ࡱ>  bjbjΚΚ 8*22Tj&&&&&&&&.000000,Ǥy\&&&&&\.&&q...& &&..&...J<ޟ0"V ~0.ޟ.ޟ<&&&\\.&&&&&&&&&&&&2 :   Gastrointestinal MCQs Di Flood Regarding patients with upper GI bleeds which is incorrect? Use of NSAIDs doubles the risk for an upper GI bleed Urea will increase relative to creatinine in acute bleed Presence of fresh blood on aspiration of NG tube increases mortality as opposed to a clear aspirate. Active bleeding seen at endoscopy has a 10% risk of rebleeding after treatment. Most deaths occur from decompensation of other organ systems rather than exsanguination. Which of the following therapies is proven to reduce mortality and morbidity in bleeding peptic ulcers? Endoscopic procedures H2 antagonists Proton pump inhibitors Octreotide Antacids Which is not true of bleeding oesophageal varices? Mortality approaches 25-40% Use of octreotide IV is as effective as sclerotherapy controlling bleeding in 74-92% of cases. Sclerotherapy has a high rate of complications (40%) including perforation, aspiration, pyrexia, chest pain, ulcers and strictures. Endoscopic variceal ligation is as effective as sclerotherapy with fewer side effects. Use of the sengstaken-blackmore tube is effective in controlling severe bleeding, is easy to insert and has almost no complications. Which is the most common cause of lower GI bleed under 50 years of age? Anal fissures Benign polyps Haemorrhoids Inflammatory bowel disease Diverticulosis Which is not a characteristic of diverticulosis? Acquired defects in bowel wall More common in distal colon Bleeding usually intermittent Significant bleeding usually arises from right side of colon Occur at point of entry nutrient vessel 1=D 2=A 3=E 4=C 5=C A 55 year old woman presents with intermittent bright red PR bleeding. On examination she is stable, and PR shows small external haemorrhoid. What is appropriate treatment for this lady? Reassure, prescribe treatment for haemorrhoids Refer to surgeons for elective haemorrhoidectomy Prescribe treatment for haemorrhoids, and arrange outpatient colonoscopy with surgical follow-up. No further treatment necessary. Admit to hospital for colonoscopy or double contrast barium enema. Which is not a predisposing factor for GORD? High fatty food intake Cholinergic drugs Caffeine Nicotine Gastric outlet obstruction Which is the most common cause of oesophageal perforation? Iatrogenic causes Trauma Boerhaaves syndrome Foreign body Tumour Which is incorrect of swallowed foreign bodies? 80% occur in children 97% of adults with distal meat impactions have pathological conditions so all need Barium swallow studies. The most common area for FBs to be found in children is at the cricopharyngeal narrowing (C6). Glucagon is used to relax smooth muscle but is contraindicated in phaeochromocytoma. Carbonated drinks can be used safely in upper oesophageal obstructions to try and dilate oesophagus to allow FB to pass. Which of the following FBs needs to be removed as an emergency? 50 cent coin in the stomach 50 cent coin in the oesophagus lithium button battery in stomach lithium button battery in oesophagus 5 grams of cocaine in condom sitting in small intestine 6=C 7=B 8=A 9=E 10=D Which is the most common cause of peptic ulcer disease of the following? Smoking NSAIDs Zollinger-Ellison syndrome Ethanol excess Family hx of PUD Which is not true of H.pylori infection? 80% of patients with chronic infection will develop ulcers the most common cause of peptic ulcer disease it is a risk factor for adenocarcinoma of the stomach IgG antibody test will remain positive for up to 2 years post eradication limiting its usefulness The CLO test is approx 90% sensitive and 100% specific for H.pylori Which is not correct regarding treatment of peptic ulcer disease/ Antacids are as effective as H2 antagonists in healing ulcers Proton pump inhibitors show more rapid healing and pain relief over 2-4 weeks compared to H2 antagonists. Colloidal bismuth subcitrate will suppress H.pylori and chelate with the base of the ulcer to aid healing. H.pylori eradication with omeprazole, Amoxil and metronidazole requires only one week of treatment. Misoprostal is indicated for prevention of NSAID induced ulcers, when treatment necessary with NSAIDs. Which is the most common complication of Peptic ulcer disease? Perforation Gastric outlet obstruction Penetration Haemorrhage All are uncommon occurring in less than 5% of patients. Which is incorrect regarding acute appendicitis? Between 50-75% of patients present with the classical symptoms and signs of acute appendicitis. Presence of a good appetite makes appendicitis unlikely Rovsings sign may be helpful in diagnosis especially in obese patients PR tenderness is seen in 90% of patients with acute appendicitis Vomiting prior to onset of pain makes appendicitis unlikely 11=B 12=A 13=D 14=D 15=D Which is incorrect regarding investigation of acute appendicitis? The WCC is increased in 70-90% of patients. CRP will usually be normal in early appendicitis USS is operator dependant but has sensitivity of around 80-90%. USS sensitivity is lowered to around 30% in cases of gangrenous and perforated appendicitis. CT is the investigation of choice in children due to lower sensitivity in this group with USS. Which is the least common cause of large bowel obstruction? Neoplasm Diverticulitis Volvulus Adhesions Faecal impaction Which of the following features suggests a complete large bowel obstruction? Presence of multiple loops of bowel with plicae circularis on AXR Bilious vomiting Distended abdomen, with high pitched bowel sounds with normal flatus. Empty rectum on PR exam Dilated loops of bowel with haustra visible What is the upper limit of normal for large bowel? 