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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_40_библиотеки_им_акад_М_И_Перельмана
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CHAPTER | MOCKEXAMINATION
19. A 19- year- old student was referred to clinic with persistent non- bloody
diarrhoea, abdominal cramps, and bloating. She returned from her gap
year a month earlier.
Investigations:
Faecal microscopy and culture Negative
Faecal polymerase chain reaction (PCR) Positive for Giardia lamblia
Which statement best describes the Giardia lamblia trophozoite cycle?
A. Trophozoite colonization is limited to the upper small bowel
B. Trophozoites adhere to the mucosal surface, causing cytokine release and consequent uid
and electrolyte loss
C. Trophozoites invade tissues and gain entry to the lymphatic system, facilitating
systemic spread
D. Trophozoites invade the epithelium and alter gut hormone balance, resulting in uid and
electrolyte loss
E. Upon entry into the duodenum, intestinal bacteria break down the encapsulating cyst,
releasing the trophozoite
20. A 42- year- old presented with non- specic abdominal discomfort and
proceeded to endoscopy.
Investigations:
Gastroscopy There was a 1cm, pale yellow, sessile polypoid lesion
located at 36cm from the incisors. The lesion was
rm but passable with the endoscope and appeared
submucosal. The appearances of the upper GI tract were
otherwise normal
Endoscopic ultrasound
(EUS)
Histology of polyp Polygonal cells with granular eosinophilic cytoplasm
What is the most likely diagnosis?
A. Adenocarcinoma
B. Fibrovascular polyp
C. Granular cell tumour
D. Leiomyoma
E. Lipoma
At 36cm there is a smooth- edged, hypoechoic,
homogenous appearing lesion arising from the
submucosa
CHAPTER | QUESTIONS
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299
21. A 35- year old woman with extensive UC was admitted to hospital with
16 bloody, loose stools per day.
Investigations:
Flexible sigmoidoscopy Continuous inammation to 35cm with deep
ulceration, complete obliteration of vascular
pattern and free liquid blood in the lumen
What is the Ulcerative Colitis Endoscopic Index of Severity
(UCEIS) score?
A. 4
B. 5
C. 6
D. 7
E. 8
22. An 87- year- old man with progressive dysphagia was referred urgently
for endoscopy. The endoscope was introduced into the oesophagus with
some diculty, and the view shown in (Fig. 11.2) was seen at 31cm.
Fig.11.2 Endoscopic image of oesophagus. See also Plate 19
Which of the following is most appropriate?
A. Covered stent placement
B. Endoscopic clipping
C. Endoscopic gluing
D. Nasogastric tube placement for feeding
E. Urgent thoracotomy
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CHAPTER | MOCKEXAMINATION
23. Variants in which gene are the most common cause of hereditary
pancreatitis?
A. Calcium- sensing receptor (CASR)
B. Cystic brosis transmembrane conductance regulator (CFTR)
C. Chymotrypsin C (CTRC)
D. Serine protease 1 (PRSS1)
E. Serine protease inhibitor Kazal- type (SPINK)
24. A 45- year- old man was diagnosed with ulcerative pancolitis and
concurrent PSC one year ago. He returned for his rst annual follow- up
appointment. He was asymptomatic.
Investigations:
Serum bilirubin
Serum alkaline phosphatase (ALP) 125 U/ L
Serum alanine aminotransferase (ALT) 25 U/ L
Serum albumin 37 g/ L
Serum CA 19- 9 20 U/ ml
Colonoscopy Quiescent UC
Abdominal ultrasound 8mm polyp posterior wall of the gallbladder
What is the best next step in this patient’s management?
A. Cholecystectomy
B. EUS
C. MRCP
D. Repeat ultrasound in six months
E. Repeat ultrasound in one year
15 µmol/ L
25. A 36- year- old ex- oender was referred to the gastroenterology clinic
with nausea, vomiting, abdominal pain, and early satiety. He reported
6kg unintentional weight loss recently. He gave a history of previous
substance misuse.
Which recreational drug is associated with delayed gastric emptying?
A. Amphetamine
B. Cannabis
C. Cocaine
D. Ecstasy
E. Ketamine
CHAPTER | QUESTIONS
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26. A 48- year- old man with PSC was reviewed in clinic. He had some fatigue
but otherwise felt well. He had concomitant UC, which was in clinical
remission. His medications were ursodeoxycholic acid (UDCA) 500 mg
twice a day and mesalazine 2 g once a day.
