Patho.

Mcq mrcp

Question 1 of 274 Next

A 15 year old boy undergoes an emergency splenectomy for trauma. He makes a full
recovery and is discharged home. Eight weeks post operatively the general practitioner
performs a full blood count. Which of the following is most likely to be present?

A. Myofibroblasts

B. Howell-Jolly bodies

C. Multinucleate giant cells

D. Reed Sternberg Cells

E. None of the above

Next question

answer : b

Post splenectomy blood film features:

Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes

As the filtration function is the spleen is no longer present Howell-Jolly bodies are found.

Spleen

 Embryology: derived from mesenchymal tissue

 Shape: orange segment
 Position: below 9th-12th ribs
 Weight: 75-150g
Relations

 Superiorly- diaphragm
 Anteriorly- gastric impression
 Posteriorly- kidney
 Inferiorly- colon
 Hilum: tail of pancreas and splenic vessels (splenic artery divides here, branches
pass to the white pulp transporting plasma)
 Forms apex of lesser sac (containing short gastric vessels)

Contents
- White pulp: immune function. Contains central trabecular artery. The germinal centres
are supplied by arterioles called penicilliary radicles.
- Red pulp: filters abnormal red blood cells

Function

 Filtration of abnormal blood cells and foreign bodies such as bacteria.

 Immunity: IgM. Production of properdin, and tuftsin which help target fungi and
bacteria for phagocytosis.
 Haematopoiesis: up to 5th month gestation or in haematological disorders.
 Pooling: storage of 40% platelets.
 Iron reutilisation
 Storage red blood cells-animals, not humans.
 Storage monocytes

Disorders of the spleen

Massive splenomegaly

 Myelofibrosis
 Chronic myeloid leukaemia
 Visceral leishmaniasis (kala-azar)
 Malaria
 Gaucher's syndrome
Other causes (as above plus)

 Portal hypertension e.g. secondary to cirrhosis

 Lymphoproliferative disease e.g. CLL, Hodgkin's
 Haemolytic anaemia
 Infection: hepatitis, glandular fever
 Infective endocarditis
 Sickle-cell*, thalassaemia
 Rheumatoid arthritis (Felty's syndrome)

*the majority of adults patients with sickle-cell will have an atrophied spleen due to
repeated infarction
Question stats

Average score for registered users:

2 39%
3 71.5%
4 35.2%
Score: 25%

2-4 1/3

Previous 1 / 3 Questions 2 to 4 of 274 Next

Theme: Head and neck lumps

A. Branchial cyst
B. Cystic hygroma
C. Carotid body tumour
D. Lymphadenopathy
E. Adenolymphoma of the parotid
F. Pleomorphic adenoma of the parotid
G. Submandibular tumour
H. Thyroglossal cyst
I. Thoracic outlet syndrome
 J. Submandibular gland calculus

Please select the most likely lesion to account for the clinical scenario given. Each
option may be used once, more than once or not at all.

2. A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless neck
swelling. On examination it is located on the left side immediately anterior to the
sternocleidomastoid muscle. There are no other abnormalities to find on examination.

 You answered Cystic hygroma 

The correct answer is Carotid body tumour

Carotid body tumours typically present as painless masses. They may compress the vagus or
hypoglossal nerves with symptoms attributable to these structures. Over 90% occur
spontaneously and are more common in people living at high altitude. In familial cases up to
30% may be bilateral. Treatment is with excision.

3. A 40 year old women presents as an emergency with a painful mass underneath her right
mandible. The mass has appeared over the previous week with the pain worsening as the
lump has increased in size. On examination there is a 4cm mass underneath her mandible,
there is no associated lymphadenopathy.

 Submandibular gland calculus

The sub mandibular gland is the most common site for salivary calculi. Patients will usually
complain of pain, which is worse on eating. When the lesion is located distally the duct may
be laid open and the stone excised. Otherwise the gland will require removal.

4. A 73 year old male smoker is referred to the clinic by his GP. On examination he has a 3cm
soft mass immediately anterior to his ear. It has been present for the past five years and is
otherwise associated with no symptoms.

 You answered Pleomorphic adenoma of the parotid 

The correct answer is Adenolymphoma of the parotid

Warthins tumours (a.k.a. adenolymphoma) are commoner in older men (especially

 smokers). They are the second commonest benign tumour of the parotid gland, they may be
bilateral. They are soft and slow growing and relatively easy to excise. Pleomorphic
adenomas typically present in females aged between 40 - 60 years.
Score: 33.3%

10

Previous Question 10 of 274 Next

A 58 year old man has been suffering from mechanical back pain for several years. One
morning he awakes from sleep and feels a sudden onset of pain in his back radiating
down his left leg. Which of the following events is most likely to account for his
symptoms?

A. Prolapse of inner annulus fibrosus

B. Prolapse of outer annulus fibrosus

C. Prolapse of nucleus pulposus

D. Rupture of the ligamentum flavum

E. None of the above

Next question

Theme from 2009 Exam answer : c

The symptoms would be most likely the result of intervertebral disk prolapse. In disk
prolapse the nucleus pulposus is the structure which usually herniates. 

Intervertebral discs

 Consist of an outer annulus fibrosus and an inner nucleus pulposus.

 The anulus fibrosus consists of several layers of fibrocartilage.

  The nucleus pulposus contains loose fibres suspended in a mucoprotein gel with
the consistency of jelly. The nucleus of the disc acts as a shock absorber.

 Pressure on the disc causes posterior protrusion of the nucleus pulposus. Most
commonly in the lumbrosacral and lower cervical areas.

 The discs are separated by hyaline cartilage.

 There is one disc between each pair of vertebrae, except for C1/2 and the
sacrococcygeal vertebrae.

Score: 28.6%

Previous Question 15 of 274 Next

A 53 year old man from Hong Kong presents with symptoms of fatigue, weight loss and
recurrent epistaxis. Clinical examination reveals left sided cervical lymphadenopathy and
oropharyngeal examination reveals an ulcerated mass in the naso pharynx. Which of the
following viral agents is most commonly implicated in the development of this condition?

A. Cytomegalovirus

B. Epstein Barr virus

C. Cosackie virus

D. Herpes simplex virus

E. None of the above

Next question
answer : b

The clinical scenario is most typical for nasopharyngeal carcinoma. An association with
previous Epstein Barr Virus is well established. Infection with the other viruses listed is
not a recognised risk factor for the development of the condition.

Nasopharyngeal carcinoma

 Squamous cell carcinoma of the nasopharynx

 Rare in most parts of the world, apart from individuals from Southern China
 Associated with Epstein Barr virus infection

Presenting features
Systemic Local

Cervical Otalgia
lymphadenopathy

Unilateral serous otitis media

Nasal obstruction, discharge and/ or epistaxis

Cranial nerve palsies e.g. III-VI

Imaging
Combined CT and MRI.

Treatment
Radiotherapy is first line therapy.
An 18 year old male presents with lethargy, night sweats and on examination is found to
have left supraclavicular lymphadenopathy. A surgical registrar performs a left
supraclavicular lymph node biopsy. The pathologist identifies Reed- Sternberg cells on
the subsequent histology sections, what is the most likely diagnosis?

A. Metastatic gastric cancer

B. Hodgkins lymphoma

C. Non Hodgkins lymphoma

D. Tuberculosis
 E. None of the above
Next question
answer : b
Reed-Sternberg cells are characteristic histological cell type found in Hodgkins disease.

Lymphadenopathy

 Lymphadenopathy in the neck, axillae, groins and abdomen

 Need to note: solitary/multiple, defined/indistinct, hard/rubbery/soft,
tender/painless

Causes of lymphadenopathy

Mnemonic: Hodgkins disease

H aematological: Hodgkins lymphoma, NHL, Leukaemia

O ncological: metastases
D ermatopathic lympadenitis
G aucher's disease
K awasaki disease
I nfections: TB, glandular fever, Syphilis
N iemann Pick disease
S erum sickness
D rug reaction (phenytoin)
I mmunological (SLE)
S arcoidosis
E ndocrinological (Hyperthyroidism)
A ngioimmunoplastic lymphadenopathy
S LE
E osinophilic granulomatosis

Which of the following lesions is least likely to occur in the presence of severe atrophic
gastritis?

A. Duodenal ulcer
 B. Gastric cancer

C. Gastric polyp

D. Iron deficiency anaemia

E. Pernicious anaemia
Next question

answer : a
Due the absence of acid a duodenal ulcer is unlikely to occur.

Gastric cancer

Overview
There are 700,000 new cases of gastric cancer worldwide each year. It is most common
in Japan and less common in western countries. It is more common in men and
incidence rises with increasing age. The exact cause of many sporadic cancer is not
known, however, familial cases do occur in HNPCC families. In addition, smoking and
smoked or preserved foods increase the risk. Japanese migrants retain their increased
risk (decreased in subsequent generations). The distribution of the disease in western
countries is changing towards a more proximal location (perhaps due to rising obesity). 

