Clinical SBAs
Clinical Gastroenterology: (31 questions)

Questions

• 1
  What is a commonly experienced side-effect of omeprazole?
  Difficulty: Medium     Topic: Omeprazole side-effects
  a

  Acute tubular necrosis

  b

  CYP-enzyme inducer effects

  c

  Headache

  d

  Hepatitis

  e

  Myalgia
  Explanation: Its most common side-effects are GI disturbance and headache. It is an inhibitor of hepatic CYP enzymes that metabolise warfarin and digoxin therefore can increase their levels. Omeprazole is a well recognised cause of tubulo-interstitial nephritis, as well as analgesics and antibiotics; it does not cause acute tubular necrosis. Omeprazole may rarely cause LFT changes but hepatitis is extremely rare. Statins are commonly associated with myalgia but less often for omeprazole.
• 2
  A 20-year old man presents with a history of bloody diarrhoea, abdominal cramps and weight loss. He has iron deficiency anaemia. Barium enema shows a cobblestone appearance. Which of the following is least likely to be present?
  Difficulty: Medium     Topic: Blood diarrhoea and cobblestone enema
  a

  Erythema nodosum

  b

  Erythema marginatum

  c

  Pyoderma gangrenosum

  d

  Anterior uveitis

  e

  Nephrolithiasis
  Explanation: Cobblestone appearance on barium enema is typical of Crohn's disease, which may also show: strictures and 'rose thorn' ulcers. Erythema nodosum is associated with both Crohn's and UC as well as sarcoidosis and Streptococcal infection. Pyoderma gangrenosum and anterior uveitis are both features of IBD. Nephrolithiasis occur because there is increased oxalate absorption, which precipitates as stones in the kidney. Erythema marginatum occurs with rheumatic fever.
• 3
  A 22-year old woman presents with cramping lower abdominal pain, bloody diarrhoea and malaise. She gives a history of gradual onset of 1-2 years following by this acute worsening. Which of the following is least likely to be part of her long-term management?
  Difficulty: Hard     Topic: Cramping abdominal pain and bloody diarrhoea
  a

  Prednisolone

  b

  Mesalazine

  c

  Azathioprine

  d

  Cyclophosphamide

  e

  Methotrexate
  Explanation: This woman is experiencing a flare of ulcerative colitis, an idiopathic condition characterised by mucosal inflammation and ulceration of the colon. It affects the bowel in one continuous section whereas Crohn's disease can sporadically affect areas with 'skip lesions'. In contrast to Crohn's disease it is not a granulomatous condition. The inflammation is not transmural therefore strictures are less common than in Crohn's disease however perforation is still a risk, especially during active flares. Prednisolone and mesalazine are used in combination to induce remission. 5-ASA inhibitors (e.g. mesalazine) are used to maintain remission by reducing inflammation in the mucosa. Prednisolone may be used long-term for some severe patients but most patients are maintained on a 5-ASA inhibitor alone. Surgery can be part of treatment of UC but is a last resort, it is used for perforation and massive haemorrhage.
• 4
  An 18-year old medical student has completed a course of hepatitis B vaccination. Anti-HBs antibody titre is 90IU/L. What is the most appropriate management?
  Difficulty: Hard     Topic: Hepatitis B vaccination
  a

  Reassurance

  b

  Retest in 4 years

  c

  Retest in 1 year

  d

  Give booster and re-test

  e

  Give booster, re-test and check HBsAg & and HBcAg titre
  Explanation: Following HBV vaccination, anti-HBs antibody should ideally be >100IU/L, in which case they should be re-tested in 4 years. If close to 100IU/L, they should be re-tested in 1 year. If <100IU/L, then they only have partial immunity so should be given a booster then re-tested. If <10IU/L, then they have not responded at all, which may be due to active infection or past infection - tested for with HBsAg and HBcAg respectively.
• 5
  A 43-year old woman with a history of Grave’s disease presents with itch and fatigue. Liver biopsy shows intrahepatic cholestasis with granuloma formation. Which of the following antibodies is most likely to be raised?
  Difficulty: Medium     Topic: Intrahepatic cholestasis with granulomas
  a

