1 / 3 question 51-53 of 147

1 / 3 Question 51-53 of 147

Theme: Thyroid neoplasms

A. Follicular carcinoma

B. Follicular adenoma

C. Papillary carcinoma

D. Papillary adenoma

E. Anaplastic carcinoma

F. Medullary carcinoma Please select the most likely underlying diagnosis for the thyroid masses described. Each option may be used once, more than once or not at all.

51. A 78 year old lady presents to the surgical clinic with symptoms of both dysphagia and

dyspnoea. On examination there is a large mass in the neck that moves on swallowing. CT

scanning of the neck shows a locally infiltrative lesion arising from the thyroid and

invading the strap muscles.

You answered Follicular carcinoma

The correct answer is Anaplastic carcinoma

Marked local invasion is a feature of anaplastic carcinoma. These tumours are more

common in elderly females.

52. A 25 year old female presents with a lump in her neck. On examination she has a discrete

nodule in the right lobe of the thyroid. A fine needle aspirate shows papillary cells. An

adjacent nodule is also sampled which shows similar well differentiated papillary cells.

You answered Follicular adenoma

The correct answer is Papillary carcinoma

Multifocal disease is a recognised feature of papillary lesions. Papillary adenomas are not

really recognised and most well differentiated lesions are papillary carcinomas.

53. A 45 year old man presents with a fracture of his right humerus. On examination there is a

lytic lesion of the proximal humerus and a mass in the neck, this moves on swallowing.

Follicular carcinoma

Follicular carcinomas are a recognised source of bone metastasis. Up to 60% will show

vascular invasion histologically.

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Thyroid neoplasms

Lesion Common features

Follicular adenoma

Usually present as a solitary thyroid nodule

Malignancy can only be excluded on formal histological assessment

Papillary

carcinoma

Usually contain a mixture of papillary and colloidal filled follicles

Histologically tumour has papillary projections and pale empty nuclei

Seldom encapsulated

Lymph node metastasis predominate

Haematogenous metastasis rare

Account for 60% of thyroid cancers

Follicular

carcinoma

May appear macroscopically encapsulated, microscopically capsular

invasion is seen. Without this finding the lesion is a follicular adenoma.

Vascular invasion predominates

Multifocal disease rare

Account for 20% of all thyroid cancers

Anaplastic

carcinoma

Most common in elderly females

Local invasion is a common feature

Account for 10% of thyroid cancers

Treatment is by resection where possible, palliation may be achieved

through isthmusectomy and radiotherapy. Chemotherapy is ineffective.

Medullary

carcinoma

Tumours of the parafollicular cells (C Cells)

C cells derived from neural crest and not thyroid tissue

Serum calcitonin levels often raised

Familial genetic disease accounts for up to 20% cases

Both lymphatic and haematogenous metastasis are recognised, nodal

http://emrcs.com/question/question.php?q=0#left-panel

Lesion Common features

disease is associated with a very poor prognosis.

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Question 54 of 147

Which of these lesions is most closely associated with Barretts oesophagus?

Squamous cell carcinoma

Gastro intestinal stromal tumours

Carcinoid tumours

Leiomyosarcoma

Adenocarcinoma

Theme from September 2014 Exam Barretts oesophagus is most closely associated with adenocarcinoma, and it confers a 30 fold increased risk of developing the condition. Please rate this question:


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Oesophageal cancer

Incidence is increasing

In most cases in the Western world this increase is accounted for by a rise in the number of cases of adenocarcinoma. In the UK adenocarcinomas account for 65% of cases.

Barretts oesophagus is a major risk factor for most cases of oesophageal adenocarcinoma. In other regions of the world squamous cancer is more common and is linked to smoking,

alcohol intake, diets rich in nitrosamines and achalasia.

Surveillance of Barretts is important, as it imparts a 30 fold increase in cancer risk and if invasive malignancy is diagnosed early then survival may approach 85% at 5 years.

Diagnosis

Upper GI endoscopy is the first line test

Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours


Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary

If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound.

Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.

Treatment

Operable disease is best managed by surgical resection. The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis. The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage. In addition to surgical resection many patients will be treated with adjuvant chemotherapy.

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Question 55 of 147

A 56 year old man presents with epigastric discomfort and episodes of migratory thrombophlebitis. On examination he is mildly jaundiced. A CT scan shows peri hilar lymphadenopathy and a mass in the pancreatic head. Which of the following is the most likely underlying diagnosis?

Squamous cell carcinoma of the pancreas

Adenocarcinoma of the pancreas

Insulinoma

Glucagonoma

Gastrinoma

Adenocarcinoma of the pancreas is the most likely diagnosis and migratory thrombophlebitis is associated with the condition. Squamous cells carcinoma is extremely uncommon in the pancreas. Gastrinoma are extremely rare and thus not the most likely diagnosis. Please rate this question:


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Pancreatic cancer

Adenocarcinoma Risk factors: Smoking, diabetes, adenoma, familial adenomatous polyposis Mainly occur in the head of the pancreas (70%)

Spread locally and metastasizes to the liver Carcinoma of the pancreas should be differentiated from other periampullary tumours with

better prognosis

Clinical features

Weight loss

Painless jaundice Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late feature)


Pancreatitis Trousseau's sign: migratory superficial thrombophlebitis

Investigations

USS: May miss small lesions CT Scanning (pancreatic protocol). If unresectable on CT then no further staging needed PET/CT for those with operable disease on CT alone ERCP/ MRI for bile duct assessment

Staging laparoscopy to exclude peritoneal disease

Management

Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques include pylorus preservation and SMA/ SMV resection

Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable Usually adjuvent chemotherapy for resectable disease ERCP and stent for jaundice and palliation Surgical bypass may be needed for duodenal obstruction

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Question 56 of 147

What is the urinary diagnostic marker for carcinoid syndrome?

B-HCG

Histamine

Chromogranin A

5-Hydroxyindoleacetic acid

5-Hydroxytryptamine

Urinary measurement of 5- HIAA is an important part of clinical follow up. Please rate this question:


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Carcinoid syndrome

Carcinoid tumours secrete serotonin Originate in neuroendocrine cells mainly in the intestine (midgut-distal ileum/appendix) Can occur in the rectum, bronchi Hormonal symptoms mainly occur when disease spreads outside the bowel

Clinical features

Onset: insidious over many years Flushing face Palpitations

Pulmonary valve stenosis and tricuspid regurgitation causing dyspnoea Asthma Severe diarrhoea (secretory, persists despite fasting)


Investigation

5-HIAA in a 24-hour urine collection Somatostatin receptor scintigraphy

CT scan Blood testing for chromogranin A

Treatment

Octreotide

Surgical removal

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Question 57 of 147

A 22 year old man presents with symptoms of headache, lethargy and confusion. On examination he is febrile and has a right sided weakness. A CT scan shows a ring enhancing lesion affecting the left motor cortex. Which of the following is the most likely diagnosis?

Arteriovenous malformation

Cerebral abscess

Herpes simplex encephalitis

Metastatic renal adenocarcinoma

Glioblastoma multiforme

The combination of rapidly progressive neurology, fever and headache is highly suggestive of cerebral abscess. CT scanning will show a ring enhancing lesion because the intravenous contrast cannot penetrate the centre of the abscess cavity. HSV encephalitis does not produce ring enhancing lesions. Please rate this question:


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Brain abscess

CNS abscesses may result from a number of causes including, extension of sepsis from middle ear or sinuses, trauma or surgery to the scalp, penetrating head injuries and embolic events from endocarditis.

The presenting symptoms will depend upon the site of the abscess (those in critical areas e.g.motor cortex) will present earlier. Abscesses have a considerable mass effect in the brain and raised intra cranial pressure is common.

Although fever, headache and focal neurology are highly suggestive of a brain abscess the absence of one or more of these does not exclude the diagnosis, fever may be absent and even if present, is usually not the swinging pyrexia seen with abscesses at other sites.