Pathology
There is some evidence of support a stepwise progression of the disease through
intestinal metaplasia progressing to atrophic gastritis and subsequent dysplasia, through
to cancer. The favoured staging system is TNM. The risk of lymph node involvement is
related to size and depth of invasion; early cancers confined to submucosa have a 20%
incidence of lymph node metastasis. Tumours of the gastro-oesophageal junction are
classified as below:

Type True oesophageal cancers and may be associated with Barrett's oesophagus.
1

Type Carcinoma of the cardia, arising from cardiac type epithelium 

2 or short segments with intestinal metaplasia at the oesophagogastric junction.

Type Sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer.
3
Groups for close endoscopic monitoring

 Intestinal metaplasia of columnar type

 Atrophic gastritis
 Low to medium grade dysplasia
 Patients who have previously undergone resections for benign peptic ulcer
disease (except highly selective vagotomy).

Referral to endoscopy

Patients of any age with dyspepsia Patients without dyspepsia Worsening dyspepsia
and any of the following

Chronic gastrointestinal bleeding Dysphagia Barretts oesophagus

Dysphagia Unexplained abdominal Intestinal metaplasia

pain or weight loss

Weight loss Vomiting Dysplasia

Iron deficiency anaemia Upper abdominal mass Atrophic gastritis

Upper abdominal mass Jaundice Patient aged over 55 years with

unexplained or persistent dyspepsia

Upper GI endoscopy performed for dyspepsia. The addition of dye spraying (as shown
in the bottom right) may facilitate identification of smaller tumours
 Image sourced from Wikipedia

Staging

 CT scanning of the chest abdomen and pelvis is the routine first line staging
investigation in most centres.
 Laparoscopy to identify occult peritoneal disease
 PET CT (particularly for junctional tumours)

Treatment

 Proximally sited disease greater than 5-10cm from the OG junction may be
treated by sub total gastrectomy
 Total gastrectomy if tumour is <5cm from OG junction
 For type 2 junctional tumours (extending into oesophagus)
oesophagogastrectomy is usual
 Endoscopic sub mucosal resection may play a role in early gastric cancer
confined to the mucosa and perhaps the sub mucosa (this is debated)
 Lymphadenectomy should be performed. A D2 lymphadenectomy is widely
advocated by the Japanese, the survival advantages of extended
 lymphadenectomy have been debated. However, the overall recommendation is
that a D2 nodal dissection be undertaken.
 Most patients will receive chemotherapy either pre or post operatively.

Prognosis

UK Data

Disease extent Percentage 5 year survival

All RO resections 54%

Early gastric 91%

cancer

Stage 1 87%

Stage 2 65%

Stage 3 18%

Operative procedure

Total Gastrectomy , lymphadenectomy and Roux en Y anastomosis

General anaesthesia
Prophylactic intravenous antibiotics
Incision: Rooftop.
Perform a thorough laparotomy to identify any occult disease.
Mobilise the left lobe of the liver off the diaphragm and place a large pack over it. Insert
a large self retaining retractor e.g. omnitract or Balfour (take time with this, the set up
should be perfect). Pack the small bowel away.
Begin by mobilising the omentum off the transverse colon.
Proceed to detach the short gastric vessels.
Mobilise the pylorus and divide it at least 2cm distally using a linear cutter stapling
device.
Continue the dissection into the lesser sac taking the lesser omentum and left gastric
artery flush at its origin.
The lymph nodes should be removed en bloc with the specimen where possible.
Place 2 stay sutures either side of the distal oesophagus. Ask the anaesthetist to pull
back on the nasogastric tube. Divide the distal oesophagus and remove the stomach. 
The oesphago jejunal anastomosis should be constructed. Identify the DJ flexure and
bring a loop of jejunum up to the oesophagus (to check it will reach). Divide the jejunum
at this point. Bring the divided jejunum either retrocolic or antecolic to the oesophagus.
Anastamose the oesophagus to the jejunum, using either interrupted 3/0 vicryl or a
stapling device. Then create the remainder of the Roux en Y reconstruction distally. 
Place a jejunostomy feeding tube.
Wash out the abdomen and insert drains (usually the anastomosis and duodenal stump).
Help the anaesthetist insert the nasogastric tube (carefully!)
Close the abdomen and skin.
Enteral feeding may commence on the first post-operative day. However, most surgeons
will leave patients on free NG drainage for several days and keep them nil by mouth. 

A 28 year old man develops and acute paronychia and subsequent spreading sepsis.
The tissue exudate has a higher protein content than normal tissue because?

A. Breakdown of tissue cells release protein

B. Capillary walls are more permeable

C. Increased blood flow transports more protein into the area

D. Intracapillary pressure is raised

E. Plasma cells release gamma globulin

Next question
answer :b

The increased permeability allows the exudation of plasma proteins.

Acute inflammation

 Inflammation is the reaction of the tissue elements to injury. Vascular changes

occur, resulting in the generation of a protein rich exudate. So long as the injury
 does not totally destroy the existing tissue architecture, the episode may resolve
with restoration of original tissue architecture.

Vascular changes

 Vasodilation occurs and persists throughout the inflammatory phase.

 Inflammatory cells exit the circulation at the site of injury.
 The equilibrium that balances Starlings forces within capillary beds is disrupted
and a protein rich exudate will form as the vessel walls also become more
permeable to proteins.
 The high fibrinogen content of the fluid may form a fibrin clot. This has several
important immunomodulatory functions.

Sequelae
Resolution  Typically occurs with minimal initial injury
 Stimulus removed and normal tissue architecture results

Organisation  Delayed removed of exudate

 Tissues undergo organisation and usually fibrosis

Suppuration  Typically formation of an abscess or an empyema

 Sequestration of large quantities of dead neutrophils

Progression to chronic  Coupled inflammatory and reparative activities

inflammation  Usually occurs when initial infection or suppuration has been
inadequately managed

Causes

 Microbacterial infections e.g. Viruses, exotoxins or endotoxins released by

bacteria
 Chemical agents
 Physical agents e.g. Trauma
 Hypersensitivity reactions
 Tissue necrosis
Presence of neutrophil polymorphs is a histological diagnostic feature of acute
inflammation 

A 40 year old man undergoes a complex appendicectomy and the wound fails to heal
satisfactorily. The wound site itself is associated with multiple sinuses and fistulas. Pus
is sent for microbiology and shows gram positive organisms and sulphur granules. What
is the most likely underlying diagnosis?

A. Infection with Staphylococcus aureus

B. Infection with Bacteroides fragilis

C. Actinomycosis

D. Crohns disease

E. Ulcerative colitis
Next question
answer :c
The presence of chronic sinuses together with gram positive organisms and sulphur
granules is highly suggestive of Actinomycosis. Crohns disease is associated with
multiple fistulae, but not gram positive organisms with sulphur granules.

Actinomycosis

Chronic, progressive granulomatous disease caused by filamentous gram positive

anaerobic bacteria from the Actinomycetaceae family. 

Actinomyces are commensal bacteria that become pathogenic when a mucosal barrier is
breached.

The disease most commonly occurs in the head and neck, although it may also occur in
the abdominal cavity and in the thorax. 

The mass will often enlarge across tissue planes with the formation of multiple sinus
tracts.
Abdominopelvic actinomycosis occurs most frequently in individuals that have had
appendicitis (65%) cases. 

Pathology

 On histological examination gram positive organisms and evidence of sulphur

granules.
 Sulphur granules are colonies of organisms that appear as round or oval
basophilic masses.
 They are also seen in other conditions such as nocardiosis.

Treatment

 Long term antibiotic therapy usually with penicillin.

 Surgical resection is indicated for extensive necrotic tissue, non healing sinus
tracts, abscesses or where biopsy is needed to exclude malignancy.

References
Wong V, Turmezei T and Weston V. Actinomycosis. BMJ 2011;343d6099.

Previous Question 22 of 274 Next

A 56 year old surgeon has been successfully operating for many years. Over the past
few weeks she has begun to notice that her hands are becoming blistering and weepy. A
latex allergy is diagnosed. Which of the following pathological processes accounts for
this scenario?

A. Type 1 hypersensitivity reaction

B. Type 2 hypersensitivity reaction

C. Type 4 hypersensitivity reaction

D. Type 3 hypersensitivity reaction

E. None of the above

Next question
answer :c
 Hypersensitivity reactions: ACID

type 1 --Anaphylactic
type 2 --Cytotoxic
type 3 --Immune complex
type 4 --Delayed hypersensitivity

Theme from 2012 Exam

Contact dermatitis of a chronic nature is an example of a type 4 hypersensitivity reaction.
Type 4 hypersensitivity reactions are cell mediated rather than antibody mediated. 