  Anti-neutrophil cytoplasmic antigen

  b

  Anti-nuclear antibody

  c

  Anti-mitochondrial antibody

  d

  Anti-smooth muscle antigen

  e

  Anti-liver, kidney, microsomal antigen
  Explanation: This woman has primary biliary cirrhosis. PBC is 9x more common in women and presents in middle age with these features. It is a granulomatous disorder that destroys intrahepatic bile ducts. It is treated with ursodeoxycholic acid though this does not give any survival benefit. AMA is positive in 95% of patients. ANCA can be raised in PSC, which does not form granulomas, and also in many vasculitidies. ANA, ASMA and anti-LKM antibodies are raised in autoimmune hepatitis (AIH).
• 6
  An asymptomatic 55-year old diabetic woman is referred for abnormal liver function tests. She does not drink alcohol. ALP and ALT are mildly raised. All other blood tests are normal. Hepatitis virus and antibody serology are negative. What is the most appropriate management?
  Difficulty: Hard     Topic: Asymptomatic abnormal LFT
  a

  Diet and lifestyle advice

  b

  Abdominal ultrasound scan

  c

  Liver biopsy

  d

  Desferrioxamine

  e

  Ursodeoxycholic acid
  Explanation: This woman has non-alcoholic fatty liver disease, the most common cause of abnormal LFTs - usually mild increases in ALP and ALT>AST. Biopsy shows steatosis or steatohepatitis, which can progress to cirrhosis. Patients are not initially biopsied, unless there is suspicion of cirrhosis. This lady needs good diabetic management and lifestyle advice. USS might be performed but is unlikely to management. Desferrioxamine is an iron chelator used in haemochromatosis. Ursodeoxycholic acid is given in PBC and PSC.
• 7
  A 30-year old man is referred for abnormal LFT. Examination with a slit-lamp shows a ring of green-brown discolouration around the cornea. What is the least likely diagnosis?
  Difficulty: Medium     Topic: Abnormal LFT with corneal discolouration
  a

  Wilson's disease

  b

  Hereditary haemochromatosis

  c

  Primary biliary cirrhosis

  d

  Primary sclerosing cholangitis

  e

  Recurrent intrahepatic cholestasis
  Explanation: This man has Kayser-Fleischer rings, which are deposition of copper-containing pigments in the outer cornea. K-F rings occur in any condition that causes chronic cholestasis and in Wilson's disease. PBC, PSC and recurrent intrahepatic cholestasis are causes of chronic cholestasis. Haemochromatosis causes hepatocellular damage and is not associated with K-F rings.
• 8
  A 50-year old man presents with fatigue and arthralgia. He has osteoarthritis of the 2nd MCP joint and both knees. He has palmar erythema, clubbing, leukonychia and atrophic testes. Fasting venous glucose is 9.2mmol/L. What is the most appropriate management?
  Difficulty: Hard     Topic: Fatigue, OA and palmar erythema
  a

  Venesection till iron-depleted

  b

  Augmentation therapy with alpha-1-antitrypsin

  c

  Prednisolone and azathioprine

  d

  D-penicillamine

  e

  Ursodeoxycholic acid
  Explanation: This man has hereditary haemochromatosis (HH), which causes iron-overload due to increased absorption. Osteoarthritis characteristically affects the 2nd & 3rd MCP-joints and knees. It also causes: cirrhosis, diabetes, skin pigmentation, cardiomyopathy and hypogonadism. Venesection is the best treatment, or desferrioxamine if not tolerated. Alpha-1-antitrypsin augmentation therapy is the treatment for respiratory complications of AAT-deficiency. Prednisolone with azathioprine is therapy for autoimmune hepatitis. D-penicillamine is given for Wilson's disease. Ursodeoxycholic acid is given in PBC and PSC.
• 9
  A 68-year old man has alcoholic cirrhosis with ascites. He is brought to A&E jaundiced, confused and complaining of abdominal pain following a 2 day deterioration. Ascitic tap shows a raised neutrophil count. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Confusion and abdominal pain with ascites
  a