Assessment of the patient includes imaging with CT scanning. Treatment is usually surgical, a craniotomy is performed and the abscess cavity debrided.

The abscess may reform because the head is closed following abscess drainage.


Question 58 of 147

A 56 year old man from Egypt has suffered from recurrent attacks of haematuria for many years. He presents with suprapubic discomfort and at cystoscopy is found to have a mass lesion within the bladder. What is the most likely diagnosis?

Squamous cell carcinoma

Transitional cell papilloma

Adenocarcinoma

Leiomyosarcoma

Rhabdomyosarcoma

Theme from April 2016 exam In Egypt, Schistosomiasis is more common than in the UK and may cause recurrent episodes of haematuria. In those affected with the condition who develop a bladder neoplasm, an SCC is the most common type. Please rate this question:


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Bladder cancer

Bladder cancer is the second most common urological cancer. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder inflammation arising from Schistosomiasis infection remains a common cause of squamous cell carcinomas, in those countries where the disease is endemic. Benign tumours

Benign tumours of the bladder including inverted urothelial papilloma and nephrogenic adenoma are uncommon. Bladder malignancies


Transitional cell carcinoma (>90% of cases) Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis) Adenocarcinoma (2%)

Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of "field change" within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are usually superficial in location and accordingly have a better prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or higher) risk of regional or distant lymph node metastasis. TNM Staging

Stage Description

T0 No evidence of tumour

Ta Non invasive papillary carcinoma

T1 Tumour invades sub epithelial connective tissue

T2a Tumor invades superficial muscularis propria (inner half)

T2b Tumor invades deep muscularis propria (outer half)

T3 Tumour extends to perivesical fat

T4 Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina

T4a Invasion of uterus, prostate or bowel

T4b Invasion of pelvic sidewall or abdominal wall

N0 No nodal disease

Stage Description

N1 Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external

iliac, or presacral lymph node)

N2 Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)

N3 Lymph node metastasis to the common iliac lymph nodes

M0 No distant metastasis

M1 Distant disease

Presentation Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection excluded). Staging Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT. Treatment

Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy. Prognosis

T1 90%

T2 60%

T3 35%

T4a 10-25%

Any T, N1-N2 30%

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Question 59 of 147

A newborn infant is noted to have a unilateral cleft lip only. What is the most likely explanation for this process?

Incomplete fusion of the second branchial arch

Incomplete fusion of the nasolabial muscle rings

Incomplete fusion of the first branchial arch

Incomplete fusion of the third branchial arch

Incomplete fusion of the secondary palate

Theme from April 2012 Exam Unilateral isolated cleft lip represents a failure of nasolabial ring fusion. It is not related to branchial arch fusion. Arch disorders have a far more profound phenotype and malformation sequences. Please rate this question:


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Cleft lip and palate

Cleft lip and palate are the most common congenital deformity affecting the orofacial structures. Whilst they may be an isolated developmental malformation they are also a recognised component of more than 200 birth defects. The incidence is as high as 1 in 600 live births. The commonest variants are:

Isolated cleft lip (15%)

Isolated cleft palate (40%) Combined cleft lip and palate (45%)

The aetiology of the disorder is multifactorial; both genetic (affected first degree relative increases risk) and environmental factors play a role. Cleft lip

Cleft lip occurs as a result of disruption of the muscles of the upper lip and nasolabial region. These


muscles comprise a chain of muscles viz; nasolabial, bilabial and labiomental. Defects may be unilateral or bilateral. Cleft palate The primary palate consists of all anatomical structures anterior to the incisive foramen. The secondary palate lies more posteriorly and is sub divided into the hard and soft palate. Cleft palate occurs as a result of non fusion of the two palatine shelves. Both hard and soft palate may be involved. Complete cases are associated with complete separation of the nasal septum and vomer from the palatine processes. Treatment Surgical reconstruction is the mainstay of management. The procedures are planned according to the extent of malformation and child age. Simple defects are managed as a single procedure. Complex malformations are usually corrected in stages. Affected individuals have a higher incidence of hearing and speech problems.

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Question 60 of 147

A 72 year old woman with back pain and chronic renal failure has the following blood test results:

Reference range

Ca2+ 2.03 2.15-2.55 mmol/l

Parathyroid hormone 10.4 1-6.5 pmol/l

Phosphate 0.80 0.6-1.25 mmol/l

What is the most likely diagnosis?

Hypoparathyroidism

Primary hyperparathyroidism

Secondary hyperparathyroidism

Tertiary hyperparathyroidism

Pseudohypoparathyroidism

In relation to secondary hyperparathyroidism; there is a HIGH PTH and the Ca2+ is NORMAL or LOW. In secondary hyperparathyroidism there is hyperplasia of the parathyroid glands in response to chronic hypocalcaemia (or hyperphosphataemia) and is a normal physiological response. Calcium is released from bone, kidneys and the gastrointestinal system. Please rate this question:


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Parathyroid glands and disorders of calcium metabolism


Hyperparathyroidism

Disease type Hormone profile Clinical features Cause

Primary

hyperparathyroidism

PTH (Elevated)

Ca2+(Elevated)

Phosphate (Low)

Urine calcium :

creatinine clearance

ratio > 0.01

May be

asymptomatic if

mild

Recurrent

abdominal pain

(pancreatitis, renal

colic)

Changes to

emotional or

cognitive state

Most cases due to

solitary adenoma

(80%), multifocal

disease occurs in 10-

15% and parathyroid

carcinoma in 1% or

less

Secondary

hyperparathyroidism

PTH (Elevated)

Ca2+ (Low or

normal)

Phosphate

(Elevated)

Vitamin D levels

(Low)

May have few

symptoms

Eventually may

develop bone

disease, osteitis

fibrosa cystica and

soft tissue

calcifications

Parathyroid gland

hyperplasia occurs as

a result of low

calcium, almost

always in a setting of

chronic renal failure

Tertiary

hyperparathyroidism

Ca2+(Normal or

high)

PTH (Elevated)

Phosphate levels

(Decreased or

Normal)

Vitamin D (Normal

or decreased)

Alkaline

phosphatase

(Elevated)

Metastatic

calcification

Bone pain and /

or fracture

Nephrolithiasis

Pancreatitis

Occurs as a result of

ongoing hyperplasia

of the parathyroid

glands after

correction of

underlying renal

disorder, hyperplasia

of all 4 glands is

usually the cause

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 (urine 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

Allow 12 months to elapse following transplant as many cases will resolve 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 Endocrinol 2011; 2011: 251410.

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1 / 3 Question 61-63 of 147

Theme: Pharyngitis

A. Infectious mononucleosis

B. Acute bacterial tonsillitis

C. Quinsy

D. Lymphoma

E. Diptheria Please select the most likely underlying cause for the following patients presenting with pharyngitis. Each option may be used once, more than once or not at all.

61. An 8 year old child presents with enlarged tonsils that meet in the midline and are covered

with a white film that bleeds when you attempt to remove it. He is pyrexial but otherwise

well.

You answered Infectious mononucleosis

The correct answer is Acute bacterial tonsillitis

Theme from April 2012 Exam

In acute tonsillitis the tonsils will often meet in the midline and may be covered with a

membrane. Individuals who are systemically well are unlikely to have diptheria.

62. A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal

examination confirms this finding and you also notice peticheal haemorrhages affecting

the oropharynx. On systemic examination he is noted to have splenomegaly.

Infectious mononucleosis

A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics

containing penicillin may produce a rash when given in this situation, leading to a

mistaken label of allergy.

63. A 19 year old man has had a sore throat for the past 5 days. Over the past 24 hours he has

notices increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial

and on examination he is noted to have a swelling of this area.

You answered Infectious mononucleosis

The correct answer is Quinsy

Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually

produces prompt resolution of symptoms.