Hypersensitivity reactions

The Gell and Coombs classification divides hypersensitivity reactions into 4 types

Type I Type II Type III Type IV

Description Anaphylacti Cytotoxic Immune Delayed type

c complex

Mediator IgE IgG, IgM IgG, IgM T-cells

Antigen Exogenous Cell surface Soluble Tissues

Response Minutes Hours Hours 2-3 days

time

Examples Asthma Autoimmune haemolytic Serum sickness Graft versus host

Hay fever anaemia SLE disease
Pemphigus Aspergillosis Contact dermatitis
Goodpasture's

Previous Question 23 of 274 Next

A 56 year old motorcyclist is involved in a road traffic accident and sustains a displaced
femoral shaft fracture. Not other injuries are identified on the primary or secondary
surveys. The fracture is treated with closed, antegrade intramedullary nailing. The
following day the patient becomes increasingly agitated and confused. On examination
he is pyrexial, hypoxic SaO2 90% on 6 litres O2, tachycardic and normotensive. Systemic
examination demonstrates a non blanching petechial rash present over the torso. Which
of the following is the most likely explanation?
 A. Pulmonary embolism with paradoxical embolus

B. Fat embolism

C. Meningococcal sepsis

D. Alcohol withdrawl

E. Chronic sub dural haematoma

Next question
answer : b
This man has a recent injury and physical signs that would be concordant with fat
embolism syndrome. Meningococcal sepsis is not usually associated with hypoxia
initially. Pulmonary emboli are not typically associated with pyrexia.

Fat embolism

 Traditionally occurs following long bone fractures

Diagnosis and clinical features

System Feature

Cardiothoracic  Early persistent tachycardia

 Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
 Pyrexia

Dermatologica  Red/ brown impalpable petechial rash (usually only in 25-50%)

l  Subconjunctival and oral haemorrhage/ petechiae

CNS  Confusion and agitation

 Retinal haemorrhages and intra-arterial fat globules on fundoscopy

Imaging

 May be normal
  Fat emboli tend to lodge distally and therefore CTPA may not show any vascular
occlusion, a ground glass appearance may be seen at the periphery

Treatment

 Prompt fixation of long bone fractures

 Some debate regarding benefit Vs. risk of medullary reaming in femoral shaft/
tibial fractures in terms of increasing risk (probably does not).
 DVT prophylaxis
 General supportive care


Theme: Renal stones

A. Calcium oxalate
B. Uric acid
C. Cystine
D. Struvite
E. Calcium phosphate


Please select the most likely stone type for each of the following urinary tract
stone scenarios. Each option may be used once, more than once or not at all.

26. A 73 year old lady is undergoing chemotherapy for treatment of acute leukaemia. She
develops symptoms of renal colic. Her urine tests positive for blood. A KUB x-ray shows
no evidence of stones.

 Uric acid

Chemotherapy and cell death can increase uric acid levels. In this acute setting the uric
acid stones are unlikely to be coated with calcium and will therefore be radiolucent.

27. A 16 year old boy presents with renal colic. His parents both have a similar history of the
condition. His urine tests positive for blood. A KUB style x-ray shows a relatively
 radiodense stone in the region of the mid ureter.

 Cystine

Cystine stones are associated with an inherited metabolic disorder.

28. A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a staghorn
calculus of the left kidney. Her urinary pH is 7.3. A KUB x-ray shows a faint outline of the
calculus.

 You answered Calcium oxalate 

The correct answer is Struvite

Chronic infection with urease producing enzymes can produce an alkaline urine with
formation of struvate stone.

 Next question

 Renal stones


Type of Features Percentage of all

stones calculi

Calcium Hypercalciuria is a major risk factor (various causes) 85%

oxalate Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate forms complexes with calcium
making it more soluble
Stones are radio-opaque (though less than calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to which calcium oxalate binds

Cystine Inherited recessive disorder of transmembrane cystine transport leading to 1%

decreased absorption of cystine from intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain sulphur

Uric acid Uric acid is a product of purine metabolism 5-10%

May precipitate when urinary pH low
May be caused by diseases with extensive tissue breakdown e.g.
malignancy 
More common in children with inborn errors of metabolism
Radiolucent
Calcium May occur in renal tubular acidosis, high urinary pH increases 10%
phosphate supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone formation (types
2 and 4 do not)
Radio-opaque stones (composition similar to bone)

Struvite Stones formed from magnesium, ammonium and phosphate 2-20%

Occur as a result of urease producing bacteria (and are thus associated with
chronic infections)
Under the alkaline conditions produced, the crystals can precipitate
Slightly radio-opaque


Effect of urinary pH on stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls
as purine metabolism will produce uric acid. Then the urine becomes more
alkaline (alkaline tide). When the stone is not available for analysis the pH of
urine may help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium Normal- alkaline >5.5

phosphate

Calcium oxalate Variable 6

Uric acid Acid 5.5

Struvate Alkaline >7.2

Cystine Normal 6.5

Previous Question 24 of 274 Next

Which of the following tumour markers is most helpful in identifying an individual with
hepatocellular carcinoma?

A. Serum AFP

B. Serum CA19-9

C. CEA

D. Beta HCG
 E. CA125
Next question
answer : a
Hepatocellular carcinoma is commonly diagnosed with imaging and an elevated alpha
fetoprotein. Biopsy may seed the tumour and should be avoided. Up to 80% of
hepatocellular carcinoma arise in cirrhotic livers.

Liver tumours

Primary liver tumours

The most common primary tumours are cholangiocarcinoma and hepatocellular

carcinoma. Overall metastatic disease accounts for 95% of all liver malignancies making
the primary liver tumours comparatively rare. 

Primary liver tumours include:

 Cholangiocarcinoma
 Hepatocellular carcinoma
 Hepatoblastoma
 Sarcomas (Rare)
 Lymphomas
 Carcinoids (most often secondary although primary may occur)

Hepatocellular carcinoma

These account for the bulk of primary liver tumours (75% cases). Its worldwide incidence
reflects its propensity to occur on a background of chronic inflammatory activity. Most
cases arise in cirrhotic livers or those with chronic hepatitis B infection, especially where
viral replication is actively occurring. In the UK it accounts for less than 5% of all
cancers, although in parts of Asia its incidence is 100 per 100,000.
The majority of patients (80%) present with existing liver cirrhosis, with a mass
discovered on screening ultrasound. 

Diagnosis
  CT/ MRI (usually both) are the imaging modalities of choice
 a-fetoprotein is elevated in almost all cases
 Biopsy should be avoided as it seeds tumours cells through a resection plane.
 In cases of diagnostic doubt serial CT and aFP measurements are the preferred
strategy.

Treatment

 Patients should be staged with liver MRI and chest, abdomen and pelvic CT
scan.
 The testis should be examined in males (testicular tumours may cause raised
AFP). PET CT may be used to identify occult nodal disease.
 Surgical resection is the mainstay of treatment in operable cases. In patients with
a small primary tumour in a cirrhotic liver whose primary disease process is
controlled, consideration may be given to primary whole liver resection and
transplantation.
 Liver resections are an option but since most cases occur in an already diseased
liver the operative risks and post-operative hepatic dysfunction are far greater
than is seen following metastectomy.
 These tumours are not particularly chemo or radiosensitive however, both may
be used in a palliative setting. Tumour ablation is a more popular strategy.

Survival
Poor, overall survival is 15% at 5 years.

Cholangiocarcinoma
This is the second most common type of primary liver malignancy. As its name suggests
these tumours arise in the bile ducts. Up to 80% of tumours arise in the extra hepatic
biliary tree. Most patients present with jaundice and by this stage the majority will have
disease that is not resectable. 
Primary scelerosing cholangitis is the main risk factor. In deprived countries typhoid and
liver flukes are also major risk factors.

Diagnosis

 Patients will typically have an obstructive picture on liver function tests.

  CA 19-9, CEA and CA 125 are often elevated
 CT/ MRI and MRCP are the imaging methods of choice.

Treatment

 Surgical resection offers the best chance of cure. Local invasion of peri hilar
tumours is a particular problem and this coupled with lobar atrophy will often
contra indicate surgical resection.
 Palliation of jaundice is important, although metallic stents should be avoided in
those considered for resection.

Survival
Is poor, approximately 15% 5 year survival.

Previous Question 31 of 274 Next

A 32 year old man is involved in a house fire and sustains extensive partial thickness
burns to his torso and thigh. Two weeks post operatively he develops oedema of both
lower legs. The most likely cause of this is:

A. Iliofemoral deep vein thrombosis

B. Venous obstruction due to scarring

C. Hypoalbuminaemia

D. Excessive administration of intravenous fluids

E. None of the above

Next question

Theme from 2009 Exam answer :c

Loss of plasma proteins is the most common cause of oedema developing in this time
frame.

Burns pathology
Extensive burns

 Haemolysis due to damage of erythrocytes by heat and microangiopathy

 Loss of capillary membrane integrity causing plasma leakage into interstitial
space
 Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h
after injury)- decreased blood volume and increased haematocrit
 Protein loss
 Secondary infection e.g. Staphylococcus aureus
 ARDS
 Risk of Curlings ulcer (acute peptic stress ulcers)
 Danger of full thickness circumferential burns in an extremity as these may
develop compartment syndrome

Healing

 Superficial burns: keratinocytes migrate to form a new layer over the burn site
 Full thickness burns: dermal scarring. Usually need keratinocytes from skin grafts
to provide optimal coverage.

