2004
Question 1.
The major mechanism by which pain from the gastrointestinal tract is signalled
involves:
A. sympathetic neurones in the prevertebral ganglia
B. enteric neurones
C. vagal afferent neurones
D. spinal afferent neurones
E. spinal efferent neurones
Question 2.
The major neurotransmitters involved in transmission by enteric neurones are:
A. glutamate, glycine and acetylcholine
B. noradrenaline, acetylcholine and dopamine
C. acetylcholine and 5-hydroxytryptamine
D. nitric oxide, glutamate and gamma amino butyric acid (GABA)
E. acetylcholine, tachykinins and nitric oxide
Question 3.
Migrating myoelectric complexes are patterns of motor activity that:
A. are found only in the colon and precede defecation
B. involve large propagating contractions, and which do not occur after eating
C. are activated by feeding and help propel the food during digestion
D. propagate orally and often occur before episodes of vomiting
E. occur throughout the whole gastrointestinal tract and always precede
defecation
continued next page ...
Question 4.
Interstitial cells of Cajal are specialised non-muscular cells located within
the smooth muscle layers of the gut wall. Their major roles include:
A. generating smooth muscle action potentials and responding to gastrointestinal
hormones
B. triggering slow waves in smooth muscle cells and mediating the effects of
neurotransmitters released by enteric motor neurones
C. triggering slow waves in smooth muscle cells and detecting nutrients
D. activating sensory neurones and responding to hormones
E. signalling gut distension and responding to gastrointestinal hormones
released by nutrients from specialised entero-endocrine cells in the mucosa
Question 6.
Regarding the Oesophagus:
A. the muscularis mucosae is not composed of smooth muscle
B. the circular muscle of the muscularis propria of the distal third is not
comprised of smooth muscle
C. the longitudinal muscle layer of the muscularis propria of the proximal third
is not composed of striated muscle fibres
D. the lower oesophegeal sphincter is an anatomical feature composed of a
thickened layer of muscularis propria circular smooth muscle
E. the epithelium of the middle third of the oesophagus is comprised of
non-keratinising stratified squamous epithelium
Question 7.
Regarding the Pharynx:
A. The choanae are the paired anterior openings of the nasal cavity into the
pharynx
B. The pathway of a food bolus through the laryngopharynx is via the tonsilar
fossae, located to either side of the cricoid cartilage
C. The oropharynx lies above the laryngopharynx and below the nasopharynx
D. The pharynx lies posterior to the cervical vertebral bodies
E. The blood supply to the pharynx is via the internal carotid artery
Question 8.
Regarding the Stomach:
A. parietal cells are a component of the gastric glands of the body of the
stomach
B. fundic mucosal glands contain parietal cells
C. gastric pH is approx 5 or more
D. the pyloric sphincter is a physiological feature, not an anatomical structure
E. glands of the cardia contain mainly acid secreting cells
Question 9.
Which one of the following statements about the duodenum is true?
A. Brunner’s glands of the duodenal submucosa are present in the third part
B. The common bile duct drains into the third part
C. The pancreatic duct drains via the duodenal papilla
D. Duodenal ulcers are most common in the second part
E. A posterior relation of the second part are the left renal vessels
Question 23.
Cox-2 inhibitors :
A. selectively inhibit cyclooxygenase
B. do not cause peptic ulceration
C. cause more complicated peptic ulcers than NSAID’s
D. improve platelet function
E. have some inhibitory activity against helicobacter pylori in vitro
Question 24.
Helicobacter pylori is associated with:
A. peptic ulcers
B. terminal ileal ulceration
C. Barratts oesophagus
D. gasto oesophageal ulceration
E. gastroparesis2005
Question 7
Regarding the anatomy of the oral cavity:
a. there are 4 types of tongue papillae
b. the pharyngeal tongue has 2 types of papillae
c. levator veli palatini arises from the soft palate
d. the palatoglossal fold defines the posterior border of the oral cavity
e. genioglossus is an intrinsic tongue muscle
Question 12
The major mechanism by which pain from the gastrointestinal tract is signalled
involves:
a. sympathetic neurones in the prevertebral ganglia
b. enteric neurones
c. vagal afferent neurones
d. spinal afferent neurones
e. hormones released from the gut mucosa
Question 16
Helicobacter pylori is associated with:
a. pernicious anaemia
b. gastric cancer
c. Barratts oesophagus
d. gasto oesophageal ulceration
e. gastroparesis
2006
Patient Presentation
A 68 y.o. Italian olive picker, Ms Gail Ulsarre presents to your GP surgery. She
has a long history of
osteoarthritis. She has a 2 month history of new onset upper abdominal pain and
tiredness.
Over the last 2 days she has developed tarry black malodorous stools. She is
waking at night with hunger
type pains relieved by drinking milk.
There is no associated nausea, vomiting, haemetemesis or weight loss.
You had prescribed Brufoxicam, a traditional non-steroidal anti-inflammatory
agent 3 months ago for her
arthritis which she has been taking twice daily, religiously. She is otherwise
well and on no other
medications.