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Acute tonsillitis

Characterised by pharyngitis, fever, malaise and lymphadenopathy. Over half of all cases are bacterial with Streptococcus pyogenes the most common organism The tonsils are typically oedematous and yellow or white pustules may be present

Infectious mononucleosis may mimic the condition. Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis. Bacterial tonsillitis may result in local abscess formation (quinsy)

Acute streptococcal tonsillitis


Image sourced from Wikipedia

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http://en.wikipedia.org/wiki/Tonsillitis

http://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb089b.jpg


Question 64 of 147

A 4 year old boy is brought to the clinic by his mother who has noticed a small lesion at the external

angle of his eye. On examination there is a small cystic structure which has obviously been recently

infected. On removal of the scab, there is hair visible within the lesion. What is the most likely

diagnosis?

Dermoid cyst

Desmoid cyst

Sebaceous cyst

Epidermoid cyst

Keratoacanthoma

Dermoid cysts occur at sites of embryonic fusion and may contain multiple cell types. They occur

most often in children.

The lesion is unlikely to be a desmoid cyst as these are seldom located either at this site or in this

age group. In addition they do not contain hair. Sebaceous cysts will usually have a punctum and

contain a cheesy material. Epidermoid cysts contain keratin plugs.



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Dermoid cysts


A cutaneous dermoid cyst may develop at sites of embryonic developmental fusion. They are most

common in the midline of the neck, external angle of the eye and posterior to the pinna of the ear.

They typically have multiple inclusions such as hair follicles that bud out from its walls. They may

develop at other sites such as the ovary and in these sites are synonymous with teratomas.

A desmoid tumour is a completely different entity and may be classified either as low grade

fibrosarcomas or non aggressive fibrous tumours. They commonly present as large infiltrative

masses. They may be divided into abdominal, extra abdominal and intra abdominal. All types share

the same biological features. Extra abdominal desmoids have an equal sex distribution and primarily

arise in the musculature of the shoulder, chest wall, back and thigh. Abdominal desmoids usually

arise in the musculoaponeurotic structures of the abdominal wall. Intra abdominal desmoids tend to

occur in the mesentery or pelvic side walls and occur most frequently in patients with familial

adenomatous polyposis coli syndrome.

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Question 65 of 147

Which of the following tumours are most likely to give rise to para-aortic nodal metastasis early?

Ovarian

Bladder

Rectal

Caecal

Cervical

Theme from 2009 Exam Ovarian tumours are supplied by the ovarian vessels, these branch directly from the aorta. The cervix drains to the internal and external iliac nodes. Please rate this question:


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Para-aortic lymphadenopathy

Organ sites that may metastasise (early) to the para-aortic lymph nodes:

Testis

Ovary Uterine fundus

Many other organs may result in para-aortic nodal disease. However, these deposits will represent a much later stage of the disease, since other nodal stations are involved earlier.

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Question 66 of 147

Which of the following statements relating to malignant mesothelioma is false?

It may be treated by extrapleural pneumonectomy.

It is linked to asbestos exposure.

It is linked to cigarette smoking independent of asbestos exposure.

It may occur intra abdominally.

It is relatively resistant to radiotherapy

It is not linked to cigarette smoking. When identified at an early stage a radical resection is the favored option. Radiotherapy is often given perioperatively. However, it is not a particularly radiosensitive tumour. Combination chemotherapy gives some of the best results and most regimes are cisplatin based. Please rate this question:


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Occupational cancers

Occupational cancers accounted for 5.3% cancer deaths in 2005. In men the main cancers include:

Mesothelioma Bladder cancer Non melanoma skin cancer Lung cancer

Sino nasal cancer

Occupations with high levels of occupational tumours include:


Construction industry Working with coal tar and pitch Mining Metalworkers

Working with asbestos (accounts for 98% of all mesotheliomas) Working in rubber industry

Shift work has been linked to breast cancer in women (Health and safety executive report RR595). The latency between exposure and disease is typically 15 years for solid tumours and 20 for leukaemia. Many occupational cancers are otherwise rare. For example sino nasal cancer is an uncommon tumour, 50% will be SCC. They are linked to conditions such as wood dust exposure and unlike lung cancer is not strongly linked to cigarette smoking. Another typical occupational tumour is angiosarcoma of the liver which is linked to working with vinyl chloride. Again in the non occupational context this is an extremely rare sporadic tumour.

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2 / 3 Question 67-69 of 147

Theme: Thyroid disorders

A. Sick euthyroid

B. Hyperthyroidism

C. Hypothyroidism

D. Normal euthyroid

E. Anxiety state

F. Factitious hyperthyroidism For each of the scenarios please match the scenario with the most likely underlying diagnosis. Each answer may be used once, more than once or not at all.

67. A 33 year old man is recovering following a protracted stay on the intensive care unit

recovering from an anastomotic leak following a difficult trans hiatal oesophagectomy. His

progress is slow, and the intensive care doctors receive the following thyroid function test

results:

TSH 1.0 u/L

Free T4 8

T3 1.0 (1.2-3.1 normal)

Sick euthyroid


Sick euthyroid syndrome is caused by systemic illness. With this, the patient may have an

apparently low total and free T4 and T3, with a normal or low TSH. Note that the levels

are only mildly below normal.

68. A 28 year old female presents to the general practitioner with symptoms of fever and

diarrhoea. As part of her diagnostic evaluation the following thyroid function tests are

obtained:

TSH < 0.01

Free T4 30

T3 4.0

Hyperthyroidism

The symptoms are suggestive of hyperthyroidism. This is supported by the abnormal blood

results; suppressed TSH with an elevated T3 and T4.

69. A 19 year old lady presents with palpitations. The medical officer takes a blood sample for

thyroid function tests. The following results are obtained:

TSH > 6.0

Free T4 20

T3 2.0

You answered Sick euthyroid

The correct answer is Hypothyroidism

An elevated TSH with normal T4 indicates partial thyroid failure. This is caused by

Hashimotos, drugs (lithium, antithyroids) and dyshormogenesis.



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Hyperthyroidism

Causes of hyperthyroidism include:

Diffuse toxic goitre (Graves Disease)

Toxic nodular goitre Toxic nodule Rare causes

Graves disease Graves disease is characterised by a diffuse vascular goitre that appears at the same time as the clinical manifestations of hyperthyroidism. It is commonest in younger females and may be associated with eye signs. Thyrotoxic symptoms will predominate. Up to 50% of patients will have a familial history of autoimmune disorders. The glandular hypertrophy and hyperplasia occur as a result of the thyroid stimulating effects of the TSH receptor antibodies.


Toxic nodular goitre In this disorder the goitre is present for a long period of time prior to the development of clinical symptoms. In most goitres the nodules are inactive and in some cases it is the internodular tissue that is responsible for the hyperthyroidism. Toxic nodule Overactive, autonomously functioning nodule. It may occur as part of generalised nodularity or be a true toxic adenoma. The TSH levels are usually low as the autonomously functioning thyroid tissue will exert a negative feedback effect. Signs and symptoms

Symptoms Signs

Lethargy Tachycardia

Emotionally labile Agitation

Heat intolerance Hot, moist palms

Weight loss Exopthalmos

Excessive appetite Thyroid goitre and bruit

Palpitations Lid lag/retraction

Diagnosis The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH level of <0.5U/L suggests hyperthyroidism. TSH receptor antibodies may be tested for in the diagnosis of Graves. Treatment

First line treatment for Graves disease is usually medical and the block and replace regime is the favored option. Carbimazole is administered at higher doses and thyroxine is administered orally. Patient are maintained on this regime for between 6 and 12 months. Attempts are then made to wean off medication. Where relapse then occurs the options are between ongoing medical therapy, radioiodine or surgery.

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Question 70 of 147

Which of the following conditions is least likely to exhibit the Koebner phenomenon?

Vitiligo

Molluscum contagiosum

Lichen planus

Psoriasis

Lupus vulgaris

Lupus vulgaris is not associated with the Koebner phenomenon. Please rate this question:


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Koebner phenomenon

The Koebner phenomenon describes skin lesions which appear at the site of injury. It is seen in:

Psoriasis

Vitiligo Warts Lichen planus Lichen sclerosus

Molluscum contagiosum

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Question 71 of 147

Which of the tumour types listed below is found most frequently in a person with aggressive

fibromatosis?