  Development of hepatocellular carcinoma

  b

  Gastroenteritis

  c

  Portal vein thrombosis

  d

  Spontaneous bacterial peritonitis

  e

  Hepatic infection
  Explanation: Acute decompensation in cirrhosis can be due to: further insult (alcohol/drugs), infection, HCC development, variceal bleed or spontaneous bacterial peritonitis - as in this patient. SBP presents with fever, decompensation, encephalopathy and abdominal pain. Gram-stain, culture and WCC should be done on the ascitic tap. the other options may present in a similar way but are unlikely to cause a raised neutrophil count in the ascites.
• 10
  A 55-year old woman with long-standing primary biliary cirrhosis presents with a haemarthrosis. INR = 3.6. She does not take warfarin. What is the best treatment for her coagulopathy?
  Difficulty: Hard     Topic: Raised INR in primary biliary cirrhosis
  a

  Oral vitamin K

  b

  IV vitamin K

  c

  Fresh frozen plasma

  d

  Platelets transfusion

  e

  Activated factor VIIa
  Explanation: Long-standing cholestasis results in deficiency of the fat-soluble vitamins (ADEK). Bile salts are not present to aid their absorption. Therefore parenteral vitamin K will correct the underlying deficiency; oral vitamin K will not be absorbed. FFP or activated factor VIIa may be given if the patient has a life-threatening bleed but vitamin K would still be required. Haemarthroses more commonly occur due to clotting-pathway disorders, whereas platelets disorders present with purpura, epistaxis and menorrhagia.
• 11
  A 40-year old woman presents with icteric sclera. She says that her urine is dark and her stools are pale. Urobilinogen is not present in the urine. Which of the following is least likely to be the cause?
  Difficulty: Medium     Topic: Jaundice with pale stools
  a

  Alcoholic cirrhosis

  b

  Primary sclerosing cholangitis (PSC)

  c

  Primary biliary cirrhosis (PBC)

  d

  Choledocholithiasis

  e

  Oral contraceptive pill
  Explanation: This woman has obstructive jaundice. Absence of urobilinogen from the urine suggests that no Br is passing into the bowel. Alcoholic cirrhosis causes an intrahepatic jaundice and some Br will still pass into the bowel. PSC causes inflammation of intra- or extra-hepatic ducts, whereas PBC only affect intrahepatic bile ducts; both cause cholestasis. Choledocholithiasis are stones in the common bile duct. The OCP block bile exporters on hepatocytes and can cause cholestasis.
• 12
  A 37-year old woman presents with icteric sclera. She says that her urine is dark but stools are the same colour. Urobilinogen is present in the urine. Which of the following is least likely to be the cause?
  Difficulty: Medium     Topic: Jaundice with dark urine
  a

  Amanita phalloides ingestion

  b

  Anti-tuberculosis medication

  c

  Halothane

  d

  Hepatitis A virus

  e

  Lymphadenopathy
  Explanation: This woman has intra-hepatic jaundice with conjugated hyperbilirubinaemia, which is soluble in urine. Urobilinogen in the urine confirms that Br has passed into the bowel. Lymphadenopathy would cause an obstructive jaundice by compression the common bile duct. Amantia mushroom is highly hepato-toxic and causes rapid ALF. Isoniazid, rifampicin and pyrazinamide all can cause hepatitis. Halothane rarely causes a severe hepatitis especially on re-exposure. HAV is a common infectious cause of acute hepatitis.
• 13
  A 38-year old man presents with icteric sclera. He has not noted any change in stool or urine colour. Urobilinogen is present in the urine. Which of the following is most likely to be the cause?
  Difficulty: Medium     Topic: Jaundice with urobilinogen present
  a

  Adenocarcinoma of pancreatic head

  b

  Cholangiocarcinoma

  c

  Glucose-6-phosphate dehydrogenase (G6PD) deficiency

  d

  Primary sclerosing cholangitis (PSC)

  e

  Secondary biliary strictures
  Explanation: This man has pre-hepatic jaundice with unconjugated hyperbilirubinaemia that is insoluble in urine. The presence of urobilinogen in the urine means that bilirubin in passing through the bowel, being modified by colonic bacteria and being reabsorbed - this excludes obstructive causes of jaundice. Haemolysis results in Br production in excess of the liver's conjugating capacity. Hereditary G6PD deficiency is a cause of haemolysis. Cancer of the head of pancreas and cholangiocarcinoma (tumour of biliary epithelial cells) are obstructive causes of jaundice. PSC is an idiopathic condition with biliary strictures and cirrhosis, causing obstructive jaundice. Secondary biliary structures cause bile obstruction after previous bile duct damage e.g. post-ERCP.
• 14
  Which of the following statements about laxatives is true?
  Difficulty: Medium     Topic: Laxatives
  a