3cm 4cm 5cm 6cm 10cm A 50 year old women presents with small bowel obstruction, and on examination has a hard tender mass lateral and inferior to symphysis pubis. What is this most likely to be? direct inguinal hernia indirect inguinal hernia femoral hernia obturator hernia spigelian hernia Which of the following hernia is most likely to incarcerate and strangulate? Congenital umbilical hernia Spigelian hernia Direct inguinal hernia Sportsman hernia Indirect inguinal hernia 16=E 17=D 18=E 19=C 20=C 21=E Which is incorrect regarding inflammatory bowel disease? The risk of developing ulcerative colitis is higher in non-smokers than smokers. Patients with Crohns disease are more at risk of colorectal cancer than UC patients. Effectiveness of colonoscopic surveillance in detecting colorectal cancer is controversial in IBD. Toxic megacolon occurs in Crohns and ulcerative colitis. Cobblestone appearance on bowel wall is more characteristic of Crohn disease Which is not an extra-abdominal manifestation of inflammatory bowel disease? Erythema marginatum Ankylosing spondylitis Episcleritis Thromboembolic disease Sacroiliitis Which is true of the complications of Crohns disease? Perianal complications occur in 50% of patients. GI bleeding is common and often life-threatening Toxic megacolon occurs in 6% but almost never perforates. There is no increased risk of neoplasm of GI tract unlike UC. The majority of patients will not require surgery throughout their illness. Which is incorrect regarding management of Crohns Disease? Mesalamine (pentasa) has fewer side effects than sulphasalazine. Azathioprine has been used in severe cases. Metronidazole has a role in long-term treatment of perianal disease postoperatively to prevent relapse. Corticosteroids have a proven role in maintenance therapy to prevent relapse. Loperamide can be used to control diarrhoea. Which is INCORRECT regarding Ulcerative Colitis? Affects men more than woman Mild disease affects 60% of patients and consists of less than 4 bowel motions per day, with the disease limited to rectum in 80%. In severe disease there is usually hypoalbuminemia and mildly deranged LFTs. Loperamide and other antidiarrhoeal agents should be avoided as they increase the risk of toxic megacolon. Toxic megacolon is usually treated conservatively unless the bowel is wider than 6 cm or the patient severely ill. 22=B 23=A 24=C 25=D 26=E Which is not true of pseudomembranous colitis? Usually occurs following a course of antibiotic treatment. Approx 25% will resolve with supportive treatment only. Vancomycin is the treatment of choice The ELISA C. difficile toxin test is 60-90% sensitive It may rarely result in toxic megacolon and perforation. Which is not true of diverticulitis? Occurs in 10-25% of patients with diverticulae Mostly occurs in the left side of the colon Urinary frequency, pyuria and dysuria is not uncommon Sigmoidoscopy is the best diagnostic tool at time of presentation. Mild cases can be treated as outpatients with oral Amoxil plus clavulanic acid for 7 days. Which is not true of haemorrhoids? Portal venous hypertension can cause enlarged external haemorrhoids Third degree are permanently prolapsed to some degree Thrombosed external haemorrhoids can usually be excised under local anaesthetic. Blood mixed in with the stool raises the possibility of other diagnoses like carcinoma. Internal haemorrhoids occur proximal to the dentate line. Which is true regarding these anorectal disorders? Anal fissures usually occur on the anterior wall medially and any fissure outside of this area raises suspicion for other pathology. Glycerol trinitrate ointment has been used with success in anal fissures. Perianal abscess is usually located in the natal cleft in the midline. Ischiorectal abscesses are usually very obvious on examination of the perineum with fluctuant abscess lateral to anus. Anal fistulae are most commonly secondary to Crohns disease. Which of the following is not true regarding antiemetics? There is a 1% incidence of dystonic reactions with metoclopramide. Prochlorperazine is a category A drug in pregnancy. Droperidol is from the butyrophenome family. Warm flushing and headache are among the most common side effects of ondansetron. Promethazine is relatively contraindicated in children less than 2 yrs. Which is not true regarding diarrhoea? Wrights stain detects faecal leucocytes C. difficle toxin test is a rapid assay available within 2 hours. Ciprofloxacin 500mg BD for 7 days has shown to shorten the duration of infectious diarrhoea secondary to bacteria. Patients with acute diarrhoea should avoid caffeine. Loperamide is not harmful to use in a patient with Salmonella gastroenteritis. 