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G.PATH-SBA-71-140 71. A 47-year-old barmaid presents to the Accident and Emergency department with a 12-hour history of right upper quadrant pain and vomiting. She says that the pain is radiating to her right scapula and exacerbates on breathing. She appears pale and mildly jaundiced. On examination, her pulse rate is 98/min, blood pressure is 126/84 mmHg and temperature is 37.6º C. Abdominal examination reveals tenderness over the right hypochondrium but no mass is palpable. Plain radiographs of the abdomen (supine) and chest (erect) are unremarkable. From the options below choose the ONE that you think is the most likely diagnosis in this patient:

Perforated peptic ulcer

Acute pancreatitis

Acute biliary cholangitis

Acute cholecystitis Correct answer

Infective hepatitis

The history, signs and symptoms in this patient are suggestive of acute cholecystitis. Acute cholecystitis is more common in females over the age of 40 and with high BMI. Gallstones are the commonest cause for acute cholecystitis. Obstruction of the common bile duct due to stones leads to accumulation of bile and inflammation, resulting in an acutely inflammed gall bladder. Other risk factors for acute cholecystitis include alcohol abuse and tumours of the gall bladder. The signs and symptoms of acute cholecystitis include severe right hypochondrial pain exacerbated by respiration, nausea and vomiting, and increase in temperature. The rise in temperature is frequently mild to moderate; a very high temperature with or without chills and rigors may point to a diagnosis of acute cholangitis. A tender, inflamed gall bladder may be palpable in some patients. Likewise, jaundice may or may not be present. The differential diagnoses for acute cholecystitis include acute pancreatitis, peptic ulcer disease or perforated peptic ulcer, appendicitis, acute infective hepatitis and pleurisy. 72. A 51-year-old lady presents to the Surgical Emergency Assessment Unit with a 12-hour history of central colicky abdominal pain and vomiting. She has undergone a subtotal colectomy and formation of an end ileostomy for ulcerative colitis 7 years ago. Her ileostomy has not functioned for 2 days. On examination, she is tender over the upper abdomen and the abdomen is mildly distended. Plain abdominal radiograph reveals number of small loops in the centre of the abdomen. From the options below choose the ONE that you think is the most likely diagnosis in this patient:

Acute colonic pseudo-obstruction

Incarcerated incisional hernia

Bacterial peritonitis

Adhesional small bowel obstruction Correct answer

Sigmoid volvulus

Small bowel obstructions make up 80-85% of all intestinal obstructions. Of these, adhesions accounts for nearly 90% of all small bowel obstructions. Adhesions usually develop following laparotomy and/or surgery to the bowel. It can occur as a sequlae of ‘minor’ abdominal surgeries such as appendicectomies or ‘major’ surgeries such as resection of large sections of the bowel. In females, gynaecological procedures are an important cause; in addition, pelvic inflammatory disease can also lead to adhesions even in the absence of a surgical intervention in the abdomen. The cardinal features of small bowel obstruction are pain, vomiting and abdominal distension; untreated, this leads to constipation with reduction in flatus which then becomes absolute. The pain is usually colicky due to excessive peristalsis, but may become continuous if strangulation or perforation occurs. Vomiting is early in high small bowel obstruction, late in low small bowel obstruction and delayed or absent in large bowel obstruction. The management involves appropriate resuscitation of the patient and surgical exploration of the abdomen to relieve the obstruction. 73. A 25-year-old footballer presents to the Accident and Emergency department with pain in his left lower leg after he was violently kicked (in his leg) during a tackle. On examination, his pulse rate is 96/min and blood pressure is 116/74 mmHg. There is considerable bruising over the posterior aspect of his leg, and that part of the limb is tense, swollen and tender. He complains of altered sensation over the dorsum of his foot. Dorsiflexion of the foot and extension of the toes are painful and limited. Although he had normal anterior tibial and dorsalis pedis pulsations when he was brought to the Accident and Emergency department, they soon become weak and difficult to palpate. Plain radiograph of this limb does not reveal any fractures. From the options below choose the most appropriate cause for this patient’s signs and symptoms:

Deep venous thrombosis

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Torn muscle bellies of gastrocnemius and soleus

Compartment syndrome Correct answer

Ruptured Achilles tendon

Thrombosis of the popliteal artery

Compartment syndrome is defined as an increase in the interstitial fluid pressure within an osteofascial compartment of sufficient magnitude to cause a compromise of the microcirculation leading to necrosis of the affected nerve(s) and muscle(s). It is a well-recognised and important complication of lower limb injuries, most commonly seen after fractures and crush injury, although it can occur in the absence of bony injury. The other causes for compartment syndrome include electrical injuries, deep thermal burns, venom from snake bites, restricting tourniquets, and fluid extravasation (e.g. intravenous regional anaesthesia). The patient may present with unremitting pain that is not relieved by high doses of opioid analgesics. Severe pain in response to passive stretch of the ischaemic muscles is by far the most dramatic and reliable clinical sign of compartment syndrome. Sensory loss occurs before motor loss. Early in its development, the peripheral pulses are normal, as is the colour and temperature of the affected part, since it is the microvasculature that is initially affected. Loss of peripheral pulses is usually a late and often sinister sign. With progression of the condition, the limb becomes tense and swollen, and if left treated, the muscle weakness progresses to paralysis. Untreated, irreversible myoneural necrosis occurs within 6-8 hours. The areas of muscle may also infarct causing rhabdomyolysis, hyperkalaemia, hyperphosphataemia, high uric acid levels and metabolic acidosis. 74. A 28-year-old hair stylist presents to her General Practitioner with a three-month history of crampy lower abdominal pain, diarrhoea (12-15 times/day), mouth ulcers and loss of appetite. She reckons that she has lost nearly a stone in weight during this period. She smokes 20 cigarettes/day. Abdominal examination reveals a mildly tender mass over her right iliac fossa. A few abscesses with sinus formation are noticed in the perianal region. From the options below choose the ONE which you think is the most likely diagnosis in this patient: .

Pelvic inflammatory disease

Pseudomembranous colitis

Ulcerative colitis

Crohn’s disease Correct answer

Carcinoma of the colon

The signs and symptoms in this patient are very suggestive of Crohn’s disease. Crohn’s disease can affect the whole of the GI tract, leading to ulcers in the mouth. Risk factors for Crohn’s disease include a strong positive family history, a variety of food, smoking (increases the risk by three folds), and infective agents such as mycobacterium and cell wall deficient organisms such as pseudomonas. The clinical presentation of this condition includes cramp-like or constant pain over the umbilical region/right iliac fossa, low-grade fever, loss of appetite, loss of weight, anaemia and general fatigability. Diarrhoea may be troublesome, which is usually non-bloody and intermittent. If the colon is involved, patients may present with diffuse abdominal pain accompanied by mucus, blood and pus in the stool. Perianal fissures or fistulae (e.g., entero-colic, entero-cutaneous), intra-abdominal abscesses and adhesions, and intestinal obstruction may develop with progression of the disease. 75. A 44-year-old female presents to the Surgical Emergency Assessment Unit with a 72-hour history of abdominal pain, vomiting and being generally unwell. She has also noticed pale stools and dark urine. On examination, she is jaundiced and is tender over the right upper quadrant. An ultrasound reveals a dilated proximal common bile duct with intra hepatic duct dilatation. A MR cholangiopancreatogram confirms a fistula between the gallbladder and the common bile duct, and a large calculi is found in the common bile duct just distal to the fistula. From the options below choose the ONE that you think is the most likely diagnosis in this patient: .