Examination reveals a pale complexion. She is normotensive, pulse regular 76 bpm
and afebrile. Some
mild epigastric discomfort on deep palpation is present. There are no abdominal
masses. The rectum
contains black sticky stool on examination. Examination of the hands reveals
changes in the distal
phalangeal joints consistant with osteoarthritis. The remaining physical
examination is normal.
Question 1. (5 marks)
List Ms Ulsarre’s symptoms and signs.
Question 2. (5 marks)
What are the most likely diagnoses and why?
SECTION A Mini Case - Ms Gail Ulsarre
Part 2 (Total marks 15:
Suggested writing time 15 minutes)
Answer all questions.
Write your answers in booklet marked ‘Section A Part 2’.
Start each question on a new page.
You see the patient in the Emergency Department. The following investigations
were performed:
HAEMATOLOGY NORMAL RANGE
HB 90 115-160 G/DL
Platelets 313 150-400 / 109/L
MCV 87 80-100 FL
WCC 6 3.5-11 /109/L
BIOCHEMISTRY
Sodium 142 135-145 mmol/L
Potassium 4.1 3.5-5.0 mmol/L
Bicarbonate 23 20-30 mmol/L
Chloride 103 95-105 mmol/L
Creatinine 0.083 0.050-0.110 mmol/L
Blood Sugar 3.6 3.5-7.2 mmol/1
Alk. Phos. 77 35-125 U/L
Bilirubin 10 2-17 Umol/L
ALT 23 0-35 U/L
Urea 12 2.5-7.0 mmol/1
GGT 12 0-35 U/L
Albumin 41 36-52 g/L
Phosphate 0.73 0.7-1.4 mmol/L
Calcium 2.30 2.2-2.6 mmol/L
CRP 19 <5 Mg/L
IRON STUDIES
Ferritin 25 30-400 μg/L
Serum iron 12 9-27 μmol/L
Transferrin 3.2 1.8-3.7 g/L
Transferrin saturation 30 10-55 %
HELICOBACTER PYLORI SEROLOGY: Positive
Question 3. (10 minutes)
Discuss these results.
Explain your reasoning.
Question 4. (5 marks)
What investigation(s) will you order next and why?
SECTION A Mini Case - Ms Gail Ulsarre
Part 3 (Total marks 15:
Suggested writing time 15 minutes)
Answer all questions.
Write your answers in booklet marked ‘Section A Part 3’.
Start each question on a new page.
An endoscopy is performed that day and the position of the endoscope and
pathology seen shown:
Question 5. (5 marks)
What does the picture above show?
What is the differential diagnosis?
Question 6. (10 marks)
What are the treatment options?
How will you follow up this patient?
2006
Question 13.
Regarding the anatomy of the oral cavity:
A. There are 4 types of tongue papillae
B. The pharyngeal tongue has no papillae
C. Levator veli palatini arises from the soft palate
D. The palatoglossal fold defines the anterior border of the oral cavity
E. Genioglossus is an intrinsic tongue muscle
Question 15.
Peristalsis in the small intestine is primarily caused by:
A. Food in the gut sequentially releasing gut hormones from the intestinal
mucosa
B. Sinal afferent neurones activating sympathetic efferent pathways to the gut
C. Vago-vagal reflexes
D. A central program generator in the brainstem
E. Enteric afferent neurones, interneurones and motor neurones organised in
functional circuits
Question 16.
Which class of neurone that innervates the gut releases noradrenaline to cause
pre-synaptic
inhibition in the myenteric and submucous plexuses?
A. Enteric interneurones
B. Vagal afferent neurones
C. Sympathetic post-ganglionic neurones
D. Spinal afferent neurones
E. Enteric inhibitory motor neurones
Question 23.
The most important neurotransmitters used by excitatory motor neurones that
directly innervate
gut smooth muscle are:
A. Acetylcholine and substance P (or similar tachykinins)
B. Nitric oxide and adenosine triphosphate
C. Cholecystokinin and gastrin
D. Glutamate and aspartate
E. Nitric oxide and vasoactive intestinal polypeptide (VIP)
Question 24.
Factors not important in gastrooesophageal reflux include:
A. Transient relaxation of the lower oesophageal sphincter
B. Increased upper oesophageal sphincter pressure
C. Hiatus hernia
D. Reflux of acid into the oesophagus
E. Poor gastric emptying
2007
Question 10.
The blood supply of the second part of the duodenum is usually derived from:
A. The left gastric artery
B. The common hepatic artery
C. The splenic artery
D. The superior mesenteric artery
E. The inferior mesenteric artery
Question 23.
Which class of neurone that innervates the gut releases noradrenaline to cause
pre-synaptic inhibition in the myenteric and submucous plexuses?