27=C 28=D 29=A 30=B 31=B 32=B Which is not a cause of unconjugated hyperbilirubinemia? Sepsis Gilberts syndrome Congestive cardiac failure Prematurity neonates Infectious mononucleosis Which is not a risk factor for gallstones? Cystic fibrosis Congestive cardiac failure Familial tendency Diabetes Pregnancy Which is incorrect regarding biliary tract disease? Pigment stones are more radio-opaque than cholesterol stones. Bacterial infection occurs in 50-80% of patients with cholecystitis. Murphies sign is 97% sensitive for cholecystitis. CT is as sensitive as USS for detecting gallstones. The classic Charcots triad is present in only 25% of patients with cholangitis. Which is not a cause of acute hepatitis? Wilsons disease Mushroom poisoning amanita phalloides Halothane Ecstasy poisoning Cytomegalovirus Which is not correct regarding viral hepatitis? Anti HAV IgG indicates past infection and immunity to Hep A. Chronic hepatitis occurs in about 5% of patients infected with Hep B. Anti HBc indicates immunity and recovery from Hep B. Hep B immunoglobulin protects 75% of people exposed to Hep B if given within 7 days of exposure. Patients with Hep B have approx 15% risk of transmission with sexual contacts. Which is NOT a complication of hepatic cirrhosis? Spontaneous bacterial peritonitis. Hepatocellular carcinoma. Thrombocytosis. Portal hypertension. Portal vein thrombosis. 33=E 34=B 35=D 36=A 37=C 38=C Which is incorrect regarding LFTs? Normally conjugated bilirubin makes up 70% of the total bilirubin. ALT is a more specific marker of hepatocellular dysfunction than AST. AST: ALT ratio of greater then 2 is common in alcoholic hepatitis. Isolated elevation of ALP may be seen in primary biliary cirrhosis and sclerosing cholangitis. Elevated ammonia levels do not correlate with worsening hepatic function in cirrhosis. The half life of albumin is 3 weeks so is not a good indicator of acute decline in liver function unlike PR which will climb in days. Which statement regarding spontaneous bacterial peritonitis is incorrect? The yearly risk with ascites is about 30%. Diagnosis is confirmed by paracentesis with WBC > 1000/ cubic mm, and PMN > 250/ cubic mm. Bacterial are rarely grown from ascitic fluid. The most common bacteria are anaerobes. Antibiotic choices include cefotaxime or ceftriaxone 2g/day. Which is true of hepatic encephalopathy? It only occurs in chronic hepatic failure. Stage 3 consists of drowsiness and asterixis. Can be due to cerebral oedema as well as accumulation of toxic wastes. Lactulose use is now been shown to be the treatment of choice. Ammonia levels can be used as an index of encephalopathy. Which is not true of acute liver failure? Use of N-acetyl cysteine has been shown to reduce mortality up to 36 hrs post ingestion. Hypotension is usually treated with dobutamine as it is due to cardiac suppression. Mortality is higher in acute liver failure due to Hepatitis B than Hep A. Mortality from paracetamol acute liver failure is higher if the patient is acidotic. Encephalopathy can be managed by dietary protein withdrawal initially. Which is not true of pancreatitis? Alcohol is the most common cause. Pain is usually severe and relieved by sitting forward. Cullens sign is blue discolouration around umbilicus secondary to hemoperitoneum. Amylase is less sensitive in alcoholic pancreatitis than gallstone pancreatitis. CT will be abnormal in the vast majority including mild disease. 39=A 40-D 41=C 42=B 43=E Which is not part of Ransons criteria at initial presentation? Calcium < 1.9 mm/l Age >55 WCC >16 000. LDH > 400 IU Glucose > 11 mmol/l Which number of Ransons criteria fits with predicted mortality? 1-2 risk factors - 5% mortality 3-4 risk factors 16% mortality 5-6 risk factors 50% mortality > 6 risk factors 90% mortality All of the above are correct. Which is not true of pancreatitis? Pancreatic necrosis is often seen on CT and may result in pancreatic insufficiency. Most of the mortality is secondary to systemic effects. Choledocholithiasis does not cause chronic pancreatitis. Abdominal pain associated with chronic pancreatitis improves with progression of the disease. Serum lipase and amylase are usually normal in acute bouts of chronic pancreatitis. 44=A 45=B 46=D GASTOINTESTINAL SUSAN TUCKER Answer questions 1-5 by choosing the correct answers from the list below. Multiple answers may be correct. HBs Ag +ve Anti HepBs Ab +ve HepBc Ag +ve Anti HepBc Ab +ve IgG Anti HepBc Ab +ve IgM E Ag +ve Anti Hep E Ab Hep B DNA Anti delta virus 1.In a person with up to date vaccination of Hepatits B, with no history of infection, what would the serology show? 2.What serology would be seen in seen in a person with prior (5years ago) completely resolved Hepatitis B infection? 