Carcinoma of the head of the pancreas

Cholangiocarcinoma

Mirizzi’s Syndrome Correct answer

Hepatocellular carcinoma

Carcinoma of the ampulla of Vater

Mirizzi’s syndrome is caused due to impaction of gallstones either in the cystic duct or the Hartmann pouch of the gallbladder, leading to compression of the common hepatic duct from the outside, resulting in symptoms of obstructive jaundice. Impaction

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of gallstones in the Hartmann pouch or cystic duct results in the Mirizzi syndrome either by: (i) chronic and/or acute inflammatory changes leading to contraction of the gallbladder and stenosis of the common hepatic duct, or (ii) cholecystocholedochal fistula formation due to direct pressure necrosis of adjacent duct walls from large impacted stones. Patients may present with pain over the right upper quadrant of the abdomen, vomiting, fever, recurrent cholangitis, cholecystitis or pancreatitis. Pale stools and dark urine result from obstruction of the flow of bile into the intestine. Treatment of this condition is exploration of the common bile duct by either open or laparoscopic cholecystectomy and placement of a T-tube. 76. A 56-year-old man, who drinks about 60-70 units of alcohol per week, presents to the Accident and Emergency department with severe abdominal pain and 2-3 episodes of vomiting blood. On examination, he appears pale with a pulse rate of 110/min. Abdominal examination reveals dilated veins in the anterior abdominal wall, mild ascites, a large spleen and a small nodular liver. From the options below choose the ONE that you think is the most likely diagnosis in this patient: .

Chronic pancreatitis

Hepatocellular carcinoma

Amoebic hepatitis

Portal hypertension Correct answer

Myeloproliferative disorder

Portal hypertension is defined as an increase in the portal vein pressure of more than 10mmHg (the normal portal vein pressure is in the range of 5-10 mmHg). Among other causes, cirrhosis of the liver is one of the important causes of portal hypertension and currently accounts for up to 90% of cases in the UK. Collateral channels develop in portal hypertension between the portal system and systemic circulation such as in the lower end of oesophagus (resulting in oesophageal varices), distal rectum, and anterior abdominal wall (resulting in dilated tortuous veins in the anterior abdominal wall known as caput medusae). Some of the signs and symptoms of portal hypertension include abdominal pain, ascites, jaundice, splenomegaly and signs of cirrhosis (such as spider naevi, gynaecomastia, palmar erythema and testicular atrophy); signs of shock may be present if there is bleeding from sites of porto-systemic anastamosis, particularly oesophageal varices leading to haematemesis and/or melaena. 77. A 22-year-old female is referred by her General Practitioner to the rapid access breast clinic with a lump in her left breast. She says that it has been present for about 8-weeks now and is painless. There is no bleeding or discharge from her nipples. On examination, there is a 2-cm sized, firm, mobile and smooth lump in the upper outer quadrant of her left breast. There is no palpable axillary lymphadenopathy. Her paternal aunt died from breast cancer at the age of 62. From the options below choose the ONE that you think is the most likely diagnosis in this patient: .

Cystosarcomma phyllodes

Fibroadenoma Correct answer

Fibrocystic disease

Mondor’s disease

Paget’s disease

Fibroadenoma is the most commonly diagnosed breast tumour in women under 30 years of age. They are benign tumours originating from the breast lobule. They show proliferation of both epithelium and connective tissue elements, and is considered as an 'Aberration of Normal Development and Involution (ANDI)'. Most fibroadenomas measure 2-3 cm in diameter. Fibroadenoma is common between 16 and 24 yrs of age; the incidence decreases towards menopause. Fibroadenomas are usually mobile, firm and smooth lumps (but sometimes may be lobulated). It may be multiple in approximately 10% of the cases. The diagnosis is confirmed by triple assessment: (i) clinical examination (ii) radiological assessment (mammography or ultrasound scan), and (iii) cytological/histological (fine needle aspiration, core biopsy). Over a 5-year period, 50% increase in size, 25% remain stable and 25% decrease in size. Risk of malignant transformation is approximately 1 in 1,000. 78. A 54-year-old male presents to his General Practitioner with a two-week history of sweating, headache, constipation and itchy lesions over his back. On examination, his blood pressure is 162/94 mmHg and his pulse rate is 102/min. Twenty-four hour urinary catecholamines, metanephrines and vanillyl-mandellic acid are found to be elevated. A CT and a 131I-meta-iodo-benzyl-guanidine scan confirms a phaeochromocytoma. He is subsequently found to have a medullary carcinoma of the thyroid. From the options below choose the ONE that you think is the most likely diagnosis in this patient: .

Multiple Endocrine Neoplasia I

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Secondary hyperparathyroidism

Multiple Endocrine Neoplasia IIB

Carcinoid tumour

Multiple Endocrine Neoplasia IIA Correct answer

Multiple Endocrine Neoplasia II (MEN II) is an autosomal dominant disorder caused by mutations in the RET proto-oncogene. MEN II has 3 distinct subtypes - MEN IIA, MEN IIB, and familial medullary thyroid carcinoma-only. MEN II describes the association of medullary thyroid carcinoma, phaeochromocytomas and parathyroid tumours. MEN IIB is characterised by MEN IIA plus Marfanoid features and mucosal neuromas. In MEN IIB, the medullary cancer is very aggressive with most patients dying before developing either a phaeochromocytoma or hyperparathyroidism. A patient with medullary carcinoma of the thyroid may present with diarrhoea due to elevated prostaglandin or calcitonin levels. Patients with hypercalcemia may present with constipation, polyuria, polydipsia, depression, nephrolithiasis, glucose intolerance, gastroesophageal reflux, loss of bone density and fatigue. Patients with pheochromocytomas may present with hypertension, tachycardia, sweating and headaches. Cutaneous lichen amyloidosis in patients with MEN IIA manifests as multiple pruritic scaly skin lesions in the scapular area of the back. 79. A 30-year-old woman presents with a lump in the right lobe of the thyroid. It is hard, non-tender and has rapidly increased in size. Her lymph nodes are enlarged. She has previously had radiotherapy to her neck. Histology shows Orphan Annie nuclei . The most likely tumour is?

Follicular adenoma

Anaplastic carcinoma

Medullary carcinoma

Papillary carcinoma Correct answer

Follicular carcinoma

Papillary carcinoma is the commonest malignant thyroid tumour. This is more common in younger patients, females and those with a past history of head and neck irradiation. It often spreads to local lymph nodes. Orphan Annie nuclei are characteristic, Psammoma bodies may also be seen. 80. The histology from a lymph node biopsy reveals Reed-Sternberg cells. The patient has?