Previous Question 35 of 274 Next

A 22 year old man is kicked in the head during a rugby match. He is temporarily
concussed, but then regains consciousness. Half an hour later he develops slurred
speech, ataxia and loses consciousnesses. On arrival in hospital he is intubated and
ventilated. A CT Scan is performed which shows an extradural haematoma. What is the
most likely cause?

A. Basilar artery laceration

B. Middle meningeal artery laceration

C. Laceration of the sigmoid sinus

D. Laceration of the anterior cerebral artery

 E. Laceration of the middle cerebral artery
Next question

Theme based on September 2011 Exam answer : b

The most likely vessel from those in the list to cause an acute extra dural haemorrhage
is the middle meningeal artery. The anterior and middle cerebral arteries may cause
acute sub dural haemorrhage. Acute sub dural haemorrhages usually take slightly longer
to evolve than acute extra dural haemorrhages. 

Middle meningeal artery

 Middle meningeal artery is typically the third branch of the first part of the
maxillary artery, one of the two terminal branches of the external carotid artery.
After branching off the maxillary artery in the infratemporal fossa, it runs through
the foramen spinosum to supply the dura mater (the outermost meninges) .
 The middle meningeal artery is the largest of the three (paired) arteries which
supply the meninges, the others being the anterior meningeal artery and the
posterior meningeal artery.
 The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at
this point, where the skull is thin. Rupture of the artery may give rise to an extra
dural hematoma.
 In the dry cranium, the middle meningeal, which runs within the dura mater
surrounding the brain, makes a deep indention in the calvarium.
 The middle meningeal artery is intimately associated with the auriculotemporal
nerve which wraps around the artery making the two easily identifiable in the
dissection of human cadavers and also easily damaged in surgery.

Previous Question 40 of 274 Next

A 20 year old man is involved in a road traffic accident. Following the incident he is
unable to extend his wrist. However, this improves over the following weeks. Which type
of injury is he most likely to have sustained?

A. Radial nerve neurotmesis

 B. Radial nerve neuropraxia

C. Axillary nerve axonotmesis

D. Ulnar nerve neuropraxia

E. Ulnar nerve axonotmesis

Next question

Theme from April 2011 Exam answer b

Transient loss of function makes neuropraxia the most likely injury. The wrist extensors
are innervated by the radial nerve making this the most likely site of injury.

Neuropraxia

 Nerve intact but electrical conduction is affected

 Myelin sheath integrity is preserved
 Full recovery
 Autonomic function preserved
 Wallerian degeneration does not occur

Previous Question 41 of 274 Next

A 53 year old lady has undergone a bilateral breast augmentation procedure many years
previously. The implants are tense and uncomfortable and are removed. During their
removal the surgeon encounters a dense membrane surrounding the implants, it has a
coarse granular appearance. The tissue is sent for histology and it demonstrates fibrosis
with the presence of calcification. The underlying process responsible for these changes
is:

A. Hyperplasia

B. Dysplasia

C. Metastatic calcification
 D. Dystrophic calcification

E. Necrosis
Next question

answer : d
Breast implants often become surrounded by a pseudocapsule and this may secondarily
then be subjected to a process of dystrophic calcification. 

Pathological calcification

Dystrophic Deposition of calcium deposits in tissues that have undergone, degeneration, damage or
calcification disease in the presence of normal serum calcium levels

Metastatic Deposition of calcium deposits in tissues that are otherwise normal in the presence of
calcification increased serum calcium levels

Previous Question 43 of 274 Next

From which of the following cell types do giant cells most commonly originate?

A. Neutrophils

B. Myofibroblasts

C. Fibroblasts

D. Macrophages

E. Goblet cells
Next question

Theme from September 2011 and 2009 Exam answer: d

Although many cell types may give rise to giant cells, macrophages remain the most
common.

Giant cells
  A giant cell is a mass formed by the union of several distinct types of cells.
 They are most commonly comprised of macrophages.
 They are different to granulomas although causative agents may overlap.

Previous Question 44 of 274 Next

A 43 year old lady with hypertension is suspected of having a phaeochromocytoma.
Which of the following investigations is most likely to be beneficial in this situation?

A. Urinary vanillymandelic acid measurements

B. Histamine provocation test

C. Tyramine provocation test

D. Dexamethasone suppression test

E. None of the above

Next question

Theme from September 2011 Exam answer: a

Urinary VMA measurements are not completely specific but constitute first line
assessment. Stimulation tests of any sort are not justified in first line assessments.

Phaemochromocytoma and adrenal lesions

Phaeochromocytoma

Neuroendocrine tumour of the chromaffin cells of the adrenal medulla. Hypertension and
hyperglycaemia are often found.

 10% of cases are bilateral.

 10% occur in children.

  11% are malignant (higher when tumour is located outside the adrenal).

 10% will not be hypertensive.

Familial cases are usually linked to the Multiple endocrine neoplasia syndromes
(considered under its own heading).

Most tumours are unilateral (often right sided) and smaller than 10cm.

Diagnosis

Urine analysis of vanillymandelic acid (VMA) is often used (false positives may occur
e.g. in patients eating vanilla ice cream!)

Blood testing for plasma metanephrine levels.

CT and MRI scanning are both used to localise the lesion.

Treatment

Patients require medical therapy first. An irreversible alpha adrenoreceptor blocker

should be given, although minority may prefer reversible bockade(1). Labetolol may be
co-administered for cardiac chronotropic control. Isolated beta blockade should not be
considered as it will lead to unopposed alpha activity. 

These patients are often volume depleted and will often require moderate volumes of
intra venous normal saline perioperatively.

Once medically optimised the phaeochromocytoma should be removed. Most

adrenalectomies can now be performed using a laparoscopic approach(2). The adrenals
are highly vascular structures and removal can be complicated by catastrophic
haemorrhage in the hands of the inexperienced. This is particularly true of right sided
resections where the IVC is perilously close. Should the IVC be damaged a laparotomy
will be necessary and the defect enclosed within a Satinsky style vascular clamp and the
defect closed with prolene sutures. Attempting to interfere with the IVC using any
instruments other than vascular clamps will result in vessel trauma and make a bad
situation much worse.

Incidental adrenal lesions

Adrenal lesions may be identified on CT scanning performed for other reasons(3).

Factors suggesting benign disease on CT include(4):

 Size less than 3cm

 Homogeneous texture

 Lipid rich tissue

 Thin wall to lesion

All patients with incidental lesions should be managed jointly with an endocrinologist and
full work up as described above. Patients with functioning lesions or those with adverse
radiological features (Particularly size >3cm) should proceed to surgery.

Previous Question 47 of 274 Next

A 20 year old African lady undergoes an open appendicectomy. She is reviewed for an
unrelated problem 8 months later. On abdominal inspection the wound site is covered by
shiny dark protuberant scar tissue that projects beyond the limits of the skin incision.
Which of the following is the most likely underlying process?

A. Hypertrophic scar

B. Keloid scar

C. Marjolins ulcer
 D. Repeated episodes of wound sepsis

E. Mycosis fungoides
Next question

answer :b
Keloid scars extend beyond the limits of the incision. Mycosis fungoides is a cutaneous
T cell lymphoma. 

Wound healing

Surgical wounds are either incisional or excisional and either clean, clean contaminated
or dirty. Although the stages of wound healing are broadly similar their contributions will
vary according to the wound type.

The main stages of wound healing include:

Haemostasis

 Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin

rich clot.

Inflammation

 Neutrophils migrate into wound (function impaired in diabetes).

 Growth factors released, including basic fibroblast growth factor and vascular
endothelial growth factor.
 Fibroblasts replicate within the adjacent matrix and migrate into wound.
 Macrophages and fibroblasts couple matrix regeneration and clot substitution.

Regeneration
  Platelet derived growth factor and transformation growth factors stimulate
fibroblasts and epithelial cells.
 Fibroblasts produce a collagen network.
 Angiogenesis occurs and wound resembles granulation tissue.

Remodelling

 Longest phase of the healing process and may last up to one year (or longer).
 During this phase fibroblasts become differentiated (myofibroblasts) and these
facilitate wound contraction.
 Collagen fibres are remodelled.
 Microvessels regress leaving a pale scar.

The above description represents an idealised scenario. A number of diseases may

distort this process. It is obvious that one of the key events is the establishing well
vascularised tissue. At a local level angiogenesis occurs but if arterial inflow and venous
return are compromised then healing may be impaired or simply nor occur at all. The
results of vascular compromise are all too evidence in those with peripheral vascular
disease or those poorly constructed bowel anastomoses.

Conditions such as jaundice will impair fibroblast synthetic function and overall immunity
with a detrimental effect in most parts of healing.

Problems with scars:

Hypertrophic scars

Excessive amounts of collagen within a scar. Nodules may be present histologically

containing randomly arranged fibrils within and parallel fibres on the surface. The tissue
itself is confined to the extent of the wound itself and is usually the result of a full
thickness dermal injury. They may go on to develop contractures.