Medullary thyroid cancer

Basal cell carcinoma of the skin

Desmoid tumours

Dermoid tumours

Malignant melanoma



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Aggressive fibromatosis

Aggressive fibromatosis is a disorder consisting of desmoid tumours, which behave in a locally

aggressive manner. Desmoid tumours may be identified in both abdominal and extra-abdominal

locations. Metastatic disease is rare. The main risk factor (for abdominal desmoids) is having APC

variant of familial adenomatous polyposis coli. Most cases are sporadic.

Treatment is by surgical excision.

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Question 72 of 147

A 20 year old man is suspected of having an inflamed Meckels diverticulum. At which of the following locations is it most likely to be found?

Approximately 60 cm distal to the ileo-caecal valve

Approximately 60 cm proximal to the ileocaecal valve

Approximately 200cm distal to the ileocaecal valve

Approximately 200cm proximal to the ileocaecal valve

50cm distal to the DJ flexure

Rule of 2's 2% of population 2 inches (5cm) long 2 feet (60 cm) from the ileocaecal valve 2 x's more common in men 2 tissue types involved

They are typically found 2 feet proximal to the ileocaecal valve (or approximately 60cm). Please rate this question:


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Meckel's diverticulum

Congenital abnormality resulting in incomplete obliteration of the vitello-intestinal duct Normally, in the foetus, there is an attachment between the vitello-intestinal duct and the yolk

sac.This disappears at 6 weeks gestation.

The tip is free in majority of cases. Associated with enterocystomas, umbilical sinuses, and omphaloileal fistulas. Arterial supply: omphalomesenteric artery. 2% of population, 2 inches long, 2 feet from the ileocaecal valve. Typically lined by ileal mucosa but ectopic gastric mucosa can occur, with the risk of peptic

ulceration. Pancreatic and jejunal mucosa can also occur.


Clinical

Normally asymptomatic and an incidental finding. Complications are the result of obstruction, ectopic tissue, or inflammation.

Removal if narrow neck or symptomatic. Options are between wedge excision or formal small bowel resection and anastomosis.

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Question 73 of 147

A 43 year old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?

Endovascular stent

Medical therapy with beta blockers

Medical therapy with ACE inhibitors

Sutured aortic repair

Aortic root replacement

Proximal aortic dissections are generally managed with surgical aortic root replacement. The proximal origin of the dissection together with chest pain (which may occur in all types of aortic dissection) raises concerns about the possibility of coronary ostial involvement (which precludes stenting). There is no role for attempted suture repair in this situation. Please rate this question:


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Aortic dissection

More common than rupture of the abdominal aorta 33% of patients die within the first 24 hours, and 50% die within 48 hours if no treatment

received Associated with hypertension Features of aortic dissection: tear in the intimal layer, followed by formation and propagation

of a subintimal hematoma. Cystic medial necrosis (Marfan's)

Most common site of dissection: 90% occurring within 10 centimetres of the aortic valve

Stanford Classification

Type Location Treatment


Type Location Treatment

A Ascending aorta/ aortic root Surgery- aortic root replacement

B Descending aorta Medical therapy with antihypertensives

DeBakey classification

Type Site affected

I Ascending aorta, aortic arch, descending aorta

II Ascending aorta only

III Descending aorta distal to left subclavian artery

Clinical features

Tearing, sudden onset chest pain (painless 10%)

Hypertension or Hypotension A blood pressure difference (in each arm) greater than 20 mm Hg Neurologic deficits (20%)

Investigations

CXR: widened mediastinum, abnormal aortic knob, ring sign, deviation of the trachea/oesophagus

CT angiography of the thoracic aorta

MRI angiography Conventional angiography (now rarely used diagnostically)

Management

Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg

For type A dissections the standard of care is aortic root replacement

Question 74 of 147

A 45 year old lady presents with a pathological fracture of her femoral shaft. She is a poor historian, but it transpires that she underwent a thyroidectomy 1 year previously. She has no other illness or co-morbidities. What is the most likely underlying diagnosis?

Hyperparathyroidism

Metastatic papillary carcinoma of the thyroid

Metastatic medullary carcinoma of the thyroid

Metastatic follicular carcinoma of the thyroid

None of the above

Follicular carcinomas are a recognised cause of bone metastasis. Papillary lesions typically spread via the lymphatics. Please rate this question:


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Thyroid malignancy

Papillary carcinoma

Commonest sub-type

Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so

called 'orphan Annie' nuclei They typically metastasise via the lymphatics and thus laterally located apparently ectopic

thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma


Are less common than papillary lesions


Like papillary tumours, they may present as a discrete nodule. Although they appear to be well encapsulated macroscopically there is invasion on microscopic evaluation

Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate

Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy

Anaplastic carcinoma

Less common and tend to occur in elderly females Disease is usually advanced at presentation and often only palliative decompression and

radiotherapy can be offered.

Medullary carcinoma

These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin. The serum calcitonin may be elevated which is of use when monitoring for recurrence.

They may be familial and occur as part of the MEN -2A disease spectrum. Spread may be either lymphatic or haematogenous and as these tumours are not derived

primarily from thyroid cells they are not responsive to radioiodine.

Lymphoma

These respond well to radiotherapy

Radical surgery is unnecessary once the disease has been diagnosed on biopsy material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

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Question 75-77 of 147

Theme: Cardiac murmurs

A. Pulmonary stenosis

B. Mitral regurgitation

C. Tricuspid regurgitation

D. Aortic stenosis

E. Mitral stenosis

F. Aortic sclerosis

What is the most likely cause of the cardiac murmur in the following patients? Each option may be

used once, more than once or not at all.

75. A 35 year old Singaporean female attends a varicose vein pre operative clinic. On auscultation a

mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the

left lateral position.

You answered Pulmonary stenosis

The correct answer is Mitral stenosis

Theme from September 2011 exam

A mid diastolic murmur at the apex is a classical description of a mitral stenosis murmur. The

most common cause is rheumatic heart disease. Complications of mitral stenosis include atrial

fibrillation, stroke, myocardial infarction and infective endocarditis.

76. A 22 year old intravenous drug user is found to have a femoral abscess. The nursing staff contact

the on call doctor as the patient has a temperature of 39oC. He is found to have a pan systolic

murmur loudest at the left sternal edge at the 4th intercostal space.


The correct answer is Tricuspid regurgitation

Intravenous drug users are at high risk of right sided cardiac valvular endocarditis. The character

of the murmur fits with a diagnosis of tricuspid valve endocarditis.

77. An 83 year old woman is admitted with a left intertrochanteric neck of femur fracture. On

examination the patient is found to have an ejection systolic murmur loudest in the aortic region.

There is no radiation of the murmur to the carotid arteries. Her ECG is normal.


The correct answer is Aortic sclerosis

The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of aortic stenosis,

however as there is no radiation of the murmur to the carotids and the ECG is normal, this is less

likely.



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Cardiac murmurs

Type of Murmur Conditions

Ejection systolic Aortic stenosis

Pulmonary stenosis, HOCM

ASD, Fallot's


Pan-systolic Mitral regurgitation

Tricuspid regurgitation

VSD

Late systolic Mitral valve prolapse

Coarctation of aorta

Early diastolic Aortic regurgitation

Graham-Steel murmur (pulmonary regurgitation)

Mid diastolic Mitral stenosis

Austin-Flint murmur (severe aortic regurgitation)

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Question 78 of 147

A 55 year old lady presents with discomfort in the right breast. On clinical examination a small lesion

is identified and clinical appearances suggest fibroadenoma. Imaging confirms the presence of a

fibroadenoma alone. A core biopsy is taken, this confirms the presence of the fibroadenoma.

