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 II

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Question 1

Stem 1 of 5

A 57 year-old female presents with heartburn on lying down and occasional regurgitation.  A lifelong smoker, like her parents, she states her mother died of oesophageal cancer.  Physical examination is normal and history contains GORD diagnosis three years previously.
Distal oesophageal mucosa changes are noted on biopsy.  Which of the below definitions best describe what is expected on pathology report?
A
Abnormal, excessive growth escaping regular control mechanisms
B
A premalignant abnormal growth
C
A premalignant excessive growth
D
A reversible change in cell growth/function
Question 1 Explanation: 
This is the definition of metaplasia. The most likely situation in this patient's case is a progression from GORD to Barrett's oesophagus due to poor treatment/management. Due to the family history, the patient is at increased risk further of neoplasia occurring.
Question 2

Stem 2 of 5

What is the most likely change to physical examination were this condition to be left untreated?
A
Increase in appetite
B
Pyrosis
C
Haemoptysis
D
Weight loss
Question 2 Explanation: 
It is likely that as the pain worsens, the patient will be reluctant to swallow food. Thus, weight loss and malnutrition are the most common short-medium term results of this. The patient already has pyrosis aka heartburn.
Question 3

Stem 3 of 5

What is the anatomic origin of the pain referral from this region?
A
T7
B
T2
C
T4
D
T8
E
T10
Question 3 Explanation: 
T5-9 is the remit of foregut. The patient has damage to the oesophagus, ergo foregut referral is likely.
Question 4

Stem 4 of 5

What is the mechanism of the medication that the patient is likely to have been placed on at onset of moderate GORD-related symptoms?
A
A polysaccharide, insoluble raft
B
A neutraliser of stomach acid pH
C
A histamine receptor antagonism
D
An irreversible proton pump inhibitor
Question 4 Explanation: 
PPI should be commenced with all but mild cases.
Question 5

Stem 5 of 5

Which of the following lifestyle advice options would you give to the patient?
A
Eat more fatty food
B
Drink less hot drinks
C
Exercise should be kept to a minimum
D
Sleep flat
Question 5 Explanation: 
The patient should be counselled to reduce fatty food intake, quit smoking, exercise and sleep slightly raised as supine positioning can exacerbate reflux. The use of hot drinks should be minimised as this too can worsen symptoms.
Question 6

Stem 1 of 5

A patient presents with GORD symptoms for three months.  His physical examination is unremarkable save bowel sounds heard by the left lower lung base.
Which of the below differentials best match the above presentation?
A
Umbilical hernia
B
Indirect inguinal hernia
C
Petit's triangle hernia
D
Hiatus hernia
E
Direct inguinal hernia
Question 6 Explanation: 
A hiatus hernia is defined as a hernia through which abdominal viscus protrudes through the oesophageal hiatus of the diaphragm.
Question 7

Stem 2 of 5

An anterior plexus is damaged by the hernia in question.  Which of the following consequences may result from such a lesion?
A
Aperistalsis
B
Increased colonic movement
C
Decreased action of the lower oesophageal sphincter
D
A decreased activation of parietal cells
E
An increased agonism of gastrin cell receptors
Question 8

Stem 3 of 5

During surgery to repair, the surgeon is careful to protect the arterial supply to the portion of gut tube herniating through the orifice.  What is the origin of those arteries?
A
Splenic artery
B
Right gastric artery
C
Left gastroomental artery
D
Right gastroduodenal
E
Direct off the coeliac trunk
Question 8 Explanation: 
It is likely the fundus of the stomach has herniated through the oesophageal diaphragmatic hiatus. The blood supply to this region of the stomach is the short gastric arteries from the splenic artery - a common question.
Question 9

Stem 4 of 5

What vertebral level has the hernia occurred at?
A
T9
B
T10
C
T12
D
L1
E
L3
Question 9 Explanation: 
Classically the oesophageal hiatus is at the level T10 (some texts say T11).
Question 10

Stem 5 of 5

Which of the below are the least likely presentation of a patient with the diagnosis of hiatus hernia?
A
Asymptomatic
B
Reflux
C
Waterbrash
D
Acidbrash
E
Haemoptysis
Question 10 Explanation: 
Hiatus hernia is often asymptomatic. Quite often its finding is incidental.
Question 11

Stem 1 of 5

A patient in ICU with complications of liver cirrhosis suddenly undergoes massive haematemesis. Endoscopic banding and rapid resuscitation is commenced.
Which is not a key sign of liver cirrhosis?
A
Propensity to bruise significantly
B
Ascites
C
Caput medusae
D
Day-night somnolence inversion
E
Scleral pallor
Question 12

Stem 2 of 5

What is the most common cause of haematemesis in the UK today?
A
Liver failure
B
GORD
C
Peptic ulceration
D
Cancer
E
Bronchial metastasis
Question 13

Stem 3 of 5

Using the presentation above, which vessel(s) is/are more likely to have ruptured?
A
Coeliac axis
B
Inferior mesenteric artery
C
Azygous vein
D
Oesophageal venous plexus
E
Right gastric vein
Question 14

Stem 4 of 5

The patient quickly becomes tachycardic, has a significant decrease in consciousness and is cold to the touch.  His JVP is not raised.  What best matches this outcome?  
A
Cardiogenic shock
B
Distributive shock
C
Septic shock
D
Hypovolaemic shock
E
Exchange-vessel shock
Question 15

Stem 5 of 5

For the previous few months, the patient has noted a tremor and has been told by family that his behaviour has markedly changed. Which of the following would most likely account for this pathophysiology?
A
Deposition of copper about the primary somatosensory cortex
B
Hypertrophy of hepatocyte tissue
C
Vertebrobasilar insufficiency
D
Accumulation of ammonia in the primary motor cortex
E
Occlusion of the hepatic portal vein leading to portal hypertension
Question 15 Explanation: 
Liver failure causes a decrease in the conversion of ammonia to ammonium. This results in toxic accumulation of the NH3 in places such as the cerebral cortex. This can have upper motor neuron lesion symptoms as a result.
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