Image of hypertrophic scarring. Note that it remains confined to the boundaries of the
original wound:
 Image sourced from Wikipedia

Keloid scars

Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the
boundaries of the original injury. They do not contain nodules and may occur following
even trivial injury. They do not regress over time and may recur following removal. 

Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:

Image sourced from Wikipedia

Drugs which impair wound healing:

 Non steroidal anti inflammatory drugs

 Steroids
 Immunosupressive agents
 Anti neoplastic drugs

Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few
days but before granulation tissue becomes macroscopically evident. 

Secondary closure refers to either spontaneous closure or to surgical closure after

granulation tissue has formed.

Previous Question 48 of 274 Next

The pathogenicity of the tubercle bacillus is due to which of the following?

A. Necrosis caused by expanding granulomas

B. Ability to multiply within fibroblasts

C. Delayed hypersensitivity reaction against bacteria

D. Effect of antibody response

E. Direct toxic effect on host cells

Next question

answer :c
Mycobacteria stimulate a specific T cell response of cell mediated immunity. This is
effective in reducing the infection, the delayed hypersensitivity also damages tissues.
Necrosis occurs in TB but is usually within the granuloma.

Tuberculosis pathology
  Is a form of primary chronic inflammation, caused by the inability of macrophages
to kill the Mycobacterium tuberculosis.
 The macrophages often migrate to regional lymph nodes, the lung lesion plus
affected lymph nodes is referred to as a Ghon complex.
 This leads to the formation of a granuloma which is a collection of epithelioid
histiocytes.
 There is the presence of caseous necrosis in the centre.
 The inflammatory response is mediated by a type 4 hypersensitivity reaction.
 In healthy individuals the disease may be contained, in the immunocompromised
disseminated (miliary TB) may occur.

Diagnosis

 Waxy membrane of mycobacteria prevents binding with normal stains. Ziehl -

Neelsen staining is typically used.
 Culture based methods take far longer.

Image showing acid- alcohol fast mycobacteria stained using the Ziehl- Neelsen method

Image sourced from Wikipedia

Previous Question 50 of 274 Next

A 53 year old man is due to undergo a splenectomy as a treatment for refractory
haemolytic anaemia. The underlying pathological basis for haemolytic anaemia is
thought to be a Type 2 hypersensitivity response. Which of the following mechanisms
best describes this process

A. Deposition of immune complexes

B. Cell mediated immune response

C. IgE mediated response

D. Formation of autoantibodies against cell surface antigens

E. None of the above

Next question

answer: d

Mnemonic for the reactions and the mediators involved

ACID EGG-T 
Type 1 Anaphylactic
Type 2 Cytotoxic
Type 3 Immune complex
Type 4 Delayed type 

EGG T (mediators)

IgE
IgG
IgG
T cells

Type 2 hypersensitivity reactions (which includes haemolytic anaemia) are associated

with formation of antibody against cell surface antigens.

Hypersensitivity reactions

The Gell and Coombs classification divides hypersensitivity reactions into 4 types
 Type I Type II Type III Type IV

Description Anaphylacti Cytotoxic Immune Delayed type

c complex

Mediator IgE IgG, IgM IgG, IgM T-cells

Antigen Exogenous Cell surface Soluble Tissues

Response Minutes Hours Hours 2-3 days

time

Examples Asthma Autoimmune haemolytic Serum sickness Graft versus host

Hay fever anaemia SLE disease
Pemphigus Aspergillosis Contact dermatitis
Goodpasture's

Previous Question 51 of 274 Next

A 25 year old man is injured in a road traffic accident. His right tibia is fractured and is
managed by fasciotomies and application of an external fixator. Over the next 48 hours
his serum creatinine rises and urine is sent for microscopy, muddy brown casts are
identified. What is the most likely underlying diagnosis?

A. Acute interstitial nephritis

B. Acute tubular necrosis

C. Glomerulonephritis

D. IgA Nephropathy

E. Thin basement membrane disease

Next question
answer : b
This patient is likely to have had compartment syndrome (tibial fracture + fasciotomies)
which may produce myoglobinuria. The presence of worsening renal function, together
with muddy brown casts is strongly suggestive of acute tubular necrosis. Acute
interstitial nephritis usually arises from drug toxicity and does not usually produce urinary
muddy brown casts. Thin basement membrane disease is an autosomal dominant
condition that causes persistent microscopic haematuria, but not worsening renal
function. 
Acute Renal Failure

 Final pathway is tubular cell death.

 Renal medulla is a relatively hypoxic environment making it susceptible to renal
tubular hypoxia.
 Renovascular autoregulation maintains renal blood flow across a range of arterial
pressures.
 Estimates of GFR are best indices of level of renal function. Useful clinical
estimates can be obtained by considering serum creatinine, age, race, gender
and body size. eGFR calculations such as the Cockcroft and Gault equation are
less reliable in populations with high GFR's.
 Nephrotoxic stimuli such as aminoglycosides and radiological contrast media
induce apoptosis. Myoglobinuria and haemolysis result in necrosis. Overlap
exists and proinflammatory cytokines play and important role in potentiating
ongoing damage.
 Post-operative renal failure is more likely to occur in patients who are elderly,
have peripheral vascular disease, high BMI, have COPD, receive vasopressors,
are on nephrotoxic medication or undergo emergency surgery.
 Avoiding hypotension will reduce risk of renal tubular damage.
 There is no evidence that administration of ACE inhibitors or dopamine reduces
the incidence of post-operative renal failure.

Previous Question 53 of 274 Next

A 73 year old man presents with haemoptysis and is suspected of suffering from lung
cancer. On examination he has an enlarged supraclavicular lymph node. Which of the
following features is most likely to be present on histological examination?

A. Increased mitoses

B. Apoptosis

C. Barr Bodies

D. Multinucleate giant cells

 E. Granuloma
Next question
answer : a
Theme from 2011 Exam

Increased mitoses are commonly seen in association with malignant transformation of

cells. Apoptosis is not a common feature of metastatic cancer. Barr Bodies are formed
during X chromosome inactivation in female somatic cells.

Histopathology of malignancy

 Abnormal tissue architecture

 Coarse chromatin
 Invasion of basement membrane*
 Abnormal mitoses
 Angiogenesis
 De-differentiation
 Areas of necrosis
 Nuclear pleomorphism

*= Those features that distinguish invasive malignancy from in situ disease

Previous Question 56 of 274 Next

A 35 year old type 1 diabetic presents with difficulty mobilising and back pain radiating to
the thigh. He has a temperature of 39 oC and has pain on extension of the hip. He is
diagnosed with an iliopsoas abscess. Which of the following statements is false in
relation to his diagnosis?

A. Staphylococcus aureus is the most likely primary cause

B. Recurrence occurs in 60% cases

C. More common in males

D. Crohn's is the most likely secondary cause

 E. CT guided drainage is preferable first line management
Next question
answer : b
Classical features include: a limp, back pain and fever. Recurrence rates are about 15-
20%.Staphylococcus is the commonest primary cause, others
include Streptococcus and E.coli. Management is ideally by CT guided drainage.

Iliopsoas abscess

 Collection of pus in iliopsoas compartment (iliopsoas and iliacus)

 Causes:

Primary

 Haematogenous spread of bacteria

 Staphylococcus aureus: most common

Secondary 

 Crohn's (commonest cause in this category)

 Diverticulitis, Colorectal cancer
 UTI, GU cancers
 Vertebral osteomyelitis
 Femoral catheter, lithotripsy
 Endocarditis

Note the mortality rate can be up to 19-20% in secondary iliopsoas abscesses compared
with 2.4% in primary abscesses.

Clinical features

 Fever
 Back/flank pain
 Limp
  Weight loss

Clinical examination

 Patient in the supine position with the knee flexed and the hip mildly externally
rotated

 Specific tests to diagnose iliopsoas inflammation:

Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against
your hand. This will cause pain due to contraction of the psoas muscle.

Lie the patient on the normal side and hyperextend the affected hip. In inflammation this
should elicit pain as the psoas muscle is stretched.

Investigation

 CT is gold standard

Management

 Antibiotics
 Percutaneous drainage
 Surgery is indicated if:

1. Failure of percutaneous drainage

2. Presence of an another intra-abdominal pathology which requires surgery

Surgical approach
The authors technique for draining these collections is given here.
Review the CT scans and plan surgical approach. An extraperitoneal approach is
important.
The collection usually extends inferiorly and can be accessed from an incision at a level
of L4 on the affected side.

GA
Transverse laterally placed incision.
Incise external oblique.
Split the subsequent muscle layers.
As you approach the peritoneum use blunt dissection to pass laterally around it.
Remember the ureter and gonadal veins lie posterior at this level.
Eventually you will enter the abscess cavity, a large amount of pus is usually released at
this point. Drain the area with suction and washout with saline.
Place a corrugated drain well into the abscess cavity. 
If you have made a small skin incision it is reasonable to bring the drain up through the
skin wound. Otherwise place a lateral exit site and close the skin and external oblique. If
you do this ensure that you use interrupted sutures.