Hodgkin’s lymphoma Correct answer

Follicle centre cell lymphoma

Langerhan’s cell histiocytosis

Burkitt’s lymphoma

Non-Hodgkin’s lymphoma

Reed-Sternberg cells are characteristic of Hodgkin’s lymphoma. B and D are examples of non-Hodgkin’s lymphoma along with B-cell and T-cell lymphoma. Langerhan’s cell histiocytosis is a neoplastic condition of the Langerhan’s cells causing lymphadenopathy. 81. You receive the histology report from a specimen from a colonic resection. It reveals that the tumour extends through the muscularis propria to the serosal surface. There are local lymph nodes involved, but not the node at the level of the ligated vascular pedicle. What is the Dukes stage of the tumour:

A

B

C1 Correct answer

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C2

D

The Dukes classification is: A – Confined to the bowel wall, not extending through the muscularis propria B – Extends through the bowel wall into the serosa. No lymph node involvement C1 – Local lymph nodes involved, but not the apical node (at vascular pedicle) C2 – Local lymph nodes involved including the apical D – Distant metastases 82. In a patient with bladder transitional cell carcinoma, the occupation most likely to have exposed them to a carcinogen is?

Painter

Peanut farmer

Printer

Dye worker Correct answer

Miner

Beta-naphthylamine exposure is related to transitional cell carcinoma, and this is used in the dye industry. Painting and printing are linked to benzopyrene exposure and an increased risk of lung cancer. Mining is linked to chromium, asbestos, arsenic and nickel exposure, and increases the risk of lung cancer. Peanut farming causes exposure to aflatoxin and increases the risk of hepatocellular carcinoma. 83. The predominant cell in a healing wound 5 days old is?

Neutrophils

Myofibroblasts

Endothelial cells Correct answer

Macrophages

Fibroblasts

The cells involved in wound healing appear in the following order: Immediately – Platelets – for clot formation Neutrophils – for initiation of phagocytosis respectively. Intermediate (1 – 2 days) – Macrophages – for continued phagocytosis and growth factor secretion Fibroblasts – for synthesis of extracellular matrix components Myofibroblasts – for wound contraction Late (3 – 5 days) – Endothelial cells – for capillary formation 84. When classifying surgical procedures according to the risk of wound contamination, appendicectomy is an example of?

Clean

Clean contaminated Correct answer

Contaminated

Dirty

Infected

Infected is not part of the classification of risk of wound contamination. In a clean wound the viscus wall is not breached. In a clean contaminated wound the viscus wall is breached, but the contents are contained and no spillage occurs. In a contaminated wound the viscus wall is breached and contents spilled. In a dirty wound there is already pus or spilled bowel contents. 85. A 50-year-old man has an adrenal mass noted on CT scan. This is a metastasis. The most likely primary source is:

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Kidney

Lung Correct answer

Prostate

Pancreas

Colorectal

Tumours commonly metastasising to the adrenal glands are lung and breast cancers. Kidney and prostate more commonly metastasize to lung and bone, pancreas to liver and colorectal to lung and liver. 86. A 70-year-old female presents with increasing pain in the right femur. X-rays reveal a single lytic lesion consistent with bony metastasis. Which of the following is LEAST likely to be the primary: Single best answer question – choose ONE correct option only

Colon Correct answer

Breast

Bronchus

Kidney

Thyroid

The five tumours commonly metastasising to bone are breast, bronchus, kidney, thyroid and prostate, however prostate tend to cause sclerotic lesions. Colorectal cancer commonly metastasises to lung and liver. 87. An 18-year-old male presents with a left testicular lump. Which of the following tumour markers would be LEAST useful?

Alpha-fetoprotein

LDH

Beta-HCG

Ca 15-3 Correct answer

GGT

Alpha-fetoprotein, beta-HCG and LDH are elevated by NSGCT. Beta-HCG can be elevated with seminoma. GGT can be elevated by testicular tumours, but is not commonly used in clinical practice. Ca 15-3 is a tumour marker for breast cancer. 88. An 18-month-old presents with septic arthritis of the left hip. The most likely causative organism is?

Neisseria gonorrhoeae

Haemophilus influenzae Correct answer

Staphylococcus aureus

Haemolytic streptococcus

Salmonella

Haemophilus influenzae is the most common cause of septic arthritis in infants <5 years, Staphylococcus aureus is the second commonest cause. Staphlococcus aureus is most common in children >5 years and adults >50 years, and second most common in adults <50 years. In adults <50 years the commonest cause is Neisseria gonorrhoeae. Salmonella may be seen in sickle cell patients. Haemolytic streptococcus is a more common cause of osteomyelitis in children <5 years. 89. A 60-year-old female presents with a painful knee. The pain has been gradually increasing, is worse at the end of the day, and with exercise and is associated with a swollen joint. Her FBC, ESR and CRP are all normal. The most likely condition is?

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Septic arthritis

Osteoarthritis Correct answer

Rheumatoid arthritis

Gout

Bursitis

This is a chronic condition, septic arthritis, gout and bursitis all have a more acute presentation, and the pain of these is unaffected by exercise. Rheumatoid arthritis pain is relieved by exercise and worse on waking/resting, in contrast to osteoarthritis, which is worse with exercise and at the end of the day. Rheumatoid arthritis causes anaemia of chronic disease and during flare-ups a raised ESR and CRP. Osteoarthritis does not cause any such blood result abnormalities. The knee is very commonly affected by osteoarthritis. 90. Which virus is most commonly associated with hepato-cellular carcinoma?

Hepatitis A

Hepatitis B Correct answer

Hepatitis D

Hepatitis E

Epstein Barr Virus

Hepatitis B is strongly associated with hepatocellular carcinoma, and patients are often HbsAg positive. Hepatitis A and E are self-limiting diseases, not known to cause chronic liver disease. Hepatitis D requires HbsAg co-existence. EBV is linked to nasopharyngeal carcinoma, Burkitt’s lymphoma and Hodgkin’s lymphoma. 91. A swab result from one of your patients shows a gram positive aerobic coccus, which is coagulase negative. Which of the following is the most likely organism? Single best answer question - choose ONE true option only

Staphylococcus aureus

Streptococcus viridans

Staphylococcus epidermidis Correct answer

Streptococcus faecalis

Enterococcus faecalis

Staphylococcus and streptococcus are both aerobic gram positive cocci, enterococcus faecalis is anaerobic. The presence of the coagulase enzyme is a test to subdivide the staph micro-organisms. Staphylococcus aureus is coagulase positive. Haemolytic groupings are used for Streptococcus. 92. An 80-year-old patient on IV cefuroxime develops diarrhoea. The organ ism that you should test the stool sample for is:

Clostridium difficile Correct answer

Clostridium perfringens

Clostridium tetani

Clostridium botulinum

Escherichia coli

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The patient is on antibiotics which increases the risk of pseudomembranous colitis, cephalosporins are particularly linked to this, and Clostridium difficile is the causative organism. E. coli can cause diarrhoea, but is a less likely cause in this patient. Clostridium perfringens can cause gas gangrene, clostridium tetani causes tetanus, and clostridium botulinum causes botulism. 93. A patient presents with hyponatraemia. The chest X-ray shows a lesion. The most l ikely type of lung cancer is:

Squamous cell carcinoma

Adenocarcinoma

Giant cell carcinoma

Clear cell carcinoma

Small cell carcinoma Correct answer

The patient has a syndrome of inappropriate ADH secretion secondary to the lung mass. Small cell (oat cell) tumours are most commonly associated with paraneoplastic syndromes (15% of patients have them at presentation).Increased ADH secretion and increased ACTH secretion are most common. Squamous cell tumours can cause ectopic PTH secretion. 94. A 30-year-old female who has had recurrent UTIs, presents with loin pain. The KUB shows a staghorn calculus. The most l ikely type of calculus is:

Calcium

Struvite Correct answer

Oxalate

Urate

Xanthine

Struvite stones are radio-opaque and associated with infections with urea splitting organisms e.g. Proteus. They are also more commonly responsible for staghorn calculi. The calculi associated with urate and xanthine are radiolucent. Calcium are associated with excess calcium absorption and bone disorders. Oxalate are associated with bowel pathology. 95. A biopsy result from a colonoscopy reveals changes throughout the layers of the bowel wall including a non-caseating epitheloid granuloma, cobblestone appearance of the mucosa and fissuring ulcers. The most l ikely diagnosis is:

Crohn’s Correct answer

Ulcerative colitis

Pseudomembranous colitis

Familial adenomatous polyposis

Ischaemic colitis

The appearances are those of inflammatory bowel disease. In order to differentiate between Crohn’s and ulcerative colitis, UC is limited to the mucosa, doesn’t feature granulomas and only causes small, shallow ulcers. 96. A patient has anti-A and anti-B antibodies in their blood. The ir blood group genotype must be:

OO Correct answer

AA

AO

BB

AB

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Phenotypically O patients have antigen O and antibodies to A and B. Since O is recessive, genotypically the patient must be OO, as AO would give a phenotypically A patient, and BO would give a phenotypically B patient. 97. A patient presents with a painful slowly enlarging left parotid mass and a facial nerve palsy. The most likely lesion is: Single best answer question - choose ONE true option only

Pleomorphic adenoma

Warthin’s tumour

Myoepithelioma

Adenoid cystic carcinoma Correct answer

Ductal papilloma

The facial nerve involvement points to a malignant tumour. The other tumours are all benign. Benign tumours are also more often painless. 98. A patient has primary hyperparathyroidism, in order to confirm adenoma, the best biopsy type would be:

Fine needle aspiration cytology

CT guided biopsy

Core biopsy

US guided biopsy

Intra-operative frozen section Correct answer

The difficulty with parathyroid biopsy is the variable location of the glands, making them inaccessible to simple biopsy techniques, even with image guidance, so intra-operative frozen section is the only way of being certain that parathyroid tissue has been sampled. 99. A 33-year-old woman underwent a total unilateral thyroid lobectomy for a suspicious dominant nodule. Subsequent histology demonstrated multi-focal papillary cancer with 18mm and 4mm foci. Resection margins were clear, with no lymphadenopathy noted at operation. Which of the following treatment options is the most appropriate next stage of treatment?

Completion total thyroidectomy and radical neck dissection

Completion total thyroidectomy Correct answer

Local radiotherapy

Radioactive iodine (131I) imaging and ablation

Regular out-patient follow-up with thyroglobulin measurements

Micropapillary tumours (<10mm diameter) are frequently co-incidental findings and can be safely managed without total thyroidectomy in the absence of clinically overt contralateral or metastatic disease. Larger tumours, especially when multi-focal, should be considered for completion thyroidectomy. There is no evidence to support radical block dissection of the neck. Excision of locally infiltrated structures may be required with extensive extrathyroidal disease, along with radiotherapy. Radioactive iodine is a useful means of detecting metastatic disease after total thyroidectomy. Measurement of thyroglobulin is a sensitive indicator of recurrent disease after total thyroidectomy when the patient is on full thyroxine replacement therapy. 100. A 26-year-old woman presents with right upper quadrant discomfort and elevated serum transaminases. A diagnosis of hepatitis C is made following detection of antihepatitis C virus antibodies. Which of the following represents the most likely subsequent event?

Complete recovery

Development of chronic hepatitis C Correct answer

End stage liver disease

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Transmission to her monogamous partner

Vertical transmission to potential children

Hepatitis C is transmitted by parenteral or permucosal exposure to infected blood or body fluids. Many patients have a history of intravenous drug abuse or transmission of blood products before the implementation of antihepatitis C virus screening of blood donors in 1992. 70-85% of those with acute hepatitis C will develop a chronic infection and of these 20% will develop end stage liver failure due to progressive cirrhosis. Transmission to monogamous partners and vertical transmission is uncommon and accounts for the minority of new cases of hepatitis C. Hepatocellular carcinoma occurs in 1-4% of those with associated cirrhosis per year. 101. A 48-year-old woman presents with a painless slow growing mass in the left parotid gland. There is no apparent involvement of the facial nerve. From the following list, which is the most likely finding on biopsy?

Adenoid cystic carcinoma

Adenolymphoma (Warthin’s tumour)

Monomorphic adenoma

Mucoepidermoid tumour

Pleomorphic adenoma Correct answer

Pleomorphic adenoma is the most common benign salivary gland tumour accounting for approximately 80% of parotid tumours. It contains mixed epithelial and mesenchymal elements and generally develops superficial to the facial nerve. Facial nerve involvement is suggestive of malignant disease and adenoid cystic carcinomas in particular are unusual in their predilection for peri-neural spread. Adenolymphomas constitute 18% of all salivary gland neoplasms occurring in the sixth and seventh decades of life. Monomorphic adenomas are rare and although 90% of malignant mucoepidermoid tumours arise in the parotid, they are much rarer than pleomorphic adenomas. 102. A mammogram undertaken as part of a screening programme demonstrates an area of coarse linear branching calcification. Which of the following conditions is this calcification pattern most likely to represent?

Atypical ductal hyperplasia

Comedo type ductal carcinoma in situ Correct answer

Lobular carcinoma in situ

Non-comedo type ductal carcinoma in situ

Sclerosing adenosis

Ductal carcinoma in situ is divided into two main sub-types according to the presence or absence of comedo necrosis. A tumour can be designated as comedo if atypical cells, with abundant luminal necrosis, fill at least one duct. This necrotic material frequently calcifies producing a characteristic coarse linear branching pattern. Lobular carcinoma in situ is not evident on mammography. Sclerosing adenosis can sometimes be difficult to differentiate from invasive carcinoma on mammography alone with heterogeneous calcification and tissue distortion. Similarly there are no pathognomonic mammographic features of atypical ductal hyperplasia, however areas are sometimes represented by clustered microcalcifications. 103. A 42-year-old man with a past history of a parathyroid adenoma presents with a mass in the neck and enlarged cervical lymph nodes. Fine needle aspiration cytology confirms a diagnosis of medullary carcinoma of the thyroid. Which one of the following forms of familial endocrine disease is this most likely to represent?

Cowden’s syndrome

Familial medullary carcinoma of the thyroid

Multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type 2A Correct answer

Multiple endocrine neoplasia type 2B

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The principle features of multiple endocrine neoplasia (MEN) 1 are parathyroid hyperplasia, anterior pituitary adenoma and neuroendocrine tumours of pancreas & duodenum . MEN 2A is characterised by a combination of medullary thyroid cancer (MTC), phaeochromocytoma and hyperparathyroidism (hyperplasia or adenoma of the parathyroid glands). Some patients with MEN 2A have Hirschsprung’s disease. Individuals with MEN 2B have the thyroid and adrenal features of MEN 2A, no parathyroid involvement, mucosal neuromas and a marfanoid habitus. Familial medullary carcinoma of the thyroid is a condition in which affected individuals only develop MTC. Cowden’s syndrome is associated with hamartomatous lesions of the thyroid but not MTC. 104. A middle-aged woman presents with a moderately enlarged thyroid gland. The enlargement is symmetrical with a rubbery texture. She is euthyroid. Anti-thyroglobulin and anti-thyroid peroxidase / anti-microsomal antibodies are raised. Which one of the following is the most likely diagnosis?

