Answers for Medical Finals Quiz - August 2007

Below are the authors' answers and teaching points for this Quiz.

Question 1

A 45 year old man presents after an episode of haematemesis, and is clinically anaemic (see picture below).

Anaemic Eye

Which of the following factors is not important when predicting his chance of mortality?

(a) Age
(b) History of renal failure
(c) Blood pressure
(d) Diagnosis on endoscopy
(e) Previous haematemesis
Answer: (e) Previous haematemesis

The Rockall score can be calculated in cases of gastrointestinal tract bleeding to give an estimate of mortality risk. The factors influencing the score are:

  • Age
  • Signs of shock (pulse and blood pressure)
  • Comorbidity
  • Diagnosis on endoscopy
  • Stigmata of recent haemorrhage on endoscopy (visible evidence of recent bleeding)

A score of 0 is associated with a mortality of 0.2%, whereas a score of 6 is associated with 49% mortality. Further details can be found here: http://www.bsg.org.uk/bsgjava/rockall.html

Question 2

A 37 year old female complains of fatigue and right upper quadrant abdominal discomfort. She is found to have high circulating levels of anti-nuclear antibodies and anti-smooth muscle antibodies.

Which of the following is the most likely diagnosis?

(a) Wilson's disease
(b) Autoimmune hepatitis
(c) Hereditary haemochromatosis
(d) Hepatitis B
(e) Primary biliary cirrhosis
Answer: (b) Autoimmune hepatitis

These presenting symptoms are vague, but are typical of patients with this condition. Autoimmune hepatitis is commoner in women than men, and may be associated with other autoimmune conditions. Anti-nuclear, anti-smooth muscle and anti-liver/kidney microsomal 1 antibodies are typically associated with this condition, and increased levels of globulins are characteristic. Treatment is with immunosuppression. Cessation of therapy can be considered when the patient is asymptomatic, when bilirubin and liver enzymes are normal or near normal, when gamma globulin levels are normal and when a biopsy specimen is found to be normal or near-normal.

Question 3

You review a patient with haemochromatosis at a clinic. He asks you about the potential complications of the condition.

Which of the following options is not a common complication?

(a) Hypopituitarism
(b) Diabetes mellitus
(c) Pulmonary fibrosis
(d) Pseudogout
(e) Cardiomyopathy
Answer: (c) Pulmonary fibrosis

Haemochromatosis results from a genetic mutation in the HFE gene that controls iron transport in the gut. It is characterised by iron overload. Iron deposition in various organs produces the clinical manifestations and complications of the disease:

  • Liver - cirrhosis
  • Skin - discolouration
  • Pancreas - diabetes mellitus
  • Pituitary gland - hypopituitarism
  • Heart - cardiomyopathy
  • Joints - pseudogout

Question 4

Which of the following drugs can cause oesophagitis?
(a) Calcium
(b) Lithium
(c) Baclofen
(d) Nifedipine
(e) Potassium
Answer: (e) Potassium

Drugs commonly linked with oesophagitis include:

  • Potassium supplements
  • Bisphosphonates
  • Non-steroidal anti-inflammatory drugs
  • Tetracyclines

Question 5

Which of the following cancers is not commoner in patients with coeliac disease?
(a) T-cell lymphoma of the small bowel
(b) Small cell lung cancer
(c) Oesophageal adenocarcinoma
(d) Squamous cell carcinoma of the pharynx
(e) Oesophagel squamous cell carcinoma
Answer: (b) Small cell lung cancer

All the other cancers mentioned may occur more commonly in patients with coeliac disease. However, the risk associated with these cancers is no greater than that of the general population if patients adhere to a gluten-free diet.

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