3.What would the serology show in a currently infected person with acute Hep B? 4.What would the serology show in a Hep B carrier? 5.What would the serology show in chronic active hepatitis? 6.What would the serology show in co infection with delta virus? 7.Which of the above parameters cannot be measured in the serum? 8.Which statement is false regarding hepatitis A? it is usually mild to moderate in severity with adults usually worse than children chronic hepatitis does not occur both vaccination and immunoglobulin are available it is spread by the faecal oral route it has a high mortality in pregnant women 9.Which is false about hepatitis C? it is usually a mild acute disease the chronicity rate is very high, about 50-80% immunoglobulin is available for contacts there is no vaccine available treatment is symptomatic, interferon being useful for some patients 10.Which drug is not well known to cause acute hepatitis? isoniazid flucloxacillin amioderone chlorpromazine cephalothin 11.Which of the below has been shown to be of benefit in the ED in upper GI bleeding due to duodenal ulceration. antacids proton punp inhibitors H2 antagonists Octroetide None of the above 12.Which is the first line pharmacological agent in the use of upper GI bleeding from oesophageal varices? H2 antagonists Vasopressin Octreotide Proton pump inhibitors Antacids 13.Which statement is false of peptic ulcer disease? helicobacter pylori is found in more duodenal ulcers than gastric ulcers NSAIDS cause more ulcers than helicobacter pylori The rate of release with peptic ulceration if treated with H2 antagonists alone is about 80% NSAIDS cause more gastric ulcers than duodenal ulcers Omeprazole heals ulcers more quickly than H2 antagonists 14.Which is false about hepatic encephalopathy? it is due to ammonia produced in the gut reaching the brain unchanged increased dietary protein and GIT bleeding are both risk factors renal failure is a risk factor neomycin works by removing urease producing gram ves in the bowel lactulose is the agent of choice, causing increased transit time as well as decreased ammonia production 15.Which statement is false regarding amylase and lipase in pancreatitis? lipase remains elevated longer than amylase lipase is elevated to the same extent in both alcohol and gallstone pancreatitis amylase is elevated more in gallstone pancreatitis than alcholol lipase may be elevated in conditions other than pancreatitis amylase may be elevated in conditions than other pancreatitis 16.Which is not part of Ransons criteria on presentation? AST >150 Glucose >11 Calcium <1.9 Age >55 WCC>16 000 17.The recommended antibiotics for acute cholecystitis are? ampicillin ,gentimicin and flagyl ampicillin and gentamicin cefotaxime gentamicin and flagyl ampicillin and cefotaxime 18.Which is NOT true of staph aureus and bacillus cereus gastroenteritis ? They both have a short incubation period They both cause an illness limited to no more than 24 hours Illness is caused by ingesting food with the toxin already produced by these bacteria Illness is caused by ingesting the bacteria which then form the toxin in the gut Antibiotic treatment is not indicated 19.Which statement is FALSE? Enterohemorrhagic E coli gastro is associated with haemolytic ureamic syndrome Giardia Lamblia is usually treated with Norfloxacin in adults Salmonella gastro in children can cause osteomyelitis and meningitis Campylobactor gastro has been associated with reactive arthritis Campylobactor gastro has been associated with guillain-barre syndrome 20.Which of these hernias frequently incarcerate? indirect inguinal direct inguinal femoral umbilical A and C 21.How should a babe with an asymptomatic umbilical hernia be managed? referred for urgent operation referred for operation if still present at 6 months of age referred for operation if still present at 1 year of age referred for operation if still present at 4 years of age referred for operation if still present at 12 years of age 22.Which is the most common hernia in women? indirect femoral umbilical incisional direct 23.Which statement is true? all incarcerated inguinal hernias should be reduced in ED regardless of the duration no incarcerated inguinal hernias should be reduced in ED if there are signs of bowel obstruction an incarcerated inguinal hernias should be reduced in ED if a patients vital signs are unstable an incarcerated inguinal hernia should be reduced in ED urgently if there are signs of bowel obstruction and ischemia an incarcerated inguinal hernias should NOT be reduced ED 24.What is the ost common cause of a large bowel obstruction? adhesions neoplasms volvulus diverticulitis foreign body 25.In patients under 50 hears what is the most common cause of rectal bleeding? haemorhoids anal fissure inflammatory bowel disease carcinoma diverticulosis 26.In patients over 50 years with rectal bleeding and obvious hemorrhoids, how much further