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In 2008, Takabuti was taken to Manchester Royal Infirmary where radiography and CT-scanning were performed; recent analysis has revealed several unexpected and unusual features. Initially, the scans indicated that she was around 25-35 years of age at death; there were no signs of disease and her cause of death remained unidentified. Current research on the CT-scans has revealed that the only organ tissue returned to the body after evisceration was the heart which, as the locus of the owner’s personality, was usually afforded special treatment. Endoscopy was used to take samples to identify any traces of disease. Partial visual examination of her teeth, together with the CT scans, enabled Takabuti’s dental state to be determined: all her teeth were present, there is no evidence of tooth decay and little indication of gum disease, in contrast to many ancient Egyptians who suffered from worn, sensitive and abscessed teeth. Stable carbon and isotope analysis undertaken on a sample of Takabuti’s hair has demonstrated that she probably ate a diet lacking cereals but rich in food derived from trees and shrubs as well as legumes, beans and pods. The lack of cereals is unusual in an ancient Egyptian diet.

A 76-year-old woman was admitted to the acute medical unit with a one-week history of diarrhoea. She was opening her bowels four times per day. She had recently started a new medication.

On examination, her temperature was 36.4°C, pulse was 74 beats per minute, and blood pressure was 134/78 mmHg. She had a resting tremor in the right upper limb. Her abdomen was soft, with mild generalized tenderness.

This chapter includes a range of miscellaneous curriculum topics including endoscopy, anorectal disorders and gastrointestinal (GI) investigations. Questions discussing the role and indications for antibiotic prophylaxis in endoscopy, sedation, performance measures and consent will provide education on best practice in endoscopy. Coverage is also given to the management of anticoagulation pre- and post-endoscopy together with commonly encountered procedural complications: post-polypectomy syndrome, post-endoscopic retrograde cholangiopancreatography pancreatitis and caustic injury. The presentation and management of key anorectal disorders (haemorrhoids, anal fissures, anal intraepithelial neoplasia, infectious proctitis) are also presented here. Finally, principles of salient GI investigations including anorectal manometry and breath tests are well described. Additional curriculum material regarding miscellaneous gastrointestinal conditions and investigations will be covered in the mock examination chapter.

This chapter covers core curriculum topics relating to gastrointestinal haemorrhage. This includes risk assessment for upper gastrointestinal haemorrhage incorporating natural history and prediction of rebleed following peptic ulcer bleeding. Comprehensive coverage of assessment and management of variceal bleeding (gastric and oesophageal) is included including the role of stenting. Causes of presentations with lower gastrointestinal bleeding, including following radiotherapy, are presented along with guidance on assessing shock index, investigation and management strategies. The role of acute imaging versus endoscopic intervention is discussed. Furthermore, investigation and management of obscure and occult gastrointestinal bleeding is covered including small bowel endoscopy and specialist imaging. Additional curriculum material regarding gastrointestinal haemorrhage will also be covered in the mock examination chapter.

This chapter covers core curriculum topics relating to small intestinal disorders and malabsorption. This includes a discussion of key gut hormones involved in digestion and absorptive processes including with relevance for obesity. Questions on gastrointestinal neurotransmitters and transporters provide education in gut physiology. The protean presentations of several micronutrient deficiencies seen in clinical practice are discussed. Focus is given to the diagnosis, initial management and follow up of patients with coeliac disease and villous atrophy including later-onset complications such as enteropathy-associated T cell lymphoma. Also covered is the investigation of small intestinal motility disorders and the manifestations and management of functional abdominal conditions such as irritable bowel syndrome. Disorders of bile acid recirculation, microbial dysregulation including through acute infections, and key medications causing presentations with diarrhoea are incorporated in this chapter. Additional curriculum material regarding small intestinal disorders will also be covered in the mock examination chapter.