Anchor the drain with strong securely tied silk sutures (it is extremely tiresome if it falls
out!)

Reference

Iliopsoas abscesses 
I H Mallick, M H Thoufeeq, T P Rajendran 
Postgrad Med J 2004;80:459-462

Previous Question 57 of 274 Next

Which of the following statements relating to parathyroid neoplasms is incorrect?

A. 15% of cases are due to parathyroid carcinoma

B. 80% of cases are due to parathyroid adenomas

C. Parathyroid adenomas are often encapsulated

D. 10% of parathyroid adenomas develop in ectopically located glands

E. 85% of cases of primary hyperparathyroidism are due to solitary

adenomas
Next question
answer :a

Parathyroid carcinomas account for up to 5% of tumours. Adenomas are often

encapsulated .Lesions that are fibrotic and densely adherent to the gland may be a
carcinoma. 85% cases of primary hyperparathyroidism are due to a single adenoma and
this is the reason some surgeons favour a focussed parathyroidectomy.

Parathyroid glands and disorders of calcium metabolism

Hyperparathyroidism
Disease type Hormone profile Clinical features Cause

Primary  PTH (Elevated)  May be Most cases due to solitary

hyperparathyroidism  Ca2+(Elevated) asymptomatic if mild adenoma (80%), multifocal
 Phosphate (Low)  Recurrent disease occurs in 10-15%
 Serum Calcium : abdominal pain and parathyroid carcinoma
Creatinine clearance (pancreatitis, renal in 1% or less
ratio > 0.01 colic)
 Changes to
emotional or cognitive
state

Secondary  PTH (Elevated)  May have few Parathyroid gland

hyperparathyroidism  Ca2+ (Low or normal) symptoms hyperplasia occurs as a
 Phosphate (Elevated)  Eventually may result of low calcium,
 Vitamin D levels develop bone disease, almost always in a setting
(Low) osteitis fibrosa cystica of chronic renal failure
and soft tissue
calcifications

Tertiary  Ca2+(Normal or high)  Metastatic Occurs as a result of

hyperparathyroidism  PTH (Elevated) calcification ongoing hyperplasia of the
 Phosphate levels  Bone pain and / or parathyroid glands after
(Decreased or Normal) fracture correction of underlying
 Vitamin D (Normal or  Nephrolithiasis renal disorder, hyperplasia
decreased)  Pancreatitis of all 4 glands is usually the
 Alkaline phosphatase cause
(Elevated)

Differential diagnoses
It is important to consider the rare but relatively benign condition of benign familial
hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder.
Diagnosis is usually made by genetic testing and concordant biochemistry (Serum
Calcium : Creatinine clearance ratio <0.01-distinguished from primary
hyperparathyroidism).

Treatment

Primary hyperparathyroidism
Indications for surgery

 Elevated serum Calcium > 1mg/dL above normal

 Hypercalciuria > 400mg/day
 Creatinine clearance < 30% compared with normal
 Episode of life threatening hypercalcaemia
 Nephrolithiasis
 Age < 50 years
 Neuromuscular symptoms
 Reduction in bone mineral density of the femoral neck, lumbar spine, or distal
radius of more than 2.5 standard deviations below peak bone mass (T score
lower than -2.5)

Secondary hyperparathyroidism
Usually managed with medical therapy.

Indications for surgery in secondary (renal) hyperparathyroidism:

 Bone pain
 Persistent pruritus
 Soft tissue calcifications

Tertiary hyperparathyroidism
Usually treatment is surgical
The presence of an autonomously functioning parathyroid gland may require surgery. If
the culprit gland can be identified then it should be excised. Otherwise total
parathyroidectomy and re-implantation of part of the gland may be required.

References
1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical
Management. Surg Clin North Am 2009 Oct;89(5):1227-39.

2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J

Endocrinol2011; 2011: 251410. 

Previous Question 60 of 274 Next

An 18 year old rock climber falls onto his left arm and sustains a large haematoma of the
left upper arm. Unfortunately the wound associated with the injury is neglected and it
becomes infected. Which of the following changes is least likely to occur?

A. Axillary lymphadenopathy

B. Leucopenia

C. Tenderness

D. Mild pyrexia

E. Local formation of yellow pus

Next question
answer : b
Leucopenia would be unusual and should prompt a search for another cause.

Acute inflammation

 Inflammation is the reaction of the tissue elements to injury. Vascular changes

occur, resulting in the generation of a protein rich exudate. So long as the injury
does not totally destroy the existing tissue architecture, the episode may resolve
with restoration of original tissue architecture.

Vascular changes

 Vasodilation occurs and persists throughout the inflammatory phase.

 Inflammatory cells exit the circulation at the site of injury.
 The equilibrium that balances Starlings forces within capillary beds is disrupted
and a protein rich exudate will form as the vessel walls also become more
permeable to proteins.
  The high fibrinogen content of the fluid may form a fibrin clot. This has several
important immunomodulatory functions.

Sequelae
Resolution  Typically occurs with minimal initial injury
 Stimulus removed and normal tissue architecture results

Organisation  Delayed removed of exudate

 Tissues undergo organisation and usually fibrosis

Suppuration  Typically formation of an abscess or an empyema

 Sequestration of large quantities of dead neutrophils

Progression to chronic  Coupled inflammatory and reparative activities

inflammation  Usually occurs when initial infection or suppuration has been
inadequately managed

Causes

 Microbacterial infections e.g. Viruses, exotoxins or endotoxins released by

bacteria
 Chemical agents
 Physical agents e.g. Trauma
 Hypersensitivity reactions
 Tissue necrosis

Presence of neutrophil polymorphs is a histological diagnostic feature of acute

inflammation 

Previous 1 / 3 Questions 61 to 63 of 274 Next

Theme: Tumour markers

A. Invasive ductal carcinoma of the breast

B. Prostate cancer
C. Gastric cancer
D. Ovarian cancer
E. Colorectal cancer
F. Pancreatic adenocarcinoma
G. Seminoma testicular cancer
H. Non-seminomatous testicular cancer
I. Hepatocellular carcinoma

For each tumour marker please select the most likely underlying malignancy. Each
option may be used once, more than once or not at all.

61. Raised beta-human chorionic gonadotropin with a raised alpha-feto

protein level

 You answered Prostate cancer 

The correct answer is Non-seminomatous testicular cancer

A raised alpha-feto protein level excludes a seminoma

62. Elevated CA 19-9

 You answered Colorectal cancer 

The correct answer is Pancreatic adenocarcinoma

63. Raised alpha-feto protein level in a 54-year-old woman

 Hepatocellular carcinoma

Previ
Question 72 of 274 Next
ous

A keen surgical trainee is about to embark on her first hemi arthroplasty for a fractured
neck of femur. In the anaesthetic room the patient is given 1.2g intravenous co-
amoxyclav. There is a possible history of penicillin allergy but the patient is demented
and the history is not checked. The patient then develops severe respiratory
compromise and haemodynamic collapse. Which of the following pathological processes
accounts for this event?

A. Binding of the drug to circulating IgG class antibodies

B. Recognition of the drug by IgE receptors on mast cells

C. Drug initiated formation of hapten-protein complexes

D. Binding of the drug to circulating IgM class antibodies

E. None of the above

Next question

answer : b

Anaphylactic shock:
Antigen recognised by IgE molecules on the surface of mast cells resulting in rapid degranulation
with release of histamine and other inflammatory cytokines.

This is a case of anaphylactic shock. In anaphylaxis the mast cells degranulate.

Anaphylactic shock

 Suspect if there has been exposure to an allergen

Management

- Remove allergen
- ABCD
- Drugs:

Adrenaline 1:1000 0.5ml INTRAMUSCULARLY (not IV). Repeat after 5 mins if no

response.
Then Chlorpheniramine 10mg IV
Then Hydrocortisone 100-200mg IV
Previous Question 74 of 274 Next
Which of the following is not associated with thrombosis?

A. Endothelial cell damage

B. Use of tourniquets in surgery

C. Formation of platelet aggregates

D. Thrombocytopenia

E. Carcinoma of the stomach

Next question
answer : d
All the other options either act directly to promote thrombosis e.g. endothelial cell
damage or via changes in consistency or flow of blood.

Abnormal coagulation

Cause Factors affected

Heparin Prevents activation factors 2,9,10,11

Warfarin Affects synthesis of factors 2,7,9,10

DIC Factors 1,2,5,8,11

Liver Factors 1,2,5,7,9,10

disease

Interpretation blood clotting test results

Disorder APTT PT Bleeding time

Haemophilia Increased Normal Normal

von Willebrand's Increased Normal Increased

disease

Vitamin K deficiency Increased Increased Normal

Previous Question 75 of 274 Next
A 16 year old boy develops a painful swelling of his distal femur. An osteoblastic
sarcoma is diagnosed. To which of the following sites is this lesion most likely to
metastasise?