Investigations:
Serum bilirubin
Serum alkaline phosphatase (ALP) 195 U/ L
Serum alanine transferase (ALT) 285 U/ L
Serum albumin 39 g/ L
Full blood count Normal
INR 1.0
Antinuclear antibody Positive
Antinuclear cytoplasmic antibody Positive
Anti- mitochondrial antibody Negative
Anti- smooth muscle antibody Negative
IgA 1.8 g/ L
IgG 19 g/ L
IgM 1.5 g/ L
What investigation would you order next?
A. Anti- sp100 and anti- gp210
B. Liver biopsy
C. Liver elastography
D. MRCP
E. No further investigations required
16 µmol/ L
27. A 46- year- old female with a history of CD attended clinic. She
underwent an ileocaecal resection four years ago and was on no
maintenance therapy. She continued to smoke 15 cigarettes/ day. She
underwent a colonoscopy for symptoms of loose stool.
Investigation:
Colonoscopy Insertion to neo- terminal ileum. Ileocolic anastomosis patent.
Colon normal. Diuse aphthous ileitis with diusely inamed
What is her Rutgeerts score?
A. i0
B. i1
C. i2
D. i3
E. i4
mucosa. No evidence of stenosis or large ulcers.
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CHAPTER | MOCKEXAMINATION
28. A 37- year- old male presented with a ve- week history of fevers, nonproductive cough, bloody diarrhoea, and myalgia. Four weeks ago, he
returned to the UK from travelling in rural India where he had been in
contact with fresh water lakes. On close questioning, he had developed
an itchy rash at the start of his symptoms, which had resolved within
3– 4days.
Investigations:
Haemoglobin 130 g/ L
White cell count 7.0 × 109/ L
Platelet count 180 × 109/ L
Eosinophil count 0.6 × 109/ L
Serum C- reactive protein (CRP) 30 mg/ L
Serum alanine transferase (ALT) 34 U/ L
Serum alkaline phosphatase (ALP) 110 U/ L
Serum bilirubin 10 µmol/ L
Faecal microscopy and culture Negative including ova, cysts, and parasites
Chest radiograph Ill- dened nodular pulmonary inltrates
Which is the next most appropriate diagnostic test?
A. Kato- Katz thick smear technique
B. Rectal biopsy
C. Repeat stool microscopy
D. Serology
E. Urine microscopy
29. A 65- year- old woman with alcohol- related cirrhosis is seen with her
husband in the hepatology clinic. She has been abstinent from alcohol
for two years. Her husband is concerned that she is not her usual self.
She appears oriented to time and place.
Which of the following is correct in the diagnosis of hepatic
encephalopathy (HE)?
A. Arise in blood ammonia level is diagnostic of HE
B. Brain imaging is essential for diagnosis
C. Electroencephalography (EEG) examination is only useful in grade IV HE
D. The Stroop test can be used to help make a diagnosis of HE
E. There is no indication for screening for minimal HE
CHAPTER | QUESTIONS
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30. A 37- year- old man with UC had required multiple courses of oral
corticosteroids over the past two years. Bowel symptoms recurred
whenever prednisolone was reduced below 15 mg daily. Azathioprine
was therefore recommended.
Investigation:
Thiopurine methyltransferase 16 U/ L
Which of the following statements about thiopurine methyltransferase
(TPMT) levels is most accurate?
A. Normal TPMT levels predict clinical response to thiopurines
B. TPMT activity is absent in 1% of the population
C. TPMT activity is normal in 50% of the population
D. TPMT levels accurately predict the risk of leucopenia
E. Variants in TPMT account for up to 25% of thiopurine- induced leucopenia
31. A65- year- old man with Child- Pugh C (10) alcohol- related cirrhosis
presents with Grade 3 ascites. Routine blood tests and a diagnostic
paracentesis are performed.
Investigations:
Serum bilirubin
58 µmol/ L
Serum creatinine 105 µmol/ L
Serum sodium 129mmol/ L
Ascites white cell count 410 cells/ µL
Ascites neutrophil count 220 cells/ µL
Ascites albumin 5 g/ L
Ascites total protein 9 g/ L
The patient has been referred for consideration of liver transplantation
(LT) or transjugular intrahepatic portosystemic shunt (TIPSS) and in the
interim repeated large volume paracentesis is performed.
Which of the above would be an indication for long- term antibiotic
prophylaxis?