However, the pathologist notices that a small area of lobular carcinoma in situ is also present in the

biopsy. What is the best management?

Whole breast irradiation

Simple mastectomy

Mastectomy and sentinal lymph node biopsy

Wide local excision and sentinel lymph node biopsy

Breast MRI scan

Lobular carcinoma in situ has a low association with invasive malignancy. It is seldom associated

with microcalcification and therefore MRI is the best tool for determining disease extent. Resection of

in situ disease is not generally recommended and most surgeons would simply pursue a policy of

close clinical and radiological follow up.



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Lobular carcinoma of the breast

Lobular breast cancers are less common than their ductal counterparts. They typically present

differently, the mass is usually more diffuse and less obvious on the usual imaging modalities of

ultrasound and mammography. This is significant since the disease may be understaged resulting in


inadequate treatment when wide local excision is undertaken.

In women with invasive lobular carcinoma it is usually safest to perform an MRI scan of the breast, if

breast conserving surgery is planned.

Lobular carcinomas are also more likely to be multifocal and metastasise to the contralateral breast.

Lobular carcinoma in situ is occasionally diagnosed incidentally on core biopsies. Unlike DCIS,

lobular carcinoma in situ is far less strongly associated with foci of invasion and is usually managed

by close monitoring.

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Question 79 of 147

Which one of the following may be associated with an increased risk of venous thromboembolism?

Diabetes

Cannula

Hyperthyroidism

Tamoxifen

Amiodarone

Consider thromboembolism in breast cancer patients on tamoxifen! Please rate this question:


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Venous thromboembolism: risk factors

Common predisposing factors include malignancy, pregnancy and the period following an operation. The comprehensive list below is partly based on the 2010 SIGN venous thromboembolism (VTE) guidelines: General

increased risk with advancing age obesity family history of VTE pregnancy (especially puerperium)

immobility hospitalisation anaesthesia central venous catheter: femoral >> subclavian

Underlying conditions


malignancy thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency heart failure antiphospholipid syndrome

Behcet's polycythaemia nephrotic syndrome sickle cell disease paroxysmal nocturnal haemoglobinuria hyperviscosity syndrome

homocystinuria

Medication

combined oral contraceptive pill: 3rd generation more than 2nd generation

hormone replacement therapy raloxifene and tamoxifen antipsychotics (especially olanzapine) have recently been shown to be a risk factor

SIGN also state that the following are risk factors for recurrent VTE:

previous unprovoked VTE

male sex obesity thrombophilias

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Question 80 of 147

A 42 year old lady is investigated for symptoms of irritability and altered bowel habit. On examination she is noted to have a smooth enlargement of the thyroid gland. As part of her investigations thyroid function tests are requested, these are as follows:

TSH 0.1 mug/l

Free T4 35 pmol/l

The most likely underlying diagnosis is:

Multinodular goitre

Follicular carcinoma of the thyroid gland

Graves disease

Pregnancy

None of the above

TSH receptor antibodies will cause stimulation of the thyroid to synthesise T4. However, this will have a negative feedback effect on the pituitary causing decrease in TSH levels. Where hyperthyroidism occurs secondary to pregnancy the TSH is typically elevated. Please rate this question:


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Thyroid disease

Patients may present with a number of different manifestations of thyroid disease. They can be broadly sub classified according to whether they are euthyroid or have clinical signs of thyroid dysfunction. In addition it needs to be established whether they have a mass or not. Assessment


History Examination including USS If a nodule is identified then it should be sampled ideally via an image guided fine needle

aspiration

Radionucleotide scanning is of limited use

Thyroid Tumours

Papillary carcinoma

Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Lymphoma's

Multinodular goitre

One of the most common reasons for presentation Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they

can be reassured. In those with compressive symptoms surgery is required and the best operation is a total

thyroidectomy. Sub total resections were practised in the past and simply result in recurrent disease that

requires a difficult revisional resection.

Endocrine dysfunction

In general these patients are managed by physicians initially.

Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).

Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis, however, with time the toxic phase passes and patients can simply be managed with thyroxine.

Complications following surgery

Anatomical such as recurrent laryngeal nerve damage. Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory

compromise owing to laryngeal oedema.

Damage to the parathyroid glands resulting in hypocalcaemia.

Further sources of information

1. http://www.acb.org.uk/docs/TFTguidelinefinal.pdf- Association of Clinical Biochemistry guidelines for thyroid function tests. 2. British association of endocrine surgeons website- http://www.baets.org.uk

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Question 81 of 147

Which of the following is not a risk factor for developing tuberculosis?

Gastrectomy

Solid organ transplantation with immunosupression

Intravenous drug use

Haematological malignancy

Amiodarone

Risk factors for developing active tuberculosis include:

silicosis

chronic renal failure HIV positive solid organ transplantation with immunosuppression intravenous drug use haematological malignancy

anti-TNF treatment previous gastrectomy



Next question

Tuberculosis

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis that most commonly affects the lungs. Understanding the pathophysiology of TB can be difficult - the key is to differentiate between primary and secondary disease. Primary tuberculosis

A non-immune host who is exposed to M. tuberculosis may develop primary infection of the lungs. A small lung lesion known as a Ghon focus develops. The Ghon focus is composed of tubercle-laden macrophages. The combination of a Ghon focus and hilar lymph nodes is known as a Ghon complex


In immunocompetent people the initial lesion usually heals by fibrosis. Those who are immunocompromised may develop disseminated disease (miliary tuberculosis). Secondary (post-primary) tuberculosis

If the host becomes immunocompromised the initial infection may become reactivated. Reactivation generally occurs in the apex of the lungs and may spread locally or to more distant sites. Possible causes of immunocomprise include:

immunosuppressive drugs including steroids HIV malnutrition

The lungs remain the most common site for secondary tuberculosis. Extra-pulmonary infection may occur in the following areas:

central nervous system (tuberculous meningitis - the most serious complication)

vertebral bodies (Pott's disease) cervical lymph nodes (scrofuloderma) renal gastrointestinal tract

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Question 82 of 147

Which of the following is not true of gastric cancer?

There is an association with blood group A

Adenocarcinoma is the most common subtype

Individuals with histological evidence of signet ring cells have a lower incidence of

lymph node metastasis

Lymphomas account for 5% cases

In Western Countries a more proximal disease distribution has been noted

Signet ring cells are features of poorly differentiated gastric cancer associated with a increased risk of metastatic disease. Please rate this question:


Next question

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

1

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

Type

2

Carcinoma of the cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at the oesophagogastric junction.

Type

3

Sub cardial cancers that spread across the junction. Involve similar nodal stations to

gastric cancer.

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 and any of the

following

Patients without

dyspepsia

Worsening dyspepsia

Chronic gastrointestinal bleeding Dysphagia Barretts oesophagus

Dysphagia Unexplained abdominal pain or weight loss

Intestinal metaplasia

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.

http://en.wikipedia.org/wiki/Gastric%20cancer



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 cancer 91%

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.

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Question 83 of 147

What is the most common presentation of a parotid gland tumour?

Parapharyngeal mass

Mass at anterior border of masseter

Mass inferior to the angle of the mandible

Mass behind the angle of the mandible

Mass anterior to the ear

Parotid tumours may present at any region in the gland. However, most lesions will be located behind the angle of the mandible, inferior to the ear lobe. Tumours of the deep lobe of the parotid may present as a parapharyngeal mass and large lesions may displace the tonsil. Please rate this question:


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Parotid gland malignancy

Most parotid neoplasms (80%) are benign lesions

Most commonly present with painless mass around the mandible Up to 30% may present with pain, when this is associated with a discrete mass lesion in the

parotid it usually indicates perineural invasion. Perineural invasion is very unlikely to occur in association with benign lesions 80% of patients with facial nerve weakness caused by parotid malignancies will have nodal

metastasis and a 5 year survival of 25%

Types of malignancy

Mucoepidermoid

carcinoma

30% of all parotid malignancies

Usually low potential for local invasiveness and metastasis (depends

mainly on grade)


Adenoid cystic

carcinoma

Unpredictable growth pattern

Tendency for perineural spread

Nerve growth may display skip lesions resulting in incomplete excision

Distant metastasis more common (visceral rather than nodal spread) 5 year survival 35%

Mixed tumours Often a malignancy occurring in a previously benign parotid lesion

Acinic cell carcinoma Intermediate grade malignancy

May show perineural invasion

Low potential for distant metastasis

5 year survival 80%

Adenocarcinoma Develops from secretory portion of gland

Risk of regional nodal and distant metastasis

5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement

Lymphoma Large rubbery lesion, may occur in association with Warthins tumours

Diagnosis should be based on regional nodal biopsy rather than parotid

resection Treatment is with chemotherapy (and radiotherapy)

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Question 84 of 147

A 52 year old male is referred to urology clinic with impotence. He is known to have hypertension.

