Without a keen understanding of pertinent anatomy and physiology, students will struggle to apply pathology and pharmacology throughout their training and practice. MedGuide are happy to introduce this series of MCQ sets comprising core clinically-relevant physiology pulled from many sources common to the medical school undergraduate. We hope this allows you to test your knowledge, and apply synoptic links to some key preclinical conditions you will encounter as a practising healthcare professional.
Gastrointestinal Clinical Correlates Part I
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Stem 1 of 5
A 42 year-old male presents to his GP, at his wife’s insistence, after noting a lump in his neck accompanied with foul-smelling breath. He states difficulty swallowing his meals for several weeks and is concerned about it getting worse.Which of the following symptoms are present in the above case?
Question 1 Explanation:
Halitosis is literally defined as "bad breath"
Stem 2 of 5The patient is diagnosed with a false-diverticulum of Zenker. What about this case makes for a "false" diverticulum?
There is no arterial supply in the pouch
The pouch is everted
The pouch is inferiorly placed
The pouch does not contain all four gastrointestinal wall layers
Question 2 Explanation:
A false-diverticulum is an out pouching of the tract that does not contain all four layers of the wall - in this case only the mucosa ± submucosa.
Stem 3 of 5The patient had a previous neck operation second to trauma suffered in road traffic incident. During this surgery there was iatrogenic damage to branches of the vagus nerve. Which of the following structures could have received denervation to contribute to the patient's diagnosis?
Upper oesophageal sphincter
Question 3 Explanation:
It is postulated that a major cause of Zenker's diverticula is a difficulty in maintaining upper oesophageal sphincter's patency during swallowing. Such causing an increase in pressure and risks herniation through Killian's triangle between inferior constrictor and cricopharyngeus.
Stem 4 of 5Which of the following investigations are most appropriate to confirm the diagnosis?
Stem 5 of 5The patient is contraindicated for the gold-standard investigation to confirm. The physician attempts a transcutaneous ultrasound of the mass. What is the attachment point of a muscle that is implicated in the pharyngeal wall weakness?
Question 5 Explanation:
The "pharyngeal raphe" is band of connective tissue running from the occipital bone to C6 vertebra that is a common attachment point of the pharyngeal constrictor muscles.
Stem 1 of 5
A 40 year-old female presents to their GP with a few week’s history of heartburn that is exacerbated on eating. They have regular regurgitation and complained, rather hesitantly, that they had struggled to belch recently.Barium swallow finds a "bird-beak" appearance of the distal oesophagus with notable decline in peristalsis. Which of the following differentials best matches the history and investigation?
Neoplasia of the distal oesophagus
Question 6 Explanation:
From the Greek "without loosening", achalasia is a failure of relaxation of the smooth muscle of the distal oesophagus.
Stem 2 of 5Which plexus is absent/decreased in the patient?
Vagal oesophageal plexus
Question 7 Explanation:
The myenteric plexus - most responsible for regulation of smooth muscle cell tone in the oesophageal wall - is deficient of many ganglionic cells and neurotransmitters to inhibit contraction. The precise mechanism of achalasia is unknown, though often is deemed to be caused second to intra-luminal high pressure damage.
Stem 3 of 5The patient has corrective surgery. In the consent process, the surgeon warns about risk of damaging the arterial supply to the distal oesophagus. What is the origin of said supply?
Inferior thyroid artery
Superior thyroid artery
Blood supply to the spleen
Blood supply from the lesser curvature of the stomach
Question 8 Explanation:
The left gastric artery is the usual origin of the blood supply to the distal oesophagus. Note that the lesser gastric arcade is formed of the anastomosis of the right and left gastric arteries.
Stem 4 of 5On history, how might achalasia and GORD be distinguished?
Central burning chest pain
Symptoms worse on lying down
Symptoms worse with hot drinks
Symptoms worse with cold air
Odd taste to regurgitation food
Question 9 Explanation:
The food is often said to taste "sour" in GORD, on account of the gastric acid taste in the stomach. Otherwise, both conditions have similar "heartburn"-like symptoms and should form base-line differentials for every presentation initially.
Stem 5 of 5The distal portion of the oesophagus is mostly affected in achalasia. What is the motor innervation of influence to this portion of anatomy?
A mix of somatic and autonomic nerves
None of the above
Question 10 Explanation:
The lower oesophagus comes entirely under the remit of the parasympathetic (autonomic) nervous system via the vagus nerve (CN X). As a general rule, the upper third of the oesophagus is under somatic control, the middle third both somatic and ANS, and the lower third purely ANS. Thus as the bolus moves distally through the oesophagus, swallowing becomes increasingly LESS voluntary.
Stem 1 of 5
A patient has been referred to his GP after the pharmacist’s OTC Rennie was ineffective in managing a recent “burning” heart-pain. The patient states the pain worsens shortly after eating.Which differential best fits this presentation?
Dysplastic changes of the oesophagus
Neoplasm of the oesophagus
Lower oesophageal sphincter insufficiency
Question 11 Explanation:
These findings are typical of GORD. The short-term nature of the condition would make it less likely to be the other described conditions at this juncture.
Stem 2 of 5What key question could you use to distinguish the pain from inflammation of the serous lining of the heart?
Does the pain relieve with GTN spray?
Is the pain replicable with touching the region?
Is the pain improved by leaning forward?
Is the pain worse on sharp inhalation?
Is the pain diffuse or localised?
Question 12 Explanation:
Pericarditis can be differentiated - classically - by asking the patient to lean forward, relieving pressure on the phrenic nerve branches from the fluid as it pools anteroinferiorly.
Stem 3 of 5What is the mechanism of calcium carbonate pharmacology with gastric mucosa?
Form a non-dissolvable "raft" that prevents reflux of gastric contents into the oesophagus
Reduces the pH of the serum
Increase the acidity of gastric mucosa
Increases stimulation of Auerbach's plexus
Reduces influence of H+ on gastric luminal content pH level
Question 13 Explanation:
Rennie contains magnesium and calcium carbonate to neutralise - or at least increase - the luminal content pH of the stomach.
Stem 4 of 5Given the onset of pain for this patient, were this condition to progress to a perforation of the region, which of the arteries listed below are at greatest risk of haemorrhage?
Anterior superior pancreatioduodenal artery
Common hepatic artery
Question 14 Explanation:
The onset of symptoms suggests a gastric, verses duodenal, ulcer. With a great proportion of the body and fundus of the stomach supplied by short gastric arteries from the splenic artery.
Stem 5 of 5Which of the following situations would most likely not exacerbate the patient’s pain?
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