A. Ascites protein concentration
B. Ascites total white cell count
C. Prospective LT
D. Prospective TIPSS
E. Repeated large volume paracentesis
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CHAPTER | MOCKEXAMINATION
32. A 56- year- old man presented with a three- month history of intermittent
vomiting and weight loss. He had no past medical history, drank 10 units
of alcohol a week, and was a non- smoker.
Investigations:
Gastroscopy 4cm antral tumour
Histology Adenocarcinoma
With regard to the initial staging of gastric cancer, which is the most
useful modality as an adjunct to CT scanning?
A. Barium meal
B. Endoscopic mucosal resection (EMR)
C. Endoscopic ultrasound
D. Laparoscopy
E. Magnetic resonance imaging (MRI)
33. A 28- year- old Iranian farmer, who had recently immigrated to the UK,
was referred to clinic with persistent diarrhoea. He also complained
of hair loss, taste disturbance, and a supercial scaling erythematous
patchy rash that was most prominent in intertriginous areas and
periorally. There was no cognitive impairment.
Which is the most likely nutrient deciency?
A. Niacin
B. Selenium
C. Vitamin A
D. Vitamin E
E. Zinc
CHAPTER | QUESTIONS
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34. A 68- year- old woman attended for a gastroscopy having been referred
by her GP with anaemia, 4kg weight loss, and abdominal discomfort.
No melaena had been witnessed, although she reported occasional dark
stools.
Investigations:
Haemoglobin 122 g/ L
White cell count 4.6 × 109/ L
Mean corpuscular volume 76 fL
Platelet count 209 × 109/ L
Serum ferritin 6 µg/ L
Serum folate 2.6 µg/ L
Serum vitamin B12 178 ng/ L
Serum C- reactive protein (CRP) 16 mg/ L
The endoscopic images demonstrated the ndings shown in (Fig. 11.3).
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Fig.11.3 Endoscopic image of stomach. See also Plate 20
Which of the following is the most appropriate next step?
A. Antrectomy
B. Argon plasma coagulation
C. Iron supplementation
D. Propranolol
E. Transjugular intrahepatic portosystemic stent shunt (TIPSS)
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CHAPTER | MOCKEXAMINATION
35. A 47- year- old woman presented to the emergency department with
recurrent episodes of right upper quadrant pain. She underwent an
elective laparoscopic cholecystectomy six months before for similar
‘attacks’ despite no evidence of biliary calculi found on imaging. Her
serum liver enzymes and amylase have always been within the normal
limit with each episode.
Investigations:
Gallbladder histology Chronic cholecystitis with no gallstones
MRCP Common bile duct (CBD) diameter 4.9mm, main
pancreatic duct diameter 1.2mm, no features of
chronic pancreatitis
EUS CBD 4.5mm, no evidence of biliary microlithiasis
or sludge
What is the next most appropriate management strategy?
A. Endoscopic intra- sphincteric botulinum toxin injection
B. ERCP with biliary sphincterotomy
C. ERCP with manometry
D. ERCP with pancreatic sphincterotomy
E. Trial of calcium- channel blocker
36. A 56- year- old woman presented with progressive dysphagia to solids but
not liquids. She took omeprazole 20 mg twice daily for heartburn.
Investigations:
Gastroscopy Impassable stricture at 34cm which appeared
endoscopically benign
Which of the following is true with regards to dilatation of benignappearing peptic strictures?
A. Balloon dilatation is more eective than wire- guided bougie dilatation
B. Barium swallow must be performed for all oesophageal strictures
C. Biopsies should be taken before proceeding to dilatation
D. Oesophageal perforation occurs in 4% of procedures
E. The use of post- dilatation H2 receptor antagonists reduces rates of stricture recurrence
CHAPTER | QUESTIONS
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37. A 78- year- old woman was reviewed in outpatients for dysphagia.
She described intermittent diculties swallowing for several years
associated with occasional regurgitation and a sensation of ‘bubbling’
at the back of her throat. She had a persistent cough and friends had
commented that her breath smelt foul. She had a hospital admission
with pneumonia a year ago but had fully recovered. Her only medication
was amlodipine 5 mg once a day for hypertension.
Investigation:
Barium swallow (Fig. 11.4)
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Fig.11.4 Barium swallow
Image courtesy of Dr Horace D’Costa, Consultant Radiologist, Oxford University Hospitals NHS Foundation Trust
Given the diagnosis, which of the following would provide denitive
management?
A. Cognitive behavioural therapy
B. Cricopharyngeal myotomy and pouch excision
C. Endoscopic balloon dilatation
D. Endoscopic diverticulectomy
E. Long- term antibiotics
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