  Stimulant laxatives result in abdominal cramps

  b

  Senna is an osmotic agent

  c

  Lactulose is most used for constipation

  d

  Docusate is a bulking agent

  e

  Calcium antacids act as osmotic laxatives
  Explanation: Stimulants (senna and bisacodyl) increase smooth muscle activity, which can cause cramping pain. Lactulose is an osmotic agent that reduces growth of ammonia-producing organisms; it is most used to treat hepatic encephalopathy. Docusate has both softening and stimulant action but not bulking, which would be methylcellulose. Calcium antacids are constipating whereas magnesium antacids act as osmotic laxatives.
• 15
  A 56-year old man presents with a 2 month history of painless diarrhoea without blood visible. Which investigation is least appropriate?
  Difficulty: Medium     Topic: Painless diarrhoea without blood
  a

  ESR

  b

  FBC

  c

  TSH

  d

  Anti-smooth muscle antibody

  e

  Anti-transglutaminase antibody
  Explanation: ASMA is associated with autoimmune hepatitis and SLE therefore is of least use here. ESR may be raised in Crohn's, UC, malignancy or infection. FBC may indicate iron deficiency anaemia or macrocytosis from folate/B12 deficiency or alcohol use. TSH would be low in hyperthyroidism, which causes diarrhoea. Anti-transglutaminase is positive in Coeliac's, which shows a 2nd peak in presentation at 50-60yrs.
• 16
  A 68-year old woman presents with GORD. CXR shows a bubble shaped air-fluid level in the lower left thorax. Which of the following statements regarding this condition is correct?
  Difficulty: Medium     Topic: Air-fluid level in thorax
  a

  Rolling are more common than sliding

  b

  Sliding have the gastro-oesophageal sphincter inside the abdomen

  c

  Not all patients have symptomatic GORD

  d

  Nissen fundoplification is a common treatment

  e

  Upper GI endoscopy is the best investigation
  Explanation: Hiatus hernias can cause resistant GORD. On CXR the gastric bubble may be visible in the thorax. In sliding hernias the gastro-oesophageal sphincter moves through the diaphragm. Rolling are less common, where a section of stomach bulges into the thorax but the sphincter remains in the abdomen. GORD may be asymptomatic. Fundoplification is the surgical treatment but is only for intractable symptoms. OGD may show the hernia but barium swallow is more sensitive.
• 17
  Which of these is not a complication of haemochromatosis?
  Difficulty: Medium     Topic: Haemochromatosis complications
  a

  Hypogonadotrophic hypogonadism

  b

  Osteoarthritis

  c

  Slate-grey appearance

  d

  Liver failure

  e

  Hypertrophic cardiomyopathy (HCM)
  Explanation: Haemochromatosis is a disorder of iron overload. It affects the endocrine glands causing diabetes and hypogonadotrophic hypogonadism. Iron is toxic to the liver and causes cirrhosis and ultimately liver failure. Deposition in the skin causes a slate-grey appearance (or 'bronze'). Deposition in the heart results in a restrictive cardiomyopathy. HCM occurs due to mutations in contractile proteins.
• 18
  A 42-year old woman who suffers from severe asthma presents with epigastric pain that is worse before meals and is relieved by milk. Which of the following statements about this condition is false?
  Difficulty: Hard     Topic: Epigastric pain in asthmatic
  a