should the lower GIT be imaged? no further sigmoidocsopy or all colonscopy for all only investigate further if bleeding still present in 6 months only investigate further if still bleeding in 12 months 27.Which statement is false about inflammatory bowel disease? perianal disease is more common with Crohns disease than UC steroids are used to induce and maintain remission aminosalicylates are used to induce and maintain remission metronidazole can be useful in treating perianal disease the risk of developing UC is higher in smokers than non smokers 28.Which statement is false re IBD? Crohns disease is transmural inflammation UC is mucosal inflammation only Neoplasia is more common with UC than Crohns Total proctocolectomy is curative in both UC and Crohns UC always involves the rectum, Crohns does not ANSWERS 1)B 2)B,D,G 3)A,E,F,H 4)E 5)A,D,F,H 6)A,E,F,H,I 7)C 8)E 9)C 10)E 11)E 12)C 13)B 14)E 15)D 16)C 17)B 18)D 19)B 20)E 21)D 22)A 23)E 24)B 25)A 26)C 27)B 28)D Surgery MCQs 1 Which of the following regarding rectal bleeding is incorrect? 50 - 70% of diverticular bleeding occurs in the right colon 10-15% cases originate proximal to the small bowel haemorrhoids are the most common cause in patients under 50 most angiodysplastic lesions are acquired rather than congenital intermittent minor bleeds are characteristic of diverticular bleeds Which of the following regarding rectal bleeding are true? labelled RBC scans enable precise location of bleeding source most aortoenteric fistulae occur in an untreated AAA most bleeds can have definitive treatment electively the majority of angiodysplastic lesions will cause problems angiography is usually sensitive in detection of bleeding site With regards to anorectal abscesses waiting until fluctuance develops assists in healing post op most are due to anal gland obstruction majority can be managed with simple incision and drainage some degree of external swelling will be visible fistula formation and recurrence occur in <10 % Which of these is incorrect with regards to perianal conditions? GTN ointment can be an effective treatment for anal fissure Chlamydia can cause rectal scarring Syphilitic chancres usually involve the rectal mucosa Laxatives for haemorrhoids should not liquefy stool Salbutamol is effective in treatment of proctalgia fugax Choose the most correct w.r.t. suspected urinary tract trauma the degree of haematuria corresponds to the degree of injury perineal lacerations should be explored to determine depth adult patients with isolated microscopic haematuria do not require imaging almost 95% of bladder injuries are associated with gross haematuria suprapubic catheterisation is contraindicated in severely injured patients Surgery MCQs 2 In urinary tract trauma Grade III renal injury extends through to collecting system Renal pedicle injuries are usually not associated with other injuries CT is the most useful imaging to visualise renovascular injury Renal injuries are the most common Renal contusion accounts for about 60% of renal injuries Which of the following is incorrect? Posterior urethral injuries result in the classic butterfly perineal haematoma The classic triad of bladder rupture is abdo pain, haematuria and inability to void Extraperitoneal bladder ruptures can be managed by catheter placement alone 80% of female urethral injuries present with vaginal bleeding Renal parenchymal lacerations extending to renal collecting system does not always need surgical repair 3. With regards to renal vein thrombosis, which of the following is incorrect? pregnancy is a predisposing factor it often presents with loin pain children who develop it are commonly volume depleted adults who develop it usually have underlying nephropathy it can cause haematuria 4. With regards to haematuria, which of the following is correct? treatment of the primary streptococcal infection with antibiotics prevents poststreptococcal glomerulonephritis there is an underlying pathology in up to 80% of patients who develop haematuria while on oral anticoagulants the most common cause of haematuria worldwide is bacterial infection urethral catheterisation causes microscopic haematuria in up to 80% of patients chronic hypertension is a predisposing factor Surgery MCQs 3 1. With regards to dipstick urine testing for blood, which of the following is incorrect? household bleach in the urine container can cause a false positive result high concentration of ascorbic acid in the urine can cause a false negative result betadine can cause a false negative result high specific gravity can cause a false negative result porphyrins can cause a false positive result 2. Which of the following is not considered a specific risk group for UTIs? neonates older men girls young women young men 3. Which of the following is incorrect? bacteriuria is rare in males under the ago of 50 asymptomatic bacteriuria occurs in up to 30% of pregnant women E.coli is responsible for 50% of urinary infections in pregnancy, UTI may precipitate pre eclampsia and