Acute suppurative thyroiditis

Autoimmune thyroiditis (Hashimoto’s thyroiditis) Correct answer

Graves’ disease

Riedel’s thyroiditis

Subacute thyroiditis (de Quervain’s thyroiditis)

Hashimoto’s thyroiditis tends to present with painless enlargement of the thyroid. It is often rubbery in texture and can mimic multinodular disease or malignancy. Anti-thyroglobulin and anti-thyroid peroxidase / anti-microsomal antibodies are raised (although can be raised in 8% of the normal population). Thyroid infiltration by lymphocytes and plasma cells is evident with a small risk of developing primary lymphoma. De Quervain’s thyroiditis is often associated with a viral infection and painful goitre. Graves’ disease is typified by a diffuse toxic gland and positive thyroid-stimulating antibodies. Riedel’s thyroiditis is usually iron hard and associated with other sites of idiopathic fibrosis. 105. For gallbladder pathology, which of the following clinical conditions is most likely to be associated with identification of Aschoff-Rokitansky sinuses?

Acute cholecystitis

Cholesterosis of the gallbladder (strawberry gallbladder)

Chronic cholecystitis Correct answer

Mucocele of the gallbladder

Xanthogranulomatous cholecystitis

Chronic cholecystitis is associated with a fibrotic thick walled gallbladder. Within the thickened wall are Aschoff-Rokitansky sinuses, mucosal herniations often containing inspissated bile. Acute cholecystitis is associated with increased vascular permeability and infiltration with acute inflammatory cells. Mucocele of the gallbladder normally occurs in a thin walled non-inflammed gallbladder. Cholesterol-laden macrophages in the lamina propria of the gallbladder mucosa is a feature of cholesterosis. Xanthogranulomatous cholecystitis is a rare form of chronic cholecystitis characterised by huge numbers of lipid-laden macrophages and giant cells. Xanthogranulomatous cholecystitis can easily be mistaken for carcinoma. 106. Concerning operative intervention for an incompetent sapheno-popliteal junction (SPJ), which of the following is imperative?

Closure of popliteal fascia

Flush ligation of the SPJ

Identification of the Giacomini vein (upward continuation of the short saphenous vein)

Pre-operative marking of the SPJ with duplex imaging Correct answer

Stripping of the short saphenous vein

Location of the SPJ is extremely variable and marking is essential to prevent misplaced incisions. Tracing the Giacomini vein can be helpful in SPJ identification, SPJ, however is not a constant anatomical feature. Flush ligation of the SPJ is generally thought to reduce recurrence but can be difficult to achieve, especially in the obese where possible benefit is outweighed by

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potential nerve and vascular injury. Stripping of the short saphenous vein is associated with an unacceptable risk to the sural nerve. Closure of the popliteal fascia prevents an unsightly bulge at the back of the knee. 107. In case of contact dermatitis from latex based gloves, which of the following is the related hypersensitivity reaction?

Gell and Coombs Type I

Gell and Coombs Type II

Gell and Coombs Type III

Gell and Coombs Type IV Correct answer

Un-classified by Gell and Coombs

Gell and Coombs classified hypersensitivity reactions in to four categories: Type I immediate hypersensitivity due to overproduction of IgE antibody on mast cells or basophils; Type II causes antibody to cell-bound antigen; Type III causes immune complex reactions; Type IV is delayed hypersensitivity mediated by T-cells. Latex, as the sensitising antigen or hapten, becomes bound to skin proteins. This complex is presented to T-lymphocytes in association with MHC class II antigen by Langerhans’ cells. Induction of T-cells usually occurs after months of exposure to small amounts of antigen with cytokine release in the epidermis. Inflammation and induration is effected at the contact site. 108. A 35-year-old man is admitted with ischaemic rest pain in both feet. There is no history of preceding intermittent claudication. He is a heavy smoker. Femoral and popliteal pulses are palpable. From the list below select the most likely diagnosis.

Atherosclerosis

Fibromuscular dysplasia

Polyarteritis nodosa

Takayasu’s arteritis

Thromboangiitis obliterans (Buerger’s disease) Correct answer

Buerger’s disease is characterised by segmental thrombotic occlusions of the small and medium sized arteries usually of the distal lower limb. It occurs predominantly in young male smokers, frequently associated with rest pain and tissue loss. Intermittent claudication is not a major feature. Tobacco abstinence is essential. Takayasu’s arteritis has a female preponderance manifest by an obliterative arteritis of the aorta and its branches. Polyarteritis nodosa occurs between 40-60 years and affects small and medium sized arteries. Fibromuscular dysplasia affects renal and carotid arteries. Atherosclerosis tends to have a preceding history and very rarely manifests at such an early age. 109. A 2-year-old boy presents with a pedunculated polyp prolapsing through the child’s anus. Which of the following types of polyp is this most likely to represent?

Adenoma

Benign lymphoma

Hamartomatous polyp Correct answer

Hyperplastic polyp

Lipoma

Hamartomatous polyps (juvenile polyps) occur predominately in infants and children. The polyp is characteristically 1-2 cm in diameter with a smooth surface and slender stalk. Hamartomatous polyps mostly occur in the rectum and can proplapse through the anus. Hyperplasic polyps also occur commonly in the rectum, although they are usually small plaque like lesions occurring at all ages. Lipomas occur mainly in the right colon and caecum, often ulcerating with the appearance of an adenocarcinoma. Benign lymphomas appear as reddish purple rounded polyps throughout the large bowel. Adenomas can occur at any age but become progressively more common with advancing years. 110. A 56-year-old Caucasian man is diagnosed with a liver abscess . He has no recent history of foreign travel, or significant past medical history. Which of the following micro-organisms is the most likely to be the causative agent?

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Candida albicans

Echinococcus

Entamoeba histolytica

Escherichia coli Correct answer

Streptococcus milleri

Pyogenic abscesses account for 75 per cent of liver abscesses in developed counties. Most pyogenic liver abscesses are secondary to intra-abdominal infections. The most common cause is cholangitis associated with biliary stones followed by diverticulitis. Most are polymicrobial with Gram negative aerobic and anaerobic organisms predominating. Streptococcus milleri usually arises from bacterial endocarditis. Fungal abscesses are associated with immunosuppression. World wide, amoebic abscesses are the commonest cause of liver abscess with 10 per cent of the world’s population infected with Entamoeba histolytica. Hydatid disease is common in many sheep-raising countries. Echinococcus granulosus is the causative species of Hydatid disease. 111. A 35-year-old man has a clinical diagnosis of a testicular malignancy in a previously maldescended testis. From the following list of testicular malignancies which is the most likely histological diagnosis?

