THEME:

Diarrhea LEAD IN: Each of the following patients presents with diarrhea. OPTIONS: A. Acute self-limiting colitis L. Haemolytic Uraemic Syndrome B. Amoebic dysentery M. Ischaemic colitis C. Bacillary dysentery N. Lymphocytic colitis D. Campylobacter jejuni O. Norovirus E. Coeliac disease P. Pseudomonas colitis F. Collagenous colitis Q. Rotavirus infection G. Colonic carcinoma R. Salmonella enteritis H. Crohns disease S. Staphylococcus aureus I. Cryptosporidium parvum T. Ulcerative colitis J. Diverticulitis U. Vibrio cholera K. Giardiasis V. Whipples disease Q1. A mother brings her 4 y.o child to GP coz she is concerned that he is not putting on weight as he should be. She has noticed that he has chronic diarrhea and describes the stool as being pale and greasy. The GP refers the child to a Paediatrician and a duodenal biopsy is taken at endoscopy, which shows binucleate pear shaped trophozoites immediately adjacent to the duodenal surface epithelium. The small intestinal mucosa is within normal limits. The most likely cause is: Q2. A 6 y.o boy is brought to his GP with 2 weeks history of watery diarrhea with cramping lower abdominal pain. A stool sample is sent for culture and microscopy and a modified Ziehl-Neelsen stain shows characteristic organisms. The most likely diagnosis is: Q3. A 28 y.o female presented with fever, diarrhea, weight loss, abdominal cramping and migratory arthralgia. A small bowel autopsy showed multiple distended PAS positive macrophages within the lamina proproa with minimal inflammation. The diagnosis is: Q4. A 26 y.o female has recently returned from a holiday in the tropics and presents to the local casualty department with abdominal pain, bloody diarrhea and weight loss. During the work up for her condition an ultrasound for the liver is performed which shows numerous discrete masses. The diagnosis: Q5. A 23 y.o woman attends her GP with 2 days Hx of abdominal pain and blood stained diarrhea. She also has N & V. One week previously, she was at a music festival and ate a chicken drumstick and coleslaw from a takeaway food van.

THEME: Tumours affecting the GI tract LEAD IN: Select most appropriate answer. Each options may used once, more than once or not at all. OPTIONS: A. Adenocarcinoma (no special type) K. Leiomyosarcoma B. Adenocarcinoma (diffuse type) L. MALToma C. Adenocarcinoma (intestinal type) M. Mucinous cystadenocarcinoma D. Adenoid cystic carcinoma N. Mucoepidermoid carcinoma E. Burkitts lymphoma O. Pleomorphic adenoma F. Carcinoid tumour P. Squamous cell carcinoma G. Diffuse large B cell lymphoma Q. Tubular adenoma H. GI stromal tumour R. Tubulovillous adenoma I. Hamartomas polyp S. Villous adenoma J. Hyperplastic polyp T. Warthins tumour Q1. A 56 y.o man present to his GP with dysphagia associated with 2 stone in weight loss over the last 6 weeks. He has a 30 year smoking Hx nad has suffered a long standing oesophagitis over the last 10 years. He drinks approx. 20 pints a week. He is referred to a gastroenterologist who performed an upper GI endoscopy and discovers a polypoidal exophytic mass in the middle third of his oesophagus. The diagnosis: Q2. A 41 y.o female presents with a mass in front of her left ear. She has been aware of it for the last year and says it has only increase slightly in size. After examination of the mass, the GP refers her for a surgical opinion as he thinks it is arising within her parotid gland. The tumour is removed and is composed of heterogenous epithelial elements in a loose myxoid stroma. The diagnosis: Q3. A 61 y.o male presents with abdominal discomfort, recurrent vomiting and a significant weight loss. When he is referred for endoscopy, the entire stomach appears to be extensively infiltrated by malignancy and appears thickened and rigid. A biopsy is sent to the histological department, which shows cell with abundant mucin and eccentric nuclei (signet ring cells). The diagnosis: Q4. A 36 y.o female presents to casualty with abdominal pain. She is admitted to hospital and has a CT scan which shows a 4cm mass in her rectum that appear to arise in the submucosa. The tumor is surgically removed and sent for a histological evaluation. It is composed of a spindle cells and is diffusely positive for the immunohistochemical marker CD117 (C-KIT). On discussion at the multidisciplinary meeting the pathologist comments that because of this, it may be suitable for treatment with a molecular targeted cancer therapy. The diagnosis:

Q5. A 28 y.o male presents to casualty with intestinal obstruction. He is known to be HIV positive with a low CD4 count and high viral load. A CT scan shows a full thickness mural thickening of the colonic wall. The lesion is biopsied at the time of the CT scan and this shows a tumour composed of large atypical lymphoid cells with coarse chromatin, several nucleoli and basophilic cytoplasm. There is a characteristic starry sky appearance and abundant mitotic figure. The diagnosis: THEME: Liver histology LEAD IN: Each of the following histology reports a suggestive of a particular illness affecting the liver. OPTIONS: A. Acute viral hepatitis L. Hep B infection (chronic) B. Alcoholic hepatitis M. Hep C infection (chronic) C. Alpha one antitrypsin deficiency N. Hepatocellular carcinoma D. Angiosarcoma O. Large duct obstruction E. Autoimmune hepatitis P. Metastatic carcinoma F. Cholangiocarcinoma Q. Primary biliary cirrhosis G. Cirrhosis R. Primary sclerosing cholangitis H. Drug induced hepatitis S. Veno-occlusive disease I. Focal nodular hyperplasia T. Von Meyenberg complex J. Haemachromatosis U. Wilsons disease K. Hepatic adenoma Q1. Histological examination of the liver shows a well demarcated but poorly encapsulated nodule with a central scar containing large arteries that exhibit fibro muscular hyperplasia and radiating septa exhibiting foci of intense lymphocytic infiltrates and exuberant bile duct proliferation along margins. Q2. Histological examination of the liver shows extensive macro vesicular steatosis with neutrophil accumulation around degenerating hepatocytes. Occasional Mallory bodies are identified. There is evidence of sinusoidal and perivenular fibrosis with mild periportal fibrosis. Q3. Histological examination shows concentric periductal fibrosis around a single duct onion skin fibrosis. The remaining ducts show lymphocytic inflammation and seem to be reduced in number. The surrounding liver parenchyma shows cholestasis. Q4. Histological examination of the liver shows a tumour composed of hepatocytes arranged in a trabecular pattern with cytoplasmic inclusions resembling Mallory bodies and prominent bile staining. Immunohistochemical staining shows positivity for alpha feto-protein.

Q5. Histological examination of the liver shows round to oval cytoplasmic globular inclusions within hepatocytes, which on routine staining are acidophilic and indistinctly demarcated from the surrounding cytoplasm. They are strongly PAS positive and diastase resistant. SAMPLE MCQ: Q1. The most common form of primary malignant tumour of the salivary gland is: A) Adenoid cystic carcinoma B) Pleomorphic adenoma C) Mucoepidermoid carcinoma D) Warthins tumour E) Acinic cell carcinoma Q2. Biotransformation reactions generally produce a protein that is: A) More likely to distributed intracellularly B) More likely to produce unwanted effects C) Less lipid soluble than the original chemical D) More lipid soluble than the original chemical E) Stored in liver Q3. Which one of the following reactions is NOT considered as Phase II biotransformation? A) Glucuronidation B) Acetylation C) Sulfation D) Epoxidation E) Methylation Q4. The following drugs are used to increase intestinal motility EXCEPT: A) Bulk and osmotic laxatives B) Stimulant purgatives C) Cholinergic agonist D) Opiates E) Faecal softeners Q5. The following association are true EXCEPT: A) Microsatellite instability and colon cancer B) Coeliac disease and small bowel lymphoma C) Helicobacter pylori and gastric lymphoma D) Abnormal B-cell response and Crohns disease E) Autoimmune gastritis and gastric carcinoma

CLINICAL QUESTIONS: Q1. A 48 y.o male is referred by his GP to a gastroenterologist for investigation of dyspepsia and epigastric pain with associated weight loss. He describe the pain as a burning aching pain, which is worse at night and is relieved by drinking milk. The gastroenterologist performs an endoscopy, which shows a discrete lesion in the duodenum. The lesion is biopsied and is sent to pathology lab. He reassures the patient gives him a prescription for medication and arranges to review his case in 4 weeks time. i) What is his likely diagnosis and why? (3m) ii) What are the risk factors for the development of his condition? (5m) iii) What is the pathologist likely to see on the biopsy? (4m) iv) What are the complications of his condition? (4m) v) What medications is the gastroenterologist likely to have prescribed? (5m) vi) There is a multi-system disorder that maybe rarely associated with his condition. What is it? (4m) Q2. A 26 y.o female presents to the casualty department of a busy Dublin hospital. She has noticed a yellow tinge to her skin in the past few weeks and has been feeling very tired and unwell with no appetite. Reluctantly she admits to injecting heroin on occasion. Her blood shows elevated AST and ALT with normal alkaline phosphatase, prolonged prothrombin time and hyperbnilirubinaemia. Her serology reveals HBsAg and HBeAg positivity. i) What is the most likely diagnosis? Is the patient infective? (4m) ii) What is the most likely mode of transmission in this case? What are the other possible modes of transmission? (4m) iii) What are the possible outcomes of this condition? (6m) iv) Write a short note on the Hep D infection? (5m) v) Are there any treatment options for this patient? (6m)