miscarriage anaerobes do not grow well in urine and are rarely pathogenic 4. With regards to urinary infection, which of the following is correct? urethral gram stain is more sensitive than urinary leucocytosis in detecting chlamydial infection 10% of patients develop UTI after single catheterisation cloudiness in urine is usually due to WBC or bacteria in an infected and obstructed kidney, pyuria may be absent the presence of urinary nitrites is highly sensitive for UTI, but with only moderate specificity Surgery MCQs 4 1. With respect to abdominal herniae which of the following statements is incorrect? congenital failure of obliteration of the processus vaginalis is one of the causes of indirect inguinal herniae direct inguinal herniae rarely incarcerate and strangulate a Richter hernia is incarceration of a single wall of a hollow viscus obturator herniae frequently incarcerate epigastric hernia is of approximately equal incidence by sex 2. Which of the following is not a likely cause of large bowel obstruction in a 70 year old man? carcinoma of the colon volvulus adhesions pseudo-obstruction faecal impaction 3. Which of the following statements is incorrect? a postural blood pressure change is discriminatory for intravascular volume depletion the presence of hyperactive/obstructive bowel sounds increases the likelihood of SBO fivefold false positive rebound tenderness occurs in on in four patients without peritonitis positive Murphys sign is 97% sensitive for cholecystitis pain in diverticulitis is confined to the LLQ in < of cases 4. Which of the following statements is incorrect? likelihood ratio of a positive test is the true positive rate over the false positive rate (TPR/FPR) a negative likelihood ratio is the likelihood that a negative test result would be found in a patient without the target disorder the specificity of a test is the number of true negatives over (true negatives + false positives) a positive likelihood ratio is clinically significant if >1 a test with a high specificity has a low number of false negatives Surgery MCQs 5 1. Which of the following is not true of mesenteric ischaemia? patients with mesenteric ischaemia tend to have a substantial degree of age-related comorbidity the small bowel has a warm ischaemia time of 2-3 hours serial serum lactates that remain persistently normal reduce the pretest likelihood of diagnosing mesenteric ischaemia by more than tenfold patients may become transiently better after a few hours of ischaemia initial presentation is characterised by abdominal pain and tenderness Regarding swallowed foreign bodies a. The most common site of foreign body oesophageal obstruction in the paediatric patient is at the level of the aortic arch. b. Button batteries lodged in the oesophagus can be treated by watching and waiting for them to pass. c. Meat impaction in the oesophagus should be treated immediately with papain. d. 15-35% of ingested open safety pins or razor blades will cause intestinal perforation. e. Coins in the oesophagus lie in the sagittal plane on xray. 30. Regarding acute appendicitis a. A white count above 10000/ul is highly specific for appendicitis. b. Graded compression ultrasonography for diagnosis of appendicitis is reported to have sensitivity of 60-69%. c. Vomiting occurs in >80% of patients presenting with acute appendicitis. d. Appendicitis is the 2nd most common extrauterine surgical emergency in pregnancy. e. Mortality rates for patients over 70 with acute appendicitis approach 30%. 31. Many patients with abdominal pain present to ED daily. Complications of gallstone disease must be treated emergently. Which of the following statements is correct? a. The classic Charcot triad of fever, jaundice, and RUQ pain is noted in about 45% of patients with cholangitis. b. Emphysematous cholecystitis complicates the course of ~ 5% of patients with cholecystitis. c. Of all patients with gallstones, 15-20% will develop pancreatitis as a result of biliary calculi. d. Gall bladder empyema is usually caused by staphylococcal organisms. e. The sensitivity of Murphys sign is only 68% in the elderly. 19The following are used as Ranson Criteria in acute pancreatitis EXCEPT: Age over 55 years Systolic BP < 90mmHg Hyperglycaemia Hypocalcaemia Metabolic acidosis Regarding ischaemic colitis which is incorrect angiography has no role and if performed will be negative pain is often diffuse Commonly have diarrhoea 27 Regarding intussusception A ileocaecal is the commonest site B On abdominal X ray loops in the RUQ suggest colonic intussusception 14 = a 27 = a 6. Which of the following is NOT a Ransons criterion for acute pancreatitis on admission: age > 55 years old serum calcium < 2mmol/L white cell count > 16,000 cells/microlitre serum LDH > 350 IU/L serum glucose > 10mmol/L (b: The Emergency Medicine Manual vol 4. page 330) B 45. The commonest causes of large bowel obstruction in adults, in decreasing order, are: diverticulitis, volvulus, neoplasm, adhesions, hernia