Interstitial (Leydig) cell tumour

Lymphoma

Seminoma Correct answer

Teratoma

Yolk sac tumour

Seminomas and teratomas are of germ cell origin accounting for 85-90 per cent of testicular tumours. Peak incidence of seminomas is 30-50 years compared to 20-30 years for teratomas. Seminomas are the commonest testicular tumours to develop in maldescended testicles. Lymphomas of the testis are far less common with a peak incidence of 60-70 years. They are often bilateral and can be a manifestation of more diffuse disease. Yolk sac tumours occur before the age of three years and are the commonest testicular malignancy in children. 112. A 72-year-old man has a swelling behind his knee consistent with a popliteal artery aneurysm. Which of the following is the strongest indication for surgical intervention?

Diameter of the aneurysm

Patient’s concern of the risk of rupture

Presence of all three patent run-off vessels

Presence of an associated abdominal aortic aneurysm

Presence of thrombus within the aneurysmal sac and a single patent run-off vessel Correct answer

Rupture of a popliteal aneurysm is rare. 50% of cases present with limb threatening ischaemia. Laminated thrombus can develop within the sac and is constantly subjected to flexion and extension movements that greatly increase the risk of fragmentation. Microembolisation of the distal circulation occurs silently until sudden occlusion of the remaining run-off vessels. Thus, the presence of thrombus is a strong indication for surgical intervention, especially if a single run-off vessel remains. In the absence of laminated thrombus, it is generally accepted that aneurysms with a diameter of 2cm or greater warrant consideration for repair. 113. Which of the following associated extra-alimentary conditions is more suggestive of ulcerative colitis than Crohn’s disease?

Ankylosing spondylitis

Arthropathy

Erythema nodosum

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Primary sclerosing cholangitis Correct answer

Pyoderma gangrenosum

Primary sclerosing cholangitis is far more commonly seen in ulcerative colitis than Crohn’s disease. The condition is characterised by a fibrous inflammatory reaction within the biliary tree leading to irregularity with multiple stenosis and biliary obstruction. There is no apparent relationship between duration or severity of ulcerative colitis and ultimately progresses to liver failure. Arthropathy and ankylosing spondylitis are both features of ulcerative colitis and Crohn’s disease. Erythema nodosum is the commonest cutaneous manifestation of inflammatory bowel disease and occurs slightly more commonly in Crohn’s disease. Conversely pyoderma gangrenosum is slightly more prevalent in ulcerative colitis. 114. A 40-year-old man is diagnosed with right sided synchronous colonic tumours, which are mucinous and poorly differentiated. His mother had died at an early age of ovarian cancer and his maternal grandfather had died aged approximately 40 years of advanced caecal carcinoma. From the following list of inherited syndromes which is most likely to be prevalent in this family?

Cowden’s syndrome

Familial adenomatous polyposis

Hereditary non-polyposis colorectal cancer Correct answer

Juvenile polyposis

Peutz-Jeghers syndrome

Colonic tumours associated with hereditary non-polyposis colorectal cancer (HNPCC) tend to have certain distinguishing pathological features. They occur on average twenty years before the peak incidence of sporadic tumours and are frequently synchronous and metachronous with a predilection for the proximal colon. They tend to be mucinous, poorly differentiated and “signet-ring” in appearance. Ovarian cancer is associated with NHPCC along with cancers of the endometrium and stomach. 115. A 75-year-old woman is admitted with small bowel obstruction and pain radiating down the medial aspect of the right thigh to the knee. There is no palpable abnormality in the groin but the inner aspect of the groin is tender. From the following list, which is the most likely diagnosis?

Femoral hernia

Gluteal hernia

Lumbar hernia

Obturator hernia Correct answer

Sciatic hernia

An obturator hernia is six times more common in women and twice as common on the right side. It particularly affects elderly women who have had recent rapid weight loss. The hernial sac protrudes through the obturator canal potentially compressing the geniculate branch of the obturator nerve causing referred pain. Strangulated femoral hernias are generally palpable and lumbar hernias are associated with paralysed muscles especially by poliomyelitis or spina bifida. Gluteal and sciatic hernias are very rare and are suggested by the presence of a painful swelling in the buttock or pain in the distribution of the sciatic nerve. 116. A 16-year-old girl presents with a four month history of an aching discomfort in the distal right femur, relieved with simple analgesia. Plain radiograph of the knee shows an area of slight sclerosis. Which is the most likely diagnosis?

Chondroma

Fibroma

Osteochondroma

Osteoclastoma

Osteoid osteoma Correct answer

Osteoid osteomas are commonest in the femur and tibia. They are unusual as benign tumours in that they produce a constant aching pain which is classically relieved by simple analgesia. They can be difficult to see on plain radiographs.

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Osteochondromas often appear as a bony pedicle growing away from the epiphyseal plate, covered in a large cartilage cap. Chondromas are made up almost entirely of cartilage and are common in the hands and feet. Fibromas are well-circumscribed lytic lesions and osteoclastomas are commonly found lying close to the epiphyseal plate with destruction of the overlying cortex. 117. A 56-year-old woman presents with a rapidly growing raised solitary lesion on her face. Over the course of four weeks it has reached two centimetres in diameter. The lesion has now developed a necrotic, crusted centre. From the following list of skin lesions which is the most likely diagnosis?

Basal cell carcinoma

Histiocytoma

Keratocanthoma Correct answer

Pyogenic granuloma

Squamous cell carcinoma

Keratocanthomas are epidermal nodules almost indistinguishable from squamous cell carcinomas, however unlike squamous cell carcinomas, they grow very rapidly. Having attained the size of two to three centimetres over several weeks they spontaneously involute leaving a pitted scar. Histiocytomas appear as firm flesh coloured nodules mainly on the lower limb. Pyogenic granulomas also grow rapidly, however they usually occur on the fingers after trivial trauma and appear as raised, wet, pedunculated lesions. Basal cell carcinomas are slow growing. 118. A 30-year-old man presents with a painless swelling behind the anterior edge of the upper third of the right sternomastoid muscle. Fine needle aspiration reveals opalescent fluid. From the list below which is the most likely diagnosis?

Branchial cyst Correct answer

Branchial fistula

Chemodectoma

Pharyngeal pouch

Thyroglossal cyst

Branchial cysts originate from embryonic branchial cleft tissue remnants. Most present in the third decade with swelling behind the anterior border of sternomastoid. These cysts often present when they become infected and contain inflamed lymphoid tissue. Classically opalescent fluid containing cholesterol crystals can be aspirated. Branchial fistulae arising from abnormalities of the first cleft appear as a sinus anterior or posterior to the ear and those of the second, along the anterior boarder of sternomastoid. Pharyngeal pouches present behind sternomastoid and thyoglossal cysts, in the midline. Chemodectomas are slow growing, often painful, pulsatile masses at the angle of the mandible. 119. In pulmonary tuberculosis, what is the most discriminating lung pathology feature?

Multinucleate giant cells

Caseating necrosis Correct answer

Gram negative organisms

Macrophages

Colliquative necrosis

Caseating necrosis is characteristic of TB, and rarely seen in other conditions. It refers to the creamy white appearance of the dead tissue, that resembles cheese. Multinucleate giant cells are seen in TB, but also in some viral infections and malignancies. TB is not gram negative, but requires specialised Ziehl Neelson staining. Colliquative (Liquefaction) necrosis occurs in the brain and spinal cord. 120. A patient develops an erythematous rash under the dressing site 24 hours post operatively. Whatis the most likely hypersensitivity reaction type?