He does not have any morning erections. On further questioning the patient reports pain in his

buttocks, this worsens on mobilising. On examination there is some muscle atrophy. The penis and

scrotum are normal. What is the most likely diagnosis?

Leriche syndrome

S3-S4 cord lesion

Pudendal nerve lesion

Psychological impotence

Beta blocker induced impotence

Leriche syndrome

Classically, it is described in male patients as a triad of symptoms:

1. Claudication of the buttocks and thighs

2. Atrophy of the musculature of the legs

3. Impotence (due to paralysis of the L1 nerve)

Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of

the iliac arteries. Management involves correcting underlying risk factors such as

hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.



Next question


Leriche syndrome

Atheromatous disease involving the iliac vessels. Blood flow to the pelvic viscera is compromised.

Patients may present with buttock claudication and impotence (in this particular syndrome).

Diagnostic work up will include angiography, where feasible, iliac occlusions are usually treated with

endovascular angioplasty and stent insertion.

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Question 85 of 147

A 23 year old man presents with diarrhoea and passage of mucous. He is suspected of having ulcerative colitis. Which of the following is least likely to be associated with this condition?

Superficial mucosal inflammation in the colon

Significant risk of dysplasia in long standing disease

Epsiodes of large bowel obstruction during acute attacks

Haemorrhage

Disease sparing the anal canal

Large bowel obstruction is not a feature of UC, patients may develop megacolon. However, this is a different entity both diagnostically and clinically. Ulcerative colitis does not affect the anal canal and the anal transitional zone. Inflammation is superficial. Dysplasia can occur in 2% overall, but increases significantly if disease has been present over 20 years duration. Granulomas are features of crohn's disease. Other features:

Disease maximal in the rectum and may spread proximally Contact bleeding Longstanding UC crypt atrophy and metaplasia/dysplasia



Next question

Ulcerative colitis

Ulcerative colitis is a form of inflammatory bowel disease. Inflammation always starts at rectum, does not spread beyond ileocaecal valve (although backwash ileitis may occur) and is continuous. The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years. It is less common in smokers.


The initial presentation is usually following insidious and intermittent symptoms. Features include:

bloody diarrhoea urgency tenesmus abdominal pain, particularly in the left lower quadrant

extra-intestinal features (see below)

Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are common. Extra-intestinal features include sclerosing cholangitis, iritis and ankylosing spondylitis.

Common to both Crohn's disease

(CD) and Ulcerative colitis (UC)

Notes

Related to

disease activity

Arthritis: pauciarticular, asymmetric

Erythema nodosum

Episcleritis

Osteoporosis

Arthritis is the most common extra-

intestinal feature in both CD and UC

Episcleritis is more common in

Crohns disease

Unrelated to

disease activity

Arthritis: polyarticular, symmetric

Uveitis

Pyoderma gangrenosum

Clubbing

Primary sclerosing cholangitis

Primary sclerosing cholangitis is

much more common in UC

Uveitis is more common in UC

Pathology

Red, raw mucosa, bleeds easily No inflammation beyond submucosa (unless fulminant disease) Widespread superficial ulceration with preservation of adjacent mucosa which has the

appearance of polyps ('pseudopolyps') Inflammatory cell infiltrate in lamina propria Neutrophils migrate through the walls of glands to form crypt abscesses Depletion of goblet cells and mucin from gland epithelium Granulomas are infrequent

Barium enema

Loss of haustrations Superficial ulceration, 'pseudopolyps' Long standing disease: colon is narrow and short -'drainpipe colon'

Endoscopy

Superficial inflammation of the colonic and rectal mucosa Continuous disease from rectum proximally

Superficial ulceration, mucosal islands, loss of vascular definition and continuous ulceration pattern.

Management

Patients with long term disease are at increased risk of development of malignancy

Acute exacerbations are generally managed with steroids, in chronic patients agents such as azathioprine and infliximab may be used

Individuals with medically unresponsive disease usually require surgery- in the acute phase a sub total colectomy and end ileostomy. In the longer term a proctectomy will be required. An ileoanal pouch is an option for selected patients

References Ford A et al. Ulcerative colitis. BMJ 2013 (346):29-34.

Next question

Question 86 of 147

A 23 year old lady undergoes a total thyroidectomy as treatment for a papillary carcinoma of the thyroid. The pathologist examines histological sections of the thyroid gland and identifies a psammoma body. What are these primarily composed of?

Clusters of calcification

Aggregations of neutrophils

Aggregations of macrophages

Giant cells surrounding the tumour

Clusters of oxalate crystals

Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in papillary carcinomas. Please rate this question:


Next question

Thyroid malignancy

Papillary carcinoma

Commonest sub-type

Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so

called 'orphan Annie' nuclei They typically metastasise via the lymphatics and thus laterally located apparently ectopic

thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma


Are less common than papillary lesions


Like papillary tumours, they may present as a discrete nodule. Although they appear to be well encapsulated macroscopically there is invasion on microscopic evaluation

Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate

Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy

Anaplastic carcinoma

Less common and tend to occur in elderly females Disease is usually advanced at presentation and often only palliative decompression and

radiotherapy can be offered.

Medullary carcinoma

These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin. The serum calcitonin may be elevated which is of use when monitoring for recurrence.

They may be familial and occur as part of the MEN -2A disease spectrum. Spread may be either lymphatic or haematogenous and as these tumours are not derived

primarily from thyroid cells they are not responsive to radioiodine.

Lymphoma

These respond well to radiotherapy

Radical surgery is unnecessary once the disease has been diagnosed on biopsy material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

Next question

Question 87 of 147

A 52 year old woman attends clinic for investigation of abdominal pain and constipation. On examination you note blue lines on the gum margin. She mentions that her legs have become weak in the past few days. What is the most likely diagnosis?

Acute intermittent porphyria

Lead poisoning

Constipation

Guillan Barre syndrome

Rectal carcinoma

This would be an impressive diagnosis to make in the surgical out patient department! The combination of abdominal pain and a motor periperal neuropathy, should indicate this diagnosis. The blue line along the gum margin can occur in up to 20% patients with lead poisoning. Please rate this question:


Next question

Lead poisoning

Along with acute intermittent porphyria, lead poisoning should be considered in questions giving a combination of abdominal pain and neurological signs Features

abdominal pain peripheral neuropathy (mainly motor) fatigue constipation

blue lines on gum margin (only 20% of adult patients, very rare in children)

Investigations


The blood lead level is usually used for diagnosis. Levels greater than 10 mcg/dl are considered significant

Full blood count: microcytic anaemia. Blood film shows red cell abnormalities including basophilic stippling and clover-leaf morphology

Raised serum and urine levels of delta aminolaevulinic acid may be seen making it sometimes difficult to differentiate from acute intermittent porphyria

Urinary coproporphyrin is also increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased)

Management - various chelating agents are currently used:

Dimercaptosuccinic acid (DMSA)

D-penicillamine EDTA Dimercaprol

Next question


Theme: Vasculitis

A. Wegeners granulomatosis

B. Polyarteritis nodosa

C. Giant cell arteritis

D. Takayasu's arteritis

E. Buergers disease For each of the scenarios provided please select the most likely underlying diagnosis from the list below. Each option may be used once, more than once or not at all.