This chapter argues that knowledge of reproductive biology is crucial to understanding the ecology and natural history of a species. However, the reproductive biology of many reptile species is poorly known, particularly for tropical and subtropical species. In this vein, the chapter aims to encourage further studies on natural history, internal anatomy, external morphology, and on the evolutionary biology of reproduction. Several research methods are discussed in this chapter; to wit: dissection, endoscopy, external examination and palpation, imaging (via radiology, ultrasound, and computerized tomography), the study of blood chemistry via the hormones present in blood samples, and hormonal induction via an intramusculary injection.

Gastroenterology and hepatology encompass a vast array of organs that have diverse structure and function and are affected by a multitude of disease processes. Diseases of the digestive tract are a major cause of morbidity and mortality in the United Kingdom (UK) and worldwide. There have been great advances in our understanding, diagnosis, and management of gastrointestinal (GI) disease, and knowledge continues to develop at a great pace. Understanding the physiology and cellular and molecular events that drive pathological processes, as well as the devel­opment of sophisticated endoscopic and radiological tests, have trans­formed diagnostic capability. Therapeutic endoscopy has progressed to replace surgical management of common GI emergencies such as upper GI tract bleeding and decompressing biliary tract obstruction. However, as ever, there is still much work to be done. For example, the advances in biologic immunotherapy in inflammatory bowel disease has greatly im­proved patients’ quality of life and a reduction in the need for surgery, though the overall impact of these medications on the natural history of the disease is debatable at present. Hepatology is a greatly misunderstood specialty. The physiological changes that occur as cirrhosis and portal hypertension develop are the key to understanding all manifestations of a decompensating liver. Recently, there has been a significant increase in the prevalence of chronic liver disease in the UK, and as a result, hospital admissions have increased. Liver disease is the only major cause of death still increasing year on year, and twice as many people now die from liver disease than in 1991. The 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) of patients with alcohol- related liver disease (ARLD) found that less than half the number of patients who died from ARLD received ‘good care’, and avoidable deaths were identified. Allied to this, the enquiry shed light on a cultural pessimism regarding outcomes and prognosis of chronic liver disease and, in particular, ARLD from both the public and the medical profession as a whole. There is now a concerted drive towards improving awareness of chronic liver disease, and initial simple supportive treatments can greatly improve sur­vival, more so than previously thought.

The common complaint of a watering eye may be caused by a variety of problems, including lacrimal hyposecretion, lacrimal hypersecretion, or blockage of the lacrimal drainage system. This system is a complex membranous channel whose function depends on the interaction of anatomy and physiology. Effective tear drainage depends on a variety of factors, including the volume of tear secretion, eyelid position, and anatomy of the lacrimal drainage passages. Epiphora is defined as an abnormal overflow of tears down the cheek. The patient with symptomatic tearing may have a normal lacrimal drainage system overwhelmed by primary or secondary (reflex) hypersecretion or a drainage system that is anatomically compromised and unable to handle normal tear production. On the other hand, a patient with partial drainage obstruction may have a concomitant reduction in tear production and therefore be completely asymptomatic or may even suffer from symptomatic dry eye syndrome. Epiphora is determined by the balance between tear production and tear drainage, not by the absolute function or dysfunction of either one. The causes of lacrimal drainage problems can be divided into two categories: anatomic and functional. Anatomic obstruction refers to a mechanical or structural abnormality of the drainage system. The obstruction may be complete, such as punctal occlusion, canalicular blockage, or nasolacrimal duct fibrosis, or partial, caused by punctal stenosis, canalicular stenosis, or mechanical obstruction within the lacrimal sac (i.e., dacryolith or tumor). In patients with functional obstruction, epiphora results not from anatomic blockage but from a failure of lacrimal drainage physiology. This failure may be caused by anatomic deformity such as punctal eversion or other eyelid malpositions, but can also result from lacrimal pump inadequacy caused by weak orbicularis muscle action. It is helpful to determine whether the patient’s complaint is true epiphora or a “watery eye.” Detailed history-taking and careful examination will help direct the evaluation of a tearing eye. A host of clinical tests have been described, and the selection of appropriate tests will depend on the initial history and ophthalmic examination. 13-1-1 History-Taking. Any clinical evaluation should begin with a thorough history. A complaint of watery eye does not necessarily imply a lacrimal drainage problem.