A. Inguinal lymph nodes

B. Common iliac lymph nodes

C. Liver

D. Brain

E. Lung
Next question

answer : e

Sarcomas in which Lymphatic Metastasis is seen:

'RACE For MS'

R: Rhabdomyosarcoma
A: Angiosarcoma
C: Clear cell sarcoma
E: Epithelial cell sarcoma

For: Fibrosarcoma

M: Malignant fibrous histiocytoma

S: Synovial cell sarcoma

Or

'SCARE'
 Synovial sarcoma
Clear cell sarcoma 
Angiosarcoma 
Rhabdomyosarcoma
Epithelioid sarcoma

Sarcomas often metastasise via the haematogenous route and the lung is a common
site for sarcoma metastasis. The liver and brain are often spared (at least initially). A
smaller number may develop lymphatic metastasis (see above).

Sarcomas

 Malignant tumours of mesenchymal origin.

Types 
May be either bone or soft tissue in origin. 
Bone sarcoma include:

 Osteosarcoma.
 Ewings sarcoma (although non boney sites recognised).
 Chrondrosarcoma - originate from Chondrocytes.

Soft tissue sarcoma are a far more heterogeneous group and include:

 Liposarcoma-adipocytes.
 Rhabdomyosarcoma-striated muscle
 Leiomyosarcoma-smooth muscle
 Synovial sarcomas- close to joints (cell of origin not known but not synovium)

Malignant fibrous histiocytoma is a sarcoma that may arise in both soft tissue and bone.

Features
Certain features of a mass or swelling should raise suspicion for a sarcoma these
include:

 Large >5cm soft tissue mass.

 Deep tissue location or intra muscular location.
 Rapid growth.
 Painful lump.

Assessment
Imaging of suspicious masses should utilise a combination of MRI, CT and USS. Blind
biopsy should not be performed prior to imaging and where required should be done in
such a way that the biopsy tract can be subsequently included in any resection.

Ewings sarcoma

 Commoner in males.
 Incidence of 0.3 / 1, 000, 000.
 Onset typically between 10 and 20 years of age.
 Location by femoral diaphysis is commonest site.
 Histologically it is a small round tumour.
 Blood borne metastasis is common and chemotherapy is often combined with
surgery.

Osteosarcoma

 Mesenchymal cells with osteoblastic differentiation.

 20% of all primary bone tumours.
 Incidence of 5 per 1,000,000.
 Peak age 15-30. Commoner in males.
 Limb preserving surgery may be possible and many patients will receive
chemotherapy.

Liposarcoma

 Malignancy of adipocytes.
  Rare approximately 2.5 per 1,000,000. They are the second most common soft
tissue sarcoma.
 Typically located in deep locations such as retroperitoneum.
 Affect older age group usually >40 years of age.
 May be well differentiated and thus slow growing although may undergo
dedifferentiation and disease progression.
 Many tumours will have a pseudocapsule that can misleadingly allow surgeons to
feel that they can 'shell out' these lesions. In reality tumour may invade at the
edge of the pseudocapsule and result in local recurrence if this strategy is
adopted.
 Usually resistant to radiotherapy although this is often used in a palliative setting.

Malignant Fibrous Histiocytoma

 Tumour with large number of histiocytes.

 Most common sarcoma in adults.
 Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin
is not known).
 Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid
(less aggressive), giant cell and inflammatory.
 Treatment is usually with surgical resection and adjuvant radiotherapy as this
reduces the likelihood of local recurrence.

Previous Question 78 of 274 Next

Which of the following cellular types or features is not seen in sarcoidosis?

A. Reed Sternberg Cells

B. T lymphocytes

C. Macrophages

D. Asteroid bodies

E. B lymphocytes
Next question
answer :a
Reed Sternberg cells are seen in Hodgkins disease. All of the other cell types are seen
in sarcoid.

Chronic inflammation

Overview
Chronic inflammation may occur secondary to acute inflammation.In most cases chronic
inflammation occurs as a primary process. These may be broadly viewed as being one
of three main processes:

 Persisting infection with certain organisms such as Mycobacterium tuberculosis

which results in delayed type hypersensitivity reactions and inflammation.
 Prolonged exposure to non-biodegradable substances such as silica or suture
materials which may induce an inflammatory response.
 Autoimmune conditions involving antibodies formed against host antigens.

Acute vs. Chronic inflammation

Acute inflammation Chronic inflammation

Changes to existing vascular structure and increased permeability Angiogenesis predominates

of endothelial cells

Infiltration of neutrophils Macrophages, plasma cells and

lymphocytes predominate

Process may resolve with: Healing by fibrosis is the main result

 Suppuration
 Complete resolution
 Abscess formation
 Progression to chronic inflammation
 Healing by fibrosis

Granulomatous inflammation
A granuloma consists of a microscopic aggregation of macrophages (with epithelial type
arrangement =epitheliod). Large giant cells may be found at the periphery of
granulomas.

Mediators
Growth factors released by activated macrophages include agents such as interferon
and fibroblast growth factor (plus many more). Some of these such as interferons may
have systemic features resulting in systemic symptoms and signs, which may be present
in individuals with long standing chronic inflammation.

The finding of granulomas is pathognomonic of chronic inflammation, as illustrated in

this biopsy from a patient with colonic Crohns disease

Image sourced from Wikipedia

Previous Question 80 of 274 Next

A 78 year old man presents with unilateral deafness which has been present for the past
3 months. On examination he has a positive Rinne's test and a CT scan of his head
shows a thickened calvarium with areas of sclerosis and radiolucency. His blood tests
show an elevated alkaline phosphatase, normal serum calcium and normal PTH levels.
Which of the following is the most likely underlying diagnosis?

A. Multiple myeloma with skull involvement

B. Osteoporosis

C. Pagets disease with skull involvement

D. Lung cancer with skull metastasis

E. Osteopetrosis with skull involvement

 Next question

answer : c

Of the conditions listed Pagets disease is the most likely diagnosis. Multiple myeloma
would typically result in multiple areas of radiolucency and usually raised calcium in this
setting. Osteopetrosis is a recognised cause of the features described. However, it is a
rare inherited disorder and usually presents in children in young adults. Presentation at
this stage with no prior symptoms would be extremely rare and therefore this is not
the most likely diagnosis.

Pagets disease

Paget's disease is a disease of increased but uncontrolled bone turnover and is

characterised by architecturally abnormal bones. It is thought to be primarily a disorder
of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic
activity causing areas of sclerosis and deformity. Paget's disease is common (UK
prevalence 5%) but symptomatic in only 1 in 20 patients

Predisposing factors

 increasing age
 male sex
 northern latitude
 family history

Clinical features 

 bone pain (e.g. pelvis, lumbar spine, femur)

 classical, untreated features: bowing of tibia, bossing of skull
 raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
 skull x-ray: thickened vault, osteoporosis circumscripta

Indications for treatment include bone pain, skull or long bone deformity, fracture,
periarticular Paget's

 bisphosphonate (either oral risedronate or IV zoledronate)

  calcitonin is less commonly used now

Complications

 deafness (cranial nerve entrapment)

 bone sarcoma (1% if affected for > 10 years)
 fractures
 skull thickening
 high-output cardiac failure

*usually normal in this condition but hypercalcaemia may occur with prolonged
immobilisation

Previous Question 90 of 274 Next

Which of the metastatic bone tumours described below is at the greatest risk of
pathological fracture ?

A. Proximal humeral lesion from a prostate cancer

B. Vertebral body lesions from a prostate cancer

C. Peritrochanteric lesion from a carcinoma of the breast

D. Proximal humeral lesion from a carcinoma of the breast

E. Peritrochanteric lesion from a prostate cancer

Next question
answer : c
Peritrochanteric lesions have the greatest risks of fracture (due to loading). The lesions
from breast cancer are usually lytic and therefore at higher risk rather than the sclerotic
lesions from prostate cancer.

Metastatic bone disease- risk of fracture

Metastatic bone tumours may be described as blastic, lytic or mixed. Osteoblastic

metastatic disease has the lowest risk of spontaneous fracture when compared to
osteolytic lesions of a similar size. 
Lesions affecting the peritrochanteric region are most prone to spontaneous fracture
(because of loading forces at that site). 
The factors are incorportated into the Mirel Scoring system to stratify the risk of
spontaneous fracture for bone metastasis of varying types.

Mirel Scoring system

Score Site Radiographic Width of bone Pain

points appearance involved

1 Upper extremity Blastic Less than 1/3 Mild

2 Lower Mixed 1/3 to 2/3 Moderate

extremity

3 Peritrochanteric Lytic More than 2/3 Aggravated by

function

Depending upon the score the treatment should be as follows:

Score Risk of fracture Treatment

9 or Impending (33%) Prophylactic fixation

greater

8 Borderline Consider fixation

7 or less Not impending (4%) Non operative management

Previous Question 97 of 274 Next

A 22 year old lady presents with an episode of renal colic and following investigation is
suspected of suffering from MEN IIa. Which of the following abnormalities of the
parathyroid glands are most often found in this condition?