  It is the most common upper GI ulcer

  b

  Blood group B is a risk factor

  c

  H. pylori is involved in 30%

  d

  Smoking reduces risk

  e

  May be caused by a VIP-secreting tumour
  Explanation: This woman has a duodenal ulcer (DU), which causes pain (that may radiate to the back) before meals, whereas gastric ulcers (GU) causes pain associated with meals and relief with antacids. NSAIDs or steroids (for her asthma) and blood group O increase risk of ulcers. DU are more common than GU. (Group A is a risk factor for gastric cancer.) VIPomas cause profuse watery diarrhoea, whereas Zollinger-Ellison syndrome occurs when a gastrinoma causes recurrent upper GI ulcers.
• 19
  A 30-year old man presents with fatigue and describes a 2 year history of intermittent small volume malaena. Hb = 9.1g/dl. There are multiple perioral telangiectasia but examination is otherwise normal. What is the most likely diagnosis?
  Difficulty: Hard     Topic: Intermittent, small volume malaena
  a

  Osler-Weber-Rendu syndrome

  b

  Addison's disease

  c

  Sturge-Weber syndrome

  d

  Peutz-Jegher's syndrome

  e

  Limited systemic sclerosis
  Explanation: Osler-Weber-Rendu syndrome (hereditary haemorrhagic telangiectasia) is an autosomal dominant condition with multiple telangiectasia on mucous membranes causing GI bleeds and epistaxis with anaemia. Addison's causes mucous membrane hyperpigmentation but not GI bleeds. Sturge-Weber causes a port-wine stain on the face and epilepsy. Peutz-Jeghers causes perioral freckles of hyperpigmentation with increased cancer risk. Scleroderma can cause telangiectasia but they are not confined to the mouth and GI bleeds are uncommon.
• 20
  A 25-year old man presents with erythematous and swollen gums. Which of the following is least likely to be responsible?
  Difficulty: Medium     Topic: Swollen gums
  a

  Phenytoin

  b

  Ciclosporin

  c

  Digoxin

  d

  Acute myeloid leukaemia

  e

  Poor oral hygiene
  Explanation: This man has gingivitis, which can occur due to a number of conditions including those listed above plus nifedipine and vitamin C deficiency. Digoxin does not cause gingivitis but may cause xanthopsia (yellow vision), gynaecomastia and arrhythmias.
• 21
  A 78-year old woman being treated with ciprofloxacin becomes severely unwell with a pyrexia, severe diarrhoea with streaks of blood and generalised guarding. An enzyme immunoassay confirms the diagnosis. What is the most appropriate antibiotic management?
  Difficulty: Medium     Topic: Pyrexia after ciprofloxacin treatment
  a

  Amoxicillin IV + metronidazole orally

  b

  Ciprofloxacin IV

  c

  Metronidazole IV

  d

  Metronidazole orally + vancomycin orally

  e

  Metronidazole IV + vancomycin IV
  Explanation: This woman has pseudomembranous colitis, the most severe infection with C. difficile, which can be tested for using an assay however stool culture is usually also performed. Ciprofloxacin is commonly indicated in C. difficile colonisation and should be changed if there is serious infection. Metronidazole is the treatment of choice but should ideally be given orally. Severe infection also requires addition of oral vancomycin. Intravenous vancomycin will not enter the GI tract and therefore has no action on treating C. difficile. She will need high volume fluid replacement with crystalloid and should be isolated in a side-room. Amoxicillin IV is not part of the treatment regimen. Ciprofloxacin should be stopped as it is the causative agent in allowing proliferation of C. difficile.
• 22
  A 87-year old man with terminal colorectal cancer presents with colicky abdominal, abdominal distension and severe vomiting. Which of the following medical treatments is likely to be most effective in treating his symptoms?
  Difficulty: Hard     Topic: Anti-emetics
  a

  Dexamethasone alone

  b

  Metoclopramide and dexamethasone

  c

  Cyclizine and hyoscine butylbromide

  d

  Metoclopramide and hyoscine butylbromide

  e

  Cyclizine alone
  Explanation: This man has presented with malignant large bowel obstruction. If possible then a stent may be inserted endoscopically but the patient will also require medical management. Cyclizine (a histamine-receptor antagonist) is effective for chemical and gastro-intestinal causes of emesis. Hyoscine is an anti-muscarinic that acts to reduce secretion of intestinal fluid, which reduces the distension. Dexamethasone is anti-emetic and reduces tumour oedema if the obstruction is malignant, however is unlikely to be as effective alone. Metoclopramide is a prokinetic agent therefore is contraindicated in suspected mechanical bowel obstruction but is effective in ileus.
• 23
  A 81-year old man presents with persistent progressive dysphagia. Which of the following diagnoses is least likely?
  Difficulty: Easy     Topic: Progressive dysphagia
  a

