(a) A 65-year-old lady has progressively increasing dysphagia for last 6 months. She also has significant weight loss. How will…

(a) Investigation of progressive dysphagia with weight loss in a 65-year-old woman

Progressive dysphagia with weight loss means oesophageal cancer (squamous cell carcinoma, common in India, or adenocarcinoma at the gastro-oesophageal junction) until proved otherwise; achalasia, benign stricture and extrinsic compression are the other possibilities.

History and examination: onset, solids before liquids, regurgitation, pain, hoarseness, cough on swallowing (fistula), tobacco, alcohol and reflux; look for pallor, cachexia, hoarse voice, and cervical and supraclavicular nodes, hepatomegaly and ascites. Blood tests: haemoglobin (iron deficiency), liver and renal function, albumin and electrolytes, with nutritional assessment. Upper gastrointestinal endoscopy is the first and key investigation: it shows the site and extent of the growth and allows multiple biopsies (at least six) for histology. Barium swallow when endoscopy is not available or the stricture cannot be passed: an irregular filling defect with shouldering ("apple-core") suggests carcinoma, while a smooth "bird's beak" narrowing suggests achalasia. Staging once cancer is confirmed: contrast CT of neck, chest and abdomen; endoscopic ultrasound for depth of invasion and nodes (with fine-needle aspiration); PET-CT for distant spread; bronchoscopy for tumours of the upper and middle oesophagus (airway invasion); and laparoscopy for junctional tumours. HER2, PD-L1 and mismatch-repair status are tested in adenocarcinoma. If endoscopy is normal, oesophageal manometry for achalasia and motility disorders. Assess performance status and fitness, and plan treatment in a multidisciplinary tumour board.

(b) Management of severe haematemesis in alcoholic liver disease with portal hypertension

Variceal bleeding is the likely cause, and the aim is to restore the circulation, stop the bleeding and prevent rebleeding and complications. Resuscitation: airway protection (intubation if consciousness is reduced or bleeding is massive), oxygen, two large-bore cannulas, cross-match and monitoring in an ICU. Transfuse restrictively to keep haemoglobin at 7 to 8 g/dL, because over-transfusion raises portal pressure; correct severe coagulopathy but do not aim to normalise the INR. Vasoactive drugs, started at once before endoscopy: terlipressin (2 mg every 4 hours) or octreotide (50 μg bolus then 50 μg/hour) for 2 to 5 days. Antibiotic prophylaxis: ceftriaxone 1 g daily for up to 7 days, which lowers infection and mortality. Endoscopy within 12 hours: band ligation of oesophageal varices; cyanoacrylate glue for gastric varices; sclerotherapy only if banding is not possible. Prevent complications: lactulose for hepatic encephalopathy; thiamine and prevention of alcohol withdrawal; avoid sedatives; treat renal impairment. Failure to control: Sengstaken-Blakemore or Minnesota tube balloon tamponade (not beyond 24 hours) or a self-expanding oesophageal stent as a bridge, then TIPS. Early TIPS (within 72 hours) is advised in high-risk patients (Child-Pugh C 10 to 13, or B with active bleeding). Secondary prophylaxis: non-selective β-blocker (carvedilol or propranolol) with repeat banding to eradicate varices, alcohol abstinence, and assessment for liver transplantation.

(c)(i) Five risk factors for pelvic organ prolapse

Vaginal childbirth, especially several deliveries, instrumental delivery, a large baby or a prolonged second stage, which damages the levator ani and its nerve supply. Advancing age and menopause (oestrogen deficiency weakens the supporting tissue). Raised intra-abdominal pressure: chronic cough, constipation with straining, and heavy lifting. Obesity. Connective tissue weakness (Ehlers-Danlos and Marfan syndromes), family history, and previous pelvic surgery such as hysterectomy.

(c)(ii) Management options for procidentia with cystocoele, enterocoele and rectocoele

Conservative: lifestyle change, weight reduction, treatment of cough and constipation; pelvic floor muscle exercises; local vaginal oestrogen; and a vaginal pessary (ring or Gellhorn) for patients unfit or unwilling for surgery. Obliterative surgery: colpocleisis (Le Fort partial or total) with perineorrhaphy, suitable for an elderly, sexually inactive woman or one unfit for a long operation, with a high success rate. Reconstructive surgery: vaginal hysterectomy with anterior colporrhaphy, posterior colporrhaphy with perineorrhaphy, McCall culdoplasty for the enterocoele, and apical support by sacrospinous fixation or uterosacral ligament suspension. Abdominal, laparoscopic or robotic sacrocolpopexy with mesh, for a fit woman needing a durable apical repair. Uterus-preserving procedures (Manchester repair, sacrohysteropexy) if the uterus is to be kept. The choice depends on fitness, sexual activity and the patient's wish.

(d) Chronic pelvic pain: definition and causes

Definition. Chronic pelvic pain is non-cyclical pain felt in the lower abdomen or pelvis, lasting 6 months or more, severe enough to cause functional disability or to need medical care, and not due only to menstruation, intercourse or pregnancy.

Causes: Gynaecological: endometriosis, adenomyosis, chronic pelvic inflammatory disease and tubo-ovarian adhesions, pelvic congestion syndrome, fibroids, ovarian remnant, and post-surgical adhesions. Urological: interstitial cystitis (bladder pain syndrome), recurrent urinary infection, urethral syndrome and stones. Gastrointestinal: irritable bowel syndrome, inflammatory bowel disease, chronic constipation, diverticular disease and hernia. Musculoskeletal and neurological: pelvic floor myofascial pain, coccydynia, piriformis syndrome, symphysis pubis dysfunction, and pudendal or other nerve entrapment. Psychological: depression, anxiety, and past sexual or physical abuse, which amplify pain through central sensitisation.

(e) Entitlements under the Janani-Shishu Suraksha Karyakram (JSSK)

JSSK (launched in 2011 by the Ministry of Health and Family Welfare) removes out-of-pocket expenses at government health facilities. Pregnant women: free and cashless normal delivery and caesarean section; free drugs and consumables; free diagnostics (blood tests, ultrasound); free provision of blood; free diet during the stay (3 days for normal delivery and 7 days for caesarean section); exemption from all user charges; and free transport from home to the facility, between facilities if referred, and drop-back home after 48 hours. Sick newborns (extended to sick infants up to one year): free treatment, drugs and consumables, diagnostics and blood; exemption from user charges; and free transport from home to the facility, between facilities if referred, and drop-back home.