adhesions, hernia, neoplasm, diverticulitis, volvulus volvulus, neoplasm, adhesions, hernia, diverticulitis neoplasm, diverticulitis, volvulus, adhesions, hernia volvulus, neoplasm, diverticulitis, hernia, adhesions Cam 233 D 52. Superior mesenteric artery thrombosis is associated with: Decreased haematocrit Positive abdominal paracentesis Abdominal XR with a paucity of bowel gas Raised serum amylase Decreased serum phosphate Abdominal paracentesis should be normal Early signs of mesenteric ischaemia and intestinal ischaemia mimic bowel obstruction, but as vascular occlusion progresses the bowel wall becomes oedematous and necrotic with severe thickening Serum amylase levels: Raised in pancreatitis, small bowel perforation, pancreatic cancer, salivary gland disease, impaired renal function, CBD obstruction AND ischaemic bowel Decreased amylase levels associated with PET, chronic pancreatitis, cirrhosis, hepatitis Bowel infarction is associated with SMA occlusion and is associated with HYPER-phosphataemia Associated with atherosclerosis and low cardiac output states D A staff member is referred to the ED with the following results of a routine hepatitis B serology assay. He is asymptomatic, and cannot recall if he has received Hep B vaccination before. HBs antigen: significantly positive Anti-HBs: not detected Anti-HBc: low titres Select the correct statement: he has received Hep B vaccination and is immune he has received Hep B vaccnation, but is not immune he is a highly infective chronic carrier there is a 2-30% risk of seroconversion in a recipient if he was the source in a needlestick injury none of the above Cam 333 D 53. Re-bleeding occurs most commonly with which cause of upper gastrointestinal bleeding? Oesophagitis Gastritis Mallory-Weiss tear Peptic ulcer disease Varices Ros 1904 E 56. Regarding Hepatitis A: It is a reportable / notifiable disease in Australia. It is caused by a DNA virus. The incubation period is usually longer than that of Hep B. Passive immunisation against Hep A is not available. Chronic hepatitis often succeeds the acute infection. Cam 332 A 22. Oesophageal foreign bodies can be treated with all of the following EXCEPT: a) foley catheter b) sodium bicarbonate c) papain d) glucagon e) tartaric acid C 2) With regards to abdominal hernias a. Femoral hernias is more common than inguinal hernia in women b. Saphena varix and femoral hernia can only be distinguished at operation c. Umbilical hernias rarely strangulate d. Inguinal hernias may transilluminate e. 2) With regard to abdominal hernias a. Femoral hernias are more common than inguinal hernias in women. Femoral hernias are more common in women vs men but they are still less frequent than inguinal hernias in women. b. Saphena varinx and femoral hernia can only be distinguished at operation. crap just use a colour flow Doppler c. Umbilical hernias rarely strangulate. Crap they frequently complicate in adults but rarely complicate in children less than 4 years old. d. ** Inguinal hernias may transilluminate unlikely but not impossible, they need to be fluid filled to transilluminate and this is more common with hydrocoele. 5) Inflammatory bowel disease, which is correct a. Ulcerative colitis needs an operation in >80% b. Chrons disease involves the terminal ileum most commonly c. d. e. 5) Inflammatory bowel disease, which is correct a. *Ulcerative colitis needs operation in >80%. Often responds to medical management however risk of colon cancer quite high b. **Crohns involves terminal ileum most often. 10) Regarding acute cholecystitis which is false a. 2-12% are Acalculus b. In penicillin allergy it is appropriate to treat with cefotaxime only c. Is commonly associated with mild jaundice d. Is associated with cystic duct obstruction e. Commonly cultured organisms are GN and anaerobes 10) Regarding acute cholecystitis which is false a. 2-12% acalculus. Tintanelli syas 5-10% b. In penicillin allergy it is appropriate to treat with cefotaxime as a single agent. True antibiotic guidelines say that anaerobic infection is rare. Recommends Amoxy + gent or cefotaxime/ceftriaxone as single agents c. Is commonly associated with mild jaundice true d. Is associated with cystic duct obstruction. True e. *Commonly cultured organisms are GN and anaerobes. False anaerobes rare, gram negs common 25) Regarding a febrile oncology patient, which is true a. Increased risk of bacterial infection if neutrophils >500mm3 b. Increased risk of fungal infection with broad spectrum antibiotic administration c. Line sepsis is most common source d. e. 26) Regarding GI bleed, which is true a. 60% associated with PUD b. Octreotide is of no additive benefit to sclerotherapy in banding c. d. e. 25) Regarding febrile oncology patients which is true? a. Increased risk of bacterial infection if neutrophils >500/mm no < 500 b. *Increased risk of fungal infection with broad spectrum antiobiotics this is true for any one but especially immunocompromised c. Line sepsis is most common source false, it can be a source but it is