  Achalasia

  b

  Benign oesophageal stricture

  c

  Compression due to lymphadenopathy

  d

  Gastric carcinoma

  e

  Oesophageal carcinoma
  Explanation: Progressive dysphagia implies difficulty swallowing solids first and then liquids. It is caused by mechanical obstruction that can be benign or malignant but where the lumen size is gradually reducing. Neurological causes result in dysmotility and equally affect solids and liquids. Achalasia is the condition with failure of relaxation of the lower oesophageal sphincter due to deregulation of the myenteric plexus. Patients commonly present with regurgitation, chest pain and dysphagia to both solids and liquids that may be intermittent. Benign strictures may occur secondary to ulcers or oesophagitis. Lymphadenopathy may be from lymphoma or bronchial carcinoma. Carcinoma of the fundus or cardia of the stomach can cause dysphagia.
• 24
  A 44-year old man presents to the GP with severe dyspepsia. 1 month of lifestyle management has not helped. He is otherwise well. What is the most appropriate initial management?
  Difficulty: Hard     Topic: Management of dyspepsia
  a

  Upper GI endoscopy

  b

  Treat with omeprazole for 4 weeks

  c

  C-13 breath test

  d

  Treat with ranitidine for 2 weeks

  e

  Treat with simple antacids for 4 weeks
  Explanation: In patients <55yrs old with no 'red flags' the first treatment is antacids. If this fails then H. pylori should be tested for with the C-13 breath test. If absent, a PPI (omeprazole) or histamine-receptor antagonist (ranitidine) can be given for 2 weeks. If H. pylori is present then treated with: PPI + amoxicillin + clarithromycin. If >55yrs with persistent dyspepsia or weight loss/anaemia etc., then an OGD should be performed.
• 25
  A 60-year old man with alcoholic cirrhosis is vomiting pints of fresh blood. Following the primary survey, what is the most appropriate management?
  Difficulty: Medium     Topic: Acute upper GI bleed
  a

  Fluid resuscitation, then urgent OGD, then terlipressin

  b

  Terlipressin, then fluid resuscitation, then urgent OGD

  c

  Fluid resuscitation, then terlipressin, then urgent OGD

  d

  Fluid resuscitation, then tranexamic acid, then urgent OGD

  e

  Fluid resuscitation, then urgent OGD, then tranexamic acid
  Explanation: This man has ruptured oesophageal varices, which causes massive haematemesis that requires aggressive resuscitation. As with all acutely unwell patients, fluid resuscitation should occur before invasive treatment (except in ruptured AAA etc.). Terlipressin is an ADH-agonist that vasoconstricts and limits blood loss; it can be given before OGD. Endoscopy allows banding, sclerotherapy or placing a Sendstake-Blakemore tube to control bleeding. Tranexamic acid inhibits activation of plasminogen, and is used in non-variceal causes of upper GI bleeds.
• 26
  A 42-year old man of no fixed abode is attends A&E. He says he has been vomiting for several hours then brought up a teaspoon of fresh blood. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Multiple vomiting
  a

  Oesophageal varices

  b

  Boerhaave's syndrome

  c

  Mallory-Weiss tear

  d

  Gastric ulcer

  e

  Duodenal ulcer
  Explanation: Mallory-Weiss tears are small breaks in the mucosa around the lower oesophageal sphincter caused by forceful vomiting. Variceal bleeds cause large volume haematemesis. Boerhaave's syndrome is the rare condition of oesophageal rupture due to vomiting. It presents with chest pain, shock and pleural effusion. Gastric and duodenal ulcers may cause small volume haematemesis however the blood is more likely to be present from the beginning and 'coffee-ground' in colour due to reaction with gastric acid.
• 27
  A 22-year old woman presents with fatigue and weight loss. She gives a history of intermittent bloating, bloodless diarrhoea and abdominal cramps. Dermatitis herpetiformis is seen on her elbows. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Fatigue and weight loss in a woman
  a