A. Hypertrophy

B. Hyperplasia

C. Adenoma

D. Carcinoma
 E. Metaplasia
Next question

answer :b

MEN IIa

 Medullary thyroid cancer

 Hyperparathyroidism (usually hyperplasia)
 Phaeochromocytoma

In MEN IIa the commonest lesion is medullary thyroid cancer, with regards to the
parathyroid glands the most common lesion is hyperplasia. In MEN I a parathyroid
adenoma is the most common lesion.

Multiple Endocrine Neoplasia

Multiple endocrine neoplasia (MEN) is inherited as an autosomal dominant disorder.

The table below summarises the three main types of MEN:

MEN type I MEN type IIa MEN type IIb

Mnemonic 'three P's': Phaeochromocytoma Same as MEN IIa with

Medullary thyroid cancer addition of:
Parathyroid (95%): Parathyroid adenoma  (70%) Marfanoid body habitus
Pituitary (70%): Prolactinoma/ACTH/Growth Hyperparathyroidism Mucosal neuromas
Hormone secreting adenoma (60%)
Pancreas (50%): Islet cell tumours/Zollinger Ellison
syndrome

also: Adrenal (adenoma) and thyroid (adenoma)

MENIN gene (chromosome 11) RET oncogene RET oncogene

(chromosome 10) (chromosome 10)
Most common presentation = hypercalcaemia
Previous Question 98 of 274 Next
A 22 year old man is admitted to hospital with a lower respiratory chest infection. He had
a splenectomy after being involved in a car accident. What is the most likely infective
organism?

A. Haemophilus influenzae

B. Staphylococcus aureus

C. Rhinovirus

D. Mycobacterium tuberculosis

E. Moraxella catarrhalis
Next question

answer : a

Organisms causing post splenectomy sepsis:

Streptococcus pneumoniae
Haemophilus influenzae
Meningococci

Encapsulated organisms carry the greatest pathogenic risk following splenectomy. The
effects of sepsis following splenectomy are variable. This may be the result of small
isolated fragments of splenic tissue that retain some function following splenectomy.
These may implant spontaneously following splenic rupture (in trauma) or be surgically
implanted at the time of splenectomy.

Post splenectomy sepsis

The loss of splenic function renders individuals at increased risk of fulminant sepsis.
Young children are at the highest risk, especially in the first 2 years following surgery.
Surgery for trauma is associated with a lower risk than when splenectomy is performed
as a treatment for haematological disorders. 
Infection with encapsulated organisms poses the greatest risk, these organisms may be
opsonised, but this then goes undetected at an immunological level due to loss of the
spleen. 
Prophylactic vaccinations are usually administered to reduce the risk of pneumococcal
septicaemia. Since the vaccine only covers up to 80% of pneumococcal infections,
patients will usually recieve long term, low dose penicillin prophylaxis in addition to
vaccination. 

Previous Question 99 of 274 Next

A 24 year old man presents with symptoms of malaise, weight loss and
lymphadenopathy. A lymph node biopsy is performed and the subsequent histology
report states that there is evidence of granuloma formation and central necrosis. What is
the most likely underlying cause?

A. Non Hodgkins lymphoma

B. Churg Strauss syndrome

C. Epstein Barr Virus infection

D. Rheumatoid nodule

E. Infection with Mycobacterium tuberculosis

Next question

answer: e
These histological features are typically seen in TB. Necrosis occurring in granulomas is
usually indicative of an underlying infective cause. Churg Strauss syndrome is a form of
vasculitis, which is the usual histological finding. Granulomas are reported in the
condition, but it is rare for them to demonstrate necrosis.

Tuberculosis pathology

 Is a form of primary chronic inflammation, caused by the inability of macrophages

to kill the Mycobacterium tuberculosis.
 The macrophages often migrate to regional lymph nodes, the lung lesion plus
affected lymph nodes is referred to as a Ghon complex.
 This leads to the formation of a granuloma which is a collection of epithelioid
histiocytes.
  There is the presence of caseous necrosis in the centre.
 The inflammatory response is mediated by a type 4 hypersensitivity reaction.
 In healthy individuals the disease may be contained, in the immunocompromised
disseminated (miliary TB) may occur.

Diagnosis

 Waxy membrane of mycobacteria prevents binding with normal stains. Ziehl -

Neelsen staining is typically used.
 Culture based methods take far longer.

Image showing acid- alcohol fast mycobacteria stained using the Ziehl- Neelsen method

Image sourced from Wikipedia

Previous Question 100 of 274 Next

A 20 year old man develops acute appendicitis, his appendix is removed and he makes
a full recovery. Which of the following pathological processes is least likely to be present
in the acutely inflamed tissues?

A. Altered Starlings forces.

B. Seqestration of neurophils

C. Formation of fluid exudate

 D. Formation of granulomas

E. None of the above

Next question

answer : d

Neutrophil polymorphs=Acute inflammation.

Granuloma = Chronic inflammation.

Acute inflammation:

 3 phases:

1. Changes in blood vessel and flow: flush, flare, wheal

2. Fluid exudates (rich in protein i.e. Ig, coagulation factors) produced via increased
vascular permeability
3. Cellular exudates mainly containing neutrophil polymorphs pass into extravascular
space. 

Neutrophils are then transported to tissues via:

a. Margination of neutrophils to the peripheral plasmatic of the vessel rather than the
central axial stream
b. Pavementing: Adhesion of neutrophils to endothelial cells in venules at site of acute
inflammation
c. Emigration: neutrophils pass between endothelial cells into the tissue

Acute inflammation

 Inflammation is the reaction of the tissue elements to injury. Vascular changes

occur, resulting in the generation of a protein rich exudate. So long as the injury
does not totally destroy the existing tissue architecture, the episode may resolve
with restoration of original tissue architecture.
Vascular changes

 Vasodilation occurs and persists throughout the inflammatory phase.

 Inflammatory cells exit the circulation at the site of injury.
 The equilibrium that balances Starlings forces within capillary beds is disrupted
and a protein rich exudate will form as the vessel walls also become more
permeable to proteins.
 The high fibrinogen content of the fluid may form a fibrin clot. This has several
important immunomodulatory functions.

Sequelae
Resolution  Typically occurs with minimal initial injury
 Stimulus removed and normal tissue architecture results

Organisation  Delayed removed of exudate

 Tissues undergo organisation and usually fibrosis

Suppuration  Typically formation of an abscess or an empyema

 Sequestration of large quantities of dead neutrophils

Progression to chronic  Coupled inflammatory and reparative activities

inflammation  Usually occurs when initial infection or suppuration has been
inadequately managed

Causes

 Microbacterial infections e.g. Viruses, exotoxins or endotoxins released by

bacteria
 Chemical agents
 Physical agents e.g. Trauma
 Hypersensitivity reactions
 Tissue necrosis
Previous Question 79 of 227 Next
A laceration of the wrist produces a median nerve transaction. The wound is clean and
seen immediately after injury. Collateral soft tissue damage is absent. The patient asks
what the prognosis is. You indicate that the nerve should regrow at approximately:

A. 0.1 mm per day

B. 1 mm per day

C. 5 mm per day

D. 1 cm per day

E. None of the above

Next question
answer : b
Transaction of a peripheral nerve results in hemorrhage and in retraction of the several
nerve ends. Almost immediately, degeneration of the axon distal to the injury begins.
Degeneration also occurs in the proximal fragment back to the first node of Ranvier.
Phagocytosis of the degenerated axonal fragments leaves neurilemmal sheath with
empty cylindrical spaces where the axons were. Several days following the injury, axons
from the proximal fragment begin to regrow. If they make contact with the distal
neurilemmal sheath, regrowth occurs at about the rate of 1 mm/day. However, if
associated trauma, fracture, infection, or separation of neurilemmal sheath ends
precludes contact between axons, growth is haphazard and a traumatic neuroma is
formed. When neural transaction is associated with widespread soft tissue damage and
hemorrhage (with increased probability of infection), many surgeons choose to delay
reapproximation of the severed nerve end for 3 to 4 weeks.

Nerve injury

There are 3 types of nerve injury:

Neuropraxi  Nerve intact but electrical conduction is affected
a  Full recovery
 Autonomic function preserved
 Wallerian degeneration does not occur

Axonotmesi  Axon is damaged and the myelin sheath is preserved. The connective tissue framework
s is not affected.
 Wallerian degeneration occurs.

Neurotmesis  Disruption of the axon, myelin sheath and surrounding connective tissue.
 Wallerian degeneration occurs.

Wallerian Degeneration

 Axonal degeneration distal to the site of injury.

 Typically begins 24-36 hours following injury.
 Axons are excitable prior to degeneration occurring.
 Myelin sheath degenerates and is phagocytosed by tissue macrophages.

Nerve repair

 Neuronal repair may only occur physiologically where nerves are in direct
contact. Where a large defect is present the process of nerve regeneration is
hampered and may not occur at all or result in the formation of a neuroma.
Where nerve regrowth occurs it typically occurs at a rate of 1mm per day.