1. ESA Q A 25 year old patient presents to your surgery with crampy suprapubic pain, loss of appetite, watery diahorrea, fatigue and unintentional weight loss i.What part of the GI tract does suprapubic pain refer to? (1 mark) ii.Name the structures within this section of the GI tract (2 marks) iii.What is the blood supply to this region? (1 mark) 1

2. i.The hindgut which is from the distal 1/3 of the transverse colon to the proximal 2/3rds of the anus ii. iii.The Inferior Mesenteric Artery (IMA) 2

3. You decide that the patient has an irritable bowel disease and decide to do a colonoscopy to differentiate between Crohn’s disease and Ulcerative Collitis i.What are major differences you would expect to find between these two conditions? (3 marks) 3

4. i. 4 Crohn’s diseaseUlcerative colitisCoeliac disease Affected Region: All of GI tract, Mouth to anus Distal colon and rectum Duodenum / Jejunum Macroscopic appearance of mucosa Bowel wall thickened, patchy. Skip lesions, Cobblestone appearance Area affected continuous, inflamed, contact bleeding Smooth mucosa Microscopic appearance of mucosa Transmural. Granulomas, Goblet cell present Superficial crypt abscesses, Goblet cell depletion Partial / Total absence of villi Common presenting symptoms Abdo pain, Diarrhoea, Weight loss Diarrhoea with blood and mucus, malaise lethargy Malabsorption, Iron deficient anaemia

5. i. 5

6. A diagnosis of Crohns is made. You remember that crohns often affects the ileum Q) What is absorbed in the terminal ileum? (2 marks) 6

7. A)Vitamin B 12, Bile salts i.What symptom would a patient complain of if they didn’t have enough bile? (1 mark) ii.What type of anaemia could this patient develop? (1 mark) 7

8. i.Steatorrhea ii.Macrocytic, Normochromic The Patient believes that he developed this diseased from eating some dodgy food after a night out in Coventry i.Give for examples of where peoples lay beliefs come from? (2 mark) ii.Why should you take account of peoples lay beliefs? (1 mark) 8

9. i.Personal knowledge and experience, Previous medical encounters, Folk knowledge, The media and the Internet, Spiritual beliefs, Alternative and complementary medicine ii.Understand patients illness related behaviour, Understand Patients needs and expectations, More Satisfied patients 9

10. You know that the cause of Crohns is unknown but that it is thought to be due to a combination of environmental and genetic factors. Q) Name 3 Bradford Hill Criteria and explain briefly what they mean? (6 mark) 10

11. Association features – Strength of Association - A strong association (e.g. a high incidence rate ratio or odds ratio) is more likely to be causal. This is because strong associations are less likely to be explained by undetected confounding or bias. – Specificity of Association - One exposure leads to one outcome e.g. asbestos and mesothelioma. However, most diseases are now felt to be multi ‑ factorial in their causation, and many factors can cause several diseases. – Consistency of Association - An association that has been repeatedly observed by different study designs, on different people, in different places, at different times. 11

12. Exposure/outcome – Temporal Sequence - Exposure to putative factor has been demonstrated to precede outcome of interest. – Dose Response (Biological Gradient) - Larger exposure to the putative factor leads to a higher rate of disease. – Reversibility (Experiment) - Reduction in exposure to the putative factor leads to a reduced or non ‑ existent risk of acquiring the disease (outcome). 12

13. Other evidence – Coherence of Theory - An association that conforms with current knowledge and theory. – Biological Plausibility - Makes sense, according to the biological knowledge of the time. – Analogy - Cause and effect relationship already established for a similar exposure or disease. 13

14. Question 2 A 14-year-old girl is complaining of lethargy and thirst combined with excessive urination of several weeks duration. Upon physical examination you find she is underweight for her age and height. She has type I Diabetes. 14

15. 1)Give the biochemical explanation for weight loss, thirst and fatigue commonly seen in type I diabetes (5) 1)Name THREE different biochemical pathways/processes that are stimulated by insulin and three pathways that are inhibited by Insulin. Such pathways may include those that result in the synthesis or breakdown of specific classes of molecules, important individual molecules as well as other metabolic or structural changes. (6) 15

16. 3) List 3 hormones that counter-act some of the actions of Insulin (3) 4) Diabetes is a chronic disease. What is the impact of chronic disease on a person’s life (4) 5) What are two long term consequences of poor diabetes control. (2) 16

17. Answers 1) Give the biochemical explanation for weight loss, thirst and fatigue commonly seen in type I diabetes (5) 17

18. 2) Name THREE different biochemical pathways/processes that are stimulated by insulin and three pathways that are inhibited by Insulin 18

19. 3) List 3 hormones that counter-act some of the actions of Insulin (3) Glucagon Cortisol Adrenaline Tri-iodothironine Growth Hormone 19

20. 4) Diabetes is a chronic disease. What is the impact of chronic disease on a person’s life (4) Sense of self Daily living Social relationships Identity (the view that people hold of them) 20

21. 5) What are two long term consequences of poor diabetes control. (2) Retinopathy - blindness Neuropathy – nerve damage Diabetic Foot ulcers Renal failure Stroke Coronary Heart Disease Death 21

22. Question 3 60 year old Indian male who spent his entire working life in the paint spraying industry comes to you complaining of feeling unwell for some time. This is the first time he has spoken to a doctor about this. Following specialist referral Mr S is diagnosed with cancer 22

23. 1)Define ethnicity and culture (4) 2)As a male, Mr S is less likely to live longer than his wife. List 5 reasons as to why this may occur (5) 23

24. During your research in to this diagnosis, you read a paper that describes a cohort study investigating the relationship between prolonged exposure to chemical X (a commonly used commercial paint thinner) and the development of cancer 3) What is a cohort study (2) 4) What are the advantages of Cohort studies (2) 24

25. Mr S was diagnosed with Lung cancer which has spread to his bowel. 5) What are the different types of cancer which can present in the GI tract and where can they occur (6) 25

26. 1)Define ethnicity and culture (4) Ethnicity (2) A long shared history, of which the group is conscious as distinguishing it from other groups and the memory of which keeps it alive Ethnic group is subjective and self-reported and can change over time reflecting social developments 26

27. Culture (2) Concentrates on shared experiences, beliefs and values Members of an ethnic group may have the same culture 27

28. 2) As a male, Mr S is less likely to live longer than his wife. List 5 reasons as to why this may occur (5) 28

29. 3) What is a cohort study (2) -A prospective observational study that choices disease free people and defines them based on their exposure -They then look to see how many people of each group have a disease 29

30. 4) What are the advantages of Cohort studies (2) Can establish that exposure precedes disease Can directly measure incidence Can study range of outcomes/diseases for each exposure 30

31. 5) What are the different types of cancer which can present in the GI tract and where can they occur (6) -Squamous cell carcinoma – mouth, upper and middle oesphagus, anus -Adenocarcinoma – stomach, SI, LI, Colon -Lymphoma (MALToma) – Stomach (often associated with H.Pylori) 31