88. A 20 year old lady is referred to the vascular clinic. She has been feeling generally unwell

for the past six weeks. She works as a typist and has noticed increasing pain in her

forearms whilst working. On examination she has absent upper limb pulses. Her ESR is

measured and mildly elevated.

You answered Wegeners granulomatosis

The correct answer is Takayasu's arteritis

Takayasus arteritis may be divided into acute systemic phases and the chronic pulseless

phase. In the latter part of the disease process the patient may complain of symptoms such

as upper limb claudication. In the later stages of the condition the vessels will typically

show changes of intimal proliferation, together with band fibrosis of the intima and media.

89. A 32 year old man presents to the vascular clinic with symptoms of foot pain during

exertion. He is a heavy smoker and has recently tried to stop smoking. On examination he

has normal pulses to the level of the popliteal. However, foot pulses are absent. A

diagnostic angiogram is performed which shows an abrupt cut off at the level of the

anterior tibial artery, together with the formation of corkscrew shaped collateral vessels

distally.


The correct answer is Buergers disease

Buergers disease is most common in young male smokers. This demographic is changing

in those areas where young female smokers are more common. In the acute lesion the

internal elastic lamina of the vessels is usually intact. As the disease progresses the

changes progress to hypercellular occlusive thrombus. Tortuous corkscrew collaterals may

reconstitute patent segments of the distal tibial or pedal vessels.

90. A 78 year old man presents with symptoms of headaches and deteriorating vision. He

notices that there is marked pain on the right hand side of his face when he combs his hair.


The correct answer is Giant cell arteritis

Temporal arteritis may present acutely with symptoms of headache and visual loss, or with

a less acute clinical picture. Sight may be threatened and treatment with

immunosupressants should be started promptly. The often requested temporal artery

biopsy (which can be the bane of many surgeons) is often non diagnostic and unhelpful.



Next question

Vasculitis

The vasculitides are a group of conditions characterised by inflammation of the blood vessel walls. This may, in turn, compromise vessel integrity. Constitutional symptoms may be present. Whilst certain disease subtypes are reported to affect specific vessels, there is often a degree of overlap clinically. Vessel diameter and vasculitis classification

Aorta and branches Takayasu's arteritis

Buergers disease

Giant cell arteritis

Large and medium sized arteries Buergers disease

Giant cell arteritis

Polyarteritis nodosa

Medium sized muscular arteries Polyarteritis nodosa

Wegeners granulomatosis

Small muscular arteries Wegeners granulomatosis

Rheumatoid vasculitis

Specific conditions


Takyasu's arteritis Inflammatory, obliterative arteritis affecting aorta and branches

Females> Males

Symptoms may include upper limb claudication

Clinical findings include diminished or absent pulses

ESR often affected during the acute phase

Buergers disease Segmental thrombotic occlusions of the small and medium sized

lower limb vessels

Commonest in young male smokers

Proximal pulses usually present, but pedal pulses are lost

An acuter hypercellular occlusive thrombus is often present

Tortuous corkscrew shaped collateral vessels may be seen on

angiography

Giant cell arteritis Systemic granulomatous arteritis that usually affects large and

medium sized vessels

Females > Males

Temporal arteritis is commonest type

Granulomatous lesions may be seen on biopsy (although up to

50% are normal)

Polyarteritis nodosa Systemic necrotising vasculitis affecting small and medium sized

muscular arteries

Most common in populations with high prevalence of hepatitis B

Renal disease is seen in 70% cases

Angiography may show saccular or fusiform aneurysms and

arterial stenoses

Wegeners

granulomatosis

Predominantly affects small and medium sized arteries

Systemic necrotising granulomatous vasculitis

Cutaneous vascular lesions may be seen (ulceration, nodules and

purpura)

Sinus imaging may show mucosal thickening and air fluid levels

Treatment Conditions such as Buergers disease are markedly helped by smoking cessation. Immunosupression is the main treatment for vasculitides.

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Question 91 of 147

A 28 year old man presents with right upper quadrant pain and hydatid disease is suspected. Which of the following statements relating to the disease is untrue?

First line treatment is with pentavalent antimony.

Peritoneal contamination with active daughter cysts may complicate surgery.

CT scanning of the liver may show a floating membrane.

Biliary communication with the cysts may occur.

It is caused by Echinococcus granulosus.

Drug treatment is with albendazole or mebendazole. Praziquantzel may be used in the pre operative stages. Please rate this question:


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Hydatid cysts

Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed containing multiple small daughter cysts. These cysts are allergens which precipitate a type 1 hypersensitivity

reaction.

Clinical features are as follows:

Up to 90% cysts occur in the liver and lungs Can be asymtomatic, or symptomatic if cysts > 5cm in diameter Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal

and cerebrospinal fluid outflow obstruction)

In biliary ruputure there may be the classical triad of; biliary colic, jaundice, and urticaria

CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts.


Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).

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Question 92 of 147

Which of the following statements relating to neutrophil polymorphs is true?

Produce nitrogen peroxide as a microbicidal agent

Not involved in opsonisation

Deficiency leads to AIDS

Neutrophil disorders always result in chronic granulomatous diseases

Have a lifespan of 9 hours

Neutrophils are the main cells of acute inflammation, important action against gram -ve and +ve bacteria

Appearance of segmented nucleus and granulated cytoplasm Have a lifespan of 1-3 days (shorter when consumed during septic process, though 9 hours

is unusual) Actions include: movement, opsonise microorganisms, phagocytosis & intracellular killing of

microorganisms via aerobic (produce HYDROGEN PEROXIDE) & anaerobic mechanisms. Neutrophil disorders include chronic granulomatous diseases: rare AIDS associated with T cell deficiency



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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 removal 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

inflammation

Coupled inflammatory and reparative activities

Usually occurs when initial infection or suppuration has

been inadequately managed

Causes

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

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Question 93 of 147

A 33 year old man is involved in a road traffic accident. He is initially stable and transferred to the

accident and emergency department. On arrival he is catheterised. One minute later he becomes

hypotensive, with evidence of angioedema surrounding his penis. What is the most likely explanation

for this event?

Type V latex hypersensitivity reaction

Type IV latex hypersensitivity reaction

Type III latex hypersensitivity reaction

Type I latex hypersensitivity reaction

Type II latex hypersensitivity reaction

Theme from January 2013 exam


Sudden collapse and angioedema following exposure to latex (of which most urinary catheters are

manufactured) suggests a type I hypersensitivity reaction.



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Hypersensitivity reactions

The Gell and Coombs classification divides hypersensitivity reactions into 4 types


Type I Type II Type III Type IV

Description Anaphylactic Cytotoxic Immune

complex

Delayed type

Mediator IgE IgG, IgM IgG, Ig A, IgM T-cells

Antigen Exogenous Cell surface Soluble Tissues

Response

time

Minutes Hours Hours 2-3 days

Examples Asthma

Hay fever

Autoimmune haemolytic

anaemia

Pemphigus

Goodpasture's

Serum sickness

SLE

Aspergillosis

Graft versus host

disease

Contact dermatitis

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Question 94 of 147

A 43 year old female develops severe chest wall cellulitis following a mastectomy. On examination the skin is markedly erythematous. Which of the acute inflammatory mediators listed below is least likely to produce vasodilation?