Type I

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Type II

Type III

Type IV Correct answer

Type V

There are 4 types of hypersensitivity reaction, I to IV; Type I is the immediate IgE mediated response Type II is antibody mediated towards antigen attached to cells Type III is antibody mediated towards antigen not attached to cells Type IV, or delayed type hypersensitivity reaction is T cell mediated, and onset is typically between 24 and 72 hours after exposure 121. A 2-year-old boy presents with painful, swollen right knee. Apart from recurrent epistaxis, he is fit and well. His blood results reveal the following abnormalities.

Hb 13.2 g/dl

MCV 95 fl

WCC 8.3 x109/l

Plts 250 x109/l

PT Normal

APTT Prolonged

What is the most likely diagnosis? Single best answer question - choose ONE true option only

Septic arthritis

Haemophilia

Disseminated intravascular coagulation (DIC)

Von Willebrand Disease (VWD) Correct answer

Factor V Leiden

The child has a bleeding disorder of the intrinsic pathway indicated by the raised APTT. The recurrent epistaxis suggests VWD due to abnormality of platelets and factor 8. Platelets cause mucosal bleeding, factor 8 deficiency causes deep bleeding, such as hemoarthroses in this case. Haemophilia which does not involve platelets would not explain the epistaxis. 122. A 52-year-old lady’s breast biopsy histology shows poorly differentiated duct epithelial cells which do not breach the basement membrane. Whatis the best classification of this breast pathology?

Phyllodes tumour

Ductal carcinoma in situ Correct answer

Lobular carcinoma in situ

Fibroadenoma

Von Willebrand Disease (VWD)

The cells arise from the ductal cells as opposed to the gland or lobule cells, in lobular carcinoma in situ. The cells have not invaded the basement membrane, so this is a carcinoma in situ as opposed to a carcinoma. Phyllodes tumour is a type of fibroadenoma with malignant potential 123. A 56-year-old woman presents with abdominal pain and constipation. She has no past medical history. Her blood tests show the following.

Hb 15.3 g/dl (13-18 g/dl)

MCV 95 fl (76-96 fl)

WCC 10.3 x109/l (4-11 x109/l)

Serum corrected calcium 2.95 mmol/l (2.12-2.65 mmol/l)

Serum phosphate 0.7 mmol/l (1.2-1.7 mmol/l)

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Serum alkaline phosphatase 150 iu/l (30-35 iu/l)

What is the underlying diagnosis? Single best answer question - choose ONE true option only

Primary hyperparathyroidism Correct answer

Secondary hyperparathyroidism

Tertiary hyperparathyroidism

Osteoporosis

Paget’s disease

The calcium is inappropriately high suggesting this is primary hyperparathyroidism. Secondary hyperparathyroidism is an appropriately high PTH to a low calcium level. Tertiary hyperparathyroidism is an inappropriately high PTH following prolonged stimulation for example following renal transplant for chronic renal failure. Osteoporosis and Paget’s disease have no effect on calcium unless there is prolonged immobility when it is raised. ALP is markedly raised in Paget’s disease. 124. A 60-year-old man is 2 weeks post-renal transplant complaining of polyuria and polydypsia. His blood tests show the following;

Hb 10.1 g/dl (13-18 g/dl)

MCV 80 fl (76-96 fl)

Ca 2.95 mmol/l (2.12-2.65 mmol/l)

Phosphate 0.70 mmol/l (1.2-1.7 mmol/l)

ALP 150 iu/l (30-35 iu/l)

What is the underlying problem? Single best answer - choose ONE true option only

Primary hyperparathyroidism

Secondary hyperparathyroidism

Tertiary hyperparathyroidism Correct answer

Osteoporosis

Paget’s disease

Tertiary hyperparathyroidism is an inappropriately high PTH following prolonged stimulation, for example following renal transplant for chronic renal failure. Osteoporosis and Paget’s disease have no effect on calcium unless there is prolonged immobility when it is raised. ALP is markedly raised in Paget’s disease. Secondary hyperparathyroidism is an appropriately high PTH to a low calcium level. Primary hyperparathyroidism is an inappropriately raised PTH, for example due to a parathyroid adenoma, causing hypercalcaemia. 125. A 26-year-old man presents with a hard, non-tender lump in his left testicle. Both AFP and βHCG are raised. Whatis the most likely nature of the lump?

Hematoma

Abscess

Teratoma Correct answer

Seminoma

Hydrocoele

Testicular lumps are often noticed after trauma. Seminomas do not cause a raised AFP and peak age is 30-40 years. Teratomas are derived from multipotent germ cells so cause both AFP and bHCG to rise, peak age being 20-30 years. 126. A 21 year old man undergoes drainage of a perianal abscess. Which is the best method to manage the wound?

Primary closure

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Delayed primary closure

Healing by secondary intention Correct answer

Permanent fistula

Tertiary closure by skin graft

Infected wounds are best left open to heal by secondary intention. Primary closure is achieved by suturing or stapling or steristrip. Delayed primary closure is needed for contaminated wounds that are left open day 1 and closed by suturing by day 3 to 5 before excessive granulation is started. 127. A 19-year-old girl develops lip swelling and stridor after administration of Penicillin. What is the type of hypersensitivity reaction seen here?

Type I Correct answer

Type II

Type III

Type IV

Type V

There are 4 types of hypersensitivity reaction, I to IV; · Type I is the immediate IgE mediated response · Type II is antibody mediated towards antigen attached to cells · Type III is antibody mediated towards antigen not attached to cells · Type IV, or delayed type hypersensitivity reaction is T cell mediated, and onset is typically between 24 and 72 hours after exposure 128. A 76-year-old man develops a pyrexia and cough 7 days after an open cholecystectomy. What is the most likely organism involved?

Gram negative bacteria Correct answer

Streptococcus pneumoniae

Clostridium difficile

Staphylococcus aureus

Mycobacterium tuberculosis

This is a hospital acquired infection, mostly likely to be caused by gram negative bacteria. 129. In Barrett’s oesophagus, what is the pathological process that converts squamous cells to gastric type cells?

Dysplasia

Hypertrophy

Hyperplasia

Apoptosis

Metaplasia Correct answer

Metaplasia is the replacement of one differentiated cell type with another as in this case. Hypertrophy is the increase in cell size, hyperplasia an increase in cell number. Apoptosis is programmed cell death, while dysplasia is the abnormal development of cells which is often a pre-malignant state. 130. A 35-year old lady develops a DVT 7 days following a panproctocolectomy for Crohn's disease. She is positive for anticardiolipin and lupus anticoagulant antibodies. What is the underlying condition behind this DVT?

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Factor V Leiden

Protein C deficiency

Protein S deficiency

Antiphospholipid syndrome Correct answer

Antithrombin III deficiency

The presence of the two antibodies indicate that this patient has the hypercoagulable state of antiphospholipid syndrome. 131. What is the pathological process in benign prostate enlargement?

Hypertrophy

Hyperplasia Correct answer

Dysplasia

Metaplasia

Neoplasia

Hyperplasia, the increase in number of cells is responsible for BPH 132. An 81-year-old man with newly diagnosed AF develops sudden onset left leg pain and pallor. What is the underlying pathology?