  Crohn's disease

  b

  Coeliac’s disease

  c

  Whipple's disease

  d

  Ulcerative colitis

  e

  Hyperthyroidism
  Explanation: Dermatitis herpetiformis is a erythematous papulovesicular rash that is associated with Coeliac's disease. IBD can be diagnosed with barium enema or colonoscopy and may also cause haematochezia. Whipple's disease is caused by Tropheryma whippelli and begins with an arthralgia followed by GI symptoms, malabsorption and systemic infection (CNS and endocarditis). It is diagnosed by jejunal biopsy. Hyperthyroidism is unlikely to cause bloating and cramps though can cause her other symptoms.
• 28
  A 20-year old man presents weight loss. He has had diarrhoea and bloating for the last year. He admits to drinking excess alcohol and having multiple sexual partners. He has a microcytic hypochromic anaemia and anti-transglutaminase antibodies are negative with normal IgA levels. Colonoscopy with biopsy shows deep ulcers with non-caseating granulomas. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Weight loss and bloating in 20-year old man
  a

  Alcoholism

  b

  HIV-enteropathy

  c

  Coeliac’s disease

  d

  Crohn's disease

  e

  Ulcerative colitis
  Explanation: Crohn's typically presents with abdominal pain, diarrhoea (that may be bloody), weight loss and iron-deficiency anaemia. Crohn's is a granulomatous disease, causes transmural inflammation and can have skip lesions, in contrast with ulcerative colitis. Complications of Crohn's include: strictures and obstruction, fistulae and perforation. Alcohol dependency and HIV-enteropathy may present similarly but do not form granulomas. Coeliac's disease shows villous atrophy and crypt hyperplasia in the duodenum and may be anti-transglutaminase positive unless the patient has IgA deficiency.
• 29
  Which of the following is not a complication of acute liver failure (ALF)?
  Difficulty: Easy     Topic: Acute liver failure
  a

  Renal failure

  b

  Raised intracranial pressure

  c

  Respiratory failure

  d

  Sepsis

  e

  Ketoacidosis
  Explanation: Ketoacidosis occurs due to hepatic metabolism of lipids. It is a feature of untreated type 1 diabetes and alcohol toxicity. ALF results in hepato-renal syndrome, which is a very severe form of pre-renal failure in the setting of ascites. Cerebral oedema occurs in ALF. Pulmonary oedema and pleural effusions a complications of ALF. Infection is common cause of death in ALF, which may include spontaneous bacterial peritonitis.
• 30
  A previously well medical student returns from their elective in Belize with pyrexia, right upper quadrant pain and dark urine. They deny any sexual activity or drug use. ALT = 869IU/L. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Hepatitis viruses
  a

  Hepatitis A virus (HAV) infection

  b

  Hepatitis B virus (HBV) infection

  c

  Hepatitis C virus (HCV) infection

  d

  Hepatitis D virus (HDV) infection

  e

  Hepatitis E virus (HEV) infection
  Explanation: HAV has faeco-oral transmission and is endemic in many countries including South America, it can cause an ALT of >1000IU/L. HBV can cause acute hepatitis but is transmitted by body fluids. HCV is almost exclusively transmitted by blood (mostly IVDU) but does not cause acute hepatitis. HDV can only infect in presence of HBV. HEV is similar to HAV but much less common therefore HAV is more likely.
• 31
  A 30-year old man presents 1 week with profuse watery diarrhoea with blood mixed in. He recently returned from a holiday to Portugal. What is the most likely diagnosis?
  Difficulty: Hard     Topic: Profuse watery diarrhoea
  a

  Diverticulitis

  b

  Shigella dysenteriae

  c

  Clostridium difficile

  d

  Bacillus cereus

  e

  Yersinia enterocolitica
  Explanation: Shigella is an infectious cause of bloody diarrhoea as well enterohaemorrhagic E. coli. Diverticulitis may cause similar symptoms but is unlikely due to the age of the patient. C. difficile may cause bloody diarrhoea however it is preceding by a history of antibiotic treatment. Bacillus and Yersinia typically cause watery diarrhoea.