more frequently due to UTI> chest 26) Regarding GIT bleed which is true? a. *60% associated with PUD true according to tintanelli b. Octreotide is of no added benefit to sclerotherapy in banding I presume this is talking about oesophageal varacies where octreotide has a proven and important role either alone or in combination with other treatments 41) Which of the following is most likely to result in a non therapeutic laparotomy following stab wound to the anterior abdomen a. Generalised peritonitis b. Fresh blood in the NGT c. Diaphragm involvement d. Extravasation of contrast on CT in the upper GI region e. 41) Which of the following is most likely to result in a non theraputic laparotmy following a stab wound to the anterior abdomen a. Generalized peritonitis. True b. *Fresh blood in NGT. Possible but maybe from nose bleed/trauma of putting in NGT c. Diaphragm involvement. True d. Extravasation of contrast on CT in the upper GI region. True 51) With respect to anal fissures a. They often point away from the anal verge b. Originate at anal valves c. Situated between internal & external shincters d. e. 52) With respect to large bowel obstruction a. Often associated with diverticulitis in the elderly b. Associated with sigmoid volvulus in children under 2 c. d. e. 51) With respect to anal fissures a. **They often point away from the anal verge. True b. Originate at anal valves. False originate in skin and rarely extend to valves. Usually valses spasm causing more pain c. Situated btn internal and external valves. Bosh 52) With respect to large bowel obstruction a. Often associated with diverticulitis in the elderly. More often Ca b. *Associated with sigmoid volvulus in under 2 14) Regarding pancreatitis which of the following is TRUE? a. Amylase is negative in 50% of cases b. c. d. e. 15) With respect to the diagnosis of appendicitis a. b. c. d. WCC is greater than 10,000 in 70% of cases e. 14) Regarding pancreatitis which of the following is true a. Amylase is negative in 50%. Acute pancreatitis amylase has sensitivity 80-90 and specificity 75. Lipase sensitivity is 90 and specificity is 90. Pancreatitis occurs with no rise in amylase in 10-20% especially in chronic. Lipase is more useful in this setting 15) With repsct to the diagnosis of appendicitis a. WCC >10,000 in 70%. WCC >10,000/ul is 70-90% sensitive but specificity is very low 26) With respect to abdominal hernias which of the following statements is TRUE? a. Hydrocele is the commonest testicular abnormality in kids b. Inguinal hernias are commonest in premature infants c. Male and female ratio of femoral hernias d. e. 26) With respect to abdominal hernias a. Hydrocoele is the commonest abnormality in kids. Hernias probably more common than hydrocoeles and can be difficult to distinguish. b. **Inguinal hernias are commonest in prems c. Male:female ratio of fem hernias = 5:1 3. Acute Liver failure Paracetamol most common cause hepatitis B with D according to Rosen, viral hepatitis according to ICU manual but in the UK paracetamol poisoning is the most common. UK and USA is paracetamol (google) 9. The following is true of abdominal xrays except Free air 1-2ml can be detected not true Lateral decubitis xray has high sensitivity for free air if the patient cannot stand Definitive diagnosis is made in 80% of small bowel obstruction Dose of radiation 50 times that of CXR Most children < 3yo need diagnostic barium enema 10. Regarding diverticular disease Attacks are more severe in patients under 40yo True (Dunn) A mass is rarely felt can be felt PR or on abdominal palpation 50% of patients have occult blood in bowel motions Some may have only right sided tenderness 1.5%, increased in Asians Most AXRs in diverticular disease show ileus and distension 17Which of the following is TRUE regarding meat impaction in the oesophagus? Endoscopy should be performed within 6 h, even in patients who are handling their own secretions. Oesophageal pathology is present in up to 50% of patients. Glucagon, nifedipine, and meat tenderiser should all be tried before endoscopy. After the patient feels the bolus has passed, a barium swallow should be performed. Patients without airway compromise can be observed as outpatients and scheduled for a 24-h follow up. 18Which of the following statements is MOST correct regarding abdominal pain the elderly? Elderly patients are unlikely to have the problems of younger patients, such as appendicitis or cholecystitis. Given the same underlying diagnosis for an acute abdominal disorder, the elderly have about the same mortality rate as younger patients. The elderly exhibit less pain and tenderness than younger patients, but they are more likely to have fever and leukocytosis than are younger patients. Diagnostic delays and pre-existing illnesses lead to a higher mortality in elderly patients than in younger patients. The elderly are more likely than younger patients to seek early medical attention for abdominal pain. 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