🤔 MEDIUM

Abdominal pain can be as a result of numerous causes, test yourself against a few different ones here in this quiz! Good luck!

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Approach to the patient with Chronic Abdominal Pain

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Question 1

Stem 1, question 1 of 4

Victoria, a 44 year old female, presents with a 6 month history of intermittent aching abdominal pain under her right rib cage
Which of the following is NOT a risk factor for gall stone disease?  
A
Female
B
Obesity
C
Infertility
D
Family History
E
Pregnancy
Question 1 Explanation: 
Hopefully this is one to ease you into this set. Classically the common risk factors for gallstone disease are the 5 F's: Fat, Female, Fertile, Forty and Family History. In addition, pregnancy, oral contraceptives, haemolytic anaemia and malabsorption are risk factors.
Question 2

Stem 1, question 2 of 4

Why do Victoria's symptoms worsen after the consumption of foods such as cheeseburgers, cream cakes and chips?
A
Fatty acids stimulate the duodenum endocrine cells to release lipase, which in turn stimulates contraction of the gallbladder
B
Fatty acids stimulate the duodenum endocrine cells to release cholecystokinin (CCK), which in turn stimulates contraction of the gallbladder
C
Fatty acids stimulate the duodenum endocrine cells to release leptin, which in turn inhibits contraction of the gallbladder
D
Fatty acids inhibits the duodenum endocrine cells to release renin, which in turn inhibits contraction of the gallbladder
E
Fatty acids inhibit the duodenum endocrine cells to release cholecystokinin (CCK), which in turn stimulates contraction of the gallbladder
Question 2 Explanation: 
Often individuals find their symptoms get much worse or are precipitated after eating fat rich foods. The consumption of fatty acids stimulate the duodenum endocrine cells to cause the release of cholecystokinin which stimulates the contraction of the gallbladder. If an individual already has stones, this can result in a blockage of the outflow of the common bile duct, resulting in pain. Lipase is released by the pancreas, leptin is related to appetite and hunger, renin is involved in blood pressure regulation by the kidney.
Question 3

Stem 1, question 3 of 4

What is the initial imaging that should be done for gallstone disease?
A
Erect abdominal X-ray
B
Abdominal X-ray
C
CT abdomen and pelvis
D
Magnetic resonance cholangiopancreatography (MRCP)
E
Ultrasound scan of gallbladder
Question 3 Explanation: 
A key aspect of imaging is you have to be able to justify exposing an individual to radiation! Gallstones (calculi) are often visible on ultrasound with associated inflammation and bile duct dilation. Erect abdominal X-rays are used to detect pneumoperitoneum (air in the peritoneal cavity) often when a perforation is suspected. CT and abdominal X-rays can be helpful when suspecting conditions other than gallstone disease, but may be normal. MRCP can be used when ultrasound has not detected common bile duct stones, but there is clinical suspicion.
Question 4

Stem 1, question 4 of 4

Victoria continues to have episodes of biliary colic. The GP refers her to the general surgeons
What is the definitive management of gallstone disease?
A
Analgesia
B
Lifestyle and dietary changes
C
Laxatives
D
Cholecystectomy
E
Hemicolectomy
Question 4 Explanation: 
The definitive management is an elective cholecystectomy (BMJ practice). Analgesia is used for episodes of biliary colic and dietary and lifestyle can help to manage the condition from worsening. A hemicolectomy would not solve the issue as this procedure does not involve removal of the gallbladder.
Question 5

Stem 2, question 1 of 4

Simon, a 40 year old man, presents to A&E with chronic epigastric pain that radiates to his back, eased by leaning forwards. He states he has been in constant pain for 5 months. He does not drink alcohol, and has been trying to loose some weight due to a recent high cholesterol blood test.
What is the most likely cause of Simon's pain?
A
Biliary colic
B
Peptic ulcer disease
C
Chronic pelvic inflammatory disease
D
Constipation
E
Chronic pancreatitis
Question 5 Explanation: 
Simon is presenting with chronic pancreatitis, although 60% of cases are caused by chronic alcohol abuse, hyperlipidaemia is a recognised metabolic cause. Chronic pancreatitis presents with chronic epigastric pain, radiating to the back which is eased by leaning forwards. This may be associated with nausea and vomiting. Biliary colic presents with right upper quadrant pain, peptic ulcer disease with pointing sign (can point exactly to site of pain), constipation presents with infrequent stools and sensation of incomplete evacuation. Chronic pelvic inflammatory disease affects the upper female genital tract and is often caused by STIs.
Question 6

Stem 2, question 2 of 4

What is the innervation of the foregut?
A
T1-4
B
T5-9
C
T10-11
D
T12-L1
E
L2-5
Question 6 Explanation: 
Oh some anatomy and embryology... Yay! (or not). The foregut consists of the mouth to the entrance of the common bile duct into the duodenum and includes the pancreas, liver and gallbladder. The foregut is supplied by T5-9 nerves so pain will be referred to the epigastrium. Midgut is T10-11 and Hindgut is T12-L1
Question 7

Stem 2, question 3 of 4

What biomarker is most likely to be raised in Simon?
A
Haemoglobin
B
Blood glucose
C
Faecal elastase
D
Amylase
E
Creatinine
Question 7 Explanation: 
According to BMJ Best Practice, blood glucose is likely to be raised in chronic pancreatitis. Faecal elastase is an indirect pancreatic function test and is reduced in severe disease. Amylase is not listed as an investigation for chronic pancreatitis. Haemoglobin may be reduced as a consequence of anaemia of chronic disease, creatinine may be elevated if there is a concurrent AKI but is unlikely in this case.
Question 8

Stem 2, question 4 of 4

During his admission Simon is given pancreatin, what is the mechanism of action?
A
Blockade of smooth muscle transporters
B
Gastric acid neutralisation
C
Helicobacter pylori eradication
D
Restoration of pancreatic enzymes
E
Restoration of stomach mucus barrier
Question 8 Explanation: 
Pancreatin (Phase II drugs list) as the name suggests is used in pancreatic insufficiency such as pancreatitis or cystic fibrosis and acts to restore pancreatic enzymes.
Question 9
Marcus, a 45 year old male, presents with chronic nausea, vomiting, epigastric pain, bloating and early satiety. No mechanical obstruction has been detected with extensive investigations
What is the most likely diagnosis?
A
Achalasia
B
Crohn's disease
C
Oesophageal cancer
D
Gastroparesis
E
Irritable bowel syndrome
Question 9 Explanation: 
It is important to consider functional causes of chronic abdominal pain such as gastroparesis, irritable bowel syndrome and non-ulcer dyspepsia. A functional disorder does not mean that an individual is making up their symptoms. Gastroparesis is a symptomatic chronic disorder of the stomach defined as delayed emptying of solids by the stomach in the absence of any mechanical obstruction. Gastroparesis is treated with pro kinetic agents, antiemetics and analgesia.
Question 10
Eloise, a 32 year old female, presents with chronic pelvic and abdominal pain.
What are the examination findings in chronic pelvic inflammatory disease? Select all that apply
A
Uterine tenderness
B
Adnexal tenderness
C
Abdominal bloating
D
Cervical motion tenderness
E
Skin rashes
Question 10 Explanation: 
Chronic pelvic inflammatory disease (PID) effects the female genital tract and is often linked to sexually transmitted diseases but normal vaginal flora can cause PID too. Uterine, adnexal and cervical motion tenderness are the three findings on exam that make up diagnostic criteria.
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