Complement component C5a

Lysosomal compounds

Histamine

Serotonin

Prostaglandins

Erythema is a classical feature of acute inflammation. Potent mediators of vascular dilatation include; histamine, prostaglandins, nitric oxide, platelet activating factor, complement C5a (and C3a) and lysosomal compounds. Although serotonin is associated with acute inflammation it is a vasoconstrictor. The effects of serotonin are dependent upon the state of the vessels in the tissues. Intact and healthy tissues and vessels will respond to a serotonin infusion with vasodilation (hence the flushing seen in carcinoid syndrome). In contrast it worsens cardiac ischaemia in myocardial infarcts when released from damaged platelets. Please rate this question:


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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 removal 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

inflammation

Coupled inflammatory and reparative activities

Usually occurs when initial infection or suppuration has

been inadequately managed

Causes

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

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Question 95 of 147

A 43 year old man presents with a 3 week history of malaise, sore throat, odynophagia and

dysphagia. On examination he is found to have patchy white spots in his oropharynx. An upper GI

endoscopy is performed and similar lesions are identified in the oesophagus. Which investigation is

most likely to identify the underlying pathology in this case?

Serum urea and electrolytes

Oesophageal biopsy for culture

Oesophageal biopsy for histology

Glucose tolerance testing

Viral serology

Oesophageal candidiasis is associated with immunosupression; mainly in patients on chemotherapy,

with haematological malignancy, HIV or inhaled steroids. In patients with HIV, oesophageal

candidiasis is part of the spectrum of AIDS defining illnesses and usually occurs when the CD4

count is less than 200. Others include PCP pneumonia and CMV infections.



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Oesophageal candidiasis

Characterised by white spots in the oropharynx with extension into the oesophagus. Associated with

broad spectrum antibiotic usage, immunosupression and immunological disorders.

Patients may present with oropharyngeal symptoms, odynophagia and dysphagia.


Treatment is directed both at the underlying cause (which should be investigated for) and with oral

antifungal agents.

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Theme: Colonic obstruction

A. Malignant obstruction

B. Ogilvies syndrome

C. Volvulus

D. Diverticular stricture

E. Ischaemic stricture Please select the most likely cause of obstruction for the situation described. Each option may be used once, more than once or not at all.

96. A 78 year old man has undergone a hemi-arthroplasty for a intracapsular hip fracture. Post

operatively he develops electrolyte derangement and receives intravenous fluids. Over the

previous 24 hours he develops marked abdominal distension. On examination he has a

tense, tympanic abdomen which is not painful. A contrast enema shows flow of contrast

through to the caecum and through the ileocaecal valve.

You answered Malignant obstruction

The correct answer is Ogilvies syndrome

Patients with electrolyte disturbance and previous surgery may develop colonic pseudo-

obstruction (Ogilvies syndrome). The diagnosis is made using a contrast enema and

treatment is usually directed at the underlying cause with colonic decompression if

indicated.

97. A 67 year old man has had multiple episodes with fever and left iliac fossa pain. These

have usually resolved with courses of intravenous antibiotics. He is admitted with a history

of increasing constipation and abdominal distension. A contrast x-ray is performed which

shows flow of contrast to the sigmoid colon, here the contrast flows through a long narrow

segment of colon into dilated proximal bowel.


The correct answer is Diverticular stricture

The long history of left iliac fossa pain and development of bowel obstruction suggests a

diverticular stricture. These may contain a malignancy and most will require resection.

98. A 78 year old lady from a nursing home is admitted with a 24 hour history of absolute

constipation and abdominal pain. On examination she has a distended abdomen with a soft

mass in her left iliac fossa. An x-ray is performed which shows a large dilated loop of

bowel in the left iliac fossa which contains a fluid level.


The correct answer is Volvulus

Sigmoid volvulus may present with an asymmetrical mass in an elderly patient. It may

contain a fluid level, visible on plain films.



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Colonic obstruction

Cause Features Treatment

Cancer Usually insidious onset

History of progressive constipation

Systemic features (e.g. anaemia)

Abdominal distension

Absence of bowel gas distal to site of

obstruction

Establish diagnosis (e.g.

contrast enema/ endoscopy)

Laparotomy and resection,

stenting, defunctioning

colostomy or bypass

Diverticular

stricture

Usually history of previous acute

diverticulitis

Long history of altered bowel habit

Evidence of diverticulosis on imaging or

endoscopy

Once diagnosis established,

usually surgical resection

Colonic stenting should not

be performed for benign

disease

Volvulus Twisting of bowel around its mesentery

Sigmoid colon affected in 76% cases

Patients usually present with abdominal

pain, bloating and constipation

Examination usually shows asymmetrical

distension

Plain X-rays usually show massively

dilated sigmoid colon, loss of haustra and

Initial treatment is to

untwist the loop, a flexible

sigmoidoscopy may be

needed

Those with clinical

evidence of ischaemia

should undergo surgery

Patient with recurrent


"U" shape are typical, the loop may

contain fluid levels

volvulus should undergo

resection

Acute colonic

pseudo-

obstruction

Symptoms and signs of large bowel

obstruction with no lesion

Usually associated with metabolic

disorders

Usually a cut off in the left colon (82%

cases)

Although abdomen tense and distended,

it is usually not painful

All patients should undergo contrast

enema (may be therapeutic!)

Colonoscopic

decompression

Correct metabolic disorders

IV neostigmine

Surgery

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Question 99 of 147

A 52 year old man with dyspepsia is found to have a duodenal ulcer. A CLO test is taken and is

positive. Which statement relating to the likely causative organism is false?

It is a gram negative organism

It preferentially colonises gastric type mucosa

It may occupy areas of ectopic gastric metaplasia

In patients who are colonised there is commonly evidence of fundal gastritis on endoscopy

It produces a powerful urease that forms the basis of the Clo test

Helicobacter pylori accounts for >75% cases of duodenal ulceration. It may be diagnosed with either

serology, microbiology, histology or CLO testing.

Theme from January 2011 Exam

Helicobacter pylori rarely produces any typical features on endoscopy. Where infection is suspected

the easiest course of action is to take an antral biopsy for Clo testing in the endoscopy suite.



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Helicobacter Pylori

Infection with Helicobacter Pylori is implicated in many cases of duodenal ulceration and up to 60%

of patients with gastric ulceration.

It is a gram negative, helical shaped rod with microaerophillic requirements. It has the ability to


produce a urease enzyme that will hydrolyse urea resulting in the production of ammonia. The effect

of ammonia on antral G cells is to cause release of gastrin via a negative feedback loop.

Once infection is established the organism releases enzymes that disrupt the gastric mucous layer.

Certain subtypes release cytotoxins cag A and vac A gene products. The organism incites a

classical chronic inflammatory process of the gastric epithelium. This accounts for the development

of gastric ulcers. The mildly increased acidity may induce a process of duodenal gastric metaplasia.

Whilst duodenal mucosa cannot be colonised by H-Pylori, mucosa that has undergone metaplastic

change to the gastric epithelial type may be colonised by H- Pylori with subsequent inflammation

and development of duodenitis and ulcers.

In patients who are colonised there is a 10-20% risk of peptic ulcer, 1-2% risk gastric cancer and

<1% risk MALT lymphoma.

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Question 100 of 147

A 34 year old male presents with painful rectal bleeding and a fissure in ano is suspected. On examination he has an epithelial defect at the mucocutaenous junction that is located anteriorly. Approximately what proportion of patients with fissure in ano will present with this pattern of disease?

90%

10%

50%

25%

100%

Only a minority of patients with fissure in ano will have an anteriorly sited fissure. They are particularly rare in males and an anterior fissure in a man should prompt a search for an underlying cause. Please rate this question:


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Anal fissure

Anal fissures are a common cause of painful, bright red, rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Multiple fissures and those which are located at other sites are more likely to be due to an underlying cause. Diseases associated with fissure in ano include:

Crohns disease

Tuberculosis Internal rectal prolapse

Diagnosis


In most cases the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated with colonoscopy and EUA with biopsies of the area. Treatment Stool softeners are important as the hard stools may tear the epithelium and result in recurrent symptoms. The most effective first line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste. Side effects of diltiazem are better tolerated. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy (beware in females). Advancement flaps may be used to treat resistant cases. Sphincterotomy produces the best healing rates. It is associated with incontinence to flatus in up to 10% of patients in the long term.

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