A. Enteric interneurones
B. Vagal afferent neurones
C. Sympathetic post-ganglionic neurones
D. Spinal afferent neurones
E. Enteric inhibitory motor neurones
Question 29. (5 marks)
For each of the stems listed below, select an option which best matches. Each
option may be used once, more than once, or not at all.
Stems
28.1 The major neurons by which pain from the gastrointestinal tract is
signalled are
28.2 The major neurotransmitters involved in transmission by enteric neurones
are
28.3 Interstitial cells of Cajal are specialised non-muscular cells located
within the smooth muscle layers of the gut wall. Their major roles include
28.4 Migrating myoelectric complexes are patterns of motor activity
distinguished by
28.5 Neurones that release noradrenaline to cause pre-synaptic inhibition in the
myenteric and submucous plexuses
Options
A. triggering slow waves in smooth muscle cells and detecting nutrients
B. propagating orally and often occurring before episodes of vomiting
C. acetylcholine, tachykinins and nitric oxide
D. enteric neurones
E. involving large propagating contractions, not occurring after eating
F. noradrenaline, acetylcholine and dopamine
G. spinal afferent neurones
H. triggering slow waves in smooth muscle cells and mediating the effects of
neurotransmitters released by enteric motor neurones
I. being found only in the colon, preceding defecation
J. sympathetic post-ganglionic neurones
K. vagal afferent neurones
L. acetylcholine, glutamate and GABA
Question 12.
With regard to the innervation of the gut, please state whether the following
statements are True or False:
a) Spinal afferents (from dorsal root ganglia) carry most of the nociceptive
information.
b) The majority of axons to the gut traveling in the vagus nerve belong to
parasympathetic efferents.
c) Vagal efferent (parasympathetic axons) directly innervate gastric glands and
muscle, among other targets in the gut wall.
d) Sympathetic efferents release noradrenaline in the gut wall, causing
presynaptic inhibition of transmitter release via alpha 2 adrenoceptors.
e) Parasympathetic efferents reach the gut wall via both cranial (vagal) and
sacral pathways.
(2.5 marks)2008
Question 23.
With regard to Gastroesophageal Reflux Disease (GORD), please read the
statements below and identify them as being True or False:
a) There is a strong association between GORD and squamous cell carcinoma of the
oesophagus.
b) Transient relaxation of the lower oesophageal sphincter is the major
mechanism underlying GORD.
c) GORD is a common cause of chronic cough.
d) Proton Pump Inhibitor’s (PPI’s) inhibit the proton pump (H+K+ATPase) in the
peptic (chief) cells.
e) PPI’s are most effective when taken just before meals.
(2.5 marks)
Question 24.
Regarding Helicobacter pylori, please indicate whether the following statements
are True or False:
a) It is typically acquired in childhood.
b) It produces Urea.
c) It is associated with MALT lymphoma.
d) The majority of people with chronic infection remain asymptomatic throughout
their lives.
e) It typically causes an atrophic gastritis involving the gastric body.
(2.5 marks)
2009
Question 12.
With regard to the duodenum, please indicate which of the following statements
is CORRECT:
a) The common bile duct drains into the third part.
b) All of the duodenum is retroperitoneal.
c) The distal half of the duodenum is supplied by the inferior mesenteric
artery.
d) The duodenum develops from both the foregut and midgut.
e) Duodenal ulcers secondary to Helicobacter pylori are most common in the
second part of the duodenum.
Question 13.
Please indicate which one of the following statements about Barrett’s Oesophagus
is CORRECT:
a) Barrett’s Oesophagus is found in approximately 50% of patients with chronic
reflux.
b) The risk of adenocarcinoma in patients with Barrett’s is approximately 10%
per year.
c) H. pylori is associated with an increased risk of Barrett’s.
d) In Barrett’s Oesophagus, the best marker of increased cancer risk is the
presence of dysplasia.
e) Oesophagectomy is recommended in all patients with Barrett’s Oesophagus.
Question 14.
Regarding COX-2 inhibitors, NSAIDS and gastrointestinal toxicity, please state
which one of the following statements is INCORRECT:
a) Advanced age is a risk factor for development of NSAID associated
gastroduodenal ulcer.
b) Concomitant use of corticosteroids increases the risk of NSAID associated
gastroduodenal ulcers.
c) Proton Pump Inhibitors have been shown to prevent NSAID related ulcers.
d) COX-2 Inhibitors cause fewer ulcers than NSAIDS.
e) Enteric coating is effective in preventing NSAID associated ulcers.
Question 24.
With regard to the diagnostic tests available for Helicobacter pylori, please
indicate which of the following statements is INCORRECT:
a) The standard hematoxylin-eosin stain is not able to demonstrate H. pylori
organisms.
b) The rapid urease test is based on the ability of H. pylori to catalyse the
hydrolysis of urea into ammonia.
c) The rapid urease test has specificity and sensitivity >90%.
d) Serological testing (IgG Antibody) is not recommended to confirm successful
eradication after microbial therapy.
e) Proton pump inhibitor therapy at the time of urea breath testing may cause a
false negative result.