Embolus Correct answer

Thrombophilia

Atheroma

Thrombocytopenia

Thrombosis

The leg is acutely ischaemic, most probably an atrial embolus has caused a sudden blockage to the arterial supply of the leg. 133. A 45-year-old lady presents with right flank mass and haematuria. She also complains of depression, constipation and vomiting. What is the underlying diagnosis? Single best answer question - choose ONE true option only

Colorectal carcinoma

Renal stones

Renal carcinoma Correct answer

Bladder carcinoma

Pyelonephritis

This collection of symptoms can all be explained by renal carcinoma with hypercalcaemia as a paraneoplastic syndrome. Paraneoplastic syndromes are non-metastatic systemic effects caused by cancer. Hypercalcaemia causes depression, abdominal pain, lethargy and constipation. 134. An 81-year-old man, an ex-smoker, presents with a 2 year history of left calf pain after walking 500 metres. What is the underlying pathological process?

Embolus

Thrombophilia

20

Atheroma Correct answer

Thrombocytopenia

Thrombosis

This is intermittent claudication due to chronic ischaemia caused by atheroma. 135. An 81-year-old ex-smoker presents with a 2-day history of worsening left calf pain even at rest. He has been getting pain for the last 10 years but was able to walk 500 metres. What is the underlying pathological process?

Embolus

Thrombophilia

Atheroma

Thrombocytopenia

Thrombosis Correct answer

This is acute on chronic ischaemia, caused by rupture of the atheroma and formation of a thrombus on top. 136. A 72-year-old diabetic man with chronic renal failure has the following blood results;

Hb 15.3 g/dl (13-18 g/dl)

MCV 95 fl (76-96 fl)

WCC 10.3 x109/l (4-11 x109/l)

Serum corrected calcium 1.95 mmol/l (2.12-2.65 mmol/l)

Phosphate 1.8 mmol/l (1.2-1.7 mmol/l)

ALP 150 iu/l (30-35 iu/l)

What is the underlying diagnosis?

Primary hyperparathyroidism

Secondary hyperparathyroidism Correct answer

Tertiary hyperparathyroidism

Osteoporosis

Paget’s disease

In chronic renal failure, secondary hyperparathyroidism is an appropriate response to low calcium levels that occur due to low calcitriol levels, which is produced in the kidneys. Phosphate is high as it cannot be cleared from the kidneys. 137. Which of the following cells secretes intrinsic factor?

Goblet cells

Kupffer cells

Peptic cells

Chief cells

Parietal cells Correct answer

Goblet cells are mucus-secreting cells widely distributed in epithelial surfaces, but especially dense in the gastrointestinal and respiratory tracts. Kupffer cells have phagocytic properties and are found in the liver. They participate in the removal of ageing erythrocytes and other particulate debris. The gastric mucosa contains many cell subtypes, including acid-secreting cells (also known as parietal or oxyntic cells), pepsin secreting cells (also known as peptic, chief or zymogenic cells) and G-cells (gastrin-secreting cells). Peptic cells synthesise and secrete the proteolytic enzyme, pepsin. Parietal cells actively secrete hydrochloric acid into the gastric lumen, accounting for

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the acidic environment encountered in the stomach. However parietal cells are also involved in the secretion of the glycoprotein, intrinsic factor. Intrinsic factor plays a pivotal role in the absorption of vitamin B12 from the terminal ileum. Autoimmune damage to parietal cells leads to a lack of intrinsic factor and hydrochloric acid, leading to vitamin B12 deficiency and achlorhydria. This is known as pernicious anaemia. 138. Splenectomy increases susceptibility to which of the following organisms?

Streptococcus pyogenes

Schistosoma haematobium

Bacteroides fragilis

Neisseria meningitidis Correct answer

Staphylococcus aureus

The spleen plays an important role in the removal of dead and dying erythrocytes and in the defence against microbes. Removal of the spleen (splenectomy) leaves the host susceptible to a wide array of pathogens, but especially to encapsulated organisms. Certain bacteria have evolved ways of evading the human immune system. One way is through the production of a ‘slimy’ capsule on the outside of the bacterial cell wall. Such a capsule resists phagocytosis and ingestion by macrophages and neutrophils. This allows them not only to escape direct destruction by phagocytes but also to avoid stimulating T-cell responses through the presentation of bacterial peptides by macrophages. The only way that such organisms can be defeated is by making them more palatable by coating their capsular polysaccharide surfaces in opsonising antibody. The production of antibody against capsular polysaccharide primarily occurs through T-cell independent mechanisms. The spleen plays a central role in both the initiation of the antibody response and the phagocytosis of opsonised encapsulated bacteria from the bloodstream. This helps to explain why following a splenectomy the host is most susceptible to infection by encapsulated organisms, notably Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and Haemophilus influenzae. Understanding the above, one can quickly envisage what preventative strategies must be employed post-splenectomy. Patients are given relevant immunisations and are advised to take prophylactic penicillin, in most cases for the rest of their lives. In addition they are advised to wear a MedicAlert bracelet to warn other health care professionals of their condition. 139. A 65-year-old man suffered a massive myocardial infarction that was complicated by shock and prolonged hypotension. On arrival in the Emergency Department he was found to have focal neurological signs in addition to feature consistent with low-output cardiac failure. Despite the best efforts of the medical team he died the next day. At autopsy, the most likely change you would expect to see in a brain biopsy would be:

Acute haemorrhagic change

Coagulative necrosis

Granulomatous change

Lacunar infarct

Liquefactive necrosis Correct answer

Liquefactive necrosis is characteristic of focal bacterial or, occasionally, fungal infections, because microbes stimulate the accumulation of inflammatory cells. Hypoxic death of cells within the central nervous system often evokes liquefactive necrosis, though the reasons for this are obscure. Whatever the pathogenesis, liquefaction completely digests the dead cells. The end result is transformation of the tissue into a viscous liquid mass. If the process was initiated by acute inflammation the material is frequently creamy yellow in colour because of the presence of dead white cells and this is called 'pus'. 140. A 42-year-old woman has complained of mild, burning, substernal or epigastric pain following meals for the past 3 years. Upper gastrointestinal endoscopy is performed and biopsies are taken of an erythaematous area of the lower oesophageal mucosa 3 cm above the gastro-oesophageal junction. There is no mass lesion, no ulceration and no haemorrhage is noted. The biopsies demonstrate the presence of columnar epithelium with goblet cells. Which of the following mucosal alterations is most likely to be represented by these findings?

Carcinoma

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Dysplasia

Hyperplasia

Ischaemia

Metaplasia Correct answer

Metaplasia is the substitution of one tissue type normally found at a site for another. The epithelium undergoes metaplasia in response to ongoing inflammation from reflux of gastric contents. It is common in the lower oesophagus with gastro-oesophageal reflux disease. The growth of the epithelial cells must become disordered to be dysplastic. Hyperplasia can occur with inflammation, as the number of cells increases, but hyperplasia does not explain the presence of the columnar cells. Carcinoma is characterised by cellular atypia with hyperchromatism and pleomorphism. Goblet cells would not be seen. Ischaemia would be unusual at this site and would be marked by coagulative necrosis.