Caucasians and individuals of Jewish descent. Extraintestinal manifestations at diagnosis may include small-joint polyarthritis seronegative arthritis, erythema nodosum, clubbing and sacroiliitis. Endoscopic features of Crohns disease include asymmetric disease, deep longitudinal fissuring, a cobblestone appearance and the presence of strictures. Crypt distortion, inflammation and granulomas may also be present. Acute therapy revolves around the use of corticosteroids, with the addition of 5aminosalycilic acid compounds with or without azathioprine as a steroid-sparing agent. Injectable antitumour necrosis factor (anti-TNF) compounds are also now finding an important role in the treatment of Crohns disease. Surgical intervention should be avoided if at all possible.

194. A 34-year-old man with profuse watery diarrhoea was referred for assessment of a possible neuroendocrine tumour of the gastrointestinal tract. Which of the following statements regarding gastrointestinal hormones is correct? Gastrin increases gastric motor activity Somatostatin increases gastrin secretion Pancreatic polypeptide stimulates pancreatic bicarbonate secretion Enteroglucagon increases the small-bowel transit rate Secretin maintains mucosal growth Your answer

Gastrin (secreted by gastric antral G cells) causes acid secretion, mucosal growth and smooth muscle contraction. Somatostatin reduces gastrointestinal motility and secretion of gastrin. It also downregulates portal blood flow and all GI tract secretions. Pancreatic polypeptide inhibits enzyme secretion. Enteroglucagon is released in response to food, promoting mucosal growth and slowing transit thus enhancing food absorption. Secretin stimulates pancreatic secretions in response to the presence of duodenal acid. 195. A 66-year-old man presents with worsening jaundice, intermittent abdominal pain and weight loss. He is jaundiced, cachectic and has a non-tender mass in the right upper quadrant. Which of the following investigations is most likely to establish the diagnosis? CT scan of the abdomen Liver biopsy Sweat test Alpha-fetoprotein level Serum gastrin level Your answer

The combination of jaundice with a non-tender right upper abdominal mass and weight loss suggests that the underlying disorder is carcinoma of the pancreas. A CT scan of the abdomen is diagnostic.

196. A 54-year-old obese woman presents to casualty. She has rigors and reports a fever. On examination there is jaundice and tenderness over the right upper quadrant of her abdomen. She has an elevated white blood cell count and a markedly raised alkaline phosphatase level; transaminases and bilirubin are also abnormal. Which of these diagnoses best fits the clinical picture? Peptic ulcer disease Acute hepatitis Pancreatitis Ascending cholangitis Your answer Right kidney stone

The clinical picture is of an obese woman who is likely to have biliary obstruction due to gallstones. Patients usually have fever, rigors, and abdominal pain with tenderness over the right upper quadrant and jaundice. All signs are present in 5085% of patients. Bacteraemia and septicaemia may occur in up to 50% of cases. Hepatic abscess and pancreatitis may also occur. Cholangitis is usually secondary to gallstones, and most often occurs at the age of 60 years and above, being rare below the age of 50. Other causes include prior biliary tract surgery and endoscopic retrograde cholangiopancreatoscopy (ERCP). There is usually a markedly elevated white blood cell count with neutrophilia and abnormal liver function tests, with a markedly raised alkaline phosphatase level and smaller rises in transaminases. Ultrasound, CT or ERCP are the favoured imaging modalities. Broad-spectrum antibiotics with specific Gram-negative activity are the treatment of choice, with sphincterotomy via ERCP to allow the passage of trapped gallstones.

197. A 56-year-old woman was referred with right upper quadrant pain and nausea. On ultrasound she had multiple gallstones. Which of the following increases the risk of gallstones? Coeliac disease Crohns disease Diverticulosis Hypertriglyceridaemia Ulcerative colitis

Your answer

Gallstones are increasing in frequency (however, this may just be due to the increasing numbers of abdominal ultrasound examinations being carried out). The risk factors are: female sex; multiparity; oral contraceptive use; terminal ileal disease; high dietary animal fat intake; rapid weight loss; and diabetes mellitus.

198. A 45-year-old man with a 20-year history of ulcerative colitis, who was lost to follow-up, was reviewed and found to have had a change in his bowel habit for 4 months, with increasing diarrhoea. What is the most important management step? Plain abdominal X-ray

Oral mesalazine Oral prednisolone Stool microscopy and culture Urgent colonoscopy Your answer There is a stepwise increased risk of colonic adenocarcinoma that starts 710 years after the onset of ulcerative colitis. The risk is proportional to the severity of the disease and its extent. Surveillance colonoscopy is offered to patients starting at 10 years, with multiple biopsies (at least 32) for assessment for dysplasia. 5-Aminosalicylic acid (5-ASA) drugs (eg mesalazine) probably reduce this risk. A new change in bowel habit should be investigated in a patient with long-standing disease.

199. A 44-year-old man who runs a bar in Alicante, returns to the UK to visit relatives. Over the past few months he has been troubled by itching and has noticed his fluid intake has increased markedly. On presentation to the GP he is extremely tanned, has loss of body hair and evidence of gynaecomastia. He has elevated ALT, AST and alkaline phosphatase levels on liver function testing. What is the most likely diagnosis? Alcoholic cirrhosis Haemochromatosis Primary biliary cirrhosis Pancreatic carcinoma Type-1 diabetes mellitus

Your answer

So-called bronze diabetes, haemochromatosis most commonly presents in men in their fifth decade of life. Examination may be normal, but presentations include increased skin pigmentation, hepatosplenomegaly, ascites, reduced body hair, amenorrhoea in 25% of females and loss of libido in 50% of males at presentation. This mans polydipsia is related to the development of diabetes mellitus, related to iron deposition within the pancreas. Laboratory tests usually reveal abnormal LFTs and elevated ferritin and transferrin saturation. Measurement of the hepatic iron index normally confirms the diagnosis, and it is now possible to send blood samples for mutation screening (autosomal-recessive mode of inheritance). Heterozygotes,

like this man, present with accelerated progression towards cirrhosis due to an additional cause, often the consumption of alcohol.

200. A 22-year-old patient presents with unexplained jaundice repeatedly during episodes of starvation. What is the most likely diagnosis? Haemochromatosis Hepatitis B virus infection Gilberts syndrome Wilsons disease Alcohol abuse

Your answer

Gilbert's syndrome is a mild unconjugated hyperbilirubinaemia. Factors that raise serum bilirubin are fasting, infection and haemolysis. Symptoms such as fatigue are loosely linked but many consider them incidental findings. The M : F ratio is 7 : 2.